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Tze Pin Ng

Publications and source records attributed to Tze Pin Ng.

16 recordsLinked to original sources

Omics signature of new-onset mild cognitive impairment and dementia in a population-based study.

Plasma proteomics and metabolomics snapshots reveal a molecular signature in circulation delineating pathophysiology of major and minor neurocognitive disorder. To identify new cues to disease aetiology and diagnostic approach, we applied plasma proteomics and metabolomics profiling platforms to samples collected in a population-based study of the Singapore Longitudinal Ageing Studies Wave 2 (SLAS-2). In this longitudinal study, blood samples were analysed with standard clinical chemistry, plasma proteomics (Sengenics) and metabolomics (Nightingale) panels. Participants were followed up for the development of mild cognitive impairment (MCI) and dementia for 3-5 years. Of the total 1,892 molecules in all assay types, 463 demonstrated significant associations with baseline prevalent MCI and dementia. We trained an automatic linear modelling of predictors for follow-up new-onset MCI and dementia. The best model consists of 10 variables including ZSCAN18, PRKD3, SPANXN4, DDX43, saturated fatty acids, PPP3CA, NFATC4, IL-8, PAK6, and PDGFB. In terms of molecular function, these molecular markers are involved in immunological dysfunction and inflammatory reaction, protein coding, lipids, DNA-binding transcription factor activity, and nervous system development. In conclusion, our current research has identified an omics signature linked to new-onset mild cognitive disorder and dementia, which we hope can help enhance the accuracy of their diagnosis using circulating blood samples.

Humans↗

Development and Validation of Machine Learning Models for Predicting Early Cognitive Decline Using Home Sensor-Derived Behavioral Data: Sensors in-Home for Elder Wellbeing (SINEW) Cohort Study.

BACKGROUND: As the global population continues to age, the prevalence of geriatric conditions, including dementia and frailty, is also increasing. Early identification of individuals at an elevated risk of these conditions, such as those presenting with mild cognitive impairment (MCI) or prefrailty, can provide a critical window for prompt intervention aimed at preventing or reversing disease progression. To promote such early identification, there is a burgeoning interest in the use of digital sensor technology and predictive modeling. OBJECTIVE: This study aimed to use a continuous, home-based monitoring sensor system for older adults to distinguish those exhibiting normal aging from those with MCI, early dementia, prefrailty, or frailty, and to predict their transition from normal aging to one of these conditions. METHODS: This longitudinal cohort study will recruit 200 community-dwelling adults aged ≥65 years with normal cognition or MCI at baseline. A multi-sensor system will be installed in participants' homes, including passive infrared motion sensors, door contact sensors, bed sensors, medication box sensors, wearable activity bands, and Bluetooth proximity beacons. These devices will continuously capture spatiotemporal activity patterns, mobility indicators, sleep behaviors, and medication-taking routines. Annual assessments will include standardized cognitive tests (eg, Montreal Cognitive Assessment, Mini-Mental State Examination, Rey Auditory-Verbal Learning Test, digit span, Color Trails Test, semantic fluency, Stroop), frailty measures (modified Fried phenotype, gait speed, grip strength), mental health scales, sleep quality, and psychosocial indicators. Sensor-derived features-such as gait variability, activity regularity, sleep fragmentation, and medication adherence patterns-will be integrated with clinical data to develop supervised machine learning models. Planned approaches include logistic regression, random forests, gradient boosting, and deep learning. Model performance will be evaluated using cross-validation and independent test sets. Primary metrics will include area under the receiver operating characteristic curve, sensitivity, specificity, precision, recall, and F1-score. Models will be benchmarked against gold-standard clinical diagnoses and validated using temporal subsets of the dataset. RESULTS: Enrollment for this study started in November 2019 and will continue until March 2030. As of June 2025, we have enrolled 138 participants. Full data analysis has yet to begin. CONCLUSIONS: We aim to develop a reliable and effective sensor system for in-home use that will facilitate the early detection of cognitive and physical decline. In so doing, it will add to our current understanding of digital biomarkers. It is common for older adults to seek clinical intervention only when their cognitive impairment has already reached an advanced stage. The implementation of readily deployable sensor systems within community settings presents us with opportunities for prompt intervention, which holds the potential for delaying or reversing disease progression and allowing for a greater number of functional and meaningful years.

Humans↗

Brief informant screening test for mild cognitive impairment and early Alzheimer's disease.

BACKGROUND/AIMS: Recent research has attempted combinations of instruments to improve screening accuracy for mild cognitive impairment (MCI) and early Alzheimer's disease (AD). We compared Mini-Mental State Examination (MMSE), Immediate and Delayed Recall (Logical Memory I and II; LM-I and LM-II, respectively), a single-item informant report of memory problem (IRMP), and a four-item Instrumental Activities of Daily Living (4IADL) scale, and combinations of these tests. METHOD: The tests were administered together with Clinical Dementia Rating (CDR) to subjects who were cognitively intact (CDR = 0, n = 88), and with diagnoses of MCI (CDR = 0.5, n = 37) and early AD (CDR = 1-2, n = 19). RESULTS: Screening accuracy (receiver operating characteristic area under curve, AUC) for identifying MCI or MCI-AD was lowest for MMSE (AUC 67.6% for MCI or 77.9% for MCI-AD), and better for IRMP (79.5 or 83.2%), 4IADL (76.9 or 84.7%), LM-I (81.2 or 87.1%) and LM-II (86.1 or 90.8%). Combining IRMP, 4IADL and LM-II was most accurate (AUC 91.7% for MCI or 94.5% for MCI-AD); sensitivity: 86.5 or 89.3%; specificity: 86.4 or 88.6%. However, combining IRMP and 4IADL gave nearly as good accuracy (AUC 87.2 or 91.6%); sensitivity: 86.5 or 85.7%; specificity: 79.5 or 85.2%. CONCLUSION: A brief instrument combining an IRMP and 4IADL items is potentially useful in screening for MCI and early AD.

Aged↗

Psychiatric morbidity and acute hospitalization in elderly people.

BACKGROUND: Few studies have investigated the association of psychiatric morbidity with acute hospitalization risk in elderly people. METHOD: We examined this association using population-based data for 1092 older adults aged > or =60 years in Singapore, including subjects who reported at least one acute hospitalization from any medical condition(s) in the 12 months prior to interview (N = 136). Psychiatric morbid/comorbid disorders were diagnosed using the Geriatric Mental State examination. RESULTS: In a multivariate analysis, comorbid psychiatric disorders were independently associated with hospitalization [adjusted odds ratio 2.76, 95% confidence interval 1.20-6.33], after controlling for age, ethnicity, employment status, number of medical comorbidities, number of activities of daily living limitations, hearing and visual impairment, SF-12 Physical and Mental Component Summary scores, social, productive, fitness and health activities, and regular visits to health-care providers. Neither dementia diagnosis nor cognitive impairment measured by the Mini-mental State Examination was associated with increased hospitalization risk. CONCLUSION: Psychiatric morbidity in old age was significantly associated with increased hospitalization risk. This finding underlines the importance of treating psychiatric illness to reduce the risk of acute hospitalization in elderly patients.

Activities of Daily Living↗

Generalised anxiety disorder in Singapore: prevalence, co-morbidity and risk factors in a multi-ethnic population.

BACKGROUND: There has been a relative lack of epidemiological data on generalised anxiety disorder (GAD) in Southeast Asia. A previous study reported a lifetime prevalence of 1.5% and highlighted low preference for seeking professional help and consultation by persons suspected to be suffering from mental health problems. The present study is part of a National Mental Health survey of adults conducted from February 2003-March 2004 specifically assessing anxiety and depression in Singapore. In this paper we report on prevalence, co-morbidity and risk factors associated with GAD. METHODS: We interviewed 2,847 households from an ethnically stratified random sample of adults aged 20-59 years who were Singapore citizens or permanent residents. The General Health Questionnaire and Schedule for Clinical Assessment of Neuropsychiatry were administered, which generated Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses of GAD. We assessed socio-demographic correlates, life events, medical and other psychiatric co-morbidities related to GAD. RESULTS: Lifetime prevalence of GAD was 3.3%, current prevalence is 3.0%. Female to male ratio is 3.6:1. GAD was significantly associated (p<0.001) with the presence of other psychiatric co-morbidities, including major depressive disorder, dysthymia, panic disorder, agoraphobia and social phobia. Prevalence increased in older individuals, with the odds of association greatest in subjects with three or more co-morbid medical conditions [adjusted odds ratio (OR) 3.66]. Those who had experienced one or more threatening life events showed increased odds of association with GAD. Chinese ethnicity, the divorced and persons from both the upper and the lowest socio-economic status had highest odds of association with GAD. CONCLUSIONS: We challenge established notions that GAD tends to be a disorder of the socially disadvantaged. Life events are important as precipitating factors in GAD, and uniquely different types of events appear to affect both extremes of social classes. High co-morbidity associations with current GAD are grounds for concern. This may suggest failure to seek treatment, hence giving rise to an increase in severity of the primary condition.

Adult↗

Comparing the stigma of mental illness in a general hospital with a state mental hospital: a Singapore study.

The stigma faced by psychiatric patients associated with the type of psychiatric facilities is controversial. This study was conducted to compare the stigma faced by patients with schizophrenia and non-schizophrenia psychiatric disorders in the outpatient departments of a state mental hospital with those in a general hospital in Singapore. A cross-sectional study involving two groups of outpatients in a state mental hospital (n=300) and in a university general hospital (n=300) were assessed with a 12-item stigma scale. Components of the scale assessed included social rejection, negative media perception, shame and social discrimination. Among schizophrenia patients, state mental hospital patients had significantly lower stigma scores compared to their counterparts in the general hospital. For other mental illnesses, the reverse was true: state mental hospital patients had significantly higher stigma scores compared to their counterparts in the general hospital. Stigma was also associated with a younger age and being employed though not by gender. The stigma faced by psychiatric patients is complex and may have institutional and disorder-specific elements. Possible reasons for this are discussed.

Adolescent↗

Prevalence and determinants of excessive daytime sleepiness in an Asian multi-ethnic population.

BACKGROUND AND PURPOSE: To investigate the prevalence and determinants of daytime sleepiness in an Asian multi-ethnic population. Cross-sectional survey based on a questionnaire in multi-ethnic Asian adult population of Singapore (2.4 million). PATIENTS AND METHODS: Measured frequency of excessive daytime sleepiness (EDS), socio-demographic status, sleep duration, perceived sleep insufficiency, frequent awakenings, difficulty falling asleep, snoring, breathing pauses, GHQ-12, shift work, solvent exposure at work, substance use, medications, and chronic diseases in random sample of 2,298 adults, aged 20-74 years, representing Chinese, Malays and Indians. RESULTS: Among the respondents, 10.8% reported usually feeling sleepy in the daytime, and 9.0% were classified as having EDS. Marked ethnic difference was observed, with higher rates of EDS in Malays and Chinese, compared to Indians. Increased risk of EDS was associated with perceived sleep insufficiency; snoring and breathing pauses; shift work and solvent exposure at work; psychiatric morbidity and chronic diseases, particularly chronic rhinitis; and medications with sedating effects. CONCLUSIONS: Daytime sleepiness is associated with a multiplicity of highly prevalent risk factors in the community, including sleep behavior, breathing-, work- and medically related factors. Significant ethnic differences, which were not explained by these factors, were observed between Chinese, Malays and Indians.

Adult↗

Ethnic differences in quality of life in adolescents among Chinese, Malay and Indians in Singapore.

BACKGROUND: Health-related quality of life in adolescents and ethnic and cultural differences are not well characterized. We used the Quality of Life Questionnaire for Adolescents (QOLQA) to examine ethnic differences in reported QOL scores among Chinese, Malay and Indian ethnicities in Singapore. METHODS: The 70-item QOLQA measuring five QOL domains (physical, psychological, independence, social and environmental) was administered to a random sample of 1363 school-children aged 10-15 years, representative of the ethnic composition of Singapore adolescents (Chinese 72%, Malays 20% and Indians 8%). RESULTS: Indians reported the highest overall QOL (mean 3.71 +/- SD 0.54) compared to Chinese (3.59 +/- 0.43), p < 0.05, and Malays (3.58 +/- 0.44), p < 0.05. In particular, Indians had significantly higher psychological QOL scores (3.73 +/- 0.61) compared to Chinese (3.55 +/- 0.54), p < 0.01. On the other hand, Chinese scored highest on physical and independence domains (3.97 +/- 0.54), p < 0.01 compared to Malays (3.82 +/- 0.55). There were no statistically significant gender differences in QOL scores. QOL declined significantly from age 10 to 15 for overall score, psychological, physical (p < 0.01) and environmental (p < 0.05). Lower socio-economic status and the self-report of a significant health problem were significantly associated with lower overall QOL and most domains. These ethnic differences persisted after adjusting for differences in socio-economic and health status. Psychometric properties and known group construct validity appeared to be similar across different ethnic groups, but compared to Chinese (r = 0.39) or Malays (r = 0.39), Indians showed a higher correlation of psychological scores with physical score (r = 0.59) and with other domain scores. CONCLUSION: Significant ethnic differences in reported adolescent quality of life among Chinese, Malays and Indians in Singapore that are independent of socioeconomic and health status suggest important cultural differences.

Adolescent↗

Changing prevalence of gastroesophageal reflux with changing time: longitudinal study in an Asian population.

BACKGROUND: The purpose of the present paper was to study previously obtained population-based data on the prevalence of reflux symptoms in a random sample of community adults in Singapore. This sample was re-investigated 5 years later to determine changes in the prevalence of reflux symptoms. METHODS: In 1999, 237 (34%) of the original cohort of 696 persons who were interviewed in 1994, were re-interviewed using a validated Gastrointestinal Symptoms Questionnaire. The original cohort was a race-stratified random sample of residents in a Singaporean town. Reflux was defined as heartburn and/or acid regurgitation occurring at least once a month. RESULTS: Among the 237 respondents (aged 25-89 years; male : female, 49:51; Chinese n = 106, 45%; Malay n = 69, 29%; Indian n = 60, 25%), reflux was reported by 25 respondents, giving a prevalence of 10.5 +/- 2.0%. This compared with the prevalence of 5.5 +/- 1.5% (odds ratio [OR], 2.2; 95% confidence interval [CI]: 1.0-5.2; P = 0.05) among the same 237 respondents in the 1994 survey. Of the 25 subjects who reported reflux in the current survey, 22 (88.0%) did not complain of reflux symptoms in the 1994 survey. The ethnic-adjusted prevalence of reflux in 1999 was estimated to be 9.9 +/- 1.9%. This was an increase above the prevalence in 1994 of 1.6 +/- 1.0% (P = 0.051). The upward trend in the prevalence of reflux was not related to age, smoking, alcohol consumption, or increase in bodyweight. CONCLUSIONS: There is a rising trend of reflux symptoms frequency in the general population of Singapore over a 5-year period.

Adult↗

Trends and ethnic differences in COPD hospitalization and mortality in Singapore.

STUDY OBJECTIVE: COPD mortality alone among major causes of diseases continues to rise in most countries worldwide. We examine trends, and gender and ethnic differences in COPD hospitalization and mortality in Singapore from 1991 to 1998, and examine possible explanations. DESIGN: Analysis of population-based health administrative data. SETTING: Multi-ethnic (Chinese, Malay and Indian) population of Singapore (3 million population). METHOD: Data on hospitalizations and deaths due to COPD as the underlying cause (ICD codes 491, 492, 496), extracted from national databases, were used to calculate age-specific and standardized rates for the population aged 55 + years. COPD accounted for 4.6% of total deaths (5.8% in those aged 55 +), and 1.02% of all hospitalizations (3.1% in those aged 55 +). RESULTS: COPD mortality in 1998 decreased steeply by -43.7% from 1991 (a decline that continued a steady trend since 1970), while hospitalization showed little significant change (-3.3%). Men had 4 and 5 times higher mortality and hospitalization, and also showed less favorable trends than women. Malays, especially males, showed the highest level and least favorable decline of mortality. CONCLUSION: Exceptionally steady declines in COPD mortality rates, and stable rates of hospitalization are observed in Singapore in the 1990s. Differing levels and trends of hospitalization and mortality by gender and ethnicity are related to known demographic variations and trends of smoking prevalence in the country.

Age Distribution↗

The use of Chinese herbal medicines and their correlates in Chinese older adults: the Singapore Chinese Longitudinal Aging Study.

BACKGROUND: There are very few studies of the use of Chinese herbal medicine and their psychosocial and health-related determinants in older adults. OBJECTIVES: To determine the prevalence of use of Chinese herbal medicine in community-living Chinese older adults in Singapore and its associations with socio-economic status, social support, health behaviour, health and functional status. DESIGN: Cross-sectional analyses of baseline data from a longitudinal cohort study of old adults (Singapore Chinese Longitudinal Aging Study). SETTING: Community of Toa Payoh in Singapore (total population 22800 out of 3 million). PARTICIPANTS: community residents comprising 2010 Chinese older adults aged 65 years and above. MEASUREMENTS: participants completed a questionnaire on Chinese herbal medicine use and other information on psychosocial and health-related variables. RESULTS: The use of Chinese herbal medicine over the past year was reported by 25.3% of the subjects, among whom 52% reported concurrent use of Western prescription medications. Significant factors that were strongly and independently associated with Chinese herbal medicine use were limited to extensive social support (OR = 2.66-5.56), current smoking (OR = 1.35), regular taiqi (OR = 1.94), arthritis (OR = 2.36), cancer (OR = 3.15), hypnotic use (OR = 2.08), IADL disability (OR = 1.72) and poor treatment compliance (OR = 2.35). CONCLUSION: Positive and negative psychosocial and health-related factors determine the use of Chinese herbal medicine use in Chinese older adults, consistent with the dual-pattern use of Chinese herbal medicine as health supplement and complementary/alternative medicine.

Age Factors↗

Epidemiology of respiratory viruses in patients hospitalized with near-fatal asthma, acute exacerbations of asthma, or chronic obstructive pulmonary disease.

PURPOSE: We compared the prevalence and spectrum of common respiratory viruses among patients with near-fatal asthma, acute exacerbations of asthma, or chronic obstructive pulmonary disease (COPD), and the relation of these findings to acute respiratory symptoms. METHODS: We obtained adequate samples of respiratory secretions from 17 patients hospitalized with near-fatal asthma, 29 with acute asthma, and 14 with COPD. We used a polymerase chain reaction-based method to test for six common respiratory viruses in samples from endotracheal tube aspirates from patients with near-fatal asthma, and from induced sputum specimens from patients with acute asthma or COPD. Respiratory symptoms (runny nose, sore throat, fever, chills, malaise, and cough) were recorded. Quiescent-phase induced sputum specimens were examined from patients who were initially virus positive. RESULTS: Viral nucleic acids were detected in 52% (31/60) of acute-phase specimens and 7% (2/29) of quiescent-phase specimens examined (P <0.001), with similar proportions of virus-positive patients during the acute phase in the three groups: 59% (10/17) of those with near-fatal asthma, 41% (12/29) with acute asthma, and 64% (9/14) with COPD. Picornavirus (47% [n = 8]) and adenovirus (24% [n = 4]) were most commonly identified in near-fatal asthma, whereas influenza virus (36% [n = 5]) predominated in COPD. Virus-positive patients had a significantly increased frequency of runny nose, sore throat, fever, chills, and malaise (odds ratio = 4.1 to 18; P = 0.02 to 0.001). CONCLUSION: Respiratory viruses are associated with hospitalizations for near-fatal asthma, acute asthma, and COPD, with some differences in the spectrum of viruses involved in the different groups of patients. Respiratory viruses are a target for the prevention and perhaps the treatment of these conditions.

Acute Disease↗

Trends and ethnic differences in asthma hospitalization rates in Singapore, 1991 to 1998.

BACKGROUND: A few reports have indicated that asthma hospitalization rates in several countries have stopped rising or started falling in the 1990s. AIM: To describe recent trends and ethnic differences in asthma hospitalization rates in Singapore from 1991 to 1998. METHODS: Asthma hospitalization rates in all hospitals were analyzed by age groups, sex, ethnicity, and individual years, using aggregated data for asthma (ICD-9 493 and ICD-10 J45, J46) from 1991 to 1998, when nationwide data from the Central Claims Processing System were available. RESULTS: Between 1991 and 1998 there were a total of 37,615 hospital admissions for asthma, giving an annual average rate of 17.1 hospital admissions per 10,000 persons. Overall, the rates of asthma hospitalization fell by 28% from 21.7 per 10,000 in 1991 to 15.4 per 10,000 in 1998 (3.5% annually). The trends were broadly based across all age, sex, and ethnic groups. Hospitalizations were more common in boys than in girls aged 0 to 4 (male/female ratio 1.69), but less common in men than women aged 35 to 64 (male/female ratio 0.81). Rates of asthma hospital admissions were higher in Malays (32.8 per 10,000) and Indians (40.8 per 10,000) than Chinese (11.9 per 10,000). CONCLUSIONS: In line with findings from several countries, there have been recent declines in rates of hospital admissions for asthma in Singapore in the 1990s. The declines were broadly based across all population subgroups and parallel previously observed declines in mortality in adults. However, considerable ethnic differences in levels of asthma hospitalization still exist.

Adolescent↗

Preference, need and utilization of mental health services, Singapore National Mental Health Survey.

OBJECTIVE: To ascertain the extent of the community's preference, needs for and utilization of mental health services, and their socio-demographic determinants in the multi-ethnic Asian community in Singapore. The extent to which need, enabling and predisposing factors determine the likelihood to seek professional help was also examined. METHOD: Data were analyzed from the Singapore National Mental Health Survey of 1996, based on a stratified random sample of 2947 Chinese, Malay and Indian subjects of the general population aged 13-64 years. RESULTS: An estimated 37% of the general population indicated they would seek professional help if they experienced a serious emotional or mental problem. Although 16.9% were determined by their high general health questionnaire (GHQ) score to need mental health services, only 2.6% in the population used the services of any professional caregiver. Among persons with high GHQ scores, only 5.9% sought any professional help. Among those with a high GHQ score and who were receptive to professional help, only 10.4% actually sought professional help. General practitioners were the most commonly preferred caregiver (49.3%), and were used by 41.1% of those who sought help. Those who sought professional help were more likely to have a high GHQ score and to be inclined to seek professional help. Malays used mental health services more than Chinese, but they did not show a significantly greater prevalence of high GHQ scores, or a greater preference to seek professional help. Receptivity to professional help, high GHQ score, and Malay ethnicity were independent significant predictors of use of mental health service. CONCLUSION: Need and attitudinal factors predict mental health service utilization, but they still do not explain why a large majority of the population chose not to use mental health services.

Adolescent↗

Prevalence of lens opacity in Chinese residents of Singapore: the tanjong pagar survey.

OBJECTIVE: To determine the prevalence of lens opacity among Chinese residents of Singapore. DESIGN: Population-based, cross-sectional survey. PARTICIPANTS: Chinese men and women aged 40 years or more in Singapore. METHODS: A stratified, clustered, random sampling method, with more weights given to the older age groups, was used to initially select 2000 Chinese persons aged 40 to 79 years from the 1996 electoral register in the Tanjong Pagar district in Singapore. Eligible subjects (n = 1717) were invited for a comprehensive ocular examination at a centralized clinic, after which nonrespondents were examined in their homes with portable instruments. MAIN OUTCOME MEASURES: Lens opacity, as determined clinically at the slit lamp using a modification of the Lens Opacity Classification System III. Prevalence rates were age adjusted to the 1997 Singapore census population. RESULTS: Of the 1232 persons examined (71.8%), 1206 (70.2%) provided lens data for this analysis. The age-adjusted prevalence of any cataract surgery was 5.1% (95% confidence interval [CI], 3.6, 6.5), with similar rates between men and women. The age-adjusted prevalence of specific types of lens opacity was 22.6% (95% CI, 19.8, 25.4) for any nuclear opacity, 23.9% (95% CI, 21.0, 26.8) for any cortical opacity, and 7.0% (95% CI, 5.3, 8.8) for any posterior subcapsular opacity. The overall age-adjusted prevalence of any cataract or cataract surgery was 34.7% (95% CI, 31.5, 38.0), increasing from 7.0% in those 40 to 49 years and to 94.3% in those 70 years and older (P < 0.001, test for trend for age). When the prevalence of distinct types of lens opacity in an eye was considered, the most common was mixed (age-adjusted prevalence, 11.5%, based on right eye data), followed by nuclear only (9.7%), cortical only (8.3%), and posterior subcapsular only (0.6%). For all cataract types, the prevalence was similar in men and women and was higher in persons examined at their homes than in those examined at the study clinic. CONCLUSIONS: These population-based data suggest that cataract is common among adult Chinese residents in Singapore, despite ready access to cataract surgical services. Persons accepting the offer of free eye examinations were less likely to have cataract than those who did not take up this offer.

Adult↗