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Bleeding esophageal varices.

The unresolved issue of the optimal treatment of portal hypertension attests to the disappointments in present treatment. In reality, the disappointments are a result of progressive liver disease, which is not helped and probably deteriorates more rapidly after shunting operations. This dissatisfaction has led some to abandon shunts and to accept a higher incidence or potential for recurrent bleeding after nonshunting operations. The long-term results of splenic artery ligation and perhaps embolization are awaited with interest. Until then, as Conn has said, "We must learn to select better who should be shunted or to shunt better those we select".

Embolization, Therapeutic↗

5-lipoxygenase inhibitors and their anti-inflammatory activities.

A wide variety of agents have been reported as 5-LO inhibitors. The majority of the series appear to be lipophilic reducing agents, including phenols, partially saturated aromatics, and compounds containing heteroatom-heteroatom bonds. Many of these are not selective 5-LO inhibitors, but often affect CO and other LOs as well. In vivo systemic activity for many of these has been, in general, disappointing, probably because of poor bioavailability caused by lipophilicity and metabolic instability (oxidation, and conjugation of phenolic compounds). However, topically a number of agents have shown promise for skin inflammation, with Syntex's lonapalene the most advanced of these. Most results published to date appear more disappointing in the allergy/asthma field. More excitingly, a few structural types are selective 5-LO inhibitors which have shown systemic activity in vivo and in the clinic. Abbott's zileuton (136) appears to be one of the leading compounds in this category, along with other hydroxamates such as BW-A4C (129) from Burroughs-Wellcome. Recent selective non-reducing agents such as Wyeth-Ayerst's Wy-50,295 (143) and the similar ICI compounds such as ICI 216800 (145) also hold promise. The enantiospecific effects of (106) and (145) are especially interesting for the design of new inhibitors. If compounds like these validate the hypothesis that inhibition of 5-LO will have a significant anti-inflammatory effect, a redoubling of effort throughout the industry to find second- and third-generation selective agents may be expected. Part of the difficulty in interpreting and comparing the 5-LO literature is the plethora of test methods and activity criteria. As pointed out in the introduction, inhibition of product release from cells, often stimulated with A23187, has commonly been used to demonstrate 5-LO inhibition. However, this type of assay cannot be assumed to be diagnostic for 5-LO inhibition. Only if specificity for 5-LO product generation and (ideally) activity in cell-free enzymes is also shown should mechanistic interpretations be made. Recently, a new class of compounds was found at Merck which inhibited LT biosynthesis without inhibiting 5-LO, but apparently by a novel, specific mechanism. L-655,240 (169) and L-663,536 (MK-886) (170) were both active in human ISN, with IC50 values in the low micromolar range. Both also orally inhibited GPB (< 1 mg/kg). MK-886 was effective in Ascaris-induced asthma in squirrel monkeys, in rat carrageenan pleurisy, in rat Arthus pleurisy, and (topically) in guinea-pig ear oedema induced by A23187.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗

Continent vesicostomy in the absence of the appendix: three methods in 16 children.

OBJECTIVES: To review our experience with three methods of continent vesicostomy and to examine the morbidity and long-term outcome of each method. In the absence of an appendix, the surgical options for constructing continent vesicostomies include the use of the ureter, retubularized ileum, or stomach, a Benchekroun valve, or creation of a continent stoma from the reservoir itself. METHODS: Between 1984 and 1999, 16 children, 14 with neurogenic bladder, 1 with cloacal malformation, and 1 with valve bladder, required access to their continent reservoir other than the urethra. The appendix was unavailable in all, either because it had been removed surgically at an earlier date or it had been used for an antegrade continent enema procedure. Eighteen continent vesicostomies were performed in 16 children. In 5 children, a Benchekroun valve was constructed. Two were subsequently replaced by tapered small bowel. In 7 children, a segment of small bowel was harvested, retubularized, and reimplanted in the reservoir in a submucosal or seromuscular tunnel. In 6 children, a flap of bowel forming the reservoir was raised, tubularized, and then a Nissen valve was constructed. RESULTS: The early results of the Benchekroun valve were satisfactory; however, the results with long-term follow-up were disappointing because 4 of 5 children developed stomal stenoses and one subsequent valve perforation. One of the 5 children continued to do well 6 years postoperatively. The 7 children in whom a segment of small bowel was retubularized (Monti procedure) continued to do well and to catheterize their stomas without difficulty. At last follow-up, 1 child was awaiting collagen implant of her bladder neck for urinary incontinence. Five of the 6 children with a Nissen valve were doing well 1 to 8 years postoperatively. One child did well initially, but was lost to follow-up 1 year later. CONCLUSIONS: The appendix is the preferred conduit for a catheterizable stoma. In its absence, our experience with the Benchekroun valve was disappointing. The retubularized ileum provided an excellent and reliable alternative to the appendix and is preferable if the bladder capacity is marginal. The Nissen valve constructed out of the reservoir has the advantage of avoiding intraperitoneal dissection and the use of additional small bowel. The two latter methods appear to be reliable in the long-term and are viable options when the appendix is not available.

Adolescent↗

Combination alpha-interferon and lamivudine therapy for alpha-interferon-resistant chronic hepatitis B infection: results of a pilot study.

BACKGROUND/AIMS: Alpha-interferon achieves seroconversion in about one third of naive patients. Attempts to achieve seroconversion in patients who have previously failed alpha-interferon have proved disappointing. Combination chemotherapy (alpha-interferon with a nucleoside analogue) might provide a treatment alternative for these patients. We have undertaken a phase 2 study in 20 patients who had previously failed at least one course of alpha-interferon. The study was designed to assess the safety, tolerability and efficacy of the combination. METHODS: All patients were treated for 16 weeks with alpha-interferon in combination with 12 or 16 weeks of Lamivudine (3'TC). Patients were followed for 16 weeks post-treatment. Pharmacokinetic studies were performed to identify/exclude significant pharmacokinetic drug interaction. RESULTS: The combination was well tolerated, and side-effects of the combination were indistinguishable from the recognised side-effects of alpha-interferon. Pharmacokinetic studies performed on days 1 and 29 did not show any significant interaction. All patients achieved HBV DNA clearance during treatment, but 19 relapsed at the end of treatment. HBeAg/anti-HBe seroconversion was observed for four patients, but was sustained for a single patient (who also had sustained DNA clearance). CONCLUSIONS: Combination therapy with alpha-interferon and lamivudine given for 16 weeks appears safe and is well tolerated. However, for this group of patients who had previously failed interferon monotherapy, the efficacy of combination interferon/lamivudine therapy appears disappointing, and other treatment strategies should be investigated.

Adult↗

Prevention of pre-eclampsia: status and perspectives 2000.

Because pre-eclampsia is a relatively common complication of pregnancy and forms a major cause of maternal, fetal, and neonatal morbidity and mortality, attempts at prevention are justified, but hampered by the fact that as yet no reliable and acceptable screening tests for women at risk are available. Analysis of the many interventions advocated to prevent or delay the onset of pre-eclampsia reveals that dietary calcium supplementation and prophylactic low-dose aspirin treatment have shown promise of efficacy in small randomized, placebo-controlled trials, but the results of large, multicenter trials are generally disappointing. The disappointing results obtained in large, multicenter trials may in part be explained by the lack of strict criteria for inclusion, late initiation of treatment, use of ill-defined end points, different timing of aspirin ingestion, and low patient compliance. Recent evidence that supplementation with vitamins C and E could prevent pre-eclampsia awaits confirmation. Future clinical trials on prevention of pre-eclampsia should be based on results of basic research.

Antioxidants↗

Serial precision of metabolite peak area ratios and water referenced metabolite peak areas in proton MR spectroscopy of the human brain.

The precision of cerebral proton magnetic resonance spectroscopy (MRS) measurements is critical both in the clinical setting and for research purposes. Marshall et al. have recently concluded that "disappointing in vivo repeatability...is likely to limit" the ability of MRS to detect modest changes. We present here a comprehensive study of the precision of short- and long-term metabolite peak area ratios and water referenced metabolite peak areas for long echo time point resolved spectroscopy (PRESS) spectra (repetition time (TR) = 2000 ms, echo time (TE) = 136 ms) acquired from the occipital lobes of normal volunteers and a phantom using a conventional whole body 1.5 T MR system and conventional acquisition and analysis protocols. Short-term in vitro precision determined by five repeat scans on five occasions was excellent as measured by a mean coefficient of variation (NAA/Cho = 1.3%, NAA/Cr + PCr = 1.0%, Cho/Cr + PCr = 1.6%, NAA/H2O = 0.5%, Cho/H2O = 1.2%, Cr + PCr/H2O = 0.8%). Long term in vitro precision using 100 spectra acquired over 2 years was also very good (NAA/Cho = 2.7%, NAA/Cr + PCr = 1.4%, Cho/Cr + PCr = 2.2%, NAA/H2O = 1.5%, Cho/H2O = 2.4%, Cr + PCr/H2O = 1.5%). Short-term in vivo precision determined by five repeat scans in a single scanning session on eight subjects was also excellent (NAA/Cho = 5.2%, NAA/Cr + PCr = 3.0%, Cho/Cr + PCr = 6.6%, NAA/H2O = 1.4%, Cho/H2O = 4.9%, Cr + PCr/H2O = 2.7%) and only worsened slightly for long-term in vivo precision determined by five repeat scans on eight subjects over 3 months (NAA/Cho = 5.2%, NAA/Cr + PCr = 4.8%, Cho/Cr + PCr = 7.7%, NAA/H2O = 2.5%, Cho/H2O = 6.4%, Cr + PCr/H2O = 3.8%). We attribute the excellent precision reported here to the use of highly automated techniques for voxel shimming, water suppression and peak area measurements. These results allow us to repudiate Marshall's assertion regarding disappointing repeatability of in vivo MRS.

Adult↗

Arthroscopic evaluation of anterior cruciate ligament reconstructions.

Fourteen patients who underwent anterior cruciate ligament (ACL) reconstruction, using fascia lata or patellar tendon, were examined arthroscopically at a mean time of 16 months following surgery. The postoperative care and rehabilitation program was standardized for all patients. Eleven of these 14 patients were recalled for a functional evaluation. Nine of these 11 patients were satisfied with the outcome of their reconstruction. Two patients complained of an occasional giving way of the knee. The arthroscopic findings were disappointing. Four patients appeared to have viable ligamentous structures in the intercondylar notch. Four patients had lax ligamentous tissue in the notch. In other cases, the notch was filled with varying degrees of amorphous scar tissue. The tissue was tested by palpation with a probe and with an anterior drawer test applied. The scar tissue did develop tension and give a firm end point to the drawer test. Other arthroscopic findings included instances of Grade II, III, and IV chondromalacia of the articular cartilage, adhesions, and capsular scarring not seen at the time of original surgery. While the patient satisfaction and functional results were generally good, we were disappointed with the arthroscopic findings. Based on the generally poor quality of the reconstructed tissue and the articular cartilage lesions, we have changed our surgical technique and postoperative regime.

Adult↗

The left ventricular resectoscope. A new instrument for the comprehensive resection of the left ventricular outflow tract in hypertrophic obstructive cardiomyopathy (HCOM).

After disappointing results with non-surgical measures there is now a move back towards surgical left ventricular outflow tract resection as a treatment of choice for hypertrophic obstructive cardiomyopathy. The traditional operation presents various technical difficulties and occasionally disappointing results. Using a diathermy loop to resect the hypertrophied outflow tract has provided a much more convenient and reliable technique. This paper describes an instrument incorporating all the features of this technique (Left ventricular resectoscope).

Cardiac Surgical Procedures↗

[Impressions od couples treated with fertilization in vitro of their treatment by the IVF center].

A preliminary study was designed to evaluate, among French couples treated for in vitro fertilization, their feelings about the delivered information on IVF and the degree of satisfaction about their treatment by the center. Anonymous forms were mailed to 3,000 couples, from which 835 were returned on time to be analyzed. Most of the couples expressed their satisfaction. However, 25% were disappointed by their first consultation, too short (14%) or too long to obtain (13%), especially for those treated in a public hospital. One quarter of couples waited for more than six months before their first cycle, more often in public practice than in private one, and 80% found this time lapse too long. One third of the couples changed of unit, 62% of them because of disappointment, mostly because of their relationship with the medical team, and only 20% because of poor results. Two thirds of the couples found IVF had repercussions on their couple's life, negatively in 31% of the cases. This percentage was higher for those with unsuccessful IVF (45%) than for those who got a pregnancy (22%). Information on IVF was judged as satisfactory only for two thirds of the couples, for any kind of information, and less than half of men were told how the inseminated semen quality was. Moreover, only 57% of the couples found the information reassuring. Local conditions for semen collection were judged to be bad by 30% of the men. Finally, this study showed that efforts still have to be made by units to better treat and inform IVF couples. It also seems necessary to undertake a prospective and more detailed study to better investigate the degree of satisfaction and its parameters.

Adult↗

Importance of attributions as a predictor of how people cope with failure.

This study examined the extent to which causal attributions were predictive of depressed mood in college students who experienced a negative event. In a replication and extension of a study by Metalsky, Abramson, Seligman, Semmel, and Peterson (1982), we evaluated students' attributional style and their attributions for an examination performance in the college classroom. Additionally, an indirect probe was used to assess unsolicited attributions. Subjects were asked about their plans to prepare for the next examination in order to test for the motivational deficits predicted by the reformulated learned helplessness (RLH) model. Unlike Metalsky et al., attributional style did not predict depressed mood following a disappointing examination performance. Attributions for the particular examination performance were predictive of depressed mood for students who were disappointed in their examination performance. Few subjects, 31%, gave attributions in response to the indirect probe, and there was no support for the prediction that unexpected negative events would lead to subjects' making more attributions. Internal, stable, and global attributions for poor examination performance resulted in students making more plans to study for the next examination, a finding contrary to what is predicted by the RLH model.

Achievement↗

Rescue of hybrid sterility in crosses between D. melanogaster and D. simulans.

The genetic analysis of reproductive isolation between species of Drosophila has now reached the resolution necessary to start answering one of the fundamental questions of evolution: what is the genetic basis of species differences? A.H. Sturtevant, one of the founders of Drosophila genetics, was fascinated by this question and thought he had found a way to analyse it when he realized that 'Drosophila melanogaster' was actually two species: D. melanogaster and D. simulans. By passing genes between these two species he hoped to investigate their genetic differences directly. No doubt he was disappointed to find that the D. melanogaster/D. simulans hybridization resulted only in unisexual sterile hybrids, a disappointment appreciated all the more by modern evolutionary biologists. Seventy-five years after Sturtevant's description of D. melanogaster/D. simulans hybrid sterility, we have discovered a strain of D. simulans that produces fertile female hybrids in crosses with D. melanogaster. Our discovery promises to bring the enormous resolution of D. melanogaster genetics to the study of reproductive isolation and species differences.

Animals↗

Weight loss expectations in patients with binge-eating disorder.

OBJECTIVE: To study weight loss expectations in patients with binge-eating disorder and to examine whether expectations differed by sex and motivation for treatment. RESEARCH METHODS AND PROCEDURES: One hundred and thirty patients (104 women and 26 men), aged 23 to 61 (mean age, 43.0 years), with BED completed a measure of desired weights that included their dream weight, happy weight, acceptable weight, and disappointed weight. In a structured interview, participants were asked their primary motivation for seeking treatment (appearance or health) and their lowest adult weight (LAW). RESULTS: The BED participants reported weight loss expectations that far exceeded expert and governmental guidelines. In this sample, desired dream body mass index (BMI), happy BMI, and acceptable BMI averaged reductions in current weight of 36%, 29%, and 23%, respectively. Even the "disappointed" BMI was an average 14% reduction in current weight, and was 1.5 to 3 times greater than the expert recommendation (5% to 10%). Comparisons of desired weights were significantly different for women and men, whereas percent reductions from current weight were not. Although weight goal expectations were significantly lower for those motivated by appearance, compared with those motivated by health, percent reductions for current weight were not. Desired dream weight correlated with reported LAW, and the mean difference between these weights was not significant. DISCUSSION: These findings suggest that patients with BED have weight loss expectations that far exceed expert and governmental guidelines and that these expectations do not differ by sex or motivation for seeking treatment. One possible explanation for these unrealistic desired weights may be the patients' recollections of their LAWs.

Adult↗

Biological purging of breast cancer cell lines using a replication-competent oncolytic virus in human stem cell autografts.

Autologous hematological stem cell transplantation (ASCT) is used for the treatment of many hematological and several solid cancers. ASCT, however, has proven disappointing as a therapeutic strategy for breast cancer. Our group and others have previously shown that breast cancer micrometastases found in patients' apheresis products (APs) predict shorter progression-free and overall survival. The implications of this finding are twofold: (i) contaminating tumor cells (CTCs) in AP reflect a higher systemic disease burden and/or (ii) reinfused CTCs contribute to relapse/progressive disease. To date, purging strategies have been disappointing. We have previously demonstrated the oncolytic properties of reovirus in in vitro, in vivo and ex vivo systems. In the present study, we tested the hypothesis that reovirus purges CTCs in a breast cancer cell line purging model. Reovirus-infected human breast cancer cell lines (HTB 133, HTB 132, SKBR3 and MCF7) exhibited cell death within days. Admixtures of AP with cells from breast tumor cell lines, which were then exposed to reovirus, showed complete purging of CTCs (assessed via flow cytometry/tumor cell outgrowth analysis) without deleterious effect on CD34+ cells. Our results provide preclinical support for the ex vivo use of reovirus as a purging modality for breast cancer during ASCT.

Antigens, CD34↗

Re-auditing a regional lithotripsy service.

OBJECTIVE: To assess, in a repeat audit of a regional lithotripsy service, whether changes implemented after a regional audit in 1994 (which showed disappointing results from shock wave lithotripsy, attributable to both poor patient selection and an inadequate fixed-site lithotripter) have had any effect. PATIENTS AND METHODS: A data-collection sheet was devised to gather information on the site, size and number of stones treated, together with information on the lithotripsy treatment and outcome. Patients selected for the audit were the first 50 new patients treated with lithotripsy at each centre in 1999. As only one hospital has a fixed-site lithotripsy machine, the results of mobile lithotripsy were grouped by machine for analysis. RESULTS: There was an overall improvement in patient selection from the previous audits. Few stones of > 16 mm or < 4 mm were treated. Two units treated more ureteric stones, thought to reflect first the influence of a fixed-site lithotripter, and second a willingness to insert a ureteric stent and await the next mobile lithotripter visit. The stone free rates were all disappointingly low (16.7-26.7%) but the results improved when fragments of < 4 mm were included as "successful" giving an "overall success rate" of 45.9-66.7%. The unit with a fixed-site lithotripter appeared to perform better (two-thirds successful) than the mobile machines (Modulith SLX, 51%; Modulith SLK, 46%). One centre visited by both mobile machines had a success rate of 65% but a high rate of auxiliary procedures (35% vs 16-19% vs the fixed-site). CONCLUSION: Although these results show some improvement in patient selection for our regional lithotripsy service, stone-free and success rates are poorer than those reported elsewhere. This may reflect the modern lithotripsy machines that allow day-case treatment with minimal analgesia, and confirms reports by other authors who encourage a re-examination of success rates of shock wave lithotripsy.

Humans↗

Pathophysiology of septic shock and multiple organ dysfunction syndrome and various therapeutic approaches with special emphasis on immunoglobulins.

The pathophysiology of sepsis and septic shock is dominated by an imbalance of pro- and antiinflammatory mediators produced by toxin-activated inflammatory cells. Both the overshooting of proinflammatory mediators as well as the development of immune paralysis are deleterious to the patient. Available therapeutic approaches with monoclonal antibodies and antagonists targeted against toxins and mediators have focused mainly on inhibition of overshooting proinflammation: the results, however, have been disappointing. Due to these disappointing results of specific antiinflammatory regimens, adjuvant treatment of sepsis and septic shock with intravenous immunoglobulins (IVIgs) has regained interest although this indication has at best been validated in part. Likely beneficial mechanisms of action may include the improvement of serum bactericidal activity due to neutralizing and opsonizing IgG and IgM antibodies as well as stimulation of phagocytosis and neutralization of bacterial endo- and exotoxins; another attractive mode of action may represent Ig-mediated modification and specific suppression of proinflammatory cytokine release from endotoxin- and superantigen-activated blood cells. For the total group of patients with sepsis and septic shock, a reduction in mortality by IVIg could not be documented; however, in the SBITS study with 653 patients included, a moderate improvement in sepsis morbidity and multiple organ dysfunction syndrome was demonstrated. In defined sepsis sub-groups, a reduction in mortality by IVIg has been seen in each small, not yet confirmed trial. Thus, IVIg is not a magic bullet of sepsis treatment, but it may reduce morbidity and thereby may be useful in the therapeutic mosaic of sepsis treatment.

Animals↗

Prediction and prevention of pregnancy-induced hypertensive disorders.

Because hypertensive disorders complicating pregnancy are common and constitute a leading cause of maternal, fetal and neonatal morbidity and mortality, prevention attempts appear to be justified. Primary prevention is only possible by avoiding pregnancy. Secondary prevention requires identification of patients at risk. A large number of predictive methods have been published and the majority appear to be of no or limited value. At present only the determination of inactive urinary kallikrein and uteroplacental colour-pulsed Doppler velocimetry show promise and require further assessment. Analysis of the many interventions advocated for prevention of pre-eclampsia reveals that only dietary calcium supplementation and prophylactic low-dose aspirin have shown promise of efficacy in small controlled clinical trials, but the results of large, multicentre trials are disappointing. The disappointing results obtained in large, multicentre trials may be explained, at least in part, by the lack of strict eligibility criteria and end-points and by low patient compliance. Prophylactic low-dose aspirin is recommended in women at high risk because it is associated with a moderate reduction in risk, may reduce the severity of pre-eclampsia if it develops and appears to be safe for mother and infant. The present data do not support any prophylactic intervention in pregnant women at low or medium risk.

Antihypertensive Agents↗

The use of methotrexate, colchicine, and other immunomodulatory drugs in the treatment of primary biliary cirrhosis.

Primary biliary cirrhosis (PBC) is an immunologically mediated disease in which activated T lymphocytes attack and destroy epithelial cells in the small intralobular bile ducts of genetically susceptible patients. This article reviews the results of treatment of PBC with immunomodulatory agents. Results with drugs such as glucocorticoids, azathioprine, and chlorambucil have been disappointing because of either limited efficacy (azathioprine), toxicity (chlorambucil), or both (glucocorticoids). Colchicine improved tests of liver function in three prospective studies and was associated with improved survival for up to 4 years. However, survival benefits were lost at 8 years. Colchicine appears to slow the rate of progression of PBC but not to stop it. Preliminary results suggest that colchicine may have synergistic effects if used together with ursodeoxycholic acid, particularly in patients who are only partially responsive to ursodeoxycholic acid. Results with cyclosporine have been disappointing because of limited efficacy and predictable toxicity. The modest improvement in tests of liver function and survival are counterbalanced by the development of hypertension in some and worsening renal function in most. There is little beneficial effect on symptoms or histology. Results with methotrexate are promising. There are improvements in symptoms and tests of liver function that are equal to those seen with ursodeoxycholic acid and significant improvement in liver histology. Some patients, particularly those with striking inflammation and granulomas in portal triads, appear to have achieved sustained remission while on methotrexate. The effects of methotrexate are additive to those of ursodeoxycholic acid in patients whose blood tests have responded only partially to ursodeoxycholic acid. The most effective treatment of PBC will most likely use a combination of drugs such as ursodeoxycholic acid, colchicine, and methotrexate.

Adjuvants, Immunologic↗

Emotions generated by meat and other food products in women.

Eating behaviour depends partly on food preference, which is itself determined by different types of emotions. Among the emotions generated by food, disgust with red meat is common in women and can lead to reduced meat consumption. We tested the hypothesis that low meat intake is related to different negative emotions towards meat but does not affect the emotions expressed towards other food categories. Food intake of sixty women was followed throughout each day for 1 week and allowed us to assign women to two groups (low v. high meat-eating women). They were then invited to assess the intensity of twenty-six emotions described by words and induced by thirty food pictures. We determined the number of necessary dimensions to describe the space created by the twenty-six words. The results showed differences in emotions between the low and high meat-eating women. As expected, there were overall differences in the emotions generated by the thirty food pictures. Six clusters of emotions were necessary and sufficient to summarise the emotional space. These dimensions were described by 'disappointment', 'satisfaction', 'guilt', 'doubt', 'amused' and 'indifference'. As expected, the low meat-eating women felt more 'disappointment', 'indifference' and less 'satisfaction' towards meat than did the high meat-eating women. However, the low meat-eating women also stated other negative emotions such as 'doubt' towards some starchy foods. The only foods that they liked more than high meat-eating women were pears and French beans. In conclusion, low meat consumption was associated with specific negative emotions regarding meat and other foods.

Adolescent↗