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At least 19 recordsLinked to original sources
PubMed2000

Reperfusion injury significantly impacts clinical outcome after pulmonary transplantation.

BACKGROUND: Reperfusion injury after pulmonary transplantation can contribute significantly to postoperative pulmonary dysfunction. We hypothesized that posttransplantation reperfusion injury would result in an increase in both in-hospital mortality and morbidity. We also hypothesized that the incidence of reperfusion injury would be dependent upon the cause of recipient lung disease and the interval of donor allograft ischemia. METHODS: We performed a retrospective study of all lung transplant recipients at our institution from June 1990 until June 1998. One hundred patients received 120 organs during this time period. We compared two groups of patients in this study: those experiencing a significant reperfusion injury (22%) and those who did not (78%). RESULTS: In-hospital mortality was significantly greater in patients experiencing reperfusion injury (40.9% versus 11.7%, p < 0.02). Posttransplantation reperfusion injury also resulted in prolonged ventilation (393.5 versus 56.8 hours, p < 0.001) and an increased length of stay in both the intensive care unit (22.2 versus 10.5 days, p < 0.01) and in the hospital (48.8 versus 25.6 days, p < 0.03). The incidence of reperfusion injury could not be attributed to length of donor organ ischemia (221.5 versus 252.9 minutes, p < 0.20). The clinical impact of reperfusion injury was significantly greater in patients undergoing transplantation for preexisting pulmonary hypertension (6/14) than those with chronic obstructive pulmonary disease or emphysema alone (6/54) (42.9% versus 11.1%, p < 0.012). CONCLUSIONS: Clinically significant pulmonary reperfusion injury increased in-hospital mortality and morbidity resulting in prolonged ventilation, length of stay in the intensive care unit, and cost of hospitalization. The incidence of reperfusion injury was not dependent upon the duration of donor organ ischemia but increased with the presence of preoperative pulmonary hypertension. These findings suggest that recipient pathophysiology and donor allograft quality may play important roles in determining the incidence of reperfusion injury.

Female↗
PubMed2000

Clinical impact of hypnotic-titration guidelines based on EEG bispectral index (BIS) monitoring during routine anesthetic care.

STUDY OBJECTIVES: To examine the impact on perioperative care of routine Bispectral Index (BIS) monitoring during general anesthesia throughout an entire operating room (OR) suite. DESIGN: Open, observational trial with retrospective analysis of guideline performance. Data were analyzed from 1,552 adult patients receiving general anesthesia with surgical times of at least 1 hour and who were extubated by postanesthesia care unit (PACU) discharge. Staff were trained using a simple decision matrix, which integrated BIS titration goals with anesthetic management. Unmonitored patients were compared to either BIS-monitored patients or to performance subgroups based on BIS measurements recorded during anesthetic maintenance ("deep", BIS < 50; "target", 50-65; "light", >65). SETTING: Large, urban academic/trauma center. MEASUREMENTS AND MAIN RESULTS: Demographic profiles of all groups and subgroups were similar. Anesthetic emergence, recovery times, and volatile drug use were significantly shortened or reduced only when BIS values were maintained between 50 and 65. Extubation time from end of surgery decreased by 2.1 minutes from 5.7+/-7 (37%); OR exit time decreased by 2.2 minutes from 9.3+/-6 (24%); eligibility for phase 1 PACU discharge decreased by 4 minutes from 22+/-42 (23%); and actual PACU discharge decreased by 15 minutes from 130+/-78 (7%). PACU extubation frequency decreased from 6.9% to 2.6%. Modest decreases in total intraoperative drug use were noted with an increase in PACU analgesic administration. CONCLUSIONS: Routine application of BIS monitoring throughout an OR suite impacted clinical outcome only if guideline targets were met. BIS values within the last 30 minutes of surgery were not predictive of emergence or recovery. Hypnotic maintenance at BIS < 50 did not confer any clinical advantage over unmonitored cases. Anesthetic maintenance at BIS values between 50 and 65 was associated with shortened emergence and recovery from general anesthesia.

Adult↗
PubMed2005

Clinical impact associated with corrected results in clinical microbiology testing.

We developed a strategy to determine the clinical impact associated with errors in clinical microbiology testing. Over a 9-month period, we used a sequential three-stage method to prospectively evaluate 480 consecutive corrected microbiology laboratory reports. The three stages were physician review of the corrected report, medical record review, and interview with the clinician(s) taking care of the patient. Of the 480 corrected reports, 301 (62.7%) were ruled out for significant clinical impact by physician review and an additional 25 cases (5.2%) were ruled out for clinical impact by medical record review. This left 154 cases (32.1%) that required clinician interview to determine clinical impact. The clinician interview revealed that 32 (6.7%) of the corrected reports were associated with adverse clinical impact. Of these 32 cases, 19 (59.4%) involved delayed therapy, 8 (25.0%) involved unnecessary therapy, 8 (25.0%) were associated with inappropriate therapy, and 4 (12.5%) were associated with an increased level of care. The laboratory was entirely responsible for the error in 28 (87.5%) of the 32 cases and partially responsible in the other 4 cases (12.5%). Twenty-six (81.3%) of the 32 cases involved potentially preventable analytic errors that were due to lack of knowledge (cognitive error). In summary, we used evaluation of corrected reports to identify laboratory errors with adverse clinical impact, and most of the errors were amenable to laboratory-based interventions. Our method has the potential to be implemented in other laboratory settings to identify and characterize errors that impact patient safety.

Bacteria↗
PubMed2000

Technical aspects and clinical impact of hematopoietic progenitor subset quantification.

As high-dose therapy for malignancies is now being applied to newly diagnosed patients as adjuvant therapy, it has become a requirement that quality and safety assessment of hematopoietic stem cell grafts be evidence-based. This process has developed a new institution in medicine, the stem cell laboratory. In most cases this speciality has evolved from or within hematological research laboratories. However, the increased routine technologies applied in quality evaluation, ex vivo manipulation and safety assessment in stem cell handling naturally places this activity in transfusion medicine. Multiparametric flow cytometry can identify progenitor subsets in normal human bone marrow and peripheral blood, and such subset quantification has been used retrospectively to predict three-lineage engraftment following high-dose therapy for malignancies. Published single center data have suggested an impact on clinical outcome, and a standardized technique for subset enumeration needs to be established before prospective multicenter trials can be initiated to document the prognostic value of such quality assessment in autografting. Based on experiences of CD34 enumeration, which we consider to be the first step in quality assessment of hematopoietic stem cell grafts, this review discusses flow cytometry subset identification by lineage-specific differentiation markers, stromal-dependent adherence molecules, and regulatory growth factor receptors from a technical point of view. The aim of this review is:To recommend a simple method based on the experiences of the Nordic workshop III on subset identification; To present new molecular genetic-based methods for future use in quality assessment; and To propose new endpoints necessary for validation of the likely clinical impact of subsets in prospective trials. As sample differences between blood and marrow result in technical difficulties, this review only focuses on the methodology of identifying subsets in blood and leukapheresis products. Methods for subset analysis in diagnostic bone marrow samples will be covered in a forthcoming review.

Antigens, CD34↗
PubMed1990

Doppler echocardiography in aortic stenosis: feasibility and clinical impact.

The clinical utility of Doppler echocardiography for the assessment of aortic stenosis was prospectively studied in 425 consecutive patients referred to the echocardiography laboratory over 1 year with the clinical diagnosis of aortic stenosis. Optimal peak Doppler velocities were obtained in 405 (95%) patients of all ages. In 108 patients, the severity of aortic stenosis as determined by subsequent cardiac catheterization was compared with that found by Doppler assessment. Categorization of severity was concordant in 8 (89%) of 9 cases of mild aortic stenosis and in 28 (78%) of 36 cases of severe aortic stenosis, but there was considerable diagnostic overlap in cases of moderate stenosis. Forty-nine patients with mild aortic stenosis as determined clinically had moderate or severe stenosis as assessed by Doppler; 7 (14%) of these patients underwent subsequent replacement of the aortic valve. Increased aortic velocity, as determined by Doppler, was associated with a significant incidence of subsequent (mean follow-up period, 22 months) cardiac events (cardiac death, aortic valvar replacement, New York Heart Association functional class III or IV). Patients with mild aortic stenosis as assessed by Doppler (peak aortic velocity less than 2.5 m/sec) had greater than 95% event-free survival at 1 year and rarely required cardiac catheterization. Conversely, only 45% of patients with severe aortic stenosis as determined by Doppler were free of a cardiovascular event at 1 year. Although the noninvasive assessment of aortic stenosis should ideally include determination of the area of the aortic valve and the mean aortic gradient by Doppler echocardiography, this is not always possible. Prognostic information derived from peak aortic velocity alone is clinically useful. It has the additional advantage that it is much less laborious and time-consuming to obtain and is obtainable in almost all (99%) patients.

Aged↗
PubMed1998

Onchocercal dermatitis: clinical impact.

The clinical features of onchocercal dermatitis include itching, papular and papulomacular rash, skin atrophy and depigmentation. The results of a multi-country study have shown that > 30% of the population in communities where onchocerciasis is endemic have onchocercal dermatitis. The most troubling symptom suffered by those affected was itching and this was closely related to reactive onchocercal dermatitis (acute papular, chronic papular and/or lichenified lesions). Reactive onchocercal dermatitis and troublesome itching were common in all age-groups and were an important cause of stigma in most endemic communities, those affected suffering from poor self-esteem. Concern about onchocercal depigmentation varied between study sites and subjects.

Adolescent↗
PubMed2025

Real-world clinical impact of plasma cell-free DNA metagenomic next-generation sequencing assay.

OBJECTIVE: To describe the real-world clinical impact of a commercially available plasma cell-free DNA metagenomic next-generation sequencing assay, the Karius test (KT). METHODS: We retrospectively evaluated the clinical impact of KT by clinical panel adjudication. Descriptive statistics were used to study associations of diagnostic indications, host characteristics, and KT-generated microbiologic patterns with the clinical impact of KT. Multivariable logistic regression modeling was used to further characterize predictors of higher positive clinical impact. RESULTS: We evaluated 1000 unique clinical cases of KT from 941 patients between January 1, 2017-August 31, 2023. The cohort included adult (70%) and pediatric (30%) patients. The overall clinical impact of KT was positive in 16%, negative in 2%, and no clinical impact in 82% of the cases. Among adult patients, multivariable logistic regression modeling showed that culture-negative endocarditis (OR 2.3; 95% CI, 1.11-4.53; P .022) and concern for fastidious/zoonotic/vector-borne pathogens (OR 2.1; 95% CI, 1.11-3.76; P .019) were associated with positive clinical impact of KT. Host immunocompromised status was not reliably associated with a positive clinical impact of KT (OR 1.03; 95% CI, 0.83-1.29; P .7806). No significant predictors of KT clinical impact were found in pediatric patients. Microbiologic result pattern was also a significant predictor of impact. CONCLUSIONS: Our study highlights that despite the positive clinical impact of KT in select situations, most testing results had no clinical impact. We also confirm diagnostic indications where KT may have the highest yield, thereby generating tools for diagnostic stewardship.

Humans↗
PubMed1985

Clinical impact of rapid susceptibility testing.

The clinical impact of susceptibility testing in general, and rapid same-day susceptibility tests in particular, was assessed from two perspectives: does the performance of susceptibility testing in the laboratory influence the clinical use of antibiotics? Does laboratory susceptibility testing affect the outcome of patients with infectious diseases? The following conclusions were derived from this investigation. In vitro susceptibility testing does significantly influence antibiotic usage, but it is difficult to demonstrate a direct relationship between the results of the susceptibility tests and disease outcome. There is little objective evidence to support the contention that rapid susceptibility tests have a greater clinical impact than traditional overnight procedures. Additional studies directed at addressing this issue are clearly necessary, however; in the absence of such studies, routine performance of same-day susceptibility testing should be considered only if the cost of such testing is less than the cost of overnight procedures, or if cost is not a limiting consideration.

Anti-Bacterial Agents↗
PubMed2006

Detection of hepatic portal venous gas: its clinical impact and outcome.

The clinical impact and outcome of a rare radiographic finding of hepatic portal venous gas (HPVG) as well as the effectiveness of computed tomography (CT), CT scanogram, and conventional radiography in the detection of HPVG were retrospectively analyzed. CT scans, CT scanogram, and plain film radiographs of 11 patients with HPVG were reviewed and compared with their medical records and surgical and pathology reports. Eight of the 11 patients underwent plain film radiographs 1 day before or after the CT scan. HPVG was detected at CT in all 11 patients, on CT scanogram in three (3 of 11, 27.3%), and on plain films in one (one of eight, 12.5%). In nine of 11 patients (81.8%), CT revealed an associated pneumatosis intestinalis. In six of the 11 patients (54.6%), acute mesenteric ischemia was the underlying disease for HPVG. Seven patients (63.6%) underwent emergency exploratory laparotomy. The mortality rate for HPVG alone was 27.3% (3 of 11) and for HPVG related to mesenteric bowel disease 50% (three of six). Acute mesenteric ischemia is the most common cause of HPVG, which continues to have a predictably higher mortality. CT is superior to CT scanograms and radiographs in the detection of HPVG and its underlying diseases and, therefore, should be used as the primary diagnostic tool.

Aged↗
PubMedDate not supplied

Assessing the clinical impact of a predictive system in severe head injury.

Many computer-assisted diagnostic or prognostic systems have been described in the literature, but as yet such systems have had little impact upon routine clinical practice. There are many possible explanations for the limited success which these systems have enjoyed, but one of the most significant must be the dearth of well-designed and carefully executed trials to assess their performance. Many evaluations only address the scientific question of whether the diagnoses or prognoses are accurate; they stop short of answering the crucial pragmatic question of whether the system benefits patients, i.e. is clinical care improved by the use of such a system? This brief paper describes a predictive system in severe head injury which has been developed by an international group based in the Institute of Neurological Sciences at the Southern General Hospital, Glasgow. The various steps involved were first the establishment of a clinical databank according to a strict protocol and with carefully designed scales to quantify the impairment of consciousness and outcome, the development of prognostic models relating outcome to initial severity, the comparison of the performance of this model with predictions made by clinicians, and finally a multi-centre prospective trial assessing the clinical impact of the system. The results of this trial are not yet available, but a consideration of the design of the trial raises important points which are relevant to many other clinical fields where 'decision aids' need to be evaluated.

Craniocerebral Trauma↗
PubMed2004

Clinical impact of endoscopic ultrasonography on the management of malignancies.

BACKGROUND & AIMS: There are limited data evaluating the clinical impact of endoscopic ultrasonography (EUS). We assessed the impact of EUS on management of known or suspected malignancies. METHODS: Physicians requesting EUS were contacted before the examination and asked: "How would you manage this patient if EUS were not available?" Pre-EUS responses were recorded on standardized forms, and compared with management recommendations as determined by the same requesting physician after EUS. Endosonographers performing the study were blinded to the pre-EUS responses. RESULTS: Responses were obtained from requesting physicians before and after EUS in 90 patients. Requesting physicians were composed of surgeons (33%), non-EUS-performing gastroenterologists (58%), oncologists (3%), internists (4%), and a pulmonologist (1%). After EUS, referring clinicians altered management plans in 46 of 90 patients (51%). By anatomic site, management changes occurred in 12 of 22 patients (56%) undergoing esophageal EUS, 9 of 15 (60%) undergoing gastric EUS, 21 of 43 (49%) undergoing pancreatic EUS, and 4 of 10 (40%) undergoing rectal EUS. There were no significant differences in the frequency of post-EUS management changes with respect to examination site (P = .76). EUS fine-needle aspiration (FNA) altered management in 9 of 20 (45%) patients. Management changes involved less complex or decreased risk-associated approaches in the majority (70%), and included 14 of 50 (28%) patients in whom surgical procedures were no longer planned. CONCLUSIONS: Based on EUS examination findings, clinicians requesting EUS alter patient management in one half of cases, and more often pursue a less-complicated approach. EUS substantially impacts clinical care, and should be used in appropriate settings to guide patient management.

Adult↗
PubMed2005

Prospective study of the clinical impact of EUS.

BACKGROUND: Studies on the clinical impact of EUS are lacking. The aim of this study was to examine the impact of EUS on the management plans by referring doctors and patient outcomes. METHODS: Consecutive patients undergoing EUS between August 2002 and June 2004 were prospectively studied. Referring doctors were given a pre-EUS questionnaire that asked about provisional diagnosis and management plan. A post-EUS questionnaire was sent 6 weeks after the procedure. RESULTS: A total of 330 patients were examined, and completed questionnaires were received in 70%. EUS-guided FNA was performed in 69 (30%) patients. EUS resulted in a change in diagnosis and management in 26% and 48% of cases, respectively. Thirty-nine of the latter patients (33%) avoided unnecessary surgery. In 50% of cases, additional investigations were avoided. Doctors reported EUS as very or moderately useful in 210 patients (91%). Doctors of 223 patients (97%) reported that they would use EUS again. CONCLUSIONS: The use of EUS had a significant clinical impact on patients. EUS resulted in a change of diagnosis in a fourth of patients and a change in management in half of patients studied.

Adult↗
PubMed2004

Assessment of clinical impact of endoscopic ultrasound on rectal cancer.

INTRODUCTION: Endoscopic ultrasound (EUS) with fine needle aspiration (FNA) is the most accurate imaging modality for locoregional staging of rectal cancer. It remains unclear whether this technology impacts the clinical outcome of patients with this malignancy. The aim of this study was to assess the impact of EUS FNA by comparing the clinical outcomes of patients with rectal cancer before and after the introduction of EUS in our institution. METHODS: Outcomes of patients with de novo nonmetastatic rectal cancer seen in 1999 without EUS evaluation (non-EUS control group) were compared to patients evaluated in 2000/2001 with EUS FNA (EUS group). RESULTS: Outcomes of 68 (non-EUS control group) and 73 (EUS group) patients with nonmetastatic rectal cancer were compared. Among patients with advanced T or N stage, adjuvant therapy was administered to 45 patients (84.9%; preoperative to 31 (58.5%) patients and postoperative to 14 (26.4%)) in the EUS group; adjuvant therapy was administered to 37 patients (78.7%; preoperative to 7 (14.9%) patients and postoperative to 30 (63.8%)) in the non-EUS group. Cox proportional hazards demonstrated EUS FNA to be associated with reduced tumor recurrence risk, hazard ratio, 0.72 (95% CI: 0.52-0.97, p= 0.03). CONCLUSIONS: EUS staging of rectal cancer appears to facilitate appropriate employment of preoperative neoadjuvant therapy in those patients with advanced disease. EUS use is associated with a recurrence-free survival advantage in patients, supporting its routine use in rectal cancer staging.

Female↗
PubMedDate not supplied

Midterm clinical impact versus procedural success of balloon angioplasty for pulmonary artery stenosis.

The objective of this study was to determine the procedural success rate of balloon angioplasty for branch pulmonary artery stenosis in terms of its clinical impact on the subsequent management of these patients. Most previous studies of balloon angioplasty have concentrated on the initial success rate (50-60%), complications (6-10%), recurrence rate ( approximately 15%), and technical issues. A favorable clinical impact was noted in only 35% of patients. Over a 3-year period (March 1990 to March 1993), 32 patients (17 boys, 15 girls) underwent 34 balloon angioplasty procedures. Their mean age at dilation was 7.6 +/- 4.3 years (range 1.1-19.0 years). Postoperative tetralogy of Fallot and tetralogy of Fallot with pulmonary atresia were the most frequent cardiac lesions (44%). The procedures were "technically" successful in 56% (19 of 34) of balloon dilations on the basis of at least two of the following criteria: an increase of >50% of the predilation diameter; an increase of >20% in the relative flow to the affected lung by radioisotope study; or a decrease in the systolic right ventricular/aortic pressure ratio from 85-100% to <60%. Twelve percent of the patients had transient complications (two deep vein thromboses, one unilateral pulmonary edema, and one pneumothorax). In 17 of 19 (89%) of the patients there was a favorable clinical impact on their subsequent care as based on one of the following criteria: resolution of the stenosis and avoidance of surgical intervention (n = 14); optimization of future surgical procedure (n = 3); reduction in right ventricular pressure to <60% of aortic pressure (n = 13). Five patients who had unsuccessful balloon angioplasty and one with initially successful balloon angioplasty later underwent endovascular stent placement, which also favorably influenced their clinical status. The success rate of balloon angioplasty for branch pulmonary artery stenosis, when measured by strict procedural criteria, is accompanied by a favorable clinical impact in more than 50% of patients. Hence this procedure should be the initial therapeutic modality in this setting despite the relatively high transient complication rate. The use of endovascular stents probably increases the favorable clinical impact.

Adolescent↗
PubMed2005

Adverse reactions related to drugs for headache treatment: clinical impact.

OBJECTIVE: To assess the clinical impact of adverse reactions related to drugs for primary headache treatment. METHODS: We examined the adverse reactions to 360 medications prescribed by the specialists of the Headache Centre of the University of Modena and Reggio Emilia to 256 consecutive outpatients (214 female, 42 male; mean age: 38.88 +/- 14.06 years; range 10-72 years). Adverse reactions were reported by patients during scheduled follow-up visits, classified by specialists and reassessed by a clinical pharmacologist. RESULTS: Adverse reactions with a causal relationship classified as definite/probable/possible were 202 (56%): 62% (80/129) were due to acute treatments and 53% (122/231) to prophylactic treatments (chi2 test, P = 0.115 ns). More than 90% of the adverse reactions were of limited intensity [mild (58%) or moderate (36%)]. Only 5% were severe, and two reactions (1%) were serious. The most affected apparatus was the nervous system (41%). Of these adverse reactions, 43% caused the discontinuance of the treatment, especially of prophylaxis (54%). Patients evaluated 70% of the medications as effective, but, at the same time, they considered most of the adverse reactions (69%) unacceptable. CONCLUSION: Adverse reactions related to headache medications have a strong impact on patients' management, even if their real intensity and severity are usually very limited. Drugs for headache treatment are still far from being ideal drugs. To prevent the discontinuance of effective medications, the physician, prior to prescribing, should assess, together with the patient, the acceptability of the more common adverse drug reactions.

Adolescent↗
PubMed1988

Preadmission screening of Medicare patients. The clinical impact of reimbursement disapproval.

The clinical impact of a statewide Medicare preadmission certification program was assessed with a retrospective survey of Connecticut physicians. In a three-month period, only 100 (0.37%) of 28,450 Medicare admission requests were disapproved for reimbursement. Following disapproval, 22 patients were admitted immediately, 44 received outpatient care, and eight additional outpatients were not evaluated or treated. The remaining 26 patients subsequently were admitted with preadmission approval due to changed clinical condition or failed outpatient plan. Although some patients had minor problems that their physicians believed would have been avoided by immediate admission, no severe morbidity resulted from admission delay. Many physicians expressed concern about preadmission certification program-related patient anxiety and inconvenience. Although this limited survey provides preliminary evidence that preadmission certification programs can be implemented without major deleterious short-term medical effects, continued monitoring of physicians and patients involved in disapproved admissions is necessary to evaluate potential medical and psychosocial problems.

Adult↗
PubMed2001

Clinical impact of endoscopic ultrasound-guided fine needle aspiration biopsy in patients with upper gastrointestinal tract malignancies. A prospective study.

BACKGROUND AND STUDY AIMS: Several studies have evaluated the accuracy of endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) in the upper gastrointestinal tract, but so far no studies have specifically evaluated the clinical impact of EUS-FNAB in upper gastrointestinal tract cancer patients. In this consecutive and prospective study, EUS-FNAB was only performed if a positive malignant finding would change the therapeutic strategy. PATIENTS AND METHODS: Between 1997 and 1999, 307 consecutive patients were referred for EUS with a diagnosis or strong suspicion of esophageal, gastric or pancreatic cancer; 274 patients were potential candidates for surgical treatment and had EUS. According to predefined impact criteria, 27% (75/274) of the patients had EUS-FNAB for staging or diagnostic reasons. RESULTS: The overall clinical impact of EUS-FNAB was 13%, 14%, and 30% in esophageal, gastric, and pancreatic cancer, respectively. The staging-related clinical impact was similar for all three types of cancer (11-12.5%), whereas the diagnosis-related impact was highest in pancreatic cancer patients (86%). EUS-FNAB was inadequate in 13% and gave false-negative results in 5%. The overall sensitivity, specificity and accuracy for EUS-FNAB were 80%, 78% and 80%, respectively. No complications related to the biopsy procedure were seen. CONCLUSIONS: If EUS-FNAB was performed only in cases where a positive malignant result would change patient management, then approximately one out of four patients with upper gastrointestinal tract cancer would require a biopsy. With this approach the actual clinical impact of EUS-FNAB ranged from 13% in esophageal cancer to 30% in pancreatic cancer. EUS-FNAB plays a limited, but very important clinical role in the assessment of upper gastrointestinal tract cancer.

Adult↗