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TECHNOLOGICAL INNOVATION
HeLP: Development of occupational protection mask against surgical smoke
Revista Brasileira de Enfermagem. 2023;76:e20220647
11-10-2023
Abstract
TECHNOLOGICAL INNOVATIONHeLP: Development of occupational protection mask against surgical smoke
Revista Brasileira de Enfermagem. 2023;76:e20220647
11-10-2023DOI 10.1590/0034-7167-2022-0647
Views0ABSTRACT
Objectives:
to describe a technological innovation in the development of an individual, ergonomic, sustainable and effective occupational respiratory protection mask for workers exposed to surgical smoke.
Methods:
applied, exploratory, quantitative research, using design methods and tools: Sense Intent, Know Context, Know People, Frame Insights, Explore Concepts, Frame Solutions, Realize Offerings, in addition to the Product Development Process tools. It was developed from March 2019 to December 2021.
Results:
from the prototyping mold, it became possible to represent the abstract to the physical, where all the concepts created in the methodological steps were implemented and the necessary adjustments were made to create the model as a technological innovation, which will have the concept for product commercialization.
Conclusions:
a mask for protection against surgical smoke (HeLP) was developed, from the design step to the prototype development, being a technological innovation.
Keywords:Air Pollutants, OccupationalPersonal Protective EquipmentRespiratory Protective DevicesSmokeTechnological Development and Innovation ProjectsSee more
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ORIGINAL ARTICLE
Validation of the Advanced Practice Nursing Competency Assessment Instrument in a hospital environment
- Júlia Altafini
, - Flávia Carvalho Pena Dias ,
- Thelen Daiana Mendonça Ferreira ,
- Pedro Sastre-Fullana ,
- Thaís Moreira São-João , [ … ],
- Renata Cristina Gasparino
11-10-2023
Abstract
ORIGINAL ARTICLEValidation of the Advanced Practice Nursing Competency Assessment Instrument in a hospital environment
Revista Brasileira de Enfermagem. 2023;76:e20220705
11-10-2023DOI 10.1590/0034-7167-2022-0705
- Júlia Altafini ,
- Flávia Carvalho Pena Dias ,
- Thelen Daiana Mendonça Ferreira ,
- Pedro Sastre-Fullana ,
- Thaís Moreira São-João ,
- Renata Cristina Gasparino
Views0See moreABSTRACT
Objectives:
to evaluate the measurement properties of the Advanced Practice Nursing Competency Assessment Instrument – Brazilian version, in the hospital environment.
Methods:
a methodological study conducted in a hospital with 238 nurses. Three instruments collect the data: sample characterization form, Brazilian version of the Advanced Practice Nursing Competency Assessment Instrument, and the category “therapeutic interventions” of the nurse competence scale. Construct validity was verified by confirmatory factor analysis and Spearman’s correlation coefficient, and reliability by Cronbach’s Alpha and composite reliability.
Results:
in the factor analysis, the model converged to a satisfactory result. The study found acceptable evidence of reliability (Cronbach’s Alpha, 0.76-0.87; and composite reliability, 0.85-0.90).
Conclusions:
the instrument demonstrated evidence of construct validity and internal consistency and can be used in practice
- Júlia Altafini
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ERRATUM
ERRATUM
Revista Brasileira de Enfermagem. 2023;76(3):e2023n3e01
10-30-2023
Abstract
ERRATUMERRATUM
Revista Brasileira de Enfermagem. 2023;76(3):e2023n3e01
10-30-2023DOI 10.1590/0034-7167.20237603e01
Views0In the article “Perceptions of adults with obesity about multiprofessional remote monitoring at the beginning of the COVID-19 pandemic”, with DOI number: , published in Revista Brasileira de Enfermagem, 2021;74(Suppl 1): e20200710, on page 8:Where it read:[…]See more -
ORIGINAL ARTICLE
Experience of the patient regarding their safety in the hospital environment
- Ana Cristina Pretto Báo ,
- Cassiana Gil Prates ,
- Marcelo Prado Amaral-Rosa ,
- Diovane Ghignatti da Costa ,
- João Lucas Campos de Oliveira , [ … ],
- Gisela Maria Schebella Souto de Moura
10-09-2023
Abstract
ORIGINAL ARTICLEExperience of the patient regarding their safety in the hospital environment
Revista Brasileira de Enfermagem. 2023;76(5):e20220512
10-09-2023DOI 10.1590/0034-7167-2022-0512
- Ana Cristina Pretto Báo ,
- Cassiana Gil Prates ,
- Marcelo Prado Amaral-Rosa ,
- Diovane Ghignatti da Costa ,
- João Lucas Campos de Oliveira ,
- Simone Coelho Amestoy ,
- Ana Maria Müller de Magalhães ,
- Gisela Maria Schebella Souto de Moura
Views0See moreABSTRACT
Objectives:
to analyze the factors that can impact patients’ experience concerning safety-related measures in the hospital setting.
Methods:
this qualitative, descriptive, and exploratory study was conducted with patients and their family members at a hospital in southern Brazil. Semi-structured interviews were carried out using the Critical Incident Technique between January and February 2022. The collected data underwent content analysis with the assistance of IRaMuTeQ software.
Results:
five patients, four family members, and three patient-family units participated in the study. The following categories emerged: “Patientprofessional interaction as a component of safe care,” “Recognition of safety protocols in the patient’s experience,” and “Safe care and the challenges in hospital care.”
Conclusions:
patient-professional interaction, communication, awareness of safety protocols, and the availability of the nursing team are factors that influence patients’ experience regarding the safety of their care during hospitalization.
- Ana Cristina Pretto Báo
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ORIGINAL ARTICLE
Variabilidade glicêmica e mortalidade em unidades de terapia intensiva oncológicas
Revista Brasileira de Enfermagem. 2023;76(4):e20220812
10-09-2023
Abstract
ORIGINAL ARTICLEVariabilidade glicêmica e mortalidade em unidades de terapia intensiva oncológicas
Revista Brasileira de Enfermagem. 2023;76(4):e20220812
10-09-2023DOI 10.1590/0034-7167-2022-0812
Views0See moreRESUMEN
Objetivo:
investigar la asociación entre la variabilidad glucémica y la mortalidad en pacientes ingresados en unidades de cuidados intensivos oncológicos.
Métodos:
Se llevó a cabo un estudio de cohorte retrospectivo utilizando una muestra de conveniencia de 30 historias clínicas de pacientes de ambos sexos mayores de 18 años. La variabilidad glucémica se midió utilizando la desviación estándar y la amplitud general. El análisis estadístico se realizó utilizando la curva ROC (receiver operating characteristic) y el área bajo la curva (AUC). El nivel de significancia (α) se estableció en un 5% con un intervalo de confianza (IC) del 95%.
Resultados:
El estudio incluyó a 14 pacientes masculinos (46,67%) con una edad media de 60±15 años. Se recopilaron un total de 1503 muestras de glucemia. El análisis AUC para la desviación estándar no mostró ningún resultado estadísticamente significativo (p = 0,966; IC del 95% = [0,283, 0,726]). Por el contrario, la amplitud general tuvo una asociación estadísticamente significativa con la mortalidad (p = 0,049; IC del 95% = [0,514, 0,916]).
Conclusiones:
Este estudio encontró que la variabilidad glucémica medida por la amplitud general está significativamente asociada con la mortalidad del paciente en unidades de cuidados intensivos oncológicos. Estos hallazgos sugieren que el monitoreo de la variabilidad glucémica puede ser un factor importante en el manejo de pacientes críticamente enfermos en unidades de cuidados intensivos oncológicos.
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Content validation of an instrument for medical record audits
Revista Brasileira de Enfermagem. 2023;76(4):e20220109
10-09-2023
Abstract
Content validation of an instrument for medical record audits
Revista Brasileira de Enfermagem. 2023;76(4):e20220109
10-09-2023DOI 10.1590/0034-7167-2022-0109
Views0See moreABSTRACT
Objective:
To build and validate the content of an instrument to conduct medical record audits; to conduct a pre-test.
Methods:
Methodological study conducted from May/2020 to May/2021 in three stages: 1) development of the instrument by bibliographic survey and benchmarking; 2) content validation using the Delphi technique; 3) application of the instrument and descriptive analysis in a sample of 200 medical records.
Results:
An instrument was constructed with 11 domains containing sub-items that characterize the quality of care. Two stages of the Delphi technique were necessary to reach a content validity index higher than 0.90. For each domain, a graduated scale with a numerical value from 1 to 4 points was attributed, reflecting the quality of its completion. The average time of application was 35 minutes per record.
Conclusions:
The tool proved to be viable to support clinical audits to identify the level of excellence and reveal opportunities for improvement in care processes.
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ORIGINAL ARTICLE
Intestinal parasitic infections: telephone health literacy with men in areas of poverty in the syndemic
- Julio Cesar Pegado Bordignon ,
- Antonia de Castro Ribeiro ,
- Érica Tex Paulino ,
- Maria de Fatima Leal Alencar ,
- Marcio Neves Boia , [ … ],
- Antonio Henrique Almeida de Moraes Neto
10-09-2023
Abstract
ORIGINAL ARTICLEIntestinal parasitic infections: telephone health literacy with men in areas of poverty in the syndemic
Revista Brasileira de Enfermagem. 2023;76(4):e20220300
10-09-2023DOI 10.1590/0034-7167-2022-0300
- Julio Cesar Pegado Bordignon ,
- Antonia de Castro Ribeiro ,
- Érica Tex Paulino ,
- Maria de Fatima Leal Alencar ,
- Marcio Neves Boia ,
- Antonio Henrique Almeida de Moraes Neto
Views0See moreABSTRACT
Objectives:
to assess Popular Health Education practices on intestinal parasites, carried out by telephone contact with men living in urban communities in Rio de Janeiro, Brazil, during the COVID-19 syndemic.
Method:
a quasi-experimental, quantitative and descriptive study, carried out with men aged 20 to 59 years. Pre-test was applied, and participants were divided into two groups: control and experimental. Popular Education in Health practices were carried out with an experimental group, and post-test was applied for both.
Results:
health education practices were significant in the experimental group, with a reduction in incorrect answers. There was an increase in incorrect answers in the control group’s post-test.
Conclusions:
the Brazilian National Policy for Popular Education in Health contributed to qualify men’s health literacy on intestinal parasites. Practice by telephone contact proved to be a powerful strategy for nursing and public policies to access this group and promote health in Primary Health Care.
- Julio Cesar Pegado Bordignon
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ORIGINAL ARTICLE
Tradução e validação do Multidimensional Individual and Interpersonal Resilience Measure
- Jéssica Diniz Rodrigues Ferreira ,
- Mariana Figueiredo Miranda ,
- Millena Figueiredo Miranda ,
- Marco Aurélio Romano-Silva ,
- Maria Aparecida Camargos Bicalho , [ … ],
- Bernardo de Mattos Viana
10-09-2023
Abstract
ORIGINAL ARTICLETradução e validação do Multidimensional Individual and Interpersonal Resilience Measure
Revista Brasileira de Enfermagem. 2023;76(4):e20220696
10-09-2023DOI 10.1590/0034-7167-2022-0696
- Jéssica Diniz Rodrigues Ferreira ,
- Mariana Figueiredo Miranda ,
- Millena Figueiredo Miranda ,
- Marco Aurélio Romano-Silva ,
- Maria Aparecida Camargos Bicalho ,
- Bernardo de Mattos Viana
Views0See moreRESUMEN
Objetivo:
traducir, adaptar culturalmente y validar el Multidimensional Individual and Interpersonal Resilience Measure para el portugués brasileño.
Método:
después de la traducción inicial, la versión pre-final pasó por rigurosos procedimientos de adaptación cultural. Como resultado, la versión final adaptada fue sometida a un estudio de validez.
Resultados:
los procedimientos de adaptación proporcionaron equivalencia entre las versiones pre-final y original en términos semánticos, idiomáticos, experienciales y conceptuales. Un total de 187 ancianos fueron incluidos en el estudio de validez. El análisis factorial exploratorio (AFE) generó un modelo de cinco factores ((RMSEA = 0,030; TLI = 0,959; X = 151,590 p> 0,05). La versión final mostró adecuada consistencia (α de Cronbach = 0,705) y confiabilidad prueba-reprueba (ICC=0,835). No se encontró correlación estadísticamente significativa entre la resiliencia y las variables sociodemográficas y epidemiológicas evaluadas en este estudio.
Conclusión:
EMRII-BR es un instrumento válido y confiable para medir la resiliencia en ancianos brasileños.
- Jéssica Diniz Rodrigues Ferreira
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EXPERIENCE REPORT
Implementation of an Artificial Intelligence Algorithm for sepsis detection
- Luciana Schleder Gonçalves ,
- Maria Luiza de Medeiros Amaro ,
- Andressa de Lima Miranda Romero ,
- Fernanda Karoline Schamne ,
- Jacson Luiz Fressatto , [ … ],
- Carolina Wrobel Bezerra
04-09-2020
Abstract
EXPERIENCE REPORTImplementation of an Artificial Intelligence Algorithm for sepsis detection
Revista Brasileira de Enfermagem. 2020;73(3):e20180421
04-09-2020DOI 10.1590/0034-7167-2018-0421
- Luciana Schleder Gonçalves ,
- Maria Luiza de Medeiros Amaro ,
- Andressa de Lima Miranda Romero ,
- Fernanda Karoline Schamne ,
- Jacson Luiz Fressatto ,
- Carolina Wrobel Bezerra
Views0See moreABSTRACT
Objectives:
to present the nurses’ experience with technological tools to support the early identification of sepsis.
Methods:
experience report before and after the implementation of artificial intelligence algorithms in the clinical practice of a philanthropic hospital, in the first half of 2018.
Results:
describe the motivation for the creation and use of the algorithm; the role of the nurse in the development and implementation of this technology and its effects on the nursing work process.
Final Considerations:
technological innovations need to contribute to the improvement of professional practices in health. Thus, nurses must recognize their role in all stages of this process, in order to guarantee safe, effective and patient-centered care. In the case presented, the participation of the nurses in the technology incorporation process enables a rapid decision-making in the early identification of sepsis.
- Luciana Schleder Gonçalves
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ORIGINAL ARTICLE
Caring for the carer: quality of life and burden of female caregivers
- Michelly Guedes de Oliveira Araújo ,
- Michelinne Oliveira Machado Dutra ,
- Carla Carolina Silva Leite Freitas ,
- Tatiane Gomes Guedes ,
- Francisco Stélio de Souza , [ … ],
- Rosilene Santos Baptista
06-27-2019
Abstract
ORIGINAL ARTICLECaring for the carer: quality of life and burden of female caregivers
Revista Brasileira de Enfermagem. 2019;72(3):728-736
06-27-2019DOI 10.1590/0034-7167-2018-0334
- Michelly Guedes de Oliveira Araújo ,
- Michelinne Oliveira Machado Dutra ,
- Carla Carolina Silva Leite Freitas ,
- Tatiane Gomes Guedes ,
- Francisco Stélio de Souza ,
- Rosilene Santos Baptista
Views0See moreABSTRACT
Objective:
To assess the quality of life and the burden of female caregivers.
Method:
Descriptive, cross-sectional, quantitative study carried out with 224 informal caregivers from March to July 2016. Three instruments were used: a characterization form for the caregiver, the WHOQOL-Bref questionnaire and the Zarit Burden Interview. The following tests were used: Cronbach’s Alpha, Kolmogorov-Smirnov, Kruskal-Wallis, Spearman and Mann-Whitney.
Results:
The mean age of caregivers was 51.8 years with a standard deviation of 13.7. They were predominantly married, had a low income and low level of education, were first-degree relatives, had been providing care for one to five years and presented some pathology. The associations of quality of life that presented statistical significance were: income, marital status, number of people living with the caregiver and time of care.
Conclusion:
The burden was negatively correlated with QOL, that is, the greater the burden, the more impaired will be the life of these caregivers.
- Michelly Guedes de Oliveira Araújo
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REVIEW
Development of clinical competence in nursing in simulation: the perspective of Bloom’s taxonomy
- Juliana da Silva Garcia Nascimento ,
- Tainá Vilhar Siqueira ,
- Jordana Luiza Gouvêa de Oliveira ,
- Mateus Goulart Alves ,
- Daniela da Silva Garcia Regino , [ … ],
- Maria Celia Barcellos Dalri
03-24-2021
Abstract
REVIEWDevelopment of clinical competence in nursing in simulation: the perspective of Bloom’s taxonomy
Revista Brasileira de Enfermagem. 2021;74(1):e20200135
03-24-2021DOI 10.1590/0034-7167-2020-0135
- Juliana da Silva Garcia Nascimento ,
- Tainá Vilhar Siqueira ,
- Jordana Luiza Gouvêa de Oliveira ,
- Mateus Goulart Alves ,
- Daniela da Silva Garcia Regino ,
- Maria Celia Barcellos Dalri
Views0See moreABSTRACT
Objectives:
to investigate the scientific evidence on the use of Bloom’s taxonomy for developing competence in nursing professionals and students in clinical simulation.
Methods:
integrative review of the National Library of Medicine (NLM), National Institutes of Health (NIH), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Latin American and Caribbean Literature in Health Sciences (LILACS), Web of Science and SCOPUS databases, using the Rayyan application.
Results:
a total of 871 studies were identified; four composed the sample. The development of clinical competence occurred through the coordination of knowledge, skills, and attitudes. To develop the cognitive domain, the objectives of knowledge and comprehension of the Bloom’s taxonomy were mobilized. The psychomotor domain required development of the skills demanded by the proposed clinical care. The affective domain was developed through will and motivation to learn.
Conclusions:
it is possible to develop clinical competence in nursing by adopting Bloom’s taxonomy in each phase of clinical simulation.
- Juliana da Silva Garcia Nascimento
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ORIGINAL ARTICLE
Package of menthol measures for thirst relief: a randomized clinical study
- Viviane Moreira Serato ,
- Lígia Fahl Fonseca ,
- Marcela Maria Birolim ,
- Edilaine Giovanini Rossetto ,
- Lílian Denise Mai , [ … ],
- Aline Korki Arrabal Garcia
06-27-2019
Abstract
ORIGINAL ARTICLEPackage of menthol measures for thirst relief: a randomized clinical study
Revista Brasileira de Enfermagem. 2019;72(3):600-608
06-27-2019DOI 10.1590/0034-7167-2018-0057
- Viviane Moreira Serato ,
- Lígia Fahl Fonseca ,
- Marcela Maria Birolim ,
- Edilaine Giovanini Rossetto ,
- Lílian Denise Mai ,
- Aline Korki Arrabal Garcia
Views0See moreABSTRACT
Objective:
To evaluate the effectiveness of the menthol package (lip hydration and ice popsicles) compared to a package of non-menthol measures (lip hydration and ice popsicles) as a way to relieve thirst in patients in the Anesthetic Recovery Room.
Method:
Randomized and parallel trial study, with 120 patients randomized patients in an experimental group – menthol measurements (n=59) and control group – measures without menthol (n = 61).
Results:
There was a significant (p<0.05) decrease in intensity, hydration, dryness and taste in the oral cavity between the three moments of assessment/intervention in the two groups. The difference was significant in the experimental group for thirst intensity at the second assessment/intervention point (p<0.05) after a single administration of the menthol package.
Conclusion:
There was a reduction in thirst intensity in both groups. Patients who received menthol packages showed a significant decrease in intensity after a single evaluation/intervention time. NCT: 02869139.
- Viviane Moreira Serato
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EDITORIAL
Coronavirus 2020
Revista Brasileira de Enfermagem. 2020;73(2):e2020n2
03-27-2020
Abstract
EDITORIALCoronavirus 2020
Revista Brasileira de Enfermagem. 2020;73(2):e2020n2
03-27-2020DOI 10.1590/0034-7167-2020730201
Views0Emerging and reemerging infectious diseases are constant challenges for public health worldwide. Recent cases of pneumonia of unknown cause in Wuhan, China, have led to the discovery of a new type of Coronavirus (2019-nCoV), which are enveloped RNA viruses, commonly found in humans, other mammals and birds, capable of causing respiratory, enteric, hepatic, and neurological […]See more -
ORIGINAL ARTICLE
Pressure injury related to the use of personal protective equipment in COVID-19 pandemic
- Manuela de Mendonça Figueirêdo Coelho ,
- Viviane Mamede Vasconcelos Cavalcante ,
- Juliano Teixeira Moraes ,
- Luciana Catunda Gomes de Menezes ,
- Sarah Vieira Figueirêdo , [ … ],
- Solange Gurgel Alexandre
12-04-2020
Abstract
ORIGINAL ARTICLEPressure injury related to the use of personal protective equipment in COVID-19 pandemic
Revista Brasileira de Enfermagem. 2020;73:e20200670
12-04-2020DOI 10.1590/0034-7167-2020-0670
- Manuela de Mendonça Figueirêdo Coelho ,
- Viviane Mamede Vasconcelos Cavalcante ,
- Juliano Teixeira Moraes ,
- Luciana Catunda Gomes de Menezes ,
- Sarah Vieira Figueirêdo ,
- Mírian Ferreira Coelho Castelo Branco ,
- Solange Gurgel Alexandre
Views0See moreABSTRACT
Objective:
To describe the prevalence and factors associated with pressure injuries related to the use of personal protective equipment during the COVID-19 pandemic.
Methods:
Cross-sectional study conducted using an instrument made available in social networks with 1,106 health professionals. The data were analyzed using descriptive statistics and compared, considering pvalue < 0.05.
Results:
There was a prevalence of 69.4% for pressure injuries related to the use of personal protective equipment, with an average of 2.4 injuries per professional. The significant factors were: under 35 years of age, working and wearing personal protective equipment for more than six hours a day, in hospital units, and without the use of inputs for protection.
Conclusion:
Pressure injuries related to the use of medical devices showed a high prevalence in this population. The recognition of the damage in these professionals makes it possible to advance in prevention strategies.
- Manuela de Mendonça Figueirêdo Coelho
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ORIGINAL ARTICLE
Accessibility of children with special health needs to the health care network
- Eliane Tatsch Neves ,
- Aline Cristiane Cavicchioli Okido ,
- Fernanda Luisa Buboltz ,
- Raíssa Passos dos Santos ,
- Regina Aparecida Garcia de Lima
12-13-2019
Abstract
ORIGINAL ARTICLEAccessibility of children with special health needs to the health care network
Revista Brasileira de Enfermagem. 2019;72:65-71
12-13-2019DOI 10.1590/0034-7167-2017-0899
- Eliane Tatsch Neves ,
- Aline Cristiane Cavicchioli Okido ,
- Fernanda Luisa Buboltz ,
- Raíssa Passos dos Santos ,
- Regina Aparecida Garcia de Lima
Views0See moreABSTRACT
Objective:
To know how children with special health needs access the health care network.
Method:
This is a qualitative research of descriptive-exploratory type, developed using semi-structured interviews mediated by the Talking Map design. Participants were 19 family caregivers of these children in two Brazilian municipalities. Data were submitted to inductive thematic analysis.
Results:
Difficulties were mentioned from the diagnosis moment to the specialized follow-up, something represented by the itinerary of the c hild and his/her family in the search for the definition of the medical diagnosis and the access to a specialized professional; a gap between the children’s needs and the care offered was observed in primary health care.
Conclusion:
The access of children with special health needs is filled with obstacles such as slowness in the process of defining the child’s diagnosis and referral to a specialist. Primary health care services were replaced by care in emergency care units.
- Eliane Tatsch Neves
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REVIEW
Vulnerability of the elderly: a conceptual analysis
- Keylla Talitha Fernandes Barbosa ,
- Fabiana Maria Rodrigues Lopes de Oliveira ,
- Maria das Graças Melo Fernandes
12-05-2019
Abstract
REVIEWVulnerability of the elderly: a conceptual analysis
Revista Brasileira de Enfermagem. 2019;72:337-344
12-05-2019DOI 10.1590/0034-7167-2018-0728
- Keylla Talitha Fernandes Barbosa ,
- Fabiana Maria Rodrigues Lopes de Oliveira ,
- Maria das Graças Melo Fernandes
Views0See moreABSTRACT
Objective:
To analyze the concept of vulnerability of the elderly.
Method:
A concept analysis, according to the method proposed by Walker and Avant, operationalized through integrative review through search in scientific data portals using the
Descriptors:
Health vulnerability, aged, health services for the aged, health of the elderly, vulnerable populations and geriatric health services. To compose the literary corpus, 36 studies were selected.
Results:
Concept antecedents, as well as its attributes, were identified in individual, social and programmatic characteristics, which make up the characteristics of “vulnerability of the elderly”, besides consequences of the phenomenon. These characteristics were analyzed with emphasis on aspects that contribute to the process of vulnerability of the elderly.
Conclusion:
The study demonstrated the multidimensionality of the phenomena studied, highlighting the peculiarities of vulnerability during aging. However, there is a need for further studies on the construct.
- Keylla Talitha Fernandes Barbosa
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