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ORIGINAL ARTICLE09-20-2024
Risk assessment for postoperative complications in patients undergoing cardiac surgical procedures
Revista Brasileira de Enfermagem. 2024;77(4):e20230127
Abstract
ORIGINAL ARTICLERisk assessment for postoperative complications in patients undergoing cardiac surgical procedures
Revista Brasileira de Enfermagem. 2024;77(4):e20230127
DOI 10.1590/0034-7167-2023-0127
Views0See moreABSTRACT
Objectives:
to evaluate the risk of postoperative complications in cardiac patients.
Methods:
an evaluative study using the Tuman Score on medical records of 70 adult patients who underwent cardiac surgery at a University Hospital. The R for Windows software was used for the analyses. Descriptive statistics and bivariate analysis were employed to verify the association between the risk score and complications. The relative risk between the Tuman Score and postoperative complications was obtained through Quasi-Poisson regression, with a 95% confidence interval.
Results:
the majority of the patients were male (58.57%), aged between 41-64 years (50%), who underwent myocardial revascularization (50%). These patients were associated with a lower risk of postoperative complications (p=0.003), (p=0.008), and (p=0.000), respectively. High-risk patients had pulmonary complications (RR=1.32, p=0.002) and neurological complications (RR=1.20, p=0.047).
Conclusions:
preoperative risk assessment promotes qualified care to reduce postoperative complications.
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EXPERIENCE REPORT09-20-2024
Researchers’ experience in data collection with families of femicide victims
Revista Brasileira de Enfermagem. 2024;77(4):e20230119
Abstract
EXPERIENCE REPORTResearchers’ experience in data collection with families of femicide victims
Revista Brasileira de Enfermagem. 2024;77(4):e20230119
DOI 10.1590/0034-7167-2023-0119
Views0See moreABSTRACT
Objectives:
to describe researchers’ experience in collecting data from families of femicide victims.
Methods:
this descriptive, qualitative study took the form of an experience report and was conducted in Manaus, Amazonas, Brazil. It involved documentary consultation, training researchers, scheduling and conducting interviews, and using a field diary to record the researchers’ perceptions and experiences.
Results:
the descriptions and photographs of the crime scene were both distressing and impactful for the researchers. The mementos of the victims (including clothing, objects, and childhood photos) shown by their families were deeply moving. Identifying with these experiences facilitated listening to the stories told by the relatives. It was essential to maintain a non-judgmental attitude, acknowledge the loss, provide support for the suffering, and demonstrate a willingness to help.
Final Considerations:
the experience encompassed both theoretical and methodological aspects that were planned and executed in data collection, fostering the development of skills and sensitivity towards the cases. Beyond knowledge and preparation, researchers are expected to exhibit ethical conduct and empathetic capacity.
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ORIGINAL ARTICLE09-20-2024
Factors associated with preventable infant mortality in 2020: a Brazilian population-based study
Revista Brasileira de Enfermagem. 2024;77(4):e20230072
Abstract
ORIGINAL ARTICLEFactors associated with preventable infant mortality in 2020: a Brazilian population-based study
Revista Brasileira de Enfermagem. 2024;77(4):e20230072
DOI 10.1590/0034-7167-2023-0072
Views0See moreABSTRACT
Objectives:
to identify factors associated with preventable infant deaths, classified as neonatal and post-neonatal.
Methods:
this is an epidemiological and population-based study relating to 2020. Data from the Mortality Information System (MIS) and the preventability classification proposed in the Brazilian Health System List of Causes of Deaths Preventable by Interventions were used.
Results:
prematurity, living in the North and Northeast regions and the occurrence of the event at home were associated with preventable neonatal deaths. To the avoidable post-neonatal component, death outside the hospital, low maternal education and children of brown or yellow color/race were associated.
Conclusions:
the main risk factor associated with preventable deaths was prematurity, in the case of neonatal death. Low maternal education and occurrence outside the hospital were associated with post-neonatal deaths.
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09-09-2024
Potential of Artificial Intelligence in Evidence-Based Practice in Nursing
Revista Brasileira de Enfermagem. 2024;77(5):e770501
Abstract
Potential of Artificial Intelligence in Evidence-Based Practice in Nursing
Revista Brasileira de Enfermagem. 2024;77(5):e770501
DOI 10.1590/0034-7167.2024770501
Views0Evidence-based practice (EBP) has established itself as a fundamental pillar in nursing, driving effective clinical decision-making based on high-quality scientific research. The primary goal of EBP is to ensure that patients receive the most appropriate and safe care, based on the best available evidence. In this context, knowledge synthesis methods are essential tools for EBP, […]See more -
REVIEW09-06-2024
Parents’ or legal guardians’ beliefs and attitudes about childhood vaccination: a scoping review
Revista Brasileira de Enfermagem. 2024;77(4):e20240126
Abstract
REVIEWParents’ or legal guardians’ beliefs and attitudes about childhood vaccination: a scoping review
Revista Brasileira de Enfermagem. 2024;77(4):e20240126
DOI 10.1590/0034-7167-2024-0126
Views0See moreABSTRACT
Objective:
to map scientific evidence about perceptions, beliefs, knowledge and attitudes of parents or legal guardians of children under 5 years of age regarding routine childhood vaccination.
Methods:
a scoping review, conducted in accordance with the JBI framework. The searches were carried out in the PubMed/MEDLINE, Web of Science, Scopus and LILACS databases. A total of 5,535 studies were returned and 77 were selected, which met the inclusion criteria.
Results:
perceptions related to interaction with healthcare professionals and services, with family organization and structure, with social interaction and public policies, cultural, religious and personal beliefs, knowledge about vaccination schedule, vaccination and immunization process and sources of information are the main factors mapped and which can positively or negatively influence parents’ or legal guardians’ attitudes towards vaccinating children.
Conclusions:
the findings allow us to identify factors related to parents’ perception and beliefs about childhood vaccination.
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ORIGINAL ARTICLE09-06-2024
Construction and validation of an instrument for event-related sterility of processed healthcare products
Revista Brasileira de Enfermagem. 2024;77(4):e20240021
Abstract
ORIGINAL ARTICLEConstruction and validation of an instrument for event-related sterility of processed healthcare products
Revista Brasileira de Enfermagem. 2024;77(4):e20240021
DOI 10.1590/0034-7167-2024-0021
Views0See moreABSTRACT
Objective:
To construct and validate an instrument to assess events related to maintaining the sterility of processed healthcare products.
Methods:
This methodological study developed the instrument through analysis by a panel of experts, focusing on the integrity of commonly used packaging: spunbond-meltblown-spunbond and medical-grade paper. The instrument was analyzed using the Content Validity Index and Content Validity Ratio (≥ 0.80) and modified Kappa (≥ 0.74). The instrument underwent pre-testing.
Results:
Six experienced professionals participated in the expert panel. After two rounds, the final version of the instrument contained five dimensions. In the pre-test, 30 nursing professionals participated, of whom 86.67% considered the instrument good, and 90% found it understandable.
Conclusion:
The construction and validation followed literature recommendations. The instrument is available, aiding in the safe use of processed healthcare products.
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ORIGINAL ARTICLE09-06-2024
Reflective practice of nurse residents in the teaching-learning process in teaching hospitals
Revista Brasileira de Enfermagem. 2024;77(4):e20230540
Abstract
ORIGINAL ARTICLEReflective practice of nurse residents in the teaching-learning process in teaching hospitals
Revista Brasileira de Enfermagem. 2024;77(4):e20230540
DOI 10.1590/0034-7167-2023-0540
Views0See moreABSTRACT
Objective:
To analyze reflective practice in the teaching-learning process of nurses in residency programs in teaching hospitals in Minas Gerais, Brazil.
Methods:
Case study, based on the reflective practice framework, conducted in two teaching hospitals. Observation and interviews were conducted with first and second-year residents, and five participants were included for in-depth analysis, with their data subjected to frequency distribution analysis and Critical Discourse Analysis.
Results:
In 519 observed activities, elements of reflection were identified in 22.2%, especially active listening and expression of doubts. Discourses indicated practice as the best moment for teaching-learning due to its potential to generate reflections. Learning by doing and case discussion were considered potential strategies for reflective learning.
Conclusion:
Know-in-action reflection was evidenced as the predominant formative aspect for residents, with few opportunities for reflection on reflection-in-action.
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ORIGINAL ARTICLE09-06-2024
Middle-Range theory of the nursing diagnosis of sedentary lifestyle in young adults
Revista Brasileira de Enfermagem. 2024;77(4):e20230516
Abstract
ORIGINAL ARTICLEMiddle-Range theory of the nursing diagnosis of sedentary lifestyle in young adults
Revista Brasileira de Enfermagem. 2024;77(4):e20230516
DOI 10.1590/0034-7167-2023-0516
Views0See moreABSTRACT
Objective:
To construct a middle-range theory for the nursing diagnosis of Sedentary Lifestyle in young adults.
Methods:
A methodological study for the validation of a nursing diagnosis based on a Middle-Range Theory, carried out in six stages: definition of the approach; definition of theoretical-conceptual models; definition of main concepts; development of a pictorial scheme; construction of propositions; establishment of causal relationships and evidence for practice. The theory construction was operationalized through an integrative review and supported by Roy’s adaptation model.
Results:
Three essential attributes were identified; 10 antecedents; 7 clinical consequences; a pictogram, 9 propositions, and 11 causal relationships and evidence for practice.
Conclusion:
The middle-range theory for the nursing diagnosis of Sedentary Lifestyle in young adults was constructed, expanding the understanding of this phenomenon, to be applied in clinical practice by nurses.
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12-04-2023
A cronicidade e o seu impacto na saúde do trabalhador: uma chamada para ações concretas
Revista Brasileira de Enfermagem. 2023;76:e76suppl301
Abstract
A cronicidade e o seu impacto na saúde do trabalhador: uma chamada para ações concretas
Revista Brasileira de Enfermagem. 2023;76:e76suppl301
DOI 10.1590/0034-7167.202376suppl301pt
Views0A relação entre cronicidade e trabalho tem sido uma preocupação crescente na sociedade contemporânea. À medida que o número de doenças crônicas aumenta em todo o mundo, é fundamental compreender como essas condições impactam a saúde dos trabalhadores(). Neste editorial, exploraremos os impactos da cronicidade na saúde do trabalhador, destacando dados da Carga Global de […]See more -
12-04-2023
Chronicity and its impact on workers’ health: a call for concrete actions
Revista Brasileira de Enfermagem. 2023;76:e76suppl301
Abstract
Chronicity and its impact on workers’ health: a call for concrete actions
Revista Brasileira de Enfermagem. 2023;76:e76suppl301
DOI 10.1590/0034-7167.202376suppl301
Views0The relationship between chronicity and work has been a growing concern in contemporary society. As the number of chronic illnesses increases around the world, it is critical to understand how these conditions impact workers’ health(). In this editorial, we will explore the impacts of chronicity on workers’ health, highlighting data from the Global Burden of […]See more -
12-04-2023
General Law on Personal Data Protection and applicability to Nursing
Revista Brasileira de Enfermagem. 2023;76:e20230126
Abstract
General Law on Personal Data Protection and applicability to Nursing
Revista Brasileira de Enfermagem. 2023;76:e20230126
DOI 10.1590/0034-7167-2023-0126
Views0See moreABSTRACT
Objectives:
to reflect on the impacts of the General Personal Data Protection Law on Nursing practice.
Methods:
reflection article, through the intentional collection of materials relating to the topic.
Results:
legislation regulates confidentiality, processing and data sharing, requiring institutional protection measures. The nursing team is responsible for acting preventively, both in care and in the management role, in order to avoid the misuse of the patient’s personal data. The law allows academic research to be carried out as long as the purpose is clear, data collection occurs with an explicit purpose and data is anonymized.
Final Considerations:
although the General Personal Data Protection Law requires greater care in relation to data processing, it is established on precepts of good faith and respect for the rights of the individual, concepts aligned with the nursing code of ethics.
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REVIEW12-04-2023
Supervision of professional nursing practice in Brazil: a scoping review
Revista Brasileira de Enfermagem. 2023;76:e20230077
Abstract
REVIEWSupervision of professional nursing practice in Brazil: a scoping review
Revista Brasileira de Enfermagem. 2023;76:e20230077
DOI 10.1590/0034-7167-2023-0077
Views0See moreABSTRACT
Objectives:
to map studies that analyze the audit process of nursing councils.
Methods:
this is a scoping review, anchored in the JBI framework, with the guiding question: what is the evidence of the audit process of legal practice of nursing by class councils (COFEN/COREN system)? The searches were carried out in October and November 2022 without limitation of language and year.
Results:
of the 9 selected studies, all are Brazilian and published from 2014 onwards. Among the topics addressed are the role, challenges, costs and difficulties in nurse auditors’ daily work process, in addition to the contribution of the audit sector in Brazil.
Conclusions:
the studies gathered discuss aspects related to costs, challenges and difficulties, but there is no focus on corrective, disciplinary and educational activities as well as little is said about the audit process, its reporting, referral and outcomes.
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ORIGINAL ARTICLE12-04-2023
Overview of nursing ethics teaching in Brazilian public higher education institutions
Revista Brasileira de Enfermagem. 2023;76:e20220808
Abstract
ORIGINAL ARTICLEOverview of nursing ethics teaching in Brazilian public higher education institutions
Revista Brasileira de Enfermagem. 2023;76:e20220808
DOI 10.1590/0034-7167-2022-0808
Views0See moreABSTRACT
Objectives:
to outline the teaching of ethics in undergraduate Nursing programs in Brazilian public higher education institutions.
Methods:
descriptive and exploratory study, carried out through the documentary analysis of pedagogical projects of undergraduate Nursing programs in Brazil.
Results:
153 active undergraduate Nursing programs were found, of which 106 provide the pedagogical project. In addition to deontological teaching, the teaching of ethics was identified in a transversal way associated with themes such as Social Context, Hospital and Community Care, Pharmacology, Systematization of Nursing Care, Surgical Nursing, Epidemiology, Palliative Care, Management in Nursing, Diversity, Women’s, Children’s, Adolescent’s, Adult’s and Older People’s Health, and Mental Health.
Final Considerations:
the challenge in teaching nursing ethics is its integration with each action of caring, teaching and managing.
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12-04-2023
La ética de la atención de enfermería a las personas transgénero
Revista Brasileira de Enfermagem. 2023;76:e20220797
Abstract
La ética de la atención de enfermería a las personas transgénero
Revista Brasileira de Enfermagem. 2023;76:e20220797
DOI 10.1590/0034-7167-2022-0797es
Views0See moreRESUMEN
Objetivos:
debatir sobre aspectos éticos en la atención de enfermería a personas transgénero.
Métodos:
estudio reflexivo fundamentado sobre los dilemas que se plantean en los cuidados de enfermería a personas transgénero. El relato se ha estructurado en torno a los cuatro principios bioéticos.
Resultados:
la atención sanitaria a las personas trans es compleja, transversal a muchos dispositivos y especialidades y longitudinal en el tiempo por lo que precisa de la actuación coordinada. Existe un marco ético en el que se encuadran los cuidados de enfermería que se precisan en la atención a este colectivo.
Consideraciones Finales:
la enfermera como agente de salud puede asumir diversas líneas generales en la atención a pacientes transgénero. Para ello, se debe brindar formación adicional no solo a los profesionales, también a los estudiantes de enfermería y de las demás ciencias de la salud.
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12-04-2023
Ethical dilemmas at the end of life: a reflection from the Philosophical Perspective of Luigina Mortari
Revista Brasileira de Enfermagem. 2023;76:e20220759
Abstract
Ethical dilemmas at the end of life: a reflection from the Philosophical Perspective of Luigina Mortari
Revista Brasileira de Enfermagem. 2023;76:e20220759
DOI 10.1590/0034-7167-2022-0759
Views0See moreABSTRACT
Objectives:
to reflect on the ethical dilemmas involved in the care of patients at the end of their lives.
Methods:
this is a theoretical-reflective study based on the ethics of care proposed by Luigina Mortari.
Results:
discussing care involves addressing the ways of being inherent to human existence and understanding the unique characteristics of this condition. Ethical care constitutes an action driven by interest in the other and by the perception of their need. Ethical dilemmas are a part of end-of-life care, making it essential to maintain respectful assistance that considers the patient’s autonomy, using strategies for expressing their wishes, and ensuring continuous clear and empathetic communication among all those involved in providing care.
Final Considerations:
issues related to being, stemming from one’s reality of dependency and vulnerability, contribute to the emergence of ethical dilemmas present in care actions.
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01-01-2016
Health needs and nursing care
Revista Brasileira de Enfermagem. 2016;69(6):1236-1239
Abstract
Health needs and nursing care
Revista Brasileira de Enfermagem. 2016;69(6):1236-1239
DOI 10.1590/0034-7167-2016-0128
Views0See moreABSTRACT
Objective:
to present the concept of needs according to different approaches to discuss the possibility of health care that incorporates a broader view of human vulnerabilities in health services.
Methods:
the arguments are founded on nursing theorists who worked on the construction of frameworks relevant to care, based on needs and on philosophers who show the possibility of identifying the vulnerabilities of human beings, defending art as a therapeutic instrument that can promote health care.
Conclusion:
although care can acquire a new dimension with the introduction of art, according to certain perspectives, philosophical studies on ethics and aesthetics should be resumed to identify human vulnerabilities that can in fact be compensated by sensible understanding of the outer world. To incorporate art in nursing care requires studies from theorists to be recovered, deepening concepts and working on empirical investigations for their adequate use.
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01-01-2016
Case studies and role play: learning strategies in nursing
Revista Brasileira de Enfermagem. 2016;69(6):1231-1235
Abstract
Case studies and role play: learning strategies in nursing
Revista Brasileira de Enfermagem. 2016;69(6):1231-1235
DOI 10.1590/0034-7167-2016-0277
Views0See moreABSTRACT
Objective:
to report professors’ experience in a public university of Southern region of Brazil using case studies and role play as learning strategies for nursing care of hospitalized adults.
Method:
learning experience report from the Nursing Care of Adults I class of nursing undergraduate course.
Results
the development of case studies and role play considered health care needs from epidemiological profile of chronic noncommunicable diseases morbidity and mortality, nursing as an assisting method, and social aspects of hospitalized individuals. Role play planning was made by creating a stage in laboratory of practices and dialogues comprising students and professors interaction.
Conclusion
case studies and role play encouraged students to active search for learning and brought theory closer to real health care situations.
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01-01-2016
Politicy of care in the criticism towards gender stereotypes
Revista Brasileira de Enfermagem. 2016;69(6):1223-1230
Abstract
Politicy of care in the criticism towards gender stereotypes
Revista Brasileira de Enfermagem. 2016;69(6):1223-1230
DOI 10.1590/0034-7167-2016-0441
Views0See moreABSTRACT
Objectives:
analyze gender inequalities among Brazilian women in Portugal and in contemporary nursing based on care politicity in the light of gender; disclose oppression of the female produced by the stereotypes that look upon women as natural caregivers; point out politicity to deconstruct gender stereotypes.
Method:
theoretical reflection with narrative review of literature to analyze classic references in the feminist epistemology combined with the care politicity thesis.
Results:
the similarities between the stereotypes of the Brazilian Eves and the Portuguese Maries as either the sexualized or sanctified nurse are inserted in the Jewish-Christian moral genealogy that reaffirms the subservience of the female to the male.
Conclusion:
by attaching priority to care that needs non-care to expand the possibilities of care giving, the theoretical assumption of politicy of care can contribute to subvert the stereotypical images of Brazilian women in Portuguese lands and in contemporary nursing.
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01-01-2016
Strategies for thirst relief: integrative literature review
Revista Brasileira de Enfermagem. 2016;69(6):1215-1222
Abstract
Strategies for thirst relief: integrative literature review
Revista Brasileira de Enfermagem. 2016;69(6):1215-1222
DOI 10.1590/0034-7167-2016-0317
Views0See moreABSTRACT
Objective:
to analyze the strategies used to relieve the thirst of hospitalized patients.
Method:
an integrative review, for which the databases PubMed, LILACS, CINAHL and the group of references organized by the Group for Study and Research of Thirst were selected for the search of primary studies, with the keywords: thirst, ice, cold, intervention, nursing care, artificial saliva.
Results:
the review sample was composed of ten primary studies. The strategies found were: low temperature using frozen gauze, ice chips, and cold water, menthol associated with cold strategies, chewing gum, acupressure, and the use of a thin straw, substitute saliva, and early fluid ingestion.
Conclusion:
the temperature was presented as a predominant and effective strategy to relieve the thirst for surgical patients in intensive care and hemodialysis treatment.
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01-01-2016
Care of the self and power relations: female nurses taking care of other women
Revista Brasileira de Enfermagem. 2016;69(6):1204-1214
Abstract
Care of the self and power relations: female nurses taking care of other women
Revista Brasileira de Enfermagem. 2016;69(6):1204-1214
DOI 10.1590/0034-7167-2016-0021
Views0See moreABSTRACT
Objective:
to analyze the care of self of female nurses and the power relations established by them in the care of other women.
Method:
integrative review of literature published between 2005 and 2015. There were 25 publications in the sample.
Results:
qualitative state of the art with reference domain of a liberating perspective, based on humanization, autonomy and empowerment as a risk reduction strategy in the practice of care to women. The findings suggest solidified power relations among female nurses and women, focused on professional domain concentrated on nurse education under the patriarchal and society’s normalization discourse. Some studies consider the importance of understanding power in a capillary way, operating on the bodies of individuals.
Conclusion:
there is little discussion about the care of self of nurses and the effects on their professional practice, indicating gaps in knowledge in this field.
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01-01-2016
Nursing competencies in promoting the health of individuals with chronic diseases
Revista Brasileira de Enfermagem. 2016;69(6):1195-1203
Abstract
Nursing competencies in promoting the health of individuals with chronic diseases
Revista Brasileira de Enfermagem. 2016;69(6):1195-1203
DOI 10.1590/0034-7167-2016-0312
Views0See moreABSTRACT
Objective:
to identify nurse’s competencies related to health promotion of individuals with chronic cardiac disease, in the light of the Galway consensus.
Method:
integrative literature review was conducted to search for studies published between 2010 and 2014 in the databases LILACS, BDENF, IBECS; and PubMed in February 2015. The 21 included studies were analyzed according to the eight domains of competence: Catalyzing change, Leadership, Evaluation, Planning, Implementation, Assessment, Advocacy and Partnerships.
Results:
all domains of competence were included in the nursing interventions in health promotion of chronic cardiac patients, and the Planning and Evaluation were the most evident competences.
Conclusion:
the results of this research highlighted the nurse as an agent capable of operating care management, in order to improve coordination of the latter with work and education and, thus, the health care of the population.
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01-01-2016
Assisted therapy with dogs in pediatric oncology: relatives’ and nurses’ perceptions
Revista Brasileira de Enfermagem. 2016;69(6):1188-1194
Abstract
Assisted therapy with dogs in pediatric oncology: relatives’ and nurses’ perceptions
Revista Brasileira de Enfermagem. 2016;69(6):1188-1194
DOI 10.1590/0034-7167-2016-0243
Views0See moreABSTRACT
Objective:
to understand the perception of nursing staff professionals and legal guardians of children and adolescents with cancer regarding Assisted Therapy with dogs.
Method:
qualitative study based on participant observation conducted with 16 participants in a reference hospital of child cancer. We applied an in-depth interview and interpreted the data according to a content analysis technique.
Results:
the practice is admittedly beneficial to participants despite the fact they do not understand its true objectives and therapeutic applications. Participants only associate it with something distracting and entertaining without realizing the occurrence of a more complex process behind it, which comprises changes besides the emotional ones (more easily perceived).
Conclusion:
the perceptions of participants reinforce recommendations that can be applied in the hospital environment, also showing that the therapy in question can become an effective technology to promote the health of children and adolescents with cancer.
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01-01-2016
Socio-environmental approach in nursing: focusing on rural labor and the use of pesticides
Revista Brasileira de Enfermagem. 2016;69(6):1179-1187
Abstract
Socio-environmental approach in nursing: focusing on rural labor and the use of pesticides
Revista Brasileira de Enfermagem. 2016;69(6):1179-1187
DOI 10.1590/0034-7167-2016-0364
Views0See moreABSTRACT
Objective:
to apply a socio-environmental approach to the relationship between human health and rural labor through a link verification/association between health disorders and the use of pesticides.
Method:
this is a quantitative, cross-sectional, observational and exploratory study with 331 inhabitants of two cities in the state of Rio Grande do Sul, Brazil. Data analysis was conducted by Poisson regression.
Results:
reported health disorders included: mental (62.2%); circulatory (49.8%); dermatologic (45%); respiratory (41%); and gastric (36.2%). Workers who apply pesticides showed a 90% higher prevalence of dermatological alterations when compared to those who did not.
Conclusion:
the socio-environmental approach, comprising elements of the rural environment, of workers, and of the use of pesticides in the work process in connection/association with potential health disorders has shown that rural workers who apply pesticides present a higher prevalence of dermatological alterations.
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