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ERRATUM01-13-2024
ERRATUM
Revista Brasileira de Enfermagem. 2024;77(6):e2024n6e08
Abstract
ERRATUMERRATUM
Revista Brasileira de Enfermagem. 2024;77(6):e2024n6e08
DOI 10.1590/0034-7167.20247706e08
Views0In the article “Brazilian nursing specific situation, middle and micro-range theories: a bibliometric study”, with DOI number: , published in Revista Brasileira de Enfermagem, 2024;77(4):e20230520, Chart 1: Where it read: […]See more -
ERRATUM01-13-2024
ERRATA
Revista Brasileira de Enfermagem. 2024;77(6):e2024n6e07
Abstract
ERRATUMERRATA
Revista Brasileira de Enfermagem. 2024;77(6):e2024n6e07
DOI 10.1590/0034-7167.20247706e06pt
Views0No artigo “Crenças e atitudes de pais ou responsáveis legais sobre a vacinação infantil: revisão de escopo”, com número DOI: , publicado no periódico Revista Brasileira de Enfermagem, 2024;77(4):e20240126, página 5:Onde se lia:[…]See more -
ORIGINAL ARTICLE01-13-2024
Indicators associated with severity and mortality in hospitalized people with HIV: A retrospective cohort
Revista Brasileira de Enfermagem. 2024;77(6):e20240204
Abstract
ORIGINAL ARTICLEIndicators associated with severity and mortality in hospitalized people with HIV: A retrospective cohort
Revista Brasileira de Enfermagem. 2024;77(6):e20240204
DOI 10.1590/0034-7167-2024-0204
Views0See moreABSTRACT
Objectives:
to compare the sociodemographic and clinical severity indicators of hospitalized people with HIV in relation to clinical outcomes and urgent hospital admission.
Methods:
a retrospective cohort study was conducted with 102 medical records of HIV-infected individuals hospitalized in a hospital in southern Brazil. In addition to descriptive analysis, Fisher’s exact test, Pearson’s Chi-square, and logistic regression were used.
Results:
the data showed a significant direct effect on severity indicators in the following variables: male sex (p=0.013), skin color (p=0.023), level of education (p=0.000), urgent admissions (p=0.000), late diagnosis (p=0.001), diabetes mellitus (p=0.001), hypertension (p=0.004), kidney disease (p=0.002), high viral load (p=0.006), CD4+ count below 200 (p=0.005), fever (p=0.016), weight loss (p=0.013), co-infection with hepatitis C (p=0.004), and mortality (p=0.007).
Conclusions:
three sociodemographic and thirteen clinical markers were identified as being associated with the risk of clinical deterioration in hospitalized people with HIV.
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ORIGINAL ARTICLE01-13-2024
Nurses’ perspectives on the use of telemonitoring in the management of people with diabetes and hypertension
Revista Brasileira de Enfermagem. 2024;77(6):e20230481
Abstract
ORIGINAL ARTICLENurses’ perspectives on the use of telemonitoring in the management of people with diabetes and hypertension
Revista Brasileira de Enfermagem. 2024;77(6):e20230481
DOI 10.1590/0034-7167-2023-0481
Views1See moreABSTRACT
Objectives:
to understand the perspective of nurses on the use of telemonitoring in the management of people with type 2 diabetes mellitus and arterial hypertension in primary care.
Methods:
this qualitative research involved sixteen nurses from eight municipalities in Paraná. Data were collected between November 2022 and January 2023 through inperson or remote interviews, which were audio-recorded and subjected to content analysis.
Results:
according to the nurses, telemonitoring enhances users’ knowledge about these conditions, communication and connection with the team, and productivity. However, the lack of electronic resources and equipment, high staff turnover, low user adherence, and the limited availability of professional time present significant challenges.
Final Considerations:
the effective implementation and operation of telemonitoring in the management of people with diabetes and hypertension involve both potential benefits and barriers. It is essential to have the availability of human and technological resources, managerial support, and the commitment of professionals and users.
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ORIGINAL ARTICLE01-13-2024
Knowledge, Attitudes, and Practices of nurses regarding blood culture collection
Revista Brasileira de Enfermagem. 2024;77(6):e20230424
Abstract
ORIGINAL ARTICLEKnowledge, Attitudes, and Practices of nurses regarding blood culture collection
Revista Brasileira de Enfermagem. 2024;77(6):e20230424
DOI 10.1590/0034-7167-2023-0424
Views0ABSTRACT
Objectives:
to investigate the knowledge, attitudes, and practices of nurses regarding blood culture collection.
Methods:
a cross-sectional study was conducted in five Brazilian public hospitals with 112 nurses. Data were collected using an adapted questionnaire and analyzed through descriptive and inferential statistics.
Results:
nurses who did not consider themselves capable of collecting blood cultures had a 72% lower chance of performing the collection at the recommended site and an 83% lower chance of using the same needle for blood inoculation into the vials. Nurses working in the emergency department had a 75% lower chance of knowing the international benchmark for blood culture contamination rates, and those with less than 5 years in the position decreased their chance of accuracy in this matter by 79%.
Conclusions:
there are gaps in the knowledge, attitudes, and practices of nurses regarding blood culture collection. Standardization of the technique, periodic education, supervision and guidance of the collection team, and process auditing are recommended coping strategies.
Keywords:Blood CultureBlood Specimen CollectionHealth Knowledge, Attitudes, PracticeNursing CareQuality of Health CareSee more -
ORIGINAL ARTICLE01-13-2024
Evaluation of care for people with HIV in Primary Health Care: construct validation
Revista Brasileira de Enfermagem. 2024;77(6):e20230190
Abstract
ORIGINAL ARTICLEEvaluation of care for people with HIV in Primary Health Care: construct validation
Revista Brasileira de Enfermagem. 2024;77(6):e20230190
DOI 10.1590/0034-7167-2023-0190
Views0ABSTRACT
Objectives:
to verify the construct validation of an instrument for evaluating care for people living with HIV in Primary Health Care.
Methods:
methodological study carried out in 2021 with 260 health professionals in Recife, PE. Validation based on the internal structure was carried out at this stage using exploratory and confirmatory factor analysis, and validity based on item response theory.
Results:
the validation determined the retention of five factors and 63 items. The instrument’s internal consistency and quality of fit was 0.90, the Tukey-Lewis index was 0.915 and the comparative fit index was 0.918 in the confirmatory factor analysis. The indication for the absolute majority of items is adequate fit.
Conclusions:
the instrument has construct validity, making it possible to use it to evaluate the decentralization process and care for People Living with HIV in Primary Health Care.
Keywords:Acquired Immunodeficiency SyndromeComprehensive Health CareHIVPrimary Health CareProgram EvaluationSee more -
ORIGINAL ARTICLE01-10-2024
Inventory of ethical problems in mobile pre-hospital care
Revista Brasileira de Enfermagem. 2024;77:e20230539
Abstract
ORIGINAL ARTICLEInventory of ethical problems in mobile pre-hospital care
Revista Brasileira de Enfermagem. 2024;77:e20230539
DOI 10.1590/0034-7167-2023-0539
Views0See moreABSTRACT
Objective:
to construct and validate the content of an inventory of ethical problems experienced by nurses in mobile pre-hospital care.
Method:
a psychometric approach study, developed with the following stages: (1) instrument construction through a theoretical matrix based on deliberative bioethics, scoping review and online qualitative research; (2) content validity by judges; (3) pre-testing with Mobile Emergency Care Service nurses in various Brazilian states. For content validity analysis, the Content Validity Ratio was calculated (CVR>0.45 for judges and CVR>0.35 for the target population).
Results:
the instrument had 44 items, distributed across four dimensions.
Final considerations:
the constructed instrument presented sources of evidence of content validity, providing good psychometric measurements and constituting a useful tool for nurses’ practice in the pre-hospital setting.
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Evidências do cuidado centrado no paciente no contexto da prática profissional de saúde brasileira
Revista Brasileira de Enfermagem. 2023;76(5):e20220448
Abstract
Evidências do cuidado centrado no paciente no contexto da prática profissional de saúde brasileira
Revista Brasileira de Enfermagem. 2023;76(5):e20220448
DOI 10.1590/0034-7167-2022-0448
Views0RESUMEN
Objetivos:
analizar las actitudes centradas en el paciente en el cuidado y compartir prácticas de profesionales de enfermería, logopedia, odontología y medicina.
Métodos:
se utilizó una investigación transversal con 411 profesionales, y como medida de resultado se aplicó el instrumento Patient-Practitioner Orientation Scale.
Resultados:
los médicos presentaron puntuaciones medias más altas, lo que refleja una orientación centrada en el paciente, control compartido y enfoque en la persona, con diferencia estadística para todos los dominios (p<0,02). Los odontólogos fueron los profesionales que presentaron puntajes más bajos, especialmente en el dominio compartir, con diferencia estadística en relación a los enfermeros, logopedas y médicos (p<0,05).
Conclusiones:
finalmente, las actitudes de los profesionales de las áreas de salud estudiadas indicaron preferencia autorreferida por la centralidad en los pacientes. En este contexto, el cuidado centrado en el paciente puede ser un recurso importante en el cuidado de la salud cuando se apuesta por la superación del objeto hombre.
Keywords:Assistência Centrada no PacienteCuidado Centrado no PacientePessoal de SaúdePrática ProfissionalProfissional de SaúdeSee more -
ORIGINAL ARTICLE10-06-2023
Patient-centered care – evidence in the context of professional health practice
Revista Brasileira de Enfermagem. 2023;76(5):e20220448
Abstract
ORIGINAL ARTICLEPatient-centered care – evidence in the context of professional health practice
Revista Brasileira de Enfermagem. 2023;76(5):e20220448
DOI 10.1590/0034-7167-2022-0448
Views0ABSTRACT
Objectives:
to analyze patient-centered attitudes in care and sharing practices of nursing, speech therapy, dentistry and medicine professionals.
Methods:
cross-sectional research was used with 411 professionals, and the Patient-Practitioner Orientation Scale instrument was applied as a measure of outcome.
Results:
physicians presented higher mean scores, reflecting a patient-centered orientation, shared control, and focus on the person, with statistical difference for all domains (p<0.02). Dentists were the professionals who presented lower scores, especially in the sharing domain, with statistical difference in relation to nurses, speech therapists, and physicians (p<0.05).
Conclusions:
finally, the attitudes of professionals in the health areas studied indicated self-reported preference for centrality in patients. In this context, patient-centered care can be an important resource in health care when committed to overcoming the object man.
Keywords:Health Care ProfessionalHealth PersonnelPatient-Centered CarePerson Centered CareProfessional PracticeSee more -
ORIGINAL ARTICLE10-06-2023
Perception of graduates about the education of Nursing Technicians
Revista Brasileira de Enfermagem. 2023;76(5):e20220325
Abstract
ORIGINAL ARTICLEPerception of graduates about the education of Nursing Technicians
Revista Brasileira de Enfermagem. 2023;76(5):e20220325
DOI 10.1590/0034-7167-2022-0325
Views0ABSTRACT
Objectives:
to interpret the perception of graduates from the nursing technician program on the learning process developed during their education.
Methods:
a qualitative study was conducted from March to September 2021, based on interviews with 20 graduates from a nursing technician program at a school in the Midwest of São Paulo, using thematic analysis and the NVivo tool.
Results:
the following themes were identified: traditional teaching methods, active learning strategies, valuing proactivity and experiences in professional practice.
Final Considerations:
according to the graduates, the teaching process is essentially based on traditional methods, although there are initiatives to implement active strategies and recognition of the importance of advancing student proactivity and practical experience.
Keywords:AssociateEducationEducation, NursingHealth Human Resource TrainingLearningProfessional TrainingSee more -
ORIGINAL ARTICLE10-06-2023
Effect of guided imagery relaxation on anxiety in cervical cancer: randomized clinical trial
Revista Brasileira de Enfermagem. 2023;76(5):e20210874
Abstract
ORIGINAL ARTICLEEffect of guided imagery relaxation on anxiety in cervical cancer: randomized clinical trial
Revista Brasileira de Enfermagem. 2023;76(5):e20210874
DOI 10.1590/0034-7167-2021-0874
Views0See moreABSTRACT
Objectives:
to evaluate the effect of guided imagery relaxation through virtual reality on anxiety in women with cervical cancer undergoing radiochemotherapy.
Methods:
randomized, non-blinded, single-center clinical trial conducted at a cancer reference hospital. 52 women participated, with randomized allocation of 24 in the control group and 28 in the experimental group (12 sessions of guided imagery relaxation through virtual reality, applied three times a week). The outcome was evaluated using the State-Trait Anxiety Inventory and statistical analysis was performed using the Generalized Linear Mixed Model.
Results:
n the experimental group, women presented significant anxiety traits (p=0.010) before the intervention. Between the 4th and 12th week of follow-up, there was a reduction in anxiety levels, without statistical significance.
Conclusions:
guided imagery relaxation through virtual reality provided evidence of anxiety reduction in women with cervical cancer undergoing radiochemotherapy and may contribute to clinical practice. Brazilian Clinical Trial Registry: RBR-7ssvytb.
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A inteligência artificial como aliada na enfermagem brasileira: desafios, oportunidades e responsabilidade profissional
Revista Brasileira de Enfermagem. 2023;76(3):e760301
Abstract
A inteligência artificial como aliada na enfermagem brasileira: desafios, oportunidades e responsabilidade profissional
Revista Brasileira de Enfermagem. 2023;76(3):e760301
DOI 10.1590/0034-7167.2023760301pt
Views0O estado atual da enfermagem no Brasil apresenta desafios e oportunidades complexas que requerem soluções inovadoras. Nesse contexto, a inteligência artificial (IA) surge como uma ferramenta promissora para enfrentar esses desafios e aproveitar as oportunidades. Em particular, os modelos de processamento de linguagem natural, como o ChatGPT da OpenAI, demonstram potencial para serem recursos valiosos […]See more -
Artificial intelligence as an ally in Brazilian nursing: challenges, opportunities and professional responsibility
Revista Brasileira de Enfermagem. 2023;76(3):e760301
Abstract
Artificial intelligence as an ally in Brazilian nursing: challenges, opportunities and professional responsibility
Revista Brasileira de Enfermagem. 2023;76(3):e760301
DOI 10.1590/0034-7167.2023760301
Views0The current state of nursing in Brazil presents complex challenges and opportunities that require innovative solutions. In this context, artificial intelligence (AI) emerges as a promising tool to address these challenges and seize opportunities. In particular, natural language processing models, such as OpenAI’s ChatGPT, demonstrate the potential to be valuable resources for nurses at all […]See more -
ORIGINAL ARTICLE09-18-2023
Vaccination coverage in children under one year of age and associated socioeconomic factors: maps of spatial heterogeneity
Revista Brasileira de Enfermagem. 2023;76(4):e20220734
Abstract
ORIGINAL ARTICLEVaccination coverage in children under one year of age and associated socioeconomic factors: maps of spatial heterogeneity
Revista Brasileira de Enfermagem. 2023;76(4):e20220734
DOI 10.1590/0034-7167-2022-0734
Views0See moreABSTRACT
Objective:
to analyze vaccination coverage spatial distribution in children under one year old and the socioeconomic factors associated with meeting the recommended goals in Minas Gerais.
Methods:
an ecological study, carried out in 853 municipalities in the state. Pentavalent, poliomyelitis, meningococcal conjugate, yellow fever, rotavirus, and 10-valent pneumococcal conjugate vaccination coverage were analyzed. Scan statistics and multiple logistic regression were performed to identify spatial clusters and factors associated with meeting coverage goals.
Results:
spatial analysis revealed clusters with risk of low coverage for all vaccines. Number of families with per capita income of up to 1/2 wage, Minas Gerais Social Responsibility Index and percentage of the poor or extremely poor population were associated with meeting the established goals.
Conclusions:
the results are useful for designing interventions regarding the structuring of vaccination services and the implementation of actions to increase vaccination coverage in clusters with less propensity to vaccinate.
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La cronicidad en el siglo XXI: frente a los desafíos de una sociedad cambiante
Revista Brasileira de Enfermagem. 2023;76(4):e760401
Abstract
La cronicidad en el siglo XXI: frente a los desafíos de una sociedad cambiante
Revista Brasileira de Enfermagem. 2023;76(4):e760401
DOI 10.1590/0034-7167.2023760401es
Views0Actualmente, existe un aumento de las enfermedades no transmisibles (ENT), el envejecimiento de la población y los cambios en el estilo de vida, lo que corrobora el aumento de la cronicidad, uno de los mayores desafíos que enfrenta la sociedad contemporánea. En este editorial examinaremos la cronicidad en el siglo XXI y la necesidad de […]See more
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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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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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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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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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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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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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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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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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