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ORIGINAL ARTICLE06-28-2024
Quality of Care Transition for COVID-19 Patients in a University Hospital in Southern Brazil
Revista Brasileira de Enfermagem. 2024;77:e20230402
Abstract
ORIGINAL ARTICLEQuality of Care Transition for COVID-19 Patients in a University Hospital in Southern Brazil
Revista Brasileira de Enfermagem. 2024;77:e20230402
DOI 10.1590/0034-7167-2023-0402
Views0See moreABSTRACT
Objective:
To assess the quality of care transition from hospital to home for COVID-19 patients.
Method:
A cross-sectional study conducted at a University Hospital in Southern Brazil, involving 78 patients discharged after COVID-19 hospitalization. Data collection was performed via telephone using the Brazilian version of the Care Transitions Measure (CTM-15). Data were analyzed using descriptive and analytical statistics.
Results:
The mean quality of care transition was 70.8 on a scale ranging from zero to 100, indicating moderate quality of care transition. The highest score was attributed to factor 1, “Preparation for self-management,” and the lowest to factor 4, “Care Plan.”
Conclusions:
It is important to enhance communication and support provided to patients during the transition process, especially regarding understanding prescribed medications and the development of clear care plans.
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REVIEW06-28-2024
Desfechos clínicos em recém-nascidos de mulheres grávidas com COVID-19: revisão integrativa
Revista Brasileira de Enfermagem. 2024;77:e20230400
Abstract
REVIEWDesfechos clínicos em recém-nascidos de mulheres grávidas com COVID-19: revisão integrativa
Revista Brasileira de Enfermagem. 2024;77:e20230400
DOI 10.1590/0034-7167-2023-0400
Views0See moreRESUMEN
Objetivos:
analizar los desenlaces clínicos en recién nacidos de mujeres embarazadas con COVID-19.
Métodos:
revisión integradora realizada en PubMed, Web of Knowledge, SCOPUS, CINHAL; se obtuvieron 2.111 estudios y 8 artículos conformaron la muestra final.
Resultados:
los desenlaces clínicos en neonatos de mujeres embarazadas positivas para COVID-19 se clasificaron según las siguientes categorías: a) contaminación por COVID-19, reportada en el 62,5% de los estudios; b) alta hospitalaria debido a mejoría, mencionada en el 37,5% de los artículos; c) fallecimiento, representando casos raros en el 25% de la muestra. La complicación gestacional más prevalente fue la prematuridad, mencionada en el 75% de los estudios. Esta complicación se observó debido a casos de rotura prematura de membranas y desprendimiento de placenta.
Conclusiones:
a pesar del conocimiento del comportamiento asintomático y levemente sintomático en los recién nacidos, es importante continuar la búsqueda de nuevos datos clínicos, ya que este público presenta reacciones inciertas a la infección por el SARS-CoV-2.
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REVIEW06-28-2024
Clinical outcomes in newborns of pregnant women with COVID-19: integrative review
Revista Brasileira de Enfermagem. 2024;77:e20230400
Abstract
REVIEWClinical outcomes in newborns of pregnant women with COVID-19: integrative review
Revista Brasileira de Enfermagem. 2024;77:e20230400
DOI 10.1590/0034-7167-2023-0400
Views0See moreABSTRACT
Objectives:
to analyze clinical outcomes in newborns of pregnant women with COVID-19.
Methods:
integrative review conducted in PubMed, Web of Knowledge, SCOPUS, CINHAL; 2,111 studies were obtained, and 8 articles comprised the final sample.
Results:
clinical outcomes in neonates of pregnant women positive for COVID-19 were classified according to the following categories: a) contamination by COVID-19, reported in 62.5% of the studies; b) hospital discharge due to improvement, mentioned in 37.5% of the articles; c) death, representing rare cases in 25% of the sample. The most prevalent gestational complication was prematurity, mentioned in 75% of the studies. This complication has been observed due to cases of premature rupture of membranes and placental abruption.
Conclusions:
despite the knowledge of asymptomatic and mildly symptomatic behavior in neonates, it is important to continue the search for new clinical data, as this public has uncertain reactions to SARS-CoV-2 infection.
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ORIGINAL ARTICLE06-28-2024
Nursing leadership strategies in addressing COVID-19 in light of John Kotter’s framework
Revista Brasileira de Enfermagem. 2024;77:e20230289
Abstract
ORIGINAL ARTICLENursing leadership strategies in addressing COVID-19 in light of John Kotter’s framework
Revista Brasileira de Enfermagem. 2024;77:e20230289
DOI 10.1590/0034-7167-2023-0289
Views0See moreABSTRACT
Objective:
To analyze the leadership strategies of nurses in university hospitals in response to care management changes during the COVID-19 pandemic, informed by John Kotter’s insights.
Methods:
This multicentric study utilized qualitative and analytical methods. It was conducted through semi-structured interviews with 139 lead nurses from 10 university hospitals in Brazil. Data analysis included Bardin’s content analysis and the webQDA software.
Results:
The primary category identified was “Nursing Leadership Strategies in the Battle Against COVID-19,” encompassing five subcategories. This category underscored the importance of strategic vision in nursing leadership for combating COVID-19 within hospital settings, as well as the necessity of working collaboratively with their teams and other healthcare professionals.
Final Considerations:
The results highlight the strategies used by lead nurses in confronting COVID-19, which can be associated with John Kotter’s theoretical framework and his model of change.
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ORIGINAL ARTICLE06-28-2024
Palliative Care for SARS-CoV-2 Patients in the Intensive Care Unit: A Comprehensive Study
Revista Brasileira de Enfermagem. 2024;77:e20230218
Abstract
ORIGINAL ARTICLEPalliative Care for SARS-CoV-2 Patients in the Intensive Care Unit: A Comprehensive Study
Revista Brasileira de Enfermagem. 2024;77:e20230218
DOI 10.1590/0034-7167-2023-0218
Views0See moreABSTRACT
Objective:
To comprehend the multiprofessional actions regarding palliative care for patients in the Intensive Care Unit affected by SARS-CoV-2.
Methods:
A comprehensive qualitative study conducted with 31 professionals from the Intensive Care Units of a university hospital, based on the Theory of Peaceful End of Life.
Results:
The analysis of the discourse led to the identification of two categories: “Multidisciplinary actions to promote comfort at the end of life” and “Palliative care during the pandemic period and the promotion of emotional and spiritual comfort.”
Final Considerations:
It became evident that local administration needs to invest in measures that reduce barriers to the implementation of palliative care during times of crisis. Understanding the discourse highlighted that non-specialized professionals can provide basic palliative care appropriately, without diminishing the importance and necessity of the presence of palliative care specialists in various hospital areas.
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ORIGINAL ARTICLE06-28-2024
Uncertainties experienced by nursing professionals who contracted Covid-19: a priori, everyone is human
Revista Brasileira de Enfermagem. 2024;77:e20230142
Abstract
ORIGINAL ARTICLEUncertainties experienced by nursing professionals who contracted Covid-19: a priori, everyone is human
Revista Brasileira de Enfermagem. 2024;77:e20230142
DOI 10.1590/0034-7167-2023-0142
Views0See moreABSTRACT
Objective:
To analyze the uncertainties experienced by nursing professionals who contracted COVID-19.
Methods:
This qualitative research was conducted with 20 nursing professionals who fell ill from COVID-19. Data collection was carried out through semi-structured interviews; the data were then organized using thematic analysis and discussed in the context of Merle Mishel’s Reconceptualized of Uncertainty in Illness Theory.
Results:
The antecedents of the disease had a strong influence on how nursing professionals who contracted COVID-19 perceived uncertainty. The media coverage of the increasing number of cases, the collapse of the healthcare system, and the high mortality rate contributed to associating the disease with fear and panic.
Final Considerations:
Viewing it from the perspective of the disease’s antecedents, the illness of a nursing professional from COVID-19 underscores that before being professionals, they are human beings just like anyone else, undergoing adversities and facing the possibilities associated with being ill.
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ORIGINAL ARTICLE06-28-2024
COVID-19 pandemic: what factors compromised the mental capacity to work of nursing technicians?
Revista Brasileira de Enfermagem. 2024;77:e20220783
Abstract
ORIGINAL ARTICLECOVID-19 pandemic: what factors compromised the mental capacity to work of nursing technicians?
Revista Brasileira de Enfermagem. 2024;77:e20220783
DOI 10.1590/0034-7167-2022-0783
Views0See moreABSTRACT
Objectives:
to identify the factors that influenced the mental capacity to work of nursing technicians during the COVID-19 pandemic.
Methods:
a cross-sectional study, carried out at two reference hospitals in assisting the population during the COVID-19 pandemic. A total of 237 professionals from Intensive Care Units participated and answered a questionnaire. Multiple linear regression models were used to assess the correlation between mental capacity to work and variables related to risks of contamination, institutional support and health.
Results:
lack of COVID-19 tests, lack of knowledge of routine, absences in 2021 and mental illness contributed to worse mental capacity to work. Management embracement and physical capacity were considered protective factors.
Conclusions:
reduced work capacity in relation to mental demands can affect professional performance and quality of care, with implications for patients and health institutions.
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ORIGINAL ARTICLE06-17-2024
Website for families of non-breastfed children: development and validation of content and interface
Revista Brasileira de Enfermagem. 2024;77(3):e20230490
Abstract
ORIGINAL ARTICLEWebsite for families of non-breastfed children: development and validation of content and interface
Revista Brasileira de Enfermagem. 2024;77(3):e20230490
DOI 10.1590/0034-7167-2023-0490
Views0See moreABSTRACT
Objectives:
to develop and validate the content and interface of a guidance website to support families in promoting Food and Nutrition Security for children under six months who are not breastfed.
Methods:
methodological study, Knowledge Translation, in two stages of creation: 1) content and validation on the criterion of accuracy in a panel of experts; 2) interface and validation on the criteria of content, language, illustrations, layout, motivation, culture and applicability.
Results:
the “Milky Way” website is freely available: . The content was structured in a decision tree made up of types of milk: milk formula, whole cow’s milk and powdered milk; and utensils: bottle, cup and measuring spoon. There were 46 illustrations to elucidate the content, facilitate understanding and engage the target population. The Content Validity Index was 0.91.
Conclusions:
the website is a validated technology with evidence-based written and pictorial content translated for use with families.
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ORIGINAL ARTICLE12-13-2024
Nurses’ experience regarding patient safety in mobile pre-hospital care
Revista Brasileira de Enfermagem. 2024;77(5):e20230529
Abstract
ORIGINAL ARTICLENurses’ experience regarding patient safety in mobile pre-hospital care
Revista Brasileira de Enfermagem. 2024;77(5):e20230529
DOI 10.1590/0034-7167-2023-0529
Views0See moreABSTRACT
Objectives:
to understand nurses’ experience regarding patient safety in mobile pre-hospital care.
Method:
a qualitative, exploratory and descriptive study, conducted with nurses active in mobile pre-hospital care services. Semi-structured interviews were conducted, audio-graved and submitted to Bardin’s content analysis.
Results:
from four thematic categories established, nurses reported the care and management skills necessary to work in this service. They demonstrated a commitment to ensuring safe care for patients, staff and spectators. They highlighted the actions taken to prevent and mitigate incidents. However, they based their experiences on practice protocols and individual actions, expressing the need to improve knowledge about patient safety.
Final Considerations:
mobile pre-hospital care nurses’ experience in relation to patient safety was limited, suggesting the need for training on the subject, alignment of work processes and implementation of strategies, aiming to guarantee safe care.
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ORIGINAL ARTICLE12-13-2024
Repercussions of the pandemic on tuberculosis control actions from the perspective of health professionals
Revista Brasileira de Enfermagem. 2024;77(5):e20230477
Abstract
ORIGINAL ARTICLERepercussions of the pandemic on tuberculosis control actions from the perspective of health professionals
Revista Brasileira de Enfermagem. 2024;77(5):e20230477
DOI 10.1590/0034-7167-2023-0477
Views0See moreABSTRACT
Objectives:
to analyze the repercussions of the COVID-19 pandemic on tuberculosis control actions from the perspective of primary health care professionals.
Methods:
this descriptive study with a qualitative approach was conducted from November 2022 to April 2023, using semi-structured interviews with 11 key informant professionals from primary health care units in a Brazilian capital. Data were organized using Atlas.ti 22.0 software and subjected to thematic-categorical content analysis.
Results:
the pandemic scenario caused alterations in the work process, necessitating abrupt adaptations, and led to detrimental impacts on the health of professionals and tuberculosis control actions, which were reduced or discontinued.
Final Considerations:
there was evident unpreparedness and a lack of resources from various governmental levels and health services to handle the public health emergency situation without severe harm to the provision of essential services.
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Training of Brazilian indigenous nurses: between human rights, valuing diversity and inclusion
Revista Brasileira de Enfermagem. 2024;77(5):e20230430
Abstract
Training of Brazilian indigenous nurses: between human rights, valuing diversity and inclusion
Revista Brasileira de Enfermagem. 2024;77(5):e20230430
DOI 10.1590/0034-7167-2023-0430
Views0See moreABSTRACT
Objectives:
to analyze the possibilities and potential of training indigenous nurses, given the Brazilian Health System (SUS), understanding the relationships between education and health.
Methods:
theoretical-reflective study, based on scientific literature, aligned with the experience, critical thinking of its authors and the Sustainable Development Goals in Brazil.
Results:
this text articulates three axes: Potential for including indigenous students in nursing training; Paths to achieving equity through inclusion and retention policies for indigenous students at different levels; and Implications of this for the SUS and global health.
Final Considerations:
indigenous students, beneficiaries of affirmative actions, face challenges of inclusion and retention in public universities that directly impact their academic training. Added to this are the difficulties identified in basic education, professor training and implementation of permanence policies, with consequences for services and training at other levels.
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ORIGINAL ARTICLE12-13-2024
Interobserver agreement in Reception and Risk Stratification in Obstetrics implementation
Revista Brasileira de Enfermagem. 2024;77(5):e20230361
Abstract
ORIGINAL ARTICLEInterobserver agreement in Reception and Risk Stratification in Obstetrics implementation
Revista Brasileira de Enfermagem. 2024;77(5):e20230361
DOI 10.1590/0034-7167-2023-0361
Views0See moreABSTRACT
Objectives:
to analyze interobserver agreement in the Reception and Risk Stratification in Obstetrics protocol implementation.
Methods:
a cross-sectional study carried out during Reception and Risk Stratification in Obstetrics implementation, conducted in a tertiary hospital in southern Brazil with 891 participants in January 2020. Descriptive and interobserver agreement analysis was carried out using the Kappa coefficient in the risk stratification assigned by the triage nurse and reviewed by the researcher.
Results:
around half of the calls (55.6%) were stratified as not very urgent (green), followed by urgent (yellow) (31.8%), very urgent (orange) (9.3%), not urgent (blue) (3.4%) and no emerging stratification (red). Agreement analysis of revised stratification found Kappa values of 0.20 (blue), 0.54 (green), 0.77 (yellow) and 0.80 (orange).
Conclusions:
most appointments were non-urgent. The agreement analysis between the revised and assigned risk stratification revealed greater interobserver agreement as the priority level increased.
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ORIGINAL ARTICLE12-13-2024
Adaptation and implementation of a Nursing care protocol for children in the Amazon Region
Revista Brasileira de Enfermagem. 2024;77(5):e20230245
Abstract
ORIGINAL ARTICLEAdaptation and implementation of a Nursing care protocol for children in the Amazon Region
Revista Brasileira de Enfermagem. 2024;77(5):e20230245
DOI 10.1590/0034-7167-2023-0245
Views0See moreABSTRACT
Objectives:
to describe the process of implementing an adapted protocol for pediatric nursing care in a health unit located in a municipality in the Amazon Region.
Methods:
methodological research conducted in a basic health unit with four family health teams in the state of Rondônia, involving seven nursing professionals. Data collection occurred between October 2020 and April 2022, following the research phases: situational diagnosis, exploratory phase, protocol definition, implementation, and evaluation.
Results:
the outcome was the adaptation and implementation of a nursing care protocol for children.
Final Considerations:
the adaptation and implementation process can be an effective approach to improving care, strengthening nursing as a profession with a solid foundation in scientific and clinical evidence. This facilitates early problem identification and appropriate guidance, leading to better health outcomes for children.
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ORIGINAL ARTICLE12-13-2024
Nurses’ experiences in caring for people with mental health problems hospitalized due to clinical comorbidities
Revista Brasileira de Enfermagem. 2024;77(5):e20230136
Abstract
ORIGINAL ARTICLENurses’ experiences in caring for people with mental health problems hospitalized due to clinical comorbidities
Revista Brasileira de Enfermagem. 2024;77(5):e20230136
DOI 10.1590/0034-7167-2023-0136
Views0See moreABSTRACT
Objectives:
to understand nurses’ experiences in caring for people with mental health problems hospitalized due to clinical comorbidities in non-psychiatric Inpatient Units.
Methods:
qualitative study, guided by Alfred Schutz’s social phenomenology. Sixteen phenomenological interviews were conducted. The content was analyzed and discussed based on the literature, through the composition of three categories of analysis.
Results:
three categories emerged in the study: Challenges in care faced by nurses; Fragmented care action; and Ideal care. The disarticulation of the clinic was revealed, as described by nurses, showing care as an action far removed from the comprehensiveness of a person. Nurses’ performance is guided predominantly by biomedical reference, disregarding appreciation of subjectivity.
Final Considerations:
it was observed that nurses attribute the responsibility for patient care to factors external to their life-world, when, in fact, these aspects should be components that help them in comprehensive care construction.
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REVIEW11-29-2024
Assessment of knowledge in oncology about care for transgender people: a scoping review
Revista Brasileira de Enfermagem. 2024;77:e20230532
Abstract
REVIEWAssessment of knowledge in oncology about care for transgender people: a scoping review
Revista Brasileira de Enfermagem. 2024;77:e20230532
DOI 10.1590/0034-7167-2023-0532
Views0ABSTRACT
Objective:
to identify evidence available in the literature on instruments and methodologies used to assess healthcare professionals’ knowledge about cancer care for the transgender population.
Methods:
a scoping review was conducted in seven databases, including studies that answered the question: what is the healthcare professionals’ level of knowledge about cancer care for the transgender population?
Results:
forty-one articles were selected that dealt specifically with healthcare professionals’knowledge in relation to care for the LGBTQIAPN+ population, especially the transgender population. Eighteen studies assessed patients’ perceptions of professionals’knowledge, whereas other studies used their own assessment tools, considering the global context of LGBTQIAPN+ health.
Conclusions:
there is no tested and validated instrument that assesses the knowledge about the transgender population’s oncological health, highlighting the need to construct and validate an instrument focused on this population’s needs.
Keywords:Health Services for Transgender PeopleNeoplasmsOncologyProfessional TrainingTransgender PeopleSee more
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EDITORIAL01-01-2017
Enfermagem em cardiologia: estado da arte e fronteiras do conhecimento
Revista Brasileira de Enfermagem. 2017;70(3):451-452
Abstract
EDITORIALEnfermagem em cardiologia: estado da arte e fronteiras do conhecimento
Revista Brasileira de Enfermagem. 2017;70(3):451-452
DOI 10.1590/0034-7167.2017700301
Views0As doenças cardíacas lideram o grupo das desordens clínicas de maiores taxas de hospitalização e mortalidade, além de apresentarem um progressivo aumento da incidência na população devido ao envelhecimento concomitante ao desenvolvimento das terapias e tecnologias em saúde. Uma estimativa obtida pelo DATASUS() acusa um gasto onerado ao sistema de saúde do país, no ano […]See more -
EDITORIAL01-01-2017
Nursing in cardiology: state of the art and frontiers of knowledge
Revista Brasileira de Enfermagem. 2017;70(3):451-452
Abstract
EDITORIALNursing in cardiology: state of the art and frontiers of knowledge
Revista Brasileira de Enfermagem. 2017;70(3):451-452
DOI 10.1590/0034-7167.2017700301
Views0Heart diseases lead the group of clinical disorders with higher rates of hospitalization and mortality and present a progressive increase in incidence due to population ageing, simultaneously to the development of new health therapies and technology. DATASUS() estimated a cost of nearly 700 million Reais for the country’s health care system in 2015, only for […]See more -
REFLECTION01-01-2017
Nursing care in early childhood: contributions from intersubjective recognition
Revista Brasileira de Enfermagem. 2017;70(2):446-450
Abstract
REFLECTIONNursing care in early childhood: contributions from intersubjective recognition
Revista Brasileira de Enfermagem. 2017;70(2):446-450
DOI 10.1590/0034-7167-2016-0319
Views0See moreABSTRACT
Objective:
to understand the elements composing intersubjective recognition that are relevant for nursing care in early childhood in favor of comprehensive child development.
Method:
reflexive study based on the Honnethian concept of intersubjective recognition in the dimensions of affection, defense of rights, and social esteem.
Results:
nursing knowledge and practices, permeated by the intersubjective recognition in the mentioned dimensions, contribute to the dynamism of interpersonal relations, the production of co-responsibility, and shared construction of health care in early childhood, with benefits to comprehensive development.
Conclusion:
a successful coordination of the three intersubjective dimensions enables the expansion of the understanding on childhood and nursing care in child health in the field of human development promotion, covering affection, defense of rights, and social esteem in the established relationships with future positive individual and social possibilities.
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REFLECTION01-01-2017
Hand hygiene as a caring practice: a reflection on professional responsibility
Revista Brasileira de Enfermagem. 2017;70(2):442-445
Abstract
REFLECTIONHand hygiene as a caring practice: a reflection on professional responsibility
Revista Brasileira de Enfermagem. 2017;70(2):442-445
DOI 10.1590/0034-7167-2016-0189
Views0ABSTRACT
Hand hygiene represents a fundamental nursing care practice and is traditionally considered the most important and effective measure in the prevention and control of healthcare-related infections. However, studies indicate that adherence to the procedure is unsatisfactory throughout the world, and show low adherence rates. In a context in which patient safety stands out as a priority, this text submits refl ections about professional responsibility when not adhering to hand hygiene practices, and ethical aspects related to this conduct.
Keywords:Cross InfectionsHand hygieneKnowledge, Health Knowledge, Attitudes, PracticeNursing CarePatient SafetySee more -
REFLECTION01-01-2017
Brazilian method for the development terminological subsets of ICNP®: limits and potentialities
Revista Brasileira de Enfermagem. 2017;70(2):430-435
Abstract
REFLECTIONBrazilian method for the development terminological subsets of ICNP®: limits and potentialities
Revista Brasileira de Enfermagem. 2017;70(2):430-435
DOI 10.1590/0034-7167-2016-0308
Views1See moreABSTRACT
Reflection on the limits and potentialities of a Brazilian method for the development of terminological subsets of ICNP®,(International Classification for Nursing Practice) based on the correlation between this method and international methods. This issue has been debated by the International Council of Nurses (ICN). Although the council propose a guideline for elaboration, they encourage and reinforce the use of various perspectives and processes in the development of subsets. Brazilian Nursing needs to propose a method and deepen reflections on the use of terminological subsets of ICNP® in the reality of the country. The development of subsets in Brazil is considered incipient and the proposed method needs to be used and deepened in order to spread the use of terminology through the application of subsets.
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EXPERIENCE REPORT01-01-2017
Focus group on qualitative research: experience report
Revista Brasileira de Enfermagem. 2017;70(2):424-429
Abstract
EXPERIENCE REPORTFocus group on qualitative research: experience report
Revista Brasileira de Enfermagem. 2017;70(2):424-429
DOI 10.1590/0034-7167-2016-0091
Views0See moreABSTRACT
Objective:
to report the experience of applying the focus group technique for production of data in qualitative research.
Method:
four group sessions were held from May to June 2015, with the participation of professionals from the public sector of PHC and from specialized service.
Results:
the way focus group was developed is described in steps: planning, recruitment, ambience, group sessions, and evaluation.
Conclusion:
we highlight that the focus group, as a technique to produce data in collective space, can contribute not only to the construction of knowledge in Nursing, but also to the research approach with the assistance practice.
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REVIEW01-01-2017
Patient with stroke: hospital discharge planning, functionality and quality of life
Revista Brasileira de Enfermagem. 2017;70(2):415-423
Abstract
REVIEWPatient with stroke: hospital discharge planning, functionality and quality of life
Revista Brasileira de Enfermagem. 2017;70(2):415-423
DOI 10.1590/0034-7167-2016-0166
Views0See moreABSTRACT
Objective:
analyze the strategies of hospital discharge planning for these patients, increasing the knowledge related to hospitalhome transition, discharge planning processes and the main impact on the quality of life and functionality.
Method:
integrative literature review using the PICOD criteria, with database research.
Results:
19 articles were obtained, using several approaches and contexts. For quality of life, the factors related to the patient satisfaction with care and the psychoemotional aspects linked with functionality are the most significant.
Conclusion:
during the hospitalization period, a careful hospital discharge planning and comprehensive care to patients and caregivers – in particular the functional and psychoemotional aspects – tend to have an impact on the quality of life of patients.
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