SCOPING REVIEW PROTOCOL

 

NURSING TELECONSULTATION FOR ADULT ONCOLOGY PATIENTS IN PALLIATIVE CARE: A SCOPING REVIEW PROTOCOL

 

TELECONSULTA DE ENFERMERÍA PARA PACIENTES ONCOLÓGICOS ADULTOS EN CUIDADOS PALIATIVOS: UN PROTOCOLO DE REVISIÓN DEL ALCANCE

 

TELECONSULTA DE ENFERMAGEM PARA PACIENTES ADULTOS ONCOLÓGICOS EM CUIDADOS PALIATIVOS: PROTOCOLO DE REVISÃO DE ESCOPO

 

https://doi.org/10.31011/reaid-2025-v.99-n.4-art.2625

 

1Dayana Feital Pimentel

2Fatima Helena do Espirito Santo

3Mariana Roberta Lopes Simões

 

1Mestranda no Programa de Mestrado Profissional de Enfermagem da Universidade Federal Fluminense, Niterói, Brazil. ORCID: https://orcid.org/0000-0002-3773-5698

2Profª Drª da Universidade Federal Fluminense, Niterói, Brazil. ORCID: https://orcid.org/0000-0003-4611-5586

3Profª Drª da Universidade Federal dos Vales Jequitinhonha e Mucuri, Diamantina, Brazil. ORCID: https://orcid.org/0000-0003-0543-6906

 

Corresponding Author

Dayana Feital Pimentel

Rua Hannibal Porto 501 BL16 APT 304, Irajá, Rio de Janeiro, RJ. Brazil. CEP: 21230-330. phone: +55(21) 981027657 E-mail: daypimentel992@gmail.com

 

Submission: 14-08-2025

Approval: 14-10-2025

 

ABSTRACT

Introduction: Assistance in the area of palliative care is characterized by its complexity, requiring the multi-professional team to have a comprehensive set of skills aimed at promoting patients' quality of life. The clinical conditions associated with the diseases that affect these individuals often make it difficult to visit them in person. In this context, the use of technologies such as telephone follow-up is a promising strategy for ensuring continuity of care. Objective: To map scientific evidence on nursing teleconsultation for adult oncology patients in palliative care. Method: This is a scoping review protocol and will follow the methodological recommendations proposed by the Joanna Briggs Institute (JBI). Searches will be carried out in the electronic databases SCOPUS, BDENF, CINAHL, PUBMED, LILACS and Google Scholar. Studies will be considered eligible if they answer the research question: “What is the evidence for building a nursing teleconsultation service for adult oncology patients in palliative care?”. After searching the databases, all the articles will be exported to the EndNote reference manager (Clarivate Analytics, PA, USA), where they will be organized to automatically identify and remove duplicates. The records will then be transferred to the Rayyan platform (Qatar Computing Research Institute), where blind screening will be conducted by two independent reviewers, and if there is any disagreement, it will be resolved by a third reviewer. The results will be presented in accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). This protocol has been registered with the Open Science Framework (OSF).

Keywords: Remote Consultation; Palliative Care; Medical Oncology; Nursing.

 

RESUMEN

Introducción: Los cuidados paliativos se caracterizan por su complejidad, lo que requiere un conjunto integral de habilidades del equipo multidisciplinario para promover la calidad de vida de los pacientes. Las condiciones clínicas asociadas con las enfermedades que afectan a estos individuos a menudo dificultan las consultas presenciales. En este contexto, el uso de tecnologías, como el seguimiento telefónico, se presenta como una estrategia prometedora para garantizar la continuidad de la atención. Objetivo: Mapear la evidencia científica sobre la teleconsulta de enfermería para pacientes adultos con cáncer en cuidados paliativos. Método: Este es un protocolo de revisión exploratoria que seguirá las recomendaciones metodológicas propuestas por el Instituto Joanna Briggs (JBI). Se realizarán búsquedas en las bases de datos electrónicas SCOPUS, BDENF, CINAHL, PUBMED, LILACS y Google Académico. Se considerarán elegibles los estudios que respondan a la pregunta de investigación: "¿Cuál es la evidencia para el desarrollo de un servicio de teleconsulta de enfermería para pacientes adultos con cáncer en cuidados paliativos?". Tras la búsqueda en las bases de datos, todos los artículos se exportarán al gestor de referencias EndNote (Clarivate Analytics, PA, EE. UU.), donde se organizarán para la identificación y eliminación automática de duplicados. Los registros se transferirán a la plataforma Rayyan (Qatar Computing Research Institute), donde dos revisores independientes realizarán una revisión a ciegas. En caso de desacuerdo, un tercer revisor resolverá los hallazgos. Los resultados se presentarán según la extensión PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews). Este protocolo se ha registrado en el Open Science Framework (OSF).

Palabras clave: Consulta Remota; Cuidados Paliativos; Oncología Médica; Enfermería.

 

RESUMO

Introdução: A assistência na área dos cuidados paliativos caracteriza-se por sua complexidade, exigindo da equipe multiprofissional um conjunto abrangente de competências voltadas à promoção da qualidade de vida dos pacientes. As condições clínicas associadas às doenças que acometem esses indivíduos frequentemente dificultam a realização de consultas presenciais. Nesse contexto, a utilização de tecnologias, como o acompanhamento telefônico, configura-se como uma estratégia promissora para assegurar a continuidade do cuidado. Objetivo: mapear evidências científicas sobre teleconsulta de enfermagem em pacientes adultos oncológicos em cuidados paliativos. Método: Trata-se de um protocolo de uma revisão de escopo, e seguirá as recomendações metodológicas propostas pela Joanna Briggs Institute (JBI). Serão realizadas pesquisas nas bases de dados eletrônicas SCOPUS, BDENF, CINAHL, PUBMED, LILACS e Google Acadêmico, os estudos serão considerados elegíveis aqueles que respondam à pergunta de pesquisa: “Quais as evidências para a construção de um serviço de teleconsulta de enfermagem para pacientes adultos oncológicos em cuidados paliativos?”. Após a busca nas bases de dados, todos os artigos serão exportados para o gerenciador de referências EndNote (Clarivate Analytics, PA, EUA), onde serão organizados para a identificação e remoção automática de duplicatas. Em seguida, os registros serão transferidos para a plataforma Rayyan (Qatar Computing Research Institute), onde será conduzida a triagem as cegas por dois revisores independentes, caso haja divergência, a resolução será dada por um terceiro revisor. Os resultados serão apresentados conforme orientações do Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Esse protocolo foi registrado na Open Science Framework (OSF).

Palavras-chave: Consulta Remota; Cuidados Paliativos; Oncologia; Enfermagem.

 

 

INTRODUCTION

Palliative Care is defined as a multidisciplinary approach that aims to improve the quality of life of patients facing a life-threatening illness or clinical condition. ¹The National Palliative Care Policy, in accordance with the principles of the Unified Health System (SUS), confirms that access should be universal throughout the entire Health Care Network (RAS), and as early as possible, in conjunction with disease treatment. ²

 There is a shortage in the supply of palliative care services, with only one in ten patients having access to this type of care. However, given the growth of the elderly population and the increase in the incidence of chronic non-communicable diseases, an even greater demand for these services is projected in the coming years. 3

 An estimated 56.8 million people require palliative care, approximately 50% of whom are in their final year of life, and 78% live in low- and middle-income countries. Furthermore, approximately 40 million people are referred for palliative care, yet only 14% benefit from this assistance. 3,4

 In Brazil, the National Palliative Care Policy (PNCP) within the Unified Health System (SUS) advocates that palliative care should be disseminated based on the principles of transversality and capillarity. This implies that this care should not be restricted to a single location or institution. The most appropriate location depends on both clinical needs and care goals, based on the individual's wishes and values. 2

 Palliative care is characterized by its complexity, requiring a comprehensive set of skills from the multidisciplinary team focused on promoting patients' quality of life. The clinical conditions associated with the diseases that affect these individuals often hinder in-person consultations. In this context, the use of technologies, such as telephone follow-up, represents a promising strategy to ensure continuity of care. 4,5

 Teleconsultations were first recorded in Brazil in the 1980s, but this modality was only implemented in 2007 through Ordinance No. 35 GM/MS, which established the National Telehealth Program to support Primary Health Care. This program was reformulated in 2011 by Ordinance No. 2,546. 5,6

 In 2020, during the coronavirus pandemic, there was a significant call for the use of telehealth. This modality of care was essential for the safe continuity of care for both patients and professionals, thus reducing exposure to the virus and overcrowding in health services. 5,7,8,9

 Many changes in healthcare have occurred following the COVID-19 pandemic, one of which was the progressive increase in the use of teleconsultations and their benefits for patients in palliative care. This provided these patients with continued care and symptom control. Furthermore, it was considered an important facilitator for patients with low KPS and those for whom movement is a factor that increases pain and discomfort. 10

Patients in palliative care constantly experience the impacts of their illness, such as progressive functional loss, disability, psychosocial and financial suffering, and image disturbances, making feelings of anger, fear, anguish, and sadness a routine reality. The healthcare team must be prepared to manage these conflicts, promoting quality of life with dignity, empathy, and comfort, recognizing limits, and offering quality service in the most comfortable setting for the patient, whether in the outpatient clinic, hospital, home, or long-term care facility.

 Nursing telemonitoring has proven beneficial for patients with chronic illnesses, enabling more direct communication, strengthening trust, improving self-care, medication adherence, and reducing hospitalizations and emergency room visits.

 Depending on the level of functionality, the ability to perform active work and self-care, managing the patient's health becomes increasingly difficult, and continuing treatment becomes a challenge for the multidisciplinary team. 13

 Thus, the objective of this scoping review is to map scientific evidence on nursing teleconsultation for adult cancer patients receiving palliative care.

 Research Question

 The research question was formulated based on the acronym PCC (Population, Concept, and Context), where P = Population: Adult cancer patients; C = Concept: Nursing teleconsultation; C = Context: Palliative care.

Therefore, the following research question was formulated: "What is the evidence for developing a nursing teleconsultation service for adult cancer patients receiving palliative care?"

 

METHODS

This study is part of a protocol for developing a scoping review and will follow methodological recommendations proposed by the Joanna Briggs Institute (JBI)14 and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols - Extension for Scoping Reviews (PRISMA-ScR)15. This review was registered with the Open Science Framework: DOI 10.17605/OSF.IO/T4VMW

 Eligibility Criteria

 Primary and secondary studies addressing the topic of nursing teleconsultation for cancer patients in palliative care will be included. These studies will be obtained from scientific databases and gray literature sources, with no restrictions on language or year of publication. Studies presented as abstracts, proceedings and programs of scientific meetings, and texts from preprint repositories will be excluded.

 Search Strategy

 The search strategy will be implemented as follows: in the first stage, the indexed terms of each database will be identified, originating from Health Sciences Descriptors (DECs)/Medical Subject Headings (MESH) and Emtree Terms. Subsequently, searches will be conducted in the electronic databases SCOPUS, BDENF, CINAHL, PUBMED, LILACS, and Google Scholar, using the selected search strategy. In the third and final stage of the search, the references of the selected articles will be examined, seeking the identification of any additional studies.

 No limitations will be imposed on the publication period or language used in the search for evidence. If additional information is needed, the authors of the original studies may be contacted. During the review, if the reviewers identify new descriptors, alternative terms, or additional relevant sources, these will be added to the search strategy and duly reported in the final version of the review, in a transparent manner.

 The search strategy was implemented by combining keywords or identified synonyms to expand the results. The descriptors were combined with the Boolean operators “AND” and “OR”, as described in Table 1.

Table 1 - Search strategy.

SEARCH STRATEGY

PUBMED

(Telenursing[mh] OR Remote Consultation[mh] OR Telenursing[tiab] OR Virtual Nursing[tiab] OR Remote Consultation*[tiab] OR Teleconsultation*[tiab] OR Digital Consultation*[tiab] OR Telemonitoring[tiab] OR Tele-Referral*[tiab] OR Telereferral*[tiab] OR Telehealth[tiab] OR Telecare[tiab] OR Virtual Health[tiab] OR eHealth[tiab] OR e-health[tiab] OR Mobile Health[tiab] OR mHealth[tiab] OR m-Health[tiab] OR e-Nursing[tiab] OR Telepalliative Care[tiab]) AND (Nursing[mh] OR Nursing Care[mh] OR Nurses[mh] OR Nursing[tiab] OR Nurse*[tiab]) AND (Palliative Care[mh] OR Palliative[tiab] OR Palliative Medicine[mh] OR Palliative Care[tiab] OR Palliation[tiab]) AND (Neoplasms[mh] OR Carcinoma[mh] OR Adenocarcinoma[mh] OR Sarcoma[mh] OR Neoplas*[tiab] OR Cancer*[tiab] OR Tumor*[tiab] OR Tumour*[tiab] OR Carcinoma*[tiab] OR Adenocarcinoma*[tiab] OR Sarcoma[tiab] OR Malignan*[tiab] OR Onco*[tiab])

SCOPUS

TITLE-ABS(Telenursing OR "Virtual Nursing" OR "Remote Consultation*" OR Teleconsultation* OR "Digital Consultation*" OR Telemonitoring OR Tele-Referral* OR Telereferral* OR Telehealth OR Telecare OR "Virtual Health" OR eHealth OR e-health OR "Mobile Health" OR mHealth OR m-Health OR e-Nursing OR "Telepalliative Care") AND TITLE-ABS(Nursing OR "Nursing Care" OR Nurse*) AND TITLE-ABS("Palliative Care" OR Palliative OR Palliation) AND TITLE-ABS(Neoplas* OR Cancer* OR Tumor* OR Tumour* OR Carcinoma* OR Adenocarcinoma* OR Sarcoma OR Malignan* OR Onco*)

CINAHL

(Telenursing OR "Virtual Nursing" OR "Remote Consultation*" OR Teleconsultation* OR "Digital Consultation*" OR Telemonitoring OR Tele-Referral* OR Telereferral* OR Telehealth OR Telecare OR "Virtual Health" OR eHealth OR e-health OR "Mobile Health" OR mHealth OR m-Health OR "Telepalliative Care") AND (Nursing OR "Nursing Care" OR Nurse*) AND ("Palliative Care" OR Palliative OR Palliation) AND (Neoplas* OR Cancer* OR Tumor* OR Tumour* OR Carcinoma* OR Adenocarcinoma* OR Sarcoma OR Malignan* OR Onco*)

LILACS

(Telenursing OR "Virtual Nursing" OR "Remote Consultation" OR Teleconsultation* OR "Digital Consultation" OR Telemonitoring OR Tele-Referral* OR Telereferral* OR Telehealth OR Telecare OR "Virtual Health" OR "Mobile Health" OR "Telepalliative Care" OR "Tele-enfermagem" OR Telenfermagem OR "Enfermagem Virtual" OR "Consulta Remota" OR Teleconsulta* OR "Consulta Digital" OR Telemonitoramento OR Telerreferência* OR Telessaúde OR Teleassistência OR "Saúde Virtual" OR "Saúde Móvel" OR Teleenfermería OR "Enfermería Virtual" OR Telemonitoreo OR Telesalud OR Teleasistencia OR "Salud Virtual" OR "Salud Móvil") AND ("Palliative Care" OR Palliative OR Palliation) AND (Neoplas* OR Cancer* OR Tumor* OR Tumour* OR Carcinoma* OR Adenocarcinoma* OR Sarcoma OR Malignan* OR Onco*) AND (db:("LILACS"))

GOOGLE

(Telenfermagem OR Telessaúde OR Teleconsulta) AND ("Cuidados Paliativos") AND (Cancer OR Neoplasia* OR Oncol*)

https://abre.ai/telenfermagem-google

Source: Author, 2025

Data Selection

 

After searching the previously selected databases, all records will be exported to the EndNote reference manager (Clarivate Analytics, PA, USA), where they will be organized for automatic duplicate identification and removal. The records will then be transferred to the Rayyan platform (Qatar Computing Research Institute)16, where study screening will be conducted in two stages: in stage 1, selection will be based on reading the titles and abstracts; in stage 2, the selected texts will be read in full, based on the eligibility criteria previously defined in the protocol.

 Both screening stages will be conducted independently by two reviewers. Disagreements will be resolved by consensus or, when necessary, by a third reviewer.

 In accordance with the Joanna Briggs Institute (JBI) Handbook guidelines, a pilot study selection phase will be conducted beforehand to discuss and adjust the inclusion criteria, aiming for a minimum agreement of 75% among the reviewers.

 The entire process will be reported in the final version of the scoping review, with a flowchart containing the results obtained from the various sources of evidence consulted (databases and additional sources), the number of duplicates removed, and the results of the screening and selection phases (phases 1 and 2), including the reasons for exclusion and the final number of studies included.

 

Data Extraction

 

Data extraction from the selected studies will be conducted independently by two reviewers using a data collection instrument developed by the authors themselves, based on the recommendations of the Joanna Briggs Institute (JBI) Handbook. The extracted information will include essential data from the evidence source, such as: name of author(s), year of publication, country of origin, study objective, type and methodological design (clinical or laboratory), methodology employed, main results, and conclusion.

A pilot test will be conducted with three studies to improve consistency among reviewers during the extraction process. If changes to the collection instrument are necessary, these will be duly documented and reported in the final version of the review. As in the screening stage, any disagreements between reviewers will be resolved by consensus or, if necessary, with the mediation of a third reviewer.

 

Data Presentation

 The obtained data will be synthesized and presented in tables and/or charts and/or images, according to the objective of this scoping review. A narrative will be provided to enhance the reader's understanding of the research topic.

 

Conflict of Interest

 

The authors declare no conflict of interest.

 

REFERENCES

 

1.                  World Heath Organization. National cancer control programmes: policies and managerial guidelines.  2ed. Geneva: WHO; 2002. [citado 2024 Jul 25]. Disponível em: https://iris.who.int/bitstream/handle/10665/42494/9241545577.pdf?sequence=1&isAllowed=y.

 

2.                  Ministério da Saúde (BR). Política Nacional de Cuidados Paliativos - PNCP no âmbito do Sistema Único de Saúde - SUS. Portaria GM/MS Nº 3.681, de 07 de maio de 2024. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2024/prt3681_22_05_2024.html. Acesso em: julho/2024

 

3.                  Organização Pan Americana de Saúde. OMS divulga recursos para lidar com flagrante escassez de serviços de cuidados paliativos de qualidade [Internet]. Genebra: OPAS; 5 Out. 2021. [citado 2024 Jul 25]. Disponível em: https://www.paho.org/pt/noticias/5-10-2021-oms-divulga-recursos-para-lidar-com-flagrante-escassez-servicos-cuidados.

 

4.                  Fonseca EEC, Pereira SC da C. Teleconsulta em ambulatório de cuidados paliativos: Relato de experiência. EJHR [Internet]. 2023 Jan 2 [cited 2025 Feb. 10];3(4 Ed. Esp.):992-1001. Disponível em: https://ojs.europubpublications.com/ojs/index.php/ejhr/article/view/617

 

5.                  Silva PL, Santos RS, Xavier KK, Monteiro FS. O uso das teleconsultas em cuidados paliativos: uma revisão integrativa. GEPNEWS [Internet]. maio/ago. 2024 [cited 2025 Feb. 10];8(2):415-20.  Disponível em: https://www.seer.ufal.br/index.php/gepnews/article/view/18614/12144

 

6.                  Cezário LR, Ferreira BF, Manoel AV, Oliveira JM, Mendes KL, Pecorari VA. Telessaúde no Brasil: uma revisão de escopo. Rev Baiana Saúde Pública [Internet] abr./jun. 2024 [cited 2025 Feb. 10]; 48(2):209-24. Disponível em: https://rbsp.sesab.ba.gov.br/index.php/rbsp/article/view/4010/3475

 

7.                  Catapan SC, Calvo, MCM. Teleconsulta: uma Revisão Integrativa da Interação Médico-Paciente Mediada pela Tecnologia. Rev Bras Educação Médica [Internet]. 2020[cited 2025 Feb. 10]; 44(1). Disponível em:  https://www.scielo.br/j/rbem/a/kgh8jpmcFWnTCxfFv6P9RTj/?lang=en

 

8.                  Morais BQ, Santos AF, Araujo PP, França VR, Vezzani MF, Araújo MFSS, et al. O papel da telemedicina no acompanhamento de pacientes crônicos: benefícios e limitações na prática clínica. SHS [Internet]. 2024 Dec. 10 [cited 2025 Feb. 10];5(4):e11894. Disponível em: https://ojs.studiespublicacoes.com.br/ojs/index.php/shs/article/view/11894.

 

9.                  Calton B, Abedini N, Fratkin M. Telemedicine in the Time of Coronavirus. J Pain Symptom Manage. 2020 Jul;60(1):e12-e14. doi: 10.1016/j.jpainsymman.2020.03.019. Epub 2020 Mar 31. PMID: 32240756; PMCID: PMC7271287.

 

10.              Caetano R, Silva AB, Guedes ACCM, Paiva CCN de, Ribeiro G da R, Santos DL, et al. Desafios e oportunidades para telessaúde em tempos da pandemia pela COVID-19: uma reflexão sobre os espaços e iniciativas no contexto brasileiro. Cad Saúde Pública [Internet]. 2020 [cited 2025 Feb. 10];36(5):e00088920. Disponível em: https://doi.org/10.1590/0102-311X0008892

 

11.              Pinto CS, Borsatto AZ, Vaz DC, Sampaio SGSM, Oliveira LC. Telemedicina em Cuidados Paliativos Oncológicos: um Legado da Pandemia. Rev Bras Cancerol [Internet]. 2023 [cited 2025 Feb. 10]; 69(1): e-142698. Disponível em: https://docs.bvsalud.org/biblioref/2023/09/1452015/art14_69-1.pdf

 

12.              Instituto Nacional de Câncer (BR). A avaliação do paciente em cuidados paliativos / Instituto Nacional de Câncer [Internet]. Rio de Janeiro: INCA; 2022 [cited 2025 Feb. 10]. Disponível em: https://www.inca.gov.br/sites/ufu.sti.inca.local/files/media/document/completo_serie_cuidados_paliativos_volume_1.pdf

 

13.              Mussi FC, Palmeira CS, Silva RM, Costa ALS. Telenfermagem: contribuições para o cuidado em saúde e a promoção do conforto. Rev. Cient. Sena Aires [Internet]. 2018 [cited 2025 Feb. 10]; 7(2):76-9. Disponível: https://rdcsa.emnuvens.com.br/revista/article/view/720

 

14.              Fonseca EEC, Pereira SCC. Teleconsulta em ambulatório de cuidados paliativos: Relato de experiência. EJHR [Internet]. 2023 Jan. 2 [cited 2025 Mar 15];3(4 Ed Esp.):992-1001. Disponível em: https://ojs.europubpublications.com/ojs/index.php/ejhr/article/view/617

 

15.              Peters MDJ, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil H. Chapter 11: Scoping Reviews (2020 version). In: Aromataris E, Munn Z (Editors). JBI Manual for Evidence Synthesis, JBI, 2020. https://synthesismanual.jbi.global. https://doi.org/10.46658/JBIMES-20-12

 

16.              Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ [Internet]. 2021 [cited 2025 Mar 15];372(71). Doi: https://doi.org/10.1136/ bmj.n71

 

17.              Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Systematic Reviews. 2016; 5:1-10.

 

Funding and Acknowledgments:

This research did not receive funding.

Authorship Criteria (Author Contributions)

Dayana Feital Pimentel: Contributed substantially to the study design and planning, data collection, analysis, and/or interpretation, and drafting and/or critical review and final approval of the published version.

Fatima Helena do Espírito Santo: Contributed substantially to the study design and planning, data collection, analysis, and/or interpretation, and final approval of the published version.

Mariana Roberta Lopes Simões: Contributed substantially to the study design and planning, data collection, analysis, and/or interpretation, and final approval of the published version.

Declaration of Conflict of Interest:

Nothing to declare

Scientific Editor: Francisco Mayron Morais Soares. Orcid: https://orcid.org/0000-0001-7316-2519

 

Rev Enferm Atual In Derme 2025;99(4): e025141                 

 Atribuição CCBY