A Cross-sectional, Descriptive, Quality Improvement Project to Assess Undergraduate Nursing Students’ Clinical Exposure to Patients With Wounds in an Introductory Nursing Course
Because nurses frequently participate in decisions related to wound care, learning about wounds and their care during undergraduate education is critical. A cross-sectional, descriptive, quality improvement project was conducted in an introductory baccalaureate nursing course to identify: 1) the types of patients with wounds assigned to beginning students, 2) patient wound care procedures and dressings, and 3) student level of participation in wound care.
Data were collected from the weekly notes recorded about students’ (N = 49) patient care experiences in 3 acute care hospitals for 9 clinical days during 1 semester. Data were recorded on a paper-and-pencil form by instructors at the end of the clinical day and included type of wound, wound irrigation, dressing, technique of care, and student’s participation. Descriptive statistics were used to examine the frequency and distribution of the wound characteristics and care assessed. Of the 284 patients assigned to students, 75 (26.4%) had a wound. The most common wound was a surgical incision (49, 65%) and was closed (36, 73.5%). Twenty-six (26) patients had a pressure ulcer, most commonly Stage II. The most common dressing was dry gauze (29). Damp gauze was used on 18 wounds. Wound irrigation was recorded for 24 wound protocols and performed with a bulb syringe or by pouring the solution from a container. Generally, nonsterile wound care was performed. Twenty-five (25) students performed wound care with the instructor, 16 watched the care performed by another clinician, and 10 participated with another nurse in the wound care. For 22 patients, the wound care was neither observed nor performed because either it was not time for the dressing to be changed or it was only to be changed by a medical team. From these data, it was concluded beginning nursing students had some, but limited, clinical experience with patients with wounds. Students’ wound care experiences need further examination, especially across multiple educational courses.
Individuals with wounds are an increasing concern in health care, and nurses typically participate in the interdisciplinary care of these patients. The Centers for Disease Control and Prevention1 identified 51.4 million inpatient surgical procedures performed in the United States each year; operative procedures may include an incision requiring care. In addition, 6.5 million patients in the US have chronic wounds.2 Patients with wounds also reside outside of a facility and are seen in outpatient clinics. The incidence and burden of wounds disproportionately afflict older adults and impose substantial morbidity and mortality on aging Americans.2,3 Besides the burden of illness, wounds and their care have a great impact on quality of life, socioeconomic living status, and the economics of health care, to name but a few considerations.3,4
Wound management involves scientific-based knowledge as well as clinical experience.5 Receiving theoretical information and participating in the clinical care of patients with wounds are important in undergraduate nursing education. The Essentials for Baccalaureate Education for Professional Practice6 stresses the importance of learning safe care, knowledge, and skills. Education and the clinical experience of caring for patients with wounds may begin at a basic level in the student’s first clinical course. The purposes of this quality improvement project performed in an introductory baccalaureate nursing course were to identify: 1) the types of patients with wounds assigned to beginning students, 2) these patients’ wound care procedures and dressings, and 3) the students’ level of participation in wound care.
Nursing education and wound care. Undergraduate nursing education includes a broad array of theoretical and clinical topics. Faculty must make tough curricular decisions as to what is taught and what is left out.7 Nursing students generally obtain theoretical and clinical content about wounds in the classroom and through varied clinical placements. The clinical setting is the least controlled of the learning environments because of the patients’ changing health status.7 Thus, nursing students may see wound management performed by other practitioners, may not see it at all, or sometimes be allowed to perform wound care.7 The limited research regarding undergraduate nursing education in terms of wounds and their care is summarized to follow.
Huff8 conducted a quantitative, quasi-experimental nonrandomized study of undergraduate nursing students’ knowledge of wound care. She compared 65 undergraduate nursing students in their second year of a baccalaureate nursing program (intervention group) with 55 first-year nursing students in a 2-year community college program (control group). All students received basic instruction on wound care and read a chapter about wound care in their textbook. Huff used a 10-item questionnaire to measure wound care knowledge before and after an intervention. The intervention was a 2-hour lecture and clinical laboratory experience delivered by a wound care specialist. The students who received the intervention had significantly higher test scores compared to the control group; the knowledge persisted for 2 months. Huff concluded a modest increase in curricular time may help fill a void in wound care education.
Romero-Collado et al9 examined course content regarding chronic wounds in 114 centers in Spain that offered a nursing degree; 95 programs posted their course content online and were the basis for the analysis. No center offered a course dedicated to chronic wounds or presented content about wound pain and its management. The concept/content of pressure ulcer prevention was lacking in 60 of the centers; 36 centers did not mention pressure ulcer treatment. Twenty-one (21) centers included content on wound dressing selection. Only 4 courses in 4 centers presented content about care of the diabetic foot; in contrast, venous and arterial disorders of the lower extremities were presented in 55 centers. Only 1 course presented wound bed assessment. The study authors concluded course content related to chronic wounds was deficient and nursing degree programs need to guarantee the acquisition of minimum basic skills in the prevention and treatment of chronic wounds and thus reduce theory-practice gaps.
Ousey et al10 examined final year nursing students’ (N = 217) formal teaching about skin integrity during their clinical placement at 2 educational institutions in England. Students were invited to complete a questionnaire. A majority of all respondents (67.9%) reported receiving <10 hours of formal teaching on skin integrity across their 3-year nursing education at the university. Most (70.3%) participants stated the teaching had developed their knowledge and skills to maintain skin integrity for all patients. Formal teaching also occurred during clinical experiences. The authors concluded it was essential for mentors and clinical staff to understand the importance of actively contributing to nursing students’ learning about skin integrity.
Ribu et al11 explored home care nurses’ (n = 31) and nursing students’ (n = 30) knowledge of the treatment of patients with leg and foot ulcers in the community in Norway. The authors used a structured observation form. They did not compare nurses with nursing students or separate the care by the nurse’s educational level. They reported some patients (16/32) lacked an ulcer diagnosis; most (79.9%) of the patients had other chronic diseases. The authors observed 35 wound care treatments on 32 patients. The most common ulcers were venous (7), diabetes-related foot/leg ulcers (5), and mixed cause ulcers (4). Nurses performed poorly in several aspects of wound care: lack of clinical assessment of the wound, poor use of wound care protocols, lack of hand washing, poor pain management, and poor documentation. The authors concluded nurses in the community needed more education about wound care and more time to provide wound treatments and documentation.
Day et al12 presented a 2-hour session about basic wound management to mental health nursing students (N = 20) in England. Wound types included trauma, leg ulcers, pressure ulcers, burns, and melanoma. Students raised questions about dressing selection, application of dressings, and documentation. Mental health nursing students acknowledged a deficit in skill acquisition, especially wound care, within the practice setting related to a lack of physical resources, support, mentor time, and knowledge. The authors concluded mental health nursing students need to be exposed to clinical skill teaching preregistration; one of the key areas was wounds.
Ayello et al13 conducted a survey of nurses’ wound care knowledge through a questionnaire placed in 2 journals; 692 nurses from 48 states, 5 Canadian provinces, and 7 other countries returned the survey. Of the 23 survey questions and statements regarding wound care knowledge and practice, 1 question was about chronic wound education in basic nursing education programs. Only 30% of respondents believed they received sufficient education about chronic wounds in their basic nursing education program. Younger, less experienced nurses compared to older, more experienced nurses felt better about their level of wound care education. The authors concluded the difference between less and more experienced nurses may reflect improved education about wound care, forgetting what they learned, or not knowing what they do not know until they have some experience. Only 20% of nurses who work with the most vulnerable populations (ie, home care, long-term care/subacute care, and the like) believed they had received sufficient wound care education. When nurses were asked how comfortable they were about making recommendations to practitioners on appropriate wound dressings, the most common response was sometimes (41%).
Medical education and wound care. Collaboration among health care providers is a means to improve patient outcomes. Nurses work collaboratively with other clinicians in determining interventions for wound care; thus, they need to be cognizant of what other practitioners offer in terms of knowledge and skill. The lack of education in medical schools about wounds and their care has been identified. Patel and Granick4 examined the time devoted to physiology of tissue injury, physiology of wound healing, and clinical wound healing at 50 medical schools in the US. Data were obtained from the American Association of Medical Colleges database. The mean hours of education in physiology of tissue injury were 0.05 in year 1, 0.2 in year 2, and none in years 3 and 4. The mean hours of education about physiology of wound healing were 2.1 in year 1, 1.9 in year 2, and <1 hour in years 3 and 4. The clinical education about wound management was highest at 2.1 hours in year 2 compared to 0.4 hours in years 1 and 4. Total hours of wound education across the 3 topics (physiology of tissue injury, physiology of wound healing, and clinical wound healing) for 4 years were 9.2. The study authors concluded there was a lack of direct education about wound topics in American medical schools.4
Fourie5 examined themes about wound management and treatment that medical professionals (N = 30) considered during their studies. The author interviewed 9 medical practitioners and had 21 others complete a questionnaire. During their training, 88% stated they received none to minimal formal wound management education. For specific wounds, 77% of participants were uncertain about what the best wound care treatment would be. Five themes were identified as challenges in wound management within their practice/setting: lack of resources (23%), uncertainty of what products to use and when (44%), patient factors of sepsis and complications (13%), poor continuity of nursing care and failure to follow instructions (15%), and lack of team work (5%). Most participants (75%) stated no formal policy was available on wound management best practice in their practice or institution. Most (97%) medical practitioners said wound care education was very important and more training should be provided about it.5
Summary. Theoretical knowledge about wounds and their care and clinical experience with patients with wounds are important components in undergraduate nursing education. Studies about wound care in nursing education are scant. Two (2) studies from the US8,13 and 4 from Europe9-12 examined wound care education in nursing, and 2 studies looked at wound care education in medicine.4,5 All studies identified deficiencies in wound care education. In the US, the number of individuals with wounds is increasing with the aging population and the number of persons with chronic health conditions.
The literature lacks information about the exposure and experiences of students in an introductory baccalaureate nursing course to patients who have wounds. The current study authors had the following questions: 1) What types of patients with wounds are assigned to beginning students? 2) What wound care procedures and dressings are ordered for patients with wounds? 3) What experiences do students have providing wound care?
Design. A quality improvement project was conducted by a faculty team at an urban, research-intensive university using a cross-sectional, descriptive design. The data were collected from faculty’s notes about the students’ clinical experience during a Fundamentals of Nursing course presented in the Winter 2015 semester. The clinical component of the course was taught by 6 instructors who offered 8 clinical sections. One instructor of a clinical section did not participate; thus, data were collected from 5 instructors who supervised 7 clinical sections, each with 7 to 8 students. Students’ (N = 49) clinical placements were in 3 acute care hospitals, all of which were part of major health care systems. Two (2) surgical and 4 medical/surgical units were included. Excluding clinical orientation and final examination week, the clinical experience comprised 1 day a week for 9 weeks. Because the goal of the project was to examine the wound care experiences students were provided, a patient care experience was not eliminated if that patient had been cared for by more than 1 student. Hence, the data include 2 patients that were recorded twice.
In addition to the clinical experience, students had 3 lecture hours in the theoretical component of the course devoted to wounds (pressure ulcer prevention and treatment and the surgical incision as prototypes), wound treatment, and care products. The lecture content included many pictures of wounds, attributes of wound assessment, and wound care products. Content in the Skills Laboratory experience included 2 hours about sterile gloving and 3.5 hours about incision dressing change, drains, irrigating wounds, and packing wounds. The Skills Laboratory experience provided time to view and discuss videos and practice clinical skills on a manikin under the supervision of the clinical instructors. Although a Simulation Laboratory was available, in this course it was used to teach nasogastric-tube nutrition and oxygen therapy.
Procedure and instrument. Clinical instructors completed a form each time a student cared for a patient who had a wound. The form included the type of wound(s), presence/type of drains, wound irrigation and method, dressing type, wound care technique (sterile or not sterile), and whether the student performed the dressing change with the faculty or with a staff nurse, watched the nurse or another provider, or was not able to do the dressing change. The reasons for not performing the wound care included 1) it was not time to change the dressing or 2) the medical team wanted to do all dressing changes. The patient’s age, gender, and race also were recorded as part of the notes faculty kept about students’ clinical experiences.
Because this was a quality project, not a human subjects research study, it was not necessary to request Institutional Review Board approval. The authors assessed a component of an internal educational program in terms of beginning nursing students’ exposure to patients with wounds in order to determine ways to enhance the students’ clinical experience. Knowledge sought directly benefitted the Fundamentals of Nursing course; by sharing this information with other persons involved in educational programs, other nursing programs may benefit.
Data analysis. Descriptive statistics were used to examine the frequency and distribution of types of wounds and their care. Data were analyzed using SPSS (Chicago, IL).
Patients with wounds. Forty-nine (49) students provided care to 284 patients, including 75 patients with wounds (26.4% of the students’ experiences). Among the patients with wounds, 49 (65.3%) were men, 50 (66.7%) were African American, and the mean age was 56 years (SD 18.25 years). The most common wound was a surgical incision (49, 65%) located on the abdomen (37, 75.5%) and closed (36, 73.5%) (see Table 1). Twenty-six (26) patients had a pressure ulcer, most commonly Stage II. The 7 patients with more than 1 wound had a surgical incision and a pressure ulcer.
Wound care procedures and dressings. Wound care procedures and dressings are described in Table 2. Nine (9) patients had no dressing listed. The most common dressing was dry gauze (29), which was used on closed surgical incisions. Moist gauze was used on 18 patients who had an open incision (10), pressure ulcer (7, Stage II, Stage IV, or nonstageable), or an abscess (1). Other products used for wound care were barrier ointment (8), foam (6), and gel (4). A drain was present in 25 patients (33.3%). Wound irrigation was recorded for 24 wound protocols and included bulb syringe (11) or pouring solution from a container (7). The most common solution was normal saline (20). Nonsterile dressing care was performed for 45 of the 59 of dressing changes. Clinical instructors allowed students to perform 14 dressing changes as sterile for the experience of handling sterile equipment.
Students’ participation in wound care. A clinical instructor observed 25 students perform wound care, 16 students watched the care being done by another health care provider, and 10 students participated with another nurse performing the wound care. For 22 patients, the wound care was neither observed nor performed either because it was too soon to change the dressing or the medical team requested to do all dressing changes.
This project examined introductory baccalaureate nursing students’ clinical experiences providing care to patients with wounds, the types of wounds, and wound care procedures and dressings. Across the total potential clinical days, 26.4% of the assigned patients had wounds. The most common wound categories were surgical incisions followed by pressure ulcers. Gauze, either moist (18) or dry (29), was the most common dressing used. Students had little experience with other dressing products. Students were limited, in part, in wound care experiences because the dressings were not scheduled to be changed or another practitioner had desired to do all wound care. Ousey et al10 stated clinical practice and teaching help facilitate wound care skill acquisition and knowledge about maintaining skin integrity. Romero-Collado et al9 noted nursing faculty need to design courses so students achieve essential clinical competencies along with theoretical knowledge. Knowledge gained in the theory portion of the students’ learning experiences should correlate with simulation and clinical practice.
Although the number of wound care experiences appears low, these students were in their first clinical nursing course; thus, the data represent a starting point with regard to wound care. In addition, faculty who teach introductory nursing are challenged to give students varied and numerous clinical skill experiences in order to meet multiple objectives in varied content areas (ie, hygiene, transfer and ambulation, nutrition, urinary and fecal elimination, to name a few). A patient who has a wound may not be assigned to a student because of other learning requirements. Selecting clinical experiences means balancing types of patients available with experiences that students need. In an exploratory qualitative study, Haraldseid et al14 (N = 19) explored student perceptions of their learning environment in a clinical skills laboratory via a focus group. They found creating an authentic environment, facilitating motivation, and providing methods of skill training in the clinical skills laboratory are important because the mastery of clinical skills may be limited due to lack of opportunities for varied skills in clinical practice.
The role, nature, and timing of clinical skills teaching is a global issue.15 Ousey et al10 reported that over the 3 years of university education students generally spend <10 hours of formal instructional time on skin integrity, yet 56% of respondents reported they had sufficient exposure to wound care. This is similar to medical school curriculum where the total number of hours of direct wound education across 4 years was 9.2 hours.4 This is in contrast to Haraldseid et al’s14 research that found skills acquisition is a complex process of incorporating practical performance with knowledge and critical thinking.14
Surgical incisions are a common occurrence in acute care. Although these wounds were generally closed (73.5%) and covered with dry gauze, they provided learning for beginning student in terms of postoperative wound assessment for healing and infection as well as patient mobility, nutrition, and preparation and teaching for discharge. Twenty-six (26) patients had pressure ulcers; 2 also had a surgical incision.
Patients with complex chronic wounds such as venous ulcers and diabetic neuropathic foot ulcers were seen infrequently by these students. Chronic wounds are most commonly treated in the community.2,16 In addition, students receive theoretical content about complex wounds in advanced courses and would lack an understanding of these conditions in an introductory nursing course. Nursing wound care education should occur sequentially across all academic years and in many clinical settings.
Sometimes nursing students observed wound care that did not align with current best practice. Wound irrigation or wound cleansing was performed with a bulb syringe or pouring the solution from a container. In contrast, the recommended method uses normal saline administered with a 19-guage angiocatheter and a 35-mL syringe to deliver 4 to 15 psi of pressure to remove debris without harming healthy tissue; bulb syringes do not provide enough pressure.17 The most common primary dressing used was gauze. Although dry gauze dressings may have been correctly used on closed surgical incisions or moist gauze applied over an open area, issues with the frequency of dressing changes, patient comfort, infection, and lower healing rates were possible.17 Nurses need knowledge about varied dressings, not just gauze, in terms of dressing properties, use, frequency of change, and evaluation. Very few students in this project saw “modern” longer-wear dressings such as foam, hydrocolloid, and alginate. Because these products decrease the occurrence of dressing changes, students may not have participated in their removal and re-application as part of the wound care experience. These products should be discussed in terms of their use in the clinical setting. By comparison, physicians often stated receiving little information about wound care treatment during their medical education; as such, their lack of knowledge of wound products and how to manage wound care correctly were concerns.5
To enhance students’ learning about wound care, education on wound assessment and treatment should begin in the students’ introductory clinical course. This allows the student time to obtain clinical experience with patients with wounds across all courses. When a student is assigned a patient with a wound, the clinical instructor should consider multiple areas of critical thinking, including wound assessment, type of dressing, dressing selection, protocol for changing the dressing, pain, nutrition, and long-term care. In addition to teaching sterile technique, nursing programs should consider protocols for teaching nonsterile dressing change. Clinical instructors need to continuously examine the clinical units used for education and decide what settings provide experiences that meet the objectives of the course. Clinical instructors should be aware of what is current in wound care. This may facilitate discussion with staff nurses in terms of the appropriate use of varied dressings and wound care procedures.
Knowledge about wounds and their care has undergone significant changes and these changes need to be reflected in undergraduate curricula.7 Romero-Collado et al9 noted the need to address theory-practice gaps; courses must be designed to achieve essential competencies along with knowledge of theory. Educational programs should combine textbook content with a variety of learning methods, including hands-on experiences.
Houghton et al’s18 qualitative, multiple case study reported clinical skills laboratories can provide a pathway to practice; they can be realistic and authentic. Qualitative, descriptive design, clinical skills laboratories can be a bridge between theoretical content and practice.19 The current authors support the availability of varied dressing supplies for students to see and use in the Skills Laboratory or Simulation Laboratory. According to Hope et al,20 simulation learning encouraged active transition of theory to practice, was a safe environment, and provided confidence.20 During all types of experience, students should be encouraged to link theoretical content about wound assessment and dressing selection to the experience. Photographs also may be used for teaching; for example, in a questionnaire study,21 burn photographs were rated as useful for teaching patient management and improving patient care.21
The project had limitations. It represents data collected during 1 semester in an introductory clinical nursing course. Students were not followed sequentially throughout their other nursing courses. Faculty who provided wound care information did so voluntarily. The types of experiences were dependent upon the unit/hospital; for example, some surgical settings delayed dressing changes for 48 hours or required dressing changes be performed by the surgical team. These data did not identify the number of patients with wounds each student had or how many students had no opportunity to provide wound care during the semester. Possibly having students keep a list of their experiences will help identify clinical learning needs during their progression throughout the program.
Nursing students in an introductory nursing class received basic clinical experiences with patients with wounds. The wounds they saw were the most common ones in acute care — that is, surgical incisions and pressure ulcers. The use of a variety of wound care products by classification was limited, but students were provided information about them in the theoretical component of the course. Clinicians should understand the function of dressings and treatment modalities and where and how to apply them.5 Wound education should occur across the curriculum. Wound management and treatment is vested in the knowledge, skill, and understanding of providers about the complexity of wound healing.5
1. Centers for Disease Control and Prevention. Inpatient surgery. Available at: www.cdc.gov/nchs/fastats/inpatient-surgery.htm. Accessed May 12, 2015.
2. Sen CK, Gordillo GM, Roy S, et al. Human skin wounds: a major and snowballing threat to public health and the economy. Wound Repair Regen. 2009;17(6):763–771.
3. Gould L, Abadir P, Brem H, et al. Chronic wound repair and healing in older adults: current status and future research. Wound Repair Regen. 2015;23(1):1–13.
4. Patel NP, Granick MS. Wound education: American medical students are inadequately trained in wound care. Ann Plast Surg. 2007;59(1):53–55.
5. Fourie A. The inadequacy of wound management training for medical practice. Wound Healing Southern Africa. 2013;6(1):21–24.
6. American Associations of Colleges of Nursing. The Essentials of Baccalaureate Education for Professional Practice. Washington, DC: American Associations of Colleges of Nursing;2008:30–33.
7. Madsen W, Reid-Searl K. Overcoming tradition: teaching wound management into the twenty-first century. Collegian. 2007;14(4):7–10.
8. Huff JM. Adequacy of wound education in undergraduate nursing curriculum. J Wound Ostomy Continence Nurs. 2011;38(2):160–164.
9. Romero-Collado A, Raurell-Torreda M, Zabaleta-del-Olmo E, Horns-Romero E, Bertran-Noguer C. Course content related to chronic wounds in nursing degree programs in Spain. J Nurs Scholarsh. 2015;47(1):51–61.
10. Ousey K, Stephenson J, Cook L, Kinsey L, Batt S. Final year student nurses’ experiences of wound care: an evaluation. Wound Care. 2013;2013:S7–S16.
11. Ribu E, Haram R, Rustoen T. Observations of nurses’ treatment of leg and foot ulcers in community health care. J Wound Ostomy Continence Nurs. 2003;30(6):342–350.
12. Day J, Moriarty A, Tremayne P. Addressing a deficit: wound care and mental health nursing. Br J Nurs. 2007;16(3 suppl):S32–S37.
13. Ayello EA, Baranoski S, Salati DS. A survey of nurses’ wound care knowledge. Adv Skin Wound Care. 2005;18:268–275.
14. Haraldseid C, Friberg F, Aase K. Nursing students’ perceptions of factors influencing their learning environment in a clinical skills laboratory: a qualitative study. Nurse Edu Today. 2015;doi: 10.1016/j.nedt.2015.03.015.
15. Borneuf A-M, Haigh C. The who and where of clinical skill teaching: a review from the UK perspective. Nurse Ed Today. 2010;30(2010):197–201.
16. Wellborn J, Moceri JT. The lived experience of persons with chronic venous insufficiency and lower extremity ulcers. J Wound Ostomy Continence Nurs. 2014;41(2):122–126.
17. Rolstad BS, Bryant RA, Nix DP. Topical management. In: Bryant RA, Nix DP (eds). Acute & Chronic Wounds Current Management Concepts. St. Louis, MO: Elsevier Mosby;2012:289–306.
18. Houghton CE, Casey D, Shaw D, Murphy K. Staff and students’ perceptions and experiences of teaching and assessment in Clinical Skills Laboratories: Interview findings from a multiple case study. Nurse Ed Today. 2012;32(2012):e29–e34.
19. Ewertsson M, Allvin R, Holmstrom IK, Blomberg K. Walking the bridge: nursing students’ learning in clinical skill laboratories. Nurse Ed Pract. 2015; doi: 10.1016/j.nepr.2015.03.006.
20. Hope A, Garside J, Prescott S. Rethinking theory and practice: pre-registration student nurse experiences of simulation teaching and learning in the acquisition of clinical skills in preparation for practice. Nurse Ed Today. 2011;31(2011):711–715.
21. Nelson L, Boyle M, Taggart S, Watson S. Are burn photographs useful? Burns. 2006;32(2006):876–879.
Dr. Pieper is a Professor/Nurse Practitioner; Ms. Keves-Foster, Ms. Ashare, and Ms. Zugcic are clinical instructors; and Ms. Albdour and Ms. Alhasanat are teaching assistants, College of Nursing, Wayne State University, Detroit, MI. Please address correspondence to: Barbara Pieper, PhD, RN, CWOCN, ACNS-BC, FAAN, 1356 Yorkshire, Grosse Point, MI 48202; email: firstname.lastname@example.org.
Potential Conflicts of Interest: none disclosed