Judy L LeFlore

Children's Medical Center Dallas, Dallas, Texas, United States

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Publications (23)25.34 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: How long should a simulated scenario last? Little literature exists, and what does exist, offers unsubstantiated opinions on the optimal timeframe. The authors of this article discuss the merits of both short scenarios, scenarios-defined as <30 minutes; and long scenarios-defined as >30 minutes. Advantages and disadvantages of both types of scenarios are presented. Substantiated research is needed on the appropriate time to simulate.
    Clinical Simulation in Nursing 01/2014; 10(5):e271–e276.
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    ABSTRACT: Background Measures of competence during education and training of the health care workforce are in place, but how can ongoing competence be assessed, especially those who live and work outside metropolitan areas? Pediatrix Medical Group and the University of Texas at Arlington College of Nursing formed a collaboration to develop a comprehensive program of testing that will be designed to eventually provide standardized and validated assessment of neonatal advanced practitioners by creating simulation opportunities using high-fidelity simulators for education across a distance, that is, remote-controlled distance simulation (RCDS). The purpose of this paper is to report the determination of the feasibility testing of training participants using a high-fidelity manikin-based simulator at a clinical site that was being controlled by an operator located at the distant control site. This article seeks to describe the collaboration between the University of Texas at Arlington College of Nursing and Pediatrix Medical Group that enabled the pilot testing of RCDS. Method SimBaby™, the patient monitor, and SimView™, a high-definition audio and/or visual capture and playback system, were set up at a large metropolitan children's hospital. At the control site, there were two laptops, one of which was used for remote access of SimBaby's™ laptop and the other to control SimView™ remotely. A remote access desktop program enabled the operator access to and the ability to control SimBaby's™ software on the laptop at the clinical site. The scenario scene was set in a delivery room, where a post-term infant had been delivered through thick meconium-stained amniotic fluid. The baby developed respiratory distress and ultimately, a pneumothorax. Results The feasibility of training participants at a clinical site with a simulator that was being controlled by an operator at a remote distant control site was demonstrated. Minor challenges with the technology occurred but did not interfere with the participants' ability to perform during the simulation. Conclusion RCDS may offer several advantages for health care provider employers, especially those with multiple locations where physical competency validation with high-fidelity manikins may be difficult or impossible.
    Clinical Simulation in Nursing 01/2014;
  • Mindi Anderson, Judy L. LeFlore, JoDee M. Anderson
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    ABSTRACT: Introduction This descriptive pilot study compares the effectiveness of the addition of videotaped role-modeling to a traditional method of teaching Crisis Resource Management (CRM) principles and clinical management of pediatric patients with respiratory distress. Method Data were collected from nurse practitioner students (N = 16) to evaluate knowledge, self-efficacy, team behaviors, and technical skills at 3 time-points. All students participated in a Pretest (Time 1) scenario and CRM lecture. Group A (control; n = 8) received no further intervention. Group B (experimental group; n = 8) watched a videotape of experts modeling CRM. All groups completed another scenario (Time 2). Twelve weeks later, each group completed a third scenario (Time 3). Satisfaction was measured at 2 times. Results No differences were noted in knowledge, self-efficacy, or technical skills between the groups at the 3 times. There was a significant difference between the groups on both the Pretest and Posttest 1 on team behaviors. Satisfaction scores showed no differences between the groups. Discussion One experience watching a 15-minute role-modeling videotape may not be an effective means of instruction for CRM principles or clinical management of pediatric patients.
    Clinical Simulation in Nursing 01/2013; 9(9):e343–e354.
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    ABSTRACT: Virtual environments offer a variety of benefits and may be a powerful medium with which to provide nursing education. The objective of this study was to compare the achievement of learning outcomes of undergraduate nursing students when a virtual patient trainer or a traditional lecture was used to teach pediatric respiratory content. This was a randomized, controlled, posttest design. A virtual pediatric hospital unit was populated with four virtual pediatric patients having different respiratory diseases that were designed to meet the same learning objectives as a traditional lecture. The study began in Spring 2010 with 93 Senior I, baccalaureate nursing students. Students were randomized to receive either a traditional lecture or an experience with a virtual patient trainer. Students' knowledge acquisition was evaluated using multiple-choice questions, and knowledge application was measured as timeliness of care in two simulated clinical scenarios using high-fidelity mannequins and standardized patients. Ninety-three students participated in the study, of which 46 were in the experimental group that received content using the virtual patient trainer. After the intervention, students in the experimental group had significantly higher knowledge acquisition (P = 0.004) and better knowledge application (P = 0.001) for each of the two scenarios than students in the control group. The purpose of this project was to compare a virtual patient trainer to a traditional lecture for the achievement of learning outcomes for pediatric respiratory content. Although the virtual patient trainer experience produced statistically better outcomes, the differences may not be clinically significant. The results suggest that a virtual patient trainer may be an effective substitute for the achievement of learning outcomes that are typically met using a traditional lecture format. Further research is needed to understand how best to integrate a virtual patient trainer into undergraduate nursing education.
    Simulation in healthcare: journal of the Society for Simulation in Healthcare 02/2012; 7(1):10-7. · 1.64 Impact Factor
  • Judy L. LeFlore, Mindi Anderson
    Clinical Simulation in Nursing 11/2011; 7(6):e256.
  • Judy L LeFlore, William D Engle
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    ABSTRACT: We compared postnatal growth and neurodevelopment in extremely low-birth-weight (<1000 g) neonates who did or did not receive postnatal steroid (PNS) therapy for bronchopulmonary dysplasia (BPD). One hundred seventy-three neonates with Bayley Scales of Infant Development II (BSID II) testing performed at 18- to 22-month adjusted age were studied. Growth parameters and BSID II scales were compared among three groups: group I, no BPD; group II, BPD, no PNS; group III, BPD and PNS exposure. A subset of 77 neonates' growth parameters were retrieved at 12-month adjusted age. Psychomotor Development Index (PDI) and Mental Development Index (MDI) scales were lower in group III versus groups I and II. Growth velocity (GV) was lower in group III versus group I and II during the initial hospital stay. In the subset, GV from birth to 1-year adjusted age and weight, length, and head circumference determined at 1-year adjusted age were similar among the groups. Multivariate analysis revealed a significant effect of group membership and cystic periventricular leukomalacia on PDI. These results suggest that a deleterious effect of PNS therapy on neurodevelopment can occur by a mechanism that does not impair overall growth or growth of head circumference.
    American Journal of Perinatology 04/2011; 28(8):635-42. · 1.57 Impact Factor
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    ABSTRACT: The purpose of this education project is to prepare neonatal nurse practitioners using a nonlinear (random exposure to information delivered in context rather than abstracting information as is done in a traditional lecture), asynchronous approach. The Internet-based 3-dimensional virtual "living world" classroom will have a living textbook and a virtual neonatal intensive care unit (NICU). Deploying the program within a virtual living world will enhance program accessibility and overcome the challenges of nurses returning to school. Greater accessibility can help to alleviate the shortage of neonatal providers, which are needed to meet the needs of the growing population.A Neonatal Curriculum Consortium comprising expert neonatal nurse practitioners and faculty are developing multimedia learning modules for core content defined by national organizations and certifying bodies. Our Internet-based, multisite, nonlinear, asynchronous universal neonatal curriculum has at its core a 3-dimensional virtual "living text book" for didactic instruction and a "living world" NICU for "deliberate practice." The NICU will feature an interactive virtual infant patient. Our "Virtual NICU" will assist students to transition from the classroom, to the simulation laboratory, and ultimately to the clinical area. Providing clinical learning experiences in the virtual NICU will enhance the students' opportunities to learn to care for the culturally diverse populations they will serve as neonatal nurse practitioners.
    The Journal of perinatal & neonatal nursing 01/2011; 25(2):200-5. · 0.81 Impact Factor
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    ABSTRACT: The use of standardized patients (SPs) integrated into students' educational experience is one suggestion for overcoming clinical site challenges facing nursing educators today. This article describes one university nursing school's experience with starting an SP program and integrating SPs into the curricula for the undergraduate and graduate nursing programs. Additionally, this article discusses how one school expanded the role of SPs to serve as family or caregivers with manikin-based simulation. Questions to consider when starting an SP program are discussed.
    Clinical Simulation in Nursing 01/2010; 6(2):e61–e66.
  • Judy L LeFlore, Mindi Anderson
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    ABSTRACT: Few studies compare instructor-modeled learning with modified debriefing to self-directed learning with facilitated debriefing during team-simulated clinical scenarios. : To determine whether self-directed learning with facilitated debriefing during team-simulated clinical scenarios (group A) has better outcomes compared with instructor-modeled learning with modified debriefing (group B). This study used a convenience sample of students. The four tools used assessed pre/post knowledge, satisfaction, technical, and team behaviors. Thirteen interdisciplinary student teams participated: seven in group A and six in group B. Student teams consisted of one nurse practitioner student, one registered nurse student, one social work student, and one respiratory therapy student. The Knowledge Assessment Tool was analyzed by student profession. There were no statistically significant differences within each student profession group on the Knowledge Assessment Tool. Group B was significantly more satisfied than group A (P = 0.01). Group B registered nurses and social worker students were significantly more satisfied than group A (30.0 +/- 0.50 vs. 26.2 +/- 3.0, P = 0.03 and 28.0 +/- 2.0 vs. 24.0 +/- 3.3, P = 0.04, respectively). Group B had significantly better scores than group A on 8 of the 11 components of the Technical Evaluation Tool; group B intervened more quickly. Group B had significantly higher scores on 8 of 10 components of the Behavioral Assessment Tool and overall team scores. The data suggest that instructor-modeling learning with modified debriefing is more effective than self-directed learning with facilitated debriefing during team-simulated clinical scenarios.
    Simulation in healthcare: journal of the Society for Simulation in Healthcare 02/2009; 4(3):135-42. · 1.64 Impact Factor
  • Mindi Anderson, Judy Leflore
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    ABSTRACT: Health care professionals are expected to make prompt, accurate decisions in life-threatening emergency situations in the OR. Perioperative leaders are faced with the challenge of ensuring that OR team members are prepared to respond to potentially lethal emergencies, including rare and infrequent events. This article describes the importance of team training for all members of the OR team. The use of simulation is discussed as a tool to accomplish this goal. Steps for developing a simulation scenario are presented.
    AORN journal 05/2008; 87(4):772-9.
  • Judy L LeFlore, William D Engle
    Journal of the American Academy of Nurse Practitioners 04/2007; 19(3):111-5. · 0.71 Impact Factor
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    ABSTRACT: There are no reports in the literature that compare instructor-modeled learning to self-directed learning when simulation is used. Therefore, no evidence exists to know which approach is superior. This study aims to test the hypothesis that instructor-modeled learning is more effective compared with self-directed learning during a simulated clinical experience. This is a descriptive pilot study to compare instructor-modeled learning with self-directed learning during a clinical simulated experience. Four evaluation tools were used at three time points to evaluate knowledge, self-efficacy (self confidence), and behaviors. Sixteen students participated. There were no statistically significant differences between the groups on the Knowledge Assessment Test. There were significant differences between the groups in the Self-Efficacy Tool (SET) at three times (time 1: P = 0.006, time 2: P = 0.008, time 3: P = 0.012). The only significance between the groups on the Technical Evaluation Tool was time to start Albuterol. The Behavioral Assessment Tool (BAT) showed significant differences between the groups in 8 out of 10 components of the tool. A strong correlation was observed between the overall score of the BAT and the SET Score. Although the small sample size prohibits definitive conclusions, the data suggest that instructor-modeled learning may be more effective than self-directed learning for some aspects of learning during a clinical simulated experience.
    Simulation in healthcare: journal of the Society for Simulation in Healthcare 02/2007; 2(3):170-7. · 1.64 Impact Factor
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    ABSTRACT: Extracorporeal membrane oxygenation (ECMO) is a form of long-term cardiopulmonary bypass used to treat infants, children, and adults with respiratory and/or cardiac failure despite maximal medical therapy. Mechanical emergencies on extracorporeal membrane oxygenation (ECMO) have an associated mortality of 25%. Thus, acquiring and maintaining the technical, behavioral, and critical thinking skills necessary to manage ECMO emergencies is essential to patient survival. Traditional training in ECMO management is primarily didactic in nature and usually complemented with varying degrees of hands-on training using a water-filled ECMO circuit. These traditional training methods do not provide an opportunity for trainees to recognize and interpret real-time clinical cues generated by human patients and their monitoring equipment. Adult learners are most likely to acquire such skills in an active learning environment. To provide authentic, intensive, interactive ECMO training without risk to real patients, we used methodologies pioneered by the aerospace industry and our experience developing a simulation-based training program in neonatal resuscitation to develop a similar simulation-based training program in ECMO crisis management, ECMO Sim. A survey was conducted at the 19th Annual Children's National Medical Center ECMO Symposium to determine current methods for ECMO training. Using commercially available technology, we linked a neonatal manikin with a standard neonatal ECMO circuit primed with artificial blood. Both the manikin and circuit were placed in a simulated neonatal intensive care unit environment equipped with remotely controlled monitors, real medical equipment and human colleagues. Twenty-five healthcare professionals, all of whom care for patients on ECMO and who underwent traditional ECMO training in the prior year, participated in a series of simulated ECMO emergencies. At the conclusion of the program, subjects completed a questionnaire qualitatively comparing ECMO Sim with their previous traditional ECMO training experience. The amount of time spent engaged in active and passive activities during both ECMO Sim and traditional ECMO training was quantified by review of videotape of each program. Hospitals currently use lectures, multiple-choice exams, water drills, and animal laboratory testing for their ECMO training. Modification of the circuit allowed for physiologically appropriate circuit pressures (both pre- and postoxygenator) to be achieved while circulating artificial blood continuously through the circuit and manikin. Realistic changes in vital signs on the bedside monitor and fluctuations in the mixed venous oxygen saturation monitor were also effectively achieved remotely. All subjects rated the realism of the scenarios as good or excellent and described ECMO Sim as more effective than traditional ECMO training. They reported that ECMO Sim engaged their intellect to a greater degree and better developed their technical, behavioral, and critical thinking skills. Active learning (eg, hands-on activities) comprised 78% of the total ECMO Sim program compared with 14% for traditional ECMO training (P < 0.001). Instructor-led lectures predominated in traditional ECMO training. Traditional ECMO training programs have yet to incorporate simulation-based methodology. Using current technology it is possible to realistically simulate in real-time the clinical cues (visual, auditory, and tactile) generated by a patient on ECMO. ECMO Sim as a training program provides more opportunities for active learning than traditional training programs in ECMO management and is overwhelmingly preferred by the experienced healthcare professionals serving as subjects in this study. Subjects also indicated that they felt that the acquisition of key cognitive, technical, and behavioral skills and transfer of those skills to the real medical domain was better achieved during simulation-based training.
    Simulation in healthcare: journal of the Society for Simulation in Healthcare 01/2006; 1(4):220-7. · 1.64 Impact Factor
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    Judy L LeFlore, William D Engle
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    ABSTRACT: Decisions regarding the need for volume replacement in neonates often are made in the immediate newborn period. Capillary refill time (CRT) is used as an indicator of circulatory status; however, recent data show that CRT varies considerably with age, ambient and skin temperature, anatomical site of measurement, and duration of pressure. The purpose of this study was to (1) examine the relationship between CRT and heart rate (HR) and blood pressure (BP) in term neonates, and (2) evaluate the differences among CRT values measured at 3 body sites and with varying duration of cutaneous pressure. This was a prospective, cross-sectional, correlational study. Subjects Forty-two appropriate-weight-for-gestational-age (AGA) neonates with birthweights, (M = 3407; SD = +/- 540 g), gestational ages (M = 39 weeks; SD = +/- 1 week), and sex (21 males, 21 females). Infants had no history of perinatal distress or maternal chorioamnionitis. Each neonate was studied prospectively 1 to 4 hours after birth. The infants were clothed with only a diaper and evaluated on a radiant warmer bed set to achieve an axillary temperature of 36.5 degrees to 37.0 degrees C. Capillary refill time was measured with a digital stopwatch at 3 sites: volar surface of finger (F), plantar surface of heel (H), and lower sternum (St), using brief (1- to 2-second) and extended (3- to 4-second) pressure. Heart rate was auscultated and counted for 60 seconds, and BP was measured by oscillometry. Relationships among variables were assessed by Pearson correlation coefficient, analysis of variance, and multiple regression analysis. The Bonferroni correction for multiple comparisons was applied. Capillary refill time, blood pressure, and heart rate. There was no significant site variation for CRT for either brief (2.4 +/- 0.6 to 2.9 +/- 1.0 seconds) or extended (3.8 +/- 0.8 to 4.3 +/- 0.8 seconds) pressure. However, regardless of site, CRT was greater when extended versus brief pressure was used (P < 0.001). There were no significant correlations between HR and CRT. There was a moderate, direct relationship between BP and CRT observed in the following anatomic sites: (1) sternum/extended pressure and systolic BP (SBP), diastolic BP, and mean BP (r = 0.35, P = 0.02; r = 0.49, P = 0.001; and r = 0.43, P = 0.005, respectively); (2) sternum/brief pressure and SBP (r = 0.31, P = 0.05); and (3) finger/extended pressure and SBP (r = 0.30, P = 0.05). An unanticipated moderate, direct correlation between BP and CRT was observed; prolongation of CRT occurred with elevated blood pressure. This finding may have been secondary to increased circulating vasoactive substances in the newborn period; measurement of these substances was beyond the scope of this study. In addition, CRT was highly dependent on the duration of cutaneous pressure, regardless of the site. These 2 findings indicate that CRT may be an unreliable indicator of cardiovascular status in the term neonate during the first 4 hours after birth.
    Advances in Neonatal Care 06/2005; 5(3):147-54.
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    ABSTRACT: To compare the results of neurosonography (NSG) with subsequent neurodevelopmental testing in extremely low birth weight (ELBW; < or =1000 g) neonates. NSG at hospital discharge was available in 164 neonates and Bayley Scores of Infant Development (BSID II) evaluations (MDI and PDI) were performed in 158 of these infants at 18 to 22 months. Neurosonographic studies obtained prior to the discharge study also were evaluated. Neurosonograms were interpreted by pediatric radiologists, and BSID II examinations were performed by certified examiners masked to the results of the neurosonographic studies. A normal sonographic study at discharge was observed in 44% (14/32) of neonates with MDI <70 and 29% (7/24) with PDI <70. Furthermore, the sonographic study at discharge was normal in 59% (36/61) of neonates with MDI 70 to 84 and 56% (31/55) with PDI 70 to 84. Conversely, approximately 30 to 40% of those with an abnormality noted on neurosonogram at discharge, or at any time during hospitalization, had MDI and/or PDI scores > or =85. The association between abnormal NSG at discharge and low BSID II results was stronger for the PDI exam compared with the MDI exam. These results emphasize the limitations of NSG in predicting subsequent neurodevelopmental outcome in ELBW neonates. The primary role for NSG in ELBW neonates may be in the diagnosis and management of acute problems, such as intraventricular hemorrhage and posthemorrhagic hydrocephalus, and not as a tool to predict subsequent outcome.
    Journal of Perinatology 12/2003; 23(8):629-34. · 2.25 Impact Factor
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    ABSTRACT: Recent studies of preterm neonates have indicated that antenatal dexamethasone (ADX) may have adverse effects on cranial ultrasound findings at the time of hospital discharge, including periventricular leukomalacia. Furthermore, both ADX and postnatal dexamethasone (PDX) may have adverse effects on subsequent neurodevelopmental outcome. 1) To assess the effects of ADX exposure on cranial ultrasound findings at the time of hospital discharge and 2) to evaluate the individual effects of ADX and/or PDX exposure on subsequent neurodevelopmental outcome in extremely low birth weight (ELBW) neonates in whom confounding risk factors known to influence outcome were controlled. One hundred seventy-three ELBW (< or =1000 g) neonates were studied using a prospectively collected database and hospital and clinic records. Study patients were assigned to 1 of 4 groups according to dexamethasone exposure: group I, no dexamethasone exposure; group II, ADX exposure to hasten fetal lung maturity; group III, PDX exposure for chronic lung disease; group IV, both ADX and PDX exposure. The 4 groups were compared using multinomial logistic regression or analysis of covariance to control for confounding variables. Primary outcome variables were cranial ultrasound findings at hospital discharge and results of developmental testing at 18 to 22 months' corrected age (Bayley Scales of Infant Development). Cranial ultrasound results as well as Bayley Scales of Infant Development scores were similar in groups I and II and in groups III and IV. The likelihood of abnormal cranial ultrasound studies and lower scores on neurodevelopmental testing was greater in groups III and IV versus groups I and II. In this study, ADX did not seem to increase the risk of periventricular leukomalacia. ADX exposure is not associated with an increase in abnormal cranial ultrasound findings in ELBW neonates. PDX exposure, but not ADX exposure, is associated with worse neurodevelopmental outcome in this population. These results are supportive of the recent statement by the American Academy of Pediatrics (Committee on Fetus and Newborn) and the Canadian Paediatric Society (Fetus and Newborn Committee) and emphasize that PDX should be used with caution in ELBW neonates.
    PEDIATRICS 08/2002; 110(2 Pt 1):275-9. · 4.47 Impact Factor
  • W. D. Engle, J. L. LeFlore
    NeoReviews 01/2002; 3(8).
  • J L LeFlore, W D Engle, C R Rosenfeld
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    ABSTRACT: To define the range of normal blood pressures (BP) for very low birth weight (VLBW;</=1500 g) neonates and to study perinatal variables affecting BP measurements after birth, including the effects of antenatal steroids. Antenatal steroids were rarely administered at Parkland Memorial Hospital before May 1994, permitting us to establish a cohort of VLBW neonates exposed to antenatal steroids [n=70, 1166+/-253 (S.D.) g, and 28.7+/-2.1 weeks] who were matched with neonates delivered during the prior year (n=46, 1100+/-241 g, 28.9+/-1.8 weeks). Maternal and neonatal charts were abstracted for pertinent data, and neonatal BP measurements (determined directly when an arterial catheter was available or indirectly by the oscillometric method) were extracted every 3 h for the first 12 h and every 6 h until 72 h postnatal. Antenatal steroids did not affect BP immediately after birth or for the subsequent 72 h postnatal. Therefore, data from all neonates </=1500 g were combined and the pattern of BP change over 72 h postnatal assessed. Systolic, diastolic and mean BP increased (P<0.001) 33%, 44% and 38%, respectively, during the first 72 h. Although neonates weighing </=1000 g and 1001-1500 g demonstrated gradual increases (P<0.001) in systolic, diastolic and mean BP by 72 h, values were consistently lower (P<0.01) in neonates </=1000 g. Of interest, only 11 neonates (9.5%) were treated for clinical hypotension. In VLBW neonates antenatal steroids do not modify BP measurements either immediately after birth or the 30-40% rise occurring in the first 72 h postnatal. Further, BP is developmentally regulated and is gestationally and birth weight dependent. These data provide additional insight into assessing the need for treating hypotension.
    Early Human Development 07/2000; 59(1):37-50. · 2.02 Impact Factor
  • Pediatric Research 01/1998; 43. · 2.67 Impact Factor
  • Pediatric Research 01/1998; 43. · 2.67 Impact Factor

Publication Stats

100 Citations
25.34 Total Impact Points


  • 2002–2014
    • Children's Medical Center Dallas
      Dallas, Texas, United States
  • 2005–2013
    • University of Texas at Arlington
      Arlington, Texas, United States
  • 2000
    • University of Texas Southwestern Medical Center
      • Department of Pediatrics
      Dallas, TX, United States