Louis R Pizano

Jackson health system, Miami, Florida, United States

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Publications (35)69.14 Total impact

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    ABSTRACT: Abstract Background: Infection is the leading cause of death in burn patients. Historically, this was due to burn wound sepsis but pneumonia has now emerged as the most common source. In light of the increasing incidence of multi-drug-resistant organisms, the description of rare infections is paramount in continuing the fight against deadly pathogens. We aim to describe the second case of non-tuberculous mycobacterium (NTM) reported in a burn patient. Difficulties in diagnosis and management will also be highlighted. Methods: A 70-y-old Caucasian female, with a past medical history for type 2 diabetes mellitus, was transferred to our facility after a house fire. She had sustained a 28% total body surface area (TBSA) flame burn to her neck, torso, and all four extremities. She underwent excision and grafting on hospital day five with multiple subsequent attempts at excision and grafting due to graft loss. On hospital day 14, a tracheostomy was performed. Her hospital course was complicated by ongoing respiratory failure, renal injury, and sepsis. Results: Mycobacterium abscessus was found on blood cultures from central venous catheters and arterial line catheters as well as on tracheal aspirate and bronchoalveolar lavage (BAL) on hospital day 86. Imaging then revealed multiple pulmonary nodular densities with patchy ground-glass opacities. After multiple adjustments to the antibiotic regimen, tigecycline, clarithromycin, and cefoxitin therapy was started. She remained on this regimen for almost 4 wks. Her other infections included Acinetobacter baumanii treated with tobramycin and colistin, as well as Candida albicans for which she received fluconazole. Ultimately, her clinical state worsened leading to withdrawal of care. Conclusions: Sepsis NTM is rare in burn patients with only one other case described in the English-language literature. Both cases reflect differences in diagnosis and management. This highlights the need to discuss rare infections in an attempt to broaden the clinician's awareness of such pathogens, as well as to collaborate to form a consensus about their management.
    Surgical Infections 12/2014; · 1.87 Impact Factor
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    ABSTRACT: There continues to be debate about the routine use of deep vein thrombosis (DVT) prophylaxis in burn patients. The concern is routine prophylaxis may lead to adverse events. The debate hinges on the incidence of DVT and its relation to the risk-benefit ratio. This study seeks to estimate the true rate of DVT in burn patients, and to evaluate possible risk factors to its development. The Nationwide Inpatient Sample was queried for all patients with age ≥18 years with ICD-9 codes for burn injuries. Demographic data, comorbidities, burn data, length of stay, total charges, procedures, presence of central venous catheter, and mortality were recorded. Patients were classified based on the presence of DVT. Student's t-test, χ test, and logistic regression were performed. 36,638 burn patients were identified. DVT rate was 0.8%. Patients with DVT were older, had longer hospitalizations, more procedures, and higher charges. On logistic regression, black race, TBSA ≥20%, history of previous VTE, blood transfusion, and mechanical ventilation were the significant factors associated with DVT. Patients with DVT were almost twice as likely to die during the admission (P = .011). This is the largest series to date examining the risk factors for DVT in burn patients. DVT developed in approximately 0.8% of burn patients. Black race, TBSA ≥20%, blood transfusions, and mechanical ventilation were associated with approximately 2-fold odds of developing DVT. Identification of these additional risk factors may allow targeted patient prophylaxis. Additionally, patients with DVT incurred higher total charges and longer hospitalization.
    Journal of burn care & research: official publication of the American Burn Association 07/2014; · 1.54 Impact Factor
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    ABSTRACT: Traumatic vascular injuries of the lower extremity in the pediatric population are rare but can result in significant morbidity. We aimed at describing our experience with such complex injuries, with associated patterns of injury, diagnostic and therapeutic challenges, and outcomes.
    The Journal of Trauma and Acute Care Surgery 06/2014; 76(6):1386-9. · 2.35 Impact Factor
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    ABSTRACT: Our institution continued to experience a hyperendemic situation with carbapenem-resistant Acinetobacter baumannii despite a bundle of interventions. We aim to describe the effect of the subsequent implementation of electronic dissemination of the weekly findings of a bundle of interventions. This was a quasiexperimental study performed at a 1,500-bed, public, teaching hospital. From January 2011 to March 2012, weekly electronic communications were sent to the hospital leadership and intensive care units (ICUs). These communications aimed to describe, interpret, and package the findings of the previous week's active surveillance cultures, environmental cultures, environmental disinfection, and hand cultures. Additionally, action plans based on these findings were shared with recipients. During 42 months and 1,103,900 patient-days, we detected 438 new acquisitions of carbapenem-resistant A baumannii. Hospital wide, the rate of acquisition decreased from 5.13 ± 0.39 to 1.93 ± 0.23 per 10,000 patient-days, during the baseline and postintervention periods, respectively (P < .0001). This effect was also observed in the medical and trauma ICUs, with decreased rates from 67.15 ± 10.56 to 17.4 ± 4.6 (P < .0001) and from 55.9 ± 8.95 to 14.71 ± 4.45 (P = .0004), respectively. Weekly and systematic dissemination of the findings of a bundle of interventions was successful in decreasing the rates of carbapenem-resistant A baumannii across a large public hospital.
    American journal of infection control 05/2014; 42(5):466-71. · 3.01 Impact Factor
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    ABSTRACT: We aimed to determine the association between environmental exposure to carbapenem-resistant Acinetobacter baumannii and the subsequent risk of acquiring this organism. Patients exposed to a contaminated hospital environment had 2.77 times the risk of acquiring carbapenem-resistant A. baumannii than did unexposed patients (relative risk, 2.77 [95% confidence interval, 1.50-5.13]; P = .002).
    Infection Control and Hospital Epidemiology 04/2014; 35(4):430-3. · 4.02 Impact Factor
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    ABSTRACT: Generalized pustular psoriasis (GPP) is an immune-mediated dermatologic condition that is characterized by a widespread eruption of sterile, subcorneal pustules. Cases of GPP may present to the burn intensive care unit (ICU), and they may be confused with toxic epidermal necrolysis (TEN) due to the generalized erythema and desquamation. GPP often benefits from admission to an ICU for management of fluid and electrolyte imbalances and for complications such as pneumonitis, renal dysfunction and sepsis. We present the case of a 42 year-old man who was transferred to the burn unit for presumed TEN where he was diagnosed with GPP and successfully treated with intravenous cyclosporine and supportive care. Our objective is to increase awareness of this condition in the critical care community, discuss clinical and laboratory findings, and to review the treatment guidelines published by the National Psoriasis Foundation in August 2012. We also discuss the latest reports utilizing biological response modifying drugs.
    Burns: journal of the International Society for Burn Injuries 01/2014; · 1.95 Impact Factor
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    ABSTRACT: To characterize the descriptive and molecular epidemiology of Acinetobacter baumannii in our hospital. Longitudinal analysis of electronic microbiology laboratory records and isolates. A 1,500 bed public teaching hospital in the Miami area. Consecutive patients with A. baumannii from January 1994 to December 2011. None MEASUREMENTS AND MAIN RESULTS:: Data on all A. baumannii isolates were clustered at the patient level, and the first isolate per single patient was determined. Yearly trends were analyzed based on carbapenem susceptibilities and originating units for all first isolates and first blood isolates per unique patient. Additionally, carbapenem nonsusceptible isolates frozen in the microbiology laboratory since 1998 were retrieved and evaluated using polymerase chain reaction and randomly amplified polymorphic DNA techniques. A total of 9,334 A. baumannii isolates were detected, of which 4,484 isolates (48%) were identified as first positive isolates per unique patient. Most of the burden of disease was located in the ICUs (odds ratio, 2.64 [95% CI, 2.17-3.22]; p < 0.0001) and in the adult wards (odds ratio, 3.867 [95% CI, 2.71-5.52]; p < 0.0001). Respiratory specimens constituted the most frequent source (49%; odds ratio, 1.619 [95% CI, 1.391-1.884]; p < 0.0001). Of the 4,484 first isolates, 846 isolates (18.9%) were carbapenem nonsusceptible and 3,638 isolates (81.1%) were carbapenem susceptible. Over the years, the number of carbapenem nonsusceptible isolates increased, whereas the number of carbapenem susceptible decreased (p < 0.0001). The trauma ICU had the highest burden of carbapenem nonsusceptible first isolates (205 of 846; 24.2%). Seven clones were discovered among 144 carbapenem nonsusceptible isolates; one of these clones was found from 1999 to 2005. OXA-23 and OXA-40 were identified in 96 and 13 isolates, respectively. One isolate harbored a novel CTX-M-115 enzyme. This constitutes the largest experience with A. baumannii reported to date from a single center. Half of all isolates were respiratory specimens and were from adult ICUs, especially trauma. Even though this was a polyclonal process, a single clone was identified in the hospital through a 6-year span.
    Critical care medicine 08/2013; · 6.37 Impact Factor
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    ABSTRACT: The American Burn Association recommends that patients with toxic epidermal necrolysis-Stevens Johnson syndrome (TEN-SJS) or burn inhalation injuries would benefit from admission or transfer to a burn center (BC). This study examines to what extent those criteria are observed within a regional burn network. Hospital discharge data from 2000 to 2010 was obtained for all hospitals within the South Florida regional burn network. Patients with International Classification of Disease-9th revision discharge diagnoses for TEN-SJS or burn inhalation injury and their triage destination were compared using burn triage referral criteria to determine whether the patients were triaged differently from American Burn Association recommendations. Two hundred ninety-nine TEN-SJS and 131 inhalation injuries were admitted to all South Florida hospitals. Only 25 (8.4%) of TEN-SJS and 27 (21%) of inhalation injuries were admitted to the BC. BC patients had greater length of stay (TEN-SJS 22 vs 10 days; inhalation 13 vs 7) and were more likely to be funded by charity or be self-paid (TEN-SJS 24 vs 9.5%, P = .025; inhalation 44 vs 14%, P < .001), but less likely to hold some form of private or government insurance (TEN-SJS 72 vs 88%, P = .02; inhalation 48 vs 81%, P = .006). TEN-SJS BC patients were more frequently discharged home for self-care (76 vs 50%, P = .006). Non-BC patients were more often discharged to other healthcare facilities (28 vs 0% TEN-SJS, 20 vs 7.4% inhalation). Nonrecommended triage may occur in more than 3 of 4 of the TEN-SJS and inhalation injury patients within our burn network. Unfamiliarity with triage criteria, patient insurance status, and overcoding may play a role. Further studies should fully characterize the problem and implement education or incentives to encourage more appropriate triage.
    Journal of burn care & research: official publication of the American Burn Association 08/2013; · 1.54 Impact Factor
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    ABSTRACT: Hypercoagulability is a homeostatic response to trauma, but relatively little information is available about coagulation changes after burn injury. Therefore, we tested the hypothesis that burn patients are hypercoagulable at admission and/or during recovery. A prospective observational trial was conducted at an American Burn Association verified Burn Center. Thromboelastography (TEG) was performed on blood drawn from indwelling catheters upon admission and weekly for those who remained hospitalized. Routine and special coagulation tests were performed on stored samples. Data are expressed as median (interquartile range). Twenty-four patients (88% male) were enrolled, with a median age of 49 (20) years and a median total body surface area burn of 29% (23%); 21 experienced thermal burns (4 inhalational injuries), and 3 had electrical burns. There were no significant differences in TEG or coagulation assays between patients with thermal versus electrical burn injury, but there were significant differences between men versus women and between those with or without inhalational injury. Sixteen patients had repeat samples 1 week after intensive care unit admission. The repeat TEG was more hypercoagulable (all p < 0.05). Fibrinogen and natural anticoagulation proteins (protein C, protein S, and antithrombin III) were also increased (all p < 0.05). Two patients (8%) developed venous thromboembolism (VTE); TEG reaction time, fibrinogen, and partial thromboplastin time were decreased (all p < 0.05) at admission compared with those with no VTE. All changes occurred despite pharmacologic thromboprophylaxis. There was no significant correlation between TEG and total body surface area or between TEG and fluid balance. In general, burn patients have normal coagulation parameters at admission but become hypercoagulable during recovery. However, those who are hypercoagulable at admission may have an increased risk of VTE. Additional monitoring and/or thromboprophylaxis may be indicated. Epidemiologic/prognostic study, level III.
    The journal of trauma and acute care surgery. 07/2013; 75(1):37-43.
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    ABSTRACT: OBJECTIVE:: To establish the presence of air contamination with Acinetobacter baumannii in the trauma ICU. DESIGN:: Point prevalence microbiological surveillances. SETTINGS:: A 1,500-bed public teaching hospital in the Miami metro area. PATIENTS:: Trauma ICU patients. MEASUREMENTS:: Pulsed field electrophoresis was performed on environmental and clinical isolates to determine the association of any isolates from the air with clinical isolates. MAIN RESULTS:: Out of 53 patient areas cultured, 12 (22.6%) had their air positive for A. baumannii. The presence of an A. baumannii-positive patient (underneath the plate) was associated with positive air cultures for A. baumannii (11 of 21 [52.4%] vs 0 of 25 [0%]; p < 0.0001). However, we were not able to find differences in air contamination based on the presence of A. baumannii in respiratory secretions vs absence (p = 1.0). Air and clinical isolates were found to be clonally related. CONCLUSIONS:: Aerosolization of A. baumannii in the ICUs is a concern, and its role in the transmission of this organism among patients should be further clarified.
    Critical care medicine 06/2013; · 6.37 Impact Factor
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    ABSTRACT: Maintaining burn patients' body temperature during surgery is a significant challenge. Although increasing the ambient operating room (OR) temperature and other passive rewarming methods help, such measures have limited effectiveness and prove taxing on OR personnel. Initial studies indicate that an intravascular warming catheter may improve and sustain burn patient body temperatures. The authors hypothesize that the warming catheter is similarly effective at maintaining normothermia despite a lower OR temperature than in a cohort of matched control burn patients. This is a retrospective case-control study involving patients with major burns treated between January 2006 and June 2011. Cases received an intravascular warming catheter, whereas controls receive traditional temperature conserving interventions. As the catheters maintained body temperature, the room temperature was gradually lowered to normal. Twenty-three patients were involved in 31 cases using the catheter, compared with 39 controls in 62 surgeries. The mean temperature deviation for each catheter group was -0.76 ± 1°C and -0.80 ± 0.9°C for the control group. Given 20-minute intervals throughout the operations, the mean patient temperature for cases and controls never deviated by more than 1°C. OR staff satisfaction has improved with decreased room temperatures. An intravenous warming catheter reliably maintained patient core body temperature during surgery. To date, this is the largest cohort study of such a catheter among burn patients. This system may be more effective than current warming techniques, with the potential to decrease the total number of procedures and the time to complete wound closure.
    Journal of burn care & research: official publication of the American Burn Association 01/2013; 34(1):191-5. · 1.54 Impact Factor
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    ABSTRACT: IntroductionThe elderly are the fastest growing population segment, and particularly susceptible to burns. Predicting outcomes for these patients remains difficult. Our objective was to identify early predictors of mortality in elderly burn patients.Methods Our Burn Center's prospective database was reviewed for burn patients 60+ treated in the past 10 years. Predictor variables were identified by correlative analysis and subsequently entered into a multivariate logistic regression analysis examining survival to discharge.Results203 patients of 1343 (15%) were eligible for analysis. The average age was 72 ± 10 (range 60–102) and the average total body surface area (TBSA) burned was 23 ± 18% (range 1–95). Age, TBSA, base deficit, pO2, respiratory rate, Glasgow Coma Score (GCS), and Revised Trauma Score (RTS, based on systolic blood pressure, respiratory rate, and GCS) all correlated with mortality (p ≤ 0.05). Using multiple logistic regression analysis, a model with age, TBSA and RTS was calculated, demonstrating:increased risk of mortality=β0+1.12 (age)+1.094 (TBSA)+0.718 (RTS)increased risk of mortality=β0+1.12 (age)+1.094 (TBSA)+0.718 (RTS)In this model, β0 is a constant that equals −8.32.Conclusions Predicting outcomes in elderly burn patients is difficult. A model using age, TBSA, and RTS can, immediately upon patient arrival, help identify patients with decreased chances of survival, further guiding end-of-life decisions.
    Burns: journal of the International Society for Burn Injuries 12/2012; 38(8):1114–1118. · 1.95 Impact Factor
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    ABSTRACT: Advances in burn care have decreased mortality in the past 20 years, but affecting elderly mortality rates (>65 years) remain challenging. This study evaluates the impact of home caregiver support on elderly burn patients' mortality. The authors retrospectively reviewed patients aged 65 and older admitted to their burn center from July 1995 to October 2004. Patient demographics, Injury Severity Score, TBSA, and patients' primary caregiver were collected. The outcomes were mortality, disposition, and length of stay and these were evaluated using univariate and subsequently multivariate regression. Significance was calculated at P ≤ .05. A total of 112 patients were included in the analysis. The mean age was 76 ± 8. Male patients constituted 47%, whereas 53% were female patients, and mean TBSA was 21 ± 16%. Thirty patients' primary caregiver was a spouse, 38 had a child, and 44 had no caregiver. Fifty-eight patients survived (51.7%), and 54 patients died (48.3%). Only 21% of the survivors had a child as their primary caregiver; however, 48% of the nonsurvivors had a child as the primary caregiver (P ≤ 0.05). On multivariate analysis, age, TBSA, and child as primary caregiver were all independent predictors of mortality. Having a child as a caregiver provided the largest impact, with an odds ratio of 4.4 (95% confidence interval, 1.2-15.62; P = .02).
    Journal of burn care & research: official publication of the American Burn Association 11/2012; · 1.54 Impact Factor
  • Jason Daniel Sciarretta, Louis R Pizano
    The American surgeon 09/2012; 78(9):427-8. · 0.92 Impact Factor
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    ABSTRACT: The American Burn Association publishes a list of defined criteria for patients who require admission or transfer to a burn center. This study examines the extent to which those criteria are observed within a regional burn network. Hospital discharge data for 2008 were obtained for all hospitals within the South Florida regional burn network. Patients with International Classification of Diseases, 9th revision discharge diagnoses for burns were reviewed, and their triage destination was compared with the burn triage referral criteria to determine whether patients were inappropriately triaged. Descriptive statistics were used to analyze the data. Four hundred ninety-eight burn admissions were documented to non-burn center center hospitals, 269 (54%) of which were deemed inappropriate by burn triage referral criteria. Burn center patients had greater length of stay when compared with non-burn center patients (14 vs 7 days), but a greater percentage were discharged home for self-care (88 vs 57%). Thirty-three percent of the inappropriate admissions were in a neighboring county, whereas 27% were in the same county where the burn center is located. Inappropriate burn patient triage may be occurring to more than half of the burn patients within our regional burn network despite better functional outcomes at the burn center. This may be because of a lack of knowledge regarding triage criteria, patient insurance status, or other factors. Further studies are necessary to fully characterize the problem and implement education or incentives to encourage appropriate burn patient triage.
    Journal of burn care & research: official publication of the American Burn Association 08/2012; · 1.54 Impact Factor
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    ABSTRACT: Introduction Reports of arterial injuries from both the civilian and military arenas report the brachial artery as the most frequently injured vessel, accounting for approximately 25–33% of all peripheral arterial injuries. The brachial artery is surrounded by important peripheral nerves —the median, ulnar and radial, and also parallels the humerus and associated veins. Due to its close proximity to these structures, associated nerve and osseous injuries are frequent with residual neuropathy from such nerve injuries, often the main sources of permanent disability. Materials and methods Systematic review of the literature, with emphasis in the diagnosis, treatment and outcomes of these injuries, incorporating the authors experience. Conclusions The morbidity and mortality rates associated with brachial artery injuries depend on the cause of the injury itself, which vein or tendon is injured, and whether musculoskeletal and nerve injuries are also present. During the last 20 years, amputation associated with upper extremity arterial injuries has decreased to a rate of 3% because of advances in the treatment of shock, the use of antibiotic therapy, and increased surgical experience.
    European Journal of Trauma and Emergency Surgery 10/2011; · 0.26 Impact Factor
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    ABSTRACT: Burn cellulitis is an infection of the unburned skin at the margin of a burn wound or graft donor site, typically caused by group A beta-hemolytic streptococci and Staphylococcus aureus. beta-Lactam antibiotics exhibit time-dependent killing and, because of their narrow spectrum, minimize bacterial resistance. We therefore use continuous-infusion oxacillin in the treatment of burn cellulitis. Patients at a regional burn center who were treated for burn cellulitis from January 2003 to December 2005 were included. Charts were reviewed for all pertinent data regarding the antibiotic treatment methods and outcomes. Successful treatment was defined as resolution of physical findings, fever, and leukocytosis and intravenous antibiotic cessation. Thirty-seven patients were treated for burn cellulitis, 26 (70%) of whom were treated initially with continuous-infusion oxacillin. Other initial antibiotics were chosen because of concomitant infections, penicillin allergy, or development of cellulitis during treatment with a beta-lactam antibiotic. Oxacillin treatment was successful in 19 patients (73%). Success required an average of 5.16 days, with 1.53 days required for fever resolution and 0.89 days for resolution of leukocytosis. Seven patients who did not respond rapidly were switched to intravenous vancomycin an average of 2.4 days after starting oxacillin, leading to a 100% success rate. There were no deaths, and only one suspected case of allergic reaction to oxacillin. In eleven patients treated with other antibiotics, the success rate was 75%. Success with these drugs required a longer treatment course of 6.45 days. Leukocytosis resolved significantly more slowly at 4.45 days (p = 0.02), and fever resolution was also slower at 3.18 days. Continuous-infusion oxacillin was successful in the treatment of 73% of patients, a success rate that might have been higher with clinical patience, and leukocytosis resolved faster than with other antibiotics. Failure of continuous-infusion oxacillin can be managed without clinical consequence by conversion to intravenous vancomycin.
    Surgical Infections 03/2009; 10(1):41-5. · 1.87 Impact Factor
  • Journal of Surgical Research - J SURG RES. 01/2009; 151(2):299-299.
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    ABSTRACT: There are an estimated 1.2 million burn injuries per year in the United States, one third of which occur in children. Most of these injuries will be treated nonoperatively, frequently in an outpatient setting. This article aims to provide the practitioner with a understanding of the pathophysiology of burn injuries, a guide to the initial assessment of the patient, and management recommendations for nonoperative treatment of the burned pediatric patient.
    The Journal of craniofacial surgery 07/2008; 19(4):877-81. · 0.81 Impact Factor
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    ABSTRACT: Burn injuries continue to be a significant cause of pediatric morbidity in the United States, with approximately 20,000 admissions per year to centers specializing in the treatment of burn injuries. In this article, we aim to provide the practitioner with a guideline to the unique challenges, advances and current expectations, and treatment in this patient population.
    The Journal of craniofacial surgery 07/2008; 19(4):929-32. · 0.81 Impact Factor

Publication Stats

134 Citations
69.14 Total Impact Points

Institutions

  • 2014
    • Jackson health system
      Miami, Florida, United States
  • 2003–2014
    • University of Miami Miller School of Medicine
      • • Division of Trauma and Surgical Critical Care
      • • Division of Trauma and Surgical Critical Care Services
      Miami, Florida, United States
  • 2009
    • Yale University
      • Department of Surgery
      New Haven, CT, United States
  • 2007
    • University of Miami
      • Department of Surgery
      Coral Gables, FL, United States
    • Jackson Memorial Hospital
      Miami, Florida, United States
    • Partners HealthCare
      Boston, Massachusetts, United States