Georges Azzie

University of Toronto, Toronto, Ontario, Canada

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Publications (34)75.08 Total impact

  • Dorotea Mutabdzic · Georges Azzie

    No preview · Article · Jan 2016 · Annals of Surgery
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    ABSTRACT: Objective: There is a growing need to address the global burden of surgical disease along with increasing interest in international surgical practice, necessitating an understanding of the challenges and issues that arise on a systems level when practicing abroad. Design: This elective is a month-long rotation in which senior surgical residents participate in patient care as part of a surgical team in the main tertiary and teaching hospital in Gaborone, the capital city of Botswana. Clinical experience is combined with formal readings and educational sessions, with the attending surgeon supervising the program to develop a systems-based curriculum that contextualizes the clinical experience. A formal debriefing and written reflections by the residents at the conclusion of the rotation are used to qualitatively assess resident development and insight into systems-based international surgical practice. Setting: Princess Marina Hospital, Gaborone, Botswana. Participants: General surgery residents in their fourth clinical year of training. Results: Our elective met important requirements outlined in the literature for foreign practice, including adequate supervision of the American trainees and care to not detract from local trainees' educational experience. Residents' debriefing and written reflections demonstrated an increased understanding of systems-based practice and awareness of issues important to successful international surgical practice and collaboration. Conclusions: Our global surgery elective with a focus on systems-based practice sensitizes residents to the challenges and issues they must be aware of when practicing internationally.
    No preview · Article · Nov 2015 · Journal of Surgical Education
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    ABSTRACT: This study aims to adapt an existing multiport pediatric laparoscopic surgery simulator to be suitable for pediatric single-port laparoscopy and to investigate construct validity for its use as a resource for skills training and assessment. An existing pediatric-sized box trainer was modified to accommodate a commercially available port. A total of 41 participants (18 novices, 16 intermediates and 7 experts) were recruited to complete four curriculum tasks via a single-port access approach. Objective task performance scores were evaluated. Task completion times and performance scores were significantly different between novices and experts for the peg transfer (P=0.02, P=0.008 respectively), pattern cut (P<0.001, P<0.001 respectively) and ligating loop (P=0.038, P=0.035 respectively). There were significant differences in outcomes between novices and intermediates for all tasks, including the intracorporeal suture task (P≤0.001). There were no significant differences in outcomes between intermediates and experts for all tasks. The Pediatric Laparoscopic Surgery (PLS) simulator can be easily adapted for single-port laparoscopic surgery to be construct valid for the peg transfer, ligating loop and pattern cut tasks. There is scope for additional tasks to be developed that focus on the unique technical challenges and skills associated with single-port techniques. Copyright © 2015. Published by Elsevier Inc.
    No preview · Article · Apr 2015 · Journal of Pediatric Surgery
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    ABSTRACT: Excessive or inappropriate tissue interaction force during laparoscopic surgery is a recognized contributor to surgical error, especially for robotic surgery. Measurement of force at the tool-tissue interface is, therefore, a clinically relevant skill assessment variable that may improve effectiveness of surgical simulation. Popular box trainer simulators lack the necessary technology to measure force. The aim of this study was to develop a force sensing unit that may be integrated easily with existing box trainer simulators and to (1) validate multiple force variables as objective measurements of laparoscopic skill, and (2) determine concurrent validity of a revised scoring metric. A base plate unit sensitized to a force transducer was retrofitted to a box trainer. Participants of 3 different levels of operative experience performed 5 repetitions of a peg transfer and suture task. Multiple outcome variables of force were assessed as well as a revised scoring metric that incorporated a penalty for force error. Mean, maximum, and overall magnitudes of force were significantly different among the 3 levels of experience, as well as force error. Experts were found to exert the least force and fastest task completion times, and vice versa for novices. Overall magnitude of force was the variable most correlated with experience level and task completion time. The revised scoring metric had similar predictive strength for experience level compared with the standard scoring metric. Current box trainer simulators can be adapted for enhanced objective measurements of skill involving force sensing. These outcomes are significantly influenced by level of expertise and are relevant to operative safety in laparoscopic surgery. Conventional proficiency standards that focus predominantly on task completion time may be integrated with force-based outcomes to be more accurately reflective of skill quality. Copyright © 2015 Elsevier Inc. All rights reserved.
    No preview · Article · Feb 2015 · Surgery
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    ABSTRACT: Laparoscopic models for ex vivo up-skilling are becoming increasingly important components of surgical education. This study aims to establish the construct validity and possible educational role of a new laparoscopic box trainer equipped with a motion-tracking device. A structured questionnaire was used to assign participants into novice, intermediate, or expert categories according to level of experience in minimal access surgery (MAS). Participants carried out a well-defined intracorporeal suturing task. Three specific motion analysis parameters (MAPs)-velocity, acceleration, and range-were measured and analyzed as movements in the four degrees of freedom available in traditional MAS using tracking sensors at the trocar insertion sites. The number of extreme velocity and acceleration events in all four degrees of freedom proved capable of differentiating between participants in the three categories of surgical experience using an ANOVA test (p < 0.001). Post hoc analysis confirmed these differences in the number of extreme velocity and acceleration events between all groups tested except for the velocity of the roll between the intermediates and experts. These findings confirm construct validity for this new laparoscopic box trainer system, which employs a novel analysis based on motion parameters. Motion parameters provide information regarding the overall smoothness of the operator's instrument handling, an important aspect of a surgeon's technique. This preliminary data will be used to design a simulator with real-time motion feedback to enhance its educational value.
    No preview · Article · Dec 2014 · Surgical Endoscopy
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    ABSTRACT: IntroductionAttention to surgical conditions in low- and middle-income countries (LMICs) has increased in recent years. Because half of the population in the world’s poorest countries are children [1], paediatric surgical conditions compose a significant proportion of the global burden of disease (BoD), and there are critical shortages in workforce and skills to treat these diseases in LMICs. Several population-based studies have highlighted the magnitude of the need for paediatric surgery and the limited capacity, both in human resources and in infrastructure, to tackle the problem [2, 3]. Africa, in particular, has a grave shortage of paediatric surgeons. The number of fully trained paediatric surgeons ranges from 1 in Malawi (population 13 million) to 120 in Egypt (population of 80 million). In more than half of African countries, no full-time paediatric surgeon is available [4, 5]. LMICs in other world regions have a similar challenge. The problem is not only limited to a poor rati ...
    No preview · Article · Oct 2014 · World Journal of Surgery
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    ABSTRACT: Objective: Differences in opinion exist as to the feasibility of establishing sustainable laparoscopic programs in resource-restricted environments. At the request of local surgeons and the Ministry of Health in Botswana, a training program was established to assist local colleagues with laparoscopic surgery. We reviewed our multifaceted and evolving international collaboration and highlighted those factors that have helped or hindered this program. Methods: From 2006 to 2012, a training program consisting of didactic teaching, telesimulation, Fundamentals of Laparoscopic Surgery certification, yearly workshops, and ongoing mentorship was established. We assessed the clinical outcomes of patients who underwent laparoscopic cholecystectomy, comparing them with patients who underwent open cholecystectomy, and measured the indicators of technical independence and program sustainability. Results: Twelve surgeons participated in the training program and performed 270 of 288 laparoscopic cholecystectomies. Ninety-six open cases were performed by these and 5 additional surgeons. Fifteen laparoscopic cases were converted (5.2%). The median postoperative length of hospital stay was significantly shorter in the laparoscopic group than in the open group (1 day vs 7 days, P < 0.001). As the training program progressed, the proportion of laparoscopic cases completed without an expatriate surgeon present increased significantly (P = 0.001). Conclusions: A contextually appropriate long-term partnership may assist with laparoscopic upskilling of colleagues in low- and middle-income countries. This type of collaboration promotes local ownership and may translate into better patient outcomes associated with laparoscopic surgery. In resource-restricted environments, the factors threatening sustainability may differ from those in high-income countries and should be identified and addressed.
    No preview · Article · Jun 2014 · Annals of Surgery
  • Ahmed Nasr · Brian Carrillo · J. Ted Gerstle · Georges Azzie
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    ABSTRACT: Background Construct validity for the Pediatric Laparoscopic Surgery (PLS) simulator has been established through a scoring system based on time and precision. We describe the development and initial validation of motion analysis to teach and assess skills related to pediatric minimal access surgery (MAS). Methods Participants were asked to perform a standardized intracorporeal suturing task. They were classified as novices, intermediates, and experts. Motion in the four degrees of freedom available during traditional MAS (PITCH, YAW, ROLL and SURGE) was assessed using range, velocity, and acceleration. Results Analysis of motion allowed discrimination between the 75 participants according to level of expertise. The most discriminating motion parameter was the acceleration in performing the ROLL (pronation/supination) with values of 30 ± 27 for novices, 15 ± 5 for intermediates, and 3.7 ± 3 for experts (p < 0.001). Conclusions Tracking and analyzing the motion of instruments within the PLS simulator allows discrimination between novices, intermediates, and experts, thus establishing construct validity. Further development may establish motion analysis as a useful “real time” modality to teach and assess MAS skills.
    No preview · Article · May 2014 · Journal of Pediatric Surgery
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    ABSTRACT: Importance Surgical conditions are an important component of global disease burden, due in part to critical shortages of adequately trained surgical providers in low- and middle-income countries.Objectives To assess the use of Internet-based educational platforms as a feasible approach to augmenting the education and training of surgical providers in these settings.Design, Setting, and Participants Access to two online curricula was offered to 75 surgical faculty and trainees from 12 low- and middle-income countries for 60 days. The Surgical Council on Resident Education web portal was designed for general surgery trainees in the United States, and the School for Surgeons website was built by the Royal College of Surgeons in Ireland specifically for the College of Surgeons of East, Central and Southern Africa. Participants completed an anonymous online survey detailing their experiences with both platforms. Voluntary respondents were daily Internet users and endorsed frequent use of both print and online textbooks as references.Main Outcomes and Measures Likert scale survey questionnaire responses indicating overall and content-specific experiences with the Surgical Council on Resident Education and School for Surgeons curricula.Results Survey responses were received from 27 participants. Both online curricula were rated favorably, with no statistically significant differences in stated willingness to use and recommend either platform to colleagues. Despite regional variations in practice context, there were few perceived hurdles to future curriculum adoption.Conclusions and Relevance Both the Surgical Council on Resident Education and School for Surgeons educational curricula were well received by respondents in low- and middle-income countries. Although one was designed for US surgical postgraduates and the other for sub-Saharan African surgical providers, there were no significant differences detected in participant responses between the two platforms. Online educational resources have promise as an effective means to enhance the education of surgical providers in low- and middle-income countries.
    No preview · Article · Feb 2014 · JAMA SURGERY
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    ABSTRACT: To examine how a mass-gathering event (the Federation Internationale de Football Association World Cup, 2010, South Africa) impacts trauma and mortality in the pediatric (≤18 years) population. We investigated pediatric emergency visits at Cape Town's 3 largest public trauma centers and 3 private hospital groups, as well as deaths investigated by the 3 city mortuaries. We compared the 31 days of World Cup with equivalent periods from 2007-2009, and with the 2 weeks before and after the event. We also looked at the World Cup period in isolation and compared days with and without games in Cape Town. There was significantly decreased pediatric trauma volume during the World Cup, approximately 2/100 000 (37%) fewer injuries per day, compared with 2009 and to both pre- and post-World Cup control periods (P < .001). This decrease occurred within a majority of injury subtypes, but did not change mortality. There were temporal fluctuations in emergency visits corresponding with local match start time, with fewer all-cause emergency visits during the 5 hours surrounding this time (-16.4%, P = .01), followed by a subsequent spike (+26.2%, P = .02). There was an increase in trauma 12 hours following matches (+15.6%, P = .06). In Cape Town, during the 2010 Federation Internationale de Football Association World Cup, there were fewer emergency department visits for traumatic injury. Furthermore, there were fewer all-cause pediatric emergency department visits during hometown matches. These results will assist in planning for future mass-gathering events.
    Full-text · Article · Nov 2013 · The Journal of pediatrics
  • Ahmed Nasr · J Ted Gerstle · Brian Carrillo · Georges Azzie
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    ABSTRACT: The Pediatric Laparoscopic Surgery (PLS) simulator is the only validated tool for pediatric Minimal Access Surgery. Construct validity (the ability to discriminate between novice, intermediate and expert) for the PLS simulator had previously been established on the basis of the total PLS score, as well as the individual performance on three of the five tasks. We describe the process and methods used to establish independent construct validity for a fourth task: pattern-cutting. After considering various options for the possible modifications of the task itself, we retrospectively altered the way the pattern-cutting task was scored by modifying the weighting of precision versus time without changing the task itself. This was subsequently tested prospectively at the 2011 Canadian Association of Pediatric Surgeons meeting. Modification in the scoring metrics allowed differentiation within a previously tested cohort of 84 candidates (20 novices: score=48±16, 19 intermediates: score=59±18, 45 experts: score=69±12 p=0.01). This was validated prospectively in a cohort of 18 experts and 7 intermediates (65±8, 54±17 p=0.03). Construct validity for the pattern-cutting task was established by modification of the scoring metrics. This was validated both retrospectively and prospectively.
    No preview · Article · Oct 2013 · Journal of Pediatric Surgery
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    ABSTRACT: Background: Constipation in children is a commonly encountered problem with a broad variety of causes. Constipation caused by a narrow pelvis has, to our knowledge, not been reported in the human literature. Methods: Retrospective review of patient chart, in depth follow-up appointment with the patient and review of literature. Results: A 15 year old girl with sacral agenesis and significant co-morbidities was referred for consideration of cecostomy tube placement to manage her constipation. Digital rectal exam revealed a very narrow pelvic outlet and CT scan confirmed abnormal configuration of the bony pelvis. Discussions with orthopaedic colleagues concluded that bilateral pelvic osteotomies to widen her pelvis may relieve her constipation. The procedure was uneventful and radiologic follow-up confirmed widening of the pelvic outlet and increased pelvic volume. Her stooling pattern improved postoperatively and she was satisfied with the result on follow up at one year. Conclusions: Although previously described only in the veterinary literature, surgical widening of a narrow pelvis can be considered for the management of constipation in the rare patient with appropriate physical and radiologic findings.
    No preview · Article · May 2013 · Journal of Pediatric Surgery
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    ABSTRACT: Abstract Fibroblastic and myofibroblastic tumours constitute an important group of neoplasms in children and adolescents. These span the full spectrum of clinical behaviour ranging from benign, to intermediate and malignant. We report a case of a benign mesenchymal tumour with myofibroblastic differentiation in a 9-year-old girl arising in the left groin which met the histologic features described for myofibroblastoma in adults. Two types are recognized in adults, namely angiomyofibroblastoma and mammary-type myofibroblastoma of soft tissue. Our case shared features of both these subtypes but was not typical of either one, and we therefore designated our case simply as 'myofibroblastoma'. Our case showed expression of estrogen receptor protein characteristic of adult lesions but not a deletion of 13q14 as has been reported in some adult cases. In a review of the English literature, only six cases have been reported in patients under 21 and all were teenagers except one. Pediatric surgeons, oncologists and pathologists should be aware that such a benign entity can occur in this patient population and could be confused with other lesions including malignant ones.
    No preview · Article · Aug 2012 · Pediatric and Developmental Pathology
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    ABSTRACT: Background: The global burden of surgical disease and severe shortage of trained surgeons around the world are now widely recognized. The greatest challenge in improving access to surgical care lies in sub-Saharan Africa, where the number of surgeons per population is lowest. One part of the solution may be to create programs to train surgeons locally. We present our experience with an approach to designing a contextually appropriate surgical curriculum in Botswana. Methods: Surgical logbooks from the largest tertiary care center in Botswana, dating from 2004 through 2010, were analyzed to yield total case numbers within clearly defined categories. Case numbers and local surgical opinion were combined to design a contextually relevant curriculum, with the Surgical Council on Resident Education curriculum as a template. Results: Logbook analysis revealed that general surgeons in Botswana manage burns and perform a large number of skin grafts and extremity amputations. However, they perform few colonoscopies and complex laparoscopic procedures. The new curriculum included greater emphasis on surgical subspecialty procedures and surgical management of locally relevant conditions, such as the complications of infectious diseases. Less emphasis was placed on management of uncommon conditions such as inflammatory bowel disease. Conclusions: There are important differences in the scope of general surgery and the knowledge and skills required by general surgeons in Botswana compared with their North American counterparts. We present a simple and inexpensive approach that could serve as a potential model for designing contextually relevant surgical training programs in other low-resource settings.
    No preview · Article · Aug 2012 · World Journal of Surgery
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    ABSTRACT: Surgical conditions account for a significant portion of the global burden of disease and have a substantial impact on public health in low- and middle-income countries. This article reviews the significance of surgical conditions within the context of public health in these settings, and describes selected approaches to global surgery delivery in specific contexts. The discussion includes programs in global trauma care, surgical care in conflict and disaster, and anesthesia and perioperative care. Programs to develop surgical training in Botswana and pediatric surgery through international partnership are also described, with a final review of broader approaches to training for global surgical delivery. In each instance, innovative solutions, as well as lessons learned and reasons for program failure, are highlighted.
    No preview · Article · May 2011 · Mount Sinai Journal of Medicine A Journal of Translational and Personalized Medicine
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    ABSTRACT: Although a validated simulator exists for adult laparoscopy, there is no pediatric counterpart. The objective of this study is to develop and validate a pediatric laparoscopic surgery (PLS) simulator. A PLS simulator was developed. Participants were stratified according to level of expertise and tested on the fundamentals of laparoscopic surgery (FLS) and PLS simulators. A subsequent group was tested exclusively on the PLS simulator. The PLS intracorporeal suturing score was lower than its adult counterpart (P = .02). The PLS pattern-cutting score was higher than in the FLS simulator (P < .001). If the latter was eliminated from the calculation, the revised total FLS score was significantly better than the revised PLS score. When all participants were combined, total PLS scores as well as performance on 3 of 5 tasks allowed differentiation between novice, intermediate, and expert. The PLS simulator was able to discriminate between the novice, intermediate, and expert using the total PLS score and the performance on 3 of the 5 tasks, thus providing evidence for construct validity. The other 2 tasks will require formal modification or a change in the scoring metrics to establish their independent construct validity.
    No preview · Article · May 2011 · Journal of Pediatric Surgery
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    ABSTRACT: Telesimulation is a novel concept coupling the principles of simulation with remote Internet access to teach procedural skills. This study's objective was to determine if telesimulation could be used by pediatricians in Toronto, Ontario, Canada, to teach a relatively new intraosseous (IO) insertion technique to physicians in Africa. One simulator was located in Toronto and the other in Gaborone, Botswana. Instructors and trainees could see one another, see inside each other's simulators, and communicate in real time. Learner's opinions and skills were evaluated. Before and after the curriculum, physicians completed a self-assessment questionnaire, a multiple-choice test, and during session 3, a demonstration of competence using an IO infusion system was timed and scored locally and via the Internet. Twenty-two physicians participated. The scores on the pretest ranged from 1 to 12 out of 15. The range of scores on the posttest was 10 to 15 out of 15. The mean (±SD) score on pre- and post-multiple choice testing increased by +5 (±2.75; 95% confidence interval [CI] for mean difference = 3.92 to 6.35). Based on McNemar's chi-square test, physicians reported a significant improvement in their comfort and knowledge inserting IO needles (p < 0.01), familiarity with the EZ-IO infusion system (p < 0.01), and knowledge handling the IO equipment (p < 0.01). Postintervention, all physicians reported that telesimulation teaching was a worthwhile experience, and 95% felt more prepared to manage pediatric resuscitation. There was no evidence of a difference in scoring or timing of IO insertion tasks whether measured locally or remotely (mean ± SD score difference = -0.11 ± 1.22 [95% CI = -0.66 to 0.43]; mean ± sd time difference = 0.01 ± 0.15 seconds [95% CI = -0.06 to 0.08 seconds]). Telesimulation is a novel method for teaching procedural skills. The session improved physicians' knowledge, self-reported confidence, and comfort level in inserting the IO needle. Accurate scoring is possible via the Internet. This modality offers potential for teaching other procedural skills over distances.
    Full-text · Article · Apr 2011 · Academic Emergency Medicine
  • Dan Poenaru · Eric Borgstein · Alp Numanoglu · Georges Azzie
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    ABSTRACT: The management of patients with colorectal disease in the pediatric population is challenging. Such management is all the more challenging when facing the constraints imposed by an environment with limited clinical resources. Three types of colorectal problems are highlighted in this article: anorectal malformations, Hirschsprung's disease, and acquired rectovaginal fistula in the human immunodeficiency virus-positive population. Through the use of illustrative cases, the authors discuss the pitfalls and challenges encountered in the diagnosis, treatment, and appropriate disposition of these patients. The bulk of the experience used to write this article was acquired in low- and middle-income countries in Africa. The authors hope that the lessons learned will help others manage such patients in the context of limited resources, but recognize that challenges will vary from place to place. There is no substitute for local, contextual expertise.
    No preview · Article · May 2010 · Seminars in Pediatric Surgery
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    ABSTRACT: The global disparities in both surgical disease burden and access to delivery of surgical care are gaining prominence in the medical literature and media. Concurrently, there is an unprecedented groundswell in idealism and interest in global health among North American medical students and trainees in anesthesia and surgical disciplines. Many academic medical centers (AMCs) are seeking to respond by creating partnerships with teaching hospitals overseas. In this article we describe six such partnerships, as follows: (1) University of California San Francisco (UCSF) with the Bellagio Essential Surgery Group; (2) USCF with Makerere University, Uganda; (3) Vanderbilt with Baptist Medical Center, Ogbomoso, Nigeria; (4) Vanderbilt with Kijabe Hospital, Kenya; (5) University of Toronto, Hospital for Sick Children with the Ministry of Health in Botswana; and (6) Harvard (Brigham and Women's Hospital and Children's Hospital Boston) with Partners in Health in Haiti and Rwanda. Reflection on these experiences offers valuable lessons, and we make recommendations of critical components leading to success. These include the importance of relationships, emphasis on mutual learning, the need for "champions," affirming that local training needs to supersede expatriate training needs, the value of collaboration in research, adapting the mission to locally expressed needs, the need for a multidisciplinary approach, and the need to measure outcomes. We conclude that this is an era of cautious optimism and that AMCs have a critical opportunity to both shape future leaders in global surgery and address the current global disparities.
    Full-text · Article · Mar 2010 · World Journal of Surgery

  • No preview · Article · Oct 2009 · Pediatric Annals

Publication Stats

340 Citations
75.08 Total Impact Points


  • 2008-2015
    • University of Toronto
      • • Hospital for Sick Children
      • • Faculty of Medicine
      • • Department of Surgery
      Toronto, Ontario, Canada
    • University of New Mexico Hospitals
      Albuquerque, New Mexico, United States
  • 2012-2014
    • SickKids
      • Department of Surgery
      Toronto, Ontario, Canada
  • 2010
    • University of Cape Town
      Kaapstad, Western Cape, South Africa
  • 2002-2007
    • Canterbury District Health Board
      • Department of Paediatric Surgery
      Christchurch, Canterbury Region, New Zealand
  • 2006
    • University of New Mexico
      • Department of Surgery
      Albuquerque, New Mexico, United States