Daniel H Solomon

University of San Francisco, San Francisco, California, United States

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Publications (390)2633.82 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: There is increasing interest in discontinuing biological therapies for patients with rheumatoid arthritis (RA) achieving good clinical responses, provided patients maintain clinical benefit. We assessed patients with RA from the Corrona registry who discontinued treatment with their first tumour necrosis factor inhibitor (TNFi) while in low-disease activity (LDA) or lower levels of disease activity. Patients were followed until they lost clinical benefit, defined as increased disease activity or change in RA medications. Duration of maintenance of clinical benefit was estimated using the Kaplan-Meier method. Cox proportional hazard models were assessed to identify factors related to maintenance of benefit. We identified 717 eligible patients with RA from 35 656 in the Corrona registry. At discontinuation, patients had a median RA duration of 8 years, mean clinical disease activity score of 4.3±0.11; 41.8% were using TNFi as monotherapy. 73.4% of patients maintained benefit for >12 months after discontinuing therapy and 42.2% did so through 24 months. Factors predictive of maintaining clinical benefit in multivariate analysis included lower disease activity, less pain and better functional status at the time of TNFi discontinuation. Among 301 patients initiating their first TNFi within the registry, faster responders (ie, those who achieved LDA in 4 months or less) did better than slower responders (HR 1.54 (95% CI 1.17 to 2.04)). RA disease duration did not affect maintenance of clinical benefit. Discontinuation of a first course of TNFi may be associated with persistent clinical benefit. Half of patients maintained response through 20 months. Several patient characteristics may help predict persistent benefit. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
    Annals of the rheumatic diseases. 12/2014;
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    ABSTRACT: Osteoporosis and cardiovascular disease may share common biological pathways, with inflammation playing a role in the development of both. Although observational studies have suggested that statin use is associated with a lower risk of fractures, randomized trial data addressing this issue are scant. To determine whether statin therapy reduces the risk of fracture and, in a secondary analysis, whether baseline levels of the inflammatory biomarker high-sensitivity C-reactive protein (hs-CRP) are associated with the risk of fracture. The JUPITER (Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin) trial was an international, randomized, double-blind, placebo-controlled study enrolling 17 802 men older than 50 years and women older than 60 years with hs-CRP level of at least 2 mg/L. Participants were screened from 2003 to 2006 and observed prospectively for up to 5 years (median follow-up, 1.9 years). Rosuvastatin calcium, 20 mg daily, or placebo. Incident fracture was a prespecified secondary end point of JUPITER. Fractures were confirmed by radiographs, computed tomography, bone scan, or other methods. Cox proportional hazards models were used to calculate hazard ratios (HRs) and associated 95% confidence intervals for the risk of fracture according to randomized treatment assignment, as well as increasing tertiles of hs-CRP, controlling for potential confounders. During the study, 431 incident fractures were reported and confirmed. Among participants allocated to rosuvastatin, 221 fractures were confirmed, compared with 210 among those allocated to placebo, such that the incidence of fracture in the rosuvastatin and placebo groups was 1.20 and 1.14 per 100 person-years, respectively (adjusted HR, 1.06 [95% CI, 0.88-1.28]; P = .53). Overall, increasing baseline hs-CRP level was not associated with an increased risk of fractures (adjusted HR for each unit increase in hs-CRP tertile, 1.06 [95% CI, 0.94-1.20]; P for trend, .34). Among men and women with elevated hs-CRP level enrolled in a large trial of rosuvastatin therapy for cardiovascular disease, statin therapy did not reduce the risk of fracture. Higher baseline hs-CRP level was not associated with an increased risk of incident fracture. clinicaltrials.gov Identifier: NCT00239681.
    JAMA Internal Medicine 12/2014; · 13.25 Impact Factor
  • Lindsey A MacFarlane, Chih-Chin Liu, Daniel H Solomon
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    ABSTRACT: Gout is a common inflammatory arthropathy associated with hyperuricemia. Substantial evidence links hyperuricemia to the metabolic syndrome and diabetes. Rising serum insulin levels correlate with an increase in serum uric acid (UA). The current study evaluated the effect of pharmacologic insulin on serum UA levels in patients with diabetes. We conducted a retrospective analysis of previously collected data. The study cohort consisted of patients with both gout and diabetes who had initiated insulin therapy and a matched set of non-insulin users. The change in UA levels was calculated in both groups and compared. Potential confounders were assessed and adjusted for in a matched linear regression model. In total, 23 patients met criteria for insulin initiators and were matched to 23 non-insulin users. In unadjusted analyses, patients started on insulin had a larger increase in UA (mean change = 1.25mg/dl, interquartile range, IQR: -0.7-2.3) in comparison to those not starting insulin (mean change = 0.06mg/dl, IQR: -1.1-0.9). After controlling for baseline UA and time between UA measurements, regression modeling showed that insulin use was significantly associated with an increase in UA (β = 1.25mg/dl, p = 0.02). Initiation of insulin among patients with diabetes was associated with a statistically significant increase in serum UA levels. This may affect the risk of gout flares and might suggest the potential for prophylactic therapy. Copyright © 2014 Elsevier Inc. All rights reserved.
    Seminars in arthritis and rheumatism. 10/2014;
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    ABSTRACT: Current recommendations advocate treatment with disease-modifying antirheumatic drugs (DMARD) in all patients with active rheumatoid arthritis (RA). We investigated the frequency of and reasons for inconsistent DMARD use among patients in a clinical rheumatology cohort.
    Annals of the Rheumatic Diseases 10/2014; · 9.11 Impact Factor
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    ABSTRACT: Objective: To compare the risk of incident hyperlipidemia in early rheumatoid arthritis (ERA) patients after initiation of various disease modifying anti-rheumatic drugs (DMARDs). Methods: We conducted a cohort study using insurance claims data (2001-2012) in ERA patients. ERA was defined by the absence of any RA diagnosis or DMARD prescriptions for 12 months. Four mutually exclusive groups were defined based on DMARD initiation, TNF-α inhibitors ± non-biologic (nb) DMARDs, methotrexate ± non-hydroxycholorquine nbDMARDs, hydroxychloroquine ± non-methotrexate nbDMARDs, and other nbDMARDs only. The primary outcome was incident hyperlipidemia, defined by a diagnosis and a prescription for a lipid-lowering agent. For the subgroup of patients with laboratory results available, change in lipid levels was assessed. Multivariable Cox proportional hazard models and propensity score (PS) decile stratification with asymmetric trimming were used to control for confounding. Results: Of the 17,145 ERA patients included in the study, 364 developed incident hyperlipidemia. The adjusted hazard ratios (95% CI) for hyperlipidemia were 1.41 (0.99-2.00) for TNF-α inhibitors, 0.81 (0.63-1.04) for hydroxychloroquine, and 1.33 (0.95-1.84) for other nbDMARDs compared with methotrexate in the full cohort, while 1.18 (0.80-1.73), 0.75 (0.58-0.98) and 1.41 (1.01-1.98), respectively in the PS trimmed cohort. In the subgroup analysis, hydroxychloroquine use showed significant reduction in low density lipoprotein (-8.9 mg/dl, 95% CI -15.8, -2.0), total cholesterol (-12.3 mg/dl, 95% CI -19.8, -4.8) and triglyceride (-19.5 mg/dl, 95% CI -38.7, -0.3) levels from baseline compared with methotrexate. Conclusion: Use of hydroxychloroquine may be associated with a lower risk of hyperlipidemia among ERA patients. © 2014 American College of Rheumatology.
    Arthritis care & research. 10/2014;
  • Seoyoung C. Kim, Jun Liu, Daniel H. Solomon
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    ABSTRACT: Background: Patients with hyperuricemia or gout often have metabolic syndrome. Few prospective studies examined the risk of incident diabetes mellitus (DM) in patients with gout, and no data exist whether the DM risk in gout differs by sex.Methods: Using data from a US commercial insurance plan (2003-2012), we conducted a cohort study to examine the overall and sex-specific incidence rate (IR) of DM in patients aged ≥40 years with gout compared to those with osteoarthritis. Incident DM was defined based on a diagnosis of DM and a dispensing for anti-diabetic drugs. We tested the sex-specific effect of gout on DM risk.Results: The study cohort consisted of 54,075 gout and 162,225 osteoarthritis patients, matched on age, sex and index date. The mean age was 56.2 years and 84.8% were men. Over a mean follow-up of 1.9 years, the IR of DM was 1.91 per 100 person-years in gout and 1.12 per 100 person-years in osteoarthritis patients. After adjusting for age, comorbidities, medications, and health care utilization, gout was associated with an increased risk of DM (hazard ratio [HR] 1.45, 95%CI 1.37-1.54) for both sexes. The impact of gout on the risk of incident DM was greater in women (HR 1.78, 95%CI 1.51-2.09) than men (HR 1.41, 95%CI 1.33-1.50) with a significant interaction between sex and gout (p=0.0009).Conclusion: Gout was associated with an increased risk of developing DM compared with osteoarthritis after adjusting for potential confounders, and the risk associated with gout was higher among women than men. © 2014 American College of Rheumatology.
    Arthritis & Rheumatology. 10/2014;
  • Katherine P. Liao, Daniel H. Solomon
    Arthritis & Rheumatology. 10/2014;
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    ABSTRACT: Abstract Background: Some evidence suggests that women with rheumatoid arthritis (RA) are at increased risk for the development of cervical cancer; however, it is unclear how this increase risk is conferred. We aimed to assess the factors related to abnormal Papanicolaou (Pap) tests in women with RA to determine whether they are similar to those reported for the general population. Methods: A structured questionnaire was mailed to 503 female patients from a longitudinal RA cohort. The survey included items on sociodemographic, behavioral, and gynecological factors. Univariate and multivariable logistic regression models examined the association of self-reported abnormal Pap results with a number of potential behavioral risk factors. Results: The questionnaire response rate was 57.5% (n=289). Median age was 61 years and 97% had ≥1 Pap test previously. Twenty-nine percent of respondents reported a previous abnormal Pap result. In the multivariable logistic model adjusted for age, number of lifetime sexual partners, age at menarche, birth control use, and history of sexually transmitted disease (STD), ever using birth control (odds ratio [OR] 2.31, 95% confidence interval [CI] 1.18-4.52) and previous STD (OR 3.38, 95% CI 1.70-6.70) were associated with an increased risk of abnormal Pap result. Compared with either the state or national population, a greater proportion of the respondents was older, married, and previous smokers, and completed postsecondary education and obtained a Pap test. Conclusions: In this cross-sectional study, self-reported abnormal Pap results were associated with use of birth control and history of STD in RA patients.
    Journal of women's health (2002). 09/2014; 23(9):771-776.
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    ABSTRACT: Objective Current recommendations advocate treatment with disease-modifying anti-rheumatic drugs (DMARDs) in all patients with active rheumatoid arthritis (RA). We analyzed short-term disease outcome in patients according to the consistency of DMARD use in a clinical rheumatology cohort. Methods Patients in an RA registry (N=617) were studied for DMARD use at semi-annual study time points during the first 18 months of follow-up, and were divided into 4 groups according to the number of study time points with any DMARD use (0-1 study time points (n=31), 2 study time points (n=24), 3 study time points (n=77), and 4 study time points (n=485). The primary outcome analyses were performed at 24 months and included Disease Activity Score 28 (DAS28-CRP), modified Health Assessment Questionnaire (MHAQ) change, Short Form Health Survey-12 physical and mental summary scores (SF-12 PCS, SF-12 MCS), EuroQol 5-Dimensional health index (EQ-5D) and radiographic progression. Unadjusted, adjusted and analyses stratified for seropositivity and disease activity were performed. A secondary analysis investigated 36 month-outcomes. Results No significant 24-month outcome differences could be found between the DMARD use categories. For seropositive patients there was evidence of a linear trend for SF-12 PCS (p=0.02) and EQ-5D (p=0.01) with worse outcomes for inconsistent DMARD users. At 36 months, there was a linear trend for higher DAS28-CRP scores for inconsistent users (p<0.01) Conclusions Overall, we found poor correlation between inconsistent DMARD use and short-term disease outcome. However, outcome in the longer term could be negatively influenced by inconsistent DMARD use, as well as short-term outcome in seropositive patients.
    Seminars in Arthritis and Rheumatism 08/2014; · 3.81 Impact Factor
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    ABSTRACT: Proton pump inhibitors (PPIs) have been associated with diminished bone mineral density (BMD) and an increased risk of fracture, however prior studies have not yielded consistent results and many have sub-optimal ascertainment of both PPI use and BMD. We used data from the Study of Women's Health Across the Nation (SWAN), a multi-center, multi-ethnic community-based longitudinal cohort study of women across the menopause transition to examine the association between annualized BMD changes and new use of PPIs. We compared changes in BMD in new PPI users with changes in BMD in new users of Histamine 2 receptor antagonists (H2RAs) and with changes in BMD in subjects who did not use either class of medications. Mixed linear regression models included recognized risk factors for osteoporosis, including demographics, menopausal transition stage, BMI, lifestyle factors, as well as comorbidities and concomitant medications. To provide further evidence for the validity of our analytic approach, we also examined the effects of hormone therapy (HT), a class of medications that should reduce bone loss, on changes in BMD as an internal positive control group. We identified 207 new users of PPIs, 185 new users of H2RAs and 1,676 non-users. Study subjects had a mean age of 50 years and were followed for a median of 9.9 years. Adjusted models found no difference in the annualized BMD change at the lumbar spine, femoral neck or total hip in PPI users compared with H2RA users or non-users. These results were robust to sensitivity analyses. BMD increased as expected in HT users, supporting the validity of our study design. These longitudinal analyses plus similar prior studies argue against an association between PPI use and BMD loss. © 2014 American Society for Bone and Mineral Research
    Journal of bone and mineral research: the official journal of the American Society for Bone and Mineral Research 08/2014; · 6.04 Impact Factor
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    ABSTRACT: Sugar-sweetened soda consumption is consistently associated with an increased risk of several chronic inflammatory diseases such as type 2 diabetes and cardiovascular diseases. Whether it plays a role in the development of rheumatoid arthritis (RA), a common autoimmune inflammatory disease, remains unclear.OBJECTIVE: The aim was to evaluate the association between sugar-sweetened soda consumption and risk of RA in US women.DESIGN: We prospectively followed 79,570 women from the Nurses' Health Study (NHS; 1980-2008) and 107,330 women from the NHS II (1991-2009). Information on sugar-sweetened soda consumption (including regular cola, caffeine-free cola, and other sugar-sweetened carbonated soda) was obtained from a validated food-frequency questionnaire at baseline and approximately every 4 y during follow-up. Incident RA cases were validated by medical record review. Time-varying Cox proportional hazards regression models were used to calculate HRs after adjustment for confounders. Results from both cohorts were pooled by an inverse-variance-weighted, fixed-effects model.RESULTS: During 3,381,268 person-years of follow-up, 857 incident cases of RA were documented in the 2 cohorts. In the multivariable pooled analyses, we found that women who consumed ≥1 servings of sugar-sweetened soda/d had a 63% (HR: 1.63; 95% CI: 1.15, 2.30; P-trend = 0.004) increased risk of developing seropositive RA compared with those who consumed no sugar-sweetened soda or who consumed <1 serving/mo. When we restricted analyses to those with later RA onset (after age 55 y) in the NHS, the association appeared to be stronger (HR: 2.64; 95% CI: 1.56, 4.46; P-trend < 0.0001). No significant association was found for sugar-sweetened soda and seronegative RA. Diet soda consumption was not significantly associated with risk of RA in the 2 cohorts.CONCLUSION: Regular consumption of sugar-sweetened soda, but not diet soda, is associated with increased risk of seropositive RA in women, independent of other dietary and lifestyle factors.
    American Journal of Clinical Nutrition 07/2014; · 6.50 Impact Factor
  • Katherine P Liao, Daniel H Solomon
    Circulation Cardiovascular Imaging 07/2014; 7(4):575-7. · 5.80 Impact Factor
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    ABSTRACT: Objective: The impact of increasing utilization of total knee arthroplasty (TKA) on lifetime costs in persons with knee OA is under-studied.Methods: We used the Osteoarthritis Policy Model to estimate total lifetime costs and TKA utilization under a range of TKA eligibility criteria among US persons with symptomatic knee OA. Current TKA utilization was estimated from the Multicenter Osteoarthritis Study and calibrated to Health Care Utilization Project (HCUP) data. OA treatment efficacy and toxicity were drawn from published literature. Costs in 2013 USD were derived from Medicare reimbursement schedules and Red Book Online®. Time costs were derived from published literature and the US Bureau of Labor Statistics.Results: Estimated average discounted (3%/year) lifetime costs for persons diagnosed with knee OA were $140,300. Direct medical costs were $129,600, with $12,400 (10%) attributable to knee OA over 28 years. OA patients spent, on average, 13 (SD 10) years waiting for TKA after failing non-surgical regimens. Under current TKA eligibility criteria, 54% of knee OA patients underwent TKA over their lifetimes. Estimated OA-related discounted lifetime direct medical costs ranged from $12,400 (54% TKA uptake) when TKA eligibility was limited to K-L 3 or 4 to $16,000 (70% TKA uptake) when eligibility was expanded to include symptomatic OA with a lesser degree of structural damage.Conclusion: Due to low efficacy of non-surgical regimens, knee OA treatment-attributable costs are low, representing a small portion of all costs for OA patients. Expanding TKA eligibility increases OA-related costs substantially for a population, underscoring the need for more effective non-operative therapies. © 2014 American College of Rheumatology.
    Arthritis Care & Research. 07/2014;
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    ABSTRACT: Dipeptidyl peptidase-4 (DPP4), also known as CD26, is a transmembrane glycoprotein that has a costimulatory function in the immune response. DPP4 inhibitors (DPP4i) are oral glucose-lowering drugs for type 2 diabetes mellitus (T2DM). This study evaluated the risk of incident rheumatoid arthritis (RA) and other autoimmune diseases (AD) such as systemic lupus erythematosus, psoriasis, multiple sclerosis and inflammatory bowel disease, associated with DPP4i in patients with T2DM.
    Annals of the rheumatic diseases. 06/2014;
  • Annals of the Rheumatic Diseases 06/2014; 73(Suppl 2):448-448. · 9.11 Impact Factor
  • Annals of the Rheumatic Diseases 06/2014; 73(Suppl 2):243-243. · 9.11 Impact Factor
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    ABSTRACT: Background Linkages between registries and administrative data may provide a valuable resource for comparative effectiveness research. However, personal identifiers that uniquely identify individuals are not always available. We describe methods to link a de-identified arthritis registry and U.S. Medicare data. The linked dataset was also used to evaluate the generalizability of the registry to the U.S. Medicare population. Methods Rheumatoid arthritis (RA) patients participating in the Consortium of Rheumatology Researchers of North America (CORRONA) registry were linked to Medicare data restricted to rheumatology claims or claims for RA. Deterministic linkage was performed using age, sex, provider identification number, and geographic location of the CORRONA site. We then searched for visit dates in Medicare matching visit dates in CORRONA, requiring at least 1 exact matching date. Linkage accuracy was quantified as a positive predictive value (PPV) in a sub-cohort (n=1581) with more precise identifiers. Results CORRONA participants with self-reported Medicare (n=11,001) were initially matched to 30,943 Medicare beneficiaries treated by CORRONA physicians. A total of 8,431 CORRONA participants matched on at least 1 visit; 5,317 matched uniquely on all visits. The number of patients who linked and linkage accuracy (from the subcohort) was high for patients with >2 visits (n=3458, 98% accuracy), exactly 2 visits (n=822, 96% accuracy) visits, and 1 visit (n=1037, 79% accuracy) visit that matched exactly on calendar date. Demographics and comorbidity profiles of registry participants were similar to non-participants, except participants were more likely to use DMARDs and biologics. Conclusion Linkage between a national, de-identified outpatient arthritis registry and Medicare data on multiple non-unique identifiers appears feasible and valid. © 2014 American College of Rheumatology.
    Arthritis care & research. 06/2014;
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    ABSTRACT: Among 125,954 new users of osteoporosis (OP) medications, 77 % of subjects stopped OP medications, and 23 % of subjects added or started a new OP medication during follow-up, with the first addition or start of a new OP medication occurring in a mean of 739 days after original OP treatment.
    06/2014;
  • Source
    Arthritis & rheumatology (Hoboken, N.J.). 04/2014; 66(4):775-82.
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    ABSTRACT: Objective: Osteoarthritis (OA) of the knee is a painful condition affecting ~13% of persons >65 years old. We sought to examine whether the use of opioids in older persons with OA has increased over the past decade and what patient characteristics may correlate with their use.Methods: We assembled national cohorts of individuals with knee OA using data from 2003, 2006, and 2009 waves of the Medicare Beneficiary Survey (MCBS). Survey data contained demographics, health status and prescribed medications linked to Medicare claims. We used multivariate logistic regression to establish whether opioid use changed over time and identify factors associated with greater opioids use. The outcome was defined as receiving ≥1 opioid prescription in the study year.Results: Mean age and sex were similar across years (77 years, 69% females). There was a significant increase in opioid prescribing between 2003 and 2009, with 31% of the patients receiving opioids in 2003, 39% in 2006 and 40% in 2009 (OR 1.5, 95% CI 1.1, 2.0 for 2006 and 2009 compared to 2003). Independent correlates of opioid use across time periods included: female sex (OR 1.5, 95% CI 1.2, 2.0), functional limitation (OR 2.1, 95% CI 1.6, 2.7), poor self-reported health status (OR 1.6, 95% CI 1.2, 2.0), COPD (OR 1.4, 95% CI 1.0, 1.8) and musculoskeletal disease besides OA (OR 1.9, 95% CI 1.2, 2.8).Conclusion: As prevalence and incidence of knee OA continues to increase, the public health impact of greater opioid use should be monitored carefully. © 2014 American College of Rheumatology.
    Arthritis Care & Research. 04/2014;

Publication Stats

10k Citations
2,633.82 Total Impact Points

Institutions

  • 2014
    • University of San Francisco
      San Francisco, California, United States
  • 2000–2014
    • Harvard Medical School
      • Department of Medicine
      Boston, Massachusetts, United States
  • 1999–2014
    • Brigham and Women's Hospital
      • • Department of Medicine
      • • Center for Brain Mind Medicine
      • • Division of Pharmacoepidemiology and Pharmacoeconomics
      Boston, Massachusetts, United States
  • 2013
    • Academic Medical Center (AMC)
      Amsterdamo, North Holland, Netherlands
    • Mayo Clinic - Rochester
      Rochester, Minnesota, United States
  • 2012–2013
    • Oregon Health and Science University
      • Department of Public Health & Preventive Medicine
      Los Angeles, CA, United States
    • Johns Hopkins University
      Baltimore, Maryland, United States
    • Diakonhjemmet Hospital (Norway)
      Kristiania (historical), Oslo County, Norway
    • University of Pennsylvania
      • Center for Clinical Epidemiology and Biostatistics
      Philadelphia, PA, United States
  • 2011–2013
    • Kaiser Permanente
      Oakland, California, United States
    • Yale-New Haven Hospital
      New Haven, Connecticut, United States
    • Northeastern University
      • Department of Physical Therapy
      Boston, MA, United States
  • 2009–2013
    • University of Alabama at Birmingham
      • Division of Infectious Diseases
      Birmingham, AL, United States
    • University of Massachusetts Medical School
      • Division of Rheumatology
      Worcester, Massachusetts, United States
    • Okinawa Chubu Hospital
      Okinawa, Okinawa, Japan
    • Beth Israel Deaconess Medical Center
      Boston, Massachusetts, United States
  • 2001–2013
    • Partners HealthCare
      Boston, Massachusetts, United States
  • 2005–2012
    • Massachusetts General Hospital
      • Division of Cardiology
      Boston, Massachusetts, United States
  • 2009–2011
    • The University of Manchester
      Manchester, England, United Kingdom
  • 2007–2011
    • Stanford University
      • Division of Nephrology
      Stanford, CA, United States
    • Harvard University
      • • Department of Health Policy and Management
      • • Department of Epidemiology
      Boston, MA, United States
    • University of Ottawa
      Ottawa, Ontario, Canada
    • University Health Network
      Toronto, Ontario, Canada
  • 2006–2011
    • University of Toronto
      • • Leslie L. Dan Faculty of Pharmacy
      • • Institute of Health Policy, Management and Evaluation
      Toronto, Ontario, Canada
    • Aintree University Hospital NHS Foundation Trust
      Liverpool, England, United Kingdom
  • 2003–2011
    • Vanderbilt University
      • Department of Preventive Medicine
      Nashville, MI, United States
    • University of Texas Health Science Center at Houston
      Houston, Texas, United States
  • 2003–2009
    • Boston University
      • Department of Biostatistics
      Boston, MA, United States
  • 2008
    • University of Liverpool
      Liverpool, England, United Kingdom
  • 2006–2007
    • Teine Keijinkai Hospital
      Sapporo, Hokkaidō, Japan
  • 2002
    • University of California, San Diego
      • Division of Rheumatology, Allergy and Immunology
      San Diego, CA, United States