C Cooper

NIHR Oxford Biomedical Research, Oxford, England, United Kingdom

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Publications (603)2881.95 Total impact

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    ABSTRACT: Loss of bone and muscle with advancing age represent a huge threat to loss of independence in later life. “Osteoporosis represents a major public health problem through its association with fragility fractures, primarily of the hip, spine and distal forearm” (Moselhy et al., 2012). Sarcopenia, the age related loss of muscle mass and function, may add to fracture risk by increasing falls risk. In the context of muscle aging, it is important to remember that it is not just a decline in muscle mass which contributes to the deterioration of muscle function. Other factors underpinning muscle quality come into play, including muscle composition, aerobic capacity and metabolism, fatty infiltration, insulin resistance, fibrosis and neural activation. Genetic, developmental, endocrine and lifestyle factors, such as physical activity, smoking and poor diet have dual effects on both muscle and bone mass in later life and these will be reviewed here. These include poor nutrition, lack of physical activity and cigarette smoking, comorbidities or medication use. Recent work has highlighted a possible role for the early environment. Inflammaging is an exciting emerging research field that is likely to prove relevant to future work, including interventions designed to retard to reverse bone and muscle loss with age. This article is protected by copyright. All rights reserved
    Journal of Cellular Physiology 03/2015; DOI:10.1002/jcp.25001 · 3.87 Impact Factor
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    ABSTRACT: Reference Point Micro-Indentation (RPI) has been proposed as a new clinical tool to aid the diagnosis of Osteoporosis. This study has examined the performance of the tool within entire femurs to improve the understanding of the mechanical properties of bone and also to guide future RPI testing to optimize repeatability of results obtained using the technique. Human, bovine, porcine and rat femurs were indented along three longitudinal axes: anterior and posterior: medial and lateral as well as around the circumference of the femoral head and neck. Cortical and subchondral bone thickness was measured using CT and radiography. The study shows that in some samples, bone is too thin to support the high loads applied with the technique and in these cases, RPI values are highly influenced by thickness. The technique will be useful in the mid-shaft region where cortical thickness is greatest, providing previously established guidelines are followed to optimize measurement repeatability, including performing multiple measurements per sample and investigating multiple samples. The study has also provided evidence that RPI values vary significantly with test site, hence mechanical properties should not be inferred from RPI findings alone away from the test site, even within the same bone. In conclusion, RPI appears to be a useful tool for scientific investigation, however further work is required to examine the feasibility of using RPI for assessing differences between healthy and diseased bone in a clinical setting.
    Journal of the Mechanical Behavior of Biomedical Materials 02/2015; DOI:10.1016/j.jmbbm.2015.02.004 · 3.05 Impact Factor
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    ABSTRACT: Summary There is scarce data on the association between early stages of type 2 diabetes and fracture risk. We report a 20 % excess risk of hip fracture in the first years following disease onset compared to matched non-diabetic patients. Introduction Type 2 diabetes mellitus (T2DM) is a chronic disease that affects several target organs. Data on the association between T2DM and osteoporotic fractures is controversial. We estimated risk of hip fracture in newly diagnosed T2DM patients, compared to matched non-diabetic peers. Methods We conducted a population-based parallel cohort study using data from the Sistema d’Informació per al Desenvolupament de la Investigació en Atenció Primària (SIDIAP) database. Participants were all newly diagnosed T2DM patients registered in SIDIAP in 2006–2011 (T2DM cohort). Up to two diabetes-free controls were matched to each T2DM participant on age, gender, and primary care practice. Main outcome was incident hip fracture in 2006–2011, ascertained using the tenth edition of the International Classification of Diseases (ICD-10) codes. We used Fine and Gray survival modelling to estimate risk of hip fracture according to T2DM status, accounting for competing risk of death. Multivariate models were adjusted for body mass index, previous fracture, and use of oral corticosteroids. Results During the study period (median follow-up 2.63 years), 444/58,483 diabetic patients sustained a hip fracture (incidence rate 2.7/1,000 person-years) compared to 776/113,448 matched controls (2.4/1,000). This is equivalent to an unadjusted (age- and gender-matched) subhazard ratio (SHR) 1.11 [0.99–1.24], and adjusted SHR 1.20 [1.06–1.35]. The adjusted SHR for major osteoporotic and any osteoporotic fractures were 0.95 [0.89–1.01] and 0.97 [0.92–1.02]. Conclusions Newly diagnosed T2DM patients are at a 20 % increased risk of hip fracture even in early stages of disease, but no for all fractures. More data is needed on the causes for an increased fracture risk in T2DM patients as well as on the predictors of osteoporotic fractures among these patients.
    Osteoporosis International 12/2014; DOI:10.1007/s00198-014-2986-9 · 4.17 Impact Factor
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    ABSTRACT: Dear Editor,We thank Dr Sugiyama and colleagues for their comments [1] on our recent review on the role of vitamin D status in bone health during growth [2], and read with great interest their hypothesis relating to potential mechanisms.As Sugiyama et al. suggest, there are complex relationships among bone mineral density (BMD), bone size, bone strength and fracture risk in children. Indeed, physical activity has been positively associated with both measures of bone size and density in children [3, 4], yet is also associated with increased fracture risk in childhood [5]. The mechanostat theory recognises that muscular strains stimulate bone modelling and mineralisation [6]; however, more active children are also likely to have greater exposure to potential fracture-causing events. It is possible that a similar explanation also confounds associations between childhood vitamin D status and fracture occurrence: children following sedentary indoor lifestyles are more likely to have lower s ...
    Osteoporosis International 12/2014; DOI:10.1007/s00198-014-2976-y · 4.17 Impact Factor
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    ABSTRACT: The worldwide uptake of FRAX is described. The aim of this report was to determine the usage of FRAX worldwide over a 1-year period from 1 May 2012. The number of FRAX calculations from each country was assessed over a 1-year period and expressed as calculations per million of the population aged 50 years or more. Countries were colour coded according to usage to populate a world map. Over the index year, there were estimated to be 2,391,639 calculations sourced from 173 counties. Uptake was high in North America, the Antipodes and most countries of Europe; intermediate in Latin America and the Middle East; and very low in Africa and much of South East Asia. It is expected that the comparative data will encourage the development of new FRAX models and the uptake of FRAX into assessment guidelines.
    Archives of Osteoporosis 12/2014; 9(1):166. DOI:10.1007/s11657-013-0166-8
  • A Litwic, C Cooper, E Dennison
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    ABSTRACT: Osteoporosis is a systemic disorder characterized by low bone mass and microarchitectural deterioration of bone tissue with a consequent increase in bone fragility and susceptibility to fracture. It has a significant impact on public health through the increased morbidity, mortality, and economic costs associated with fractures. Despite the severe medical and socioeconomic consequences of fragility fractures, relatively few adults with fractures are evaluated and/or treated for osteoporosis. In this review, we summarize the existing treatment options and promising new therapies for the prevention and treatment of osteoporosis.
    Panminerva medica 12/2014; 56(4):273-83. · 2.28 Impact Factor
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    ABSTRACT: This paper provides a systematic review of the literature from January 2003 to April 2014 pertaining to the incidence, pathophysiology, diagnosis and treatment of osteonecrosis of the jaw (ONJ), and offers recommendations for its management based on multidisciplinary international consensus. ONJ is associated with oncology-dose parenteral anti-resorptive therapy of bisphosphonates (BP) and denosumab (Dmab). The incidence of ONJ is greatest in the oncology patient population (1-15%) where high doses of these medications are used at frequent intervals. In the osteoporosis patient population, the incidence of ONJ is estimated at 0.001% to 0.01%, marginally higher than the incidence in the general population (<0.001%). New insights into the pathophysiology of ONJ include anti-resorptive effects of BPs and Dmab, effects of BPs on gamma delta T-cells and on monocyte and macrophage function, as well as the role of local bacterial infection, inflammation and necrosis. Advances in imaging include the use of cone beam computerized tomography assessing cortical and cancellous architecture with lower radiation exposure, magnetic resonance imaging, bone scanning and positron emission tomography, although plain films often suffice. Other risk factors for ONJ include glucocorticoid use, maxillary or mandibular bone surgery, poor oral hygiene, chronic inflammation, diabetes mellitus, ill-fitting dentures, as well as other drugs, including anti-angiogenic agents. Prevention strategies for ONJ include elimination or stabilization of oral disease prior to initiation of anti-resorptive agents, as well as maintenance of good oral hygiene. In those patients at high risk for the development of ONJ, including cancer patients receiving high-dose BP or Dmab therapy, consideration should be given to withholding anti-resorptive therapy following extensive oral surgery until the surgical site heals with mature mucosal coverage. Management of ONJ is based on the stage of the disease, size of the lesions, as well as the presence of contributing drug therapy and comorbidity. Conservative therapy includes topical antibiotic oral rinses and systemic antibiotic therapy. Localized surgical debridement is indicated in advanced non-responsive disease and has been successful. Early data have suggested enhanced osseous wound healing with teriparatide in those without contraindications for its use. Experimental therapy includes bone marrow stem cell intralesional transplantation, low-level laser therapy, local platelet-derived growth factor application, hyperbaric oxygen, and tissue grafting. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
    Journal of bone and mineral research: the official journal of the American Society for Bone and Mineral Research 11/2014; DOI:10.1002/jbmr.2405 · 6.04 Impact Factor
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    ABSTRACT: We previously reported an association between high bone mass (HBM) and a bone-forming phenotype of radiographic hip osteoarthritis (OA). As knee and hip OA have distinct risk factors, in this study we aimed to determine (i) whether HBM is also associated with knee OA, and (ii) whether the HBM knee OA phenotype demonstrates a similar pattern of radiographic features to that observed at the hip.HBM cases (defined by DXA BMD Z-scores) from the UK-based HBM study were compared with unaffected family controls and general population controls from the Chingford and Hertfordshire cohort studies. A single blinded observer graded AP weight-bearing knee radiographs for features of OA (Kellgren–Lawrence score, osteophytes, joint space narrowing (JSN), sclerosis) using an atlas. Analyses used logistic regression, adjusting a priori for age and gender, and additionally for BMI as a potential mediator of the HBM–OA association, using Stata v12.609 HBM knees in 311 cases (mean age 60.8 years, 74% female) and 1937 control knees in 991 controls (63.4 years, 81% female) were analysed. The prevalence of radiographic knee OA, defined as Kellgren–Lawrence grade ≥ 2, was increased in cases (31.5% vs. 20.9%), with age and gender adjusted OR [95% CI] 2.38 [1.81, 3.14], p < 0.001. The association between HBM and osteophytosis was stronger than that for JSN, both before and after adjustment for BMI which attenuated the ORs for knee OA and osteophytes in cases vs. controls by approximately 50%.Our findings support a positive association between HBM and knee OA. This association was strongest for osteophytes, suggesting HBM confers a general predisposition to a subtype of OA characterised by increased bone formation.
    Bone 10/2014; 71. DOI:10.1016/j.bone.2014.10.015 · 4.46 Impact Factor
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    ABSTRACT: Information on the epidemiology of rheumatoid arthritis (RA) in Southern Europe is scarce. We estimated the age- and gender-adjusted incidence and prevalence of RA in Catalonia using routinely collected primary care records. We identified incident (2009-2012) and prevalent (on 31 December 2012) cases of RA in the SIDIAP database using ICD-10 codes. SIDIAP contains anonymized data from computerized primary care records for about five million adults (>80 % of the population). We estimated age- (5-year groups) and gender-specific, and directly standardized incidence and prevalence of RA and confidence intervals (95% CIs) assuming a Poisson distribution. A total of 20,091 prevalent (among whom 5,796 incident) cases of RA were identified among 4,796,498 study participants observed for up to 4 years. Rates of RA increased with age in both genders, peaking at the age of 65-70 years. Age- and gender-standardized incidence and prevalence rates were 0.20/1,000 person-years (95% CI 0.19-0.20) and 4.17/1,000 (4.11-4.23) respectively. Rheumatoid factor was positive (≥10 IU/mL) in 1,833 (73.9 %) of 2,482 cases tested in primary care. The incidence and prevalence of RA in Catalonia are similar to those of other Southern European regions, and lower than those of northern areas. This data will inform health care planning and resource allocation.
    Clinical Rheumatology 10/2014; DOI:10.1007/s10067-014-2801-1 · 1.77 Impact Factor
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    ABSTRACT: Reference Point Indentation (RPI) is a novel microindentation tool that has emerging clinical potential for the assessment of fracture risk as well as use as a laboratory tool for straight-forward mechanical characterisation of bone. Despite increasing use of the tool, little research is available to advise the set-up of testing protocols or optimisation of testing parameters. Here we consider five such parameters: maximum load, sample orientation, mode of use, sample preparation and measurement spacing, to investigate how they affect the Indentation Distance Increase (IDI), the most published measurement parameter associated with the RPI device. The RPI tool was applied to bovine bone; indenting in the proximal midshaft of five femora and human bone; indenting five femoral heads and five femoral neck samples. Based on the findings of these studies we recommend the following as the best practice. (1) Repeat measurements should be utilised to reduce the coefficient of variation (e.g. 8-15 repeats to achieve a 5-10% error, however the 3-5 measurements used here gives a 15-20% error). (2) IDI is dependent on maximum load (r=0.45 on the periosteal surface and r=0.94 on the machined surface, p<0.05), mode of use (i.e. comparing the device held freehand compared to fixed in its stand, p=0.04) and surface preparation (p=0.004) so these should be kept consistent throughout testing. Though sample orientation appears to have minimal influence on IDI (p>0.05), care should also be taken in combining measurements from different orientations. (3) The coefficient of variation is higher (p=0.04) when holding the device freehand, so it should ideally be kept supported in its stand. (4) Removing the periosteum (p=0.04) and machining the surface of the bone (p=0.08) reduces the coefficient of variation, so should be performed where practical. (5) There is a hyperbolic relationship between thickness and IDI (p<0.001) with a sample thickness 10 fold greater than the maximum indentation depth recommended, to ensure a representative measurement. (6) Measurement spacing does not appear to influence the IDI (p>0.05), so it can be as low as 500µm. By following these recommendations, RPI users can minimise the potential confounding effects associated with the variables investigated here and reduce the coefficient of variation, hence achieving more consistent testing. This optimisation of the technique enhances both the clinical and laboratory potential of the tool. Copyright © 2014 Elsevier Ltd. All rights reserved.
    Journal of the Mechanical Behavior of Biomedical Materials 10/2014; 42. DOI:10.1016/j.jmbbm.2014.09.030 · 3.05 Impact Factor
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    ABSTRACT: Ankylosing spondylitis (AS) leads to osteopenia/osteoporosis and spine rigidity. We conducted a case-control study and found that AS-affected patients have a 5-fold and 50 % increased risk of clinical spine and all clinical fractures, respectively. Excess risk of both is highest in the first years and warrants an early bone health assessment after diagnosis.
    Osteoporosis International 10/2014; 26(1). DOI:10.1007/s00198-014-2939-3 · 4.17 Impact Factor
  • Osteoporosis International 09/2014; 26(1). DOI:10.1007/s00198-014-2883-2 · 4.17 Impact Factor
  • Journal of Epidemiology &amp Community Health 09/2014; 68(Suppl 1):A27-A27. DOI:10.1136/jech-2014-204726.54 · 3.29 Impact Factor
  • Journal of Epidemiology &amp Community Health 09/2014; 68(Suppl 1):A69-A69. DOI:10.1136/jech-2014-204726.151 · 3.29 Impact Factor
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    ABSTRACT: Investigators have suggested a link between birth weight and both hand and lumbar spine osteoarthritis (OA). In this study, we sought to extend these observations by investigating relationships between growth in early life, and clinical and radiological diagnoses of OA at the hand, knee and hip, among participants from the Hertfordshire Cohort Study. Data were available for 222 men and 222 women. Clinical OA was defined based on American College of Rheumatology criteria. Radiographs were taken of the knees and hips, and graded for the presence of osteophytes and overall Kellgren and Lawrence (KL) score. Lower weight at year one was associated with higher rates of clinical hand OA (OR 1.396, 95% CI 1.05, 1.85, P=0.021). Individuals with lower birth weights were more likely to have hip osteophytes (OR 1.512, 95% CI 1.14, 2.00, P=0.004) and this remained robust after adjustment for confounders. Furthermore, a low weight at one year was also associated with a higher osteophyte number in the lateral compartment of the knee, after adjustment for confounders (OR 1.388, 95% CI 1.01, 1.91, P=0.043). We have found further evidence of a relationship between early life factors and adult OA. These findings accord with previous studies.
    Journal of Developmental Origins of Health and Disease 08/2014; 5(6):1-6. DOI:10.1017/S2040174414000373 · 0.77 Impact Factor
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    ABSTRACT: During growth, severe vitamin D deficiency in childhood can result in symptomatic hypocalcaemia and rickets. Despite the suggestion from some studies of a secular increase in the incidence of rickets, this observation may be driven more by changes in population demographics than a true alteration to age, sex and ethnicity-specific incidence rates; indeed, rickets remains uncommon overall and is rarely seen in fair-skinned children. Additionally, the impact of less severe vitamin D deficiency and insufficiency has received much interest in recent years, and in this review, we consider the evidence relating vitamin D status to fracture risk and bone mineral density (BMD) in childhood and adolescence. We conclude that there is insufficient evidence to support the suggestion that low serum 25-hydroxyvitamin D [25(OH)D] increases childhood fracture risk. Overall, the relationship between 25(OH)D and BMD is inconsistent across studies and across skeletal sites within the same study; however, there is evidence to suggest that vitamin D supplementation in children with the lowest levels of 25(OH)D might improve BMD. High-quality randomised trials are now required to confirm this benefit.
    Osteoporosis International 08/2014; 25(12). DOI:10.1007/s00198-014-2783-5 · 4.17 Impact Factor
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    ABSTRACT: FTO is the strongest known genetic susceptibility locus for obesity. Experimental studies in animals suggest the potential roles of FTO in regulating food intake. The interactive relation among FTO variants, dietary intake, and body mass index (BMI) are complex and results from previous often small-scale studies in humans are highly inconsistent. We performed large-scale analyses based on data from 177,330 adults (154,439 whites, 5,776 African Americans, and 17,115 Asians) from 40 studies to examine: 1) the association between the FTO-rs9939609 variant (or a proxy SNP) and total energy and macronutrient intake; and 2) the interaction between the FTO variant and dietary intake on BMI. The minor allele (A-allele) of the FTO-rs9939609 variant was associated with higher BMI in whites (effect per allele =0.34 [0.31, 0.37] kg/m(2), P=1.9×10(-105)), and all participants (0.30 [0.30, 0.35] kg/m(2), P=3.6×10(-107)). The BMI-increasing allele of the FTO variant showed a significant association with higher dietary protein intake (effect per allele =0.08[0.06, 0.10]%, P=2.4×10(-16)), and relative weak associations with lower total energy intake (-6.4[-10.1, -2.6] kcal/day, P=0.001) and lower dietary carbohydrate intake (-0.07 [-0.11, -0.02]%, P=0.004). The associations with protein (P=7.5×10(-9)) and total energy (P =0.002) were attenuated but remained significant after adjustment for BMI. We did not find significant interactions between the FTO variant and dietary intake of total energy, protein, carbohydrate, or fat on BMI. Our findings suggest a positive association between the BMI-increasing allele of FTO variant and higher dietary protein intake and offer insight into potential link between FTO, dietary protein intake and adiposity.
    Human Molecular Genetics 08/2014; 23(25). DOI:10.1093/hmg/ddu411 · 6.68 Impact Factor
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    ABSTRACT: This consensus article reviews the diagnosis and treatment of osteoporosis in geriatric populations. Specifically, it reviews the risk assessment and intervention thresholds, the impact of nutritional deficiencies, fall prevention strategies, pharmacological treatments and their safety considerations, the risks of sub-optimal treatment adherence and strategies for its improvement. This consensus article reviews the therapeutic strategies and management options for the treatment of osteoporosis of the oldest old. This vulnerable segment (persons over 80 years of age) stands to gain substantially from effective anti-osteoporosis treatment, but the under-prescription of these treatments is frequent. This report is the result of an ESCEO (European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis) expert working group, which explores some of the reasons for this and presents the arguments to counter these beliefs. The risk assessment of older individuals is briefly reviewed along with the differences between some intervention guidelines. The current evidence on the impact of nutritional deficiencies (i.e. calcium, protein and vitamin D) is presented, as are strategies to prevent falls. One possible reason for the under-prescription of pharmacological treatments for osteoporosis in the oldest old is the perception that anti-fracture efficacy requires long-term treatment. However, a review of the data shows convincing anti-fracture efficacy already by 12 months. The safety profiles of these pharmacological agents are generally satisfactory in this patient segment provided a few precautions are followed. These patients should be considered for particular consultation/follow-up procedures in the effort to convince on the benefits of treatment and to allay fears of adverse drug reactions, since poor adherence is a major problem for the success of a strategy for osteoporosis and limits cost-effectiveness.
    Osteoporosis International 07/2014; 25(11). DOI:10.1007/s00198-014-2755-9 · 4.17 Impact Factor
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    ABSTRACT: There is variation in how services to prevent second fractures after hip fracture are organised. We explored this in more detail at 11 hospitals. Results showed that there was unwarranted variation across a number of aspects of care. This information can be used to inform service delivery in the future. Hip fractures are usually the result of low impact falls and underlying osteoporosis. Since the risk of further fractures in osteoporotic patients can be reduced by between 20 and 70 % with bone protection therapy, the NHS is under an obligation to provide effective fracture prevention services for hip fracture patients to reduce risk of further fractures. Evidence suggests there is variation in service organisation. The objective of the study was to explore this variation in more detail by looking at the services provided in one region in England. A questionnaire was designed which included questions around staffing, models of care and how the four components of fracture prevention (case finding, osteoporosis assessment, treatment initiation and adherence (monitoring) were undertaken. We also examined falls prevention services. Clinicians involved in the delivery of osteoporosis services at 11 hospitals in one region in England completed the questionnaire. The service overview showed significant variation in service organisation across all aspects of care examined. All sites provided some form of case finding and assessment. However, interesting differences arose when we examined how these components were structured. Eight sites generally initiated treatment in an inpatient setting, two in outpatients and one in primary care. Monitoring was undertaken by secondary care at seven sites and the remainder conducted by GPs. The variability in service provision was not explained by local variations in care need. Further work is now needed to establish how the variability in service provision affects key patient, clinical and health economic outcomes.
    Osteoporosis International 06/2014; 25(10). DOI:10.1007/s00198-014-2775-5 · 4.17 Impact Factor
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    ABSTRACT: Epidemiological studies have shown an association between increased bone mineral density (BMD) and osteoarthritis (OA), but whether this represents cause or effect remains unclear. In this study, we used a novel approach to investigate this question, determining whether individuals with High Bone Mass (HBM) have a higher prevalence of radiographic hip OA compared with controls.
    Osteoarthritis and Cartilage 06/2014; 22(8). DOI:10.1016/j.joca.2014.06.007 · 4.66 Impact Factor

Publication Stats

28k Citations
2,881.95 Total Impact Points


  • 2010–2014
    • NIHR Oxford Biomedical Research
      Oxford, England, United Kingdom
  • 2008–2014
    • University of Oxford
      • Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)
      Oxford, England, United Kingdom
  • 1986–2014
    • University of Southampton
      • • MRC Lifecourse Epidemiology Unit
      • • Developmental Origins of Health and Disease
      • • Institute of Sound and Vibration Research (ISVR)
      Southampton, England, United Kingdom
  • 2001–2012
    • Universiteit Utrecht
      • • Utrecht Institute for Pharmaceutical Sciences
      • • Division of Pharmacoepidemiology and Pharmacotherapy
      Utrecht, Provincie Utrecht, Netherlands
  • 2000–2012
    • University Hospital Southampton NHS Foundation Trust
      • • Department of Rheumatology
      • • Department of Medical Physics and Bioengineering
      Southampton, England, United Kingdom
  • 2008–2009
    • Circumcision Resource Center
      Boston, Massachusetts, United States
  • 1995–2008
    • Medical Research Council (UK)
      Londinium, England, United Kingdom
  • 2005
    • University of Nottingham
      Nottigham, England, United Kingdom
    • University of Brighton
      • Brighton and Sussex Medical School
      Brighton, ENG, United Kingdom
  • 2004
    • Netherlands Institute for Space Research, Utrecht
      Utrecht, Utrecht, Netherlands
    • CUNY Graduate Center
      New York City, New York, United States
  • 2000–2002
    • Keele University
      Newcastle-under-Lyme, England, United Kingdom
  • 1992–2001
    • The University of Manchester
      • School of Nursing, Midwifery and Social Work
      Manchester, England, United Kingdom
  • 1998–2000
    • Procter & Gamble
      Cincinnati, Ohio, United States
    • VU University Amsterdam
      Amsterdamo, North Holland, Netherlands
  • 1999
    • University College London
      • Institute of Child Health
      Londinium, England, United Kingdom
  • 1995–1998
    • Newcastle University
      Newcastle-on-Tyne, England, United Kingdom
  • 1997
    • Università degli Studi di Siena
      Siena, Tuscany, Italy
  • 1996
    • University of Amsterdam
      • Department of Endocrinology
      Amsterdamo, North Holland, Netherlands
  • 1989–1996
    • The Chinese University of Hong Kong
      Hong Kong, Hong Kong
  • 1993–1995
    • Mayo Clinic - Rochester
      • Department of Health Science Research
      Rochester, MN, United States