John P Bilezikian

CUNY Graduate Center, New York City, New York, United States

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Publications (229)1207.76 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective: Asymptomatic primary hyperparathyroidism (PHPT) is routinely encountered in clinical practices of endocrinology throughout the world. This report distills an update of current information about diagnostics, clinical features, and management of this disease into a set of revised guidelines. Participants: Participants, representing an international constituency, with interest and expertise in various facets of asymptomatic PHPT constituted four Workshop Panels that developed key questions to be addressed. They then convened in an open 3-day conference September 19-21, 2013, in Florence, Italy, when a series of presentations and discussions addressed these questions. A smaller subcommittee, the Expert Panel, then met in closed session to reach an evidence-based consensus on how to address the questions and data that were aired in the open forum. Evidence: Preceding the conference, each question was addressed by a relevant, extensive literature search. All presentations and deliberations of the Workshop Panels and the Expert Panel were based upon the latest information gleaned from this literature search. Consensus Process: The expert panel considered all the evidence provided by the individual Workshop Panels and then came to consensus. Conclusion: In view of new findings since the last International Workshop on the Management of Asymptomatic PHPT, guidelines for management have been revised. The revised guidelines include: 1) recommendations for more extensive evaluation of the skeletal and renal systems; 2) skeletal and/or renal involvement as determined by further evaluation to become part of the guidelines for surgery; and 3) more specific guidelines for monitoring those who do not meet guidelines for parathyroid surgery. These guidelines should help endocrinologists and surgeons caring for patients with PHPT. A blueprint for future research is proposed to foster additional investigation into issues that remain uncertain or controversial.
    The Journal of clinical endocrinology and metabolism. 08/2014;
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    ABSTRACT: Objective: This report summarizes data on traditional and nontraditional manifestations of primary hyperparathyroidism (PHPT) that have been published since the last International Workshop on PHPT. Participants: This subgroup was constituted by the Steering Committee to address key questions related to the presentation of PHPT. Consensus was established at a closed meeting of the Expert Panel that followed. Evidence: Data from the 5-year period between 2008 and 2013 were presented and discussed to determine whether they support changes in recommendations for surgery or nonsurgical follow-up. Consensus Process: Questions were developed by the International Task Force on PHPT. A comprehensive literature search for relevant studies was undertaken. After extensive review and discussion, the subgroup came to agreement on what changes in the recommendations for surgery or nonsurgical follow-up of asymptomatic PHPT should be made to the Expert Panel. Conclusions: 1) There are limited new data available on the natural history of asymptomatic PHPT. Although recognition of normocalcemic PHPT (normal serum calcium with elevated PTH concentrations; no secondary cause for hyperparathyroidism)is increasing,data on the clinical presentation and natural history of this phenotypeare limited. 2) Although there are geographic differences in the predominant phenotypes of PHPT (symptomatic, asymptomatic, normocalcemic), they do not justify geography-specific management guidelines. 3) Recent data using newer, higher resolution imaging and analytic methods have revealed that in asymptomatic PHPT, both trabecular bone and cortical bone are affected. 4) Clinically silent nephrolithiasis and nephrocalcinosis can be detected by renal imaging and should be listed as a new criterion for surgery. 5) Current datadonot support a cardiovascular evaluation or surgery for the purpose of improving cardiovascular markers, anatomicalor functional abnormalities. 6) Some patients with mildPHPT have neuropsychological complaints and cognitive abnormalities, and some of these patients may benefit from surgical intervention. However, it is not possible at this time to predict which patients with neuropsychological complaints or cognitive issues will improve after successful parathyroid surgery.
    The Journal of clinical endocrinology and metabolism. 08/2014;
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    ABSTRACT: Context: We previously reported on four patients treated with PTH(1-84) who recovered from postoperative hypoparathyroidism many years after onset. Because vascular endothelial growth factor (VEGF) has been shown to be necessary for the induction of PTH-mediated angiogenesis, we postulated a possible role for VEGF in the recovery of parathyroid function in these subjects. Objective: Our objective was to measure VEGF levels in subjects with hypoparathyroidism who regained parathyroid gland function and matched controls. Setting and Design: Subjects with hypoparathyroidism who regained parathyroid gland function were each matched to two hypoparathyroid controls by postoperative etiology, age (within 5 y), menopausal status, and duration of hypoparathyroidism. We measured serum VEGF levels at baseline and through 48 months of PTH(1-84) therapy. Results: VEGF levels increased after the initiation of PTH(1-84) therapy for the entire cohort, from 309.7 ± 162 pg/ml at baseline to 380.2 ± 178 pg/ml at 12 months (P = .03). Levels trended downward thereafter. There were no significant differences in VEGF levels between the subjects with recovery of parathyroid function and the matched controls. Conclusions: PTH(1-84) alters serum VEGF levels in subjects with hypoparathyroidism. Additional investigation is necessary to understand the mechanisms by which some subjects with postoperative hypoparathyroidism recover parathyroid gland function.
    The Journal of clinical endocrinology and metabolism. 08/2014;
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    ABSTRACT: Objective: Primary hyperparathyroidism (PHPT) is one of the most frequently diagnosed endocrine disorders, but few studies focused on hospital management of the disease in Europe. We investigated the frequency of hospital admission for diagnosis and surgical treatment for PHPT in Italy. Design: retrospective study. Methods: We retrieved data from the "Record of Hospital Discharge" (SDO) of the Italian Health Ministry, from the year 2006 to 2011 and analyzed the codes corresponding to PHPT-related diagnoses and surgical procedures. Results: Overall, 46,275 hospitalization episodes for PHPT were identified during the entire period [69% in women and 31% in men); mean age 63.3±39.8 years]. Patients' mean age significantly increased during the years (p<0.001). The mean length of stay was 8.2±10.5 days (28% of the episodes requiring less than 3 days of stay). Admissions for surgical procedures were 12,457 accounting for 26.9% of the total hospitalizations. There was a trend to a significant increase in the percentage of surgery (p<0.05). The mean hospitalization rate for PHPT was 12.9/100,000 inhabitants/year and the trend showed a significant decrease during the period 2006-2011 (p<0.0001). The mean hospitalization rate for PHPT surgery was 3.65/100,000 per year, significantly increasing over time (p<0.001). Conclusions: PHPT considerably influences the Italian Hospital healthcare system. We observed a tendency to a decrease in the frequency of hospitalization during the period 2006-2011, most probably because of economic issues, a concomitant increased age of patients, and, interestingly, also a progressive increase in the percentage of surgical treatment among patients admitted for PHPT.
    European journal of endocrinology / European Federation of Endocrine Societies. 07/2014;
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    ABSTRACT: Several factors are involved in determining bone quality including bone density, bone turnover, the extent of trabecular bone connectivity, cortical porosity and geometry. Metabolically active and in a continuous process of remodeling, approximately 20% of bone tissue is renewed annually. Bone turn over markers (BTM) are frequently used in clinical trials and to provide valid information about the effectiveness of osteoporosis treatment, reflecting the state of bone metabolism and its response to treatment, although they are not useful alone to estimate bone loss. In this review the behavior of BTM from different clinical trials or different osteoporotic drugs will be addressed.
    Arquivos brasileiros de endocrinologia e metabologia. 07/2014; 58(5):504-513.
  • Barbara C Silva, John P Bilezikian
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    ABSTRACT: The trabecular bone score (TBS) is a new method to describe skeletal microarchitecture from the dual energy X-ray absorptiometry (DXA) image of the lumbar spine. While TBS is not a direct physical measurement of trabecular microarchitecture, it correlates with micro-computed tomography (µCT) measures of bone volume fraction, connectivity density, trabecular number, and trabecular separation, and with vertebral mechanical behavior in ex vivo studies. In human subjects, TBS has been shown to be associated with trabecular microarchitecture and bone strength by high resolution peripheral quantitative computed tomography (HRpQCT). Cross-sectional and prospective studies, involving a large number of subjects, have both shown that TBS is associated with vertebral, femoral neck, and other types of osteoporotic fractures in postmenopausal women. Data in men, while much less extensive, show similar findings. TBS is also associated with fragility fractures in subjects with secondary causes of osteoporosis, and preliminary data suggest that TBS might improve fracture prediction when incorporated in the fracture risk assessment system known as FRAX. In this article, we review recent advances that have helped to establish this new imaging technology.
    Arquivos brasileiros de endocrinologia e metabologia. 07/2014; 58(5):493-503.
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    ABSTRACT: Bone disease in severe primary hyperparathyroidism (PHPT) is described classically as osteitis fibrosa cystica (OFC). Bone pain, skeletal deformities and pathological fractures are features of OFC. Bone mineral density is usually extremely low in OFC, but it is reversible after surgical cure. The signs and symptoms of severe bone disease include bone pain, pathologic fractures, proximal muscle weakness with hyperreflexia. Bone involvement is typically characterized as salt-and-pepper appearance in the skull, bone erosions and bone resorption of the phalanges, brown tumors and cysts. In the radiography, diffuse demineralization is observed, along with pathological fractures, particularly in the long bones of the extremities. In severe, symptomatic PHPT, marked elevation of the serum calcium and PTH concentrations are seen and renal involvement is manifested by nephrolithiasis and nephrocalcinosis. A new technology, recently approved for clinical use in the United States and Europe, is likely to become more widely available because it is an adaptation of the lumbar spine DXA image. Trabecular bone score (TBS) is a gray-level textural analysis that provides an indirect index of trabecular microarchitecture. Newer technologies, such as high-resolution peripheral quantitative computed tomography (HR-pQCT), have provided further understanding of the microstructural skeletal features in PHPT.
    Arquivos brasileiros de endocrinologia e metabologia. 07/2014; 58(5):553-561.
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    ABSTRACT: Context: In hypoparathyroidism, quality of life (QOL) is compromised as compared to normal subjects. We previously reported our results showing an association with recombinant human PTH(1-84) therapy in hypoparathyroidism and improvement in QOL measures through 1 year. Objective: We tested the hypothesis that PTH(1-84) therapy in hypoparathyroidism through 5 years would be associated with continued improvement in QOL measures. Design: Sixty-nine hypoparathyroid subjects received open-label PTH(1-84). Before and during therapy, subjects completed the RAND 36-Item Short Form (SF-36) Health Survey, a measure of health-related QOL covering 8 domains of physical and mental health. Results: At baseline, subjects scored significantly lower than the normative reference range in all 8 domains (T-scores -1.4 to -0.9; p<0.001 for all). With PTH therapy, intention-to-treat analysis showed significant improvement in the overall score at 2 months that persisted through 5 years (386 ± 19 to 482 ± 25; p<0.0001). The mental component summary score improved at 2 months and was sustained through 5 years (199 ± 11 to 246 ± 14; p=0.001), as did all 4 individual mental health domains and T-scores (vitality, social functioning, role emotional, mental health). The physical component summary score improved at 2 months and was sustained through 5 years (187 ± 10 to 237 ± 13; p<0.0001), as did 3 physical health domains and T-scores (physical functioning, role physical, general health). Conclusions: PTH(1-84) therapy is not only associated with improvement in biochemical and skeletal indices, previously well-documented, but also in mental and physical health as determined by the SF-36 metric.
    The Journal of clinical endocrinology and metabolism. 06/2014;
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    ABSTRACT: Altered bone micro-architecture is an important factor in accounting for fragility fractures. Until recently, it has not been possible to gain information about skeletal microstructure in a way that is clinically feasible. Bone biopsy is essentially a research tool. High-resolution peripheral Quantitative Computed Tomography, while non-invasive, is available only sparsely throughout the world. The trabecular bone score (TBS) is an imaging technology adapted directly from the Dual Energy X-Ray Absorptiometry (DXA) image of the lumbar spine. Thus, it is potentially readily and widely available. In recent years, a large number of studies have demonstrated that TBS is significantly associated with direct measurements of bone micro-architecture, predicts current and future fragility fractures in primary osteoporosis, and may be a useful adjunct to BMD for fracture detection and prediction. In this review, we summarize its potential utility in secondary causes of osteoporosis. In some situations, like glucocorticoid-induced osteoporosis and in diabetes mellitus, the TBS appears to out-perform DXA. It also has apparent value in numerous other disorders associated with diminished bone health, including primary hyperparathyroidism, androgen-deficiency, hormone-receptor positive breast cancer treatment, chronic kidney disease, hemochromatosis, and autoimmune disorders like rheumatoid arthritis. Further research is both needed and warranted to more clearly establish the role of TBS in these and other disorders that adversely affect bone.
    Endocrine 05/2014; · 1.42 Impact Factor
  • Aline G Costa, John P Bilezikian, E Michael Lewiecki
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    ABSTRACT: Introduction: Disorders with inactivating mutations of the SOST gene result in reduced or absent expression of sclerostin and are associated with high bone mass. Sclerostin is an important regulator of bone formation due to its inhibitory actions in the osteoanabolic Wnt signaling pathway. Advances in understanding the mechanisms of action of this signaling molecule have led to the development of a pharmacological inhibitor of sclerostin with potential clinical applications as an osteoanabolic drug for the treatment of osteoporosis. Areas covered: Romosozumab is the first humanized monoclonal sclerostin antibody to be tested in clinical trials. Similar to preclinical animal studies with sclerostin antibodies, initial clinical studies show that romosozumab increases bone formation and bone mineral density. Expert opinion: Blocking sclerostin action with romosozumab is a promising new therapeutic approach to osteoanabolic therapy of osteoporosis; efficacy and safety data on large controlled studies are awaited.
    Expert opinion on biological therapy 03/2014; · 3.22 Impact Factor
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    ABSTRACT: Dual-energy X-ray absorptiometry (DXA) is an inexpensive, noninvasive, widely available method for diagnosing osteoporosis, assessing fracture risk, and monitoring the effects of therapy. By diagnosing high-risk patients before a fracture occurs, clinicians can intervene early to reduce fracture risk. Appropriate use of DXA results in money saving for healthcare systems that might otherwise be spent for fracture-related care. Recent reports of studies evaluating DXA screening criteria and intervals for retesting have received considerable media coverage, sometimes suggesting that DXA is expensive, over-utilized, and unnecessary. This may lead to more patients who might benefit from early detection of osteoporosis remaining undiagnosed. We advocate for the use of current clinical practice guidelines with individualization of patient care factors to determine the optimal intervals for DXA testing.
    Current Osteoporosis Reports 03/2014;
  • Nelson B Watts, John P Bilezikian
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    ABSTRACT: Abstract Not Available.
    The Journal of clinical endocrinology and metabolism 01/2014; · 6.50 Impact Factor
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    ABSTRACT: The trabecular bone score (TBS) is a gray-level textural metric that can be extracted from the 2-dimensional lumbar spine dual-energy X-ray absorptiometry (DXA) image. TBS is related to bone microarchitecture and provides skeletal information that is not captured from the standard bone mineral density (BMD) measurement. Based on experimental variograms of the projected DXA image, TBS has the potential to discern differences between DXA scans that show similar BMD measurements. An elevated TBS value correlates with better skeletal microstructure; a low TBS value correlates with weaker skeletal microstructure. Lumbar spine TBS has been evaluated in cross-sectional and longitudinal studies. The following conclusions are based upon publications reviewed in this article: 1) TBS gives lower values in post-menopausal women and in men with previous fragility fractures than their non-fractured counterparts; 2) TBS is complementary to data available by lumbar spine DXA measurements; 3) TBS results are lower in women who have sustained a fragility fracture but in whom DXA does not indicate osteoporosis or even osteopenia; 4) TBS predicts fracture risk as well as lumbar spine BMD measurements in postmenopausal women; 5) Efficacious therapies for osteoporosis differ in the extent to which they influence the TBS; 6) TBS is associated with fracture risk in individuals with conditions related to reduced bone mass or bone quality. Based on these data, lumbar spine TBS holds promise as an emerging technology that could well become a valuable clinical tool in the diagnosis of osteoporosis and in fracture risk assessment. © 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 01/2014; · 6.04 Impact Factor
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    ABSTRACT: The 2013 Santa Fe Bone Symposium included plenary sessions on new developments in the fields of osteoporosis and metabolic bone disease, oral presentations of abstracts, and faculty panel discussions of common clinical conundrums: scenarios of perplexing circumstances where treatment decisions are not clearly defined by current medical evidence and clinical practice guidelines. Controversial issues in the care of osteoporosis were reviewed and discussed by faculty and participants. This is a review of the proceedings of the Santa Fe Bone Symposium, constituting in its entirety an update of advances in the understanding of selected bone disease topics of interest and the implications for managing patients in clinical practice. Topics included the associations of diabetes and obesity with skeletal fragility, the complexities and pitfalls in assessing the benefits and potential adverse effects of nutrients for treatment of osteoporosis, uses of dual-energy X-ray absorptiometry beyond measurement of bone mineral density, challenges in the care of osteoporosis in the very elderly, new findings on the role of osteocytes in regulating bone remodeling, and current concepts on the use of bone turnover markers in managing patients with chronic kidney disease who are at high risk for fracture.
    Journal of Clinical Densitometry 01/2014; · 1.71 Impact Factor
  • Natalie E. Cusano, Mishaela R. Rubin, John P. Bilezikian
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    ABSTRACT: Hypoparathyroidism is a disease characterized by hypocalcemia and insufficient parathyroid hormone (PTH). It is a rare disorder that has been given an orphan disease designation in the United States and European Union. Hypoparathyroidism is the only endocrine deficiency disease for which the missing hormone, PTH, is not yet an approved therapy. Conventional therapy includes calcium and active vitamin D supplementation, often in large doses. Although serum calcium can be controlled with conventional therapy, it can be a challenge and, moreover, does not address other aspects of the disease, such as abnormal skeletal features and reduced quality of life. This review focuses on PTH replacement therapy in hypoparathyroidism, utilizing the full-length molecule PTH(1-84) as well as the fully active but truncated form PTH(1-34). PTH therapy addresses some aspects of the disease not ameliorated with conventional therapy.
    Best Practice & Research: Clinical Endocrinology & Metabolism 01/2014; · 4.91 Impact Factor
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    ABSTRACT: Hypoparathyroidism results in impaired mineral homoeostasis, including hypocalcaemia and hyperphosphataemia. Treatment with high-dose oral calcium and active vitamin D does not provide adequate or consistent control of biochemical indices and can lead to serious long-term complications. We aimed to test the efficacy, safety, and tolerability of once-daily recombinant human parathyroid hormone 1-84 (rhPTH[1-84]) in adults with hypoparathyroidism. In this double-blind, placebo-controlled, randomised phase 3 study (REPLACE), we recruited patients with hypoparathyroidism (≥18 months duration) aged 18-85 years from 33 sites in eight countries. After an optimisation period, during which calcium and active vitamin D doses were adjusted to achieve consistent albumin-corrected serum calcium, patients were randomly assigned (2:1) via an interactive voice response system to 50 μg per day of rhPTH(1-84) or placebo for 24 weeks. Active vitamin D and calcium were progressively reduced, while rhPTH(1-84) could be titrated up from 50 μg to 75 μg and then 100 μg (weeks 0-5). The primary endpoint was the proportion of patients at week 24 who achieved a 50% or greater reduction from baseline in their daily dose of oral calcium and active vitamin D while maintaining a serum calcium concentration greater than or the same as baseline concentrations and less than or equal to the upper limit of normal, analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00732615. Between June 23, 2009, and Feb 28, 2011, 134 eligible patients were recruited and randomly assigned to rhPTH(1-84) (n=90) or placebo (n=44). Six patients in the rhPTH(1-84) group and seven in the placebo group discontinued before study end. 48 (53%) patients in the rhPTH(1-84) group achieved the primary endpoint compared with one (2%) patient in the placebo group (percentage difference 51·1%, 95% CI 39·9-62·3; p<0·0001). The proportions of patients who had at least one adverse event were similar between groups (84 [93%] patients in the rhPTH[1-84] group vs 44 [100%] patients in the placebo group), with hypocalcaemia, muscle spasm, paraesthesias, headache, and nausea being the most common adverse events. The proportions of patients with serious adverse events were also similar between the rhPTH(1-84) group (ten [11%] patients) and the placebo group (four [9%] patients). 50 μg, 75 μg, or 100 μg per day of rhPTH(1-84), administered subcutaneously in the outpatient setting, is efficacious and well tolerated as a PTH replacement therapy for patients with hypoparathyroidism. NPS Pharmaceuticals.
    The lancet. Diabetes & endocrinology. 12/2013; 1(4):275-83.
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    ABSTRACT: Major aims of the 5th Central and Eastern Europe (CEE) Summit on Osteoporosis held in Bratislava, Slovakia, on 2 and 3 December 2011, were to provide participants with state-of-the-art knowledge in the fields of osteoporosis research, diagnosis, and therapy and to evaluate, compare, and discuss the very heterogeneous health care situations and related challenges in the different countries in CEE and elsewhere. The summit was attended by 70 delegates from 15 countries. State-of-the-art lectures given by international authorities on osteoporosis covered a broad spectrum of topics ranging from osteoporosis in the male population, novel therapies in osteoporosis such as cathepsin K and sclerostin inhibitors, and the implementation and use of FRAX® in CEE, to an update on denosumab for the management of osteoporosis. Workshops organized to enable the exchange of individual experiences addressed the importance and current availability of osteology training for physicians and the impact of patient training programs on therapy compliance. Furthermore, the availability of and need for standardized quality controls and therapy guidelines in different CEE countries were discussed. Finally, based on a questionnaire, a very up-to-date analysis of all participating countries regarding incidences of osteoporosis, commonly used diagnostic and therapeutic measures, the number of specialists and specialized hospitals, and differences in the reimbursement situation in the different countries was generated and presented. On the whole, the very authentic contributions and the synergistic exchange of ideas allowed the identification of both positive developments as well as still existing issues and needs in diagnosis and therapy of osteoporosis.
    Archives of Osteoporosis 12/2013; 8(1-2):123.
  • Natalie E Cusano, John P Bilezikian
    Journal of comparative effectiveness research. 11/2013; 2(6):511-3.
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    ABSTRACT: Although high-resolution peripheral quantitative computed tomography (HRpQCT) and central quantitative computed tomography (QCT) studies have shown bone structural differences between Chinese American (CH) and white (WH) women, these techniques are not readily available in the clinical setting. The trabecular bone score (TBS) estimates trabecular microarchitecture from dual-energy X-ray absorptiometry spine images. We assessed TBS in CH and WH women and investigated whether TBS is associated with QCT and HRpQCT indices. Areal bone mineral density (aBMD) by dual-energy X-ray absorptiometry, lumbar spine (LS) TBS, QCT of the LS and hip, and HRpQCT of the radius and tibia were performed in 71 pre- (37 WH and 34 CH) and 44 postmenopausal (21 WH and 23 CH) women. TBS did not differ by race in either pre- or postmenopausal women. In the entire cohort, TBS positively correlated with LS trabecular volumetric bone mineral density (vBMD) (r = 0.664), femoral neck integral (r = 0.651), trabecular (r = 0.641) and cortical vBMD (r = 0.346), and cortical thickness (C/I; r = 0.540) by QCT (p < 0.001 for all). TBS also correlated with integral (r = 0.643), trabecular (r = 0.574) and cortical vBMD (r = 0.491), and C/I (r = 0.541) at the total hip (p < 0.001 for all). The combination of TBS and LS aBMD predicted more of the variance in QCT measures than aBMD alone. TBS was associated with all HRpQCT indices (r = 0.20-0.52) except radial cortical thickness and tibial trabecular thickness. Significant associations between TBS and measures of HRpQCT and QCT in WH and CH pre- and postmenopausal women demonstrated here suggest that TBS may be a useful adjunct to aBMD for assessing bone quality.
    Journal of Clinical Densitometry 09/2013; · 1.71 Impact Factor
  • Luigi Gennari, John P Bilezikian
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    ABSTRACT: Over the last decade, the increasingly significant problem of osteoporosis in men has begun to receive much more attention than in the past. In particular, recent observations from large scale population studies in males led to an advance in the understanding of morphologic basis of growth, maintenance and loss of bone in men, as well as new insights about the pathophysiology and treatment of this disorder. While fracture risk consistently increases after age 65 in men (with up to 50 % of cases due to secondary etiologies), osteoporosis and fractures may also occur in young or middle aged males in the absence of an identifiable etiology. For this category (so called idiopathic osteoporosis), there are still major gaps in knowledge, particularly concerning the etiology and the clinical management. This article provides a summary of recent developments in the acquisition and maintenance of bone strength in men, as well as new insights about the pathogenesis, diagnosis, and treatment of idiopathic osteoporosis.
    Current Osteoporosis Reports 09/2013;

Publication Stats

7k Citations
1,207.76 Total Impact Points

Institutions

  • 1992–2014
    • CUNY Graduate Center
      New York City, New York, United States
  • 1984–2014
    • Columbia University
      • • Division of Endocrinology
      • • Department of Medicine
      • • College of Physicians and Surgeons
      New York City, New York, United States
  • 2013
    • Park Nicollet Health Services
      Minneapolis, Minnesota, United States
  • 2009–2013
    • McMaster University
      • Department of Medicine
      Hamilton, Ontario, Canada
    • University of Cincinnati
      Cincinnati, Ohio, United States
    • Università di Pisa
      • Department of Clinical and Experimental Medicine
      Pisa, Tuscany, Italy
  • 2006–2013
    • Universidade Católica de Brasília
      Brasília, Federal District, Brazil
    • University of Vermont
      Burlington, Vermont, United States
  • 2005–2013
    • Università degli Studi di Siena
      • Department of Medicine, Surgery and Neuroscience
      Siena, Tuscany, Italy
  • 2012
    • University of Cambridge
      • Department of Medicine
      Cambridge, ENG, United Kingdom
  • 2005–2012
    • New Mexico Clinical Research and Osteoporosis Center
      Albuquerque, New Mexico, United States
  • 2003–2012
    • Mayo Foundation for Medical Education and Research
      • • College of Medicine
      • • Division of Endocrinology, Diabetes, Metabolism, and Nutrition
      Scottsdale, AZ, United States
  • 2011
    • Massachusetts General Hospital
      • Division of Endocrinology
      Boston, MA, United States
    • University of California, Los Angeles
      • Department of Orthopaedic Surgery
      Los Angeles, CA, United States
  • 2008–2011
    • GlaxoSmithKline plc.
      Londinium, England, Belgium
    • Beth Israel Medical Center
      New York City, New York, United States
    • St. Luke's Hospital
      Cedar Rapids, Iowa, United States
    • University of California, Berkeley
      • Department of Mechanical Engineering
      Berkeley, CA, United States
    • New York Medical College
      • Department of Medicine
      New York City, New York, United States
  • 2003–2011
    • University of California, San Francisco
      • • Division of Hospital Medicine
      • • Division of Endocrinology and Metabolism
      • • Department of Epidemiology and Biostatistics
      San Francisco, CA, United States
  • 2010
    • Universidade Federal do Paraná
      Pontal do Paraná, Paraná, Brazil
    • The University of Hong Kong
      • Department of Medicine
      Hong Kong, Hong Kong
  • 2005–2009
    • Università degli Studi di Brescia
      • • Department of Clinical and Experimental Sciences
      • • Department of Medicine and Surgery
      Brescia, Lombardy, Italy
  • 2006–2007
    • University of Wisconsin, Madison
      • Department of Medicine
      Madison, MS, United States
  • 2004–2007
    • Saint Francis Hospital And Medical Center, Hartford, Ct
      Hartford, Connecticut, United States
    • Gracie Square Hospital, New York, NY
      New York City, New York, United States