Correspondence
*Rengaswamy Sankaranarayanan, Pulikkottil Okkuru Esmy, Rajamanickam Rajkumar, Richard Muwonge, Rajaraman Swaminathan [email protected] International Agency for Research on Cancer, 69008 Lyon, France (RS, RM); Christian Fellowship Community Health Center, Ambilikkai, Dindigul District, Tamil Nadu, India (POE); Community Medicine, Meenakshi Medical College and Research Institute, Enathur, Kanchipuram, Tamil Nadu, India (RR); and Cancer Institute, Chennai, India (RS) 1
2
3
4
5
Murillo R, Almonte M, Pereira A, et al. Cervical cancer screening programs in Latin America and the Caribbean. Vaccine 2008; 26: L37–48. Sankaranarayanan R, Esmy PO, Rajkumar R, et al. Effect of visual screening on cervical cancer incidence and mortality in Tamil Nadu, India: a cluster-randomised trial. Lancet 2007; 370: 398–406. Sankaranarayanan R, Rajkumar R, Esmy PO, et al. Effectiveness, safety and acceptability of ‘see and treat’ with cryotherapy by nurses in a cervical screening study in India. Br J Cancer 2007; 96: 738–43. Swaminathan R, Selvakumaran R, Esmy PO, et al. Cancer pattern and survival in a rural district in South India. Cancer Epidemiol 2009; 33: 325–31. Krishnan S, Madsen E, Porterfield D, et al. Advancing cervical cancer prevention in India: implementation science priorities. Oncologist 2013; 18: 1285–97.
Assessing the French Alzheimer plan Assessment of funding use and scientific academic output is crucial to provide an objective basis to formulate further research strategies at regional, national, and international level. The 2008–12 French Alzheimer plan had three major objectives: to understand, to cure, and to care.1 For this plan, €115·1 million of public funds were used. €27·6 million were provided by the Ministry of Health and the French National Research Agency to 58 clinical research projects, €31·2 million were provided from the French National Research Agency to 58 basic or technological research projects, and €56·3 million were provided by the Alzheimer Foundation Plan. The Alzheimer Foundation Plan had a coordinating role and launched different types of initiatives: calls for www.thelancet.com Vol 383 May 24, 2014
research projects in social sciences, experimental models and imaging (€8·5 million); education and training facilities (€18·8 million); and national infrastructure (€29 million), mainly in genetics, through the European Alzheimer’s Disease Initiative,2 cohort studies (the Three Cities and MEMENTO cohorts); and a research neuroimaging platform. The Ministry of Health added €3 million to support the Centres for Early-Onset Alzheimer Disease (in Rouen, Lille, and Paris). This national network recruited 225 families who met the criteria of one confirmed case of Alzheimer disease in the family with early onset (before 65 years old).3 The Ministry of Health also provided €17·4 million to support the National Alzheimer Data Bank, based in Nice, which by 2012 had collected standardised information on 403 458 consultations nationwide.4 In an attempt to assess measures impact, we did a bibliometric evaluation of the potential effect of the plan on scientific research, 1 year after its end, in 2013. We searched the Web of Science Core Collection for articles on Alzheimer’s disease (Alzheimer in the title, abstract, or keywords), identified the top 10% most-cited original articles in the field worldwide, and analysed the contribution of France and 13 other countries on publications on Alzheimer’s disease (appendix). Between 2007 and 2012, the number of articles in the top most-cited articles increased from 726 to 1117—a 54% increase—globally. The largest participation in the top 10% came from authors in the USA (71%), the UK (17%), and Germany (15%). The participation of French authors in the top 10% mostcited articles increased from 4·8% to 8·4% (a 75% increase)—third largest increase after China (208%) and Spain (188% increase). We also assessed, through a MeSH query, original articles about dementia in the Système d’Interrogation, de Gestion et d’Analyse des Publications Scientifiques (SIGAPS), which collects all French university hospital
publications from PubMed. Between two 5 year periods, 2003–07 and 2008–12, the proportion of articles attributed to a French university hospital decreased by 6% (from 2·18% to 2·04%), whereas the proportion of articles on dementia increased by 10% (from 3·53% to 3·89%). Whether or not there is a direct relation between national funding and scientific output on Alzheimer’s disease requires further analysis and followup. Monitoring and benchmarking of production of original articles will help to assess the effect of international collaboration encouraged by the 2013 London G8 Dementia Summit.5
Simon Rawles
We declare no competing interests.
We declare no competing interests. PD and NHC contributed equally.
Patrick Devos, Nicole Haeffner-Cavaillon, Sylvie Ledoux, Cécile Balandier, *Joël Ménard [email protected] Department of Research, Lille University Hospital, Lille, France (PD); Inserm, Department of Scientific Evaluation, Bibliometric Unit, Paris, France (NH-C); Fondation Plan Alzheimer, 75013 Paris, France (SL, JM); and Ministry of Health and Social Affairs, Paris, France (CB) 1 2
3
4
5
Spinney L. Alzheimer’s disease funding and the French health system. Lancet 2008; 7: 26–27. European Alzheimer’s Disease Initiative (EADI); Genetic and Environmental Risk in Alzheimer’s Disease; Alzheimer’s Disease Genetic Consortium; Cohorts for Heart and Aging Research in Genomic Epidemiology. Metaanalysis of 74 046 individuals identifies 11 new susceptibility loci for Alzheimer’s disease. Nat Genet 2013; 45: 1452–58. Wallon D, Rousseau S, Rovelet-Lecrux A, et al. The French series of autosomal dominant early onset Alzheimer’s disease cases: mutation spectrum and cerebrospinal fluid biomarkers. J Alzheimers Dis 2012; 30: 847–56. Le Duff F, Develay AE, Quetel J, et al. The 2008–2012 French Alzheimer plan: description of the national Alzheimer information system. J Alzheimers Dis 2012; 29: 891–902. Barr RA. NIA funding for Alzheimer’s research. Lancet Neurology 2011; 10: 683.
See Online for appendix
The Blackfriars Consensus on brain health and dementia Dementia prevalence has remained stable despite ageing of the population because of a reduction in prevalence in the age group in which most dementia
Published Online May 20, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60758-3
1805
Correspondence
Published Online May 19, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60761-3
Published Online May 19, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60760-1
1806
occurs. 1 We might be seeing the benefit of earlier population policies for the health of these generations. Yet in most countries, including the UK, this potential for benefit is poorly reflected in current public health policy or research. The Blackfriars Consensus was developed after a meeting in London in January, 2014, hosted by the UK Health Forum and Public Health England, and is supported by 60 experts and organisations in dementia and non-communicable diseases (NCD) prevention. Effective approaches to prevent NCDs should integrate the potential to improve brain health in populations, thus helping to mitigate the anticipated increase in need for health and social care services due to population ageing. Population-based studies suggest that Alzheimer’s disease and vascular pathologies underlie a substantial proportion of dementias, 2 and there is an overlap between risk factors for vascular disease and dementia. A substantial proportion of dementia might be delayed or averted if modifiable risk factors are effectively addressed. There is a growing consensus that the scientific evidence is now sufficient to justify policy action across the life course and for further research to reduce the modifiable risk factors and improve the population profile for recognised protective factors. Action on the same behavioural and intermediate risk factors for NCDs (including tobacco, poor diet, physical inactivity, and alcohol) and consequent reductions in raised blood pressure, blood cholesterol, obesity, and diabetes could prevent between 3% and 20% of predicted new cases of dementia in 20 years.3,4 These gains are likely to be greater if combined with action to protect brain health throughout life —including addressing alcohol and substance abuse and head injuries in adolescents and young people; supporting lifelong learning and
improved workplace health in middle life; and improving social interactions, stimulation, and supportive care in later life. In the UK, costs from dementia are estimated at £23 billion per year.5 Although the number of people with dementia in the past 20 years in the UK was stable, the financial impact of dementia is set to rise. An integrated prevention approach would demand both populationlevel and community-level measures to improve protective factors and reduce behavioural and intermediate risk factors. The best strategy would be to work throughout the life course to bring people to the threshold of older age in good health, without any NCD. We need evidence to support decision making about the balance between individual approaches such as increased awareness, reducing stigma, and the place of early diagnosis and treatment, in tandem with the role of measures for the whole population such as legislation and taxation. National policy guidelines and greater collaboration between practitioners, experts, and researchers are also needed. Lessons can be learned from other countries national policies, such as Finland’s healthy brain and heart programmes. There is a disproportionately small research focus generating evidence for dementia prevention and risk reduction to inform discussion. A strategic, coordinated research agenda should include: studies on dementia mechanisms, epidemiology and modelling of burdens and trends, early diagnosis and prevention of deterioration, and social inequalities in dementia risk.1 Adoption of an integrated approach makes better use of current efforts and resources, offering the opportunity to strengthen and expand existing programmes and research with great benefit and minimal risk of harm. We declare no competing interests.
Paul Lincoln, Kevin Fenton, Charles Alessi, Martin Prince, Carol Brayne, Marc Wortmann, Kiran Patel, John Deanfield, *Modi Mwatsama [email protected] UK Health Forum, London EC4Y 8JX, UK (PL, MM); Health and Wellbeing Directorate, Public Health England, London, UK (KF); Prevention of Dementia, Public Health England, London, UK (CA); Institute of Psychiatry, King’s College London, London, UK (MP); Cambridge Institute of Public Health, School of Clinical Medicine, Cambridge University, Cambridge, UK (CB); Alzheimer’s Disease International, London, UK (MW); Heart of England NHS Trust, Birmingham, UK and NHS England area team for Birmingham and Black Country, Birmingham, UK (KP); and National Centre for Cardiovascular Prevention and Outcomes, London, UK (JD) 1
2
3
4
5
Matthews FE, Arthur A, Barnes LE, et al, for the Medical Research Council Cognitive Function and Ageing Collaboration. A two-decade comparison of prevalence of dementia in individuals aged 65 years and older from three geographical areas of England: results of the Cognitive Function and Ageing Study I and II. Lancet 2013; 382: 1405–12. Matthews FE, Brayne C, Lowe J, McKeith I, Wharton SB, Ince P. Epidemiological pathology of dementia: attributable-risks at death in the Medical Research Council Cognitive Function and Ageing Study. PLoS Med 2009; 6: e1000180. WHO. Dementia: a public health priority. http://www.who.int/mental_health/ publications/dementia_report_2012/en/ (accessed May 12, 2014). Smith D, Yaffe K. Dementia (including Alzheimer’s Disease) can be prevented: Statement supported by International Experts. J Alzheimer’s Dis 2014; 38: 699–703. Alzheimer’s Society. Dementia 2012: a national challenge. http://www.alzheimers. org.uk/dementia2012 (accessed May 12, 2014).
Department of Error Prost A, Colbourn T, Seward T, et al. Women’s groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis. Lancet 2013; 381: 1736–46—In this Article (May 18), meta-analyses should have been run on the log odds ratios rather than on the odds ratios. The data in the Findings (Summary), Results, figures 2–4, and appendix of the online version of this Article have been corrected as of May 19, 2014. Petrou P, Patwary S, Banerjee PJ, Kirkby GR. Bilateral macular hole from a handheld laser pointer. Lancet 2014; 383: 1780—This Case Report (May 17) should have had an appendix. This correction has been made to the online version as of May 19, 2014.
www.thelancet.com Vol 383 May 24, 2014
*Rengaswamy Sankaranarayanan, Pulikkottil Okkuru Esmy, Rajamanickam Rajkumar, Richard Muwonge, Rajaraman Swaminathan [email protected] International Agency for Research on Cancer, 69008 Lyon, France (RS, RM); Christian Fellowship Community Health Center, Ambilikkai, Dindigul District, Tamil Nadu, India (POE); Community Medicine, Meenakshi Medical College and Research Institute, Enathur, Kanchipuram, Tamil Nadu, India (RR); and Cancer Institute, Chennai, India (RS) 1
2
3
4
5
Murillo R, Almonte M, Pereira A, et al. Cervical cancer screening programs in Latin America and the Caribbean. Vaccine 2008; 26: L37–48. Sankaranarayanan R, Esmy PO, Rajkumar R, et al. Effect of visual screening on cervical cancer incidence and mortality in Tamil Nadu, India: a cluster-randomised trial. Lancet 2007; 370: 398–406. Sankaranarayanan R, Rajkumar R, Esmy PO, et al. Effectiveness, safety and acceptability of ‘see and treat’ with cryotherapy by nurses in a cervical screening study in India. Br J Cancer 2007; 96: 738–43. Swaminathan R, Selvakumaran R, Esmy PO, et al. Cancer pattern and survival in a rural district in South India. Cancer Epidemiol 2009; 33: 325–31. Krishnan S, Madsen E, Porterfield D, et al. Advancing cervical cancer prevention in India: implementation science priorities. Oncologist 2013; 18: 1285–97.
Assessing the French Alzheimer plan Assessment of funding use and scientific academic output is crucial to provide an objective basis to formulate further research strategies at regional, national, and international level. The 2008–12 French Alzheimer plan had three major objectives: to understand, to cure, and to care.1 For this plan, €115·1 million of public funds were used. €27·6 million were provided by the Ministry of Health and the French National Research Agency to 58 clinical research projects, €31·2 million were provided from the French National Research Agency to 58 basic or technological research projects, and €56·3 million were provided by the Alzheimer Foundation Plan. The Alzheimer Foundation Plan had a coordinating role and launched different types of initiatives: calls for www.thelancet.com Vol 383 May 24, 2014
research projects in social sciences, experimental models and imaging (€8·5 million); education and training facilities (€18·8 million); and national infrastructure (€29 million), mainly in genetics, through the European Alzheimer’s Disease Initiative,2 cohort studies (the Three Cities and MEMENTO cohorts); and a research neuroimaging platform. The Ministry of Health added €3 million to support the Centres for Early-Onset Alzheimer Disease (in Rouen, Lille, and Paris). This national network recruited 225 families who met the criteria of one confirmed case of Alzheimer disease in the family with early onset (before 65 years old).3 The Ministry of Health also provided €17·4 million to support the National Alzheimer Data Bank, based in Nice, which by 2012 had collected standardised information on 403 458 consultations nationwide.4 In an attempt to assess measures impact, we did a bibliometric evaluation of the potential effect of the plan on scientific research, 1 year after its end, in 2013. We searched the Web of Science Core Collection for articles on Alzheimer’s disease (Alzheimer in the title, abstract, or keywords), identified the top 10% most-cited original articles in the field worldwide, and analysed the contribution of France and 13 other countries on publications on Alzheimer’s disease (appendix). Between 2007 and 2012, the number of articles in the top most-cited articles increased from 726 to 1117—a 54% increase—globally. The largest participation in the top 10% came from authors in the USA (71%), the UK (17%), and Germany (15%). The participation of French authors in the top 10% mostcited articles increased from 4·8% to 8·4% (a 75% increase)—third largest increase after China (208%) and Spain (188% increase). We also assessed, through a MeSH query, original articles about dementia in the Système d’Interrogation, de Gestion et d’Analyse des Publications Scientifiques (SIGAPS), which collects all French university hospital
publications from PubMed. Between two 5 year periods, 2003–07 and 2008–12, the proportion of articles attributed to a French university hospital decreased by 6% (from 2·18% to 2·04%), whereas the proportion of articles on dementia increased by 10% (from 3·53% to 3·89%). Whether or not there is a direct relation between national funding and scientific output on Alzheimer’s disease requires further analysis and followup. Monitoring and benchmarking of production of original articles will help to assess the effect of international collaboration encouraged by the 2013 London G8 Dementia Summit.5
Simon Rawles
We declare no competing interests.
We declare no competing interests. PD and NHC contributed equally.
Patrick Devos, Nicole Haeffner-Cavaillon, Sylvie Ledoux, Cécile Balandier, *Joël Ménard [email protected] Department of Research, Lille University Hospital, Lille, France (PD); Inserm, Department of Scientific Evaluation, Bibliometric Unit, Paris, France (NH-C); Fondation Plan Alzheimer, 75013 Paris, France (SL, JM); and Ministry of Health and Social Affairs, Paris, France (CB) 1 2
3
4
5
Spinney L. Alzheimer’s disease funding and the French health system. Lancet 2008; 7: 26–27. European Alzheimer’s Disease Initiative (EADI); Genetic and Environmental Risk in Alzheimer’s Disease; Alzheimer’s Disease Genetic Consortium; Cohorts for Heart and Aging Research in Genomic Epidemiology. Metaanalysis of 74 046 individuals identifies 11 new susceptibility loci for Alzheimer’s disease. Nat Genet 2013; 45: 1452–58. Wallon D, Rousseau S, Rovelet-Lecrux A, et al. The French series of autosomal dominant early onset Alzheimer’s disease cases: mutation spectrum and cerebrospinal fluid biomarkers. J Alzheimers Dis 2012; 30: 847–56. Le Duff F, Develay AE, Quetel J, et al. The 2008–2012 French Alzheimer plan: description of the national Alzheimer information system. J Alzheimers Dis 2012; 29: 891–902. Barr RA. NIA funding for Alzheimer’s research. Lancet Neurology 2011; 10: 683.
See Online for appendix
The Blackfriars Consensus on brain health and dementia Dementia prevalence has remained stable despite ageing of the population because of a reduction in prevalence in the age group in which most dementia
Published Online May 20, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60758-3
1805
Correspondence
Published Online May 19, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60761-3
Published Online May 19, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60760-1
1806
occurs. 1 We might be seeing the benefit of earlier population policies for the health of these generations. Yet in most countries, including the UK, this potential for benefit is poorly reflected in current public health policy or research. The Blackfriars Consensus was developed after a meeting in London in January, 2014, hosted by the UK Health Forum and Public Health England, and is supported by 60 experts and organisations in dementia and non-communicable diseases (NCD) prevention. Effective approaches to prevent NCDs should integrate the potential to improve brain health in populations, thus helping to mitigate the anticipated increase in need for health and social care services due to population ageing. Population-based studies suggest that Alzheimer’s disease and vascular pathologies underlie a substantial proportion of dementias, 2 and there is an overlap between risk factors for vascular disease and dementia. A substantial proportion of dementia might be delayed or averted if modifiable risk factors are effectively addressed. There is a growing consensus that the scientific evidence is now sufficient to justify policy action across the life course and for further research to reduce the modifiable risk factors and improve the population profile for recognised protective factors. Action on the same behavioural and intermediate risk factors for NCDs (including tobacco, poor diet, physical inactivity, and alcohol) and consequent reductions in raised blood pressure, blood cholesterol, obesity, and diabetes could prevent between 3% and 20% of predicted new cases of dementia in 20 years.3,4 These gains are likely to be greater if combined with action to protect brain health throughout life —including addressing alcohol and substance abuse and head injuries in adolescents and young people; supporting lifelong learning and
improved workplace health in middle life; and improving social interactions, stimulation, and supportive care in later life. In the UK, costs from dementia are estimated at £23 billion per year.5 Although the number of people with dementia in the past 20 years in the UK was stable, the financial impact of dementia is set to rise. An integrated prevention approach would demand both populationlevel and community-level measures to improve protective factors and reduce behavioural and intermediate risk factors. The best strategy would be to work throughout the life course to bring people to the threshold of older age in good health, without any NCD. We need evidence to support decision making about the balance between individual approaches such as increased awareness, reducing stigma, and the place of early diagnosis and treatment, in tandem with the role of measures for the whole population such as legislation and taxation. National policy guidelines and greater collaboration between practitioners, experts, and researchers are also needed. Lessons can be learned from other countries national policies, such as Finland’s healthy brain and heart programmes. There is a disproportionately small research focus generating evidence for dementia prevention and risk reduction to inform discussion. A strategic, coordinated research agenda should include: studies on dementia mechanisms, epidemiology and modelling of burdens and trends, early diagnosis and prevention of deterioration, and social inequalities in dementia risk.1 Adoption of an integrated approach makes better use of current efforts and resources, offering the opportunity to strengthen and expand existing programmes and research with great benefit and minimal risk of harm. We declare no competing interests.
Paul Lincoln, Kevin Fenton, Charles Alessi, Martin Prince, Carol Brayne, Marc Wortmann, Kiran Patel, John Deanfield, *Modi Mwatsama [email protected] UK Health Forum, London EC4Y 8JX, UK (PL, MM); Health and Wellbeing Directorate, Public Health England, London, UK (KF); Prevention of Dementia, Public Health England, London, UK (CA); Institute of Psychiatry, King’s College London, London, UK (MP); Cambridge Institute of Public Health, School of Clinical Medicine, Cambridge University, Cambridge, UK (CB); Alzheimer’s Disease International, London, UK (MW); Heart of England NHS Trust, Birmingham, UK and NHS England area team for Birmingham and Black Country, Birmingham, UK (KP); and National Centre for Cardiovascular Prevention and Outcomes, London, UK (JD) 1
2
3
4
5
Matthews FE, Arthur A, Barnes LE, et al, for the Medical Research Council Cognitive Function and Ageing Collaboration. A two-decade comparison of prevalence of dementia in individuals aged 65 years and older from three geographical areas of England: results of the Cognitive Function and Ageing Study I and II. Lancet 2013; 382: 1405–12. Matthews FE, Brayne C, Lowe J, McKeith I, Wharton SB, Ince P. Epidemiological pathology of dementia: attributable-risks at death in the Medical Research Council Cognitive Function and Ageing Study. PLoS Med 2009; 6: e1000180. WHO. Dementia: a public health priority. http://www.who.int/mental_health/ publications/dementia_report_2012/en/ (accessed May 12, 2014). Smith D, Yaffe K. Dementia (including Alzheimer’s Disease) can be prevented: Statement supported by International Experts. J Alzheimer’s Dis 2014; 38: 699–703. Alzheimer’s Society. Dementia 2012: a national challenge. http://www.alzheimers. org.uk/dementia2012 (accessed May 12, 2014).
Department of Error Prost A, Colbourn T, Seward T, et al. Women’s groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis. Lancet 2013; 381: 1736–46—In this Article (May 18), meta-analyses should have been run on the log odds ratios rather than on the odds ratios. The data in the Findings (Summary), Results, figures 2–4, and appendix of the online version of this Article have been corrected as of May 19, 2014. Petrou P, Patwary S, Banerjee PJ, Kirkby GR. Bilateral macular hole from a handheld laser pointer. Lancet 2014; 383: 1780—This Case Report (May 17) should have had an appendix. This correction has been made to the online version as of May 19, 2014.
www.thelancet.com Vol 383 May 24, 2014
