- Email: [email protected]
Timing of surgery for symptomatic carotid stenosis
CORRESPONDENCE
The important thing about promoting safe cycling and walking is that the environment, transport, and urban planning sectors are essential partners. Since 1999 when European Member States adopted the WHO Charter on Transport, Environment and Health, health policymakers have worked alongside colleagues from other sectors to place health and environmental considerations firmly on the agenda of transport and land-use policy-makers. There is no time to lose. Physical inactivity has become one of the leading risk factors for the health of Europeans. Across the WHO European Region, the proportion of deaths attributable to physical inactivity is estimated at 5–10% of the total number of deaths4—ie, about 600 000 deaths per year. Children’s health is of immediate concern. In countries where figures are available, the levels of physical activity among children have declined greatly in the past 15 years. The prevalence of overweight and obesity has increased in parallel. World Health Day was dedicated to “Move for Health” in 2002 and since then a World Day on physical activity takes place annually on May 10. Also in May, 2004, the WHO Global Strategy on Diet and Physical Activity will be discussed at the World Health Assembly. In the European Region, we have emphasised safe walking and cycling, not only to achieve higher levels of physical activity but also better quality of urban life through reduced air pollution, noise, traffic, and congestion.5 The joint UNECE–WHO Transport, Health and Environment Pan-European Programme (THE PEP) established in 2002 is pushing the agenda forward in the European Region, and at WHO’s Fourth Ministerial Conference on Environment and Health, to be held in Budapest, Hungary, in June, 2004, the emphasis will be on children and how to protect their health from environmental hazards. Inactivity is a hazard. It also costs society dear. Work is also underway to develop guidelines for health impact assessment and costbenefit analysis of transport-related policies and interventions that might have implications for levels of physical activity through walking and cycling. *Francesca Racioppi, Roberto Bertollini, Vivienne Taylor Gee *Accidents, Transport and Health (FR) and Division of Technical Support “Health Determinants” (RB), WHO Regional Office for Europe, European Centre for Environment and Health, Via Francesco Crispi 10, 00187 Rome, Italy; and WHO Regional Office for Europe, Copenhagen, Denmark (VTG) (e-mail: [email protected])
1 2
3
4
5
The Lancet. The catastrophic failures of public health. Lancet 2004; 363: 745. Andersen LB, Schnohr P, Schroll M, Hein HO. All-cause mortality associated with physical activity during leisure time, work, sports, and cycling to work. Arch Intern Med 2000; 160: 1621–28. Rowland D, DiGuiseppi C, Gross M, Afolabi E, Roberts I. Randomized controlled trial of site specific advice on school travel patterns. Arch Dis Child 2003; 88: 8–11. WHO. World Health Report 2002: reducing risks, promoting healthy life. Geneva: World Health Organization, 2002. http://www.who. int/whr/2002/en/ (accessed Mar 6, 2004). Racioppi F, Dora C, Krech R, von Ehrenstein O. A physically active life through everyday transport: with a special focus on children and older people and examples and approaches from Europe. Copenhagen: WHO Regional Office for Europe, 2002. http://www.euro.who.int/ document/e75662.pdf (accessed Feb 1, 2004).
Sir—In your Editorial,1 you point out the failures of public health in the developed world, particularly in relation to chronic diseases. But what of the state of public health in the developing world? The developing world’s limited resources bear a much higher burden of communicable diseases and an almost equal burden of noncommunicable diseases.2 Addressing the root cause of poverty would do more good to the health of people than any number of specific interventions. The need for health research is also imperative in the generation of the good quality data governments need to formulate national policies. Decision frameworks must be evidencebased and take into account disease burden, prevention effectiveness, costeffectiveness, and affordability.3 Pakistan faces an ever increasing double burden of disease: the infant mortality rate is 80 per 1000—the highest in south Asia—and cardiovascular diseases account for more than 100 000 deaths per year. The development of public health faces serious challenges in Pakistan. As the country undergoes epidemiological transition, the new realities in the health sector point towards a wide range of health issues that are faced with a lack of capacity to respond. This discrepancy between need and capacity underscores the importance of health research to identify priority areas.4 More than a third of Pakistan’s population lives below the poverty line. Pakistan spends only 0·7% of its gross national product on health. Pakistan’s spending on preventive health care and education is about 10 times less than Nepal and Bhutan, its poorer and smaller neighbours.5 Effective
THE LANCET • Vol 363 • May 8, 2004 • www.thelancet.com
interventions require a functioning health system, which must be able to use and effectively promulgate researchbased knowledge. Low-cost interventions such as health education in schools and effective media campaigns carry a lot of promise if implemented sincerely. We agree that by targeting the youth (more than 40% of Pakistan’s population is younger than 15 years), a lot can be gained. Public health needs the support of poverty reduction, higher literacy, good governance, and accountability if it is to begin making its much needed impact on the lives of more than 150 million citizens of Pakistan. *Fawad Aslam, Muhammad Ahad Qayyum *Aga Khan University Medical College, Stadium Road, Karachi 74800, Pakistan (FA); and Punjab Medical College, Faisalabad, Pakistan (MAQ) (e-mail: [email protected]) 1 2
3
4
5
The Lancet. The catastrophic failures of public health. Lancet 2004; 363: 745. Global Forum for Health Research. The 10/90 Report on Health Research 2000. Geneva: GFHR, 2000. White F. Developing effective and affordable models for non-communicable disease prevention and control. Int J Epidemiol 2001; 30: 1494–95. Hyder AA. Health research investments: a challenge for national public health associations. J Pak Med Assoc 2002; 52: 276–77. Wallerstein C. Pakistan lags behind in reproductive health. BMJ 1998; 317: 1546.
Timing of surgery for symptomatic carotid stenosis Sir—P M Rothwell and colleagues (Mar 20, p 915)1 present an important study. If the optimum timing of surgery for symptomatic carotid stenosis is 2 weeks after the patient’s last symptoms, the implications for healthcare provision are enormous. To be able to offer the highest-risk patients early surgery, an attempt to stratify the risk of waiting needs to be made. Transcranial doppler can be used to assess middle cerebral artery velocity and platelet microemboli. Immediately after a carotid-territory transient ischaemic attack (TIA) or stroke, there is a rise in microemboli in the middle cerebral artery, and patients who continue to embolise are at a greater risk of a further neurological event.2 A high microembolic load after carotid endarterectomy is associated with early carotid thrombosis. Control of this load by means of intravenous transcranial doppler-directed antiplatelet agents reduces the risk of early postoperative
1553
For personal use. Only reproduce with permission from The Lancet publishing Group.
CORRESPONDENCE
stroke3. It is possible to influence the timing of carotid surgery in patients with recurrent or crescendo TIAs. Control of both emboli and symptoms with transcranial doppler-directed dextran allows these high-risk patients to undergo carotid surgery safely on the next elective list.4 Microemboli seem to be surrogate markers for future embolic events (TIAs or strokes) and the pharmacological efficacy of any therapeutic intervention can now rapidly and non-invasively be assessed. Transcranial doppler emboli detection could offer an approach to the management of patients both medically and surgically. *Chris Imray, Dan Higman, Carl Tiivas Coventry and Warwickshire County Vascular Unit, Coventry CV2 2DX, UK (e-mail: [email protected]) 1
2
3
4
Rothwell PM, Eliasziw M, Gutnikov SA, Warlow CP, Barnett HJM, for the Carotid Endarterectomy Trialists Collaboration. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet 2004; 363: 915–24. Goertler M, Blaser T, Krueger S, Lutze G, Wallesch CW. Acetylsalicylic acid and microembolic events detected by transcranial Doppler in symptomatic arterial stenoses. Cerebrovasc Dis 2001; 11: 324–29. Lennard N, Smith J, Dunville J, et al. Prevention of postoperative thrombotic stroke after carotid endarterectomy: the role of transcranial Doppler ultrasound. J Vasc Surg 1997; 26: 579–84. Lennard NS, Vijayasekar C, Tiivas C, Chan CWM, Higman DJ, Imray CH. Control of emboli in patients with recurrent or crescendo transient ischaemic attacks using preoperative transcranial Dopplerdirected Dextran therapy. Br J Surg 2003; 90: 166–70.
A network of excellence Sir—Nathan Clumeck and Christine Katlama’s ambitious proposal of a network of centres of excellence in clinical research across Europe (Mar 13, p 901)1 is to be welcomed. They identify the threat posed to noncommercial academic research, which is especially difficult in oncology because surgery and radiotherapy attract little commercial support. Optimum delivery of radiotherapy can make substantial contributions to improving local control. Currently, about 90% of all cancers are cured by local treatment with surgery and radiotherapy. Kogelnik and Lukas have estimated that, if a 100% local control rate could be achieved, cancer survival rates would rise from 45% to 60%.2 At present, there are many opportunities to improve local control—eg, advances in radiation planning and delivery such as intensity-modulated radiotherapy,
1554
and integration of structural (CT, MRI) and functional (positron emission tomography) scans into the radiotherapy planning process. In addition, positron emission tomography imaging could provide valuable information on response to multimodal therapy—eg, with radiotherapy and inhibitors of tumour angiogenesis. There are rising clinical and laboratory needs to obtain cellular and molecular information in vivo.3 Developments in molecular imaging could allow us to identify the optimum time in the cell cycle for radiotherapy and chemotherapy to be delivered for individual tumours. Ring-fenced European Union research funding for biological and clinical aspects of combined modality therapy for cancer would help redress the current imbalance in the provision of funding. Networks of excellence would facilitate the collaboration needed to deliver these research priorities. Ian Kunkler University Department of Clinical Oncology, Western General Hospital, University of Edinburgh, Crewe Road, Edinburgh EH2 2XU, UK (e-mail: [email protected]) 1
2
3
Clumeck N, Katlama C. Call for network of centres of excellence in clinical research in Europe. Lancet 2004; 363: 901–02. Kogelnik HD, Lukas P, Sedlmayer F. Foreword. In: Kogelnik HD, Lukas P, Sedlmayer F, eds. Progress in radiooncology, VII. Bologna: Monduzzi Editore, 2002. Sullivan DC. Challenges and opportunities for in vivo imaging in oncology. Technol Cancer Res Treat 2003; 6: 419–22.
Sir—In their Correspondence letter (Mar 13, p 901),1 Nathan Clumeck and Christine Katlama put forward the intriguing idea that clinical research in Europe should be done only by networks of centres of excellence appointed by research specialists and selected from European agencies. Centres of excellence in basic research already exist since their establishment represents a priority for the recently launched European Commission Framework Project 6. However, the negative consequences of the establishment of such clinical networks should be carefully considered and weighed against the advantages pointed out by Clumeck and Katlama. The criteria by which clinical centres across Europe will get the status of “excellence” might not be easy to identify. Should clinical centres be drawn up on the basis of the number of patients referring to them, the availability of high-tech equipment, or compliance with the national standards
of care? Any of these criteria will influence the applicability of the results of clinical trials to the general population. Clumeck and Katlama correctly state that there are great differences in quality of clinical investigation and in standards of care across Europe. But are we sure that results obtained in top-level clinical centres can be easily applied to less than optimum clinical settings? As an example, if high-tech centres are included in the networks of excellence, then large areas of Europe will not benefit from the results. Conversely, if clinical trials are done in small and less-equipped centres, results might not represent the best available treatment for any given disease. Similar arguments have been used to criticise evidence-based medicine.2 Networks of centres of clinical excellence will be of limited usefulness for individual patients across Europe, and their research priorities will not match the needs of patients and the health-care system.3 In this light, I do not think that the establishment of such networks will generate data which in turn will determine standards of care across Europe. Rather, the minimum standards of care should be set first; only then will clinical trials done in any European country yield results applicable to the general European population. Finally, I agree with Clumeck and Katlama in their criticism of the procedure by which the European Commission financially supports scientific proposals, since it is burdened with unnecessary bureaucratic difficulties. These limitations are known by the Commission, which is working to improve its procedures. However, I would not say that it “claims to support investigative centres of excellence, but in practice the political will is not apparent”.1 To my knowledge, any decision on a proposal’s scientific accuracy and adequacy of budget is not taken by “Eurobureaucrats” but by independent international peer-reviewers with expertise in the field. Alessandro Laviano Department of Clinical Medicine, University La Sapienza, Viale dell’Università 37, 00185 Rome, Italy (e-mail: [email protected]) 1
2
3
Clumeck N, Katlama C. Call for network of Centres of Excellence in clinical research in Europe. Lancet 2004; 363: 901–02. Cohen AM, Stavri PZ, Hersh WR. A categorization and analysis of the criticisms of Evidence-Based Medicine. Int J Med Inf 2004; 73: 35–43. Tallon D, Chard J, Dieppe P. Relation between agendas of the research community and the research consumer. Lancet 2000; 355: 2037–40.
THE LANCET • Vol 363 • May 8, 2004 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet publishing Group.
The important thing about promoting safe cycling and walking is that the environment, transport, and urban planning sectors are essential partners. Since 1999 when European Member States adopted the WHO Charter on Transport, Environment and Health, health policymakers have worked alongside colleagues from other sectors to place health and environmental considerations firmly on the agenda of transport and land-use policy-makers. There is no time to lose. Physical inactivity has become one of the leading risk factors for the health of Europeans. Across the WHO European Region, the proportion of deaths attributable to physical inactivity is estimated at 5–10% of the total number of deaths4—ie, about 600 000 deaths per year. Children’s health is of immediate concern. In countries where figures are available, the levels of physical activity among children have declined greatly in the past 15 years. The prevalence of overweight and obesity has increased in parallel. World Health Day was dedicated to “Move for Health” in 2002 and since then a World Day on physical activity takes place annually on May 10. Also in May, 2004, the WHO Global Strategy on Diet and Physical Activity will be discussed at the World Health Assembly. In the European Region, we have emphasised safe walking and cycling, not only to achieve higher levels of physical activity but also better quality of urban life through reduced air pollution, noise, traffic, and congestion.5 The joint UNECE–WHO Transport, Health and Environment Pan-European Programme (THE PEP) established in 2002 is pushing the agenda forward in the European Region, and at WHO’s Fourth Ministerial Conference on Environment and Health, to be held in Budapest, Hungary, in June, 2004, the emphasis will be on children and how to protect their health from environmental hazards. Inactivity is a hazard. It also costs society dear. Work is also underway to develop guidelines for health impact assessment and costbenefit analysis of transport-related policies and interventions that might have implications for levels of physical activity through walking and cycling. *Francesca Racioppi, Roberto Bertollini, Vivienne Taylor Gee *Accidents, Transport and Health (FR) and Division of Technical Support “Health Determinants” (RB), WHO Regional Office for Europe, European Centre for Environment and Health, Via Francesco Crispi 10, 00187 Rome, Italy; and WHO Regional Office for Europe, Copenhagen, Denmark (VTG) (e-mail: [email protected])
1 2
3
4
5
The Lancet. The catastrophic failures of public health. Lancet 2004; 363: 745. Andersen LB, Schnohr P, Schroll M, Hein HO. All-cause mortality associated with physical activity during leisure time, work, sports, and cycling to work. Arch Intern Med 2000; 160: 1621–28. Rowland D, DiGuiseppi C, Gross M, Afolabi E, Roberts I. Randomized controlled trial of site specific advice on school travel patterns. Arch Dis Child 2003; 88: 8–11. WHO. World Health Report 2002: reducing risks, promoting healthy life. Geneva: World Health Organization, 2002. http://www.who. int/whr/2002/en/ (accessed Mar 6, 2004). Racioppi F, Dora C, Krech R, von Ehrenstein O. A physically active life through everyday transport: with a special focus on children and older people and examples and approaches from Europe. Copenhagen: WHO Regional Office for Europe, 2002. http://www.euro.who.int/ document/e75662.pdf (accessed Feb 1, 2004).
Sir—In your Editorial,1 you point out the failures of public health in the developed world, particularly in relation to chronic diseases. But what of the state of public health in the developing world? The developing world’s limited resources bear a much higher burden of communicable diseases and an almost equal burden of noncommunicable diseases.2 Addressing the root cause of poverty would do more good to the health of people than any number of specific interventions. The need for health research is also imperative in the generation of the good quality data governments need to formulate national policies. Decision frameworks must be evidencebased and take into account disease burden, prevention effectiveness, costeffectiveness, and affordability.3 Pakistan faces an ever increasing double burden of disease: the infant mortality rate is 80 per 1000—the highest in south Asia—and cardiovascular diseases account for more than 100 000 deaths per year. The development of public health faces serious challenges in Pakistan. As the country undergoes epidemiological transition, the new realities in the health sector point towards a wide range of health issues that are faced with a lack of capacity to respond. This discrepancy between need and capacity underscores the importance of health research to identify priority areas.4 More than a third of Pakistan’s population lives below the poverty line. Pakistan spends only 0·7% of its gross national product on health. Pakistan’s spending on preventive health care and education is about 10 times less than Nepal and Bhutan, its poorer and smaller neighbours.5 Effective
THE LANCET • Vol 363 • May 8, 2004 • www.thelancet.com
interventions require a functioning health system, which must be able to use and effectively promulgate researchbased knowledge. Low-cost interventions such as health education in schools and effective media campaigns carry a lot of promise if implemented sincerely. We agree that by targeting the youth (more than 40% of Pakistan’s population is younger than 15 years), a lot can be gained. Public health needs the support of poverty reduction, higher literacy, good governance, and accountability if it is to begin making its much needed impact on the lives of more than 150 million citizens of Pakistan. *Fawad Aslam, Muhammad Ahad Qayyum *Aga Khan University Medical College, Stadium Road, Karachi 74800, Pakistan (FA); and Punjab Medical College, Faisalabad, Pakistan (MAQ) (e-mail: [email protected]) 1 2
3
4
5
The Lancet. The catastrophic failures of public health. Lancet 2004; 363: 745. Global Forum for Health Research. The 10/90 Report on Health Research 2000. Geneva: GFHR, 2000. White F. Developing effective and affordable models for non-communicable disease prevention and control. Int J Epidemiol 2001; 30: 1494–95. Hyder AA. Health research investments: a challenge for national public health associations. J Pak Med Assoc 2002; 52: 276–77. Wallerstein C. Pakistan lags behind in reproductive health. BMJ 1998; 317: 1546.
Timing of surgery for symptomatic carotid stenosis Sir—P M Rothwell and colleagues (Mar 20, p 915)1 present an important study. If the optimum timing of surgery for symptomatic carotid stenosis is 2 weeks after the patient’s last symptoms, the implications for healthcare provision are enormous. To be able to offer the highest-risk patients early surgery, an attempt to stratify the risk of waiting needs to be made. Transcranial doppler can be used to assess middle cerebral artery velocity and platelet microemboli. Immediately after a carotid-territory transient ischaemic attack (TIA) or stroke, there is a rise in microemboli in the middle cerebral artery, and patients who continue to embolise are at a greater risk of a further neurological event.2 A high microembolic load after carotid endarterectomy is associated with early carotid thrombosis. Control of this load by means of intravenous transcranial doppler-directed antiplatelet agents reduces the risk of early postoperative
1553
For personal use. Only reproduce with permission from The Lancet publishing Group.
CORRESPONDENCE
stroke3. It is possible to influence the timing of carotid surgery in patients with recurrent or crescendo TIAs. Control of both emboli and symptoms with transcranial doppler-directed dextran allows these high-risk patients to undergo carotid surgery safely on the next elective list.4 Microemboli seem to be surrogate markers for future embolic events (TIAs or strokes) and the pharmacological efficacy of any therapeutic intervention can now rapidly and non-invasively be assessed. Transcranial doppler emboli detection could offer an approach to the management of patients both medically and surgically. *Chris Imray, Dan Higman, Carl Tiivas Coventry and Warwickshire County Vascular Unit, Coventry CV2 2DX, UK (e-mail: [email protected]) 1
2
3
4
Rothwell PM, Eliasziw M, Gutnikov SA, Warlow CP, Barnett HJM, for the Carotid Endarterectomy Trialists Collaboration. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet 2004; 363: 915–24. Goertler M, Blaser T, Krueger S, Lutze G, Wallesch CW. Acetylsalicylic acid and microembolic events detected by transcranial Doppler in symptomatic arterial stenoses. Cerebrovasc Dis 2001; 11: 324–29. Lennard N, Smith J, Dunville J, et al. Prevention of postoperative thrombotic stroke after carotid endarterectomy: the role of transcranial Doppler ultrasound. J Vasc Surg 1997; 26: 579–84. Lennard NS, Vijayasekar C, Tiivas C, Chan CWM, Higman DJ, Imray CH. Control of emboli in patients with recurrent or crescendo transient ischaemic attacks using preoperative transcranial Dopplerdirected Dextran therapy. Br J Surg 2003; 90: 166–70.
A network of excellence Sir—Nathan Clumeck and Christine Katlama’s ambitious proposal of a network of centres of excellence in clinical research across Europe (Mar 13, p 901)1 is to be welcomed. They identify the threat posed to noncommercial academic research, which is especially difficult in oncology because surgery and radiotherapy attract little commercial support. Optimum delivery of radiotherapy can make substantial contributions to improving local control. Currently, about 90% of all cancers are cured by local treatment with surgery and radiotherapy. Kogelnik and Lukas have estimated that, if a 100% local control rate could be achieved, cancer survival rates would rise from 45% to 60%.2 At present, there are many opportunities to improve local control—eg, advances in radiation planning and delivery such as intensity-modulated radiotherapy,
1554
and integration of structural (CT, MRI) and functional (positron emission tomography) scans into the radiotherapy planning process. In addition, positron emission tomography imaging could provide valuable information on response to multimodal therapy—eg, with radiotherapy and inhibitors of tumour angiogenesis. There are rising clinical and laboratory needs to obtain cellular and molecular information in vivo.3 Developments in molecular imaging could allow us to identify the optimum time in the cell cycle for radiotherapy and chemotherapy to be delivered for individual tumours. Ring-fenced European Union research funding for biological and clinical aspects of combined modality therapy for cancer would help redress the current imbalance in the provision of funding. Networks of excellence would facilitate the collaboration needed to deliver these research priorities. Ian Kunkler University Department of Clinical Oncology, Western General Hospital, University of Edinburgh, Crewe Road, Edinburgh EH2 2XU, UK (e-mail: [email protected]) 1
2
3
Clumeck N, Katlama C. Call for network of centres of excellence in clinical research in Europe. Lancet 2004; 363: 901–02. Kogelnik HD, Lukas P, Sedlmayer F. Foreword. In: Kogelnik HD, Lukas P, Sedlmayer F, eds. Progress in radiooncology, VII. Bologna: Monduzzi Editore, 2002. Sullivan DC. Challenges and opportunities for in vivo imaging in oncology. Technol Cancer Res Treat 2003; 6: 419–22.
Sir—In their Correspondence letter (Mar 13, p 901),1 Nathan Clumeck and Christine Katlama put forward the intriguing idea that clinical research in Europe should be done only by networks of centres of excellence appointed by research specialists and selected from European agencies. Centres of excellence in basic research already exist since their establishment represents a priority for the recently launched European Commission Framework Project 6. However, the negative consequences of the establishment of such clinical networks should be carefully considered and weighed against the advantages pointed out by Clumeck and Katlama. The criteria by which clinical centres across Europe will get the status of “excellence” might not be easy to identify. Should clinical centres be drawn up on the basis of the number of patients referring to them, the availability of high-tech equipment, or compliance with the national standards
of care? Any of these criteria will influence the applicability of the results of clinical trials to the general population. Clumeck and Katlama correctly state that there are great differences in quality of clinical investigation and in standards of care across Europe. But are we sure that results obtained in top-level clinical centres can be easily applied to less than optimum clinical settings? As an example, if high-tech centres are included in the networks of excellence, then large areas of Europe will not benefit from the results. Conversely, if clinical trials are done in small and less-equipped centres, results might not represent the best available treatment for any given disease. Similar arguments have been used to criticise evidence-based medicine.2 Networks of centres of clinical excellence will be of limited usefulness for individual patients across Europe, and their research priorities will not match the needs of patients and the health-care system.3 In this light, I do not think that the establishment of such networks will generate data which in turn will determine standards of care across Europe. Rather, the minimum standards of care should be set first; only then will clinical trials done in any European country yield results applicable to the general European population. Finally, I agree with Clumeck and Katlama in their criticism of the procedure by which the European Commission financially supports scientific proposals, since it is burdened with unnecessary bureaucratic difficulties. These limitations are known by the Commission, which is working to improve its procedures. However, I would not say that it “claims to support investigative centres of excellence, but in practice the political will is not apparent”.1 To my knowledge, any decision on a proposal’s scientific accuracy and adequacy of budget is not taken by “Eurobureaucrats” but by independent international peer-reviewers with expertise in the field. Alessandro Laviano Department of Clinical Medicine, University La Sapienza, Viale dell’Università 37, 00185 Rome, Italy (e-mail: [email protected]) 1
2
3
Clumeck N, Katlama C. Call for network of Centres of Excellence in clinical research in Europe. Lancet 2004; 363: 901–02. Cohen AM, Stavri PZ, Hersh WR. A categorization and analysis of the criticisms of Evidence-Based Medicine. Int J Med Inf 2004; 73: 35–43. Tallon D, Chard J, Dieppe P. Relation between agendas of the research community and the research consumer. Lancet 2000; 355: 2037–40.
THE LANCET • Vol 363 • May 8, 2004 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet publishing Group.