rates for the individual endpoints are not presented. This finding is also consistent with no beneficial effect reported with anakinra in patients with STEMI2 and NSTEMI.3 In these studies2,3 anakinra also showed blunting of the inflammatory response, yet it did not prevent recurrent adverse events. Unfortunately, the incidence of heart failure after NSTEMI was not reported in this study.3 Both studies, of losmapimod1 and anakinra,3 showed a significant increase in C-reactive protein concentrations in patients 2 weeks after cessation of active treatment. The implications of this so-called rebound occurrence is unknown.4 We request that the authors1 report the incidence of heart failure as an individual endpoint in their groups to allow for comparisons with other studies. We also ask them to describe the group of patients with rebound after treatment to identify potential risk factors or predictors, and assess whether the rebound is predictive of (or even causes) long-term adverse events in patients with NSTEMI. AA reports grants from Novartis and Swedish Orphan Biovitrum, outside the submitted work. ACM and DCC declare no competing interests.

*Antonio Abbate, Allison C Morton, David C Crossman [email protected]

For the International New School of Medicine’s website see

Virginia Commonwealth University, Richmond, VA 23298, USA (AA); University of Sheffield, Sheffield, UK (ACM); and University of St Andrews, Glasgow, UK (DCC) 1





Newby LK, Marber MS, Melloni C, et al, on behalf of the SOLSTICE Investigators. Losmapimod, a novel p38 mitogen-activated protein kinase inhibitor, in non-ST-segment elevation myocardial infarction: a randomised phase 2 trial. Lancet 2014; 384: 1187–95. Abbate A, Van Tassell BW, Biondi-Zoccai G, et al. Effects of interleukin-1 blockade with anakinra on adverse cardiac remodeling and heart failure after acute myocardial infarction [from the Virginia Commonwealth University-Anakinra Remodeling Trial (2) (VCU-ART2) pilot study]. Am J Cardiol 2013; 111: 1394–400. Morton AC, Rothman AMK, Greenwood JP, et al. The effect of interleukin-1 receptor antagonist therapy on markers of inflammation in non-ST elevation acute coronary syndromes: the MRC-ILA heart study. Eur Heart J 2015; 36: 377–84. Abbate A, Dinarello CA. Anti-inflammatory therapies in acute coronary syndromes: is IL-1 blockade a solution? Eur Heart J 2014; 36: 337–39.

A 21st-century medical school In their Comment (Feb 21, p 672) about the so-called 21st-century medical school Hilliard Jason and Andrew Douglas explicitly invited “questions, suggestions, even expressions of scepticism”. As junior medical educators from five different continents, we applaud the premise of the International New School of Medicine (iNSoMed)— “helping to enhance the wellbeing of people and communities, as well as promoting economic growth in low-income and middle-income countries”. We approach this with cautious optimism because previous attempts at such development have led to reinforcement of paternalism, ethnocentrism, and universalism.2 We are keen to learn how the authors anticipate overcoming this common occurrence in global development initiatives and how they expect iNSoMed to be sustainable in lowincome and middle-income countries. The description and accompanying website, while attractive, lack specifics about methods of teaching, learning, and assessment. Details are missing on how iNSoMed intends to break with traditional approaches to student selection for medical education to fit their highly aspirational criteria (in view of the limitations of admission tools available)3 and on how the proposed individual pathways will be created and validated. Lastly, the medical educators advising iNSoMed are exclusively from western Europe and the USA, with seemingly little student and junior doctor engagement during the development process of iNSoMed.4 We wonder what effect such limited diversity could have on the implementation of change. Rhetoric aside, real change in medical education is hard to achieve. The “how can we get there”5 is precisely what is missing from the Comment, leaving it to read more like an advertisement for the programme than a description of educational innovation. 1

We declare no competing interests.

*Robbert J Duvivier, Matthew J Stull, Andrea Srur Colombo, Jirayu Phillip Chantanakomes, Chijioke Kaduru [email protected] Faculty of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308, Australia (RJD); Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA (MJS); Ministerio de Salud de Chile, Santiago, Chile (ASC); Saraburi Hospital, Bangkok, Thailand (JPC); and Young People for Global Health Issues, Abuja, Nigeria (CK) 1





Jason H, Douglas A. Are the conditions right for a 21st-century medical school? Lancet 2015; 385: 672–73. Hodges BD, Maniate JM, Martimianakis MA, Alsuwaidan M, Segouin C. Cracks and crevices: globalization discourse and medical education. Med Teach 2009; 31: 910–17. Hamdy H, Prasad K, Anderson MB, et al. BEME systematic review: predictive values of measurements obtained in medical schools and future performance in medical practice. Med Teach 2006; 28: 103–16. Stigler FL, Duvivier RJ, Weggemans M, Salzer HJF. Health professionals for the 21st century: a students’ view. Lancet 2010; 376: 1877–78. Skochelak S. A decade of reports calling for change in medical education: what do they say? Acad Med 2010; 85: S26–33.

Authors’ reply We are grateful to Robbert Duvivier and colleagues for their thoughtful questions in response to our Comment.1 Their questions give us an opportunity to add some information that we did not previously have space to include. We will make more detail available on our website in the near future, but for now, the site contains a list of our advisers and collaborating organisations, many of whom have had extensive experience working in low-income and middle-income countries. We are about to begin seeking the foundation and donor funds needed for this philanthropic effort. Our central commitment is to be the opposite of paternalistic. We aim to provide help at the request of and in collaboration with local leaders. Our goal is to strengthen self-sustaining health systems in multiple developing countries to meet their local needs. We will offer guidance, substantial resources and Vol 385 June 27, 2015

A 21st-century medical school.

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