Correspondence
4
5
6
7
Kamar N, Bendall R, Legrand-Abravanel F, et al. Hepatitis E. Lancet 2012; 379: 2477–88. Shrestha A, Lama TK, Karki S, et al. Hepatitis E epidemic, biratnagar, Nepal, 2014. Emerg Infect Dis. 2015; 21: 711–13. Teshale EH, Howard CM, Grytdal SP, et al. Hepatitis E epidemic, Uganda. Emerg Infect Dis 2010; 16: 126–29. United Nations. Nepal—Severity of Districts in term of the earthquake intensity area. http:// un.org.np/sites/default/files/Serveriity%20 of%20Areas_0.pdf (accessed June 11, 2015). Zhu FC, Zhang J, Zhang XF, et al. Efficacy and safety of a recombinant hepatitis E vaccine in healthy adults: a large-scale, randomised, double-blind placebo-controlled, phase 3 trial. Lancet 2010; 376: 895-902.
Sustaining progress in maternal and child health in Nepal Nepal has made substantial progress in reducing maternal and child mortality since 1990.1 With limited resources, the Nepal Government has strived to maintain health services, until the country was hit by a 7·9 Richter scale earthquake on April 25, 2015, followed by another 7·4 Richter scale quake within 3 weeks. The resulting damages are massive, with 600 000 people displaced, 750 000 houses destroyed, 8600 deaths, and 17 000 people injured.2 The economic cost is estimated to be US$5–10 billion.3 Our concern is the sustainability of maternal and child health care following the earthquake. Maternal and child health services are severely disrupted. The country’s only tertiary maternity hospital in Kathmandu is damaged, and 90% of health facilities in affected districts are non-functional. An estimated 126 000 pregnant women are now at risk of adverse maternal outcomes, while 2 million women and girls of reproductive age could be affected.4 According to Child Health Division, Nepal, 90% of health facilities are destroyed in the epicentre Gorkha. Similarly, damages to health facilities exceed 50% in Nuwakot www.thelancet.com Vol 385 June 27, 2015
district and 85% in Dhading district, disrupting antenatal, delivery, and postnatal care in the catchment areas. Latest information from the Family Health Division, Nepal, confirmed that 19 out of 21 birthing centres in Dolakha district and 18 out of 21 birthing centres in Sindhupalanchok district are nonoperational. The Nepal Prime Minister announced that relief, rehabilitation and reconstruction will be the government’s priority, which implied possible diversion of the limited health budget to these areas. Evidence from previous disasters in the world have shown a decrease in access and use of prenatal care, with increased rates of miscarriage, premature birth, intrauterine growth, low birthweight, and unwanted pregnancies in the aftermath of disaster.5 Interruption of breastfeeding practice is a major risk factor for adverse infant health. For example, after the 2006 earthquake in Indonesia, increase in formula feeding from 32% to 43% was associated with a higher incidence of childhood diarrhoea.6 This situation will be replicated in Nepal unless unregulated use and donation of infant formula are discouraged. The network of outreach clinics should be reinstated, and skilled health workers should be encouraged to attend home deliveries while birthing centres are being rebuilt. The high rate of routine immunisation must be preserved at >90%. As long as the cold chain is maintained, this is feasible since immunisations are mostly done in outreach clinics which require little infrastructure support. We declare no competing interests.
*Vishnu Khanal, Pratik Khanal, Andy H Lee [email protected] Nepal Development Society, Bharatpur, Nepal (VK); Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal (PK); and School of Public Health, Curtin University, Perth, Australia (VK, AHL)
1
2
3
4
5
6
Government of Nepal, National Planning Commission / United Nations Country Team of Nepal. Nepal Millennium Development Goals. Progress Report 2013. http://www.np.undp. org/content/dam/nepal/docs/reports/ millennium%20development%20goals/ UNDP_NP_MDG_Report_2013.pdf (accessed June 11, 2015). Government of Nepal. Incident Report of Earthquake 2015. http://drrportal.gov.np/ (accessed May 25, 2015). Koirala J. Effects of 2015 Earthquake on Nepalese Economy. Kathmandu, Nepal: USEF Education Foundation; 2015. UNFPA. Nepal earthquake: Women and girls in need. 2015. http://www.unfpa.org/resources/ nepal-earthquake-women-and-girls-need (accessed May 16, 2015). Nour NN. Maternal health considerations during disaster relief. Rev Obstet Gynecol 2011; 4: 22–27. Hipgrave DB, Assefa F, Winoto A, Sukotjo S. Donated breast milk substitutes and incidence of diarrhoea among infants and young children after the May 2006 earthquake in Yogyakarta and Central Java. Public Health Nutr 2012; 15: 307–15.
Anti-inflammatory therapies in myocardial infarction
Kampee Patisena
3
Published Online June 16, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)60963-1
Losmapimod blunted the acute inflammatory response in patients with non-ST-segment elevation myocardial infarction (NSTEMI) in L Kristin Newby and colleagues’ study (Sept 27, p 1187).1 Despite only small effects on infarct size, losmapimod reduced dyspnoea and brain natriuretic peptide levels and significantly improved left ventricular ejection fraction compared with placebo.1 Losmapimod is an inhibitor of p38 mitogen activated protein kinase, which is downstream of cytokine receptors including interleukin 1. Of note, interleukin 1 blockade with anakinra in patients with ST-segment elevation myocardial infarction (STEMI) also blunted the acute inflammatory response and showed a trend towards reduced onset of heart failure.2 Although losmapimod does not seem to have substantial effect on atherothrombotic or ischaemic events compared with placebo,1 the 2573
Correspondence
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 http://www.insomed.org
Virginia Commonwealth University, Richmond, VA 23298, USA (AA); University of Sheffield, Sheffield, UK (ACM); and University of St Andrews, Glasgow, UK (DCC) 1
2
3
4
2574
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
2
3
4
5
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 www.thelancet.com Vol 385 June 27, 2015
4
5
6
7
Kamar N, Bendall R, Legrand-Abravanel F, et al. Hepatitis E. Lancet 2012; 379: 2477–88. Shrestha A, Lama TK, Karki S, et al. Hepatitis E epidemic, biratnagar, Nepal, 2014. Emerg Infect Dis. 2015; 21: 711–13. Teshale EH, Howard CM, Grytdal SP, et al. Hepatitis E epidemic, Uganda. Emerg Infect Dis 2010; 16: 126–29. United Nations. Nepal—Severity of Districts in term of the earthquake intensity area. http:// un.org.np/sites/default/files/Serveriity%20 of%20Areas_0.pdf (accessed June 11, 2015). Zhu FC, Zhang J, Zhang XF, et al. Efficacy and safety of a recombinant hepatitis E vaccine in healthy adults: a large-scale, randomised, double-blind placebo-controlled, phase 3 trial. Lancet 2010; 376: 895-902.
Sustaining progress in maternal and child health in Nepal Nepal has made substantial progress in reducing maternal and child mortality since 1990.1 With limited resources, the Nepal Government has strived to maintain health services, until the country was hit by a 7·9 Richter scale earthquake on April 25, 2015, followed by another 7·4 Richter scale quake within 3 weeks. The resulting damages are massive, with 600 000 people displaced, 750 000 houses destroyed, 8600 deaths, and 17 000 people injured.2 The economic cost is estimated to be US$5–10 billion.3 Our concern is the sustainability of maternal and child health care following the earthquake. Maternal and child health services are severely disrupted. The country’s only tertiary maternity hospital in Kathmandu is damaged, and 90% of health facilities in affected districts are non-functional. An estimated 126 000 pregnant women are now at risk of adverse maternal outcomes, while 2 million women and girls of reproductive age could be affected.4 According to Child Health Division, Nepal, 90% of health facilities are destroyed in the epicentre Gorkha. Similarly, damages to health facilities exceed 50% in Nuwakot www.thelancet.com Vol 385 June 27, 2015
district and 85% in Dhading district, disrupting antenatal, delivery, and postnatal care in the catchment areas. Latest information from the Family Health Division, Nepal, confirmed that 19 out of 21 birthing centres in Dolakha district and 18 out of 21 birthing centres in Sindhupalanchok district are nonoperational. The Nepal Prime Minister announced that relief, rehabilitation and reconstruction will be the government’s priority, which implied possible diversion of the limited health budget to these areas. Evidence from previous disasters in the world have shown a decrease in access and use of prenatal care, with increased rates of miscarriage, premature birth, intrauterine growth, low birthweight, and unwanted pregnancies in the aftermath of disaster.5 Interruption of breastfeeding practice is a major risk factor for adverse infant health. For example, after the 2006 earthquake in Indonesia, increase in formula feeding from 32% to 43% was associated with a higher incidence of childhood diarrhoea.6 This situation will be replicated in Nepal unless unregulated use and donation of infant formula are discouraged. The network of outreach clinics should be reinstated, and skilled health workers should be encouraged to attend home deliveries while birthing centres are being rebuilt. The high rate of routine immunisation must be preserved at >90%. As long as the cold chain is maintained, this is feasible since immunisations are mostly done in outreach clinics which require little infrastructure support. We declare no competing interests.
*Vishnu Khanal, Pratik Khanal, Andy H Lee [email protected] Nepal Development Society, Bharatpur, Nepal (VK); Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal (PK); and School of Public Health, Curtin University, Perth, Australia (VK, AHL)
1
2
3
4
5
6
Government of Nepal, National Planning Commission / United Nations Country Team of Nepal. Nepal Millennium Development Goals. Progress Report 2013. http://www.np.undp. org/content/dam/nepal/docs/reports/ millennium%20development%20goals/ UNDP_NP_MDG_Report_2013.pdf (accessed June 11, 2015). Government of Nepal. Incident Report of Earthquake 2015. http://drrportal.gov.np/ (accessed May 25, 2015). Koirala J. Effects of 2015 Earthquake on Nepalese Economy. Kathmandu, Nepal: USEF Education Foundation; 2015. UNFPA. Nepal earthquake: Women and girls in need. 2015. http://www.unfpa.org/resources/ nepal-earthquake-women-and-girls-need (accessed May 16, 2015). Nour NN. Maternal health considerations during disaster relief. Rev Obstet Gynecol 2011; 4: 22–27. Hipgrave DB, Assefa F, Winoto A, Sukotjo S. Donated breast milk substitutes and incidence of diarrhoea among infants and young children after the May 2006 earthquake in Yogyakarta and Central Java. Public Health Nutr 2012; 15: 307–15.
Anti-inflammatory therapies in myocardial infarction
Kampee Patisena
3
Published Online June 16, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)60963-1
Losmapimod blunted the acute inflammatory response in patients with non-ST-segment elevation myocardial infarction (NSTEMI) in L Kristin Newby and colleagues’ study (Sept 27, p 1187).1 Despite only small effects on infarct size, losmapimod reduced dyspnoea and brain natriuretic peptide levels and significantly improved left ventricular ejection fraction compared with placebo.1 Losmapimod is an inhibitor of p38 mitogen activated protein kinase, which is downstream of cytokine receptors including interleukin 1. Of note, interleukin 1 blockade with anakinra in patients with ST-segment elevation myocardial infarction (STEMI) also blunted the acute inflammatory response and showed a trend towards reduced onset of heart failure.2 Although losmapimod does not seem to have substantial effect on atherothrombotic or ischaemic events compared with placebo,1 the 2573
Correspondence
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 http://www.insomed.org
Virginia Commonwealth University, Richmond, VA 23298, USA (AA); University of Sheffield, Sheffield, UK (ACM); and University of St Andrews, Glasgow, UK (DCC) 1
2
3
4
2574
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
2
3
4
5
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 www.thelancet.com Vol 385 June 27, 2015
