The edition · Top Clinical Updates
A neuroprotectant that worked in a 997-patient stroke trial, and the 24 prescribing cascades worth knowing by name
Loberamisal raised the proportion of stroke patients reaching full functional recovery from 56.3% to 69.7% at 90 days - in one country, in a selected population. And a two-million-person cohort names the drug-begets-drug sequences that fill older patients' repeat lists.
The edition in brief
Six items chosen for clinicians outside the specialty each belongs to. The lead is LAIS, a phase 3 placebo-controlled trial at 32 Chinese hospitals in which 997 patients with acute ischaemic stroke and NIHSS 7 to 20, treated within 48 hours, received intravenous loberamisal or placebo for ten days. Full functional outcome at 90 days - modified Rankin 0 to 1 - occurred in 69.7% versus 56.3%, a risk difference of 13.3 percentage points (95% CI 7.2 to 19.3), with no excess of serious adverse events. This is a large effect for a neuroprotectant, a class with a long history of positive early trials that did not replicate, and it comes from a single country with a median NIHSS of 8. A BMJ cohort comparing cardiovascular risk equations derived in New Zealand and China among people with diabetes found the age coefficient differs sharply - hazard ratio 1.61 per decade in New Zealand women versus 2.51 in Chinese women - and that recalibrating a high-income equation does not fix it; replacing the age coefficient does. A network meta-analysis of 124 exercise trials in 18,429 adults over 40 puts numbers on bone: brisk walking or jogging and combined aerobic-resistance training raise bone density modestly, with benefit plateauing around 600 METs-minutes a week. AIROPLANE, a cluster crossover trial in 1,818 neonates born at 32 to 35 weeks, found starting resuscitation at FiO2 0.30 rather than 0.21 made no difference to the primary outcome, though fewer infants escalated to higher support. The practice-changer is a two-million-person Ontario cohort naming 24 high-priority prescribing cascades. Plus a pearl on how to take a drug history that finds them.
A neuroprotectant raised full recovery after stroke from 56% to 70% at 90 days
A positive phase 3 for a stroke neuroprotectant, single-country and unreplicated - follow it, do not yet plan around it.
Imported cardiovascular risk equations fail on age, and recalibration does not fix it
An imported risk equation misestimates by age in a way recalibration does not fix - use the score to rank your patients, not to quote them a percentage.
Exercise for bone: brisk walking, about 600 METs-minutes a week, and a plateau after that
Two to three hours a week of brisk walking, with resistance work added for the spine, is the dose - above roughly 600 METs-minutes there is no further bone gain.
Starting late-preterm resuscitation at 30% oxygen changed nothing that was measured first
No reason to change the initial FiO2 you use at 32 to 35 weeks - the primary outcome was flat and both approaches were safe.
Ask when each drug was started, not just what the patient takes
Ask when each drug was started and what prompted it; sequence is the information a medication list omits and the only way to see a cascade.
Twenty-four prescribing cascades worth recognising by name
Before treating a new symptom in an older patient, look at what was prescribed in the previous three months - and check it against the named cascades.
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