The edition · Top Clinical Updates
Tuberculosis and lung nodules back to first principles, and immunotherapy moves into resectable gastric cancer
Two clinical reviews worth an hour of anyone's time, a pig kidney that kept a patient off dialysis for 271 days, and a phase 3 survival result that changes the perioperative standard.
The edition in brief
Two practical reviews lead: tuberculosis, still the world's leading infectious cause of death and now rising in high-income settings, where confirmation needs smear, nucleic acid amplification and culture together and treatment runs four to nine months under drug sensitivity testing; and pulmonary nodules, where management turns on solid versus subsolid, on comparison with old imaging, and on the two-year stability rule that applies to solid nodules but not subsolid ones. In 4,804 adults with Down syndrome across seven cohorts, epilepsy rose steeply once Alzheimer's disease became symptomatic, from a cumulative 9.5% at diagnosis to 56.9% nine years later, and late-onset myoclonic epilepsy carried a doubled mortality (hazard ratio 2.10, 95% CI 1.57 to 2.82) with faster cognitive decline; interictal EEG was of little diagnostic help. A first-in-human report describes a gene-edited porcine kidney that gave one patient 271 days free of dialysis before thrombotic microangiopathy forced nephrectomy, with no porcine pathogen transmission, no change in anti-HLA antibodies, and a successful human transplant 82 days later. The practice-changer is MATTERHORN: in 948 patients with resectable gastric or gastro-oesophageal junction adenocarcinoma, adding perioperative durvalumab to FLOT chemotherapy improved overall survival, hazard ratio 0.78 (95% CI 0.63 to 0.96), establishing a new standard treatment option and a new reason to discuss oncology referral before surgery rather than after it.
Tuberculosis, reviewed for clinicians who do not see it every week
Send all three microbiological tests, isolate on suspicion rather than confirmation, and take responsibility for contact screening rather than delegating it onwards.
The pulmonary nodule on someone else's scan
Before acting on any incidental nodule, get the old scans and establish whether it is solid or subsolid — those two steps determine everything that follows.
Epilepsy in Down syndrome rises steeply once dementia becomes symptomatic
In an adult with Down syndrome and symptomatic dementia, ask about myoclonic jerks at every review and diagnose clinically — a normal EEG does not settle it.
271 days off dialysis on a pig kidney, then a human transplant that worked
Nothing to act on — but if a patient asks about pig kidneys, the honest answer is now 271 days of function in one person, ended by a rejection mechanism that is not yet understood.
The old scan is the test you already have
Before investigating anything described as new, spend two minutes establishing whether it is actually new.
Perioperative durvalumab improves survival in resectable gastric cancer
A patient with newly diagnosed resectable gastric or gastro-oesophageal junction adenocarcinoma should reach medical oncology before they reach a surgical date.
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