Nature Physics

Delamination within stratified epithelia like the skin epidermis describes the detachment and upward motion of cells originating from the basal layer. Despite its fundamental importance for tissue development, homeostatic regeneration and repair, the mechanisms that drive delamination remain a longstanding open question. Upward motion follows cell shape changes, which are inherently driven by physical forces, but their role is elusive. Here, we investigate delamination in stratifying keratinocytes by combining imaging, force measurements and theoretical modeling. We identify a local change in force balance between differentiating cells and their environment as the key step initiating delamination. Within a homogeneous cell layer with apically polarized contractility, differentiation leads to actomyosin remodeling, redistributing cellular force exertion to the basal side. Such mechanical heterogeneity then results in differentiating cells experiencing and inward basal and outward apical forces that manifest in the formation of a +1 force defect and promote shape changes culminating in upward motion. Simultaneously, delaminating cells actively pull on their underlying neighbors, generating convergent tissue flows which close the basal layer below. Together, we propose a general physical description of delamination initiation, which may act across various multilayered epithelia.

Cell shape changes during migration, division, or differentiation require the dynamic regulation of actin network mechanics. Actin crosslinkers are central to this regulation, controlling network connectivity and the transmission of contractile forces. A large diversity of crosslinkers exists, differing in length, domain structure, and binding kinetics, yet why cells deploy specific crosslinkers in a physiological context remains unclear. To bridge this gap, we developed a light-controlled actin crosslinker toolbox spanning three physiologically relevant lengths: ~9 nm (fascin-like), ~16 nm (fimbrin-like), and ~56 nm (alpha-actinin-like). Using magnetic pincher experiments and in silico modelling, we show that short and mid-length crosslinkers dynamically tune cortical stiffness and thickness in a density- and myosin-dependent manner, with short crosslinkers also driving pronounced stress-stiffening as the cortex is deformed. Strikingly, minute-scale activation reveals a length-dependent switch in cell behaviour: short crosslinkers cause cortical delamination, while long ones instead drive cell polarization and symmetry breaking. This switch can be overridden by perturbing actin turnover, which unlocks polarization in mid-length crosslinkers that otherwise delaminate. Crosslinker-induced polarization is not merely a local cortical event: it directs subsequent cell spreading, coupling a nanometre-scale molecular choice to a cell-scale decision about movement. Together, these findings establish a versatile optogenetic platform for manipulating actin crosslinking, and show that the cortex can encode a behavioural switch directly in its material architecture.

Biological aging is accompanied by systematic changes in epigenetic modifications and chromatin organization. The reversal of the effects of aging, rejuvenation, is experimentally achieved by the transient induction of factors that modify these marks in cells and organisms. Here, we show that key features of rejuvenation experiments emerge from the biophysical interplay between dynamic epigenetic marks and the three-dimensional conformation of chromatin. Using a minimal field theory and molecular dynamics simulations, we show that the system responds in three distinct temporal regimes. The intermediary regime fulfills necessary conditions for successful rejuvenation. In this regime, the system spends time near a separatrix, allowing for high epigenetic plasticity, while memory retained in the chromatin conformation enables restoration of the original epigenetic correlations. Analysis of sequencing data further supports the predicted coupling between chromatin compaction and epigenetic correlations. Our results provide a physical explanation for how rejuvenation may remodel age-associated epigenetic states without irreversibly erasing cellular identity. We identify a general mechanism by which memory stored in a slow structural variable permits reversible remodeling of a faster internal state.

Radiation-induced DNA double-strand breaks (DSBs) drive cellular mortality, mutagenesis, and severe evolutionary bottlenecks. While classical phenomenological models, such as the Linear-Quadratic (LQ) framework, reliably predict macroscopic population survival, they obscure the intrinsic single-cell stochasticity that governs critical rare events like tumor recurrence or the emergence of radioresistant persisters. To bridge this divide, we develop a mathematically exact stochastic differential equation (SDE) framework that models continuous DSB induction and repair as a Feller square-root process. By deriving exact closed-form expressions for the foci moments, we establish a highly efficient Maximum Likelihood Estimation (MLE) pipeline that circumvents computationally exhaustive Monte Carlo simulations, allowing the direct extraction of deterministic repair velocities and intrinsic molecular noise from empirical single-cell $\gamma$-H2AX data. Integrating this kinetic model with a cumulative damage hazard via the Feynman-Kac formalism, our framework seamlessly recovers the classic macroscopic LQ survival topology from microscopic first principles. Furthermore, systematic sensitivity analysis uncovers a fundamental evolutionary duality: while initial physical damage operates additively, ultimate cellular fate is driven by a nonlinear survival response governed by the trade-off between the damage hazard rate and intrinsic molecular noise strength. Crucially, we demonstrate that this molecular noise inherently enhances population survival. Governed by Jensen's inequality, stochastic variance acts as a non-genetic bet-hedging mechanism that buffers the population by favoring cells with transiently low damage loads. Ultimately, this exact stochastic framework bridges microscopic biophysics and macroscopic demographics, offering deep mechanistic insights into the evolutionary roots of radioresistance.

Focal adhesions maintain force-bearing attachment between cells and the extracellular matrix but can also undergo dynamic remodeling. Their assembly and actomyosin tension are coupled through mechanochemical feedback. The processes underlying this feedback are not instantaneous and therefore involve a time delay. However, how this delayed feedback gives rise to stable adhesion maintenance or dynamic remodeling remains unclear. Here, paired time-lapse measurements of vinculin fluorescence and traction stress revealed distinct local adhesion-force dynamics, including low-fluctuation and recurrent fluctuation patterns. To examine how these patterns could arise, we formulated a minimal mechanochemical model coupling focal adhesion assembly and actomyosin force through delayed reciprocal feedback. The model exhibited stable and oscillatory modes depending on feedback strength, the balance of opposing feedback effects, and the effective feedback delay. Bistability and hysteretic switching also occurred in a subset of parameter space, and the oscillation period followed a power-law relation with the delay. These results suggest that stable adhesion maintenance and dynamic remodeling can emerge from a common mechanochemical feedback architecture.

Single-cell technologies have generated cell censuses of tissues, however, how tissue geometry reflects functional needs remains poorly characterized. The human pilosebaceous unit offers a tractable model, a prenatally-formed complex mini-organ combining hair and sebum production with a stem cell reservoir. Using histomorphology, spatial transcriptomics, and single-cell multiomics on the same human prenatal scalp skin samples (8-19 post-conception weeks), integrated and analyzed using machine learning approaches, we built a spatiotemporal map of pilosebaceous unit development. We demonstrate that epithelial-mesenchymal interactions coordinate cellular fate and organogenesis, using an in vitro hair-bearing skin organoid model to validate this tissue-patterning. In addition, we show sebaceous gland developmental programmes are overcome during tumor formation. Our large-scale multi-modal analysis provides a unique framework for understanding form and function of tissues with applications in tissue engineering and pathology.

Biomolecular condensates (BMCs) organize cellular biochemistry by concentrating selected molecules into dynamic membrane-free compartments. Yet the molecular parameters that determine not only whether condensates form, but also how they behave and what they do, remain poorly defined. Here we show that scaffold binding affinity (Kd) is a quantitative determinant of condensate phase behavior, internal dynamics and biochemical output. Using a modular SUMO-SIM system in which scaffold valency was held constant while binding affinity was systematically varied, we found that affinity governs the phase boundary, resistance to chemical perturbation, and molecular mobility of condensates in vitro and in human cells. In multicomponent mixtures, the highest-affinity scaffold dominated dense-phase composition and dynamics, revealing a hierarchical rule for condensate organization. Finally, affinity-dependent changes in condensate dynamics translated into tunable enzyme activity, establishing binding energetics as an engineerable parameter for programming condensate biochemistry.

Cell motility drives spatial pattern formation across diverse biological systems. Here, we engineer Escherichia coli motility in semi-solid agar to control Voronoi patterns in two and three dimensions, partitioning space into regions closest to their respective inoculation seeds. Consistent with our reaction-diffusion model, we observed that collisions between expansion fronts generate either biomass depletion (''gaps'') or accumulation (''anti-gaps''), governed by the relative diffusion rates of bacteria and nutrients. By engineering strains with distinct expansion rates and tuneable motility, and by integrating these experimental data into a dynamic Voronoi model, we achieved precise control over pattern geometry. This enabled the generation of gaps with varying widths, curved boundaries, asymmetric structures, seedless regions, and complex composite patterns. Together, these findings establish bacterial Voronoi patterns as a programmable platform for engineering multicellular spatial organization, with potential applications in synthetic biology and materials science.

Many biological processes rely on mechanical forces, with protein molecules acting as key mediators. Understanding how proteins respond to mechanical stress is essential for conditions including cardiomyopathy and muscular dystrophy. Natural proteins such as dystrophin and utrophin are composed of heterogeneous folding domains with distinct mechanical properties; deciphering domain-level behavior provides insights into disease mechanisms and informs therapeutic strategies. Single-molecule force spectroscopy (SMFS) enables probing the mechanical properties of entire proteins, yet current approaches struggle to identify heterogeneous folding domains, particularly without prior knowledge. Here, we present the first automated framework to identify heterogeneous folding domains in SMFS data, applying both existing clustering methods and a novel physics-aware deep clustering architecture, LatentUnfold. LatentUnfold learns complementary latent representations from force magnitude and the force-extension physical relationship through dual autoencoders, jointly optimized for clustering assignments. We apply our framework to experimental SMFS data collected from a synthetic two-domain protein (ddFLN4-Titin I27) as well as natural protein constructs of dystrophin and utrophin, with Monte Carlo simulated datasets serving as controlled validation. For the synthetic protein, we recover mechanical properties consistent with previously reported values for each domain. For the natural proteins, we uncover two mechanically distinct domain populations - corresponding to the N-terminal domain and spectrin-like repeats - with differences in both unfolding force and contour length increase, and reveal different unfolding order between them for the first time. This work enables domain-level biological inference, overcoming prior limitations that relied on averaging and overlooked heterogeneity, thus advancing the understanding of mechanical behavior in protein unfolding.

In linear polysomes, excluded-volume interactions among ribosomes can induce dimensional reduction of mRNA. Yet linear architectures allow steric stress to relax at open ends-- limiting how strongly crowding can remodel the mRNA's structure and dynamics. Using coarse-grained molecular-dynamics simulations, we compare circular and linear polysomes over a range of ribosome densities. Circular closure selects a predominantly quasi-planar global conformational ensemble, as indicated by a shape dimensionality dshape {approx} 2 over a range of ribosome densities. Crucially, circular topology and ribosome crowding act cooperatively to suppress structural fluctuations. While closure alone or linear crowding reduces relative global size fluctuations ({Delta}Rg/Rg) only to {approx} 0.16, their combined effect drives this fluctuation down to {approx} 0.07. Within this stabilized architecture, increasing ribosome density drives a distinct in-plane reorganization: the ring becomes more isotropic, global size fluctuations are strongly suppressed, and the scaling exponent increases toward {nu} [~=] 0.74 - 0.77, consistent with two-dimensional self-avoiding walk-like value over the accessible finite-size window, 1000 [≤] N [≤] 4969. Closure shortens the radius-of-gyration decorrelation time of circular polysomes by 40-fold relative to matched linear systems, reflecting the topological elimination of free ends. Within this closureselected ensemble, ribosome crowding further reduces the decorrelation time by up to 20% at the highest density. A fluctuation-informed crossover model links the density dependence of the global scaling exponent to inter-ribosomal subchain statistics. These results distinguish the geometric role of circular closure from the density-dependent steric response that it enables, revealing a confined yet dynamically responsive conformational regime for circular polysomes.

Genomic instability is a major driver of tumor evolution, promoting diversification and adaptation while simultaneously increasing the accumulation of deleterious alterations. How tumor populations balance these opposing effects remains poorly understood. Here, we introduce a computational framework that explicitly represents diploid genomes, functional gene classes, point mutations, and chromosome-segregation errors in spatially constrained and well-mixed tumor populations. We identify a viability boundary separating sustained tumor expansion from instability-induced population collapse. Within the viable regime, mutation and selection generate a stable distribution of genomic-instability classes that is accurately captured by an analytical replicator--mutator description. Near the viability boundary, tumor dynamics exhibit prolonged extinction transients and strong sensitivity to stochastic fluctuations, with important differences between solid and liquid architectures. Chromosomal alterations further modify growth by creating transient benefits through increased gene dosage and genetic redundancy, while ultimately increasing genomic fragility. Finally, simulated interventions show that eliminating low-instability subpopulations or increasing the global mutational burden can displace tumors beyond their viability boundary and trigger irreversible collapse. These results identify genome instability as both an evolutionary advantage and an intrinsic vulnerability, providing a quantitative framework for developing therapies that exploit the limits of tumor evolution.

Spatial-omics workflows enable molecular analysis within tissue spatial context. Despite the prognostic value of tissue stiffness, these approaches have not incorporated direct, mechanical measurements. This omission reflects several challenges, including sample requirements, low throughput, specialized equipment, and complex data registration. Here, we introduce mechanoMaST (mechanics mapped to spatial transcriptomics), the first workflow to combine absolute mechanical measurements with spatial-omics. It pairs atomic force microscopy-based nanoindentation stiffness maps with spatial transcriptomics maps from adjacent tissue cryosections. The two modalities are then computationally co-registered to enable direct spatial correlation at 100 um resolution, with mapping accuracy quantified through error propagation, providing ground-truth mechanical data directly linked to spatial gene expression. We demonstrate mechanoMaST in human colorectal cancer liver metastasis, generating a spatial resource from 10 patients and revealing a four-gene stiffness signature. mechanoMaST is readily adaptable to other tissues across development and disease, and extendable to additional spatial-omics modalities in adjacent sections.

The symbiosis with photosynthetic dinoflagellate algae enables corals to build and sustain reef ecosystems. Individual coral polyps hold algal symbionts in their epithelial endoderm cells and lose them under environmental stress, leading to coral bleaching. How the host integrates symbionts into its body plan is not well understood. Here, using a combination of high-resolution imaging, quantitative analysis, and environmental perturbations in the sea anemone Exaiptasia diaphana (Aiptasia) and reef-building coral Pocillopora damicornis, we uncover a spatial organisation of symbionts along the aboral-oral axis of cnidarian polyps that emerges under the long-range translocation of symbionts between host cells through a fluid-filled cavity. The symbiont distribution becomes specifically enriched in the tentacle bud endoderm during Aiptasia polyp morphogenesis. This pattern can form in darkness and with algae-sized inert spheres, suggesting an innate host-intrinsic mechanism. Symbiont-occupied host cells are mechanically constrained within the endoderm and thus unable to rearrange; instead, they go through cycles of symbiont expulsion and re-uptake via the host gastric cavity, with regionally biased rates of these behaviours providing a route to enrich symbionts in the tentacles. Symbiont organisation is remodelled under increased light in adult coral polyps, with a characteristic pattern of reduced tentacle enrichment, lateral clustering and retention in the body column emerging over a timescale of days. Together, our findings reveal that the spatial organisation of symbionts is dynamically regulated in cnidarian host tissues, a capacity that may shape both the establishment of symbiosis and its resilience under environmental change.

Living organisms must sense and adapt to physiological demands of varying intensity, requiring cells to remain responsive over time. While continuous changes in hormone concentrations communicate these demands, sustained stimulation desensitizes signaling, protecting cells from overstimulation but potentially blunting future responses. How cells preserve responsiveness remains unclear. Using epinephrine, a major mediator of stress responses, we show that natural ultradian oscillations provide a solution. Oscillatory, but not constant, hormone enabled receptor resensitization when hormone levels fell, preserving alertness to subsequent stress and tunability across intensities. Furthermore, oscillation supported coordinated responses among diverse cell types by more consistently maintaining responsiveness across hormone concentrations and receptor kinetics. Oscillations thus provide a general strategy by which endocrine systems retain protective desensitization while preserving responsiveness to future physiological demands.

Background Childhood respiratory mortality in China has fallen by over 90% in three decades alongside sustained national warming, yet national long-run evidence on temperature and child respiratory mortality is lacking. Methods We linked Global Burden of Disease (GBD) 2021 mortality estimates for China - lower respiratory infections (LRI), ages 0-19, and asthma, ages 0-24, 1990-2021 - with C-LSAT 0.5 deg gridded temperature data (1990-2019), aggregated nationally and to five climate zones. Four annual indicators (mean temperature, diurnal temperature range, seasonal amplitude, interannual variability) entered regressions of log mortality rates with Newey-West standard errors. A bootstrapped (500 resamples) quadratic model probed the minimum mortality temperature (MMT), with PM2.5-adjusted analyses and future-exposure, permutation, and detrended falsification tests. Results LRI deaths fell by 96.3% (330,194 in 1990 to 12,098 in 2021; 95% uncertainty interval 9,669-14,891) and asthma deaths by 94.9% (3,287 to 167), while mean temperature rose 0.364 deg C per decade and diurnal temperature range narrowed 0.092 deg C per decade. Baseline coefficients were large (mean temperature -1.696, SE 0.174; diurnal temperature range +2.408, SE 0.336; seasonal amplitude -0.162, SE 0.082; interannual variability +2.924, SE 1.514, per 1 deg C in log rate), but the future-exposure test failed and detrending nullified every coefficient: the associations are trend-level, and short-cycle causal effects are not identifiable. Nor was the national MMT identifiable - observed temperature support spans only 6.66-8.13 deg C, and the nominal turning point of 35.84 deg C is an extrapolation artifact (quadratic term p = 0.963). Within the observed range, warming and declining mortality moved in the same direction. Conclusions The 96% decline in childhood respiratory mortality cannot be attributed to warming. China sits on the low-temperature side of the optimum, and the marginal direction of future warming requires stronger designs to establish. The falsification framework offers a discipline for climate-health inference in China.

Importance Non-inferiority trials are becoming increasingly popular in abdominal surgery. The non- inferiority margin is critical in the interpretation and conclusion of these trials. Objective This systematic review aims to assess the methodological and reporting quality of non- inferiority randomized controlled trials in abdominal surgery. Evidence Review Non-inferiority trials were systematically identified by searching Ovid Medline, Embase and the CENTRAL databases from 2006 until December 2025. Randomized controlled trials in adult patients with any type of abdominal surgical intervention in at least one trial arm and a sample size greater than or equal to 100 were eligible for inclusion. The primary outcome was the definition of the non- inferiority margin. Secondary outcomes were the reporting of the non-inferiority margin, the robustness of its estimation, the uncertainty of the point estimate and the adequacy of conclusions. Findings A total of 11 045 trials were identified, of which 101 were eligible, enrolling 44 370 patients. Most trials provided a rationale for the non-inferiority design, while six (5.9%) trials did not. Previous literature was commonly used (n=56; 55.4%), but the non-inferiority margin was most often based on a clinical fixed margin or on historical comparison of the treatment and the active comparator. Based on the margin, investigators tolerated substantially worse outcomes of the treatment compared to the comparator. Conclusions were appropriate based on the confidence interval and the predefined non- inferiority margin in 88 (87.1%) of trials. The clinical judgement of the conclusion was overall adequate. Confidence interval estimations were reported in 16 (15.8%) of trials. Simulation studies were limited by the reporting quality. Conclusions and Relevance Clinical fixed margins are commonly used in abdominal surgery non-inferiority randomized controlled trials, however, substantial shortcomings in reporting limit the interpretability and reproduction of study findings. Based on the findings of this study, guidance on surgical- specific non-inferiority margin definitions is needed.

Background In adults, cold-attributable mortality exceeds heat-attributable mortality roughly 17-fold. Child-specific evidence has begun to emerge only recently - a nationwide Brazilian case-crossover study located the minimum mortality temperature (MMT) for under-five deaths, and a 56-country survey-based analysis linked monthly temperature anomalies to under-five mortality - but no multi-country, climate-zone-resolved estimate of the childhood respiratory-infection MMT exists, and whether temperature variability is independently associated with childhood respiratory mortality at the global scale is unknown. We quantified both. Methods We combined Global Burden of Disease 2023 mortality estimates, lower respiratory infection (LRI) deaths at ages 0-19 years and asthma deaths at ages 0-24 years, 171 countries, 1990-2023 - with 0.5 deg monthly land temperature and diurnal temperature range (DTR) fields from C-LSAT/C-LDTR (1901-2023). Four exposure dimensions (annual mean, DTR, seasonal amplitude, interannual variability) entered two-way fixed-effects models with Driscoll-Kraay standard errors. A quadratic term in mean temperature located the MMT, with percentile confidence intervals from a 300-replication country-cluster bootstrap. Future-exposure leads, country-level detrending, and permutation tests assessed contemporaneous causality, applied to both the linear coefficients and the quadratic term generating the MMT; national pneumococcal conjugate vaccine (PCV3) coverage and ambient PM2.5 exposure series were added as time-varying mechanistic covariates. Results The childhood LRI MMT was 17.1 C (95% CI 14.7-19.8), the 36th percentile of the annual-temperature distribution; zone estimates were 24.7 C in tropical and 15.8 C in subtropical countries, with weak temperate and no subarctic identification. The quadratic term underpinning the MMT, however, failed both falsification checks - future temperatures reproduced the U-shape and country-level detrending erased it - so these MMT values describe a trend-level geographic pattern of the annual construct rather than a contemporaneous dose-response. Interannual temperature variability was positively associated with LRI (+0.278, 95% CI 0.102-0.454; p = 0.002) and asthma mortality (+0.836, 95% CI 0.447-1.226; p = 2.6 x 10^-5) per 1 C, but future-exposure models returned nearly identical significant coefficients and detrending erased significance, supporting only a trend-level association; adjustment for national PCV3 coverage and PM2.5 exposure left these estimates essentially unchanged. Annual mean temperature was likewise inversely associated with both outcomes at the trend level; DTR and seasonal amplitude showed no independent within-country effects. Conclusions This study provides the first multi-country, climate-zone-resolved geography of the optimal temperature for childhood respiratory survival, spanning 171 countries; because the underlying quadratic association is trend-level, the estimates are directional. The observed variability-mortality associations are trend-level signals rather than contemporaneous causal evidence; daily-scale, child-specific designs are required to determine whether short-term thermal variability affects paediatric respiratory mortality.

Abstract Objective: Glaucoma is a chronic disorder that impairs ocular health and may exacerbate ocular surface disease leading to tear film instability, dry eye symptoms and decreased quality of life. This study compared changes in tear quantity among glaucoma subjects living with and without diabetes mellitus, attending an eye clinic in Nigeria. Methods: A comparative cross sectional research design was used. 157 subjects which comprised 74 glaucoma subjects living with diabetes mellitus and 83 glaucoma subjects living without diabetes mellitus participated in the study. Tear quantity assessment included the Schirmer I test and tear meniscus height (TMH) measurement. Descriptive statistics, independent samples t-test and Chi-square test were used to examine the data at 0.05 level of significance. Results: Glaucoma subjects living with diabetes mellitus showed substantially decreased tear production (11.4 +/- 6.8 mm) compared with glaucoma subjects living without diabetes mellitus (19.6 +/- 9.6 mm; p < 0.001). Tear meniscus height in glaucoma subjects living with diabetes mellitus (0.8 +/- 0.3 mm) was significantly greater than in subjects living without diabetes mellitus (0.7 +/- 0.3 mm; p = 0.034). Conclusion: Diabetes mellitus dramatically deteriorates the ocular surface function in glaucoma subjects by decreasing tear production, altering the tear meniscus height and increasing the severity of ocular surface symptoms. Routine glaucoma care, especially in patients with diabetes mellitus, should include a full ocular surface evaluation including Schirmer I test, TBUT, TMH, and OSDI assessment to allow early detection and management of ocular surface disease, better treatment adherence, and improved visual outcomes. Keywords: Glaucoma, Diabetes Mellitus, Tear production, Tear Meniscus Height, Ocular Surface Disease.

Inadequate autophagy promotes smoking-induced cellular senescence involved in chronic obstructive pulmonary disease (COPD) pathogenesis. Transcription factor EB (TFEB) is a master regulator of the autophagy-lysosome axis. For the first time, we investigated the therapeutic potential of pemafibrate, a putative TFEB inducer. COPD lung epithelial cells showed reduced TFEB expression. Pemafibrate enhanced autophagy/mitophagy flux and restored lysosomal acidification observed during cigarette smoke (CS) extract exposure in human bronchial epithelial cells, resulting in reduced cellular senescence. TFEB knockdown demonstrated involvement of pemafibrate-induced TFEB in these effects. Pemafibrate induced TFEB expression, mitigated alveolar enlargement and airflow obstruction, and attenuated the CS-induced increase in static lung compliance in a long-term CS-exposed mouse model. It reduced the CS exposure-induced cellular senescence, possibly through autophagy/mitophagy, as suggested by bulk RNA sequencing of mouse lungs. A retrospective cohort study showed that patients given pemafibrate displayed attenuated FEV1.0 decline compared with those given bezafibrate or fenofibrate. In conclusion, pemafibrate is a promising therapeutic agent for COPD, potentially exerting its effects through the regulation of the TFEB-autophagy/mitophagy-lysosome axis.

Background: Prostate cancer enzalutamide treatment is approved at a standard dose of 160 mg daily. Concerns for real-world patients -- older and more fragile than those enrolled in clinical trials -- have prompted consideration of initiating treatment with lower doses, but the long-term efficacy of this approach remains unknown. We evaluate the long-term survival and longevity in patients treated with standard versus upfront low-dose enzalutamide. Methods: Retrospective analysis of 151 patients treated with enzalutamide (102 receiving 160 mg; 49 receiving [&le;]80 mg) between 2014--2021 at the Centre Hospitalier Universitaire de Martinique, with complete follow-up through end of life (98.7% completeness of follow-up). Primary outcomes were overall survival (OS), progression-free survival (PFS), and longevity (attained age). Results: Doses [&le;]80 mg were associated with longer median OS (36.3 vs. 20.7 months), improved restricted mean OS (difference of 0.7 years, p=0.05), and enhanced longevity (median 82.5 vs. 78.3 years, p=0.004). PSA response rate at 12 weeks was higher with lower-dose (71.4% vs. 48.8%, p=0.016). In multivariable models adjusted for prognostic factors, [&le;]40 mg compared with 160 mg was non-inferior regarding OS (HR=0.61, 95% CI 0.36--1.06), superior regarding PFS (HR=0.59, 95% CI 0.35--0.99), and superior regarding longevity (HR=0.48, 95% CI 0.28--0.84). Bone metastasis, poor performance status, PSA response, time to PSA nadir, and disease duration were independent predictors of outcomes. A post-hoc analysis revealed a strong association between dose and physician-prescribing profiles, ranging from "endorse-lowest-dose" to "never-deviate-from-full-dose". Conclusions: Lower doses of enzalutamide were non-inferior to full-dose. Dose-adapted strategies warrant further investigation.