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BackgroundThe incidence and mortality of colorectal cancer (CRC) are increasing among the young. Adenoma detection, removal and subsequent endoscopic surveillance may modify the risk of CRC before 50 years of age. This study aims to evaluate the situation of colorectal adenoma detection in Filipino patients less than 50 years of age.MethodsThis is a retrospective, descriptive study with 6211 patients less than 50 years of age who underwent colonoscopy. The endoscopy databank from January 1, 2010 until December 31, 2020 of the Institute of Digestive and Liver Diseases of St. Luke’s Medical Center Global City was used to identify cases and obtain data for this study.ResultsOverall, 6211 less than 50 years of age were included in this study. The mean age of the cohort was 43 years old; 58% were males. Family history of colorectal cancer was present in 34.8%. Asymptomatic screening was the main indication for colonoscopy.Overall, 2103 patients (33.9%) were found to have polyps. Hyperplastic polyps were the most common (25.1%), followed by adenomas (9%). Fourteen patients who were found to have hyperplastic polyp were also found to have concomitant adenomas. Advanced neoplasm was seen in 252 patients (4.1%), with 23 of these patients having concomitant adenomas.Polyps and advanced neoplasm were more likely seen among those aged 40–49 (60.1%). Among those with polyps in the 40–49 age group, hyperplastic polyps and adenomas were most common (42% and 14.1%, respectively). Advanced neoplasms were also most common in the 40–49 age group (14.1%).Polyps are more frequent in males (39.3%) compared to females. Hyperplastic polyps and advanced neoplasms were likewise common in males (26.4% and 4.4%, respectively). Adenomas were more common in females (9.3%).ConclusionsWith the limitations of this study, we found that the overall prevalence of adenomas and advanced neoplasm among those aged less than 50 years to be 9% and 4.1% respectively. Increasing age and sex were associated with the development of adenomas. More research on risk factors, including whether detection, removal, and surveillance of adenomas in the young have the potential to impact early-onset colorectal cancer incidence and mortality.

The dense outflow through Denmark Strait is the largest contributor to the lower limb of the Atlantic meridional overturning circulation, yet a description of the full velocity field across the strait remains incomplete. Here we analyze a set of 22 shipboard hydrographic–velocity sections occupied along the Látrabjarg transect at the Denmark Strait sill, obtained over the time period 1993–2018. The sections provide the first complete view of the kinematic components at the sill: the shelfbreak East Greenland Current (EGC), the combined flow of the separated EGC, and the North Icelandic Jet (NIJ), and the northward-flowing North Icelandic Irminger Current (NIIC). The total mean transport of overflow water is 3.54 ± 0.29 Sv (1 Sv ≡ 10 6 m 3 s −1 ), comparable to previous estimates. The dense overflow is partitioned in terms of water mass constituents and flow components. The mean transports of the two types of overflow water—Atlantic-origin Overflow Water and Arctic-origin Overflow Water—are comparable in Denmark Strait, while the merged NIJ–separated EGC transports 55% more water than the shelfbreak EGC. A significant degree of water mass exchange takes place between the branches as they converge in Denmark Strait. There are two dominant time-varying configurations of the flow that are characterized as a cyclonic state and a noncyclonic state. These appear to be wind-driven. A potential vorticity analysis indicates that the flow through Denmark Strait is subject to symmetric instability. This occurs at the top of the overflow layer, implying that the mixing/entrainment process that modifies the overflow water begins at the sill.

Previously, results from the TheraP trial showed that treatment with lutetium-177 [177Lu]Lu-PSMA-617 improved frequency of prostate-specific antigen (PSA) response rate and progression-free survival compared with cabazitaxel in men with metastatic castration-resistant prostate cancer. In this study, we aimed to analyse gallium-68 [68Ga]Ga-PSMA-11 PET (PSMA-PET) and 2-[18F]fluoro-2-deoxy-D-glucose PET (FDG-PET) imaging parameters as predictive and prognostic biomarkers in this patient population. TheraP was a multicentre, open-label, randomised phase 2 trial that recruited men with metastatic castration-resistant prostate cancer after treatment with docetaxel who were suitable for cabazitaxel from 11 hospitals in Australia. Participants were required to be 18 years old or older; have adequate haematological, renal, and liver function; and an Eastern Cooperative Oncology Group performance status of 0–2. Participants were randomly assigned (1:1) using a centralised system using minimisation with a random component and that stratified patients by disease burden, previous treatment with enzalutamide or abiraterone, and study site. Patients were either given cabazitaxel (20 mg/m2 intravenously every 3 weeks for up to ten cycles) or [177Lu]Lu-PSMA-617 (6·0–8·5 GBq intravenously every 6 weeks for up to six cycles). The primary study endpoint, analysed previously, was PSA response rate. The prespecified tertiary study endpoint was association between total tumour quantitative parameters on PSMA-PET, FDG-PET, and baseline characteristics with clinical outcomes. A SUVmean of 10 or higher on PSMA-PET was evaluated as a predictive biomarker for response to [177Lu]Lu-PSMA-617 versus cabazitaxel. A metabolic tumour volume (MTV) of 200 mL or higher on FDG-PET was tested as a prognostic biomarker. Both cutoff points were prespecified. The analysis was intention-to-treat, using logistic regression. This trial is registered with ClinicalTrials.gov, NCT03392428. 200 patients were randomly assigned between Feb 6, 2018, and Sept 3, 2019. 101 men were assigned to the cabazitaxel group and 99 were assigned to the [177Lu]Lu-PSMA-617 group. The median follow-up at data cutoff of July 20, 2020, was 18·4 months (IQR 12·8–21·8). 35 (35%) of 99 men who were assigned [177Lu]Lu-PSMA-617 and 30 (30%) of 101 men who were assigned cabazitaxel had high PSMA uptake (SUVmean of ≥10). Odds of PSA response to [177Lu]Lu-PSMA-617 versus cabazitaxel were significantly higher for men with SUVmean of 10 or higher compared with those with SUVmean of less than 10 (odds ratio [OR] 12·19 [95% CI 3·42–58·76] vs 2·22 [1·11–4·51]; padj=0·039 for treatment-by-SUVmean interaction). PSA response rate for [177Lu]Lu-PSMA-617 compared with cabazitaxel was 32 (91% [95% CI 76–98]) of 35 men versus 14 (47% [29–65]) of 30 men in patients with SUVmean of 10 or higher, and 33 (52% [39–64]) of 64 men versus 23 (32% [22–45]) of 71 men in those with SUVmean of less than 10. High-volume disease on FDG-PET (MTV ≥200 mL) was seen in 30 (30%) of 99 men who were assigned [177Lu]Lu-PSMA-617 and 30 (30%) of 101 men who were assigned cabazitaxel. PSA response rate for both treatment groups combined for FDG-PET MTV of 200 mL or higher versus FDG-PET MTV of less than 200 mL was 23 (38% [95% CI 26–52]) of 60 men versus 79 (56% [48–65]) of 140 men (OR 0·44, 95% CI 0·23–0·84; padj=0·035). In men with metastatic castration-resistant prostate cancer, PSMA-PET SUVmean was predictive of higher likelihood of favourable response to [177Lu]Lu-PSMA-617 than cabazitaxel, which provides guidance for optimal [177Lu]Lu-PSMA-617 use. High FDG-PET MTV was associated with lower responses regardless of randomly assigned treatment, warranting further research for treatment intensification. A strength of this analysis is the validation of pre-specified cutpoints within a multicentre, randomised, controlled trial. Quantitative PET parameters used, however, require specialised software and are not yet routinely available in most clinics. Prostate Cancer Foundation of Australia, Endocyte (a Novartis Company), Australian Nuclear Science and Technology Organisation, Movember Foundation, It's a Bloke Thing, CAN4CANCER, The Distinguished Gentleman's Ride.

Bispecific T-cell Engagers (BITEs) are a novel form of immunotherapy that overcome a deficiency of immune checkpoint inhibitors (ICI) by targeting a preidentified tumor associated antigen and redirecting a polyclonal population of effector T-cells against the tumor. High grade serous ovarian cancer is a lethal disease in the recurrent setting and has not been amenable to ICI therapy. MUC16/CA125 is overexpressed in high grade serous ovarian cancer. BITEs targeting the tumor-retained portion of MUC16/CA125 have recently been described and are in early-phase clinical trials. To identify mechanisms of resistance to BITEs, we collected serum, peripheral blood mononuclear cells, and ascites samples from patients with disease progression on MUC16-directed bispecific antibodies. Analysis of these samples showed downregulation of MUC16/CA125, elevated secretion of VEGF, and epithelial-to-mesenchymal transition in tumor cells. Interestingly, hypoxia was determined to be a driver of these changes. These findings were prospectively validated in ovarian cancer cell lines with CRISPR/Cas9 knockout of MUC16/CA125 and VEGF. Peripheral blood mononuclear cells from patients with disease progression were capable of effective cytolysis ex vivo, suggesting that resistance to therapy was primarily tumor driven. Restoration of MUC16/CA125 expression did not restore cytotoxicity in the presence of increased VEGF secretion. Combination treatment with a VEGF inhibitor rescued cytotoxicity in hypoxia-conditioned ovarian cancer cell lines with preserved target antigen expression. Collectively, these data outline a link between hypoxia and the development of resistance to BITEs and posits inhibition of VEGF inhibition as a potentially important therapeutic intervention.

ObjectiveThere is a lack of standardisation in the terminology used to describe gout. The aim of this project was to develop a consensus statement describing the recommended nomenclature for disease states of gout.MethodsA content analysis of gout-related articles from rheumatology and general internal medicine journals published over a 5-year period identified potential disease states and the labels commonly assigned to them. Based on these findings, experts in gout were invited to participate in a Delphi exercise and face-to-face consensus meeting to reach agreement on disease state labels and definitions.ResultsThe content analysis identified 13 unique disease states and a total of 63 unique labels. The Delphi exercise (n=76 respondents) and face-to-face meeting (n=35 attendees) established consensus agreement for eight disease state labels and definitions. The agreed labels were as follows: ‘asymptomatic hyperuricaemia’, ‘asymptomatic monosodium urate crystal deposition’, ‘asymptomatic hyperuricaemia with monosodium urate crystal deposition’, ‘gout’, ‘tophaceous gout’, ‘erosive gout’, ‘first gout flare’ and ‘recurrent gout flares’. There was consensus agreement that the label ‘gout’ should be restricted to current or prior clinically evident disease caused by monosodium urate crystal deposition (gout flare, chronic gouty arthritis or subcutaneous tophus).ConclusionConsensus agreement has been established for the labels and definitions of eight gout disease states, including ‘gout’ itself. The Gout, Hyperuricaemia and Crystal-Associated Disease Network recommends the use of these labels when describing disease states of gout in research and clinical practice.

The progression of Parkinson’s disease (PD) is associated with microstructural alterations in neural pathways, contributing to both motor and cognitive decline. However, conflicting findings have emerged due to the use of heterogeneous methods in small studies. Here we performed a large diffusion MRI study in PD, integrating data from 17 cohorts worldwide, to identify stage-specific profiles of white matter differences. Diffusion-weighted MRI data from 1654 participants diagnosed with PD (age: 20–89 years; 33% female) and 885 controls (age: 19–84 years; 47% female) were analyzed using the ENIGMA-DTI protocol to evaluate white matter microstructure. Skeletonized maps of fractional anisotropy (FA) and mean diffusivity (MD) were compared across Hoehn and Yahr (HY) disease groups and controls to reveal the profile of white matter alterations at different stages. We found an enhanced, more widespread pattern of microstructural alterations with each stage of PD, with eventually lower FA and higher MD in almost all regions of interest: Cohen’s d effect sizes reached d  = −1.01 for FA differences in the fornix at PD HY Stage 4/5. The early PD signature in HY stage 1 included higher FA and lower MD across the entire white matter skeleton, in a direction opposite to that typical of other neurodegenerative diseases. FA and MD were associated with motor and non-motor clinical dysfunction. While overridden by degenerative changes in the later stages of PD, early PD is associated with paradoxically higher FA and lower MD in PD, consistent with early compensatory changes associated with the disorder.

In the future, powerful AI systems may be deployed in high-stakes settings, where a single failure could be catastrophic. One technique for improving AI safety in high-stakes settings is adversarial training, which uses an adversary to generate examples to train on in order to achieve better worst-case performance. In this work, we used a safe language generation task (``avoid injuries'') as a testbed for achieving high reliability through adversarial training. We created a series of adversarial training techniques -- including a tool that assists human adversaries -- to find and eliminate failures in a classifier that filters text completions suggested by a generator. In our task, we determined that we can set very conservative classifier thresholds without significantly impacting the quality of the filtered outputs. We found that adversarial training increased robustness to the adversarial attacks that we trained on -- doubling the time for our contractors to find adversarial examples both with our tool (from 13 to 26 minutes) and without (from 20 to 44 minutes) -- without affecting in-distribution performance. We hope to see further work in the high-stakes reliability setting, including more powerful tools for enhancing human adversaries and better ways to measure high levels of reliability, until we can confidently rule out the possibility of catastrophic deployment-time failures of powerful models.