A specialized population of monocyte-derived tracheal macrophages promote airway epithelial regeneration through a CCR2-dependent mechanism.

Macrophages are critical for maintenance and repair of mucosal tissues. While functionally distinct subtypes of macrophage are known to have important roles in injury response and repair in the lungs, little is known about macrophages in the proximal conducting airways. Single-cell RNA sequencing and flow cytometry demonstrated murine tracheal macrophages are largely monocyte-derived and are phenotypically distinct from lung macrophages at homeostasis. Following sterile airway injury, monocyte-derived macrophages are recruited to the trachea and activate a pro-regenerative phenotype associated with wound healing. Animals lacking the chemokine receptor CCR2 have reduced numbers of circulating monocytes and tracheal macrophages, deficient pro-regenerative macrophage activation and defective epithelial repair. Together, these studies indicate that recruitment and activation of monocyte-derived tracheal macrophages is CCR2-dependent and is required for normal airway epithelial regeneration.

Graph attention-based fusion of pathology images and gene expression for prediction of cancer survival.

Multimodal machine learning models are being developed to analyze pathology images and other modalities, such as gene expression, to gain clinical and biological insights. However, most frameworks for multimodal data fusion do not fully account for the interactions between different modalities. Here, we present an attention-based fusion architecture that integrates a graph representation of pathology images with gene expression data and concomitantly learns from the fused information to predict patient-specific survival. In our approach, pathology images are represented as undirected graphs, and their embeddings are combined with embeddings of gene expression signatures using an attention mechanism to stratify tumors by patient survival. We show that our framework improves the survival prediction of human non-small cell lung cancers, outperforming existing state-of-the-art approaches that leverage multimodal data. Our framework can facilitate spatial molecular profiling to identify tumor heterogeneity using pathology images and gene expression data, complementing results obtained from more expensive spatial transcriptomic and proteomic technologies.

In Salmonella enterica, the pathogenicity island 2 (SPI-2) regulator PagR regulates its own expression and the expression of a five-gene operon that encodes transketolase C.

The enteropathogen Salmonella enterica subsp. enterica sv. Typhimurium str. LT2 (hereafter S. Typhimurium) utilizes a cluster of genes encoded within the pathogenicity island 2 (SPI-2) of its genome to proliferate inside macrophages. The expression of SPI-2 is controlled by a complex network of transcriptional regulators and environmental cues, which now include a recently characterized DNA-binding protein named PagR. Growth of S. Typhimurium in low-phosphate, low-magnesium medium mimics conditions inside macrophages. Under such conditions, PagR ensures SPI-2 induction by upregulating the transcription of slyA, which encodes a known activator of SPI-2. Here, we report that PagR represses the expression of a divergently transcribed polycistronic operon that encodes the two subunits of transketolase TktC (i.e., tktD, tktE) of this bacterium. Transketolases contribute to the nonredox rearrangements of phosphorylated sugars of the pentose phosphate pathway, which provide building blocks for amino acids, nucleotides, cofactors, etc. We also demonstrate that PagR represses the expression of its own gene and define two PagR-binding sites between stm2344 and pagR.

Investigating the sequence landscape in the Drosophila initiator core promoter element using an enhanced MARZ algorithm.

The core promoter elements are important DNA sequences for the regulation of RNA polymerase II transcription in eukaryotic cells. Despite the broad evolutionary conservation of these elements, there is extensive variation in the nucleotide composition of the actual sequences. In this study, we aim to improve our understanding of the complexity of this sequence variation in the TATA box and initiator core promoter elements in Drosophila melanogaster. Using computational approaches, including an enhanced version of our previously developed MARZ algorithm that utilizes gapped nucleotide matrices, several sequence landscape features are uncovered, including an interdependency between the nucleotides in position 2 and 5 in the initiator. Incorporating this information in an expanded MARZ algorithm improves predictive performance for the identification of the initiator element. Overall our results demonstrate the need to carefully consider detailed sequence composition features in core promoter elements in order to make more robust and accurate bioinformatic predictions.

A systematic review of animal personality in conservation science.

Although animal personality research may have applied uses, this suggestion has yet to be evaluated by assessing empirical studies examining animal personality and conservation. To address this knowledge gap, we performed a systematic review of the peer-reviewed literature relating to conservation science and animal personality. Criteria for inclusion in our review included access to full text, primary research articles, and relevant animal conservation or personality focus (i.e., not human personality studies). Ninety-two articles met these criteria. We summarized the conservation contexts, testing procedures (including species and sample size), analytical approach, claimed personality traits (activity, aggression, boldness, exploration, and sociability), and each report's key findings and conservation-focused suggestions. Although providing evidence for repeatability in behavior is crucial for personality studies, repeatability quantification was implemented in only half of the reports. Nonetheless, each of the 5 personality traits were investigated to some extent in a range of conservations contexts. The most robust studies in the field showed variance in how personality relates to other ecologically important variables across species and contexts. Moreover, many studies were first attempts at using personality for conservation purposes in a given study system. Overall, it appears personality is not yet a fully realized tool for conservation. To apply personality research to conservation problems, we suggest researchers think about where individual differences in behavior may affect conservation outcomes in their system, assess where there are opportunities for repeated measures, and follow the most current methodological guides on quantifying personality.

Aunque la investigación sobre la personalidad animal puede tener usos aplicados, esta propuesta aún no ha sido evaluada mediante el análisis de estudios empíricos que examinan la personalidad animal y la conservación. Realizamos una revisión sistemática de la literatura revisada por pares relacionada con las ciencias de la conservación y la personalidad animal para abordar este vacío en el conocimiento. Los criterios para la inclusión dentro de nuestra revisión incluyen el acceso al texto completo, artículos de investigación primaria y un enfoque relevante en la conservación animal o en la personalidad (es decir, no estudios sobre la personalidad humana). Noventa y dos artículos cumplieron con estos criterios y de ellos resumimos los contextos de conservación, procedimientos de análisis (incluyendo el tamaño de la muestra y de la especie), estrategia analítica, características declaradas de la personalidad (actividad, agresión, audacia, exploración y sociabilidad) y los hallazgos más importantes de cada reporte y sus sugerencias enfocadas en la conservación. Aunque proporcionar evidencias para la repetitividad en el comportamiento es crucial para los estudios de personalidad, la cuantificación de la repetitividad sólo se implementó en la mitad de los reportes. Sin embargo, cada una de las cinco características de la personalidad se investigaron hasta cierto punto dentro de una gama de contextos de la conservación. Los estudios más sólidos en el campo mostraron varianza en cómo la personalidad se relaciona con otras variables de importancia ecológica a través de las especies y los contextos. Además, muchos estudios fueron los primeros intentos del uso de la personalidad con propósitos de conservación en un sistema dado de estudios. En general, parece que la personalidad todavía no es una herramienta completamente realizada para la conservación. Para poder aplicar la investigación sobre la personalidad a los problemas de conservación, sugerimos que los investigadores piensen en dónde pueden afectar las diferencias individuales en el comportamiento a los resultados de la conservación dentro de su sistema, evalúen en dónde hay oportunidades para repetir medidas y sigan las guías metodológicas más actuales sobre la cuantificación de la personalidad.

Fifty Years of Motor Unit Number Estimation.

The objective was to use bibliometric analysis to create an infographic of motor unit number estimation methods over the past 50 years. The original method was published in 1971, but secondary and tertiary waves of research using alternative methods occurred in the early 2000s and a decade later. A metric of influence was used to determine if different methods had clear peaks of use over the past 50 years. While the original method continues to register influence, the MUNIX method introduced in 2004 stands out as the most influential method to estimate the innervation status of skeletal muscles.

Automated detection of enteric tubes misplaced in the respiratory tract on chest radiographs using deep learning with two centre validation.

AIM: To develop and test a model based on a convolutional neural network that can identify enteric tube position accurately on chest radiography. MATERIALS AND METHODS: The chest radiographs of adult patients were classified by radiologists based on enteric tube position as either critically misplaced (within the respiratory tract) or not critically misplaced (misplaced within the oesophagus or safely positioned below the diaphragm). A deep-learning model based on the 121-layer DenseNet architecture was developed using a training and validation set of 4,693 chest radiographs. The model was evaluated on an external test data set from a separate institution that consisted of 1,514 consecutive radiographs with a real-world incidence of critically misplaced enteric tubes. RESULTS: The receiver operator characteristic area under the curve was 0.90 and 0.92 for the internal validation and external test data sets, respectively. For the external data set with a prevalence of 4.4% of critically misplaced enteric tubes, the model achieved high accuracy (92%), sensitivity (80%), and specificity (92%) for identifying a critically misplaced enteric tube. The negative predictive value (99%) was higher than the positive predictive value (32%). CONCLUSION: The present study describes the development and external testing of a model that accurately identifies an enteric tube misplaced within the respiratory tract. This model could help reduce the risk of the catastrophic consequences of feeding through a misplaced enteric tube.

Optimization of ovine bone decalcification for increased cellular detail: a parametric study.

There are many published methods of decalcifying bone for paraffin histology; however, the current literature lacks details regarding the processing of ovine tissue. Ovine bone tissue presents challenges, as samples are often denser and larger than other comparative animal models, thus increasing decalcification times. Trifluoroacetic Acid (TFAA) has previously been used to decalcify ovine bone samples for histological analysis. Unfortunately, TFAA is a strong acid and often results in loss of cellular detail, especially in the connected soft tissue. This is generally manifested as over staining with eosin, and a decrease in cellular features which impacts overall histological interpretation. It is well known that leaving tissue in acid for long periods degrades cellular detail; therefore, minimizing decalcification time is critical to accurately determine cellular morphology. Six decalcification solutions (8% TFAA, 20% TFAA, 8% formic acid, 20% formic acid, Formical-4, and XLCal, and three temperatures (room temperature, 30°C, 37°C), were examined to determine their effects on cellular detail in ovine vertebrae and humeral heads. These data clearly indicate that 20% formic acid at 30°C yielded better decalcification rates (2.6 d ± 0.9 d) and cellular detail (none to mild changes) for the vertebrae samples, and 20% formic acid at RT yielded the best cellular detail (none to minimal loss) for humerus samples with a moderate amount of time (6.5 d ± 1.7). These results should establish the optimal demineralization procedures for ovine bone used in scientific studies resulting in improved cellular detail while minimizing decalcification times.

Putting machine learning into motion: applications in cardiovascular imaging.

Heart and circulatory diseases cause a quarter of all deaths in the UK and cardiac imaging offers an effective tool for early diagnosis and risk-stratification to improve premature death and disability. This domain of radiology is unique in that assessing flow and motion is essential for understanding and quantifying normal physiology and disease processes. Conventional image interpretation relies on manual analysis but this often fails to capture important prognostic features in the complex disturbances of cardiovascular physiology. Machine learning (ML) in cardiovascular imaging promises to be a transformative tool and addresses an unmet need for patient-specific management, accurate prediction of future events, and the discovery of tractable molecular mechanisms of disease. This review discusses the potential of ML across every aspect of image analysis including efficient acquisition, segmentation and motion tracking, disease classification, prediction tasks and modelling of genotype-phenotype interactions; however, significant challenges remain in access to high-quality data at scale, robust validation, and clinical interpretability.

The impact of behavioural skills training on the knowledge, skills and well-being of front line staff in the intellectual disability sector: a clustered randomised control trial.

BACKGROUND: Staff with varying backgrounds and educational qualifications can be effectively trained to implement procedures in line with evidence-based practice. Behavioural skills training (BST) is a competency-based training model used to effectively educate a broad selection of professionals, including front line staff, in a range of work-related skills. However, BST has yet to be evaluated in a large group-based experiment. METHODS: This study involved a parallel cluster randomised control trial. Six service sites, with a total of 54 participants, were randomised to the intervention condition using the 'coin toss' method. The intervention condition used BST to coach intellectual disability staff in reinforcement, systematic prompting, functional communication training and task analysis. Six service sites, with a total of 50 participants, were also randomised to a control condition in which generalised training in behavioural interventions was restricted. Recruited service sites were randomly assigned to the intervention condition (N = 6, n = 54) or the control condition (N = 6, n = 50) at one point in time, immediately after recruitment and before baseline testing took place. Allocations were stratified by service type (residential or day) and geographical region. One member of the research team allocated service sites using the 'coin toss' method, and another member, blind to the allocations, decided which experimental arm would receive the intervention and which would be designated as control. It was not possible to mask the intervention from participants, but they were recruited prior to randomisation. RESULTS: Participants in the intervention condition demonstrated statistically significant improvements in their knowledge scores over the study period. Participants in the control condition showed no change or a statistically significant decrease in their knowledge scores. No statistically significant changes to well-being were observed for either group. There was clear evidence of knowledge maintenance, as well as skill acquisition and subsequent generalisation to the workplace environment, among participants in the intervention condition. Participants also evaluated the BST intervention positively. CONCLUSIONS: Results support BST as a method for disseminating evidence-based practice to front line staff working with adults with intellectual and developmental disabilities.

Memory Performance Influences Male Reproductive Success in a Wild Bird.

Despite decades of comparative research, how selection shapes the evolution of cognitive traits remains poorly understood [1-3]. Several lines of evidence suggest that natural selection acts on spatial memory in food-caching species [3-6]. However, a link between reproductive fitness and spatial memory ability has yet to be demonstrated in any caching species [1, 3, 6]. Here, we show that memory performance influences reproductive success differentially for males and females in a caching songbird, the New Zealand robin (Petroica longipes). Males' memory performance in a spatial task during winter influenced their subsequent breeding success; individuals with more accurate performance produced more fledglings and independent offspring per nesting attempt. Males with superior memory performance also provided an increased proportion of large prey items to chicks in the nest and spent less time flying while foraging and provisioning. No such effects were found for females. Previous research reveals that trade-offs may constrain selection and act to maintain variation in cognitive traits [7]. The gender dimorphism in the reproductive benefits of robin memory performance suggests an additional role for divergent selection between the sexes in constraining runaway selection on male memory ability [8], ultimately maintaining variation in this cognitive trait.

A biological model of scabies infection dynamics and treatment informs mass drug administration strategies to increase the likelihood of elimination.

Infections with Sarcoptes scabiei, or scabies, remain common in many disadvantaged populations. Mass drug administration (MDA) has been used in such settings to achieve a rapid reduction in infection and transmission, with the goal of eliminating the public health burden of scabies. While prevalence has been observed to fall substantially following such an intervention, in some instances resurgence of infection to baseline levels has occurred over several years. To explore the biology underpinning this phenomenon, we have developed a theoretical model of scabies life-cycle and transmission dynamics in a homogeneously mixing population, and simulate the impact of mass drug treatment strategies acting on egg and mite life cycle stages (ovicidal) or mites alone (non-ovicidal). In order to investigate the dynamics of the system, we first define and calculate the optimal interval between treatment doses. We calculate the probability of eradication as a function of the number of optimally-timed successive treatment doses and the number of years over which a program is run. For the non-ovicidal intervention, we first show that at least two optimally-timed doses are required to achieve eradication. We then demonstrate that while more doses over a small number of years provides the highest chance of eradication, a similar outcome can be achieved with fewer doses delivered annually over a longer period of time. For the ovicidal intervention, we find that doses should be delivered as close together as possible. This work provides a platform for further research into optimal treatment strategies which may incorporate heterogeneity of transmission, and the interplay between MDA and enhancement of continuing scabies surveillance and treatment strategies.

Identifying the optimal regional predictor of right ventricular global function: a high-resolution three-dimensional cardiac magnetic resonance study.

Right ventricular (RV) function has prognostic value in acute, chronic and peri-operative disease, although the complex RV contractile pattern makes rapid assessment difficult. Several two-dimensional (2D) regional measures estimate RV function, however the optimal measure is not known. High-resolution three-dimensional (3D) cardiac magnetic resonance cine imaging was acquired in 300 healthy volunteers and a computational model of RV motion created. Points where regional function was significantly associated with global function were identified and a 2D, optimised single-point marker (SPM-O) of global function developed. This marker was prospectively compared with tricuspid annular plane systolic excursion (TAPSE), septum-freewall displacement (SFD) and their fractional change (TAPSE-F, SFD-F) in a test cohort of 300 patients in the prediction of RV ejection fraction. RV ejection fraction was significantly associated with systolic function in a contiguous 7.3 cm2 patch of the basal RV freewall combining transverse (38%), longitudinal (35%) and circumferential (27%) contraction and coinciding with the four-chamber view. In the test cohort, all single-point surrogates correlated with RV ejection fraction (p < 0.010), but correlation (R) was higher for SPM-O (R = 0.44, p < 0.001) than TAPSE (R = 0.24, p < 0.001) and SFD (R = 0.22, p < 0.001), and non-significantly higher than TAPSE-F (R = 0.40, p < 0.001) and SFD-F (R = 0.43, p < 0.001). SPM-O explained more of the observed variance in RV ejection fraction (19%) and predicted it more accurately than any other 2D marker (median error 2.8 ml vs 3.6 ml, p < 0.001). We conclude that systolic motion of the basal RV freewall predicts global function more accurately than other 2D estimators. However, no markers summarise 3D contractile patterns, limiting their predictive accuracy.

Examination of the Effectiveness of a Brief, Adapted Dialectical Behavior Therapy-Skills Training Group for Bariatric Surgical Candidates.

BACKGROUND: Bariatric surgery is the most effective treatment for morbid obesity, yet 20 to 30% of such patients regain weight approximately 2 years post-surgery. A psychological intervention adjunctive to bariatric surgery that addresses eating pathology often observed in bariatric populations may improve outcomes. In the present study, a brief, adapted DBT-ST group for bariatric surgical candidates was evaluated as an adjunctive intervention to bariatric surgery in the pre-surgical period to reduce eating pathology and clinical impairment. METHODS: Participants included 95 bariatric surgery candidates, with 50 candidates in the DBT-ST plus treatment as usual (TAU) group and 45 candidates in the TAU (i.e., comparison) group. Participants completed measures of eating pathology at three time points (i.e., T1 = pre-DBT-ST program; T2 = post-DBT-ST program; T3 = 4 months post-DBT-ST; comparable time points employed for TAU group). Average wait time for surgery following the pre-surgical program was approximately 2 to 4 months. RESULTS: A series of 2 (group: DBT-ST + TAU versus TAU) × 3 (assessment time: T1, T2, and T3) mixed-model ANOVAs were completed. Participants in the DBT-ST plus TAU group showed significant reductions in binge eating, emotional eating, global eating pathology, and clinical impairment related to eating difficulties over time in comparison to TAU. CONCLUSIONS: Findings demonstrated that a brief DBT-ST group integrated as an adjunctive intervention to TAU in a bariatric pre-surgical program could aid in addressing eating pathology. Bariatric participants in a DBT-ST plus TAU group may be on a better weight loss trajectory than those who only receive TAU.

Computational study of aortic hemodynamics for patients with an abnormal aortic valve: The importance of secondary flow at the ascending aorta inlet.

Blood flow in the aorta is helical, but most computational studies ignore the presence of secondary flow components at the ascending aorta (AAo) inlet. The aim of this study is to ascertain the importance of inlet boundary conditions (BCs) in computational analysis of flow patterns in the thoracic aorta based on patient-specific images, with a particular focus on patients with an abnormal aortic valve. Two cases were studied: one presenting a severe aortic valve stenosis and the other with a mechanical valve. For both aorta models, three inlet BCs were compared; these included the flat profile and 1D through-plane velocity and 3D phase-contrast magnetic resonance imaging derived velocity profiles, with the latter being used for benchmarking. Our results showed that peak and mean velocities at the proximal end of the ascending aorta were underestimated by up to 41% when the secondary flow components were neglected. The results for helical flow descriptors highlighted the strong influence of secondary velocities on the helical flow structure in the AAo. Differences in all wall shear stress (WSS)-derived indices were much more pronounced in the AAo and aortic arch (AA) than in the descending aorta (DAo). Overall, this study demonstrates that using 3D velocity profiles as inlet BC is essential for patient-specific analysis of hemodynamics and WSS in the AAo and AA in the presence of an abnormal aortic valve. However, predicted flow in the DAo is less sensitive to the secondary velocities imposed at the inlet; hence, the 1D through-plane profile could be a sufficient inlet BC for studies focusing on distal regions of the thoracic aorta.

Attributes of excellent surgical trainers: An analysis of outstanding trainers.

Excellent surgical trainers play a key role in teaching, mentoring and inspiring the next generation of trainee surgeons. Although there are differences in approach, personality and technique among trainers, common themes exist for those that truly shine as examples of good training. The good surgical trainer has long been the "unsung hero" of patient safety, inspiring and imparting wisdom and skill in trainee surgeons, and instilling a sense of confidence and compassion. In order to recognise exceptional trainers, the Association of Surgeons in Training (ASiT) introduced the Silver Scalpel Award in 2000. The award acknowledges talented trainers who go the "extra mile" for their trainees, and the selection process includes both written nominations and structured interviews with the nominees. We wished to identify what makes the best trainers excellent, to see if these attributes could be used to develop recommendations on how to train and how to support trainers. Here we present an outline of key attributes of an excellent surgical trainer, based on qualitative synthesis of the interview sheets from Silver Scalpel interviews. These results clearly highlight that good trainers are first and foremost good doctors, and that good training goes hand-in-hand with excellent patient care. This symbiotic relationship between training and patient outcomes should be acknowledged, and trainers should be supported by their employers to empower them to carry out their dual roles of training and patient care to the best of their ability. Trainers are key role models to inspire the next generation of surgeons and exceptional trainers should be celebrated.

Diet-induced obesity causes visceral, but not subcutaneous, lymph node hyperplasia via increases in specific immune cell populations.

OBJECTIVES: The spatial proximity of adipose depots to secondary lymph nodes allows a unique relation between the two systems. Obesity, predominately visceral adiposity, links to numerous diseases; hence, we postulate that secondary lymphatics within this region contributes to disease risk. MATERIAL AND METHODS: Male C57BL/6 mice were fed standard CHOW (18% kcal fat) or Western diet (45% kcal fat) for 7 weeks. Visceral and subcutaneous lymph nodes and associated adipose depots they occupy were excised. Lymph node morphology and resident immune cell populations were characterized via histopathology, immunofluorescence and flow cytometry. Adipose tissue immune cell populations were also characterized. RESULTS: Obesity caused lymph node expansion, increased viable cell number and deviations in immune cell populations. These alterations were exclusive to visceral lymph nodes. Notably, pro-inflammatory antigen presenting cells and regulatory T cells increased in number in the visceral lymph node. Obesity, however, reduced T regulatory cells in visceral lymph nodes. The visceral adipose depot also had greater reactivity towards HFD than subcutaneous, with a greater percent of macrophages, dendritic and CD8+ T cells. Immune cell number, in both the visceral and subcutaneous, however decreased as adipose depots enlarged. CONCLUSION: Overall, HFD has a greater influence on visceral cavity than the subcutaneous. In the visceral lymph node, but not subcutaneous, HFD-induced obesity decreased cell populations that suppressed immune function while increasing those that regulate/activate immune response.

On the choice of outlet boundary conditions for patient-specific analysis of aortic flow using computational fluid dynamics.

Boundary conditions (BCs) are an essential part in computational fluid dynamics (CFD) simulations of blood flow in large arteries. Although several studies have investigated the influence of BCs on predicted flow patterns and hemodynamic wall parameters in various arterial models, there is a lack of comprehensive assessment of outlet BCs for patient-specific analysis of aortic flow. In this study, five different sets of outlet BCs were tested and compared using a subject-specific model of a normal aorta. Phase-contrast magnetic resonance imaging (PC-MRI) was performed on the same subject and velocity profiles extracted from the in vivo measurements were used as the inlet boundary condition. Computational results obtained with different outlet BCs were assessed in terms of their agreement with the PC-MRI velocity data and key hemodynamic parameters, such as pressure and flow waveforms and wall shear stress related indices. Our results showed that the best overall performance was achieved by using a well-tuned three-element Windkessel model at all model outlets, which not only gave a good agreement with in vivo flow data, but also produced physiological pressure waveforms and values. On the other hand, opening outlet BCs with zero pressure at multiple outlets failed to reproduce any physiologically relevant flow and pressure features.

Efficacy and Safety Results of the Afatinib Expanded Access Program.

INTRODUCTION: Afatinib is an oral, irreversible ErbB family blocker approved for first-line treatment of metastatic epidermal growth factor receptor (EGFR) mutation-positive non-small cell lung cancer (NSCLC). The expanded access program (EAP) allowed early access to afatinib and provided additional data on its safety, tolerability, and efficacy. METHODS: The afatinib EAP was an open-label, multicenter, single-arm program in the United States that treated and followed patients with locally advanced or metastatic NSCLC harboring EGFR mutations. Afatinib 40 mg was administered orally once daily until discontinuation due to disease progression, adverse events (AEs), or transition to commercially available drug. RESULTS: Three hundred twenty-two patients received ≥1 dose of afatinib. Most patients had received prior therapies. Drug-related AEs occurred in 89.4% of patients, including 7.8% with serious AEs. The most common afatinib-related AEs (all grades) were diarrhea (77.0%) and rash (36.0%). Dose reductions occurred in 31.1% of patients. Discontinuation rates due to diarrhea (1.6%) or rash/acne (0.3%) were low. Efficacy data were collected and analyzed when available, with 17.1% and 69.9% of patients achieving objective response and disease control, respectively, in this highly pretreated population. CONCLUSIONS: No additional or unexpected safety concerns were revealed, and afatinib demonstrated antitumor activity in a heavily pretreated NSCLC patient population in a routine clinical setting. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01649284. FUNDING: Boehringer Ingelheim Pharmaceuticals, Inc.