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Despite the abundant evidence of impairments to plant performance and survival under hotter-drought conditions, little is known about the vulnerability of reproductive organs to climate extremes. Here, by conducting a comparative analysis between flowers and leaves, we investigated how variations in key morphophysiological traits related to carbon and water economics can explain the differential vulnerabilities to heat and drought among these functionally diverse organs. Due to their lower construction costs, despite having a higher water storage capacity, flowers were more prone to turgor loss (higher turgor loss point; ΨTLP) than leaves, thus evidencing a trade-off between carbon investment and drought tolerance in reproductive organs. Importantly, the higher ΨTLP of flowers also resulted in narrow turgor safety margins (TSM). Moreover, compared to leaves, the cuticle of flowers had an overall higher thermal vulnerability, which also resulted in low leakage safety margins (LSM). As a result, the combination of low TSMs and LSMs may have negative impacts on reproduction success since they strongly influenced the time to turgor loss under simulated hotter-drought conditions. Overall, our results improve the knowledge of unexplored aspects of flower structure and function and highlight likely threats to successful plant reproduction in a warmer and drier world.

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OBJECTIVES: Important differences in Stage I non-small-cell lung cancer (NSCLC) are related to the delay in the diagnosis to the treatment, hospitals' specialised status, comorbidities, tumour stage and histological type. METHODS: A 19-year retrospective cohort study was conducted, including 681 patients with NSCLC in clinical-stage IA-IB. The variables analysed were gender, age, schooling, type of health care provider, type of treatment, period of 5-year treatment, the time between first attendance to diagnosis and the time between diagnosis and treatment, and hospital's specialised status. RESULTS: Patients who underwent radiotherapy alone had three times more risk of death than those who underwent surgery alone (adjusted hazard ratio [adjHR] = 3.44; 95% confidence interval [CI]: 2.45-4.82; p <0.001). The independent risk of death factors was being treated in nonhigh complexity centres in oncology hospitals and having started the treatment more than 2 months after diagnosis (adjHR = 1.80; 95% CI: 1.26-2.56; p <0.001) and (adjHR = 2.00; 95% CI: 1.33-3.00; p <0.001), respectively. In addition, the patients diagnosed between 2011 and 2015 had a 40% lower risk of death when compared to those diagnosed between 2000 and 2005 (95% CI: 0.38-0.94; p = 0.027). CONCLUSION: The overall survival in curative intent Stage-I lung cancer patients' treatment was associated with the 5-year diagnosis group, the delayed time between diagnosis and treatment and the hospital qualification.

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INTRODUCTION: Nowadays the majority of the surgical procedures are video surgeries. Despite technological advances, some problems remain. The buildup of residues in front of the lens is an example of this problem. To solve it, Abreu et al. (Surg Technol Int 26:43-47, 2015) developed LacrimaSurg, which works as a lacrimal duct in the optics preventing fogging and residues buildup on it. This had 98.1% of efficiency in an experimental study. OBJECTIVE: Study feasibility and safety of the device under real surgical conditions. MATERIALS AND METHODS: A pilot study included 30 patients undergoing thoracic procedures using LacrimaSurg. Procedures were recorded for further analysis by investigators. The characteristics of patients (age, sex, body mass index, Charlton comorbidity index), data of environment (Temperatures variances), and data of procedures (type of surgery and duration of it) were recorded. The investigators watched the videos and recorded the residue buildup and fogging events that impaired surgeon's vision. The number of times the optics got dirty, need for further jets of crystalloid solution, and need for mechanical cleaning were collected to evaluate efficacy. Comparative serum measurements of electrolytes before and after surgery were studied. Data were organized and analyzed by simple linear correlations and t test for continuous variables and Fisher's test for categorical variables. RESULTS: The use of the device allowed 97% of the procedures to be performed without interruption. No characteristics inherent to the patients or to the procedures that lead to fogging or filth of the optics were identified. There were no statistically significant differences between pre- and postoperative serum ions, and no postoperative complications related to the use of the device were observed. CONCLUSION: The device was effective in preventing interruption of surgical procedures due to dirt or fogging, its use was considered safe, and did not cause postoperative complications.

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PURPOSE: This real-life cohort of patients describes the treatment patterns and compares the overall survival (OS) and hazard risk of utilization of multiple therapies. MATERIALS AND METHODS: Electronic medical registries of patients with stage III non-small-cell lung cancer (NSCLC) regularly attended in 72 hospitals were included. Univariate and multivariate analyses were conducted to evaluate the primary patients' characteristics leading to better OS and cancer-specific survival. RESULTS: A total of 3,363 patients with stage III NSCLC followed over 19 years were included in this study. The median age was 66.00 (58.00-72.00) years, 65% male, and 41.2% with squamous cell carcinoma followed by adenocarcinoma (34.6%) and undifferentiated carcinoma (13.1%) in clinical stage T3 (50.3%), T2 (29.3%), and T4 (12.3%). The median survival (in months) was 18.4 (95% CI, 16.9 to 19.5) in patients submitted to radiotherapy plus chemotherapy, 11.2 (95% CI, 10.5 to 12.1) to chemotherapy, 31.5 (95% CI, 25.9 to 37.7) to surgery plus chemotherapy, and 33.8 (95% CI, 28.3 to 47.8) to chemotherapy plus radiotherapy plus surgery. The median cancer-specific survival (in months) was 19.3 (95% CI, 17.9 to 20.9) in patients submitted to radiotherapy plus chemotherapy, 12.1 (95% CI, 11.1 to 12.9) to chemotherapy, 36.9 (95% CI, 29.6 to 43.2) to surgery plus chemotherapy, and 41.3 (95% CI, 32.1 to 61.3) to chemotherapy plus radiotherapy plus surgery. The patients treated with multiple chemotherapy plus radiotherapy followed by surgery had significantly better OS and lower mortality rates than those treated with other treatments (adjusted hazard ratio, 0.55; 95% CI, 0.45 to 0.66; P < .001). At the end of the study, 11.2% and 10.7% of the patients were living with and without cancer, respectively. CONCLUSION: Our real-life 19-year cohort study has shown that only 30.3% of the total patients with stage III NSCLC have been submitted to standard chemotherapy and radiotherapy treatment. This may show a substantial difference between the recruited clinical trials' patients and the real-life patients' characteristics in daily routine treatment.

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BACKGROUND: In Low-Middle Income Countries (LMICs), resource optimization and infrastructure availability are recurrently in debate. In order to assist the development and implementation of guidelines, LMICs often exemplify from High-Income Countries protocols. At the final, it will be: content adaption is often needed. In this study, we demonstrated the preliminary analysis of the Brazilian experience by adapting the ERAS® Protocol for thoracic surgery patients (PROSM). METHODS: Patients' data were extracted from the surgical group database that operated in the city of Sao Paulo. Patients' data were organized for analysis after the institution's ethics committee gave their approval. Patients' variables were analyzed and compared to a control group. Subgroup analysis included patients without ICU Admission. RESULTS: PROSM patients had reduced ICU length of stay (LOS) (Mean of 0.3±0.58 days, 1.2±1.65 days, P=0.001), Hospital LOS (Mean of 1.6±1.32 days, 3.9±3.25 days, P=0.001) and Chest Drain duration (Median 1.0±1.00 days, 3.0±3.00 days, P=0.001). Analyses of patients that were not admitted to the ICU demonstrated reduced Hospital LOS and Chest drain duration. Cost analysis, such as procedure, daily, and post-surgical costs were also significantly lower towards PROSM group. CONCLUSIONS: This study revealed important aspects for improvement of the delivered care quality and opportunity for expenditure management. We expect to assist more countries to improve knowledge under the implementation of enhanced protocols.

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BACKGROUND: It is known that survival from lung cancer can differ between countries and even between different regions of the same country. The variability between hospitals, the age and social profile, and the time when this patient was treated, can influence survival, and these factors are intrinsic to each region. Knowing the profile of patients, hospitals, and other factors associated with the treatment of stage I and II lung cancer in a given region is important to understand outcomes and propose improvements that can be replicated in any region of the world that presents the same profile of patients and care structure. This study evaluates survival and possible predictors in all patients with stage I and II lung cancer adenocarcinoma through the Hospital's Cancer Registry (HCR), responsible for the State of Sao Paulo's cancer registry, a geographical area with 40 million inhabitants. METHODS: Based on the HCR, an observational study was conducted, including 1,278 patients diagnosed with lung adenocarcinoma at clinical stages (CS) I and II. Sex, age at diagnosis, education, neighbourhood, CS at diagnosis, the time between diagnosis and treatment, 5-year periods in which patients were treated, treatment modality and hospitals where patients were treated were analysed. Cox univariate and multiple regression analyses were used to estimate the hazard ratio (HR). RESULTS: A total of 1,278 lung cancer patients with clinical lung cancer adenocarcinoma stages I and II were included. About 40.06% of patients did not receive surgery, and only 55.8% started the treatment within 2 months. The majority of the patients were treated in high complexity hospitals, 69%. Five-year overall survival (OS) was 45.6% in CS I and 27.5% in CS II. Patients treated in high complexity centres have lower mortality rates than those treated in Partial Hospital Complexity Centers in Oncology (PHCCO) (adjHR 1.18; 95% CI: 1.00-1.40; P=0.047). Patients diagnosed between 2010-2014 had a protective factor against the risk of death concerning patients diagnosed between 2000-2004. CONCLUSIONS: The 5-year OS has significantly improved as long as the 5-year group analysed. Also, the 5-year OS of the patients treated in high complexity hospitals is higher than those treated in PHCCO.

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BACKGROUND: It is known that malignant pleural effusion (MPE) recurs rapidly, in a considerable number of patients. However, some patients do not have MPE recurrence. Since MPE is associated with an average survival of 4-7 months, accurate prediction of prognosis may help recognize patients at higher risk of pleural recurrence, aiming to individualize more intensive treatment strategies. METHODS: A prospectively assembled database of cases with pleural effusion treated at a single institution analyzed a subset of patients with symptomatic MPE. Prognostic factors for pleural recurrence were identified by univariable analysis using Kaplan-Meier method and the log-rank test was used for the comparison between the curves. Univariate and multiple Cox regression models were used to evaluate the risk (HR) of recurrence. Receiver operating characteristics (ROC) analysis determined the cutoff points for continuous variables. RESULTS: A total of 288 patients were included in the analysis. Recurrence-free survival was of 76.6% at 6 months and 73.3% at 12 months. Univariable analysis regarding factors affecting postoperative recurrence was: lymphocytes, platelets, pleural procedure, chemotherapy lines and number of metastases. The independent factors for recurrence-free survival were pleural procedure and chemotherapy lines. Patients who were submitted to pleurodesis had a protective factor for recurrence, with an HR =0.34 (95% CI, 0.15-0.74, P=0.007). On the other hand, patients submitted to the 1st and 2nd line of palliative CT had, respectively, an HR risk = 2.81 (95% CI, 1.10-7.28, P=0.034) and HR =3.23 (95% CI, 1.33-7.84, P=0.010). CONCLUSIONS: patients receiving the first or second line of systemic treatment have a higher risk of MPE recurrence when compared to patients who underwent MPE treatment before starting the systemic treatment. The definitive treatment of MPE, such as pleurodesis, was associated with a lower risk of MPE recurrence.

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BACKGROUND: A malignant pleural effusion (MPE) in patients with cancer is evidence of the underlying disease progression, resulting in many symptoms, and may lead to hospitalization. The treatment options include talc pleurodesis (TP) or the implantation of an indwelling pleural catheter. The costs of the latter approach are often seen to be inhibitive for the Brazilian and other emerging markets' public health system. OBJECTIVES: To assess the feasibility of utilizing a low-cost device (LunGO) through a case-control study. METHODS: Eighteen patients with recurrent neoplastic pleural effusion and contraindications to pleurodesis were recruited between June 2016 and November 2017. The patients were submitted to pleural catheter prototype implantation. Data on the underlying disease and hospital length of stay after the procedure were collected and compared with patients who underwent pleurodesis in the same period (control group, n = 34). RESULTS: In the LunGO group, 7 patients died due to the natural evolution of the underlying disease with the drain, whereas it was removed in 11 patients at a median of 43 days. Recurrence requiring an intervention was seen with the LunGO in 2, compared to 5 (OR = 1.37, p = 1) with TP. Complications were observed in only 1 with the LunGO, compared to 5 with TP. The chances of recurrence in both cohorts do not have a statistically significant difference, with an OR = 1.08 (p = 0.93). There was a tendency towards lower mortality in the LunGO cohort, despite that fact that we did not observe statistical significance (OR = 0.16, p = 0.23). CONCLUSION: LunGO was shown to be a viable and safe device for the treatment of symptomatic MPE.

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BACKGROUND: The aim of this study is to evaluate the interaction between treatment delay and stage on the mortality from non-small cell lung cancer (NSCLC). METHODS: We performed a survival analysis in a cohort of patients admitted to the reference cancer center. The following data were collected: age, gender, smoking status, tumor staging, type of lung cancer, and time from the date when the patient was diagnosed with cancer to the starting date of effective treatment. Univariable and multivariable Cox proportional hazard models were used to investigate the association between potential confounders identified during the study design. After the final adjusted model was determined, tests for interaction among all predictors were performed. RESULTS: Inclusion criteria were met by 359 patients. In the adjusted analysis, delayed treatment delivery was a protective factor for the risk of death, with a crude hazard ratio (HR) =0.75 (0.59-0.97; P=0.02) and an adjusted HR =0.59 (0.46-0.77; P<0.001). However, a statistically significant interaction with mortality was observed between timely treatment and tumor stage. Patients with stage II disease who received delayed treatment had a higher risk of death [HR =3.08 (1.05-9.0; P=0.04)]. On the other hand, stage IV patients who received delayed treatment had a 52% reduction in mortality [HR =0.48 (0.35-0.66; P<0.001)]. CONCLUSIONS: Stage of disease influenced the association between start of the treatment and mortality, and only the subgroup of stage II patients seemed to benefit from early treatment.

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INTRODUÇÃO: A cirurgia torácica pode causar uma série de complicações pulmonares após o processo cirúrgico. O momento e a circunstância ideais para sedestação fora do leito e suas implicações clínicas, após cirurgias no tórax, ainda necessitam de padronização. Assim, faz-se necessário um tratamento de mobilização precoce adequado visando minimizar as complicações no período pós-operatório. OBJETIVOS: Objetivamos avaliar o efeito do atendimento fisioterapêutico no pós-operatório imediato de pacientes submetidos à cirurgia torácica. MATERIAIS E MÉTODOS: Este será um ensaio clínico randomizado, no qual um grupo de pacientes submetidos às cirurgias de ressecções pulmonares eletivas (segmentectomias, lobectomias ou pneumonectomias) com idade superior a dezoito anos receberão atendimento fisioterapêutico através do PROSM. Serão excluídos os pacientes incapazes de assinar o termo de consentimento livre esclarecido, com performance status comprometido (ECOG superior à 2), com peso corporal inferior à 60 Kg ou superior à 120 Kg, com alergia a qualquer uma das drogas utilizadas na anestesia, portadores de disfunção renal, disfunção hepática (Child B e C) e Insuficiência Cardíaca (classe Funcional III e IV). O instrumento de classificação do grau da dor por meio da Escala Visual Analógica (EVA) e instrumento de classificação da independência funcional por meio da Escala MIF (medida de independência funcional) serão aplicados antes do início e após o término de cada sessão de fisioterapia. Também será analisado o número de sessões de cada paciente e o tempo de internação. Para análise estatística será utilizado o programa SPSS Statistics e o teste de Shapiro-Wilk será usado para identificar a normalidade dos dados coletados. Espera-se um menor tempo de internação e melhor independência funcional na alta hospitalar nos pacientes submetidos ao PROSM. [AU]

INTRODUCTION: Thoracic surgery can cause a series of pulmonary complications after the surgical procedure. The ideal timing and circumstance for out-of-bed sedation and its clinical implications, after chest surgeries, still require standardization. Thus, an appropriate early mobilization treatment is necessary in order to minimize complications in the postoperative period. OBJECTIVES: We aimed to evaluate the effect of physical therapy care in the immediate postoperative period of patients undergoing thoracic surgery. METHODS AND MATERIALS: This will be a randomized clinical trial in which a group of patients undergoing elective pulmonary resections (segmentectomies, lobectomies or pneumonectomies) aged over eighteen years will receive physiotherapeutic care through PROSM. Patients under the age of eighteen years, unable to sign the informed consent form, with compromised performance status (ECOG greater than 2), with a body weight below 60 kg or greater than 120 kg, with a history of allergy to any of the drugs used in anesthesia, patients with renal dysfunction, liver dysfunction (Child B and C) and Heart Failure (Functional class III and IV). The instrument of classification of pain grade by means of the Visual Analogue Scale (EVA) and instrument of classification of functional independence by means of the MIF Scale (functional independence measure) will be applied before the beginning and after the end of each physiotherapy session. We will also analyze the number of sessions of each patient and the length of hospital stay. For statistical analysis, the SPSS Statistics program will be used and the Shapiro-Wilk test will be used to identify the normality of the data collected. It is expected a shorter hospitalization time and better functional independence at hospital discharge in patients submitted to PROSM. [AU]

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