Surgical decisions in older women with early breast cancer: patient and disease factors.

BACKGROUND: Studies reporting lower rates of surgery for older women with early invasive breast cancer have focused on women with oestrogen receptor (ER)-positive tumours. This study examined the factors that influence receipt of breast surgery in older women with ER-positive and ER-negative early invasive breast cancer . METHODS: Women aged 50 years or above with unilateral stage 1-3A early invasive breast cancer diagnosed in 2014-2017 were identified from linked English and Welsh cancer registration and routine hospital data sets. Logistic regression analysis was used to evaluate the influence of tumour and patient factors on receipt of surgery. RESULTS: Among 83 188 women, 86.8 per cent had ER-positive and 13.2 per cent had ER-negative early invasive breast cancer. These proportions were unaffected by age at diagnosis. Compared with women with ER-negative breast cancer, a higher proportion of women with ER-positive breast cancer presented with low risk tumour characteristics: G1 (20.0 versus 1.5 per cent), T1 (60.8 versus 44.2 per cent) and N0 (73.9 versus 68.8 per cent). The proportions of women with any recorded co-morbidity (13.7 versus 14.3 per cent) or degree of frailty (25 versus 25.8 per cent) were similar among women with ER-positive and ER-negative disease respectively. In women with ER-positive early invasive breast cancer aged 70-74, 75-79 and 80 years or above, the rate of no surgery was 5.6, 11.0 and 41.9 per cent respectively. Among women with ER-negative early invasive breast cancer, the corresponding rates were 3.8, 3.7 and 12.3 per cent. The relatively lower rate of surgery for ER-positive breast cancer persisted in women with good fitness. CONCLUSION: The reasons for the observer differences should be further explored to ensure consistency in treatment decisions.

Endoscopic vein harvesting in lower extremity arterial bypass: a systematic review.

OBJECTIVE: Endoscopic vein harvesting (EVH) for arterial bypass surgery may be associated with lower wound complication rates than open vein harvesting (OVH), but other long-term outcomes remain controversial, and there are concerns that graft patency may be poorer after EVH compared with OVH. We conducted a systematic review of all available evidence for EVH in lower extremity arterial bypass (LEAB). METHODS: A literature search of Medline, Embase, Ovid and Cochrane databases between 1996 and 2013 was performed using the terms "endoscopic vein harvesting", "minimally invasive vein harvest", "peripheral bypass surgery", and "lower extremity bypass surgery", and detailed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Primary outcomes were graft patency and overall wound complication rates. Secondary outcomes were wound infection, length of hospital stay, and cost-effectiveness. Summary estimates were calculated by random effects meta-analysis if sufficient data were available. RESULTS: We identified 18 cohort studies and case series, with considerable clinical heterogeneity, including 2,343 patients. Meta-analysis of six studies revealed a significantly reduced rate of primary patency after EVH (hazard ratio 1.29, 95% confidence interval [CI] 1.03-1.63), with no significant difference between EVH and OVH with respect to wound infection in 12 studies (odds ratio 0.81, 95% CI 0.61-1.08). There was a lack of strong evidence to support the secondary outcomes of EVH. CONCLUSION: EVH reduces primary patency rates after LEAB, but does not demonstrate an advantage with respect to postoperative wound complications. However, the available data are heterogeneous, and uncertainty is introduced by both evolution in technology and increasing technical experience. EVH should be used with caution and in the context of formal research.

The anti-dopaminergic agent, haloperidol, antagonises the feminising effect of neonatal serotonin on sexually dimorphic hypothalamic nuclei and tyrosine hydroxylase immunoreactive neurones.

There is a transient fall in hypothalamic serotonin (5-hydroxytryptamine; 5-HT) activity in the second week post partum in male but not female rats. When this fall is masked by administration of the 5-HT(2) agonist (-) 2,5-dimethoxy-4-iodophenyl]-2-aminopropane hydrochloride [(-)DOI], over days 8-16 post partum, males are feminised in adulthood. To investigate whether the effect of 5-HT is mediated by dopamine and whether testosterone exerts its masculinising effect by reducing 5-HT and dopamine activity, male pups were treated with (-)DOI alone or together with the dopamine antagonist, haloperidol, over days 8-16 post partum, whereas females were treated with testosterone propionate on day 2 post partum. In adulthood, the volumes of the anteroventral periventricular nucleus (AVPV), sexually dimorphic nucleus of the preoptic area (SDN-POA) and arcuate nucleus (ARC) were determined, together with the number of tyrosine hydroxylase-immunoreactive (TH-ir) cells and fibres within them. The concentrations of 5-HT, dopamine and their metabolites were also measured. (-)DOI treatment increased the volume of the AVPV, decreased that of the SDN-POA and increased the number of TH-ir cells in the AVPV. These feminising effects were antagonised by concurrent haloperidol treatment. Neonatal testosterone propionate masculinised the volumes of the female AVPV and SDN-POA and reduced the number of TH-ir cells in the AVPV. Dopamine and 5-HT turnover in the AVPV was greater in female compared to male rats and neonatal testosterone propionate reduced dopamine concentration in the female AVPV. Neonatal (-)DOI had no effect on dopamine and 5-HT activity in the AVPV but increased both in the ARC. The findings that TH-ir neurone number and dopamine activity are greater in the female AVPV; the feminising effect of 5-HT is prevented by a haloperidol; and the masculinising effect of testosterone propionate is accompanied by a decrease in TH-ir neurone number and dopamine concentration in the female AVPV, suggest that dopamine is involved in hypothalamic sexual differentiation and may mediate the effect of 5-HT.