Monitors -- Bigger is Better

In the 80's, the newly-identified yuppie women were fond of saying "you can't be too rich, too thin, or own too many silk blouses." My computer version of that mantra is "you can't have too much RAM, too much bandwidth, or too big of a monitor." Notwithstanding the astonishing gains in processor speeds, I think those three things -- RAM, bandwidth, and monitor screen area -- have the greatest effect on productivity when working with electronic documents. Of those three, it's the monitor that has the greatest effect on our day-to-day "paperless offices."

People prefer paper -- no monitor can approach the resolution of laser toner on paper, and the lower resolution of electronic documents, along with glare and lighting issues, can add considerably to your fatigue. There are, however, things that can enhance your ability to work electronically.

First -- there is just no substitute for sheer screen area. The typical lawyer may have a 15" or 17" monitor attached to his PC. On that screen, you can see most of a single page of text -- whether it's a Word document or PDF. On a 17" monitor set to a screen resolution of 1280 x 1024 pixels, you can get two pages side by side, but the text is pretty darned small.

Look at it this way -- what if, instead of spreading books and papers out across your desk, you had to work on a single clipboard, on which you could see about two-thirds of only the topmost page? Any one of the many pages you must read can only be accessed by bringing it up to the top of the stack, where you can view two-thirds of it. How much would that slow you down? Yet we continue to work with such a system on our computer screens.

My PC at work has a 17" LCD -- it's okay. I use it because I have to. I've also used a 20" Hitachi, and a 21" Cornerstone CRT -- each about the size of a Miata -- which had the advantage of sheer screen area. I could have two full pages open side by side. That makes a big difference in getting work done. LCDs are the way to go now, though, as they are easier on your eyes due to lack of screen flicker and reduced glare.

Second -- it turns out that some operating systems just draw the text better. I have an Apple 23" Cinema Display (circa 1999) in my home office, and just turning that thing on makes me feel happy. And it's not just the size of the screen. I don't begin to understand all the technical bits, but Mac OS 10.3 (any of the OS X versions) just creates clearer screen text, which makes it a lot easier to work with electronic documents. I haven't spent much time on the newer Apple displays, but they seem like more of the same -- beautiful, big, and bright. My experiments with Linux (on an old Powerbook) and Windows tell me that the operating system does make a real difference.

Third, we are seeing what I think is a paradigm shift with regard to monitors, and it is one that will have implications for people who work in electronic documents. The "computer" is starting to disappear, and the screen -- the interface with our real work-- is gaining more prominence. In some instances, like the new iMac G5, the computer has literally disappeared into the screen. The Mac Mini seems to be another harbinger of this. PC manufacturers like Gateway and Sony are also making 1-piece computers. Even my PC at work is stuffed under my desk, and I never even look at it unless a CD won't eject. This is just the beginning -- we are only beginning to explore what it means to have a visual interface with our information -- wherever it may reside.

In conclusion, I believe that using as many high-resolution monitors as you can reasonably fit on your desk is the way to go. I could replace the processor in my PC with one that runs at double or even triple the speed, and it would not make any real difference to me. Put a 23" flat screen (or better yet, TWO of them!) on my desk, and it would make a substantial difference in how I work, and how much I get done.

Prices on LCD monitors are coming down drastically, and the productivity gains from large, multiple, LCDs are making the ROI better all the time. Do the math.

-- Dave

Comments

[Gregory D. Pawelski]

"Whole Brain Radiation Doesn’t Aid Brain Cancer Survival"

The initial approach to using radiation postoperatively to treat brain metastases, used to be whole brain radiation, but this was abandoned because of the substantial neurological deficits that resulted, sometimes appearing a considerable time after treatment. Whole brain radiation was routinely administered to patients after craniotomy for excision of a cerebral metastasis in an attempt to destroy any residual cancer cells at the surgical site. However, the deleterious effects of whole brain radiation, such as dementia and other irreversible neurotoxicities, became evident.

This raised the question as to whether elective postoperative whole brain radiation should be administered to patients after excision of a solitary brain metastasis. Current clinical practice, at a number of leading cancer centers, use a more focused radiation field (Radiotherapy) that includes only 2-3cm beyond the periphery of the tumor site. This begins as soon as the surgical incision has healed.

Many metastatic brain lesions are now being treated with stereotactic radiosurgery. In fact, some feel radiosurgery is the treatment of choice for most brain metastases. There are a number of radiation treatments for therapy (Stereotatic, Gamma-Knife, Cyber-Knife, Brachyradiation and IMRT to name a few). These treatments are focal and not diffuse. Unlike surgery, few lesions are inaccessible to radiosurgical treatment because of their location in the brain. Also, their generally small size and relative lack of invasion into adjacent brain tissue make brain metastases ideal candidates for radiosurgery. Multiple lesions may be treated as long as they are small.

The risk of neurotoxicity from whole brain radiation is not insignificant and this approach is not indicated in patients with a solitary brain metastasis. Observation or focal radiation is a better choice in solitary metastasis patients. Whole brain radiation can induce neurological deterioration, dementia or both. Those at increased risk for long-term radiation effects are adults over 50 years of age. However, whole brain radiation therapy has been recognized to cause considerable permanent side effects mainly in patients over 60 years of age. The side effects from whole brain radiation therapy affect up to 90% of patients in this age group. Focal radiation to the local tumor bed has been applied to patients to avoid these complications.

Aggressive treatment like surgical resection and focal radiation to the local tumor bed in patients with limited or no systemic disease can yield long-term survival. In such patients, delayed deleterious side effects of whole brain radiation therapy are particularly tragic. Within 6 months to 2 years patients can develop progressive dementia, ataxia and urinary incontinence, causing severe disability and in some, death. Delayed radiation injuries result in increased tissue pressure from edema, vascular injury leading to infarction, damage to endothelial cells and fibrinoid necrosis of small arteries and arterioles.

Even the studies performed by Dr. Roy Patchell, et al, in the early and late 90's have been recognized incorrectly, sometimes, in the radiation oncology profession. The studies were thought to have been the difference between surgical excision of brain tumor alone vs. surgical excision & whole brain radiation. It was a study of whole brain radiation of a brain tumor alone vs. whole brain radiation & surgical excision. The increased success had been the surgery. And they measured "tumor recurrence", not "long-term survival". Patients experiencing any survival could have been dying from radiation necrosis, starting within two years of whole brain radiation treatment and documented as "complications of cancer" not "complications of treatment". There may have been less "tumor recurrence" but not more "long-term survival".

Patchell's studies convincingly showed there was no survival benefit or prolonged independence in patients who received postoperative whole brain radiation therapy. The efficacy of postoperative radiotherapy after complete surgical resection had not been established. It never mentioned the incidence of dementia, alopecia, nausea, fatigue or any other numerous side effects associated with whole brain radiation. The most interesting part of this study were the patients who lived the longest. Patients in the observation group who avoided neurologic deaths had an improvement in survival, justifying the recommendation that whole brain radiation therapy is not indicated following surgical resection of a solitary brain metastasis.

An editorial to Patchell's studies by Drs. Arlan Pinzer Mintz and J. Gregory Cairncross (JAMA 1998;280:1527-1529) described the morbidity associated with whole brain radiation and emphasized the importance of individualized treatment decisions and quality-of-life outcomes. The morbidity associated with whole brain radiation does not indicate whole brain radiation therapy following surgical resection of a solitary brain metastasis. Patients who avoided the neurologic side effects of whole brain radiation had an improvement in survival. His studies convincingly showed there was no survival benefit or prolonged independence in patients who received postoperative whole brain radiation therapy. There may have been some less tumor recurrence but not more long-term survival.

Had fatigue, memory loss and other adverse effects of whole brain radiation been considered, and had quality of life been measured, it might be less clear that whole brain radiation is the right choice for all patients. These patients do not remain functionally independent longer, nor do they live longer than those that have surgery alone, said researchers in a report in an issue of The Journal of the American Medical Association. Patchell's standard for proving the value (improving overall survival) of whole brain radiation fell short of this criteria.

The UCLA Metastatic Brain Tumor Program treats metastatic disease focally so as to spare normal brain tissue and function. Focal treatment allows retreatment of local and new recurrences (whole brain radiation is once and done, cannot be used again). UCLA is equipped with X-knife and Novalis to treat tumors of all sizes and shapes. For patients with a large number of small brain metastases (more than 5), they offer whole brain radiotherapy.

http://neurosurgery.ucla.edu/Programs/BrainTumor/Metastatic_Intro.html

As reported in MD Anderson's OncoLog, in the past the only treatment for multiple metastases was whole brain radiation, which on its own had little effect on survival. There are now a variety of effective treatment modalities for people who have fewer than four tumors. Dr. Jeffrey Weinberg at the Department of Neurosurgery at MD Anderson has said "with a small, finite number of tumors, it may be better to treat the individual brain tumors themselves rather than the whole brain." Anderson is equipped with Linac Linear Accelerator. The critical idea is to focally treat all tumors.

http://www2.mdanderson.org/depts/oncolog/articles/05/1-jan/1-05-1.html

The results of a study at the University of Pittsburgh School of Medicine reported that treating four or more brain tumors in a single radiosurgery session resulted in improved survival compared to whole brain radiation therapy alone. Patients underwent Gamma-Knife radiosurgery and the results indicate that treating four or more brain tumors with radiosurgery is safe and effective and translates into a survival benefit for patients.

http://newsbureau.upmc.com/UPCI/GammaKnifeStudy2005.htm

Sometimes, symptoms of brain damage appear many months or years after radiation therapy, a condition called late-delayed radiation damage (radiation necrosis or radiation encephalopathy). Radiation necrosis may result from the death of tumor cells and associated reaction in surrounding normal brain or may result from the necrosis of normal brain tissue surrounding the previously treated metastatic brain tumor. Such reactions tend to occur more frequently in larger lesions (either primary brain tumors or metastatic tumors). Radiation necrosis has been estimated to occur in 20% to 25% of patients treated for these tumors. Some studies say it can develop in at least 40% of patients irradiated for neoplasms following large volume or whole brain radiation and possibly 3% to 9% of patients irradiated focally for brain tumors that developed clinically detectable focal radiation necrosis. In the production of radiation necrosis, the dose and time over which it is given is important, however, the exact amounts that produce such damage cannot be stated.

Late effects of whole brain radiation can include abnormalities of cognition (thinking ability) as well as abnormalities of hormone production. The hypothalamus is the part of the brain that controls pituitary function. The pituitary makes hormones that control production of sex hormones, thyroid hormone, cortisol. Both the pituitary and the hypothalamus will be irradiated if whole brain radiation occurs. Damage to these structures can cause disturbances of personality, libido, thirst, appetite, sleep and other symptoms as well. Psychiatric symptoms can be a prominent part of the clinical picture presented when radiation necrosis occurs.

Again, whole brain radiation is the most damaging of all types of radiation treatments and causes the most severe side effects in the long run to patients. In the past, patients who were candidates for whole brain radiation were selected because they were thought to have limited survival times of less than 1-2 years and other technology did not exist. Today, many physicians question the use of whole brain radiation in most cases as one-session radiosurgery treatment can be repeated for original tumors or used for additional tumors with little or no side effects from radiation to healthy tissues. Increasingly, major studies and research have shown that the benefits of radiosurgery can be as effective as whole brain radiation without the side effects.

Of course, surgical excision is the gold standard of treatment for surgically accessible lesions. Many studies in the medical literature clearly demonstrate the efficacy and superiority of surgical resection followed by focal radiation over radiation therapy as a first-line treatment for metastatic brain tumors. Doctors at UCLA and MD Anderson say that even for patients with up to four metastases, surgical excision of all intracranial disease has been shown to provide the long survival with good quality of life, and has the same prognosis as someone who has only one brain tumor.