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Background and aims Type 2 diabetes mellitus (T2DM) is a well-recognized independent risk factor for ASCVD, the aim of this study was to investigate the effects of a dipeptidyl peptidase-4 inhibitor, sitagliptin, on prevention of progression of coronary atherosclerosis assessed by three-dimensional quantitative coronary angiography (3D-QCA) in T2DM patients with coronary artery disease (CAD). Methods This was a prospective, randomized, double-center, open-label, blinded end point, controlled 18-month study in patients with CAD and T2DM. A total of 149 patients, who had at least 1 atherosclerotic plaque with 20%–80% luminal narrowing in a coronary artery, and had not undergone intervention during a clinically indicated coronary angiography or percutaneous coronary intervention, were randomized to sitagliptin group (n = 74) or control group (n = 75). Atherosclerosis progression was measured by repeat 3D-QCA examination in 88 patients at study completion. The primary outcome was changes in percent atheroma volume (PAV) from baseline to study completion measured by 3D-QCA. Secondary outcomes included change in 3D-QCA-derived total atheroma volume (TAV) and late lumen loss (LLL). Results The primary outcome of PAV increased of 1.69% (95%CL, −0.8%–4.2%) with sitagliptin and 5.12% (95%CL, 3.49%–6.74%) with the conventional treatment (p = 0.023). The secondary outcome of change in TAV in patients treated with sitagliptin increased of 6.45 mm3 (95%CL,-2.46 to 6.36 mm3) and 9.45 mm3 (95%CL,-4.52 to 10.14 mm3) with conventional treatment (p = 0.023), however, no significant difference between groups was observed (p = 0.175). Patients treated with sitagliptin had similar LLL as compared with conventional antidiabetics (−0.06, 95%CL, −0.22 to 0.03 vs. −0.08, −0.23 to −0.03 mm, p = 0.689). Conclusions In patients with type 2 diabetes and coronary artery disease, treatment with sitagliptin resulted in a significantly lower rate of progression of coronary atherosclerosis compared with conventional treatment.

Stereotactic biopsy is often performed for diagnostic purposes before treating patients whose imaging studies highly suggest glioma. Indications cited for biopsy include diagnosis and/or the "inoperability" of the tumor. This study questions the routine use of stereotactic biopsy in the initial management of gliomas. At The University of Texas M. D. Anderson Cancer Center, we retrospectively reviewed a consecutive series of 81 patients whose imaging studies suggested glioma and who underwent stereotactic biopsy followed by craniotomy/resection (within 60 days) between 1993 and 1998. All relevant clinical and imaging information was reviewed, including computerized volumetric analysis of the tumors based on pre- and postoperative MRI. Stereotactic biopsy was performed at institutions other than M. D. Anderson in 78 (96%) of 81 patients. The majority of tumors were located either in eloquent brain (36 of 81 = 44%) or near-eloquent brain (41 of 81 = 51%), and this frequently was the rationale cited for performing stereotactic biopsy. Gross total resection (>95%) was achieved in 46 (57%) of 81 patients, with a median extent of resection of 96% for this series. Diagnoses based on biopsy or resection in the same patient differed in 40 (49%) of 82 cases. This discrepancy was reduced to 30 (38%) of 80 cases when the biopsy slides were reviewed preoperatively by each of three neuropathologists at M. D. Anderson. Major neurologic complications occurred in 10 (12.3%) of 81 surgical patients and 3 (3.7%) of 81 patients undergoing biopsy. Surgical morbidity was probably higher in our series than it would be for glioma patients in general because our patients represent a highly selected subset of glioma patients whose tumors present a technical challenge to remove. Stereotactic biopsy is frequently inaccurate in providing a correct diagnosis and is associated with additional risk and cost. If stereotactic biopsy is performed, expert neuropathology consultation should be sought.

Object. Twenty-two patients who had solitary metastatic brain tumors with dural extension were treated surgically over a 3-year period. Their cases were reviewed to characterize these lesions and to compare the patients with a similar cohort in which there was no dural involvement. Methods. The median age of the patients was 58 years (range 11–68 years) and the male/female ratio was 12:10. The median preoperative Karnofsky Performance Scale (KPS) score in the group was 90 (range 70–100). The most common histological diagnoses seen in these patients included breast cancer, adenocarcinoma and squamous cell carcinoma of the lung, and renal cell carcinoma. All patients underwent gross-total resection of the tumor and 86% received radiation therapy. The median patient survival time was 11 months, with a median time to recurrent intracranial disease of 19 months. Survival was related to the histological diagnosis. Recurrent disease occurred in 41% of cases. Leptomeningeal disease occurred in three patients (14%). The frequency and time course of development of recurrent disease was not affected by dural resection nor was survival. These results for patients having metastatic brain tumors with dural extension were compared with those for a cohort of 26 patients in which there were similar histological diagnosis, age, gender, and preoperative KPS score were distributed similarly but in which each patient had a single subcortical metastatic lesion. Those patients had a median survival of 10 months and the median time to recurrence was not reached. Leptomeningeal disease occurred in one patient (4%). Conclusions. To the authors' knowledge, this is the first reported series of patients with metastatic brain tumors with dural extension. Patients with this disease may be more likely to develop recurrences along the dura and leptomeningeal disease, but the overall survival time in these patients is not different from those patients with intraparenchymal lesions.

OBJECTIVE The goals were to critically review all complications resulting within 30 days after craniotomies performed for excision of intra-axial brain tumors relative to factors likely to affect complication rates and to assess the value of these data in predicting the risk of surgical morbidity, particularly for surgery in eloquent brain regions. METHODS Neurosurgical outcomes were studied for 327 patients who underwent 400 craniotomies for removal of intra-axial parenchymal brain neoplasms in a 21-month period. Tumors removed included gliomas (206 tumors) and metastases (194 tumors) located both supratentorially (358 tumors) and infratentorially (42 tumors). RESULTS The major complication incidence was 13%, and the operative mortality rate was 1.7%. The overall morbidity rate was 32%, but more types of complications were considered than in previous studies. The major neurological morbidity rate was 8.5%. Based on pre- versus postoperative (at 4 wk) Karnofsky Performance Scale scores, 9% of patients deteriorated neurologically, 32% improved, and 58% showed no change. The median postoperative hospital stay was 5 days. Tumors were defined as Grade I, II, or III based on their location relative to brain function, and this tumor functional grade was the most important variable affecting the incidence of any neurological deficit. Patients with tumors in eloquent (Grade III) or near-eloquent (Grade II) brain areas incurred more neurological deficits than did patients with tumors in noneloquent areas (Grade I). Neither repeat surgery for recurrent disease nor extent of surgical resection affected outcome significantly. Although most tumors in this study, including those in eloquent regions, were removed by gross total resection, this did not lead to more major neurological deficits. Regional complications (at the surgical sites) and systemic complications (medical) were more prevalent among older patients (age >60 yr) with lower preoperative Karnofsky Performance Scale scores (< or = 50) and posterior fossa masses. We showed how our data can be used to predict the total risk of surgical morbidity for a given patient, to facilitate patient counseling and surgical decision-making. CONCLUSION The finding that gross total resections could be performed in eloquent brain regions with an acceptable level of neurological impairment suggested that the mere presence of a tumor in eloquent brain does not automatically contraindicate surgery. Our results have practical risk-predictive value, and they should aid in the construction of subsequent outcome studies, because we have identified the key areas to monitor.

Residual tumor volume has been considered important in predicting survival following brain surgery. The purpose of this study was to develop a procedure for quantifying pre- and postsurgical brain tumor volumes that is less subjective than the traditional qualitative grading scale still used by surgeons and radiologists to assess extent of resection (such as gross total, subtotal, and partial resection). Pre- and postsurgical magnetic resonance (MR) imaging brain scans on GE Medical System optical disks were transferred to a Macintosh personal computer using a Pioneer optical disk drive subsystem, and the MedVision 1.41 computer software program was used to analyze regions of interest (ROIs) within them for computation of the volume of tumor tissue therein. Because this procedure puts the original MRI (or CT scan) data file for a patient directly into the personal computer, it bypasses the need for scanning and digitizing MR (or CT scan) film images. Between June 1993 and May 1996, pre- and postsurgical volumetric measurements were made in more than 1,000 brain tumor resection cases and 49 radiosurgery cases. The average intra-observer error was estimated to be 1.8%. This method should facilitate the examination of the effects of various therapies on extent of brain tumor resection. The method is fast, is more precise than intraoperative visual assessment of tumor removal or qualitative comparison of pre- and postoperative scans, and it allows the computation of pre- and postsurgical (three-dimensional) volumes of even irregularly shaped tumors.

A neutron detector is developed by evaporating a layer of 10B on (100)-oriented diamond film. At the electric field of 1 V/μm, the energy resolution is 9.3%, the detecting efficiency to252Cf neutron is 1.67%.

✓ Surgery and radiosurgery are effective treatment modalities for brain metastasis. To compare the results of these treatment modalities, the authors followed 31 patients treated by radiosurgery and 62 patients treated by surgery who were retrospectively matched. Patients were matched according to the following criteria: histological characteristics of the primary tumor, extent of systemic disease, preoperative Karnofsky Performance Scale score, time to brain metastasis, number of brain metastases, and patient age and sex. For patients treated by radiosurgery, the median size of the treated lesion was 1.96 cm3 (range 0.41–8.25 cm3) and the median dose was 20 Gy (range 12–22 Gy). The median survival was 7.5 months for patients treated by radiosurgery and 16.4 months for those treated by surgery; this difference was found to be statistically significant using both univariate (p = 0.0018) and multivariate (p = 0.0009) analyses. The difference in survival was due to a higher rate of mortality from brain metastasis in the radiosurgery group than in the surgery group (p < 0.0001) and not due to a difference in the rate of death from systemic disease (p = 0.28). Log-rank analysis showed that the higher mortality rate found in the radiosurgery group was due to a greater progression rate of the radiosurgically treated lesions (p = 0.0001) and not due to the development of new brain metastasis (p = 0.75). On the basis of their data, the authors conclude that surgery is superior to radiosurgery in the treatment of brain metastasis. Patients who undergo surgical treatment survive longer and have a better local control. The data lead the authors to suggest that the indications for radiosurgery should be limited to surgically inaccessible metastatic tumors or patients in poor medical condition. Surgery should remain the treatment of choice whenever possible.

✓ A prospective study of 70 patients with intraparenchymal brain lesions (36 gliomas and 34 metastases) was performed to evaluate the efficacy of intraoperative ultrasound (IOUS) in localizing and defining the borders of tumors and in assessing the extent of their resection. Eighteen of the 36 glioma patients had no previous therapy. All of these 18 tumors were well localized by IOUS; margins were well defined in 15 and moderately defined in three. The extent of resection was well defined on IOUS in all 18 patients, as confirmed by measurements taken on postoperative magnetic resonance (MR) images (p = 0.90). The remaining 18 patients with gliomas had undergone previous surgery and/or radiation therapy; five had recurrent tumors and 13 had radiation-induced changes. The extent of resection of the recurrent tumors was well defined in all but one patient, as confirmed by postoperative MR imaging. The extent of resection was poorly defined in all 13 patients whose pathology showed radiation effects. All 34 metastatic lesions were well localized and had well-defined margins. In addition, IOUS accurately determined the extent of resection in all cases; the results were confirmed with postoperative MR imaging. In conclusion, IOUS is not only helpful in localizing and defining the margins of gliomas and metastatic brain lesions, it also accurately determines the extent of resection, as confirmed by postoperative MR imaging. This assessment does not apply, however, when the lesion is due primarily to radiation effect.

This paper extends the application of cost function-based analysis of productivity to the complex service sector, where it is generally believed that the influence of worker attitudes on productivity is greater than in manufacturing sectors. Also introduced is an explicit model of worker attitude formation, based on measures of workload, supervision, and the organization of production. The data base for the study is a cross-section of 200 Management Sectional Centers for the United States Postal Service (LISPS) for 1984. These Management Sectional Centers (MSCs) have responsibility for mail collection, forwarding, and delivering for geographic regions that completely cover all 50 states. The resulting cost model is used to estimate productivity at these 200 MSCs, as well as the cost of serving the particular geographic areas, characterized in terms of the number of delivery points, population, and areas served in square miles.