Bio-energetic impairment in human calf muscle in thyroid disorders: a P MRS study

Mitochondrial metabolism particularly oxidative phosphorylation is greatly influenced by thyroid hormones. Earlier studies have described neuromuscular symptoms as well as impaired muscle metabolism in hypothyroid and hyperthyroid patients. In this study, we intend to look in to the muscle bioenergetics including phosphocreatine recovery kinetics based oxidative metabolism in thyroid dysfunction using in vivo ³¹P nuclear magnetic resonance spectroscopy (MRS). ³¹P MRS was carried out at resting state on 32 hypothyroid, 10 hyperthyroid patients and 25 control subjects. Nine out of 32 hypothyroid patients and 17 out of 25 control subjects under went exercise protocol for oxidative metabolism study and performed plantar flexion exercise while lying supine in 1.5 T magnetic resonance scanner using custom built exercise device. MRS measurements of inorganic phosphate (Pi), phosphocreatine (PCr), phosphodiesters (PDE) and adenosine triphosphate (ATP) of the calf muscle were acquired during rest, exercise and recovery phase. PCr recovery rate constant (k_PCr) and oxidative capacity were calculated by monoexponential fit of PCr versus time (t) at the beginning of recovery. During resting condition in hypothyroid patients, PCr/Pi ratio was reduced whereas PDE/ATP and Pi/ATP were increased. However, in case of hyperthyroidism, an increased PCr/Pi ratio and reduced PDE/ATP and Pi/ATP were observed. The results confirmed differential energy status of the muscle due to increased or decreased levels of thyroid hormone. Our results also demonstrate reduced oxidative metabolism in hypothyroid patients based on PCr recovery kinetics. PCr recovery kinetics study after exercise revealed decreased PCr recovery rate constant (k_PCr) in hypothyroid patients compared to controls that resulted in decrease in oxidative capacity of muscle by 50% in hypothyroids. These findings are consistent with a defect of high energy phosphate mitochondrial metabolism in thyroid dysfunction.     

鼠S180肉瘤的体内31P MRS研究

利用表面线圈³¹P NMR研究了小鼠S180肉瘤生长过程中能量代谢和磷脂类变化的特点.结果发现:随着肿瘤体积的增大,(1)Pi和PME升高;(2)PCr降低,在肿瘤体积较大时常检测不到;(3)β-NTP(通常用来表示ATP的量)变化较小;(4)PDE波动性较大;(5)PCr/Pi和β-NTP/Pi比值均下降,且PCr/Pi比β-NTP/Pi下降得快;(6)PME/β-NTP比值升高;(7)肿瘤pH下降,且与PCr/Pi、β-NTP/Pi或(PCr+β-NTP)/Pi比值有相关性.讨论了与这些参数变化相关联的生物学意义.     

急性低氧大鼠脑31P核磁共振波谱研究

³¹P磁共振波谱是目前唯一可以用作在体无损伤的检测细胞水平能量代谢变化的非侵入性技术,可测得脑内多种能量代谢产物.目的：急性低氧大鼠脑组织的³¹P MRS检测.方法：(1)20只成年SD大鼠分为4组：低氧0min(对照),5min,10min,15min后,迅速液氮冷冻;(2)将脑组织研碎后,加入高氯酸(PCA),冷冻干燥;(3)将提取物用0.5mL D\-2O溶解后进行MRS检测.结果：(1)急性低氧早期即引起³¹P MRS中PCr和ATP峰降低,ADP和Pi峰增高,PCr/Pi和ATP/Pi降低,而ADP/ATP增高.可交换磷池(EPP)中PCr的正常值为42.4%,低氧5min后降到28.9%, ATP从33.8%降到19.2%,Pi从17.7%升到42.0%.(2)急性低氧时³¹P MRS中脑内磷酯分解代谢产物GPC、GPE含量增加,说明低氧早期脑内即有膜磷酯的分解增加.结论：³¹P磁共振波谱可用于脑低氧性疾病的诊断,我们波谱中最敏感的指标是PCr/Pi和ATP/Pi,尤其早期降低更为显著.     

In vivo 31P echo-planar spectroscopic imaging of human calf muscle

Localized phosphorus-31 NMR spectra of human calf muscle in vivo were obtained by means of echo-planar spectroscopic imaging (EPSI) with a 1.5-T whole-body scanner. The technique permits the measurement of two-dimensional 31P SI data at a minimum acquisition time of 2.4 s (8x8 voxels, TR=300 ms). With 9.4 min measurement time (TR=1100 ms, 64 averages) and 25x25x40 mm spatial resolution in vivo the 31P NMR signal-to-noise ratio (S/N) of the phosphocreatine (PCr) resonance was about 45; the multiplets of nucleoside 5'-triphosphates were resolved. Spectral quality permits quantitative assessment of the PCr signal in a measurement time that is shorter by a factor of 2 or more than the minimum measurement time feasible with chemical-shift imaging. In a functional EPSI study with a time resolution of 20.5 s on the calf muscle of volunteers, spectra showed a 40% decrease of the PCr signal intensity (at rest: S/N congruent with12) upon exertion of the muscle.     

In vivo 31P MRS of human brain at high/ultrahigh fields: a quantitative comparison of NMR detection sensitivity and spectral resolution between 4 T and 7 T

The primary goal of this study was to establish a rigorous approach for determining and comparing the NMR detection sensitivity of in vivo ³¹P MRS at different field strengths (B₀). This was done by calculating the signal-to-noise ratio (SNR) achieved within a unit sampling time at a given field strength. In vivo ³¹P spectra of human occipital lobe were acquired at 4 and 7 T under similar experimental conditions. They were used to measure the improvement of the human brain ³¹P MRS when the field strength increases from 4 to 7 T. The relaxation times and line widths of the phosphocreatine (PCr) resonance peak and the RF coil quality factors (Q) were also measured at these two field strengths. Their relative contributions to SNR at a given field strength were analyzed and discussed. The results show that in vivo ³¹P sensitivity was significantly improved at 7 T as compared with 4 T. Moreover, the line-width of the PCr resonance peak showed less than a linear increase with increased B₀, which leads to a significant improvement in ³¹P spectral resolution. These findings indicate the advantage of high-field strength to improve in vivo ³¹P MRS quality in both sensitivity and spectral resolution. This advantage should improve the reliability and applicability of in vivo ³¹P MRS in studying high-energy phosphate metabolism, phospholipid metabolism and cerebral biogenetics in the human at both normal and diseased states noninvasively. Finally, the approach used in this study for calculating in vivo ³¹P MRS sensitivity provides a general tool in estimating the relative NMR detection sensitivity for any nuclear spin at a given field strength.     

Phosphorus-31 MR spectroscopic imaging (MRSI) of normal and pathological human brains.

The goals of this study were to evaluate 31P MR spectroscopic imaging (MRSI) for clinical studies and to survey potentially significant spatial variations of 31P metabolite signals in normal and pathological human brains. In normal brains, chemical shifts and metabolite ratios corrected for saturation were similar to previous studies using single-volume localization techniques (n = 10; pH = 7.01 +/- 0.02; PCr/Pi = 2.0 +/- 0.4; PCr/ATP = 1.4 +/- 0.2; ATP/Pi = 1.6 +/- 0.2; PCr/PDE = 0.52 +/- 0.06; PCr/PME = 1.3 +/- 0.2; [Mg2+]free = 0.26 +/- 0.02 mM.) In 17 pathological case studies, ratios of 31P metabolite signals between the pathological regions and normal-appearing (usually homologous contralateral) regions were obtained. First, in subacute and chronic infarctions (n = 9) decreased Pi (65 +/- 12%), PCr (38 +/- 6%), ATP (55 +/- 6%), PDE (47 +/- 9%), and total 31P metabolite signals (50 +/- 8%) were observed. Second, regions of decreased total 31P metabolite signals were observed in normal pressure hydrocephalus (NPH, n = 2), glioblastoma (n = 2), temporal lobe epilepsy (n = 2), and transient ischemic attacks (TIAs, n = 2). Third, alkalosis was detected in the NPH periventricular tissue, glioblastoma, epilepsy ipsilateral ictal foci, and chronic infarction regions; acidosis was detected in subacute infarction regions. Fourth, in TIAs with no MRI-detected infarction, regions consistent with transient neurological deficits were detected with decreased Pi, ATP, and total 31P metabolite signals. These results demonstrate an advantage of 31P MRSI over single-volume 31P MRS techniques in that metabolite information is derived simultaneously from multiple regions of brain, including those outside the primary pathological region of interest. These preliminary findings also suggest that abnormal metabolite distributions may be detected in regions that appear normal on MR images.     

Impact of aging on cardiac high-energy phosphate metabolism determined by phosphorus-31 2-dimensional chemical shift imaging (31P 2D CSI)

Previous echocardiographic and experimental animal studies have shown that cardiac function, structure, and metabolism change with age. The aim of this study was to evaluate the impact of age on left ventricular high-energy phosphate metabolism. Using a 1.5 Tesla whole-body MR scanner 31P 2D CSI (8 x 8 phase encoding steps, 320 mm field of view) was performed in 76 healthy male volunteers (41.7 +/- 13 years) without any history of coronary heart disease. Fourier interpolation, corrections for T1 saturation effects, the nucleus Overhauser effect, and the blood contamination were applied to the spectroscopic data. The volunteers were divided into two groups, younger (n = 37) and older (n = 39) than 41.7 years. In all volunteers, laboratory specimen were sampled, and transthoracal echocardiography was carried out. Significant differences in left ventricular phosphocreatine (PCr) to beta-adenosine-triphosphate (beta-ATP) ratios (2.16 vs. 1.83, p < 0.001), fasting serum glucose levels (83.3 vs. 98.7 mg/dl, p < 0.001), E/A (1.51 vs. 1.14 p < 0.001), and ejection fraction (EF, 65.3 vs. 59.9%, p = 0.005) were detected between the two groups of volunteers, younger and older than 41.7 years. Moreover, age correlated moderately to well with left ventricular PCr to beta-ATP ratios (r = -0.44), fasting serum glucose levels (r = 0.4), E/A (r = -0.7), left ventricular myocardial mass (r = -0.41), and EF (r = -0.55). In conclusion, our study shows that left ventricular PCr to beta-ATP ratios decrease moderately with age, as suggested by previous experimental animal studies. Additionally, age correlates negatively with E/A, left ventricular myocardial mass, and EF, as reported by previous echocardiography studies. The present study is the first to show the impact of age on left ventricular PCr to beta-ATP values in humans.     

利用频域近红外光谱仪和磁共振谱仪测量骨骼肌能量代谢

利用频域近红外光谱技术(NIRS)可以实现生物组织光学参数的实时定量测量。由于生物组织的吸收系数与组织中的血红蛋白的合氧状态有关,使得频域近红外光谱技术可以用来无损测量肌肉组织中与能量代谢过程密切相关的氧气供应与消耗这个动态平衡过程。磷磁共振谱仪(31P-MRS)是无损检测骨骼肌能量代谢的金标准。为了研究细胞内pH值(pHi)对磷酸肌酸重新合成和氧合血红蛋白恢复过程的影响,作者利用频域NIRS和31P-MRS联合进行了健康成人的踝关节曲展(plantar flexion)实验。通过动脉阻断和长时间全力运动尽量降低肌肉组织细胞内pH值。对照结果表明,细胞环境酸化(pHi=6.42)明显地延长了运动停止后磷酸肌酸的重新合成和氧合血红蛋白的恢复过程。     

Cardiac phosphorus-31 two-dimensional chemical shift imaging in patients with hereditary hemochromatosis

Hemochromatosis is a hereditary iron overload syndrome characterized by increased iron storage, followed by liver cirrhosis and is often associated with restrictive cardiomyopathy. The purpose of this study was to detect alterations of cardiac high-energy phosphate metabolism in patients with hereditary hemochromatosis (HHC) prior to the development of structural heart diseases. Therefore cardiac phosphorus-31 two-dimensional chemical shift imaging ((31)P 2D CSI) was employed. Twenty-four male patients (mean age 47.2 +/- 12 years) homozygous for the C282Y mutation in the hemochromatosis associated HFE gene and twenty-four male healthy volunteers (mean age 47 +/- 11 years) as age-matched controls were included in this study. Using a 1.5-Tesla whole-body magnetic resonance scanner, electrocardiograph-triggered transversal 31P 2D CSI was performed. Left ventricle mean phosphocreatine (PCr) to beta-adenosine triphosphate (beta-ATP) ratios of patients with HHC (1.60 +/- 0.41) were significantly decreased in comparison to healthy volunteers (1.93 +/- 0.36; p = 0.004). Furthermore, we detected moderate, negative correlations between left ventricular PCr to beta-ATP ratios and transferrin saturation, cholesterol, low-density lipoprotein as well as triglyceride. This study shows that 31P 2D CSI permits the detection of alterations of cardiac high-energy phosphate metabolism in patients with HHC, but without any evidence for heart disease. The decreased PCr to beta-ATP ratios in HHC might be caused by mitochondrial impairment due to cardiac iron overload.     

Quantitative Evaluation of Oxygenation and Metabolism in the Human Skeletal Muscle

The forearm muscles of five healthy males were monitored for changes in microvessel hemoglobin saturation (SO_2-TRS) by near infrared time-resolved spectroscopy (NIR_TRS) and changes in phosphorus metabolites by magnetic resonance spectroscopy (³¹P-MRS) during 12 min of resting arterial occlusion. Muscle oxygenation and phosphorus metabolites were also measured during grip exercises at varying intensities. Upon the initiation of occlusion, SO_2-TRS fell progressively until it reached a plateau in the latter half of the occlusion. Phosphocreatine (PCr) began to decrease around 6 min after the initiation of arterial occlusion. The resting O₂ store and O₂ consumption were 295 μM and 0.95 μM/sec, respectively-values which reasonably agree with the reported results. A significant correlation was observed between the changes in SO_2-TRS and PCr during exercise (r² = 0.80, p < 0.001). These results indicate that NIR_TRS is able to provide reliable information about resting metabolism and oxidative rate during exercise. NIR_TRS and MRS are useful to monitor oxygenation and energetics noninvasively in the human muscle.     

大鼠急性缺血心肌31P磁共振波谱的基础研究

利用³¹P磁共振波谱（MRS）检测了急性缺血心肌组织提取物中高能磷酸化合物的变化. 方法：成年SD大鼠在心肌梗塞后0、5、 20、45 min后进行取材,梗塞区、边缘区及正常区的心肌组织经高氯酸萃取后进行高分辨MRS检测. 结果：梗塞区,缺血5 min PCr/Pi比值下降到对照组的12 ％;20 min ATP/Pi 比值下降至0.05,Pi/EPP比值上升至0.8;45 min 梗塞区PDE/ATP上升至1.93,与45 min心肌的不可逆损伤超微结构相吻合. 边缘区各代谢产物出现改变的程度要小于梗塞区,大于正常区. 正常区也有能量代谢的改变. 结论：心肌组织的³¹P MRS能够反映心肌缺血后心肌不同部位的动态能量代谢改变. PDE/ATP是判断心肌不可拟性损伤的可靠指标.     

Considerations for brain pH assessment by 31P NMR

Recently in vivo NMR spectroscopy has been used to measure brain pH non-invasively. Both the inorganic orthophosphate (Pi) chemical shift (delta) and the difference between the chemical shifts of phosphocreatine (PCr) and Pi(delta delta PCr-Pi) have been proposed as indicators of brain pH. However, the precise delta of Pi may be difficult to determine under normoxic conditions as is the delta of PCr under hypoxic/ischemic conditions. Ideally one needs a NMR delta parameter that: (1) linearly changes between pH 6.0-8.0, (2) is either relatively unaffected or predictably affected by cations (e.g., Mg2+) other than H+, and that (3) comes from readily observable 31P NMR resonances whose delta's can be accurately assessed under all physiological conditions. Therefore, we undertook a systematic 31P NMR study of the pH and Mg2+ titration curves for 16 phosphorus-containing metabolites observed in brain by 31P NMR. On the basis of the titration curves, the delta delta's for PCr-Pi, phosphoethanolamine (PE)-Pi, and PCr-PE fulfill criteria (1) and (2), but not criterion (3). However, the delta delta of ATP gamma-alpha fulfills all three criteria and potentially provides information on the intracellular Mg2+ concentration.     

Correlation between skin temperature and heart rate during exercise and recovery,and the influence of body position in these variables in untrained women

It was known that the thermal response varies according to some variables. Until now, there are no studies that have investigated the relationship of skin temperature and heart rate during and after the workout, either the thermal behavior during postural changes. Objective: the aim of this study was to evaluate the behavior of skin temperature and heart rate, during exercise and up to an hour of recovery (with postural change), performed in two different intensities sessions (70% and 85% of 10 repetitions maximum) and observe the correlation between them. Method: This was a short longitudinal study, carried out with women aged from 18 to 30 years. A sample of 31 untrained women, aged 18 and 30 was used. The volunteers were randomized into two groups: Biceps Group (BG), with 15 women, and Quadriceps Group (QG) with 16 women. Results: During and after completion of the exercise session, there was a significant reduction in skin temperature on the active muscles in both groups (BG and QG), with similar thermal responses for the two intensities studied (70% and 85%) to the minute 15 (which marks the end of the recovery in the standing position). From minute 15 to minute 20–60, the skin temperature increases abruptly and significantly, returning to levels close to those observed before exercise. Conclusion: There were no statistical differences in thermal response to exercises in 70% or 85% of 10RM. There is a negative correlation between heart rate and skin temperature when untrained women perform anaerobic exercise. It was observed that after a change of posture (from a standing position to a sitting posture) skin temperature increased abruptly and significantly.     

紫杉醇治疗小鼠S180肉瘤的体内31P MRS研究

为了研究紫杉醇治疗小鼠S180肉瘤的³¹P MRS参数的变化及这些参数的变化是否早于常规观察的瘤体积的变化.方法:利用表面线圈³¹P NMR方法,研究小鼠皮下接种的S180肉瘤.结果:用药48h后给药组的PCr/Pi、β-NTP/Pi、PME/β-NTP比值与对照组有显著性差别(P<0.05),而肿瘤体积在给药组和对照组之间无显著性差别,³¹P MRS参数的变化早于瘤体积变化.结论:小鼠S180肉瘤³¹P MRS不仅可以给出定量的结果,而且可以较早地显示出治疗的效果.     

On neglecting chemical exchange effects when correcting in vivo (31)P MRS data for partial saturation

Signal acquisition in most MRS experiments requires a correction for partial saturation that is commonly based on a single exponential model for T(1) that ignores effects of chemical exchange. We evaluated the errors in (31)P MRS measurements introduced by this approximation in two-, three-, and four-site chemical exchange models under a range of flip-angles and pulse sequence repetition times (T(R)) that provide near-optimum signal-to-noise ratio (SNR). In two-site exchange, such as the creatine-kinase reaction involving phosphocreatine (PCr) and gamma-ATP in human skeletal and cardiac muscle, errors in saturation factors were determined for the progressive saturation method and the dual-angle method of measuring T(1). The analysis shows that these errors are negligible for the progressive saturation method if the observed T(1) is derived from a three-parameter fit of the data. When T(1) is measured with the dual-angle method, errors in saturation factors are less than 5% for all conceivable values of the chemical exchange rate and flip-angles that deliver useful SNR per unit time over the range T(1)/5 < or = T(R) < or = 2T(1). Errors are also less than 5% for three- and four-site exchange when T(R) > or = T(1)(*)/2, the so-called "intrinsic" T(1)'s of the metabolites. The effect of changing metabolite concentrations and chemical exchange rates on observed T(1)'s and saturation corrections was also examined with a three-site chemical exchange model involving ATP, PCr, and inorganic phosphate in skeletal muscle undergoing up to 95% PCr depletion. Although the observed T(1)'s were dependent on metabolite concentrations, errors in saturation corrections for T(R) = 2 s could be kept within 5% for all exchanging metabolites using a simple interpolation of two dual-angle T(1) measurements performed at the start and end of the experiment. Thus, the single-exponential model appears to be reasonably accurate for correcting (31)P MRS data for partial saturation in the presence of chemical exchange. Even in systems where metabolite concentrations change, accurate saturation corrections are possible without much loss in SNR.     

31P-spectroscopy of head and neck tumors--surface coil technique

Comparative phosphorus-31 magnetic resonance spectroscopy (MRS) and magnetic resonance imaging (MRI) of 15 patients with superficial masses such as sarcoma, carcinoma, lymphoma, adenoma, and tuberculosis revealed significant increased concentrations of phosphomonoester, phosphodiester, and inorganic phosphorus in the lesion, whereas the concentration of the phosphocreatine was lower in comparison to muscle tissue. In nearly all masses, pH showed a slight alkaline shift. Existence of necrotic regions detected by MRI was marked by an increase of inorganic phosphorous in the spectra. Tumor growth was characterized by raised concentrations of phosphomonoester. Follow-up studies in a case of lymphoma showed a six-fold decrease of the tumor, while the spectra indicated a gradual transition of tumor values to muscle values. A follow-up study during irradiation of a squamous cell carcinoma revealed a considerable decrease of inorganic phosphate and a subsequent increase of phosphodiester.     

用3lP NMR研究小鼠脑在缺氧状态下能量代谢的动态变化

用³¹P体内核磁共振方法无损伤地观察了C57小鼠脑在缺氧时与能量代谢有关的含磷化合物Pi,PCr,ATP的动态变化,当气体中氧气含量降到5%时,小鼠大脑的PCr,ATP逐渐减少,Pi不断增加,脑组织内pH值降低至6.83~6.93.当Pi与PCr的峰高比等于1时给予复氧,发现复氧时Pi立即降低且pH立即升高的小鼠可以恢复,反之则不可恢复,表明Pi和pH反映了大脑缺氧损伤程度.     

维拉帕米对离体大鼠心脏缺血-再灌注损伤保护作用的31P核磁共振研究

为评价维拉帕米(Ver)防治心脏缺血-再灌注损伤的作用,采用³¹P核磁共振(^3lP NMR)技术对大鼠心肌缺血前,缺血过程中及缺血后高能磷化物的含量及细胞内pH (pH_i)的变化过程进行了动态跟踪测定,离体心脏于37℃下平衡灌流30min,停止灌流30min,再灌注30min.灌流液中始终含有Ver (0.2μmol·L^-1).Ver可使再灌注后心脏的冠脉流量有较高程度的恢复,^3lP NMR测定显示Ver可使心脏产生代谢上的改善作用.缺血10min后对照组心脏即检测不到磷酸肌酸(PCr),而Ver组心脏PCr仍保持在缺血前的20%.缺血过程中治疗组比未治疗组心脏ATP下降减缓,至缺血结束时心肌ATP分别为缺血前的53%和34%.再灌注后两组心肌的ATP均未回升,但Ver使PCr的恢复显著提高(P<0.05),给药心脏PCr/P_i(无机磷酸盐)无论在缺血前或再灌注阶段,都非常显著(P<0.01)地高于对照组心脏.Ver还可显著减轻缺血过程中的酸中毒并防止再灌注后心肌出现严重酸化的区域.     

离体心脏的31P NMR谱

³¹P NMR谱自70年代后期开始被用于离体心脏中含磷化合物代谢的动态研究.^3lP NMR谱不仅可以鉴定心肌组织中浓度较高的含磷化合物,即ATP、磷酸肌酸和无机磷酸盐,而且可提供有关这些化合物化学环境(包括pH和Mg²⁺)和细胞内分布的信息.利用这一非损伤性的定量分析方法,可连续观测心肌的代谢并可同时测定离体心脏的机械功能.利用饱和转移技术还能对完整心脏中肌酸激酶和腺苷酸激酶反应的速率加一测定.本文综述介绍了近年来进行离体灌流心脏^3lP NMR谱测定的实验方法以及这一技术所提供的各种信息.     

Serial Precision of Metabolite Peak Area Ratios and Water Referenced Metabolite Peak Areas in Proton MR Spectroscopy of the Human Brain

The precision of cerebral proton magnetic resonance spectroscopy (MRS) measurements is critical both in the clinical setting and for research purposes. Marshall et al. have recently concluded that “disappointing in vivo repeatability…is likely to limit” the ability of MRS to detect modest changes. We present here a comprehensive study of the precision of short- and long-term metabolite peak area ratios and water referenced metabolite peak areas for long echo time point resolved spectroscopy (PRESS) spectra (repetition time (TR) = 2000 ms, echo time (TE) = 136 ms) acquired from the occipital lobes of normal volunteers and a phantom using a conventional whole body 1.5 T MR system and conventional acquisition and analysis protocols. Short-term in vitro precision determined by five repeat scans on five occasions was excellent as measured by a mean coefficient of variation (NAA/Cho = 1.3%, NAA/Cr + PCr = 1.0%, Cho/Cr + PCr = 1.6%, NAA/H₂O = 0.5%, Cho/H₂O = 1.2%, Cr + PCr/H₂O = 0.8%). Long term in vitro precision using 100 spectra acquired over 2 years was also very good (NAA/Cho = 2.7%, NAA/Cr + PCr = 1.4%, Cho/Cr + PCr = 2.2%, NAA/H₂O = 1.5%, Cho/H₂O = 2.4%, Cr + PCr/H₂O = 1.5%). Short-term in vivo precision determined by five repeat scans in a single scanning session on eight subjects was also excellent (NAA/Cho = 5.2%, NAA/Cr + PCr = 3.0%, Cho/Cr + PCr = 6.6%, NAA/H₂O = 1.4%, Cho/H₂O = 4.9%, Cr + PCr/H₂O = 2.7%) and only worsened slightly for long-term in vivo precision determined by five repeat scans on eight subjects over 3 months (NAA/Cho = 5.2%, NAA/Cr + PCr = 4.8%, Cho/Cr + PCr = 7.7%, NAA/H₂O = 2.5%, Cho/H₂O = 6.4%, Cr + PCr/H₂O = 3.8%). We attribute the excellent precision reported here to the use of highly automated techniques for voxel shimming, water suppression and peak area measurements. These results allow us to repudiate Marshall’s assertion regarding disappointing repeatability of in vivo MRS.