Screening cervical spine CT in the emergency department, Phase 2: A prospective assessment of use.

BACKGROUND AND PURPOSE: The National Emergency X-Radiography Utilization Study Low-Risk Criteria were established to identify patients with a low probability of cervical spine injury in whom imaging of the cervical spine was unnecessary. The purpose of this study was to ascertain the number of unnecessary cervical spine CT studies on the basis of proper application of established clinical guidelines and, secondarily, to determine indications for ordering studies in the absence of guideline criteria. MATERIALS AND METHODS: All patients presenting to a level I trauma center for whom a screening cervical spine CT was ordered in the setting of blunt trauma were eligible for enrollment. For each study, the requesting clinician completed a survey regarding study indications. CT examinations were evaluated by a board-certified radiologist blinded to survey data to determine the presence or absence of cervical spine injury. RESULTS: Of 507 CT examinations, 5 (1%) were positive and 497 (98.0%) were negative for acute cervical spine injury. Five studies (1%) were indeterminate for acute injury but demonstrated no abnormality on subsequent imaging and clinical follow-up. Of the 502 studies without cervical spine injury, 81 (16.1%) were imaged despite meeting all 5 NEXUS criteria for nonimaging. Of these, the most common study indication was dangerous mechanism of injury (48.1%) followed by subjective neck pain (40.7%). CONCLUSIONS: Strict application of NEXUS criteria could potentially reduce the number of screening cervical spine CT scans in the setting of blunt trauma; this change would avoid a considerable amount of unnecessary radiation and cost.

A randomized trial of decision-making in asymptomatic carotid stenosis.

OBJECTIVE: We sought to evaluate whether different presentation formats, presenter characteristics, and patient characteristics affect decision-making in asymptomatic carotid stenosis. METHODS: Subjects included individuals presenting to a neurology clinic. Participants included those over age 18 without known carotid stenosis. Subjects were randomized to a 30-second video with 1 of 5 presentation formats (absolute risk, absolute event-free survival, annualized absolute risk, relative risk, and a qualitative description) delivered by 1 of 4 presenter physicians (black woman, white woman, black man, white man). Subjects then completed a one-page form regarding background demographics and their decision regarding treatment choice. RESULTS: A total of 409 subjects watched the video and completed the survey. Overall, 48.4% of subjects chose surgery. Presentation format strongly predicted choice of surgery (qualitative [64%], relative risk [63%], absolute risk [43%], absolute event-free survival [37%], and annualized absolute risk [35%], p < 0.001). There was a trend for younger age (mean age 52 vs 55, p = 0.054), male gender (53% vs 45%, p = 0.08), and advanced education (42% for high school education or less vs 52% for more than high school education, p = 0.052) to predict surgery choice. Gender and race of presenter, and race of subject, had no influence on the choice of treatment. CONCLUSIONS: Presentation format (information framing) strongly determines patient decision-making in asymptomatic carotid stenosis. Subject age, gender, and education level may also influence the decision. Clinicians should consider the influence of these variables when counseling patients.

In vivo correlation of tumor blood volume and permeability with histologic and molecular angiogenic markers in gliomas.

BACKGROUND AND PURPOSE: Tumor angiogenesis is very heterogeneous and in vivo correlation of perfusion imaging parameters with angiogenic markers can help in better understanding the role of perfusion imaging as an imaging biomarker. The purpose of this study was to correlate PCT parameters such as CBV and PS with histologic and molecular angiogenic markers in gliomas. MATERIALS AND METHODS: Thirty-six image-guided biopsy specimens in 23 patients with treatment-naive gliomas underwent PCT examinations. We correlated MVD, MVCP, VEGFR-2 expression, tumor cellularity, and WHO grade of the image-guided biopsy specimens with the PCT parameters. Histologic sections were stained with hematoxylin-eosin, CD34, and VEGFR-2 and examined under a light microscope. These histologic and molecular angiogenic markers were correlated with perfusion parameters of the region of interest corresponding to the biopsy specimen. Pearson correlation coefficients and multiple regression analyses by using clustering methods were performed to assess these correlations. RESULTS: CBV showed a significant positive correlation with MVD (r = 0.596, P < .001), whereas PS showed a significant positive correlation with MVCP (r = 0.546, P = .001). Both CBV (r = 0.373, P = .031) and PS (r = 0.452, P = .039) also showed a significant correlation with WHO grade. VEGFR-2 positive specimens showed higher PS and CBV; however, neither was statistically significant at the .05 level. CONCLUSIONS: CBV showed a significant positive correlation with MVD, whereas PS showed a significant positive correlation with MVCP, suggesting that these 2 perfusion parameters represent different aspects of tumor vessels; hence, in vivo evaluation of these could be important in a better understanding of tumor angiogenesis.

Quantitative estimation of permeability surface-area product in astroglial brain tumors using perfusion CT and correlation with histopathologic grade.

BACKGROUND AND PURPOSE: Glioma angiogenesis and its different hemodynamic features, which can be evaluated by using perfusion CT (PCT) imaging of the brain, have been correlated with the grade and the aggressiveness of gliomas. Our hypothesis was that quantitative estimation of permeability surface area product (PS), cerebral blood volume (CBV), cerebral blood flow (CBF), and mean transit time (MTT) in astroglial brain tumors by using PCT will correlate with glioma grade. High-grade gliomas will show higher PS and CBV as compared with low-grade gliomas. MATERIALS AND METHODS: PCT was performed in 32 patients with previously untreated astroglial tumors (24 high-grade gliomas and 8 low-grade gliomas) by using a total acquisition time of 170 seconds. World Health Organization (WHO) glioma grades were compared with PCT parameter absolute values by using Student or nonparametric Wilcoxon 2-sample tests. Receiver operating characteristic (ROC) analyses were also done for each of the parameters. RESULTS: The differences in PS, CBV, and CBF between the low- and high-grade tumor groups were statistically significant, with the low-grade group showing lower mean values than the high-grade group. ROC analyses showed that both CBV (C-statistic 0.930) and PS (C-statistic 0.927) were very similar to each other in differentiating low- and high-grade gliomas and had higher predictability compared with CBF and MTT. Within the high-grade group, differentiation of WHO grade III and IV gliomas was also possible by using PCT parameters, and PS showed the highest C-statistic value (0.926) for the ROC analyses in this regard. CONCLUSIONS: Both PS and CBV showed strong association with glioma grading, high-grade gliomas showing higher PS and CBV as compared with low-grade gliomas. Perfusion parameters, especially PS, can also be used to differentiate WHO grade III from grade IV in the high-grade tumor group.

Role of perfusion CT in glioma grading and comparison with conventional MR imaging features.

BACKGROUND AND PURPOSE: Perfusion imaging using CT can provide additional information about tumor vascularity and angiogenesis for characterizing gliomas. The purpose of our study was to demonstrate the usefulness of various perfusion CT (PCT) parameters in assessing the grade of treatment-naïve gliomas and also to compare it with conventional MR imaging features. MATERIALS AND METHODS: PCT was performed in 19 patients with glioma (14 high-grade gliomas and 5 low-grade gliomas). Normalized ratios of the PCT parameters (normalized cerebral blood volume [nCBV], normalized cerebral blood flow [nCBF], normalized mean transit time [nMTT]) were used for final analysis. Conventional MR imaging features of these tumors were assessed separately and compared with PCT parameters. Low- and high-grade gliomas were compared by using the nonparametric Wilcoxon 2-sample tests. RESULTS: Mean nCBV in the high- and low-grade gliomas was 3.06 +/- 1.35 and 1.44 +/- 0.42, respectively, with a statistically significant difference between the 2 groups (P = .005). Mean nCBF for the high- and low-grade gliomas was 3.03 +/- 2.16 and 1.16 +/- 0.36, respectively, with a statistically significant difference between the 2 groups (P = .045). Cut points of >1.92 for nCBV (85.7% sensitivity and 100% specificity), >1.48 for nCBF (71.4% sensitivity and 100% specificity), and <1.94 for nMTT (92.9% sensitivity and 40% specificity) were found to identify the high-grade gliomas. nCBV was the single best parameter; however, using either nCBV of >1.92 or nCBF of >1.48 improved the sensitivity and specificity to 92.9% and 100%, respectively. The sensitivity and specificity for diagnosing a high-grade glioma with conventional MR imaging were 85.7% and 60%, respectively. CONCLUSIONS: PCT can be used for preoperative grading of gliomas and can provide valuable complementary information about tumor hemodynamics, not available with conventional imaging techniques. nCBV was the single best parameter correlating with glioma grades, though using nCBF when nCBV was <1.92 improved the sensitivity. An nCBV threshold of >1.92 was found to identify the high-grade gliomas.

Splenic and immune alterations of the Sparc-null mouse accompany a lack of immune response.

Sparc-null mice have been used as models to assess tumor-host immune cell interactions. However, it is not known if they have a competent immune system. In this study, the immune systems of Sparc wild-type and null mice were compared. Mice were assessed for differences in total body weight, spleen weight and spleen-to-body weight ratios. Spleens were compared with respect to morphology, and Sparc, Ki-67, MOMA-1 and IgM expression. Immune cells in blood, bone marrow and spleen were assessed by blood smears, automated blood panel, and flow cytometry. Additionally, the ability of Sparc-null mice to respond to immune challenge was evaluated using a footpad model. The morphological and immunohistochemical results indicated that Sparc-null spleens had more white pulp, hyperproliferative B cells in the germinal centers, and decreased marginal zones. Sparc-null spleens lacked normal Sparc expression in red and white pulp, marginal zones, endothelial and sinusoidal cells. By flow analysis, B cells were decreased and T cells were increased in the bone marrow. Finally, Sparc-null mice were unable to mount an immune response following footpad lipopolysaccharide challenge. These data confirm that Sparc-null mice have an impaired immune system.

A second look at comorbidity in victims of trauma: the posttraumatic stress disorder-major depression connection.

BACKGROUND: We examine whether traumatic events increase the risk for major depression independent of their effects on posttraumatic stress disorder (PTSD). METHODS: Data come from the Epidemiologic Study of Young Adults in southeast Michigan (N = 1007). Retrospective and prospective data were used to estimate the risk of major depression in persons with PTSD and persons exposed to trauma with no PTSD, compared with persons who did not experience a trauma. National Comorbidity Survey data were used to evaluate the influence of trauma type. RESULTS: In the retrospective lifetime data, hazard ratios were, for first-onset major depression in exposed persons with PTSD, 2.8 and, in exposed persons with no PTSD, 1.3 (not significant), as compared with persons who were not exposed. Corresponding estimates from the prospective data were 11.7 and 1.4 (not significant). The difference in the risk for depression associated with PTSD versus exposure without PTSD is unlikely to be due to differences in trauma type. CONCLUSIONS: The findings of a markedly increased risk for major depression in persons with PTSD, but not in exposed persons without PTSD, do not support the hypothesis that PTSD and major depression in trauma victims are influenced by separate vulnerabilities.

Prospective, single-blind, randomized, controlled study to assess the efficacy of the 585-nm flashlamp-pumped pulsed-dye laser and silicone gel sheeting in hypertrophic scar treatment.

OBJECTIVE: To determine the efficacy of the 585-nm flashlamp-pumped pulsed-dye laser and silicone gel sheeting in the treatment of hypertrophic scars in lighter- and darker-skinned patients. DESIGN: Prospective, single-blind, randomized, internally controlled, comparison investigation. SETTING: Large academic dermatology department. PATIENTS: Twenty patients with hypertrophic scars (19 completed the laser treatments and 18 completed the silicone gel sheeting treatments). MAIN OUTCOME MEASURES: Clinical measurements included hypertrophic scar blood flow, elasticity, and volume. Patients' subjective complaints of pruritus, pain, and burning were also monitored. Histological assessment of fibrosis, number of telangiectasias, and number of mast cells was performed. Statistically significant improvements in clinical measurements and patients' subjective complaints determined treatment success. RESULTS: Mean scar duration was 32 months (range, 4 months to 20 years). There was an overall reduction in blood flow, volume, and pruritus over time (P = .001, .02, and .005, respectively). However, no differences were detected among treatment and control groups. There was no reduction in pain or burning (0-40 weeks), elasticity (8-40 weeks), or fibrosis (0-40 weeks, n = 5 biopsies) in the treated or control sections of the scars. Unlike in a previous study, the number of mast cells in the scars was similar to the number of mast cells in healthy skin. CONCLUSION: Clinical results demonstrate that the improvements in scar sections treated with silicone gel sheeting and pulsed-dye laser were no different than in control sections.

Major depression and stages of smoking. A longitudinal investigation.

BACKGROUND: Epidemiologic studies have reported an association between major depression and smoking. This prospective study examines the role of depression in smoking progression and cessation, and the role of smoking in first-onset major depression. METHODS: Data are from a 5-year longitudinal epidemiologic study of 1007 young adults. Incidence and odds ratios (ORs) are based on the prospective data. Hazards ratios are based on the combined lifetime data and estimated in Cox proportional hazards models with time-dependent covariates. RESULTS: Based on the prospective data, history of major depression at baseline increased significantly the risk for progression to daily smoking (OR, 3.0; 95% confidence interval, 1.1-8.2), but did not decrease significantly smokers' rate of quitting (OR, 0.8; 95% confidence interval, 0.4-1.6). History of daily smoking at baseline increased significantly the risk for major depression (OR, 1.9; 95% confidence interval, 1.1-3.4). These estimates were reduced somewhat when history of early (ie, before age 15 years) conduct problems was controlled. Estimates based on lifetime data were consistent with these results. CONCLUSIONS: The observed influences from major depression to subsequent daily smoking and smoking to major depression support the plausibility of shared etiologies. Separate causal mechanisms in each direction might also operate, including self-medication of depressed mood as a factor in smoking progression and neuropharmacologic effects of nicotine and other smoke substances on neurotransmitter systems linked to depression.

Rib enlargement in patients with chronic pleural disease.

OBJECTIVE: The purpose of this study was to assess the width of ribs in patients with chronic pleural disease. MATERIALS AND METHODS: On posteroanterior radiographs, we measured the horizontal width of ribs in the midaxillary line of four groups of patients: 41 selected patients with widened ribs and chronic pleural disease (group I), 30 consecutive patients with the clinical diagnosis of tuberculosis for 5 or more years who had radiographs that showed unilateral pulmonary or pleural disease (group II), 25 consecutive patients with the clinical diagnosis of empyema who had radiographs that showed unilateral pleural and often pulmonary parenchymal disease (group III), and 60 consecutive persons who received routine preemployment examinations that revealed no pulmonary or pleural disease (control subjects). Available clinical data were reviewed. RESULTS: We found a significant difference between the size of the ribs on the side of disease and the nondiseased side for groups I and II (p = .0008 and p = .045, respectively). We found no such difference for group III or the control group. The mean absolute values of the different widths of ribs on the side of disease and the nondiseased side were greater for groups I, II, and III than the absolute values of the different widths for the right and left ribs of the control subjects (p < .05). We identified tuberculosis, nontubercular empyema, thoracic surgery, blunt trauma, and metastatic tumor as causative agents in 24 (59%) of the 41 patients in group I. CONCLUSION: Rib enlargement is occasionally displayed radiographically in cases of chronic pleural disease and is confirmed by comparison of the two sides. In our selected patients (group I) with rib enlargement, tuberculosis was the most common cause of pleural disease, but nontubercular empyema, thoracic surgery, blunt trauma, and metastatic tumor were also found. Conversely, we found no rib enlargement in association with pleural disease of short duration. We have shown that rib enlargement can indicate the chronicity of pleural disease.

Giant cell fibroblastoma with dermatofibrosarcoma protuberans-like transformation.

A giant cell fibroblastoma (GCF) presented in the subcutis of the breast in a 13-month-old girl which recurred 6 years later as a dermal and subcutaneous neoplasm whose patterns were in part GCF and spindle cells with a storiform configuration resembling dermatofibrosarcoma protuberans (DFSP). The issue remains unsettled as to whether GCF is the juvenile variant of DFSP, but an argument about this relationship is supported circumstantially by a case such as ours.

Acute elevation and recovery of intracellular [Mg2+] following human focal cerebral ischemia.

We used 31P magnetic resonance spectroscopy (MRS) to investigate changes in brain intracellular [Mg2+] following human focal cerebral ischemia. Mean brain pMg (where pMg = -log[Mg2+]) was significantly lower in the ischemic focus of all stroke patients (pMg = 3.34 +/- 0.28, n = 45, p < 0.01) when compared with normal controls (pMg = 3.50 +/- 0.08, n = 25). Ischemic brain pMg was also significantly reduced when the pH of the stroke region was acidotic (pH < 6.90, pMg = 3.07 +/- 0.44, n = 11, p < 0.01) and when the phosphocreatine index (PCrI = PCr/[PCr+Pi (inorganic phosphate)]) was reduced (PCrI < 0.47, pMg = 3.12 +/- 0.42, n = 13, p < 0.01). Mean brain pMg was significantly reduced at days 0 to 1 (acute) poststroke (pMg = 3.32 +/- 0.28, n = 26, p < 0.01) and at days 2 to 3 (subacute) poststroke (pMg = 3.38 +/- 0.28, n = 21, p = 0.03). There was also a significant (p < 0.01) correlation between decreased pMg and increased relative signal intensity of Pi (normalized by total phosphate signal, Pi/TP) for all stroke groups studied. During the temporal evolution of stroke, pH returned to normal levels by days 2 to 3, and pMg returned to normal by days 4 to 10 (subacute). PCrI and Pi/TP returned toward normal levels after 10 days (chronic), at a time when ischemic brain pH had become significantly alkalotic (pH = 7.10 +/- 0.24, n = 15, p < 0.01). Elevation of ischemic brain [Mg2+] is temporally linked to the acidotic phase of human stroke as well as the breakdown of energy metabolism. These acute changes in [Mg2+] may contribute to, or be a marker for, cellular injury.

Oral contraceptive use may protect against low bone mass. Henry Ford Hospital Osteoporosis Cooperative Research Group.

This cross-sectional retrospective epidemiologic study investigated risk factors for low bone mineral density (BMD) in a group of 2297 women, 76% of whom were postmenopausal. Reproductive information, history of oral contraceptive use, BMD measurements, and other data were available from women presenting to 12 osteoporosis screening centers in 1986 and 1987. Each woman was classified into a BMD category based on the range of BMD measurements at her respective center. Menopause, increasing age and years since menopause, and decreasing body mass index were associated with low BMD. A history of oral contraceptive use was protective against low BMD (odds ratio = 0.35, 95% confidence interval = 0.23 to 0.53). Multivariate analyses confirmed this result and further demonstrated that increasing duration of use was protective. These data suggest that prior use of oral contraceptive agents is associated with higher levels of BMD and that the degree of protection from lower BMD is related to duration of exposure.

The cost and effectiveness of an education program for adults who have asthma.

STUDY OBJECTIVE: To determine whether a self-management training program decreases emergency department visits and reduces costs for patients with asthma. DESIGN: Randomized controlled trial of an educational program. SETTING: Two sites--an urban emergency room and a suburban emergency room. PATIENTS: 241 asthma patients between the ages of 18 and 70 years. Of the 119 patients in the intervention group and the 122 in the control group, 185 (76%) were available for follow-up. INTERVENTION: All patients seen in the emergency departments were given usual medical care and follow-up. Patients in the intervention group were asked to attend three educational sessions on asthma conducted by a specially trained RN. The program stressed importance of medication compliance, methods to control and prevent attacks, effects of drugs and rationale for their use, relaxation exercises, and smoking cessation. MEASUREMENT AND MAIN RESULTS: All patients received telephone interviews four, eight, and 12 months after entry into the study. Reports based on hospital admissions and emergency room utilization were verified by billing records. Three patients died during the study, none from asthma-related problems. The intervention group had significantly fewer asthma-related emergency visits (16 visits per 100 persons) than did the control group (39 per 100 persons); p = 0.0005 for the 12 months of follow-up. The effect of the intervention on asthma-related emergency department visits was strongest during the initial four months postintervention (68 per 100 persons versus 220 per 100 persons, p = 0.003). The financial analysis showed that the $85/person cost for the educational sessions was offset by the $628/person reduction in emergency room charges. CONCLUSION: Education enables patients with asthma to decrease utilization of emergency services.

Experience with intestinal lengthening for the short-bowel syndrome.

Patients with the short-bowel syndrome frequently develop dilated intestinal segments that may lead to impaired motility and malabsorption. Although intestinal tapering alone improves motility, the intestine can be lengthened as well. We reviewed our experience with six children undergoing intestinal lengthening to improve intestinal absorption secondary to the short-bowel syndrome. The procedure was performed by dissecting the vessels along the mesenteric border and dividing the intestine longitudinally with a stapler. Five patients were receiving total parenteral nutrition (TPN) and one was becoming malnourished with enteral feedings alone. Bacterial overgrowth was documented in four patients and abnormal liver function in three patients. The intestinal segments were dilated up to 10 cm in diameter and remnant length ranged from 15 to 79 cm. Segments 5 to 25 cm in length were divided, resulting in an average increase in length of 52%. Necrosis of one of the divided limbs necessitated resection in one patient. Follow-up ranged from 2 to 84 months. TPN has been discontinued in four patients and avoided in another. Symptomatic improvement occurred in all patients. We feel the tapering and lengthening procedure should be considered in patients with symptomatic, dilated intestinal segments in whom the need for TPN may potentially be obviated.

Cerebrovascular complications of the use of the "crack" form of alkaloidal cocaine.

BACKGROUND AND METHODS: The use of cocaine, especially one of its alkaloidal forms ("crack"), has been increasingly associated with cerebrovascular disease. To clarify the clinical, radiologic, and pathological features of the events associated with cocaine use, we identified 28 patients at four medical centers who had stroke temporally related to the use of alkaloidal cocaine (during or within 72 hours of use). RESULTS: The 28 patients had the following types of cerebrovascular event: cerebral infarction (n = 18 [2 hemorrhagic; 1 fatal]) in the areas supplied by the middle cerebral artery (n = 10), anterior cerebral artery (n = 3), posterior cerebral artery (n = 1), and vertebrobasilar arteries (n = 4); subarachnoid hemorrhage (n = 5); intraparenchymal hemorrhage (n = 4); and primary intraventricular hemorrhage (n = 1). Eighteen patients (64 percent) had acute neurologic symptoms immediately or within one hour of using cocaine. Fifteen patients (45 percent) with either occlusive or hemorrhagic strokes had sever headache as an early symptom. Vasculitis was not suggested by radiography in any patient, nor was it identified on pathological examination in one patient who died. All the patients were young (mean age, 34 years; range, 23 to 49) and had no other apparent, direct cause of stroke. Other risk factors for stroke among the patients included mild mitral-valve prolapse (n = 4), hypertension (n = 4), cigarette smoking (n = 8), and regular alcohol use (n = 6). CONCLUSIONS: There is a strong temporal association of the use of alkaloidal cocaine with both ischemic and hemorrhagic cerebrovascular events. Cocaine-related stroke probably has many causes. A thorough history focusing on the use of cocaine and toxicologic screening of urine and serum should be part of the evaluation of any young patient with a stroke.

Risk of colorectal cancer among automotive pattern and model makers.

Twofold to threefold increases in risk for colorectal cancer associated with pattern and model making in the automobile industry have been suggested by several reports. This paper reports the investigation of a cohort of 7545 General Motors pattern and model makers originally defined for the purpose of cancer screening. All-cause mortality for this cohort was lower than that of the US population (standardized mortality ratio [SMR] = 0.7; 95% confidence limits 0.6, 0.8). There were 22 colon cancer deaths v 10.9 expected, resulting in a significantly elevated SMR of 2.0 (95% confidence limits of 1.3, 3.0), consistent with previous studies. The colon cancer SMR for nonparticipants in the screening programs was 4.0 (95% confidence limits of 2.2, 6.7), emphasizing the importance of complete follow-up for all members of a defined cohort.

Effects of cigarette smoking and propranolol in survivors of acute myocardial infarction.

The effect of propranolol on mortality and reinfarction after acute myocardial infarction (AMI) in cigarette smokers and nonsmokers was studied in the Beta Blocker Heart Attack Trial. Cigarette smokers (n = 2,332) were 5 years younger than nonsmokers and had a lower incidence of diabetes mellitus, systemic hypertension, previous AMI and cardiomegaly. Among cigarette smokers, the placebo group had a higher total mortality rate than the propranolol group (11.0 vs 7.4%, p less than 0.0008) and more sudden cardiac deaths (7.1 vs 4.6%, p less than 0.009). In nonsmokers the placebo group had a mortality (7.9 vs 7.1%, p greater than 0.64) similar to the propranolol group. After baseline adjustment, cigarette smokers were estimated to have 1.6 times the risk of dying as compared to nonsmokers (p less than 0.0007). Adjusting for baseline differences, both treatment with propranolol and nonsmoking were predictors of survival. No detectable nonsmoking/propranolol interaction could be identified. In survivors of AMI a beneficial effect of propranolol is observed for cigarette smokers. Nevertheless, cigarette smoking continues to be a risk factor for mortality after AMI even for those receiving propranolol.

Preliminary observations on brain energy metabolism in migraine studied by in vivo phosphorus 31 NMR spectroscopy.

We measured brain energy phosphate metabolism and intracellular pH (pHi) in a cross-sectional study of migraine patients by in vivo phosphorus 31 NMR spectroscopy. During a migraine attack the ratio ATP/total phosphate signal (mole % ATP) was preserved, but there was a decrease in mole % phosphocreatine (PCr) and an increase in mole % inorganic phosphate (Pi) resulting in a decrease of the PCr/Pi ratio, an index of brain phosphorylation potential. This was found in classic but not common migraine. Mole % Pi was also increased in combined brain regions between attacks. There was no alteration in brain pHi during or between attacks. Energy phosphate metabolism but not pHi appears disordered during a migraine attack.