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An applicable annealing temperature is 5ºC below the true melting temperature (Tm) of the amplification primers 150 mg wellbutrin sr otc depression symptoms of. The range of enzyme activity varies by two orders of magnitude between 20 and 85ºC generic 150mg wellbutrin sr amex depression uplifting quotes. Increasing the annealing temperature enhances discrimination against incorrectly annealed primers and reduces mis-extension of incorrect nucleotides at the 3¢ end of primers purchase wellbutrin sr pills in toronto depression recovery definition. Primer extensions are traditionally performed at 72°C because this temperature is near optimal for extending primers. An extension time of 1 min at 72°C is considered sufficient for products up to 2 kb in length. Typical denaturation conditions are 95°C for 30 s, but higher temperatures may be appropriate, especially for G+C-rich genomes. Denaturation steps that are too high and/or too long lead to unnecessary loss of enzyme activity. A common mistake is to execute too many cycles, which can increase the amount and complexity of non-specific background products. Higher primer concentrations may promote mispriming and accumulation of non-specific product and may increase the probability of generating a template independent artefact termed a primer-dimer. The technique has the added advantage that it is easy to prepare replicate filters, allowing many filter-bound sequences to be analysed at the same time, for example with different probes or under different hybridization and washing conditions. Dot blots do not distinguish between the number and size of the molecules hybridizing, so the hybridization ‘signal’ is the sum of all sequences hybridizing to the probe under the conditions used. Nylon membranes, due to their higher resistance, are now the most commonly used type for Southern and dot blots. This will prevent the gradual leaching-off of the nucleic acids from the surface when filters are hybridized for long periods, particularly at high temperature. Hybridization strategy Nucleic acid hybridization, the formation of a duplex between two complementary nucleotide sequences, is the basis for a range of techniques now in widespread use in modern biology. On the other hand, as the salt concentration is decreased, the stringency increases. There are various types of hybridization commonly in use, such as filter hybridization and in situ hybridization. Hybridization is followed by extensive washing of the filter to remove unreacted probe. The procedure is widely applicable, being used for Southern Blot and dot blot hybridization for example. The choice of probe depends on three factors: the hybridization strategy, the availa- bility or source of material for use as a probe and the degree to which it can be labelled. However, for nucleic acid hybridization, 32P is the isotope of choice since its high energy results in short scintillation counting times and short autoradiographic exposures. Phosphorus-32 has the advantage over other radionuclides in that high specific activities can be readily attained. However, precautions must 32 be taken when handling P because of the radiation emitted (Chapter 2). Detection by autoradiography, while sensitive, may take a long time if there are few counts in the hybrids. This method is suitable for probes and primers that are single stranded and short (20–30 bases). The probes should be boiled prior to addition to the hybridization solution in order to be single stranded. In some cases, it is preferable to apply these labelled probes directly to cells and tissues to localize the source of the signal. Following several washing steps, a detection method is used to localize the signal indicating areas in which the probe has bound to the tissue. When radioactive probes are used, the tissue sections on microscope slides are dipped in a silver emulsion similar to an X ray film. These slides are kept in the dark for a period of time (from days to weeks) after which the emulsion is developed in a fashion similar to developing a film. Introduction The therapeutic use of radionuclides may be a potential radiation risk for both family members and individuals close to the patient, as well as health workers and the environment. Radionuclides must be used in strict accordance with safety measures and any special instructions, and all precautions must be taken to avoid unnecessary exposure to radiation. This chapter summarizes the steps to be taken before commencing therapy procedures. Licensing The administration of therapeutic doses of radionuclides must be under the responsibility of a physician who is licensed under national regulations to administer radioactive materials to humans. Radioactive material for diagnosis or therapy should only be used and stored at medical institutions which have purpose designed facilities. Licensing requirements vary from country to country and may even include minimum design and construction requirements for the facility. Facility design and construction The general principles for the design of nuclear medicine units are discussed in Chapter 3, and further information regarding therapy units is provided in Section 6. When designing therapy units, it is important to bear in mind the following: (a) Patients must be housed in a separate room, with dedicated bathroom and toilet. Close cooperation between the nuclear medicine staff and architects and builders is vital. If an existing space is to be modified, it may be necessary to determine experimentally the adequacy of walls and floors as radiation shields. If any building work is to be performed, a regular inspection of work in progress is advisable to ensure adherence to agreed plans and specifications. In particular, it should be noted that: —Brick walls often have inadequate mortar joints, which can be a shielding problem. Responsibilities The physician administering the therapeutic radionuclide dose is ultimately responsible for taking every precaution to avoid unnecessary radiation to staff, other patients, visitors and the general public. Before commencing therapy, agreement should be reached on medical and radiation safety protocols. In addition to normal medical records, a logbook should be kept, listing the patient’s name, the radiopharmaceutical and radioactive quantities adminis- tered, and the administration date. Training Radionuclide therapy may involve staff outside the nuclear medicine department, especially nurses and medical staff. A little effort devoted to famil- iarization and training in the medical and safety aspects of radionuclide therapy can avoid potentially serious problems later. General principles Radionuclide therapy presents relatively few hazards to staff and patients, but there are a number of common principles of radiation safety that have to be observed. This section will consider the requirements for patient accommodation (design requirements including shielding), as well as radiation safety procedures necessary for safe practice. For safety purposes, each therapy can be divided into different stages, with specific safety issues that may need to be considered (Table 6. The specific radiation safety issue for each of the common therapies is discussed later in this section. Discharge limits Patients may be discharged only when the remaining activity is less than that prescribed by the local regulatory authority.

No such receptors have been found Therefore purchase generic wellbutrin sr online depression symptoms on dogs, does alcohol work by changing membrane fluidity (and thereby alter receptors/channels? Taxonomy: Alcohol abusers tend to remain alcohol abusers and alcohol dependent patients tend to remain alcohol dependent wellbutrin sr 150mg otc depression young living. Alcoholism can be divided into Alcohol related problems - social wellbutrin sr 150 mg otc anxiety worksheets for children, psychological or physical Alcohol dependence - manifested similarly to any other physical dependence: Secretiveness Buying extra rounds Gulping drinks Drinking alone Stocking up Giving other activities up 2525 People who start smoking often experience disconcerting nausea, cough, and dizziness and yet, if social pressure is strong enough, may persist with the habit to the point of dependence. Performance impairment, often subtle, is greater in older people than can be 2529 accounted for by blood alcohol concentration. Non-intoxication in the presence of a blood alcohol level in excess of 200 mg/dL is pathognomonic of alcoholism. Have you ever neglected your obligations, your family, or your work for 2 or more days in a row because you were drinking? The scores are not shown to the user in the form in which the questionnaire is used in practice, but they are given here for convenience sake. Have you ever had a drink first thing in the morning (eye-opener) to steady your nerves or to get rid of a hangover? One unit of alcohol equals a half-pint glass of beer, lager or stout, a glass of wine or sherry, or a single measure of spirits. Having excess drink on each occasion of drinking (say > 5 drinks) is as important as the overall intake when it comes to social and personal complications. The annual cost of alcohol misuse in Britain for 1990 was estimated at stg £2 bn if one includes ill health, crime, accidents and absenteeism. Treatment of illnesses and injuries due to alcohol costs the British Government in the early twenty-first century up to £176 bn annually, total costs (absenteeism, crime, etc) reaching as high as £20 bn. This takes no account of the effects on health, relationships, and child development. About 25% of acute male admissions to medical wards, and an even higher percentage in the case of acute surgical emergency admissions, are related to alcohol misuse. If someone looks sober with a high blood alcohol level this suggests a regular heavy alcohol intake - the 2536 levels can still be high 24 hours after the drinking has stopped. Reasons for misdiagnosis of excess alcohol consumption in the elderly (O’Connell ea, 2003) Non-disclosure Low index of clinical suspicion Low referral rate because seen as understandable (poor health and life changes) and untreatable Atypical (falls, confusion, depression) or masked (comorbid physical or psychiatric disorders) presentation Non-applicability of ‘sensible limits’ (metabolic changes, ill health, increased sensitivity to alcohol) Lack of consequences (social, legal, occupational) Focus on recent (rather than lifetime) intake by diagnostic criteria and screening instruments Self-disclosure of alcohol intake by elderly Irish interviewed in their homes showed a significant positive association between consumption and being male and widowed. It was held that 6- 20% of alcoholics commited suicide, although the accepted figure has dropped below the lower of these 2537 two figures in recent years. The alcoholic who was seen as at the highest risk for suicide was older, socially isolated, male, had made previous suicide attempts of serious intent, was physically ill and had a 2533 Gamma glutamyl transpeptidase levels are also elevated with hepatic disease, obesity, and a number of drugs (e. He also believes that 25% of suicides are solely due to alcohol (alcohol is present in the bodies of 58% of Irish suicides). Elder abuse is usually related to chronic stress and low support, but a minority is associated with drug and alcohol abuse, sociopathy, intellectual disability, and various psychiatric disorders in the abuser, e. Wrigley, 1991) Depression in alcohol misusers is often secondary to alcohol, although it may be primary in some cases (bipolar > unipolar depression). Opinion differs on how long a period of sobriety is required before an (alcohol-) independent diagnosis of depression can be made. Alcoholics are at high risk for marital breakdown, unemployment, accidents, doing physical or psychological harm to others, becoming involved in unwise sexual encounters, and of imprisonment. It may also causes gradual coarsening of the personality and the emergency of sociopathic traits. Syndromes associated with alcohol Alcoholic dementia: Lishman (1987) suggested that this condition might account for at least 10% of all end-stage dementias. Radiological studies revealed decreases in brain volume in many chronic alcoholics. This is at least partially and very slowly reversible with prolonged abstinence: it is debated as to whether reversal is due to rehydration of the brain or repair of neurones or myelin. In both cortical areas there was evidence that alcoholics had smaller, shrunken neurones than controls. Possible causes of cognitive disorders in alcoholics include premorbid intellectual deficit, direct ethanol neurotoxicity, neurological complications of alcohol (e. Korsakoff’s), thiamine or nicotinic acid deficiency, recurrent head trauma, and hepatocerebral degeneration. There is controversial evidence that light to moderate drinking may reduce the chances of developing dementia, even when other variables like smoking are controlled for. Most cases clear up quickly after drinking is stopped although hallucinations may return if drinking restarts. The patient may become paranoid, hostile or suicidal as a result, or he/she may take flight or hide. Treatment includes detoxification from alcohol and neuroleptics for hallucinations. Features include intense fear, restlessness, 2540 2541 illusions, delusions, visual hallucinations , tremulousness, ataxia, vestibular dysfunction , hypertension, tachycardia, leucocytosis, impaired hepatic function, and pyrexia. Fever may be part of the core syndrome or due to a complication such as aspiration pneumonia. High blood pressure, tachycardia, and tremor may be obscured by medication that the patient is taking, e. Death can be due to 2543 2544 cardiovascular collapse, infection, and self-injury when restless. Subdural haematoma, pneumonia, and meningitis should be considered in the disorientated alcoholic. Fluids should be replaced sparingly because alcoholics have a reduced ability to excrete water and a tendency to cerebral oedema. Black-outs: This refers to memory lapses (‘memory blackouts’) following a heavy bout of drinking despite observers not noting any significant change in level of consciousness. It is more likely to be abnormal if it occurs frequently or if the episodes of amnesia last for days. The drinker cannot remember where he left his car, who was with him at the time, and so on. Hypoglycaemia: Factors responsible include malnourishment (low hepatic stores of glycogen) and inhibition of hepatic gluconeogenesis by alcohol. Children who take alcohol (not necessarily in large quantity), binge drinkers, and chronic alcoholics have relatively little glycogen reserve in their livers and may present in a comatose state with hypothermia. Hypertension: About a quarter of alcoholics have systemic hypertension, often resolving (to various degrees) with abstention. Retrobulbar neuritis and optic atrophy: These are classically associated with methanol but can occur with ethanol. The retrobulbar neuritis usually comes on insidiously and causes central loss of vision, typically red-green blindness. Neuropathy: This is usually a polyneuropathy, with sensory, motor and autonomic signs: numbness, paraesthesiae, burning dysesthesia, pain, weakness, muscle cramps, gait ataxia, loss of tendon reflexes (including ankle jerks), defective perception of touch and vibration sensation.

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Group 1 (n = 22) received 20 Although most balneotherapy trials involving rheu- minutes of bathing once a day cheap wellbutrin sr 150mg free shipping depression symptoms wanting to be alone, five times per matic conditions such as fibromyalgia report positive week purchase wellbutrin sr 150 mg on line mood disorder unspecified dsm 5. Patients participated in the study for 3 findings order online wellbutrin sr depression la definition, many studies have been assessed as being weeks (total of 15 sessions). Patients ‘positive findings’ should be interpreted with caution were evaluated by the number of tender (Verhagen et al 2003). All participants differences in the number of tender points, stayed for 10 days at a Dead Sea spa. However, program incorporating manual lymph drainage, there was no statistical difference in Beck’s exercise therapy, massages, psychological counseling, Depression Index scores compared to the relaxation training, carbon dioxide baths and mud control group (p >0. This study the greatest short-term improvements found for shows that balneotherapy is effective and may mood-related aspects of quality of life, the most lasting be an alternative method in treating improvements found for physical complaints (e. Older patients, non-obese patients, – in which the patient floats in warm water patients with a greater lymphedema and patients sourced from hot springs (35°C) while having with an active coping style showed slightly greater the moves and stretches of Zen Shiatsu applied improvements. The combination of inpatient rehabilitation with spa therapy provides a promising approach for breast cancer rehabilitation (Van Tubergen et al 2006). Spa therapy As spa therapy is typically practiced in a health Spa therapy and depression resort, it is sometimes called health resort medicine. Spa therapy combines hydrotherapy, balneotherapy, There is a modest degree of support for the value of patient education, nutrition and physical therapy as spa therapy in the treatment of moderate depression. In combination, spa therapy The majority of spas do not accept individuals with has been shown to be clinically beneficial for a variety serious behavioral problems or those who are at risk of common health conditions. Thus, this form of therapeutic intervention et al 2002) show that spa therapy is cost-effective as has only limited evidence of value in these conditions compared to standard treatment alone, for example in due to the lack of research (Dubois 1973, Dubois & treatment of osteoarthritis of the knee. While spas may not accept serious behavioral problems, it is important to consider chronic pain or other medical conditions as Spa therapy and fibromyalgia causes for depression or thoughts of suicide. The In a Turkish study (Cimbiz et al 2005), 470 patients evaluation of the depressed patient and determina- with fibromyalgia and other conditions received spa tion of a positive treatment outcome is based on the therapy twice a day (with underwater exercise in the cause of depression. Given that chronic pain and other spa pool), 20 minutes total duration per day in the first medical conditions may seriously affect the activities week and 30 minutes for the following weeks. Results of daily living, it is plausible that hydrotherapy, bal- showed a significant decrease in pain and high blood neotherapy or spa therapy may improve these medical pressure without hemodynamic risk. Thirty-seven patients (14 men and 23 women) women, aged 32–82 years, who participated in the suffering from chronic pain participated in the study. Quality They were randomly assigned to either a control 530 Naturopathic Physical Medicine group (17 participants) or an experimental group (20 ment are T5–T8 and T11–L2. The overarch- indicated that the most severe perceived pain inten- ing goal of the treatment system is to ‘improve the sity was significantly reduced, whereas low perceived quality of the circulating blood’. In the words of the developer of constitutional Current (2006) calls for continued and expanded hydrotherapy, Dr O. Carroll: research are occurring at an international level by the Health must at all times come from and be maintained Cochrane Library and the International Society of by digested foods. Naturopathic Physicians understand Medical Hydrology and Climatology (Bender 2006). These necessary naturopathic approaches, will continue to clarify the elements can come only from digested foods. After possibilities of hydrotherapy application in a wide a food is digested, it goes through a process of variety of conditions. Remember this process begins first with the Naturopathic applications and the role digestion of food, and no drug yet offered can rectify of constitutional hydrotherapy damage done by failure of digestion. Unique The strategy of application within the constitutional naturopathic approaches have also been developed. Dr Carroll developed a flexible is determined by the pathology and the physical clinical system that combined Kneipp hydrotherapy effects of the modality chosen. Relative to the terminology of his respiratory tree affected is a very common modifica- day, as described in Chapter 3, Dr Carroll would have tion. Or, in the case of osteoarthritis of the knee, a been considered not in the nature curist camp but in standard constitutional treatment with the addition of the physiotherapist camp of the naturopathic profes- 10 minutes of constant low voltage alternating current sion due to his wide inclusion of electrotherapy to the limb affected is a very common modification modalities. Dr Carroll also incorporated irisdiagnosis, heart The standard treatment is a tonification of the organ- tone diagnosis, food intolerance evaluation and ism and as such represents the basic treatment of the physiomedicalist botanical prescriptions, and used system. The approach is constitutional in nature, treat- the Schuessler Biochemic minerals in a systematic ing the whole organism to enhance general adaptation approach to naturopathic clinical practice. As men- mechanisms particularly relevant to circulatory distri- tioned above, Dr Carroll was trained by Dr Ledoux of bution and metabolic function. Dr developed during the 1920s, which was a particularly Carroll was encouraged to move to the American fruitful period for the profession. While he the whole-body constitutional approach that utilized was unable to do that, he did operate a very busy and physical medicine for a wide variety of complaints well-known clinic until his death in 1962. It was during The standard constitutional hydrotherapy treatment this period that the general naturopathic tonic treat- combines a modified Kneipp torso pack with the ment was originally developed, as well as the basic spondylotherapy methods of Dr Abrams (see Chapter spinal and abdominal treatments of neuromuscular 12). Chapter 11 • Naturopathic Hydrotherapy 531 Constitutional hydrotherapy treatments are still replaces the two Turkish towels previously widely taught, applied and researched because of applied. Slide two 4-inch electrode pads tional hydrotherapy represents the clinical evolution underneath the patient, one from each side, so of an eclectic, flexible, constitutional and uniquely that each is on one side of the spine with the naturopathic approach to comprehensive physiother- upper edge of the electrode approximately apy treatment for a general clinical setting. Replace the hot towel with one Turkish towel well wrung from cold water from the Standard constitutional hydrotherapy faucet (40–55°F/4–12°C; note this does not include iced or especially cold water) and As previously discussed in the naturopathic applica- folded in half. Again cover the patient with the dard treatment’, the representative treatment and cor- blanket. Place the low volt alternating current sine Indications wave unit within reach of the patient and instruct the patient to adjust the intensity. The The standard constitutional treatment is designed to current output should be on the surge tonify digestion, enhance appropriate immune func- (massage) setting with a low duty cycle of tion, improve intestinal flora balance and gently 6–10 cycles each minute. Modifications of the physiotherapy adjusted by the patient, and the following modalities allow for a flexible application to a large levels are noted in this order: variety of clinical conditions such as inflammatory bowel disease, asthma, upper respiratory infection, a. The patient will feel a gentle contraction dysfunction, cancer, musculoskeletal injury and/or somewhere in the abdomen, usually under disease, metabolic diseases as well as cardiac condi- the costal margin on the right, but not tions (Blake 2006b, Boyle & Saine 1988e, Scott 1992). The patient will feel strong contractions of Methodology the muscles of the upper back. This is Patient supine, undressed from the waist up, covered unnecessary and counterproductive. Two Turkish towels, each folded in half, well minutes of total treatment time have elapsed), wrung from hot water (130–140°F/54–60°C; check the center of the towel over the solar note the relatively high temperature of the plexus to see if the patient has warmed the compress) are applied covering chest and towel to at least body temperature. If the patient has not, the towel as needed so that they do not lie then cover the patient again with the blanket, beyond the anterior axillary line. Ask the patient to arch the back or lift the is used to separate the patient and the shoulder in order to move the sine wave pads blanket, as is common for sanitation reasons, from the upper back to the abdomen.

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Outpatients who fail to demonstrate the gallbladder after morphine or delayed imaging should be held until reviewed with the radiologist purchase discount wellbutrin sr on line mood disorder resources. If sincalide is unavailable generic wellbutrin sr 150 mg online depression hormones, Ensure Plus may be substituted as an appropriate cholecystagogue upon discussion with the Radiologist buy cheap wellbutrin sr on-line anxiety attack treatment. Radiopharmaceutical: Tc mebrofenin or Tc disofenin is prepared according to the Radiopharmacy procedure manual. Preset counts for 1M counts or time for 240 sec for adults, 300K/image for infants (0-6 months). Sincalide-Stimulated Cholescintigraphy: A Multicenter Investigation to Determine Optimal Infusion Methodology and Gallbladder Ejection Fraction Normal Values Harvey A. Morgan Department of Radiology and Radiologic Science, Baltimore, Maryland; 2Nuclear Medicine Division, Department of Radiology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; 3Department of Radiology, Memorial Health University Medical Center, Savannah, Georgia; 4Biostatistics Consulting Center, Temple University School of Medicine, Philadelphia, Pennsylvania; 5Gastroenterology Section, Temple University School of Medicine, Philadelphia, Pennsylvania; and 6Department of Radiology, Temple University School of Medicine, Philadelphia, Pennsylvania Sincalide-stimulated cholescintigraphy is performed to quantify gallbladder contraction and emptying. Methods: Sixty healthy volunteers at 4 medical cen- ters were injected intravenously with 99mTc-mebrofenin. This sincalide infu- sion method should become the standard for routine clinical use. Two literature reviews found insufficient evidence to confirm the diagnostic utility of sincalide cholescintigraphy to predict outcome after cholecystectomy for chronic acalculous gallbladder dis- ease, precluding any definitive recommendation regarding its diagnostic use (4,5). They concluded that a well- designed sufficiently powered prospective study is needed. One concern the reviews mentioned was the lack of standardization of sincalide infusion methodology. Almost 30 investigations have now been published that have used different sincalide infusion methodologies, that is, different total doses, infusion times, dose rates, and normal values (3). The dose, duration of sincalide infusion, and normal values used in clinical practice also vary considerably among different imaging centers. Some of these methods have validated normal values; however, many have not been validated. The purpose of this investigation was to determine an optimal method for sincalide infusion by comparing 3 different sincalide infusion methods in clinical use, 0. Both 99mTc- mebrofenin and sincalide were provided free of charge by Bracco Diagnostics, Inc. The company had no involvement in the de- velopment of the protocol or its analysis. Study Subjects Sixty healthy volunteers were investigated between July 2008 and June 2009. Four medical institutions each recruited, per- formed, and completed studies on 15 research volunteer subjects, who had 3 studies each. Before this investigation, the 4 institutions used different sincalide infusion durations, including 15 min (1 institution), 30 min (2 institutions), and 60 min (1 institution). To be included, the subjects had to be healthy men or women 18–65 y old, with no gastrointestinal disease as confirmed by initial screening using a modified Mayo Clinic Research Gastro- intestinal Disease Screening Questionnaire. They also had to have a high probability for compliance and completion of the study. In addition, they had to have normal results for complete blood count, metabolic profile (including liver, renal, and thyroid function tests), serum amylase, and gallbladder ultrasonography. Subjects were excluded from participation in the study if they had prior gastrointestinal surgery (excluding appendectomy); any surgery within the past 6 mo; cardiovascular, endocrine, renal, gastrointestinal, or other chronic disease likely to affect motility (including diabetes, renal insufficiency, gastroesophageal reflux disease, gastroparesis, irritable bowel syndrome, or peptic ulcer disease); gastrointestinal symptoms (e. In addition, any subject was excluded if taking chronic opiate pain medica- tions, atropine, nifedipine (calcium channel blockers), indometh- acin, progesterone oral contraceptives, octreotide, theophylline, benzodiazepine, or phentolamine. Women were excluded if they were pregnant or lactating or if they were not practicing birth control. Study Protocol Each of the 60 subjects had 3 infusion studies at least 2 d apart, and all studies were completed within 3 wk. The order in which the 3 different sincalide infusions were performed was determined by randomization at the time of enrollment. Subjects reported to the test facility fasting; 45 subjects at 3 institutions fasted overnight and the morning before the exami- nation, 15 subjects at 1 institution fasted for 4 h before the study. Images were acquired using a wide-field-of-view g-camera and a low- energy collimator. The syringe was connected to infusion tubing, which was primed before placing it in the infusion pump. At 3 in- stitutions, images were acquired for 60 min regardless of the infusion duration in 45 subjects. In 15 subjects at one institution, imaging was discontinued at the end of the infusion duration, that is, at 15, 30, or 60 min. To determine the incidence of side effects associated which each infusion method, the subjects were asked about any adverse symptoms. Healthy subjects were recruited to provide an appropriate mixture of both men and women and a wide, evenly distributed age range. Further analysis was done to determine whether there were significant differences based on age, order, or sex. Only 2 subjects complained of adverse symptoms during the sincalide infusion, that is, mild nausea and abdominal cramping, and these were reported only for the 15-min-infusion method. However, because the data did not have a gaussian distribution and were skewed somewhat to the left, the first, fifth, 95th, and 99th percentiles were considered more appropriate for defining normal values (Table 2; Fig. For the 15- and 30-min infusions, the lower limits of normal for all infusion lengths were all less than 25% and 19% (fifth percentile), respectively, and less than 17% and 13% (first percentile), respectively (Table 2). This disorder has been called by various names, including chronic acalculous gallblad- der disease, chronic acalculous cholecystitis, gallbladder dyskinesia, cystic duct syndrome, gallbladder spasm, and functional gallbladder disease. The reasons for this discrepancy are uncertain, but there could be several factors, including referral bias, small sample size, or the retrospective nature of the investigations. Alternatively, the discrepancy may be due to the many different methodologies and normal values used for sincalide-stimulated cholescintigraphy, many of which have not been well validated. This multicenter investigation was designed to determine the optimal methodology for infusion of sincalide and to establish normal values. Our approach was to compare 3 different sincalide infusion methods in clinical use, that is, 0. This approach allowed us to also look at additional intervals and dose rates during and after sincalide infusion; for example, a 60-min infusion at 30 min represents a total dose of 0. The slower infusions, that is, 30–60 min, almost never produce adverse symptoms; the 15-min infusion occasionally causes adverse symptoms, as seen in this study. In the era of oral cholecystography, bolus infusions of sincalide were reported to sometimes cause nausea and abdominal cramping and spasm of the neck of the gallblad- der, with ineffective contraction (13,14). However, the adverse symptoms and ineffective gallbladder contraction seen with a 3-min infusion of sincalide are similar to what is reported with bolus infusions.