By P. Gunnar. Chicago School of Professional Psychology. 2019.

Extra esophageal symptoms include sore throat generic caverta 50 mg without a prescription prices for erectile dysfunction drugs, cough order 100mg caverta with amex erectile dysfunction protocol download free, dysphagia and sleep disturbance discount 100 mg caverta overnight delivery list all erectile dysfunction drugs. Other processes denominated as atypical manifestations, or extra esophageal manifestations have been classified basically in three groups: breathing manifestations, thoracic atypical pain and manifestations of the oto- rhino-laryngea area and of the oral cavity. This is important considering that permanent acid reflux can induce esophageal complications such as esophagitis (i. Moreover, calorie density intake correlates with the severity of gastroesphageal reflux (6). Heartburn in Belgium: prevalence, impact on daily life, and utilization of medical resources. Prevalence, risk factors validated Chinese and impact of gastroesophageal reflux version of the Reflux disease symptoms: a population-based Disease study in South China. Gastroesophageal 100,000 patients referred for reflux disease: prevalence, clinical, population/year. Health Interview Prevalence and sociodemographics of and Examination reflux symptoms in Germany--results from Survey a national survey. Prevalence of 6035 Japanese gastroesophageal reflux disease and subjects who visited gastroesophageal reflux disease a clinic for a routine symptoms in Japan. Frequency of volunteers, with a functional bowel disorders among mean age of 35 healthy volunteers in Mexico City. Prevalence of participants in gastro-oesophageal reflux symptoms Nord-Trondelag, and the influence of age and sex. Republic of 1,53% 2005 Local National Data from Department of Belarus Register for Gastroenterology and Nutrition, Gastroenterological Byelorussian Medical Academy Disease Postgraduate Education. Republic of 1,41% 2007 Local National Data from Department of Belarus Register for Gastroenterology and Nutrition, Gastroenterological Byelorussian Medical Academy Disease Postgraduate Education. Republic of 1,15% 2006 Local National Data from Department of Belarus Register for Gastroenterology and Nutrition, Gastroenterological Byelorussian Medical Academy Disease Postgraduate Education. Spain 32% 2004 Questionnaire Data from Sociedad Espaola de based studies Patologa Digestiva. Reflux-inducing dietary case-control study factors and risk of adenocarcinoma of the esophagus and gastric cardia. Risk factors for gastro- subjects, stratified oesophageal reflux disease symptoms: a by age, gender community study. Overlap of valid simptom gastro-oesophageal reflux disease and questionnaire irritable bowel syndrome: prevalence and risk factors in the general population. Yemen 34% 2006 Longitudinal study Data from Yemen Gastroenterology among 2002-2006 Association. Gastro Endoscopic Unit Hospital The survey has detected a prevalence ranging from 11% to 38. Malaysia, Mexico, Spain and Yemen reported figures on the top quartile of prevalence, whereas the Asian countries reported prevalence rates in the lowest quartile. Variability in methodology for obtaining data may explain some of the differences between countries. Helicobacter pylori Infection The Gram-negative spiral bacteria Helicobacter pylori is known to cause infection of the gastric mucosa. Survey Author/Source of Country Prevalence Type of Study Data information Argentina 40%(children in 2007 Survey with 395 Goldman C, Barrado A, Janjetic M, et al. Buenos Aires) children with upper Factors associated with Helicobacter gastrointestinal pylori epidemiology in symptomatic symptoms referred to children in Buenos Aires, Argentina. Unit of the Children Hospital "Sor Maria Ludovica" Argentina 36% 2000 Nationwide Olmos, J. Prevalence of Helicobacter pylori infection in Argentina: results of a nationwide epidemiologic study. Helicobacter pylori and prevalence of Helicobacter heilmannii in children, A Helicobacter pylori Bulgarian study. Helicobacter and women aged 50- pylori infection in Ontario: prevalence 80 years belonged to and risk factors. Czech Epidemiological Study pylori prevalence and of Helicobacter pylori prevalence and incidence incidence Czech 42% 2006 Cross-sectional of Bures J, Kopacova M, Koupil I, et al. Republic representative Epidemiology of Helicobacter pylori population study in infection in the Czech Republic. Republic 2309 persons aged 5- Epidemiology of Helicobacter pylori in the 100yrs, representative Czech Republic. Frecuencia de patients infeccin benigna por Helicobacter pylori en pacientes con patologa gastrointestinal benigna (abstract). Decreasing representative sample seroprevalence of Helicobacter pylori of population infection during 1993-2003 in Guangzhou, southern China. Indigenous Greenlanders have a higher sero- prevalence of IgG antibodies to Helicobacter pylori than Danes. Results of a southern Germany from the general representative cross-sectional study. Seroepidemiology of 21,1%(group aged randomly selected Helicobacter pylori infection in an urban, 12-20 years) urban upper class upper class population in Chennai. The a rural area in Northern Loiano-Monghidoro population-based Italy (792 men, 741 study of Helicobacter pylori infection: women, age range 28- prevalence by 13C-urea breath test and 80 years) associated factors. Risk factors for acquiring Helicobacter pylori infection in a group of Tuscan teenagers. Seroprevalence of consecutive volunteer Helicobacter pylori infection among blood donors blood donors in Torino, Italy. Japan 29%(children aged 2001 Comparative study Yamashita Y, Fujisawa T, Kimura A, Kato H. Helicobacter pylori group) healthy individuals in infection in Kazakhstan: effect of water Kazakhstan source and household hygiene. A relatively low children prevalence of Helicobacter pylori infection in a healthy paediatric population in Riga, Latvia: a cross- sectional study. A community-based seroepidemiologic study of Helicobacter pylori infection in Mexico. Mexico 66% 2007 Serology Data from Asociacin Mexicana de Gastroenterologa Netherlands 1% (children) 2007 Seroprevalence study Mourad-Baars, P. Low population prevalence of Helicobacter pylori infection in young children in the Netherlands. The effects of environmental factors on the prevalence of Helicobacter pylori infection in inhabitants of Lublin Province. Portugal 80% in 1998 Cross-sectional study Data from Sociedade Portuguesa de asymptomatic Gastroenterologa Portugal 52,9% in children 1999 Cross-sectional study Data from Sociedade Portuguesa de aged 6-11 years. Gastroenterologa Republic of 55-76% 1995-2004 Comparison in adults Data from Department of Belarus (dependent from and Childhood gastric Gastroenterology and Nutrition, diseases) 50-60% mucous lesion in same Byelorussian Medical Academy (health person) 10- population sources Postgraduate Education. Dramatic changes in the prevalence of Helicobacter pylori infection during childhood: a 10-year follow-up study in Russia. Journal of Gastroenterology & Hepatology 2005; 20: 1603-9 Spain 69% 2006 Breath test Data from Sociedad Espaola de Patologa Digestiva.

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The plantar dysphasia there is a specic defect in recognition and response is upgoing cheap caverta 100 mg otc trimix erectile dysfunction treatment. There is failure to understand the meaning of knee exion and ankle dorsiexion than in their words although the motor aspects of speech are pre- antagonist movements purchase 100mg caverta overnight delivery erectile dysfunction laser treatment. This can produce uent dysphasia when the patient responds to questions with meaningless Consequently a hemiplegic person tends to walk with responses purchase caverta 50mg on line erectile dysfunction drugs bangladesh. Bulbar and pseudobulbar palsies Proximal myopathy The symptoms of dysarthria, dysphagia and nasal regurgitation result from paralysis of the 9th, 10th and Proximal muscle wasting and weakness seen in 12th cranial nerves. Acquired dyslexia (difculty in reading), dysgra- Patterns of sensory loss in phia(difcultyinwriting)anddyscalculia(difcultyin calculating) are features of lesions in the posterior the limbs parietal lobe. Agnosia denotes damage to the contra- Peripheral neuropathy lateral sensory cortex and is the inability to under- stand or recognise objects and forms in the presence Reduction or absence of vibration and position senses of normal peripheral sensation. Tactile agnosia is not only suggest dorsal column loss but also may be most common. Visual agnosia describes the inability part of a mixed sensorimotor peripheral neuropathy. In 23% of people, the ulnar nerve supplies all the Spinothalamic loss without dorsal hand muscles. Sensory loss may be very limitedbecausethemedianandulnarnerveterritories Dissociated sensory loss is a feature of spinal cord overlap the radial territory. Lateral cutaneous nerve of the Cerebral cortical lesions thigh Astereognosis and dysgraphaesthesia occur with par- Compression causes meralgia paraesthetica, a syn- ietal sensory loss. Isolated peripheral nerve lesions Lateral popliteal lesion Median nerve lesion (carpal tunnel syndrome) The lateral popliteal (common peroneal) nerve sup- plies the peroneal muscles which dorsiex and evert Patients with carpal tunnel syndrome complain of the foot. The nerve may be damaged as it passes over tinglingandnumbnessofthengersand/orweakness the head of the bula, resulting in foot-drop. There of the thumb, which are at their worst on waking and may be sensory loss over the outer aspect of the leg relieved by hanging the arm downwards. Pain at the exor aspect of the wrist may occasionally radiate up to the elbow and, exception- ally, as far as the shoulder. Cerebellar incoordination Ulnar nerve lesion Cerebellar incoordination is characterised by ipsilat- The ulnar nerve supplies all the small muscles of the eral intention tremor, past-pointing and failure of hand except three of the four muscles of the thenar rapid repetitive coordinated movements (dysdiado- eminence. It is associated with truncal ataxia, the wrist or in the ulnar groove at the elbow. The ring and little ngers still place the limbs accurately by looking at them; Neurological system 55 tests are performed with the eyes open and the eyes Sensory (dorsal column) ataxia closed. When the patients coordination is worse with the eyes closed than with them open they are A high stepping gait. Fingernose Steppage (drop-foot) gait and heelshin tests are normal when the patient There is no dorsiexion of the foot as it leaves the can see but incoordinate when they cannot. The pelvis drops on each side as the leg leaves the Combined lower and upper motor ground due to myopathic changes in the pelvic neuron lesions muscles. Classically this is seen in sub- acute combined degeneration of the cord (severe Tremors vitamin B12 deciency) and hereditary ataxias such as the hereditary spinomuscular ataxias (including A tremor is a rhythmic oscillating movement of a limb Friedrichs ataxia). Increased muscle tone and spas- or part of a limb and may be seen at rest or in action. Examination of the feet reveals pes cavus due to the combined motor This is best seen with the arms outstretched and is neuron effects. Hemiplegia Exaggerated physiological tremor Theaffectedlegisrigidanddescribesasemicirclewith the toe scraping the oor (circumduction). The arms tend to be held exed Essential tremor and characteristically do not swing. Dystonia refers to slow sinuous writhing move- mentsofthefaceandlimbs,especiallythedistalparts. Asterixis In torsion spasm (dystonia) the movements are This is the apping tremor associated with metabolic similar but slower and affect the proximal parts of the disorders. Diabetes mellitus, thyroid disease syndromes and polycystic ovary syndrome are common, most. The emphasis of the examination of the endocrine system should be dictated by the particular organ system that appears to be involved. Trousseaus sign maintaining the cuff at above systolic pressure for 3 min induces carpal spasm of. Chvosteks sign tapping over the facial nerve anterior to the ear induces ipsilateral twitching of. To demonstrate this, the patient should be T establish stocking sensory neuropathy if given a sip of water to hold in the mouth and then appropriate swallow when asked. Often the clinical T unilateral solitary nodules problem relates to their size, which may produce. The major symptoms of musculoskeletal detailed examination of the musculoskeletal system. Look for obvious clues including and radionuclide scans if indicated, together with evidence of joint replacements, mobility aids and blood tests for inammatory markers, haematology hand warmers. Swan neck, Boutonniere deformities of ngers` T rheumatoid arthritis, steroid usage. Key features of assessment tools An understanding of the way in which examinations are designed, implemented and scored ensures better Reliability: reects the reproducibility of the preparation for the range of assessment formats that assessment tool and the accuracy with which a may be encountered during medical education and score is being measured. In this chapter some important assessments such as multiple choice and extend- characteristics of assessment will be described briey ed matching question formats, and lower in clinical followed by a focus on the assessment of clinical competency-based assessments where there are competence. Reliability is quanti- Summative assessments measure the achieve- tative and reected by the statistic known as ment of learning goals at the end of a course or Cronbachsalpha. Summative assessments are formal and used to determine progression to the next theory can be performed to account for complex stage of a course, to signify the need for remediation, variables. A num- gression such as Finals examinations in medical ber of categories of validity are described; for school, membership of Royal Colleges or Specialty example, the content validity reects the way in Board Examinations in North America. Formative assessments should be ongoing, fre- nature of the assessment and high construct quent, non-judgemental and carried out in informal validity suggests that the test discriminates well settings. Feedback is central to formative encourage learners to acquire the desired know- assessment and should encourage learners towards ledge, skills and attitudes. Formative assess- Cost-effectiveness: reects the practical aspects ments may be in a number of different formats, of assessment and helps determine the choice of including Objective Structured Clinical Examin- assessment tool. Blueprinting: ensures the assessment tool sam- ples content across the full range of learning objectives for the curriculum. In essence, each examiner scores the can- Norm-referencing: in norm-referenced assess- didate using the station checklist this constitutes ments the pass mark is determined by examiners the candidates score for that station. In addition, using comparison within the cohort of examinees and the examiner awards the candidate a global score, thus the pass-markvariesat each sitting. Global of candidates will pass the assessment on each occa- rating scales include a spread of judgements such as sion (Fixed Percentage Method). Norm-referencing fail borderline fail borderline pass clear pass doesnottakeaccountofthecontentoftheassessment outstanding. Thesemethodshave experienced examiners using their judgement about gained credibility as they allow experienced clinicians the degree of difculty of the assessment and the to make judgements about professional competence minimum score expected of a candidate who just and they are currently the gold-standard methods for reachestheacceptablestandard.

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Positive culture results may take 48 hours generic 100 mg caverta visa erectile dysfunction caused by medications, and Gram stains of ascitic fluid are only positive in 10-50% of infected patients buy caverta 100mg otc erectile dysfunction caused by high cholesterol. A five-day course of Cefotaxime 2 g intravenously every 8- 12 hours is effective as a ten-day course order caverta 100 mg on-line erectile dysfunction diagnosis. Micro-organisms that can cause spontaneous bacterial peritonitis Gram negative bacilli Gram positive organisms Anaerobes E. These options explore the possibility of giving part of the treatment course as outpatients, thereby shortening the duration of hospital stay. However, monitoring patient compliance becomes mandatory if this course of action is to be followed. One study has shown that the First Principles of Gastroenterology and Hepatology A. Shaffer 528 concomitant use of albumin can reduce the risk of renal impairment in these patients. However, further studies have shown that only patients with a baseline serum creatinine of >88. The response to treatment should be assessed by both evaluating the symptoms and signs of infection, and performing at least one follow-up paracentesis after 48 hours of antibiotic therapy. A reduction of less than 25% in relation to the pre-treatment value is often considered to represent failure of antibiotic treatment. If secondary bacterial peritonitis is suspected, antibiotic coverage should be broadened with the addition of metronidazole and ampicillin. Radiographic examinations are required to exclude perforation of the gastrointestinal tract, with emergency surgery only where gut perforation is confirmed. Routine selective intestinal decontamination with oral non-absorbable antibiotics has proved to be effective in reducing recurrence. Norfloxacin 400 mg daily, Trimethoprim/sulfamethoxazole 160/800mg daily, or Ciprofloxacin 750 mg weekly are the drugs of choice, as they rarely cause bacterial resistance and have a low incidence of side effects when administered chronically. Trimethoprim/sulfamethoxazole 160/800mg daily may confer greater gram-positive coverage. Antibiotic prophylaxis is effective in improving survival in cirrhotic patients with gastrointestinal hemorrhage. The optimal dose and the duration of treatment in this setting have not yet been established. There are no studies to date to determine whether these patients require antibiotic prophylaxis. The recommended dose of albumin is 1 g/kg of body weight per day up to a maximum of 100 g/day. The splanchnic arterial vasodilation that results from severe portal hypertension is a key initiating event. Cirrhotic cardiomyopathy results in an inappropriately low compensatory increase in cardiac output, further compromising renal perfusion. A number of soluble circulating vasoactive mediators have also been implicated in decreasing renal perfusion and the glomerular microcirculation. Parenchymal kidney disease can result from many different First Principles of Gastroenterology and Hepatology A. A renal biopsy is occasionally required to discriminate between causes of parenchymal kidney disease. An assessment of liver function and investigations to rule in or out the presence of sepsis are indicated. Urine microscopy and studies for electrolytes and protein can help rule in or out parenchymal renal disease. Daily serum electrolytes and creatinine help follow responses to therapy and to screen for the development serious electrolyte disturbances (such as severe hyponatremia and hyperkalemia). Treatment with agents thought to be directly vasodilatory for the renal arterial supply (such as non-pressor doses of dopamine) are ineffective (Angeli 1999). Terlipressin, which is not currently available in North America, is the most comprehensively studied pressor (Table 2). Contraindications to terlipressin include ischemic cardiovascular disease, and patients should be observed for the development of ischemic heart disease, arrhythmias, mesenteric and digital ischemia and volume overload. Clinical Presentation Patients with this condition will present in a variety of ways (Table 1). Patients with chronic disease often have other manifestations of their liver disease including jaundice, ascites and gastrointestinal bleeding. The usual physical signs and laboratory abnormalities associated with advanced liver disease may be present. These physical findings include muscle wasting, jaundice, peripheral edema, and ascites. Occasionally fetor hepaticus, a sickly-sweet smell from the mercaptanes in the breath, will be present. Hepatic encephalopathy is characterized by changes in personality, consciousness, behavior and neuromuscular function. West Haven Criteria for Hepatic Encephalopathy Stage Consciousness Intellect and Behaviour Neurological findings 0 - Normal - Normal - Normal exam 1 - Mild lack of - Shortened attention span - Mild asterixis or tremor awareness Impaired attention or subtraction 2 - Lethargic - Disoriented - Obvious asterixis - Inappropriate behavior - Slurred speech 3 - Somnolent but - Gross disorientation - Muscular rigidity and clonus arousable - Bizarre behaviour - Hyperreflexia 4 - Coma - Coma - Decerebrate posturing First Principles of Gastroenterology and Hepatology A. The earliest feature is often reversal of the diurnal sleep pattern or subtle personality changes and irritability. Asterixis (asymmetric flapping motions of the outstretched, dorsiflexed hands) can be easily checked in a routine clinical exam. Hepatic encephalopathy associated with acute liver failure has a rapid onset and progression. It is usually complicated with cerebral edema, which can lead to seizures and lateralizing neurologic signs. Occasionally, a refractory pattern emerges leading to debilitating syndromes such as dementia, spastic paresis, cerebellar degeneration and extrapyramidal movement disorders. When approaching a patient with severe liver disease who has an altered level of consciousness or other neurological features, it is important to rule out other causes of changes in mental status and neurologic disease. One may need to distinguish the neurologic changes commonly seen in patients with alcoholic liver disease and Wilson disease. It may reflect either a reversible metabolic encephalopathy, brain atrophy, brain edema or any combination of these conditions. The mechanisms of brain dysfunction in liver failure are not clearly known (Table 3). Encephalopathy probably results from a number of mechanisms that include, in part, one or more toxic products that originate in the gut that are usually metabolized by the liver entering the systemic circulation and reaching the brain. Ammonia derived from colonic bacteria and from deamination of dietary glutamine in the small bowel is absorbed into the portal circulation. The intact liver clears almost all of portal vein ammonia, converting it to glutamine and preventing its entry into the systemic circulation. In severe liver disease, ammonia reaches the systemic circulation because of spontaneously created vascular shunts within and around the hepatocytes and the inability of the liver to metabolize the ammonia. Increased blood-brain barrier permeability likely facilitates the entrance of ammonia and other toxic metabolites into the brain.

Consider the need for protection against exposure from high-energy beta rays in cases involving therapy with P-32 and Y-90 cheap 50mg caverta amex erectile dysfunction and heart disease. In some cases order generic caverta from india erectile dysfunction and stress, exposure reduction may be accomplished by removing tissues for dissection to a location where the exposure rate is lower purchase caverta 100mg with mastercard erectile dysfunction doctors near me. State on your application, "We have developed Model Leak Testing Procedures for your review that are appended as Appendix K," and submit your spill procedures. Model Leak Test Program Facilities and Equipment To ensure achieving the required sensitivity of measurements, leak tests should be analyzed in a low-background area. Model Procedure for Performing Leak Testing and Analysis For each source to be tested, list identifying information such as sealed source serial number, radionuclide, and activity. For example, [(counts per minute from standard) (counts per minute from background)] Efficiency = (activity of standard in microcurie) Analyze each wipe sample to determine net count rate. State on your application, "We have developed rules for the safe use of unsealed sources for your review that are appended as Appendix L," and submit your model rules for the safe use of radiopharmaceuticals. Model Requirements Wear long-sleeved laboratory coats or other protective clothing at all times in areas where radioactive materials are used. In these exceptional cases, consider the use of other protective methods such as remote delivery of the dose (e. When not being worn to monitor occupational exposures, personnel monitoring devices should be stored in the work place in a designated low-background area. Areas used to prepare and administer therapy quantities of radiopharmaceuticals must be surveyed daily (except when administering therapy dosages in patients rooms when patients are confined). Mark the label with the radionuclide, the activity, the date for which the activity is estimated, and the kind of materials (i. If the prescribed dosage requires a written directive, the patients identity must be verified and the administration must be in accordance with the written directive (4731. Indicate on your application, "We have developed a procedure for safely opening packages containing radioactive material that is appended as Appendix M," and submit your procedure. Model Procedure All shipping packages received and known to contain radioactive material must be monitored for radiation levels and radioactive surface contamination in accordance with 4731. The following procedures for opening each package will be followed: Put on gloves to prevent hand contamination. The surface dose rate for such packages should not exceed 200 millirem per hour at any point on the package. The amount of radioactivity measured on any single wiping material when averaged over the surface wiped, must not exceed the following limits: Beta-gamma-emitting radionuclides; all radionuclides with half-lives 2 less than ten days. Look for broken seals or vials, loss of liquid, condensation, or discoloration of the packing material. The detection efficiency must be determined to convert wipe samples counts per minute 92 to disintegrations per minute. For Packages Received under a General License The following procedure for opening each package will be followed for packages received under a general license: Visually inspect the package for any sign of damage (e. State on your application, "We have developed procedures for administrations that require written directives for your review that are appended as Appendix N," and submit your spill procedures. Written Directive Procedures This model provides guidance to licensees and applicants for developing, maintaining, and implementing procedures for administrations that require written directives. This model does not restrict your use of other guidance in developing, implementing, and maintaining written procedures for administrations requiring a written directive. Such procedures are to provide high confidence that the objectives specified in 4731. The written directive must be prepared for any administration of I-131 sodium iodide greater than 30 Ci (1. The administration of radioactive materials can be a complex process for many types of diagnostic and therapeutic procedures in nuclear medicine or radiation oncology departments. Therefore, instructions must be clearly communicated to the professional team members with constant attention devoted to detail during the treatment process. Complicated processes of this nature require good planning and clear, understandable procedures. To help ensure that all personnel involved in the treatment fully understand instructions in the written directive or treatment plan, the licensee should instruct all workers to seek guidance if they do not understand how to carry out the written directive. Specifically, workers should ask if they have any questions about what to do or how it should be done before administration, rather than continuing a procedure when there is any doubt. Licensees should also consider verification of written directives or treatment plans by at least one qualified person (e. The administration of radioactive materials can involve a number of treatment modalities, e. Procedures for Any Therapeutic Dose or Dosage of a Radionuclide or Any Dosage of Quantities Greater Than 30 Microcuries (1. The following is a model procedure: An Authorized User must date and sign a written directive prior to the administration of any dose or dosage. Asking or calling the patients name does not constitute positive patient identity verification. Appropriate verification methods include: measuring the activity in the dose calibrator, checking the serial number of the sealed sources behind an appropriate shield, using color-coded sealed sources, or using clearly marked storage locations. Additional Procedures for Sealed Therapeutic Sources and Devices Containing Sealed Therapeutic Sources Licensees are required to have written directives for certain administrations of doses and to have procedures for administrations for which a written directive is required. However, for some brachytherapy procedures, the use of various fixed geometry applicators (e. An Authorized User or a qualified person under the supervision of an Authorized User (e. Methods for checking the calculations include the following: o For computer-generated dose calculations, examining the computer printout to verify that correct input data for the patient was used in the calculations (e. The therapy dose will be manually calculated to a single key point and the results compared to the computer-generated dose calculations. If the manual dose calculations are performed using computer-generated outputs (or vice versa), verify the correct output from one type of calculation (e. Parameters such as the transmission factors for wedges and applicators and the source strength of the sealed source used in the dose calculations will be checked. Acceptance testing will be performed before the first use of a treatment planning or dose calculating computer program for therapy dose calculations. Each treatment planning or dose calculating computer program will be assessed based on specific needs and applications. A check of the acceptance testing will also be performed after each source replacement or when spot check measurements indicate that the source output differs by more than 5% from the output obtained at the last full calibration corrected mathematically for radioactive decay. The independent check will include an output measurement for a single specified set of exposure conditions and will be performed within 30 days following the full calibration measurements. The independent check will be performed by either: o An individual who did not perform the full calibration using a dosimetry system other than the one that was used during the full calibration (the dosimetry system will meet the requirements specified in 4731. Such media may be reused (and must be relabeled) in accordance with the manufacturers instructions.

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