From: Subject: Assessing Risk of Insulin Resistance & Metabolic Syndrome-Slides/Transcript Date: Thu, 21 Aug 2008 16:53:20 +0800 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0112_01C903AE.6A8A9670" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.3350 This is a multi-part message in MIME format. ------=_NextPart_000_0112_01C903AE.6A8A9670 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.medscape.com/viewarticle/577683 Assessing Risk = of Insulin Resistance & Metabolic Syndrome-Slides/Transcript

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Selection = from: Small for = Gestational Age: Issues in 2008

Assessing the Risk of Insulin Resistance and Metabolic = Syndrome=20 (Slides With Transcript) CME

Disclosures

Slide 1.

Claire L=E9vy-Marchal, MD: Thank you for = the=20 invitation of being here and explaining thoroughly to you = the=20 relation between born SGA, developing later in life type 2 = diabetes,=20 and also the metabolic syndrome.

Slide 2.

I will first show you the epidemiological evidence that = relates=20 being born small for gestational age and the further risk of = type 2=20 diabetes.

Slide 3.

The very first observation actually published by David = Barker=20 related the birth weight here plotted on the X axis. = Actually, it is=20 the weight at 1 year of age experienced in British pounds. = The=20 weight at 1 year of age was taken as a surrogate of birth = weight,=20 which, in turn, was taken as a surrogate of fetal growth. = You can=20 see here that there is an inverse relationship between the = mortality=20 by cardiovascular accident and the birth -- and the weight = at 1=20 year. Meaning that an increased cardiovascular mortality was = associated with poor fetal growth.

From cardiovascular mortality you can go down to that = type 2=20 diabetes, and you are here expressed the relative risk for=20 developing type 2 diabetes by the age of 64 with respect of = birth=20 weight here. You cannot see anything, but here at the birth = weight=20 below 2.5 kg, and here above 3.5 kg, and you can see that = there is=20 one more time an inverse relationship between the risk of = developing=20 type 2 diabetes and birth weight.

The first of these observations was made on the = Hertfordshire=20 cohort, made of men born at the beginning of the = 20^th=20 century. The same observation was replicated in a birth = cohort in=20 Finland. When you have here the prevalence of type 2 = diabetes in=20 adults, according to birth weight, here once more the cutoff = point=20 of 2.5 kg. Here, in a different population, you also observe = an=20 inverse relationship between birth weight and the prevalence = of type=20 2 diabetes.

Slide 4.

In the last example, we show that the association that is = indeed=20 broadest between type 2 diabetes and low birth weight is one = taken=20 from the Pima Indians. The Pima Indians, who develop type 2 = diabetes=20 quite frequently when they are adults, you can see here the = relation=20 with the birth weight. It is a U-shaped relationship with an = increased risk whether you have a high birth weight related = to=20 obesity and diabetes in the mother, but you have also an = increase=20 with the low birth weight, even in a population like the = Pima, where=20 the genetic background is very, very strong. But in this = population,=20 being born SGA or with a low birth weight can explain as = much as 6%=20 of the cases of diabetes in adults.

Slide 5.

This association is robust and in many populations, you = can=20 identify a U-shaped relationship between birth weight and = the risk=20 of type 2 diabetes. These observations here, you have the = example in=20 India and here in the US. This is just to show that once = more the=20 association is robust. But the difficulty starts here, = because they=20 can see that the inflection point on the two lines is quite=20 different, 2.9 kg vs 3.4 kg. That points to the real = difficult task=20 of defining what is real, a low birth weight or SGA? We will = come=20 back to that point later.

Slide 6.

If we are talking about type 2 diabetes, you might ask = whether it=20 comes from a defect in insulin secretion or a defect in = insulin=20 sensitivity, so to say insulin resistance.

Slide 7.

Let's go to insulin secretion. The insulin secretion, as = we=20 measured in children at the age of 9 years, measuring the = first=20 phase insulin release and the glucose stimulation, and also = the=20 sustained insulin release under glucose stimulation. The = results=20 here from one of the Dutch groups show that there is no = difference=20 between the yellow and the orange color. That means there is = no=20 difference in insulin secretion between children born either = SGA or=20 adapted for gestational age, AGA. In our group, we also show = exactly=20 the same data in young adults, born either SGA in yellow, or = AGA. At=20 the age of 22, there was still no difference whatsoever in = insulin=20 secretion at least the way we can measure it.

Slide 8.

If it is not a primary defect in insulin secretion, it = can be=20 something related to insulin sensitivity or the other way, = insulin=20 resistance.

Slide 9.

Insulin sensitivity has been measured using the minimal = model=20 technique under glucose intravenous infusion, and you have = here the=20 result according to a quartile of birth weight. The lowest = quartile=20 is below 3 kg. You can see that the lower insulin = sensitivity is=20 observed in this lower quartile, and there is quite a = continuous=20 relation between insulin sensitivity and birth weight. That = was=20 measured in young men, and the same kind of relation was = observed in=20 young children, prepubertal children, either born SGA or in=20 comparison with short stature children, but not born = SGA.

You have here the birth weight expressed in this score, = so the=20 lower birth weight on your left hand side; and you have here = the=20 insulin sensitivity measured with the same minimal model. = You can=20 see that the lower insulin sensitivity was observed in the = ones who=20 were born SGA with lowest birth weight.

Slide 10.

That is two examples that insulin sensitivity is reduced = in=20 individuals born SGA, meaning insulin resistance. We in = France have=20 been working with a cohort of young adults. This cohort was = taken=20 more than 10 years ago from a Maternity Registry, meaning = that the=20 cohort is a population-based cohort, and not a clinically = referred=20 cohort. We compare 2 groups, the SGA in yellow were born = below the=20 tenth percentile for gender gestational age, compared with = the AGA,=20 born between the 25^th and the 75^th=20 percentiles. The two groups are quite different in terms of = birth=20 weight, not in terms of gestational age. They were all = full-term.=20 They are also shorter, the SGA, and the AGA are also lighter = at=20 birth.

Slide 11.

When they are under observation at the age of 22, you can = already=20 see differences in glucose tolerance. The number of the = proportion=20 of individuals with impaired glucose tolerance at the age of = 22 was=20 two times higher in the SGA in comparison with the AGA. = Point number=20 one, there is indeed already impaired glucose tolerance.

Point number two, if you look at the rest of the = individuals with=20 normal tolerance to glucose, you can see here that the = fasting=20 insulin taken as a surrogate for insulin resistance in this = cohort=20 is significantly higher compared with the AGA by about = 20%.

If you measure the insulin sensitivity, using euglycemic=20 hyperinsulemic clamp technique, and measuring the peripheral = glucose=20 uptake, you can confirm that indeed insulin sensitivity as = measured=20 by this peripheral glucose uptake is reduced in the SGA-born = individuals. When you look at the individual data here, the = point I=20 want to make in this graph, that there is mostly a reduced=20 proportion of the individuals being born SGA were highly = insulin=20 resistant with a very low glucose uptake. But some of them = are=20 normal. That is one message that is important here, that not = all the=20 individuals born SGA will later in life develop insulin = resistance=20 and type 2 diabetes.

Slide 12.

In the same cohort, if you compare and measure all the = different=20 parameters that are associated or encompassed with the = metabolic=20 syndrome, you can see that when you compare SGA to AGA in = orange,=20 you have a difference in fat mass, in the waist-to-hip = ratio,=20 circumference ratio, in fasting insulin taken for insulin=20 resistance, and systolic blood pressure and in lipid = profile. The=20 differences are modest, but they are statistically = significant and=20 all pointing to the same direction of the metabolic = syndrome.

Slide 13.

Actually, when you look at the definition of the = metabolic=20 syndrome, as given by the ATP 3 panel, the proportion of the = individuals being affected by the full metabolic syndrome is = sixfold=20 higher in the SGA group in comparison with the AGA. They are = supposed to be healthy but already some of them have some = indication=20 for the disease.

Slide 14.

We will go now over the role of the catch-up growth or = the=20 inference of the catch-up growth on the metabolic risk in = SGA. You=20 may know, and you will see later that most of the children = born SGA=20 will catch up, and will do so during the first year of = life.

Slide 15.

In the Haguenau cohort, which is a natural-history,=20 under-observation cohort with no treatment at all, by the = adult age,=20 10% of the individuals remain with short stature below -2 = standard=20 deviations. If you compare those two groups of SGA-born = individuals,=20 according to the adult stature, you can see that there is no = difference in the QUICKI index that measures insulin = sensitivity.=20 The catch-up in height, that is not inference, the later = metabolic=20 risk for insulin resistance.

Slide 16.

If it is not the catch-up in height, it may be the = catch-up in=20 body size and adiposity. The way we have looked through the = point in=20 the Haguenau cohort is to look first at the body size at = birth. You=20 have here the BMI expressed in three tertiles. The lower = tertile is=20 in the, let's say, dark yellow, and the higher tertiles are = in=20 almost white. You have here insulin resistance as on the Y = axis.

You can see that the normal one -- I mean, we are not = skinny, but=20 around the mean, and the BMI expressed in this cohort goes = from -0.9=20 to 1.5. They are normal in term of body size. They are = short, but=20 they are not skinny.

They have the lowest insulin resistance. But the ones who = were=20 more skinny at birth, they are more insulin resistant. A way = to=20 evaluate the degree of catch-up is to compare the body size = by BMI=20 at birth, and in the adult age at 22 years of age. The = difference=20 between those two BMIs is taken as a surrogate for catch-up = in body=20 size. You can see here that the higher -- this marker for = catch-up,=20 the higher the insulin resistance. If you have a higher = catch-up,=20 you are more insulin resistant. If you put the two sets of = results=20 together, you have here the BMI expressed in tertiles, = expressed in=20 z score. So the mean is here at 0, and you have birth and = adult. The=20 more skinny the experience in the dark yellow line, the = experience=20 is stronger catch-up, and they end up around 0 and around = the=20 mean.

The ones who were not skinny at birth, they almost = experience no=20 catch-up at all, and they end up with BMI similar to the = other two=20 tertiles. You may notice that all those BMIs when adults are = just=20 around the mean and there is a widespread of their = individual value.=20 But still, it does mean obesity, there is a catch-up, but = toward the=20 mean. So it has nothing to do with obesity itself, but it = has been=20 shown that it has to do with relatively more adiposity, even = though=20 the body size does impede for obesity. So the more the catch = -- the=20 more skinny, the more the catch up, and the more insulin = resistant=20 you are.

Slide 17.

The role of the catch-up has been pointed out by = different=20 groups. You have here an observation in British children = with a body=20 size expressed at 5 years of age, and with the birth weight=20 expressed on the X axis. You can see the relationship with = the lower=20 birth weight, the higher insulin, fasting insulin, = indicating=20 insulin resistance. You can see that the effect is also=20 potentialized by your higher body size at 5 years of age in = the=20 orange line.

This observation was also made in a different ethnic = group. This=20 graph is taken from the Indian group. You have three = tertiles of=20 birth weight in the X axis, and you have the three tertiles = of=20 weight by the age of 8 years. You can see an effect or an = influence=20 of weight at 8 years of age on insulin resistance, which has = been=20 known for a long time. But you can see also this interaction = with=20 the birth weight. Eventually, the more insulin resistant, = the ones=20 who were born with the lowest birth weight but also who = showed the=20 highest weight were body size by the age of 8.

Slide 18.

The same thing was also observed already at 1 year of = age,=20 indicating that most of the catch-up and most of the, let's = say,=20 metabolic effect of the catch-up can be seen by the age of 1 = year,=20 when here, SGA-born babies with catch-up are more insulin = resistant=20 than the SGA with no catch-up at all.

Slide 19.

What about catch-up growth? You have here a natural = observation=20 of a cohort of SGA-born babies, and you have the time course = of=20 weight expressed in this curve, and the time course in = height=20 expressed in this curve. What you can see here, that most of = the=20 catch-up has been done by the age of 3 months, continues = very, very=20 slightly over the first year. You have to keep that in mind. = The=20 very first months are the most important with respect to = catch-up,=20 but what you can see also, if you want catch-up in height, = you need=20 catch-up in weight. That means you need calories and to put = on=20 weight first in order to grow in height, which follows more=20 regularly and more smoothly along the first 2 years of life, = so to=20 say.

Slide 20.

Here I have taken indication of the role of weight gain = during=20 the first year of life, and the later occurrence of the = metabolic=20 syndrome. It is a Swedish birth cohort observed at the age = of 17=20 years, and here you have the events between birth and 6 = months of=20 life, and what it is indicated in orange here, that the = weight gain=20 during infancy influenced the risk of developing a metabolic = syndrome by the age of 17. By contrast, the weight gain = observed=20 between 3 and 6 years of age has no statistical effect on = the risk=20 of developing the metabolic syndrome by the age of 17. One = more=20 time, this study on the Swedish cohort points to the very = important=20 role of the very first month of life.

Slide 21.

There have not been many, many examples of intervention, = and I=20 have taken two, which are actually indirect evidence for = that.

Slide 22.

This paper appeared in Circulation about a year = ago. It=20 has been performed by the British group of Cole and Lucas, = and the=20 intervention was on SGA, fed either a standard formula or an = enriched formula for 9 months. What they have looked at here = is at=20 the blood pressure by the age between 6 and 8 years. There = is a=20 statistical difference, either on the diastolic blood = pressure or at=20 the mean arterial blood pressure at the age of 6, according = to the=20 group they were assigned. When you look at the group as a = whole,=20 there was a correlation between the mean arterial blood = pressure and=20 the delta in weight between the intervention period. For one = standard deviation gained in weight, you would gain 1.5 mg = Hg in=20 mean arterial blood pressure.

Slide 23.

Actually, the purpose of the intervention was not about = the=20 metabolic consequences, but it is the observation now. Here = you may=20 be familiar with this paper by Singhal with just an = intervention on=20 low birth weight and premature babies, with a very specific=20 population. The premies were assigned a preterm formula, = breast=20 milk, or standard formula, or in hashed here that the = comparison=20 combined between the two groups. What this complicated graph = shows=20 is that at the time of discharge, there is an effect in the = weight=20 gain on both the formula and the breast-fed. If you combine = the two,=20 you have a very low significant difference in weight gain. = Then when=20 you look at the pro-insulin concentration, when those = preemies were=20 adolescents, there is an increased concentration of = pro-insulin,=20 indicative of insulin resistance with the weight gain during = the=20 intervention strategy. So one more time, the very first here = weeks=20 of life seem very important in the determining the later = metabolic=20 complications.

Slide 24.

The other contributing factors on nutrition could be, as = Ken=20 alluded to, the genes.

Slide 25.

According to the Thrifty genotype hypothesis, some genes = that can=20 promote survival of the fittest and their deleterious = environment=20 can also promote insulin resistance later in life. The first = candidate gene with this aspect would be the insulin gene. = We have=20 been told that there is a common variant at the insulin gene = level,=20 and this common variant was tested for the association = between birth=20 weight and the risk of later type 2 diabetes or insulin = resistance.=20 You have here different examples and different cohorts where = the=20 association was looked for.

Actually, you can see that the results are not really = robust or=20 strong consistent of other cohorts. This best candidate gene = appears=20 not to be a very good candidate gene at the end of the = day.

Slide 26.

We have tested in the Haguenau cohort a series of = candidate=20 genes, ones some related to growth, some related to the = adipose=20 tissue, and here the TCF7L2. We could not find any robust or = strong=20 association between birth weight and insulin resistance. It = is=20 either one, but not two. So it does not work with the = hypothesis of=20 the Thrifty genotype.

Slide 27.

If you think what is SGA? We can debate on that for quite = a long=20 time.

Slide 28.

SGA is mostly an epidemiological definition according to = birth=20 weight most of the time. There has been a consensus = statement a year=20 ago on recommending the definition of -2 standard deviations = for the=20 definition of SGA. But even though we can agree on the = definition,=20 it reflects a number of clinical conditions with respect to = the=20 mother, to the fetus, or difference. Right now about a third = of the=20 cases are not really explained.

Slide 29.

Here is a plot for fetal growth according to gestational = age.=20 According to the method developed by Jason Gardosi, you can = estimate=20 the fetal weight measured by the different parameters from = the=20 ultrasound, and you can plot the growth velocity of the = fetus=20 according to maternal characteristic like the ethnicity, the = parity,=20 the birth of the mother, different parameters that can = explain to=20 you. Here you have a baby who is definitely a small = individual, but=20 normal growth pattern, a low one, but the normal growth = velocity. By=20 contrast, you have here individual who was not supposed to = be, let's=20 say, genetically really small. But when the fetal growth=20 restriction, and the two of them will be called SGA at least = by the=20 definition of birth weight. This one is really SGA; this one = is=20 really IUGR, intrauterine growth restriction.

Slide 30.

The current hypothesis now is to explain the association = between=20 SGA or low birth weight and the risk of type 2 diabetes. You = have=20 seen that it goes through insulin resistance, but because = this SGA=20 is on the epidemiological definition related to birth = weight, it=20 does not tell you very much how it works.

Slide 31.

Now if you look at the pattern of the fetal growth, you = have here=20 this regular and also to say normal pattern of fetal growth = with a=20 small individual. Probably you see in terms of metabolic=20 complications, nothing will happen to this baby. It may = happen in=20 terms of stature, but nothing in terms of metabolic = complications.=20 By contrast, the one who experiences a real fetal growth=20 restriction, they will be born thin with a low birth weight. = during=20 the first year of the first months of life, they will = experience=20 catch-up growth. While catching up, they will put relatively = more=20 fat mass than lean mass, promoting the beginning of insulin=20 resistance, which in turn will lead later in life to the = development=20 of metabolic syndrome and maybe type 2 diabetes in some=20 individuals.

Slide 32.

What are the mechanisms? What I want to determine is = whether we=20 facing a real specific programming. That means that the = fetal period=20 is definitely unique and very important? Or is it only a = matter of=20 wasting and so losing weight and catching up with a = relatively=20 higher fat mass? What is the trigger? It can be hypoxia, = like in the=20 example of preeclampsia. It can be, let's say, quantitative=20 undernutrition, which actually does not happen very often = nowadays,=20 but with the example of the Dutch famine in Rotterdam, with = many=20 publications related to that. Very recently, it has been = shown that=20 it could be a qualitative undernutrition, in that the defect = of zinc=20 or B12 vitamin during pregnancy can explain a large amount = of the=20 risk of type 2 diabetes in the people born SGA, at least in=20 India.

The critical window, there are at least three. The = association of=20 diabetes with in vitro fertilization has been reported. Then = with=20 prematurity, pointing to the role of the second trimester of = life,=20 and also the association with SGA. Definitely there can be = different=20 windows, different triggers, making the mechanisms = altogether quite=20 complex.

Slide 33.

Currently, the most favored hypothesis has been proposed = as the=20 developmental mismatch by Peter Gluckman. Stating that the = fetus is=20 able to adapt to an unfavorable environment, and it will = adapt to,=20 let's say, poor nutrition or poor environment, but later = what is=20 important is actually the mismatch of the environment that = when the=20 fetus will face more favorable environment, then the = complications=20 start. But if it were to be adapted to a low or poor = environment, it=20 will work with no complications. This stipulation remains to = be,=20 let's say, maybe confirmed under prospective observation. I = have=20 shown you some data with respect to catch-up growth, with = the risk=20 of SGA and type 2 diabetes, even though the mechanisms, or = the=20 cellular mechanisms of this association remain to be = elucidated. I=20 thank you for your attention.

Go=20 to CME Test Questions = =BB

Contents = of: Small=20 for Gestational Age: Issues in 2008=20

All sections of this activity = are=20 required for credit.

Genetic=20 Determinants of Size at BirthKen = K. Ong,=20 MD, PhD, MRCPCHAvailable As: = Slides/Audio = ;| Slides/Transcript=
Assessing=20 the Risk of Insulin Resistance and Metabolic = SyndromeClaire L=E9vy-Marchal, MDAvailable As: Slides/Audio = ;| Slides/Transcript=
The=20 Treatment of Growth Failure in SGA ChildrenAnita Hokken-Koelega, MDAvailable As: Slides/Audio = ;| Slides/Transcript=
Panel=20 DiscussionAnita Hokken-Koelega, = MD; Ken K.=20 Ong, MD, PhD, MRCPCH; Claire L=E9vy-Marchal, = MDAvailable As: Slides/Audio = ;| Slides/Transcript=

Go=20 to CME Test = Questions=20 =BB

CME Information=20
Earn=20 CME Credit =BB =

All material on this website is protected by = copyright, Copyright = =A9 1994-2008=20 by Medscape. This website also contains material copyrighted by 3rd = parties.=20

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P.qadiscussion { MARGIN: 9px 0px 6px; COLOR: #363636 } .yourscore { FONT-SIZE: 21px; MARGIN: 0px 0px 7px; COLOR: #003366; FONT-FAMILY: = verdana, sans-serif } .scoringtext { MARGIN: 0px 0px 11px } .incorrectanswer { =09 } .incorrectquestion { COLOR: #ff6600 } .correctanswer { FONT-WEIGHT: bold; COLOR: #33cc00; WHITE-SPACE: nowrap } .pollresultscell { FONT-WEIGHT: bold; FONT-SIZE: 11px; BORDER-LEFT: #b3b3b3 1px solid } .proceedlink { FONT-WEIGHT: bold; FONT-SIZE: 15px } #newscmeqa .incorrectanswer { FONT-WEIGHT: bold; COLOR: #ff6600 } .pollheader { BORDER-RIGHT: #b3b3b3 1px solid; PADDING-RIGHT: 0px; BORDER-TOP: = #b3b3b3 1px solid; PADDING-LEFT: 3px; FONT-WEIGHT: bold; PADDING-BOTTOM: = 2px; BORDER-LEFT: #b3b3b3 1px solid; COLOR: #666666; PADDING-TOP: 0px } .polltable { BORDER-RIGHT: #b3b3b3 1px solid; BORDER-TOP: #b3b3b3 1px solid; = MARGIN-BOTTOM: 5px; BORDER-LEFT: #b3b3b3 1px solid; BORDER-BOTTOM: = #b3b3b3 1px solid } .polltable TD { FONT-SIZE: 11px } .useranswerheader { FONT-WEIGHT: bold } .useranswer { MARGIN-LEFT: 10px } P#preassessmentlink { FONT-WEIGHT: bold; MARGIN: 15px 0px } #learnobjectauthors { MARGIN: 0px 0px 10px; BACKGROUND-COLOR: #ffffff; TEXT-ALIGN: left } #learnobjectauthors H6 { FONT-SIZE: 12px; MARGIN: 0px; FONT-FAMILY: arial, sans-serif } #learnobjectauthors P { FONT-SIZE: 11px; MARGIN: 0px } #learnobjectauthors OL { PADDING-RIGHT: 0px; PADDING-LEFT: 23px; FONT-SIZE: 11px; = PADDING-BOTTOM: 6px; MARGIN: 0px; PADDING-TOP: 0px } #learnobjectauthors UL { PADDING-RIGHT: 0px; PADDING-LEFT: 23px; FONT-SIZE: 11px; = PADDING-BOTTOM: 6px; MARGIN: 0px; PADDING-TOP: 0px } #authorrightcolscroll { BORDER-RIGHT: #c3c3c3 1px solid; PADDING-RIGHT: 0px; BORDER-TOP: = #c3c3c3 1px solid; PADDING-LEFT: 3px; PADDING-BOTTOM: 2px; OVERFLOW: = auto; BORDER-LEFT: #c3c3c3 1px solid; PADDING-TOP: 2px; BORDER-BOTTOM: = #c3c3c3 1px solid; HEIGHT: 180px; TEXT-ALIGN: left } #learnobjectauthors2 { BORDER-RIGHT: #aec6d4 1px solid; PADDING-RIGHT: 5px; BORDER-TOP: = #aec6d4 1px solid; PADDING-LEFT: 5px; FLOAT: right; PADDING-BOTTOM: 5px; = MARGIN: 12px 0px 8px 8px; BORDER-LEFT: #aec6d4 1px solid; WIDTH: 150px; = PADDING-TOP: 8px; BORDER-BOTTOM: #aec6d4 1px solid; BACKGROUND-COLOR: = #f5f9ff; TEXT-ALIGN: left } #learnobjectauthors2 H6 { FONT-SIZE: 11px; MARGIN: 0px; FONT-FAMILY: arial, sans-serif } #learnobjectauthors2 P { FONT-SIZE: 11px; MARGIN: 0px } #learnobjectauthors2 OL { PADDING-RIGHT: 0px; PADDING-LEFT: 23px; FONT-SIZE: 11px; = PADDING-BOTTOM: 6px; MARGIN: 0px; PADDING-TOP: 0px } #learnobjectauthors2 UL { PADDING-RIGHT: 0px; PADDING-LEFT: 23px; FONT-SIZE: 11px; = PADDING-BOTTOM: 6px; MARGIN: 0px; PADDING-TOP: 0px } #learnobjectauthors2 #authorrightcolscroll { BORDER-RIGHT: #c3c3c3 1px solid; PADDING-RIGHT: 0px; BORDER-TOP: = #c3c3c3 1px solid; PADDING-LEFT: 3px; PADDING-BOTTOM: 2px; OVERFLOW: = auto; BORDER-LEFT: #c3c3c3 1px solid; PADDING-TOP: 2px; BORDER-BOTTOM: = #c3c3c3 1px solid; HEIGHT: 150px; TEXT-ALIGN: left } ------=_NextPart_000_0112_01C903AE.6A8A9670 Content-Type: text/css; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: http://images.medscape.com/medcss/footer/footer-global.css #medscapefooter { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; PADDING-BOTTOM: 5px; = PADDING-TOP: 0px } #footersearch { PADDING-RIGHT: 0px; BACKGROUND-POSITION: left bottom; BORDER-TOP: #ddd = 8px solid; PADDING-LEFT: 0px; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/ornaments/bg-userinfo.gif); = PADDING-BOTTOM: 1px; PADDING-TOP: 6px; BACKGROUND-REPEAT: repeat-x; = BACKGROUND-COLOR: #fff; TEXT-ALIGN: center } #footercontents { BORDER-BOTTOM: #d4d4d4 1px solid; BACKGROUND-COLOR: #eee } #footerbar { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; PADDING-BOTTOM: 0px; MARGIN: 6px = 0px 10px 14px; PADDING-TOP: 0px } #footerbar UL { PADDING-RIGHT: 0px; LIST-STYLE: none none inside; PADDING-LEFT: 0px; = PADDING-BOTTOM: 0px; MARGIN: 0px; PADDING-TOP: 0px } #footertextinput { BORDER-RIGHT: #e4e4e4 2px solid; PADDING-RIGHT: 0px; BORDER-TOP: #999 = 2px solid; PADDING-LEFT: 3px; FONT-SIZE: 11px; PADDING-BOTTOM: 0px; = MARGIN: 0px; BORDER-LEFT: #999 2px solid; WIDTH: 465px; CURSOR: text; = PADDING-TOP: 2px; BORDER-BOTTOM: #e4e4e4 2px solid; HEIGHT: 16px; = BACKGROUND-COLOR: #fff } INPUT#footersubmit { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; PADDING-BOTTOM: 0px; MARGIN: 0px = 0px 4px; VERTICAL-ALIGN: middle; PADDING-TOP: 0px } #radioformfooter { FONT-SIZE: 0.95em } .inactiveradio { DISPLAY: none } .activeradio { DISPLAY: block } #adtagfooter { MARGIN: 3px 0px 0px 15px } #footerbar A { FONT-WEIGHT: bold } .footernavstart { BORDER-RIGHT: #666 1px solid; PADDING-RIGHT: 8px; DISPLAY: inline; = FONT-WEIGHT: normal; FONT-SIZE: 0.85em } .footernav { BORDER-RIGHT: #666 1px solid; PADDING-RIGHT: 8px; DISPLAY: inline; = PADDING-LEFT: 7px; FONT-WEIGHT: normal; FONT-SIZE: 0.85em; BORDER-LEFT: = #b6b5b4 1px solid } .footernavend { DISPLAY: inline; PADDING-LEFT: 8px; FONT-WEIGHT: normal; FONT-SIZE: = 0.85em; BORDER-LEFT: #b6b5b4 1px solid } .legaltext { FONT-SIZE: 0.85em; MARGIN: 12px 10px 0px; COLOR: #444 } ------=_NextPart_000_0112_01C903AE.6A8A9670 Content-Type: text/css; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: http://images.medscape.com/medcss/header/header-global.css #medscapeheadercontainer { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; FONT-SIZE: 1.05em; = PADDING-BOTTOM: 3px; MARGIN-LEFT: auto; WIDTH: 760px; MARGIN-RIGHT: = auto; PADDING-TOP: 0px; FONT-FAMILY: arial, sans-serif; = BACKGROUND-COLOR: #ddd; TEXT-ALIGN: left } #adtagheader { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; PADDING-BOTTOM: 0px; MARGIN: = 0px; PADDING-TOP: 0px; BACKGROUND-COLOR: #ddd; TEXT-ALIGN: center } #headertop { MARGIN: 0px 0px 0px 1px; WIDTH: 758px } #headertop A:link { COLOR: #006699; TEXT-DECORATION: none } #headertop A:visited { COLOR: #006699; TEXT-DECORATION: none } #headertop A:hover { COLOR: #24a2dd; TEXT-DECORATION: underline } #headertop A:active { COLOR: #006699; TEXT-DECORATION: none } #headerleft { FLOAT: left; WIDTH: 235px } #headerright { FLOAT: right; WIDTH: 516px } #headerright2 { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; PADDING-BOTTOM: 5px; MARGIN: = 0px; WIDTH: 513px; PADDING-TOP: 0px; TEXT-ALIGN: right } #supernav { BORDER-RIGHT: #fff 2px solid; PADDING-RIGHT: 0px; BACKGROUND-POSITION: = left top; BORDER-TOP: #fff 2px solid; PADDING-LEFT: 0px; FONT-SIZE: = 10px; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/ornaments/bg-supernavbox.gif); = PADDING-BOTTOM: 0px; MARGIN: 1px 0px 0px; BORDER-LEFT: #fff 2px solid; = WIDTH: 230px; PADDING-TOP: 3px; BORDER-BOTTOM: #fff 2px solid; = BACKGROUND-REPEAT: repeat } #supernav UL { PADDING-RIGHT: 0px; PADDING-LEFT: 19px; PADDING-BOTTOM: 0px; MARGIN: = 0px; COLOR: #ff7e00; PADDING-TOP: 0px; LIST-STYLE-TYPE: square } #supernav LI { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; PADDING-BOTTOM: 2px; MARGIN: = 0px; PADDING-TOP: 0px } #supernavselected A:link { TEXT-DECORATION: none } #supernavselected A:visited { TEXT-DECORATION: none } #supernavselected A:hover { TEXT-DECORATION: underline } #supernavselected A:active { TEXT-DECORATION: none } #supernavpulldown { DISPLAY: inline } #supernavpulldown A { COLOR: #919191 } #supernavleft { FONT-SIZE: 12px; FLOAT: left; WIDTH: 90px } #supernavright { FLOAT: right; WIDTH: 135px } #headersearch { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; FLOAT: left; PADDING-BOTTOM: = 0px; MARGIN: 0px; WIDTH: 305px; PADDING-TOP: 0px } #headersearchtop { BACKGROUND-POSITION: left bottom; FONT-SIZE: 1px; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/ornaments/bg-searchtop760.gif); = WIDTH: 305px; LINE-HEIGHT: 1px; BACKGROUND-REPEAT: no-repeat; HEIGHT: = 4px } #headersearchcontent { BACKGROUND-POSITION: left bottom; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/ornaments/bg-searchmid760.gif); = WIDTH: 305px; BACKGROUND-REPEAT: repeat-y; HEIGHT: 45px; = BACKGROUND-COLOR: #fdfefe; TEXT-ALIGN: center } #headersearchtypes { PADDING-RIGHT: 0px; PADDING-LEFT: 10px; FONT-SIZE: 11px; = PADDING-BOTTOM: 2px; PADDING-TOP: 2px; TEXT-ALIGN: left } #headersearchtypes A.searchtypeselected { FONT-WEIGHT: normal; COLOR: #000 } #headertextinput { BORDER-RIGHT: #e4e4e4 2px solid; PADDING-RIGHT: 0px; BORDER-TOP: #999 = 2px solid; PADDING-LEFT: 3px; FONT-SIZE: 11px; PADDING-BOTTOM: 0px; = MARGIN: 0px; BORDER-LEFT: #999 2px solid; WIDTH: 195px; CURSOR: text; = PADDING-TOP: 2px; BORDER-BOTTOM: #e4e4e4 2px solid; HEIGHT: 15px; = BACKGROUND-COLOR: #fff } INPUT#headersubmit { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; PADDING-BOTTOM: 0px; MARGIN: 0px = 0px 4px; VERTICAL-ALIGN: middle; PADDING-TOP: 0px } #headersearchbtm { BACKGROUND-POSITION: left top; FONT-SIZE: 1px; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/ornaments/bg-searchbtm760.gif); = WIDTH: 305px; LINE-HEIGHT: 1px; BACKGROUND-REPEAT: no-repeat; HEIGHT: = 4px } #userinfo { BORDER-RIGHT: #fff 2px solid; PADDING-RIGHT: 0px; BACKGROUND-POSITION: = left bottom; BORDER-TOP: #fff 2px solid; PADDING-LEFT: 0px; FLOAT: = right; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/ornaments/bg-userinfo.gif); = PADDING-BOTTOM: 2px; MARGIN: 1px 0px 0px; BORDER-LEFT: #fff 2px solid; = WIDTH: 200px; PADDING-TOP: 1px; BORDER-BOTTOM: #fff 2px solid; = BACKGROUND-REPEAT: no-repeat; HEIGHT: 41px; BACKGROUND-COLOR: #fff; = TEXT-ALIGN: center } .welcomename { FONT-WEIGHT: normal; FONT-SIZE: 11px; FONT-FAMILY: georgia, times, = serif } .usertools { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; FONT-SIZE: 10px; PADDING-BOTTOM: = 2px; COLOR: #cccbcb; PADDING-TOP: 2px } .headerinvites { FONT-SIZE: 11px } .headerinvitesnumber { FONT-WEIGHT: bold; COLOR: #ff7e00 } #splashuserinfo { BORDER-RIGHT: #fff 2px solid; PADDING-RIGHT: 0px; BACKGROUND-POSITION: = left bottom; BORDER-TOP: #fff 2px solid; PADDING-LEFT: 0px; FLOAT: = right; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/ornaments/bg-userinfo.gif); = PADDING-BOTTOM: 2px; MARGIN: 0px; BORDER-LEFT: #fff 2px solid; WIDTH: = 195px; PADDING-TOP: 1px; BORDER-BOTTOM: #fff 2px solid; = BACKGROUND-REPEAT: no-repeat; HEIGHT: 40px; BACKGROUND-COLOR: #fff; = TEXT-ALIGN: center } #splashuserinfo A.userinfoselected:link { COLOR: #767676; TEXT-DECORATION: none } #splashuserinfo A.userinfoselected:visited { COLOR: #767676; TEXT-DECORATION: none } #splashuserinfo A.userinfoselected:hover { COLOR: #767676; TEXT-DECORATION: underline } #splashuserinfo A.userinfoselected:active { COLOR: #767676; TEXT-DECORATION: none } .splashusertools { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; FONT-SIZE: 0.95em; = PADDING-BOTTOM: 0px; COLOR: #cccbcb; PADDING-TOP: 13px } #specialtieslayer { BORDER-RIGHT: #333 3px solid; MARGIN-TOP: 25px; Z-INDEX: 1000; LEFT: = 0px; MARGIN-LEFT: 5%; BORDER-BOTTOM: #333 3px solid; POSITION: absolute; = TOP: 0px; TEXT-ALIGN: left } #specpdlist { BORDER-RIGHT: #b3b3b3 1px solid; BORDER-TOP: #333 1px solid; = BORDER-LEFT: #333 1px solid; WIDTH: 460px; BORDER-BOTTOM: #b3b3b3 1px = solid; BACKGROUND-COLOR: #fff } #specpdlist TD { PADDING-RIGHT: 10px; PADDING-LEFT: 10px; PADDING-BOTTOM: 10px; = PADDING-TOP: 0px } #specpdlist UL { PADDING-RIGHT: 0px; LIST-STYLE: none none outside; PADDING-LEFT: 0px; = FONT-SIZE: 11px; PADDING-BOTTOM: 0px; MARGIN: 0px; PADDING-TOP: 0px } #specpdlist UL LI { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; PADDING-BOTTOM: 3px; = PADDING-TOP: 0px } #specpdlist TD#specpdlistheading { PADDING-RIGHT: 0px; PADDING-LEFT: 10px; FONT-WEIGHT: bold; = PADDING-BOTTOM: 5px; TEXT-TRANSFORM: uppercase; PADDING-TOP: 8px } #closespecpd { PADDING-RIGHT: 10px; FONT-SIZE: 11px; FLOAT: right } .inactive { DISPLAY: none } .active { DISPLAY: block } #medscapeheader { CLEAR: both; BORDER-RIGHT: #cccbcb 1px solid; BACKGROUND-POSITION: left = top; BORDER-TOP: #cccbcb 1px solid; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/ornaments/bg-header.gif); = MARGIN: 6px 0px 7px; BORDER-LEFT: #cccbcb 1px solid; BORDER-BOTTOM: = #cccbcb 1px solid; BACKGROUND-REPEAT: no-repeat; HEIGHT: 58px } #medscapeheaderleft { FLOAT: left; WIDTH: 440px } #medscapeheaderright { FLOAT: right; WIDTH: 318px } H1#headerh1 { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; FONT-WEIGHT: bold; FONT-SIZE: = 1.25em; PADDING-BOTTOM: 0px; MARGIN: 0px; WIDTH: 440px; COLOR: #003366; = PADDING-TOP: 0px; FONT-FAMILY: palatino, georgia, times, serif; HEIGHT: = 58px } H1#headerh1 A { FLOAT: left; WIDTH: 440px; HEIGHT: 58px; TEXT-DECORATION: none } H1#headerh1 A:link { FLOAT: left; WIDTH: 440px; HEIGHT: 58px; TEXT-DECORATION: none } H1#headerh1 A:visited { FLOAT: left; WIDTH: 440px; HEIGHT: 58px; TEXT-DECORATION: none } H1#headerh1 A:hover { FLOAT: left; WIDTH: 440px; HEIGHT: 58px; TEXT-DECORATION: none } H1#headerh1 A:active { FLOAT: left; WIDTH: 440px; HEIGHT: 58px; TEXT-DECORATION: none } #spnamehide { DISPLAY: none } #sitelinks { PADDING-RIGHT: 10px; PADDING-LEFT: 0px; FLOAT: right; PADDING-BOTTOM: = 0px; MARGIN: 0px; PADDING-TOP: 14px } #medscapenavbar { TEXT-TRANSFORM: uppercase; COLOR: #4b4b4b; FONT-FAMILY: frutiger, = arial, sans-serif } #medscapenavbar UL { PADDING-RIGHT: 0px; LIST-STYLE: none none inside; PADDING-LEFT: 0px; = PADDING-BOTTOM: 6px; MARGIN: 0px; PADDING-TOP: 0px; TEXT-ALIGN: right } .navlist1 { DISPLAY: block } .navlist2 { DISPLAY: block } .navlinkstart { BORDER-RIGHT: #bbc9d0 1px solid; PADDING-RIGHT: 11px; DISPLAY: inline; = FONT-WEIGHT: normal; FONT-SIZE: 11px } .navlinkstart A:link { COLOR: #006699; TEXT-DECORATION: none } .navlinkstart A:visited { COLOR: #006699; TEXT-DECORATION: none } .navlinkstart A:hover { COLOR: #24a2dd; TEXT-DECORATION: underline } .navlinkstart A:active { COLOR: #006699; TEXT-DECORATION: none } .navlink { BORDER-RIGHT: #bbc9d0 1px solid; PADDING-RIGHT: 11px; DISPLAY: inline; = PADDING-LEFT: 10px; FONT-WEIGHT: normal; FONT-SIZE: 11px } .navlink A:link { COLOR: #006699; TEXT-DECORATION: none } .navlink A:visited { COLOR: #006699; TEXT-DECORATION: none } .navlink A:hover { COLOR: #24a2dd; TEXT-DECORATION: underline } .navlink A:active { COLOR: #006699; TEXT-DECORATION: none } .navlinkend { DISPLAY: inline; PADDING-LEFT: 11px; FONT-WEIGHT: normal; FONT-SIZE: = 11px } .navlinkend A:link { COLOR: #006699; TEXT-DECORATION: none } .navlinkend A:visited { COLOR: #006699; TEXT-DECORATION: none } .navlinkend A:hover { COLOR: #24a2dd; TEXT-DECORATION: underline } .navlinkend A:active { COLOR: #006699; TEXT-DECORATION: none } .navlinkstarton { BORDER-RIGHT: #bbc9d0 1px solid; PADDING-RIGHT: 11px; DISPLAY: inline; = FONT-WEIGHT: normal; FONT-SIZE: 11px } .navlinkstarton A:link { FONT-WEIGHT: bold; COLOR: #4b4b4b; TEXT-DECORATION: none } .navlinkstarton A:visited { FONT-WEIGHT: bold; COLOR: #4b4b4b; TEXT-DECORATION: none } .navlinkstarton A:hover { FONT-WEIGHT: bold; COLOR: #4b4b4b; TEXT-DECORATION: none } .navlinkstarton A:active { FONT-WEIGHT: bold; COLOR: #4b4b4b; TEXT-DECORATION: none } .navlinkon { BORDER-RIGHT: #bbc9d0 1px solid; PADDING-RIGHT: 11px; DISPLAY: inline; = PADDING-LEFT: 11px; FONT-WEIGHT: normal; FONT-SIZE: 11px } .navlinkon A:link { FONT-WEIGHT: bold; COLOR: #4b4b4b; TEXT-DECORATION: none } .navlinkon A:visited { FONT-WEIGHT: bold; COLOR: #4b4b4b; TEXT-DECORATION: none } .navlinkon A:hover { FONT-WEIGHT: bold; COLOR: #4b4b4b; TEXT-DECORATION: none } .navlinkon A:active { FONT-WEIGHT: bold; COLOR: #4b4b4b; TEXT-DECORATION: none } .navlinkendon { DISPLAY: inline; PADDING-LEFT: 11px; FONT-WEIGHT: normal; FONT-SIZE: = 11px } .navlinkendon A:link { FONT-WEIGHT: bold; COLOR: #4b4b4b; TEXT-DECORATION: none } .navlinkendon A:visited { FONT-WEIGHT: bold; COLOR: #4b4b4b; TEXT-DECORATION: none } .navlinkendon A:hover { FONT-WEIGHT: bold; COLOR: #4b4b4b; TEXT-DECORATION: none } .navlinkendon A:active { FONT-WEIGHT: bold; COLOR: #4b4b4b; TEXT-DECORATION: none } #sp_splash { BACKGROUND-POSITION: left top; 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function footermainsearch(radiobtn, thislink) {=0A= if (document.getElementById("footertextinput").value =3D=3D "") {=0A= document.getElementById("footertextinput").focus();=0A= var radiobtnlist =3D radiobtn.length;=0A= if (radiobtnlist =3D=3D undefined) {=0A= radiobtn.checked =3D (radiobtn.value =3D=3D thislink.toString());=0A= return;=0A= }=0A= for (var i =3D 0; i < radiobtnlist; i++) {=0A= radiobtn[i].checked =3D false;=0A= if (radiobtn[i].value =3D=3D thislink.toString()) {=0A= radiobtn[i].checked =3D true;=0A= }=0A= }=0A= if (thislink =3D=3D "all") {=0A= var searchlinkstate1 =3D document.getElementById("allsearchlink2");=0A= var searchlinkstate2 =3D = document.getElementById("medscapesearchlink2");=0A= var searchlinkstate3 =3D document.getElementById("emedsearchlink2");=0A= var searchlinkstate4 =3D = document.getElementById("drugrefsearchlink2");=0A= var searchlinkstate5 =3D = document.getElementById("medlinesearchlink2");=0A= setElementClass(searchlinkstate1, 'searchtypeselected');=0A= setElementClass(searchlinkstate2, '');=0A= setElementClass(searchlinkstate3, '');=0A= setElementClass(searchlinkstate4, '');=0A= setElementClass(searchlinkstate5, '');=0A= }=0A= else if (thislink =3D=3D "medscape") {=0A= var searchlinkstate1 =3D document.getElementById("allsearchlink2");=0A= var searchlinkstate2 =3D = document.getElementById("medscapesearchlink2");=0A= var searchlinkstate3 =3D document.getElementById("emedsearchlink2");=0A= var searchlinkstate4 =3D = document.getElementById("drugrefsearchlink2");=0A= var searchlinkstate5 =3D = document.getElementById("medlinesearchlink2");=0A= setElementClass(searchlinkstate1, '');=0A= setElementClass(searchlinkstate2, 'searchtypeselected');=0A= setElementClass(searchlinkstate3, '');=0A= setElementClass(searchlinkstate4, '');=0A= setElementClass(searchlinkstate5, '');=0A= }=0A= else if (thislink =3D=3D "emedicine") {=0A= var searchlinkstate1 =3D document.getElementById("allsearchlink2");=0A= var searchlinkstate2 =3D = document.getElementById("medscapesearchlink2");=0A= var searchlinkstate3 =3D document.getElementById("emedsearchlink2");=0A= var searchlinkstate4 =3D = document.getElementById("drugrefsearchlink2");=0A= var searchlinkstate5 =3D = document.getElementById("medlinesearchlink2");=0A= setElementClass(searchlinkstate1, '');=0A= setElementClass(searchlinkstate2, '');=0A= setElementClass(searchlinkstate3, 'searchtypeselected');=0A= setElementClass(searchlinkstate4, '');=0A= setElementClass(searchlinkstate5, '');=0A= }=0A= else if (thislink =3D=3D "drug") {=0A= var searchlinkstate1 =3D document.getElementById("allsearchlink2");=0A= var searchlinkstate2 =3D = document.getElementById("medscapesearchlink2");=0A= var searchlinkstate3 =3D document.getElementById("emedsearchlink2");=0A= var searchlinkstate4 =3D = document.getElementById("drugrefsearchlink2");=0A= var searchlinkstate5 =3D = document.getElementById("medlinesearchlink2");=0A= setElementClass(searchlinkstate1, 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else {=0A= return obj.style;=0A= }=0A= }=0A= return null;=0A= }=0A= =0A= =0A= function counter(entrance,exit,text,characters) {=0A= var entranceObj=3DgetObject(entrance);=0A= var exitObj=3DgetObject(exit);=0A= var length=3Dcharacters - entranceObj.value.length;=0A= if(length <=3D 0) {=0A= length=3D0;=0A= text=3D' '+text+' ';=0A= entranceObj.value=3DentranceObj.value.substr(0,characters);=0A= }=0A= exitObj.innerHTML =3D text.replace("{CHAR}",length);=0A= }=0A= =0A= /* Remove OSUN Notice */=0A= function removeosun(state) {=0A= if (document.getElementById) {=0A= if (document.getElementById("whiteoutlayer")) {=0A= var element2 =3D document.getElementById("whiteoutlayer");=0A= while (element2.firstChild) {=0A= element2.removeChild(element2.firstChild);=0A= }=0A= document.getElementById("whiteoutlayer").id =3D ""; =0A= }=0A= var osunid =3D document.getElementById("osun");=0A= setElementClass(osunid, state);=0A= }=0A= }=0A= =0A= /* CME Search Layer Functions */=0A= function addalertlayer(continueURL) {=0A= var newDiv =3D parent.document.createElement("div");=0A= newDiv.setAttribute("id", "cmesearchalert2");=0A= continueURL=3DcontinueURL.replace(/\"/g,""");=0A= newDiv.innerHTML =3D "

Medscape physician members have an = opportunity to earn CME credits for Internet Point of Care (PoC) through = self directed learning on topics relevant to clinical care. Physicians = participate in a 3 step learning cycle to receive a half (0.5) AMA = PRA Category 1 credit.

The 3 steps include:

Search = Medscape: Identify a clinical question by entering a search term
Learn: Review information sources = (search results)
Complete Action Plan: Briefly document how you = will implement learning in clinical practice

These = activities will be recorded in your CME Tracker with the 3 step = documentation available in print format on your certificate and CME = Tracker.

CANCEL CONTINUE »

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The 3 steps include:

Search = Medscape: Identify a clinical question by entering a search term
Learn: Review information sources = (search results)
Complete Action Plan: Briefly document how you = will implement learning in clinical practice

These = activities will be recorded in your CME Tracker with the 3 step = documentation available in print format on your certificate and CME = Tracker.

CLOSE";=0A= incompletealert =3D "

Please note that in order to earn = AMA/PRA category 1 credit, you must first read at least one article from = your list of search results.

The 3 steps include:

Search = Medscape: Identify a clinical question by entering a search term
Learn: Review information sources = (search results)
Complete Action Plan: Briefly document how you = will implement learning in clinical practice

These = activities will be recorded in your CME Tracker with the 3 step = documentation available in print format on your certificate and CME = Tracker.

CLOSE";=0A= emptydiv =3D "

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document.getElementById("flashcontent300x600");=0A= setElementClass(flashid2, 'active');=0A= PlayFlashMovie("POMFlashAd"); =0A= }=0A= function addjscript(onepx) {=0A= if (document.getElementById("hidden1x1")) {=0A= var onepx2 =3D document.getElementById("hidden1x1").value;=0A= var newDiv =3D document.createElement("div");=0A= newDiv.setAttribute("id", "1x1enlargepx");=0A= newDiv.innerHTML =3D " $3D\"\"$ ";=0A= if (document.getElementById("1x1enlargepx")) {=0A= addjscript2();=0A= }=0A= else {=0A= var my_div =3D document.getElementById("endofpomad");=0A= my_div.parentNode.insertBefore(newDiv, my_div);=0A= addjscript2();=0A= }=0A= }=0A= else {=0A= var newDiv =3D document.createElement("div");=0A= newDiv.setAttribute("id", "1x1enlargepx");=0A= newDiv.innerHTML =3D " $3D\"\"$ ";=0A= if (document.getElementById("1x1enlargepx")) {=0A= addjscript2();=0A= }=0A= else {=0A= var my_div =3D document.getElementById("endofpomad");=0A= my_div.parentNode.insertBefore(newDiv, my_div);=0A= 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"http://images.medscape.com/pi/features/scrollbox/icon-widgetoff.gif";=0A= setElementClass(listel[1], 'active');=0A= document.getElementById('featwidgetled2').src =3D = "http://images.medscape.com/pi/features/scrollbox/icon-widgeton.gif";=0A= setElementClass(listel[2], 'inactive');=0A= document.getElementById('featwidgetled3').src =3D = "http://images.medscape.com/pi/features/scrollbox/icon-widgetoff.gif";=0A= document.getElementById('featnuminput').value =3D "1";=0A= }=0A= }=0A= =0A= function scrollwidgetto0() {=0A= clearTimeout(timeset);=0A= var listel =3D new Array();=0A= listel =3D = document.getElementById('featurewidgetcontent').getElementsByTagName('li'= );=0A= setElementClass(listel[0], 'active');=0A= document.getElementById('featwidgetled1').src =3D = "http://images.medscape.com/pi/features/scrollbox/icon-widgeton.gif";=0A= setElementClass(listel[1], 'inactive');=0A= document.getElementById('featwidgetled2').src =3D = "http://images.medscape.com/pi/features/scrollbox/icon-widgetoff.gif";=0A= setElementClass(listel[2], 'inactive');=0A= document.getElementById('featwidgetled3').src =3D = "http://images.medscape.com/pi/features/scrollbox/icon-widgetoff.gif";=0A= document.getElementById('featnuminput').value =3D "0";=0A= }=0A= function scrollwidgetto1() {=0A= clearTimeout(timeset);=0A= var listel =3D new Array();=0A= listel =3D = document.getElementById('featurewidgetcontent').getElementsByTagName('li'= );=0A= setElementClass(listel[0], 'inactive');=0A= document.getElementById('featwidgetled1').src =3D = "http://images.medscape.com/pi/features/scrollbox/icon-widgetoff.gif";=0A= setElementClass(listel[1], 'active');=0A= document.getElementById('featwidgetled2').src =3D = "http://images.medscape.com/pi/features/scrollbox/icon-widgeton.gif";=0A= setElementClass(listel[2], 'inactive');=0A= document.getElementById('featwidgetled3').src =3D = "http://images.medscape.com/pi/features/scrollbox/icon-widgetoff.gif";=0A= document.getElementById('featnuminput').value =3D "1";=0A= }=0A= function scrollwidgetto2() {=0A= clearTimeout(timeset);=0A= var listel =3D new Array();=0A= listel =3D = document.getElementById('featurewidgetcontent').getElementsByTagName('li'= );=0A= setElementClass(listel[0], 'inactive');=0A= document.getElementById('featwidgetled1').src =3D = "http://images.medscape.com/pi/features/scrollbox/icon-widgetoff.gif";=0A= setElementClass(listel[1], 'inactive');=0A= document.getElementById('featwidgetled2').src =3D = "http://images.medscape.com/pi/features/scrollbox/icon-widgetoff.gif";=0A= setElementClass(listel[2], 'active');=0A= document.getElementById('featwidgetled3').src =3D = "http://images.medscape.com/pi/features/scrollbox/icon-widgeton.gif";=0A= document.getElementById('featnuminput').value =3D "2";=0A= }=0A= /* Utility Function For Showing Hidden Layer */=0A= function showcontent(state, layerid) {=0A= if (document.getElementById) {=0A= var contentlayer =3D document.getElementById(layerid);=0A= setElementClass(contentlayer, state);=0A= movelayers(layerid);=0A= }=0A= }=0A= /* Utility Function For Showing Hidden Layer */=0A= function invitereminder(state, layerid) {=0A= if (document.getElementById) {=0A= var contentlayer =3D document.getElementById(layerid);=0A= setElementClass(contentlayer, state);=0A= movelayers(layerid);=0A= }=0A= }=0A= =0A= /* Utility Function Move Layers */=0A= function movelayers(num)=0A= {=0A= if (window.innerHeight)=0A= {=0A= pos =3D window.pageYOffset=0A= }=0A= else if (document.documentElement && document.documentElement.scrollTop)=0A= {=0A= pos =3D document.documentElement.scrollTop=0A= }=0A= else if (document.body)=0A= {=0A= pos =3D document.body.scrollTop=0A= }=0A= =0A= if (pos < theTop)=0A= {=0A= pos =3D theTop;=0A= }=0A= else=0A= {=0A= pos +=3D 75;=0A= }=0A= =0A= if (pos =3D=3D old)=0A= {=0A= document.getElementById(num).style.top =3D (pos + 'px');=0A= document.getElementById(num).style.left =3D '150px';=0A= }=0A= else=0A= {=0A= old =3D pos;=0A= movelayers(num);=0A= }=0A= }=0A= =0A= /* Function For Header Specialty List Menu */=0A= function headershowspeclist(state, layerid) {=0A= if (document.getElementById) {=0A= var contentlayer =3D document.getElementById(layerid);=0A= setElementClass(contentlayer, state);=0A= }=0A= }=0A= =0A= /* Utility Functions */=0A= function getElementClass(element) {=0A= if (element.getAttribute("class")) {=0A= return element.getAttribute("class");=0A= } else if (element.getAttribute("className")) {=0A= return element.getAttribute("className");=0A= }=0A= }=0A= =0A= function setElementClass(element, classValue) {=0A= if (element.setAttribute("class", classValue)) {=0A= element.setAttribute("class", classValue);=0A= } else if (element.setAttribute("className", classValue)) {=0A= element.setAttribute("className", classValue);=0A= }=0A= } ------=_NextPart_000_0112_01C903AE.6A8A9670 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: http://www.medscape.com/files/scripts/hp-pulldown.js function goToUrl(myUrl)=0A= {=0A= if (myUrl!=3D"")=0A= {=0A= parent.location.href=3DmyUrl;=0A= }=0A= }=0A= ------=_NextPart_000_0112_01C903AE.6A8A9670 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: http://www.medscape.com/files/scripts/popup.js function resizeWin(newLoc, newHeight, newWidth) {=0A= newWin =3D = open("",newLoc,"scrollbars=3Dyes,resizable=3Dyes,height=3D" + newHeight = + ",width=3D" + newWidth);=0A= }=0A= ------=_NextPart_000_0112_01C903AE.6A8A9670 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: http://www.medscape.com/files/scripts/swfobject.js /**=0A= * SWFObject v1.4.4: Flash Player detection and embed - = http://blog.deconcept.com/swfobject/=0A= *=0A= * SWFObject is (c) 2006 Geoff Stearns and is released under the MIT = License:=0A= * http://www.opensource.org/licenses/mit-license.php=0A= *=0A= * **SWFObject is the SWF embed script formerly known as FlashObject. = The name was changed for=0A= * legal reasons.=0A= */=0A= if(typeof deconcept =3D=3D "undefined") var deconcept =3D new Object();=0A= if(typeof deconcept.util =3D=3D "undefined") deconcept.util =3D new = Object();=0A= if(typeof deconcept.SWFObjectUtil =3D=3D "undefined") = deconcept.SWFObjectUtil =3D new Object();=0A= deconcept.SWFObject =3D function(swf, id, w, h, ver, c, = useExpressInstall, quality, xiRedirectUrl, redirectUrl, detectKey){=0A= if (!document.getElementById) { return; }=0A= this.DETECT_KEY =3D detectKey ? detectKey : 'detectflash';=0A= this.skipDetect =3D deconcept.util.getRequestParameter(this.DETECT_KEY);=0A= this.params =3D new Object();=0A= this.variables =3D new Object();=0A= this.attributes =3D new Array();=0A= if(swf) { this.setAttribute('swf', swf); }=0A= if(id) { this.setAttribute('id', id); }=0A= if(w) { this.setAttribute('width', w); }=0A= if(h) { this.setAttribute('height', h); }=0A= if(ver) { this.setAttribute('version', new = deconcept.PlayerVersion(ver.toString().split("."))); }=0A= this.installedVer =3D deconcept.SWFObjectUtil.getPlayerVersion();=0A= if(c) { this.addParam('bgcolor', c); }=0A= var q =3D quality ? quality : 'high';=0A= this.addParam('quality', q);=0A= this.setAttribute('useExpressInstall', useExpressInstall);=0A= this.setAttribute('doExpressInstall', false);=0A= var xir =3D (xiRedirectUrl) ? xiRedirectUrl : window.location;=0A= this.setAttribute('xiRedirectUrl', xir);=0A= this.setAttribute('redirectUrl', '');=0A= if(redirectUrl) { this.setAttribute('redirectUrl', redirectUrl); }=0A= }=0A= deconcept.SWFObject.prototype =3D {=0A= setAttribute: function(name, value){=0A= this.attributes[name] =3D value;=0A= },=0A= getAttribute: function(name){=0A= return this.attributes[name];=0A= },=0A= addParam: function(name, value){=0A= this.params[name] =3D value;=0A= },=0A= getParams: function(){=0A= return this.params;=0A= },=0A= addVariable: function(name, value){=0A= this.variables[name] =3D value;=0A= },=0A= getVariable: function(name){=0A= return this.variables[name];=0A= },=0A= getVariables: function(){=0A= return this.variables;=0A= },=0A= getVariablePairs: function(){=0A= var variablePairs =3D new Array();=0A= var key;=0A= var variables =3D this.getVariables();=0A= for(key in variables){=0A= variablePairs.push(key +"=3D"+ variables[key]);=0A= }=0A= return variablePairs;=0A= },=0A= getSWFHTML: function() {=0A= var swfNode =3D "";=0A= if (navigator.plugins && navigator.mimeTypes && = navigator.mimeTypes.length) { // netscape plugin architecture=0A= if (this.getAttribute("doExpressInstall")) { = this.addVariable("MMplayerType", "PlugIn"); }=0A= swfNode =3D '

';=0A= } else { // PC IE=0A= if (this.getAttribute("doExpressInstall")) { = this.addVariable("MMplayerType", "ActiveX"); }=0A= swfNode =3D '

";=0A= }=0A= return swfNode;=0A= },=0A= write: function(elementId){=0A= if(this.getAttribute('useExpressInstall')) {=0A= // check to see if we need to do an express install=0A= var expressInstallReqVer =3D new deconcept.PlayerVersion([6,0,65]);=0A= if (this.installedVer.versionIsValid(expressInstallReqVer) && = !this.installedVer.versionIsValid(this.getAttribute('version'))) {=0A= this.setAttribute('doExpressInstall', true);=0A= this.addVariable("MMredirectURL", = escape(this.getAttribute('xiRedirectUrl')));=0A= document.title =3D document.title.slice(0, 47) + " - Flash Player = Installation";=0A= this.addVariable("MMdoctitle", document.title);=0A= }=0A= }=0A= if(this.skipDetect || this.getAttribute('doExpressInstall') || = this.installedVer.versionIsValid(this.getAttribute('version'))){=0A= var n =3D (typeof elementId =3D=3D 'string') ? = document.getElementById(elementId) : elementId;=0A= n.innerHTML =3D this.getSWFHTML();=0A= return true;=0A= }else{=0A= if(this.getAttribute('redirectUrl') !=3D "") {=0A= document.location.replace(this.getAttribute('redirectUrl'));=0A= }=0A= }=0A= return false;=0A= }=0A= }=0A= =0A= /* ---- detection functions ---- */=0A= deconcept.SWFObjectUtil.getPlayerVersion =3D function(){=0A= var PlayerVersion =3D new deconcept.PlayerVersion([0,0,0]);=0A= if(navigator.plugins && navigator.mimeTypes.length){=0A= var x =3D navigator.plugins["Shockwave Flash"];=0A= if(x && x.description) {=0A= PlayerVersion =3D new = deconcept.PlayerVersion(x.description.replace(/([a-zA-Z]|\s)+/, = "").replace(/(\s+r|\s+b[0-9]+)/, ".").split("."));=0A= }=0A= }else{=0A= // do minor version lookup in IE, but avoid fp6 crashing issues=0A= // see = http://blog.deconcept.com/2006/01/11/getvariable-setvariable-crash-intern= et-explorer-flash-6/=0A= try{=0A= var axo =3D new ActiveXObject("ShockwaveFlash.ShockwaveFlash.7");=0A= }catch(e){=0A= try {=0A= var axo =3D new ActiveXObject("ShockwaveFlash.ShockwaveFlash.6");=0A= PlayerVersion =3D new deconcept.PlayerVersion([6,0,21]);=0A= axo.AllowScriptAccess =3D "always"; // throws if player version < = 6.0.47 (thanks to Michael Williams @ Adobe for this code)=0A= } catch(e) {=0A= if (PlayerVersion.major =3D=3D 6) {=0A= return PlayerVersion;=0A= }=0A= }=0A= try {=0A= axo =3D new ActiveXObject("ShockwaveFlash.ShockwaveFlash");=0A= } catch(e) {}=0A= }=0A= if (axo !=3D null) {=0A= PlayerVersion =3D new = deconcept.PlayerVersion(axo.GetVariable("$version").split(" = ")[1].split(","));=0A= }=0A= }=0A= return PlayerVersion;=0A= }=0A= deconcept.PlayerVersion =3D function(arrVersion){=0A= this.major =3D arrVersion[0] !=3D null ? parseInt(arrVersion[0]) : 0;=0A= this.minor =3D arrVersion[1] !=3D null ? parseInt(arrVersion[1]) : 0;=0A= this.rev =3D arrVersion[2] !=3D null ? parseInt(arrVersion[2]) : 0;=0A= }=0A= deconcept.PlayerVersion.prototype.versionIsValid =3D function(fv){=0A= if(this.major < fv.major) return false;=0A= if(this.major > fv.major) return true;=0A= if(this.minor < fv.minor) return false;=0A= if(this.minor > fv.minor) return true;=0A= if(this.rev < fv.rev) return false;=0A= return true;=0A= }=0A= /* ---- get value of query string param ---- */=0A= deconcept.util =3D {=0A= getRequestParameter: function(param) {=0A= var q =3D document.location.search || document.location.hash;=0A= if(q) {=0A= var pairs =3D q.substring(1).split("&");=0A= for (var i=3D0; i < pairs.length; i++) {=0A= if (pairs[i].substring(0, pairs[i].indexOf("=3D")) =3D=3D param) {=0A= return pairs[i].substring((pairs[i].indexOf("=3D")+1));=0A= }=0A= }=0A= }=0A= return "";=0A= }=0A= }=0A= /* fix for video streaming bug */=0A= deconcept.SWFObjectUtil.cleanupSWFs =3D function() {=0A= if (window.opera || !document.all) return;=0A= var objects =3D document.getElementsByTagName("OBJECT");=0A= for (var i=3D0; i < objects.length; i++) {=0A= objects[i].style.display =3D 'none';=0A= for (var x in objects[i]) {=0A= if (typeof objects[i][x] =3D=3D 'function') {=0A= objects[i][x] =3D function(){};=0A= }=0A= }=0A= }=0A= }=0A= // fixes bug in fp9 see = http://blog.deconcept.com/2006/07/28/swfobject-143-released/=0A= deconcept.SWFObjectUtil.prepUnload =3D function() {=0A= __flash_unloadHandler =3D function(){};=0A= __flash_savedUnloadHandler =3D function(){};=0A= if (typeof window.onunload =3D=3D 'function') {=0A= var oldUnload =3D window.onunload;=0A= window.onunload =3D function() {=0A= deconcept.SWFObjectUtil.cleanupSWFs();=0A= oldUnload();=0A= }=0A= } else {=0A= window.onunload =3D deconcept.SWFObjectUtil.cleanupSWFs;=0A= }=0A= }=0A= if (typeof window.onbeforeunload =3D=3D 'function') {=0A= var oldBeforeUnload =3D window.onbeforeunload;=0A= window.onbeforeunload =3D function() {=0A= deconcept.SWFObjectUtil.prepUnload();=0A= oldBeforeUnload();=0A= }=0A= } else {=0A= window.onbeforeunload =3D deconcept.SWFObjectUtil.prepUnload;=0A= }=0A= /* add Array.push if needed (ie5) */=0A= if (Array.prototype.push =3D=3D null) { Array.prototype.push =3D = function(item) { this[this.length] =3D item; return this.length; }}=0A= =0A= /* add some aliases for ease of use/backwards compatibility */=0A= var getQueryParamValue =3D deconcept.util.getRequestParameter;=0A= var FlashObject =3D deconcept.SWFObject; // for legacy support=0A= var SWFObject =3D deconcept.SWFObject;=0A= ------=_NextPart_000_0112_01C903AE.6A8A9670 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: http://as.medscape.com/js.ng/transactionid%3D1219308715822&site%3D1&pos%3D901&affiliate%3D1&pf%3D10&usp%3D60&ct%3Dmy&artid%3D577683&spon%3Dcme&ssp%3D34 document.write('');=0A= if ("html" =3D=3D "html"){ =0A= document.bgColor =3D 'transparent';=0A= }=0A= document.write('

\n'); ------=_NextPart_000_0112_01C903AE.6A8A9670 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: http://www.medscape.com/files/scripts/articletools.js var theTop =3D 75;=0Dvar old =3D theTop;=0D=0Dwindow.onload =3D = function() {=0D hidearticletools();=0D hidecontent();=0D = hiddenlayers();=0D}=0D=0Dfunction hidearticletools()=0D{=0D if = (document.getElementById('emailtoolbox')) {=0D = document.getElementById('emailtoolbox').style.display =3D "none";=0D = }=0D if (document.getElementById('ratingtoolbox')) {=0D = document.getElementById('ratingtoolbox').style.display =3D "none";=0D = }=0D if (document.getElementById('emailconfirmation')) {=0D = document.getElementById('emailconfirmation').style.display =3D = "none";=0D }=0D if (document.getElementById('ratingthanks')) {=0D = document.getElementById('ratingthanks').style.display =3D "none";=0D = }=0D if (document.getElementById('ratingthanks2')) {=0D = document.getElementById('ratingthanks2').style.display =3D "none";=0D = }=0D if (document.getElementById('synonymskeywords')) {=0D = document.getElementById('synonymskeywords').style.display =3D "none";=0D = }=0D}=0D=0Dfunction hidecontent()=0D{=0D if = (document.getElementById('references')) {=0D = document.getElementById('references').style.display =3D "none";=0D = document.getElementById('references').style.top =3D '75px';=0D = document.getElementById('references').style.left =3D '150px';=0D = document.getElementById('references').style.position =3D "absolute";=0D = document.getElementById('references').style.zIndex =3D 500;=0D }=0D = if (document.getElementById('suggestedreading')) {=0D = document.getElementById('suggestedreading').style.display =3D "none";=0D = document.getElementById('suggestedreading').style.top =3D '75px';=0D = document.getElementById('suggestedreading').style.left =3D '150px';=0D = document.getElementById('suggestedreading').style.position =3D = "absolute";=0D = document.getElementById('suggestedreading').style.zIndex =3D 500; =0D = }=0D if (document.getElementById('relatedlinkswin')) {=0D = document.getElementById('relatedlinkswin').style.display =3D "none";=0D = document.getElementById('relatedlinkswin').style.top =3D '75px';=0D = document.getElementById('relatedlinkswin').style.left =3D '150px';=0D = document.getElementById('relatedlinkswin').style.position =3D = "absolute";=0D document.getElementById('relatedlinkswin').style.zIndex = =3D 500; =0D }=0D if (document.getElementById('cmeinformation')) = {=0D document.getElementById('cmeinformation').style.display =3D = "none";=0D document.getElementById('cmeinformation').style.top =3D = '75px';=0D document.getElementById('cmeinformation').style.left =3D = '150px';=0D document.getElementById('cmeinformation').style.position = =3D "absolute";=0D = document.getElementById('cmeinformation').style.zIndex =3D 500; =0D = }=0D if (document.getElementById('authordisclosures')) {=0D = document.getElementById('authordisclosures').style.display =3D = "none";=0D document.getElementById('authordisclosures').style.top =3D = '75px';=0D document.getElementById('authordisclosures').style.left =3D = '150px';=0D = document.getElementById('authordisclosures').style.position =3D = "absolute";=0D = document.getElementById('authordisclosures').style.zIndex =3D 500; = =0D }=0D}=0D=0Dfunction showcontent(tent) {=0D if = (document.getElementById(tent).style.display =3D=3D "none") {=0D = hidecontent();=0D document.getElementById(tent).style.display =3D = "block";=0D document.getElementById(tent).style.height =3D "auto";=0D = movelayers(tent);=0D } else {=0D = document.getElementById(tent).style.display =3D "none";=0D = }=0D}=0D=0Dfunction movecontent(tent)=0D{=0D if (window.innerHeight)=0D = {=0D pos =3D window.pageYOffset=0D }=0D else if = (document.documentElement && document.documentElement.scrollTop)=0D {=0D = pos =3D document.documentElement.scrollTop=0D }=0D else if = (document.body)=0D {=0D pos =3D document.body.scrollTop=0D }=0D =0D if = (pos < theTop)=0D {=0D pos =3D theTop;=0D }=0D else=0D {=0D pos = +=3D 75;=0D }=0D =0D if (pos =3D=3D old)=0D {=0D = document.getElementById(tent).style.top =3D (pos + 'px');=0D = document.getElementById(tent).style.left =3D '150px';=0D }=0D else=0D = {=0D old =3D pos;=0D movelayers(tent);=0D }=0D}=0D=0D=0Dfunction = hiddenlayers() {=0D var displaystr =3D null;=0D var stylestr =3D = null;=0D=0D for(n =3D1; n < 100; n++){=0D if(n <10)=0D displaystr =3D = 'hiddenlayer0' + n;=0D else=0D displaystr =3D 'hiddenlayer' + n;=0D = stylestr =3D document.getElementById(displaystr);=0D if(stylestr !=3D = null) {=0D stylestr.style.display =3D "none";=0D stylestr.style.top = =3D '75px';=0D stylestr.style.left =3D '150px';=0D = stylestr.style.position =3D "absolute";=0D stylestr.style.zIndex =3D = 500;=0D } =0D else=0D break;=0D }=0D}=0D=0Dfunction = showlayers(num) {=0D if (document.getElementById(num).style.display = =3D=3D "none") {=0D hiddenlayers();=0D = document.getElementById(num).style.display =3D "block";=0D = document.getElementById(num).style.height =3D "auto";=0D = movelayers(num);=0D } else {=0D = document.getElementById(num).style.display =3D "none";=0D = }=0D}=0D=0Dfunction movelayers(num)=0D{=0D if (window.innerHeight)=0D = {=0D pos =3D window.pageYOffset=0D }=0D else if = (document.documentElement && document.documentElement.scrollTop)=0D {=0D = pos =3D document.documentElement.scrollTop=0D }=0D else if = (document.body)=0D {=0D pos =3D document.body.scrollTop=0D }=0D =0D if = (pos < theTop)=0D {=0D pos =3D theTop;=0D }=0D else=0D {=0D pos = +=3D 75;=0D }=0D =0D if (pos =3D=3D old)=0D {=0D = document.getElementById(num).style.top =3D (pos + 'px');=0D = document.getElementById(num).style.left =3D '150px';=0D }=0D else=0D = {=0D old =3D pos;=0D movelayers(num);=0D }=0D}=0D=0Dfunction = showemailtoolbox()=0D{=0D if = (document.getElementById('emailtoolbox').style.display =3D=3D "none")=0D = {=0D document.getElementById('emailtoolbox').style.display =3D = "block";=0D if (document.getElementById('ratingtoolbox')) {=0D = document.getElementById('ratingtoolbox').style.display =3D "none";=0D = }=0D }=0D else=0D {=0D = document.getElementById('emailtoolbox').style.display =3D "none";=0D = }=0D =0D}=0D=0Dfunction confirmsent()=0D{=0D if = (document.getElementById('emailconfirmation').style.display =3D=3D = "none")=0D {=0D = document.getElementById('emailconfirmation').style.display =3D = "block";=0D document.getElementById('emailform').style.display =3D = "none";=0D return false;=0D }=0D}=0D=0Dfunction = showratingtoolbox()=0D{=0D if = (document.getElementById('ratingtoolbox').style.display =3D=3D = "none")=0D {=0D document.getElementById('ratingtoolbox').style.display = =3D "block";=0D if (document.getElementById('emailtoolbox')) {=0D = document.getElementById('emailtoolbox').style.display =3D "none";=0D = }=0D }=0D else=0D {=0D = 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