From: Subject: Comprehensive Management of Pediatric Asthma-Guidelines (Slides/Transcript) Date: Mon, 15 Sep 2008 12:12:31 +0800 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0000_01C9172C.54773C30" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.3350 This is a multi-part message in MIME format. ------=_NextPart_000_0000_01C9172C.54773C30 Content-Type: text/html; charset="utf-8" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.medscape.com/viewarticle/577795 =EF=BB=BF Comprehensive = Management of Pediatric Asthma-Guidelines (Slides/Transcript)

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Comprehensive Management of Pediatric Asthma: Using the=20 Guidelines to Develop Effective, Long-Term Plans (Slides = With=20 Transcript) CME

Andrew Liu, MD Disclosures

Slide 1.

Hello, my name is Dr. Andy Liu. I am a pediatric = allergist at the=20 National Jewish Medical and Research Center in Denver. = Welcome to=20 today's program on the Comprehensive Management of Pediatric = Asthma:=20 Using the Guidelines to Develop Effective, Long-Term = Plans.

In the United States, we have new national guidelines for = the=20 management of asthma published at the end of 2007. They are=20 comprehensive and they work well in achieving asthma = control, but in=20 being comprehensive, they are somewhat lengthy.

What are the main messages? What are the keys to = achieving,=20 maintaining good asthma control? That will be the main focus = of=20 today's program. I will begin with a little bit of = background on=20 asthma and spend most of the time talking about these new = asthma=20 guidelines and what are the key messages from them to = provide great=20 care for asthmatic patients.

Slide 2.

Let's begin with some pediatric asthma statistics = briefly. You=20 can see that asthma is very common in children, especially 9 = million=20 American children are affected with asthma. It is on the = rise, up=20 75% over the last 15 years. It is a highly morbid condition, = a lot=20 of missed school days, a lot of emergency department (ED) = visits,=20 hospitalizations; in children, it is the most common cause = of missed=20 school days and ED visits and hospitalizations of any = chronic=20 condition, and as such, it is costly to us in the United = States.

Slide 3.

This feature requires the newest version = of Flash.=20 You = can=20 download it here.

I would like to share with you this case study of this = 2-year-old=20 child with asthma.

Slide 4.

As you can see, the clinical symptoms of asthma vary. = They are=20 intermittent. The types of symptoms vary from individual to=20 individual. Coughing and/or wheezing are common, sometimes = with=20 shortness of breath and chest pain as symptoms become more=20 pronounced or progressive. There is daily variation; asthma = tends to=20 be worse at night. And it can limit exercise tolerance. Even = less=20 common are the exacerbations that are progressive and often = occur in=20 asthmatics several times a year. We also ask about frequency = of=20 rescue medication or albuterol usage to treat symptoms.

Slide 5.

Underlying this clinical intermittence is a chronic = condition of=20 the airways; causing this airway blockage includes smooth = muscle=20 bronchoconstriction and an inflammation of the airways that = is=20 eosinophilic or allergic in nature. This inflammation makes = the=20 airways twitchy or hyperresponsive, and this blockage tends = to be=20 reversible in terms of the inflammation and the = bronchoconstriction.=20 However, there are also structural changes of the airway's = tissue,=20 called airway remodeling, that do not appear so = reversible.

Slide 6.

With airway obstruction comes ventilation defects as seen = here in=20 these exquisite ventilation scans by MRI. You can see, = compared with=20 normal, that as asthma moves from mild to moderate to = severe, you=20 can see gross ventilation defects that ultimately end up = involving=20 most of the lungs.

Slide 7.

Is the airway obstruction in asthma reversible? Well, yes = and no.=20 We can see that some aspects are reversible and we = understand how to=20 reverse them, the bronchoconstriction, the mucous secretion, = edema,=20 the eosinophilic inflammation, and with the healing of the=20 inflammation, the airway lining also heals. This improves = the=20 bronchial hyperresponsiveness. But there are features of the = tissues=20 of the airways in asthma that seem irreversible to us at = this point=20 in time: the smooth muscle and mucous gland hypertrophy, = airway wall=20 thickening, and changes in how the airways are held open. As = well,=20 if beginning in early life, this can affect early lung = growth and=20 development of the airways.

Slide 8.

I would like to share with you a little background on the = natural=20 history and the types of pediatric asthma.

Slide 9.

There are different types of pediatric asthma that are=20 exemplified well in early life. Here seen, the most commons = types=20 are described as those who are transient early wheezers and=20 immunoglobulin (Ig) E-associated wheeze or asthma, otherwise = called=20 classic asthma.

Slide 10.

These two common types of childhood asthma are well = exemplified=20 in this classic study in Tucson where over 1000 children = were=20 enrolled from birth and followed for the development of = wheezing.=20 What we can see is that in the first 6 years of life, it is = as=20 common to have wheezing problems as to never wheeze. Almost = 50% of=20 the population experienced some wheezing problems during = their early=20 childhood. All together, about 20% experienced a transient = type of=20 wheeze, meaning that they became better on their own between = the=20 ages of 3 to 6 years. In comparison, 14% of the total = population had=20 persistent wheezing problems through these early years of = childhood.=20 How do you distinguish these different types of wheeze?

Slide 11.

The risk factors for transient wheeze are listed here. = You can=20 see that they are associated with respiratory viral = infections and,=20 in particular, the susceptible are those young children who = have=20 smaller air passages and smaller airways due to lung size, = male=20 gender, low birth weight, and maternal smoking.

Slide 12.

In comparison, we can tease out those young children with = early=20 wheezing who are likely to have persistent asthma using this = Asthma=20 Predictive Index. In a young child who has had some wheezing = problems in early life, those who are likely to persist may = have 1=20 major or 2 minor criteria. You can see that the criteria are = largely=20 about allergy. One major criteria might be a parent with = asthma or=20 early atopic dermatitis or early sensitization to inhaled = allergens;=20 2 minor criteria, allergic rhinitis, wheezing apart from = colds,=20 eosinophilia, or sensitization to foods.

As you can see from these criteria, it is not that a = child needs=20 to have most or all of these criteria to be at increased = risk, just=20 1 major or 2 minor criteria.

Slide 13.

Now let's turn our attention to the new national = guidelines for=20 asthma management.

Slide 14.

The US national guidelines are now in their third major = iteration=20 over the last 20 years and continue to be divided into the 4 = major=20 components of asthma management: the first, how asthma is = diagnosed,=20 assessed, and monitored; the second, how we best work with = our=20 patients to be most effective and efficient in achieving = good asthma=20 care; the third, control of environmental factors and = comorbid=20 conditions that affect asthma, primarily those that promote=20 inflammation in the airways; and the fourth, optimal = pharmacotherapy=20 to control asthma and to treat exacerbations or increased=20 symptoms.

Slide 15.

In these new guidelines, asthma management is first = assessed when=20 diagnosed based on its severity in order to initiate = therapy.=20 Subsequently, in all follow-up visits, asthma control is = assessed,=20 and this is a new element of this new version of the = national=20 guidelines and is perhaps its biggest change and a very = helpful one=20 at that.

Both asthma severity and control are assessed by similar=20 parameters and those parameters are divided into impairment = and risk=20 parameters.

Slide 16.

The parameters in the new national guidelines for = assessing=20 asthma severity and control can be divided into parameters = of=20 impairment and risk.

Listed on the left, impairment is assessed by asking = about=20 daytime symptoms, nighttime awakening, albuterol usage to = treat=20 symptoms, and impairment of daily activities, missed work or = school,=20 exercise limitation; as well, lung function can be measured = in the=20 office as a helpful measure of impairment.

The main risk category is that of asthma exacerbations, a = helpful=20 one especially when working with children. Exacerbations may = be=20 defined as requiring oral corticosteroids to treat a = progressive=20 flare or urgent visits, ED visits, or hospitalizations. When = assessing asthma control, additional risk measures include=20 continuous obstruction as measured by lung function, or=20 treatment-related adverse effects.

Slide 17.

Here is the heart of asthma assessment for the new = guidelines,=20 these new tables. There are tables that differ for asthma = severity=20 assessment as well as asthma control, and they also differ = by age, a=20 younger age group, here as you can see 0 to 4 years of age, = but also=20 different tables for those children 5 to 11 years of age, = and those=20 12 years of age and older including adults. While these = tables=20 differ, they are very similar in how they are used. I will = spend=20 most of my time on this first table and then I will show you = in=20 subsequent tables how they differ from the first.

When initially assessing asthma severity, once asthma is=20 diagnosed, you can see that asthma severity is divided = across the=20 top into 4 main categories, just as prior guidelines have = been:=20 intermittent, mild, moderate, and severe persistent = asthma.

To determine how severe asthma is, we use the parameters = listed=20 on the left column divided into those of impairment and = risk, asthma=20 symptoms during the day, nighttime awakenings, albuterol use = to=20 treat symptoms, interference with normal activities, and = highlighted=20 in yellow is this new criteria, asthma exacerbations. There = are=20 different degrees for each of these parameters that help to = define=20 their level of severity.

Finally, it is worth noting that the single parameter = that rates=20 the worst is the one that is used to define the level of = severity.=20 Let me just give you an example. Let's take a young child = who is=20 having essentially no current problems, no symptoms, = nighttime=20 awakenings, or albuterol usage. However, this child has had = 3=20 significant asthma exacerbations in the past year. This = child would=20 rate as having at least mild asthma based on the parameter = of=20 exacerbation risk.

Slide 18.

The second table of asthma severity assessment differs = only from=20 the first table in that it is applied to the slightly older = child,=20 ages 5 to 11 years of age. The main way in which this table = differs=20 is that it adds to the impairment assessment, a measure of = lung=20 function by spirometry.

Children younger than 5, are unable to perform = spirometry, hence,=20 the addition of this new parameter for assessing impairment = in the=20 slightly older child.

Slide 19.

The third table for assessing asthma severity is now, as = you can=20 see, for the child who is 12 years of age and older, = including=20 adults. In this case, we can see that this table differs = from the=20 earlier tables in that lung function is adjusted by age. As = you can=20 see on the far left side under impairment, normal lung = function is=20 given, and as we age, there is a slight decline in what is=20 considered normal lung function.

Slide 20.

One of the main reasons why we assess and rate asthma = severity in=20 patients is because it helps guide us as to what controller = therapy=20 to begin with in order to achieve and maintain control.

The controller therapies, as you can see here, are = referred to as=20 a step ladder such that with intermittent disease, step 1 is = appropriate; mild disease, step 2; moderate, step 3 or 4; = and=20 severe, step 5 or 6. It is a 6-step ladder that is also used = to help=20 manage and control asthma, and we will be going over those = in a few=20 slides.

Slide 21.

But first, let's talk about assessing asthma control, = which is=20 probably the main change in the new guidelines.

Slide 22.

The goal of asthma management is to achieve control, to = reduce=20 impairment and risk, to achieve and then subsequently to = maintain=20 good asthma control. This is aided by periodic assessments = at about=20 1- to 6-month intervals and is a combination of clinician = assessment=20 and patient self-assessment in order to help determine how = well or=20 inadequately asthma is controlled.

Slide 23.

What is well controlled asthma? Well, the new guidelines = do an=20 excellent job of defining asthma control as achieving and=20 maintaining all of these parameters: minimal day symptoms; = no=20 limitations of activities including exercise; nocturnal = symptoms or=20 awakening from asthma should be very rare, no more than once = a=20 month; minimal need for reliever treatment such as albuterol = for=20 asthma symptoms; normal or near-normal lung function; and no = more=20 than 1 asthma exacerbation per year.

Slide 24.

This definition of well controlled asthma can also be = seen in=20 these tables for assessing asthma control. This is the table = that is=20 applied to the youngest aged child, and we can see now = across the=20 top that asthma control is categorized into 1 of 3 levels: = well=20 controlled, not well controlled, or very poorly controlled=20 asthma.

The parameters that we use to assess asthma control, = those=20 parameters of impairment and risk, are again familiar as = they were=20 for asthma severity: day symptoms, nighttime awakening, = interference=20 with normal activities, and albuterol usage to treat those = symptoms.=20 There is also the familiar new exacerbation criterion which = is very=20 helpful, and there is one more added, which is = treatment-related=20 adverse effects.

So we can see now that under well-controlled asthma, that = the=20 goal of control is well defined.

Slide 25.

The second of these asthma control assessment tables is = for the=20 slightly older child, ages 5 to 11 years. Again, this table = differs=20 from the control assessment for younger children simply by = the=20 addition of lung function criteria.

Lung function in the older child and adult are used to = assess=20 asthma impairment but are also used to assess asthma risk. = What this=20 means is that spirometry or measurements of lung function = are=20 considered helpful on a continuous basis to make sure that=20 continuous obstruction is not occurring or developing in an = occult=20 way in some asthmatics.

Slide 26.

In the older child, 12 years of age, and the adult, we = can see=20 again that the table is familiar. However, there is the = addition of=20 new validated questionnaires that can help us assess asthma = control.=20 They are listed here in the impairment category, ATAQ, ACQ, = asthma=20 control test ACT, and I will be showing you an example = toward the=20 end of how these validated questionnaires can be used to = simplify=20 your life and clinical assessment with asthma.

Slide 27.

To summarize briefly, the goals of asthma therapy are to = decrease=20 impairment and reduce risk of asthma by normalizing the = symptoms,=20 the lung function, and physical activity and decreasing the = risk of=20 exacerbations and progressive airflow obstruction.

Slide 28.

Once we have assessed a level of asthma severity and = control, how=20 do we achieve good control? That information helps us apply = these=20 stepwise tables for asthma management. Here you can see in = the=20 middle a 6-step ladder of increasing intensity of asthma = controller=20 therapy that can be used to achieve asthma control.

Let's use the example of asthma severity first. As you = might=20 recall, in those tables for intermittent asthma, step 1 = therapy is=20 applied; that is albuterol on an as-needed basis only. But = with=20 mild-persistent asthma, step 2 therapy is appropriate. We = can see=20 that there is a preference of low-dose inhaled = corticosteroids that=20 is highlighted, but there are also alternatives that are = acceptable:=20 cromolyn or montelukast. For moderate asthma, step 3 or step = 4=20 therapy is appropriate, and for severe asthma, step 5 or = step 6=20 level therapy is appropriate as a starting place.

The ladder is also helpful in that initially, we start at = a=20 certain step to achieve control, but once control is = achieved, then=20 we can step down to maintain control. If control is not = achieved, we=20 step up the ladder. And so, with these progressive follow-up = visits,=20 we see that we can apply this ladder by stepping up or = stepping down=20 in the level of asthma therapy needed to maintain asthma=20 control.

The other important elements as seen here include = consultation=20 with a specialist if asthma is difficult to control or step = 3 level=20 care is needed, as well, patient education and environmental = control=20 considerations at every step.

Slide 29.

The assessment and control algorithm for management in = the=20 slightly older child, age 5 to 11 years, is shown here and = differs=20 slightly from that applied to the younger child.

Step 1 and step 2 level care looks similar. At step 3, = there is a=20 slight difference: for the younger child, step 3 care is = preferably=20 inhaled corticosteroids at a higher dosage; here we can see = that for=20 step 3 care, that is one of the options, but as well, = combination=20 controller therapy is an early option. Combination = controller=20 therapy is considered add-on to inhaled corticosteroids with = either=20 a long-acting bronchodilator, a leukotriene antagonist, or=20 theophylline. Stepping up to step 4 or step 5 provides a = preferred=20 alternative primarily of increasing the inhaled = corticosteroid=20 dosage. There are also alternatives that are provided.

Slide 30.

Finally, for the older child 12 years of age and older to = adulthood, we can see again that there is only a slight = modification=20 in the stepwise approach to care. That modification exists = primarily=20 at the step 3 level where we can see that there is a = preference for=20 either combination controller therapy with low-dose inhaled=20 corticosteroids plus long-acting bronchodilator, or = medium-dose=20 inhaled corticosteroids.

One other change in this algorithm for the older child = and adult=20 is for the severe asthmatic, or the difficult-to-control = asthmatic,=20 at step 5 or step 6 where one option is the addition of = omalizumab=20 therapy; this is an anti-IgE monoclonal antibody therapy = that is=20 approved for use in children older than 12 and = adults.

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All material on this website is protected by = copyright, Copyright = =C2=A9 1994-2008=20 by Medscape. This website also contains material copyrighted by 3rd = parties.=20

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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; 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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: 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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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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_0000_01C9172C.54773C30 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_0000_01C9172C.54773C30 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_0000_01C9172C.54773C30 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: http://as.medscape.com/js.ng/transactionid%3D1221451807888&site%3D1&pos%3D901&affiliate%3D1&pf%3D10&usp%3D60&ct%3Dmy&artid%3D577795&spon%3Dcme&ssp%3D9 document.write('');=0A= if ("html" =3D=3D "html"){ =0A= document.bgColor =3D 'transparent';=0A= }=0A= document.write('

\n'); ------=_NextPart_000_0000_01C9172C.54773C30 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 = document.getElementById('ratingtoolbox').style.display =3D "none";=0D = }=0D =0D}=0D=0D/* Multi Nav Btn */=0D=0Dfunction = togglearticlelist(state) {=0D if (document.getElementById) {=0D var = multiarticlebtn =3D document.getElementById("multiarticlebtn");=0D = multiarticlebtn.setAttribute("href", "#"); // get rid of the href=0D = var menu =3D = document.getElementById("multiarticlelist").firstChild;=0D// Make sure = the firstChild is an HTML tag and nothing else=0D while (menu.nodeType = !=3D 1) { //nodeType 1 is HTML element=0D menu =3D menu.nextSibling; = // assign next sibling instead=0D }=0D = setElementClass(multiarticlebtn, state);=0D setElementClass(menu, = state);=0D if (document.getElementById("searchType")) {=0D if (state = =3D=3D "active") { =0D = document.getElementById("searchType").style.visibility =3D "hidden";=0D = } else {=0D document.getElementById("searchType").style.visibility = =3D "visible";=0D }=0D }=0D }=0D}=0D=0Dfunction = getElementClass(element) {=0D if (element.getAttribute("class")) {=0D = return element.getAttribute("class");=0D } else if = (element.getAttribute("className")) {=0D return = element.getAttribute("className");=0D }=0D}=0D=0Dfunction = setElementClass(element, classValue) {=0D if = (element.setAttribute("class", classValue)) {=0D = element.setAttribute("class", classValue);=0D } else if = (element.setAttribute("className", classValue)) {=0D = element.setAttribute("className", classValue);=0D }=0D}=0D=0D=0D/* = Script For Rate Form 1 */=0Dfunction overstars1()=0D{=0D = document.getElementById('star1').style.backgroundPosition=3D'0px = -16px';=0D}=0Dfunction offstars1()=0D{=0D = document.getElementById('star1').style.backgroundPosition=3D'0px = 0px';=0D}=0D=0Dfunction overstars2()=0D{=0D = document.getElementById('star1').style.backgroundPosition=3D'0px = -16px';=0D = document.getElementById('star2').style.backgroundPosition=3D'0px = -16px';=0D}=0Dfunction offstars2()=0D{=0D = document.getElementById('star1').style.backgroundPosition=3D'0px = 0px';=0D = document.getElementById('star2').style.backgroundPosition=3D'0px = 0px';=0D}=0D=0Dfunction overstars3()=0D{=0D = document.getElementById('star1').style.backgroundPosition=3D'0px = -16px';=0D = document.getElementById('star2').style.backgroundPosition=3D'0px = -16px';=0D = document.getElementById('star3').style.backgroundPosition=3D'0px = -16px';=0D}=0Dfunction offstars3()=0D{=0D = document.getElementById('star1').style.backgroundPosition=3D'0px = 0px';=0D = document.getElementById('star2').style.backgroundPosition=3D'0px = 0px';=0D = document.getElementById('star3').style.backgroundPosition=3D'0px = 0px';=0D}=0D=0Dfunction overstars4()=0D{=0D = document.getElementById('star1').style.backgroundPosition=3D'0px = -16px';=0D = document.getElementById('star2').style.backgroundPosition=3D'0px = -16px';=0D = document.getElementById('star3').style.backgroundPosition=3D'0px = -16px';=0D = document.getElementById('star4').style.backgroundPosition=3D'0px = -16px';=0D}=0Dfunction offstars4()=0D{=0D = document.getElementById('star1').style.backgroundPosition=3D'0px = 0px';=0D = document.getElementById('star2').style.backgroundPosition=3D'0px = 0px';=0D = document.getElementById('star3').style.backgroundPosition=3D'0px = 0px';=0D = document.getElementById('star4').style.backgroundPosition=3D'0px = 0px';=0D}=0D=0Dfunction overstars5()=0D{=0D = document.getElementById('star1').style.backgroundPosition=3D'0px = -16px';=0D = document.getElementById('star2').style.backgroundPosition=3D'0px = -16px';=0D = document.getElementById('star3').style.backgroundPosition=3D'0px = -16px';=0D = document.getElementById('star4').style.backgroundPosition=3D'0px = -16px';=0D = document.getElementById('star5').style.backgroundPosition=3D'0px = -16px';=0D}=0Dfunction offstars5()=0D{=0D = document.getElementById('star1').style.backgroundPosition=3D'0px = 0px';=0D = 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