From: Subject: The Treatment of Growth Failure in SGA Children (Slides With Transcript) Date: Thu, 21 Aug 2008 16:11:05 +0800 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0000_01C903A8.8386D310" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.3350 This is a multi-part message in MIME format. ------=_NextPart_000_0000_01C903A8.8386D310 Content-Type: text/html; charset="utf-8" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.medscape.com/viewarticle/577686 =EF=BB=BF The Treatment = of Growth Failure in SGA Children (Slides With Transcript)

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

The Treatment of Growth Failure in SGA Children (Slides = With=20 Transcript) CME

Anita Hokken-Koelega, MD Disclosures

Slide 1.

Dr. Hokken-Koelega: I would like to go = through=20 the following issues.

Slide 2.

First of all, the definitions of SGA and intrauterine = growth=20 retardation very shortly, because Claire L=C3=A9vy-Marchal = has addressed=20 this item, then postnatal growth of children born SGA, and=20 characteristics of children born SGA. Then the efficacy of = growth=20 hormone treatment, also the other effects on future risk of = diabetes=20 type 2. Also the present guidelines for growth hormone = treatment,=20 and take home message.

Slide 3.

Small for gestational age, you have seen, is just a = definition we=20 have made.

Slide 4.

It is relatively arbitrary, because it means that you are = born=20 with a size that is below the -2 SD for your gestational = age. It=20 means you can be born either premature or at term, and it = says=20 something about the size. There are also children born = appropriate=20 for gestational age, but they have also had this = intrauterine growth=20 retardation. So SGA is either because the child has grown = below the=20 -2 SD or the have had IUGR during fetal life.

Slide 5.

Then the definition, IUGR is intrauterine growth = retardation and=20 they can only be based when they are at least two fetal=20 measurements, otherwise you cannot make this growth chart. = SGA means=20 small for gestational age, so it is either due to = intrauterine=20 growth retardation or because you are genetically small.

Slide 6.

What about the catch-up growth in height in this light of = SGA=20 children? When we look at the catch-up growth, which means = height=20 above the -2 SD, and we have the age, the X axis, and on the = Y axis,=20 the percentage of children reaching a height above the -2. = You can=20 see that those who are born full term already after 3 months = in more=20 than 50%, have reached this height. At the age of 2, 85% = have=20 reached a normal height or normal length.

The preterm babies, they do it more slowly, but at the = end, at 2=20 years, they reach more or less the same percentage. We know = that=20 after the age of 2 years, there will be another 5% with = catch-up=20 growth. So at the end, we also have 10% which will remain = very=20 small, short.

Slide 7.

We have worked with these short children SGA born already = from=20 the early '90s. It was in '90, '92, that we found out some = very=20 peculiar characteristics in children born SGA. Because most = of them=20 have a very bad appetite, and they have very low food = intake, it is=20 not a surprise that have very low weight for height. They = are very=20 tiny. They also have accelerated bone maturation between 8 = and 10=20 years. It almost spoiled the whole trial because there was = this=20 acceleration, and we thought it was due to growth hormone, = but it=20 turned out that it was just due to the fact that they were = born SGA.=20 And even Tenner described this already in the 1970s.

They have a relatively early start of puberty. It is not=20 precocious, but because they are so short, you would have = liked=20 delayed puberty and not a normal puberty. That is why we = call it a=20 relatively early puberty. Their average IQ is quite low, it = is 85,=20 which compared with reference is too low. Most of them are = very=20 hyperactive.

Slide 8.

When we measured growth hormone levels, we performed = stimulation=20 tests, and 25% had partial growth hormone deficiency. It is = not very=20 low; the maximum growth hormone peak, but it is just too low = for the=20 normal curve.

Then we performed 24-hour growth hormone profiles. We = found out=20 that 60% of them had very low levels during the day. Without = any=20 stimulation, they did not produce much growth hormone. You = can call=20 that a kind of narrow secretory dysfunction. IGF-I and BP3 = levels=20 are always quite low. It is still in the normal range, but = it is=20 significantly lower than average. Although they have some = signs,=20 some of them, of partial growth hormone deficiency, they = have no=20 clinical signs of growth hormone deficiency like the fat = face and=20 doll face and fat on the abdomen.

Slide 9.

When we performed at the age of 7.5 years oral glucose = tolerance=20 test, we found that 8% had impaired glucose tolerance. We = also found=20 a reduced insulin sensitivity at the age of 7.5 years, and = we are=20 all talking about short SGA children. We found out the = highest=20 systolic blood pressure. First of all, we thought that the = children=20 were maybe nervous or something like that, but we had to = repeat this=20 and confirmed it in all the trials. It is really something = related=20 to short SGA children.

Slide 10.

Already halfway through the 1990s, we had the idea that = these=20 short SGA children were not just short and healthy normal = children,=20 but there was something peculiar about them. We thought = maybe they=20 have another fetal programming, and is that maybe due to = other=20 environmental also factors? Or is it due to the fact that = they have=20 not a genetic profile?

Later on, Barker came with this hypothesis, and after = that,=20 others followed. But we could see that they had this = hypothesis=20 because we, personally we thought that they were different = from=20 other short, healthy children.

Slide 11.

What about growth hormone therapy? Because some children = had=20 quite low growth hormone levels, we thought it would be = worthwhile=20 to see whether these children could benefit from growth = hormone=20 treatment. For that we included children with birth length = below the=20 -2 SD with a height below -2 with a height velocity below 0 = SD,=20 which means no catch-up growth any more, and an age above = the 3=20 years.

Slide 12.

The first study was a randomized double-blind study, = multicenter=20 trial, no control group because it was not allowed by the = ethics=20 committees. We had no choice then to divide them in two = groups, one=20 group was treated with 33 mcg/kg/day, and the other one with = the=20 double dose, is the 67 mcg/kg/day, from start until adult=20 height.

Slide 13.

During the first years, both dosage groups increased = height SD.=20 You can see after 2 years, both groups have already reached = on=20 average the heights which is in the normal range. You can = see during=20 the first years that the double dose has a higher increase = in height=20 SD, although this wanes over time, and then we go to the = next=20 slide.

Slide 14.

This gives you the same results in a different = expression. Here=20 we have adult height, and you can see that adult height, = there is=20 not so much difference between the two dosages. It also = shows that=20 85% of the children reached a normal height.

Slide 15.

When we express it in a different way, we can see that = the ones=20 with the 33 mcg/kg/day, they have lower target height of = mean=20 parental height range than the ones with the higher dose. So = 98% of=20 them reached adult height within their target range, and = there is=20 absolutely no difference between the two dosage groups.

Slide 16.

When we compared them with a non-randomized control group = in the=20 other part of The Netherlands, they were not part of this = trial,=20 which went on in the western part of The Netherlands. We can = see=20 that these ones reached a lower height as when they had = attained=20 adult height.

Slide 17.

IGF-I levels were relatively low, at least significantly = lower=20 than 0 at the start and they increased significantly. You = can see=20 that the ones with the higher dose reached higher IGF-I = levels=20 compared with these. They go up on the average with IGF-I = levels=20 around close to SD, which means that some of the children = with the=20 higher dose had really high IGF-I levels.

Slide 18.

Compared with the IGFBP3 levels, they also went up, but = not to=20 the same extent as the IGF-I levels. It is around 1 SD. From = this=20 and also combining that with the adult height data, we do = not treat=20 children with the higher dose. We think that the dose of 33 = or 35=20 mcg/kg/day is on average for these children a good idea, = although of=20 course there are exceptions still, and that are very short = or are=20 relatively older, you might choose to give a higher dose = from the=20 start.

Slide 19.

This is just a growth chart of a boy, and when you start = early,=20 there is not a huge increase in height, but over time, there = will be=20 a very good catch-up growth. In the end, at final height, = there is=20 normal adult height.

Slide 20.

What about the other effects? I can't show you all the = parameters=20 we have measured, but I think it is very important to show = the oral=20 glucose tolerance test. On the left side, we see the ones = treated=20 with the 1 mg/m²/d and the other ones with the 2=20 mg/m²/d. Here we see the glucose levels in both = charts.=20 At baseline in white, after 6 years of growth hormone = treatment,=20 then in green, the ones after growth hormone treatment, half = year=20 after stop, and the controls. I think I do not have to show = you the=20 analyses. It is very obvious that there is absolutely = nothing=20 happening at all.

Slide 21.

But there is something with insulin when we give growth = hormone.=20 There is an increase in insulin in both groups. It is no = different.=20 It is not that it is higher in the higher dose group.

Slide 22.

Then we stop growth hormone, we see that insulin levels = drop. We=20 were a bit worried about this one because it did not go back = to=20 this, the baseline value. On the other hand, these children = are now=20 9 years older than at the baseline.

Slide 23.

When we compared them with age-matched reference values, = we see=20 that they are completely within the normal range for glucose = -- for=20 insulin levels.

Slide 24.

When we looked at the blood pressure, it was = significantly higher=20 than average, than 0 SD, but there is this decline over = time. This=20 is after growth hormone treatment, and then it is around = 0.

Slide 25.

The same with the diastolic blood pressure, is completely = normal=20 at the start but there is also decline over time, and it = remains the=20 same.

Slide 26.

Cholesterol levels, the higher dose, it seems to decline = a bit=20 more than the other ones. This is a significant change from = the=20 start until 4 years. HDL remains the same. So altogether, we = have=20 studied a lot of these parameters in the children.

Slide 27.

But what about risk of growth hormone in later life?

Slide 28.

We performed a study in previously growth hormone-treated = children, that are the ones you have just seen, and we = during growth=20 hormone and after growth hormone. These children were = treated for=20 7.3 years, and now we have data 6.5 years after stop of = growth=20 hormone treatment. It means that we studied them at the = start after=20 6 years, then half a year after stop, and 6.5 years after = stop. Then=20 their ages were on average 8.5, 15.8, and 22.3 years. Then = we had a=20 cross-sectional comparison with untreated short SGA from the = other=20 part of The Netherlands, who did not have the growth hormone = because=20 it was not offered to them.

Slide 29.

The clinical characteristics of the GH treated and the = untreated=20 ones, we can see that the ones that were treated just by = chance had=20 a shorter gestational age, not significantly different from = the=20 other ones. They were a bit shorter and a little bit lower = birth=20 weight, but this was not significantly different between the = groups.=20 The height at the start of growth hormone was -2.9 in the = treated=20 ones, and you can see the untreated ones, they reached an = adult=20 height of -2.6. But these ones were treated, and on average, = they=20 had a height SD of -1.4. Ages at follow-up are around 22 = years.

Slide 30.

What happens with the systolic blood pressure? You can = see here=20 at start and 6 years again, and then half a year after stop, = 6.5=20 years after stop, in growth hormone-treated and untreated, = this is=20 what happens with the ones with growth hormone. Decline in = systolic=20 blood pressure, it remains the same, and then 6.5 years, it = is=20 around 0. The untreated were still quite high with a +1.25 = SD. The=20 diastolic blood pressure, it was normal at start. There was = a=20 decline. It went up a bit, and then around 0 and this is in = the=20 untreated ones.

Slide 31.

People were always worried when we had high insulin = levels during=20 growth hormone treatment, what will happen with the beta = cell=20 function? Maybe they will have problems already when they = are 22=20 years. I have to remind us that glucose homeostasis is = depending, on=20 one hand, on insulin sensitivity, and on the other hand, of = course,=20 on the insulin release from the beta cells. In a normal = situation,=20 when your insulin sensitivity is going down, there should be = more=20 insulin release. For instance in puberty, insulin = sensitivity drops=20 and the insulin release will be higher. So as long as this = is going=20 along this line, it is normal. There is normal glucose = homeostasis.=20 The problem arises when you have a lower insulin = sensitivity, and=20 there is no increase in insulin release. Then you get this = impaired=20 glucose tolerance going to the diabetes.

Slide 32.

We performed a frequent sampling intravenous glucose = tolerance=20 (FSIGT) test, which really measures insulin sensitivity with = insulin=20 sensitivity and also the acute insulin response. Here we see = the=20 data for the growth hormone treated and here are the = untreated ones.=20 This is insulin sensitivity and you can see insulin = sensitivity is=20 absolutely the same. Also the SD is the glucose uptake = without=20 insulin, it is the same. Also the acute insulin response is = a bit=20 higher here, but this is not significantly different, is = almost the=20 same. Then the disposition index, which is the times the = insulin=20 sensitivity gives you an impression of whether there is a = diabetes=20 -- increased risk for diabetes mellitus type 2, is also the = same. It=20 is not significantly different, but you might say it is a = bit=20 higher, but that is not true. It is not significantly = different. So=20 altogether, you can't say that this is a problem in for = these=20 children. Also the blood pressure is even a bit better, is=20 significantly better in the ones that were treated.

Of course, these persons are around 22 years, and at this = moment,=20 we do not know what will happen when they are 30 years. But = at least=20 at the beginning of their adult route, they are not in a = very bad=20 position compared with the untreated ones.

Slide 33.

Also metabolic syndrome, the GH treated, none had central = obesity. They had the same percentage of the high = triglycerides, low=20 HDL, it was 16.2% in the ones GH treated. The untreated, it = was=20 quite high, 43.5%. And also high blood pressure according to = the ATP=20 3 criteria none here, whereas it was 30% here. None had high = fasting=20 glucose levels, which mean that none of them had signs of = the=20 metabolic syndrome; whereas the untreated, well, 2 out of = 25. It is=20 a small number, and we have to realize that -- but so what = does it=20 say? Well, it says, I think, at this moment, that they are = not more=20 in danger compared with untreated maybe.

Slide 34.

What about the current guidelines? The last two slides, = the=20 current guidelines are for FDA for the US. You can start = growth=20 hormone treatment from the age of 2, a height SD at start is = not=20 stated. Growth velocity, there should be no catch-up growth. = There=20 is no reference made to the mean parental height, and the = dosage is=20 70 mcg/kg, what I call the higher growth hormone dose. The = European=20 Agency Evaluation of Medicinal Products says to start at the = age of=20 4, the height should be below -2.5, no catch-up growth, less = than --=20 or more than 1 SD below the mean parental height, and the = dosage is=20 35. Is this evidence-based? I think we can say no, it is = absolutely=20 not evidence-based. It is just a matter of some arbitrary=20 definitions, and of course, I think you can say that this is = based=20 on some consensus and some discussions. It is not so that = children=20 that are 2 years grow better than 4, or something like = that.

I think this is something that we have to look at in the = coming=20 years to see whether we can really get some evidence for = these=20 cutoff levels.

Slide 35.

Then the take-home messages, the diagnosis of SGA is = based upon=20 the data, the anthropometry at birth. That is one of the = major=20 problems in SGA because most countries do not measure their = babies.=20 Most of the time, we have some birth rates, maybe even not = too good.=20 Birth length is in many institutes, and also not measured=20 unfortunately, and is really a mistake, and also head = circumference=20 is not measured. So please try to convince your midwives and = other=20 people involved to measure.

The next one is when there is a baby short SGA, I think = it is=20 important to follow up with their growth, and when there is = no sign=20 of catch-up, they should be referred to a doctor to keep = them under=20 control.

Then early intervention with growth hormone is important, = also=20 maybe before the age of 4 in case of severe growth = retardation,=20 particularly the children with Silver-Russell syndrome. = There is no=20 evidence to perform extensive endocrine investigations. This = is all=20 due to the consensus meeting, because when there is no = difference=20 whether you are growth hormone-deficient or not. There is = absolutely=20 no difference in side effects or in efficacy of growth = hormone=20 treatment. So it has been concluded at the consensus meeting = not to=20 do 24-hour growth hormone profiles. Personally, I think that = it=20 might be a good idea to do some stim tests to know at least = whether=20 this child has growth hormone deficiency, but according to = the=20 consensus, that is not really necessary.

Slide 36.

Growth hormone treatment of SGA children is effective and = safe. I=20 think it is very important and that is also the consensus = idea that=20 they should keep long-term surveillance of all the children = that=20 receive the growth hormone because there are still doubts = whether=20 there is an adverse metabolic outcome in SGA children. The = last one=20 was that we do not know what will happen when they are = around 30=20 years, so we have to follow them. On the other hand, we have = to keep=20 in mind that SGA children are the group of children that are = investigated most, compared with Turner syndrome, growth = hormone=20 deficiency, but I think it is not only for the SGA children=20 important to follow, but also our Turner syndrome patients. = So we=20 should not say that it is only for them.

Thank you for your attention.

Go=20 to CME Test Questions = =C2=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=C3=A9vy-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=C3=A9vy-Marchal, = MDAvailable As: Slides/Audio = ;| Slides/Transcript=

Go=20 to CME Test = Questions=20 =C2=BB

CME Information=20
Earn=20 CME Credit =C2=BB =

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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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_0000_01C903A8.8386D310 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; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-medscape.gif); = BACKGROUND-REPEAT: no-repeat } #sp_38 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-allergy.gif); = BACKGROUND-REPEAT: no-repeat } #sp_21 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-business.gif); = BACKGROUND-REPEAT: no-repeat } #sp_2 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-cardiology.gif);= BACKGROUND-REPEAT: no-repeat } #sp_32 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-criticalcare.gif= ); BACKGROUND-REPEAT: no-repeat } #sp_33 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-dermatology.gif)= ; BACKGROUND-REPEAT: no-repeat } #sp_22 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-diabetes.gif); = BACKGROUND-REPEAT: no-repeat } #sp_45 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-emergencymed.gif= ); BACKGROUND-REPEAT: no-repeat } #sp_34 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-familymed.gif); = BACKGROUND-REPEAT: no-repeat } #sp_20 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-gastro.gif); = BACKGROUND-REPEAT: no-repeat } #sp_14 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-surgery.gif); = BACKGROUND-REPEAT: no-repeat } #sp_1 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-hivaids.gif); = BACKGROUND-REPEAT: no-repeat } #sp_7 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-hematology.gif);= BACKGROUND-REPEAT: no-repeat } #sp_3 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-diseases.gif); = BACKGROUND-REPEAT: no-repeat } #sp_18 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-internalmed.gif)= ; BACKGROUND-REPEAT: no-repeat } #sp_25 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-medstudents.gif)= ; BACKGROUND-REPEAT: no-repeat } #sp_17 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-medscape.gif); = BACKGROUND-REPEAT: no-repeat } #sp_44 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-nephrology.gif);= BACKGROUND-REPEAT: no-repeat } #sp_26 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-neuro.gif); = BACKGROUND-REPEAT: no-repeat } #sp_24 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-nurses.gif); = BACKGROUND-REPEAT: no-repeat } #sp_16 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-obgyn.gif); = BACKGROUND-REPEAT: no-repeat } #sp_36 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-ophthalmology.gi= f); BACKGROUND-REPEAT: no-repeat } #sp_8 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-orthopaedics.gif= ); BACKGROUND-REPEAT: no-repeat } #sp_43 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-labmed.gif); = BACKGROUND-REPEAT: no-repeat } #sp_9 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-pediatrics.gif);= BACKGROUND-REPEAT: no-repeat } #sp_30 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-pharmacists.gif)= ; BACKGROUND-REPEAT: no-repeat } #sp_12 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-psych.gif); = BACKGROUND-REPEAT: no-repeat } #sp_42 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-pubhealth.gif); = BACKGROUND-REPEAT: no-repeat } #sp_13 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-pulmonary.gif); = BACKGROUND-REPEAT: no-repeat } #sp_35 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-radiology.gif); = BACKGROUND-REPEAT: no-repeat } #sp_27 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-rheumatology.gif= ); BACKGROUND-REPEAT: no-repeat } #sp_29 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-transplantation.= gif); BACKGROUND-REPEAT: no-repeat } #sp_15 { BACKGROUND-POSITION: left top; BACKGROUND-IMAGE: = url(http://images.medscape.com/pi/global/header/sp/bg-sp-urology.gif); = BACKGROUND-REPEAT: no-repeat } #msjournalheader { BACKGROUND-POSITION: left top; 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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_01C903A8.8386D310 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_01C903A8.8386D310 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_01C903A8.8386D310 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: http://as.medscape.com/js.ng/transactionid%3D1219304565777&site%3D1&pos%3D901&affiliate%3D1&pf%3D10&usp%3D60&ct%3Dmy&artid%3D577686&spon%3Dcme&ssp%3D34 document.write('');=0A= if ("html" =3D=3D "html"){ =0A= document.bgColor =3D 'transparent';=0A= }=0A= document.write('

\n'); ------=_NextPart_000_0000_01C903A8.8386D310 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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