PRODIGY Guidance - Sore throat

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PRODIGY Guidance - Sore throat - = acute

Have I got the right guidance ?

Applies to all ages

This guidance covers the management of acute sore throat due to = pharyngitis, laryngitis, or tonsillitis.

This guidance does not cover the management of chronic sore = throat or=20 hoarseness.

Changes

Last revised in November 2004

http://www.prodigy.nhs.uk/guidance.asp?gt=3DSore%20throat%20-%20acu= te

May 2004 - reviewed. Validated in September 2004 and = issued in=20 November 2004.

March 2002 - updated to incorporate referral advice from = the=20 National Institute for Clinical Excellence. Issued in April = 2002.

January 2001 - reviewed. Validated in July 2001 and = issued in=20 October 2001.

September 1998 - written, replacing guidance on Acute = pharyngitis, Acute laryngitis, Acute tonsillitis = and=20 Streptococcal sore throat.

Goals and Outcome Measures

Goals

To alleviate symptoms.

To avoid complications.

Background Information

What=20 is it?

How=20 common is it?

How=20 do I know my patient has it?

What=20 else might it be?

Complications=20 and prognosis

What is it?

Sore throat is usually due to a viral infection, = often as=20 part of an upper respiratory tract infection or flu-like illness = [DTB,=20 1995].

Group A beta-haemolytic streptococcus (GABHS), also = known as=20 Streptococcus pyogenes, is the most common bacterial = cause of=20 sore throat. GABHS can be isolated from up to 30% of people = presenting=20 with sore throat [DTB, 1995]. However, figures for asymptomatic = carriage=20 range from 6% to 40% [Little and Williamson, 1996].

Definitions:

Pharyngitis is the term used if there is = predominantly=20 inflammation of the oropharynx but not of the tonsils. =

Tonsillitis is the term used if there is = inflammation of=20 the tonsils.

Laryngitis is the term used if there are few = visible signs=20 of infection but the person complains of soreness lower down = the=20 throat, often with a hoarse voice.

The clinical distinction between tonsillitis and pharyngitis = is=20 unclear in the literature. The condition is therefore referred = to as=20 'sore throat'.

How common is it?

A GP with 2000 patients will see around 120 cases of = acute throat=20 infection every year [MeReC, 1999]. However, most people = with sore=20 throat do not attend their GP: one UK study found that only 1 in = 18=20 episodes of sore throat led to a GP consultation [SIGN, 1999]. =

Acute throat infections most commonly occur in = children aged=20 5-10 years and in young adults aged 15-25 years [MeReC, 1999]. =

Asymptomatic carriage of group A beta-haemolytic=20 streptococcus is common, with rates of 6-40% [Little and = Williamson,=20 1996]. Carriers have low infectivity and are not at risk of = developing=20 complications.

How do I know my patient has = it?

Symptoms are usually sore throat, pain on swallowing, = fever,=20 headache, malaise, and hoarseness if there is laryngeal = involvement=20 (laryngitis).

Signs are commonly redness of the pharynx and = tonsils,=20 presence of exudate, enlarged tonsils, and swollen tender neck = glands.=20 However, examination of the throat should not be attempted in = people=20 with breathing difficulty or stridor, as epiglottitis may be = present=20 (urgent admission indicated) [SIGN, 1999].

Clinical examination should not be relied upon to = differentiate=20 between viral and bacterial sore throat (B). Streptococcal = infection=20 is likely, however, if a scarlet-fever rash is present (red = punctate=20 skin eruption that has a sandpaper-like texture and is prominent = in skin=20 creases; usually begins on the chest and spreads to the abdomen = and=20 extremities; a flushed face with circumoral pallor; and a = 'strawberry=20 tongue').

Throat swabs should not be carried out routinely in sore = throat=20 (B). Throat swabs cannot differentiate between infection and = carriage, they have poor sensitivity, results take up to 48 = hours to be=20 reported, and the test is relatively expensive [Little and = Williamson,=20 1996; MeReC, 1999; SIGN, 1999]. The results of throat swabs vary = according to technique, culture site, and culture conditions = [Cooper et=20 al, 2001]. However, swabs may be useful in high-risk groups, to = guide=20 choice of treatment if treatment failure occurs (see the section = on=20 antibiotics in Management issues).

Rapid antigen tests should not be carried out routinely = in sore=20 throat (B). Rapid antigen tests detect the presence of group = A=20 streptococcal antigen on a throat swab and produce results = within a few=20 minutes. However, they have poor sensitivity and make little = impact on=20 prescribing decisions [SIGN, 1999; Cooper et al, 2001]. =

What else might it = be?

Infectious mononucleosis (glandular fever)

Epiglottitis (requires urgent admission)

Thyroiditis

Gonococcal pharyngitis (rare)

Diphtheria (very rare in the UK)

Neutropenia (ensure the person is not on medication = known to=20 cause immunosuppression)

Complications and=20 prognosis

Complications

Otitis media

Sinusitis

Peritonsillar abscess (quinsy)

Cervical adenitis

Scarlet fever

Streptococcal toxic shock syndrome (rare)

Non-suppurative complications (these are both rare in = developed=20 countries, but are still a problem in developing countries): =

Rheumatic fever

Post-streptococcal glomerulonephritis

[McKerrow, 2003; Del Mar et al, 2004]

Prognosis

Sore throat is a self-limiting condition. Symptoms = resolve=20 within 3 days in 40% of people and within 1 week in 85% of = people,=20 irrespective of whether or not the sore throat is due to a = streptococcal=20 infection [Del Mar et al, 2004].

Management Issues

General=20 issues

What=20 pain relief should be advised for a person with a sore = throat?=20

When=20 should an antibiotic be prescribed for a person with a sore = throat?=20

When=20 should tonsillectomy be considered for a person with recurrent = sore=20 throat?

What=20 are the indications for referral of a person with sore throat to = a=20 specialist?

General=20 issues

Sore throat is a self-limiting = condition.=20 Symptoms resolve within 3 days in 40% of people and within 1 = week in 85%=20 of people, irrespective of whether or not the sore throat is due = to a=20 streptococcal infection [Del Mar et al, 2004].

Explanation, reassurance, and advice on symptomatic = treatment=20 is frequently all that is necessary when a person consults = with a=20 sore throat, as only a third of people want or expect an = antibiotic=20 [Butler et al, 1998]. Presentation with sore throat may be part = of a=20 wider agenda [SIGN, 1999].

Prescription of an antibiotic increases re-attendance = rates=20 for further episodes of sore throat [Little et al, 1997]. There = is also=20 the risk of adverse effects, and there is concern that = indiscriminate=20 prescribing increases bacterial resistance in the community = [Standing=20 Medical Advisory Committee, 1998].

What pain = relief=20 should be advised for a person with a sore throat?

Paracetamol or ibuprofen is the analgesic = drug of=20 choice in sore throat. A systematic review found that = paracetamol or=20 nonsteroidal anti-inflammatory drugs reduce the pain of sore = throat=20 compared with placebo [Del Mar and Glasziou, 2003].

Gargles have been poorly researched and no specific=20 recommendations can be made regarding their use. = Anecdotally,=20 gargling with salt water or aspirin is reported to relieve pain = in some=20 people. One small study found that benzydamine as a gargle for = sore=20 throat resulted in significantly greater relief of pain and = dysphagia at=20 24 hours than did placebo, but this requires confirmation [SIGN, = 1999].=20

When = should an=20 antibiotic be prescribed for a person with a sore throat?

Antibiotics should not be used for = symptomatic=20 relief in sore throat (A). A Cochrane systematic review = found that=20 the absolute benefit of antibiotics was modest. The maximum = benefit was=20 seen by day 3 of treatment, with an average reduction in illness = time of=20 1 day. The overall reduction in illness time was 16 hours for = the first=20 week. The effectiveness of antibiotics was greater in those with = throat=20 swabs positive for streptococcus. For every four people with = confirmed=20 streptococcal throat infection given antibiotics, one extra = person had=20 their symptoms resolved by day 3 compared with those taking = placebo (NNT=20 =3D 4). Without treatment, however, symptoms had disappeared = within 3 days=20 in 40% of people and by 1 week in 85% of people, irrespective of = whether=20 they were streptococcal-positive or not. The effect of = antibiotics on=20 symptom severity was uncertain [Del Mar et al, 2004].

The prevention of suppurative complications is not a = specific=20 indication for antibiotic therapy in sore throat (C). = Antibiotics=20 reduce the risk of developing sinusitis, otitis media, and = peritonsillar=20 abscess (quinsy). However, the absolute risk of developing = complications=20 is low, and little actual benefit is gained from antibiotics. It = is=20 estimated that to prevent one case of acute otitis media about = 200=20 people need to be given antibiotics [Del Mar et al, 2004]. =

Sore throat should not be treated with antibiotics = specifically=20 to prevent the development of rheumatic fever or acute=20 glomerulonephritis (B). Studies undertaken between 1951 and = 1961=20 (when the incidence of rheumatic fever was much higher than it = is today)=20 showed that antibiotics decreased the risk of rheumatic fever by = about=20 70%. More recent studies, however, have not shown any benefit = from=20 antibiotic use [DTB, 1995; Little and Williamson, 1996; SIGN, = 1999; Del=20 Mar et al, 2004]. Antibiotics have not been shown to reduce the = risk of=20 post-streptococcal glomerulonephritis.

The National Institute for Clinical Excellence recommends = antibiotics for the following situations [NICE, 2001]: =

Features of marked systemic upset secondary to the acute = sore=20 throat.

Unilateral peritonsillitis.

A history of rheumatic fever.

An increased risk from acute infection (such as a child = with=20 diabetes mellitus or immunodeficiency).

Antibiotics may prevent cross-infection with group A=20 beta-haemolytic streptococcus in closed institutions = (such as=20 barracks or boarding schools) but should not be used routinely = to=20 prevent cross-infection in the general community (B). =

If an antibiotic is indicated, phenoxymethylpenicillin or = erythromycin (if the person is allergic to penicillin) is = preferred=20 [Cooper et al, 2001; HPA, 2003; Schaad, 2004]. Note that = ampicillin=20 and amoxicillin almost always cause maculopapular rashes in = people with=20 glandular fever, and should therefore not be used for 'blind' = treatment=20 of a sore throat - people who develop rashes may mistakenly be = labelled=20 as penicillin-allergic.

A 10-day course of antibiotic has been used in most studies, = and is=20 recommended to eradicate possible streptococcal infection [DTB, = 1995;=20 SIGN, 1999]. Shorter courses may be appropriate, however, as = there is no=20 good correlation between microbiological and clinical cure for = relief of=20 symptoms. The Health Protection Agency recommends either twice- = or=20 four-times-daily dosing, lasting 7-10 days for penicillin and = 5-10 days=20 for erythromycin [HPA, 2003].

When=20 should tonsillectomy be considered for a person with recurrent = sore=20 throat?

Tonsillectomy is occasionally = recommended for=20 recurrent attacks of tonsillitis. The quality of the evidence is = poor=20 (and no study has been performed in adults), but it suggests = that=20 surgery may be beneficial in selected cases [Burton et al, = 2004].=20

Surgery should be considered only if the person meets all = of the=20 following criteria (C):

Sore throats are due to tonsillitis.

The person has five or more episodes of sore throat per = year.=20

Symptoms have been occurring for at least a year. =

The episodes of sore throat are disabling and prevent = normal=20 functioning.

This is consistent with referral advice from the National = Institute=20 for Clinical Excellence [NICE, 2001].

What are the indications for = referral=20 of a person with sore throat to a specialist?

The National Institute for Clinical = Excellence, in=20 Referral advice: a guide to appropriate referral from general = to=20 specialist services [NICE, 2001], advises the=20 following for recurrent episodes of acute sore throat in = children aged=20 up to 15 years. The referral advice is meant to encourage = local=20 health communities to discuss referral issues and enable local = referral=20 guidelines and protocols to be produced (for further = information, see http://www.nice.org.uk/). =

Almost all children with recurrent sore throat can be = managed in=20 primary care. However, children should be referred to a = specialist=20 service in the circumstances shown in Table=20 1, with the referral timings shown.

Table 1.

Referral timing	Reason for referral
****	They have, or are suspected of having, a = quinsy
****	The swelling is causing acute upper airways = obstruction
****	The swelling is interfering with swallowing, causing = dehydration=20 and marked systemic upset
**	They have a history of sleep apnoea, daytime somnolence, = and=20 failure to thrive
*	They have had five or more episodes of acute sore throat = in the=20 preceding 12 months, documented by the parent or clinician, = and=20 these episodes have been severe enough to disrupt the = child's normal=20 behaviour or day-to-day activity
*	They have guttate psoriasis, which is exacerbated by = recurrent=20 tonsillitis
^	There is suspicion of a serious underlying disorder such = as=20 leukaemia
Key to referral = timings:=20 arrangements should be made so that the = person:
****	is seen immediately = (within a=20 day)
***	is seen urgently (maximum = wait of 2=20 weeks recommended, but to be agreed = locally)
**	is seen soon (maximum = waiting time=20 to be agreed locally)
*	has a routine appointment = (maximum=20 waiting time to be agreed locally)
^	is seen within an = appropriate time=20 depending on his or her clinical circumstances=20 (discretionary)

References

NHS staff in England can link, free of = charge,=20 from references to full text journals by clicking on [Full = text]. You=20 will need an Athens password to access these resources. Click here = for=20 Athens=20 registration.

Note: all users can access the full texts of DH papers without = an=20 Athens password.

Cited

1. Burton, M.J., Towler, B., and Glasziou, P. (2004) = Tonsillectomy=20 versus non-surgical treatment for chronic/recurrent acute = tonsillitis=20 (Cochrane Review). The Cochrane Library (Issue 1). Chichester, = UK:=20 John Wiley & Sons, Ltd.

2. Butler, C.C., Rollnick, S., Pill, R., et al. (1998) = Understanding=20 the culture of prescribing: qualitative study of general = practitioners'=20 and patients' perceptions of antibiotics for sore throats. = British=20 Medical Journal 317(7159), 637-642. [Full=20 text]

3. Cooper, R.J., Hoffman, J.R., Bartlett, J.G., et al. (2001)=20 Principles of appropriate antibiotic use for acute pharyngitis in = adults:=20 background. Annals of Internal Medicine 134(6), = 509-517.

4. CSM (2002) Aspirin and Reye's syndrome in children up to and = including 15 years of age. Current Problems in = Pharmacovigilance=20 28(Apr), 4.

5. Del Mar, C. and Glasziou, P. (2003) Upper respiratory tract=20 infection. Clinical Evidence 10(Dec), 1747-1756.

6. Del Mar, C.B., Glasziou, P.P., and Spinks, A.B. (2004)=20 Antibiotics for sore throat (Cochrane Review). The Cochrane = Library=20 (Issue 2). Chichester, UK: John Wiley & Sons, Ltd.

7. DTB (1995) Diagnosis and treatment of streptococcal sore = throat.=20 Drug & Therapeutics Bulletin 33(2), 9-12.

8. HPA (2003) Management of infection guidance for primary = care: for=20 consultation and local adaptation. Health Protection Agency. = http://www.hpa.org.uk/ = [Accessed:=20 26-2-2004].

9. Little, P., Gould, C., Williamson, I., et al. (1997) = Reattendance=20 and complications in a randomised trial of prescribing strategies = for sore=20 throat: the medicalising effect of prescribing antibiotics. = British=20 Medical Journal 315(7104), 350-352. [Full=20 text]

10. Little, P. and Williamson, I. (1996) Sore throat management = in=20 general practice. Family Practice 13(3), = 317-321.

11. McKerrow, W. (2003) Tonsillitis. Clinical Evidence=20 10(Dec), 644-648.

12. MeReC (1999) Managing sore throats. MeReC Bulletin=20 10(11), 41-44.

13. NICE (2001) Referral advice - a guide to appropriate = referral=20 from general to specialist services. National Institute for = Clinical=20 Excellence. http://www.nice.org.uk/=20 [Accessed: 11-8-2002].

14. Schaad, U.B. (2004) Acute streptococcal = tonsillopharyngitis: a=20 review of clinical efficacy and bacteriological eradication. = Journal of=20 International Medical Research 32(1), 1-13.

15. SIGN (1999) Management of sore throat and indications = for=20 tonsillectomy: a national clinical guideline. Report No. 34. = Scottish=20 Intercollegiate Guidelines Network. http://www.sign.ac.uk/ = [Accessed:=20 14-6-2004].

16. Standing Medical Advisory Committee (1998) The path of = least=20 resistance. London: Department of Health. http://www.dh.gov.uk/ = [Accessed:=20 27-4-2004]. [Full=20 text]

Evidence grading

Evidence grading is from the Scottish Intercollegiate Guideline = Network=20 (SIGN) guideline on Management of sore throat and indications = for=20 tonsillectomy (1999). The evidence grading is as follows:

Strength of evidence

Ia - Evidence obtained from meta-analysis of randomized = controlled=20 trials.

Ib - Evidence obtained from at least one randomized controlled=20 trial.

IIa - Evidence obtained from at least one well-designed = controlled=20 study without randomization.

IIb - Evidence obtained from at least one other type of = well-designed=20 quasi-experimental study.

III - Evidence obtained from well-designed non-experimental = descriptive=20 studies, such as comparative studies, correlation studies, and = case=20 studies.

IV - Evidence from expert committee reports or opinions and/or = clinical=20 experiences of respected authorities.

Strength of recommendation

A - Requires at least one randomized controlled trial as = part of=20 a body of literature of overall good quality and consistency = addressing=20 the specific recommendation.

(Evidence levels Ia, Ib)

B - Requires the availability of well- conducted = clinical=20 studies but no randomized clinical trials on the topic of=20 recommendation.

(Evidence levels IIa, IIb, III)

C - Requires evidence obtained from expert committee = reports or=20 opinions and /or clinical experiences of respected authorities. = Indicates=20 an absence of directly applicable clinical studies of good = quality.

(Evidence level IV)

Scenario -=20 Sore throat - acute

Which Therapy ?

Sore throat (pharyngitis, tonsillitis, laryngitis) is a=20 self-limiting condition.

Explanation, reassurance, and advice on symptomatic = treatment are=20 usually adequate.

Pain relief with paracetamol or ibuprofen will help. =

Gargles are reported to help some people, but there is = inadequate=20 evidence on which to base any recommendations for their use. =

Antibiotics are not indicated for most people with sore=20 throat.

The National Institute for Clinical Excellence recommends=20 antibiotics in the following situations:

Features of marked systemic upset secondary to the acute = sore=20 throat

Unilateral peritonsillitis

A history of rheumatic fever

An increased risk from acute infection (such as a child = with=20 diabetes mellitus or immunodeficiency)

If an antibiotic is indicated, phenoxymethylpenicillin or=20 erythromycin (if the person is allergic to penicillin) is = preferred.=20

Prescribing points

For further information, please see the Medicines = Compendium (http://www.medicines.org.uk/) = or=20 the British National Formulary (http://www.bnf.org/).

The Committee on Safety of Medicines (CSM) advises that all=20 nonsteroidal anti-inflammatory drugs (NSAIDs) are associated = with=20 serious gastrointestinal toxicity. The risk is greatest in the = elderly.=20 All non-selective NSAIDs (such as ibuprofen) are contraindicated = in=20 people with a history of peptic ulceration. The CSM also warns = that any=20 degree of worsening of asthma may be related to the ingestion of = NSAIDs=20 either prescribed or over-the-counter.

Paracetamol (and increasingly, ibuprofen) are present = in many=20 over-the-counter cold remedies. People who are also = self-medicating must=20 take care to avoid accidental overdosage.

Erythromycin: use with caution in people with hepatic = and=20 renal impairment, those with prolongation of the QT interval, = and women=20 who are breastfeeding. Erythromycin may increase the level of = certain=20 drugs (e.g. theophylline, carbamazepine, statins), or potentiate = warfarin.

Should I refer or investigate ?

Refer?

The National Institute for Clinical Excellence, in = Referral=20 advice: a guide to appropriate referral from general to = specialist=20 services, advises the following for recurrent = episodes of=20 acute sore throat in children aged up to 15 years. The = referral=20 advice is meant to encourage local health communities to discuss = referral issues and enable local referral guidelines and = protocols to be=20 produced (for further information, see http://www.nice.org.uk/). =

Almost all children with recurrent sore throat can be = managed in=20 primary care. However, children should be referred to a = specialist=20 service in the circumstances shown in Table=20 2.

Table 2.

Referral timing	Reason for referral
****	They have, or are suspected of having, a = quinsy
****	The swelling is causing acute upper airways = obstruction
****	The swelling is interfering with swallowing, causing = dehydration=20 and marked systemic upset
**	They have a history of sleep apnoea, daytime somnolence, = and=20 failure to thrive
*	They have had five or more episodes of acute sore throat = in the=20 preceding 12 months, documented by the parent or clinician, = and=20 these episodes have been severe enough to disrupt the = child's normal=20 behaviour or day-to-day activity
*	They have guttate psoriasis, which is exacerbated by = recurrent=20 tonsillitis
^	There is suspicion of a serious underlying disorder such = as=20 leukaemia
Key to referral = timings:=20 arrangements should be made so that the = person:
****	is seen immediately = (within a=20 day)
***	is seen urgently (maximum = wait of 2=20 weeks recommended, but to be agreed = locally)
**	is seen soon (maximum = waiting time=20 to be agreed locally)
*	has a routine appointment = (maximum=20 waiting time to be agreed locally)
^	is seen within an = appropriate time=20 depending on his or her clinical circumstances=20 (discretionary)

Investigate?

Throat swabs cannot differentiate between infection and = carriage,=20 they have poor sensitivity, and there is usually delay in = getting the=20 result; they are therefore usually of little value.

Consider a monospot blood test if glandular fever = (infectious=20 mononucleosis) is suspected. It is reasonable to delay this = until the=20 sore throat has persisted longer than 10 days.

Doctor/patient discussion points

Most bouts of sore throat and tonsillitis are due to a virus = infection. The immune system usually clears the infection within = a few=20 days.

Paracetamol or ibuprofen can ease the pain. A = regular=20 full dose is better than 'now and then' to ease pain until = symptoms go.=20

Gargles, sprays, and lozenges that you can buy from the = pharmacist=20 may soothe the throat. They do not shorten the length of the = illness.=20

Antibiotics are not usually advised, apart from in certain=20 circumstances such as for severe infections or for someone with = a poor=20 immune system.

Drug Rationale

Drugs not included

Aspirin and nonsteroidal anti-inflammatory drugs = (NSAIDs),=20 other than ibuprofen, are excluded because of their relatively = extensive=20 adverse-effect profiles. In addition, aspirin should not be used = in=20 children under the age of 16 years because of the risk of Reye's = syndrome [CSM, 2002].

Weak opioids: there is little evidence to suggest = that=20 combining paracetamol with a weak opioid offers any additional=20 advantage, and adverse effects are more likely [SIGN, 1999]. =

Antibiotics other than phenoxymethylpenicillin and = erythromycin=20 are no more effective in most people and are more expensive = [DTB,=20 1995]. Alternative antibiotics are mainly of a broad-spectrum = nature,=20 which increases the risk of complications and resistance. In = particular,=20 ampicillin and amoxicillin virtually always cause maculopapular = rashes=20 in people with glandular fever, and should therefore not be used = for=20 'blind' treatment of a sore throat (people who develop rashes = may=20 mistakenly be labelled as penicillin-allergic).

Gargles and sprays have been poorly researched = and no=20 specific recommendations can be made. Anecdotally, gargling with = salt=20 water or aspirin is reported to relieve pain in some people. One = small=20 study showed that benzydamine as a gargle for sore throat = resulted in=20 significantly greater relief of pain and dysphagia at 24 hours = than did=20 placebo, but this requires confirmation [SIGN, 1999].

Drugs included

Paracetamol and ibuprofen are effective = antipyretics and analgesics in children and adults.

Phenoxymethylpenicillin, and erythromycin = (for=20 those with penicillin allergy): 10-day treatment has been = used in=20 most studies and is recommended in order to eradicate possible=20 streptococcus infection [DTB, 1995; SIGN, 1999]. However, = shorter=20 courses may be appropriate, as there is no good correlation = between=20 microbiological and clinical cure for relief of symptoms. The = Health=20 Protection Agency recommends either twice- or four-times-daily = dosing,=20 lasting 7-10 days for penicillin and 5-10 days for erythromycin = [HPA,=20 2003]. As it is difficult to recommend any one particular = regimen,=20 PRODIGY offers twice- or four-times-daily dosing for 7 or 10 = days.=20

PILs attached to this guidance

Antibiotics - Why No Antibiotic?=20
Anti-inflammatory Painkillers=20
Laryngitis=20
Sore Throat=20
Tonsillitis

Therapy Groups

Therapy=20 Group: Analgesia: use when required

Paracetamol=20 s/f susp: 60mg to 120mg up to four times a day
NHS = Prescription for=20 age: 3 to 11
Paracetamol=20 120mg/5ml s/f susp

di2s.

150 ml

Licensed

=A30.65

=A31.15

No CSM warning = in BNF

Usage Instructions: Take = 2.5ml to=20 5ml every 4 to 6 hours when required for pain relief. Maximum of 4 = doses=20 in 24 hours.
Patient Info:

Paracetamol=20 s/f susp: 120mg to 240mg up to four times a day
NHS = Prescription=20 for age: 12 to 71
Paracetamol=20 120mg/5ml s/f susp
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability di2s. 300 ml Licensed =A31.30 =A32.29 No CSM warning = in BNF OK

Usage Instructions: Take = one to two=20 5ml spoonfuls every 4 to 6 hours when required for pain relief. = Maximum of=20 4 doses in 24 hours.
Patient Info:

Paracetamol=20 s/f susp: 250mg to 500mg up to four times a day
NHS = Prescription=20 for age: 72 to 143
Paracetamol=20 250mg/5ml s/f susp
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability di2u. 300 ml Licensed =A32.20 =A33.87 No CSM warning = in BNF OK

Usage Instructions: Take = one to two=20 5ml spoonfuls every 4 to 6 hours when required for pain relief. = Maximum of=20 4 doses in 24 hours.
Patient Info:

Paracetamol=20 tablets: 500mg to 1g up to four times a day
NHS = Prescription for=20 age: 144 to 191
Paracetamol=20 500mg tablets
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability di21. 56 tablets Licensed =A30.42 =A30.67 No CSM warning = in BNF OK

Usage Instructions: Take = one to two=20 tablets every 4 to 6 hours when required for pain relief. Maximum = of 8=20 tablets in 24 hours.
Patient Info:

Paracetamol=20 tablets: 1g up to four times a day
NHS Prescription for = age: 192 to=20 3060
Paracetamol=20 500mg tablets
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability di21. 56 tablets Licensed =A30.42 =A30.67 No CSM warning = in BNF OK

Usage Instructions: Take = two tablets=20 every 4 to 6 hours when required for pain relief. Maximum of 8 = tablets in=20 24 hours.
Patient Info:

Paracetamol=20 soluble tabs: 500mg to 1g up to four times a day
NHS = Prescription=20 for age: 144 to 191
Paracetamol=20 500mg soluble tabs
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability di22. 60 tablets Licensed =A32.82 =A34.97 No CSM warning = in BNF OK

Usage Instructions: Take = one to two=20 tablets every 4 to 6 hours when required for pain relief. Maximum = of 8=20 tablets in 24 hours.
Patient Info:

Paracetamol=20 soluble tabs: 500mg to 1g up to four times a day
NHS = Prescription=20 for age: 192 to 3060
Paracetamol=20 500mg soluble tabs
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability di22. 60 tablets Licensed =A32.82 =A34.97 No CSM warning = in BNF OK

Usage Instructions: Take = two tablets=20 every 4 to 6 hours when required for pain relief. Maximum of 8 = tablets in=20 24 hours.
Patient Info:

Ibuprofen=20 s/f susp: 50mg three to four times a day
NHS Prescription = for age:=20 12 to 35
Ibuprofen=20 100mg/5ml s/f susp
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability j28Y. 100 ml Licensed =A31.82 =A33.21 CSM warning in = BNF OK

Usage Instructions: Take = 2.5ml three=20 to four times a day when required for pain relief. Do not exceed = the=20 stated dose.
Patient Info:

Ibuprofen=20 s/f susp: 100mg three to four times a day
NHS Prescription = for age:=20 36 to 95
Ibuprofen=20 100mg/5ml s/f susp
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability j28Y. 150 ml Licensed =A32.73 =A34.81 CSM warning in = BNF OK

Usage Instructions: Take = one 5ml=20 spoonful 3 to 4 times a day when required for pain relief. Do not = exceed=20 the stated dose.
Patient Info:

Ibuprofen=20 s/f susp: 200mg three to four times a day
NHS Prescription = for age:=20 96 to 143
Ibuprofen=20 100mg/5ml s/f susp
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability j28Y. 300 ml Licensed =A35.46 =A39.62 CSM warning in = BNF OK

Usage Instructions: Take = two 5ml=20 spoonfuls 3 to 4 times a day when required for pain relief. Do not = exceed=20 the stated dose.
Patient Info:

Ibuprofen=20 tablets: 400mg three times a day
NHS Prescription for age: = 144 to=20 3060
Ibuprofen=20 400mg tablets
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability j282. 24 tablets Licensed =A30.70 =A31.24 CSM warning in = BNF OK

Usage Instructions: Take = one tablet=20 three times a day when required for pain relief. Do not exceed the = stated=20 dose.
Patient Info:

Therapy=20 Group: Penicillin V for 7 days (rarely appropriate)

Penicillin=20 V solution: 125mg twice a day
NHS Prescription for age: 1 = to=20 11
Penicillin=20 V 125mg/5ml sol
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability e155. 100 ml Licensed =A31.66 No CSM warning = in BNF OK

Usage Instructions: Take = one 5ml=20 spoonful twice a day for 7 days.
Patient Info: Continue = to take=20 pain killers if needed. Discard any unused medicine = safely.

Penicillin=20 V solution: 250mg twice a day
NHS Prescription for age: 12 = to=20 71
Penicillin=20 V 250mg/5ml sol
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability e157. 100 ml Licensed =A32.29 No CSM warning = in BNF OK

Usage Instructions: Take = one 5ml=20 spoonful twice a day for 7 days.
Patient Info: Continue = to take=20 pain killers if needed. Discard any unused medicine = safely.

Penicillin=20 V solution: 500mg twice a day
NHS Prescription for age: 72 = to=20 143
Penicillin=20 V 250mg/5ml sol
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability e157. 200 ml Licensed =A34.58 No CSM warning = in BNF OK

Usage Instructions: Take = two 5ml=20 spoonfuls twice a day for 7 days.
Patient Info: Continue = to take=20 pain killers if needed. Discard any unused medicine = safely.

Penicillin=20 V tablets: 1g twice a day
NHS Prescription for age: 144 to=20 3060
Penicillin=20 V 250mg tablets
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability e153. 56 tablets Licensed =A33.56 No CSM warning = in BNF OK

Usage Instructions: Take = four=20 tablets twice a day for 7 days.
Patient Info: Continue = to take=20 pain killers if needed.

Penicillin=20 V solution: 62.5mg four times a day
NHS Prescription for = age: 1 to=20 11
Penicillin=20 V 125mg/5ml sol
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability e155. 100 ml Licensed =A31.66 No CSM warning = in BNF OK

Usage Instructions: Take = 2.5ml four=20 times a day for 7 days.
Patient Info: Continue to take=20 painkillers if needed. Discard any unused medicine = safely.

Penicillin=20 V solution: 125mg four times a day
NHS Prescription for = age: 12 to=20 71
Penicillin=20 V 125mg/5ml sol
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability e155. 200 ml Licensed =A33.32 No CSM warning = in BNF OK

Usage Instructions: Take = one 5ml=20 spoonful four times a day for 7 days.
Patient Info: = Continue to=20 take painkillers if needed. Discard any unused medicine = safely.

Penicillin=20 V solution: 250mg four times a day
NHS Prescription for = age: 72 to=20 143
Penicillin=20 V 250mg/5ml sol
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability e157. 200 ml Licensed =A34.58 No CSM warning = in BNF OK

Usage Instructions: Take = one 5ml=20 spoonful four times a day for 7 days.
Patient Info: = Continue to=20 take painkillers if needed. Discard any unused medicine = safely.

Penicillin=20 V tablets: 500mg four times a day
NHS Prescription for age: = 144 to=20 3060
Penicillin=20 V 250mg tablets
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability e153. 56 tablets Licensed =A33.56 No CSM warning = in BNF OK

Usage Instructions: Take = two tablets=20 four times a day for 7 days.
Patient Info: Continue to = take=20 painkillers if needed.

Therapy=20 Group: Penicillin V for 10 days (rarely appropriate)

Usage Instructions: Take = one 5ml=20 spoonful twice a day for 10 days.
Patient Info: Continue = to take=20 painkillers if needed.

Usage Instructions: Take = two 5ml=20 spoonfuls twice a day for 10 days.
Patient Info: = Continue to=20 take painkillers if needed.

Penicillin=20 V tablets: 1g twice a day
NHS Prescription for age: 144 to=20 3060
Penicillin=20 V 250mg tablets
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability e153. 80 tablets Licensed =A35.09 No CSM warning = in BNF OK

Usage Instructions: Take = four=20 tablets twice a day for 10 days.
Patient Info: Continue = to take=20 painkillers if needed.

Usage Instructions: Take = 2.5ml four=20 times a day for 10 days.
Patient Info: Continue to take=20 painkillers if needed.

Usage Instructions: Take = one 5ml=20 spoonful four times a day for 10 days.
Patient Info: = Continue to=20 take painkillers if needed.

Penicillin=20 V tablets: 500mg four times a day
NHS Prescription for age: = 144 to=20 3060
Penicillin=20 V 250mg tablets
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability e153. 80 tablets Licensed =A35.09 No CSM warning = in BNF OK

Usage Instructions: Take = two tablets=20 four times a day for 10 days.
Patient Info: Continue to = take=20 painkillers if needed.

Therapy=20 Group: Erythromycin for 7 days (rarely appropriate)

Erythromycin=20 s/f suspension: 250mg twice a day
NHS Prescription for age: = 1 to=20 23
Erythromycin=20 250mg/5ml sf susp
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability e91F. 100 ml Licensed =A31.90 No CSM warning = in BNF OK

Usage Instructions: Take = one 5ml=20 spoonful twice a day for 7 days.
Patient Info: Continue = to take=20 pain killers if needed. Discard any unused medicine = safely

Erythromycin=20 s/f suspension: 500mg twice a day
NHS Prescription for age: = 24 to=20 107
Erythromycin=20 500mg/5ml sf susp
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability e91R. 100 ml Licensed =A33.22 No CSM warning = in BNF OK

Usage Instructions: Take = one 5ml=20 spoonful twice a day for 7 days.
Patient Info: Continue = to take=20 pain killers if needed. Discard any unused medicine = safely.

Erythromycin=20 s/f suspension: 1g twice a day
NHS Prescription for age: = 108 to=20 143
Erythromycin=20 500mg/5ml sf susp
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability e91R. 200 ml Licensed =A36.44 No CSM warning = in BNF OK

Usage Instructions: Take = two 5ml=20 spoonfuls twice a day for 7 days.
Patient Info: Continue = to take=20 pain killers if needed. Discard any unused medicine = safely.

Erythromycin=20 tablets: 1g twice a day
NHS Prescription for age: 144 to=20 3060
Erythromycin=20 250mg e/c tablets
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability e911. 56 tablets Licensed =A36.16 No CSM warning = in BNF OK

Usage Instructions: Take = four=20 tablets twice a day for 7 days.
Patient Info: Continue = to take=20 painkillers if needed.

Erythromycin=20 s/f suspension: 125mg four times a day
NHS Prescription for = age: 1=20 to 23
Erythromycin=20 125mg/5ml sf susp
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability e91E. 200 ml Licensed =A32.22 No CSM warning = in BNF OK

Usage Instructions: Take = one 5ml=20 spoonful four times a day for 7 days.
Patient Info: = Continue to=20 take painkillers if needed. Discard any unused medicine = safely.

Erythromycin=20 s/f suspension: 250mg four times a day
NHS Prescription for = age: 24=20 to 107
Erythromycin=20 250mg/5ml sf susp
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability e91F. 200 ml Licensed =A33.80 No CSM warning = in BNF OK

Usage Instructions: Take = one 5ml=20 spoonful four times a day for 7 days.
Patient Info: = Continue to=20 take painkillers if needed. Discard any unused medicine = safely.

Erythromycin=20 s/f suspension: 500mg four times a day
NHS Prescription for = age:=20 108 to 143
Erythromycin=20 500mg/5ml sf susp
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability e91R. 200 ml Licensed =A36.44 No CSM warning = in BNF OK

Usage Instructions: Take = one 5ml=20 spoonful four times a day for 7 days.
Patient Info: = Continue to=20 take painkillers if needed. Discard any unused medicine = safely.

Erythromycin=20 e/c tablets: 500mg four times a day
NHS Prescription for = age: 144=20 to 3060
Erythromycin=20 250mg e/c tablets
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability e911. 56 tablets Licensed =A36.16 No CSM warning = in BNF OK

Usage Instructions: Take = two tablets=20 four times a day for 7 days.
Patient Info: Continue to = take=20 painkillers if needed.

Therapy=20 Group: Erythromycin for 10 days (rarely appropriate)

Usage Instructions: Take = one 5ml=20 spoonful twice a day for 10 days.
Patient Info: Continue = to take=20 painkillers if needed.

Usage Instructions: Take = two 5ml=20 spoonfuls twice a day for 10 days.
Patient Info: = Continue to=20 take painkillers if needed.

Erythromycin=20 e/c tablets: 1g twice a day
NHS Prescription for age: 144 = to=20 3060
Erythromycin=20 250mg e/c tablets
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability e911. 80 tablets Licensed =A38.80 No CSM warning = in BNF OK

Usage Instructions: Take = four=20 tablets twice a day for 10 days.
Patient Info: Continue = to take=20 painkillers if needed.

Usage Instructions: Take = one 5ml=20 spoonful four times a day for 10 days.
Patient Info: = Continue to=20 take painkillers if needed.

Erythromycin=20 e/c tablets: 500mg four times a day
NHS Prescription for = age: 144=20 to 3060
Erythromycin=20 250mg e/c tablets
Read=20 Code Quantity Licence NHS=20 Cost OTC=20 Cost CSM Bioavailability e911. 80 tablets Licensed =A38.80 No CSM warning = in BNF OK

Usage Instructions: Take = two tablets=20 four times a day for 10 days.
Patient Info: Continue to = take=20 painkillers if needed.

Note: No part of this publication may be copied, reproduced, = translated=20 or converted into any electronic or machine readable form in whole = or in=20 part without the prior written approval of the Department of = Health

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BORDER-TOP: 0px; BORDER-LEFT: 0px; BORDER-BOTTOM: = 0px } FORM { PADDING-RIGHT: 0px; PADDING-LEFT: 0px; PADDING-BOTTOM: 0px; MARGIN: = 0px; PADDING-TOP: 0px } INPUT.box { BORDER-RIGHT: black 1px solid; BORDER-TOP: black 1px solid; FONT-SIZE: = 8pt; BORDER-LEFT: black 1px solid; BORDER-BOTTOM: black 1px solid; = FONT-FAMILY: Arial } SELECT { FONT-SIZE: 8pt; FONT-FAMILY: Arial } TD { FONT-SIZE: 9pt; COLOR: black; FONT-FAMILY: arial, tahoma, sans-serif } TD.main { FONT-SIZE: 9pt; COLOR: black } TD.menucontent { FONT-SIZE: 8pt; COLOR: black } TD.position { FONT-SIZE: 8pt; COLOR: black } TD.contentTitle { FONT-WEIGHT: bold; FONT-SIZE: 11pt; COLOR: white } TD.subcontenttitleblack { FONT-WEIGHT: bold; FONT-SIZE: 11pt; COLOR: black } TD.blackFont10Bold { FONT-WEIGHT: bold; FONT-SIZE: 10pt; COLOR: black } TD.blackFont10Underline { FONT-SIZE: 10pt; COLOR: black; TEXT-DECORATION: underline } TD.blackFont11 { FONT-SIZE: 11pt; COLOR: black } TD.subtitle { FONT-WEIGHT: bold; FONT-SIZE: 10pt; COLOR: white } TEXTAREA { FONT-SIZE: 8pt; FONT-FAMILY: Arial } .submenucontent { FONT-SIZE: 8pt; COLOR: black; FONT-FAMILY: Arial, Helvetica, sans-serif } .submenucontent2 { FONT-WEIGHT: bold; FONT-SIZE: 8pt; COLOR: black; FONT-FAMILY: Arial, = Helvetica, sans-serif } .white { COLOR: white } .footer { FONT-SIZE: 8pt; COLOR: gray; FONT-FAMILY: Tahoma } IMG { BORDER-RIGHT: 0px; BORDER-TOP: 0px; BORDER-LEFT: 0px; BORDER-BOTTOM: = 0px } INPUT { FONT-SIZE: 8pt; COLOR: black; FONT-FAMILY: Arial, Helvetica, sans-serif } .mainHeading { PADDING-LEFT: 3pt; FONT-WEIGHT: bold; FONT-SIZE: 12pt; MARGIN-BOTTOM: = 3pt; PADDING-BOTTOM: 3pt; WIDTH: 100%; COLOR: #1c256d; PADDING-TOP: 3pt; = BACKGROUND-COLOR: #b3bbf2 } .bigHeading { PADDING-LEFT: 5px; FONT-WEIGHT: bold; FONT-SIZE: 14pt; MARGIN-BOTTOM: = 10px; PADDING-BOTTOM: 15px; COLOR: white; PADDING-TOP: 15px; = FONT-FAMILY: tahoma, arial, helvetica, "sans serif"; BACKGROUND-COLOR: = #444c7a } .whiteFontDkBlueBg { FONT-WEIGHT: bold; FONT-SIZE: 11pt; COLOR: white; BACKGROUND-COLOR: = #1c256d } .body { MARGIN-LEFT: 15px; COLOR: #1c256d } .blueFont { COLOR: #1c256d } OPTION.bgBlueFontBold { FONT-WEIGHT: bold; COLOR: black; BACKGROUND-COLOR: #e1e4fb } .redFont { COLOR: red } .subContentHeadingBlack { FONT-WEIGHT: bold; FONT-SIZE: 10pt; COLOR: black } .subContentHeadingBlackUnderline { FONT-SIZE: 10pt; COLOR: black; TEXT-DECORATION: underline } .basebar { FONT-SIZE: 10px; COLOR: #999999 } A.basebar:link { FONT-SIZE: 10px; COLOR: #999999; TEXT-DECORATION: none } A.basebar:visited { FONT-SIZE: 10px; COLOR: #999999; TEXT-DECORATION: none } A.basebar:hover { FONT-SIZE: 10px; COLOR: #999999; TEXT-DECORATION: underline } A.basebar:active { FONT-SIZE: 10px; COLOR: #999999; TEXT-DECORATION: none } .lightBlueBackground { BACKGROUND-COLOR: #e1e4fb } ------=_NextPart_000_0000_01C59D94.75E771B0 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: http://www.prodigy.nhs.uk/liveGuidance/ssm.js //Static Slide Menu 6.5 =A9 MaXimuS 2000-2001, All Rights Reserved. //Site: http://www.absolutegb.com/maximus //E-mail: maximus@nsimail.com //Script featured on Dynamic Drive (http://www.dynamicdrive.com) NS6 =3D (document.getElementById&&!document.all) IE =3D (document.all) NS =3D (navigator.appName=3D=3D"Netscape" && = navigator.appVersion.charAt(0)=3D=3D"4") tempBar=3D'';barBuilt=3D0;ssmItems=3Dnew Array(); moving=3DsetTimeout('null',1) function moveOut() { if ((NS6||NS)&&parseInt(ssm.left)<0 || IE && ssm.pixelLeft<0) { clearTimeout(moving);moving =3D setTimeout('moveOut()', = slideSpeed);slideMenu(10)} else {clearTimeout(moving);moving=3DsetTimeout('null',1)}}; function moveBack() {clearTimeout(moving);moving =3D = setTimeout('moveBack1()', waitTime)} function moveBack1() { if ((NS6||NS) && parseInt(ssm.left)>(-menuWidth) || IE && = ssm.pixelLeft>(-menuWidth)) { clearTimeout(moving);moving =3D setTimeout('moveBack1()', = slideSpeed);slideMenu(-10)} else {clearTimeout(moving);moving=3DsetTimeout('null',1)}} function slideMenu(num){ if (IE) {ssm.pixelLeft +=3D num;} if (NS||NS6) {ssm.left =3D parseInt(ssm.left)+num;} if (NS) {bssm.clip.right+=3Dnum;bssm2.clip.right+=3Dnum;}} function makeStatic() { if (NS||NS6) {winY =3D window.pageYOffset;} if (IE) {winY =3D document.body.scrollTop;} if (NS6||IE||NS) { if (winY!=3DlastY&&winY>YOffset-staticYOffset) { smooth =3D .2 * (winY - lastY - YOffset + staticYOffset);} else if (YOffset-staticYOffset+lastY>YOffset-staticYOffset) { smooth =3D .2 * (winY - lastY - (YOffset-(YOffset-winY)));} else {smooth=3D0} if(smooth > 0) smooth =3D Math.ceil(smooth); 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'+tempBar+'

')} function initSlide() { if = (NS6){ssm=3Ddocument.getElementById("thessm").style;bssm=3Ddocument.getEl= ementById("basessm").style; bssm.clip=3D"rect(0 "+document.getElementById("thessm").offsetWidth+" = "+document.getElementById("thessm").offsetHeight+" = 0)";ssm.visibility=3D"visible";} else if (IE) = {ssm=3Ddocument.all("thessm").style;bssm=3Ddocument.all("basessm").style bssm.clip=3D"rect(0 "+thessm.offsetWidth+" "+thessm.offsetHeight+" = 0)";bssm.visibility =3D "visible";} else if (NS) {bssm=3Ddocument.layers["basessm1"]; bssm2=3Dbssm.document.layers["basessm2"];ssm=3Dbssm2.document.layers["the= ssm"]; bssm2.clip.left=3D0;ssm.visibility =3D "show";} if (menuIsStatic=3D=3D"yes") makeStatic();} function buildMenu() { if (IE||NS6) {document.write('

')} if (NS) {document.write('')} if (NS6){document.write('

')} document.write(''); for(i=3D0;i')} if(!ssmItems[i][1]){ document.write('')} else {if(!ssmItems[i][2])ssmItems[i][2]=3DlinkTarget; document.write('')} if(ssmItems[i][4]!=3D"no"&&barBuilt=3D=3D0){buildBar();barBuilt=3D1} if(ssmItems[i][4]!=3D"no"){document.write('')}} document.write('

'+ssmItems[i][0]+'

'+ssmItems[i][0]+'

') if (NS6){document.write('

')} if (IE||NS6) {document.write('

')} if (NS) {document.write('')} theleft=3D-menuWidth;lastY=3D0;setTimeout('initSlide();', 1)} ------=_NextPart_000_0000_01C59D94.75E771B0--