From: Subject: Nemours.org - New England Journal of Medicine reports Date: Wed, 10 Aug 2005 08:48:27 +0700 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0000_01C59D88.46AEC8A0" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.2180 This is a multi-part message in MIME format. ------=_NextPart_000_0000_01C59D88.46AEC8A0 Content-Type: text/html; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.nemours.org/internet?url=no/news/releases/2002/020423_strep_resistance.html Nemours.org - New England Journal of Medicine = reports
I am a Nemours: *Patient/Visitor |=20 *Health Care=20 Professional
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Media=20 Room =95 Press=20 Releases =95 Media=20 Contacts =95 Featured=20 Physicians =95 Nem= ours=20 in the News
April 18, = 2002: The=20 New England Journal of Medicine reports=20 on:
"Erythromycin-Resistant=20 Group A Streptococci in Schoolchildren = in=20 Pittsburgh"=20

April 19, 2002 - Comments from = Frederick Meier, M.D., Chairman of the=20 Department of Pathology and Director of = Clinical=20 Laboratory at the Nemours-owned Alfred = I. duPont=20 Hospital for Children in response to the = NEJM's=20 article on Erythromycin-resistant = children.

The study from Ellen R. Wald, M.D.'s = group in=20 Pittsburgh tells us three new = things:

  1. Erythromycin resistance to group A=20 streptococci has emerged in a North = American=20 school-aged pediatric population.=20
  2. The resistance is due to a single = mechanism=20 that appears to have conferred a = selective=20 advantage on one strain of Streptococcus = pyogenes, the group A hemolytic = streptococcus=20 which is the most common bacterial = pathogen=20 causing sore throats.=20
  3. The same erythromycin resistant = strain is=20 present in a substantial fraction of S. = pyogenes=20 isolates from the background community = to which=20 the study pediatric population belonged. =

The report from Pittsburgh also = confirms=20 three previously made observations:

  1. Increased use of macrolide = antibiotics,=20 erythromycin and its relatives = azithromycin and=20 clarithromycin, etc., for the treatment = of upper=20 respiratory infections - not just strep = throat=20 but also otitis media (middle ear = infection) -=20 prompts the emergence of S. pyogenes = macrolide=20 resistance. This pattern of emergence = has been=20 seen previously in Japan and Finland.=20
  2. Although the prevalence rate of S. = pyogenes=20 in throat specimen is by itself = relatively high=20 - the 18% rate seen in the study = population=20 reported here is typical - even more = impressive=20 is acquisition of the organism over time = in=20 school age populations. In the = Pittsburgh study=20 group 60% of subjects were demonstrated = to have=20 harbored the bacterium at one time or = another=20 over the 7 months of surveillance.=20
  3. The most common mechanism that = bacteria use=20 to nullify macrolide antibiotics' = inhibitory=20 effect is the "M-phenotype" that works = by=20 efficiently ejecting the macrolide = molecules=20 from bacterial cells before the = antibiotics can=20 work. This is the mechanism documented = in the=20 Pittsburgh study.

In the context of these new and = recurrent=20 findings, three other considerations = come to=20 mind:

  • First, penicillin is still the drug = of=20 choice for group A streptococcal = pharyngitis.=20 Penicillin has been used for 50 years to = treat=20 strep throat, decrease its suppurative=20 complications (local spread of the = infection)=20 and, most importantly, prevent strep = throat's=20 main non-suppurative complication: = rheumatic=20 fever. In all those five decades, = penicillin=20 resistance has not emerged. The arrival = of=20 resistance in an important category of=20 non-penicillin antibiotics makes using=20 penicillin in all penicillin = non-allergic strep=20 throat patients even more important than = it has=20 been in the recent past.=20
  • Second, accurate clinical diagnosis = of strep=20 throat also grows in importance. The = majority=20 (70%-80%) of pediatric sore throats are = due to=20 viruses and should not receive = antibacterial=20 treatments that won't affect their = self-limited=20 course. As an aide to clinical = assessment, I=20 suggest a clinical evaluation strategy = recently=20 validated by Magdy Attia, M.D., and his=20 colleagues at the Nemours-owned Alfred = I. duPont=20 Hospital for Children and duPont = Pediatric=20 office practices in Wilmington, = Delaware. Dr=20 Attia's approach, as described in the = June 2001=20 Archives of Pediatrics and Adolescent = Medicine,=20 uses clinical features to divide sore = throat=20 patients into three groups:

    1. High Risk
      In a "high = risk" group,=20 about 20% of pediatric patients, whose = chances=20 are better than two out of three (since = they=20 have the characteristic combination of=20 symptoms), will have a strep throat. = These=20 children can be treated for strep = without delay=20 because any negative test results would = more=20 likely be false negatives than true.=20
    2. Usual Risk
      The biggest = "usual=20 risk" group, which affects a little less = than=20 80% of all children along the sore = throat=20 spectrum, has a range of probabilities = for strep=20 of between 15% and 65%. These are the = patients=20 who need rapid testing. Only those among = this=20 group with positive strep antigen test = results=20 need to be treated with antibiotic = therapy.=20
    3. Low Risk
      Finally the small = "low=20 risk" group comprises of fewer than one = patient=20 in twenty. These patients complain of = having a=20 sore throat, but no other findings = suggest=20 strep. They don't even require testing, = because=20 positive test results among them are = more likely=20 to be misleading than accurate.=20

This 'stratifying' approach matches = treatment=20 to patients who really need it (thus = avoiding=20 treatment in those that don't) which is = better=20 for physicians who may merely trust = their=20 subjective judgement of whom among their = patients has strep and who doesn't. Such = superior matching techniques become more = important when trying to limit = unnecessary=20 therapy which encourages the emergence = of=20 resistance, as would be the case for=20 pen-allergic patients in circumstances = like the=20 high frequency of resistance to = macrolides,=20 discovered in = Pittsburgh.

  • Third, throat cultures become more=20 important. North American = microbiologists, in=20 their list-serv conversations, are = already=20 drawing the conclusion from this study = that=20 group A streptococcal isolates from = throat=20 specimens need to be tested for = erythromycin=20 resistance. Such testing will soon = discover how=20 widespread the Pittsburgh resistance = phenotype=20 has become. For patients who are truly = allergic=20 to penicillin, macrolides are now a less = attractive alternative; other choices = like=20 doxycycline or the now famous quinolone=20 ciprofloxacin, are available. If the = Pittsburgh=20 phenomenon is widespread, then the = macrolides=20 may have to be abandoned as penicillin=20 alternatives in strep throat patients.=20 Macrolides role in the treatment of = otitis media=20 should be re-examined as well. Their = widespread=20 use for this purpose most likely was the = most=20 powerful stimulus to the emergence of = strep=20 erythromycin resistance.

Frederick A. Meier, M.D.
Chairman = of the=20 Department of Pathology and Director of = Clinical=20 Laboratory

For more information or to interview = Dr.=20 Meier, please contact Nemours National = Media=20 Relations.

For more information, = contact:
Odette=20 Struys
National Media Relations = Nemours=20
4600 Touchton Road East
Building = 200,=20 Suite 500
Jacksonville, FL = 32246
Tel :=20 (904) 232-4186
Fax: (904) 232-4180 =
Email:=20 ostruys@nemours.org=20

About=20 Nemours

Nemours = physicians and=20 surgeons care for more than 225,000 = complex or=20 chronically ill children each year = during more=20 than 870,000 patient visits, making = Nemours one=20 of the nation's largest pediatric = sub-specialty=20 group practices.

Nemours owns = and=20 operates the Alfred I. duPont Hospital = for=20 Children in Wilmington, Delaware, in = addition to=20 five major children's specialty centers = in=20 Wilmington, Jacksonville, Orlando, = Pensacola,=20 and Atlantic City, employing = approximately 400=20 pediatric sub-specialty physicians = dedicated to=20 providing treatment and curative = services to=20 acutely and chronically ill children.=20

Nemours is = affiliated=20 with the Mayo Clinic, Thomas Jefferson=20 University, University of Delaware, = Christiana=20 Care Health System, Baptist Medical = Center=20 (Wolfson Children's Hospital), Orlando = Regional=20 Medical Center (Arnold Palmer Hospital = for=20 Children), Virtua Health, and Sacred = Heart=20 Hospital. Additional information can be = found at=20 www.nemours.org.=20 =

3D""=20
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Editorial=20 Policy HIPAA=20 Privacy Privacy= =20 & Security Terms=20 & Conditions Co= ntact=20 Us About=20 Nemours
  =A9 2003-2005 Nemours. = All rights=20 reserved.  
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'Helvetica' } UL { FONT-WEIGHT: normal; FONT-SIZE: 11px; COLOR: #666666; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica' } OL { FONT-WEIGHT: normal; FONT-SIZE: 11px; COLOR: #666666; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica' } LI { FONT-WEIGHT: normal; FONT-SIZE: 11px; COLOR: #666666; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica' } INPUT { BORDER-RIGHT: #999999 1px solid; PADDING-RIGHT: 0px; BORDER-TOP: = #999999 1px solid; PADDING-LEFT: 0px; FONT-SIZE: 10px; PADDING-BOTTOM: = 0px; BORDER-LEFT: #999999 1px solid; COLOR: #000000; PADDING-TOP: 0px; = BORDER-BOTTOM: #999999 1px solid; FONT-FAMILY: 'Verdana', 'Arial', = 'Helvetica', serif; BACKGROUND-COLOR: #cce5f2 } TEXTAREA { BORDER-RIGHT: #999999 1px solid; PADDING-RIGHT: 0px; BORDER-TOP: = #999999 1px solid; PADDING-LEFT: 0px; FONT-SIZE: 10px; PADDING-BOTTOM: = 0px; BORDER-LEFT: #999999 1px solid; COLOR: #000000; PADDING-TOP: 0px; = BORDER-BOTTOM: #999999 1px solid; FONT-FAMILY: 'Verdana', 'Arial', = 'Helvetica', serif; BACKGROUND-COLOR: #cce5f2 } SELECT { BORDER-RIGHT: #999999 1px solid; PADDING-RIGHT: 0px; BORDER-TOP: = #999999 1px solid; PADDING-LEFT: 0px; FONT-SIZE: 10px; PADDING-BOTTOM: = 0px; BORDER-LEFT: #999999 1px solid; COLOR: #000000; PADDING-TOP: 0px; = BORDER-BOTTOM: #999999 1px solid; FONT-FAMILY: 'Verdana', 'Arial', = 'Helvetica', serif; BACKGROUND-COLOR: #cce5f2 } OPTION { BORDER-RIGHT: #999999 1px solid; PADDING-RIGHT: 0px; BORDER-TOP: = #999999 1px solid; PADDING-LEFT: 0px; FONT-SIZE: 10px; PADDING-BOTTOM: = 0px; BORDER-LEFT: #999999 1px solid; COLOR: #000000; PADDING-TOP: 0px; = BORDER-BOTTOM: #999999 1px solid; FONT-FAMILY: 'Verdana', 'Arial', = 'Helvetica', serif; BACKGROUND-COLOR: #cce5f2 } .normal { FONT-WEIGHT: normal; FONT-SIZE: 11px; COLOR: #666666; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica' } .article-headline { FONT-WEIGHT: bold; FONT-SIZE: 15px; COLOR: #666666; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica' } IMG { BORDER-RIGHT: 0px; BORDER-TOP: 0px; BORDER-LEFT: 0px; BORDER-BOTTOM: = 0px } KBD { BORDER-RIGHT: 2px solid; PADDING-RIGHT: 1px; BORDER-TOP: 1px solid; = PADDING-LEFT: 1px; PADDING-BOTTOM: 0px; BORDER-LEFT: 1px solid; = PADDING-TOP: 0px; BORDER-BOTTOM: 2px solid } abbr { CURSOR: help; BORDER-BOTTOM: 1px dashed } ACRONYM { CURSOR: help; BORDER-BOTTOM: 1px dashed } DFN { CURSOR: help; BORDER-BOTTOM: 1px dashed; FONT-STYLE: normal } CODE { BORDER-RIGHT: #cccccc 1px solid; PADDING-RIGHT: 1px; BORDER-TOP: = #cccccc 1px solid; PADDING-LEFT: 1px; BORDER-LEFT: #cccccc 1px solid; = BORDER-BOTTOM: #cccccc 1px solid; FONT-FAMILY: courier, monospace; = BACKGROUND-COLOR: #ffffcc } SAMP { BORDER-RIGHT: #cccccc 1px solid; PADDING-RIGHT: 1px; BORDER-TOP: = #cccccc 1px solid; PADDING-LEFT: 1px; BORDER-LEFT: #cccccc 1px solid; = BORDER-BOTTOM: #cccccc 1px solid; FONT-FAMILY: courier, monospace; = BACKGROUND-COLOR: #ccffcc } TABLE { FONT-SIZE: 1em } IMG.left { FLOAT: left; MARGIN-RIGHT: 3px } IMG.right { FLOAT: right; MARGIN-LEFT: 3px } P { MARGIN: 0.5em 0px 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#ff0000; FONT-FAMILY: 'Verdana', 'Arial', = 'Helvetica'; TEXT-DECORATION: none } A:active { FONT-SIZE: 11px; COLOR: #2992c6; FONT-FAMILY: 'Verdana', 'Arial', = 'Helvetica'; TEXT-DECORATION: none } A.mainnav:link { FONT-SIZE: 11px; COLOR: #ffffff; FONT-FAMILY: 'Verdana', 'Arial', = 'Helvetica'; TEXT-DECORATION: none } A.mainnav:visited { FONT-SIZE: 11px; COLOR: #ffffff; FONT-FAMILY: 'Verdana', 'Arial', = 'Helvetica'; TEXT-DECORATION: none } A.mainnav:hover { FONT-WEIGHT: bold; FONT-SIZE: 11px; COLOR: #ffffff; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica'; TEXT-DECORATION: none } A.mainnav:active { FONT-SIZE: 11px; COLOR: #ffffff; FONT-FAMILY: 'Verdana', 'Arial', = 'Helvetica'; TEXT-DECORATION: none } A.subnav:link { FONT-WEIGHT: bold; FONT-SIZE: 10px; COLOR: #666666; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica'; TEXT-DECORATION: none } A.subnav:visited { FONT-WEIGHT: bold; FONT-SIZE: 10px; COLOR: #666666; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica'; TEXT-DECORATION: none } A.subnav:hover { FONT-WEIGHT: bold; FONT-SIZE: 10px; COLOR: #666666; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica'; TEXT-DECORATION: underline } A.subnav:active { FONT-WEIGHT: bold; FONT-SIZE: 10px; COLOR: #666666; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica'; TEXT-DECORATION: none } A.header:visited { FONT-WEIGHT: bold; COLOR: #666666; TEXT-DECORATION: none } A.header:link { FONT-WEIGHT: bold; COLOR: #666666; TEXT-DECORATION: none } A.header:hover { FONT-WEIGHT: bold; COLOR: #cc0000; TEXT-DECORATION: none } TD.footer { FONT-WEIGHT: normal; FONT-SIZE: 9px; COLOR: #666666; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica' } A.footer:link { FONT-SIZE: 11px; COLOR: #ffffff; FONT-FAMILY: 'Verdana', 'Arial', = 'Helvetica'; TEXT-DECORATION: none } A.footer:visited { FONT-SIZE: 11px; COLOR: #ffffff; FONT-FAMILY: 'Verdana', 'Arial', = 'Helvetica'; TEXT-DECORATION: none } A.footer:hover { FONT-WEIGHT: bold; FONT-SIZE: 11px; COLOR: #ffffff; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica'; TEXT-DECORATION: none } A.footer:active { FONT-SIZE: 11px; COLOR: #ffffff; FONT-FAMILY: 'Verdana', 'Arial', = 'Helvetica'; TEXT-DECORATION: none } TD.ad { FONT-WEIGHT: normal; FONT-SIZE: 9px; COLOR: #000000; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica' } A.ad:link { FONT-SIZE: 9px; COLOR: #000000; FONT-FAMILY: 'Verdana', 'Arial', = 'Helvetica'; TEXT-DECORATION: none } A.ad:visited { FONT-SIZE: 9px; COLOR: #000000; FONT-FAMILY: 'Verdana', 'Arial', = 'Helvetica'; TEXT-DECORATION: none } A.ad:hover { FONT-SIZE: 9px; COLOR: #000000; FONT-FAMILY: 'Verdana', 'Arial', = 'Helvetica'; TEXT-DECORATION: underline } A.ad:active { FONT-SIZE: 9px; COLOR: #000000; FONT-FAMILY: 'Verdana', 'Arial', = 'Helvetica'; TEXT-DECORATION: none } TD.tab-ad { FONT-WEIGHT: normal; FONT-SIZE: 9px; COLOR: #666666; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica' } TD.tab-ad-big { FONT-WEIGHT: normal; FONT-SIZE: 11px; COLOR: #666666; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica' } .red { FONT-WEIGHT: bold; FONT-SIZE: 9px; COLOR: #ff0000; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica' } .nem-red { FONT-WEIGHT: bold; FONT-SIZE: 11px; COLOR: #cc0000; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica' } .yellow { FONT-WEIGHT: bold; FONT-SIZE: 9px; COLOR: #ffcf00; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica' } .blue { FONT-WEIGHT: bold; FONT-SIZE: 9px; COLOR: #2992c6; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica' } .green { FONT-WEIGHT: bold; FONT-SIZE: 9px; COLOR: #9ccf63; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica' } .orange { FONT-WEIGHT: bold; FONT-SIZE: 9px; COLOR: #ff7d00; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica' } .red-big { FONT-WEIGHT: bold; FONT-SIZE: 11px; COLOR: #ff0000; LINE-HEIGHT: 2; = FONT-FAMILY: 'Verdana', 'Arial', 'Helvetica' } .yellow-big { FONT-WEIGHT: bold; FONT-SIZE: 11px; COLOR: #ffcf00; LINE-HEIGHT: 2; = FONT-FAMILY: 'Verdana', 'Arial', 'Helvetica' } .blue-big { FONT-WEIGHT: bold; FONT-SIZE: 11px; COLOR: #2992c6; LINE-HEIGHT: 2; = FONT-FAMILY: 'Verdana', 'Arial', 'Helvetica' } .green-big { FONT-WEIGHT: bold; FONT-SIZE: 11px; COLOR: #9ccf63; LINE-HEIGHT: 2; = FONT-FAMILY: 'Verdana', 'Arial', 'Helvetica' } .orange-big { FONT-WEIGHT: bold; FONT-SIZE: 11px; COLOR: #ff7d00; LINE-HEIGHT: 2; = FONT-FAMILY: 'Verdana', 'Arial', 'Helvetica' } A.headline:link { FONT-WEIGHT: bold; FONT-SIZE: 15px; COLOR: #666666; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica' } A.headline:visited { FONT-WEIGHT: bold; FONT-SIZE: 15px; COLOR: #666666; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica' } A.headline:hover { FONT-WEIGHT: bold; FONT-SIZE: 15px; COLOR: #666666; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica' } A.headline:active { FONT-WEIGHT: bold; FONT-SIZE: 15px; COLOR: #666666; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica' } A.article:link { FONT-SIZE: 11px; COLOR: #2992c6; FONT-FAMILY: 'Verdana', 'Arial', = 'Helvetica'; TEXT-DECORATION: none } A.article:visited { FONT-SIZE: 11px; COLOR: #2992c6; FONT-FAMILY: 'Verdana', 'Arial', = 'Helvetica'; TEXT-DECORATION: none } A.article:hover { FONT-SIZE: 11px; COLOR: #ff0000; FONT-FAMILY: 'Verdana', 'Arial', = 'Helvetica'; TEXT-DECORATION: none } A.article:active { FONT-SIZE: 11px; COLOR: #2992c6; FONT-FAMILY: 'Verdana', 'Arial', = 'Helvetica'; TEXT-DECORATION: none } A.bios:link { FONT-SIZE: 11px; COLOR: #319cce; FONT-FAMILY: 'Verdana', 'Arial', = 'Helvetica'; TEXT-DECORATION: none } A.bios:visited { FONT-SIZE: 11px; COLOR: #319cce; FONT-FAMILY: 'Verdana', 'Arial', = 'Helvetica'; TEXT-DECORATION: none } A.bios:hover { FONT-WEIGHT: bold; FONT-SIZE: 11px; COLOR: #319cce; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica'; TEXT-DECORATION: none } A.bios:active { FONT-SIZE: 11px; COLOR: #319cce; FONT-FAMILY: 'Verdana', 'Arial', = 'Helvetica'; TEXT-DECORATION: none } .search-hdr { FONT-WEIGHT: bold; FONT-SIZE: 10px; COLOR: #000000; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica'; BACKGROUND-COLOR: #e7e7e7 } A.search-hdr:link { FONT-WEIGHT: bold; FONT-SIZE: 10px; COLOR: #2992c6; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica'; TEXT-DECORATION: none } A.search-hdr:visited { FONT-WEIGHT: bold; FONT-SIZE: 10px; COLOR: #2992c6; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica'; TEXT-DECORATION: none } A.search-hdr:hover { FONT-WEIGHT: bold; FONT-SIZE: 10px; COLOR: #2992c6; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica'; TEXT-DECORATION: underline } A.search-hdr:active { FONT-WEIGHT: bold; FONT-SIZE: 10px; COLOR: #2992c6; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica'; TEXT-DECORATION: none } A.ecard:link { BORDER-RIGHT: #c0c0c0 2px solid; BORDER-TOP: #c0c0c0 2px solid; = FONT-WEIGHT: bold; FONT-SIZE: 10px; BORDER-LEFT: #c0c0c0 2px solid; = COLOR: #ffffff; BORDER-BOTTOM: #c0c0c0 2px solid; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica'; TEXT-DECORATION: none } A.ecard:visited { BORDER-RIGHT: #c0c0c0 2px solid; BORDER-TOP: #c0c0c0 2px solid; = FONT-WEIGHT: bold; FONT-SIZE: 10px; BORDER-LEFT: #c0c0c0 2px solid; = COLOR: #ffffff; BORDER-BOTTOM: #c0c0c0 2px solid; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica'; TEXT-DECORATION: none } A.ecard:hover { BORDER-RIGHT: #3399cc 2px solid; BORDER-TOP: #3399cc 2px solid; = FONT-WEIGHT: bold; FONT-SIZE: 10px; BORDER-LEFT: #3399cc 2px solid; = COLOR: #3399cc; BORDER-BOTTOM: #3399cc 2px solid; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica'; TEXT-DECORATION: underline } A.ecard:active { BORDER-RIGHT: #c0c0c0 2px solid; BORDER-TOP: #c0c0c0 2px solid; = FONT-WEIGHT: bold; FONT-SIZE: 10px; BORDER-LEFT: #c0c0c0 2px solid; = COLOR: #ffffff; BORDER-BOTTOM: #c0c0c0 2px solid; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica'; TEXT-DECORATION: none } H1 { CLEAR: both; FONT-WEIGHT: bold; FONT-SIZE: 15px; COLOR: #666666; = FONT-FAMILY: 'Verdana', 'Arial', 'Helvetica' } H2 { CLEAR: both; FONT-WEIGHT: bold; FONT-SIZE: 13px; COLOR: #666666; = FONT-FAMILY: 'Verdana', 'Arial', 'Helvetica' } HR { WIDTH: 90%; COLOR: black; HEIGHT: 1px } .required { FONT-WEIGHT: normal; FONT-SIZE: 11px; COLOR: #ff0000; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica' } .warning { FONT-WEIGHT: normal; FONT-SIZE: 11px; COLOR: #ff0000; FONT-FAMILY: = 'Verdana', 'Arial', 'Helvetica' } ------=_NextPart_000_0000_01C59D88.46AEC8A0 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: http://www.nemours.org/styles/global.js function validatePageReview(){ //keep validating as long as last all have succeeded. As soon as = one fails, nothing else gets validated, and the submit is cancelled. var status =3D true; status =3D hasComments(); if (status){ //finally, submit the form document.the_form.submit(); } } function validatePageEdit(){ validatePageEdit(null); } function validatePageEdit(pageContentName){ //keep validating as long as last all have succeeded. As soon as = one fails, nothing else gets validated, and the submit is cancelled. var status =3D true; status =3D hasComments(); if (status){ status =3D isValidPageName(); } if (status){ status =3D hasMetaTags(); } if (status){ //copy the content from the xstandards component into the hidden = field, if applicable. Homepages dont use this, for example if (pageContentName !=3D null){ document.getElementById('editor1').EscapeUNICODE =3D true; document.getElementById(pageContentName).value =3D = document.getElementById('editor1').value; } //finally, submit the form document.the_form.submit(); } } function validateTabHomePageEdit(){ //keep validating as long as last all have succeeded. As soon as = one fails, nothing else gets validated, and the submit is cancelled. var status =3D true; status =3D hasComments(); if (status){ status =3D isValidPageName(); } if (status){ status =3D hasMetaTags(); } if (status){ //copy the content from the xstandards component into the hidden = field, if applicable. Homepages dont use this, for example document.getElementById('editor1').EscapeUNICODE =3D true; document.getElementById('CONTENT').value =3D = document.getElementById('editor1').value; document.getElementById('editor2').EscapeUNICODE =3D true; document.getElementById('BOTTOM_LEFT_CONTENT').value =3D = document.getElementById('editor2').value; document.getElementById('editor3').EscapeUNICODE =3D true; document.getElementById('BOTTOM_RIGHT_CONTENT').value =3D = document.getElementById('editor3').value; //finally, submit the form document.the_form.submit(); } } function hasComments(){ value=3Ddocument.the_form.comments.value; if (value =3D=3D ""){ alert("Please enter Reason for Editing and/or Comments."); return false; }else{ return true; } } function isValidPageName(){ value=3Ddocument.the_form.path.value; if (value =3D=3D null || value =3D=3D ""){ alert("Please enter a Path to the Page."); return false; }else{ var lengthOfPath =3D value.length; var indexOfHtml =3D value.indexOf(".html"); var predictedIndexOfHtml =3D lengthOfPath - 5; if (indexOfHtml !=3D predictedIndexOfHtml){ alert("The Path to the Page must end with .html"); return false; } return true; } } function hasMetaTags(){ value=3Ddocument.the_form.keywords.value; if (value =3D=3D ""){ alert("Please enter Meta Keywords."); return false; }else{ value=3Ddocument.the_form.description.value; if (value =3D=3D ""){ alert("Please enter Meta Description."); return false; }else{ return true; } } } /******** * Image swaping (mouseover) for the navigation.jspf ********/ function swapImage(daImage, daSrc){ var objStr, obj; if(document.images){ if (typeof(daImage) =3D=3D 'string') { objStr =3D 'document.' + daImage; obj =3D eval(objStr); obj.src =3D daSrc; } else if ((typeof(daImage) =3D=3D 'object') && daImage && = daImage.src) { daImage.src =3D daSrc; } } } /******** * Opens a new window ********/ var curPopupWindow =3D null; function openWindow(url, winName, width, height, center, winType) { var xposition =3D 50; // Postions the window vertically in px var yposition =3D 50; // Postions the window horizontally in px var location, menubar, resizable, scrollbars, status, titlebar; if ((parseInt(navigator.appVersion) >=3D 4 ) && (center)){ xposition =3D (screen.width - 800) / 2; yposition =3D (screen.height - 600) / 2; }=20 =20 if (winType =3D=3D "1") { // winType 1 is for regular popup = windows location=3D1; menubar=3D1; resizable=3D1; scrollbars=3D1; status=3D1; titlebar=3D1; } else if (winType =3D=3D "2") { // winType 2 is for Quick Tour = like popups location=3D0; menubar=3D0; resizable=3D0; scrollbars=3D0; status=3D0; titlebar=3D1; } else if (winType =3D=3D "3") { // winType 3 is for footer like = popups location=3D0; menubar=3D0; resizable=3D1; scrollbars=3D1; status=3D0; titlebar=3D1; } else if (winType =3D=3D "4") { // winType 4 sforce footer - no = resizing location=3D0; menubar=3D0; resizable=3D0; scrollbars=3D1; status=3D0; titlebar=3D0; } else { // if no arg is passed for winType location=3D1; menubar=3D1; resizable=3D1; scrollbars=3D1; status=3D1; titlebar=3D1; }=20 =20 // Features to specify for a new window args =3D "width=3D" + width + "," + "height=3D" + height + "," + "location=3D" + location + "," + "menubar=3D" + menubar + "," + "resizable=3D" + resizable + "," + "scrollbars=3D" + scrollbars + "," + "status=3D" + status + "," + "titlebar=3D" + titlebar + "," + "toolbar=3D0," + "hotkeys=3D0," + "screenx=3D" + xposition + "," //NN Only + "screeny=3D" + yposition + "," //NN Only + "left=3D" + xposition + "," //IE Only + "top=3D" + yposition; //IE Only =20 // Performs the opening of the window (and closing of a window already = opened for that page). if (curPopupWindow !=3D null) { curPopupWindow.close(); } curPopupWindow =3D window.open(url, winName, args, false); curPopupWindow.focus(); } /******** * Opens a URL location in the parent window of a popup ********/ function switchWindows(url) { parent.opener.location.href =3D url;=20 } /******** * Close tour window and bring up signup screen(s) ********/ function switchAndClose(url) { top.opener.location.href=3Durl; =20 top.close(); top.opener.focus(); } /******** * Takes a Select option value and loads it into a higher level frame ********/ function goto_URL(object) { = parent.frames[0].location.replace(object.options[object.selectedIndex].va= lue); } /******** * Takes a Select option value and loads reloads the URL in the current = window ********/ function goto_URL_2(object) { location.replace(object.options[object.selectedIndex].value); } /******** * Validate phone number for international countries ********/ function isValidPhoneNumber(num, requiredDigits) { var digits =3D 0; if (num =3D=3D null) return false; for( i=3D0; i=3D48) && (c<=3D57) ) digits++; } =20 return (digits >=3D requiredDigits); } /******** * Verify that an email addres is valid * Written by Paolo Wales (paolo@taize.fr) ********/ function isValidEmail(emailad) { var exclude=3D/[^@\-\.\w]|^[_@\.\-]|[\._\-]{2}|[@\.]{2}|(@)[^@]*\1/; var check=3D/@[\w\-]+\./; var checkend=3D/\.[a-zA-Z]{2,4}$/; if(((emailad.search(exclude) !=3D -1) || (emailad.search(check)) =3D=3D -1) || (emailad.search(checkend) =3D=3D -1)){ return false; } else { return true; } } /******** * Ensures valid emails are present and that the sender email doesn't = contain * an 'salesforce.com' in the sender's domain. *=20 * use: for "email a friend" security * created by: Scott Yancey ********/ function isValidEmails() { =20 var recipientEmail =3D document.forms[0].recipientEmail.value; var senderEmail =3D document.forms[0].senderEmail.value; var error =3D false; =20 var errorMessage =3D "The following errors are present:\n\n"; =20 if (recipientEmail.indexOf(',') < 0) { if (!isValidEmail(recipientEmail)){ error =3D true; errorMessage +=3D "The recipient's Email address is not valid\n" }=09 } else { =20 var addresses =3D new Array(); addresses =3D recipientEmail.split(','); var currentAddress; var i; for (var i=3D0; i < addresses.length; i++) { =20 =09 if (!isValidEmail(trim(addresses[i]))){ error =3D true; } =09 } if (i > 10) { error =3D true; errorMessage +=3D "Only 10 addresses are allowed\n"=09 }=20 if (error) { errorMessage +=3D "A recipient's Email address is not valid\n"=09 }=20 =20 } if (!isValidEmail(senderEmail)) { error =3D true; errorMessage +=3D "The sender's Email address is not valid" } if (senderEmail.indexOf("salesforce.com") >=3D 0) { error =3D true; errorMessage +=3D "The sender's Email address can not contain = 'salesforce.com'." } =20 if (error) { alert(errorMessage); return false; } else { return true; } } /******** * Removes leading and trailing spaces from the passed string. Also = removes * consecutive spaces and replaces it with one space. If something = besides * a string is passed in (null, custom object, etc.) then return the = input. *=20 * created by: Scott Yancey ********/ function trim(inputString) { =20 if (typeof inputString !=3D "string") { return inputString; } var retValue =3D inputString; var ch =3D retValue.substring(0, 1); while (ch =3D=3D " ") { // Check for spaces at the beginning of the = string retValue =3D retValue.substring(1, retValue.length); ch =3D retValue.substring(0, 1); } ch =3D retValue.substring(retValue.length-1, retValue.length); while (ch =3D=3D " ") { // Check for spaces at the end of the string retValue =3D retValue.substring(0, retValue.length-1); ch =3D retValue.substring(retValue.length-1, retValue.length); } while (retValue.indexOf(" ") !=3D -1) { // Note that there are two = spaces in the string - look for multiple spaces within the string retValue =3D retValue.substring(0, retValue.indexOf(" ")) + = retValue.substring(retValue.indexOf(" ")+1, retValue.length); // Again, = there are two spaces in each of the strings } return retValue; // Return the trimmed string back to the user } // Ends the "trim" function /******** * Handle form dropdown redirects=20 ********/ function gotoURL(object) { window.location.href =3D object.options[object.selectedIndex].value; } function isChecked(object) { if (object.checked) return true; else return false; } /******** * parses name=3Dvalue argument pairs from * the query string of the URL. It stores the pairs in=20 * properties of an object and returns that object from the * billing inqury form. (billing-contact.jsp) ********/ function getArgs() { var args =3D new Object(); // Get query string. var query =3D location.search.substring(1); =20 // Break at ampersand. var pairs =3D query.split("&");=20 for (var i =3D 0; i < pairs.length; i++) { // Look for "name=3Dvalue" var pos =3D pairs[i].indexOf('=3D'); // If not found, skip. if (pos =3D=3D -1) continue;=20 =20 // Extract the name. =20 var argname =3D pairs[i].substring(0,pos); =20 =20 // Extract the value. var value =3D pairs[i].substring(pos+1); =20 // Store as a property.=20 args[argname] =3D unescape(value); =20 } return args; } //this is used by the detectBrowser function and checkIt function. //Leave these global because the values are set and retreived between //the two functions. var detect =3D navigator.userAgent.toLowerCase(); var OS,browser,version,total,thestring; function detectBrowser(){ // Browser detect script copyright http://www.quirksmode.org if (checkIt('konqueror')){ browser =3D "Konqueror"; OS =3D "Linux"; } else if (checkIt('safari')) browser =3D "Safari"; else if (checkIt('omniweb')) browser =3D "OmniWeb"; else if (checkIt('opera')) browser =3D "Opera"; else if (checkIt('webtv')) browser =3D "WebTV"; else if (checkIt('icab')) browser =3D "iCab"; else if (checkIt('firefox')) browser =3D "Firefox"; else if (checkIt('msie')) browser =3D "Internet Explorer"; else if (!checkIt('compatible')){ browser =3D "Netscape Navigator"; version =3D detect.charAt(8); } else browser =3D "An unknown browser"; if (!version) version =3D detect.charAt(place + thestring.length); if (!OS){ if (checkIt('linux')) OS =3D "Linux"; else if (checkIt('x11')) OS =3D "Unix"; else if (checkIt('mac')) OS =3D "Mac"; else if (checkIt('win')) OS =3D "Windows"; else OS =3D "an unknown operating system"; } //browser must equal "Internet Explorer", "Firefox", "Netscape = Navigator" for XStandards to work. //any other return value will not display XStandards component return browser; } function checkIt(string) { place =3D detect.indexOf(string) + 1; thestring =3D string; return place; } //use when you want to disable a form so the user cannot click submit = twice. function disableForm(theform) { if (document.all || document.getElementById) { for (i =3D 0; i < theform.length; i++) { var tempobj =3D theform.elements[i]; if (tempobj.type.toLowerCase() =3D=3D "submit") tempobj.disabled =3D true; } return true; } } ------=_NextPart_000_0000_01C59D88.46AEC8A0 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: http://www.nemours.org/styles/apymenu.js //=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D // Apycom DHTML Menu 2.80 // dhtml-menu.com // (c) Apycom Software, 2004 // www.apycom.com //=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D ////////////////////////////////////////////// // Obfuscated by Javascript Obfuscator 2.19 // // 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