From: Subject: NEJM -- Digital Disease Detection -- Harnessing the Web for Public Health Surveillance Date: Fri, 8 May 2009 09:09:27 -0700 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_00C7_01C9CFBC.B014E350" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5579 This is a multi-part message in MIME format. ------=_NextPart_000_00C7_01C9CFBC.B014E350 Content-Type: text/html; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: http://content.nejm.org/cgi/content/full/NEJMp0900702?query=TOC NEJM -- Digital Disease Detection -- Harnessing the = Web for Public Health Surveillance
3D"
3D"The
  FREE=20 NEJM E-TOC    HOME =   |   SUBSCRIBE=20   |   CURRENT ISSUE=20   |   PAST ISSUES=20   |   COLLECTIONS=20   |   Search = Term =20  Advanced = Search=20
3D"
3D"
Sign in | Get NEJM's = E-Mail Table=20 of Contents =97 Free | Subscribe=20
 
3DPerspective =
Published at www.nejm.org May 7, 2009=20 (10.1056/NEJMp0900702) =

Digital=20 Disease Detection =97 Harnessing the Web for Public Health=20 Surveillance
John S. Brownstein, Ph.D., Clark C. Freifeld, = B.S., and=20 Lawrence C. Madoff, M.D.

 
3D"
3D"This
3D"
3D"
3D-=20 PDF
3D"
3D"
3D"Tools
3D"
3D"
3D-=20 Add=20 to Personal Archive
3D-=20 Add= =20 to Citation Manager
3D-=20 Notify=20 a Friend
3D-=20 E-mail=20 When Cited
3D"
3D"
3D"More
3D"
3D"
3D-=20 PubMed Citation
3D"
The=20 Internet has become a critical medium for clinicians, public = health=20 practitioners, and laypeople seeking health information. Data = about=20 diseases and outbreaks are disseminated not only through = online=20 announcements by government agencies but also through = informal=20 channels, ranging from press reports to blogs to chat rooms = to=20 analyses of Web searches (see Digital Resources for Disease=20 Detection). Collectively, these sources provide a view of = global=20 health that is fundamentally different from that yielded by = the=20 disease reporting of the traditional public health = infrastructure.1=20

Over the past 15 years, Internet technology has become integral = to=20 public health surveillance. Systems using informal electronic=20 information have been credited with reducing the time to = recognition=20 of an outbreak, preventing governments from suppressing = outbreak=20 information, and facilitating public health responses to = outbreaks=20 and emerging diseases. Because Web-based sources frequently=20 contain data not captured through traditional government=20 communication channels, they are useful to public health = agencies,=20 including the Global Outbreak Alert and Response Network of = the=20 World Health Organization (WHO), which relies on such sources = for daily surveillance activities.

Early efforts in this area were made by the International = Society=20 for Infectious Diseases' Program for Monitoring Emerging = Diseases,=20 or ProMED-mail, which was founded in 1994 and has grown into = a=20 large, publicly available reporting system, with more than = 45,000=20 subscribers in 188 countries.2=20 ProMED uses the Internet to disseminate information on = outbreaks by=20 e-mailing and posting case reports, including many gleaned = from=20 readers, along with expert commentary. In 1997, the Public = Health=20 Agency of Canada, in collaboration with the WHO, created the = Global=20 Public Health Intelligence Network (GPHIN), whose software = retrieves=20 relevant articles from news aggregators every 15 minutes, = using=20 extensive search queries. ProMED and GPHIN played critical = roles in=20 informing public health officials of the outbreak of SARS, or = severe=20 acute respiratory syndrome, in Guangdong, China, as early as=20 November 2002, by identifying informal reports on the Web = through=20 news media and chat-room discussions.

More recently, the advent of openly available news aggregators = and=20 visualization tools has spawned a new generation of = disease-surveillance=20 "mashups" (Web application hybrids) that can mine, = categorize,=20 filter, and visualize online intelligence about epidemics in=20 real time. For instance, HealthMap=20 (see image)=20 is an openly available public health intelligence system that = uses=20 data from disparate sources to produce a global view of = ongoing=20 infectious disease threats. It has between 1000 and 150,000 = users per=20 day, including public health officials, clinicians, and=20 international travelers. Other similar systems include = MediSys,=20 Argus, EpiSPIDER, BioCaster, and the Wildlife Disease = Information=20 Node. Automated analysis of online video materials and radio=20 broadcasts will soon provide additional sources for early=20 detection.

3D"Figure
View larger = version=20 (68K):
[in=20 this window]
[in a new window]
=
 =20 		Screen Shot of HealthMap during the = Recent=20 Salmonella Typhimurium Outbreak.

HealthMap displays 319 articles about the outbreak that = has=20 affected 38 U.S. states. =

 
The = ease of=20 use of blogs, mailing lists, RSS (Really Simple Syndication) = feeds,=20 and freely available mapping technology has meant that even = an=20 individual expert can create an important global resource. = For=20 instance, Declan Butler, a reporter at Nature, took = aggregated=20 data from various sources to provide a view of the spread of = H5N1=20 avian influenza on a Google Earth interface. Similarly, = Claudinne Roe=20 of the Office of the Director of National Intelligence = produces the=20 Avian Influenza Daily Digest and blog, a collection of = unclassified=20 information about confirmed and suspected human and animal = cases of=20 H5N1 influenza.

Although news media represent an important adjunct to the public = health infrastructure, the information they report pales in=20 comparison to the potential collective intelligence that can = be=20 garnered from the public. An estimated 37 to 52% of Americans = seek=20 health-related information on the Internet each year, generally = using=20 search engines to find advice on conditions, symptoms, and=20 treatments. Logs of users' chosen keywords and location = information=20 encoded in their computers' IP (Internet Protocol) addresses = can be=20 analyzed to provide a low-cost data stream yielding important = insights into current disease trends.3=20 The power of these data has been demonstrated by studies of=20 search engines provided by Google4=20 and Yahoo,5=20 in which data on searches using influenza-related keywords = were used=20 to generate an epidemic curve that closely matched that = generated by=20 traditional surveillance for influenza-related illness, = deaths, and=20 laboratory results. Google Flu Trends now provides a = prospective view=20 of current influenza search patterns throughout the United = States. By=20 making the information freely available to public health=20 officials, clinicians, and ordinary citizens, such tools = could help=20 to guide medical decision making and underscore the = importance=20 of vaccination and other preventive measures.

An example of the power of search-term surveillance can be found = in an examination of the recent peanut-butter=96associated=20 outbreak of Salmonella enterica serotype = Typhimurium.=20 Using Google Insights for Search, a search-volume reporting = tool=20 from Google, we compared the epidemic curve of onset dates = for=20 confirmed infections with trends in the volume of Internet = searches=20 on related terms in the United States (see graph).=20 Search terms included "diarrhea," "peanut butter," "food = poisoning,"=20 "recall," and "salmonella," and search volumes were compared = with=20 the corresponding volumes from the previous year. The initial = public report of salmonella was released on January 7, 2009,=20 triggering an increase in searches for "salmonella," = "recall," and=20 "peanut butter," but we saw earlier peaks in searches for=20 "diarrhea" and "food poisoning." Admittedly, these data = provide only=20 preliminary evidence of an emerging problem and require = further=20 study, but they highlight possibilities for early disease=20 detection.

3D"Figure
View larger = version=20 (42K):
[in=20 this window]
[in a new window]
=
 =20 		Infections with the Outbreak = Strain of=20 Salmonella Typhimurium, as reported by the CDC as of = February=20 8, 2009.

Lines show data from Google Insights for Search, = representing a=20 portion of Web searches based in the United States across = all Google=20 domains relative to the total number of searches done on = Google over=20 time and scaled to a maximum value of 100. The data have = been=20 standardized by subtracting the mean volume from the = previous 12=20 months for each term. =

 
Thou= gh=20 mining the Web is a valuable new direction (see Influenza A = (H1N1)=20 Virus, 2009 =97 Online Monitoring), these sources cannot = replace the=20 efforts of public health practitioners and clinicians. The = Internet=20 is also providing new opportunities for connecting experts = who=20 identify and report outbreaks. Information technologies such = as=20 wikis, social networks, and Web-based portals can facilitate=20 communication and collaboration to accelerate the = dissemination of=20 reports of infectious diseases and aid in mobilizing a = response. Some=20 scientific societies are now leveraging technologies for = distributed=20 data exchange, analysis, and visualization. For instance, the = International Society for Disease Surveillance has created = the=20 Distributed Surveillance Taskforce for Real-Time Influenza = Burden=20 Tracking and Evaluation (DiSTRIBuTE), a group of state and = local=20 health departments that use the Web to share, integrate, and = analyze=20 health data across large regions. And the International = Society of=20 Travel Medicine, in collaboration with the Centers for = Disease=20 Control and Prevention (CDC), has created the GeoSentinel = project,=20 which brings together travel and tropical-medicine clinics in = an=20 electronic network for surveillance of travel-related = illnesses.=20 Similarly, the Emerging Infections Network, administered by = the=20 Infectious Diseases Society of America in collaboration with = the CDC,=20 is a Web-based network of more than 1000 infectious disease=20 specialists that is geared toward finding cases during = outbreaks and=20 detecting new or unusual clinical events.

Broader Web-based networks are also proving useful for = surveillance.=20 Social-networking sites for clinicians, patients, and the = general=20 public hold potential for harnessing the collective wisdom of = the masses for disease detection. Given the continued = deployment=20 of personally controlled electronic health records, we expect = that patients' contributions to disease surveillance will = increase.=20 Eventually, mobile-phone technology, enabled by global = positioning=20 systems and coupled with short-message-service messaging = (texting)=20 and "microblogging" (with Twitter), might also come into = play.=20 For instance, an organization called Innovative Support to=20 Emergencies, Diseases, and Disasters (InSTEDD) has developed=20 open-source technology to permit seamless cross-border = communication=20 between mobile devices for early warning and response in=20 resource-constrained settings.

These Internet-based systems are quickly becoming dominant = sources=20 of information on emerging diseases, though their effects on=20 public health measures remain uncertain. Information = overload,=20 false reports, lack of specificity of signals, and = sensitivity=20 to external forces such as media interest may limit the = realization=20 of their potential for public health practice and clinical = decision=20 making. Sources such as analyses of search-term use and news=20 media may also face difficulties with verification and = follow-up.=20 Though they hold promise, these new technologies require = careful=20 evaluation. Ultimately, the Internet provides a powerful=20 communications channel, but it is health care professionals = and the=20 public who will best determine how to use this channel for=20 surveillance, prevention, and control of emerging = diseases.=20

Digital Resources for Disease Detection.

Sample Web-based data sources

ProMED-mail, http://www.promedmail.org/

Global Public Health Intelligence Network (GPHIN), www.phac-aspc.gc.ca/media/nr-rp/2004/2004_gphin-rmispbk-eng.php

HealthMap, http://www.healthmap.org/

MediSys, http://medusa.jrc.it/

EpiSPIDER, http://www.epispider.org/

BioCaster, http://biocaster.nii.ac.jp/

Wildlife Disease Information Node, http://wildlifedisease.nbii.gov= /

H5N1 Google Earth mashup, www.nature.com/avian= flu/google-earth

Avian Influenza Daily Digest and blog, http://www.aidailydigest.= blogspot.com/

Google Flu Trends, www.google.org/flutrends

Google Insights for Search, www.google.com/insights/se= arch

DiSTRIBuTE, www.syndromic.o= rg/projects/DiSTRIBuTE.htm

GeoSentinel, www.istm.org/geosentin= el/main.html

Emerging Infections Network, http://ein.idsociety.org/

Argus, http://biodefense.georgetown.e= du/

Sample health-related social-networking sites

Physicians, http://www.sermo.com/

Patients, http://www.patientslikeme.com/

Everyone, http://www.healthysocial.org/

Dr. Brownstein, Mr. Freifeld, and Dr. Madoff report=20 receiving grant support from Google.org. No other potential = conflict=20 of interest relevant to this article was reported. =


Source Information

Dr. Brownstein is a faculty member at the Children's = Hospital=20 Informatics Program, Children's Hospital Boston, and an assistant = professor of=20 pediatrics at Harvard Medical School, Boston. Mr. Freifeld is a research = software developer at the Children's Hospital Informatics Program in = Boston and=20 a master's candidate in the New Media Medicine Group of the MIT Media = Laboratory=20 in Cambridge, MA. Dr. Brownstein and Mr. Freifeld are the cocreators of = the=20 HealthMap system. Dr. Madoff is a professor of medicine at the = University of=20 Massachusetts Medical School, Worcester, an infectious disease physician = with=20 the Massachusetts Department of Public Health, Boston, and editor of=20 ProMED-mail, a program of the International Society for Infectious=20 Diseases.

This article (10.1056/NEJMp0900702) was = published=20 at NEJM.org on May 7, 2009. It will appear in the May 21 issue of the=20 Journal.

References

  1. Brownstein JS, Freifeld CC, Reis BY, Mandl KD. = Surveillance Sans=20 Fronti=E8res: Internet-based emerging infectious disease intelligence = and the=20 HealthMap Project. PLoS Med 2008;5:e151-e151. [CrossRef][Medline]
  2. Madoff LC. ProMED-mail: an early warning system for = emerging=20 diseases. Clin Infect Dis 2004;39:227-232. [CrossRef][ISI][Medline]
  3. Eysenbach G. Infodemiology: tracking flu-related = searches on the=20 web for syndromic surveillance. AMIA Annu Symp Proc 2006:244-8.
  4. Ginsberg J, Mohebbi MH, Patel RS, Brammer L, Smolinski = MS,=20 Brilliant L. Detecting influenza epidemics using search engine query = data.=20 Nature=20 2009;457:1012-1014. [CrossRef][ISI][Medline]
  5. Polgreen PM, Chen Y, Pennock DM, Nelson FD. Using = Internet=20 searches for influenza surveillance. Clin Infect Dis = 2008;47:1443-1448. [CrossRef][ISI][Medline]

 
3D"
3D"This
3D"
3D"
3D-=20 PDF
3D"
3D"
3D"Tools
3D"
3D"
3D-=20 Add=20 to Personal Archive
3D-=20 Add= =20 to Citation Manager
3D-=20 Notify=20 a Friend
3D-=20 E-mail=20 When Cited
3D"
3D"
3D"More
3D"
3D"
3D-=20 PubMed Citation
3D"

HOME  |  SUBSCRIBE=20  |  SEARCH  |  CURRENT=20 ISSUE  |  PAST ISSUES =  |  COLLECTIONS =  | =20 PRIVACY =  | =20 TERMS=20 OF USE  |  HELP  |  beta.nejm.org=20

Comments and = questions?=20 Please con= tact=20 us.

The New=20 England Journal of Medicine is owned, published, and copyrighted =A9 = 2009=20 Massachusetts Medical = Society. All=20 rights reserved.

------=_NextPart_000_00C7_01C9CFBC.B014E350 Content-Type: application/octet-stream Content-Transfer-Encoding: base64 Content-Location: http://content.nejm.org/icons/ntpagetag.gif?js=0 R0lGODlhAQABALMNAAAAAIAAAACAAICAAAAAgIAAgACAgICAgMDAwP8AAAD/AP//AAAA//8A/wD/ /////yH5BAEAAA0ALAAAAAABAAEAQAQCsEUAOw== ------=_NextPart_000_00C7_01C9CFBC.B014E350 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://content.nejm.org/icons/spacer.gif R0lGODlhAQABAIAAAP///wAAACH5BAEAAAAALAAAAAABAAEAQAICRAEAOw== ------=_NextPart_000_00C7_01C9CFBC.B014E350 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://content.nejm.org/icons/banner/v2_title_large.gif R0lGODlh4gFfANUAAP///wAAAICAgMDAwEBAQP8zABAQEP+ZgPDw8KCgoP/NwP/z8ODg4CAgINDQ 0GBgYDAwMP+zoP9AEP+AYP+NcP9mQP9ZMP/Z0LCwsFBQUHBwcP/m4P+mkP/AsP9zUJCQkP9NIAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAACH5BAAAAAAALAAAAADiAV8AQAb/QIBw SCwaj8ikcslsOp/QqHRKrVqv2Kx2y+16v+CweEwum8/otHrNbrvf8Lh8Tq9zLyBQZ8IZHgocHUIT BwcKABeFB0IeBRsVG0KFHRIWF1YCARAEBA0BDZwQAQIAolwDowiiAQYMRqgBSwQBo0UYCUoftA1G sw60AQhFrMJRwANFAg5NmQMOBrQQR5kESBjAGE0Iy7K0pFYNGUIatNVOzc/R0wHmSsdK5LTcdmkW FYaIBZcAGxYWQhwoLFCyT8gGPkIsHJBQoEJBBRwqVKgy60gtAAwuokoA4UGxJg/YHUknUqSSWRel xMsQ4IGRX6we8Kryboqnb0USABOACmcR/1gpk9RMgtInkV9Jfkk7co3YkptHdHrryWRoVGDz6JGR EIECgAV7GHIF4IHIhAIF9Nw7ZKSfBwkTFlgiUpaDBA8gCkwQQoEDCK2AAwseTLjwEg+EhCj4k/bS IguE4FqIEEEC2woFFGIe+NUeB38TJlD4t0hBQw+FIh24Z7i169ewY3/ZUKArgLMTInA40KeDoIQN Ly04pGDDBgULNhTkkJkzh0MTJPQx26EA5ydAjRYJqenjdmC4kGSkFV58uSW6aBVJH+CDE+60siGJ h6zJNZYBxDkZH0D+l2ukJMDSUkigpEkSQAVQXhLxtEOETtoN0VQsRSAgADTeLIEANktwB/+Bd0SI 4mAR8RCohFS0aJBEUxESMeFIBozIxAIgTBYBEREUcABtHfDG2QY9KnJAB5EMUcFkAHgVgUSHHBCB P9dNYdUQ2Z0zpRBXFjFLfQgC4yUtXFrpoCq0tCIEKiYiEZJ/QmTCShNZMhOAK0KENA9VTngiIXhC zEInAFgt4WY7COgi4yvAMIHSoViCiUSVmJzHBCzfxTcELSAiqp6E0HRxUGYR7EHBb0qARcGoEeQ1 QZFdJMoEBp7QkoEAtOLXAJtKwOrlJqsEoKISA2gQKzANaBCmA8NCwNNHCGDwAIa0PJDAn0dBE+EH wxqgAa4AOIDfLmwy8AF8wMRIALQBhGn/hJtl4poJE8J6acADYW7yk4GfaIeBAMMCw+uXIDrwAb6f PCCABgY2sKAR4n5bzgdZrYuhtrQ+C4x7tsRb7raZBtsvARAfQSaj3QpA8CecfMmtbCI3IECmLMcs 88w012zzzTjnrPPOPPfs889ABy300EQXbfRBDOUGESEUCHlA030pEEEjElDAamwktZQEArG2CMCG Ga6HaYUY6mdErDMVAdOHT0yoLgIhpZmTlwsfFacQUhlQNwADYOi1EDB9gkWC1C6BooJJ3Q0Ae1w2 63AGMBs9xAV3UQbAHgAwh1YFCxRQCUET6ai5INFJ8qQEUU6RScQAcAJ3tETEY6acDsaD//iZmxJV TgacdK1hoIvfDgB3v16DsRTAPMDJuY4qGtQqBsxDDRLAkJzA8thzontQUZDDJtjCn/R8mdKb5E7z SbAruRAVeCDQEAqoyldAFkhQEFkUTOA+ahV4NcQCE1CV/1KVFtMYZzVlicKG5IaK+qBCWnzLD0Yw oC4ksOdvq3BJElCkt/owYADwWUJGDKAEUeztCfCBAAa44QAMLCoJ36rgEBiAoRNyqkwvE9tOTuSl DHgwAb57BYZkCDh/RS6GSaAheTrkJTY5wHYEKFzRVlOa+qEFEEkiSCVAwDnKVQIsFSCVEbwilytK QDWsWZ8a18hGNFygABAZgm2EcIEbHf8hR38xwgWolrohcOAS9ZuOJKpztTYa8pCIxEKOFnObvMzl fw4hwgYMIZBCQOQAUVKABwZSgS8qoH6XoIBp7Ig89BVhFSQjAvgYpbjWcU9TFCICLFZ2BKpMSIOy zN0SDKAfBGCIlkZoZRVQkcqftAd8uBSCL3kxKCY080HFjKAuryIPoZjylJKqwjOrUg0ldieY6VoC UIqQEUUWwAMd2KQQQHAJAkqHLGgBQAEA0L/STYBzcDGIBxTQSTFaIU78iSaKpNgn2J1vUq4agoGI 2AvzkQg8DkWU3BSaoiXEiQBmQ5RPWEKEZljJKLZrj5bClr5svqRF49wahn5FvWuqEkP/0cwAS5Nh 0pLG0hbJq4g4E2oEuJnhOAoozhpixdBEsswB1AqHUZfK1KY69alQjapUp0rVqlr1qljNqla3ytWu evWrYA2rWMf61eGsxgJXTKsFUMOWmSFseZArUPaWt6DrzfWuyXTAXeeh17mytK/Zs+E47nrX42kJ ezM9CmEJwDoiMCAByvMSRj9Q1G4t1gp2raxCEYsEwM41YvuilQB4h9hlUdUuXJlaBPrYgaZNoK3/ i0BuUOvPMDBAAA8gKBWuAa0TSqUbrxSCCl8CvCL01gg6mahFXYoRA0RuHKwgn5oimktLAYu6DQ0u FDLygaaQ8AnkmFhjh4fdYTA3eGV6/67kcpQbMhqif/SsmhBauwCvCESUADhAI0AQgQ0whIwUmJr9 qCCA43lUCD5snXKpgKfAZVSawPUJhIA705AgoykmsrCUTKlhZ4YTvSLtaHlfuIWiWOFcH1lFYkta H/YYFgDTW+6HYVhTyVHAMnvh5yRrY5oLXGAgG+AAIYRKx8XwYSALkMhe6veWP5JFARJYBEVueqlb YQknGXDJNYBJ0xGRiRXLIGaEtfQ3ITSFF6hIbKyywUuamNKXmnWlUUjCtky0CCVpSwJ8HpzdMm/w S4AOwHiJMIs5Y6jO2iVCK7kTTZ+BQDTJkUAHyli/r3jgfuyjhGUckk49dpEze8lvcv9Ck0fkySgj 30CFfA4MhVmQjF3lpah2N6KEWCmXPbp1QpwykWuSZtfXaju0EsBXWRMTl1G+FLRNF9wor+HLz3fD z+wkZxffAIC/EYHjIL4iAYmgBTEWEOQRRhOdAdMTAE8iVR9CVZsnIGAA8IZ3Vt5NpwF84E+FSoB6 lRnvfsNbt96C2bv9TfB+D1pCGorzET5Y8IZLkeEFj9wH/DyEZo0WrgJIwMG/1nCHV6jgrHMAwakF cYJL3Gslh3doRZsAhQetOkEFgGWKgxBMFoECaHnajScyuW5bJr+hlmQfGtEQJ13ONLAlq9KX3oV7 LKK1imCnqC3DxSN5oJOZY0gHvJj/CEjwk4p5OF1+LycBPcTvRlRkutrXjgUqDueKErmR/5KwgP8y Ao4WmDsSvGKXIUSijiAQN9sHT3gmVEA0lq67kP/xnCJQwgMJRMIfJmABf0oNAGg1YyQoAHknYEBj PbQhA7gDCt5NLIePIti8FnTbfrWkcKMP9Jc8wgQgeimZRBjXl4q1cRjvwgkDIFixBDsGB5iMWIa7 /YuVia1yYa9fMmSe7IGRAeLftle70IBgY/+JWWWgV8PNicV6KAApBn9XMPs8uubFretJdnnYpzi6 4SjlI/1YIV+ZwB5TBwjMXIAQeQBbn0QBPJcXabUIhlAAtQUn55VsiaZMaGNNM9ZS/2WWUi5SY4/i K2gDM5TSBNxVCsB2PhPIBRnRaJeiMXyGEezAHX62TeQ0aBbYU71SVHfjgMRnMjZlguzwLeN1XlTC U7YABaMUF/8jCHgAAgOxRzZXKk/DKp0TF/VzCAvgAcyRdFCQJZDiYdUETiPYUMtnTNP0DNHzBDqB S/CxIB24BBDwXbhDC7mmaD5Ye+jyK9cjCqDAWPASTvzhEw3gXNJEZeugCSvnCdEUgwUiKxJIRFlI YBjIMIKDN8ljXpUFFAMgWihhBdWRGzeyf0kiAfbTCJ1zYx1QARHwB0joPlWoI0ZAGWeBaRvWhUIQ gU1gKy0Fi4Rmiz+YOw6Ie4JCXf8O1i2xJgS6sAlzFSvRdDcH51Csxmo75SAoAkL9QQRr1osR9UQI NU09xSe1yFDQcwUu2CWAyDW7IAydslPYaIJM0A86sgdsEQGaxHjn9A8VsBj/kCqQoBi58QecwwVA aARnqGeNKAT8MYYvAQ1cZmbAUDgkQZAl9Igi0yskMx5FVUNbczE9BRWdZT4b4hPMqATQsGL4wYvf aAQNMl0tMiEEhQAowZAi00oGckJpSJIBGTtuCJD9aAQvchXo6ARBlnn34I4XEFRCWYqYkRkc0Edc sDZTtW+GQQ5ZwJSDB5WGBBO8WHhn8AG9YmVWuZVc2ZVe+ZVgGZZiOZZkWZZmeZb/aJmWarmWbNmW bvmWcBmXcjmXdFmXdnmXeJmXermXfNmXfvmXgBmYbbkAU4MWkGEIQimUB0B537ZaMeMA5KJcDmB7 yYMBIIIBEClaozUsqoSZ5aJvLuIw5VdxnolDb/g1CQAtBmOJMGUN+LJiZ3IhG8NQ3Dd89iYAvaI3 W5Oau9Jy4ICI9vGajyKbZWIsyBWZnIAu+eFybARAaREI+dNfS7ABXSFKB5AXSxgbIeU1blJUxiY2 FRQPeXaL2KiCuLiNR8BRDXk3l/hnYJYU1sIEqyB/SvAAEIAfsJkE2MdQ7SmCFcQA39IAvbc+U1gA ozKPdJQbdLQAC7AIe5EcQiBb/3I0Aa11TkgJBSLXcZQFC1LZBD2xko0Vk0fwnRWCBLGyYjoRK3zG EsRnEQ3YixhwaDATY0egok2AMM7zgHLiChRpJTEaDTMajI2CiyiSgmsEZRagSZGwAUhIG6MiCYkg CAHBSLQBCEjojojwWqCkTWnDarqpU1pAFXQGIiLaZ2SmBPyRFRkhDtxhWNdQlVXxZgYQZx6FIiJZ XiFUYiEIBdcQHvxxmkNQp5HYZXF6nuCTn0ZDObNlEAzRCHVkHTyXf4tZJDRSHRJATyDwCBCaG9Hh ik3gAB/BagzgCtrTLaDpWMypC2aDIjNVpiO1gqGwpw/ye8pkAGmDIfNgq1SQPP+kRVSzGGLkZV1t Ul7VwwUkGgUZkUx54wQscTzwwSY0mojUCIhGIxeTIWXM8RicVxs7IgTDsRuF8BzX8RxVM2lv9BmX oKX/cGLUCgrKowu41DeVCKy9OCJIFEHFRKITxkS+Eot+2IYzERKAip5D0GHd4BPi6BS+1yLF2lmg Vw42dKxQYABsWLDq4DwIGyv/ameFWlnqc6S1sUm0gaXRoQD4tQFNU0htcSoDQRma0xBRZmnM4alO AKaKhhMpcUwQwGyESjZAWoJjJktxhqssUTjxQC/RuKvXNC1NUGiw5BL7KpM1iaYuKauL05CaqZkZ hLFPCwBRK621VlFqtEhz10n/hwAJDEqhRQAC8QMCnGcXkTdf72MXN3I1FNpuNlGxl5JqF6ETBMCc rsQodiqkEjsEGvCFRZQlw4KoDIiLEDBosgofIeFs6SVjxRa540kEk5sEsUJ8kZs8OgooPpiwRio0 i7QIF4AZkNABHBAJ/pB3RXAP90SAeEBKfhcRRUBAe6F/2mZqiCIfDTSsgAsAnqC3lSKkJwojypYE 6XFC47GTjiiss2q8MwScD7lD7vlNR8AexGdrMihBgUi1PjgepftlOrqHCwc9A9ozPOIVqXtOizER rLsYASZpVydlStABIPAWqIMPNXKdkzQQAWYdUECZePiD9SEV8gE9ZcYAD1sw/zIkjhEyetg3fULa On+DLQyWAa43fdoBQsoJARpAUDChWdwXDcszMbOyNxRswV5iFAxQwQRQN8TZLrI0fv4ywiNxXiDU webSQ8O7M4jhFdURbii7CFjKDw1RGyDAGyrrrfZQI/oLPzdCCBzwFvpQX4ghmFzsGm/EugCAHF+x JMphu0XsG5SDtz2HGf2FJETQuqOWGR5AGgbUxXY8GG4XP8wRKougd0WApAHEGZTTST+GeOMWxlLj I4iQKoJ3x448B0P8x9KJScRhHJVMT7RbAY6UHHrwY8jhY4igGui2SQORGGn3yKg8B06XOYYZGo5B T/FjCVS4EF9RlBHwRjXCGf/908R6nAdjtwDiOhySkEapXMxukHYbgMVrJQhWMyTO7CQIMX+ZgXMN MRCLsRtBkgh94BUHoBBXp22nbMzirAYwhxyOSQTZuYrd1laUU3mqiARBliSYFlS9O872fAa14cdm cUcMYYXeuslHsBcXQAlrxRl9calNkABZq5nEZ3GkNSuaVYkLnXGONdGjqUr9hgAfpNC0ggED67Wa ibgwZtEmTCsKJ9EL3aJhgNId7UxZu3AWPdGd1W8L7Qz7EdMt6tDLk3G6xdETbX5ZGzk+nbU0HNNZ O7B0O2lcwRBum39EMMioswTdfGNRkmPumJiXQwm2+6u78IbpoTA/AT1clkL/zwUfg5Y1AulC/uIE 7BE+wWa9TDAsLgcfBNChUlCaDQBBnKuNSNArjPs1xlgh3YkE5kslkOUlDaBZULRvX60uDEBiDAMt B9k3g3q9n6Be34Jc8dkEkCEQC+BjSRNut+EYkvY//ddtkGEBbCtH9vDZXqEcscwWKNt5CsTXyFUm bwgfDNVKVtuGgIgfpTs35TJe6SGVBAABf/oEwlQFejJD3uklRBQSQaQEI9knXmOIQ+AAfm25PKSw CxcjOeiBX3JCMDHZNwlj6NjE72Md8XNG3kqERWAdq0F5HZB3gqdJDOoBKGuUO1JfAaS0tsgeTIki J9RKGAmOgAgLf/2DyiCj/5riBOQgDFKRuWDrBWLmBBvJLlLkPW4S3MMaUQjQotj9UrRKsNtbucMm 0tVtEXWtvi46if0o0kqwvwdwCRewpILwRfmVzktQX1JGOXgwYH0Qv+v6ikSEvTlKraJ7nnJmjoCY CTybS9+AIkbhqrddHtzh4ZcSh0xwWxi1MHjSBLqADNzxr5DoHhimhWMCCteo5BWH5Fy4270tJxeM JeZAEjLC5YaonlLwFiZrBH+QI3aEslHzxwFhNYiwT3xxTot0G1Cmz1fIXItI3VlStTBOHq7QLBS7 vsPqICCai0zwC7g33f5JBTSUahSLN8eNMgcsPrKWNg/k21poq19SiOdNnv8kEyeTLgUrDoYitkRb fumaAGhVoKiWczl6gW4MAbOXc6FBLltIiG65K1vm5mawiExWMjZx3g3CHm/4wTZPEK3d4uAXrlLs kD290qLLfQQQkGespgv06ZDEqw5Au+VM/o3K0+byKbYuiouVzYh1LqJfRpDlCYZUphNXwF6lSASE 3DkG+g+QAUeOEHiHJ3NN495DwKlq/E/nZTsHKQQrVYvE5ydOnnsWCeHYxaqAUkyeQFDJXepRQTK/ wJHL63sKpxMZ5YAZoKvkWWa9fl0FH6jA8Fx3wy4mfEI/vyfUSmeupO9f0M6aJEYKgVZAck7zZAEo O486kj+IEKGvBQLVjgX/t+57vf1lXmM7g+a3Tj9D4tW0seYwqRQSiLqsMG9M1/08JtKRugPD5QIi K0GNJHOfGRj0ruTd/V5U7CLjOkFESf/hzPsla0+S1BsFC6EHskUqwvEWf9E/VxwlskUZYN/IYk/4 dZI8IPLY0bJvh3PRXyObcPqqWvPWrFBUlGju4JuewN7X42hB5RImA7AKE/lhF+IdmQCVpEemU0ue Zn6RU3J+tvgtda1KH3BoG8ceHm6+2rHiCVvzhO034vMmS/AtMMyCW/B/niNKPXIqk6AAQaL+7B8d evHEWjD2aoMwE0MAGsDpEhJZZQIEBAEDUDQeiwPBkskcIAGJDMFA0BCL04zm9gmNNhzeLROq3CaO 5vF66D0mCJkP9igIuOvrbjGxT66h2AShEsYeCBARNT7C8P7Y0BwRpCACLAMarDAQAgXpjAQjoRwa RAkF1z4dV702IigqCmRnZSUqKCI2WHdZPywfeIOFh4mLjY+Rk4sIGpSdn6Gjpaepq62NfAOAr7m7 vb8BMgIyMAB8/cDT1dfZ260dDAxM3enr7e/x8/X3rTn5/wEGFDiQYEGDBxEmVLiQYUOHDyFGlDiR YkWLFzFm1LiRY0ePH0GGFDmSZEmTJ1FCDAIAOw== ------=_NextPart_000_00C7_01C9CFBC.B014E350 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://content.nejm.org/icons/home/email.gif R0lGODlhEAALALMAAI2Nif/+/s7Nz62sq4eIft/f3+vq8Pz7+Xt7cfTy9Zuamfr5/YGAe+7u7Lu6 v4CBdSH5BAAAAAAALAAAAAAQAAsAAARckMhJAXkAEaBK+MsXLGExII+gCGAbCICzJUUsfo0DGAHB fAaFohE4NAaKQ2hzwBE6NYCnKPkUCAKYVMU6bALIqYEXKCgGDQBDmCgWmzgkA9uEi+xaQGbj21gk FhEAOw== ------=_NextPart_000_00C7_01C9CFBC.B014E350 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://content.nejm.org/icons/content/v2_perspective_banner.gif R0lGODlhTQEfAMQAAPv87pmZmTNmmcbU1562xmiOsKvAzNPe3U56pO7y6IOiu+Do43aYtUBwn1uE qrjK0pCswQAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAACH5BAAA AAAALAAAAABNAR8AAAX/YCCOZGmeaKqubOu+cCzPdG3feJ4CfO//wKBwSCwaj8ikcslsOp/QqHQK FFGv2Kx2y+16v1QreEwum8/oNFKsbrvf8LicLa/b7/j8ka7v+/+AY3yBhIWGh0WDiIuMjXmKjpGS k2SQlJeYmU+WmkwHBaAFDAQJPgahoQY+EKgMqj4JBA4CAggKBz6oBQQLPp+6EEAGDA0CDQwDPKe6 oK8AzT0KoKU8D6DJPMwFnVOc3EkDtOICDtQABOO0BLnpAus9Be3OAO0NuDzh6ds9CQztCKXQtXPX Q10PA7ScKTBmbuC3KN4eGslHYIA/Ac4EDtg4oBc8cgMeIKjV4wAtBxsJ/+wrKEDBAIEKelDkeI8H BFoIDIQsgG1BSnUbPdIjyCMBLQY9isVk6ZKjxE0Bnj7Jl8wo0XO0hsTbJ1DmUXM/DAKYtZJqkAU4 wQIxG/YqgIUCej2gVXPoO6lQ8TYxa/KqQAKA5z0DOWAWAh8jawnmYTDBSKT4aCkAfBcrxiJsfYiN THDhYc0CdgEWqndN1NJK8k0uFreHQHErs7WrvGAWzrpDd9l2lm+cD42YaWEDXRnASAcAihVvNxy1 kYjOvY5rMO9v4B/xGiR+EMRA4gak2wWTPhnw74TBBTRn7NayQLW0RPOKvuc0/fSTH6jtKmQrxSF/ gbaLAaQBkJkvaRFxIMN7xaElDmTE3ZcEdPQt6FpW/YU2WGs9jNJLX5Vt9oOFsoGEz3oWisjDRQJw 11ZxEg5BYXQkWjZObFsB0NdSBg4UXnvSpQNLYuN8Jt16dgmDUxADIRkjDzM6V+NrsLGzD1z3HAAX LdS9KERvvsGiAGtHkZYikMkJMF5b6Tj5ZJRPbnHAALhlMWedT8ypVpxKwMnnn4Au4WeghBYaxKCG Jlooooo2yiejjkZ6H6SSVloapZZmKpEOnHbq6aeghirqqKR6GgIAOw== ------=_NextPart_000_00C7_01C9CFBC.B014E350 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://content.nejm.org/icons/home/spacer.gif R0lGODlhAQABAIAAAP///wAAACH5BAEAAAAALAAAAAABAAEAQAICRAEAOw== ------=_NextPart_000_00C7_01C9CFBC.B014E350 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://content.nejm.org/icons/v3_this_article.gif R0lGODlhSQAIALMPADNmmWOJqLjFwpSrt3uar6y9vtDXym+RrFeApKC0u8TOxoejs9zfzUt3oD9v nejo0SH5BAEAAA8ALAAAAABJAAgAQATpMEi5XgAv3zyAeMoFBExmMgBiJhPBsFOgCMCQCQcwKs9o WpNExqfBFDkeU8EBMPwWqQag8OhAK8jPg2YjAHg/4hAh0PYCpktZgDB2Pl7Xz4TIYd+oQ/ZWe0DN Q2gmYoFpRhZuSTk6BD8FfQ85DG80gm98Ng8JTDpUOjo2nyMDHQ0DQhtHVYpTBZk/HU1IBFAEAgMX BAMGXA8GDg0FAo1nYaYDWmIionsMFw5UPwoACQcNSJ/Rl1t9qWGCQ5+D4N6plwUJOF8/wKQAjW8X TqtavTQITslkAk4pZWBzAgr0xW+gwYMBy8xDGAEAOw== ------=_NextPart_000_00C7_01C9CFBC.B014E350 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://content.nejm.org/icons/v3_arrow_right.gif R0lGODlhCQAIAKIGAP8zAP/k3f9pRP+FZv+giP/x7v///wAAACH5BAEAAAYALAAAAAAJAAgAQAMX KBPWLiDGZaCkFeA3GZdTYWmeQZSOkQAAOw== ------=_NextPart_000_00C7_01C9CFBC.B014E350 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://content.nejm.org/icons/v3_tools_service.gif R0lGODlhZwAJALMPADNmmbjFwmOJqJSrtz9vndzfzdDXyqy9vleApKC0u3uar8TOxoejs0t3oG+R rOjo0SH5BAEAAA8ALAAAAABnAAkAQAT/8MlJq724GiXcyWAojmERBJaJgicWLI9ZVCZMTsaKLW+W GxQBYAIQUIoPJNEopCQIAMeMwgAABoNhpXqVCK2ogNXKkDgI4o948MjqJGNtQUj4JAaNK/sAQBye BEB8foBATRILUQEDbw8CgQ1lFVmMDDNCWAkPYgIDBA1tAB8KBCZdDwgElUAADVgoDqIHbF5aoQoF BggAKFm4uryOvD0MAXwOFJQFVlhTDwaMlMInYXoAmhJQkmsxBGjPrAgnMH8BsQsMAurqEge7UTYP 7lYONocSnq20E2cHDQQpFFgR9yCdujIL1tV78K/dNW7PSPXRtE6ApoRWBEy5l2qKmDIdgyV8FIYD wDcLx7BVSNAHSC0K3FI9A6DgAYGa3Pjsg2NkgkBcQWw1ACXBAE2GRGfWvCehQKyaE/go2EUAmYUF uygOmyGGFIIJLBEQ5cZyZxJxbw5AccmUi0mVbglg+1IkABST8Z7laQWl1IQsAy/F2XSlgLcpAl1C XLAXQJk4RmJZqRkBADs= ------=_NextPart_000_00C7_01C9CFBC.B014E350 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://content.nejm.org/icons/v3_more_information.gif R0lGODlhdAAIALMPADNmmbjFwmOJqJSrtz9vnVeApEt3oNzfzcTOxqC0u4ejs9DXynuar6y9vm+R rOjo0SH5BAEAAA8ALAAAAAB0AAgAQAT/MAD2KgOhHkaAGdUjjEJTkUISVoBQDYByuk+CIg/iAEBh 5iQH7uEJJQCgSiNWUaBcsExu1/tJCi8M4FggLDNHlQWwIBYEhLI5IF21sg+FhwYbBHAX9cNgeEg4 WCwDBgVaSYVoAAcnACFRD3khfH4YSwZaSHE8GUtJIopELnI4byshpTAEBgcjWW1yUgcEWBIgXSxv S5kPBwA7P5+OGJqxs5QdCFEYCAQHElIIlzwCi6GfGTzTpqiNOdxtNR08MpQDss1EIATYIKMVxsGu FQniTJQZB5cSZA8LmxWF7Owg52FAoTIF7Wyj86/VAxgMBgxYsIAAgQQNCpmQIGCAKlxiii552tGn xiAkIB5VvJgRwEYeKbUYaEZAwLBH8rL1wMXDlLWHLmM4hKHN5gqj+8axuIRgxC4YFSkwEpbBaAik W2YpC3DBzrBzGWDQaPGHRQE2Q04x5HWJYZsrCzZkqgVDDJIjLjIhaDHgghirQDPAlQvi2QMqPhMj CKAnsePHkH2yqRa5suUQkyFHAAA7 ------=_NextPart_000_00C7_01C9CFBC.B014E350 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://content.nejm.org/content/vol0/issue2009/images/small/NEJMp0900702f1.gif R0lGODlhgABbANUAAMvO0SNUgixHd0qTxRBId3KSrGltWE1zmVJZTIuIdf///5K0ziM8awU/cFdl V7nG0HV6ZY6Qh3yEdOfo50pWbbK2u4V9Y1lmbGR1kM7b5Wd1Y2RoYIGdt1p2pIGqyGN/qnh6cSE1 X+Dj5PP09C42Nztciml3c6qooj1KY0dPROfixWBhUaGXh+Tt8xouV1tqf+fEiurx9z1EPPf5+XBw Y5mdmNfZ2JtUUfT3+FZDX/n29P38++vs6+/v7vHx8d7f3yH5BAAAAAAALAAAAACAAFsAAAb/QIVw SCwaj8ikcslsOp/JWWZKzfx+tqp2y+16v+CwmAsYc0fCDGHNJtxubUJjPY/b5fe8fs/XHw4BgYI0 FGuCBxgEAYqKJR2LjAEUFIF0AGlscyUFb2uAJZUlJQcdfwSfoKkldX2trnsNBREHBQUYBy8sCbW2 JR8nGLyALyAfxgUvARs3wasNlwpqhh4enAaBHLwFH7Tbxh3HHxgf2wclr+jpcayZkbAMduxy0NIN HBkLAwMaHgGAwX9oBfQn8BY5bpDUKVzYSpQgUIFUQZSTYUY0Ogc8ZND3QEIlRRETGjIUERDDkyjt BKj1YVStW7zEcTjX4AEmOhRqZHiggYAv/3EHWpJDJC6AOG6+bB2Ql7KpU5V0MtxsUyBAgwYBRI1S 9WdURIhZzT0dq3COWTxnr5qlRxKSoEpuGUWC2+at3bt48+rdy7fvQ62AA2slYPNiCQ/6BiBOzLix Y31LFT2eTLmy5cuYG1ecwbmz5xk7ZrQIUFjNYWoeFizOzPiAIcWoYatOjZiaatWwUytesIDDgAe3 dyPmzXs3btaVWxTZoWCCCBETJvyYEIN0mgYDWsSI0aK7du7gt2sf3z08hzkBUKtPzZu27du23cMn Pp92e/fr8+tXn1s58/8K8FBGFgD8MFppsehggw0ijCDCDDzwwNwTHlx1QAw1RHBChhlG0P+hhzWE GOIJJIbo4YYdilgDiRqKuGGLInIg44zZaFNANjRyAOKOHs4oSwQ4YsDBDNZFEwsPD1RgwwQAMPlA D0/sUGEDB4gQQQQVPLCBAQY4YIIDDkggQQRfOmAADRIkAIEFa4oJAQQaaACBDAgYECcEEuApgQY0 gOAnCBJ80MGghA76wgWFFvokAADY0IMNPwDwgKQ/KHlCBRUwWgAORWZwJAC8MZqpDUpSaCEAl7ao gZlwSrBiBKsi4AAECeSZpwW10grBlRds6YCcb4opAQhvymmBoIkmm+gHFUzwwAkAPBrppUpWIEIN FUBrQwE6dBpLDxmkJh2kEzA4IRPnnfL/bAUaAlDBClxqEAEEJnioQQoa5PkmnrXmS6Yse7qKKYnZ DkwitRXQR1/CCi+QbYm4AhpBmrasAEICIIzTwabeFiCgYu5mGrINTixg4QMF1ADClRUksEKdv4Kg wQkRgJkvnG9maEKcGtS6ZwU7BL0cEkEXXbQORgstBIQnjBlBAnGaAK+uLwjKQbcIFvDoAk/y8IMI PYjwAw8+6ODDCGefS8R5DXRQgQAlnPCAAxraCQEIBiTgwAUSOCBrnAbsm6fdeiawww8P2NAoAGIz yrgOE6hwxLlqDzHDAxnwkKaYgHOJqwU0DMoBp1n3UEbiktqQJKTuPuA6ADwcMeUBD2SF/wELKWzw QIYkJmCBBAiY8OUGEpgQuK0S2BmwmDM8CqkVDC4IKdiSQyHECADg4IOacmoAr/c9Q42oB1hf5zEA N0YXHQ/kTpD05BWqKwoGESCAQIsTJ7CLBhesmu+e+cpX/8QkPBNIAA3Wg0JoAgSonckMBA7IXQIm toIOjK5jPgAABjCguA5KqlGVk10IqFS7uD1ABhvYAAhopgFA9W1vvxqT/qBmgg3QAE/CixMOZiAC H/TAB2f7IWdGMIMJDPFsOBgBD3CwQx/OwAdDnAEOhNaD4m2JgBEMEwhMgIAScGAHHUPSpBanuALp oAlSmgPtQPECDFDgfmGqwf/ARMcwpf/pSnvaAM80sDMTFPEB5XKW4hIngkEqDnGvY9QYJ5U41Smu B8zRXL4AlYAupSCGYrrABbM2gjKqIFLTgdQZmzC7B8CtBBjoQPAMeKWd2S8FsgITrVyoAT1qoEt8 LMAImLQkETTpOQWC1A55oAId6GAGx8TBMZHJzB12hjk9AAENTAAnnw1LXk9bGenMxyQYwGCMjHKW 4zBFMiSwjXYCEAAxghIME5yABRK4QK8uYLNf2WxVv4pTPiXwR8dNqoypc44KVBBCJQjNBxKAlwSa NiYx4ZEGNKjBNo2kNRt4c1xX4IH6sPCDUR7BZCQUQADaiMpxvCBD8UzhBsq0szp6KXn/YVpVBHCA xoIygYogWAHxalAvEGxgb3rUqUTD2DpSQStk1arAD5SQLnSqEwMluAACPvCCGtaAngigAJhktScw HQCfv8qhCYZ5thEkEzQzGEHQ0hqa0BBxByPYYWhoSgRkKiCaNLAh/wCVV5/6dAUz7djWHnCFRl2h XCIAUBJKmU4KvABuCACH38QUQQTgS1YGLJPNDEhACeygBY2cVKUU+c/XEfaDqgMnIM+FgwzswAcQ 2MAK0MTHnJ4ptiugQASIlDWvDYADkWoUkxi11CWkMaRPhZtjBbXSL8WSjsu7Z7GKx08BTcCHPvja Fbb7g4FqNELfDW90IDmE1kLoZQjQ/6n9LAtL4tnwBBP1lMdEy7oyPqeMNrCpAjzAAOSWAASndISg VsBH++nzkgZwVd9uFrArHY6RjCxjpCY1UP0iwQcPaN7LUpiCDsMyvSqE6AlGIFjVBbNRCxIB+1Kc hDSe4m3JBYwxKLCCGugNX36DJQ16ZjMV0mpe5VRA0YxgYSdUgE50SoEMOpyDOiWPS0MtHQBAFrLg MoqUJ2MA3B4rCrgF5QUO2ICHarbVOt1SAwhYqZ8IaAIldbCMi3ScIgFwrkTKec6okoGel+zhDusU zX5LAG/NN9gegDdC0uEBMulqziwL4AIYSGeAS9BSL0HNTAaQlR63JK+VTQyAPLPkkv9lQIJSj7rU ERBCNEtdaiW3mtR8VvKe+wymC9TwS1E2H5IAoAJRSYq+SYIGEkBKOy2X4LHpDAwGMn1JyzpgBejV qR1xeEMcttTDCNjzrGVgAOYAIAWmljWsO6xny45ayR1GwAvAgQhwWDC+n+KNIT95BRsY08JNrYCW 6Qc3SWsFFytwAI1fBm37fU9Oaqo2nnC43vVCmwR6JgECEnsCbUc84iTw8Ln1rGT7VQ0XHdig1eCt y215wJeM8loZsUxCLRPD35PuAJhXOisLZJrAtSTelZ5WKwuwKU87A5YFpGkAvD1ABxEI+AVQEOsO g2lMdNSq3569gXGsKgVVI9QXw/j/zwLJGQsLYhSjlwNSt2nZsZLu9ymDYoJe1ckCLwMTly4ZAV2c iU13IpaxHPA7CJjpBFa62wtegAuXgslDbZ/VzuzkAGLwzATG+MYmzdfJSTmnSRwN23MSm4RzPsDY AO63YGSe3mznjU02s1+aKnlbCwCrlhveFQRWAIEKWGBvpQjKNui51QD675Y3v4DsexaUb1hw0BR1 FurcxagTBNm4xP58OpEtesAgIszQnibUzSRbnea1TyyY15vymsIdP9nmKx2H8I7RN/vJcl9v4pJK 9eQ3BIwj8pM30hd3MAEeGLMHSIM0RTYExKZvDMABMFYCpxRzV4cAfoImCwZtszVL/xejLzgTfzuW VzolM0EHJ7VEWWeiAbgCAVwSOAtHK4ynUuMQARuwdaXhEzYSgzI4g5HRAQvAAAyAJTDnEKJACrKV AjL0bIC2JcRCAz7nPYTzJkd4MxAFUaxiJyawQSawDW2kKxJAAxOoJgYAdwiwKgZgayZAA4cSWC8I EnVxB4uQhiOhhnJQbOmkZdWnFXCDAeilPy/DeLTnOxv4ZPyyJvGnPBLwUzbkAEZYJ+OAAfSyDSEX OIFjAVJjcxhjACmUMR+AWxtwAPlnGrVBDYqRG7FhGa7xYmkHc3CTFaNwAFiIABZgcBFgACmAKxEA OnXCAhClL3LSfYETQHdDJjQQZv9VZzy3Rw69CG2B4zJ8t4VbwjcFsDOQNngd4AHwdgCeuB65cRlL 0XJpp4AKuIMd4DdNuAKfk14roD+zB4594jsJhjErtWN4ojwTsy+QV0M6FQxYuFIfkCZcAifwEoXG gAEaAA74Vz4U5R0E6R3cUR7g8R0KmQEFMAc2CIejqI3Jhgs39zk+5zs2RANcMlt9okJ+MkPwJwGg QytpooQg8AIqVXTSpELFk4oi6DtVgywA6W4CgAEkt2sL0gI4oB0jEANElAFiQzQZ4HkQuYPVB2aY ZoQgADpa2CWzYkNXWG09M3RKyDlbaIT4uALyVHBbVFUqlUJnoib2l0pUZQKD91j/DBACGIB88vUD l5I6GYQFmKMAvmQDFkFkLZBvRZmNandsNTd0bKKH32gAT8MC4acmbGJzZ1JteZSFV7hSuaVTgdIr KeR6cMImtJd1G/QCkzAJKMAAa1liQPlmWWJYKUc0LdCQ2DiKopdso1AnJnglJHgmLJgDKWCET0MD vuM7sUUDCHABoJNXQigm+uNzoBOGoHMmKbRhSxiF4IABnJkDFHABnnkAAilf2dUCPCA2EcJR0/Ec CGQEosE2D7mXrLllsDmOLLAmNmcBAKAm8KKbEICFRmiEbGJZNzBbLURN+jKSNidN6TWfXSKOL4Mo glKWnDkJuRUCLhCavVUGO+E4/yfAJJliXDhAnhUQAji4oQLAof52AGHiirhihLNHAyfgO6pIi7Pl cxp5N5Q0fhvGhMoJbdQkWydIK3C3bh/gWNFJASmAAp/5mSHQASTXAwZipNARIdChA+FJNPulRhnK oVLaof72Uzdnh/BiADZWmaAjgXVyQxDVQoASWxuAgjpVcDrFiBuAdxOkkoKigCjQmXFKAZ+Jgw1K crs0mquDOADgUS32pFRigBs6qB66ZRAFLyPIoiwAdwmwqDo1iX8ynykUhm2ikfazJRpJiL4TZhG0 hVySAKlEp9Mpp2k5qHcaRgYiNtMjHSBkXAqAoS5AqIPaoVrWZBQAKPCSA4AVi/9dugKL6pvptZQR 4CeSqlKTtCU2Ki97siaalleZJomQRwEC4Jl0CqSDqqGnyknPAZSMAilYIGx/OjtRKquzCqRzegFY OFtL6Sc+Z5gscKLQVklqkidxspwOQCxv4jd4YiwaeCeLKYnQiQIKqGXkuqEh8AJs+S0/sEsFYl2N 0nX5NTmv6pALEKsFS6giFVUt5IBN+JHvapg0YwCzVZy/Q02VtAF/YzcT8ysWcEn/U03zaQGpJACf OZ1xKk+0arA22TEOEgOBlF3lIj1YwHlEBqgHIKilSq5UOq0zN7K40qi+QyLBuWFQC1GS6Jt6pYoJ BitnulLAV0veaAAvMLA58AL/c4oCGiqrRCpYIpABJtatkyICruOnQ5NvaZu2BZtOQDqd8epTFrCo jPpOffKAgHJLN2RDKmW1KxVbLRRq9Zq4bYQCNBunWVWnGKuWeCoC3bFd6iMd0VE2EVI5zDElboO3 F0ulWuYPL5BeOaCbuYk3RqgLgMkmdjNB9Mqps3KFuOQ9aYZPKqQB40ABDDAJOUCdIWC6HBoCB5Cw WjMBVuA4VtY6SpUpdzkEzEGeFXu6BFuoHTBwYia7XfqlOdWEcJI3Uaknq3JDCWBD0PZscEeIOtWP npkCaYm8hKqWzJtdmzc25eIDSmO9omu0D2C/27u0cKhl5sCZF/Orfgu467uU//MJUWxSfnbjALXi foLoN7O1AW0UqtAmW2grq2+Ig8qbv5qLcgwCO05wvVBKwAe8tDA8nTnwXu9kQ7jyTu7qOz7nqUVn fqsyOBq5JTo1m5BnKCVQrZaLsabqoITWthnQrYuDYhUAJU4qrheLg6hLsNlIacdSd933t4DZqIZp AT84pnZySyQ4fvlILCnEbh2wjR2qoS68odlqPj6guV6jYl9DLl7jA39qt1K6vVgMkeb5AsfSAXXn mxLsc7Foh+KIJn53tbUUW8KTuGkmKKRwAJJGwlecli6AsBjkxCJjeQVyU0Y7roGcyuYpCiaQAOCg hyLLlLpgmCxoPybIJfKErv8XUHwyJ09GmEqDosmDzMkcGqck/MnMa6TaWUgctZ3PMXZFi6EamsRK C8Oj2AHS9AJPcyZbiCvhR4u4QoxvcgFnKXJvXHzGAJwrQHilIKumGwKOtQEUcLzIzLNt2wKksiCj ojoTYFCAanZTOsxarMVpxwCvnEpdCjrGqT8ayYIrMMORd6Cl8G8AiQFYWAqlQKs5K8c4SAEbYLwM +gJgVDqpOh0T8EOe+78SC8idPMijCJEYcAIWcGyzuYUz1MhX0iWDcoqCkWzG8H3r9gdZXL93C6Q5 gLYuQAKgzEnO8cQoVlj97KqlZLF5i7EjPIofAHeOIE3xygI1QItrJokTDRj/rqmN7vZs5CwKAp20 cny8bv3J12kPOtACz1FYWBC0PyAtSTAB2KvEqlzA5+kLIEABXHyH+pOb5RcBtwDHNzsJ/TaTKUR4 AZCzpdrWJOzWIZ2wH+A6rvMwC0Atl5IkWeLUcgYcH9CGSKu0Lk3IrHkAZDI/IosA9aibCm0CbwyR x3YB0qmNP4EUSCGtnMzRmI3Z9VyGaIgOInG0cwzY5lnQqCQBj3UAeANifcUCIkt4pJhsOz195kAK /ajWlV3Zw03PS40JJYAclXGNyq29b3iegX0A1CkAAAeOH5kAWHgBXZaNvKwVk0AD5OxupSC5d0vU 492gbOkT1XAf1WAbrHEO/wRQuknr15Tt3qMorZPwAulKA16MsvgtkVkBkN8gCuT8Anz0B8Ygh+FN 1ERd3NcxAGKAOTC+EzKOORthIahc1UXZ3CLVmoSNAYTYyiyAsvbTZQoI4iF+xI51AJNQdGOrFQIr AMdLzG1dxxQ1Am7rTJ2hAJyh5aHxGZ6xA2VXsRxd1ahL4f422UB6KIMLAvAkPE3uZd9wS2M7qxfA tHtD2EfcbwxgsXhL3sw7AW/5TwvCSLHDBOK63LNK0O7N2JPQK7OlU1BbPKoAkPi0dFpMARJwSkjp ANMaVZ3JACTgAqJOAtjKxBTVA4ljaD+E0jxAXuhyFW7D5xGe6NZM4XAMh//EMN1rOqzy7AgA+QJ2 kgIlgMVwGgKkbuwhILnH5pEXIwNJTepJLeqmLl+dBMXERUglY+MNMODVXNC27t79g7KTCDonCeJd YiefqbfHS+rD66OTkFUAysFHTM5p5skvgKeso6pQxBkDKASw6s55a+bnSchzCm0o2DO0kgBNQzfC zMnKTgqcWQLWKgBZtQKSC6TytG4owOIUhQMEoqpNmu0tt73TLMK1LvBUmhUbGqfep5iAE1PQ3aFa MZNdoRVwGKfSibc9SAFULl9O0q3lAs2vLormWrNnWeaSBtwoj8WjuLcp4NEcfI9xMiZmWc6RN9EL yNpXHWAvAJrMiwOqegX/z9EDQq8EpUQAukrYxduZnUmdbC/wktvp0qqAhK2300qzFKB+E4RHBKTh 3zC25qC3ZH3rk1aTf15aifR8xhU/5RkCcYwCNIABJzmqGk3mx+ZGx3aWJQVVmd/j6IoBY/IirqIy NbANqVTOqHSWnLn60joOtrBBHFAdnMQg0QEdIxBXUDA7AnJnZRDFpc37wB/8wk9ajOK23qqqWUAg ePZBv2ZaZVBvVjABJNZbiS8CCaQAJ2Ahj1Ig5TIdGrUk/Kc4/V601rvCk/MfimVQKi375gMhz7Gd h/Uc62PoFiIgnc18g45iqSM2mwcEop9IOBkqkEnlktl0PqHLWOCBzDQKhyMAwNbddm2icHTnaTQO vG6ldqpUTnF43E2fy0+PCiDa9/+hpqoUrjh2un5+vH54RHb+Fs4OFEZ0LBV2MjU1MTcfPS8BRUfJ qKwaSgoKPj5WWVtbOWRnaWkPzgJqdXd5e31/gYN7CwgGcQAekpWXmZudkZGdpaepq62vsZ1xSEUf ub/Bw6OCAAA7 ------=_NextPart_000_00C7_01C9CFBC.B014E350 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://content.nejm.org/icons/powerpoint/get_pp_slide_center.gif R0lGODlhZAAeAOZtAP////8zAP+ZgP9mQAAAAMvLy5CQkO7u7v/Mv/9zUP+zn//m3/+AYP9NIP9Z MP+/r/+McP/y7//Zz/7+/v9AEO/v7/+mj0BAQP39/TAwMPn5+d/f38/Pz/Hx8XBwcI+Pj/Ly8uXl 5fX19fv7+1xcXPT09Pz8/BAQEPf39+3t7b6+vubm5tzc3G1tbfr6+urq6mFhYbq6uoaGhomJiba2 tujo6MjIyBgYGGVlZfDw8MbGxpGRkezs7Pb29tjY2JaWltfX11VVVX19feDg4HR0dC0tLdra2s3N zSQkJI6OjqKiotTU1NnZ2dHR0bOzs8PDw8TExHt7e5SUlLy8vKqqqpeXl8HBweTk5MrKyqenp/Pz 8+Li4k5OTnZ2dkVFRTExMTY2NicnJzo6OldXVyAgIB0dHa2trWpqapiYmPj4+HJycklJSc7Ozv// /wAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAACH5 BAEAAG0ALAAAAABkAB4AQAf/gG2Cg4MlPjFKPzsGjI2Oj5CRkpOUlY0fSTMyaCovhJ9tSgUApKUC AaQSA6sRAQ8ADwESCAEIpQCnqw0UCxANpAkOAA0QArsLAQoQwgAOCQABAxG40QPHvsDCqwDb0ALc A7ekLgYXbV/i6err7O3u7/DxEx1MBIIVGS0pPSYT8euxBghgkMybtwgUHAigUCsWAwiuSg0IEIDB gn/uMIhYcYREhgqfNNAYdetBggEMbMVDIKClgIsY27F0CTOdAgXxZIABKQhGCXYKTr78FgGCwGkA IDwrxTIdAgYJcJKyYAGAhJekTCZQKUBlU3FPo5K6CYAsLluqXokTseTEBjL+//zFXEeQgQKVBgO8 pNBgYS1aCQiq5UaRYgOpc9e5eMHmxgZQbThcuDHmh4oCmDNr3sy5s+fPoENzxmKDxo4gNy5wgByy SQwfiWPLnk0DxowOkHXoEIcMgsRfRQdAmGYhQFVTqAC0+hYW59UFEbqWrapVbVcBV5MvB9B8LM6b DwQCWODAQU1SXTwIUmFGHTIGEmtFjICAfq1bp8RhAxAMVoAGCFijDTMSSGAQNfr9wp824XSjFzjp YAACDh9cMNuFGGZIiggbEMAFFBqWokBFxgRw0YMDIMbdfetYo2KIpGgQQhXmcFBEChpgIFeGEShA wTMP6pXfigEWFk18RlZ0Xv9sGPSwhRVIrEYIPjj4sEIOKIygI4xzIXXhBCOg0EEIS0zhEU+stVHB E07YcAUKXMb5Tw9MZOGBECykKYgGMXBggpyAyqZBEl7kAIoGbYpzCgMCTPQiKbTgRY0uJmqYizWV pgOBb+p0U0oUHw3yghIjiDPiktxQYIwwDgTADClDImMBYARhlwwt4TSQUgCBRfRfLbEaRyuKDVKg VDI+UvAiCEWsdsAM6hR30QKNymckApHiJyRW3eTHgDOnnLLARIWF8yA1NEGI4DYOfuNpKSbkUMYG MwCxDkQCDcBQM32VZ1VF2oLFK0REUUSNbw5B9Mq5QzI1MLHqPpgAgOJMUAL4FResEejGXIowBAFi cCxyhiWwQEAGHcSpAAMoGXjWy6VQiypTHJvAgw4n7KAGl91EkKJB0iGQQALF2VLdLeQeFucEWrAQ xAdtXCCFljvOFgEDDRhmYJACjGjgiAgsQ4ozSBqpNIYSGkGEOYJ44EEHaWw527elkM11LAYWPQCB LhNWmEUZYoDCCgWQoN6UGZxRAwg5Vh2T0AMkYJ0t0kkQ2ANYaSUpSjMnNoELHQxhw5msVeBBGEIA sUEIL/CQwgGwxy777LTXbvvtuOceewo8vBACC008QQQSHqCpZxsbVHgCAcw37/zz0Ecv/fTUVy/9 CRd88BhrgQAAOw== ------=_NextPart_000_00C7_01C9CFBC.B014E350 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://content.nejm.org/content/vol0/issue2009/images/small/NEJMp0900702f2.gif R0lGODlhgABwANUAANmaYujSm////1qgoGVnULq5tOTi1cTGxuC+hpCOiejo6fj26dnY06DNzPr4 6p94Y1uSddTSy6elo7a7v7m2e6LJtvXz5b+RjHiztO/du36qjfLx8dHU1sO3pc/m5rK3uv387tDJ v/v7/Pj25+7r3dvc3vn6+en09a2sp8jKzM3c27za0fX7+p2dmPb155G0qvr58cHCwOTx762ytv// 8f39/bKxrv789vf39+Li4M7P0Xt6du3t7f/7//v7+/D5+CH5BAAAAAAALAAAAACAAHAAAAb/QIFw SCwaj8ikcslsOp/QqHRKrVqv2Kx2m1SUcuCweEwum8/otHrNZpeMJYt8Tq/b7/i8fs/v+/8RIkU5 FguGhwsOICCIjY6PkJGSk5SVlA6KDo8OET6DhY0OJBEhmAsjqKmqq6ytrq+uCyCwtKiYtZgMBiER mqGBn46iNgkREgXIycrLzM3Oz8/E0NPILcfTKAwRMSgxI8LARISOILsRIzEiNevs7e7v8PHy8AIb CQLz80ItMfjyPhEsaAvBwBciToLEgQq1yMUBLlh8bNiAgoqIDQIkPFRSg8EIRYu+/Uo4ZBwkVBt5 KFi5coMJBTWIbMAhZJ0QESZ88BBgwkqK/xY8WlDBsYNDtyUdv6GChDBYJAshhByYMePDhxlfGBw4 YEOCjhwFYuRIQdZGCx06wn4oUEVHAgUSYk5JYHRjkqSTmiqU5FBICR0c0OpQgINDCh0HUjDgoYPB hsUlEucowYEDAw5VDuyAazFBiqMcPeYNV3LhIwt2jdToOcSTCE8Yi7AeIoIHTk9NULxtIVdKggk2 +oUWGUlv6U0gHIx4iKNDhwvOL4TIESNw4gIHGudIADhHBA5bY+iIcPgAvxKxmcwgwMOGxR06QN8V Lcm4EJMHSWgbEWJ1iA4h/BcgD2FJIIENKYQ1QQ42oJCCAO3xk5gNE4RllgJPpMCdUFRwJ/8fEnjV R9p9phkiim4RsNXDijis6KIJ6uAjSA/riEBSbwJ4UoOOUBxAQAso8EBTFCJ4Jl8NC6hGX3EjCoDf IaIYYEBfNVhAwpVXWpDDARMpwAMHOfCwAYE88DDZmCopsAEYDODAQwkr6bBTEiJIsEMOLZQwJxQ+ nIWCXTcgAAOOITJJEonIKXdADzAg4OijAeSAAgoSWMONBB/gqZEAJXTVQgtdSVDCMTEQ88GQSqCw 2QxhTpEnaEgCYEERHSWCiUEHNfmkI1AJ4eKvbqo05kwqmeCmJyupJKSXOHhZJmFN/KRAAq1GUcOr wgmwAAAZ9EBER6JguYmuJTbSFxJjDlH/A7QCFBaTs6ylW096TpjHQwrVRqFRcENkwK0ROoxSagwu gHOokwuZgghqAtwQwMMQZwBWAWbZ8IENBUzAQALBKaADgqCisJZGqDpRAlDU7gmFV/KR8AACNxQR kDYxnGOwUy6QYBpK+Nx6Cwg4MJADWgwoAIaelGG4wRcHfGE0vlJwkMAGrKrsRA2e8StEBgQgQKtH Hyk8UjDlJBACI7a6EJU/NbDAjgn04tDbnDiUjMNMVMRnT75QwCcf1xT88O2STJEry8YGJEeCAQH1 40MFkEe+QgkF6JBgDGGlAGYCiXksHnlkWf1ECY5VPcUOXAlHQwUQJBCzuoSPe/A4ZScu/0oBLRjA lg8r9O67CiR8cOkHKWAu1sWYbXBADDFIwAG9UfCwWAv5+lACjkkYaRcCEEAwAg2wE4cICDB8Yx/C iRhQjOIWuLAcETfED75NNREq12o7XuHDDAnwkOmeJtAB9o6gAL9liwIaoAAJBic+E9VME+czSQgS YAAIaoJhPvCABjcoAwVwoEw58GAIy1QALw1NB2M6k9HQw5KVDG2AQ3BLDiSQLxNwAIayiQEP5EOB FWggA6/DR+xkkQAU0CARhqNBDHZwtkPwjAUYiKIUG6AAFHiqGx/AFJ7+JAAFxKBCKEAMpVoQFvGk YAItwA0SDvAWGgLwhkwwgVhAgwMKtP9AA2uryRAXkIACMCKChSgbA9BmiF7ZrwY/mMhM7iYRl9xN LjOZiAlycLe7ucQTOZjAEjREkRrCcQk52EEMZpCtBxCAAhRgoDASEIM/Gm4EG4sAIRdwLohUQWpB 8SQOiRADAgxMCCAwpQRSGT5H0CABEjgiIB1ggUolbmGpsWUUfJCAt5hOCDbc5RBKgDouNmwHBHiA BoKYFLE5wAA7sIEyDVcOCZBAEy5wn9qkmRkbKIB6b9SmAHrAgx0Apx80GEE4L6ABGMAOE/E0ETrV icTZBbIAFMQE40JAgmzRMwp4UsD/hpBNJuAgASUAjUAvQNBZDSECJOiGLBNBAgk0EZD/iWAARRWh uwLo7qJQMJMAPtCCaemSJ29Y4w52KByuheACL1ABEUJgAFA1EQQRYKIrHSoL9VUwShV8EE6dYLQa rEUBB/hpAHG4geeBhmsGuIAEKvA6cGEJgvppX0PJxgACPBMTIGDYVpvwJiehJ2UchWMAmSAB4QSA AM1pQQVgZyuDNPOl7DQAAXQwy17tlQleGAIONopNweqAsBsJAQGgStD7xQ6q/JhqMBzAgB2s9BC1 vGwXcjCEaX2wNSnAyGCXUNiGdYAAPXCZBkzbwBGAgIyq3YsDIPpOaMp2CX0VwrQmsKcaTOANu1VC bwXwW56I8wR6bGAiULBSmIpCAhW0/9UpovncIkS3i6Ks7nV58lne9oMFFHjAPgmqVCE2UBFAWidV mSmBlbbPBQ7IY3uN8F646FBdC1pNfbW7kRbcg7sJWKx/jVlEAdO1Be8UBTcMYNEFEyG664qvAARh XewK0L4CAEER9xmCB2i4UIaA6g6MONe9gIABIMYECQqA3hKbWAgN3sEHwFsCmkQ4u0no7Q0eEALw MUCc8zttDFoA2QFHIHeMkAOC2XtkFBfwAxhpkwDmO1beHqAGI3hABLYmTg9sGBEfIQgEDbfciCai kGQ2cZJngJEmrzkHEiZsPwRqALlcAAAakIEAPJIcX4iCAAw1bwF28ExD8OzI7g0qfP/RXANDs/nF FA4oAWjbsEf70AQMEIguNAECbrbAApiI7A5aIDbLgnoIlZnTmVXCAZrE4AC2+QokMVSE3pKAAOAT Qge4VYEXRIABVuzFKWjQAk7nesDqKwCuYvvr7LyhBv38wJc44LZRMqAGaMFNZpvdjwxAwFs16MFR EUADDbzgxwxo7imOkdzjOOBTBTERMwO94MMEVQEEoG5lejJKFcBbBwmZNxE2FQEIRNtJFwhABlgQ A5AYxAGFLTiiXICCmRbynQoutw4engB1V0Zuo7xevKUr6iH0FgEaUFcPHkACBCRFfMxEbo8NboEC NBe1DCiAPq2Ag9ko4TBtwkEJCGD/8w/6YJTFRosIaOIFDEja5/3owDiJIB0EZKAExtxyMj/C5wmu FKpFximcmnAA8KRgK7/50l94EAPiXeaz6NkABgawgo3H4AYIFDU/iY4ABgjDADZI7zKbiYL02up9 F907E/qemL9zXfAonEoK/oJ4HHhgAB7AwMYfgtRGD6EHbQ8ADkJBYs2Ty7gRSMAgnQh6euqJ735P TM2/pIIPFl5zgXGS4hsAxd6knJWizncOLpABQYWCBEqHaTl2MPxD+Fqax2eC5mJAFh9J/C8beD5l PquABmBAASQwu8/fnIAVMKAIQ1cCAUEOfaRy6PNjCSBwhkBuEJF+RPASk0ZbGzAB/8mnITZHGYT3 ART4dwKgAgOgAt2nAY0nBBoBAhqgAP9HBPp2ATngCMaFAn60dIhSNq8FaHonOkEjANXRRTPgd6b3 fql3FRzwRQKAARVQAh2QARQgeyR4AP1GAhyAAeB1e1QmDBvDY+LXWp2WCMWHfjj4Bk3Dgz6YAkq2 bh90AEK4FTXwgSqAACDgQ/tnARrwAxUwAEzoKx3wADRwKzm2RFjITlGlgDB3g0agdQLQd2JYeppx gWeYhgcQeyXwMCxgglOoERbgcRhgfyMoBBvQAUhiACRwCMfVSjKIMMohAX5GA3bHFqGnAFZXGxwg AgfwfwrQg4pYhpUBJmjYg+yXif8lQAG0VQMN0AAkOAEZoAE9MAA/wAIDMIVSEXU20EQLcEyZxk4T 9Ew/lnlGxgWUwWpINoQKsHrrYovt50+o93dpOAMDgAAB0AGIJgA+ZFCo2AEU4IFCsAJ3eAIxMAoE 8Ufq84deJnx/lAkMlwWk440QAo6ak4hkQYYX2H5CmAIvkAAAQAEGcG4nAAELhIoUUAEN8AJDkImx Z4SLkBw5FnzVSFXHZTaVVZBYQDowMQRfEgPh+Aa1CB468AIDYI4cUAJkUXg9mAIDIAH+cpFDoAEB wAKo6FIN8AEsIAQ/EEUe8AOWZ0wpR3dUZQERYAC4RnwueQXdeGIKiRk3mR0DMAD/BIAB0qMClrOL SAgBKhAACBABrAZFFGAButGRGGAXvYFjnpZapUgIymEWCrgA56cF0ccpf4EDipGQNLmQZSmUE7AD dtg0bXkVEQAAEBACFOAoMTl9AZAAFrZ4MbB3MBAAFhATQ3RcLRBQ4qc+NUhLX0kkXxQTJVACMbAB H/AQM1mTYiiRAzAD/rR4K3CZEwAACYABFFAAHwAArKYAL4ABwVRNA1ABE4AvFiByDyMQl0dGHrYX LGUaCwcRNcA8thkZuvkgvQmZQRmcH8AxCEABA/ACiNGcATAAKEABE3CcD/cBsocCD9A9KvABHBAC AUACIMAC2dkBs4AINLBpRoSV/07RdFtYCDGHBSJgnpyiAlxCPPUAHr55kxMwABOwHj2ESnaoA4/m gcu5n+yID15kfxoQoBAQAJ2JAA4QE23zY+RgALMWmIGkPsP3Y7nDikSQARAjchmAoEzAA+vAPIJw m2FFPGZyRiUQAghgADnwASVAmvlVAcdmo2e5A4uXQBOggRGAAGOiAJrkAQRAABBQAZhXASRwAgYV XsJQaUAaU34mCgGRGjWwnXOQAYSKpA+zpCSwpESgAyZQnjFwnokxA393Rh9Aj5wZn/eJShQQcVUx AZ0JANGpnBqogSWAAJbDpjVgSt2zAgpQOZNRXXuUKyppYZ2mCLEliSwgPywwif8VIAMjkKiF+jBy wQGNCqWKmR2SShYVQgExwKEl0D0QwJz8YxUaaAMViUoI0AHUuiAA0AEcAFYkZUofWIuD4YB4ITZj o1xZgmegxwJIOkAs8AIaoAE0QAOTeK8iJwQc4AOOapscGgEtlx2Wmh0pUAEacJZnKpzUOm0BgDk2 EAFToYHXFQIA8EEocAEIkAARBwYf8BXocVBiVjhUpV6NYFlI+gOIdCMvUAF0WAHYE6gBUAP7Kkcx 8JSUEQOaqqkdcGwcMAEQ4J8Q0AIAcAHpBBwA4CBACR4zcKbXVQIAoAMysAMhV01HuKX44oACkAIk EAIPJDtOAQkOUQNIygIrYLD/K4shGuCyN8ACGtBf6sICDxMChHemRvMBqGQDL8ABKWIViTEBadsB EKCZzkEAAFC4HbCf21qiTPsXCAAACPAAABABBPAbX8C3h7FUNRWbUGI4T5EC2Wm2K3ADJ1BtaZur MeEBc4g9LGAAD6OprYtA3eNvEpsdLRC4O6ABBTCvNuBPHWAxiEutwHtd1XEAF/AyL9A611WLwkMW ICsHIvu1DDECHRAA/parbMMCMvCUQ0C2basCvVOoGTC99HijGgABkFu4OwABCQS53TOfCau+/iSx ZzqqGri0pNp3H/AAKKCOFnZdW7q8WuVfEPS84Pl9DEADFAABFAAxCIABHeAo/3L5MOz4MJDWkRWQ ABRAqCKHANBRuxrQAWoRIBKgAQlQvhCAASWwn4gLAQTgb/v5RSqMuIvbrAnwABpSAcSQvFbBfgHs lzdTwAeBefbWAof6ArerAYUAA4lavCTldgbgvWB6uwmwAzMwkRCwAx1gDZVyIAcwAcyDsDHAAAay xRr7ptCqAXf0Amr8AhooHtf5AHcEATqAigvyvzxcTCIysrxXcuEKThhAUldMUsUrt1ubvlFUTRAg AQwgrwa7Aw/wyJD8yOH0AAnAwjUcyZFMABcwA56yA+D0pmZcviZMAPM5A+ZBuRoFwHhsKNB7EIsQ ncPoAS3SA7G3tTngIvjYAP8ncD9RiQGI0aV2SIGjup82wD+kfAEJoFYcsLQlehX+xMwwjDvIDMmg TACFVaKn7L87zLx4mset7AgTsMvq0A4Y4AEucgID0AAyAEMNcJb21wKLt3gvIMM6iQExfF2/W6JK ZhUqzM8xfCA2cAHMSa3ZDCdVccfdzMpA7AgMiA+xRyPovAIDxBoecwA4sJ/YwQEtAMZnyczyywES W7/7HNL0q7j3TL8FXQL8zIEJTcDH8RTslYMY0HwYsAIqUDL4EIs4UB2aY7/bungdzc8hzbRMq7D2 +7tC7c/0y7f9O9RWwWw+nK4v/QifRgTuEnuMJwA6gNMicEMXDR7LPL/bOsL/S+3UYq2wSl3WMryt TP0bQt3MUB2rm6vHDKE22FMYQpCJblNstOLVwxvWwSuxPk3UiVu/EVfYwJu4R93W88u0VzEnSWGS Lo0olxcCemXVKfgDQbXVtIJxX42sVkEVg10V1EraoZ2wVJEAVJHYVxHapm3aV5HNsE0VcQ0VhSmr 3ywLdvewNMMADPAxvp0gvh0Wvk0ew81+zBMWRAaDBWBFGXMgFAPdzZ0M1zABulEhZIQMzE1k1I0M DTIpnNzaGBPdyJAC15Yi2FZ+PzzV+dELJBBPFmAAtBTfDuACVoIK8T3foTgC8Y2gOqMIV5IccrAI OpNX/w0CoUhTYWMByfFj/7eCa8phO7+aHPYtJaKwCAPOTAiq4YZgACMQELiC2wsNJX8EJdPYPBBu aSpuCA9aACSLribSTgJ3cpY2jUDWXCdn4okAAgS34iby4zRw47O03pRtCUoETlU2CSAQAp68hZCA 4C1AADwWCcalPph2RPXRTDuQAAim5BMkSlg+2ehj5L2EOpRAA7vLRCHeo558a2s+PiTgyQVQLgwh AdZM540Q5J5ccm8+17n9CEsumlXW5zk2QS2g3kxBAtWEApL95BtTgIRuK6gYZEoefCx5CZybFzTQ UmcT6YpgAS0gS+LVCMlhFntYHzTAcowe6bLAWpSO6i3VSqy+p0ouU4vTlf+RsORbOSV5MWT6cduk rju3zuoOEANSAux7POyVAFP1sQApZdmeHt8th+u5vrWZN+ShwEzIgOzjswBNJd95wUwYQ+2jQdfG BAKTUt+RTgPHZQMDXBw0EHyBJAmLsGXqruTgRzDEDgIQJQez7ucjvrl2Io1MYieIvgkkoBkS8BH1 oTu+xPD0rujd0KDF4QDEgFL/DvDsfRAH50unDrbJ0W0H/whHvuqT8KBS3uhPDuqchu3kwOQ2oPLL nukHQQOo2EqjfgibbmExEFAnD/MI+vOiBAOejuCo6OSP4AJH7kcZL+IbbyuqMkisbgCqQvCREO87 UADsXh8gEAOs9PGSoOj/IObyDtpUAmkJRD7mJN5tSU7vIUAMB5wXCCgBt5DrD1pEME4OX0ZBZA9b BmAnMZ/zmE7XyYECBBABYZ7rIUBeiQ/oLrBEWh/pP6YqJk8Jx9X2xWEBuxaDaJ/2+MHvu0s9/85M xK7oO0buPbroef/kUtL3onhtPt/5Ul3kIEAMJdf5/24BHNPl9TECzQ32y57xMi/7JkLznLD6xJ/t yC8MypH8zu/8zC6Kz38JTT/91i/7EYRgPrP93N/93v/94B/+4j/+5F/+PtMkfxEB6r/+7N/+7v/+ 8B//8j//9F//9m//AawuPrD/NgIEIuGQWDQekUnlktl0Jn01wZRatV6xD1ntltv1fsFh8ZhcNp+v QQA7 ------=_NextPart_000_00C7_01C9CFBC.B014E350 Content-Type: text/css; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: http://content.nejm.org/v3.css A.collectionsLinks { FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: #000000; FONT-SIZE: = 13px; FONT-WEIGHT: bold; TEXT-DECORATION: none } A.collectionsLinks:hover { COLOR: #ff3300; FONT-SIZE: 13px; FONT-WEIGHT: bold; TEXT-DECORATION: = underline } A.contentboxLinks { FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: #000000; FONT-SIZE: = 11px; FONT-WEIGHT: bold; TEXT-DECORATION: none } A.contentboxLinks:hover { COLOR: #ff3300; FONT-SIZE: 11px; TEXT-DECORATION: underline } A.navBarLinks { FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: #000000; FONT-SIZE: = 12px; FONT-WEIGHT: bold; TEXT-DECORATION: none } A.navBarLinks:hover { COLOR: #ff3300; FONT-SIZE: 12px; TEXT-DECORATION: underline } A.subnavBarLinks { FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: #000000; FONT-SIZE: = 12px; FONT-WEIGHT: normal; TEXT-DECORATION: none } A.subnavBarLinks:hover { COLOR: #ff3300; FONT-SIZE: 12px; TEXT-DECORATION: underline } A.navBarLinksCurrentPage { COLOR: #336699; FONT-SIZE: 12px; FONT-WEIGHT: bold; TEXT-DECORATION: = none } A.leftNavBarLinks { FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: #000000; FONT-SIZE: = 12px; FONT-WEIGHT: bold; TEXT-DECORATION: none } A.leftNavBarLinks:hover { COLOR: #ff3300; FONT-SIZE: 12px; TEXT-DECORATION: underline } A.footerLinks { FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: #000000; FONT-SIZE: = 12px; FONT-WEIGHT: normal; TEXT-DECORATION: none } A.footerLinks:hover { COLOR: #ff3300; FONT-SIZE: 12px; TEXT-DECORATION: underline } A.signupLinks { FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: #000000; FONT-SIZE: = 12px; FONT-WEIGHT: normal; TEXT-DECORATION: none } A.signupLinks:hover { COLOR: #ff3300; FONT-SIZE: 12px; TEXT-DECORATION: underline } A.homeArticleLinks { FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: #000000; FONT-SIZE: = 16px; FONT-WEIGHT: bold; TEXT-DECORATION: underline } A.homeArticleLinks:hover { COLOR: #ff3300; FONT-SIZE: 16px; TEXT-DECORATION: underline } A.homeArticleLinks:visited { COLOR: #666699; FONT-SIZE: 16px; TEXT-DECORATION: underline } A.homeSpecialLinks { FONT-STYLE: italic; FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: = #000000; FONT-SIZE: 16px; FONT-WEIGHT: bold; TEXT-DECORATION: underline } A.homeSpecialLinks:hover { COLOR: #ff3300; FONT-SIZE: 16px; TEXT-DECORATION: underline } A.homeSpecialLinks:visited { COLOR: #666699; FONT-SIZE: 16px; TEXT-DECORATION: underline } A.homeIssueLinks { FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: #000000; FONT-SIZE: = 14px; FONT-WEIGHT: normal; TEXT-DECORATION: underline } A.homeIssueLinks:hover { COLOR: #ff3300; FONT-SIZE: 14px; TEXT-DECORATION: underline } A.homeIssueLinks:visited { COLOR: #666699; FONT-SIZE: 14px; TEXT-DECORATION: underline } A.homeFeaturedLinks { FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: #000000; FONT-SIZE: = 12px; FONT-WEIGHT: bold; TEXT-DECORATION: underline } A.homeFeaturedLinks:hover { COLOR: #ff3300; FONT-SIZE: 12px; TEXT-DECORATION: underline } A.homeFeaturedLinks:visited { COLOR: #666699; FONT-SIZE: 12px; TEXT-DECORATION: underline } A.homeSearchLinks { FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: #000000; FONT-SIZE: = 10px; FONT-WEIGHT: bold; TEXT-DECORATION: none } A.homeSearchLinks:hover { COLOR: #ff3300; FONT-SIZE: 10px; TEXT-DECORATION: underline } A.homeCollectionsLinks { FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: #000000; FONT-SIZE: = 10px; FONT-WEIGHT: bold; TEXT-DECORATION: none } A.homeCollectionsLinks:hover { COLOR: #ff3300; FONT-SIZE: 10px; TEXT-DECORATION: underline } A.homeCopyrightLinks { COLOR: #000000; TEXT-DECORATION: underline } A.homeCopyrightLinks:hover { COLOR: #ff3300; TEXT-DECORATION: underline } A.homeLinks { COLOR: #000000; TEXT-DECORATION: underline } A.homeLinks:hover { COLOR: #ff3300; TEXT-DECORATION: underline } A.homeLinks:visited { COLOR: #666699; TEXT-DECORATION: underline } A.tweekArticleLinks { FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: #000000; FONT-SIZE: = 13px; FONT-WEIGHT: bold; TEXT-DECORATION: underline } A.tweekArticleLinks:hover { COLOR: #ff3300; FONT-SIZE: 13px; TEXT-DECORATION: underline } A.tweekArticleLinks:visited { COLOR: #666699; FONT-SIZE: 13px; TEXT-DECORATION: underline } A.listLinks { FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: #000000; FONT-SIZE: = 12px; FONT-WEIGHT: bold; TEXT-DECORATION: none } A.listLinks:hover { COLOR: #ff3300; FONT-SIZE: 12px; TEXT-DECORATION: underline } .contenthead { PADDING-LEFT: 6px; FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: = #000000; FONT-SIZE: 11px; FONT-WEIGHT: bold } .PersSubtitle { PADDING-BOTTOM: 0.5em; FONT-FAMILY: Verdana, Arial, Helvetica, = sans-serif; LETTER-SPACING: 0.1em; COLOR: #ff3300; FONT-SIZE: 14px; = FONT-WEIGHT: bold; TEXT-DECORATION: none; PADDING-TOP: 0.5em } .notonscreen { DISPLAY: none } ------=_NextPart_000_00C7_01C9CFBC.B014E350 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: http://www.nejm.org/_scripts/searchNavFunctions.js /* SEARCH NAVIGATION FUNCTIONS */ function clickClear(thisField, defaultText) { if (thisField.value =3D=3D defaultText) { thisField.value =3D ""; thisField.style.color =3D "#000"; } } function clickRecall(thisField, defaultText) { if (thisField.value =3D=3D "") { thisField.value =3D defaultText; thisField.style.color =3D "#000"; } } // for SLI search forms function verifySearch(thisField,defaultText) { var searchUrl; if (thisField.value =3D=3D defaultText || thisField.value =3D=3D = "Keyword, citation, or author") { location.href=3D "http://search.nejm.org"; return false; } else { return true; } } /* END SEARCH NAVIGATION FUNCTIONS */ /* INDIA ACCESS FUNCTIONS */ // The following two country code and institution states // will cause the window to pop. var triggerCountryCode =3D "IN"; var triggerInstitutionState =3D false; // The following two variables provide the URL of the page // to display and any special options. var windowUrl =3D "http://www.nejm.org/india/info/pop.html"; var windowOptions =3D = "width=3D515,height=3D425,resizable=3Dyes,scrollbars=3Dno,status=3Dno,men= ubar=3Dno,directories=3Dno,toolbar=3Dno"; // Pop up info window function popInfoWindow(countryCode,isInstitution) { var infoWin; =20 // If client accepts cookies =20 // and cookie is not set // and India and not institution if (cookiesAreEnabled() && getCookie("suppressInfoWindow") =3D=3D null=20 && countryCode =3D=3D triggerCountryCode && isInstitution =3D=3D triggerInstitutionState) { =20 // Set session cookie setCookie("suppressInfoWindow","true",null,"/","nejm.org"); =20 // If window does not exist or is closed, // pop it. if (!infoWin || infoWin.closed) { infoWin =3D window.open(windowUrl, "infoWin", windowOptions); } else { // Otherwise, focus on it infoWin.focus(); } } } // Change cookie state, depending upon state of passed-in checkbox. function changeCookieState(checkBox,cookieName) { if (checkBox.checked) { setCookie(cookieName,"true","Wed, 01-Jan-2020 00:00:01 = GMT","/","nejm.org"); } else { setCookie(cookieName,"true",null,"/","nejm.org"); } } // Checks if cookies are enabled in browser. function cookiesAreEnabled() { setCookie( "foo", "bar" ); if ( getCookie( "foo" ) ) { deleteCookie( "foo" ); return true; } else { return false; } } function getCookie( name ) { var arg =3D name + "=3D"; var alen =3D arg.length; var clen =3D document.cookie.length; var i =3D 0; while ( i < clen ) { var j =3D i + alen; if ( document.cookie.substring(i, j) =3D=3D arg ) return = getCookieVal(j); i =3D document.cookie.indexOf( " ", i ) + 1; if ( i =3D=3D 0 ) break; } return null; } function deleteCookie( name, path, domain ) { if ( getCookie( name ) ) { document.cookie =3D name + "=3D" + ( ( path ) ? "; path=3D" + path : "" ) + ( ( domain ) ? "; domain=3D" + domain : "" ) + "; expires=3DThu, 01-Jan-70 00:00:01 GMT"; } } function setCookie( name, value, expires, path, domain, secure ) { document.cookie =3D name + "=3D" + escape (value) + ( ( expires ) ? "; expires=3D" + expires : "" ) + ( ( path ) ? "; path=3D" + path : "" ) + ( ( domain ) ? "; domain=3D" + domain : "" ) + ( ( secure ) ? "; secure" : "" ); } /** * Helper function for getCookie() */ function getCookieVal( offset ) { var endstr =3D document.cookie.indexOf ( ";", offset ); if ( endstr =3D=3D -1 ) endstr =3D document.cookie.length; return unescape( document.cookie.substring( offset, endstr ) ); } /* END INDIA ACCESS FUNCTIONS */ ------=_NextPart_000_00C7_01C9CFBC.B014E350 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: http://content.nejm.org/misc/folders.js ------=_NextPart_000_00C7_01C9CFBC.B014E350 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: http://content.nejm.org/ntpagetag.js /* NetTracker Page Tagging Script=0A= * Copyright 2004 Sane Solutions, LLC. All rights reserved.=0A= * Visit http://www.sane.com for more information.=0A= */=0A= =0A= var NTPT_IMGSRC =3D '/icons/ntpagetag.gif';=0A= =0A= var NTPT_FLDS =3D new Object();=0A= NTPT_FLDS.lc =3D true; // Document location=0A= NTPT_FLDS.rf =3D true; // Document referrer=0A= NTPT_FLDS.rs =3D true; // User's screen resolution=0A= NTPT_FLDS.cd =3D true; // User's color depth=0A= NTPT_FLDS.ln =3D true; // Browser language=0A= NTPT_FLDS.tz =3D true; // User's timezone=0A= NTPT_FLDS.jv =3D true; // Browser's Java support=0A= =0A= var NTPT_MAXTAGWAIT =3D 1.0; // Max delay (secs) on link-tags and = submit-tags=0A= =0A= // Optional variables:=0A= var NTPT_HTTPSIMGSRC =3D '';=0A= var NTPT_GLBLEXTRA =3D '';=0A= var NTPT_GLBLREFTOP =3D false;=0A= =0A= /*** END OF USER-CONFIGURABLE VARIABLES ***/=0A= =0A= function = O0000(O0OO0O,OOO0O0O){return(eval("\x74\x79\x70\x65\x6f\x66\x20"+O0OO0O+"= \x20\x21\x3d\x20\x22\x75\x6e\x64\x65\x66\x69\x6e\x65\x64\x22")?eval(O0OO0= O):OOO0O0O);}function = OOOO000(OOOO0O,O0O000){return(OOOO0O+(((OOOO0O=3D=3D'')||((O0O000=3D=3D''= )||(O0O000.substring((0xdc3+3768-0x1c7b),(0x1219+1511-0x17ff))=3D=3D"\x26= ")))?'':"\x26")+O0O000);}function O0O00O(){var O00O00=3Dnew = Date();return(O00O00.getTime()+"\x2e"+Math.floor(Math.random()*(0x11f7+41= -0xe38)));}function = O0OOO(OOO0OO,O0OOO0){OO0OO[OOO0OO]=3DO0OOO0.toString();}function = O00OO0(OOO0OO){OO0OO[OOO0OO]=3D'';}function OO00OO0(OOOOO){var = O00OOO=3D'',OOO0O,OOO0O0;OOO000(O0000("\x4e\x54\x50\x54\x5f\x47\x4c\x42\x= 4c\x45\x58\x54\x52\x41",''));if(!LnkLck)OOO000(O0000("\x4e\x54\x50\x54\x5= f\x50\x47\x45\x58\x54\x52\x41",''));OOO000(OOOOO);for(OOO0O in = OO0OO){OOO0O0=3DOO0OO[OOO0O];if(OOO0O0&&(OOO0O0!=3D''))O00OOO=3DOOOO000(O= 00OOO,(OOO0O+"\x3d"+escape(OOO0O0)));}return O00OOO;}function = O0OO000(){var OOO0O;OO00O0.OO0OO=3Dnew Array();for(OOO0O in = OO0OO)OO00O0.OO0OO[OOO0O]=3DOO0OO[OOO0O];}function OOOOO0(){var = OOO0O;OO0OO=3Dnew Array();for(OOO0O in = OO00O0.OO0OO)OO0OO[OOO0O]=3DOO00O0.OO0OO[OOO0O];}function = OOO00O(O0O0O0,OO00OO,OOOO0){if(OO0O0[O0O0O0]!=3Dnull){var O00O0O=3Dnew = Function(OO00OO);OO0O0[O0O0O0].onload=3DO00O0O;OO0O0[O0O0O0].onerror=3DO0= 0O0O;OO0O0[O0O0O0].onabort=3DO00O0O;}setTimeout(OO00OO,(OOOO0*(0x1a5f+189= 5-0x1dde)));}function = OO0OO0(O0OO0,OOOO00){if(O0OO0=3D=3D'')return;O00OO=3D((O00OO+(0x1060+3795= -0x1f32))%OO0O0.length);if(OO0O0[O00OO]=3D=3Dnull)OO0O0[O00OO]=3Dnew = Image((0x1717+366-0x1884),(0xde0+520-0xfe7));OO0O0[O00OO].src=3DO0OO0+"\x= 3f"+OOOO00;}function OO0000(OOOOO){var O0OO0;var = OOOO00;if((OO000O!=3D'')&&(document.location.protocol=3D=3D"\x68\x74\x74\= x70\x73\x3a"))O0OO0=3DOO000O;else = O0OO0=3DO0OO00O;OOOO00=3DOO00OO0(OOOOO);OO0OO0(O0OO0,OOOO00);OOOOO0();}fu= nction OOO000(OOOOO){var OO0O00;var = O0OO00;if(!OOOOO)return;OOOOO=3DOOOOO.toString();if(OOOOO=3D=3D'')return;= OO0O00=3DOOOOO.split("\x26");for(O0OO00=3D(0xc96+706-0xf58);O0OO00(0x2e6+6443-0x1c11)){var = OO0O0O;if(O00O0.click){O00O0.tmpclck=3DO00O0.onclick;O00O0.onclick=3Dnull= ;OO0O0O=3D"\x69\x66\x20\x28\x20\x4c\x6e\x6b\x4c\x63\x6b\x20\x29\x20\x7b\x= 20\x4c\x6e\x6b\x4c\x63\x6b\x2e\x63\x6c\x69\x63\x6b\x28\x29\x3b\x20\x4c\x6= e\x6b\x4c\x63\x6b\x2e\x6f\x6e\x63\x6c\x69\x63\x6b\x20\x3d\x20\x4c\x6e\x6b= \x4c\x63\x6b\x2e\x74\x6d\x70\x63\x6c\x63\x6b\x3b\x20\x4c\x6e\x6b\x4c\x63\= x6b\x20\x3d\x20\x6e\x75\x6c\x6c\x3b\x20\x7d";}else = OO0O0O=3D"\x69\x66\x20\x28\x20\x4c\x6e\x6b\x4c\x63\x6b\x20\x29\x20\x7b\x2= 0\x77\x69\x6e\x64\x6f\x77\x2e\x6c\x6f\x63\x61\x74\x69\x6f\x6e\x2e\x68\x72= \x65\x66\x20\x3d\x20\x22"+O00O0.href+"\x22\x3b\x20\x4c\x6e\x6b\x4c\x63\x6= b\x20\x3d\x20\x6e\x75\x6c\x6c\x3b\x20\x7d";OOO00O(O00OO,OO0O0O,OO00O);ret= urn false;}LnkLck=3Dnull;return true;}function = O0O0O0O(OO000,OOOOO,OOOO0){var OO00O;if(!OO000||!OO000.submit)return = true;if(FrmLck)return = false;FrmLck=3DOO000;O0O0OO(OOOOO);if(OOOO0)OO00O=3DOOOO0;else = OO00O=3DNTPT_MAXTAGWAIT;if(OO00O>(0x157d+1827-0x1ca0)){OO000.tmpsbmt=3DOO= 000.onsubmit;OO000.onsubmit=3Dnull;OOO00O(O00OO,"\x69\x66\x20\x28\x20\x46= \x72\x6d\x4c\x63\x6b\x20\x29\x20\x7b\x20\x46\x72\x6d\x4c\x63\x6b\x2e\x73\= x75\x62\x6d\x69\x74\x28\x29\x3b\x20\x46\x72\x6d\x4c\x63\x6b\x2e\x6f\x6e\x= 73\x75\x62\x6d\x69\x74\x20\x3d\x20\x46\x72\x6d\x4c\x63\x6b\x2e\x74\x6d\x7= 0\x73\x62\x6d\x74\x3b\x20\x46\x72\x6d\x4c\x63\x6b\x20\x3d\x20\x6e\x75\x6c= \x6c\x3b\x20\x7d",OO00O);return false;}FrmLck=3Dnull;return true;}var = O0OO00O=3DNTPT_IMGSRC;var OOO00=3DNTPT_FLDS;var = OO000O=3DO0000("\x4e\x54\x50\x54\x5f\x48\x54\x54\x50\x53\x49\x4d\x47\x53\= x52\x43",'');var = O000OO=3DO0000("\x4e\x54\x50\x54\x5f\x50\x47\x52\x45\x46\x54\x4f\x50",O00= 00("\x4e\x54\x50\x54\x5f\x47\x4c\x42\x4c\x52\x45\x46\x54\x4f\x50",false))= ;var = O0000O=3DO0000("\x4e\x54\x50\x54\x5f\x4e\x4f\x49\x4e\x49\x54\x49\x41\x4c\= x54\x41\x47",false);var ntptAddPair=3DO0OOO;var = ntptDropPair=3DO00OO0;var ntptEventTag=3DO0O0OO;var = ntptLinkTag=3DO00000;var ntptSubmitTag=3DO0O0O0O;var OO0OO=3Dnew = Array();var OO00O0=3Dnew Object();var = OO0O0=3DArray((0x4e0+41-0x4ff));var = O00OO;for(O00OO=3D(0x27+2948-0xbab);O00OO(0x1904+3371-0x262d))O0O0O=3DO0O0O.substring((= 0xc13+2301-0x1510),(0x10a6+2670-0x1b12));O0O0O=3DO0O0O.toLowerCase();O0OO= O("\x6c\x6e",O0O0O);}if(OOO00.tz){var O0O00;var O00O00=3Dnew Date();var = O000O=3DO00O00.getTimezoneOffset();var = O000O0;O0O00=3D"\x47\x4d\x54";if(O000O!=3D(0x7f1+865-0xb52)){if(O000O>(0x= 12d5+3648-0x2115))O0O00+=3D"\x20\x2d";else = O0O00+=3D"\x20\x2b";O000O=3DMath.abs(O000O);O000O0=3DMath.floor(O000O/(0x= 13b3+2831-0x1e86));O000O-=3DO000O0*(0x1324+5143-0x26ff);if(O000O0<(0x3c9+= 541-0x5dc))O0O00+=3D"\x30";O0O00+=3DO000O0+"\x3a";if(O000O<(0x2192+484-0x= 236c))O0O00+=3D"\x30";O0O00+=3DO000O;}O0OOO("\x74\x7a",O0O00);}if(OOO00.j= v){var OO0OOO;if(navigator.javaEnabled())OO0OOO=3D"\x31";else = OO0OOO=3D"\x30";O0OOO("\x6a\x76",OO0OOO);}O0OO000();if(!O0000O)OO0000('')= ;=0A= ------=_NextPart_000_00C7_01C9CFBC.B014E350 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: http://survey.nejm.org/scripts/survey.js function invite(inviteurl,frmWidth,frmHeight,svyName,expire) { //******************************************************************** // Display invitation if specific cookie not found and set cookie // Parameters // inviteurl: URL of invite form // frmWidth & frmHeight: dimensions of invitation window // svyName: Name of the specific survey // expire: Number of days before cookie expires //=20 // Created by Chris Miceli 2/25/2004 //******************************************************************** // define variables var theCookie =3D document.cookie; var today =3D new Date(); var expDate =3D new Date(); // Check if user has visited page before if (theCookie.indexOf(svyName) =3D=3D -1) { =20 expDate =3D whenIs(today, expire); expDate =3D expDate.toGMTString(); document.cookie =3D svyName + "; path=3D/; expires=3D" + expDate + = ";"; window.open(inviteurl, "", "toolbar=3Dno,status=3Dno,width=3D" + = frmWidth + ",height=3D" + frmHeight + ",top=3D150,left=3D50"); //window.open(surveyurl, "", = "toolbar=3Dno,status=3Dno,width=3D270,height=3D220,top=3D150,left=3D50");= } } function invite(inviteurl,frmWidth,frmHeight,svyName,expire,path) { //******************************************************************** // Display invitation if specific cookie not found and set cookie // Parameters // inviteurl: URL of invite form // frmWidth & frmHeight: dimensions of invitation window // svyName: Name of the specific survey // expire: Number of days before cookie expires // path: cookie path //=20 // Created by Chris Miceli 2/25/2004 //******************************************************************** // define variables var theCookie =3D document.cookie; var today =3D new Date(); var expDate =3D new Date(); // Check if user has visited page before if (readCookie(svyName) =3D=3D null) { =09 createCookie(svyName, svyName, expire); window.open(inviteurl, "", "toolbar=3Dno,status=3Dno,width=3D" + = frmWidth + ",height=3D" + frmHeight + ",top=3D150,left=3D50"); } } function whenIs(anyDate, n){ //-- Returns the date that is n days from any date. var newDate =3D new Date(); newDate.setTime(anyDate.getTime()+(n*1000*60*60*24)); return newDate; } //******************************************************************** // Display invitation if specific cookie not found and set cookie // Parameters // Display invitation every nthe hit on page, every 5th customer or = every 163rd customer. =20 // Created by SFungafat , Modified RKumar June 2004 //******************************************************************** function intercept(surveyurl) { // define variables var cookie_ls =3D document.cookie; var date_ls =3D new Date(); var S =3D new Date(); // if not yet sampled if (cookie_ls.indexOf("NEJM062004WEB") =3D=3D -1) { rnd.today=3Dnew Date(); rnd.seed=3Drnd.today.getTime(); =20 function whenIs(anyDate, n){ //-- Returns the date that is n days from any date. var newDate =3D new Date(); = newDate.setTime(anyDate.getTime()+(n*1000*60*60*24)); return newDate; } function rnd() { rnd.seed =3D (rnd.seed*9301+49297) % 233280; return rnd.seed/(233280.0); }; function rand(number) { return Math.ceil(rnd()*number); }; =20 sample=3Drand(5); // for the sample grab 1 in 5 if (sample=3D=3D5) { S =3D whenIs(date_ls, 3); S =3D S.toGMTString(); document.cookie =3D "NEJM062004WEB; path=3D/; expires=3D" + = S + ";"; window.open(surveyurl, "", = "toolbar=3Dno,status=3Dno,width=3D600,height=3D300,top=3D150,left=3D50") } } } //************************************************ // Set pop-up cookie based on country and IP type // Parameters // country: two character country code // instFlag: NEJM Institution, 1=3DTrue, 0=3DFalse // ** Use ISO 3166 standard 2-letter country codes ** //************************************************ function intlSurvey(country, instFlag) { /* var validCtys =3D "GB"; if (cookiesAreEnabled()) { country =3D country.toUpperCase() =09 // Invite only displayed for valid countries if (country.indexOf(validCtys) > -1) { if (instFlag =3D=3D 1) { //Set cookie one day for NEJM Institutions = invite('http://survey.nejm.org/NEJMUK0608/popup.aspx',510,260,'NEJMGBINST= ',1, 'nejm.org'); } else { //45 days for all others = invite('http://survey.nejm.org/NEJMUK0608/popup.aspx',510,260,'NEJMGBNONI= NST',45, 'nejm.org'); } =09 } } */ } //************************************************ // Set pop-up cookie based on country.=20 // Parameters // userCty: Country user from // validCty: Country or countries to test against // inviteurl: URL of invite form // svyName: Name of the specific survey // expire: Number of days before cookie expires // frmWidth & frmHeight: dimensions of invitation window //************************************************ function surveyByCty(userCty, validCty, inviteurl, svyName, expire, = frmWidth, frmHeight) { if (cookiesAreEnabled()) { userCty =3D userCty.toUpperCase() validCty =3D validCty.toUpperCase() =09 // Invite only displayed for valid countries if (userCty.indexOf(validCty) > -1) { //Display invite invite(inviteurl, frmWidth, frmHeight, svyName, expire); } } } // Checks if cookies are enabled in browser. function cookiesAreEnabled() { setCookie( "foo", "bar" ); if ( getCookie( "foo" ) ) { deleteCookie( "foo" ); return true; } else { return false; } } function setCookie( name, value, expires, path, domain, secure ) { document.cookie =3D name + "=3D" + escape (value) + ( ( expires ) ? "; expires=3D" + expires : "" ) + ( ( path ) ? "; path=3D" + path : "" ) + ( ( domain ) ? "; domain=3D" + domain : "" ) + ( ( secure ) ? "; secure" : "" ); } function getCookie( name ) { var arg =3D name + "=3D"; var alen =3D arg.length; var clen =3D document.cookie.length; var i =3D 0; while ( i < clen ) { var j =3D i + alen; if ( document.cookie.substring(i, j) =3D=3D arg ) return = getCookieVal(j); i =3D document.cookie.indexOf( " ", i ) + 1; if ( i =3D=3D 0 ) break; } return null; } /** * Helper function for getCookie() */ function getCookieVal( offset ) { var endstr =3D document.cookie.indexOf ( ";", offset ); if ( endstr =3D=3D -1 ) endstr =3D document.cookie.length; return unescape( document.cookie.substring( offset, endstr ) ); } function deleteCookie( name, path, domain ) { if ( getCookie( name ) ) { document.cookie =3D name + "=3D" + ( ( path ) ? "; path=3D" + path : "" ) + ( ( domain ) ? "; domain=3D" + domain : "" ) + "; expires=3DThu, 01-Jan-70 00:00:01 GMT"; } } function createCookie(name, value, days) { if (days) { var date =3D new Date; date.setTime(date.getTime() + days * 24 * 60 * 60 * 1000); var expires =3D "; expires=3D" + date.toGMTString(); } else { var expires =3D ""; } document.cookie =3D name + "=3D" + value + expires + "; path=3D/" } function readCookie(name) { var nameEQ =3D name + "=3D"; var ca =3D document.cookie.split(";"); for (var i =3D 0; i < ca.length; i++) { var c =3D ca[i]; while (c.charAt(0) =3D=3D " ") { c =3D c.substring(1, c.length); } if (c.indexOf(nameEQ) =3D=3D 0) { return c.substring(nameEQ.length, c.length); } } return null; } ------=_NextPart_000_00C7_01C9CFBC.B014E350 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: http://ipinvite.iperceptions.com/Invitations/Javascripts/ip_Layer_Invitation_624.js var browser =3D new BrowserDetect();=20 var localSwitch=3D true; //var localSwitch=3D false; var _http =3D document.location.protocol; //var gJSFile =3D "javascript/Layer_624.js"; var gJSFile =3D _http + = "//ipinvite.iperceptions.com/Invitations/Javascripts/Layer_624.js"; function BrowserDetect() { ua =3D navigator.userAgent.toLowerCase(); this._string =3D = navigator.userAgent.toLowerCase(); this.isOpera=3D (ua.indexOf('opera') !=3D -1); this.isGecko=3D = (ua.indexOf('gecko') !=3D -1 && ua.indexOf('safari') =3D=3D -1); this.isIE=3D (ua.indexOf('msie') !=3D -1 && !this.isOpera && = (ua.indexOf('webtv') =3D=3D -1) );=20 this.isMozilla=3D (this.isGecko && ua.indexOf('gecko/') + 14 =3D=3D = ua.length); this.isFirefox=3D (ua.indexOf('firefox') !=3D -1); } function lScript(file) { var script =3D document.createElement('script'); script.type =3D 'text/javascript'; script.src =3D file;=09 if (typeof(script.onreadystatechange) =3D=3D 'undefined')=20 script.onload =3D function() { this.onload =3D null; };=20 else =20 script.onreadystatechange =3D function() { if (this.readyState !=3D = 'loaded' && this.readyState !=3D 'complete') return; = this.onreadystatechange =3D null; };=20 =09 document.getElementsByTagName('head')[0].appendChild(script); } function CC(name,value,days) { if (days) { var expDate =3D new Date(); = expDate.setTime(expDate.getTime()+(days*24*60*60*1000)); var expires =3D = "; expires=3D"+expDate.toUTCString(); }=09 else var expires =3D ""; document.cookie =3D = name+"=3D"+value+expires+"; path=3D/"; } function RC(NameOfCookie) { if (document.cookie.length > 0) { begin =3D document.cookie.indexOf(NameOfCookie+"=3D"); if (begin !=3D -1) { begin +=3D NameOfCookie.length+1; end =3D = document.cookie.indexOf(";", begin); =20 if (end =3D=3D -1) end =3D document.cookie.length; return unescape(document.cookie.substring(begin, end));=20 } } return null; } =09 function EC(name) { CC(name,"",-1); } function Exec() { var sCName =3D "IPERCEPTIONS_624"; var sCVal =3D = "IPERCEPTIONS_624_COOKIE"; var sCValRet; var tCVName=3D"IPERCEPTIONS_TEST"; var = tCVVal=3D"IPERCEPTIONS_TEST_COOKIE"; var tCVValRet; CC(tCVName,tCVVal,1); tCVValRet =3D RC(tCVName); =09 sCValRet =3D RC(sCName); EC(tCVName); var rndNum=3D Math.floor ((Math.random()*1050)); =09 if (rndNum < 2 && tCVValRet !=3D null && sCValRet =3D=3D null) { =20 CC(sCName, sCVal, SetVariantCookie()); lScript(gJSFile); } } if (localSwitch) { var GJS =3D _http + = "//ipinvite.iperceptions.com/Invitations/Javascripts/Layer_Global.js"; = lScript(GJS); }=09 =09 var SubscriberType =3D "1" // IsInstitution=3D1 ; IsSubscriber =3D 2 function SetVariantCookie() { var IsInstitution =3D document.getElementById('IsInstitution'); var IsSubscriber=3D document.getElementById('IsSubscriber'); if (IsInstitution !=3D null )=20 { if (IsInstitution.value.toLowerCase() =3D=3D"true") { = SubscriberType =3D 1; return 3; } } if ( IsSubscriber !=3D null) { if (IsSubscriber.value.toLowerCase() =3D=3D"true") { = SubscriberType =3D 2; return 90; } } SubscriberType =3D 1; =20 return 90; } ------=_NextPart_000_00C7_01C9CFBC.B014E350--

This file created with dataman.pl -- if it is empty, that's an upload error.