The prediction of streptococcal pharyngitis in adults.

The usefulness of clinical and laboratory findings for prediction of the presence of Group A streptococci on throat culture and of an increase in antistreptococcal antibodies was investigated in 693 adult patients. Several findings were shown to increase the likelihood of streptococcal isolation, alone and in combination: tonsillar exudate, tonsillar enlargement, tender anterior cervical adenopathy, myalgias, and a positive throat culture in the preceding year. Compared with a frequency of 9.7% in all patients, the probabilities of a positive culture were quite different (ranging from 2 to 53%) in subgroups of patients with different combinations of these clinical findings. The results of a leukocyte count and measurement of C-reactive protein added little additional predictive information. While clinical findings can never predict perfectly the results of a throat culture, they nevertheless can provide useful information--particularly in tending to "rule out" streptococcal infection--in adult patients with pharyngitis.

Serologic evidence of chlamydial and mycoplasmal pharyngitis in adults.

In a study of 763 adult patients we found serologic evidence of infection (a fourfold increase in antibodies) with Chlamydia trachomatis in 20.5 percent of the patients and with Mycoplasma pneumoniae in 10.6 percent, but with group A streptococcus (by culture) in only 9.1 percent. Pharyngitis, the most common problem for which patients seek medical care in the United States, may be caused by nonviral, potentially treatable organisms more often than had been suspected.

Heterophil antibody in adults with sore throat: frequency and clinical presentation.

We studied the prevalence and the clinical and laboratory findings of infectious mononucleosis in ambulatory adult patients with the presenting symptom of sore throat. Extensive clinical data, heterophil antibody test, and differential leukocyte count were obtained prospectively for 709 patients, aged 16 to 73 years, seen in four primary care settings. Heterophil tests were positive in 15 of 709 patients (2%); four of the 15 had greater than 10% atypical lymphocytes. No heterophil-negative patient had greater than 10% atypical lymphocytes. Heterophil-positive patients had mild disease; none was older than 40 years. Of 70 symptoms and signs evaluated, four were found significantly more often (p less than 0.005 for each) in the heterophil-positive patients: palatine petechiae, posterior auricular adenopathy, marked axillary adenopathy, and inguinal adenopathy. If any of these four easily shown physical findings was present, the likelihood of the patient having heterophil antibody was considerably increased; if absent, the probability of infectious mononucleosis was so low that not ordering a heterophil test or differential leukocyte count would have been efficient and safe.

Prevalence of pharyngeal gonorrhea in general medical patients with sore throats.

The prevalence of pharyngeal gonorrhea was investigated in a previously unstudied population: adult patients seeking care for sore throats and other symptoms of respiratory infection in general medical practices. The complaint of sore throat accounts for at least 15 million patient visits each year in the United States. A prospective study of 239 patients in three different settings revealed prevalences of 1% (95% confidence interval of 0.1-3%) in the 192 patients with sore throats, and of zero (95% confidence interval of zero to 3.4%) in 47 patients with respiratory infection symptoms other than sore throat. The data support the position that routine pharyngeal culturing for Neisseria gonorrhoeae for patients who have sore throats is not cost-efficient.

Protocols in ambulatory care.

Protocols offer a mechanism for bringing together two major trends in outpatient care. The first trend is the delegation of certain clinical tasks and responsibilities to health workers other than physicians, and to patients themselves. The second trend is the movement toward standard-setting, peer review, audit and quality assurance, and cost-effectiveness of medical practices. Most of the studies of the use of protocols have been with nurse practitioners, physician assistants, office nurses, and health workers. These studies indicate that non-physicians using protocols - in comparison with physicians using traditional methods - give care that is equally thorough, and that leads to comparably accurate diagnosis treatment, and appropriate referral to physicians. Additionally, health workers guided by protocols achieve relief of patients; symptoms and patient satisfaction, and provide care that is efficient in terms of practitioner time, medication, and test ordering. Consequently, health workers using protocols can reduce the cost of care. Protocols have been developed for use in out-patient areas in both developed and developing nations. Protocosl can also be easily audited as part of a quality assurance program, effecting even further saving in costly provider time.