Reconsidering sore throats. Part I: Problems with current clinical practice.

OBJECTIVE: To provide evidence-based answers to clinical questions posed by family physicians about Group A streptococcus pharyngitis and to further understanding of why management is controversial. QUALITY OF EVIDENCE: Evidence from randomized trials was not found for most questions. The most critical information came from high-quality community prevalence studies and criterion standard studies of physician clinical judgement. MAIN FINDINGS: Expert recommendations for physician management are not likely to help prevent rheumatic fever, as most people with sore throats do not seek medical care. Current clinical practices result in overuse of antibiotics because accuracy of clinical judgment is limited. CONCLUSIONS: Costs associated with visits for upper respiratory infections as well as increasing antibiotic resistance necessitate reconsidering the current clinical approach. An alternative management strategy is presented in part 2.

Reconsidering sore throats. Part 2: Alternative approach and practical office tool.

OBJECTIVE: To identify a management approach for Group A streptococcal (GAS) pharyngitis that would address overuse of antibiotics and could be implemented immediately. QUALITY OF EVIDENCE: No randomized, controlled trials were found; four observational studies met our criteria: simplicity, discrimination ability for GAS pharyngitis compared with throat culture, and validation in a different patient population. Only one scoring system fulfilled all three criteria. MAIN FINDINGS: Formal clinical scoring systems have the potential to improve family physicians' ability to identify and manage GAS pharyngitis. One system had been sufficiently validated to support its use in clinical practice. Four clinical characteristics (no cough, fever higher than 38 degrees C, exudate, and tender cervical nodes) linked to explicit management decisions form the basis for a sore throat score. CONCLUSIONS: Use of a clinical score for management of GAS pharyngitis can be recommended on the basis of the rarity of rheumatic fever in modern society, the resources devoted to management of upper respiratory tract illnesses, the volume of antibiotics prescribed, and the emergence of antibiotic resistance as a growing health issue.

Discharge of superior collicular neurons during saccades made to moving targets.

1. The discharge of neurons in the deeper layers of the monkey superior colliculus was recorded during saccades made to stationary and to smoothly moving visual targets. 2. All neurons that discharged for saccades made to stationary targets also discharged during saccades made to moving targets, but there was a systematic shift in the saccade vector yielding maximal activity (i.e. center of the movement field) of collicular neurons for the latter class of movements. The shift moved the center of the movement fields toward larger-amplitude pursuit saccades for target motion away from the fovea, in comparison with saccades made to stationary targets. However, the discharge at the center of the movement field for pursuit saccades was 14% lower when averaged over the sample of recorded cells. 3. The saccades made during pursuit tracking of moving visual stimuli have different dynamics than saccades made to stationary targets. At similar amplitudes pursuit saccades are slower, and their velocity profiles often show secondary velocity peaks or inflection points and have longer-duration decelerating phases. 4. The combined experimental observations of a change in saccade dynamics and the shift in movement fields in collicular neurons for pursuit saccades are compatible with the hypothesis that saccades made to moving targets are controlled by neural processing in two partially separate pathways. In this theory, one path is concerned with correction of a presaccadic retinal position error (a path that includes the colliculus) and another path is concerned with position extrapolations based on the velocity of the moving target (a path that does not include the colliculus).