Antibiotics for tonsillitis: should the emergency department emulate general practice?

OBJECTIVES: To determine whether antibiotics are prescribed appropriately for acute tonsillitis in an emergency department (ED). METHODS: Cross-sectional observational study in large district general hospital in London. Patients diagnosed and coded with 'acute tonsillitis' in the ED over a 3-month period in 2015. Medical records were reviewed for Centor criteria, which is a clinical scoring system to guide antibiotic prescribing in UK general practice. Drug charts were reviewed for the specific antibiotic(s) prescribed, and throat swab (TS) cultures were recorded. RESULTS: 273/389 patients with tonsillitis were analysed-186 children, 87 adults. Exclusions were missing patient records (86), patients had/awaiting tonsillectomy (22), receiving antibiotics (6) and immunocompromised (2). Centor score (CS) was not recorded for any patient. Based on derived CS from documented signs/symptoms, antibiotics were prescribed inappropriately to 196/273 patients (80%; 95% CI 74% to 85%) including broad-spectrum antibiotics to 25%. These included co-amoxiclav (18%), amoxicillin (6%), azithromycin (0.5%) and ceftriaxone (0.5%). TSs were taken in 66/273(24%) patients; 10/66 were positive for group A streptococcus (GAS). However, 48/56 GAS negative patients were prescribed antibiotics. CONCLUSIONS: CS was not being used in the ED to guide antibiotic prescribing for acute tonsillitis. Antibiotic prescribing was based on clinical judgement. Based on derived CS (<3), 80% of patients were inappropriately prescribed antibiotics, particularly broad-spectrum antibiotics. Further studies need to assess use of CS to guide antibiotic prescription in ED. TSs were commonly performed in the ED but did not either improve diagnosis or guide antibiotic prescription.

Sleep's influence on a reflexive form of memory that does not require voluntary attention.

STUDY OBJECTIVES: Studies to date have examined the influence of sleep on forms of memory that require voluntary attention. The authors examine the influence of sleep on a form of memory that is acquired by passive viewing. DESIGN: Induction of the McCollough effect, and measurement of perceptual color bias before and after induction, and before and after intervening sleep, wake, or visual deprivation. SETTING: Sound-attenuated sleep research room. PARTICIPANTS: 13 healthy volunteers (mean age = 23 years; age range = 18-31 years) with normal or corrected-to-normal vision. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: ) ENCODING: sleep preceded adaptation. On separate nights, each participant slept for an average of 0 (wake), 1, 2, 4, or 7 hr (complete sleep). Upon awakening, the participant's baseline perceptual color bias was measured. Then, he or she viewed an adapter consisting of alternating red/horizontal and green/vertical gratings for 5 min. Color bias was remeasured. The strength of the aftereffect is the postadaptation color bias relative to baseline. A strong orientation contingent color aftereffect was observed in all participants, but total sleep duration (TSD) prior to the adaptation did not modulate aftereffect strength. Further, prior sleep provided no benefit over prior wake. Retention: sleep followed adaptation. The procedure was similar except that adaptation preceded sleep. Postadaptation sleep, irrespective of its duration (1, 3, 5, or 7 hr), arrested aftereffect decay. By contrast, aftereffect decay was arrested during subsequent wake only if the adapted eye was visually deprived. CONCLUSIONS: Sleep as well as passive sensory deprivation enables the retention of a color aftereffect. Sleep shelters this reflexive form of memory in a manner akin to preventing sensory interference.

Practice makes imperfect: restorative effects of sleep on motor learning.

Emerging evidence suggests that sleep plays a key role in procedural learning, particularly in the continued development of motor skill learning following initial acquisition. We argue that a detailed examination of the time course of performance across sleep on the finger-tapping task, established as the paradigm for studying the effect of sleep on motor learning, will help distinguish a restorative role of sleep in motor skill learning from a proactive one. Healthy subjects rehearsed for 12 trials and, following a night of sleep, were tested. Early training rapidly improved speed as well as accuracy on pre-sleep training. Additional rehearsal caused a marked slow-down in further improvement or partial reversal in performance to observed levels below theoretical upper limits derived on the basis of early pre-sleep rehearsal. This decrement in learning efficacy does not occur always, but if and only if it does, overnight sleep has an effect in fully or partly restoring the efficacy and actual performance to the optimal theoretically achieveable level. Our findings re-interpret the sleep-dependent memory enhancement in motor learning reported in the literature as a restoration of fatigued circuitry specialized for the skill. In providing restitution to the fatigued brain, sleep eliminates the rehearsal-induced synaptic fatigue of the circuitry specialized for the task and restores the benefit of early pre-sleep rehearsal. The present findings lend support to the notion that latent sleep-dependent enhancement of performance is a behavioral expression of the brain's restitution in sleep.