Developing managed aquifer recharge (MAR) to augment irrigation water resources in the sand and gravel (Crag) aquifer of coastal Suffolk, UK.

Managed aquifer recharge (MAR) offers a potential innovative solution for addressing groundwater resource issues, enabling excess surface water to be stored underground for later abstraction. Given its favourable hydrogeological properties, the Pliocene sand and gravel (Crag) aquifer in Suffolk, UK, was selected for a demonstration MAR scheme, with the goal of supplying additional summer irrigation water. The recharge source was a 4.6 km drainage channel that discharges to the River Deben estuary. Trialling the scheme in June 2022, 12,262 m3 of source water were recharged to the aquifer over 12 days via a lagoon and an array of 565 m of buried slotted pipes. Groundwater levels were raised by 0.3 m at the centre of the recharge mound with an approximate radius of 250 m, with no detrimental impact on local water features observed. The source water quality remained stable during the trial with a mean chloride concentration (133 mg L-1) below the regulatory requirement (165 mg L-1). The fraction of recharge water mixing with the groundwater ranged from 69% close to the centre and 5% at the boundary of the recharge mound, leading to a reduction in nitrate-N concentration of 23.6 mg L-1 at the centre of the mound. During July-September 2022, 12,301 m3 of recharge water were abstracted from two, 18 m boreholes to supplement surface irrigation reservoirs during drought conditions. However, the hydraulic conductivity of the Crag aquifer (∼10 m day-1) restricted the yield and thereby reduced the economic viability of the scheme. Construction costs for the MAR system were comparatively low but the high costs of data collection and securing regulatory permits brought the overall capital costs to within 18% of an equivalent surface storage reservoir, demonstrating that market-based mechanisms and more streamlined regulatory processes are required to incentivise similar MAR schemes.

Headteachers' and chairs of governors' perspectives on adolescent obesity and its prevention in English secondary school settings.

BACKGROUND: Secondary schools are an important setting for preventing obesity in adolescence. Headteachers and chairs of governors are identified in national guidance as crucial stakeholders for school-based preventative action. Despite this, their views remain unexplored and unrepresented. METHODS: A sequential mixed method study was conducted. Semi-structured interviews were undertaken with a purposive sample of 22 secondary school headteachers and chairs of governors in England. Data were thematically analysed and informed the development of a descriptive cross-sectional survey, completed by 127 participants from the same population. RESULTS: Unhealthy dietary and sedentary behaviours were viewed as a more significant problem than adolescent obesity. Obesity was perceived as complex and multi-causal, and a range of stakeholders were deemed to have responsibility for its prevention, most notably parents. Support was identified for the role of secondary schools, although this was not an explicit priority and extensive internal and external barriers exist, which hinder preventative action. CONCLUSIONS: Whilst secondary school settings in England remain an important setting for the prevention of adolescent obesity, it is crucial for policy makers and public health professionals to recognize the factors affecting school leaders' ability and willingness to contribute to this agenda.

Dietary patterns of university students in the UK: a cross-sectional study.

BACKGROUND: University represents a key transition into adulthood for many adolescents but there are associated concerns about health and behaviours. One important aspect relates to diet and there is emerging evidence that university students may consume poor quality diets, with potential implications for body weight and long-term health. This research aimed to characterise dietary patterns of university students in the UK and their sociodemographic and lifestyle antecedents. METHODS: An online, cross-sectional survey was undertaken with a convenience sample of 1448 university students from five UK universities (King's College London, Universities of St Andrews, Southampton and Sheffield, and Ulster University). The survey comprised a validated food frequency questionnaire alongside lifestyle and sociodemographic questions. Dietary patterns were generated from food frequency intake data using principal components analysis. Nutrient intakes were estimated to characterise the nutrient profile of each dietary pattern. Associations with sociodemographic variables were assessed through general linear modelling. RESULTS: Dietary analyses revealed four major dietary patterns: 'vegetarian'; 'snacking'; 'health-conscious'; and 'convenience, red meat & alcohol'. The 'health-conscious' pattern had the most favourable micronutrient profile. Students' gender, age, year of study, geographical location and cooking ability were associated with differences in pattern behaviour. Female students favoured the 'vegetarian' pattern, whilst male students preferred the 'convenience, red meat & alcohol' pattern. Less healthful dietary patterns were positively associated with lifestyle risk factors such as smoking, low physical activity and take-away consumption. The health-conscious pattern had greatest nutrient density. The 'convenience, red meat & alcohol' pattern was associated with higher weekly food spending; this pattern was also identified most consistently across universities. Students reporting greater cooking ability tended towards the 'vegetarian' and 'health-conscious' patterns. CONCLUSIONS: Food intake varied amongst university students. A substantial proportion of students followed health-promoting diets, which had good nutrient profiles obviating a need for dietary intervention. However, some students consumed poor diets, incurred greater food costs and practised unfavourable lifestyle behaviours, which may have long-term health effects. University policy to improve students' diets should incorporate efforts to promote student engagement in cooking and food preparation, and increased availability of low cost healthier food items.

Search for Neutrinoless Double-ß Decay in

The Majorana Collaboration is operating an array of high purity Ge detectors to search for neutrinoless double-ß decay in ^{76}Ge. The Majorana Demonstrator comprises 44.1 kg of Ge detectors (29.7 kg enriched in ^{76}Ge) split between two modules contained in a low background shield at the Sanford Underground Research Facility in Lead, South Dakota. Here we present results from data taken during construction, commissioning, and the start of full operations. We achieve unprecedented energy resolution of 2.5 keV FWHM at Q_{ßß} and a very low background with no observed candidate events in 9.95 kg yr of enriched Ge exposure, resulting in a lower limit on the half-life of 1.9×10^{25} yr (90% C.L.). This result constrains the effective Majorana neutrino mass to below 240-520 meV, depending on the matrix elements used. In our experimental configuration with the lowest background, the background is 4.0_{-2.5}^{+3.1} counts/(FWHM t yr).

Observation of coherent elastic neutrino-nucleus scattering.

The coherent elastic scattering of neutrinos off nuclei has eluded detection for four decades, even though its predicted cross section is by far the largest of all low-energy neutrino couplings. This mode of interaction offers new opportunities to study neutrino properties and leads to a miniaturization of detector size, with potential technological applications. We observed this process at a 6.7σ confidence level, using a low-background, 14.6-kilogram CsI[Na] scintillator exposed to the neutrino emissions from the Spallation Neutron Source at Oak Ridge National Laboratory. Characteristic signatures in energy and time, predicted by the standard model for this process, were observed in high signal-to-background conditions. Improved constraints on nonstandard neutrino interactions with quarks are derived from this initial data set.

The utility of near-infrared spectroscopy in the regression of low-frequency physiological noise from functional magnetic resonance imaging data.

Near-infrared spectroscopy (NIRS) signals have been shown to correlate with resting-state BOLD-fMRI data across the whole brain volume, particularly at frequencies below 0.1Hz. While the physiological origins of this correlation remain unclear, its existence may have a practical application in minimizing the background physiological noise present in BOLD-fMRI recordings. We performed simultaneous, resting-state fMRI and 28-channel NIRS in seven adult subjects in order to assess the utility of NIRS signals in the regression of physiological noise from fMRI data. We calculated the variance of the residual error in a general linear model of the baseline fMRI signal, and the reduction of this variance achieved by including NIRS signals in the model. In addition, we introduced a sequence of simulated hemodynamic response functions (HRFs) into the resting-state fMRI data of each subject in order to quantify the effectiveness of NIRS signals in optimizing the recovery of that HRF. For comparison, these calculations were also performed using a pulse and respiration RETROICOR model. Our results show that the use of 10 or more NIRS channels can reduce variance in the residual error by as much as 36% on average across the whole cortex. However the same number of low-pass filtered white noise regressors is shown to produce a reduction of 19%. The RETROICOR model obtained a variance reduction of 6.4%. Our HRF simulation showed that the mean-squared error (MSE) between the recovered and true HRFs is reduced by 21% on average when 10 NIRS channels are applied and by introducing an optimized time lag between the NIRS and fMRI time series, a single NIRS channel can provide an average MSE reduction of 14%. The RETROICOR model did not provide a significant change in MSE. By each of the metrics calculated, NIRS recording is shown to be of significant benefit to the regression of low-frequency physiological noise from fMRI data.

Transient haemodynamic events in neurologically compromised infants: a simultaneous EEG and diffuse optical imaging study.

We describe a series of novel simultaneous EEG and diffuse optical imaging studies of newborn infants. These experiments provide evidence of large, transient haemodynamic events which occur repeatedly and consistently within and across several infants with neurological damage, all of whom were diagnosed with seizures. A simple but independent process of rejecting artifacts and identifying events within diffuse optical imaging data is described, and this process is applied to data from 4 neurologically damaged neonates and from 19 healthy, age-matched controls. This method results in the consistent identification of events in three out of four of the neurologically damaged infant group which are dominated by a slow (>30s) and significant increase in oxyhaemoglobin concentration, followed by a rapid and significant decrease before a slow return to baseline. No comparable events are found in any of our control data sets. The importance and physiological implications of our findings are discussed, as is the suitability of a combined EEG and diffuse optical imaging approach to the study and monitoring of neonatal brain injury.

A tissue equivalent phantom for simultaneous near-infrared optical tomography and EEG.

We describe a phantom which enables EEG and near-infrared optical tomography to be performed simultaneously over the same volume. The phantom provides a surface electrical contact impedance comparable to that of the human scalp, whilst also possessing an optical scattering coefficient and electrical conductivity equivalent to that of brain tissue. The construction of the phantom is described, as is the resulting simultaneous EEG and near infrared optical tomography experiment, which, to our knowledge, is the first performed on a scale comparable to that of the infant human brain. This imaging experiment successfully shows the suitability of this phantom construction for the assessment of simultaneous EEG and near infrared optical tomography systems.

Solo doctors and ethical isolation.

This paper uses the case of solo doctors to explore whether working in relative isolation from one's peers may be detrimental to ethical decision-making. Drawing upon the relevance of communication and interaction for ethical decision-making in the ethical theories of Habermas, Mead and Gadamer, it is argued that doctors benefit from ethical discussion with their peers and that solo practice may make this more difficult. The paper identifies a paucity of empirical research related to solo practice and ethics but draws upon more general medical ethics research and a study that identified ethical isolation among community pharmacists to support the theoretical claims made. The paper concludes by using the literary analogy of Soderberg's Doctor Glas to illustrate the issues raised and how ethical decision-making in relative isolation may be problematical.

A tissue-like optically turbid and electrically conducting phantom for simultaneous EEG and near-infrared imaging.

We describe a phantom for simultaneous electroencephalography (EEG) and near-infrared imaging which consists of a solid, optically turbid and electrically conducting interface enclosing a tissue-mimicking aqueous scattering solution. The interface provides an electrical contact impedance comparable to that of the human scalp while the phantom as a whole has optical properties and electrical conductivity equivalent to that of head tissue. The construction is described and our design is evaluated experimentally using an optically absorbing target which also provides an EEG-equivalent electric field source. The results of this simultaneous EEG and near-infrared imaging experiment are presented.

'Islands' and 'doctor's tool': the ethical significance of isolation and subordination in UK community pharmacy.

Empirical ethics research is increasingly valued in offering insights into how ethical problems and decision-making occur in healthcare. In this article, the findings of a qualitative study of the ethical problems and decision-making of UK community pharmacists are presented, and it is argued that the identified themes of pharmacists' relative isolation from others and their subordination to doctors are ethically significant. Semi-structured interviews were conducted with 23 community pharmacists in England, UK. Analysis of interviews revealed that isolation involved separation of pharmacists from their peers, other healthcare professionals, patients and customers. Such isolation is argued to be inimical to ethical practice - impeding ethical discourse as understood by Habermas, resulting in a form of anomie that inhibits the transmission of professional values, leading to a lack of proximity between pharmacist and patient or customer that may impede ethical relationships and resulting, psychologically, in less ethical concern for those who are less close. Pharmacists' subordination to doctors not only precipitated some ethical problems but also allowed some pharmacists to shift ethical responsibility to a prescribing doctor, as in the case of emergency hormonal contraception. The emergence of atrocity stories further supports a culture of subordination that may cause ethical problems. The study has implications for community pharmacy practice in terms of supervision issues, developments such as prescribing responsibilities and how ethical values can be taught and communicated. The potential for isolation and subordination in other healthcare professions, and resultant ethical problems, may also need to be addressed and researched.

Design and evaluation of a probe for simultaneous EEG and near-infrared imaging of cortical activation.

We present a novel probe design which enables simultaneous electroencephalography (EEG) and near-infrared (NIR) optical imaging to be performed in a manner which is easy to apply, allows for optimum co-registration of the two forms of data and maximizes the number of sensors which can be applied to a given area. Our probe design is evaluated using a dual-modality, tissue-mimicking phantom and by performing a simple functional activation study of the human motor cortex. We successfully acquired NIR optical and EEG data simultaneously for both our phantom and our human motor cortex experiments, clearly demonstrating the effectiveness and suitability of our 'opto-electrode'.

Ethical decision-making, passivity and pharmacy.

BACKGROUND: Increasing interest in empirical ethics has enhanced understanding of healthcare professionals' ethical problems and attendant decision-making. A four-stage decision-making model involving ethical attention, reasoning, intention and action offers further insights into how more than reasoning alone may contribute to decision-making. AIMS: To explore how the four-stage model can increase understanding of decision-making in healthcare and describe the decision-making of an under-researched professional group. METHODS: 23 purposively sampled UK community pharmacists were asked, in semi-structured interviews, to describe ethical problems in their work and how they were resolved. Framework analysis of transcribed interviews utilised the four decision-making stages, together with constant comparative methods and deviant-case analysis. RESULTS: Pharmacists were often inattentive and constructed problems in legal terms. Ethical reasoning was limited, but examples of appeals to consequences, the golden rule, religious faith and common-sense experience emerged. Ethical intention was compromised by frequent concern about legal prosecution. Ethical inaction was common, typified by pharmacists' failure to report healthcare professionals' bad practices, and ethical passivity emerged to describe these negative examples of the four decision-making stages. Pharmacists occasionally described more ethically active decision-making, but this often involved ethical uncertainty. DISCUSSION: The four decision-making stages are a useful tool in considering how healthcare professionals try to resolve ethical problems in practice. They reveal processes often ignored in normative theories, and their recognition and the emergence of ethical passivity indicates the complexity of decision-making in practice. Ethical passivity may be deleterious to patients' welfare, and concerns emerge about improving pharmacists' ethical training and promoting ethical awareness and responsibility.

A new prescription for empirical ethics research in pharmacy: a critical review of the literature.

Empirical ethics research is increasingly valued in bioethics and healthcare more generally, but there remain as yet under-researched areas such as pharmacy, despite the increasingly visible attempts by the profession to embrace additional roles beyond the supply of medicines. A descriptive and critical review of the extant empirical pharmacy ethics literature is provided here. A chronological change from quantitative to qualitative approaches is highlighted in this review, as well as differing theoretical approaches such as cognitive moral development and the four principles of biomedical ethics. Research with pharmacy student cohorts is common, as is representation from American pharmacists. Many examples of ethical problems are identified, as well as commercial and legal influences on ethical understanding and decision making. In this paper, it is argued that as pharmacy seeks to develop additional roles with concomitant ethical responsibilities, a new prescription is needed for empirical ethics research in pharmacy-one that embraces an agenda of systematic research using a plurality of methodological and theoretical approaches to better explore this under-researched discipline.

Interaction between bunk management and monensin concentration on finishing performance, feeding behavior, and ruminal metabolism during an acidosis challenge with feedlot cattle.

Two commercial feedlot experiments and a metabolism study were conducted to evaluate the effects of monensin concentrations and bunk management strategies on performance, feed intake, and ruminal metabolism. In the feedlot experiments, 1,793 and 1,615 steers were used in Exp. 1 and 2, respectively, in 18 pens for each experiment (six pens/treatment). Three treatments were evaluated: 1) ad libitum bunk management with 28.6 mg/kg monensin and clean bunk management strategies with either 2) 28.6 or 3) 36.3 mg/kg monensin. In both experiments, 54 to 59% of the clean bunk pens were clean at targeted clean time, or 2200, compared with 24 to 28% of the ad libitum pens. However, only 13% of the pens were clean by 2000 in Exp. 1 (summer), whereas 44% of the pens in Exp. 2 (winter) were clean by 2000. In Exp. 1, bunk management and monensin concentration did not affect carcass-adjusted performance. In Exp. 2, steers fed ad libitum had greater DMI (P < 0.01) and carcass-adjusted ADG (P < 0.01) but feed efficiency (P > 0.13) similar to that of clean bunk-fed steers. Monensin concentration had no effect on carcass-adjusted performance (P > 0.20) in either experiment. A metabolism experiment was conducted with eight fistulated steers in a replicated 4 x 4 Latin square acidosis challenge experiment. An acidosis challenge was imposed by feeding 125% of the previous day's DMI, 4 h later than normal. Treatments consisted of monensin concentrations (mg/kg) of 0, 36.7, 48.9, or 36.7 until challenged and switched to 48.9 on the challenge day and 4 d following. Each replicate of the Latin square was managed with separate bunk management strategies (clean bunk or ad libitum). Feeding any concentration of monensin increased number of meals and decreased DMI rate (%/h) (P < 0.12) for the 4 d following the acidosis challenge. Meal size, pH change, and pH variance were lower (P < 0.10) for steers fed monensin with clean bunk management. However, no monensin effect was observed for steers fed ad libitum. Bunk management strategy has the potential to decrease DMI and ADG when steers managed on a clean bunk program are restricted relative to traditional, ad libitum bunk programs. Monensin helps control intake patterns for individuals, but increasing concentration above currently approved levels in this study seemed to have little effect.

Effect of corn processing on starch digestion and bacterial crude protein flow in finishing cattle.

Six ruminally and duodenally cannulated yearling steers (523 kg) were used in a replicated 3 x 3 Latin square design experiment to study the effects of corn processing on nutrient digestion, bacterial CP production, and ruminal fermentation. Dietary treatments consisted of 90% concentrate diets that were based on dry-rolled (DRC), high-moisture (HMC), or steam-flaked (SFC) corn. Each diet contained 2.0% urea (DM basis) as the sole source of supplemental nitrogen. Each period lasted 17 d, with d 1 through 14 for diet adaptation and d 15 through 17 for fecal, duodenal, and ruminal sampling. Dry matter and OM intakes were similar for DRC and SFC but were approximately 15% higher (P < 0.05) for HMC. True ruminal OM digestibilities were 18 and 10% greater (P < 0.05) for HMC than for DRC or SFC, respectively. Ruminal starch digestibilities were similar between HMC and SFC and were approximately 19% greater (P < 0.05) than DRC. Postruminal OM digestibility was similar among treatments; however, postruminal starch digestibility was 15% greater (P < 0.05) for SFC than for DRC or HMC, which were similar. Total-tract DM and OM digestibilities were similar between HMC and SFC and were 4% greater (P < 0.05) than DRC. Likewise, total-tract starch digestibilities were similar between HMC and SFC and were 3% greater (P < 0.05) than DRC. Bacterial CP flow to the duodenum was 29% greater (P < 0.05) for HMC than for DRC or SFC, which were similar. Bacterial N efficiencies were similar among treatments. Based on bacterial CP flow from the rumen, we estimate that dietary DIP requirements are approximately 12% higher for HMC-based diets than for DRC or SFC-based diets, which were similar.

Effect of corn processing on degradable intake protein requirement of finishing cattle.

Three finishing trials were conducted to determine effect of corn processing on degradable intake protein requirement (DIP) of feedlot cattle. In Trial 1, 252 steers were fed 90% concentrate, high-moisture corn-based diets that contained 0, 0.4, 0.8, or 1.2% urea (DM basis) to provide dietary DIP values of 7.0, 8.2, 9.3, and 10.5% of DM, respectively. Nonlinear analysis predicted maximal feed efficiency at 10.2% dietary DIP (95% confidence interval was 9.9 to 13.3%). In Trial 2, 264 steers were fed 90% concentrate, steam-flaked corn-based diets that contained 0, 0.4, 0.8, 1.2, 1.6, or 2.0% urea (DM basis) to provide dietary DIP values of 4.7, 5.8, 7.0, 8.2, 9.3, and 10.5% of DM, respectively. Nonlinear analysis predicted maximal feed efficiency at 7.1% dietary DIP (95% confidence interval was 7.0 to 7.2%). In Trial 3, 90 individually-fed steers were fed 90% concentrate, dry-rolled, high-moisture, or steam-flaked corn-based diets. Urea was factored across diets at 0, 0.5, 1.0, or 2.0% of DM to provide dietary DIP values of 4.8. 6.3, 7.8, 9.2, and 10.7% for dry-rolled, 6.7,8.1,9.6, 11.1, and 12.5% for high-moisture, and 4.7, 6.1, 7.6, 9.0, and 10.5% for steam-flaked corn-based diets, respectively. For the dry-rolled corn-based diet, nonlinear analysis could not predict a requirement because feed efficiency was not improved beyond the first increment of dietary DIP, suggesting that the DIP requirement was met at 6.3% of DM. For the high-moisture corn-based diet, nonlinear analysis predicted maximal feed efficiency at 10.0% dietary DIP (95% confidence interval was 9.2 to 11.3%). For the steam-flaked corn based diet, nonlinear analysis predicted maximal feed efficiency at 9.5% dietary DIP (95% confidence interval was 9.2 to 9.5%). Our estimate of the DIP requirement for dry-rolled corn-based diets (6.3%) agrees well with past research and predicted values. Our estimate of the DIP requirement for high-moisture corn-based diets (10.1%) was very consistent between trials and higher than predicted. Our estimates of the DIP requirement for steam-flaked corn-based diets varied from 7.1 to 9.5%, with an average of 8.3% of dietary DM.

Differential transduction efficiency of SCID-repopulating cells derived from umbilical cord blood and granulocyte colony-stimulating factor-mobilized peripheral blood.

The gene transfer efficiency into nonobese diabetic/severe combined immunodeficient (NOD/SCID)-repopulating cells (SRCs) derived from umbilical cord blood (UCB) (n = 11 NOD/SCID mice) and granulocyte-colony stimulating factor (G-CSF)-mobilized peripheral blood (MPB) (n = 64 NOD/SCID mice) was compared using a clinically relevant protocol and a retrovirus vector expressing the enhanced green fluorescent protein (EGFP). At 6-9 weeks after transplantation, the frequency of transduced human cells in the bone marrow (BM) (40.5% +/- 2.4% [mean +/- SE]) and spleen (SPL) (36.4% +/- 3.2%) in recipients of UCB cells was significantly higher (p < 0.001) than that observed in the BM (2.2% +/- 1.8%) and SPL (2.0% +/- 2.6%) in recipients of MPB. In subsequent studies, MPB was cultured for 2-8 days in cytokines prior to transduction to determine if longer prestimulation was required for optimal gene transfer. A significant increase in gene transfer into CD45(+) human cells and clonogenic cells derived from MPB SRCs was observed when cells were prestimulated for 6 days compared to 2 days prior to transduction (p = 0.019). However, even after 6 days of prestimulation, transduction was still significantly less than UCB. A substantial discrepancy exists in the ability to introduce genes effectively via retrovirus vectors into SRCs derived from MPB as compared to UCB.

Principles of appropriate antibiotic use for treatment of acute respiratory tract infections in adults: background, specific aims, and methods.

The need to decrease excess antibiotic use in ambulatory practice has been fueled by the epidemic increase in antibiotic-resistant Streptococcus pneumoniae. The majority of antibiotics prescribed to adults in ambulatory practice in the United States are for acute sinusitis, acute pharyngitis, acute bronchitis, and nonspecific upper respiratory tract infections (including the common cold). For each of these conditions--especially colds, nonspecific upper respiratory tract infections, and acute bronchitis (for which routine antibiotic treatment is not recommended)--a large proportion of the antibiotics prescribed are unlikely to provide clinical benefit to patients. Because decreasing community use of antibiotics is an important strategy for combating the increase in community-acquired antibiotic-resistant infections, the Centers for Disease Control and Prevention convened a panel of physicians representing the disciplines of internal medicine, family medicine, emergency medicine, and infectious diseases to develop a series of "Principles of Appropriate Antibiotic Use for Treatment of Acute Respiratory Tract Infections in Adults." These principles provide evidence-based recommendations for evaluation and treatment of adults with acute respiratory illnesses.This paper describes the background and specific aims of and methods used to develop these principles. The goal of the principles is to provide clinicians with practical strategies for limiting antibiotic use to the patients who are most likely to benefit from it. These principles should be used in conjunction with effective patient educational campaigns and enhancements to the health care delivery system that facilitate nonantibiotic treatment of the conditions in question.

Principles of appropriate antibiotic use for acute pharyngitis in adults: background.

The following principles of appropriate antibiotic use for adults with acute pharyngitis apply to immunocompetent adults without complicated comorbid conditions, such as chronic lung or heart disease, and history of rheumatic fever. They do not apply during known outbreaks of group A streptococcus. 1. Group A beta-hemolytic streptococcus (GABHS) is the causal agent in approximately 10% of adult cases of pharyngitis. The large majority of adults with acute pharyngitis have a self-limited illness, for which supportive care only is needed. 2. Antibiotic treatment of adult pharyngitis benefits only those patients with GABHS infection. All patients with pharyngitis should be offered appropriate doses of analgesics and antipyretics, as well as other supportive care. 3. Limit antibiotic prescriptions to patients who are most likely to have GABHS infection. Clinically screen all adult patients with pharyngitis for the presence of the four Centor criteria: history of fever, tonsillar exudates, no cough, and tender anterior cervical lymphadenopathy (lymphadenitis). Do not test or treat patients with none or only one of these criteria, since these patients are unlikely to have GABHS infection. For patients with two or more criteria the following strategies are appropriate: (a) Test patients with two, three, or four criteria by using a rapid antigen test, and limit antibiotic therapy to patients with positive test results; (b) test patients with two or three criteria by using a rapid antigen test, and limit antibiotic therapy to patients with positive test results or patients with four criteria; or (c) do not use any diagnostic tests, and limit antibiotic therapy to patients with three or four criteria. 4. Throat cultures are not recommended for the routine primary evaluation of adults with pharyngitis or for confirmation of negative results on rapid antigen tests when the test sensitivity exceeds 80%. Throat cultures may be indicated as part of investigations of outbreaks of GABHS disease, for monitoring the development and spread of antibiotic resistance, or when such pathogens as gonococcus are being considered. 5. The preferred antibiotic for treatment of acute GABHS pharyngitis is penicillin, or erythromycin in a penicillin-allergic patient.