Biomedical subjects

J van der Palen

Publications and source records attributed to J van der Palen.

At least 19 recordsLinked to original sources

PubMed2006

Towards a VR trainer for EVAR treatment.

Endovascular repair of aortic abdominal aneurysms (AAA) is more and more becoming part of clinical practice. Up to approximately 30 clinical procedures however are necessary to obtain the surgical skills to make the procedure reliable and safe. The current study aims to generate a VR trainer to speed up the training process of experienced vascular surgeons to become experienced EVAR (endovascular AAA repair) surgeons by introducing a VR environment. This manuscript describes the contents and validation of the first step in the VREST - EVAR trainer, i.e. the proper definition of the knowledge and skills that need to be transferred.

Aortic Aneurysm, Abdominal↗

PubMed2006

Capecitabine, epirubicin and cisplatin in the treatment of oesophagogastric adenocarcinoma.

BACKGROUND: Inoperable or metastatic oesophagogastric adenocarcinoma has a poor prognosis. From the many different chemotherapeutic regimens used in the past, a combination of epirubicin, cisplatin and continuous 5-fluorouracil infusion (ECF) showed a consistent response rate of +/- 50% with acceptable toxicity. Continuous 5-FU infusion may be replaced by oral fluoropyrimidines. Here we evaluate treatment with epirubicin and cisplatin combined with oral capecitabine (ECC), replacing intravenous 5-FU infusion. METHODS: Retrospectively, we analysed 23 consecutive patients who were treated with epirubicin, cisplatin and oral capecitabine for inoperable or metastatic oesophagogastric adenocarcinoma during 2002 and 2003. RESULTS: The overall response rate was 57%; another 26% achieved stable disease and only 17% had progressive disease. The median duration of response was 6.4 months; the median survival was 9.0 months. Previously treated patients (n=10) had a significantly worse overall response rate (20%) compared with previously untreated patients (85%). A nonsignificant difference in median survival was found between these groups (3.9 vs 9.8 months in previously treated vs untreated patients). An acceptable incidence of grade 3 and 4 toxicity was found. CONCLUSION: Capecitabine in combination with epirubicin and cisplatin is an effective and safe alternative to ECF, without the risks of a continuous venous access.

Adenocarcinoma↗

PubMed2005

Cost effectiveness of inhaled steroid withdrawal in outpatients with chronic obstructive pulmonary disease.

BACKGROUND: The evidence for the effectiveness and safety of inhaled corticosteroids (ICS) in chronic obstructive pulmonary disease (COPD) is inconclusive. This study determined the cost effectiveness of withdrawing fluticasone propionate (FP) in outpatients with COPD. METHODS: The cost effectiveness analysis was based on a randomised, placebo controlled FP withdrawal study. After a 4 month run in period on FP, patients were randomly assigned to continue FP 500 microg twice daily or to receive placebo for 6 months. A decision analytical model evaluated the 6 month incremental cost effectiveness of the ICS versus ICS withdrawal strategy. One way sensitivity analyses and a Monte Carlo simulation were performed to evaluate the robustness of the findings. RESULTS: The average patient with COPD in the FP group generated 511 in direct medical costs, including 238 for FP. The cost of the placebo strategy was 456. The higher direct drug cost of 212 per patient for the FP strategy during the 6 month follow up period compared with the placebo group was partially offset by a lower exacerbation and hospital admission cost of 157. The 6 month incremental cost effectiveness of the FP strategy compared with placebo was 110 per exacerbation prevented and 1286 per hospital admission prevented. CONCLUSIONS: Over a 6 month period, withdrawing FP in a pre-selected trial population of COPD patients led to absolute cost savings but with a higher rate of exacerbations and hospital admissions.

Administration, Inhalation↗

PubMed2005

Performance of methicillin-resistant Staphylococcus aureus protocols in Dutch hospitals.

BACKGROUND: Although numerous studies have stressed the importance of compliance with methicillin-resistant Staphylococcus aureus (MRSA) protocols with regard to cost reduction and a safer environment for health care workers and patients, an evaluation of the usability of the protocols themselves is lacking. In this study, we evaluated the usability and performance of those protocols. METHODS: The performance of MRSA protocols was examined in 5 Dutch hospitals by means of a questionnaire (n = 63), followed by a practical test (n = 50), in a stratified random sample of 3 types of health care workers (physicians, nursing staff, and cleaning personnel). The questionnaire consisted of constructs related to exposure to risk, risk perception, knowledge of and attitude toward the protocols and safety preventive measures, self-reported behavior, and social and organizational support. The practical test consisted of "what if" scenarios that simulate the actual use of the protocol as a guideline for solving infection problems. The health care workers were asked to verbalize their thoughts and actions while using the protocol. RESULTS: The questionnaire demonstrated adequate knowledge of and attitude toward the MRSA protocols. However, the practical test revealed that the majority of respondents had problems with the accessibility, comprehensibility, applicability, and acceptability of the protocols. Problems not only occurred because of unclear information about the preventive measures and a poor infrastructure but also because of preventive measures that conflict with principles in providing care. CONCLUSION: The protocols do not reflect the practical needs of the health care workers. In view of the different decisions that health care workers have to take in various circumstances, it would be impracticable to use the same MRSA protocol for all hospital staff. Finally, the practical test provided more reliable results than the questionnaire.

Adult↗

PubMed2004

Outcome of abdominal aortic aneurysm repair in the era of endovascular treatment.

BACKGROUND: The effect on outcome of the introduction of endovascular techniques for the exclusion of abdominal aortic aneurysm (AAA) is largely unknown. The aim of the study was to contrast the early and mid-term outcome after open and endovascular AAA repair. METHODS: Consecutive patients who underwent transfemoral endovascular aneurysm repair (EVAR; n = 93) between April 1998 and January 2003, or conventional open aneurysm repair in the time intervals before (n = 113) and after (n = 82) the introduction of EVAR were studied. All data were collected prospectively. All patients underwent elective and primary repair. Patient survival was calculated by the Kaplan-Meier method and the possible predictive value of more than 25 perioperative variables on five outcome variables (length of intensive care unit stay, morbidity, and 30-day, 6-month and overall mortality) was assessed by multivariate analysis. RESULTS: There were no differences in risk profiles between the three groups. Selection for EVAR was based on anatomical grounds only. All five outcome variables were significantly better with EVAR than either former or recent open repair. The only significant predictors of failure were advanced age and the need to perform an additional procedure for former open repair; hypertension and the preoperative use of anticoagulants for recent open repair; and renal insufficiency and pulmonary insufficiency for EVAR. CONCLUSION: EVAR offered considerable benefits compared with conventional open repair at early and mid-term follow-up, which was not explained by selection of patients with a favourable risk profile. In the current era, in which patients are selected for open repair as a consequence of unfavourable anatomy, morbidity and mortality rates following conventional open treatment of AAA have increased at early and mid-term, but not at long-term, follow-up.

Aged↗

PubMed2004

The distal radial fracture in elderly women and the bone mineral density of the lumbar spine and hip.

The incidence of distal radial fractures in elderly women is high and is associated with osteoporosis and hip fracture. Osteoporosis can be detected by measuring the bone mineral density (BMD) of the lumbar spine or hip with dual energy X-ray absorptiometry. Low BMD of the lumbar spine or hip is a strong predictor for future vertebral deformities and hip fractures. At present, elderly women with a distal radial fracture are not investigated for osteoporosis on a routine basis. The BMD of the lumbar spine and hip were assessed in 94 women (mean age, 69 years) with a distal radial fracture. A low BMD was found in 85% of the patients, and osteoporosis was diagnosed in 51%. The mean BMD decreased by 0.04 SD per year and there was a significant relationship between post-menopausal status and decreased BMD of the hip. The BMD in patients treated with bisphosphonate medication increased significantly in 1 year. As more than half of the elderly women with a distal radial fracture have osteoporotic BMD values for the lumbar spine or hip, it is our opinion that such patients should be screened for osteoporosis.

Aged↗

PubMed2004

Respiratory muscle strength and the risk of incident cardiovascular events.

BACKGROUND: Maximal inspiratory pressure (MIP) is a measure of inspiratory muscle strength. The prognostic importance of MIP for cardiovascular events among elderly community dwelling individuals is unknown. Diminished forced vital capacity (FVC) is a risk factor for cardiovascular events which remains largely unexplained. METHODS: MIP was measured at the baseline examination of the Cardiovascular Health Study. Participants had to be free of prevalent congestive heart failure (CHF), myocardial infarction (MI), and stroke. RESULTS: Subjects in the lowest quintile of MIP had a 1.5-fold increased risk of MI (HR 1.48, 95% CI 1.07 to 2.06) and cardiovascular disease (CVD) death (HR 1.54, 95% CI 1.09 to 2.15) after adjustment for non-pulmonary function covariates. There was a potential inverse relationship with stroke (HR 1.36, 95% CI 0.97 to 1.90), but there was little evidence of an association between MIP and CHF (HR 1.22, 95% CI 0.93 to 1.60). The addition of FVC to models attenuated the HR associated with MIP only modestly; similarly, addition of MIP attenuated the HR associated with FVC only modestly. CONCLUSIONS: A reduced MIP is an independent risk factor for MI and CVD death, and a suggestion of an increased risk for stroke. This association with MIP appeared to be mediated through mechanisms other than inflammation.

Cardiovascular Diseases↗

PubMed2004

Economic evaluation of a comprehensive self-management programme in patients with moderate to severe chronic obstructive pulmonary disease.

AIMS: The main objective of this study was to investigate whether a comprehensive self-management programme, including self-treatment guidelines for exacerbations and a fitness programme, is an efficient treatment option for chronic obstructive pulmonary disease (COPD) patients. METHOD: We randomly allocated 248 COPD patients to either self-management (127) or usual care (121). Data on preference-based utilities (EuroQol-5D), health-related quality of life (HRQoL), health-care resource use and productivity losses associated with exacerbations were prospectively collected. Quality-adjusted life years (QALYs) were calculated. The economic analysis took the societal perspective and the observation period was one year. RESULTS: As we observed that the groups were equally effective in terms of QALYs and HRQoL (SGRQ), we described a cost minimization analysis only. The self-management programme-specific costs amounted to Euro 642 per patient. In the base-case cost analysis, the incremental cost difference amounted to Euro 838 per patient per year in favour of usual care. When only direct medical costs were included, the incremental annual cost of self-management relative to usual care was Euro 179 per person per year. If time costs for the fitness programme were set to zero, the costs for self-management diminished to Euro 542. Sensitivity analysis showed that these results were robust to changes in the underlying assumptions. CONCLUSION: We conclude that the COPE self-management programme is not an efficient treatment option for moderate to severe COPD patients who rate their HRQoL relatively high. The programme was twice as expensive as usual care and had no measurable beneficial effects on QALYs or HRQoL.

Adult↗

PubMed2003

Self-management education for chronic obstructive pulmonary disease.

BACKGROUND: In asthma, self-management programmes have been proven to be effective. In COPD, their value is not clear. OBJECTIVES: To assess the efficacy of COPD self-management/ education programmes on health outcomes and use of health services SEARCH STRATEGY: We searched the Cochrane Airways Group trial registers, MEDLINE (January 1985 to October 2001), reference lists, and abstracts of medical conferences. We also contacted research groups in the field for ongoing trials and unpublished material. SELECTION CRITERIA: Controlled trials (randomised and non-randomised) of self-management education in patients with COPD. Studies focusing mainly on physical pulmonary rehabilitation were excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. Investigators were contacted for additional information. MAIN RESULTS: The reviewers included 12 articles describing 8 randomised-controlled trials and 1 controlled clinical trial. Self-management education was compared with usual care in 8 studies. The studies in this review assessed a broad-spectrum of outcome measures with different follow-up times. Synthesis of the results using meta-analysis was always not possible. The studies showed no effect of self-management education on hospital admissions, emergency room visits, days lost from work and lung function. Inconclusive results were observed on health-related quality of life (HRQoL): studies using the disease specific SGRQ showed a better quality of life in the patients in the intervention group, but only in the activity component where there was heterogeneity between the results of the two included studies. A potential reason for the absence of convincing effects on HRQoL is the limited use of COPD-specific instruments. Inconclusive results were observed on COPD-symptoms and use of other health care resources such as doctor and nurse visits. Self-management education reduced the need for rescue medication, and led to an increased use of courses of oral steroids and antibiotics for respiratory symptoms. REVIEWER'S CONCLUSIONS: The data available for this review are insufficient for forming recommendations. Further research on the effectiveness of self-management programmes should be focussed on behavioural change evaluated in well designed randomised controlled trials with standardised outcomes designed for use in COPD patients, and with long follow-up time so that definite conclusions can be made.

Humans↗

PubMed2003

Synchronous, bilateral breast cancer: prognostic value and incidence.

The purpose of this study was to address the question whether patients with bilateral breast cancer (BBC) have a worse prognosis in terms of recurrence and survival than patients with primarily unilateral breast cancer (UBC) following breast-conserving treatment (BCT). From 1983 to 2000, a total of 1760 BCT were registered in the Radiotherapy Department of the Medisch Spectrum Twente. We defined synchronous a BBC as cancer diagnosed in both breasts at the same time or within a period of 3 months of diagnosis of the first tumor. One thousand seven hundred and sixty BCT were performed on 1705 patients, 26 of whom presented with BBC. Of these 26 patients, 18 had BCT for both breasts. A higher proportion of patients with BBC showed more tubular carcinoma (P=0.029) and medially located tumors (P=0.076) than those with UBC did. The 5- and 10-year local recurrence rates (LRRs) were 4.5% and 9.1%, respectively, in BBC patients, as against 3.3% and 7.6% for UBC after BCT. The 5- and 10-year distant metastasis rates were 26.9% and 50.7%, respectively, for BBC as against 13.4% and 21.1% for UBC after BCT (P=0.065 and P=0.014, respectively). The 5- and 10-year disease-specific survival (DSS) rates for the 1705 patients were 82.1% and 41%, respectively, after BBC, and 91.4% and 84% after UBC (P=0.086 and P=0.0045, respectively). Patients with BBC have a higher rate of distant metastasis and a worse DSS than those with UBC. As the LRR is similar for BBC and UBC, BCT is not contraindicated in BBC. The incidence of BBC is low, at 1.5% which makes it difficult to reach any more definitive conclusions on outcome and treatment.

Adult↗

PubMed2003

Peak inspiratory flow through diskus and turbuhaler, measured by means of a peak inspiratory flow meter (In-Check DIAL).

With a handheld peak inspiratory flow (PIF) meter (In-Check DIAL), the internal resistance of the Diskus (DKR) and the Turbuhaler (THR) can be simulated by means of calibrated resistances. This study investigated whether patients with asthma or chronic obstructive pulmonary disease could generate a PIF which is optimal for the Diskus (DK) (30 l/min) and theTurbuhaler (TH) (60 l/min). Peak expiratory flow (PEF) and maximal inspiratory pressure (MIP) were also assessed. All 50 patients (30 males, mean age 56.9) achieved the required flow of 30 l/min with the DKR, while six patients (five females) could not generate the optimal flow of 60 l/min via theTHR. Analysis showed that MIP was an independent predictor of an adequate PIF through theTHR. During the study eight patients were treated for an exacerbation of which four could not generate an adequate PIF via the THR. Analysis showed that the female gender and an exacerbation appeared to be independent predictors of the inability to generate an adequate PIF via the THR. Twelve per cent of patients (25% of females) could not generate the optimal inspiratory flow via the THR. When in doubt whether the patient can generate an adequate inspiration, measurement with the In-Check DIAL is recommended.

Asthma↗

PubMed2003

Self-management education for patients with chronic obstructive pulmonary disease: a systematic review.

BACKGROUND: The idea of self-management is to teach patients how to carry out the activities of daily living optimally in the face of their physiological impairment, and to prevent or decrease the severity of exacerbations by means of life style adaptation. In chronic obstructive pulmonary disease (COPD) the value of self-management education is not clear. This review was undertaken to clarify the effectiveness of self-management programmes in COPD. METHODS: A search was made of the Cochrane Airways Group trial registers, Medline, reference lists, and abstracts of medical conferences for controlled trials of self-management education in patients with COPD. Two reviewers independently assessed each paper for methodological quality and extracted the data. RESULTS: The reviewers included 12 articles describing eight randomised controlled trials and one controlled clinical trial in which self-management education was compared with usual care. The studies assessed a broad spectrum of outcome measures with different follow up times so meta-analysis could not be undertaken. Self-management education had no effect on hospital admissions, emergency room visits, days lost from work, and lung function. Inconclusive results were observed on health related quality of life, COPD symptoms, and use of healthcare facilities such as doctor and nurse visits. Self-management education reduced the need for rescue medication and led to increased use of courses of oral steroids and antibiotics for respiratory symptoms. CONCLUSIONS: Insufficient data were obtained to make recommendations because of the wide variation in outcome measures used and other limitations to generalisations in the current published literature. Further research in this area is needed.

Female↗

PubMed2003

Effects of a comprehensive self-management programme in patients with chronic obstructive pulmonary disease.

The aim of this study was to assess the effects of a comprehensive self-management intervention on health-related quality of life (HRQoL), symptoms and walking distance in patients with stable moderately severe chronic obstructive pulmonary disease (COPD). This study was part of the overall COPD study of the Dept of Pulmonary Medicine, Enschede, which consisted of an inhaled corticosteroid (ICS) trial and a self-management trial. After the ICS trial, all patients were randomised again to a self-management and a control group. The self-management intervention consisted of a skill-oriented patient education programme and a near-home fitness programme, on top of usual care. The control group received usual care by the treating chest physician. HRQoL was measured by the St George's Respiratory Questionnaire (SGRQ) and walking distance by the 6-min walking test. Patients recorded their symptoms in diaries and graded their health status from 1-10 in a weekly report. Altogether, 248 COPD patients were randomly allocated to either an intervention (127) or control (121) group. No differences in the SGRQ scores within and between both groups were observed over 1 yr. Similarly, no differences in symptom scores and 6-min walking distance were found within and between groups. The intervention group reported more exacerbations than the control group. The majority (69%) of the exacerbations in the intervention group were self-treated at home. This study failed to show positive effects of a self-management programme among moderately severe chronic obstructive pulmonary disease patients.

Administration, Inhalation↗

PubMed2001

Behavioural effect of self-treatment guidelines in a self-management program for adults with asthma.

To assess the efficacy of self-management programs it is important to know what behavioural changes take place. This paper assesses whether including self-treatment guidelines (action plans) in a self-management program for adult asthmatics, leads to greater behavioural changes than a program without these guidelines. Patients were randomised into a self-treatment group (n=123) or an active control group (n=122). All subjects received self-management training. Discussed topics included the pathophysiology of asthma, medication and side-effects, triggers, symptoms, smoking, physical exercise, and compliance. The only difference was that the self-treatment group received instructions about self-treatment of exacerbations and the control group did not. At 1 year of follow-up asthma-specific self-efficacy expectancies, outcome expectancies, and asthma-specific knowledge improved significantly in all patients. Only self-treatment group patients demonstrated favourable changes in generalised self-efficacy, social support, and self-treatment and self-management behaviour, in case of a hypothetical scenario of a slow-onset exacerbation. We conclude that our self-management program is effective in changing the behavioural variables, and including self-treatment guidelines (action plans) has added benefit.

Adult↗

PubMed2001

The impact of age on local control in women with pT1 breast cancer treated with conservative surgery and radiation therapy.

The aim of the study was to evaluate the importance of young age with regard to local control in a prospective cohort of 1085 women with pathological T1 tumours treated with breast conservative treatment (BCT). Patients were divided into two age groups: 40 years or younger, 7.8%, and older than 40 years, 92.2%. With a median follow-up of 71 months, the local recurrence rate was 10.6% in women < or =40 years, and 3.7% in older women. The local recurrence-free survival (LRFS) was significantly different for the two age groups, respectively 89%, < or =40 years, and 97.6%, >40 years (P=0.0046). A separate analysis showed a significantly decreased LRFS for young women with a positive family history, 75.4% versus 98.4% 5-year LRFS for older women. A worse LRFS for young women with a negative lymph node status was also observed, respectively 84% versus 98% 5-year LRFS (both P<0.001). In a multivariate analysis, taking into account the pre-treatment and treatment factors, age < or =40 years, was the only significant predictor of a decreased LRFS. Thus, young age is an important factor in relation to local control. In a subset analysis, this significant adverse effect of young age on outcome appears to be limited to the node-negative patients and those with a positive family history. To date, there is no evidence that young women with pT1 breast cancer, treated by mastectomy have an improved outcome when compared with those treated with conservative surgery and radiotherapy. Taking into account results from a subset analysis suggests that giving systemic therapy to a subgroup of women who are < or =40 years, node-negative and/or have a positive family history might give a better local control.

Adult↗

PubMed2001

Benefit from the inclusion of self-treatment guidelines to a self-management programme for adults with asthma.

This study assessed the long-term efficacy of adding self-treatment guidelines to a self-management programme for adults with asthma. In this prospective randomized controlled trial, 245 patients with stable, moderate to severe asthma were included. They were randomized into a self-treatment group (group S) and a control group (group C). Both groups received self-management education. Additionally, group S received self-treatment guidelines based on peak expiratory flow (PEF) and symptoms. Outcome parameters included: asthma symptoms, quality of life, pulmonary function, and exacerbation rate. The 2-yr study was completed by 174 patients. Both groups showed an improvement in the quality of life of 7%. PEF variability decreased by 32% and 29%, and the number of outpatient visits by 25% and 18% in groups S and C, respectively. No significant differences in these parameters were found between the two groups. After 1 yr, patients in both groups perceived better control of asthma and had more self-confidence regarding their asthma. The latter improvements were significantly greater in group S as compared to group C. There were no other differences in outcome parameters between the groups. Individual self-treatment guidelines for exacerbations on top of a general self-management programme does not seem to be of additional benefit in terms of improvements in the clinical outcome of asthma. However, patients in the self-treatment group had better scores in subjective outcome measures such as perceived control of asthma and self-confidence than patients in the control group.

Adult↗

PubMed2000

Family history in breast cancer is not a prognostic factor?

The aim of this study is to determine if breast conservative treatment is justified for patients with a positive family history of breast cancer and to investigate whether they have a worse prognosis. We performed a prospective cohort study of breast cancer patients, treated with breast conservative treatment with radiotherapy at the Radiotherapy Department of the Medisch Spectrum Twente. Between 1984 and 1996, 1204 patients with T1 and T2 < or =3 cm were treated. Family history (FH) was recorded according to first degree relative (FDR). Treatment consisted of lumpectomy with axillary dissection followed by radiotherapy to the whole breast with a boost to the primary area. Adjuvant systemic therapy was given to patients with positive nodes. A positive FH was noted in 243 (20.5%) patients, of whom 208 (17.6%) had one FDR, and 35 (3.0%) > or =2 FDRs. The local recurrence rate was 4.1%, with similar rates for all groups. In young patients, < or =40 years, a significant relation between local recurrence and FH was found. The distant metastasis rate was 15.5%, with the lowest rate (5.7%) among patients with > or =2 FDRs. Patients with a positive FH had significantly more contralateral tumours. The 5-year corrected survival was 91.3%. Among patients with a positive FH, a 5-year corrected survival of 91% was observed and the survival 100% among patients with one and > or =2 FDR. Family history is not a contraindication for breast conservative treatment and is not associated with a worse prognosis. Family history is not a prognostic factor for local recurrence rate in patients older than 40 years.

Journal Article↗

PubMed1999

[General knowledge of the performance of Mantoux-test procedure deemed inadequate].

OBJECTIVE: To investigate whether health care professionals have sufficient knowledge of the Mantoux test procedure. DESIGN: Descriptive. METHODS: The hospital pharmacy records of the Medisch Spectrum Twente, a large teaching hospital in Enschede (1034 beds), the Netherlands, were reviewed to determine which departments had performed Mantoux tests in 1996. The municipal health service and the industrial/occupational medicine department of the hospital were included in the investigation. Knowledge of the Mantoux test procedure was assessed in 44 randomly chosen health care professionals by means of a multiple-choice questionnaire. They were also asked how often they had performed Mantoux tests in 1996 and whether they thought themselves able to perform the total Mantoux test procedure correctly. RESULTS: The frequency of setting and/or reading the Mantoux test was generally low and varied per department. Ninety-three percent of the 44 subjects under investigation presumed themselves able to perform the Mantoux test correctly. From the questionnaire forty percent knew how to set a Mantoux test, while 15 of the 33 persons (45%) who had read a Mantoux reaction knew how to do this correctly. Nine of these 33 (27%) had sufficient knowledge to execute the whole Mantoux test procedure correctly. The knowledge of the correct Mantoux test procedure was significantly better among those who performed the Mantoux test more often. CONCLUSION: The theoretical knowledge regarding the Mantoux test is insufficient, especially among those health care professionals who rarely perform the test. It appears advisable to have the Mantoux tests performed by a few well-trained professionals.

Education, Professional↗