Does chair type influence outcome in the timed "Up and Go" test in older persons?

OBJECTIVE

To test the effects of the use of a collapsible, portable chair (chair B), as opposed to a 'standard' chair (chair A), on the outcome of the timed "Up and Go" (TUG) test.

DESIGN

Cross-sectional.

SETTING

Multipurpose senior centres.

PARTICIPANTS

Mobile older persons (N=118, mean age 77 years (range 62-99 years)).

OUTCOME MEASURES

Time to complete the timed "Up and Go" test using chair A and chair B, and inter-rater agreement in the time scores.

RESULTS

Time taken to complete the TUG test did not differ by chair type [median (interquartile range, IQR) = 12.3 (9.53-15.9) and 12.6 (9.7-16.6)] seconds for Chair A and B respectively, p-value=0.87. In multiple regression analyses, factors that impacted on time difference in test performance for the two chairs were use of a walking aid during the test [Odds ratio (OR) = 3.7 95%CI 1.1-11.9, p=0.031], observed difficulty with mobility (OR= 27.7 95%CI 2.6-290, p=0.006), and a history of arthritis in the knees (OR= 2.9 95%CI 1.0-8.7, P=0.05). In an inter-rater agreement analysis, no significant difference was found between time scores recorded by the two raters; median (IQR) = 12.4 (10.9-15.9) and 12.3 (7.2-59.1) seconds for the occupation therapist and for the research assistant, respectively (Wilcoxon matched pairs test, p=0.124, Spearman correlation coefficient = 0.99, p < 0.001).

CONCLUSION

The use of a portable canvas chair with standardised specifications offers an acceptable alternative to the use of a 'standard' chair in assessments of fall risk using the TUG test in field settings where field workers are reliant on public transport.

Chest radiograph in acute respiratory infections

BACKGROUND

Chest radiography is widely used during the management of acute lower respiratory infections, but the benefits are unknown.

OBJECTIVES

To assess the effects of chest radiography on clinical outcome in acute lower respiratory infections.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 1), MEDLINE (1950 to January 2007) and EMBASE (January 1976 to February 2007).

SELECTION CRITERIA

Randomised or quasi-randomised trials of chest radiography in acute respiratory infections.

DATA COLLECTION AND ANALYSIS

Both review authors independently applied the inclusion criteria, extracted data and assessed trial quality.

MAIN RESULTS

We identified two trials. One, of 522 outpatient children (and performed by the review authors), found that 46% of both radiography and control participants had recovered by seven days (relative risk (RR) 1.01, 95% confidence interval (CI) 0.79 to 1.31). Thirty-three per cent of radiography participants and 32% of control participants made a subsequent hospital visit within four weeks (RR 1.02, 95% CI 0.79 to 1.30) and 3% of both radiography and control participants were subsequently admitted to hospital within four weeks (RR 1.02, 95% CI 0.41 to 2.52). The other trial involving 1502 adults attending an emergency department found no significant difference in length of illness, the single outcome prespecified for this review (mean of 16.9 days in radiograph group versus 17.0 days in control group, P > 0.05).

AUTHORS' CONCLUSIONS

There is no evidence that chest radiography improves outcome in outpatients with acute lower respiratory infection. The findings do not exclude a potential effect of radiography, but the potential benefit needs to be balanced against the hazards and expense of chest radiography. The findings apply to outpatients only.

Randomised controlled trial of the efficacy of a metered dose inhaler with bottle spacer for bronchodilator treatment in acute lower airway obstruction

BACKGROUND

Inhaled bronchodilator treatment given via a metered dose inhaler (MDI) and spacer is optimal for relief of bronchoconstriction. Conventional spacers are expensive or unavailable in developing countries, but there is little information on the efficacy of low-cost spacers in young children.

OBJECTIVE

To compare the response to bronchodilator treatment given via a conventional or a low-cost bottle spacer

METHODS

A randomised controlled trial of the efficacy of a conventional spacer compared with a bottle spacer for bronchodilator treatment in young children with acute lower airway obstruction. Bronchodilator treatment was given from an MDI via an Aerochamber or a bottle spacer. Clinical score and oximetry recording were carried out before and after 15 min of treatment. MDI-spacer treatment was repeated up to three times, depending on clinical response, after which nebulisation was used. The primary outcome was hospitalisation.

RESULTS

400 children, aged (median (25th-75th centile)) 12 (6-25) months, were enrolled. The number of children hospitalised (n = 60, 15%) was identical in the conventional and bottle spacer groups (n = 30, 15% in each). Secondary outcomes including change in clinical score (-2 (-3 to -1)), oxygen saturation (0 (-1 to 1)) and number of bronchodilator treatments (2 (1 to 3)) were similar in both groups. Oral corticosteroids, prescribed for 78 (19.5%) children, were given to a similar number in the conventional (37 (18.5%)) and bottle spacer groups (41 (20.5%)).

CONCLUSION

A low-cost bottle spacer is as effective as a conventional spacer for bronchodilator treatment in young children with acute obstruction of the lower airways.

Diagnostic accuracy of chest radiography in detecting mediastinal lymphadenopathy in suspected pulmonary tuberculosis

OBJECTIVE

To estimate the diagnostic accuracy of chest radiography in the detection of chest lymphadenopathy in children with clinically suspected pulmonary tuberculosis.

DESIGN

Prospective cross sectional study.

SETTING

A short stay ward in a children's hospital in South Africa.

PATIENTS

Consecutive children under 14 years of age admitted with suspected pulmonary tuberculosis.

DIAGNOSTIC TEST

Antero-posterior and/or lateral chest x rays interpreted independently and blind to the reference standard by three primary care clinicians and three paediatricians, all with a special interest in tuberculosis. Reference standard: Spiral chest computed tomography (CT) with contrast injection.

RESULTS

One hundred children (median age 21.5 months) were enrolled. Lymphadenopathy was present in 46 of 100 reference CT scans and judged to be present in 47.1% of x ray assessments. Overall sensitivity was 67% and specificity 59%. Primary care clinicians were more sensitive (71.5% v 63.3%, p = 0.047) and less specific (49.8% v 68.9%, p<0.001) than paediatricians. Overall accuracy was higher for the paediatricians (diagnostic odds ratio 3.83 v 2.49, p = 0.008). The addition of a lateral to an antero-posterior view did not significantly increase accuracy (diagnostic odds ratio 3.09 v 3.73, p = 0.16). Chance adjusted inter-observer agreement (kappa) varied widely between viewer pairs, but was around 30%.

CONCLUSIONS

Detection of mediastinal lymphadenopathy on chest x ray to diagnose pulmonary tuberculosis in children must be interpreted with caution. Diagnostic accuracy might be improved by refining radiological criteria for lymphadenopathy.

Chest radiograph in acute respiratory infections in children

BACKGROUND

Chest radiography is widely used in children with acute lower respiratory infections, but the benefits are unknown.

OBJECTIVES

To assess the effects of chest radiography for children with acute lower respiratory infections.

SEARCH STRATEGY

The searches were updated in November 2004. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2005), MEDLINE (1966 to February, Week 1 2005) and EMBASE (January 1990 to September 2004). We contacted experts in the fields of acute respiratory infections and paediatric radiology to locate additional studies.

SELECTION CRITERIA

Randomised or quasi-randomised trials of chest radiography in children with acute respiratory infections.

DATA COLLECTION AND ANALYSIS

One reviewer extracted data and assessed trial quality.

MAIN RESULTS

We identified only one trial of 522 participants, which was performed by the review authors. The participants were ambulatory children aged two months to five years. Forty-six per cent of both radiography and control participants had recovered by seven days (odds ratio (OR) 1.03, 95% confidence interval (CI) 0.64 to 1.64). Thirty-three per cent of radiography participants and 32% of control participants made a subsequent hospital visit within four weeks (OR 1.02, 95% CI 0.71 to 1.48). Three per cent of both radiography and control participants were subsequently admitted to hospital within four weeks (OR 1.02, 95% CI 0.40 to 2.60). There were no deaths in either group.

AUTHORS' CONCLUSIONS

There is no evidence that chest radiography improves outcome in ambulatory children with acute lower respiratory infection. The findings do not exclude a potential effect of radiography, but the potential benefit needs to be balanced against the hazards and expense of chest radiography. The findings apply to ambulatory children only.

Guideline for the management of upper respiratory tract infections

INTRODUCTION

Inappropriate use of antibiotics for upper respiratory tract infections (URTIs), many of which are viral, adds to the burden of antibiotic resistance. Antibiotic resistance is increasing in Streptococcus pneumoniae, responsible for most cases of acute otitis media (AOM) and acute bacterial sinusitis (ABS).

METHOD

The Infectious Diseases Society of Southern Africa held a multidisciplinary meeting to draw up a national guideline for the management of URTIs. Background information reviewed included randomised controlled trials, existing URTI guidelines and local antibiotic susceptibility patterns. The initial document was drafted at the meeting. Subsequent drafts were circulated to members of the working group for modification. The guideline is a consensus document based upon the opinions of the working group.

OUTPUT

Penicillin remains the drug of choice for tonsillopharyngitis. Single-dose parenteral administration of benzathine penicillin is effective, but many favour oral administration twice daily for 10 days. Amoxycillin remains the drug of choice for both AOM and ABS. A dose of 90 mg/ kg/day is recommended in general, which should be effective for pneumococci with high-level penicillin resistance (this is particularly likely in children < or = 2 years of age, in day-care attendees, in cases with prior AOM within the past 6 months, and in children who have received antibiotics within the last 3 months). Alternative antibiotic choices are given in the guideline with recommendations for their specific indications. These antibiotics include amoxycillin-clavulanate, some cephalosporins, the macrolide/azalide and ketolide groups of agents and the respiratory fluoroquinolones.

CONCLUSION

The guideline should assist rational antibiotic prescribing for URTIs. However, it should be updated when new information becomes available from randomised controlled trials and surveillance studies of local antibiotic susceptibility patterns.

Inhuman shields--children caught in the crossfire of domestic violence

BACKGROUND

Child abuse is a worldwide scourge. One of its most devastating manifestations is non-accidental head injury (NAHI).

METHODS

This is a retrospective chart review of children presenting to the Red Cross Children's Hospital trauma unit with a diagnosis of NAHI over a 3-year period.

RESULTS

Sixty-eight children were included in the study and 2 different groups were identified. Fifty-three per cent of the children were deliberately injured (median age 2 years), while 47% were allegedly not the intended target of the assailant (median age 9 months). The assailant was male in 65% of the intentional assaults and male in 100% of the unintentional assaults, with the intended adult victim female in 85% of the latter cases. Overall, 85% of the assaults were committed in the child's own home.

CONCLUSIONS

The high proportion of cases in which a young child was injured unintentionally suggests that these infants effectively become shields in assaults committed by adults. In this context any attempts to deal with child abuse must also address the concurrent intimate partner violence.

Clinical predictors of outcome in acute upper gastrointestinal bleeding

OBJECTIVE

Endoscopy has traditionally been used to risk-stratify patients with upper gastrointestinal bleeding (UGIB). This is problematic in resource-poor environments. The study aimed to identify patients who would not require urgent endoscopy by identifying clinical variables before endoscopy that predict uneventful recovery.

DESIGN

Prospective, descriptive cross-sectional study.

SETTING

Groote Schuur Hospital, Cape Town.

SUBJECTS

Two hundred consecutive patients aged over 12 years, presenting with haematemesis and/or melaena.

OUTCOME MEASURES

Good outcome, i.e. no blood transfusion, endotherapy or surgery, and alive at 1 month following presentation.

RESULTS

Eighty patients (40%) had a good outcome. Haemoglobin > 10 g/dl (odds ratio (OR) 25.5, 95% confidence interval (CI): 8.9-74.8; p < 0.001), absence of melaena (OR 4.8, 95% CI: 1.79-12.94, p = 0.002) and absence of syncope (OR 4.0, 95% CI: 1.67-9.48; p = 0.002) were independent predictors of good outcome. The three variables combined as a positive test had the best association with good outcome when compared with a single variable or a combination of two variables. The three-variable model had sensitivity for good outcome of 34%, specificity of 98%, and likelihood ratio for a positive test of 13.5 and for a negative test of 0.68. Thirty patients (15%) had the combination for the prediction rule, i.e. haemoglobin > 10 g/dl, no melaena and no syncope; 3 (10%) had a poor outcome (required endotherapy).

CONCLUSION

The prediction rule accurately excluded poor outcome, a priority in the clinical context, but did not predict good outcome. Clinical implications are a 15% reduction in unnecessary urgent endoscopies, with less than 5% of patients with poor outcome not undergoing urgent endoscopy. These findings may have particular clinical relevance in under-resourced health care environments.

Randomised trials in the South African Medical Journal, 1948-1997

OBJECTIVE

To describe randomised controlled trials (RCTs) published in the South African Medical Journal (SAMJ) over a 50-year period from 1948 to 1997 with regard to number, topic and quality.

METHODS

We hand searched all issues of the SAMJ published during the study period to identify all published RCTs.

OUTCOME MEASURES

Number, topic and quality of RCTs published from 1948 to 1997.

RESULTS

Eight hundred and fifty-eight clinical trials were published during the period reviewed. Eighty-four per cent of RCTs were published as full articles. During the 1980s the number of RCTs published increased rapidly, with a peak of 35 in 1985, but then declined to only 5 in 1997. The majority (92%) of RCTs were conducted in a hospital setting. A varied range of subjects was covered, with gastroenterology taking the lead and no trials in public health. The sample size in more than 50% of RCTs was smaller than 50 patients. Fifty-one per cent (435 trials) used random allocation and 49% (423) quasi-random methods of allocation. Concealment of treatment allocation was judged to be adequate in 46% of studies (N = 200), blinding of observers assessing outcomes was adequate in 28% (123), and all the allocated test subjects were included in the primary analysis in 28% (123). The follow-up period was more than 1 year in 4% (17) and less than 6 days in 16% (71).

CONCLUSIONS

Compared with other international journals the SAMJ is highly regarded in terms of the number of trials published. There are, however, a number of deficiencies in the quality of the trials.

Radiologic differentiation between bacterial and viral lower respiratory infection in children: a systematic literature review

A systematic literature review was performed to quantify the accuracy of chest radiography in differentiating bacterial from viral lower respiratory infection in children. Relevant studies were identified in a systematic literature search and were included in the review according to predetermined criteria. Five of 13 relevant identified studies met the inclusion criteria. No clinically useful degree of accuracy was demonstrated, but great caution is needed in interpreting the findings because of the suboptimal nature of the reference standards, even in included studies. It is recommended that future surveys of the microbial etiology of pneumonia that employ a credible reference standard (such as lung aspiration) be used as opportunities to perform studies of diagnostic accuracy.

Duration of illness in ambulatory children diagnosed with bronchiolitis

OBJECTIVES

To measure the duration of illness in ambulatory children diagnosed with bronchiolitis and to examine clinical predictors of duration of illness.

DESIGN

Validation inception cohort study. Duration of follow up was 28 days.

SETTING

A primary-level ambulatory department of a public sector children's hospital in Cape Town, South Africa.

PATIENTS

One hundred eighty-one children aged 2 to 23 months who went to the hospital as their first contact for that episode of illness, and had a clinical diagnosis of bronchiolitis were enrolled consecutively on weekday mornings if their guardian stated that they were contactable by telephone.

MAIN OUTCOME MEASURE

Resolution of symptoms, as judged by the guardian, measured by twice-weekly telephone interviews.

RESULTS

Median duration of illness (calculated as the reported duration of symptoms before initial hospital visit plus the time from first consultation to recovery) was 12 days (95% confidence interval, 11-14 days). After 21 days, 18% were still ill and after 28 days, 9% were still ill. Sixty-two patients (34.2%) had unscheduled consultations within 28 days, a median of 13 days after the first consultation. There was no association of duration of illness with age, sex, z score for weight for age, or respiratory rate.

CONCLUSIONS

Ambulatory children diagnosed with bronchiolitis recover with few complications, but the resolution of symptoms may take several weeks. Providing parents with this information could help reduce the high rate of unscheduled return visits as observed in this cohort.

An effectiveness trial of a diagnostic test in a busy outpatients department in a developing country: issues around allocation concealment and envelope randomization

Methods to ensure allocation concealment in a randomized controlled trial in a busy outpatients department may disrupt usual clinical behavior, and thereby modify the effect of a diagnostic test. In a clinical trial of chest radiography in ambulatory children, concealment was maintained by means of sealed sequentially numbered manila envelopes. Baseline information was collected on all potential participants before they were presented to a clinician for a decision on inclusion in the trial. Excluded patients were followed up. Of 59 excluded patients, only 16 allocation envelopes had been opened or were not accounted for, although 12 of these had non-radiograph allocations (P = 0.05). There was no difference between patients excluded from radiograph and non-radiograph groups in baseline characteristics or primary outcome measure. Most of the improper exclusions occurred early in the study; improved monitoring and feedback reduced the problem. Sealed opaque sequentially numbered envelopes may be appropriate for trials of diagnostic tests in settings where centralized randomization is not feasible, and given careful monitoring of the enrollment process.

Telephone follow-up in a randomized controlled trial in a less developed country: feasibility, validity and representativeness

Telephone follow-up would offer considerable advantages over other modes of follow-up in less developed countries, if it were feasible and the findings were valid and generalizable. Telephone follow-up was assessed in the context of a randomized controlled trial of chest radiography in South African children. Hospital-based clinical outcomes were measured from hospital records, and also by telephone, in a subset of the same patients who offered a contact telephone number. Of 398 subjects offering a telephone number 308 (77.4%) were followed to recovery or for 28 days. Kappa statistics for a subsequent hospital visit, hospital admission, and chest radiograph were 0.88, 0.83, and 0.56, respectively. The effect of chest radiography did not differ significantly in participants accessible and not accessible by telephone. Telephone follow-up was feasible and produced valid and generalizable results at low cost.

Chest radiography in ambulatory children with acute lower respiratory infections: effective tuberculosis case-finding?

A study was performed to determine the proportion of ambulatory children with acute lower respiratory infections in whom clinical management was changed by findings on routine chest radiography that suggested tuberculosis. The children studied were aged between 2 and 59 months and met the World Health Organization's case definition for pneumonia. They lived in an area with a very high prevalence of tuberculosis. Exclusion criteria included a cough of more than 14 days' duration and a history of a current household contact with active tuberculosis. Twelve (4.4%) of 273 children had radiological findings suggesting tuberculosis, nine of which were suspected mediastinal lymphadenopathy. Eight children were further investigated for tuberculosis: seven of them did not require treatment for tuberculosis and one was lost to follow-up. It is concluded that chest radiography in ambulatory children with acute lower respiratory infections of less than 14 days' duration and not in contact with active tuberculosis does not result in a meaningful increase in the diagnosis of tuberculosis.

Chest radiograph in acute respiratory infections in children

BACKGROUND

Chest radiography is widely used in acute lower respiratory infection in children, but the benefits are unknown.

OBJECTIVES

To assess the effects of chest radiography for children with acute lower respiratory infections.

SEARCH STRATEGY

We searched the Cochrane Respiratory Infections Group trials register, the Cochrane Controlled Trials Register and MEDLINE up to December 1999. We contacted experts in the fields of acute respiratory infections and paediatric radiology to locate additional studies.

SELECTION CRITERIA

Randomised or quasi-randomised trials of chest radiography in acute respiratory infections in children.

DATA COLLECTION AND ANALYSIS

One reviewer extracted data and assessed trial quality.

MAIN RESULTS

We identified only one trial of 522 participants, performed by the reviewers. The participants were ambulatory children aged two months to five years. Forty six percent of both radiography and control participants had recovered by seven days - odds ratio (1.03, 95% confidence interval 0.64 to 1.64). Thirty three percent of radiography participants and 32% of control participants made a subsequent hospital visit within four weeks - odds ratio 1.02 (95% confidence interval 0.71 to 1.48). Three percent of both radiography and control participants were subsequently admitted to hospital within four weeks - odds ratio 1.02 (95% confidence interval 0.40 to 2.60). There were no deaths in either group.

REVIEWER'S CONCLUSIONS

There is no evidence that chest radiography improves outcome in ambulatory children with acute lower respiratory infection. The findings do not exclude a potential effect of radiography, but the potential benefit needs to be balanced against the hazards and expense of chest radiography. The findings apply to ambulatory children only.

Randomised controlled trial of clinical outcome after chest radiograph in ambulatory acute lower-respiratory infection in children

BACKGROUND

When available, chest radiographs are used widely in acute lower-respiratory-tract infections in children. Their impact on clinical outcome is unknown.

METHODS

522 children aged 2 to 59 months who met the WHO case definition for pneumonia were randomly allocated to have a chest radiograph or not. The main outcome was time to recovery, measured in a subset of 295 patients contactable by telephone. Subsidiary outcomes included diagnosis, management, and subsequent use of health facilities.

FINDINGS

There was a marginal improvement in time to recovery which was not clinically significant. The median time to recovery was 7 days in both groups (95% CI 6-8 days and 6-9 days in the radiograph and control groups respectively, p=0.50, log-rank test) and the hazard ratio for recovery was 1.08 (95% CI 0.85-1.34). This lack of effect was not modified by clinicians' experience and no subgroups were identified in which the chest radiograph had an effect. Pneumonia and upper-respiratory infections were diagnosed more often and bronchiolitis less often in the radiograph group. Antibiotic use was higher in the radiograph group (60.8% vs 52.2%, p=0.05). There was no difference in subsequent use of health facilities.

INTERPRETATION

Chest radiograph did not affect clinical outcome in outpatient children with acute lower-respiratory infection. This lack of effect is independent of clinicians' experience. There are no clinically identifiable subgroups of children within the WHO case definition of pneumonia who are likely to benefit from a chest radiograph. We conclude that routine use of chest radiography is not beneficial in ambulatory children aged over 2 months with acute lower-respiratory-tract infection.

An evaluation of a board game as an aid to teaching neonatal primary care

A postal questionnaire survey was sent to the recipients of the first printing of a board game designed to help midwives learn neonatal primary care. Of 99 questionnaires, 79 (79.8%) were returned. Of the 79 respondents 67 (84.8%) had used the game. Of the 67 who had used the game, 58 (86.6%) found it "very" or "quite" easy to learn, 63 (94.0%) enjoyed it and 66 (98.5%) intended to use the game again. Sixty six (98.5%) felt there was a need for similar games dealing with other subjects. It is concluded that "Neonopoly" functions well as a game and that there are indications that it aids learning. The most important drawback was an insufficient number of question cards. There is a widely perceived need for similar games dealing with other subjects.

The antenatal prevention of congenital syphilis in a peri-urban settlement

The obstetric records of patients from Khayelitsha were examined to assess the efficiency of a system for the antenatal prevention of congenital syphilis, and to identify points of breakdown in the process. Seventy-seven (12.7%) of 607 mothers had serological evidence of syphilis, including 10 (32.3%) of 31 mothers who had received no antenatal care. Of 70 patients who required routine management, only 36 (51.4%) received 3 or more of the recommended 4 penicillin injections. Two main weaknesses in the system were identified. One was the centralisation of serological testing. This delayed results reaching the relevant unit, and was responsible for a high cumulative attrition of patients during the many stages necessitated by the centralised testing. The other was a 24.5% attrition of patients referred from the antenatal clinic to a separate sexually transmitted diseases clinic.

Summer-type hypersensitivity pneumonitis in southern Africa. A report of 5 cases in one family

Five patients, from a family of 8 who all lived in the same house, developed chronic hypersensitivity pneumonitis. The 4 patients followed up showed features strikingly similar to summer-type hypersensitivity pneumonitis, previously thought unique to Japan. The clinical setting and limited immunological investigations suggest the cause to be a bacterial or fungal growth in the roof of the house.

The impact of routine admission tests on the care of Third-World children

To determine the clinical usefulness of routine diagnostic tests on admission of Third-World children to hospital, the records of 306 children admitted to a Ciskei hospital were examined. The tests performed were 'dipstick' urinalysis, Mantoux testing and bedside haemoglobin measurement. Of the 164 Mantoux tests performed, 16 were unexpectedly positive and 15 (94%) of these 16 patients had their treatment changed as a result. Measurement of the haemoglobin concentration revealed that 31 of 278 patients had a haemoglobin value unexpectedly below 10 g/dl, but in 28 of these 31 cases (90%) this result was ignored. Of the 3 patients followed up, 2 had their treatment changed. An unexpected abnormal result was obtained in 76 of 233 urinalyses performed, but 72 (95%) of these were ignored. Follow-up in the remaining 4 cases did not result in any change in treatment. Routine urine and haemoglobin testing had negligible impact on patient care because unexpected abnormal results were ignored. This finding is similar to those of similar studies on Western adults. The possible reasons for this, and for the striking exception of the Mantoux test, are discussed.