A blood test can help diagnose invasive aspergillosis early in people who have severely weakened immune systems. Select regional labs in the AR Lab Network perform screening to monitor and track the emergence of azole-resistant A. fumigatus in the United States. Testing is available to all states For the skin test, a small amount of aspergillus antigen is injected into the skin of your forearm. If your blood has antibodies to the mold, you'll develop a hard, red bump at the injection site. Blood tests look for high levels of certain antibodies, indicating an allergic response The diagnostic criteria for ABPA include the presence of a predisposing condition (asthma or cystic fibrosis) and positive allergen specific IgE to aspergillus species and a total IgE >1000 IU/mL. 21,37-39 Serum aspergillus IgG precipitins and a blood eosinophil count >500 cells/L in corticosteroid naive patients support the diagnosis of ABPA. SASP : Aspergillus fumigatus is one of the causative agents of hypersensitivity pneumonitis (HP), as well as invasive lung disease with cavitation or pneumonitis and allergic bronchopulmonary disease.(1) Other causative microorganisms of HP include Micropolyspora faeni and Thermoactinomyces vulgaris. The development of HP and allergic bronchopulmonary disease caused by Aspergillus fumigatus is. Aspergillus precipitin is a laboratory test performed on your blood. It's ordered when a doctor suspects that you have an infection caused by the fungus Aspergillus. The test may also be called:..
Aspergillus antibody testing There are multiple marketed IgG antibody tests to detect A. fumigatus antibodies. A smaller number of less well used and often usually incompletely validated tests are available for other species of Aspergillus including A. flavus, A. terreus, A. niger, A. versicolor and A. clavatus. All testing is on serum Aspergillus-specific IgG, IgM test were conducted following the collection of the blood samples. According to the diagnostic criteria, the cases were divided into 4 groups: Group 1a (proven CPA), Group 1b (possible CPA), Group 2 (Aspergillus colonization), Group 3 (other pulmonary disease). 2.2.1 Diagnostic criteri Blood tests: Antibodies against Aspergillus proteins can be measured in a patient's blood and this indicates if the patient may have an Aspergillus infection - this is done using an enzyme-linked immunosorbent assay (ELISA), such as the ImmunoCAP ® Specific IgE Blood Test. An abnormal test result will conclude that the patient's blood had the Aspergillus fungus antibodies in it. Procedure for Allergy - Aspergillus Fumigatus Test The process of this test follows the normal blood sample test and the procedure are as follows: Before drawing vein from the veins, an antiseptic would be applied by the Nurse or Doctor blood or skin test for IgE antibodies to Aspergillus can be done to see if a person is sensitized (allergic) to this fungus. If these skin tests are negative (i.e. does not show a skin reaction) to Aspergillus fumigatus, the person usually does not have ABPA
Skin and blood tests: These tests are useful to diagnose ABPA, especially in cases where the patient has asthma, bronchiectasis or cystic fibrosis. The doctor or technician injects a small quantity of aspergillus antigen into the skin, usually the lower arm. A small red bump at or near the site will show that you have an allergic reaction The aspergillus fumigatus allergy blood test measures the amount of allergen-specific IgE antibodies in the blood in order to detect an allergy to aspergillus fumigatus. Preparation: No special preparation required. Test Results: 2-5 days. May take longer based on weather, holiday or lab delays The Platelia Aspergillus enzyme immunoassay (EIA) is a 1-stage immunoenzymatic sandwich microplate assay that detects galactomannan in human serum. The assay uses the rat monoclonal antibody EBA-2, which is directed against Aspergillus galactomannan
. Species-specific real-time PCR assays for A fumigatus and for A terreus could be used to rule out or identify the common A fumigatus and the amphotericin B-resistant A terreus. [ 34 Two or more consecutive positive results should be obtained from separately drawn specimens before the patient is considered to have a positive Aspergillus antigen test. Numerous foods (pasta, rice, etc.) contain galactomannan. It is thought that damage to the gut wall by cytotoxic therapy, irradiation, or graft- versus-host disease enables. Allergic fungal rhinosinusitis is usually diagnosed using blood tests (to detect antibodies to the fungus), CT scan, endoscopy and culture of samples taken from the sinus. Nasal polyposis is often present (N.B. these are NOT cancerous even though they are described as tumours). Aspergillus sinusitis is thought to be caused by repeated. Aspergillosis precipitin is a laboratory test to detect antibodies in the blood resulting from exposure to the fungus aspergillus. How the Test is Performed A blood sample is needed. The sample is sent to a laboratory where it is examined for precipitin bands that form when aspergillus antibodies are present Many people who are diagnosed with Chronic Fatigue Syndrome, Fibromyalgia, Lyme Disease, and others may actually be suffering from the consequences of mold and mycotoxin exposure. In the United States, there is now the only laboratory that will test blood serum for 12 mycotoxins: it is MyMycoLab. Up to now, there has only been a urine test
Aspergillosis precipitin is a laboratory test to detect antibodies in the blood resulting from exposure to the fungus aspergillus. Alternative Names. Aspergillus immunodiffusion test; Test for precipitating antibodies. How the Test is Performed. A blood sample is needed Aspergillus fumigatus Ab IgG: 26954-8 * Component test codes cannot be used to order tests. The information provided here is not sufficient for interface builds; for a complete test mix, please click the sidebar link to access the Interface Map. Aliases Other names that describe the test. Synonyms
Aspergillus hyphae may be difficult to proliferate in a blood culture bottle. We investigated the sensitivity of each test in vitro in detecting circulating Aspergillus components. 4 Aspergillus. The uncertainty of which blood fraction to use has led to a variety of fractions being recommended for use in Aspergillus PCR testing including whole blood , serum , and even blood clots . There is evidence that whole blood is more likely to test positive for Aspergillus DNA than plasma [246, 253] In recent years galactomannan antigen testing (GM) and also Aspergillus PCR have become increasingly important for diagnosis of invasive aspergillosis (IA). Whether or not these tests need to be performed with bronchoalveolar lavage fluid (BALF; i.e., primary site of infection), or testing of blood Test Code: 8900. Expand All Collapse All. Clinical and Procedure. Clinical Utility. Inhaled dormant Aspergillus spores (conidia) can germinate and cause invasive pulmonary aspergillosis, a disease with a mortality rate often exceeding 50%. Invasive pulmonary aspergillosis is seen primarily in the immunocompromised host Blood. 2001 March 15;97(6):1604-1610. 2. Pinel C, Fricker-Hidalgo H, Lebeau B, et al: Detection of circulating Aspergillus fumigatus galactomannan: value and limits of the Platelia test for diagnosing invasive aspergillosis. J Clin Microbiol. 2003 May;41(5):2184-218
The purpose of these tests is to establish that the drug levels in your blood are neither too low (when it won't be as effective in fighting infection) or too high (when you might start experiencing side effects). Once reached the patient must keep taking the dose required to keep blood drug levels steady until told otherwise by a doctor Aspergillus Antigen. For the following tests, please send serum (700 µl minimum) or 7 mL clotted blood in a plain tube; EDTA blood is not suitable. BAL and CSF samples can also be tested (700 µl minimum). Send in white topped universal Diagnostic criteria for ABPA include the presence of bronchial asthma, immediate skin test reactivity to A. fumigatus, elevated serum IgE levels, total and A. fumigatus-specific, pulmonary infiltrates (transient or fixed), central bronchiectasis, peripheral blood eosinophilia, and elevated levels of total and Aspergillus-specific IgE. 1
Patients whose antigen test turned negative during the amphotericin B treatment had significantly lower mortality than patients with persistently positive antigen test (2/10 vs. 8/8, p = 0.002). We conclude that Aspergillus galactomannan can be detected by ELISA in serum, urine and BAL samples of haematological patients, but the higher. Aspergillus organisms are seen in or cultured from a tissue biopsy. The fungus is not usually seen in nasal discharge, but may be recovered by flushing the nasal cavity. A blood test is positive for antibodies against an Aspergillus species. General anesthesia is necessary for diagnostic imaging (X-rays or CT scans), as well as for rhinoscopy We retrospectively analyzed the performance and relevance of the SeptiFast assay in detecting Aspergillus fumigatus DNA in whole blood samples from 38 critically ill intensive care unit (ICU) patients with probable or proven invasive aspergillosis (IA) and 100 ICU patients without IA. The assay exhibited 66% sensitivity, 98% specificity, a 93% positive predictive value, and an 88% negative.
Fever. Chest pain. Cough. Coughing up blood. Shortness of breath. Other symptoms can develop if the infection spreads from the lungs to other parts of the body. Contact your healthcare provider if you have symptoms that you think are related to any form of aspergillosis ASPERGILLUS GALACTOMANNAN, BLOOD (SERUM) TEST NOT AVAILABLE. The ASPERGILLUS GALACTOMANNAN, BLOOD (SERUM) test is no longer offered by Geisinger Medical Laboratories. Here is a complete list of tests we perform. If you need additional assistance, please contact our Client Services Department at 800 695 6491 Blood must be collected in a gold-top (SST) tube. Centrifuge and send specimen in this original collection tube. Do not aliquot or open tube. Clinical Indications. The Platelia™ Aspergillus Galactomannan EIA is a test, when used in conjunction with other diagnostic procedures, such as microbiological culture, histological examination of.
. They can also test for food sensitivities if you are interested ASPERGILLUS EIA. GALACTOMANNAN TEST. Test Code. 309. CPT Code. 87305. Clinical Significance. The aspergillus EIA test is an aid in the early diagnosis of invasive aspergillosis. In conjunction with other diagnostic tests and clinical signs of disease, it is an aid in the effective early treatment of disease Alternatively, a blood test (Aspergillus specific IgE) can be used if the skin test is not available. If the test is positive, then an additional test (total IgE) is required to make the diagnosis of allergic bronchopulmonary aspergillosis). A physician may also perform a blood test to determine whether any aspergillosis antibodies are present Aspergillus-specific As-IgG and As-IgM levels were measured using the Aspergillus fumigates IgG and IgM Quantitative Test kit (Dynamiker, China), based on enzyme-linked immunosorbent assay (ELISA), according to the manufacturers' instructions. Briefly, serum samples were diluted 1:1000 and incubated in ELISA plates for 60 min at 37°C Tests to diagnose aspergillus infection include: Aspergillus antibody test; Chest x-ray; Complete blood count; CT scan; Galactomannan (a sugar molecule from the fungus that is sometimes found in the blood) Immunoglobulin E (IgE) blood level; Lung function tests; Sputum stain and culture for fungus (looking for aspergillus) Tissue biops
Doctors make a diagnosis by evaluating a patient's history, risk factors, symptoms, physical exam, lab tests, and imaging tests like a chest X-ray or CT. They may send respiratory fluid for tests (for example, Aspergillus galactomannan test, a blood test that detects galactomannan, a molecule found in the cell wall of Aspergillus) and microscopic exams (view Aspergillus hyphae and conidia. This IgE antibody allergy test uses a blood sample to determine if you are allergic to Aspergillus niger fungus (black mold) spores.. Aspergillus is the most commonly found fungi and typically resides in the soil. There are many strains of the Aspergillus, but Aspergillus niger is by far the most common. A. niger, is responsible for the post-harvest decay of fresh fruit such as grapes, apples. Alternative names: Aspergillus immunodiffusion test; Test for precipitating antibodies Definition: Aspergillosis precipitin is a laboratory test to detect antibodies in the blood resulting from exposure to the fungus aspergillus. How the Test is Performed. A blood sample is needed.. The sample is sent to a laboratory where it is examined for precipitin bands that form when aspergillus Mycotoxin testing. MycoTOX Profile screens for 40 species of mold from eleven different mycotoxins in one urine sample. Mold / mycotoxin testing for patients. We are currently measuring 11 different mycotoxins in our test from a wide variety of 13 mold types (genera) including Aspergillus, Penicill
Test Name Aspergillus Antigen Test (Galactomannan) Test Code SAGAL1 Specimen Type. Serum - Gel OR Broncheolar Lavage (BAL) Minimum Volume 2 - 3 mL Comments. Laboratory Notes: Serum: Centrifuge, aliquot and freeze (Frozen Sendaway Aliquots cryobox) BAL - freeze (Frozen Sendaway Aliquots cryobox Aspergillosis precipitin is a laboratory test performed on a patient's blood. It is ordered when a doctor suspects that you have an infection that could be caused by the fungus Aspergillus What tests can be done? Many different tests may be employed if aspergillosis is suspected. Each test provides another piece of the puzzle, and often multiple tests are needed to give more clarity. A complete blood count (CBC) with a dramatic elevation in the white blood cells may initially raise suspicion of an Aspergillus infection
The best test to order in a patient with a bloodstream infection is a routine blood culture, which includes one anaerobic and one aerobic bottle. Routine blood culture can easily recover aerobic and anaerobic bacterial organisms as well as Candida spp., Aspergillus spp . and sometimes Fusarium spp . which are the most common fungal organisms to. When the diagnosis is suspected, a skin prick test with Aspergillus antigen is the best first step, but serologic testing for Aspergillus precipitins may be a more practical initial test. An immediate wheal-and-flare reaction should prompt measurement of serum IgE and Aspergillus precipitins because up to 25% of patients with asthma without ABPA may have a positive skin test Test Code Asper Fum ASPERGILLUS FUMIGATUS (M3) IgE ALLERGEN, BLOOD Performing Laboratory. St. Louis Children's Hospital. Last Reviewed. May 2019. Website Feedback. Portions ©2021 Mayo Foundation for Medical Education and Research..
Blood tests and serology. The first stage involves exposing the skin to Aspergillus fumigatus antigens; an immediate reaction is hallmark of ABPA. The test should be performed first by skin prick testing, and if negative followed with an intradermal injection Clinical microbiology tests. For a list of the Microbiology accredited assays, please see the UKAS schedule of accreditation. Please contact the laboratory on 0121 371 6538 if you require a test that is not listed below. Threadworm - press approximately 5cm sellotape to perianal area before washing or defecation Identification of Aspergillus spp. via cytology or biopsy: The fungus can be sampled directly from the inside the frontal sinuses and nasal passages and viewed under the microscope.; Positive fungal culture: Secretions from the nose can be handled to see if the fungus will grow on specific culture media.; Positive blood serology test: The body produces special proteins called antibodies in.
Signs and symptoms. A fungus ball in the lungs may cause no symptoms and may be discovered only with a chest X-ray, or it may cause repeated coughing up of blood, chest pain, and occasionally severe, even fatal, bleeding. A rapidly invasive Aspergillus infection in the lungs often causes cough, fever, chest pain, and difficulty breathing.. Poorly controlled aspergillosis can disseminate. A diagnosis can also be made based on a specific blood test used to detect antibodies to Aspergillus in the blood. Sometimes, however, the test can be falsely negative, especially if the bird's immune system is suppressed. How is aspergillosis treated. Surgery may be performed to remove accessible lesions A radioallergosorbent test (RAST) is a blood test used to determine the substances a subject is allergic to. This is different from a skin allergy test, which determines allergy by the reaction of a person's skin to different substances. There are a number of advantages of a RAST test vs. conventional skin testing, including
The third test was an Aspergillus RNA extraction and NASBA assay. Total RNA was extracted from plasma using a blood/liquid sample total RNA rapid extraction kit (BioTeke, Beijing, China) Clinical Information. All allergens are reported down to a cutoff level of 0.10 kU/L. The significance of allergen specific IgE levels between 0.10 and 0.35 kU/L remains undefined. Cumulative levels of multiple allergen specific IgE antibodies may have an additive effect in producing clinical symptoms. Individual allergen specific IgE antibody.
sometimes miss the infection. There is also a test that identifies parts of the fungus in your blood, called the serum galactomannan test. However, this test is not 100% accurate. It may miss a few cases, but a positive test increases the chance you have the infection, especially if you have risk factors for aspergillosis, an Results of serum G test, GM test, and Aspergillus IgG and IgM antibody detection in each group. The results of the serum G test, Aspergillus IgG and Aspergillus IgM antibody detection and the GM test are listed in Tables 3, 4 and 5 for the different groups. Primitively, positive rates of the above serum indexes were found among the pulmonary aspergillosis, community-acquired bacterial.
. In a systematic review of 9 studies using reference IA definitions strictly adherent to the EORTC/MSG criteria, the sensitivity and specificity of PCR of BAL were 77% and 94%, respectively  Fungal Panel II. Detection of antibodies to Blastomyces, Coccidioides, Histoplasma, and Aspergillus by agar gel immunodiffusion (AGID); and antigen to Cryptococcus neoforman s by agglutination. All techniques can be used for diagnostic purposes. Collect serum from clotted blood in a non-additive tube (e.g. plain red top or serum separator)
Antigen detection: Several antigen tests for the detection of Aspergillus from blood, urine and CFS are now available. In a person with invasive aspergillosis, there may be high titers of galactomannan antigen in serum. As galactomannan is rapidly eliminated from blood, serial screening twice weekly is recommended for optimal diagnosis Aspergillus is a family of at least 250 species of mold first discovered in 1729 by an Italian priest and biologist named Pier Antonio Micheli. It begins white, then becomes green, brown, black or yellow as it grows, depending on species. Aspergillus spores spread in the air, and are thought to be more concentrated indoors than outdoors Serological blood tests confirmed a diagnosis of allergic bronchopulmonary aspergillosis: total IgE 8045 kIU/l, Aspergillus-specific IgE 36.7 kUa/l, Aspergillus-specific IgG >200 mg/l. After 1 year of itraconazole there was complete resolution of the mass on CT The majority of molecular tests developed to date for the diagnosis of fungal disease are polymerase chain reaction (PCR)-based assays focused primarily on the detection of Candida, Aspergillus, or Pneumocystis jirovecci from clinical samples. With that said, development of an assay for detection of fungal nucleic acid circulating in blood.
Our Blood, Urine and Stool Profiles are Unique. Our blood,urine and stool profiles are unique throughout the industry. Our custom blood profile panels test for multiple species of the most common species of Mold found in the homes and businesses throughout North America. Aspergillus Penicillium Stachybotrys and Multiple other Specie Description. Order an allergen profile mold blood test to detect an allergy to various common molds. This test measures the amount of allergen-specific antibodies in a blood sample. The predominant allergen in mold is the seed, referred to as mold spores. These spores are tiny fungi that are continuously floating in the air and thrive in moist. Aspergillosis is an infection, usually of the lungs, caused by the fungus Aspergillus. A ball of fungus fibers, blood clots, and white blood cells may form in the lungs or sinuses. People may have no symptoms or may cough up blood or have a fever, chest pain, and difficulty breathing. If fungi spread to the liver or kidneys, these organs may. standard method for detecting Aspergillus precipitins, but it is a qualitative test of low sensitivity. Enzyme linked immunosorbent assay (ELISA)methods for detecting specific IgG antibodies to Afumigatus have greater sensitivity.5 Many comparisons have been made between ELISA and agar gel double diffusion tests, but these have usually bee .15. This private blood test for Aspergillus Precipitins in London has a guaranteed turnaround time of 6 working days and tests for Aspergillus Precipitins only. Turnaround Time. Order Online Now. A GP Referral is Included. Attend the Walk-in Laboratory. Receive Accredited Testing. Doctor's Comments are Available
Blood tests check for the presence of Aspergillus antibodies (Aspergillus precipitins). These precipitins bind with the spores and form tiny solids. Around half of all people with ABPA have elevated levels of immunoglobulin E, or IgE, which is a type of blood protein that prompts allergic reactions Aspergillus antigen (galactomannan) Microbiology Notes. This test is useful for diagnosis of invasive aspergillosis and monitoring treatment of invasive aspergillosis; This test is only performed after discussion with a Consultant Microbiologist; Sample requirements. Serum - paired samples not required. 8.5ml of blood taken into a plain gel.
Blood tests like RAST and ELISA can test for a range of allergies, including food allergies, drug allergies, seasonal allergies, and pet allergies.. Along with diagnosing current allergies, blood. . Results above 0.1 kU A/l are indicative of an allergen-specific IgE sensitization.1 Total IgE reference ranges are dependent on age. You must use your lab's reference range for Total IgE located on the results. Specific IgE1 normal Total IgE3 3normal Birch, Common Silver <0.1
This study was undertaken to examine the performance of the Fungitell β-glucan (BG) assay, to compare it with that of the galactomannan (GM) test for the diagnosis of invasive aspergillosis (IA) in patients with hematological malignancies, and to examine the rates of false-positive BG and GM test results due to β-lactam antibiotics among sera of patients with Gram-positive or Gram-negative. Two or more consecutive positive results should be obtained from separately drawn specimens before the patient is considered to have a positive Aspergillus antigen test. Specimen requirement is a red top tube of blood or 1.5 mL of bronchoalveolar lavage fluid. Reference . Micelli MH and Kauffman CA Blood tests for fungal antigens, antibodies or molecular tests may be used to determine if a patient has, or recently had, a specific fungal infection. They are more rapid than fungal cultures but only test for a few specific fungal species which cause systemic infections, so the doctor has to know what fungal organism to test for Aspergillosis. Aspergillosis is a condition caused by breathing in aspergillus mould. Most people who breathe in the mould do not get ill, as the body's immune system destroys the spores. But it can develop in people with an existing lung condition or a weakened immune system. There are different types of aspergillosis - most affect the lungs.
Pre-Test Preparation: Complete LifeLabs requisition. Note: All of the following tests (when ordered together), can be combined into one 3.5 mL SST Gold top tube. Actinomyces Vulgaris (AVP) Aspergillus Antibody (ASPER) Avian Preciptin Antibody (AVI) Thermophillic Fungi Precipitate (TFP) Specimen Handling: Collect blood in a 3.5 mL SST Gold top tube 0.1ml blood (LT), slides 0.3ml plasma (GT) 99.00: Aspergillus Panel (Antibody, EPH+ Galactomannan) 0.12ml plasma (GT) 95.00: Aspergillus Panel PLUS (Antibody, EPH+ Galactomannan, Gliotoxin) 0.25ml plasma (GT) 135.00: Aspergillus Panel - Dolphin (Antibody by ELISA, SAA, EPH) 0.1ml plasma (GT) 125.00: Aspergillus Panel - Penguin. These values provide labs with the numeric references they need to interpret a blood test result. Each allergen has its own reference value which the lab will interpret individually. Most labs will report the RAST findings on a scale of 0 to 5 or more. A 0 value suggests a low likelihood of an allergy. Values at the upper end are indicative of. 1 /2 Division of Laboratory Medicine Immunology mft.nhs.uk/laboratorymedicine 1/2 Aspergillus fumigatus precipitins General information Precipitin testing: These tests detect the presence of IgG antibodies to Aspergillus fumigatus, Aspergillus precipitins - see also: Farmer's lung and Avian Precipitin
Humidity and water damage can cause mold growth in your house. An allergy blood test for Stachybotrys Chartarum Atra, IgE can help determine if you are at risk from this common type of mold. Request A Test is the leading provider of affordable nationwide allergy testing An example is cystic fibrosis in which the baseline Aspergillus IgG antibody titres are higher than normal controls. IgE antibody testing against A. fumigatus is useful to detect Aspergillus sensitisation. The skin prick test against A. fumigatus is more sensitive than blood testing. Either is required for the diagnosis of ABPA (usually both. The Aspergillus-specific LFD test is based on the detection of an extracellular glycoprotein (different from GM) secreted by Aspergillus spp. constitutively during active growth (Thornton, 2008). This test can be performed in serum and BALF samples with comparable sensitivity to GM detection and higher specificity, although it shows cross. This blood test measures: Penicillium. Cladosporium. Aspergillus. Alternaria. Test instructions. Download and print your pathology form from your i-screen dashboard. Take your form to one of our affiliated collection centres to have your sample taken
Chemotherapy lowers the white blood cell count or weakens the immune system for a long time. This puts the patients at a high risk of getting a serious fungal infection of the internal organs or blood. One of these infections is caused by a mold called Aspergillus and can be life threatening Fungitell®, an FDA cleared and CE marked diagnostic test, is used for the detection of (1→3)-β-D-Glucan, which is frequently associated with the presence of fungal pathogens. The majority of these are Candida and Aspergillus species. Rapid Screening For Invasive Fungal Infection
Researchers are currently attempting to develop a practical, specific, and rapid blood test that would confirm Aspergillus infection. Signs of ABPA include a worsening of bronchial asthma accompanied by a low-grade fever. Brown flecks or clumps may be seen in the sputum. Pulmonary function tests may show decreased blood flow, suggesting an. Test Interpretation and Management Options Utilizing ImmunoCAP®' KU/L Results * Pediatric reference ranges are age dependent. See medical report. The ImmunoCAP test demonstrates patient sensitivity to speci˜c allergens - reporting in number of kilounits per liter (KU/L). Management Options for ImmunoCAPSpeci˜c IgE Blood Test Speci˜c IgE.
Test Information. This is a searchable database of information about tests offered by Severn Pathology. You can browse the index, enter a test name, part of a test name, abbreviation or clinical indication below. The containers listed refer to those used to collect samples from adults locally in GP practices and hospital wards/outpatients