Ambient Voice Technology
We are trialing Ambient Voice Technology in some Outpatient appointments
From March 2026, we are running a 12-month trial of Ambient Voice Technology (AVT) in some of our Outpatient appointments.
Ambient Voice Technology (AVT) is like having a smart helper that, with your permission, listens to you and your clinician’s conversation during your consultation, automatically turning the conversation into notes.
This trial is starting with a small number of clinicians in Gynaecology, Urology, Neurology, Gastroenterology and Hepatology Outpatient clinics.
If your clinic has the option to use AVT, you will be informed at the start of your appointment. We will only use AVT with your consent. If you choose not to consent to the use of AVT, your appointment will continue as normal.
What is AVT?
AVT is a smart tool that helps your healthcare team take notes during your appointment.
- It only listens to what you and your clinician talk about if you give consent, and it never records.
- It captures your conversation in real time and turns it into notes and letters for your health record.
- Your clinician checks everything to make sure it’s correct.
You might have seen something like this if you’ve ever talked to your phone, used voice commands in a car, or asked a smart speaker to do something.
What will happen if you say yes to AVT?
- A microphone, mobile device, or laptop will listen to what you and your clinician say during your appointment.
- Your appointment will feel the same, but your clinician won’t need to type as much – they can focus more on you.
- The AVT captures your words into text straight away and creates a summary and clinic letter.
- After your appointment, your clinician checks the notes and letters to make sure they are correct before adding them to your health record.
Why are we trialing AVT?
We want to see if AVT helps our patients and clinical teams.
- It lets clinicians spend more time talking to you instead of typing notes.
- It writes while you talk in real time, so your health records are more accurate and ready faster.
- This could mean letters or referrals get sent to your GP or other healthcare services more quickly after your appointment.
Your privacy is really important. At the start of your appointment, your clinician will tell you if AVT is an option. You can choose to have your appointment with or without AVT.
Your information is always encrypted and securely handled meeting GDPR and NHS standards. Only authorised staff at the hospital access it.
Do you store recordings of my appointment?
No, we don’t keep recordings.
- AVT writes down the words while you talk - it does not save the sound.
- Only discussions that are relevant to your care and documentation will be added to your health record.
- Private or sensitive conversations that aren’t about your care are not added.
- We always follow consent protocols in line with NHS guidance.
Can I choose not to have AVT during my appointment?
Yes, you can choose not to use AVT in your appointment. Your appointment will continue as normal. You are welcome to discuss your choice or concerns with your clinician who will respect your choice and ensure it is documented.
Who can I contact if I have questions about AVT before my appointment?
Contact your clinical team or clinic using the information at the top of your appointment letter. You are welcome to ask questions during your appointment.
More information
For details on how we collect, use and store personal information, including data collected via digital tools in outpatient settings, please visit our Privacy Policy and Data Protection webpage.
Low insoluble fibre diet
Introduction
You have been asked to follow a low insoluble fibre diet. This can help improve symptoms, give your bowel time to rest after surgery, or help prevent a blockage in your bowel.
You may only need this diet for a short time. If your doctor says you need to follow it for longer than a month, we might suggest taking a daily multivitamin to make sure you get all the nutrients you need.
If you have any questions or worries about this diet, ask your doctor or healthcare professional.
Types of fibre
There are different types of fibre in the foods we eat. The two main types are called "soluble fibre" and "insoluble fibre."
Soluble fibre
Soluble fibre mixes with water in your gut and turns into a gel-like substance that your gut bacteria can break down. It can help with both diarrhoea and constipation. Soluble fibre is usually safe for you to eat.
Here are some examples of foods with soluble fibre:
- Milled or ground oats, like Quaker Oat So Simple or Ready Brek.
- Fruit without the peel, seeds, or skin.
- Vegetables without the peel, seeds, or skin.
Insoluble fibre
Insoluble fiber is the "roughage" in our food. It does not get broken down by our body and helps make our stools bigger and easier to pass.
Here are some examples of foods with insoluble fiber:
- Wholegrain foods like brown or seeded bread, cereal, rice, pasta, and couscous.
- Skins of vegetables, fruits, beans, and pulses
- Pith, seeds, and stringy parts of fruits and vegetables.
- Nuts and seeds.
- Salad and leafy greens.
Removing insoluble fibre
Many foods, like some fruits, vegetables, beans, and lentils, have both soluble and insoluble fibre. To make these foods easier for you to eat, you need to remove the insoluble fibre.
Here’s how you can do that:
- Peel the skins and cook vegetables until they’re soft.
- Peel the skins and stew fruits until they’re soft.
- Peel and remove seeds, then blend vegetables into a smooth soup or sauce, or fruits into a smoothie.
- If you can’t peel or remove seeds, blend the fruit or vegetable and then use a sieve to strain out the “bits”.
Recommended foods and foods to watch
| Food type | Recommended foods (low insoluble fibre) | Foods to watch (higher insoluble fibre or foods that increase risk of blockage) |
|---|---|---|
| Meat, fish and meat alternatives | Most meats, fish or meat alternatives are fine to eat. Including:
| Processed meats or fish dishes that have fruit or vegetables are not suitable. Including:
|
| Dairy and dairy alternative foods | Most dairy or dairy alternative products are fine to eat. Including:
| Dairy or dairy alternative products containing fruit or vegetables are not suitable. Including:
|
| Vegetables |
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| Fruit | Some fruits are suitable but you need to peel, remove seeds and cook well. Including:
| Fruits where you cannot peel, remove seeds, or piths are not suitable. Including:
|
| Cereals | ‘White’ varieties are suitable. Make sure there are no nuts, seeds or dried fruit. Including:
| Wholemeal, wholegrain and brown varieties are not suitable. Including:
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| Miscellaneous |
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Meal ideas
Breakfast:
- Cereal with milk, such as cornflakes, rice crispies.
- White toast, low fat spread and a topping such as smooth jam, smooth peanut butter.
Midday meal:
- White bread sandwich with lean meat, fish, eggs, cheese or a meat alternative.
- Jacket potato with cheese , fish, chili without beans and blended onions or onion powder. Remember to avoid the potato skin.
- Smooth pesto pasta with chicken breast and cheese.
- Smooth soup with white bread.
- Peeled roasted root vegetables with white pasta, couscous, rice.
Evening meal:
- Meat, fish, or a meat alternative with peeled mashed potatoes, and peeled, well-cooked carrots and broccoli florets.
- Stew with peeled and well-cooked carrots, potatoes, and courgette.
- Meat or meat alternative stir fry with white rice or noodles, and peeled carrot, courgette, and broccoli florets.
- Spaghetti Bolognese made with lean mince, peeled carrots, onion/garlic puree or powder, and passata tomato sauce (using white spaghetti).
- Fish pie with peeled carrots, broccoli florets, and a peeled mashed potato topping.
- Meat, fish, or cheese risotto made with onion/garlic puree or powder.
Tips
- High insoluble fibre foods include:
- Nuts
- Pips
- Piths
- Seeds
- Skins on fruits and vegetables
- Wholemeal/grain
- Leaves
- If you cannot peel a fruit or vegetable, like raspberries, they’re not suitable - unless blended into a smooth consistency. Sieve any remaining bits out.
- Prepare a sauce as usual (e.g. with onions, garlic, peppers), then blend and sieve to remove large bits. Cook meat or meat alternatives separately, then add the blended sauce.
- Blend onions, garlic, and ginger, then freeze in portions using an ice cube tray to add to meals later.
- Batch freeze peeled vegetables to save time later.
- Onion, garlic, and ginger powder can be used instead of whole onions, garlic, or ginger.
- Salad alternatives:
- Cooled white pasta with smooth pesto or a smooth tomato sauce (such as passata).
- White rice or couscous with peeled and roasted root vegetables.
- Peeled white or sweet potato salad with a smooth dressing.
- Add protein like cheese (such as feta, halloumi) or egg.
© North Bristol NHS Trust. This edition published January 2025. Review due January 2028. NBT003820
Charities
AAC charities
Assistive technology charities
Others
- Sequal Trust
- Digital Legacy Association. Information about end of life wishes related to digital assets.
Powered AAC resources
AAC software and apps
- Windows software - see AAC suppliers below.
- AAC apps for iPad and Android:
- Aphasia Software Finder (The Tavistock Trust for Aphasia)
- AAC Language Library (Ace Centre)
AAC Suppliers
See our recommendation on arranging supplier visits on How AAC WEST work with independent professionals, suppliers and charities
- Smartbox (Grid 3, Grid for iPad)
- Tobii Dynavox (TD Snap, Communicator 5, TD Talk)
- Jabbla UK (Mind Express 5, Allora)
- Liberator (NuVoice, Lamp, Touch Chat)
- AssistiveWare (Proloquo, Proloquo2Go, Proloquo4text, simPODD)
- Therapy Box (Predictable, Scene & Heard)
- Abilia (Lightwriter, MicroVoice)
- Widgit Online
Mounting and switches
Access
Accessibility settings
Accessibility settings on mainstream devices can be changed and may support someone to use direct touch.
- Ability Net – how to guide
- Apple iOS iPad / iPhone accessibility
- Google accessibility
- Microsoft Windows accessibility
Styluses
Styluses are available from a number of suppliers including these:
- Standard pen styluses
- Ultra Lightweight Ball Stylus from Liberator
- Dad In A Shed Styluses
Switch access
- Single message switches such Talking Tiles (black ones are £9), Little Mack, Big Mack available from www.inclusive.com
- Other switches such as Buddy button, Specs switch, Palpad available www.inclusive.com
Developing switching skills
- Switch Heroes – Jiao
- FUNctional Switching - CENMAC
- Inclusive Technology Switch progression road map
- HelpKidzLearn - Switch Skills Journey
Eye gaze access
Developing eye gaze skills
Other useful links
- Digital Legacy Association – information about end of life wishes related to digital assets.
- Charities - AAC/assistive technology
- Voice and message banking
- AAC WEST Service Products
Resources for symbol users (child or adult)
Paper-based AAC resources
Symbolised communication boards and books:
- Core First Communication Books (Tobii Dynavox UK)
- Super Core boards (Smartbox) and Super Core book (Smartbox)
- Visual support for healthcare (Widgit Health)
- Communication books / charts (Widgit Online) – communication books/charts
- Symbol charts in Resources (Ace Centre)
- Symbols for All
- Clues Book (Ace Centre)
- Communication Pack for Adults who Benefit from Symbol Support (Ace Centre)
When pointing is difficult (note the above resources may also be accessed with partner assisted scanning).
- AAC WEST Partner Assisted Scanning Training [link coming soon]
- Access to paper-based symbol resources when pointing is difficult (Ace Centre)
- Look to Talk (Ace Centre) – eye pointing communication book
- PODD communication books – pragmatically organised communication books made for direct and alternative access
- PODD books (direct access) – Mind Express 5 (Jabbla UK)
- PODD books (alternative access) – Mind Express 5 (Jabbla UK)
- PODD app for making books - simPODD (AssistiveWare)
- For other partner assisted scanning charts and books you can explore Ace Centre’s resources, such as Pragmatic chart and Pragmatic book.
Communication passports/Health passports
Powered AAC resources
Multilingual resources
AAC Assessment Tools
- Talking Mats – Readiness for AAC
- I-ASC Explanatory Model of AAC Decision Making
- Frenchay AAC screening tool
- The Pragmatics Profile for People who use AAC (Ace Centre)
- C.O.D.E.S - Paeds and Adult versions
- DAGG-3 (Tobii Dynavox)
- Eye pointing classification scale (UCL)
- Communication Matrix
- AAC Evaluation Genie App - App Store
AAC Implementation Resources
- Smartbox Academy
- Pathways (Tobii Dynavox)
- STAR Video Library
- Online AAC Training (Call Scotland)
- Stepping into AAC (Angelman Syndrome Foundation)
- Communication Bill of Rights | Widgit Symbol Resources
Yes/No shaping
- Getting Started with Yes/No | Ace Centre
- Teaching Learners with Multiple Special Needs: The Yes/No Series - Part One
Modelling
- AAC WEST Modelling training
- The AAC Coach (free resources - requires sign up)
- AAC Everyday: Communication Opportunities in Everyday Life (Avaz Inc.)
- Getting Started with Modelling (Ace Centre)
- Modeling: Use AAC to teach AAC (AssistiveWare)
- Choosing activity first available at Handouts and Presentations | Liberator Ltd
- Planning for core words (AssistiveWare)
Communication partner training/resources:
- Communication Partner Training | North Bristol NHS Trust
- Simple AAC framework (Smartbox)
- The Do's and Don'ts of AAC (AssistiveWare)
- Getting Started with Paper-Based Symbol Resources (Ace Centre)
- Videos about coaching parents (Rachel Madel - SLP)
- Communication Partners training and resources (Ace Centre)
- How to be a respectful communication partner (AssistiveWare)
- Please also see on this page the Person-Centred Communication Partner Checklist.
- Communication Partner Profile - OpenAAC
Resources for alphabet users (child or adult)
These resources are designed for people who will use the alphabet to spell messages to support their communication.
Paper based resources
For the alphabet charts you need to convert to PDF before printing. This will make sure background colours print correctly. (How to: Once editing done 'Save as' and change the file type to PDF OR Print and select 'Print to PDF'. Open the PDF and then print).
Alphabet charts - direct touch
These documents are for you to download, edit, and print. Remember to save as PDF before printing.
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Alphabet charts - partner assisted scanning (PAS)
These documents are for you to download, edit, and print. Remember to save as PDF before printing.
| Preview | Document |
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For other alphabet charts you can explore the Ace Centre Resources:
Alphabet and phrase charts - eye pointing
- Eye Talk (free) - 2 step alphabet for fist pointing or eye pointing - go to KM CAT for health professionals and scroll down to Eye Pointing resources and then Eye Talk
- Eye Link (free) – alphabet for eye pointing
- E-tran Frame (comes with letters) – alphabet for colour encoded eye pointing
- Speakbook (free) – alphabet and phrases for colour encoded eye pointing
Phrase charts and books - partner assisted scanning
These documents are for you to download, edit, and print.
| Name | Information | Preview | Resource |
|---|---|---|---|
| Simple scanning communication chart | A simple communication chart for users to scan and respond yes or no to various options. |
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| Pragmatic PAS chart (adapted) | This chart is adapted from the work of Linda J Burkhart and from the version available on Ace Centre. The communication chart is designed to be read aloud by the communication partner. When the person who is using the chart to communicate hears the option they want to communicate, they indicate “yes” in some way. Try and read aloud the options in a neutral voice. When an option is selected, you could repeat the word or phrase selected in a livelier voice. You will see examples of this in the videos below. Begin by personalising the vocabulary on the chart. You will find it easier if you keep to the structure provided, but anything can be changed. Consider laminating the chart, ideally using a matt laminate pouch. Or you could print the chart on tearproof/waterproof paper or use card. The chart references a spelling chart. You can download a wide range of alphabet charts from Ace Centre. You can view videos of communication books based around similar principles as this chart being used on the Ace Centre’s YouTube page Ace Centre - YouTube. |
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| PAS chart (5 blank categories) |
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PAS Chart (5 categories).docx29.56 KB
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- For other partner assisted scanning charts and books you can explore:
- Ace Centre’s resources, such as Pragmatic chart and Pragmatic book.
- Resource center (Tobii Dynavox UK)
Powered AAC resources
Multilingual resources
AAC assessment tools
- The Pragmatics Profile for People who use AAC (Ace Centre)
- C.O.D.E.S (Paeds and Adult versions)
- Talking Mats – Readiness for AAC
AAC implementation resources
- Communication partner training | North Bristol NHS Trust
- Being a Communication Partner (Ace Centre)
- AAC for MND (MND Association)
- How to be a respectful communication partner (AssistiveWare)
- Please also see on this page the Person-Centred Communication Partner Checklist.
Resources for adults with aphasia
These resources are for supporting people with aphasia to use AAC within a total communication approach with communication partner support.
Paper-based AAC resources
Powered AAC resources (aphasia specific)
- Grid (iPad / Windows) – Aphasia Duo (Smartbox)
- TD Snap (iPad / Windows) – Aphasia Pageset (Tobii Dynavox)
- Touch Chat (iPhone / iPad / Android) - Communication Journey Aphasia (Liberator)
- Aphasia Software Finder (The Tavistock Trust for Aphasia)
- Also see Powered AAC resources (including AAC software and apps, AAC suppliers, resources for support access methods)
Multilingual resources
Articles, webinars and blogs for SLTs
- Journal article: Revisiting the Role of AAC in Aphasia Rehabilitation (Dietz et al. 2020)
- PrAACtical AAC blog about AAC strategies for people with aphasia
- Podcasts, webinars, interviews - scroll down to PODCASTS (TD Snap)
- Webinar: Introducing Aphasia Duo (Smartbox)
- AAC for persons with primary progressive aphasia
AAC Assessment Tools
- See above for articles, webinars and blogs for SLTs
- Multimodal Communication Screening Task For Persons With Aphasia (MCST-A)
- Framework for assessment and implementing AAC with people with aphasia on CAYA Resources. Scroll to AAC Resource for Individuals with Aphasia (revised 2024).
- Frenchay AAC Screening tool (AAC WEST) AAC WEST Products
- The Pragmatics Profile for People who use AAC (Ace Centre)
- C.O.D.E.S (Paeds and Adult versions)
- Readiness for AAC (Talking Mats / Ace Centre)
AAC implementation resources
- See above for articles, webinars and blogs for SLTs
- Framework for assessment and implementing AAC with people with aphasia on CAYA Resources. Scroll to AAC Resource for Individuals with Aphasia (revised 2024).
- Supporting Communication for People with Aphasia (Ace Centre)
- Talking to Your Family Member/Friend with Aphasia: Conversation Basics (Aphasia Institute)
- Communication Bill of Rights | Widgit Symbol Resources
Support with AAC devices
Support with AAC devices
Here is some information about what to do for some common issues with AAC devices.
Please only contact AAC WEST about devices that we are responsible for.
Our contact details are at the bottom of this page.
Mounting problem
Issue with a current mount?
- Contact AAC WEST Tech Team (see details at the bottom of the page).
Need a new mount?
- Complete a mounting referral form AAC WEST Referral | North Bristol NHS Trust
Hardware problem
Issues with:
- Screens
- Camera
- Charger
- Turning device on
Contact AAC WEST Tech Team (see details at the bottom of the page).
Software problem
Issues with:
- Device not speaking.
- Device freezing/crashing.
- Device not working as normal.
First try:
- Power off and turn it on.
- For iPads, try a hard shut down.
- Complete all hardware and software updates.
If not resolved first contact:
- The local team, for example teacher, support worker, and local speech and language therapist.
- The supplier see (details at the bottom of the page).
If not resolved:
Contact AAC WEST Tech Team (see details at the bottom of the page).
Editing
Need to make changes to the vocabulary such as:
- Adding words.
- Changing symbols.
- Adding pages.
First explore:
- Editing and training videos: Software Training
- Read the dos and don'ts of editing: Editing vocabulary - dos and don'ts
- Supplier website (see details at the bottom of the page).
If not resolved first contact:
- The local team, for example teacher, support worker, and local speech and language therapist.
- The supplier (see details at the bottom of the page).
If not resolved:
- Contact AAC WEST Tech Team (see details at the bottom of the page).
Supporting AAC users
Support with:
- Help to learn how to use their AAC.
- Modelling AAC.
- Communication partner skills.
First explore:
- AAC WEST - Training videos
- Emails and/or reports from AAC WEST.
If not resolved first contact:
- The local team, for example teacher, support worker, and local speech and language therapist.
- The supplier (see details at the bottom of the page).
If not resolved:
- Contact AAC WEST Tech Team (see details at the bottom of the page).
Supplier contact details
Check your device for the company name. Suppliers can support with a range of issues. If you give them consent they can have remote access to your device to provide support.
- Smartbox (Grid)
- info@thinksmartbox.com
- 01684 578 868
- www.thinksmartbox.com
- Jabbla UK (previously called Techess)
- info@jabbla.co.uk
- 01476 561 991
- www.jabbla.co.uk
- Tobii Dynavox
- support.uk@tobiidynavox.com
- 0114 481 0011
- www.uk.tobiidynavox.com
- Liberator
- info@liberator.co.uk
- 01733 370 470
- www.liberator.co.uk
AAC WEST contact details
Please contact us if the above do not resolve your device issue.
Admin
For admin, appointments, and referral queries.
- aacwestadmin@nbt.nhs.uk
- 0117 414 5850
Tech Team
For hardware issues like faulty batteries, broken screens, missing equipment, and frozen iPads.
- aacwesttech@nbt.nhs.uk
- 0117 414 5850
Support
Support for software issues like missing grid sets/cells, Dropbox/account issues, and connectivity.
- aacwestsupport@nbt.nhs.uk
- 0117 414 5850
© North Bristol NHS Trust. This edition published October 2025. Review due October 2028. NBT003817.
Cellular Immunology / Immunophenotyping Laboratory
Leukaemia and Non-Hodgkin Lymphoma Diagnosis and Monitoring
The laboratory provides a comprehensive service in the investigation of Leukaemia and Non-Hodgkin Lymphoma. Immunophenotyping provides additional information to morphology and cytogenetics in the diagnosis, classification and monitoring of these disorders.
HIV Monitoring
Immunophenotyping is used serially to monitor CD4 levels.
Investigation of Cellular Immunodeficiency Disease
Wrong choice of tests, especially in the paediatric setting, can mean rare cases of immunodeficiency are missed. Vital information includes type and site of infections, family history, other pathology results, X-rays and clinical features. Please refer to the Clinical Immunologists: ward or clinic referral is the ideal.
- Immunophenotyping identifies numerical defects in lymphocyte subsets, inherited or acquired, and are indicated in cases with recurrent viral, fungal or mycobacterial infection.
- PNH Testing performed on peripheral blood samples looking for the absence of GPI-linked proteins on neutrophils, monocytes and red blood cells.
- Functional Leucocyte Assays
These assays are technically complex and require prior discussion with the laboratory. Abnormalities are rare, most commonly due to poor sample quality, testing during drug therapy or intercurrent infection. Abnormal findings should always be confirmed on a second sample. True abnormalities may need further, more specialised tests to specify the disorder.
- Lymphocyte function studies are indicated in cases of recurrent viral, fungal and mycobacterial infections in whom no numerical lymphocyte defect has been defined. The investigation provides a measure of lymphocyte activation. Lymphocytes are cultured for 5 days with mitogens which mimic antigen activation.
- Neutrophil function studies screen for defects in the metabolic burst and adhesion molecules and are indicated in cases with recurrent fungal or bacterial infection with a normal neutrophil count (>1x109/1).A normal result excludes major defects in neutrophil function.
Quantiferon Assay
The QuantiFERON-TB test is an interferon gamma release assay (IGRA) used for the diagnosis of latent Tuberculosis (TB). The assay requires special blood tubes and has specific sample handling requirements. The laboratory can issue guidance and sample tubes to requestors. Interpretation of the result needs to be in the context of clinical history and other laboratory and clinical investigations. The antigens used in the test are absent from all BCG vaccine strains of TB and from most known non-tuberculoid mycobacteria, it is possible to have a reactions to M. kansasii, M. szulgai and M. marinarum. If such infections are suspected, alternative testing should be sought.
The QuantiFERON-TB test (and other TB IGRAs) may give false negative results in immunosuppressed patients. The laboratory provides a positive control tube for all tests to ensure the validity of results. Where the positive control fails (indeterminate result) the laboratory may suggest alternative testing. Please see guide below for interpreting indeterminate results.
Guide to interpretation
• Negative: A negative result indicates that latent infection with M. tuberculosis is NOT likely. This result does NOT exclude active TB infection. The investigation of suspected active TB requires clinical, radiological and microbiological assessment.
• Positive: A positive result is consistent with latent or active TB. This result may be due to exposure to M.tuberculosis complex (except M. bovis BCG), M. kansasii, M. szulgai or M. marinarum. IGRA should not be used for the investigation of suspected active TB. The investigation of suspected active TB requires clinical, radiological, and microbiological assessment.
• Indeterminate: The likelihood of the patient having M. tuberculosis infection cannot be determined from the blood sample provided. Please see the guide to interpreting indeterminate results below.
Quick guide to interpreting INDETERMINATE and EQUIVOCAL QuantifFERON-TB results
INDETERMINATE RESULTS
An indeterminate result from the QuantiFERON-TB assay means that the likelihood of the patient having M. tuberculosis infection cannot be determined from the blood sample provided.
The majority of indeterminate results are caused by a low T lymphocyte response to mitogen stimulation (reported as mitogen tube failure).
This can be caused by:
• An insufficient number of T lymphocytes in the blood sample. Is the patient immunosuppressed?
• A functional inability of the patient’s lymphocytes to generate Interferon-gamma (IFN-γ) in response to mitogenic stimulation, for example if they are taking drugs that supress their immune system.
• Reduced lymphocyte function due to improper sample handling.
Ideally repeat the QuantiFERON-TB test once with a fresh blood sample. If a mitogen tube failure is reported a second time, there is no value in repeating the QuantiFERON-TB test again until the underlying cause has been identified and resolved.
Rarely a high background in the negative control (Nil) tube generates an indeterminate result.
This can be caused by:
• Excessive levels of circulating IFN-γ or the presence of heterophile antibodies in the sample. Stimulating the cells further as part of the QuantiFERON-TB test does not produce a further IFN-γ response.
Ideally repeat the QuantiFERON-TB test once with a fresh blood sample. If a high background is reported a second time, there is no value in repeating the QuantiFERON-TB test again until the underlying cause has been identified and resolved.
Other causes of indeterminate results can include:
• Incorrect filling/mixing of the Lithium Heparin or QuantiFERON-TB tubes.
• If the time between venepuncture and sample incubation in the laboratory is greater than 16 hours.
These indeterminate samples should be repeated using the correct sampling and handling procedures.
For further information please see:
EQUIVOCAL RESULTS
An equivocal reference range of 0.2 – 0.7 IU/mL is now applied to the Q-TB results generated when subtracting the negative control tube value (NIL) from the TB1 and TB2 tube results: TB1-NIL and TB2-NIL.
Where both TB1-NIL and TB2-NIL results are within the equivocal range (0.2 – 0.7), or where one result is equivocal (0.2 – 0.7) and one is true negative (<0.2) the Q-TB results will be reported as EQUIVOCAL with the following interpretation applied:
The significance of this result is uncertain. The risk of progression to active TB disease is likely to be different when compared to patients with clear positive (>0.7) or clear negative (<0.2) results. Suggest repeat testing if clinically indicated; approximately one third of patients with equivocal results will revert to either a clear positive or clear negative result when a fresh blood sample is analysed within six months. We would recommend repeat testing again in 4-8 weeks where practical. Where this is not practical, we would recommend a repeat test in weeks rather than days.
Why have we implemented an equivocal reference range?
Reversion and conversion of low positive (TB-NIL: 0.35 – 0.7) and high negative (TB-NIL: 0.2 – 0.34) Q-TB results on repeat testing is a well-recognised phenomenon. To address this issue, multiple European centres have proposed an equivocal range of 0.2 – 0.7 IU/mL [1-7]; conversion to true positive results have been shown to occur most frequently when the first Q-TB result is between 0.2 – 0.35 IU/mL, and reversions to a true negative result have been shown to occur more frequently when the initial result is between 0.35 – 0.7 IU/mL [5].
The Royal Free hospital in London has implemented this equivocal range in line with other low-incidence TB European settings [6]. Data from the Royal Free lends support to the use of the equivocal range for the reporting of Q-TB results; ~1/5th of their results that fell just below the 0.35 cut-off were positive when repeated on a fresh blood sample, and half of those just above the 0.35 threshold were negative when repeated on a fresh blood sample. This data strongly implies that relying on results within the equivocal range could result in either over-treatment or under-treatment of patients.
- Torres Costa J, Silva R, Sa R, et al. Serial testing with the interferon-gamma release assay in Portuguese healthcare workers. Int Arch Occup Environ Health 2011; 84: 461–469.
- Schablon A, Harling M, Diel R, et al. Serial testing with an interferon-gamma release assay in German healthcare workers. GMS Krankenhhyg Interdiszip 2010; 5: Doc05.
- Schablon A, Diel R, Diner G, et al. Specificity of a whole blood IGRA in German nursing students. BMC Infect Dis 2011; 11: 245.
- Ringshausen FC, Schablon A, Nienhaus A. Interferon-gamma release assays for the tuberculosis serial testing of health care workers: a systematic review. J Occup Med Toxicol 2012; 7: 6
- Nienhaus A, Ringshausen FC, Costa JT, et al. IFN-gamma release assay versus tuberculin skin test for monitoring TB infection in healthcare workers. Expert Rev Anti Infect Ther 2013; 11: 37–48.
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- Hermansen TS, Lillebaek T, Langholz Kristensen K, et al. Prognostic value of interferon-gamma release assays, a population-based study from a TB low-incidence country. Thorax 2016; 71: 652–658.
Test Information
Includes details of sample types, volumes, special precautions, turnaround times & reference ranges.