In situ bypass and diabetes

From 1986 through to 1990 a total of 483 in situ bypass procedures were performed in 444 patients. Preoperative risk-factors were equally distributed among diabetic (DM) and non-diabetic (NDM) patients, except for smoking habits (DM:48%, NDM:64%, p = 0.002) and cardiac disease (DM:45%, NDM:29%, p = 0.005). Critical limb-ischaemia was more often present in diabetic than non-diabetic patients (DM:57%, NDM:36%, p = 0.0002). Diabetic patients had a significantly lower distal anastomosis than non-diabetic patients (p = 0.00001). There were no differences among diabetic and non-diabetic patients regarding three years primary and secondary patency (58% and 64% respectively), and regarding major amputations. However, the rate of minor amputations was higher in insulin-dependent compared with non-insulin-dependent diabetics, who in turn had a higher rate than non-diabetics (p < 0.00001). A markedly decreased survival rate was found in diabetics (p < 0.00005). We found the in situ bypass technique very useful in the treatment of critical ischaemia of the lower limb in diabetic patients. The overall results in diabetic patients, whether insulin-dependent or not, were equal to those in non-diabetic patients.     

The contribution of non-insulin-dependent diabetes to lower-extremity amputation in the community

BACKGROUND: Despite the significant public health burden of lower-extremity amputations in diabetes mellitus, few data are available on the epidemiology of lower-extremity amputations in diabetes mellitus in the community setting. METHODS: A retrospective incidence cohort study based in Rochester, Minn, was conducted. RESULTS: Among the 2015 diabetic individuals free of lower-extremity amputation at the diagnosis of diabetes mellitus, 57 individuals underwent 79 lower-extremity amputations (incidence, 375 per 100,000 person-years; 95% confidence interval, 297 to 467). Among the 1826 patients with non-insulin-dependent diabetes mellitus, 52 underwent 73 lower-extremity amputations, and the subsequent incidence of lower-extremity amputation among these residents was 388 per 100,000 person-years (95% confidence interval, 304 to 487). Of the 137 insulin-dependent diabetic patients, four subsequently underwent five lower-extremity amputations (incidence, 283 per 100,000 person-years; 95% confidence interval, 92 to 659). Twenty-five years after the diagnosis of diabetes mellitus, the cumulative risk of one lower-extremity amputation was 11.2% in insulin-dependent diabetes mellitus and 11.0% in non-insulin-dependent diabetes mellitus. When compared with lower-extremity amputation rates for Rochester residents without diabetes, patients with non-insulin-dependent diabetes mellitus were nearly 400 times more likely to undergo an initial transphalangeal amputation (rate ratio, 378.8) and had almost a 12-fold increased risk of a below-knee amputation (rate ratio, 11.8). In this community, more than 60% of lower-extremity amputations were attributable to non-insulin-dependent diabetes mellitus. CONCLUSIONS: These population-based data document the magnitude of the elevated risk of lower-extremity amputation among diabetic individuals. Efforts should be made to identify more precisely risk factors for amputation in diabetes and to intervene in the processes leading to amputation.     

How far should blood pressure be reduced in diabetic hypertensive patients?

EPIDEMIOLOGY OF DIABETES: Diabetes mellitus and arterial hypertension are closely related diseases that strongly predispose an individual to atherosclerotic cardiovascular disease and to renal failure. High blood pressure is twice as frequent in diabetics compared with the general population, and often precedes and contributes to the development of diabetic nephropathy. The prevalence of coexisting arterial hypertension and non-insulin-dependent diabetes mellitus (NIDDM) is increasing as populations age, giving an increased prevalence of both diseases. TREATMENT OF HYPERTENSIVE DIABETIC PATIENTS: The goal of treating arterial hypertension in diabetic patients is to prevent death and disability associated with high blood pressure. In addition, other reversible risk factors for cardiovascular disease, seen so frequently in hypertensive diabetics, also need to be addressed. The optimal goal of blood pressure control in diabetics has not been established, but there are indications that it should be lower than the 130/85 mmHg systolic/diastolic pressure recommended by current guidelines. In the presence of multiple associated risk factors, most guidelines suggest a threshold for intervention of > or = 140/90 mmHg. In particular, in hypertensive diabetic patients intervention must be early and aggressive.     

Benefit of a favorable cardiovascular risk-factor profile in middle age with respect to Medicare costs

BACKGROUND: People without major risk factors for cardiovascular disease in middle age live longer than those with unfavorable risk-factor profiles. It is not known whether such low-risk status also results in lower expenditures for medical care at older ages. We used data from the Chicago Heart Association Detection Project in Industry to assess the relation of a low risk of cardiovascular disease in middle age to Medicare expenditures later in life. METHODS: We studied 7039 men and 6757 women who were 40 to 64 years of age when surveyed between 1967 and 1973 and who survived to have at least two years of Medicare coverage in 1984 through 1994. Men and women classified as being at low risk for cardiovascular disease were those who had the following characteristics at the time they were initially surveyed: serum cholesterol level, <200 mg per deciliter (5.2 mmol per liter); blood pressure, < or =120/80 mm Hg; no current smoking; an absence of electrocardiographic abnormalities; no history of diabetes; and no history of myocardial infarction. We compared Medicare costs for the 279 men (4.0 percent) and 298 women (4.4 percent) who had this low-risk profile with those for the rest of the study group, who were not at low risk. Health Care Financing Administration charges for services to Medicare beneficiaries were used to estimate average annual health care costs (total costs, those for cardiovascular diseases, and those for cancer). RESULTS: Average annual health care charges were much lower for persons at low risk - the total charges for the men at low risk were less than two thirds of the charges for the men not at low risk ($1,615 less); for the women at low risk, the charges were less than one half of those for the women not at low risk ($1,885 less). Charges related to cardiovascular disease were lower for the low-risk groups of men and women than for those not at low risk (by $979 and $556, respectively), and charges related to cancer were also lower (by $134 and $189). CONCLUSIONS: People with favorable cardiovascular risk profiles in middle age had lower average annual Medicare charges in older age. Having optimal status with respect to major cardiovascular risk factors may result not only in greater longevity but also in lower health care costs.     

Lipoproteins, apolipoproteins, and low-density lipoprotein size among diabetics in the Framingham offspring study

Diabetes mellitus has been shown to be associated with lipid abnormalities. Prior studies have indicated that women with diabetes have a risk of coronary heart disease similar to that of men. We compared lipid parameters in diabetic and nondiabetic participants in cycle 3 of the Framingham Offspring Study. Values for plasma total cholesterol (TC), triglyceride, lipoprotein, cholesterol, apolipoprotein (apo) A1, B, apo and lipoprotein(a) [Lp(a)] and low-density lipoprotein (LDL) particle size were analyzed in 174 diabetic and 3,757 nondiabetic subjects. Data from a total of 2,025 men and 2,042 women participating in the third examination (1983 to 1987) of the Framingham Offspring Study were subjected to statistical analysis. Male and female diabetics showed lower high-density lipoprotein (HDL) cholesterol, higher triglycerides, higher very-low-density lipoprotein (VLDL) cholesterol, lower apo A1, and higher LDL particle scores, indicating smaller size, than nondiabetics. Female diabetics also showed significantly higher TC and apo B values than nondiabetics. The results remained statistically significant after controlling for obesity and menopausal status. The presence of small dense LDL particles (pattern B) was highly associated with diabetes and hypertriglyceridemia in both sexes, and the relative odds for pattern B remained significant in women but not in men after adjustment for age and hypertriglyceridemia. No differences in apo E isoform distribution were found for diabetics and nondiabetics. Diabetes was not associated with elevated LDL cholesterol levels. In conclusion, diabetics have lower HDL cholesterol and higher triglyceride levels and are more likely to have small dense LDL particles. Diabetes is not a secondary cause of elevated LDL cholesterol. Lipid screening of diabetics should include full quantification of lipids for proper assessment of potential atherosclerotic risk.     

Angiographically documented coronary artery disease in asymptomatic middle aged men suspected of silent ischaemic heart disease

One hundred and fourteen asymptomatic middle aged men, with a positive stress test, underwent coronary angiography at Armed Forces Institute of Cardiology/National Institute of Heart Diseases (AFIC/NIHD), Rawalpindi. Of these, 66 (58%) were found to have significant disease (> 50% luminal narrowing in at least one of the major epicardial arteries) while 48 (42%) had normal coronary arteries. Of the former, 27 (41%) had 1-vessel CAD, 18 (27%) had 2-vessel CAD and 21 (32%) had 3-vessel CAD. There were significantly more hypertensives, hyperlipidaemics and diabetics in CAD group, while other risk factors were the same. The overall risk factor prevalence was low. The major reasons for performing coronary angiography were a positive stress test done as part of routine annual medical checkup and resting ECG changes of enough significance to warrant further investigations. It is concluded that the presence of significant coronary artery disease can be silent in a large number of asymptomatic middle aged men, especially those who have conventional risk factors.     

Characteristics of West Virginians having myocardial infarction

BACKGROUND: Prevalence of risk factors in patients having myocardial infarction (MI) have been reported in large US and international studies, but little is known about the prevalence of risk factors in West Virginians having MI. METHODS: Risk factors for MI were identified by ICD-9 codes. Logistic regression analysis was used to compute odds ratios and 95% confidence intervals. RESULTS: In this cohort (n = 727), 72% of men less than 65 years old were current smokers. Women were older and had a lower frequency of smoking and a higher frequency of diabetes mellitus and obesity than men. Women less than 65 years old had significantly more hypertension than men. CONCLUSIONS: In West Virginia, women who have MI are more likely to be nonsmoking diabetics with hypertension.     

Risk factors for postoperative morbidity

OBJECTIVE: Analysis of outcomes after coronary artery bypass grafting has focused on risk factors for operative mortality. Nonfatal perioperative morbidity is far more costly and more common after operation. To identify the risk factors that lead to postoperative morbidity, we evaluated 938 patients undergoing coronary artery bypass grafting at Albany Medical Center Hospital during 1993. METHODS: Multivariate statistical analysis was performed on preoperative patient variables to identify risk factors for either serious postoperative morbidity or increased hospital length of stay. Variables were considered both individually and in combination. For example, age was considered individually or in combination with other variables, including parameters of blood volume (i.e., age divided by red blood cell volume or Age/RBCVOL). Similar multivariate analysis was performed to identify independent risk factors for hospital mortality. RESULTS: In order of decreasing importance, the following patient variables were significantly associated with increased length of stay by stepwise Cox regression analysis: Age/RBCVOL, history of congestive heart failure, hypertension, femoral-popliteal peripheral vascular disease, chronic obstructive lung disease, and renal dysfunction. The combination variable, Age/RBCVOL, was an important risk factor for both increased length of stay and serious postoperative morbidity. Variables that were significant independent predictors of increased mortality, such as preoperative shock, and redo operation, were not risk factors for either serious morbidity or increased length of stay. CONCLUSIONS: We conclude that risk factors for postoperative morbidity are different from those for postoperative mortality. These results suggest that older patients with preoperative anemia and low blood volume who also have other comorbidities (congestive heart failure, stroke, chronic obstructive pulmonary disease, or hypertension) are at increased risk for postoperative complications. This allows identification of a high-risk cohort of patients who are likely candidates for interventions to lessen postoperative morbidity.     

Parvovirus B19 quiescence during the course of human immunodeficiency virus infection in persons with hemophilia

One hundred and seventy patients with major lower limb amputation (MLLA) presenting to The National Prosthetic-Orthotic Centre (NPOC) in Khartoum over a 1-year period were studied. There were 141 males and 29 females giving a M:F ratio of 4.9: 1.0, with mean age of 37 years (range 5-72 years). Forty-one patients (24%) underwent amputation of diabetic septic foot, 30 patients (17.6%) underwent amputation as a result of trauma from road traffic accidents and Madura foot, and war injuries accounted for 29 amputations (17%). One hundred and eleven patients had below knee amputation (BKA), 52 had above knee amputation (AKA) and seven patients had Syme's amputation. Diabetic amputees had higher rate of revisional surgery compared with others because of sepsis and/or flap necrosis. Stump pain was reported by amputees with excessive scarring of the stump and those with undue prominence of bony ends. There are two types of prostheses provided by the NPOC for both BKA and AKA: the peg leg and the conventional prostheses. The Syme's amputees were fitted with either simple hoof or articulated prostheses with solid ankle cushion heel (SACH). The peg leg consists of a leather lined side bearing metal socket connected to a rocker base by side steels. It is used by the country natives as it suits different weather and job conditions, particularly farming, and it can be repaired locally. The urban population use the conventional prostheses which is lighter in weight, can be put on and taken off easily and is cosmetically acceptable. However, these prostheses are more expensive and require frequent repair or replacement. The functional outcome of patient's rehabilitation with the prostheses was significantly affected by the level and indication of amputation. Those with BKA and those amputated because of trauma or Madura foot experienced better functional outcome compared with the diabetics, independent of age. 50% of patients with the AKA and 19% of those with BKA reported poor functional outcome. Surgeons should be more involved with the long-term evaluation of functional outcome in such patients, to offer help if feasible and to modify their technique for future procedures.     

Evaluation of cow-level risk factors for the development of winter dysentery in dairy cattle

OBJECTIVE: To identify exposures to etiologic agents and to identify characteristics that could explain risk of disease for adult cattle in herds affected by winter dysentery (WD). ANIMALS: 229 lactating and nonlactating adult cattle (125 case and 104 control cattle) selected from 12 dairy herds. PROCEDURE: A case-control study, using multivariate conditional logistic regression and controlling for herd effects, was used to develop a model for risk factors associated with disease for each cow. RESULTS: Likelihood of developing disease increased as the ELISA value for bovine coronavirus (BCV) antigen detectable in feces increased (odds ratio [OR] = 2.94 for each 0.100 increase in BCV antigen ELISA value). Pregnant cattle were less likely to develop WD, compared with nonpregnant herdmates. Cows with high acute BCV antibody titers that seroresponded had greater odds of developing disease, compared with seroresponding cows with low acute titers. However, among those cows that did not serorespond, high acute antibody titers were associated with lower odds of developing the disease. CONCLUSION: In herds affected by WD, ill cows were more likely to shed detectable amounts of BCV antigen in their feces, and pregnancy appeared to protect cattle from the disease. The measured interaction between BCV seroresponse and acute BCV antibody titer may be evidence of an immunopathologic condition, but could also have been attributable to dynamics of the ELISA or study design. CLINICAL RELEVANCE: Factors that explained a cow's risk for illness within WD-affected herds may have been surrogate measures for that cow's nonspecific and BCV-specific immune profile.     

Multivariate risk estimation for coronary heart disease: the Busselton Health Study

Coronary heart disease (CHD) is a multifactorial disease and CHD risk should be estimated by assessing all cardiovascular risk factors simultaneously. Simply adding up the number of factors with 'at risk' values fails to identify high-risk subjects with multiple risk factors at moderately elevated values. A more efficient approach is to use a quantitative multivariate risk score. A number of overseas studies have produced CHD risk scoring systems for men. There are few risk scores developed for women and no CHD risk scores have been developed from Australian data. This study used data on CHD risk factors and morbidity/mortality follow-up for the 1978 Busselton Health Survey participants to provide age-specific estimates of absolute risk of CHD hospitalisation or death, and to develop multivariate CHD risk scoring systems for men and women. The scores are based on age, blood pressure, anti-hypertensive medication, total and HDL cholesterol, smoking, diabetes, left ventricular hypertrophy and previous history of CHD. The generalisability and applicability of these risk estimation systems to Australian populations in the late 1990s is discussed.     

Diabetic foot ulcers: prevention, diagnosis and classification

Diabetic ulcers are the most common foot injuries leading to lower extremity amputation. Family physicians have a pivotal role in the prevention or early diagnosis of diabetic foot complications. Management of the diabetic foot requires a thorough knowledge of the major risk factors for amputation, frequent routine evaluation and meticulous preventive maintenance. The most common risk factors for ulcer formation include diabetic neuropathy, structural foot deformity and peripheral arterial occlusive disease. A careful physical examination, buttressed by monofilament testing for neuropathy and noninvasive testing for arterial insufficiency, can identify patients at risk for foot ulcers and appropriately classify patients who already have ulcers or other diabetic foot complications. Patient education regarding foot hygiene, nail care and proper footwear is crucial to reducing the risk of an injury that can lead to ulcer formation. Adherence to a systematic regimen of diagnosis and classification can improve communication between family physicians and diabetes subspecialists and facilitate appropriate treatment of complications. This team approach may ultimately lead to a reduction in lower extremity amputations related to diabetes.     

At risk of first or recurring heart disease

OBJECTIVES: The self-reported prevalence of risk factors for heart disease among Canadians with and without heart disease is estimated. The characteristics associated with these risk factors are examined in order to identify groups to be targeted for primary and secondary prevention. DATA SOURCE: The data are from the household component of the 1994/95 National Population Health Survey (NPHS). ANALYTICAL TECHNIQUES: For the population aged 20 and older with and without heart disease, bivariate and multiple regression analyses were used to determine associations between four risk factors (smoking, high blood pressure, diabetes, and inactivity) and demographic characteristics and socioeconomic status. MAIN RESULTS: According to the NPHS, 4.4% of people aged 20 and older reported that they heart disease. However, many more adults had risk factors for this disease. As well, about one-quarter of those without heart disease and half of those with heart disease had two or more risk factors. To some extent, many of these risks are modifiable. The groups particularly at risk were people older than 35, those with less than high school graduation, those in households with inadequate income, people who consumed three or more drinks a day, and residents of the Atlantic provinces, Quebec and Ontario.     

Case control study of feline Borna disease in Sweden

A questionnaire-based, retrospective case-control study of 174 Swedish cats was used to identify possible risk factors for feline Borna disease. The questionnaire consisted of 32 questions on a wide range of subjects, including lifestyle and possible modes of virus transmission. Two control groups were used: a healthy-control and a hospital-control. Variables with significant odds ratios in either the Borna disease:healthy-control or Borna disease:hospital-control comparison were included in multiple logistic regression analyses. Overall, the models suggested that feline Borna disease has a predominantly rural/woodland distribution, that affected cats were more likely to be males than females and intact than neutered, and that they were more likely than not to have hunted mice. The results indicate that, in contrast to other feline viral infections, Borna disease virus is not readily transmitted between cats. The natural reservoir of the virus is unknown. The fact that exposure to mice by hunting was a risk factor for the disease suggests that rodents may be subclinically infected and act as virus carriers.     

Studies on functional status of circulating lymphocytes in unaffected members from cancer families

That the inheritance of mutations in tumor susceptibility genes alone cannot determine risk for developing cancer is now well accepted. Immune functions have long been recognized as one of the important risk modifying factors in this regard. In an attempt to develop a multiparametric approach to identify high risk individuals from cancer families, we have examined NK cell function in unaffected members from familial breast cancer families. We have also carried out a parallel study of T lymphocyte functions in these individuals. Our studies demonstrate a significantly lower NK cell activity in members from cancer families. T lymphocyte activity also showed a similar trend, with the unaffected members demonstrating a notably lowered T lymphocyte function. In addition the data from patients reveals differential sensitivity of NK and T lymphocyte function to the disease phenotype. Implications of these observations are discussed.     

Effects of cigarette smoke on allergic diseases

INTRODUCTION: Macrovascular diseases such as angina, myocardial infarction, stroke and peripheral occlusive arterial disease are common causes of mortality and morbidity in transplant patients. OBJECTIVES: To study the frequency and determinants if vascular disease in Sri Lankan patients with renal transplants. PATIENTS: A cohort of 237 renal transplant recipients (163 males (76%), mean age 35.09, SD 11.05 years). SETTING: Patients under follow up at the Faculty of Medicine Transplant program. METHOD: Prospective study of a cohort of patients. RESULTS: Macrovascular diseases developed in 42% of transplant recipients. 5.6% had transient ischaemic attacks, 2.8% strokes, 18.2% angina, 8.4% myocardial infarctions, 2.3% underwent lower extremity amputations because of vascular insufficiency, 7% peripheral vascular occlusive disease and 49.5% were hypertensive. Male sex (odds ratio of 2.87, 95% CI 1.33-6.85, p = 0.006), serum cholesterol greater than 6.2 mmol/l at transplant (odds ratio 8.60, 95% CI 2.53-38.9, p = 0.0001) at 5 years after transplant (odds ratio 10.25, 95% CI 1.22-22.9, p = 0.01) were associated with a higher risk of macrovascular disease. Pre-transplant diabetes was associated with a higher risk of macrovascular disease and lower extremity amputation (odds ratio 4.53, 95% CI 1.32-6.76, p = 0.007). CONCLUSIONS: Strategies to screen for and treat potential risk factors should form an integral part of the follow up for Sri Lankan and Asian kidney transplant recipients.     

Fate of the contralateral leg after infrainguinal bypass

PURPOSE: To identify variables predictive of the need for future vascular intervention in a leg contralateral to one currently undergoing infrainguinal bypass. METHODS: We reviewed the records of 450 consecutively treated patients undergoing infrainguinal bypass for occlusive disease to examine the outcome of a previously untreated contralateral leg. Patients with coexistent contralateral limb-threatening ischemia at the time of initial ipsilateral operation were excluded, as were patients with bilateral disease who underwent a staged contralateral procedure within 3 months of the ipsilateral operation. This yielded a study cohort of 383 patients with no anticipated intervention in the contralateral leg who were followed for a mean value of 38 months. Patient survival and subsequent intervention in the contralateral leg were examined with life-table and regression analysis. RESULTS: Mean age of the patients was 68 years; 60% were men; 54% had diabetes; and 50% had coronary artery disease. The initial ipsilateral operation was performed for limb threat in 90% of instances. Twenty percent of patients subsequently needed intervention in the contralateral leg (infrainguinal bypass 83%, primary major amputation 17%). According to life-table analysis, 30% of patients needed intervention at 5 years, and the overall survival rate was 51% at 5 years. Multivariate analysis indicated that the need for future contralateral intervention was independently predicted with the following four risk factors: diabetes (relative risk [RR] 2.4x), coronary artery disease (RR 1.8x), lower initial ankle-brachial index (RR 2.1x with ankle-brachial index less than 0.7), and younger age (RR 2.2x if age less than 70 years). Regression models predicted the need for contralateral intervention for only 8% of patients at 5 years when none of these risk factors was present but for 67% when all risk factors were present. CONCLUSION: The fate of the contralateral leg after infrainguinal bypass is affected by diabetes, coronary artery disease, contralateral ankle-brachial index, and age at initial ipsilateral bypass. The effect of these risk factors is additive in prediction of the likelihood of future intervention. Knowledge of these factors may help identify instances in which the contralateral greater saphenous vein will be important for future limb salvage and also determine which patients need more careful follow-up care.     

Prevalence and impact of risk factors for lower body difficulty among Mexican Americans, African Americans, and whites

BACKGROUND: The purpose of the study was to estimate the prevalence of sociodemographic, health behavior, chronic disease, and impairment factors and their impact on difficulty in lower body function among two age-cohorts (51-61 and 71-81 years) of Mexican Americans, African Americans, and Whites. METHODS: Reports from 8,727 and 4,510 self-respondents of the 1992 baseline Health and Retirement Survey and the 1993 baseline Assets and Health Dynamics Study, respectively, were used to estimate prevalence. Multiple linear regression of the 4-item lower body difficulty scale (alpha = .80) was used to estimate the direct effects of the risk factors within the age-cohort and ethnicity groups. RESULTS: Overall, the risk factors are more prevalent among both minority groups and the older age-cohort. Lower body deficits are particularly high among Mexican Americans and the younger age-cohort of African Americans. The impact of risk factors does not vary much by ethnicity or age-cohort. Female gender, pain, arthritis, and heart and lung disease are the major risk factors, and they account for about one-third of the variance in lower body difficulty for each group. CONCLUSIONS: Efforts to prevent or reduce lower body difficulty should pay particular attention to pain, arthritis, and heart and lung disease. The central role of sociodemographic and behavioral factors in chronic disease argues for their continued inclusion in disability modeling and prevention.     

Immunoblotting detection of autoantibodies to human epidermis filaggrin: a new diagnostic test for rheumatoid arthritis

OBJECTIVE: We previously reported that so-called antikeratin antibodies (AKA) and antiperinuclear factor (APF) recognize epitope(s) present on human epidermal filaggrin. In the present study, we developed a new diagnostic test for rheumatoid arthritis (RA) based on detection of antifilaggrin autoantibodies (AFA) by immunoblotting. METHODS: We tested 670 serum samples, including 190 RA. AFA titers were estimated by immunoblotting on filaggrin enriched human epidermis extracts, and AKA titers by indirect immunofluorescence (IIF) on rat esophagus epithelium. Diagnostic values of the tests were compared. RESULTS: Each test resulted in diagnosis of more than 40% of RA samples, with a specificity of 0.99. Although the tests were strongly correlated, their association allowed the diagnosis of more than 60% of RA samples, with the same specificity. CONCLUSION: Immunoblot detection of AFA, a simple and standardizable test, may be an alternative or complement to conventional IIF detection of AKA.