Engagement and factors associated with annual anal human papillomavirus screening among sexual and gender minority individuals.

BACKGROUND: While self-sampling could help address anal cancer screening barriers, no studies have investigated annual engagement with this method or compared it to annual screening with a provider. Building on our baseline paper,(7) we compared annual anal screening engagement between home-based self-sampling and clinic-based clinician sampling. METHODS: The Prevent Anal Cancer Self-Swab Study recruited and randomized sexual and gender minority individuals 25 years and over who have sex with men to a home or clinic arm. Home-based participants were mailed an anal human papillomavirus self-sampling kit at baseline and 12 months, while clinic-based participants were asked to schedule and attend one of five participating clinics at baseline and 12 months. Using Poisson regression, we conducted an intention-to-treat analysis of 240 randomized participants who were invited to screen at both timepoints. RESULTS: 58.8% of participants completed annual (median = 370 days) anal screening. In the home arm, 65.0% of participants engaged in annual screening compared to 52.5% of clinic-based participants (p = 0.049). When stratified by HIV status, persons living with HIV had a higher proportion of home (71.1%) versus clinic (22.2%) annual screening (p < 0.001). Non-Hispanic Black participants participated more in home-based annual anal screening(73.1%) than annual clinic screening(31.6%) (p = 0.01). Overall, annual screening engagement was significantly higher among participants who had heard of anal cancer from an LGBTQ organization, reported "some" prior anal cancer knowledge, preferred an insertive anal sex position, and reported any prior cancer diagnosis. CONCLUSIONS: Annual screening engagement among those at disproportionate anal cancer risk was higher in the home arm.

The influence of home versus clinic anal human papillomavirus sampling on high-resolution anoscopy uptake in the Prevent Anal Cancer Self-Swab Study.

Background Anal cancer disproportionately affects sexual and gender minority individuals living with HIV. High-resolution anoscopy (HRA) is an in-clinic procedure to detect precancerous anal lesions and cancer, yet prospective data on factors associated with HRA attendance are lacking. We examined whether anal HPV sampling at home versus in a clinic impacts HRA uptake and assessed HRA acceptability. Methods Sexual and gender minority individuals were randomised to home-based self-sampling or clinical sampling. All were asked to attend in-clinic HRA 1year later. We regressed HRA attendance on study arm using multivariable Poisson regression and assessed HRA acceptability using χ 2 tests. Results A total of 62.8% of 196 participants who engaged in screening attended HRA. Although not significant (P =0.13), a higher proportion of participants who engaged in clinic-based screening attended HRA (68.5%) compared to home-based participants (57.9%). Overall, HRA uptake was higher among participants with anal cytology history (aRR 1.40, 95% CI 1.07-1.82), and lower among participants preferring a versatile anal sex position versus insertive (aRR 0.70, 95% CI 0.53-0.91), but did not differ by race or HIV serostatus. In the clinic arm, persons living with HIV had lower HRA attendance (42.9%) versus HIV-negative participants (73.3%) (P =0.02) and Black non-Hispanic participants had lower HRA attendance (41.7%) than White non-Hispanic participants (73.1%), (P =0.04). No differences in attendance by race or HIV status were observed in the home arm. Conclusions HRA uptake differed significantly by race and HIV status in the clinic arm but not the home arm.

Home-based self-sampling vs clinician sampling for anal precancer screening: The Prevent Anal Cancer Self-Swab Study.

Sexual minority men are at increased risk for anal squamous cell carcinoma. Our objective was to compare screening engagement among individuals randomized to self-collect an anal canal specimen at home or to attend a clinic appointment. Specimen adequacy was then assessed for human papillomavirus (HPV) DNA genotyping. A randomized trial recruited cisgendered sexual minority men and transgender people in the community and assigned them to use a home-based self-collection swabbing kit or attend a clinic-based swabbing. Swabs were sent for HPV genotyping. The proportions of participants completing screening in each study arm and the adequacy of their specimens for HPV genotyping were assessed. Relative risks were estimated for factors associated with screening. A total of 240 individuals were randomized. Age (median, 46 years) and HIV status (27.1% living with HIV) did not differ by study arm. A total of 89.2% and 74.2% of home-arm and clinic-arm individuals returned the swab, respectively (P = .003), difference between groups, 15.0% (95% CI 5.4%-24.6%). Among black individuals, 96.2% and 63.2% in the home and clinic arms screened (P = .006). Among individuals with HIV, 89.5% and 51.9% in the home and clinic arms screened (P < .001). Self-collected swabs and clinician-collected swabs were comparable in adequacy for HPV genotyping (96.3% and 93.3%, respectively). People at highest risk for anal cancer may be more likely to screen if they are able to self-collect swabs at home rather than attend a clinic.

Evidence for Environmental-Human Microbiota Transfer at a Manufacturing Facility with Novel Work-related Respiratory Disease.

Rationale: Workers' exposure to metalworking fluid (MWF) has been associated with respiratory disease.Objectives: As part of a public health investigation of a manufacturing facility, we performed a cross-sectional study using paired environmental and human sampling to evaluate the cross-pollination of microbes between the environment and the host and possible effects on lung pathology present among workers.Methods: Workplace environmental microbiota were evaluated in air and MWF samples. Human microbiota were evaluated in lung tissue samples from workers with respiratory symptoms found to have lymphocytic bronchiolitis and alveolar ductitis with B-cell follicles and emphysema, in lung tissue samples from control subjects, and in skin, nasal, and oral samples from 302 workers from different areas of the facility. In vitro effects of MWF exposure on murine B cells were assessed.Measurements and Main Results: An increased similarity of microbial composition was found between MWF samples and lung tissue samples of case workers compared with control subjects. Among workers in different locations within the facility, those that worked in the machine shop area had skin, nasal, and oral microbiota more closely related to the microbiota present in the MWF samples. Lung samples from four index cases and skin and nasal samples from workers in the machine shop area were enriched with Pseudomonas, the dominant taxa in MWF. Exposure to used MWF stimulated murine B-cell proliferation in vitro, a hallmark cell subtype found in the pathology of index cases.Conclusions: Evaluation of a manufacturing facility with a cluster of workers with respiratory disease supports cross-pollination of microbes from MWF to humans and suggests the potential for exposure to these microbes to be a health hazard.

Racial and Ethnic Variation Associated With Human Papillomavirus Genotype in Anal Dysplasia.

BACKGROUND: Human Papillomavirus (HPV) is known to cause dysplasia and cancer. In cervical disease, there are documented differences in prevalence of HPV genotypes among racial/ethnic groups. Little is known about prevalence of HPV genotypes in anal dysplasia. This study aimed to evaluate association between HPV genotypes and race/ethnicity in a racially heterogenous population with anal dysplasia. METHODS: This was a single-institution retrospective review of patients treated for anal dysplasia between 2008 and 2019. HPV genotype, obtained via anal swab testing, was recorded as HPV 16, HPV 18, or other non-16/18 high-risk (HR) HPV genotypes. Univariate and multivariate logistic regression analyses were used to evaluate the association between patient factors and HPV genotype. RESULTS: Of 517 patients meeting inclusion criteria, 46.8% identified as White, 37.1% as Black, 13.2% as Hispanic, and 2.9% as other/unknown. Race/ethnicity (P = 0.016) and sex (P < 0.001) were significantly associated with differences in prevalence of HPV genotypes. Black (odds ratio 1.56, 95% confidence interval 1.00-2.44) and male (odds ratio 2.35, 95% confidence interval 1.42-3.92) patients were significantly more likely to have non-16/18 HR HPV genotypes. CONCLUSIONS: In a racially and socioeconomically diverse cohort of patients with anal dysplasia, Black race and male sex were associated with increased likelihood of infection with a non-16/18 HR HPV genotype. Many of these genotypes are not covered by currently available vaccines. Further study is warranted to evaluate anal HPV genotypes in a larger cohort, as this may have important implications in HPV vaccination and anal dysplasia screening efforts.

Race Is Associated With Burden of Anal Condyloma and Need for Operative Intervention.

BACKGROUND: Human papillomavirus is a common sexually transmitted infection that may affect the oropharynx, genitalia, or anus. Some strains of this virus may cause bulky growths around the anus known as giant anal condylomas. These can become large, disfiguring, and may cause bleeding, as well as difficulty with defecation and hygiene. Surgical management is usually necessary for large condylomas, whereas office-based procedures are common for smaller lesions. It is unclear why some develop large anal margin tumors, whereas others develop limited disease. The aim of the present study was to evaluate for risk factors that may play a role in the development of extensive disease warranting operative management. MATERIALS AND METHODS: A retrospective chart review of patients seen within the Anal Dysplasia Clinic at the Medical College of Wisconsin was undertaken. Clinic encounters for patients with anogenital condyloma were abstracted for demographic information, operative interventions, Human Immunodeficiency Virus status, and smoking history to determine risk factors that predicted operative intervention for giant anal condylomas. RESULTS: A total of 239 patients met inclusion criteria; 211 (88.3%) were male and 28 (11.7%) were female. Racial makeup of the cohort included 49% Caucasian, 38.9% African-American, 9.2% Hispanic, and 2.9% were identified as another ethnicity. One hundred forty-three patients (60.1%) were current or past smokers. One hundred ninety-eight (82.8%) patients tested positive for human immunodeficiency virus (HIV), whereas 41 (17.2%) were negative. Multiple linear regression identified only African-American race as predictive of greater disease burden. CONCLUSIONS: African-American race was associated with increased size of anal condyloma. As the size of anal condylomas increase, management shifts from topical treatments to operative intervention. This is the first study to correlate race with burden of disease in the general population.

Portable Remote Imaging Spectrometer coastal ocean sensor: design, characteristics, and first flight results.

The design, characteristics, and first test flight results are described of the Portable Remote Imaging Spectrometer, an airborne sensor specifically designed to address the challenges of coastal ocean remote sensing. The sensor incorporates several technologies that are demonstrated for the first time, to the best of our knowledge, in a working system in order to achieve a high performance level in terms of uniformity, signal-to-noise ratio, low polarization sensitivity, low stray light, and high spatial resolution. The instrument covers the 350-1050 nm spectral range with a 2.83 nm sampling per pixel, and a 0.88 mrad instantaneous field of view, with 608 cross-track pixels in a pushbroom configuration. Two additional infrared channels (1240 and 1610 nm) are measured by a spot radiometer housed in the same head. The spectrometer design is based on an optically fast (F/1.8) Dyson design form coupled to a wide angle two-mirror telescope in a configuration that minimizes polarization sensitivity without the use of a depolarizer. A grating with minimum polarization sensitivity and broadband efficiency was fabricated as well as a slit assembly with black (etched) silicon surface to minimize backscatter. First flight results over calibration sites as well as Monterey Bay in California have demonstrated good agreement between in situ and remotely sensed data, confirming the potential value of the sensor to the coastal ocean science community.

Engagement and factors associated with annual anal human papillomavirus screening among sexual and gender minority individuals.

Objectives: Annual screening with a provider has been recommended for groups at highest risk for anal cancer. Anal self-sampling could help address screening barriers, yet no studies have examined annual engagement with this method. Methods: The Prevent Anal Cancer Self-Swab Study recruited sexual and gender minority individuals 25 years and over who have sex with men in Milwaukee, Wisconsin to participate in an anal cancer screening study. Participants were randomized to a home or clinic arm. Home-based participants were mailed an anal human papillomavirus self-sampling kit at baseline and 12 months, while clinic-based participants were asked to schedule and attend one of five participating clinics at baseline and 12 months. Using Poisson regression, we conducted an intention-to-treat analysis of 240 randomized participants who were invited to screen at both timepoints. Results: 58.8% of participants completed annual (median=370 days) anal screening. When stratified by HIV status, persons living with HIV had a higher proportion of home (71.1%) versus clinic (22.2%) annual screening ( p <0.001). Non-Hispanic Black participants had a higher proportion of home-based annual anal screening engagement (73.1%) compared to annual clinic screening engagement (31.6%) ( p =0.01). Overall, annual screening engagement was significantly higher among participants who had heard of anal cancer from an LGBTQ organization, reported "some" prior anal cancer knowledge, preferred an insertive anal sex position, and reported a prior cancer diagnosis. Annual screening engagement was significantly lower for participants reporting a medical condition. Conclusions: Annual screening engagement among those at disproportionate anal cancer risk was higher in the home arm.

The Mapping Imaging Spectrometer for Europa (MISE).

The Mapping Imaging Spectrometer for Europa (MISE) is an infrared compositional instrument that will fly on NASA's Europa Clipper mission to the Jupiter system. MISE is designed to meet the Level-1 science requirements related to the mission's composition science objective to "understand the habitability of Europa's ocean through composition and chemistry" and to contribute to the geology science and ice shell and ocean objectives, thereby helping Europa Clipper achieve its mission goal to "explore Europa to investigate its habitability." MISE has a mass of 65 kg and uses an energy per flyby of 75.2 W-h. MISE will detect illumination from 0.8 to 5 µm with 10 nm spectral resolution, a spatial sampling of 25 m per pixel at 100 km altitude, and 300 cross-track pixels, enabling discrimination among the two principal states of water ice on Europa, identification of the main non-ice components of interest: salts, acids, and organics, and detection of trace materials as well as some thermal signatures. Furthermore, the spatial resolution and global coverage that MISE will achieve will be complemented by the higher spectral resolution of some Earth-based assets. MISE, combined with observations collected by the rest of the Europa Clipper payload, will enable significant advances in our understanding of how the large-scale structure of Europa's surface is shaped by geological processes and inform our understanding of the surface at microscale. This paper describes the planned MISE science investigations, instrument design, concept of operations, and data products.

The influence of home versus clinic anal human papillomavirus sampling on high-resolution anoscopy uptake in the Prevent Anal Cancer Self-Swab Study.

Background: Anal cancer disproportionately affects men who have sex with men (MSM) living with HIV. High-resolution anoscopy (HRA) is an in-clinic procedure to detect precancerous anal lesions and cancer, yet prospective data on factors associated with HRA attendance are lacking. We examined whether anal HPV sampling at home versus in a clinic impacts HRA uptake and assessed HRA acceptability. Method: MSM and trans persons 25 years and older were randomized to home-based self-sampling or clinical sampling. All were asked to attend in-clinic HRA one year later. We regressed HRA attendance on study arm using multivariable Poisson regression and assessed HRA acceptability using χ 2 tests. Results: 62.8% of 196 participants who engaged in screening attended HRA. Although not significant ( p =0.13), a higher proportion of participants who engaged in clinic-based screening attended HRA (68.5%) compared to home-based participants (57.9%). Overall, HRA uptake was higher among participants with anal cytology history (aRR 1.44, 95% CI 1.11 - 1.87) and lower among participants preferring versatile anal sex position versus insertive (aRR 0.70, 95% CI 0.53 - 0.91), but did not differ by race or HIV serostatus. In the clinic arm, persons living with HIV had lower HRA attendance (42.9%) versus HIV-negative participants (73.3%) ( p =0.02) and Black non-Hispanic participants had lower HRA attendance (41.7%) than White non-Hispanic participants (73.1%), ( p =0.04); however, no differences in attendance by race or HIV status were observed in the home arm. Conclusions: HRA uptake differed significantly by race and HIV status in the clinic arm but not the home arm.

Impact of Clostridium difficile on inflammatory bowel disease.

BACKGROUND & AIMS: Clostridium difficile-associated disease has increased significantly in North American medical centers. The impact of C difficile on patients with IBD (Crohn's disease, ulcerative colitis) at the present time is unknown. METHODS: A retrospective, observational study evaluating IBD patients followed in a referral center to evaluate the impact of C difficile was performed. Diagnosis was confirmed with stool toxin analysis. Demographic information, diagnosis, anatomic location, IBD therapy, antibiotic exposure, hospitalizations, and surgeries were recorded. Available endoscopic and histologic data were evaluated. RESULTS: Rate of C difficile infection increased from 1.8% of IBD patients in 2004 to 4.6% in 2005 (P < .01). Proportion of IBD patients within the total number of C difficile infections at our institution increased from 7% in 2004 to 16% in 2005 (P < .01). IBD colonic involvement was found in the majority of C difficile-infected patients in 2005 (91%), and the majority contracted infection as an outpatient (76%). Antibiotic exposure was identified in 61% of IBD patients with C difficile infection in 2005. Pseudomembranes and fibrinopurulent eruptions were not seen endoscopically or histologically. During 2004-2005 more than half of the infected IBD patients required hospitalization, and 20% required colectomy. Univariate and multivariate analysis identified maintenance immunomodulator use and colonic involvement as independent risk factors for C difficile infection in IBD. CONCLUSIONS: C difficile infection has increased significantly in IBD patients and negatively impacts clinical outcome. Increased vigilance regarding this infection in IBD patients with colitis activity is warranted.

Clinical factors contributing to rapid reoperation for Crohn's disease patients undergoing resection and/or strictureplasty.

Although surgically induced remission of Crohn's disease following segmental resection/strictureplasty is effective and durable, a subpopulation of patients will require rapid reoperation. We reviewed our inflammatory bowel disease center's database to identify patients who underwent multiple laparotomies. A retrospective analysis of consecutive Crohn's disease patients (1998-2004) was performed, and patients requiring repeat laparotomy were identified. Rapid reoperation was defined as repeat intestinal surgery within 2 years. Demographic data and medical treatment were recorded. Clinical factors contributing to rapid reoperation were defined as (1) symptomatic adhesion, (2) residual strictures/technical error, (3) lack of effective medical therapy, and (4) severe disease despite medical treatment. Of 432 patients, 65 required two or more abdominal explorations, with 32 patients requiring rapid reoperation (50 surgeries). Residual strictures and technical error accounted for 20% of procedures; ineffective medical therapy was identified in 64%, whereas severe disease despite medical therapy was a contributing factor in 14%. Adhesions were found in a single patient. Kaplan-Meier analysis confirmed that rapid reoperation patients had significant and consistently shorter intervals between surgical procedures (i.e., interval between procedures 1 and 2 and 2 and 3). Residual strictures manifest during postop year 1, whereas recurrence of severe disease was the dominant contributing factor during year 2. Our data suggest that operative strategies emphasizing occult stricture detection and adequate medical therapy in Crohn's disease patients may improve outcome and decrease the need for rapid re-exploration.

Clostridium difficile enteritis: an early postoperative complication in inflammatory bowel disease patients after colectomy.

Clostridium difficile, the leading cause of hospital-acquired diarrhea, is known to cause severe colitis. C. difficile small bowel enteritis is rare (14 case reports) with mortality rates ranging from 60 to 83%. C. difficile has increased in incidence particularly among patients with inflammatory bowel disease. This case series of six patients from 2004 to 2006 is the largest in the literature. All patients received antibiotics before colectomies for ulcerative colitis and developed severe enteritis that was C. difficile toxin positive. Three patients underwent ileal pouch anal anastomosis and loop ileostomy. Four of the six patients had C. difficile colitis before colectomy. Presenting symptoms were high volume watery ileostomy output followed by ileus in five of six patients. Four of the six patients presented with fever and elevated WBC. Five of the six developed complications requiring further surgery or prolonged hospitalization. Patients were treated with intravenous hydration and metronidazole then converted to oral metronidazole and/or vancomycin. None of the patients died. A high suspicion of C. difficile enteritis in patients with inflammatory bowel disease and history of C. difficile colitis may lead to more rapid diagnosis, aggressive treatment, and improved outcomes for patients with C. difficile enteritis.

Transrectal and transvaginal sonographic intervention of infected pelvic fluid collections: a complete approach.

Infected pelvic fluid collections are relatively common particularly after abdominal or pelvic surgery or in patients suffering from benign intestinal disease such as diverticulitis, appendicitis, or Crohn's disease. Historically the treatment of pelvic abscess has been either laparotomy with lavage or blind surgical incision and drainage through the rectal or vaginal wall. More recently, computed tomography and ultrasound-guided percutaneous drainage has become the procedure of choice, when feasible, for the treatment of pelvic abscess. However, many deep pelvic collections are not amenable to percutaneous technique. Transrectal or transvaginal ultrasound-guided abscess drainage is a safe and effective method used in the treatment of deep pelvic abscesses. The purpose of this article is to review the techniques, patient selection, pre- and post-procedural care, and monitoring aspects of transrectal or transvaginal ultrasound-guided drainage.

Radiographic underestimation of small bowel stricturing Crohn's disease: a comparison with surgical findings.

BACKGROUND: The purpose of this study was to determine the accuracy of barium radiography compared with intraoperative evaluation with passage of a balloon catheter for assessment of stricturing Crohn's disease (CD). METHODS: After institutional review board approval, we retrospectively reviewed a tertiary inflammatory bowel disease center's consecutive records of surgical patients between 1998 and 2003 with small intestinal CD to compare the number of strictures found at surgery with those identified preoperatively by barium imaging. Age, gender, prior surgical procedures, and steroid usage were recorded. By decision of the surgeons, all patients were treated with an identical approach that utilized intraluminal sizing with passage of a balloon-tipped catheter. RESULTS: In 118 patients, 230 strictures were identified by barium examination; 365 strictures were identified using the balloon catheter technique. Barium examination overestimated or underestimated the number of strictures in 43 of 118 patients (36%). Overall, barium radiography was least accurate in patients with strictures amenable to strictureplasty. Prior surgery and multiple strictures identified preoperatively by barium studies were found to decrease the accuracy of the barium examination, but the decrease did not reach statistical significance. After successful surgery for stricturing small intestinal CD, more than 90% of patients can successfully be weaned from their steroids within 3 months. Failure to be able to wean from steroids may suggest a missed stricture. CONCLUSIONS: Our data suggest that careful exploration and intraoperative, intraluminal testing of intestinal patency identify additional strictures compared with barium radiographs in a significant number of patients with CD undergoing small bowel surgical intervention.

Abnormal cervicovaginal smears due to endometriosis: a continuing problem.

Endometriosis may be challenging when identified on cervicovaginal smears (CVS), leading to an incorrect interpretation of high-grade squamous intraepithelial lesion (HSIL), or atypical glandular cells of undetermined significance (AGUS) including adenocarcinoma in situ (AIS). Awareness of cervical endometriosis, particularly in predisposed patients, is crucial for a correct diagnosis. While cervical endometriosis has been reported to be a diagnostic pitfall of glandular abnormalities, its characteristic features are still not well-established. This may partially be attributed to the varied cytomorphologic features endometriosis shows, depending on menstrual cycle hormonal changes. We describe our experience with three examples where CVS were interpreted as either AGUS or HSIL, which led to a hysterectomy in 2 of 3 patients. Cervical endometriosis needs to be considered with other well-known benign conditions that mimic glandular abnormalities, including cervicitis, tubal metaplasia, lower uterine segment sampling, and microglandular hyperplasia. Published series and our own experience lead us to suggest that these smears will continue to present diagnostic difficulties.

History of medical hospitalization predicts future need for colectomy in patients with ulcerative colitis.

BACKGROUND: Patients who require hospitalization for the management of ulcerative colitis (UC) may represent a subset with severe disease. These patients may be more likely to require future colectomy. There are limited data examining whether medical hospitalization is predictive of subsequent colectomy. METHODS: This was a retrospective case-control study utilizing the inflammatory bowel disease center database at our academic referral center. Cases comprised UC patients who underwent colectomy for disease refractory to medical management. The control population was comprised of all patients with UC who had not undergone colectomy. Multivariate logistic regression was used to identify independent predictors of requiring colectomy. RESULTS: There were a total of 246 UC patients included in our study, with 103 being hospitalized sometime in their disease course (41.9%). A total of 27 patients underwent colectomy (11%). Colectomy patients were significantly more likely to have been on infliximab therapy (51.8% versus 22.4%, P = 0.001) but no more likely to have been on immunomodulator therapy (74.1% versus 59.4%, P = 0.14). Patients who required medical hospitalization for UC were more likely to require future colectomy (20.4% versus 4.2%, P < 0.001) than those who had not required hospitalization. On multivariate analysis, requiring medical hospitalization for management of UC (odds ratio [OR] 5.37, 95% confidence interval [CI] 2.00-14.46) and ever requiring infliximab therapy (OR 3.12, 95% CI 1.21-8.07) were independent predictors of colectomy. CONCLUSIONS: Requiring medical hospitalization for the management of disease activity in UC is an independent predictor of the need for colectomy. Future studies will determine whether aggressive medical management may modify the need for colectomy in this cohort.

Permanent work disability in Crohn's disease.

OBJECTIVE: Crohn's disease (CD) frequently presents during early adulthood, a peak time of work productivity. There are limited data from the United States on work disability from CD. We performed this study to identify clinical factors associated with permanent work disability in a CD tertiary referral cohort. METHODS: Cases were identified as patients who received permanent work disability compensation from the social security administration (SSA) related to CD. Four control patients who were not receiving work disability were selected for each case. Multivariate logistic regression was performed to identify characteristics that were independently associated with work disability. RESULTS: A total of 737 patients with CD were seen in our center, and 185 CD patients were included in our study (37 disability cases, 148 controls). On multivariate analysis, an SIBDQ score