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Objective: Empirically based data support the validity of the distress thermometer recommended by the National Comprehensive Cancer Network as a standard screen for patient distress. However, the feasibility and utility of the distress thermometer has not been studied in the pediatric oncology setting. We conducted a study to: (1) investigate the validity of an adapted distress thermometer with pediatric oncology patients, (2) assess the degree of agreement among different respondents, including physician and psychosocial staff, with respect to (a) the pediatric cancer patient's distress and (b) the caregiver/parent's distress, and (3) to evaluate the relationship between distress levels and the psychosocial services provided to patients and families. Methods: Ninety-one patients and their English and Spanish-speaking caregivers were prospectively assessed at 3-month intervals for 1 year. The quantity of psychosocial services provided to each family was logged for a 12-month period. Results: Convergent validity was demonstrated by reasonable agreement between the pediatric distress rating tool and standardized measures. Additionally, the demographic and medical predictors of distress were consistent with previously reported findings using more extensive assessment. There was reasonable agreement among multiple raters of the child's distress; however, there was discrepancy between self-ratings of caregiver distress and psychosocial staff ratings of caregiver distress. This difference in perception impacted the quantity of psychosocial services provided following the baseline assessment. Conclusion: The single-item distress thermometer is a viable option as a rapid screening tool of patient and caregiver distress to help efficiently identify those who should be evaluated further. Copyright © 2010 John Wiley & Sons, Ltd.

As the number of cancer survivors continues to grow, identification of brief, valid psychological screening measures will be a critical step in providing them with appropriate psychosocial care. The distress thermometer (DT) is a one-item distress screening that is recommended by the National Comprehensive Cancer Network (NCCN) for screening cancer patients, but has not been evaluated for cancer survivors. This study evaluated the validity of the DT compared to the Symptom Checklist-90-Revised (SCL-90-R) in a sample of 119 adult survivors of childhood cancer aged 18–45 (median=23.5). Results indicated that when using the NCCN suggested cut-off score of 5, the DT only identified 20 of the 36 SCL-90-R-positive cases of psychological distress (sensitivity 55.6%; specificity 80.7%). Using an alternative DT cut-off score of 4 identified 23 of the 36 SCL-90-R-positive cases (sensitivity 63.9%; specificity 65.1%). Receiver operating characteristics analysis indicated that the DT had only fair diagnostic utility relative to the SCL-90-R (AUC=0.72). Results do not support the validity of the DT in adult survivors of childhood cancer. Copyright © 2007 John Wiley & Sons, Ltd.

94 Background: Lay patient navigators can screen patients using a distress tool (DT) to identify and address multiple patient concerns. Patient-reported distress can be used to characterize the needs of patients with ovarian, endometrial, and cervical cancer through all phases of care from initial diagnosis through active treatment and into survivorship. Methods: The Patient Care Connect Program (PCCP) includes 12 cancer centers throughout Alabama, Mississippi, Georgia, Florida, and Tennessee and navigates Medicare beneficiaries with cancer. Within the PCCP, navigators documented distress levels, causes of distress, and requests for intervention. Distress screening results were used to describe needs of patients with gynecologic malignancies and to assess effective resolution of distress. Results: Initial DT results were collected on 360 patients with gynecologic cancers: 206 (57%) ovarian, 111 (31%) endometrial, and 43 (12%) cervical cancers. Fifty-six (16%) were African American. Twenty-four percent of patients reported a distress score ≥ 4 and 4% reported scores ≥8. Physical symptoms most frequently caused distress (44%) particularly fatigue, pain, and neuropathy. Practical problems (11%), informational needs (16%) and emotional issues (19%) were also common. Patients were most likely to request assistance with transportation (63%), financial/insurance issues (77%), and nutritional concerns (75%). Lay navigators were able to address these concerns in 92% of patients. Conclusions: Gynecologic cancer patients report diverse sources of distress extending beyond symptom management. By administering DTs, patient navigators may effectively facilitate resolution of patient identified distress. The project described was supported by Grant Number 1C1CMS331023 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this abstract are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

68 Background: Distress is a non-stigmatic description of emotional, physical, spiritual or psychiatric stressors experienced by patients (pts) diagnosed with cancer. We sought to determine the prevalence of distress in different cancer population of pts seen in our cancer center as they are commencing chemotherapy. Methods: We retrospectively examined data using the Distress Thermometer (DT) based on the National Comprehensive Cancer Network (NCCN) and assessed a single encounter on 240 consecutive patients undergoing their first chemotherapy session. Univariate associations were examined between specific problems and overall distress levels with a 2-tailed between-group t-test. Problem area scores were computed for each subject by taking the mean number of problems rated positive within each area, and associations between each problem area score and distress was examined using Spearman correlations. Results: Among the 240 patients in the sample, mean age was 60 ± 14, 61% were female, and 82% had solid tumors. The overall mean distress, based on the DT reading, was 3.6 ± 3.0. Specific problems reported by the largest number of patients included worry (n = 85), nervousness (n = 79), fatigue (n = 70), sleep (n = 66), and fears (n = 57). Of these, all but fatigue were significantly associated with global distress in univariate analysis. When mean problems per area were calculated, and correlated with global distress, each problem area (practical, emotional, family, physical) had a significant univariate association with global distress, with emotional problems having the highest correlation (r = .52, p < .0001). The only predictors with significant independent associations to predict global distress in the general linear model were emotional problems (p = .0001) and family problems (p = .0062), independent of age, sex and tumor types. Conclusions: In cancer patients undergoing distress screening as they receive their first chemotherapy, emotional and family problems appear to have the highest correlation with distress. Improvement of supportive care services geared towards the betterment of these symptoms is of paramount importance in improving outcomes.

79 Background: A significant percentage of cancer patients experience psychosocial distress with the highest prevalence observed in breast cancer patients. The importance of psychosocial distress screening and assessment in women with breast cancer has clearly been established. Patients in our clinic are screened for distress. The results were reviewed in an attempt to better understand the psychosocial distress of breast cancer patients undergoing radiotherapy. Methods: Patients treated curatively for breast cancer prospectively completed the 30 question patient reported distress (PRD) survey that also included a linear analog measure of overall distress. The recorded clinical results of the PRD survey were retrospectively assessed in patients receiving breast radiotherapy from June 1, 2013 to February 2, 2015. Results: Completed PRD questionnaires were available on 179 female patients. 21 (12%) were treated for ductal carcinoma in situ and 91 (51%), 35 (20%), and 32 (18%) were treated for invasive carcinoma Stages I, II, and III. 85 (47%) received chemotherapy. Overall distress ranged from 0 to 10, with a median value of 5. Mean distress scores per category ranged from a low of 1.25 to a high of 2.52. Top concerns in descending order of importance were: “How will I feel during treatment” (2.52), “Fatigue” (2.46), “Sleep difficulties” (2.32), “How will I feel about appearance related to treatment” (2.23), & “Pain that affects daily functioning” (2.19). Least distressing symptoms “Spirituality” (1.25), “Housing during treatment” (1.26), “Control of anger” (1.28), “End of life concerns” (1.32), & “Transportation” (1.34). Conclusions: Distress over tumor related issues ranked low among women’s concerns in comparison to distress related to the side effects of therapy concerning treatment related discomfort, fatigue, and changes in appearance, and anxiety. Pain was a significant concern, although in this group of patients receiving definitive, adjuvant or neoadjuvant therapy, this was likely related to treatment associated discomfort rather than from disease progression. These findings highlight the importance of careful patient education and communication of the expected symptoms and effects of therapy.

9575 Background: Distress is defined as an unpleasant emotional experience that may interfere with the ability to cope with cancer or its treatment. Distress screening is recommended during transitions including survivorship. We describe distress in cancer survivors before and after participation in a multidisciplinary survivorship clinic. Methods: All patients participating in the Yale Adult Survivorship Clinic were asked to complete the National Comprehensive Cancer Network Distress Thermometer (DT) immediately before and after a visit. Survivors ranked distress from 0 (none) to 10 (extreme) and indicated associated problems from a 39-item list. A score ≥ 4 was considered clinically significant. Survivors were seen by an MD/APRN, social worker, registered dietitian and physical therapist. Survivors received individual counseling on topics including survivorship care, diet and exercise, and coping. All were offered a follow-up visit approximately 8 weeks later. Distress screening was repeated at the foll...

e20593 Background: According to the Dutch guideline, detection of need for care (DNC) is the process of completing a distress screening instrument, discussing the response pattern, and referral to ...

Purpose: The purpose of this study was to determine the prevalence of distress and to investigate the related problems in breast cancer patients at the end of primary treatment. Methods: A sample of 118 participants was recruited among outpatients who had successfully completed primary treatment of breast cancer. Data were collected between July, 2013 and October, 2014 using the Distress Thermometer (DT) scale and problem lists. Descriptive statistics and logistic regression analysis were used to analyze data. Results: Among the 118 patients that participated in this study, 34 patients (28.8%) suffered from elevated distress using the previously validated cut point ≥4 for the DT. Problems most frequently encountered were fatigue (68.8%), worry (59.3%), appearance (51.7%) and memory/concentration (48.3%). Multivariate logistic regression analysis revealed that depression (OR=9.55), worry (OR=8.34), fatigue (OR=8.19) and age (OR=1.14) were independent predictors for elevated distress scores. Conclusion: Utilizing the DT, onethird of breast cancer patients screened met criteria for distress at the end of the primary treatment. Breast cancer patients with depression, worry, fatigue and older age should be targeted for distress screening and management.

Up to half of all adults with cancer experience clinically significant psychological distress and much of this distress goes unrecognized and untreated. As part of an effort to improve the care of cancer patients, the National Comprehensive Cancer Network (NCCN) has developed clinical practice guidelines for distress management that include recommendations about the evaluation and treatment of distress. These authors conducted a study to evaluate the implementation of these distress management guidelines by NCCN member institutions. The NCCN member institutions that treat adults were asked in April and May 2005 to describe their distress management practices, and 15 (83%) provided responses. Of these, 8 (53%) conduct routine distress screening for at least some patient groups, with 4 additional institutions (27%) pilot-testing screening strategies. However, only 20% of surveyed member institutions screened all patients as the guidelines recommend. In addition, whether institutions that conduct routine distress screening do so through standardized assessment methods is unclear, because 37.5% of institutions that conduct screening rely only on interviews to identify distressed patients. Findings suggest that most institutions consider screening patients' mental health concerns important and worthwhile, but that greater implementation of guideline recommendations is needed.

Centre for Psycho-Oncology Research and Training, School of Public Health, The University of Hong Kong, 5/f,WMW Mong Building, 21, Sassoon Road, Pokfulam, Hong Kong, ChinaSir,The critique of Coyne, 2013 of the Carlson et al, 2012 paper andresponse by Carlson et al, 2013 raise important issues regardingscreening patients for cancer-related distress that have concernedus for some time. Relevant to the debate are the following:(1) The comment by Coyne, 2013 regarding declines in distressover time following cancer diagnosis and treatment is widelybelieved, but incorrect. Distress trajectories based on group meanvalues are problematic. The problem is, if in a study 50% of thesample score 10 out of 10 on a notional distress scale declining to 0out of 10 over time, whereas the other 50% score 0 out of 10increasing to 10 out of 10 over the same period, the observed groupmean will remain at 5 out of 10 and the conclusion would be thereis no change in distress. This of course is the wrong conclusion.Analyses using Mixture Growth modelling, a method thatdecomposes samples into distinct trajectories, reveal patterns ofdistress distinctly different to the accepted wisdom of a steadydecline over time (Helgeson et al, 2004; Deshields et al, 2006,Henselmans et al, 2010; Lam et al, 2010, 2011, 2012a, 2012b).These studies consistently show that a broad majority of cancerpatients, around 60% are resilient, experiencing persistently lowdistress with only marginal and transient peaks throughout thecancer trajectory. A second subset of patients who have low distressearly in the cancer trajectory report gradually increasing distresslevels that peak around the end of treatment and quickly declinethereafter. A third set follow the classic pattern mentioned byCoyne, 2013, with high levels early in the trajectory declining overtime thereafter. Finally, a fourth group, 5–20%, show stable levelsof high distress persisting over the duration of the cancertrajectory. (Henselmans et al, 2010; Lam et al, 2010, 2011, 2012a,2012b) Patterns of distress in the first year following diagnosispredict distress outcomes up to 6 years following diagnosis(Helgeson et al, 2004; Lam et al, 2011, 2012a). These patternsbroadly mirror the resilience model of response to trauma(Bonanno et al, 2011).(2) Evidence increasingly points to unresolved symptoms asbeing a major predictor of cancer-related distress trajectories (Lamet al 2010; 2012b). This suggests that more effective symptommanagement would be a more cost-effective approach to cancer-related distress. However, there are always going to be patients whoneed distress-support services and such patients need to beidentified. In particular, there is a pressing need to differentiate andidentify the chronic distress patients who would benefit most fromsupportive interventions from those with transient distress.(3) Given the above, the timing of any programme for distressscreening in cancer patients will give quite different resultsdepending on when screening is performed. Currently, evidencesuggests that the greatest proportion of patients (B80%)experience some signs of distress at around 1 month followingprimary treatment. Mostly, this distress is transient, and patientsand their families cope well with it; for some it is part of a longerdecline from an earlier peak, for others it is increasing, only todecline later. Only about 1 in 6 to 1 in 8 of those positivelyscreened as distressed would have chronic distress that is unlikelyto remit on its own. Any one point estimate will not tell you towhich group a screened distressed patient belongs and hencewhether they would, or would not benefit from additionalintervention: this is relevant to Coyne’s point about outcomes.Coyne suggests the effects reported by Carlson et al, 2012are due to recognised declines in distress over time. Of greaterconcern to us is that most patients show very little distress for mostof the cancer trajectory, although they might get picked up ifrepeatedly screened, during a fleeting peak of distress, probably atcritical points in the cancer trajectory (diagnosis, treatmentcessation, recurrence). Hence, including them in any randomisedcontrolled trial is unlikely to confer much benefit and, potentially,both dilute any group-intervention effects and increase dropout, aphenomena clearly evidenced in Carlson et al’s cohort wherearound one out of three patients dropped out. This is misleading,as for the chronically distressed group the benefits of supportiveinterventions may be more substantial than published studiessuggest.(4) It is well recognised that uptake and completion ofinterventions tends to be much greater in randomised controlledtrials than in everyday clinical practice. This is likely to be the casefor therapeutic interventions targeting cancer-related distress. Ineveryday practice, most people cope with cancer. The challenge isto identify and help those who don’t.(5) Frankly put, it seems that most cancer patients are resilientand it is not cost-effective to include them in distress-supportprogrammes, because they will simply not attend or drop out.Identifying the approximately one in eight distressed patients who

33 Background: Hospital admissions create physical, financial and emotional stress for oncology patients. Hospital avoidable readmissions are considered a marker of poorer quality patient care. To reduce readmissions, cancer hospitals must understand modifiable readmission risk factors AND establish screening systems to triage at-risk patients to outpatient palliative/supportive care services. The James Cancer Hospital is in Phase II development of a model to reduce patient suffering and readmission via the James Supportive Care Screening (JSCS), a 48-item validated clinical-research instrument. Methods: In 2013, the James Cancer Hospital began implementation of Supportive Care Screening to meet Standard 3.2 (Psychosocial Distress Screening) of the Commission on Cancer. The JSCS asks patients to rate distress in six palliative care domains including emotional concerns, physical symptoms, social/practical problems, spiritual problems, cognitive concerns, and healthcare decision-making/communication issues. Between January 2011 and December 2013, one-thousand and one patients completed the JSCS in the Outpatient Palliative Care clinic. During this period, 57 patients had at least one readmission. Hierarchical linear regression was used to predict the number of future readmissions with JSCS subscales as independent variables. Results: The overall model predicting readmissions was significant, F(7,959) = 37.074, p

e20564 Background: Distress is 6th vital sign in cancer survivors & designates patient-reported psychosocial or physical suffering. Distress screening is not commonly performed yet is prevalent in ...

e17679 Background: Given current standards for distress screening, it is essential to identify patients seeking psychosocial support. CancerSupportSource (CSS) is a validated, distress screening to...

A recent paper by Barclay and Kent (1998) raised various issues with regards to motherhood and recent immigration. They expressed reservations with conceptualizing extreme misery in new mothers as depression, and with screening for postnatal distress in women from non-English-speaking backgrounds (NESB). They argued that a common self-report measure for postnatal distress screening, the Edinburgh Postnatal Depression Scale (EPDS), was flawed. They also argued that the concept of postnatal depression implies a medical aetiology and, thus, fails to recognise the socio-cultural aspects experienced by NESB women. We address these issues, by demonstrating that the EPDS is not flawed, and by arguing that screening for postpartum distress results in more NESB women being identified and, consequently, offered a service, than if such screening does not occur. We also disagree with the view that the term 'postnatal depression' necessarily implies any aetiology, and that work by our unit, as well as others around the world, indicates that the psychosocial and cultural aspects related to distress in new immigrant mothers is being recognised and acted upon.

107 Background: NCCN and the Institute of Medicine recommend distress screening for all cancer patients. Surveys have found that 20% to 47% of newly diagnosed and recurrent cancer patients experience significant levels of distress. Less than half of distressed patients with cancer are actually identified and referred for psychosocial help. The development of screening tools, processes, appropriate timing, and systems for follow up on concerns is an ongoing challenge for many cancer programs. Mountain States Tumor Institute p,iloted a distress screen process as part of our work with NCCCP. Methods: From October 24, 2011, to April 30, 2012, 133 patients completed distress screens. Most frequently reported concerns included fatigue (50%), sleep changes (32%), and anxiety/worry (31%). 51% of patients reported three or more concerns. 90% of all patients reporting anxiety also reported fatigue or sleep problems. All patients who reported concerns were offered social work and other supports. Screens were reviewed by social workers and discussed at weekly multidisciplinary psychosocial care rounds by social workers, psychiatrist, nurse practitioners, and chaplains. A variety of interventions were used to respond to distress including symptom management, education and referrals to on-site social workers, chaplains, supportive care clinic, integrative medicine and psychiatry. Results: A task was created in Mosaiq Electronic Medical Record to cue Health Information Specialists to schedule patients for distress screening as close as possible to 45 days from first chemotherapy treatment. Patients completed screens before seeing their medical provider. The majority of patients screened received one or more interventions in follow-up. Conclusions: EMRs can be effective tools to cue scheduled screening of patient distress. The use of multidisciplinary psychosocial care rounds can effectively help clinics plan interventions to alleviate patient distress. The use of rounds can ensure staff from different disciplines are not duplicating efforts and can help determine appropriate timing of various psychosocial interventions. Project funded with Federal funds from the NCI, Contract No HHSN261200800001E.

250 Background: Although the Institute of Medicine provided a vision for effective psychosocial care for cancer survivors, guidance regarding the essential components of comprehensive care or progressive steps for implementing each component is limited. This abstract presents a unique tool for self-assessing capacity to provide quality psychosocial care to cancer survivors and results of the first full-scale implementation of this tool. Methods: The psychosocial workgroup of the National Cancer Institute Community Cancer Centers Program (NCCCP) developed the Psychosocial Care Matrix Assessment Tool which covers 7 domains (e.g., distress screening, patient-provider communication, evaluation of psychosocial programs). All NCCCP sites (16 enrolled in 2007, 14 enrolled in 2010) completed the matrix in 2010 regarding their capacity for psychosocial care at entry into NCCCP (baseline), after two years of NCCCP participation (2007 sites only), and within the coming year (future aspirations). Results: At baseline, matrix responses reflected few or no systematic processes in place for most components of psychosocial care. However, reported capacity to deliver specific components improved at two years post-NCCCP entry for the 2007 sites and in all sites’ future aspirations. For example, about 80% of all sites reported no or inconsistent distress screening at baseline. After two years, 48% of the 2007 sites reported consistent screening with a standardized tool or consistent screening plus a comprehensive interview. Nearly all 2007 sites (89%) aspired to provide consistent screening plus comprehensive interview with 50% also hoping to add systematic follow-up screenings. The majority of 2010 sites (71%) aspired to provide consistent screening with a standardized tool. Conclusions: The psychosocial matrix tool was found to be useable and valuable. At the NCCCP sites, some aspects of psychosocial care (e.g., communicating the importance of psychosocial care) are more readily implemented than others (e.g., follow-up after a positive distress screen). With growing demand on cancer centers to meet new metrics of quality care, the psychosocial matrix can help identify and develop steps to address gap areas.

Screening is the optimal strategy for detecting diseases (such as major depression and adjustment disorders) that are prevalent, not evident, and treatable and that benefit from early treatment. In oncology settings, psychological interventions have been shown to alleviate depressive disorders detected by psychological screening. This evidence supports the efficacy of psychological screening, and guidelines such as the National Comprehensive Cancer Network have recommended routine screening for depressive disorders in clinical practice. Our group also has spent several years developing a practical psychological screening program for cancer patients. Collaboration with medical oncologists or nurses is the cue to develop these programs. In this symposium, I will present the current status and future direction concerning screening program.

e19504 Background: Cancer care still fails to address psychosocial problems, which can compromise the effectiveness of health care and thereby adversely affect cancer patients. The present retrospective study explores a routine of distress screening, followed by a multidisciplinary discussion, in order to devise strategies for intervention and treatment. Methods: Over two years, 328 patients from a private cancer center, located in Brasilia, the capital of Brazil, participated in a longitudinal study. They were evaluated three times over a 6-month period using the Distress Thermometer and the Hospital Anxiety and Depression Scale. The data of each evaluation were discussed between oncologist assistant and psychologist, establishing appropriate intervention. Descriptive statistics, Pearson’s correlation and a logistic regression were employed to analyze the data. Results: There was a prevalence of female patients (64%). They were between 18 - 86 years (M = 54.7, SD = 15.8). Gastrointestinal (28%), breast (23.8%) and hematologic cancer (22.6%) were the main diagnosis, being 29% with early disease stage and 59.1% with late stage. The distress level progressively decreased along the evaluations: first day (55.8%), middle (27%) and last day of chemotherapy (13.4%). The same decrease occurred in anxiety and depression scale. There was a significant association (p < .001) between distress vs. anxiety and distress vs. depression over phases of evaluation: first day (r = 0.8, t(328) = 21.6; r = 0.8, t(328) = 16.2; R2 = 0.85), middle (r = 0.8, t(285) = 18.4; r = 0.8, t(285) = 20.9; R2 = 0.86) and last day of chemotherapy (r = 0.8, t(261) = 14.7; r = 0.8, t(261) = 20.8; R2 = 0.82). The incidence of distress shows to be related to anxiety, depression, gender, emotional and physical problems. Conclusions: Preliminary results suggest that distress, anxiety and depression scores tends to reduce during the 6-months period of evaluation. This results support the multidisciplinary discussion in order to propose the best intervention and treatment tailored to each case, being more assertive. In our experience we note the importance of distress screening and the health team integration to understand patient's experiences and to improve cancer care.

Objective: Although several large distress studies have been conducted in outpatient oncology treatment settings, there are few, if any, studies that describe the incidence of psychological and physical distress in the inpatient oncology treatment setting. This pilot study hypothesized that inpatients experience levels of psychological distress that are equivalent to or greater than those reported in large outpatient studies. The study also sought to contribute to physical and psychological symptom distress incidence data. Methods: Using two measures designed to screen for psychological and physical distress, the Brief Symptom Inventory—18 and the M.D. Anderson Symptom Inventory, 52 oncology patients were screened within 24 h of admission to a hospital oncology unit. Results: Nearly two-thirds of the inpatient respondents reported levels of psychological distress that were not only within the clinically significant range but also at a rate that was nearly double that found in the outpatient distress screening studies that have been conducted to date. The physical symptoms most often rated at the severe level included fatigue (34.6%), pain (27.4%), and dry mouth (25.5%). Conclusions: Failure to screen for psychological and physical symptom distress has lead to under recognition of a population that may have higher levels of distress than their outpatient counterparts and could potentially lead to uneven access to biopsychosocial support. Results support the notion that routinely screening for psychological and physical distress should become a first step in the assessment of the biopsychosocial needs of people receiving inpatient treatment for cancer. Copyright © 2011 John Wiley & Sons, Ltd.

s / Biol Blood Marrow Transplant 21 (2015) S374eS390 S387 Discussion & Implications: Staff engagement is essential in hospital efforts and evidence-based practices to improve quality of care for optimal patient outcomes. Nursing leadership is instrumental in providing structure, consistency, and specific feedback on progress as well as real time CLABSI rates to the team. CLABSIs are common and can be fatal in the transplant population. Continued surveillance of techniques and practices learned are ongoing and monitored for compliance. Improvements in all aspects of nursing carewith meticulous infection control techniques and environmental monitoring is essential for improved patient outcomes and reducing CLABSI rates in a bone marrow transplant population.