Comprehensive profiling of L1 retrotransposons in mouse.

L1 elements are retrotransposons currently active in mammals. Although L1s are typically silenced in most normal tissues, elevated L1 expression is associated with a variety of conditions, including cancer, aging, infertility and neurological disease. These associations have raised interest in the mapping of human endogenous de novo L1 insertions, and a variety of methods have been developed for this purpose. Adapting these methods to mouse genomes would allow us to monitor endogenous in vivo L1 activity in controlled, experimental conditions using mouse disease models. Here, we use a modified version of transposon insertion profiling, called nanoTIPseq, to selectively enrich young mouse L1s. By linking this amplification step with nanopore sequencing, we identified >95% annotated L1s from C57BL/6 genomic DNA using only 200 000 sequencing reads. In the process, we discovered 82 unannotated L1 insertions from a single C57BL/6 genome. Most of these unannotated L1s were near repetitive sequence and were not found with short-read TIPseq. We used nanoTIPseq on individual mouse breast cancer cells and were able to identify the annotated and unannotated L1s, as well as new insertions specific to individual cells, providing proof of principle for using nanoTIPseq to interrogate retrotransposition activity at the single-cell level in vivo.

Dyadic Investigation of Posttraumatic Stress Symptoms and Daily Sleep Health in Patients With Cancer and Their Caregivers.

OBJECTIVE: Cancer can be a traumatic experience affecting multidimensional aspects of sleep among patients and caregivers. This study examined the differential associations of cancer-related posttraumatic stress symptoms (PTSS) with various sleep markers in this population. METHODS: Patients newly diagnosed with colorectal cancer ( n = 138, mean age = 56.93 years, 31.88% female, 60.14% Hispanic, 6.53 months after diagnosis) and their sleep-partner caregivers ( n = 138, mean age = 55.32 years, 68.12% female, 57.97% Hispanic) completed questionnaires assessing the four PTSS clusters (intrusion, avoidance, alterations in arousal and reactivity, negative alterations in cognitions and mood). Participants also completed daily sleep diaries for 14 consecutive days, from which sleep onset latency (SOL), wake after sleep onset (WASO), and sleep duration were derived. RESULTS: Actor-partner interdependence model revealed that caregivers' greater alterations in arousal and reactivity were associated with their own longer SOL ( b = 15.59, p < .001) and their patients' longer sleep duration ( b = 0.61, p = .014), whereas patients' arousal and reactivity were associated with their caregivers' shorter SOL ( b = -8.47, p = .050). Patients' and caregivers' greater negative alterations in cognitions and mood were associated with patients' longer SOL ( b = 9.15, p = .014) and shorter sleep duration ( b = -0.41, p = .050), respectively. Caregivers' greater intrusion was related to their own shorter SOL ( b = -10.14, p = .004). CONCLUSIONS: The four PTSS clusters, particularly arousal and reactivity and negative cognitions and mood, have distinct associations with sleep markers individually and dyadically in patients and caregivers affected by cancer. Investigations of psychosocial and biobehavioral pathways underlying these relations are warranted. Tailored trauma treatments and sleep interventions may improve the well-being of this population.

A multi-state analysis on the effect of deprivation and race on PICU admission and mortality in children receiving Medicaid in United States (2007-2014).

INTRODUCTION: In the United States (US), racial and socioeconomic disparities have been implicated in pediatric intensive care unit (PICU) admissions and outcomes, with higher rates of critical illness in more deprived areas. The degree to which this persists despite insurance coverage is unknown. We investigated whether disparities exist in PICU admission and mortality according to socioeconomic position and race in children receiving Medicaid. METHODS: Using Medicaid data from 2007-2014 from 23 US states, we tested the association between area level deprivation and race on PICU admission (among hospitalized children) and mortality (among PICU admissions). Race was categorized as Black, White, other and missing. Patient-level ZIP Code was used to generate a multicomponent variable describing area-level social vulnerability index (SVI). Race and SVI were simultaneously tested for associations with PICU admission and mortality. RESULTS: The cohort contained 8,914,347 children (23·0% Black). There was no clear trend in odds of PICU admission by SVI; however, children residing in the most vulnerable quartile had increased PICU mortality (aOR 1·12 (95%CI 1·04-1·20; p = 0·0021). Black children had higher odds of PICU admission (aOR 1·04; 95% CI 1·03-1·05; p < 0·0001) and higher mortality (aOR 1·09; 95% CI 1·02-1·16; p = 0·0109) relative to White children. Substantial state-level variation was apparent, with the odds of mortality in Black children varying from 0·62 to 1·8. CONCLUSION: In a Medicaid cohort from 2007-2014, children with greater socioeconomic vulnerability had increased odds of PICU mortality. Black children were at increased risk of PICU admission and mortality, with substantial state-level variation. Our work highlights the persistence of sociodemographic disparities in outcomes even among insured children.

Correlates of posttraumatic stress in cancer patients and their family caregivers across two years following diagnosis.

OBJECTIVE: To examine risk-factors of cancer-related PTSS in the 2-years post-diagnosis in adult colorectal cancer patients and caregivers. METHODS: Patients with colorectal cancer and their caregivers (N = 130 dyads) self-reported sociodemographic, psychosocial, and medical factors at diagnosis/treatment initiation (T1), at 1- (T2), and 2-year (T3) post-diagnosis. Cancer-related PTSS were assessed, and path analysis examined associations between proposed correlates and PTSS. RESULTS: Among patients, higher neuroticism and greater physical symptom distress were concurrently associated with higher PTSS (Bs ≥ 0.10, ps ≤ 0.02); greater physical symptom distress at T1 and greater social support at T2 were associated with higher PTSS at T3 (Bs ≥ 0.37, ps ≤ 0.04). Among caregivers, female gender, higher neuroticism (Bs ≥ 0.12, ps < 0.01), and lower social support (Bs  ≤ -0.24, ps ≤ 0.02) were associated with higher concurrent PTSS; lower patient physical symptom distress and social support at T1 (Bs  ≤ -0.27, ps ≤ 0.03) and longer hours spent caregiving at T2 (B = 0.03, p = 0.05) were associated with higher PTSS at T3. CONCLUSIONS: Findings identify cancer-specific risk factors (physical symptoms, hours caregiving), in addition to established risk factors (female, neuroticism, social support) in non-medical populations. The identified subgroups should receive ongoing screening and psychosocial referral for cancer-related PTSS.

Retention, engagement, and binge-eating outcomes: Evaluating feasibility of the Binge-Eating Genetics Initiative study.

OBJECTIVE: Using preliminary data from the Binge-Eating Genetics Initiative (BEGIN), we evaluated the feasibility of delivering an eating disorder digital app, Recovery Record, through smartphone and wearable technology for individuals with binge-type eating disorders. METHODS: Participants (n = 170; 96% female) between 18 and 45 years old with lived experience of binge-eating disorder or bulimia nervosa and current binge-eating episodes were recruited through the Recovery Record app. They were randomized into a Watch (first-generation Apple Watch + iPhone) or iPhone group; they engaged with the app over 30 days and completed baseline and endpoint surveys. Retention, engagement, and associations between severity of illness and engagement were evaluated. RESULTS: Significantly more participants in the Watch group completed the study (p = .045); this group had greater engagement than the iPhone group (p's < .05; pseudo-R2 McFadden effect size = .01-.34). Overall, binge-eating episodes, reported for the previous 28 days, were significantly reduced from baseline (mean = 12.3) to endpoint (mean = 6.4): most participants in the Watch (60%) and iPhone (66%) groups reported reduced binge-eating episodes from baseline to endpoint. There were no significant group differences across measures of binge eating. In the Watch group, participants with fewer episodes of binge eating at baseline were more engaged (p's < .05; pseudo-R2 McFadden  = .01-.02). Engagement did not significantly predict binge eating at endpoint nor change in binge-eating episodes from baseline to endpoint for both the Watch and iPhone groups. DISCUSSION: Using wearable technology alongside iPhones to deliver an eating disorder app may improve study completion and app engagement compared with using iPhones alone.

Nursing Faculty's Perceptions of Climate Change and Sustainability.

AIM: The aim of this research study was to investigate the perceptions of climate change and sustainability of faculty teaching in associate and baccalaureate degree nursing programs in South Carolina and their attitudes toward inclusion of relevant content into the nursing curriculum. BACKGROUND: Climate change is a topic that receives limited discussion in most nursing education curricula. METHOD: This cross-sectional, descriptive study gathered data from 21 schools of nursing via an online survey consisting of demographic questions, the New Ecological Paradigm Scale, and the Sustainability Attitudes in Nursing Survey 2 and two questions regarding the current inclusion of content. RESULTS: Eighty-one percent of respondents did not include health implications of climate change in their teaching content; 67% did not include health implications of sustainability. CONCLUSION: Results provide preliminary evidence of gaps and areas of need for curricular content related to climate change and sustainability.

Prevalence and Sequelae of Cryptococcal Antigenemia in Antiretroviral Therapy-Experienced Populations: An Evaluation of Reflex Cryptococcal Antigen Screening in Botswana.

BACKGROUND: Evidence to inform cryptococcal antigen (CrAg)-screening guidelines among ART-experienced populations is lacking. We performed a study evaluating the utility of reflex CrAg screening in Gaborone, Botswana. METHODS: CD4 count data were collected from the HIV reference laboratory from 2014-2016. CrAg screening was performed on samples with CD4 ≤100 cells/µL beginning January 2015. The proportion of CD4 counts ≤100 cells/µL was determined and the frequency of repeat CrAg testing described. Analyses ascertained the impact of ART status on CrAg prevalence and outcomes, and whether CrAg titers could be used for risk stratification. RESULTS: Overall, 5.6% (3335/59 300) of individuals tested had CD4 ≤100 cells/µL; 2108 samples with CD4 ≤100 cells/µL from 1645 unique patients were CrAg tested. Over half of samples were from ART-experienced individuals: 40.9% (863) on ART and 12.1% (255) defaulters; 22% (463) of CrAg tests were on repeat samples. CrAg prevalence was 4.8% (72/1494; 95% CI, 3.8-6.0%) among outpatients and 21.9% (32/151; 95% CI, 15.3-28.5%) among inpatients. CrAg prevalence rates did not differ by ART status, but 6-month mortality was significantly lower in CrAg-positive individuals on ART at screening. Ten CrAg positives were identified through repeat testing. A CrAg titer cutoff ≥1:80 provided the best discrimination for 6-month survival. CONCLUSIONS: CrAg-positivity rates in an ART-experienced population were comparable to those seen in ART-naive populations. Repeat screening identified individuals who seroconverted to CrAg positivity and were at risk of cryptococcal disease. CrAg titers ≥1:80 can help identify the individuals at highest risk of death for more intensive management.

Cloth Lanyards as a Source of Intermittent Transmission of Candida auris on an ICU.

OBJECTIVES: Candida auris has been implicated in ICU outbreaks worldwide and is notable for being difficult to identify and treat, its resilience in the environment, and significant patient mortality associated with invasive disease. Here, we describe a small C. auris outbreak and how it was terminated. DESIGN: Single-center, observational. SETTING: Two general adult ICUs at an urban U.K. teaching hospital. PATIENTS: All patients positive for C. auris during the 5-month outbreak were included (n = 7). INTERVENTIONS: Stepwise implementation of enhanced infection prevention and control precautions was introduced including twice-weekly screening, contact tracing, isolation precautions, and environmental decontamination. A detailed environmental screen was performed to identify potential reservoirs. This included the patient bed space and clinical equipment and a frequently handled cloth lanyard attached to a key used to access controlled drugs. Personal possessions such as mobile phones, lanyards, and identification badges were also screened. MEASUREMENTS AND MAIN RESULTS: The index case and six linked acquisitions were identified. Four of six (67%) patients were identified after discharge of all known previous C. auris cases from ICU, highlighting potential for an environmental reservoir. Environmental screening identified C. auris from a patient bed space following deep cleaning, prompting review and enhancement of cleaning procedures. The controlled drug cloth lanyard was positive for C. auris, which prompted removal and culture of all staff lanyards. C. auris was identified on 1/100 staff lanyards (1%). No mobile phones or identification badges were positive for C. auris. The outbreak terminated following withdrawal of lanyards from ICU. CONCLUSIONS: This outbreak further implicates environmental reservoirs as sustaining C. auris ICU outbreaks. Identification of C. auris on cloth lanyards highlights the need to identify commonly handled moveable objects during an outbreak. We suggest that ICUs with a C. auris outbreak should investigate similar infrequently cleaned items as potential reservoirs and review their policies on lanyard use.

Effect of an Electronic Health Record "Nudge" on Opioid Prescribing and Electronic Health Record Keystrokes in Ambulatory Care.

BACKGROUND: Multiple policy initiatives encourage more cautious prescribing of opioids in light of their risks. Electronic health record (EHR) redesign can influence prescriber choices, but some redesigns add to workload. OBJECTIVE: To estimate the effect of an EHR prescribing redesign on both opioid prescribing choices and keystrokes. DESIGN: Quality improvement quasi-experiment, analyzed as interrupted time series. PARTICIPANTS: Adult patients of an academic multispecialty practice and a federally qualified health center (FQHC) who received new prescriptions for short-acting opioids, and their providers. INTERVENTION: In the redesign, new prescriptions of short-acting opioids defaulted to the CDC-recommended minimum for opioid-naïve patients, with no alerts or hard stops, such that 9 keystrokes were required for a guideline-concordant prescription and 24 for a non-concordant prescription. MAIN MEASURES: Proportion of guideline-concordant prescriptions, defined as new prescriptions with a 3-day supply or less, calculated per 2-week period. Number of mouse clicks and keystrokes needed to place prescriptions. KEY RESULTS: Across the 2 sites, 22,113 patients received a new short-acting opioid prescription from 821 providers. Before the intervention, both settings showed secular trends toward smaller-quantity prescriptions. At the academic practice, the intervention was associated with an immediate increase in guideline-concordant prescriptions from an average of 12% to 31% of all prescriptions. At the FQHC, about 44% of prescriptions were concordant at the time of the intervention, which was not associated with an additional significant increase. However, total keystrokes needed to place the concordant prescriptions decreased 62.7% from 3552 in the 6 months before the intervention to 1323 in the 6 months afterwards. CONCLUSIONS: Autocompleting prescription forms with guideline-recommended values was associated with a large increase in guideline concordance in an organization where baseline concordance was low, but not in an organization where it was already high. The redesign markedly reduced the number of keystrokes needed to place orders, with important implications for EHR-related stress. TRIAL REGISTRATION: www.ClinicalTrials.gov protocol 1710018646.

Comparing the PHQ-9 to the Multidimensional Behavioral Health Screen in Predicting Depression-Related Symptomatology in a Primary Medical Care Sample.

Depression is the most common form of psychopathology affecting people in the US. It is commonly diagnosed and treated in primary medical care settings, creating a need for a reliable, quick self-report tool used for the assessment of depression in this context. There is an emerging shift in the way psychopathology is conceptualized, as the field begins to transition from a categorical, syndrome-based model to a dimensional model. This change should be reflected in the assessment tool used within the primary care setting. The PHQ-9 is currently the most frequently used assessment tool for evaluating depression within primary care clinics, despite being based on the heterogenous, categorical method of conceptualizing psychopathology. The Multidimensional Behavioral Health Screen is a brief and efficient screening-level assessment tool for core psychopathology components (rather than syndromes), with a specific focus on depressive symptomatology. This study presents empirical evidence supporting the implementation of the MBHS in primary care clinics as a useful alternative to the PHQ-9.

Application of psychological theories on the role of gender in caregiving to psycho-oncology research.

BACKGROUND: Cancer affects both men and women, yet systematic understanding of the role of gender in caregiving and dyadic caregiver-patient interactions is lacking. Thus, it may be useful to review how gender theories apply to cancer caregiving and to evaluate the adequacy of current cancer caregiving studies to the gender theories. METHODS: Several databases, including MEDLINE (Ovid), PsychINFO, PubMed, and CINAHL, were used for searching articles published in English between 2000 and 2016. The search was restricted by age (≥18) and yielded 602 articles, which were subject to further screen and review based on selection criteria. Of 108 full texts reviewed to determine inclusion eligibility for this review, 55 met the criteria and included for review. RESULTS: The reviewed studies supported the "gender role" and "doing gender" perspectives for caregiver selection. The role identity, role strain, and transactional stress theories were supported for predicting caregiving outcomes at the individual level. Furthermore, attachment, self-determination, and interdependence theories incorporated caregiver factors that predicted the patients' outcomes, and vice versa. CONCLUSION: Despite limited gender theory-driven research in cancer caregiving and psycho-oncology in general, the utility of gender theories in (a) identifying subgroups of caregiver-patient dyads who are vulnerable to the adverse effects of cancer in the family and (b) developing evidence-based interventions is promising. Integrating broader issues of medical trajectory, lifespan, sociocultural, and biological factors in gender-oriented research and practice in psycho-oncology is encouraged.

Optimization of Nonambulant Mass Casualty Decontamination Protocols as Part of an Initial or Specialist Operational Response to Chemical Incidents.

Objective: The UK's Initial Operational Response (IOR) is a new process for improving the survival of multiple casualties following a chemical, biological, radiological or nuclear incident. Whilst the introduction of IOR represents a patient-focused response for ambulant casualties, there is currently no provision for disrobe and dry decontamination of nonambulant casualties. Moreover, the current specialist operational response (SOR) protocol for nonambulant casualty decontamination (also referred to as "clinical decontamination") has not been subject to rigorous evaluation or development. Therefore, the aim of this study was to confirm the effectiveness of putatively optimized dry (IOR) and wet (SOR) protocols for nonambulant decontamination in human volunteers. Methods: Dry and wet decontamination protocols were objectively evaluated using human volunteers. Decontamination effectiveness was quantified by liquid chromatography-mass spectrometry analysis of the recovery of a chemical warfare agent simulant (methylsalicylate) from skin and hair of volunteers, with whole-body fluorescence imaging to quantify the skin distribution of residual simulant. Results: Both the dry and wet decontamination processes were rapid (3 and 4 min, respectively) and were effective in removing simulant from the hair and skin of volunteers, with no observable adverse effects related to skin surface spreading of contaminant. Conclusions: Further studies are required to assess the combined effectiveness of dry and wet decontamination under more realistic conditions and to develop appropriate operational procedures that ensure the safety of first responders.

Parental perception of child vulnerability in childhood cancer survivors.

BACKGROUND: Parents' perception of their children's vulnerability to illness following cancer treatment is largely unknown, but is important to understand given known challenges of transitioning survivors to postcancer care. We investigated the frequency of and factors associated with perceived vulnerability by parents of childhood cancer survivors attending a regional survivorship clinic. PROCEDURE: This cohort study was offered to all parents of pediatric patients (currently ≤18 years) attending the Yale childhood cancer survivorship clinic January 2010 to October 2016 who were ≥1 year postcurative cancer therapy. Participating parents (one per patient) completed the standardized Child Vulnerability Scale at the beginning of the clinic visit (cutoff score ≥10 for perceived vulnerability). Patient sociodemographics, cancer history, and posttherapy complications were abstracted from medical records. RESULTS: Overall, 116 parents participated (98% participation rate) consisting of 89% mothers; survivors were 46% female, had a current mean age of 12.7 ± 3.9 years, and were a mean of 6.4 ± 3.8 years posttherapy. Twenty-eight percent (n = 33) of parents perceived their children as vulnerable. Survivor sociodemographics (age, sex, race/ethnicity, family income, insurance, parental marital status, number of siblings), cancer diagnosis, years off-therapy, survivorship visit number, treatment intensity, and late complications (number, type, severity) were not associated with perception of vulnerability. CONCLUSIONS: A sizeable proportion of parents continue to perceive their children as vulnerable even years after cancer therapy completion independent of current health status or past cancer history. Our data suggest the need to educate all parents of childhood cancer survivors regarding health risk, including those at lower risk for late complications.

Physical activity barriers, preferences, and beliefs in childhood cancer patients.

PURPOSE: Childhood cancer patients report low physical activity levels despite the risk for long-term complications that may benefit from exercise. Research is lacking regarding exercise barriers, preferences, and beliefs among patients (1) on- and off-therapy and (2) across the age spectrum. METHODS: Cross-sectional study in the Yale Pediatric Hematology-Oncology Clinic (October 2013-October 2014). Participants were ≥ 4 years old, > 1 month after cancer diagnosis at < 20 years, not acutely ill, expected to live > 6 months, and received chemotherapy and/or radiation. Participants (or parents if < 13 years) completed a survey. RESULTS: The 162 patients (99% participated) were 34% children (4.0-12.9 years), 31% adolescents (13.0-17.9 years), and 35% adults (≥ 18 years). Most had leukemia/lymphoma (66%); 32% were on-therapy. On-therapy patients were more likely than off-therapy patients (73 vs. 48%; p = 0.003) to report ≥ 1 barrier related to physical complaints, such as "just too tired" (46 vs. 28%; p = 0.021) or "afraid" of injury (22 vs. 9%; p = 0.027). The majority preferred walking (73%), exercising at home (91%), exercising in the afternoon (79%), and a maximum travel time of 10-20 min (54%); preferences did not vary significantly by therapy status or age. Most respondents (94%) recognized the benefits of exercise after cancer, but 50% of on- vs. 12% of off-therapy patients believed "their cancer diagnosis made it unsafe to exercise regularly" (p < 0.001). CONCLUSIONS: Physical activity barriers pertaining to physical complaints and safety concerns were more pronounced in on-therapy childhood cancer patients but persisted off-therapy. Preferences and beliefs were relatively consistent. Our data can inform interventions in different patient subgroups.

Recalling support provision decreases distress and anger in response to partner suffering.

OBJECTIVES: Thinking about a loved one's suffering can be emotionally stressful and have negative effects on a person's psychological and physical health over time. This study examined the hypotheses that when thinking about a partner's suffering (1) recalling past support provision to the suffering partner can decrease distress and anger and increase compassion, and (2) attachment orientation moderates these effects. METHOD: Seventy-seven older adult spouses of individuals with chronic pain were video-recorded while they disclosed: (1) an instance of partner suffering and (2) an instance of partner suffering plus their support provision. Compassion for the partner and their own distress and anger were self-reported immediately after each account. Accounts were coded for statements of support. Attachment was assessed with the Experiences with Close Relationships measure. RESULTS: As hypothesized, distress and anger were lower in the 'suffering with support' condition versus the 'suffering only' condition. There was no evidence that attachment orientation significantly moderated the effect of support recollection on emotional responses; however, more avoidant individuals reported less compassion and anger and used more words reflecting anger across conditions. More anxiously attached individuals reported greater compassion across conditions. CONCLUSION: When thinking about a partner's suffering, there are attachment-related differences in emotional reactions. Yet, regardless of these differences, it may be adaptive for spouses to think about their role in providing support to their partner to decrease their own negative emotions.

Metabolic Responses to a Battling Rope Protocol Performed in the Seated or Stance Positions.

Brewer, W, Kovacs, R, Hogan, K, Felder, D, and Mitchell, H. Metabolic responses to a battling rope protocol performed in the seated or stance positions. J Strength Cond Res 32(12): 3319-3325, 2018-The purpose of this study is to compare the levels of oxygen consumption and heart rate responses elicited by a treadmill or cycle V[Combining Dot Above]O2max test with a standing or sitting battling rope protocol (BRP) (treadmill vs. standing BRP) (cycle vs. seated BRP). Forty healthy subjects performed either a ramped V[Combining Dot Above]O2max treadmill or cycle test. At least 3 days later, the subjects who performed the ramped treadmill test did the standing BRP, and the subjects who performed the ramped cycle test did the sitting BRP. Each BRP consisted of 10 sets of 15/45 seconds of work/rest for 10 sets. V[Combining Dot Above]O2peak and HRpeak were recorded. Metabolic responses were significantly lower for the sitting BRP and standing as compared to the HRmax and V[Combining Dot Above]O2max values derived from the bicycle and treadmill tests. The BRP produced a V[Combining Dot Above]O2peak that was 71.87% (sitting) and 68.37% (standing) of the subjects' V[Combining Dot Above]O2max assessed u the bicycle and treadmill protocol. Moderate correlations were found between the V[Combining Dot Above]O2 during the seated (r = 0.61; p = 0.003) and standing (r = 0.43; p = 0.03) BRP and the bicycle and treadmill V[Combining Dot Above]O2max tests, respectively. The HRpeak elicited by the BRP performed in sitting (r = 0.52; p = 0.009) and standing (r = 0.67; p = 0.001) had a moderate correlation with the HRmax derived from the bicycle and treadmill tests. Battling ropes may be a low cost, accessible option to improve cardiovascular endurance for individuals who cannot stand or move their lower extremities in a rhythmic manner to conduct aerobic exercise.

Advanced Human Immunodeficiency Virus Disease in Botswana Following Successful Antiretroviral Therapy Rollout: Incidence of and Temporal Trends in Cryptococcal Meningitis.

Background: Botswana has a well-developed antiretroviral therapy (ART) program that serves as a regional model. With wide ART availability, the burden of advanced human immunodeficiency virus (HIV) and associated opportunistic infections would be expected to decline. We performed a nationwide surveillance study to determine the national incidence of cryptococcal meningitis (CM), and describe characteristics of cases during 2000-2014 and temporal trends at 2 national referral hospitals. Methods: Cerebrospinal fluid data from all 37 laboratories performing meningitis diagnostics in Botswana were collected from the period 2000-2014 to identify cases of CM. Basic demographic and laboratory data were recorded. Complete national data from 2013-2014 were used to calculate national incidence using UNAIDS population estimates. Temporal trends in cases were derived from national referral centers in the period 2004-2014. Results: A total of 5296 episodes of CM were observed in 4702 individuals; 60.6% were male, and median age was 36 years. Overall 2013-2014 incidence was 17.8 (95% confidence interval [CI], 16.6-19.2) cases per 100000 person-years. In the HIV-infected population, incidence was 96.8 (95% CI, 90.0-104.0) cases per 100000 person-years; male predominance was seen across CD4 strata. At national referral hospitals, cases decreased during 2007-2009 but stabilized during 2010-2014. Conclusions: Despite excellent ART coverage in Botswana, there is still a substantial burden of advanced HIV, with 2013-2014 incidence of CM comparable to pre-ART era rates in South Africa. Our findings suggest that a key population of individuals, often men, is developing advanced disease and associated opportunistic infections due to a failure to effectively engage in care, highlighting the need for differentiated care models.

Role of family caregivers' self-perceived preparedness for the death of the cancer patient in long-term adjustment to bereavement.

BACKGROUND: A substantial number of family caregivers go through bereavement because of cancer, but little is known about the bereaved caregivers' long-term adjustment. This study aimed to document levels of bereavement outcomes (prolonged grief symptoms, intense emotional reaction to the loss, depressive symptoms, and life satisfaction) among family cancer caregivers 3-5 years post-loss and to investigate how self-rated preparedness for the patient's death predicted those bereavement outcomes. METHODS: Family members participated in a nationwide survey for cancer caregivers 2 years after the relative's diagnosis (T1). Of those, 109 were identified as bereaved by 5 years post-diagnosis (T2). Of those, 88 continued to participate at 8-year follow-up (T3) and provided valid data for the study variables. Caregivers' distress risk factors were measured at T1, satisfaction with palliative care and preparedness for the death of the patient at T2, and time since death of the patient at T2 or T3. RESULTS: Substantial numbers of family members (18% to 48%) displayed heightened levels of bereavement-related psychological distress years after the loss. Hierarchical general linear modeling revealed that perceived preparedness for the death of the patient concurrently and prospectively predicted better adjustment to bereavement, independent of contributions of other factors studied. CONCLUSIONS: Findings underscore the high prevalence of long-lasting bereavement-related distress among family cancer caregivers and the role of preparedness for the relative's death in the level of that distress. Findings suggest that psychosocial programs among caregivers focus on not only caregiving skills per se but also preparedness for the death of the patient. Copyright © 2015 John Wiley & Sons, Ltd.

A home-based physical activity intervention using activity trackers in survivors of childhood cancer: A pilot study.

BACKGROUND: Over 70% of childhood cancer survivors develop late complications from therapy, many of which can be mitigated by physical activity. Survivors engage in exercise at similar or lower rates than their sedentary healthy peers. We piloted a novel home-based exercise intervention with a motivational activity tracker. We evaluated (i) feasibility, (ii) impact on activity levels and physical fitness, and (iii) barriers, preferences, and beliefs regarding physical activity. METHODS: Childhood cancer survivors currently 15 years or older and not meeting the Centers for Disease Control and Prevention physical activity guidelines were enrolled and instructed to wear the Fitbit One, a 4.8 cm × 1.8 cm motivational activity tracker, daily for 6 months. Baseline and follow-up evaluations included self-report surveys, an Actigraph accelerometer for 7 days, and a VO2 maximum test by cardiac stress test. RESULTS: Nineteen participants were enrolled (13.4% participation rate) with a mean age of 24.3 ± 5.8 years (range 15-35). Four participants withdrew with a 79% retention rate. Participants wore the Fitbit an average of 19.0 ± 4.7 days per month during months 1-3 and 15.0 ± 7.9 days per month during months 4-6. Total weekly moderate to vigorous physical activity increased from 265.6 ± 117.0 to 301.4 ± 135.4 min and VO2 maximum increased from 25.7 ± 7.7 to 27.2 ± 7.4 ml/kg/min. These changes were not statistically significant (P = 0.47 and 0.30, respectively). Survey responses indicated no change in barriers, preferences, and beliefs regarding physical activity. CONCLUSIONS: This pilot study of a motivational activity tracker demonstrated feasibility as measured by participant retention, receptivity, and belief of utility. Future studies with a large sample size are needed to demonstrate the efficacy and sustainability of this intervention.