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Charles Muiruri,1,2 Eline M van den Broek-Altenburg,3 Hayden B Bosworth,1,4 Crystal W Cené,5 Juan Marcos Gonzalez1,6 1Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA; 2Duke Global Health Institute, Duke University, Durham, NC, USA; 3University of Vermont Larner College of Medicine, Burlington, VT, USA; 4Durham Veterans Affairs Medical Center, Durham, NC, USA; 5University of California San Diego Health, San Diego, CA, USA; 6Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USACorrespondence: Charles Muiruri, Department of Population Health Sciences Duke University School of Medicine, 215 Morris St., Suite 210, Durham, NC, 27701, USA, Tel +19196603212, Email charles.muiruri@duke.eduIntroduction: Medication non-adherence remains a significant challenge in healthcare, impacting treatment outcomes and the overall effectiveness of medical interventions. This article introduces a novel approach to understanding and predicting medication non-adherence by integrating patient beliefs, efficacy expectations, and perceived costs. Existing theoretical models often fall short in quantifying the impact of barrier removal on medication adherence and struggle to address cases where patients consciously choose not to follow prescribed medication regimens. In response to these limitations, this study presents an empirical framework that seeks to provide a quantifiable model for both individual and population-level prediction of non-adherence under different scenarios.Methods: We present an empirical framework that includes a health production function, specifically applied to antihypertensive medications nonadherence. Data collection involved a pilot study that utilized a double-bound contingent-belief (DBCB) questionnaire. Through this questionnaire, participants could express how efficacy and side effects were affected by controlled levels of non-adherence, allowing for the estimation of sensitivity in health outcomes and costs.Results: Parameters derived from the DBCB questionnaire revealed that on average, patients with hypertension anticipated that treatment efficacy was less sensitive to non-adherence than side effects. Our derived health production function suggests that patients may strategically manage adherence to minimize side effects, without compromising efficacy. Patients’ inclination to manage medication intake is closely linked to the relative importance they assign to treatment efficacy and side effects. Model outcomes indicate that patients opt for full adherence when efficacy outweighs side effects. Our findings also indicated an association between income and patient expectations regarding the health of antihypertensive medications.Conclusion: Our framework represents a pioneering effort to quantitatively link non-adherence to patient preferences. Preliminary results from our pilot study of patients with hypertension suggest that the framework offers a viable alternative for evaluating the potential impact of interventions on treatment adherence.Keywords: medication adherence, patient preferences, health production, behavioral model, quantitative framework, treatment efficacy, side effects

Jelle E Bousema,1 Fieke Hoeijmakers,2 Marcel GW Dijkgraaf,3 Jouke T Annema,4 Frank JC van den Broek,1 M Elske van den Akker-van Marle5 On behalf of the MEDIASTrial Study Group1Department of Surgery, Máxima MC, Veldhoven, 5500 MB, the Netherlands; 2Department of Surgery, Leiden University Medical Center, Leiden, 2300 RC, the Netherlands; 3Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam, 1100 DE, the Netherlands; 4Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, 1100 DE, the Netherlands; 5Department of Biomedical Data Sciences, Unit Medical Decision Making, LUMC, Leiden, 2300 RC, the NetherlandsCorrespondence: Frank JC van den BroekDepartment of Surgery, Máxima MC, Veldhoven, P.O. BOX 7777, Veldhoven, 5500 MB, the NetherlandsEmail lung.resurge@mmc.nlBackground: Variability in practice and ongoing debate on optimal invasive mediastinal staging of patients with resectable non-small cell lung cancer (NSCLC) are widely described in the literature. Patients’ preferences on this topic have, however, been underexposed so far.Methods: An internet-based questionnaire was distributed among MEDIASTrial participants (NTR6528, randomization of patients to mediastinoscopy or not in the case of negative endosonography). Literature, expert opinion and patient interviews resulted in five attributes: the risk of a futile lung resection (oncologically futile in case of unforeseen N2 disease), the length of the staging period, resection of the primary tumor, complications of staging procedures and the mediastinoscopy scar. The relative importance (RI) of each attribute was assessed by using adaptive conjoint analysis and hierarchical Bayes estimation. A treatment trade-off was used to examine the acceptable proportion of avoided futile lung resections to cover the burden of confirmatory mediastinoscopy.Results: Ninety-seven patients completed the questionnaire (57%). The length of the staging period was significantly the most important attribute (RI 26.24; 95% CI: 25.05– 27.43), followed by the risk of a futile surgical lung resection (RI 23.44; 95% CI: 22.28– 24.60) and resection of the primary tumor (RI 22.21; 95% CI: 21.09– 23.33). Avoidance of 7% (IQR 1– > 14%) futile lung resections would cover the burden of confirmatory mediastinoscopy, with a dichotomy among patients always (39%) or never (38%) willing to undergo confirmatory mediastinoscopy after N2 and N3-negative endosonography.Conclusion: Although a strong dichotomy among patients always or never willing to undergo confirmatory mediastinoscopy was found, the length of the staging period was the most important attribute in invasive mediastinal staging according to patients with resectable NSCLC.Trial Registration: Not applicable.Keywords: patients’ preferences, non-small cell lung cancer, mediastinal nodal staging, endosonography, mediastinoscopy, thoracic surgery

BackgroundMany studies have focused on the characteristics of symptomatic patients with COVID-19 and clinical risk factors. This study reports the prevalence of COVID-19 in an asymptomatic population of a hospital service area (HSA) and identifies factors that affect exposure to the virus. ObjectiveThe aim of this study is to measure the prevalence of COVID-19 in an HSA, identify factors that may increase or decrease the risk of infection, and analyze factors that increase the number of daily contacts. MethodsThis study surveyed 1694 patients between April 30 and May 13, 2020, about their work and living situations, income, behavior, sociodemographic characteristics, and prepandemic health characteristics. This data was linked to testing data for 454 of these patients, including polymerase chain reaction test results and two different serologic assays. Positivity rate was used to calculate approximate prevalence, hospitalization rate, and infection fatality rate (IFR). Survey data was used to analyze risk factors, including the number of contacts reported by study participants. The data was also used to identify factors increasing the number of daily contacts, such as mask wearing and living environment. ResultsWe found a positivity rate of 2.2%, a hospitalization rate of 1.2%, and an adjusted IFR of 0.55%. A higher number of daily contacts with adults and older adults increases the probability of becoming infected. Occupation, living in an apartment versus a house, and wearing a face mask outside work increased the number of daily contacts. ConclusionsStudying prevalence in an asymptomatic population revealed estimates of unreported COVID-19 cases. Occupational, living situation, and behavioral data about COVID-19–protective behaviors such as wearing a mask may aid in the identification of nonclinical factors affecting the number of daily contacts, which may increase SARS-CoV-2 exposure.

BackgroundThe COVID-19 pandemic forced many health systems to proactively reduce care delivery to prepare for an expected surge in hospitalizations. There have been concerns that care deferral may have negative health effects, but it is hoped that telemedicine can provide a viable alternative. ObjectiveThis study aimed to understand what type of health care services were being deferred during the COVID-19 pandemic lockdown, the role played by telemedicine to fill in care gaps, and changes in attitudes toward telemedicine. MethodsWe conducted a cross-sectional analysis of survey responses from 1694 primary care patients in a mid-sized northeastern city. Our main outcomes were use of telemedicine and reports of care deferral during the shutdown. ResultsDeferred care was widespread—48% (n=812) of respondents deferred care—but it was largely for preventive services, particularly dental and primary care, and did not cause concerns about negative health effects. In total, 30.2% (n=242) of those who delayed care were concerned about health effects, with needs centered around orthopedics and surgery. Telemedicine was viewed more positively than prior to the pandemic; it was seen as a viable option to deliver deferred care, particularly by respondents who were over 65 years of age, female, and college educated. Mental health services stood out for having high levels of deferred care. ConclusionsTemporary health system shutdowns will give rise to deferred care. However, much of the deferrals will be for preventive services. The effect of this on patient health can be moderated by prioritizing surgical and orthopedic services and delivering other services through telemedicine. Having telemedicine as an option is particularly crucial for mental health services.

Leonie van den Broek,1 Jutte van der Werff-ten Bosch,2 Pieter-Jan Cortoos,3 Susanne van Steijn,1 Machiel van den Akker1,21Department of Pediatrics, Queen Paola Children’s Hospital, Antwerp, Belgium; 2Department of Pediatric Hematology Oncology, UZ Brussel, Brussels, Belgium; 3Pharmacy, UZ Brussel, Brussels, Belgium Abstract: Neonatal neutropenia is regularly seen with variable etiology. We describe a breastfed infant with maternal medication use as a probable cause of neonatal neutropenia. An 8 days old exclusively breastfed female infant of Arab-Berber descent was referred to our hospital because of an infection of the umbilicus. Complete blood count showed a picture of severe isolated neutropenia. After initiating intravenous antibiotic treatment, the infection quickly resolved, but the isolated neutropenia persisted. Bone marrow aspiration indicated severe congenital neutropenia. The mother was known to have Crohn’s disease, treated with methylprednisolone and adalimumab up to 3 months before delivery, and latent tuberculosis, for which she used isoniazid postnatally. Breast-feeding was terminated and filgrastim was started, with an increase of the neutrophilic count. After several weeks, filgrastim could be terminated. Bone marrow and complete blood count were repeated and were completely normal. This case report describes a very young breastfed female infant with severe neutropenia, causing an infection, in which maternal adalimumab use could not be excluded as a possible cause. Maternal isoniazid use is highly unlikely. Keywords: congenital neutropenia, neonate, breast-feeding, adalimumab, isoniazid

Diagnostic errors are a major, largely preventable, patient safety concern. Error interventions cannot feasibly be implemented for every patient that is seen. To identify cases at high risk of error, clinicians should have a good calibration between their perceived and actual accuracy. This experiment studied the impact of feedback on medical interns' calibration and diagnostic process. In a two-phase experiment, 125 medical interns from Dutch University Medical Centers were randomized to receive no feedback (control), feedback on their accuracy (performance feedback), or feedback with additional information on why a certain diagnosis was correct (information feedback) on 20 chest X-rays they diagnosed in a feedback phase. A test phase immediately followed this phase and had all interns diagnose an additional 10 X-rays without feedback. Outcome measures were confidence--accuracy calibration, diagnostic accuracy, confidence, and time to diagnose. Both feedback types improved overall confidence--accuracy calibration (R[superscript 2][subscript]No Feedback = 0.05, R[superscript 2][subscript]Performance Feedback = 0.12, R[superscript 2][subscript]Information Feedback = 0.19), in line with the individual improvements in diagnostic accuracy and confidence. We also report secondary analyses to examine how case difficulty affected calibration. Time to diagnose did not differ between conditions. Feedback improved interns' calibration. However, it is unclear whether this improvement reflects better confidence estimates or an improvement in accuracy. Future research should examine more experienced participants and non-visual specialties. Our results suggest that feedback is an effective intervention that could be beneficial as a tool to improve calibration, especially in cases that are not too difficult for learners.

Objectives: This study adds to the ongoing discussion on how to ease the transition from undergraduate medical training to postgraduate training. In the Netherlands there is no central matching system for admission to residency. Medical school graduates just apply for a position in an open job market. Many choose to acquire general or specialty-specific clinical experiences after the medical degree before residency, to further explore career opportunities and to increase their chances to get into their preferred specialty. To shorten this gap between undergraduate and the start of postgraduate training, the sixth and final year of most Dutch medical schools is designed as a “transitional year”. Students work with more clinical responsibilities than in the earlier clerkships, and this year includes many elective options. Our study focuses on these elective options and explores how medical students use these transitional year electives to prepare for transition to postgraduate training.Methods: In 2012-2013 we asked all 274 graduating students at one Dutch medical school to complete an open-answer questionnaire with the following topics: Questionnaire results were coded by two researchers and were discussed with all members of the research team. Results: A total of 235 students responded (86%). Answers about motivation for choices revealed that most electives where chosen for career orientation and to optimize chances to get into a residency program. Students also focused on additional experiences in specialties related to their preferred specialty. Many students chose electives logically related to each other, e.g. combinations of surgery and radiology. About two-thirds of the respondents stated that their elective experiences did confirm their specialty preferences or resulted in a more clear insight.Conclusion: We conclude that students use the transitional year electives to focus on their future postgraduate training program, i.e. for orientation and to align their curriculum vitae with their preferred specialty, resulting in spontaneous early specialty streaming. To take advantages of this streaming, and to make sure students can transfer their experiences to other specialties if their career preferences change, individual elective Entrustable Professional Activities (EPAs), next to the core EPAs for all medical students, may serve to prepare a smooth transition to a specialty of choice and should be fully documented.