Reassessing the approach to informed consent: The case of unrelated hematopoietic stem cell transplantation in adult thalassemia patients

Introduction: The informed consent process is the legal embodiment of the fundamental right of the individual to make decisions affecting his or her health., and the patient's permission is a crucial form of respect of freedom and dignity, it becomes extremely important to enhance the patient's understanding and recall of the information given by the physician. This statement acquires additional weight when the medical treatment proposed can potentially be detrimental or even fatal. This is the case of thalassemia patients pertaining to class 3 of the Pesaro classification where Allogenic hematopoietic stem cell transplantation (HSCT) remains the only potentially curative treatment. Unfortunately, this kind of intervention is burdened by an elevated transplantation-related mortality risk (TRM: all deaths considered related to transplantation), equal to 30% according to published reports. In thalassemia, the role of the patient in the informed consent process leading up to HSCT has not been fully investigated. This study investigated the hypothesis that information provided by physicians in the medical scenario of HSCT is not fully understood by patients and that misunderstanding and communication biases may affect the clinical decision-making process.Methods: A questionnaire was either mailed or given personally to 25 patients. A second questionnaire was administered to the 12 physicians attending the patients enrolled in this study. Descriptive statistics were used to evaluate the communication factors.Results: The results pointed out the difference between the risks communicated by physicians and the risks perceived by patients. Besides the study highlighted the mortality risk considered to be acceptable by patients and that considered to be acceptable by physicians.Conclusions: Several solutions have been suggested to reduce the gap between communicated and perceived data. A multi-disciplinary approach may possibly help to attenuate some aspects of communication bias. Several tools have also been proposed to fill or to attenuate the gap between communicated and perceived data. But the most important tool is the ability of the physician to comprehend the right place of conscious consent in the relationship with the patient

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

Stainless steel reinforcing bars – reason for their high pitting corrosion resistance

In harsh chloride bearing environments stainless steel reinforcing bars offer excellent corrosion resistance and very long service life for concrete structures, but the high costs limit a more widespread use. Manganese bearing nickel-free stainless steels could be a cost-effective alternative. Whereas the corrosion behavior of stainless steels in alkaline solutions, mortar and concrete is quite well established, only few information on the reasons for the high pitting resistance are available. This work reports the results of pitting potential measurements in solutions simulating alkaline and carbonated concrete on black steel, stainless steel DIN 1.4301, duplex steel DIN 1.4462 and nickel-free stainless steel DIN 1.4456. Duplex and nickel-free stainless steels are fully resistant even in 5 M NaCl solutions with pH 13 or higher, the lower grade DIN 1.4301 shows a wide scatter between fully resistant and pitting potentials as low as +0.2 V SCE. In carbonated solutions with pH 9 the nickel-free DIN 1.4456 shows pitting corrosion at chloride concentrations ≥ 3 M. This ranking of the pitting resistance can be rationalized based on XPS surface analysis results: both the increase of the Cr(III)oxy-hydroxide and Mo(VI) contents in the passive film and a marked nickel enrichment beneath the film improve the pitting resistance. The duplex DIN 1.4464 shows the highest pitting resistance, which can be attributed to the very high Cr(III)oxy-hydroxide, to a medium Mo(VI) content in the film and to a nickel enrichment beneath the film. Upon time, the protective properties of the surface film improve. This beneficial effect of ageing (transformation of the passive film to a less Fe2+ containing, more hydrated film) will lead to higher pitting potentials. It can be concluded that short-term solution experiments give conservative results in terms of resistance to chloride-induced corrosion in reinforced concrete structures

Nickel-free manganese bearing stainless steel in alkaline media - electrochemistry and surface chemistry

The use of austenitic nickel-containing stainless steels as concrete reinforcement offers excellent corrosion protection for concrete structures in harsh chloride bearing environments but is often limited due to the very high costs of these materials. Manganese bearing nickel-free stainless steels can be a cost-effective alternative for corrosion resistant reinforcements. Little, however, is known about the electrochemistry and even less on surface chemistry of these materials in alkaline media simulating concrete pore solutions. In this work a combined electrochemical (ocp = open circuit potential) and XPS (X-ray photoelectron spectroscopy) surface analytical investigation on the austenitic manganese bearing DIN 1.4456 (X8CrMnMoN18-18-2) stainless steel immersed into 0.1 M NaOH and more complex alkaline concrete pore solutions was performed. The results show that the passive film composition changes with immersion time, being progressively enriched in chromium oxy-hydroxide becoming similar to the conventional nickel-containing stainless steels. The composition of the metal interface beneath the passive film is strongly depleted in manganese and enriched in iron; chromium has nearly the nominal composition. The results are discussed regarding the film growth mechanism (ageing) of the new nickel-free stainless steel in alkaline solutions compared to traditional austenitic steels. Combining the results from pitting potential measurements with the composition of the passive film and the underlying metal interface, it can be concluded that the resistance against localized corrosion of the new nickel-free stainless steel relies on the strong chromium(III) and molybdenum (VI) oxy-hydroxide enrichment in the passive film