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Background/Objectives: Postoperative delirium is common in the elderly and is associated with poor outcome. However, its diagnosis is often missed or delayed. Nursing staff is at the frontline and plays a crucial role in the early detection and management of delirium. This study was designed to explore the knowledge and attitudes of nursing staff about delirium in the scope of an educational program implementation. Methods: Qualitative and quantitative analyses conducted in four surgical wards and one intensive care unit in an Academic Hospital in France. A questionnaire was administered to 171 nurses and nursing assistants and semistructured interviews were conducted. Results: A total of 89 questionnaires were completed (response rate of 52%). Regarding symptoms, most of the nursing staff knew about disorientation and incoherent speech. However, few knew about acute onset and fluctuation, and the hypoactive form of delirium was virtually unknown. Regarding risk factors, while many knew about dehydration, drug use and the use of physical restraints, few knew about fecaloma, sensory impairment and infection. The staff globally knew about the main prevention measures, but knowledge on patient management was especially poor. Finally, no respondent knew about or used the Confusion Assessment Method. The qualitative analysis revealed a trivialization of delirium onset among older inpatients and the continuity of preconceived ideas on delirium, its diagnosis and its risk factors. Conclusions: On the whole, this study provides a clearer understanding of staff learning needs and identifies potential issues to be addressed in order to increase future intervention efficacy.

International audience

article; International audience; Early postpartum bleeding remains in France the leading cause of maternal mortality in perinatal period. In association with obstetrical and medical measures to control bleeding, uterine arteries embolization constitutes an efficient non-surgical measure whose potential side effects must be kept in mind. We report the case of a patient that presented a popliteal sciatic paralysis in the hours following the procedure. Through this case, we will review the different types of embolization complications.

Over the last 18 years, we have developed the transplantation of fetal liver cells to treat severe immunodeficiencies, hematological disorders and inborn errors of metabolism. Post-natally, this treatment is successful in two-third of patients and it is therefore very valuable, especially when there is no perfectly matched donor for a bone marrow transplant. Since 1 988 we have carried out these fetal liver transplants (FLTs) in utero, immediately after prenatal diagnosis. Engraftment and reconstitution have been obtained, and several advantages appear to be associated with in utero FLT : increased probability of graft take, ideal isolation of the patient (in the maternal uterus) and optimal environment for the differentiation of the transplanted fetal liver cells (in the fetal host).

Four human fetuses were treated by transplantation of human fetal liver stem cells. Two of them had severe immunodeficiency disease and thc two other ones had thalassemia major. Three of these in utero transplants were followed by engraftment. The three patients are now born : the first one is now very healthy thanks to the reconstitution of cell-mediated immunity associated with this transplant, and he lives normally at home ; the two other ones, who have been more recently treated, have a significant improvement of their condition and they also live normally at home. This procedure, for the first time used in humans, has therefore demonstrated its feasibility and its efficacy : during early fetal development, foreign cells engraft readily and may result in cure or significant correction of a large variety of inherited diseases.

Based on the experience acquired in post-natal liver transplantation since 1974, we recently initiated pre-natal, in utero stem cell transplantation from the human fetal liver. The first two fetuses that we treated had immunodeficiencies, the third one had thalassemia major. Donors and recipients were not matched. The fetal cells were infused in the umbilical vein of the first two patients and injected intraperitoneally into the third one, under ultrasonic visualization. The first patient, born in 1988, has both engraftment of donor cells and reconstitution of cell-mediated immunity. This child, who had bare lymphocyte syndrome, has no clinical manifestation of the disease and he lives normally at home. The second child, born in 1989, has not yet developed a significant reconstitution of immunity although donor cell engraftment has been proven (Y chromosome in this female patient). The third patient has also evidence of donor cell take (Y chromosome in a female patient) but the effect on thalassemia has not yet been fully analyzed (donor hemoglobin present in small quantity). In all 3 cases, no side-effect of any kind developed in the mother nor in the fetus. Several advantages appear to be associated with in utero FLT: increased probability of graft take, ideal isolation of patient (in the uterus), optimal environment for fetal cell development (in the fetal host).

Microcalcifications previously located by radiography were extracted from 25 fresh specimens obtained from patients who had undergone tumorectomy or systematized mammary exeresis. Two principal types of microcalcifications were distinguished: Type I microcalcifications were amber in color and generally crystalline on scanning electron microscopy, with only one calcium peak on microprobe analysis; x-ray diffraction revealed that weddellite was involved. Type II microcalcifications were whitish, nonbirefringent under polarized light, and generally ovoid or fusiform, with two peaks, one calcium and the other phosphorus, on microprobe analysis; these microcalcifications were composed of calcium phosphate, the most characteristic form of which is hydroxyapatite, in the form of needles arranged in rosettes on transmission electron microscopy. Type I microcalcifications were observed in four of eight benign breast lesions, in two of three in situ lobular carcinomas, and in no intraductal adenocarcinomas or infiltrating carcinomas. Type II microcalcifications were present in all infiltrating carcinomas and intraductal adenocarcinomas; they were also found in benign lesions (four of eight) and even associated with type I microcalcifications in one in situ lobular carcinoma. There are, therefore, no "benign" or "malignant" microcalcifications; however, the presence of weddellite is a strong indication that a lesion is benign or, at most, an in situ lobular carcinoma.

Gestational trophoblastic diseases include partial and complete molar pregnancies together with trophoblastic tumors, namely invasive mole, choriocarcinoma and placental site trophoblastic tumor. Important advances continue to occur in both our understanding and management of these diseases. The general guidelines we display here are intended to standardize the essential current management of trophoblastic diseases and justify the creation of a reference center in France. The goal of such a center is to optimize the treatment of patients. The center can help in drawing and interpreting the human chorionic gonadotrophin regression curve and give the multidisciplinary current recommendations to the physician in charge of the patient. The aim is to diagnose and treat as soon as possible the malignant forms of the disease as the interval between the previous pregnancy and the initiation of treatment is a major prognostic factor.

The therapeutic field of in utero transplantation of stem cells, into human fetuses, has developed since 1988 with the hope of improved probability of engraftment and tolerance, due to immune immaturity of the host. Fifteen years later, it is possible to evaluate the results that we and others have obtained in the treatment of several fetal diseases. Seven fetal patients have been treated in Lyon: In 2 cases, pregnancy termination was induced by the in utero injection; in the 5 other cases, engraftment was obtained and repeatedly documented with presence of donor HLA antigens and/or Y chromosome in recipients. In the 2 patients with combined immunodeficiency disease, a sustained reconstitution of immunity was obtained as a result of the transplant but other complications occurred thereafter. In patients with thalassemia major, Niemann-Pick disease or hemophilia, a very partial and very transitory benefit was only obtained. Approximately 33 other patients with immunodeficiencies, hemoglobinopathies or inborn errors of metabolism have been treated worldwide, over the last 13 years, with a comparable method, using parental or fetal stem cells transplanted in utero. Successful treatment has usually been recorded in immunodeficiencies, and insufficient results have been obtained in the other cases. This form of treatment can therefore be recommended after prenatal diagnosis of combined immunodeficiency but additional research is required to improve the degree of engraftment, the lack of resistance of the host and the ‘space’ available for hematopoiesis in the other conditions.

FOLLOWING 19 years of experience in postnatal fetal liver transplantation (FLT), we have developed a new therapeutic method, namely the in utero transplantation of stem cells from the human fetal liver. This early transplant takes advantage of the immunological tolerance that exists in young fetal recipients. The six fetuses that we treated were 28, 26, 17, 14, and 12 weeks postfertilization. Three patients had immunodeficiencies, two others had thalassemia major and the last one had Niemann-Pick disease (type A). Donor cells were obtained from 7- to 13-week-old fetuses, with conditions approved by the National Committee for Bioethics. Donors and recipients were not matched. Under ultrasonic visualization, the fetal cells were infused through the umbilical vein of four patients and injected intraperitoneally into the 2 other ones. The first patient, born in 1988, has evidence of engraftment (T lymphocytes of donor origin expressing donor HLA specificities, in the host peripheral blood) and reconstitution of cell-mediated immunity. This child, who had bare lymphocyte syndrome,1 has no clinical manifestation of the disease and lives normally at home. The second child was born in 1989; donor cell engraftment has been proven (distinct HLA phenotype) and the severe immunodeficiency has been corrected to a large degree. One fetus with chronic granulomatous disease developed fatal bradycardia after a second in utero FLT. One fetal patient with thalassemia major had cardiac arrest following the intravenous infusion. The fifth patient, transplanted intraperitoneally at 12 weeks of fetal age, to treat thalassemia major, has evidence of donor cell take (Y chromosome in a female patient) and a partial effect on thalassemia has been obtained (HbA increased up to 30%, 1 year after birth); the proportion of donor versus host cells however tended to decrease over the following years suggesting that, in contrast with immunodeficient patients, thalassemic patients exhibit a selective advantage for the development of host, rather than donor, stem cells. The last patient treated by in utero FLT had Niemann-Pick disease. Engraftment was again obtained (donor HLA phenotype) but due to either the limited number of donor cells or the blood-brain barrier, moderate clinical and metabolic effects were seen, especially in the CNS. In all four patients who were born, no side-effect developed in the mother nor in the fetus. Several advantages appear to be associated with in utero FLT2: increased probability of graft take with development of specific immunological tolerance, ideal isolation of patient (in the uterus), and optimal environment for fetal cell development (in the fetal host). Immunological tolerance, in T cells deriving from donor stem cells, after education within host thymus, was shown to involve clonal deletion for donor antigens (deletion induced by donor dendritic cells and macrophages), and clonal anergy for host antigens (anergy induced by host thymic epithelial cells).3 High IL-10 production persisted for many years and was likely to play a role in the stable chimerism and tolerance maintenance.2