EWSR1/FUS-CREB fusions define a distinctive malignant epithelioid neoplasm with predilection for mesothelial-lined cavities.

Gene fusions constitute pivotal driver mutations often encoding aberrant chimeric transcription factors. However, an increasing number of gene fusion events have been shown not to be histotype specific and shared among different tumor types, otherwise completely unrelated clinically or phenotypically. One such remarkable example of chromosomal translocation promiscuity is represented by fusions between EWSR1 or FUS with genes encoding for CREB-transcription factors family (ATF1, CREB1, and CREM), driving the pathogenesis of various tumor types spanning mesenchymal, neuroectodermal, and epithelial lineages. In this study, we investigate a group of 13 previously unclassified malignant epithelioid neoplasms, frequently showing an epithelial immunophenotype and marked predilection for the peritoneal cavity, defined by EWSR1/FUS-CREB fusions. There were seven females and six males, with a mean age of 36 (range 9-63). All except three cases occurred intra-abdominally, including one each involving the pleural cavity, upper, and lower limb soft tissue. All tumors showed a predominantly epithelioid morphology associated with cystic or microcystic changes and variable lymphoid cuffing either intermixed or at the periphery. All except one case expressed EMA and/or CK, five were positive for WT1, while being negative for melanocytic and other mesothelioma markers. Nine cases were confirmed by various RNA-sequencing platforms, while in the remaining four cases the gene rearrangements were detected by FISH. Eleven cases showed the presence of CREM-related fusions (EWSR1-CREM, 7; FUS-CREM, 4), while the remaining two harbored EWSR1-ATF1 fusion. Clinically, seven patients presented with and/or developed metastases, confirming a malignant biologic potential. Our findings expand the spectrum of tumors associated with CREB-related fusions, defining a novel malignant epithelioid neoplasm with an immunophenotype suggesting epithelial differentiation. This entity appears to display hybrid features between angiomatoid fibrous histiocytoma (cystic growth and lymphoid cuffing) and mesothelioma (peritoneal/pleural involvement, epithelioid phenotype, and cytokeratin and WT1 co-expression).

Accident and emergency nurses' attitudes towards patients who self-harm.

The study aimed to assess if accident and emergency (A&E) nurses have positive or negative attitudes towards patients with deliberate self-harm, and to assess if nurses' age, length of A&E experience, or in-service education influence their attitudes towards these patients. An adapted version of the Suicide Opinion Questionnaire was used to assess attitudes towards patients with deliberate self-harm. Data were collected from 43 Registered Nurses in the A&E department of a major city hospital in Australia. Data were analysed using SPSS. Most nurses had received no educational preparation to care for patients with self-harm. Over 20% claimed the department either had no practice guidelines for DSH or they did not know of their existence; one-third who knew about them had not read them. There were significant differences between respondents on several variables. Older and more experienced nurses had more supportive attitudes than younger and less experienced nurses. Nurses who had attended in-service education on DSH had more positive attitudes than non-attendees. Overall, the findings have implications for improving the educational preparation of A&E nurses, improving awareness and adoption of practice guidelines, mentoring nurses, and improving attitudes towards patients who self-harm.

A retrospective analysis of inpatient compared to outpatient care for the management of patients with transient ischaemic attack.

The management of transient ischaemic attacks (TIA) involves rapid evaluation and treatment to reduce the risk of subsequent stroke. In this study we compared the investigation, management and outcome of TIA in those patients who had been admitted to hospital and in those who were evaluated on an outpatient basis. We retrospectively reviewed all patients presenting to the emergency department during a 2.5-year period with a diagnosis of TIA. Follow-up data were obtained by accessing the outpatient records of local neurologists and general practitioners. Patients managed on an outpatient basis were compared to those who were admitted for further evaluation. A total of 140 patients were available for analysis: 40% of presentations were evaluated on an outpatient basis. Admitted patients had higher mean ABCD(2) scores (4.4 versus [vs.] 3.6). They were significantly more likely to receive carotid ultrasonography (95% vs. 73%), 24-hour electrocardiographic monitoring (40% vs. 13%) and lipid evaluations (89% vs. 58%) than those managed as outpatients. The 7-day and 90-day stroke rates were 2% and 6% respectively. No patients with a score of ≤2 suffered subsequent stroke. As expected, patients with higher ABCD(2) scores were more likely to be admitted for further evaluation. Outpatients were investigated less assiduously, but therapeutic management was similar in the two groups. This suggests that inpatient care is superior to outpatient management for high-risk patients but dedicated, specialist outpatient care remains a model worthy of further consideration.

Echocardiography in the detection of cardioembolism in a stroke population.

Both transthoracic (TTE) and transoesophageal (TOE) echocardiography are used routinely to investigate ischaemic stroke. We retrospectively assessed the incidence of abnormalities on TTE/TOE and whether an abnormal TTE/TOE result could have been predicted on the basis of ancillary tests and clinical cardiological examination. Data from 428 patients were analysed. The diagnostic yield of TTE was 12%. For TOE there was a diagnostic yield of 40% in tests actually performed. Overall, echocardiography altered management in 5% of patients. A significant correlation was found between clinical cardiac disease, stroke subtype and the diagnostic yield of TTE. We conclude that the vast majority of abnormal findings occur in patients who already have clinical evidence of cardiac disease. This suggests that the use of these tests should not be "routine", but determined on an individual patient basis.

Deliberate self-harm: emergency department nurses' attitudes, triage and care intentions.

AIM AND OBJECTIVES: This exploratory study investigates emergency department nurses' attitudes towards patients who engage in deliberate self-harm. It examines their attitudes towards, and triage and care decisions with, patients who self-harm. BACKGROUND: Emergency department nurses sometimes show unsympathetic attitudes towards patients who present with self-harm and these can contribute to difficulties in assessing and providing appropriate care. DESIGN: A modified version of the Suicide Opinion Questionnaire was used. A non-probability sample of 43 emergency department nurses from a large Australian hospital participated in the study. Data were analysed using SPSS. RESULTS: Most nurses had received no educational preparation to care for patients with self-harm; over 20% claimed that the department either had no practice guidelines for deliberate self-harm or they did not know of their existence and one-third who knew of them had not read them. Overall, nurses had sympathetic attitudes towards patients who self-harm, including both professional and lay conceptualizations of deliberate self-harm. They did not discriminate against this group of patients in their triage and care decisions. CONCLUSIONS: The findings of this exploratory study are important because attitudes can affect care decisions. Recommendations are made for improving the educational preparation of emergency department nurses, for improving awareness and implementation of practice guidelines, and for improving attitudes towards patients with deliberate self-harm. Further research is needed to confirm these results.