Cancer patients are at a significant risk of requiring unscheduled care and admission. Strategies and services to limit the burden on patients and the health care system should be reviewed to minimise the incidence of unplanned admission.

Objectives & Background We identified that there is a cohort of people who attend our Emergency Department (ED) extremely frequently (>24 times per year) or who have frequent admissions (>12 per year). Analysing hospital clinical records identified that in many cases medically unexplained symptoms (MUS) drive the frequent presentation. The needs of these patients were not being met by a traditional dualistic approach in which people are seen in either physical or mental health settings. Indeed, despite frequent medical investigations/treatments, their symptoms persist, their problems are not resolved, they frequently complain and they keep coming back. This carries risk and distress for the patients, and heavy use of resources for the hospitals involved. Methods Each month we looked at attendance data for the previous 3 months (this identified people who in an acute phase of repeat presentations). By accessing patients clinical records we determined the main factors which appeared to drive their frequent attendance and admissions and identified those who presented with MUS. Care plans were developed and each patient was contacted and offered weekly Cognitive Behavioural Therapy (CBT) sessions to help them manage their symptoms. This was part of a case management approach in which coordinated, multidisciplinary reviews were undertaken resulting in an individualised care plan. Results Thus far the pilot has seen a reduction in attendances at ED for 100% of patients included in study (N=20). Crucially, all now attend less than once per month. In total 245 attends were saved after the CBT interventions Conclusion Providing a psychological intervention to this patient cohort is effective in reducing hospital costs by containing the most frequent attenders. CBT and care plans have reduced attendance to under once per month and subsequently reduced medical interventions and prescribing costs. 866Emerg Med J 2013;30(10):866-880

Detection of ovarian cancer (OC) circulating tumour cells (CTCs) is primarily based on targeting epithelial markers, thus failing to detect mesenchymal tumour cells. More importantly, the immune checkpoint inhibitor marker PD-L1 has not been demonstrated on CTCs from OC patients. An antibody staining protocol was developed and tested using SKOV-3 and OVCA432 OC cell lines. We targeted epithelial (cytokeratin (CK) and EpCAM), mesenchymal (vimentin), and OC-specific (PAX8) markers for detection of CTCs, and CD45/16 and CD31 were used for the exclusion of white blood and vascular endothelial cells, respectively. PD-L1 was used for CTC characterisation. CTCs were enriched using the Parsortix™ system from 16 OC patients. Results revealed the presence of CTCs in 10 (63%) cases. CTCs were heterogeneous, with 113/157 (72%) cells positive for CK/EpCAM (epithelial marker), 58/157 (37%) positive for vimentin (mesenchymal marker), and 17/157 (11%) for both (hybrid). PAX8 was only found in 11/157 (7%) CTCs. In addition, 62/157 (39%) CTCs were positive for PD-L1. Positivity for PD-L1 was significantly associated with the hybrid phenotype when compared with the epithelial (p = 0.007) and mesenchymal (p = 0.0009) expressing CTCs. Characterisation of CTC phenotypes in relation to clinical outcomes is needed to provide insight into the role that epithelial to mesenchymal plasticity plays in OC and its relationship with PD-L1.