Psychiatric liaison service referral patterns during the UK COVID-19 pandemic: An observational study.

BACKGROUND AND OBJECTIVES: COVID-19 has had a profound effect on mental health. Liaison psychiatry teams assess and treat people in mental health crises in emergency departments (EDs) and on hospital wards. During the first pandemic wave, new Mental Health Crisis Assessment Services (MHCAS) were created to divert people away from EDs. Our objective was to describe patterns in referrals to psychiatric liaison services across the North Central London care sector (NCL) and explore the impact of a new MHCAS. METHODS: Retrospective study using routinely collected data (ED and ward referrals) from five liaison psychiatry services across NCL (total population 1.5 million people). We described referrals (per week and month) by individual liaison services and cross-sector, and patterns of activity (January 1st 2020 -September 31st 2020, weeks 1-39) compared with the same period in 2019. We calculated changes in the proportion of ED attendees (all-cause) referred to liaison psychiatry. RESULTS: From 2019-2020, total referrals decreased by 16.5% (12,265 to 10,247), a 16.4% decrease in ED referrals (9528 to 7965) and 16.6% decrease in ward referrals (2737 to 2282). There was a marked decrease in referrals during the first pandemic wave (March/April 2020), which increased after lockdown ended. The proportion of ED attendees referred to liaison psychiatry services increased compared to 2019. CONCLUSIONS: People in mental health crisis continued to seek help via ED/MHCAS and a higher proportion of people attending ED were referred to liaison psychiatry services just after the first pandemic wave. MHCAS absorbed some sector ED activity during the pandemic.

Psychiatric liaison service referral patterns during the UK COVID-19 pandemic: An observational study

Abstract, Background and objectives. COVID-19 has had a profound effect on mental health. Liaison psychiatry teams assess and treat people in mental health crises in emergency departments (EDs) and on hospital wards. During the first pandemic wave, new Mental Health Crisis Assessment Services (MHCAS) were created to divert people away from EDs. Our objective was to describe patterns in referrals to psychiatric liaison services across the North Central London care sector (NCL) and explore the impact of a new MHCAS. Methods. Retrospective study using routinely collected data (ED and ward referrals) from five liaison psychiatry services across NCL (total population 1.5 million people). We described referrals (per week and month) by individual liaison services and cross-sector, and patterns of activity (January 1st 2020 -September 31st 2020, weeks 1–39) compared with the same period in 2019. We calculated changes in the proportion of ED attendees (all-cause) referred to liaison psychiatry. Results. From 2019–2020, total referrals decreased by 16.5% (12,265 to 10,247), a 16.4% decrease in ED referrals (9528 to 7965) and 16.6% decrease in ward referrals (2737 to 2282). There was a marked decrease in referrals during the first pandemic wave (March/April 2020), which increased after lockdown ended. The proportion of ED attendees referred to liaison psychiatry services increased compared to 2019. Conclusions. People in mental health crisis continued to seek help via ED/MHCAS and a higher proportion of people attending ED were referred to liaison psychiatry services just after the first pandemic wave. MHCAS absorbed some sector ED activity during the pandemic.

Awareness in severe Alzheimer's disease: a systematic review.

Objective: There is limited understanding about how people in the severe stages of Alzheimer's disease (AD) experience and demonstrate awareness. We synthesised all available evidence with the aim of understanding how awareness is preserved or impaired in severe AD and what evidence there is for different levels of awareness according to the levels of awareness framework.Method: A systematic search of the following databases: Embase, PsycINFO, MEDLINE and Web of Science was carried out. A narrative synthesis and analysis was conducted of all included studies. All studies were assessed for quality using the AXIS and CASP tools.Results: Our findings suggest that lower level sensory awareness is relatively maintained in severe AD. Findings for higher level awareness are variable and this may be related to the diversity of methods that have been used to explore awareness in these circumstances.Conclusion: Awareness is complex, heterogeneous and varies significantly between individuals. Environmental and contextual factors have a significant impact on whether awareness is observed in people with severe AD. Adaptation of the environment has the potential to facilitate the expression of awareness while education of caregivers may increase understanding of people with severe AD and potentially improve the quality of care that is received.

Experiences of advance care planning in Parkinson's disease and atypical parkinsonian disorders: a mixed methods systematic review.

BACKGROUND AND PURPOSE: Advance care planning allows people to plan for their future care needs and can include medical, psychological and social aspects. However, little is known on the use, experience of and attitudes towards advance care planning in patients with parkinsonian disorders, their family carers and healthcare professionals. METHODS: A systematic search of online databases was conducted in April 2019 using a narrative synthesis approach with thematic analysis and tabulation to synthesize the findings. RESULTS: In all, 507 articles were identified and 27 were included. There were five overarching themes: (i) what is involved in advance care planning discussions, (ii) when and how advance care planning discussions are initiated, (iii) barriers to advance care planning, (iv) the role of healthcare professionals and (v) the role of the family carer. This evidence was used to highlight eight effective components to support optimal advance care planning in parkinsonian disorders: advance care planning discussions should be individualized in content, timing and approach; patients should be invited to discuss advance care planning early and regularly; palliative care services should be introduced early; a skilled professional should deliver advance care planning; support to family carers should be offered in the advance care planning process; healthcare professionals should be educated on parkinsonian disorders and palliative care; advance care planning should be clearly documented and shared with relevant services; and healthcare professionals should be enabled to conduct effective advance care planning. CONCLUSIONS: These components can inform best practice in advance care planning in patients with parkinsonian disorders.

Healthcare utilization and monetary costs associated with agitation in UK care home residents with advanced dementia: a prospective cohort study.

OBJECTIVE: Nearly half of care home residents with advanced dementia have clinically significant agitation. Little is known about costs associated with these symptoms toward the end of life. We calculated monetary costs associated with agitation from UK National Health Service, personal social services, and societal perspectives. DESIGN: Prospective cohort study. SETTING: Thirteen nursing homes in London and the southeast of England. PARTICIPANTS: Seventy-nine people with advanced dementia (Functional Assessment Staging Tool grade 6e and above) residing in nursing homes, and thirty-five of their informal carers. MEASUREMENTS: Data collected at study entry and monthly for up to 9 months, extrapolated for expression per annum. Agitation was assessed using the Cohen-Mansfield Agitation Inventory (CMAI). Health and social care costs of residing in care homes, and costs of contacts with health and social care services were calculated from national unit costs; for a societal perspective, costs of providing informal care were estimated using the resource utilization in dementia (RUD)-Lite scale. RESULTS: After adjustment, health and social care costs, and costs of providing informal care varied significantly by level of agitation as death approached, from £23,000 over a 1-year period with no agitation symptoms (CMAI agitation score 0-10) to £45,000 at the most severe level (CMAI agitation score >100). On average, agitation accounted for 30% of health and social care costs. Informal care costs were substantial, constituting 29% of total costs. CONCLUSIONS: With the increasing prevalence of dementia, costs of care will impact on healthcare and social services systems, as well as informal carers. Agitation is a key driver of these costs in people with advanced dementia presenting complex challenges for symptom management, service planners, and providers.

Key components of the delirium syndrome and mortality: greater impact of acute change and disorganised thinking in a prospective cohort study.

BACKGROUND: Delirium increases the risk of mortality during an acute hospital admission. Full syndromal delirium (FSD) is associated with greatest risk and subsyndromal delirium (SSD) is associated with intermediate risk, compared to patients with no delirium - suggesting a dose-response relationship. It is not clear how individual diagnostic symptoms of delirium influence the association with mortality. Our objectives were to measure the prevalence of FSD and SSD, and assess the effect that FSD, SSD and individual symptoms of delirium (from the Confusion Assessment Method-short version (s-CAM)) have on mortality rates. METHODS: Exploratory analysis of a prospective cohort (aged ≥70 years) with acute (unplanned) medical admission (4/6/2007-4/11/2007). The outcome was mortality (data censored 6/10/2011). The principal exposures were FSD and SSD compared to no delirium (as measured by the CAM), along with individual delirium symptoms on the CAM. Cox regression was used to estimate the impact FSD and SSD and individual CAM items had on mortality. RESULTS: The cohort (n = 610) mean age was 83 (SD 7); 59% were female. On admission, 11% had FSD and 33% had SSD. Of the key diagnostic symptoms for delirium, 17% acute onset, 19% inattention, 17% disorganised thinking and 17% altered level of consciousness. Unadjusted analysis found FSD had an increased hazard ratio (HR) of 2.31 (95% CI 1.71, 3.12), for SSD the HR was 1.26 (1.00, 1.59). Adjusted analysis remained significant for FSD (1.55 95% CI 1.10, 2.18) but nonsignificant for SSD (HR = 0.92 95% CI 0.70, 1.19). Two CAM items were significantly associated with mortality following adjustment: acute onset and disorganised thinking. CONCLUSION: We observed a dose-response relationship between mortality and delirium, FSD had the greatest risk and SSD having intermediate risk. The CAM items "acute-onset" and "disorganised thinking" drove the associations observed. Clinically, this highlights the necessity of identifying individual symptoms of delirium.

Project Career: Perceived benefits of iPad apps among college students with Traumatic Brain Injury (TBI).

BACKGROUND: Project Career is an interprofessional five-year development project designed to improve academic and employment success of undergraduate students with a traumatic brain injury (TBI) at two- and four-year colleges and universities. Students receive technology in the form of iPad applications ("apps") to support them in and out of the classroom. OBJECTIVE: To assess participants' perspectives on technology at baseline and perceived benefit of apps after 6 and 12 months of use. METHODS: This article address a component of a larger study. Participants included 50 college-aged students with traumatic brain injuries. Statistical analysis included data from two Matching Person and Technology (MPT) assessment forms, including the Survey of Technology Use at baseline and the Assistive Technology Use Follow-Up Survey: Apps Currently Using, administered at 6- and 12-months re-evaluation. Analyses included frequencies and descriptives. RESULTS: Average scores at baseline indicated positive perspectives on technology. At 6 months, quality of life (67%) and academics (76%) improved moderately or more from the use of iPad apps. At 12 months, quality of life (65%) and academics (82%) improved moderately or more from the use of iPad apps. CONCLUSION: Students with a TBI have positive perspectives on technology use. The results on perceived benefit of apps indicated that students with a TBI (including civilians and veterans) report that the apps help them perform in daily life and academic settings.

After the Liverpool Care Pathway--development of heuristics to guide end of life care for people with dementia: protocol of the ALCP study.

INTRODUCTION: End of life care guidance for people with dementia is lacking and this has been made more problematic in England with the removal of one of the main end of life care guidelines which offered some structure, the Liverpool Care Pathway. This guidance gap may be eased with the development of heuristics (rules of thumb) which offer a fast and frugal form of decision-making. OBJECTIVE: To develop a toolkit of heuristics (rules of thumb) for practitioners to use when caring for people with dementia at the end of life. METHOD AND ANALYSIS: A mixed-method study using a co-design approach to develop heuristics in three phases. In phase 1, we will conduct at least six focus groups with family carers, health and social care practitioners from both hospital and community care services, using the 'think-aloud' method to understand decision-making processes and to develop a set of heuristics. The focus group topic guide will be developed from the findings of a previous study of 46 interviews of family carers about quality end-of-life care for people with dementia and a review of the literature. A multidisciplinary development team of health and social care practitioners will synthesise the findings from the focus groups to devise and refine a toolkit of heuristics. Phase 2 will test the use of heuristics in practice in five sites: one general practice, one community nursing team, one hospital ward and two palliative care teams working in the community. Phase 3 will evaluate and further refine the toolkit of heuristics through group interviews, online questionnaires and semistructured interviews. ETHICS AND DISSEMINATION: This study has received ethical approval from a local NHS research ethics committee (Rec ref: 15/LO/0156). The findings of this study will be presented in peer-reviewed publications and national and international conferences.

European palliative care guidelines: how well do they meet the needs of people with impaired cognition?

OBJECTIVE: Numbers of people dying with cognitive impairment (intellectual disability (ID), dementia or delirium) are increasing. We aimed to examine a range of European national palliative care guidelines to determine if, and how well, pain detection and management for people dying with impaired cognition are covered. METHODS: Questionnaires were sent to 14 country representatives of the European Pain and Impaired Cognition (PAIC) network who identified key national palliative care guidelines. Data was collected on guideline content: inclusion of advice on pain management, whether cognitively impaired populations were mentioned, assessment tools and management strategies recommended. Quality of guideline development was assessed with the Appraisal of Guidelines Research and Evaluation (AGREE) instrument. RESULTS: 11 countries identified palliative care guidelines, 10 of which mentioned pain management in general. Of these, seven mentioned cognitive impairment (3 dementia, 2 ID and 4 delirium). Half of guidelines recommended the use of pain tools for people with cognitive impairment; recommended tools were not all validated for the target populations. Guidelines from the UK, the Netherlands and Finland included most information on pain management and detection in impaired cognition. Guidelines from Iceland, Norway and Spain scored most highly on AGREE rating in terms of developmental quality. CONCLUSIONS: European national palliative care guidelines may not meet the needs of the growing population of people dying with cognitive impairment. New guidelines should consider suggesting the use of observational pain tools for people with cognitive impairment. Better recognition of their needs in palliative care guidelines may drive improvements in care.

The association between C-reactive protein and delirium in 710 acute elderly hospital admissions.

BACKGROUND: Delirium is a common neuropsychiatric syndrome associated with poor outcomes. Evidence supports a neuroinflammatory etiology, but the role of the inflammatory marker C-reactive protein (C-RP) remains unclear. We investigated the relationship between C-RP and delirium and its severity as well as interaction with medical diagnosis. METHODS: From an existing database (710 patients over 70 years old admitted to a Medical Acute Admissions Unit) we analyzed data which included C-RP levels, delirium (using the Confusion Assessment Method), and other clinical and demographic factors. Primary diagnoses were grouped (cardiovascular, musculoskeletal, infection, metabolic, and other). RESULTS: There was a strong association between elevated C-RP and delirium (t = 5.09; p < 0.001), independent of other potential risk factors for delirium (odds ratio (OR) = 1.32 (95% CI: 1.10-1.58) p = 0.003). There was no significant association between C-RP and delirium severity, and between C-RP and delirium in the populations with cardiovascular disease, infection upon admission, or from the metabolic group despite an OR of 2.24 (95% CI: 0.92-5.45). There was an association in the musculoskeletal group (OR 2.19 (95% CI: 1.19-4.02)). CONCLUSIONS: There is an association between elevated C-RP and delirium. This is strongest in patients admitted with musculoskeletal disease but not in others, implying that C-RP is involved in the genesis of delirium in musculoskeletal disease, but that other factors or processes may be more important in those with cardiovascular disease or infection.

Gene signature critical to cancer phenotype as a paradigm for anticancer drug discovery.

Malignant cell transformation commonly results in the deregulation of thousands of cellular genes, an observation that suggests a complex biological process and an inherently challenging scenario for the development of effective cancer interventions. To better define the genes/pathways essential to regulating the malignant phenotype, we recently described a novel strategy based on the cooperative nature of carcinogenesis that focuses on genes synergistically deregulated in response to cooperating oncogenic mutations. These so-called 'cooperation response genes' (CRGs) are highly enriched for genes critical for the cancer phenotype, thereby suggesting their causal role in the malignant state. Here, we show that CRGs have an essential role in drug-mediated anticancer activity and that anticancer agents can be identified through their ability to antagonize the CRG expression profile. These findings provide proof-of-concept for the use of the CRG signature as a novel means of drug discovery with relevance to underlying anticancer drug mechanisms.

Increased atherogenesis during Streptococcus mutans infection in ApoE-null mice.

Streptococcus mutans, a dental caries pathogen, also causes endocarditis and is detected in atheroscelerotic plaque. We investigated the potential for an invasive strain of S. mutans, OMZ175, to accelerate plaque growth in apolipoprotein E deficient (ApoE(null)) mice without and with balloon angioplasty (BA) injury, a model of restenosis. ApoE(null) mice were divided into 4 groups (N = 10), 2 with and 2 without BA. One each of the BA and non-BA groups was infected with S. mutans (Sm). S. mutans DNA, plaque area, inflammatory cell invasion, and Toll-like receptor (TLR) expression were measured at 6-20 weeks post-infection. S. mutans genomic DNA was detected in the aorta, liver, spleen, and heart. Plaque growth was significantly increased in infected mice with BA (Sm+BA) vs. those in the non-infected groups (p < 0.03). Plaque size was increased after infection without BA (Sm), but did not reach significance. Aortic specimens from both S. mutans and Sm+BA groups displayed increased numbers of macrophages, and TLR4 expression was increased in BA mice. In conclusion, S. mutans infection accelerated plaque growth, macrophage invasion, and TLR4 expression after angioplasty. S. mutans may also be associated with atherosclerotic plaque growth in non-injured arteries.

Prospective cohort study of adverse events in older people admitted to the acute general hospital: risk factors and the impact of dementia.

BACKGROUND: Reported adverse events (RAEs) are relatively common in the acute hospital and are associated with significant mortality and morbidity. Dementia is increasing in hospital in-patients, however there have been few studies exploring risk factors for RAEs, in particular cognitive impairment and dementia. Our objective was to identify the prevalence of RAEs in older acute medical inpatients and associated demographic, clinical or cognitive risk factors. METHOD: A longitudinal cohort study set on acute medical wards in a large general hospital. We recruited 710 people aged over 70 years undergoing emergency medical admission. Dementia was diagnosed using operationalised DSM-IV criteria. Patients were assessed using standardised tools including the Confusion Assessment Method, mini-mental state examination, the Functional Assessment Staging scale, the APACHE scale and Charlson co-morbidity index. Data on adverse events was supplied independently by the hospital clinical risk department. RESULTS: 8.6% (95% CI 6.4-10.6) of patients experienced an RAE; 5.9% (95% CI 4.2-7.6) were patient-related and 2.7% (95% CI 1.5-3.8) system-related (incidence rate for all RAEs was 2.1 (95% CI 1.7-2.8)) per person year of hospital admission. Median length of admission was 8 days (inter-quartile range 4-17 days). Patient-related RAEs were associated with male gender, delirium, mild/moderate cognitive impairment and a FAST score of 2-6. Overall, 11.1% died during the admission-this was not associated with experiencing an RAE. Staff comments on incident forms indicated an apparent lack of understanding of the impact of cognitive impairment. CONCLUSIONS: RAEs were common and associated with risk factors identifiable at admission.

Assessment of liver fibrosis before and after antiviral therapy by different serum marker panels in patients with chronic hepatitis C.

BACKGROUND: Liver biopsy is the reference standard to assess liver fibrosis in chronic hepatitis C. AIM: To validate and compare the diagnostic performance of non-invasive tests for prediction of liver fibrosis severity and assessed changes in extracellular matrix markers after antiviral treatment. METHODS: The performances of Forns' score, AST to platelet ratio index (APRI), FIB-4 index and Enhanced Liver Fibrosis (ELF) score were validated in 340 patients who underwent antiviral therapy. These scores were determined 24 weeks after treatment in 161 patients. RESULTS: Forns' score, APRI, FIB-4 and ELF score showed comparable diagnostic accuracies for significant fibrosis [area under the receiver operating characteristic curve (AUROC) 0.83, 0.83, 0.85 and 0.81, respectively]. To identify cirrhosis, FIB-4 index showed a significantly better performance over APRI and ELF score (AUROC 0.89 vs. 0.83 and 0.82, respectively). ELF score decreased significantly in patients with sustained virological response (SVR) (P < 0.0001) but remained unchanged in nonresponders. Non-1 hepatitis C virus (HCV) genotype, baseline lower HCV RNA, glucose, hyaluronic acid and higher cholesterol levels were independently associated with SVR. CONCLUSIONS: Simple panel markers and ELF score are accurate at identifying significant fibrosis and cirrhosis in chronic hepatitis C. A decrease in ELF score after antiviral treatment reflects the impact of viral clearance in hepatic extracellular matrix and probably in the improvement of liver fibrosis.

The impact of sharing results of a randomized breast cancer clinical trial with study participants.

BACKGROUND: There has been growing interest in providing clinical trial participants with study results yet only limited information exists regarding the process and impact of sharing results. We sought to evaluate patient perceptions of how results had been shared from a large randomized cooperative group trial, and the impact of learning results. PATIENTS AND METHODS: A subset of women who participated in NCCTG 9831 (A Phase III Trial of Adjuvant Chemotherapy with or without Trastuzumab for Women with HER2-positive Breast Cancer) were mailed surveys after the preliminary study results were released to the public and mailed to participants. RESULTS: One hundred and 67 of 228 surveys sent (73%) were returned; 61% reported receiving trastuzumab on study; 4% reported recurrent disease. Ninety-five percent of participants were glad they received results; 81% were satisfied with how results were shared; 23% were more anxious after learning the results. Sixty-nine percent correctly interpreted the results. Logistic regression revealed that satisfaction with the process of receiving results was associated with satisfaction with treatment (P = 0.04), and increased anxiety was associated with dissatisfaction with treatment (0.02), incorrect interpretation of results (0.04), and not having received trastuzumab (P < 0.0001). CONCLUSION: Sharing results directly with study participants is met with overwhelmingly favorable responses from patients, although some may not initially understand the findings. The potential for increased anxiety should be considered, and psychosocial support may be required by some. A plan to share results should be routinely and prospectively considered in the design of cancer clinical trials.

Metal protein attenuating compounds for the treatment of Alzheimer's disease.

BACKGROUND: Alzheimer's disease (AD) may be caused by the formation of extracellular senile plaques comprised of beta-amyloid (Ass). In vitro and mouse model studies have demonstrated that metal protein attenuating compounds (MPACs) promote the solubilisation and clearance of Ass. OBJECTIVES: To evaluate the efficacy of metal protein attenuating compounds (MPACs) for the treatment of cognitive impairment due to Alzheimer's disease. SEARCH STRATEGY: The Cochrane Dementia and Cognitive Improvement Group's Specialized Register was searched on 15 February 2007 using the terms clioquinol, PBT*, MPAC*. The Register contains records from major health care databases, many ongoing trial databases and grey literature and is updated regularly. The Internet was searched using the term: clioquinol, PBT*, MPAC* SELECTION CRITERIA: Randomised double-blind trials in which treatment with clioquinol was administered to participants with Alzheimer's disease in parallel group comparison with placebo are included. DATA COLLECTION AND ANALYSIS: Three reviewers (RM, LJ, ELS) independently assessed the quality of trials according to the Cochrane Collaboration Handbook. The primary outcome measures of interest were cognitive function (as measured by psychometric tests). The secondary outcome measures of interest were in the following areas: quality of life, functional performance, effect on carer, safety and adverse effects, and death. MAIN RESULTS: There was one included trial of clioquinol (PBT1) compared with placebo in 36 patients. There was no statistically significant difference in cognition (as measured on the ADAS-Cog scale) between active treatment and placebo groups at 36 weeks. One subject in the active treatment group developed neurological symptoms (impaired visual acuity and colour vision) which resolved on cessation of treatment and was thought to be possibly attributable to the drug. AUTHORS' CONCLUSIONS: There is an absence of evidence as to whether clioquinol (PBT1) has any positive clinical benefit for patients with AD, or whether the drug is safe. We have some concerns about the quality of the study methodology, particularly the randomisation (subjects in the active treatment group had higher mean pre-morbid IQ as measured by the NART and this may have biased the results), the secondary analyses of results stratified by baseline disease severity and whether the study was adequately powered for the analysis of the other data collected on Ass, zinc and copper levels.

Runx2-mediated activation of the Bax gene increases osteosarcoma cell sensitivity to apoptosis.

The Runx family of transcription factors regulate cell growth and differentiation, and control the expression of target genes involved in cell fate decisions. We examined the role of the bone-related member of this family, Runx2, in regulating apoptosis via modulation of the Bcl2 family of genes in the osteosarcoma cell line Saos2. Our data demonstrate that Runx2 directly binds to two Runx-specific regulatory elements on the human bax promoter thereby inducing Bax expression. Furthermore, bone morphogenetic protein-induced or vector-mediated expression of Runx2 resulted in upregulation of Bax expression, and subsequent increased sensitivity of Saos2 cells to apoptosis. Finally, the observed upregulation of Bax expression and increased apoptosis were Runx2 dependent as Runx2 loss of function abrogated these effects. Our study provides the first evidence for Bax as a direct target of Runx2, suggesting that Runx2 may act as a proapoptotic factor in osteosarcoma cells.

'Stockholm syndrome': psychiatric diagnosis or urban myth?

OBJECTIVE: 'Stockholm syndrome' is a term used to describe the positive bond some kidnap victims develop with their captor. High-profile cases are reported by the media although the diagnosis is not described in any international classification system. Here we review the evidence base on 'Stockholm syndrome'. METHOD: Databases (PubMED, EMBASE, PsycINFO, CINAHL) were systematically searched. We compared features of cases widely reported in the English language media to identify common themes which may form a recognizable syndrome. RESULTS: We identified 12 papers that met inclusion criteria. The existing literature consists mostly of case reports; furthermore there is ambiguity in the use of the term. No validated diagnostic criteria have been described. Four common features were found between the five cases studied. CONCLUSION: There is little published academic research on 'Stockholm syndrome' although study of media reports reveals similarities between well publicized cases. This may be due to reporting and publication bias.