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1.  Mental health admissions in paediatric populations in North Wales: two cohorts compared 1875–1924 and 1994–2008 
BMJ Open  2014;4(3):e004331.
Objectives
To investigate frequency of under-18s admitted to mental health services (MHS) in North West Wales (NWW) between 1875 and 2008. There are claims that 1 in 10 children have a mental illness, but there are little data on their inpatient MHS utilisation.
Setting
Looking at admissions at the secondary care level, three data samples were included; the first comprises historical asylum admissions, the second comprises contemporary admissions to acute psychiatric beds, and the third comprises admissions to district general hospital (DGH) beds that resulted in a mental health coding.
Participants
All were under 18. There were 65 historical patients, 41 contemporary mental illness admissions and 943 DGH admissions.
Primary and secondary outcome measures
The primary outcome measures were diagnoses based on case notes of the historical cohort between 1875 and 1924, as well as details of paediatric admissions to MHS from 1994 to 2008 and paediatric admissions with a mental health component to the DGH in NWW.
Results
The incidence of admission to a mental health bed was 1.55 per year in the historical cohort compared with 2.9 in the contemporary. The overall incidence of admission to any bed in the contemporary cohort was 129 patients per year. There has been a twofold increase in the incidence of admissions for schizophrenia and related psychosis, but this most likely stems from an earlier age of admission rather than a true increase.
Conclusions
There is a greater frequency of hospital admissions for youth under the age of 18 in NWW for mental health today than previously. The rates reported in the DGH sample are consistent with data from community surveys of patients meeting criteria for mental disorders and complement such data when it comes to planning for paediatric MHS. However, they also raise questions about the boundaries between disease and distress.
doi:10.1136/bmjopen-2013-004331
PMCID: PMC3975741  PMID: 24682574
Psychiatry
2.  Mortality in schizophrenia and related psychoses: data from two cohorts, 1875–1924 and 1994–2010 
BMJ Open  2012;2(5):e001810.
Objective
To investigate death rates in schizophrenia and related psychoses.
Design
Data from two epidemiologically complete cohorts of patients presenting for the first time to mental health services in North Wales for whom there are at least 1, and up to 10-year follow-up data have been used to calculate survival rates and standardised death rates for schizophrenia and related psychoses.
Setting
The North Wales Asylum Denbigh (archived patient case notes) and the North West Wales District General Hospital psychiatric unit.
Population
Cohort 1: The North Wales Asylum Denbigh (archived patient case notes). Of 3168 patients admitted to the North Wales Asylum Denbigh 1875–1924, 1074 had a schizophrenic or related psychosis. Cohort 2: Patients admitted between 1994 and 2010 to the North West Wales District General Hospital psychiatric unit, of whom 355 had first admissions for schizophrenia or related psychoses.
Results
We found a 10-year survival probability of 75% in the historical cohort and a 90% survival probability in the contemporary cohort with a fourfold increase in standardised death rates in schizophrenia and related psychoses in both historical and contemporary periods. Suicide is the commonest cause of death in schizophrenia in the contemporary period (SMR 35), while tuberculosis was the commonest cause historically (SMR 9). In the contemporary data, deaths from cardiovascular causes arise in the elderly and deaths from suicide in the young.
Conclusions
Contemporary death rates in schizophrenia and related psychoses are high but there are particular hazards and windows of risk that enable interventions. The data point to possible interventions in the incident year of treatment that could give patients with schizophrenia a normal life expectancy.
doi:10.1136/bmjopen-2012-001810
PMCID: PMC3488735  PMID: 23048063
3.  International collaboration: a retrospective study examining the survival of Irish citizens following lung transplantation in both the UK and Ireland 
BMJ Open  2012;2(2):e000605.
Objective
Prior to 2005, Irish citizens had exclusively availed of lung transplantation services in the UK. Since 2005, lung transplantation has been available to these patients in both the UK and Ireland. We aimed to evaluate the outcomes of Irish patients undergoing lung transplantation in both the UK and Ireland.
Design
We retrospectively examined the outcome of Irish patients transplanted in the UK and Ireland. Lung allocation score (LAS) was used as a marker of disease severity.
Results
A total of 134 patients have undergone transplantation. 102 patients underwent transplantation in the UK and 32 patients in Ireland. In total, 52% were patients with cystic fibrosis, 19% had emphysema and 15% had idiopathic pulmonary fibrosis. In Ireland, 44% of the patients suffered from idiopathic pulmonary fibrosis, 31% had emphysema and 16% had cystic fibrosis. A total of 96 double sequential transplants and 38 single transplants have been performed. LAS of all patients undergoing lung transplantation was 37.8 (±1.02). The mean LAS for patients undergoing lung transplantation in Ireland was 44.7 (±3.1), and 35 (±0.4) for patients undergoing lung transplantation in the UK (p<0.05). The 5-year survival of all Irish citizens who had undergone lung transplantation was 73%. The 5-year survival of Irish patients transplanted in the UK was 69% and in Ireland was 91% and 73% at 5.01 years.
Conclusions
International collaboration can be achieved, as evidenced by the favourable outcomes seen in Irish citizens who undergo lung transplantation in both the UK and Ireland. Irish citizens undergoing lung transplantation in Ireland have a higher LAS score. Despite excellent outcomes, an intention-to-treat analysis of the treatment utility (transplant) indicates the limited effectiveness of lung transplantation in Ireland and emphasises the need for increased rates of lung transplantation.
Article summary
Article focus
Determine the survival outcomes following lung transplantation for Irish patients undergoing lung transplantation in experienced UK programmes and a newly established transplant programme in Ireland.
Compare recipient lung allocation scores (a marker of disease severity) between programmes.
Key messages
International collaboration for complex medical services can be achieved, as demonstrated by the favourable outcomes seen in Irish citizens who undergo lung transplantation in both in the UK and Ireland.
Irish citizens undergoing lung transplantation in Ireland have a higher LAS (44.7 (±3.1) vs 37.8 (±1.02)), suggesting that local services can accommodate patients with a greater disease burden.
Despite excellent outcomes, an intention-to-treat analysis of the treatment utility (transplant) indicates the limited effectiveness of lung transplantation in Ireland and emphasises the need for increased rates of lung transplantation.
Strengths and limitations of this study
This study is unique in that it gives insight into an Anglo-Irish collaboration delivering a successful highly complex service to severely ill patients. It shows excellent outcomes and offers a platform on which further development may result in increase levels of transplant activity benefiting both Ireland and the UK. A limitation of the study is the modest number of lung transplants in Ireland.
doi:10.1136/bmjopen-2011-000605
PMCID: PMC3317140  PMID: 22457478
4.  The incidence of admissions for schizophrenia and related psychoses in two cohorts: 1875–1924 and 1994–2010 
BMJ Open  2012;2(1):e000447.
Objective
To investigate changes in incidence of admissions for schizophrenia and related non-affective psychoses in North Wales.
Design
Data from two epidemiologically complete cohorts of patients presenting for the first time to mental health services in North Wales between 1875–1924 and 1994–2010 are used in this study to map the incidence of hospital admissions for schizophrenia and non-affective psychoses.
Setting
The North Wales Asylum Denbigh (archived patient case notes) and the North West Wales District General Hospital psychiatric unit.
Population
3168 patients admitted to the North Wales Asylum Denbigh between 1875 and 1924 and 355 patients admitted to the District General Hospital psychiatric unit between 1994 and 2010.
Results
There was an increasing admission incidence for schizophrenia between 1875 and 1900, a higher admission rate in the 1990s for men, followed by a drop in rates of admission for both genders since 2006. Admission incidences switch from parity between the sexes in the historical period to a doubling of the admission rates for men compared with women in the modern period. This admission pattern differs from the admission patterns for affective psychoses or organic disorders.
Conclusion
There have been changes in the incidence of admissions for schizophrenia in North Wales.
Article summary
Article focus
This article investigates the incidence of schizophrenia and related psychoses in the 19th, 20th and 21st centuries.
It is a first report covering both historical and contemporary data drawn from one geographical area, with comprehensive patient ascertainment.
The data address longstanding questions concerning the incidence of schizophrenia in historical and contemporary periods.
Key messages
This article is the first to report a specific rise in the admission incidence of schizophrenia in the 19th century. It reports a specific drop in the admission incidence of schizophrenia in the 21st century.
It demonstrates a switch in gender ratios for this illness in cohorts drawn from the same ethnic group and geographical area.
Strengths and limitations
This study has unique access to 19th and early 20th centuries asylum records.
The late 20th and early 21st century diagnosis are drawn from clinical consensus rather than administrative databases.
It is unlikely that the historical arm of this study can be replicated elsewhere. Confirmation of the findings will hinge on studies of 21st century incidence rates.
This is a study of hospital admission incidence and is therefore one step removed from the true incidence.
doi:10.1136/bmjopen-2011-000447
PMCID: PMC3263437  PMID: 22267688

Results 1-4 (4)