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Getting trained how to not to go to those urges, like fidget or think before you speak. Re-engaged young adult patient 05 I said I still want help. Re-engaged young adult patient 16 Parents wanted services to help their child learn appropriate strategies for managing ADHD as an adult.
So yes, consistency and someone to actually help us manage his ADHD in the next few years. I worked with her just to do some awareness with her and her mum round the symptoms regarding ADHD. Me and my colleague. The OTs [occupational therapists] will do the normal OT [occupational therapy]. Accommodation issues will be the social worker will deal with that. Pre-transition patient 09 I usually sort everything out for him. He will just flip at the slightest thing. Child and adolescent psychiatrist 07 Medication management was particularly highlighted as a role parents adopted: sorting prescriptions, observing effects of medication trials and ensuring adherence.
Although, as already described, patients were considering short-term goals, the parents that were interviewed perceived an ongoing need for support, with most viewing medication as beneficial to support their child and the wider family: I have to keep a track of whatever she is taking, the medication. Parent 03 Interviewer: Do you think her symptoms or the effect that has on her, do you think that will change as she becomes an adult?
It sounds pathetic, I know, but he needs that, and we need him to have that, for our sanity as much as his own. Parent 07 Parents felt that an emotional immaturity associated with ADHD meant that there was a greater need for continued parental guidance into adulthood.
I think at some point they kind of need to acknowledge the limitations of the condition to access the service independently like an adult. I would make a big. But then you do feel bad doing that and you do feel like you are sort of overstepping the mark. My mum has always been very involved. I normally just give up at the second hurdle because I know from my experience it never works properly. I think we see quite a lot of problems when individuals are seen just as individuals not in the context of those who have been supporting them up to then.
Basically, nothing. We would not automatically send the clinic letters to parents; we send them to young people. This is all-round difficult. But then there are. They really struggle with that sometimes. You have to be very diplomatic. Whilst if you put that same kid into a dysfunctional family, in a dysfunctional area, in a dysfunctional school it would be all negatives. Paediatrician 21 Because I work with special needs kids I understand a little bit of the educational side of the system.
Parent 18 Preparation for transition and adult life with attention deficit hyperactivity disorder Patients reported different levels of readiness for the transfer to adult services. Some felt ready for and welcomed the change in care model and environment, others were overwhelmed by it and saw adult services as less caring, and others were ambivalent.
Have you spoken to your school to get extra time? Transitioned patient 05 When I was in CAMHS, that was more them telling me what to do rather than listening to me, so I felt more understood in that appointment with the doctor there in adult services and I felt like I was in a bit more control which to me was good. Transitioned patient 21 The importance of patient familiarity with adult services before transition was described by a number of interviewees across sample groups; however, the experience of preparation for transition and for adult life with ADHD was varied: I describe ADHD as trying to pay attention to everything at the same time.
So, we are probably not doing that very well. Experiences of group 2 post transition were mixed. Re-engaged young adult patient 05 We had a bit of a bad experience with one who was expecting the same service as they were getting from us. Paediatrician 05 Interviewer: How did you feel about changing? Because they prepared me before. Transitioned patient 17 Parents of pre-transition patients typically did not know at what age transition would occur.
One parent had assumed child services would continue to provide support until the end of full-time education. Another assumed CAMHS went on indefinitely and reflected that discussion of transition and remit of services needs to be repeated and reinforced with patients and their families over time.
And or I suppose maybe it goes back to his GP. What is it? What happens if it becomes too much for her? Who does she turn to? Parent 01 The interviews with patients who had re-entered adult services without transition group 3 highlighted a need for clearer information for discharged patients about what to do if symptoms deteriorate and support is required. Those who dropped out and re-entered services and those who had been on waiting lists for adult services described information about how to make an appointment and where to get medication, in case difficulties develop, as essential: So, what might have helped before we decided to drop out, [is] if they gave us some information for later on in life.
So, it might have been just nice to give a heads up of what we could do if we really found an issue. That would be my big thing. The limited nature of this information was also the experience of parents: Do you talk to them about what happens kind of later on in life or a few years down the line in their mids if they decide they need more support?
It was all about the now. Re-engaged young adult patient 16 What I find most shocking is that when you ask them what is ADHD and what does that mean to you they have no idea. So if they have a better understanding of what ADHD is and how ADHD affects them then they are more likely to be able to feel they have more control and put stuff into place. But a lot of the youngsters that come have no idea. Re-engaged young adult patient 02 Parents felt that it would have been helpful if clinicians had explained the restrictions that ADHD medication might have on specific employment.
Parent 22 Not knowing what the long-term effects are. That still bothers me now. It seems like some kind of guidance is needed, otherwise it just sits on our record and they carry on the medication. It seems a bit open-ended. GP 11 Many of the young adults in group 3 believed that a better understanding of ADHD might have prevented them from dropping out of services.
Some described the shock they felt when they found out ADHD was a long-term condition: So I do feel I just need to be generally more informed about ADHD, about the services that are on offer and that would be much more useful to me, because now. That was horrible. I got really upset. A few referred to uncertainties about ADHD diagnosis, which may make clinicians cautious in presenting ADHD as a long-term condition: I was seeing cases that were 17 and a half where there had been no discussion about what was going to happen to them in adulthood.
Are you going to be on it for a long time? And if not, what are the alternatives? I take the opportunity to talk about the long-term consequences of ADHD. Paediatrician 14 A lack of dedicated appointment time for preparation for transition was highlighted as a barrier to transition.
Paediatrician 20 Interviewer: In your opinion do you feel like transition is working quite well in your trust in your area? And I can understand that. So, we need to sort of focus. We do ask about drugs and alcohol and whatever else you are doing but we probably tend to forget a bit about. Paediatrician 11 Clinicians and parents described a need for better information to be provided about adult services and ADHD in adulthood. The need for this information to be in an accessible format for young people with ADHD was emphasised: A psycho-educational process where they are prepared to either look at some information, material, or attend educational sessions around the ADHD.
Our young people. We would love there to be better written information for the young people as well, for them to kind of take away and digest and look at. As discussed in the Mapping Study, a wide variety in configuration of adult services was reported by interviewees in this qualitative study.
A few areas had specialised ADHD services but, even with specialist services, gaps existed in what was provided and who could access it. Clinicians largely described transition protocols as being recently introduced or a work in progress.
Parent 11 You said the transition protocol at your service is in progress. Is that specific to ADHD or is that just a transition in general? Transition in general. How accessible a service is, the remit of services provided and handover practices were identified as interlinked factors influencing transition.
Although some clinicians reported having clear shared care protocols with primary care, the interviews revealed that GPs can end up in a care co-ordination role by default during transition and their role is discussed further below. Accessibility The lack of equivalent adult service to which ADHD patients could be transitioned was highlighted as a barrier to transition.
Paediatrician 15 Well we have a transition protocol that involves a structured interview through the clinical nurse specialist service and then of course is the issue of what do you transfer to? Re-engaged young adult patient 07 Finding who could support him in terms of the life skills stuff that he needed to know. No local provision could mean no transition, or long delays while funding was sought for services outside the CCG region: Interviewer: OK, have you encountered any real difficulties with transitioning them?
Only the practicalities of knowing who it is. Paediatrician 19 We cover a massive area. And we also have lots of people from out of areas. Mother: No. It stops at Interviewer: How long is that to get to M? Transitioned patient 21 I was in college.
I had just started college and I thought I was doing really well. It was getting a bit too much and I was like, do you know what. Re-engaged young adult patient 14 I think the fact that our service is less able to go out, to as many sort of geographical locations, so people are having to travel further, and I think we do quite a lot of people at that stage because yes, having been to quite a local clinic to see someone they know and then realising they are going to have to travel quite a distance to see somebody new.
I would spend hours trying to persuade this healthy, normal, mentally healthy young person with ADHD or autism that they had to turn up to a transition clinic in the loony bin. It may have been grossly untrue but. It was a bit like. And so to think [son] is using that same service is a bit odd really. Parent 15 Typically, patients and parents viewed the accessibility of adult services in a negative light compared with their experience of child services, with concerns reported that adult services were less easy to contact and less flexible with appointments: I have tried with adults; I rang them obviously the other day and told them to ring me back and they never did.
Transitioned patient 10 Interviewer: What do you think the best or worst things might be about that change into adult service? She makes that quite clear. Some clinicians recognised the impact of these policies on young people with limited organisational skills, describing how they were adapting practices to respond to patient needs: The reality is we just cannot have DNAs [did not attends].
We have so little resources to deal with the demand, so if people want to be seen they really need to make an effort. And that can go on for around four or five appointments and then they come back in for a face to face. It just saves them having to keep coming in. They also know that. Adult clinician 15 Remit Adult clinicians described the fragmented design of adult services in comparison with their perceptions of child services. Interventions provided were often restricted by limited remit of commissioned adult services.
The other thing is melatonin is an issue. And risperidone for aggressive behaviour as well. Some expressed views that the lack of joined-up working made it very challenging for patients with ADHD to navigate services. These views were supported by interviews with patients, who found the limited remit difficult to understand: They are kind of used to just having the one therapist with us and so it is a bit more hard to organise the transition when you are sort of saying you need to go here for that bit and here for that bit.
Child and adolescent psychiatrist 13 A lot of the other aspects of my health are completely separate, well in the NHS are completely separate even though they are not. GP 13 Adult psychiatrists. They are stretching all the services and having to make savings. Child and adolescent psychiatrist 03 In addition to ongoing medication use, the interviews suggest that eligibility for adult services was based on complexity of need and presence of comorbidities.
Parent 05 He was below the level of illness at the point that he needed transition that would be accepted through secondary services, so then I ended up coming up with a transition plan with his general practitioner. Sometimes the tight remit of adult services could leave those with the more severe and complex problems without a service: It landed up with me having to write some quite rude letters.
The young people would get the same number of reviews which are normally held multiagency anyway. So, putting them on CPA is a bit of an admin [administrative] task rather than a clinical task. Child and adolescent psychiatrist 08 We do a lot of screening of those referrals to really make sure that we get this segment of this adult ADHD population that we are commissioned to look after. The idea really is to not provide care co-ordination, so patients who are too complex or too risky.
So, we are not staffed to provide the service for these patients. Although clinicians reported that transferring patients with ADHD and coexisting LD to adult services was typically easier because of established LD services, patients whose LD was borderline fell into gaps between services.
So, these kids really fit in a bit of a between the two. Child and adolescent psychiatrist 13 As with learning disabilities, interviewees reported that a psychiatric comorbidity could potentially make it easier to have a service to transition to. However, they noted that adult mental health teams may be configured to manage episodic illness rather than long-term conditions, such as ADHD: It depends what their other needs are.
Many expressed a view that highly specified teams create gaps in provision for patients with complex needs. The varied needs of patients with ADHD led some to suggest that a specific ADHD transition protocol would not work as there would be no adult service that would suit all: I have been around in the NHS for a long time and my experience is that when. I think locally mental health services are restructuring again, constantly restructuring.
I work in the field. I have to battle to get my service users mental health services. I think it all comes into one circle really. There is no indication of how that was diagnosed or when. What we end up doing is set out in the NICE guidelines, the architecture is we have to kind of reassess them really, do a full history.
So, information is not very easily obtainable, and this is what adds to the pressure because we would have to really assess someone to know what is happening and what is the impact on someone. I think, ideally, we would like the last appointment with the previous service to have. You do end up questioning the diagnosis, whether that diagnosis just becomes a non-diagnosis at 18, if there is no plan and no follow-up and no management plan.
GP 11 This mistrust could be picked up by patients and have an impact on engagement with services. Patients and parents questioned the handover of patient information and valued not having to retell their history. I was like, right, OK. Because every time you see anybody, you have to start right from the beginning and go through everything. Parent 21 Joint appointments with both services present or telephone case conferences were viewed as helpful handover practices, whether on a formal or on an ad hoc basis.
However, because of demands on time because of high workloads in both child and adult services, clinicians reported that typically these processes were reserved for complex cases: We have started to hold joint transitional clinics. I think this transition concept, transition process, should be a bridge, slight overlap between children and adult services.
I know that nobody has rung me up to say. We have talked about that a lot, how we would love to know, are they still with them 6 months later, are they still with them a year later? As far as I am aware, nobody collects that data. Interviewer: When you said she got rid of him, do you remember the last appointment?
Parent 23 [Child services] will send a letter saying the age is now out of their hands. But they never actually transfer care to adult ADHD services. Paediatrician 12 I think previously we would try and do what we could to refer on to another service and persuade adult mental health services to take them, we are now just passing those back to the GP because I think it needs to be really highlighted back to the commissioners in terms of what service is needed.
Paediatrician 18 Interviewer: How long did you have to wait as well to get an appointment? But I should have been, if you put it that way. She refused to shut my case. Can I chase them? Transitioned patient 03 [mum] We see them often coming back when they start studying at university and realise that actually they struggle. And then they end up on a waiting list which is again quite unfortunate. We still have quite long waiting lists for assessments in the adult ADHD service.
Others felt strongly that prescribing and monitoring ADHD medication was outside their role, even with additional training. For some GPs, this was linked to concerns over the risks of prescribing without specialist oversight. GP 12 I think the role of the GP should be managing their primary health needs and not their mental health needs. My personal view is that this is not my job. There were also reports of clinicians supporting GP prescribing while the patient was waiting to be seen in a secondary care service; however, shared care protocols between primary and secondary care were not always implemented, causing concerns about continued access to medication.
Stakeholders discussed a number of perceived barriers to shared care and primary care prescribing, including GP workload, funding of prescriptions, responsibility for medication monitoring, different ADHD medication licences for children and adults, and beliefs and knowledge around ADHD.
We would then support GPs in prescribing until we are able to see the young person. GPs had not signed up to it. Then you are stuck. Parent 14 Secondary care clinicians largely reported that continued specialist oversight was important. In particular, individually tailored medication plans and support of underlying impulsive behaviour was considered to be a specialist role: I give them much more options in planning their medication, like we could do a combination of long acting and short acting.
People do come back and do see me, and we talk about it and we change the meds and see how they go. The overall finding is that the experience of transition from child to adult services for young people with ADHD is highly varied.
For some it is straightforward, for others challenging. The qualitative strand of this study suggests that transition between child and adult services for ADHD patients depends on how invested stakeholders are in the process and the architecture of services. Being invested The stakeholders interviewed for this study suggest that there are gaps in the understanding of ADHD as a long-term condition, particularly in respect of ongoing impairment and how it may affect people in different ways at different stages of life.
Across the stakeholder groups, concerns were expressed as to the long-term use of ADHD medication, and clinicians reported a lack of clarity around the licensing for adult ADHD medication. Patients associated taking ADHD medication with managing behaviour in school and academic achievement, with pre-transition and post-transition patients both envisaging a time in the future when their schooling would finish and their medication would stop. Only the patients in this study who did not transition but re-entered adult services as a young adult reported an understanding of ADHD as a long-term condition that impacts their life outside education.
Who can become a member? Anyone over the age of 12 who based in Lincolnshire or its surrounding areas can be a member of LPFT. Restrictions to membership are outlined under section 11 of the Trust Constitution To become a member you'll need to complete a membership application form. How much does membership cost? Membership is completely free and there are no subscriptions or hidden charges. I have no experience of mental health problems, am I still okay to become a member?
Although you may have no experience of these services, statistically, you are just as likely to know someone who has received treatment from mental health services. We actively encourage all individuals to talk openly about mental health and support society in breaking any stigma and discrimination surrounding this.
Does the Trust solely focus on services for mental health? The Trust provides a range of specialist services from support for people with learning disabilities and their families, to rehabilitation, to psychological therapies. The list of our services is very comprehensive. Will my details be given to others? No, the information you provide is solely for use by us and will remain confidential.
All membership data is managed in accordance with the General Data Protection Regulation GDPR Act and will not be given to third parties or used for marketing purposes.
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We are seeking three individuals to join our board, to bring support and constructive challenge, and help lead the strategic direction of the Trust. Being a non-executive director is demanding, but very rewarding. You have the chance to join a highly capable board that prides itself on keeping patients at the heart of its decisions. The NHS continues to face challenges and we are no exception to these pressures. However, with focussed hard work on doing the very best we can for our patients and making the very best use of our resources, I am confident we will continue to lead a vibrant and successful Trust.
This is an exciting time to join our organisation. Anyone interested in applying can download an information pack via the Trust website by visiting www. Acknowledgements None Funding To P. Contributor Information B. References 1. Cellular physiology and clinical manifestations of fascicular arrhythmias in Normal hearts. Aiba T, Tomaselli G. Electrical remodeling in dyssynchrony and resynchronization.
J Cardiovasc Transl Res. Arrhythmogenic ion-channel remodeling in the heart: Heart failure, myocardial infarction, and atrial fibrillation. Physiol Rev. Poelzing S, Rosenbaum DS. Altered connexin43 expression produces arrhythmia substrate in heart failure. Electrophysiologic changes in heart failure: Focus on pacemaker channels. Can J Physiol Pharmacol. Ionic remodeling of cardiac purkinje cells by congestive heart failure.
Calcium and arrhythmogenesis. Aronson RS. Afterpotentials and triggered activity in hypertrophied myocardium from rats with renal hypertension. Circ Res. Triggered activity and automaticity in ventricular trabeculae of failing human and rabbit hearts. Cardiovasc Res. Congestive heart failure after myocardial infarction in the rat: Cardiac force and spontaneous sarcomere activity. Ann N Y Acad Sci.
Distinct patterns of calcium transients during early and delayed afterdepolarizations induced by isoproterenol in ventricular myocytes. Reentrant and nonreentrant mechanisms contribute to arrhythmogenesis during early myocardial ischemia: Results using three-dimensional mapping. Mechanisms underlying spontaneous and induced ventricular arrhythmias in patients with idiopathic dilated cardiomyopathy.
Reentrant and focal mechanisms underlying ventricular tachycardia in the human heart. Electrophysiological mechanisms of ventricular arrhythmias resulting from myocardial ischemia and infarction. Basis for ventricular arrhythmias accompanying myocardial infarction: Alterations in electrical activity of ventricular muscle and purkinje fibers after coronary artery occlusion. Arch Intern Med. Transient outward currents in subendocardial purkinje myocytes surviving in the infarcted heart.
J Cardiovasc Electrophysiol. Ankyrin-G participates in INa remodeling in myocytes from the border zones of infarcted canine heart. Reduced calcium currents in subendocardial purkinje myocytes that survive in the and hour infarcted heart. Circ Arrhythm Electrophysiol. Spontaneous and induced cardiac arrhythmias in subendocardial purkinje fibers surviving extensive myocardial infarction in dogs.
Heterogeneous gap junction remodeling in reentrant circuits in the epicardial border zone of the healing canine infarct. Cabo C, Boyden PA. Heterogeneous gap junction remodeling stabilizes reentrant circuits in the epicardial border zone of the healing canine infarct: A computational study. Long-term electrophysiological abnormalities resulting from experimental myocardial infarction in cats.
Time course for reversal of electrophysiological and ultrastructural abnormalities in subendocardial purkinje fibers surviving extensive myocardial infarction in dogs. Mutations in the cardiac ryanodine receptor gene hRyR2 underlie catecholaminergic polymorphic ventricular tachycardia. Purkinje cell calcium dysregulation is the cellular mechanism that underlies catecholaminergic polymorphic ventricular tachycardia. Heart Rhythm. Abnormal propagation of calcium waves and ultrastructural remodeling in recessive catecholaminergic polymorphic ventricular tachycardia.
Purkinje cells from RyR2 mutant mice are highly arrhythmogenic but responsive to targeted therapy. Arrhythmogenesis in a catecholaminergic polymorphic ventricular tachycardia mutation that depresses ryanodine receptor function.
Use of whole exome sequencing for the identification of ito-based arrhythmia mechanism and therapy. J Am Heart Assoc. Purkinje cells as sources of arrhythmias in long QT syndrome type 3. Sci Rep. Biochem Biophys Res Commun. Multifocal ectopic purkinje-related premature contractions: A new SCN5A-related cardiac channelopathy. J Am Coll Cardiol. J Clin Invest. Bundle branch re-entrant Ventricular Tachycardia: Novel genetic mechanisms in a life-threatening arrhythmia.
Mapping and ablation of idiopathic ventricular fibrillation. Successful catheter ablation of electrical storm after myocardial infarction. Mode of initiation and ablation of ventricular fibrillation storms in patients with ischemic cardiomyopathy. Role of purkinje fibers in post-infarction ventricular tachycardia.
Ischemic ventricular tachycardia presenting as a narrow complex tachycardia. Indian Pacing Electrophysiol J. Identification and ablation of three types of ventricular tachycardia involving the his-purkinje system in patients with heart disease. Novel mechanism of postinfarction ventricular tachycardia originating in surviving left posterior purkinje fibers.
Sustained bundle branch reentry as a mechanism of clinical tachycardia. Bundle branch reentrant ventricular tachycardia: Cumulative experience in 48 patients. Radiofrequency catheter ablation for treatment of bundle branch reentrant ventricular tachycardia: Results and long-term follow-up. Left bundle branch-purkinje system in patients with bundle branch reentrant tachycardia: Lessons from catheter ablation and electroanatomic mapping.
Cure of interfascicular reentrant ventricular tachycardia by ablation of the anterior fascicle of the left bundle branch. Different forms of ventricular tachycardia involving the left anterior fascicle in nonischemic cardiomyopathy: Critical sites of the reentrant circuit in low-voltage areas.
Structural basis of ventricular arrhythmias in human myocardial infarction: A hypothesis. Hum Pathol. Mechanisms of idiopathic left ventricular tachycardia. Clinical and electrophysiologic spectrum of fascicular tachycardias. Am Heart J. Non-reentrant fascicular tachycardia: Clinical and electrophysiological characteristics of a distinct type of idiopathic ventricular tachycardia. The number of the statements may be higher than the number of citations provided by EuropePMC if one paper cites another multiple times or lower if scite has not yet processed some of the citing articles.
Explore citation contexts and check if this article has been supported or disputed. Ventricular tachycardia originating from the His bundle: A case report. Similar Articles To arrive at the top five similar articles we use a word-weighted algorithm to compare words from the Title and Abstract of each citation.
Ventricular arrhythmias and the His-Purkinje system. Role of the His-Purkinje system in the genesis of cardiac arrhythmia. In his speech, Undip Rector, Prof. Non investing active lpfb The V1 electrode is placed in the fourth intercostal space just to the right of the sternum.
Furthermore, Taj Yasin advised the students to always think creatively in bcs forex license to mathematics financial actuarial able to open their own business opportunities. Rate, regularity, and rhythm are commonly grouped together. Additional studies on the electrical properties of the His-Purkinje network and interactions with the surrounding myocardium will improve the clinical diagnosis and treatment of these arrhythmias.
As the activation process spreads through the ventricular wall, more cells are recruited, and here visible record can be detected on the body surface, the beginning of the QRS complex. The design of the Frank7,8 and similar lead systems used in recording the VCG is complex and will not be discussed here, but it is important to understand that the relationships between the X, Y, and Z leads used in recording a VCG and each of the 12 standard ECG leads is known, and mathematical transformations allow us to convert information from lead systems designed for recording the VCG to the standard 12 leads of the ECG.
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