Audacity Issue 8

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Audacity ...a British Society of Audiology Publication

issue 8 May 2016 .........................

43

Cerebellar Ataxia with Neuropathy and Vestibular Areflexia Syndrome...

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The research at Aston University...

62

Teach a man to fish and you feed him for a lifetime...

RESEARCH ROUND-UP

Can drugs make you hear better? Facebook “f ” Logo

CMYK / .eps

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audacity@thebsa.org.uk ................................. www.thebsa.org.uk

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The British Society of Audiology

Annual Conference June 2017

Doncaster Racecourse More information available:

www.thebsa.org.uk

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Editorial

W

elcome to the 8th edition of Audacity. We publish this issue just after the successful new-look annual

conference in Coventry. Congratulations to all those who were involved in its organisation. If you were not one of the fortunate ones who were there then read the conference catch up section by our own correspondent, Andrew Causon. Make sure you put the date of next year’s conference in your diaries – Doncaster Racecourse 14th June 2017.

The Professional Practice Committee (PPC) had its final meeting on 14th March- read Graham Frost’s final report from the PPC. I think we can all agree that the PPC and prior to that the BSA Education Committee have left an impressive legacy of BSA documents, procedures and training courses for which all those involved should be justifiably proud.

The diversity of articles within this edition highlights that there is more to Audiology than meets the eye (or the ear!). It would be unfair to single out any one article, so read them all and enjoy.

This is the penultimate edition of Audacity to be edited by the current team. We are pleased to announce that from 2017, editing Audacity will be handed over to Jane Wild and the team from Betsi Cadwaladr University Health Board. Have a wonderful summer and we shall see you again in November for our final edition – do let us know if you would like to contribute.

Martin O’Driscoll Editor-in-Chief On behalf of the editorial team E: martin.odriscoll@cmft.nhs.uk

editorial

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Contents meet the editorial team...

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Editorial

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Chairman’s Message

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Conference Catch Up

Martin O’Driscoll

Huw Cooper

information and updates conferences in audiology Section Editor: Danny Kearney / E: danny.kearney@cmft.nhs.uk

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SIG Segment

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Knowledge Learning Practice Impact

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Hearsay

Martin O’Driscoll E: martin.odriscoll@cmft.nhs.uk

information and updates from BSA Special Interest Groups Section Editor: Martin O’Driscoll / E: martin.odriscoll@cmft.nhs.uk

Rachel Booth E: rachel.booth@cmft.nhs.uk

information and updates from the BSA Professional Practice Committee (PPC) and the Learning and Events Group (LEG) Section Editor: Rachel Booth / E: rachel.booth@cmft.nhs.uk

News from Regional Groups and BSA Members Section Editor: Danny Kearney / E: danny.kearney@cmft.nhs.uk Dion Jones E: dion.jones@cmft.nhs.uk

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Lunch & Learn

a summary of the latest bite size online seminars for you to get your teeth into! Section Editor: Shahad Howe / E: shahad.howe@cmft.nhs.uk

Audacity is published by: The British Society of Audiology 80 Brighton Road, Reading, RG6 1PS, UK. E: audacity@thebsa.org.uk | W: www.thebsa.org.uk Design: Pinpoint Scotland Ltd

E: audacity@thebsa.org.uk

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Jenny Griffin E: jenny.griffin@cmft.nhs.uk

W: www.thebsa.org.uk

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welcome to

Audacity ....a British Society of Audiology Publication

32 Ear to the Ground

a guide to all things Ear-related in the media‌ Section Editor: Dion Jones / E: dion.jones@cmft.nhs.uk

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meet the editorial team...

Clinical Catch-up

Short articles on relevant clinical topics. Section Editor: Rachel Hopkins / E: rachel.hopkins@cmft.nhs.uk Rachel Hopkins E: rachel.hopkins@cmft.nhs.uk

54 Research Round-up

a spotlight on major ongoing research projects in the Audiology community worldwide. Section Editor: Rachel Hopkins / E: rachel.hopkins@cmft.nhs.uk

62 Ear Reach

find out about the latest charity and humanitarian work going on within audiology, both in the UK and abroad, with some opportunities for you to get involved. Section Editor: Jenny Griffin / E: jenny.griffin@cmft.nhs.uk

Shahad Howe E: shahad.howe@cmft.nhs.uk

66 Essentials

Key information for the membership Section Editor: Danny Kearney / E: danny.kearney@cmft.nhs.uk

Danny Kearney E: danny.kearney@cmft.nhs.uk The British Society of Audiology publishes Audacity as a means of communicating information among its members about all aspects of audiology and related topics. Audacity accepts contributions, features and news articles concerning a wide range of clinical and research activities. Articles typically emphasise practical rather than theoretical material. Audacity welcomes announcements, enquiries for information and letters to the editor. Letters may be in response to material in Audacity or may relate to professional issues. Submissions may be subject to editorial review and alteration for clarity and brevity. Please email audacity@thebsa.org.uk for further information. Audacity is published in May and November. Contributions should preferably be emailed to: audacity@thebsa.org.uk or sent to; The Editor, Audacity, 80 Brighton Road, Reading, RG6 1PS. Views expressed in Audacity do not necessarily reflect those of The British Society of Audiology, or of the editors. The Society does not necessarily endorse the content of advertisements or non-Society documents included with their mailings. The Society reserves the right to refuse to circulate advertisements, without having to state a reason.

W: www.thebsa.org.uk

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Julie Reading E: julie.reading@cmft.nhs.uk

E: audacity@thebsa.org.uk

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chairman’s message

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Chairman’s Message - May 2016 All successful organisations must be prepared to change and

lowing the PGG to focus on the core workload of document

keep moving forward. In my view, the ability to adapt and im-

processing. I would like to thank Graham Frost and the other

prove is the key to the evolution of a relevant and valuable

members of the PPC, including Robert Rendell, Fiona Bark-

society, which is how I hope the BSA is widely regarded.

er, Wayne Ellis, Barry Downes, Jills Kurian and David Green-

There has certainly been plenty of change for our society over the last 12 months.The closure of the BSA’s Reading office last year and partnership with Fitwise has enabled us to focus on the issues that really matter, and to turn our gaze outwards instead of inwards. One example of successful change has been

berg, for everything that you have done over the years for the PPC and the BSA. This work has required great persistence and dedication and is much appreciated. We wish the newly formed PGG led by Donna Corrigan the very best in taking forward this important workload.

the move and re-shaping of the annual conference which took

The BSA’s advisory role has grown considerably in recent

place very successfully in April at the Ricoh arena, Coventry.

times, led by one of our trustees, John Day. John, and Helen

This meeting was very well attended and all the feedback I

Pryce, who represents the BSA on the Alliance on Deafness

have heard so far has been universally positive. It was a bold

and Hearing loss, have been playing a key role in contributing

move to change the time of year for the annual conference,

to some rapidly evolving national policy making in relation to

and I think we can now safely say that it has worked.The struc-

the commissioning framework for hearing loss. The BSA has a

ture of the meeting, with sessions organised and chaired by

key part to play in this process, in collaboration with BAA and

each of the BSA’s special interest groups, worked very well

other friends. The rest of the Audiological community look to

indeed; this allowed those attending with specific interests in

the BSA for sound, unbiased, sensible advice and information

areas of audiology and hearing science to hear from the world

about any issues related to hearing loss, and John and Helen,

experts in that field about the latest thinking and research.

along with other BSA members, have demonstrated how to

Following the conference, the organising committee will think

do that well.

through what worked well and what could be changed for next year’s conference, at Doncaster Racecourse and will be in June 2017 at Doncaster. I am convinced that we have now demonstrated that the new, improved model for the structure of the conference, at a new time of year, is successful and will now go from strength to strength. A huge thank you to Mel Ferguson, Laura Turton and the rest of the organising committee for the enormous amount of work that went into making this event such a success. Another change for the BSA has been the re-structuring of

Finally, the BSA depends for its evolution and success on enthusiastic, motivated people from within our membership to take forward our strategic aims and ideas. In September (only 4 months away!) there will be vacancies for trustees and also for a Vice-Chair. The latter is a vitally important position to fill. If you want to help take the BSA forward to even greater success please consider taking the plunge and putting your name forward. If you’d like to find out more about what this entails and the commitment then please contact me: Huw.Cooper@ uhb.nhs.uk- we look forward to hearing from you.

what was formerly the PPC (Professional Practice Committee). For many years (going back to the early 1970’s), the PPC has been a core and important part of the BSA’s activities and has worked with great patience and conscientiousness on the commissioning, development, writing and reviewing

Best wishes to all. Huw Cooper Chairman

of recommended procedures, guidance and other important documents, for which the BSA is internationally known. The PPC has now been relaunched as the Professional Guidance Group (PGG). Responsibility for accreditation of training will be taken forward by the LEG (Learning Events Group), al-

chairman’s message

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British Society of Audiology Annual Conference 2016

Andrew Causon (PhD) Trainee Clinical Scientist Central Manchester Foundation Trust

The 2016 BSA Annual Conference took place from 25th to 27th April and was brimming with posters, presentations, seminars and exhibitions. It was held at the Ricoh Arena, Coventry and saw strong British and international attendance, with speakers and delegates from at least four different continents. The first day focussed on Basic Science and was opened by chair of the BSA, Dr Huw Cooper. The two days that followed hosted experts from various fields, who discussed research priorities in Audiology, cognition in rehabilitation, tinnitus, adult rehabilitation, electrophysiology, the psychology of balance disorders, paediatric audiology, auditory processing disorders, and ways to improve audiological measurements. Interest in the conference was evident on social media, with the twitter hashtag #BSAConf buzzing with tweets and retweets before the conference even started.

in cross-talk cancellation in bilateral BAHAs are on the horizon. The Action on Hearing Loss twilight lecture by Professor Daniel De Wet Schwanepoel detailed exciting advances in the use of smartphones for audiological telemedicine and e-health delivery. When combined with calibrated headphones, common smart phones were used to establish hearing thresholds in the homes and schools of people who did not have access to audiological assessment services. The conference also warmly greeted the implementation of an innovative South African smart phone app which delivered the Digit Triplet Test with the scope of improving hearing loss detection and awareness of audiological services. The team ran a viral marketing campaign which has already encouraged hundreds of people to seek professional audiological services. Sharing and learning was punctuated with socialising and glamour at the BSA gala dinner, held on the second day of the conference. Attendees reminded each other how they look

The Ted Evans keynote lecture, by Professor John Culling, began with a self-confessed 20 year-old (but still very relevant!) slide describing the cocktail-party effect. The Cardiff University professor gave much more recent findings implying that positioning yourself at a 30 degree angle to your conversation partner (as opposed to face to face) could improve signal to noise ratios. He also gave hopeful indications that advancements

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8 outside of the lab or clinic, and some were brave enough to don their penguin suit or evening dress. Then again, none were quite as brave in their choice of clothing as the evening’s entertainment. Tasty wining and dining created the right environment for pleasant conversation and socialising, as well as the occasional good piece of gossip! Congratulations to Professor David Moore; now based at Cincinnati Children’s Hospital, USA, for the Thomas Simm Littler Lectureship award presented on the third and final day of the conference. He used the time to emphasise the rise in popularity of smartphone listening apps and ‘hearables’, and their unlocked potential in personalised Audiology. His talk also highlighted the role of cognition in listening, and the importance of testing beyond the audiogram. The British Society of Audiology Awards 2016 Yearly prizes are awarded to individuals who have shown excellence in their field. Nominations for the BSA prizes are submitted throughout the year and the winner determined by the Trustees of the Society. The awards and prizes are made at the Annual dinner of the Society, at the Annual Conference. In order to nominate a member, you need to submit a letter of support including a citation for the award and a CV or brief biography. The BSA proudly announced the following awards this year: The Jos Millar Shield Prize (nominations by the editorial team of Audacity) Winner: Dr Chris Wood The Jos Millar shield Prize, consisting of a certificate and shield, was established in 2000 and is awarded to the best article published in Audacity. Senior Research and Policy Officer Chris Wood received the award for his article about the main findings and recommendations of the Action on Hearing Loss report, ‘Under Pressure: NHS Audiology Across the UK’. The Ruth Spencer Prize (nominations by members) Winner: Dr Nicci Campbell The Ruth Spencer prize was established in 1976 to honour the memory of Ruth Spencer. It is made in recognition of a contribution to clinical services by a registered practitioner. Associate Professor and Principal Audiological Scientist Nicci Campbell received this award in recognition of her contribution to audiology, particularly in the field of Auditory Processing Disorders The Denzil Brooks Trophy (nominations by trustees) Winner: Inga Ferm The Denzil Brooks trophy was established in 2007 in memory

BSA Conference 2016

of the late Denzil Brooks who was a pioneer of adult hearing aid provision within the UK. The award is made to a member in recognition of promoting excellence in audiological practice. The certificate and trophy were given to Inga Ferm for her work in the use of ABR in newborn screening and hearing assessment. The George Harris Award (nominations by trustees) Winner: Dr John Day The George Harris award was established in 2006 using an endowment from the late George Harris who was a hearing aid audiologist working in the independent sector. The award is made in recognition of a notable contribution to hearing aid audiology in any one year. The biennial award of a certificate and discretionary honorarium was given to John Day, who is BSA Advisory Role Lead and a trustee. He has been recognised for his management of BSA expertise, and raising awareness of the BSA. The Thomas Simm Littler Prize (nominations by members) Winner: Dr Michael Stone The Thomas Simm Littler prize was established in 1970 to honour Dr Thomas Simm Littler, a pioneer of British audiology. The prize was awarded to Senior Research Fellow Michael Stone, in recognition of his academic contributions to Audiology. His name is well known in the field of speech recognition psychoacoustics and, more recently, has developed a research interest in hidden hearing loss. The Thomas Simm Littler Lecture (nominations by trustees) Winner: Prof David Moore The Thomas Simm Littler lectureship was established in 1970 to honour Dr Thomas Simm Littler, a pioneer of British audiology. David Moore was awarded the lectureship in recognition of a sustained academic contribution to the discipline of audiology, particularly in the field of Auditory Processing Disorders.

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A avour of the BSA Conference 2016

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SIG segment

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SIG Segment Information and updates from BSA Special Interest Groups

BSA Special Interest Groups

Adult Rehabilitation Interest Group (ARIG) Mel Ferguson, Chair of Adult Rehabilitation Interest Group (ARIG)

April in Nottingham with a packed agenda, and a number of agreed actions that address the group’s revised objectives.

E: melanie.ferguson@nottingham. ac.uk

1. To review and promote patient centred rehabilitation interventions and the supporting evidence

It’s all change on the ARIG front. We say goodbye to Lucy Handscomb (Chair), Amanda Casey, Helen Pryce and Beth-Ann Culhane, and thank them for their contributions to ARIG over recent years. In particular, for their input into the revision of the 2012 practice guidance now known as the Common Principles of Rehabilitation for Adults in Audiology Services. This document has recently been out for consultation and comments have been sought from international opinion leaders in the field. It was encouraging to see a large number of responses. Overall, responses have been very positive, and the document is likely to be published sometime in the summer. So as the lone survivor of the previous ARIG outfit, I’m delighted to welcome the new crowd who bring forth a range of experiences from audiology, speech and language therapy, and the independent, third and commercial sectors (see website). Laura Turton, the ARIG secretary, played a blinder getting such a great group of people together, and I’m so pleased that Jane Wild has agreed to be Vice Chair. The first meeting of the new group was held on 13th

2. To advise on the holistic application of evidence based rehabilitation interventions 3. To advise on the evaluation of these interventions and the patient journey 4. To forge links between clinicians, researchers, policy makers and educators to promote and support current and future best practice in adult rehabilitation Firstly, a meeting on Complex Adult Rehabilitation will be held in September at De Montfort University, which will run in parallel with the PAIG meeting. Then following discussions on priorities within adult rehabilitation, we agreed on two pieces of work for starters. The first will be a practical “what works” companion to the more theoretical common principles practice guidance. We will seek and compile examples of best practice and service innovations, supported where possible with an evidence base. The second, will be to identify a toolkit of outcome and assessment measures for services - a what, why, how, when and for whom. With ARIG likely to play a key role in the development of the NICE Guidance on Adult Onset Hearing Loss for the BSA, it looks like the start of some promising, necessary and exciting work – all good stuff and plenty to keep us out of mischief.

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SIG segment

11 Auditory Processing Disorder Interest Group (APDIG)

Cognition in Hearing Interest Group (CHIG)

Pauline Grant, Chair of Auditory Processing Disorders (APDIG)

Piers Dawes, Chair of Cognition in Hearing (CHIG)

E: pg.apdsig@gmail.com

E: pier.dawes@manchester.ac.uk

As I write, we are preparing for our next APD Information Day in Exeter on May 19th. This time we are targeting professionals from Audiology and Education – raising awareness and offering practical strategies for helping children with auditory processing difficulties to reach their academic potential. Kelvin Wakeham is masterminding this event and has worked hard to attract sponsorship so that costs for delegates are kept as low as possible. Huge thanks are due to all our sponsors. Our new Leaflet ‘APD in Children’ is now available to download from the APD pages on the BSA website. Dilys Treharne provided the framework for the new leaflet and the finished product is a collaborative effort by all members of the SIG! Printed versions will be available soon. Nicci Campbell and Dave Moore have worked tirelessly on our revised APD Position Statement – there is no doubt that the work of the APD SIG is helping to shape international thinking. Developing our international links with APD professionals in Australia, the USA, Germany, Canada and New Zealand remains one of our priorities. We continue to highlight the news (reported in the previous edition) that the National Foundation for the Deaf in NZ views the perceived lack of APD services in their country as breaching the UN Convention on the Rights of Persons with Disabilities. The APD SIG is actively recruiting! If you would like to find out more about our group and feel that you can help us develop our work, please contact me – Pauline - at pg.apdsig@gmail.com I’d be delighted to hear from you! My thanks to all the hard working APD SIG Members and Advisors: Doris-Eva Bamiou, Nicci Campbell, Sandra Duncan, David Moore, Stuart Rosen,Tony Sirimanna, Dilys Treharne, Kelvin Wakeham and our advisory members, David Canning (Acoustics) and Andrew Strivens (Parents) More information about our Special Interest Groups and its members is available on the BSA website.

The aim of the special interest group for cognition in hearing is to promote research in and raise awareness of new developments on cognitive issues in hearing science, assessment and intervention. BSA Conference; Ricoh Arena Coventry 25-27 April 2016. The SIG for cognition in hearing will have a 2 hour session on the second day of the conference, “Cognitive perspectives on hearing assessment and rehabilitation”, focusing on older adults with cognitive impairment. Confirmed speakers include Dr Piers Dawes (University of Manchester), Dr Doug Beck (Oticon), Prof Sven Mattys (University of York), Dr Graham Naylor (MRC Institute of Hearing Research Scottish Section), Chris Morley (Royal Cornwall NHS Trust), Dr Sarah Bent (Betsi Cadwaladr University Health Board). Development of assessment and treatment guidelines for adults with learning disabilities (Siobhan Brennan) and adults with dementia (Sarah Bent). Working groups to develop NICE-compliant BSA guidelines will hold their first meetings at the BSA annual conference, with draft guidelines to be produced by the end of 2016. Dr Sarah Bent gave a lightning update on dementia (March 16th), talking about the BSA’s involvement with the current NICE consultation on treatment guidelines for dementia, the recent SIG workshop on assessment and management of hearing impairment in people with dementia and development of assessment and treatment guidelines for people with dementia. Sarah’s update was one of the most viewed lightening updates ever! You can view Sarah’s update here: http://www.thebsa.org. uk/lightning

If you would like to join the SIG and be added to the mailing list, or suggest an activity for the SIG, please feel free to email me piers.dawes@manchester.ac.uk

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SIG segment

12 Balance Interest Group (BIG) Katy Morgan, Chair of Balance (BIG)

As I write this update the Balance Interest Group (BIG) committee members are looking forward to the BIG session at the BSA Conference in April on the ‘Psychology of Balance Disorders’. Once this edition of Audacity has come out the conference will have already happened. So I thought I’d point you towards the work of the speakers, in case you were not able to make it to the conference. Anyone who has spent much time with vestibular patients will understand how important it is to gain an understanding of the potential psychological interactions and impacts of their disorders. Jeffrey Staab, Associate Professor of Psychiatry at the Mayo Clinic in the United States has a specialist interest in chronic dizziness, and the interactions between neurotologic and behavioural variables that trigger and sustain chronic dizziness symptoms. He and his colleagues described a syndrome of chronic subjective dizziness (CSD), a development of what German neurologists Brandt and Dieterich had previously coined phobic postural vertigo. Further clarification amongst scientists has led to the diagnostic term of Persistent Postural-Perceptual Dizziness (PPPD), which the World Health Organization has included in a draft list of diagnoses to be added to the next International Classification of Disease (ICD-11) in 2017. See these papers for further information on this condition and proposed underlying mechanisms: • Indovina I, Riccelli R, Chiarella G, Petrolo C, Augimeri A, Giofre L, Lacquaniti F, Staab JP, Passamonti L. Role of the insula and vestibular system in patients with chronic subjective dizziness: an fMRI study using sound-evoked vestibular stimulation. Front Behav Neurosci. 2015; 9: 334. • Staab JP. Chronic subjective dizziness. Continuum (Minneap Minn). 2012; 18 (Neuro-otology): 1118-41. • Ruckenstein MJ, Staab JP. Chronic subjective dizziness. Otolaryngol Clin North Am. 2009; 42: 71-7. • Staab JP. Chronic dizziness: the interface between psychiatry and neuro-otology. Curr Opin Neurol. 2006; 19: 41-8.

I am currently studying to teach Mindfulness Based Cognitive Therapy (MBCT) and during my online searches on mindfulness I was excited to come across an audiologist offering mindfulness to her vestibular patients on a systematic and expert basis. I think this approach has great potential to aid the effective rehabilitation of dizzy patients. Joanna Remenyi has set up her own practice, Seeking Balance Australia, as both a vestibular audiologist and a mindfulness educator. She has over 15 years’ experience of mindfulness practice and infuses vestibular rehabilitation with mindfulness approaches. See her website for further information: www.seekingbalance.com.au Researchers at the European Centre for Environment and Human Health at the University of Exeter Medical School have been carrying out some interesting work into Meniere’s disease. One of these researchers is Dr Sarah Bell, Associate Research Fellow, who has been examining the mental wellbeing impacts of living with Meniere’s Disease. See her university profile at: http://medicine.exeter.ac.uk/profiles/index.php?web_ id=Sarah_Bell Her profile outlines how her research study is based upon “in-depth interviews with Meniere’s patients and their significant others to discuss how they experience, manage and adapt to the illness in the context of their everyday lives”. Dr Sarah Kirby is a Health Psychologist and Lecturer in Psychology at the University of Southampton. Her research interests include health issues relating to self-management, acceptance and adjustment to chronic illness, to include dizziness, vertigo and specifically Meniere’s disease. Here are some of her research papers to take a look at: • Meniere’s disease: a systematic review. Psychol Health Med. 2008; 13: 257-73. • Kirby S. Conditions associated with anxiety in Meniere’s Disease. J Psychosom Res. 2008; 66: 111-8. Dr David Scott is a Clinical Psychologist at the Royal National Throat Nose and Ear Hospital and has 16 years’ experience working with patients with balance and other physical health problems (including tinnitus, hearing loss, hyperacusis, and misophonia), with an approach based upon Cognitive Behavioural Therapy (CBT). He has a website at: www.drdavidscott.co.uk In other news, please add the date Friday 16th September 2016 to your calendar in anticipation of the next BIG bi-annual conference, to be held at the Ear Institute in London. Further details coming soon.

SIG segment

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SIG segment

13 Evoked Potential Interest Group (EPIG) Siobhan Brennan, Chair of Evoked Potential (EPIG) E: Siobhan.brennan@manchester.ac.uk

input the document will then be distributed for BSA membership consultation. CERA Training Day A provisional date of 5th of December has been set for the next CERA training day. This will include a demonstration lecture, implementation of the CERA guidance in clinical practice, and future CERA directions. If you have any thoughts on documents or training regarding auditory electrophysiology you would like to see the BSA SIG provide in the future do let us know at Siobhan.brennan@manchester.ac.uk

It’s been an interesting time for the EP SIG not least because we move to meeting virtually. This gives us a wonderful opportunity to gather input from members outside the UK and have attendees who would not otherwise been able to join us. If anyone would like further information on the platform used and our experiences with this meeting format do get in touch. We will continue to have annual face-to-face meetings to ensure we don’t miss out on break-off pre- and post meeting discussions.

Tinnitus and Hyperacusis Interest Group (THIG)

The work continues to focus on guidance provision. Of particular mention is;

E: tendai.ngwerume2@nhs.net

• OAE Guidance This document’s first draft has been completed and feedback from the SIG is being collated for the second draft. It is garnering a great deal of interest within the group and promises to be a very useful document on completion. • CERA Guidance Following very useful feedback during the BSA consultation this document is now complete and available on the BSA website. This document will be reviewed in 2019. • Peer Review Document The existing peer review document currently available on the EP SIG portion of the website is being re-written and expanded by a working group within the EP SIG to incorporate the peer review process for all auditory electrophysiological measures that require visual interpretation. All being well this would make it applicable to a broader range of clinicians and address the risks that are associated with electrophysiological measures irrespective of the age of the patient. • ABR in Older Children and Adults The ABR in Older Children document is now with external reviewers. Following consideration of their

Tendai Ngwerume, Chair of Tinnitus and Hyperacusis (THIG)

It is a pleasure to introduce the newly formed Tinnitus and Hyperacusis SIG. The group was formed in December 2015 after a consultation with a number of BSA members who felt that there was a desperate need to address practice issues in this evolving and exciting field. The group is made up of professionals from a wide range of sectors including public and private practice, education and research. As elected Chair I will work with Derek Hoare, Senior Research Fellow at the NIHR Nottingham Hearing Biomedical Research Unit who was elected to serve as Vice Chair and Alice Davies, Lecturer at Swansea University who was elected to serve as Secretary. The main objectives of the SIG are: 1. To develop evidenced based assessment and management practice guidance for tinnitus and hyperacusis. 2. To raise the standards across the private and public sector in tinnitus and hyperacusis management. 3. To promote relevant research, disseminate commentary on new studies and provide lifelong learning for professionals through a range of CPD activities.

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SIG segment

14 4. To promote tinnitus and hyperacusis awareness to the professional community, particularly at primary care level.

www.thebsa.org.uk

5. To advise professionals of onwards referral options and signposting. The first official TH SIG meeting was held on the 23rd of February at the Royal Derby Hospital. We discussed the current situation in tinnitus practice, research and education in the UK. It was a good opportunity for group members to share their wide ranging concerns which included: • Driving better access to mental health for patients • Raising professional awareness of tinnitus and hyperacusis in primary and secondary care. • Promoting research in clinical practice • Generating procedures and guidelines in a wide range of topics from using outcome measures to fitting ear level devices. Unsurprisingly, these broad work themes fit in with the main objectives of the SIG. In generating an action plan, we identified two priorities for the group to work on over the next twelve months. Our first priority is to produce a foregrounding position statement on the principles of professionalism in tinnitus practice. As there is variability of consensus regarding best practices in this field, the group agreed a general need to professionalise practice, enabling a reflexive, rather than a protocol driven approach to patient care. A first draft will be ready for the group to discuss at our next meeting in May. Our second priority is to implement a survey of hyperacusis management in the UK. The group felt that not enough is known about the state of practice in this area. This topic will be discussed further at our next meeting in May. We are excited about the opportunity to influence tinnitus and hyperacusis practice and I look forward to keeping you updated on our progress.

Our website allows for online registration for new members and renewal of membership for current members. You can Facebook and Tweet us – or reach us in more traditional ways.

We are there for you – on your ipad, notebook or computer, in a format that is quick and easy to access.

Some of the key elements of the new website are: • The BSA Chairman’s message • Online access to electronic versions of BSA publications

British • Easy and Society free access toof BSAAudiology Policies and Procedures

| PRACTICE | IMPACT •KNOWLEDGE Easy access |toLEARNING our very popular recorded Lunch & Learn and Lightning Updates

• Direct access and updates on the work of the BSA Special Interest Groups • Information about conferences and events

• Information about global projects British Society ofoutreach Audiology

• Job adverts and information and links to organisations. KNOWLEDGE | LEARNING | PRACTICE | IMPACT

For any further information on the work of the TH SIG please contact Tendai Ngwerume, Senior Audiologist, Derby Teaching Hospitals NHS Foundation Trust, (tendai.ngwerume2@nhs.net)

British Society of Audiology KNOWLEDGE | LEARNING | PRACTICE | IMPACT

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knowledge learning practice impact

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Knowledge Learning Practice Impact Professional Practice Committee Update Graham Frost, BSc, MSc, MIOA, MIEE, RHAD Technical Consultant Chairman, PPC E: ppcadmin@thebsa.org.uk

When the British Society of Audiology was formed in 1967, and its constitution approved in 1968, one of the principle aims for which it was established was “The enhancement of audiological practice by education, dissemination of knowledge in Audiology and allied sciences, provision of vocational training, recommendation of clinical procedures and specification of training requirements, where appropriate”. As from the early days of the BSA this role had become increasingly more important, the BSA established in the late 1970’s its Education Committee, which was later to become The Professional Practice Committee. At that time the Education Committee was asked by the BSA Council to consider the various methods of audiometry used for diagnostic and clinical purposes, for hearing aid fitting and in connection with hearing conservation in industry. As a result, the first BSA Recommended Procedure produced by the Education Committee was published in The British Journal of Audiology in 1981. This first publication was not only a significant step forward for the BSA, but it also represented the first consensus of opinion on good practice in the UK from the diverse range of disciplines and views involved. Other BSA publications produced by the Education Committee followed and included guidance and training documents, a Careers Booklet, which included all the professions within the field of audiology at that time, and a Hearing Aid Handbook, which provided clear and concise step by step information on hearing aid technology and aspects of hearing aid fitting. The publication of further BSA Recommendations and Guidance documents, which now cover a broad range of procedures and disciplines, has continued to demonstrate consensus of opinion on good practice within the UK. Many of these documents are now recognised Internationally and have been extensively adopted elsewhere, both Nationally

and Internationally, as representing best practice. In addition to the development of recommended procedures, the Education Committee produced guidance documents and specifications of minimum training requirements to carry out some of these procedures. An accreditation process was subsequently established where those providing a course, which complies with the minimum training requirements, can apply to the BSA for accreditation of that course. The Education Committee also organised a number of Education and Training meetings which were open to the Membership of the Society. The processes of document development and course accreditation have been continued and maintained by the PPC, together with other complimentary activities such as providing BSA/PPC representation on relevant British Standards Institution Technical Committees relating to Audiology. The workload placed on the PPC has continued to grow, particularly with the establishment of more and more BSA Special Interest Groups, many wishing to develop their own good practice documents relevant to their particular specialty or discipline. The publication and maintenance of documents together with the accreditation of courses, and other activities identified as being the responsibility of the PPC, have required a huge commitment from its members, and the need to be able to process larger numbers of documents, particularly those resulting from the increasing activities of the Special Interest Groups, has grown more apparent. The BSA Council has therefore been exploring ways in which this significant workload might be better managed in order to spread the load, accommodate the greater demand and make processes more efficient and effective. At the meeting of the BSA Council held in December last year it was agreed that a dedicated document processing group should be established and that the BSA accreditation of courses would perhaps be more suited to the Learning Events Group (LEG). Since that meeting the new “Documents & Guidance Group” (DGG) has been established and responsibility for the processing of BSA documents has now been transferred to it.The LEG has also confirmed agreement

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16 to take over the BSA accreditation of courses and is currently reviewing the next steps. I am also pleased to report that at the March Council meeting it was agreed that the BSA should continue to have representatives on relevant BSI Technical Committees and that, rather than reporting to the PPC, these should now report to the DGG and submit updates for inclusion on the BSA website. As a result of the Council’s decisions, the PPC held its final meeting on 14 March and the Committee was formally disbanded at the close of the meeting. As Chairman of the PPC at that time I would like to personally

thank all those who have been involved with and supported the work of the PPC and, prior to that, the BSA Education Committee. These not only include past Committee Members and Chairs, but also the many BSA members who have drafted, revised and commented on BSA documents, participated in the accreditation and moderation of courses, and organised or spoken at Education Committee/PPC training days, meetings and symposiums. I would also like to thank those of you who attended the final PPC symposium at this year’s annual conference. The Education Committee and the Professional Practice Committee have left a huge and extremely impressive legacy, of which we should all be justifiably proud, and I wish those who will be continuing this work every success in the future.

BSA Learning and Events Group Update Siobhan Brennan Lead, Learning and Events Group E: Siobhan.brennan@manchester.ac.uk

series continues with presentations including Richard Gans on “Vestibular Rehabilitation for Children”, Ann-Marie Dickinson and Imran Mullah on “How to Run a Journal Club” and Ross Roeser on “What to look for in a research paper”. The Lunch and Learn events will be moved to “members access for free” format with a charge for non-members payable through the website.

In September 2017 we are planning the UK’s largest virtual Audiology conference. In addition to the top-drawer speakers that you would expect at a BSA conference, this will also give delegates the opportunity to attend without the need for travel. This will be in addition to our annual conference. Follow our updates on both conferences on the BSA website, Facebook or Twitter pages.

The Journal Club continues to extend their events across the country to allow the greatest number of people to benefit – the topic this autumn is “Single -sided Deafness and Bone-Conduction Amplification” and are currently being planned in Glasgow, Nottingham and Bristol. Other exciting events include the Twilight Meeting on “Are two ears better than one?”, the impelling Research Round-Ups and one day events including the CERA Training Day and the BIG Annual Conference to name only a few. If you would like to host an event with the support and advertising of the BSA we can send you the new Event Guidelines document which walks you through the process.

2017 is also the BSA’s 50th birthday! We look forward to marking the occasion and we would love to hear from you on how you would like to see the BSA celebrate!

If you have any thoughts on events or training you would like to see from the BSA in the future do let us know at Siobhan.brennan@manchester.ac.uk

It is with delight that I feedback on the work of the Learning and Events group since taking on the Chair this year. It has been a busy year so far and there are lots more great events to look out for.

The BSA Learning and Events Group is delighted to be joining forces with the BSA Course Accreditation team. If you have any queries about BSA course accreditation in general or have a course in mind and need information about the BSA course accreditation process do get in touch and we can supply all the information you may need. The excellent Lunch and Learn presentation by Sarah Bent on Dementia was extremely popular and the Lunch and Learn

Keep up to date: www.thebsa.org.uk Follow us on: twitter Facebook “f ” Logo

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17

We were all ears – feedback on BSA membership Figure 1 Q7 Which of the following sectors matches your professional interest? (Tick all that apply) Answered: 306

Skipped: 8

500 400

Laura Turton, BSA Operations Manager

300 200

210

100

Membership Survey In October and November 2015 we ran an electronic survey on the membership of the BSA. Two hundred and ninety-five respondents completed the questionnaire (with two hundred and twenty nine fully completed data sets), 65.7% are BSA members, 13.9% used to be a member and 20.4% have never been a BSA member. Figure 1 demonstrates the spread of different sectors who responded.

“It is an excellent point of reference for information. I wish I had more time to access the resources available.” “Given me access to professional updates and knowledge which has improved my teaching and clinical practice.”

25

11

21

11

14

7

10

83

0

Private Private sector sector NHS

Private Private sector sector loc... nat...

Univer- Non Third sity Univer- sector sity emp

Volunteer

Retired I’m a mem ber of the

Other (please spe...

2014-2015 MEMBERSHIP BREAKDOWN (MEMBERS = 1,469 & CATEGORIES TICKED N = 1,959)

Student, 186

Other, 10

Audiological Physician, 76

Retired, 34

Clinical Medical Officer, 54

Clinical Audiologist, 424

Research, 91

Community Medical Officer in Audiology, 6

Private Sector, 94

Interestingly, there is a comparable spread of disciplines and sectors in figure 2, which shows the spread of membership across the entire BSA database. Benefits / Usefulness of membership We asked an open ended question about the perceived usefulness of being a BSA member. Seventy-four percent (n= total 227) reported that they felt the BSA had supported their career over the last 5 years. Examples of this included:

20

54

Educational Audiologist, 43 Electrical/Electronic Engineer, 14

Relative of Hearing Impaired Person, 8

General Medical Practitioner, 3

Hearing Therapist, 34 Industrial Audiometrician, 2

National Health Service, 419

Health Visitor, 3

Marketing & Sales,19

Paediatrician, 28

Hearing Impaired Person, 11

Occupational Therapist, 8

Charity Professional, 13

Scientist/Acoustician (Audiology), 39

Psychologist, 21

Academic, 170 Social Worker with the Deaf, 1

Medical Physicist, 9

Teacher of the Deaf, 8

Otolaryngologist/ENT Surgeon, 33

School Hearing Screener, 1

Registered Hearing Aid Dispenser, 67

Teacher fo Lipreading, 2

NHSP Screener/Paediatric Screener, 1

Teacher of the Deaf (Audiology), 9

Figure 2

“Good networking opportunities and means of keeping in touch with national situation.”

“It has helped me provide evidence

Speech & Language Therapist, 18

at my appraisal to show involvement with wider community.” •

“I have got information about various audiological topics for CPD

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18 and met some interesting people at the Twilight meetings which has made me learn from a range of professionals.” •

“The BSA has given me an opportunity to be a part of a group with

similar interests, and providing an environment for knowledge exchange and learning.” •

“I have received a research grant which helped me disseminate my findings”

“IJA subscription has been invaluable for my studies and keeping up with research in the profession. BSA membership is viewed positively on job application forms.”

“The BSA has given me access to important information and a connection to other people to advance my knowledge.”

“It has helped me know who else works within my interest area in research.”

“It has allowed me to contribute to BSA recommended procedure.”

Figure 3 General membership • Make clear changes between what members and non members do and don’t get • You don’t have to be a member to benefit from the most useful aspects of the BSA Events • Annual conference being more clinically relevant • Other online learning and distance learning / tutorials • Develop the role of the SIGs more so more interactive with the membership Communications • Emails about the titles in the latest IJA • Members area of the website to have links to useful resources, lists of speakers on different topics etc. International Journal of Audiology • Hard copy of the IJA Stakeholder / Advisory • Greater awareness of humanitarian audiology projects would be great • Represent all health sectors and not focus on NHS • Greater involvement in challenging prevailing ideas in audology and a renewed focus on evidence based practice Protocols / Research • Provide a forum for breaking down the communication barriers between basic researchers and clinicians • Speed up the production of protocols for clinical practice

Table 1

Membership benefit 1

Online resources including our internationally recognised BSA procedures

2

Online access to the International Journal of Audiology

3

Access to Continued Professional Development opportunities such as webinars and other learning events

4

Access to our respected members’ magazine, Audacity

5

Membership of a Special Interest Group

6

Reduced rates for conferences and meetings

7

The opportunity to network and present research to fellow researchers, policy makers and clinicians

8

Advanced notice of conference and meetings

9

Representation - we are approached in an advisory capacity to help shape the profession, through joining you are able to have your say

10

Kept up to date on industry trends and how to deal with them

11

Opportunity to apply for a small research grant

12

Access to job opportunitites

13

Grant for travel, attendance at scientific meetings and projects

14

Given priority places at conferences and meetings

15

Free NDCS membership

16

Opportunitites to win a BSA award

Seventy-one percent would like the BSA to be more useful to them through their membership. These were divided up in to themes. Figure 3 represents these themes and gives a couple of examples under each. All examples have been discussed with the advisors / committees / groups who are responsible for these areas for further discussion and changes. BSA members were asked how they viewed their membership in terms of value for money. Table 1 shows various membership benefits and their ranking amongst BSA members. Additionally, 76.7% reported wanting an e-newsletter, 54.6% wanted research paper feedback, 59.5% wanted to be able to access a free research forum and 38% wanted to access mentoring opportunities. When asked if the respondents (n=233) would recommend membership of the BSA to anyone who had an interest in hearing and balance; 96% said either yes (64%) and maybe (32%). Non-Members All non-members (n=53) were asked what their reasons were for not joining. Thirty four percent were unaware of their eligibility to join, with 29% stating it was for financial reasons. Eleven percent reported there were no perceived benefits from joining as can access events and website without being a members. A further 11% said they had never considered it and 15% has not heard of the BSA before, or did not state a reason.

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19 When asked if they would consider joining 96.3% said yes (44.4%) or maybe (51.9%). Views on the direction of the BSA When asked what one thing they would like the BSA to accomplish, some of the following themes came up: • “Lobby for and achieve suitable revision of the NICE position on candidacy for auditory implants.” • “At Government strategy level raising the wider impact of hearing loss on wellbeing, depression, communication, depression and guidance for audiologist” • “Treatment pathways that include better education for patients and audiologists as how to get the best out of their hearing devices” • “Keep guidance up to date” • “Greater cooperation between scientists and clinicians” • “Maintain its advisory, consultative and educational role in the field of audiology” • “Raise the profile and encourage everyone working in Audiology (and related fields) to become members” • “Increase awareness research councils/funding bodies of audiology/ hearing loss-related research” • “Promote best practice in audiology” • “To work collaboratively with all audiology related bodies” • “Improve members”

communication

with

• “Raise the profile of hearing research” • “Consider new Special Groups to be formed”

Interest

• “Maintain support for research. It is important and can easily be neglected in times of austerity. This is not prioritised by any other organisations representing audiologists.” • “Represent member’s interests and involve them” • “To be a major contributor to Government and Health policy and represent the multidisciplinary view of hearing nationally.” • “To have strategies to get the

Figure 4

Online access to the IJA and regular updates on the contents of each copy - the previous year’s IJA can also be bought as a hard ocpy through the BSA Adminstration Two postal issues of Audacity Membership of BSA Special Interest Groups (which also includes access to Facebook groups and website pages with more regular communication on particular areas of interest) Access to CPD opportunities - both online and face to face meetings - with a minimum of 25% discount on all events and monthly webinars emailed directly to you Monthly e-newsletters keeping you updated about what the BSA is doing and how you can get involved The opportunity to network and present our research to fellow researchers, policy-makers and practitioners Seminars and conferences bringing together researchers, policy-makers and practitioners Opportunities to win one of our awards Representation - we are approached in an Advisory capacity and help shape the profession - through joining you are able to have your say Opportunity to apply for up to £5K in research grants Access to BSA Advisors who can answer any enquiry about Audiology, Hearing and Balance Science To be involved in shaping internationally recognised Practice Guidance and Recommended clincial procedures

researchers and working together”

clinicians

really

So has anything changed based on what we found out? Thank you to everyone who completed this questionnaire, it revealed some interesting areas for the BSA and we have made some changes to our membership offer from this information. These include having a greater clarity on what we offer. Figure 4 lists the full offering of the BSA. Some new additions include: 1. At least 25% discount at all BSA Learning Events 2. More widely advertising that members can purchase a compiled version of the IJA at the beginning of each calendar year 3. Formation of the Tinnitus & Hyperacusis Special Interest Group 4. Facebook forums from the Balance Interest Group and the Auditory Processing Disorder SIG 5. Monthly e-Updates emailed to all members to create a more accessible and cohesive communication a. This also includes a full list of

what is published in each IJA so all members can see the titles before logging on 6. More password protected areas of the website so that non-members cannot access the benefits that members can, this will also mean that the following areas will be fully members only: a. Lunch and Learn webinars b. Past copies of Audacity c. The Special Interest Group pages d. The membership pages general will be updated

in

This will not include the Resources page for the Recommended Procedures 7. Updates in our Code of Conduct 8. Introduction of membership cards 9. Members will be provided with information on their membership fee being tax deductible 10. The option for members to pay in either one or two 6 monthly payments 11. Produce new marketing literature on all aspects of the BSA – come

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20 and see this at our stand at the annual conference 12. Provide guides on accessing the IJA online please see http://www. thebsa.org.uk/accessing-international-journal-audiology/ 13. The main membership year will still sit at 1st June – 31st May but any new member signing up outside of

this time will have their membership dates set as the date approved by Council to allow ease of administration and allow faster access to membership benefits There are a number of other new projects we are looking to launch later in the year based on the infor-

mation we gathered, so watch this space. If you would like any further information on the data collected, or have other ideas for improving BSA membership (and our wider activities) then please contact me on laura@ thebsa.org.uk

Trustee Vacancies from September 2016

British Society of Audiology KNOWLEDGE | LEARNING | PRACTICE | IMPACT

British Society of Audiology KNOWLEDGE | LEARNING | PRACTICE | IMPACT

British Society of Audiology KNOWLEDGE | LEARNING | PRACTICE | IMPACT

In September, a number of our trustees come to the end of their terms of office and this means there is an exciting opportunity for you to join our team. Whether you have a wealth of experience or you are new to the profession we would like to hear from you. Particularly if are motivated to build and empower professionals to improve the lives of people with hearing and balance problems. We have 5 vacancies: three for trustees, one for Vice Chair and one for Secretary (both of whom are also trustees). Council members serve for a period of 3 years and can be re-elected for a further three years. Council meets four times a year and in addition to these meetings, you will usually support an area of activity of the BSA. Trustee: The role of trustee is to help determine and enact strategy by making decisions that will affect the way the BSA is run. You will join us at an exciting time where we are working to achieve the strategy we have laid out for the next 4 years. Candidates must be a member of BSA and a BSA Proposer and a Seconder is required (who must be full members). A member may not propose or second more than one candidate. Thereafter there is a ballot by the membership. Vice Chair: Nominees for this role can be current trustees but can also be

from the general membership. As Vice Chair you will perform the Chair responsibilities in the Chair’s absence and after your two year tenure is completed, you take over the Chair. Secretary: The BSA Secretary is a member of the BSA Council who supports the BSA by ensuring the smooth functioning of Council and is responsible for the governance of the BSA Council and the membership. The term of office is 3 years with a possible renewal for a further 3 years. For full role descriptions please sign in to the website and click here: http://www.thebsa.org.uk/members-pages/council-members/ If you wish to nominate someone, please complete a “Call for nominations form”, together with a brief statement from the candidate supporting their candidacy. If you wish to be nominated, please identify a proposer and seconder, send them your statement and ask them to fill in the form. The statement should be no more than 250 words, and accompanied by a recent head and shoulders photograph. Full inductions, training and support are provided for all of these roles. If you would like any further information please contact:

Laura Turton, Operations manager E: laura@thebsa.org.uk

T: 0118 9660622.

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Northwest Complex Hearing Needs Network 10th meeting Shahad Howe, Clinical Scientist, Manchester Royal Infirmary E: Shahad.howe@cmft.nhs.uk

devices and some advice on how we could receive financial incentives for this, which in the current climate could prove very motivating to NHS departments. Finally, two members of the Audiology team at Manchester Royal Infirmary presented on our current Assistive Listening Devices Loan policy; detailing which devices we have available to offer patients on short-term loan, how the loan system works, how patients access devices on a long-term basis and

On 25th January 2016, we held the 10th Northwest Complex Hearing Needs Network (NWCHNN) meeting. This group is currently made up of 32 Audiologists who represent 20 departments across the North West and have a special interest in adults with complex hearing losses. The objectives of the group are shown in Figure 1.The meetings are held 2 or 3 times a year and move around the region.Topics to date have included implantable devices, non-routine hearing aid fittings, assessment and management of dead regions, multi-disciplined approaches to tinnitus, non-organic hearing loss and otological pathologies, among others. The 10th meeting was about assistive listening devices and wireless accessories, which are playing an ever-more crucial part in rehabilitating patients with

plans for a volunteer-led drop in service. Feedback following the meeting was excellent with an average score of 5 out of 6 for the overall evaluation. The attendees commented that what they most liked about it was the educational and CPD aspect, the range of speakers, the opportunity to network and that the meeting was conducive to effective discussion. Arrangements are now underway to hold the next meeting in Bolton in the summer, focusing on the very current and relevant topic of adults with learning difficulties and dementia. Figure 1: NWCHNN objectives

complex hearing losses. A representative from Sensory Support in Central Manchester

Share new information and technologies

attended to give an update on local social services provision for the hearing impaired. It was really useful to have a round table discussion regarding the differing provisions across the region and quite concerning to hear that some areas have withdrawn free provision of assistive listening devices completely.

Present and discuss complex cases

Standardise practice and identify training needs

As Manchester Royal Infirmary is a tertiary referral centre, we see patients from across the region and so it is critical to be

NWCHNN objectives

able to accurately inform patients of what they can expect from their local services. We also had representatives from hearing aid companies –

Develop treatment pathways

Share good practice

Phonak, Oticon and GN Resound – presenting an update on their wireless accessories. With the recent release of new hearing aid models, it was valuable to get an idea of the avail-

Develop good practice guidelines

ability of accessories to compliment the new hearing aids on the NHS contracts. They also gave information on how Audiology departments could signpost patients to purchase these

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‘Open Access’ and the International Journal of Audiology Kevin Munro Ewing Professor of Audiology E: kevin.j.munro@manchester. ac.uk

Peter West Consultant Audio Vestibular Physician E: pdbwest@doctors.org.uk

BSA representatives on IJA Council

What is Open Access? Historically, subscribers to a scientific journal received a hard copy of each issue. More recently, many journals have moved to an online system, which is available to subscribers only. The International Journal of Audiology (IJA) is available online but can only be accessed by subscribers to IJA and members of the organisations that own it: British Society of Audiology, International Society of Audiology and Nordic Society of Audiology. There is now a way for the public to view some IJA articles free of charge online and this is called ‘Open Access’ (OA). The potential benefits of OA are illustrated in the figure. How does one publish an article using Open Access? There are two ways that research studies can be made available via OA: 1. GOLD OA • This is where the final version of the publication is freely available to the public, via the publishers’ website, immediately on publication. • Publishers normally apply a charge to cover publication costs (typically around £2,000 per article) and this is paid by the funder of the research or, less commonly, by the author.

• Currently, around 5-10% of publications in audiology-related journals are available via Gold OA. 2. GREEN OA • This is where authors self-archive their research study via a repository belonging to, for example, a university or research institute. • Authors do not pay a fee but: (i) the version is usually the authors accepted manuscript at the point of acceptance by the editor and before it has been passed to the publisher for the final steps of publication, and (ii) there is a publisher embargo period, typically around 12 months from the date of first online publication for subscribers. What model of OA is used by the International Journal of Audiology? As of April 2016, the International Journal of Audiology has implemented a hybrid model of publication. This is where subscribers continue to have access to the online journal but some articles will also be available to the public via OA, either immediate/Gold OA or after a 12 month embargo period for Green OA. At least initially, it is anticipated that around 10% of articles will be available via Gold OA because this is typical of current audiology-related journals. Most of the major grant-awarding bodies make it a condition of the award that the research output is made available via OA. Some funders specify that this must be Gold OA while others allow Green OA. The policy of the Medical Research Council is that all publications must be made available to the public via OA, either immediate Gold OA or Green OA, the latter with an embargo period no longer than 6 months . The policy of the National Institute for Health Research is that the main research output from a funded study must be made available to the public using Gold OA and that all research output must be deposited in Europe PMC, a discipline-specific repository, within 6 months of publication. For comparison, the US National Institutes of Health require that all final peer-reviewed journal manuscripts that arise from NIH funds are submitted to PubMed Central immediately upon acceptance for publication (immediate Green OA). What are implications for the Research Excellence Framework? The Research Excellence Framework (REF; formerly known as the Research Assessment Exercise) is a method of assessing the research of UK higher education institutions. The REF is very important for universities and academics because the results determine how much research funding they are granted:

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23 FIGURE ILLUSTRATING THE BENEFITS OF OPEN ACCESS

(SOURCE: DANNY KINGSLEY AND SARAH BROWN, LICENSED UNDER CC BY 4.0)

a poor performance can close a department while a top rating means steady funding. To be eligible for assessment in the next REF, all publications will need to be OA with deposit in a repository within 3 months and an embargo period of no more than 12 months. While a BSA member who undertakes self-funded research does not need to use OA, they would not be able to enter their publication into the REF. Reference 1. The current fee for IJA is £1,788 (exc tax) but BSA members receive a 25% discount.

2.

Research Councils UK (RCUK; a Government body that manages the strategic partnership between the seven individual UK research councils) allocate a block grant to institutions to provide for the costs of Gold OA. Other funders allow for the publication fee to be included in the grant costs.

3.

Since IJA has an embargo period of 12 months, this journal will not satisfy the Green OA policy of the Medical Research Council.

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24

The latest news, information and reviews, in one place, to your door, free of charge; welcome to ENT and Audiology News! ENT & audiology

Gareth Smith, Audiology Editor of ENT and Audiology News Deputy Head Audiology Service, Southend University Hospital, UK

ISSN 2042-2156

SPECIAL FOCUS THE EAR ENT Endoscopic Ear Surgery – Page 35 AUDIOLOGY MATTERS What’s New? – Page 65

news

ENT & audiology news

Vol 25 No 2 May/June 2016

www.entandaudiologynews.com

ISSN 2042-2156

Special Focus

Patient-centred Care – Page 43

AUDIOLOGY MATTERS European Tinnitus Research Network (TINNET) – Page 71

ENT & audiology

Vol 24 No 6 January/February 2016 www.entandaudiologynews.com

ISSN 2042-2156

SPECIAL FOCUS Head and Neck Cancer: the Changing Landscape – Page 41

AUDIOLOGY MATTERS Caring for the World’s Hearing: Global Business Models in Audiology – Page 71

news

001 ENTMJ16 cover.indd 1

Many will be familiar with ENT and Audiology News but did you know it is now free to UK subscribers? No more scrabbling round to find a copy when it arrives, no more opening it to find your colleagues have cut out articles, no more searching through to find the course directory has already been highlighted. Your own copy, to your door, just for you!

ENT JF 16.indb 1

ENT & audiology news

22/04/2016 16:45

ISSN 2042-2156

SPECIAL FOCUS Evaluation and Management of the Dizzy Patient ENT - Page 39 AUDIOLOGY - Page 63

16/12/2015 15:53

Vol 24 No 5 November/December 2015 www.entandaudiologynews.com

ENT & audiology

ISSN 2042-2156

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This bi-monthly magazine brings you regular features and articles from contributors around the globe; both the regular section editors and the invited guest editors use their experience, expertise and interests to source some amazing contributors. From the basic scientist in the laboratory to the clinician in the clinic to the social scientist in the field; ENT and Audiology News draws them together to explore and consider the latest opinions and evidence.

Vol 25 No 1 March/April 2016

www.entandaudiologynews.com

01-105 ENTND15.indb 1

History of ENT – Page 37

AUDIOLOGY MATTERS Single-sided Deafness – Page 71 Vol 24 No 4 September/October 2015 www.entandaudiologynews.com

28/10/2015 10:03

Famous composer, Giacomo Puccini, who died of laryngeal cancer. See feature by Rosario Marchese-Ragona and Alessandro Martini, page 48.

ENTSO15_part1.indb 3

With regular sections featuring news from around the world, journal, internet and book reviews, hands-on technical guides, product reviews, opinion on training and of course our famous course directory, ENT and Audiology News really does prove to be a one stop publication. The magazine also provides an excellent platform to contemplate the current direction and synergies with our ENT colleagues for an all-round approach to research and patient care.” Follow this link to subscribe for free https://pinpoint3.typeform.com/to/qV4ZCJ

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lunch and learn

26

Lunch and Learn CD

Facilitators and Correspondence

Shahad Howe Clinical Scientist, Manchester Royal Infirmary

Christopher Cartwright Professional Marketing Manager, Phonak

E: Shahad.howe@cmft.nhs.uk

E: Chris.cartwright@phonak.com

BSA Lunch and Learn eSeminars

An exciting Series of online presentations covering current topics of interest and clinically relevant research findings in Audiology and related professions, free of charge to all BSA members.

Recent bites

Coming up on the menu

These and other earlier seminars are available to access at www.thebsa.org.uk (please note these are no longer available to non-BSA members). You may need to request connection through firewalls from your local IT department for your first eLearning experience.

To go live on the first Monday of every month for access by the emailed link, or archived at www.thebsa.org.uk (please note these are no longer available to non-BSA members).You may need to request connection through firewalls with your local IT department for your first eLearning experience.

January 2016

Dementia and Hearing Loss: the role of Audiology › Dr Sarah Bent, Principal Clincal Scientist (Audiology)

• University of Manchester Research Roundup • Dr Ann-Marie Dickinson – How to analyse a research paper

February 2016

Hyperacusis – Measurements, Mechanisms and Models › Roland Schaette, Senior Research Associate

March 2016

The UK Research Agenda for ENT, Hearing and Balance Care; patients and professionals have decided on the priorities for research in our field. › Anne G.M. Schilder, NIHR Research Professor

• Professor Ross J. Roeser – How to write a research paper

If you would like to contribute a seminar, have any queries or would like regular email updates, please email:

Chris.cartwright@phonak.com

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Guess who’s talking? An investigation of patient-centred communications in adult audiology consultations This short communication is based on the online BSA Lunch and Learn seminar by Caitlin Grenness, PhD, 05/10/2015. The recording is available on www.thebsa.org.uk. These studies were conducted by Caitlin Grenness, Carly Meyer, Katie Ekberg, Ariane Laplante-Lévesque, Bronwyn Davidson and Louise Hickson. Despite significant improvements in hearing devices and technology, rates of uptake and success with hearing rehabilitation remains poor. Recently, researchers have identified a gap in our understanding of the importance or impact of the patient-practitioner interaction and clinical processes such as decision making and the development of a therapeutic relationship. At a similar time, studies have found that non-audiological factors such as support from significant others, significantly impact success with hearing rehabilitation. Beyond audiology, the impact of the patient-practitioner interactions and social support has been, and continues to be, well researched. That is, the nature of communication between the practitioner and the patient, and involvement of family members, can influence outcomes (such as treatment adherence, satisfaction, quality of life). Together, these findings highlight the importance of exploring the nature of patient-audiologist interactions. Communication that occurs between patient and practitioner in a health consultation can occur on a spectrum from practitioner-centred to consumerist. In practitioner-centred consultations, typically the practitioner controls the agenda and decisions, and little time is spent building a relationship or engaging in psychosocial conversation; a consumerist consultation differs in that the patient controls the agenda and decisions. The middle ground between these two communicative styles can be termed ‘patient-centred’. Patient-centred care, in the medical and nursing context, broadly refers to a ‘meeting of two experts’ rather than doing what the patient wants; the expertise of both parties are acknowledged, the relationship is valued, and decisions are shared. Patient-centred care has become a popular term in hearing care and yet, beyond what can be learned from medicine and other areas of healthcare, we have little understanding of what it means in the context of hearing rehabilitation. In this presentation, we discussed the results of two studies where we first asked: what is patient-centred audiological rehabilitation? Followed by: does patient-centred audiological rehabilitation occur?

In the first study, we attempted to answer the first question. We interviewed ten older adults who had sought help for their hearing loss and who had varying experiences. We asked participants about their experiences and how they would define patient-centred hearing care. Analyses revealed four main themes: the therapeutic relationship; being informed; being involved; and, individualised hearing care. That is, participants valued their clinician having good interpersonal skills that extended beyond friendliness (i.e., genuine empathy and care) and that this was associated with trusting the audiologist. Participants reported the importance of bilateral information exchange; and, of having appropriate input into decisions, along with significant others, where possible. Ultimately, participants highlighted that no single equation would work for everyone. Instead, audiologists need to be flexible and get to know the patient well enough to know what may be appropriate for that individual. To answer the second question: does patient-centred hearing care occur?, we used the definition provided by the previous study and filmed 63 initial consultations between adults with hearing loss and audiologists where we could observe a) relationships being built; b) decision-making and c) exchange of information. These consultations were analysed using either the Roter Interaction Analysis System (RIAS) or Conversation Analysis (CA). In the 63 consultations there were 26 different audiologists and a significant other was present in 17. If we take all the results together, we can juxtapose key findings

INDIVIDUALISE

THERAPEUTIC RELATIONSHIP

INFORM

INVOLVE

Figure 1. Model of patient-centred care in audiological rehabilitation (from Grenness, C., Hickson, L., Laplante-Lévesque, A., & Davidson, B. (2014). Patient-centred audiological rehabilitation: Perspectives of older adults who own hearing aids. International Journal of Audiology, 53(S1), S68-S75.)

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28 on the results of the initial interview study. When exploring how relationships were built, we observed that audiologists often missed patients’ psychosocial concerns and offered little empathy where opportunities arose. In a number of instances, this resulted in a less efficient consultation as the patient re-presented their concern on multiple occasions. In terms of information exchange, audiologists asked the majority of questions and did the majority of the talking, relative to both patients and significant others (NB: significant others only contributed about 10% of the conversation, when present). This style of information exchange was seen in the history, and when hearing aids were discussed. Decision making processes typically involved hearing aids, and patients’ opinions where rarely directly sought, often in the interests of timeliness. Lastly, when audiologists were filmed on more than one occasion, consultations were very similar, suggesting that little individualisation occurred. In summary, these results indicate that there is an opportunity to optimise the patient-audiologist interaction which may have a significant impact on patient, audiologist and clinic outcomes. To make changes towards patient-centred hearing rehabilitation, we recommend audiologists consider observing their own practice and specifically reflect on: attending to psychosocial concerns; shifting away from a biomedical perspective;

sharing the control; and involving family members wherever possible. To find out more about the studies discussed here, please see the articles in the reference list for full details. References for further information on this research 1.

2.

3.

4.

Ekberg, K., Grenness, C., & Hickson, L. (2014). Addressing patients’ psychosocial concerns regarding hearing aids within audiology appointments for older adults. American Journal of Audiology, 23(2), 337-350. Grenness, C., Hickson, L., Laplante-Lévesque, A., & Davidson, B. (2014). Patient-centred audiological rehabilitation: Perspectives of older adults who own hearing aids. International Journal of Audiology, 53(S1), S68-S75. Grenness, C., Hickson, L., Laplante-Lévesque, A., Meyer, C., & Davidson, B. (2015). Communication Patterns in Audiological History-Taking: Audiologists, Patients and their Companions. Ear & Hearing, 36(2), 191-204. Grenness, C., Hickson, L., Laplante-Lévesque, A., Meyer, C., & Davidson, B. (2015). The nature of communication throughout diagnosis and management planning in initial audiologic rehabilitation consultations. Journal of the American Academy of Audiology, 26(1), 36-50.

Keep it simple! The impact of audiologists’ language on patients’ decisions to obtain hearing aids. This short communication is based on the on-line BSA Lunch and Learn seminar by Carly Meyer, PhD, 05/10/2015. The recording is available on www.thebsa.org.uk. This study was conducted by Carly Meyer, Anna Sciacca, Caitlin Grenness, Katie Ekberg, and Louise Hickson. There is growing recognition in the literature that older adult patients with hearing loss want to be involved in decisions about their hearing healthcare. The involvement of both the patient and the audiologist in the decision making process is referred to as shared decision making, and is a key component of patient-centred care. Obviously, for shared decision making to occur between the patient and the audiologist, the patient needs to understand the information presented by the clinician. For older adults with hearing loss, understanding can be impacted by their health literacy. Health literacy is defined as the ability to “access, understand, appraise, and apply health information in order to make judgements and take decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life …”

(p.3)1. Health literacy is lower in older adults compared to younger adults. Both written and spoken health information should be presented to patients in a way that can be easily understood. Previous research that has evaluated written materials (i.e., hearing aid user guides, information about hearing available on the Internet) has found the information to be overly com-

Figure 1: Image depicting the audiological jargon terms frequently used during audiology appointments.

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29 plex, with most information requiring a minimum of 8 years of formal education to read and understand 2-4. Comparatively less research has investigated the understand-ability of spoken information provided within audiology appointments; however, audiologists’ language has been reported to be more complex than that of their patients4, include audiological jargon5, and be very biomedical in context6. The aim of this study was to further build on our knowledge of audiologists’ use of language during audiology appointments and to explore associations between audiologists’ language in the appointment and patients’ decisions to obtain hearing aids by the end of the appointment. The participants included 25 audiologists and 62 patients who were attending an initial hearing assessment appointment; the patients were aged between 55 and 93 years (NB: we presented on a subsample of 58 adult clients for the Lunch and Learn Seminar; however, the results from the full sample of 62 patients will be reported here). All appointments were filmed using an Apple iPhone or iPod touch attached to a 15cm tripod, and later transcribed by a professional transcription service. First, to build on our knowledge of audiologists’ use of language during audiology appointments, we analysed the counselling phase of each of the transcripts for general language complexity and jargon use. General language complexity was analysed using Microsoft Word grammar summary statistics, including: • number of sentences, • number of words per sentence, • percentage of sentences in passive voice, • Flesch Reading Ease Score (scale 1-100), and • Flesch-Kincaid Reading Grade Level (RGL; years of education needed to comprehend text). Jargon use was analysed using a list of 33 jargon terms compiled by the research team and included: • total incidence of jargon, • number of different jargon terms, • number of terms not well clarified, and • percentage of terms not well clarified. Second, in order to explore associations between audiologists’ language and patients’ decisions to obtain hearing aids by the end of the appointment, we applied a multivariate, binomial logistic regression model to the data. The question was: Which variables were associated with the decision to obtain hearing aids?

using more complex language when describing test results and hearing aid options. Audiologists typically used between 3 and 4 different jargon terms per appointment and almost twothirds of these were not clarified. The most commonly used jargon terms were: high/low frequency, (hearing aid) channels, advanced directional microphone, mould, and decibels. Only one variable, Flesch-Kincaid RGL, was found to significantly influence patients’ decisions to obtain hearing aids (p = 0.007). Patients were more likely to obtain hearing aids when audiologists used less complex language during the counselling phase of the appointment. We found that a difference of one grade level influenced patients’ decisions to obtain hearing aids by the end of initial hearing assessment appointments. In summary, our results indicated that audiologists should consider using simple language and shorter sentences to facilitate better patient understanding of hearing rehabilitation options. This will promote shared decision making and may result is better hearing aid uptake rates. A full manuscript, based on these results, will be submitted for publication in 2016. References 1.

2.

3.

4.

5.

6.

Sørensen K, Van Den Broucke S, Fullam J, et al. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health. 2012;12(1). Caposecco A, Hickson L, Meyer C. Hearing aid user guides: Suitability for older adults. International Journal of Audiology. 2014;53(S1):S43-S51. Laplante-Lévesque A, Thorén ES. Readability of internet information on hearing: Systematic literature review. American Journal of Audiology. 2015;24(3):284-288. Nair EL, Cienkowski KM. The impact of health literacy on patient understanding of counseling and education materials. International Journal of Audiology. 2010;49(2):71-75. Watermeyer J, Kanji A, Mlambo N. Recall and understanding of feedback by adult patients following diagnostic audiological evaluation. International Journal of Audiology. 2015;54(10):758-763. Grenness C, Hickson L, Laplante-Lévesque A, Meyer C, Davidson B. The nature of communication throughout diagnosis and management planning in initial audiologic rehabilitation consultations. Journal of the American Academy of Audiology. 2015;26(1):36-50.

Our results indicated that most audiologists involved in this study used relatively simple language that could be understood by a patient with less than 5 years of formal education (average RGL = 4.80). Importantly, however, there was a lot of variability within and across appointments, with some clinicians

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The Research Agenda for ENT, Hearing and Balance Care: Opening Opportunities for Research N Bohm, A Reid, A Schilder The UK research agenda for ENT, Hearing and Balance care was launched last December at a public event well attended by national health policy-makers, research funders, industry, researchers, healthcare professionals, patients and members of the public. The diverse audience reflected the broad engagement of all groups in the process of setting the research priorities for ENT, Hearing and Balance care. The agenda is the outcome of the GENERATE initiative, the research priority setting exercise designed and run by the evidENT team at UCL and commissioned by ENT UK, the BSA and the BAA. The aim of GENERATE was to decide which questions around the care of people with ENT, Hearing and Balance problems are most in need of research. This has resulted in an agenda focused on developing patient-centred research leading to sustainable, high value health care. The research priorities span a wide range of ENT, Hearing and Balance problems and the different age groups affected by them. The agenda balances research priorities focused on improving existing treatments and services with those around developing novel approaches such as molecular and cell-based therapies for hearing loss and loss of other senses such as balance and smell. Patients feel it is important that there is research into self-management and peer support, in particular for those suffering from dizziness. The agenda can be accessed at http://www.ucl.ac.uk/ear/evident/projects/research_agenda or at http://www.thebsa.org.uk/category/news/ and following the GENERATE link. Having national attention from research funders and health policy-makers, the GENERATE research agenda presents a critical opportunity for clinicians and researchers to engage with patients and develop the prioritised areas into deliverable research projects. The clinical and academic communities need to consider who is best placed to adopt each research priority, and to build on the collaborations that have been initiated through the prioritisation process. Ideas for moving this forward include: organising multidisciplinary workshops to refine research questions and design the projects to answer them; supporting the ENT trainee research collaboratives to develop their multicenter trainee led studies; liaise with your local NIHR Clinical Research Network ENT Specialty Lead and let him/her know you are interested in identifying and recruiting patients to studies; using the agenda to apply for fellowship or project funding and negotiate for local resources.

To facilitate this, ENT UK and evidENT are developing the MomENTum database of groups and people currently active in ENT, Hearing and Balance research in the UK and the areas of research they are working on. This public database will provide a ‘UK map of ENT, Hearing and Balance research’ that will be a valuable resource for the research community; it connects those seeking experts and collaborators, and will help our professional organisations to identify the research areas in which capacity and capability need to grow. All researchers are invited to submit their information to the database by accessing the link at http://www.thebsa.org.uk/momentum-mapping-uk-research-activity-in-ent-hearing-balance/ Importantly, the research agenda belongs to the ENT, Hearing and Balance community of patients, carers, clinicians, researchers and funders. We encourage everyone involved in the care of patients with ENT, Hearing and Balance problems to read the agenda and consider how they can contribute to developing and delivering the research that will underpin our future clinical practice.

How can you help take the ENT, Hearing and Balance research agenda forward? • Organise or take part in a workshop to develop one of the priorities into a research project • Strengthen your next funding application by referencing the research agenda and how your project addresses a priority • Join MomENTum, the online database of ENT, Hearing and Balance researchers, showcase your research profile and get connected to those looking for research expertise or collaborators. Access MomENTum at http://www.thebsa.org.uk/ momentum-mapping-uk-research-activity-in-ent-hearing-balance

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Jan 2016 Issue.qxp_Layout 1 14/01/2016 21:11 Page 1

Coming soon CROS II and Tinnitus Solutions from Phonak

Phonak are proud to announce our new CROS II and Tinnitus Solutions are coming on contract shortly however, you can order direct through your Sales Manager. CROS II features the unique Phonak Binaural VoiceStream TechnologyTM, wirelessly transmitting the sound from the unaidable ear to a the hearing aid on the better hearing ear. The Phonak Tinnitus Solution consists of three key elements of tinnitus management; hearing aids, broadband noise generator and further sound therapy via an app. All our tinnitus products come with a patient management pack to help you support your tinnitus patients further and two free receivers of your choice!* Terms and conditions apply. Please speak to your Regional Sales Manager

*

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32

Ear to the ground

for all things ear-related in the media This edition of Ear to the Ground covers a broad range of topics. There is a nod to some of the pressing matters of the time, for example the link between hearing loss and dementia, or the lack of hearing aid uptake in the UK. There are also some lighter articles including employees who have gone the extra mile for their profoundly deaf customers. In her Twitterarty article, Amanda Hall gives a focus on some tweets from the vestibular world, as well as a focus on the #Wecommunities and a roundup of tweets from conferences and meetings.

Hearing loss dementia risk confirmed

The Daily Mail is among many media outlets to report on Frank Lin’s finding that hearing loss exerts an effect on the risk of dementia that is not solely being driven by a correlation from a common cause. The commentary given by this paper outlines the results of the study and considers the implications in the current climate of cuts to hearing aid provision in the NHS. There are quotes from the chief executives of Action on Hearing Loss and the Ear Foundation, paraphrasing their position statements on adult hearing provision. Quotes from Dr Lin clarify that it is still unknown whether improved hearing aid provision will slow cognitive decline, though the tone of the article suggests this will be the case. Read the Daily Mail’s article at http://www.dailymail.co.uk/wires/pa/article-3446885/Scientists-probe-links-hearing-loss-dementia.html

AC/DC frontman dropped over hearing loss

Another story which has been widely reported is that AC/DC had to postpone several gigs on their current tour because frontman Brian Johnson risked “total deafness” if he continued to perform. He has since been replaced on the tour by Guns’n’Roses singer Axl Rose. Quotes in the Daily Mail explain that Johnson is “personally crushed” but that he is “hoping that in time my hearing will improve and allow me to return to live concert performances”. Whether he is experiencing significant temporary threshold shifts or permanent outer hair cell damage is not clear. Some commentators, such as Eddie Trunk, have refuted the claims that hearing is the cause of Johnson’s withdrawal. His opinion is reported at http://www.dailymail.co.uk/tvshowbiz/article-3547642/Musicblogger-claims-Brian-Johnson-68-left-AC-DC-didn-t-want-work-hard-younger-bandmatesfans-complain-Axl-Rose-taking-place.html. The main article in the Daily Mail is available at http://www.dailymail.co.uk/wires/reuters/ article-3548424/AC-DC-frontman-says-crushed-hearing-loss-not-retired.html.

Facebook “f ” Logo

CMYK / .eps

Facebook “f ” Logo

CMYK / .eps

Don’t forget that any piece that appears on a news website can be commented on or shared via social media, allowing the reader to add their voice to a debate and pass the story to friends and colleagues.

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33 Royal Opera House sued over noise-induced hearing loss

The BBC News website recently highlighted a case in which a viola player is suing the Royal Opera House for hearing loss which is reported as a permanent threshold shift caused by brass instruments directly behind him. The website reports that sound levels during Wagner’s “Die Walklure” peak at 137dB, and the musician believes this is what has caused his hearing loss and subsequent hyperacusis. An interesting side-note to this case is that one of the strands of the Royal Opera House’s defence is that the artistic beauty of the piece justifies the disability. This is something as yet untested in UK law. From an Audiology point of view, it is pleasing to see professional noise induced hearing loss thrust into the limelight.. Read more at http://www.bbc.co.uk/news/entertainment-arts-35938704.

Health Survey back up Action on Hearing Loss data on untreated hearing loss

The BBC reported on the results of England’s annual health survey, which for the first time has compared participants’ perception of their hearing with audiometric thresholds. Unsurprisingly, the results back up widely quoted statistics from the charity Action on Hearing Loss, suggesting that almost 6 million people in the UK have some form of hearing loss, and that less than a third of adults with a hearing loss use any form of aural rehabilitation. The piece alludes to some of the possible negative consequences of untreated hearing loss, but perhaps this is something which could have been explored further to encourage readers who may need a hearing aid to seek help. The BBC report on the findings can be accessed at http://www.bbc.co.uk/news/health-35112343.

Nice explanation of motion sickness

The Independent responded to reports that Chris Evans, one of the new presenters of BBC2’s Top Gear, was spotted looking a little carsick after a ride, by writing an article on the theory behind motion sickness. The explanation of the conflict theory is nicely put and easy for lay readers to understand, with enough science to reassure healthcare professionals. However, the explanation of why treatments work is a little less scientific. The explanation of why focussing on a point above the horizon is helpful may be clear, but the ensuing list of potential remedies doesn’t go into any detail of the mechanisms of recovery. However, it’s clear that anecdotally, some people find each treatment helpful, so for a motion sickness sufferer, it does provide plenty of options Read the piece at http://www.independent.co.uk/life-style/health-and-families/health-news/car-sickness-the-scientificway-to-beat-nausea-while-travelling-a6859156.html.

Noise Exposure concern for Deaf music festival

In an article with a much more scandalous headline than its content, the Mirror reports on a festival for the Deaf which may be cancelled because of fears about nuisance noise. However, when the article is read, the noise fears are not specifically because the festival is aimed at the Deaf community, but because a previous festival (for the hearing population!) in the same village had caused a problem for locals. It also turns out that the numbers advertised on the website for the festival are significantly higher than those in the application for a festival licence. Perhaps this story is a bit of a storm in a 2cc coupler, but interesting nevertheless. The article is available at http://www.mirror.co.uk/news/uk-news/festival-deaf-people-faces-ban-7331817.

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34 “Was my deaf baby disabled?”

In a thought provoking article in the Guardian, an Australian mother provides an insight into the conflicts of early implantation for a parent of a profoundly deaf baby. She compares the overwhelming academic evidence that early implantation leads to better speech and quality of life outcomes with the opinions of some within the Deaf community that cochlear implants amount to the genocide of Deaf culture. The article contends with issues such as a child’s “critical window” for speech development, as well as the perception that Audiologists may treat children with a hearing loss as pathologically deficient to normally hearing children. She comes to the conclusion that her own child’s wellbeing is paramount, and it is interesting to hear a parent’s perspective on a diagnosis of hearing loss. The article is available at http://www.theguardian.com/commentisfree/2016/mar/25/was-my-deaf-baby-disabled-if-so-ifelt-an-overwhelming-urge-to-fix-her.

Cochlear Implant processor returned after it was lost on the beach

The Mirror recently posted a heartwarming story on its website about an 8 year old girl who was reunited with her Frozen cochlear implant processor after losing it on the beach. Darcie Pallister lost the implant on Scarborough beach and her mum was asked by her Audiologist to make every effort to find it. She posted an appeal on social media, which was picked up by lost-and-found site Lostbox, and after seeing the post, a retired gentleman decided to comb the beach once more. He found the device not far from where Darcie had been playing, allowing her Audiologist to send it to be refurbished to offset the cost of the replacement. There is a beautiful picture of Darcie’s thank you card to Dominic Roe, who found the processor. See this and read the article at http://www.mirror.co.uk/news/uk-news/stranger-reunites-deafgirl-aged-7654701.

Learning sign language for your customers

Finally, two stories have recently appeared of employees who have gone the extra mile to put a smile on their customers’ faces. The first comes from Disney World in Florida, where Tinkerbell addresses a deaf 4 year old child in sign language. The footage is caught on camera, and the girl is delighted. The Sun report that she was also asked back three years later, and greeted by Minnie Mouse, who explained that she is also learning to sign. The girl coolly replies, “good job, that’s great!” The video and an accompanying article is available at http://www.thesun.co.uk/sol/homepage/ features/7080459/A-deaf-girls-dreams-come-true-when-Tinkerbell-starts-talking-to-her-in-signlanguage-at-Disney-World.html.

We also have the story of a Starbucks barista from Virginia who learned American Sign Language “so that you can have the same experience as everyone else”. The stunned regular customer of the branch took a photo of the note he was given and shared in on social media. The picture went viral and has been fantastic publicity for the Deaf and hearing communities working together. Below is a link to one of the many articles highlighting the gesture https://www.washingtonpost. com/news/local/wp/2016/02/22/this-starbucks-barista-learned-sign-language-to-communicatewith-her-deaf-customer

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35

Twitterarty @HallAmandJ introduces you to the audiology Twitter community

#WeCommunities is a way of connecting with other healthcare professionals on twitter. The aim of #WeCommunities is for healthcare professionals within professional groups to virtually meet and discuss topics. They host regular tweet chats which are scheduled every week or few weeks at specific dates and time. Each chat has a title and includes guest tweeters.

This edition of Twitterarty looks at recent twitter feeds of some of the charities and organisations supporting people with hearing loss, tinnitus and balance problems. We focus on tweets relating to campaigns as well as those promoting events and resources for patients and professionals.

The #WeDocs recently discussed “Patients as partners”. The discussion included: Jarrod McMaugh MPS @pharmefour . Dec 16 @WeDocs #WeDocs what’s the most effective way to emplower patients in health so that we cater their choices, not tell them what to do Leigh Kendall @leighakendall @pharmerfour @WeDocs ask them! Create ways for pts to feedback - listen when 1-1, graffiti boards, tops & pants - be innovative #WeDocs TinyTonyH @TinyTonyH . Dec 16 @pharmefour @We Docs “most effective way to empower patients”? Write your notes to the pt for the pt #WeDocs #wedocs Dr Kit Byatt @Laconic_doc Get them to set agenda? MT @TinyTomyH: “most effective way to empower patients”? Write your notes to the pt for the pt #WeDocs #wedocs WeDocs @WeDocs Q3. What has worked well and how we achieved it? This Q will be led by @Irisbenson1004 #WeDocs

You can follow different community groups on twitter to find out about the chat topics planned and news relevant to the professional group. Of relevance to members of BSA is @ WeAHPs and their tweet chats #WeAHPs (the #WeAHPs group uses a broad definition of AHPs, which includes audiology, defined as “healthcare professions distinct from nursing, medicine and pharmacy”) and @WeDocs and their tweet chats #WeDocs.

Karen @KarenPharm @WeDocs Recovery college’s where peer & practitioner trainers work together to deliver courses to service users, carers & staff #WeDocs

The @WeAHPs chatted about the public health impact of AHP work. WeAHPs @WeAHPs . 7h TONIGHT! Join @HindleLinda @R_S_P_H on measuring the public health impact wecommunities.org/tweet-chats/ ch...#WeMDT

Other groups of interest include • @WeNurses and their chats #WeNurses • @WeCommissioners and their chats #WeComsers • @WeHVs and chats #WeHVs • @WeSpeechies and chats #WeSpeechies • @WeLDnurses and chats #WeLDNs

You can find out more about the different communities and read the chat archives at: www.wecommunities.org

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36 Looking at the vestibular and balance tweeting, there have been tweets about recently published research studies: Donncha Lane PT @DonnchaLanePT . Feb 28 Using the Physical Examination to Diagnose Patients with Acute Dizziness and Vertigo buff.ly/21zunw5 Nice overview of vestibular ax.

Tweets from the debate included: David Herdman @DavidRHerdman . Feb 25 The results are in! Pleasure to present at #bigbalancedebate today..

Hearing Review @HearingReview . Jan 28 3.3 million US children have dizziness, according to survey findings from @NIDCD. #audpeeps #vestibular #balance ow.ly/XEfWn

JAMAOtolaryngology @JAMAOto . Feb 29 Can we predict the #vestibular Dx in pts based on a structured intake questionnaire? ja.ma/1mXLQ1C

David Herdman @DavidRHerdman .Feb 25 Do calorics still have a place in vestibular testing? 100% agreement here! #bigbalancedebate

Lots of tweets from the neuro section of the American Physical Therapy Association conference (#CSMneuro and #APTACSM)

Donncha Lane PT @DonnchaLanePT . Feb 27 Hot off the press: #Vestibular Rehab for Vestibular Hypofunction: An Evidence-Based CPG buff.ly/1QDb0Kx buff.ly/1QDb10V

Vestibular Rehab SIG @VestibularRehab . Feb 19 Patients with anxiety and depression get better too! #CSMNeuro #APTACSM

Useful resources and information: EMBalance @em_balance . Feb 3 How to preform vestibular testing - 19 educational videos released! #EMBalance #FP7 Follow the link: youtube.com/channel/ UCXFf9... Balance Course 2016 @AdvBalance . Feb 11 Yes this little app is good. ACPIVAR @acpivr thanks Nova! titter.com/novamullin/sta...

Vestibular Rehab SIG @VestibularRehab . Feb 18 A special edition publication on vestibular function testing is up to view o the website. Check it out: neuropt.org/sepcialintere.

Tweets about recent conferences and meetings: ACPIVA @acpivr . Jan 28 ACPIVR members are invited to this exciting event courtesy of Interacoustics UK #BigBalanceDebate

Vestibular Rehab SIG Retweeted Center for Balance @cincibalance .Feb 20 Along with a functional risk of fall assessment! #somatosensory #visual #vestibular #howwekeepourbalance Vestibular Rehab SIG @VestibularRehab vHIT should be considered in annual exams in the elderly to assess vestibular function #APTACSM #CSMNeuro

Vestibular Rehab SIG @VestibularRehab . Feb 18 Laura Morris suggests using the Migraine Assessment Tool (Marcus 2004) to evaluate for migraine related dizziness #CSMNeuro

Vestibular Rehab SIG @VestibularRehab . Feb 18 #CSMNeuro Rob Landel is discussing the importance of preprioception retraining in cervicogenic dizziness

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The Perfect OAE+ABR Combination

Sample Otoport OAE+ABR screens

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Building knowledge in professionals: Learning Events and CPD opportunities – Be the best you can be

The BSA is the leading UK organisation for all professionals integrated in the latest science and its application in improving people’s lives with hearing and balance. Both members and non-members can access a range of learning opportunities with the BSA. We are an internationally respected source of scientific and clinical knowledge, expertise and advice. We provide opportunities for a greater exchange with multi-disciplines discussing and exchanging ideas and this exchange can be a catalyst for great things to happen scientifically and clinically.

The aim of our learning opportunities is for changes in practice to occur to ultimately increase the impact professionals have and play in the lives of people with hearing loss. Our resources are accessible, vibrant and relevant across all disciplines and for whatever point you are at in your career. They are available in different locations across the UK with virtual options.

See some examples of different resources we provide listed on the adjacent page >>

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BSA Resources 

clinically relevant research findings in audiology and related professions, which are emailed directly to BSA members. They last around 20 minutes and are designed for you to maintain your CPD at accessible times.  Previous titles include:  “Keep it simple! The impact of audiologists’ language on clients’ decisions to obtain hearing aids” Carly Meyer, Communication Disability Centre at The University of Queensland  “How patient-centred are initial audiological rehabilitation consultations? An investigation of audiologistpatient communication” Caitlin Grenness, HEARing Cooperative Research Centre in Australia and is affiliated with the Communication Disability Centre at the University of Queensland  “Paediatric Vestibular Assessment” – Dr Devin McCaslin, Vanderbilt Bill Wilkerson Center in Nashville  For more information please log on to www.thebsa.org.uk/lunchlearn

Journal Clubs – An intimate gathering to discuss and perform a detailed critique of three publications concerning a

particular theme. Facilitators enable discussion to take place on the scientific design of the studies, the reliability of the data, the conclusions drawn and implications for clinical practice. All participants read the papers in preparation and have to be willing to engage in discussion.  Previous topics include:  Dementia and Hearing Loss  Hearing Screening

Twilight Meeting Series – An evening meeting on a range of themes across the UK.

Previous topics include:  Does Auditory Verbal Therapy have a role in Paediatric Habilitation?  Comorbidities of hearing loss: impact of dementia, diabetes and visual impairment

Research Round Up e-Seminars – These are quarterly webinars from each of the large research centres across the UK,

summarising the work they are undertaking. Each webinar has six speakers speaking for 10 minutes on their work. Choose who you want to listen to through links sent directly to BSA members.  Example research centres include:  Nottingham Hearing Biomedical Research Unit  University of Manchester  Institute of Hearing Research  University College of London Ear Institute  University of Southampton  For more information please log on to www.thebsa.org.uk/events/category/research-roundup

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>>

Lunch and Learn e-Seminars – This is an exciting series of online presentations covering current topics of interest and

Special Interest Group Events – The BSA has a range of Special Interest Groups who run events across the UK on areas of importance for each group. Some of these events are 1-day conferences and some are more practical, hands-on workshops.  Previous examples include:  APD - Auditory Processing Disorder, Information Day For Families & Professionals  Balance Interest Group Biennial Conference  Paediatric Audiology Interest Group Annual Conference  Electrophysiology SIG – Cortical Evoked Potential Measurements In Children and Adults

For more information on all current BSA Learning Events please visit www.thebsa.org.uk/events/event or contact the BSA: Blackburn House | Redhouse Road | Seafield | Bathgate | EH47 7AQ Tel: 0118 966 0622 | Fax: 0118 935 1915 bsa@thebsa.org.uk

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What causes a sloping ABR? CD

Author and Correspondence Guy Lightfoot PhD ERA Training & Consultancy Ltd E: admin@eratraining.co.uk W: www.eratraining.co.uk W: www.abrpeerreview.co.uk

Take-home message The slope or curve sometimes seen in an ABR waveform appears to be related to the artefact rejection level. An initial suspicion that the ECG was the cause has been confirmed.

Those of us involved in recording auditory brainstem response (ABR) waveforms will recognise the problem: every so often we record a waveform with a slope or a curve that can make interpretation difficult. In the case of adult ABRs at rates of over 30/s we sometimes, rightly or wrongly, attribute this to the middle latency response (MLR) evoked by the preceding stimulus but that explanation is unlikely in newborns whose MLR is immature. Figure 1 is an example of a sloping ABR. There is a typical clear response (CR) at 50 dBnHL and a response absent (RA) at 40 dBnHL but both are upward-sloping. Whilst these interpretations are not in serious doubt, the 40 dB waveforms do not strictly meet the NHSP guidance relating to interpretation, which includes a requirement for RA waveforms to be “appropriately flat”. Cardiac Activity and the ABR In the raw “EEG” data used for a study into the effects of artefact rejection level (Lightfoot & Stevens, 2014) several records

Figure 1: Example of a sloping ABR recorded in a 4-week old baby (CR =clear response; RA = response absent)

contained obvious cardiac activity (ECG). It was considered possible that the rejection of ECG beats by the artifact rejection facility might in some way underpin the origin of sloping ABR baselines. Consider the example in Figure 2 of the ECG as recorded by ABR electrodes and 30-1500 Hz filters (which are fine for ABR but obviously not ideal for ECG). The upper trace shows the incoming activity from the electrodes and although we refer to this as the “EEG” in this example this is an obvious misnomer as it is in fact dominated by the ECG. The numbers at the top show the elapsed time of the recording in seconds. The vertical scale of the upper trace is such that full scale is ±40 µV (which was the artefact rejection level used when acquiring the raw

Figure 2: Upper trace: incoming ”EEG” containing cardiac activity. Lower trace: ABR stimulus trigger pulses.

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41 data). Three heartbeats are apparent in this figure, the heart rate being 143 beats per minute – typical for newborns. Some non-ECG myogenic activity is also evident after the 2nd beat and buried in the waveform is true EEG and, too tiny to see, an ABR response. The lower trace shows ABR stimulus trigger pulses generated by the ABR system; these were recorded so that the ABR could be re-averaged using a variety of recording parameters. A stimulus rate of 49.1/s was used so the time between trigger pulses is 20.37 ms. In this example there is on average one heart beat every 20.53 stimuli and this particular ECG is so large that each beat causes 3 out of 20-21 ABR epochs to be rejected if a 5 µV rejection level is used and 1 of 20-21 ABR epochs to be rejected if a 10 µV rejection level is used. Three considerations emerge. The first is that the trailing edge of each heart beat is likely to be below the artifact rejection level and so has the potential to contaminate the averaged ABR. The second is that this contamination will vary depending on the size of the ECG and the artifact rejection level we use.The third is that the ECG is not synchronous with the ABR stimulus and we cannot predict the point (the latency) within our ABR recording epoch at which the peak of the ECG will occur. We would therefore expect any such ECG contamination to cancel out in an averaging period comprising several thousand stimuli. So much for theoretical considerations; what do we see in practice? The effect of artifact rejection level on ABR waveform slope The raw “EEG” data used by Lightfoot & Stevens (2014) comprised 100 samples of 61 seconds each (3000 sweeps) with varying degrees of myogenic noise. In the current study, the 47 lowest noise samples were re-averaged using artifact rejection levels of 5, 7 and 10 µV. For each average, the slope of the ABR was measured (the voltage difference in the waveform at latencies of 0 & 19 ms). Air conduction tone pip stimuli at 4

Figure 3: A case in which relaxing the artefact rejection level causes a downward baseline slope.

kHz were used. All other recording parameters were in accordance with current NHSP guidance (Sutton & Lightfoot 2013). For the purpose of this analysis any slope less than 50 nV was considered to be insignificant and was ignored. For each sample the typical size, polarity and asymmetry of any ECG component was noted. Summary of observations: • The mean heart rate was 138 beats per minute (SD 15; max=162; min=93). • 9/47 had no visually identifiable ECG in the record, but 38/47 did. • Of the 9 with no apparent ECG, none had an ABR slope of >50 nV at any of the artifact rejection levels. This might suggest that the ECG is implicated in the creation of a slope. • 26/47 had a significant slope when using an artifact rejection level of 5 µV. • 2 cases had a significant slope yet their ECG was not large enough to cause consistent rejections even at the 5 µV level. This then would suggest that ECG is not involved in the creation of a slope but occasional bursts of myogenic noise may have caused ECG rejections in a minority of epochs containing an ECG beat. Figures 3 and 4 are examples of cases in which changing the artifact rejection level leads to a change in slope of the ABR waveform. In these figures the waveforms were aligned at time = 0 ms. Green waveform shows the ABR waveform for a 5 µV artifact rejection level.: In Figure 3 changing the artifact rejection level from 5 µV to 10 µV resulted in a downward slope whereas in Figure 4 the opposite occurs with the downward slope reducing from 5 µV to 10 µV, with 7 µV being intermediate.

Figure 4: A case in which relaxing the artefact rejection level causes a reduction in the downward slope.

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42 More detailed analyses were attempted with the aim of identifying any characteristic of the ECG that resulted in a sloping ABR. Parameters included the size, polarity and asymmetry of the ECG and its slope in the 10-30 ms period following the point at which rejection occurred. The direction and magnitude of the slope were considered. Unfortunately, no clear relationship between ECG characteristics and ABR slope could be established beyond the summary statistics described above. A summary of this study was presented at the annual BSA conference in April 2016, at which time the origin of the effect was unconfirmed. In the Q & A session that followed it was suggested that the ECG beats of the raw data be edited out and the analysis repeated.The following day this was tried, using

two cases in which the effect of artifact rejection level on ABR was most pronounced. This involved manually deleting about 50-60 ms sections of data containing each beat. The data (both edited and unedited) was then low-pass filtered at 1 kHz to remove any transient step in voltage caused by the deletion. In Figure 5 the left panel is the original data, containing ECG and shows a clear change in ABR slope as the artifact rejection level is changed from 5 µV to 10 µV.The right panel is the same data with the ECG removed. It is clear that the effect has disappeared. The same effect was seen in a second case investigated. Further cases are currently being assessed to ensure this finding was not spurious.

Figure 5: The effect of changing artifact rejection is clearly evident (left panel) but when ECG beats were manually edited from the raw data the effect disappears (right panel).

Where does that leave us? It is likely that the slope we sometimes observe in an ABR waveform is related to the artifact rejection level we apply and it is the presence of cardiac activity that appears to be the responsible mechanism. There are no practical steps we can take to reduce the extent of cardiac activity picked up by our ABR electrodes but when we do record a sloping or curved ABR waveform, changing the artifact rejection level from 5 µV to 10 µV, even if the baby is settled, may help our interpretation in some cases. Testers are encouraged to try this tactic whenever they encounter a sloping ABR waveform; it would be very helpful to collect more data on this and send suitably anonymised waveforms to the author. Increasing the artifact rejection level will naturally allow more noise to enter the average but the consequences of this will be largely mitigated by the application of Bayesian averaging, which is recommended for those with this facility. Indeed, there is a good argument to routinely adopt an artifact rejection level of 10 µV in systems offering Bayesian averaging. For those without Bayesian averaging, the use of a 10

µV artifact rejection level should be combined with an appropriate increase in the number of sweeps and the repeated and immediate use of the pause facility to minimise the destructive effects of intermittent myogenic noise.

Acknowledgement: Thanks to Sebastian Hendricks for his suggestion to remove ECG beats from the raw data. References 1. Lightfoot, G. & Stevens, J., 2014. Effects of artefact rejection and Bayesian weighted averaging on the efficiency of recording the newborn ABR. Ear and Hearing, 35(2), pp.213–20. 2. Sutton G and Lightfoot G (co-editors), 2013. Guidance for Auditory Brainstem Response testing in Babies, Version 2.1, March 2013, Available at: http://www.thebsa.org.uk/ wp-content/uploads/2014/08/NHSP_ABRneonate_2014. pdf.

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Cerebellar Ataxia with Neuropathy and Vestibular Areflexia Syndrome (CANVAS) CD

Author and Correspondence David Szmulewicz Royal Victorian Eye and Ear Hospital, 32 Gisborne St, East Melbourne, Victoria, Australia 3002 E: dsz@me.com

Take-home message CANVAS is a recently described balance disorder that affects the vestibular system, brain co-ordination centre (cerebellum) and the nerves that carry feeling from the limbs

Biography Dr David Szmulewicz is a Neurologist, Neuro-otologist and medical researcher. He holds a PhD from the University of Melbourne. His clinical and research interests include balance disorders that affect the vestibular system, cerebellum, and the combination of the two. He is Head of the Balance Disorders & Ataxia Service at the Royal Victorian Eye & Ear Hospital, consults at the Balance Disorders Clinic at Epworth Camberwell, and is Honorary Consultant Neurologist at St Vincent’s Hospital and Lecturer at Melbourne University. David is lead investigator on research defining a novel ataxia – Cerebellar Ataxia with Neuropathy and Vestibular Areflexia Syndrome (CANVAS) and is co-director of The Australian Temporal Bone Bank. Cerebellar Ataxia with Neuropathy and Vestibular Areflexia Syndrome, or CANVAS, is a recently discovered balance disorder with 3 key components: (1) cerebellar impairment, (2) bilateral vestibular hypofunction and (3) a somatosensory deficit1. Let’s look at each of these in turn. The functions of the cerebellum include co-ordination and balance. Clinically, cerebellar ataxia may manifest in a number of ways including speech, swallow and limb incoordination, but for our purposes, it is the eye movement or oculomotor abnormalities that are most relevant. These abnormalities include saccadic (or broken up) visual pursuit, abnormal vestibulo-ocular reflex (VOR) suppression and gaze evoked nystagmus amongst others. A bilateral peripheral vestibulopathy means that the inner ear balance system (akin to the accelerometers in our smart phones which allow them to sense movement) are underactive and this is

the second component of CANVAS. The third component of CANVAS is that of reduced feeling in the feet, legs, hands and arms. Broadly speaking there are 3 causes of an ataxic gait: cerebellar, vestibular and sensory. So, one can see that CANVAS patients have all 3 reasons for having an ataxic gait. It then follows that vision is the only prop of normal balance that remains unaffected by CANVAS and with this we can understand why these patients are so visually dependent and why the patient’s imbalance is so much worse in poorly lit situations. This triad of cerebellar, vestibular and somatosensory impairment may also be seen in a handful of uncommon neurological conditions such as Friedreich’s ataxia and spinocerebellar ataxia type 3, which can be excluded by simple genetic tests that a neurologist will order2. An accurate diagnosis of CANVAS relies on audiologists for confirmation of bilateral vestibular hypofunction and central or cerebellar eye movement abnormalities. An abnormal VOR has traditionally been assessed via bi-thermal caloric irrigation, however for reasons of accuracy, patient comfort and clinical efficiency, this modality is increasingly replaced by the video Head Impulse Test (vHIT)3 (Fig 1). The rotational chair may also play a role here. Further confirmation of the extent of vestibular involvement may be garnered from the results of otolith organ testing (utricle and saccule) with tests such as Vestibular Evoked Myogenic Potentials (VEMPs). The occurrence of false negative results on the clinical HIT means that we perform vestibular function tests on all suspected CANVAS patients4. Hearing is not affected by CANVAS5. Interestingly, the primary site of vestibular pathology in CANVAS is neither the hair cells nor the vestibular nerve it is the vestibular (or Scarpa’s) ganglia6. Ganglia act as small relay stations within the nervous system and allow for added control from other parts of the nervous system.Temporal bone or otopathology has found a very marked reduction in the number of these cells6 (Fig 2). It was this finding that prompted further research to uncover the cause of the loss of sensation in the limbs to be the same pathology - reduced ganglia cells of the spinal cord (called dorsal root or spinal ganglia)7. The cochlear and its associated nerve are microscopically intact in CANVAS (Fig 2). The combination of cerebellar and bilateral vestibular impairment also results in an abnormality of the visually enhanced vestibulo-ocular reflex (VVOR)8. Clinically, the VVOR is tested by having the patient stare at an earth fixed target, such as the clinician’s nose, whilst the clinician passively moves the patient’s head at 0.5 – 1 Hz. This is generally assessed in the

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Figure 1. Video head impulse test (top panel). Black trace is head movement, red trace is eye movement. Marked reduction in VOR gain is seen bilaterally. Abnormal (saccadic) video VVOR (bottom panel).

Figure 2. Top panel: normal vestibular and cochlear nerves (left) compared to an atrophic vestibular nerve in the CANVAS patient (right). Lower panel: marked reduction in vestibular (Scarpa’s) ganglion cells (right) in comparison to a normal Scarpa’s ganglion (left)

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45 horizontal plane and so, the patient’s head is slowly rotated left and right. The abnormal VVOR produces saccadic - broken up or jerky -eye movement as opposed to the normally smooth eye tracking. This remarkably simple test to perform is only abnormal when the vestibulo-ocular reflex (VOR) and two cerebellar reflexes, the optokinetic reflex (OKR) and smooth pursuit (SP), are malfunctioning. Hence, patients with CANVAS have an abnormal VVOR9,10. Similarly to VOR testing, the VVOR can be assessed clinically but we find it very helpful to use an infra-red video-oculography (IR VOG) unit, preferably one with quantitative measurement such as those that the vHIT is performed with. We term this test the video VVOR9 (Fig 1). Cerebellar eye movement abnormalities may also be assessed clinically or quantitatively with IR VOG, looking for signs such as abnormal nystagmus (e.g. gaze-evoked nystagmus), broken up visual pursuit and dysmetric saccades to target. The assessment of a possible somatosensory deficit is best performed using electrophysiological modalities such as nerve conduction studies which can identify a peripheral neuropathy or neuronopathy (ganglionopathy)11. Neurologists and neurophysiologists generally perform these tests. CANVAS patients tend to present in their fifties or sixties with a slowly progressive ataxic syndrome, however, we have seen patients whose disease began in their thirties and forties, although this appears to be unusual. We recently published proposed graded diagnostic criteria for CANVAS2, and at a minimum these require (1) clinical evidence of cerebellar impairment (for example, one or more of central oculomotor abnormalities, cerebellar speech or upper limb ataxia); (2) bilateral vestibular hypofunction and (3) evidence of a sensory deficit on nerve conduction studies. Approximately a third of our CANVAS patients to date have one or more affected relatives and this raises the distinct possibility of a genetic basis, most likely recessive or dominant with reduced penetrance.

Our experience with CANVAS has shown that in addition to the aforementioned 3 cardinal features of the syndrome, many patients have a chronic dry cough. A smaller proportion of patients complain of disturbing alterations in sensation, more often in the legs, that range from numbness to sharp pain. Another variably present feature is that of orthostatic hypotension, or a drop in blood pressure on standing, which results in the patient feeling light headed5. Management is divided into strategies that reduce the patient succumbing to the syndrome and those that aim to improve daily function. The two principle threats to the patient with CANVAS are falls (and their complications) and aspiration (or breathing in rather than swallowing food and drink). Vestibular physiotherapy and assessment by a falls and balance clinic are helpful in reducing falls and medical investigation for bone thinning or osteoporosis may guide the use of bone strengthening medications. We recommend the use of calcium and vitamin D supplements for all patients at risk of falls (assuming no contra-indication exists). Disturbed swallow or dysphagia is best assessed by speech therapists and is often managed well with conservative measures. Orthostatic hypotension, chronic cough of neurological origin and painful limbs may be treated by a neurologist. Attempts to improve or maintain day-to-day function depend on the individual patient but usually include neuro-vestibular physiotherapy that aims to encourage safe mobility. Occupational therapy may be beneficial for activities of daily living that can be affected by CANVAS, examples include interventions to address difficulties managing regular cutlery, enhancing work place function or personal care. References 1. Szmulewicz DJ, Waterston JA, Halmagyi GM, et al. Sensory neuropathy as part of the cerebellar ataxia neuropathy vestibular areflexia syndrome. Neurology. 2011 May 30;76(22):1903–1910.

What does this mean for Audiologists? Dr Szmulewicz’s article highlights a newly described balance disorder which straddles several different healthcare disciplines. Patients with CANVAS are starting to be referred to Audiology-led vestibular services in the UK with histories of progressive gait ataxia and suspicion of associated bilateral vestibular hypofunction. This article summarises the most useful diagnostic tests to perform in the vestibular clinic, including some quick and efficient tests like vHIT, in order to inform a neurologist’s conclusions regarding CANVAS. It is expected that most patients with this condition would initially be referred to a neurologist, rather than ENT or Audiology services, based on their usual primary complaint of unsteadiness, rather than dizziness. However, in case of direct referral to ENT or Audiology, it is important to have an awareness of the cerebellar signs (both in the oculomotor assessment and general clinical examination) which would indicate the need for onward referral to Neurology following a finding of bilateral vestibular hypofunction. It is also important to consider whether these patients would benefit from the addition of Audiology-led vestibular rehabilitation to their management plan, which may already include Neurophysiotherapy and Falls Service input. For any vestibular service, development of links with local neurology departments and a multi-disciplinary approach are essential in offering patients with suspected CANVAS improved diagnostic certainty and optimised outcomes.

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46 2. Szmulewicz DJ, Roberts L, McLean CA. Proposed diagnostic criteria for cerebellar ataxia with neuropathy and vestibular areflexia syndrome (CANVAS). Neurology: Clinical Practice. 2016; 6: 61-68. 3. Curthoys IS, Manzari L, Smulders YE, Burgess AM. A review of the scientific basis and practical application of

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a new test of utricular function--ocular vestibular-evoked myogenic potentials to bone-conducted vibration. Acta Otorhinolaryngol Ital. 2009 Aug;29(4):179–186. 4. MacDougall HG, Weber KP, McGarvie LA, Halmagyi GM, Curthoys IS. The video head impulse test: diagnostic accuracy in peripheral vestibulopathy. Neurology. 2009 Oct 6;73(14):1134–1141. 5. Szmulewicz DJ, McLean CA, MacDougall HG, Roberts L, Storey E, Halmagyi GM. CANVAS an update: clinical presentation, investigation and management. J Vestib Res. 2014; 24(5-6):465-474. 6. Szmulewicz DJ, Merchant SN, Halmagyi, GM. Cerebellar Ataxia With Neuropathy and Bilateral Vestibular Areflexia Syndrome: A Histopathologic Case Report. Otol. Neurotol. 2011 Oct; 32(8): e63-5. 7. Szmulewicz DJ, McLean CA, Rodriguez ML, et al. Dorsal root ganglionopathy is responsible for the sensory impairment in CANVAS. Neurology. 2014 Apr 21;82(16):1410– 1415. 8. Baloh RW, Jenkins HA, Honrubia V, Yee RD, Lau CGY. Visual-vestibular interaction and cerebellar atrophy. Neurology. 1979 Jan 1;29(1):116–119. 9. Szmulewicz DJ, Waterston JA. Cerebellar ataxia, neuropathy, vestibular areflexia syndrome (CANVAS): a review of the clinical features and video-oculographic diagnosis. Annals of the New Academy of Science. 2011 Sep; 1233: 139-47. 10. Peterson JA, Wichmann WW, Weber, KP.The pivotal sign of CANVAS. Neurology 2013;81:1642-1643.
 11. Szmulewicz DJ, Seiderer L, Halmagyi GM, Storey E, Roberts L. Neurophysiological evidence for generalized sensory neuronopathy in cerebellar ataxia with neuropathy and

Follow us on Twitter to keep up to date with BSA courses, meetings and conferences. Find out about relevant events and conferences worldwide; as well as all the latest news from the world of audiology. Get involved by sharing meeting photos and contributing to regular discussion points and surveys.

bilateral vestibular areflexia syndrome. Muscle & Nerve. 2015 Jan 5;51(4):600–603..

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The use of mindfulness techniques in patients with chronic dizziness: A preliminary investigation CD

Author and Correspondence Debbie Cane MSc CS Senior Clinical Scientist and Lecturer in Audiology. Current post: Lecturer in Audiology (Balance) Manchester Centre for Audiology and Deafness (ManCAD) University of Manchester, M13 9PL

Take home message The benefits of mindfulness in patients with chronic dizziness- could you use these techniques for patients in your clinic?

E: Debbie.cane@manchester.ac.uk

What is Mindfulness? Mindfulness is a technique that has been modified from its original Buddhist origins for use in chronic medical conditions. It has been used successfully in a variety of chronic medical conditions such as chronic pain and in conjunction with cognitive behavioural therapy techniques for recurrent depression2 . It is described as ‘paying attention, in a particular way, in the present moment on purpose and non- judgementally’ (Kabat-Zinn3). Patients are taught a series of exercises/meditations to help them become more mindful/ aware of their body sensations (e.g. breathing, hearing, taste) and thoughts and feelings (pleasant or unpleasant), and to identify how they are reacting to these. Patients are then more aware of unhelpful, automatic or habitual thoughts and behaviours, often common in chronic medical conditions, and learn to react differently to these. Burch and Penman4 suggest a model of how mindfulness can be helpful in those with chronic pain, (and other long term health conditions) and have developed a successful5,6 eight week course (delivered face to face, online or self-administered) for these patients. They suggest that the primary symptoms (‘suffering’) of chronic pain may be enhanced by habitual or

automatic emotional responses such as anxiety, worry, stress or depression, which they describe as ‘secondary suffering’. This ‘secondary suffering’ can enhance the primary physical symptoms. They further suggest that whilst the ‘primary suffering’ may not be able to be controlled medically, ‘secondary suffering’ can be alleviated or reduced by techniques such as mindfulness. When combined with acceptance of the symptoms (instead of resistance and fighting against them), symptoms of pain begin to reduce, sometime beyond that which is expected from alleviation of secondary suffering alone. It was postulated that this model could be applied to patients with chronic dizziness in whom conventional vestibular rehabilitation techniques in isolation are often not effective. In a similar way to pain, it was postulated that mindfulness techniques may help patients to identify and alter their emotional responses (such as anxiety and worry) to their dizziness, and help them become more accepting of their symptoms. This in turn may lessen or help them cope better with their symptoms of dizziness, allowing them to restart activities they had previously ceased due to their symptoms, thus improving their quality of life. Burch and

Penman’s model was therefore adapted (with the authors’ permission) for the patient with dizziness (see Figure 1). There is only one published study on the use of mindfulness-based techniques in patients with vestibular disorders (Naber et al7). Patients with vestibular disorders (with or without secondary psychological disorders) were offered six sessions of rehabilitation. This plan was delivered by a neuropsychologist and vestibular therapist in a group setting and included mindfulness and cognitive behavioural techniques in combination with vestibular rehabilitation exercises. Although there was no control group, results showed significant improvements in many areas including mood, functionality and coping, with patients also reporting significantly less impairment from dizziness. Introduction of mindfulness into patients’ rehabilitation plans Ten patients presenting to the Royal Berkshire Hospital Balance Service with diagnoses of persistent postural perceptual dizziness (PPPD), peripheral vestibular dizziness exacerbated by anxiety or uncontrolled episodic rotatory vertigo were offered mindfulness as part of an integrated, individualised rehabilitation plan. Other rehabilitation techniques

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48 Primary dizziness/suffering Basic unpleasant symptoms from vestibular disorder including rotatory vertigo, dizziness, light headedness, nausea and vomiting

_ Resistance and emotional response to symptoms

_ Secondary suffering- minds ‘reaction’ to primary dizziness Thoughts, feelings and emotions, and memories associated with the dizziness e.g. anxiety, stress, anger, worry, depression, hopelessness, fatigue and exhaustion This is (in part) the result of the body’s resistance to dizziness Resistance causes worsening of symptoms ‘What you resist, persists’ Mindfulness teaches: Greater awareness of negative thought processes and unhelpful behaviours (and subsequent challenging of thoughts and altering of behaviours) Reduction of resistance to primary symptoms Non reactance-‘surfing the wave’ of the symptoms rather than ‘swimming against the tide’ Acceptance of symptoms- with goals of continuing with a full and active life even if dizziness persists

Figure 1: Mindfulness in chronic dizziness. Adapted for dizziness with permission from http://www.breathworksmindfulness.org.uk/images/blocking_and_drowning_chart.pdf

such as cognitive behavioural therapy (CBT) techniques, routine vestibular rehabilitation and breathing and relaxation exercises were also given if appropriate. Due to the absence of a locally available mindfulness course for patients with chronic dizziness, and in light of the recent meta-analysis by Cavanaugh8 suggesting the efficacy of mindfulness given via a self-administered plan (with limited or no therapist support),

,patients were encouraged to engage in the eight week course outlined in the book ‘Mindfulness for Health’ (Burch and Penman)5. The Clinical Scientist supporting the patients’ rehabilitation had extensive experience in vestibular rehabilitation. Additionally she had some training in mindfulness and CBT (having attended an eight week mindfulness course, one day course in teaching mindfulness, two day course in accept-

ance and commitment therapy, and an 8 day CBT course), but was not a fully qualified mindfulness teacher. Patients were introduced to the concepts of mindfulness including information on and the evidence base for mindfulness in other medical conditions, how it was postulated these techniques could be applied to dizziness (see the model in Table 1) and what was involved in completing a mindfulness programme. This information was backed up by a patient information leaflet on mindfulness and dizziness. Interested patients were then encouraged to complete the eight week programme by reading the relevant chapter for the week and completing the meditations and other exercises as suggested (for more detail please refer to the book). The patient was helped to set goals to work towards and the vestibular rehabilitation benefit questionnaire (VRBQ)9 was completed. This latter psychometrically robust questionnaire was developed by Morris et al to specifically measures the effects of vestibular rehabilitation exercises. It has sections on dizziness and anxiety, motion provoked dizziness and effect on quality of life. Both these outcome measures were used in the department’s routine vestibular rehabilitation clinics. The course suggested two ten minute meditations per day for six days out of seven and a ‘habit releaser’ in which patients were encouraged to become more mindful in routine daily activities, such as when brushing their teeth or by spending some time in nature each day. Pacing diaries (in which patients kept diaries to see whether there was any modifiable exacerbating factors to dizziness eg working for too many hours without a break) were also completed if felt to be appropriate. All patients continued to have rehabilitation follow up appointments.These were to monitor how the course was going and offer general support, to address any questions or concerns, to help tailor the mindfulness techniques to their individual symptoms, to discuss how to apply the techniques in their everyday lives, and to continue or start additional

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49 Week

Meditation

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Body scan meditation

2

Breathing anchor meditation

3

Mindful movement

4

Compassionate acceptance

5

Treasure of Pleasure

6

Open heart meditation (and breathing anchor)

7

Connection meditation (and open heart)

8

Body scan, breathing anchor, 3 minute breathing space

Table 1: Mindfulness programme

rehabilitation work. Often meditations were done together in the appointment and the patient was asked to share their experiences. At the end of the course patients were asked to fill out a questionnaire about how they found the mindfulness (see Appendix 1). Method1 Ten patients (eight female and two male, age range 30-62 years) began the mindfulness course as part of their rehabilitation plan. Nine completed the plan fully and one partially completed it but returned to the techniques at a later date after joining the dizziness mindfulness group. Classification of PPPD used in Table 2 was similar to that suggested by Staab10: ‘Otogenic’ (if there was a clear preceding

neurotologic illness), or ‘non-otogenic’ (where PPPD was precipitated by an episode of acute anxiety). A third term of ‘interactive’ was used for those patients who experienced a medical condition causing dizziness, the symptoms of which were then exacerbated by a pre-existing history of anxiety. Results All patients achieved at least one or more of their goals set before the rehabilitation programme commenced. These were specific to the individual patient, and did not necessarily require the patient to be completely symptom-free to achieve. Examples included getting back to work, playing golf, being able to pick up their child from school, and being able to go on a shopping trip. 90% of patients reported that they found the mindfulness beneficial, with many suggesting that they would continue to use the techniques once

Diagnosis

Age

Sex

Complicated otogenic PPPD (post head injury + BPPV)

62

f

Non otogenic PPPD

47

f

Non otogenic PPPD

35

m

Interactive PPPD

42

f

Interactive PPPD

51

f

Ongoing episodic vertigo of unclear origin

30

f

Ongoing episodic vertigo of unclear origin

39

f

Active Menieres + stress/anxiety

51

f

Active Menieres + stress/anxiety

39

f

Delayed endolymphatic hydrops (episodic vertigo) + stress/ anxiety

41

m

Table 2: Patients enrolled on to the mindfulness course as part of their rehabilitation plan 1

they had completed the course. Patients with non-otogenic PPPD achieved almost complete symptom resolution. The patient with delayed endolymphatic hydrops combined with stress-induced dizziness who was reporting symptoms weekly before rehabilitation, reported resolution of his latter symptoms in conjunction with a quiescent period of his hydropic vertigo. Many patients reported benefits of mindfulness even though their PPPD symptoms or uncontrolled episodic rotatory vertigo continued. Most were able to resume their previously ceased normal daily activities and work. In lieu of many patients continuing to experience symptoms of dizziness, it was therefore unsurprising that the vestibular rehabilitation benefit questionnaire did not consistently show significant improvement in all scores. This may have been because a large focus of this questionnaire is on frequency of dizziness, spinning or imbalance. Two patients were trialled with the short form version of the five facet mindfulness questionnaire11 (FFMQ-SF), a questionnaire for use in patients using mindfulness to help medical conditions. However, although this questionnaire measures different aspects of mindfulness, both patients felt that the questions did not provide an accurate representation of how useful they found mindfulness. Help with stress and anxiety: Patients with stress or anxiety found the techniques useful at identifying when this was building, and taking appropriate steps to ensure that this stress or anxiety (which in turn led to dizziness) did not escalate. One patient with episodic vertigo and anxiety attacks said that he found he was able to differentiate what was a true vertigo attack, and what were symptoms of anxiety (and he in turn was able to use different strategies to manage these). He said: (mindfulness) ‘for most, prevented my anxiety attacks, it’s helped me immensely in everyday life, how I approach and deal with things in work and family’. Control and insight: A patient with recurrent episodic vertigo felt the programme had ‘helped her take

Written consent was given by patients for inclusion of their results in this paper

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50 control’ rather than ‘sit passively’ and provided her with a ‘good insight into how to cope with the condition better’ and ability to find ‘the positive in the negative’. Acceptance: A patient with vertigo which then led to panic attacks felt mindfulness helped her accept her symptoms and feel more in control. ‘I think that mindfulness has helped me focus and stay in / take control of the panic attacks I now get as well as the dizziness. It’s accepting them, even embracing them, and experiencing them, it helps make me feel stronger by allowing them to come out’. Another patient with recurrent episodic vertigo felt it helped with acceptance ‘stopping the rot before it goes too far’, helping her realise when she is ‘fighting’ and when would be better ‘to accept’. Pacing diaries and compassionate acceptance meditation Many patients did not feel the pacing work was relevant to them, and so as this became apparent, this part of the programme was excluded if not felt to be of benefit. Week four of the programmes consisted of the ‘compassionate acceptance meditation’. This is a meditation designed to teach patients to sit with their dizziness, (rather than distract themselves from it). The aim is for the patient to observe the symptoms with ‘calm detachment’ rather than have a strong emotional response to the symptoms which in turn may enhance them. Patients found this meditation both difficult to practise and struggled with the language used, some of which was felt exacerbate the symptoms of dizziness. One patient with PPPD noted ‘I didn’t think it related very much to my condition. I found it really difficult to imagine my symptoms because they are related to outside experiences causing my symptoms and not in my body all the time. My mind was very resistant to imitating the experience and while the breathing was very relaxing it didn’t do much for my condition’. Although many found the compassionate acceptance meditation difficult

Patient feedback regarding mindfulness Before and after: How I was then: ‘December 2014: I arrived at the balance clinic depressed, anxious and scared, not really understanding what was going on with me and unable to get a grip on any aspect of my life. I was just about getting through half a day at work, not leaving the house for any other reason if I really didn’t have to and I had no energy at all’ How I am now: June 2015 – ‘Back living life to the full, still feeling dizzy/catch up sensation but in a place that I can now cope with my condition that being from a position of understanding as to why I am feeling the way I do, and with strategies in place that will help me maintain where I am and hopefully help me reduce my symptoms still further over time’. This lady with PPPD subsequently achieved her main goal of getting back to play golf where she won a competition, and also returned to work full- time.

to do, many realised its potential usefulness. One patient said: ‘This (compassionate acceptance meditation) is difficult to do, as it focusses you on where the symptoms are, but it is interesting to note that the symptoms do change and what you thought you felt one moment isn’t necessarily the same the next moment. This meditation is surely the key to breaking down the fear cycle about your symptoms’. Follow up work: Patient involvement in the recording of a dizzy-specific compassionate acceptance meditation On further discussion with the patient group about the compassionate acceptance meditation, patients mentioned they felt that this meditation could be improved to be dizzy-specific. One of the authors of the book, Vidyamala Burch was contacted and agreed to write and record a dizziness specific compassionate acceptance meditation. Patients were then asked to comment on how they felt the original compassionate acceptance meditation could be improved. Consistent responses were that sentences which included ‘movement words’ such as ‘rocking’ or ‘cradling’ (intended to help sooth sensations) actually exacerbated them (as movement normally exacerbated their dizziness). The meditation also asked for the patients to visualise certain

images. One of these images was that of leaning against a bale of hay. This was intended to help patients have an image of gently yielding to their symptoms and overcoming resistance to them - a contributor of secondary suffering in pain patients. However some patients disliked trying to imagine this, as due to their general imbalance, this led to a fear that they may fall, rather than overcoming resistance. A preliminary script using the patient feedback was written by Ms Burch, further patient feedback again obtained, and more amendments made. A final meditation was recorded and the meditation circulated to those who were interested. Feedback was positive amongst those who used the meditation: ‘I listened to the meditation yesterday when I felt horrid and thought it was goodthere seemed like a lot of bits to it, which was good as if I got distracted I could still come back to the meditation and keep up’ (patient with acute episodic vertigo) ‘It is very very good’.. ‘I was worried that the script I had seen focused a lot on acute vertigo and was almost giving it too much emphasis, I think that’s the word. But this script is more general and it works really well.’ (patient with PPPD). Some negative feedback came about the quality of recording (hiss heard through head phones) and from a colleague

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51 with experience in mindfulness. She felt that the meditation could be enhanced by re-recording with longer periods of silence after each instruction for contemplation and to enable development of non-reactance to symptoms. Setting up of a monthly mindfulness group As it is common for follow-up mindfulness sessions post treatment to occur, (to encourage continued practise and support of this), it was suggested that such a group was set up by patients. A patient was happy to lead this and meetings commenced. The aim was for the group to be patient led, but initially the clinician attended and helped lead meetings. Meetings have consisted of a variety of short guided meditations (e.g. mindful walking breathing or eating) followed by general discussion of how individual practise is proceeding. All patients who attended said they found the meetings useful, and benefited from group member’s support and understanding

Conclusions and future work This work was a preliminary investigation into whether incorporating mindfulness into the rehabilitation plan of patients with chronic dizziness may be useful. It is acknowledged that the approaches used with these patients were not compared against a control group, and that mindfulness was not the sole approach used in the patient’s rehabilitation. However, early results appear encouraging. Both the two patients who were previously struggling with other rehabilitation approaches, and those for whom mindfulness was introduced at the start of rehabilitation, appeared to gain benefit from the addition of a tailored mindfulness meditation programme. Most patients achieved their goals, even if this was in the context of continuing dizziness, and showed greater acceptance/understanding of and less reactance to their symptoms. Future work is therefore recommended to see if these initial observations are correct, which patient groups these techniques are best suited to and the optimal

way for their delivery. Along with achievement of realistic goals, it is suggested that outcome measures focussing on acceptance of and coping with symptoms of dizziness (such as the newly developed vertigo acceptance questionnaire by Kirby), rather than those focussing on physical symptoms of dizziness would be more appropriate for this patient group. The author would be keen to hear from others who are interested to collaborate in future work and use the newly developed dizziness-specific compassionate acceptance meditation. References 1. Kabat-Zinn, J., Lipworth, L., Burncy, R. and Sellers, W., 1986. Four-Year Follow-Up of a Meditation-Based Program for the Self-Regulation of Chronic Pain: Treatment Outcomes and Compliance. The Clinical Journal of Pain, 2(3),159-774. 2. Piet, J. and Hougaard, E., 2011. The effect of mindfulness-based cognitive

Appendix 1

Mindfulness feedback Questionnaire Name: Diagnosis: Which book/resource did you use: Time over which completed (weeks): What you found helpful: What you didn’t find helpful: Comments about compassionate acceptance meditation (good and bad- in the context of you being symptomatic) Comments about new dizziness meditation Do you think you will continue with mindfulness? Other comments:

Thank you for taking time to fill in this questionnaire- the information you give will remain confidential but your feedback will be used to better help others with this technique.

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52 6. Henriksson, J and Vasara Moller E (2013) Online mindfulness training for chronic pain. http://www.breathworks-mindfulness.org.uk/images/ Henriksson_och_Vasara_M%C3%B6ller_1.pdf (accessed 07/04/2016)

therapy for prevention of relapse in recurrent major depressive disorder: a systematic review and meta-analysis. Clinical psychology review, 31(6),1032-1040. 3. Kabat-Zinn, J., 1994. Where Ever You Go There You Are. Mindfulness meditation in everyday life. Hyperion New York p4

7. Naber, C. M., Water-Schmeder, O., Bohrer, P. S., Matonak, K., Bernstein, A. L., Merchant, M. A. (2011). Interdisciplinary treatment for vestibular dysfunction: the effectiveness of mindfulness, cognitive-behavioural techniques, and vestibular rehabilitation. Otolaryngology Head And Neck Surgery, 145, 117-124.

4. Burch, V., Penman, D. Mindfulness for Health – a practical guide to relieving pain, reducing stress and restoring well-being. Piatkus, 2013 5. Cusens B, Duggan GB, Thorne K, Burch V. (2010) Evaluation of the breathworks mindfulness-based pain management programme: effects on well-being and multiple measures of mindfulness. Clin Psychol Psychother. 2010 Jan-Feb;17(1):63-78

8. Cavanagh, K., Strauss, C., Forder, L. and Jones, F., (2014). Can mindfulness and acceptance be learnt by self-help? A systematic review and meta-analysis of mindfulness and

acceptance-based self-help interventions. Clinical psychology review, 34(2),118-129. 9. Morris, A. E., Lutman, M. E., Yardley, L. (2009). Measuring outcome from vestibular rehabilitation, part 2: refinement and validation of a new self-report measure. International Journal of Audiology, 48(1), 24-37. 10. Staab, J. P. (2012). Chronic subjective dizziness. Continuum Lifelong Learning in Neurology, 18(5),1118-1141. 11. Bohlmeijer, E., Peter, M., Fledderus, M., Veehof, M. and Baer, R., 2011. Psychometric properties of the five facet mindfulness questionnaire in depressed adults and development of a short form. Assessment, 308-319

Useful websites: Website of the book used • http://www.breathworks-mindfulness.org.uk/

General websites on mindfulness • http://bemindful.co.uk/

• website of a similar plan tailored to stress reduction

• http://www.oxfordmindfulness.org/about-mindfulness/

• http://franticworld.com/

• http://www.mindfulnet.org/index.htm

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54

The QuicK+fire study. Can a new pharmaceutical drug candidate help people with cochlear implants to hear better in noisy conditions?

CD

Authors and Correspondence Charles Large Peter Harris Alice Grant Barbara Domayne-Hayman Autifony Therapeutics Limited

It is thought that by increasing the precision and timing of neural firing (allowing neurons to “quickfire”), AUT00063 will enhance central auditory performance, and in particular, temporal resolution.

Cochlear implants (CIs) have transformed the lives of people with profound hearing loss, and represent a unique synthesis of surgical expertise, electronic advancement and psychoacoustics. However, not all outcomes are optimal and there are many people who still struggle to hear clearly in certain situations e.g. understanding speech in noisy environments. Fundamental to the ability to decode speech, in particular in a noisy background, is the ability to detect the rapid sounds that make up speech. Hearing loss and age are associated with deterioration of the neural circuits that underpin central auditory processing, which leads to a reduction in auditory temporal resolution. A UK based company called Autifony Therapeutics is developing a drug, AUT00063, which modulates voltage-gated Kv3 potassium channels that are critical to the function of the neural circuits involved in central auditory processing. It is thought that by increasing the precision and timing of neural firing (allowing neurons to “quickfire”), AUT00063 will enhance central auditory performance, and in particular, temporal resolution. Autifony is conducting a pilot evaluation of the benefits of AUT00063 on aspects of central auditory processing for CI users. Recognizing that post-lingually deafened adult CI recipients often reach a plateau in performance at approximately 9-12 months following initial stimulation , this study recruits subjects 9-36 months post CI. AUT00063: a K+ channel modulator – preclinical data support the hypothesis AUT00063 positively modulates Kv3 potassium channels, found at all levels of the auditory system, and which are important in central auditory neurons that must fire rapidly and with precise timing to support auditory temporal processing. •

Processing of auditory information in the brain requires fast, accurate firing of neurons in auditory centres, which is dependent on the expression of Kv3 channels (Song et al., 2005)

Hearing loss is associated with a reduction of function of Kv3 channels in neurons of the dorsal cochlear nucleus in rodents; loss of Kv3 function is likely to contribute to a degradation of auditory temporal processing (Pilati et al., 2012)

Ageing is also associated with reduced Kv3 expression in auditory centres, and may account for aspects of reduced hearing performance (Zettel et al., 2008; see also von Hehn et al, 2004; Jung et al., 2005)

Elderly humans show age-related deficits in auditory temporal processing as measured by their ability to detect short gaps in a sound. Young humans can reliably detect gaps in sound as short as 2-3 milliseconds, whereas with age this ability deteriorates such that people over the age of 67 require the gap to be twice as long (Mazelova et al. 2003). Furthermore, in this study, Mazelova et al (2003) showed that the elderly subjects’ ability to detect gaps in sound correlated significantly with their performance in a speech-in-noise test. Aged rodents suffer a similar deterioration of hearing ability, and using behavioural techniques, their ability to detect gaps in sound can be measured. In a study conducted by Prof Josef Syka and his group at the Institute of Experimental Medicine in

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55 Prague, elderly rats showed a significant deficit in gap detection compared to younger animals. However, following a single dose of AUT00063, the elderly rats showed gap detection performance similar to the younger animals. In a further rodent study, Dr Dan Polley and colleagues at the Massachusetts Eye and Ear Infirmary in Boston explored the ability of central auditory pathways in mice to respond to sound. They found that in mice who had been profoundly deafened by a 95% destruction of the auditory nerve (a model of auditory neuropathy), the response of neurons in the inferior colliculus to auditory stimuli was dramatically affected, with neural firing poorly synchronized (timed) to the auditory signal. However, following a single dose of AUT00063, the timing of firing and synchronisation of neurons to auditory stimuli was significantly improved. A clinical study with AUT00063, called ‘QuicK+fire’ is starting soon With regulatory (MHRA) and REC approvals granted, Autifony’s clinical trial is planned to start in April 2016, in four clinical trial sites in the UK: London, Manchester, Birmingham and Cambridge. This is a pilot study which has a crossover design, so each subject will act as their own control. There will be around 20 participants in total. Recruitment will be limited to pre-existing patients at participating sites. AUT00063 is an orally active drug that will be taken during the clinical trial as 4 capsules once daily with food each day continuously for 28 days. This drug is presented in yellow capsules each of 200mg. Subjects will be randomised in a 1:1 ratio to receive either AUT00063 800 mg/day or matched placebo for 28 days, followed by a 2 - 4 week washout period before commencing the second 28-day dosing period with the other medication (drug or placebo). Clinical end points In this pioneering pilot study, a variety of clinical endpoints will be investigated, including the following three broad categories of endpoints:

will be better with drug than with placebo and at baseline; this difference is expected to be larger than at low rates. Similarly, it is hypothesized that gap detection will be improved with drug compared to placebo and/or baseline conditions. This part of the study requires more specialist equipment and will be carried out in the MRC Cognition & Brain Sciences Unit, Cambridge, for all participants, for whom travel logistics will be organized.

a) Direct stimulation of the auditory nerve via implant One of the proposed effects of AUT000063 is, via modulation of Kv3.1 channels, to restore the ability of auditory neurons to fire in a fast, sustained, and temporally accurate manner. To provide a direct test of this hypothesis subjects will perform two psychophysical tasks that are likely to rely on fast sustained firing. The tests will involve direct stimulation of one electrode with trains of pulses, bypassing the speech processor. One of these (Fig. 1) will measure sensitivity to changes in pulse rate, both at low and high overall rates.The other (Fig. 2) will involve the detection of a gap in a high-rate pulse train.

b) Minimum Speech Test Battery The Minimum Speech Test Battery (MSTB) was assembled to identify a set of materials to be used clinically and in research studies to assess the performance of adults with CIs, and this will be used in Autifony’s clinical study.

On the basis of the Kv3 mechanism of AUT00063 it can be hypothesized that the Rate discrimination at high rates

• One 20-sentence list of AzBio sentences test presented in noise.

The battery comprises: • One 20-sentence list of AzBio sentences test presented in quiet

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56 Figure 1

CURRENT AMPLITUDE

Lower pulse rate

noisy backgrounds. Autifony has recently obtained the regulatory approvals required, and plans to start recruitment in London, Manchester, Birmingham and Cambridge in April 2016.

References

CURRENT AMPLITUDE

35% higher pulse rate

1.

Advanced Bionics, Cochlear America, & Med El. NEW Minimum Speech Test Battery (MSTB) For Adult Cochlear Implant Users 2011. http://www.auditorypotential.com

2.

Jung DK, Lee SY, Kim D et al. Age-related changes in the distribution of Kv1.1 and Kv3.1 in rat cochlear nuclei. Neurol Res 2005; 27: 436–440.

3.

Kang, R., Nimmons, G. L., Drennan, W., Longnion, J., Ruffin, C., Nie, K., Won, J. H., Worman, T., Yueh, B., & Rubinstein, J. (2009). Development and validation of the University of Washington Clinical Assessment of Music Perception test. Ear and hearing, 30, 411–418

4.

Pilati N, Large C, Forsythe ID, Hamann M. Acoustic over-exposure triggers burst firing in dorsal cochlear nucleus fusiform cells. Hear Res. 2012 Jan; 283(1-2):98-106

5.

Song P, Yang Y, Barnes-Davies M et al. Acoustic environment determines phosphorylation state of the Kv3.1 potassium channel in auditory neurons. Nat Neurosci 2005; 8: 1335-1342.

6.

M.L. Zettel, X. Zhu, W.E. O’Neill, R.D. Frisina; Age-related decline in Kv3.1b expression in the mouse auditory brainstem correlates with functional deficits in the medial olivocochlear efferent system. J. Assoc. Res. Otolaryngol., 8(2) (2007 Jun)

TIME

Figure 2

CURRENT AMPLITUDE

Standard: high pulse rate without gap

CURRENT AMPLITUDE

Signal: high pulse rate with gap

TIME

• One 50-word list of Consonant-Nucleus-Consonant (CNC) words • One 16-sentence list-pair of the Bamford-Kowal-Bamford Speech-in-Noise (BKB-SIN) test c) Clinical Assessment of Music Perception (CAMP) Cochlear Implant users particularly struggle with pitch discrimination, which leads to difficulties understanding tonal languages (e.g. Chinese), detecting emotional content, and appreciating music. Although this is perhaps not an issue of poor auditory temporal processing, it is possible that AUT00063 could facilitate pitch perception in CI users. The CAMP is a self-administered, computer-based music test for CI patients licensed by University of Washington. The tests evaluate the ability to perceive the intervallic direction of pitch pairs, to identify common melodies and the sounds of various musical instruments (timbre) from closed sets {Kang et al Ear Hear. 2009}.

Submit an article We welcome the submission of articles on relevant clinical, research and academic or other themes within Audiology. The reader may not always be an expert or have previous interest in your specialist area and the article is an opportunity to increase the British Society Audiology knowledge base ofand interest in new | LEARNING | PRACTICE | IMPACT areasKNOWLEDGE of audiology. We are keen to publish articles that present alternative or challenging themes that will British Society Audiology debate. encourage andofprovoke KNOWLEDGE | LEARNING | PRACTICE | IMPACT

Conclusion The clinical study testing AUT00063 with cochlear implant users will be the first study of its kind with this novel mechanism of action, to aim to improve speech discrimination especially in

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British Society of Audiology KNOWLEDGE | LEARNING | PRACTICE | IMPACT

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The research at Aston University CD

Author and Correspondence

Dr Helen Pryce (BA (hons); Dip Hearing Therapy; MSc (Oxon); PD Health) Senior Lecturer in Audiology & Hearing Therapist Sirona care and Health St Martins Hospital, Bath Life and Health Sciences Aston University Birmingham B4 7ET Professional Advisor British Tinnitus Association, Trustee British Society Audiology Member Commissioning Framework Group (adult) NHS England E: h.pryce-cazalet@aston.ac.uk

Aston University prides itself on its inter-disciplinary applied health research. Audiology are proud members of the School of Life and Health Sciences. The school’s output was ranked 5th in the UK for Professions Allied to Healthcare (REF 2014). Audiology staff are members of the Aston Research Centre in Health Ageing (ARCHA) and Aston Research Centre in Children and Young People (ARCHY). In addition our staff work collaboratively with optometry, psychology, pharmacy and neuroscience to investigate the application of healthcare through the Applied Health Research Group.

Currently our work is focussed on a number of themes relating to hearing and use of hearing healthcare. Decision making and help-seeking In adult hearing loss… Our decision making and help-seeking theme brings together projects around the mechanisms of decision making and coping in hearing conditions. Our researchers are leading the way in developing Decision Aids to support shared decision making in Audiology. The first International Standard Decision Aid for Hearing is a collaboration between Dr Helen Pryce, Dr Amanda Hall, Melanie Ward, Elizabeth Clark, Dr Ariane Laplante-Lévesque and colleagues at Dartmouth College in the US. Our background research into decision making in hearing loss has provided insight into how typical audiology appointments share information and how decisions are made before, during and after help-seeking.

Amanda Hall are collaborating on a study into clinical decision making for children with otitis media and Down Syndrome. We have identified the range of professional views that influence decision making in otitis media for children with Down syndrome. This enables us to understand the mechanisms behind the decision making process currently and the information that could promote consistent choice. Amy Jauncey is examining parents perceptions of children with unilateral hearing loss and how they weigh up pros and cons in help-seeking. This helps us to understand the complex choices that impact use and response to audiology services.

The role of illness perceptions in help-seeking has been a long standing interest of ours and Dr Lisa Wolber has been conducting feasibility work to see if illness perceptions could be a predictor of hearing aid use and uptake. In Paediatric services…. Within Paediatric audiology the decision making process impacts on outcomes for children. Dr Helen Pryce and Dr

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58 In tinnitus‌ Decision making in tinnitus will be supported in the future through the development of an Option Grid with the Dartmouth College group. This work brings a team of Health psychologists, Audiologists, Hearing Therapists and public health experts to develop the first decision aid for people with tinnitus. This work is funded by the British Tinnitus Association. Our team of research fellows, Sarah Swift, Beth Claesen and Beth-Anne Culhane are investigating how decision making occurs when people have tinnitus. They are gathering data from clinical populations in Bristol, Bath and London to provide insight into how decisions are made and what is important in making the decisions. They will identify what information patients need to make decisions on management for tinnitus. In related work, the thoughts and decisions that influence coping choices in tinnitus has been examined by Yash Dajee and Katie Chilvers has identified how thoughts about tinnitus and impact coping.

How patients experience clinical processes and service improvement Our expertise in qualitative and social research methods mean that we are well placed to investigate patient experiences of clinical services. Often these services have never included patient perspectives in their design and so this is novel and ground breaking work. Our projects include investigations of hearing aid clinics, finding out how patients experience the support available. Emma Wilson is leading work into how practical hearing aid management impacts patient experiences of clinics. Rosemary Monk is leading novel research into how vestibular testing is experienced by patients and what they find valuable and difficult about the procedures.

Amanda Casey is working alongside colleagues at the University of Nottingham on a study of psychological interventions for tinnitus. This study will involve 3 UK audiology departments. Interviews with selected patients and audiologists will provide in-depth information about what elements of counselling are most beneficial and why.

Previous work has looked at the transfer of performance gains (following a short training program) across different types of adjusted speech, the role of the electrophysiological representation of speech sounds in the neural pathway and their relationship with hearing in noise and the role that the inhibition of unwanted information may play in the perception of hearing in noise.

The first stage of the project is underway and is a Delphi survey to find out what should be included in audiologist delivered psychological interventions. This will enable us to identify training needs for audiologists. We are exploring how to refine clinical procedures. Wahid Zaman is leading projects in the areas of Auditory Brainstem Responses: studying artefact reject levels and optimum electrode placement distances, Cortical Auditory Evoked Potentials (CAEPs): studying the effect of alertness and the use of different stimuli on the amplitude and latency of CAEPs and hearing aid amplification verification: studying the efficacy of Real Ear Measurements (REMs) and Real Ear Coupler Difference methods, factors that affect their measurement and clinical issues. Cognition and hearing Our work aims to develop further our understanding of the role of working memory and other cognitive processes in hearing speech in sub-optimal conditions.This work also involves the role that auditory training may have in improving both cognitive and listening skills. Our researchers led by Scott Richards, alongside Dr Carol Holland from psychology, are currently investigating the role of communication training using the Listening and Communication Enhancement (LACE) program with newly fitted hearing aid patients. Further planned work involves the perception of an individual’s own ability to hear in noise compared to their actual performance in order to examine how well individuals can judge their own abilities.

Application into practice Our team recognise the importance of applying our research findings into clinical settings and are involved in policy making through our professional bodies. Rosemary Monk has recently provided a review of evidence to inform the Balance service pathway section of the new commissioning framework in England. Helen Pryce has contributed to the non-complex, complex and tinnitus pathways. Our team have key roles within BSA, BAA and RCCP. On a local level all our staff retain clinical experience and practice and this enables better translation of research into practice and a better understanding of the issues in applying new practices. Our teaching programmes Aston University is the only site in the UK to offer programmes in Audiology from foundation degree, BSc, MSc and Professional Doctorate. The research

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59 training at Aston is multidisciplinary, enabling a collaboration between colleagues in Experimental, Health or Social Psychology, Pharmacy, Neurosciences, Optometry & biomedical sciences. We aim to support students to become independent researchers, planning and delivering their own projects. We are particularly interested in collaborating on projects that are important to the workplace.

The first Professional Doctorate in Hearing Therapy Our latest programme is the Professional Doctorate in Hearing Therapy which brings together teaching and research from Audiology and Health Psychology disciplines to provide professional development and research opportunities for audiological rehabilitation. This route will provide an additional doctoral training route for those with an interest in

research. In addition we are always interested to hear from potential PhD candidates. For further information contact h.pryce-cazalet@aston.ac.uk. For more information please see http://www.aston.ac.uk/lhs/research/centres-facilities/applied-health-research-group/

Taming the paperwork mountain: The logistics of a randomised clinical trial CD

Author and Correspondence Dr Bonnie Millar Research Assistant NIHR Nottingham Hearing Biomedical Research Unit University of Nottingham NG1 5DU E: bonnie.millar@nottingham.ac.uk

Background In October 2014, a clinical trial (QUIET-1; ClinicalTrials.gov Identifier: NCT02315508) to test the effectiveness of a capsule (containing the Autifony Therapeutics Ltd AUT00063 compound) taken orally to treat chronic subjective Tinnitus started recruiting. The multi-centre trial was intended to recruit up to 152 participants across 18 NHS sites including the Nottingham University Hospitals NHS Trust (NUH). Recruitment closed in October 2015. It was a complex trial with many different assessments and complex inclusion criteria.The logistics proved challenging due to the numerous assessments, multiple departments and many external organisations concerned. The time commitment required of busy clinicians and the tight timescales involved between and during each stage (as illustrated in Figure 1) increased the difficulties. This article is intended to reflect on the relative effectiveness of the different strategies we employed in co-ordinating site activities for QUIET-1 and the impact of the trial management. Comparable to previous reports (UK Trial Manager’s Network, 2014; Pocock, 1983) and reviews (Farrell et al., 2010), good trial management methodology was found to be crucial to the project and the effectiveness

Take home message: “Don’t underestimate the amount of paperwork, logistical requirements and monitoring involved in a randomised controlled drug trial. Attention to detail and good communication are key, to maintain participant and staff engagement and to ensure successful delivery of the study aims.”

of the various stratagems to reduce patient and staff disengagement and could inform the design and conduct of future projects. Trial Logistics The site delegation log numbered 25 people; 2 Investigators from ENT, 1 from Evoked Potentials, 5 from the Clinical Trial Pharmacy, 6 (including audiologists) from the Nottingham Hearing Biomedical Research Unit, 1 from Anaesthesia, 8 nurses and practitioners from the Clinical Research Unit and 2 from Clinical Neurophysiology. The Nottingham site was the only site to perform phEEG and ABR tests. Additional involvement included hospital Clinical Pathology and 4 Clinical Research Organisations, the Sponsor (Autifony Therapeutics), and an external pharmaceutical services company, all of which made further demands on the study team’s time with information, data and documentation requests. The large study team was mirrored in the large Investigator Site File (ISF), all the essential site trial documents, housed in two specially purchased fireproof lockable cabinets which, by the close of the trial, contained 121kg of paperwork exclusive of folders (145kg inclusive of folders), the equivalent of 43 A4 75mm spine box files. To deal with this logistical mountain the Nottingham site had a full time study co-ordinator.

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60 Planning At the outset, a review of NUH Standard Operating Procedures (SOPs) was conducted with the sponsor, in order to establish which SOPs were relevant to the trial and should be followed where information on process was not available via the study protocol. Two additional trial-specific ones were required to be written. For each visit, a clearly itemised itinerary with every task timed was developed to ensure obstacles to participant engagement and staff involvement were reduced. Standardised trial source data sheets, in the same order as the electronic case report forms (eCRFs) were developed to make it easier to collect all the required data and accelerate data inputting without compromising accuracy. The source data sheets were modified as the study continued to capture additional information and to be more intuitive. Existing systems often proved insufficient for study purposes, necessitating the creation of alternative methods, for example for referrals and collection of results. This created a functional modus operandi for both the trial and the departments involved. Figure 1. Table listing all the assessments and visits for the participants Organisation It quickly became apparent that a single point of contact was required to facilitate Streamlining effective communication flow both for Having trial-specific participant folders organised per visit constaff and participants. The study co-ordinator was this single taining the source data sheets, forms, questionnaires and particclear point of contact, always accessible, and with oversight of ipant information leaflets reduced the risk of failing to capture every participant activity from pre-screening through to the data or recording it incompletely. It instigated a right-first-time last follow-up visit. approach. Furthermore, it limited the amount of patient time

“The study co-ordinator made the trial happen. Without her, everything would fall apart.� Mr Matija Daniel, Principal Investigator for the Nottingham Site This central contact, combined with clear study team role definition (each task owned), avoided duplication of effort and tasks not being actioned through slippage between the borders of remits. Another useful addition was the participant chaperone, who accompanied patients on Day 1 and Day 28 visits which were complex due to a tight schedule and the need to visit multiple departments for multiple assessments; by supporting and assisting the participant in this manner, their commitment and interest in the study was hopefully also encouraged.

required for appointments and proved a lighter touch for staff involvement. Upon reviewing processes after 3 months, study specific labels with the clinical details for the required samples were developed to further save time and ensure accuracy. As the study progressed what we learnt from the early stages was evaluated as per the Kolb cycle (Kolb, 1984) and fed back into the systems used. Training Rather than having blanket training on all trial aspects, targeted training on, for example, the unfamiliar Tinnitus Functional Index, Loudness Matching and the study-specific eligibility calculation based on the Pure Tone Audiometric results for audiologists seemed to be more popular and effective. Training in the paperwork was also invaluable as the trial paperwork

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61 requirements differed to varying degrees from standard NHS forms and notes. If the paperwork was not properly filled in, it had a knock-on effect on data inputting. It also proved more effective for staff to be trained solely in the study aspects they needed for their role, and that this training should take place just before staff start their role, lessening demands on their time and allowing them to immediately put into practice the knowledge gained. Monitoring Regular internal auditing and query-chasing ensured clean data. Indeed, the longer the time lapse between data capture/ input/checking/correction, the lower the likelihood of queries getting resolved, and the longer the time needed to achieve resolution.

Figure 2. Chart illustrating the trial logistics. White squares indicate the people and components which made demands on the study team’s time. Black squares indicate the methods used to negotiate them. The circles indicate how these methods fed into each other in a continuous cycle.

Outcomes At the start, we accommodated one or two eligibility assessments per day, often just a single participant. However, there was an increase in the number of appointments per day to three or four participants from May onwards, even when the complex Day 1 visits took place. It proved possible, for instance, to accommodate one Day 1 visit (consisting of seven appointments with clinicians from five departments over eleven hours), one Day 28 (consisting of five appointments with clinicians from five departments over four hours) and two eligibility assessment appointments (with clinicians from three departments over three hours) on the same day through tight scheduling, utilising the timing of each task, with a chaperone accompanying patients on Day 1 and Day 28 visits. Also, by utilising a trial-specific result collection system, the results review process was expedited, thus allowing more time to book subsequent appointments. A similar improvement was seen in the cleanness of the data in the eCRF. On 24th June 2015 we had 50 data queries, which dropped to 33 by 26th August 2015 and to 9 by 15th October 2015. As a result, external reporting by Clinical Research Associates highlighted no discrepancies between the telephone randomisation system and the eCRF with regard to audiology markers and the reconciliation of both was quick and straightforward. Furthermore, external medical reviews of data proved straightforward with minimal incidental actions. This efficiency in data capture and cleaning cut down on the number of data actions, freed up clinical time and facilitated more patient appointments and maximised the functionality of the data collected. Monitoring visits by the trial sponsor noted that the Nottingham files were the tidiest that the monitor had ever seen!

All the participants who were found to be eligible and enrolled on the trial remained fully engaged, attended all their appointments, complied with all the study requirements and consented to the optional assessments. Future Delivery It is essential to have adequate administrative, logistical, and data experience amongst the study team. Taking the time to adequately plan and set-up systems and logistics will cut down on workload during the study and will ensure clinicians’ time is maximised with more clinician patient contact time. Combining initial planning and organisation with ongoing streamlining, training and monitoring will ensure the smooth running of a study and that study requirements can be met as they arise. Using systems to reduce the impact on participant and staff time will facilitate continued engagement with a study.

References 1. Farrell B, Kenyon S, and Shakur H (2010) Managing clinical trials. Trials 11:78. 2. Kolb DA (1984) Experiential Learning, Englewood Cliffs, NJ.: Prentice Hall. 3. Pocock SJ (1983) Clinical Trials: A Practical Approach. Chichester: Wiley. 4. UK Trial Manager’s Network (2014) Trial Managers’ Network (TMN) Guide to Efficient Trial Management [http://c. ymcdn.com/sites/www.tmn.ac.uk/resource/resmgr/TMN_ Guide/tmn-guidelines-web_[amended_.pdf].

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62 Teach a man to fish and you feed him for a lifetime:

From charity towards the first independent audiology service in Malawi

CD

The adult hearing service at ABC HCTC provides a service not dissimilar to the UK. Most of the hearing aids are secondhand and so lots of different software is required. Power cuts are common; the clinic has a back-up generator, but switching from mains to generator electricity causes just enough disruption to wipe out any hearing aid programming you happen to be doing, every time.

Author and Correspondence Helen Brough Clinical Scientist in Audiology E: Helen.Brough@addenbrookes. nhs.uk

Earmoulds are made in the clinic – only hard acrylic material is available, but they can often be ready for the patient within hours of the impressions being taken.

I am a Clinical Scientist in Audiology working at Addenbrooke's Hospital, Cambridge. I have a special interest in humanitarian audiology and working with people with learning disabilities.

The paediatric service offers the usual array of paediatric testing and habilitation.There isn’t currently a routine newborn hearing screening service, however there are facilities for electrophysiological testing, generally for sedated testing of difficult-to-test older children.

Correspondence details Audiology Department, Box 94, Addenbrooke’s Hospital, Cambridge, Hills Road, CB2 0QQ

How would you design an audiology service in one of the poorest countries in the world1? Long-term sustainability is the focus for projects supported by Ears Inc, a small Christian charity based in Australia. Their aim is to develop services for under-served populations, and then train local people to take over the work. The clinic they set up in Malawi - African Bible College Hearing Clinic and Training Centre (ABC HCTC) – is very nearly at the handover stage, only 6 years after the first Ears Inc volunteers arrived. I spent 3 months volunteering at ABC HCTC in 2014, and a further 3 months there in 2015.

Outreach A key element of ABC HCTC is offering free audiology services to people in remote areas who cannot come to the clinic. The dedicated staff regularly take the HARK and audiotrailer up and down the country, partnering with local charities and setting up clinics in fields and villages so isolated that I’ve never found them on any map. Conditions aren’t always easy, doing audiometry in the audiotrailer one day, it got so hot that my Malawian interpreter asked if she could go outside for a while!

ABC HCTC has three priorities: provision of high quality audiology services at the clinic, training and rural outreaches, and my time there was an ever-changing mix of all three. Clinical work Some of the clinical work is identical to that of an NHS department, at least, almost identical. Otoscopy is the same, except that a normal eardrum is something of a novelty and the idea of throwing away a speculum after a single use is unthinkable. A nurse learning to do dewaxing with the clinic was surprised and excited (!) to discover that the first ear she cleared was blocked by a dead cockroach – not an uncommon occurrence.

Arriving for an outreach clinic in Ntcheu

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63 Teaching On my second trip, I arrived in Malawi having been asked to teach the Vestibular Assessment and Rehabilitation module to the Audiology students. I had lots of notes but no clear idea of what the course would consist of. My first full day in the country was an outreach at the huge Dzaleka refugee camp. When that was over we sat down to talk through my teaching, and I started my first two-hour class three days later. Designing the course and writing the content as I went along went more smoothly than I expected, although it was certainly time-consuming.

Timeline for setting up the first Audiology clinic in Malawi

2010

Peter and Rebecca Bartlett, experienced Australian audiologists, move to the campus of the African Bible College in Lilongwe, Malawi. They start a basic audiology clinic in a spare room in the ABC Maternity clinic, with college students acting as interpreters.

Long-term sustainability is the focus I was grateful for the generosity and ingenuity of Rob MacKinnon, a trainee at Addenbrooke’s who designed, built and donated a pair of Frenzels for the clinic. A cushion, a couch, an otoscope and the Frenzels were all the equipment we had for vestibular testing, but a lot can be done with these, particularly when we discovered we could record eye-movements very clearly through the Frenzels using a mobile phone camera. Nobody knew whether there would be a demand for a vestibular service, however when word was passed around the local clinical officers, we had a significant number of referrals. Generally the clinic runs on a drop-in basis, because appointments are difficult to arrange when many people have limited literacy and no access to a phone. We insisted that patients had to be booked in for vestibular appointments, and amazingly this worked out well. My priority was not only to teach the students but also to update Peter Bartlett’s knowledge in vestibular practice. He’s an experienced audiologist, but hasn’t done any vestibular work for a long time. Our plan was that he should be ready to continue the service by the time I left. As the clinic manager and BSc Audiology curriculum developer, Peter is already overworked, but he somehow found the time to study the course and is continuing to see vestibular patients. To have set up an embryo vestibular service in just three months feels like a significant achievement, and I hope to return later this year to continue working with the staff and helping develop their clinical skills.

2011

2013

• The first purpose-built Audiology clinic in the country (ABC HCTC), designed by the Bartletts, is opened. • The first audiology students qualify and start work as assistant audiologists. • The clinic receives a HARK - the distinctive mobile Ear Clinic from Sound Seekers - and an Audiotrailer from Sonova Hear the World Foundation. Outreach clinics can now be expanded substantially, offering primary ear care and audiology services free of charge to remote communities throughout the country.

2014

More volunteers are always welcome in Malawi Are you an experienced audiologist interested in sharing your skills? More volunteers are always welcome in Malawi; it is a chance to stretch your clinical understanding in a new environment, and I would definitely recommend it. If you are interested and want to find out more, please contact hearingabcclinic@gmail.com. More information about Ears

Six undergraduate students at ABC start taking classes in Audiology in their spare time.

2015

The second cohort of students begin audiology training. It is hoped that their course will be recognised by the Malawi Medical Council and accepted as a BSc Audiology.

Three of the assistant audiologists start the MSc audiology course at the University of Manchester, aiming to become the first ever Malawian audiologists.

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64 Inc can be found at: http://www.earsinc.org and about ABC HCTC at: http://www.africanbiblecolleges.net/clinic/ears/audiology-at-abc-malawi. Reference 1.

http://data.worldbank.org/indicator/NY.GDP.PC AP. CD?order=wbapi_data_value_2013+wbapi_data_ value&sort=asc, retrieved 21 March 2016.

The hope for the future

2016

The Manchester students will graduate and return to Malawi. Two will return to Lilongwe, the third will move to Blantyre where a second clinic, modelled on the first, is being built under the direction of American audiologist Courtney Caron, supported by Sound Seekers. The newly-qualified audiologists will undergo a year of clinical supervision, supported by experienced overseas volunteers.

Teaching vestibular assessment at ABC HCTC

2017

The Malawian staff will take over the clinical management of ABC HCTC, with continuing visits from overseas professionals to help maintain their continuing professional development.

Rural outreach

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65 Want to Make a Difference to the Lives of Deaf Children Globally? • Professionals working in sexual & reproductive health with experience and / or interest of working in Deaf / disability contexts & settings • Sign language interpreters skilled in BSL and, variously, French, Spanish, Arabic and Pashto Sign The DeafKidz International Registry is a newly established database of professionals working in child protection, ear & hearing care, health, development and humanitarian programming, who are interested in working with Deaf children and young people in low resource health and complex humanitarian settings. With a Board and programmatic advisory / implementation team that draws its pedigree from agencies such as ICRC, Great Ormond Street, War Child UK, Plan International, UK Police, the Royal College of Paediatrics and Child Health, we’re about getting things done in the most difficult of places and in the most challenging of circumstances. We’re a total communication organisation and we’re about Deaf / Hearing partnership. Being Deaf led we’re the authentic voice of a hard to reach and underserved group; Deaf children and young people. We’ve got a raft of work that needs developing and we need people to do it; need assessments in Europe (the migrant crisis), Pakistan (trafficking of Deaf girls and women for sex and labour), Sierra Leone (the development of paediatric ear & hearing care capacities) and Kosovo (child protection needs of Deaf children) are just for starters. In addition, we’re working with a number of medical Royal Colleges to develop a new global, registered, standard in sexual and reproductive health for Deaf children and young people. So as you might guess, we are looking for some energetic and resourceful people to join our Registry. We’re especially interested in; • Paediatric audiologists – namely those with experience of New Born Screening (NBS) programme design and implementation in primary healthcare settings

• Deaf people with academic or field experience of global health, development and humanitarian work – eg. through academic training or VSO placements • Global health, development and humanitarian programme design, implementation, monitoring & evaluation specialists, with experience, or an interest in Deafness & disability Contributing to our work does not always entail travel overseas; some projects are likely to involve desk-based reviews and also the hosting of visiting partners in the UK. But when deployments do take place, you’ll be paid a daily fee and a per diem as negotiated with the respective donor / partner. Flights and accommodation and also covered, but be advised, we’re not a travel agency; the work is both hard and demanding. Inevitably, there can be a degree of ‘hurry up and wait’ whilst we wait for contracts and assignments to be confirmed, but if you’re interested in being part of a team that’s really making a difference, then drop us your CV, a one pager on what you’re about and a passport photo of yourself to registry@deafkidzinternational.org

DeafKidz International Chestnut Field House, Chestnut Field, Rugby, Warwicks, CV21 2PD

• Child protection specialists with experience of Deafness and disability in complex settings

Registered Charity No. 1151219

• Speech & language therapists

Regd. Company No. 07922360

www.deafkidzinternational.org

• Professionals with experience of working with and supporting the parents of Deaf children in low resource settings

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66

Essentials Council Members / Meeting Dates Officers Dr Huw Cooper – Chairman

BSA COUNCIL MEETNGS

Prof. Kevin Munro – Immediate Past Chairman

Council (3rd Tuesday of the month) – all Trustees and (Advisors when requested / required) All Council Meetings are planned to run from 10.30am 4.30pm, unless otherwise advised nearer the meeting

Prof. David Furness – Secretary

15th March 2016 - Birmingham

Mrs Elizabeth Midgley – Vice Chairperson

Mr Barry Downes – Treasurer Elected Trustees

21st June 2016 - Birmingham 20th September 2016 6th December 2016 - Birmingham

Dr Michael Akeroyd Ms Siobhan Brennan

BSA HOUSEKEEPING MEETINGS

Mr Chris Cartwright

Housekeeping (3rd Tuesday of the month) – for Officers All Housekeeping meetings are planned for 11am - 2pm, unless otherwise advised nearer the meeting

Dr Piers Dawes

17th May 2016 - Birmingham

Mr John Day

16th August 2016 - Birmingham

Dr Nicci Campbell

Dr David Greenburg

15th November 2016 - Birmingham

Dr Ted Killan Dr Helen Pryce Dr Gareth Smith Council Advisors Mrs Donna Corrigan (Professional Guidance Group) Dr Melanie Ferguson (Adult Rehabilitation Interest Group)

Meeting dates and venues may be liable to change and these will be communicated directly to Council if any changes occur new dates will be released imminently. For further information, please contact BSA Admin Office

Ms Pauline Grant (Auditory Processing Disorder Special Interest Group) Ms Katy Morgan (Balance Interest Group) Mr Tendai Ngwerume (Tinnitus & Hyperacusis Special Interest Group) Mrs Yvonne Noon (New Members Representative) Dr Martin O’Driscoll (Audacity Magazine) Mrs Lauren Smalley (Paediatric Audiology Interest Group)

British Society of Audiology Blackburn House Redhouse Road Seafield, Bathgate, EH47 7AQ Tel: 0118 966 0622 Fax: 01506 811477 Email: bsa@thebsa.org.uk Web: www.thebsa.org.uk

Miss Charlotte Turtle (Social Media Coordinator) Dr Peter West (International Journal of Audiology)

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67

Essentials Examination Passes The following students have passed accredited BSA courses over recent months:

BSA Certificate in Industrial Audiometry (Audio-Training) Sarah Davidson

Louise Porter

Billie Butler

Joanne Doran

Susan Broadhurst

Ella Tidswell

Anna Quary

Sarah Skellon

Nick Scoffield

Pedro Meha

Kyle Marshall

Mark Bell

Jason Weightman

Gus Colville

Andy Heslop

Cliff Purvis

Vivien Coltherd

Gary Scott

Elesha Sopel

Angela McCallum

Abbigail Welsh

Penelope Callan

Graham Larmour

Gabrielle Larkin

Gayle Currie

Agatha Lyons

Marian McKenna

Helen McClelland

Shona Anderson

Vivienne Costley

Roisin MacCann

Joseph McCloskey

Marguerite Browne

Christine Connor

Joanna Elliott

Arlene Donnelly

Paulo Alexandre Dos Santos

Jane Walder

Christopher Fazakerley

Oonagh Always

Anne Dempsey

Anne McGee

Elizabeth Weir

Chris Simpson

Sara AnnauCatriona Heath

Kelly Ireland

Mhairi Deas

Gillian Marelic

Jade Welch

Claire McLeod

Valantine Lawson

Lynsay Boyle

Elspeth Chalmers

Julie Falconer

Elaine O’Neil

David Sim

Samantha Eastcroft

Wendy Meldrum

Virginija Kuizinaite

Hilary Best

Lynn Minter

Gill Corner

Nicola Street

Elizabeth Wakeling

Kathryn Gallagher

Sue Carroll

Kerri Tyler

Mary Goves

Lesley Tindale

Sally Hobson

Adele Martin

Phillip Sparks

Cathy McDowall

Sharon Wilkinson

Stella Tomkinson

Claudia Santos

Ruby Thibeault

Gerry Smith

BSA Certificate in Otoscopy & Impression Taking (Adults & over 5’s) (Audio-Training) Roger Williams

Darren Williams

Anna Budwisz

Toni Formoy

Jerrin Johny

Joe Morphew

Joanne Snelling

Daniel Bennett

Earl Panagi

Joy Williams

Neil Bennett

Richard Glover

Bruce Marks

Ashley Small

Mark Skinner

BSA Certificate in Otoscopy & Impression Taking Danielle Boyle

Paris Walker

BSA Certificate in Basic Audiometry and Tympanometry Ciara O’Connor Lauren Darvall Anna Budwisz Abigail Sisson Eileen Morgan Masa Klubicka-Herdic

Congratulations to all candidates Details of all accredited course providers, together with information on providing accredited courses, are available from the BSA office and via the BSA website www.thebsa.org.uk. The BSA also retains a list of delegates who have completed accredited courses.

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68 BSA Connections and Collaborations where we represent you OCTOBER 2016

6th October, London “Developing a population system of care for adults with a hearing loss”

20th November, Leicester “Meeting with De-Montfort University” 26th – 27th November, Harrogate “Attendance at the British Academy of Audiology’s Annual Conference”

13th October, London “The Ear Foundations Conference on Adult Deafness; Bending the Spend”

27th October, Birmingham “Meeting with British Society of Hearing Aid Audiologists and the British Academy of Audiology” NOVEMBER 2016

13th -14th November, University Clinical of Navarra, Madrid, Spain “Vestibular Testing: Today’s Advances” a conference held by the Department of Otolaryngology, and Otometrics

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25th January, “Alliance meeting” 27th January, Hamilton “Meeting with Oticon and Interacoustics”

DECEMBER 2016

FEBRUARY 2017

11th December, London “Meeting with the Association of Chartered Physiotherapists in Vestibular Rehabilitation”

16th February, Coventry “Meeting with loop manufacturer, Contacta”

JANUARY 2017

8th March, London, “Meniere’s Society – Balance Professionals Dinner”

15th January, Nottingham “Meeting with the Institute of Hearing Research” 20th January, Derbyshire “Meeting with the British Academy of Audiology”

MARCH 2017

APRIL 2017 7th April, Birmingham “Humanitarian work in Audiology and ENT” with ENT UK

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Essentials Sponsor Members The partnership with Sponsor members of the British Society of Audiology (BSA) is of fundamental importance to the Society. As the largest multidisciplinary society concerned with hearing and balance in the UK, the BSA seeks to include commercial colleagues and organisations in its mission to promote knowledge, research and clinical practice in these areas. Being a Sponsor member places an organisation in close dialogue with senior members of the BSA, supporting meetings and publications. The outworking of this are yearly meetings between the Officers of the BSA and the Sponsor members to share information and perspectives on the strategic direction of the BSA. Sponsor members have direct input to the Learning Events Group, and their input is especially valued in the organisation of meetings and supporting exhibitions, these being a crucial element of successful events. ACOUSTIC METROLOGY LIMITED Manufacturers of VRA systems. Repair service of Audiometers, tympanometers and acoustics instruments. E: info@a-met.com W: www.a-met.com

INDUSTRIAL ACOUSTICS COMPANY LTD World leader in the design, supply and installation of high performance, state-of-the-art of Audiometric Rooms. E: info@iac-acoustics.com W: www.industrialacoustics.com/uk

GN RESOUND LIMITED ReSound is part of GN ReSound Group, one of the world’s largest providers of hearing instruments and diagnostic audiological instrumentation E: iinfo@gnresound.co.uk W: www.gnresound.co.uk

OTICON LIMITED Oticon designs and manufactures both hearing solutions for adults, and specialized paediatric instruments. E: info@oticon.co.uk W: www.oticon.co.uk

SIVANTOS LIMITED Leader in the provision of digital hearing systems to the NHS and private hearing aids dispensers. E: info-hearingaids.shi.ukhealthcare@ siemens.com

AUDITDATA LIMITED Auditdata provides office management systems for hearing clinics, innovative audiometry fitting systems, and hearing instrument testing. E: uksupport@auditdata.com W: www.auditdata.com

OTODYNAMICS LIMITED Otodynamics Ltd. pioneered OAE screening 25 years ago and sells a wide range of OAE screening and diagnostic instruments and makes in-house research and development its top priority E: sales@otodynamics.com W: www.otodynamics.com

SPECSAVERS Specsavers is largest provider of the free NHS digital hearing aids and 60% of its 17.3m customers in the UK are from the NHS. W: www.specsavers.co.uk

BIOSENSE MEDICAL LIMITED Biosense Medical supply specialist equipment for use in Audiology, Vestibular and Balance, Neurophysiology, Pressure Measurement, Human Movement and Biomechanics W: www.biosensemedical.com

PHONAK UK Phonak offers latest product information, an interactive content about hearing and a specific children section W: www.phonak.com

THE BRITISH TINNITUS ASSOCIATION The British Tinnitus Association (BTA) is a world leader, with a trained team of friendly and experienced advisers for anyone who experiences tinnitus or those simply seeking guidance or information about the condition E: info@tinnitus.org.uk W: www.tinnitus.org.uk

FREEMAN HOSPITAL Audiology Department Freeman Hospital Newcastle

PURETONE Limited Manufacturers of quality digital and analogue hearing aids, tinnitus management systems. E: info@puretone.net W: www.puretone.net

THE TINNITUS CLINIC The Tinnitus Clinic is the leading provider of the latest evidence-based tinnitus treatments in the UK. W: www.thetinnitusclinic.co.uk

GUYMARK UK LIMITED Guymark is a distributor of GSI audiological equipment, Vivosonic ABR equipment and Micromedical Technologies balance equipment E: sales@guymark.com W: www.guymark.com

QUIETSTAR With over 100 years collective experience within the design, manufacture, delivery and installation of noise control products and services, QuietStar Limited is fast becoming the UK’s leading noise control provider. E: info@quietstar.co.uk W: www.quietstar.co.uk

P C WERTH LIMITED PC Werth supplies calibrate and service the UK’s leading range of instruments for every diagnostic and audiology need. E: sales@pcwerth.co.uk W: www.pcwerth.co.uk

AMPLIVOX LIMITED Amplivox provides a range of audiological products and services that combine innovation and reliability E: n.court@amplivox.ltd.uk W: www.amplivox.ltd.uk

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Essentials Audacity Advertising rates THE BSA ADVERTISING RATES : 2016 / 17 The following rates are in to force on 1st June 2016 and will be in place for 12 months. The British Society of Audiology provides different methods of advertising opportunities which are listed below. All prices are subject to VAT

Website Advertising (up to 2months) Cost (£) Jobs listing x 1* £ 455 Each additional job advertised (50% discount)* £ 225 Commercial courses/events £ 285 Non-commercial external events/courses £ 55 *

includes entry to that months e-Update

Website Advertising (up to 12months) Commercial courses/events Non-commercial external events/courses

£ 1,155 £ 205

Mailshot to BSA members (in the BSA e-Update email sent out on the 15th of each month) Job listings* £ 455 Each additional job advertised (50% discount)* £ 225 Commercial courses/events £ 215 Non - commercial courses/events £ 65 *

includes a 1 month website advert

Mailshot to BSA members (for job listings only) Job listings £ 260 Each additional job advertised (50% discount)* £ 130

COMBINED ADVERT (Website for 1month + one e-Update email) - 15% discount Commercial courses/events £ 425 Non-commercial external events/courses £ 100 Mailing/Special Single A4 sheet (flyer provided by the customer) £ 1,120 Single A4 sheet (B/W printed by BSA) £ 1,620 Audacity Magazine: (per issue) - sponsors receive around 35% discount 1/2 Page (sponsors) colour £ 340 1/2 Page (non-sponsors) colour £ 520 Full A4 Page (sponsors) colour £ 570

Full A4 Page (non-sponsors) colour £ 890 Full page colour inside front cover or back cover (non-sponsor) £ 970 Full page colour inside front back cover (sponsor) £ 630 Technology Update per issue £ 240 Single A4 sheet (flyer provided by the customer) £ 675 Single A4 sheet (B/W printed by BSA) £ 940 Audacity Magazine - Special Rates (annually in both publications) - 15% discount Full page colour 2 issues (sponsor) 1/2 page colour 2 issues (sponsor) Full page colour 2 issues (non-sponsor) 1/2 page colour 2 issues (non-sponsor)

£ 970 £ 580 £ 1,780 £ 885

Premium advertising packages Full page in Audacity (one issue) + Web listing (2months) + Bulk Email (one email) £ 1,445 1/2 page in Audacity (one issue) + Web listing (2months) + Bulk Email (one email) £ 1,045 Full page colour in Audacity [unlimited words] (one issue) + Web listing (2 months) £ 1,255 1/2 page colour in Audacity [unlimited words] (one issue) + Web listing (2months) £ 810 1/4 page colour [200 words] (one issue) + Web listing (2months) £ 620

2016 / 17 - AUDACITY PUBLICATION SCHEDULE Advertisements (copy date deadline)

Audacity (dispatch date)

1st October 2016 1st April 2017

15th November 2016 15th May 2017

For further information please contact the BSA Admin Office by: Email: bsa@thebsa.org.uk or Tel: 0118 966 0622

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For more information visit

www.thebsa.org.uk Audacity April16.indd 72

@BSAudiology1 The British Society of Audiology

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