Notes

MKK4-MPK3-WRKY17-mediated salicylic acid deterioration boosts the likelihood of Glomerella leaf place throughout apple.
This review has been carried out to inform recommendations about which questionnaires are most clinically and cost effective and valuable in contributing to the best possible management strategy for a person with tinnitus. Separate reviews focus more specifically on assessment of psychological impact and quality of life (evidence reviews F and G).Tinnitus can have an important negative impact on a person’s quality of life. It can affect how they go about their usual daily activities and impact on work, school, home and relationships as well as their mental health. The majority of tinnitus management strategies are focussed on improving the quality of life of the person living with tinnitus. Whilst the majority of management strategies available cannot permanently obliterate the tinnitus percept, they can increase acceptance of the tinnitus and improve quality of life. It is useful to assess quality of life to enable a management plan to be developed between the healthcare professional and the person with tinnitus. This review considers the most clinically and cost-effective way to assess the impact tinnitus has on quality of life. These assessments would be followed up by appropriate interventions for tinnitus and the resulting patient outcomes assessed. These assessments can also be used to record and assess progress after using the interventions described in other reviews.A number of physiological mechanisms for tinnitus have been proposed. One of these proposed mechanisms is that the perception of tinnitus is caused by abnormal synchronisation of neural activity in the central auditory nervous system. Neuromodulation aims to normalise neural activity of the auditory system, thereby reducing the perception of tinnitus. There are a variety of methods which report to use a neuromodulation approach. Neuromodulation therapies may involve the application of electrical, acoustic and/or magnetic energy to the head or neck to alleviate the tinnitus symptoms. None are currently available on the National Health Service. The aim of this review question is to examine the evidence to determine whether neuromodulation is a clinically and cost effective treatment for people with tinnitus.While tinnitus is recognised as a physical symptom it is understood that it can have a profound emotional impact and that this is a major factor in the degree of suffering experienced. There are a variety of different psychological therapies available currently within the NHS as interventions for a broad range of presentations. The following therapies have been applied either clinically or within a research context for people with tinnitus cognitive behavioural therapy (CBT), mindfulness-based interventions e.g. mindfulness based cognitive therapy (MBCT) and mindfulness based stress reduction (MBSR), brief solution focused therapy, narrative therapy, acceptance and commitment therapy (ACT) and Eye Movement Desensitisation and Reprocessing (EMDR). These psychological therapies can be used with adults and can also be adapted for use with children and young people. Current practice includes psychological therapies within individual and group settings. When working with children, this often involves also working with their families and possibly schools. CBT has been the main focus clinically and within research. Cognitive Behaviour Therapy (CBT) is based on the theory that an individual’s distress arises out of an interaction between their environment and past experiences, thoughts (cognitions), behaviour and physiological experiences. The aim of this review is to determine the clinical and cost-effectiveness of psychological therapies including cognitive behavioural therapy and mindfulness based cognitive therapy in improving psychological outcomes and the impact of tinnitus on the person.In certain groups of individuals with tinnitus, it is important to image the head and neck to exclude an organic cause for their symptoms. The role of imaging is to detect specific pathology that can be treated. A variety of imaging modalities may be considered depending on the type of tinnitus (pulsatile/non-pulsatile) and/or associated symptoms reported. Imaging modalities include ultrasound, computerised tomography and magnetic resonance imaging. A thorough history and clinical examination can direct the decision for imaging and the type of imaging. Non-pulsatile tinnitus, which is heard as a continuous sound, is more common than pulsatile tinnitus. It can be idiopathic or associated with ontological, neurological or metabolic disorders. Unilateral or asymmetrical non-pulsatile tinnitus that is associated with neurological, audiological or head and neck signs and symptoms is more likely to indicate pathology than bilateral tinnitus or where there are no associated signs and symptoms. Following medical examination, healthcare professionals need to decide whether people with non-pulsatile tinnitus should be offered medical imaging, with options including CT scans, MRI and MRA. Scanning allows the diagnosis of significant and often treatable underlying diseases, for example a vestibular schwannoma which can cause tinnitus by compressing adjacent structures. Whilst it is crucial not to miss significant pathology, it is also important not to scan people where significant pathology is unlikely. Not only is this cost unnecessary, it may be unpleasant and stressful for the person and possibly expose them to an unnecessary dose of ionising radiation.This guideline covers the assessment, investigation and management of tinnitus in primary, community and secondary care. It offers advice to healthcare professionals on supporting people presenting with tinnitus and on when to refer for specialist assessment and management. For adults with tinnitus and hearing loss, this guideline should be read together with the NICE guideline on hearing loss in adults.People with tinnitus who seek help often do so because the tinnitus is causing some level of distress or because they believe it may be a symptom of some underlying serious disease. Support may include reassurance and tinnitus counselling. Tinnitus counselling, however, means many things to many people. Rapamycin Clinicians, as well as people with tinnitus, have differing perceptions about the meaning of the term. Currently, ‘tinnitus counselling’ may be used to describe a brief information-giving session or a series of sessions facilitated by a psychologist, or anything in between. For the purpose of this guideline, the term ‘tinnitus support’ is favoured over ‘tinnitus counselling’ and is defined as an interactive process between the individual with tinnitus and healthcare professional. Within this, the concerns and needs of the individual are identified and explored, including difficulties associated with tinnitus and the individual’s understanding of the emotions related to tinnitus. As part of this process, delivery of information about tinnitus involves a two-way discussion promoting an understanding of the tinnitus.
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