DRAFT
UNION EUROPEENNE DES MEDECINS SPECIALISTES (UEMS)
EUROPEAN UNION OF MEDICAL SPECIALISTS (UEMS)
Hearing and Balance in adults
Training Programme and Logbook
October 2012 / revised October 2013
Subspecialty working group:
Chair Kajsa-Mia Holgers
Ligija Kise
Ulf Schönsted-Madsen
Rene Dauman
Heikko Löppönen
Eva Raglan
Consensus curriculum
• This document presents the content of the hearing and balance module
based on the curriculum for audiovestibular medicine, speciality
concerned with investigation, diagnosis and management of disorders of
balance, hearing ,tinnitus and auditory communication.
• The aim of the curriculum is to define the core competencies including
knowledge , skills and attitudes for a specialist practicing that subject as
applied to adults.
• Paediatric audiology although an intergral part of audiovestibular
medicine in some countries ,is practiced separately in the others or in
conjuction with phoniatrics in some other countries. ( the curriculum for
peadiatric audiology is within the Phoniatrics training program and
logbook document).
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curriculum
• General internal medicine and neurosciences
form the basic foundations for Hearing and
Balance module. Modern care for hearing and
balance disorders requires the whole system
approach in which the “ ear “ problem is not
considered in isolation but as part of the
patient’s overall health.
• Multidisciplinary team
curriculum
• This curriculum adapted from the Audiovestibular
Medicine Curriculum of the Royal College of Physicians of
England 2010/2013, comprises two main fields of clinical
practice, that of Adult Hearing and Adult
Balance/Vestibular.
• In addition and common to all the fields are the backround
knowledge, generic skills and experience in related
medical disciplines. Training in those specific areas can
occur either before or during specialist training.
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• This training program is a guide for trainers and trainees,
and is endorsed by the International Association of
Audiovestibular Physicians. .
CONTENT -logbook of training sections
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2.1
Background Knowledge
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a/Basic Sciences
b/Preventive Medicine
c/ Instrumentation
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Generic skills
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a/ clinical skills
b/ communication skills
c/ attitudes
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Core Fields
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a/ Adult Hearing Section
a/1/ knowledge base, skills and attitudes
b/ Adult Balance Section
b/1/ knowledge base, skills , attitudes
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2.4
. Practical procedures
a/ for specialist in adult hearing disorders
b/ for specialist in adult balance disorders
CONTENT
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2.5 Related medical disciplines
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a/ otolaryngology
b/ neurology
c/ophthalmology
d/psychology/ psychiatry
e/genetics
f/care of the elderly
g/ immunology and allergy
h/ radiology
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3.
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Learning and teaching , training programs
a/ Diploma in Audiovestibular medicine ( relevant modules)
b/ Requirements of training posts
4.
Assessments
2. BACKGROUND KNOWLEDGE
a) BASIC SCIENCES
A sound and comprehensive knowledge of the basic sciences subserving the audiological and vestibular systems is essential to
practice.
Knowledge
Detailed anatomy, physiology, neurochemistry and pharmacology of the auditory
and vestibular systems, their central pathways and connections and related
systems or organs.
Embryological development of the above.
Psychology of hearing and balance including psychoacoustics.
Basic acoustics including room acoustics.
Requirements for sound proofing.
Standards relating to acoustics, calibration and audiological medicine.
Physics of sound, waves and motion.
Basic electroacoustic properties of hearing aids.
Recent advances in molecular biology: repair and regeneration in relation to the
cochlea and vestibular system, stem cell research in relation to the ear, genetic
manipulation etc.
Performance
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b) PREVENTIVE MEDICINE
Knowledge
General principles of primary, secondary and tertiary prevention
Screening principles, methods and practice; including setting up a screening
programme in a district, dealing with screen failures, monitoring and audit
Screening for hearing loss — newborn, school, industrial, elderly etc.
Noise and its effect on the audio-vestibular system, damaging noise levels, sources
of such noise and prevention of exposure including noise surveys, hearing
conservation, ear protection and international standards
Ototoxicity; substances and drugs that affect the audio-vestibular system and their
effects, including industrial toxins
Genetics affecting predisposition to ototoxic agents
Epidemiology and prevention of hearing loss
Role of immunisation and therapy in the prevention of hearing and balance
disorders
Performance
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c) INSTRUMENTATION
Practice of hearing and balance specialist requires a comprehensive knowledge of auditory and vestibular
test equipment, and of amplification, including assistive listening devices for adults .
Knowledge
Principles, technology and limitations of auditory and vestibular test
equipment
Analogue and digital hearing aids, including body worn, post aural, in the ear,
in-the-canal, totally-in-the-canal aids, vibrotactile aids, bone-anchored
hearing aids (BAHA), frequency transposition aids, CR05 (contralateral
routing of signal) and BiCR0S aids and implantable hearing aids including
cochlear implants
Hearing aid fitting formulae and real ear measurements in adult practice
The “plumbing system” (hooks, moulds, tubing etc) and its effect on sound
amplification
Assistive devices available including the radio aid and FM soundfield systems,
alarm systems, loop systems
Methods of assessing benefit of amplification in adults
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c) INSTRUMENTATION Continued
Skills: To be able to:
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Critically review audiometric and vestibular test results
Determine the appropriateness and type of amplification (including
cochlear implant) through discussion with audiological colleagues,
patients
Discuss the current best technology with both patients, their families,
and other professionals
Refer appropriately for amplification
To have practical experience of:
Selecting, testing and fitting of hearing aids including BAHA and cochlear
implants in adults
Measuring benefit of amplification
Use of hearing aid test box for testing hearing aids and measuring
insertion gain and RECD
3. GENERIC SKILLS
Aside from the generic
skills required of all
practicing doctors there are
specific required generic
skills These are an
integral part of training in
all aspects of the work.
a. SKILLS
Clinical Skills: To be able to:
Take an accurate, relevant and detailed history of auditory and vestibular
disorders and associated problems from the patient or their carer
including a developmental or psychosocial history.
Perform a relevant and detailed clinical examination, including ENT,
neuro-otological, oculomotor, neurological, and full general examination.
Select and interpret audiological, vestibular and aetiological tests
appropriate to the patient’s presentation, age and additional difficulties
Select and interpret appropriate multidisciplinary assessments including
speech and language assessment, psychometric assessment
Integrate the history, examination and investigative findings and
formulate a diagnosis and management plan
Select appropriate management strategies through multidisciplinary team
discussion and discussion with the patient and carers; e.g. hearing aids,
tinnitus instruments, cognitive therapy, relaxation, pharmacological
options, physiotherapy, occupational therapy, educational strategies,
surgical options - depending on the cause and impact of the problem and
the age and additional disabilities of the patient
Assess the impact of a management strategy using appropriate outcome
measures
Assess disability accurately and judge occupational fitness e.g. use of
machinery and fitness to drive
Identify additional medical problems which may be causative or may
adversely affect rehabilitation e.g. visual defects, neurological disease,
endocrine disease, joint pathology, cardiac disease, developmental delay
Identify psychological problems needing psychology/psychiatric referral
Identify syndromic and genetic causes of hearing and balance disorders
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3. GENERIC SKILLS - Continued
Communication Skills: to be able to:
Communicate effectively with patients of all ages, including the elderly
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with disorders of hearing
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with poor speech production due to deafness or other disorders of speech
and language
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with visual disorders including the deaf-blind
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with intellectual disability
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needing sign language or spoken language interpretation in order to
explain clearly to all patients and their carers the results of investigations,
the management options and the prognosis of audiovestibular problems
so that they understand and can make informed decisions, where able to
do so.
Communicate effectively with colleagues within the multidisciplinary team and
with specialists in other disciplines
Determine the communication abilities and needs of the congenitally deaf and
the deaf/blind patient and where needed use finger spelling and some basic
signs
Counsel the patient appropriately
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b. ATTITUDES
The specialist must recognise and understand:
The need for an empathetic, tactful and positive approach
The impact of disorders of hearing and balance on the individual and their
family with regard to everyday function including employment, psychology and
social interaction
The impact of disorders of hearing on the development and maintenance of
speech and language and education
The combined effect of deafness with other difficulties, such as visual defects,
learning disability etc.
The importance of holistic care
The importance of the history including family history & developmental history
in making a diagnosis.
The importance of a social, educational and psychological history in managing
individuals with audiovestibular impairment
The importance of education of significant others to aid rehabilitation
The value of multidisciplinary team working both within and outside the clinic
The attitudes of those within the Deaf Community
The use and value of complementary medical approaches to holistic
management of tinnitus and of otitis media with effusion
The importance of patient confidentiality and informed consent.
The importance of effective multidisciplinary team work and communication
with colleagues both verbally and in writing
The importance of sharing information with patients and their carers
The value of voluntary agencies in supporting the patient with hearing and
balance disorders and their family/carers
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4.. CORE FIELDS
a. Adult “ Hearing” module
Clinical Topics - Knowledge Base
Tinnitus
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Aetiological and triggering factors
Current pathophysiological theories about tinnitus generation
Prevalence of tinnitus and its natural history of habituation.
Audiometric and aetiological investigations
Psychological effects on the patient and how these can be
managed
Management of patients with tinnitus including instrumentation
Sudden hearing loss
Presentation and causes.
Audiological and aetiological investigations
The psychological impact of sudden hearing loss, particularly if
permanent and bilateral.
Current evidence based management of acute presentation
Management including indications for surgery, communication
strategies and hearing tactics
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Clinical Topics - Knowledge Base - Continued
Unilateral hearing loss, progressive or fluctuating unilateral or
bilateral hearing loss
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Presentation and causes
Audiometric and aetiological investigations
Identification of site of lesion
Impact on the patient
Current evidence based pharmacological management
Indications for surgical referral.
Hearing problems in younger adults
Conditions leading to hearing problems in younger adults
Audiometric and aetiological investigations
Current evidence-based management of hearing problems including
pharmacological, surgical, audiological and rehabilitative
The possible impact of the hearing problems on the individual’s life
and the effect on immediate family members, including psychosocial
and speech & language issues
Management including:
i.
appropriate instrumentation and the benefits and limitations
e.g. Hearing aids, BAHA, CI, tactile and environmental aids
i.
non instrumental rehabilitation e.g. Hearing tactics,
speechreading
External support agencies, voluntary bodies and policies including
employment support
Clinical Topics - Knowledge Base - Continued
Congenitally deaf adult
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Causes of congenital deafness/hearing impairment
Effects on speech & language and communication
Impact on individuals and significant others, including psychosocial
effects
Associated symptoms such as tinnitus or balance difficulties
Alternative communication systems
Deaf culture and the local support facilities for deaf people
Hearing aids and environmental aids
Rapid advances in the research of genetic deafness and its impact on
patient management
Hearing problems in the elderly
Causes of hearing impairment in the elderly.
Effects of the general ageing process on the auditory system
General medical problems or other impairments which might affect
rehabilitation e.g. Loss of tactile sensitivity, joint mobility, blindness,
poor memory
Associated problems such as balance disturbance and falls
Psychosocial issues including feelings of isolation and avoidance
Rehabilitative approaches in the elderly
External support agencies, voluntary bodies and policies e.g. Social
workers
Date
Clinical Topics - Knowledge Base - Continued
Dysacuses, auditory processing disorders (APD) and auditory
neuropathy/dysynchrony (AN/AD)
Performance
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Presentation and causes of dysacuses, APD and AN/AD
Investigation and management of dysacuses and their causes
Methods of testing the function of the different parts of the central
auditory pathway
The rehabilitative approaches available for APD and AN/AD
The psychosocial effects of these hearing difficulties
Intellectually disabled adult
Audiological or neuro-otological problems that may be associated with
intellectual handicap and the specific effects that such problems may
have
Presentation, diagnosis, investigation and management of hearing
problems in adults with learning difficulties
Rehabilitative approaches available for such patients
Issues concerning ‘consent’ in these patients
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b. Adult “ Balance “ Module
Background Knowledge Specific to the Field
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An understanding of vestibular test equipment, investigative
techniques, and interpretation of results
The anatomy and physiology of the vestibular system, its central
connections and interactions with the visual and oculomotor
systems.
When and to whom to refer adults with balance problems e.g.
psychology, social services, neurology, cardiology, ophthalmology,
physiotherapy, occupational therapy etc.
An understanding of multidisciplinary working and its value
The existence of national guidelines and their value and limitations.
The specialist should be able to
Determine the cause of acute and chronic vertigo, chronic imbalance,
drop attacks and falls in the elderly
Assess the impact of the balance disorder on the individual
Select and interpret an appropriate set of investigations
Identify factors likely to affect rehabilitation
Define a management plan
Explain to the patient the likely cause and outcome of the problem
Identify those patients for whom the condition affects their fitness to
drive
Adult Balance - Clinical Topics - Knowledge Base
Acute vertigo
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Causes, presentation and natural history of acute vertigo
Associated eye movement abnormalities
Audiovestibular and aetiological investigation
Management options, including rehabilitation, dietary manipulation,
pharmacological and surgical
Recurrent disequilibrium
The sensorimotor physiology involved in balance maintenance
Causes of peripheral and central vestibular disorders with remitting and
relapsing courses
Factors hindering vestibular compensation including pathology in other
stabilising sensory and motor effector systems
The psychological impact of recurrent disequilibrium
Vestibular tests and aetiological investigation
Management options including pharmacological, physical rehabilitation and
psychological /psychiatric interventions
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Adult Balance - Clinical Topics - Knowledge Base
Chronic imbalance
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The range of central vestibular disorders causing chronic imbalance
Pathology in the stabilising sensory systems which give rise to
multisensory imbalance
Pharmacotherapeutic agents causing chronic imbalance
Aetiological and vestibular investigations
Management options
Blackouts/drop attacks
The mechanisms of epilepsy, pseudo-epilepsy, syncope, vasovagal attacks,
and blackouts, and to
know the aetiological factors involved
The investigation protocol and type of abnormalities found for each of
the above
The pharmacotherapeutic options available to treat each cause
The law regarding black-outs and syncope and fitness to drive
Adult Balance - Clinical Topics - Knowledge Base
Falls in the elderly
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The effects of ageing and neurological disorder on the postural and
righting reflexes
The causes of black-outs and drop attacks including cardio- and
cerebrovascular pathology
The musculo-skeletal disorders impairing maintenance of the upright
posture and locomotion
Audiovestibular and aetiological investigations
The pharmacological and physiotherapeutic management options
Skills
With regard to the above stated clinical topics a specialist in addition to the generic skills
outlined in Section 2.2 needs:
To be able to:
Performance
Category
Distinguish peripheral from central vestibular causes of vertigo and
define site of lesion in the CNS
Carry out particle repositioning manoeuvres e.g. Epley, Semont etc
Instruct the patient in appropriate exercises e.g. Cawthorne-Cooksey,
Brandt-Darroff, customised, exercises and protocols for visual vertigo
Attitude
With regard to the above stated clinical topics a specialist in this filed, needs to
develop the attitudes outlined in Section 2.2.c.
5. PRACTICAL PROCEDURES
a. PRACTICAL PROCEDURES – specialist in adult hearing disorders
Knowledge:
Theoretical basis of audiological testing See Basic Sciences section 2.1a
Indications for the various audiological tests
Values, limitations and practical difficulties of audiological testing
Performance
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a. PRACTICAL PROCEDURES – specialist in adult hearing disorders - Continued
Skills
Performance
Category
Select appropriately and interpret correctly all the following audiological tests.
Practical experience of all the following tests. Competency in performing
particular tests will depend on the specific clinical practice of the country.
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Subjective tests of hearing and auditory function:
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Pure tone audiometry (air conduction, bone conduction with or without
masking)
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Behavioural and conditioning techniques for soundfield and ear specific
audiometry in
learning disabled adults
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Speech perception tests including speech in noise
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Tests of auditory processing
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Objective tests of auditory function
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Acoustic immitance measures and middle ear reflex measures
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Otoacoustic emissions (transient, distortion product, spontaneous, contralateral
suppression)
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Evoked responses (electro-cochleography, auditory brainstem responses,
middle latencies,
cortical responses, auditory steady state responses etc)
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b. PRACTICAL PROCEDURES- Specialist in adult balance / vestibular disorders
Knowledge:
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Theoretical basis of vestibular testing see Basic Sciences section 3a
Indications for vestibular testing
Values, limitations and practical difficulties of vestibular testing in adults.
Age-related changes in postural control and responses to visuo-vestibular
stimulation
Skills:
To be able to select appropriately and interpret correctly all the following
vestibular tests in adults.
To have practical experience of all the following tests. Competency in
performing particular tests will depend on the specific clinical practice of the
country
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Dix-Hallpike testing
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Video-nystagmoscopy
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Caloric irrigations
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Posturography , HTT, VDA
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ENG/EOCJ recordings during visuo-vestibular stimulation
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Vestibular evoked myogenic potentials (VEMPs)
To be able to integrate the results of audiological, vestibular and aetiological
tests to formulate a diagnosis and a management plan
6. RELATED MEDICAL DISCIPLINES
a, OTORHINOLARYNGOLOCY
Objectives:
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To gain a detailed knowledge of pathology and management of
otological conditions
To observe audiology related ENT surgery such as grommet
insertion, mastoidectomy,
tympanoplasty, surgery for cochlear implantation, bone anchored
hearing aids and vestibular
schwannoma.
To be experienced and competent in use of ENT referral criteria
To gain knowledge of rhinological, oropharyngeal, upper airway and
other head & neck
conditions that may affect the audiovestibular system and speech.
Knowledge:
Embryology, anatomy, physiology of the ear and head & neck
Pathology, appropriate investigations (including imaging) and
management of congenital, acquired and other conditions of the
ear including indications, risks, outcomes and complications of
surgery
Head and neck conditions that may produce aural symptoms
including conductive hearing loss, and their appropriate
management
a, OTORHINOLARYNGOLOCY - Continued
Skills: To be able to:
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Take a full otological/ENT history relevant to the audiovestibular
system and speech.
Perform an accurate and comprehensive examination of the ear, nose,
oral cavity, pharynx and head & neck including use of otoscope,
operating microscope, head mirror
Examine the ear competently using a microscope and describe and
identify abnormalities accurately.
Identify and treat causes of otalgia, external and middle ear
dysfunction
Perform intratympanic injections of medications
To be competent at:
Removal of wax and debris from the external auditory canal using
appropriate instruments, syringing or suction either under direct
vision or using the operating microscope as appropriate
b. NEUROLOGY
Objectives
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To make an accurate neurological assessment of a patient
To know when to refer a patient to a neurologist or a neurosurgeon
Knowledge
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Causes of central audiological and vestibular disorders
Neurological disorders with neuro-otological manifestations
Investigation protocols for the above disorders
Pharmacological treatments and side-effects of common neurological
disorders with neuro-otological manifestations
Skills: To be able to:
Take a complete neurological history and perform competently a full
neurological examination
Recognise neuro-otological manifestations of neurological disorders
and select appropriate investigations
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c. OPHTHALMOLOGY
Objectives:
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To know how to screen a patient for ophthalmological and
oculomotor disorders
To know when to refer a patient with such symptoms
Knowledge:
Ophthalmological disorders with associated audiological and
neuro-otological manifestations
Eye movement disorders
Impact of visual disorders on balance and the confounding
effect upon vestibular test procedures
Impact of visual problems on communication for the hearing
impaired
Management of common visual problems
Causes, impact and management (including the role of
voluntary bodies) of dual sensory impairment
Skills: To be able to:
Take a history of ophthalmological symptoms from a patient
Make an accurate assessment of a strabismus, latent nystagmus,
saccades, smooth pursuit, spontaneous and optokinetic
nystagmus
Perform a full ophthalmological examination and correctly
recognise optic field defects, papilloedema, conjunctivitis,
choroiditis, iritis, retinitis and disordered eye movements
Recognise relevant and common visual disorders i.e. Altered
visual acuity. strabismus, benign intracranial hypertension,
glaucoma, presby- and hyper-metropia
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d. PSYCHOLOGY/PSYCHIATRY
Objectives:
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To understand the psychological difficulties and psychiatric disorders
associated with deafness and hearing impairment and the
presentation of these disorders in the deaf patient
To understand the psychological difficulties and psychiatric disorders
associated with tinnitus, dysacuses, vertigo and imbalance
To obtain an adequate psychological profile, to recognise manageable
conditions and refer appropriately
To acquire appropriate counseling skills
Knowledge:
Psychiatric disorders with audiological and vestibular manifestations
How psychotropic medication may influence audiovestibular disorders
Psychological/psychiatric morbidity of neuro-otological disorders,
tinnitus, dysacusis and sudden hearing loss
Pathogenesis and presentation of non-organic hearing loss.
Psychological morbidity of hearing impairment including dual sensory
impairment
Presentation of psychological problems and psychiatric disorder in the
congenitally deaf patient
Skills: To be able to:
Identify behavioural disturbances and psychiatric disorder from the
clinical presentation
Discuss psychological/psychiatric disorder appropriately with patient
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e. GENETICS
Objectives:
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To obtain an understanding of genetics in audiovestibular disorders
and the role of the clinical geneticist
Knowledge:
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Inheritance patterns of hearing loss.
Genetics of and available tests for conditions associated with
audiovestibular disorders.
The psychological impact of genetic disorders.
Skills: To be able to:
Elicit and record correctly a detailed family tree.
Interpret correctly a diagnostic DNA report together with its
implications
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f. CARE OF THE ELDERLY
Objectives:
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To obtain an overview and understanding of the medical conditions
affecting the elderly including falls, multi-system disease, cognitive and
visual impairment
Knowledge:
Common causes of falls and imbalance in the elderly.
The effect of ageing on cognition and memory
The impact of multi-system disease and its pharmacological management
Roles of other members of the multi-disciplinary teams caring for the
elderly.
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g. IMMUNOLOGY & ALLERGY
Objectives
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To understand the effect of disordered immunity and allergy on the
audiovestibular system
Knowledge:
The pathophysiology, presentation, diagnosis, management and prognosis of
auto-immune diseases that affect the audiovestibular system
The pathophysiology, presentation, diagnosis and management of allergy
affecting audiovestibular function, in particular allergic rhinitis
Immune deficiency disorders affecting the audiovestibular system their
pathophysiology, diagnosis and management
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h. RADIOLOGY
Objectives
To appreciate the value of imaging in the diagnosis and management of
audiovestibular disorders
Ability to select and request optimal imaging technique and views for
specific disorders
Knowledge
The congenital and acquired abnormalities of the petrous temporal bone
and central nervous system that can be identified by radiological imaging
techniques, such as CT scan, MRI scan, fMRl scan and PET scans.
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Training programs
Diploma / MSc in Audiovestibular Medicine ( UCL)
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SYLLABUS( Diploma)
Module 1 – Audiovestibular Physics
Module 1.1 –
Physics and Acoustics
Module 1.2 –
Statistics and Research Methodology
Module 2 – Anatomy and Physiology
Module 3 – Audiovestibular Diagnosis
Module 4 – Clinical Disciplines Allied to Audio vestibular Medicine
Module 4.1 –
Pathology, Speech and Language, Genetics &
Radiology
Module 4.2 –
Evidence based Medicine, Immunology,
Ophthalmology,
Psychology/Psychiatry.
Module 5 - Vestibular Medicine
Module 6 - Clinical Auditory Medicine – Children and Adults
Training programs
Requirements of the training posts
• In institutions with appropriate standard of clinical governance
• Training posts must provide the necessary clinical exposure
• Training posts must provide the evidence that required supervision and
assessments can be achieved.
• The sequence of training should ensure appropriate progression in
experience and responsability
• The trainees have access to all facilities required to gain practical
competencies
• Training should take place in a range of district general hospitals ,teaching
hospitals ,community clinics.
• Trainee has an educational and clinical supervisors
• Learning through observation, clinical practice, attendance at regional
training days, presentations, national audit meetings, attendance at
lectures, tutorials, journal reviews, additional courses, research projects,
ASSESSMENT METHODS
Principles
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It is expected that trainees will undergo regular assessment of competencies in
the various areas of the curriculum covered according to the training
requirement of the individual country.
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The intergrated assessment system should comprise both work based
assessments and knowledge based assessments ( Diploma or similar course)
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Workplace assessments should take place throughout the training program to
allow trainee to continually gather evidence of learning and to provide trainee
with formative feedback.
Assessments methods
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Workplace based assessments
MSF – multisource feedback
Mini-Cex-miniclinical evaluation exercise
CBD - case based discussion
DOPS – direct observation of practical skills
PS
- patient survey
TO teaching observation
Assessments methods
• MSFcommunication, leadership,team working, reliability
• Mini-CEX competencce in practical skills,essential good clinical care
• CbD
competence in clinical reasoning, decision making,
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application of medical knowledge to patient care.
• PS
behaviour of the doctor,effectiveness of the consultation,
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assessment of interpersonal skills, communication skills,
professionalism,
Reference:
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Specialty Training Curriculum for Audiovestibular Medicine May
2010/2013. Joint Royal College of Physicians Training Board
http://www.jrcptb.org.uk/trainingandcert/ST3-SpR/Pages/AudiologicalMedicine.aspx
• Diploma/ MSc in Audiovestibular Medicine , UCL, London