Through molecular dynamics (MD) simulation, it is observed that halogen bonds can be formed between Y6 dimers, which can provide external channels for electron carrier transfer. Meanwhile, the “A-to-A” type J-aggregates are more likely to be generated between Y6 molecules, and the π–π stacking can be also enhanced, thus increasing the charge transfer rate and electron mobility between Y6 molecules.The fluorination strategy is one of the most efficient and popular molecular modification methods to develop new materials for organic photovoltaic (OPV) cells. For OPV materials, it is a broad agreement that fluorination can reduce the energy level and change the morphology of active layers. To explore the effect of fluorination on small molecule acceptors, we selected two non-fullerene acceptors (NFA) based bulk heterojunction (BHJ) films, involving PM6:Y6 and PM6:Y5 as model systems. The electron mobilities of the PM6:Y5 and PM6:Y6 BHJ films are 5.76 × 10 In recent years, organic photovoltaic (OPV) cells have developed rapidly and the photoelectric conversion efficiency (PCE) of OPV cells has been over 19% ,3,4. DesFluorination is one of the most effective molecular modification methods to adjust the photoelectric properties of π-conjugated materials . For OPVIn this work, we selected PM6:Y5 and PM6:Y6 bulk heterojunction (BHJ) films to investigate the effect of end-group fluorination of small molecule acceptor materials on charge transport properties. To quantify the charge transport properties, we extracted the charge carrier mobilities and energetic disorder values of the PM6:Y5 and PM6:Y6 systems by using the space-charge-limited current (SCLC) and the Gaussian disorder model (GDM) measurements. The PM6:Y6 system exhibits high mobility and low energetic disorder of electron transport. To explore the origin of electron mobility differences, molecular dynamics (MD) was adopted to simulate the molecular stacking of PM6:Y5 and PM6:Y6 systems. The results show that the F atoms in the Y6 molecules can form halogen bonds with the F, N, and O atoms in the adjacent Y6 molecules, and the formed halogen bonds enhance the channels for intermolecular electron transfer. Fluorination of terminal groups makes it easier for A–D–A type NFA molecules to form the “A-to-A” type J-aggregates, and the π–π stacking is strengthened. This work explains the effect of fluorination on the charge transport behavior of small molecule acceptors and enriches insights into charge carrier transport in OPV materials.OC) of 0.828 V, an average short-circuit current density (JSC) of 25.12 mA/cm−2, and an average fill factor (FF) of 76.31%. Compared to the Y6-based cells, the PM6:Y5 devices exhibit a lower average PCE of 6.83%, with a lower average JSC of 12.72 mA/cm−2, an average FF of 57.47%, and an average VOC of 0.934 V. It is worth noting that the larger JSC value of PM6:Y6-based devices can be partly attributed to the broadened and enhanced photo response of the Y6 acceptors.The fluorination strategy will reduce the energy levels of OPV materials, considering that the energy level alignment of PM6 and Y5 is not rational. We study the charge transport properties of PM6:Y5, PM6:Y6, PBDB-T:Y5, and PBDB-T:Y6 BHJ films. The space-charge-limited current (SCLC) measurements are performed to evaluate their electron and hole transport properties. The zero-field electron mobility of the organic film can be expressed as:eσ. In organic semiconductors, the energetic disorder σ describes the width of the state distribution in energy , small internal reorganization energy and large intermolecular transfer integrals are helpful to speed up the charge transfer processes between neighboring molecules. In the BHJ film, electron carriers mainly transport in acceptor materials, and hole carriers typically transport donor materials [ijV > 0.1 meV). This means that there are more electron transfer channels between Y6 molecules. The average electron transfer integral is 7.59 meV for Y5 dimers and 8.47 meV for Y6 dimers. Therefore, the results show that Y6 acceptor molecules have a faster electron transfer rate.From the above equation, we can observe that the electron transfer rate of organic semiconductors mainly depends on the recombination energy and the transfer integral. The reorganization energy has both internal and external contributions, with the internal contribution arising from changes in the geometry of the molecular dimer when the electron transfer takes place, and the external contribution arising from changes in the surrounding media that accompany the charge transfer . In orgaaterials ,29. TherThe halogen bond assists the intermolecular electron transfer, resulting in the intermolecular electron transfer integral of Y6 being greater than that of Y5. In organic transport materials, a weak interaction is generally considered a way to realize charge transfer between molecules . HalogenPM6, PBDB-T, Y5, and Y6 were purchased from Solarmer Materials Inc. . All the materials were used as received.The aggregation and intermolecular interactions of donor and acceptor molecules in the donor–acceptor nanostructured blending film have been explored by a combination of molecular dynamics (MD) simulations and density functional theory (DFT) calculations. All atomistic MD simulations are performed using the GROMACS 5.1.1. software . The atoThe PM6:Y5 and PM6:Y6 BHJ films are built and imitated using the following procedure : (1) theThe electron-only devices were fabricated with a configuration of ITO/Al(50 nm)/BHJ/PDIN/Al . The ITOIn summary, we investigated the effect of terminal group fluorination on electron transport in OPV acceptor materials of BHJ films by using both experimental and MD simulation methods. From the SCLC measurement, it can be observed that the PM6:Y6 system has higher electron mobility than the PM6:Y5 film. Through the MD simulation, we found that the “A-to-A” type J aggregates are more likely to generate between Y6 molecules in PM6:Y6 BHJ film, which enhances the π–π stacking. In addition to π–π stacking, there are non-covalent interactions, such as C-F⋯F and C-F⋯N halogen bonds. These non-covalent interactions can provide more electron transfer channels between acceptors. This work shows that the fluorination of terminal groups can change the stacking pattern and provides support for the rationality of the fluorination strategy for OPV materials.


In conclusion, hyperglycemia, hypercholesterolemia, hypertriglyceridemia, MetS, duodenal polyps, gastric and duodenal ulcers, reflux esophagitis, and low BMD are independent risk factors associated with colorectal polyps in the middle-aged and elderly Taiwanese population.Colorectal polyps are the precursor lesions of most colorectal cancers. This study aimed to evaluate associations between bone mineral density (BMD), metabolic syndrome (MetS), and gastrointestinal diseases with colorectal polyps in middle-aged and elderly populations. A retrospective cross-sectional study was performed using data from the health examination database of a tertiary medical center in southern Taiwan in 2015. Subjects aged 50 years and older who had been assessed for metabolic factors and had undergone colonoscopy, upper gastrointestinal endoscopy, and dual energy X-ray absorptiometry scan (DEXA) were included. Factors associated with colorectal polyps were evaluated using univariate and multivariate logistic regression. In total, 1515 subjects were included, with mean age 60.1 years. Among them, 710 (46.9%) had colorectal polyps. Multivariate logistic regression analysis showed that high fasting glucose (OR = 1.08,  The incidence of colorectal cancer (CRC) has been increasing dramatically worldwide during the last two decades. CRC is the third most common cancer among men and the second most common cancer among women . ColorecSeveral studies have shown that gender, age, body mass index (BMI), and metabolic syndrome (MetS) are associated with colorectal polyps ,3,4,5,6.This retrospective cross-sectional study was performed using data extracted from the database of the Health Management and Evaluation Center of a tertiary medical center located in southern Taiwan from populations undergoing health examinations from January 2015 to December 2015. The center offers comprehensive medical tests and procedures as part of routine physical examinations. Among 5361 subjects aged from 20 to 87 years-old and 3120 (58.2%) subjects aged 50 years and over who underwent annual routine medical check-ups at the health examination center, most were free of symptoms. Subjects aged 50 years and older who had been assessed for metabolic factors and had undergone colonoscopy, upper gastrointestinal endoscopy, and dual energy X-ray absorptiometry scan (DEXA) were included. Subjects who were aged younger than 50 years; had not undergone colonoscopy, upper gastrointestinal endoscopy, or dual energy X-ray absorptiometry scan (DEXA); had incomplete data; or had prior or current colorectal cancer were excluded. Finally, the data of 1515 subjects were retained as the analytic sample. The study protocol was approved by the Institutional Review Board of the study hospital. (IRB No.: 202100126B0) on 25 February 2021. Because of the retrospective nature of the study, signed informed consent of subjects was waived.2). Waist circumference (WC) was measured in centimeters at the mid-level between the iliac crest and the lower border of the 12th rib while subjects stood with feet 25–30 cm apart. BMD values were measured in g/cm2 by DEXA  at the lumbar spine, total femoral , and femoral neck.Body height and weight were measured as the distance of the vertex point from the basis using the same testing equipment  with accuracy of 1 mm and 0.1 kg, respectively. Subjects were standing upright, barefoot, and wearing light clothing. BMI was then calculated as weight in kilograms divided by height in meters squared  for Asian populations . The modThe diagnosis of osteoporosis was defined according to the World Health Organization (WHO) definition. The T-score was calculated automatically; the lowest value of the lumbar spine, total femoral , and femoral neck was chosen for the diagnosis of osteoporosis. Osteoporosis was defined as T-score ≤–2.5; osteopenia as −2.5 < T-score < −1; and normal as ≥−1. A definition of low BMD included both osteopenia and osteoporosis.n, %) for categorical variables. The 𝜒2-test was used to compare subjects’ categorical characteristics, and the Student’s t-test was used to compare continuous variables. Multivariate logistic regression analysis was applied to determine odds ratios (ORs) and 95% confidence interval (CI). Pearson correlated coefficients were calculated between continuous data. To respect the assumption of independence between variables in a multivariable analysis, the highly correlated variable would not be included. Model 1 was conducted for all variables except parameters of MetS, and backward selection was used to establish the risk factors for colorectal polyps. Model 2 was conducted for all variables except MetS disease, and backward selection was used to establish the risk factors for colorectal polyps. Due to correlations between selected indicators of MetS, such as WC and HDL-C, stratified analysis was conducted for gender. A p-value < 0.05 was considered as statistically significant. SPSS software version 22.0  was used for all statistical analysis.Data are expressed as mean and standard deviation (mean ± SD) for continuous variables and frequency with counts and percentages  females and 891 (58.8%) males. The mean age was 60.1 ± 6.6 years. The prevalence of colorectal polyps and low BMD were 46.9% and 47.7%, respectively.p < 0.001), total cholesterol (p = 0.004) and triglycerides (p < 0.001), and lower high-density lipoprotein cholesterol (HDL-C) (p = 0.008). Subjects with colorectal polyps also had significantly higher incidence of MetS (p < 0.001), reflux esophagitis (p = 0.003), duodenal polyps (p = 0.014), gastric ulcers (p = 0.007), duodenal ulcers (p = 0.030), and low BMD (p < 0.001).p = 0.001), triglycerides (p = 0.002), and MetS (p = 0.010) remained significantly associated with colorectal polyps.p = 0.009), reflux esophagitis , duodenal polyps , gastric ulcers , duodenal ulcers , osteopenia , and MetS  were independently and significantly associated with colorectal polyps (Model 1). Among the components of MetS, only high fasting glucose  and high triglycerides  were independently and significantly associated with colorectal polys (Model 2).Results of multivariate logistic regression analyses are shown in p = 0.031), reflux esophagitis , duodenal ulcers , osteopenia , and MetS  were independently and significantly associated with colorectal polyps . For females, after backward selection, multivariate logistic regression analyses showed that only MetS  was independently and significantly associated with colorectal polyps .For males, after backward selection, multivariate logistic regression analyses showed that high total cholesterol .In the present study, the prevalence of colorectal polyps was 46.9% among subjects aged 50 years and older. In previous studies, the prevalence of colorectal polyps ranged from 30–50% ,14,15,16The present study showed that MetS, high fasting blood glucose, and hypertriglyceridemia were independent risk factors for colorectal polyps, consistent with previous findings. A systematic review by Passarelli et al.  showed tThe present study found that hypercholesterolemia was independently associated with colorectal polyps. However, the relationship between total cholesterol and colorectal polyps remains conflicting. Demers et al.  showed nHelicobacter pylori (H. Pylori) infection [H. pylori is also a risk factor for development of gastric and duodenal ulcers, both ulcers may be associated with colorectal polyps. The present study also found associations between gastric and duodenal polyps with colorectal polyps in the population without familial adenomatous polyposis. Studies have shown that patients with duodenal adenomas have higher prevalence of colonic adenomas compared to the general population [Associations between colorectal polyps, gastrointestinal ulcers and polyps have not been studied previously. The present study showed that gastric and duodenal ulcers are independently associated with colorectal polyps. The mechanism of the association is not completely understood, but several studies have shown that colorectal polyps and colorectal cancer are associated with nfection ,30,31,32pulation ,34. DuodThe present study also found that reflux esophagitis was associated with colorectal polyps. Several studies have found that Barrett’s esophagitis and erosive esophagitis are associated with colorectal polyps ,36,37,38The present study found an association between low BMD and colorectal polyps. Lim et al.  showed tThe present study showed that gender differences were displayed in patients with low BMD and gastrointestinal diseases but not in those with MetS. Meanwhile, no associations were found in the present study between colorectal polyps and gender, age, and BMI, which may be illustrated by characteristics of the study population. It has been reported that age over 50–65 years and BMI higher than 25 are independent risk factors for colorectal polyps [This study has several limitations. First, the data were obtained from an administrative computer database and were analyzed in a study with retrospective, cross-sectional design, which limits inferences of causality such as the cause-and-effect of colorectal polyps and its associations with BMD and other variables that still need verification through further prospective study. Second, the study participants were from a single health-promotion center in Taiwan and may not be representative of the general population or other ethnic populations, which limits generalization to other populations. Third, lifestyle factors, such as smoking, alcohol consumption, and dietary habits, and physical activity that may affect the formation of colorectal polyps and BMD were not available in the database and could not be adjusted in statistical models. In addition, because of using retrospective data, pathology reports of polyps were not available for most subjects to complete our analysis. Lastly, further evaluation is needed to explore the possibility of two-way dependencies between colorectal polyps and its associated factors, such as how colorectal polyps can stimulate bone loss, while low bone mass may increase the risk of colorectal polyps.Hyperglycemia, hypercholesterolemia, hypertriglyceridemia, MetS, reflux esophagitis, duodenal ulcers, duodenal polyps, and low BMD are independent risk factors associated with colorectal polyps. Further large prospective cohort studies are needed to make a more convincing case for these associations.


Implementing rehabilitation programs to hearing impaired adults is of great importance, mainly in the elderly population, and it is necessary to add them to the routine of outpatient care programs.to present a group care program for elderly patients who are fitted with hearing aids.to carry out a pilot study of clinical and experimental type, with the participation of 40 elderly users of hearing aids donated by the government, distributed within six groups, with maximum of eight participants jointly with their respective companions. Program consisted of three meetings every fifteen days, where information and education on the proper use hearing aids was transmitted.Most of the patients participated actively in the meetings spontaneously giving their opinion or answering questions when so requested. All elderly had been informed as to the importance of accepting their auditory deficiency and on the need to be motivated towards using hearing aids. Moreover, listening to depositions of other elderly users seemed to facilitate understanding of their own difficulties and stimulated them in the process of getting used to the sound amplification.Groups structure facilitated interaction among aged ones, helping them to clarify communication doubts and strategies and, consequently, it promoted their adaptation. In the last century we have seen an increase in population longevity and demographic aging is a world trend.According to data from the Brazilian Institute of Geography and Statistics (IBGE)With the development of medical technology, life expectancy increased and as a consequence there are much more senile illnesses and problems associated with this group of peopleAging is defined as a progressive and degenerative process characterized by less functional efficiency with the weakening of defense mechanisms. It is a universal and intrinsic process, that is to say, it is not determined by environmental factors despite their influence and it is different from diseases that many times are reversible and not seen in all old people in the same wayAmong the several problems which affect the quality of life of the elderly, hearing problems are among the most common complications as it has been showed in several epidemiological studies.8The term presbycusis refers to hearing loss as a consequence of the aging processAccording to the literatureSome authorsThus, social relationship of elderly people is affected by the disabilities of the aging process because they feel less valued and with less self-esteem. This gets worse with their difficulty to communicate.The old person who complains of hearing sensitivity must be sent for a complete audiological evaluation. However, it is necessary to state that audiometric measurements are not enough to describe the patient's reaction to hearing loss and the determination of communicative skills in their daily life and psycho-social functionWhen presbycusis and its consequences for the life of the elderly are verified, we notice the importance of hearing rehabilitation work in order to minimize the effects of hearing deficiency in the geriatric populationGetting used to a hearing device is hard at any age, especially for elder people. This is because elder people usually require more time to comprehend all the stages on the selection and adaptation process of amplification, and as a consequence, information should be presented gradually.Education must be stressed so the user understands the way the hearing device works together with its components and the auricular mold. They must be trained in how to place it inside the ear and how to remove it, how to change batteries and to handle the control systemThus, it is extremely important to implementat rehabilitation programs for hearing disabled adults and it is necessary to include these programs into the daily tasks of speech therapy outpatient clinics. These programs corroborate the elderly national policy which aims to guarantee the elderly social rights, preparing conditions for promoting their independence, interaction and effective participation in societyIn order to illustrate this situation, here are some data from a Public Service on the diagnosis of hearing deficiency, selection and adaptation of hearing devices by the SIA-SUS  (APACS).In this Service, 266 patients received a hearing device during March and July 2005. 120 (45 %) of them were elderly people, 46 (38.3%) were men and 74 (61.7%) were women. Out of the total number of old people 18 (15%) received a monoaural fitting and 102 (85%) received binaural fitting, with 222 hearing devices donated.According to what it has been said above, this piece of work aims to show a group service program for elderly people with hearing devices.A research and outreach project was prepared with the proposal of this Service and the Research EthicsCommittee of a Further Education Institution approved it with protocol number 1107/05.Following ethical and legal principles, elderly people signed a Free and Informed Consent to take part in the project which had information on this service, such as its goal, justification, benefits for the participants and additional information.A pilot study was done to evaluate the feasibility of this program. The sample included 40 elderly people with 15 men and 25 women aged between 60 and 90 years old (average age 76.3 years old) and who had received a device on this Service through the Public Health CareAppendix A1°Questionnaire for elderly peopleName: _________________________________________ Date: ___ / ___ /___1)What is your general health like? Do you have any vision problems, do you wear glasses  good general health  diabetes, high blood pressure, _____________________2)For how long do you use the hearing device each day? Until 4 hours a day  between 4 and 8 hours a day  more than 8 hours a day3)Did you complain of ringing in your ear before you started using the hearing device? no  yesIf you answered yes, did your complaint improve with the use of the hearing device? no  yes4)Which difficulties did you face during the adaptation process to the hearing device? handling and cleaning the device  keeping a conversation in a noisy place  understanding what people say  talking on the phone your own voice sounds different  sounds are too intense sounds are too weak5)Which are the benefits you had with the use of the hearing device? improved social and/or professional life improved dialogue with relatives and friends the chance of watching TV or listening to the radio in a pleasant intensity talking on the phone without great difficulties better relationship with relatives and friends improved self-esteem and quality of life6)In which items you still have some doubts or would like to have further information: hearing loss at an old age strategies to facilitate communication care with the hearing device (cleaning/maintenance/batteries) others, which one: ________________________________________Age: ___________________ Gender:  female  maleAppendix BQuestionnaire for assistantsName: _________________________________________ Date: ___ / ___ /___1)Do you believe the hearing device brought benefits to your _________ ? no Why?  does not use the device correctly he/she says is not adapting himself/herself to the use of the device other reason: ______________________ yes which one?  improved social and/or professional life watches TV and listens to the radio in a pleasant intensity for everyone at home improved dialogue with relatives and friends better relationship with relatives improved self-esteem and quality of life started doing things he/she did not used to do before using the device (for example __________)2)Your relative/friend complains about something related to the use of the hearing device?  no  yesIf you answered yes, which are the complaints? handling and cleaning the device difficulty in talking on the phone keeping a conversation in a noisy place sounds are too weak understanding what people say sounds are too intenseKinship: ________ Age: ________ Gender:  female  maleAppendix CHow to take good care of your hearing deviceYour hearing device is a delicate instrument and it should be handled with care in order to work efficiently.Pay attention:Dust, heat, humidity and wax can damage your device!Avoid dropping your device, this could be fatal!Rinse it with a soft and dry cloth and do not forget: never use water to clean it.Store the device inside your case when you are not using it and remove the battery. Keep it in a safe place.Your device does not work without batteries. They provide the energy for the device to work. In order to make the best use of your batteries please follow the instructions below:Remove the stamp of the battery and wait a moment to activate the charge.Only remove the stamp of the battery when you are really going to use it;Watch the sign “+” and “-” on the battery to insert it correctly;Do always have batteries handy for the hearing devices.In case your device is retro auricular (the one that is placed behind the ear), you should handle the mold as follows:Remove and gently place the mold on the ear;Always keep the mold clean!!! Wash it with water and soap frequently but before doing so detach it from the device, because the device cannot get wet.After cleaning it, rinse the mold and the plastic tube well, always using a syringe to remove the remaining water.Do not use any chemical product to clean the mold, only water and soap!Change the mold and the plastic tube every time they are too dry, torn or yellowish.Appendix DHelpful hints for the elderly user of hearing devicesSome strategies that facilitate your communication:Always look the person you are talking to in the face because you can use the visual hints.Make the place where you are talking brighter and lower the noise. It will be difficult to talk if the TV or the radio is on very loud.Let other people know about your difficulty to hear and try not to hide your hearing disability because people can try to look for other ways of communicating better with you.Be always alert!!! Pay attention to the speaker, watch his/her face and facial and body expressions.Try not to interrupt very often the person who is talking, pay attention, give him/her a sign to speak slower and/or increase a little bit the intensity of his/her speech.Be patient and keep your sense of humor!!! Try not to quarrel with your family over communication difficulties. A quite family environment favors dialogue!!!ALWAYS remember the importance of using your hearing device since it can benefit you a great deal. However, hearing devices have their limitations.Helpful hints for the familySome ways to behave with a person using a hearing device:First call his/her attention, be sure you drew the attention of the person with hearing difficulties before you start talking.Speak face to face to the person with hearing difficulties, giving him/her visual hints.Make the place where you are having a conversation brighter because your face will be lit. But remember not to stand facing a light source (such as a window for example), because it will be difficult for him/her to see your face;Do not place obstacles in front of your face: always talk with your mouth empty, because you will be helping him/her with visual hints of your lips.Speak clearly and reduce the speed.Do not shout!!! Just talk a little bit above your usual intensity.Use facial expressions and gestures; however, do not exaggerate in your speech articulation.Reduce the noise of the room: avoid having a conversation if the TV or the radio is on.Re-phrase or instead of repeating, if the old person does not seem to have understood what you said, re-phrase the sentence very calmly!!!Ask how you can help: ask the old person for suggestions on ways to improve communication.Be patient and keep your sense of humor!!!A quiet family environment favors dialogue!!!ALWAYS encourage him/her to use the hearing device because it benefits the user and your family a great deal.Appendix E2°Questionnaire for elderly people1)If your device “beeps”, when in your ear, what should you do? check the placement of the device or mold (if it is a retro auricular device) check the volume (if it has volume control) clean the device change the battery wait until it stops beeping if none of the above helps, ask a speech therapist for help2)In case your device is “weak”, what can you do? change the battery check the volume button (if it has this control) gently knock your device wait until the device starts working correctly again if none of this helps, ask a speech therapist for help3)In case your device is not working, what should you do? check if the device is on check if the batteries are new check if the box is completely closed wait until the device starts working correctly again if none of the above helps, ask a speech therapist for help4)Do you still have any doubts on your hearing device? no  yes Which one? _____________________________5) Are you happy with your hearing device? yes  no Why? ____________________________6)Are you using the communication strategies offered by the interns at the group meetings? no Why? ________________________________________________ yesIf you answered yes, did it benefit your communication? no  yes7)Do you believe group meetings were useful? no Why? _______________________________________________ yes Why? _______________________________________________System (SUS).Name: _________________________________________ Date: ___ / ___ /___•Minimum age 60 years old ;•Time availability to attend the meetings after the donation of hearing devices;•To live near the Service (Southern area of the city of São Paulo-SP);•Without any moving disabilities.Inclusion criteria were as follows:The elderly people using hearing devices were divided into six groups with a maximum number of eight with their own relatives and/or assistants. The distribution of the elderly people into small groups aimed to offer them a better attention and to facilitate interaction among participants.The program included three fortnightly meetings coordinated by speech therapists at the Service who use audio-visual resources and group techniques to share necessary information and orientations with the elderly. Each meeting had different goals.a)Introducing the participants of the group;b)Explaining how group service works, clarifying the importance of their presence at all meetings and the need of having a relative or a close person attending the meetings together with the elderly person.c)Explaining the following questions: What is hearing loss? Which are the degrees of hearing loss? What are hearing devices for? What is the reason for binaural or monoaural fitting? In order to make explanations easier, professionals used slides with the average acoustic values of frequency and intensity of Brazilian Portuguese speech sounds, displayed in the graphic registry of the audiogram24. Thus, it was possible to show each person what his/her hearing loss configuration was like, proving which sounds were audible without the hearing device and which he/she started to hear after using the device.d)Strengthening guidance on how the hearing device works and how to clean it and maintain it.e)Two questionnaires were used, one to be answered by the elderly person and the other one for a relative and/or assistant, aiming to compare the perceptions of both on the difficulties and the benefits regarding the use of the hearing device (Appendix A and Appendix B).The first meeting was held one week after the hearing devices were donated and had the following goals:Questionnaires were specifically prepared for this study and they were given to the group by the responsible speech therapists, however each old person had the opportunity to voice his/her opinion. During the questionnaire old people did not have access to alternative answers.Questionnaires had questions with multiple choice questions and others had open questions. For those multiple questions, the speech therapist selected, among the alternative answers, the ones corresponding to those mentioned by the elderly people. On the other hand, for the open questions, the speech therapist transcribed the answer given by the elderly person.At the end of this first meeting, participants received an information brochure specially prepared for this program with clearly written orientations (Appendix C).a)Promoting the exchange of opinions on the impact of hearing disability and hearing devices fitting at an old age with their statements on how they experienced the use of devices, their main difficulties and benefits until this moment, among other issues.b)Offering facilitating communication strategies for elderly people, besides giving them an information brochure at the end of the meeting with communication guidelines for people with hearing disabilitiesThe second meeting was held 21 days after the hearing devices were given and it had the following goals:a)Promoting the reading and further discussion of a text on social isolation experienced by old people with communication problems as a consequence of a hearing disability;b)Clarifying the possible doubts they may still have on adaptation to the hearing device;c)A new questionnaire also done specially for this program aiming to evaluate the understanding of the guidelines offered during the group meetings. (Appendix E).The third meeting took place 35 days after the hearing devices were given and it had the following goals:Most elderly people actively participated in the meetings, expressing their opinions in a spontaneous way or answering the questions when they were asked. All of them were guided on the importance of accepting hearing loss and on the need of being motivated to use the hearing devicesSimilarly to literatureFurthermore, speech therapists can introduce strategies to facilitate communication, to strengthen guidance on how to take care, handle and clean hearing devices and/or auricular molds, and also they can provide patients with information on hearing.Regarding communication strategies, some authorsIn regard to questionnaires, they have been used to evaluate the benefit, use and satisfaction of people with hearing devices, as well as in following up the adaptation processIn the last meeting we discussed social isolation due to communication difficulties. One of the participants, a 78 year old lady said that “.. I used to watch TV very loud and no one in my family would stay in the room… I stopped attending an elderly group because I didn't hear what the coordinator said. I couldn't understand or talk to the doctors on my visits…”. This lady's report clearly shows the social difficulties these elderly people experience, a fact already commented by several authorsGroup work was useful for the interaction among the elderly people and it made possible to clarify doubts and communication strategies, favoring the adaptation process.It is believed that more studies on the effectiveness of this type of service proposal are needed, since there are an increasing number of registered services for the donation of hearing devices by the Public Health System (SUS) and therefore, geriatric population increasingly demands this service.


Dear editor,1 published online in this journal. The article presents an analysis of several risk factors of colorectal cancer and the results of colonoscopy of 6508 subjects suggesting a new scoring system for colorectal cancer and polyp screening. The authors concluded that according to this new scoring system, screening for colorectal cancer should start at the age of 45 in patients with scores ≥4.We read with interest the article “A New Risk-Scoring System for Colorectal Cancer and Polyp Screening by Turkish Colorectal Cancer and Polyp Study Group” by Erdem et alThe authors should be congratulated on their efforts in conducting such an important study and analysis of a large amount of data and highlighting a very clinically relevant and prevalent topic.Although we agree with many of the conclusions, we would like to make some comments.The number of points assigned to body mass index, male sex, and smoking does not correspond between the text (methods) and Table 1. Also, it would be interesting to see the logistic regression analysis results with the odds ratios.There is an ambiguous definition of overweight status which should be explained.Should also be mentioned among the study limitations that the study participants were preselected by general practitioners, and thus, the study results may not entirely correspond with a whole population data.4 We wonder if the data related to the diabetes history are available as these might further increase the study impact.Available data show that patients with diabetes have an increased risk of colorectal adenoma and carcinoma and an increased risk of colorectal carcinoma at a lower age.We respectfully suggest taking these points into account if the continuation of this important study is planned.


Some individuals with hearing loss choose to be fitted with hearing aids. Compliance is significantly affected by how satisfied patients are with their hearing aids. Patient satisfaction can be assessed through questionnaires and scales.To assess the degree of satisfaction of patients fitted with hearing aids.Scale “Satisfaction With Amplification in Daily Life” (SADL) was applied to 180 patients fitted with hearing aids; results were categorized based on the mean values observed for global satisfaction scores and scores attained on each subscale. Patients were interviewed for additional information.Mean global score was 5.6; 48.9% of the subjects were very satisfied, 47.2% were satisfied, and 3.9% were dissatisfied. The mean score on subscale Positive Effects was 5.6; the mean score for Service and Cost was 6.2; for Negative Factors the mean score was 4.9; and the mean score on subscale Personal Image was 5.8. Of the patients fitted with in-the-ear hearing aids, 83.3% were very satisfied. Fifteen percent of the individuals were dissatisfied with their Personal Image. Sensorineural and profound hearing loss patients were less satisfied, with 5.4% and 50.0% of the subjects revealing dissatisfaction with their hearing aids.Patients were generally very satisfied with their hearing aids. Satisfaction rates were higher among patients fitted with in-the-ear hearing aids. Dissatisfaction was higher in subscale Personal Image. Lesser degrees of satisfaction were seen in patients with sensorineural and profound hearing loss. Hearing loss or hypacusis is characterized by reductions on the ability to hear and/or detect sounds, and may arise in various stages on an individual's lifeMany conditions in which hearing loss occurs concurrently may be addressed through clinical treatment and/or surgery. However, many types of hearing loss cannot be treated using these approaches. In these cases, hearing aids become an important tool in the auditory training and/or rehabilitation of the involved subjectsHearing aids have been significantly improved with the development of technology in the area. The contributions yielded from such progress refer mainly to air conduction aids and include component miniaturization, enhancements in components such as amplifiers, and the introduction of new algorithms to reduce noise and intensify speech detectionSatisfação com o Aparelho Auditivo em sua Vida DiáriaObjective and subjective methods can be used to assess the benefits of hearing aids to their users. Subjective methods resort to scales to assess patient satisfaction levels. One of the tools used with this purpose is the Satisfaction With Amplification in Daily Life scale - SADL - designed by Cox & AlexanderA study carried out with hearing aid users from the army health system revealed considerable levels of satisfaction with the devices, despite the low scores on subscale negative features, particularly in what concerns using a telephoneThe army health system study also indicated that the subjects with fewer complaints of auditory involvement (intolerance to intense sounds and tinnitus) and without bilateral sensorineural hearing loss had better outcomes with their hearing aidsOther Brazilian studies using the SADL scale found higher global satisfaction scores than the standardized values reported in the original studyAccording to Arawaka et al.The satisfaction of subjects fitted with hearing aids is affected by the benefit yielded by the device. It is also associated with user expectations, cost of treatment, psychological aspects, issues faced during the rehabilitation process, and communication difficulties that remain despite the use of amplificationTherefore, this study aimed to assess the degree of satisfaction of subjects fitted with hearing aids seen at a high complexity service.This cross-sectional contemporary cohort study was carried out at a high complexity service between August 18, 2011 and August 2, 2012. The study was approved by the Ethics Committee for Research with Human Beings of the institution and was given permit 2140/2011.The study included individuals fitted with hearing aids at the hospital's auditory care unit.The following enrollment criteria were applied: subjects had to be 14 or older, have hearing loss of any kind or degree in at least one ear, had to be wearing their hearing aids for at least 30 days, and had to agree to join the study and sign an Informed Consent Term.Patients with ages under 14 years, individuals fitted with hearing aids at other care centers, and subjects who could not or refused to join the study were excluded.The following variables were analyzed: age, gender, education, marital status, type of hearing loss in each ear, degree of hearing loss, type of hearing aids, time since using the current hearing aids, number of hours per day with hearing aids on, presence of comorbidities, and level of satisfaction with the hearing aids based on the SADL scale (Annex 1)In order to prevent interpretation errors or biased results, each individual was given a copy of the scale to follow the items with the help of a caretaker while the questions were asked orally by the researcher. Patient charts were used as reference to collect subject personal data.The SADL scale contains 15 items and assesses the satisfaction of hearing aid users through a global score and a set of specific scores related to the following subscales: PE , SC , NF , and PI . Participants answered the questions by picking one of the following possible answers: not at all; a little; somewhat; medium; considerably; greatly; tremendously. In 11 items, ‘tremendously' indicates maximum satisfaction and is assigned a score of seven, while ‘not at all' means maximum dissatisfaction and is given a score of one . However, the other items in the scale are reversed, and ‘tremendously' suggests maximum dissatisfaction and is given a score of one, while ‘not at all' indicates maximum satisfaction and is assigned a score of sevenThe scores in the four subscales were calculated based on the mean value of the scores attained in each component item. The subjects in this study were given their hearing aids free of charge, and thus item 14 was not considered. Therefore, subscale SC was limited to two items (12 and 15). Additionally, when subjects claimed they could hear well on the phone without hearing aids, question 11 was suppressed from subscale NF, thus limiting it to two items (2 and 7). The satisfaction GS was calculated from the mean value of the scores attained in the 14 or 13 - for patients who could hear well on the phone without hearing aids - items of the SADL scale.th percentile according to the standard, ‘very satisfied' when their scores were above the 80th percentile, and ‘satisfied' when their scores were between the 20th and 80th percentiles.After the SADL scores of our sample were calculated, they were compared to the standard scores as shown in Table 1The Brazilian Portuguese version of the SADL scale contains four additional items. Yet, this study considered only the time since wearing hearing aids and the number of hours per day with hearing aids on®.The descriptive analysis of the data was carried out on Microsoft Excel 2010This study included 180 individuals, 72 (40%) males and 108 (60%) females. Subject mean age was 65.1 ± 15.5 years, ranging from 14 to 94. In terms of education, 23 (12.8%) patients were illiterate, 115 (63.9%) went to elementary school, 28 (15.6%) attended middle school, and 14 (7.8%) had higher education degrees. When marital status was considered, 100 (55.6%) subjects were married or were in a steady union and 80 (44.4%) were single, separated, or widows. Fifteen (8.3%) did not have comorbidities and/or tinnitus, and 165 (91.7%) had. Eight (4.4%) patients had unilateral hearing loss and 172 (95.6%) had bilateral deafness, adding to a total of 352 ears with hearing loss.The mean global and subscale scores are shown in According to patient global scores, 88 (48.9%) subjects were very satisfied, 85 (47.2%) were satisfied, and seven (3.9%) were dissatisfied.The levels of satisfaction for each SADL subscale are presented in In order to assess the correlation between age and level of satisfaction, patients were divided into three groups: teens (12 to 17 years of age), adults (18 to 59 years of age), and elderly (60 years of age and above). The teen group had two (1.1%) subjects, the adult group had 50 individuals (27.8%), and the elderly group had 128 (71.1%) members. Each ear was considered individually in the assessment of degree of satisfaction based on type of hearing loss. Eight (2.3%) ears had conductive hearing loss, 261 (74.1%) had sensorineural hearing loss, and 83 (23.6%) had mixed hearing loss. The better ear of the patients with bilateral hearing loss was considered in the assessment of level of satisfaction based on hearing loss type. Forty-eight (26.7%) patients had mild hearing loss; 74 (41.1%) had moderate hearing loss; 43 (23.9%) had moderate to severe hearing loss; 11 (6.1%) had severe hearing loss; and four (2.2%) had profound hearing loss. The 330 devices fitted were air conduction hearing aids. Three-hundred and eight (93.3%) were behind-the-ear (BTE) devices, six (1.8%) were in-the-ear (ITE) aids, 14 (4.2%) were intracanal (ITC) devices, and two (0.6%) were completely-in-the-canal (CIC) hearing aids. Lastly, the level of satisfaction with the type of fitting was analyzed. Three-hundred and four (92.1%) hearing aids had closed fittings and 26 (7.9%) had open fittings. Female subjects accounted for 60% of the population included in this study. Predominance of female over male individuals was also reported by Lessa et al.CarvalhoPatient mean satisfaction GS was 5.6 ± 0.7, i.e., the subjects were satisfied with their devices. The breakdown of the global score indicated that 48.9% of the patients were very satisfied, 47.2% were satisfied, and 3.9% were dissatisfied. Subscale PI stood out from the pack as 15% of the individuals were dissatisfied, although the mean score suggested they were satisfied. Cox & AlexanderRusso et al.Therefore, the appearance of the devices and the stigma connected to wearing hearing aids and having hearing loss adversely affect a considerable portion of the patients. It is important to stress that this study looked into the factors connected to lower satisfaction ratings of individuals who chose to use hearing aids. We do not know why patients with hearing loss decide not to wear hearing aids. Awareness building campaigns are needed to inform patients of the potential benefits of wearing hearing aids and to educate the population in general on the principles of equality and tolerance.Considering the factors related to differences in levels of satisfaction, patients with sensorineural hearing loss were more dissatisfied than individuals with mixed or conductive hearing loss. The mean GS of patients with sensorineural hearing loss was 5.5 ± 0.7, suggesting they were satisfied when compared to standard values, but 5.4% were dissatisfied against none with other types of hearing loss. Veiga et al.Cochlear function is normal in subjects with conductive hearing loss. Therefore, the quality of hearing is expected to be better in these patients as they use hearing aids than in subjects with sensorineural hearing loss, in whom some degree of discrimination involvement and recruitment may be presentPatients with profound hearing loss also had lower satisfaction global scores. Their mean GS was 4.6 ± 0.9, which indicates they were satisfied, however less than the study's general population. Additionally, 50% of the subjects with profound hearing loss were dissatisfied. This finding may be explained by the presence of less residual hearing to take advantage of amplification. It should be noted that all patients with profound hearing loss in this study wore BTE aids, possibly a confounding factor. Differently from this study and from Veiga et al.High satisfaction global scores were seen among patients fitted with ITE aids, and a well above the average mean GS of 6.4 ± 0.5. In this group of patients, 83.3% were very satisfied, 16.7% were satisfied, and none were dissatisfied. It is important to mention that all users of ITE aids in this study had moderate to severe hearing loss. Farias & RussoTo Wrobel & GabardIn general terms, the population enrolled in this study was satisfied with the hearing aids during the 30 days of the fitting process, regardless of type and degree of hearing loss. More studies on patient satisfaction with longer observation periods may bring new useful data to the assessment of hearing aids.This study revealed patients were highly satisfied with their hearing aids, as most subjects were very satisfied or satisfied and only a few were dissatisfied with their devices. Dissatisfaction was more noticeable on subscale personal image, and was a relevant finding among patients with profound hearing loss and, to a lesser degree, among subjects with sensorineural hearing loss.In-the-ear hearing aids were correlated with higher satisfaction scores, as most users were very satisfied and none were dissatisfied with their devices.


Diabetes is a chronic progressive metabolic disorder that is caused by the body’s inability to regulate blood glucose levels. If uncontrolled, it can lead to various complications. Among its various complications, long-term diabetes leads to diabetic retinopathy (DR). It is a disease involving blood vessels and the destruction of retinal nerves. It is usually classified into two types: proliferative diabetic retinopathy (PDR) and nonproliferative diabetic retinopathy (NPDR). It progresses and causes loss of vision. The leading cause of loss of vision is diabetic macular edema (DME). The argon laser is used as a modality in the management of PDR. There are various types of laser photocoagulation, such as peripheral retinal laser photocoagulation, focal macular laser photocoagulation, and grid photocoagulation. DR results in various adverse consequences such as vitreous hemorrhage, fibrosis, traction, detachment of the retina, and glaucoma. To assess DR, a detailed fundus examination with a slit lamp biomicroscope needs to be done. Seven-standard field stereoscopic-color fundus photography needs to be done for documentation and follow-up. Patients with diabetes mellitus (DM) type 1 have a greater risk of suffering from DR. Another major complication of the condition is DME, which is characterized by an increase in the permeability of vessels and the thickening of the central part of the retina along with the accumulation of hard exudates on the macula. This article discusses various laser therapy modalities for the treatment of DR, their types, mechanisms, and aims. Clinical features of DR include abnormal dilatation of capillaries, and outpouchings in the form of microaneurysm from the capillary wall are one of the earliest and most dangerous changes; later, non-perfusion of the retina occurs, which is associated with cotton wool spots and blot hemorrhages. In patients suffering from PDR and maculopathy, peripheral retinal laser photocoagulation is used as a mode of intervention. Diabetes mellitus (DM) is a progressive disease and, if longstanding, it will lead to cataracts and diabetic retinopathy (DR) . DR, a cDM is an accelerating pathologic condition that results from the body's inability to regulate blood glucose levels . DR is uDR is a very serious complication of diabetes. It has become the primary reason for the loss of vision globally. Its overall occurrence is on the rise. Early detection and well-timed management of this vision-threatening DR will decrease the occurrence and development of sight loss. Screening for DR  is precise, secure, and economical . ExaminaSeven-standard field stereoscopic-color fundus photography, which should be evaluated by a trained reader, is considered the standard screening modality for DR, though direct ophthalmoscopy or indirect slit-lamp fundoscopy through the dilated pupil or digital fundus photography may also be used . At the Characteristics of diabetic retinopathyDR is characterized by retinal damage, specifically to retinal vessels, which in turn is caused due to uncontrolled blood sugar levels. Dilatation of capillaries is one of the earliest changes observed. The next thing to happen is the closing of capillaries, which causes a decrease in the supply of blood to some part of the retina, which is termed non-perfusion of the retina. On fundus examination, large pale areas are seen on the retina as they are devoid of blood supply. But in cases of smaller zones, they can be seen only by fluorescein angiography (FA). In this procedure, retinal blood vessels can be detected when the dye is passed through the vein and is then passed through the artery. The most crucial feature of DR is occluded capillaries, which lead to the stoppage of blood supply to the retina. The closing of capillaries is also associated with other two characteristic features. They are cotton wool spots. There is also the presence of dot and blot hemorrhages, which is due to hemorrhage of retinal infarcts. The appearance of greyish-white colored patches on the retina is called cotton wool spots. It appears due to infarcts on the retina. If many greyish-white patches are found (more than 6-10 in one eye), then it may be suggestive of rapid extensive retinal ischemia, but more commonly in DR, there is the presence of fewer cotton wool spots. And in the case of hemorrhages, they appear in various sizes and shapes often called "dot and blot". The smaller red-colored dots present on the retina are called micro-aneurysms, which result from the abnormal dilatation of capillaries. Differentiation of hemorrhages and micro-aneurysms cannot be done by performing ophthalmoscopy. Another cause of arterial damage is the thickening of the arterial wall and also the decrease in the width of the lumen known as stenosis, as well as arterial occlusion, which causes decreased blood supply to some parts of the retina . There aPathophysiology of diabetic retinopathyHistopathological findings associated with DR include the loss of pericytes and cells of the endothelium, as well as basilar membrane thickening. Biochemically, there will be a synthesis of advanced glycation end products, caused by the rise in the activity of protein kinase C (PKC) and glycosylation of proteins. All these processes will cause communication between the cells, which also include vascular endothelial growth factor (VEGF), which functionally causes the production of new vessels in both the segments of the eye - anterior as well as posterior - as well as an increase in the permeability of the retinal vessels, and distortion of the barrier between blood and retina .Pathophysiology of NPDRIt is characterized by abnormal permeability of the capillaries of the retina, which leads to retinal edema, and also the closing of capillaries, which leads to non-perfusion of the retina and ischemia.Pathophysiology of PDRWhen retinal ischemia is severe enough to lead to neovascularization, it is called PDR. It will further progress to vitreous detachment and vitreous hemorrhage, which leads to vision loss. If not treated appropriately, 50% of patients suffering from PDR will lose their vision in the span of five years .Mechanisms of diabetic retinopathyIt involves several pathways such as oxidative stress, an increase in pro-inflammatory mediators, and an increase in the secretion of VEGF secretion. These factors will cause the development of micro-aneurysms, non-perfusion of capillaries, leakage from vessels, and the formation of new vessels, which is termed neovascularization . Oxygen Assessment of diabetic retinopathyThe American Diabetes Association (ADA) has suggested that patients suffering from type 1 DM should examine the retina within five years of getting diagnosed with diabetes. They should also undergo regular life-long retinal examinations . In diabTypes of laser treatment modalitiesPeripheral Retinal Laser PhotocoagulationIn the case of patients suffering from pre-proliferative retinopathy, this intervention will lower the occurrence of severe visual loss (SVL) . It is uFocal Macular Laser PhotocoagulationIt is mainly performed in patients with focal DME plus mild to moderate pre-proliferative DR as it will decrease the probability of moderate visual loss.Grid PhotocoagulationIn cases of diffuse maculopathy, grid photocoagulation can be done in areas of the retina, which has been thickened to enhance vision. In general, photocoagulation is not likely to be effective in eyes with maculopathy but without DME. Maculopathy is a disease of the macula and DME occurs when blood vessels leak into a part of the retina called the macula . AccordiFeatures of laser photocoagulationLaser photocoagulation is a treatment modality very commonly used to manage DR and prevent further complications. In this intervention, light energy is applied to achieve the goal of ceasing the production of new blood vessels, which stops the neovascularization and in turn will prevent vision loss. It can be given in one sitting or, in order to reduce the chances of side effects, in multiple sittings. New treatments are on the rise, and hence the use of laser therapy may become less prevalent in higher-income countries but will still be relevant as it is economical. New modalities such as anti-VEGF agents may lead to a decline in the use of laser photocoagulation in developed and high-income countries, but it will still remain relevant because it is suitable in other parts of the world . The addMechanism of laser photocoagulationLaser photocoagulation decreases the oxygen demand of the retina, which will help to redirect enough oxygen and nutrients to the retina, thereby changing the hemodynamics. Secondly, it also acts by reducing the occurrence of vasoactive factors such as VEGF and PKC . Direct Aim of laser photocoagulationVEGF is produced in the areas of ischemia, and when the laser is applied to non-ischemic areas, it coagulates the tissues, which decreases the oxygen demand of the peripheral retina, which will stop the production of VEGF. After the energy is absorbed by the pigments of the tissues, thermal damage will occur and the laser acts by this way .Adverse effects of laser photocoagulationLaser is associated with various side effects. These reportedly include foveal burns, visual field defects, retinal fibrosis, and scars due to lasers. Also, there may be sub-retinal and vitreous bleeding, and it may also lead to epiretinal proliferation with retinal traction. It can affect the ability of a person to drive a vehicle. Therefore, laser therapy is given only after all these factors are carefully studied and considered . While lDiabetic Macular EdemaETDRS has mentioned primary DME as it results from the disruption of the barrier between blood and retina, which is secondary to leakage occurring from micro-aneurysms, capillaries, and arterioles from the retina. Factors contributing to the increased occurrence of DME include hypertension, cardiovascular disease, abnormal functioning of the renal system, and poor control of blood glucose . Fluid aStudies have shown that DME patients who were treated with laser photocoagulation had fewer chances of developing vision loss in comparison with the patients who were not given laser in a span of three years . After 1In this article, we have examined various laser treatment modalities for DR. Also, we have discussed in detail the pathology of DR, its clinical features, clinical assessment, and related complications. Prolonged DM leads to several complications, one of which is DR. To assess DR patients, a detailed fundus examination is done. Clinical features of DR include dilatation of capillaries, which is also one of the earliest changes, and non-perfusion of the retina, which is associated with the presence of cotton wool spots. Dot and blot hemorrhages are also seen due to hemorrhage of retinal infarcts. Laser photocoagulation has been the most commonly used intervention for DR for a long period of time; however, newer interventions such as intravitreal anti-VEGF are used more frequently nowadays. Argon laser is commonly preferred over xenon, as xenon laser causes more complications. Thermal energy is used to cease the production of new retinal vessels, which is also called neovascularization. Secondly, it also acts by decreasing the synthesis of vasoactive peptides, which are VEGF and PKC. Feeding vessels are coagulated by applying direct heavy burns, which stops neovascularization. There are various adverse effects of laser photocoagulation, and these include foveal burns, visual field defects, retinal fibrosis, and scars due to lasers. It can also affect the ability of a person to drive. Laser photocoagulation is very useful, but as with any other surgery, it also causes certain complications such as choroidal effusions, exudative retinal detachment, DME, defects of visual fields, and defects in vision at night. Additionally, there are some rare complications of retinal laser photocoagulation, which include weakness in the accommodation of the eye, dilatation of the pupil with myopia, which is transient in nature, and sensitivity of the cornea being impaired badly. Despite all these drawbacks, laser photocoagulation is still the most efficient treatment available to prevent vision loss in patients with DR.


Four auditory profiles differing in terms of audiometric hearing loss and supra-threshold hearing abilities were identified. To enable auditory profile-based hearing-aid treatment, a fitting rationale leveraging differences in gain prescription and signal-to-noise (SNR) improvement was developed. This report describes the translation of this rationale to clinical devices supplied by three industrial partners. (2) Methods: Regarding the SNR improvement, advanced feature settings were proposed and verified based on free-field measurements made with an acoustic mannikin fitted with the different hearing aids. Regarding the gain prescription, a clinically feasible fitting tool and procedure based on real-ear gain adjustments were developed. (3) Results: Analyses of the collected real-ear gain and SNR improvement data confirmed the feasibility of the clinical implementation. Differences between the auditory profile-based fitting strategy and a current ‘best practice’ procedure based on the NAL-NL2 fitting rule were verified and are discussed in terms of limitations and future perspectives. (4) Conclusion: Based on a joint effort from academic and industrial partners, the BEAR fitting rationale was transferred to commercially available hearing aids. Clinical hearing rehabilitation involves the sensory management of a hearing loss, which is typically addressed by means of hearing-aid (HA) fitting based on a set of audiometric thresholds. However, it is well known that there are hearing deficits that are only partially captured by an audiogram ,2. As suTo address this shortcoming, the Danish “Better hEAring Rehabilitation” (BEAR) project recently developed strategies for individual hearing loss characterization and compensation. The characterization of hearing deficits is based on the concept of auditory profiling. Using various diagnostic tests, patients are stratified into four distinct groups called profiles A, B, C and D. This is achieved using a data-driven method . This meBased on the results from this pilot evaluation, a large-scale randomized controlled trial was designed and carried out at two public hearing clinics. All participants underwent an initial evaluation, based on which they were stratified into one of the four auditory profiles. They were then randomly assigned to either the “BEAR” fitting strategy or a “current” fitting strategy. The participants assigned to the “current” strategy were fitted with HAs in accordance with current best clinical practice. That is, insertion gains (IGs) according to the “National Acoustic Laboratories—Non-Linear version 2” (NAL-NL2) fitting formula, which aims to maximize speech intelligibility and which was optimized based on empirical adjustments ,10, wereThe current report focuses on the clinical implementation of the BEAR fitting strategy. Its purpose is to demonstrate the transfer of this strategy to the hearing aids used in the large-scale clinical study. Technical measurements characterizing the HA fittings were performed in the laboratory to ensure that the targeted SNR improvement was achieved. Furthermore, REM performed in the clinics on the HA fittings made as part of the large-scale clinical study were evaluated.l) and frequencies (f) and for the different profiles (p), and p). The constant factor 0.31 reflects the proportion of gain applied in relation to the HTL (“1-third rule”); for convenience, we use that specific value as it is specified in the original NAL formula [δ(p) does not represent an arithmetic sum but the SNR improvement. It does not affect the insertion gain.The BEAR rationale  includes formula ,13. The To implement the BEAR rationale in three different commercially available devices, the key properties needing to be transferred first had to be identified. Commercial fitting tools were not suited for the implementation, as they could not readily accommodate all required HA settings.While REM could be used for verifying IG targets, no clinically feasible method for verifying SNR improvement targets is currently available.The BEAR strategy had to be sufficiently different from the current HA fitting strategy to warrant a formal investigation into its perceptual benefits.The HA solutions for the four auditory profiles had to be sufficiently different from each other to warrant a formal investigation into their perceptual benefits.A number of challenges related to the clinical implementation of the BEAR rationale were identified, as listed below:For the final implementation, the BEAR rationale was slightly modified compared to the original proposal . First, The methods described below focus on a fitting tool developed for the clinical study, the procedure used for making real-ear measurements as part of the clinical study, and SNR improvement measurements made on an acoustic mannikin in preparation for the clinical study.A clinically feasible fitting tool was developed to allow the commercial HAs to be fitted in accordance with the BEAR rationale. First, a Microsoft Excel sheet for calculating the BEAR target gains was prepared, into which the audiologists entered the audiometric thresholds at 0.25, 0.5, 1, 2, 4, and 8 kHz together with the profile of a given patient. The Excel sheet then generated a figure that was carefully designed to resemble the visual display in the REM system used for verification purposes . Using the open-source software ‘OnTopReplica’ , the calThe efficacy of the developed fitting tool and procedure was verified by performing several HA fittings on a CARL manikin . Care was taken to make the fitting process as straightforward as possible for the audiologists who handled the HA fittings in the clinical study. To accomplish this, detailed instructions were prepared to guide them through all necessary steps. Since three hearing aids from three different manufacturers were used, a set of instructions was needed for each device. Importantly, the instructions covered not only the gain adjustments, but also the activation and parameters of advanced features corresponding to the choices made for each profile in the BEAR fitting group, and the fitting protocol for the current fitting group.As part of the clinical study, real-ear insertion gain (REIG) data were collected at 55, 65, and 80 dB SPL input levels to ensure close fits to the target. The International Speech Test Signal  was useThe participants for the clinical trial were recruited at two university hospitals . Two-hundred-and-five adults with bilateral symmetric sensorineural hearing loss, Danish as their primary language, and no prior HA experience were included. They were 45–83 years old (mean and standard deviation: 68.3 ± 7.5 years), and 54% of them were male. Some participants dropped out of the study after the first visit. In total, 165 participants completed the study. At the first visit, the participants completed a clinical test battery for auditory profiling [To characterize the SNR improvement, electroacoustic measurements were performed in an IEC-standardized listening room at the Technical University of Denmark with a free-field setup with five loudspeakers placed in a circle with a radius of 1.5 m. At the center of the loudspeaker array, a head-and-torso simulator  with pinnae  was placed see . The HATThe measurements consisted of a series of 30 s recordings. The first 10 s of each recording were discarded. In this way, it was ensured that the advanced HA features had reached a steady state. To calculate the achieved SNR improvement, the Hagerman–Olofsson method  was usedavg, was then calculated as the difference between the SNR estimated for each of the HA settings and the SNR from the unaided condition.An additional reference recording was made with the unaided HATS. The SNR improvement, ΔSNRAs there were only six participants in profile D, the differences in REIGs between the two fitting strategies can be largely explained based on differences in individual audiograms. To enable a comparison of the differences in gain between the two strategies for profile D, the gains measured for participants who received a BEAR fitting are compared with NAL-NL2 target gains for the same participants . This is illustrated in avg values for three input SNRs  and the three HAs that were used in the clinical study . Each panel corresponds to one of the profiles. HA1 provided hardly any SNR improvement for profile A, but a notable SNR improvement (~3 dB) was seen for profile C. HA2 and HA3 provided 1–2 dB of SNR improvement for profiles A and D and >2 dB SNR improvement for profiles B and C. In terms of dependencies on the input SNR, there were only clear differences for profile B, especially with HA1, for which the SNR improvement decreased with increasing input SNR. This could have been a consequence of HA1 using fast-acting compression.The present study focused on challenges and solutions for implementing the BEAR fitting strategy in real HAs. The results of the technical evaluation showed that the three HAs were able to provide SNR improvement targets in accordance with the BEAR strategy. This was especially true for HA1, which did not provide any SNR improvement for profiles A and D but a substantial SNR improvement for profile C and, to a lesser extent, profile B at lower input SNRs. Overall, it was therefore possible to find advanced feature settings that fulfilled the requirements.The REIG data were collected as part of the clinical study. As expected, the IGs for HAS-A and HAS-B were very similar to the ones prescribed by NAL-NL2. This was because the BEAR rationale prescribes IG based on the same principles as NAL-NL2  for these two profiles. In contrast, the IGs corresponding to HAS-C and HAS-D deviated substantially from NAL-NL2. The IGs prescribed by the BEAR rationale for HAS-C and HAS-D are based on empirical comparisons between the gains required for loudness normalization, based on loudness perception measurements. The goal here is to provide sufficient amplification to normalize loudness at soft and conversational input levels and to reduce amplification for signal inputs above 75–80 dB SPL. This is partly motivated by the expected presence of ‘rollover’ in profile-C listeners, which can affect speech intelligibility at above-conversational levels . To achiA practical realization of the BEAR fitting strategy could be found based on a joint effort from the academic and industrial partners. The main limitation was that no modifications to the HA fitting software could be made. Instead, a procedure combining real-ear gain measurements with an open-source software was chosen for the gain adjustments. However, this procedure can be difficult for clinicians to perform, and thus errors can occur along the way.While the REIG data were obtained from individual participants as part of the clinical study, the SNR improvement data could only be obtained in the laboratory. This makes a comparison of the current and BEAR fittings difficult. Currently, there is no systematic method for characterizing advanced HA signal processing in real ears. Although there are techniques that can successfully quantify signal modification ,20, theyThe BEAR fitting rationale was implemented for use in a large-scale clinical trial. The joint efforts by the industrial and academic partners resulted in a procedure for HA fitting that allowed the investigation of profile-based HA fittings with commercially available devices. As expected, the differences in IG between the BEAR and current fitting strategies were only apparent for profiles C and D, while the differences in SNR improvement were apparent for all profiles. The BEAR fitting rationale is the first fitting strategy that prescribes not only gain targets but also the adjustment of advanced HA features.


To perform vestibular assessment using cervical and ocular vestibular evoked myogenic potential, video head impulse test and caloric testing in patients with sudden hearing loss. Moreover, to evaluate the correlation of dizziness with vestibular tests and the correlation of vestibular tests with hearing prognosis.p ≤ 0.05 was considered statistically significant.This is an observational, longitudinal and prospective study, including participants diagnosed with sudden hearing loss. The participants underwent cervical and ocular vestibular evoked myogenic potential, video head impulse test and caloric testing. The audiometric assessment was performed at the beginning and at the end of the follow-up. A value of Seventeen patients were included in the study sample, with a mean age of 45.4 ± 11.1 years. Five participants (29.41%) had dizziness and 15 (88.23%) had tinnitus. All participants underwent vestibular evaluation through cervical and ocular vestibular evoked myogenic potential and video head impulse test, and 13 of them were evaluated through caloric testing. The cervical vestibular evoked myogenic potential was considered altered in five (29.41%) participants, while 11 (64.71%) showed alterations at the ocular vestibular evoked myogenic potential. The video head impulse test and the caloric testing were considered altered in seven (41.18%) and five (38.46%) participants, respectively. There was no statistically significant correlation between the clinical data and the results of vestibular tests or hearing recovery, nor between the results of vestibular tests and hearing recovery.The assessment through vestibular evoked myogenic potential, video head impulse test and caloric testing showed vestibular involvement in some participants. However, it cannot be stated that the results of the vestibular tests are related to the hearing prognosis of sudden hearing loss. Sudden hearing loss (SHL) is defined as a hearing loss of at least 30 dB, affecting three or more consecutive audiometric frequencies, with sudden onset within 72 h.In addition to damage to the hearing function, SHL can also compromise vestibular function, which could be explained by the hypothesis of disease extension due to the anatomical proximity of the cochlea, vestibule and semicircular canals.It is believed that the prognosis regarding hearing recovery may be related to several factors, such as the patient’s age, presence of vertigo at symptom onset, degree and configuration of the hearing loss observed in the audiometry and the time between hearing loss onset and the treatment.This is an observational, longitudinal and prospective study, approved by the Research Ethics Committee of the institution (Opinion n. 2937124/CAAE 97623018.2.0000.5505).Patients diagnosed with idiopathic unilateral SHL, who met the eligibility criteria, from November 2019 to March 2021 were included in this study. All study participants had undergone oral corticosteroid treatment prior to inclusion in the study (prednisone 60 mg/day or deflazacort 90 mg/day) with maximum dose duration depending on the case evolution, at the discretion of the assistant otorhinolaryngologist. The inclusion criteria were: idiopathic unilateral SHLThe patients underwent hearing assessment during the follow-up, performed by the same professional and using the AD 28 Interacoustics audiometer and AZ 7 Interacoustics immittanciometer. Pure tone audiometry was performed, evaluating the frequencies of 250, 500, 1000, 2000, 3000, 4000, 6000 and 8000 Hz, and vocal audiometry with assessment of the speech recognition threshold and the speech recognition index (SRI). The degree of the initial hearing loss was classified according to the pure tone average (PTA) at 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz in: normal hearing (0–25 dB); mild (26 dB–40 dB); moderate (41 dB–60 dB); severe (61 dB–80 dB); and profound (≥81 dB) hearing loss.The ICS Charter EP 200 equipment  was used to perform the cVEMP. Adhesive and disposable surface electrodes were used, placed after dermabrasion at the sites as shown in Earphones were inserted into the patient’s ear to present the sound stimuli via air conduction. The electrode impedance values remained below 5 kΩ, with a maximum difference of 2 kΩ between them. The potential was assessed with 95 dBHL of intensity. The tests were repeated at least twice to obtain replicable responses. Peaks p13 and n23 were marked for cVEMP and n10 and p15 for oVEMP.14The ICS impulse equipment  was used to perform the vHIT. The participant remained seated in a chair, positioned approximately 1.20 m from a fixed target on the wall. After placing the equipment’s glasses on the participant and calibrating them according to the program requirements, the semicircular canals were tested by a head impulse test. During the test, the participants were asked to keep their eyes fixed on the target positioned in front of them. Twenty head impulses were performed for each canal with a velocity of 150–250/s. The vestibulo-ocular reflex (VOR) gain was automatically calculated by the equipment.The ICS Charter EP 200 equipment  was used to perform the caloric testing. The participant remained seated in a chair positioned at approximately 1.20 m from the light bar. After placing the equipment’s glasses on the participants and calibrating them according to the program requirements, the oculomotricity assessment was performed. Then, the participants lay in the supine position on a stretcher with the head tilted at 30° forward. Eye movements were recorded after stimulation with air at temperatures of 24 °C (cold) and 50 °C (hot), both for 60 s with an air flow rate of 8 L/min. Each ear was evaluated separately, with a 5-min interval between each stimulus. The value of the slow component angular velocity (SCAV) of post-caloric nystagmus was automatically measured by the equipment.The cVEMP and oVEMP tests were considered abnormal when the response was absent or asymmetric (AI > 43% in cVEMP and >35.3% in oVEMP).Hearing recovery was assessed based on the hearing gains observed on the PTA and SRI, according to the 2019 SHL Guidelines.p ≤ 0.05). To analyze the age variable and the degree of hearing loss in relation to the results of vestibular tests, the Student’s t-test and Mann–Whitney U-test were used, respectively. The evaluation between these variables and hearing recovery was performed using Spearman’s correlation test.The SPSS Statistics software, version 25.0  was used to perform the statistical analysis. The statistical significance value was set at ≤5%  male and 8 (47.06%) female participants. Hearing loss occurred on the right side in 9 participants (52.94%) and on the left side in 8 (47.06%). Of the total number of assessed participants, 5 (29.41%) had dizziness and 15 (88.23%) had tinnitus ipsilateral to the ear affected by SHL, with all participants having associated dizziness or tinnitus. Four participants had comorbidities, one with systemic arterial hypertension (SAH) and hypothyroidism (participant 12), one with SAH and osteoarthrosis (participant 10), one with SAH (participant 11) and one with osteoarthrosis (participant 16). The demographic and clinical data for each patient are described in The initial and final audiometric evaluations were performed, on average, 7 days after the onset of SHL and, on average, 40 days after the initial audiometric evaluation, respectively. The vestibular tests were performed on average 13 days after the onset of SHL .Table 2PThe degree and configuration of the initial and final hearing loss are described in In the cVEMP, five participants (29.41%) showed no response on the side affected by SHL , while oVEMP was altered in 11 (64.71%) participants. Of these, 10  showed no response on the side affected by SHL and one showed asymmetric responses (participant 2), with the response amplitude being lower in the ear affected by SHL .Table 4RAll seventeen participants underwent the vHIT. Seven (41.18%) had a decrease in the VOR gain on the side affected by SHL, as described in Thirteen participants underwent caloric testing (76.47%). Of these, 5 (38.46%) had altered results due to unilateral hypofunction on the side affected by SHL , as described in There was no statistically significant difference between age, tinnitus, degree and configuration of hearing loss and the vestibular test results. Similarly, no statistically significant correlation was observed between these variables and hearing recovery.p = 0.171).No statistically significant association was observed between the presence of dizziness and the vestibular test results . SimilarThere was no statistically significant difference between the vestibular test results and hearing recovery .Table 6AThe presence of dizziness and alterations in the vestibular tests, such as caloric testing, vHIT, and VEMP, have been associated with a worse prognosis in SHL.Regarding the possible prognostic factors related to SHL, the literature data are conflicting. Although some retrospective studies have suggested that older age, presence of tinnitus and more pronounced hearing loss could be factors of worse prognosis for hearing recovery,25In the present study, most of the participants (76.47%) were aged between 30 and 60 years, which is, therefore, in agreement with the literature regarding the age of highest incidence of SHL.In the current study, vestibular involvement in SHL was very frequent, approximately 88.23%, as demonstrated by the altered vestibular tests in most participants. The oVEMP was the most frequently altered vestibular test when compared to vHIT, caloric testing and cVEMP. This finding is in agreement with some studies,Regarding the final hearing evaluation, it was observed that all participants who showed complete hearing recovery had their hearing improvement observed within the first two weeks of the onset of SHL. According to these findings, even though the follow-up should be prolonged for a better assessment of patients with SHL, it is suggested that complete hearing recovery may preferably occur within the first weeks after SHL.The present study observed that all participants who did not show hearing recovery had alterations in the oVEMP test. As for the cVEMP, vHIT and caloric testing, it was observed that most participants with altered results also did not show complete hearing recovery. However, no statistically significant association was observed between the presence of alterations in the cVEMP, oVEMP, vHIT or caloric testing and hearing recovery. This fact suggests that the recovery of cochlear function in SHL could, to some extent, be independent of the extent of damage to the vestibular system.Considering the studies published in the literature, only one, a retrospective study, evaluated patients with SHL associated with dizziness, through the analysis of all the tests discussed in the present study  and correlated them with the presence of a vestibular clinical manifestation, spontaneous nystagmus.The main limitation of our study is the small number of participants allocated to the subgroups of variables, which could have reduced the power of the statistical analysis. However, based on the performed literature review, this is the first prospective study that evaluated hearing recovery in patients with SHL using a comprehensive vestibular assessment through cVEMP, oVEMP, caloric testing and vHIT. Unlike most studies published in the literature, the criteria defined by the latest clinical practice guideline on SHLThe vestibular tests cVEMP, oVEMP, vHIT and caloric testing may be altered in patients with idiopathic unilateral SHL, but their results were not related to the hearing prognosis in SHL in the assessed sample.The authors declare no conflicts of interest.