To analyze hearing performance and expectations regarding the use of hearing aids (HA) by participants with minimal hearing loss.This research is a primary, observational, longitudinal and prospective study. Two questionnaires, the Speech Spatial Qualities Questionnaire (SSQ) and the Expected Consequences of Hearing Aid Ownership (ECHO), were used, respectively, to verify hearing performance in complex listening situations and expectations regarding the use of HA. The convenience sample consisted of adults aged 53 to 72.SSQ showed that, for hearing performance, greater difficulties were observed in unfavorable situations such as speech and speech-in-noise, followed by greater ease in locating the sound source and in the quality and naturalness of the sound. ECHO showed that, for the expectations regarding the use of the HA, the variables with significant correlation values were age x general expectation with HA and age x HA's positive aspects. No statistically significant association existed between performance scores in complex listening situations and the analyzed variables.Minimal hearing loss can negatively influence everyday communicative situations, and the expectation of individuals with minimal hearing loss regarding the use of HA was shown to be high. In addition, the hearing performance of individuals in this study did not show correlations with the age, gender and education level of the sample. However, researchers have suggested a new classification of hearing loss called “minimal hearing loss”. This classification is defined in three categories: unilateral sensorineural hearing loss, bilateral mild sensorineural hearing loss and sensorineural loss in high frequencies. Minimal hearing loss can become an obstacle to communication in specific situations, such as unfavorable listening situations in environments with noise and reverberation or when there is a great distance between the speaker and the interlocutor.Commonly, hearing loss is classified in degrees related to the sound intensity needed to trigger sound perception in the individual's auditory system.Thus, to improve the hearing skills of individuals with hearing loss, hearing aids (HA) are recognized as one of the therapeutic alternatives and should always be indicated, even in mild hearing loss, to reduce hearing effort-8. Therefore, to verify the HA, the literature has questionnaires that subjectively quantify and qualify, from the user's perspective, the aspects of hearing performance in realistic and complex communication situations and the expectation and satisfaction with HA. In this regard, researchers developed the Speech Spatial Qualities Questionnaire (SSQ), which explores aspects of hearing by measuring the individual's ability to hear speech in different complex listening contexts. This instrument demonstrates the benefits of bilateral hearing capacity in different day-to-day situations and different hearing aptitudes.Although the objective data about the HA verification during the rehabilitation process are essential to prove the electroacoustic characteristics, several researchers defend that only the user can determine how well the device solved his need, which aims to measure the expectations of future HA users, addressing issues such as costs, personal image and expected negative aspects.Concerning the qualification and quantification of pre-fitting expectations of individuals who are candidates for HA, researchers have developed the scale known as Expected Consequences of Hearing Aid Ownership (ECHO).Despite technological advancements, HA fitting continues to be a challenge for audiologists, and the high rate of abandonment of the use of HA is an obstacle for health servicesTherefore, the present study aimed to analyze the hearing performance and expectations regarding HA use by participants with minimal hearing loss.This research was approved by the institution's Research Ethics Committee  following the ethical principles of Resolution n° 466/12. This research is a primary, observational, longitudinal, and prospective study. Participants were invited to participate in the research and signed the informed consent form.Sociodemographic data  and characteristics of hearing loss were obtained through previous analysis of medical records of individuals scheduled to be seen in the sector.Subjects who met the following eligibility criteria participated in the research:Diagnosis of mild bilateral sensorineural hearing loss  and less than or equal to 40 dB HL, unilateral sensorineural hearing loss (with an average of thresholds greater than 20 dB HL) and hearing loss at high frequencies (thresholds greater than 20 dB HL in frequencies from 2000 to 8000 Hz), as recommended by the National Workshop on Mild and Unilateral Hearing Loss (2005). The degree was established according to the criteria from WHO (1997), as used by the institution;Age ranged from 18 to 80 years old;No experience with HA.Subjects who met the following exclusion criteria were removed from the research:individuals with cognitive and/or intellectual alterations, identified by the multidisciplinary team's evaluation, that would compromise the data collection.Two questionnaires were used: the Speech Spatial Qualities Questionnaire (SSQ), which functionally assess hearing difficulties and possible day-to-day difficulties that the participants could present, and the Expected Consequences of Hearing Aid Ownership (ECHO), which qualifies and quantifies the expectations of individuals who are candidates for the use of hearing aids before fitting. Participants answered both SSQ and ECHO on the same day in an interview format.The collected data were compiled and analyzed using descriptive statistical analysis, with the following parameters: mean, median, confidence interval, standard deviation, minimum, maximum and range. Subsequently, inferential analyses were performed, applying hypothesis tests consistent with the objectives: Student's t-test and Spearman's correlation coefficient. Such hypothesis tests adopted a significance level of less than 0.05 (p = 5%).As a classification of the degree of correlation, that is, the strength between the variables, the following parameters were used: weak when (0) < r < (0.4), moderate when (0.4) < r < (0.7) and strong when (0.7) < r < (1.0). Correlations had statistical significance when the p-value was less than 0.05, and there was a moderate or strong degree of correlation (12).The characterization of the sample had 15 participants with an average age of 62.7 years. The standard deviation for age was 5.95, with a median of 64 years and a range equal to 19. As for gender, 8 females (53%) and 7 males (47%) participated.As for the schooling variable, completed high school was the most recurrent . Education categories with a long duration of years were the lowest recurrence, with only 1 participant with higher education. Four participants (27%) had incomplete or complete elementary school .Concerning classifications regarding the type of minimal hearing loss, mild bilateral sensorineural hearing loss was prevalent , while only 3 individuals had sensorineural hearing loss at high frequencies (20%), and 1 had mild sensorineural hearing loss in the left ear and high-frequency sensorineural loss in the right.The SSQ had a lower overall score, with greater difficulty in answering questions 3, 4 and 12, which respectively address the following complex hearing situations: speech-in-speech, speech-in-noise and listening effort. The best answers were obtained in questions 6 (location) and 11 . As for the amplitude of the collected data, there was a dispersion of answers with variation between minimum and maximum in four questions , with borderline answers and greater standard deviation for question 9 (segregation). A total of 4.5 per question was obtained in the analysis of means, with a standard deviation of 1.01.The results obtained are shown in Spearman's correlation coefficient was used to analyze a possible correlation between age/schooling and performance in complex listening situations, and no statistically significant relationships were found in the samples studied for such variables. Student's t-test was used to analyze a possible correlation between gender and hearing performance in complex listening situations, and, again, no statistically significant results were found in the studied sample.For the ECHO instrument, the following results were collected according to the answers and calculations of the central tendency measures, shown in As for the overall score, the results are shown in In the analysis of a possible correlation between age and schooling with the expectation regarding the use of HA, statistically significant correlations were found  for the variables age and positive effects, and age and the global ECHO score scale .Student's t-test was used to assess the expectation regarding the use of HA obtained with ECHO considering gender, and no statistically significant results were found in the studied sample ..After a bibliographic survey in the main databases using keywords in Portuguese and English, little scientific production was found that focused on minimal hearing loss in adults. Consequently, relating the findings of this research with previous studies was difficult. Still, minimal hearing loss can cause adversities in the daily life of affected individuals. Also, the harm caused by mild hearing loss may not be completely measurable only with objective tests, such as pure tone audiometry, but in these cases, using questionnaires and instruments that assess the quality of life of these individuals is the best option to understand their current clinical and functional status,12,13. These data align with the findings in this study since a lower general score was verified in hearing performance, indicating greater difficulty in speech-in-speech, speech-in-noise and listening effort.In general, the literature points out listening situations in complex environments, with reverberation, competitive noise and greater distance from sound sources, as major obstacles. Of these situations, those in which speech is present as competitive noise become the most challenging,14. Thus, the capture of sounds that prevented the volunteers from hearing what they wanted to hear had a negative impact even during the hours of daily use of HA.Consistent with the unfavorable everyday listening situations most affected by mild sensorineural hearing loss, some studies found that HA users' greatest dissatisfaction is the hearing aid's management regarding background noise, regardless if the noise is caused by speech. Similarly, this study found an overall average score of 54 points on the SSQ in a population with minimal hearing loss. Therefore, it is clear that even minimal hearing loss can interfere with hearing performance in complex listening situations since our data are similar to those of the original study. Also, this score corresponds to less than half of the maximum score that can be obtained with SQQ (120).In the original validation of the SSQ, an overall result of 49 points was obtained in a population of 153 adults and elderly people with bilateral moderate sensorineural hearing loss. In contrast, using the same instrument, the present study generated a global mean response of 4.5. Such low scores may be related to the higher age of the sample and the hearing thresholds, two variables known to cause greater difficulty in daily hearing performance, either due to sensory restriction or cognitive decline. Other authors noticed similar performances when comparing young people and middle-aged adults; yet, when there were masking noises, the older individuals experienced substantially more difficulty when the noise had a message in the speech spectrum. However, in another study, when evaluating young adults with normal hearing, authors concluded that even those individuals did not report hearing capacity, with great variability of responses.When analyzing young people with normal hearing, researchers observed a global average of 8.8 in hearing performance in complex listening circumstances,14,18.The data collected in this study demonstrated better performances in the domains of location  and sound quality and naturalness, with the perception of a clear and not cloudy sound. These results align with what is exposed in other national and international studies with different populations, corroborating the design of a profile of hearing abilities more accessible to individuals with minor hearing lossAs for the domains presented in the SSQ, this study found that the hearing-to-speak and hearing quality factors had the lowest scores, which may mean greater difficulty in tasks related to such domains. Through these answers, audiologists work with different actions during hearing rehabilitation to address the mentioned difficulties better. When aware of the greatest obstacles in the daily life of individuals with minimal hearing loss and with the objective data of the assessment evaluations, audiologists can develop a rehabilitation process that moves towards the singularity needed for a successful HA fitting.,19. In fact, for most of the sample, the scores obtained were close to the maximum score of the questionnaire in all sub-items, especially the HA's design and the statement that the HA would “be worth it.” As for the subscale of negative aspects, lower average values of expectation were observed, mainly concerning frustration when the HA detects noises that are unwanted by the user.Concerning the expectation regarding the use of hearing aids by the participants, the sample of this study showed results consistent with the literature in general, as high expectations scores were verifiedAlso, a significant relationship was observed between the age variable and the expectation regarding the use of HA among the participants. The increase in age seems proportional to the expectations that the HA will meet all the needs of future users. Unfortunately, this belief can lead to unrealistic ideas about amplification and become an obstacle to the effective use of HA; therefore, greater care is needed in the orientation stage, especially for older individuals.,18. Indeed, in a systematic review, the authors noted a series of non-audiological factors that could determine the use of HA among the elderly, such as demographic characteristics, the health professional involved in the fitting and the companion of the hearing aid user.However, the conclusion that there is a positive relationship between age and the expectation of HA use cannot be taken as definitive in the audiological rehabilitation process since several factors, whether personal or environmental, corroborate the success or failure of the HA fitting.Some scholars point out the fine line regarding future HA users' expectations: individuals who do not expect to benefit from the use of HA will not look for them or make optimal use of them; in contrast, those with high expectations may want to try them, but discontinue HA use when they do not provide the expected level of satisfactionThe present study did not demonstrate significant associations (p > 0.05) between gender and education compared with the expectations demonstrated regarding the use of HA or hearing performance in complex listening situations. However, future national studies with the same theme and a larger and more varied sample of participants may lead to new conclusions on the subject.In general, SSQ's responses had lower scores than those obtained on the ECHO. Therefore, the studied population showed limitations in daily listening environments, mainly in complex listening situations. Such individuals observe and feel these impasses, mainly in communicative situations. A high level of expectation regarding the use of HA was also observed, mainly regarding the positive aspects, which can cause unrealistic expectations and be an obstacle to fitting the HA.Thus, a service centered on the individual, focused on their needs and particularities, is crucial even in cases of minimal hearing loss. Therefore, this research hopes to corroborate national studies in the area and promote a better understanding of the hearing clinical characteristics of this population in order to maximize their assistance, hearing rehabilitation and quality of life.Minimal hearing loss can negatively influence everyday communicative situations, and the expectation of individuals with minimal hearing loss regarding the use of hearing aids was high. In addition, the hearing performance of the individuals in this study did not show correlations with the age, gender and education of the sample. .A perda de audição pode ser significativa e ocasionar prejuízo nas interações sociais e no equilíbrio psicológico, bem como comprometer a qualidade de vida do indivíduo acometido. Estudiosos sugeriram uma nova classificação de perda auditiva chamada de ‘’perda auditiva mínima”, essa classificação é definida em três categorias, são elas: perdas auditivas sensorioneurais unilaterais, perdas auditivas sensorioneurais leves bilaterais e perdas sensorioneurais em frequências altas. Principalmente em ocasiões específicas, a perda auditiva mínima pode se tornar um obstáculo para a comunicação, como em situações desfavoráveis de escuta em ambientes com ruído e reverberação, distância maior entre locutor e interlocutor, entre outros aspectos.Comumente, a perda auditiva é classificada em graus de comprometimento, relacionados à intensidade de som necessária para desencadear a percepção sonora no sistema auditivo do indivíduo.Assim, na tentativa de proporcionar a melhora das habilidades auditivas dos indivíduos com perda de audição, o aparelho de amplificação sonora individual (AASI) é reconhecido como uma das alternativas terapêuticas. Esse dispositivo deve ser sempre indicado, mesmo na presença de perdas auditivas de grau leve, visando a redução do esforço auditivo-8. Para verificação do dispositivo de amplificação sonora, a literatura dispõe de questionários que quantificam e qualificam subjetivamente na visão do usuário, os aspectos do desempenho auditivo em situações realísticas e complexas de comunicação, a expectativa e a satisfação frente ao AASI. Nesse aspecto, pesquisadores desenvolveram o Speech Spatial Qualities Questionnaire (SSQ), questionário que explora aspectos da audição mensurando a capacidade do indivíduo para ouvir a fala em diferentes contextos complexos de escuta. Esse instrumento, demonstra os benefícios da capacidade auditiva bilateral nas diferentes situações do dia a dia e em diversas aptidões auditivas.Diversos pesquisadores defendem que, embora os dados objetivos acerca da verificação do AASI durante o processo de reabilitação sejam essenciais para comprovar as características eletroacústicas na verificação, somente o usuário pode determinar quão bem o dispositivo resolveu sua necessidadeExpected Consequences of Hearing Aid Ownership (ECHO). O instrumento visa mensurar a expectativa dos futuros usuários de AASI com seu uso, abordando questões que envolvem assuntos como custos, imagem pessoal e aspectos negativos esperados.No que tange à qualificação e à quantificação das expectativas de pré-adaptação dos indivíduos candidatos ao uso de AASI, pesquisadores desenvolveram a escala conhecida como: .Apesar do avanço tecnológico, a adaptação do usuário de AASI continua sendo um desafio para os audiologistas, e a alta taxa de abandono do uso do dispositivo de amplificação é um entrave para os serviços de saúdeSendo assim, o presente estudo teve como objetivo analisar o desempenho auditivo e expectativas quanto ao uso dos aparelhos de amplificação sonora individual (AASI) dos participantes com perda auditiva mínima.Trata-se de pesquisa aprovada pelo Comitê de Ética em Pesquisa da instituição (4.315.301), de acordo com os princípios éticos da Resolução n° 466/12. Estudo com delineamento de pesquisa primária, observacional do tipo longitudinal e prospectivo. Os participantes foram convidados a participar da pesquisa e todos assinaram o Termo de Compromisso Livre e Esclarecido (TCLE).Os dados sociodemográficos foram obtidos por meio da análise prévia dos prontuários: idade, gênero, ocupação e nível de escolaridade dos indivíduos que estavam agendados para serem atendidos no setor, bem como as características da perda auditiva.Participaram da pesquisa sujeitos que apresentaram os seguintes critérios de elegibilidade:National Workshop on Mild and Unilateral Hearing Loss (2005). O grau foi estabelecido de acordo com os critérios da OMS (1997), conforme utilizado pela instituição;Diagnóstico de perda auditiva sensorioneural bilateral de grau leve  e menor ou igual a 40 dB NA, perda auditiva sensorioneural unilateral (com média de limiares maior que 20 dB NA) e perda auditiva em altas frequências, com limiares superiores a 20 dB NA nas frequências de 2000 a 8000 Hz, conforme preconiza o Faixa etária de 18 a 80 anos;Sem experiência com o AASI.Exclusão: indivíduos com alterações cognitivas e/ou intelectuais que comprometam a realização da coleta de dados, identificadas por avaliação da equipe multidisciplinar.Speech Spatial Qualities Questionnaire (SSQ) para avaliar a dificuldade auditiva de forma funcional, obtendo possíveis dificuldades cotidianas que o participante pudesse apresentar e o instrumento Expected Consequences of Hearing Aid Ownership (ECHO), com o objetivo qualificar e quantificar as expectativas dos indivíduos candidatos ao uso de AASI antes da adaptação. Ressalta-se que, tanto a escala ECHO como o questionário SSQ foram aplicados no mesmo dia no formato de entrevista.Foram aplicados dois questionários: Student e coeficiente de correlação de Spearman. Tais testes de hipótese adotaram nível de significância menor que 0,05 (p = 5%).Os dados coletados foram compilados e analisados por meio da análise estatística descritiva, com os seguintes parâmetros descritos: média, mediana, intervalo de confiança, desvio padrão, mínimo, máximo e amplitude. Posteriormente, foram realizadas análises inferenciais, com aplicação dos testes de hipótese coerentes aos objetivos: teste T de .Como classificação do grau de correlação, ou seja, da força entre as variáveis, lançou-se mão dos seguintes parâmetros: fraca quando (0) < r < , moderada quando  < r <  e forte quando  < r < . Foram consideradas correlações com significância estatística apenas as que apresentaram valor de p menor que 0,05 e grau de correlação moderado ou forteA caracterização da amostra contou com 15 participantes com média de 62,7 anos. O desvio padrão para a idade foi de 5,95, com mediana de 64 anos e amplitude igual a 19. Quanto ao gênero, participaram 8 indivíduos do gênero feminino e 7 do gênero masculino, com percentuais de 53% e 47%, respectivamente.Quanto à variável escolaridade, observou-se como mais recorrente o Ensino Médio completo, com 33% de ocorrência, n = 5. As categorias de ensino com maior duração de anos, como o ensino superior, foram as de menor número, com apenas 1 participante graduado. Para o ensino fundamental incompleto e fundamental completo obteve-se número igual a 4, com percentual de 27% .No que diz respeito às classificações quanto ao tipo de perda auditiva mínima, foi observada prevalência do tipo sensorioneural de grau leve bilateral, com percentual de 73% em 11 participantes, ao passo que apenas três indivíduos possuíam perda auditiva sensorioneural em altas frequências (20%), e um possuía perda auditiva sensorioneural de grau leve em orelha esquerda e perda sensorioneural em altas frequências à direita.O questionário SSQ, teve uma menor pontuação geral, com maior dificuldade nas respostas das questões 3, 4 e 12, as quais abordam respectivamente as seguintes situações complexas de audição: fala na fala, fala no ruído e esforço de escuta. Em contrapartida, as melhores respostas foram obtidas nas questões 6  e 11 . Quanto à amplitude dos dados coletados, verificou-se dispersão das respostas com variação entre mínimo e máximo em quatro questões  com respostas limítrofes no questionário apresentado, e maior desvio padrão para questão 9 (segregação). Na análise das médias, obteve-se um total de 4,5 por questão, com desvio padrão de 1,01.Quanto à pontuação geral, os resultados obtidos estão expressos na Na análise de uma possível correlação entre a idade/escolaridade e o desempenho em situações complexas de escuta, utilizou-se o coeficiente de correlação de Spearman. Não foram verificadas relações estatisticamente significantes nas amostras estudadas para tais variáveis. Além disso, para a avaliação do desempenho auditivo em situações complexas de escuta obtidas com o SSQ, considerando o gênero, utilizou-se o teste T de Student. Não foram verificados resultados estatisticamente significantes na amostra estudada.Para o instrumento ECHO, foram coletados os seguintes resultados conforme as respostas e cálculos das medidas de tendências centrais, que se apresentam na Quanto à pontuação geral, foram obtidos os resultados expressos na p abaixo de 0,05 e coeficiente de correlação de grau moderado) para as variáveis idade e efeitos positivos, e para idade e a escala global de pontuação do instrumento ECHO  entre gênero e escolaridade em comparação com as expectativas demonstradas quanto ao aproveitamento do AASI, ou mesmo quanto ao desempenho auditivo em situações de escuta complexa. No entanto, mais estudos nacionais com a mesma temática e com amostra maior e variável de participantes podem suscitar novas conclusões acerca do assunto.O presente trabalho não demonstrou associações de significância (Observou-se de modo geral, respostas com escores inferiores no questionário SSQ, se comparado com as respostas obtidas na escala ECHO. Portanto, a população estudada demonstrou possuir limitações em atividades enfrentadas em ambientes de escuta diária, principalmente em situações complexas de escuta. Estes impasses são observados e sentidos por tais indivíduos principalmente em situações comunicativas. Também foi observado nível elevado de expectativa quanto ao uso do AASI principalmente no que tange aos aspectos positivos, o que pode causar expectativas irreais e ser um obstáculo à adaptação do AASI.Assim, salienta-se a importância de um atendimento centrado no indivíduo, voltado para suas necessidades e particularidades, mesmo em casos de perdas auditivas mínimas. Portanto, a presente pesquisa esperou corroborar com estudos nacionais na área e promover uma melhor compreensão acerca das características clínicas auditivas de tal população no intuito de maximizar sua assistência, reabilitação auditiva e qualidade de vida.Concluiu-se que a perda auditiva mínima pode influenciar negativamente em situações comunicativas cotidianas, como também, a expectativa dos indivíduos com perda auditiva mínima quanto ao uso do AASI mostrou-se elevada. Além disso, o desempenho auditivo nos indivíduos desse estudo não apresentou correlações com idade, gênero e escolaridade da amostra.


Faecal immunochemical test (FIT)-directed pathways based on a single test have been implemented for symptomatic patients. However, with a single test, the sensitivity is 87 per cent at 10 µg haemoglobin (Hb) per g faeces. This aims of this study were to define the diagnostic performance of a single FIT, compared with double FIT in symptomatic populations.Two sequential prospective patient cohorts referred with symptoms from primary care were studied. Patients in cohort 1 were sent a single FIT, and those in cohort 2 received two tests in succession before investigation. All patients were investigated, regardless of having a positive or negative test (threshold 10 µg Hb per g).rs = 0.58), and 16.8 per cent of double tests were discordant, 11.4 per cent in patients with colorectal cancer and 18.3 per cent in those with significant bowel pathology.In cohort 1, 2260 patients completed one FIT and investigation. The sensitivity of single FIT was 84.1 (95 per cent c.i. 73.3 to 91.8) per cent for colorectal cancer and 67.4 (61.0 to 73.4) per cent for significant bowel pathology. In cohort 2, 3426 patients completed at least one FIT, and 2637 completed both FITs and investigation. The sensitivity of double FIT was 96.6 (90.4 to 99.3) per cent for colorectal cancer and 83.0 (77.4 to 87.8) per cent for significant bowel pathology. The second FIT resulted in a 50.0 per cent reduction in cancers missed by the first FIT, and 30.0 per cent for significant bowel pathology. Correlation between faecal Hb level was only modest  strategies were tested in high-risk symptomatic patients. A double-FIT strategy reduced missed colorectal cancers by 50.0 per cent and all significant bowel pathology by 30.0 per cent, while improving prioritization to investigation. The high proportion of colorectal cancers with discordant FIT results underscores the rationale for double testing. Double FIT could reduce investigation by 68.9 per cent. Colorectal symptoms are a common presentation in primary care; of those referred to secondary care only 3–5 per cent of patients are diagnosed with colorectal cancer2. The number of suspected colorectal cancer referrals to secondary care is increasing without a proportionate increase in early cancer diagnoses3.Early detection strategies for colorectal cancer, in parallel with preventive measures, are key to improving survival5. Its quantitative nature can optimize resource use by prioritizing those with the highest risk, and tailoring investigation type to the degree of risk and patient characteristics. FIT has been proposed as a gatekeeper investigation in a resource-constrained system, and may even have a role as a rule-out test for colorectal cancer5. However, the sensitivity for colorectal cancer at a threshold of 10 µg haemoglobin (Hb) per g in symptomatic patients is unacceptably low (87.2–88.7 per cent)6–8. Furthermore, although acceptability studies have suggested that patients favour FIT over colonoscopy at a hypothetical 1 per cent false-negative rate, there was very low acceptability for any test that missed even one additional cancer9.Faecal immunochemical test (FIT) is commonly used to prioritize investigation in symptomatic patients and outperforms symptomatic assessment alone in identifying colorectal cancer10. A recent retrospective study11 in a symptomatic population found a sensitivity of 97.8 per cent when either test value was over 10 µg Hb per g. However, the colorectal cancer prevalence in this study was only 1.1 per cent as the population comprised patients with both low- and high-risk symptoms.Evidence for the use of more than one FIT to improve test sensitivity is limited and contradictoryThe aim of this study was to define the diagnostic performance of a single FIT compared with testing twice in succession in sequential cohorts of patients referred with symptoms suspicious of colorectal cancer. Diagnostic performance was assessed by measuring overall test performance, the rate of missed colorectal cancers and adenomas, and sensitivity, and implications for workload demand at varying faecal Hb thresholds were considered. A secondary aim was to evaluate whether the results could inform a change in clinical practice.The study was designed as two sequential, prospective cohort studies of patients referred consecutively from primary care in South-East Scotland, served by a single National Health Service Trust (Lothian). This captured all urgent or urgent suspected of cancer (USOC) primary care referrals to the Edinburgh Colorectal Surgery Unit. No ethical approval was required as this work formed part of routine care.Inclusion criteria were USOC or urgent priority referrals with the following high-risk lower gastrointestinal symptoms: repeated rectal bleeding without obvious rectal cause or blood mixed in stool, persistent change in bowel habit, palpable abdominal or rectal mass, weight loss, and/or abdominal pain with or without unexplained iron deficiency anaemia. Exclusion criteria were symptoms not fulfilling the above criteria, known inflammatory bowel disease (IBD), and those undergoing bowel cancer screening or emergency admission investigations.Patients were allocated to cohorts based on the interval in which their referral was sent. Patients in cohort 1 received a single FIT , and those in cohort 2 were sent two FITs on average 13 days apart . Patients were encouraged to prepare and return each FIT test on the day of completion. Tests were distributed before colorectal investigation for all patients, and investigation was performed regardless of the FIT being returned or result. Patients in the double-FIT cohort who returned only one FIT before investigation were included in the analysis of the first FIT sample analysed (FIT1) for the double-FIT cohort, whereas those who completed both FITs and colorectal investigation comprise the completed double-test (DT) protocol group. If the second FIT was collected on the same day as the first, it was discounted as a true second test. Endoscopy and CT with colorectal protocols were accepted as colonic/rectal assessment.Only patients with completed investigations were included in the analysis. However, the electronic patient records of all patients sent a FIT were reviewed, including multidisciplinary team notes and South-East Scotland Cancer Network registry data, at the end of July 2022  to ensure complete capture of cancer diagnoses in South-East of Scotland. No further cases of colorectal cancer were identified from this review.Demographic data and symptoms at primary care referral were collected prospectively for all patients. High-risk symptoms of abdominal or rectal mass, change in bowel habit (to loose stool or diarrhoea), anaemia, and rectal bleeding were recorded. Hb levels within 3 months were used to evaluate anaemia . FIT values and test dates were recorded. All investigation findings were categorized as: normal; colorectal cancer; advanced adenoma ; advanced colorectal neoplasia, which accounted for the presence of either colorectal cancer or advanced adenoma; IBD; and significant bowel pathology, defined as either advanced colorectal neoplasia or IBD.12. The FITTER checklist can be found in Fig. S1.FIT kits  were mailed to patients with instructions from secondary care and return address envelopes. Samples were analysed at the biochemistry centre using an HM-JACKarc analyser  which has a reporting limit of quantification (LoQ) of 7 µg Hb per g and a maximum reported result of 400 µg Hb per g. The test positivity threshold was a faecal Hb value of 10 µg Hb per g or greater, consistent with National Institute for Health and Care Excellence (NICE) guidance DG302 test, Fisher’s exact test, or Mann–Whitney U test. Correlation was assessed with Spearman’s rank correlation coefficient. Diagnostic accuracy, in terms of positive predictive value, negative predictive value, sensitivity, and specificity, were calculated with 95 per cent confidence intervals. The diagnostic test performance, sensitivity, and workload implications of single- and double-FIT strategies were calculated. Number needed to investigate  was determined for bowel pathology at varying thresholds by dividing the number of FIT-positive cases at the given threshold by the cases of bowel pathology within each cohort. Receiver operating characteristic (ROC) curves were generated at different FIT thresholds. Data analysis was performed using R version 4.0.5  with associated packages, and GraphPad Prism .Quantitative values were compared using χFig. 1). In a minority of patients, based on the GP referral, the triaging consultant considered that FIT was inappropriate, or an emergency admission predated FIT postage. Of the FIT returners, 321 patients (12.4 per cent) in the single-FIT cohort and 464 (11.9 per cent) in the double-FIT cohort did not undergo investigation. This included patients who cancelled investigations, non-attenders, and patients for whom, following consultant review, colorectal investigation was not required. Cancer registry review confirmed that no further colorectal cancers were diagnosed in any patient with minimum 12-month follow-up.Following consultant triage of eligible general practitioner (GP) referrals received during the study interval, FIT(s) were sent to 93.7 and 95.5 per cent of the single-FIT and double-FIT cohorts respectively (14.Investigations in the double-FIT cohort (commenced March 2020) were affected by the COVID-19 pandemic. Some 79 per cent of patients in the single-FIT cohort underwent colonoscopy and 21 per cent CT, whereas fewer patients underwent colonoscopy in the double-FIT cohort (53 per cent) than colonic imaging (47 per cent). Although decreased colonoscopy may have reduced adenoma detection in the double-FIT cohort, colorectal cancer detection using CT has been shown to be equivalent to that for colonoscopyTable S1). There was no difference in median age (65 (i.q.r. 56–74) years), sex distribution, FIT positivity, and colorectal cancer or advanced colorectal neoplasia prevalence between cohorts (Table 1). There was a lower prevalence of IBD in the double-FIT cohort and this led to a reduced prevalence of overall significant bowel pathology among those who completed the DT protocol, although colorectal cancer and advanced colorectal neoplasia rates were similar. A greater proportion of patients in the single-FIT cohort had anaemia, likely owing to reduced asymptomatic anaemia diagnoses during the COVID phase of double-FIT cohort acquisition, when routine blood tests in primary care ceased.In total, 2260 patients in the single-FIT cohort completed a FIT and colorectal investigation. In the subsequent double-FIT cohort, 3426 patients returned at least one FIT and had colorectal investigation, whereas 2637 completed two FITs (completed DT protocol). The double-FIT cohort included 21 patients from the single-FIT cohort who were re-referred during the double-FIT time frame. Investigation of this group revealed one advanced adenoma  diagnosed among those who did not return a FIT in the single-FIT cohort, and 23 (5.0 per cent) in the double-FIT cohort. Hence, the overall colorectal cancer prevalence in all those appropriate for and sent a FIT, including the non-returners, was 3.0 per cent in the single-FIT cohort and 3.6 per cent in the double-FIT cohort.Table 2). If FIT had not been deployed, 33 patients would need investigation to find a colorectal cancer (NNI without FIT: 33). Investigations would be required in 155 patients when the FIT value was below 10 µg Hb per g, compared with 10 patients with the FIT value above the threshold.At a threshold of 10 µg Hb per g, the sensitivity was 84.1 (95 per cent c.i. 73.3 to 91.8) per cent for detecting colorectal cancer and 64.4 (56.8 to 71.5) per cent for advanced colorectal neoplasia (Table S2) and would have been missed by a single test without investigation. All affected patients were aged over 70 years, eight were anaemic, and six of those with anaemia had a right-sided tumour as did a further two without anaemia. Overall, a single-FIT strategy would miss 15.9 per cent of colorectal cancers and 32.6 per cent of all significant bowel pathology.Eleven colorectal cancers were associated with a FIT value below 10 µg Hb per g . Application of the DT protocol, using the higher of the two FIT results (FITMAX), further increased the sensitivity to 96.6 (90.4 to 99.3) per cent (Table 3). Indeed, compared with the single-FIT cohort, completion of the DT protocol resulted in significantly fewer cases of potentially missed colorectal cancer (P = 0.009), advanced colorectal neoplasia (P < 0.001), and significant bowel pathology (P < 0.001). There was a significant improvement in sensitivity for advanced colorectal neoplasia (81.6 (75.3 to 86.9) versus 64.4 (56.8 to 71.5) per cent) and significant bowel pathology (83.0 (77.4 to 87.8) versus 67.4 (61.0 to 73.4) per cent) in the completed double-FIT compared with the single-FIT cohort.The median interval between completing FITs was 13 (i.q.r. 7–17) days. Some 3426 patients completed the first FIT before colorectal investigation, and 2637 completed both FITs and investigation (completed DT protocol). In the overall double-FIT cohort, the first FIT performed better at identifying colorectal cancer than the previous single-FIT cohort, with a sensitivity of 93.3 (95 per cent c.i. 87.7 to 96.9) per cent (Table S3).A total of 789 patients completed the first but not the second FIT. The real-world nature of this study meant that investigations were not delayed in order for the second test to be completed. This group were younger, of equal socioeconomic status, and had a colorectal cancer prevalence of 6.0 per cent (MAX), suggested that adding the second test led to a 50.0 per cent reduction in missed colorectal cancer, 29.2 per cent reduction in advanced colorectal neoplasia, and 30.0 per cent decrease in significant bowel pathology (Table 4). Where both FIT values were below 10 µg Hb per g, the prevalence of colorectal cancer was 0.17 per cent, indicating that 606 patients with 2 negative tests would need to be investigated to find 1 additional colorectal cancer. The reassuringly low colorectal cancer prevalence in patients with two negative FITs suggests that urgent investigation could be deferred in lieu of a safety-netting interval of active observation. In the absence of anaemia, the colorectal cancer prevalence with two negative tests was 0.06 per cent with a NNI of 1546.Internal comparison within the completed DT protocol group, between the first test (FIT1) and maximum result of the two FITs  . Overall, 442 patients (16.8 per cent) had discordant FIT results . This occurred both in the presence and absence of significant colorectal pathology (Table 5). Of concern, 11.4 per cent of colorectal cancers and 20.5 per cent of advanced colorectal neoplasia had discordant results, which cautions against a single-test strategy whereby this pathology would have been missed.Comparing the FIT results for those with two tests, the correlation was only moderate . The degree of discordance and direction was not obviously affected by the time between samples. There was no trend in separate analyses of those with and without significant bowel pathology.To explore whether the interval between FITs influenced discordance levels, discordance was examined at 5-day intervals (Table S4). Nonetheless, anaemia remained associated with FIT-negative cancers. The colorectal cancer prevalence in anaemic patients with a single negative FIT was 1.9 per cent, compared with 0.7 per cent in those with two negative FITs. The proportion of anaemic patients with cancers and a negative FIT was similar across the groups: 72.7 per cent in the initial single-FIT cohort, 66.7 per cent in the overall double-FIT cohort, and 66.7 per cent in the completed DT protocol groups where both or the only FIT value was less than 10 µg Hb per g. Of the ten colorectal cancers with discordant FIT results, six were in anaemic patients (Table S2). Among patients with diarrhoea, the colorectal cancer prevalence in those with a negative result in the single-FIT cohort was 0.6 per cent, compared with 0.17 per cent in those with two negative FITs. Interestingly, among the 45 patients who had cancers with rectal bleeding as the predominant symptom, none had 2 negative FITs.The double-FIT strategy worked well in all symptoms as a filter to enrich for pathology  and 3.4 to 10.2 per cent (FITMAX). Hence, 10 µg Hb per g appears to be the optimal threshold in a double-FIT strategy for balancing workload against detecting colorectal cancer.Among those who completed the DT protocol, the positivity was 7.3 per cent higher than when only one test was used. Positivity rate drives workload and is dependent on what threshold for investigation is set. The impact of diagnostic threshold on the NNI and the trade-off in terms of missed pathology is summarized in Fig. 5). These patients and their referring practitioner may be reassured by the low colorectal cancer prevalence if both FIT values are below 10 µg Hb per g, particularly in the absence of anaemia.Modelling of the proposed double-FIT pathway showed that 68.9 per cent of all referrals to secondary care may not require urgent investigation . The equally high sensitivity in this wider population supports the use of double testing in low-risk groups. Both this previous work and the present study included referred populations, and are therefore different from unselected patients attending primary care. Increased pathology yield with two positive tests is known to aid colonoscopy resource prioritization16. Previous smaller studies have compared one against two FITs in symptomatic patients with mixed results, from no benefit from a second test17, to improved sensitivity for colorectal cancer18 and advanced colorectal neoplasia19. The rates of discordance in these studies varied from 6.1 to 15.3 per cent18. Previous studies did not systematically report discordance between repeat tests, in the same patient over time, and the relationship to significant bowel pathology. Notable proportions of those with significant bowel pathology had discordant FIT results. The variability occurred consistently over time and irrespective of pathology, presumably owing to intermittent bleeding. Hence, a pragmatic approach of testing a few days apart and ensuring that one stool is not resampled seems appropriate.A recent retrospective study20 have recently published guidelines on the use of FIT in symptomatic patients. This study has demonstrated how a second FIT could be positioned to offer a repeat opportunity to reach the diagnostic threshold and mitigate missed colorectal cancer within an acceptable time frame . Those with two negative FITs, following reassessment for ongoing clinical concern, may be directed to alternative pathways.The Association of Coloproctology of Great Britain and Ireland and the British Society of Gastroenterology22. Lowering the diagnostic threshold to 2 µg Hb per g improves the sensitivity for colorectal cancer detection from 92.2 to 97.7 per cent, but an increased positivity threshold (20.4–39.5 per cent) would adversely affect colonoscopy resource23. In this study, FIT enriched sensitivity for colorectal cancer for all common referral symptoms, including rectal bleeding, previously excluded from FIT studies and NICE guidelines in lower-risk symptomatic patients24, with no colorectal cancers when both FIT values were below 10 µg Hb per g. Conversely, anaemia was associated with a FIT result below 10 µg Hb per g in those with colorectal cancer and colorectal cancer with discordant FIT results. The addition of serum Hb to single FIT raises the sensitivity from 91.8 to 98.3 per cent, but at an increase in NNI to diagnose a colorectal cancer from 18 to 2625. This would create a greater workload than the double-FIT strategy without a significant improvement in colorectal cancer detection. Further targeted research into this group is required.Strategies to improve single-FIT sensitivity have been explored. Risk stratification models such as COLONOFIT and FAST achieved high sensitivity (98 and 100 per cent respectively), but at the cost of 49.3 and 88 per cent of referrals requiring investigation16. No subsequent cancers were found in patients undergoing MPCT or CTC with a minimum 12-month follow-up. Although direct comparisons between the single-FIT and double-FIT cohorts are challenging because of inherent differences created by the two time intervals, there are key similarities between the cohorts. Sex and age distributions, FIT1 positivity, and baseline colorectal cancer prevalence were no different. Furthermore, the similar performance of FIT in the single-FIT cohort to published findings suggests that the comparisons of the missed rate of significant colorectal pathology between the cohorts are valid. A second limitation is that not all patients in the double-FIT cohort completed both tests. This was due to planned investigation scheduling at endoscopy, in the real-world context of the study. These patients did not have any greater demographic risk factors for colorectal cancer (Table S3), but their increased prevalence of significant bowel pathology justified urgent investigation. The analyser used in this study was an HM-JACKarc with a LoQ of 7 µg Hb per g. This limited the analysis that could be performed at faecal Hb levels below 10 µg Hb per g; comparisons between analysers have reported analytical differences particularly at levels of 4 µg Hb per g and below with OC-Sensor, Eiken Chemical Co., Ltd., Tokyo, Japan (LoQ 2.4 µg Hb per g)26.There are limitations to this study. During the double-FIT cohort acquisition, the COVID-19 pandemic resulted in a reduction in endoscopy, with more imaging being performed. The use of CT colonography (CTC) and minimal-preparation CT of the colon (MPCT), used here, has been shown to be comparable to colonoscopy for colorectal cancer diagnosisznad016_Supplementary_DataClick here for additional data file.


Following the increase in colorectal neuroendocrine tumors (NETs), there is a consequent increase in the importance of their appropriate treatment and post‐treatment management. It is widely accepted that colorectal NETs sized ≥20 mm and those with muscularis propria invasion are indicated for radical surgery, and those sized <10 mm without the invasion are indicated for local resection. No consensus has been reached regarding the treatment strategy for those sized 10–19 mm without the invasion. Endoscopic resection has become a primary option for the local resection of colorectal NETs. For rectal NETs sized <10 mm, modified endoscopic mucosal resection, such as endoscopic submucosal resection with ligation device and endoscopic mucosal resection with a cap‐fitted panendoscope, seems favorable because of its ability to achieve a high R0 resection rate, safety, and convenience. Endoscopic submucosal dissection can also be helpful for these lesions; however, this procedure may be more effective for large lesions or those in the colon. Management following local resection of colorectal NETs is based on the pathological evaluation of factors associated with metastasis, including tumor size, invasion depth, tumor cell proliferative activity (NET grading), presence of lymphovascular invasion, and resection margins. There remain unclear issues in managing cases with NET grading ≥2, positive lymphovascular invasion, and positive resection margins following local resection. In particular, there is confusion regarding managing positive lymphovascular invasion because positivity has become remarkably high with the increased use of the immunohistochemical/special staining. Further evidence based on long‐term clinical outcomes is required to address these issues. Gastrointestinal (GI) neuroendocrine tumors (NETs) are rare tumors that account for a small portion of GI neoplasia.There are several guidelines for the treatment of colorectal NETs worldwide, including the European Neuroendocrine Tumor Society consensus guidelines, National Comprehensive Cancer Network guidelines, North American Neuroendocrine Tumor Society consensus guidelines, and Japanese Neuroendocrine Tumor Society clinical practice guidelines.It is essential to evaluate the risk of metastasis from colorectal NETs to select a treatment for colorectal NETs without any metastasis findings on imaging examinations. Notably, previous studies that mainly examined surgically resected colorectal NETs have indicated that tumor size, invasion depth, NET grading based on mitotic index and/or Ki‐67 labeling index, and lymphovascular invasion are factors associated with metastasis.For invasion depth, it is widely accepted that the invasion to the muscularis propria or deeper is a vital risk factor for metastasis. Colorectal NETs with the invasion are indicated for radical surgery even though no metastasis findings are detected on imaging examinations.etc.), and endoscopic submucosal dissection (ESD).Endoscopic resection has become the primary option for the local resection of colorectal NETs, although transanal surgery is another option for rectal NETs. Several endoscopic resection procedures are available, including polypectomy, conventional endoscopic mucosal resection (EMR), modified EMR . ESD can also be useful for treating these lesions but may be more effective for large or colon lesions.Following the local resection of colorectal NETs, the pathological evaluation of the resected specimens was performed. The pathologically evaluated factors associated with metastasis are tumor size, invasion depth, tumor cell proliferative activity (NET grading), lymphovascular invasion, and resection margins.Tumor cell proliferative activity is a critical factor in deciding the management following local resection of colorectal NETs.Lymphovascular invasion is a hot topic in this field. Lymphovascular invasion, including lymphatic and venous invasion, was previously assessed only with hematoxylin and eosin staining. However, because tumor cells of colorectal NETs exhibit minute cytological atypia, the lymphovascular invasion of NETs is often difficult to identify. Even colorectal adenocarcinoma, which shows more remarkable cytological atypia than NET, is known to show interobserver variation in diagnosing lymphovascular invasion with hematoxylin and eosin staining, and the necessity of the special and immunohistochemical staining for a reproducible diagnosis has been recommended.Previous studies that mainly examined surgically resected colorectal NETs have suggested that positive lymphovascular invasion is a strong risk factor for metastasis.Concerning resection margins, the Japanese guidelines recommend radical surgery following endoscopic resection with a positive resection margin.As described above, confusion remains on the management following local resection with NET grading ≥2, positive lymphovascular invasion, and positive resection margins. Further investigation and discussion are necessary to reach a consensus. Since the significance of lymph node metastasis, particularly micrometastasis from small colorectal NETs, as a prognostic factor has not yet been established, more evidence based on long‐term clinical outcomes is warranted. Data on the long‐term clinical outcomes of colorectal NET patients with a sufficiently long follow‐up period and consideration of all important lesion factors  are presently lacking. Therefore, appropriate follow‐up periods are unknown and surveillance programs are yet to be established.To achieve high‐quality data on the long‐term clinical outcomes of colorectal NET patients and contribute to the establishment of their appropriate treatment and follow‐up, a multicenter prospective study of colorectal NETs, the “C‐NET study” , is ongoing in Japan.This review summarizes the current status of the treatment and post‐treatment management of colorectal NETs. Despite the development in treatment and pathological evaluation for colorectal NETs, there are still issues on which non‐consensus has been reached, including the appropriate treatment for colorectal NETs sized 10–19 mm, and management following local resection of lesions with NET grading ≥2, positive lymphovascular invasion, and positive resection margins. Further data on the long‐term clinical outcomes of colorectal NETs are required to address these issues.The authors have no conflict of interest.


This systematic review evaluates the efficacy and benefit of cartilage conduction hearing aids (CC-HAs) and that factors that influence purchasing decisions. The hearing thresholds and functional gain following CC-HA wear were synthesised. A one-way analysis of variance compared the differences in the hearing thresholds and functional gain at individual frequencies and in patients with a variety of pathological changes. The synchronised aided hearing threshold and functional gain at 2.0 kHz were significantly better than at 0.5, 1.0, and 4.0 kHz. There was no significant difference in the synchronised unaided hearing thresholds across individual frequencies between 0.5 and 4.0 kHz. The synchronised functional gain in patients with atresia was significantly greater than in patients with aural atresia or stenosis and middle ear pathologies with normal ear canals. The acceptability of CC-HAs in terms of purchase decision is influenced by the condition of the external auditory meatus and severity of hearing loss, with the highest purchase rate seen in patients with aural atresia or stenosis. CC-HAs’ fitting procedure advantages and cosmetic considerations make these devices a viable and preferred choice for individuals with microtia and aural atresia. Additional research to evaluate the benefits towards emotional well-being is crucial to gain insights into the psychological impact of CC-HA use. Bone conduction (BC) is defined as the transmission of sound waves to the inner ear through the vibrating bones of the skull, bypassing the outer and middle ear, that enable the perception of sound. BC can be beneficial for patients with conductive hearing loss (CHL), as it allows for sound to be transmitted directly to the inner ear, instead of being conveyed through air conduction (AC) via the ear canal . BC hearWith advances in technology, new and improved BC hearing devices (BCHDs) have been developed to address their disadvantages. For example, bone-anchored hearing aids (BAHAs) that use a new electronic signal transmission and an optimised transducer design to improve the bone conduction efficiency have been developed . Evidenc®) has some reported drawbacks. There are high complication rates associated with abutment failure due to soft tissue infection from using a percutaneous and bone-anchored implant [®Attract) or directly into the bone . Apart from avoiding skin-penetration-related complications, the shift from percutaneous to transcutaneous sound transmission also enhances aesthetics. Comparing the hearing threshold improvement among devices, direct-drive BCHDs  provide greater gains compared to skin-drive BCHDs  due to direct bone vibrations without the vibrations becoming attenuated through the soft skin [However, evidence shows that percutaneous BAHA  is another type of semi-implantable BC hearing device. It differs from the BAHA in terms of its surgical attachment to the ossicular chain and its direct stimulation of the inner ear through the mechanical vibration of the ossicles. Several recent studies have shown that the VSB has some advantages over the BAHA, such as better sound quality, feedback control, and appearance . A recenA Japanese research group proposed a new concept with cartilage conduction as a third sound transmission pathway . Its mecBased on this sound transmission mechanism, a new cartilage conduction hearing aid (CC-HA) has been commercialised and used in clinical practice in Japan since 2017. It was shown to be a safe and effective alternative hearing rehabilitation tool for patients with hearing loss, particularly those who cannot use conventional AC hearing aids due to outer ear obstructions or malformations  . HoweverTaking into consideration the tracing of the evolutionary trajectory of any advancements and research associated with CC-HA, we decided to commence our search of the literature from the year 2004, spanning over the past two decades. As a result, PubMed and Cochrane were searched to identify relevant studies published from May 2004 to April 2023 using the following search terms: (1) “Hearing Loss, Conductive” OR “Conductive hearing Loss” OR “Conductive hearing impairment” OR “Conductive deafness” OR “Hearing Loss, Mixed” OR “Mixed hearing Loss” OR “Mixed hearing impairment” OR “Mixed deafness” OR “Otoscleros*” OR “Otospongios*” OR “Aural atresia” OR “Tympanic membrane perforation” OR “Otitis media” OR “Cholesteatoma”; (2) “Bone conduction device” OR “Cartilage conduction hearing aid” OR “Cartilage conduction device” OR “Cartilage conduction”. In addition, we searched the bibliographies of all identified relevant publications and the bibliographies from the citations of relevant articles. The publication language was restricted to English. The titles and abstracts of all the studies identified using the search strategy were then screened by three independent authors . Subsequently, the same three authors confirmed the full text of the selected papers and evaluated their eligibility. The articles were selected on the basis of the inclusion and exclusion criteria shown in Three authors  independently used an agreed data collection form to extract the data from the included studies. The extracted data were the study authors, publication year, study site, study design, sample classification and size, and main audiological outcomes . The extracted data were double checked for accuracy, and any disagreements after discussion were arbitrated by one of the other authors (FZ and TK).https://www.statstodo.com/CombineMeansSDs.php (accessed on 24 May 2023). A one-way analysis of variance (ANOVA) was performed to compare the differences in the hearing thresholds at individual frequencies and in patients with various pathological changes. The level of significance was set at the conventional 5% level in each case. The hearing thresholds obtained from the individual studies were synthesised to calculate the combined means and Standard Deviations (SDs) using the formula coded by R in the website, which can be accessed via the following link: According to the search strategy, 29 studies were retrieved, with 16 remaining after the removal of duplicates, irrelevant studies, and studies that did not meet the inclusion criteria. Of these, four studies were excluded after further examination because of insufficient outcomes reported. As a result, 12 eligible papers were included in the review .A summary of the characteristics in the 12 included studies ,23,24,25The first clinical trial result was from a case study conducted by Hosoi et al. . It indiIn general, these studies show that the CC-HAs are efficacious in improving hearing thresholds, speech recognition, and overall auditory ability in adults and children with various pathologies of the ear, particularly aural atresia or stenosis.p > 0.05). In the 12 studies included in this review, the averaged hearing thresholds across frequencies 0.5 to 4.0 kHz were presented in ten studies. The AC hearing thresholds ranged from 58.04 to 85.99 dB HL, whilst the BC hearing thresholds ranged from 8.3 to 49.12 dB HL. The average synchronised AC and BC thresholds were 69.30 dB HL SD: 15.68 dB HL) and 18.19 (SD: 15.19 dB HL), respectively. .68 dB HLp < 0.0005). A further analysis revealed that the aided hearing thresholds were significantly better at 2.0 kHz than at 0.5, 1.0 kHz, and 4.0 kHz . The aided hearing thresholds at 0.5 kHz were also significantly better than the aided hearing thresholds at 1.0 and 4.0 kHz . However, there was no significant difference in the synchronised aided hearing thresholds between 1.0 and 4.0 kHz .The aided hearing thresholds measured in the free field ranged from 27.5 to 55.95 dB HL, and the synchronised hearing threshold was 38.16 dB HL (SD: 13.50 dB HL). p < 0.0005). A further analysis revealed that the synchronised functional gain at 2.0 kHz was significantly higher than the gains at 0.5, 1.0, and 4.0 kHz . The gains at 0.5 Hz and 4.0 kHz were also significantly greater than that at 1.0 kHz . 0.5 vs. 4 kHz = 8.55, p < 0.005).Seven studies provided data on the functional gain provided by CC-HAs. The data show a functional gain between 16.66 and 49.00 dB, with an average synchronised gain at 29.27 dB (SD: 9.91 dB). p < 0.005). The synchronised functional gain in patients with atresia was significantly greater than those with stenosis and middle ear pathologies but with normal ear canals  . With the atresia or stenosis patients showing the higher gains, the results indicate that cartilage conduction is effective in improving the hearing ability in these two groups. Although there were no significant differences in the unaided hearing thresholds in the different categories of pathology, there were significant differences in the synchronised functional gains in aided patients with various ear canal pathologies  . HoweverAkasaka et al.  examinedThe various influencing factors on CC-HA performance and benefits have been explored, such as fixation and coupling methods of the transducer and the condition of the external ear canal that can influence the transmission efficacy of CC-HAs. Several studies show an improvement from the use of various tapes as a fixation method as they provide additional compression over the CC-HA transducer and are simple and safe to use ,17,19. FAs shown in A later study by Nishimura et al.  investigIt is noteworthy that there were challenges in obtaining the desired gains as a result of the severity of hearing loss . LimitatThe concept of cartilage conduction as the third sound transmission pathway, along with traditionally accepted AC and BC pathways, is of great interest. A recent review by Nishimura et al.  summarisBC headphones, a commercial product that utilises Bluetooth to connect to mobile phones, have been specifically designed for users such as runners or cyclists. These headphones enable them to enjoy music or answer phone calls while keeping their ear canals open, ensuring they remain aware of their surroundings and minimizing the risk of accidents. Depending on the design, these headphones seem to be using similar cartilage conduction mechanisms for sound transmission, although different transducers are used in these two devices. Recently, an innovation report was published on the use of BC headphones as a part of a hearing assistant kit for children with glue ear, with the preliminary results showing some significant benefits . This woHowever, it should be noted that there are limited studies available, and the concept and application have not yet been recognised widely in the professional community and by service users in comparison to other BC hearing devices. A further exploration of the mechanism of cartilage conduction is needed. Conducting theoretical investigations using a computer model analysis ) would be a valuable approach to simulate and quantify the contribution of cartilage conduction as a third pathway for sound transmission. Such studies would help to determine the extent to which cartilage conduction influences the overall sound transfer function. The significant results derived from these studies provide valuable insights into the role of cartilage conduction in auditory function, and thus facilitate the applications of CC-HAs.Furthermore, evidence has shown that measuring the effective gain is a useful approach for evaluating the effectiveness of sound transmission to cochlea for BAHA users, independent of the impact by the AC-BC gap ,28. The The successful application of CC-HAs in patients with various external ear canal and middle ear disorders is evident. There are benefits in terms of improving hearing ability and providing optimal hearing amplification, fitting procedure advantages, and cosmetic considerations. Consequently CC-HAs provide an advantageous choice for some patients with microtia and aural atresia as they may have reservations or preferences against surgical interventions like BAHAs. They may also be beneficial for patients who do not experience an improvement or amplification after undergoing ear reconstruction surgery or for patients with chronic continuous otorrhea who have not had success with conventional AC hearing aids. In comparison to other BCHDs, although there is a small advantage of BCHDs over CC-HAs, mainly in high-frequency performance, CC-HAs and BCHDs perform similarly in speech testing in most listening conditions . In addi(1)Potential risks such as surgical complications, device-related issues, and the need for ongoing maintenance and care;(2)Long-term implications in terms of the child’s comfort, speech and language development, social interactions, and educational outcomes;(3)Financial implications of device cost and ongoing expenses;(4)Psychological impact such as the emotional distress associated with worrying about the potential impact of their decision on their child’s well-being and quality of life.It is noteworthy that patients with congenital aural atresia could experience decisional conflict, which refers to the uncertainty, doubt, or difficulty in making a decision when faced with two or more options, each with potential benefits and drawbacks ,30. In tIn regard to CC-HA fitting, the results obtained by Nishimura et al.  suggest A study by Li et al.  found thFurther development of CC-HA fitting algorithms to incorporate real-ear measurements (REMs) would provide benefits in terms of verifying the AC sound amplification in users with stenotic ear canals and those with normal ear canals. This approach facilitates essential adjustments to achieve optimal amplification, and thus maximise speech intelligibility. Moreover, in light of recent advancements within the hearing aid industry, together with new commercially available CC-HA models equipped with feedback suppression functions  , the incFurthermore, additional research is necessary to measure and evaluate the subjective benefits and satisfaction of CC-HA use with relevant outcome measures, such as the International Outcome Inventory for Hearing Aids ). Besides audiometric improvements, these questionnaires would provide standardised and validated methods to assess patients’ subjective experiences with CC-HAs, their perceived benefit, and overall satisfaction. In the meantime, to evaluate the psychological benefits of using hearing aids, several questionnaires have been developed, including the Psychosocial Impact of Assistive Devices Scale (PIADS) and the Glasgow Hearing Aid Benefit Profile (GHABP). In future studies, these questionnaires will help in gaining insights into the psychological impact and emotional well-being of individuals using CC-HAs. As a result, professionals can better understand the psychological effects of CC-HA use and address concerns such as emotional distress. This will enable them to optimise interventions and collaborate with patients in making informed decisions for a personalised and effective approach to their hearing healthcare.This systematic review shows that CC-HAs appear to be effective hearing devices to improve hearing thresholds, speech recognition, and overall hearing ability in patients with various types of hearing loss. Both the synchronised aided hearing thresholds and functional gain at 2.0 kHz were significantly better than those at the frequencies of 0.5, 1.0, and 4.0 kHz. Furthermore, the synchronised functional gain in patients with atresia was significantly greater than in patients with stenosis and those with middle ear pathologies but with open ear canals. This suggests that CC-HAs may provide greater benefits for individuals with atresia. The acceptability in terms of purchasing the device is affected by the condition of the external auditory meatus and the severity of hearing loss. Patients with aural atresia or stenosis demonstrated the highest purchasing rate. Although CC-HAs do not demonstrate advantages in terms of functional gain in comparison to existing BCHDs, due to its fitting procedure advantages and cosmetic considerations, CC-HAs are shown as a viable and advantageous choice for some patients with aural atresia or microtia. Further research is needed to assess the subjective benefits and satisfaction of CC-HAs using objective outcome measures. This will provide insight into patients’ experiences, perceived benefits, and overall satisfaction as well as the psychological impact and emotional well-being of CC-HA users. Furthermore, an FE analysis and the inclusion of effective gain measurements in future studies would provide valuable insights into the role of cartilage conduction for sound transmission in auditory function and thus further facilitate the application of CC-HAs.


Burkholderia cepacia complex (Bcc) is composed of highly related opportunistic species that establish pulmonary infections in immunodeficient hosts, such as those with cystic fibrosis and chronic granulomatous disease. Due to their innate antibiotic-resistant phenotypes and capacity to form biofilm, Bcc infections are difficult to eradicate with traditional antibiotics. Peptide-conjugated phosphorodiamidate morpholino oligomers (PPMOs) offer an alternative therapeutic approach. These nucleotide analogues penetrate the outer membrane, bind specific mRNA, and inhibit translation. Due to high affinity base-pairing dynamics, these molecules can be rapidly modified and deployed to precisely inactivate innumerable bacterial gene targets. Previously, we found PPMOs targeting an acyl carrier protein (AcpP) are bactericidal against planktonic Bcc. It remains unknown whether PPMOs could modulate biofilm formation in these pathogens.The Proposed Mechanism of Action of PPMOsInside a bacterial cell, peptide-conjugated phosphorodiamidate morpholino oligomers (PPMOs) targeting the acpP gene bind to mRNA near the Shine-Dalgarno sequence and AUG start site, sterically inhibiting translation. This inhibition disrupts the expression and essential functions of acyl carrier protein (ACP).B. cenocepacia K56-2 DsRed was imaged over time to evaluate colocalization. PPMO toxicity was assessed over 24 h in A549 cells by LDH release.Minimum biofilm eradication concentration assays were used to test two AcpP PPMOs on 24 h biofilms formed on pegs. Viable cells were enumerated. This activity was further evaluated by microscopy and 7-day biofilm kinetic studies. Fluorescein-labeled AcpP PPMO added to p< 0.0001) in biofilm burden across five clinical isolates of Bcc tested and B. thailandensis E264. PPMO bactericidal activity was visualized with confocal and scanning electron microscopy. Fluorescently labeled AcpP PPMO associated with the membrane of B. cenocepacia K56-2 DsRed in a temporal fashion. Additionally, AcpP PPMOs exhibited low toxicity in human pneumocytes.Treatment (10-40 μM) with AcpP PPMOs demonstrated more than a 3-log reduction (PPMOs are active and bactericidal in established Bcc biofilms; thus, the biofilm setting is not a deterrent against PPMO delivery. This is further supported by the observations that AcpP PPMOs and Bcc cells colocalize in biofilm, resulting in membrane destruction and biomass reduction. Together, these data provide evidence that PPMOs are active in the biofilm setting of Bcc and could be a promising therapeutic strategy for these infections.David E. Greenberg, MD, University of Texas Southwestern Medical Center: Dr. Greenberg has numerous patents on PPMOs


Congenital auditory impairment is a prevalent anomaly observed in approximately 2–3 per 1,000 infants. The consequences associated with hearing loss among children encompass the decline of verbal communication, linguistic skills, educational progress, social integration, cognitive aptitude, and overall well-being. Approaches to reversing or preventing genetic hearing loss are limited. Patients with mild and moderate hearing loss can only use hearing aids, while those with severe hearing loss can only acquire speech and language through cochlear implants. Both environmental and genetic factors contribute to the occurrence of congenital hearing loss, and advancements in our understanding of the pathophysiology and molecular mechanisms underlying hearing loss, coupled with recent progress in genetic testing techniques, will facilitate the development of innovative approaches for treatment and screening. In this paper, the latest research progress in genetic etiology of non-syndromic deafness in children with the highest incidence is summarized in order to provide help for personalized diagnosis and treatment of deafness in children. Congenital deafness is a common birth defect. It is estimated that there are 2–3 clinically deaf babies for every 1,000 births . CongeniHearing loss can be caused by a variety of environmental and genetic factors, statistically equal parts of each . Among tThe majority of cases involving hereditary auditory impairment are not accompanied by additional symptoms. Approximately 80% of non-syndromic cases can be attributed to autosomal recessive hearing loss (ARNSHL), while autosomal dominant hearing loss (ADNSHL) accounts for 20%, and X-linked or mitochondrial inheritance contributes to approximately 1–2% of the total number of cases . To dateHowever, the primary pathologic mechanisms by which these genes contribute to hearing loss are still unclear. Therefore, we review the genes associated with nonsyndromic hearing loss in recent years. We explore the causes of congenital deafness and clarify their pathologic mechanisms, aiming to provide assistance in the clinical diagnosis and treatment of congenital deafness.Over 180 genes associated with deafness have been identified and investigated in past studies . HereditCochlear ciliopathy refers to a condition resulting from the disruption of normal ciliary function. These disorders, known as cochlear ciliopathies, affect the growth and maintenance of bundles of mechanosensory stereocilia on the apical surface of sensory hair cells that are crucial for auditory perception. Although stereocilia themselves are not classified as cilia, their proper development and alignment depend on primary cilia present in hair cells ; AuditorIndividuals with nonsyndromic deafness have only symptoms of deafness. In most cases, the onset of non-syndromic deafness in patients with autosomal dominant inheritance occurs in the first to fourth decade of life . AutosomThe connexin gene family is the most common gene contributing to hearing loss, with mutations in Connexin 26 being the major protein responsible for non-characteristic hearing loss and the most abundantly expressed connexin in the inner ear . ConnexiGJB2 encodes connexin 26 protein  and autosomal dominant deafness (DFNA3B)  . Mice laommenced .GJB gene lead to deafness remains unclear, and several current findings contradict previous hypotheses, which remain to be clarified by further studies.However, the underlying mechanism of how mutations in the SLC26A4 is responsible for encoding pendrin, a transmembrane transporter that facilitates the transport of anions  across cellular membranes (EVA) (DFNB4)  . SLC26A4malities . SLC26A4r system . The undr system . The stu SLC26A4 .KCNQ, a cluster of potassium channels, is associated with various medical conditions such as auditory impairment and cardiac arrhythmia , which is low-level sound produced in the cochlea as a result of mechanical activity of OHCs, and recording auditory brainstem response (ABR), which measures the electrophysiological response evoked by acoustic stimulation of the auditory nerve and brainstem, are clinical tests for sensorineural hearing impairment. With auditory neuropathy, the outer hair cells of the cochlea are still functional but the ABR is absent or badly distorted while the OAE is preserved. Auditory neuropathy affects the neurotransmission of auditory signals. The first gene associated with cochlear cell disease in humans is called DFNB59, and it is found on chromosome 2q31.1–q31.3. This gene was first identified as the source of four congenic families’ autosomal recessive hereditary auditory neuropathy, and it has since been linked to autosomal recessive inheritance in numerous other families . PejvakiPejvakin, a 352-residue protein, has been linked to the oxidative stress-induced proliferation of this organelle, according to studies. Peroxisomes play a vital role in homeostasis and defense against noise-induced hearing loss in the auditory system, as shown by pejvakin defective mice . It is tACTG1 (DFNA20/26), which encodes gamma actin; DIAPH1 (DFNA1), which regulates actin filament polymerization; ESPN (DFNB36), involved in producing actin bundles; RDX (DFNB24), facilitating connections between actin filaments and stereocilia. Additionally, several unconventional myosin-encoding genes such as MYO7A , MYO6 (DFNA22 and DFNB37) and MYO15A (DFNB3) are also implicated.The cytoskeleton is a complex network of interconnected filaments and tubules that extend from the nucleus to the plasma membrane , consistACTG1 is responsible for the production of gamma actin, predominantly found in the hair cells of the inner ear. Mutations in this gene have been associated with autosomal dominant inherited hearing loss (known as DFNA20/DFNA26) (ACTG1 mutations (The gene /DFNA26) . Exposur/DFNA26) . Consequutations .DIAPH1 plays a crucial role in the regulation of actin polymerization within the hair cells of the inner ear. The expression of DIAPH1 is predominantly observed in the inner pillar cells, as well as the basal and outer pillar cells of outer hair cells  (ir cells . Mutatio (DFNA1) .MYO7A and MYO15A are implicated in Usher syndrome, accounting for approximately 50% of cases   , resulti complex .+, Na+, and Cl+, etc.(2) Changes in ATP release and Ca+ signaling, which may lead to impaired development of the columnar cytoskeleton as well as cochlea development  Electrolyte cycling, including imbalance and impaired uptake of Kelopment  (3) Audielopment .Congenital hearing loss is the most prevalent congenital defect, affecting two to three out of every 1,000 newborns. The etiology of congenital deafness is multifactorial and can be attributed to both genetic and environmental factors. In recent decades, genetic studies on hearing loss have yielded valuable insights into the molecular basis, development, and function of the auditory system. Furthermore, recent technological advancements have significantly improved our ability to accurately diagnose various forms of hereditary deafness at a molecular level. At present, we can use Sanger sequencing, Gene chip and other hot spot mutation screening technology, Deafness gene targeted capture sequencing (Panel sequencing), Whole exome sequencing, Whole genome sequencing, Whole genome scanning, and other genetic testing methods  and other technologies to improve our early identification and diagnosis of hereditary deafness.However, despite the numerous advancements made in this field, certain limitations exist. The timely detection and intervention of congenital hearing impairment in newborns can significantly enhance their linguistic and verbal development while also improving their motor, cognitive, and social capabilities. Therefore, it is imperative to prioritize active screening for hearing loss in infants as well as molecular genetic screening procedures. Identifying the etiology of congenital deafness in some cases will help to achieve the best therapeutic effect and personalize each etiology in the future.YF: Data curation, Formal analysis, Investigation, Methodology, Writing – original draft. SH: Data curation, Formal analysis, Methodology, Software, Writing – original draft. SZ: Conceptualization, Project administration, Supervision, Validation, Visualization, Writing – review & editing. MC: Conceptualization, Funding acquisition, Project administration, Supervision, Validation, Visualization, Writing – review & editing.


JSC) and open-circuit voltage (VOC) are significantly increased at the same time. A small amount of PSEHTT has a broad absorption spectrum in the short wavelength region and has good compatibility with PM6, which is conducive to fine-tuning the photon collection and improving the JSC. In addition, the highest occupied molecular orbital (HOMO) energy level of PSEHTT is deeper than that of PM6, which broadens the optical bandgap. This study provides an effective method to fabricate high-performance ternary OSCs by using a lower concentration of PSEHTT with PM6 as a hybrid donor material, which ensures a better surface and bulk morphology, improves photon collection, and broadens the optical bandgap.We prepared ternary organic solar cells (OSCs) by incorporating the medium wavelength absorption polymer PSEHTT into the PM6:L8-BO binary system. The power conversion efficiency (PCE) is improved from 15.83% to 16.66%. Although the fill factor (FF) is slightly reduced, the short-circuit current density ( Solution-processed bulk-heterojunction (BHJ) organic solar cells (OSCs) have become indispensable in renewable energy due to the advantages of lightweight and flexibility as well as the potential for a large area roll-to-roll production ,2,3. OveIt is well known that the common polymer donor and small molecules are non-fullerene acceptors with relatively narrow absorption windows and limit the photon harvesting of binary photoactive layers. Therefore, the absorption spectrum of binary photoactive (a blend of one donor and one acceptor) can hardly cover the whole solar spectrum , which is not conducive to efficient solar absorption and limits the further enhancement of photocurrent. Ternary OSCs  can be easily fabricated and improve photon harvesting and exciton dissociation due to the different optical band gaps and good compatibility ,12. SecoWhile incorporating third component materials into binary films, it is inevitable to introduce charge traps at the D/A interface due to the lowest unoccupied molecular orbital (LUMO) energy level barriers of the two acceptors or highest occupied molecular orbital (HOMO) energy level barriers of the two donors ,16. The JSC and VOC. In this manuscript, the efficient short wavelength light absorption polymer PSEHTT was used as the third component material, and we have designed a ternary OSC with a small amount of polymer donor (PSEHTT) as the third component material (guest donor), which possesses highly efficient light absorption and can generate cascade energy levels with the host donor (PM6) and acceptor (L8-BO). More efficient light absorption and exciton dissociation are achieved without destroying the crystallinity and surface and bulk morphology of the binary photoactive film (PM6:L8-BO). In all binary and ternary OSCs, the PSEHTT content in the hybrid donor (PM6:PSEHTT) was adjusted from 0 wt% to 15 wt%, and the weight ratio of the hybrid donor to the acceptor remained unchanged (1:1.4). The binary OSCs based on PM6:L8-BO had a PCE of 15.83% with a VOC of 0.870 V, a JSC of 24.39 mA cm−2, and an FF of 74.6%. Upon incorporation of PSEHTT into the PM6:L8-BO binary film, the ternary OSC showed a higher PCE of 16.66%  compared to the PM6:L8-BO based binary OSC. The results demonstrate that constructing a ternary system by introducing a PSEHTT into the PM6:L8-BO binary film is an effective way to further improve the PCE of OSC.The PM6 and L8-BO show efficient medium wavelength and near-infrared wavelength light absorption, respectively. However, the PM6:L8-BO binary films have lost a large number of short-wavelength photons. Therefore, on the basis of not damaging the surface and bulk morphology of the photoactive layer film, further blue shifting the absorption peak and widening the band gap of the photosensitive layer films are also conducive to further increasing The normalized UV-Vis absorption spectra of thin films of the neat materials are shown in J-V) curves and external quantum efficiency (EQE) spectra of three typical OSCs  are shown in VOC, JSC, and FF) for all OSCs are listed in VOC of 0.870 V, a JSC of 24.39 mA cm−2, and an FF of 74.6%. When the ratio of PM6:PSEHTT:L8-BO is 0.9:0.1:1.4, JSC is increased significantly (from 24.39 to 25.66 mA cm−2), VOC is increased slightly (from 0.87 to 0.875 V), and FF is decreased slightly (from 74.6% to 74.2%). However, when excess PSEHTT was introduced into the PM6:L8-BO-based binary film, all photovoltaic parameters decreased simultaneously, with the high PSEHTT ternary OSC (PM6:PSEHTT:L8-BO ratio of 0.85:0.15:1.4) showing the lowest performances . The JSC values calculated from the EQE curves are 23.62 mA cm−2, 24.76 mA cm−2, and 22.25 mA cm−2, corresponding to PM6:L8-BO binary OSC, optimized ternary OSC, and high PSEHTT ternary OSC, respectively. The average error between the measured and calculated JSC values is less than 4%.The current density-voltage  was measured  values, respectively; the bimolecular recombination and trap-assisted recombination can be considered negligible if α and n are very close to 1. As shown in n value deviation of optimized ternary OSCs  is slightly larger than PM6:L8-BO binary OSCs , while the α and n value deviation of high PSEHTT ternary OSCs  is significantly large than the above two OSCs. This result indicated that the low PSEHTT content in the hybrid donor produced more ideal charge recombination. While an excess amount of PSEHTT was used as the donor, it indicates that the bimolecular recombination and trap-assisted recombination in high PSEHTT ternary OSCs was very serious. Therefore, the high PSEHTT ternary OSCs showed the low photovoltaic performance [n values of optimized ternary OSCs are slightly larger than those of the PM6:L8-BO binary OSCs due to the charge recombination of optimized ternary OSCs is slightly larger than PM6:L8-BO binary OSCs. However, according to VOC and JSC of optimized ternary OSCs are both higher than those of the PM6:L8-BO binary OSCs. We believe that the VOC and JSC are determined using a variety of factors such as energy bandgap, light absorption, charge carrier mobility, exciton dissociation, surface and bulk morphology, and so on. Charge recombination is only one of the multiple factors affecting VOC and JSC. We will further investigate the effect of PSEHTT as a third component on light absorption, charge carrier mobility, exciton dissociation, and surface and bulk morphology. The changes in VOC and JSC of the three components will be analyzed.The bimolecular recombination under the short circuit condition and trap-assisted recombination under the open circuit condition in the photoactive layers can be evaluated from the exponential factor (α) and ideality factor (formance . The devJph-Veff) curves were employed to study the exciton dissociation and charge extraction processes, as shown in Jph is defined as JL-JD, where JL is the current density value under standard illumination, and JD is the current density value without standard illumination. Veff is defined as V0-Va, where V0 is the voltage when Jph is 0, and Va is the applied voltage. P represents the exciton dissociation efficiency (ηdiss) and charge collection efficiency (ηcoll) of the OSCs and is given using the following equation [Jsat is the photocurrent at the saturated state (when Veff is 3 V) and Gmax is the maximum exciton generation rate; all the photogenerated excitons can be dissociated, and charges can be transported and collected under the saturated state. The Pa and Pb are defined as Jpha/Jsat and Jphb/Jsat, which represent the exciton dissociation efficiency (ηdiss) and charge collection efficiency (ηcoll), respectively [ηdiss and ηcoll values  compared to the PM6:L8-BO binary OSCs , while the high PSEHTT ternary OSCs showed lowest ηdiss and ηcoll values . This suggests that PM6:L8-BO binary OSCs and optimized ternary OSCs have similar exciton dissociation and charge transport capability, while high PSEHTT ternary OSCs have low exciton dissociation and charge transport efficiencies [Jsat of optimized ternary OSCs is attributed to the efficient exciton generation rate and light absorption of optimized ternary film compared to the PM6:L8-BO binary OSCs [JSC values. Therefore, the JSC values of optimized ternary OSCs are significantly larger than those of PM6:L8-BO binary OSCs.The photogenerated current versus the effective voltage  and V is the SCLC effective voltage. The parameter The space charge limited current (SCLC) method was employed to measure the hole and electron mobilities of binary and ternary SCLC devices  and hole mobility  decrease only slightly, whereas the µe and µh value of high PSEHTT ternary SCLC devices decrease significantly to 3.34 and 3.94 × 10−4 cm2 V−1 s−1.When a small amount of PSEHTT is doped into PM6:L8-BO binary films, the electron mobility (The photoluminescence (PL), transient photocurrent (TPC), and transient photovoltage (TPV) were employed to investigate the effect of PSEHTT as a third component material on exciton dissociation and charge carrier recombination in both binary and ternary films. The PM6 neat film showed a stronger PL spectrum, while the PM6 PL peak was quenched strongly, and the L8-BO PL peak appeared slightly for the PM6:L8-BO binary film. Both the PM6:L8-BO binary film and the optimized ternary film show similar PM6 residual PL peaks and the L8-BO PL peaks, which suggests that exciton dissociation is stable in the presence of a small amount of PSEHTT as the third component material. However, for high PSEHTT ternary films, the PM6 residual PL peaks are significantly enhanced compared to the optimized ternary films, suggesting that excess PSEHTT disrupts exciton dissociation. To further understand the charge extraction/recombination kinetics of the binary and ternary films, we measured TPC and TPV to calculate the charge extraction time and carrier lifetime, respectively. As shown in VOC of binary OSCs mainly depends on the energy level difference between the LUMO of the acceptor and HOMO of the donor (Eg) as well as the energy loss (Eloss) according to the empirical relation shown below [It is commonly recognized that the wn below :VOC=Ege−Eloss value will be inevitable in photoelectric conversion processes. PSEHTT showed deeper HOMO energy levels than PM6 , which is beneficial to form the cascade HOMO energy levels. The energy levels of the hybrid donor are calculated according to the empirical relation shown below [f is the weight ratio, Ne is the quasi-frontier orbital density, and E is the energy level value. The energy levels of the relevant materials are calculated from other papers [Ne can be calculated according to the following formula [n and l are the molecular number of the unit mass and the number of quasi-degenerate HOMOs per molecule (<0.1 eV) of the donor, respectively, the molecular weight, n, l, and Ne values of neat PSEHTT and PM6 are list in Eg value is also observed, which is beneficial to the enhancement of VOC values of the ternary OSCs. However, the VOC values of the ternary OSCs decrease when an excess amount of PSEHTT is added to the PM6:L8-BO binary films, which could be attributed to the variation of phase separation and surface morphology. Although the charge recombination of optimized ternary OSCs is slightly large than that of PM6:L8-BO binary OSCs, the HOMO energy levels of the blend donor are obviously downshifting, and the energy bandgap is obviously broadening, which is conducive to the enhancement of the VOC values of optimized ternary OSCs. Therefore, the VOC values of optimized ternary OSCs are slightly larger than those of PM6:L8-BO binary OSCs.However, after incorporating the third component materials into binary films, the HOMO energy levels of the hybrid donor will be shifted. In addition, the r papers ,47. The  formula :Ne=nlwhThe phase separation and surface morphology of the binary and ternary films were characterized using transmission electron microscope (TEM) and atomic force microscope (AFM), respectively. The three typical films  showed different molecular aggregations. As shown in λ is the wavelength of the X-ray radiation (0.154 nm), θ is the peak position half-angle, and d is the interplanar distance. The XRD spectra of neat PM6, PSEHTT, and L8-BO films are shown in In order to further investigate the effect of PSEHTT content in the hybrid donor on the molecular arrangement of the ternary films, X-ray diffraction (XRD) was performed. The angles at which the peak intensities occur are related to the interplanar distances of the atomic structure of the photoactive layer and the crystallinity of the photoactive layer; these angles are related to Bragg’s law :λ=2dsinθ−1 in total) with the solvent additive of 1-chloronaphthalene (CN) .PM6, PSEHTT, and L8-BO were purchased from Solarmer Materials Inc.  Chloroform (CF) and isopropanol were purchased from Sigma-Aldrich Co.  PEDOT:PSS, clevios PVP Al 4083 was purchased from H.C. Starck Co., Ltd.  Al, and Ag were purchased from Alfa Aesar Co. . The ratio of donor:acceptor was kept constant (1:1.4) in all binary and ternary OSCs, and the PSEHTT content in donor blends was adjusted from 0 wt% to 15 wt%. The blend of PM6, PSEHTT, and L8-BO was dissolved in CF as a function of the ratio of PM6:PSEHTT . Then, the solution of PFN-Br was dissolved in methanol with a concentration of 0.5 mg/mL and spin-coated over the active layers at 3000 rpm for 35 s. Finally, the Al films (120 nm) were sequentially deposited on top of the photoactive layer by thermal evaporation, and the photoactive area was 4 mm2 (2 × 2 mm2).Indium–tin-oxide (ITO) glasses were ultrasonicated at 30 °C in isopropyl alcohol, acetone, and deionized water for 30 min. The PEDOT:PSS solution was spin-coated onto the ITO glass and baked at 150 °C for 20 min in the air (the thicknesses of the PEDOT:PSS thin films are 20 nm). The photoactive blend solution was spin-coated on the PEDOT:PSS layer in an NJ-V) characteristics were measured in a glove box with a computer-controlled Keithley 236 Source Measure Unit under illumination at 100 mW cm−2 using an AM 1.5 G solar simulator. Average photovoltaic parameter values were obtained from ten devices fabricated in parallel. The EQE spectrum was measured with a Stanford Research Systems model SR830 digital signal processor (DSP) lock-in amplifier coupled to a WDG3 monochromator and a 500 W xenon lamp.The current density versus voltage  was achieved when the ratio of PM6:PSEHTT:L8-BO was 0.9:0.1:1.4. The slight enhancement of VOC was due to the deeper HOMO level of PSEHTT than that of PM6, which broadens the optical bandgap. We conclude that a small amount of PSEHTT replaces PM6 to achieve efficient light absorption and broaden the optical bandgap while maintaining the surface and bulk morphology of the ternary film. However, an excessive amount of PSEHTT instead of PM6 disrupts the surface and bulk morphology of the ternary films, which is detrimental to exciton dissociation charge carrier transport and enhances charge carrier recombination. The results suggest that the ternary strategy is an effective method to further improve the performance of OSCs.In summary, ternary OSCs were fabricated using neat L8-BO as the electron acceptor and a blend of PM6 and PSEHTT as the donor. The PM6:L8-BO-based binary OSCs showed a PCE of 15.83%, a