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BACKGROUND: Congenital cholesteatomas account for just up to 5% of all cholesteatomas and most commonly arise in the petrous apex and middle ear. Congenital cholesteatomas arising in the mastoid are rare and typically present late. METHODS: In this study, we report a case series of 3 cases managed in our department between 2006 and 2021 and present a summary of the current literature. RESULTS: Congenital cholesteatomas arising in the mastoid is a rare finding and even among reported cases, not all are clearly mastoid in origin. Their location allows for considerable growth before symptoms develop. Pain and localized swelling in the temporal area are the most common presenting symptoms which can lead to diagnostic challenges. Our cases show that although surgery is often appropriate, conservative management may be suitable in certain situations. CONCLUSION: Congenital cholesteatoma of mastoid origin is rare and can present a diagnostic challenge. Greater awareness is important to facilitate early detection. A high index of suspicion is needed in those presenting with retro-auricular pain and swelling in the context of a normal ontological examination. KEYWORDS: Congenital cholesteatoma, ear surgery, otology, temporal bone

We report the case of a cochlear implant patient who developed multiple infections with device extrusion necessitating explanation and reimplantation twice. An approach using a vancomycin washout followed by a temporalis muscle rotation and scalp rotation flap was utilized to salvage the device.

Background Ear, Nose, and Throat (ENT) services in the National Health Service (NHS) face escalating pressure, exacerbated by the COVID-19 pandemic, resulting in prolonged waiting times and increased referrals. Understanding the factors driving pressure on ENT services is crucial for enhancing patient care and resource allocation. Methods A retrospective single-centre cohort study was conducted at Queen's Medical Centre, Nottingham, UK, over five weeks. A total of 156 referrals to the ENT Emergency Clinic (E-Clinic) were analyzed, assessing the appropriateness of referrals and healthcare professionals' involvement in reviewing cases. Results The analysis revealed 28 distinct case categories, with certain conditions being predominant in specific reviews (e.g., otitis externa, nasal fractures, epistaxis). Notably, 21.8% of cases were deemed unsuitable or inappropriate for E-Clinic assessment. Strategic restructuring was suggested, distributing cases among healthcare professionals based on expertise and complexity. Discussion The findings underscore the need for a refined referral process and appropriate allocation of cases, emphasising the importance of nurse-led reviews for certain conditions and the necessity for senior review in complex cases. Improving the primary-secondary care interface and educating healthcare professionals on appropriate referrals are crucial for refining the system. Conclusion Optimising the quality of referrals and allocation of cases within ENT E-Clinics can alleviate workload pressures and enhance patient care. Strategic distribution of cases based on expertise and complexity, alongside refined referral processes, can significantly improve clinic efficiency and patient outcomes in the NHS.

A 7-month-old boy presented to the emergency department with reduced oral intake, neck swelling and fever. Clinical examination revealed a 3 cm left parotid and left level I neck swelling with left medialised tonsil but no trismus. Computed imaging confirmed the presence of an abscess in the peritonsillar area with extension into the parapharyngeal space and deep lobe of the parotid gland. The abscess was incised and drained transorally. Following drainage of the abscess, a small 3 mm suspicious foreign body was seen. After extraction, this was revealed to be a 60 mm feather. We would like to highlight this unusual case in an infant and to ensure that foreign body is considered as aetiology. There are only a handful of cases in the literature involving feathers causing neck abscesses and, to our knowledge, this is the first case where the patient presented with a pharyngeal abscess, which was drained transorally.

Conventional gastrointestinal schwannomas are rare, most frequently occurring in the stomach while colorectal locations are uncommon and only a small number of cases have been reported. We are reporting this case as it is a very rare tumour at a very rare location. Though schwannomas are considered benign neoplasms, rare cases of malignant schwannoma have been reported. Owing to the uncertainty of the prognosis, our patient is under long-term endoscopic surveillance.

Conventional gastrointestinal schwannomas are rare, most frequently occurring in the stomach while colorectal locations are uncommon and only a small number of cases have been reported. We are reporting this case as it is a very rare tumour at a very rare location. Though schwannomas are considered benign neoplasms, rare cases of malignant schwannoma have been reported. Owing to the uncertainty of the prognosis, our patient is under long-term endoscopic surveillance.

IntroductionUpper limb problems have a significant impact on the global population leading to pain and restricted joint mobility, ultimately impacting their quality of life. Traditional treatments, such as non-steroidal anti-inflammatory drugs and corticosteroids, often come with undesirable side effects, prompting patients to seek alternative therapies. In this trial, we hypothesise that soothing cream gel (SCG) will improve range of motion and chronic pain in the shoulder and elbow. The objective of this trial is to evaluate the efficacy of SCG in improving the range of motion and chronic pain in the shoulder and elbow.Methods and analysisA double-blinded, randomised, placebo-controlled trial is conducted to compare the effects of SCG and placebo gel. SCG contains Vitis vinifera essence, Melaleuca viridiflora essential oil, etc, and is manufactured according to Good Manufacturing Practice standards. The placebo gel will be processed with similar appearance, texture and scent but will lack active ingredients. 70 participants with upper limb problems will be recruited from four study sites, including clinical centres and a sport department at the Chinese University of Hong Kong (CUHK). Participants will be randomly assigned to either treatment group or placebo group for 2 weeks. Primary outcome will be the range of motion in the upper limb, assessed by a goniometer, to measure active flexion and abduction for the shoulder, and active flexion and extension for the elbow. The primary efficacy analyses will be based on the full analysis set following the intention-to-treat principle.Ethics and disseminationThe trial has obtained approval from the joint CUHK–New Territories East Cluster (CRE-2023.142), and the patient enrolment commenced in July 2023. Written informed consent will be obtained from all participants prior to participation. Study results will be disseminated through publication in peer-reviewed journals and presentations at conference.Trial registration number NCT05799391.

BackgroundProgrammed cell death protein 1 (PD-1) pathway blockade with immune checkpoint inhibitors (ICIs) is a standard therapy in advanced hepatocellular carcinoma (HCC) nowadays. No strategies to overcome ICI resistance have been described. We aimed to evaluate the use of ipilimumab and anti-PD-1 ICIs (nivolumab or pembrolizumab) combinations in patients with advanced HCC with progression on prior ICIs.MethodsPatients with advanced HCC with documented tumor progression on prior ICIs and subsequently received ipilimumab with nivolumab/pembrolizumab were analyzed. Objective response rate (ORR), median duration of response (DOR), time-to-progression (TTP), overall survival (OS), and treatment-related adverse events (TRAEs) were assessed.ResultsTwenty-five patients were included. The median age was 62 (range: 51–83). About 68% were of Child-Pugh (CP) Grade A and 48% had primary resistance to prior ICI. At median follow-up of 37.7 months, the ORR was 16% with a median DOR of 11.5 months (range: 2.76–30.3). Three patients achieved complete response. The median TTP was 2.96 months (95% CI: 1.61 to 4.31). Median OS was 10.9 months (95% CI: 3.99 to 17.8) and the 1 year, 2 year and 3 year survival rates were 42.4%, 32.3% and 21.6%, respectively. The ORR was 16.7% in primary resistance group and 15.4% in acquired resistance group (p=1.00). All responders were of CP A and Albumin-Bilirubin (ALBI) Grade 1 or 2. CP and ALBI Grades were significantly associated with OS (p=0.006 and p<0.001, respectively). Overall, 52% of patients experienced TRAEs and 12% experienced Grade 3 or above TRAEs.ConclusionsIpilimumab and nivolumab/pembrolizumab can achieve durable antitumor activity and encouraging survival outcomes with acceptable toxicity in patients with advanced HCC who had prior treatment with ICIs.

Climate change has been significantly affecting human activities due to the accumulation of greenhouse gases, such as carbon dioxide. Biofixation of carbon dioxide (CO2) has been investigated to reduce the atmospheric CO2 level and slow the rapid increase in the global temperature. Carbon capture and utilization (CCU) can be performed by either physio-chemical or biological methods. The latter takes place in ambient temperature and mild conditions, such that there is no need for high pressure and high energy consumption nor hazardous chemicals. Biofixation by microalgae has been utilized to capture CO2 and the microalgae biomass collected after the process can be further utilized in renewable biofuel generation. On the other hand, microbial enzymes, such as carbonic anhydrase (CA), have been investigated to speed up the whole biofixation process by increasing the conversion rate of CO2 into bicarbonate (HCO3−) in a culture medium and the latter can be readily used by microalgae to increase CO2 removal. In this study, in the presence of 20% CO2 (v/v) gas in air and 5 mL CA enzyme extract (0.5 mg mL−1 protein), we can significantly increase the biofixation rate using marine green microalgae, Tetraselmis sp. Results showed that the biofixation rate can be increased from 0.64 g L−1 day−1 (no CA and at 0.04% CO2) to 4.26 g L−1 day−1. The effects of different experimental conditions such as pH, nutrient levels and working CO2 concentration levels on Tetraselmis sp. growth and CO2 biofixation (CO2 removal) rate have been investigated. This study demonstrates a new alternative approach for effective carbon capture and utilization (CCU) using microalgae which can be applied to achieve the goal of carbon neutrality.

In hepatocellular carcinoma (HCC) patients with extrahepatic metastasis, the lung is the most frequent site of metastasis. However, how the lung microenvironment favors disseminated cells remains unclear. Here, it is found that nidogen 1 (NID1) in metastatic HCC cell‐derived extracellular vesicles (EVs) promotes pre‐metastatic niche formation in the lung by enhancing angiogenesis and pulmonary endothelial permeability to facilitate colonization of tumor cells and extrahepatic metastasis. EV‐NID1 also activates fibroblasts, which secrete tumor necrosis factor receptor 1 (TNFR1), facilitate lung colonization of tumor cells, and augment HCC cell growth and motility. Administration of anti‐TNFR1 antibody effectively diminishes lung metastasis induced by the metastatic HCC cell‐derived EVs in mice. In the clinical perspective, analysis of serum EV‐NID1 and TNFR1 in HCC patients reveals their positive correlation and association with tumor stages suggesting the potential of these molecules as noninvasive biomarkers for the early detection of HCC. In conclusion, these results demonstrate the interplay of HCC EVs and activated fibroblasts in pre‐metastatic niche formation and how blockage of their functions inhibits distant metastasis to the lungs. This study offers promise for the new direction of HCC treatment by targeting oncogenic EV components and their mediated pathways. Nidogen 1‐enriched extracellular vesicle (EV‐NID1) activates pulmonary fibroblasts to secrete tumor necrosis factor receptor 1 (TNFR1) which favors lung metastasis of liver cancer. Serum EV‐NID1 and TNFR1 are potential noninvasive biomarkers for the early detection of liver cancer. This study also provides insights into a new direction of treatment by blocking the signals of EVs derived from tumor cells.