Liver Metastases and Immune Checkpoint Inhibitor Efficacy in Patients With Refractory Metastatic Colorectal Cancer: A Secondary Analysis of a Randomized Clinical Trial.

Importance: Immune checkpoint inhibitors (ICIs) have limited activity in microsatellite-stable (MSS) or mismatch repair-proficient (pMMR) colorectal cancer. Recent findings suggest the efficacy of ICIs may be modulated by the presence of liver metastases (LM). Objective: To investigate the association between the presence of LM and ICI activity in advanced MSS colorectal cancer. Design, Setting, and Participants: In this secondary analysis of the Canadian Cancer Trials Group CO26 (CCTG CO.26) randomized clinical trial, patients with treatment-refractory colorectal cancer were randomized in a 2:1 fashion to durvalumab plus tremelimumab or best supportive care alone between August 10, 2016, and June 15, 2017. The primary end point was overall survival (OS) with 80% power and 2-sided α = .10. The median follow-up was 15.2 (0.2-22.0) months. In this post hoc analysis performed from February 11 to 14, 2022, subgroups were defined based on the presence or absence of LM and study treatments. Intervention: Durvalumab plus tremelimumab or best supportive care. Main Outcomes and Measures: Hazard ratios (HRs) and 90% CIs were calculated based on a stratified Cox proportional hazards regression model. Plasma tumor mutation burden at study entry was determined using a circulating tumor DNA assay. The primary end point of the study was OS, defined as the time from randomization to death due to any cause; secondary end points included progression-free survival (PFS) and disease control rate (DCR). Results: Of 180 patients enrolled (median age, 65 [IQR, 36-87] years; 121 [67.2%] men; 19 [10.6%] Asian, 151 [83.9%] White, and 10 [5.6%] other race or ethnicity), LM were present in 127 (70.6%). For patients with LM, there was a higher proportion of male patients (94 of 127 [74.0%] vs 27 of 53 [50.9%]; P = .005), and the time from initial cancer diagnosis to study entry was shorter (median, 40 [range, 8-153] vs 56 [range, 14-181] months; P = .001). Plasma tumor mutation burden was significantly higher in patients with LM. Patients without LM had significantly improved PFS with durvalumab plus tremelimumab (HR, 0.54 [90% CI, 0.35-0.96]; P = .08; P = .02 for interaction). Disease control rate was 49% (90% CI, 36%-62%) in patients without LM treated with durvalumab plus tremelimumab, compared with 14% (90% CI, 6%-38%) in those with LM (odds ratio, 5.70 [90% CI, 1.46-22.25]; P = .03). On multivariable analysis, patients without LM had significantly improved OS and PFS compared with patients with LM. Conclusions and Relevance: In this secondary analysis of the CCTG CO.26 study, the presence of LM was associated with worse outcomes for patients with advanced colorectal cancer. Patients without LM had improved PFS and higher DCR with durvalumab plus tremelimumab. Liver metastases may be associated with poor outcomes of ICI treatment in advanced colorectal cancer and should be considered in the design and interpretation of future clinical studies evaluating this therapy.

Evaluation of nanoceria on cadmium uptake in Triticum aestivum (L.) and its implications for dietary health risk.

In recent times, significant attention has been directed toward the synthesis and application of nanoparticles (NPs) in agriculture sector. In current study, nanoceria (CeO2 NPs) synthesized by green method were employed to address cadmium (Cd) accumulation in wheat (Triticum aestivum L.) cultivated in field with excess Cd. The application of CeO2 NPs was carried out through foliar spraying, performed twice during the growth of T. aestivum. Four levels of CeO2 NPs were used: T0, T1, T2, and T3 as 0, 50, 75, and 100 mgL-1, respectively. Results highlighted the positive effects of CeO2 NPs on various growth parameters, including plant height, spike length, photosynthetic related attributes, as well as straw and grain of grains in comparison to T1 (control group). Furthermore, CeO2 NPs led to a reduction in oxidative stress in the leaves and enhanced in enzyme activities in comparison to T1. Notably, Cd concentrations in straw, roots, and grains exhibited a decline following the treatment with CeO2 NPs, in contrast to the control group. In terms of health implications, the calculated health risk index associated with dietary consumption of grains by adults remained below the defined threshold with supply of nanoparticles. Foliar application of CeO2 NPs proved to be an effective approach in reducing cadmium content in wheat grains. This reduction holds significant potential for minimizing the risk of cadmium exposure to human health through the food chain. Employing the green synthesis method amplifies the potential for extensive production and a wide array of environmental applications for CeO2 NPs. This dual capacity makes them proficient in tackling environmental stresses while concurrently mitigating adverse ecological effects.

Comparative efficacy of silicon and iron oxide nanoparticles towards improving the plant growth and mitigating arsenic toxicity in wheat (Triticum aestivum L.).

Nano-enabled agriculture has emerged as an attractive approach for facilitating soil pollution mitigation and enhancing crop production and nutrition. In this study, we conducted a greenhouse experiment to explore the efficacy of silicon oxide nanoparticles (SiONPs) and iron oxide nanoparticles (FeONPs) in alleviating arsenic (As) toxicity in wheat (Triticum aestivum L.) and elucidated the underlying mechanisms involved. The application of SiONPs and FeONPs at 25, 50, and 100 mg kg-1 soil concentration significantly reduced As toxicity and concurrently improved plant growth performance, including plant height, dry matter, spike length, and grain yield. The biochemical analysis showed that the enhanced plant growth was mainly due to stimulated antioxidative enzymes (catalase, superoxide dismutase, peroxidase) and reduced reactive oxygen species (electrolyte leakage, malondialdehyde, and hydrogen peroxide) in wheat seedlings under As stress upon NPs application. The nanoparticles (NPs) exposure also enhanced the photosynthesis efficiency, including the total chlorophyll and carotenoid contents as compared with the control treatment. Importantly, soil amendments with 100 mg kg-1 FeONPs significantly reduced the acropetal As translocation in the plant root, shoot and grains by 74%, 54% and 78%, respectively, as compared with the control treatment under As stress condition, with relatively lower reduction levels (i.e., 64%, 37% and 58% for the plant root, shoot and grains, respectively) for SiONPs amendment. Overall, the application of NPs especially the FeONPs as nanoferlizers for agricultural crops is a promising approach towards mitigating the negative impact of HMs toxicity, ensuring food safety, and promoting future sustainable agriculture.

Effect of soil texture and zinc oxide nanoparticles on growth and accumulation of cadmium by wheat: a life cycle study.

Cadmium (Cd) is getting worldwide attention due to its continuous accumulation in agricultural soils which is due to anthropogenic activities and finally Cd enters in food chain mainly through edible plants. Cadmium free food production on contaminated soils is great challenge which requires some innovative measures for crop production on such soils. The current study evaluated the efficiency of zinc oxide nanoparticles (ZnONPs) (0, 150 and 300 mg/kg) on the growth of wheat in texturally different soils including clay loam (CL), sandy clay loam (SCL), and sandy loam (SL) which were contaminated with were contaminated with 25 mg/kg of Cd before crop growth. Results depicted that doses of ZnONPs and soil textures significantly affected the biological yields, Zn and Cd uptake in wheat plants. The application of 300 mg/kg ZnONPs caused maximum increase in dry weights of shoot (66.6%), roots (58.5%), husk (137.8%) and grains (137.8%) in CL soil. The AB-DTPA extractable Zn was increased while Cd was decreased with doses of NPs depending upon soil textures. The maximum decrease in AB-DTPA extractable Cd was recorded in 300 mg/kg of ZnONPs treatment which was 58.7% in CL, 33.2% in SCL and 12.1% in SL soil as compared to respective controls. Minimum Cd concentrations in roots, shoots, husk and grain were found in 300 mg/kg ZnONPs amended CL soil which was 58%, 76.7%, 58%, and 82.6%, respectively. The minimum bioaccumulation factor (0.14), translocation index (2.46) and health risk index (0.05) was found in CL soil with the highest dose of NPs. The results concluded that use of ZnONPs significantly decreased Cd concentration while increased Zn concentrations in plants depending upon doses of NPs and soil textures.

Patient and Physician Satisfaction with Telemedicine in Cancer Care in Saskatchewan: A Cross-Sectional Study.

Background: Telemedicine is a useful tool that connects patients to their care team remotely and improves access to medical care for rural residents. This study aimed to determine the telemedicine experience of both rural patients with cancer and their physicians, and to explore factors associated with a positive patient experience. Methods: In this cross-sectional study, cancer patients and physicians in Saskatchewan completed a paper-based survey composed of 32 items or an electronic survey of 18 items, respectively. Logistic regression analysis was performed to assess patient satisfaction in relation to various sociodemographic and cancer-related factors. Results: Overall, 25 physicians and 165 patients participated in the study. Among the physicians, 94% were confident in their telemedicine assessment, 58% agreed that telemedicine improved clinical efficiency, and 73% agreed that doctor−patient rapport was unimpaired with telemedicine. Of 165 patients, 61% had used telemedicine for the first time, 81% felt that their needs were met, 83% were satisfied with the quality of their care, and 88% had a positive experience. Overall, 83% patients vs. 45% physicians preferred telemedicine to a face-to-face clinic visit (p = 0.005). On univariate analysis, patients ≥ 65 years old had a greater positive telemedicine experience compared to patients < 65 years old (odds ratio 4.1 [1.2−13.8], p = 0.02). Conclusion: Both patients and physicians have a high rate of positive experiences with telemedicine. However, patients have a higher preference for telemedicine over face-to-face visits compared to physicians. In addition, elderly patients have more positive telemedicine experiences compared to younger patients.

Effect of Combined Immune Checkpoint Inhibition vs Best Supportive Care Alone in Patients With Advanced Colorectal Cancer: The Canadian Cancer Trials Group CO.26 Study.

Importance: Single-agent immune checkpoint inhibition has not shown activities in advanced refractory colorectal cancer (CRC), other than in those patients who are microsatellite-instability high (MSI-H). Objective: To evaluate whether combining programmed death-ligand 1 (PD-L1) and cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) inhibition improved patient survival in metastatic refractory CRC. Design, Setting, and Participants: A randomized phase 2 study was conducted in 27 cancer centers across Canada between August 2016 and June 2017, and data were analyzed on October 18, 2018. Eligible patients had histologically confirmed adenocarcinoma of the colon or rectum; received all available standard systemic therapies (fluoropyrimidines, oxaliplatin, irinotecan, and bevacizumab if appropriate; cetuximab or panitumumab if RAS wild-type tumors; regorafenib if available); were aged 18 years or older; had adequate organ function; had Eastern Cooperative Oncology Group performance status of 0 or 1, and measurable disease. Interventions: We randomly assigned patients to receive either 75 mg of tremelimumab every 28 days for the first 4 cycles plus 1500 mg durvalumab every 28 days, or best supportive care alone (BSC) in a 2:1 ratio. Main Outcomes and Measures: The primary end point was overall survival (OS) and a 2-sided P<.10 was considered statistically significant. Circulating cell-free DNA from baseline plasma was used to determine microsatellite instability (MSI) and tumor mutation burden (TMB). Results: Of 180 patients enrolled (121 men [67.2%] and 59 women [32.8%]; median [range] age, 65 [36-87] years), 179 were treated. With a median follow-up of 15.2 months, the median OS was 6.6 months for durvalumab and tremelimumab and 4.1 months for BSC (hazard ratio [HR], 0.72; 90% CI, 0.54-0.97; P = .07). Progression-free survival was 1.8 months and 1.9 months respectively (HR, 1.01; 90% CI, 0.76-1.34). Grade 3 or 4 adverse events were significantly more frequent with immunotherapy (75 [64%] patients in the treatment group had at least 1 grade 3 or higher adverse event vs 12 [20%] in the BSC group). Circulating cell-free DNA analysis was successful in 168 of 169 patients with available samples. In patients who were microsatellite stable (MSS), OS was significantly improved with durvalumab and tremelimumab (HR, 0.66; 90% CI, 0.49-0.89; P = .02). Patients who were MSS with plasma TMB of 28 variants per megabase or more (21% of MSS patients) had the greatest OS benefit (HR, 0.34; 90% CI, 0.18-0.63; P = .004). Conclusions and Relevance: This phase 2 study suggests that combined immune checkpoint inhibition with durvalumab plus tremelimumab may be associated with prolonged OS in patients with advanced refractory CRC. Elevated plasma TMB may select patients most likely to benefit from durvalumab and tremelimumab. Further confirmation studies are warranted. Trial Registration: ClinicalTrials.gov Identifier: NCT02870920.

Cardiac tamponade induced by dabrafenib and trametinib combination therapy for melanoma: Case report.

RATIONALE: BRAF and MEK inhibitors (BRAF/MEKi) are targeted therapy for proto-oncogene BRAF mutated metastatic unresectable melanoma. Compared to monotherapy, an increased cardiovascular toxicity is reported with the combination of Dabrafenib and Trametinib. This case report documents Grade 4 cardiac treatment emergent adverse effect of pericardial effusion and cardiac tamponade induced by this combination therapy. PATIENT CONCERNS: A 52 year old man presented with clinical stage II unresectable melanoma with BRAF mutation, was initiated on treatement with Dabrafenib and Trametinib. He complained of generalised edema and increased his weight by 27 kg. This progressed to shortness of breath and he underwent echocardiogram which revealed cardiac tamponade. DIAGNOSES: Emergent pericardiocentesis was performed. No definited pathology was demonstrated in laboratory analysis of pericardial fluid. Re- initiating treatment resulted in cardiac tamponade and pericardiotomy was performed by video-assisted thoracic surgical (VATS). Pericardial biopsy revealed nonspecific chronic inflammation. INTERVENTIONS: Discontinuation of treatment with Dabrafenib and Trametinib and diuretics resolved peripheral edema. Cardiac function normalized after pericardiocentesis and pericardiotomy. OUTCOMES: Treatment with Dabrafenib and Trametinib caused significant peripheral edema and pericardial effusion resulting in cardiac tamponade. Naranjo score suggests probable association of treatment induced pericardial effusion and cardiac tamponade. LESSONS: This is the first documented report of pericardial effusion and cardiac tamponade induced by Dabrafenib and Trametinib. Cardiac toxicity of BRAF/MEK inhibitors is rare but clinicans must monitor for treatment emergent adverse effects.

Biochar application increased the growth and yield and reduced cadmium in drought stressed wheat grown in an aged contaminated soil.

Cadmium (Cd) and drought stress in plants is a worldwide problem, whereas little is known about the effect of biochar (BC) under combined Cd and drought stress. The current study was conducted to determine the impact of BC on Cd uptake in wheat sown in Cd-contaminated soil under drought stress. Wheat was grown in a soil after incubating the soil for 15 days with three levels of BC (0%, 3.0% and 5.0% w/w). Three levels of drought stress (well-watered, mild drought and severe drought containing 70%, 50%, and 35% of soil water holding capacity respectively) were applied to 45-d-old wheat plants. Drought stress decreased plant height, spike length, chlorophyll contents, gas exchange parameters, root and shoot dry biomasses and grain yields. Drought stress also caused oxidative stress and decreased the antioxidant enzymes activities whereas increased the Cd concentration in plants. Biochar increased morphological and physiological parameters of wheat under combined drought and Cd stress and reduced the oxidative stress and Cd contents and increased antioxidant enzymes activities. The decrease in Cd concentration with BC application in drought-stressed plant might be attributed to BC-induced increase in crop biomass production and reduction in oxidative stress. These results indicate that BC could be used as an amendment in metal contaminated soil for improving wheat growth and reducing Cd concentrations under semiarid conditions.

Effect of biochar on alleviation of cadmium toxicity in wheat (Triticum aestivum L.) grown on Cd-contaminated saline soil.

Soil degradation by salinity and accumulation of trace elements such as cadmium (Cd) in the soils are expected to become one of the most critical issues hindering sustainable production and feeding the increasing population. Biochar (BC) has been known to protect the plants against soil salinity and heavy metal stress. A soil culture study was performed to evaluate the effect of BC on wheat (Triticum aestivum L.) growth, biomass, and reducing Cd and sodium (Na) uptake grown in Cd-contaminated saline soil under ambient conditions. Soil salinity decreased the plant growth, biomass, grain yield, chlorophyll contents, and gas exchange parameters and caused oxidative stress in plants compared with Cd stress alone. Salt stress increased Cd and Na uptake and reduced the potassium (K) and zinc (Zn) uptake by plants. AB-DTPA-extractable Cd and soil electrical conductivity (ECe) increased under salt stress compared to the soil without NaCl stress. Biochar application improved the plant growth and reduced the Cd and Na uptake except in plants treated with higher BC and salt stress (5.0% BC + 50 mM NaCl). Biochar application reduced the oxidative stress in plants and modified the antioxidant enzyme activities, and reduced the bioavailable Cd under salt stress. The positive effects of BC under lower salt stress while the negative effects of BC under higher BC and salt levels indicated that BC doses should be used with great care in higher soil salinity levels simultaneously contaminated with Cd to avoid the negative effects of BC on growth and metal uptake.

Residual effects of biochar on growth, photosynthesis and cadmium uptake in rice (Oryza sativa L.) under Cd stress with different water conditions.

Soil cadmium (Cd) contamination and drought stress are among the main issues hindering global food security. Biochar has been used to reduce metal uptake by plants and water stress mitigation, but long-term residual effects of biochar under Cd stress at different moisture levels needs to be investigated. A following rice (Oryza sativa L.) was grown after wheat on Cd-contaminated soil amended with different levels of biochar (0, 3.0, and 5.0%, w/w). Thirty five days old plants were irrigated with three moisture levels including zero drought as a control (1-2 cm water layer on soil), mild drought (MD, 50% of soil water holding capacity, WHC), and severe drought (SD, 35% of soil WHC) for an accompanying 35 days. Plant height, biomass and photosynthesis were reduced whereas oxidative stress increased under MD and SD than control in un-amended soil while opposite trends were observed in plants grown in biochar amended soil. At the same biochar addition, Cd concentrations in seedlings were lower in continuous flooding than MD and SD treatments. The biochar supply reduced the bioavailable Cd in the soil whereas increased the soil EC and pH than the control treatment. In conclusion, continuous flooding plus residual biochar can be strategized in mitigating Cd-contamination in paddy soils and decreased Cd concentrations in rice which may reduce the potential risks to humans.

Effect of biochar on cadmium bioavailability and uptake in wheat (Triticum aestivum L.) grown in a soil with aged contamination.

Cadmium (Cd) is a well-known and widespread toxic heavy metal while the effects of biochar (BC) on Cd bioavailability and toxicity in wheat, especially in soils with aged contamination are largely unknown. In the present study, the effect of rice straw BC on Cd immobilization in soil and uptake by wheat in an agricultural contaminated-soil was investigated. Different levels of rice straw BC (0%, 1.5%, 3.0% and 5% w/w) were incorporated into the soil and incubated for two weeks. After this, wheat plants were grown in the amended soil until maturity. The results show that the BC treatments increased the soil and soil solution pH and silicon contents in the plant tissues and in the soil solution while decreased the bioavailable Cd in soil. The BC application increased the plant-height, spike-length, shoot and root dry mass and grain yield in a dose additive manner when compared with control treatment. As compared to control, BC application increased the photosynthetic pigments and gas exchange parameters in leaves. Biochar treatments decreased the oxidative stress while increased the activities of antioxidant enzymes in shoots compared to the control. The BC treatments decreased the Cd and Ni while increased Zn and Mn concentrations in shoots, roots, and grains of wheat compared to the control. As compared to the control, Cd concentration in wheat grains decreased by 26%, 42%, and 57% after the application of 1.5%, 3.0%, and 5.0% BC respectively. Overall, the application of rice straw BC might be effective in immobilization of metal in the soil and reducing its uptake and translocation to grains.

Outcomes and Drug Costs of Sunitinib Regimens for Metastatic Renal Cell Carcinoma: A Provincial Population-Based Study.

BACKGROUND: Conventional sunitinib dosing in metastatic renal cell carcinoma (mRCC) administers 50 mg daily on a 4 weeks on/2 weeks off (4/2) schedule. Not all patients tolerate this regimen and many undergo modifications to schedule, dose, or both. MATERIAL AND METHODS: All patients with mRCC treated with sunitinib by the Saskatchewan Cancer Agency between January 1, 2006, and January 1, 2013, were included. Regimens were categorized as standard intermittent dosing (SID), modified intermittent schedule (MIS), modified intermittent dosing (MID), combination of modified schedule and dosing (MSD), or continuous dosing (CD). The primary objective was to compare overall survival (OS) between regimens. Secondary outcomes included progression-free survival (PFS), discontinuation due to adverse effects (AE), and medication cost. RESULTS: Among 161 patients, 18.0%, 51.6%, and 30.4% had favorable, intermediate, and poor Heng risk prognoses, respectively. A total of 140 (87.0%) received sunitinib as first-line therapy. MID was associated with longer OS compared with SID (estimated median 28.4 vs. 11.2 months). PFS was longer for MID, MSD, and CD compared with SID (estimated median 12.0, 9.0, and 8.0 months vs. 3.0 months, respectively). Adjustment for potential confounders did not negate these associations. SID also had higher average monthly drug costs than MIS, MID, and MSD. Overall discontinuation rate due to AE was high (24%). CONCLUSION: An adjusted-dose sunitinib regimen is associated with improved OS and PFS over SID, with lower costs. The development of toxicities requiring dose reductions serves as a predictive biomarker for better outcomes.

Cadmium minimization in wheat: A critical review.

Cadmium (Cd) accumulation in wheat (Triticum aestivum L.) and its subsequent transfer to food chain is a major environmental issue worldwide. Understanding wheat response to Cd stress and its management for aiming to reduce Cd uptake and accumulation in wheat may help to improve wheat growth and grain quality. This paper reviewed the toxic effects, tolerance mechanisms, and management of Cd stress in wheat. It was concluded that Cd decreased germination, growth, mineral nutrients, photosynthesis and grain yield of wheat and plant response to Cd toxicity varies with cultivars, growth conditions and duration of stress applied. Cadmium caused oxidative stress and genotoxicity in wheat plants. Stimulation of antioxidant defense system, osmoregulation, ion homeostasis and over production of signalling molecules are important adaptive strategies of wheat under Cd stress. Exogenous application of plant growth regulators, inorganic amendments, proper fertilization, silicon, and organic, manures and biochar, amendments are commonly used for the reduction of Cd uptake in wheat. Selection of low Cd-accumulating wheat cultivars, crop rotation, soil type, and exogenous application of microbes are among the other agronomic practices successfully employed in reducing Cd uptake by wheat. These management practices could enhance wheat tolerance to Cd stress and reduce the transfer of Cd to the food chain. However, their long-term sustainability in reducing Cd uptake by wheat needs further assessment.

Regional Lymph Nodes Status and Ratio of Metastatic to Examined Lymph Nodes Correlate with Survival in Stage IV Colorectal Cancer.

BACKGROUND: Although lymph nodes status and the ratio of metastatic to examined lymph node (LNR) are important prognostic factors in early-stage colorectal cancer (CRC), their significance in patients with metastatic disease remains unknown. The study aims to determine prognostic importance of nodal status and LNR in patients with stage IV CRC. METHODS: A cohort of 1109 eligible patients who were diagnosed with synchronous metastatic CRC in Saskatchewan during 1992-2010 and underwent primary tumor resection was evaluated. We conducted the Cox proportional multivariate analyses to determine the prognostic significance of nodal status and LNR. RESULTS: Median age was 70 years (22-98) and M:F was 1.2:1. Rectal cancer was found in 26 % of patients; 96 % had T3/T4 tumor, and 82 % had node positive disease. The median LNR was 0.36 (0-1.0). Fifty-four percent received chemotherapy. Median overall survival of patients who had LNR of <0.36 and received chemotherapy was 29.7 months (95 % CI 26.6-32.9) compared with 15.6 months (95 % CI 13.6-17.6) with LNR of ≥0.36 (P < .001). On multivariate analyses, no chemotherapy (HR 2.36 [2.0-2.79]), not having metastasectomy (HR 1.94 [1.63-2.32]), LNR ≥0.36 (HR 1.59 [1.38-1.84]). nodal status (HR 1.34 [1.14-1.59]), and T status (HR 1.23 [1.07-1.40]) were correlated with survival. Test for interaction was positive for LNR and high-grade cancer (HR 1.51 [1.10-2.10]). CONCLUSIONS: Our results suggest that nodal status and LNR are important prognostic factors independent of chemotherapy and metastasectomy in stage IV CRC patients.

Typhoid ulcer causing life-threatening bleeding from Dieulafoy's lesion of the ileum in a seven-year-old child: a case report.

INTRODUCTION: We describe a case of rare complication of typhoid fever in a seven-year-old child and review the literature with regard to other rare causes of bleeding per rectum. Dieulafoy's lesion is an uncommon but important cause of recurrent gastrointestinal bleeding. Dieulafoy's lesion located extragastrically is rare. We report a case of typhoid ulcer with Dieulafoy's lesion of the ileum causing severe life-threatening bleeding and discuss the management of this extremely uncommon entity. CASE PRESENTATION: As a complication of typhoid fever, a seven-year-old Kurdish girl from Northern Iraq developed massive fresh bleeding per rectum. During colonoscopy and laparotomy, she was discovered to have multiple bleeding ulcers within the Dieulafoy's lesion in the terminal ileum and ileocecal region. CONCLUSION: Although there is no practical way of predicting the occurrence of such rare complications, we emphasize in this case report the wide array of pathologies that can result from typhoid fever.

Small intestinal obstruction due to phytobezoar: a case report.

INTRODUCTION: Patients with mechanical small-bowel obstructions usually present with abdominal pain, vomiting, absolute constipation and varying degrees of abdominal distention. Causes can be classified as benign or malignant, or as extra- or intraluminal. A bezoar occurs most commonly in patients with impaired gastrointestinal motility. In edentulous older patients with abnormal food habits, it can also be an intestinal concretion that fails to pass along the alimentary canal. Small bowel phytobezoars are rare and almost always obstructive. In a normal stomach, vegetable fibres that cannot pass through the pylorus undergo hydrolysis within the stomach, which softens them enough to go through the small bowel. We present an unusual case of small intestinal obstruction caused by a phytobezoar in a patient who had neither a history of gastric surgery nor of intestinal pathology. CASE PRESENTATION: A 70-year-old Iraqi Kurdish man was hospitalized due to abdominal pain, vomiting and dehydration. Investigations concluded small intestinal obstruction. Subsequent laparotomy revealed that the cause of the obstruction was an eggplant phytobezoar. CONCLUSION: Many types of bezoar can be removed endoscopically, but some will require operative intervention. Subsequently, prevention of any recurrence should be emphasized.