Diagnostic accuracy of conventional and cholangioscopy-guided sampling of indeterminate biliary lesions at the time of ERCP: a prospective, long-term follow-up study

BACKGROUND

The diagnostic accuracy of cholangioscopy-guided sampling has not been rigorously evaluated.

OBJECTIVE

To prospectively evaluate the accuracy of cholangioscopy-guided mini-forceps sampling and compare it with standard cytology brushings and forceps biopsies for the tissue diagnosis of indeterminate biliary lesions.

DESIGN

Prospective, long-term follow-up, paired design cohort study.

SETTING

Tertiary center.

PATIENTS

Patients undergoing cholangioscopy for the evaluation of indeterminate biliary lesions.

INTERVENTIONS

Each patient underwent triple sampling with cholangioscopy-guided mini-forceps, cytology brushing, and standard forceps.

MAIN OUTCOME MEASUREMENTS

Diagnostic accuracy of each sampling method compared with the patient final status (cancer vs no cancer).

RESULTS

A total of 26 patients (17 cancer positive/9 cancer negative) were enrolled. The mean follow-up in the patients with no cancer was 21.78 (SD ±6.78) months. The procedure was technically successful in all cases (100%). Sample quality was adequate in 25 of 26 (96.2%) of the cytology brushings, in 26 of 26 (100%) of the standard forceps biopsies, and in 25 of 26 (96.2%) of the mini-forceps biopsies. The sensitivity, accuracy, and negative predictive values were 5.9%, 38.5%, and 36% for standard cytology brushings; 29.4%, 53.8%, and 42.8% for standard forceps biopsies; and 76.5%, 84.6%, and 69.2% for mini-forceps biopsies, respectively. When comparing the 3 methods of sampling, mini-forceps biopsy provided significantly better sensitivity and overall accuracy compared with standard cytology brushing (P < .0001) and standard forceps biopsy (P = .0215).

LIMITATIONS

Potential for selection bias.

CONCLUSIONS

Cholangioscopy-guided biopsies of indeterminate biliary lesions have significantly higher accuracy compared with ERCP-guided cytology brushings and standard forceps biopsies, but negative findings on mini-forceps biopsy cannot rule out malignancy with a high degree of certainty. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT01227382.).

Randomized, controlled trial of standard, large-capacity versus jumbo biopsy forceps for polypectomy of small, sessile, colorectal polyps

BACKGROUND

Polypectomy with cold biopsy forceps is a frequently used technique for removal of small, sessile, colorectal polyps. Jumbo forceps may lead to more effective polypectomy because of the larger size of the forceps cup.

OBJECTIVE

To evaluate the efficiency of cold jumbo biopsy forceps compared with standard forceps for polypectomy of small, sessile, colorectal polyps.

DESIGN

Randomized, controlled trial.

SETTING

Outpatient endoscopy center.

PATIENTS

This study involved 140 patients found to have at least one eligible polyp defined as a sessile polyp measuring ≤6 mm.

INTERVENTION

Polypectomy with cold biopsy forceps.

MAIN OUTCOME MEASUREMENTS

Complete visual polyp eradication with one forceps bite.

RESULTS

In 140 patients, a total of 305 eligible polyps were detected (151 removed with jumbo forceps and 154 with standard forceps). Complete visual eradication of the polyp with one forceps bite was achieved in 78.8% of the jumbo forceps group and 50.7% of the standard forceps group (P < .0001). Biopsies from the polypectomy sites of adenomatous polyps thought to be visually completely eradicated with one bite showed a trend toward a higher complete histologic eradication rate with the jumbo forceps (82.4%) compared with the standard forceps (77.4%), but the difference did not reach statistical significance (P = .62). The withdrawal time for visual inspection of the colon and time to perform polypectomies were significantly shorter in the jumbo forceps group (mean 21.43 vs 18.23 minutes; P = .02).

LIMITATIONS

Lack of blinding to the type of forceps used.

CONCLUSION

The jumbo biopsy forceps is superior to the standard forceps in removing small, sessile polyps. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT00855790.).

The NOTES approach to management of urinary bladder injury

BACKGROUND AND OBJECTIVES

Inadvertent bladder injury is a potential complication of various urological and pelvic surgeries. Bladder injury can also be a complication of natural orifice transluminal endoscopic surgery (NOTES). The aim of this study was to test the feasibility of a NOTES approach to repair bladder lacerations in a blinded porcine study.

METHODS

Intentional bladder lacerations were made to mimic accidental injury during NOTES in 7 pigs. In 3 animals, the site of bladder injury was identified and repaired by a blinded endoscopist. Bladder laceration and transluminal access sites were closed with Endoclips. Leak test was performed to confirm adequate closure. Survival animals were monitored postoperatively and surgical sites were inspected for abscess, bleeding, or damage to surrounding structures at necropsy.

RESULTS

Complete endoscopic closure of bladder injuries was achieved in all 7 animals with a negative leak test. The site of laceration was successfully identified by the blinded endoscopist and repaired in all 3 animals in which it was attempted. Survival animals had an uneventful postoperative course without any complications.

CONCLUSION

This blinded feasibility study shows that urinary bladder injury occurring during NOTES can be successfully managed via a NOTES approach using currently available endoscopic accessories.

Endoscopic management of intraoperative small bowel laceration during natural orifice translumenal endoscopic surgery: a blinded porcine study

BACKGROUND

Natural orifice translumenal endoscopic surgery (NOTES) has recently gained great enthusiasm, but there is concern regarding the ability to endoscopically manage complications purely via natural orifices.

AIM

To assess the feasibility of endoscopically managing enteral perforation during NOTES using currently available endoscopic accessories.

METHODS

Twelve pigs underwent transgastric or transcolonic endoscopic exploration. Full-thickness enterotomies were intentionally created to mimic accidental small bowel lacerations during NOTES. These lacerations were then closed with endoclips. In the blinded arm of the study, small bowel repair was performed by a second blinded endoscopist. Adequate closure of the laceration was confirmed with a leak test. Primary access sites were closed with endoclips or T-anchors. At necropsy, the peritoneal cavity was inspected for abscesses, bleeding, or damage to surrounding structures. The enterotomy site was examined for adequacy of closure, adhesions, or evidence of infection.

RESULTS

Fifteen small bowel lacerations were performed in 12 animals. Successful closure was achieved in all 10 cases in the nonblinded arm. Survival animals had an uncomplicated postoperative course and all enterotomy sites were well healed without evidence of necrosis, adhesions, abscess, or bleeding at necropsy. Leak test was negative in all animals. In the blinded arm, both small intestinal lacerations could not be identified by the blinded endoscopist. Necropsy revealed open small bowel lacerations.

CONCLUSION

Small intestinal injuries are difficult to localize with currently available flexible endoscopes and accessories. Endoscopic clips, however, may be adequate for closure of small bowel lacerations if the site of injury is known.

Algorithm for the management of endoscopic perforations: a quality improvement project

Perforations are an uncommon but serious complication of endoscopy. Although they are well recognized, no universally accepted strategy for their management exists. The need for management algorithms in situations that call for multiple interventions in a short time, with coordinated effort encompassing multiple providers from different specialties, has long been recognized, but no such clinical care pathway has been developed for the management of endoscopic perforations. Since perforations are uncommon, a predetermined plan of action can streamline patient management. Furthermore, such a plan demonstrates preparedness on the part of the gastroenterologist. We developed an endoscopic perforation management strategy based on the best available scientific evidence and our specific resources. We report our experience in the hope that it may form a useful framework for gastroenterologists attempting to do the same at their own institution.

Prospective evaluation of the clinical utility of ERCP-guided cholangiopancreatoscopy with a new direct visualization system

BACKGROUND

Older systems for cholangiopancreatoscopy have demonstrated improved diagnostic and therapeutic abilities over standard ERCP but have shown limited feasibility. The SpyGlass Direct Visualization System addresses many of the shortcomings of the older platforms, but its potential advantages have not been rigorously evaluated.

OBJECTIVE

To prospectively evaluate the feasibility, clinical efficacy, and safety of the SpyGlass system.

DESIGN

Prospective cohort study.

SETTING

Tertiary care center.

PATIENTS

All patients undergoing cholangiopancreatoscopy at our institution.

INTERVENTIONS

Cholangiopancreatoscopy with the SpyGlass system.

MAIN OUTCOME MEASUREMENTS

Procedure success, defined as complete stone clearance for stone cases. For nonstone-related lesions, success was defined when all 3 of the following were met: (1) advancement of the SpyScope to the desired target, (2) adequate visualization, and (3) successful applications of all necessary diagnostic and/or therapeutic maneuvers.

RESULTS

Overall, SpyGlass was successful in 70 of 75 patients (93.3%). In patients with biliary stones, complete stone clearance was achieved in 24 of 26 patients (92.3%). Cholangioscopy for nonstone-related indications was successful in 43 of 44 patients (97.7%). Pancreatoscopy was attempted in 5 patients and was successful in 3 (60%). The mean total procedure time (standard ERCP plus SpyGlass) was 64.3 minutes, the total SpyGlass time was 27.5 minutes, the mean SpyGlass visualization time was 14.2 minutes, the mean SpyBite sampling time was 12.1 minutes, the mean Spy therapy time was 8.4 minutes, and the mean set-up time was 5 minutes. There were 4 adverse events (4.8%).

LIMITATIONS

Single-center experience, no comparison group, potential for selection bias.

CONCLUSIONS

ERCP-guided cholangiopancreatoscopy with the SpyGlass system is technically feasible and can be successfully and safely performed in the vast majority of patients. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT00861198.).

Complications during natural orifice translumenal endoscopic surgery: endoscopic management of splenic laceration and hemorrhage

BACKGROUND

Accidental splenic laceration and hemorrhage during natural orifice translumenal endoscopic surgery (NOTES) can lead to life-threatening consequences. The NOTES approach may need to be aborted in these circumstances for a standard laparoscopy or laparotomy.

AIM

To determine the feasibility of endoscopically managing intraoperative splenic laceration and hemorrhage during NOTES using standard endoscopic tools.

METHODS

Nine pigs underwent transcolonic endoscopic surgery, and 18 intentional splenic lacerations were made. Animals were treated as follows: (1) control group with no therapy (n = 3), (2) endoscopic tamponade/packing (n = 3), and (3) endoscopic hemostasis with bipolar cautery (n = 12). A blinded second endoscopist performed NOTES exploration and attempted to identify the site and treat the laceration in 3 cases. The colonic incision was closed using endoclips in the survival studies. Necropsy was performed immediately after surgery in acute cases and at the end of 1 week in the survival cases.

RESULTS

Bleeding persisted beyond 10 minutes in all control cases without therapy. In the tamponade group, bleeding persisted beyond 17 minutes in 2 and a large clot formed at 12 minutes in 1 case that precluded further assessment. Bleeding was controlled endoscopically using standard bipolar cautery in all animals (mean time: 12 minutes). All lacerations were identified and managed by the blinded endoscopist. Survival animals had an uncomplicated postoperative course. No bleeding was seen at necropsy.

CONCLUSION

We demonstrate the management of intraoperative splenic hemorrhage during NOTES using standard endoscopic tools. The site of splenic bleeding could be correctly identified and treated in a blinded fashion.

Surgery insight: natural orifice transluminal endoscopic surgery--an analysis of work to date

Traditional flexible endoscopy has been limited to the confines of the gastrointestinal lumen; however, recent developments involving transluminal access to intra-abdominal structures hold the potential to revolutionize flexible endoscopy. Over the past few years various studies have detailed techniques that intentionally breach the lumen and provide endoscopic access to the peritoneal cavity for diagnostic and therapeutic procedures. Unlike standard surgical approaches, which require incisions to be made in the abdominal wall, natural orifice transluminal endoscopic surgery (NOTES) avoids the need for abdominal incisions and can offer specific advantages to select patient populations. Animal models have been used to demonstrate the possible applications of NOTES, including transgastric peritoneoscopy, tubal ligation, gastrojejunostomy, partial hysterectomy, oophorectomy, and transcolonic exploration, liver biopsy and cholecystectomy. In this Review, we highlight important advances in NOTES since it was first described and analyze the hazards and potential benefits associated with this innovative approach.

Indomethacin for post-ERCP pancreatitis prophylaxis: another attempt at the Holy Grail

Acute pancreatitis continues to be the most dreaded complication after ERCP. Various risk factors for post-ERCP pancreatitis have now been recognized including patient-related, procedure-related, and operator-related factors. Numerous attempts at finding the ideal pharmacological agent for prevention of this complication have been made but nearly all drugs evaluated have failed to demonstrate clinical efficacy. Predictably, these agents have shown promise in early single-center studies but met with disappointing results when tested in larger multicenter randomized controlled trials. As the quest for the "magic bullet" continues, selecting patients with appropriate indications for ERCP and prophylactic pancreatic duct stenting in high-risk cases appears to be the best approach to averting this complication.

Indomethacin for post-ERCP pancreatitis prophylaxis: another attempt at the Holy Grail

Acute pancreatitis continues to be the most dreaded complication after ERCP. Various risk factors for post-ERCP pancreatitis have now been recognized including patient-related, procedure-related, and operator-related factors. Numerous attempts at finding the ideal pharmacological agent for prevention of this complication have been made but nearly all drugs evaluated have failed to demonstrate clinical efficacy. Predictably, these agents have shown promise in early single-center studies but met with disappointing results when tested in larger multicenter randomized controlled trials. As the quest for the "magic bullet" continues, selecting patients with appropriate indications for ERCP and prophylactic pancreatic duct stenting in high-risk cases appears to be the best approach to averting this complication.

In vivo delivery of heat shock protein 70 accelerates wound healing by up-regulating macrophage-mediated phagocytosis

Injury causes tissue breakdown, which releases large quantities of intracellular contents into the extracellular space. Some of these materials are well-established activators of the immune system and include heat shock proteins (HSPs), uric acid, nucleotides, High Mobility Group Box-1 protein (HMGB-1), and DNA. Here, we show that in vivo delivery of HSPs into BALB/cJ mice with full-thickness wounds accelerates the rate of wound closure by 60% as compared with control-treated mice. The onset is rapid and the effect is sustained, dose dependent, and protein specific. Adoptive transfer of RAW264 macrophages pretreated with HSP70 into naïve recipients with a wound transfers the HSP-mediated effect on the rate of wound closure. Further, we demonstrate that part of the mechanism by which HSP70 accelerates wound closure is through the stimulation of macrophage-mediated phagocytosis of wound debris. Disabling the HSP70-mediated enhancement of phagocytosis abrogates the HSP-mediated acceleration of the healing process. These findings create two opportunities: one, therapeutic, wherein HSP70 could be used in the clinical management of wounds; and two, pathophysiologic, to decode signals by which the host defenses recognize and respond to injury.

Animal models for endoscopic simulation

Animal models for GI endoscopy are a safe, reliable, and reproducible method for teaching diagnostic and therapeutic procedures and for developing techniques that have the potential to advance GI endoscopy. Although these methods never can replace human endoscopy as a modality for endoscopic training, animal models may serve as an adjunct to standard endoscopic training and safely enhance the hands-on experience.

Peroral transgastric organ resection: a feasibility study in pigs

BACKGROUND

The feasibility of peroral transgastric peritoneoscopy, liver biopsy, and tubal ligation has been demonstrated in prior animal studies. This approach has the potential to reduce postoperative morbidity.

OBJECTIVE

To explore the technical challenges and complications of performing a transgastric organ resection.

DESIGN

Two-week animal survival study.

INTERVENTIONS

Five female Yorkshire pigs underwent peroral transgastric partial hysterectomy. With the animals under general anesthesia, a sterile esophageal overtube was placed and a gastric antibiotic lavage was performed. Subsequently, a needle-knife and through-the-scope dilating balloon were used to make an anterior gastric wall incision through which a therapeutic gastroscope was advanced into the peritoneal cavity. Endoscopes and instruments previously had been disinfected in a 2.4% glutaraldehyde bath or were disposable. An endoloop and polypectomy snare were used to resect a portion of the uterus, which was removed through the mouth. Gastric incision closure was attempted with endoclips. After 2 weeks of observation, necropsy was performed.

RESULTS

Transgastric partial hysterectomy was performed on all 5 animals. One animal became lethargic and febrile, so necropsy was performed on day 4. An incompletely closed gastric incision and suppurative peritonitis were found. A second animal developed a fever; necropsy performed on day 14 revealed a gastric abscess at the incision site and scattered abdominal pus. No complications were encountered in the 3 remaining animals, and necropsy revealed well-healed gastric incisions and no evidence of peritonitis.

CONCLUSION

Endoscopic transgastric partial hysterectomy is technically feasible in a porcine model. Strict sterility seems mandatory but cannot always be assured. Incomplete closure of the gastric incision may lead to significant complications.

Survival studies after endoscopic transgastric oophorectomy and tubectomy in a porcine model

BACKGROUND

Advances in endoscopic equipment have enabled endoluminal techniques to supplant select surgical procedures. Access to extraluminal structures holds the potential to revolutionize flexible endoscopy but, to date, has been limited. The aim of this study was to demonstrate the feasibility of endoscopic transgastric organ resection (oophorectomy and tubectomy) with 2-week survival.

METHODS

Female Yorkshire pigs underwent general anesthesia, and a sterile esophageal overtube was placed. Antibacterial gastric lavage was performed, and a sterile gastroscope was passed through the overtube. Subsequently, a transgastric incision was made with a needle knife. The endoscope then was advanced into the peritoneal cavity, and the ovaries and the fallopian tubes were identified. An endoloop was used to secure the ovary, the fallopian tube, and the mesosalpinx. Snare cautery oophorectomy and tubectomy was performed, and the specimen was retrieved through the gastrotomy. The incision was closed with endoclips, and 2-week survival studies were performed.

OBSERVATIONS

The peritoneal cavity was accessed in all animals (n = 6) without significant complications. The ovaries and the fallopian tubes were easily identified, and unilateral oophorectomy and tubectomy were successfully performed. Postoperative 2-week survival was uneventful in all animals. At necropsy, the gastric incision was seen as a well-healed scar with giant-cell reaction. There was histologic evidence of chronic inflammation at the resection site, without abscess, hematoma, adhesion, or damage to surrounding viscera.

CONCLUSIONS

Endoscopic transgastric oophorectomy and tubectomy with 2-week survival is feasible with meticulous closure of the gastrotomy. This novel technique may extend the applications of flexible endoscopy to include aspects of abdominal surgery.

Endoscopic transgastric abdominal exploration and organ resection: initial experience in a porcine model

BACKGROUND & AIMS

The evolution of flexible endoscopes and endoscopic devices has recently enabled per-oral transgastric abdominal exploration in animal models. This study was undertaken to assess the ability to systematically identify abdominopelvic organs and to determine the feasibility of organ resection via the transgastric route.

METHODS

Female Yorkshire pigs were used for the study. Under general anesthesia, a gastroscope was used to place a sterile overtube into the esophagus. After antibacterial lavage, the gastric wall was incised, and a sterile dual-channel endoscope was advanced into the peritoneal cavity. Endoscopic abdominal exploration was then methodically performed in 9 animals with oophorectomy and partial hysterectomy in 6 animals. The gastric incision was closed with endoclips. Of the animals that underwent organ resection, 3 were sacrificed immediately after surgery, and the subsequent 3 survived.

RESULTS

The peritoneal cavity was accessed uneventfully, and the stomach, liver, small bowel, colon, urinary bladder, uterus, fallopian tubes, and ovaries were able to be evaluated in all cases. The gallbladder could be visualized in only 5 of the 9 animals, and retroperitoneal structures could not be consistently identified. Oophorectomy with partial hysterectomy was performed in 6 animals. The 3 animals in the survival group did well for 24 hours without sequelae.

CONCLUSIONS

This study shows the ability of endoscopic transgastric peritoneal exploration to successfully identify most abdominopelvic organs and demonstrates the technical feasibility of transgastric organ resection.

In vivo treatment of mice with heat shock protein, gp 96, improves survival of skin grafts with minor and major antigenic disparity

Immunization with high doses of heat shock protein, gp 6 given in vivo, has been shown to mediate the activation of CD4+ T cell, which in turn suppresses an ongoing CD8+ immune response. Here we demonstrate that high doses of gp 6 (HDgp 6) (100 microg given subcutaneously on days 0 and 7 following skin graft transplantation) improve survival of skin grafts with both minor and major histocompatibility. First, skin from male C57BL/6 donors was grafted onto female C57BL/6 recipients that were subsequently treated with either HDgp 6 or buffer and graft survival was monitored. At 64 days post-transplantation, graft recipients treated with HDgp 6 showed 56% graft survival compared to 10% in those treated with buffer. Further, HDgp 6 down regulates a secondary immune response as well. Skin graft obtained from a male C57BL/6 donor was transplanted to a female C57BL/6 recipient that had previously rejected a male skin graft. Recipients that were treated with HDgp 96 showed a 75% graft survival of the secondary graft at 64 days post-transplantation, whereas recipients treated with buffer rejected their secondary grafts within 37 days. Finally, the effect of HDgp 96 treatment on survival of graft with major histoincompatibility was tested. Skin grafts from female BALB/c donors were transplanted to female C57BL/6 recipients previously treated with either HDgp 96 or buffer. Although all the grafts were ultimately rejected, mice treated with HDgp96 showed a delay in the rejection as compared with buffer controls. Our findings indicate that HDgp 96 improves survival of grafts with both minor and major antigenic disparity and could lead to developing novel therapies in transplant medicine.

Surveillance and screening for Barrett esophagus and adenocarcinoma

Current recommendations for screening and surveillance of Barrett esophagus and related lesions are based on recent guidelines by the Practice Parameters Committee of the American College of Gastroenterology. The purpose of this review is to critically examine the rationale and evidence behind these recommendations. There is strong rationale for vigorous initial testing to document the baseline status and identify early adenocarcinoma, and for surveillance of high-grade dysplasia. Recommendations for esophagectomy in patients with high-grade dysplasia need to be individualized. However, recommendations for surveillance of low-grade dysplasia and specialized intestinal metaplasia without dysplasia are largely opinion statements not well supported by objective data. Although cancers identified by surveillance are at earlier stages than those diagnosed without prior endoscopic evaluation, surveillance failures are common. Recommendations for screening and surveillance are not evidence-based and unlikely to alter national mortality from esophageal adenocarcinoma. Their impact on individual patients depends on individual circumstances. Current recommendations are limited by inconsistent endoscopic findings and sampling errors, inconsistent histologic diagnoses of Barrett esophagus and dysplasia, and our poor understanding of the natural history of various histologic lesions. Future directions include validation of methods that reduce these inconsistencies by in vivo detection of abnormalities and by objective diagnostic markers besides grades of dysplasia, such DNA content analysis and molecular markers, and improved understanding of the disease progression. Effective screening programs depend on development of simple, inexpensive, and reliable methods to identify the small group of patients truly at high risk for adenocarcinoma for endoscopic screening.

Immune modulation with high-dose heat-shock protein gp96: therapy of murine autoimmune diabetes and encephalomyelitis

Immunization with heat-shock protein (HSP) gp96 elicits protective immunity to the cancer or virus-infected cells from which it is derived. Low doses of gp96 generate immunity, while doses 10 times the immunizing dose do not. We show here that injection of high doses of gp96 generates CD4(+) T cells that down-regulate a variety of ongoing immune responses. Immunization with high doses of gp96 prevents myelin basic protein- or proteolipid protein-induced autoimmune encephalomyelitis in SJL mice and the onset of diabetes in non-obese diabetic mice. The suppression of immune response can be adoptively transferred with CD4(+) cells and does not partition with the CD25 phenotype. The immunomodulatory properties of gp96 (and possibly other HSP) may be used for antigen-specific activation or suppression of cellular immune responses. The latter may form the basis for novel immunotherapies for autoimmune diseases.

Life-threatening acute airway obstruction in achalasia

Acute airway obstruction from mega-esophagus is an extremely rare presentation of achalasia. We present the case of an 82-year-old woman without previously diagnosed achalasia who presented with shortness of breath. Her respiratory status deteriorated rapidly, with development of stridor. Prompt nasogastric tube placement decompressed the dilated esophagus and relieved airway obstruction. This case illustrates an unusual presentation of achalasia and underscores the need for emergent life-saving esophageal decompression. Hypotheses regarding the mechanism of airway compromise as well as treatment options are reviewed.

The dual nature of specific immunological activity of tumor-derived gp96 preparations

Mice immunized with optimal doses of autologous tumor-derived gp96 resist a challenge with the tumor that was the source of gp96. Immunization with quantities of gp96 5-10 times larger than the optimal dose does not elicit tumor immunity. This lack of effect is shown to be an active, antigen-specific effect, in that immunization with high doses of tumor-derived gp96, but not normal tissue-derived gp96, downregulates the antitumor immune response. Furthermore, immunization with fractionated doses of gp96 elicits the same kind and level of response as elicited by a single dose equivalent to the total of the fractionated doses. This is true of the tumor-protective doses as well as the high downregulatory doses of gp96. The downregulatory activity can be adoptively transferred by CD4(+) but not CD8(+) T lymphocytes from mice immunized with high doses of gp96. These observations indicate that immunization with gp96 induces a highly regulated immune response that, depending upon the conditions of immunization, results in tumor immunity or downregulation.

Identical unusual subtotal penile amputation in children: a report of four cases

4 cases are reported in whom an accidental or iatrogenic near complete slow amputation of the penis at the corona glandis was observed at first presentation. A representative case is presented in detail with illustrations showing the surgical repair carried out. The future erectile ability of this reconstructed phallus is speculated upon.