Activation of NFAT by HGF and IGF-1 via ARF6 and its effector ASAP1 promotes uveal melanoma metastasis

Preventing or effectively treating metastatic uveal melanoma (UM) is critical because it occurs in about half of patients and confers a very poor prognosis. There is emerging evidence that hepatocyte growth factor (HGF) and insulin-like growth factor 1 (IGF-1) promote metastasis and contribute to the striking metastatic hepatotropism observed in UM metastasis. However, the molecular mechanisms by which HGF and IGF-1 promote UM liver metastasis have not been elucidated. ASAP1, which acts as an effector for the small GTPase ARF6, is highly expressed in the subset of uveal melanomas most likely to metastasize. Here, we found that HGF and IGF-1 hyperactivate ARF6, leading to its interaction with ASAP1, which then acts as an effector to induce nuclear localization and transcriptional activity of NFAT1. Inhibition of any component of this pathway impairs cellular invasiveness. Additionally, knocking down ASAP1 or inhibiting NFAT signaling reduces metastasis in a xenograft mouse model of UM. The discovery of this signaling pathway represents not only an advancement in our understanding of the biology of uveal melanoma metastasis but also identifies a novel pathway that could be targeted to treat or prevent metastatic uveal melanoma.

Chloroquine Sensitizes GNAQ/11-mutated Melanoma to MEK1/2 Inhibition

PURPOSE

Mutational activation of GNAQ or GNA11 (GNAQ/11), detected in >90% of uveal melanomas, leads to constitutive activation of oncogenic pathways, including MAPK and YAP. To date, chemo- or pathway-targeted therapies, either alone or in combination, have proven ineffective in the treatment of patients with metastatic uveal melanoma.

EXPERIMENTAL DESIGN

We tested the efficacy of chloroquine or hydroxychloroquine, in combination with MAPK pathway inhibition in GNAQ/11-mutated cells in vitro and in vivo and identified mechanisms of MEK1/2 inhibitor plus chloroquine-induced cytotoxicity.

RESULTS

Inhibition of GNAQ/11-mediated activation of MAPK signaling resulted in the induction of autophagy. Combined inhibition of Gα and autophagy or lysosome function resulted in enhanced cell death. Moreover, the combination of MEK1/2 inhibition, using trametinib, with the lysosome inhibitor, chloroquine, also increased cytotoxicity. Treatment of mice bearing GNAQ/11-driven melanomas with trametinib plus hydroxychloroquine resulted in inhibition of tumor growth and significantly prolonged survival. Interestingly, lysosomal- and autophagy-specific inhibition with bafilomycin A1 was not sufficient to promote cytotoxicity in combination with trametinib. However, the addition of YAP inhibition with trametinib plus bafilomycin A1 resulted in cell death at comparable levels to trametinib plus chloroquine (T/CQ) treatment. Furthermore, T/CQ-treated cells displayed decreased YAP nuclear localization and decreased YAP transcriptional activity. Expression of a constitutively active YAP^5SA mutant conferred resistance to T/CQ-induced cell death.

CONCLUSIONS

These results suggest that YAP, MEK1/2, and lysosome function are necessary and critical targets for the therapy of GNAQ/11-driven melanoma, and identify trametinib plus hydroxychloroquine as a potential treatment strategy for metastatic uveal melanoma.

Mouse models of uveal melanoma: Strengths, weaknesses, and future directions

Uveal melanoma is the most common primary malignancy of the eye, and a number of discoveries in the last decade have led to a more thorough molecular characterization of this cancer. However, the prognosis remains dismal for patients with metastases, and there is an urgent need to identify treatments that are effective for this stage of disease. Animal models are important tools for preclinical studies of uveal melanoma. A variety of models exist, and they have specific advantages, disadvantages, and applications. In this review article, these differences are explored in detail, and ideas for new models that might overcome current challenges are proposed.

Small GTPase ARF6 controls VEGFR2 trafficking and signaling in diabetic retinopathy

The devastating sequelae of diabetes mellitus include microvascular permeability, which results in retinopathy. Despite clinical and scientific advances, there remains a need for new approaches to treat retinopathy. Here, we have presented a possible treatment strategy, whereby targeting the small GTPase ARF6 alters VEGFR2 trafficking and reverses signs of pathology in 4 animal models that represent features of diabetic retinopathy and in a fifth model of ocular pathological angiogenesis. Specifically, we determined that the same signaling pathway utilizes distinct GEFs to sequentially activate ARF6, and these GEFs exert distinct but complementary effects on VEGFR2 trafficking and signal transduction. ARF6 activation was independently regulated by 2 different ARF GEFs - ARNO and GEP100. Interaction between VEGFR2 and ARNO activated ARF6 and stimulated VEGFR2 internalization, whereas a VEGFR2 interaction with GEP100 activated ARF6 to promote VEGFR2 recycling via coreceptor binding. Intervening in either pathway inhibited VEGFR2 signal output. Finally, using a combination of in vitro, cellular, genetic, and pharmacologic techniques, we demonstrated that ARF6 is pivotal in VEGFR2 trafficking and that targeting ARF6-mediated VEGFR2 trafficking has potential as a therapeutic approach for retinal vascular diseases such as diabetic retinopathy.

The small GTPase ARF6 regulates protein trafficking to control cellular function during development and in disease

The activation of the small GTPase ARF6 has been implicated in promoting several pathological processes related to vascular instability and tumor formation, growth, and metastasis. ARF6 also plays a vital role during embryonic development. Recent studies have suggested that ARF6 carries out these disparate functions primarily by controlling protein trafficking within the cell. ARF6 helps direct proteins to intracellular or extracellular locations where they function in normal cellular responses during development and in pathological processes later in life. This transport of proteins is accomplished through a variety of mechanisms, including endocytosis and recycling, microvesicle release, and as yet uncharacterized processes. This Commentary will explore the functions of ARF6, while focusing on the role of this small GTPase in development and postnatal physiology, regulating barrier function and diseases associated with its loss, and tumor formation, growth, and metastasis.

ARF6 Is an Actionable Node that Orchestrates Oncogenic GNAQ Signaling in Uveal Melanoma

Activating mutations in Gαq proteins, which form the α subunit of certain heterotrimeric G proteins, drive uveal melanoma oncogenesis by triggering multiple downstream signaling pathways, including PLC/PKC, Rho/Rac, and YAP. Here we show that the small GTPase ARF6 acts as a proximal node of oncogenic Gαq signaling to induce all of these downstream pathways as well as β-catenin signaling. ARF6 activates these diverse pathways through a common mechanism: the trafficking of GNAQ and β-catenin from the plasma membrane to cytoplasmic vesicles and the nucleus, respectively. Blocking ARF6 with a small-molecule inhibitor reduces uveal melanoma cell proliferation and tumorigenesis in a mouse model, confirming the functional relevance of this pathway and suggesting a therapeutic strategy for Gα-mediated diseases.

The effect of environmental temperature on protein and energy changes following burn injury in the rat

The metabolic response to a standard burn injury in rats (25% of body surface area) was investigated at environmental temperature 20 degrees C and 30 degrees C. With an intake of 15 g diet (20% w/w protein) per day, burned rats at 20 degrees C were found to be in negative energy balance mainly due to increased insensible (evaporative) losses, and they lost weight. Fat was the main endogenous source of energy, although protein was also catabolised from both carcass and pelt. At 30 degrees C, insensible losses of burned rats were still high, but they had lower sensible (mainly radiative) losses leading to a positive energy balance and a gain in weight. This consisted mainly of carcass water, fat and protein. Urine catecholamines were higher in burned rats at 20 degrees C than at 30 degrees C and correlated with heat loss, urine nitrogen and urine 3-methylhistidine, supporting the hypothesis that catecholamines play a central role in mediating the protein and energy changes following burn injury. For the first 4-6 days, urine nitrogen and 3-methylhistidine excretion increased in rats at 30 degrees C, suggesting that this early part of the metabolic response is obligatory. These findings support the use of raised environmental temperatures to reduce the metabolic response to burns.

Pelvic free fluid: clinical importance for reproductive age women with blunt abdominal trauma

OBJECTIVE

To evaluate the importance of isolated pelvic free fluid (FF) detected by ultrasound examination in pregnant patients and in non-pregnant reproductive age women with blunt abdominal trauma (BAT).

METHODS

Reproductive age women aged 10-50 years who presented with BAT and underwent focused abdominal sonography for trauma (FAST) from January 1995 to June 2002 at a Level 1 trauma center were included. Patients were assigned to four groups according to the location of FF detected by ultrasound (Group 1, no FF; Group 2, FF in pelvis; Group 3, FF in abdomen; Group 4, FF in abdomen and pelvis). Ultrasound findings were compared with intra-abdominal and pelvic injuries detected by computed tomography and/or laparotomy. Pair-wise comparison was performed using a Fisher's exact test.

RESULTS

Ultrasound detection of FF in the abdomen alone or FF in the abdomen and pelvis was significantly associated with intra-abdominal injury (IAI) compared to those without FF (P < 0.001) for both pregnant and non-pregnant reproductive age women. FF isolated to the pelvis was also associated with a higher injury rate compared to no FF in pregnant women (30% vs. 3%, P = 0.005) and in non-pregnant reproductive age women (39.5% vs. 3.7%, P < 0.001).

CONCLUSIONS

In reproductive age women with BAT, ultrasound detection of FF in the abdomen alone, in both the abdomen and pelvis, or isolated to the pelvis is associated with a higher IAI rate. Therefore, isolated FF in the pelvis should not necessarily be considered physiological in pregnant and non-pregnant patients with BAT.

From the RSNA refresher courses: focused abdominal US for trauma

Focused abdominal ultrasonography (US) has been introduced in Europe as a method to evaluate blunt abdominal trauma. The main focus of the examination is detection of free fluid in the abdomen secondary to injury of the abdominal organs. The examination takes only a few minutes to perform. In the authors' experience, trauma patients in unstable condition and in whom significant free fluid is detected are immediately taken to the operating room for surgical exploration without undergoing computed tomographic (CT) correlation. The authors have also used US to identify the specific site of organ injury. Injuries to solid organs such as the liver, spleen, and kidney that are identified with US usually appear heterogeneous or hyperechoic. A hematoma surrounding the injured organ may appear echogenic or hypoechoic. However, pitfalls of focused abdominal US for trauma include failure to show contained solid-organ injuries; injuries to the diaphragm, pancreas, and adrenal gland; and some bowel injuries. Thus, negative findings at US do not exclude an intraperitoneal injury, and close clinical observation or CT is warranted.

Ultrasound detection of blunt splenic injury

The purpose of this study was to determine the sensitivity of emergency ultrasound (US) for the detection of blunt splenic injury (BSI), and to describe sonographic parenchymal patterns. Over 3 years, 2138 emergency US were performed, and 162 patients had BSI. CT was performed for 76 patients, and there were 86 laparotomies. Seventy patients (43%) had concomitant intraabdominal injuries. Ultrasound detected free fluid in 109 patients (67%), and parenchymal injury in 31 patients (19%). There were 48 false negative US (30%). Sonographic patterns included a diffuse heterogeneous appearance, hyperechoic and hypoechoic perisplenic crescents, and discrete hypoechoic or hyperechoic areas within the spleen. Overall sensitivity of US for detection of BSI was 69%, but was 86% for grade III or higher injuries. Ultrasound is most sensitive for the detection of grade III or higher BSI based on the presence of haemoperitoneum. Ultrasound may also identify BSI on the basis of parenchymal abnormality, with a diffuse heterogeneous pattern most commonly encountered. Sonographic evaluation for both free fluid and parenchymal injury improves sensitivity of US.

Acute lung injury from intratracheal exposure to fugitive residual oil fly ash and its constituent metals in normo- and spontaneously hypertensive rats

We have recently shown that the spontaneously hypertensive (SH) rats with underlying cardiovascular disease exhibited greater pulmonary vascular leakage and oxidative stress than healthy normotensive (Wistar Kyoto, WKY) rats after a 3-day inhalation exposure to residual oil fly ash (ROFA) particles (Kodavanti et al., 2000). Since host responsiveness to a 3-day episodic ROFA inhalation could be different from a single acute exposure, we examined ROFA and its constituent metal (vanadium, V; nickel, Ni)-induced lung injury after a single intratracheal (IT) exposure. Male SH and WKY rats (12-13 wk) were IT instilled with either saline or ROFA (0.0, 0.83 or 3.33 mg/kg). The bronchoalveolar lavage fluid (BALF) was analyzed for lung injury markers at 24 and 96 h post-IT. Rats were also IT instilled with 0.0 or 1.5 micromol/kg of either VSO(4) or NiSO(4).6H(2)O in saline (equivalent to a dose of 2-3 mg ROFA), and assessed at 6 and 24 h post-IT. Basal levels of BALF protein, macrophages, and neutrophils, but not lactate dehydrogenase (LDH), were higher in control SH compared to control WKY rats. Lung histology of control SH rats exhibited mild focal alveolitis and perivascular inflammation; these changes were minimal in control WKY rats. ROFA-induced increases in BALF protein, and to a lesser extent in LDH, were greater in SH compared to WKY rats. ROFA IT was associated with the increases in BALF total cells in both strains (SH > WKY). BALF neutrophils increased at 24 h and macrophages at 96 h in a dose-dependent manner (SH > WKY). The increase in BALF neutrophils was largely reversed by 96 h in both rat strains. The V-induced increases in BALF protein and LDH peaked at 6 h post-IT and returned to control by 24 h in WKY rats. In SH rats, BALF protein and LDH were not affected by V. Ni caused BALF protein to increase in both strains at 6 and 24 h; however, the control values at 24 h were high in SH rats, and were not distinguishable from exposed rats. The Ni-induced increase in LDH activity was progressive over a 24-h time period (WKY > SH). The number of macrophages decreased following V and Ni exposure at 6 h, and this decrease was reversed by 24 h in both strains. V caused BALF neutrophils to increase only in WKY rats. The Ni-induced increase in BALF neutrophils was more dramatic and progressive than that of V, but was similar in both strains. Lung histology similarly revealed more severe and persistent edema, perivascular and peribronchiolar inflammation, and hemorrhage in Ni- than in V-exposed rats. This effect of Ni appeared slightly more severe in SH than in WKY rats. In summary, the acute single IT exposure to ROFA resulted in greater pulmonary protein leakage and inflammation in SH rats than in WKY rats. The metallic constituents of ROFA produced these effects in a strain-specific manner such that, at the dose level used, V caused pulmonary injury only in WKY rats, whereas Ni was toxic to both strains.

Interobserver agreement in the electrocardiographic diagnosis of acute myocardial infarction in patients with left bundle branch block

STUDY OBJECTIVE

To determine the interobserver agreement between cardiologists and emergency physicians in the ECG diagnosis of acute myocardial infarction (AMI) in patients with left bundle branch block (LBBB) using the ECG algorithm previously described by Sgarbossa et al.

METHODS

Using the Sgarbossa ECG algorithm, 4 cardiologists and 4 emergency physicians independently interpreted a test set of 224 ECGs with LBBB, of which 100 ECGs were from patients with an evolving AMI. A subset of 25 ECGs was reinterpreted by each reader to test intraobserver agreement for AMI as well as interobserver agreement for the degree of ST-segment deviation. Agreement rates for AMI were estimated using the kappa statistic. In addition, the sensitivity and specificity for diagnosing AMI were determined for each reader, using the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO I) enzyme criteria for AMI as the gold standard. The study was conducted at 3 university-affiliated medical centers. The test set contained ECGs from 100 patients enrolled in the GUSTO I trial with LBBB on their initial ECG and an evolving AMI confirmed by serum cardiac enzyme changes, and 124 control patients from the Duke Databank for Cardiovascular Disease who had stable, angiographically documented coronary artery disease and LBBB.

RESULTS

There was excellent interobserver agreement (kappa=0.81, 95% confidence interval [CI] 0.80 to 0.83) between cardiologists and emergency physicians for diagnosing AMI. Intraobserver agreement kappa values for AMI diagnosis by cardiologists and emergency physicians were 0.81 (95% CI 0.67 to 0.94) and 0.71 (95% CI 0.54 to 0.89). The median sensitivity for diagnosing AMI by cardiologists and emergency physicians was 73% (range 66% to 80%) versus 67% (range 61% to 75%); median specificity was 98% (range 97% to 99%) versus 99% (range 98% to 99%). Spearman rank correlation coefficients for the degree of ST-segment deviation in all 12 leads was 0.86 (95% CI 0.85 to 0.87) among all readers.

CONCLUSION

There is excellent interobserver agreement between cardiologists and emergency physicians for diagnosing AMI when applying the Sgarbossa ECG algorithm to patients with LBBB. Emergency physicians should be able to reliably use this algorithm when evaluating patients.

Comparison of US utilization and technical costs before and after establishment of 24-hour in-house coverage for US examinations

PURPOSE

To compare data regarding the cost and number of ultrasonographic (US) examinations performed for 6 months, before and after institution of 24-hour in-house sonographer coverage.

MATERIALS AND METHODS

Data for a 6-month period during which US services were provided by a sonographer on call from 11 PM to 7 AM were compared with data for a 6-month period during which a sonographer was in house during this shift.

RESULTS

With 11 PM to 7 AM on-call coverage, the sonographers performed 147 examinations in a 6-month period, an average of 0.81 examination per shift. After institution of in-house coverage for this shift, 792 US examinations were performed in 6 months, an average of 4.3 examinations per shift. The cost for 11 PM to 7 AM in-house sonographer coverage for 6 months was approximately $16,000 more than that for on-call coverage. This cost would be offset by revenues from one additional examination per night. The cost per examination for the 11 PM to 7 AM shift decreased from $124.70 to $43.33.

CONCLUSION

At the authors' institution, 24-hour in-house sonographer coverage resulted in additional cost, which was offset by revenues from additional examinations. There was nearly a fivefold increase in the number of US examinations performed per shift. These examinations were performed more expediently, enabling more rapid patient triage.

Advanced Trauma Life Support (ATLS): necessary for emergency physicians?

A survey was conducted to determine differences in perspective towards Advanced Trauma Life Support (ATLS) between emergency medicine (EM) physicians and other specialties (OS), assess its value in the management of acute trauma, and identify areas in the course which could be revised or updated. The survey was devised and completed by physicians after ATLS. Of 26 course participants, there were 11 EM physicians (42%), four family practitioners (15%), four surgeons (15%), four internists (15%), two paediatricians (8%), and one anaesthesiologist (4%). Both groups found ATLS useful and relevant, and reported little deviation from their prior management of acute trauma. Unclear topics identified were airway, spine trauma, and burns/cold injury for EM, and head, abdominal, and paediatric trauma for OS. Significant differences were noted for the following: 91% EM vs. 13% OS felt ATLS could be shortened into a one-day course (p = 0.002), 64% EM vs. 7% OS thought the laboratory could be omitted (p = 0.003), and all (100%) EM vs. 60% OS believed the course could be taught by EM physicians as effectively as surgeons (p = 0.02). EM disagreed with OS over the proposed requirement that all EM physicians be required to take ATLS (2.0 +/- 0.2 vs. 3.5 +/- 0.4, p = 0.03). The EM group reported doing > 20 per year of airway, vascular, and thoracostomy procedures in their own practice, whereas OS did significantly fewer. ATLS may not be useful for EM practitioners actively involved in trauma care. Proposed changes from the EM perspective include shortening ATLS to one day, increased use of EM instructors, clarifying certain portions of the manual, and omitting the laboratory section or making it optional.

Patterns of tooth wear associated with methamphetamine use

BACKGROUND

Methamphetamine (MAP) abuse is a significant worldwide problem. This prospective study was conducted to determine if MAP users had distinct patterns of tooth wear.

METHODS

Methamphetamine users were identified and interviewed about their duration and preferred route of MAP use. Study participants were interviewed in the emergency department of a large urban university hospital serving a geographic area with a high rate of illicit MAP production and consumption. Tooth wear was documented for each study participant and scored using a previously validated index and demographic information was obtained using a questionnaire.

RESULTS

Forty-three MAP patients were interviewed. Preferred route of administration was injection (37%) followed by snorting (33%). Patients who preferentially snorted MAP had significantly higher tooth wear in the anterior maxillary teeth than patients who injected, smoked, or ingested MAP (P = 0.005).

CONCLUSION

Patients who use MAP have distinct patterns of wear based on route of administration. This difference may be explained anatomically.

Rhabdomyolysis and drugs of abuse

Rhabdomyolysis is a disorder in which injury to muscle results in leakage of myocyte intracellular contents into the plasma. It has been associated with a tremendous number and diversity of clinical conditions and substances. Several physiological and biochemical mechanisms for this syndrome have been described. The most likely etiology of rhabdomyolysis in patients presenting to the emergency department is ingestion of drugs of abuse, most commonly ethanol, heroin, amphetamines, cocaine, and other sedatives or stimulants. In this article, the association between rhabdomyolysis and drugs of abuse is explored, as well as its diagnosis and treatment.

Survey of directors of emergency departments in California on overcrowding

OBJECTIVE

To survey the directors of emergency departments in California on their opinions of the extent and factors associated with overcrowding in emergency departments.

METHODS

Surveys were mailed to a random sample of emergency department directors. Questions included estimated magnitude, frequency, causes, and effects of overcrowding.

RESULTS

Of 160 directors surveyed, 113 (71%) responded, and 109 (96%) reported overcrowding as a problem. All (n = 21) university or county hospital directors and most (n = 88 [96%]) private or community hospital directors reported overcrowding. The 4 private or community hospital directors reporting no overcrowding serve smaller communities with populations less than 250,000. Thirty-two directors (28%) reported daily overcrowding. The most cited causes were increasing patient acuity and volume, hospital bed shortage, laboratory delays, and nursing shortage. These putative causes were similar between university or county and private or community hospital directors, except for consultant delays, which were more prevalent in university or county hospital emergency departments.

CONCLUSIONS

Overcrowding is perceived to be a serious problem by emergency department directors. Many factors may contribute to overcrowding, and most are beyond the control of emergency departments.

The spontaneously hypertensive rat as a model of human cardiovascular disease: evidence of exacerbated cardiopulmonary injury and oxidative stress from inhaled emission particulate matter

Cardiovascular disease is considered a probable risk factor of particulate matter (PM)-related mortality and morbidity. It was hypothesized that rats with hereditary systemic hypertension and underlying cardiac disease would be more susceptible than healthy normotensive rats to pulmonary injury from inhaled residual oil fly ash (ROFA) PM. Eight spontaneously hypertensive (SH) and eight normotensive Wistar-Kyoto (WKY) rats (12-13 weeks old) were implanted with radiotelemetry transmitters on Day -10 for measurement of electrocardiographic (ECG) waveforms. These and other nonimplanted rats were exposed to filtered air or ROFA (containing leachable toxic levels of metals) on Day 0 by nose-only inhalation (ROFA, 15 mg/m(3) x 6 h/day x 3 days). ECGs were monitored during both exposure and nonexposure periods. At 0 or 18 h post-ROFA exposure, rats were assessed for airway hyperreactivity, pulmonary and cardiac histological lesions, bronchoalveolar lavage fluid (BALF) markers of lung injury, oxidative stress, and cytokine gene expression. Comparisons were made in two areas: (1) underlying cardiopulmonary complications of control SH rats in comparison to control WKY rats; and (2) ROFA-induced cardiopulmonary injury/inflammation and oxidative burden. With respect to the first area, control air-exposed SH rats had higher lung and left ventricular weights when compared to age-matched WKY rats. SH rats had hyporeactive airways to acetylcholine challenge. Lung histology revealed the presence of activated macrophages, neutrophils, and hemorrhage in control SHrats. Consistently, levels of BALF protein, macrophages, neutrophils, and red blood cells were also higher in SH rats. Thiobarbituric acid-reactive material in the BALF of air-exposed SH rats was significantly higher than that of WKY rats. Lung inflammation and lesions were mirrored in the higher basal levels of pulmonary cytokine mRNA expression. Cardiomyopathy and monocytic cell infiltration were apparent in the left ventricle of SH rats, along with increased cytokine expression. ECG demonstrated a depressed ST segment area in SH rats. With regard to the second area of comparison (ROFA-exposed rats), pulmonary histology indicated a slightly exacerbated pulmonary lesions including inflammatory response to ROFA in SH rats compared to WKY rats and ROFA-induced increases in BALF protein and albumin were significantly higher in SH rats than in WKY rats. In addition, ROFA caused an increase in BALF red blood cells in SH rats, indicating increased hemorrhage in the alveolar parenchyma. The number of alveolar macrophages increased more dramatically in SH rats following ROFA exposure, whereas neutrophils increased similarly in both strains. Despite greater pulmonary injury in SH rats, ROFA-induced increases in BALF GSH, ascorbate, and uric acid were attenuated when compared to WKY rats. ROFA inhalation exposure was associated with similar increases in pulmonary mRNA expression of IL-6, cellular fibronectin, and glucose-6-phosphate dehydrogenase (relative to that of beta-actin) in both rat strains. The expression of MIP-2 was increased in WKY but attenuated in SH rats. Thus, SH rats have underlying cardiac and pulmonary complications. When exposed to ROFA, SH rats exhibited exacerbated pulmonary injury, an attenuated antioxidant response, and acute depression in ST segment area of ECG, which is consistent with a greater susceptibility to adverse health effects of fugitive combustion PM. This study shows that the SH rat is a potentially useful model of genetically determined susceptibility with pulmonary and cardiovascular complications.

Munchausen syndrome presenting acutely in the emergency department

Munchausen syndrome is a rare psychiatric disorder in which patients purposely harm themselves to gain medical attention. These patients may present to unsuspecting emergency department (ED) staff members with life-threatening signs and symptoms. We report a case of Munchausen syndrome in which a young man with ties to the medical community and a history of substance abuse presented to our ED with refractory hypoglycemia and a dilated right pupil. The patient required large amounts of dextrose, endotracheal intubation, mechanical ventilation, and admission to the intensive care unit. Further investigation revealed that he had purposely injected himself with a large dose of insulin and instilled atropine drops in his right eye for the purpose of seeking hospitalization. The history, details, diagnosis, treatment, and prognosis are discussed in the context of this case.

Overcrowding in the nation's emergency departments: complex causes and disturbing effects

Ten years ago, serious overcrowding in emergency departments became a national issue. Although temporary improvement of the problem occurred, the issue of ED overcrowding has now resurfaced and threatens to become worse. Overcrowding is caused by a complex web of interrelated issues described in this article. ED overcrowding has multiple effects, including placing the patient at risk for poor outcome, prolonged pain and suffering of some patients, long patient waits, patient dissatisfaction, ambulance diversions in some cities, decreased physician productivity, increased frustration among medical staff, and violence. Solving the problem of overcrowding will not only require a major financial commitment from the federal government and local hospitals, but will also require a cooperation from managed care. Unless the problem is solved in the near future, the general public may no longer be able to rely on EDs for quality and timely emergency care, placing the people of this country at risk.

Sonographic detection of blunt hepatic trauma: hemoperitoneum and parenchymal patterns of injury

OBJECTIVES

To determine the sensitivity and utility of emergency sonography for the detection of blunt hepatic injury (BHI) in patients with abdominal trauma and to describe parenchymal sonographic patterns of BHI.

METHODS

This report was a prospective clinical study in which the findings of all patients who had emergency sonograms were recorded on a data sheet by the initial sonographer and interpreting physicians. All patients with hepatic injuries during this period were identified and physical examination, laboratory, computed tomographic and intraoperative findings were compared with the prospective data sheets.

RESULTS

From January of 1995 to December of 1998, 2,622 emergency sonograms were performed, and in this group, a total of 146 patients had BHI. Emergency sonograms allowed detection of free fluid in 98 patients (67%), and parenchymal injury with no free fluid in seven patients (5%). There were 41 false negatives (28%). The most common pattern identified on a sonogram was a discrete area of increased echogenicity followed by a diffuse hyperechoic pattern. Seventy-six patients (52%) had concomitant intra-abdominal injuries, including spleen (n = 46), bowel (n = 30), and kidney (n = 19). There were 102 exploratory laparotomies performed. Abdominal tenderness or distention was present in 127 patients (87%), and 108 patients had right rib fractures (74%). Based on detection of free fluid, parenchymal injury, or both, the overall sensitivity of sonography for the detection of BHI was 72 % but was 98 % for grade III or higher injuries.

CONCLUSION

Emergency sonography is sensitive for the detection of grade III or higher liver injuries resulting from blunt abdominal trauma. Sonography may also reveal BHI on the basis of parenchymal abnormality, with a discrete hyperechoic area the most commonly encountered pattern.

Methamphetamine abuse and rhabdomyolysis in the ED: a 5-year study

Patients with methamphetamine toxicity are presenting in greater numbers each year to emergency departments (ED) in the US. These patients are frequently agitated, violent, and often require physical and chemical restraint. The incidence and risk of rhabdomyolysis in this subpopulation is unknown. We conducted a 5-year retrospective review of all ED patients who received the final diagnosis of rhabdomyolysis. Patients with toxicology screens positive for methamphetamine were identified, and demographics, laboratory results, resource utilization, disposition, and outcome were compared to the remaining patients. Of the total 367 patients identified, 166 (43%) were toxicology positive for methamphetamine. Methamphetamine patients differed significantly from nonmethamphetamine patients with regard to demographics and hospital utilization. Methamphetamine patients had significantly higher mean initial creatine phosphokinase (CK), 12,439 U/L versus 5,678 U/L (P = 0.02), and lower mean peak CK, 16,827 U/L versus 19,426 U/L (P = 0.03). The development of acute renal failure was not significantly different between the 2 groups. There were 16 total deaths in the study population, 11 from concomitant infection/sepsis. An association between methamphetamine abuse and rhabdomyolysis may exist, and CK should be measured in the ED as a screen for potential muscle injury in this subpopulation. Patients with rhabdomyolysis with an unclear cause should be screened for methamphetamine or other illicit drugs.

Lung injury from intratracheal and inhalation exposures to residual oil fly ash in a rat model of monocrotaline-induced pulmonary hypertension

A rat model of monocrotaline (MCT)-induced pulmonary injury/hypertension has been recently used in particulate matter (PM) health effects studies, however, results have been equivocal. Neither the mechanism by which mortality occurs in this model nor the variation in response due to differences in PM exposure protocols (i.e., a bolus dose delivered intratracheally versus a similar cumulative dose inhaled over three days) have been fully investigated. Sprague Dawley rats (SD, 60 d old; 250-300 g) were injected with either saline (healthy) or MCT, 60 mg/kg, i.p. (to induce pulmonary injury/hypertension). Ten days later they were exposed to residual oil fly ash (ROFA), either intratracheally (IT; saline, 0.83 or 3.33 mg/kg) or by nose-only inhalation (15 mg/m3 x 6 h/d x 3 d). Lung histology, pulmonary cytokine gene expression (0 and 18 h postinhalation), and bronchoalveolar lavage fluid (BALF) markers of injury were analyzed (24 and 96 h post-IT; or 18 h post-inhalation). Data comparisons examined three primary aspects, 1) ROFA IT versus inhalation effects in healthy rats; 2) pulmonary injury caused by MCT; and 3) exacerbation of ROFA effects in MCT rats. In the first aspect, pulmonary histological lesions following ROFA inhalation in healthy rats were characterized by edema, inflammatory cell infiltration, and thickening of alveolar walls. Increases in BALF markers of lung injury and inflammation were apparent in ROFA-IT or nose-only exposed healthy rats. Increased IL-6, and MIP-2 expression were also apparent in healthy rats following ROFA inhalation. In regards to the second aspect, MCT rats exposed to saline or air showed perivascular inflammatory cell infiltrates, increased presence of large macrophages, and alveolar thickening. Consistently, BALF protein, and inflammatory markers (macrophage and neutrophil counts) were elevated indicating pulmonary injury. In regards to the third aspect, 58% of MCT rats exposed to ROFA IT died within 96 h regardless of the dose. No mortality was observed using the inhalation protocol. ROFA inhalation in MCT rats caused exacerbation of lung lesions such as increased edema, alveolar wall thickening, and inflammatory cell infiltration. This exacerbation was also evident in terms of additive or more than additive increases in BALF neutrophils, macrophages and eosinophils. IL-6 but not MIP-2 expression was more than additive in MCT rats, and persisted over 18 h following ROFA. IL-10 and cellular fibronectin expression was only increased in MCT rats exposed to ROFA. In summary, only the bolus IT ROFA caused mortality in the rat model of lung injury/hypertension. Exacerbation of histological lesions and cytokine mRNA expression were most reflective of increased ROFA susceptibility in this model.

Triage ability of emergency medical services providers and patient disposition: a prospective study

STUDY OBJECTIVE

To determine the ability of emergency medical services (EMS) providers to subjectively triage patients with respect to hospital admission and to determine patient characteristics associated with increased likelihood of admission.

METHODS

A prospective, cross-sectional study of a consecutive sample of patients arriving by ambulance during the month of February 1997 at an urban, university hospital, Emergency Department. Emergency medical services providers completed a questionnaire asking them to predict admission to the hospital and requested patient demographic information. Predictions were compared to actual patient disposition.

RESULTS

A total of 887 patients were included in the study, and 315 were admitted to the hospital (36%). With respect to admission, EMS providers had an accuracy rate of 79%, with a sensitivity of 72% and specificity of 83% (kappa = 0.56). Blunt traumatic injury and altered mental status were the most common medical reasons for admission. Variables significantly associated with high admission rates were patients with age > 50 years, chest pain or cardiac complaints, shortness of breath or respiratory complaints, Medicare insurance, and Hispanic ethnicity. The EMS providers most accurately predicted admission for patients presenting with labor (kappa = 1.0), shortness of breath/respiratory complaints (kappa = 0.84), and chest pain (kappa = 0.77).

CONCLUSION

Emergency medical services providers can predict final patient disposition with reasonable accuracy, especially for patients presenting with labor, shortness of breath, or chest pain. Certain patient characteristics are associated with a higher rate of actual admission.

Intravenous urography in the emergency department: when do we need it?

Intravenous urography (IVU) is a useful radiographic study in the detection of renal and ureteral calculi. However, it is time consuming, expensive, and exposes the patient to i.v. contrast and radiation. To determine the impact of utilizing IVU less for the detection of renal calculi, criteria for ordering IVU in the emergency department (ED) were evaluated, and patients with high probability of positive IVU were identified. Variables included presence of acute flank pain with haematuria, prior history of renal calculus, degree of haematuria, and uncontrolled pain. We reviewed patients presenting with acute flank and abdominal pain with haematuria from May 1995 to May 1996 at a large urban university hospital. Charts were abstracted for prior history, reason for ordering IVU, time in the ED, laboratory results, IVU result, final diagnosis, and disposition. Data was analysed with Student's t-test, Wilcoxon rank-sum and receiver operating characteristic (ROC) analysis. A total of 302 patients were identified, and 185 underwent IVU during the study period. For patients with prior history of renal calculi 82% had positive IVU (sensitivity 51%, specificity 87%). For patients with both acute flank pain and haematuria, 92% had a positive IVU (sensitivity 93%, specificity 43%), and 19% of patients with abdominal pain of unclear aetiology with haematuria had a positive IVU. All patients with uncontrolled pain had evidence of high-grade obstruction on IVU. Degree of haematuria was not predictive of a positive IVU from ROC curve derivation. IVU is a useful study in the ED but may be overutilized, leading to lengthy patient stays. The combined objective findings of acute flank pain and haematuria are sensitive, and prior history is specific in identifying patients with renal calculi. Degree of haematuria was not useful in predicting renal calculi. By utilizing the criteria of acute flank pain and haematuria as a decision aid, 66% of all IVUs ordered could have been avoided.

Bowel and mesenteric injury: evaluation with emergency abdominal US

PURPOSE

To assess emergency ultrasonography (US) for detection of bowel and mesenteric injury from blunt trauma.

MATERIALS AND METHODS

For 3 years, prospective data on all patients undergoing emergency US were recorded. Patients with bowel and mesenteric injury were identified, and physical examination, laboratory, computed tomographic (CT), and intraoperative findings were compared with prospective data.

RESULTS

From January 1995 to January 1998, emergency US was performed in 1,686 patients; 71 patients had bowel and mesenteric injury. Forty-one examinations were true-positive (i.e., with free fluid), and 30 were false-negative. Twenty-five of the 41 patients with true-positive US results had concomitant injuries that may have accounted for the free fluid, including liver, spleen, pancreas, gallbladder, kidney, and/or bladder injuries. The remaining 16 patients had isolated bowel and mesenteric injury. Bowel and mesenteric damage was identified intraoperatively in 70 patients. Twenty-nine of 30 patients with false-negative US examinations had abdominal tenderness. Sixteen patients with false-negative US results had bowel and mesenteric injury that was detected 12 or more hours after initial scanning.

CONCLUSION

Free fluid in the abdomen is not detected in the majority of patients with isolated bowel and mesenteric injury. For clinical suspicion of bowel and mesenteric injury, observation, serial physical abdominal examination, and CT may be helpful in diagnosing this condition.

Methamphetamine abuse and emergency department utilization

Methamphetamine (MAP) abuse continues to increase worldwide, based on morbidity, mortality, drug treatment, and epidemiologic studies and surveys. MAP abuse has become a significant health care, environmental, and law enforcement problem. Acute intoxication often results in agitation, violence, and death. Chronic use may lead to infection, heart failure, malnutrition, and permanent psychiatric illness. MAP users frequently use the emergency department (ED) for their medical care. Over a 6-month period we studied the demographics, type, and frequency of medical and traumatic problems in 461 MAP patients presenting to our ED, which serves an area noted for high levels of MAP production and consumption. Comparison was made to the general ED population to assess use patterns. MAP patients were most commonly Caucasian males who lacked health insurance. Compared to other ED patients during this time, MAP patients used ambulance transport more and were more likely to be admitted to the hospital. There was a significant association between trauma and MAP use in this patient population. Our data suggest MAP users utilize prehospital and hospital resources at levels higher than the average ED population. Based on current trends, we can expect more ED visits by MAP users in the future.

Use of ultrasonography in the patient with acute renal trauma

The purpose of this study was to assess the use of emergent ultrasonographic examination in acute traumatic renal injuries. Over a 3 year period, prospective data of all patients who had an emergency ultrasonogram were recorded. Thirty-two patients with 37 renal injuries were studied retrospectively to identify in how many patients the sonogram detected free fluid or a renal parenchymal abnormality. Free fluid in the abdomen was identified in 19 of 32 patients (59%). However, 12 of these 19 patients had concomitant injury, such as splenic rupture requiring splenectomy, severe liver lacerations, or bowel lacerations requiring repair, that were possible causes of the free fluid. Eliminating these patients, only seven of 20 patients with isolated renal injuries had free fluid in the abdomen (35%), whereas 13 of 20 patients (65%) had no evidence of free fluid. All seven patients with free fluid had moderate or severe renal injuries. Renal parenchymal abnormalities were identified on ultrasonograms in eight of 37 (22%) of injured kidneys. The abnormalities were detected more commonly in cases of severe injury (60%). In conclusion, acute injuries of the kidney from blunt abdominal trauma often are associated with significant splenic, hepatic, or bowel trauma. Isolated renal injuries frequently occur without the presence of free fluid in the abdomen. Furthermore, the ultrasonogram of the kidney often is normal with acute renal injuries, but it is more likely to be abnormal with severe (grade II or greater) renal injuries. Sonography may be used in the triage of patients with blunt abdominal trauma and possible renal injury. However, a negative ultrasonogram does not exclude renal injury, and, depending on clinical and laboratory findings, other imaging procedures such as computed tomography should be performed.

Inappropriate use of emergency medical services transport: comparison of provider and patient perspectives

OBJECTIVES

To determine the extent of inappropriate ambulance use from the perspectives of both emergency medical services (EMS) providers and patients utilizing EMS transport, assess level of agreement, and identify variables associated with inappropriate ambulance use.

METHODS

A prospective cross-sectional study was done of a consecutive sample of patients arriving by ambulance during the month of February 1997 at an urban university hospital ED. EMS providers and patients completed a survey with questions regarding their perceptions of whether the need for ambulance transport was an emergency or a nonemergency. Patient demographic information and availability of alternate means of transportation to the hospital were also evaluated.

RESULTS

Eight hundred eighty-seven patients were included in the study. EMS providers thought that 501 patient transports were appropriate and represented true emergencies, whereas 689 patients believed their medical problems were true emergencies. A significant number of patients (n=415, 47%) had access to alternative transportation to the hospital. Blunt traumatic injury and altered mental status were the most common reasons for EMS transport. Patient characteristics significantly associated with EMS provider perception of a true emergency were male gender, age >51 years, higher education, chest pain/cardiac complaints, shortness of breath/respiratory complaints, and Medicare insurance. Characteristics significantly associated with patients who perceived themselves to have true emergencies were black ethnicity, higher education, shortness of breath/respiratory complaints, and Medicare insurance. There was 75% agreement between EMS providers and patients on appropriateness of ambulance transport (kappa=0.84).

CONCLUSION

Inappropriate ambulance use is a significant problem from both EMS provider and patient perspectives. Certain patient characteristics are associated with a higher probability of appropriate and inappropriate uses of EMS transport. A large number of patients transported by ambulance have alternative means of transportation but elect not to use them.

Computed tomography for blunt abdominal trauma in the ED: a prospective study

A study was undertaken to determine the criteria for ordering abdominal computed tomography (CT) in the emergency department (ED) for stable patients who sustained blunt trauma and to identify a patient population at high risk for having intra-abdominal injury (IAI) utilizing physical examination, decrease in hematocrit, and hematuria. Patients in a university ED who had abdominal CT from April 1995 to October 1995 were evaluated prospectively. Before the scan, the examining physician completed an entry form that included physical findings, hematocrit, hematuria, Glasgow Coma Scale score, intoxication, distracting injuries, reasons for obtaining the scan, and planned disposition. Patients were followed until discharge. A total of 196 patients were evaluated. Abdominal tenderness was present in 120 patients. Twenty-two patients had IAI. Eight required surgical intervention, and all 8 had abdominal tenderness. A total of 40 potential trauma admissions were averted by obtaining CT within the ED. The combined abnormal abdomen examination and presence of hematuria had a sensitivity of 64%, specificity of 94%, positive predictive value of 56%, and negative predictive value of 95%. Decrease of > or = 5 in hematocrit was not statistically significant for detection of IAI. CT had no false negatives in this cohort. These results show that early CT scanning of stable patients who have sustained blunt trauma is an effective screen for IAI and may result in fewer total admissions, but has potential for overuse. Patients with abdominal pain and hematuria should be scanned. The benefit of a CT scan for patients without tenderness or with an isolated decrease in hematocrit is questionable.

Chemical restraint for the agitated patient in the emergency department: lorazepam versus droperidol

Patients presenting to the emergency department with acute agitation frequently require physical and chemical restraint. To determine the efficacy of lorazepam vs. droperidol, we conducted a prospective, randomized study of violently agitated patients requiring chemical restraint. Patients were randomized to receive either lorazepam or droperidol i.v. A six-point sedation scale was used. Sedation scores were recorded at time 0, 5, 10, 15, 30, and 60 min. Vital signs were compared at time 0 and at 60 min. Repeat dosages of each drug could be given at 30 min. Toxicology screen, ethanol and creatinine phosphokinase levels were obtained. A total of 202 patients were evaluated. One hundred patients received lorazepam and 102 patients received droperidol. Agitation was attributed to methamphetamine toxicity in 146 patients (72%), cocaine toxicity in 28 (14%), psychiatric illness in 20 (10%), and ethanol withdrawal in 8 (4%). Ethanol intoxication was present in 98 patients (49%). Both drugs had similar sedation profiles at 5 min. Patients receiving droperidol had significantly lower sedation scores at times 10, 15, 30, and 60 than lorazepam. More repeat doses of lorazepam were given (40) than droperidol (8) at 30 min. We conclude that droperidol produces a more rapid and better sedation than lorazepam at the doses used in this study in agitated patients requiring chemical restraint. Lorazepam is more likely to require repeat dosing than droperidol. Methamphetamine toxicity was present in the majority of patients in this study.

Methamphetamine toxicity: treatment with a benzodiazepine versus a butyrophenone

Patients with methamphetamine toxicity often present to the emergency department (ED) agitated, violent and psychotic. To determine the efficacy of a benzodiazepine versus a butyrophenone for chemical restraint we conducted a prospective, randomized study at a large urban university ED between January 1995 and January 1997. Patients were randomized to receive either lorazepam or droperidol intravenously. A 6-point sedation scale was devised, with 6 representing extreme agitation and 1 deep sleep. Sedation scores were recorded at time 0, 5, 10, 15, 30 and 60 min. Vital signs were recorded at time 0 and at 60 min. If sedation was inadequate, repeat dosages of each drug could be repeated at 30 min. Toxicology screen, ethanol and creatinine phosphokinase levels were obtained. A total of 146 patients were evaluated. Seventy-four patients received lorazepam and 72 received droperidol. Both drugs had similar sedation profiles at 5 min. Patients receiving droperidol had significantly improved sedation scores at times 10, 15, 30 and 60 min than lorazepam (p < 0.001). More repeat doses of lorazepam were given (26) than droperidol (6) at 30 min. Both drugs produced significant reduction in pulse, systolic blood pressure, respiratory rate, and temperature over 60 min. We conclude droperidol produces a more rapid and profound sedation than lorazepam for methamphetamine toxicity. Lorazepam is more likely to require repeat dosing than droperidol.

Emergency medicine in Cuba: report from a country in isolation

Cuba is one of the poorest countries of the world. For the past 34 years the United States has maintained an economic embargo against Cuba. Because of this, Cuba has not been able to share in advances in American medical technology, pharmaceuticals, or research. The country has also been abandoned by the former Soviet Union. Recent political developments have assured continuation of the embargo. This report describes the current state of prehospital and emergency medical care in Cuba, how the embargo has affected emergency services, and possibilities for the future.

Emergency medicine in Vietnam

The Socialist Republic of Vietnam is one of the poorest countries in the world. Recent economic developments, as the country attempts to start a market economy, have had a profound impact on its health care system. This report describes the state of prehospital and emergency medical care in Vietnam and possibilities for the future.

Computed tomography and blunt abdominal injury: patient selection based on examination, haematocrit and haematuria

The criteria for ordering abdominal CT scans in the secondary survey of stable bluntly injured patients was examined. A patient population at high risk for having intra-abdominal injury (IAI) was identified by physical examination, a fall in haematocrit, and haematuria. A total of 444 patients receiving abdominal CT scans at a large urban trauma centre were reviewed. IAI was diagnosed in 49 (11 per cent), by radiographic and/or intra-operative findings. Abdominal tenderness was present in all 17 patients who underwent surgery. The sensitivity and specificity of abdominal CT scanning was 90 per cent and 99 per cent, respectively. The abdominal exam had a sensitivity of 63 per cent and a specificity of 65 per cent. A fall in haematocrit > or = 5 was not statistically significant. The combined abdominal exam and haematuria yielded a specificity of 93 per cent with a negative predictive value (NPV) of 93 per cent. Early CT scanning of stable patients who had sustained blunt injuries is an effective screen for IAI. The benefit of a CT scan for patients without abdominal tenderness or with an isolated fall in haematocrit is questionable. Serial abdominal examinations should remain the most timely and cost-effective method for identifying IAI in stable patients. The specificity and NPV of abdominal tenderness combined with haematuria approaches that of CT.

Differential regulation of macrophage arginine metabolism: a proposed role in wound healing

Nitric oxide (NO) and ornithine, products of NO synthase or arginase, respectively, have opposing biological activities. The effect of mediators of leukocyte activation and inhibition on arginine metabolism of resident mouse peritoneal exudate cells (MPEC) was determined. Factors that increased basal NO synthase activity, interferon (IFN)-gamma and lipopolysaccharide (LPS), decreased arginase activity in intact cells. Transforming growth factor (TGF)-beta1 decreased IFN-gamma-stimulated NO synthase activity and produced a reciprocal increase in urea and ornithine release. TGF-beta1 had no effect on the activity of these enzymes in LPS-stimulated MPEC. Corticosterone (Cort, 100 ng/ml) decreased the basal activity of both enzymes. However, Cort inhibited NO synthase activity and increased ornithine release in MPEC exposed to IFN-gamma or LPS. The difference between arginase activity in intact cells vs. that of cell lysates suggested intracellular inhibition of arginase activity. Products of NO synthase, NO and citrulline, were shown to inhibit MPEC arginase activity under maximal assay conditions. Intracellular pH was not altered by exposure of MPEC to LPS, IFN-gamma, TGF-beta, and Cort. This reciprocal change in arginine metabolism is proposed to be an important component of wound healing. Expression of NO synthase creates a cytotoxic environment that may be important to the early phase of wound healing. As wound healing progresses, increased arginase activity produces an environment favorable for fibroblast replication and collagen production.

An easy cricothyrotomy approach: the rapid four-step technique

A simplified 4-step cricothyrotomy technique is described. The procedure can be completed in < 30 seconds without use of suction or additional light source. The only equipment needed is a #20 scalpel, a tracheal hook with a large radius, and a cuffed tracheostomy tube. The 4 steps are: 1) palpation, 2) stab incision, 3) inferior traction, and 4) tube insertion. This streamlined method is simple and quick. Because the operator's body position and hand movements (steps 3 and 4) are similar to those in orotracheal intubation, there is a feeling of familiarity that enhances retention of the procedure. The steps are illustrated and 4 cases using this technique are reported. Since the hands at each step are stabilized on the patient and no special equipment is needed, this technique also may be ideal for the out-of-hospital environment.

Nephrarious goings on. Kidney sales and moral arguments

From all points of the political compass, from widely different groups, have come indignant outcries against the trade in human organs from live vendors. Opponents contend that such practices constitute a morally outrageous and gross exploitation of the poor, inherently coercive and obviously intolerable in any civilized society. This article examines the arguments typically offered in defense of these claims, and finds serious problems with all of them. The prohibition of organ sales is derived not from the principles and argument usually invoked in support of prohibition, but rather, from strong feelings of repugnance which exert an invisible but powerful influence on the debate, distorting the arguments [and working] to the detriment of the [very] people most in need of protection.