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The patient may also present with fever and abdominal pain buy zenegra 100 mg on-line erectile dysfunction drugs in nigeria, with hematuria zenegra 100mg lowest price erectile dysfunction caused by hemorrhoids, intestinal obstruction or hypertensionQ as a result of pressure from the tumor 100mg zenegra otc impotence occurs when. The components of this syndrome are W – Wilm’s tumor A – Aniridia G – Genital anomalies R – Mental retardation 123 generic zenegra 100 mg on line erectile dysfunction drugs market share. Moreover, additional presence of consti- tutional symptoms, such as fever and weakness, increase the suspicion of a renal cell carcinoma. There is now a 90% survival rate for this tumor with combined therapy with surgery, chemotherapy, and radiotherapy. Renal cell carcinoma (choice A) and transitional cell carcinoma of the bladder (choice D) are malignant tumors of adults. Renal hamartoma (fbroma; choice B) causes a small, gray, benign module in the renal pyramids and is usually only identifed as an incidental fnding. Similar lesions are also seen in the colon, lungs, bones, kidneys, prostate, and epididymis. Schistosoma haematobium infections in endemic areas like Egypt and Sudan are an established risk. The ova are deposited in the bladder wall and incite a brisk chronic infammatory response that induces progressive mucosal squamous metapla- sia and dysplasia and, in some instances, neoplasia. This can be associated with highly elevated bilirubin levels with bile cast formation (also known as cholemic nephrosis) in distal nephron segments. The casts can extend to proximal tubules, resulting in both direct toxic effects on tubular epithelial cells and obstruction of the involved nephron. The reversibility of the renal injury depends upon the severity and duration of the liver dysfunction. The syndrome features a constellation of skin (fbrofolliculomas, trichodiscomas, and acrochordons), pulmonary (cysts or blebs), and renal tumors with varing histologies. Additional variant of renal cell cancer (as if clear cell, papillary, chromophobe and collecting duct were not enough!!! Mucosa consisting of epithelial layer, lamina propria and muscularis mucosae Serosa is absent in the esopha- 2. Submucosa having submucosal glands and Meissner’s plexus gus except for intra-abdominal 3. Muscularis propria consisting of inner circular layer, outer longitudinal layer and portion. Surgically, it provides strength to intestinal It is a muscular tube almost 25 cm in length in adults (it is about 10 cm in a newborn) taking anastomosis the food from the oral cavity into the stomach. The esophagus is having the following four constrictions in it: • Cricopharyngeus constriction: present at 15 cm (6 inches) from the incisor teethQ. Diagnosis • Barium swallow shows ‘bird beak’ or ‘rat tail’ appearanceQ Q of the esophagus (due to normal upper esophagus with tapering in the lower part). Treatment It is medically managed with botulinum toxin but the treatment of choice is surgical excision of the muscle of the lower esophagus and cardia (Heller myotomyQ). Sliding hernia (95%): Characterized by upward dislocation of cardioesophageal junction. Paraesophageal/Rolling hernia (5%): A part of the stomach enters the thorax without any displacement of the cardioesophageal junction. Dysphagia is common and chest pain may also be present (usually relieved by a loud belch). In most of the cases (90%), the tear is present at the cardia Q tear is present immediately below the squamocolumnar junction at the cardia whereas in 10% cases, it is present in the esophagus. These tears never involve the muscular layer of the esophagus whereas, in contrast, in Boerhaave syndrome, rupture of all the esophageal layers is seen including the muscle layer. Most common location of the perforation in this syndrome is in left posterolateral part 3-5 cm above the gastroesophageal junction. The refux is associated with obesity, alcohol intake, Barrett’s esophagus is the most important risk factor for the smoking, pregnancy and overeating. It is classifed as long segment (if >3 cm is involved) or short segment from normal mucus secreting (if <3 cm is involved). Microscopically, esophageal squamous epithelium is replaced by foveolar cells of the stomach by the fact that in the former, there columnar epithelium. Defnite diagnosis is made only when columnar mucosa contains the intestinal goblet cells. Q is presence of distinct mucous vacuoles (not present in gastric Note: Barrett’s ulcer is the ulcer in the columnar lined portion of Barrett’s esophagus. Flat, diffuse infltrative form spreading in the esophageal wall (15%) Barium swallow in esophageal iii. Ulcerative lesion (25%) cancer shows “rat tail” Risk factors for Adenocarcinoma appearance of the esophagus. Multiple foci of dysplastic epithelium are present adjacent to the cancer in India: Squamous mucosa. The lymph node metastasis is dependent on cancer in upper 1/3rd of the anatomic site of the primary tumor. Presence of neutrophils above the basement membrane in direct contact with the epithelial cells is indicative of active infammationQ. Chronic gastritis can be of the following two types: Autoimmune gastritis causes 1. Histology remains the gold Intraepithelial neutrophils and subepithelial plasma cells (meaning plasma cells in the standard for detection of H. Autoimmune gastritis (in 10% patients) silver stains (like Warthin- It is caused due to formation of autoantibodies against the proton pump, gastrin Starry, Steiner etc. This is particularly associated with damage to the mucosa of the body and fundus with less involvement of the antrum. Hyperplasia of gastrin producing G cells in the antral mucosa may result in gastric carcinoid tumor formation. The histologic features of chronic gastritis include regenerative change, intestinal metaplasia (columnar absorptive cells and goblet cells of intestinal type), atrophy and dysplasia. In autoimmune gastritis, there is presence of infammatory infltrate having lymphocytes, macrophages in the deeper layers. Autoimmune gastritis maybe associated with symptoms seen in pernicious anemia (beefy tongue, paresthesia, numbness, sensory ataxia, loss of vibration and position sense). Males are more commonly affected than females Duodenal ulcers are located near the pyloric ring and gastric ulcers are predominantly located near the lesser curvature and the antrum. More commonly, there is involvement of the anterior wall of the duodenum as compared to the posterior wall. Benign peptic ulcer is classically punched with margins of the ulcer usually at level with the surrounding mucosa whereas heaping up of the margins is more frequently associated with malignancy. Zone of fbrous or collagenous scar Clinical features include burning epigastric pain (usually getting worse at night), nausea, vomiting and bloating. Complications of Peptic Ulcer Gastroduodenal artery is the Bleeding source of the bleeding in duo- • Most frequent complicationQ.
If repair is unsuccessful cheap 100mg zenegra with mastercard erectile dysfunction treatment kerala, p53 causes apoptosis of the cell by activating bax (apoptosis inducing gene) cheap 100mg zenegra visa erectile dysfunction medicine names. Dysregulation of c-myc expression resulting from translocation of gene occurs in Burkitt’s lymphoma buy zenegra 100 mg low cost erectile dysfunction estrogen. Viral oncogenes do not contain introns and that’s how they are different from human oncogenes buy discount zenegra 100mg line erectile dysfunction medication class. Genes that favor cell survival and protect from apoptosis are: - bcl-2, bcl-xL • Genes that favor programmed cell death are: bax, bad, bcl-xL and p53. Nucleotide excision repair (Ref: Harrison 17th/d/387 Robbins 7th/d 287, 9/e 314) 168 Neoplasia 54. Colon adenomas usually occur in patients in 50-60 years old and are considered premalignant. Early detection and excision of adenomatous polyps is therefore, an effective prophylaxis for colon adenocarcinoma. The malignant potential of adenomatous polyps is determined by the following: • Size of the polyp: – < 1cm - Unlikely to undergo malignant transformation – > 4cm- 40% risk of malignancy • Microscopic/Histologic appearance: Villous adenomas are more prone to be malignant than tubular adenomas. The transformation of normal mucosal cells into malignant ones is caused by a series of gene mutations called the “adeno- ma-to-carcinoma sequence. Increase in the size of adenomatous polyps (and, therefore, increase in their malignant potential) is attributed to K-ras protooncogene mutation which results in unregulated cell proliferation. So, it is said to be in a state of confict because its activity is dependent on the absence or presence of growth factors. Colon cancer is one of the common malignancy whose incidence increases with age, and it affects males and females equally. Evaluating the other options, • (Choice A): Cyclin D is a protein that regulates cell cycle. Its overexpression is seen in breast, lung, and esophageal cancers, and certain types of lymphomas. Please revise: • Associate bcl-2 (option A) with follicular and undifferentiated lymphomas. Café-au-lait spots are not considered to be premalignant lesions of skin (option D). As can be deduced from above mentioned information that the p53 is associated with both the types of checkpoints. Hereditary/Familial retinoblastoma Non-Hereditary/Sporadic retinoblastoma • Seen in 40% cases • Seen in 60% cases(more common ) • Usually bilateral and multifocal • Usually unilateral and unifocal • Can also develop extraocular tumors (osteosarcoma and pinealoblastoma) 66. In addition, they may be associated with pinealoblastoma (“trilateral” retinoblastoma). One of the critical events required for metastasis is the growth of a new network of blood vessels, called tumor angiogenesis. The latter can cause double base substitutions in the p53 resulting in the development of skin cancers. The absence of this protective mechanism is seen in patients of Xeroderma pig- mentosum causing high incidence of skin cancers. Thorotrast is a suspension containing particles of the radioactive compound thorium dioxide. It emits alpha particles due to which it has been found to be extremely carcinogenic. Concept: for future exam • Tumor cells in Sertoli-Leydig tumors (Androblastomas) may stain positively with inhibin, but Call-Exner bodies are not present. Sertoli-Leydig tumors also may secrete androgens and produce virilization in women. It is a marker of hepatocellular cancer and non-seminomatous germ cell tumors of testes. Adolescent patients with primary osteosarcoma demonstrate abnormal glucose, insulin and growth hormone responses to oral glucose loading in 78% of the study population. No statistical association exists between any two of the three factors and, therefore, no primary abnormality can be identifed. High somatomedin levels were noted in 72% of the group studied accompanied by simultaneous elevations of growth hormones. Studies of adrenal, gonadal and gonadotropic hormones were essentially normal, thereby ruling these out as associated endocrine abnormalities”. It is associated with the following paraneoplastic syndromes: • Myasthenia gravis (most common)Q • Acquired hypogammaglobulinemiaQ • Pure red cell aplasiaQ • Graves disease • Pernicious anemia • Dermatomyositis-polymyositis • Cushing syndrome. The important examples include: Cytokeratin (carcinoma), Desmin (Leiomyoma and Rhabdomyosarcoma) and vimentin (Sarcomas). Another approach is based on the differentiation between the different isoenzymes on the basis of heat susceptibility. The fnding of an elevated serum alkaline phosphatase level in a patient with a heat-stable fraction strongly suggests that the placenta or a tumor is the source of the elevated enzyme in serum. Susceptibility to inactivation by heat increases, respectively, for the intestinal, liver, and bone alkaline phosphatase, bone being by far the most sensitive and the liver being most resistant. Mnemonic: bone burns but liver lasts • The conditions having elevated placental alkaline phosphatase include: – Seminoma – Choriocarcinoma – Third trimester of pregnancy 95. Other causes of secondary polycythemia are diseases that impair oxygenation, including pulmonary diseases (including smoking) and congestive heart failure. Colon cancer (option B) and stomach cancer (option D) can present with anemia secondary to blood loss. Causes include autoim- mune destruction, congenital adrenal hyperplasia, hemorrhagic necrosis, and replacement of the glands by either tumor (usually metastatic) or granulomatous disease (usually tuberculosis being the commonest cause in India). The symptoms can be subtle and nonspecifc (such as those illustrated), so a high clinical index of suspicion is warranted. In some cases, however, mineralocorticoid replacement may also be needed for symptoms of salt wasting with lower circulating volume. Except in the case of primary pancreatic cancer, complete tumor replacement of the endocrine pancreas (option B) would be uncommon. Involvement of the ovaries (option C) by metastatic tumor (classically gastric adenocarcinoma) would produce failure of menstruation. Involvement of the pituitary gland (option D) could produce Addisonian symptoms, but the pigmented skin suggests a primary adrenal problem rather than pituitary involvement. Migratory thrombophlebitis is mostly associated with tumors of the pancreas, lung, and colon. Breast and prostate cancers are the most common sources of bone metastases, but prostate metastases are usually blastic. Now almost25% of individuals with pheochromocytomas and paragangliomas harbor a germline mutation in the succinate dehydrogenase genes. Also note that – Notably, malignancy is more common (20% to 40%) in extra-adrenal paragangliomas, and in tumors arising in the setting of certain germline mutations. They occur with a frequency of 1 in 20,000 to 40,000 live births, and are four times more common in girls than boys • Serum alpha fetoprotein is a useful marker for sacrococcygeal teratoma. Even Harrison says “The most common cause of adrenal tumors is metastasis from another solid tumor like breast cancer and lung cancer”. Malignant Prevalence Adrenocortical carcinoma 2-5 Malignant pheochromocytoma <1 Adrenal neuroblastoma <0.
It follows order 100 mg zenegra with mastercard erectile dysfunction doctor sydney, then discount zenegra 100 mg on-line diabetes obesity and erectile dysfunction, that the only information that can be conveyed by a single action potential is its presence or absence 100 mg zenegra otc reasons erectile dysfunction young age. Relationships between and among action potentials safe 100 mg zenegra erectile dysfunction questions to ask, however, can convey large amounts of information, and this is the system found in the sensory transmission process. To review, in physiologic sensory systems, an input signal provided by some physical quantity is continuously measured and converted into an electrical signal (the generator potential), whose amplitude is proportional to the input signal. This signal controls the frequency of action potential generation in the impulse initiation region of a sensory nerve fiber. Because action potentials are of a constant height and duration, the amplitude information of the original input signal is now in the form of a frequency of action potential generation. Perception The interpretation of encoded and transmitted information into a perception requires several other factors. For this reason, for example, all information arriving on the optic nerves is interpreted as light, even though the signal may have arisen as a result of pressure applied to the eyeball. The remainder of this chapter deals with specific sensory receptors, including those of both the somatosensory system (i. These sensory receptors cover the skin and epithelia, skeletal muscles, bones and joints, and internal organs. The system responds to a number of diverse stimuli using the following receptors: mechanoreceptors (movement/pressure), chemoreceptors, thermoreceptors, and nociceptors. Signals from these receptors pass via sensory nerves through tracts in the spinal cord and into the brain. Neural information is processed primarily in the somatosensory area in the parietal lobe of the cerebral cortex (see Chapter 7 for details). The skin has a rich supply of sensory receptors that provide cutaneous sensations, such as touch (light and deep pressure), temperature (warmth and coldness), and pain. Cutaneous receptors can be mapped over the skin by using highly localized stimuli of heat, cold, pressure, or vibration. These areas are correspondingly well represented in the somatosensory area of the cerebral cortex (see Chapter 7). Touch Several types of sensory receptors are involved in the sensation of touch (Fig. Three of these receptors (Merkel disk, Meissner corpuscles, and Pacinian corpuscles) are distributed on various areas of the skin but are concentrated in regions void of hair (e. The nerve endings of these receptors respond to pressure and texture; therefore, they are classified as mechanoreceptors. When these receptors are deformed, either due to pressure or release of pressure, they cause receptor potentials to be generated by opening pressure-sensitive cation ion channels in the axon membrane, which allows an influx of positive ions resulting in the eventual formation of an action potential in the sensory neuron. Cutaneous receptors providing a sense of touch, pressure, stretch, and vibration are the Merkel disk, Meissner corpuscle, Pacinian corpuscle, Ruffini corpuscle, and the hair follicle receptor. The Merkel disks are receptors (located in the lowest layer of the epidermis) that exhibit slow adaptation and also respond to steady pressure. These receptors provide information about an object’s qualities like edges or its curves. The Meissner corpuscle is a cutaneous touch receptor that mediates the sensation of light touch. These receptors are distributed on various areas of the skin but are concentrated in areas sensitive to light touch, such as fingertips, lips, and nipples. The Meissner corpuscle is a capsule surrounding the ending of a sensory nerve (or nerves) that wind between stacks of flattened Schwann cells in the capsule interior. These Schwann “cushions” dissipate deformation of the nerve endings caused by sustained points of pressure on the skin. The Pacinian corpuscle is a very highly adaptive receptor that is responsible for sensitivity to pressure. These receptors comprise nerve endings surrounded by multiple gel-like envelopes within capsules that act collectively as a mechanical filter. When the capsule is deformed, for example, by a point of pressure, the underlying nerve ending is deformed and generates an electrical potential. However, the multiple gel envelopes almost immediately equalize pressure surrounding the nerve, thus removing any local deformation. The nerve ending only deforms again to generate an electrical potential when the initial deforming pressure is suddenly released. Thus, the Pacinian corpuscle best detects the beginning and ending of a rapidly changing local pressure on the skin. This makes these receptors especially suited for detecting fast-changing stimuli such as vibrations. Thermoreceptors are sensory nerve endings that code for absolute and relative temperatures. Humans can discriminate a wide range of innocuous and noxious skin temperatures that are sensed by temperature receptors (thermoreceptors). The density of temperature receptors differs at various places on the body surface. They are present in much lower numbers than cutaneous mechanoreceptors, and there are many more cold receptors than warm receptors. The adequate stimulus for a warm thermoreceptor is warming, which results in a concomitant increase in rate of firing of its action potentials. Conversely, cooling results in a decrease in the action potential discharge rate of the warm receptor. The perception of temperature stimuli is closely related to the properties of the receptors. The phasic component of the response is apparent in our adaptation to sudden immersion in, for example, a warm bath. The sensation of warmth, apparent at first, soon fades away, and a less intense impression of the steady temperature may remain. Moving to somewhat cooler water produces an immediate sensation of cold that soon fades away. Over an intermediate temperature range (the “comfort zone”), there is no appreciable temperature sensation. This range is approximately 30°C to 36°C for a small area of skin; the range is narrower when the whole body is exposed. Outside this range, steady temperature sensation depends on the ambient (skin) temperature. Cold pain can be activated under certain abnormal conditions, such as with peripheral neuropathy or from chemotherapy. Severely diabetic patients who suffer from peripheral neuropathy and patients who undergo chemotherapy can exhibit a cold-induced pain response when they touch a cool object. At very high skin temperatures (>45°C), there is a sensation of paradoxical cold, caused by nonspecific activation of a part of the innocuous cold receptor population.
Biological substitutes are acellular or cellular: There is a high incidence of hypertrophic scarring zenegra 100mg low cost erectile dysfunction pills cheap, so they should be excised to a viable acellular: allograft (glycerol preserved) generic zenegra 100 mg fast delivery erectile dysfunction early 20s, depth and skin grafted within 5–10 days buy zenegra 100mg visa erectile dysfunction specialists. Non-biological substitutes are Integra (dermal Unless they are very small so that healing can substitute) and biobrane order zenegra 100mg without prescription erectile dysfunction surgical treatment options. Essentials of burn reconstruction Requires a strong patient–surgeon relationship Timing of surgery and psychological support. Early excision Start with a ‘winner’, an easy and quick of the burn is essential as it terminates the physio- operation. Urgent procedures Fascial excision is a faster technique with less Exposure of vital structures (such as eyelid blood loss, but more tissue is removed resulting releases). After burn excision, wound coverage is required either to achieve healing or to act as a temporary Essential procedures dressing and reduce loss of exudate and develop- Reconstruction of function (such as a limited ment of infection, while the donor sites regenerate range of motion). Split skin graft (autograft) Desirable procedures Sheet grafts provide a superior cosmetic and Reconstruction of passive areas. High voltage Outpatient follow-up should be regular and High voltage burns occur as a result of injury from comprehensive. Electrical injuries are divided into three groups: low Lightning voltage, high voltage and lightning strike. These injuries result from an ultra-high tension, Low voltage high amperage, short duration electrical discharge of direct current. The energy imparted from 240 V usually gives a A direct strike is when the discharge is through the deep burn in the form of a small entry and exit victim and this has a high mortality. If alternating current crosses the strikes an object of high resistance such as a tree myocardium, arrhythmias may arise. If the electro- and the current is then deflected through a victim cardiogram is normal and there is no history of loss on its way to the ground. Hydrofluoric acid penetrates tissues deeply and All electrical burns should be referred to a Burns can cause fatal systemic toxicity even in small burns. Unit They should be treated immediately with copious lavage and topical calcium gluconate gel. Systemic calcium may be required as hydrofluoric acid seques- ters calcium with the burn. Progressive injury dehydrates the cells and denatures the collagen Alkali burns and protein. Often the onset of pain is delayed, Common household alkalis such as bleaches, thus postponing first aid and allowing more tissue cleaning agents and cement cause a liquefactive damage. Burnand The common causes of civilian trauma are road trauma teams, based at trauma centres, has been to traffic, household, work place (especially the con- reduce early deaths from injury by providing rapid struction industry) and sports accidents plus help and resuscitation at or close to the point of civilian violence. Military and police in the first ‘golden hour’ would reduce the mortality force injuries mainly occur as a consequence of war of serious injury. The overall process can be summarized as: circulation) – is followed by rapid transfer to the nearest emergency department or base hospital. Assess the cause and extent Running parallel and associated with this pathway of the injury/accident is triage – priority selection: first, at the place of injury It has to be recognized that initial estimates of the (especially when many patients are injured at once); number of casualties are often inaccurate because second, in the A&E (where priority must be given of confused communications and the shock experi- to the resuscitation of the most severely injured); enced at the scene of the disaster by many of those and third for treatment, especially when facilities are involved, including the eye witnesses. It should also limited and priority must be given to patients who be remembered that it may take some time to reach require urgent intervention to save their lives. Catastrophic circumstances any fall can be relayed to the trauma centre (a soft landing area can result in a favourable outcome). Exsanguinating bleeding should be stopped Inform the recipient emergency whenever possible by direct digital pressure or in services military casualties the application of a tourniquet applied by a buddy. After a major injury alert, the emergency services The value of local pressure in preventing arterial will ask the major trauma centres (often more than haemorrhage has been recognized by the first-aid one if a large number of injuries are expected) to manuals for many years. When a small number war injuries made before the 1950s showed their of casualties is expected, one or more trauma teams use to be associated with a high rate of subsequent should be assembled. To stay alive ischaemia they caused made arterial reconstruction a patient must be able to breathe, for which they worthless. The maximum period of application Similarly, there is no point in being able to should be kept below 6 hours to avoid an inevita- breathe if the patient is engulfed in a poisonous gas ble amputation. Airway this with the statement that the first-aider’s first task was to ‘remove the cause from the patient or, if The airway should be assessed and secured first, this was not possible, the patient from the cause’. Clinical assessment and treatment at the site of injury 115 Although the importance of damage to the spinal under direct vision. Vomit and blood runs to the cord by moving an unstable cervical spine while back of the throat and can only be removed with attempting to clear the airway has been emphasized a sucker. Nevertheless, every effort A Guedel airway should be inserted if this is should be made to stabilize the cervical spine while available (Fig 6. Unconscious patients should have their airway Alternatives include the insertion of a laryngeal cleared of any obstructing agent (e. Breathing Once an open airway has been established, breath- ing can be taken over by a bag valve mask or by direct connection to the tube. An inflation bag giving oxygen at 10–12L per minute can be used to control ventilation until a mechanical ventilator becomes available. The cervical spine must be immobilized while airway access is obtained and ventilation com- menced by manual support of the neck in the early stages or by the application of a cervical collar (Fig 6. Once the patient has been intubated, the cervical spine protection must be continued. Patients should be transferred lying on a rigid board with their neck in a neutral position. This following neck protection policies at the expense approach reduces the risk of entering the vicious of preventing other major causes of mortality such circle of raising the blood pressure, restarting bleed- as overt bleeding has probably cost lives. It may of breathing and the C of circulation should take also avoid the marked reduction of mesenteric and precedence in patients with limb injuries and no renal perfusion, which is the normal homeostatic evidence of head or neck injuries. Circulation mum also reduces the complications of interstitial fluid overload – heart failure, pulmonary oedema, Almost all patients who have a major injury will be peripheral oedema and paralytic ileus – and pre- in ‘hypovolaemic shock’ as evidenced by the pres- vents the dilution of clotting factors, which may ence of tachycardia, hypotension, pale and clammy ultimately lead to more bleeding problems. The treatment of shock requires resto- Animal experiments suggest that the rapid res- ration of the circulation. Two intravenous cannulae toration of blood volume results in a lower mortal- should be inserted, one in each antecubital fossa. It seems probable tive route for filling the circulation if a peripheral that both approaches may be beneficial in differ- vein cannot be cannulated. Another alternative is to cut down als probably benefit from an early and complete over, expose and insert a catheter directly into the restoration of their blood volume, whereas elderly long saphenous vein at the ankle. Hartmann’s or Ringer’s lactate should be rapidly Fractured limbs should be stabilized by inflat- infused. Fluid infusion should be given if available, especially if the wounds are be slowed when the systolic blood pressure reaches extensive and heavily contaminated. It Before transfer, wounds should be covered (espe- was originally thought that fluid administration cially chest wounds). Pressure dressings or digital should continue to maintain the blood pressure at a pressure may be appropriate. The rationale was that this would enable United Kingdom is the ambulance, which has the patient to better overcome a rapid decompensa- usually been summoned by an eye witness with a tion from further bleeding and reduce the risk of mobile phone. Satellite locating devices now allow developing some of the complications of prolonged a rapid response to a recognized position.
