Annotations possible and, second, the renal vein renin tests were performed in the supine position and after administration of oral furosemide (1 mg./Kg. body weight) on the afternoon before the test. Such slight stimulation of the renal vein renin ratios may have been inadequate to demonstrate overproduction of renin by the involved kidney. Thus, although there is some evidence to support the existence of such a syndrome in various animal models,” its existence in man still remains to be conclusively proven. E.P. MacCarthy, M.R.C.P.I. G.S. Stokes, M.D. Cardio-Renal Unit Kanematsu Memorial Institute Sydney Hospital Sydney, N.S. W., 2000 Australia REFERENCES 1.

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The reviving of the apparently dead has long been a popular subject in the public imagination, particularly since the development of closed-chest massage and external defibrillation. Physicians must be prepared to analyze the results in order to avoid being carried away by the excessive enthusiasm generated by even an occasional success. It is essential for due regard to be given to the most efficient employment of resources, and to the suffering inflicted on the relatives of patients when prolonged attempts at resuscitation are made in the face of an inevitably hopeless outcome. Resuscitation is more likely to be successful in coronary and intensive care units,’ and there is no doubt that in such circumstances a very energetic policy must be pursued. In the more general areas of the hospital, however, the position is less clear. A ten-year survey of the results of resuscitation in such areas has recently been carried out at the Central Middlesex Hospital in London.2 The cases studied were those treated by the hospital’s cardiac arrest service, excluding patients in the coronary care and intensive therapy units. Successful resuscitation was defined as survival of the patient to be discharged alive from hospital. In the ten-year period there were 93 survivors out of 1,063 cardiac arrest cases. The 80 patients from the first nine years of the survey were followed up for at least one year and information was collected about their subsequent health. An actuarial life table showed an annual mortality rate of 7 per cent in the survivors, a figure similar to that following uncomplicated myocardial infarction3 Assessment was made of their physical condition and only four of the 80 subjects showed significant deterioration of their health or working capacity due to the arrest, and all these four died

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Bourgoignie, J., Kurz, S., Catanzaro, F. J., Serinat, P., and Perry, H. M.: Renal venous renin in hypertension, Am. J. Med. 48:332, 1970. Marks, L. S., and Maxwell, M. H.: Renal vein renin. Value and limitations in the prediction of operative results, Urol. Clin. North Am. 2:311, 1975. Stokes, G. S., Weber, M. A., Gain, J., Scott, A. J.,

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Roberts, B. A., and Sheil, A. G. R.: Diazoxide-induced renin release in diagnosis of remediable renovascular hypertension, Aust. N.Z. J. Med. 626, 1976. Maxwell, M. H., Bleifer, K. H., Franklin, S. S., and Varady, P. D.: Co-operative study of renovascular hypertension. Demographic analysis of the study, J.A.M.A. 220:1195, 1972. Streeten, D. H. P., Anderson, G. H., and Dalakos, T. G.: Angiotensin blockade: Its clinical significance, Am. J. Med. 60:817, 1976. Keenan, R. E.: Test for role of angiotensin in hypertension, N. Engl. J. Med. 291:258, 1974. Thomas, R. D., Ball, S. G., and Lee, M. R.: Failure of saralasin to predict a response to surgery in renovascular hypertension, Lancet 1:724, 1977. Streeten, D. H. P., Anderson, G. H., Freiberg, J. M., and Dalakos. T. G.: Use of ansiotensin II antagonist (Saralasin) in the recognition if “angiotensinogknic” hypertension, N. Engl. J. Med. 292:657, 1975. Marks, L. S., Maxwell, M. H., and Kaufman, J. J.: Nonrenin-mediated renovascular hypertension: A new syndrome? Lancet 1:615, 1977. MacCarthy, P. and Stokes, G.: Non-renin-mediated renovascular hypertension, Lancet 1:1312, 1977. Davis, J. 0.: The pathogenesis of chronic renovascular hypertension, Circ. Res. 40:439, 1977.

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within 30 months of it. In the remaining survivors, the good quality of life was impressive. The most significant factor influencing the outcome is the primary diagnosis. The success rate ranges from 22 per cent in drug overdose cases to 20 per cent in surgical cases and 15 per cent in myocardial infarction cases. In contrast, following severe generalized trauma or advanced neurological .disease the success rate was less than 2 per cent. Patients whose arrest complicated such conditions as cardiac failure, pulmonary embolism, or respiratory failure, fell into an intermediate group of between 4 per cent and 8 per cent. There were no long-term survivors after cardiac arrest as a complication of head injury or subarachnoid hemorrhage. Thirty-six per cent of the arrests occurred in the Accident and Emergency Department, 58 per cent were in the wards of the hospital, and most of the remainder in the operating theatres. The over-all success rate was highest in the Emergency Department, but this was due entirely to the large number of cases of myocardial infarction who suffered cardiac arrest there. Of the 93 survivors of the whole series, 54 had arrested due to myocardial infarction in the Emergency department. The majority of the patients included in this series were aged between 50 and 70 years. Because of the concentration of the more favorable diagnostic categories in this age group, the success rate was highest in these two decades. In earlier decades respiratory, traumatic and neurological causes were predominant with fewer survivors.’ The numbers of cases of myocardial infarction in the Emergency Department were sufficiently large to show that age was without influence on

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the survrva: rate in that particular category. Attempts at resuscitation were made in 216 patients over the age of 70 with a long-term survival rate of 4.7 per cent. Although the over-all success rate in this large series was low, the subsequent general condition and life expectancy of the survivors was good. The findings suggest that greater emphasis must be placed on the circumstances of each arrest. Clearly the primary diagnosis is paramount and rather less attention should be paid to location or, in particular, to the age of the patient. The best service must be provided in the Emergency Department, and a policy of energetic resuscitation should be mandatory there. In other parts of the hospital, and especially in certain diagnostic categories, the results of resuscitation are so poor that a much more selective approach would appear to be indicated. Richard Peayield, M.A., M.R.C.P. Cardiothoracic Department Central Middlesex Hospital London N. W.10 England

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Coskey, R. L.: il resuscitation progrtim iri 4 ::ommunity hospitai-five year experience, Geriatrics 2 Peatfield, Ft. C., Sillett, R. W., ‘I’aylor, D. ?Vi. W,: Survival after cardiac arrest in hospital, Lancet a:: 1223, 1977. Beard, 0. W., Wipp, H. R., Robins, M., ahd Verzohni, V. R.: Initial myocardial infarction among veterans: Tenvear survival, AM. HEART J. 733317, 1967. ;%ldsmith, J. A. W., Dennyson, W. G., anti Myers, K. W.: Results of resuscitation following car&at: arrest. A review from a major teaching hosgtai, Hr. J. Anaesth. 1716. 1972.

Towards more selective resuscitation.

Annotations possible and, second, the renal vein renin tests were performed in the supine position and after administration of oral furosemide (1 mg./...
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