Hospital practice (1995)
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Hospital practice (1995) · May 1997
Case ReportsTherapeutic options in atrial flutter and fibrillation.
Newer antiarrhythmic agents can control atrial flutter and fibrillation in many patients, although individual episodes may require cardioversion. Catheter ablation is often curative for refractory flutter. Ablation of atrial fibrillation is more difficult, because of its different mechanism. Surgical and catheter-based ablation procedures have been pioneered for fibrillation but remain experimental.
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A 52-year-old woman was admitted to the hospital with a rash, periorbital edema, dysphagia, and muscle weakness. The rash had appeared on the back of her neck nine months earlier, and because she had recently returned from a wildlife preserve on Assateague Island, Maryland, she assumed that it was due to tick bites. Over the next two months, the rash spread to her forehead, back, chest, and upper extremities, and scaly lesions appeared over metacar-pophalangeal joints. ⋯ She became feverish and increasingly fatigued, depressed, and irritable. These later symptoms were attributed to the medication, but when she was weaned from it, her rash, weakness, and dysphagia increased. Over the ensuing months, she was given intramuscular injections of methotrexate (up to 25 mg/wk), followed by oral doses of hydroxychloroquine and azathioprine, but the symptoms persisted.
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Choices about referrals, tests, and prescriptions offer physicians many opportunities to reduce health care costs. Some commonsense measures are described, and the principles to which cost-effectiveness analyses should adhere are explained.