Fatigue resident survival guide

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Fatigue
Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Tayyaba Ali, M.D.[2]Mounika Lakhmalla, MBBS[3]Ramyar Ghandriz MD[4]

Synonyms and keywords:Approach to weakness, Approach to tiredness, Approach to lethargy, Approach to debility

Overview

Fatigue is a common nonspecific symptom due to a wide range of etiologies. Patients often use this term to describe a range of issues like difficulty initiating activity; decreased capacity to maintain activity; Trouble with concentration, memory, and emotional stability; or sleepiness or an uncontrollable need to sleep. The term fatigue can sometimes be used synonymously with Tiredness. Fatigue can present alone as a primary symptom or in association with other localizing symptoms.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

Common Causes

  • Multiple sclerosis
  • After malignancy treatment, patients can experience different patterns of fatigue from chemotherapy, radiation treatment, or surgery.

Diagnosis

The approach to the diagnosis of fatigue is based on a step-wise testing strategy. Below is an algorithm summarising the identification and laboratory diagnosis of fatigue.

  • Diagnostic evaluation of fatigue when it presents as a predominant symptom includes a detailed history and physical examination, basic laboratory studies, and updated cancer screening interventions.
  • Additional diagnostic testing depends on associated localized findings.
  • Extensive laboratory studies without a suggestive history or physical exam findings is of limited diagnostic utility while evaluating chronic fatigue.


 
 
 
 
 
 
 
 
 
 
 
 
Seek proper history, ask patients to describe in their own words, what do they mean by fatigue?
This will help distinguish fatigue from
somnolence
muscle weakness
The history should also determine the characteristics, severity, and temporal pattern of fatigue:
❑ Onset – Abrupt or gradual, relationship to illness or life event
❑ Course – Stable, improving, or worsening
❑ Duration and daily pattern
❑ Factors that alleviate or exacerbate it
❑ Impact on daily life – Ability to work, socialize, participate in family activities
❑ Accommodations that the patient/family has had to make to deal with symptom
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Characterize the cardiac symptoms:
Dyspnea on exertion
Orthopnea
❑ Leg swelling
 
Characterize the pulmonary symptoms:
❑ Dyspnea
❑ Chronic cough
❑ Sputum production
❑ Snoring
❑ Interrupted breathing during sleep
 
Characterize the endocrinologic / metabolic symptoms:
Cold intolerance
Weight gain
Constipation
❑ Dry skin
Heat intolerance
Weight loss
❑ Diarrhea
❑ Moist skin
❑ Nausea/vomiting
❑ Mental status changes
❑ Decreased urine
❑ Abdominal distention
❑ Gastrointestinal bleeding
❑ Salt craving
❑ Gastrointestinal complaints
❑ Malaise
❑ Cognitive dysfunction
Anorexia
Polydipsia/polyuria
 
Characterize the hematologic / neoplastic symptoms:
❑ Dizziness
❑ Weakness
Palpitations
Dyspnea
❑ Weight loss
 
Characterize the Infectious diseases symptoms:
❑ Fever/chills
❑ Sore throat
❑ Tender lymph nodes
❑ Nausea/vomiting
❑ Abdominal discomfort
Weight loss
Night sweats
❑ Myalgias
 
Characterize the rheumatologic symptoms:
❑ Chronic diffuse muscle pain
❑ Aching/morning stiffness of shoulders, neck, and hips
 
Characterize the psychological symptoms:
❑ Sad mood
Anhedonia
❑ Altered sleep
❑ Cognitive dysfunction
❑ Generalized nervousness
Panic attacks
Phobias
❑ Multiple chronic constitutional and localized complaints
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:
❑ Elevated jugular venous distension
❑ Peripheral edema
❑ S3 gallop
❑ Inspiratory rales
 
Examine the patient:
❑ Evidence of hyperinflation
Wheezing
Rales
Obesity
❑ Hypertension
 
Examine the patient:
Bradycardia
Goiter
❑ Slow deep tendon reflex relaxation phase
Tachycardia
❑ Ophthalmopathy
❑ Hypertension
❑ Peripheral edema
Jaundice
Palmar erythema
Gynecomastia
Splenomegaly
❑ Evidence of ascites
❑ Hypotension
❑ Hyperpigmentation
❑ Vitiligo
 
Examine the patient:
Tachycardia
Pallor
 
Examine the patient:
Fever
❑ Exudate pharyngitis
❑ Tender cervical adenopathy
Jaundice
❑ Tender hepatomegaly
❑ New (regurgitant) murmur
Cough
Chest pain
❑ Dyspnea
Hemoptysis
 
Examine the patient:
❑ Multiple "tender points" on palpation
❑ Decreased range of motion of shoulders, neck, and hips
 
Examine the patient:
❑ Tachycardia
❑ Muscle tension
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnostic work-up:
❑ Chest radiograph
❑ Echocardiogram
 
Diagnostic work-up:
❑ Chest radiograph
❑ Sleep study
 
Diagnostic work-up:
Thyroid function tests
Renal function tests/ serum electrolytes
Hepatic function tests
❑ Morning cortisol/ACTH, ACTH stimulation test
❑Serum sodium level
❑Serum calcium level
 
Diagnostic work-up:
Complete blood count
 
Diagnostic work-up:
❑ Complete blood/differential count
❑ Monospot
Hepatic function tests
❑ Viral hepatitis serologies
HIV serology
❑ Blood cultures
Echocardiogram
❑ PPD/gamma-interferon assay
❑ Chest radiograph
 
Diagnostic work-up:
Erythrocyte sedimentation rate
 
Diagnostic work-up:
❑ Screening tests (eg, PHQ-2, PHQ-9, GAD-7, SSS-8
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider differential diagnosis:
Congective heart failure
Atypical angina [1]
 
Consider differential diagnosis:
Chronic obstructive pulmonary disease [2]
Sleep apnea [3]
 
Consider differential diagnosis:
Hypothyroidism [4]
Hyperthyroidism [5]
❑ Inflammatory bowel disease [6]
Chronic renal disease [7]
Chronic hepatic disease [8]
Adrenal insufficiency [9]
Hyponatremia [10]
Hypercalcemia [11]
 
Consider differential diagnosis:
Anemia [11]
Occult malignancy [12]
 
 
 
Consider differential diagnosis:
Depression [20]
Anxiety disorder [21]
Somatization disorder [22]

Treatment

.

 
 
 
 
 
 
 
 
 
 
 
 
Treat the underlying causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fatigue due to heart failure[23][24][25][26] :
❑Diuretics
❑Vasodilator Therapy
❑Inotropic Therapy
❑Vasopressor Support
❑ACE Inhibition
❑Beta Blockers
❑Aldosterone Antagonism
❑Morphine
Fatigue due to stable angina[27]:
❑Antiplatelet agents
❑Antianginal agents
❑ACEI/RAAS Blockers
 
Ftigue due to Chronic obstructive pulmonary disease[28][29][30].:
❑Beta Adrenergic Receptor Agonists
❑Long Acting Beta-2 Adrenergic Receptor Agonist
❑Anticholinergics
❑Phosphodiesterase Inhibitor
❑Steroid
❑Antibiotics
❑Mucolytic
Fatigue due to sleep apnea[31].[32][33][34][35]:
❑Weight loss
❑Continuous positive airway pressure
❑Oral appliances
❑Modafinil 200-400 mg per day
❑Acetazolamide
 
Fatigue due to hypothyroidism:.[36][37][38]
❑Synthetic T4(Levothyroxin)
Fatigue due to hyperthyroidism:[39]
❑Beta blockers
❑Methimazole
❑Propylthiouracil
Fatigue due to Chronic Renal Failure[40]:
❑Blood pressure management
❑Kidney Transplant
 
Fatigue due to anemia:
❑Blood transfusion,
❑Iron transfusion
❑Folate therapy
❑Vit B12
 
Fatigue due to Mononucleosis
NSAID
❑Intravenous corticostreoid
Acyclovir
❑Opioid analgesics
Fatigue due to Viral Hepatitis:
❑Entecavir
❑Tenofovir
❑Interferon-α 2b
❑PegIFNα
❑Telbivudine
❑Adefovir
❑Lamivudine
Fatigue due to Endocarditis:
❑Empiric antibiotics
❑Antithrombotic therapy
 
Fatigue due to Fibromyalgia:
❑Amitriptiline
❑Cyclobenzaprine
❑Dulexitine
❑Minlacipran
❑Pregabalin
Fatigue due to Polymyalgia:
❑Glucocorticosteroids
Fatigue due to Rheumatoid artheritis
❑Leflunomide
❑Sulfasalazine
❑Hydroxycloroquine
❑Rituximab
❑Tocolizumab
❑Azathioprim
❑Cyclosporine
❑Anakirna
❑Abatacept
❑Baricitinib
❑DMARDS
Fatigue due to Sjögren's syndrome
❑Pilocarpine
❑Cevimeline
❑Methotroxate
 
Fatigue due to Mood disorders
❑CBT
❑Anti depresant therapy
❑Anxiolytic therapy

Do's

  • Though most of the conditions presenting with fatigue have the luxury of time for appropriate evaluation & Treatment, a few may require Immediate diagnosis & Treatment to prevent death or serious sequelae.
  • In case of Cardiovascular emergencies: In symptomatic Heart failure secondary to atrial fibrillation, Hemodynamically unstable patients require urgent direct-current Cardioversion.
  • Endocrine disorders: Diabetic ketoacidosis or nonketotic hyperglycemic states require urgent correction of Blood sugar levels, acidosis, electrolyte & Fluid imbalances.
  • Infectious disease
    • Untreated tuberculosis: respiratory failure and systemic spread of disease in immunocompromised individuals.
    • HIV, if not diagnosed or treated appropriately with antiretroviral drugs, may result in overt AIDS and eventually death.
    • Coronavirus disease 2019 (COVID-19)
      • Patients may develop severe viral pneumonia leading to acute respiratory distress syndrome that is potentially fatal.
      • Suspected COVID-19 infection should be isolated from others, along with Contact and droplet precautions, airborne precautions if performing aerosol-generating procedures.

Don'ts

  • Extensive laboratory work-up is rarely helpful in the absence of suggestive signs and symptoms.
  • Mannitol is Contraindicated in fatigue treatment.

References

  1. Smith OR, Michielsen HJ, Pelle AJ, Schiffer AA, Winter JB, Denollet J (2007). "Symptoms of fatigue in chronic heart failure patients: clinical and psychological predictors". Eur J Heart Fail. 9 (9): 922–7. doi:10.1016/j.ejheart.2007.05.016. PMID 17631047.
  2. Theander K, Unosson M (2004). "Fatigue in patients with chronic obstructive pulmonary disease". J Adv Nurs. 45 (2): 172–7. doi:10.1046/j.1365-2648.2003.02878.x. PMID 14706002.
  3. Vgontzas AN, Papanicolaou DA, Bixler EO, Hopper K, Lotsikas A, Lin HM; et al. (2000). "Sleep apnea and daytime sleepiness and fatigue: relation to visceral obesity, insulin resistance, and hypercytokinemia". J Clin Endocrinol Metab. 85 (3): 1151–8. doi:10.1210/jcem.85.3.6484. PMID 10720054.
  4. Louwerens M, Appelhof BC, Verloop H, Medici M, Peeters RP, Visser TJ; et al. (2012). "Fatigue and fatigue-related symptoms in patients treated for different causes of hypothyroidism". Eur J Endocrinol. 167 (6): 809–15. doi:10.1530/EJE-12-0501. PMID 22989469.
  5. Kaltsas G, Vgontzas A, Chrousos G (2010). "Fatigue, endocrinopathies, and metabolic disorders". PM R. 2 (5): 393–8. doi:10.1016/j.pmrj.2010.04.011. PMID 20656620.
  6. Qazi T (2020). "Fatigue in inflammatory bowel disease: a problematic ailment". Curr Opin Gastroenterol. 36 (4): 284–294. doi:10.1097/MOG.0000000000000644. PMID 32398564 Check |pmid= value (help).
  7. Jhamb M, Liang K, Yabes J, Steel JL, Dew MA, Shah N; et al. (2013). "Prevalence and correlates of fatigue in chronic kidney disease and end-stage renal disease: are sleep disorders a key to understanding fatigue?". Am J Nephrol. 38 (6): 489–95. doi:10.1159/000356939. PMC 3925636. PMID 24335380.
  8. Dwight MM, Kowdley KV, Russo JE, Ciechanowski PS, Larson AM, Katon WJ (2000). "Depression, fatigue, and functional disability in patients with chronic hepatitis C." J Psychosom Res. 49 (5): 311–7. doi:10.1016/s0022-3999(00)00155-0. PMID 11164055.
  9. Colombo C, De Leo S, Di Stefano M, Vannucchi G, Persani L, Fugazzola L (2019). "Primary Adrenal Insufficiency During Lenvatinib or Vandetanib and Improvement of Fatigue After Cortisone Acetate Therapy". J Clin Endocrinol Metab. 104 (3): 779–784. doi:10.1210/jc.2018-01836. PMC 6402317. PMID 30383218.
  10. "Correction to Lancet Infectious Diseases 2020; published online April 29. https://doi.org/10.1016/ S1473-3099(20)30064-5". Lancet Infect Dis. 20 (7): e148. 2020. doi:10.1016/S1473-3099(20)30370-4. PMID 32595044 Check |pmid= value (help). External link in |title= (help)
  11. 11.0 11.1 McGill KC, Lau K, Dorfman LJ, Westwick CR, Peterson DL, Gleisner JM, Blakley RL (February 1991). "A comparison of turns analysis and motor unit analysis in electromyography". Electroencephalogr Clin Neurophysiol. 81 (1): 8–17. doi:10.1016/0168-5597(91)90098-i. PMID 1705223.
  12. Howell SJ, Radford JA, Smets EM, Shalet SM (2000). "Fatigue, sexual function and mood following treatment for haematological malignancy: the impact of mild Leydig cell dysfunction". Br J Cancer. 82 (4): 789–93. doi:10.1054/bjoc.1999.1000. PMC 2374403. PMID 10732747.
  13. Katz BZ, Shiraishi Y, Mears CJ, Binns HJ, Taylor R (2009). "Chronic fatigue syndrome after infectious mononucleosis in adolescents". Pediatrics. 124 (1): 189–93. doi:10.1542/peds.2008-1879. PMC 2756827. PMID 19564299.
  14. Poynard T, Cacoub P, Ratziu V, Myers RP, Dezailles MH, Mercadier A; et al. (2002). "Fatigue in patients with chronic hepatitis C." J Viral Hepat. 9 (4): 295–303. doi:10.1046/j.1365-2893.2002.00364.x. PMID 12081607.
  15. "Retraction notice to "Differential impact of diabetes and hypertension in the brain: adverse effects in grey matter" [Neurobiol. Dis., 44 (2011) 161–173, http://dx.doi.org/10.1016/ j.nbd.2011.06.005]". Neurobiol Dis. 68: 229. 2014. doi:10.1016/j.nbd.2014.05.006. PMID 25077353. External link in |title= (help)
  16. Holmes GP, Kaplan JE, Gantz NM, Komaroff AL, Schonberger LB, Straus SE; et al. (1988). "Chronic fatigue syndrome: a working case definition". Ann Intern Med. 108 (3): 387–9. doi:10.7326/0003-4819-108-3-387. PMID 2829679.
  17. Schmoldt A, Benthe HF, Haberland G, Kahn A, Vives JL, Bertrand O, Cottreau D, Marie J, Boivin P, Flohr H, Breull W, Smith RJ, Bryant RG, Koolman J, Karlson P (September 1975). "Digitoxin metabolism by rat liver microsomes". Biochem. Pharmacol. 24 (17): 1639–41. doi:10.1016/0009-8981(76)90051-6. PMID 10.
  18. "Reorganized text". JAMA Otolaryngol Head Neck Surg. 141 (5): 428. 2015. doi:10.1001/jamaoto.2015.0540. PMID 25996397.
  19. Green DJ, Muller S, Mallen CD, Hider SL (2015). "Fatigue as a precursor to polymyalgia rheumatica: an explorative retrospective cohort study". Scand J Rheumatol. 44 (3): 219–23. doi:10.3109/03009742.2014.959047. PMID 25366389.
  20. Visser MR, Smets EM (1998). "Fatigue, depression and quality of life in cancer patients: how are they related?". Support Care Cancer. 6 (2): 101–8. doi:10.1007/s005200050142. PMID 9540167.
  21. Fischler B, Cluydts R, De Gucht Y, Kaufman L, De Meirleir K (1997). "Generalized anxiety disorder in chronic fatigue syndrome". Acta Psychiatr Scand. 95 (5): 405–13. doi:10.1111/j.1600-0447.1997.tb09653.x. PMID 9197905.
  22. Manu P, Lane TJ, Matthews DA (1989). "Somatization disorder in patients with chronic fatigue". Psychosomatics. 30 (4): 388–95. doi:10.1016/S0033-3182(89)72244-1. PMID 2798731.
  23. Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN (2010). "HFSA 2010 Comprehensive Heart Failure Practice Guideline". Journal of Cardiac Failure. 16 (6): e1–194. doi:10.1016/j.cardfail.2010.04.004. PMID 20610207. Retrieved 2013-04-29. Unknown parameter |month= ignored (help)
  24. Gray A, Goodacre S, Newby DE, Masson M, Sampson F, Nicholl J (2008). "Noninvasive ventilation in acute cardiogenic pulmonary edema". N. Engl. J. Med. 359 (2): 142–51. doi:10.1056/NEJMoa0707992. PMID 18614781. Unknown parameter |month= ignored (help)
  25. Peter JV, Moran JL, Phillips-Hughes J, Graham P, Bersten AD (2006). "Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: a meta-analysis". Lancet. 367 (9517): 1155–63. doi:10.1016/S0140-6736(06)68506-1. PMID 16616558. Unknown parameter |month= ignored (help)
  26. Weng CL; Zhao YT; Liu QH; et al. (2010). "Meta-analysis: Noninvasive ventilation in acute cardiogenic pulmonary edema". Ann. Intern. Med. 152 (9): 590–600. doi:10.1059/0003-4819-152-9-201005040-00009. PMID 20439577. Unknown parameter |month= ignored (help); Unknown parameter |author-separator= ignored (help)
  27. Smith SC, Feldman TE, Hirshfeld JW, Jacobs AK, Kern MJ, King SB et al. (2006) ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). Circulation 113 (1):156-75. DOI:10.1161/CIRCULATIONAHA.105.170815 PMID: 16391169
  28. Rice KL, Dewan N, Bloomfield HE, Grill J, Schult TM, Nelson DB, Kumari S, Thomas M, Geist LJ, Beaner C, Caldwell M, Niewoehner DE (2010). "Disease management program for chronic obstructive pulmonary disease: a randomized controlled trial". American Journal of Respiratory and Critical Care Medicine. 182 (7): 890–6. doi:10.1164/rccm.200910-1579OC. PMID 20075385. Retrieved 2012-03-20. Unknown parameter |month= ignored (help)
  29. Dewan NA, Rice KL, Caldwell M, Hilleman DE (2011). "Economic evaluation of a disease management program for chronic obstructive pulmonary disease". Copd. 8 (3): 153–9. doi:10.3109/15412555.2011.560129. PMID 21513435. Retrieved 2012-03-20. Unknown parameter |month= ignored (help)
  30. Chapman KR, Rennard SI, Dogra A, Owen R, Lassen C, Kramer B (2011). "Long-term safety and efficacy of indacaterol, a long-acting β₂-agonist, in subjects with COPD: a randomized, placebo-controlled study". Chest. 140 (1): 68–75. doi:10.1378/chest.10-1830. PMID 21349928. Retrieved 2012-03-19. Unknown parameter |month= ignored (help)
  31. Barbé F, Durán-Cantolla J, Sánchez-de-la-Torre M; et al. (2012). "Effect of continuous positive airway pressure on the incidence of hypertension and cardiovascular events in nonsleepy patients with obstructive sleep apnea: a randomized controlled trial". JAMA. 307 (20): 2161–8. doi:10.1001/jama.2012.4366. PMID 22618923. Unknown parameter |month= ignored (help)
  32. Martínez-García M, Capote F, Campos-Rodríguez F, et al. Effect of CPAP on Blood Pressure in Patients With Obstructive Sleep Apnea and Resistant Hypertension: The HIPARCO Randomized Clinical Trial. JAMA. 2013;310(22):2407-2415. doi:10.1001/jama.2013.281250.
  33. Pedrosa RP, Drager LF, de Paula LK, Amaro AC, Bortolotto LA, Lorenzi-Filho G (2013). "Effects of OSA Treatment on BP in Patients With Resistant Hypertension: A Randomized Trial". Chest. 144 (5): 1487–94. doi:10.1378/chest.13-0085. PMID 23598607.
  34. Johansson K, Neovius M, Lagerros YT, Harlid R, Rössner S, Granath F; et al. (2009). "Effect of a very low energy diet on moderate and severe obstructive sleep apnoea in obese men: a randomised controlled trial". BMJ. 339: b4609. doi:10.1136/bmj.b4609. PMC 2788899. PMID 19959590.
  35. Hsu AA, Lo C (2003). "Continuous positive airway pressure therapy in sleep apnoea". Respirology. 8 (4): 447–54. doi:10.1046/j.1440-1843.2003.00494.x. PMID 14708553. Unknown parameter |month= ignored (help)
  36. McDermott MT (2009). "In the clinic. Hypothyroidism". Ann. Intern. Med. 151 (11): ITC61. doi:10.7326/0003-4819-151-11-200912010-01006. PMID 19949140.
  37. Hollowell JG, Staehling NW, Flanders WD, Hannon WH, Gunter EW, Spencer CA, Braverman LE (2002). "Serum TSH, T(4), and thyroid antibodies in the United States population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III)". J. Clin. Endocrinol. Metab. 87 (2): 489–99. doi:10.1210/jcem.87.2.8182. PMID 11836274.
  38. Aoki Y, Belin RM, Clickner R, Jeffries R, Phillips L, Mahaffey KR (2007). "Serum TSH and total T4 in the United States population and their association with participant characteristics: National Health and Nutrition Examination Survey (NHANES 1999-2002)". Thyroid. 17 (12): 1211–23. doi:10.1089/thy.2006.0235. PMID 18177256.
  39. ADAMS DD (1965). "PATHOGENESIS OF THE HYPERTHYROIDISM OF GRAVES'S DISEASE". Br Med J. 1 (5441): 1015–9. PMC 2166943. PMID 14262190.
  40. Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M; et al. (2006). "ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society". Circulation. 114 (10): e385–484. doi:10.1161/CIRCULATIONAHA.106.178233. PMID 16935995.


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