Clinical Practice Points
This study found that giving participants a choice between 2 diets did not improve
weight loss, dietary adherence, or weight-related quality of life.
Use this study to:
- Ask your learners what they tell patients regarding the best approach to dieting.
Do they know what a low-carbohydrate diet really involves? How about a Mediterranean
diet? Does the choice matter? In what way?
- Suggest to your learners that they each try one of the diets described in this trial
for the next week. Then, ask them how they did. Did they adhere to their selected
diets? Was it difficult? What were the challenges? Did this experience change how
they will discuss (or think about) their patients' ability to diet?
- Ask what the results of this randomized trial tell us regarding the choice of diet.
Do your learners think the results might have differed if participants had been provided
more than two choices of diet to follow?
- Invite a nutritionist to discuss dietary counseling and healthy eating habits. Review
low-fat versus low-carbohydrate diets. Plan with your learners how they will help
their patients choose a weight-loss strategy—does this study make them more
or less likely to let their patients choose?
Initiation of antiretroviral therapy (ART) for HIV-1 infection is associated with
a loss in bone mineral density (BMD) of 2% to 6%. This trial found that vitamin D3
plus calcium supplementation mitigated bone loss associated with ART initiation.
Use this study to:
- Review the potential side effects and toxicities of antiretroviral agents. Use ACP Smart Medicine: HIV. There is a Table “Drug Treatment for HIV Infection,” as well as a
link to download the 2015 Department of Health and Human Services guidelines for the
use of antiretroviral agents in HIV-1-infected adults and adolescents (in the “Evidence”
section of the “Follow-up” tab).
- 90% of the participants in this randomized trial were men. Why is that important when
considering applying the results in practice? Are there reasons why the results may
have differed in women? Ask how your learners will use these data to inform their
practice, particularly in women beginning anti-retroviral therapy.
- Review bone metabolism with your learners. Who is at risk for osteopenia or osteoporosis?
How is a bone density test interpreted? What prevention strategies are available for
those at risk?
These papers evaluate current evidence regarding the diagnosis and treatment of myalgic-encephalomyelitis/chronic
fatigue syndrome and point to substantial deficiencies in our knowledge of this frequently
debilitating, and frustrating, disease.
Use these papers to:
- Start a teaching session with a multiple-choice question. We've provided one below.
- Ask your learners why some physicians have dismissed myalgic-encephalomyelitis/chronic
fatigue syndrome, and considered it a “psychological” problem? Is that
fair? Is such an attitude harmful?
- Read the accompanying editorial, “Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: A Real Illness” in which the author succinctly reviews the biological abnormalities that
have been identified in association with this disease.
- In a recent Annals for Educators Alert we suggested you ask your learners how changing the name of this disease to “systemic
exertion intolerance disease”, as suggested by the IOM, might be helpful. The
editorialist argues that it will be. Do your learners agree? Review the differential
diagnosis and evaluation of fatigue, and ask your learners if they think they could
differentiate systemic exertion intolerance disease from other causes of fatigue.
A 32-year-old woman is evaluated following a diagnosis of chronic fatigue syndrome.
She has a several-year history of chronic disabling fatigue, unrefreshing sleep, muscle
and joint pain, and headache. A comprehensive evaluation has not identified any other
medical condition, and a screen for depression is normal. Her only medications are
multiple vitamins and dietary supplements. Physical examination is normal.
Which of the following is the most appropriate management for this patient's symptoms?
B. Evening primrose oil
C. Graded exercise program
D. Growth hormone
C. Graded exercise program
Effective treatment options for chronic fatigue syndrome include graded exercise programs
and cognitive-behavioral therapy.
Manage chronic fatigue syndrome.
The most appropriate management for this patient is to begin a graded exercise program.
Chronic fatigue syndrome (CFS) is defined as medically unexplained fatigue that persists
for 6 months or more and is accompanied by at least four of the following symptoms:
subjective memory impairment, sore throat, tender lymph nodes, muscle or joint pain,
headache, unrefreshing sleep, and postexertional malaise lasting longer than 24 hours.
Management of CFS is challenging and is geared toward managing symptoms and maintaining
function, rather than seeking cure. A comprehensive, individually tailored approach
is required, typically based on nonpharmacologic therapy, such as lifestyle modification
and sleep hygiene. Specific treatment options that have been demonstrated to improve
symptoms include graded exercise programs and cognitive-behavioral therapy (CBT).
CBT in this setting is targeted in part at breaking the cycle of effort avoidance,
decline in physical conditioning, and increase in fatigue, and can work well in combination
with graded exercise in this regard. CBT reduces fatigue and improves functional status.
Although Epstein-Barr virus and a host of other infectious agents have been considered
in the pathogenesis of CFS, none have been borne out by careful study; therefore,
antiviral therapy, including acyclovir, has no role in the treatment of CFS. A variety
of other medications have been tried, including corticosteroids, mineralocorticoids,
growth hormone, and melatonin, but with no clear evidence of benefit, and are not
indicated for this patient.
Current evidence is not sufficiently robust to recommend dietary supplements, herbal
preparations (evening primrose oil), homeopathy, or even pharmacotherapy. Patients
with concomitant depression should be treated with antidepressants. Although no specific
class of antidepressant is recommended in this setting, tricyclic antidepressants
are often utilized in patients with CFS and depression owing to their adjunct effectiveness
in treating muscle pain.
Reid S, Chalder T, Cleare A, Hotopf M, Wessely S. Chronic fatigue syndrome. Clin Evid
(Online). 2011;05:(1101)1-52. PMID: 21615974 PMID:
This question was derived from MKSAP® 16, the latest edition of the Medical Knowledge Self-Assessment Program.