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June 16, 2015 Issue

Clinical Practice Points

Patient Care
Medical Knowledge
Interpersonal / Communication Skills

Effect of allowing choice of diet on weight loss. A randomized trial.

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?

Patient Care
Medical Knowledge

Vitamin D and calcium attenuate bone loss with antiretroviral therapy initiation. A randomized trial.

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?

Patient Care
Medical Knowledge
Interpersonal / Communication Skills

Diagnostic methods for myalgic-encephalomyelitis/chronic fatigue syndrome: a systematic review for a National Institutes of Health pathways to prevention workshop

Treatment of myalgic encephalomyelitis/chronic fatigue syndrome: a systematic review for the National Institutes of Health pathways to prevention workshop

National Institutes of Health Pathways to Prevention Workshop: advancing the research on myalgic encephalomyelitis/chronic fatigue syndrome

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.

Clinical Guideline

Medical Knowledge
Patient Care
High Value Care

Cervical cancer screening in average risk women: best practice advice from the clinical guidelines committee of the American College of Physicians.

In this best practice advice article, the Clinical Guidelines Committee of the American College of Physicians describes the indications for screening for cervical cancer in asymptomatic, average-risk women aged 21 years or older.

Use this study to:

  • Review the seven best practice advice statements presented in the article. Does the evidence support these?
  • Ask your learners if we more frequently consider the benefits than the harms of a screening program. Ask what the potential harms of screening for cervical cancer are. The authors discuss these on the second page of the paper, together with the benefits. Do your learners agree with the balance of harms and benefits represented by the advice provided in this paper?
  • Review how HPV testing is performed.

Medical Knowledge
Interpersonal / Communication Skills

Hemorrhagic stroke probably caused by exercise combined with a sports supplement containing β-methylphenylethylamine (BMPEA): a case report

This report describes the identification of an isomer of amphetamine, β-methylphenylethylamine, in the dietary supplement consumed by a middle-aged woman who subsequently had an exercise-associated stroke.

Use this report to:

  • Ask your learners what the value of a case report is. Should it alter practice?
  • Do your learners inquire whether their patients use “sports supplements?” Do they think they should ask?
  • How do you report a potential serious adverse event to the FDA?

Understanding Clinical Science

Medical Knowledge
High Value Care

The Lake Wobegon effect: why most patients are at below-average risk

This commentary discusses the paradoxical finding that most patients are at below-average risk and can expect to experience less-than-average benefits from a treatment. This “Lake Wobegon effect,” the authors argue, can result in too many patients being screened, diagnosed, and treated.

Use this paper to:

  • Invite a colleague with expertise in biostatistics to carefully explain the authors' message – that better use of risk-prediction in research and clinical practice will help us focus attention on patients most likely to gain from our interventions.
  • Review the figure – and be sure your learners understand why a treatment can be worthwhile for patients on average, yet not worthwhile for the average patient.

Humanism and Professionalism

High Value Care

On Being a Doctor: The Rectal Exam

Dr. Lamas describes his memory from internship of waking a patient early in the morning to perform a rectal examination.

Use this article to:

  • Listen to an audio recording of the essay, read by Dr. Michael LaCombe.
  • Ask your learners what it means to be “patient-centered.”
  • Ask how they feel when, like Dr. Lamas, they do uncomfortable or unpleasant things to patients. What systems and pressures make it difficult for them to be patient-centered?
  • Brainstorm practice habits in your system that could be changed to improve patient centeredness. How will your team act upon these ideas?


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?

A. Acyclovir
B. Evening primrose oil
C. Graded exercise program
D. Growth hormone
E. Sertraline

Correct Answer
C. Graded exercise program

Key Point
Effective treatment options for chronic fatigue syndrome include graded exercise programs and cognitive-behavioral therapy.

Educational Objective
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.

From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Program Director in Internal Medicine, Thomas Jefferson University.


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