Patients need accurate, evidence-based information to understand a diagnosis, learn about treatment options, and make autonomous and informed decisions about their health care. Doctors are still the preferred and trusted source of medical information for most people, but the internet, social media, family and friends, and other sources are commonly used to explore health problems, medication side-effects, diagnoses, and other health-related topics. However, there are growing concerns about the accuracy of information obtained online and the consequences of misinformation on patient outcomes. During the pandemic, the widespread effects of medical misinformation around vaccines and COVID-19 treatments were plain to see. A report published in January 2023 by the Council of Canadian Academies showed that, between March and November 2021, misinformation contributed to vaccine hesitancy for an estimated 2·35 million people in Canada. Misinformation on social media has been amplified by political unrest, distrust in the health-care system, and growing health and racial disparities. More than 70% of adults in the USA report ever using social media, so the potential to rapidly spread inaccurate medical information is high. Social media platforms have, historically, favoured posts with scandalous or radical content to drive engagement and statistics; working with these platforms is an essential step to develop algorithms that reduce the prominence of unreputable sources of information. Part of the solution needs to involve giving trusted sources of information more prominence, but deciphering factually accurate information from reliable sources is a substantial challenge. Another key step is teaching patients how to critically assess medical information on social media and the internet. Methods such as SIFT (stop, investigate the source, find trusted coverage, and trace to the original context) are a good starting point in questioning where content comes from and how reliable and accurate it is. Misinformation can negatively affect the patient–doctor relationship. Although studies have shown that patients would prefer to speak with a physician first, access to health care, associated costs, and long waiting times mean that only 10·9% of patients went to their doctor before seeking information online. However, research suggests that when patients share information found online with their doctor and feel that the doctor is receptive to discussing it, this can have a positive effect on the consultation. Most patients seek information online so that they can be actively involved in health-care decision making; embracing this fact and proactively engaging patients about the use of online sources for medical information might help the doctor and patient to work together and give the physician an opportunity to correct any inaccurate information. One reason patients seek information on the internet is due to a shortage of clear information for treatments provided at the time of prescription. On May 30, 2023, the US FDA proposed a requirement for prescription drugs and some biological products to provide clear, concise, and accessible information delivered in an easy-to-understand one-page format. This information should allow patients to understand important safety information and common side-effects, and empower patients in understanding how to take their medications. The need for reliable information is a global issue. Healthcare Information For All (HIFA) is a global movement, started in 2006, to improve the availability of health-care information in low-income and middle-income countries (LMICs) and to protect people from misinformation. Eight of ten caregivers in LMICs do not know the two key symptoms of childhood pneumonia, and prescriptions for tuberculosis treatment are frequently incorrect. Improved access to information for health-care providers and caregivers is needed. HIFA is launching a HIFA-WHO consultation in August 2023 to identify opportunities and challenges in achieving universal access to reliable health information and to promote public support. The internet and social media as a source of medical information is here to stay. Doctors and nurses need to understand the sources of information that patients are using, teach them how to evaluate the quality of information, and provide them with trusted sources of further information. While ongoing work aims to better regulate harmful social media content and provide high-quality medical information for all, it is reassuring that health professionals are still the most trusted source of information for most people. Health-care staff could have a pivotal role in enabling patients to seek the information they require and, in the process, strengthen the patient–provider relationship. High-quality health systems in the Sustainable Development Goals era: time for a revolutionAlthough health outcomes have improved in low-income and middle-income countries (LMICs) in the past several decades, a new reality is at hand. Changing health needs, growing public expectations, and ambitious new health goals are raising the bar for health systems to produce better health outcomes and greater social value. But staying on current trajectory will not suffice to meet these demands. What is needed are high-quality health systems that optimise health care in each given context by consistently delivering care that improves or maintains health, by being valued and trusted by all people, and by responding to changing population needs. Full-Text PDF Open Access

Vivienne Kahlmann and colleagues1Kahlmann V Moor CC van Helmondt SJ et al.Online mindfulness-based cognitive therapy for fatigue in patients with sarcoidosis (TIRED): a randomised controlled trial.Lancet Respir Med. 2023; 11: 265-272Summary Full Text Full Text PDF PubMed Google Scholar did a randomised controlled trial to assess the effect of a 12-week online mindfulness-based cognitive therapy (eMBCT) on fatigue in sarcoidosis. Kahlmann and colleagues1Kahlmann V Moor CC van Helmondt SJ et al.Online mindfulness-based cognitive therapy for fatigue in patients with sarcoidosis (TIRED): a randomised controlled trial.Lancet Respir Med. 2023; 11: 265-272Summary Full Text Full Text PDF PubMed Google Scholar reported that eMBCT improves fatigue in patients with the disease. Fatigue is common (in up to 90% of patients) in mood disorders, inflammatory diseases, and other chronic diseases, such as diabetes, thyroid dysfunction, neuroendocrine disorders, mental health disorders (especially depression), obstructive sleep-apnoea syndrome, small-fibre neuropathy, vitamin-D deficiency, heart failure, and neurological diseases. Many patients have fatigue without extensive organ involvement,2Baughman RP Valeyre D Korsten P et al.ERS clinical practice guidelines on treatment of sarcoidosis.Eur Respir J. 2021; 582004079Crossref PubMed Scopus (117) Google Scholar and fatigue has been identified in more than a half of patients with sarcoidosis. Although fatigue is not synonymous with impaired quality of life (QOL), many studies of sarcoidosis specifically identify fatigue as a major cause of impaired QOL.1Kahlmann V Moor CC van Helmondt SJ et al.Online mindfulness-based cognitive therapy for fatigue in patients with sarcoidosis (TIRED): a randomised controlled trial.Lancet Respir Med. 2023; 11: 265-272Summary Full Text Full Text PDF PubMed Google Scholar Most patients with sarcoidosis have symptoms of fatigue at the time of diagnosis, probably caused by inflammatory cytokines. This fatigue and small-fibre neuropathy, depression, and cognitive impairment are often recognised as non-granulomatous parasarcoidosis syndromes.3Grunewald J Grutters JC Arkema EV Saketkoo LA Moller DR Müller-Quernheim J Sarcoidosis.Nat Rev Dis Primers. 2019; 5: 45Crossref PubMed Scopus (180) Google Scholar The Article1Kahlmann V Moor CC van Helmondt SJ et al.Online mindfulness-based cognitive therapy for fatigue in patients with sarcoidosis (TIRED): a randomised controlled trial.Lancet Respir Med. 2023; 11: 265-272Summary Full Text Full Text PDF PubMed Google Scholar reports on an interesting and poorly known subject; however, we deem it useful to discuss some further points. A brief description of the pathophysiological mechanisms of fatigue should have been reported. Although fatigue was defined according to the Fatigue Assessment Scale, diagnosis would have been improved by sleep research at home or in hospital and by monitoring daytime physical activity. In addition, obstructive sleep apnoea (OSA) was not reported by the authors, even though sleepiness is known to frequently be associated with fatigue.4Patterson KC Huang F Oldham JM Bhardwaj N Hogarth DK Mokhlesi B Excessive daytime sleepiness and obstructive sleep apnea in patients with sarcoidosis.Chest. 2013; 143: 1562-1568Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar Advanced fatigue is common in sarcoidosis, and OSA could be a relevant comorbidity that could be ameliorated by continuous positive airway pressure treatment.5Mari PV Pasciuto G Siciliano M et al.Obstructive sleep apnea in sarcoidosis and impact of CPAP treatment on fatigue.Sarcoidosis Vasc Diffuse Lung Dis. 2020; 37: 169-178Google Scholar We also wondered whether fatigue related to COVID-19 infection could have been a confounding factor in the data analysis of patients with sarcoidosis enrolled in 2020 and 2021. Furthermore, it is unclear whether fatigue was attributable to other associated comorbidities and how long the clinical benefit and Fatigue Assessment Scale improvement persisted. Finally, it would have been useful to evaluate fatigue in different ways, including extreme tiredness after very little activity, waking up feeling as tired as when the patient went to sleep, the presence of so-called heavy limbs, and difficulties with balance, vision, or concentration. We declare no competing interests. Online mindfulness-based cognitive therapy for fatigue in patients with sarcoidosis (TIRED): a randomised controlled trial12 week eMBCT improves fatigue, anxiety, depression, mindfulness, and health status in patients with sarcoidosis-associated fatigue. Full-Text PDF

We congratulate Jean Reignier and colleagues1Reignier J Plantefeve G Mira JP et al.Low versus standard calorie and protein feeding in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group trial (NUTRIREA-3).Lancet Respir Med. 2023; (published online March 20.)https://doi.org/10.1016/S2213-2600(23)00092-9Summary Full Text Full Text PDF Scopus (2) Google Scholar for completing the NUTRIREA-3 trial, wherein mechanically ventilated, critically ill patients receiving vasoactive therapy for shock within 24 h of intubation were randomly assigned to receive either low or standard feeding (6 vs 25 kcal/kg per day and 0·2–0·4 vs 1·0–1·3 g of protein/kg per day, respectively). The authors concluded that an early low energy and protein intake was associated with faster recovery and fewer complications. We respectfully suggest that the conclusion should be revised to reflect the findings that an early high energy and protein intake in patients with shock is harmful and not that “restriction was superior to standard” intake. In the NUTRIREA-3 trial, patients received high-dose norepinephrine (median 0·5 μg/kg per min), and were provided with early high energy and protein that contradicts international clinical practice guidelines.2McClave SA Taylor BE Martindale RG et al.Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).JPEN J Parenter Enteral Nutr. 2016; 40: 159-211Crossref PubMed Google Scholar, 3Singer P Blaser AR Berger MM et al.ESPEN guideline on clinical nutrition in the intensive care unit.Clin Nutr. 2019; 38: 48-79Summary Full Text Full Text PDF PubMed Scopus (1183) Google Scholar The authors state that they “compared with the standard calorie and protein intakes recommended in current guidelines”. Although the energy and protein goals are correct, the authors overlooked the associated recommendation to deliver nutrition progressively over a week. In NUTRIREA-3 (as with NUTRIREA-24Reignier J Boisrame-Helms J Brisard L et al.Enteral versus parenteral early nutrition in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2).Lancet. 2018; 391: 133-143Summary Full Text Full Text PDF PubMed Scopus (288) Google Scholar) there was an immediate full nutrition delivery, which is warned against in the guidelines since such practice is known to be deleterious. Furthermore, the investigators have overlooked the results of NUTRIREA-2, which showed that early high energy intake via enteral nutrition increased the risk of bowel ischaemia, which is an outcome replicated in NUTRIREA-3. The harm of an early high energy intake might also be attributed to the significantly higher incidence of hypophosphataemia, because a previous study showed higher 60-day mortality in this population even when electrolytes were adequately replenished.5Doig GS Simpson F Heighes PT et al.Restricted versus continued standard caloric intake during the management of refeeding syndrome in critically ill adults: a randomised, parallel-group, multicentre, single-blind controlled trial.Lancet Respir Med. 2015; 3: 943-952Summary Full Text Full Text PDF PubMed Google Scholar Notably, NUTRIREA-3 can be compared with the TARGET trial,6Chapman M Peake SL Bellomo R et al.Energy-dense versus routine enteral nutrition in the critically ill.N Engl J Med. 2018; 379: 1823-1834Crossref PubMed Scopus (175) Google Scholar which did not show harm when a higher energy dose than that in NUTRIREA-3 was administered during the first 2 days of admission to an intensive care unit. Notably, the energy dose for the lower nutrition group in TARGET was similar to that of the standard treatment in NUTRIREA-3 (table). The potential reasons for the absence of harm in TARGET could be that the mortality risk of the patients in TARGET was lower than those in NUTRIREA-3, and if low energy and protein were indeed beneficial (as posited by NUTRIREA-3), then TARGET might have represented a trial comparing two harmful interventions. These uncertainties might be resolved through a network meta-analysis, because there exist enough trials with varying caloric doses.TableComparison of patient characteristics and nutrition interventions between the TARGET and NUTRIREA-3 trialsTARGET (N=3957)NUTRIREA-3 (N=3036)Higher energy group (n=1971)Lower energy group (n=1986)Higher energy group (n=1515)Lower energy group (n=1521)Patient characteristicsAge57·2 (16·6)57·5 (16·5)66 (13)66 (13)Medical diagnosis at admission1443 (73·2%)1435 (72·3%)1258 (83·0%)1253 (82·4%)BMI29·2 (7·2)29·3 (7·9)27·0 (23·0–31·5)26·7 (23·0–31·1)Sequential organ failure assessmentNRNR10 (8–13)10 (8–13)Acute physiology and chronic health evaluation II22·0 (8·3)22·1 (8·5)NRNRSimplified acute physiology score IINRNR61 (48–74)60 (48–74)Patients with vasoactive drugs1235 (62·7%)1253 (63·1%)1486 (98·1%)1481 (97·4%)Norepineprine dose, μg/kg per minNRNR0·50 (0·25–1·00)0·50 (0·25–0·99)Patients with renal replacement therapy172 (8·7%)177 (8·9%)183 (12·1%)161 (10·6%)90-day mortality in the control group505/1966 (25·7%)..648 (42·8%)..InterventionsStart time, hIntensive care unit admission to starting trial nutrition: 15·8 (7·7–26·3)Intensive care unit admission to starting trial nutrition: 15·9 (7·9–28·3)Intubation to feeding: 17·0 (10·8–21·8)Intubation to feeding: 16·7 (10·6–21·6)Duration of intervention, days6 (3–11), continuing for up to 28 days6 (3–11), continuing for up to 28 daysUp to 7 daysUp to 7 daysEnergy receivedKcal per day (trial nutrition)1863 (478)1262 (313)NRNRKcal/kg per day (trial nutrition)29·1 (6·2)19·6 (4·0)19·9 (15·3–22·6)5·1 (4·0–5·9)Protein receivedg per day69·6 (17·8)69·4 (17·2)NRNRg/kg per day1·09 (0·22)1·08 (0·23)0·9 (0·7–1·0)0·2 (0·2–0·3)Fluids, LVolume of trial nutrition similar between groupsVolume of trial nutrition similar between groups17·2 (9·7–23·4)11·1 (6·1–16·4)Enteral nutrition routeAll patientsAll patients846 (55·8%)932 (61·3%)Supplemental parenteral nutrition route109 (5·5%)85/1985 (4·3%)296 (19·5%)208 (13·7%)Data shown as mean (SD), %, or median (IQR). NR=not reported. Open table in a new tab Data shown as mean (SD), %, or median (IQR). NR=not reported. Overall, we acknowledge the importance and efforts of identifying the optimal energy and protein doses for critically ill patients; however, the lessons learned from previous studies require careful consideration. We declare no competing interests. Low versus standard calorie and protein feeding in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group trial (NUTRIREA-3)Compared with standard calorie and protein targets, early calorie and protein restriction did not decrease mortality but was associated with faster recovery and fewer complications. Full-Text PDF

Among adults who are critically ill who require a vasopressor support, Jean Reignier and colleagues1Reignier J Plantefeve G Mira J-P et al.Low versus standard calorie and protein feeding in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group trial (NUTRIREA-3).Lancet Respir Med. 2023; (published online March 20.)https://doi.org/10.1016/S2213-2600(23)00092-9Summary Full Text Full Text PDF Scopus (2) Google Scholar found, in the NUTRIREA-3 study, that standard early nutrition therapy (actual intake: 22 kcal/kg per day, 0·9 g protein per kg per day) is harmful when compared with a low intake (actual intake: 7·4 kcal/kg per day, 0·2 g protein per kg per day). Nutrition was mostly enteral and guided by bodyweight. The standard intake resulted in a longer time to be ready for discharge from the intensive care unit associated with a greater frequency of gastrointestinal and metabolic intolerance (vomiting, diarrhoea, higher peak glucose concentration, and more patients needed insulin to reach glucose targets). The possible implications of NUTRIREA-3 for clinical practice should take into account the method of nutrition (ie, enteral route) and the underlying disease (ie, septic shock) of the enrolled patients. Since similar, unwanted gastrointestinal side-effects had already been found in the NUTRIREA-2 trial,2Reignier J Boisramé-Helms J Brisard L et al.Enteral versus parenteral early nutrition in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2).Lancet. 2018; 391: 133-143Summary Full Text Full Text PDF PubMed Scopus (288) Google Scholar comparing 17·8 kcal/kg per day enterally with 19·6 kcal/kg per day parenterally, it is likely that in NUTRIREA-3 the enteral route by itself contributed to the complications associated with a shock-induced worsening of gastrointestinal perfusion. Furthermore, in NUTRIREA-3, an exclusively weight-based calorie intake might not have been appropriate for all enrolled patients. 58·0% had septic shock, which causes a particular intolerance towards exogenous nutrients.3Wolfe RR Sepsis as a modulator of adaptation to low and high carbohydrate and low and high fat intakes.Eur J Clin Nutr. 1999; 53: S136-S142Crossref PubMed Google Scholar Excess calories might provoke unwanted effects, such as the inhibition of autophagy.4Van Niekerk G Meaker C Engelbrecht A-M Nutritional support in sepsis: when less may be more.Crit Care. 2020; 24: 53Crossref Scopus (11) Google Scholar Such adverse effects could have possibly been avoided, if additional management tools had been used to individualise calorie intake (indirect calorimetry to identify resting energy expenditure [caloric target]) and the extent of insulin requirement to estimate the patients' capacity to metabolise exogenous nutrients.5Elke G Hartl WH Kreymann KG et al.Clinical nutrition in critical care medicine – guideline of the German Society for Nutritional Medicine (DGEM).Clin Nutr ESPEN. 2019; 33: 220-275Summary Full Text Full Text PDF PubMed Scopus (46) Google Scholar We declare no competing interests. Low versus standard calorie and protein feeding in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group trial (NUTRIREA-3)Compared with standard calorie and protein targets, early calorie and protein restriction did not decrease mortality but was associated with faster recovery and fewer complications. Full-Text PDF

Cough is a common and troublesome symptom in people with asthma and is often associated with poorer asthma control and exacerbations. Apart from asthma, other causes or comorbidities might underlie cough in asthma, such as rhinosinusitis and bronchiectasis. Eosinophilic inflammation and bronchoconstriction can lead to an acute episode of cough or worsen chronic cough. Cough hypersensitivity with laryngeal paraesthesia, allotussia, and hypertussia might underlie the cough of asthma through augmented sensory nerve excitability of upper-airway vagal sensory nerves. Cough associated with bronchoconstriction and type 2 inflammation should respond to inhaled corticosteroids and long-acting β-adrenoceptor agonist therapy. For cough hypersensitivity in adults, speech and language therapy and neuromodulators (eg, gabapentin) could be considered. In children, there is no consistent association of asthma with cough sensitivity or between cough and asthma severity. Further research is needed to realise the potential of cough as a measure of asthma control, to understand the mechanisms of cough in asthma, and to develop safe, effective treatments and a precision-medicine approach to the management of cough in asthma in children and adults.

We thank Roberto Carbone and colleagues for their relevant questions. The causes of fatigue are multifaceted and physical, psychological, and behavioural factors have a role in the onset and persistence of fatigue. Furthermore, treatment such as corticosteroids can also cause fatigue. We agree with Carbone and colleagues that treatable traits should be assessed and adequately managed first (figure). It is important to note that many patients in our study cohort already had fatigue for a prolonged period of time (median 5·5 years, range 0·4–39·0). The majority of patients have had extensive work up to investigate the causes of fatigue before study inclusion.1Kahlmann V Moor CC Wijsenbeek MS Managing fatigue in patients with interstitial lung disease.Chest. 2020; 158: 2026-2033Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 2Kahlmann V Patel DC Marts LT Wijsenbeek MS Non-organ-specific manifestations.in: Bonella F Culver DA Israël-Biet D Sarcoidosis (ERS monograph). 96. 2022: 206-222Crossref Scopus (3) Google Scholar In our cohort, 63 (68%) of 93 patients had one or more comorbidities, including cardiovascular disease (13%), obstructive sleep apnoea (13%), obstructive lung disease (8%), and hypothyroidism (4%). Patients could only be included if they had stable sarcoidosis and other causes of fatigue were adequately treated. During the TIRED trial,3Kahlmann V Moor CC van Helmondt SJ et al.Online mindfulness-based cognitive therapy for fatigue in patients with sarcoidosis (TIRED): a randomised controlled trial.Lancet Respir Med. 2023; 11: 265-272Summary Full Text Full Text PDF PubMed Google Scholar the COVID-19 pandemic emerged, which had a huge impact on mental health in the general population.4Manchia M Gathier AW Yapici-Eser H et al.The impact of the prolonged COVID-19 pandemic on stress resilience and mental health: a critical review across waves.Eur Neuropsychopharmacol. 2022; 55: 22-83Crossref PubMed Scopus (91) Google Scholar The COVID-19 pandemic could also have had a negative impact on mental health and fatigue in our study cohort. As the trial was randomised, we expect a similar effect from COVID-19 in the intervention and control group. In our study, two patients (one in each group) had COVID-19 more than 8 weeks before study start, and two patients in the intervention group reported a COVID-19 infection during the study period. Therefore, we believe that the effect of COVID-19 in our study was neglectable. Carbone and colleagues suggested to assess fatigue in different ways. The complexity of studying fatigue is that there is no unambiguous definition of fatigue.5Saketkoo LA Russell AM Jensen K et al.Health-related quality of life (HRQoL) in sarcoidosis: diagnosis, management, and health outcomes.Diagnostics. 2021; 11: 6Crossref Scopus (15) Google Scholar Fatigue is a subjective description of the feeling of a person and often divided in a physical and mental component. The Fatigue Assessment Scale is a validated questionnaire developed for patients with sarcoidosis, including questions about physical and mental fatigue.6De Vries J Michielsen H Van Heck GL Drent M Measuring fatigue in sarcoidosis: the fatigue assessment scale (FAS).Br J Health Psychol. 2004; 9: 279-291Crossref PubMed Scopus (237) Google Scholar Other topics suggested seem relevant, but are not yet incorporated in validated questionnaires for fatigue. As stated in our discussion, we agree that it would be interesting to include other secondary endpoints in future studies, such as physical activity and cognitive function, to increase our knowledge about fatigue in sarcoidosis. Although the effect of the 12-week online mindfulness-based cognitive therapy persisted after 3 months, we have no data beyond that. A form of maintenance online therapy could probably be beneficial for the long term. We declare no competing interests. Online mindfulness-based cognitive therapy for fatigue in patients with sarcoidosis (TIRED): a randomised controlled trial12 week eMBCT improves fatigue, anxiety, depression, mindfulness, and health status in patients with sarcoidosis-associated fatigue. Full-Text PDF