451 - Diagnosing COVID-19, Sunscreen 2022, Belonging or Be Longing

From the Cochrane Database of Systematic Reviews

1)  Diagnosing COVID-19 by Clinical Presentation

As mask mandates and social distancing rules took effect at the start of the pandemic, we enjoyed an obvious decline in other upper respiratory diseases – influenza, “cold” viruses, etc. As a result, there was a higher likelihood that people presenting with symptoms of upper respiratory illness had COVID-19. Now that mask mandates are lifted and there is less social distancing behavior, we are seeing a predictable resurgence of these other conditions. This leads to the question, “How good are we at distinguishing COVID-19 from other diseases based on signs and symptoms?”

A large-scope Cochrane review has been recently released which tries to tackle this topic. The authors searched for and selected articles about outpatient (including hospital outpatient and emergency department) presentations of suspected COVID-19. They were unable to clearly distinguish disease severity, so lumped all severities of illness together. They found 44 studies of ~26,000 patients. The prevalence of COVID-19 averaged 21% but varied dramatically from 3-71% across the studies. Each of 84 different symptoms was assessed for its sensitivity and specificity at diagnosing COVID-19. Only a few symptom combinations were assessed by the studies.

There was a high risk of bias in these studies in the categories of patient selection and the index test. Even though the study was focused on outpatient presentations, some studies evaluated only patients with pneumonia on radiography, and most included patients for whom the index of suspicion for COVID-19 was already high (e.g., they were presenting to COVID testing centers, etc.). There was apparently little detail about how the symptoms (the index tests) were assessed across the studies, which leaves room for variability and error.

Most symptoms had low sensitivity and high specificity, and only cough and fever had sensitivities above 50%. Anosmia and ageusia had relatively high specificities, but low sensitivities. None of the calculated likelihood ratios (LR) reached a useful diagnostic threshold in either direction. The symptom combinations studied (usually cough and fever plus other symptoms) improved specificity, but at the cost of decreased sensitivity.

          (A useful rule-of-thumb for LRs: They are most helpful to rule in disease with an       LR+ > 5, and rule out disease with an LR- < 0.2)

The authors conclude that no symptom has good enough characteristics to rule in or rule out COVID-19.

John’s Comments:

Recently, I have seen both patients and fellow clinicians attempting to distinguish the risk of COVID-19 based solely on symptoms. Suffice it to say, the evidence does not support this. None of the likelihood ratios are sufficiently low for us to be able to rule out COVID-19 based on symptoms. At some point, when our hospital capacity is no longer threatened by the spread of this infection, it won’t matter so much – after all, we don’t currently try to distinguish between adenovirus and rhinovirus. But we’re still in the pandemic phase of this illness, and the need to rule out COVID-19 is still a priority to prevent uncontrolled spread. And that can currently only be done by testing.

Reference:

Struyf T, Deeks JJ, Dinnes J, et al. Signs and symptoms to determine if a patient presenting in primary care or hospital outpatient settings has COVID-19. Cochrane Database Syst Rev. 2022;5:CD013665. Link

From Consumer Reports, the AAD, and in Preparation for Summer

2)  Sunscreen 2022:  Let the Wearer Beware

According to the American Academy of Dermatology (AAD), it is estimated that one in five Americans will develop skin cancer in their lifetime.  Sun protection is the most effective way to prevent skin cancer.  For sunscreen, the sun protection factor (SPF) is a relative measure of how long a sunscreen will protect from UVB rays, which are the chief cause of sunburn and a contributor to skin cancer.  Usually the number is explained as the amount of time it takes an individual’s skin to burn when it’s covered in sunscreen compared with when it’s not. For example, assuming you apply—and reapply—the sunscreen correctly (recommended every 2 hours), if you’d normally burn after 20 minutes it would take 10 hours with the application of SPF 30 sunscreen.

SPF calculations do not apply to UVA rays, which can tan and age skin and cause skin cancer. That’s why it is necessary to use a broad-spectrum sunscreen that provides protection against both types of UV rays.  However, no sunscreen blocks 100 percent of UVA or UVB rays. The breakdown: SPF 30 blocks 97 percent of UVB rays, SPF 50 blocks 98 percent, and SPF 100 blocks 99 percent.  The AAD recommends everyone use water resistant sunscreen that offers broad-spectrum protection against UVA and UVB rays at a SPF 30 or higher.

It is also important to note that sun protection may be required indoors if much time is spent sitting near a sunny window. Glass blocks UVB rays, but it can let through some  UVA rays.  Automobile windshields do a good job for both UAA and UVB light (particularly newer models), but automobile side windows don’t provide as effective protection for UVA light. 

The Consumer Reports company has recently published its 2022 sunscreen ratings.  In the past few years, the company has consistently noted that many tested products perform at less than half their labeled SPF number and many are inconsistent in their protection across product batches and various products from the same company.  They’ve also found that cost and brand name do not necessarily correlate with quality.  Since the AAD recommends using a product with an SPF of 30 or higher, this means that many cases, users are not adequately protected, even with listed SPF ratings of 50.  This also means that most products with an SPF rating of 30 are not sufficient.   

Additionally, testing has consistently found that so-called natural or mineral sunscreens (those that contain only titanium dioxide, zinc oxide, or both as active ingredients) have tended to perform less well.  This does not include products labeled sunblock, such as higher concentration zinc oxide products (think white noses on lifeguards).

According to the FDA, there are no chemical sunscreens that are generally regarded as safe and effective (GRASE) because additional data needed.  Note, this does not mean they are unsafe (comparable to an “I” recommendation from the USPSTF).

Top Rated/Recommended Products per Consumer Reports:

·       Lotion:  - La Roche-Posay Anthelios Melt-In Milk Lotion SPF 60 (quite expensive)

              - Equate (Walmart) Ultra Lotion SPF 50 (best value)

                   - Kiehl’s Activated Sun Protector Lotion SPF 30 (quite expensive)

                   - Equate (Walmart) Sport Lotion SPF 50

·       Spray:   - Trader Joe’s SPF Spray 50 + (highest rated of any product)

                  - Alba Botanica Hawaiian Coconut Clear Spray SPF 50

                   - Sun Bum Spray SPF 50

My Comment:

What makes the Consumer Reports evaluation compelling is that the same process was used on all products under the same conditions (less potential bias than a company testing their own product).  They also buy the product off the shelf.  

Note that the application of the product is vitally important.  The AAD indicates that most people only apply 25-50 percent of the recommended amount of sunscreen and don’t reapply at recommended intervals or after water exposure.

References:

·       Consumer Reports Sunscreen Ratings:  May 2022 (by subscription):  Link

·       American Academy of Dermatology Sunscreen FAQs:  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  It’s Either Belonging or Be Longing …

“True belonging doesn't require you to change who you are; it requires you to be who you are.”   Brené Brown, Braving the Wilderness: The Quest for True Belonging and the Courage to Stand Alone

What was the best job you ever had?  While for you the answer might be “being a physician,” that is not the case for me.  Being a summer camp counselor during college continues to be the standard by which I have measured every job since.

Last year I hired a leadership coach to help guide me through some professional questions I was having at the time, and she encouraged me to explore this seemingly nostalgic standard, asking “What was it about being a camp counselor that so spoke to your soul?”  While there were many aspects I loved about camp and being a counselor, the quality that sets it apart from my other jobs was the sense of being part of something where I felt I belonged – where all of me was welcomed, and where others felt the same.  It was truly a “come as you are” and “let’s grow together” time. 

In a 2013 study entitled “To Belong is to Matter,” Nathaniel Lambert and colleagues concluded, “Using a diverse set of methods, we found converging evidence that feeling a sense of belongingness is a powerful predictor and cause of finding life meaningful.”  Not only did belonging predict a sense of meaning – it actually caused it.  This identical conclusion was reached by Eric Barker in his 2022 book, Plays Well With Others, where he boldly states, “ … belonging is the meaning of life.”  He goes on, “… the most memorable moments in my life … are always when I was with a group where I felt accepted.  Where I felt I belonged.” 

True belonging is not the same as inheriting (“I belong to my family”), joining (“I belong to my professional society), being selected (I belong to this medical group) or fitting in, selling out, or pretending (I belong to this social group).  As Brené Brown, quoted above, goes on to say, “It's a practice that requires us to be vulnerable, get uncomfortable, and learn how to be present with people without sacrificing who we are.”  That includes the less than perfect parts of ourselves.  Belonging does not require you to change yourself, nor others to change themselves.  It is not about adaptation – it is about acceptance, starting with yourself. 

Indeed, what was most impactful for me about those summers working at YMCA camp was the level of acceptance I experienced – the opportunity to both "bring the best of me, and the rest of me."  We encouraged each other and we "graced" each other, and in the process, “the rest of me” slowly began to transform, to heal, to soften, to grow.  And that is what I have aspired to in every job since then.  Certainly, there are other places outside of work to find this as well, but given the amount of “life energy” one spends at work, I believe if we are not able to find a sense of belonging there, we will continually find ourselves in a place of “be longing.”

It therefore shouldn’t surprise me that as I have become more vulnerable and allowed more of me to show up in my present job, I’ve experienced a greater sense of belonging … and deeper meaning.  If I keep that up it could become my new “best job ever”!  And that’s something I’d wish for all of us.  So who are those people in your work who engender a sense of belonging for you?  How might you show up differently with them?  Doing so could change everything … for the better … starting with you ….

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org