Myasthenia Gravis and Thymoma Surgery: A Clinical Update for the Cardiothoracic Anesthesiologist

Myasthenia gravis (MG) is a rare neuromuscular disorder characterized by skeletal muscle weakness. Patients with MG who have thymoma and thymic hyperplasia have indications for thymectomy. The perioperative care of patients with MG scheduled for thymus resection should be focused on optimizing their neuromuscular function, identifying factors related to postoperative mechanical ventilation, and avoiding of triggers associated with myasthenic or cholinergic crisis. Minimally invasive surgical techniques, use of regional analgesia, and avoidance or judicious administration of neuromuscular blocking drugs (NMBs) is recommended during the perioperative period. If NMBs are used, sugammadex appears to be the drug of choice to restore adequately the neuromuscular transmission. In patients with postoperative myasthenic crisis, plasma exchange or intravenous immune globulin and mechanical support is recommended.

The Potential Public Health Impact of Herpes Zoster Vaccination of People Aged ≥ 50 Years in Japan: Results of a Markov Model Analysis

INTRODUCTION

The aim of this study was to compare the public health impact of introducing two herpes zoster (HZ) vaccines into the vaccination programs for the Japanese population aged ≥ 50 years: a single-dose Varicella Vaccine Live (VVL) or a two-dose adjuvanted Recombinant Zoster Vaccine (RZV).

METHODS

A multi-cohort static Markov model was developed to follow age cohorts (50-59, 60-69, 70-79 and ≥ 80 years) over their remaining lifetime. Japan-specific data inputs for the model were obtained from Japanese data sources. Age-stratified vaccine efficacy and waning rates were based on published clinical trial data. In the base-case analysis, vaccine coverage was assumed to be 40% for both vaccines, and compliance with second-dose of the RZV vaccine was set to 95%.

RESULTS

Vaccination with RZV was projected to prevent approximately 3.3 million HZ cases, 692,000 cases of postherpetic neuralgia (PHN), and 281,000 cases of other complications, compared with the prevention of 0.8 million HZ cases, 216,000 PHN cases, and 57,000 other complications with vaccination with VVL. The number of individuals needed to vaccinate in order to prevent one HZ case ranged from 6 to 14 using RZV (depending on age and assumed second-dose compliance) and from 21 to 138 depending on age using VVL. By preventing a higher number of HZ cases and its complications, RZV vaccination led to fewer outpatient visits and hospitalizations than vaccination with VVL.

CONCLUSION

Both vaccines had a positive public health impact compared to no vaccination, but due to its higher vaccine efficacy, RZV demonstrated a superior public health impact compared with VVL.

FUNDING

GlaxoSmithKline Biologicals SA.

Risk factors associated with postoperative pain and discomfort in oculoplastic surgery with general anesthesia: a prospective study

Purpose

To evaluate patient pain and discomfort following oculoplastic surgery performed under general anesthesia and to assess key factors associated with postoperative pain and discomfort.

Methods

A prospective observational cohort study was conducted among 212 consecutive patients who underwent oculoplastic surgery performed under general anesthesia. The patients were assessed according to quantified levels of pain and discomfort postoperatively. Analgesic requests were recorded, and responses were statistically analyzed.

Results

Pain and discomfort after oculoplastic surgery under general anesthesia were reported by 32.1% and 28.3% of the patients, respectively; 2.8% of the patients requested analgesic medication within 18 hours after surgery. The patients who underwent orbital decompression, secondary orbital implantation, and orbital fracture repair were more likely to develop significant postoperative pain and discomfort (P<0.001), and the patients who underwent enucleation/evisceration during orbital implantation were more likely to develop postoperative discomfort (P<0.001). The predictors of pain were smoking history, prior surgery on the operative eye, and anxiety (P<0.05), and the predictor of discomfort was anxiety (P<0.05).

Conclusion

Patients undergoing oculoplastic surgery tend to experience postoperative pain and discomfort. Anxiety is a risk factor for both postoperative pain and discomfort, while smoking history and prior surgery on the operative eye may be associated with postoperative pain.

Effectiveness of continuous epidural analgesia on acute herpes zoster and postherpetic neuralgia: A retrospective study

Despite early treatment of herpes zoster (HZ), postherpetic neuralgia (PHN) can persist. This study was designed to compare the therapeutic and pain relief effects of continuous epidural analgesia (CEA) on the chronic phase as well as the acute phase of HZ with standard medical treatment.Medical records of 227 patients with moderate to severe zoster-associated pain that had not responded to standard medications were retrospectively reviewed. Patients received standard treatment alone (medical group) or standard treatment plus concurrent CEA (epidural group). The acute and chronic groups were classified according to a 4-week cut-off with regard to time between the onset of the rash and the first treatment. Four groups were studied: Group A (acute/medical group); Group B (acute/epidural group); Group C (chronic/medical group); and Group D (chronic/epidural group). Pain was assessed using the visual analog scale (VAS) and measured every 2 weeks for 6 months. We compared the pain rating at 6 months after the first treatment with the initial pain rating. Response to treatment was defined as a ≥50% reduction in pain severity since the initial visit. Remission was considered complete for patients whose VAS pain score was ≤2 for >3 successive visits and who no longer needed medical support.Patients who received a combination of standard treatment plus CEA (Groups B and D) had significantly higher response to treatment (P = .001) than patients receiving standard treatment alone (Groups A and C). The adjusted odds ratio (OR) for response to treatment in the epidural group versus the medical group was 5.17 (95% confidence interval [CI]: 1.75-15.23) in the acute group and 5.37 (95% CI: 1.62-17.79) in the chronic groups. The adjusted OR for complete remission in the epidural group versus the medical group was 3.05 (95% CI: 1.20-7.73) in the acute group and 4.46 (95% CI: 1.20-16.54) in the chronic group.CEA can effectively relieve pain caused by PHN and acute HZ and increase remission rates. Combining CEA with standard medical treatment may offer a clinical advantage in the management of pain caused by PHN as well as acute HZ.

[Video-assisted thoracoscopic thymectomy in myasthenia gravis. New approach]

AIM

To present possibility and technical aspects of anesthetic management during video-assisted thoracoscopic thymectomy in patients with myasthenia gravis.

MATERIAL AND METHODS

The article describes the proposed modified anesthetic method that is suitable for video-assisted thoracoscopic thymectomy in patients with myasthenia gravis. Nine patients with myasthenia underwent VATS-thymectomy. Anesthesia was performed with artificial airway and auxiliary ventilation without muscle relaxants administration.

[Herpes Zoster Vaccine]

Herpes zoster, or shingles, results from the reactivation of latent varicella- zoster virus (VZV) in the dorsal-root or cranial-nerve ganglia, usually decades after primary infection. Herpes zoster is characterized by a vesicular rash with a unilateral and dermatomal distribution and is almost always accompanied by pain. Herpes zoster is not only skin disease, but also sometimes affects other organs, including central nerve system, eye, and facial nerve. The most common complications, such as postherpetic neuralgia (PHN), are more frequent, severe and impair patients' quality of life. For more than 10 years, in US, EU, and Australia, a live-attenuated vaccine against herpes zoster (Zostavax) containing the Oka VZV strain is licensed for use in adults who are 50 years of age or older. In Japan, a live attenuated varicella vaccine is also licensed for preventing herpes zoster in 2016. Two large randomized multinational efficacy trials (ZOE-50 and ZOE-70) showed that the novel herpes zoster subunit vaccine (shinglix) candidate containing varicella-zoster virus glycoprotein E (gE) and the AS01B adjuvant system reduced the risk of herpes zoster and PHN by more than 90%. This article aimed to review the epidemiology, pathophysiology and complications of herpes zoster and mention the efficacies and problems of the live-attenuated and the new recombinant herpes zoster vaccines.

The Role of Bolus Injection of Saline with Arm Elevation on Rocuronium onset Time: A Randomized Control Study

Background:

The onset time of neuromuscular blockade is a crucial time associated with the risk of hypoxia and pulmonary aspiration. Various strategies have been undertaken to shorten this onset time. Therefore, we investigated the effects of bolus of 20 ml saline followed by limb elevation after administration of rocuronium in a dose of 0.6 mg/kg to study the onset time.

Methodology:

Thirty patients were randomly allocated to the bolus saline group or control group. General anesthesia was induced and maintained with fentanyl and propofol. Rocuronium 0.6 mg/kg intravenous (IV) was administered followed by 20 ml saline bolus and limb elevation in the study group compared to administration of 0.6 mg/kg in a running drip only in the control. Onset of neuromuscular block was assessed by acceleromyography at the adductor pollicis muscle with train-of-four stimulation.

Results:

The lag time was shorter in bolus group (34 s median) than in control group (45 s median), P < 0.017. The onset time was shorter in bolus group (55 s median) than in control group (110 s median), P < 0.001. The T1 recovery to 25% was longer in bolus group (42 min median) than in control group (39 min median) which was statistically not significant.

Conclusion:

Rocuronium 0.6 mg/kg IV followed by bolus 20 ml saline and concomitant limb elevation resulted in shorter lag time, faster onset of neuromuscular blockade, good intubating conditions without prolonging clinical duration of action when compared to the control.

Can nerve regeneration on an artificial nerve conduit be enhanced by ethanol-induced cervical sympathetic ganglion block?

This study aimed to determine whether nerve regeneration by means of an artificial nerve conduit is promoted by ethanol-induced cervical sympathetic ganglion block (CSGB) in a canine model. This study involved two experiments—in part I, the authors examined the effect of CSGB by ethanol injection on long-term blood flow to the orofacial region; part II involved evaluation of the effect of CSGB by ethanol injection on inferior alveolar nerve (IAN) repair using polyglycolic acid-collagen tubes. In part I, seven Beagles were administered left CSGB by injection of 99.5% ethanol under direct visualization by means of thoracotomy, and changes in oral mucosal blood flow in the mental region and nasal skin temperature were evaluated. The increase in blood flow on the left side lasted for 7 weeks, while the increase in average skin temperature lasted 10 weeks on the left side and 3 weeks on the right. In part II, fourteen Beagles were each implanted with a polyglycolic acid-collagen tube across a 10-mm gap in the left IAN. A week after surgery, seven of these dogs were administered CSGB by injection of ethanol. Electrophysiological findings at 3 months after surgery revealed significantly higher sensory nerve conduction velocity and recovery index (ratio of left and right IAN peak amplitudes) after nerve regeneration in the reconstruction+CSGB group than in the reconstruction-only group. Myelinated axons in the reconstruction+CSGB group were greater in diameter than those in the reconstruction-only group. Administration of CSGB with ethanol resulted in improved nerve regeneration in some IAN defects. However, CSGB has several physiological effects, one of which could possibly be the long-term increase in adjacent blood flow.

Three-dimensional image in lung transplantation

Three-dimensional computed tomography (3D-CT) technologies have been developed and, recently, high-speed and high-quality 3D-CT technologies have been introduced to the field of thoracic surgery. The purpose of this manuscript is to demonstrate the clinical application of 3D-CT technologies in lung transplantation. In Japan, because of the severe donor shortage, living-donor lobar lung transplantation (LDLLT) is essential, in addition to cadaveric lung transplantation. In LDLLT, size matching is a grave issue, since ideal size matching between donor and recipient is usually difficult because of the limited population of potential donor. Size matching using pulmonary function test results has been widely used as a gold standard, but anatomical size matching using 3D-CT volumetry data has also been utilized in LDLLT. In donor lobectomy, 3D-CT images provided a variety of information regarding anatomical variation of pulmonary vessels and bronchial trees preoperatively. These images ensure surgical quality and safety, and they also affect surgical procedures for the recipient. 3D-CT images are also utilized in various aspects of postoperative care, such as detection of chronic lung allograft dysfunction and clarification of its subtypes. Furthermore, preoperative 3D-CT simulation is useful in developing and performing a special surgical procedure, such as right-to-left inverted LDLLT. In conclusion, following the introduction of 3D-CT to the field of thoracic surgery, various 3D-CT images and their application to preoperative simulations have been introduced in lung transplantation. In the near future, this technique will become more prevalent, and frequent use by thoracic surgeons will be seen worldwide in daily practice.

Effects of Linearly Polarized Near-Infrared Irradiation Near the Stellate Ganglion Region on Pain and Heart Rate Variability in Patients with Neuropathic Pain

Background

Neuropathic pain associated with sympathetic overactivity can be effectively relieved by light irradiating the region near stellate ganglion (SGI), applied as an alternative to a conventional sympathetic blockade. The clinical effect of SGI on heart rate variability (HRV) and its association with pain outcomes require investigation.

Objective

This study attempted to identify the effects of SGI on pain outcomes and HRV indices and to determine the association between pain and HRV outcomes.

Design

A prospective double-blind, randomized study.

Setting

An outpatient pain medicine clinic.

Subjects and Methods

A total of 44 patients were enrolled and randomized into the experimental group ( n = 22) and control group ( n = 22). The experimental group received 12 sessions (twice weekly) of standard SGI, whereas the control group received the same protocol with sham irradiation. Pain and HRV were measured before and after each irradiation session. All outcome measures used in the first- and second-half treatment courses were analyzed.

Results

Pain and HRV outcome measures of the experimental group significantly improved after SGI when compared with the control group in both courses. Considering time and frequency domains, the changes in HRV in the second-half treatment course exceeded those in the first-half treatment course. Pain was significantly associated with postirradiated HRV indices ( P < 0.001).

Conclusions

Twelve sessions of SGI exerted time-dependent positive effects on pain and sympathovagal imbalance. HRV outcomes, including time and frequency domains, were an independent indicator of the clinical efficiency of SGI for treating pain in patients with neuropathic pain.

A Comparative Study of Dexmedetomidine and Diltiazem for Attenuating Pressor Responses to Laryngoscopy and Endotracheal Intubation: A Double-blind, Randomized Study

CONTEXT

Endotracheal intubation has been suggested to be one of the most invasive stimuli in anesthesia, particularly during induction and after tracheal intubation. The present study aims to evaluate the efficacy of dexmedetomidine as compared to diltiazem on hemodynamic response to laryngoscopy and intubation.

AIMS

To assess and compare the hemodynamic response of dexmedetomidine as compared to diltiazem in patients undergoing laryngoscopy and intubation and rate and type of side effects of the drugs if any.

SETTINGS AND DESIGN

This study design was a prospective, randomized, and double-blind trial.

SUBJECTS AND METHODS

The patients were randomly allocated into three groups: Group I (control), Group II (dexmedetomidine), and Group III (diltiazem) of 45 patients each. Group I (n = 45): 0.9% NaCl 10 ml was given to the patients over 10 min before intubation in Group I (control). Group II (n = 45): injection dexmedetomidine (0.5 μg/kg) in 10 ml normal saline was given to the patients over 10 min before intubation. Group III (n = 45): injection diltiazem (0.3 mg/kg) in 10 ml normal saline was given to the patients over 10 min before intubation.

STATISTICAL ANALYSIS USED

The data so collected were subjected to statistical analysis using Statistical Package for the Social Sciences version 15.0.

RESULTS

Mean percentage increase in systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) following intubation was 17.90%, 19.96%, and 19.04%, respectively, in control group, 9.04%, 6.32%, and 7.53%, respectively, in dexmedetomidine group, and 12.30%, 10.32%, and 11.14%, respectively, in diltiazem groups. Statistically, there was a significant difference in postintubation SBP, DBP, and MAP of the three groups (P < 0.001). Dexmedetomidine at a dose of 0.5 μg/kg showed to have a better attenuation of pressor response as compared to diltiazem at a dose of 0.3 μg/kg.

CONCLUSIONS

Both dexmedetomidine and diltiazem were safe and effective in attenuating the hemodynamic response following laryngoscopy and endotracheal intubation; however, between two trial drugs, dexmedetomidine had a better response.

Factors that affect the onset of action of non-depolarizing neuromuscular blocking agents

Neuromuscular blockade plays an important role in the safe management of patient airways, surgical field improvement, and respiratory care. Rapid-sequence induction of anesthesia is indispensable to emergency surgery and obstetric anesthesia, and its purpose is to obtain a stable airway, adequate depth of anesthesia, and appropriate respiration within a short period of time without causing irritation or damage to the patient. There has been a continued search for new neuromuscular blocking drugs (NMBDs) with a rapid onset of action. Factors that affect the onset time include the potency of the NMBDs, the rate of NMBDs reaching the effect site, the onset time by dose control, metabolism and elimination of NMBDs, buffered diffusion to the effect site, nicotinic acetylcholine receptor subunit affinity, drugs that affect acetylcholine (ACh) production and release at the neuromuscular junction, drugs that inhibit plasma cholinesterase, presynaptic receptors responsible for ACh release at the neuromuscular junction, anesthetics or drugs that affect muscle contractility, site and methods for monitoring neuromuscular function, individual variability, and coexisting disease. NMBDs with rapid onset without major adverse events are expected in the next few years, and the development of lower potency NMBDs will continue. Anesthesiologists should be aware of the use of NMBDs in the management of anesthesia. The choice of NMBD and determination of the appropriate dosage to modulate neuromuscular blockade characteristics such as onset time and duration of neuromuscular blockade should be considered along with factors that affect the effects of the NMBDs. In this review, we discuss the factors that affect the onset time of NMBDs.

Comparison of efficacy of continuous epidural block and pulsed radiofrequency to the dorsal root ganglion for management of pain persisting beyond the acute phase of herpes zoster

Background

There is little evidence regarding the effectiveness of intervention methods in the treatment of zoster-related pain (ZAP) after the acute phase of zoster. Generally, if ZAP remains after more than 180 days from its onset, the likelihood of pain reduction is very low; this condition is considered as a “well established” post-herpetic neuralgia (PHN). Although the clinical efficacy of intrathecal steroid injection and spinal cord stimulation (SCS) for ZAP management has been reported, these interventions are not widely used due to inherent disadvantages. Continuous epidural block is widely used in clinical practice, and the effectiveness of pulsed radiofrequency (PRF) to the dorsal root ganglion (DRG) in the treatment of ZAP already has been reported.

Objectives

The purpose of this study was to compare the clinical efficacy of continuous epidural block and DRG PRF beyond acute phase of zoster, bur before PHN was well established (from 30 days to180 days after zoster onset).

Study design

Retrospective comparative study.

Methods

A total of 42 medical records were analyzed. Patients were divided into two groups according to the type of procedure utilized: continuous epidural block (continuous epidural group) and DRG PRF (PRF group). The clinical efficacy of the procedure was evaluated using a numeric rating scale (NRS) and the medication dose before and 1 to 6 months after the procedure.

Results

There was a significant decrease in the NRS value with time in both groups. However, this decrease was more significant in the PRF group than in the continuous epidural group. The medication doses decreased significantly in the PRF group over time, but not in the continuous epidural group. The rate of clinically meaningful PHN (NRS≥3) was also lower in the PRF group than in the continuous epidural group.

Conclusions

This study revealed that DRG PRF was more effective than a continuous epidural block in treating ZAP after the acute phase of zoster. A neuromodulation method such as DRG PRF may be a useful option for reducing the progression of neuropathic changes caused by the persistent transmission of a pain signal after the acute phase of zoster.

Liver injury after aluminum potassium sulfate and tannic acid treatment of hemorrhoids

We are reporting a rare case of acute liver injury that developed after an internal hemorrhoid treatment with the aluminum potassium sulfate and tannic acid (ALTA) regimen. A 41-year-old man developed a fever and liver injury after undergoing internal hemorrhoid treatment with a submucosal injection of ALTA with lidocaine. The acute liver injury was classified clinically as hepatocellular and pathologically as cholestastic. We could not classify the mechanism of injury. High eosinophil and immunoglobulin E levels characterized the injury, and a drug lymphocyte stimulation test was negative on postoperative day 25. Fluid replacement for two weeks after hospitalization improved the liver injury. ALTA therapy involves injecting chemicals into the submucosa, from the rectum to the anus, and this is the first description of a case that developed a severe liver disorder after this treatment; hence, an analysis of future cases as they accumulate is desirable.

Efficacy of Stellate Ganglion Blockade Applied with Light Irradiation: A Systemic Review and Meta-analysis

OBJECTIVE

Stellate ganglion block has mostly been used to relieve symptoms of neuropathic pain; several potential complications have been reported. Noninvasive stellate ganglion block application using light irradiation (SG-LI) can be used as an alternative to conventional injection blockades. Based on the variety of application protocols among previous studies, it was needed to further identify the clinical efficacy of SG-LI in managing neuropathic pain or other disorders associated with sympathetic hyperactivity.

DESIGN

A comprehensive search of online databases was performed to identify experimental or observational studies reporting the efficacy of SG-LI in treating patients with disorders requiring sympatholytic management. The included studies were subjected to a meta-analysis and risk-of-bias assessment.

RESULTS

Twenty-one experimental studies with a Physiotherapy Evidence Database score of 6/10 and 5 observational studies with a Newcastle-Ottawa scale score of 7/9 were included in the analysis. A significant effect on pain relief favoring SG-LI was identified at a standard mean difference (SMD) of -2.05 [95% confidence interval (CI), -2.49 to -1.61; P < 0.00001]. Similar effects favoring SG-LI were found in peripheral blood flow (SMD, 1.26; 95% CI, 0.26-2.25; P = 0.01) and skin temperature (SMD, 1.31; 95% CI, 0.55, 2.08; P = 0.0007).

CONCLUSIONS

Stellate ganglion block application using light irradiation effectively relieves pain of various etiologies and successfully induces a sympatholytic response. Stellate ganglion block application using light irradiation may be a valuable addition to the contemporary pain management armamentarium.

A lateral paracarotid approach for ultrasound-guided stellate ganglion block with a linear probe

Recent reports suggest that ultrasound-guided stellate ganglion block (SGB) is safer and more accurate than classic SGB by the using the surface anatomical landmark. However, previous reports concern the classic paratracheal approach using a small specialized curved probe, which may not be appropriate in some patients. The authors have attempted several approaches, including paratracheal, trans-thyroidal, lateral paracarotid, and lateral approaches, to find a safe and suitable method for real-time ultrasound-guided SGB using a standard high-frequency linear probe. A total of 27 injections were performed on 27 patients with sensorineural hearing loss. The lateral paracarotid out-of-plane and lateral in-plane approaches were identified as the easiest and safest methods among the four tested. In this report, we describe a new lateral paracarotid approach for ultrasound-guided SGB. An ipsilateral paratracheal short-axis transverse scan was acquired at the C6 level with a linear probe (6-13 MHz). The probe was moved laterally, scanning the thyroid, carotid artery, internal jugular vein, longus colli muscle, and the transverse process of the C6, placing the carotid artery in the middle of the view. Light pressure was applied to the probe postero-medially to displace the carotid artery medially and completely compress the internal jugular vein. The needle was inserted out-of-plane between the lateral margin of the carotid artery and Chassaignac's tubercle, traversing the collapsed internal jugular vein, and targeted between the longus colli muscle and the prevertebral fascia. A total of 4 ml of 0.2% ropivacaine was injected for each procedure after a negative aspiration test. Successful blockade was confirmed with the onset of Horner's sign. All 27 injections resulted in successful blockade with Horner's sign presenting within 5 min after injection. Side effects were minor and caused minimal discomfort; they included hoarseness and a foreign body sensation. No hematomas formed after any injections. We suggest that this new lateral paracarotid approach, with out-of plane needle insertion at the C6 tubercle under transverse scan, is a convenient and safe method for performing real-time ultrasound-guided SGB, as it provides a wide, safe space for needle passage without risking thyroid or esophageal injury.

Looking back to move forward: a twenty-year audit of herpes zoster in Asia-Pacific

Background

Herpes zoster (HZ) is a prevalent viral disease that inflicts substantial morbidity and associated healthcare and socioeconomic burdens. Current treatments are not fully effective, especially among the most vulnerable patients. Although widely recommended, vaccination against HZ is not routine; barriers in Asia-Pacific include long-standing neglect of adult immunisation and sparse local data. To address knowledge gaps, raise awareness, and disseminate best practice, we reviewed recent data and guidelines on HZ from the Asia-Pacific region.

Methods

We searched PubMed, Scopus, and World Health Organization databases for articles about HZ published from 1994 to 2014 by authors from Australia, China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, New Zealand, the Philippines, Singapore, Taiwan, Thailand, and Vietnam. We selected articles about epidemiology, burden, complications, comorbidities, management, prevention, and recommendations/guidelines. Internet searches retrieved additional HZ immunisation guidelines.

Results

From 4007 retrieved articles, we screened-out 1501 duplicates and excluded 1264 extraneous articles, leaving 1242 unique articles. We found guidelines on adult immunisation from Australia, India, Indonesia, Malaysia, New Zealand, the Philippines, South Korea, and Thailand.

HZ epidemiology in Asia-Pacific is similar to elsewhere; incidence rises with age and peaks at around 70 years – lifetime risk is approximately one-third. Average incidence of 3–10/1000 person-years is rising at around 5% per year. The principal risk factors are immunosenescence and immunosuppression. HZ almost always causes pain, and post-herpetic neuralgia is its most common complication. Half or more of hospitalised HZ patients have post-herpetic neuralgia, secondary infections, or inflammatory sequelae that are occasionally fatal. These disease burdens severely diminish patients’ quality of life and incur heavy healthcare utilisation.

Conclusions

Several countries have abundant data on HZ, but others, especially in South-East Asia, very few. However, Asia-Pacific countries generally lack data on HZ vaccine safety, efficacy and cost-effectiveness. Physicians treating HZ and its complications in Asia-Pacific face familiar challenges but, with a vast aged population, Asia bears a unique and growing burden of disease. Given the strong rationale for prevention, most adult immunisation guidelines include HZ vaccine, yet it remains underused. We urge all stakeholders to give higher priority to adult immunisation in general and HZ in particular.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2198-y) contains supplementary material, which is available to authorized users.

Association of cigarette smoking with a past history and incidence of herpes zoster in the general Japanese population: the SHEZ Study

Few studies have examined the impact of cigarette smoking on the risk for herpes zoster. The Shozu Herpes Zoster (SHEZ) Study is a community-based prospective cohort study over 3 years in Japan aiming to clarify the incidence and predictive and immunological factors for herpes zoster. We investigated the associations of smoking status with past history and incidence of herpes zoster. A total of 12 351 participants provided valid information on smoking status and past history of herpes zoster at baseline survey. Smoking status was classified into three categories (current, former, never smoker), and if currently smoking, the number of cigarettes consumed per day was recorded. The participants were under the active surveillance for first-ever incident herpes zoster for 3 years. We used a logistic regression model for the cross-sectional study on the association between smoking status and past history of herpes zoster, and a Cox proportional hazards regression model for the cohort study on the association with risk of incidence. The multivariable adjusted odd ratios (95% CI) of past history of herpes zoster for current vs. never smokers were 0·67 (0·54–0·80) for total subjects, 0·72 (0·56–0·93) for men and 0·65 (0·44–0·96) for women. The multivariable adjusted hazard ratios (95% CI) of incident herpes zoster for current vs. never smokers were 0·52 (0·33–0·81) for total subjects, 0·49 (0·29–0·83) for men and 0·52 (0·19–1·39) for women. Smoking status was inversely associated with the prevalence and incidence of herpes zoster in the general population of men and women aged ⩾50 years.

Risk Vessels of Retropharyngeal Hematoma During Stellate Ganglion Block

BACKGROUND AND OBJECTIVE

Bleeding into the retropharyngeal space is a potential complication in stellate ganglion block (SGB). Retropharyngeal hematoma formation is considered to be due to damage of small arteries in the region, although only scanty details of the region are available. The aim of this study was to map the risk blood vessels in the retropharyngeal space to avoid accidental damage during SGB.

METHODS

Contrast-enhanced 3-dimensional computed tomography images performed on 80 patients were reanalyzed retrospectively to construct detailed map of cervical blood vessels that are prone to damage and bleeding during SGB.

RESULTS

Of the 160 bilateral necks, 6 (3.8%) and 82 (51.3%) small arteries were identified in the medial portions of the ventral surface of the transverse processes of the sixth and seventh cervical vertebrae, respectively. In particular, 5 of the 6 small arteries detected in the medial portion of the ventral surface of the transverse process of the sixth cervical vertebra were the inferior thyroid artery (ITA). Of the 160 vertebral arteries, 2 arteries were missing, 4 (2.5%) entered the transverse foramen of the fifth cervical vertebra, whereas 1 artery (0.6%) entered the transverse foramen of the fourth cervical vertebra.

CONCLUSIONS

Three-dimensional computed tomography identified the ITA in the medial portion of the ventral surface of the transverse process of the sixth cervical vertebra. The risk vessels of retropharyngeal hematoma during SGB could include the ITA.

Effects of applying nerve blocks to prevent postherpetic neuralgia in patients with acute herpes zoster: a systematic review and meta-analysis

BACKGROUND

Postherpetic neuralgia (PHN) is a common and painful complication of acute herpes zoster. In some cases, it is refractory to medical treatment. Preventing its occurrence is an important issue. We hypothesized that applying nerve blocks during the acute phase of herpes zoster could reduce PHN incidence by attenuating central sensitization and minimizing nerve damage and the anti-inflammatory effects of local anesthetics and steroids.

METHODS

This systematic review and meta-analysis evaluates the efficacy of using nerve blocks to prevent PHN. We searched the MEDLINE, EMBASE, Cochrane Library, ClinicalTrials.gov and KoreaMed databases without language restrictions on April, 30 2014. We included all randomized controlled trials performed within 3 weeks after the onset of herpes zoster in order to compare nerve blocks vs active placebo and standard therapy.

RESULTS

Nine trials were included in this systematic review and meta-analysis. Nerve blocks reduced the duration of herpes zoster-related pain and PHN incidence of at 3, 6, and 12 months after final intervention. Stellate ganglion block and single epidural injection did not achieve positive outcomes, but administering paravertebral blockage and continuous/repeated epidural blocks reduced PHN incidence at 3 months. None of the included trials reported clinically meaningful serious adverse events.

CONCLUSIONS

Applying nerve blocks during the acute phase of the herpes zoster shortens the duration of zoster-related pain, and somatic blocks (including paravertebral and repeated/continuous epidural blocks) are recommended to prevent PHN. In future studies, consensus-based PHN definitions, clinical cutoff points that define successful treatment outcomes and standardized outcome-assessment tools will be needed.

Incidence of serum antibody titers against varicella zoster virus in Japanese patients with herpes zoster

Herpes zoster is an internal reactivation of varicella zoster virus following establishment of latent infection in the dorsal root ganglia during primary infection, which presents as chickenpox. Therefore, serologically, herpes zoster patients already have anti-varicella zoster virus immunoglobulin G at the onset of disease. Hence, positive serum antibody does not confirm the diagnosis of herpes zoster. We retrospectively investigated the incidence of varicella zoster virus-specific complement fixation in 865 zoster patients at initial presentation to a dermatology clinic. As a result, 66% of patients showed negative complement fixation, with patient numbers decreasing as titer increased. Paired complement fixation tests conducted within a short period showed a marked elevation in titer, and complement fixation titer gradually decreased after a year. Furthermore, incidence showed no correlation with patient age. These observations indicate that the complement fixation titer at first visit is mainly influenced by the duration from onset to presentation at clinic. Our findings indicate that a positive complement fixation result by single-point testing confirms at least recent onset of herpes zoster, while paired tests can confirm disease when primary tests are negative.

Efficacy of Noninvasive Stellate Ganglion Blockade Performed Using Physical Agent Modalities in Patients with Sympathetic Hyperactivity-Associated Disorders: A Systematic Review and Meta-Analysis

BACKGROUND

Stellate ganglion blockade (SGB) is mainly used to relieve symptoms of neuropathic pain in conditions such as complex regional pain syndrome and has several potential complications. Noninvasive SGB performed using physical agent modalities (PAMs), such as light irradiation and electrical stimulation, can be clinically used as an alternative to conventional invasive SGB. However, its application protocols vary and its clinical efficacy remains controversial. This study investigated the use of noninvasive SGB for managing neuropathic pain or other disorders associated with sympathetic hyperactivity.

MATERIALS AND METHODS

We performed a comprehensive search of the following online databases: Medline, PubMed, Excerpta Medica Database, Cochrane Library Database, Ovid MEDLINE, Europe PubMed Central, EBSCOhost Research Databases, CINAHL, ProQuest Research Library, Physiotherapy Evidence Database, WorldWideScience, BIOSIS, and Google Scholar. We identified and included quasi-randomized or randomized controlled trials reporting the efficacy of SGB performed using therapeutic ultrasound, transcutaneous electrical nerve stimulation, light irradiation using low-level laser therapy, or xenon light or linearly polarized near-infrared light irradiation near or over the stellate ganglion region in treating complex regional pain syndrome or disorders requiring sympatholytic management. The included articles were subjected to a meta-analysis and risk of bias assessment.

RESULTS

Nine randomized and four quasi-randomized controlled trials were included. Eleven trials had good methodological quality with a Physiotherapy Evidence Database (PEDro) score of ≥6, whereas the remaining two trials had a PEDro score of <6. The meta-analysis results revealed that the efficacy of noninvasive SGB on 100-mm visual analog pain score is higher than that of a placebo or active control (weighted mean difference, -21.59 mm; 95% CI, -34.25, -8.94; p = 0.0008).

CONCLUSIONS

Noninvasive SGB performed using PAMs effectively relieves pain of various etiologies, making it a valuable addition to the contemporary pain management armamentarium. However, this evidence is limited by the potential risk of bias.

Efficacy of continuous epidural block in acute herpes zoster: Incidence and predictive factors of postherpetic neuralgia, a retrospective single-center study

The aim of the present study was to investigate efficacy of continuous epidural block for prevent postherpetic neuralgia (PHN) progression in cases of acute herpes zoster with severe pain and also to identify predictive factors for PHN in such conditions.We retrospectively analyzed the clinical data of patients with herpes zoster who underwent continuous epidural block between March 2013 and October 2015. Time points were set as 1 month, 3 months, and 6 months after zoster onset. PHN was defined as the presence of pain with NRS ≥3 at certain time points.The incidence of developing PHN was 38.1%, 27.0%, and 19.0% 1 month, 3 months, and 6 months after zoster onset, respectively. Age and duration of catheterization were predictive factors for PHN at 1 month. Age, duration of catheterization, and NRS at first visit were identified as predictive factors for PHN at 3 months. Presence of diabetes, duration of catheterization, and NRS during catheterization were significant predictive factors for PHN at 6 months.The incidence of PHN is higher in zoster patients with severe pain that requires continuous epidural block compared to incidence in the general population. Advanced age and severe initial pain intensity were predictive factors of PHN development. Prolonged catheterization resulting from weak response to treatment strongly suggested progression to PHN.

Efficacy and safety of live varicella zoster vaccine in diabetes: a randomized, double-blind, placebo-controlled trial

AIMS

To elucidate varicella zoster virus (VZV)-specific cell-mediated immunity and humoral immunogenicity against live attenuated Oka varicella zoster vaccine concurrently vaccinated with 23-valent pneumococcal polysaccharide vaccine (PPSV23) in elderly people with diabetes mellitus.

METHODS

This double-blind randomized controlled single-centre study of 60-70-year-old people with diabetes compared immunity and safety profiles 3 months after one dose of varicella zoster vaccine or placebo. PPSV23 was immunized simultaneously. Primary analysis evaluated cell-mediated immunity using the VZV skin test. Secondary analyses were a VZV interferon-γ enzyme-linked immunospot (ELISPOT) assay and immunoadherence haemagglutination test. Adverse experiences were recorded using diary questionnaires.

RESULTS

By intent-to-treat analysis, 27 participants with diabetes who had been administered the vaccine were compared with 27 participants who were given a placebo. Changes in skin test scores were 0.41 ± 0.80 and 0.11 ± 0.93 (P = 0.2155), and geometric mean fold rises of the ELISPOT counts were 1.2 [95% confidence interval (CI) 0.2, 7.9] and 1.2 (95% CI 0.2, 7.3) (P = 0.989) in the vaccine and placebo groups, respectively. The geometric mean titre did not increase 3 months after vaccination in either group. No vaccination-related severe adverse experience was reported and no participant developed herpes zoster.

DISCUSSION

Our previous results demonstrated that varicella zoster vaccine safely enhanced VZV-specific immunity in elderly people with or without diabetes. The results of this study showed that varicella zoster vaccine can be used safely, but it cannot boost virus-specific immunity in elderly people with diabetes when administered with concurrent PPSV23. Alternative strategies are needed to prevent VZV-associated diseases in this population.

Clinical and immunologic features of recurrent herpes zoster (HZ)

BACKGROUND

Recurrent herpes zoster (HZ) is thought to be rare, but there have been few large-scale studies of recurrent HZ.

OBJECTIVE

We conducted a large-scale prospective cohort study to characterize recurrent HZ.

METHODS

We examined 12,522 participants aged 50 years or older in Shozu County and followed them up for 3 years. We compared the incidence of HZ and postherpetic neuralgia, severity of skin lesions and acute pain, cell-mediated immunity, and varicella-zoster virus-specific antibody titer between primary and recurrent HZ.

RESULTS

A total of 401 participants developed HZ: 341 with primary HZ and 60 with recurrent HZ. Skin lesions and acute pain were significantly milder and the incidence of postherpetic neuralgia was lower in patients aged 50 to 79 years with recurrent HZ than in those with primary HZ. Varicella-zoster virus skin test induced a stronger reaction in patients aged 50 to 79 years with recurrent HZ than in those with primary HZ.

LIMITATIONS

Information on previous HZ episodes was self-reported by participants, so it could not be confirmed that they actually had a history of HZ.

CONCLUSION

Recurrent HZ was associated with milder clinical symptoms than primary HZ, probably because of stronger varicella-zoster virus-specific cell-mediated immunity in the patients with recurrence.

Stellate Ganglion Block for Debilitating Photophobia Secondary to Trigeminal, Postherpetic Neuralgia

OBJECTIVES

The primary objective of this case report was to demonstrate the therapeutic benefit of stellate ganglion block in trigeminal postherpetic neuralgia.

METHODS

This was a case report on a single patient who presented with debilitating photophobia secondary to left-sided trigeminal postherpetic neuralgia. A left-sided stellate ganglion block was performed on the patient under fluoroscopic guidance. The primary endpoints were VAS pain scores and changes in functional capacity.

RESULTS

The patient demonstrated significant reduction in her VAS pain score and improved functional capacity for approximately 6 months after the intervention. This case report provides evidence that sympathectomy via a stellate ganglion block can treat photophobia secondary to postherpetic neuralgia in the V1 distribution.

Development of varicella vaccine in Japan and future prospects

In Japan, Dr. Michiaki Takahashi (1928-2013) successfully developed the first live attenuated varicella vaccine in the world. The virus used for this vaccine was varicella-zoster virus isolated from the vesicular fluid of a child with typical varicella and it was named the Oka strain after the family name of the child. In 1974, a patient with nephrosis developed varicella in the Pediatric Ward, and uninfected pediatric patients received varicella vaccine immediately. As a result, there were no cases of varicella in the other children and all of the vaccinated children acquired immunity to the disease. These results were published in the Lancet, demonstrating the safety and efficacy of varicella Oka strain vaccine for the first time. When clinical studies were conducted at the start of vaccine development, most of the subjects were pediatric patients with a high risk of contracting severe varicella. Therefore, the development process was different from that for other vaccines, since clinical studies are generally performed in healthy individuals. This vaccine was approved in Japan in 1986, and voluntary single-dose vaccination for children aged 1 year or older was started in 1987. However, the vaccination coverage rate remained low and the number of patients with varicella did not decrease significantly. Due to its voluntary status, the cost of vaccination was borne by the child's family and this was considered to be a reason for the low coverage rate. Moreover, although the vaccine achieved a good antibody response, the number of cases of breakthrough varicella (BV) was relatively high and showed an increasing trend that was also a concern. In order to increase the coverage rate and reduce BV, the Japanese government changed the varicella vaccination policy from voluntary to routine vaccination in October 2014. At the same time, a two-dose schedule was introduced that involved administration of the vaccine twice at an interval of at least 3 months up to the age of 3 years. At present, cases of varicella are only monitored at the pediatric sentinel clinics in Japan. Therefore, we need to establish a system to survey all patients, in order to demonstrate the efficacy of varicella vaccine based on detailed surveillance data. We also need to investigate the optimum timing of the second dose of the vaccine and the necessity for further booster vaccination. A combined live vaccine containing varicella vaccine has not yet been approved in Japan. Because of the greater convenience of combined vaccines, development and introduction of such a vaccine in the future would be desirable. Routine varicella vaccination is also expected to eventually reduce the occurrence of herpes zoster, although there are no supporting epidemiological data. The prevalence of herpes zoster has attracted attention, but it is necessary to develop a surveillance system for this disease. In March 2016, use of varicella vaccine to prevent herpes zoster in adults aged 50 years or older was approved in Japan, and the results of this policy change need to be assessed.

Efficacy of a New Blind Insertion Technique of Arndt Endobronchial Blocker for Lung Isolation: Comparison With Conventional Bronchoscope-Guided Insertion Technique-A Pilot Study

This study aimed to find other methods of blind insertion of Arndt endobronchial blocker (AEB) for lung isolation when a fiberoptic bronchoscope (FOB) is unavailable.We compared the effectiveness and safety of 3 insertion techniques of AEB: Gum elastic bougie (GEB)-, bougie combined with cricoid displacing (BCD)-, and fiberoptic bronchoscope (FOB)-guided insertion. Seventy-eight patients undergoing esophageal procedure and requiring left thoracotomy were randomly assigned to 1 of 3 groups: GEB group, BCD group, and FOB group. We recorded the successful placement of AEBs at first attempt, placement time, malposition of AEBs in supine and lateral decubitus position, the bronchus injury score, and other complications.The successful placement of AEB for the first attempt was 22/26, 25/26, and 26/26 patients in GEB, BCD, and FOB groups, respectively. The placement times in GEB and BCD groups were longer than those in the FOB group (P < 0.05). AEB malposition occurred in 1/26, 2/26, 1/26 patients after lateral decubitus position, and AEBs were repositioned in 5/26, 3/26, 1/26 patients by FOB due to poor lung isolation in GEB, BCD, and FOB groups, respectively. There was no difference for the bronchus injury scores and other complications among 3 groups (P > 0.05).Bougie and cricoid displacing-guided blind insertion of AEB seems to be a novel method, which is an effective and safe alternative when FOB was unavailable.

Evaluation of new approach to ultrasound guided stellate ganglion block

BACKGROUND

Ultrasound imaging is an ideal tool for stellate ganglion block (SGB) due to clarity, portability, lack of radiation, and low cost. Ultrasound guided anterior approach requires the application of pressure to the anterior neck and is associated with more risk of injury to inferior thyroid artery, vertebral artery, and esophagus. The lateral approach does not interfere with nerve or vascular structures. Blockade at the C6 vertebral level results in more successful sympathetic blockade of the head and neck with less sympathetic blockade of the upper extremity compared to sympathetic blockade at C7 vertebral level, which produces successful sympathetic blockade of upper extremity. This is helpful in patients of complex regional pain syndrome of the upper limb. Hence, we conducted a study using the lateral approach at C7 level.

MATERIALS AND METHODS

Ultrasound guided SGBs using lateral in-plane technique at C7 level were given in 20 patients suffering from chronic pain patients of upper extremity, head, and neck using 4 ml of 0.25% bupivacaine and 1 ml of 40 mg triamcinolone. The patients were assessed for a numeric pain intensity score (NPIS), the rise in axillary temperature, the range of motion of joints of upper extremity, and resolution of edema at various time intervals up to 3 months.

RESULTS

NPIS showed a statistically significant decrease from baseline at 30 min, which was sustained till 3(rd) month. The rise in axillary temperature after the block was statistically significant, which was sustained till 2(nd) week. The edema score decreased significantly at all-time intervals (P ≤ 0.001). The restriction of motion in all joints of upper limb decreased from 13 to 3 patients.

CONCLUSION

There is a significant variation in the anatomy of stellate ganglion at the level of C6 and C7. Ultrasound guided lateral approach increases the efficacy of SGB by deposition of drug subfascially with real-time imaging.

Holt-Oram Syndrome Associated with Aortic Atresia: A Rare Association

Holt-Oram syndrome (HOS) is a rare autosomal dominant disorder that causes abnormalities of the upper limbs and heart. It is seen in 1:1, 00, 000 live births. It is linked to a single-gene TBX5 “protein-producing” mutation with gene map locus 12q24. Most commonly it is characterized by the cardiac septation defects and pre-axial radial ray abnormalities. We are reporting a case of HOS with aortic atresia which is a rare association.

[Relation between disease modifying anti-rheumatic drugs and herpes zoster in rheumatoid arthritis]

Biologics have revolutionized the treatment of rheumatoid arthritis (RA). However certain amount of the patients cannot achieve goal of therapy. Recently, compounds targeting the intracellular kinase, Janus kinase (JAK) have demonstrated therapeutic effects resembling biologics. Tofacitinib is the only JAK inhibitor approved for RA and during the clinical trial, increased events of herpes zoster (HZ) was observed. Incidence rate was twice as much as patients treated with conventional anti-rheumatic drug and was especially increased in Japan that was four times as much. The risk factors were age and glucocorticoid that is identical to that of common RA patients and there was nothing specific for tofacitinib. Mechanism of increased incidence of HZ and the difference in ethnicity remains unknown. Analysis of clinical trials have identified that HZ do not correlate with further adverse events. Therefore, it is extremely important to accumulate clinical data with considerable amount of patients with long term follow up including the post marketing surveillance in Japan to reveal the significance of increased HZ in RA patients.

CHD associated with syndromic diagnoses: peri-operative risk factors and early outcomes

CHD is frequently associated with a genetic syndrome. These syndromes often present specific cardiovascular and non-cardiovascular co-morbidities that confer significant peri-operative risks affecting multiple organ systems. Although surgical outcomes have improved over time, these co-morbidities continue to contribute substantially to poor peri-operative mortality and morbidity outcomes. Peri-operative morbidity may have long-standing ramifications on neurodevelopment and overall health. Recognising the cardiovascular and non-cardiovascular risks associated with specific syndromic diagnoses will facilitate expectant management, early detection of clinical problems, and improved outcomes--for example, the development of syndrome-based protocols for peri-operative evaluation and prophylactic actions may improve outcomes for the more frequently encountered syndromes such as 22q11 deletion syndrome.

Treatment of herpes zoster with ultrasound-guided superficial cervical plexus block

Herpes zoster most commonly occurs in elderly patients, and usually affects sensory neurons. Therefore, its characteristic symptoms are segmental pain, itching, and sensory changes in the affected areas. A 71-yr-old woman experienced painful herpetic rash on the right cervical 2-4 dermatomes for 16 days. Two days after the onset of the rash, she was diagnosed with herpes zoster, and prescribed 250 mg famciclovir three times a day for 7 days, pregabalin 150 mg twice a day, and tramadol 150 mg once a day for 14 days, by a dermatologist. Despite medication, her pain was rated at an intensity of 6/10 on the numeric rating scale. In addition, she complained of severe itching sensation on the affected dermatomes. Superficial cervical plexus block (SCPB) was performed at the right C4 level with 15 ml 0.5% lidocaine plus triamcinolone 30 mg. Five days after the procedure, pain and itching completely disappeared. SCPB may be an effective option for the treatment of acute pain and itching arising from herpes zoster, and for the prevention of postherpetic neuralgia.

[Tropical spastic paraparesis - anesthetic approach]

INTRODUCTION

HTLV-1 infection is endemic in Japan, Caribbean, Africa, and South America. It is transmitted from mother to child, sexual contact, blood transfusions, or sharing needles. Tropical Spastic paraparesis (TSP) is a chronic degenerative neurological disease associated with this infection. It results from a spinal cord symmetrical degeneration at the thoracic level and is characterized by progressive motor weakness in the lower limbs, hyperreflexia, sensitivity changes, urinary incontinence, and bladder dysfunction.

CLINICAL CASE

Female, 53 years old, HTLV-1 infection and TSP. She had decreased strength in the lower limbs and hyperreflexia, paretic gait, spasticity, and neurogenic bladder symptoms, with recurrent urinary infections. She was scheduled for cystectomy. The patient was monitored according to standard ASA. Due to severe coagulopathy and the possibility of neurological worsening, epidural catheter was not placed. The induction of general anesthesia was performed with midazolam and fentanyl, followed by etomidate and cisatracurium. She was intubated with a tube size seven and maintained with desflurane and oxygen. Anesthesia was uneventful; the surgery lasted 1 hour and 50minutes. There were no complications in the immediate postoperative period, during hospitalization, nor deterioration of the neurological examination. The patient was discharged 20 days later.

DISCUSSION/CONCLUSION

There are reports of decreased electromyographic response and neurological deterioration associated with propofol in these patients, etomidate was used. The hepatic metabolism of rocuronium posed a risk, we chose to use cistracurium. It was concluded that the anesthesia chosen did not affect the course of the disease.

Functional decline and herpes zoster in older people: an interplay of multiple factors

Herpes zoster is a frequent painful infectious disease whose incidence and severity increase with age. In older people, there is a strong bidirectional link between herpes zoster and functional decline, which refers to a decrement in ability to perform activities of daily living due to ageing and disabilities. However, the exact nature of such link remains poorly established. Based on the opinion from a multidisciplinary group of experts, we here propose a new model to account for the interplay between infection, somatic/psychiatric comorbidity, coping skills, polypharmacy, and age, which may account for the functional decline related to herpes zoster in older patients. This model integrates the risk of decompensation of underlying disease; the risk of pain becoming chronic (e.g. postherpetic neuralgia); the risk of herpes zoster non-pain complications; the detrimental impact of herpes zoster on quality of life, functioning, and mood; the therapeutic difficulties due to multimorbidity, polypharmacy, and ageing; and the role of stressful life events in the infection itself and comorbid depression. This model underlines the importance of early treatment, strengthening coping, and vaccine prevention.