Use of S-LANSS, a tool for screening neuropathic pain, for predicting postherpetic neuralgia in patients after acute herpes zoster events: a single-center, 12-month, prospective cohort study

A systematic literature review of the epidemiology and burden of herpes zoster in selected locales in Asia Pacific

Herpes zoster (HZ) is a painful rash which typically affects older adults. This is of concern in Asia-Pacific given its aging population. As HZ epidemiology and burden are evolving, this systematic literature review aimed to update the current understanding of HZ burden and associated costs for selected Asia-Pacific locales. MEDLINE and Embase were searched for English articles of HZ studies conducted in Australia, China, Hong Kong, Japan, Korea, New Zealand, Singapore, and Taiwan. Eligible outcomes included HZ incidence and prevalence, occurrence of HZ-related complications, healthcare resource utilization, costs, and HZ-associated quality of life outcomes. This paper focused on HZ data in the general adult population (N = 90 articles). Substantial HZ-related disease and economic burden were observed in these locales, consistent with global trends. These findings reinforce the increasing burden of HZ and need for preventive strategies, which may include raising awareness and encouraging timely vaccination.

The Incidence of Herpes Zoster Complications: A Systematic Literature Review

INTRODUCTION

The objective of this work was to summarize the incidence of herpes zoster (HZ) complications in different populations.

METHODS

Systematic literature review of PubMed, Embase, and Virtual Health Library records between January 1, 2002 and October 20, 2022 using search strings for HZ, complications, and frequency measurements.

RESULTS

The review included 124 studies, most conducted in the general population (n = 93) and on individuals with comorbidities (n = 41) ≥ 18 years of age. Most studies were conducted in Europe (n = 44), Asia (n = 40), and North America (n = 36). Postherpetic neuralgia (PHN) was the most studied neurological complication. Variable relative PHN incidence was found in the general population (2.6-46.7%) or based on diagnosis: immunocompromised (3.9-33.8%), depression (0-50%), and human immunodeficiency virus (HIV) (6.1-40.2%). High incidence rates were observed in hematological malignancies (HM) and solid organ malignancies (132.5 and 93.7 per 1000 person-years, respectively). Ocular complications were frequently reported with herpes zoster ophthalmicus (HZO). The relative incidence (incidence rate) of HZO in the general population was reported as 1.4-15.9% (0.31-0.35 per 1000 person-years). High relative incidence was observed in HIV (up to 10.1%) and HM (3.2-11.3%). Disseminated HZ was the most frequently reported cutaneous complication. The relative incidence of disseminated HZ was 0.3-8.2% in the general population, 0-0.5% in the immunocompetent, and 0-20.6% in patients with comorbidities. High relative incidence was reported in HM and solid organ transplant (up to 19.3% and 14.8%, respectively).

DISCUSSION

Most reported complications were neurological (n = 110), ocular (n = 48), and cutaneous (n = 38). Few studies stratified complications by age or gender (or both). Incidence appeared higher in select immunocompromised populations. Higher incidence was associated with older age in several studies; the general association with gender was unclear.

CONCLUSIONS

Variable incidence of HZ complications was reported by population subgroup. Further research is required to quantitatively analyze incidence by age, gender, and location.

A new susceptibility index to predict the risk of severe herpes zoster-associated pain: A Japanese regional population-based cohort study, the Shizuoka study

BACKGROUND

Approximately 7-20% of patients with herpes zoster (HZ) develop zoster-associated pain (ZAP). ZAP not only impairs quality of life and psychological well-being, but also can reduce work effectiveness, which has negative economic effects. Reports of ZAP risk factors are inconsistent.

OBJECTIVE

To confirm risk factors for the development of severe ZAP in HZ patients in Japan using a large-scale database, the Shizuoka Kokuho Database.

METHODS

A population-based cohort study using the Shizuoka Kokuho Database was conducted. Of 792,647 patients, 7491 (0.95%) experienced "severe ZAP" (as defined in this study). We developed a ZAP risk prediction scoring system by identifying risk factors using logistic regression analysis of several candidate risk factors for severe ZAP: age, sex, seasonality, and presence of comorbidities (using the Charlson comorbidity index), excluding HIV/AIDS.

RESULTS

We identified peripheral vascular disease and the onset from October to December as novel risk factors for severe ZAP, in addition to the previously reported risk factors of age and comorbidities (cerebral vascular disease, chronic pulmonary disease, rheumatic disease, peptic ulcer, liver disease, diabetes, and malignant neoplasms with/without metastasis). In contrast, dementia was found to reduce ZAP risk. We developed a susceptibility index to predict the risk of ZAP.

CONCLUSION

We newly demonstrated that peripheral vascular disease and the onset from October to December are ZAP risk factors. Our comorbidity findings support previous observations. The susceptibility index proposed here provides a new approach to the prevention of ZAP using early intervention for high-risk patients.

Validation of the Nepali Version of the Self-reported Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) in Adults With Chronic Pain and Predominantly Low-literacy Levels

Neuropathic pain research and clinical care is limited in low- and middle-income countries with high prevalence of chronic pain such as Nepal. We translated and cross-culturally adapted the Self-report version of the Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS)-a commonly used, reliable and valid instrument to screen for pain of predominantly neuropathic origin (POPNO)-into Nepali (S-LANSS-NP) and validated it using recommended guidelines. We recruited 30 patients with chronic pain in an outpatient setting for cognitive debriefing and recruited 287 individuals with chronic pain via door-to-door interviews for validation. For known-group validity, we hypothesized that the POPNO group would report significantly more pain intensity and pain interference than the chronic pain group without POPNO using a cut-off score of ≥10/24. The S-LANSS-NP was comprehensible based on the ease of understanding the questionnaire and lack of missing responses. The validation sample consisted of predominantly low-levels of literacy (81% had 5 years or less education); 23% were classified as having POPNO. Internal consistency was good (alpha = .80). Known-group validity was supported (chronic pain with POPNO reported significantly greater pain intensity than those without). The S-LANSS-NP is a comprehensible, unidimensional, internally consistent, and valid instrument to screen POPNO in individuals with chronic pain with predominantly low-levels of literacy for clinical and research use. PERSPECTIVE: This paper shows that the Nepali version of the S-LANSS is comprehensible, reliable and valid in adults with chronic pain and predominantly low-levels of literacy in rural Nepal. The study could potentially develop research and clinical care of neuropathic pain in this resource-limited setting where chronic pain is a significant problem.

Circulating Level of Myelin Basic Protein Predicts Postherpetic Neuralgia: A Prospective Study

OBJECTIVES

Patients with herpes zoster (HZ) would benefit from accurate prediction of whether they are likely to develop postherpetic neuralgia (PHN). We investigated whether a circulating biomarker of neuronal damage could be a predictor of PHN in this nonmatched prospective, nested, case-control study.

MATERIALS AND METHODS

We included patients with HZ who were within 90 days after rash onset. Volunteers without a history of HZ were recruited as controls. We evaluated epidemiologic factors and circulating neuronal damage biomarkers, including cell-free DNA, myelin basic protein (MBP), and soluble protein-100B (S100B). We conducted logistic regression analyses to develop a prediction model of PHN.

RESULTS

We found that cell-free DNA and MBP levels were higher in patients with HZ (n=71) than in controls (n=37). However, only MBP level was higher in patients who developed PHN (n=25), in comparison with those who did not (n=46). MBP level and 3 clinical factors, age, acute pain severity, and response to treatment drugs were identified as independent predictors of PHN. Receiver operating characteristic (ROC) curve analysis showed that the prediction made using a combination of MBP level and clinical factors had an area under ROC curve of 0.853 (95% confidence interval: 0.764 to 0.943), which was better than prediction using clinical factors alone (area under ROC curve: 0.823, 95% confidence interval: 0.728 to 0.917).

DISCUSSION

Our results indicate that circulating MBP level in patients with HZ is a predictor for PHN. The combination of clinical predictors and MBP level enhanced the prediction performance.

Prevalence of peripheral neuropathy and associated pain in patients with diabetes mellitus: Evidence from a cross-sectional study

Background

Diabetic peripheral neuropathy (DPN) is the most common and troublesome complication of diabetes mellitus. It affects almost half the population with diabetes and worsens quality of life of the patient. This study was aimed to determine the prevalence of peripheral neuropathy and associated pain in patients with diabetes mellitus.

Methods

This was a cross-sectional study conducted over a period of six months. Patient's ≥ 18 years with confirmed diagnosis of diabetes mellitus were included in the study. Patients with hypothyroidism, medical illness such as cancer, liver or renal disease, cervical or lumbar spondylosis, pregnant patients with diabetes and patients receiving any treatment that might influence nerve function (e.g., cytotoxic or antiepileptic agents) were excluded from the study. DPN was diagnosed using 10 g monofilament test. The S-LANSS questionnaire was used to assess the associated painful symptoms. Association was calculated using chi-square test. A p- value of ≤0.05 was considered statistically significant. All the statistical analysis was performed using SPSS v22.

Result

The overall prevalence of DPN was found to be 28.85% from which 88% patients were found to have painful symptoms. A significant association of DPN was observed with the duration of diabetes (p = 0.004), poor glycaemic control (p = 0.03) and other diabetic complications such as nephropathy (p = 0.002). No association of neuropathy was found with retinopathy and hypertension. Duration of diabetes (>15 years), and HbA1c (>9%) was found to be positively associated the painful DPN.

Conclusion

The current study found a high prevalence of DPN and it was found to be significantly associated with duration of diabetes, poor glycaemic control and nephropathy.

Evaluation of spatio-temporal gait parameters and gait symmetry in diabetic polyneuropathic patients with burn injury: A pilot study

PURPOSE

The purpose of this study was to investigate the effects of burn injury on spatio-temporal gait parameters and gait symmetry in individuals with diabetic polyneuropathy (DPN)-related lower extremity burn injury.

METHODS

Demographic information and the physical examinations of the lower extremities of 14 patients with unilateral lower extremity burn injury due to DPN (DPN_B) and 14 uninjured patients with DPN (DPN₀) were recorded. The GAITRite computerized gait analysis system was used to evaluate the spatio-temporal parameters of gait. Symmetry Index (SI) was calculated to determine gait symmetry. The Mann Whitney U test was used to determine the demographical and clinical differences between the groups, the Wilcoxon's test was used to compare both sides of all the participants for all gait parameters and linear regression analysis was used to find the variables that affect gait parameters.

RESULTS

The groups were similar in terms of their demographic information except for age. Compared with the DPN₀ group, DPN_B group had increased extent of area with sensory loss and severity of DPN, decreased ankle joint range of motions and intrinsic foot muscles strength and they displayed lower gait speed, step length, stride length and swing percentage but their double support and stance percentage were increased.

CONCLUSION

This study results have shown that, spatio-temporal gait parameters of DPN_B patients are different. These differences in spatiotemporal parameters are found on both sides, probably owing to the symmetric and bilateral sensory loss is superior to unilateral burn injury due to symmetrical and bilateral sensory loss. Gait analysis should be considered in order to reveal the changes in gait parameters and to improve appropriate healing process of patients with DPN-related lower extremity burn injury.

The Epidemiology of Herpes Zoster and Postherpetic Neuralgia in China: Results from a Cross-Sectional Study

Introduction

Few studies have examined the epidemiology of herpes zoster (HZ) and postherpetic neuralgia (PHN) in China. The aim of this study was to estimate the prevalence of HZ and PHN in China, and to examine the clinical characteristics of patients identified with PHN.

Methods

This was a cross-sectional study conducted in 24 hospitals in seven cities in China. Prevalence of HZ and PHN was determined by physician (n = 100) chart review of patients (n = 36,170) aged ≥ 40 years seeking medical care over a 30- to 60-day period. The health history of patients identified with PHN was obtained and included time since diagnosis of HZ or PHN, time since onset of PHN-related pain, and the methods used for diagnosing HZ and PHN.

Results

The prevalence rates of HZ and PHN were 7.7% [95% confidence interval (CI) 7.5–8.0] and 2.3% (95% CI 2.2–2.5), respectively. Of patients with HZ, 29.8% developed PHN. Rates of HZ and PHN increased with age and were highest in patients aged ≥ 70 years (10.6% and 4.1%, respectively). The majority of patients with PHN were diagnosed with HZ (80.9%) and PHN (83.8%) for < 1 year, and had experienced PHN-related pain for < 1 year (80.5%). Patient description and clinical examination were most commonly used to diagnose HZ and PHN.

Conclusion

These results provide current estimates of the prevalence of HZ and PHN in the general adult population in urban China. These rates are similar to previously reported rates in China and worldwide, and highlight the global nature of HZ and PHN.

Funding

Pfizer Inc.

The characteristics of chronic pain after non-traumatic, non-compressive myelopathy: Focus on neuropathic pain

OBJECTIVES

The aim of this study was to assess the characteristics of neuropathic pain after non-traumatic, non-compressive (NTNC) myelopathy and find potential predictors for neuropathic pain.

DESIGN

We analyzed 54 patients with NTNC myelopathy. The Short Form McGill Pain Questionnaire (SF-MPQ) and the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) were used to assess pain. Health-related QOL was evaluated by the Short Form 36-item (SF-36) health survey.

RESULTS

Out of 48 patients with pain, 16 (33.3%) patients experienced neuropathic pain. Mean age was significantly lower in patients with neuropathic pain than in patients with non-neuropathic pain (39.1 ± 12.5 vs. 49.8 ± 9.3, P = 0.002). There were no statistically significant differences in the other variables including sex, etiology of myelopathy, pain and QOL scores between the two groups. A binary logistic regression revealed that onset age under 40, and non-idiopathic etiology were independent predictors of the occurrence of neuropathic pain. Both SF-MPQ and LANSS scores were significantly correlated with SF-36 scores, adjusted by age, sex, presence of diabetes mellitus, and current EDSS scores (r = -0.624, P < 0.0001 for SF-MPQ; r = -0.357, P = 0.017 for LANSS).

CONCLUSION

Neuropathic pain must be one of serious complications in patients with NTNC myelopathy and also affects their quality of life. Onset age and etiology of myelopathy are important factors in the development of neuropathic pain in NTNC myelopathy.

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.

VZV skin-test reaction, but not antibody, is an important predictive factor for postherpetic neuralgia

BACKGROUND

The decline of cell-mediated immunity (CMI) is thought to be related to the risk of postherpetic neuralgia (PHN) as well as herpes zoster (HZ). However, the relationship between immunological condition and the incidence of PHN is still unclear.

OBJECTIVE

We conducted a large-scale prospective cohort study to clarify the relationship between immunological factors for varicella-zoster virus (VZV) and the incidence of PHN.

METHODS

We carried out a cohort study on VZV immunity in a population living on an island cluster, Shozu County in Japan, and examined the people who developed HZ during a follow-up period of 3 years, with a focus on the relationship between cell-mediated and humoral immunity and the incidence of PHN. A total of 12,522 people over the age of 50 were enrolled in this study, and 401 registrants were diagnosed with HZ, including 79 PHN cases. We evaluated anatomical location and severity of skin lesion, acute pain severity, presence or absence of abnormal sensations, CMI assessed by VZV skin test, and VZV-specific antibody titer measured by serological tests.

RESULTS

The incidence of PHN was significantly associated with a weak response to the VZV skin test, as well as facial or lumbosacral localization of skin rash, severe skin lesion, severe acute pain, and presence of abnormal sensations, but not related to VZV-specific antibody titer.

CONCLUSION

The incidence of PHN is significantly associated with the decline of VZV-specific CMI, but not related to VZV-specific humoral immunity.

Systematic review of incidence and complications of herpes zoster: towards a global perspective

OBJECTIVE

The objective of this study was to characterise the incidence rates of herpes zoster (HZ), also known as shingles, and risk of complications across the world.

DESIGN

We systematically reviewed studies examining the incidence rates of HZ, temporal trends of HZ, the risk of complications including postherpetic neuralgia (PHN) and HZ-associated hospitalisation and mortality rates in the general population. The literature search was conducted using PubMed, EMBASE and the WHO library up to December 2013.

RESULTS

We included 130 studies conducted in 26 countries. The incidence rate of HZ ranged between 3 and 5/1000 person-years in North America, Europe and Asia-Pacific, based on studies using prospective surveillance, electronic medical record data or administrative data with medical record review. A temporal increase in the incidence of HZ was reported in the past several decades across seven countries, often occurring before the introduction of varicella vaccination programmes. The risk of developing PHN varied from 5% to more than 30%, depending on the type of study design, age distribution of study populations and definition. More than 30% of patients with PHN experienced persistent pain for more than 1 year. The risk of recurrence of HZ ranged from 1% to 6%, with long-term follow-up studies showing higher risk (5-6%). Hospitalisation rates ranged from 2 to 25/100 000 person-years, with higher rates among elderly populations.

CONCLUSIONS

HZ is a significant global health burden that is expected to increase as the population ages. Future research with rigorous methods is important.