Herpes Zoster (Shingles) Patient-Centered Wound Outcomes: A Literature Review

GENERAL PURPOSE

To present a comprehensive review of patient-centered outcomes of topical or systemic interventions applied to those with shingles or postherpetic neuralgia to inform clinical practice and identify related research needs.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will be able to:1. Explain the importance of early diagnosis and treatment of herpes zoster (HZ).2. Identify interventions that have resulted in documented improvement of validated patient-centered outcomes in patients with HZ or postherpetic neuralgia.3. Recognize the average per patient medical costs of HZ in the US.

WILLINGNESS TO PAY, QUALITY OF LIFE, AND KNOWLEDGE ON HERPES ZOSTER AMONG THAI PATIENTS PRIOR ZOSTER VACCINE ERA

Herpes zoster is a devastating condition affecting patients’ wellbeing. Policy on zoster vaccine in developing countries needs more data on the disease burden. This study was designed to assess willingness to pay, quality of life, and the patients’ knowledge on herpes zoster disease. All of the patients were asked to complete questionnaires about the willingness to pay for zoster treatment using the Dermatology Life Quality Index (DLQI) questionnaires in Thai version and basic knowledge about herpes zoster. The demographic and clinical data were all recorded. Eighty-two from one hundred and eighteen patients in this study were female (69.5%), and the mean (SD) age was 57.6 (14.9) years. The median of their willingness to pay for zoster treatment was THB500 (range of THB50-10,000) or only 4.2% of median income per month. The mean of total DLQI score (SD) was 10.7 (6.2), which indicated moderate to severe impact on quality of life. From multiple linear regression analysis, three factors were related to inferior patients’ quality of life including facial involvement (regression coefficients, b=4.789, p=0.001), presence of zoster complications (b=5.018, p=0.001) and advanced pain score (b=0.883, p<0.001). Moreover, more than half of them still had mistaken knowledge about the disease.

The Incidence and Risk of Herpes Zoster in Patients With Sleep Disorders: A Population-Based Cohort Study

Lack of sleep can compromise the immune system, which may reactivate latent varicella-zoster virus. Studies on sleep disorders and the risk of herpes zoster (HZ) are scant.We conducted a population-based cohort study to evaluate the risk of HZ in patients with sleep disorders and potential risk factors for HZ development. We identified patients with sleep disorders without apnea from 2002 to 2005 by using the Taiwan Longitudinal Health Insurance Database. The patients without sleep disorders were randomly selected and frequency matched with patients with sleep disorders according to age, sex, and index year. We estimated the follow-up time in person-years for the patients from the entry date until HZ diagnosis, loss to follow-up, or the end of 2010. We used Cox proportional hazards regression models and a sensitivity analysis to estimate the risk of HZ while controlling for demographic characteristics and comorbidities. A total of 131,001 study participants (follow-up, 948,177 person-years; mean age, 51.2 ± 16.5 years; 62.2% women) were included in the study. Patients with sleep disorders exhibited a higher incidence of HZ compared with a comparison cohort when stratified by age, sex, and comorbidities. After adjustment for covariates, the sleep disorder cohort exhibited a 1.23-fold greater risk of HZ compared with the comparison cohort (95% confidence interval [CI] = 1.17-1.30). The incidence of HZ increased with age. Adults ages 65 years and older exhibited a 6.11-fold greater risk of HZ development compared with their younger counterparts (95% CI = 5.34-7.00). Cancers and autoimmune diseases were independent risk factors of HZ development. The patients with sleep disorders may carry an increased risk of developing HZ.

Is herpes zoster an additional complication in old age alongside comorbidity and multiple medications? Results of the post hoc analysis of the 12-month longitudinal prospective observational ARIZONA cohort study

OBJECTIVES

To examine the burden of comorbidity, polypharmacy and herpes zoster (HZ), an infectious disease, and its main complication post-herpetic neuralgia (PHN) in young (50-70 years of age: 70-) and old (≥ 70 years of age: 70+) patients.

DESIGN

Post hoc analysis of the results of the 12-month longitudinal prospective multicentre observational ARIZONA cohort study.

SETTINGS AND PARTICIPANTS

The study took place in primary care in France from 20 November 2006 to 12 September 2008. Overall, 644 general practitioners (GPs) collected data from 1358 patients aged 50 years or more with acute eruptive HZ.

OUTCOME MEASURES

Presence of HZ-related pain or PHN (pain persisting >3 months) was documented at day 0 and at months 3, 6, and 12. To investigate HZ and PHN burden, pain, quality of life (QoL) and mood were self-assessed using validated questionnaires (Zoster Brief Pain Inventory, 12-item Short-Form health survey and Hospital Anxiety and Depression Scale, respectively).

RESULTS

As compared with younger patients, older patients more frequently presented with comorbidities, more frequently took analgesics and had poorer response on all questionnaires, indicating greater burden, at inclusion. Analgesics were more frequently prescribed to relieve acute pain or PHN in 70+ than 70- patients. Despite higher levels of medication prescription, poorer pain relief and poorer response to all questionnaires were reported in 70+ than 70- patients.

CONCLUSIONS

Occurrence of HZ and progression to PHN adds extra burden on top of pharmacological treatment and impaired quality of life, especially in older patients who already have health problems to cope with in everyday life.

[Zoster and postherpetic neuralgia: vaccine prevention is available]

Herpes zoster (HZ) infection is a common condition in the elderly. Immunosuppression involving cellular immunity favors its occurrence. The pain is the most frequent complications of HZ. It occurs in about 30% of people aged over 70 years. The virological diagnosis of typical HZ is not useful, and the diagnosis is mainly based on clinical data. Skin care is essential to limit cutaneous damage. Antiviral drugs will reduce the risk of post-herpetic neuralgia, if they are early prescribed within 72 hours after the rash onset. Analgesia is essential and should be conducted in relation evolution. Vaccination is the most effective way to prevent the occurrence of HZ complications in the elderly, in particular post-herpetic neuralgia.

Prevalence of shingles and its association with PTSD among HIV-infected women in Rwanda

OBJECTIVE

To examine the prevalence of reported shingles in the last 6 months and its association with post-traumatic stress disorder (PTSD), depression and severity of HIV disease in Rwandan women with HIV.

SETTINGS

This cross-sectional study was conducted as part of the Rwanda Women's Interassociation Study and Assessment (RWISA), an observational cohort study designed to assess the impact of HIV and residual factors from experiencing rape in the 1994 genocide in Rwandan women. Participants were recruited through grassroots women's associations of people living with HIV infection and clinical care sites for HIV infection. Most participants (58.5%, n=405/692) had PTSD.

PARTICIPANTS

This cross-sectional analysis was conducted in 710 HIV-infected women enrolled in RWISA. Inclusion criteria were: age >15 years, informed consent, HIV test, ability to complete the interview in the local language, travel to and from the research site and participate in a baseline outpatient visit, and being naive to antiretroviral therapy at enrolment.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcome of interest was self-reported shingles in the past 6 months. The exposure was PTSD defined using the cross-culturally validated Harvard Trauma Questionnaire.

RESULTS

Overall prevalence of reported shingles in the past 6 months was 12.5% (n=89/710). There was an inverse relationship between shingles prevalence and immunological status: 7.6%, 12.3% and 16.7% of women with CD4 >350, 200-350 and <200 cells/µL, respectively, reported singles (p=0.01). In multivariate analysis, PTSD (aOR 1.7; 95% CI 1.02 to 2.89) and low CD4 (aOR 2.4; 95% CI 1.23 to 4.81) were independently associated with reported shingles in the past 6 months.

CONCLUSIONS

Our study found a significant independent relationship between PTSD and reported shingles, suggesting that PTSD may be associated with immune compromise that can result in herpes zoster reactivation. Further study is needed. It also confirmed previous findings of a strong relationship between shingles and greater immunosuppression in women with HIV infection.

Quality of pain in herpes zoster patients

Pain typically accompanies acute herpes zoster and persists well beyond rash healing. Different types of pain are reported by patients with herpes zoster. Current studies show that these types of pain vary with respect to their presence, location, duration, intensity and quality, hence pain needs to be analyzed more thoroughly. The aim of the study was to assess different components of pain in patients with herpes zoster. The study subjects were 46 patients diagnosed with herpes zoster and selected out of 493 patients treated at the Pain Therapy Clinic, the outpatient facility of Zagreb Clinic for Traumatology, in 2010. Measures used to assess pain and daily activities were the following: SF McGill Pain Questionnaire, Visual Analogue Scale, Self-Assessment of Life Satisfaction, Health Satisfaction and Enjoyment in Life. Analgesic treatment together with demographic and clinical characteristics of patients were also taken into account. The results have shown that the patients report about spontaneous pain mostly in terms of the following qualities of high level pain intensity: throbbing, aching, hot-burning and sharp. The results also demonstrate that herpes zoster pain significantly affects the patients' everyday living quality and their emotional health. Comprehensive assessment of pain is necessary for clinical research about the epidemiology, natural history, pathophysiologic mechanisms, treatment, and prevention of pain in herpes zoster.

Effect of hyperbaric oxygen therapy on patients with herpes zoster

BACKGROUND

The purpose of this study was to observe the effect of hyperbaric oxygen (HBO2) therapy on patients with herpes zoster.

METHODS

A total of 68 cases with herpes zoster were randomly divided into HBO2 and control groups. The patients in the control group were treated with drugs, while the patients in the HBO2 group were treated with both drugs and HBO2. Parameters of therapeutic efficacy including period of blister resolution, scar formation time and percentage of patients developing post-herpetic neuralgia (PHN) were determined for the patients in both groups. Numeric Pain Rating Scale (NPRS) and Hamilton Depression Rating Scale (HAMD) were also scored for the patients before and after treatment.

RESULTS

The therapeutic efficacy in the control group was 81.25%, which was significantly lower than that (97.22%) in the HBO2 group (p < 0.05). The percentage of patients developing PHN, scar formation time and NPRS score in the HBO2 groups were significantly lower than those in the control group (p < 0.05). HAMD score in the HBO2 group was significantly lower than that in the control group (p < 0.05).

CONCLUSION

HBO2 can significantly enhance therapeutic efficacy, relieve pain, accelerate herpes blister healing and lesion resolution, reduce the percentage of patients developing PHN and improve depression in patients with herpes zoster.

Perceptions of herpes zoster and attitudes towards zoster vaccination among 50-65-year-old Danes

INTRODUCTION

Herpes zoster (HZ or shingles) and its complication post-herpetic neuralgia (PHN) are common in persons above 50 years of age. A vaccine that decreases the incidence and morbidity associated with HZ was licensed for use in 2006 and will be marketed in Denmark as from 2013. This study aimed to explore the relations between illness perceptions of shingles and attitudes towards zoster vaccination.

MATERIAL AND METHODS

Three qualitative focus group interviews were conducted with 22 patients, relatives and individuals with no personal experiences with HZ. Semi-structured interview guides were applied including questions identified in a literature study. The data were analysed using a medical anthropological approach.

RESULTS

The study showed that HZ and PHN, in particular, have severe impacts on patients' quality of life (QoL) and often affect their relatives' daily lives as well. Nevertheless, people who have no experience with HZ underrate both its prevalence and its QoL impacts. Such misperceptions often result in delayed treatment and may lead to a low uptake of zoster vaccination.

CONCLUSION

Individual attitudes towards zoster vaccination are closely related to subjective perceptions of HZ and views on vaccination in general. Vaccination recommendations to target groups are necessary, but individual choice is determined by knowledge about the disease, personal risk assessment and the recommendations of the general practitioner.

FUNDING

The study was funded by a research grant from Sanofi Pasteur MSD.

TRIAL REGISTRATION

not relevant.

Major depressive disorder and immunity to varicella-zoster virus in the elderly

Major depressive disorder has been associated with activation of inflammatory processes as well as with reductions in innate, adaptive and non-specific immune responses. The objective of this study was to evaluate the association between major depression and a disease-relevant immunologic response, namely varicella-zoster virus (VZV)-specific immunity, in elderly adults. A cross-sectional cohort study was conducted in 104 elderly community dwelling adults ≥ 60years of age who were enrolled in the depression substudy of the shingles prevention study, a double blind, placebo-controlled vaccine efficacy trial. Fifty-two subjects had a current major depressive disorder, and 52 age- and sex-matched controls had no history of depression or any mental illness. VZV-specific cell-mediated immunity (VZV-CMI) was measured by VZV responder cell frequency (VZV-RCF) and interferon-γ enzyme-linked immunospot (ELISPOT) assays, and antibody to VZV was measured by an enzyme-linked immunosorbent assay against affinity-purified VZV glycoproteins (gpELISA). VZV-CMI, measured by VZV-RCF, was significantly lower in the depressed group than in the controls (p<0.001), and VZV-RCF was inversely correlated with the severity of depressive symptoms in the depressed patients. In addition, an age-related reduction in VZV-RCF was observed in the depressed patients, but not in the controls. Furthermore, there was a trend for depressive symptom severity to be associated with lower ELISPOT counts. Finally, VZV-RCF was higher in depressed patients treated with antidepressant medications as compared to untreated depressed patients. Since lower levels of VZV-RCF appear to explain the increased risk and severity of herpes zoster observed in older adults, these findings suggest that, in addition to increasing age, depression may increase the risk and severity of herpes zoster.

The impact of acute herpes zoster pain and discomfort on functional status and quality of life in older adults

OBJECTIVES

To describe the interference of herpes zoster (HZ) pain and discomfort with activities of daily living (ADLs) and health-related quality of life (HRQL) during the acute rash phase, and to quantify the relationship between acute HZ pain and discomfort and impaired ADLs and HRQL in older persons.

METHODS

Prospective, observational study of 160 HZ outpatients age > or =60 at 4 US study sites who completed the Zoster Brief Pain Inventory (ZBPI), Zoster Impact Questionnaire (ZIQ), McGill Pain Questionnaire, EuroQol, and SF-12 questionnaires on a predetermined schedule. Patients rated interference on a 0 to 10 scale for ADL items in the ZBPI and the ZIQ. Interference scores were averaged to create summary measures for the ZBPI items (ZBPI ADLI) and ZIQ items (ZIQ ADLI). A composite pain score was used in mixed-effects models analyses of the association between pain and discomfort and ADLI and HRQL measures during the first 35 days after HZ rash onset.

RESULTS

HZ pain interfered with all ADLs but interference was greatest for enjoyment of life, sleep, general activity, leisure activities, getting out of the house, and shopping. For every 1.0 point increase in pain and discomfort intensity, there was a 0.69 and 0.53 point increase in ZBPI and ZIQ interference, respectively, and a 2.81 point, 1.57 point, and 1.95 point decrease in EuroQol, SF-12 physical, and SF-12 mental scales, respectively.

DISCUSSION

Acute zoster pain and discomfort has a significant negative impact on functional status and HRQL in older adults. The magnitude of interference increases with increasing pain and discomfort intensity.

Pain, medication use, and health-related quality of life in older persons with postherpetic neuralgia: results from a population-based survey

Persons aged >65 years with pain caused by postherpetic neuralgia (PHN) were recruited via advertisements in 24 US newspapers and were mailed a questionnaire that addressed pain intensity (average, worst, least, current), pain interference (with general activity, mood, relations with other people, sleep, enjoyment of life), and health-related quality of life (using the EuroQoL health measure [EQ-5D] and a global rating scale). Respondents also were asked about their use of medication for shingles pain. A total of 385 persons completed the survey; 61% were >75 years of age. Mean (+/-standard deviation) duration of PHN was 3.3 (+/-4.0) years. Only about one half had taken prescription medication for shingles pain during the prior week; dosages were typically low. Mean average, worst, least, and current pain caused by shingles (0- to 10-point scale) was 4.6 (+/-2.1), 6.0 (+/-2.4), 2.9 (+/-2.3), and 4.0 (+/-2.7), respectively. Mean pain interference with general activity, mood, relations with other people, sleep, and enjoyment of life (0- to 10-point scale) was 3.7 (+/-3.1), 4.3 (+/-2.9), 3.0 (+/-2.8), 3.8 (+/-2.9), and 4.5 (+/-3.1), respectively. The mean EQ-5D health index score was 0.61; respondents rated their overall health as 65.7 (+/-21.1) on a 100-point scale. PHN causes substantial pain, dysfunction, and poor health-related quality of life in older persons, many of whom might be suboptimally treated.

PERSPECTIVE

Many older persons (age >65 years) with PHN experience longstanding, severe, and debilitating pain and poor health-related quality of life; levels of dissatisfaction with treatment are high. Our study highlights the need for improved management of this disease.

Development of a measure of the burden of pain due to herpes zoster and postherpetic neuralgia for prevention trials: adaptation of the brief pain inventory

In preparation for clinical trials of a vaccine against herpes zoster (HZ), we conducted a prospective, observational study to evaluate (1) the Zoster Brief Pain Inventory (ZBPI), an HZ-specific questionnaire to quantify HZ pain and discomfort, (2) an operational definition of postherpetic neuralgia (PHN), and (3) a severity-duration measure of the burden of illness caused by HZ. HZ patients aged 60 years or older (n = 121) were enrolled within 14 days of rash onset and completed ZBPI, McGill Pain Questionnaire Present Pain Intensity (PPI), quality of life (QoL), and activities of daily living (ADL) questionnaires on a predetermined schedule. Reliability, measured by intraclass correlation coefficients within 14 days of rash onset, ranged between 0.63 and 0.78. ZBPI pain scores were strongly correlated with other pain measures, interference with ADL, and worsening QoL. The operational definition of PHN, a ZBPI pain score of 3 or greater occurring 90 or more days after rash onset, had high agreement with pain worse than mild on the PPI (kappa = 0.72). The ZBPI pain severity-duration measure had high correlations with severity-duration measures of ADL interference, worsening QoL, and other pain scales. These findings support the validity and utility of the ZBPI, the definition of PHN, and the severity-duration measure of the burden of HZ illness.

PERSPECTIVE

Herpes zoster pain, as measured by the ZBPI severity-duration measure, is associated with impairment in daily living activities and quality of life. The ZBPI measure appears useful for quantifying herpes zoster pain, postherpetic neuralgia, and impairment in daily living activities for clinical trials of herpes zoster prevention.

Acute pain in herpes zoster and its impact on health-related quality of life

Although the effects of postherpetic neuralgia on physical and emotional functioning have been examined in a number of studies, the impact of acute pain in herpes zoster ("shingles") on health-related quality of life has been neglected. We describe the characteristics of herpes zoster pain and examine its relationship to physical, role, social, and emotional functioning in 110 patients with herpes zoster. When we controlled for relevant covariates, we found that greater pain burden, as assessed by the product of pain intensity and duration, was associated with poorer physical functioning, increased emotional distress, and decreased role and social functioning. The results demonstrate that herpes zoster pain has broad effects on the daily lives of patients and on their emotional health. The increasing incidence of herpes zoster that can be anticipated as the population ages requires that clinical trials that examine interventions to prevent or treat herpes zoster pain be given a high priority.

Z�n�sthesie nach Varicella-zoster-Infektion

The case report is presented of a 33-year-old male who developed coenaesthesia after suffering from chickenpox. While central nervous involvement of the herpes zoster virus infection was not found, suffering a children's disease at an adult age proved an important psychodynamic factor for release of the coenaesthetic symptomatology.

Herpes zoster in the medically healthy child and covert severe child abuse

Herpes zoster is associated with depressed cell-mediated immunity and occurs rarely in the medically healthy nonimmunocompromised child. We report 4 cases of childhood-onset herpes zoster in the absence of a medical disorder. All 4 patients reported experiencing severe, chronic child abuse when the herpes zoster first appeared. It is possible that the severe chronic psychologic stress resulting from the abuse depressed the patients' cell-mediated immune status and thereby predisposed them to herpes zoster. Our findings suggest that the clinician's suspicion should be heightened for the possibility of covert child abuse and secondary stress when managing an otherwise apparently healthy child with herpes zoster.

Are health states "timeless"? The case of the standard gamble method

The standard gamble method, as currently recommended for use in health care program evaluation, provides an individual's preference score or "utility weight" for living in a given health state for the rest of the individual's life. Many researchers interpret this value as a time-independent or "timeless" one and order health states on a scale of zero (death) to one (full health), regardless of the time spent in the health state. This article examines whether preference scores for a severe pain health state are "timeless," or in other words whether the utility independence assumption is satisfied. Our study results suggest that for the majority of respondents, the preference scores are not independent of time.

Behavioural changes in the rat following infection with varicella-zoster virus

Following the establishment of a chronic varicella-zoster virus infection in the rat, behavioural allodynia and hyperalgesia were observed in the injected, but not the contralateral hind limb up to 33 days post-infection. This model may prove useful in investigating mechanisms involved in the establishment of post-herpetic neuralgia.

A mixed model for factors predictive of pain in AIDS patients with herpes zoster

A unifying model of herpes zoster pain presents considerable analytical challenges due to the requirement for prospective data collection and the varying rates of pain resolution reported by individual patients. Demographic, clinical, and quality-of-life measures were collected on 166 human immunodeficiency virus (HIV)-infected patients enrolled in a randomized, controlled trial of antiviral therapy of herpes zoster comparing acyclovir with sorivudine. A "mixed model" was used to assess factors predictive of pain severity, activity impairment, and sleep interruption. The average rate of change in acute pain was -0.04 unit pain per day for the first month. Chronic pain decreased -0.12 per month for months 1-12. Acute pain severity was positively correlated with number of new skin vesicles, analgesic use, and baseline pain, and negatively related to percentage of lesion healing and crusting. Postherpetic neuralgia was correlated with baseline pain, pain at 1 month, and duration of lesions. Treatment group, gender, race, and CD4 count were not related to change in pain severity. These analyses verify the significance of baseline pain as a significant predictor of pain resolution and average pain severity as a predictor of return to normal daily activities and sleep. The severity of acute pain at presentation and at 1 month are significant predictors of chronic pain.

Race and stress in the incidence of herpes zoster in older adults

OBJECTIVES

To examine the effect of black race and acute (negative life events) and chronic (lack of social support) psychological stress on the risk of herpes zoster in late life.

DESIGN

A population-based, prospective cohort study.

SETTING

Central North Carolina.

PARTICIPANTS

Duke Established Populations for Epidemiological Studies of the Elderly, a stratified probability sample of community-dwelling persons more than 65 years of age.

MEASUREMENTS

Interviewers administered a comprehensive health survey to the participants in 1986-1987 (P1, n = 4162), 1989-1990 (P2, n = 3336), and 1992-1994 (P3, n = 2568). Incident cases of zoster between P1 and P2 and P2 and P3 served as the dependent variable. Hypothesis-testing variables included race, negative life events, and five measures of social support. Control variables included age, sex, education, cancer, chronic diseases, basic ADLs, instrumental ADLs, depression, self-rated health, hospitalization, and cigarette smoking. Statistical analyses employed chi-square tests and proportional hazards model.

RESULTS

At baseline, the sample had a mean age of 73.6 years and was 55% black, 45% white, and 65% female. There were 65 cases of zoster between P1 and P2 and 102 cases of zoster between P2 and P3. From P1 to P2, 1.4% of blacks and 3.4% of whites developed zoster (P < .001). From P2 to P3, 2.9% of blacks and 7.5% of whites developed zoster (P < .001). After controlling for the above variables, blacks were significantly less likely to develop zoster (adjusted risk ratio = 0.35; 95% confidence interval (CI), 0.24-0.51; P < .001). Negative life events increased the risk of zoster, but the result was borderline for statistical significance (adjusted RR = 1.38, 95% CI 0.96-1.97; P = .078). No measures of social support were significantly associated with zoster.

CONCLUSION

Black race decreased the risk of zoster in late life significantly. Measures of stress were not significantly related to zoster, but study limitations preclude definitive conclusions. Future research should focus on these factors in larger samples and different populations.

Estimating the value of a generic quality-of-life measure

In this paper, data from a clinical trial of a new antiviral agent for treating patients with zoster are used to answer the following question: Does the Nottingham Health Profile (NHP) add to the information obtained from the clinical measures? Three ways in which the NHP could add information are measured. First, Cox's regression analysis is used to determine whether health-related quality-of-life scores obtained at diagnosis give information about disease prognosis. Second, changes in mean NHP scores in different dimensions are computed after pain resolution to determine whether NHP scores provide more sensitive indicators of disease resolution. Third, linear regression is used to determine whether the impacts of disease on quality of life are measured adequately by the clinical parameters. These analyses show that use of the physical mobility and energy dimensions of the NHP increases understanding of disease prognosis; demonstrates the continuing impact of zoster on patients' sleep patterns and energy levels, disease symptoms not included as clinical measures, that persist after the cessation of zoster-associated pain; and gives a measure of the impact of zoster on the patient, which includes unmeasured and measured levels of severity.

The Nottingham Health Profile as a measure of quality of life in zoster patients: convergent and discriminant validity

The main symptoms of zoster, a disease caused by the reactivation of the varicella zoster virus (that causes chicken-pox) are: rash, associated with pain, burning, or itching, and pain that outlasts the rash sometimes by months or years. The uncomfortable and long-lasting symptoms of herpes zoster are likely to compromise the patient's quality of life. However, the impact of zoster on health-related quality of life has not previously been measured directly. Recent papers have demonstrated the ability of generic measures to discriminate among patients with different clinical symptoms. In this paper, we demonstrate the convergent validity for zoster of a generic measure, the Nottingham Health Profile (NHP), by measuring its correlation with rash progression, pain levels, and pain medications. The discriminant validity of the NHP was demonstrated by its ability to distinguish between different levels of pain severity. The NHP dimensions most highly correlated with the pain measures, were pain (0.42-0.50), energy (0.34-0.38) and sleep (0.32-0.38). The NHP scores in all six dimensions show large differences at different levels of pain severity that are statistically significant. These results demonstrate the NHP's validity as a measure of health-related quality of life in zoster patients.

Herpes zoster: a comparative study of general practitioner and patient experience

A study was carried out to compare attitudes, perceptions and experiences of general practitioners and patients who had treated/suffered from herpes zoster, or shingles, in the recent past. Randomized samples of 224 general practitioners and 236 patients were drawn from different locations in Italy, Germany and the United Kingdom, and interviews were undertaken as semi-structured face-to-face discussions with the subjects. Most of the discussion questions were the same for both samples but specifically targeted either towards the professional or the patient group. Analysis of the findings showed that although there was a high level of correlation between the two groups on opinions and attitudes on a number of issues, there were significant, important differences on others. For example, prodromal symptoms acknowledged by patients were not always recognized by general practitioners and there appeared to be an inability of some to diagnose early enough to take advantage of appropriate anti-viral therapy whilst they acknowledged the need to do so. This in turn led to a number of patients either not receiving specific therapy or having inadequate therapy. Similarly, whilst general practitioners mainly reflected the current medical view that shingles is a benign and self-limiting condition, patients tended to consider shingles and post-herpetic neuralgia as a painful and serious condition that adversely affected their quality of life and to a greater extent than appreciated by many doctors. The findings of the survey indicate that there is need for improved understanding of the disease and its effects by both doctors and patients.(ABSTRACT TRUNCATED AT 250 WORDS)

T-lymphocyte subsets in otherwise healthy patients with herpes zoster and relationships to the duration of acute herpetic pain

T-lymphocyte subsets (CD3, CD4, and CD8 lymphocytes) in peripheral blood, parameters of cell-mediated immunity, were serially measured in 62 otherwise healthy Japanese patients with herpes zoster (HZ), and the findings were compared with those of 20 age-matched healthy controls who had had varicella but not HZ. Our objective was to elucidate whether there were changes in cell-mediated immunity, even in immunocompetent patients with HZ, and to investigate relationships between these variables and the duration of acute herpetic pain (AHP). All the patients underwent repeated sympathetic nerve blocks until pain was relieved. As compared with controls, there were slight increases in the percentages of CD4 lymphocytes (helper/inducer) and highly significant increases in the percentages of CD8 lymphocytes (suppressor/cytotoxic), resulting in marked decreases in CD4/CD8 ratios in the acute phase of HZ. The percentages of CD3 lymphocytes (pan-T lymphocytes) did not differ significantly. The duration of AHP was analyzed in 49 patients in whom T-lymphocyte subsets were measured more than twice. There was a weak but statistically significant positive linear correlation between age and the duration of AHP (r = 0.43, P < 0.01). There were statistically highly significant positive linear correlations between the number of days on which percentages of CD3 (r = 0.72, P < 10(-8)) and CD4 lymphocytes (r = 0.60, P < 10(-5)), and CD4/CD8 ratios (r = 0.62, P < 10(-5)) reached the maximum values after the onset of HZ and the duration of AHP. These correlation coefficients were higher than that between age and the duration of AHP.(ABSTRACT TRUNCATED AT 250 WORDS)

An application of the fear avoidance model to three chronic pain problems

The Fear Avoidance Model of Exaggerated Pain Perception was developed in an attempt to explain how, and why, some individuals develop a more substantial psychological overlay to their low back pain problem than do others. The present paper describes a study in which three chronic pain groups, consisting of Post-Herpetic neuralgia patients, Reflex Sympathetic Dystrophy patients and chronic low back pain patients were compared with three pain-free comparison groups using the Fear Avoidance Model of Exaggerated Pain Perception. The results show statistically significant differences between the chronic groups and the recovered comparison groups. These results demonstrate the usefulness of the Fear Avoidance Model as an explanation of psychological overlay in chronic pain conditions regardless of pathology.

Encephalitis associated with herpes zoster: a case report and review

This paper describes the case of a patient with a history of affective disorder who developed encephalitis associated with herpes zoster which presented as a delirium with prominent manic symptoms. Published reports of encephalitis following herpes zoster infections are reviewed. The diagnosis of herpes zoster-associated encephalitis should be suspected in individuals with changes in his or her mental state, an abnormal electroencephalogram and an abnormal cerebrospinal fluid examination which closely follow a cutaneous herpes zoster lesion.

A high-risk method for studying psychosocial antecedents of chronic pain: The prospective investigation of herpes zoster

Although patients with chronic pain are often psychologically distressed, it has been difficult to determine whether this distress is an antecedent of chronic pain or whether it is caused by the experience of living with chronic pain. The aim of this investigation was to develop a method that would allow individuals who are at risk for the development of chronic pain to be studied before their pain has become chronic. Patients with acute herpes zoster were assessed with demographic, medical, pain, and psychosocial measures. Pain was assessed in follow-up interviews at 6 weeks and 3, 5, 8, and 12 months after these initial assessments. There were no significant differences between patients who developed short-term herpes zoster pain and patients who did not develop short-term pain for any of the measures at the initial assessment, except for one measure of pain intensity. Patients who developed chronic herpes zoster pain, however, had significantly greater pain intensity, higher state and trait anxiety, greater depression, lower life satisfaction, and greater disease conviction at the initial assessment than patients who did not develop chronic pain. In discriminant analyses, disease conviction, pain intensity, and state anxiety each made a unique contribution to discriminating patients who did and who did not develop chronic pain. This study demonstrates the feasibility of investigating psychosocial antecedents of the development of chronic pain by prospectively examining the longitudinal course of herpes zoster.

Are stressful life events risk factors for herpes zoster?

To determine if psychologically stressful life events are risk factors for herpes zoster, we conducted a case-control study of zoster and self-reported recent negative life events and major changes in spousal relationships. The subjects were 101 healthy community-dwelling cases of zoster and 101 healthy controls matched for age, sex, and race and generated by random digit dialing. The Geriatric Scale of Recent Life Events was administered to case and control subjects, and additional questions were asked regarding the perception of the life event. The results showed that case subjects experienced negative life events significantly more often than subjects in the control groups in the 2 months before zoster onset by analysis of discordant pairs (26 versus 10, odds ratio 2.60, 95% confidence interval [CI] 1.13, 6.27, P = .012), 3 months before (29 versus 11, odds ratio 2.64, 95% CI 1.20, 6.04, P = .007), or 6 months before (35 versus 16, odds ratio 2.00, 95% CI 1.04, 3.93, P = .012). The mean number of total life events was significantly higher in cases at 6 months before zoster (case means = 2.64, control means = 1.82, P = .008), but there were no significant differences at 2, 3, or 12 months before. There were no significant differences between case subjects and control subjects for spousal events, or any given single life event. In conclusion, we found that whereas patients with herpes zoster experienced the same kinds of life events in the year preceding the illness as did control subjects, recent events perceived as stressful were significantly more common among patients with zoster.(ABSTRACT TRUNCATED AT 250 WORDS)

[Post-herpetic neuralgia: clinical predictors and psychopathologic findings]

48 patients, who had had acute Herpes zoster were screened for a retrospective investigation concerning the development of post-herpetic neuralgia. Subjects with and without neuralgia were compared with respect to medical, demographic and psychological variables. Nine patients were excluded from the investigation because of reported pain, which was not due to Herpes zoster. From the 39 subjects who remained in the analysis, 59% had postherpetic neuralgia for at least three months, and 28% for more than a year. No medical or demographic risk factor was sufficient for a prediction of the pain group. By applying objective criteria to psychometric test protocols, an index was constructed which differed between the groups. The pain-group showed a higher frequency of psychopathological impairment than those without post-herpetic neuralgia. However, the psychopathology was not consistently related to the length of neuralgia or the intensity of persistent pain.