Increased Incidence of Herpes Zoster and Postherpetic Neuralgia in Adult Patients following Traumatic Brain Injury: A Nationwide Population-Based Study in Taiwan

Herpes Zoster: Risk Factors for Occurrence, Complications, and Recurrence with a Focus on Immunocompromised Patients

BACKGROUND

The varicella-zoster virus is a highly contagious human herpesvirus that primarily causes varicella (chickenpox) as an initial infection, targeting T cells, neurons, as well as skin cells, and can later reactivate to cause herpes zoster (shingles). Following reactivation, the varicella-zoster virus infection can lead to severe complications, the most common of which is postherpetic neuralgia. Risk factors include aging, immunosuppression, chronic diseases such as diabetes, cardiovascular disorders, respiratory conditions, and others.

OBJECTIVE

In this article, we present an analysis of factors increasing the risk of herpes zoster occurrence, complications, and recurrences (in particular in immunocompromised patients).

Risk factors for herpes zoster infections: a systematic review and meta-analysis unveiling common trends and heterogeneity patterns

PURPOSE

The burden of herpes zoster (HZ) is substantial and numerous chronic underlying conditions are known as predisposing risk factors for HZ onset. Thus, a comprehensive study is needed to synthesize existing evidence. This study aims to comprehensively identify these risk factors.

METHODS

A systematic literature search was done using MEDLINE via PubMed, EMBASE and Web of Science for studies published from January 1, 2003 to January 1, 2023. A random-effects model was used to estimate pooled Odds Ratios (OR). Heterogeneity was assessed using the I2 statistic. For sensitivity analyses basic outlier removal, leave-one-out validation and Graphic Display of Heterogeneity (GOSH) plots with different algorithms were employed to further analyze heterogeneity patterns. Finally, a multiple meta-regression was conducted.

RESULTS

Of 6392 considered records, 80 were included in the meta-analysis. 21 different conditions were identified as potential risk factors for HZ: asthma, autoimmune disorders, cancer, cardiovascular disorders, chronic heart failure (CHF), chronic obstructive pulmonary disorder (COPD), depression, diabetes, digestive disorders, endocrine and metabolic disorders, hematological disorders, HIV, inflammatory bowel disease (IBD), mental health conditions, musculoskeletal disorders, neurological disorders, psoriasis, renal disorders, rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and transplantation. Transplantation was associated with the highest risk of HZ (OR = 4.51 (95% CI [1.9-10.7])). Other risk factors ranged from OR = 1.17-2.87, indicating an increased risk for all underlying conditions. Heterogeneity was substantial in all provided analyses. Sensitivity analyses showed comparable results regarding the pooled effects and heterogeneity.

CONCLUSIONS

This study showed an increased risk of HZ infections for all identified factors.

High pesticide exposures events, pesticide poisoning, and shingles: A medicare-linked study of pesticide applicators in the agricultural health study

OBJECTIVES

Self-reported shingles was associated with history of high pesticide exposure events (HPEE) in licensed pesticide applicators aged >60 years in the Agricultural Health Study (AHS). In the current study, using AHS-linked Medicare claims data, we examined incident shingles in relation to pesticide-related illness and pesticide poisoning, as well as HPEE.

METHODS

We studied 22,753 licensed private pesticide applicators (97% white males, enrolled in the AHS 1993-97), aged ≥66 years with >12 consecutive months of Medicare fee-for-service hospital and outpatient coverage between 1999 and 2016. Incident shingles was identified based on having ≥1 shingles claim(s) after 12 months without claims. At AHS enrollment, participants were asked if they ever sought medical care or were hospitalized for pesticide-related illness, and a supplemental questionnaire (completed by 51%) asked about HPEE and poisoning. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated using Cox proportional hazards regression, adjusted for age, sex, race, state, and education.

RESULTS

Over 192,053 person-years (PY), 2396 applicators were diagnosed with shingles (10.5%; age-standardized rate, 13.6 cases per 1,000PY), with higher rates among those reporting hospitalization for pesticide-related illness, pesticide poisoning, and HPEE (23.2, 22.5, and 16.6 per 1,000PY, respectively). In adjusted models, shingles was associated with hospitalization for pesticide-related illness (HR 1.69; 1.18, 2.39), poisoning (1.49; 1.08, 1.46), and HPEE (1.23; 95% CI = 1.03, 1.46), especially HPEE plus medical care/poisoning (1.78; 1.30, 2.43).

CONCLUSION

These novel findings suggest that acute, high-level, and clinically impactful pesticide exposures may increase risk of shingles in subsequent years to decades following exposure.

Early intervention combining Chinese and Western medicine in traumatic brain injury with diffuse axonal injury: A report of three cases

Background

Traumatic brain injury (TBI) is characterized by high prevalence, morbidity, and mortality. Diffuse axonal injury (DAI) is a specific type of TBI leading to prolonged consciousness impairment and disability. There is still no standard treatment for DAI, so we introduced traditional Chinese medicine into the treatment of these patients.

Case summaries

Three patients had TBI after traffic accidents. Their Glasgow Coma Scale (GCS) scores in the intensive care unit (ICU) were E₁V_EM₂-₃, E₁V_EM₂-₃, and E₁V_EM₂ respectively. All of them were diagnosed with DAI based on magnetic resonance imaging (MRI). Because of continuing consciousness disturbances, their families agreed to combine traditional Chinese medicine and modern medicine treatments through inpatient consultation in Taoyuan General hospital. Two patients took Buyang Huanwu Decoction, and one Tianma Gouteng Decoction twice a day. All of them received 20 min of acupuncture treatments 5 times per week. Acupuncture points included Baihui (GV20), Sishencong (EX-HN1), Shuigou (GV26), Hegu (LI4), and Taichong (LR3). All of them started Traditional Chinese medicine treatment within 2 weeks after TBI. The GCS of all three patients recovered to E₄M₅V₆.

Conclusions

The early addition of traditional Chinese medicine treatments to Western medical care can improve the prognosis of patients with diffuse axonal injury.

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Traumatic brain injury diagnosed with diffuse axonal injury, the lower GCS, the poorer outcome. This article points out that combining Chinese medicine and modern medicine can lead to better outcome(motor, speech function and GCS score).

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Chinese medicine has neuroprotective effect and it’s safe when combining with modern medicine in severe traumatic brain injury in this cases report.

Association between suicide risk and traumatic brain injury in adults: a population based cohort study

Background

Traumatic brain injury (TBI) is a major cause of death and disability worldwide, and its treatment is potentially a heavy economic burden. Suicide is another global public health problem and the second leading cause of death in young adults. Patients with TBI are known to have higher than normal rates of non-fatal deliberate self-harm, suicide and all-cause mortality. The aim of this study was to explore the association between TBI and suicide risk in a Chinese cohort.

Method

This study analysed data contained in the Taiwan National Health Insurance Research Database for 17 504 subjects with TBI and for 70 016 subjects without TBI matched for age and gender at a ratio of 1 to 4. Cox proportional hazard regression analysis was used to estimate subsequent suicide attempts in the TBI group. Probability of attempted suicide was determined by Kaplan-Meier method.

Results

The overall risk of suicide attempts was 2.23 times higher in the TBI group compared with the non-TBI group (0.98 vs 0.29 per 1000 person-years, respectively) after adjustment for covariates. Regardless of gender, age or comorbidity, the TBI group tended to have more suicide attempts, and the risk attempted suicide increased with the severity of TBI. Depression and alcohol attributed disease also increased the risk of attempted suicide in the TBI group.

Conclusion

Suicide is preventable if risk factors are recognised. Hence, TBI patients require special attention to minimise their risk of attempted suicide.

Risk Factors for Herpes Zoster Infection: A Meta-Analysis

Background

The burden of herpes zoster (HZ) is significant worldwide, with millions affected and the incidence rising. Current literature has identified some risk factors for this disease; however, there is yet to be a comprehensive study that pools all evidence to provide estimates of risk. Therefore, the purpose of this study is to identify various risk factors, excluding immunosuppressive medication, that may predispose an individual to developing HZ.

Methods

The literature search was conducted in MEDLINE, EMBASE, and Cochrane Central, yielding case control, cohort, and cross-sectional studies that were pooled from January 1966 to September 2017. Search terms included the following: zoster OR herpe* OR postherpe* OR shingle* AND risk OR immunosupp* OR stress OR trauma OR gender OR ethnicity OR race OR age OR diabetes OR asthma OR chronic obstructive pulmonary disease OR diabetes. Risk ratios (RRs) for key risk factors were calculated via natural logarithms and pooled using random-effects modeling.

Results

From a total of 4417 identified studies, 88 were included in analysis (N = 3, 768 691 HZ cases). Immunosuppression through human immunodeficiency virus/acquired immune deficiency syndrome (RR = 3.22; 95% confidence interval [CI], 2.40–4.33) or malignancy (RR = 2.17; 95% CI, 1.86–2.53) significantly increased the risk of HZ compared with controls. Family history was also associated with a greater risk (RR = 2.48; 95% CI, 1.70–3.60), followed by physical trauma (RR = 2.01; 95% CI, 1.39–2.91) and older age (RR = 1.65; 95% CI, 1.37–1.97). A slightly smaller risk was seen those with psychological stress, females, and comorbidities such as diabetes, rheumatoid arthritis, cardiovascular diseases, renal disease, systemic lupus erythematosus, and inflammatory bowel disease compared with controls (RR range, 2.08–1.23). We found that black race had lower rates of HZ development (RR = 0.69; 95% CI, 0.56–0.85).

Conclusions

This study demonstrated a number of risk factors for development of HZ infection. However, many of these characteristics are known well in advance by the patient and clinician and may be used to guide discussions with patients for prevention by vaccination.

Migraine and traumatic brain injury: a cohort study in Taiwan

OBJECTIVE

Traumatic brain injury is now a major contributor to the global healthcare burden. Migraine is another debilitating disease with a global health impact. While most researchers agree that traumatic brain injury is a risk factor for migraine, whether migraine is a risk factor for traumatic brain injury still remains under debate. We therefore aimed to investigate whether migraine was a risk factor for developing traumatic brain injury.

STUDY DESIGN

Retrospective population-based cohort study.

SETTING

Data for people who had been diagnosed with migraine were retrieved from Taiwan's National Health Insurance Research Database.

PARTICIPANTS

We identified 7267 patients with newly diagnosed migraine during 1996-2010. The migraineurs to non-migraineurs ratio was set at 1:4 to enhance the power of statistical tests.

PRIMARY AND SECONDARY OUTCOME MEASURES

We used multivariate Cox proportional hazard regression models to assess the effects of migraines on the risk of traumatic brain injury after adjusting for potential confounders.

RESULTS

The overall traumatic brain injury risk was 1.78 times greater in the migraine group compared with the non-migraine group after controlling for covariates. Additionally, patients with previous diagnoses of alcohol-attributed disease, mental disorders and diabetes mellitus had a significantly higher traumatic brain injury risk compared with those with no history of these diagnoses.

CONCLUSIONS

This study of a population-based database indicated that migraine is a traumatic brain injury risk factor. Greater attention to migraine-targeted treatment modalities may reduce traumatic brain injury-related morbidity and mortality.

Risk Factors for Herpes Zoster: A Systematic Review and Meta-analysis

OBJECTIVE

To systematically review studies examining risk factors for herpes zoster (HZ).

METHODS

We performed a literature search using PubMed, EMBASE, and Web of Science for articles published from January 1, 2003, to February 1, 2017. A random-effects model was used to summarize the risk ratio (RR) or odds ratio (OR) and 95% CI.

RESULTS

Of the 3450 studies screened, we included 84 studies in the systematic review and conducted meta-analysis in 62 studies. Women were at increased risk of HZ compared with men (pooled adjusted RR, 1.31; 95% CI, 1.27-1.34). Black individuals had almost half the risk of HZ as white individuals (pooled RR, 0.54; 95% CI, 0.47-0.63). Family history was found to be a risk factor for HZ (pooled OR, 3.59; 95% CI, 2.39-5.40). Autoimmune diseases, including rheumatoid arthritis (pooled RR, 1.67; 95% CI, 1.41-1.98) and systemic lupus erythematosus (pooled RR, 2.10; 95% CI, 1.40-3.15), were associated with an elevated risk of HZ. Other comorbidities were associated with an increased risk of HZ, with the pooled RRs ranging from 1.25 (95% CI, 1.13-1.39) for asthma to 1.30 (95% CI, 1.17-1.45) for diabetes mellitus and 1.31 (95% CI, 1.22-1.41) for chronic obstructive pulmonary disease.

CONCLUSION

Our review revealed that female sex, race/ethnicity, family history, and comorbidities are risk factors for HZ. Efforts are needed to increase the uptake of zoster vaccination.

Traumatic Brain Injury and Substance Related Disorder: A 10-Year Nationwide Cohort Study in Taiwan

Whether traumatic brain injury (TBI) is causally related to substance related disorder (SRD) is still debatable, especially in persons with no history of mental disorders at the time of injury. This study analyzed data in the Taiwan National Health Insurance Research Database for 19,109 patients aged ≥18 years who had been diagnosed with TBI during 2000-2010. An additional 19,109 randomly selected age and gender matched patients without TBI (1 : 1 ratio) were enrolled in the control group. The relationship between TBI and SRD was estimated with Cox proportional hazard regression models. During the follow-up period, SRD developed in 340 patients in the TBI group and in 118 patients in the control group. After controlling for covariates, the overall incidence of SRD was 3.62-fold higher in the TBI group compared to the control group. Additionally, patients in the severe TBI subgroup were 9.01 times more likely to have SRD compared to controls. Notably, patients in the TBI group were prone to alcohol related disorders. The data in this study indicate that TBI is significantly associated with the subsequent risk of SRD. Physicians treating patients with TBI should be alert to this association to prevent the occurrence of adverse events.

Herpes zoster as a risk factor for osteoporosis: A 15-year nationwide population-based study

The objective of this study was to investigate the risk of osteoporosis in patients with herpes zoster (HZ) infection using a nationwide population-based dataset. The Taiwan National Health Insurance Research Database was used to compare data between 11,088 patients aged 20 to 49 years diagnosed with HZ during 1996 to 2010 and a control group of 11,088 patients without HZ. Both cohorts were followed up until the end of 2010 to measure the incidence of osteoporosis. Cox proportional-hazards regression and Kaplan-Meier analyses were used to calculate hazard ratio and cumulative incidences of osteoporosis, respectively. The overall risk of osteoporosis was 4.55 times greater in the HZ group than in the control group (2.48 vs. 0.30 per 1000 person-years, respectively) after adjusting for age, gender, Charlson Comorbidity Index, and related comorbidities. Compared with controls, patients with HZ and subsequent postherpetic neuralgia had a 4.76-fold higher likelihood of developing osteoporosis (95% confidence interval: 2.44-9.29), which was a statistically significant difference (P <0.001). Osteoporosis risk factors included female gender, age, advanced Charlson Comorbidity Index, depression, and postherpetic neuralgia. This study identified HZ is associated with an increased osteoporosis risk. Further evaluation of the value of bone mineral density test in detecting osteoporosis after HZ may be suggested. HZ vaccination could also be evaluated to lower the incidence of HZ and possibly subsequent osteoporosis. Physicians should be alerted to this association to improve early identification of osteoporosis in patients with HZ.

Treatment of Postherpetic Neuralgia Using Narrow Band Ultraviolet B Radiation (UVB)

Postherpetic neuralgia (PHN) is a common complication of herpes zoster, frequently unresponsive to most available treatment. The disease is especially difficult to manage in elderly people and has a great impact on the quality of life of patients. Narrow band ultraviolet B radiation may play a role in the prevention and treatment of PHN. Present paper describes a case of a 59 year-old female patient, diagnosed with ophthalmic herpes zoster and postherpetic neuralgia, with positive results using narrow UVB.