Shingles Overview

What is Shingles?

After a person has had chicken pox the virus that causes it stays sleeping for decades in nerves near the spine.  The virus is herpes zoster.  About 20% of people who have had chicken pox will later have a shingles outbreak.  Shingles usually affects older people and people with weak immune systems.

Cold sores on the lips and genital herpes are caused by different herpes viruses, herpes simplex viruses.

Symptoms

If the virus wakes up, it travels along nerve fibers to the skin, usually appearing in one area, on one side of the body, and along the line of a nerve.  But shingles can be anywhere on the body.  The rash is painful and has fluid-filled blisters.  The first symptoms start 1 to 5 days before the rash and include:

• Itching
• Tingling
• Burning sensation
• Pain, sometimes worse at night

Less common symptoms are fever, chills, headache and stomach ache.  Shingles near the eye or ear can cause vision or hearing loss and are usually treated aggressively.

The blisters usually scab over in 7 to 10 days and disappear completely in 2 to 4 weeks.  In most people the rash leaves no scars and the pain and itching go away after a few weeks or months.

In some people the pain from shingles stays for months or even years after the rash is gone.  The pain is from damage to the nerves in the skin.  This is called post-herpetic neuralgia. 

Treatment

There is no cure for shingles.  But there are antiviral medications that can make the episode shorter and milder if given early.  They also reduce the risk of pain after the rash is gone.  The antiviral drug should be started at the first sign of symptoms to be most effective.

Over-the-counter pain and itch medicines, such as calamine lotion, work fairly well for many people.  If the pain is severe or the rash is near the eye or ear, the doctor may prescribe steroids to reduce the inflammation.  Using a compress dampened with cool water may help with itching.  Scratching should be avoided to prevent damage to the skin and to prevent breaking the blisters.

Vaccine

A shingles vaccine is available.  It prevents about half of shingles cases and reduces the frequency of post-shingles pain.  The Centers for Disease Control recommend that all adults 60 years and older be vaccinated.  The vaccine does not work well in people over 80 and is generally not recommended for this age group.

Is It Contagious?

Yes, but you can’t get shingles from another person; only chicken pox.  If you have never had chicken pox, or the vaccine for it, and you are then exposed to the fluid in the shingles blisters, you can get chicken pox.

Caregivers can carry the virus from one person to another and if the second person has not had chicken pox, they may get it.  Shingles can only be transmitted when the blisters have burst and are oozing, before they crust over. 

What can you do to prevent spread?

• Prevent blisters from breaking open.
• Keep the rash covered to prevent the blister fluid from contaminating others. 
• Assist the resident with shingles to wash hands often. 
• Only caregivers who have already had chicken pox should be assigned to residents with shingles. 
• No one who is pregnant should be assigned to a resident with shingles.
• Keep surfaces clean and disinfected.
• If the resident has shingles on the buttocks, he or she should not use common toilets.
• All caregivers and housekeepers should wear gloves in the resident’s room until he is no longer contagious.  Hands should be washed after removing gloves.
• Determine if roommates or others the resident socializes with are at risk.
• Use common sense precautions.
• Washing Linens

People handling sheets and towels of a person with shingles should wear gloves.  Sheets and towels should not be shaken or set down on a surface, even the floor.  They should immediately be put into a linen bag.  No special procedures are needed for washing linens.

Staff with Shingles

Staff members who have shingles should not care for vulnerable residents, including people with cancer, residents with compromised immune systems or those who have not had chicken pox. 

This article was originally published in Pathways & Partners Newsletter - Issue 27.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Hand Sanitizers vs Norovirus

People in densely populated living situations, like cruise ships and skilled nursing facilities, are reaching for the alcohol-based hand sanitizing gel in hopes of avoiding the norovirus.  But does it prevent infection from the gastrointestinal bug?  It looks like the answer is “No.”

Many studies have shown that alcohol-based sanitizers reduce germ counts on hands and can reduce the spread of some strains of flu.  But the nasty norovirus that causes vomiting and diarrhea is resistant.

Some viruses, including the flu virus, have a coating that the alcohol in the sanitizer can burst open, killing the virus.  But the norovirus doesn’t have a capsule that alcohol can penetrate.  So it lives on even when you believe your hands are disinfected.  Noroviruses are so infectious that as little as 10 missed microscopic particles can cause infection.

Bleach kills the norovirus, and a solution of 10% bleach is great for wiping down counters and surfaces that may have been contaminated.  But since we really can’t wash our hands in bleach, experts say we should wash hands frequently with plain old soap and water.

In 2011 the Centers for Disease Control and Prevention studied records from the winter of 2006-07 in 91 long-term care facilities; they found 23 outbreaks of the norovirus.  Facilities where staff regularly cleaned their hands with alcohol-based sanitizers had six times as many norovirus outbreaks than facilities where the staff used soap and water. 

The CDC says that to prevent the spread of the norovirus, alcohol sanitizers should only be used “in addition” to hand washing, but not as a substitute.

This article was originally published in Pathways & Partners Newsletter - Issue 27.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

How Not to Catch a Cold

Meditation Works

If there were a way to avoid getting colds and the flu, would you do it?  There is some compelling evidence that there may be just such an antidote!  Meditation and exercise both appear to reduce the frequency of acute respiratory infections—colds and flu.

Researchers at the University of Wisconsin assigned 149 participants, mostly women and all over 50 years old, to one of three groups.  One group took an 8-week training program in mindfulness meditation, the second an 8-week training in moderate intensity sustained exercise and the third served as an observational control group.  They studied the participants for the duration of one cold and flu season.  These results were pretty remarkable.

Acute Respiratory Infections by Group
Meditation - 27   
Exercise - 26   
Control - 40   

Total Days of Illness by Group   
Meditation - 257   
Exercise - 241   
Control - 453   

Days of Work Missed by Group
Meditation - 16
Exercise - 32
Control - 67

The research was funded by the National Institutes of Health and reported in the Annals of Family Medicine in July, 2012.

In addition to washing your hands and getting your flu shot, this cold and flu season you may also want to engage in some mindful meditation techniques or sustained exercise!

This article was originally published in Pathways Residential Care Journal - Issue 5.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Reducing Anger

Have you ever felt a flame of anger igniting when you were provoked—and wished you could keep your cool instead?  New research has a trick that can help do just that.

The trick is to pretend that you have stepped back and are seeing the situation from a distance, as though you are an observer instead of a participant.  From this more distant spot you can look at your feelings.

“Self-distancing” is the term researchers at Ohio State University and the University of Michigan gave to the technique.  The findings of two related experiments were published online in the Journal of Experimental Social Psychology.

“The secret is to not get immersed in your own anger and, instead, have a more detached view,” says Dominik Mischkowski, an Ohio State graduate student and lead author of the research.  “You have to see yourself in this stressful situation as a fly on the wall would see it.”  Mischkowski says the self-distancing approach helped people regulate their angry feelings and also reduced their aggressive thoughts.

Other studies have shown that self-distancing can minimize how angry and aggressive people feel when aggravated, but this research shows that the technique can be learned quickly and can work in the heat of the moment, when people are most likely to act aggressively.

Student participants were provoked to anger in a series of situations, then were assigned to a control group, to visualize the situation again, or to imagine the scene from a distance.  Their levels of aggression were then measured when given the opportunity to retaliate to those who provoked them.

“If you focus too much on how you’re feeling, it usually backfires.  It keeps the aggressive thoughts and feelings active in your mind, which makes it more likely that you’ll act aggressively,” says Brad J. Bushman, a professor of communication and psychology at Ohio State and one of the study’s co-authors.

Another technique sometimes suggested is to use distraction when angered.  Mischkowski says that although this may work in the moment, the anger will return when the person is no longer distracted.  “But self-distancing really works, even right after a provocation.  It is a powerful intervention tool that anyone can use when they’re angry.”  

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Predicting Heart Failure Death in the ER

Ten pieces of information often gathered in the ER may be able to predict the risk of death for people with heart failure within seven days of presentation.

The new tool is called the Emergency Heart Failure Mortality Risk Grade (EHMRG).  To develop the tool lead researcher Douglas Lee, MD, PhD, of the Institute for Clinical Evaluative Sciences in Toronto, and colleagues examined three years’ worth of data from 12,591 heart failure patients in 86 hospitals in Ontario, Canada, from 2004 to 2007.

Within seven days of presentation 2% of the patients had died.  Researchers looked for common links—everything from medications, to lab values and transportation.  After adjustments were made, the 10 factors significantly associated with a greater risk of death in the first week were:

• Older age
• Transportation by emergency medical services
• Lower triage systolic blood pressure
• Higher triage heart rate
• Reduced oxygen saturation
• Higher creatinine
• Potassium level of 4.6 mmol/L or higher
• Elevated serum troponin
• Active cancer
• Use of metolazone at home

The researchers noted limitations of the study, especially the lack of information about left ventricular ejection fractions and brain natriuretic peptide.  The authors also noted that, “Symptomatic improvement, ability of the patient to seek follow-up care, and social circumstances should also be considered, along with quantification of acute prognosis.”  They indicated that the tool is not for use in patients who have chronic, symptomatically stable heart failure.

Lee is applying for a U.S. patent.

For more details or to read the entire study see the June 5 issue of the Annals of Internal Medicine, Prediction of Heart Failure Mortality in Emergent Care. 

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Distractions Cut Pain

It is established that distracting mental activities can minimize perception of pain, but how this happens has not been well understood.  A study published in Current Biology online has found that it is related to a spinal process involving opioid neurotransmission.

A study of 20 men with an average age of 27 found that distraction not only takes the focus away from the pain, but can dampen the body’s initial physiological response to pain through endogenous opioids.
Painful levels of heat were administered to the subject while undergoing functional MRIs.  Those doing complex memory tasks were pre-occupied to the extent that they experienced 19% less pain than those doing simpler mental tasks.

“This phenomenon is not just a psychological phenomenon, but an active neuronal mechanism reducing the amount of pain signals ascending from the spinal cord to higher-order brain regions,” said lead author Christian Sprenger, of the University Medical Center Hamburg-Eppendorf in Hamburg, Germany.

Sprenger and his colleagues repeated the experiment with another group of 15 men, average age 25.  This time they administered naloxone to block opioid effect or saline solution.  Perception of pain was 40.5% greater for those with the difficult cognitive task when given the opioid antagonist naloxone. This provided the evidence that endogenous opioids play a role in the distraction phenomenon.

“Our findings strengthen the role of cognitive-behavioral therapeutic approaches in the treatment of pain diseases, as it could be extrapolated that these approaches might also have the potential to alter the underlying neurobiological mechanisms as early as in the spinal cord,” Sprenger and colleagues concluded.  

For more information see the May 17, 2012 online issue of Current Biology.

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Therapy by Telephone

Can therapy for depression work when done by telephone?  The short answer is yes.  This type of therapy may be slightly less effective than face-to-face meetings, but patients are less likely to drop out of phone therapy. 

These were the findings of David Mohr and colleagues at the Northwestern University Feinberg School of Medicine published in the Journal of the American Medical Association in June of this year.  Mohr said, “One of the things we’ve found over the years is that it’s very difficult for people with depression to access psychotherapy.”  The authors speculated that reducing time commitments, transportation problems and cost may play a role in the lower drop-out rate for phone therapy.

Around 25% of all primary care visits are with patients who have clinically significant depression, according to the authors.  Cognitive behavioral therapy is an effective treatment for depression, but the drop-out rate is high.

Researchers in the randomized study had 325 people diagnosed with depression undergo 18 weeks of therapy, half by phone and half in person.  The quality of the telephone therapy was calculated to be equivalent to in-person treatment. By the end of the period 53 participants had dropped out of face-to-face therapy compared with 34 in the phone therapy group.

Patients in both groups felt decreased levels of their depression, however six months later patients who met with their therapists in person tended to feel less depressed than those who had phone sessions, but the difference was very small.

“At this point these findings do suggest that psychotherapy for depression can be administered both safely and effectively over the phone. Providers can be comfortable doing that and insurers and payers should feel comfortable” reimbursing for it, Mohr said.  Cognitive behavioral therapy by phone, “can overcome barriers to adhering to face-to-face treatment.” 

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.