Talk:Shingles/Archive 2

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Laboratory diagnosis

A positive test for VZV-specific IgM is very useful, but the gold-standard is PCR for VZV DNA in lymph taken from a vesicle. Viral culture for VZV can be used but the virus takes up to 14 days to grow in cell culture, (so not very helpful). I wouldn't rely at all on a raised leukocyte count, viruses tend to stimulate lymphocyte production more than polymorphs so the results of the full blood count would need careful consideration. A rise in titre to antibody in the blood is of little use; samples are taken two weeks apart and tested together and used to demonstrate the rise, again not so helpful. --GrahamColmTalk 18:58, 10 December 2007 (UTC)

Since a patient that presents with symptoms needs to start anti-viral treatment within 48-72 hours, test aren't very useful from a clinical standpoint. OrangeMarlin Talk• Contributions 19:20, 10 December 2007 (UTC)
PMID 11952291 says diagnosis via PCR is possible during the early rash stage, before blisters form. --Una Smith (talk) 19:48, 13 January 2008 (UTC)

This sentence needs to be reworded

Further studies during the 1950s on immunosuppressed individuals showed that the disease lost much of its benign characteristics and the search for various therapeutic and preventive measures was initiated Something not quite right about it.--Filll (talk) 02:45, 12 December 2007 (UTC)

I must have been eating turkey or drinking heavily while writing that section. But I certainly knew what I was talking about. LOL. OrangeMarlin Talk• Contributions 22:31, 12 December 2007 (UTC)

Detailed review

I'm a bit concerned to find the odd bit of text that is unsupported by the given source (and I haven't examined many of the sources). Also there are many cases where the paragraph ends with a double or triplet of footnote numbers. This isn't a particularly controversial subject, that needs multiple sources. Can these visually intrusive strings of numbers be reduced to just one good review? Sources 3 and 7 aren't in the same league as the journal reviews--can they be dropped?

Lead
  • The lead is not an adequate summary of the topic. Some of this may reflect Una's criticism that the article expects the reader to have some familiarity with shingles. There are some big questions that need addressed for any infectious disease and could be summarised in the lead.
    • How to I get this
    • How common is it? Is there a distribution pattern to infection (age group, social/class, geography, etc). How likely am I to get it? [Still like to know the lifetime prevalence]
      • I would say that this shouldn't be in the lead OrangeMarlin Talk• Contributions 22:23, 12 December 2007 (UTC)
        • I'm not looking for detail and the distribution pattern is only relevant if significant (e.g., if it is only a disease of the elderly). The reader will want to know in very general terms whether this is a rare disease or quite common. It appears that if you live to a good age, you have a 50% chance of an attack. So could some word like "common" be used? Colin°Talk 23:57, 12 December 2007 (UTC)
    • How long does it last (not necessisarily a number of days, we need to know basic stuff like if it is chronic or acute).
    • How often might I get it (Stankus 2000 says repeat attacks are "uncommon"). [Since repeats are uncommon, I can accept this not being mentioned in the lead.]
    • How bad can it be (commonly/rarely). Currently it just says "painful blisters", which could be regarded as relatively trivial (on the scale of a cold sore or mouth ulcer). How often are folk "disabled" (i.e., off work) by it; hospitalised by it?
    • How often is medical treatment required/sought/available?[I get the impression that antivirals are routine. If perhaps they were only used/needed in the minority of cases (in developed countries) then we should say so.]
    • How can I avoid getting it? [Doesn't seem to be a way (for healthy folk) other than avoiding chickenpox]
      • Almost impossible to avoid if you contracted chickenpox. OrangeMarlin Talk• Contributions 22:23, 12 December 2007 (UTC)
        • Your History contradicts that since we have near 100% chickenpox but only 50% shingles (if you live old enough) stats. Whether you can do anything to influence those figures is another matter. I guess active avoidance (prophylaxis) is important if immunocompromised. I'm not sure I like the latest lead text "When aging, stress, or disease cause the virus to reactivate and reproduce". This misses out the important fact that those things depress the immune system which allows the virus to reactivate and reproduce. The "immune system" must be mentioned in the lead. Colin°Talk 23:57, 12 December 2007 (UTC)
          • I guess I wasn't clear. Not sure there is anything to do to avoid it. Since the causal factors are only somewhat understood, it is nearly impossible. However, one of the references says that a VZV vaccination seems to increase resistance to shingles at least in older individuals. That is pretty definitive as a preventative measure for that age group. But then again, some individuals develop shingles as a result of the vaccine or just get it a few years later. OrangeMarlin Talk• Contributions 00:23, 13 December 2007 (UTC)
            • Am I the only editor involved here who is in the US? The latest thing among "seniors" is to get the vaccine, to fend off shingles, and many of them are upset that their insurance does not cover the vaccine for them. --Una Smith (talk) 06:46, 14 December 2007 (UTC)
              • I'm in the US. I have to tell you, I'm personally not a big fan of bashing pharmaceutical companies, their pricing or policies. I am a fan of bashing insurance companies! But I digress. I don't think seniors in the US complaining is very notable to this article. OrangeMarlin Talk• Contributions 06:51, 14 December 2007 (UTC)
Signs and symptoms
  • Somewhat vague terms are used throughout this section. Examples: "may be followed"; "may be extreme"; "often misdiagnosed"; "Some patients"; "In most cases"; "commonly occurs on"; "can also appear"; "are generally"; "is often"; "rarely left with". Some of these are quite acceptable--it would be tedious to give explicit percentages/ratio for every detail. But overall, I think an encyclopaedic article should give more detail than this. In particular, I'd like some figures on how common "zoster sine herpete" is; torso vs other parts; extreme pain vs tingling; how "rare" is scarring (rare could be 1:50 or 1:5000).
  • I question whether the misdiagnosis is "often" (previous text said "frequently"), which could imply anything upto the majority of cases. The wording "misdiagnosed ... other diseases with similar symptoms" has redundancy. Perhaps we could simply say "The cause of this pain may be misdiagnosed, such as from a heart attack or renal colic".[topic moved to Diagnosis, which is better]
  • The "scarring and pigmented skin" belong in the Prognosis section, since these aren't symptoms.
  • The word "patients" is used twice, which should be avoided (see WP:MEDMOS) as it frames the text from a physician's point of view.[Though the word is still used elsewhere in the article].
Causes
  • "The disease arises from various events which" isn't good prose. It also repeats "arise", which isn't IMO a particularly good word for what we are talking about.
  • It is self-evident that "immunosuppression" will "depress the immune system". Need to say something about deliberate suppression, disease-related suppression (HIV).
  • "There is no need for" is giving advice, which should be avoided. The sentence starts on the defensive ("Although") as though the author is involved in an argument, rather than just stating the facts. This whole sentence is based on a lay summary of a medical paper. Can we either source this to the actual paper or (preferably) just drop the topic as irrelevant?[Discussion of has moved to Complications section, and is better worded]
Transmission
  • I recommend the Transmission section be combined with causes as the first two paragraphs don't concern person-to-person transmission anyway. Also, there is some repetition in the chickenpox/reactivation story.
  • "ganglia"/"dorsal root ganglion" Singluar or plural?
  • The text here repeats the reason for the immune system failing to keep on top of the virus. Could this be combined with the text from Causes? The word "patients" again.
Diagnosis
  • The first paragraph has no source and needs to be rephrased. The first sentence is overlong and contains nested parenthetical statements (", which is...(although it"). The "few other diseases mimic" statement contradicts the earlier "frequently misdiagnosed". Can it be made clearer that if/once there is a rash, diagnosis can be performed visually due to the distinctive appearance/location. The text says "localization" is important but doesn't go on to say what the difference is. Being unfamiliar with "poison oak/ivy" rashes, I wouldn't know what part of the body they affect.
  • How does someone with "zoster sine herpete" get diagnosed? The source (Ozcan 2007) mentions (in the abstract) a serologic test. Is this how?
  • There appear to be four lab tests. Rather than introduce each one as we go along with a "could do this", "may do that" style, could the text be up front in saying "There are several laboratory tests...".
  • The reader will wonder why someone may do an "inferior" test, even if "reliable". The source implies it is "easy, quick, reproducible, and inexpensive". Of the four tests, is any one a clear leader in terms of popularity?
  • The possibility of VZV encephalitis should be mentioned in the Signs and symptoms section.
It's very rare indeed. Would it not be best to leave in Complications?--GrahamColmTalk 16:01, 15 December 2007 (UTC)
Treatment
  • Some treatments are not covered:
    • Corticosteroids are apparently commonly used (see Stankus 2000).
      • Not sure it has any effect on the course of the disease. I have read almost nothing about corticosteroids being used as a common course of treatment. I think for undue weight, we are not required to mention every tiny little treatment regimen, especially one not commonly accepted. OrangeMarlin Talk• Contributions 22:23, 12 December 2007 (UTC)
        • The source (which is used eight times) says "Orally administered corticosteroids are commonly used in the treatment of herpes zoster". Perhaps if you disagree then you need to find a more up-to-date source? Can Graham advise here? Colin°Talk 23:57, 12 December 2007 (UTC)
    • Pain relief from OTC drugs to narcotics may be required.
      • I would contend pain relief is not a treatment for the disease, just a symptom. And it would be the same for any pain relief, whatever the cause (from OTC drugs like Tylenol to powerful narcotics like Morphine.) OrangeMarlin Talk• Contributions
        • If the pain from shingles can be significant enough to require narcotic drugs, this is notable. To provide contrast, if some people's pain can be managed with aspirin, then that is relevant too. Colin°Talk 23:57, 12 December 2007 (UTC)
    • Drugs to treat neuropathic pain[I'll look at postherpetic neuralgia later]
      • See my previous response. OrangeMarlin Talk• Contributions 22:23, 12 December 2007 (UTC)
      • Added some more drug stuff. Please see if it works. OrangeMarlin Talk• Contributions 06:06, 13 December 2007 (UTC)
        • I haven't studied the Prognosis section yet, but long term pain seems to be a problem and there are specific drugs to deal with this. Colin°Talk 23:57, 12 December 2007 (UTC)

That's as far as I've got so far. Colin°Talk 18:25, 12 December 2007 (UTC)

Title and scope

Varicella zoster virus and Herpes zoster are the exact same virus. One name is used in the context of chickenpox, the other in the context of shingles. That problem needs to be stated up front, in a manner that helps to define the scope of this article. I would prefer this article to be titled "Shingles", for that very reason. This article is not about Herpes zoster, the virus that causes both shingles and chickenpox; this article is about shingles. --Una Smith (talk) 17:28, 13 December 2007 (UTC)

Well, I disagree. This article is about the virus. OrangeMarlin Talk• Contributions 17:39, 13 December 2007 (UTC)
Let me elaborate. Herpes zoster is specifically defined as the reactivate form of Varicella zoster. HZ causes an acute localized infection (along usually one dermatone). VZV causes a more general infection. I would contend that they might be genetically identical, but they are functionally quite different. Again, although Shingles is the disease, it can only be caused by one virus, Herpes zoster, which can only be there if one is infected by VZV. I think part of the problem here is that the VZV article is so poorly written that it can't be used as a reference for this article. I've thought about merging the articles, but they really aren't the same disease or same virus (in function). OrangeMarlin Talk• Contributions 17:46, 13 December 2007 (UTC)
"Herpes zoster is specifically defined as the reactivate form of Varicella zoster." That is not a taxonomic definition. Please cite a reference.

If this is to be an article specifically about Herpes zoster, then I suggest moving much of the discussion about shingles to its own page, and expand in this article a discussion of the relationship between shingles and chickenpox. --Una Smith (talk) 17:55, 13 December 2007 (UTC)

I recommend merge Varicella zoster virus and Herpes zoster. Also, keep all clinical details re chickenpox and shingles in separate articles by those names. --Una Smith (talk) 17:59, 13 December 2007 (UTC)

I disagree. Herpes zoster is a disease and not a virus. VZV is also called Human Herpes Virus 3, Herpes simplex virus type 1 is HHV-1 and Herpes simplex virus type 2 is HHV-2. Cytomegalovirus is HHV-4 and Epstein-Barr virus is HHV-5. The problem in the article is caused by not making it clear enough that herpes zoster is not a virus. I have tried to fix this.--GrahamColmTalk 19:37, 13 December 2007 (UTC)
Thank you Graham for you polite response to these questions. I also disagree with the merger. Typical of many editors, I am not an EXPERT on the virology, especially taxonomic definitions. VZV and HZ are two different medical articles, and should not be merged. OrangeMarlin Talk• Contributions 20:01, 13 December 2007 (UTC)
Una, I've re-read the lead, and it is crystal clear. I'm not sure why you've focused on this issue, but I can tell you, as a physician but not a virologist, the lead is extremely clear as to the two diseases. Shingles is really not the clinical name for the disease--it's Herpes zoster. OrangeMarlin Talk• Contributions 20:04, 13 December 2007 (UTC)
Per this discussion, I agree varicella zoster virus and herpes zoster should not be merged. However, this is a general encyclopedia, not a medical encyclopedia, which argues against using the clinical name for the disease. I don't care one way or the other what name is used here to refer to the disease. I do care that in the cluster of pages relating to this topic there is a consistent and clear distinction between disease(s) and virus. --Una Smith (talk) 00:03, 14 December 2007 (UTC)
  • The lead says "Herpes zoster......is a disease". The confusion has arisen, IMHO, by capitalisation errors. It should be herpes zoster throughout, (grammar permitting). Also varicella zoster is a disease chickenpox, whereas Varicella zoster virus, is a virus. Also, someone is pressing the space bar on their keypads twice, and I keep having to change this , into this. Please mend your ways ;-)--GrahamColmTalk 20:18, 13 December 2007 (UTC)
I'm a touch typist who long ago learned to follow an end of sentence with two spaces. I'm NEVER going to change, because I have been typing like this for about 35 years.  :) But if you insist....... OrangeMarlin Talk• Contributions 23:03, 13 December 2007 (UTC)
I believe that the actual taxonomy for the virus runs like this: Herpesviridae:Alphaherpesvirinae:Varicellovirus[1] The current international name for the virus is human herpes virus-3 (HHV-3); one popular older name (there are half a dozen) is varicella zoster virus-1 (VZV-1).
The CRISP thesaurus at the U.S.'s NIH says that shingles is the preferred name for the reactivated disease[2] and that varicella zoster virus is the preferred name for the virus itself.[[3]] Our international friends, however, firmly disagree: The WHO codes name the first disease Varicella (just the single word), and the second disease Zoster (again, just the single word).[4]
I am slightly inclined to have different articles for the virus and the two human diseases, because I seriously doubt that a patient is going to care about, oh, say, the number of base pairs in the viral genome. However, because Wikipedia is an international encyclopedia, I would like to suggest that, whatever decision is made about the scope of the article, we use the international names for the diseases and the virus, with appropriate redirects and explanation of the common English names. WhatamIdoing (talk) 22:31, 13 December 2007 (UTC)
Well, this article has focused on the disease, so it can be retitled Shingles, I suppose. Shingles already redirects here, so I'm not sure it matters one way or another.OrangeMarlin Talk• Contributions 23:03, 13 December 2007 (UTC)
If we're going to retitle it (a task that I think is of low importance), then I think that the article should be retitled Zoster (also a redirect to this article), not Shingles. Zoster is apparently the preferred name for everyone outside the U.S. WhatamIdoing (talk) 23:22, 13 December 2007 (UTC)
Erm, nope. We call it Shingles in Ozcheers, Casliber (talk · contribs) 01:34, 14 December 2007 (UTC)
It's called shingles in the UK.--GrahamColmTalk 05:36, 14 December 2007 (UTC)

Ah, I have been confused by the capitalization of "Herpes zoster". As the name of a disease, not the name of a taxon, it should not be capitalized. So now the three article entities, and their various names:

I can't find any others, except HHV-3 and VZV and both take you to the Varicella zoster virus page. I far as I can see there are three articles; two about disease and one about the virus. That's the way it should be. We seem to have come full circle on this. --GrahamColmTalk 06:15, 14 December 2007 (UTC)

I think simian varicella is not relevant and why was the comment changed after I had already responded?--GrahamColmTalk 16:39, 14 December 2007 (UTC)
  • Sorry. I changed the list, and only the list, to reflect additional information. --Una Smith (talk) 19:17, 14 December 2007 (UTC)
Done. I have edited the relevant articles re SVV and monkeypox. --Una Smith (talk) 20:21, 14 December 2007 (UTC)

Most of the discussion of the virus itself, the history and current understanding of the relationship between these two diseases, and the vaccine, would seem to belong in an article about the virus. Changing the title is of low importance, but also very easy to do. What is of high importance is reaching agreement on the scope of the article(s). --Una Smith (talk) 23:58, 13 December 2007 (UTC)

So, is Herpes zoster to be specifically about the disease, not about the virus also? --Una Smith (talk) 20:23, 14 December 2007 (UTC)

The article should either be called herpes zoster or shingles. Other folk are more qualified than me to judge this. From what I've read, the former seems to be used in formal circumstances but the latter conversationally, but both appear in medical papers and books, with one in parenthesis (i.e., they are considered equivalent). Discussion of the virus and overlap with that article are inevitable and not to be avoided. Take polio for example, where the virus has its own article. We need to summarise the virus info that is necessary to understand the disease, assuming the reader might not click on the link. The relationship between chickenpox and shingles belongs in all three articles, but the emphasis will change. The time when we need to worry about pulling info out of this article, into another, is when this article becomes too long. It is not a long article. Colin°Talk 18:53, 15 December 2007 (UTC)

History

The history section currently does not address the (presumably) separate histories of chickenpox and shingles, and how the viruses causing each were eventually found to be one and the same. --Una Smith (talk) 18:06, 13 December 2007 (UTC)

Una, I have (I hope) fixed this. --GrahamColmTalk 19:38, 13 December 2007 (UTC)

Transmission

  • The article now states VZV exhibits latency. However, it would appear the correct term is dormancy. If that is not correct, then Clinical latency and Dormancy both need to be revised. --Una Smith (talk) 20:16, 14 December 2007 (UTC)
The correct term is latency and I have revised both Clinical latency and Dormancy.--GrahamColmTalk 20:34, 14 December 2007 (UTC)
Good. I edited both some more. Latency needs a disambig; I will do that now. --Una Smith (talk) 21:23, 14 December 2007 (UTC)
FWIW, Latent (DAB) links to viral latency and incubation period. --Una Smith (talk) 21:28, 14 December 2007 (UTC)
I have improved viral latency a little, but incubation period needs more work, as it does not differentiate at all between clinical latency and dormancy in the sense of viral latency. --Una Smith (talk) 21:48, 14 December 2007 (UTC)
On reflection, I think incubation period and clinical latency are the same thing, whereas viral latency is a form of dormancy. I have proposed merging Clinical latency into Incubation period. Herpes zoster has a viral latency of months, years, decades, or censored (ie, the person dies first), but how long is its incubation period? --Una Smith (talk) 04:31, 15 December 2007 (UTC)
The incubation period of chickenpox is about 14 days, with a range between 7 and 23 days. The incubation period of shingles, ie. the period between infection and symptoms, is the same as the period of latency.--GrahamColmTalk 10:21, 15 December 2007 (UTC)
Let me ask the question again. Clinical latency aka incubation period is defined here on Wikipedia as the time during which the virus is replicating but the person shows no signs. So how much time passes from when the virus reactivates, to when clear symptoms appear? --Una Smith (talk) 14:28, 15 December 2007 (UTC)
The virus is never completely inactive. See the comment I have put in the article. So the incubation period is the length of time from the disapperance of the symptoms of chickenpox to the appearance of zoster. Is it going to help the article or reader to go into this?--GrahamColmTalk 15:07, 15 December 2007 (UTC)
Yes. The question of incubation period relates to two important clinical problems: (1) diagnosis before blisters appear, and (2) antiviral drugs helpful only if taken during onset of accute disease. Also, as defined in Wikipedia, incubation period aka clinical latency requires viral replication. It causes readers extreme confusion if they read "X" on one page and then "not X" on a linking page. So I think it is important, especially in a Featured Article, that linking pages be checked for consistency with this page and edited as needed. That does not mean every linking page must be totally correct, only that with respect to this page they are not contradictory. Finally, transcription of viral proteins (at a low level) is not replication. By the way, I wonder if laboratory assays for those proteins might not be used as an early warning of onset of herpes zoster. --Una Smith (talk) 16:31, 16 December 2007 (UTC)
Una, you keep stating "Clinical latency aka incubation period is defined here on Wikipedia as the time during which the virus is replicating but the person shows no signs." This "definition" is not helpful. Please drop the "is replicating" stuff and remember that Wikipedia defines nothing. It is not a source. Colin°Talk 17:53, 16 December 2007 (UTC)
  • Is HZ infectious or not? I think the intended meaning is not clear. The intended meaning is something like this: the virus is transmitted from persons with HZ to others, but in others it causes chickenpox, then HZ; it does not cause HZ directly. --Una Smith (talk) 20:16, 14 December 2007 (UTC)
Zoster is very infectious and susceptible individuals who have been in close contact with a suffer are likely to get chickenpox and, in later life, might get shingles.

If we can't get this simple fact right, how on earth are we going to sort out the problems with the incidence and prevalence data that Colin has spotted?--GrahamColmTalk 20:34, 14 December 2007 (UTC)

Una, I appreciate what you're doing, but this article has headed downhill quickly. I've never seen a FAC that actually made the article worse, but your edits and commentary here are not helpful. I have shown the article to physicians and lay people, and they immediately understood what it was saying. Now the complex writing has made it much worse in clarity. I don't understand your goals, but might I suggest stating your issues and see if there are others who might agree? OrangeMarlin Talk• Contributions 21:31, 14 December 2007 (UTC)

The lead now says (wrt the dormant state) that "This is called a chronic infection." I have to say that this is terribly confusing, even if it were technically correct. Lets leave the words acute and chronic to refer to disease/illness. Both chickenpox and shingles are generally acute illnesses. Postherpetic neuralgia is a chronic disease that is a long-term consequence of shingles. During the latent phase, one is not ill. Colin°Talk 19:04, 15 December 2007 (UTC)

Hi Colin, I've only just seen this comment. I deleted that erroneous statement a few edits ago. Thanks again. G. --GrahamColmTalk 22:11, 15 December 2007 (UTC)

Causes

I think I have unscrambled the topics in this section, mostly by moving sentences between paragraphs. As a result, I notice some points not mentioned. I have left an inline comment or two about what's missing. --Una Smith (talk) 22:45, 14 December 2007 (UTC)

I have tackled some of these are there any I have missed?--GrahamColmTalk 16:03, 15 December 2007 (UTC)
A few loose ends still remain, but I'll leave them alone for now because they touch on other sections that may yet change. --Una Smith (talk) 16:21, 16 December 2007 (UTC)

Now combined with Transmission, Causes might better be titled "Natural history". --Una Smith (talk) 16:21, 16 December 2007 (UTC)

Any section titled "natural history" should be part (e.g. as a subsection) of "signs and symptoms". JFW | T@lk 09:32, 17 December 2007 (UTC)

Complexity and clarity or lack thereof

  • OM wrote: "Una, I appreciate what you're doing, but [...]"
I don't think you do, but that's okay; you'll get there. --Una Smith (talk) 04:41, 15 December 2007 (UTC)
  • Graham wrote: "If we can't get this simple fact right, how on earth are we going to sort out [...]"
Not to worry. Before the current FAC the article read smoothly but underneath the polish now we are finding weak spots, and fixing them. A new round of polishing the prose and copy-editing can come later. On that topic, do you know Joseph M. Williams' book Style:_Lessons_in_Clarity_and_Grace? I highly recommend it. --Una Smith (talk) 04:41, 15 December 2007 (UTC)
I do, and in front of me I also have "The Complete Plain Words" by Sir Ernest Gowers, (a copy I have had since 1964) and "Fowler's Modern English Usage" (1987), ;-)--GrahamColmTalk 16:09, 15 December 2007 (UTC)
William's book is especially good on technical writing at the sentence level and above. And one suggestion he makes I use a lot as an editor on wikipedia. Educated readers tend to allow an article to remind them of what they already know, so they may overlook all but the worst errors of fact. I try to set aside what I know and read the article as if learning about the topic for the first time. --Una Smith (talk) 16:48, 16 December 2007 (UTC)
Una, this article would be improved if you could you restore the stuff you knew and stop editing as though learning the topic for the first time. :-) Colin°Talk 17:59, 16 December 2007 (UTC)

Where to put History section

As written now, the History section comes last, yet gives important context to the Epidemiology section. --Una Smith (talk) 04:53, 15 December 2007 (UTC)

You make a valid point but this has been discussed and a consensus reached.--GrahamColmTalk 10:26, 15 December 2007 (UTC)

I read the discussion and the argument for History last (because other medical articles put it there) is not compelling. In the case of this article, I think History needs to come sooner, because that history now includes the wide use of a vaccine, and one emerging theme of this article (not yet fully developed) is the changing incidence of herpes zoster as a result of the vaccine. --Una Smith (talk) 16:17, 16 December 2007 (UTC)

I prefer History to be a the top of articles and this is where I originally put it. WRT your other point re: changing incidence of zoster thanks to the vaccine, we need to remember the vaccine is not used widely outside the US, (it is not used yet in the UK), and has the incidence changed? The vaccine has been in use in the US for how long? is it ten years? not very long wrt to zoster.--GrahamColmTalk 17:50, 16 December 2007 (UTC)
WHO mentions the issue of epidemiological shift due to the vaccine and also the potential significant benefit of the vaccine in preventing herpes zoster (a benefit not considered in the cost-benefit analyses at the time of introduction of the vaccine for use against chickenpox). Searching PubMed for "varicella vaccine zoster" may yield some good references along these lines. --Una Smith (talk) 18:09, 16 December 2007 (UTC)
Una, If I have shown you guys anything, it's that I know how to do a PubMed search even though I still mess up the referencing of the article. Very sorry Colin.--GrahamColmTalk 18:20, 16 December 2007 (UTC)
Don't worry Graham. At least using the tool means there won't be any typos in the references. I changed the format back to one line rather than multiline since I believe that's how Orangemarlin prefers it. I spotted a few duplicates and it looks like many URLs got lost in the tidy up. Nearly cried. Finding those took a while :-(. Colin°Talk 21:16, 16 December 2007 (UTC)
Lots of sections have mild dependencies on each other; there is no one perfect order. Generally, the History section contains material that depends on having read the rest of the article. That is why it makes sense for it to be last. The other sections are supposed to be up-to-date, so won't depend on history to any extent. Epidemiology often discusses trends (as diseases are defeated, for example) but that is no reason why it needs to be before or after History. Colin°Talk 18:12, 16 December 2007 (UTC)
When I originally rewrote the article 6 months ago or so, I was told (not sure by whom, and I'm not going to look back at 5000 edits to find it), I was told that following WP:MEDMOS was recommended for this type of article. And that MOS says put history at the last. I guess we could fight the battle there. Sorry about my personal anality on references. By by no means do I own this article, so as long as we have inline citations, I'm so happy that I might cry. OrangeMarlin Talk• Contributions 23:15, 16 December 2007 (UTC)
It is occasionally necessary to deviate from WP:MEDMOS. For instance, it is sometimes necessary to move the "classification" section down when the classification relies very heavily on information obtained from the clinical history, examination and imaging/laboratory findings. I don't really see a reason to deviate from MEDMOS here. "Epidemiology" should be about the present situation and recent trends, while "history" should cover the initial description of the disease and major milestones in its elucidation. There is occasionally a bit of overlap if the disease has only recently been described (e.g. SARS). JFW | T@lk 09:30, 17 December 2007 (UTC)

USA-centered

This article only mentions the USA and I think it might help to get some facts and figures from other countries as well just for balance. The least we could do is move the US-bias from the lead to the epidemiology section, replacing it with a more general statement. --Steven Fruitsmaak (Reply) 18:47, 15 December 2007 (UTC)

This has been on my mind too.--GrahamColmTalk 18:50, 15 December 2007 (UTC)
I have added some UK, Europe and Australian data.--GrahamColmTalk 22:08, 15 December 2007 (UTC)
This one PMID 10906803 says seroprevalance to VZV not very high in India and gives percentages from survey, add to this the estimated reactivation of varicella to zoster in adult life is about normally 15%, after a mean quiescent period of 40 years PMID 11799191 and you can work out estimates of rates of Zoster in India. Although this may not apply as the rate of HZ seems to have nearly doubled in some areas due to HIV? India district, overall ‘(rate of 1990 being 11.3/1000 compared to 6.5/1000 in 1989,)’associated with AIDS epidemic PMID 8034996 It could be worth noting that the geographical reactivation rates may vary with HIV prevalance. Also similar in Africa; Zimbabwe ‘the cumulative herpes zoster incidence for 1986-89 of 250/1200 inhabitants,’ associated with epidemic PMID 1604717 Uganda; ‘The mean rate of herpes zoster was 53.6/1000 person-years in HIV-positive and 4.4 in HIV-negative participants.’ PMID 11216931 The mean rates are not dis-similar to elsewhere but the large AIDS/HIV population numbers in these regions alters the overall incidence rates considerably. Jagra (talk) 04:31, 23 December 2007 (UTC)
I recall that you quote mine regularly, and that you're quite incapable of reading medical literature. Now you're making conclusions from literature using your own research. I loved watching how many of your edits were reverted at CFD and other places. Please, go edit somewhere else, because your tendentious edits will be reverted here too, like we did for a month in this article, until several admins kicked your ass.OrangeMarlin Talk• Contributions 04:40, 23 December 2007 (UTC)
I see your bedside manners have worsened of Late, not that they were ever good, and I see you haven't lost that pithy colourful turn of phrase or POV that I enjoy exposing. Oh you may be interested to learn that your call of WP:RS Here was also shown as such, I have quite a collection of them now ? Merry Christmas Jagra (talk) 05:56, 23 December 2007 (UTC)

Etymology

I agree with Colin that etymology is interesting, but I recommend moving the etymology to Wiktionary and linking there. The etymologies of both zoster and shingles are more complex than "The words zoster and shingles come from the Greek and Latin words for a belt or girdle and refer to the rash on the body." Wiktionary provides for a far more comprehensive treatment of the etymology. See for example this and this.

  • I don't think the article is about the etymology, I think it about the disease. I put that line in because it is interesting, that's all.--GrahamColmTalk 18:06, 16 December 2007 (UTC)
Graham, do you have any objection to moving it to Wiktionary, leaving behind links, like this?
Look up shingles in Wiktionary, the free dictionary.

--Una Smith (talk) 18:37, 16 December 2007 (UTC)

Una, I didn't nominate the article. I'm just trying to help out. But to answer you question, yes I think it's a bad idea. The similar link you put on Rotavirus directed the reader to the worst definition on the World Wide Web!--GrahamColmTalk 20:14, 16 December 2007 (UTC)
    • Moving content to Wiktionary is effectively moving it off Wikipedia. To be honest, I'd rather read an online proper dictionary than the largely unsourced wiktionary. I fail to see the "far more comprehensive treatment" you mention. An encyclopaedic coverage of a medical condition will include the etymology of them name. This must remain here IMO. Colin°Talk 18:18, 16 December 2007 (UTC)
Well, Wiktionary at least has provision for adding sources. Some of its articles are very well sourced, and if not you can make a request for verification (RFV). The Wiktionary entry for "shingle" suggests that shingles meaning herpes zoster is derived from the characteristic angular patch shape of the rash. --Una Smith (talk) 18:37, 16 December 2007 (UTC)
Your Wiktionary must be a different one to mine as I can find no etymology for "shingles", and nothing about angular patch shapes. To quote a The American Heritage® Dictionary of the English Language: Fourth Edition:
shingles (plural noun): Middle English, alteration (influenced by Old French cengles, pl. of cengle, shingles, and by Old French sengle, single, chingle, belt) of Medieval Latin cingulus (translation of Greek zoster, girdle, shingles, from the fact that the inflammation often extends around the middle of the body), variant of Latin cingulum, girdle, from cingere, to gird.
Note I specified "shingle", not "shingles". Derivation from shingle (rectangular piece of wood) makes sense; derivation from any word meaning encircling the body like a belt, or extending around the middle of the body, is not consistent with the appearance of shingles. So I question the accuracy of the dictionary. Go ahead and say in the article that X dictionary says the term is derived from some word meaning girdle or belt, but then explain the inconsistency of this derivation. --Una Smith (talk) 05:39, 17 December 2007 (UTC)
Una, you are creating a false etymology and are in conflict with WP:V. It really doesn't matter if you personally think an alternative derivation makes more sense. I consulted lots of dictionaries and found agreement, the one I quoted was the most detailed. The worlds experts in language origins think that "shingles", the disease, has the origin given above. The "shingle" stones and wood have their own separate etymologies. To request that this article "explain[s] the inconsistency of this derivation" is original research and would be the POV of one person. Colin°Talk 12:55, 17 December 2007 (UTC)
"Una, you are creating a false etymology and are in conflict with WP:V." Colin, that remark is ad hominem, hence inappropriate. You may say text is in conflict with WP:V. --Una Smith (talk) 16:13, 17 December 2007 (UTC)
It is verifiable that dictionaries give this etymology, but to verify the etymology itself requires some direct proof via quotation a la "I call it shingles because it looks like ...". (That is a job for Wiktionary.) I find it interesting that the etymology given in these dictionaries is not consistent with the characteristic of the rash. That is neither original research nor creation of a false etymology. --Una Smith (talk) 16:13, 17 December 2007 (UTC)

<unindent> I can't say the "text is in conflict with WP:V" because (fortunately) you haven't added your invented etymology. The request "Go ahead and say in the article that X dictionary says the term is derived from some word meaning girdle or belt, but then explain the inconsistency of this derivation." is a personal request from you that we deviate from WP:V, since you haven't provided a source that claims the derivation is inconsistent. Let's please move on from who or what disagrees with WP:V.

Our requirement to source an etymology stops with a professionally published dictionary from an authoritative publishing house. Your requirement that someone find the "Aha! I know, lets call it shingles because ..." moment written and preserved for posterity is frankly quite amazing. Any dictionary editor would choke on his Earl Grey if asked to comply with that.

To quote from the lead of false etymology, "A false etymology is an assumed or postulated etymology that is incorrect from the perspective of modern scholarly work in historical linguistics." You are postulating an etymology that is in conflict with all modern scholarly work that I have been able to find. I'm struggling to find a better example of Original Research than this. Colin°Talk 17:53, 17 December 2007 (UTC)

In my experince, Wiktionary is either a copyvio, inexact or incorrect. Writing a dictionary is best left to the professionals IMO. Colin°Talk 20:09, 16 December 2007 (UTC)
The same can be (and often is) said about Wikipedia. --Una Smith (talk) 05:39, 17 December 2007 (UTC)

By the way, VZV is sometimes known as "varicella-zoster virus" (with hyphen) because it causes both "varicella" and "zoster". --Una Smith (talk) 18:00, 16 December 2007 (UTC)

    • This article should use either "varicella-zoster" or "varicella zoster" and make its mind up (it currently uses both). Of course the reference titles should be preserved whatever they are. Colin°Talk 18:18, 16 December 2007 (UTC)
Agreed. The relevant page here is varicella zoster virus. On this page, after the first use (in the lead), I would just call it "virus". --Una Smith (talk) 18:37, 16 December 2007 (UTC)

Lead

I noticed that the names of the drugs used to treat shingles were eliminated from the lead. Is there a reason, especially when I attack my next article? Since there is a LOT of evidence that the only way to treat shingles are with antiviral drugs within 72 hours, I think that's a critical point. OrangeMarlin Talk• Contributions 23:17, 16 December 2007 (UTC)

I wasn't involved in that change but I did feel that listing all the variants (plus US brand names) was OTT for the lead. The "critical point" is preserved. I suspect what drug your physician actually prescribes may vary depending on where you live and how good your insurance cover is. Colin°Talk 00:22, 17 December 2007 (UTC)

For the purposes of the lead, I would generalise that all these drugs are antivirals or thymidine kinase inhibitors, and give one or two very common examples. Listing all drugs registered for VZ is unnecessary and distractive. JFW | T@lk 09:24, 17 December 2007 (UTC)

Stats (again)

"It is most common in people more than 65 years old, affecting just over one in ten.". I've read that source. I has a big Incidence and Epidemiology section but I'm no expert. I can't find "65" or "one in ten". Once again we have this vague "affecting" wording. Do "1:10" over 65s currently have shingles? Will "1:10" over 65s develop shingles at some point? This says the lifetime prevalence is 25% but I'd like to have a better source. The Weaver2007 source cites this source which cites another giving a 20% lifetime prevalence. Weaver also says "Sixty percent of cases occur in individuals aged 50 years or older." This report says 15% of those who get chickenpox will go on to get shingles and cites an article in the Lancet (I can't read it).

Given the overwhelming evidences that most people who get shingles are over 60, and that chickenpox is usually a childhood infection, do we really need to say "Years, or decades later" in the lead. I wonder what the average latency is? The above Slovenian report says 75% of chickenpox was in under 7s. So the latency is probably over 50 years, on average. The lead should be simple (you can give details and exceptions later). Could this be changed to just "many decades later"? Colin°Talk 00:22, 17 December 2007 (UTC)

  • The epidemiology coverage needs a good deal of work. You are correct that the cited source doesn't support the "65" or the "one in ten". The cited source says that HZ "develops" so we can use that wording. The other points need a citation. I started things off with this change but more work is needed. Eubulides (talk) 03:23, 17 December 2007 (UTC)
  • The lead says "In the UK 189,000 cases are reported each year" but the cited source (Brisson & Edmunds 2003, PMID 14500303) says that the figures are estimates of cases requiring physician consultation in England and Wales only. It is not clear how to relate this 189,000 figure to the 1 million U.S. figure. What we really should be doing is comparing incidence rates. The lead also says "the incidence is similar in the rest of Europe" but the cited source (Sengupta et al. 2008, PMID 17334784) does not say that; this citation should go. The lead also says incidence "is slightly higher in Australia" but the cited source (Araújo et al. 2007, PMID 17939895) says the incidence is about the same worldwide. I attempted to clean up these problems with this change. As a general rule, every citation in the lead should also be cited in the corresponding part of the body, so that the lead should contain only <ref name=foo/> citations. Eubulides (talk) 03:40, 17 December 2007 (UTC)
  • The first two sentences of Herpes zoster#Epidemiology says "VZV only infects humans". Not true: it also infects at least rats and chimpanzees, at least in the lab. It says "chickenpox occurs in epidemics" that are "seen every two or three years". But there isn't evidence for regular epidemics in the usual sense; it's just seasonal variation, at least in temperate zones. There have been irregular epidemics in the tropics, I think. It says the epidemics occur "during the late winter"; more accurate would be to say that seasonal variation peaks in winter and spring. I attempted to fix these problems with this change. Eubulides (talk) 05:59, 17 December 2007 (UTC)
  • Re "VZV only infects humans", it depends where you draw the line. The abstract of one paper says VZV is transmissible to household dogs and cats, but that the animals are dead-end (blind alley) hosts. The animals become sick but not infectious. --Una Smith (talk) 06:12, 17 December 2007 (UTC)
  • I agree about the dogs and cats. But if the article says VZV infects "only humans" then it needs to say what it means by "infects", to avoid confusion. The simplest fix was to remove the phrase; perhaps a better fix would be to explain it better. Eubulides (talk) 06:39, 17 December 2007 (UTC)
  • So delete "VZV only infects humans" from this article (it doesn't really belong here), and perhaps say in Varicella zoster virus that "VZV is only infectious in humans" but is known to infect dogs, cats, rats, and chimpanzees. Is that true, or do rats or chimps develop blisters and shed virus? --Una Smith (talk) 06:57, 17 December 2007 (UTC)
Don't frighten the animal lovers unnecessarily :-) Do people with chickenpox/shingles have to avoid touching their pets? Is this something that people ever take their dog to the vet with? Keeping WP:UNDUE in mind, if this is extremely rare or only occurs in labs, it may not be relevant here. I agree, some rewording is required, and possibly a bit more investigations. Anyone know a WikiVet? Colin°Talk 07:52, 17 December 2007 (UTC)
  • I'm willing to defer this issue to the editors for Varicella zoster virus who no doubt have vet experts on call :-). I'm no expert but my understanding is that chimps do get a rash; see Cohen et al. 1996 (PMID 8950684). Also, natural VZV infection has been observed in one gorilla (not in a lab); see Myers et al. 1987 (PMID 2826674). Eubulides (talk) 08:38, 17 December 2007 (UTC)
  • I'm leaving this paper here on the talk page so I can use it to rewrite the epidemiology section slightly. But if anyone else wants to use it be my guest. It's getting late here, and I need some sleep!!!! OrangeMarlin Talk• Contributions 06:17, 17 December 2007 (UTC)
  • I took a quick look; that's mostly about the incidence of complications for HZ. That would be nice to cover too. Right now I'm worried about the basics like the incidence of HZ itself, so I'll focus on that. Eubulides (talk) 06:39, 17 December 2007 (UTC)
  • Herpes zoster#Epidemiology said "The incidence rate of herpes zoster in persons aged 65 or older is approximately 19 per 1000 individuals per year in the U.S." and cites Weaver 2007 (PMID 17488884). But Weaver contains no data supporting this claim. Ouch. I fixed the problem for now by removing the claim. Eubulides (talk) 06:44, 17 December 2007 (UTC)
  • Herpes zoster#Epidemiology said "The incidence in this age group of a white ethnic background is approximately 3.5 times higher than in the same age group of a Hispanic ethnic background." and cited Chaves et al. 2007 (PMID 17357357). I read that source and I don't think it's worth mentioning in Wikipedia. First, it relies on self-reporting, which is fairly unreliable for HZ (suspected cases are often not confirmed). Second, it's a phone survey. Third, this sort of thing really needs confirmation; for example, Chaves et al. report no significant difference for HZ incidence among black vs. white adults, contradicting Schmader et al. 1995 (PMID 7876622) which reported a 4x greater incidence among older blacks. This sort of result needs a reliable review to place it into context, which we don't have yet: I looked for other papers citing Chaves et al. but didn't find anything useful (not too surprising, it's so new). For now, I think it best to remove that citation, until it gets reviewed or cited in a useful way by some other reliable source; so I did that. Eubulides (talk) 07:47, 17 December 2007 (UTC)
  • This recent change to the lead has some problems. First, it introduces citations to the lead that are not in the body, which is a bad sign: it means the lead isn't summarizing the body as it should. Second, even if this new stuff is moved to the body, it's detail that needs more explanation, as the question whether HZ incidence is actually increasing (as opposed to just being reported more) is not clear. Third, the inserted text says "the causes of these increases are unknown but arguably are not due to use of the varicella vaccine" which is not the case for the Canadian result (the increases preceded the introduction of the vaccine there). My own feeling is that the article currently doesn't cover the basics of HZ epidemiology well (it still needs a lot of work in the epidemiology section). However, I think I'll take a bit of a break from editing now, partly to let others weigh in, partly because I've run out of free time for now. Eubulides (talk) 08:02, 17 December 2007 (UTC)
    • I like your "Use <ref name=foo/> in the lead" guideline, as a way of ensuring that any citations (if necessary) only repeat what is already covered in the body. My habit had been to ensure the full version was the first in the entire text, as I had a vague idea (possibly incorrect) the software originally required that ordering. Colin°Talk 09:02, 17 December 2007 (UTC)
      • The software used to require that the information be given on the first occurrence, but that changed, oh, about a year ago, maybe less. The developers fixed it so that it would recognize the ref tag anywhere in the article. I now try to remember to follow the convention of adding the full text *later* (not in the lead), for exactly the reason given, and so that if someone alters the lead, I won't lose the main ref. SandyGeorgia (Talk) 01:38, 18 December 2007 (UTC)
  • Herpes zoster#Epidemiology cited studies showing that HZ incidence is increasing, without also citing studies showing the opposite. It also took the incidence rate from a single study. I made this change so that it uses reviews to talk about incidence rates. Incidence rate trends are not clear, as near as I can tell. Eubulides (talk) 00:35, 18 December 2007 (UTC)
  • Herpes zoster#Epidemiology said that the HZ incidence "rate is approximately 131 per 100,000 person-years in white individuals" and cited Dworkin et al. 2007 (PMID 17143845). But that reference does not have that statistic. The number is plausible but it is a duplicate statistic (the next paragraph estimates 120 to 340 per 100,000 person-years), so I removed it. I also removed the unsourced claim that HZ affects 10–20% of the U.S. and UK population. Eubulides (talk) 04:30, 18 December 2007 (UTC)
  • Herpes zoster#Epidemiology said, "According to a review of the disease in the United States, one million consultations for herpes zoster occur per year; approximately 250,000 of the people examined develop herpes zoster ophthalmicus. A subset of 50% of these people develop complications of herpes zoster ophthalmicus." and cited Pavan-Langston 1995 (PMID 8545020). But that source does not give the one million or the 250,000 or the "subset of 50%" figures. It also said, "Ramsay Hunt syndrome is the cause of as many as 12% of all cases of facial paralysis." and cited Johnson & Dworkin 2003 (PMID 12676845); but that source says nothing about Ramsay Hunt syndrome. These claims are all plausible but we can't include them without sources, so I removed them for now. Eubulides (talk) 05:34, 18 December 2007 (UTC)

Zoster

Can someone please clear up whether the sole word "zoster" is a "common term" for shingles. The word was reintroduced with this source in the edit summary. That article appears to use both varicella and zoster as convenient abbreviations. A single source by one author proves nothing about common usage. Looking solely at PubMed titles: "zoster[TI] NOT herpes[TI] NOT varicella[TI]" gives 22 pages, compared to 315 for "zoster[TI]" and 162 for "herpes zoster[TI]". Perhaps I'm doing something wrong, but it doesn't seem particularly common among medical writers. Is there an English-speaking country where that word is mainly used? Or, as I suspect, are medical folk who study herpes viruses merely using the single word "zoster" as shorthand. If so, this is an abbreviation, not a synonym. Colin°Talk 00:22, 17 December 2007 (UTC)

Once again, not being a virologist, nor playing one on TV, but being a physician, and definitely never playing one on TV, I've never heard the term "zoster" referring to shingles. I've heard varicella frequently, but never zoster. Of course, I never dealt with infectious diseases (yuck), I was more concerned about coronary arteries, so I'm kind of useless here. Maybe I should play something on TV, make more money, and ignore the whole topic. OrangeMarlin Talk• Contributions 00:58, 17 December 2007 (UTC)
I have heard zoster, and read it too. --Una Smith (talk) 06:19, 17 December 2007 (UTC)
Did you ever hear a lay person use the word? Can you find an example in a newspaper, for example? Has a book been written with that as the title? My concern is that it is right up at the start of the lead, which give a heck of a lot of WP:UNDUE weight if it is a rarely used piece of jargon. I wouldn't mind if some phrase like "sometimes shortened to just zoster" appeared later in the text. Colin°Talk 07:45, 17 December 2007 (UTC)
Forgive any POV but I've never heard (or read) it called just "zoster" always "shingles" or "herpes zoster". --GrahamColmTalk 09:08, 17 December 2007 (UTC)
It is a jargonesque abbreviation, like "the roids" is used as an abbreviation for steroids. JFW | T@lk 09:22, 17 December 2007 (UTC)

A Google Web search on zoster -"herpes zoster" returns about 478,000 hits. Some of the first 20 hits are below. --Una Smith (talk) 17:36, 17 December 2007 (UTC)

Most of the 478,000 hits will be discussing "varicella zoster" (chickenpox). The majority use of "zoster" is as a medical shorthand once the full medical term has been used. I've restored the word to the lead, with appropriate emphasis, because it appears WHO's ICD 10 is now using the term alone (compare ICD 9). Their classifications have authority, even if not (yet) widely adopted. Colin°Talk 18:53, 17 December 2007 (UTC)
That Google search (zoster -"herpes zoster") returns pages in which "herpes zoster" never occurs, hence in those pages zoster is specifically not "medical shorthand once the full medical term has been used". --Una Smith (talk) 19:00, 17 December 2007 (UTC)
I said "majority", not all. *sigh* I spent an hour looking at a variety of professional articles, not just whatever detritus Google turns up. I'm a wee bit puzzled by your Google search, which gives me 1.1 million more hits than yours. Anyway, can we please move on to more productive territory. Colin°Talk 20:02, 17 December 2007 (UTC)

The etymology is quite interesting and complex. From the time when much of the European medical and scientific world communicated internationally in pseudo-Latin and pseudo-Greek, two common terms were "zoster" (from Greek) and "cingule" (from Latin) etc. Both date back before the 19th Century. Medical dictionaries published in the 19th Century (scads of these now on Google Books) are full of derivative terms, spelling variants, etc., for the Latin term. From among the Latin derivatives "shingles" emerged. Zoster has stood the test of time, but in English vernacular use zoster is not nearly as common as shingles. In addition, there were numerous other names of vernacular origin, that have not survived. --Una Smith (talk) 21:54, 18 December 2007 (UTC)

By the way, in the older sources I have read there are some hints that "zoster" predates "herpes zoster"; the "herpes" got tacked on later, when experts began to group diseases into classification systems. --Una Smith (talk) 21:57, 18 December 2007 (UTC)

I agree that the etymology is interesting, but etymology belongs in the Herpes zoster#History section, with only a brief summary (at best) in the lead. Please see the 2nd paragraph of Autism#History for an example of what I'd like to see here. Autism doesn't mention etymology in its lead, and I'm not convinced etymology should be in the lead here either; it's a bit of a side issue to be honest. Eubulides (talk) 22:07, 18 December 2007 (UTC)
Etymology is somtimes mentioned in the lead if it can be kept brief. Coeliac disease mentions it in the lead and the history. We have two words to explain, and I agree with Una's FAC comment that the History could probably be expanded. Lets put in the history for now and worry about the lead once the body is improved. It may well be that some other historical fact is more relevant for the lead. Colin°Talk 23:45, 18 December 2007 (UTC)

Finishing it off

I tweaked the lead some more. It now mentions painful blisters twice, and the second instance is a bit too imprecise. The pain is caused by virus in the nerves, not in the surrounding skin. The pain often starts first, followed by the characteristic dermatomic rash; the blisters come last and occur within the area of the rash. --Una Smith (talk) 21:43, 18 December 2007 (UTC)

zoster sine herpete

Does zoster sine herpete occur only after an earlier episode of herpes zoster? That would make it a complication of sorts. If not, explanation of zoster sine herpete should go with the other sub-categories of HZ, now under Signs and symptoms. --Una Smith (talk) 16:51, 17 December 2007 (UTC)

Agree that zoster sine herpete needs to be mentioned in the "signs & symptoms" section. Obviously this diagnosis can only be made if the clinical suspicion is high. It requires someone to request VZV serology on someone with unexplained symptoms (such as burning pain in a dermatomal distribution). Compare the bizarre naming conundrums like "amigranous migraine" or "pseudopseudohypoparathyroidism". JFW | T@lk 17:20, 17 December 2007 (UTC)
Oh Doctor, my head hurts. :-) --Una Smith (talk) 17:37, 17 December 2007 (UTC)

Prevention

I found some problems in Herpes zoster#Prevention.

  • The first paragraph covered not-that-relevant topics such as how exposure to chickenpox boosts the effect of chickenpox vaccine. That last point was particularly confusing, since it made it sound like exposure to chickenpox boosts the effect of Zostavax, which is plausible but was not supported by the cited references. The paragraph also referenced Brooks et al. 2005 (PMID 15960856) but that source says they don't know whether varicella vaccination caused the HZ incidence increase. Better to tone this stuff down a bit, and focus on varicella prevention. The bottom line is that the best-known method is Zostavax (50% incidence reduction), and exposure to chickenpox is 2nd-best (25% reduction). So I made this change to do that. Eubulides (talk) 20:37, 17 December 2007 (UTC)
  • The discussion of Thomas et al. 2006 (PMID 16330478) was backwards: it started by mentioning vitamins but the actual study found the best-supported effect among fresh fruit. It is not clear whether the micronutients themselves help prevent herpes zoster, or whether they are a stand-in for something else. I reworded that in an attempt to improve things. Eubulides (talk) 21:15, 17 December 2007 (UTC)
  • The discussion of Irwin et al. 2007 (PMID 17397428) had some problems. It wikilinked to Tai Chi Chuan but the study actually was of Tai Chi Chih. It didn't make it clear that the study provided no direct evidence that Tai Chi Chih affects the incidence of HZ. I made this change to try to improve things. Eubulides (talk) 21:42, 17 December 2007 (UTC)

Sources

The following sources were removed along with text that apparently wasn't supported by them. I've copied them here in case they prove useful later. Feel free to add other potentially useful sources. Colin°Talk 22:49, 17 December 2007 (UTC)

I'm running out of time. Here are some tidbits for others to use. --Una Smith (talk) 23:33, 18 December 2007 (UTC)

  • The first vaccine against VZV was developed in Japan in the 1970s and has been in widespread use since the mid-1990s[1]. This vaccine is based on VZV serotype J. Serotype J is relatively rare in Europe, where serotypes B and C are most abundant. Now that evidence is accumulating re transmission of the vaccine-derived strains of VZV, differences between serotypes and their global distribution patterns may have an impact on epidemiology.
  • Diagnostic methods not mentioned(?): serology, viral culture. Recall Wikipedia is a world encyclopedia, and not all of the world has ready access to electron microscopes and automated PCR/DNA sequencing.
  • Prior to vaccination, the incidence of zoster in first decade of life is reported to be nearly 0.74 cases per thousand per year[2]
  • A small study of herpes zoster diagnosed in children found a positive association between herpes zoster and a history of subclinical or very mild clinical chickenpox.[3] This relates to the ideas that (a) good immunologic protection against HZ requires a strong immune response to chickenpox, and that (b) childhood vaccination may produce an immune response that is not adequate to protect against HZ. There are other papers on these ideas.
  • From the 9th Century to the 13th Century herpes zoster ravaged Europe, where the disease was widely known as "Saint Anthony's fire" and treated ("cured") with lard. A Catholic hospital order, the Antonines (see Anthonians), was founded to treat herpes zoster patients.
  • <quote>... it can merely be said that any influence sufficient to induce inflammation of a sensory nerve or its ganglion may be followed by the objective signs of the disease. Zoster occurs occasionally in small epidemics; some observers strongly favor the theory of infection.</quote> HydeMongtomery1897 pages 245-246. Researchers had looked for an infectious agent but found none; viruses were too small for the technology of the times.

Lead

The lead has improved in terms of coverage (I've struck through most of my questions in the review above), but the prose has deteriorated IMO. The lead sentence needs to be a compact description of the disease yet actually tells us nothing about the illness. Yes, we should mention its viral origin but the actual virus and the preceding chickenpox infection are secondary, though very important. Saying "the second in a sequence" makes the reader ask a question in the middle of reading the very first sentence ("what was the first?") when she should be concentrating on learning. "Chickenpox occurs first but after the symptoms go away..." is clumsy and over-simple prose. It goes on. There's no mention of the immune system failing to keep the virus in its place, which is a key feature of every summary I've read.

The middle paragraph can't be fixed until the body text is sorted. The third paragraph is too short. The first paragraph could be worked on now, and could probably all be based on one good review paper (excepting the etymology). Would it help to offer suggested alternatives below, along with rationale/commentary, rather than destabilise the article? It doesn't need to be a whole paragraph, just a revised sentence could help. Colin°Talk 23:22, 17 December 2007 (UTC)

Vesicle is unlinked in the lead; it's a dab page. SandyGeorgia (Talk) 01:57, 18 December 2007 (UTC)

Update: The lead sentence is now a better summary of the illness, thanks Wouterstomp. The mention of "zoster" is less intrusive now, if slightly less informative. Some of the other issues I've had are a bit better now (thanks Una). I'd like one of our medical editors to double check the language in the lead is technically correct. For example, would you use the term "late complication" to describe HZ? The lead section still needs more work, but slowly getting there I hope. Colin°Talk 18:35, 18 December 2007 (UTC)

Oops, I missed this new section about the Lead, and added comments to the earlier section. --Una Smith (talk) 22:00, 18 December 2007 (UTC)

I changed "very rare" to "rare"

(In the Management section) I changed the sentence "Repeat attacks are very rare" to "rare," as the primary reference only said "unusual" (not "very unusual" or "very rare"). The secondary reference is only viewable to Medline subscribers, so I couldn't verify what it said, yet the article is from an Ocular Immunology magazine, and may refer strictly to ocular HZ manifestations. (I also note that all of the info I've read on the internet regarding shingles seems to suggest that the condition can and does reoccur, if immunological function is sufficiently decreased. [Which would possibly stand to reason for a herpes virus, if it's even a tiny bit similar to HS.]) Softlavender (talk) 06:48, 18 December 2007 (UTC)

Electron micrograph

I see Colin has moved the micrograph to the History section and this is fine by me. Yes, it is decorative, it is a superb example, but it is also exactly what one looks for when diagnosing shingles by electron microscopy. So, I hope it stays in the article. As for it being black and white, we must remind ourselves that viruses are smaller than the wavelengths of light that produce the colour response in us. Viruses are smaller than colour.--GrahamColmTalk 08:37, 18 December 2007 (UTC)

You know, I regretted my edit summary ("Move black & white virus image to History. It is decoration, really, and looks better if the images aren't all clustered together.") as soon as I saved it. It reminded me of a old fashioned pencil/charcoal sketch, but of course it is computer generated from electrons and stuff. Somehow, a black and white picture seemed appropriate for the history bit. By "decoration" I didn't mean to imply it could/should go, just there there didn't appear to be any section that depended on it for ones understanding of the article (and so could go more-or-less anywhere). If we had separate substantial Cause and Mechanisms sections then I guess the virus could go in Cause and the diagram in Mechanism. Colin°Talk 13:42, 18 December 2007 (UTC)
Personally, I liked that image in the Diagnosis section. I will try to find an illustration for the History section. Graham, any chance you have a photo of multinucleated giant cells? There is a photo and nice description of the diagnostic features (including molded nuclei!) on the NEMJ website, but it isn't usable here. --Una Smith (talk) 14:56, 18 December 2007 (UTC)
Una, I'll have a look through my collection this evening when I get home.--GrahamColmTalk 16:03, 18 December 2007 (UTC)
No luck, just an old scratched 35mm slide. I'll ask around in the morning, my histopathology colleages might have one we can use.--GrahamColmTalk 18:22, 18 December 2007 (UTC)

Cimetidine

Herpes zoster#Management had a subsection on cimetidine that I reproduce below. As near as I can make out, this treatment is obsolete and shouldn't be mentioned (except perhaps under "History"). So I removed the subsection.

Cimetidine, a common component of over-the-counter heartburn medication, can lessen the severity of herpes zoster outbreaks.[4][5][6] This application is considered an off-label use of the drug. In addition, cimetidine and probenecid reduce the renal clearance of aciclovir.[7] These compounds also reduce the rate at which valaciclovir is converted into aciclovir. Due to the tendency of aciclovir to precipitate in renal tubules, combinations of these drugs should only be used under the supervision of a physician.

Eubulides (talk) 09:15, 18 December 2007 (UTC)

There is no interaction listed in BNF 53 between acyclovir and cimetidine, but there are interactions listed between cimetidine and the anti AIDS drugs atazanavir and amprenavir. I guess that most mild interactions would be better placed on pages for the drugs rather than on this page. Snowman (talk) 16:40, 20 December 2007 (UTC)

Lysine

The subsection Herpes zoster#Lysine is problematic. It cites just one source, Perfect et al. 2005 (PMID 16209859), but this source does not mention herpes zoster or shingles or varicella zoster at all. As far as I can see, this subsection is original research, and should be removed. I notice that it's been edited recently, though, so for now I have just added an OR tag and will ask for others to comment. Eubulides (talk) 09:32, 18 December 2007 (UTC)

The text originally (well, last week) cited a subjective questionnaire-based study on the effect of lysine on herpes simplex. This was added, I believe, due to a request on FAC that something should be said about lysine since it is a popular alt-med "treatment". On the scale of WP:MEDRS sourcing, that was a pretty lame study [sorry, Orangemarlin] and so I replaced it with a modern review in this edit which says:

Most herpes-related research on the amino acid lysine was conducted during the the 1970s and 1980s, before the availability of aciclovir. Various small studies investigated the effect of taking a lysine supplement on people with herpes simplex virus (which causes oral and genital herpes). The results were contradictory and the studies to date have failed to provide adequate information from which to base a clinical therapy.

I think that is faithful to the source. I left in a line at the end of the paragraph, which said "There is no published evidence that lysine has any effect on herpes zoster." That line is unsourced and if we are being strict, is OR. Having said that, WP:V is only need for info that "is challenged or is likely to be challenged" and proving the absence of something is jolly hard. A PubMed search throws up no clinical studies, its just a shame we don't have our friend Cochrane to quote here.

More recent edits to this section are indeed WP:OR (a synthesis of published material that serves to advance a position). To be honest, I think that without clinical studies on HZ, the mere mention of a treatment for HS is effectively suggesting to the reader this may be something relevant to HZ. Orangmarlin said that the original paper "made reference to zoster that it might work too". However, if you read my comments on his talk page, you'll see why I think such a suggestion should be taken with a pinch of salt. In summary, unless a secondary independent and unbiased source can be found suggesting lysine as a treatment for HZ, I support the wholesale removal of this section. Colin°Talk 10:00, 18 December 2007 (UTC)

I was the one who edited the section to remove the POV and add information from the article about lysine–herpes interactions, which are pertinent as to causality. All of the statements, and every single sentence, now in the section are directly from the cited article. Rather than source each and every sentence separately from the exact same article, I kept the citation only at the end, as it had been originally. (If desired, one could cite the three primary sources for the arginine-lysine and the replication-inhibitory info from the three primary sources the article cites: 34. Tankerley; 35. Griffith; and 36. Park.) In terms of the section itself, I do not care if this section on lysine remains in the article or not, but if it does remain, it needs to be NPOV and neutral. I did what I felt was my best to make it so; if there are further ways to make it so, please feel free. The now-removed statement "the studies to date have failed to provide adequate information from which to base a clinical therapy" is not supported by the sourced article. Even if it had been so stated in the article, that statement would not be considered a provable fact, as that article is two years old even now. Softlavender (talk) 10:45, 18 December 2007 (UTC)
This section is neither helpful nor important and should be removed. IMO--GrahamColmTalk 11:13, 18 December 2007 (UTC)
I have no problem with that. If anyone is looking up shingles on the internet, especially if looking for CAM remedies, they're going to be finding a lot of mentions of lysine anyway. Softlavender (talk) 12:01, 18 December 2007 (UTC)
Wikipedia's responsibility is to present verifiable statements not support CAM crazies. There is NO evidence that lysine works for any herpes infection. I added the section just so the CAM nutjobs will come here and find out that it doesn't work. I'm quite happy about that. OrangeMarlin Talk• Contributions 17:44, 18 December 2007 (UTC)
Whoa there. OK, I'd best unwatch now; lighting bonfires not a good strategy when a struggling FAC is underway. Good luck, all. SandyGeorgia (Talk) 18:00, 18 December 2007 (UTC)

In response:

  • The added statement "Persons with herpes zoster (shingles) have also, for this reason, consumed lysine supplements." is OR, and not backed up by the source. The lysine/arginine stuff isn't OR but isn't consistent with the source (see below)
  • The text about arginine has a subtle change of emphasis. The text says "lysine has an antagonistic effect on arginine" whereas the source says "It has been proposed that L-lysine is antagonistic to another amino acid, arginine".
  • The text says "arginine... is necessary for herpes virus growth" whereas the source merely says it has a "growth-supporting action" (i.e., it doesn't claim it is necessary).
  • The text was changed to say "A 2005 article reviewed five articles and clinical studies from the 1970s and 1980s" which makes the reader wonder why they chose to review such old studies. Discussions of papers/reviews/articles complicates the matter; our reader should just be given the information, not worry about paper A vs paper B (unless the papers are themselves notable). A 2005 review may well be two years old but that isn't really a long time and the authors would certainly have included studies performed since the 1980s if they existed (any review paper that ignores research from the last 20 years would fail peer-review).
  • You claim that "'the studies to date have failed to provide adequate information from which to base a clinical therapy' is not supported by the sourced article." and changed the text to say "the studies reviewed did not provide". The source says "The studies conducted to date do not provide sufficient information to address dosing and frequency of use." To remove the "to date" bit makes it look like 20-year-old studies were inadequate but perhaps newer ones exist that do provide support. The change is subtle but effectively makes the 2005 review appear worthless; which it isn't. As for whether my text was supported by the source, how would one form a "clinical therapy" if you don't know the required dose or frequency of use.
  • You suggest that you could have cited the primary sources rather than this review. Don't. Reviews are much better, see WP:MEDRS.

Regards, Colin°Talk 13:33, 18 December 2007 (UTC)

This Talk page was archived on December 12, 2007 without consensus or discussion

The many and pertinent discussions and posts on this Talk page were all suddenly completely removed from view and archived on December 10, 2007, without discussion or consensus. This is against Wikipedia policy. Request restoration of removed discussions and posts. Softlavender (talk) 05:18, 18 December 2007 (UTC)

It's all still there and hasn't been removed at all, I just re-read it. There's no room on this page now for it.--GrahamColmTalk 06:28, 18 December 2007 (UTC)
Archiving a talk page prior to FAC is commonplace; the archive is right where it should be, at Talk:Herpes zoster/Archive 1 (Beginning to 1 December 2007. It is not against Wiki policy to archive a talk page. It is also not a valid oppose at FAC, where the relevant criteria is WP:WIAFA. SandyGeorgia (Talk) 06:46, 18 December 2007 (UTC)
It is against Wikipedia policy to archive a Talk page without consensus and discussion. It is also against Wikipedia policy to move or edit another person's Talk posts. I also feel that it is a valid consideration, in reviewing an article for Featured status, that the author and nominator has effectively removed any immediately visible disagreements with or problems with the article, by archiving the entire log of Talk page discussions on the day of the nomination, without group consensus. Softlavender (talk) 07:04, 18 December 2007 (UTC)
Softlavender, you are in error, as Sandy has pointed out. Reviewers at FAC tend to be among the most experienced and are quite capable of browsing a talk page archive to see if the article is in dispute or has outstanding issues. If you think there remain issues with the article that merit further discussion, please add them in a new section at the bottom of this talk page. Thank you. Colin°Talk 07:38, 18 December 2007 (UTC)
I am discussing Wikipedia policy and its violations. The archived material is also important to those who may be voting to support or oppose the article's Featured status. I have no staked opinion on issues brought up in the archive, but I do object to those issues and information being removed from the visible Talk page without the standard Wikipedia consensus. As there was no consensus, that information all still belongs on this Talk page. —Preceding unsigned comment added by Softlavender (talk • contribs) 08:12, 18 December 2007 (UTC)
Softlavender, you are mistaken about "Wikipedia policy and its violatoins". Please read WP:TALK, in particular Wikipedia:TALK#New topics and headings on talk pages. New sections belong at the bottom of the talk page, consensus is not required to archive a talk page (although it would be rude to archive against consensus), and the archives are right where they belong. The archives are certainly an interesting read, but this article has progressed so far beyond anything discussed there that I fail to understand your concern. SandyGeorgia (Talk) 17:50, 18 December 2007 (UTC)
Sandy, thanks for stating all these points. Arguing with you, one of the experts on Wiki-policy (I know, because I've battled you before...and I'm going to claim a tie...LOL), is a no-win situation. OrangeMarlin Talk• Contributions 17:56, 18 December 2007 (UTC)

Table of contents problem

I cannnot determine what is wrong with the TOC on this page and why there are two empty items at the top of the TOC. If no one can sort it out, pinging Gimmetrow might help. SandyGeorgia (Talk) 17:50, 18 December 2007 (UTC)

I fixed it. Eubulides (talk) 17:58, 18 December 2007 (UTC)
Thanks so much, Eubulides. I'm unwatching now; it's very hard not to be in here helping ya'll, especially seeing this great team work and nice effort. This conflict of interest thingie really is tricky. SandyGeorgia (Talk) 18:05, 18 December 2007 (UTC)

Corticosteroids as causes

Herpes zoster#Causes claimed that herpes zoster is more likely to occur in people whose immune system is impaired due to "long-term use of corticosteroids", but the cited sources do not support this claim, so I removed it. Also, Mounsey et al. 2005 (PMID 16190505) is out of place here: it is about prevention and management, not etiology. So I removed it (putting it in #Sources above). The prevention part of that reference is seriously out of date anyway. Eubulides (talk) 17:41, 18 December 2007 (UTC)

Late complication?

It's much too late to be a late complication, it doesn't complicate chickenpox, so I'm not happy with this, but I can't think of a better way saying it. It's really a sequela but perhaps we mustn't use this strange word in the lead?.--GrahamColmTalk 19:03, 18 December 2007 (UTC)

  • Second thought ....is a sequela or late effect of.......--GrahamColmTalk 19:07, 18 December 2007 (UTC)
    • My worry is that all three terms imply (to me) a knock-on effect, not directly caused by the initial infection. Like post-polio syndrome. Whereas this is a reactivation of the virus. The sentence saying "Both chickenpox and herpes zoster are caused by infection with Varicella zoster virus (VZV)." puts them on equal footing wrt an infective action directly causing the disease. I think we need to re-read a few of our sources for ideas, and revisit the reactivation + immune system phrasings Colin°Talk 20:01, 18 December 2007 (UTC)
      • My problem is reactivation is the best word and I can't find another. I introduced a cryptic analogy with a volcano, ie. dormant/erupt. A re-eruption (years later) would be understood as having the same direct cause as opposed to an indirect knock-on effect. This is such a challenge! I don't think re-reading our sources is going to help us very much. --GrahamColmTalk 20:34, 18 December 2007 (UTC)
        • If it's a reactivation then let's call it that. I made this change to the lead. One nice side effect: it shortens the lead and makes it easier to read. Eubulides (talk) 20:43, 18 December 2007 (UTC)
        • For me, that works, because we define what we mean by reactivation in the following sentence.--GrahamColmTalk 20:53, 18 December 2007 (UTC)

I'm happy with "reactivation". It is certainly more lay-friendly than "sequela". Good, this is getting better. Do you think it is clear enough that the person must have caught/had chickenpox? I'm a little worried that the reader has to finish the next sentence before realising what it is a reactivation of (i.e., what the original activation was). Saying "is the same virus" doesn't link them either within the one person or in time order. However, I disliked the much earlier "sequence" text, which had an inevitability about it. This is tricky. Perhaps I'm being over fussy. Colin°Talk 20:57, 18 December 2007 (UTC)

I think the objections to "late complication" have more to do with "complication" than with "late". So how about simply "late effect"? Late effects are a major topic in the oncology literature, and there is a related set of ICD codes. —Preceding unsigned comment added by Una Smith (talk • contribs) 21:20, 18 December 2007 (UTC)

We are talking 50 years later :-) I don't know; I defer to the medics here on what terminology is typically used. But I really want to avoid any kind of inevitability, direct cause-effect or idea that HZ is chickenpox's last symptom. The virus must reactivate, which is kind of a re-infection from within. Apologies if that's all wrong. Bigger brains that mine define and use these terms, and I just want to copy them rather than use our own alternative words. Colin°Talk 21:32, 18 December 2007 (UTC)

I just got caught in an edit conflict with Una. What I was trying to say, was that in a previous edit we had "earlier chickenpox infection" perhaps we should restore this.--GrahamColmTalk 21:29, 18 December 2007 (UTC)

Yes, if you can fit it in. Colin°Talk 21:33, 18 December 2007 (UTC)

Colin, you are a poet, it is exactly that: a reinfection from within.--GrahamColmTalk 21:37, 18 December 2007 (UTC)

Hospitalization rate

The lead and another section give a figure of 10,000 hospitalizations/year in the U.S., but this is from an old study that predates antivirals, and the figure is almost certainly incorrect now. I removed it and substituted a discussion of changing hospitalization rates in "Epidemiology". I also moved some other epidemiology-related data from other sections into "Epidemiology". Eubulides (talk) 20:03, 18 December 2007 (UTC)

No prior chickenpox

This sentence has now twice been reverted, deleting the reference to exceptions: "With rare exceptions,[8] herpes zoster occurs only in people who have had chickenpox." Those of you who reverted it, have you read this paper? The PDF is free. Note in particular its review. HZ does sometimes occur w/o evidence (evidence beyond patient history) of prior chickenpox. This information is important to timely diagnosis and treatment of HZ, particularly in infants and children. --Una Smith (talk) 23:57, 18 December 2007 (UTC)

Una, subclinical perhaps, check them for IgG I say.--GrahamColmTalk 00:03, 19 December 2007 (UTC)

Yes, Una, I did read the paper. Goodnight. Colin°Talk 00:18, 19 December 2007 (UTC)
Graham, the case report (here) states IgG negative for the patient (infant) and serology negative for the mother. Context suggests serology means HIV I, HIV II and HSV I . I don't know that an infant would be expected to produce IgG, and the article does not mention how the patient is fed. Breastmilk vs formula would make a differece, right? Anyway, the point is that it is an overstatement to say HZ always follows chickenpox. Rather say: HZ follows chickenpox except in rare cases; these cases may involve subclinical infection. --Una Smith (talk) 03:16, 19 December 2007 (UTC)

Natural history

There is no natural history of disease section to this article. Is this the desired status, or would there be interest in adding one? Antelan talk 05:19, 19 December 2007 (UTC)

There is some interest and has been some discussion of this. See Talk:Herpes_zoster#Causes. --Una Smith (talk) 00:56, 20 December 2007 (UTC)

Thanks. I couldn't help but notice that the discussion that you directed me to seemed to conflate "causes" with "natural history." The WP article I've linked to, above, does a decent job of explaining natural history. In essence, natural history is "what happens when you do nothing to treat the disease." Antelan talk 01:57, 20 December 2007 (UTC)

Complications

Herpes zoster#Complications said that HZ "is also common in the elderly, and in early infancy" and cited Dworkin et al. 2007 (PMID 17143845). The first part of that claim is redundant with what is already in Herpes zoster#Epidemiology; the second part, about early infancy, is not supported by the source. For now I removed the claim. The claim doesn't belong in that section anyway; it belongs in "Epidemiology". Eubulides (talk) 06:40, 19 December 2007 (UTC)

Incidence

I think that the (currently) quoted incidence of 1 million affected people per year in the USA is an overestimate. Most sources quote an incidence of about 500,000 per year. I am changing the article accordingly. Axl (talk) 09:58, 19 December 2007 (UTC)

Incidence estimates do vary. It's probably better to give a range, since sources disagree. This is already done for incidence rates. Eubulides (talk) 17:05, 20 December 2007 (UTC)

Discussion of this revert

I am rather surprised cold compresses, traditional treatments that have been used for for longer than modern antivirals, hygiene, and isolation precautions are called alternative medicine and useless. Maybe the RS that was used, the United States National Library of Medicine should be informed that their A.D.A.M. accredited health information has CAM cruft. CAM cruft sounds really terrible, or maybe that is the point.

The material that was added is not useless, not alternative medicine, and it comes from a RS. While the present article is extremely well researched and written, it seems to be addressed primarily to the level of medical professionals. The edit was trying to add basic and practical information about reducing Herpes zoster discomfort, and reducing the risk of spreading VZV to a fetus. Encyclopedic content is supposed to be useful to people. When established medical information from the United States National Library of Medicine is dismissed as useless, using a pejorative term CAM cruft, one has to wonder why. Ward20 (talk) 11:31, 19 December 2007 (UTC)

CAM cruft written by unknown authors at some unknown repository of unreliable, unverified, and unsubstantiated information. A publication in the Journal of the American Medical Association or better yet a review in a peer-reviewed journal would be much better. Thanks for your help. OrangeMarlin Talk• Contributions 00:47, 20 December 2007 (UTC)
  • Please explain what you mean by CAM cruft. It is not an expression that is widely understood, at least in the UK.--GrahamColmTalk 19:00, 20 December 2007 (UTC)
  • I have not heard of it in the UK, but I looked for it on the wiki and found Complementary and alternative medicine or CAM. There is a dab page CAM. Snowman (talk) 19:05, 20 December 2007 (UTC)

Wording change proposal

Just by reading the lead I am not sure it is going to be very clear to the average person that VZV causes both herpes zoster and chickenpox. I have gone through many of the diffs and know that there has been almost this same wording before but:

I suggest changing the sentence, "The disease is a reactivation of an earlier chickenpox infection." to "The disease is a reactivation of the virus from an earlier chickenpox infection." Ward20 (talk) 13:09, 19 December 2007 (UTC)

Yes that little extra helps. Colin°Talk 13:30, 19 December 2007 (UTC) Damn, I thought I was taking a break from this.... Colin°Talk 13:30, 19 December 2007 (UTC)
Agree. The chickenpox does not reactivate; the virus does. --Una Smith (talk) 01:01, 20 December 2007 (UTC)

Herpes zoster is treated with antiviral drugs; for the best effects these drugs must be taken within 72 hours of the appearance of clear symptoms. is the last paragraph of the introduction. I think that it is an over simplification, and that the introduction needs to be clearer. Treatment is also with analgesia and possibly amitryptyline, to reduce post-herpetic neuralgia (PHN), and also it is a course of 7 to 10 days that should be started before 72 hours of a rash. The reference does specifically state "a rash". Treatment is not so critical in younger people as lower risk of complications. On a world wide bases I think that the treatment is not always antivirals. I suspect that the reference quoted is not a consensus opinion on treatment. Snowman (talk) 15:40, 19 December 2007 (UTC)

Thanks for the CAM cruft. BUT, there are NO other treatments for the disease to reduce the viral attack. OrangeMarlin Talk• Contributions 00:48, 20 December 2007 (UTC)
I think Snowman's point is valid. --Una Smith (talk) 01:01, 20 December 2007 (UTC)
Be careful, Orangemarlin. There's no need to be sarcastic. We must insist that you assume good faith while interacting with other editors. Snowman (talk) 01:05, 20 December 2007 (UTC)
It's a well known fact that requesting good faith implies the writer does not assume good faith themselves. You apparently lack faith in the fact that I find CAM utter nonsense. You should assume I say that because I am well studied in the area, that I have yet to find one piece of evidence that "alternative medicine" works, and that if I were a physician outside of the US, oh yeah, I was a physician outside of the US, I would use acyclovir to treat herpes zoster. OrangeMarlin Talk• Contributions 05:11, 20 December 2007 (UTC)

Orangemarlin, I don't see any content-related objections to your point. One thought, though, that might be a useful compromise: the CAM stuff could be included, but it should be carefully and obviously emphasized that the only effective, scientific, evidence-based treatments are the antivirals. People will be interested to know if this stuff works - there's no reason not to mention it and be clear that nothing else has been proven to work. Antelan talk 02:02, 20 December 2007 (UTC)

This article is about the disease, not the virus. The Treatments section already gives several standard (not CAM) treatments for the disease other than antivirals. --Una Smith (talk) 03:36, 20 December 2007 (UTC)
I guess we forget about WP:FRINGE, WP:WEIGHT and WP:NPOV. Actually we are NOT required to describe treatments that lack verification or come from unreliable sources. Moreover, antivirals treat the disease. The other pharmaceuticals mentioned have been scientifically studies to show that they A) enhance the antiviral, or B) relieve the symptoms of the disease. OrangeMarlin Talk• Contributions 05:11, 20 December 2007 (UTC)

I think that "treatment" is more than just clearing a viral recrudescence. I think that "management" should be included in the introduction which would include specific antiviral treatment. It is a "bread and butter" subject. Shingles is not an absolute indication for antiviral treatment (in the UK anyway) especially with a presentation of a milder case after 72 hrs, in younger healthy patients. I guess that antivirals are too expensive for some parts of the world. I thought that there was good evidence for giving amitryptyline and analgesics early in shingles to reduce post herpetic Neuralgia, but I have not looked it up recently. Many issues have been raised about this article in the FAR discussion. Snowman (talk) 12:12, 20 December 2007 (UTC)

Analgesics cannot prevent postherpetic neuralgia, only antivirals. And let's not get into a discussion about weaknesses in UK's healthcare system--it's outside the parameters of this article. OrangeMarlin Talk• Contributions 19:54, 20 December 2007 (UTC)
Not, a helpful reply IMO. :-( GrahamColmTalk 20:41, 20 December 2007 (UTC)
I have no patience for snake-oil faith healers. That he received a reply is about as far as I am going. OrangeMarlin Talk• Contributions 21:34, 20 December 2007 (UTC)

Reference 7 of the listed references, supports and gives evidence for the use of analgesic treatments including tricyclics in shingles: look in the paragraph headed "Analgesic treatments" in the cited source. Snowman (talk) 22:51, 20 December 2007 (UTC)

A minor point is that the lead seems to infer one of the most distressing symptoms (pain) is only caused by blisters. Lead: "painful skin blisters", and "causing painful blisters. Although the blisters heal usually within a month, in some people the pain continues for months or years." Other sections talk about nerve pain, "The pain may be extreme in the affected nerve below." and "The pain caused by acute herpes zoster and the long-lasting nature of post herpetic neuralgia result from widespread growth of the virus in, and consequent inflammation of, the infected nerves."[18]
The lead should make it clear nerve pain is involved. I also could not find a section that definitively discusses the theory that postherpetic neuralgia pain is caused by nerve damage (except in the Shingles diagram). Ward20 (talk) 06:02, 21 December 2007 (UTC)
Question: What sources do the 24 and 72 hour durations discussed for the antivirals come from? The citation[7] in the lead seems to indicate 72 hours is arbitrary. "All of the controlled clinical trials of antiviral therapy have initiated treatment within 72 h of rash onset, an arbitrary inclusion criterion that does not necessarily reflect the cessation of viral replication....Considered together, these data are not inconsistent with there being a benefit from antiviral therapy initiated beyond 72 h after rash onset." Another citation[3] in the antiviral section mentions no time period. The other citation[25] I do not have. Ward20 (talk) 07:11, 21 December 2007 (UTC)
Also "causing painful blisters" does not explain pain occourring before blisters appear. Snowman (talk) 10:38, 21 December 2007 (UTC)
Agree with above. Also, I found this source with wording that might be able to be used as a template to help integrate some concepts that seem to be struggling for consensus in the first sentences of the lead. "Herpes zoster is the clinical manifestation of the reactivation of a lifelong latent infection with varicella zoster virus, usually contracted after an episode of chickenpox in early life." Ward20 (talk) 22:32, 21 December 2007 (UTC)
Unless you already know what it is, I don't think that sentence makes it much clearer. --WS (talk) 22:47, 21 December 2007 (UTC)
I just had an edit conflict with Wouterstomp. I was saying that I don't like clinical manifestation of the reactivation lay readers will not understand it.--GrahamColmTalk 22:52, 21 December 2007 (UTC)
No problem, I put it out there for the purpose of brainstorming. There has been a lot of good content in the lead that has changed back and forth and even eliminated. It would be nice to merge some of the concepts. I personally think mentioning the relationship between CP and HZ adds to the lead. Ward20 (talk) 23:43, 21 December 2007 (UTC)
"latent infection" is a bit difficult to understand unless you known what it means too. The viral DNA is incorporated into the DNA of the neural cell bodies, as far as I recall, so it is a special sort of latency. I think that it would be easier to understand if some of this detail was included. I think that axon, should appear in the introduction too. Higher chance of shingles in any immuno-compromised group including declining immune system in the elderly could be included and would give a better understanding of why there is a recrudescence. For an article this size it would be expected to use four paragraphs for the introduction. I think that nitty gritty details would help understanding instead of glossing over a void. Snowman (talk) 09:20, 22 December 2007 (UTC)

Re "latent infection", may I suggest this outline of the sequential steps:

  1. lytic phase (chickenpox)
  2. latent phase (indefinite duration)
  3. reactivation phase (if zoster sine herpete then return to step 2)
  4. lytic phase (herpes zoster)
  5. return to step 2

"Reactivation" needs a link. Perhaps a link to Herpesviridae would be sufficient? --Una Smith (talk) 05:17, 28 December 2007 (UTC)

Groups of special concern:

  • elderly
  • immuno-compromized, particularly AIDS
  • perinatal exposure (neonatal zoster)

--Una Smith (talk) 05:17, 28 December 2007 (UTC)

Organisation of the introduction

Suggested content of the 4 paragraphs of the introduction:

  • 1. Basics: key features, epidemiology, demographics
  • 2. Presentation and complications: rash, blisters, PHN, eye shingles. natural course
  • 3. Pathology and physiology: chicken pox, axon, neurone, ganglia, dermatome, immuno-compromised, elderly
  • 4. Treatment: analgesia, antivirals - 72 hr.

This is a suggestion only to gather a consensus for the introduction. Snowman (talk) 10:57, 22 December 2007 (UTC)

This appears to me to be what the lead has now by paragraph:
  • 1. Definition of topic with general presentation, Pathology and physiology (ganglia, dermatome, rash, blisters, viral latency vs reactivation) and complication: PHN
  • 2. Demographics, Treatment: antivirals - 72 hr
To summarize the present article: 14005 char (no spaces)
1 Signs and symptoms 2032 char
2 Causes 1684 char
3 Pathophysiology 844 char
4 Diagnosis 936 char
5 Management 1837 char
6 Prognosis 1085 char
7 Prevention 1294 char
8 Epidemiology 2418 char
9 History 1474 char
My view is that the present order of addressing the topics in the article is about right. I believe chicken pox, immuno-compromised, elderly, and a (general) comment about other complications should be added. The other details may be too minor, but I also believe there should be flexibility to keep an interesting writing style and not make it too difficult to write the lead.
I suggest more emphasis should be placed on treatment strategy instead of treatment details, "patients should receive adequate early treatment to reduce acute symptoms, accelerate healing, and prevent complications." If it mentions antivirals and analgesia fine, but leave the finer details to the treatment section. Ward20 (talk) 00:18, 23 December 2007 (UTC) Ward20 (talk) 07:42, 23 December 2007 (UTC)
You might want to read WP:MEDMOS. We're trying to follow that, so I'm glad you think it works, but we're just trying to stick with the Manual of Style for medical articles! OrangeMarlin Talk• Contributions 04:36, 23 December 2007 (UTC)

WP:MEDMOS will be followed. The present discussion is to try to achieve some consensus about details in the lead; specifically trying to satisfy the sections Establish context, Provide an accessible overview, and Relative emphasis. Ward20 (talk) 07:12, 23 December 2007 (UTC)

Number of paragraphs - Wikipedia:Lead section indicates 1 or 2 paragraphs, but for a complex subject it is probably reasonable to excess this if needed. Snowman (talk) 10:31, 23 December 2007 (UTC)

I think the present lead is the right length + depth to represent the content of the article. I agree with Snowman's general outline above. JFW | T@lk 23:31, 27 December 2007 (UTC)

Proposed word change

What do you think about this?

[5] "but do not reliably prevent postherpetic neuralgia." to "and have limited success in preventing postherpetic neuralgia." Ward20 (talk) 10:12, 26 December 2007 (UTC)

MEDMOS and jargon

I have reorganised the article according to WP:MEDMOS, which was long overdue. I believe the "causes" section was redundant, as the article already mentions the actual cause several times (VZV), and the content belonged in a somewhat expanded "pathophysiology" section. I have also moved the "diagnosis" category up, where it belongs.

There is still quite a lot of jargon in the article, often without translation into plain English. My personal practice is to use a jargon term where this is significant, with plain English in brackets. For instance, I have added "painkillers" after the word analgesics, because I am not convinced every reader is familiar with that term. JFW | T@lk 23:35, 27 December 2007 (UTC)

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  2. ^ Winkelmann RK, Perry HO. Herpes zoster in children. JAMA 1959;171:876-880.
  3. ^ Nikkels AF, Nikkels-Tassoudji N, Piérard GE (2004). "Revisiting childhood herpes zoster". Pediatr Dermatol. 21 (1): 18–23. PMID 14871320.{{cite journal}}: CS1 maint: multiple names: authors list (link)
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