Got Shingles? Let's Talk About It
As a neurologist I treat many patients for the pain associated with shingles and applaud you for a clear expose of the condition ["A Young Shingle Gal" and "In Elderly, Shingles Complications Can Be Severe, Lasting," Oct. 4] , but I would emphasize proper selection of treatments.
The chronic pain of post-herpetic neuralgia (PHN) can be disabling, but advances in our understanding of nerve pain have led to much better designed medications. Though a tricky condition to conquer, PHN may be controlled with a drug or a judicious combination of drugs begun at very low levels.
Because seizure medications can turn off nerve impulses signaling burning, itching and searing pain, I and others are studying these drugs in the treatment of PHN nerve pain. Since no one drug has proved to be a panacea, research trials are necessary and are available in our area. Readers with PHN should check with their health care providers and remember the "start low, go slow" dictum of medication use.
Perry K. Richardson, MD
Associate Professor of Neurology
The George Washington University
Medical Faculty Associates
I guess I am a young shingle guy. I am also 35 years old and I am still recovering from a case of the shingles. I got the pain first and didn't know what was going on. Then when the blisters broke out, I just assumed it was poison ivy or something. After about a week with no improvement from the medicine I was taking, I broke down and went to the doctor. He took one look at me and said shingles. Once I started talking to friends about it, I met several other people my age who had also had the disease. It apparently isn't as rare in young people as one would think.
I had shingles 15 years ago, when I was 34, and it affected my entire left side, including my left eye. Fortunately, my general practitioner spotted it early on and sent me immediately to my ophthalmologist. I avoided scarring and any permanent eye damage, but I missed almost a month of work because I could not read. Over the past 15 years I have had recurring flare-ups in my left eye, but my ophthalmologist has monitored it closely and still there has been no permanent damage. But he says that it will be with me the rest of my life, so I need to act quickly when flare-ups occur. Your readers should know that if not treated properly and quickly enough, shingles in the eye can severely impair vision and ultimately cause blindness.
Your story asks, "Isn't shingles an old person's illness?" At one time it might have been. It is well documented that the universal varicella (chickenpox) immunization program, started in 1995, is directly responsible for an increase in herpes zoster (shingles) outbreaks.
The medical journal Vaccine (May 2005 edition) states that the chickenpox vaccine suppresses asymptomatic endogenous reactivation, which is the mechanism that serves to limit shingles outbreaks in individuals who are carrying the virus.
G.S. Goldman, the principal author of the Vaccine Journal article, estimates that there will be an additional 14.6 million cases of shingles among adults less than 50 years old over the next 50 years as a result of the universal varicella program.
Joshua A. Mazer
I'm an almost-33-year-old single woman, and I am in my third week with Bell's palsy, another form of herpes zoster. It usually manifests itself as paralysis on one side of the face. I was put on antivirals to keep it from turning into shingles. Anyway, glad to know I'm not suffering alone.
One thing that you didn't cover is that people who have never gotten chickenpox will never get shingles. Therefore children should receive the chickenpox vaccine. The parents who have chickenpox play parties to make sure their children get the disease must not have ever gotten shingles and must be unaware of the risks. It can even cause blindness if the blisters reach the cornea, not to mention the continued pain that some people experience and find debilitating. My husband had them two years ago. My mother and my aunt have both had them twice. My aunt has had PHN from her second bout, which she had during pregnancy. They're a nasty business.
It was nice to read of another young person who's had it! The summer before last, when I had just turned 25, I came down with shingles -- the rash was all around my waist, which made it extremely difficult to wear clothes, lie down or even walk. I missed a month of work. It was the most painful thing I'd ever experienced -- walking past the air conditioning could be excruciating. Anyway, I've had my share of teasing for having an "old person's disease," so I appreciate the bit of solidarity.
I am 15 years old and last January I went to my family doctor and was diagnosed with shingles. At first it had started as colorless but later it began to itch and redden. I thought it might be some weird fungus or something and tried to pop the bumps. I even poured hydrogen peroxide on it as well. After the visit to the doctor, they scabbed over within a couple days without treatment. Because it lasted a little less than a week, I wondered whether the hydrogen peroxide worked. Anyway, I came upon your story while looking for an article for my biology class. It was great; it let me know that I'm not some crazy anomaly.
Mandatory chickenpox vaccination -- leaving our population little or no exposure to the real chickenpox strain -- prevents the immune system from getting the natural boost it needs to prevent shingles outbreaks.
The fact that there is yet another vaccine in the works to prevent shingles, which is in fact caused by the first vaccine, is a little scary to me. Today's children are the most vaccinated ever, they are also the most learning-disabled population we have ever seen, but that's another topic.
Vasectomy: Don't Get Snippy
You were on point with "Snip and Tuck" [Sept. 27]. I, too, had a vasectomy after my second child. It was purely a family decision and I grew tired of the way birth control made my wife feel.
What you didn't mention are the ignorant comments you get from those misinformed about the procedure. When I told family and especially male friends that I was getting the procedure, I heard some of the following: "What are you going to do if one of your children die?" "If you get a divorce, wouldn't you want more kids?" "You know, this is going to increase your chances of getting prostate cancer." I heard them all and also the "snip-snip" jokes. Well, like you, that was the best decision I ever made.
I was disappointed in the article. A vasectomy is serious elective surgery and deserves serious treatment. It is no laughing matter. You treated yoga with a more thoughtful approach.
You say in the headline of the story "One Thing You Don't Want to Lose When Having a Vasectomy Is a Sense of Humor." However, you might lose it after reading my comments.
First, you were at risk of dying! The mortality risk for women who undergo tubal ligation is 3.6 to 4.0 per 100,000 procedures, with half being due to complications from general anesthesia. This is not the case with vasectomy. Why? Because most vasectomists never do routine vasectomy under general anesthesia.
Your doctor will say he never had a death related to vasectomy under general anesthesia, and it's no wonder. The probability would be about 1 out 50,000 procedures, and I doubt he had done that many. You could have been his first!
Vasectomy should always be performed under local anesthesia unless there is a major contraindication. I do about 1,000 vasectomies per year, and I also "like to focus on what I'm doing" without putting my patients at undue risk. You fear needles? You could have sought a physician doing the no-needle jet injection anesthesia technique. The cost of travel would probably have been less than that of general anesthesia.
In addition, the vasectomy you had was a non-evidence-based procedure. Your surgery was performed in 20 minutes and you had two sutures on your scrotum. Obviously you did not benefit from no-scalpel vasectomy (NSV). NSV has been proved to be associated with a lower risk of surgical complications and is now the world standard. An NSV should be performed in less than 10 minutes with local anesthesia.
Michel Labrecque, MD, PhD
Department of Family Medicine
University of Laval
Part D, as in Difficult
Thank you for your article on the new Medicare drug benefit ["Giving Part D a Spin," Sept. 27]. You point out some of the important facts that Medicare beneficiaries should consider in their decisions about whether to enroll in the new program. I was particularly pleased to see the reference to the guide by the Center for Medicare Advocacy, which is the best I have seen.
You may be interested to know that drug companies are not required to tell beneficiaries what drugs they cover until after the beneficiary enrolls, unless the beneficiary specifically asks for the list of covered drugs. Beneficiaries will have to seek lists of covered drugs on the plan's formularies in order to determine which of the medications they are taking would be covered by a drug plan. You mention the "doughnut hole" or "no-coverage zone," which many other publications do not even discuss. A recent study estimated that about 38 percent of enrolled beneficiaries will hit the no-coverage zone. The study notes that because drug spending is fairly consistent over time, beneficiaries who experience the biggest gaps in coverage are likely to do so year after year. Nearly 14 percent of beneficiaries are estimated to exceed the catastrophic threshold.
The Medicare drug plan may be a significant benefit to many older Americans, particularly those without current drug coverage. But determining whether the new program will benefit them, and if so, which plan to choose, will require careful analysis by extremely well-informed beneficiaries.
One of the most critical issues, which will affect thousands in the Washington area, regards the dual beneficiaries -- those who have Medicare and Medicaid. Those patients who are dual beneficiaries will be qualified to receive medications through Part D, but will no longer receive prescriptions through Medicaid. If this were automatically done, it would not be so bad. However, patients who are dual beneficiaries will need to sign up for Part D in order to get their medications. Your article correctly points out how confusing this might be. Our oldest, poorest and sickest patients have the potential to be significantly adversely affected. There are many patients who will show up to their pharmacies after Jan. 1 and be told that their medications are no longer covered.
Matthew Mintz, MD
Associate Professor of Medicine
Primary Care Clerkship
George Washington University
School of Medicine