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Robert Goldstone

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MD, FACE, FLMI, board certified internist and endocrinologist, is medical director for SBLI of Massachusetts. He has extensive brokerage and life insurance experience over 30 years with Pacific Life, MetLife Brokerage and Transamerica Occidental Life. Goldstone is board certified in insurance medicine and the inaugural recipient of the W. John Elder Award for Insurance Medicine Journalism Excellence. He was also honored as a fellow of the prestigious American College of Endocrinology and has written monthly for Broker World from 1991 to September, 2021. Goldstone can be reached by ­telephone at 949-943-2310. Emaill: drbobgoldstone@yahoo.com.

Myasthenia Gravis

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Myasthenia gravis (MG) is the most common disorder of neuro-­muscular junction transmission that presents in various ways among the people it affects. There are about 10 to 20 new cases diagnosed each year per million, with more than 150 people per million affected with the disease. Forty years ago, mortality from this disorder was nearly 70 percent; today it is less than 5 percent.

More common in females than males, MG has a bimodal distribution: one between the ages of 20 and 30 and another peak in the sixties to eighties, especially in men at the older ages.

MG is best described as a varying and episodic weakness of voluntary skeletal muscles in the body. Most affected are the muscles of the eye, face, neck, tongue, lips and throat. Muscles in the limbs and trunk are affected, but less commonly.

Muscle weakness is often worse after exercise or toward the evening. Fluctuating weakness of commonly used muscles causes symptoms such as double vision, eyelid drooping and difficulty in swallowing. When respiratory muscles are affected, the disease is potentially fatal without mechanical breathing intervention.

There are two main forms of the disease: (1) ocular (affecting the eye) and (2) a generalized type. Drooping eyelids and double vision can run the gamut from mild to disabling with ocular MG. The generalized type starts with ocular symptoms and eventually spreads to muscles in the face, limbs and trunk, and those involved in speech, chewing and swallowing.

A more severe type involves weakening of the respiratory muscles to the point that breathing is paralyzed. Death can occur from pneumonia secondary to inhaled pathogens or respiratory complications where machine assisted breathing becomes predominant.

One other form worth mentioning is called Eaton–Lambert myasthenia syndrome and usually is accompanied by oat cell cancer of the lung or other tumors. Myasthenia is sometimes the first sign of involvement and cancer is then discovered on a full work-up.

While quite involved, MG is usually thought of as an autoimmune disorder in which the body mistakenly begins to produce antibodies that interfere with transmissions at most normal nerve endings, preventing motor nerves from contracting. Eventually the receptors are so severely attacked that the place of interaction for muscle stimulation is destroyed. Without specific treatment, the disease can take a progressive downhill course unless it is mild or confined only to the eyes.

Diagnosis is often made on a description of symptoms from the patient, along with physical signs and a thorough history. Many investigational tests such as the acetylcholinesterase test, blood testing, and the presence of acetylcholine receptor antibodies confirm the disease.

MG usually follows a characteristic course of remissions and relapses. Highest mortality is usually seen early in the disease, in severe cases within the first year and with progressive cases within the first five to seven years. Respiratory complications are the most common issues.

With such a serious disease, can insurance be offered?

 • When the disease is mild, non-progressive, limitations are minor and patients respond to specific medication such as anticholinesterases, a case can be slightly rated substandard.

 • When the ocular form can persist without systemic issues and those who are maintained without medicine or go into remission can sometimes be standard issues.

 • In the generalized form where there is progression and in whom respiratory complications occur, the overall prognosis is the most grave.

Heart Disease: Are Women Different?

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Both men and women will agree that women are the better half of most relationships and have the biggest hearts. But does that also translate to a higher than expected incidence of cardiac disease?

Most think of occlusive heart disease as occurring in men predominately, but heart disease is now the leading cause of death in women throughout the world. In fact, the American College of Cardiology states that more women than men die of cardiac disease each year in the United States. This is why women are encouraged to visit places like the Cardiovascular Group, once a year to get a health check.

One of the problems for doctors with women and coronary disease is that women often have atypical symptoms. Instead of the usual crushing chest pain associated with nausea, sweating and a vice-like feeling, affected women often present with shortness of breath as a primary presenting complaint. Doctors are likely to ascribe chest pain in women to stress, and sometimes think the pain has a gastroenterological source such as heartburn or gall bladder disease. Only about one in three women experience typical anginal pain as their first sign of cardiologic disease-shortness of breath, fatigue, and weakness are the primary triad of symptoms for women. Though the intake of supplements such as Boluoke (which contains enzyme extracts known as lumbrokinase) and alike, could be used to regulate cardiovascular health, it is also important to understand the atypical symptoms of cardiovascular diseases.

Women often present more diagnostic dilemmas in presentation than do men. They are twice as likely to have clean coronary arteries when catheterization is done. The difference has to do with such factors as vasospasm (when the vessel closes from spasm but is not occluded by calcium) or microvascular disease, where small arteries are diffusely affected and the larger vessels look comparatively clean. Exercise testing, or stress tests, are also proportionally more false positive in women than in men, so at times doctors will ascribe a result to a “false-positive” that truly turns out to be the real thing. In those cases a SPECT scan (computerized tomography) may yield the answer, but it, too, may have false results because of breast shadows.

Microvascular angina affects women more than men, and more than 70 percent of those who carry this diagnosis are women. A woman may present with all the classical signs of cardiac compromise, but a catheterization to look at her heart vessels is relatively normal. This condition is called syndrome X and generally is present at younger ages more frequently than in the elderly. It is a tough diagnosis to make and has to be considered by experienced cardiologists using more sophisticated methods of measuring cardiac flow reserve. Unlike when larger vessels are obstructed and cardiac stenting or bypass is used, medical treatment is more effective in helping affected females.

Of course women suffer from the traditional cardiac syndromes such as cardiac blockage, plaquing and dissection of coronary arteries. In these cases, prompt recognition and treatment of symptoms is of paramount importance. Chest pain should be taken as seriously in women as in men, and investigated even more thoroughly when the symptoms are real but traditional testing hasn’t turned up a definite answer.

One other condition worth mentioning that affects women more than men is one called stress cardiomyopathy. The more common term is “broken heart syndrome.” It’s a condition that affects mostly postmenopausal women and is associated with sudden physical or emotional stress. Affected women present with all classical signs of a heart attack or blockage but testing fails to reveal a demonstrable cardiovascular disease. The cause is not yet fully known, although sudden rupture of cardiac plaque is suspected. Most patients with this condition improve over time and recurrence is quite rare, with subsequent testing usually being quite normal.

Underwriting women with cardiac disease parallels that of men, although women have historically done better with risk factor modification and compliance with treatment. Additionally, since many of the conditions don’t have marked cardiac obstruction, medication is very effective in preserving a heart that has not sustained the physical damage associated with a larger heart attack.

The biggest question for underwriters is suspecting underlying disease in a female who has had typical symptoms but who has not had the diagnosis of cardiac disease made at the time of application. Sometimes additional testing is needed to certify a non-cardiac cause and the ability to issue at a more preferred rate.

Pituitary Adenomas

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Pituitary adenomas are the most common of pituitary gland abnormalities. Technically benign brain neoplasms, they account for up to 20 percent of brain tumors in general.

The pituitary gland sits at the base of the skull and is supported in a structural support called the sella turcica. This structure forces the growth of an adenoma upward toward the superior brain and optic nerve. Its effects can be felt by either destroying adjacent tissue or by causing the excess secretion of  hormones from the involved area.

The pituitary gland has different types of specialized cells, each producing different hormones into the bloodstream. As with all endocrine organs, any change in hormone levels triggers a series of events that affect other body organs in a stimulatory or suppressive way. If the tumor cells cause an excess of hormone to be secreted, it is called a functional adenoma. Those that don’t cause hormone to be secreted are called nonfunctional, and have their effects by occupying space and causing gland destruction just by their size and compression of neighboring structures.

Pituitary adenomas are generally characterized by their size, hormone secretion and aggressiveness. Microadenomas are generally small, less than one centimeter in size; macroadenomas are the larger ones.

Since the pituitary gland has so many functions, the hormones each cell secretes cause their effects by the nature of the hormone itself—these are referred to as functional adenomas. Most pituitary tumors are slow growing and benign, but the ones that are atypical are aggressive, sometimes make up the few that are malignant, and are most likely to recur even after surgery to remove them.

Symptoms from pituitary tumors mirror either the hormones that are being overproduced or the ones that are now lacking because the normal cells producing them have been destroyed by the growth.

For instance, in prolactinoma, the tumor causes an overproduction of prolactin, which affects menstrual periods in women and testosterone levels in men. Those related to overproduction of growth hormones cause either gigantism if the tumor occurs before growth has been completed in children, or acromegaly (large bones throughout the skeleton) in adults.

ACTH overproduction causes Cushing’s disease, where too much cortisone is produced and both the healing and structural integrity of the body is affected. TSH secreting tumors cause hyperthyroidism.

On the other end of the spectrum, a nonfunctioning tumor may compress areas that produce hormones, and the body may suffer from a decrease of each, called hypopituitarism. Infertility, hypothyroidism, secondary adrenal insufficiency and growth hormone insufficiency are a few of the problems that may occur.

If a tumor is large and grows out of the sella turcica, it can compress the optic chiasm and cause problems with vision.

The diagnostic approach to a suspected pituitary adenoma depends on the presenting syndrome. For all of the diseases mentioned above, specific blood tests and hormone stimulation testing helps to reveal the source of the problem. When the pituitary gland is implicated, an MRI is the best initial imaging study. CT scans can be used as well, although they are not as accurate, especially around the optic nerve.

For underwriting, most pituitary adenomas are evaluated by which hormone is compromised, how complete the treatment is, and if there are any permanent consequences after surgery.

When a pituitary tumor is completely removed by surgery and all systems are functioning normally, a best-case underwriting scenario is a standard issue. When residual tumor is left behind, observation time is needed to see that it has been completely treated and is not growing.

Medication can treat certain pituitary tumors, such as prolactinomas, about as well as surgery. Panhypopituitarism (a loss of all hormones from the pituitary) is treated carefully, as missing hormones must be completely and continuously replaced through replacement medication and additional hormones such as cortisol and thyroid must be augmented in life-threatening situations and surgeries. 

Paget’s Disease Of The Bone

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Paget’s disease is a relatively common disorder of the bone that has no symptoms early in the process but can progress to pain and fractures in later stages. It is more common in certain geographical areas than others, and may be familial in nature. First named after it was described by Dr. James Paget in 1877, it can affect bone in a localized manner or be present in many long bones.

Bone turnover (or bone metabolism) is a lifelong process in which mature bone tissue is removed from the skeleton (a process called bone resorption) and new bone tissue is formed (a process called ossification or new bone formation). During the first year of life, nearly 100 percent of the skeleton is replaced, while in adults, remodeling is about 10 percent per year.

Paget’s is a progressive disease in which bone in the skeleton is resorbed and then misshapenly remodeled. Think of it as a house which is disassembled and then put together again haphazardly. The new structure is weaker and the foundation compromised.

Paget’s sufferers are susceptible to fractures and pain in the involved bones and the process is vascular in formation, meaning cardiac output can be compromised at older ages from the increased blood flow to the areas at risk. Paget’s is estimated to occur in up to 3 percent of people age 55 and older and up to 8 percent of people in Europe, Canada and Australia/New Zealand. It is rare in Japan, Scandinavia, Russia and Africa for unknown reasons. Men are affected more than women.

Most people are diagnosed incidentally before there is pain and obvious deformity of the skeletal long bones. Routine blood testing, done for most doctors’ exams and insurance blood workups, shows a markedly elevated alkaline phosphatase level. X-rays of affected bones (usually done for other reasons) demonstrate as an incidental finding clear changes caused by Paget’s.

The bone density is increased but deformed in appearance and there is thickening of the long bones and skull in many cases. Headaches and hearing loss can occur, depending on which bones are involved and to what degree. In addition, there is a higher incidence of kidney stone formation from the increased calcium in the bloodstream and, in late cases, heart failure can occur when the body tries to keep up with the increased demand from bone hyperactivity.

While many early or slowly progressive cases of Paget’s don’t need treatment other than pain relief or anti-inflammatory medication, advanced cases are treated with medication that slows bone turnover. In some countries, other treatments like using THC gummies are used to help people with their pain relief as well as easing some of their daily stresses. Some prefer to use products like 1500mg CBD Oil Drops to help with pain management, especially if they’re not comfortable taking the more hardcore alternatives, but it’s really all about finding a solution that suits you best – speaking to a doctor for peace of mind beforehand may be a good idea if you’re not sure. Furthermore, etidronate was the first drug used to treat Paget’s back in 1977 and is still in widespread use today. Newer drugs in this biphosphonate family, such as risedonate and tiludronate, have fewer side effects and are more frequently used.

Medications are often given intravenously and one (zoledronic acid) may have to be used only once to have an effect for several years. They reduce bone turnover and keep the disease in remission but generally do not correct already existing deformities.

Most cases are considered on a combination of age at onset, degree of involvement and whether other body organs (heart, kidneys) are involved. Most mild to moderate cases, especially over the age of 60, can be considered at standard rates. Rated cases involve higher bone turnover and more involved medication needs. Cases where repeated fractures or heart failure are involved have the poorest outcome.

Labs: All In The Changes

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The dictionary defines the word “normal” as conforming to the usual standard, type or custom. Physicians are accustomed to getting laboratory values in terms of normal or abnormal, inferring that all normal results are good (there is nothing to worry about) and all abnormal ones are cause for alarm and concern. In truth, the answer is truly neither—changes in values are the most worrisome—both in clinical medicine and in underwriting.

Ranges of normal are broad enough to account for the diversity in people and what constitutes reasonable ranges of health. However, there is no rule of thumb for whether a higher normal is a good or bad circumstance. Too much of a measurable substance can be as dangerous to health as too little. When the values are outside the accepted range, the significance is easily grasped. More problematic is when a value in the normal range can indicate a substantial problem.

Let’s consider a CBC, or a complete blood count, as an example. Hemoglobin, measuring oxygen carried by the blood to tissues, is generally in the range of 14 to 16g/dL for a man and 12 to 14 for a female. Larger men can have higher numbers without being abnormal, while both men and women can have ethnic traits that make the values measure lower despite being healthy as well. The change in values is important. For example, a man with fatigue whose value was 16 before and is 14 now may be losing blood and could have a lesion or even cancer, despite having two values that are in the normal range. In such a case, using an attending physician statement with previous values for comparison is more helpful than the absolute measurement itself.

PSA (prostate specific antigen) values in men are another example. Every male has a measurable amount of this  in his system. It is an enzyme that rises as the prostate enlarges with age, but also significantly when there is prostate cancer. Normal range is generally up to 4ng/mL, and slightly more in older males. A level of 6 can be “normal” if a man has a benign enlarged prostate and there is no disease. A normal value of 3.8 can be quite abnormal, especially if the value previous to that was 1.6ng/mL. In that case, the rise may be due to a growing prostate cancer that needs urgent evaluation. Even the normal value in this case is quite abnormal; more so than the previous example where the value was out of range but stable.

The differences can also be used to follow treated conditions. Let’s use the above example again but apply it to a prostate cancer situation where the cancer was treated and the PSA dropped well into the normal range. In fact, after a year or two the level was barely measurable, but two years later, when an insurance profile is done, the PSA rises from .004 to 1.0. While the value of 1.0 is still well within the normal range and, in fact, is low normal, the increase in this case would be indicative that cancer has returned and that the situation is far from optimal. Thus, the difference is far more important than the absolute value.

In a way, the definition of normal is more like the usual state of affairs or conditions for a situation; in fact, normal measures the range of values that are generally seen in people of good health. There are many situations where a high or low value out of this range is not cause for alarm. Rather the change in value from one level to another without an explanation is what is truly not normal and must be considered. 

Attention Deficit Disorder (ADD/ADHD)

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Attention deficit/hyperactivity disorder has long been recognized and treated in children, but has become a commonly diagnosed adult disorder as well. It is easier to treat in adults as they can make the most of cbd products like those available at https://www.everydayoptimalcbd.com/product-category/cbd-oil/. These help sufferers to manage their symptoms as they have a calming effect. The estimate is that as many as one in three children diagnosed with this entity will actively carry the disease into adulthood. Those with children with such a diagnosis – or if they themselves have been diagnosed – may wish to seek out ADD treatment by speaking with medical experts in the field.

While ADD and ADHD are associated with other psychiatric diagnoses, there are factors that allow for favorable underwriting.

ADHD is probably the most common neurobehavioral disorder of childhood. While attention deficit disorder centers on inattentiveness and a lack of attention to detail, the hyperactive form includes impulsivity, inability to sit still or concentrate, and interpersonal problems. Early diagnosis may coincide with poor school performance, underachievement in classroom situations, and poor interpersonal relationships. Schools in the United States are doing a better job in early diagnosis and intervention, but even with intervention and medication more than half will have significant problems in adulthood if the disorder persists.

The inability to concentrate or to have difficulty with attention is probably a complaint of most adults, but the diagnosis criteria per the Diagnosis and Statistical Manual of Mental Disorders (DSM) is very specific and revolves around six or more behavior characteristics in structured and leisure environments. Doctors are reluctant to give the initial diagnosis to an adult without a history of the disorder being recognized in childhood. In addition, behavior modification often makes identifying six behavior criteria difficult. Nonetheless, the hyperactive/inattentive details are often just as significant to the prognosis and treatment.

The consequences of persistent ADD and ADHD are predictable-poor performance in school leads to lack of success in the job market, as well as in making a living; plus, difficulty with interpersonal relationships leads to low self-esteem and poor adjustment to the normal trials of everyday living.

Some disorders that go along with ADD/ADHD have worse prognoses. These include conduct disorder-with rules violation, aggressive behavior toward others and violations of the law-and oppositional defiant disorder, where hostile and disobedient behavior is manifested toward authority. Earlier onset of these behaviors is associated with poor long term outcomes.

The early use of medication and pharmacotherapy as well as cognitive behavior therapy has helped many to successfully adjust and achieve more favorable outcomes. Those with ADD/ADHD who fare best are the subsets with less hyperactivity at the root of the behavior, older age at diagnosis, stable job history, and no other coexisting psychiatric problems or diagnoses-applicants such as this can be issued as standard and, on occasion, be given preferred consideration. Some of the most successful people in business have milder forms of ADHD which contribute to more innovative and active thinking.

The biggest problems occur when there are significant other psychiatric issues, particularly depression and alcohol/drug abuse or patterns of behavior that lead to conflicts with both the law and supervisory personnel in work situations. Those are the cases that are generally postponed or declined.

Valley Fever Is Making A Comeback

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Coccidiomycosis, otherwise known as valley fever, has made a dramatic recurrence in the United States-especially in southwestern states such as Arizona and California.

Valley fever is a fungal infection caused by direct inhalation of spores which are found in the soil from these areas. Most common for those between the ages of 25 and 55, the disease has dramatically increased in incidence over the last few years.

When soil in a given area is either kicked up by new construction, digging, or farming, or when strong winds disturb the terrain, spores become airborne and are capable of being directly inhaled. This is true whether, for residents, visitors, or even those just passing through the area. Due to this, it’s important that any people in this area consider purchasing a kn95 mask, or something similar, to try and reduce their chances of inhaling this airborne disease. It’s always better to take this sort of precaution, especially when this could have dangerous respiratory impacts.

Most people who come in contact with coccidiomycosis have no discernible symptoms, but up to 40 percent may be affected. The incubation period is rather long (between 10 and 30 days) and most often manifests as a respiratory illness that can include fever, chills or flu-like symptoms. Pulmonary disease may follow in about 5 percent of cases.

While most affected will explain away transient findings as a cold or flu, persistent fever, cough, chest discomfort and fatigue are signs that the individual should seek medical attention. Skin lesions, meningitis or infection in the bones may also be found.

Diagnosing valley fever infection usually comes with a high index of suspicion-those living in an endemic area or working in occupations that have dust or dirt exposure, older people who are more immunocompromised, or those who develop progressive signs and symptoms of respiratory illness traceable to a stay in such an affected area.

Testing for coccidiomycosis involves directed blood testing. Serologic testing helps to determine both diagnosis and long term prognosis. Immunodiffusion tests help check antibodies against the disease, and culture and histopathology also help; however, as mentioned earlier, the key is having a high index of suspicion for the illness. X-ray findings may show patchy, nodular pulmonary haziness and thin walled cavities but, again, these findings aren’t specific to valley fever, and diagnosis must be confirmed by other means.

Those who have mild disease may not need anything more than supportive treatment-eventually the body develops antibodies through its own immune system and reinfection becomes unlikely. However, more serious disease requires strong antifungal medication that may need to be administered intravenously. When serious, it may require up to six months of continuous therapy. Those who develop persistent pulmonary cavities, pus, or blood within the lungs have a poorer prognosis, as do those where extension into the nervous system (meningitis) occurs. Thankfully, most infected people are asymptomatic and treatment isn’t required. An x-ray may find evidence of old exposure.

In the absence of any current or systemic disease, the prognosis is excellent and best class insurance is available.

When the disease becomes systemic or requires prolonged therapy, postponement is generally the rule. As time progresses without evidence of acute infection and with normal pulmonary testing and blood test findings, the most favorable underwriting applies.

Update On Hepatitis C

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Hepatitis C is a single-stranded RNA virus that often results in progressive inflammatory disease of the liver. In its fact sheet on hepatitis C (Fact Sheet No. 164), the World Health Organization estimates that more than 200 million people worldwide have been infected with the virus, and 170 million have chronic disease. Of this number, three to four million Americans have chronic disease, with the majority being baby boomers born between 1946 and 1964.

People who knowingly have HIV or AIDS, as well as those who have had blood or organs donated to them could also be at risk of having the disease. For the safety of your own health, hepatitis testing should be considered as soon as possible so you are able to get a clearer idea about whether or not you have the disease. If you do, then your local healthcare clinic will be able to provide you with the relevant services and treatments to prevent hepatitis from causing chronic liver disease.

In 1989 hepatitis C was first identified as a separate entity; before that time it was diagnosed only as non-A, non-B hepatitis. It is a blood-borne disease transmitted through blood and blood products, and most common after transfusions, use of contaminated syringes, organ transplant, or sexual activity with an infected person.

Screening of blood and organ donations has decreased transmission; however, even today up to three quarters of people with hepatitis C may not know they have the disease. The diagnosis is often made accidentally, by finding abnormal liver enzymes on a routine blood draw and subsequently testing for the virus.

Most people infected with hepatitis C do not show symptoms until the findings are advanced. As mentioned, most are either informed that the infection exists during routine blood testing or when donating blood. Jaundice, or liver damage, typically occurs late in the process. In those cases, complications of chronic liver disease including cirrhosis, bleeding and hepatocellular carcinoma (liver cancer) may be pre-terminal events.

Initial testing for hepatitis C looks for antibodies in the antigenic regions of the virus. A test for anti-HCV antibodies usually is positive four weeks after exposure to hepatitis C, and a high titre or viral load is confirmed with a count of more than two million viral copies per milliliter. A recombinant immunoblot assay (RIBA) test confirms that the results are indeed not false positive ones.

Other liver function tests are often raised at the same time-those are the ones that usually trigger the advanced testing for the disease. Later on, when the disease becomes chronic, liver function tests actually drop toward the normal range but do not correlate well with the stage of the disease.

Testing once the presence of hepatitis C is confirmed usually involves checking the viral load (amount of virus in the system) and a liver biopsy to determine how much the liver has been affected by the virus.

Staging on a liver biopsy goes from zero to four, with four being the most advanced and read out by a pathologist. CT scans and abdominal ultrasounds are useful screens and provide information on the extent of liver damage as well. Mortality from hepatitis C is from liver failure, liver cancer and end-stage liver damage (cirrhosis).

Thankfully, newer treatments have delayed the onset of severe problems with hepatitis C and have been able to control the disease for much longer periods of time than previously. Depending on the specific genotype of the virus, treatments such as ribavirin and interferon have had excellent responses.

While the term “cure” is used at times, it really means that at the time of testing, hepatitis C virus particles have decreased to an undetectable level. Thus, what this truly indicates is a remission in the disease, a normalization of liver function tests, and a clearance of RNA virus from the bloodstream.

Without treatment, hepatitis C does not often abate on its own; chronic infection develops and up to 20 percent of cases will progress to cirrhosis or liver cancer.

Many cases of hepatitis C may not be treated if an individual does not have symptoms, has favorable liver function testing, and has had the disease for more than 15 years. These individuals are followed carefully and treated if or when clinical problems or relapse occurs. The treatment generally requires several medications administered concurrently; it is difficult to adhere to in many cases, and contraindicated in certain disease states or concurrent medical conditions.

While previously considered to be an uninsurable disease, rated insurance is now available for many with hepatitis C virus. Those with symptoms or active disease may be declined, but those whose viral titres are low to absent, have a biopsy that shows minimal disease, and who have normal liver function tests are looked upon most favorably. The longer the disease has been observed without complication, the more favorable the outlook. 

New medications are being developed that result in longer and longer periods of remission, and although no vaccine is available against hepatitis C at present, much current research is being aimed at that goal.

Mild Cognitive Impairment

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There’s not one of us who hasn’t feared that we are accelerating in the process of mental aging when we forget where we put our keys, that our eyeglasses are right in our pockets where we left them, or what we were trying to say after having been interrupted in mid-sentence. These are normal phenomena involved with the aging process.

Cognitive changes occur normally with aging. However, impairment that causes a noticeable and measurable decline in cognitive abilities is defined as mild cognitive impairment (MCI).

MCI is the physiologic syndrome that bridges the gap between normal aging and early dementia.

People naturally process information about their world and environment with skills such as memory, language, attention, spatial relations and mental processing speed. Generally we are sharpest in our thirties and forties, level out in our fifties and sixties, and begin to slow and/or decline in our seventies and beyond.

Normal aging affects new information processing, visual acuity, memory and performance speed, all of which become slower and not as efficient—plus distractibility increases. The line, though, becomes less distinct between normal aging and MCI when the changes become more profound and are noticeable to others who may mention or point them out as being a noticeable change from their previous experience with an individual.

In normal aging, most detail is remembered without prompting, cognitive evaluation is normal, short term memory is intact, and activities and instrumental activities of daily living are preserved. With MCI, the ability to recall issues is noticeably delayed, and the affected individual is usually aware of it. Short term memory may be impaired, as may cognitive ability, and while activities of daily living are preserved, the instrumental activities (such as managing finances) may be impaired. MCI may also involve forgetting conversations, repeating oneself and forgetting appointments and events that were formerly easily remembered.

A workup for MCI involves a thorough medical history by a physician, assessment of independent function and daily living, input from closely involved family and friends who know the person well, a neurological examination to rule out other treatable causes, and basic laboratory tests. Depression must be ruled out, because it often mimics MCI with a lack of attention to detail or to situation.

Cognitive tests such as the Mini Mental State Examination (MMSE) or the Saint Louis University Mental Status examination (SLUMS) are often used in assessment. Neuropsychological tests and even brain CT scanning also help to make the diagnosis.

If aging, and MCI to some degree, are a normal function of aging, when does it become problematic in insurance evaluation? First, a person with MCI is at an increased risk of developing Alzheimer’s or other dementia. MCI is thought to have a 5 to 10 percent risk of yearly progression to dementia, according to studies such as the ones done by the Alzheimer’s Disease Cooperative Group. When reasoning and intellectual function are impaired, an individual becomes at risk for problems associated with impaired judgment. The inability to make sound decisions, poor motor and spatial skills, or the inability to carry out functions of independent living put people at significant health and accident risks.

Also remember that for individuals whose bodies show signs of vitality despite mental decline, the ability to enter into contract is always an issue to address. A person must have the faculties and reasoning to understand the goals of a purchase and to make sure it is in their best interest. At times, a medical as well as a legal professional may have to be consulted.

Dementia isn’t always a linear or gradual process either. Some forms progress from MCI to profound dementia and impairment relatively quickly.

Since the major source of evaluation of MCI is going to come from attending physician statements, a physician must be clear on whether his patient’s status reflects the process of normal aging or a faster, more pathologic process. More involved testing may be required in order to show that the changes involved are subtle and gradual; that physical activities of daily living are not expected to be compromised in the near future; and that instrumental activities such as medication management, handling finances, etc., are intact. Although no medication has been approved by the FDA for MCI, some patients actually improve with staying healthy, active and involved—thus it is important to demonstrate that when submitting an insurance application.

References:

 Alzheimer’s Disease Cooperative Study, www.adcs.org.

 “Mild Cognitive Impairment,” Ronald C. Petersen, MD, PhD, New England Journal of Medicine, June 2011.

Prognostic Signs In Cancer

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Despite the fact that situations can be markedly similar, there isn’t always one rating applicable when considering a prospective insured who has had cancer—even when the same organ is involved. While two situations can seem almost identical, underlying factors such as individual susceptibility, general health, age at onset, and numerous other factors must be considered by an underwriter.

Obviously the organ involved is a major key. Some cancers are more ominous from the beginning because they lie so close to drainage areas, as well as blood and lymph systems. For instance, cancer of the esophagus and pancreas can be so advanced before discovery that effective treatment is a long shot from the start. Yet prostate cancer is slow growing and can be effectively treated even years after discovery.

Types of cancer can be different within the same organ. For example, some pancreatic cancers can be deadly in six months, while others may take eight to 10 years to manifest lethal consequences.

The size of the tumor in cancer is important. Larger is worse, particularly in endocrine organs such as breasts or ovaries. Histopathology, or appearance, plays a role; it lets us know how invasive a cancer is and how entrenched it is likely to be at diagnosis. The grade tells us how much rogue cancer cells look like original tissue; the more original architecture that is preserved, the better the prognosis. Undifferentiated cells, which don’t look much like the original ones, have the most difficult prognosis.

Extent of involvement of cancer is a key in forecasting its course. Cancers that have spread by either blood or lymph systems means multiple other organs may be involved (metastasis). The more organs involved and the distance of metastases, the poorer the prognosis. This is even true when there is a prolonged remission, because cells can reactivate and cancer can reappear.

Other factors which have little to do with the actual pathology of a cancer can influence underwriting and its course. Age is one of those factors—generally the cure is more difficult when the diagnosis occurs at a younger age. Some cancers behave more aggressively in men than in women, or vice versa. Genetics can also play a role—cancers have more aggressive outcomes when they run in families.

Sometimes the type of treatment will enter into the prognosis for the long term. Massive courses of radiotherapy or chemotherapy for blood-borne cancers or leukemia have malignant effects and can actually increase the risk of a second cancer. Treatment may have to be so radical in order to eradicate a cancer that overall body function and/or organs such as the heart or lungs are harmed. Additionally, receptor status can play a role in cancer assessment; for example, breast cancer may have cells that are more receptive to certain curative treatments, making the outcome better over the long run because they are more amenable to therapy.

Last, remember that overall health also plays a role with cancer prognosis. Those who have other diseases that alter the immune system (diabetes, for example)  can also affect how the body will respond to treatment—both in the short and long term.

Each type of cancer is not identical in the same organ, in similar people, or in individual response to therapy. Assessing each of the elements individually helps underwriters know where the better prognoses are and which cases can qualify for more aggressive offers.