Robert Goldstone

Hypertension (high blood pressure) affects almost 70 million Americans, and as such is one of the most common conditions encountered in medical underwriting. The association of elevated blood pressure with extra mortality has been known for many years, and insurance companies have maintained extensive statistics on assessing that risk.

While most cases of hypertension can be issued standard policies (even preferred with regular and good control), there are some instances where blood pressure becomes a significant problem, especially when it is chronic and has begun to affect target organs.

Under the simplest model, the heart’s job is to pump oxygenated blood out to body organs and be sure that each site is properly perfused, or given the right amount of blood to keep the tissues functioning normally. When blood pressure is raised, the heart has to pump that much harder to try and do its job. It also means that body organs may offer that much more resistance to blood coming through to enter its individual cells. It’s easy to see that not only can a heart begin to fail under such difficult conditions, but so can body organs which do not receive the necessary blood to carry on their normal function.

There are many causes for hypertension, but thankfully most all can be adequately controlled with diet and medication. Ironically, 95 percent of cases have no specific cause that can be pinpointed (essential hypertension). Secondary hypertension (where an etiology is found) may actually be more difficult to treat, as there is more complicated pathology that also has to be considered, be it anatomical, genetic, etc.

Nonetheless, maintaining normal blood pressure is still the ultimate goal in preserving both heart function and body integrity. What is normal blood pressure? The Report of the U.S. Joint National Commission on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) sets a systolic (upper number) of 120 or less and a diastolic (lower number) of 80 or less as being normal. The well-known Framingham studies suggest the values might be optimal even a little lower than that. Just about every medical study group agrees that blood pressures of 140/90 or higher constitute hypertension and begins to indicate a health risk. Physicians in clinical medicine begin treating blood pressures between this number and the normal one indicated above in most cases, as people in this range (called prehypertension) will go on in over half of cases to high blood pressure within five years.

While most insurers will even give their best rates to hypertensive applicants who show sustained and excellent blood pressure control, sometimes end organ damage can be done that has to be accounted for in underwriting.

A heart forced to work too hard too long can go into heart failure, a very serious condition that even good control cannot always reverse. High blood pressure can also have permanent consequences for the body, such as heart attack, stroke or kidney damage. In these instances, there is permanent and irreversible damage.

Hypertension can also be an additive risk in conditions such as vascular disease, diabetes and kidney failure—primary conditions that have their own mortality far and above the existence of just high blood pressure alone.

Underwriters look to attending physician statements to see how blood pressure has been controlled, as well as to see if organ damage has to be accounted for. The insurance exam sometimes diagnoses high blood pressure before the potential insured is even aware of it, as most cases of hypertension have absolutely no symptoms. It is important this be treated, even beyond the indications of an insurance policy.

One condition that is a difficult one for insurers is called white coat hypertension. It’s a colloquial term for blood pressure that seems to elevate in the presence of a physician or health professional, where a patient gets nervous and the body reacts accordingly. Usually pulse does not rise at this time and the blood pressure rise is transient. Reassurance and taking the blood pressure after a few minutes can result in returning to normal levels, although prolonged elevations are probably true hypertension itself that requires treatment.

Hypertension is a very treatable disease and when caught early can have very minimal effects on the body and on individual health. Controlled hypertension without organ damage is often issued at standard and preferred rates by insurers, and both the exam and the attending physician statements are key in making this determination.

The adrenal glands have a number of functions, the most important of which are the production of glucocorticoids and mineralocorticoids. These are life-sustaining hormones which regulate body fluid and sodium levels as well as provide stress hormone at times of need. They are also a contributing source of adrenal androgens for the reproductive system. In some cases, medication like Selective Androgen Receptor Modulators (SARMs) is administered to treat this, however, each patient is different.

When the adrenal glands fail, replacement of these necessary hormones must occur to keep body physiology intact.

A loss of adrenal hormones can be either primary or secondary. In the primary cause (Addison’s disease), the glands themselves fail. In more than 80 percent of cases, the body’s own immune system is the culprit (hence the term autoimmune disease). Other causes include fungal infection, tuberculosis and hemorrhage within the glands. A secondary cause is when the body’s stimulative mechanism within the pituitary gland fails and the adrenals are not stimulated to produce the proper amount of hormone needed to sustain the body. Both can result in potentially catastrophic consequences for the body.

Adrenal insufficiency/failure can be a gradual process. There is weakness, easy fatigability, nausea, vomiting and weight loss. In women, menstrual periods may cease and, in both sexes, primary gland failure causes the skin to darken because excess pituitary hormone is secreted in an attempt to stimulate the non-functioning glands. The endocrine system operates on a constant set of checks and balances, thus the lack of a hormone produces a stimulus to produce more, and an excess effectively turns the system off. The loss of this balance through failure of an organ disrupts the body’s homeostasis.

When adrenal insufficiency becomes life-threatening, the body becomes fluid depleted, may suffer hypotension, dehydration and shock, and no longer produces the needed amount of stress hormone to help the functioning systems through such acute insult. When subjected to a major stress such as infection, trauma or surgery, the body is unable to respond with a large outpouring of cortisol, shuts down, and goes into crisis, which can be lethal. Prompt and aggressive administration of glucocorticoids and fluids must be undertaken.

Thankfully, replacement hormones taken orally are effective in treating the disease and supplying the body with what it needs but cannot produce. The risk comes when acute illness or stress arises and the hormones need to be increased, but the body is no longer capable of doing this on its own. Hospitalization is required to replace fluids and properly manage electrolytes. Death is uncommon, but certainly a possibility during acute crisis.

The insurance risk is not only of shock and death but also in the existence of adrenal insufficiency as an autoimmune disease. Generally these types of diseases run in concert with each other, thus pernicious anemia, diabetes and hypothyroidism frequently accompany Addison’s. Each has its own medical risk and must be accounted for and treated.

In those who have adrenal insufficiency and have been shown to be able to manage it well with medication and without complication over a long period of time (generally more than five years), standard issue is often the case. A rated offer is possible when the onset of disease is more recent or there are other accompanying autoimmune problems.

True adrenal insufficiency must be differentiated from many of the “adrenal insufficiency” labels given by alternative medical clinics and practitioners, where hormones or herbs may be administered to “aid vitality and sense of well-being.” In these cases the adrenals do function adequately and respond appropriately to stress and usually are not at risk for failure and the extreme consequences described above.

The hepatitis B virus is still one of the most prevalent and serious infections both in the United States and across the world. The estimate is that, globally, between 350 and 400 million people are chronically infected with hepatitis B virus, and more than 500,000 deaths occur each year from liver failure, cirrhosis and liver cancer.
With the insurance population reaching out well into other continents, some 85 percent of the world’s population lives where the prevalence of chronic hepatitis B infection (chronic HBV) is more than 2 percent, according to the Centers for Disease Control. The prevalence in the United States is 0.4 percent, with more than a million people chronically infected.

Hepatitis B is transmitted through contaminated secretions, such as sweat, saliva, vaginal secretions and semen, as well as contaminated blood. Besides using a contaminated syringe from an infected person, medical procedures, occupational exposure in the health care field, transmission from mother to child at childbirth, and even tattoos and body piercing are becoming common sources.

Most people have no idea they are infected until a routine blood test for something else is done (a physical exam, for instance, a general health check, or even a screen prior to donating blood) and confirms the virus.

Active infection with hepatitis B shows the usual signs of hepatitis: jaundice, yellowed skin and conjunctiva, fever, abdominal pain, nausea, vomiting, weight loss and a tender liver.

After the acute phase passes, the body either clears the virus or the virus remains to produce a chronic infected state. About 95 percent of people clear the virus normally, and their blood tests show they have produced immunity to the disease. The others will go on to generally become one of three infected statuses.

The healthy chronic carrier of the disease is generally not infectious to others and lives a very close to normal life expectancy. They have a slightly elevated risk of cirrhosis and liver failure, but their real risk is that the virus will become reactivated and aggressive if other disease states develop (such as cancer) or immune system suppressants like steroids are given for another cause.

The chronic infectious type is highly infectious to others, and even though they have few if any symptoms until late in the disease, this is progressive.

A third type referred to as a chronic mutant type is one where treatment is difficult because the virus is more resistant to conventional treatment.

When liver function tests are elevated and sometimes as a routine part of insurance testing, serology testing is carried out. This includes tests such as HBsAg (surface antigen), anti-HBc (core antibody) and anti-HBs (surface antibody). Without explaining the biology behind each of the tests, negative testing for all three shows no active infection, but a susceptibility to catching the disease (no immunity).

When the HBs and HBc are positive, the patient has probably been infected sometime in his life and is now immune, since his body has made antibodies. This is a common form now found in health care professionals as well as children going through the school system who have received hepatitis B vaccination—isolated positive anti-HBs, which also show immunity. When antigen and both antibodies are positive, a patient is acutely infected. When antigen and core antibody are positive but surface antigen is negative, there is probably chronic infection.

In chronic infections where liver blood tests are elevated and show active inflammation, a biopsy of the liver is the most accurate gauge of how much damage has been done and how aggressive the process has become. It helps to guide treatment both in type and duration.

The goal of therapy of chronic hepatitis B infection is to reduce inflammation of the liver and to prevent liver failure, cirrhosis and liver cancer. Antiviral medication is given, as well as a medication called interferon. Depending on the results of the blood testing along the way, medication is given for 6 to 12 months continuously. Oral antiviral agents are used as well, but generally the duration of treatment is longer. Relapse is a common feature and leads to antiviral resistance.

Thankfully, most testing of abnormal liver function reveals a non-infectious feature. When testing for hepatitis B occurs, the outcomes are favorable if past infection is shown and the body has created its own immunity to the disease—just as with other childhood diseases.

Hepatitis B is becoming less prevalent in the United States, as vaccination of school children is conferring immunity before the disease can be acquired. Those cases that show chronic infection and progression represent the worst outcome and least favorable action for insurance.

Lyme disease burst to the forefront of infectious medicine when a number of cases were identified in 1975 near the town of Lyme, Connecticut (hence its name). In 1981 a specific tick carrying the Borrelia burgdorferi bacteria was incriminated as the causative agent, and since then it is recognized that Lyme disease is the most common tick-borne disease in the United States and Europe.

At first a disease of exclusion-where every other cause of arthritis and myalgia symptoms was ruled out-testing has now become sophisticated and specific in looking for Lyme disease much earlier in the process.

Lyme disease can affect multiple body systems and produce a host of signs and symptoms. It has been found that the disease is not exclusive to the Northeastern United States and, in fact, can be acquired just about anywhere in the United States. Animals such as mice and deer can carry the disease as a host until humans are infected by a tick bite.

Lyme disease is tough to pinpoint early in the process, as many of the clinical symptoms early on are non-specific. With this being said, by doing something like a lyme disease test could help identify this. The earlier the symptoms are identified, the easier this could be to manage.

The serologic testing with the disease is inaccurate until later in the illness, and many cases are missed when testing is ordered and turns up negative early in the disease process.

The Three Stages of Lyme Disease Symptoms
There are basically three stages of Lyme disease symptoms. In the first stage, flu-like symptoms and a skin rash develop along the site of the tick bite. The lesion spreads like a small bull’s-eye in most cases, but often recedes after a few weeks. During this stage, symptoms are muscle aches, headache and fatigue, something that CBD premium hemp flowers or similar products can help with if the symptoms become too uncomfortable or painful. Be sure to contact a medical professional first though.

The second stage is a spread to the nervous system, with a picture that simulates meningitis, with headache and neck stiffness. At times, involvement of the heart can cause arrhythmias and heart block.

Stage three is a late, persistent infection, with mainly musculoskeletal complaints, arthritis and general disability. This can become chronic and recurrent in 10 percent or more cases.

Testing for Lyme disease requires finding antibodies specific to Borrelia burgdorferi in serological tests called IFA (indirect fluorescent antibody) or ELISA (enzyme-linked immunosorbent assay). The testing isn’t well standardized, though, and laboratories may not be consistent in their testing and results.

Many times suspected individuals are diagnosed clinically, with a history of tick bite and symptoms, and treatment is initiated even without a clear-cut laboratory confirmation of the diagnosis.

Thankfully, early suspicion and prevention, as well as more prompt treatment, makes Lyme disease less of a long term health threat. The usual recommendation of avoiding tick infested areas, covering exposed skin, and using topical tick repellent is more stressed now in endemic areas.

Antibiotics are quite effective and shorten the duration of the rash and prevent long term complications. Doxycycline is the most effective, but amoxicillin and cefuroxime have also been shown to work effectively. As long as the disease is caught early, long term sequelae are generally avoided.

Most cases of treated Lyme disease without complication are insured as if the disease had been completely eradicated. Appropriate therapy generally resolves almost all of the symptoms within a month. Those in whom the disease becomes chronic and affects the heart or central nervous system can have significant disability and, in the case of the heart, even mortality.

Rather than wait for testing to confirm the disease, many tick bite cases are treated prophylactically with antibiotics, which helps limit the disease spread and complications of later illness. Treated and eradicated Lyme disease can qualify for best class underwriting.

The push to get newer and less invasive insurance testing has been going on for at least the last decade. Competition is fierce, convenience is king, and insurance companies are striving to get the most information they can out of more simplified testing. When the testing is new and not commercially used by the average doctor in practice, decisions based on the results can cause confusion and aggressive questioning by both physician and client. Three tests in this category are BNP, CRP and CDT.

BNP, short for B-type natriuretic peptide, has actually been used for many years by cardiologists in practice to diagnose congestive heart failure and distinguish whether some non-specific signs such as shortness of breath, fatigue and leg swelling may be indicative of pulmonary or cardiac disease. It was also used by cardiologists to optimize treatment for post-heart attack patients as well as to gauge the prognosis of those with congestive heart failure.

As older people slow down, constitutional symptoms become more pronounced. Differentiating regular aging-induced changes from insidious congestive heart failure is important to clinicians and also to underwriters in determining future prognosis.

BNP has also been found to be a predictor of arrhythmia in the future and has a very important role in prognosticating diabetes and those who will undergo heart surgery in the future. Some insurers are even doing away with treadmill testing at older ages and substituting a BNP result, which adds convenience to the insurance process.

As with all testing, BNP isn’t foolproof. Renal disease will cause elevations, and even normal people may have increases. Many people with abnormal BNP are insured when their medical rating takes into account the primary disease process. However, because many physicians don’t use BNP in screening (there is still much ongoing research), it can lead to questions in the field when a result causes a rating or declination.

CRP, or C-reactive protein, has been available for many years in assessing cardiovascular risk but is as controversial today as when it first came out. The original testing of CRP, which is an acute phase protein that increases with inflammation in the body, was used to help assess people who had autoimmune disease (such as lupus, for example), systemic arthritis, and certain forms of inflammatory bowel disease. A newer, more sensitive version, called hs-CRP (high sensitivity) has been used to attempt to predict recurrent coronary events in people who have had angina or heart attack and in the prognosis of people who have stroke or peripheral artery disease.

With this in mind, it should appear that CRP would be a terrific tool as an aid to prognostication of life expectancy that insurers could use, but it hasn’t quite turned out that way in practice. The value fluctuates in different circumstances, and many results may have to be obtained to get a true representative value.

The newest ASCOT trial (Anglo-Scan­dinavian Cardiac Outcomes Trial), which the American Heart Association is following carefully, found CRP to be a weak and sometimes non-significant predictive factor; and cardiologists often use the test to determine only whether cholesterol lowering statins are good treatment in patients at risk. So while perhaps helpful as part of an overall picture, the individual results provoke almost as many questions as answers.

CDT is another test that is not usually a part of clinical practice for most doctors but which insurers have come to rely on in risk assessment. CDT is carbohydrate-deficient transferrin, and is a very useful marker for detection of sustained alcohol use. Since alcohol abuse has such a myriad of complicating factors in mortality prediction (liver, cardiac, neurologic disease, as well as an increase in accidents, overdose and suicide), insurers need to know this in risk assessment. CDT is a great helper in differentiating mild from significant alcohol use and abuse.

In years past, GGTP was the marker most used to look for alcohol abuse, especially in the presence of other signs of liver disease. However, too many other conditions caused GGTP to be elevated, including causes that had nothing to do with the liver (such as bone) and medications. CDT is much more specific diagnostically and turns out to be a good marker for large consumption of alcohol.

Like all testing, CDT isn’t foolproof. Some people have inborn disorders of glycosylation which are inconsequential in their daily function but which elevate the test falsely. Certain medications, such as those used to control seizures, also raise CDT.

The test is best used in combination with a high index of suspicion, such as when a doctor notes significant alcohol use on an attending physician statement or in a pattern of recurrent accidents or suspicious motor vehicle reports. Alcohol questionnaires and even physician assessments of alcohol abuse may not always be well-correlated, so the CDT is a good adjunct for the overall picture.

All three tests have utility in insurance assessment, but their use is as a help in drawing an overall picture of risk, not as individual factors which decide the case on their own. As the testing isn’t part of the usual metabolic profiles drawn by most doctors during a physical or office exam, both doctors and clients may have questions as to the use and reliability of the testing. Insurers are careful to always use the tests in context of the entire medical picture of the applicant, and hope that the testing provides a less invasive and more convenient way of facilitating a decision on an application in selected circumstances.

Underwriters always ask about medications being taken for an illness or disease, and often can tell a lot by what’s being prescribed and relating it to the possible severity of the disease. While a detailed APS usually answers most questions, this is particularly true in situations in which preliminary evaluations or “quick quotes” are requested.

Sometimes, however, being on medication creates a more favorable underwriting outcome, and it isn’t always worse to be on a prescription, especially since in recent years, medication is readily available through online pharmacies similar to this .

Statins, for example (known under trade names such as Lipitor, Crestor, Zocor and many others) are designed to lower cholesterol and alter the good to bad cholesterol ratio in a patient’s favor. Traditional thought was that if someone needed medication to keep cholesterol down, that made it more of a problem. This hasn’t proven to be the case. Cardiologists almost unanimously feel that statins actually cut the risk of heart disease and that many people will live far longer and avoid cardiologic compromise by taking them.

Statins also appear to have other benefits: They decrease CRP levels, an inflammatory protein in the blood thought to promote atherosclerosis and abnormal blood vessel wall deposit formation. Some recent literature shows a favorable effect in preventing the onset of Alzheimer’s disease. Cardiologists often use statins as a preventive measure for patients who have certain risk factors but normal lipid levels. In fact, many insurers actually give underwriting credits for being on a statin, so it’s a medication that is actually beneficial in risk assessment.
 
Antihypertensives are also medications that don’t have to have negative underwriting connotations. While they wouldn’t be prescribed to someone who didn’t have a problem with blood pressure in the first place, keeping a normal blood pressure is key in preventing strokes, heart attacks and heart failure. Underwriters are much more forgiving of applicants with blood pressure well controlled on medication than those whose blood pressures are elevated but are not taking anything for their problem. Preferred issues are common for treated hypertension.

Antidepressants are often prescribed for patients, and not always for severe conditions. Managed care and the health system have made it difficult for doctors to spend the proper amount of time with people to get at the root of a problem. The impersonal world of Facebook and the Internet makes a good friend who will listen to a difficult situation a lot harder to find. As such, doctors are much quicker to prescribe antidepressants on very short visits to combat any emotional distress, even when the stressor is not a serious one. These medications are often not a harbinger of severe problems but rather, one in which the treatment reflects the health care system, not the true severity of the problem.

There are cases in which medication sometimes lets an underwriter know the more serious form of a disease is being treated. Long term corticosteroids, for example, may be very helpful in treating certain cases of asthma, serologic arthritis and autoimmune diseases, but these medications have their own set of side effects which worsen other facets of overall health and also suppress the immune system to fight other diseases. In robbing Peter to pay Paul, the medication ameliorates some facets of disease but comes with a cost. They are reserved for the serious or stubborn cases of a disease.

One disease in which it is difficult to decide how medication affects the overall picture is diabetes. Almost all doctors agree that diabetes must be well controlled to prevent life threatening complications, and while the degree of control is still under debate, the mantra that “whatever best controls blood sugar is best” still rules. That means having to take a pill to normalize blood sugars might actually be better than taking nothing and sacrificing a better degree of control. Insulin use generally still is reserved for cases in which diet, exercise and oral medication fail. While blood sugar control still reigns supreme, the insulin dependent diabetic generally doesn’t have as good an outcome, even given similar levels of control, as blood sugars are more brittle and variable in these individuals.

Medication doesn’t always portend a worse underwriting outcome with any given disease, and in fact sometimes it is looked at favorably in the process of determining an offer. However, one thing to keep in mind is that disclosure is good. Nothing makes an underwriter more suspicious than a lack of candor or less than full disclosure. As such, those cases are treated with a higher index of suspicion and become steeper walls or worries to overcome.

As unusual as a term in medical science can be, an incidentaloma is exactly what it sounds like—a tumor that is found completely by coincidence while looking for something else. It has no signs or symptoms and generally is found during a scanning or x-ray procedure and reported by the radiologist. It comes as a completely “incidental” finding and often causes a significant quandary both in clinical and insurance medicine.

The boom in scanning and x-ray procedures has caused an incredible increase in finding growths (or tumors) that were completely unsuspected clinically. The advances in technology with better resolution and graphic imaging have also increased what can be seen from previous decades when these findings would have been missed or undetected.

The estimate is that more than one in 20 patients over age 60 may harbor these growths. The question to answer is whether they are no more than benign findings which have no effect whatsoever on day-to-day life, or whether they are pre-malignant growths that need further investigation and will result in increased early mortality.

The largest culprit is perhaps whole body CT scanning, which has been marketed by health screening programs as a way to detect disease before it produces clinical findings. Rather than looking for disease in a suspected organ or localizing to a patient complaint, the scan provides findings with no clinical correlating information for the radiologist. As such, the radiologist reading the scan is left to wonder whether the finding has any significance at all, or whether it is part of anatomic anomalies we all have. The infamous phrase “cannot rule in or rule out” a growth or pathology has many time exposed patients to additional x-rays, radiation and testing that turns into a search for what essentially may be nothing.

Of incidentalomas that sometimes produce significant health findings, adrenal growths are the most common. On top of the adrenal glands at the superior poles of the kidneys, the growths can be benign adenomas or tumors that may cause an increase in hormones that cause excess cortisone production or hypertension. Generally speaking, there ought to be symptoms that correlate to disease. However, the presence of such a growth often produces the need for follow-up scanning and procedures to check for growth or expansion. Thus, no clean bill of health when they are detected.

Brain scans even with no signs or symptoms of disease may show meningiomas or pituitary adenomas. When a meningioma remains stable in size, it is not commonly a worry. However, pituitary adenomas may secrete hormones that are endocrinologically active on many biological axes in the body and should be monitored. This is done more often with hormone and blood screening tests than by repeated x-rays.

Thyroid, parathyroid and kidney incidentalomas also are relatively common sites of findings, but perhaps the most concerning from both a clinical and insurance point of view are pulmonary nodules. The solitary pulmonary nodule, if it proliferates, can be a finding of early and perhaps treatable cancer, and the American College of Chest Physicians has a complete protocol of how to evaluate a newly found nodule along with testing criteria. Depending on size, density, location and change in proportion, the probability of serious pathology varies, but this finding is uniformly taken seriously by the physician, rather than being dismissed as a benign situation.

In clinical medicine, how far to pursue an incidentaloma is still a matter of debate. The costs both to the patient and to the health care system can be staggering, as is the amount of radiation a person can be exposed to following up on a lesion that may have no clinical or pathological significance. In insurance, underwriters will often want to have some resolution on whether such a growth can have a significant effect on mortality before proceeding with an offer.

Most scientific and fiscally responsible medicine and underwriting involves thorough and risk-based assessment of the probability of a finding being of pathological significance against the high likelihood that the growth found is no more than an anatomical variation in a healthy body. Both common sense and the words of the famed physician Hippocrates “above all do no harm” contribute to the degree of work-up and the decision to leave an “incidental” finding be, especially when the odds overwhelmingly favor it being nothing more than that.

Thyroid nodules are quite common in the average population and may be detected – with a careful examination – in up to 5 percent of people. Some 300,000 new cases a year are detected, and the number is high in countries where diets are deficient in iodine.

Since the thyroid gland requires iodine to produce thyroid hormone, one of the major metabolic hormones in the body, a relative lack may cause tissue to hypertrophy, or swell. Of course, having too much thyroid can cause the same finding, but most nodules are solid and relatively hypofunctioning.

Thyroid nodules are four times as common in women as in men. They are unusual in children and their prevalence increases with age. More than half of the single nodules found in the initial screening turn out to be one of many when the gland is scanned. Patients may be the first to find a nodule by either feeling it or actually seeing it when looking in the mirror.

While most thyroid nodules are benign-thankfully-about 5 percent of them turn out to need intervention. Thus, follow-up and testing is required when one is found. Thyroid function tests in blood are done; even though most people have normal thyroid levels (euthyroid), hypothyroidism (and more rarely, hyperthyroidism) is detected.

An enlarged thyroid gland can have many causes: iodine deficiency, pregnancy, inflammation of the thyroid from autoimmune disease, and infection head up the list. Multiple nodules are found as frequently as single nodules are.

The risk of a thyroid nodule being malignant is increased in those who have a family history of same, those who received head and neck radiation as a child (this was a treatment for acne and thymus gland enlargement many years ago) and in those who have a personal history of another malignancy. Sometimes even benign conditions such as inflammation of the thyroid reveal an underlying nodule on testing that may be malignant.

When a gland is enlarged or swollen and either the patient or doctor notices a thyroid mass or nodule, imaging is done along with basic thyroid function tests. An ultrasound is often the first step to determine the actual size of the growth and whether there are multiple ones that can be detected. Ultrasound also helps discriminate between a solid nodule and a thyroid cyst, which usually contains colloid material and is harmless.

Scanning with radioactive iodine may be done to determine if the nodule is hyperfunctioning (hot) or nonfunctioning (cold). CT scanning is reserved for cases in which larger glands may be suspected of growing backward and pushing on the windpipe or extending into the chest.

A biopsy with a fine needle is the best way to determine the presence or absence of malignancy in the gland. It is a procedure that can be done in the doctor’s office and is generally not painful. The tissue or liquid obtained is then looked at under the microscope for composition and type of cells.

Again, most glands and nodules turn out to be benign. They may not require treatment or may require the use of anti-inflammatory medicines or remedies to control the condition. Thyroid nodules that cause inflammation or pain may qualify for treatment with medicinal marijuana or CBD oil from companies such as https://vibescbd.co.uk/. Benign nodules often go away with time, but if persistent or increasing in size then treatment to remove them may be considered.

If malignant, several treatment modalities are available, depending on the cells and aggressiveness of the lesion. Surgery (often a total thyroidectomy) is done for lesions that are malignant on biopsy. Radioactive iodine to destroy the gland chemically may be used for multiple nodules or in hyperfunctioning glands. These modalities are often curative, and the major complication of hypothyroidism post-treatment is remedied by taking a thyroid pill for replacement each day.

Thyroid nodules and even most thyroid cancers are quite curable; benign growths are eligible for best rate issue and even malignant ones can be standard after time has elapsed with no recurrent disease.

Doctor follow-up is important, as is testing for maintenance of normal thyroid functioning, even on thyroid replacement. Obtaining insurance may be postponed when a nodule is found but no investigation has been done. However, most thyroid nodules turn out to be benign and not of underwriting significance.

Anemia is defined as a low hemoglobin level and blood count. By the World Health Organization definition, it is a measurement of hemoglobin less than 13g/dl in men and less than 12g/dl in women. Anemia is a common condition in aging and is present in more than 10 percent of all people older than age 65 and up to 50 percent of those elderly in nursing homes. While lower levels are somewhat expected as we age and our metabolic demand isn’t as high, evidence is increasing that there is a definite increase in both mortality and morbidity in untreated anemia.

Much of the cause of anemia in younger ages is acute blood loss. Trauma with blood loss is well recognized, as is gastro-intestinal bleeding from such sources as ulcer disease and diverticulitis. Female blood loss from prolonged and heavy menstrual cycles also is a cause of anemia. On the far more serious end of the spectrum, cancer is always looked for by physicians when they see sudden anemia for the first time. Often acute symptoms lead the younger individual to the doctor and the diagnosis is made quickly.

Anemia has a more insidious onset in older people. Blood counts may drop slowly and the decrease in oxygenation will cause symptoms that are often attributed simply to the process of aging. A decrease in stamina, fitness, or energy, and even dizziness or falls is often ascribed just to getting older and not to the underlying process of lowered hemoglobin levels and blood oxygenation that is behind it. Shortness of breath, fatigue and even confusion can ensue with chronic and persistent anemia, which may be overlooked by the clinician and those sub-specialists providing ancillary care.

Nutritional and chronic diseases are often implicated in anemia in the older population, short of acute blood loss or undetected cancer. Iron deficiency, folate deficiency, and low stores of B12 account for at least a third of cases. Diagnosis is difficult unless levels of each of these are drawn in blood testing. These can be readily reversed with replacement or a change in nutrition, but require a reasonable index of suspicion by the treating physician to recognize and diagnose.

Microcytic anemia is usually caused by iron deficiency. While older aged individuals usually do not intake the same diet rich in iron because of their inability to chew, process or digest iron-rich substances, gastrointestinal bleeding and malignancy are the most dangerous conditions that must be ruled out. Malignancy work-ups are generally undertaken when the blood loss is rapid and the iron stores are exceedingly low.

Macrocytic anemia has many causes, such as being secondary to drug therapy, liver disease, thyroid disease or alcoholism. The nutritional anemias referenced above are most often macrocytic in nature. Alcoholism is a very real problem in the elderly who find that alcohol relieves stress and brings short term pleasure, and who are not worried about long term health consequences. It is a significant cause of unrecognized morbidity and mortality and an underlying cause not often uncovered by a doctor during a medical visit without persistent questioning. There are some adults who realize their faults and bad habits and try to follow along with the principles of AA as well as attend support meetings and such but not everyone does, and that’s when the outcome of the situation isn’t so pleasant and could perhaps result in long term body damage or even death.

One of the biggest problems with anemia in the elderly is the inability of the body to compensate for a lowered blood count or cell oxygenation from the lowered hemoglobin concentration circulating in the bloodstream. Older individuals cannot increase their heart rate and cardiac output as easily as younger persons, and shortness of breath, fatigue and confusion become more common as the anemia worsens. This leads to instability, falls, fractures, and causes of morbidity only peripherally related to the underlying condition. Surgery in anemic individuals carries a much higher risk of mortality and may not always be able to be postponed in an acute situation.

In underwriting, mild, stable anemia with a known cause doesn’t usually result in an adverse action. A rapid onset or significant anemia found recently or as part of the underwriting process often results in a postponement until the underlying cause is identified and treated. Sometimes that cause may render an individual uninsurable, depending on its severity. There is increasing evidence that both low hemoglobin levels and anemia are significant markers of physiologic decline-a situation that has to be reviewed carefully, particularly for older clients.

Anemia is the condition in which there  is a decrease in red blood cells and volume. As a result, oxygen-rich cells carry less and less of that essential element through the bloodstream. People are fatigued and tired and their organs don’t function optimally. It would stand to reason that an excess of red cells in the circulating blood, called polycythemia, might actually be favorable to health and well being, but alas, it is not. Polycythemia carries a series of problems and complications that make it a serious disorder to underwrite.

There are two main types of polycythemia, primary and secondary. In primary, also known as polycythemia vera, bone marrow stem cells undergo slow and steady reproduction that gradually results in a taking-over of the bone marrow. Not only are red cells overproduced, but the infection-fighting white blood cells as well as platelets (which are clotting helpers) are over-created as well. Polycythemia vera is usually genetic, and 95 percent of people affected have a mutation in the signaling molecule JAK2. About 60 percent of those affected are men, and the usual age of onset is between 50 and 60 years of age.

While “normal” levels of hemoglobin and other blood products may vary within a range, that spread elevates significantly in polycythemia. Normal hemoglobin and hematocrit levels in the 13 to 15 and 40 to 46 range respectively go to 16 and 50 and often beyond. White blood cells—generally fewer than 10,000 in the absence of infection—routinely go over that. Platelets, with an upper normal limit of 400,000, go to 600,000 and over. It starts to get pretty crowded in the bone marrow and blood stream, and serious complications develop.

While there are no symptoms early on, those affected begin to manifest problems related to an expanded blood volume and increased blood viscosity, or thickness. Headache, dizziness, ringing in the ears, blurred vision and fatigue develop. Itching is a common sign related to the increased number of one type of the white blood cells overproduced (basophils) secreting excess histamine. Blood clogs the smaller blood vessels of the nose, and epistaxis (nosebleed) is not an uncommon finding.

When red cells more or less overrun the body, the spleen begins to store them up, and an enlarged spleen is a hallmark of diagnosis. The spleen may burst, causing a surgical emergency. Thrombosis (clotting) is the most common complication and is the major cause of morbidity and mortality with polycythemia because of the increased platelets, and blood clots can be thrown into major arteries and veins. Eventually a terminal phase of the disease has the overextended and clogged bone marrow failing and being replaced with fibrous tissue, and in effect the system goes from overdrive to failure.

The treatment of choice for polycythemia vera is phlebotomy, or blood removal. Often a unit of blood (about 500 ml) is removed weekly until the hematocrit decreases down to 45 (the upper normal level) and is then repeated as necessary. When the disease doesn’t respond, medications called myelosuppressors are used, especially to decrease the amount of blood platelets and lessen the risk of spontaneous clotting and thrombosis. Low dose aspirin is also used as part of the regimen.

A more treatable and less serious relative is secondary polycythemia. Here, the disease is caused by conditions that increase the secretion of erythropoietin, which is a hormone produced in the kidney that stimulates the bone marrow to produce more cells. Most cases of secondary polycythemia are caused by a decrease in the amount of oxygen in the tissues (hypoxia). It can be seen in those living in high altitudes, those with extreme obesity, in smokers, and in others with chronic lung diseases.

Much of the mortality of secondary polycythemia results from a primary cause such as smoking and obesity, and leads to heart failure, angina, blood clotting and strokes due to the thrombosis caused by the elevated platelets and thick blood. In many cases, though, treatment of the primary disorder corrects the polycythemia, which then disappears as bone marrow function returns to normal.

Underwriting polycythemia vera is quite difficult; the median survival even with aggressive treatment is 10 to 15 years. Arterial thrombosis and clotting are the major causes of death, as well as leukemia due to bone marrow shutdown in about 5 percent of cases. Careful and rigorous treatment is essential in even considering a highly rated offer, and a majority of applicants may not be able to be offered life insurance coverage at all with advanced disease.

Secondary polycythemia may be insured if the primary cause is corrected and controlled—those whose cell counts remain in the upper limits of normal and who correct obvious underlying pathological conditions such as obesity, or who discontinue smoking, may only be evaluated on their primary conditions without polycythemia being a factor.