Robert Goldstone

Liver fibrosis is the replacement of functioning hepatic tissue with fibrous tissue. Alcohol overuse, hepatitis of any kind, and nonalcoholic steatohepatitis (NASH) often leave behind damage with not only an active process but one where compromise may persist long after the cause has been controlled or eradicated. Knowing how to assess liver fibrosis in the aftermath of these conditions is an important part of underwriting liver disease.

Chronic liver disease may occur in over 10 percent of the population, and the National Vital Statistics Registry lists it as the 12th leading cause of death in the United States. The most common causes of chronic liver disease are nonalcoholic fatty liver disease (NAFLD—very commonly associated with obesity and present in over one quarter of the US population), the aforementioned NASH (a more aggressive form of the disease) and post hepatitis C infection. Hepatitis C is now potentially curable, but the damage left behind from the course of the illness may be permanent. A way to determine liver disease aside from just the blood testing that is done is certainly necessary in determining both prognosis and treatment.

Liver fibrosis (depending on the staging system used) has 4-6 stages. Stage 0 represents no fibrosis, stage 4-6 marked fibrosis with cirrhosis of the liver, and the remainder some degree in-between. Liver failure is the most extreme consequence and staging is a predictive factor for it. Additionally, conditions like hepatocellular cancer and bleeding vessels in the esophagus (varices) are high risks of advanced liver failure and have to be accounted for as well. Even potential treatments (like those for hepatitis C) need to have the degree of fibrosis assessed to choose the most appropriate drug treatment.

Historically, a liver biopsy was the only way to know for sure the degree of fibrosis and residual liver damage. Biopsies are not only painful but may result in excessive bleeding and complications that may require hospitalization. Additionally, a biopsy report is only as good as the area it is representative of. If placed in the most affected area (or least affected) a result may be misrepresentative of the overall state of disease.

Staging scores have been developed based on various testing. FIB-4 is based on the use of four factors that are representative of fibrosis: Age, AST and ALT levels (liver function tests), and platelet count. NAFLD score generally is in post biopsy patients and additionally adds body mass index as well as the absence or presence of diabetes. These are helpful but not fully diagnostic of the degree of liver involvement with fibrosis.

Newer testing has been developed with better accuracy. Fibrosure is a formula that takes into account age, sex, bilirubin, haptoglobin, GGTP, apolipoprotein A and alpha-2-macroglobulin to assess fibrosis. It has good predictive value—better than its predecessors. Imaging such as transient elastography (done with ultrasound waves), acoustic radiation force imaging (where a transducer is involved) and MRI elastography are also used and provide more definitive quantification of the degree of fibrosis that is being measured.

Many Attending Physician Statements reference this advanced testing, especially in biopsy proven disease, in assessment of post hepatitis C infection, and in diagnosing the more virulent NASH. Many drug companies are spending millions of dollars in attempting to find medication that treats or improves NASH finding or slows fibrosis. The common fatty liver disease associated with obesity generally has very limited fibrosis and is underwritten on the basis of underlying conditions. NASH is often ratable based on biopsy results or higher score indices based on the testing involved, including liver enzyme results. Even successfully treated hepatitis may be rated if the disease resulted in substantial liver damage left behind after the successful cure.

The term epilepsy denotes any disorder characterized by recurrent, unprovoked seizures. Seizures are disturbances of cerebral function that are electrical discharges in the brain. It may consist of violent shaking, convulsions, absence spells, automatisms (unusual recurrent behaviors), up to the loss of consciousness. Epilepsy is quite common and occurs in up to one in every two hundred people. Even though it is common, there can be times where living with this condition can be tough on many people. With this being said, it then comes as no surprise to find that some residents of Utah may choose to get a cannabis card in Salt Lake City. This way, they’ll be able to get their hands on medical marijuana, which is said to help manage the symptoms of Epilepsy (and other ailments/conditions). Making sure you have a local supply is important so if you aren’t in the Salt Lake City area and you live in Vermont, it might be wise to try out i49 as a local source for your medical marijuana needs.

The unprovoked seizures are generally recurrent and may persist for seconds (in absence seizures) up to hours when the post-seizure state (also known as the post-ictal state) persists. People may have seizures provoked by reversible causes, such as withdrawal from alcohol or drugs, low blood sugar and kidney failure from severe electrolyte imbalance, but these seizures are not considered to be under the true definition of epilepsy.

Most epilepsy is either structural or metabolic in origin, although genetic epilepsy does exist. Abnormalities a person is born with or injuries acquired during the birth process may cause epilepsy. Metabolic causes, vascular diseases, degenerative disorders and infectious diseases are causes. Seizures associated with infectious diseases are generally reversible when the disease passes. Trauma is a very important cause of seizures, especially in young adults.

Seizures are generally classified as either focal or generalized. Focal seizures may or may not involve loss of consciousness. They can consist of anything from jerking rapid movements to involvement of visual, auditory, olfactory and other sensations bordering on hallucinations. Generalized seizures can run the gamut from absence seizures (where someone is unaware of an impairment of consciousness for a short period of time) to tonic-clonic, or grand mal seizures. These types of seizures generally involve a sudden loss of consciousness, a fall to the ground, and rhythmic, jerky contractions followed by a period of drowsiness. Grand mal seizures are most common in adolescence and early adulthood.

Since there is a large differential diagnosis of neurologic seizures, testing is always indicated. An EEG (electroencephalogram) is the single most useful test in the diagnosis of epilepsy, with evidence of seizure activity being shown with characteristic spike and wave patterns. CT scanning (or MRI) also help to exclude lesions (such as tumors) as a cause, as a sudden seizure later in life may be the first sign of a malignancy. Focal seizures may be confused with transient ischemic attacks (TIAs), the aura to migraine headache, panic attacks and even rage attacks. Generalized seizure disorder has to be differentiated from syncope and cardiac disease. Getting the proper diagnosis is essential to providing the most appropriate treatment.

Medical and surgical treatment are both used to control epilepsy. Numerous medications, similar to cbd oil and water soluble cbd for example, are used depending on the type of seizure involved, as some may provide excellent control of the disorder. Often they are trial and error until the right medication with the least side effects is found. Surgery may also be tried, in the people who are not responsive to medical therapy, to disrupt the focus of seizure provocation.

Mortality and morbidity in general are higher in epileptics. Sudden death is a risk in those who have grand mal seizures and who are not well controlled on medication. Accidents, and in particular motor vehicle incidents, can have quite adverse consequences with the development of a seizure while driving. Falls, particularly in the elderly who have epilepsy, can result in severe consequences. Industrial accidents in those who have epilepsy and may be affected during mechanical work are also problems that have to be taken into account.

Certain information is helpful to the underwriter in assessing epilepsy and especially in evaluating the more difficult cases. Compliance with medication is foremost in a favorable outcome. Single seizures do better than multiple ones. Concurrent use of alcohol is a poor prognostic factor. Single medication use as opposed to multiple medications and the duration of time since the last attack are considered. Older age and the results of trauma from a fall also have poorer outcomes.

Many to most epilepsy cases may be handled with standard classification, and occasionally preferred status can be used when there are single seizures, no prolonged treatment, no history of alcohol use and no high risk avocations (like aviation or scuba diving). Medication records as well as MVR records are reflexed and looked at in evaluation. Medications and surgery over the recent past have shown very positive results in seizure control.

Build is one of the essential points of information in underwriting that go into a rating. Generally, height and weight are calculated into a measure called BMI, which is body mass index. Most companies make build tables available to their agents and brokers to allow a general idea of whether or not there will be debits on a case. However, more things go into an assessment than just absolute measures, so companies may vary on how they perceive build information.

BMI has been studied over hundreds of thousands of lives by reinsurers who provide ranges for what is underweight, average weight and overweight. Normal weight is a BMI of between five percent and 95 percent for age and sex, so it covers quite a lot of ground. Obesity for rating purposes generally is between the 95th and 99th percentile, and severe obesity in the upper one percent of weight and BMI. Likewise, underweight is calculated as a BMI less than the fifth percentile for age and sex. Most people fall into this mid-range for which no rating and no increased cost assessment is made. One further consideration is for preferred classes, where companies will choose a more narrowed rate of “normal” to allow better than average pricing when build is optimal and closer to the mean.

Complications from each deviation from the norm are well known. Obesity predisposes to many conditions that are hazardous to overall health. They include coronary artery disease, hypertension, stroke and Type 2 diabetes. Lipid disorders such as high cholesterol and high triglycerides may follow from overweight. Certain cancers such as prostate cancer in men and breast, colon and endometrial cancer in women have a higher incidence in overweight individuals. Sleep apnea and increased risk while undergoing surgery are also considerations to be accounted for. Most people’s weight increases as activity decreases between ages 50 and 65 but normalizes into older age.

Underweight likewise has complications which affect underwriting. Low BMI may be associated with underlying malignancy, intestinal problems and malabsorption of necessary nutrients, endocrine disorders, renal insufficiency and depression. In older persons, dementia and increased fracture risk from falls have to be considered. Alcohol abuse, arthritis and underlying connective tissue disease are often associated with underweight, as well as psychosocial diseases such as bulimia and anorexia.

Most build abnormalities that will require ratings are apparent during the submission of a case and present few surprises when they result in a rating other than as applied for. Overweight build tables are exceedingly generous, and generally one has to exceed a BMI of 35 before standard pricing is affected. It’s generally not a matter of wearing heavy clothing or being weighed after mealtime, although that can be a consideration in preferred pricing where weight cutoffs are strictly observed. There are a few more problems with evaluating underweight, which will be addressed shortly.

Weight is assumed to be relatively stable over time, so underwriters pay attention to large swings in BMI over short periods of time. When there is a history of recent weight loss that is intentional, most underwriters will add a minimum of 50 percent of the weight lost to the current weight in considering a rating, since the weight loss sadly is often temporary. A loss of weight that is unexplained or more than five to 10 percent may be an indicator of malignancy, and the case may be postponed for investigation or explanation in these circumstances.

Build becomes more of a factor when there is concomitant disease associated with the case. For instance, overweight becomes a markedly additive risk factor when an applicant already has significant cardiac disease or vascular disease. Likewise, diabetes and cholesterol problems become more difficult to control as BMI rises. Conversely, those with chronic disease who are losing weight and having BMI drop must be checked carefully for underlying cancer or failure to thrive. In these cases individual BMI differences may take on added significance, even more than a simple chart might indicate.

Two other considerations to mention are ethnicity and younger applicants. Often, many ethnic groups not raised here in the United States have slighter builds that are completely normal for them yet end up on the rateable end for underweight on the build tables. Similarly younger individuals, particularly females, have thin builds that also might be worrisome at age 65 for example but that are completely within the normal range for age 25. This includes consideration for preferred classes as well. In these cases it is important to show that these are stable builds and that the individual is healthy and has no other coexisting diseases that might contribute to underweight status. It may be as obvious as pointing out there are no malabsorption questions, no underlying illness, and even that an underweight by build tables female has normal menstrual cycles and exercises regularly. Build tables can’t take into consideration every instance, so showing that different people have different “normals” can result in the best underwriting classification.

Blood taken from insurance examinations are subject to many possible influences. Delays in handling, processing, and different atmospheric conditions may causes changes to lab results as opposed to those you would avoid when the labs are processed locally. There are also many body physiologic conditions (childhood, pregnancy, fasting, alcohol intake) that also influence test results. Insurers and underwriters are usually aware of these possibilities from the get-go, but when conditions are abnormal in a setting that is completely unexpected, it helps to know the extenuating circumstances that are involved.

Let’s start with physiologic factors. Young growing children (generally up to the age of 22) have active bone growth and turnover, and often labs that are abnormal for others are normal for them. They include alkaline phosphatase, AST and ALT, GGTP and LDH. Alkaline phosphatase particularly can be high, and in peak growth years be several times normal. It’s all part of the growing process however, and that is their normal.

Many times bloods are done fasting. This is recommended because blood sugar, cholesterol and triglycerides are optimal in a fasting state and allow the applicant to put his best foot forward. Alkaline phosphatase, GGTP and especially triglycerides will elevate if blood is taken within two hours after a meal. A prolonged fast may raise bilirubin and uric acid, but drop albumin, glucose and protein. High protein diets will raise both BUN and uric acid.

Pregnancy is one of the hardest situations for interpreting a blood test. Virtually every lab value is affected. Albumin, BUN, protein and creatinine may decrease. That is rarely a concern, but alkaline phosphatase, uric acid and urine protein may be increased. Cholesterol, triglycerides and HDL in particular may rise, and sometimes take a preferred case and throw the values well out of normal range. It makes the blood test during pregnancy of restricted usefulness in the underwriting process.

Mechanical problems can influence the sample. If, for whatever reason, there is a marked delay between obtaining the sample and running it, it often provides invalid values. Liver function tests, alkaline phosphatase, bilirubin, GGTP and glucose may drop off the map depending on how long the delay was. A1C might artificially rise, which can cause a problem. The mail has a way of making detours and, as such, processing problems may interfere with accurate determinations.

Heat in a sample can cause rises in both BUN and creatinine, simulating a kidney problem. Liver function tests, GGTP and glucose all drop. At times the lab may not be able to record a value for glucose based on the degree of heat involved. The drop may also influence A1C and cause a consideration for insurers trying to guess at what an actual value might have been.

Finally, a condition called hemolysis can exist when a sample is either knocked around too much, suffers trauma of some sort, or the blood is squirted too quickly or too forcefully through a needle into the collecting tubes. The blood cells break apart and chemistries such as albumin, AST, ALT (liver function tests), bilirubin, cholesterol and triglycerides can be reported artificially high. On the other end, it may lower fructosamine, hemoglobin A1C and triglyceride values.

Most samples are collected and transported without any problem, much like even blood testing that is done for a personal physician. Because insurance testing is more standardized and only specific laboratories are used, the handling process is subject to more variables and longer time for a sample to reach its destination. As such, an underwriter generally looks at all aspects of the sample process when assessing the results, just like he or she may have to consider different body disease and conditions to assess the readings correctly and appropriately.

There are so many permutations of responses to a positive drug test. “My client says he never used drugs.” “He hasn’t used them in a very long time.” “She only used the drug once, just to try it.” “It must have been slipped in a drink to him.” “It was prescribed for a medical condition.” Regardless of the situation in which you have taken drugs, it won’t sit well if you have to do a drug test at work and you fail. With there being kits such as ehrlich reagent out there, testing for drugs like LDS and magic mushrooms have never been easier.

Urine drug testing is a cornerstone of the overall testing in proposed insureds and yields a lot of valuable underwriting information. Those with a need to conduct such a test will often utilize this method or go with a breath test for alcohol in order to determine whether an individual has been under the influence of a substance or not. So how long do a lot of drugs stay in the system and at what time frame would they be likely to trigger a positive test? Using a 10 panel drug test can be useful for determining positivity across a range of substances – https://www.countrywidetesting.com/collections/10-panel-drug-tests.

Cocaine is generally a universal decline in the application process if testing is positive. While cocaine itself is metabolized within the first 4-5 hours, its bi-products that will produce a positive test exist for 2-4 days afterwards. Additionally, cocaine is stored as a marker in hair almost like rings in a growing tree. When a hair sample is tested it can tell you not only how long ago cocaine was used but on how many different occasions.

Marijuana testing is linked to the frequency of its use. The analyte tested (11-nor-9-carboxytetrahyrocannibol) can be detected for 2 days after a single use. In a three time a week user though, testing will likely be positive for up to two weeks after the last usage. Daily use may keep the test positive for up to a month post usage, and in very heavy users even up to 12 weeks post. The “I tried it once” or “I was in the room with someone who smoked” should not produce a positive test 72 hours after the supposed incident.

Amphetamine testing tests for several biproducts of amphetamine usage, such as and including methamphetamine, methylenedioxyamphetamine and methylenedioxymethamphetamine. Generally, the window of detection is from 2-3 days. Heavy users may it have it present for slightly longer. The test will usually report as just positive and unless it is specific testing for a metabolite, it won’t specify exactly what was found (although it can…).

Narcotics are rapidly becoming a commonly seen drug of abuse, and one both the FDA and the government are targeting in terms of doctor overprescribing and patient abuse. Oxycodone will show as any number of related metabolites and will screen positive for 36-48-hours post ingestion. The controlled release types will extend this window closer to 72 hours. Fentanyl (a substance linked to many narcotic overdose deaths) reveals a positive test for 2-3 days after ingestion. Methadone, morphine and tramadol are some of the slower metabolized drugs and may be present in the system for up to 4 days post use. “Simple” codeine (even that present in the more commercially available preparations like Tylenol #3) will be present as a positive test generally for up to 48 hours post use.

Perhaps the preparations that yield a positive test longest are the benzodiazepines, the valium and other like structured drugs. The short acting benzodiazepines stay detectible up to 5 days post use, and the longer acting ones can be present even a month post use in the sample. Most of the medications do have some legitimately prescribable uses and are quite effective for the conditions they are being used to treat. The most important thing to tell a client who may be taking any of these drugs is to be upfront in admitting the uses of such medication and the reason for treatment. Many cases are underwritten without incident where a positive drug test is obtained so long as the use is appropriate and legitimate.

Having the underwriter uncover the positive testing and then the scramble for a plausible excuse or explanation raises a high level of suspicion, and the resulting “surprise” of a declined case is not very palatable for either agent or proposed insured.

Have you been ordered to take a drug test at work? If so, you might be interested to learn about what it takes to pass. For more information, go to https://www.lpath.com/how-to-pass-a-drug-test/.

“MEN, MEN, MEN, MEN, manly MEN MEN, MEN…” OK, not the long running TV comedy Two and a Half Men. Not the one that starred Charlie Sheen and Jon Cryer. MEN is short for “multiple endocrine neoplasia,” and, coincidentally enough, there are almost two and half kinds of them. They’re referred to as MEN 1, MEN 2a and 2b, and MEN 3. Some books actually postulate an MEN 4, but that’s another show for another season.

Multiple endocrine neoplasias are inherited disorders that include a variety of combinations of endocrine and nonendocrine tumors and affect different endocrine glands. The diseases run in families enough so that genetic counseling is advised when any first degree relative is affected. There are so many different systems and hormones affected that in many TV commercials for drugs (even not during just Two and a Half Men) the usual speed talk at the end that gives all the cautions involved in taking the medications often mentions multiple endocrine neoplasia by name as an instance when the drug shouldn’t be taken.

MEN type 1 is a syndrome that affects two or more of three principal endocrine systems. These are tumors of the parathyroid glands (which help control calcium and phosphorus levels in the body), pituitary tumors, and tumors of the pancreas and GI tract. The parathyroid growths may lead to elevated calcium levels in the serum and an overgrowth of the glands. Kidney stones and abdominal and bone pain may be associated. The pituitary tumors are usually adenomas and a primary presentation in affected women. These can result in menstrual dysfunction, enlarged breasts, or breast secretion as they secrete a hormone called prolactin. The endocrine tumors of the GI tract involve gastrinoma (hyper acid secretion), insulinoma (overproduction of insulin), glucagonoma, and some adrenocortical tumors as well. Hyperparathyroid tumors are the most common; the triad most seen in unison are the parathyroid, pituitary and pancreatic growths.

The risk of cancer development in MEN 1 generally depends on which organ is involved. Parathyroid abnormalities cause changes in calcium and phosphorus metabolism (and secondarily involve the bones) but are generally non-malignant. The GI tumors (gastrinoma) are very aggressive and may have metastasized even before they are initially found. The biggest problem with MEN 1 is the malignant changes that occur in up to a third of those affected, and there is no true prevention possible in that each of the organs in which they occur are not amenable to prophylactic surgical excision and removal.

MEN 2a and 2b (our half MEN) also involve genetic expression and tumors that include parathyroid and pituitary but substitute pheochromocytoma (a growth were blood pressure hormones are involved) and familial medullary cancer of the thyroid. The 2b type has an additional feature of mucosal neuromas of the lips, tongue and GI tract. The most ominous of the findings is the medullary cancer. In these cases, there can be actual prevention attempted by prophylactic removal of the thyroid gland at a young age, after which thyroid supplementation is given.

MEN 3 is also known by the MEN 2b surname. MEN 4, only recently described, is a much rarer familial tumor syndrome where almost any combination of the previous goes. Those with MEN 4 appear susceptible to adrenal tumors, kidney tumors, testicular cancer and cervical carcinoma. Thankfully this is the rarest of the bunch.
Risk classifications generally have an added mortality, first for the effects of all the inappropriate hormone secretion from the growths and, secondarily, for the increased occurrence of tumors. MEN 2 is the more insurable of the group as elective removal of the thyroid cuts down on major malignant potential. Again, genetic screening is a must in first degree relatives of affected individuals and early diagnosis is key.

The call often comes in like this one: “My client does something called vaping. It’s not like smoking cigarettes-it’s much less toxic. He doesn’t do it that often. He can get a non-tobacco policy, right?” So, what is vaping? How toxic is it if at all? And can you get a non-tobacco policy?

Vaping is defined by the Center on Addiction as the act of inhaling and exhaling the aerosol, also referred to as vapor, which is produced by an e-cigarette or similar device for example, from somewhere like Vapebox. Vaping requires an e-liquid with it that can come in a range of flavours, which can be found from websites like Gourmet eLiquid. Vaping devices generally consist of a mouthpiece, a battery, a cartridge containing the liquid which will be aerosolized, and a heating component that is usually battery powered. Visit this website, for example, if the purchasing of a vape is something new. As there can be quite a few accessories that can go with it, maybe starting off with a simple vaping pen could be the first step to take. Additionally, see the batteries available at Oji Vape here – https://ojivape.com/category/batteries/. The battery heats up the heating coil, which converts the liquid into an aerosol that is inhaled into the lungs just as you would smoke a regular cigarette. The process in actual cigarette smoking is the same, and the incidence of vaping is quite prevalent-it’s estimated that 1 in 5 high schoolers use e-cigarettes and “vape.”

The idea behind the e-cigarette was to involve a process that was less toxic to the user and cut down on the number of tobacco-related deaths in long term smokers. The liquid that is used in the pod (as it’s also called) is usually a propylene glycol-based fluid that may contain flavoring and chemicals. However, one of the major components in most of the preparations is still nicotine. The average pod contains about 40mg of nicotine, very similar to what is contained in traditional cigarettes. Nicotine addiction can happen just as easily with vaping as it can from usual forms of smoking.

The most popular of the e-cigarettes used in vaping is called the Juul. It’s a device that looks from a distance just like a USB port. It can be carried very inconspicuously and is the method of choice in usage by students in school to avoid detection. It is, however, an entrance to nicotine addiction in the younger population who may not have been drawn to smoking otherwise. Juul provided cartridges in many different flavors, which also promoted its use. Traditional cigarette manufacturers have been looking to buy into the Juul corporation as a hedge against the decreased popularity of cigarettes.

Are e-cigarettes void of any risk besides flavoring and nicotine? Many pods contain other carcinogens such as formaldehyde and others may include marijuana. Nicotine is certainly addictive and increased heart rate and blood pressure are known side effects. While e-cigarette vapor is less harmful than tobacco smoke, it is not innocuous. Cough, increased airway difficulties, nausea and vomiting are reported effects of vaping, and of course, any other chemicals that are added to the pod have their own set of side effects.

Insurers have problems with handling vaping at the present time. The research on vaping and its long-term side effects are in its infancy. Because vaping products contain nicotine, screening tests that insurers use to detect smokers will always be positive. Some “vapers” are also smokers which makes mortality difficult to separate. The conversion of those using e-cigarettes to traditional tobacco products is unknown. Custom made pods can contain any variety of chemicals with unknown effects on the lungs and the body.

Insurers’ position on vaping is not consistent at this time. Some feel that while it may be better than tobacco smoking, it does have more effects on mortality than not smoking at all-so vaping is priced as smoking. Some insurers will price any policy where tobacco is found in the urine sample as a smoker, regardless of how the nicotine was ingested. And some price the vaping population as non-smokers. There are a lot of variables to consider and a lot of research that has to be done on the potential health effects of vaping and, until then, expect a changing landscape with how e-cigarettes and vaping will be treated.