Interesting article from Journal Watch: Large case study on a greatly overlooked impairment. We looked at various underwriting manuals and CAD was not even highlighted as a risk factor. Also, the diagnosis of this disorder has really only come to the forefront in the past 10 years, with our elderly patients there continues to be a lack of quick diagnosis, and as such the cardiac factor may have already had time to develop into a highly overlooked risk factor.
Article:
Villous atrophy, intraepithelial lymphocytosis, and latent celiac disease were all associated with excess mortality.
Celiac disease is associated with an elevated risk for mortality. To more broadly assess celiac-specific mortality according to small-intestinal histopathology, investigators conducted a retrospective, case-control study involving more than 46,000 Swedish patients for whom duodenal or jejunal biopsy samples were available.
Patients were divided into three groups by diagnosis: 29,096 had overt celiac disease (biopsy showed villous atrophy); 13,306 had small-intestinal inflammation only (biopsy showed intraepithelial lymphocytosis or excess numbers of lymphocytes in the duodenal or jejunal epithelium, considered to be early but not diagnostic histological findings of celiac disease); and 3719 had latent celiac disease (duodenal biopsy was normal, but celiac serology was positive). Five controls were matched to each patient by age, sex, county, and calendar period through a Swedish population registry.
During the first year of follow-up, risks for mortality were highest for all three groups compared with controls (hazard ratios, 2.80 for overt celiac disease, 4.66 for inflammation only, and 1.81 for latent celiac disease). Between years 1 and 5, mortality risks remained higher for all groups (HRs, 1.26 for overt celiac disease, 1.41 for inflammation only, and 1.27 for latent celiac disease). After 5 years, patients with overt celiac disease and inflammation only had persistently higher mortality risks (HRs, 1.27 and 1.30, respectively), but those with latent celiac disease had nonsignificantly higher risk (HR, 1.11). Mortality risks were highest in patients who received diagnosis of celiac disease before age 20; some decline in the magnitude of excess risk occurred with increasing age. Overall, patients had increased risk for death from cardiovascular disease, malignancy, respiratory disease, and other causes. Cardiovascular disease and malignancy were the most common causes of death.
Comment: Results of this well-done study confirm previous observations of a modest increase in risk for death in patients with celiac disease and extend previous observations to comparable risks in patients with only intraepithelial lymphocytosis and positive serologies. The excess risk for cardiovascular death in these patients might be related to chronic inflammation, given that other data have associated markers of chronic inflammation with cardiovascular risk. The increased risk for malignancy in celiac disease has recently been associated with non-Hodgkin lymphoma. This study did not address which specific cancers result in increased mortality in the three study groups.
The cause of the increasing prevalence of celiac disease is unclear. Clinicians should maintain a high index of suspicion and consider screening for celiac disease in patients who have osteoporosis, unexplained anemia, peripheral neuropathy, irritable bowel syndrome or nonulcer dyspepsia (severe enough to require referral to a gastroenterologist), type 1 diabetes, autoimmune diseases, or family members with established celiac disease. Intraepithelial lymphocytosis alone in patients with positive serologies is probably celiac disease and might warrant a trial of a gluten-free diet. Patients with intraepithelial lymphocytosis alone and asymptomatic patients with positive serologies seem to warrant observation as well as attention to and treatment of cardiovascular and pulmonary disease risk factors.
— Douglas K. Rex,
Underwriting Term Du Jour: CBC-Complete Blood Count
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Monday, October 26, 2009
Friday, October 23, 2009
Do ICD's Work Better for Men than for Women?
Interesting article I ran across on Journal Watch:
Implantable cardioverter-defibrillators for preventing sudden cardiac death had no effect on all-cause mortality in women with advanced heart failure.
Although women constitute a minority of participants in most clinical trials on treatments for cardiovascular disease — and few such studies are sufficiently powered to address sex-specific outcomes — benefits are usually assumed to apply equally to men and women. In a meta-analysis of five randomized controlled trials of implantable cardioverter-defibrillators (ICDs) for prevention of sudden cardiac death (SCD) in patients with heart failure, researchers asked whether survival benefits conferred by these devices in men also extend to women.
In a pooled population of 934 women and 3810 men, investigators compared outcomes of ICDs versus medical therapy in patients with low left ventricular ejection fraction with or without histories of arrhythmia. The hazard ratio for the effect of ICD implantation on all-cause mortality was 0.78 in men (P<0.001) and 1.01 in women.
Comment: These results suggest that the benefits of ICDs for primary prevention of sudden cardiac death in women are questionable. As an editorialist notes, what's good for the gander might not be good for the goose, at least regarding ICDs. Clearly, we need additional sex-specific data — not only about ICDs, but also about cardiovascular interventions in general. For now, clinicians should inform women that the proven benefits of ICDs for the primary prevention of SCD seem to be limited to men.
My thoughts; It is understood that coronary artery disease has taken a lead as the number one killer of women-and still least understood disease process in this group. As such, why is the medical community still taking a back seat in including women in clinical trials so they can better understand how the disease manifests in women allowing better preventative measures and treatment?
Underwriting "Term Du Jour": ICD: Implantable cardioverter-defibrillators
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Implantable cardioverter-defibrillators for preventing sudden cardiac death had no effect on all-cause mortality in women with advanced heart failure.
Although women constitute a minority of participants in most clinical trials on treatments for cardiovascular disease — and few such studies are sufficiently powered to address sex-specific outcomes — benefits are usually assumed to apply equally to men and women. In a meta-analysis of five randomized controlled trials of implantable cardioverter-defibrillators (ICDs) for prevention of sudden cardiac death (SCD) in patients with heart failure, researchers asked whether survival benefits conferred by these devices in men also extend to women.
In a pooled population of 934 women and 3810 men, investigators compared outcomes of ICDs versus medical therapy in patients with low left ventricular ejection fraction with or without histories of arrhythmia. The hazard ratio for the effect of ICD implantation on all-cause mortality was 0.78 in men (P<0.001) and 1.01 in women.
Comment: These results suggest that the benefits of ICDs for primary prevention of sudden cardiac death in women are questionable. As an editorialist notes, what's good for the gander might not be good for the goose, at least regarding ICDs. Clearly, we need additional sex-specific data — not only about ICDs, but also about cardiovascular interventions in general. For now, clinicians should inform women that the proven benefits of ICDs for the primary prevention of SCD seem to be limited to men.
My thoughts; It is understood that coronary artery disease has taken a lead as the number one killer of women-and still least understood disease process in this group. As such, why is the medical community still taking a back seat in including women in clinical trials so they can better understand how the disease manifests in women allowing better preventative measures and treatment?
Underwriting "Term Du Jour": ICD: Implantable cardioverter-defibrillators
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Thursday, October 22, 2009
Adenosine for Regular Wide-Complex Tachycardia
Interesting article I came across in "Journal Watch";
Adenosine is safe and effective for differentiating wide-complex supraventricular tachycardia from ventricular tachycardia.
Distinguishing ventricular tachycardia (VT) from supraventricular tachycardia (SVT) with aberrancy (preexisting bundle branch block or rate-related aberration in intraventricular conduction) is a dilemma in the management of regular wide-complex tachycardia. Historically, some clinicians have been reluctant to use adenosine in this setting, because of fear of degeneration of VT to fibrillation or promotion of rapid conduction through an accessory tract. To assess the safety and efficacy of adenosine in regular wide-complex tachycardia of unknown etiology, these authors reviewed patient records at nine U.S. medical centers from 1991 to 2006.
Case ascertainment criteria varied among centers. The main outcome was response to adenosine (slowing of rate sufficient to make a diagnosis or conversion to sinus rhythm). Nonresponders who did not receive a dose of at least 12 mg were excluded. The underlying rhythm was unknown at the time of adenosine administration and was determined retrospectively by the researchers, based on all available information. Of 116 patients with an ultimate diagnosis of SVT, 104 (90%) responded to adenosine; in contrast, 2 of 81 patients (2%) with an ultimate diagnosis of VT responded. No serious adverse effects from adenosine were documented. Two patients had histories of Wolff-Parkinson-White syndrome, but in no case was an atrioventricular nodal accessory tract determined to be the etiology of the tachycardia.
Comment: Regular wide-complex tachycardia is most often either VT or aberrantly conducted SVT, and this study confirms that adenosine is not harmful in either case. Rarely, antidromic conduction through an accessory pathway (e.g., Wolff-Parkinson-White syndrome) is involved, and traditional teaching is that adenosine is harmful in such cases. Because none of the patients in this study had arrhythmias caused by an accessory tract, the results cannot prove that adenosine is safe in such patients. When an accessory pathway is known or suspected in a patient with regular wide-complex tachycardia, we should exercise caution about using adenosine.
— Daniel J. Pallin, MD, MPH
Underwriting "Term Du Jour": WPW-Wolff Parkinson White Syndrome
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Adenosine is safe and effective for differentiating wide-complex supraventricular tachycardia from ventricular tachycardia.
Distinguishing ventricular tachycardia (VT) from supraventricular tachycardia (SVT) with aberrancy (preexisting bundle branch block or rate-related aberration in intraventricular conduction) is a dilemma in the management of regular wide-complex tachycardia. Historically, some clinicians have been reluctant to use adenosine in this setting, because of fear of degeneration of VT to fibrillation or promotion of rapid conduction through an accessory tract. To assess the safety and efficacy of adenosine in regular wide-complex tachycardia of unknown etiology, these authors reviewed patient records at nine U.S. medical centers from 1991 to 2006.
Case ascertainment criteria varied among centers. The main outcome was response to adenosine (slowing of rate sufficient to make a diagnosis or conversion to sinus rhythm). Nonresponders who did not receive a dose of at least 12 mg were excluded. The underlying rhythm was unknown at the time of adenosine administration and was determined retrospectively by the researchers, based on all available information. Of 116 patients with an ultimate diagnosis of SVT, 104 (90%) responded to adenosine; in contrast, 2 of 81 patients (2%) with an ultimate diagnosis of VT responded. No serious adverse effects from adenosine were documented. Two patients had histories of Wolff-Parkinson-White syndrome, but in no case was an atrioventricular nodal accessory tract determined to be the etiology of the tachycardia.
Comment: Regular wide-complex tachycardia is most often either VT or aberrantly conducted SVT, and this study confirms that adenosine is not harmful in either case. Rarely, antidromic conduction through an accessory pathway (e.g., Wolff-Parkinson-White syndrome) is involved, and traditional teaching is that adenosine is harmful in such cases. Because none of the patients in this study had arrhythmias caused by an accessory tract, the results cannot prove that adenosine is safe in such patients. When an accessory pathway is known or suspected in a patient with regular wide-complex tachycardia, we should exercise caution about using adenosine.
— Daniel J. Pallin, MD, MPH
Underwriting "Term Du Jour": WPW-Wolff Parkinson White Syndrome
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Wednesday, October 21, 2009
Life Settlement News
I subscribe to Google alerts for "life settlement news" and over the past two months the alerts that used to come twice a week-and often included news on settlements that had nothing to do with the selling of a life insurance policy- have now become daily alerts, typically with a minimum of four new stories/blog postings.
On one hand, the increased publicity for this asset class is a positive given the impact the economic crisis had on all financial markets-and specifically on baby boomers retirement plans, I just wish that I could say the actual information being written was A) True, and B) Positive. Neither is the case.
Most of the articles and blogs I have read utilize similar phrases, such as: death bonds, wall street scheme, betting on death, the second coming of sub-prime, etc. I did come across these recent articles that I felt provided a good representation of why someone would look to settle their policy and the associated benefits.
http://online.wsj.com/article/SB10001424052748704471504574447350852232082.html
http://www.peterboroughtoday.co.uk/businesscomment/Steve-Hunt-Understanding-life-settlement.5755078.jp
I am one of the pieces of the life settlement puzzle as my firm provides the life expectancy calculations utilized by investors to price the individual life insurance policies. From this vantage point, I can say that there is little difference assessing the associated mortality of these individuals from our experience on the life insurance side-other than our goal in life settlement is to make as reasonable and realistic assessment as possible-on the life side underwriters tend to take a "worst case" approach and when in doubt debit the risk (lowering the life expectancy and increasing policy premiums) or declining the risk altogether. Some of the articles would lead people to believe that depending upon who pays for the life expectancy review affects the outcome of the life expectancy provided-this is absolutely not the case for our company. We utilize all of our experience as medical underwriters, all of the "tried and true" underwriting methodologies and tools, with a good dose of clinical and actuarial expertise to come as close to the estimation of a life expectancy on each individual we review. It is unreasonable to expect that our estimation is precise, which is why you will hear talk of the need for the "law of large numbers" or portfolios of thousands of individual life insurance policies to assist in the distribution of the risk. It is reasonable to expect that the company providing the life expectancies is making an unbiased review, that they are basing it on clearly defined methodologies that are transparent to the investor groups which may be purchasing the risk, and that any assumptions made on the status of an individuals health is on a "best case" scenario-which leads to a longer than average life expectancy vs. unreasonably shorter.
The focus from the life expectancy provider standpoint should be protecting the investors bottom line-hence the glaring difference from what happened in the sub-prime market where mortgage underwriters were making highly risky decisions and overlooking their most basic underwriting principles.
"Quote Du Jour" : "The purpose of life is to fight maturity" Dick Werthimer
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On one hand, the increased publicity for this asset class is a positive given the impact the economic crisis had on all financial markets-and specifically on baby boomers retirement plans, I just wish that I could say the actual information being written was A) True, and B) Positive. Neither is the case.
Most of the articles and blogs I have read utilize similar phrases, such as: death bonds, wall street scheme, betting on death, the second coming of sub-prime, etc. I did come across these recent articles that I felt provided a good representation of why someone would look to settle their policy and the associated benefits.
http://online.wsj.com/article/SB10001424052748704471504574447350852232082.html
http://www.peterboroughtoday.co.uk/businesscomment/Steve-Hunt-Understanding-life-settlement.5755078.jp
I am one of the pieces of the life settlement puzzle as my firm provides the life expectancy calculations utilized by investors to price the individual life insurance policies. From this vantage point, I can say that there is little difference assessing the associated mortality of these individuals from our experience on the life insurance side-other than our goal in life settlement is to make as reasonable and realistic assessment as possible-on the life side underwriters tend to take a "worst case" approach and when in doubt debit the risk (lowering the life expectancy and increasing policy premiums) or declining the risk altogether. Some of the articles would lead people to believe that depending upon who pays for the life expectancy review affects the outcome of the life expectancy provided-this is absolutely not the case for our company. We utilize all of our experience as medical underwriters, all of the "tried and true" underwriting methodologies and tools, with a good dose of clinical and actuarial expertise to come as close to the estimation of a life expectancy on each individual we review. It is unreasonable to expect that our estimation is precise, which is why you will hear talk of the need for the "law of large numbers" or portfolios of thousands of individual life insurance policies to assist in the distribution of the risk. It is reasonable to expect that the company providing the life expectancies is making an unbiased review, that they are basing it on clearly defined methodologies that are transparent to the investor groups which may be purchasing the risk, and that any assumptions made on the status of an individuals health is on a "best case" scenario-which leads to a longer than average life expectancy vs. unreasonably shorter.
The focus from the life expectancy provider standpoint should be protecting the investors bottom line-hence the glaring difference from what happened in the sub-prime market where mortgage underwriters were making highly risky decisions and overlooking their most basic underwriting principles.
"Quote Du Jour" : "The purpose of life is to fight maturity" Dick Werthimer
Come visit me at:
www.linkedin.com/in/tddavisaus
www.advanceduwsolutions.com
http://twitter.com/TraciDavisAUS
H1N1-The Senior Affect
A number of calls, and emails, have come across my desk questioning the risk of H1N1 in our senior population. Obviously, it's a key question in the life settlement realm as we only underwrite ages above 65, average age of 78. I have continued to monitor this in earnest thru daily news releases, CDC announcements, and friend/associates active in the health care industries.
As we stand today, the general consensus is that the seniors appear to be spared by the H1N1 virus. The Today Show's Dr. Nancy Schneiderman indicated in this mornings newscast that of the known cases, 93% of those are affecting those under the age of 26, and a very limited number of seniors are in the remaining 7%. She went on to say that those born prior to 1968 have been previously exposed to similar strains and as such are not being affected.
I also came across an article (www.cleveland.com) which noted the following;
[In today's Senior Health column, Dr. Jennifer Hanrahan, an infectious disease specialist for the MetroHealth System, explains why the elderly are not among those targeted for the H1N1 vaccine. "Seniors may have some residual immunity from exposure to a previous influenza strain in the '50s, she says. And, if you look at the hospitalizations and deaths, the proportion of those over age 60 is very small"]
This is the one time I am happy to say I am in the pre-1968 generation!
Underwriting "Term Du Jour" : BTSA : Better than stated age
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As we stand today, the general consensus is that the seniors appear to be spared by the H1N1 virus. The Today Show's Dr. Nancy Schneiderman indicated in this mornings newscast that of the known cases, 93% of those are affecting those under the age of 26, and a very limited number of seniors are in the remaining 7%. She went on to say that those born prior to 1968 have been previously exposed to similar strains and as such are not being affected.
I also came across an article (www.cleveland.com) which noted the following;
[In today's Senior Health column, Dr. Jennifer Hanrahan, an infectious disease specialist for the MetroHealth System, explains why the elderly are not among those targeted for the H1N1 vaccine. "Seniors may have some residual immunity from exposure to a previous influenza strain in the '50s, she says. And, if you look at the hospitalizations and deaths, the proportion of those over age 60 is very small"]
This is the one time I am happy to say I am in the pre-1968 generation!
Underwriting "Term Du Jour" : BTSA : Better than stated age
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Thursday, October 15, 2009
Governor Schwarzenegger-Life Settlement Legislation
On October 11 Governor Schwarzenegger signed into law a bill that will bring full regulation of life settlements to the State of California. Historically, California has been one of the most active states for viatical settlement transactions in cases of terminally or chronic illness. This act however has broadened the definition of "viatical" settlements to life settlements and has provided further definition of insurable interest.
In response to the signing of this bill, The Life Insurance Settlement Association (LISA)made the following comment: The signing of Senate Bill 98 brings the protections of law to an important and populous state and augments the regulation of settlements to include those persons who are not terminally ill. "We worked hard to ensure that this bill contained the right protections for consumers and ensured them the full access to this market that they deserve. Because this bill has the support of so many varied interested parties, it is an excellent model of good regulation for this growing and important consumer service," explained Russel Dorsett, LISA President.
(http://www.earthtimes.org/articles/show/the-life-insurance-settlement-association,995956.shtml)
Additional praise of the bill came from Coventry First, who made the following statement: "Significantly, the new law ensures that California`s citizens can pursue a life settlement with the assistance from their life insurance agent. With the passage of the legislation, life insurance companies are no longer allowed to gag life agents who would tell their clients about life settlements or otherwise act to
harm consumers in life settlement transactions".
(http://www.reuters.com/article/pressRelease/idUS157586+12-Oct-2009+BW20091012)
All in all, this was a "win" for the Life Settlement industry, and more importantly, for life insurance policy owners.
Quote of the Day: Nothing astonishes men so much as common sense and plain dealing.
Ralph Waldo Emerson (1803 - 1882)
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In response to the signing of this bill, The Life Insurance Settlement Association (LISA)made the following comment: The signing of Senate Bill 98 brings the protections of law to an important and populous state and augments the regulation of settlements to include those persons who are not terminally ill. "We worked hard to ensure that this bill contained the right protections for consumers and ensured them the full access to this market that they deserve. Because this bill has the support of so many varied interested parties, it is an excellent model of good regulation for this growing and important consumer service," explained Russel Dorsett, LISA President.
(http://www.earthtimes.org/articles/show/the-life-insurance-settlement-association,995956.shtml)
Additional praise of the bill came from Coventry First, who made the following statement: "Significantly, the new law ensures that California`s citizens can pursue a life settlement with the assistance from their life insurance agent. With the passage of the legislation, life insurance companies are no longer allowed to gag life agents who would tell their clients about life settlements or otherwise act to
harm consumers in life settlement transactions".
(http://www.reuters.com/article/pressRelease/idUS157586+12-Oct-2009+BW20091012)
All in all, this was a "win" for the Life Settlement industry, and more importantly, for life insurance policy owners.
Quote of the Day: Nothing astonishes men so much as common sense and plain dealing.
Ralph Waldo Emerson (1803 - 1882)
www.linkedin.com/in/tddavisaus
www.advanceduwsolutions.com
Monday, October 12, 2009
The Skinny on the Swine Flu
I spoke with a friend of mine who was dealing with his four year old who was not feeling up to par after having an H1N1 vaccination the other day. What he was describing made me recall when my eldest had his one, and only, flu vaccination as a small child-and had a couple of similar days of not feeling well. I refused to put him thru the vaccination again as it seemed silly to me to encourage illness in my young child whose body (I feel) was supremely equipped naturally to handle the common flu. However, this conversation spurred on my internet quest on what the current rate of swine flu cases have been, in comparison the typical flu season, and the efficacy of the vaccination. What I found was a lot of nothing! (unless you want to consider fear mongering - in that case there was a lot of that nonsense to be found)
Essentially, there are a number of "viral flu strains", the usual flu vaccination released each year is an "umbrella" vaccination that covers the majority of the known strains. The H1N1 is the one strain not typically covered under that umbrella. Annually, there are a reported 30-50 thousands deaths in the U.S. from the flu. The CDC warned recently that the H1N1 may "maim and kill 30,000 Americans" although they admit that typically the symptoms between the "normal flu" and swine flu are the same and unless specifically tested the cases will be mixed.
The special vaccination for H1N1 is currently being produced at high levels, pushing all the the standard flu vaccinations on the back burner (essentially covering only one strain of multiple flu strains....hmmmmm). Also, the H1N1 vaccination is untested, much is being manufactured differently than what has been testing in the past so it has not passed FDA requirements but is still being released because....well, I really could not cull this information out of the multiple articles and releases other than this is just where the focus is right now.
All of this leads me to wonder, since we will only be covered for mainly one strain of flu, vs. the multiple we are usually covered for, will we not have more deaths in general as the majority of the strains are being overlooked? Also, why on earth would the FDA allow wide release of an untested flu vaccination-with a focus on delivering it to our most delicate of humans (children and the elderly) - it's my humble opinion that these groups are not where you want to "test" an unproven vaccination and seems counter intuitive to the thought that they are the groups we want to most protect.
Am I the only one who sees some holes in the logic of the CDC, FDA, and health organizations pushing this vaccination? The visual of chasing a greased pig at the local fair comes to mind!
Underwriting "Term du Jour": PIG- pertussis immune globulin
www.linkedin.com/in/tddavisaus
www.advanceduwsolutions.com
Essentially, there are a number of "viral flu strains", the usual flu vaccination released each year is an "umbrella" vaccination that covers the majority of the known strains. The H1N1 is the one strain not typically covered under that umbrella. Annually, there are a reported 30-50 thousands deaths in the U.S. from the flu. The CDC warned recently that the H1N1 may "maim and kill 30,000 Americans" although they admit that typically the symptoms between the "normal flu" and swine flu are the same and unless specifically tested the cases will be mixed.
The special vaccination for H1N1 is currently being produced at high levels, pushing all the the standard flu vaccinations on the back burner (essentially covering only one strain of multiple flu strains....hmmmmm). Also, the H1N1 vaccination is untested, much is being manufactured differently than what has been testing in the past so it has not passed FDA requirements but is still being released because....well, I really could not cull this information out of the multiple articles and releases other than this is just where the focus is right now.
All of this leads me to wonder, since we will only be covered for mainly one strain of flu, vs. the multiple we are usually covered for, will we not have more deaths in general as the majority of the strains are being overlooked? Also, why on earth would the FDA allow wide release of an untested flu vaccination-with a focus on delivering it to our most delicate of humans (children and the elderly) - it's my humble opinion that these groups are not where you want to "test" an unproven vaccination and seems counter intuitive to the thought that they are the groups we want to most protect.
Am I the only one who sees some holes in the logic of the CDC, FDA, and health organizations pushing this vaccination? The visual of chasing a greased pig at the local fair comes to mind!
Underwriting "Term du Jour": PIG- pertussis immune globulin
www.linkedin.com/in/tddavisaus
www.advanceduwsolutions.com
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