airborne82_11b2p

"MR. Secretary, I am writing this to ask your help in a situation. In June I filed multiple claims, including Chronic Fatigue SYNDROME (closest thing on claims drop down) and joint/muscle pain. I also claimed sleep apnea and headaches increase (which were both resolved favorably). During exam VA Dr stated that sleep apnea was caused by exposure to toxins during gulf war. He also states in the same report that I have chronic fatigue and random joint/muscle pain which are undiagnosed illnesses and were at least as likely as not caused by the same exposure. These two were deferred. VRO apparently contacted va Dr and asked if I had been diagnosed with fibromyalgia and Chronic Fatigue SYNDROME, which of course he said I hadn't...... They are UNDIAGNOSED illnesses according to his expert opinion. VRO sent me denials for both Fibromyalgia (which I never claimed), and Chronic Fatigue SYNDROME. I have since filed a claim for undiagnosed illness (gulf war). I feel I have not been treated fairly in these cases and should not have had to refile when there was medical evidence in my file clearly stating that I have undiagnosed illnesses at least as likely as not related to exposure in gulf war where I served as an Airborne Infantryman with the 82nd Airborne. I'm not sure if I did the right thing or not, but I thought there is a duty of those looking at claims to consider all evidence. I still feel my start date for these claims should be June when I first filed. There are plenty of lay statements supporting these claims, as well as a VA Doctor advising they are undiagnosed illnesses as least as likely as not caused by exposures during the gulf war. " The next day I got a reply saying they were having leadership look into it. Today I got a call from someone at va with the ability to fix errors. He went through the issues and stated he was canceling out the denials and granting sc for both claimed undiagnosed illnesses. He also stated he was adjusting some granted issues claim dates as they had been entered later than they should have been. Bob is the man in my book......

I sent Bob an email on a Friday afternoon and got a response back from him in less than 5 hours. It wasn't about a specific problem. Those, I'm guessing require some time to look into to get to the facts?

I filed mid June and received 3 out of 5 issues resolved positively last week. Other two are deferred and have more exams scheduled.

I did end up with a 50% rating for sleep apnea with above c&p.

I think perhaps they used the self diagnosis of migraines to say it's a diagnosed illness, as such not presumptive. Maybe go to your Dr about the headaches and history. The key would be to show headache of an unknown etiology. For the presumptives you don't have to show direct connection to time in service. Do any of your current disabilities possibly contribute to the headaches? If so you could file them as secondary.

Call Bob!

The guy seems to be the real deal. I emailed him and got a personal response within 2 hours on a Friday evening.

You should be able to see the c&p on myhealthevet under blue button reports if you have the premier acct where your identity has been verified.

I would think this should be rated at 100% even if you are working. A lot depends on your employer and the people you work with and their understanding of your limitations from the sacrifices made in service. Hopefully you have an understanding employer. I think a lot of places miss the boat when it comes to vets with disabilities. Even though it requires some adjustments, imo you can't find a better employee than a vet. Keep fighting the fight brother, things have a way of working out.

I'm currently 70% went in for cp on chronic fatigue and increase for headaches. Any thoughts? VA Doc seams to make good case for sc sleep apnea as well? 1. Medical record review ------------------------ [X] Other, describe: VBMS, VVA, CPRS with remote 2. Medical history ------------------ a. No symptoms, abnormal findings or complaints: No answer provided b. Skin and scars: No answer provided c. Hematologic/lymphatic: No answer provided d. Eye: No answer provided e. Hearing loss, tinnitus and ear: Hearing Loss and Tinnitus f. Sinus, nose, throat, dental and oral: No answer provided g. Breast: No answer provided h. Respiratory: Sleep Apnea i. Cardiovascular: No answer provided j. Digestive and abdominal wall: No answer provided k. Kidney and urinary tract: No answer provided l. Reproductive: No answer provided m. Musculoskeletal: No answer provided n. Endocrine: No answer provided o. Neurologic: Headaches (including Migraine Headaches) p. Psychiatric: No answer provided q. Infectious disease, immune disorder or nutritional deficiency: No answer provided r. Miscellaneous conditions: No answer provided 3. Diagnosed illnesses with no etiology --------------------------------------- From the conditions identified and for which Questionnaires were completed, are there any diagnosed illnesses for which no etiology was established? [X] Yes [ ] No Diagnosis #1: Sleep Apnea, both obstructive and central ICD code: 327.23, 327.27 Date of diagnosis: 9/13/2014 Name of Questionnaire: sleep apnea Diagnosis #2: Headaches ICD code: 780.79 Date of diagnosis: 6/11/2014 Name of Questionnaire: Headaches - already submitted and entered into VBMS 6/17/2014 4. Additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness" ----------------------------------------------------------------------------- Does the Veteran report any additional signs and/or symptoms not addressed through completion of DBQs identified in the above sections? [X] Yes [ ] No If yes, check all that apply: Fatigue, Muscle pain, Joint pain For all checked signs and symptoms in this section, provide pertinent information related to each (e.g. frequency, duration, severity, precipitating/relieving factors, physical exam, studies): See Veteran's Statement in support of claim dated 6/11/2014 which describes his chronic fatigue. His muscle and joint pains are random, never the same joint, flare transiently for about 1-2 days on average about once/month. Other than these short flares, he has no complaints about his joints or muscles. All this has been flaring since 1991. The Veteran is a reliable historian he gave a similar history to the C&P Gulf War Protocol examiner in 2002. 5. Physical Exam ---------------- Normal PE, except as noted on additional Questionnaires included as part of this report 6. Functional impact of additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness" ----------------------------------------------------------------------------- [ ] Yes [X] No 7. Remarks, if any: ------------------- The Veteran had a Persian Gulf Protocol exam (in CPRS) Sep 4, 2002, which documents his fatigue. He wishes to clarify today that he's applying for an increase rating on his headaches. Since the Headache DBQ was filled out by his PCP and logged into VBMS on June 17, 2014, this examiner assumes no additional headache DBQ is necessary, and it was not requested by VARO. Further questionning reveals the Veteran does not have chronic fatigue SYNDROME, but does have chronic fatigue. In addition he's requesting service connection for sleep apnea and Tinnitus. Regarding Tinnitus, this will require an Audio C&P consultation and opinion regarding tinnitus, and these have been requested. **************************************************************************** Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: Indicate method used to obtain medical information to complete this document: [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file reviewed? No If no, check all records reviewed: [X] Military service treatment records [X] Veterans Health Administration medical records (VA treatment records) [X] Other: VBMS, VVA, CPRS with remote data MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Please provide a medical statement explaining whether the Veteran's disability pattern is: (1) an undiagnosed illness, (2) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, (3) a diagnosable chronic multisymptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis. If, after examining the Veteran and reviewing the claims file, you determine that the Veteran's disability pattern is either (3) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis, then please provide a medical opinion, with supporting rational, as to whether it is "at least as likely as not" that the disability pattern or diagnosed disease is related to a specific exposure event experienced by the Veteran during service in Southwest Asia. Note: Veteran has verified service in the Gulf War, 8/1/1990- 3/15/1991. Please see his statement, dated 6/17/2014 and labeled under correspodence, on VBMS. b. Indicate type of exam for which opinion has been requested: sleep apnea TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] a. The condition claimed was at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: There are no studies of which I am aware which correlate sleep apnea to Gulf War toxic chemicals, and sleep apnea generally is considered to be a condition in which loose, floppy tissues in the throat occlude the passage of air during the relaxation of sleep. This Veteran has a narrow posterior pharynx which is mildly and chronically inflamed as evidenced by the mild redness and swelling in his throat. The question is what's causing the swelling which causes the loose floppy tissues which in turn causes the sleep apnea? Toxic chemicals which possibly can cause the Veteran's symptoms are discussed on Form 21-2507 provided to this examiner. This Veteran's array of inflammatory ailments as likely as not have common origins in the metabolic dysfunctions which toxic chemicals can create. The Veteran's diagnosable but medically unexplained chronic multisymptom illnesses of partially-explained etiology are: Migraine Headaches and sleep apnea. Undiagnosed illnesses are: Fatigue, and random muscle/joint pains. It is at least as likely as not that these illnesses were caused by exposure to toxic chemicals during the Gulf War. Environmental toxins bind to proteins and are stored in fat and cause up-regulation of the immune system with inflammatory cytokines. Without detoxification, these toxic effects accumulate and can cause problems years after initial exposure, especially if patients are taking medication. The Veteran is taking Lexapro. My conclusions are biologically plausible based on the following explanation which is a brief outline describing several major biological responses to an element that the body perceives as toxic. Examples of toxic substances are burn pit smoke, formaldehyde in building materials, contaminated water, vaccines, drugs, food or drink containing toxic chemicals (for example, pesticides, artificial sweeteners, etc.). Illnesses usually develop gradually over many years. Up-regulation and depletion of mucosal protective secretory IgA (SIgA), is the first line of intestinal defense at the level of absorption sites. This leaves the absorption sites vulnerable to assault and commonly leads to a chronic condition called "leaky gut" (increased intestinal permeability). This cascade of events leads to depletion of intestinal bacteria crucial to the gut's ability to transport nutrients through the small intestine villi into the blood. (biochemistry reviewed in The Second Brain, by Michael Gershon, M.D.; other excellent references are "The Inside Tract", by Gerard Mullin, MD, "Clean Gut" by Alejandro Junger, "The Blood Sugar Solution", by Mark Hyman, MD, and "The Textbook of Functional Medicine", 2010) Chronic leaky gut leads to dysregulation of systemic immune globulins. As more toxins are allowed to enter the bloodstream, the immune system constantly must be "on guard". This constant catabolic influence up-regulates tissue damage at the same time the nutrient absorptive function is crippled by leaky gut. The tissue is not able to be repaired at the same rate it is broken down. Inflammatory conditions ensue. As toxins enter the liver through the portal vein, Phase 1 and Phase 2 liver detoxification functions are up-regulated and eventually depleted. This puts a toxic load upon the circulatory system. Replenishment of liver detoxification pathways depends upon optimum gut function and adequate, ingestion of sulfur-bearing foods and dark leafy greens to supply the crucial glutathione pathway. With compromised liver detoxification, the systemic immune globulins become chronically up-regulated creating auto-immune conditions. The chronic immune dysregulation which imposes a catabolic influence upon various tissues depletes adrenal cortisol and the adrenal production cannot keep up with the demand. The body's own anti-inflammatory process becomes inadequate. More and more of the body's cellular energy production is allocated to stabilizing the toxic degeneration. The adrenal glands produce more adrenalin in an attempt to derive energy from the muscles in order to meet the daily needs of the person. This excess adrenalin de-sensitizes the cellular insulin receptors and leads to insulin-resistance syndrome depriving the cells of optimum glucose transport. Blood glucose can increase and lead to diabetes and other inflammatory conditions, due to tissue glycation. The patient may rely more and more upon drugs in order just to "get by". This brief biochemical explanation explains the cascade of events that can progress from the toxic chemical exposure in the Persian Gulf to the veteran's current inflammatory conditions. This examiner understands that these conditions may not be listed as caused by exposure to toxic chemicals, but with continuing inflammation, the probability increases to develop more serious illnesses. This is why I've concluded that the veteran's conditions noted above at least as likely as not are related to Persian Gulf environmental toxins. This examiner has practiced medicine since 1969 and has postgraduate training in Functional Medicine and nutritional biochemistry SLEEP APNEA references http://www.gulfwarvets.com/cgi-bin/ultimatebb.cgi?ubb=print_topic;f=1;t=00017 7 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1061276/ http://usatoday30.usatoday.com/news/health/2010-06-07-apnea_N.htm?csp=34news http://www.national-toxic-encephalopathy-foundation.org/solvent.pdf http://www.huffingtonpost.com/2013/02/07/gulf-war-syndrome-veterans_n_2634838 .html http://donate.dav.org/site/PageServer?pagename=NewBilltoHelpTroopsExposedtoTo xicBurnPits ************************************************************************* **************************************************************************** Sleep Apnea Disability Benefits Questionnaire Name of patient/Veteran: Indicate method used to obtain medical information to complete this document: [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file reviewed? [ ] Yes [X] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: If no, check all records reviewed: [X] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [X] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [X] Other: VBMS, VVA, CPRS with remote data 1. Diagnosis ------------ Does the Veteran have or has he/she ever had sleep apnea? [X] Yes [ ] No [X] Mixed, components of both ICD code: 327.23, 327.27 Date of diagnosis: 8/6/2014 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's sleep disorder condition (brief summary): The Veteran complains of tiredness since service in Desert Storm. He wakes tired. If allowed, he could sleep 16 hours and wake tired. He snores for at least the last 15 years. His wife says he thrashes and swings his arms in sleep. His wife witnessed him not breathing in his sleep. He rarely consulted doctors in service. There is no record of sleep apnea related symptoms in the STR or records in the few years post service. Polysomnogram 8/6/2014 diagnosed moderate OSA with AHI of 16.3. CPAP Titration sleep study on 9/13/2014 diagnosed moderate complex obstructive and central sleep apnea. CPAP failed to correct the AHI/CAHI so he's completed an Adaptive Servo-Ventilation study on October 8, 2014. No report is available as of today. b. Is continuous medication required for control of a sleep disorder condition? [ ] Yes [X] No c. Does the veteran require the use of a breathing assistance device? [X] Yes [ ] No d. Does the Veteran require the use of a continuous positive airway pressure (CPAP) machine? [X] Yes [ ] No 3. Findings, signs and symptoms ------------------------------- Does the Veteran currently have any findings, signs or symptoms attributable to sleep apnea? [X] Yes [ ] No If yes, check all that apply: [X] Persistent daytime hypersomnolence 4. Other pertinent physical findings, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------------- a. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any conditions listed in the Diagnosis section above? [X] Yes [ ] No If yes, describe (brief summary): He has a narrow posterior pharynx and diffuse mild reddening of the mucus membranes indicating chronic non-specific inflammation. 5. Diagnostic testing --------------------- a. Has a sleep study been performed? [X] Yes [ ] No If yes, does the Veteran have documented sleep disorder breathing? [X] Yes [ ] No Date of sleep study: 8/6/2014 Facility where sleep study performed, if known: NeuroSleep Diagnostics Results: Moderate OSA with AHI 16.3. CPAP Titration report 9/13/2014 diagnosed moderate complex (obstructive and central) sleep apnea. b. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 6. Functional impact -------------------- Does the Veteran's sleep apnea impact his or her ability to work? [ ] Yes [X] No 7. Remarks, if any: ------------------- No remarks provided. /es/ Physician Signed: 10/21/2014 14:14 ------------------------------------------------------------------------- -------------------- DoD Military Service Information ------------------- Source: DoD No information was available that matched your selection. ----------- END OF MY HEALTHEVET PERSONAL INFORMATION REPORT ----------

Just had c&p for pgw issues. I have not read this particular take on sleep apnea? Opinions? It appears VA Dr says at least as likely as not for sleep apnea, chronic fatigue, joint and muscle pain. 1. Medical record review ------------------------ [X] Other, describe: VBMS, VVA, CPRS with remote 2. Medical history ------------------ a. No symptoms, abnormal findings or complaints: No answer provided b. Skin and scars: No answer provided c. Hematologic/lymphatic: No answer provided d. Eye: No answer provided e. Hearing loss, tinnitus and ear: Hearing Loss and Tinnitus f. Sinus, nose, throat, dental and oral: No answer provided g. Breast: No answer provided h. Respiratory: Sleep Apnea i. Cardiovascular: No answer provided j. Digestive and abdominal wall: No answer provided k. Kidney and urinary tract: No answer provided l. Reproductive: No answer provided m. Musculoskeletal: No answer provided n. Endocrine: No answer provided o. Neurologic: Headaches (including Migraine Headaches) p. Psychiatric: No answer provided q. Infectious disease, immune disorder or nutritional deficiency: No answer provided r. Miscellaneous conditions: No answer provided 3. Diagnosed illnesses with no etiology --------------------------------------- From the conditions identified and for which Questionnaires were completed, are there any diagnosed illnesses for which no etiology was established? [X] Yes [ ] No Diagnosis #1: Sleep Apnea, both obstructive and central ICD code: 327.23, 327.27 Date of diagnosis: 9/13/2014 Name of Questionnaire: sleep apnea Diagnosis #2: Headaches ICD code: 780.79 Date of diagnosis: 6/11/2014 Name of Questionnaire: Headaches - already submitted and entered into VBMS 6/17/2014 4. Additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness" ----------------------------------------------------------------------------- Does the Veteran report any additional signs and/or symptoms not addressed through completion of DBQs identified in the above sections? [X] Yes [ ] No If yes, check all that apply: Fatigue, Muscle pain, Joint pain For all checked signs and symptoms in this section, provide pertinent information related to each (e.g. frequency, duration, severity, precipitating/relieving factors, physical exam, studies): See Veteran's Statement in support of claim dated 6/11/2014 which describes his chronic fatigue. His muscle and joint pains are random, never the same joint, flare transiently for about 1-2 days on average about once/month. Other than these short flares, he has no complaints about his joints or muscles. All this has been flaring since 1991. The Veteran is a reliable historian he gave a similar history to the C&P Gulf War Protocol examiner in 2002. 5. Physical Exam ---------------- Normal PE, except as noted on additional Questionnaires included as part of this report 6. Functional impact of additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness" ----------------------------------------------------------------------------- [ ] Yes [X] No 7. Remarks, if any: ------------------- The Veteran had a Persian Gulf Protocol exam (in CPRS) Sep 4, 2002, which documents his fatigue. He wishes to clarify today that he's applying for an increase rating on his headaches. Since the Headache DBQ was filled out by his PCP and logged into VBMS on June 17, 2014, this examiner assumes no additional headache DBQ is necessary, and it was not requested by VARO. Further questionning reveals the Veteran does not have chronic fatigue SYNDROME, but does have chronic fatigue. In addition he's requesting service connection for sleep apnea and Tinnitus. Regarding Tinnitus, this will require an Audio C&P consultation and opinion regarding tinnitus, and these have been requested. **************************************************************************** Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: Indicate method used to obtain medical information to complete this document: [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file reviewed? No If no, check all records reviewed: [X] Military service treatment records [X] Veterans Health Administration medical records (VA treatment records) [X] Other: VBMS, VVA, CPRS with remote data MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Please provide a medical statement explaining whether the Veteran's disability pattern is: (1) an undiagnosed illness, (2) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, (3) a diagnosable chronic multisymptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis. If, after examining the Veteran and reviewing the claims file, you determine that the Veteran's disability pattern is either (3) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis, then please provide a medical opinion, with supporting rational, as to whether it is "at least as likely as not" that the disability pattern or diagnosed disease is related to a specific exposure event experienced by the Veteran during service in Southwest Asia. Note: Veteran has verified service in the Gulf War, 8/1/1990- 3/15/1991. Please see his statement, dated 6/17/2014 and labeled under correspodence, on VBMS. b. Indicate type of exam for which opinion has been requested: sleep apnea TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] a. The condition claimed was at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: There are no studies of which I am aware which correlate sleep apnea to Gulf War toxic chemicals, and sleep apnea generally is considered to be a condition in which loose, floppy tissues in the throat occlude the passage of air during the relaxation of sleep. This Veteran has a narrow posterior pharynx which is mildly and chronically inflamed as evidenced by the mild redness and swelling in his throat. The question is what's causing the swelling which causes the loose floppy tissues which in turn causes the sleep apnea? Toxic chemicals which possibly can cause the Veteran's symptoms are discussed on Form 21-2507 provided to this examiner. This Veteran's array of inflammatory ailments as likely as not have common origins in the metabolic dysfunctions which toxic chemicals can create. The Veteran's diagnosable but medically unexplained chronic multisymptom illnesses of partially-explained etiology are: Migraine Headaches and sleep apnea. Undiagnosed illnesses are: Fatigue, and random muscle/joint pains. It is at least as likely as not that these illnesses were caused by exposure to toxic chemicals during the Gulf War. Environmental toxins bind to proteins and are stored in fat and cause up-regulation of the immune system with inflammatory cytokines. Without detoxification, these toxic effects accumulate and can cause problems years after initial exposure, especially if patients are taking medication. The Veteran is taking Lexapro. My conclusions are biologically plausible based on the following explanation which is a brief outline describing several major biological responses to an element that the body perceives as toxic. Examples of toxic substances are burn pit smoke, formaldehyde in building materials, contaminated water, vaccines, drugs, food or drink containing toxic chemicals (for example, pesticides, artificial sweeteners, etc.). Illnesses usually develop gradually over many years. Up-regulation and depletion of mucosal protective secretory IgA (SIgA), is the first line of intestinal defense at the level of absorption sites. This leaves the absorption sites vulnerable to assault and commonly leads to a chronic condition called "leaky gut" (increased intestinal permeability). This cascade of events leads to depletion of intestinal bacteria crucial to the gut's ability to transport nutrients through the small intestine villi into the blood. (biochemistry reviewed in The Second Brain, by Michael Gershon, M.D.; other excellent references are "The Inside Tract", by Gerard Mullin, MD, "Clean Gut" by Alejandro Junger, "The Blood Sugar Solution", by Mark Hyman, MD, and "The Textbook of Functional Medicine", 2010) Chronic leaky gut leads to dysregulation of systemic immune globulins. As more toxins are allowed to enter the bloodstream, the immune system constantly must be "on guard". This constant catabolic influence up-regulates tissue damage at the same time the nutrient absorptive function is crippled by leaky gut. The tissue is not able to be repaired at the same rate it is broken down. Inflammatory conditions ensue. As toxins enter the liver through the portal vein, Phase 1 and Phase 2 liver detoxification functions are up-regulated and eventually depleted. This puts a toxic load upon the circulatory system. Replenishment of liver detoxification pathways depends upon optimum gut function and adequate, ingestion of sulfur-bearing foods and dark leafy greens to supply the crucial glutathione pathway. With compromised liver detoxification, the systemic immune globulins become chronically up-regulated creating auto-immune conditions. The chronic immune dysregulation which imposes a catabolic influence upon various tissues depletes adrenal cortisol and the adrenal production cannot keep up with the demand. The body's own anti-inflammatory process becomes inadequate. More and more of the body's cellular energy production is allocated to stabilizing the toxic degeneration. The adrenal glands produce more adrenalin in an attempt to derive energy from the muscles in order to meet the daily needs of the person. This excess adrenalin de-sensitizes the cellular insulin receptors and leads to insulin-resistance syndrome depriving the cells of optimum glucose transport. Blood glucose can increase and lead to diabetes and other inflammatory conditions, due to tissue glycation. The patient may rely more and more upon drugs in order just to "get by". This brief biochemical explanation explains the cascade of events that can progress from the toxic chemical exposure in the Persian Gulf to the veteran's current inflammatory conditions. This examiner understands that these conditions may not be listed as caused by exposure to toxic chemicals, but with continuing inflammation, the probability increases to develop more serious illnesses. This is why I've concluded that the veteran's conditions noted above at least as likely as not are related to Persian Gulf environmental toxins. This examiner has practiced medicine since 1969 and has postgraduate training in Functional Medicine and nutritional biochemistry SLEEP APNEA references http://www.gulfwarvets.com/cgi-bin/ultimatebb.cgi?ubb=print_topic;f=1;t=00017 7 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1061276/ http://usatoday30.usatoday.com/news/health/2010-06-07-apnea_N.htm?csp=34news http://www.national-toxic-encephalopathy-foundation.org/solvent.pdf http://www.huffingtonpost.com/2013/02/07/gulf-war-syndrome-veterans_n_2634838 .html http://donate.dav.org/site/PageServer?pagename=NewBilltoHelpTroopsExposedtoTo xicBurnPits ************************************************************************* **************************************************************************** Sleep Apnea Disability Benefits Questionnaire Name of patient/Veteran: Indicate method used to obtain medical information to complete this document: [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file reviewed? [ ] Yes [X] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: If no, check all records reviewed: [X] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [X] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [X] Other: VBMS, VVA, CPRS with remote data 1. Diagnosis ------------ Does the Veteran have or has he/she ever had sleep apnea? [X] Yes [ ] No [X] Mixed, components of both ICD code: 327.23, 327.27 Date of diagnosis: 8/6/2014 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's sleep disorder condition (brief summary): The Veteran complains of tiredness since service in Desert Storm. He wakes tired. If allowed, he could sleep 16 hours and wake tired. He snores for at least the last 15 years. His wife says he thrashes and swings his arms in sleep. His wife witnessed him not breathing in his sleep. He rarely consulted doctors in service. There is no record of sleep apnea related symptoms in the STR or records in the few years post service. Polysomnogram 8/6/2014 diagnosed moderate OSA with AHI of 16.3. CPAP Titration sleep study on 9/13/2014 diagnosed moderate complex obstructive and central sleep apnea. CPAP failed to correct the AHI/CAHI so he's completed an Adaptive Servo-Ventilation study on October 8, 2014. No report is available as of today. b. Is continuous medication required for control of a sleep disorder condition? [ ] Yes [X] No c. Does the veteran require the use of a breathing assistance device? [X] Yes [ ] No d. Does the Veteran require the use of a continuous positive airway pressure (CPAP) machine? [X] Yes [ ] No 3. Findings, signs and symptoms ------------------------------- Does the Veteran currently have any findings, signs or symptoms attributable to sleep apnea? [X] Yes [ ] No If yes, check all that apply: [X] Persistent daytime hypersomnolence 4. Other pertinent physical findings, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------------- a. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any conditions listed in the Diagnosis section above? [X] Yes [ ] No If yes, describe (brief summary): He has a narrow posterior pharynx and diffuse mild reddening of the mucus membranes indicating chronic non-specific inflammation. 5. Diagnostic testing --------------------- a. Has a sleep study been performed? [X] Yes [ ] No If yes, does the Veteran have documented sleep disorder breathing? [X] Yes [ ] No Date of sleep study: 8/6/2014 Facility where sleep study performed, if known: NeuroSleep Results: Moderate OSA with AHI 16.3. CPAP Titration report 9/13/2014 diagnosed moderate complex (obstructive and central) sleep apnea. b. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 6. Functional impact -------------------- Does the Veteran's sleep apnea impact his or her ability to work? [ ] Yes [X] No 7. Remarks, if any: ------------------- No remarks provided. Physician ------------------------------------------------------------------------- -------------------- DoD Military Service Information ------------------- Source: DoD No information was available that matched your selection. ----------- END OF MY HEALTHEVET PERSONAL INFORMATION REPORT ----------