allan

Congratulations Belle. Hope you r recovery is a quick one. Take it easy & give it time to heal.

National Security & Veterans Affairs http://www.census.gov/compendia/statab/cat...ns_affairs.html

You can help by making sure you have contacted all health care providers you've had in the past & get copies of your medical records, "before" your C&P exams are ordered. If you have lung issues, you will need to see a respiratory specialist. If you have spinal issues, you'll need to see an orthopedic specialist. Thats the way it should work. They had a nurse do all of my C&P general medical exams including neuromuscular disorder. She didn't even look at my xrays or lab results & couldn't figure out how to write an opinion. So another C&P was ordered. When this came back fully favorable, the VARO rater ordered an IMO without examination & of course this wasn't favorable. When I had my family Dr look over my C-file & give an opinion, the VARO & BVA completely ignored it. Don't wait for the VA. Get all your past medical records together & sift through them for anything that will help your claim. If it's not in your c-file "before" the VARO orders your C&P, then it won't be a part of the record & considered by the C&P examiner.

Quicker Social Security Disability Claims for some severe illnesses See list of illnesses’ http://www.socialsecurity.gov/compassionat.../conditions.htm http://www.socialsecurity.gov/compassionateallowances/ Compassionate Allowances Social Security has an obligation to provide benefits quickly to applicants whose medical conditions are so serious that their conditions obviously meet disability standards. Compassionate allowances are a way of quickly identifying diseases and other medical conditions that invariably qualify under the Listing of Impairments based on minimal objective medical information. Compassionate allowances allow Social Security to quickly target the most obviously disabled individuals for allowances based on objective medical information that we can obtain quickly. Commissioner Astrue has held three Compassionate Allowance public outreach hearings. The hearings were on rare diseases, cancers, and traumatic brain injury (TBI) and stroke. The Commissioner will hold the fourth public outreach hearing in Chicago on July 29, 2009. The subject of the hearing is Early-Onset Alzheimer’s Disease and Related Dementias. The initial list of Compassionate Allowance conditions was developed as a result of information received at public outreach hearings, public comment on an Advance Notice of Proposed Rulemaking, comments received from the Social Security and Disability Determination Service communities, and the counsel of medical and scientific experts. Also, we considered which conditions are most likely to meet our current definition of disability. A modest 50 conditions were selected for the initiative's rollout. The list which follows will expand over time. Initial List of Compassionate Allowance Conditions Additional information about how compassionate allowances are processed Quick disability info https://secure.ssa.gov/apps10/poms.nsf/lnx/0423022010 "Keep on, Keepin' on" Dan Cedusky, Champaign IL "Colonel Dan" See my web site at: http://www.angelfire.com/il2/VeteranIssues/

JP-4: Long term exposure & toxic health effects http://www.intox.org/databank/documents/ch...fuel/cie776.htm

Public Information - Fact Sheets Fuels and Your Health A fact sheet by Cal/EPA's Office of Environmental Health Hazard Assessment and the American Lung Association http://www.oehha.ca.gov/public_info/facts/fuelstoi.html

Permissible Exposure Levels for Selected Military Fuel Vapors SUBCOMMITTEE ON PERMISSIBLE EXPOSURE LEVELS FOR MILITARY FUELS COMMITTEE ON TOXICOLOGY BOARD ON ENVIRONMENTAL STUDIES AND TOXICOLOGY COMMISSION ON LIFE SCIENCES NATIONAL RESEARCH COUNCIL NATIONAL ACADEMY PRESS WASHINGTON, D.C., 1996 http://www.nap.edu/openbook.php?isbn=NI000048

CONTENTS -------------------------------------------------------------------------------- September 1997 Public Health Statement for Benzene CAS# 71-43-2 -------------------------------------------------------------------------------- This Public Health Statement is the summary chapter from the Toxicological Profile for benzene. It is one in a series of Public Health Statements about hazardous substances and their health effects. A shorter version, the ToxFAQs™, is also available. This information is important because this substance may harm you. The effects of exposure to any hazardous substance depend on the dose, the duration, how you are exposed, personal traits and habits, and whether other chemicals are present. For more information, call the ATSDR Information Center at 1-888-422-8737. -------------------------------------------------------------------------------- This public health statement tells you about benzene and the effects of exposure. The Environmental Protection Agency (EPA) identifies the most serious hazardous waste sites in the nation. These sites make up the National Priorities List (NPL) and are the sites targeted for long-term federal cleanup. Benzene has been found in at least 816 of the 1,428 current or former NPL sites. However, it's unknown how many NPL sites have been evaluated for this substance. As more sites are evaluated, the sites with benzene may increase. This information is important because exposure to this substance may harm you and because these sites may be sources of exposure. When a substance is released from a large area, such as an industrial plant, or from a container, such as a drum or bottle, it enters the environment. This release does not always lead to exposure. You are exposed to a substance only when you come in contact with it. You may be exposed by breathing, eating, or drinking the substance or by skin contact. If you are exposed to benzene, many factors determine whether you'll be harmed. These factors include the dose (how much), the duration (how long), and how you come in contact with it. You must also consider the other chemicals you're exposed to and your age, sex, diet, family traits, lifestyle, and state of health. 1.1 What is benzene? Benzene, also known as benzol, is a colorless liquid with a sweet odor. Benzene evaporates into air very quickly and dissolves slightly in water. Benzene is highly flammable. Most people can begin to smell benzene in air at 1.5–4.7 parts of benzene per million parts of air (ppm) and smell benzene in water at 2 ppm. Most people can begin to taste benzene in water at 0.5–4.5 ppm. Benzene is found in air, water, and soil. Benzene found in the environment is from both human activities and natural processes. Benzene was first discovered and isolated from coal tar in the 1800s. Today, benzene is made mostly from petroleum sources. Because of its wide use, benzene ranks in the top 20 in production volume for chemicals produced in the United States. Various industries use benzene to make other chemicals, such as styrene (for Styrofoam® and other plastics), cumene (for various resins), and cyclohexane (for nylon and synthetic fibers). Benzene is also used for the manufacturing of some types of rubbers, lubricants, dyes, detergents, drugs, and pesticides. Natural sources of benzene, which include volcanoes and forest fires, also contribute to the presence of benzene in the environment. Benzene is also a natural part of crude oil and gasoline and cigarette smoke. back to top -------------------------------------------------------------------------------- 1.2 How might I be exposed to benzene? Benzene is commonly found in the environment. Industrial processes are the main sources of benzene in the environment. Benzene levels in the air can increase from emissions from burning coal and oil, benzene waste and storage operations, motor vehicle exhaust, and evaporation from gasoline service stations. Since tobacco contains high levels of benzene, tobacco smoke is another source of benzene in air. Industrial discharge, disposal of products containing benzene, and gasoline leaks from underground storage tanks can release benzene into water and soil. Benzene can pass into air from water and soil surfaces. Once in the air, benzene reacts with other chemicals and breaks down within a few days. Benzene in the air can attach to rain or snow and be carried back down to the ground. Benzene in water and soil breaks down more slowly. Benzene is slightly soluble in water and can pass through the soil into underground water. Benzene in the environment does not build up in plants or animals. back to top -------------------------------------------------------------------------------- 1.3 How can benzene enter and leave my body? Most people are exposed to a small amount of benzene on a daily basis. You can be exposed to benzene in the outdoor environment, in the workplace, and in the home. Exposure of the general population to benzene is mainly through breathing air that contains benzene. The major sources of benzene exposure are tobacco smoke, automobile service stations, exhaust from motor vehicles, and industrial emissions. Vapors (or gases) from products that contain benzene, such as glues, paints, furniture wax, and detergents can also be a source of exposure. Auto exhaust and industrial emissions account for about 20% of the total nationwide exposure to benzene. About 50% of the entire nationwide exposure to benzene results from smoking tobacco or from exposure to tobacco smoke. The average smoker (32 cigarettes per day) takes in about 1.8 milligrams (mg) of benzene per day. This is about 10 times the average daily intake of nonsmokers. Measured levels of benzene in outdoor air have ranged from 0.02 to 34 parts of benzene per billion parts of air (ppb) (1 ppb is 1,000 times less than 1 ppm). People living in cities or industrial areas are generally exposed to higher levels of benzene in air than those living in rural areas. Benzene levels in the home are usually higher than outdoor levels. People living around hazardous waste sites, petroleum refining operations, petrochemical manufacturing sites, or gas stations may be exposed to higher levels of benzene in air. For most people, the level of exposure to benzene through food, beverages, or drinking water is not as high as through air. Typical drinking water contains less than 0.1 ppb benzene. Benzene has been detected in some bottled water, liquor, and food. Leakage from underground gasoline storage tanks or from landfills and hazardous waste sites containing benzene can result in benzene contamination of well water. People with benzene-contaminated tap water can be exposed from drinking the water or eating foods prepared with the water. In addition, exposure can result from breathing in benzene while showering, bathing, or cooking with contaminated water. Individuals employed in industries that make or use benzene may be exposed to the highest levels of benzene. As many as 238,000 people may be occupationally exposed to benzene in the United States. These industries include benzene production (petrochemicals, petroleum refining, and coke and coal chemical manufacturing), rubber tire manufacturing, and storage or transport of benzene and petroleum products containing benzene. Other workers who may be exposed to benzene because of their occupations include steel workers, printers, rubber workers, shoe makers, laboratory technicians, firefighters, and gas station employees. back to top -------------------------------------------------------------------------------- 1.4 How can benzene affect my health? Benzene can enter your body through your lungs when you breathe contaminated air. It can also enter through your stomach and intestines when you eat food or drink water that contains benzene. Benzene can enter your body through skin contact with benzene-containing products such as gasoline. When you are exposed to high levels of benzene in air, about half of the benzene you breathe in leaves your body when you breathe out. The other half passes through the lining of your lungs and enters your bloodstream. Animal studies show that benzene taken in by eating or drinking contaminated foods behaves similarly in the body to benzene that enters through the lungs. A small amount will enter your body by passing through your skin and into your bloodstream during skin contact with benzene or benzene-containing products. Once in the bloodstream, benzene travels throughout your body and can be temporarily stored in the bone marrow and fat. Benzene is converted to products, called metabolites, in the liver and bone marrow. Some of the harmful effects of benzene exposure are believed to be caused by these metabolites. Most of the metabolites of benzene leave the body in the urine within 48 hours after exposure. back to top -------------------------------------------------------------------------------- 1.5 What levels of exposure have resulted in harmful health effects? To protect the public from the harmful effects of toxic chemicals and to find ways to treat people who have been harmed, scientists use many tests. One way to see if a chemical will hurt people is to learn how the chemical is absorbed, used, and released by the body; for some chemicals, animal testing may be necessary. Animal testing may also be used to identify health effects such as cancer or birth defects. Without laboratory animals, scientists would lose a basic method to get information needed to make wise decisions to protect public health. Scientists have the responsibility to treat research animals with care and compassion. Laws today protect the welfare of research animals, and scientists must comply with strict animal care guidelines. After exposure to benzene, several factors determine whether harmful health effects will occur and if they do, what the type and severity of these health effects might be. These factors include the amount of benzene to which you are exposed and the length of time of the exposure. Most data involving effects of long-term exposure to benzene are from studies of workers employed in industries that make or use benzene. These workers were exposed to levels of benzene in air far greater than the levels normally encountered by the general population. Current levels of benzene in workplace air are much lower than in the past. Because of this reduction, and the availability of protective equipment such as respirators, fewer workers have symptoms of benzene poisoning. Brief exposure (5–10 minutes) to very high levels of benzene in air (10,000–20,000 ppm) can result in death. Lower levels (700–3,000 ppm) can cause drowsiness, dizziness, rapid heart rate, headaches, tremors, confusion, and unconsciousness. In most cases, people will stop feeling these effects when they stop being exposed and begin to breathe fresh air. Eating foods or drinking liquids containing high levels of benzene can cause vomiting, irritation of the stomach, dizziness, sleepiness, convulsions, rapid heart rate, coma, and death. The health effects that may result from eating foods or drinking liquids containing lower levels of benzene are not known. If you spill benzene on your skin, it may cause redness and sores. Benzene in your eyes may cause general irritation and damage to your cornea. Benzene causes problems in the blood. People who breathe benzene for long periods may experience harmful effects in the tissues that form blood cells, especially the bone marrow. These effects can disrupt normal blood production and cause a decrease in important blood components. A decrease in red blood cells can lead to anemia. Reduction in other components in the blood can cause excessive bleeding. Blood production may return to normal after exposure to benzene stops. Excessive exposure to benzene can be harmful to the immune system, increasing the chance for infection and perhaps lowering the body's defense against cancer. Benzene can cause cancer of the blood-forming organs. The Department of Health and Human Services (DHHS) has determined that benzene is a known carcinogen. The International Agency for Cancer Research (IARC) has determined that benzene is carcinogenic to humans, and the EPA has determined that benzene is a human carcinogen. Long-term exposure to relatively high levels of benzene in the air can cause cancer of the blood-forming organs. This condition is called leukemia. Exposure to benzene has been associated with development of a particular type of leukemia called acute myeloid leukemia (AML). Exposure to benzene may be harmful to the reproductive organs. Some women workers who breathed high levels of benzene for many months had irregular menstrual periods. When examined, these women showed a decrease in the size of their ovaries. However, exact exposure levels were unknown, and the studies of these women did not prove that benzene caused these effects. It is not known what effects exposure to benzene might have on the developing fetus in pregnant women or on fertility in men. Studies with pregnant animals show that breathing benzene has harmful effects on the developing fetus. These effects include low birth weight, delayed bone formation, and bone marrow damage. The health effects that might occur in humans following long-term exposure to food and water contaminated with benzene are not known. In animals, exposure to food or water contaminated with benzene can damage the blood and the immune system and can even cause cancer. back to top -------------------------------------------------------------------------------- 1.6 Is there a medical test to determine whether I have been exposed to benzene? Several tests can show if you have been exposed to benzene. Some of these tests may be available at your doctor's office. All of these tests are limited in what they can tell you. The test for measuring benzene in your breath must be done shortly after exposure. This test is not very helpful for detecting very low levels of benzene in your body. Benzene can be measured in your blood. However, since benzene disappears rapidly from the blood, measurements may be accurate only for recent exposures. In the body, benzene is converted to products called metabolites. Certain metabolites of benzene, such as phenol, muconic acid, and S-phenyl-N-acetyl cysteine (PhAC) can be measured in the urine. The amount of phenol in urine has been used to check for benzene exposure in workers. The test is useful only when you are exposed to benzene in air at levels of 10 ppm or greater. However, this test must also be done shortly after exposure, and it is not a reliable indicator of how much benzene you have been exposed to, since phenol is present in the urine from other sources (diet, environment). Measurement of muconic acid or PhAC in the urine is a more sensitive and reliable indicator of benzene exposure. The measurement of benzene in blood or of metabolites in urine cannot be used for making predictions about whether you will experience any harmful health effects. Measurement of all parts of the blood and measurement of bone marrow are used to find benzene exposure and its health effects. For people exposed to relatively high levels of benzene, complete blood analyses can be used to monitor possible changes related to exposure. However, blood analyses are not useful when exposure levels are low. back to top -------------------------------------------------------------------------------- 1.7 What recommendations has the federal government made to protect human health? The federal government develops regulations and recommendations to protect public health. Regulations can be enforced by law. Federal agencies that develop regulations for toxic substances include the Environmental Protection Agency (EPA), the Occupational Safety and Health Administration (OSHA), and the Food and Drug Administration (FDA). Recommendations provide valuable guidelines to protect public health but cannot be enforced by law. Federal organizations that develop recommendations for toxic substances include the Agency for Toxic Substances and Disease Registry (ATSDR) and the National Institute for Occupational Safety and Health (NIOSH). Regulations and recommendations can be expressed in not-to-exceed levels in air, water, soil, or food that are usually based on levels that affect animals, then they are adjusted to help protect people. Sometimes these not-to-exceed levels differ among federal organizations because of different exposure times (an 8-hour workday or a 24-hour day), the use of different animal studies, or other factors. Recommendations and regulations are also periodically updated as more information becomes available. For the most current information, check with the federal agency or organization that provides it. Some regulations and recommendations for benzene include the following: EPA has set the maximum permissible level of benzene in drinking water at 5 parts per billion (ppb). Because benzene can cause leukemia, EPA has set a goal of 0 ppb for benzene in drinking water and in water such as rivers and lakes. EPA estimates that 10 ppb benzene in drinking water that is consumed regularly or exposure to 0.4 ppb benzene in air over a lifetime could cause a risk of one additional cancer case for every 100,000 exposed persons. EPA recommends a maximum permissible level of benzene in water of 200 ppb for short-term exposures (10 days) for children. EPA requires that the National Response Center be notified following a discharge or spill into the environment of 10 pounds or more of benzene. The Occupational Safety and Health Administration (OSHA) regulates levels of benzene in the workplace. The maximum allowable amount of benzene in workroom air during an 8-hour workday, 40-hour workweek is 1 part per million (ppm). Since benzene can cause cancer, the National Institute for Occupational Safety and Health (NIOSH) recommends that all workers likely to be exposed to benzene wear special breathing equipment. back to top -------------------------------------------------------------------------------- 1.8 Where can I get more information? If you have any more questions or concerns, please contact your community or state health or environmental quality department or: Agency for Toxic Substances and Disease Registry Division of Toxicology 1600 Clifton Road NE, Mailstop E-29 Atlanta, GA 30333 Information line and technical assistance: Phone: 888-422-8737 FAX: (404)498-0093 ATSDR can also tell you the location of occupational and environmental health clinics. These clinics specialize in recognizing, evaluating, and treating illnesses resulting from exposure to hazardous substances. To order toxicological profiles, contact: National Technical Information Service 5285 Port Royal Road Springfield, VA 22161 Phone: 800-553-6847 or 703-605-6000 back to top -------------------------------------------------------------------------------- References Agency for Toxic Substances and Disease Registry (ATSDR). 1997. Toxicological profile for benzene. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service. back to top -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- ATSDR Information Center / ATSDRIC@cdc.gov / 1-888-422-8737 This page was updated on Tuesday, September 16, 2003 -------------------------------------------------------------------------------- ATSDR Home | Search | Index | Glossary | Contact Us About ATSDR | News Archive | ToxFAQs | HazDat | Public Health Assessments Privacy Policy | External Links Disclaimer | Accessibility U.S. Department of Health and Human Services

What you need to ask for is a Heavy Metals Test. Don't just ask for lead. A heavy metals test is a blood test & shouldn't be that hard to get one. Atleast it wasn't for me. I simply asked for it. If your PCP denies your request, try going through your Social Worker at the VAMC to see if they can help. Explain that you were a fuel handler & have current health problems relating to it. Nerve damage, etc. Also, Benzene in fuels causes alot of damage.

VA Using Digital Imaging System To Enhance EHRs. In its May 2009 issue, FedTech magazine (7/28, Schwartz) says some US government healthcare facilities, including those run by the Veterans Affairs Department, "rely on networked digital imaging systems that let doctors and other health services providers across the country or the world consult on a patient's diagnosis while looking at the same images - be they X-rays, MRIs or CT Scans. These picture archiving and communications systems (PACS) can give radiologists, emergency room doctors, specialists and family health professionals access to patient images, no matter the location." And at the VA in particular, "PACS has allowed" a "sweeping consolidation. Clinicians at all 140 medical centers use a VA-developed PACS called VistA Imaging that handles images from all specialties. VistA Imaging is fully integrated with the Veterans Health Information Systems and Technology Architecture (VistA), an enterprisewide information network that provides a comprehensive electronic health record," or EHR, "for each patient in the medical system." Because the VA's PACS "is part of VistA, 'the system captures clinical images as well as scanned documents, video and other nontextual data files, making them part of the patient's'" EHR, "says Dr. Ruth E. Dayhoff, VistA Imaging director for the Veterans Health Administration. VistA Imaging integrates all images and reports with each patient's" EHR, Dayhoff "says, making that information accessible to clinicians nationwide." http://www.fedtechmagazine.com/print_frien...asp?item_id=569 http://www.veteranstoday.com/article8124.html

Agent Orange presumptions why the delay??? Posted on July 28, 2009 by stimeling The Institute of Medicine (IOM) announced Friday,July 24th, there is a possible connection between exposure to Agent Orange and both Parkinson's Disease and Ischemic Heart Disease. In a similar report issued in 2006, the IOM determined a connection between Agent Orange exposure and Hypertension. The VA has yet to acknowledge this link and make Hypertension a presumptive illness. The Institute of Medicine (IOM) announced Friday there is a possible connection between exposure to Agent Orange and both Parkinson's Disease and Ischemic Heart Disease. In a similar report issued in 2006, the IOM determined a similar connection between Agent Orange exposure and Hypertension. The VA has yet to acknowledge this link and make Hypertension a presumptive illness.As a presumptive illness, all the veteran who suffers from the condition needs to do is establish he served in Vietnam between 1962 and 1975. There are other areas where Agent Orange was used where the presumptive illness rules apply Korea near the DMZ is one.Since the IOM has established at least an increase in occurrence of these conditions in veterans who served in Vietnam, why then is there no presumption of service connection for veterans afflicted with these conditions?Quite simply the answer is MONEY! The Secretary of the VA cannot afford to grant presumptive status for these conditions. It would destroy his budget. The large increase in health care services within the VA budget would be wiped out immediately! This is the problem. While we all agree that our veterans deserve the best of health care from the VA, Congress has not and apparently will not consider fully funding the VA. Their failure to do so creates a system that is dependent upon a budget that has been below needs almost every year for at least a decade. Last year's budget was $3 billion short.A document prepared in June of 2005 by the Democratic staff of the House Veterans' Affairs Committee a snapshot of what shortfalls in the budget do to care for our veterans. Fifty percent of all the veterans receiving home health care through the San Antonio VAMC will now have to fend for themselves. This cost-cutting measure means that some 250 veterans, including those with spinal cord injuries, will no longer be provided this care. Veterans in need of outpatient psychiatric treatment at the Portland facility are on a waiting list because of the budget shortfall. [*]As a result of cost cutting measures to make up for the shortfall in FY 2005, the Portland, Oregon, VAMC is delaying all non-emergent surgery by at least six months. For example, veterans in need of knee replacement surgery won't be treated because of the budget shortfall. Cut like this would be commonplace if the presumptions for Parkinson's, Ischemic Heart Disease and hypertension were granted. The solution is to fully fund the VA Health Care system. Let the administrators of all VA facilities know that they are to provide the veterans with Quality health care at all times. This is in direct conflict with the current policies of delaying or refusing to treat veterans because of budget constraints. Congress does not appear to want to provide full funding. When given the option of full funding and advanced appropriations they chose advanced appropriations. Advanced appropriations will not fix the VA budget! Only full funding will. We as veterans must unite in an effort to convince the Congress and the President that the VA must be fully funded. http://www.veteranstoday.com/article8124.html

If you were affected by the errors made at these hospitals.. Pass this veterans in those areas 10,000 affected former patients at VA hospitals in Murfreesboro, Tenn., Miami and Augusta, Ga., Contact: http://www.craftsheppardlaw.com/ 214 Centerview Drive, Suite 233 Brentwood, Tennessee 37027 615-309-1707 : phone 615-309-1717 : fax http://www.msnbc.msn.com/id/3032619/#31376216 http://www.miamiherald.com/news/florida/AP...ry/1159477.html Vets affected by VA hospital errors to file claims By BILL POOVEY Associated Press Writer CHATTANOOGA, Tenn. -- An attorney is preparing to ask the U.S. Department of Veterans Affairs to pay disability benefits and damages for hospital mistakes that may have exposed veterans to infectious body fluids - a complaint that he said could ultimately multiply into many more such demands. The attorney, Mike Sheppard of Nashville, said he is preparing to file claims with the VA for about 60 veterans, including three women. Among them are veterans who have tested positive for HIV and hepatitis and others who suffered emotional distress after the VA provided them with initial positive blood tests for infections that turned out to be wrong. Sheppard also said other veterans among the roughly 10,000 affected former patients at VA hospitals in Murfreesboro, Tenn., Miami and Augusta, Ga., are likely to seek compensation beyond the VA's offer of free medical care. "I've gotten calls from all over the country," he said. Sheppard said he will file medical malpractice and emotional distress claims with the VA within 30 to 45 days. He said veterans and veterans' relatives who have contacted him by phone from Florida and elsewhere likely have sought out other attorneys. The claims process differs from a traditional malpractice lawsuit because the VA is a federal agency. The first step is to have the patient's claim reviewed by a VA regional attorney. "A regional attorney will look at it and decide yea or nay," Sheppard said. "There is one level of appeal internally then you have a right to file a lawsuit in federal court." The VA's regional counsel in Nashville, Tammy Kennedy, did not return telephone messages Friday and Monday seeking comment. Records show that between fiscal year 2004 and March 2009 the VA denied 11,299 veterans' claims for compensation related to hospital and medical care, while granting 3,229 claims. The VA denied 813 such claims filed by veterans' dependents, while granting 261 in the same period, records show. The VA has offered free medical care to the affected veterans - but Sheppard said that's no more than they already expected. He said the requested compensation will vary greatly, depending on the veteran's age, ailments and other factors. "It's a case by case basis," he said. Updated records show that among the patients who have heeded VA warnings to get follow-up blood checks, eight have tested positive for HIV. Twelve former patients have tested positive for hepatitis B and 37 have tested positive for hepatitis C. VA records show 9,141 veterans have received follow-up blood test results among the 10,320 former patients who were warned they might have even minimum risk of exposure. The VA has said the errors were limited to the three facilities, but a report released by the agency's inspector general showed some more widespread problems. Investigators conducting surprise inspections in May found that only 43 percent of the agency's medical centers had standard operating procedures in place for endoscopic equipment and could show they properly trained their staffs for using the devices. The VA has said for months that there is no way to prove that the positive tests for infectious diseases stem from exposure to improperly cleaned or erroneously rigged equipment while getting colonoscopies at Murfreesboro or Miami or while getting treatment at the ear, nose and throat clinic in Augusta. In a statement, the VA expressed regret for the mistakes but also said the agency has aggressively dealt with them, including warning former patients who in some cases were treated five years ago to get follow-up blood tests. The statement also said veterans have been informed of their legal right "to submit disability claims on account of VA negligence." The law that governs claims for compensation includes a "benefit of doubt" provision that in disputed cases give the claimant a favorable decision if there is an "approximate balance of positive and negative evidence." "Keep on, Keepin' on" Dan Cedusky, Champaign IL "Colonel Dan" See my web site at: http://www.angelfire.com/il2/VeteranIssues/

Immunization to Protect the US Armed Forces: Heritage, Current Practice, and Prospects http://epirev.oxfordjournals.org/cgi/content/full/28/1/3 http://www.vaccines.mil/documents/library/MilitaryImztn2005fulc.pdf

Hepatitis C in Vietnam Era Veterans Bradford Waters, M.D. Staff Hepatologist, Memphis VA Medical Center, Associate Professor of Medicine, University of Tennessee, Memphis Hepatitis C is a major problem in United States military veterans. In several studies of Veteran’s Affairs (VA) Medical Center patients, we find that 8-9% are positive for hepatitis C antibodies. Some VA Medical Centers had 10-20% of patients with hepatitis C antibodies.1,2 The highest rate of hepatitis C is found in the Vietnam era veterans. Several studies have been initiated to better understand the high frequency of hepatitis C in veterans of the Vietnam conflict. Areas of research include the demographic characteristics, risk factors for infection and the potential role of military service in the acquisition of hepatitis C1. Underlying this research is the question of what is unique about Vietnam or Vietnam-era veterans to help explain a high prevalence of hepatitis C which was not observed in World War II or Korean era veterans. Vietnam era veterans are generally defined as those serving on active duty between 1964 and 1975. Other sources will restrict these dates from 1964 to 1973. An estimated 8,615,000 served during the Vietnam era while 2,150,000 actually served in Vietnam. An estimated 1,600,000 served in combat3. The clear majority of Vietnam era veterans served outside Southeast Asia during the war. Likewise a distinction has to be made between active duty military personnel, veterans and veterans served by the VA Medical Centers1. The demographics of hepatitis C in United States civilians and VA patients are important. Several epidemiological studies have found hepatitis C to be higher in U.S. males, African-Americans, lower socioeconomic groups and in those Americans in the 40 to 60 year old age groups1. In addition to serving primarily males, the VA has historically served large populations of disadvantaged, uninsured and minority veterans. The VA has had well established programs for the treatment of ethanol and other substance abuse. These substance abuse programs have often attracted younger veterans with prior intranasal cocaine and intravenous drug use associated with hepatitis C infection. As a result of the VA programs’ providing care for the disadvantaged, uninsured and substance abusing veterans, the VA has acquired significant patient populations with high risk for hepatitis C. Many of the highest risk groups for hepatitis C in the U.S.--identified by the Centers for Disease Control and NHANES III study: male, poor socioeconomic group, and between the ages of 30-50 (in the 1988-94 study)--have the same demographic criteria met by many Vietnam era veterans seeking care in the VA1. Improved screening of VA patients with risk factors for hepatitis C has helped identify increasing numbers of patients with chronic hepatitis C. What are the VA patients’ risk factors for hepatitis C? In a study of 409 patients in the Palo Alto VA, 81 % of patients had a history of intravenous drug abuse (IVDA), 11% had no identified risk factor, 3% had a history of transfusion and 2% had both transfusion history and intravenous drug use4. A large multi-center VA study involving twenty six Medical Centers and approximately 5,800 patients was initiated by the San Francisco VA Medical Center to study demographic factors and treatment response in VA patients. In preliminary data from the Memphis VA Medical Center, 222 patients were entered with a mean age of 50.7 years. 216 patients were male and six were female. 119 patients were Caucasian, 100 patients were African-American and three were Hispanic-Americans. 68.5% of the patients were Vietnam-era veterans, 20.3% were Post-Vietnam/Gulf War era veterans. Only 2.7% of the hepatitis C patients served in the World War II or immediate post-World War II eras. Only 8.5% served in the Korean War or immediate post-Korean War eras. Unlike the Palo Alto VA, 47.3% of Memphis hepatitis C patients reported IVDA. 36.5% of patients reported a history of transfusion. 14.4% reported blood exposure in combat and 9.5% reported combat wounds. 19.4% reported non-combat occupational exposure to blood or body fluids. The role of tattoos in transmission of hepatitis C has been controversial1. In this group of Memphis veterans, 30.2% of patients had tattoos. 92.8% of patients reported multiple risk factors for hepatitis C. In analysis of patients with a single risk factor for hepatitis C, intranasal cocaine use, non-combat occupational exposure, surgery, transfusion, IVDA and sex with a prostitute were identified. What was unique about the Vietnam era and hepatitis C? Medical advances during the Vietnam War included rapid evacuation, improved transfusion and high rates of U.S. casualty survival in an era prior to hepatitis C screening of the blood supply. Many Vietnam combat casualties who survived with multiple transfusions would have died on the battlefield in previous conflicts. The drug culture of the 1960s and 1970s in America and Western Europe was another major factor. Drug experimentation and injection among young people were more widespread than previous generations of the Twentieth century. This seriously effected U.S. troops stationed in West Germany and the continental U.S. as well as in Southeast Asia. In Vietnam, heroin use increased significantly in 1970, and by 1971 an estimated 10-15% of servicemen had used heroin. Interestingly, 11% of these users had used heroin prior to coming to Vietnam. Another overlooked factor in Vietnam heroin use was that it was primarily smoked. In a 1971 study of heroin addiction among servicemen in Vietnam, 90-95% of addicts smoked heroin and only 5-10% injected5. Although there has been much publicity of the substance abuse in Vietnam, there has been much less awareness of the degree of IVDA among U.S. troops stationed in Europe and the United States during the Vietnam era. Likewise until the hepatitis C and HIV epidemics, many Americans had little appreciation of the widespread injection drug use among civilians from the late 1960s to 1980s. In our series of VA patients with hepatitis C serving in Southeast Asia, 43.8% had a history of IVDA. Among patients with hepatitis C who served during the Vietnam War outside of Southeast Asia, 58.8% had prior IVDA. Among veterans serving after Vietnam with hepatitis C, 42.2% had IVDA. Intravenous drug use and hepatitis C are not simply problems of veterans of the war in Southeast Asia. In recent years hepatitis C has been studied in the U.S. military. 21,000 troops were tested in 19972. Only 0.1 % of recruits and active duty troops less than 30 years old had hepatitis C antibodies. 1.1% of active duty personnel age 35-39 and 3.0% of those over 40 had hepatitis C antibodies. Approximately 0.6% of Reservists had hepatitis C with the highest prevalence of 1.2% in those over 40 years old. In this study, hepatitis C infection did not correlate with military service in Vietnam2. Although intravenous drug use is the most common risk factor in both non-veteran and VA studies, what are other risk factors for hepatitis associated with military service? This has been an area of ongoing research and controversy. In addition to the usually accepted risk factors for hepatitis C, several potential categories include: (a) blood/body fluid exposure to health care personnel (b) blood/body exposure to combat personnel © contamination of vaccinations/immune globulin (d) blood exposure through the multidose vaccination process (e) blood exposure through sharing of razors, non-sterile instruments or utensils Historically, vaccine contamination has been recognized by the military as a major cause of viral hepatitis. During World War II, the Yellow Fever vaccine used by the U.S. Army in 1942 had contamination with the hepatitis B virus. Approximately 330,000 soldiers were injected and this resulted in 50,000 hospitalizations8. No similar association has been identified with hepatitis C. Hepatitis A epidemics from contaminated food or water are common during war. U.S. troops suffered serious outbreaks of hepatitis A during World War II. Gamma-globulin injection has been used for decades by the U.S. military to prevent hepatitis A in troops going overseas and was used during the Vietnam and Gulf Wars. Gamma globulin contains antibodies obtained from blood donors. Although intramuscular use of immune globulin has not been associated with hepatitis C in the United States, intravenous immune globulin transfusion has been implicated as a risk factor for hepatitis C9. In East Germany, 14 batches of anti-D immune globulin were contaminated with hepatitis C. 1,018 East German women were injected from 1978-79 resulting in 76% hepatitis C antibody positive in a twenty year follow up study10. The relative role of immune globulin in hepatitis C transmission remains controversial11. Since the mid-1990s, the U.S. military has shifted to a longer lasting hepatitis A vaccination and the role of immune globulin has been limited. The risk of transmission of hepatitis C by multiple dose injections is the subject of ongoing research1. Fortunately, more recent studies of military recruits and follow up studies of viral hepatitis during deployments have shown very low rates of hepatitis C infection2,12,13. Hepatitis C in Vietnam era veterans is an ongoing national problem. Complex challenges remain in the epidemiology and treatment of hepatitis C. Many Vietnam era veterans are now on the front lines of the hepatitis C epidemic. Improved understanding and treatment of these patients will ultimately benefit all Americans with hepatitis C. References 1. Briggs ME, Prevalence and risk factor for hepatitis C virus infection in an urban Veterans Administration medical center. Hepatology 34:1200-1205, 2001 Hyams KC, Prevalence and incidence of hepatitis C infection in the U.S. military : A seroepidemiologic survey of 21,000 troops, American Journal of Epidemiology 153:764-70, 2001 Horne AD, The Wounded Generation, America after Vietnam, Prentice Hall, 1981 Cheung RC, Epidemiology of hepatitis C infection in American Veterans. American Journal of Gastroenterology 95:740-747, 2000 MacPherson M, Long Time Passing:Vietnam and the Haunted Generation, Doubleday, 1984 Center for Disease Control, Hepatitis C virus infection among firefighters, emergency medical technicians and paramedics – selected locations, United States, MMWR 49:660-665, 2000 Bourleiere M, Covert transmission of hepatitis C during fisticuffs, Gastroenterology 119:507, 2000 Norman JE, Mortality follow up of the 1942 epidemic of hepatitis B in the U.S. Army, Hepatology 18:790, 1993 Alter MJ, The epidemiology of acute and chronic hepatitis C. Clinics of Liver Disease 1:559, 1997 Wiese M, Low frequency of cirrhosis in a hepatitis C (genotype 1b) single source outbreak in Germany, Hepatology 32:91-96, 2000 Murphy EL, Risk factors for hepatitis C infection in U.S. blood donors, Hepatology,31:756-762, 2000 Brodine SK, The risk of Human T cell leukemia and viral hepatitis infection among U.S. Marines stationed in Okinawa, Japan, Journal of Infectious Diseases 171:693, 1995 Hawkins RE, Risk of viral hepatitis among military personnel assigned to U.S. Navy ships. Journal of Infectious Diseases 165:716, 1992 Back to Medical Writers' Circle About Hepatitis | News Updates | Community & Support | Resource Library | About HCSP | Contact Us | Site Map | Resources en Español | Home © 2003. Hepatitis C Support Project http://www.hcvadvocate.org/hcsp/articles/vietvet.html

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Did you recieve the anthrax shot? And was there anything wrong with the gamma globulin shots? I recieved this during Vietnam.

There should be. I'm not sure the VA is the place to get it since a claim for Asbestos is likely to be filed if anything shows. In other words, I don't trust the VA. If I can be tested by an outside the DVA source, I would rather go that way to insure the testing isn't intentionally inaccurate.

part two................. ................ identify the rest of it. The veteran felt that the exposure while in his civilian occupation made the condition worse. He argued that the evidence had been overlooked in the evaluation of his claim. At the hearing the veteran submitted a report dated in May 1993 from Larry M. Mitchell, M.D. who specializes in internal medicine. The history indicated that the veteran had been tested previously for asbestos disease in August 1990 and was diagnosed as having pulmonary asbestosis at that time. The pulmonary function tests were indicative of mixed obstructive restrictive lung disease and were somewhat worse than in July 1990. The chest X-ray in May 1993 revealed bilateral lateral thoracic wall pleural thickening. The impression further indicated: "The costophrenic angles are clear on the right but somewhat obscured on the left. There are numerous irregular opacities scattered throughout both lung fields associated with fibrotic changes in both lower lung fields with some obscuration of the left heart border. . . . ." The impression was pulmonary asbestosis. Subsequent to the hearing the veteran submitted a copy of a report from Dr. Douglas dated August 27, 1988. Dr. Douglas felt that the diagnosis should be chronic obstructive pulmonary disease with emphysema and some lung scarring from past surgery. Because of the discrepancies in the diagnoses pertaining to the appellant's pulmonary problems, and in light of the request by the appellant's representative for an independent medical expert opinion (IME) of the evidence prior to final appellate consideration of this issue, the Board determined that additional medical opinion was warranted. In May 1995, the Board remanded the case to obtain additional medical evidence not associated with the claims file which would be helpful to the expert who would be undertaking the IME. The case was returned to the Board and again remanded in January 1996 for chest X-rays as previously requested before obtaining an independent medical expert opinion. In August 1996, in accordance with the authority provided by 38 U.S.C.A. § 7109 (West) and 38 C.F.R. § 20.901(d) (1995), the Board requested an opinion from an independent medical expert, Kevin Cooper, M.D., a specialist in pulmonary disease. In August 1996, Dr. Cooper submitted his opinion to the Board. A copy of this opinion was forwarded to the veteran's accredited representative who was given 60 days to submit additional evidence or argument. The representative responded that he had no further evidence or argument to submit. Dr. Cooper wrote: I have reviewed the records and chest radiographs of this veteran with regard to his asbestos exposure, the determination of any lung disease present, and whether the lung disease is a result of asbestos exposure. The record of military service and asbestos exposure is stated several times and I accept these as stated. The key information in making a diagnosis of asbestosis is as follows: there must be substantial exposure to asbestos; there must be a long interval between exposure and appearance of the disease (usually 25 years); and there must be clinical evidence of disease compatible with asbestosis. The last point requires an overall assessment of the physical exam, primarily that rales should be present in the lungs, the pulmonary function tests, and the chest radiograph. Symptoms consistent with asbestosis are also considered, but to a lesser degree because the chief symptom is shortness of breath, and shortness of breath is common to many diseases of middle aged and older people. This veteran had exposure to asbestos while working as a machinist mate, in indoor areas where asbestos insulation was widely used. The work involved removing and replacing asbestos insulation in the course of making repairs and installations. Certainly there were times when airborne asbestos was intense, described as making it difficult to see across the room. The period of exposure while in military service was November 1947 - June 1950, about 2 1/2 years. Asbestosis is unlikely to result from this intensity and duration of exposure, but it is possible. Clearly the time period following exposure was adequate for the development of asbestosis. There was probably further exposure during his work in building renovation and demolition during the period 1979-1990. Although difficult to quantify, this type of exposure is usually less intense and unlikely to lead to asbestosis. Several physical examinations are recorded, and rales were not heard on physical exam. Pulmonary function tests were performed several times. These show airflow obstruction with air trapping and a reduction in diffusing capacity. The TLC (total lung capacity) is low normal or slightly reduced through 1991, and substantially reduced in 1993. The tests before 1993 are more characteristic of chronic obstructive lung disease from his cigarette smoking than asbestosis. The TLC down to 57% of predicted in 1993 indicates restrictive lung disease rather than obstructive, and is consistent with, although not diagnostic of asbestosis. Since this one measurement is so different from the earlier measurements of TLC, I have some doubt about its significance, but cannot ignore it. The chest radiographs do not show any evidence of asbestosis, or of any asbestos related condition. The 2 radiographs I saw were dated 2/6/81 and 5/29/93. Both show hyperinflation, pectus excavatum, a pleural scar involving the left hemidiaphragm, and a linear scar seen posteriorly on the lateral view. Pleural plaque and pleural calcification would be characteristic of asbestos exposure, and interstitial fibrosis would be characteristic of asbestosis, but none of these findings are present. The chest CT scan report from June 1991 shows no findings characteristic of asbestos exposure or related disease. Chest CT would be more likely than plain chest radiographs to show these abnormalities if they were present. In summary, this veteran had an exposure to asbestos while in military service which could possibly result in asbestosis, but would probably not. He does not have rales in his lungs, his chest radiographs and chest CT do not show any evidence of an asbestos related condition, and the abnormal pulmonary function tests, although not perfectly consistent over the years, are more likely the result of obstructive lung disease caused by cigarette smoking. Even if the 1993 measurement of TLC were a consistent and reproducible abnormality, this would not indicate asbestosis. In my opinion, he does not have asbestosis or any other asbestos related condition. His symptoms are most likely attributable to chronic obstructive lung disease caused by cigarette smoking, and possibly to some additional restrictive disorder other than asbestosis. Analysis Initially we note that although the veteran contends that the November 1990 denial is invalid as a diagnosis of asbestosis was of record, we do not agree that a diagnosis of pulmonary asbestosis was of record at the time of the November 1990 denial. Our review shows that the medical evidence initially received with the veteran's claim did not include the page of the letter from Dr. Guttman with his diagnosis. The complete letter was received after the rating decision had been issued. In view of the veteran's duties during the first period of service, it may be assumed that he was exposed to asbestos during that time. In 1969 when the veteran sought treatment for chest pain, he reported a history of pleurisy in 1957. Although the initial X-ray showed an increased density in the right perihilar region and calcification of both apices, a subsequent X-ray revealed the lungs to be clear. The clinical evaluation of the lungs and chest were normal at the discharge examination at the end of the second period of service. The X-ray finding of fibrosis of the right costophrenic angle was considered to result from the pleurisy experienced in 1957. In addition, the diagnosis was bullous emphysema, and old healed granulatomous disease at the right apex. Examinations in January 1972, September 1972, and July 1973 revealed no findings or symptoms relating to a lung condition. The VA examiner in February 1981 expressed an opinion that the airway disease shown was most likely secondary to heavy smoking; there was no clinical or radiological evidence of asbestos exposure. Thus, from the time of service until February 1981, no medical evidence shows clinical or radiological evidence of asbestos exposure. The record indicates that the veteran sought treatment in 1987 for shortness of breath with coughing spells due to environmental factors and denied shortness of breath due to exertion. The diagnosis was probably interstitial fibrosis. Dr. Douglas' report in August 1988 provided a diagnosis of chronic obstructive pulmonary disease with emphysema and some lung scarring from past surgery. He was later seen in 1990 for evaluation of his condition relative to his employment. The record contains conflicting diagnoses pertaining to the appellant's pulmonary disability. The appellant had furnished medical statements from three private physicians, including a Board certified pulmonologist , indicating that the appellant has pulmonary asbestosis. However, there were medical reports from VA pulmonologists, including a Board- certified pulmonologist that indicated the appellant had no evidence of asbestos disease. Additionally, a fee-basis Board-eligible pulmonologist at a July 1993 VA pulmonary examination indicated that the appellant probably had asbestos-related lung disease, but this diagnosis was overruled by the Chief of the Pulmonary Section, a Board- certified pulmonologist at a VA medical center, who indicated in an October 1993 medical statement (after consultation with the fee-basis Board-eligible pulmonologist) that the Board- eligible pulmonologist had admitted that he had based his diagnosis mainly on the reports by the appellant's private physician, who was described in the October 1993 statement as not being a pulmonologist. As the record contained conflicting medical opinions, including opinions from Board-certified pulmonary specialists, both private and VA, we requested an opinion from an independent medical expert, a specialist in the field of pulmonary diseases with the accompanying specialized knowledge. It may be reasonably assumed that this physician is versed in the medical literature and clinical studies addressing issues in the field of pulmonary diseases, inasmuch as this is the focus area of his practice. The United States Court of Veterans Appeals (Court) has stated that the credibility and weight to be attached to medical opinion evidence are within the province of the Board as adjudicators. See Guerrieri v. Brown, 4 Vet.App. 467 (1993). Although some readings of earlier X-ray reports have provided a basis for the veteran's private physicians to make a finding of asbestosis, in June 1991, a chest radiograph and computed tomography (CT) scan were performed and the impression was no evidence of asbestos exposure radiographically. In addition, the most recent chest X-ray in July 1993 revealed pectus excavatum deformity without any active disease. Upon review of the record, we conclude that the preponderance of the evidence is against the grant of service connection for a pulmonary disorder due to exposure to asbestos. Although medical opinion evidence has been presented that the veteran has asbestosis, we accord this lesser weight than the opinions of Dr. Fernandes, a specialist in pulmonary diseases and the chief of the pulmonary section at a VA hospital, and of Dr. Cooper, the independent medical expert. Dr. Guttman based his impression of asbestosis on a chest X-ray which showed moderate interstitial markings and shagginess of the left heart border. We afford greater weight to the more recent X-rays which findings were interpreted as showing no radiological evidence of asbestos exposure. Dr. Furr's diagnosis in October 1990 was probable asbestosis, not a definite diagnosis of asbestosis. In an October 1991 case summary with regard to an employment disability claim, Dr. Furr provided a diagnosis of asbestosis with pulmonary fibrosis and restrictive lung dysfunction. However, the clinical findings of the CT scan and X-ray only a few months earlier revealed no evidence of asbestos exposure radiographically. In December 1991 after review of the record, Dr. Fernandes concluded there was minimal, if any, evidence of asbestosis. After reviewing the additional findings of a VA July 1993 examination, Dr. Fernandes affirmed that the medical evidence did not support that the veteran had asbestosis. We accord substantial weight to Dr. Fernandes' opinion. He possesses credentials as a specialist in pulmonary medicine, and has reviewed the veteran's chart on several occasions. We accord great weight to Dr. Cooper's opinion. He is a specialist in pulmonary disorders, a professor of medicine, and Acting Chief of the Division of Pulmonary Disease and Critical Care of a hospital associated with a medical college. Moreover, he undertook a review of the entire record in this case, provided an overview of the generally accepted medical principles involved, and then furnished a well-reasoned opinion with regard to the facts presented. Dr. Cooper, the independent medical expert, while acknowledging that one of the 1993 pulmonary function tests, TLC, indicated restrictive lung disease, pointed out that although this was consistent with asbestosis, it was not diagnostic of asbestosis. He concluded that the abnormal pulmonary function tests were more likely the result of obstructive lung disease caused by cigarette smoking. Dr. Cooper opined that the majority of the veteran's current respiratory symptomatology was attributable to chronic obstructive lung disease caused by cigarette smoking. Further, although he allowed for the possibility of an additional restrictive disorder, he stated that it was other than asbestosis. In addition, although the veteran's private physician, an internist, provided an impression of pulmonary asbestosis based apparently in part on a May 29, 1993, chest X-ray, Dr. Cooper also reviewed that chest X-ray and specifically reported that it did not show any evidence of asbestosis or of any asbestos related condition. We conclude, therefore, that service connection for a pulmonary disorder due to exposure to asbestos is not warranted. When all of the evidence is assembled, the VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet.App. 49, 55 (1990). The evidence against the veteran's claim is predominant. It clearly outweighs the evidence in favor of it. Therefore, the "benefit of the doubt rule" does not come into play. 38 U.S.C.A. § 5107(:P (West 1991); 38 C.F.R. § 3.102 (1995). ORDER Service connection for a lung disorder due to asbestos exposure is denied. JACK W. BLASINGAME Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, 741 (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1995), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals. - 2 -

Citation NR: 9627236 Decision Date: 09/26/96 Archive Date: 10/03/96 DOCKET NO. 92-05 398 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUE Entitlement to service connection for a lung disorder due to asbestos exposure. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Chaplin, Associate Counsel INTRODUCTION The veteran had active service from November 1947 to June 1950, August 1968 to September 1969, October 1971 to January 1972, April 1972 to June 1972, and July 1972 to September 1972. In a November 1984 appellate decision, the Board denied entitlement to service connection for a lung disorder due to asbestos exposure. This matter came before the Board of Veterans' Appeals (Board) on appeal from a rating decision of November 1990, from the Jackson, Mississippi, regional office (RO) which determined that new and material evidence had not been submitted to reopen a claim of entitlement to service connection for a lung disorder due to asbestos exposure. The Board remanded the case in May 1995 for further development. After the case was returned, the Board remanded the issue of entitlement to service connection for a lung disorder due to asbestos exposure in January 1996 for additional medical evidence. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that he was exposed to asbestos while serving as a fireman on small vessels during his first period of active military duty from November 1947 to June 1950. The veteran contends, through his representative, that at the time of the denial based on no diagnosis of asbestosis of record in November 1990, in fact Dr. Guttman's medical statement and diagnosis of pulmonary asbestosis was of record, and the denial was invalid. He contends that Dr. Furr and Dr. Guttman have both diagnosed asbestosis. He further contends that the veteran has a cardiopulmonary condition which arises out of the pulmonary difficulties due to the asbestosis. Dr. John Douglas, a pulmonologist, also detailed a list of exposure to asbestos when the veteran was in the Navy from 1947 to 1950. The veteran contends that he submitted positive diagnoses of asbestosis from three private doctors. He further claims that Dr. Guttman, Dr. Pakron and Dr. Douglas are pulmonary specialists. The veteran's representative contends that the preponderance of the evidence did not favor a denial and that the benefit of the doubt should go to the veteran. He requested an independent medical expert opinion be obtained. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1995), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the claim of entitlement to service connection for a lung disorder due to asbestos exposure. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the appeal has been obtained by the agency of original jurisdiction. 2. The veteran was exposed to asbestos while serving as a fireman on naval vessels during active military duty. 3. Entitlement to service connection for a chronic lung disorder (including claimed residuals of asbestos exposure) was denied in November 1984. 4. Conflicting medical diagnoses were submitted or obtained regarding whether the veteran presently had a lung disorder due to asbestos exposure. 5. After review, in August 1996 an independent medical expert concluded that the veteran does not have asbestosis or any other asbestos related condition. CONCLUSION OF LAW Service connection for a lung disorder due to asbestos exposure is not warranted. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991); 38 C.F.R. § 3.303 (1995). REASONS AND BASES FOR FINDINGS AND CONCLUSION Our review shows that in November 1984, the Board rendered a decision that service connection for a chronic lung disorder (including claimed residuals of asbestos exposure) was not incurred in or aggravated by service. This decision was a final disallowance. 38 U.S.C.A. § 7103 (West 1991). Even though the decision was final, the claim shall be reopened, and the former disposition of the claim reviewed if new and material evidence is secured or presented. 38 U.S.C.A. § 5108 (West 1991). When a claim is disallowed by the Board, it may not thereafter be reopened and allowed, and no claim based on the same factual basis shall be considered. 38 U.S.C.A. § 7104(b) (West 1991). New evidence, however, means more than evidence that was not previously physically of record, and is evidence that is more than merely cumulative. Colvin v. Derwinski, 1 Vet.App. 171 (1991). Evidence is "material" where it is relevant to and probative of the issue at hand and where there is a reasonable possibility that, when viewed in the context of all the evidence, both new and old, it would change the outcome. Blackburn v. Brown, 8 Vet.App. 97, 102 (1995); Cox (Billy) v. Brown, 5 Vet.App. 95, 98 (1993). Stated alternatively, "new and material evidence" means evidence not previously submitted to agency decision makers which bears directly and substantially upon the specific matter under consideration, which is neither cumulative nor redundant, and which by itself or in connection with evidence previously assembled is so significant that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a) (1995). Evidence which is solely cumulative or repetitious in character will not serve as a basis for reconsideration of a previous decision. 38 C.F.R. § 3.156 (1995). When a veteran seeks to reopen a previously denied claim based upon new evidence, a two-step analysis is required. The first step is to determine if the evidence is new and material; if so, the case is reopened and the merits of the claim must be evaluated on the basis of all of the evidence, both new and old. Manio v. Derwinski, 1 Vet.App. 140, 145 (1991). The claim shall be reopened, and the former disposition of the claim reviewed if new and material evidence is secured or presented. 38 U.S.C.A. § 5108 (West 1991). In August 1990, the veteran sought to reopen his claim for service-connection for a lung condition secondary to exposure to asbestos and submitted the first page of an August 1, 1990, letter to Maples and Lomax from Stuart T. Guttman, M.D. with clinical medical evidence and a letter dated in August 1990 from Dr. Guttman to CBC stating that the veteran would benefit from working in a controlled and dust-free environment. The RO in a rating action in November 1990 determined that the material submitted was not considered a new factual basis on which to reopen the claim. The veteran initiated an appeal. The August 1, 1990, letter from Dr. Stuart T. Guttman was again submitted, now including pages 2 and 3 which showed a diagnostic impression of asbestosis. Other evidence submitted included an October 1990 medical report from Richard T. Furr, M.D., who had examined the veteran and diagnosed "probable asbestosis with pulmonary fibrosis and restrictive lung dysfunction." Also, a letter written by Dr. Guttman in January 1991 reviewed his previous evaluation and noted that a concrete diagnosis of asbestosis had been made. We find this evidence to be new as it was not previously of record, is relevant to and probative of the issue at hand, and in light of the evidence of record at that time presents a reasonable possibility that the outcome on the merits would be changed. As the Board decision found that the presence of asbestos related disease was not established and the medical evidence now submitted provided a diagnosis of asbestosis, this evidence tends to prove the merits of the claim as to an essential element that was a specified basis for the last final disallowance of the claim. See Manio v. Derwinski, 1 Vet.App. 140 (1991); Evans v. Brown, No. 93-1220 U.S. Vet. App. (Aug. 1, 1996). As we have determined that the evidence is new and material, the claim is reopened and we will consider the merits of the claim in light of all the evidence, both new and old. See Masors v. Derwinski, 2 Vet.App. 181, 185 (1992). Furthermore, he has not indicated that any probative evidence not already associated with the claims folder is available; therefore the duty to assist him has been satisfied. 38 U.S.C.A. 5107(a) (West 1991. In the veteran's first period of service from November 1947 to June 1950 he was assigned to naval vessels as a fireman for approximately 20 months. The service medical records for the period of service from November 1947 to June 1950 show no complaints, treatment, or diagnosis of lung disease. Clinical evaluation of the lungs was normal at the discharge examination for that period of service. In addition, chest X-rays were normal. In September 1969, during the second period of service, the veteran complained of chest pain. He received medical treatment and reported a history of pleurisy in 1957. Examination findings noted that the lungs were clear. X-rays showed an increased density in the right perihilar region and calcification of both apices. A subsequent X-ray evaluation revealed the lungs to be clear. The diagnosis was resolving costochondritis and pleuritis. The discharge examination at the end of the second period of service reported the clinical evaluation of the lungs and chest were normal. X-rays showed bullous emphysema on the right and fibrosis of the right costophrenic angle which was considered to be the result of the pleurisy which he had experienced in 1957 and several small calcifications in the right apex. The diagnosis was bullous emphysema, old healed granulatomous disease at the right apex and fibrous scarring at the right costophrenic angle. Separation physical examinations in January 1972 and September 1972 had normal evaluations of chest and lungs. Chest X-rays also were normal. A July 1973 Navy Reserve physical examination and report of medical history revealed no findings or symptoms relating to any lung condition. The veteran denied having had shortness of breath, chronic cough, pain or pressure in chest. A chest X-ray report in 1979 revealed tenting and indistinctness to portions of both hemidiaphragms as well as blunting of the lateral left costophrenic sulcus probably secondary to previous pleural inflammatory disease. There were no acute infiltrates. A Veterans Administration Agent Orange examination in February 1981 also included an evaluation as to his exposure to asbestos during his first period of service. Based on the examination results, an opinion was expressed that the airway disease he had was most likely secondary to heavy smoking. There was no clinical or radiological evidence of asbestos exposure at that time. At a personal appearance at the RO in May 1983 the veteran described his exposure to asbestos during his first period of service and reported a history of smoking up to two packs of cigarettes a day. A chest X-ray in February 1986 provided an impression of old adhesions in the bases but no evidence of active pulmonary pathology. The low diaphragms were suggestive of pulmonary emphysematous change. There was scarring in the lung bases with minimal segmental atelectatic changes in the left base; also there was a finding of moderate pulmonary emphysema. There is evidence in the claims file that the appellant was exposed to asbestos while working as a carpenter from 1979 into the 1990's tearing down asbestos from buildings. As previously noted, the veteran submitted the medical reports of his private physicians. The August 1990 letter from Dr. Guttman, specializing in internal medicine and pulmonary disease, provided a diagnostic impression of asbestosis. The findings indicated that the veteran had vesicular breath sounds without any ronchi, rales or wheezing. Dr. Guttman wrote that the chest X-ray showed moderate interstitial markings and shagginess of the left heart border. "This along with his previous asbestos exposure history makes for a concrete diagnosis of Asbestosis." Dr. Guttman further commented that a complete set of pulmonary function tests were made, using Crapo's Predicted, the most accurate for disability evaluation. The results were that the simple spirometry showed moderate restriction; the static lung volumes were normal; the single breath diffusion capacity of carbon monoxide was low. In October 1990, the veteran was evaluated by Dr. Furr, a Board Certified Pulmonary and Cardiovascular Specialist. The veteran was a carpenter at a Naval Construction Battalion Center in Gulfport. Dr. Furr referred to an evaluation by Dr. Douglas, a pulmonologist whom the veteran consulted in December 1987 complaining of shortness of breath with coughing spells, in association with dust, acetone, lacquer thinners, or ammonia; noting that the veteran apparently denied any shortness of breath on exertion at that time. The veteran also reported that when taken out of that work area he had fewer coughing spells. Dr. Douglas' evaluation also noted a history wherein the veteran had an open lung biopsy on the left to rule out tuberculosis in 1957, which the veteran stated never grew out tuberculosis organisms. Dr. Douglas' report also noted decreased CO diffusion capacity, indicating probably interstitial fibrosis. Dr. Furr noted that a review of the veteran's records revealed that a chest X-ray in July 1979 showed some blunting of the left costophrenic sulcus which probably was related to the open lung biopsy. The September 1990 X-ray report submitted with Dr. Furr's evaluation gave an impression of pleural thickening bilaterally, cause undetermined; mild pectus excavatum and Rule out asbestosis. Dr. Furr also reviewed Dr. Guttman's evaluation. Dr. Furr wrote: The diagnosis of asbestosis is justified in accordance with the established diagnosis criteria of (1) exposure to asbestos (2) pulmonary interstitial fibrosis especially at the lung bases with some pleural thickening bilaterally (3) evidence of restrictive lung dysfunction on chest X-rays as opposed to obstructive lung dysfunction (4) non- productive coughing. He does not have the end-inspiratory fine crackling rales at the lung bases sometimes heard in pulmonary fibrosis; however, the weight of the other criteria overrides the lack of this occasionally seen criteria. In May 1991, the veteran was afforded a VA medical examination. In July 1991, the report was returned as it was noted that additional testing was recommended prior to a final diagnosis. A notation in the record indicated that the physician who performed the examination no longer worked at VA. An X-ray in May 1991 revealed the lungs were clear and well expanded with no change seen from September 1990. The impression was mild pectus deformity without active disease or change. In June 1991, a computed tomography scan was performed. The findings were compared with the concurrently obtained chest radiograph. The lungs were normal with no evidence of pleural thickening or plaque. Minimal pleural adhesions were identified at the bases, bilaterally. The impression was no evidence of asbestos exposure radiographically. An October 1991 case summary report with regard to an employment disability claim was provided by Dr. Furr which noted the last office visit was in September 1991 and provided a diagnosis of asbestosis with pulmonary fibrosis and restrictive lung dysfunction. The report noted that the veteran has progressively developed symptoms of dyspnea on exertion and on exposure to work environment. He had developed cardiac problems. The report further indicated that because of his limited ability to perform and danger of arrhythmias, he was terminated from his job at the CBC base. The VA Chief of Pulmonology Section, L. D. Fernandes, M.D., wrote in December 1991 that the veteran was previously assessed by two VA pulmonologists, namely Dr. Pankaj K. Shah on May 22, 1991, and Dr. Dalal on February 6, 1981. Dr. Dalal's impression in 1981 was no clinical or radiological evidence of asbestos exposure. Further that in July 1991, Dr. Shah reviewed tests he had ordered and noted that he had discussed with the veteran that the CT scan showed no evidence of asbestos exposure. After review of the chart, Dr. Fernandes, concluded that at that time, there was minimal, if any, evidence of asbestosis. A memorandum dated in January 1992 signed by H. Maynard Bellamy, M.D., ACOS/AC, indicated that Dr. Bellamy had reviewed the case file and believed that Dr. Fernandes addressed all questions pertaining to Dr. Shah's original evaluation. A rating decision in January 1992 determined that new evidence had been submitted however, the evidence did not establish a material basis for the grant of service connection and entitlement to service connection remained denied. A rating decision in March 1992 confirmed the prior rating decision. A letter dated in September 1992 from Dr. Furr contained his opinion that the veteran had the classic symptoms of asbestosis in his cough and shortness of breath. He also had the classic X-ray finding of pleural thickening and increased interstitial fibrosis. The case was appealed to the Board which noted the claims folder contained conflicting medical evidence on whether the veteran has asbestos-related lung disease. The Board remanded the case in May 1993 for additional development of the record. The veteran was afforded a fee basis medical examination in July 1993 by Thomas M. Poothullil, M.D. Dr. Poothullil noted that the chest X-ray in July 1993 revealed pectus excavatum deformity without any active disease; however, chest X-ray findings in the past described by previous examiners revealed the veteran has had changes consistent with interstitial lung disease. Pulmonary function studies were suggestive of moderate obstructive as well as possible restrictive impairments. The examiner also noted that previous pulmonary function studies reported diminished diffusion as well. The diagnoses included chronic obstructive pulmonary disease and probable asbestos related lung disease. In October 1993, a meeting was held between Dr. L. D. Fernandes, a board-certified pulmonologist and Dr. Thomas Poothullil, a board-eligible but not certified pulmonologist. Dr. Fernandes maintained that there was "no supportive medical evidence that the veteran has asbestos[is]". Dr. Poothullil admitted that he was basing his decision mainly on reports from the veteran's private physician who was not a pulmonologist. The report of the meeting further noted that prior to Dr. Fernandes, two other VA pulmonologists had not found any evidence of asbestosis. A rating decision in December 1993 determined that although new evidence was received, no new and material evidence to establish that veteran had a lung disorder secondary to asbestos exposure in service has been received. Previous denial of service connection for an asbestos-related lung disability was confirmed and continued. The veteran was afforded a personal hearing in April 1994. He repeated the history of exposure to asbestos during service. The veteran testified as to his duties in service which involved exposure to asbestos and no protection was used as no one knew of the dangers of asbestos. He first had breathing problems in 1958 when he was hospitalized for suspected tuberculosis. He had no further breathing problems until 1981. In 1984, he sought treatment from John W. Douglas, M.D. who diagnosed bronchitis, but said he could not <

The Breathing test is nothing to worry about. You simply take in a deep breath & let all the air out as long as you can. It measures what your lungs put out. Mine measured a moderate lung defect for the PFT(pulmonary function test) It's a simple non painful test.

Rating Multiple Sclerosis.......... Neurological Conditions and Convulsive Disorders http://www.warms.vba.va.gov/admin21/m21_1/...4/ch04_secg.doc

Temp at our place in central Washington state today, is currently running at 113 degrees up against the east slopes of the Cascades. This whole week is expected to be this hot. I can at least drive up in the mountains just a short distance & get cool. Thats not so easy in NV unless you live near Wings. No global warming? Seattle is looking at near 100 degree weather. Thats not exactly normal. I'm sorry to hear about your situation Rockhound & can relate to it. I've been saying for over a decade how much different my families situation would change & how less dependent on others it would be if VA got it together, properly weighed the evidence & granted what is due. But life goes on and we continue to live between a rock & a hard spot. I know it isn't the best for you, but I hope theres a way for you to get that swamp cooler fixed. This heat sure isn't good for you.

Department of Memorandum Veterans Affairs Date: April 13, 2000 VAOPGCPREC 4-2000 From: General Counsel (022) Subj: Nature of Manual Provisions Concerning Claims Involving Asbestos-Related Diseases; Need for Medical-Nexus Evidence in Asbestos-Related Claims To: Chairman, Board of Veterans’ Appeals (01) QUESTIONS PRESENTED: A. Do provisions of paragraph 7.21 in Veterans Bene- fits Administration (VBA) Adjudication Procedure Manual M21-1 (Manual M21-1), Part VI, pertaining to claims in- volving asbestos-related diseases constitute regulations which are binding on the Department of Veterans Affairs (VA)? B. Is medical-nexus evidence required to establish a well-grounded claim for service connection for an asbestos-related disease referenced in paragraph 7.21 of VBA Manual M21-1, Part VI, and allegedly due to in-service asbestos exposure? DISCUSSION: 1. These issues arise in the context of an order issued by the United States Court of Veterans Appeals (now the United States Court of Appeals for Veterans Claims (CAVC)) vacating a decision of the Board of Veterans’ Appeals (Board) which denied the appellant entitlement to service connection for a lung disorder claimed to have resulted from exposure to asbestos in service. The CAVC granted a joint motion for remand for consideration of paragraph 7.21 of VBA Manual M21-1, Part VI, regarding claims involving asbestos-related diseases. You have requested our opinion as to (i) whether the manual provisions in question constitute substantive regulations that must be followed by the Board, and (ii) whether medical-nexus evidence is required to establish a well-grounded claim for service connection for an asbestos-related disease referenced in paragraph 7.21 of VBA Manual M21-1, Part VI, and allegedly due to in-service asbestos exposure. 2. We begin with the question of whether the manual provi-sions at issue constitute substantive regulations that must be followed by the Board. Section 7104© of title 38, United States Code, provides that, “[t]he Board shall be bound in its decisions by the regulations of the Depart-ment, instructions of the Secretary, [1] and the precedent opinions of the chief legal officer of the Department.” See also Young v. Brown, 4 Vet. App. 106, 109 (1993) (VA may not ignore its own regulations). Section 19.5 of title 38, Code of Federal Regulations, provides that, “[t]he Board is not bound by Department manuals, circulars, or similar administrative issues” in its review of VA decisions. The question which must therefore be addressed is whether the provisions of paragraph 7.21 of VBA Manual M21-1, Part VI, constitute “regulations” for purposes of 38 U.S.C. § 7104©. 3. In many cases, courts have concluded that internal agency issuances, such as manuals and circulars, designed to convey instructions to personnel within an agency con-cerning procedure and practice, did not constitute binding rules. See, e.g., Schweiker v. Hansen, 450 U.S. 785, 789-90 (1981) (Social Security claims manual); Hoffman v. United States, 894 F.2d 380, 384 (Fed. Cir. 1990) (Air Force regulation); Horner v. Jeffrey, 823 F.2d 1521, 1529-30 (Fed. Cir. 1987) (Federal personnel manual); Rank v. Nimmo, 677 F.2d 692, 698 (9th Cir.), cert. denied, 459 U.S. 907 (1982) (VA Circulars and handbook). However, certain provisions of VBA Manual M21-1 have been found to contain binding substantive rules. E.g., Hamilton v. Derwinski, 2 Vet. App. 671, 675 (1992). Some courts have focused on the intent of the promulgator in inquiring whether an agency statement not published in the Federal Register is a binding rule. See, e.g., Public Citizen, Inc. v. U.S. Nuclear Regulatory Comm’n, 940 F.2d 679, 681-82 (D.C. Cir. 1991). However, decisions by the CAVC have emphasized the issue of whether the statements in VA manuals and other internal publications are substantive or interpretative in determining the effect of such statements. See Morton v. West, 12 Vet. App. 477, 482 (1999) (citing cases where the CAVC found manual provisions to contain substantive rules); Dyment v. West, 13 Vet. App. 141, 145-46 (1999). 4. A substantive rule is one which “effect a change in existing law or policy or which affect individual rights and obligations.” Paralyzed Veterans of Am. v. West, 138 F.3d 1434, 1436 (Fed. Cir. 1998). Such a rule “‘nar-rowly limits administrative action.’” Fugere v. Derwinski, 1 Vet. App. 103, 107 (1990) (quoting Carter v. Cleland, 643 F.2d 1, 8 (D.C. Cir. 1980)), aff’d, 972 F.2d 331 (Fed. Cir. 1992); Morton, 12 Vet. App. at 481-82. A rule may be considered substantive where it impinges on a benefit or right enjoyed by a claimant or where its application directly affects whether a claimant’s benefits are to be granted, denied, retained or reduced. Morton, 12 Vet. App. at 483; Fugere, 1 Vet. App. at 107. In contrast, an interpretative rule “‘merely clarifies or explains an existing rule or statute.’” Morton, 12 Vet. App. at 482 (quoting Carter, 643 F.2d at 8); see also Paralyzed Veterans of Am., 138 F.3d at 1436. It is not intended to create new rights or duties, “‘but only reminds affected parties of existing duties.’” Paralyzed Veterans of Am., 138 F.3d at 1436 (quoting Orengo Caraballo v. Reich, 11 F.3d 186, 195 (D.C. Cir. 1993)); Morton, 12 Vet. App. at 483. 5. As noted by the CAVC, “substantive rules may confer enforceable rights, while internal guidelines and interpre-tive statements of a federal agency . . . cannot.” Morton, 12 Vet App. at 482 (citing cases). The CAVC has held that, “ubstantive rules . . . in the VA Adjudication Procedure Manual [M21-1] are the equivalent of Department regula-tions.” Hamilton, 2 Vet. App. at 675. Provisions of VBA Manual M21-1 have been found by the CAVC to be substantive when they have governed which rating criteria will be applied in a particular claim, Fugere, 1 Vet. App. at 107, or established an evidentiary threshold for a particular type of claim, Moreau v. Brown, 9 Vet. App. 389, 394-95 (1996), aff’d, 124 F.3d 228 (Fed. Cir. 1997); Hayes v. Brown, 5 Vet. App. 60, 66-67 (1993), appeal dismissed, 26 F.3d 137 (Fed. Cir. 1994); Hamilton, 2 Vet. App. at 674-75. 6. In Morton, which is currently on appeal to the United States Court of Appeals for the Federal Circuit, the CAVC determined that certain provisions of VBA Manual M21-1 pertaining to development of claims were not substantive rules. For example, paragraph 1.03a., Part III, of that manual provides in part that, “efore a decision is made about a claim being well grounded, it will be fully devel-oped.” The CAVC determined that those claim development provisions were “policy declarations” stating “administra-tive directions to the field containing guidance as to the procedures to be used in the adjudication process” and “do not create rights with respect to specific disabilities.” 12 Vet. App. at 483-84; see also Flynn v. Brown, 6 Vet. App. 500, 505 (1994) (circular contained only procedural guidance). The CAVC further concluded that those manual provisions only served to interpret 38 U.S.C. § 5107, id. at 484, which requires a claimant to submit and establish a “well-grounded” claim before VA is required to provide assistance in developing the facts of the claim. 7. Other provisions in VBA Manual M21-1 concerning claim development, however, have been found to be substantive in nature. In Hayre v. West, 188 F.3d 1327, 1331-32 (Fed. Cir. 1999), the Federal Circuit stated that VA had “sub-stantively defined” its obligation to obtain service medi-cal records for claim development purposes in a paragraph of VBA Manual M21-1, Part VI. The Federal Circuit observed that the manual provision at issue called for VA to make further requests for service department records under certain circumstances. 188 F.3d at 1332. In treating the manual provisions as substantive, the Federal Circuit noted that, “[t]hese requirements for obtaining records and evaluation of the complete medical history of the veteran’s condition operate to protect a claimant against adverse decisions based on an incomplete, or inaccurate, record and to enable . . . VA to make a more precise evaluation of the level of the disability and of any changes in the condi-tion.” Id. 8. CAVC case law also indicates that certain provisions in VA manuals regarding claim development with respect to spe-cific disabilities establish procedures which VA is obli-gated to follow. For example, in Patton v. West, 12 Vet. App. 272, 282 (1999), the CAVC held that provisions of paragraph 5.14c. of VBA Manual M21-1, Part III, addressing development of post-traumatic stress disorder (PTSD) claims based on personal assault, which “are favorable to a veteran when adjudicat&shy;ing that veteran’s claim,” cannot be “ignore[d]” by VA. The CAVC noted that, through these manual provisions, “the Secretary has undertaken a special obligation to assist a claimant . . . who has submitted a well-grounded claim, in producing corroborating evidence of an in-service stressor.” 12 Vet. App. at 280. In Suttmann v. Brown, 5 Vet. App. 127, 138 (1993), the CAVC held that, in developing and adjudicating the well-grounded claim of a former prisoner of war (POW) for service connection for beriberi and beriberi heart disease, VA was required to ensure compliance with VA’s “rules for adjudication of POW claims” contained in provisions of VBA Manual M21-1, Part III, regarding requests for POW records and standards for development and adjudication of POW claims. 9. We also note that, pursuant to the Administrative Procedure Act (APA), 5 U.S.C. §§ 552(a)(1), a person gener-ally may not be adversely affected by a matter required to be published in the Federal Register and not so published. Rules of procedure and substantive rules of general appli-cability are among the matters required to be published. 5 U.S.C. § 552(a)(1)© and (D); see also 5 U.S.C. § 553(b) (requiring notice of proposed rulemaking in the Federal Register); Fugere v. Derwinski, 1 Vet. App. at 110 (invali-dating VA action which did not observe procedure required by law). Accordingly, manual provisions may not be given binding effect to the extent that they purport to create substantive rules which adversely affect claimants. 10. To sum up, while the case law is still developing in this area, Federal Circuit and CAVC decisions indicate that a provision in a VA manual constitutes a substantive rule when the provision effects a change in law, affects indi-vidual rights and obligations, or narrowly limits admini-strative action. Provisions which govern determination of rating criteria or establish evidentiary thresholds for particular claims will be considered substantive. Substan-tive provisions in manuals may be considered the equivalent of regulations and confer enforceable rights on claimants. However, manual provisions may not be given binding effect to the extent that they have a direct adverse effect on claimants. Further, the case law indicates that VA will be considered obligated to follow manual provisions which establish specific claim development procedures in well-grounded claims. Manual provisions that merely interpret a statute or regulation or provide general guidance as to the procedures to be used in the adjudication process do not create enforceable rights. 11. We will now examine paragraph 7.21 of VBA Manual M21-1, Part VI, in light of these principles to determine whether the provisions of that paragraph should be consid-ered binding on VA. Paragraph 7.21a. of the VBA manual discusses asbestos and asbestos-related diseases generally. Paragraph 7.21b. of the manual describes occupational and other exposure to asbestos. Paragraph 7.21b. also discusses the latent period between first exposure to asbestos and development of an asbestos-related disease as well as the significance of the period of exposure. Paragraph 7.21c. of the manual discusses the clinical diagnosis of asbestosis. Paragraph 7.21d.(3) of the manual and the last two sentences of paragraph 7.21d.(1) provide for application of the reasonable-doubt doctrine and create internal operating procedures not affecting the outcome of a claim. These provisions do not purport to effect a change in law, or affect a claimant’s rights or obliga-tions, nor do they narrowly limit administrative action in adjudication of claims. These provisions merely provide general information or guidance for consideration by adjud-icators, remind adjudicators of existing law, or establish internal operating procedures having no effect on claim-ants’ rights and obligations. Therefore, the provisions in paragraph 7.21a., b., c., and d.(3) and the last two sen-tences of paragraph 7.21d.(1) are not substantive in nature. 12. We caution, however, that decisions of the CAVC indicate that the Board may not simply ignore the general information provisions of paragraphs 7.21a., b., and c. because they are not substantive. In McGinty v. Brown, 4 Vet. App. 428, 432-33 (1993), the CAVC vacated and remanded a Board decision which had not addressed relevant considerations, similar to those contained in paragraph 7.21b., included in a VA circular on asbestos-related diseases. The court concluded that, in view of the Board’s failure to address these considerations, the Board had failed to provide adequate reasons and bases for its decision as required by 38 U.S.C. § 7104(d)(1). 4 Vet. App. at 433. Similarly, in Ennis v. Brown, 4 Vet. App. 523, 527 (1993), the CAVC vacated and remanded a Board decision which had failed to analyze an asbestos-related claim in light of considerations discussed in the VA circular similar to those now found in paragraphs 7.21a. and b. of the manual. See also Nolen v. West, 12 Vet. App. 347, 351 (1999) (citing McGinty and Ennis in upholding a Board decision as to adequacy of reasons and bases where the Board had extensively reviewed the criteria contained in the asbestos circular in light of the evidence). These cases indicate that relevant factors discussed in paragraphs 7.21a., b., and c. of the manual must be considered and addressed by the Board in assessing the evidence regarding an asbestos-related claim in order to fulfill the Board’s obligation under 38 U.S.C. § 7104(d)(1) to provide an adequate statement of the reasons and bases for a decision. 13. Turning to the first three sentences of paragraph 7.21d.(1) of VBA Manual M21-1, Part VI, these provisions provide: When considering VA compensation claims, rating specialists must determine whether or not mili-tary records demonstrate evidence of asbestos exposure in service. Rating specialists must also assure that development is accomplished to determine whether or not there is preservice and/or post-service evidence of occupational or other asbestos exposure. A determination must then be made as to the relationship between asbestos exposure and the claimed diseases, keeping in mind the latency and exposure infor-mation noted above. These provisions direct adjudicators to develop and consider various factors in the adjudication of claims involving asbestos-related diseases. Thus, they may be viewed as limiting the discretion of adjudicators, and they could affect the outcome of claims. On the other hand, the directions provided are very general in nature, and to a large degree describe procedural steps, e.g., review of military records for evidence supporting service incur-rence, consideration of pertinent medical principles and evidence of service incurrence, that adjudicators would follow in all cases without regard to the manual. 14. In Ashford v. Brown, 10 Vet. App. 120, 124 (1997), the CAVC concluded that a VA circular containing provisions similar to paragraph 7.21d.(1) established “guidelines” which “did not . . . bestow any rights on VA claimants.” Nonetheless, the court concluded that the steps described in the circular were “mandated” and reviewed VA’s actions to determine whether they had been followed. 10 Vet. App. at 124-25 (citing Suttmann, 5 Vet. App. at 138); see also Ennis, 4 Vet. App. at 527 (remanding asbestos-exposure claim for development under circular); cf. Patton, 12 Vet. App. at 282 (remanding PTSD claim based on personal assault for development under VA manual). 15. Recently, in Dyment, 13 Vet. App. at 145, the CAVC found that provisions in former paragraph 7.68 (predecessor to paragraph 7.21) of VBA Manual M21-1, Part VI, “d[id] not give rise to enforceable substantive rights but merely contain[ed] statements of policy.” The CAVC referred generally to the provisions as “policy guidelines” and interpretive statements. 13 Vet. App. at 146. The CAVC specifically referred to predecessors to the first and second sentences of paragraph 7.21b.(2) and the first two sentences of paragraph 7.21d.(1)). 13 Vet. App. at 145. However, the court reached these conclusions in the context of determining whether the manual provisions created a presumption of exposure to asbestos based solely on shipboard service. 13 Vet. App. at 145-46. It did not address the issue of whether the provisions bestowed procedural rights on claimants. Although the referenced case law is not completely clear regarding whether the manual provisions in question are substantive or otherwise binding, we believe that the most advisable course of action is to consider the first three sentences of paragraph 7.21d.(1) to establish a procedure which adjudi-cators are required to follow in asbestos-related claims. 16. In Morton, 12 Vet. App. at 485, the CAVC noted that that court and the United States Court of Appeals for the Federal Circuit have interpreted 38 U.S.C. § 5107 as conditioning VA’s duty to assist a claimant in the development of the facts pertinent to a claim on the submission by the claimant of a well-grounded claim. The court went on to hold that “absent the submission and establishment of a well-grounded claim, [VA] cannot undertake to assist a veteran in developing facts pertinent to his or her claim.” 12 Vet. App. at 486. Further, in Hayre, 188 F.3d at 1331-32, the United States Court of Appeals for the Federal Circuit indicated that a provision of VBA Manual M21-1 obligating VA to assist in obtaining service medical records was applicable only where the claimant had submitted a well-grounded claim. Although VA has interpreted 38 U.S.C. § 5107(a) and Morton as permitting certain exceptions to this prohibition to be established by regulations and VA has proposed doing so, 64 Fed. Reg. 67,528, 67,529, procedures for development of asbestos-related claims are not among those which VA has proposed to establish as exceptions. 17. We note that the CAVC’s decision in Ashford, 10 Vet. App. at 124-25, may be read as implying that the claim-development procedures of VA’s asbestos circular applied without regard to whether the claim in question was well grounded. However, the question of whether the claim had to be well grounded was not addressed by the court, and the CAVC’s later decision in Morton appears to resolve the question. Further, although the CAVC in Ennis, 4 Vet. App. at 527, remanded for further development under the circular an asbestos-related claim which seemingly would not have been considered well grounded under the standards later announced in Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d, 78 F.3d 604 (Fed. Cir. 1996) (table), the court’s recitation of cetain factors which weighed in favor of the claim implies that the court considered the claim plausible within the criteria then current for assessing well-groundedness. See Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990) (“[a] well grounded claim is a plausible claim”). Accordingly, we conclude that, to the extent paragraph 7.21d.(1) of VBA Manual M21-1, Part VI, establishes claim-development procedures, those procedures are only applicable in the case of a well-grounded claim. 18. Section 4.20 of title 38, Code of Federal Regulations, provides that, when a condition is encountered for which there are no rating criteria provided in VA’s rating schedule, the condition may be rated by analogy to another closely related disease or injury. Paragraph 7.21d.(2) of VBA Manual M21-1, Part VI, directs adjudicators to rate certain diseases caused by exposure to asbestos by analogy to other specific conditions, such as silicosis and various types of cancer. Paragraph 7.21d.(2) narrowly limits adjudicators’ action and may affect the r ights of claimants in that, by specifying the rating criteria under which a veteran’s asbestos-related disease is to be rated by analogy, it could affect the rating assigned to the veteran’s disability. For this reason, we believe paragraph 7.21d.(2) should be regarded as substantive. However, it should not be treated as binding to the extent it may adversely affect a claimant by requiring that a particular asbestos-related disease be rated by analogy to a specified condition, where a rating more favorable to the claimant would be obtained by rating by analogy to another disease pursuant to section 4.20. 19. Further, we note that paragraph 7.21d.(2) is to a significant extent obsolete and in conflict with the rating schedule in that the rating schedule now contains rating codes and rating criteria for certain of the conditions for which paragraph 7.21d.(2) specifies analogous conditions. In particular, a diagnostic code (diagnostic code 6845) and rating criteria are now specifically provided for chronic pleural effusion and fibrosis, two conditions which paragraph 7.21d.(2) provides are to be rated by analogy to silicosis (diagnostic code 6832). Moreover, the rating criteria for diagnostic codes 6845 and 6832 differ in some respects. Paragraph 7.21d.(2) should not be treated as binding where a rating more favorable to the claimant would be obtained by reference to current rating criteria for a particular disease in VA’s rating schedule. A diagnostic code (diagnostic code 6833) and rating criteria are also provided for asbestosis, another of the conditions which paragraph 7.21d.(2) provides is to be rated by analogy to silicosis. However, since the rating criteria for asbestosis are identical to the rating criteria for silicosis, this inconsistency is of no consequence. 20. We now turn to the question of whether medical-nexus evidence is required to establish a well-grounded claim for service connection for a condition referenced in paragraph 7.21 of VBA Manual M21-1, Part VI, and allegedly due to in-service asbestos exposure. Under 38 U.S.C. § 5107(a), a person who submits a claim for benefits under a statute administered by VA has the burden of submitting “evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded.” The CAVC has defined a “well-grounded” claim as “a plausible claim, one which is meritorious on its own or capable of substantiation.” Murphy, 1 Vet. App. at 81. The CAVC has stated that such a claim need not be conclusive, but only possible, to satisfy the initial burden of section 5107(a). Id. Further, the CAVC has explained the types of evidence necessary to establish a well-grounded claim for direct service connection of a disability for purposes of 38 U.S.C. §§ 1110 and 1131 and 38 C.F.R. § 3.303, see Savage v. Gober, 10 Vet. App. 488, 493, 495-97 (1997), and for purposes of presumptive service connection for disabilities associated with herbicide exposure under 38 U.S.C. § 1116(a) and 38 C.F.R. §§ 3.307(a)(6) and 3.309(e), Brock v. Brown, 10 Vet. App. 155, 162 (1997). 21. The CAVC and the Federal Circuit have held that a well-grounded claim for direct service connection generally requires submission of appropriate evidence of: (1) a cur-rent disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the in-service disease or injury and the current disability. See Epps v. Gober, 126 F.3d 1464, 1468 (Fed. Cir. 1997), cert. denied, 524 U.S. 940 (1998); Savage, 10 Vet. App. at 493. The failure to submit evidence with respect to any of those elements may require a conclusion that the claim is not well grounded. See, e.g., Wade v. West, 11 Vet. App. 302, 305 (1998) (no evidence of nexus); Brock, 10 Vet. App. at 164 (no evidence of current disability). The quality and quantity of the evidence required to meet the burden under 38 U.S.C. § 5107(a) will depend upon the issue presented by the claim. Grottveit v. Brown, 5 Vet. App. 91, 92-93 (1993). Where the determinative issue involves medical causation or a medical diagnosis, compe-tent medical evidence to the effect that the claim is “plausible” is required. Id. at 93. 22. The determinative issues in an asbestos-related claim would generally include a medical diagnosis and medical causation. For example, the asbestos-related diseases referenced in paragraph 7.21 of VBA Manual M21-1, Part VI, such as asbestosis, pleural effusions and fibrosis, pleural plaques, and mesothelioma of pleura or peritoneum, must first be medically diagnosed and then shown to be medically related to in-service exposure to asbestos. See Nolen, 12 Vet. App. at 351 (finding no medical-nexus evidence between the veteran’s asbestosis and his service exposure). Therefore, although a claimant may provide competent evidence of a current disability and of in-service exposure to asbestos, the claimant would still need to present competent medical evidence of a nexus relating the current disability to in-service exposure to asbestos. Id. 23. If VBA Manual M21-1 creates a presumption of service connection for asbestos-related diseases referenced in paragraph 7.21 based on in-service asbestos exposure, then medical-nexus evidence would not be required to establish a well-grounded claim for service connection for those condi-tions. As discussed above, a well-grounded claim for serv-ice connection generally requires evidence of a current disability, incurrence of a disease or injury in service, and a nexus between the in-service disease or injury and the current disability. See Epps, 126 F.3d at 1468; Savage, 10 Vet. App. at 493. A presumption of service connection for asbestos-related diseases would fulfill the requirement for evidence of a medical nexus. See Darby v. Brown, 10 Vet. App. 243, 246 (1997) (holding that when the presumptive provisions governing herbicide exposure claims are satisfied, the requirement for evidence of a causal nexus is satisfied), appeal dismissed, 152 F.3d 942 (Fed. Cir. 1998) (table); Brock, 10 Vet. App. at 162. Paragraph 7.21 of VBA Manual M21-1, Part VI, however, does not create such a presumption. The first sentence in paragraph 7.21d.(1) requires a determination as to “whether or not military records demonstrate evidence of asbestos exposure in service,” and the third sentence in that para-graph requires a determination “as to the relationship between asbestos exposure and the claimed diseases.” A claimant must therefore not only present specific evidence of in-service exposure to asbestos but must also show the relationship between the asbestos exposure and the claimed disease to establish entitlement to service connection for an asbestos-related disease. Thus, paragraph 7.21d.(1) does not provide for the presumption of service connection for asbestos-related diseases. See Dyment, 13 Vet. App. at 145-46 (provisions in predecessor to paragraph 7.21d. did not create a presumption); Ashford, 10 Vet. App. at 124 (provisions in former circular which were similar to provi-sions of paragraph 7.21d.(1) did not create a presumption). Accordingly, medical nexus evidence is required to establish a well-grounded claim for service connection for an asbestos-related disease. HELD: A.(1) Paragraph 7.21a., b., c., and d.(3) of Veterans Benefits Administration Adjudication Procedure Manual M21-1, Part VI, and the fourth and fifth sentences of paragraph 7.21d.(1) of that manual are not substantive in nature. However, relevant factors discussed in paragraphs 7.21a., b., and c. must be considered and addressed by the Board in assessing the evidence regarding an asbestos-related claim in order to fulfill the Board’s obligation under 38 U.S.C. § 7104(d)(1) to provide an adequate statement of the reasons and bases for a decision. (2) The first three sentences of paragraph 7.21d.(1) of Veterans Benefits Administration Adjudication Procedure Manual M21-1, Part VI, establish a procedure which, in light of current case law, adjudicators are required to follow in claims involving asbestos-related diseases. However, to the extent that paragraph 7.21d.(1) of that manual establishes claim-development procedures, those procedures are only applicable in the case of a well-grounded claim. (3) Paragraph 7.21d.(2) of Veterans Benefits Administration Adjudication Procedure Manual M21-1, Part VI, should be regarded as substantive. However, that paragraph should not be treated as binding to the extent it may adversely affect a claimant by requiring that a particular asbestos-related disease be rated by analogy to a specified condition, where a rating more favorable to the claimant would be obtained by reference to current rating criteria for the particular disease in VA’s rating schedule. Similarly, where the current rating schedule contains no criteria specific to the asbestos-related disease, paragraph 7.21d.(2) should not be treated as binding to the extent it would adversely affect a claimant by requiring that the asbestos-related disease be rated by analogy to a particular condition, where a rating more favorable to the claimant would be obtained by rating by analogy to another disease pursuant to 38 C.F.R. § 4.20. B. Medical-nexus evidence is required to establish a well-grounded claim for service connection for an asbestos-related disease referenced in paragraph 7.21 of Veterans Benefits Administration Adjudication Procedure Manual M21-1, Part VI, and allegedly due to in-service asbestos exposure. Leigh A. Bradley http://www.hadit.com/forums/index.php?act=...p;f=36#_ftnref11 “Instructions of the Secretary” is a term of art refer-ring to a specific class of published documents providing instructions for implementation of newly enacted legisla-tion prior to issuance of regulations. VAOPGCADV 5-89 (O.G.C. Advis. 5-89); VAOPGCPREC 7-92 (O.G.C. Prec. 7-92).

http://www.vard.org/va/99/HEARING.HTM Auditory Dysfunction and Multiple Sclerosis: A Silent Concern; Stephen Fausti, PhD Hearing lost is the number one service-connected disability of veterans. Approximately 300,000 individuals are service connected and receiving compensation for their hearing losses. However, there are another million or 1.2 million that are service connected less than 10% and are still service-connected for their hearing. Add on the fact that the aging population we're dealing with, and the related statistics tell us that for anybody in the audience over 65, there is a 40% probability that you're going to have some degree of hearing loss. We've got a problem in the VA with respect to hearing sensitivity and hearing function. If you look at multiple sclerosis and the effects of multiple sclerosis on hearing, and then look at the concomitant effects of the two being additive, we have a potentially big problem. The National Center in Portland for Rehabilitative Auditory Research has been in existence for about a year and five months. Its basic mission is to alleviate the communicative, social, and economic problems resulting from auditory system impairment. This boils down to financial, social, and a lot of quality-of-life issues that exist in hearing dysfunction. It's implicit in the charge of the Center to address issues related to auditory dysfunction in veterans with MS. What is surprising is that some studies regarding MS patients have shown auditory information processing deficits that appear to be even larger in magnitude than visual processing deficits. Yet, there have been no large-scale epidemiological studies to look at extent of this problem. Before discussing the basic problems associated with MS, the differences between peripheral and center types of hearing lost have to be separated out. Hearing per se is a function that is a continuum from periphery to central function. Now it is true that multiple sclerosis basically does not effect the cochlear function. However, it does affect a cochlear function at the connection to the brainstem, and it will affect the auditory pathways of higher levels. Some of the effects of multiple sclerosis can show up as loss in hearing sensitivity. What has been shown in the literature, however, is tremendously contradictory. The only certainly is that there is a problem. The individuals who treat patients with multiple sclerosis and their hearing loss know that 85% of the cases with hearing loss show a sensory neural bilateral high frequency hearing loss. Sometimes there is unilateral hearing loss, and occasionally there is sudden hearing loss; then in periods of remission, there is some recovery. But there seems to be a sequence where it is progressive and continues to move out with time. The studies that reported hearing loss basically give us a statistic from 1 to 86%; a huge variation that leaves us with no indication of reality. The only way to know reality is to study reality and to do the prospective study that really looks at degradation of hearing as a result of the disease process. There was similar uncertainty and quite that much variability with the area of ototoxicity and how drugs affect hearing. This continues to be resolved through the process of investigation. With respect to MS and higher-level auditory dysfunction, it has been reported in the literature that up to 40% of MS patients who have normal audiograms experience difficulty hearing in everyday listening conditions. This is more in keeping with the anecdotal evidence you get from clinicians, when they tell you that hearing loss is really not a problem with my MS patients, but about a third of them complain about having a lot of difficulty hearing with a lot of background noise. There is a big difference between sensitivity and processing of auditory information, which is below the level of auditory memory—what the neuropsychologists are dealing with. There is a need to look at what is going on at the higher levels. In the past a lot of people have used auditory evoke response audiometry, and they've shown that with MS there are dramatic changes. What has been seen with the AVR is that it is a bimodal response. If the eighth auditory nerve is effected, you are going to have marked changes in the AVR. In addition, longer latencies or evoke potentials measuring higher-level functions also parallel this. In some cases these auditory processing abnormalities have been detected in the very early processes of the disease. What's needed is a large-scale epidemic study because the literature is so variable on this. Such a study should not only assess the prevalence and severity of auditory processing dysfunctions in individuals, but also should determine the extent to which such dysfunctions may add to the individual's overall disability. In other words, how does it add to existing hearing losses that the individual may have? How does it add to these existing measures of comprehension and auditory retention? The epidemiological study, if it's conducted in the right way, should spin off appropriate screening tasks that are sensitive to utilization and the early detection of these auditory dysfunctions in that population. What we're not doing much of right now is educating clinicians regarding the subtleness of auditory dysfunctions. We're really not educating the patients because patients come in and tell us that they don't know why they are having trouble hearing noise now; they never did before. Some of that information should be given to the patients up front, and their families also should be brought into the loop. Secondly, we should be testing patients as soon as we bring them into the program or get them into the following program for MS. At the very least, pure tone audiometry tests can be performed as well as some distorted speech testing to see when they start shifting and if they shift. And thirdly you can implement some degree of rehabilitation with them. If you have a veteran patient who has a peripheral hearing loss, why not upgrade that peripheral hearing loss in the rehabilitative process as well as you can, so you can approve the quality of signal with which he is coping. Other strategies would include signal noise ratios, is a real dilemma for individuals that speech annoys. There are assisted listening devices like FM units that can be worn. Simple techniques work, like improving your listening environments at home by moving signal sources closer do work. So an active plan of intervention can be formulated. However, most important is early identification, prospective planning, periodic monitoring, and updating. With the increased life expectancy, let's hope medication and pharmacology and immunology come together, and we're able to do away with this disease or we're able to hold it at bay. In summary, while there are well-documented auditory changes associated with MS, the rehabilitating strategies are really undefined. If you look, it's about, 200 to 1 ratio of publications documenting case studies of auditory dysfunction. There is a need for intervention studies to closely follow epidemiological studies. We need the documentation of change in auditory function in MS patients, and we want to characterize the deficits, which will lead to the needed rehabilitation and remediation strategies.

Article http://www3.interscience.wiley.com/cgi-bin/abstract/70002279/ABSTRACT Acute respiratory symptoms in workers exposed to vanadium-rich fuel-oil ash Mark A. Woodin, ScD, MS 1 2, Youcheng Liu, MD, ScD, MPH 1, Donna Neuberg, ScD 3, Russ Hauser, MD, ScD, MPH 1, Thomas J. Smith, PhD, MPH 1, David C. Christiani, MD, MPH 1 2 4 * 1Department of Environmental Health (Occupational Health Program), Harvard School of Public Health, Boston, MA 02115 2Department of Epidemiology, Harvard School of Public Health, Boston, MA 02115 3Department of Biostatistics, Harvard School of Public Health, Boston, MA 02115 4Pulmonary and Critical Care Unit, Department of Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114 email: David C. Christiani (dchris@hohp.harvard.edu) *Correspondence to David C. Christiani, Harvard School of Public Health, Department of Environmental Health, 665 Huntington Avenue, Boston, MA 02115. Funded by: NIEHS; Grant Number: ES05947, ES07069, ES00002 NIOSH; Grant Number: OH02421, CCU109979 Keywords vanadium; PM10; occupational epidemiology; occupational lung disease; boilermakers; industrial hygiene Abstract Background Occupational exposure to fuel-oil ash, with its high vanadium content, may cause respiratory illness. It is unclear, however, what early acute health effects may occur on the pathway from normal to compromised respiratory function. Methods Using a repeated measures design, we studied prospectively 18 boilermakers overhauling an oil-fired boiler and 11 utility worker controls. Subjects completed a respiratory symptom diary five times per day by using a 0-3 scale where 0=symptom not present, 1=mild symptom, 2=moderate symptom, and 3=severe symptom. Daily symptom severity was calculated by using the highest reported score each day for upper and lower respiratory symptoms. Daily symptom frequency was calculated by summing all upper or lower airway symptom reports, then dividing by number of reporting times. Respiratory symptom frequency and severity were analyzed for dose-response relationships with estimated vanadium and PM10 doses to the lung and upper airway by using robust regression. Results During the overhaul, 72% of boilermakers reported lower airway symptoms, and 67% reported upper airway symptoms. These percentages were 27 and 36 for controls. Boilermakers had more frequent and more severe upper and lower respiratory symptoms compared to utility workers, and this difference was greatest during interior boiler work. A statistically significant dose-response pattern for frequency and severity of both upper and lower respiratory symptoms was seen with vanadium and PM10 in the three lower exposure quartiles. However, there was a reversal in the dose-response trend in the highest exposure quartile, reflecting a possible healthy worker effect. Conclusions Boilermakers experience more frequent and more severe respiratory symptoms than utility workers. This is most statistically significant during boiler work and is associated with increasing dose estimates of lung and nasal vanadium and PM10. Am. J. Ind. Med. 37:353-363, 2000. © 2000 Wiley-Liss, Inc.