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JaeNobe

Seaman
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About JaeNobe

  • Rank
    E-3 Seaman
  • Birthday July 20

Profile Information

  • Military Rank
    E-5
  • Location
    Schofield Barracks, HI

Previous Fields

  • Service Connected Disability
    90%
  • Branch of Service
    Army

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  1. I know the feeling.... My C&P examiner had two questions for me: 1. Had I tried to claim OSA before 2. Do you have any questions for me. That was it. The rest of the time she explaining to me what sleep apnea is.
  2. Huge difference... I just hope the RO sees it in my favor.
  3. Its about 19 pages long but i tried to shorten it As my attached curriculum vitae indicates [Exhibit 1], I am a surgeon with almost thirty years of medical experience. I was Clinical Associate Professor of Surgery and Attending Surgeon in Transplantation at SUNY at Stony Brook. I served as President of the New York '·' Transplantation Society and as Assistant Editor of Transplantation Proceedings. I hold three patents. I have authored three book chapters and 106 research papers published in peer reviewed medical journals. Opinions The following opinions are all to a reasonable degree of medical certainty at least at the "more likely than not" (more than 50 percent) level. I do not have a vested interest in the assignment of this patient's medical diagnostic codes as I am an expert and paid a flat fee prior to the writing of any of my reports. My opinions are based on the judicious application of the medical principles / my training / experience. This report conforms to the federal guidelines on expert testimony as they apply to medical data/facts, reliable principles/methods (see my attached C.V. and book references), and the application of medical principles/methods to the facts/data and is therefore not in any way speculative. After reviewing the veteran's c-file and the pertinent recent medical literature, I opine that it is more likely than not that the veteran's sleep apnea is caused by and/or aggravated by his service-connected conditions of depressive disorder and chronic pain syndrome related to his service-connected injuries. Sleep apnea diagnosis A sleep medicine consult dated July 20, 2006 reports [Exhibit 2]: "The supervising practitioner of record for this patient care encounter is Dr. Sharafkhaneh, Amir. HISTORY OF PRESENTING ILLNESS Patient is a 26 y/o veteran who is being evaluated in sleep clinic for excessive day time sleepiness. He typically retires at about 10 pm .Falls asleep in about 20 mins. He does not c/o restless leg activity while going to sleep. His sleep is not interrupted by nocturnal awakenings. He wakes up at 4:30 am. On awakening patient feels /does not feel refreshed. He has a dry mouth but no head ache on waking up. He has nocturnal reflux episodes. He does not report any symptoms s/o narcolepsy of cataplexy, hypogogic hallucinations or on rare occasions he has experienced sleep paralysis. He does not report any parasornnias. Epworth Sleepiness scale 10 Depression Score ... Assessment: Patient appears to have Obstructive Sleep Apnea with an Epworth Score of 10 indicating mild excessive day time sleepiness." A medical record dated February 23, 2007 shows [Exhibit 3]: "The supervising practitioner of record for this patient care encounter is Dr. Sharafkhaneh, Amir. Referred for: Patient is a 26 year old veteran referred with Obstructive sleep apnea who is seen for follow up. CPAP machine is set at a pressure of 8 H20 .Checked against a manometer and delivers the set pressure." There are two basic mechanisms for obstructive sleep apnea. The first is static narrowing of the airways due to swelling of structures that block the airway. Some examples are septal deviation of the nose, or accumulation of fat in the retro pharynx noted in certain types of obesity. The second, and more frequent reason for sleep apnea, are dynamic processes that involve the muscle tone, mostly of the tongue due to hypotonia of the genioglossus muscle. Jordan et al.i published a study: Airway Dilator Muscle Activity and Lung Volume During Stable Breathing in Obstructive Sleep Apnea: "Obstructive sleep apnea (OSA) is a common disorder, characterized by repetitive upper airway collapse during sleep. Upper airway collapse in OSA is thought to occur at sleep onset because of the reduction of activity of several upper airway dilator muscles, which then do not hold the anatomically vulnerable airway open. The severity of OSA varies throughout the night and between sleep stages. Generally, obstructive respiratory events are more common and longer in REM than NREM sleep." airway. Jordan et al. have shown that when patients with OSA spontaneously overcome their tendency for airway collapse and have stable breathing during sleep, the genioglossus muscle is more active than during disordered breathing events: "Electrical activation of the genioglossus muscle or hypoglossal nerve is known to dilate the retroglossal airway and reduce the pharyngeal critical closing pressure in humans. Thus, it would appear lik􀀉.ly that the increased genioglossus muscle activity is playing a causal role in contributing to the sleep stage and time of night differences in the severity ofOSA ... Prior research has shown that the genioglossus is activated by chemoreceptor stimulation and by reflex activation in response to negative pressure. There is also evidence to suggest that the genioglossus receives an independent stimulation during wakefulness which is lost at sleep onset and is known as the 'wakefulness stimulus'." Sleep apnea secondary to Veteran's service-connected mood disorder It is my professional opinion that Veteran's sleep apnea is more likely than not caused by and/or aggravated by his service-connected psychiatric condition (depressive disorder). Sleep apnea in military personnel has now reached an epidemic proportion. A studyii from the Defense Medical Surveillance System (DMSS) reported the incidence of OSA and associated attrition from service in active component military members from 1 January 2004 through 31 May 2016. The study identified 223,731 incident cases of OSA with an overall incidence rate of 13 9 .2 per 10,000 person-years, between 2004 and 2015. Rates increased more than 3-fold between 2004 and 2015. In 2015, 48.1 % of all incident cases of OSA were diagnosed in the last year of service. Sharafkhanel et al. in the study Association of psychiatric disorders and sleep apnea in a large cohort iii' reviewed the Veterans Health Administration data from 1998 to 2001 and identified patient records indicating sleep apnea and various psychiatric conditions. Out of 4,060,504 unique cases, 118,105 were identified as having sleep apnea ( estimated prevalence of 2.91 % ). Psychiatric comorbid diagnoses in the sleep apnea group included depression (21.8% ), anxiety (16. 7% ), posttraumatic stress disorder (11. 9% ), psychosis (5 .1 % ), and bipolar disorders (3.3%). Compared with patients not diagnosed with sleep apnea, a significantly greater prevalence (P < .0001) was fou)!d for mood disorders, anxiety, posttraumatic stress disorder, psychosis, and dementia in patients with sleep apnea. The study concluded that sleep apnea is associated with a higher prevalence of psychiatric comorbid conditions in Veterans Health Administration beneficiaries. Scientists at the Madigan Army Medical Center have recently studied the incidence of sleep apnea in military personnel.iv Mysliwiec et alv studied the associations between sleep disorders and service-related diagnoses of depression and posttraumatic stress disorder (PTSD). They evaluated 110 active duty soldiers referred to the sleep disorders clinic within 18 months of deployment. These soldiers were young ( average age 33.6 years) and not obese. Overall, 62.7% met diagnostic criteria for obstructive sleep apnea (OSA) and 63.6% for insomnia. 38.2% had comorbid insomnia and OSA. The incidence of PTSD, TBI and mood disorder reached Conclusion After reviewing all of the veteran's medical and military records, it is my expert medical opinion that it is more likely than not (50% or more) that the veteran's sleep apnea is caused by and/or aggravated by his service-connected conditions of depressive disorder and chronic pain syndrome related to his service-connected injuries. While each of these conditions solely is sufficient to cause OSA, clearly a combination of these disabilities will cause OSA.
  4. The C&P doctor finally updated the the DBQ. Please tell me what you think... NOTE: I have submitted to ebenefits a favorable IMO along with studies to prove my secondary condition. PULMONARY C & P EXAMINATION CONSULT : LOCAL TITLE: C&P RESPIRATORY STANDARD TITLE: PULMONARY C & P EXAMINATION CONSULT DATE OF NOTE: FEB 12, 2019@12:30 ENTRY DATE: FEB 15, 2019@12:51:05 AUTHOR: xxxxxxxxxxx-AOUI EXP COSIGNER: URGENCY: STATUS: COMPLETED Sleep ApneaDisability Benefits QuestionnaireName of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P ExaminationRequest?[X] Yes [ ] NoACE and Evidence Review-----------------------Indicate method used to obtain medical information to complete this document:[X] In-person examinationEvidence Review---------------Evidence reviewed (check all that apply):[X] VA e-folder (VBMS or Virtual VA)[X] CPRSA . Diagnosis------------Does the Veteran have or has he/she ever had sleep apnea?[X] Yes [ ] No[X] ObstructiveICD code: G47.33 Date of diagnosis: 20062. Medical history------------------a. Describe the history (including onset and course) of the Veteran's sleepdisorder condition (brief summary):3/5/02STR - YES TO FREQUENT TROUBLE SLEEPING - AND DEPRESSION SINCE ONSET OF?CHAPTER PROCEDURE ENTERING ALCOHOL COUNSELLING FOR INCREASED ETOH USE(???)2/7/02HEIGHT: 5'11WEIGHT: 195 LBSBMI = 27.2BMI AT TIME OF OSA DIAGNOSIS = 32b. Is continuous medication required for control of a sleep disordercondition?[ ] Yes [X] Noc. Does the Veteran require the use of a breathing assistance device?[ ] Yes [X] Nod. Does the Veteran require the use of a continuous positive airway pressure(CPAP) machine?[X] Yes [ ] No3. Findings, signs and symptoms-------------------------------Does the Veteran currently have any findings, signs or symptoms attributableto sleep apnea?[ ] Yes [X] No4. Other pertinent physical findings, complications, conditions, signs,symptoms and scars-----------------------------------------------------------------------a. Does the Veteran have any other pertinent physical findings,complications, conditions, signs or symptoms related to any conditionslisted in the Diagnosis Section above?[ ] Yes [X] Nob. Does the Veteran have any scars (surgical or otherwise) related to anyconditions or to the treatment of any conditions listed in the DiagnosisSection above?[ ] Yes [X] Noc. Comments, if any:No response provided.5. Diagnostic testing---------------------a. Has a sleep study been performed?[X] Yes [ ] NoIf yes, does the Veteran have documented sleep disorder breathing?[X] Yes [ ] NoDate of sleep study: 7/25/06Facility where sleep study performed, if known: HOUSTON VAResults:AHI = 19RDI = 25SAO2 NADIR = 76%b. Are there any other significant diagnostic test findings and/or results?[ ] Yes [X] No6. Functional impact--------------------Does the Veteran's sleep apnea impact his or her ability to work?[ ] Yes [X] No7. Remarks, if any:-------------------FULL TIME EMPLOYED DOING INVENTORY FOR COMPUTER HARDWARE X 3 YEARS****************************************************************************Medical OpinionDisability Benefits QuestionnaireName of patient/Veteran: ACE and Evidence Review-----------------------Indicate method used to obtain medical information to complete this document:[X] In-person examinationEvidence Review---------------Evidence reviewed (check all that apply):[X] VA e-folder (VBMS or Virtual VA)[X] CPRSMEDICAL OPINION SUMMARY-----------------------RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks:**CLAIM TYPE: ORIGINAL**SPECIAL CONSIDERATIONS: FDC**INSUFFICIENT EXAM: NOELECTRONIC CLAIMS FOLDER AVAILABLE.The Veteran has filed a fully developed claim. Please expedite.Date of claim: 01/25/2019Days pending: 4Veteran has a power of attorney.Please send a courtesy copy of the exam notice letter to 049 - TEXAS VETERANS COMMISSIONAttention C&P clinical staff - This exam request was scheduled at your location based on the claimant's residing zip code and ERRA instructions.These remarks were generated using version 4.45 of the Exam Request Builder (ERB_v_4.45).The Veteran will need to report for the following exam(s) unless the ACE process is utilized. Clinician: If using the ACE process to complete the DBQ, please explain the basis for the decision not to examine the Veteran, and identify the specific materials reviewed to complete he DBQ. Also if the exam is completed using ACE, please review the Veteran's claims folder and indicate so in the exam report.DBQ RESP Sleep apnea_________________________________________________________The following contentions need to be examined:Sleep Apnea secondary to Depressive DisorderMedical Opinion Active duty service dates:Branch: ArmyEOD: 08/17/1999RAD: 06/28/2002DBQ RESP Sleep apnea:Please review the Veteran's electronic folder in VBMS and state that it was reviewed in your report.A sleep study is already of record in the Veteran's claims folder.MEDICAL OPINION REQUESTTYPE OF MEDICAL OPINION REQUESTED: Secondary Service connection.OPINION REQUESTED: Secondary Service Connection.Is the Veteran's Sleep Apnea secondary to Depressive Disorder at least as likely as not (50 percent or greater probability) proximately due to or the result of depressive disorder (claimed as depression)?Rationale must be provided in the appropriate section. Your review is not limited to the evidence identified on this request form, or tabbed in the claims folder. If an examination or additional testing is required, obtain them prior to rendering your opinion.POTENTIALLY RELEVANT EVIDENCE:NOTE: Your (examiner) review of the record is NOT restricted to the evidence listed below. This list is provided in an effort to assist the examiner in locating potentially relevant evidence.Tab A (Private treatment record in VBMS): Independent medical expert opinion dated 01/21/2019Please direct any questions regarding this request to:Diane Martinez477 Michigan AvDetroit, MI 48226Phone number: (313)471-3936 Ext 2152Email: diane.martinez@va.govb. Indicate type of exam for which opinion has been requested: SLEEP APNEA*** REFERENCED DOCUMENTATION WERE REVIEWED ***TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE CONNECTION ]b. The condition claimed is less likely than not (less than 50% probability) proximately due to or the result of the Veteran's service connected condition. c. Rationale: OBSTRUCTIVE SLEEP APNEA IS A PHYSIOLOGICAL CONDITION OF THE UPPER AIRWAYS. ALTHOUGH SLEEP DISTURBANCE IS A SYMPTOM OF MOOD DISORDER, IT WOULD NOT CAUSE THE SOFT-PALATE PROBLEM ASSOCIATEDWITH SLEEP APNEA. "SLEEP APNEA IS A PERIODIC COMPLETE (CAUSING APNEA) OR PARTIAL (CAUSING HYPOPNEA) COLLAPSE OF PHARYNGEAL SOFT TISSUE DURING SLEEP"http://www.dynamed.com/topics/dmp~AN~T115600/Obstructive-sleep-apnea-OSA-in-adults#General-InformationIT IS NOTED THAT THE VETERAN'S BMI HAD INCREASED FROM 27 TO 32 (ATTHE TIME OF DIAGNOSIS; BMI OF 30 AND ABOVE IS CATEGORIZED AS OBESE.OBESITY IS ONE OF THE STRONGEST RISK FACTOR FORSLEEP APNEA. IT IS ASSOCIATED WITH ALTERATIONS OF ANATOMY THAT MAY LEAD TO UPPER AIRWAY OBSTRUCTION BY INCREASING THE NECK CIRCUMFERENCE AND DEPOSITS OF FAT AROUND THE NECK. THIS PLACES A LOAD ON THE UPPER AIRWAY THAT MAY LEAD TO AIRFLOW OBSTRUCTION. http://www.atsjournals.org/doi/full/10.1513/pats.200708-137MG#_i1OTH REFERENCES:1) http://www.uptodate.com/contents/overview-of-obstructive-sleep-apnea-in-adults?source=search_result&search=SLEEP+APNEA&selectedTitle=1%7E150#H7601862) http://emedicine.medscape.com/article/295807-overview#a4*************************************************************************xxxxxxxPA-C, MMScSigned: 02/15/2019 12:51
  5. no that is the doctor that did my sleep study at the VA and then the same name shows up on the Article you posted. My IMO was done by Dr. David Anaise
  6. I looked at the SecondarySleepApneaArticle you posted. Same Doctor!!
  7. I thought the same thing that she was concluded the exam with no exam. Like this was a waste of time. Glad to see its some kind of VA law that looks at it in our favor. Thank you like always doc25
  8. So follow up to my C&P today: Went in and it was all about Sleep Apnea. HOWEVER.... She asked me no questions just if i had any questions for her. I made sure she seen the statement by my doctor saying it was critical that i use my CPAP. She agreed because she said anyone that has OSA should be using a CPAP. Then she goes on an on about how Sleep Apnea causes depression not the other way around. I asked her well what about aggravating.. .she said yeah same thing. Says she sees my IMO and will review it but unless there is evidence that she agrees with then she doesn't see how Sleep Apnea can be secondary to Depressive Disorder or Pain from other service connections. She believes that my weight being over 33% BMI that it may have something to do with it. I asked if it could be medications that I take for Depression and Pains that cause drowsiness she again reiterated that it could be depression because im not getting adequate sleep. After leaving the exam with my wife we looked at each other said didn't know what to take from it. Then I began to think... She didn't write anything down. She didn't take notes, measure my neck look at throat anything. So very interested in know what her notes will be. Also, discouraging that she didn't even read my file prior to coming into the office to get a good diagnoses. Furthermore, if you didn't do any test, questions or takes notes why was I even there for a C&P?
  9. One more question... my Sleep Apnea notes in the VA systems state "Necessity of the CPAP" as a subject line. She then goes on to list education etc... About two paragraphs down she states that "Treatment for your sleep apnea is critical." I'm hoping that will suffice as its "medically necessary" My C&P is Tuesday. I'm hoping for the best!
  10. Thank you so much... that gives me so much hope. I appreciate it!
  11. Thank you so much... Is there a difference in at least as "likely as not" and "more likely than not" (more than 50 percent) - This is what my IMO says.
  12. Thank you broncovet for you info. I have an IMO from Dr. David Anaise. He does use the term "more likely than not (more than 50 percent) level" several times. Also, my sleep study shows that its necessary. Im hoping that the RO is just needing an actual Dr. to fill out the Sleep Apnea DBQ.
  13. Hello All, I recently submitted a claim for Sleep Apnea secondary to depressive disorder on Friday (1/25). Along with submitting the claim I submitted and IMO from a non-VA doctor. Today Tuesday 1/29 got a call to schedule my C&P. (World Record to me) Was wondering if anyone else thought this was weird and they also said that my C&P exam was going to be conducted with a Primary Physician not a Sleep Specialist. I also just thought about it. I didn't submit a DBQ with my initial claim. Could this be the reason? Just seemed off I'm not going to a specialist.
  14. Hello Silverdollar22, Im in the same boat you were. I tried submitting a claim straight up for Sleep Apnea. Now after a lot of research Im trying to service connect it to my SC Depression. Would you be able to send me a copy of the IMO. I plan to go see the sleep rx to possibly get a Nexus. Thanks in Advance.
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