Presumptive Service Connection for Diseases Associated With Persian Gulf War Service

[Federal Register: November 17, 2010 (Volume 75, Number 221)]
[Proposed Rules] [Page 70162-70165]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr17no10-28] ======================================================================= DEPARTMENT OF VETERANS AFFAIRS
38 CFR Part 3
RIN 2900-AN83
Presumptive Service Connection for Diseases Associated With Persian Gulf War Service: Functional Gastrointestinal Disorders
AGENCY: Department of Veterans Affairs.
ACTION: Proposed rule.
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DATES: Comments must be received by VA on or before December 17, 2010.
ADDRESSES: Written comments may be submitted through http://
www.Regulations.gov; by mail or hand-delivery to Director, Regulations Management (02REG), Department of Veterans Affairs, 810 Vermont Ave., NW., Room 1068, Washington, DC 20420; or by fax to (202) 273-9026. (This is not a toll free number.) Comments should indicate that they are submitted in response to ``RIN 2900-AN83--Presumptive Service Connection for Diseases Associated With Persian Gulf War Service: Functional Gastrointestinal Disorders (FGIDs).''
Copies of comments received will be available for public inspection in the Office of Regulation Policy and Management, Room 1063B, between the hours of 8 a.m. and 4:30 p.m., Monday through Friday (except holidays). Please call (202) 461-4902 for an appointment. (This is not a toll free number.) In addition, during the comment period, comments may be viewed online through the Federal Docket Management System at http://www.Regulations.gov.
FOR FURTHER INFORMATION CONTACT: Gerald Johnson, Regulations Staff (211D), Compensation and Pension Service, Veterans Benefits Administration, Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 20420, (202) 461- 9727 (This is not a toll-free number.)
SUPPLEMENTARY INFORMATION: The Secretary of Veterans Affairs has determined that the available scientific and medical evidence presented in the National Academy of Sciences (NAS) April 2010 report, titled Gulf War and Health, Volume 8: Update on the Health Effects of Serving in the Gulf War is sufficient to warrant a presumption of service connection for FGIDs in individuals deployed to the Southwest Asia theater of operations during the Persian Gulf War. Pursuant to that determination, this document proposes to clarify that the Department of Veterans Affairs (VA) adjudication regulations (38 CFR Part 3), specifically 38 CFR 3.317, would include FGIDs as medically unexplained chronic multisymptom illnesses subject to presumptive service connection. FGIDs include, but are not limited to, such conditions as irritable bowel syndrome (IBS) and functional dyspepsia.
National Academy of Sciences (NAS) Reports FGIDs, Including, But Not Limited to, Irritable Bowel Syndrome (IBS) and Functional Dyspepsia

The NAS issued its report titled Gulf War and Health, Volume 8: Update on Health Effects of Serving in the Gulf War, on April 9, 2010. The NAS was asked to review, evaluate, and summarize the literature to determine if any of the health outcomes noted in its 2006 report, titled Gulf War and Health, Volume 4: Health Effects of Serving in the Gulf War, appear at higher incidence or prevalence levels in Gulf War-
deployed veterans. The NAS sought to characterize and weigh the strengths and limitations of the available evidence. The NAS Update committee reviewed over 1000 relevant studies and focused on over 400 relevant references, including the studies reviewed in the Volume 4 report.

The NAS determined that there is sufficient evidence of an association between deployment to the Gulf War and FGIDs, including, but not limited to, IBS and functional dyspepsia. The committee also noted that there is inadequate evidence of an association between deployment to the Gulf War and structural gastrointestinal (GI) disease.

FGIDs, such as IBS or functional dyspepsia, are syndromes characterized by recurrent or prolonged GI symptoms that occur together. They are distinguished from structural or ``organic'' GI disorders in that they generally are not associated with detectable anatomical abnormalities. The severity of FGIDs ranges from occasional mild episodes to more persistent and disabling symptoms. According to the NAS report, there have been numerous reports of GI disturbances in Gulf War veterans and the symptoms have continued to be persistent in the years since that war. All studies examined by NAS favored a greater prevalence of various GI symptoms and primary functional GI disorders, including IBS and dyspepsia. In NAS's opinion, there also was compelling emerging evidence of exposure during deployment to enteric pathogens leading to the development of post-infectious IBS.

The overall pattern of symptoms found in the primary and secondary studies NAS reviewed confirms an association between deployment to the Gulf War and functional GI symptoms, including abdominal pain, diarrhea, nausea, and vomiting. The NAS recommended that further studies be conducted to determine the role of prior acute gastroenteritis among deployed servicemembers in the development of FGIDs.
Detailed information on the committee's findings may be found at: http://www.iom.edu/Reports/2010/Gulf-War-and-Health-Volume-8-Health-
Effects-of-Serving-in-the-Gulf-War.aspx. The report findings are organized by category and can be found under the heading, ``Table of Contents.''

Statutory Provisions
Pursuant to 38 U.S.C. 1118, VA must establish a presumption of service connection for each illness shown by sound scientific and medical evidence to have a positive association with exposure to a biological, chemical, or other toxic agent, environmental or wartime hazard, or preventive medicine or vaccine known or presumed to be associated with service in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War. Because the recent NAS report was primarily a review of the prevalence of illnesses among Gulf War veterans, it generally did not state conclusions as to whether the illnesses are associated with the types of exposures referenced in Sec. 1118.

The NAS noted that there was significant emerging evidence that FGIDs may be associated with exposure to enteric pathogens during Gulf War deployments and recommended further study of that issue. However, NAS did not state a conclusion concerning the strength of the evidence of an association between FGIDs and exposure to enteric pathogens. VA has determined that resolution of that question is not necessary for purposes of this rule, because FGIDs are within the scope of the existing presumption of service connection for medically unexplained chronic multisymptom illnesses.

Section 1117 of title 38, United States Code, provides a presumption of service connection for ``qualifying chronic disability'' in veterans who served in the Southwest Asia theater of operations during the Persian Gulf War. The statute defines the term ``qualifying chronic disability'' to include ``[a] medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms.'' 38 U.S.C. 1117(a)(2)(B).

The plain language of the statute makes clear that it applies to all medically unexplained chronic multisymptom illnesses including, but not limited to, the three conditions parenthetically listed as examples. VA recently amended its regulation at 38 CFR 3.317 to clarify that the presumption is not limited to the three listed examples. See 75 FR 61995.

FGIDs are medically unexplained chronic multisymptom illnesses within the meaning of the statute and regulation. These disorders are defined by clusters of signs and symptoms affecting GI functions. Further, FGIDs are ``medically unexplained'' because they are, by definition, disorders that cannot be attributed to observable structural or organic changes and the causes of the disorders are generally not known. Irritable Bowel Syndrome, which is a form of FGID, is expressly identified in the current statute and regulation as a medically unexplained chronic multisymptom illness. Because other FGIDs, such as functional dyspepsia and functional vomiting, also are medically unexplained chronic multisymptom illnesses, the current statute and regulation, as recently amended, provide a presumption of service connection for FGIDs in veterans who served in the Southwest Asia theater of operations during the Persian Gulf War. In view of the findings in the recent NAS report identifying FGIDs as prevalent and persistent illnesses among Gulf War Veterans, VA has determined that its regulations should be revised to expressly identify FGIDs as a type of medically unexplained chronic multisymptom illness within the scope of the existing presumption.

Regulatory Amendments
We propose to amend 38 CFR 3.317 to incorporate the more specific language regarding FGIDs. We propose to: Revise Sec. 3.317(a)(2)(i)(B)(3) by removing ``Irritable Bowel Syndrome'' and replacing it with ``Functional gastrointestinal disorders, including, but not limited to, irritable bowel syndrome and functional dyspepsia (excluding structural gastrointestinal diseases)''; and add a Note with the definition of functional gastrointestinal disorders. The intended effect of this change is to clarify that FGIDs are medically unexplained chronic multisymptom illnesses and are thus within the scope of the presumption of service connection for such illnesses.
Other Illnesses

Mild Brain Damage 2010 VA Study Gulf War

RESULTS: GW veterans with suspected GB/GF exposure had reduced total GM and hippocampal volumes compared to their unexposed peers (p< or =0.01). Although there were no group differences in measures of cognitive function or total WM volume, there were significant, positive correlations between total WM volume and measures of executive function and visuospatial abilities in veterans with suspected GB/GF exposure.

CONCLUSIONS: These findings suggest that low-level exposure to GB/GF can have deleterious effects on brain structure and brain function more than decade later.


Neurotoxicology. 2010 Sep;31(5):493-501. Epub 2010 May 24.

Effects of low-level exposure to sarin and cyclosarin during the 1991 Gulf War on brain function and brain structure in US veterans.
Chao LL, Rothlind JC, Cardenas VA, Meyerhoff DJ, Weiner MW.

Center for Imaging of Neurodegenerative Diseases, San Francisco Veterans Affairs Medical Center, 4150 Clement Street, 114 M, San Francisco, CA 94121, USA. linda.chao@ucsf.edu

Abstract
BACKGROUND: Potentially more than 100,000 US troops may have been exposed to the organophosphate chemical warfare agents sarin (GB) and cyclosarin (GF) when a munitions dump at Khamisiyah, Iraq was destroyed during the Gulf War (GW) in 1991. Although little is known about the long-term neurobehavioral or neurophysiological effects of low-dose exposure to GB/GF in humans, recent studies of GW veterans from the Devens Cohort suggest decrements in certain cognitive domains and atrophy in brain white matter occur individuals with higher estimated levels of presumed GB/GF exposure. The goal of the current study is to determine the generalizability of these findings in another cohort of GW veterans with suspected GB/GF exposure.

METHODS: Neurobehavioral and imaging data collected in a study on Gulf War Illness between 2002 and 2007 were used in this study. We focused on the data of 40 GW-deployed veterans categorized as having been exposed to GB/GF at Khamisiyah, Iraq and 40 matched controls. Magnetic resonance images (MRI) of the brain were analyzed using automated and semi-automated image processing techniques that produced volumetric measurements of gray matter (GM), white matter (WM), cerebrospinal fluid (CSF) and hippocampus.

Gulf War Illness Research Needs

Recruit the Scientist Researchers and Doctors to help Gulf War Veterans who are ill!
by Denise Nichols Your note has been created.
Gulf war veterans ill with GWI need attention! We will go out and recruit scientist and researchers and notify them of VARAC GWI and the DOD CDMRP GWI research funds available! We will ask them, beg them, to become part of the team to help our gulf war veterans with gulf war illness।


We have gone too long-20 years and need the best of the best recruited to help the veterans Now. I want all gulf war veterans that are ill to help with this effort! Enough with playing computer games etc etc lets drive this force to find us real answers and help! We will recruit the researchers! We will recruit the doctors that know and are helping from the civilian side of the house.

We are tired of VA doctors looking at us like we are aliens and sending us to psych. consults, psych drugs are not the answer. This is not stress! We want our lives back! It is time for VA to listen to us we want answers and medical care, we want our lives back! WE are tired and sick and need help now! Let us go get the best of the best recruited to help us! Are you in?

Below is another candidate for us to recruit!
The neurocognitive brain damage we have is like an early althemizer's disease! We have neuro immune degenerative type diseases....Gulf War Veterans deserve no less!
You may not be able to travel veterans but you can find email or snail mail or phone numbers on these researchers. We can develop a template letter and then add our own short plead for help! Lets all make this happen!

WHO - UCSF Nobel laureate Stanley B. Prusiner, MD,
WHY -UCSF professor of neurology and director of the Institute for Neurodegenerative Diseases, has been named to receive the National Medal of Science, the nation's highest honor for science and technology.

ACTION Demand that VA-ORD and VA-GWI- Research Advisory Committee communication and listen comments of this scientist on the be half of disable gulf war veterans.
ACTION CAMPAIGN REACH OUT AND CONTACT A RESEARCHER AND
GET THEM TO LOOK GW Illness
Venus Hammack

War Veterans’ Concussions Are Often Overlooked

War Veterans’ Concussions Are Often Overlooked

“They said it was because I didn’t report it in the field and seek medical attention at the time, and there was no proof” of any obvious injury, Mr. Owsley said. “I had guys write statements for me to prove it had happened. As a soldier with 23 years in the Army, them badges mean more than anything. When you get injured, you should be recognized, even if you don’t see it over there.”

These symptoms, which may be subtle and may not surface for weeks or months after their return, are often debilitating enough to hobble lives and livelihoods.

To this day, some veterans — it is impossible to know how many — remain unscreened, their symptoms undiagnosed. Mild brain injury was widely overlooked by the military and the veterans health system until recently

Given that he never lost consciousness, he figured the discomfort would work itself out and kept it to himself.

“You keep doing your job with your injuries veterans say.
These mild concussions, which do not necessarily lead to loss of consciousness, are easy to dismiss, simple to misdiagnose and difficult to detect. The injured soldiers can walk and talk. Their heads usually show no obvious signs of trauma. CT scans cannot see the injuries. And the symptoms often mirror those found in post-traumatic stress disorder, making it hard to distinguish between them. In fact, the two ailments often go hand in hand.

http://www.nytimes.com/2008/08/26/us/26tbi.html?pagewanted=all

Mild Brain injury In Veterans

WASHINGTON — The government plans to substantially increase disability benefits for veterans with mild traumatic brain injuries, acknowledging for the first time that veterans suffering from this less severe version of the Iraq war's signature wound will struggle to make a living.
"We're saying it's real," said Tom Pamperin, a deputy director for the Department of Veteran Affairs, about the significance of the change to benefits in the regulation the VA plans to publish today.

Up to 320,000 troops who served in Iraq and Afghanistan suffered traumatic brain injury, a RAND Corp. study estimated this year. The vast majority of the cases are mild and came from exposure to an explosion, often from a roadside bomb. Most veterans with mild cases recover, Pamperin said, but some are left with permanent problems.

The regulation modifies a 1961 rating schedule for mild brain trauma and brings compensation for this ailment into the 21st Century, said Lonnie Bristow, chairman of an Institute of Medicine committee that studied veterans' benefits.

The old regulation failed to recognize that wounds such as brain injuries from blasts — which do not show up on scans — are only understood by what patients say they are suffering, Bristow said.

"VA has been assessing their injuries based on outdated science," said Sen. Daniel Akaka, D-Hawaii, chairman of the Veterans Affairs Committee.

The regulation modifies a 1961 rating schedule for mild brain trauma and brings compensation for this ailment into the 21st Century, said Lonnie Bristow, chairman of an Institute of Medicine committee that studied veterans' benefits.

The old regulation failed to recognize that wounds such as brain injuries from blasts — which do not show up on scans — are only understood by what patients say they are suffering, Bristow said.

"VA has been assessing their injuries based on outdated science," said Sen. Daniel Akaka, D-Hawaii, chairman of the Veterans Affairs Committee.

http://www.usatoday.com/news/military/2008-09-22-tbibenefits_N.htm

What piece of mind for Gulf War Veterans

Finally, piece of mind for Gulf War Veterans
by SENATOR JAY ROCKEFELLER

A long-anticipated report was recently and finally issued that
brought comfort to many Gulf War veterans and their families. The
report issued by the Congressionally-mandated Research Advisory Com-
mittee on Gulf War Veterans' Illnesses in conjunction with the
Boston University School of Public Health reached an important
conclusion ? simply put: there is substantial and overwhelming
evidence that Gulf War Syndrome is a real illness.

The Committee report is important news for Gulf War veterans and
their families. At long last, they have validation that the health
issues they live with each day are real, there is a name for their
illness, and there is hope that they can finally get the treatment
and disability benefits that they are entitled to receive.

Not long after the successful conclusion of the Gulf War, many
soldiers returned home with multiple, persistent health problems
that had no clear cause and no cure. The symptoms experienced by
these veterans included a combination of memory and concentration
problems, persistent headaches, unexplained fatigue and widespread
pain, and also included chronic digestive problems, respiratory
symptoms and skin rashes.

Unfortunately, Gulf War veterans' complaints about their health
issues fell on deaf ears at the VA and within the Pentagon. As
Chairman of the Senate Veterans Affairs Committee in the early
1990s, I believed it absolutely necessary to get to the truth ? no
matter how uncomfortable it would be for the Pentagon or the VA.

Throughout the 1990s, those of us on the Senate Committee on
Veterans' Affairs held numerous, often contentious, hearings into
what would come to be known as Gulf War Syndrome or Gulf War
Illness. The Pentagon and the VA never officially acknowledged the
cause of these symptoms. Despite the lack of an official cause, it
became clear through our investigation that pyridostigmine bromide,
a "pretreatment" for nerve agent poisoning, was at least one cause
for the symptoms experienced by Gulf War veterans.

Now, 17 years later, the Congressionally-mandated Research Advisory
Com-mittee on Gulf War Veterans' Illnesses has officially released a
450-page report that validates these suspicions. It confirms Gulf
War Illness is a result of soldiers' exposure to neurotoxic
chemicals, including pyridostigmine bromide and pesticides. The
Committee also found that the association between exposure to smoke
from oil well fires, neurotoxins, and the receipt of large numbers
of vaccines could not be ruled out as causes as well.

This report confirms the cause of Gulf War Illness, but sadly, it
also states that the majority of sick Gulf War veterans have not
seen their health improve over time. Treatment options for the
175,000 ? 210,000, or one in four, Gulf War veterans suffering from
the effects of neurotoxin exposure remain few and ineffective.

We have a moral responsibility to provide care for Gulf War
veterans. They served our country, put their lives on the line and
fought with great distinction. I will not stop fighting until our
veterans are provided with every resource and benefit they have
earned.

More research must be conducted into the proper treatment of this
illness. I am pushing now for increased funding that will keep this
issue front and center ? and bring us closer to finding a cure.

I have been working for Veterans my entire career. As a nation, we
owe them everything and can never forget how much they have
sacrificed and how deserving they are of piece of mind, support, and
a special thing called hope.
http:www.rockefeller.senate.gov/contact/

(PS) as lived by Venus Hammack a VA-DHA patient