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Friday, May 16, 2014

CHRIS HARDING GUEST POST: On the New RAC Report



Written by Chris Harding, Gulf War veteran, in response to written statements (by Jim Bunker) on the 2014 RAC Report 

Larger Studies[Jim Bunker]

Jim Bunker Quote: That is because neither the primary report nor the executive summary recommended that the Secretary of the Department of Veterans Affairs conduct any kind of follow-up research in regards to the pilot studies cited within the report. While the CDMRP has conducted over 50 different research studies, the report does not comprehensively incorporate that activity into a single follow-on study. I believe the RAC should ask the Secretary to conduct such a larger study to move research and treatment forward.[1, Jim Bunker;Page 1]

Personally, I would like to see more suggestions of larger trials too. The RAC did have a section in the 2008 report titled “Research Priorities and Recommendations.”[5] In fact, most of the RAC suggestions listed on page 16[5] appear to have been done by independent researchers such as Dr. Haley, Dr. Golomb, Dr Baraniuk, etc. Even Veterans Affairs has done some studies that turned out to be fruitful.

In truth, 1991 Gulf War illness is complex, and the reason we ill 1991 Gulf War veterans have seen success is because of the diverse pilot studies. With that said, I personally believe many of the recent studies from Dr. Baraniuk on Central Nervous System (CNS) damage, Dr. Haley on autonomic nervous system damage, Dr. Golomb on mitochondria damage, etc should be considered for larger studies. Interestingly, the Veterans Affairs could have made this decision themselves, but the VA seems to have decided to do small pilot studies to verify independent research results[6;7]. As an example, the VA appears to be verifying Dr. Haley’s and Dr. Baraniuk’s results[Quote, 6;7]. As such, the Veterans Affairs decided to do pilot studies instead of large trials.

RAC 2008 Report Quote: "Recommended research includes studies that expand on existing biological findings in Gulf War veterans—comprehensive research on brain structure and function, autonomic function, neuroendocrine and immune alterations, and processes associated with biological vulnerability to neurotoxicants—as well as studies that investigate neuroinflammatory processes and utilize genomic and related technologies to identify biological characteristics of Gulf War illness. Additional research priority areas include studies that characterize effects of neurotoxic exposures associated with Gulf War illness, and epidemiologic studies to assess rates of neurological diseases in Gulf War veterans."[5, Page 16 and 17]

A few examples: Dr. Baraniuk's studies on Central Nervous System damage (brain structure and function); Dr. Haley's studies on autonomic nervous system dysfunction (autonomic function) that was mostly verified by a VA pilot study on autonomic dysfunction[6]; Dr. Golomb's studies on mitochondria and associated toxic effects of our environmental exposures on mitochondria; etc. In fact, all researchers considered the toxic effects of our environmental exposures.

Personally, I realize that peer-repeated studies strengthens the science. As such, it might not be time for larger trials yet, but, logically, one can assume that larger studies is the next step in the process, which is not the hard part. The hard part is the actual research, and many current and past RAC members have benefited ill 1991 Gulf War veterans. 

Sadly, I also believe RAC members might be a little disgruntled with the institutional corruption at the Veterans Affairs. For this reason, I think the RAC put the responsibility for determining future trials into the Veterans Affairs corner[Quote, 2]. Still, I have no personal information to verify the latter. If true, the RAC and the VA are responsible.

RAC Quote: “Center- and consortium based treatment research efforts can capitalize on multi-disciplinary expertise and multi-pronged approaches to treatment targets and pre-clinical trials. The CDMRP treatment consortia are an important step in developing integrated treatments for ill Gulf War veterans as an initial assessment of treatment safety and efficacy in Phase I/II trials. Since CDMRP has limited capacity to fund larger clinical trials, validation studies through the VA Cooperative Studies Program (CSP) or similar large, multi-site, government sponsored programs are necessary to provide validation of the safety and efficacy outcomes identified in initial Phase I/II trials. When a pilot treatment study funded by VA or CDMRP shows promising results and is judged to have scientific merit, VA should follow up with a larger trial or other systematic assessment of the treatment’s potential benefits.”[2, Executive Summary, Page 14]

The above paragraph appears three times in the most Recent RAC report[2], and Jim Bunker actually refers to it later in his letter when he mentions page 79.

As an example of a suggested need for more studies that will lead to a potentially larger study, I believe the above quote covers the following[2, Page 25]. Still more suggestions would have been beneficial.

RAC Quote: “As described in the 2008 Committee report, only limited research has been conducted to determine cancer rates in Gulf War veterans. As of 2008, information from two studies provided no evidence of significantly increased cancer morbidity among Gulf War veterans (Macfarlane et al., 2003; McCauley et al., 2002). However, preliminary data from one pilot study indicated a significant proportional excess of testicular cancer and non-Hodgkin’s lymphoma among deployed Persian Gulf War veterans, identified in specific state cancer registries (Levine et al., 2005).”[2]



Report Falls Short[Jim Bunker]

Jim Bunker Quote: “This Report also falls short by not giving the Secretary advice or tools to request funding for much-needed research into diagnosis and treatment of Gulf War Veterans”[1, Jim Bunker, Page 1]

As mentioned before, it is my opinion that the diverse research and pilot studies are needed to properly map potential causes of our symptoms. As an example, mitochondria damage and Central Nervous System (CNS) damage can cause chronic fatigue like symptoms, and each dysfunction might be interrelated. If only CNS research would have been done, the dysfunctional mitochondria would not have been discovered. As such, potential treatments for CNS damage might not have proved to reduce all fatigue symptoms. In turn, more pilot studies would have been needed anyhow. Also, the 2008 report accurately recommended studies that have turned out to be significant in 1991 Gulf War Illnesses. In the recent RAC report, May 2014, the RAC suggests the VA now start considering the pilot studies that stemmed from the 2008 report, which were fruitful, and consider larger trials.

Also, most of the June, 2012, Congressionally Chartered Research Advisory Committee on Gulf War Veterans’ Illnesses (RAC) report covered funding and misappropriation of funds leading to inadequate research. Most advocates believe the VA retaliated against the release of the June 2012 report. Just read the first page of the report and the following quote.

2012 RAC Report Quote: “VA research officials continue to misrepresent to the Secretary of Veterans Affairs and to Congress, in the Annual Report(s) To Congress, the level of research dollars spent addressing the health of Gulf War veterans. The true figures are vastly overstated by the inclusion of funds spent on studies that have little or nothing to do with Gulf War veterans. [Appendix C].”[3]

As previously mentioned, the June, 2012, RAC report is expected as the reason for the gross charter changes that has lead the US House Committee on Veterans Affairs to introduce legislation to make the RAC independent once again. 



Suggestion of Endoscopy To Diagnose GERD[Jim Bunker]

Bunker Quote: “The study needs to be using an Endoscopy to check for damage.”[1, Jim Bunker; Page 3]

After a brief review of the literature, I disagree that endoscopy alone should be used to detect GERD. The diagnosis of GERD is complicated and many procedures might be needed to give a definitive diagnosis[8]. Also, many medical researchers state that the 24 hour pH study is the most sensitive for detecting acid that will likely progress to severe GERD[8;9].

Quote: “The pattern of esophageal acid exposure has been shown to influence severity of the disease, which increases progressively from postprandial to upright, supine and bipositional reflux (21).”[8]

Quote: ”Currently upper gastrointestinal endoscopy is the main clinical tool for visualizing esophageal lesions. Since the majority of GERD patients do not have endoscopic visible lesions other methods are required to document the abnormal acid exposure in the distal esophagus. For many clinicians ambulatory esophageal pH monitoring is the gold standard in diagnosing GERD since it quantifies distal esophageal acid exposure and allows the evaluation of the relationship between symptoms and acid reflux.”[9]

Medicine is complicated.


Gulf War Illness Treatment Research Recommendations[Jim Bunker]

Above, I provided a Veteran’s Affairs quote that suggested a larger study for autonomic dysfunction in 1991 Gulf War veterans[6], and I personally believe that Dr. Baraniuk’s study on CNS damage, Dr. Haley’s study on autonomic nervous system dysfunction, and Dr, Golomb’s study on dysfunctional mitochondria should be considered for a larger study. As mentioned several times, the Veterans Affairs have already done a pilot study that verified some of Dr. Haley’s autonomic nervous system dysfunction[6]. 



References:

[1] Bunker, Jim. National Gulf war Resuorce Center. Jim Bunker Rebuttal to Congressionally Charter Research Advisory Committee on Gulf War Veterans Illnesses, Apr. 24, 2014. Available from: http://www.scribd.com/doc/225134920/Jim-Bunkers-Rebuke-of-RAC?secret_password=AZCC8g7DWUxQ3Y1RT0Bo

[2] Research Advisory Committee on Gulf War Veterans’ Illnesses. Gulf War Illness and the Health of Gulf War Veterans: Research Update and Recommendations, 2009-2013: Updated Scientific Findings and Recommendations, April 2014. bu.edu[online]. 2014. Available from: http://www.bu.edu/sph/files/2014/04/RAC2014.pdf

[3] Research Advisory Committee on Gulf War Veterans' Illnesses. Research Advisory Committee on Gulf War Veterans' Illnesses Findings and Recommendation, June 2012. va.gov[online]. 2012. Available from: http://www.va.gov/RAC-GWVI/docs/Committee_Documents/CommitteeDocJune2012.pdf

[4] US Department of Veterans Affairs. Charter of the Research Advisory Committee on Gulf War Veterans’ Illnesses (RAC). scribd.com[online]. 2014. Available from: http://www.scribd.com/doc/150956464/Sixth-Revised-RAC-Charter-05-17-2013

[5] Research Advisory Committee on Gulf War Veterans' Illnesses. Gulf War Illness and Health of Gulf War Veterans. Scientific Findings and Recommendations, 2008. va.gov[online]. 2012. Available from: http://www.va.gov/RAC-GWVI/docs/Committee_Documents/GWIandHealthofGWVeterans_RAC-GWVIReport_2008.pdf

[6] li, M; Xu, C; Yo, W; Mahan, CM; Kang, HK; Sandbrink, F; Zhai, P; Karasik, PA. Self-reported post-exertional fatigue in Gulf War veterans:roles of autonomic testing, Jan 7, 2014. Front Neurosci[online]. 2014. vol. 7(269). Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3882719/ PMCID: PMC3882719; doi: 10.3389/fnins.2013.00269

[7] WRIISC Advantage. NJ WRIISC focuses on Gulf War Veterans in research, June 2013. drive.google.com[online]. 2013. Available from: https://docs.google.com/file/d/0B1JqJ6C1t6WHU2VpWHl2SGFYNW8/edit?usp=sharing

[8] Gorecki, P., MD. Surgical Treatment: Evidence-Based and Problem-Oriented: Gastro-esophageal reflux disease (GERD), 2001. ncbi.nlm.nih.gov[online]. 2014. Available from: http://www.ncbi.nlm.nih.gov/books/NBK6896/

[9] Tutuian, Radu. Update in the Diagnosis of Gastroesophageal Reflux Disease. jgld.ro[online]. 2006. Available from: http://www.jgld.ro/2006/3/6.pdf




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