Comment Period on Expanding Gulf War Presumptives to Include Functional G-I Disorders Extends through Dec. 17

Federal Register:
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.

SUMMARY:  The Department of Veterans Affairs (VA) is amending its adjudication regulations concerning presumptive service connection for medically unexplained chronic multi-symptom illnesses associated with service in the Southwest Asia theater of operations for which there is no record during service.  This amendment is necessary to implement a decision of the Secretary of Veterans Affairs that there is a positive association between service in Southwest Asia during certain periods and the subsequent development of functional gastrointestinal disorders (FGIDs), and to clarify that FGIDs fall within the scope of the existing presumption of service connection for medically unexplained chronic multi-symptom illnesses.  The intended effect of this amendment is to clarify the presumption of service connection for these illnesses based on service in Southwest Asia theater of operations during the Persian Gulf War.

Dates:  Comments must be received by VA on or before December 17, 2010.
Addresses:  Written comments may be submitted through http://www.Regulations.gov.

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-0f-Serving-in-the-Gulf-War.aspx. 

The report findings are organized by category and can be found under the heading, “Table of Contents.”

Study: Proof That a Gut-Wrenching Complaint -- Irritable Bowel Syndrome -- Is Not in Your Head

Irritable Bowel Syndrome is a “Presumptive” condition for Gulf War veterans

(ScienceDaily) — Irritable bowel syndrome makes life miserable for those affected -- an estimated ten percent or more of the population. And what irritates many of them even more is that they often are labeled as hypochondriacs, since physical causes for irritable bowel syndrome have never been identified.

Now, biologists at the Technische Universitaet Muenchen (TUM) have shed new light on the matter: They have discovered mini-inflammations in the mucosa of the gut, which upset the sensitive balance of the bowel and are accompanied by sensitization of the enteric nervous system.

Flatulence, constipation and diarrhea, nausea and stomach cramps: Irritable bowel syndrome (IBS) can turn digestion into a nightmare. Frequent visits to the bathroom are often accompanied by sleep disturbances, headaches, and backaches. In Germany alone, some seven million people are affected by the disorder -- and by the fact that their irritable bowel syndrome is often deemed psychosomatic. This is because the organic trigger of the disease has never been discovered, and consequently the various therapeutic interventions are disappointing for both the patients and their doctors. That may soon change, however, because now, for the first time, biologists in Munich have nailed down hidden physical causes of this bowel disorder.

Professor Michael Schemann's research team at the TUM Department for Human Biology has managed to demonstrate that micro-inflammations of the mucosa cause sensitization of the enteric nervous system, thereby causing irritable bowel syndrome. Using ultrafast optical measuring methods, the researchers were able to demonstrate that mediators from mast cells and enterochromaffin cells directly activate the nerve cells in the bowel. This hypersensitivity of the enteric nervous system upsets communication between the gut's mucosa and its nervous system, as project leader Prof. Schemann explains: "The irritated mucosa releases increased amounts of neuroactive substances such as serotonin, histamine and protease. This cocktail produced by the body could be the real cause of the unpleasant IBS complaints."

The TUM researchers in human biology are blazing a trail as they follow this lead. Their current focus is to what extent nerve sensitization correlates with the severity of symptoms. Working with colleagues from Amsterdam, they have already substantiated the clinical relevance of their results: Irritable bowel symptoms improved after treatment with an antihistamine known for its immune-stabilizing effect in the treatment of allergic reactions such as hay fever. Thanks to funding from the German Research Foundation (DFG), the scientists are now investigating whether the improved symptoms are accompanied by a normalization of nerve activity.

Successful identification of the active components could enable the development of effective drugs to treat irritable bowel syndrome. Even now, though, the TUM team have made life easier for many IBS patients, in that they have shown that the chronic disorder does have physical causes and is not merely "in their heads."

SOURCE:  Technische Universitaet Muenchen (2010, August 20). Proof that a gut-wrenching complaint -- irritable bowel syndrome -- is not in your head. ScienceDaily. Retrieved September 5, 2010, from: http://www.sciencedaily.com­ /releases/2010/08/100819141950.htm

Letter to VA Disability Compensation Advisory Committee Calls for Changes on Fibromyalgia, IBS Compensation

 

DATE:  June 22, 2010

TO:  VA Advisory Committee on Disability Compensation, ATTN: Ms. Ersie Farber, Designated Federal Officer, U.S. Department of Veterans Affairs, Veterans Benefits Administration (211A), 810 Vermont Avenue, N.W, Washington, DC 20420

SUBJECT: Gulf War Related Compensation – Fibromyalgia, Chronic Fatigue Syndrome, Irritable Bowel Syndrome

Dear Committee Members:

While searching the Public Record on another issue, I came across the notice for your public meetings, which concluded today. While my written submission obviously won’t make it to you in time for consideration at the current meeting, I hope that you will take it under consideration for your next meeting, or in the interim.

By way of introduction, I’m a service-disabled veteran, and I’ve been active on policy issues related to deployment, deployment health, and Gulf War veterans’ illnesses for about 15 years. As such, I’m an appointed member of the VA’s Research Advisory Committee on Gulf War Veterans’ Illnesses (RACGWVI), DoD’s Congressionally Directed Medical Research Program (CDMRP) Gulf War Illness Research Program (GWIRP) integration panel, and the newly created VA Gulf War Steering Committee (GWSC), which had its first meeting today.

I’m informed by my more than seven years active duty military service as a member of the U.S. Army special operations community, including service in Somalia and the 1991 Gulf War. my service as a former senior public official with the State of Wisconsin Department of Veterans Affairs, an ex-Congressional aide, active involvement with the Disabled American Veterans (DAV), the State of Wisconsin Council on Veterans Programs, 91outcomes.com (a health/news website I publish for my fellow Gulf War veterans), Veterans of Modern Warfare (VMW), and regular communications with the National Gulf War Resource Center (NGWRC).

Presumptive Claims for Gulf War Veterans. Currently, there are three “ill-defined” illnesses that are presumptive for Gulf War veterans. They are: Chronic Fatigue Syndrome, Fibromyalgia, and Irritable Bowel Syndrome.

I believe that these presumptions are appropriate, and are consistent with countless peer-reviewed scientific studies that have concluded that these conditions and/or their symptom sets have high, unusual prevalence among veterans of the 1991 Gulf War.

The first of three presumptive conditions for Gulf War veterans, Chronic Fatigue Syndrome (CFS), can currently be rated as high as 100% depending upon the level of debilitation. I believe this is appropriate and should remain as it is.

However, the second of the three conditions, Fibromyalgia (FM), can only be rated at a maximum of 40% under the current rating schedule, even though chronic fatigue and other debilitating symptoms can be totally and permanently disabling. And, because CFS is a diagnosis of last resort, a diagnosis of FM excludes a diagnosis of CFS, even if the veteran is clearly suffering from both debilitating chronic widespread pain and debilitating chronic fatigue. In other words, veterans who may be the worst off can only receive a maximum 40% rating if they have the diagnosis of FM, even with all the symptoms of CFS. VA should review these contorted rules so that veterans with FM can be rated as high as 100%, depending upon the level of debilitation.

For the third of the three current presumptive conditions, Irritable Bowel Syndrome (IBS) can be rated to a maximum rating of 30%. This rating can be made in conjunction with a rating for CFS or FM (but not both, as previously stated). VA should also review the rules governing the maximum rating for this condition to allow for higher ratings relative to the actual level of debilitation.

Given the predominance in epidemiological studies of Gulf War veterans complaining of upper and lower respiratory, digestive, and neurological symptoms, and conditions, VA should review the rules to grant presumptive service-connection for upper and lower respiratory, digestive, and neurological conditions to grant presumptive service-connection for these conditions, including but not limited to Gastro-Esophageal Reflux Disease (GERD), diagnosed respiratory disorders including but not limited to asthma, bronchitis, bronchiolitis, and chronic obstructive pulmonary disease (COPD), and diagnosed neurological disorders involving pain, cognition, and other symptoms widely reported symptoms among Gulf War veterans.

Finally, VA should work hard to establish an appropriate listing of presumptive illnesses for Gulf War veterans disability claims – the gateway to their VA health care.

Thank you for your service on behalf of all veterans.

Sincerely,

Anthony D. Hardie

Study: Regional Gray Matter Density Changes in Brains of Patients With Irritable Bowel Syndrome

Written by Anthony Hardie

(91outcomes.com) – There are visible changes in the gray matter of the brain in patients with Irritable Bowel Syndrome – a presumptive condition for service-connection for veterans with service in the Gulf War – says a new study published this month in Gastroenterology, the official journal of the American Gastroenterology Institute.

Using advanced brain imaging technology, the study found that patients with IBS had common changes in their brains’, with widespread areas of decreased grey matter density.

The areas of the brain affected are involved in cognitive/evaluative functions.

Study subjects were divided between controls without IBS and various subgroups of IBS patients separated based on their  most significant IBS symptoms.

The abstract of the study is below.

===========================

Background & Aims

Several studies have examined structural brain changes associated with chronic pain syndromes, including irritable bowel syndrome (IBS), but study sample sizes have been small and heterogeneous.

Methods

We used magnetic resonance imaging–based techniques, voxel-based morphometry, and cortical thickness analysis to examine brain anatomical differences in a relatively large, tightly screened sample of IBS patients (n = 55); we compared data with that from healthy persons (controls; n = 48).

Results

IBS was associated with decreased gray matter density (GMD) in widespread areas of the brain, including medial prefrontal and ventrolateral prefrontal cortex, posterior parietal cortex, ventral striatum, and thalamus. Compared with controls, we observed increased GMD in patients with IBS in the pregenual anterior cingulate cortex and the orbitofrontal cortex, as well as trends in the posterior insula/secondary somatosensory cortex, (para)hippocampus, and left dorsolateral prefrontal cortex. In accounting for anxiety and depression, we found that several of the regions involved in affective processing no longer differed between patients with IBS and controls, whereas the differences in prefrontal and posterior parietal cortices remained. The areas of decreased GMD associated with IBS were largely consistent across clinical subgroups, based on predominant bowel habit and pain predominance of symptoms. No overall or regional differences were observed in cortical thickness between patients with IBS and controls.

Conclusions

Changes in density of gray matter among regions involved in cognitive/evaluative functions are specifically observed in patients with IBS, whereas changes in other areas of the brain can be explained by levels of anxiety and depression.

Focus on Fibromyalgia: O, The Oprah Magazine Offers Alternative Treatment Suggestions

In his first O column, Dr. Mehmet Oz analyzes the different treatments for fibromyalgia, a presumptive condition for veterans of the 1991 Gulf War.

Written by Mehmet Oz, M.D., O, The Oprah Magazine columnist

(O, The Oprah Magazine - August 13, 2009) - Defining Fibromyalgia: Though classified as a disorder of the musculoskeletal system, the condition is now seen as a central nervous system problem. Symptoms include increased sensitivity to pain, achy and stiff joints, fatigue, and specific tender points on the back, chest, arms, and legs. Migraines, sleep disorders, and irritable bowel syndrome are also common complaints. Up to 3 percent of the population may suffer from fibromyalgia, but with no clear cause, the condition is difficult to diagnose.

Western Medicine Approach: A formal diagnosis for fibromyalgia didn't exist until 1990, but now there are three FDA-approved meds to combat the pain. Still, says Nancy Klimas, MD, director of the Allergy and Immunology Clinic at the University of Miami, "there is much more to treatment than a pill." Strategies are needed to improve sleep, stretch and restore symmetry to muscles that have been shortened by spasm, and raise overall conditioning through exercise.

Energy-Based Approach: Practitioners believe the root of fibromyalgia is a disturbance in nerves that blocks energy. The disturbance, says Devi S. Nambudripad, MD, PhD, and a licensed acupuncturist, is caused by sensitivities to substances ranging from pollen to vaccines to chemical agents in fabrics. Anxiety and depression may also play a part. Practitioners use acupuncture to release energy and allergy testing to identify problem substances.

Psychological Approach: "The pain of fibromyalgia is not caused by depression," says Leonard Jason, PhD, professor of psychology at DePaul University, "but depression can deepen a patient's experience of pain." Mental health professionals may play a complementary role in treatment, but it's a vital one. Cognitive behavioral therapy can relieve depression and help patients identify sources of stress that magnify their symptoms.

Nutrition-Based Approach: Fibromyalgia is a systemwide breakdown, says Jacob Teitelbaum, MD, medical director of the nationwide Fibromyalgia & Fatigue Centers. After suffering from the disease in the 1970s, he developed his own protocol; in studies, patients improved by as much as 91 percent. He recommends supplements to help sufferers sleep, balance hormones, boost immunity, and improve nutrition. He also prescribes regular exercise. (Try Dr. Oz's 20-minute workout plan)

My Recommendation: Because Western medicine was slow to accept fibromyalgia, it is behind in its work; this is an area where patients will want to take a serious look at alternative approaches. Energy-based medicine could offer some important advances in treatment over the next decade, but since it has yet to be tested by independent research, I think it's premature to base your therapy solely on this approach. I'm more impressed by Teitelbaum's supplement regimen, and not only because he has tested his theories: I've put patients on this program with very good results. I would add counseling, as it should always be a part of fibromyalgia treatment. If after a couple of months you don't see improvement, talk to your doctor about drug therapy.

UK Gulf War veterans suffering from IBS, PTSD, joint issues supports Debt of Honour campaign

Written by Nicola Fifield, The Press [York, UK]

(York, UK - 10:20am Friday 7th August 2009) -- A Gulf War veteran who is still coping with Post-Traumatic Stress Disorder (PTSD) 18 years after returning from combat has thrown her weight behind The Press’s Debt of Honour campaign.

Marianna Proietti, 39, of Acomb, in York, said she has to fight a constant battle to receive the full war pension she is entitled to and has given up trying to receive psychiatric treatment for her problems.

The mother-of-four also suffers from Irritable Bowel Syndrome and has undergone several operations to her shoulders and knees after they were damaged in service.

She said she strongly believed her problems were caused by exposure to inoculations and radiation in the Gulf, as well as the trauma of being at war.

“I still have nightmares and flashbacks and suffer serious mood swings,” she said.

“Low-flying aircraft and any loud bangs and noises take me back to when I was in the Gulf and make me feel sick.

“I was sat with a guy for four hours while he was dying and there was nothing I could do; I was held up in an Iraqi prisoner-of-war hospital.”

She said she had also had to clear up a soldier’s remains after he was killed in combat.

“But I’ve got no-one to discuss these things with,” she said. “People have said to me surely Combat Stress can help, but when I asked for their help they wouldn’t help me because I was going through my local mental health service.

“I’ve given up because I’m fed up with trying to fight the system.”

Marianna, who joined the Territorial Army in 1987, was the first woman soldier below the rank of officer to be sent to the Gulf in 1991 as a member of the Royal Medical Army Corps.

“I believe ex-servicemen deserve to be treated much better than they are,” she said. “It’s just one fight after another and the system needs to change so we get the support we deserve.”

Marianna feels so strongly about the issue she has set up a petition on the social networking site Facebook calling on the Government to reopen military hospitals. “If you’re on a ward with lots of other squaddies who have lost limbs, it helps the healing process because you can all talk and relate to each other,” she said.

New Congressional Bill would Restore, Make VA Health Care Permanent for Gulf War Veterans

Written by Anthony Hardie, 91outcomes

(91outcomes.blogspot.com) - Using lessons learned after Vietnam, Congressional action after the 1991 Persian Gulf War provided automatic priority health care enrollment for Gulf War veterans, regardless of whether or not they had received the often difficult-to-win service-connection for their health conditions or met other priority health care eligibility criteria.

However, quietly at the end of 2002, these inclusive statutory health care enrollment provisions for Gulf War and Vietnam (herbicide) veterans were allowed to expire.

A new bill introduced in Congress in late June would restore eligibility for both groups, and make that eligibility for VA health care permanent.

Specifically, H.R. 2926 would amend title 38, United States Code, to direct the Secretary of the U.S. Department of Veterans Affairs (VA) to provide, without expiration, hospital care, medical services, and nursing home care for certain veterans of the 1991 Persian Gulf War.

The bill would also make permanent the eligibility for VA health care for certain Vietnam-era veterans exposed to herbicide -- a provision in law after which the Gulf War health eligibility provision was originally modeled.

Like certain Gulf War veterans, certain Vietnam veterans' eligibility for VA health care under VA Health Care Enrollment Priority 6 expired on December 31, 2002. It is unclear how many veterans might potentially be affected by the change, which would affect Gulf War and Vietnam veterans with lower or no enrollment status in the VA health care system.

Introduced on June 17, 2009 by Congressman Glen C. Nye, III (D-Virg., who represents the military-heavy Hampton Roads area), H.R. 2926 has been referred to the House Committee on Veterans' Affairs Subcommittee on Health. The bill is one of 107 bills that have been referred to the Subcommittee since the beginning of the 111th Congress in January.

Claims Deadline

Veterans of the 1991 Gulf War have also had to fight to seek five-year extensions to authorization to apply for undiagnosed illnesses, which also include three diagnosed conditions: fibroymyalgia; chronic fatigue syndrome; and, irritable bowel syndrome. In December 2006, the VA issued a federal rule change that extended presumptive compensation for U.S. veterans of the 1991 Gulf War by an additional five years, to a new December 31, 2011 deadline.

Unless this claims deadline is further extended, veterans of the 1991 Gulf War must submit service-connected disability claims for presumptive conditions, including claims for unexplained illness, chronic fatigue syndrome, fibromyalgia, and/or irritable bowel syndrome prior to this date or risk denial under more stringent rules thereafter.

H.R. 2926 addresses the health-care deadline for veterans of the 1991 Gulf War; the claims deadline is a separate issue.

A bipartisan bill

The bipartisan bill's four additional cosponsors include Rep. Steve Kagen, M.D. (D-Wis.), the House's only practicing physician, as well as Rep. Jerry McNerney (D-Calif.), Rep. Walter Minnick (D-Idaho), and Rep. Ileana Ros-Lehtinen (R-Fla.).

Constituents of other Members of Congress can contact their Representative to request that he or she cosponsor H.R. 2926 by using the online, Write Your Rep service of the U.S. House of Representatives.