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Appendix C
Glossary

a priori—Proceeding from a known or assumed cause to a necessarily related effect; based on a hypothesis or theory rather than on experiment or experience; made before or without examination and not supported by factual study.

Accession—Entry into the service.

Acidosis—A pathologic state characterized by an increase in the concentration of hydrogen ions in the arterial blood above the normal level, 40 nmol/L, or pH 7.4; may be caused by an accumulation of carbon dioxide or acidic products of metabolism, or by a decrease in the concentration of alkaline compounds. (Stedman’s medical dictionary 28th ed., 2005)

Acneiform (or acneform) lesions—Lesions resembling acne. (Stedman’s medical dictionary 28th ed., 2005)

Active duty—(A) Full-time duty in the Armed Forces, other than active duty for training; (B) Full-time duty (other than for training purposes) as a commissioned officer of the Regular or Reserve Corps of the Public Health Service (i) on or after July 29, 1945, or (ii) before that date under circumstances affording entitlement to “full military benefits” or (iii) at any time, for the purposes of chapter 13 of this title (38 U.S.C.S. § 1301 et seq.); (C) Full-time duty as a commissioned officer of the National Oceanic and Atmospheric Administration or its predecessor organization the Coast and Geodetic Survey (i) on or after July 29, 1945, or (ii) before that date (I) while on transfer to one of the Armed Forces, or (II) while, in time of war or national emergency declared by the President, assigned to duty on a project for one of the Armed Forces



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Appendix C Glossary a priori—Proceeding from a known or assumed cause to a necessarily related effect; based on a hypothesis or theory rather than on experi- ment or experience; made before or without examination and not sup- ported by factual study. Accession—Entry into the service. Acidosis—A pathologic state characterized by an increase in the concen- tration of hydrogen ions in the arterial blood above the normal level, 40 nmol/L, or pH 7.4; may be caused by an accumulation of carbon dioxide or acidic products of metabolism, or by a decrease in the con- centration of alkaline compounds. (Stedman’s medical dictionary 28th ed., 2005) Acneiform (or acneform) lesions—Lesions resembling acne. (Stedman’s medical dictionary 28th ed., 2005) Active duty—(A) Full-time duty in the Armed Forces, other than active duty for training; (B) Full-time duty (other than for training purposes) as a commissioned officer of the Regular or Reserve Corps of the Public Health Service (i) on or after July 29, 1945, or (ii) before that date under circumstances affording entitlement to “full military benefits” or (iii) at any time, for the purposes of chapter 13 of this title (38 U.S.C.S. § 1301 et seq.); (C) Full-time duty as a commissioned officer of the National Oceanic and Atmospheric Administration or its predecessor organization the Coast and Geodetic Survey (i) on or after July 29, 1945, or (ii) before that date (I) while on transfer to one of the Armed Forces, or (II) while, in time of war or national emergency declared by the President, assigned to duty on a project for one of the Armed Forces 

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0 IMPROVING THE PRESUMPTIVE DISABILITY DECISION-MAKING PROCESS in an area determined by the Secretary of Defense to be of immediate military hazard, or (III) in the Philippine Islands on December 7, 1941, and continuously in such islands thereafter, or (iii) at any time, for the purposes of chapter 13 of this title (38 U.S.C.S. § 1301 et seq.); (D) Ser- vice as a cadet at the United States Military, Air Force, or Coast Guard Academy, or as a midshipman at the United States Naval Academy; and (E) Authorized travel to or from such duty or service. (Definitions. 2006. 38 U.S.C. § 101.) Active duty for training—(A) Full-time duty in the Armed Forces performed by Reserves for training purposes; (B) Full-time duty for training pur- poses performed as a commissioned officer of the Reserve Corps of the Public Health Service (i) on or after July 29, 1945, or (ii) before that date under circumstances affording entitlement to “full military ben- efits,” or (iii) at any time, for the purposes of chapter 13 of this title (38 U.S.C.S. § 1301 et seq.); (C) In the case of members of the National Guard or Air National Guard of any State, full-time duty under sec- tion 316, 502, 503, 504, or 505 of title 32 (32 U.S.C.S. § 316, 502, 503, 504, or 505), or the prior corresponding provisions of law; and (D) Duty performed by a member of a Senior Reserve Officers’ Training Corps program when ordered to such duty for the purpose of training or a practice cruise under chapter 103 of title 10 (10 U.S.C.S. § 2101 et seq.) for a period of not less than four weeks and which must be completed by the member before the member is commissioned; and (E) Authorized travel to or from such duty. The term does not include duty performed as a temporary member of the Coast Guard Reserve. (Definitions. 2006. 38 U.S.C. § 101.) Active military, naval, or air service—(A) Active duty; (B) any period of active duty for training during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty; and (C) Any period of inactive duty training during which the individual concerned was disabled or died—(i) from an injury incurred or aggravated in line of duty; or (ii) from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident occurring during such training. (Definitions. 2006. 38 U.S.C. § 101.) Acute myelogenous leukemia (AML)—A form of leukemia characterized by an uncontrolled proliferation of myelopoietic cells in the bone mar- row and in extramedullary sites, and the presence of large numbers of immature and mature granulocytic forms in various tissues (and organs) and in the circulating blood. Acute nonlymphocytic leukemia (ANLL)—Any of several forms of myelog- enous leukemia marked by an abnormal increase in the number of immature white blood cells; risk of disease is increased among people who have been exposed to massive doses of radiation.

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1 APPENDIX C Addison’s anemia (also known as primary anemia, pernicious anemia)—A chronic progressive anemia of older adults (occurring more frequently during the fifth and later decades, rarely before 30 years of age), due to the failure of absorption of vitamin B12, usually resulting from a defect of the stomach accompanied by mucosal atrophy and associated with lack of secretion of “intrinsic” factor; characterized by numbness and tingling, weakness, and a sore smooth tongue, as well as dyspnea after slight exertion, faintness, pallor of the skin and mucous membranes, anorexia, diarrhea, loss of weight, and fever; laboratory studies usually reveal greatly decreased red blood cell counts, low levels of hemoglo- bin, numerous characteristically oval shaped macrocytic erythrocytes (color index greater than normal, but not truly hyperchromic), and hypo- or achlorhydria, in association with a predominant number of megaloblasts and relatively few normoblasts in the bone marrow; the leukocyte count in peripheral blood may be less than normal, with relative lymphocytosis and hypersegmented neutrophils; a low level of vitamin B12 is found in peripheral red blood cells; administration of vitamin B12 results in a characteristic reticulocyte response, relief from symptoms, and an increase in erythrocytes, provided that perni- cious anemia is not complicated by another disease; the condition is not actually “pernicious,” as it was prior to the availability of therapy with vitamin B12. At least two autosomal recessive forms are known. In one there is a defect of intrinsic factor and in the other a defective absorption of vitamin B12 from the intestine. (Stedman’s medical dic- tionary 28th ed., 2005) Additive model—A model in which the combined effect of several fac- tors is the sum of the effects that would be produced by each of the factors in the absence of the others. For example, if factor X adds x percent to risk in the absence of Y, and if factor Y adds y percent to risk in the absence of X, an additive model states that the two factors together will add (x + y) percent to risk. (Last, 2001) Adult fibrosarcoma—A sarcoma of relatively low malignancy consisting chiefly of spindle-shaped cells that tend to form collagenous fibrils. Agent Orange—An herbicide and defoliant consisting of 2,4,5-trichloro- phenoxyacetic acid, 2,4-dichlorophenoxyacetic acid, and dioxin, that was widely used during the Vietnam War; it has been shown to produce residual postexposure carcinogenic and teratogenic effects in humans. (Stedman’s medical dictionary 28th ed., 2005) Alveolar (alveolus)—A small cell, cavity, or socket. (1) Syn: pulmonary alveolus. (2) One of the terminal secretory portions of an alveolar or racemose gland. (3) One of the honeycomb pits in the wall of the stomach. (4) Syn: tooth socket. (Stedman’s medical dictionary 28th ed., 2005)

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 IMPROVING THE PRESUMPTIVE DISABILITY DECISION-MAKING PROCESS Ambient air—The surrounding or encompassing air; pertaining to the envi- ronment in which an organism or apparatus functions. Amebiasis—Infection with the protozoon Entamoeba histolytica. (Stedman’s medical dictionary 28th ed., 2005) Amebic dysentery—An inflammation of the intestine caused by infestation with Entamoeba histolytica. Marked by dysentery, abdominal pain, and erosion of the intestinal wall. Amputation—The cutting off of a limb or part of a limb, the breast, or other projecting part. Amyloidosis—A disease characterized by extracellular accumulation of amyloid in various organs and tissues of the body; may be primary or secondary. Amyotrophic lateral sclerosis (ALS)—A rare fatal progressive degenera- tive disease that affects pyramidal motor neurons, usually begins in middle age, and is characterized especially by increasing and spreading muscular weakness. Also known as Lou Gehrig’s disease. (Stedman’s medical dictionary 28th ed., 2005) Anemia—Any condition in which the number of red blood cells/mm3, the amount of hemoglobin in 100 ml of blood, and/or the volume of packed red blood cells/100 ml of blood is less than normal; clinically, generally pertaining to the concentration of oxygen-transporting mate- rial in a designated volume of blood, in contrast to total quantities as in oligocythemia, oligochromemia, and oligemia. Anemia is frequently manifested by pallor of the skin and mucous membranes, shortness of breath, palpitations of the heart, soft systolic murmurs, lethargy, and tendency to fatigue. (Stedman’s medical dictionary 28th ed., 2005) Angioendotheliomatosis—Proliferation of endothelial cells within blood vessels. (Stedman’s medical dictionary 28th ed., 2005) Angiosarcoma—A rare malignant neoplasm occurring most often in soft tissues; believed to originate from the endothelial cells of blood vessels; microscopically composed of spindle-shaped cells, some of which line small spaces resembling vascular clefts. (Stedman’s medical dictionary 28th ed., 2005) Anthrax—Infection by the bacterium Bacillus anthracis, which in humans is caused by infected animals or animal products, and ingestion or inhala- tion of spores of the bacterium. The most common naturally occurring form of human anthrax is the cutaneous, and both the inhalational and the gastrointestinal forms are quite rare. Anthrax in animals occurs throughout the world, primarily in herbovores, especially cattle, horses, goats, and sheep. (Stedman’s medical dictionary 28th ed., 2005) Anxiety neurosis—Apprehension of danger and dread accompanied by restlessness, tension, tachycardia, and dyspnea unattached to a clearly identifiable stimulus.

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 APPENDIX C Aplastic anemia—Anemia characterized by a greatly decreased formation of erythrocytes and hemoglobin, usually associated with pronounced granulocytopenia and thrombocytopenia, as a result of hypoplasticity or aplasticity of bone marrow. (Stedman’s medical dictionary 28th ed., 2005) Appendectomy—Surgical removal of the appendix. (Stedman’s medical dictionary 28th ed., 2005) Armed Forces—The United States Army, Navy, Marine Corps, Air Force, and Coast Guard, including the reserve components thereof. (Defini- tions. 2006. 38 U.S.C. § 101.) Arrhythmia—Loss or abnormality of rhythm; denoting especially an irregu- larity of the heartbeat. (Stedman’s medical dictionary 28th ed., 2005) Arteriosclerosis—Hardening of the arteries; types generally recognized are: atherosclerosis, Mönckeberg arteriosclerosis, and arteriolosclerosis. (Stedman’s medical dictionary 28th ed., 2005) Arthritis—Inflammation of a joint or a state characterized by inflammation of joints. (Stedman’s medical dictionary 28th ed., 2005) Asbestosis—Pneumoconiosis due to inhalation of asbestos fibers suspended in the ambient air; sometimes complicated by pleural mesothelioma or bronchogenic carcinoma; ferruginous bodies are the histologic hallmark of exposure to asbestos. (Stedman’s medical dictionary 28th ed., 2005) Assay—(1) The quantitative or qualitative evaluation of a substance for impurities, toxicity, etc.; the results of such an evaluation. (2) To exam- ine; to subject to analysis. (3) Test of purity; trial. (Stedman’s medical dictionary 28th ed., 2005) Assigned share—For two groups of people that are alike, except that one group is exposed and the other is not exposed, the excess number of cases in the exposed group expressed as a fraction of the total number of cases in the exposed group. Association—Statistical dependence between two or more events, character- istics, or other variables. An association is present if the probability of occurrence of an event or characteristic, or the quantity of a variable, is related to the occurrence of one or more other events, the presence of one or more other characteristics, or the quantity of one or more other variables. The association between two variables is described as posi- tive when higher values of a variable are associated with higher values of another variable. In a negative association, the occurrence of higher values of one variable is associated with lower values of the other vari- able. An association may be fortuitous or may be produced by various other circumstances; the presence of an association does not necessarily imply a causal relationship. If the use of the term association is con- fined to situations in which the relationship between two variables is statistically significant, the terms statistical association and statistically

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 IMPROVING THE PRESUMPTIVE DISABILITY DECISION-MAKING PROCESS significant association become tautological. However, ordinary usage is seldom so precise at this. The terms association and relationship are often used interchangeably. Associations can be broadly grouped under two headings, noncausal and causal. (Adapted from Last, 2001) Asthma—An inflammatory disease of the lungs characterized by reversible (in most cases) airway obstruction. Originally, a term used to mean “difficult breathing”; now used to denote bronchial asthma. (Stedman’s medical dictionary 28th ed., 2005) Atherosclerosis—Arteriosclerosis characterized by irregularly distributed lipid deposits in the intima of large and medium sized arteries, caus- ing narrowing of arterial lumens and proceeding eventually to fibrosis and calcification. Lesions are usually focal and progress slowly and intermittently. Limitation of blood flow accounts for most clinical manifestations, which vary with the distribution and severity of lesions. (Stedman’s medical dictionary 28th ed., 2005) Atrophy—A wasting of tissues, organs, or the entire body, as from death and reabsorption of cells, diminished cellular proliferation, decreased cellular volume, pressure, ischemia, malnutrition, lessened function, or hormonal changes. (Stedman’s medical dictionary 28th ed., 2005) Attributable fraction (AF)—Fraction of disease in the population that would not have occurred had the exposure not occurred. A term sometimes used to refer to the attributable fraction in the population, and sometimes to the attributable fraction among the exposed (Last, 2001). The AF may be best understood by seeing how it is calculated: AF = (R1 – R0) / R1, where R1 is the rate of a disease (typically incidence rate) in an exposed population and R0 is the rate in that same popula- tion if unexposed. AF, then, is the fraction of the rate of disease in the exposed that is due to exposure. Dividing numerator and denominator by R0, since R1/R0 is the relative risk (RR), produces the more familiar expression, AF = (RR – 1) / RR. See Population attributable fraction. Avitaminosis—Properly, hypovitaminosis. (Stedman’s medical dictionary 28th ed., 2005) Bacillary dysentery (also known as shigellosis)—Infection with Shigella dysenteriae, Shingella flexneri, or other organisms. (Stedman’s medical dictionary 28th ed., 2005) Bancroft[ian] filariasis—Filariasis caused by Wuchereria bancrofti. (Stedman’s medical dictionary 28th ed., 2005) Bari Harbor Disaster—On December 2, 1943, German Junkers Ju 88 bombers attacked the port of Bari, a key supply center for Allied forces fighting their way up the Italian peninsula. Several Allied ships were sunk in the overcrowded harbor, including John Harvey, which was carrying mustard gas, intended for use if German forces initiated chemical warfare. The presence of the gas was highly classified, and

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 APPENDIX C authorities ashore had no knowledge of it. This increased the number of fatalities, since physicians—who had no idea that they were dealing with the effects of mustard gas—prescribed treatment proper for those suffering from exposure and immersion, which proved fatal in many cases. Basophil—(1) A cell with granules that stain specifically with basic dyes. (2) Syn: basophilic. (3) A phagocytic leukocyte of the blood character- ized by numerous basophilic granules containing heparin and histamine and leukotrines; except for its segmented nucleus, it is morphologically and physiologically similar to the mast cell though they originate from different stem cells in the bone marrow. (Stedman’s medical dictionary 28th ed., 2005) Bayes’ Theorem—A theorem for probability first derived and described by Thomas Bayes (1702-1761), an English clergyman and mathematician, in his Essay Towards Solving a Problem in the Doctrine of Chances (1763, published posthumously). In epidemiology, the theorem is often used to obtain the probability of disease in a group of people with some characteristic on the basis of the overall rate of that disease (the prior probability of disease) and the likelihoods of that characteristic in healthy and diseased individuals. The most familiar application is in clinical decision analysis, where it is used for estimating the probability of a particular diagnosis given the appearance of some symptoms or test results. A simplified version of the theorem is ( ) P S D P ( D) ( ) P DS = ( ) ( )() P S D P ( D) + P S D P D where D = disease, S = symptom, and D = no disease. The probability of disease given the symptom is the posterior probability. The prob- ability of disease before knowing of the presence or absence of the symptom is the prior probability. The formula emphasizes what clinical intuition often overlooks, namely, that the probability of disease given the symptom depends not only on how characteristic that symptom is of the disease but also on how frequent the disease is among the popu- lation being served. The theorem can also be used for estimating exposure-specific rates from case-control studies if there is added information about the overall rate of disease in that population. The theorem is sometimes presented in terms of the odds of dis- ease before knowing the symptom (prior odds) and after knowing the symptom (posterior odds). (Adapted from Last, 2001)

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6 IMPROVING THE PRESUMPTIVE DISABILITY DECISION-MAKING PROCESS Bayesian approach—A method of statistical inference that begins with the state of knowledge, i.e., the facts, prior to an exposure or an interven- tion, and augments this with the study data to yield the state of knowl- edge posterior to the study. Benzene—The basic six-carbon ring structure in most aromatic compounds; a highly toxic hydrocarbon from light coal tar oil; used as a solvent. (Stedman’s medical dictionary 28th ed., 2005) Beriberi—A specific nutritional deficiency syndrome occurring in endemic form in eastern and southern Asia, sporadically in other parts of the world without reference to climate, and sometimes in alcoholic patients, resulting mainly from a dietary deficiency of thiamin; the “dry” form is characterized by painful polyneuropathy that involves both large and small somatic nerve fibers, as well as autonomic nerve fibers, the initial symptom is burning feet, and later symptoms consist of painful parathesias in the distal upper limbs as well, weak- ness and atrophy of the feet and hands, and distal atrophic skin and hair loss; the “wet” form is characterized by edema resulting from a high-output form of heart failure, but usually there is evidence of a coexisting polyneuropathy as well. (Stedman’s medical dictionary 28th ed., 2005) Beryllium disease—Various conditions resulting from exposure to beryllium and its compounds or alloys. Bias—Deviation of results or inference from the truth, or process leading to such deviation; any trend in the collection, analysis, interpretation, publication, or review of data that can lead to conclusions that are systematically different from the truth. Among the ways in which devia- tion from the truth can occur, are the following: 1. Systematic (one-sided) variation of measurements from the true values (syn: systematc error) 2. Variation of statistical summary measures (means, rates, measure- ments of association, etc.) from their true values as result of sys- tematic variation of measurements, other flaws in data collection, or flaws in study design or analysis 3. Deviation of inferences from the truth as a result of flaws in study design, data collection, or the analysis or interpretation of results 4. A tendency of procedures (in study design, data collection, analysis, interpretation, review, or publication) to yield results or conclu- sions that depart from the truth 5. Prejudice leading to the conscious or unconscious selection of study procedures that departs from the truth in a particular direction or to one-sidedness in the interpretation of results

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 APPENDIX C The term bias does not necessarily carry an imputation of preju- dice or other subjective factor, such as the experimenter’s desire for a particular outcome.This differs from conventional usage, in which bias refers to a partisan point of view. (Adapted from Last, 2001) Biological plausibility—The criterion that an observed, presumably or puta- tively causal association is coherent with previously existing biological or medical knowledge. This judgment should be used cautiously since it could impede development of new knowledge that does not fit existing ideas. (Last, 2001) Bipolar disorder—An affective disorder characterized by the occurrence of alternating manic, hypomanic, or mixed episodes and with major depressive episodes. The DSM specifies the commonly observed pat- terns of bipolar I and bipolar II disease and cyclothymia. (Stedman’s medical dictionary 28th ed., 2005) Black lung—A form of pneumoconiosis, common in coal miners, charac- terized by deposits of carbon particles in the lung. (Stedman’s medical dictionary 28th ed., 2005) Black water fever—Hemoglobinuria resulting from severe hemolysis occur- ring in falciparum malaria. (Stedman’s medical dictionary 28th ed., 2005) Bonus Expeditionary Forces—About 20,000 WWI veterans, their families, and other affiliated groups who demonstrated in Washington, D.C., during the spring and summer of 1932 seeking immediate payment of a “bonus” granted by the Adjusted Service Certificate Law of 1924 for payment in 1945. Bradford Hill criteria—Heuristic criteria for interpreting when evidence supports moving beyond observed association to causation. The criteria include strength of association, consistency, specificity, temporality, dose-response, plausibility, coherence, experimental evidence, and analogy. Named after Sir Austin Bradford Hill. Bradley Commission—Formed in 1987 in response to concerns regarding the quality and quantity of the history taught in American classrooms. Brain hemorrhage (cerebral hemorrhage)—Hemorrhage into the substance of the cerebrum, usually in the region of the internal capsule by the rupture of the lenticulostriate. (Stedman’s medical dictionary 28th ed., 2005) Brain thrombosis (cerebral thrombosis)—Clotting of the blood in a cerebral vessel. (Stedman’s medical dictionary 28th ed., 2005) Bronchiectasis—Chronic dilation of bronchi or bronchioles as a sequel of inflammatory disease or obstruction often associated with heavy sputum production. Bronchiolo-alveolar carcinoma—A relatively uncommon lung cancer which is a type of non-small cell lung cancer.

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 IMPROVING THE PRESUMPTIVE DISABILITY DECISION-MAKING PROCESS Bronchitis—Inflammation of the mucous membranes of the bronchi. (Stedman’s medical dictionary 28th ed., 2005) Buccal cavity—That part of the mouth bounded anteriorally and laterally by the lips and the cheeks, posteriorly and medially by the teeth and/or gums, and above and below by the reflection of the mucosa from the lips and cheeks to the gums. (Stedman’s medical dictionary 28th ed., 2005) Buerger’s disease—Thromboangiitis (thromboangiitis—an inflammation of the blood vessels associated with thrombosis) of the small arteries and veins of the extremities and especially the feet resulting in occlusion, ischemia, and gangrene. Bulbar—(1) Relating to a bulb. (2) Relating to the rhombencephalon (hind- brain). (3) Bulb-shaped; resembling a bulb. (Stedman’s medical diction- ary 28th ed., 2005) Burden of persuasion—The duty upon a party in a legal proceeding to per- suade the fact-finder to decide for that party on an assertion of fact. Burden of proof—The duty of proving a disputed assertion or charge. Butadiene—A flammable gaseous open-chain hydrocarbon used in making synthetic rubbers. Cacodylic acid—Arsenical contact herbicide that defoliates or desiccates a wide variety of plant species. (Stedman’s medical dictionary 28th ed., 2005) Calculi (Calculus)—A concretion formed in any part of the body, most commonly in the passages of the biliary and urinary tracts; usually composed of salts of inorganic or organic acids, or of other material such as cholesterol. (Stedman’s medical dictionary 28th ed., 2005) Cancer—General term frequently used to indicate any of various types of malignant neoplasms, most of which invade surrounding tissues, may metastasize to several sites, and are likely to recur after attempted removal and to cause death of the patient unless adequately treated; especially, any such carcinoma or sarcoma, but, in ordinary usage, espe- cially the former. (Stedman’s medical dictionary 28th ed., 2005) Cannikin—A nuclear device detonated beneath Amchitka Island, Alaska, in 1971. Carcinogen—Any cancer-producing substance or organism, such as poly- cyclic aromatic hydrocarbons, or agents such as in certain types of irradiation. (Stedman’s medical dictionary 28th ed., 2005) Carcinoma—Any of various types of malignant neoplasm derived from epithelial cells, chiefly glandular (adenocarcinoma) or squamous (squamous cell carcinoma); the most commonly occurring kind of cancer. (Stedman’s medical dictionary 28th ed., 2005) Cardiovascular disease—Any abnormal condition characterized by dysfunc- tion of the heart and blood vessels.

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 APPENDIX C Case-control study—An epidemiologic study design in which a population sample is defined on the basis of whether (cases) or not (controls) a disease (or other endpoint) is present; cases and controls are then com- pared with respect to disease risk factors, typically exposure. Cataracts (posterior subcapsulary)—Complete or partial opacity of the ocular lens. (Stedman’s medical dictionary 28th ed., 2005) Causal association—An association between two events or characteristics that arises because one causes the other. Causal inference—Examining the structure and results of many investiga- tions in an attempt to assess and, if possible, eliminate all possible noncausal reasons for observed associations. Causal pathway—A sequence mechanism, possibly involving several inter- mediate factors, by which one factor causes another. Causation—The relating of causes to the effects they produce. A relationship between events (specific, or individual causation) or between variables (general, or population level causation) in which an outside interven- tion to change the cause would result in a change in the effect. Child—Except for purposes of chapter 19 of this title (38 U.S.C.S. § 1901 et seq.) (other than with respect to a child who is an insurable dependent under section 1965[10][B] of such chapter [38 U.S.C.S. § 1965(10)(B)] and section 8502[b] of this title [38 U.S.C.S. § 8502(b)]) a person who is unmarried and—(i) who is under the age of eighteen years; (ii) who, before attaining the age of eighteen years, became permanently incapa- ble of self-support; or (iii) who, after attaining the age of eighteen years and until completion of education or training (but not after attaining the age of twenty-three years), is pursuing a course of instruction at an approved educational institution; and who is a legitimate child, a legally adopted child, a stepchild who is a member of a veteran’s household or was a member at the time of the veteran’s death, or an illegitimate child but, as to the alleged father, only if acknowledged in writing signed by him, or if he has been judicially ordered to con- tribute to the child’s support or has been, before his death, judicially decreed to be the father of such child, or if he is otherwise shown by evidence satisfactory to the Secretary to be the father of such child. A person shall be deemed, as of the date of death of a veteran, to be the legally adopted child of such veteran if such person was at the time of the veteran’s death living in the veteran’s household and was legally adopted by the veteran’s surviving spouse before August 26, 1961, or within two years after the veteran’s death; however, this sentence shall not apply if at the time of the veteran’s death, such person was receiving regular contributions toward the person’s support from some individual other than the veteran or the veteran’s spouse, or from any public or private welfare organization which furnishes services or assistance for

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 IMPROVING THE PRESUMPTIVE DISABILITY DECISION-MAKING PROCESS between process schizophrenia and reactive schizophrenia. The “split” personality of schizophrenia, in which individual psychic components or functions split off and become autonomous, is popularly but erro- neously identified with multiple personality, in which two or more relatively complete personalities dominate by turns the psychic life of a patient. (Stedman’s medical dictionary 28th ed., 2005) Schizophreniform disorder—(1) A disorder with essential features that are identical to those of schizophrenia, with the exception that the dura- tion including prodromal, active, and residual phases is shorter than 6 months. (2) A DSM diagnosis that is established when the specific criteria are met. (Stedman’s medical dictionary 28th ed., 2005) Schwannoma—A benign, encapsulated neoplasm in which the fundamental component is structurally identical to a syncytium of Schwann cells; the neoplastic cells proliferate within the endoneurium, and the perineurium forms the capsule. The neoplasm may originate from a peripheral or sympathetic nerve, or from various cranial nerves, particularly the eighth nerve; when the nerve is small, it is usually found (if at all) in the capsule of the neoplasm; if the nerve is large, the neurilemoma may develop within the sheath of the nerve, the fibers of which may then spread over the surface of the capsule as the neoplasm enlarges. Microscopically, neurilemoma is composed of combinations of two patterns, Antoni types A and B, either of which may be predominant in various examples of neurilemomas. (Stedman’s medical dictionary 28th ed., 2005) Scleroderma—Thickening and induration of the skin caused by new collagen formation, with atrophy of pilosebaceous follicles; either a manifesta- tion of progressive systemic sclerosis or localized (morphea). (Stedman’s medical dictionary 28th ed., 2005) Sclerosis—In neuropathy, induration of nervous and other structures by a hyperplasia of the interstitial fibrous or glial connective tissue. (Stedman’s medical dictionary 28th ed., 2005) Scurvy—A disease marked by inanition, debility, anemia, and edema of the dependent parts; a spongy condition sometimes with ulceration of the gums and loss of teeth, hemorrhages into the skin from the mucous membranes and internal organs, and poor wound healing; due to a diet lacking vitamin C. (Stedman’s medical dictionary 28th ed., 2005) Seamless transition—The commitment of DoD and VA to work closely in harmonizing the medical records of Service members for a smooth transition from DoD care to VA care. Secretary—Secretary of Veterans Affairs; Secretary concerned (A) The Sec- retary of the Army, with respect to matters concerning the Army; (B) The Secretary of the Navy, with respect to matters concerning the Navy; or the Marine Corps; (C) The Secretary of the Air Force,

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 APPENDIX C with respect to matters concerning the Air Force; (D) The Secretary of Homeland Security, with respect to matters concerning the Coast Guard; (E) The Secretary of Health and Human Services, with respect to matters concerning the Public Health Service; and (F) The Secretary of Commerce, with respect to matters concerning the National Oceanic and Atmospheric Administration or its predecessor organization the Coast and Geodetic Survey. (Definitions. 2006. 38 U.S.C. § 101.) Selection bias—In a case-control study, occurs when the chance of being selected as a case or a control is influenced by exposure status. In a cohort study, occurs when the chance of participation in a study as exposed or non-exposed is influenced by disease status. Also, error due to systematic differences in characteristics between those who take part in a study and those who do not. Selection bias can invalidate conclusions and generalizations that might otherwise be drawn from such studies. Sensitivity—The proportion of truly diseased persons in the screened popu- lation who are correctly identified as diseased by the screening test; a measure of the probability of correctly diagnosing a case, or the prob- ability that any given case will be identified by the test; specifically, the ratio of those who are identified by a test to have the condition who in fact have it, divided by all those who have the condition (i.e., true positives, divided by the sum of true positives and false negatives). Sensitivity analysis—A method to determine the robustness of a result by examining the extent to which the result is affected by changes in meth- ods, values of variables, or assumptions. (Adapted from Last, 2001) Separation—Left the military before 20 years; cannot apply for retirement benefits (Source: Personal communication, Col. K. Cox, Department of Defense, January 5, 2007): 1. The act of keeping apart or dividing, or the state of being held apart. 2. In dentistry, the process of gaining slight spaces between the teeth preparatory to treatment. (Stedman’s medical dictionary 28th ed., 2005) Service-attributable disability—Disability caused by a veteran’s service. Service-attributable fraction (SAF)—The attributable fraction (AF) when the specific exposure is military service (see Attributable fraction); in other words, the proportion of a disease attributable to military service. Service-connected—With respect to disability or death, that such dis- ability was incurred or aggravated, or that the death resulted from a disability incurred or aggravated, in line of duty in the active military, naval, or air service. (Definitions. 2006. 38 U.S.C. § 101.) Seveso study—The study of a population exposed to dioxin from an indus-

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00 IMPROVING THE PRESUMPTIVE DISABILITY DECISION-MAKING PROCESS trial accident that occurred in 1976 in a small manufacturing plant in the Lombardy region in Italy. Shared psychotic disorder—A mental disorder in which a delusion develops in a person in a relationship with another person with an established delusion. (Stedman’s medical dictionary 28th ed., 2005) Shigellosis—Bacillary dysentery caused by bacteria of the genus Shigella, often occurring in epidemic patterns; an opportunistic infection of per- son with AIDS. (Stedman’s medical dictionary 28th ed., 2005) Sliding scale pension—A pension based on income level. Spanish-American War—(A) The period beginning on April 21, 1898, and ending on July 4, 1902, (B) Includes the Philippine Insurrection and the Boxer Rebellion, and (C) In the case of a veteran who served with the United States military forces engaged in hostilities in the Moro Province, means the period beginning on April 21, 1898, and ending on July 15, 1903. (Definitions. 2006. 38 U.S.C. § 101.) Specificity—The proportion of truly nondiseased persons who are cor- rectly identified by the screening test; a measure of the probability of correctly identifying a nondiseased person with a screening test; specifically, the ratio of those who are identified by a test to not have the condition who in fact do not have it, divided by all those who do not have the condition (i.e., true negatives, divided by the sum of true negatives and false positives). Spouse—A person of the opposite sex who is a wife or husband. (Defini- tions. 2006. 38 U.S.C. § 101.) Spurious association—A noncausal association due to chance, bias, failure to control for extraneous variables, confounding, etc. (see Confounder). Squamous cell carcinoma—A malignant neoplasm derived from strati- fied squamous epithelium, but which may also occur in sites such as bronchial mucosa where glandular or columnar epithelium is normally present; variable amounts of keratin are formed, in relation to the degree of differentiation, and, if the keratin is not on the surface, it may accumulate in the neoplasm as a keratin pearl; in instances in which the cells are well differentiated, intercellular bridges may be observed between adjacent cells. (Stedman’s medical dictionary 28th ed., 2005) Stakeholder—One with an interest or share in an undertaking or enterprise. State—Each of the several States, Territories, and possessions of the United States, the District of Columbia, and the Commonwealth of Puerto Rico. For the purpose of section 2303 and chapters 34 and 35 of this title (38 U.S.C.S. § 2303, 3451 et seq., and 3500 et seq.), such term also includes the Canal Zone. (Definitions. 2006. 38 U.S.C. § 101.) State home—A home established by a State (other than a possession) for veterans disabled by age, disease, or otherwise who by reason of such disability are incapable of earning a living. Such term also includes such

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01 APPENDIX C a home which furnishes nursing home care for veterans. (Definitions. 2006. 38 U.S.C. § 101.) Stratum (strata)—Subsamples according to specified criteria, such as age groups, socioeconomic status, etc. One of the layers of differentiated tissue, the aggregate of which forms any given structure, such as the retina or the skin. (Stedman’s medical dictionary 28th ed., 2005) Stroke—(1) Any acute clinical event, related to impairment of cerebral circulation, that lasts more than 24 hours. (2) A harmful discharge of lightning, particularly one that affects a human being. (3) A pulsation. (4) To pass the hand or any instrument gently over a surface. See also stroking. (5) A gliding movement over a surface. (Stedman’s medical dictionary 28th ed., 2005) Subcapsular cataracts—A cataract in which the opacities are concentrated beneath the capsule. (Stedman’s medical dictionary 28th ed., 2005) Sufficient cause—The minimum set of conditions, factors, or events needed to produce a given outcome. (Adapted from Last, 2001) Sufficient component causes model—A model that postulates disease result- ing from any of several sufficient causal constellations, each of which comprises components that are all necessary to make them a complete cause. Sulfur mustard—Cytotoxic vesicant chemical warfare agent with the ability to form large blisters on exposed skin (e.g., mustard gas). Surveillance—Continuous monitoring of disease occurrence within a population. Surviving spouse—A person of the opposite sex who was the spouse of a veteran at the time of the veteran’s death, and who lived with the vet- eran continuously from the date of marriage to the date of the veteran’s death (except where there was a separation which was due to the mis- conduct of, or procured by, the veteran without the fault of the spouse) and who has not remarried or (in cases not involving remarriage) has not since the death of the veteran, and after September 19, 1962, lived with another person and held himself or herself out openly to the public to be the spouse of such other person (except for purposes of chapter 19 of this title [38 U.S.C.S. § 1901 et seq.]). (Definitions. 2006. 38 U.S.C. § 101.) Synovial sarcoma—A rare malignant tumor of synovial origin, most com- monly involving the knee joint and composed of spindle cells usually enclosing slits or pseudoglandular spaces that may be lined by radially disposed epitheliallike cells. (Stedman’s medical dictionary 28th ed., 2005) Syringomyelia—The presence in the spinal cord of longitudinal cavities lined by dense, gliogenous tissue, that are not caused by vascular insuf-

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0 IMPROVING THE PRESUMPTIVE DISABILITY DECISION-MAKING PROCESS ficiency. Syringomyelia is marked clinically by pain and paresthesia, followed by muscular atrophy of the hands and analgesia with thermo- anesthesia of the hands and arms, but with the tactile sense preserved; later marked by painless whitlows, spastic paralysis in the lower extremities, and scoliosis of the lumbar spine. Some cases are associ- ated with low-grade gliomas or vascular malformations of the spinal cord. (Stedman’s medical dictionary 28th ed., 2005) Systematic error—One-sided variation of measurements from the true values; see also Bias. Systemic lupus erythematosus—An inflammatory connective tissue dis- ease with variable features, frequently including fever, weakness and fatigability, joint pains or arthritis resembling rheumatoid arthritis, diffuse erythematous skin lesions on the face, neck, or upper extremi- ties, with liquefaction degeneration of the basal layer and epidermal atrophy, lymphadenopathy, pleurisy or pericarditis, glomerular lesions, anemia, hyperglobulinemia, and a positive LE cell test result, with serum antibodies to nuclear protein and sometimes to double-stranded DNA and other substances. (Stedman’s medical dictionary 28th ed., 2005) Testosterone—The most potent naturally occurring androgen, formed in greatest quantities by the interstitial cells of the testes, and possibly secreted also by the ovary and adrenal cortex; may be produced in nonglandular tissues from precursors such as androstenedione; used in the treatment of hypogonadism, cryptorchism, certain carcinomas, and menorrhagia. (Stedman’s medical dictionary 28th ed., 2005) 2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD)—See Dioxin. Theater—A specific geographic area within which armed conflict occurs. Thromboangiitis obliterans (Buerger’s disease)—Inflammation of the entire wall and connective tissue surrounding medium-sized arteries and veins, especially of the legs of young and middle-aged men; associated with thrombotic occlusion and commonly resulting in gangrene. (Stedman’s medical dictionary 28th ed., 2005) Thyroid nodular disease—Presence of palpable thyroid nodules. These nodules may be solitary or one or more within a multi-nodular thyroid. Most are benign, colloid nodules. Thyroxine—The l-isomer is the active iodine compound existing normally in the thyroid gland and extracted therefrom in crystalline form for therapeutic use; also prepared synthetically; used for the relief of hypo- thyroidism, cretinism, and myxedema. (Stedman’s medical dictionary 28th ed., 2005) Tolman Committee—Also known as the Committee on Declassification; appointed by General Groves in 1944 to study the declassification of Manhattan Project research.

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0 APPENDIX C Tonsillectomy—Removal of the entire tonsil. (Stedman’s medical dictionary 28th ed., 2005) Tort litigation—Legal proceeding for a wrongful act other than a breach of contract for which relief may be obtained in the form of damages or an injunction. Toxicant—Any poisonous agent, specifically alcohol or other poison, caus- ing symptoms of what is popularly called intoxication. (Stedman’s medical dictionary 28th ed., 2005) Toxicogenomics—A scientific subdiscipline that combines toxicology (the study of the nature and effects of poisons) with genomics (the inves- tigation of the way that our genetic makeup translates into biological functions). Transparency—Characterized by visibility or accessibility of information, especially concerning business practices. 2,4,5-Trichlorophenoxyacetic acid—An herbicide and defoliant synthesized by condensation of chloracetic acid and 2,4,5-trichlorophenol, used as the principal constituent of Agent Orange. Triglyceride—Glycerol esterified at each of its three hydroxyl groups by a fatty (aliphatic) acid. Syn: triacylglycerol. (Stedman’s medical dictionary 28th ed., 2005) Trypanosomiasis—Any disease caused by a trypanosome. (Stedman’s medi- cal dictionary 28th ed., 2005) Tuberculosis (TB)—A specific disease caused by infection with Myco- bacterium tuberculosis, the tubercle bacillus, which can affect almost any tissue or organ of the body, the most common seat of the disease being the lungs. Primary tuberculosis is typically a mild or asymptom- atic local pulmonary infection. Regional lymph nodes may become involved, but in otherwise healthy people generalized disease does not immediately develop. A cell-mediated immune response arrests the spread of organisms and walls off the zone of infection. Infected tis- sues and lymph nodes may eventually calcify. The tuberculin skin test becomes positive within a few weeks, and remains positive throughout life. Organisms in a primary lesion remain viable and can become reactivated months or years later to initiate secondary tuberculosis. Progression to the secondary stage eventually occurs in 10-15 percent of people who have had primary tuberculosis. The risk of reactivation is increased by diabetes mellitus, HIV infection, silicosis, and various systemic or malignant conditions, as well as in alcoholics, IV drug abusers, nursing home residents, and those receiving adrenocortical steroid or immunosuppressive therapy. Secondary or reactivation tuber- culosis usually results in a chronic, spreading lung infection, most often involving the upper lobes. Minute granulomas (tubercles), just visible to the naked eye, develop in involved lung tissue, each consisting of a zone

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0 IMPROVING THE PRESUMPTIVE DISABILITY DECISION-MAKING PROCESS of caseation necrosis surrounded by chronic inflammatory cells (epithe- lioid histiocytes and giant cells). These lesions, which give the disease its name, are also found in other tissues (lymph nodes, bowel, kidney, skin) to which the disease may spread. Rarely, reactivation results in wide- spread dissemination of tubercles throughout the body (miliary tuber- culosis). The symptoms of active pulmonary tuberculosis are fatigue, anorexia, weight loss, low-grade fever, night sweats, chronic cough, and hemoptysis. Local symptoms depend on the parts affected. Active pulmonary tuberculosis is relentlessly chronic and, if untreated, leads to progressive destruction of lung tissue. Cavities form in the lungs, and erosion into pulmonary blood vessels can result in life-threatening hemorrhage. Gradual deterioration of nutritional status and general health culminates in death due to wasting, infection, or multiple organ failure. Variant syndromes (tuberculous lymphadenitis in children, severe systemic disease in persons with AIDS) are caused by organisms of the Mycobacterium avium-intracellulare complex (MAIC). The diag- nosis of TB is based on tuberculin skin testing (negaitive in 20 percent of people with active TB), imaging studies (computed tomography is more sensitive than standard chest radiography in detecting pleural effu- sion, miliary disease, and cavitation), and the finding of the causative organism in sputum of tissue specimens by acid-fast or fluorochrome staining, nucleic acid amplification, or culture. (Stedman’s medical dictionary 28th ed., 2005) Tumors—(1) Any swelling or tumefaction. (2) Syn: neoplasm. (3) One of the four signs of inflammation (t., calor, dolor, rubor) enunciated by Celsus. (Stedman’s medical dictionary 28th ed., 2005) Malignant tumor—A tumor that invades surrounding tissues, is usually capable of producing metastases, may recur after attempted removal, and is likely to cause death of the host unless adequately treated. (Stedman’s medical dictionary 28th ed., 2005) Type I presumptions—Shifts both the burden of production and the burden of persuasion. Type II presumptions—Establishment of the basic fact does not shift to the opponent the burden of persuading the adjudicator that the presumed fact does not exist. The opponent of the presumption only has to pro- duce evidence that is contrary to or meets the presumption. Ulcer—A lesion through the skin or a mucous membrane resulting from loss of tissue, usually with inflammation. (Stedman’s medical dictionary 28th ed., 2005) Ulceration—(1) The formation of an ulcer. (2) An ulcer or aggregation of ulcers. (Stedman’s medical dictionary 28th ed., 2005) Uncertainty—The state of being indeterminate, not certain to occur, not reli- able, not having certain knowledge, or not clearly identified or defined.

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0 APPENDIX C Undiagnosed illness (or unexplained illness)—A constellation of symptom complaints; was called “Gulf War Syndrome.” Vaccine Injury Table—Lists and explains injuries/conditions that are pre- sumed to be caused by vaccines and covered under the National Vaccine Injury Compensation Program. Valvulitis—Inflammation of a valve, especially a heart valve. (Stedman’s medical dictionary 28th ed., 2005) Vesicant—An agent that produces a vesicle. (Stedman’s medical dictionary 28th ed., 2005) Veteran—A person who served in the active military, naval, or air service, and who was discharged or released therefrom under conditions other than dishonorable. (Definitions. 2006. 38 U.S.C. § 101.) Veteran of any war—Any veteran who served in the active military, naval, or air service during a period of war. (Definitions. 2006. 38 U.S.C. § 101.) Vietnam era—(A) The period beginning on February 28, 1961, and ending on May 7, 1975, in the case of a veteran who served in the Republic of Vietnam during that period. (B) The period beginning on August 5, 1964, and ending on May 7, 1975, in all other cases. (Definitions. 2006. 38 U.S.C. § 101.) Viral exanthemas—A skin eruption occurring as a symptoms of an actual viral disease. von Recklinghausen’s neurofibromatosis (Type I neurofibromatosis)— Characterized clinically by the combination of patches of hyperpigmen- tation and cutaneous and subcutaneous tumors. The hyperpigmented skin areas, present from birth and found anywhere on the body surface, can vary markedly in size and color—the dark brown ones are called café-au-lait spots. The multiple cutaneous and subcutaneous tumors, called neurofibromas, can develop anywhere along the peripheral nerve fibers, from the roots distally. Neurofibromas can become quite large, causing a major disfigurement, eroding bone, and compressing various peripheral nerve structures; a small hamartoma (Lisch nodule) can be found in the iris of almost all patients. Has autosomal dominant inheritance, with the gene locus on chromosome 17q11, and is caused by mutation in the NF1 gene that encodes neurofibromin. Syn: Type I neurofibromatosis. (Stedman’s medical dictionary 28th ed., 2005) World War I—(A) The period beginning on April 6, 1917, and ending on November 11, 1918, and (B) In the case of a veteran who served with the United States military forces in Russia, means the period beginning on April 6, 1917, and ending on April 1, 1920. (Definitions. 2006. 38 U.S.C. § 101.) World War II—The period beginning on December 7, 1941, and ending on December 31, 1946 (except for purposes of chapters 31 and 37 of this

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06 IMPROVING THE PRESUMPTIVE DISABILITY DECISION-MAKING PROCESS title [38 U.S.C.S. § 3100 et seq. and 3701 et seq.]). (Definitions. 2006. 38 U.S.C. § 101.) Yaws—An infectious tropical disease caused by Treponema pertenue and characterized by the development of crusted granulomatous ulcers on the extremities; may involve bone, but, unlike syphilis, does not pro- duce central nervous system or cardiovascular pathology. (Stedman’s medical dictionary 28th ed., 2005) Yellow fever—A tropical mosquito-borne viral hepatitis, due to yellow fever virus, a member of the family Flaviviridae, with an urban form transmitted by Aedes aegypti, and a rural, jungle, or sylvatic form from tree-dwelling mammals by various mosquitoes of the Haemagogus species complex; characterized clinically by fever, slow pulse, albuminuria, jaundice, congestion of the face, and hemorrhages, especially hematemesis; used to occur in epidemics mainly in port cities, especially in late summer, with 20-40 percent case fatality rates; immu- nity to reinfection accompanies recovery. (Stedman’s medical dictionary 28th ed., 2005) LEGISLATION 1818 Service Pension Law 1862 General Pension Act 1862 Homestead Act 1890 Dependent Pension Act 1917 War Risk Insurance Act Amendments 1918 Vocational Rehabilitation Act 1924 World War Adjustment Compensation Act 1933 Economy Act 1943 Disabled Veterans’ Rehabilitation Act 1944 Servicemen’s Readjustment Act (GI Bill of Rights) 1950 Vocational Rehabilitation Act 1952 Veteran’s Readjustment Assistance Act (Korean GI Bill) 1954 War Claims Act Amendments 1959 Veterans’ Pension Act 1978 Veterans Disability Compensation and Survivor Act 1979 The Veterans Health Care Amendments 1979 Veterans Health Program Extension and Improvement Act 1981 Former Prisoners of War Benefits Act 1981 Veterans’ Health Care, Training, and Small Business Loan Act 1984 The Veterans Dioxin and Radiation Exposure Compensation Standards Act (VDRECSA) 1984 Veterans’ Compensation and Program Improvements Amendments

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0 APPENDIX C 1984 Veterans’ Dioxin and Radiation Exposure Compensation Standards Act 1986 Veterans Benefits Improvement and Health Care Authorization Act 1988 The Radiation-Exposed Veterans Compensation Act (REVCA) 1988 Veterans Benefits and Services Act 1990 The Radiation Exposure Compensation Act (RECA) 1991 Agent Orange Act 1994 Persian Gulf War Veterans’ Benefit Act 2000 Veterans Millennium Health Care and Benefits Act 2003 Veterans Benefits Act

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