Citation Nr: 0524113 Decision Date: 09/01/05 Archive Date: 09/13/05 DOCKET NO. 99-23 406 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 (West 2002) for cataracts, maldistribution of body fat, fluctuating blood pressure, muscle weakness, immune system deficiency, mood changes, slow healing wounds, sleeping difficulties, stomach disorder, and joint pains, all claimed to be the result of Prednisone treatment prescribed by VA. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD R. Acosta, Counsel INTRODUCTION The veteran served on active duty from July 1966 to July 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 1999 rating decision of the Department of Veterans Affairs (VA) Los Angeles, California, Regional Office (RO), which denied the veteran's claim for disability compensation benefits under Section 1151, for the medical conditions listed above. The Board remanded the case in February 2001, and then again in December 2003, for additional development. The Detroit, Michigan, RO currently has control of the veteran's claims file. FINDINGS OF FACT 1. VA has complied with its notification and assistance requirements under the laws and has obtained and developed all the evidence that is necessary for an equitable disposition of the matter on appeal. 2. The competent medical evidence of record does not demonstrate that the claimed cataracts, maldistribution of body fat, fluctuating blood pressure, muscle weakness, immune system deficiency, mood changes, slow healing wounds, sleeping difficulties, stomach disorder, and joint pains, were proximately caused by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing medical care, or were proximately caused by an event not reasonably foreseeable. CONCLUSION OF LAW The criteria for disability compensation under the provisions of 38 U.S.C.A. § 1151 for cataracts, maldistribution of body fat, fluctuating blood pressure, muscle weakness, immune system deficiency, mood changes, slow healing wounds, sleeping difficulties, stomach disorder, and joint pains, all claimed to be the result of Prednisone treatment prescribed by VA, have not been met. 38 U.S.C.A. § 1151 (West 2002 & Supp. 2005); 69 Fed. Reg. 46,433 (Aug. 3, 2004) (to be codified at 38 C.F.R. § 3.361) (effective September 2, 2004). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Preliminary matters-The Veterans Claims Assistance Act of 2000 (VCAA): The VCAA imposes obligations on VA in terms of its duty to notify and assist claimants. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2005). Regulations implementing the VCAA are codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326 (2004). A. The duty to notify Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The United States Court of Appeals for Veterans Claims (Court) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide; (4) VA must request that the claimant provide any evidence or information in his possession that pertains to the claim. Pelegrini v. Principi (Pelegrini II), 18 Vet. App. 112, 120-21 (2004); 38 C.F.R. § 3.159(b)(1). The Court has recently held, however, that failure to explicitly tell a claimant to submit relevant evidence in the claimant's possession was generally not prejudicial to the claimant. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005). With regard to element (1), the Board notes that the Reno, Nevada, RO sent to the veteran a VCAA notice letter in May 2005. That letter listed the issue on appeal and informed the veteran of the type of information and evidence necessary to establish entitlement to the disability compensation benefits that the veteran is seeking under Section 1151. With regard to elements (2) and (3), the May 2005 VCAA letter, as well as an earlier VCAA letter, issued by the Appeals Management Center in Washington, D.C., in March 2004, notified the veteran of his and VA's respective responsibilities for obtaining information and evidence under the VCAA. More specifically, the letters explained that VA would help him get such things as medical records or records held by any other Federal agencies, but that he was nevertheless responsible for providing any necessary releases and enough information about the records to enable VA to request them from the person or agency that had them. The letters also informed the veteran that VA would also provide him with a medical examination, or would obtain a medical opinion, if VA were of the opinion that such additional action was necessary to make a decision on his claim. Finally, with respect to element (4), the May 2005 VCAA letter contained specific advice to the veteran that "[i]f there is any other evidence or information that you think will support your claim, please let us know," and that "[i]f the information or evidence is in your possession, please send it to us." In Pelegrini II, the Court also held that (1) the VCAA applies to cases pending before VA on November 9, 2000, the date of VCAA's enactment, even if the initial agency of original jurisdiction (AOJ) decision was issued prior to that date, and that (2) VCAA notice must be given before an initial AOJ decision is issued on a claim. Pelegrini II, 18 Vet. App. at 115. The Court recognized that cases initially adjudicated by the AOJ prior to VCAA enactment would not have pre-adjudicatory notice, but concluded that claimants have a right to VCAA content-complying notice and proper subsequent VA process. Id. at 120. Although VCAA notice was not given prior to the first adjudication of the claim on appeal, any defect with respect to the timing of the VCAA notice requirement in the pre-VCAA adjudication was harmless. VA furnished notice prior to issuing a June 2005 supplemental statement of the case (SSOC), and prior to returning the case to the Board. Thus, the veteran had the opportunity for a de novo review of evidence furnished in response to the VCAA notice. B. The duty to assist The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim(s). 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c), (d) (2004). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination and/or opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4) (2004). The Board finds that the duty to assist has been fulfilled with respect to the claim on appeal. VA has secured all VA treatment records, to include Social Security Administration (SSA) records, and scheduled the veteran for VA medical examinations, which were conducted in April 2004 and May 2005. There is no suggestion on the current record that there remains evidence that is pertinent to the matter on appeal that has yet to be secured. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements and has obtained and developed all the evidence necessary for an equitable disposition of the matter on appeal. The appeal is thus ready to be considered on the merits. II. Factual background: The record shows that the veteran was admitted on December 14, 1990 to the VA Medical Center (VAMC) in San Francisco, California, with a two-and-a-half week history of intermittent hemoptysis, and renal insufficiency. (The term "hemoptysis" refers to the expectoration of blood, or of blood-stained sputum. Shockley v. West, 11 Vet. App. 208, 210 (1998).) He remained hospitalized until January 18, 1991. According to the discharge summary, the veteran had been in good health until approximately two weeks prior to the admission, when he had developed a cough that had gradually become associated with blood-tinged sputum and later on had progressed to frank blood, accompanied by non- bloody emesis, nausea, and fever. The veteran had initially sought medical help from his local physician, who had prescribed an antibiotic, which had only resulted in mild improvement of the symptoms. No blood work or X-rays had been obtained at that time. On December 10, and also two days later, the veteran had returned to the VAMC, where a chest X-ray revealed a very fine, growing, glass-appearing infiltrate near the right hilar area. He had been given Pseudoephedrine, as well as Diphenhydramine, for his symptoms, and sent back home. He returned to the VAMC on December 14, due to recurrence of his hemoptysis, nausea, and fever, and new symptoms including lightheadedness, mild right-sided dull chest pain, and progressive shortness of breath. He was hospitalized that day. At the time of admission, Benadryl and Pseudoephedrine were noted to be the medications taken. The veteran gave a history of smoking one to one-and-a-half packs of cigarettes every day for the past 25 years, and said that he drank one six-pack of beer every day, although he reported little to no alcohol consumption in the past two weeks. A comprehensive physical examination, and extensive laboratory studies, were performed during the month-plus admission, and it was noted that the hospital course had been significant for a diagnosis of rule out pulmonary renal syndrome, with the following major diagnoses on the differential list: Goodpasture's syndrome, Wegener's granulomatosis, infectious endocarditis, systemic necrotizing vasculitis, hemolytic uremic syndrome, systemic lupus erythematosus, cryoglobular anemia, and primary renal insufficiency, with concurrent hemoptysis, secondary to uremic platelet dysfunction. It was noted that, on the veteran's first hospital day, he was transfused, without complication, with two units of packed red blood cells, which raised his hematocrit levels, and that he was also started on steroids, with Prednisone 50 mg. administered orally "q.d." (i.e., daily). (Prednisone is a steroid used in the treatment of various diseases, including respiratory diseases such as symptomatic sarcoidosis. Carbino v. Gober, 10 Vet. App. 507, 508 (1997).) Also, because of the massive amount of bloody pulmonary secretion seen on bronchoscopy, the veteran's worsened chest X-rays, and his worsened renal function, the pulmonary and renal consulting teams recommended high-dose steroid therapy, as well as sedatoxic agents on the third day of the admission. As a result, the veteran was started on Cytoxan, at a dose of 2 mg/kg per day, as well as Solu- Medrol, 125 mg, administered intravenously. It was felt that the veteran would also benefit from plasmapheresis, given the high likelihood that his clinical situation could be explained by Goodpasture's syndrome. As of the date of discharge, it was noted that the exact etiology of the veteran's pulmonary hemorrhage and renal insufficiency was not known, but that Goodpasture's syndrome was a likely possibility. The following discharge medications were listed: Solu-Medrol, Cytoxan, Benadryl, and Guaifenesin, with codeine. An addendum to the above discharge summary, notes that the veteran was started on Prednisone, 50 mg. orally, per day, which was increased during the admission to 60 mgs. per day. The veteran's linear staining on a renal biopsy was felt most consistent with a diagnosis of Goodpasture's syndrome. The addendum also indicates that, despite the lack of improvement in his renal situation, the veteran fortunately had had good clinical response to the treatment regimen from a pulmonary standpoint, with oxygen supplemental requirements decreasing, and the chest X-rays continuing to show gradual and steady improvement. It was further noted that, at the time of his discharge, it was determined that the veteran would be maintained on Cytoxan and Prednisone, tapering the Prednisone from a level of 45 mgs., orally, per day, gradually down to a level of 20 mgs., orally, per day, over the next five months. Thereafter, he would be tapered down from 20 mgs., orally, per day, down to zero, over the ensuing six months. Medical records from Santa Rosa Memorial Hospital dated in December 1991 indicate that the veteran had been diagnosed with Goodpasture's syndrome a year earlier, that he had been treated with Cytoxan and Prednisone, and that "[h]e was tapered on the [P]rednisone nicely for his pulmonary symptoms." The veteran had been off the Prednisone for six months now, and had been completely asymptomatic, from the point of view of his pulmonary symptomatology. However, he had not recovered renal function, and had been on hemodialysis since that time. Current medications were Reglan and Zantac, as well as vitamins, iron, and calcium. There were no complaints at the time of this consultation such as fevers, cough, sputum production, chest pain, or shortness of breath. The appetite was good, there was no nausea or vomiting, and bowel movements were regular. Medical examination at the time of the above consultation revealed a dry weight of 64 kilos, with no edema, no heart enlargement, gallops, or murmurs, clear lungs, a soft abdomen, no masses or organomegaly, and a normal "CNS" (central nervous system) exam. A diagnosis of end-stage renal disease, secondary to Goodpasture's syndrome diagnosed a year ago, was confirmed, and the plan was listed as a cadaveric renal transplant. The record confirms that the planned cadaveric renal transplant was performed, a few days after the above consultation, in December 1991. The operation report from that surgery reveals a normal procedure, with no complications. In December 1999, the veteran's representative submitted to the RO a two-page document that she identified as "medication instructions for PREDNISONE 1MG TAB." The document explains that Prednisone belongs to the family of medicines called corticosteroids and that "it is like cortisone, which is needed for good health." The document also explains that, if the body does not make enough cortisone, this medicine may be used, and that it is usually used to treat bad allergies or skin problems, as well as asthma, arthritis, and "other conditions." Possible side effects of taking Prednisone, according to this document, include decreased or blurred vision, confusion, mental depression, mood or mental changes, continuing stomach pain or burning, an irregular heartbeat, muscle cramps, pain, weakness, rapid weight gain, indigestion, and trouble sleeping. VA outpatient medical records produced during the pendency of this appeal confirm diagnoses that include gastroesophageal reflux disease (GERD), degenerative joint disease (DJD) of both shoulders, chronic obstructive pulmonary disease (COPD), rotoscoliosis of the lumbar spine, hypertension, and depression. On VA general medical examination in April 2004, the examiner noted his review of the claims folders, referenced the pertinent medical history, and stated the following: Goodpasture's syndrome is brought about by glomerular basement membrane immune problems that can result in total renal failure. If the basement membranes of the lungs are involved, the bleeding into lung tissue is even more an acute problem than the renal disease. Prompt treatment with high dose steroids and anticancer medication, as well as plasmaphoresis must be undertaken in an attempt to stop the lung bleeding and also to minimize the damage to the kidneys. These procedures were undertaken and the lung bleeding did stop, although he was given a couple of transfusions in order to stabilize that. The kidneys continued on despite therapy, however, to deteriorate. He went into renal failure requiring renal transplant after one year of renal dialysis. He then continued from that on in the rest of his life with steroids and anti-rejection medications that lower his immune system. The complaints that he has in the questions on the request for disability are certainly complications that are known and expected with long-term steroids and anti-rejection medications. He is experiencing exactly what is listed as maldistributed body fat, muscle weakness, immune system deficiency, sleeping difficulties, mood changes, abdominal complaints, and joint pain, as well as osteoporosis [all of which] are expected with the medications that he has been using and will continue to use. The examiner also pointed out that the veteran had developed early cataracts, and had gained weight, from his initial 135 pounds, up to 205 pounds. The veteran reportedly experienced weakness, even to the point that there were times when he could not open jars, and said that he had been diagnosed with GERD and Barrett's esophagus. He had also been diagnosed with borderline obstructive sleep apnea, for which he had been given a steroid nasal spray. He had had surgery on both knees in the past, due to skiing accidents, "and not related to military [service] or to his Goodpasture's syndrome." On physical examination, the veteran was noted to have "the moon-shaped face of chronic [P]rednisone use," and to also have a "slight[ly] humped back on the upper thoracic spine." The veteran had experienced impingement syndrome of the shoulders, without evidence of tendon tear or rotator cuff problems, the later of which the examiner said would be due to Prednisone use. The veteran was showing some development of osteoarthritis, which the Prednisone had not stopped. There was a trace of pretibial edema, "which is not unusual with [P]rednisone." The lungs were clear to percussion and auscultation, even though the veteran had continued to smoke. The heart had regular rhythm and rate, without murmur or enlargement, and the abdomen was obese, soft, and nontender. There was no sensory loss in the extremities, and the peripheral pulses were full and equal. The VA examiner stated that the veteran was in the process of developing diabetes mellitus, type II, "which can be aggravated by [P]rednisone and for which there is a positive family history." Regarding a number of lesions removed from the veteran's skin, the examiner indicated that the skin of chronic renal patients did tend to be more sun-sensitive than the skin in other individuals. He also noted that there was no external evidence of GERD, but that there was pathological evidence of Barrett's esophagus. He then offered the following opinion: The [veteran] developed a severe renal disease, which has not been officially connected to Agent Orange and occurred well after his military service. He received at the San Francisco VA[MC,] and then [at the] University of California[,] prompt and appropriate therapy once the diagnosis of Goodpasture's syndrome was made. Despite the therapy, as can happen in the high percentage of Goodpasture's patients, kidneys went on to fail requiring renal transplant after renal dialysis. He has been fortunate through the use of many medications to avoid rejection and to have improved his renal failure through the transplant procedure. He must, however continue to take [P]rednisone and antirejection medications for the rest of his life. The weakness and symptomatologies, otherwise[,] which he is experiencing are known and expected complications of these powerful medications. Also in April 2004, the veteran underwent a VA eye examination. The examiner noted review of the claims folders. He also stated that the veteran presented with complaints of blurred midrange vision and a report of having cataracts, although there was no eye pain and the distance vision was good. It was noted that the veteran had started treatment in 1991 for Goodpasture's syndrome, that the beginning dosage of Prednisone had been in the 60 mg range and that, as of the date of the examination, he was taking 10 mg of that medication, on a daily basis. There was no current ophthalmic treatment. The examiner diagnosed age- related cataracts, bilaterally, myopia, with astigmatism, also bilaterally, and normal vision with correction. He also offered the following opinion, "There is no evidence of any lenticular changes secondary to [P]rednisone administration since 1991." VA medical records produced in 2005 confirm that the list of the medications currently being taken by the veteran included Prednisone, 5 mg. On VA re-examination in May 2005, the examiner noted review, "in detail," of the veteran's "extensive" record, currently comprising of four claims files. The examiner noted that a diagnosis of renal disease had been given 22 years after service, that the veteran had been on Prednisone since 1991, at which time he had had a renal transplant, and that the veteran's current extensive list of medications included Prednisone, 10 mgs. per day. The physical examination was essentially negative, other than for the presence of a well-healed surgical scar in the right lower quadrant, secondary to the renal transplant, and surgical scars on both knees. The examiner offered the following comments: DIAGNOSES: 1. Chronic kidney disease with renal transplant. 2. Hypertension, stable. 3. Diabetes. 4. Immunosuppresion. MEDICAL OPINION: It is the medical opinion of the examining physician with the information available to me at this time that there is concurrence with the last C&P [medical examination] done [in April 20]04 and the Nephrology consult done in Ann Arbor of this year that the veteran's circumstances are to be expected from the use of his [P]rednisone which has allowed him to maintain his renal transplant without rejecting the transplanted kidney with this, the veteran's life has been sustained. The veteran's SSA records, reveal he has been deemed disabled, for SSA purposes, since January 1991, on account of a primary diagnosis of chronic renal failure. III. Legal analysis: Pursuant to 38 U.S.C.A. § 1151, where a claimant suffers injury or aggravation of an injury as a result of VA hospitalization or medical or surgical treatment, not the result of his own willful misconduct or failure to follow instructions, and the injury or aggravation results in additional disability, then compensation, including disability compensation, shall be awarded in the same manner as if the additional disability were service-connected. 38 U.S.C.A. § 1151 (West 2002). For purposes of this section, a disability or death is a qualifying additional disability if the disability or death was not the result of the veteran's willful misconduct and (1) the disability or death was caused by hospital care, medical or surgical treatment, or examination furnished the veteran under any law administered by the Secretary, and the proximate cause of the disability or death was (A) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Department in furnishing the hospital care, medical or surgical treatment, or examination; or (B) an event not reasonably foreseeable. 38 U.S.C.A. § 1151. To establish causation, evidence must show that the hospital care, medical or surgical treatment, or examination resulted in the veteran's additional disability or death. Merely showing that a veteran received care, treatment, or examination and that the veteran has an additional disability or died does not establish cause. 69 Fed. Reg. 46,433 (Aug. 3, 2004); (to be codified at 38 C.F.R. § 3.361(c)(1)). The proximate cause of disability or death is the action or event that directly caused the disability or death, as distinguished from a remote contributing cause. 69 Fed. Reg. 46,433 (Aug. 3, 2004); (to be codified at 38 C.F.R. § 3.361(d)). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a veteran's additional disability or death, it must be shown that the hospital care, medical or surgical treatment, or examination caused the veteran's additional disability or death, and (i) that VA failed to exercise the degree of care that would be expected of a reasonable health care provider or (ii) that VA furnished the hospital care, medical or surgical treatment, or examination without the veteran's or, in appropriate cases, the veteran's representative's informed consent. 38 C.F.R. § 3.361(d)(1) (effective September 2, 2004). Whether the proximate cause of a veteran's additional disability or death was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of § 17.32 of this chapter. 38 C.F.R. § 3.361(d)(2) (effective September 2, 2004). The law applicable to the veteran's claim has undergone changes in interpretation and substance in recent years. Effective for claims filed on or after October 1, 1997, 38 U.S.C.A. § 1151 now precludes awarding benefits in the absence of evidence of VA negligence or an unforeseen event. See Pub. L. No. 104-204, § 422(a), 110 Stat. 2926 (1996); see also VAOPGCPREC 40-97; 63 Fed. Reg. 31263 (1998); as well as the above-cited current version of 38 C.F.R. § 3.361 (in effect since September 2, 2004, but applicable to all claims filed on or after October 1, 1997). In the present case, the veteran's claim for benefits under Section 1151 was filed in March 1998. Evidence of an unforeseen event or evidence of VA negligence is therefore required for this claim to be granted. In regards to the claimed cataracts, the record confirms the diagnosis in both eyes, but the VA specialist who examined the veteran in April 2004 unequivocally stated that the bilateral eye disability was age related and that there was no evidence of any related changes being secondary to the veteran's use of Prednisone since 1991. There is no competent evidence in the veteran's voluminous record indicating, or even suggesting, that this disability is the result of the administration of Prednisone, or any other medical treatment furnished by VA. In regards to the remaining complaints (maldistribution of body fat, fluctuating blood pressure, muscle weakness, immune system deficiency, mood changes, slow healing wounds, sleeping difficulties, stomach disorder, and joint pains), the Board notes that several diagnoses have been rendered during the pendency of this appeal that seem to objectively confirm the current manifestation of certain disabilities associated with some of these symptoms. Specifically, there are diagnoses of GERD and Barrett's esophagus (which may be related to the stomach-related complaints); DJD of the shoulders and rotoscoliosis of the lumbar spine (which may be related to the veteran's complaints of "joint pains"); hypertension (which may be related to the veteran's complaints of "fluctuating blood pressure"); depression (which may be related to the veteran's complaints of "mood changes"); and sleep apnea (which may be related to the veteran's complaints of "sleeping difficulties"). The above fact notwithstanding, the two VA physicians who examined the veteran in April 2004 and May 2005 concluded that, while the claimed symptoms seemed to have been a direct result of the veteran's use of VA-prescribed Prednisone, they were all "known and expected complications" associated with this medication, which had actually prevented the veteran's body from rejecting the transplanted kidney and essentially prolonged his life. These medical opinions, which have been rendered after thorough and careful analyses of the evidentiary record, clearly demonstrate that the claimed "disabilities," even if currently manifested, are not the result of VA's carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault in furnishing medical treatment, nor the result of an event not reasonably foreseeable. The veteran has not claimed, nor the record shows, that he is a medical expert, capable of rendering medical opinions. Therefore, as a lay person, without the appropriate medical training and expertise, he is not competent to render a probative opinion on a medical matter. See Bostain v. West, 11 Vet. App. 124, 127 (1998), citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) (a layman is generally not capable of opining on matters requiring medical knowledge). Inasmuch as all the competent evidence is to the effect that the claimed conditions are "known and expected complications," rather than complications arising from negligence by VA or an event not reasonably foreseeable; or are unrelated to Prednisone use, the weight of the evidence is against the claims. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Compensation under the provisions of 38 U.S.C.A. § 1151 for cataracts, maldistribution of body fat, fluctuating blood pressure, muscle weakness, immune system deficiency, mood changes, slow healing wounds, sleeping difficulties, stomach disorder, and joint pains, all claimed to be the result of Prednisone treatment prescribed by VA, is denied. ORDER Disability compensation under the provisions of 38 U.S.C.A. § 1151 for cataracts, maldistribution of body fat, fluctuating blood pressure, muscle weakness, immune system deficiency, mood changes, slow healing wounds, sleeping difficulties, stomach disorder, and joint pains, all claimed to be the result of Prednisone treatment prescribed by VA, is denied. ____________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs