Citation Nr: 1237334 Decision Date: 10/31/12 Archive Date: 11/09/12 DOCKET NO. 07-09 138 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUE Entitlement to compensation under 38 U.S.C.A. § 1151 for additional disability of the spleen, liver, and gall bladder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. Mishalanie, Counsel INTRODUCTION The Veteran served on active duty from October 1970 to October 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Reno, Nevada, in which the RO denied the Veteran's claim for compensation under 38 U.S.C.A. § 1151 as a result of VA treatment. In March 2009, the Veteran testified at a Board hearing before a Veterans Law Judge at the RO; a transcript of the hearing is of record. In December 2009, the Board remanded the claim to the RO, via the Appeals Management Center (AMC) for additional development. In February 2012, the Board requested a medical opinion from the Veterans Health Administration (VHA). In May 2012, a VA physician provided the requested opinion. In July 2012, the Veteran and his representative were sent a copy of the opinion and informed that they had 60 days to submit further evidence or argument. See 38 C.F.R. § 20.903 (2011). In July and August 2012, the Veteran and his representative submitted briefs in response. The Board notes that a review of the Virtual VA paperless claims processing system (Virtual VA) reflects that it contains recent VA treatment records dated from August 2006 through February 2012 that are not in the physical claims folder. This additional evidence was received after the last adjudication of the matter in an April 2011 supplemental statement of the case (SSOC). The Board notes that neither the Veteran nor his representative waived the procedural right to have this evidence considered initially by the agency of original jurisdiction (AOJ)/RO. However, the additional treatment records primarily relate to ongoing treatment for other disabilities and only reference the Veteran's concerns regarding his hepatitis C. The additional records are not pertinent to Veteran's claim for compensation under 38 U.S.C.A. § 1151; therefore, remand for initial consideration by the AOJ is not necessary. See 38 C.F.R. § 20.1304(c) (2012). Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT Additional disability of the spleen, liver, and gall bladder was not caused by VA treatment. CONCLUSION OF LAW The criteria for compensation pursuant to the provisions of 38 U.S.C.A. § 1151 for additional disability of the spleen, liver, and gall bladder have not been met. 38 U.S.C.A. §§ 1151, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.361 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2011), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2011), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. Additionally, the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) (West 2002) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial disability-rating and effective-date elements of a service connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The record reflects that the RO provided the Veteran with the notice required under the VCAA in pre-rating letters dated in March and August 2006. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). 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 or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). In this case, VA obtained the Veteran's service treatment records (STRs), and all of the identified post-service treatment records. In addition, the Veteran was provided with a VA examination in October 2010 and a VHA opinion was obtained in May 2012. As the medical opinions included a review of the pertinent medical history, clinical findings, and diagnoses, and were supported by medical rationale, the Board finds that the October 2010 VA examination, along with the May 2012 VHA opinion, are adequate to make a determination on the claim. The Board acknowledges the arguments made by the Veteran and his representative concerning the adequacy of the VHA opinion provided by Dr. Heuman. Specifically, the Veteran's representative argues that Dr. Heuman is not an expert in hepatotoxicology and therefore his opinion is inadequate. Although Dr. Heuman indicated that he was not a specialist in hepatotoxicity, he provided a detailed response to the questions posed by the Board. Dr. Heuman is Chief of Hepatology at the VA Medical Center (VAMC) in Richmond, Virginia. He is also a Professor of Medicine at the Virginia Commonwealth University. To the extent Dr. Heuman recommended a referral to Dr. P.W. if further specialist opinion was required in the Veteran's tort proceeding, the Board finds that an additional specialist opinion is not necessary for the purposes of the present claim. Dr. Heuman's expertise in hepatology is sufficient to answer the questions in this case. See Cox v. Nicholson, 20 Vet. App. 563, 569 (2007) (explaining that "the Board is entitled to assume the competence of a VA examiner," and the appellant bears the burden of rebutting the Board's presumption of competence). Furthermore, the Veteran's disagreement with Dr. Heuman's opinion itself does not render it adequate. His arguments as to why Dr. Heuman's opinion should not be given as much probative weight as the evidence he has provided will be discussed further below. In addition, during the Board hearing, the VLJ discussed with the Veteran the evidence required to establish entitlement to compensation under 38 U.S.C.A. § 1151. This action supplemented VA's compliance with the VCAA and complied with 38 C.F.R. § 3.103. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. The claim for compensation under 38 U.C.S.A. § 1151 is thus ready to be considered on the merits. Factual Background The Veteran, who has a history of hepatitis C, asserts that VA negligently prescribed him hepatoxic drugs (ibuprofen and Tylenol #3) from 1997 to 2004. He is seeking compensation under 38 U.S.C.A. § 1151 for additional disability (claimed as liver, spleen, and gall bladder damage) due to the VA treatment of various orthopedic complaints with these medications. The Veteran's medication profile reflects that he was prescribed 90 tablets of Ibuprofen 600 mg with 6 refills in July 1997; he did not refill this prescription. January 1998 tests indicate that aspartate transaminase (AST) (also referred to as serum glutamic oxaloacetic transaminase (SGOT)) was 112 and alanine transaminase (ALT) (also referred to as serum glutamic pyruvate transaminase (SGPT)) was 243. A July 1998 abdominal ultrasound showed mild hepatosplenomegaly with diffuse increased echogenicity in the liver probably secondary to underlying fatty replacement or hepatocellular disease. July 1998 tests indicated that AST was 118 and ALT was 238. His medication profile reflects that he was prescribed 30 tablets of ibuprofen 600 mg in July 1998. In August 1998, test results on two different days showed that AST was 83 and 114; ALT was 175 and 227. An August 1998 treatment record notes that the Veteran had no problems with hepatitis C until December 1997. He complained of tiredness, chest congestion, and erratic sleep patterns. It was noted that he occasionally took Tylenol #3 for dental problems. The Veteran's medication profile reflects that he was prescribed 20 tablets of codeine 30/acetaminophen 300 mg in September 1998. In November 1998, AST was 74. In February 1999, test results on two different days showed that AST was 83 and 87; ALT was 189 and 191. His medication profile reflects that he was prescribed 30 tablets of ibuprofen 600 mg and 60 tablets of Indomethacin 25 mg in March 1999. A March 1999 liver and spleen scan was essentially unremarkable; there was a question of mild left lobe enlargement. In April 1999, he was prescribed 90 tablets of indomethacin 25 mg with 2 refills; he did not refill the prescription. He was prescribed 90 tablets of ibuprofen 600 mg with 3 refills in June 1999; he did not refill the prescription. In July 1999, the Veteran complained of fatigue, sharp pain in his lower abdomen, and some diarrhea. He was counseled on possible therapy, but was told that he needed a liver biopsy. He said he did not want to take the risk. It was noted that his medications included ibuprofen (800 mg, tid) and Indomethacin ( 25 mg q8h) for back pain and that he should return to the clinic in 3 to 4 months. July 1999 tests indicated that AST was 80 and ALT was 230. The Veteran's medication profile reflects that he was prescribed 30 tablets of hydrocodone 5/acetaminophen 500 mg in July 1999; he was twice prescribed 20 tablets of codeine 30/acetaminophen 300 mg in August 1999. A February 2000 VA treatment record notes that the Veteran had been diagnosed with hepatitis C in December 1997 and was in the beginning process of the disease. The Veteran complained of fatigue, headaches, and nausea. The Veteran's medications were noted to include ibuprofen 500 mg (tid) and Indomethacin 25 mg The Veteran's medication profile reflects that he was prescribed 50 tablets of codeine 30/acetaminophen 300 mg in February 2000. In February 2000, test results showed that HCV viral load was 1,000,000 copies/ml; AST was 70; and ALT was 166. A March 2000 liver and spleen scan showed mild enlargement of the left lobe of the liver otherwise no significant abnormalities were shown. In May 2000, it was noted that the Veteran had declined treatment at a clinic visit in April 2000. He said he was waiting for the decision of his workers compensation case and wanted to go to an outside doctor. He was currently without symptoms and it was noted that his March 2000 liver/spleen scan did not show any cirrhosis. It was also noted that the Veteran was not drinking alcohol and was avoiding all medications when possible. He said he had noticed an intermittent problem with nausea and fatigue. The Veteran's medication profile reflects that he was prescribed 10 tablets of codeine 30/acetaminophen 300 mg in October 2000 and 30 tablets in November 2000. In January 2001, a VA physical medicine and rehabilitation consultation record notes that the Veteran complained of severe right shoulder pain with decreased range of motion. It was noted that the Veteran could not take Tylenol because of hepatitis C and that the Veteran said NSAIDs were of no use in treating his pain. An addendum notes that X-rays were negative and he was given Tylenol #3 for pain for 30 days. The Veteran's medication profile reflects that he was prescribed 100 tablets of codeine 30/acetaminophen 300 mg in January 2001. He filled the prescription each month through June 2001. In June 2001, it was noted that the Veteran's hepatitis C was untreated and that he had mildly elevated transaminases in February 2000. Labs were ordered for liver function tests and he was told to return in 6 to 8 weeks. An August 2001 note indicates that the Veteran requested a refill on Tylenol #3 for pain and that he was offered alternate medication (i.e., NSAIDs) but said that he could not take NSAIDs because of hepatitis C. Apparently a disagreement ensued and the nurse noted that the Veteran exhibited "drug seeking behavior". The Veteran vehemently denied this characterization and there is a letter of apology from the RO regarding this incident. The following day, it was noted that the Veteran was very upset that the nurse had not given him Tylenol #3. He said that knowing his liver problem, he was very careful not to take too much and only took it when he was in a lot of pain. He said that he tried Motrin, Excedrin, and Advil, but none helped with his pain. The nurse presented the Veteran's concerns to the attending physician and he was prescribed Tylenol #3 for 14 days until he could see an orthopedic physician. His medication profile reflects he was prescribed 30 tablets of codeine 30/acetaminophen 300 mg in August 2001. In October 2001, he was prescribed 60 tablets. October 2001 tests indicated that AST was 36. April 2003 test results showed AST was 75. It was noted that the Veteran's liver test was abnormal and he was referred for a liver consultation for hepatitis (HCV) evaluation. In June 2003, he was seen for evaluation and treatment for hepatitis C. He said that he felt fine that day, but did have a lot of headaches and fatigue. He also said that he experienced nausea and diarrhea. It was noted that he had a high viral load, but he was not interested in treatment. He was scheduled for an ultrasound and to return in 9 months to discuss if he wanted treatment. June 2003 tests indicated that AST was 66 and ALT was 132. The Veteran's medication profile reflects he was prescribed 30 tablets of codeine 3/acetaminophen 300 mg with 2 refills in July 2003; the Veteran did not refill the prescription. An August 2003 abdominal ultrasound showed mildly coarsened liver consistent with diffuse hepatocellular disease, which was most frequently related to fatty infiltration. There was borderline enlargement of both the liver and spleen. Cholelithiasis (gallstones) was also noted. The Veteran's medication profile reflects he was prescribed 20 tablets of codeine 30/acetaminophen 300 mg in September 2003. In October 2003, AST was 69 and ALT was 141. He was seen for an evaluation of treatment options and told the physician that he wanted to wait until his workers compensation lawsuit was complete. He said he would likely go to UCLA for treatment. Active medications were noted to include codeine 30/acetaminophen 300 mg (1 tablet four times a day for pain). In November 2003, he was prescribed 40 tablets of codeine 30/acetaminophen 300 mg and 40 tablets of hydrocodone 5/acetaminophen 500 mg. February 2004 test results indicate that AST was 132 and ALT was 233. A March 2004 record reflects that the Veteran was seen for an exacerbation of low back pain radiating around the right sacroiliac joint. He noted some help with Tylenol #3 and methocarbamol. It was noted that the Veteran had hepatitis C and was aware of the danger to his liver with these medications and that they should be used sparingly. His medication profile reflects that he was prescribed 120 tablets of codeine 30/acetaminophen 300 mg with 1 refill in March 2004, which was refilled the following month. A June 2004 treatment record indicates the Veteran's active medication included codeine 30/acetaminophen 300 mg (take 1-2 tablets every 4 hours as needed for pain). The Veteran stated that he had won his workers compensation lawsuit, but that it would likely be appealed. Treatment options were discussed for hepatitis C, but he said he wanted to go to an outside provider and refused treatment by VA. August 2004 tests indicated that AST was 88 and ALT was 147. In March 2005, the Veteran stated that he was waiting to decide on treatment for hepatitis C until his workers compensation case had resolved. He said that physical therapy and epidural injections had helped for low back pain, but that he was recently seen in the emergency room for focal low back pain and was taking Tylenol #3. He was referred back to rehab for current exacerbation of back pain and for "ginger use" of Tylenol #3. March 2005 tests indicated that AST was 108 and ALT was 172. A March 2005 CT scan of the pelvis noted that an unenhanced limited study of the liver, spleen, kidneys, adrenal glands, and pancreas was unremarkable. Cholelithiasis was noted. His medication profile reflects that he was prescribed 30 tablets of codeine 30/acetaminophen 300 mg with 1 refill in March 2005. The Veteran lost the prescription on the bus and was given a prescription for 120 tablets that same day. In August 2005, it was noted that he was seen in rehab and would continue Tylenol #3. August 2005 tests indicated that AST was 93 and ALT was 141. A treatment records from the Reno VA Medical Center (VAMC) indicate the Veteran was seen in triage in September 2005 for severe back pain. He said that he had been taking methocarbamol and Tylenol #3, but did not have a prescription. He was discharged home with a prescription. November 2005 tests indicated that AST was 82, ALT was 129, and creatinine, serum was 1.4 mg/dL. In December 2005, a physician called him after he cancelled his appointment. The Veteran said that he did not want any follow-up on his liver tests. He denied alcohol and Tylenol and was aware of his creatinine levels. He did not want any intervention. March 2006 tests indicated that AST was 56 and ALT was 98. It was noted that the Veteran's previous imaging was suggestive of diffuse hepatocellular disease, possibly related to his hepatitis C and that he did have biochemical evidence of inflammation, but that he had not been interested in interferon treatment. In a November 2006 letter, Dr. Khudatyan, a private physician, noted that Tylenol codeine and ibuprofen are known to be hepatotoxic medically and that the Veteran has a history of using these medications on a concurrent basis for several years. The physician opined that these medications caused a deterioration of the Veteran's liver function. In August 2008, Dr. Dickstein provided a qualified medical evaluation (QME) supplemental report for the Veteran's workers compensation claim, which mostly relates to the likely source of his hepatitis C infection. Of note, however, Dr. Dickstein indicated that liver dysfunction can cause gallstones. In October 2010, the Veteran underwent a VA examination. The examiner opined that it was less likely as not that any current disorder of the spleen, liver, and gallbladder was the result of VA medical treatment, in particular the prescription of Tylenol with codeine and ibuprofen; less likely as not that any current disorder was a "necessary consequence" of VA medical treatment; and that any current disorder was due to the natural progression of a disease or injury that occurred prior to the prescription of Tylenol with codeine and ibuprofen. The rationale provided was that the Veteran's liver function had been stable and did not worsen while taking the medication; that even though these medications can be found to be harmful to liver tissue when taken in large doses, they have not been found to be harmful in therapeutic doses; and that the medication prescribed did not exceed the recommended doses and was prescribed due to the Veteran's complaints of significantly painful conditions. The examiner cited several medical journal articles to support her opinion. In January 2011, the Veteran submitted a private medical opinion from Dr. Bash, a neuro-radiologist. Dr. Bash cited reports of liver injury and death being associated with acetaminophen medications. He opined that logical medical principles state that if the normal liver is damaged by acetaminophen, then it is very likely that even therapeutic Tylenol treatments to an infected liver will also cause irreversible accelerated liver damage. In May 2012, Dr. Heuman, Chief of Hepatology at the Richmond VAMC, provided a VHA opinion. Dr. Heuman provided the following opinions: 1) To a reasonable degree of medical certainty, the Veteran's chronic liver disease was caused by chronic hepatitis C viral infection. Additional contributors to liver injury may have included hepatic steatosis related to alcohol use and/or nonalcoholic fatty liver disease; from the available records the review is unable to support or exclude these possibilities. 2) His liver disease between 1997 and 2004 was not disabling but may have progressed gradually; slowly progressive liver fibrosis is typical of hepatitis C. He was offered antiviral treatment to eradicate hepatitis C and arrest the progression of his liver disease, but apparently declined on multiple occasions. 3) There is no credible evidence in the medical literature to indicate that chronic use of acetaminophen, ibuprofen, indomethacin or codeine is associated with chronic liver injury leading to cirrhosis or its complications. The assertion by Dr. Khudatyan and Dr. Bash that this occurred in the present case is pure speculation and without scientific support. 4) Acetaminophen can cause acute or subacute liver injury when taken in excessive doses (greater than 2.5 g daily), but has not been credibly associated with chronic liver injury leading to cirrhosis. The liver toxicity of acetaminophen is characterized by acute elevations of the transaminases (AST and ALT) that return to normal with days to weeks of stopping the acetaminophen. The transaminase elevations in this case were low grade and chronic, typical of liver injury caused by chronic hepatitis C. The doses given to this patient were within the safe range, even for patients with liver disease." 5) Cholelithiasis may be associated with chronic liver disease, particularly cirrhosis. 6) In my judgment the treatment prescribed by the VA for control of pain in this man with chronic hepatitis C infection was within the standard of care for a reasonable health care provider. 7) To a reasonable degree of medical certainty, the treatment prescribed by the VA did not contribute to the patient's chronic progressive liver injury. Legal Criteria The law provides that compensation may be paid for a qualifying additional disability not the result of the Veteran's willful misconduct, caused by hospital care, medical or surgical treatment, or examination furnished the Veteran when the proximate cause of the disability was: (A) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination; or (B) an event not recently foreseeable. 38 U.S.C.A. § 1151 (2012). VA regulations provide that benefits under 38 U.S.C.A. § 1151(a) for claims received by VA on or after October 1, 1997, as in this case, for additional disability due to hospital care, medical or surgical treatment, examination, require actual causation not the result of continuance or natural progress of a disease or injury for which the care, treatment, or examination was furnished, unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361 (2012). If additional disability is shown to exist, the next consideration is whether the causation requirements for a valid claim have been met. In order to establish actual causation, the evidence must show that the medical or surgical treatment rendered resulted in the Veteran's additional disability. See 38 C.F.R. § 3.361(c)(1) (2012). In addition, the proximate cause of the disability claimed must be the event that directly caused it, as distinguished from a remote contributing cause. 38 C.F.R. § 3.361(d) (2012). It must be shown that the hospital care, medical or surgical treatment, or examination caused the Veteran's additional disability, and that (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider or that (ii) VA furnished the hospital care, medical or surgical treatment, or examination without the informed consent of the Veteran or the Veteran's representative. To establish the proximate cause of an additional disability or death, it must be shown that there was 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. Whether the proximate cause of a Veteran's additional disability or death was an event not recently foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. 38 C.F.R. § 3.361(d) (2012). Analysis Upon review of the file, the Board notes that the claims file contains voluminous VA and private medical records. Although the Board has an obligation to provide adequate reasons and bases supporting its decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the issue on appeal. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). As noted above, the Veteran, who has a history of hepatitis C, asserts that VA negligently prescribed him hepatoxic drugs (ibuprofen and Tylenol #3) from 1997 to 2004. As a result, he claims additional disability of the liver, spleen, and gall bladder. At the outset, the Board notes that the Veteran is competent to describe what he has personally experienced, including the symptoms he has experienced and the medications he has used. Layno v. Brown, 6 Vet.App. 465, 469 (1994). However, competency is a separate and distinct determination from credibility. Here, the Board finds credible the Veteran's statements regarding the medications that he used to treat his orthopedic complaints; however, the contemporaneous medical records are more probative as to the exact dosages prescribed and the time periods for which they were prescribed. The threshold question in this case is whether additional disability resulted from VA treatment. The Board acknowledges that competing competent evidence has been presented with respect this question and it is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993). The Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Board, however, may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App 171 (1991). The weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, based on an examination of limited scope, or where the basis for the opinion is not stated. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Sklar v. Brown, 5 Vet. App. 140 (1993). Here, as explained below, the Board finds that the opinions rendered by the October 2010 VA examiner and the Dr. Heuman that additional disability was not caused by VA treatment are more probative than the opinions rendered to the contrary. Initially, the Board points out that the Dr. Heuman specializes in hepatology, the specific area of medicine at issue. Although he noted that he is not an expert in hepatotoxicity, he has the esoteric knowledge and expertise of the liver required to make the necessary determinations in this case. Likewise, the October 2010 VA examiner specializes in internal medicine and therefore has some additional knowledge and training in this area beyond that of a general practitioner. Cf. Black v. Brown, 10 Vet. App. 279 (1997). See also Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). On the other hand, Dr. Bash specializes in radiology and Dr. Khudatyan is a family care physician. While they presumably have some general medical knowledge of the issues at hand, they do not share the same level of expertise as the October 2010 VA examiner and Dr. Heuman. With regard to Dr. Khudatyan's opinion, the Board notes that the physician did not provide a rationale for his conclusion that Tylenol/Codeine and ibuprofen caused deterioration of the Veteran's liver function. Although he notes that these medications are known to be hepatotoxic medically, he does not address the specific amount prescribed to the Veteran nor does he address the fact that the ALT/AST elevations were chronic and low grade rather than acute. He also does not address whether there was any natural progression of the Veteran's hepatitis C, especially in light of the fact that the Veteran declined antiviral treatment during this time period. Therefore, the Board finds that Dr. Khudatyan's opinion has little probative value. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (discussing factors for determining probative value of medical opinions). With regard to Dr. Bash's opinion, the Board notes that the physician performed a google search and cited numerous news articles of cases where large doses of acetaminophen caused liver damage and even death in some instances. He then extrapolated that if large doses of acetaminophen can cause a normal liver to be damaged, it is likely that therapeutic Tylenol treatments to an infected liver will also cause irreversible accelerated liver damage. However, as Dr. Heuman pointed out, such an extrapolation is purely speculative; Dr. Bash did not provide any scientific support for this conclusion. Furthermore, he does not address the fact that the Veteran had relatively low grade and chronic AST/ALT elevations, which is consistent with the natural progression of hepatitis C (as indicated by the record). For these reasons, the Board finds that Dr. Bash's opinion also has little probative value. In this case, the Veteran has submitted numerous statements in which he attributes additional disability to the medications he was prescribed and he has submitted medical opinions in support of these assertions. The Board acknowledges that under a broad reading of Jandreau, these statements are competent. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, the Veteran's opinions have no greater weight and credibility than the underlying support, which, as discussed above, has little or no probative value. On the other hand, the October 2010 VA examiner's report included a review and discussion of the claims file, including the types and amounts of medication prescribed to the Veteran during the relevant time period and a discussion of the ALT/AST levels. The examiner also performed a search of the medical literature using the National Institute of Health PubMed database. The largest study published in "Current Medical Research & Opinion" found that acetaminophen-treated patients had low-level, transient ALT elevations which usually resolved or decreased with continued acetaminophen treatment and were unaccompanied by signs or symptoms of liver injury. Even the maximum recommended daily dose of acetaminophen did not cause liver failure or dysfunction. Another study published in "Pharmacotherapy" confirmed these findings and found that prior data indicating liver damage from therapeutic doses of acetaminophen were based on inaccurate dosage information and were actually inadvertent overdoses. Another case report published in "Clinical Therapy" indicates that a patient with HIV, hepatitis B, and hepatitis C presented with signs of liver failure after reportedly taking therapeutic doses of acetaminophen but within 11 days his AST levels decreased from 8,581 to 42 with no residual liver damage. Ultimately, the examiner opined that VA treatment did not cause any additional disability. The Board notes that the examiner's opinion was based on a thorough review of the claims file, including specific references to the amount of medications prescribed to the Veteran and the Veteran's liver function tests. The opinion was also based on a review of the medical literature from a reputable database rather than a simple google search of the Internet. For these reasons, the Board finds the October 2010 VA examiner's opinion especially probative. Likewise, Dr. Heuman's opinion was well-explained and consistent with the clinical evidence in this case. The Veteran was diagnosed with hepatitis C, which has progressed gradually since 1997. Furthermore, the Veteran refused antiviral treatment during this time period. The chronic low-grade AST/ALT elevations were consistent with slowly progressive liver fibrosis due to hepatitis C and not due to hepatoxic injury from ibuprofen or Tylenol. Because Dr. Heuman's opinion is consistent with the clinical evidence, the Board affords his opinion greater probative weight. The Veteran has also submitted numerous medical treatise articles, Internet news articles, and general information about hepatitis C. An article published in American Journal of Gastroenterology in 1998 discusses three patients with hepatitis C who had elevated liver transaminases with ingestion of ibuprofen; however, liver transaminases returned to baseline within 3 months. The study provided support for the recommendation of acetaminophen over NSAIDs in patients with chronic hepatitis. The Board notes that this study is consistent with Dr. Heuman's statement that liver toxicity due to hepatoxic medications is characterized by elevations in transaminases that return to baseline and is not consistent with the facts of this case showing chronic low grade elevations in AST/ALT levels. Other articles and information from the Internet submitted by the Veteran discuss liver injury or AST/ALT elevations caused by hepatoxic medications, suggest limited low-dose therapy with acetaminophen in patients with hepatic disease, discuss general treatment strategies for individuals with hepatitis C or chronic liver disease, discuss mildly elevated liver enzymes in healthy patients (noting mild elevation is characterized by levels less than 300 U/L.), and discuss paracetamol hepatotoxicity at therapeutic doses in malnourished individuals. The Board notes that the abstracts and articles submitted by the Veteran are non-specific and do not address whether the Veteran has additional disability due to the medications prescribed by VA. The Court has indicated that treatise evidence may suffice to establish nexus in instances where, "standing alone, [it] discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion." Wallin v. West, 11 Vet. App. 509, 514 (1998) (quoting Sacks v. West, 11 Vet. App. 314, 317 (1998)). In this case, the Veteran submitted a medical opinion from Dr. Bash, as described above; however, the medical treatise information actually tends to support the Dr. Heuman's opinion that the Veteran's chronic low grade AST and ALT elevations were not due to treatment with hepatoxic drugs. The information provided indicates that overdoses or therapeutic use of hepatoxic drugs with malnutrition tend to cause acute liver injury (rather than chronic) and are accompanied by AST and ALT elevations that return to baseline levels. While the information supports the fact that ibuprofen and Tylenol are hepatoxic drugs and can potentially cause acute liver injury, this is not disputed by any of the medical experts associated with this case. At issue, however, is whether the therapeutic use of these drugs by the Veteran caused additional disability. As discussed above, the more probative evidence simply is against the Veteran's theory that he sustained additional disability due to the medications prescribed by VA. In sum, the Veteran was diagnosed with hepatitis C in 1997. The disease progressed slowly and eventually resulted in chronic liver disease, which the Veteran refused to treat with antiviral medication. Ultimately, he sustained enlargement of both the liver and spleen and developed cholelithiasis. Also during this time period, he was treated with therapeutic doses of ibuprofen and acetaminophen. Although these drugs have been shown to cause acute liver injury, they have not been shown to cause the type of chronic and sustained low grade AST and ALT elevations demonstrated in this case. For these reasons, the Board finds the most probative evidence establishes that the Veteran did not sustain additional disability due to VA treatment. Therefore, weighing the evidence of record, after careful consideration of all procurable and assembled data, the Board finds that the preponderance of the evidence is against compensation under 38 U.S.C.A. § 1151 for additional disability of the spleen, liver, and gall bladder. There is no doubt to resolve. Accordingly, the claim is denied. ORDER Compensation under 38 U.S.C. § 1151 for additional disability of the spleen, liver, and gall bladder is denied. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs