Citation Nr: 1326595 Decision Date: 08/21/13 Archive Date: 08/29/13 DOCKET NO. 10-34 568 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boise, Idaho THE ISSUE Entitlement to service connection for a left upper extremity disability, to include a brachial plexus disability, peripheral neuropathy, Parsonage-Turner syndrome, and hereditary neuralgic amyotrophy. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. J. Houbeck, Counsel INTRODUCTION The Veteran had active service from August 1970 to June 1973. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Boise, Idaho. In May 2012, the Veteran presented testimony before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing was placed in the claims file and was considered in appellate review. In March 2013, the Board requested an independent medical expert opinion. The subsequent April 2013 opinion having been completed, the matter again is before the Board. The Board has not only reviewed the Veteran's physical claims file, but also his Virtual VA electronic claims file to ensure a total review of the evidence. FINDING OF FACT A left upper extremity disability, to include a brachial plexus disability, peripheral neuropathy, Parsonage-Turner syndrome, and hereditary neuralgic amyotrophy, was not shown in service and is not otherwise related to the Veteran's active service. CONCLUSION OF LAW A left upper extremity disability, to include a brachial plexus disability, peripheral neuropathy, Parsonage-Turner syndrome, and hereditary neuralgic amyotrophy, was not incurred in or aggravated by service, and may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claim, VA has met all statutory and regulatory notice and duty to assist provisions. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the Veteran and his or her 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); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the Veteran is expected to provide; and (4) request that the Veteran provide any evidence in his or her possession that pertains to the claim. The requirement of requesting that the Veteran provide any evidence in his possession that pertains to the claim was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Thus, any error related to this element is harmless. A VCAA letter dated in January 2009 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio, at 187. The Veteran was advised that it was ultimately his responsibility to give VA any evidence pertaining to the claim. The letter informed him that additional information or evidence was needed to support his claim, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. The letter also explained to the Veteran how disability ratings and effective dates are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). As noted above, the Veteran also was afforded a hearing before the undersigned Veterans Law Judge (VLJ) during which he presented oral argument in support of his service connection claim. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2011) requires that the VLJ/DRO who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the VLJ fully explained the issue on appeal during the hearing and specifically discussed the basis of the prior determination, the element(s) of the claim that were lacking to substantiate the claim for benefits, and suggested the submission of evidence that would be beneficial to the Veteran's claim. Indeed, based in part on the evidence elicited during the hearing the Board obtained an independent medical expert opinion. Significantly, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Furthermore, even if any notice deficiency is present in this case, the Board finds that any prejudice due to such error has been overcome in this case by the following: (1) based on the communications sent to the Veteran over the course of this appeal, the Veteran clearly has actual knowledge of the evidence the Veteran is required to submit in this case; and (2) based on the Veteran's contentions as well as the communications provided to the Veteran by VA, it is reasonable to expect that the Veteran understands what was needed to prevail. See Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). In order for the Court to be persuaded that no prejudice resulted from a notice error, "the record must demonstrate that, despite the error, the adjudication was nevertheless essentially fair." Dunlap v. Nicholson, 21 Vet. App. 112, 118 (2007). In this case, the Veteran has been continuously represented by an experienced Veterans Service Organization and has submitted argument in support of his claim. These arguments have referenced the applicable law and regulations necessary for a grant of entitlement to service connection. Thus, the Board finds that the Veteran has actual knowledge as to the information and evidence necessary for him to prevail on his claim and is not prejudiced by a decision in this case. As such, a remand for additional notice would serve no useful purpose and would in no way benefit the Veteran. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on the VA with no benefit flowing to the Veteran are to be avoided). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA medical records are in the file. Private treatment records identified by the Veteran have been obtained, to the extent possible. In addition to the private records included in the claims file, in his February 2010 notice of disagreement the Veteran also noted that his primary care physician, Dr. G.S., had concluded that his left upper extremity problems were caused by a genetic disorder. Such an opinion is not of record, but as any such records documenting this opinion would not support the Veteran's claim for entitlement to service connection, the Board concludes that a remand to obtain any such opinion or records would be of no benefit to the Veteran. As to the Veteran's claims that "other physicians" have attributed his left upper extremity problem to "an injury," there is no indication that such injury was incurred in or otherwise the result of military service and, in any case, VA has sought all private treatment providers for which authorization to obtain records has been provided. The Veteran has at no time otherwise referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claims, as defined by law. See 38 C.F.R. § 3.159(c)(4). In this case, the Veteran was provided a VA examination in February 2009. At that time, the examiner noted a diagnosis of hereditary neuralgic amyotrophy versus Parsonage-Turner syndrome that was felt to be congenital in nature. As noted above, the Board obtained an April 2013 independent medical expert opinion. At that time, the reviewer considered the Veteran's claims of intermittent left upper extremity since his April 1972 left index finger injury, residuals of which are separately service connected. The reviewer extensively discussed the Veteran's medical history and his lay contentions, but concluded that the most likely diagnosis was recurrent, idiopathic Parsonage-Turner syndrome that had no direct causal connection with the in-service left index injury and repair, to include any left supraclavicular block anesthesia. As will be discussed in greater detail below, the reviewer's opinion was based on review of the claims file and available medical records, the Veteran's reported history, and his current symptoms. The Board, therefore, finds the April 2013 independent medical expert opinion report to be thorough, complete, and sufficient upon which to base a decision with respect to the Veteran's claim for service connection. See Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007) (finding that an adequate opinion is one that is based upon consideration of the Veteran's prior medical history and examinations, describes the disability in sufficient detail, and includes a conclusion supported by an analysis that the Board can consider and weigh against contrary opinions). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131 (West 2002). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b) (2012). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be established for a current disability on the basis of a presumption under the law that certain chronic diseases, to include peripheral neuropathy, manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C.A. §§ 1112, 1113, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a) (2012). In this case, the Veteran was not diagnosed with peripheral neuropathy of the left upper extremity in service or within one year of separation from service. As such, entitlement to service connection on a presumptive basis is not warranted. To establish a right to compensation for a present disability on a direct basis, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In this case, the Veteran contends that he developed problems with the left upper extremity following multiple nerve blocks under the armpit during surgery for his service-connected left index finger disability. The Veteran further asserts that the currently diagnosed hereditary neuralgic amyotrophy is incorrect because neither his parents nor siblings are afflicted with this disorder and the symptoms affect only the left upper extremity, rather than the bilateral upper extremities. The Veteran does not report continuous left upper extremity symptoms from service, but rather about 10 to 12 separate instances of left upper extremity problems that each lasted an average of about six weeks. Since January 2008, however, his left upper extremity symptoms have been continuous. Service connection has been in effect for residuals, laceration left index finger, since June 1973. In that regard, the Veteran's service treatment records indicate that in April 1972, he sustained a laceration to the volar aspect of the left index finger. Under supraclavicular block anesthesia, exploration of the laceration was performed. The procedure included repair of the profundus tendon by advancement of the tendon and embedding the tendon into the bony flat bed at the base of the distal phalanx. A pull-out wire technique with a button was used. The Veteran contends that he received a second nerve block a few weeks after surgery following infection and cleaning of the wound site. In addition, the Veteran claims that he received a third nerve block during the subsequent removal of the wire about six weeks after the surgery, due to difficulty in the total removal of the wire that resulted in the more inner portion remaining within the index finger. Service treatment records, however, document surgery in November 1972 for removal of the pull-out wire and this procedure was performed under local anesthesia. In either case, the Veteran reported swelling and drainage of the left index finger, but no problems to the rest of the left upper extremity, which is supported by the medical evidence of record. In December 1972, the left index finger wound was healing well without discharge. After service, during a May 1974 VA examination, the Veteran reported ongoing problems with the left index finger, including swelling from vibrations, pain with grasping, and cracking fingernail, but reported no problems with the rest of the left upper extremity. In March 2008, the Veteran established care with VA and at that time reported left arm pain. The Veteran asserted that shortly after separation from service in 1973, he developed a lump in his left armpit with associated pain, numbness, and weakness. He reported about ten subsequent episodes of axillary swelling with left hand weakness thereafter, each of which resolved in several days to weeks. The lump was not present at the time of examination, but the Veteran did report some numbness of the fingers of the left hand. The assessment was injury to the brachial plexus, as well as axillary pain of unclear etiology. An April 2008 EMG suggested idiopathic brachial plexitis (Parsonage-Turner syndrome), but an MRI showed a normal brachial plexus and multilevel degenerative disc disease affecting C5-C6 and C6-C7. Based on the foregoing, in June 2008 the Veteran's diagnosis was changed to likely hereditary neuralgic amyotrophy vs. Parsonage Turner syndrome. The treatment provider discussed the possibility of genetic testing. A December 2008 VA treatment record indicated that the diagnosis was likely hereditary neuralgic amyotrophy secondary to multiple episodes of Parsonage Turner syndrome. While the possibility of genetic testing has been discussed with the Veteran, due to cost issues such testing has not been completed. The Veteran was afforded a VA examination in February 2009. The examiner attributed the Veteran's left hand weakness, decreased grip strength, hypoesthesia, and atrophy to hereditary neuralgic amyotrophy. A September 2010 private treatment record agreed with VA's assessment that the most likely diagnosis was hereditary neuralgic amyotrophy. That said, "it is not inconceivable that the axillary blocks somehow triggered this to be active." In written statements and oral testimony, the Veteran has claimed that "other physicians" believed that his left upper extremity pain and weakness was the result of an injury, rather than a hereditary condition. Moreover, the Veteran reported during his May 2012 Board hearing that in his case, neither his parents nor siblings had been diagnosed with or had complaints similar to hereditary neuralgic amyotrophy, which was unusual for such hereditary condition. In addition, hereditary neuralgic amyotrophy typically affected the bilateral upper extremities, but the Veteran's problems were confined solely to the left upper extremity. As such, the Veteran believes that his left upper extremity problems are due to the in-service nerve blocks and not a hereditary condition, such as hereditary neuralgic amyotrophy. As noted, the Board obtained an independent medical expert opinion. The April 2013 opinion extensively discussed the Veteran's documented medical history and his lay contentions. The reviewer also outlined the risk factors and bases for assigning a diagnosis of Parsonage-Turner syndrome (also known as brachial plexitis or neuralgic amyotrophy) as compared to hereditary neuralgic amyotrophy. The reviewer concluded that the Veteran's most likely diagnosis was recurrent, idiopathic Parsonage-Turner syndrome. The reviewer stated that in the absence of positive family testing or genetic testing, there was no reason to believe that the Veteran's problems represented a congenital or hereditary disease or defect, such as hereditary neuralgic amyotrophy. Finally, the reviewer concluded that there was no causal association between the Veteran's upper extremity problems and his in-service left index finger injury or repair or otherwise experienced an episode of brachial plexitis following his surgeries between April 1972 and November 1972. Initially, the Board notes that with respect to the Veteran's diagnoses of the left upper extremity, specifically hereditary neuralgic amyotrophy, there is some evidence that this may have been a disorder preexisting service. In that regard, the Board notes that every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111 (West 2002). That said, the Court has held that the presumption of soundness does not apply to hereditary or congenital defects because such defects are not considered diseases or injuries within the meaning of 38 U.S.C.A. §§ 1110 and 1111. See Quirin v. Shinseki, 22 Vet. App. 390, 396-97 (2009); see also Terry v. Principi, 340 F.3d 1378, 1385-86 (Fed. Cir. 2003); Winn v. Brown, 8 Vet. App. 510, 516 (1996). In this case, given the conflicting evidence as to whether the Veteran's current left upper extremity disability is hereditary or congenital in nature, as well as his normal upper extremity examination on entrance into service, for the purpose of this decision alone the Board will presume the Veteran's soundness on entrance into service. Thus, the Veteran has a current left upper extremity disability. The crucial question, therefore, is whether the Veteran's left upper extremity disability was incurred in or is otherwise related to his military service, to include his treatment for left index finger injury. Based on the evidence outlined above, the Board concludes that it was not. In reaching that determination, the Board finds the April 2013 independent medical expert opinion report of significant probative value. The reviewer's opinions were based on the Veteran's reported medical history, and review of the claims file (including service treatment records and post-service medical records). Further, a complete and thorough rationale was provided for the opinions rendered. Specifically, the reviewer considered the lay and medical evidence and concluded that the Veteran's neuralgic amyotrophy was not hereditary or congenital in nature and that it was not related to his treatment for and repair of the in-service left index finger injury. The reviewer noted the absence of any evidence of brachial plexitis (neuralgic amyotrophy) during service and specifically during the Veteran's treatment for left index finger problems from April 1972 to November 1972. Based on the foregoing, the Board concludes that the reviewer's overall conclusions are fully explained and consistent with the evidence of record. As to the September 2010 private medical professional's letter, this statement indicates only that it was "not inconceivable" that the in-service axillary blocks triggered the Veteran's hereditary neuralgic amyotrophy to become active. This statement is not a sufficient basis for granting entitlement to service connection. The reasonable doubt doctrine requires that there be a "substantial" doubt and "one within the range of probability as distinguished from pure speculation or remote possibility." 38 C.F.R. § 3.102; see also Bostain v. West, 11 Vet. App. 127 (1998); Obert v. Brown, 5 Vet. App. 30, 33 (1993) (holding that a physician's statement that the Veteran may have been having some symptoms of multiple sclerosis for many years prior to the date of diagnosis also implied "may or may not" and was deemed speculative); Libertine v. Brown, 9 Vet. App. 521, 523 (1996) (holding that any medical link that is speculative, general, or inconclusive in nature is of no probative value and not a sufficient basis to grant service connection). The Board notes that it also has considered the Veteran's statements that "other physicians" felt that his current left upper extremity problems were "caused by an injury." Presuming that the "injury" mentioned occurred in service, the Board recognizes that the Veteran is competent to report a contemporaneous medical diagnosis, Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); however, the Board finds that the Veteran's competence to relate a complex rationale as to the etiology of a current disability is less certain. As the Court has previously noted, "the connection between what a physician said and the layman's account of what he purportedly said, filtered as it was through a layman's sensibilities, is simply too attenuated and inherently unreliable to constitute 'medical' evidence." Robinette v. Brown, 8 Vet. App. 69, 77 (1995); see also Marciniak v. Brown, 10 Vet. App. 198 (1997); Franzen v. Brown, 9 Vet. App. 235 (1996). The Board also finds the Veteran's representations problematic in light of the utter absence of any notation in support of such an assertion, save for the equivocal and speculative notation in the September 2010 private medical provider's letter discussed above. As such, the Board finds the Veteran's representations as to etiology opinions related to him by "other physicians" to be of extremely limited probative value. Finally, the Board has considered the Veteran's contentions that his current left upper extremity problems are related to multiple nerve blocks under the armpit during surgery for his service-connected left index finger disability or other injury incurred during his military service. In that regard, the Board acknowledges that the Veteran can attest to observed physical symptoms, such as numbness, tingling, and other upper extremity problems, and his assertions in that regard are entitled to some probative weight. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). That said, there is no evidence of record that the Veteran has any medical expertise. As to non-expert or lay opinions with regard to diagnoses or a relationship of a condition to service ("nexus"), whether such opinions are competent evidence depends on the question at issue and the particular facts of the case. Although it is error to categorically reject a non-expert nexus opinion, not all questions of nexus are subject to non-expert opinion. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In Davidson, the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) drew from its earlier decision in Jandreau v. Nicholson to explain its holding. Id. In that earlier decision, the Federal Circuit stated as follows: "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau, 492 F.3d at 1377. The Federal Circuit provided an example, stating that a layperson would be competent to identify a simple condition such as a broken leg, but not competent to provide evidence as to a more complex medical question such as a form of cancer. Id at n.4. Taking that decision together with the explanation in Layno, leads the Board to the conclusion that whether a non-expert nexus opinion or diagnosis is competent evidence depends on the complexity of the particular question and whether a nexus opinion could be rendered based on personal observation. Here, the question of whether his current left upper extremity disability is due to nerve blocks in the left armpit for surgery on his left index finger from which the Veteran fully recovered during service, or any other incident of service, is a complex question and answering that question is not possible from mere observation with the five senses. The Board finds such a conclusion particularly appropriate in this case, given the complex nature of the Veteran's upper extremity symptomatology, which also involves dispute among medical professionals as to whether his neuralgic amyotrophy is hereditary in nature. The Board also finds the Veteran's conclusions particularly problematic given that he acknowledges that his symptoms began after his separation from service and have not been continuous in nature to the present. As such, the Board ascribes far more weight to the conclusions of the medical professionals of record who concluded that the Veteran's left upper extremity problems were not due to an injury in service, but to neuralgic amyotrophy that might or might not be hereditary in nature and which the April 2013 reviewing expert concluded was unrelated to the Veteran's in-service nerve block(s) or other treatment for his left index finger. In summary, there is no objective evidence of neuralgic amyotrophy during service and the most probative medical evidence of record, the April 2013 independent medical expert opinion report, explicitly concluded that the Veteran's current left upper extremity problems were unrelated to his in-service treatment for or repair of his left index finger injury. As the September 2010 private treatment provider's conclusion that it was "not inconceivable" that the in-service nerve blocks "somehow triggered" the Veteran's neuralgic amyotrophy was speculative in nature, the Board finds the letter's conclusions of extremely limited probative value. While the Veteran certainly is competent to report intermittent and recurring left upper extremity problems from service, given the complexity of these problems and his lack of demonstrated medical expertise, the Board concludes that his opinions are afforded significantly less probative weight than the April 2013 reviewing physician's opinion. In light of the foregoing, the Board finds that the preponderance of the evidence is against the claim, and the benefit of the doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). The appeal must therefore be denied. (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for a left upper extremity disability, to include a brachial plexus disability, peripheral neuropathy, Parsonage-Turner syndrome, and hereditary neuralgic amyotrophy, is denied. ____________________________________________ Bethany L. Buck Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs