Citation Nr: 1327069 Decision Date: 08/23/13 Archive Date: 08/29/13 DOCKET NO. 03-35 315 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for a lung disability, to include residuals of upper right lobectomy. REPRESENTATION Appellant represented by: James G. Fausone, Esq. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. H. Nilon, Counsel INTRODUCTION The Veteran served on active duty from June 1980 to September 1983. This case comes before the Board of Veterans' Appeals (Board) on appeal of an October 2002 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In September 2005 the Veteran testified before the undersigned Veterans Law Judge in a hearing at the RO. A transcript of the hearing is of record. The Board previously denied the appeal by decisions issued in August 2007, May 2010 and January 2012. On all three occasions the Veteran appealed the Board's decisions to the United States Court of Appeals for Veterans Claims (Court), and on all three occasions the Court granted joint motions of the parties to vacate the Board's decisions and return the case to the Board for further consideration. The most recent such Order of the Court was issued in October 2012. FINDING OF FACT The Veteran does not have a lung disorder that is etiologically related to active service. CONCLUSION OF LAW A lung disability, to include residuals of upper right lobectomy, is not due to or aggravated by service. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (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 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), 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. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate 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. Although the regulation previously required VA to request that the claimant provide any evidence in the claimant's possession that pertains to the claim, the regulation has been amended to eliminate that requirement for claims pending before VA on or after May 30, 2008. The Board also notes 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). Although full VCAA notice was not provided to the Veteran until after the initial adjudication of this claim the Board finds there is no prejudice to the Veteran in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In this regard, the Board notes that following the provision of the required notice and the completion of all indicated development of the record, the originating agency readjudicated the Veteran's claims based on all evidence of record. There is no indication in the record or reason to believe that any ultimate decision of the originating agency would have been different had complete VCAA notice been provided at an earlier time. See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (A timing error may be cured by a new VCAA notification followed by a readjudication of the claim). In any event, the Veteran has not suggested any prejudice in regard to the timing or content of the notice he was provided. See Shinseki v. Sanders, 129 S.Ct.1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). The record also reflects that service treatment records (STRs) and all available post-service medical evidence identified by the Veteran has been obtained. The last joint motion intimated that the file contained inadequate medical opinion to support the Board's finding, and the Board subsequently obtained an expert medical opinion by a specialist affiliated with the Veterans Health Administration (VHA). The Joint Motion asserted no other defects in the duties to notify or assist; the Board is confident that if any additional VCAA defects existed in its January 2012 decision, such defects would have been brought to the Court's attention in the interest of judicial economy. The Veteran has been provided appropriate VA medical examinations, most recently in April 2011, and as noted above the Board obtained an expert medical opinion in May 2013. The Veteran's representative argued in a letter dated June 2013 that the expert opinion was inadequate, and the Board subsequently obtained an addendum opinion in Jul 2013 that addressed each of the representative's objections. The Veteran has also been afforded a hearing before the Board. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires the hearing officer who chairs a hearing explain the issues and suggest the submission of evidence that may have been overlooked. Here, the presiding Veterans Law Judge identified the issues to the Veteran and asked specific questions directed at identifying the nature of the Veteran's respiratory complaints before and after service. The Veteran has not asserted that VA failed in any way to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. The hearing focused on the elements necessary to substantiate the claim on appeal, and the Veteran provided testimony relevant to those elements. As such, the Board finds that there is no prejudice in deciding the claim at this time and no further action pursuant to Bryant is necessary. Neither the Veteran nor his representative has identified any outstanding evidence that could be obtained to substantiate the claim; the Board is also unaware of any such evidence. Accordingly, the Board will address the merits of the Veteran's claim on appeal. Legal Principles Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be awarded for a "chronic" condition when: (1) a chronic disease manifests itself in service (or within the presumptive period under 38 C.F.R. § 3.307) and the veteran currently has the same condition; or, (2) a disease manifests itself in service (or within the presumptive period) but is not identified until later, and there is a showing of continuity of related symptomatology after discharge, and medical evidence relates that symptomatology to the veteran's present condition. 38 C.F.R. § 3.303(d). Service connection may be also granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Where a veteran served for at least 90 days during a period of war or after January 1, 1947, and manifests bronchiectasis to a degree of 10 percent within one year from the date of termination of such service or tuberculosis within three years of termination, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. In order to prevail on the issue of service connection there must generally be: medical evidence of a current disability; medical evidence, or in some cases lay evidence, of in-service occurrence or aggravation of a disease or injury; and, medical evidence of a nexus between an in-service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247, 253 (1999); Pond v. West, 12 Vet. App. 341, 346 (1999). For claims submitted on or after June 9, 1998, no VA benefits for disability or death are payable due to use of tobacco products in service. 38 USCA § 1103. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. The first inquiry is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the 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. Davidson, 581 F.3d 1313, 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on her behalf be discussed in detail. Rather, the Board's analysis below 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 claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Evidence In his correspondence to VA and his testimony before the Board the Veteran has essentially contended that he has a current lung disability due to exposure to floor strippers, paint fumes, acetone, naphtha, toluene and argon gasses, all exposure having been within an enclosed area without adequate ventilation. The Veteran asserts that since discharge from service he has had weak lungs with frequent pneumonia and bronchitis. During testimony the Veteran also asserted he had bronchitis prior to service on one or two occasions, although such bronchitis did not require hospitalization and did not occur during the year immediately prior to service. Service treatment records (STRs) include a preliminary physical review in April 1980, immediately prior to enlistment, in which the Veteran specifically denied history of asthma or respiratory problems prior to service. During service the Veteran was treated in February 1981 for chest pain with shortness of breath; the clinician noted the Veteran had smoked a pack of cigarettes per day for the past 9 years (since age 15) and the clinical impression was chest wall myositis and shortness of breath secondary to smoking. Pulmonary function test (PFT) was unremarkable. The Veteran was treated for bronchitis in October 1981 that apparently did not require inpatient treatment and resolved without residuals; chest X-ray showed findings compatible with inflammatory diseases such as viral pneumonitis, bronchitis or allergic disease. Subsequent chest X-rays in April 1983 and August 1983 were normal. The Veteran had a separation examination in August 1983 that cited complaint of shortness of breath after running and complaint of dry cough in the morning, chest X-ray was normal and the clinical evaluation of the lungs and chest was also "normal" on examination. The Veteran was discharged from service in September 1983. The Veteran presented to the VA emergency room in July 1998 complaining of productive cough for several days, accompanied by chills, fever, malaise, nausea and vomiting. The condition was initially assessed as community-acquired pneumonia, but that assessment was amended during inpatient treatment to include possible tuberculosis or possible right lung malignancy. Discharge summary in August 1998 showed diagnosis of tuberculosis. VA inpatient treatment notes show the Veteran had an abnormal chest X-ray in December 2001; he was noted to have a 30-year history of smoking, currently one pack per day but down from two packs per day. He underwent elective thoracotomy in April 2002, and later in April 2002 the Veteran underwent a right upper lobectomy, performed due to diagnosed right hilar lymphadenopathy. The operative notes list pertinent history of productive cough since November 2001, as well as history of tuberculosis and several episodes of pneumonia. The Veteran presented for follow-up care in May 2002 complaining of residual postoperative pain. The Veteran was noted to still be smoking one-half pack per day. The clinical impression was right upper lung mass status post lobectomy with old tuberculosis and emphysema, as well as history of pulmonary tuberculosis and current tobacco use. The file contains a handwritten statement by a VA physician dated in June 2003 that states as follows: "Patient was exposed to chemical inhalants during his active duty career. He was a cigarette smoker for many years and developed emphysema. In 1999 he developed evidence of pulmonary tuberculosis and was treated with INH and [illegible]. Subsequently hemoptysis developed and destruction and bronchiectasis of right upper lobe was seen. A mass suspicious for carcinoma was noted and lung resection was performed. Chronic lung disease may have commenced with chemical exposure and smoking and further worsened by subsequent tuberculosis." The Veteran had a VA medical examination in April 2007, performed by an examiner who reviewed the claims file and noted the Veteran's medical history in detail, including history of diagnosed chronic obstructive pulmonary disease (COPD) and tobacco abuse. The Veteran reported that since discharge from service he had episodes of bronchitis every winter, lasting 3-4 days. Over the past 25 years the Veteran had noticed progressive shortness of breath and over the past 2 years he had noticed chronic daily cough. The examiner's clinical impression following examination was COPD. The examiner stated an opinion that the Veteran's current lung condition with COPD/emphysema was not likely to be secondary to events in service. As rationale, the examiner stated the Veteran had developed emphysematous bullae and obstructive lung disease over the past 18 years. A September 2009 note by the Veteran's attending VA primary care physician's assistant (PA) states the Veteran continued to smoke, and because of this his COPD had progressed to the point of being an impairment to employability. His lung condition was not expected to improve, although cessation of smoking could reduce episodes of symptoms. The Veteran had another VA examination in December 2009, performed by a physician who reviewed the claims file. The Veteran dated his current symptoms to 1999, although he also asserted he had "always" had problems with his lungs. The examiner noted clinical observations in detail; following examination the examiner diagnosed moderate COPD. The examiner stated an opinion that the bilateral upper lobe infiltrates that had been found in July 1998 were most likely an original manifestation of tuberculosis infection, for which he was subsequently treated for one year. In regard to other symptoms, the current moderate obstructive disease is an expected complication of smoking and is not likely due the single episode of (bacterial-inducted) bronchitis noted in STRs. The Veteran had another VA examination in October 2010; again the examiner reviewed the claims file and noted the Veteran's history. The Veteran asserted he had an episode of bronchitis in service that was treated conservatively and had no further episodes during service; he began having recurring episodes after discharge that had progressively worsened. The examiner noted clinical observations in detail and diagnosed COPD. The examiner stated the Veteran had a single episode of bronchitis in service that apparently resolved, while current examination shows COPD but does not show findings consistent with chronic bronchitis. Accordingly, the Veteran's current disorder is not likely related to bronchitis in service. VA treatment records dated from October 2006 through September 2011 show continued treatment for COPD and occasional acute bronchitis but provide no opinion as to the etiology of the disease. Treatment notes document that the Veteran continued to smoke during the period although he reportedly cut back to one-half pack per day. A psychiatric inpatient treatment note in September 2009 is significant for diagnosis of nicotine dependence with physiological dependence. In November 2009 he was treated for "acute bronchitis/tobacco use disorder." A chest X-ray in March 2010 was abnormal for emphysema (noted as "smoker's lung disease") and the Veteran was urged to stop smoking to keep the disease from progressing. The Veteran's most recent VA examination was performed in April 2011, again by a physician who reviewed the claims file and noted the Veteran's medical history. The Veteran reported having had an episode of bronchitis in service and having developed tuberculosis in 1990, treated without apparent recurrence. He also reported history of COPD since the 1990s with symptoms continuing until the present. He endorsed history of smoking since age 15, averaging one pack per day. The examiner performed a clinical examination and noted observations in detail. The examiner diagnosed COPD, status post treatment for tuberculosis and status post right upper lobectomy. The examiner stated an opinion that the Veteran's current diagnosed disorder is not likely caused by or a result of the in-service respiratory condition. As rationale, the examiner stated none of the three current diagnosed disorders were shown during active duty; the disorder during active duty appears to have been acute and self-limited bronchitis that would not have caused the current disorders. There is no apparent linkage between symptoms in service and the disorders the Veteran developed later in life. Tuberculosis developed many years after service and apparently resolved; the right lung lobectomy was performed due to fears of possible cancer (fortunately, no cancer was found). The Veteran's current COPD is related to long-term smoking, not to active service. In March 2013 the Board remanded the case for an expert medical opinion by specialist affiliated with the Veterans Health Administration (VHA) to specifically determine whether the Veteran's claimed lung disorder is due to exposure to toxins in service. The VHA reviewer noted the Veteran asserted he began having respiratory symptoms in service while serving in a missile silo, with recurrent respiratory problems after discharge from service. The Veteran was considered to be in good health in 1980, with just a history of ear infection, broken nose and currently smoking a pack of cigarettes per day (PPD). In 1981 he was treated for acute bronchitis, successfully treated by medications; there was no other respiratory complaint in service, and chest x-rays in 1982 and 1983 were normal. By 1983 his smoking history was one PPD for 10 years. By 2010 the Veteran had a history of one PPD for 30 years and moderate COPD. The VHA reviewer stated there was no substantial evidence (less than 50 percent probable) to support a theory the exposure to alleged environmental hazards in service had caused COPD; rather, COPD was likely related to the Veteran's smoking habit. The Veteran's acute bronchitis in service did not appear to have been causally related to chemical exposure, and appears to have resolved without residuals. The Veteran's representative submitted a letter in June 2013 objecting to the VHA opinion cited above. First, the representative objected to the VHA reviewer's statement that surgery in 2002 (upper right lobectomy) was for tuberculosis. Second, the representative objected that the VHA reviewer had not considered the Veteran's lay testimony of having had several bouts of bronchitis after discharge from service and that he began seeking treatment for chronic respiratory symptoms in the 1990s, well before lobectomy surgery in 2002. Third, the representative objected that the VHA reviewer characterized the Veteran has having worked in a missile silo when he had actually worked in a missile [maintenance] shot. Fourth, the VHA reviewer objected that the examiner did not consider that Griffiss AFB has been identified as having significant water and soil contamination. The Veteran did not wish to refute the VHA reviewer's contention that smoking had likely increased his risk of developing respiratory problems, but was concerned that the VHA reviewer was so focused on this issue that he had failed to consider whether or not that risk was significantly increased by exposure to other contaminants in service. The Board subsequently returned the file to the VHA reviewer for an addendum opinion addressing the points raised by the Veteran's representative, as cited above. The VHA examiner issued the requested addendum opinion in June 2013. The VHA reviewer stated his overall medical opinion remained unchanged. In response to the representative's first point, the VHA reviewer stated that the Veteran's surgery in 2002 had been due to old tuberculosis with emphysema, but in any event there was no obvious relationship to active service. In response to the representative's second point, the VHA reviewer acknowledge the Veteran's report of bouts of pneumonia after discharge from service but stated that pneumonia and respiratory infections can occur in anyone (more than one million cases of pneumonia treated in the United States annually) and rates are much higher in patients with smoking habits, alcohol abuse, active and treated GERD; because the Veteran belongs in that category his treatment after service did not show direct connection to service. In response to the representative's third point, the VHA reviewer stated he had characterized the Veteran as having served in a "missile silo" because it had so been presented to him by the Board, but amending the Veteran's service from a missile silo to a missile maintenance shop did not affect his opinion. In response to the representative's fourth point, there is not enough evidence to connect alleged contamination at Griffiss AFB to the Veteran's COPD. According to standards of medical care and occupational safety and health organization recommendations, the term "occupational disease" covers any disease contracted as a result of an exposure to risk factors arising from work activity; the two main elements for definition of an "occupational disease" are causal relationship between exposure in a specific work environment or activity and a specific disease, and determination that the disease occurs among a group of exposed persons with a frequency above the average morbidity of the rest of the population. The VHA reviewer was unable to find any data satisfying those two requirements. The VHA examiner stated the Veteran's diagnosis of COPD is clearly made and indisputable, and cigarette smoking is an undisputable major cause of COPD worldwide. Analysis On review of the evidence above, the Board finds as a threshold matter that the Veteran is shown to have current COPD. Accordingly, the first element of service connection - medical evidence of a claimed disability - is met. However, evidence of a present condition is generally not relevant to a claim for service connection, absent some competent linkage to military service. Mingo v. Derwinski, 2 Vet. App. 51, 53 (1992). A veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000). Where an opinion is used to link the current disability to a cause during service, a competent opinion of a medical professional is required. Caluza, 7 Vet. App. 498. The Board finds that the weight of medical opinion shows the Veteran's current lung disorder is not etiologically related to service. Four different VA examiners, after individually reviewing the claims file and examining the Veteran, have agreed that the Veteran's respiratory symptoms during service resolved without residuals and that his post-service lung disease is most likely due to his many years of smoking. In addition to these four examiners, the VHA reviewer provided an opinion agreeing that the Veteran's COPD is due to smoking rather than to service, to include exposure to toxins in service. The findings of a physician are medical conclusions that the Board cannot ignore or disregard. Willis v. Derwinski, 1 Vet. App. 66 (1991). The Board finds at this point that the VA examiners and the VHA reviewer cited above are shown to have been fully informed of the pertinent factual premises of the case, in that they noted the Veteran's documented medical history as well as his subjective reports. These physicians also provided fully articulated opinions that were supported by reasoned analyses. Accordingly, these medical opinions are probative under the criteria cited in Nieves-Rodriguez, 22 Vet. App. 295, 303-304. The Board has carefully considered the June 2003 statement by a VA physician that asserts, in relevant part, that "chronic lung disease may have commenced with chemical exposure and smoking and further worsened by subsequent tuberculosis." Although this opinion is supportive of the Veteran's claim, medical opinions expressed in speculative language (such as "may have commenced") do not provide the degree of certainty required for medical nexus evidence. Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992); Bostain v. West, 11 Vet. App. 124, 127-28 (1998). Further, the June 2003 statement is not supported by any clinical rationale, whereas the four VA examinations and VHA review are each accompanied by the examiners' reasoning; in assessing evidence such as medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). It is the Board's duty to assess the credibility and probative value of evidence, and, provided that it offers an adequate statement of reasons or bases, the Board may favor one medical opinion over another. Owens v. Brown, 7 Vet. App. 429, 433 (1995). As true with any piece of evidence, the credibility and weight to be assigned to these opinions are within the province of the Board as adjudicators. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). For the reasons cited above, the Board finds the opinions of the four VA examiners and the VHA reviewer to be more probative of the issue on appeal than the opinion of the VA physician in June 2003. Thus, the most probative medical opinions of record weigh against service connection. VA must consider all favorable lay evidence of record. 38 USCA § 5107(b); Caluza, 7 Vet. App. 498. Accordingly, in addition to the medical evidence above the Board has carefully considered the lay evidence offered by the Veteran in the form of his testimony before the Board, his correspondence to VA and his statements to various medical providers. The Board must consider the purpose for which lay evidence is offered. Washington v. Nicholson, 19 Vet. App. 362 (2005). To the degree that the Veteran has reported acute bronchitis in service, he is competent to report events in service, and in fact his assertions are corroborated by STRs and have been accepted as credible by VA adjudicators and examiners. However, the Veteran as a layperson is not competent to express an opinion about a subject as medically complex as the etiology of a respiratory disease; Kahana, 24 Vet. App. 428. Rather, it is the province of trained health care professionals to enter conclusions that require medical expertise, such as opinions as to diagnosis and causation. Jones v. Brown, 7 Vet. App. 134, 137 (1994). As explained above, the great weight of medical opinion is against any etiological relationship between service and the current disability. For completeness of review, the Board notes that the Veteran has not argued that he had a respiratory disorder that existed prior to service and was aggravated during service. He testified that he had acute bronchitis on one or two remote occasions prior to service, but significantly he denied history of respiratory problems at the time of his entry into service, and there is no indication in STRs of a respiratory problem at the time of entry. The presumption of soundness on entry into service accordingly applies, and the question of aggravation is not reached. Similarly, the Veteran has not asserted, and the evidence does not otherwise show, that he has had continuous respiratory symptoms ever since discharge from service. The Veteran had isolated episodes of bronchiectasis and tuberculosis, both in 1999, but there is no evidence that either disease was manifest to any degree within the presumptive period specified in 38 C.F.R. § 3.307 and no evidence of active residuals of either disease, so presumptive service connection under 38 C.F.R. § 3.309(a) is not warranted. The Board acknowledges the treatise evidence submitted by the Veteran's representative in the form of articles discussing the health effects of various toxins and solvents, as well as articles addressing soil and water contamination at Griffiss AFB. A medical article or treatise can provide important support when combined with an opinion of a medical professional if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least a plausible causality based upon subjective facts rather than unsubstantiated lay opinion. Mattern v. West, 12 Vet. App. 222, 228 (1999). However, treatise evidence alone is usually "too general and inconclusive" to establish a medical nexus. Sacks v. West, 11 Vet. App. 314, 317 (1998). In this case the treatise evidence offered in support of the Veteran's claim has been thoroughly considered by the VHA reviewer, who provided a medical opinion to the effect that the treatise evidence does not support the Veteran's claim of service connection; that opinion is not contradicted by any other medical opinion of record. In sum, the Board has found on review of the evidence above that the Veteran does not have a current lung disorder that is etiologically related to service. Accordingly, the criteria for service connection are not met and the claim must be denied. Because the preponderance of the evidence is against the claim the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54. ORDER Service connection for a lung disability, to include residuals of upper right lobectomy, is denied. ____________________________________________ JOAQUIN AGUAYO-PERELES Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs