Citation Nr: 1331293 Decision Date: 09/27/13 Archive Date: 10/01/13 DOCKET NO. 09-20 174 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for residuals of a crush injury of the right great toe. 2. Entitlement to service connection for hearing loss of the right ear. 3. Entitlement to service connection for hearing loss of the left ear. 4. Entitlement to service connection for tinnitus. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD M. J. In, Associate Counsel INTRODUCTION The Veteran had active service from January 1965 to November 1968. These matters come to the Board of Veterans' Appeals (Board) on appeal from May 2007 and May 2008 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, which denied the benefits sought on appeal. The issues of entitlement to service connection for hearing loss of the right ear, service connection for hearing loss of the left ear, and service connection for tinnitus are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT There has been no demonstration by the most probative competent medical evidence, or competent and credible lay evidence, of record that the Veteran has residuals of a crush injury of the right great toe that are related to service. CONCLUSION OF LAW Residuals of a crush injury of the right great toe were not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION VCAA As provided for by the Veterans Claims Assistance Act of 2000 (VCAA) VA has duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In March 2006, the United States Court of Appeals for Veterans Claims (Court) issued its decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Court in Dingess/Hartman held that the VCAA notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a "service connection" claim. As previously defined by the courts, those five elements include: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Upon receipt of an application for "service connection," therefore, VA is required to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. This includes notice that a disability rating and/or an effective date will be assigned if service connection is awarded. In correspondence dated in January 2008, VA informed the appellant of what evidence was required to substantiate his claim for service connection for residuals of a crush injury of the right great toe, and his and VA's respective duties for obtaining evidence. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); see also Bernard v. Brown, 4 Vet. App. 384, 394 (1993). It also notified him that a disability rating and effective date would be assigned, in the event of award of the benefit sought, as required by the Court in Dingess/Hartman. In Pelegrini, the Court held that compliance with 38 U.S.C.A. § 5103 required that VCAA notice be provided prior to an initial unfavorable AOJ decision. Because VCAA notice in this case was completed prior to the initial AOJ adjudication denying the claim, the timing of the notice complies with the express requirements of the law as found by the Court in Pelegrini. The content of the notice fully complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b), and Dingess/Hartman. Further, the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claim, including the opportunity to present pertinent evidence. Simmons v. Nicholson, 487 F.3d 892, 896 (Fed. Cir. 2007). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. 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 duty to assist the Veteran has also been satisfied in this case. The record includes the Veteran's service treatment records, as well as his post service medical records, and the Veteran's lay statements. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In compliance with the Board's September 2012 remand, the RO obtained and associated with the claims file the Veteran's VA treatment records dated from March 2011 to September 2012. The Board notes that pertinent records from all relevant sources identified by him, and for which he authorized VA to request, were obtained by the RO. The Veteran has not identified any outstanding evidence to obtain. 38 U.S.C.A. § 5103A. The Board does point out, however, that in addressing the Veteran's claimed disorder, an April 2011 VA examiner purportedly reviewed the Veteran's computerized VA medical records dated September 2004 and September 2008 indicating that the Veteran was seen for prescription orthotics in relation to his reported history of fractured right second toe, as well as a March 2009 emergency room report reflecting the Veteran's diagnosis of "right ankle pain" after being involved in a motor vehicle accident. Additionally, the April 2011 VA examiner mentioned a podiatry clinic report dated May 2009 reflecting the Veteran's complaints of painful thickened toenails and history of "midfoot collapse" about 20 years previously (the 1980s). Those reports are not on file, although the April 2011 VA examiner described the findings in detail, noting all relevant symptoms and clinical findings made at those treatments. Although the actual reports are not on file, the Board notes that the reports do not specifically relate to the Veteran's right great toe disability as the April 2011 examiner noted that the fractured second toe of the right foot, ingrown toenails, and collapsed arches, were unrelated to the Veteran's right great toe injury in service. Further, the Board finds that the April 2011 examiner is clearly competent to report the results of the findings of those treatments. The physician was well aware of the Veteran's service connection claim concerning his right great toe and was addressing in particular the history reported by the Veteran and the possibility of any current right foot symptoms being related to the Veteran's service. The U.S. Court of Appeals for the Federal Circuit has made it clear that even a layperson is competent to report what his or physician says in terms of a diagnosis. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Thus, a physician surely is competent to read a medical document and convey the relevant findings. The Board's personal review of the findings is not required in such a case. See generally, Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions). Given the above, and as the remainder of the competent and credible evidence fails to show that the Veteran's current disorders involving the right foot otherwise are related to the right great toe crush injury in service, the Board finds that remand of this issue for the purpose of obtaining the computerized medical records dated September 2004, September 2008, and March and May 2009 is not required under VA's duty to assist the Veteran. The record also reflects that pursuant to the Board's remand in March 2011, the Veteran was afforded a VA examination in April 2011 to determine the current nature and etiology of any residuals of a crush injury of the right great toe. The Board finds that the VA examination was adequate to decide the claim on appeal because the examiner was provided with an accurate history, the Veteran's history and complaints were recorded, and the examination report set forth detailed examination findings to include nexus opinion with adequate bases for the opinion. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate.) Thus, further examination is not necessary regarding the right great toe issue on appeal. The Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to his claim decided herein. Law and Analysis Service connection is warranted if it is shown that a veteran has a disability resulting from an injury incurred or a disease contracted in active service or for aggravation of a pre-existing injury or disease in active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in- service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Veteran is seeking service connection for residuals of a crush injury of the right great toe. In his January 2008 statement in support of his claim, he stated that he injured his right great toe when a 5 inch shell casing fell onto his foot while serving on active duty aboard USS Lofberg in late 1967. He was seen in sick bay, given antibiotics and three days of bed rest. He further stated that he lost the nail on the toe and continued to have constant pain. In an April 2008 statement, the Veteran stated that after the injury to the right great toe, he was treated by a Royal Navy doctor in Singapore. Service treatment records reflect a diagnosis of crush injury of the right big toe in January 1968. After separation from service, in a July 2008 VA podiatry consultation report, the Veteran related history of bilateral midfoot collapse for 20 years, which was treated by orthotics. He denied any history of foot infections or ulcerations, bilaterally. The diagnoses were bilateral posterior tibial tendon dysfunction and pes planus. A September 2009 VA podiatry note reflects complaints of painful thick right hallux toenail. The Veteran stated that he had maintained all other toenails since his previous visit without complications. He again related history of bilateral midfoot collapse for 20 years, and denied any history of foot infections or ulcerations, bilaterally. The diagnoses were bilateral posterior tibial tendon dysfunction, stable and asymptomatic; pes planus; onchomycosis of all toes; and ingrown right hallux medial nail border. VA primary care note and podiatry consultation report dated June and September 2010 reflect complaints of ingrown toenail of the left big toe. The Veteran was provided a VA orthopedic examination in April 2011. The VA examiner indicated that the claims file was reviewed. The Veteran reported a history of an injury where the great toenail was "punctured" and he was confined to duty for some three days after which he returned to duty. He later was seen by a Royal Navy physician in Singapore some three weeks later because of suspect infection. He was treated with antibiotics and bed rest; after the condition improved he returned to duty. The examiner indicated that the Veteran was seen in podiatry clinic for the first time in September 2004 for consideration of prescription of orthotics. The history stated "fractured his second toe of the right foot in September 2004 and he denies pain." The examiner noted that "[t]his injury would have occurred following the [V]eteran's discharge in 1968 and apparently occurred in September 2004 and is therefore unrelated to military service." The examiner indicated that that next entry from Orthotics and Prosthetics was dated September 30, 2008, at which time the Veteran was measured for custom UCBL shoe insert with a diagnosis of tibial tendinitis. It was also noted that in March 2009, the Veteran was seen in the emergency room because of pain and swelling of his right foot and ankle following a motor vehicle accident. The resulting diagnosis was "right ankle pain." The examiner further noted that the Veteran was seen in the podiatry clinic in May 2009 complaining of painful thickened toenails and related a history of "midfoot collapse" about 20 years previously (the 1980s). It was stated that there was "no pain or problems with his arches" with a history of infections or ulcerations. There was no mention made to the podiatrist of an infection which occurred while in the military involving the great toe. Physical examination revealed mycotic toenails of all toenails. The Veteran reported that he subsequently developed recurrent ingrown toenails. Currently, he complained of throbbing pain in the medial border of the right great toe, which the examiner noted to be the area of previous ingrown toenails as documented by VA podiatry clinic records. The Veteran stated that in the 1980s "my arches collapsed." He stated that it did not occur while on active duty. On physical examination, the Veteran walked with both feet externally rotated to 40 degrees; both feet showed marked pronation and eversion with collapse of the longitudinal arches. Based on previous and present X-ray results, the examiner found that there were osteoarthritic changes with narrowing, spur formation, and subcondral sclerosis at the base of the first, second and third metatarsals and their associated cuniforms, which was worse on the left foot than the right foot. The phalanges themselves of the great toes and all other toes were negative; therefore, in regard to the great toe, there was only mild degenerative osteoarthritis of the first metatarsophalangeal joint. The examiner further stated that the findings were symmetrical bilaterally, although the osteoarthritis of the midfoot was greater on the left foot than the right. The diagnoses were severe collapsed longitudinal arches with severe pes planus and pronation and eversion of both feet with osteoarthritis at the first, second, and third metatarsal cuneiform joint, bilaterally, with mild narrowing of the first metatarsophalangeal joint of the great toe. The examiner opined that there were no residuals that would be seen from a crush injury of the great toe that were unique to the right great toe. In support of this opinion, the examiner provided the following rationale: The same degree of osteoarthritic changes of the metatarsophalangeal joint of the great toe on the right are present on the left. There are no changes in the distal phalanx, which is the site of the crush injury and the toenail injury. There is fungal infection of all toenails of both feet so that the injury in service cannot be considered a cause for that chronic fungus infection. Further, ingrown toenails are the result of chronic fungus infections of both great toes and not the result of any injury that occurred in service only to the right great toe. Therefore, the examiner concluded that it is not likely that the Veteran's current right great toe disability, chronic fungal infection, is related to his January 1968 crush injury of the right great toe in service. Additionally, the examiner noted that the Veteran's severe collapse of the longitudinal arch with pes planus, osteoarthritis, and weakness of the foot, began in the 1980s, by history, and was not related to the crush injury of the right great toe which occurred in the military in 1968. Based on a thorough review of the evidence of record, the Board finds that a preponderance of the evidence is against a grant of service connection for residuals of a crush injury of the right great toe. The medical evidence of record shows that the Veteran is currently diagnosed with various disorders involving the right foot, including mild degenerative osteoarthritis of the first metatarsophalangeal joint, pes planus, and fungus infection of all toenails and ingrown toenails. However, the evidence does not support a finding that there is a nexus between the Veteran's current right foot disorders and the crush injury of the right great toe in service. Although service treatment records document the Veteran's crush injury of the right great toe in January 1968, no complaints or abnormal findings of the right great toe were noted on his November 1968 separation examination. As for there being an in-service injury, the evidence clearly demonstrates that the Veteran sustained a crush injury to the right great toe as evidenced by his service treatment records. Despite the documentation of the injury in service, there has been no clinical finding that any of the Veteran's currently diagnosed right foot disorders represent residuals from that in-service right great toe injury or subsequent manifestations of that injury, in light of the April 2011 VA orthopedic examiner's findings and opinion. The April 2011 VA examiner opined that the Veteran's current right foot disorders, including degenerative osteoarthritis of the first metatarsophalangeal joint, pes planus, and fungus infection of all toenails and ingrown toenails, were not related to his military service. In support of this opinion, the examiner stated that the same degree of osteoarthritic changes of the metatarsophalangeal joint of the great toe on the right were present on the left and there were no changes in the distal phalanx, which was the site of the crush injury and the toenail injury. The examiner further stated that there was fungal infection of all toenails of both feet so that the injury in service could not be considered a cause for that chronic fungus infection. The Board finds that the medical opinion provided by the April 2011 examiner is based on a thorough review of the record and is supported by a well-reasoned and convincing rationale, and therefore the Board attaches significant probative value to the opinion as to whether the Veteran currently has any residuals of the crush injury of the right great toe in service. The Board therefore concludes that the evidence of record is not supportive of a finding that the Veteran has any current right great toe disability caused by his service, specifically the in-service crush injury of the right great toe in 1968. The Veteran has presented his own lay statements in support of his contention that he sustained the right great toe injury during service and continued to experience constant pain in that toe. Specifically, he argues that he lost the nail as a result of the in-service right great toe injury and experienced constant pain ever since that time. His statements are competent evidence as to the symptoms he experienced during and after service. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (holding that a lay witness is competent to testify to that which the witness has actually observed and is within the realm of his personal knowledge). Additionally, the Board has no reason to doubt the credibility of the Veteran's statements. However, to the extent that the Veteran asserts that he currently has residuals from the crush injury to the right great toe in service, the Board finds that as a layman, his statements are not competent evidence on the etiology of this disorder. In certain unique instances lay testimony may be competent to establish medical etiology or nexus. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson, 581 F.3d at 1316. However, in this case, the Board finds that whether the Veteran's in-service injury led to his current right foot pathology is not readily identifiable as it may have been caused by other factors. The etiology issue therefore does not lie within the range of common experience or common knowledge, but requires special experience or special knowledge. The evidence of record does not demonstrate that the Veteran possesses the ability, knowledge, or experience to provide competent etiological opinion in this matter. Moreover, substantial weight is given to the opinion of the April 2011 VA examiner who is a physician. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (holding that the Board is prohibited from substituting its own medical judgment in place of the opinions of competent medical professionals). There is no medical evidence of record showing that the Veteran currently has residuals from a crush injury of the great toe during military service, and the Board may not accept unsupported lay speculation with regard to medical issues. The Board has considered the benefit of the doubt doctrine when making these findings, but the preponderance of the evidence is against the Veteran's claim for entitlement to service connection. 38 U.S.C.A. 5107(b) (2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for residuals of a crush injury of the right great toe is denied. REMAND In its September 2012 remand, the Board instructed that the claims file be returned to the examiner who conducted a VA audiology examination in April 2011 for a new opinion that complies with its previous remand in March 2011. The Board found that the opinion offered by the April 2011 examiner inadequate because the opinion primarily relied on the lack of notation of hearing loss or tinnitus in service treatment records and failed to address the effect of in-service acoustic trauma alleged by the Veteran. In this regard, the Veteran has provided competent statements as to in-service acoustic trauma based on his excessive noise exposure through listening to radio communications with headphones and his proximity to the firing of shipboard guns, without ear protection. His statements are consistent with the circumstances of his service as his DD Form 214 reflects his MOS was radio operator. See VA Fast Letter 10-35 (Sept. 2, 2010) (providing Duty MOS Noise Exposure Listing and stating that if the duty position is shown to have a "Highly Probable" probability of exposure to hazardous noise, exposure to such noise will be conceded for purposes of establishing the in-service event). Further, the Board determined that the occurrence of in-service acoustic trauma is conceded and requested a nexus opinion on the basis of that concession. The Board also found problematic that the VA's examiner's notation in April 2011 that complaints of hearing loss were not noted in service treatment records, without regard to the RO's formal determination in October 2006 as to the unavailability of a portion of the Veteran's service treatment records. The April 2011 VA examiner provided another opinion in October 2012. Specifically, with regard to hearing loss of the left ear, the examiner opined in October 2012 that "it is not as least as likely that the [V]eteran's preexisting hearing loss of the left ear chronically increased beyond the normal progression of the disorder due to service to include due to acoustic trauma," because there were no complaints of hearing loss in the Veteran's service treatment records and noise exposure was limited. With regard to hearing loss of the right ear, the examiner found that "it is not as least as likely that any current hearing loss of the [V]eteran's right ear originated during his period of active service or is otherwise related to military service or any event thereof..." because there were no complaints of hearing loss by the Veteran during his active duty service and there was a significant delay in symptoms noticed, at least by 24 years. Here, the examiner again relied on the lack of notation of hearing loss in service treatment records and neglected to address the effect of in-service acoustic trauma conceded by VA. RO compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. See Stegall v. West, 11 Vet. App. 268, 271 (holding that where the remand orders of the Board are not substantially complied with, the Board errs as a matter of law when it fails to ensure compliance). Additionally, with regard to tinnitus, the examiner explained that the Veteran's tinnitus is not considered chronic tinnitus but transient ear noise because the Veteran reported at his previous VA examination that his tinnitus was very infrequent only occurring on a weekly basis. However, it is not clear how the infrequency or the transient nature of the Veteran's current tinnitus supports the examiner's conclusion that the tinnitus is not related to service. As such, given the deficiencies in the October 2012 VA medical opinion, another VA medical opinion is required to adequately decide the merits of these claims. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (noting that when the medical evidence of record is insufficient in the opinion of the Board, or of doubtful weight or credibility, the Board must supplement the record by seeking an advisory opinion or ordering a medical examination). Accordingly, the case is REMANDED for the following action: 1. Obtain any outstanding treatment records for the Veteran from the VA Medical Center in St. Louis, Missouri, and all associated outpatient clinics. All attempts to obtain those records should be documented in the claims file. 2. Thereafter, forward the Veteran's claims folder to the examiner who conducted the April 2011 VA audiology examination and offered an October 2012 addendum, if such examiner is available, or a suitable substitute if the April 2011 VA examiner is not available. If the April 2011 VA examiner is unavailable or in the event she desires to further examine the Veteran, the Veteran should be accorded an additional VA audiological examination at the applicable VA medical facility for evaluation of the nature and etiology of his claimed hearing loss and tinnitus. Following a review of the claims folder, the VA examiner is asked to address the following questions, providing a rationale that includes reference to specific facts of this case for each opinion offered: (a) Based on the Board's prior finding that hearing loss of the Veteran's left ear preexisted service, is it at least as likely as not that his preexisting hearing loss of the left ear chronically increased beyond the normal progression of the disorder due to service, to include due to acoustic trauma? The VA examiner is to concede the existence of in-service acoustic trauma and the Veteran's statements of record as to the onset and progression of his hearing loss are to be fully considered. (b) Is it at least as likely as not that any current hearing loss of the Veteran's right ear originated during his period of active service or is otherwise related to military service or any event thereof, including acoustic trauma conceded by VA? Is it at least as likely as not that any sensorineural hearing loss of the right ear is shown to have been manifested during the one-year period immediately following the Veteran's separation from service in November 1968, and, if so, how and to what degree? The VA examiner is to concede the occurrence of in-service acoustic trauma and the Veteran's statements of record as to the onset of his hearing loss and its progression are to be fully considered. (c) Is it at least as likely as not that currently shown tinnitus of the Veteran originated during his period of active service or is otherwise related to military service or any event thereof, including acoustic trauma conceded by VA? Is it at least as likely as not that tinnitus is shown to have been manifested during the one-year period immediately following the Veteran's separation from service in November 1968. The VA examiner is to concede the occurrence of in-service acoustic trauma and the Veteran's statements of record as to the onset of his tinnitus and its progression are to be fully considered. In rendering the requested opinions and rationales, the lack of notation of hearing loss or tinnitus in service treatment records is not necessarily fatal to the Veteran's claims and cannot be the only basis by which to reject a possible nexus to service. The examiner is specifically asked to address the effect of in-service acoustic trauma conceded by VA on the Veteran's current hearing disorders. The examiner is advised that the term as likely as not does not mean within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of a proposition as to find against. More likely and as likely support the contended relationship; less likely weighs against the claim. The examiner is further advised that aggravation for VA purposes is defined as a chronic worsening of the underlying disability beyond its natural progression versus a temporary flare-up of symptoms. 3. Lastly, readjudicate all of the issues on appeal. If any benefit sought on appeal continues to be denied, the Veteran and his representative must be provided with a supplemental statement of the case, followed by an appropriate period of time for a response. The case should then be returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs