Citation Nr: 1803331 Decision Date: 01/18/18 Archive Date: 01/29/18 DOCKET NO. 14-20 678 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to a rating in excess of 30 percent for right shoulder impingement, status-post superior labrum anterior-posterior repair. 2. Entitlement to a rating in excess of 20 percent for cervical radiculopathy of the right arm. 3. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Todd S. Hammond, Esq. WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD T. Joseph, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from April 1999 to March 2002 and June 2004 to June 2006. During his periods of service, the Veteran earned the Army Achievement Medal, National Defense Service Medal, Army Lapel Button, Army Commendation Medal, Noncommissioned Officer's Professional Development Ribbon, Army Service Ribbon, Army Reserve Components Overseas Training Ribbon, Sharpshooter Marksmanship Qualification Badge with Rifle Bar, and Marksman Marksmanship Qualification Badge with Grenade Bar. This matter comes before the Board of Veterans' Appeals (Board) from a October 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. During the pendency of the appeal, in a July 2016 rating decision, the RO granted entitlement to an increased evaluation of 30 percent for right shoulder impingement, status-post superior labrum anterior-posterior repair, effective from June 16, 2016; and entitlement to an increased evaluation of 20 percent for cervical radiculopathy of the right arm, effective from June 16, 2016. Nevertheless, applicable law mandates that, when a Veteran seeks an increased evaluation, it will generally be presumed that the maximum benefit allowed by law and regulation is sought, and it follows that such a claim remains in controversy where less than the maximum benefit available is awarded. See AB v. Brown, 6 Vet. App. 35 (1993). Here, the Veteran has not withdrawn his claim for an increased evaluation of his right shoulder impingement nor cervical radiculopathy; thus, the issues remain on appeal and have been recharacterized as reflected above. In June 2017, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claims file. The issue of TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's right shoulder disability manifests a limited range of motion, along with additional functional loss due to pain, weakness, and fatigability of his right shoulder, which results in a substantial limitation of use of the joint and right arm approximating limitation to 25 degrees from the side. 2. The Veteran's right arm cervical radiculopathy is manifested by, at most, mild incomplete paralysis of the middle and lower radicular groups. CONCLUSIONS OF LAW 1. The criteria for an increased rating of 40 percent for right shoulder impingement, status post superior labrum anterior-posterior repair, have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5201 (2017). 2. The criteria for a disability rating in excess of 20 percent for cervical radiculopathy of the right arm have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.71a, Diagnostic Code 8516 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has reviewed all of the evidence in the record. Although the Board has an obligation to provide adequate reasons or bases supporting its decision, there is no requirement that each item of evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board will summarize the evidence as deemed appropriate, and the analysis below will focus specifically on what the evidence shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Disability ratings are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Consideration must be given to increased evaluations under other potentially applicable Diagnostic Codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). The Veteran's entire history is reviewed when assigning disability ratings. See generally 38 C.F.R. § 4.1. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Right Shoulder Impingement The Veteran's right shoulder disability is currently evaluated under DC 5201, applicable to limitation of motion of the arm. The terms "major" and "minor" are used in the rating criteria to refer to the dominant or non-dominant upper extremity. See 38 C.F.R. § 4.69 (2017). The evidence of record reflects that the Veteran is right-handed. Therefore, his right shoulder is evaluated as major. A minimum 20 percent evaluation is warranted for the major arm when its motion is limited to the shoulder level. 38 C.F.R. § 4.71a. A 30 percent evaluation is warranted for the major arm when its motion is limited to midway between side and shoulder level, which means that flexion or abduction would need to be reduced to 45 degrees. Id. A 40 percent evaluation is warranted for the major arm when its motion is limited to 25 degrees from the side. Id. For VA compensation purposes, normal forward elevation (flexion) and abduction of the shoulder is from 0 degrees to 180 degrees, with 90 degrees being shoulder level; normal shoulder internal and external rotation is 0 degrees to 90 degrees, with 90 degrees being shoulder level. 38 C.F.R. § 4.71, Plate I. When an evaluation of a disability is based upon limitation of motion, the Board must also consider, in conjunction with the otherwise applicable Diagnostic Code, any additional functional loss the Veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy from disuse. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the Veteran. 38 C.F.R. § 4.40 (2017); Johnston v. Brown, 10 Vet. App. 80, 85 (1997). The Veteran's shoulder impingement syndrome is currently evaluated as 30 percent disabling. He seeks a higher rating. A November 2011 private examination report from Hope Orthopedics of Oregon was submitted by the Veteran in June 2013. The Veteran complained of chronic posterior right shoulder pain, which radiated down his arm and had associated burning, numbness, and tingling. Ninety-degree external rotation, ninety-degree internal rotation, and zero-degree external rotation in the active and passive ranges were to 90 degrees. Zero-degree internal rotation was to T7 degrees. Flexion and abduction in the active and passive ranges were to 180 degrees. Extension was to 60 degrees. Upon examination, the examiner noted pain during internal rotation with no limiting factors upon active range of motion testing. The Veteran was pain-free with no limiting factors upon passive range of motion testing. The examiner diagnosed right shoulder quadrilateral space syndrome/axillary neuropathy. The Veteran elected to undergo surgery, which was scheduled for December 2011, as a form of treatment. A December 2011 post-operative examination report indicated that the Veteran's status was improving and his activity level was back to pre-operative level. He stated that his pain score was 0 on a scale of 10. He further reported that he was not taking any pain medication, was not participating in rehabilitation, and had resumed heavy physical activity. The examiner noted that the Veteran had full range of motion. Motor and sensory examinations of the shoulder indicated no deficits. In April 2013, the Veteran appeared for an orthopedic consultation at Kaiser Permanente. He reported that he had been experiencing right shoulder pain for over a year. He stated that he had significant relief for about 8 months after his December 2011 surgery, but the pain had since returned. He reported that his overall range of motion had been fine, but experienced loss of strength and fatigue in certain positions. Upon active range of motion testing, forward flexion was to 170 degrees and abduction was to 170 degrees. Upon passive range of motion testing, forward flexion was to 170 degrees; abduction was to 110 degrees; external rotation abduction was to nearly 85 degrees; and external rotation with his arm at his side was to 60 degrees, with internal rotation to about L1. The examiner noted medial scapular winging. Upon resistive testing, the Veteran had good strength to empty can test, with resistance upon internal and external rotation testing. Pain was observed on the O'Brien maneuver, Hawkins maneuver, and upon cross arm adduction. The Veteran's posterior shoulder was tender to palpation along the teres minor. With Zaslav test, he had posterior shoulder pain with resisted internal rotation and none in external rotation. The Veteran returned for a follow-up examination in June 2013. He complained of constant pain in the right shoulder, which was localized to the posterior aspect of the shoulder near the posterior scar. He expressed that he occasionally felt some tightness and discomfort over the anterior aspect of the shoulder. The examiner noted winging of the lateral border of the shoulder with forward elevation. Forward flexion was to 180 degrees and abduction was to nearly 180 degrees. The examiner noted some atrophy in the posterior aspect of the infraspinatus. The Veteran's posterior shoulder was tender to palpation over the posterior scar, posterior deltoid, and teres major, with trigger point tenderness identified at the posterior border of the deltoid. On passive motion, forward flexion was to nearly 180 degrees, with abduction, abduction, and external rotation to 90 degrees. The Veteran's external rotation with his arm at his side was to 60 degrees. Internal rotation was to L1. The Veteran had good strength with resistive testing to the supraspinatus and infraspinatus. He had some pain with the O'Brien test, mostly to the posterior aspect of the shoulder. In September 2013, the Veteran appeared for another orthopedic consultation at Kaiser Permanente. He reported continued shoulder pain. Upon active and passive motion, forward flexion was to 160 degrees, with a painful arc from about 130 to 160 degrees; external rotation as about 75 degrees; and internal rotation as to T10. The Veteran appeared for a VA shoulder and arm examination in October 2013. Flexion and abduction ended at 110 degrees, with painful motion beginning at 70 degrees. Upon repetitive-use testing, flexion and abduction ended at 110 degrees. The examiner noted less movement than normal and pain on movement after repetitive-use. The examiner noted that he would expect an additional 10 degrees of loss in the Veteran's overall range of motion, strength and coordination, and fatigue upon repetitive-use. Pain on palpation and guarding was also noted. Positive results were indicated on Hawkins' impingement testing, empty-can testing, and upon external rotation and infraspinatus strength testing. The Veteran appeared for follow-up care at Kaiser Permanente in December 2013. The Veteran reported burning in his arm and radiating from his posterior shoulder down the back of his arm. The examiner noted an equivocal Spurling's maneuver. The Veteran had full, unrestricted range of motion of the shoulder. Forward flexion was to 160 degrees, external rotation was to 65 degrees, and internal rotation was to L2. The Veteran appeared for an orthopedic consultation and follow-up at Kaiser Permanente in April 2014. The Veteran reported that he continued to have pain in his shoulder, radiating pain down his arm. He continued to be able to do most activities and was otherwise doing well. The Veteran had unrestricted range of motion. Forward flexion was to 170 degrees; external rotation was to 65 degrees; internal rotation was to T10. The Veteran appeared for another VA shoulder and arm examination in June 2016. Flexion was to 60 degrees; abduction and internal rotation was to 40 degrees; and external rotation was to 20 degrees. Pain was noted on flexion, abduction, external rotation, internal rotation, and with weight bearing. The Veteran was able to perform repetitive-use testing with no addition functional loss. The examiner indicated that pain, weakness, and fatigability significantly limited the Veteran's functional ability with repeated use. The Veteran testified at the videoconference hearing in June 2017. He testified that he endured constant shoulder pain, which affected his sleep cycles and ability to perform tasks. He also had to begin using his left hand as the dominant hand, as range of motion limitations in his right arm restricted its use. The Veteran further testified that he receives bi-monthly injections in his shoulder for pain management. The Veteran submitted a private medical opinion in November 2017 from Dr. J. S. of Salem Clinic stating that the Veteran had "less than 30% range of motion." In light of the evidence noted above and as a whole, and considering the Veteran's competent and credible testimony regarding his pain and other functional loss factors in the right shoulder, resolving all reasonable doubt in favor of the Veteran, the Board finds that the evidence supports the assignment of a 40 percent disability evaluation for the service-connected right shoulder disability. The Board has also considered whether another potentially applicable diagnostic code would warrant an increased disability rating. See Schafrath, 1 Vet. App. at 595. In particular, disabilities of the shoulder and arm are to be rated under DCs 5200-5203. See 38 C.F.R. § 4.71a, DCs 5200-03. DC 5200 provides rating criteria for ankylosis of scapulohumeral articulation, where the scapula and humerus move as one piece. See Id., DC 5200. The relevant criteria indicate that favorable ankylosis is abduction to 60 degrees; while unfavorable ankylosis is abduction limited to 25 degrees. Id. A maximum 40 percent disability rating is warranted for unfavorable ankylosis of the dominant side, where abduction is limited to 25 degrees from the side. Id. DCs 5202 and 5203 contain rating criteria regarding other impairment of the humerus and impairment of the clavicle or scapula, respectively. See Id., DCs 5202-03. However, the Board finds that the above diagnostic codes do not warrant increased disability ratings in excess of 40 percent for the Veteran's right shoulder disability. There is no evidence of ankylosis of the shoulder. Moreover, there was no evidence of impairment of the humerus, clavicle, or scapula. Therefore, consideration of DCs 5200, 5202, and 5203 does not warrant increased disability ratings for the Veteran's right shoulder disability. For the foregoing reasons, the maximum schedular rating under DC 5201 of 40 percent is warranted for the right shoulder disability. As the preponderance of the evidence is against any higher schedular rating, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Cervical Radiculopathy of the Right Arm The Veteran's cervical radiculopathy is currently evaluated under DC 8511, applicable to paralysis of the middle radicular group. The terms "major" and "minor" are used in the rating criteria to refer to the dominant or non-dominant upper extremity. See 38 C.F.R. § 4.69 (2017). The evidence of record reflects that the Veteran is right-handed. Therefore, his right arm is evaluated as major. Under Diagnostic Code 8511, a 20 percent evaluation is assigned for mild incomplete paralysis of the middle radicular group of nerves of the major arm. A 40 percent evaluation is assigned for moderate incomplete paralysis of the middle radicular group of nerves of the major arm. A 50 percent evaluation is assigned for severe incomplete paralysis of the middle radicular group of nerves of the major arm. A 70 percent evaluation is assigned for complete paralysis of the middle radicular group of nerves of the major arm; adduction, abduction, and rotation of arm, flexion of elbow, and extension of wrist lost or severely affected. See 38 C.F.R. § 4.124a, Diagnostic Code 8511 (2017). The Board notes that words such as "severe," "moderate," and "mild" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be just. See 38 C.F.R. § 4.6 (2017). Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Rather, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. See 38 U.S.C. § 7104 (2012); 38 C.F.R. §§ 4.2, 4.6 (2017). In April 2013, the Veteran appeared for an orthopedic consultation at Kaiser Permanente Northwest. He described numbness at the right wrist from approximately 10 cm proximal to the wrist crease down to the wrist joint. The Veteran reported that this area was constantly numb. Palpation to the Veteran's posterior shoulder caused paresthesias down the posterior aspect of the arm to the ulnar side of the wrist. Radial pulse was 2+ and sensation to the hand was intact, but he experienced numbness at the carpal tunnel at the wrist. The Veteran returned for a follow-up examination in June 2013. He reported that his entire hand would get numb and tingly, particularly at night when he sleeps on his back, though he usually did not experience paresthesias during the day. He also noticed that his right arm was quite weak and he had difficulty holding his hand above his head for any period of time. In September 2013, the Veteran appeared for another orthopedic consultation at Kaiser Permanente. He reported continued numbness and tingling in the C5, C6, and C7 nerve distributions in the right hand. His axillary nerves were intact to light touch, with decreased sensation in the radial and ulnar nerves. Radial and ulnar pulses were 2+. The hand was warm and well perfused. The Veteran appeared for a VA peripheral neves examination in October 2013. The Veteran reported that his right forearm felt like spiders were crawling on it. The examiner noted mild intermittent pain, paresthesias, and numbness in the right upper extremity. Sensation to light touch was decreased in the inner/outer forearm and hand/fingers. The examiner also noted a sensory decrease in ulnar nerve distribution. The Veteran appeared for follow-up care at Kaiser Permanente in December 2013. The Veteran reported burning in his arm and radiating from his posterior shoulder down the back of his arm. He also reported numbness and tingling in the radial nerve distribution of his right hand. The examiner noted decreased sensation in the radial nerve distribution in the forearm and hand. Median and ulnar nerves were intact to light touch. Radial and ulnar pulses were 2+ and well perfused. The Veteran appeared for another VA peripheral nerves examination in June 2016. The examiner indicated an updated diagnosis of right arm cervical radiculopathy. The examiner noted moderate intermittent pain, paresthesias, and numbness in the right upper extremity. Sensation to light touch was decreased in the inner/outer forearm and hand/fingers. The examiner also noted mild incomplete paralysis of the middle and lower radicular groups. In addition to the VA examinations, the medical evidence also includes private and VA treatment records showing complaints of right arm numbness, which are consistent with the VA examinations of record. With regard to the Veteran's service-connected cervical radiculopathy of the right arm, the medical evidence of record does not establish that this service-connected disability warrants a disability rating in excess of 20 percent. The Board does not doubt the Veteran's sincere testimony and that he experiences decreased sensation, pain, tingling, and weakness; however, the evidence of record does not support a finding that the Veteran experiences reflect more than a mild degree of incomplete paralysis of the middle radicular group. The Board has considered whether an increased evaluation could be assigned under an alternative diagnostic code used in rating disease of the peripheral nerves. See 38 C.F.R. § 4.124a (2017). However, none of the relevant nerves allow for a rating in excess of 20 percent for mild incomplete paralysis. Therefore, an increased rating cannot be assigned for the right upper extremity under any other diagnostic code. See 38 C.F.R. § 4.124a, Diagnostic Codes 8510-8719 (2017). Accordingly, the Veteran's claim of entitlement to a disability rating in excess of 20 percent for right arm cervical radiculopathy must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. As the preponderance of the evidence is against a higher schedular rating, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. ORDER An increased rating of 40 percent for right shoulder impingement, status post superior labrum anterior-posterior repair is granted. Entitlement to a rating in excess of 20 percent for cervical radiculopathy of the right arm is denied. REMAND Although the Board sincerely regrets the additional delay, further development is necessary prior to the adjudication of the Veteran's claim of entitlement to a TDIU. When any impairment of mind or body sufficiently renders it impossible for the average person to follow a substantially gainful occupation, that impairment will be found to be causing total disability. 38 C.F.R. § 3.340. If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.34. In other words, VA will grant a TDIU when the evidence shows that a Veteran is precluded, by reason of service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. TDIU benefits are granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. If there is only one such disability, it must be rated at least 60 percent disabling to qualify for TDIU benefits; if there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). However, even where the veteran does not meet the schedular rating requirements, all Veterans who are shown to be unable to secure and follow a substantially gainful occupation by reason of a service-connected disability shall be rated totally disabled. 38 C.F.R. § 4.16(b). Therefore, for veterans who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a), VA is to refer the claim to the to the Director of Compensation Service, for extra-schedular consideration. The Veteran is currently service-connected for right shoulder impingement, status post superior labrum anterior-posterior repair, evaluated as 40 percent disabling; cervical radiculopathy of the right arm, evaluated as 20 percent disabling; tinnitus, evaluated as 10 percent disabling; right shoulder surgical scars, associated with right shoulder impingement, status post superior labrum anterior-posterior repair, evaluated as 0 percent disabling; and hearing loss, evaluated as 0 percent disabling. The Veteran's combined disability rating is evaluated at 60 percent. Accordingly, because the Veteran does not have a single service-connected disability rated at 60 percent or more, or a combined disability rating of 70 percent or more, he does not meet the percentage requirements for a TDIU under 38 C.F.R. § 4.16(a). In a November 2013 statement in support of claim, the Veteran stated that he was unemployable due to his service-connected conditions, namely his right shoulder impingement and cervical radiculopathy. The Veteran reported for VA examinations in October 2013. The examiner noted that the Veteran would not be able to tolerate physical labor as the Veteran was right-handed and his shoulder would not allow it. However, the examiner noted that sedentary employment should be tolerated, as the Veteran was attending school and had not missed time. The Veteran again reported for VA examinations in July 2016. The Veteran reported that he last worked as the maintenance director at a residential facility for Alzheimer's patients in 2010. He reported that he had to stop working due to his shoulder. The examiner opined that the Veteran's right arm condition would significantly impair any activities that involved working overhead, lifting his right arm beyond 90 degrees, and repetitive lifting. The examiner further opined that the Veteran would not likely find gainful employment beyond sedentary desk type work because of his right arm condition. The Veteran testified at a Board hearing in June 2017. He stated that it became difficult to work, as he had to begin using his left hand as his dominant hand. The Veteran also reported that his medications caused him to oversleep, with created problems with his employment. The Veteran stated that he had been attending school in an attempt to earn a nursing degree; however, the pain in his shoulder affected his sleep patterns. As he was not resting properly and could not concentrate, he had to withdraw from his courses. The Board finds that the evidence of record as discussed above suggests that the Veteran is unemployable due to his service-connected right shoulder impingement, status-post superior labrum anterior-posterior repair, and cervical radiculopathy of the right arm, particularly in light of his prior work experience, which has primarily consisted of employment as a maintenance director. As such, remand of the Veteran's claim of entitlement to TDIU is warranted for referral to the Director of Compensation Service for extraschedular consideration. See 38 C.F.R. § 4.16(b). Accordingly, the case is REMANDED for the following action: 1. Refer the Veteran's claim of entitlement to TDIU to the Director of Compensation Service for consideration of the assignment of a TDIU on an extraschedular basis under 38 C.F.R. § 4.16(b). Include a full statement as to the Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue. A copy of the Director's decision must be associated with the claims file. 2. Thereafter, readjudicate the Veteran's claim for entitlement to an extraschedular TDIU. If the benefit sought on appeal remains denied, in whole or in part, the Veteran and his representative must be provided with a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter or 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. §§ 5109B, 7112 (2012). ____________________________________________ A. S. CARACCIOLO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs