Citation Nr: 18160795 Decision Date: 12/27/18 Archive Date: 12/27/18 DOCKET NO. 09-18 764A DATE: December 27, 2018 ORDER Entitlement to an initial rating of 60 percent, but no higher, for hypothyroidism, status post ablation for Grave’s disease, from October 25, 2007 to May 12, 2015 is granted. Entitlement to a 10 percent initial rating for gastroesophageal reflux disease from October 25, 2007 to May 10, 2011 is granted. Entitlement to a rating higher than 10 percent for gastroesophageal reflux disease from October 25, 2007 to May 12, 2015 is denied. Entitlement to a rating higher than 30 percent for gastroesophageal reflux disease since May 13, 2015 is denied. FINDINGS OF FACT 1. Affording the Veteran the benefit of the doubt, from October 25, 2007 to May 12, 2015, the Veteran’s hypothyroidism, status post ablation for Grave’s disease, manifested with muscular weakness, memory impairment, depression, fatigability, weight loss, and constipation, and these symptoms more nearly approximate the criteria for a 60 percent rating for hypothyroidism. 2. From October 25, 2007 to May 12, 2015, the Veteran’s hypothyroidism, status post ablation for Grave’s disease, did not manifest with cardiovascular involvement or bradycardia, and the symptoms did not more nearly approximate the criteria for a 100 percent rating for hypothyroidism. 3. From October 25, 2007 to May 10, 2011, the Veteran’s gastroesophageal reflux disease manifested by persistently recurrent epigastric distress with pyrosis and substernal pain. 4. From October 25, 2007 to May 12, 2015, the Veteran’s gastroesophageal reflux disease has not manifested by symptoms of recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, and was not productive of considerable impairment of health. 5. Since May 13, 2015, the Veteran’s gastroesophageal reflux disease has not manifested by symptoms of pain, coming, material weight loss, hematemesis, melena, anemia, or other symptom combinations productive of severe impairment of health. CONCLUSIONS OF LAW 1. From October 25, 2007 to May 12, 2015, the criteria have been met for a 60 percent rating, but no higher, for hypothyroidism, status post ablation for Grave’s disease. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.14, 4.21, 4.119, Diagnostic Code 7903. 2. From October 25, 2007 to May 10, 2011, the criteria for an initial 10 percent rating, but no higher, for gastroesophageal reflux disease have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.14, 4.21, 4.113, 4.114, Diagnostic Code 7346. 3. From May 11, 2011 to May 12, 2015, the criteria for a rating higher than 10 percent for gastroesophageal reflux disease have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.14, 4.21, 4.113, 4.114, Diagnostic Code 7346. 4. Since May 13, 2015, the criteria for a rating higher than 30 percent for gastroesophageal reflux disease have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.14, 4.21, 4.113, 4.114, Diagnostic Code 7346. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1997 to October 2007. Increased Rating Disability evaluations are determined by the application of the VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Separate evaluations may be assigned for separate periods of time based on the facts found through “staged” ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Hypothyroidism The Veteran contends that higher initial ratings are warranted for her hypothyroidism, status post ablation for Grave’s disease. The evidence shows that the Veteran was diagnosed with hyperthyroidism in service in 1999, after the birth of her daughter. She underwent thyroid ablation surgery in 2004, which resulted in her developing hypothyroidism. The Veteran’s hypothyroidism was initially assigned a 10 percent rating, effective October 25, 2007, the day after her separation from service, in a May 2008 rating decision. In a March 2012 rating decision, the Veteran was granted entitlement to service connection for Grave’s disease in addition to hypothyroidism, and the issue was recharacterized as hypothyroidism, status post ablation for Grave’s disease, and assigned a rating of 30 percent, effective October 27, 2010. In an October 2015 rating decision, the Veteran’s evaluation for hypothyroidism was raised to 100 percent, effective May 13, 2015. As 100 percent is the maximum award that can be assigned for hypothyroidism, the period since May 13, 2015 is no longer on appeal, and will not be further addressed. The Veteran wrote in June 2008 that since her thyroid ablation, she had symptoms of fatigability, short term memory impairment, muscle weakness, constipation, cold intolerance, depression, dry skin and hair, sleepiness, and weight loss. The Veteran testified at an October 2014 Board hearing that she had symptoms of fatigability, constipation, mental sluggishness, muscle weakness, extreme weight fluctuation, cold intolerance, chest pain, anxiety, depression, dry skin, hair loss, and tiredness even after a full night of sleep. She also stated that she had been diagnosed with bradycardia. She discussed how her condition made it hard to care for and keep up with her children, and that she had missed about three weeks of work in the past few years due to her hypothyroidism. She stated that she had general forgetfulness, but no dementia. The Veteran wrote in October 2018 that from 2007 to 2010, she had symptoms of cold intolerance, anxiety, bradycardia, memory lapses, muscular weakness, and sleepiness, and that from 2010 to 2015 she had symptoms of sleepiness, cold intolerance, depression, forgetfulness, and bradycardia. The Veteran’s husband wrote in May 2012 that the Veteran’s thyroid issues plagues her daily, and caused her to always feel cold, struggle with weight loss, and have memory loss. The Veteran’s colleague Y.Z. wrote in May 2015 that she had seen the Veteran have weight loss and gains, inability to tolerate cool environments, severe acne, and hair loss, and that she looked drained and was tired and fatigued. Hypothyroidism is rated under Diagnostic Code 7903. Under 38 C.F.R. § 4.119, Diagnostic Code 7903, a 10 percent evaluation is warranted for fatigability or the required use of continuous medication for control of symptoms. A 30 percent evaluation is warranted for fatigability, constipation, and mental sluggishness. A 60 percent evaluation is warranted for muscular weakness, mental disturbance, and weight gain. A 100 percent evaluation is warranted for hypothyroidism with cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia, and sleepiness. 38 C.F.R. § 4.119, Diagnostic Code 7903. The Board notes that the United States Court of Appeals for Veterans Claims (Court) has addressed the specific application of the rating criteria for Diagnostic Code 7903. In that regard, the Court has said that the all of the symptoms listed for a particular disability rating were not required to be demonstrated in order to establish entitlement to a higher disability rating. See Tatum v. Shinseki, 23 Vet. App. 152, 155 (2009). The Court noted that symptoms that meet some of the rating criteria should be considered in light of 38 C.F.R. § 4.7 (Where there is a question as to which of the two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned.). The Court also stated that unlike the diabetes mellitus rating criteria addressed in Camacho v. Nicholson, 21 Vet. App. 360 (2007), the rating criteria for Diagnostic Code 7903 are not successive. Tatum, 23 Vet. App. at 155. A claimant could potentially establish all of the criteria required for a 30 percent or 60 percent rating without establishing any of the criteria for a lesser disability rating. Id. at 156. The Board has considered all of the medical evidence, and finds that affording the Veteran the benefit of the doubt, for the entire period on appeal, October 25, 2007 to May 12, 2015, the criteria for a 60 percent rating have been met. The Veteran has credibly asserted that during this period, she manifested all of the symptoms listed in the criteria for both the 30 percent rating and for the 60 percent rating: fatigability, constipation, mental sluggishness/disturbance, muscular weakness, and weight fluctuation. This is reflected both in the Veteran’s Board testimony and the numerous letters she submitted to VA during the appeal period. The Veteran, as a lay person, is competent to report symptoms such as feeling fatigued, being constipated, and losing weight. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). These assertions are also generally supported by the Veteran’s VA examinations. At a January 2008 VA examination, the Veteran reported symptoms of anxiety, dry skin, weight loss, fatigability, cold intolerance. At a VA examination in October 2010, the Veteran reported that she felt tired and excessively sleepy, and that she had dry skin and thin, brittle, fragile hair. She had dyspnea on moderate exertion, and also reported memory loss, decreased concentration, vision difficulty, lack of stamina, and pain. Examination found symptoms of fatigability, weakness, cold intolerance, palpitations, arthralgia, bone pain, dry skin dry and brittle hair, muscle weakness, anorexia, nausea, abdominal pain, and constipation. At a May 2015 VA examination, the Veteran was noted to have fatigability, cardiovascular involvement, constipation, mental sluggishness, depression, slowing ot thought, mental disturbance, continuous medication, weight gain, sleepiness, cold intolerance, bradycardia. On the basis of these examination findings, an October 2015 rating decision increased the Veteran’s evaluation to 100 percent, effective May 13, 2015. The Veteran’s VA treatment records from 2007-2015 also show continuous treatment for hypothyroidism, and they show complaints from the Veteran that she had lethargy and extreme fatigue, depressed mood, constipation, and hair loss, cold intolerance, and inability to gain weight. The Board therefore accepts the Veteran’s lay assertions regarding her symptomatology from 2007 to 2015, which are reasonably consistent with the medical evidence of record, and finds that a 60 percent evaluation for hypothyroidism is warranted from October 25, 2007 to May 12, 2015. See Wise v. Shinseki, 26 Vet. App. 517, 531 (2014) (“By requiring only an ‘approximate balance of positive and negative evidence’ the Nation, ‘in recognition of our debt to our veterans,’ has ‘taken upon itself the risk of error’ in awarding... benefits.”). The Board does not find, however, that a 100 percent rating is warranted from October 25, 2007 to May 12, 2015. A 100 percent evaluation can be assigned for hypothyroidism when there is cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia, and sleepiness. 38 C.F.R. § 4.119, Diagnostic Code 7903. In this case, the Veteran has been found to have cold intolerance, muscular weakness, mental disturbance (characterized by forgetfulness and depression), and sleepiness. These symptoms are the basis for her increased rating to 60 percent. The Board does not find, however, that the preponderance of the medical evidence demonstrates that the Veteran had cardiovascular involvement or bradycardia from 2007 to 2015. Symptoms of cardiovascular impairment are symptoms that would demonstrate a significant worsening from those that are listed as criteria for lower ratings of 30 or 60 percent, and the assignment of a 100 percent rating should reflect that the impairment in a veteran’s health would be tremendously disabling. In this case, the Veteran was not shown to have any heart problems from 2007 to 2015, nor was she ever diagnosed with bradycardia. The Veteran has argued that she has had bradycardia throughout the appeal, and that it is demonstrated by an October 2004 ECG test which showed “sinus bradycardia with sinus arrhythmia” but otherwise normal ECG. Her pulse was 57 beats per minute. The Veteran also submitted an October 2010 evaluation which showed a pulse of 56 beats per minute. Bradycardia, which is slowness of the heartbeat, is defined for rating purposes as less than 60 beats per minute. 38 C.F.R. § 4.119, Diagnostic Code 7903. The Board notes that the October 2004 ECG was performed several years before the current appeal period, during a time when the Veteran was still recovering from her thyroid ablation surgery. It is not evidence of a bradycardia disorder during the years on appeal which are most relevant, 2007 to 2015. While the October 2010 evaluation shows a heart rate of 56 beats per minute, the Board is also unable to find that this constitutes a diagnosis of bradycardia, as this is an isolated finding during a period of many years during which the Veteran had many, many pulse readings that were far higher and did not meet the definition of bradycardia. The Veteran’s VA treatment records contain no records showing a heartbeat slower than 60 beats per minute, but they have numerous recorded pulse readings that are in the 70s, going to as high as 80 beats per minute in November 2014 and 91 beats per minute in October 2013. At the January 2008 VA examination, the Veteran had no bradycardia, normal heart size, and no signs of congestive heart failure. The examiner found no effects of the problem on her usual daily activities. At the October 2010 VA examination, the Veteran reported dyspnea on moderate exertion, but there were no findings of congestive heart failure or pulmonary hypertension, no extra heart sounds, and normal cardiac rhythm. Her pulse was 80 beats per minute. While the December 2017 VA examiner wrote that the Veteran reported having intermittent bradycardia since she was diagnosed in 2004, this appears to be based on the Veteran’s own reports to the examiner, and is not supported by any reference to medical evidence showing intermittent bradycardia. See LeShore v. Brown, 8 Vet. App. 406, 409 (1995) (the mere transcription of a claimant's statements regarding medical history does not transform the information into competent medical evidence merely because the transcriber happens to be a medical professional). The December 2017 VA examiner also found that the Veteran’s heart rate was 60 beats per minute, an echocardiogram was normal, her heart was structurally normal, and the Veteran did not have any heart disorder. Most recently an expert medical opinion was obtained through the Veterans Health Administration in September 2018 from physician R.K. The physician reviewed all of the medical evidence and wrote that there was no documentation of a diagnosis of bradycardia from 2007 to 2015, and that the Veteran’s pulses ranged from 61 to 104 during this time. While this examiner did not directly address the Veteran’s submission of a heart evaluation from October 2010 which showed a heart rate of 56, the Board does not find that this invalidates the examiner’s findings. While he failed to acknowledge this single reading during the appeal period of a heart rate under 60 beats per minute, his statement that there was no diagnosis of bradycardia during this time is not incorrect. At no time have any of the Veteran’s treating medical professionals found that she has a bradycardia disorder, and there is no evidence of any other instances of a heart beat under 60 beats per minute during the period from October 25, 2007 to May 12, 2015. The Board therefore finds that the October 2010 notation of a heart rate of 56 is an outlier, and the preponderance of the evidence shows that on many other occasions the Veteran was found to have heart rates well above 60. There is also no evidence that the Veteran had any other cardiovascular involvement during this period. The Veteran’s heart was always evaluated as normal, and she was found, on multiple occasions, to have normal heart sounds and structure, with no congestive heart failure or other abnormality. All VA examiners found the Veteran’s heart to be normal, and there is no evidence of any diagnoses or treatment for a heart disorder from October 25, 2007 to May 12, 2015 in the Veteran’s VA or private medical records. The Board has considered the holding in Tatum, and recognizes that under Diagnostic Code 7903, not all of the symptoms listed for a particular disability rating are required to be demonstrated in order to establish entitlement to a higher disability rating for hypothyroidism. See Tatum, 23 Vet. App. at 155. The Board does not find, however, that the Veteran’s symptoms, including their severity and frequency, more nearly approximate the rating for a 100 percent evaluation. See 38 C.F.R. § 4.7. While the Veteran has continuous challenges from her hypothyroidism, the Board does not find that they have impaired her heart or functional ability to such as extent that a higher rating of 100 percent is more nearly approximated. In sum, the Board finds that a 60 percent rating, but no higher, is warranted for the Veteran’s hypothyroidism from October 25, 2007 to May 12, 2015. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against assignment of a rating higher than 60 percent, that doctrine is not further applicable. See 38 U.S.C. § 5107(b). Gastroesophageal Reflux Disease The Veteran has submitted writing statements indicating that she has frequent gastritis and gastroesophageal reflux disease, which causes the feeling of an upset or nervous stomach. She wrote that she still has bouts of gastroesophageal reflux disease when she is nervous or under stress, and that it makes it hard to eat and causes feelings of pain or burning in her stomach. She has written that although she has not had vomiting, she has severe nausea and burning that radiates to her breast and back. The Veteran testified at an October 2014 hearing that she had pain that radiated to her back, and that she treats it with antacids. She stated that she had not taken time off from work due to gastroesophageal reflux disease. Her spouse submitted a statement in May 2012 describing how her gastroesophageal reflux disease caused her burning pain and discomfort and that she does not eat very well when she has symptoms. In a May 2008 rating decision, entitlement to service connection for gastroesophageal reflux disease was granted and assigned a noncompensable (0 percent) rating, effective October 25, 2007. In a March 2012 rating decision, the Veteran’s rating for gastroesophageal reflux disease was increased to 10 percent, effective May 10, 2011. In an October 2015 rating decision, the Veteran’s evaluation was increased to 30 percent, effective May 13, 2015. Diseases of the digestive system are rated under 38 C.F.R. § 4.114. Gastroesophageal reflux disease is not a disease specifically listed in the rating schedule. It is instead rated by an analogy to a listed disorder, based on the functions affected, anatomical localization, and symptomatology. 38 C.F.R. § 4.20. The provisions of Diagnostic Code 7346, for evaluation of a hiatal hernia, have been applied here. Under Diagnostic Code 7346, hiatal hernia is assigned a 10 percent rating with two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent rating is assigned when there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent rating requires symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, Diagnostic Code 7346. The Board has reviewed all of the evidence of record, and finds that a 10 percent rating is warranted for the initial stage of October 25, 2007 to May 10, 2011. The Veteran has credibly asserted throughout the appeal period that she has had heartburn and stomach pain which radiates to her back and her substernal region. This constitutes two of the listed symptoms under the criteria for a 30 percent rating under Diagnostic Code 7346, pyrosis (heartburn) and substernal pain, which allows for a rating of 10 percent. Id. The preponderance of the evidence does not demonstrate, however, that a rating higher than 10 percent is warranted for the period from October 25, 2007 to May 12, 2015. A 30 percent rating requires findings of persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, and which is productive of considerable impairment of health. Id. While the evidence shows that the Veteran had recurrent epigastric distress with pyrosis and substernal pain, there is no evidence of any dysphagia or regurgitation, and the condition was not found to be productive of considerable impairment of health. At a January 2008 VA examination, the Veteran reported that in 1999 she began to have burning in her chest and stomach and that she treated it with antacids. She had no incapacitation, abdominal colic, nausea, vomiting, burning pain, hematesis or melena, or anemia. The examiner found that her gastroesophageal reflux disease was controlled, with no effect on daily activities. In April 2008, the Veteran was treated for epigastric pain and a burning sensation in her stomach, but she denied vomiting, diarrhea, constipation, or bloody stool. At a May 2011 VA examination, the Veteran reported that she takes antacids which provides some relief, but still has burning pain that radiates to middle of her back, with stomach bloating and variable bowels. She had daily substernal pain, nausea caused by certain foods or reclining, but no nausea, dysphagia, regurgitation, vomiting, or anemia. There was frequent moderate substernal pain. Physical examination found moderate epigastric and right upper quadrant tenderness, with some voluntary guarding. There were no masses or organomegaly. The condition had only mild effects on exercise and recreation, and her overall general health was fair. This evidence indicates that while the Veteran had burning and radiating pain, as well as some bloating, there were no more serious symptoms which would more nearly approximate the criteria for a 30 percent rating. The Veteran was not found, at any time, to have had dysphagia or regurgitation, and at no time was it ever found that the condition had considerable impairment on her health. The January 2008 VA examiner found that it had no effects on her daily activities, and the May 2011 VA examiner found that it had only mild effects on exercise and recreation. The Veteran has not provided any other examples of additional symptoms or impact on her general health during this period between 2007 and 2015, and the Board finds that a rating higher than 10 percent for the period from October 25, 2007 to May 12, 2015 is not warranted. Since May 13, 2015, the Board finds that a rating higher than 30 percent is not warranted. To assign a higher rating of 60 percent, a veteran must demonstrate symptoms of pain, vomiting, material weight loss, and hematemesis or melena with moderate anemia; or have other symptom combinations productive of severe impairment of health. Id. At a May 2015 VA examination, the Veteran reported having a burning sensation in her chest or belching acidity taste. She stated that she was sensitive to certain foods that are greasy or spicy. She had symptoms of epigastric distress, pyrosis, reflux, and substernal pain. The condition did not impact her ability to work. This examination provides evidence that the Veteran had symptoms of epigastric distress, pyrosis, regurgitation, and substernal pain, and that she had to avoid certain foods, but she did not have vomiting and was not found to have weight loss or anemia due to her gastroesophageal reflux disease. There was no finding that the condition was productive of severe impairment to her health, and the condition did not impact her ability to work. The Veteran’s VA treatment records do not indicate any other complaints or symptoms related to gastroesophageal reflux disease, and the Veteran has not testified as to any other additional symptoms or treatment that she has had since May 2015. There is no other medical evidence of record indicating any other symptoms or collective impact of symptoms from gastroesophageal reflux disease which were more severe than shown at the May 2015 VA examination or which would cause severe impairment to the Veteran’s health, and the criteria for a 60 percent rating since May 13, 2015 for gastroesophageal reflux disease have not been met. The Board does not dispute the credibility of the statements from the Veteran regarding having discomfort, pain, and nausea related to her gastroesophageal reflux disease. See Jandreau, 492 F.3d at 1376-77 (Fed. Cir. 2007). Accepting the Veteran’s statements is part of the basis for the increased 10 percent rating for the period from October 25, 2007 to May 10, 2011. A higher evaluation of 30 percent is not warranted under this evaluation unless there are additional symptoms, such as dysphagia and regurgitation, and the condition is productive of considerable impairment of health. As the medical evidence does not demonstrate that the Veteran had these symptoms or that the condition caused considerable impairment of her health, nor has she asserted that it had, an evaluation of 30 percent from October 25, 2007 to May 12, 2015 is not warranted. The Veteran also has not asserted that she has had any vomiting, material weight loss, hematemesis, melena, or anemia since May 13, 2015 due to her gastroesophageal reflux disease. At the November 2014 Board hearing, she specifically denied that these were symptoms caused by her gastroesophageal reflux disease, and she testified that she did have weight loss and anemia, but that these disorders were related to her hypothyroidism. She has never reported any vomiting related to this disorder, nor has she asserted that it causes severe impairment of her health. The Board therefore finds that a rating higher than 30 percent since May 13, 2015 is not warranted, and is consistent with the Veteran’s own reports about her symptoms and health. In sum, the Board finds that a 10 percent rating can be assigned for the initial stage of the appeal for a higher rating for gastroesophageal reflux disease, October 25, 2007 to May 10, 2011, but a rating higher than 10 percent from October 25, 2007 to May 12, 2015 or a rating higher than 30 percent since May 13, 2015 is not warranted. In reaching this conclusion, the Board has again considered the applicability of the benefit of the doubt doctrine, but finds that the preponderance of the evidence is against the assignment of any ratings higher than those now assigned. See 38 U.S.C. § 5107(b). Lastly, the question of entitlement to referral for consideration of an extraschedular rating is neither an issue argued by the claimant nor reasonably raised by the record through evidence of the collective impact of the claimant’s service-connected disabilities. Yancy v. McDonald, 27 Vet. App. 484, 494 (2016). DEREK R. BROWN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Mary E. Rude, Counsel