Citation Nr: 21067822 Decision Date: 11/05/21 Archive Date: 11/05/21 DOCKET NO. 16-34 025 DATE: November 5, 2021 ORDER New and material evidence having been received, the petition to reopen the claim for service connection for a right wrist disability, to include healed fracture at the right distal radius with internal fixation, is granted. New and material evidence having been received, the petition to reopen the claim for service connection for a migraine headache disability is granted. Service connection for a right wrist disability, to include healed fracture at the right distal radius with internal fixation, is granted. Service connection for a migraine headache disability is granted. REMANDED The claim for service connection for gastritis (claimed as acid reflux), to include as secondary to service-connected posttraumatic stress disorder and/or irritable bowel syndrome, is remanded. The claim for service connection for obstructive sleep apnea, to include as secondary to service-connected posttraumatic stress disorder, is remanded. FINDINGS OF FACT 1. Since the final March 20, 2009, decision, new and material evidence has been received that raises a reasonable possibility of substantiating the Veteran's claim for service connection for a right wrist disability, to include healed fracture at the right distal radius with internal fixation. 2. Since the final March 20, 2009, decision, new and material evidence has been received that raises a reasonable possibility of substantiating the Veteran's claim for service connection for a migraine headache disability. 3. The Veteran's right wrist disability, to include healed fracture at the right distal radius with internal fixation, is related to an in-service injury. 4. The Veteran's migraine headache disability is related to an in-service injury. CONCLUSIONS OF LAW 1. The March 20, 2009, decision that denied service connection for a right wrist disability, to include healed fracture at the right distal radius with internal fixation, is final; however, new and material evidence has been received and, thus, the claim is reopened. 38 U.S.C. §§ 5103A, 5108, 7105; 38 C.F.R. §§ 3.156, 19.52, 20.1103. 2. The March 20, 2009, decision that denied service connection for a migraine headache disability is final; however, new and material evidence has been received and, thus, the claim is reopened. 38 U.S.C. §§ 5103A, 5108, 7105; 38 C.F.R. §§ 3.156, 19.52, 20.1103. 3. The criteria for service connection for a right wrist disability, to include healed fracture at the right distal radius with internal fixation, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for a migraine headache disability are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from September 2005 until his honorable discharge in February 2009, with service in Iraq from August 2006 to November 2007. Relevant to this appeal, the Veteran filed claims for service connection for a right wrist disability and migraines in December 2008. A Regional Office of the United States Department of Veterans Affairs (VA) issued a March 20, 2009, decision denying service connection for each claim. The VA Regional Office notified the Veteran of the denial by correspondence dated March 23, 2009. That decision became final as new and material evidence was not received within one year of notification of the decision and an appeal was not otherwise taken from that decision. In January 2011, the Veteran filed a claim to reopen his claims for service connection for a right wrist disability and migraines. In addition, he filed claims for service connection for gastritis and obstructive sleep apnea. Most recently, a VA Regional Office issued a December 2013 decision confirming and continuing denial of service connection for each claimed disability. The Veteran filed a timely Notice of Disagreement and Substantive Appeal to the Board of Veterans' Appeal from the December 2013 decision. In August 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. Evidentiary Standards In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. When 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. § 5107(b). To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The law requires the Board address its reasons for rejecting evidence favorable to the Veteran. Timberlake v. Gober, 14 Vet. App. 122, 12829 (2000). The Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence within the period on appeal and on what this evidence shows, or fails to show, on the claims. New and Material Evidence To appeal a rating decision, the appellant must file a "notice of disagreement" "within one year from the date of the mailing of notice of the decision of the agency of original jurisdiction." 38 U.S.C. § 7105(b)(1)(A); 38 C.F.R. § 19.2(c). A notice of disagreement must be submitted in writing and identify the specific determination with which the claimant disagrees. 38 U.S.C. § 7105(b)(2)(A). If no notice of disagreement is filed within the prescribed period, the action or decision of the agency of original jurisdiction becomes final from the date notice was mailed. 38 U.S.C. § 7105(c). For the purposes of reopening claims decided by the agency of original jurisdiction (AOJ) before February 19, 2019 (the effective date of the Veterans Appeals Improvement and Modernization Act of 2017), such claims are still considered "legacy appeals" and are to be analyzed under VA's traditional "Legacy" process. See 38 C.F.R. § 3.156(a); 38 C.F.R. § 3.2400(b). Under the Legacy process, a veteran "may reopen a finally adjudicated legacy claim by submitting new and material evidence." 38 C.F.R. § 3.156(a). Here, the Veteran's claims for service connection for a right wrist disability and migraines were finally adjudicated by a VA Regional Office on March 23, 2009 (the date of notification of the decision), thus, the "new and material evidence" standard applies. Regardless of the VA Regional Office's determination as to whether new and material evidence was received, the Board must address the issue in the first instance because it ultimately affects the Board's jurisdiction to adjudicate the underlying claims. See Woehlaert v. Nicholson, 21 Vet. App. 456, 46061 (2007) (citation omitted). The Board must perform a two-step analysis when a veteran seeks to reopen a final decision based on new and material evidence. See Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). First, it must determine whether the evidence presented or secured since the last final disallowance is "new and material." Id. If it is, the Board must then reopen the claim and "evaluate the merits of the veteran's claim in light of all the evidence, both new and old." Id. "New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim and must raise a reasonable possibility of substantiating the claim." 38 C.F.R. § 3.156(a). The language of section 3.156(a) "does not require new and material evidence as to each previously unproven element of a claim"; instead, it compels reopening whenever a claimant submits new and material evidence "as to an unestablished fact from the previously denied claim." Shade v. Shinseki, 24 Vet. App. 110, 121 (2010). In Shade, the Court held that the language of section 3.156(a), requiring the new evidence raise a reasonable possibility of substantiating the claim, is an analytical guide that creates a low threshold rather than a separate element. Id. at 117. In determining whether the low threshold is met, however, VA should consider whether the new and material evidence could, if the claim were reopened, reasonably substantiate the claim, to include triggering VA's duty to assist or through consideration of an alternative theory of entitlement not previously established by the evidence, id. at 11719, but not including "presentation of new arguments based on evidence already of record at the time of the previous decision," Untalan v. Nicholson, 20 Vet. App. 467, 470 (2006) (emphasis added). "New evidence" "is evidence not previously part of the actual record before agency adjudicators." 38 C.F.R. § 3.156(a). VA is required to presume the credibility of newly submitted evidence for the purposes of determining whether that evidence is material and sufficient to reopen a previously denied claim. Justus v. Principi, 3 Vet. App. 510, 513 (1992). "Material evidence" means "evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim." 38 C.F.R. § 3.156(a). Since the VA Regional Office's March 2009 decision, VA has associated numerous medical records with the Veteran's claims file, including VA examinations addressing the Veteran's right wrist disability and migraine headache disability. He has also offered testimony as to his claimed disabilities. This evidence is new. Rather than addressing the individual evidence with respect to each claim to reopen, the Board finds it suffices to say that the primary unestablished fact for each claim for service connection is a nexus between the disability and military service. The new evidence of record raises a reasonable possibility of substantiating each claim because it relates to a nexus for each claim. Therefore, the Board finds reopening of each claim for service connection is warranted. 38 C.F.R. § 3.156(a). Service Connection VA provides compensation for a disability resulting from disease or injury incurred in or aggravated by service. This is referred to as a "service connection." 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to be entitled to service connection there must be competent, credible evidence of (1) a current disability, (2) an in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). When these elements are satisfied, service connection may be granted on a direct basis. 1. Service connection for a right wrist disability, to include healed fracture at the right distal radius with internal fixation. First element: A current disability Based on a July 2009 CT scan of the Veteran's right wrist, a VA physician diagnosed him with partial nonunion fracture of lunate with sclerotic changes on volar aspect. The physician opined his scan was most consistent with posttraumatic avascular necrosis involving the lunate bone. In May 2010, he underwent right radial shortening osteotomy surgery on his right wrist. During a July 2012 VA examination, a VA examiner diagnosed the Veteran with osteonecrosis of the lunate of the right wrist. "Osteonecrosis is a disease caused by reduced blood flow to bones in the joints, . . . which causes the bone to break down faster than the body can make enough new bone. The bone starts to die and may break down." Osteonecrosis, MedlinePlus Medical Encyclopedia, U.S. National Library of Medicine, https://medlineplus.gov/osteonecrosis.html (last visited Oct. 25, 2021). The Veteran's medical records also indicate right wrist functional loss and pain status post surgery. See Saunders v. Wilkie, 886 F.3d 1356 (2018) (pain alone can qualify as a disability where it diminishes the body's ability to function under the ordinary conditions of daily life including employment, even where it is not diagnosed as connected to a current underlying condition). Based on this credible and probative evidence, the Board finds the Veteran has a current disability. Therefore, the first element is satisfied. Second element: An in-service event, injury, or illness, or aggravation thereof The Veteran has continuously asserted that his initial right wrist disability, and the resulting surgical residuals, resulted from an in-service traumatic event. Specifically, he has repeatedly stated and testified that during active service a radio fell on his right hand and wrist causing pain and damage. As this event occurred during his service in Iraq, he was unable to have X-rays done immediately. The Board observes a December 2006 in-service treatment record documented the Veteran's medical treatment for his right wrist. The medical professional recorded that the Veteran reported his right hand was injured when a radio fell on it. The Veteran reported that the event occurred in November 2006. He reported being seen numerous times at his local aid station, but he was unable to have X-rays done. He said he was prescribed pain medication. The medical professional documented pain and functional loss associated with the Veteran's right hand and wrist. The Board finds the Veteran's statements to medical professionals and testimony at his August 2021 before the Board highly credible and probative. The Board also finds the December 2006 in-service treatment record is significantly credible and probative. Accordingly, the Board finds that the Veteran suffered a traumatic right wrist/hand injury in service. Therefore, the Board finds that the second element, and in-service event and/or injury, is satisfied. Third element: A causal link No VA medical professional provided an adequate opinion as to whether the Veteran's right wrist disability, from the time he filed his initial claim for service connection in 2008 to the present, was due to the injury he sustained to his right wrist/hand in service. Nor was any medical professional asked to opine whether the Veteran's right wrist disability progressively worsened to the point he needed surgery, and whether the resulting residuals from his surgery were etiologically related to his in-service injury. At most, an April 2017 VA examiner opined that he was "unable to state with 50% or greater probability that [the Veteran's] aseptic necrosis of wrist was service connected." He reasoned that "aseptic necrosis of the lunate bone is generally felt to be idiopathic or no known cause according to review of medical literature." The opinion is not necessarily a negative opinion because of the way it was worded, i.e., the examiner was not saying the Veteran's disability could not be service connected, just that the examiner could not say with 50 percent or greater certainty that it was in this case. Nevertheless, the examiner also stated that the Veteran's disability "can also be caused by trauma." The Board interprets this opinion as providing some basis to say that service connection could be warranted due to the Veteran's in-service right wrist trauma. Of significant importance to the Board are the Veteran's own statements about the continuous nature of his symptoms, pre-surgery, associated with his right wrist. See Savage v. Gober, 10 Vet. App. 488, 497 (1997) (holding that lay evidence of continuing symptoms of a disability following service can be sufficient to demonstrate a medical nexus between a current disability and an in-service event or injury, even where there is no medical opinion establishing that nexus). Since his honorable discharge from the military, the Veteran repeatedly told treating medical professionals that he continued to have pain, weakness, incoordination, and function loss in his right wrist/hand. See, e.g., August 2009, September 2009, October 2009, May 2010 VA Orthopedic Surgery Consult Notes. The Board finds the Veteran's VA medical records credibly document his right wrist symptoms. Overall, the Board finds the evidence of chronicity highly credible and probative such that it leads the Board to conclude that the Veteran's pre-surgical right wrist symptoms resulted from his in-service right wrist/hand injury. Notably, there is no evidence of any reasonable intervening event that affected the Veteran's right wrist. Consequently, the Veteran's right wrist symptoms necessitated his surgery. Thus, his current residuals, which are a result of his surgery, are reasonably connected to his in-service injury. Therefore, the third element is satisfied. Accordingly, the Board finds service connection is warranted for a right wrist disability, to include healed fracture at the right distal radius with internal fixation. 2. Service connection for a migraine headache disability. First element: A current disability The Veteran has received multiple VA examinations in association with his claim for service connection for migraine headaches. The VA examiners have diagnosed the Veteran with migraines, including migraine variants, since 2009. The Veteran's VA medical records also include multiple diagnoses of migraines and continuous treatment for migraines. Based on this credible and probative evidence, the Board finds the first element is satisfied. Second element: An in-service event, injury, or illness, or aggravation thereof The Veteran has stated to multiple examiners and has testified before the Board that during his active military service he was struck in the head by a 240-machine gun when it fell from the top of the vehicle he was traveling in when he exited. He stated that he began suffering headaches since that incident. The Board notes that during his November 2008 separation examination, he reported frequent migraines. In addition, the Veteran's in-service treatment records document that he suffered a concussion following a motor vehicle accident in December 2008 while on leave, which resulted in frequent headaches thereafter. In addition to his in-service medical records, the Board finds the Veteran's statements to VA medical professionals and his testimony before the Board credible and probative. Therefore, the Board finds the second element, an in-service event/injury, is satisfied. Third element: A causal link To date, no VA examiner who has assessed the Veteran has opined that his migraines were a direct result of his head injury(-ies) in service. Rather, the VA examiners have only focused on the Veteran's exposure to environmental hazards in Southwest Asia as a potential cause of his migraines. Nonetheless, the Board finds there is sufficient evidence within his VA medical records to find a reasonable causal link between his in-service injuries and present migraines. Most significant, the Veteran's VA medical records document continuous treatment for a traumatic brain injury. In October 2010, the Veteran received a VA Traumatic Brain Injury Consult. During the evaluation, the Veteran reported suffering a head injury following a 240-machine gun falling on his head and following a motor vehicle accident. The VA nurse practitioner documented the in-service events, the Veteran's continuous symptoms, and conducted a thorough evaluation. She opined that the Veteran did sustain a traumatic brain injury in service from his cited events. The Veteran has received continuous treatment for his migraines since the October 2010 VA medical assessment to the present. The Board finds this evidence highly credible and probative. The Veteran's report of migraines at the time of separation examination in 2008 when coupled with his 2010 diagnosis of a traumatic brain injury due to his military in-service events establishes that his present migraines have been continuous since service and are reasonably linked to his active military service. See Savage, 10 Vet. App. at 497. Therefore, the Board finds the third element is satisfied. Accordingly, service connection for a migraine headache disability is warranted. REASONS FOR REMAND 1. Service connection for gastritis (claimed as acid reflux), to include as secondary to service-connected posttraumatic stress disorder and/or irritable bowel syndrome, is remanded. 2. Service connection for obstructive sleep apnea, to include as secondary to service-connected posttraumatic stress disorder, is remanded. In addition to "direct" service connection, service connection may also be established on a secondary basis for a disability which is proximately due to or the result of, or aggravated by, a service-connected disability. 38 C.F.R. § 3.310(a), (b). Establishing service connection on a secondary basis requires evidence sufficient to show: (1) a current disability exists, (2) the veteran has a service-connected disability; and (3) the current disability was either (a) proximately due to or the result of; or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439, 448 (1995). Where aggravation is the relied upon theory, compensation may only be provided to that degree over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); Allen, 7 Vet. App. at 448. First, the Board finds that, consistent with its duty to assist, 38 C.F.R. § 3.159, remand is required to ensure the Veteran's entire VA medical records are associated with his claims file. The Board observes that the Veteran has continuously received VA medical treatment since 2009 to the present, and his medical records are part of his claims file. But there are no VA medical records associated with his claims file from January 2018 to March 2019, an approximate 13-month gap. The Board finds such records likely exist in light of his other VA medical records. Next, VA has not attempted to obtain medical opinions addressing the potential for secondary service connection for the Veteran's claims of gastritis and obstructive sleep apnea. Rather, the VA medical examinations of record have focused on the potential exposure to environmental hazards in Southwest Asia as a possible cause. The Board finds that VA examinations and opinions must be obtained on remand to address additional theories of service connection. As to the Veteran's gastritis, a January 2015 VA Gastroenterology Note states that the Veteran's abdominal pain and gastritis were "likely related to his underlying posttraumatic stress disorder (PTSD)." A December 2015 VA examiner cited this VA Note but offered no discussion about it. The Board observes the Veteran is service connected for irritable bowel syndrome (IBS) as of May 7, 2012. Thus, it is necessary to obtain an opinion addressing whether the Veteran's acid reflux is secondary to his service-connected PTSD and/or IBS, to include any potential relation among medications the Veteran was taking for his PTSD or IBS. As to the Veteran's obstructive sleep apnea, no VA examiner has addressed the etiology of this disability other than in the context of a possible relation to exposure to environmental hazards in Southwest Asia. The Veteran's in-service medical records document that the Veteran reported issues with sleeping in 2008. His VA medical record suggest that his sleep issues may be secondary to his PTSD. Thus, it is necessary to obtain an opinion addressing whether the Veteran's obstructive sleep apnea had its onset in service or is secondary to his service-connected PTSD. Accordingly, the matters are REMANDED for the following actions: 1. Obtain any of the Veteran's outstanding VA medical records and associate them with the claims file, to include any VA medical records between January 2018 and March 2019. 2. After any additional records are associated with the claims file, obtain a VA examination from an appropriately qualified clinician to provide an opinion addressing the onset and etiology of the Veteran's gastritis. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. The examiner is asked to provide an opinion regarding: (a.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran's gastritis had its onset in or is otherwise etiologically related to an in-service event, injury, or disease. (b.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran's currently diagnosed gastritis was caused by (proximately due to or as the result of) his service-connected posttraumatic stress disorder (PTSD) and/or irritable bowel syndrome (IBS), to include use of prescribed medications to treat his PTSD and/or IBS. (c.) Whether it is at least as likely as not (a 50 percent probability or more) that the Veteran's currently diagnosed gastritis was aggravated by his service-connected posttraumatic stress disorder and/or irritable bowel syndrome, to include use of prescribed medications to treat his PTSD and/or IBS. The examiner is advised "aggravation" means any increase in the severity of the underlying disability beyond its natural progression. In rending his or her opinion, the examiner should consider and, if deemed relevant, address the following, in addition to any other relevant evidence: (a.) A January 2015 VA Gastroenterology Note that states that the Veteran's abdominal pain and gastritis were "likely related to his underlying posttraumatic stress disorder (PTSD)." In rendering any opinion, the examiner should consider the application of 38 U.S.C. § 1154(b) with respect to this Veteran. The examiner is reminded to consider the Veteran's lay statements regarding the nature and onset of his disability, including any evidence concerning continuity of symptomatology, as he is legally permitted to report his symptoms, past medical history, and experiences. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran's assertion of a gastritis in service or the assertion that the Veteran's service-connected PTSD and/or IBS led to his currently diagnosed gastritis. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). A clear and detailed rationale for the opinion(s), including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list the facts on which you relied. The examiner is informed that reliance on a lack of treatment and/or gap between discharge from military service and diagnosis of a disability, without explaining why such evidence is significant, is an insufficient rationale. The examiner is informed that the absence of contemporaneous service treatment records or medical records in general, standing alone, without explaining why such evidence is significant, is an insufficient rationale. If the examiner relies on medical treatises, the examiner should identify the treatises. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 3. After any additional records are associated with the claims file, obtain a VA examination from an appropriately qualified clinician to provide an opinion addressing the onset and etiology of the Veteran's obstructive sleep apnea. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. The examiner is asked to provide an opinion regarding: (a.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran's obstructive sleep apnea had its onset in or is otherwise etiologically related to an in-service event, injury, or disease. (b.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran's currently diagnosed obstructive sleep apnea was caused by (proximately due to or as the result of) his service-connected posttraumatic stress disorder. (c.) Whether it is at least as likely as not (a 50 percent probability or more) that the Veteran's currently diagnosed obstructive sleep apnea was aggravated by his service-connected posttraumatic stress disorder. The examiner is advised "aggravation" means any increase in the severity of the underlying disability beyond its natural progression. In rendering any opinion, the examiner should consider the application of 38 U.S.C. § 1154(b) with respect to this Veteran. The examiner is reminded to consider the Veteran's lay statements regarding the nature and onset of his disability, including any evidence concerning continuity of symptomatology, as he is legally permitted to report his symptoms, past medical history, and experiences. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran's assertion of a sleep apnea in service or the assertion that the Veteran's service-connected posttraumatic stress disorder led to his currently diagnosed obstructive sleep apnea. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). A clear and detailed rationale for the opinion(s), including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list the facts on which you relied. The examiner is informed that reliance on a lack of treatment and/or gap between discharge from military service and diagnosis of a disability, without explaining why such evidence is significant, is an insufficient rationale. The examiner is informed that the absence of contemporaneous service treatment records or medical records in general, standing alone, without explaining why such evidence is significant, is an insufficient rationale. If the examiner relies on medical treatises, the examiner should identify the treatises. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. F. Sawka, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.