motor measures as determined with neurobehavioral testing. But studies of returning Gulf War veterans with at least one commonly reported symptom (fatigue, memory loss, confusion, inability to concentrate, mood swings, somnolence, gastrointestinal distress, muscle and joint pain or skin or mucous-membrane complaints) demonstrated poorer performance on cognitive tests than by returning Gulf War veterans who did not report such symptoms. Most of those studies did not include control groups (or in some cases valid control groups) so it is not possible to determine whether the combination of symptoms and neurocognitive-test decrements is uniquely associated with Gulf War service.

Several studies focused on multisymptom-based medical conditions: fibromyalgia, CFS, and MCS. Those conditions have several features in common: they do not fit a precise diagnostic category; case definitions are symptom-based (supplemented, in the case of fibromyalgia, by report of pain on digital palpation of tender points in a physical examination); there are no objective criteria independent of patient reports, such as laboratory test results, for validating the case definitions; and the symptoms among those syndromes are to some extent overlapping. Gulf War-deployed veterans report higher rates of symptoms that are consistent with the case definitions of MCS, CFS, and fibromyalgia.

Several large or population-based studies of Gulf War veterans found, by questionnaire, that the prevalence of MCS-like symptoms ranged from 2% to 6%. However, no two of the primary studies used the same definition of MCS, so it is difficult to compare them, and none performed medical evaluations to exclude other explanations, as would be required by the case definition of MCS.

The prevalence of CFS among Gulf War veterans is highly variable from study to study; most studies used the Centers for Disease Control and Prevention case definition. One primary study demonstrated a higher prevalence of CFS in deployed than in nondeployed veterans (1.6% vs 0.1%). Secondary studies also showed a higher prevalence of CFS and CFS-like illnesses among veterans deployed to the Persian Gulf than in to their counterparts who were not deployed or who were deployed elsewhere.

The diagnosis of fibromyalgia is based on symptoms and a very limited physical examination that consists of determining whether pain is elicited by pressing on several points on the body; there are no laboratory tests with which to confirm the diagnosis. Only one of the available cross-sectional studies included both Gulf War-deployed and -nondeployed veterans and used the full American College of Rheumatology case definition of fibromyalgia, including the physical-examination criteria. It found a statistically significant difference in prevalence of fibromyalgia between deployed and nondeployed veterans (2.0% vs 1.2%). Other studies using a case definition based on symptoms alone reported inconsistent results.

Other symptoms that are self-reported more often by deployed veterans are gastrointestinal symptoms, particularly dyspepsia; dermatologic conditions, particularly atopic dermatitis and warts; and joint pains.

There were many reports of gastrointestinal symptoms in Gulf War-deployed veterans. Those symptoms seem to be linked to reports of exposures to contaminated water and burning of animal waste in the war theater. The committee notes that several studies reported a higher rate of self-reported dyspepsia in deployed Gulf War veterans than in nondeployed veterans. In the context of nearly all symptoms being reported more frequently for Gulf War veterans, it is difficult to interpret those findings.

For dermatologic conditions, a few studies have included an examination of the skin and thus would be more reliable than self-reports. Those studies have reported that a few unrelated



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