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Evaluation of the U.S. Department of Defense Persian Gulf Comprehensive Clinical Evaluation Program Committee on Me DoD Persian Gulf Syndrome Comprehensive Clinical Evaluation Program Division of Heath Promotion and Disease Prevention INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1996

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NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competencies and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by the Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is the president of the Institute of Medicine. This study was supported by the U.S. Department of Defense under Contract Number DADA 15-94-C-0126. The views presented are those of the Institute of Medicine Committee on the DoD Persian Gulf Syndrome Comprehensive Clinical Evaluation Program and are not necessarily those of the funding organization. Additional copies of this report are available in limited quantities from: Division of Health Promotion and Disease Prevention 2101 Constitution Avenue, N.W. Washington, DC 20418 Call (202) 334-2383 for more information. Copyright 1996 by the National Academy of Sciences. All rights reserved. Printed in the United States. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logo-type by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemusseen in Berlin.

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COMMITTEE ON THE DOD PERSIAN GULF SYNDROME COMPREHENSIVE CLINICAL EVALUATION PROGRAM Gerard Burrow,* Chair, Dean, Yale University School of Medicine, New Haven, Connecticut Dan Blazer,* Dean of Medical Education and Professor of Psychiatry, Duke University Medical Center, Durham, North Carolina Margit Bleecker, Director, Center for Occupational and Environmental Nuerology, Baltimore, Maryland Ralph Horwitz, Chairman, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut Howard Kipen, Associate Professor and Director, Occupational Health Division, Robert Wood Johnson Medical School, Piscataway, New Jersey Adel Mah~noud,* Chairman, Department of Medicine, Case Western Reserve University and University Hospitals of Cleveland, Cleveland, Ohio Michael Osterholm, State Epidemiologist, Minnesota Department of Health, Minneapolis, Minnesota Robert Pynoos, Professor of Psychiatry, University of California at Los Angeles, Los Angeles, California Anthony Scialli, Associate Professor, Department of Obstetrics and Gynecology, Georgetown University Medical Center, Washington, D.C. Rosemary Sokas, Associate Professor of Medicine, Division of Occupational and Environmental Medicine, George Washington University School of Medicine, Washington, D.C. Guthrie Turner, Chief Medical Consultant, Division of Disability Determination Services, State of Washington, Tummwater, Washington Michael Weisman, Professor, Division of Rheumatology, University of California at San Diego Medical Center, San Diego, California Staff Michael A. Stoto, Director, Division of Health Promotion and Disease Prevention Kelley A. Brix, Study Director Deborah Katz, Research Assistant Amy Noel O'Hara, Project Assistant Donna D. Thompson, Division Assistant Mona Brinegar, Financial Associate ~Member, Insititute of Medicine . . .

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Contents EXECUTIVE SUMMARY INTRODUCTION . GOALS AND PROCEDURES OF THE CCEP Overview, 5 Committee Assessment of the Overall Goals and Procedures of the CCEP, 6 IMPLEMENTATION OF THE CCEP ................ Referrals of Patients from Phase I to Phase II of the CCEP, 7 Systematic Guidelines for Psychiatric Referrals and Adequacy of Psychiatric Resources, 8 ANALYSIS AND INTERPRETATION OF THE RESULTS OF THE CCEP Symptoms and Diagnoses in the CCEP Population, 9 Clinical Evidence of a New, Unique Persian Gulf Syndrome, 11 Potential Relationship of Illnesses in CCEP Patients to Service in the Persian Gulf, 12 Comparison of the CCEP Population with Other Populations, 13 SPECIFIC MEDICAL DIAGNOSES Psychiatric Conditions, 15 7 ... 9 v

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V1 CONTENTS Prevalence and Impact of Psychiatric Conditions Among CCEP Patients, 15 Standardization of Psychiatric Evaluations in the CCEP, 17 Recognition of Psychosocial Stressors in the CCEP Population, 18 Musculoskeletal Conditions, 20 Signs, Symptoms, and Ill-Defined Conditions, 21 Infectious Diseases, 21 Chronic Fatigue Syndrome, Fibromyalgia, and Multiple Chemica Sensitivity, 23 USE OF THE CCEP RESULTS FOR EDUCATION, IMPROVEMENTS IN THE MEDICAL PROTOCOL, AND OUTCOME EVALUATIONS .................................... Use of the CCEP Results for Education, 24 Use of the CCEP Results to Improve the Medical Protocol, 25 Use of the CCEP Results for Patient Outcome Evaluations, 26 Specialized Care Center, 27 Overview of the Goals, Structure, and Early Progress of the SCC, 27 Committee Comments on the Goals, Structure, and Early Progress of the SSC, 28 EPIDEMIOLOGIC RESEARCH RELEVANT TO THE CCEP Exposure Assessment Research Relevant to the CCEP, 30 Health Outcome Research Relevant to the CCEP, 31 REFERENCES .............................. APPENDIXES A Agendas for the Four Meetings of the IOM Committee on the DoD Persian Gulf Syndrome Comprehensive Clinical Evaluation Program ...... .......... ... . .. ... . . . B Outline of the Standardized Medical Protocol: Selected Pages from the Comprehensive Clinical Evaluation (CCEP) Guide, January 5, 1995, U.S. Department of Defense 24 . 29 . 33 .. 37 . 47