Adequacy of the Comprehensive Clinical Evaluation Program Nerve Agents (1997) / Chapter Skim
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APPENDIX A
APPENDIX A
Pages 23-43
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Appendixes
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APEX A Recommendations of me Inked CCEP Commblee 25
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Evaluation of the U.S. Department of Defense Persian Gulf Comprehensive Clinical Evaluation Program: Overall Assessment and Recommendations Committee on the DoD Persian Gulf Syndrome Comprehensive Clinical Evaluation Program Division of Health Promotion and Disease Prevention INSTITUTE OF MEDICINE Washington, D.C.
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It would require regional medical center physicians to provide adequate quality assurance of MTF work-ups and timely feedback to MTF providers.
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The decision to refer to Phase II should be based on the clinical judgment of the primary care physician, which, in turn, would be dependent on the clarity of the patient's diagnoses and the feasibility of the proposed treatment program at the MTF level. The DoD should continue its goal of enhanced accessibility of RMC physicians to allow regular consultations with MTF primary care physicians on patients with more complex diagnoses.
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2.2.2.) Alert primary care physicians about the high prevalence of psychiatric disorders: Two methods that have been proposed by RMC physicians to expedite the scheduling of psychiatric evaluations would be (1)
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There is a lack of clinical evidence of a unique Persian Gulf Syndrome: The committee agrees with DoD that there is currently no clinical evidence in the CCEP of a previously unknown, serious illness among Persian Gulf veterans. If there were a new or unique illness or syndrome among Persian Gulf veterans that could cause serious impairment in a high proportion of veterans at risk, it would probably be detectable in the population of 10,020 CCEP patients.
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Discuss the issue of causality explicitly and unambiguously in its future reports: Physicians involved with the development and the administration of the CCEP have, in various public presentations, acknowledged that some CCEP patients have developed illnesses that are directly related to their service in the Persian Gulf. The recent DoD report on 10,020 CCEP participants, however, only touches on this issue indirectly.
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The CCEP patients, as well as their primary care physicians, also need to understand the prevalence of and the concomitant morbidity that result from psychiatric disorders in the
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The DoD should consider establishing detailed guidelines for the psychiatric evaluations and should attempt to obtain greater standardization of these evaluations among the various hospitals across the country. These guidelines could provide suggested procedures for the use of selected self-report instruments for the assessment of the most commonly diagnosed disorders, as well as procedures for more in-depth structured clinical interviews when indicated.
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3.2.1.11.) Utilize results of on-going studies to revise CCEP: It is possible that the DoD will be able to use the results of on-going epidemiologic studies on psychiatric conditions to revise the CCEP, that is, to revise the standardized questionnaires or to add or delete targeted lab tests or specialty consultations.
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Provide more details of diagnostic categorization of musculoskeletal conditions: The draft and final DoD reports on 10,020 CCEP patients do not provide adequate details for the IOM committee to make a thorough evaluation of the diagnostic categorization of musculoskeletal conditions. More explanation about the diagnostic aspects of these musculoskeletal conditions would be useful, for example, information on singlejoint involvement versus multijoint conditions or articular versus non-articular conditions.
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Estimating prevalence of chronic fatigue syndrome, fibromyalgia, and multiple chemical sensitivity is difficult: The IOM committee's review of the CCEP protocol suggests that data on chronic fatigue syndrome (CFS) , fibromyalgia (FM)
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3.3.1.2.) Distribute CCEP findings to all primary care physicians at MTFs and RMCs: The medical findings of the CCEP should be distributed promptly to all primary care physicians at the MTFs and RMCs.
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Use CCEP examination results to improve standardization practices: The DoD now has results on the examinations of more than 10,000 CCEP patients, which could be used to improve the standardized questionnaires, lab tests, and specialty consultations.
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In addition, the final disposition of these cases could be evaluated, including the potential relationship between particular diseases and Persian Gulf service. The DoD could use the results of these disability determinations to predict which diseases are likely to be associated with the most impairment among CCEP patients in the future.
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Medical staff at the SCC will need to know whether a particular therapeutic plan is feasible at the patient's nearest MTF and whether long-term follow-up care can be performed. The primary care physician at the MTF needs to encourage continuous patient compliance with the carefully designed, individualized therapeutic regimens.
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Perhaps some of these elements could be disseminated and integrated into existing MTF programs that are close to where CCEP patients live and work.
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Epidemiological Research Relevant to the CCEP: 3.4.1.1.) Utilize on-going epidemiological studies for revising or improving the CCEP: The results of on-going epidemiological studies may be useful for making revisions or improvements in the CCEP medical protocol itself, for example, to revise the standardized questionnaires or to add or delete targeted lab tests.
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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 Mahmoud,* 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.
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