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Executive Summary
Pages 1-10

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From page 1...
... ask the Institute of Medicine (IOM) to convene a committee that would identify a method for assessing treatment effectiveness and describe already-validated treatments for Gulf War veterans' health problems, including the problem of medically unexplained symptoms.
From page 2...
... . Reported symptoms experienced by Gulf War veterans include fatigue, joint and muscle pain, headache, memory loss, depression, anxiety, respiratory problems, and diarrhea (Perconte et al.
From page 3...
... The task force gave greater weight to those study designs that, for methodological reasons, are less subject to bias and inferential error (USPHSTF 1996~. In evaluating treatments for Gulf War veterans, the committee chose to recommend as effective only those treatments with demonstrated efficacy using the highest level of evidence the randomized controlled trial (Level I of the USPHSTF scale)
From page 4...
... The best, strongest studies in tightly controlled situations may, however, lack generalizability to routine medical practice. · Treatment effectiveness studies, including the largest and most comprehensive outcomes studies, emphasize external validity often at the expense of internal validity.
From page 5...
... The above hierarchy implies that when the focus of evaluation is on treatment effectiveness, and in the absence of RCTs specifically designed to assess effectiveness in real-world settings, evidence from well-designed outcomes studies may provide Level I or Level II evidence and serve as the basis for clinical policies and treatment guidelines. Therefore, in conducting treatment effectiveness research, the committee recommends that the VA: · use a hierarchy of evidence structure that includes effectiveness studies as well as efficacy studies for any future treatment guidelines it develops for symptoms or illnesses of Gulf War veterans; · design future studies of treatment effectiveness that include outcomes research and effectiveness randomized clinical trials; and · develop a standard language for describing Gulf War veterans' symptoms, including their severity and temporal patterns, and that this
From page 6...
... CONDITION-SPECIFIC TREATMENTS Results of studies on conditions with unknown etiology may not generalize directly to Gulf War veterans whose similar symptoms may have a different etiology. However, given currently available diagnostic information and the lack of effectiveness studies conducted on Gulf War veterans, identification of effective treatments for such conditions as these may offer the best opportunity for alleviating the health problems of Gulf War veterans.
From page 7...
... The goals are to elicit the patient's problems and history with an eye toward making a diagnosis, to negotiate a treatment regimen that the patient will accept and that is congruent with recognized medical practice, and to teach the patient about managing his/her disease and treatment regimen so that it may be effectively implemented. Therefore, the committee recommends that the VA: · provide specific training to health care providers caring for Gulf War veterans to ensure that they are skilled in the principles and practice of patient-centered care and · ensure that health care practitioners serving Gulf War veterans are allowed sufficient time with patients to provide patient-centered care.
From page 8...
... , the committee recommends the following treatments: · pharmacological management of acute episodes, using agents listed in Table 5-6, taking into consideration the clinical effectiveness and potential side effects, as listed; · prophylactic pharmacological management for headaches that occur frequently or are disruptive to the patient's functioning, as listed in Tables 5-7 and 5-8, taking into consideration the clinical effectiveness and potential side effects, as listed; . use of behavioral and physical treatments, including relaxation training, thermal biofeedback combined with relaxation training, EMG biofeedback and cognitive behavioral therapy, or behavioral therapy combined with preventive drug therapy.
From page 9...
... Medically For Gulf War veterans with unexplained symptoms, the unexplained committee recommends that: symptoms · for the purposes of treatment efficacy and effectiveness studies, explicit criteria for medically unexplained , ~ ., ~ physical symptoms (apart from chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) be developed and used uniformly in treatment studies and · treatment studies of antidepressant medications, cognitive behavioral therapy, and a stepped intensity-of-care program be implemented for medically unexplained symptoms.
From page 10...
... Much has yet to be learned about ways to prevent, or at least mitigate, health problems associated with deployment. While research into consequences of war-related illnesses and deployment-related health effects proceeds, we are faced with the task of providing effective treatments to those who are suffering from difficult-to-diagnose, ill-defined, or unexplained illnesses.


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