UNITED STATES COURT OF APPEALS FOR VETERANS CLAIMS
No. 97-280
STEPHEN L. MCMANAWAY , APPELLANT ,
V.
TOGO D. WEST , JR.
SECRETARY OF VETERANS AFFAIRS, APPELLEE.
On Appeal from the Board of Veterans' Appeals
(Decided September 29, 1999 )
Sandra E. Booth was on the briefs for the appellant.
John H. Thompson, Acting General Counsel; Ron Garvin, Assistant General Counsel; and
Mary Ann Flynn, Acting Deputy Assistant General Counsel, were on the brief for the appellee.
Before IVERS, STEINBERG, and GREENE, Judges.
STEINBERG, Judge: The appellant, veteran Stephen L. McManaway, appeals through
counsel an October 24, 1996, decision of the Board of Veterans' Appeals (BVA or Board) denying
as not well grounded his claims for Department of Veterans Affairs (VA) service-connected
disability compensation for bilateral hearing loss and residuals of a right-knee injury. Record (R.)
at 4. The appellant has filed a brief and a reply brief, and the Secretary has filed a brief. This appeal
is timely, and the Court has jurisdiction pursuant to 38 U.S.C. §§ 7252(a) and 7266(a). For the
reasons that follow, the Court will affirm the BVA decision.
I. Background
The veteran had active service in the U.S. Army from September 1966 to September 1970.
R. at 68. He served in the Air National Guard from July 1976 to December 1992. R. at 2. His unit
was activated to participate in the Gulf War, in which he served from January 1991 to November
1991. R. at 87-89, 92. As of the time when the record on appeal (ROA) was filed, the veteran had
been awarded service connection for residuals of a left-thumb injury, carpal tunnel syndrome, and
hemorrhoids, with a combined disability rating of 10% effective February 12, 1992. R. at 407-10.
Those matters are not raised in this appeal.
In 1992, the veteran filed a claim with a VA regional office (RO) for, inter alia, service
connection for a right-knee disability and for bilateral hearing loss. R. at 95. The October 24, 1996,
BVA decision here on appeal, inter alia, denied both of those claims as not well grounded. R. at 4.
(The Board also remanded a third matter that, in light of that remand, is not before the Court. See
Marlow v. West,
11 Vet. App. 53, 55 (1998) (claims that have been remanded to the VARO are
generally not ripe for substantive review).)
A. Right-Knee Disability
As to the right-knee disability, according to medical histories provided by the veteran and
contained in VA medical records and service medical records (SMRs), he injured his right knee
before his initial period of service during a high school football game. R. at 17, 28. The veteran's
June 1966 entrance examination noted that his right knee was "normal", although he had reported
that his knee "occ[asionally] slips him". R. at 17. He was deemed to have been qualified for
induction. R. at 19. In January 1967, the veteran underwent a physical examination for the purpose
of qualification for Officer Candidate School (OCS). R. at 22-29. It was noted that he had "[i]njured
both knees" (R. at 23, 25); however, an orthopedic examination, which included an x-ray of both
knees, noted: "Views of the knees are within normal limits" (R. at 28). The impression was "old
cruciate ligament sprain, healed", and the examiner concluded that the veteran "qualifie[d] for full
duty including OCS".
Ibid.
The veteran's SMRs further indicated that in the summer of 1967, during OCS training, he
had been treated on several occasions for knee pain. R. at 31-33. At that time, he reported having
had right-knee pain for five years; however, an x-ray report stated that no abnormalities were found.
He was treated with muscle relaxants, liniments, and a knee brace, and he was temporarily placed
on limited duty.
Ibid. An orthopedic examination reported full range of motion, no locking,
questionable subluxation, tight legs, and "no internal derangement obvious at this time". R. at 33.
There are no further SMRs regarding complaints about or treatment of any knee problems during his
1966-70 period of service. See R. at 34-51.
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At the veteran's June 1970 separation physical examination, the examiner noted: "[T]rick
knee -- stated [sic] in high school . . . . Condition stated as worsening during service." R. at 54. A
subsequent orthopedic examination noted complaints of "occasional locking of [the] knees and pain
with swelling after severe exercise." R. at 57. There was no swelling or pain found on the date of
examination. Both knees were reported to be "normal". The examiner diagnosed "possible slight
weakness in [the] r[ight] anterior cruciate."
Ibid. A statement signed by the veteran on
September 17, 1970, immediately prior to his actual discharge from service, indicated that there had
"been no change" in his medical condition since the June 1970 separation examination. R. at 61.
According to the veteran's March 1994 sworn testimony to the RO, he enrolled in the
Columbus, Ohio, police academy in 1971 following his 1970 discharge, and experienced knee
problems during his training in March 1971. R. at 271. However, he was still deemed to have been
suitable for the job of police officer.
Ibid. While directing traffic in November 1977, he was struck
by a car and suffered, inter alia, a right-knee injury. R. at 73, 84. A private medical record, dated
February 1978, diagnosed him as having acute tendinitis of the right knee and ruled out internal
derangement of the right knee. R. at 70. The examining physician noted that the veteran's x-rays
were negative for a fracture or dislocation. He opined that the veteran would be able to "resume
regular duties" in approximately one month.
Ibid.
In February 1992, following his Gulf War service, the veteran filed a claim for VA
service-connected compensation for a disability of the right knee. R. at 94-97. The RO then
obtained a March 14, 1990, letter (written to an attorney representing the veteran) from a private
physician, Dr. Unverferth, who indicated that he had treated the veteran in June 1989 for "the
continued complaint of pain and swelling in his right knee." R. at 103. Dr. Unverferth stated:
Past history is significant in that Stephen McManaway has had numerous injuries to
his right knee. These injuries have necessitated two prior arthroscopic surgeries by
other surgeons, and then I performed an arthroscopic surgical procedure on
August 29, 1988. At that time, we found a very significant traumatic chondral flap
off the posterior patellar surface. This, I felt, was a direct result of a direct blow that
he had received to the anterior aspect of his knee in an auto accident.
Ibid.
Also in connection with the veteran's February 1992 claim, the RO obtained the veteran's Air
National Guard service medical records (GSMRs). In a July 1976 medical history provided by the
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veteran upon his enlistment in the Air National Guard, he checked the "NO" box as to whether he
had then or had ever had a "'[t]rick' or locked knee". R. at 120. The clinical evaluation was that his
knee was "normal". R. at 122. A May 1978 GSMR indicated that he had complained of right-knee
pain after being hit by an automobile in November 1977 and that he had had a knee operation in
1978. R. at 131. The examiner noted "[p]uncture scars" on the veteran's right knee. R. at 132. No
other knee problems were reported in his GSMRs. See 137-72.
In April 1992, the veteran underwent a VA medical examination. R. at 175-92. The
examiner noted a scar on the veteran's right knee, but found that his joints were "without erythema,
redness, or limitation of range of motion." R. at 179. The veteran was diagnosed as being obese
and having hyperlipidemia.
Ibid. An orthopedic examination noted his complaints of pain in the
right knee and diagnosed "post op injury right knee." R. at 182-83. In July 1992, the RO denied the
veteran's right-knee-disability claim. R. at 195-98.
In his June 1993 Substantive Appeal to the Board (VA Form 9), the veteran stated that,
although it was true that he had injured his right knee "prior to joining the U.S. Army in 1966", he
had "also re-injured and aggravated the injury . . . as an OCS cadet." R. at 230. He stated: "I
aggravated the knee many times while on active duty in the Army and while serving in the Air
National Guard."
Ibid. He repeated under oath at a March 1994 RO hearing essentially the same
allegations (R. at 267-73), and, after being asked whether he had had "continuing problems with the
knee" subsequent to his discharge from service (R. at 270), he responded: "Yes I have had problems
with it the rest of my life" (ibid.). In the October 24, 1996, BVA decision here on appeal, the Board
denied the veteran's knee-disability claim as not well grounded because of a lack of evidence to link
the claimed condition to his service. R. at 9-10.
B. Bilateral Hearing Loss
The veteran's SMRs for his service in the U.S. Army from September 1966 to September
1970 did not contain evidence of any hearing problems (other than an isolated November 1968
finding of wax build-up that was apparently resolved by irrigation of his ears (R. at 42-43)). See
R. at 16-62. In July 1976, upon enlistment in the Air National Guard, the veteran's hearing was
found normal. R. at 121-23.
"[H]earing loss" was first noted in an April 1978 GSMR and was apparently due to
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"problems with wax in [his] ears". R. at 131. At that time, an audiometric examination was
performed that indicated bilateral hearing loss, and an attached medical profile noted under
"INDIVIDUAL'S DEFECT (S)", "needs to use hearing protection in noise areas". R. at 133-34. Bilateral
hearing loss was also reported in GSMRs dated July 1982 (R. at 147), April 1986 (R. at 157), and
May 1990 (R. at 170-72); however, these GSMRs are silent as to etiology. At his March 1994 RO
hearing, the veteran described under oath working in the Air National Guard for "16 years" (R. at
261) beginning "during the 1980's" (R. at 273) in the vicinity of jet aircraft engines, which he
believed to be the cause of his hearing loss, and testified that he had not had any problems with his
hearing prior to that service. R. at 260-61, 273-74.
The veteran's Gulf-War SMRs for February through November 1991 were received by VA
in January 1994. R. at 283. They included a March 1991 audiometric test indicating bilateral
impaired hearing, along with the following notes: "Member is in the Air National Guard . . . and
requested a hearing exam[ination]. Discussed results with member and use of hearing [illegible]."
R. at 285. He was fitted with ear plugs, and no follow-up examination was scheduled.
Ibid.
The veteran's hearing loss was confirmed by a VA examination in April 1992, with no
etiology noted. R. at 176. However, the examiner did report "[n]o evidence" of active ear disease
or ear infection. R. at 186. The RO denied the veteran's bilateral hearing loss claim in July 1992.
R. at 197. In a statement dated March 1996, his service organization representative conceded that
"the evidence . . . does not indicate that the veteran was exposed to loud noises or acoustic trauma.
Available evidence does indicate [that] over a number of years he had a gradual development of a
hearing loss[;] however[,] no substantiation of evidence has been submitted to support the veteran's
contention." R. at 426. In the October 24, 1996, BVA decision here on appeal, the Board denied
the veteran's hearing-loss claim as not well grounded. R. at 8. The decision indicated that there was
no competent medical opinion that showed an etiological relationship between his current hearing
loss and a disease or acoustic trauma that occurred on active duty or while he was in the Air National
Guard.
Ibid.
II. Analysis
"[A] person who submits a claim for benefits under a law administered by the Secretary shall
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have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual
that the claim is well grounded." 38 U.S.C. § 5107(a). A well-grounded claim is "a plausible claim,
one which is meritorious on its own or capable of substantiation. Such a claim need not be
conclusive but only possible to satisfy the initial burden of [section 5107(a)]." Murphy v. Derwinski,
1 Vet. App. 78, 81 (1990). Generally, for a service-connection claim to be well grounded a claimant
must submit evidence of each of the following: (1) Medical evidence of a current disability; (2)
medical evidence, or in certain circumstances lay evidence, of in-service incurrence or aggravation
of a disease or injury; and (3) medical evidence of a nexus between the asserted in-service injury or
disease and the current disability. See Caluza v. Brown,
7 Vet. App. 498, 506 (1995), aff'd per
curiam,
78 F.3d 604 (Fed. Cir. 1996) (table); see also Elkins v. West,
12 Vet. App. 209, 213 (1999)
(en banc) (citing
Caluza, supra, and Epps v. Gober,
126 F.3d 1464, 1468 (Fed. Cir. 1997) (expressly
adopting definition of well-grounded claim set forth in
Caluza, supra), cert. denied sub nom. Epps
v. West,
118 S. Ct. 2348 (1998) (mem.)). Alternatively, either or both of the second and third Caluza
elements can be satisfied, under 38 C.F.R. § 3.303(b) (1998), by the submission of (a) evidence that
a condition was "noted" during service or during an applicable presumption period; (b) evidence
showing postservice continuity of symptomatology; and (c) medical or, in certain circumstances, lay
evidence of a nexus between the present disability and the postservice symptomatology. See Savage
v. Gober,
10 Vet. App. 488, 495-97 (1997). The credibility of the evidence presented in support of
a claim is generally presumed when determining whether it is well grounded. See
Elkins, 12
Vet. App. at 219 (citing Robinette v. Brown,
8 Vet. App. 69, 75-76 (1995)). The determination
whether a claim is well grounded is subject to de novo review by this Court. See
Robinette,
8 Vet. App. at 74.
A. Right-Knee Condition
At the outset, as to evidence of in-service incurrence or aggravation (the second requirement
of
Caluza, supra) of a knee problem, the veteran's June 1970 discharge examination report does
indicate complaints of knee problems and a "possible slight weakness in [the] r[ight] cruciate." R. at
57. But it is not clear that the veteran has met the first Caluza requirement, i.e., medical evidence
of a current right-knee condition. See
Caluza, supra. The only evidence of the veteran having
current knee trouble is his own sworn testimony that he has experienced knee problems "the rest of
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[his] life" following his first period of service. R. at 270. Where the determinative issue involves
medical etiology or a medical diagnosis, competent medical evidence that a claim is "plausible" or
"possible" is generally required for the claim to be well grounded. Heuer v. Brown,
7 Vet. App. 379,
384 (1995); Grottveit v. Brown,
5 Vet. App. 91, 93 (1993). Lay testimony cannot provide such
medical evidence because lay persons are not competent to offer medical opinions. See Stadin
v. Brown,
8 Vet. App. 280, 284 (1995);
Grottveit, 5 Vet. App. at 93; Espiritu v. Derwinski,
2 Vet. App.
492, 494-95 (1992). The most recent medical evidence is the April 1992 VA medical examination,
which noted complaints of pain and tenderness but found full range of motion, no significant
crepitus, and no instability. R. at 182. A concurrent x-ray examination revealed "no significant
abnormality of the bone, joints or adjacent soft tissue". R. at 188. But see R. at 103 (March 1990
letter from Dr. Unverferth indicating his belief that veteran was permanently disabled). Hence, it
is not clear that the veteran has submitted current medical evidence of an asserted knee problem.
See Stadin, Heuer, Grottveit, and Espiritu,
all supra.
Moreover, the veteran has offered no postservice medical evidence of a connection between
any current knee problem (and, again, it is not clear to the Court that the veteran actually has a
current knee disability) and either the "'[t]rick' or locked knee" noted at the veteran's induction
examination (R. at 120), the knee pain that he sustained during OCS training (R. at 230), or the
problems noted on the veteran's discharge examination report (R. at 57). Indeed, the appellant
appears to concede this point. See Brief at 9 (asserting that his claim is well grounded because
"appellant's SMRs prove an in[-]service injury and medical diagnosis" and he has "demonstrated a
current condition", but not citing to or asserting any evidence of medical nexus); Reply at 2-3
(asserting that relationship between current condition and inservice injury "is one to which a lay
person's observation is competent"). A lay opinion as to such a medical relationship is not
competent to well ground a claim for service connection. See Stadin, Grottveit, and Espiritu,
all
supra. Hence, the Court holds, on de novo review, that, based on the facts of this case, the veteran's
right-knee-disability claim is not well grounded under the criteria set forth in
Caluza, supra. See
also Epps, Elkins, and Robinette,
all supra. Because no nexus evidence is present, the Court need
not consider the appellant's arguments concerning the presumption of aggravation under 38 U.S.C.
§ 1153. See Maxson v. West,
12 Vet. App. 453, 460 (1999) (noting that presumption of aggravation
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"applies only to Caluza element 2" (incurrence or aggravation during service) and "and only after
it has been demonstrated, at the merits stage, that a permanent increase in disability has occurred or,
pursuant to [38 C.F.R. §] 3.306(b)(2) [(1998)], has been deemed to have occurred").
Nor does the Court find that the veteran's right-knee-disability claim is well grounded based
on a continuity-of-symptomatology analysis. Assuming, without deciding, that there would be
sufficient evidence of a current disability, it is not clear on the facts of this case that there is a
"plausible" showing of the requisite continuous symptomatology.
Murphy, supra. The sole
evidentiary basis for the asserted continuous symptomatology is the sworn testimony of the veteran
himself (R. at 270), and no medical evidence indicates continuous symptomatology -- in fact,
medical evidence indicates an absence of continuous symptomatology. See R. at 120, 122 (July
1976 GSMR that reported his knee as "normal" and at which the veteran himself indicated on the
patient history that he reported that he did not have knee problems). The only competent evidence
of a nexus between the asserted condition and the asserted continuous symptomatology indicated an
etiology other than the knee pain noted several times during the veteran's service (R. at 103 (March
1990 letter from Dr. Unverferth indicating that the problem that had necessitated the veteran's
August 1988 knee surgery "was a direct result of the blow that he had received to the anterior aspect
of his knee in an auto accident")). It is true that at the well-groundedness stage the Court will
generally consider only evidence in support of the claim, see
Elkins, 12 Vet. App. at 219 (noting that
after reopening claim based on new and material evidence Secretary "must determine" whether claim
is well grounded "in terms of all the evidence of record in support of the claim"); see also Winters
v. West,
12 Vet. App. 203, 206 (1999) (en banc); nonetheless, in a case such as this one, where the
veteran's testimony is the only evidence that may serve to well ground the claim and the veteran has
made contradictory statements, and where there is medical evidence that shows a lack of continuous
symptomatology as well as an intervening cause for the disability, it may well be appropriate to
consider the evidence of record that provides a more complete picture of the veteran's disability in
determining whether the claim is well grounded. We need not reach that question here, however,
because a well-grounded continuity-of-symptomatology claim generally requires medical evidence
of a nexus between the continuous symptomatology and the current claimed condition, and the
veteran has not submitted any such evidence. See
Savage, supra. Again, given the nature of the
8
disability involved, his lay opinion is insufficient in this regard. See
Savage, 10 Vet. App. at 497
(holding that "medical expertise is required to relate the appellant's present arthritis etiologically to
his post-service symptoms"); see also Stadin, Grottveit, and Espiritu,
all supra.
Accordingly, the Court holds that there is no plausible evidence of a continuous right-knee
disability related to the veteran's first period of service and holds, on de novo review, that the claim
is also not well grounded under 38 C.F.R. § 3.303(b). See Savage and Robinette,
both supra.
B. Bilateral Hearing Loss
As to the bilateral-hearing-loss claim, in his brief, the appellant appears to make no
arguments that his bilateral-hearing-loss claim was well grounded. Similarly, in his reply brief he
offers no response to the Secretary's arguments that the claim is not well grounded. Notwithstanding
the apparent agreement between the parties on this point, the Court holds, on de novo review, that
this claim is not well grounded.
First, there is medical evidence of a current disability that arose after the veteran began
serving in the Air National Guard in 1976 and before 1990. R. at 131, 134, 157, 170-72. Next, for
the purpose of assessing whether the claim is well grounded, the Court presumes the credibility of
the veteran's testimony regarding his having been exposed to jet-aircraft-engine noise during his Air
National Guard service. See Arms v. West,
12 Vet. App. 188, 195 (1999) (noting that generally "only
the evidence in support of the claim is to be considered and generally a presumption of credibility
attaches to that evidence in order to decide whether or not any VA claimant has sustained the
claimant's burden of submitting a well-grounded claim under section 5107(a)" (first emphasis
added)).
It is not enough, however, for this veteran to submit medical evidence to support a plausible
claim of a hearing loss that began during his Air National Guard service, because "section 1131 of
title 38 permits service connection for persons on inactive duty [training] only for injuries, not
diseases, incurred or aggravated in line of duty." Brooks v. Brown,
5 Vet. App. 484, 485 (1993)
(discussing 38 U.S.C. §§ 101(24), 1131); cf. Paulson v. Brown,
7 Vet. App. 466, 469-70 (1995) (if
claim relates to period of active duty for training, disability must have manifested itself during that
period; otherwise, period does not qualify as active military service and claimant does not achieve
9
veteran status for purposes of that claim). The Court notes that service as "a member of the . . . Air
National Guard of any State" is to be considered "'inactive duty training'" when it is "duty (other than
full-time duty) under sections 316, 502, 503, 504, or 505 of title 32", United States Code. 38 U.S.C.
§ 101(23). In this case, the Board did not make a finding as to the nature of or authority for the
veteran's Air National Guard service in terms of the above criteria, and the ROA does not appear to
indicate such nature or authority; however, the Court notes that the veteran's orders assigning him
to "duty at home station" during the Gulf War cited 32 U.S.C. § 503 (R. at 87). Moreover, section
101(23) specifically excludes from "inactive duty training" only those Air National Guard members
whose service was "(i) work or study performed in connection with correspondence courses, (ii)
attendance at an educational institution in an inactive status, or (iii) duty performed as a temporary
member of the Coast Guard Reserve." 38 U.S.C. § 101(23). Here, the veteran's service does not
appear to meet any of those three specified exclusions. Hence, for the purposes of a well-grounded-
claim analysis, the Court will assume that the veteran's Air National Guard service was "inactive
duty training" under 38 U.S.C. §§ 101(23) and 1131 and
Brooks, supra. Cf. Cahall v. Brown,
7 Vet. App. 232, 237 (1994) (noting that official service department records are necessary to establish
inactive duty training); Duro v. Derwinski,
2 Vet. App. 530, 532 (1992) (Board is bound by official
service department determinations of military service).
Assuming, then, that the veteran's claimed condition arose during his inactive duty training,
that condition must have been due to an injury and not a disease in order to be compensable under
38 U.S.C. § 1131. See
Brooks, supra. Thus, if the medical records contained in the ROA had
indicated that the veteran's hearing loss had been caused by a disease rather than an injury, the Court,
assuming inactive-duty-training status, would affirm the Board decision and deny this claim as
legally insufficient. See Sabonis v. Brown,
6 Vet. App. 426, 429-30 (1994) (claim denied for lack
of legal merit or lack of entitlement). However, the April 1992 VA examiner, who had been
specifically requested to address the question whether "an active ear disease is present" or "an
infectious disease of the middle or inner ear is present", noted that "[n]o evidence of active disease
was found" and that "[n]o evidence of active ear infection was found". R. at 186. The examining
physician also added that "[a]udiometry is pending at this time but there is no evidence for an acute
ear disease."
Ibid. Based on that April 1992 VA examination record, as well as the fact that no other
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medical opinions as to etiology are of record, there is enough evidence with regard to the nature of
his service and of acoustic trauma to move forward with the analysis of the well groundedness of his
claim for bilateral-hearing loss.
The veteran's claim is based on his 1976 to 1992 Air National Guard service, which, unlike
active service, is not continuous; indeed, it is episodic. Unlike active service, where incurrence
during service is necessarily incurrence during active service, this veteran could have been exposed
as a civilian during the July 1976 to December 1990 period before his activation for the Gulf War
to loud noises that could have produced hearing loss rather than during those times, from 1976 to
1991, when he was fulfilling his service obligation to the Air National Guard. Thus, even assuming
that he was exposed to loud noises, he has not submitted plausible evidence of a hearing loss
incurred during his inactive duty for training as the result of such exposure. Moreover, he has
submitted no competent evidence to suggest a nexus between his presumed exposure to jet-aircraft
noise and his hearing loss. As noted in part
II.B., supra, his own testimony is insufficient in this
regard. See Stadin, Grottveit, and Espiritu,
all supra. The lack of such evidence, as well as the lack
of clear evidence of in-service incurrence, renders his claim not well grounded under
Caluza, supra,
as well as under 38 C.F.R. § 3.303(b) and
Savage, supra. See Boyer v. West,
11 Vet. App. 477, 478-
79 (1998) (requiring nexus evidence to well ground claim for hearing loss under continuity-of-
symptomatology analysis); see also Epps, Elkins, and Robinette,
all supra.
C. Stay of Proceedings
On July 13, 1999, the Court issued a stay in this case pending the outcome of Stuckey v. West,
No. 96-1373 (argued July 29, 1999), an appeal before a panel of this Court that faced similar
questions as to the Manual M21-1 provisions cited in the appellant's pleadings. However, on August
24, 1999, the appellant filed through counsel a motion to lift the stay imposed in this case because
"the Manual M21-1 argument is of no consequence in the instant case because, if Morton [v. West,
12 Vet. App. 477 (1999)] is applied, the appellant cannot prevail on that argument." Motion at 1-2.
The Court agrees, and on August 26, 1999, the Court granted the appellant's motion to lift the stay.
III. Conclusion
Upon consideration of the foregoing analysis, the ROA, and the submissions of the parties,
11
the Court holds that the appellant has not demonstrated that the BVA committed error -- in its
findings of fact, conclusions of law, procedural processes, or articulation of reasons or bases -- that
would warrant reversal or remand under 38 U.S.C. §§ 1131, 1153, 5107(a), 7104(a), (d)(1), or 7261
or 38 C.F.R. §§ 3.303(b). Therefore, the Court affirms the October 24, 1996, BVA decision.
AFFIRMED.
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