AME Guide Grand Rounds August 2025 Session

Welcome everybody to the August, no kidding, August Grand Rounds. We are excited this week because we finally navigated through the ability to update the Guide for Aviation Medical Examiners, so you're in for a fast-paced, oh my gosh, what did they change all at once? So I hope you all have your skates on. But in the meantime, I just wanted to share a couple of statistics with you. Since the first of January, hopefully you have noticed that the backlogs that we have have improved dramatically. Our current unissued deferred case backlog is 50% what it was the first of January, which is pretty darn awesome. And the number of cases waiting for a physician to pick it up to look at it is down over 99%. So we're trying to do an awful lot. Now there's something you all can do to help me. One of the things we have been doing when we go out and speak with pilot advocacy groups and you should have seen some of the initiatives and some of the glossy magazines is we're really, really encouraging pilots to pre-flight their medicals. I have some really good data now that shows if an individual submits their paperwork through you uploading it into the system, the number cleared on first pass is really high. I used to say if I had to ask or we had to ask for additional information, we were increasing the time a case was going to sit and wait by six to eight weeks. But my current data shows that that's more like an additional 110 days. So please work with your pilots to make sure they get all of the information. In an effort to increase that likelihood, if you haven't seen it, take a look in MedExpress. One of the first set of questions we ask them now is, are you a first time applicant or have you had a significant medical change since your last application? If the answer to either of those is yes, we're directing them to the Guide for Aviation Medical Examiners and there's a really slick pamphlet in there on how to use the AME guide. So help us help them and if you're out talking to pilot groups, mention the concept of pre-flighting because it's in reality and this seems to resonate with the pilots, the medical exam we do to produce a medical certificate is really a check right for their body and they need to start thinking about it that way. So again, welcome. Thank you for being here. We're getting back on our regular cadence with AME guide updates and I'm going to toss it back to Christy Risley. Okay, thank you, Dr. Northrup. Welcome everybody this evening or this afternoon or this morning, depending on where you are in the world. We're going to go over some housekeeping things up front just like we always do. First off, this session is being recorded. No participants will be shown and the recording will be made available later via YouTube. The easiest and best way to locate those past Grand Rounds videos are to open up your favorite internet browser, plug in a search on the search bar or into whatever search engine you prefer and just search for FAA space AME space Grand Rounds. When you search that, that should give you a link to YouTube where you can actually go and view our past recordings. Due to some difficulties getting the last Grand Rounds and the short turnaround before we had this tonight's session, today's session, our July Grand Rounds that we held on August 6th have not quite made it up on the playlist, but we expect that to be there soon. Next slide, please. Some rules of engagement for Grand Rounds. If you've not joined us before, keep in mind this session is locked after 10 minutes. Well, what does that mean? Our accreditation allows us to grant you one hour of CME for each session of Grand Rounds per month. You can't get it for both sessions. You can only get it for one or the other because it is the same topics, the same material. But because it is only for one hour, the session is locked after 10 minutes. If you drop out of the Zoom session, either due to difficulties with your internet browser or whatever happens, there's a good chance you're not going to be able to get back in. You can try and email our distance training email address if you have that. But it's iffy on whether or not we'll be able to unlock it and let you in. Also, your chat and your cameras are disabled. You will not be able to turn those on because we want to capture all of your questions using the Q&A button at the bottom of the Zoom screen. If you are new to Zoom, if you'll take just a minute and locate that Q&A button on the screen, it's typically at the bottom of your screen under more if you've got a smaller screen or it may just be there where you can see it. And also, as part of our accreditation, we do have to disclose if any of our speakers have any prohibited relationships to disclose. This is our statement for this session that we have no disclosures. Next slide, please. The most important key point for requesting CME is that you need to stop right now. Make sure that your full first and last name are displayed on the Zoom screen in order to be eligible for CME. If you do not have your full first and last name, whether it is Bob, Bob's office, Dr. Smith's office, whatever it happens to be, we have to be able to match your full first and last name up with your A&E records and with the CME survey that we'll give you the link for in order to be able to grant you that CME. That's part of our accreditation. So, please stop and make sure that's so. Also, if you're watching this recording at a later date, keep in mind that we cannot give credit for watching the recording. We do appreciate your time and appreciate you joining us, but we cannot give credit for the recording. Next slide, please. This is no longer a new process, but it might be new for you if you haven't joined us in a couple of months. To request CME following the session, you can scan the QR code with your cell phone camera and all you'll have to do is take your cell phone, take your iPad, whatever device that has a camera, point it at that QR code, and it should open up a link to a Zoom survey for you to submit for your CME. Or there is a tiny URL that's been posted in the chat by Gary that will take you to the same survey. A couple of things to keep in mind. We do close the survey out about 48 hours following the session, so don't delay in asking for your CME. Go ahead and click that link following the conclusion of tonight's session. Also, the QR code and the link change monthly, so don't try to save that as a favorite in your internet browser. We do refresh those every month. Next slide, please. Why are we here tonight? Why are we here is to discuss the AME Guide updates, and with that, I'm going to turn it over to Dr. Judy Frazier. Dr. Frazier? Thanks, Christy. All right. So, we are really glad to be getting back with updates. We're going to go through what we're publishing in August. We want to make sure that you've at least seen it once. Again, go to the AME Guide for additional details. The first thing we're going to talk about is color vision. Then we're going to talk about some eye conditions, neuro, a little bit about pulmonology and medication changes. So the first thing is we have updated the color vision slide. We had questions on this on the flow charts. We realigned the flow chart to answer your questions. There's a returning pilot section, which is all in blue. There's a first-time applicant section, which is in yellow. Important parts, remember, this is the screening part of color vision. It only has to be done once. If a pilot has previously passed a test that was allowed by the FAA, they are grandfathered in. They do not have to retest. If they passed historically, they are okay for any class. If they did not pass, had an LOE, had a SOTA, or had a color vision limitation, they will leave your office with the same limitation, SOTA or LOE they had in the past, unless they try a color-based test and pass. So if they take a computer-based color test and pass, they will no longer require the SOTA, the LOE, or a limitation. We do want to make sure everybody's seen the updated flow chart. We're going to talk a little bit, we're going to talk a lot about, remember that a pilot walks out of your office with the same class or limitation that they had prior to January 1st, 2025. So make sure that your pilots, if for some reason they've had a first class, a second class, they've had an LOE, they've had a SOTA, they try and upgrade and they don't pass one of the computer tests. You don't downgrade them to a third class with a 104 limitation. They get the same limitation or their SOTA is still valid. Next question. Hold on. Do you want to footstomp that block? Dr. Northrup, will you footstomp that? Sure. Okay. So we had a lot of questions in the after, let me turn my camera on, sorry. If you could use your cursor and this, yeah, that block right there. We've got a lot of questions. If somebody's passed a color test and they're third class, they have no limitations. They can go get a first class without getting another color vision test. It's if they want to upgrade their existing SOTA or their OCVT to be without limitations and the OCVT, if it's going from a third class to a first or second class, using that as the proof because they hadn't taken the math test portion of it, they have to do that portion again. Did I screw anything up there, Judith? Nope. All good. Yeah. So it caught a lot of people off guard. We answered a lot of questions. They had a historic FAA test and they don't want to upgrade their SOTA and they don't need to do an OCVT because they only got the third class one before. They don't have a new medication that causes color vision and they don't have a condition that causes color vision. The color vision limitations or the lack thereof continues with them. Okay. Thanks. I'll shut up now. No, no. All good. All right. So important things. Pilot walks into your office with a certificate. They walk out with the same limitations or restrictions unless they get a new color test. All right. We have been able to update the score results. So remember on the Rabin, originally passed was set at 75. Dr. Chittester and his group at CAMI that do the research went back and looked at the research results and determined that we could decrease the score to pass to 55, 55 for each color. So if somebody has a Rabin, if you guys have a Rabin test passing for FAA purposes is 55 or higher for each color. Remember a pilot does not have to be color vision normal to be able to act as pilot-in-command. They have to have aromatically acceptable color vision. That doesn't mean normal. It means aromatically acceptable. So 55 and up will get you there. Also if you take the CAD test, the color assessment and diagnosis test, they're red-green, 1.7 is normal. If they are diagnosed as do-tan, their number has to be less than six. If they're diagnosed as pro-tan, they have to be less than 12. So the red-green score on the CAD test is determined by what diagnosis they have for color deficiency. If they have no deficiency, it's 1.7. For yellow-blue, yellow-blue is less than 2.4 across the board. The other question we got a lot on the Wagner test was which test does the FAA allow? Is it the FAA color vision test or is it the adult diagnostic? You can use either. There's some pluses or minuses to both. The FAA one will print out at the bottom of the score report, passed or failed. The adult diagnosis has a, adult diagnostic has a little bit different number score, but it will still be equivalent to what we require to pass. So you can use either one, whichever test you have is fine. Another thing, remember the testing has to be done in person. That's something that has, was brought up as a question a couple of months ago. They're in your office. They're in an eye doctor's office. Somebody should physically see that pilot and make sure that they're passing their color vision scores. Make sure they're passing their color vision screening test. All right. Next thing, like Dr. Northrup was talking about, if a pilot passed any of the old tests, even if they had a third class exam, but they passed a previous test, they're good for any vision, any color vision certificate level. It's only if they had a SOTA or an LOE or a color vision limitation, but they walk out of your office with whatever they had before. They don't need a new color vision screening test if they've passed a test in the past and got a certificate out of it. If they're unable to pass, they will get a letter. So let's say you've got a new pilot in your office. They're taking the color vision test for the first time and they fail. The first thing is just let them take it again. You might want to let them take it again even a third or fourth time. There's not a limit to the number of times they can take the test. Wagner is the most common, but there are of the other two tests, some of them are easier to pass. So if your pilot cannot take or cannot pass a Wagner or whatever you have in your office, the next step would be see if there is another test available and see if they can pass that. Remember we talked about you don't have to be color normal to be a pilot, but you do have to have color vision sufficient for aviation activities. That's where those cut scores were set. So if your pilot does not meet the color vision requirements, they can get a third class with what's called limitation 104. We found out this morning that when you log into AMCS and you're applying a limitation to the certificate, if you use the first area where you can click and print a certificate, the numbers are not there. But if you look onto the third tab, it has the numbers for the different limitations. The limitation 104 is the one that says not valid for day VFR only. That is on AMCS, but you have to look over towards that third tab and it'll have the number. All right. The other thing that we have asked for historically, all right, do I need to stop there for color vision questions, Leah? Do we have a bunch in the chat or no? We've got a couple. Color vision test, the pilot's in the office, does my staff have to be in the room while the pilot is using the iPad for Wagners? It's a great question. We just want to make sure that the pilot taking the test is really, the score is really that pilot. So do they have to be in the, you have to be very comfortable with your pilots and make sure that they're the ones taking the test. Okay. That one's getting answered. Could you make the illustration from the last grand round showing how different color deficiencies see the approach to runway picture available to us? It would help in explaining this to our aviators. Is that from Dr. Chidester's presentation maybe? They might be able to get that, Leah, off of the last video. Okay. And then we have the AME guide still does not address the ability to apply for IFR options with a failed color vision. The color vision limitation review does not address this choice. It would seem that the CBL review form needs an update if IFR rating is not an option for pilots with CV restrictions, I would suggest that would decrease training and increase risk of accidents for those pilots. We'll add that to the to-do list, Leah. Nothing that we can answer today, but we'll add that to the to-do list. What is the protocol to remove color deficiency limitation when a pilot wants to obtain a first-class cert? So the first thing is take a test. Take another test. If they don't pass it, take a different type of test. If they still cannot pass after multiple attempts, upload the failed test results and submit a color vision limitation review. Those are all reviewed at headquarters. Remember, if they cannot pass a color vision computer-based test, they are unlikely to have vision that is acceptable, color vision that is acceptable for air medical purposes. But the way they would do it is you would have to upload the test that they failed and a color vision limitation review. And the limitation review is really so that we can find it in our system. That's all the questions we have for right now. Well, we just had some pop-up. All right. I'm going to go ahead and go on, Leigh, and then we'll catch those at the end because it's... Yeah. All right. So we're going to move on to some other eye conditions. We'll come back and try and catch the rest of the color vision at the end. We've been asked multiple times for what's called a quality vision statement. So this is something that your pilots tell us about how they subjectively view their vision. We don't ask for every vision condition, but it's something that some of our eye doctors really use when they're reviewing a case. So we took the questions that they want answered on a vision questionnaire. And the pilot or an air traffic controller will fill this out. It's just another document that you would upload. It's like a CBC or a TSH or a stress test. It's a data element for us to review. The vision questionnaire does not need to be submitted for every pilot who has a vision issue. Only if they're asked for it or the AME guide says we need it. All right. Next item is cataracts. We've expanded the content of the AME guide for cataracts. Remember if somebody has a cataract, but it doesn't impair their vision, if they don't have problems with glare or halos or loss of contrast sensitivity or problems with night vision, and if they meet vision specs for their class, you can issue. We need a note in block 60. Pilot walks out with a certificate if they're otherwise qualified. The ones we need to see at the FAA is if a pilot does not meet vision specs or they have glare or halos or something that affects their ability to operate safely. In some cases, if they have a cataract, we'll ask for the quality of vision statement that you just saw. Remember, if they don't meet visual acuity specs, that's when you'll have to defer and it'll be an FAA decision. So on cataracts, there's a row A and a row B. Row C is if they've had cataract surgery. So remember, because cataracts progress, if they're unable to meet visual specs, it is unlikely that they would get a certificate because really they need to get their cataracts taken care of. Once they get their cataracts taken care of, usually that requires a lens implant. And in just a second, we'll show you how long they have to wait after different implants and what we're looking for. Because cataracts are very common, especially we've seen them a lot in pilots. There are two pages of FAQs that we encourage you to look at and share that information with your pilots. So again, once a pilot has cataracts, they have cataract surgery, they pull out the old cloudy lens, they input a new lens. This is what has changed. Historically, if somebody had lens replacement, we made them give us information for up to two years after the surgery. We used to ask for an 8500-7 or progress notes. After working with our eye doctors, our FAS ophthalmology consultants, and a huge shout out to our FAS ophthalmology consultants who helped us with all these new pages. If it's been three months since their lens replacement surgery, if they meet vision specs, if they don't have glare and halos and contrast sensitivity loss or night vision issues, you can just issue. Important things are make sure that they meet the visual specs and make sure they're not having any symptoms. But other than that, you can issue. Give us a note in what we call Block 60. That's row A. Row B is anybody who's had surgery, lens replacement, in the past three months. So if they've had lens surgery in the past three months, in some cases, you may be able to issue. We have had a lot of luck with these things we call status summaries. Status summaries, remember, were designed so that the treating physician in the outside can give us the information that we need and you the information that you need to quickly make a decision. Our ophthalmology consultants were able to distill down what we really needed an eye doctor to tell us to just five questions. So on this lens status report, status summary, what you will see is the five questions we need answered. The first one has to do with how much time has elapsed since the surgery. Anyone who has had a monofocal regular single distant lens replacement, it's only two weeks. So two weeks after surgery, if the other four questions are all in the yes left hand column, you'll be able to issue. The other type of lens that we're seeing a lot of is a light adjustable lens. So if they had a light adjustable lens implant, they have to wait for six weeks and at least two of those have to be after they've locked down the lens. So if they've locked down the lens at least two weeks, they're off UV avoidance and the other four questions are all in the left hand yes category, you can go ahead and issue. The third type of lens that we see a lot are the multifocal extended depth or presbyopic lenses. Those do require 12 weeks. That's kind of like getting an implanted bifocal or trifocal. Takes a little bit longer for your eye to get used to that. So that requires a 12 week recovery period. The idea of the status summary is to help outside physicians understand what we need. They answer the questions that are important to figure out if someone is safe to fly or control traffic. They give you the completed information, then you can make a decision in your office. One thing I want to call out is at the top of this page, it talks about if the individual has an AASI or an SI or an SC for some other eye condition, or they've had CK or NTAX, they don't qualify to use this rapid status summary, we want the actual eye doctor note. So this is just for low grade, low risk, kind of run of the mill, had their lens replaced. All right. So that's the lens replacement status summary. The next thing we see a lot of is refractive surgery. So there's a lot of LASIK still. Same thing, used to have to ask for information 8500-7 for up to two years after the procedure. This is really common now. It's definitely lower risk. If they are at least three months from surgery, we don't need information. You can go ahead and make sure their visual acuity meets standards. Make sure they don't have glare, halos, loss of contrast, or poor night vision. You can just issue three months after surgery. If they've had surgery within the past three months, just like on the contact lens, just like on the lens replacement, we have a similar but not identical status summary for refractive surgery. Same thing, if everything's in the left-hand category, they meet the required time, you'll be able to issue. And then, of course, anybody who doesn't fall into those categories will be C, and then we'll need information from their eye doctor. All right. So here's the refractive surgery status summary. Same thing, five simple questions. Their eye doctor needs to tell us five things. The first one is have they met the required recovery time? For LASIKs and SMIL, it's two weeks. For PRK, which involves making an abrasion, I was told of about 90% of the cornea, it takes longer for it to heal. Because it's longer for it to heal, there is a 12-week recovery period. This is not super common anymore, but if you have a pilot or an air traffic controller who's using a PRK procedure, they do have a 12-week recovery period. And then the same four questions that we asked earlier. Remember, this is for run-of-the-mill LASIKs, run-of-the-mill SMIL, or somebody who's had PRK. It's not for people with keratoconus, top paragraph. It's not for people who've had a CK. It's not for people who have another existing eye condition. But hopefully, this will speed it up for you and for your pilots and will help us bridge that gap between what the treating doctors need to tell us, what you need to see, and what we need at the FAA. All right. So we had a couple of common conditions that we added to the AME guide. One, we get asked about conjunctivitis, and most of it is more for air traffic. It's not as much for the pilots. But it's when can they go back to work, when they can go back to fly. Row A, if they've had conjunctivitis or blepharitis and it's cleared up, they can go back. If they have an active infection, most of these are viral. So you probably don't want somebody exposing other people if they've got a viral infection. We don't give a specific downtime. We just say that when the signs and symptoms have resolved, and a lot of that's up to their treating physician, if they don't have problems with flights or discharge, then they could go back. Important things, though, like Dr. Northrup said, she wants pilots to pre-flight their exam. She wants them to have information. So since they asked this question, we wanted to put where they could find the information. Anybody who is having problems after conjunctivitis, they have a chronic issue, they're going to fall into row C. We need information from their eye doctor. All right, now we're going to talk about a couple of uncommon conditions that you'll see in the ophthalmology. The first one is a colobama. It's congenital. You'll see it in some of the pilots. If it's strictly eyelid and it doesn't affect their vision, there's no functional problems, the other eye has no pathology, there's no symptoms, you can go ahead and just issue. Usually you will need to look at a report from their eye doctor just to kind of verify this information, but again, only a couple of bullet points that you have to verify, and then you can issue. If they have a colobama of any other location, in that case, we definitely need the report from the eye doctor. Any testing that was already done, you guys will have to defer and we'll make the decision at the FAA. All right, next kind of uncommon condition here, ocular histoplasmosis. We've seen enough that we made a page just so that you and your pilots would know what information we're going to ask for. We want to call out the yellow boxes on this page. The first information for an ophthalmologist or a retinal specialist is about the condition. When you see number two, if it says it must specifically include, this is how we're trying to tell the outside eye doctors, this is what we really need you to tell us. So in this case, we really need to know what are the clinical correlations and the findings? Is treatment indicated? Give us a description of a retinal fundal exam. We need a specific comment about is this static or progressive, and we also need the OCT results and their interpretation. So when you see in the AME guide or in the letters, because what we've done with the AME guide column number two, is we've translated most of that content into the letter that your pilot gets. So if your pilot or a traffic controller has ocular histoplasmosis, the letter that they get should ask for everything that's in this column number two, this evaluation data. But some of your colleagues, since they don't know what the FAA needs, I know you guys spend a lot of time on the phone talking to your colleagues and saying, yeah, but here's what I need you to tell me. If you see an item number two, it must specifically include, that's what we want to make sure that the specialist has addressed in their progress note. All right, next item that's in a yellow box here talks about visual field testing for both eyes. If there's any macular involvement, it needs to be a 10-2 or a 12-2. So that's ocular histoplasmosis, again, not super common, but if you have a pilot or an air traffic controller who has this condition, there's a place you can point to for what we're going to ask. Next one is optic neuritis. This kind of crosses that threshold between ophthalmology and neurology. Optic neuritis, again, not super common. We do need evaluations from an ophthalmologist and a neurologist. The rest of the information is listed in the evaluation data. We called this out specifically because this is one of the first conditions because it does affect color vision. This is a condition where a pilot or air traffic controller would need as part of the evaluation data, just like a CBC or a TSH or a stress test. Every year they will need a color vision test. When they are asked for a color vision test, it does need to be one of the computer-based color vision tests, one of the three that are currently allowed. So just another evaluation data, but this is an example of color vision testing being required versus color vision screening. All right, a couple of less common neurology conditions as well. On the multiple sclerosis page, our neurologists were getting a lot of cases where they had NMOSD or MOGAD or clinically isolated syndrome where they haven't quite presented as MS yet. We need basically the same information. There was just a little bit of differences. So if they have NMOSD, the number six item for lab that's listed for multiple sclerosis, we absolutely need that. And then they've got clinically isolated syndrome. We only need the MRI for the thoracic spine and their C-spine if their treating physician has already done it. So a couple of little call-outs, a little nuance between the full MS evaluation data and these specific entities. But again, it's not stuff you have to memorize. It's stuff that you should be able to find easily and tell your pilot, here's what we're going to ask for. All right, next condition, pulmonary. So bronchiectasis causes a lot of cough, a lot of mucus, can affect how they breathe. If it's due to cystic fibrosis or some other underlying condition, you'll need to get the information from that page. But if a pilot or air traffic controller has bronchiectasis, this is the information that we're going to need. All right, changing gears just a little bit. We have an amazing pharmacist at the FAA, and we are really lucky that she likes to do medications all day long. And she's made a whole bunch of updates for us. So things that are going to make hopefully your life as an AME a little easier, and we'll get some of the pilots back to flying that maybe had to wait. So here's the meds we're going to talk about. The first one is the migraine meds. So on the migraine TACI worksheet, there's a specific med called Reval. You can use it for stopping a migraine, but it's not a preventative med. So just be aware of that. I think her migraine med section in the AME guide on the pharmaceutical page, it's two or three pages long, because she has a whole section that's here's what you can take if it's a preventative med. She has another section on here's what you can take if you're stopping an episode. So if you don't know that that pharmacy page is there for migraines, you want to look at that. She also added about triptans, if they're on monotherapy for triptans, it's a no fly for 24 hours. But after that, if their migraine's improved, if they've waited the 24 hours, then they could go back. Some triptans are also used in combination with NSAIDs, and that's also a 24-hour no fly. All right, for diabetes. So there's another SGLT2 that's been out for a little bit. It's BrinZavi. That is added to group F for the other SGLT2 inhibitors, follows the same requirements. So just know there's another one that pilots could use. And then on her acceptable combination of diabetes page that she's updated, one of the things that's on page one is how long does a pilot have to wait or air traffic controller have to wait after adding or changing meds. We have some additional information from some of our endocrinologists, so we'll be updating this table again in the next couple of months. But right now, if a pilot was already on an established treatment, and they're adding, let's say they're already on a medication that's in group E, and now they're adding metformin or something like that, there's a 30-day wait time. It used to be between 30 and 60 days, depending on which group E, E1 or E2. All the E's are now the same. We're trying to combine as many as we can so you don't have to remember as many different wait periods, but they're down to 30 days. So again, this is one of those charts you don't want to memorize. You just want to be able to find it quickly and tell your pilots, these meds are all good. If you're starting or changing, here's the amount of time you have to wait afterwards. All right, this came from a lot of the HIMSS AMEs as a request. So the GLP-1 medications that are super common now, initially when the CACI came out, there was a black box warning that was applied right about the time we were going to roll out the CACI. And so because of that, anybody who had a history of substance use disorder, psychiatric symptoms, et cetera, we could not put on the CACI at that time. That has since been reviewed. Pharmacy committee looked at it again, and we have enough information to say that as long as you as an AME are not having concerns about this pilot, if they're taking their GLP for pre-diabetes or weight loss, and even if they do are on the HIMSS program, they could still qualify for the CACI pre-diabetes or weight loss medication, even if they have a history of substance abuse. So that's a new thing. We're able to take that bullet about substance abuse off. So just know if you take care of HIMSS pilots or somebody who's being monitored for a drug and alcohol problem, they could now potentially qualify for the CACI for weight loss or pre-diabetes. All right. Other medication changes that she's made. So arthritis and psoriasis, there's an old medicine out there, Imuran, it's been around for a long time. It was on some of the CACIs, but not others. It's now been added to arthritis and psoriasis. The colitis meds keep changing. So you'll see here a list of about five new meds that are added to the colitis CACI. And then the other one is the glaucoma meds. So roe kinase inhibitors used to be on the yellow row that had a wait time, had to be a special issuance. Now they've been bumped down to where they could potentially be a CACI. All right. Next item. A lot of people are still on methyltryxate. When we rolled out the original CACIs for arthritis and a couple of other conditions, if they were on methyltryxate, we asked for a lab. We've looked at it again to see how we can simplify without making things less safe. And we've determined that if somebody has a liver problem, they're going to be looked at for the liver issue. If they have a kidney problem, they're going to be looked at for the kidney problem. If they've got anemia, that's a separate issue. What all that means is we're relying on the treating physician to make sure they're checking the lab that they need to check for the methyltryxate. But you as the AME no longer have to look at that for the CACI. So if it's an arthritis CACI and somebody takes methyltryxate, you'll notice on this month's AME guide, the lab row has been removed. So that just saves you and your pilot one step. Your treating physicians still need to do whatever they need to do to take care of that patient, but you as taking care of the pilot no longer have to worry about methyltryxate and lab. All right, next item, cholesterol meds. So the injectable cholesterol meds that came out a couple of years ago, this PCK9 inhibitors, you just have a four-hour no-fly. Most of them were on special issuance. Our cardiologists said, why are you guys doing that? Those meds have been out for a long time. We don't need to do that anymore. There's not the safety risk that we thought it had. So because of that, we were able to drop that down to green. So acceptable, doesn't have a wait time. In most cases, won't even need a special issuance unless the condition does. All right, next one. We keep looking at new antidepressants. So even though Vybrid has been out for a long time, we keep looking at what other ones we could add to the antidepressant protocol. Antidepressant protocol is the old SSRI protocol. But we've expanded past SSRIs. So Vybrid is now one of the meds that can be used for the antidepressant protocol. All right, and the next item. We were getting requests from the doctors for the aeromedical summary. So you know, a lot of your pilots are prior military. They might have had a waiver in the military. Their flight surgeon might have written up this amazing aeromedical summary. If we know that somebody has a complicated case or condition, and they tell us that they were in the military and they saw the flight surgeon, sometimes we will ask for that document because it's a very comprehensive history with a risk assessment. So aeromedical summary, if you're not used to these, it's not something we ask for all the time. It does not take the place of a detailed clinical progress note if that's what we need. But if your pilots are prior military or if you as an AME are used to writing aeromedical summaries, if you're asked for it or if that's information you think that will help us make the decision, you can certainly send it in. We just wanted AMEs to know that it's not the same as a detailed clinical progress note. It's a lot of in-depth information from source documents. In some cases, if we see a really good aeromedical summary, we don't have to go out and ask for the MRI or for the lab or for the other consult report because the flight surgeon has already talked about it in their aeromedical summary. So again, just another data element that we may use to help make a safety decision. Okay. As always, we like to do a little shameless plug at the very, very end. If you have any suggestions for our AME guide improvement, you can send those to AMEguide at FAA.gov. Keep in mind that this box does not answer any case questions. I want to take one last opportunity to thank everyone for coming to Grand Rounds this evening. I don't know if we have Dr. Weirich or Dr. Northrup if they want to wrap anything up, but this does conclude our session.