AME Guide Grand Rounds August 2026 Session

Good afternoon or good morning to everyone. Thank you very much for attending. Welcome to our August Grand Rounds. Lots of changes this month. So I am not going to spend too much time, but I really appreciate everyone who was able to come to Oshkosh and meet with us. So for those of you who go to Oshkosh, we do have a meeting with the AMEs on Friday afternoon so that they can sit down with me and my folks. So I hope your summer's going well and the kids are back in school all that went swimmingly. So I am going to step away. Christy, all yours. So here are our objectives. First off, Leah Olson is going to talk about the new MAMRC registration procedure. Then we're going to hear from Dr. Richard Carter, one of our medical officers here at the FAA. And he's gonna discuss a lot of the updates that were made and released today relating to ophthalmology. Finally, Dr. Judith Fraser is going to be discussing other FAA AME guide updates as well as some medication changes. There's a lot of them, so hold tight on those. And then also we'll clarify some information regarding the psychiatry conditions that we discussed in last month's AME Grand Rounds as a result of the July AME guide updates. So without further ado, I'm gonna turn this over to Leah Olson. Leah. Thank you, Christy. We are gonna go over the new MAMRC registration process. We are moving that over into DMS. There will no longer be multiple platforms that you have to go to to complete your training. Next slide, please. So one thing I do wanna go over real quick, MAMRC is the online refresher course that you can alternate with your AME onsite seminars. We had a lot of questions today during our earlier session of what MAMRC was and is it a requirement. It is not a requirement as long as you complete a refresher training every three years, but you do have the option of completing the online training every other cycle. So let's get started on showing you how to register for that and completing that. So the first thing is you're gonna go to the designee management system website, which is designee.faa.gov. Once you come to this screen, you're gonna click on the My Access login, register just like you normally would log into DMS. Next slide, please. This will take you to the login.gov screen. I do wanna point out that if you are a US citizen, you're gonna wanna use the customer link. If you are an international AME, you're gonna wanna use the international customer link. We do have the military and federal employees as well. From my experience, it's easier if you will just use the customer link instead of the military federal. Something about the CAT cards kind of throws this off a little bit, and it's just easier if you use customer or international customer, whichever one applies to you. Next slide, please. Okay, so once you get logged in, this is your AME home screen. Over on the left side, you will see the down arrow for training. You're gonna click on that, and it will give you the option to find a course. Next slide. Under the find a course, towards the top of the page, you're gonna click in the designation type, field, select AME. That will filter out all of the other designee courses and give you just the courses for the AME designation. As you can see now, the bottom of the page is the MAMRCourse. You'll click on that. Next slide. And it will bring you to the registration screen. You'll click on the offering title. Next slide. This is actually your registration screen. We are not going to require the imitation only code as this slide shows. Whenever you do go to this screen, this will not be there, so you can just ignore that. But the enroll link will highlight, and you'll be able to click on that down at the lower right corner, next screen. Then you'll need to go in on the left side under my training and click on enrollment. That will bring up every course that you're enrolled in. You can see here that I have enrolled in this course on the far right side. If you'll click on go to the course, and that will take you into the course. Next slide. Correction. That will take you to login.gov, and you have to go through your login.gov credentials again, and then that takes you to the course. Next slide. I think we went backwards. There we go. So once you're in Blackboard, there is the course that you're registered for. You'll click on that course where it says start now. Next slide. And inside that course, you'll click on MAMRC. One more time, there's a lot of clicks here, sorry. We don't have any control over that. So click on MAMRC. Next slide. And then it will bring you to the details screen. You'll click start attempt. You only have one attempt. Next slide. Once you're inside the course, this is what it looks like. So your previous platform was Course Avenue. This is your new platform, Blackboard. You'll go down to the far right corner and click next. Next slide. As you get through the course and you finish, it will give you results for the test. Gives you an opportunity to print your certificate if you'll click on the next link on the bottom right. Next slide. Gives you your certificate of continuing medical education certificate. Down at the lower middle, you'll click print certificate. Gives you the opportunity to either print it or save it. And then you'll click on the next again on the lower right side. And once you have gotten to this screen, you are completely done. You'll go up to the upper left corner where the X is and click on that. Next screen. So back on the home screen of the training, you can click on history and that will take you and show you every course that you've taken in DMS. It also gives you an opportunity to click a transcript. Your transcript is just a list of all the courses. So basically it's gonna print this screen for you and whether or not you passed or failed it and how many hours of CME that you got. It also gives you the option to go back into Blackboard. I believe that you can go back in and reprint your certificate if you need to at a later date. Next screen. After you've completed the course, you will also receive a message in DMS that you've completed it. It will give you a pass or fail result. If you have your notifications in your DMS message box set to email, it will also email you a copy of this screen as well. I do wanna say that you do not have to finish the whole course in one setting. You can come back and back and forth and take it as you need to. There is, it's fine, it won't do anything if you leave the course and go back in. Next screen. I think that's all of our slides for this. It is. So I know we're running a little short on time today. So if you have any questions, go ahead and put those in the question and answer box. I will go over and answer those for you while they continue on with Dr. Carter. Well, good news for all of you. I'm not an ophthalmologist, so we're gonna get through this stuff quick. If there's any technical questions, I have some excellent advisors that'll help me out with that. So just be aware, there may be some technical questions you have that we will discuss with an expert then give you maybe an email response later on. Some of you may have heard me talk recently in Boston. We were at the heart, basically the heart of MIT. So we were just surrounded by a whole bunch of really smart kids. It was a great experience. Hopefully you enjoyed the conference if you were there. So let's go to the next first slide, amblyopia. So amblyopia is something that comes up all the time. You're gonna get a zero hour applicant come in who has amblyopia, can't see better than 20, 40 in one eye. And he wants a class one medical certificate because he's gonna go to medical school, or excuse me, to a flight school. So we want to try to expedite that process. And that's the point of this disposition table is you're still gonna defer, but give him reassurance that we can probably move this along pretty quickly. And by moving along quickly, what I mean in part is that if it's a mild amblyopias physiologic, i.e. he's always had that 20, 40 vision and the other eye is in pristine without pathology, then we are in the process of having a physiologic soda, a type of administrative soda issued because we feel that for that mild division deficit, a zero hour applicant doing a medical flight test would be of limited aviation safety value. So that's the real target. Now, there's some issues that come up. He has vision much worse than 20, 40. Well, we're probably gonna need another medical flight test. Or there is such a thing as binocular, i.e. both eyes have amblyopia, bilateral. So each eye in childhood never really was able to fixate well enough on the retina to get to 20, 20 vision. So we are not going, cause that questions come up. We are not going to consider a medical flight test for class one where neither eye can actually see 20, 20. And again, I mentioned, we need to be sure that in the guard variety cases, the 20, 40 guy in one eye, that in fact the other eye does not have other pathology. Other pathology does pop up. He had a retinal detachment in the other eye or something. So those issues need to be resolved. And so the next slide, we have an amblyopia table to make it easier for you. Again, this is for your help. Have the eye doctor fill it out and then we'll take it from there. And as I said, in most cases, we can expedite this disposition cause the airman and his mother are gonna be anxious to get the certificate right away. Okay, next slide. Diplopia. Just for your amusement, I asked one of our FAA consultants about diplopia and he laughed and he said, they're not gonna walk into the office with diplopia. If they have actual frank acute onset diplopia, they're not gonna be coming in to get an AME exam. That guy needs to see the eye doctor. So it's not really diplopia walking in the office per se. It's some variation on that theme, history of diplopia, issues that have come up in the past, or as the slides suggest, there's an intermittent issue. And so what's the POD call that we get? It's, is it okay if he has prisms for a persistent diplopia problem that's now stable, resolved, but he needs prisms? And the answer to that is yes. So again, a detailed report regarding that condition that it's stable and we have a better understanding of what the issue was. Now, regarding that issue of diplopia, if the airman presents a history of say, childhood strabismus treated surgically, he's now 20, 20, diplopia is not a risk, then you are okay to issue for that. If you get that history, childhood, I'm reading it out, make sure I say this to you correctly, childhood strabismus, you report in block six, he had that history. You will probably also be reporting that you had problems doing for you testing on him and make notation that there isn't actually an FA requirement that you have binocular vision, i.e. fusion stereopsis. So while that particular history may be problematic, be aware of that. What does that have to do with diplopia? Why are we doing this awful test that none of us wanna do, the forehead testing? I always dreaded that part of the AME refresher course when I was an AME, I never felt really good at it. So why are we doing that? We're doing it to test for the risk of diplopia, particularly in a fatigued airman that might evolve to diplopia over a long flight, for example, he had a mild tropia or a phoria and then there's the risk that there could be a phoria. So the phoria testing is for diplopia. So that's why we emphasize, we need an eye report from doctor. Ideally, we get a report from the eye doctor that says there's a good prognosis and he's not likely to develop diplopia under fatiguing conditions. That's what we really wanna know. So I hope that is helpful to you. Okay, next slide. Chorioretinitis, not going to come up very often, but what we wanted to emphasize is if they're stable, conditions resolved, there's no current concerns, then the AME can issue for that. So that's sitting there in the AME guide for you to use your favorite search engine. Typically for me, it's the one that starts with the letter G and this disposition table pop up and says, oh, it's been more than five years, I got a good eye report, I can just issue that. We're looking for stability, of course, if they're continuing to be treated and then if that's the case, then again, we need a detailed eye report so we can progress to considering a special issuance. Typically, we're gonna want visual field testing and OCT at a minimum for that type of issue. And of course, again, we're looking for stability. Next slide. So there's a chorioretinitis status summary to make it simple for the eye doctor to give us an outline of what's going on and what concerns might be there. For example, does the person have an autoimmune condition that we would also need to consider following? Okay, next slide. Retinoschisis, of course, is not the same thing as retinal detachment. You're talking about the layers coming apart. There's potential risk that you could have a retinal detachment with this condition. Again, our eye specialists say that this is probably going to be a presentation to you as an incidental finding. They're not gonna walk in and say, you know, I think I have this condition or I had certain symptoms or whatever, but we're thinking it's most likely going to be an incidental finding. So we need that detailed eye report. We need both the visual fields and the OCT. The visual fields are, of course, telling us if there's a larger geography of the retina that's involved or not. And the OCT is primarily focusing on how good is the retina. So this is a rare duck. I think it's extraordinarily rare. You see an item B to be thorough. This was added, but I think it's extraordinarily rare that you're gonna see an eye report that says this was due to a neurological condition. Okay, next slide. So in summary, congenital amblyopia, or at least that's the way I like to phrase it, typically they have very stable vision. They've had stable vision for a long time. We are going to consider whether we actually need a medical flight test, particularly in the vast numbers of zero hour class one applicants that are eager to get their certificate for very stable vision. So we need that eye report. Diplopia is simple, you defer. Or give us a call if they have diplopia, but it's now stable, controlled. And as I mentioned, for example, using prisms. If they have rare eye conditions, and I've mentioned examples, then defer and we're gonna look over the detailed eye reports and then see if there's a pathway for certification. And most likely there will be. So that's it for me. Headed back to our staff. So other updates that we have. Some of these are not very common conditions, but we want you to have at least seen them once. So if somebody walks into your office and they have Bruegger's disease, you'll be like, I've seen that once. I know that's in the AME guide. You all know as well as I do, the big risk is, is someone still smoking? So if someone has TAO, and they come into your office and they're stable, and they're not having any problems and they've stopped smoking, you'll be able to issue. If they still smoke, if they've had complications, in that case, the information that we're gonna need is in the middle column. You'll defer, tell us in block 60, and then it'll come up to the FAA for review. Next condition, POTS. So posterior tachycardia syndrome. If somebody gets tachycardia and passes out, probably not a good thing for them. It could be a safety concern, which is why we need the information. The biggest thing that we see when we see progress notes that talk about POTS syndrome, it's usually actually not POTS. So listed here in the evaluation data is we want a progress note from a cardiologist or a neurologist. It needs to specifically say if POTS is confirmed, equivocal, or not confirmed. Any of the other tests, treatment that they tried, the biggest concern is whether or not this is a true diagnosis of POTS. If somebody has a true diagnosis of POTS, they are unlikely to be certified. But again, most of what we see is not true POTS. So if you have a pilot who has a progress note or went to the ER and they're diagnosed with POTS, the next stage is figuring out, is that diagnosis confirmed? But again, be aware that this table is in the guide. It explains what you need to tell the pilot to collect, and then you defer and submit to the FAA. Next condition are AVMs. So since 2023, we have had a page about AVMs for neurological conditions. That's been in the guide for a while. But we've also seen a lot of pilots who have a peripheral AVM, lung, bone, liver. We obviously don't treat those the same way. They don't have the same safety risk. So if you have a pilot who just has an incidental finding, somebody did a scan, and on that scan, they find an AVM, and they don't have any symptoms, and there's not any treatment required, you can just go ahead and issue that based on the row A criteria. If you have a pilot who has a peripheral AVM, it's needed treatment, they've had symptoms, they're being surveilled because their treating physician is concerned that this AVM might change, then you'll defer. And the information that we need is in the middle column, which is really the progress note from whoever's taking care of them, any of the imaging that's been already completed. And if they ended up with surgery, usually for most surgeries, we want the HNP, we want the discharge summary, and we want the op note. If it's anything that involves pathology, we also request the pathology report. So just be aware, there's now an AVM for peripheral lesions in the AME guide. This is just an update to the neurology AVM. Neurology AVMs are easy, you have to defer. We do have the group of neurologists who will look at this. The important piece for you is what evaluation data is required. So we want the MRI, we want the CTA, we prefer an MRA, any of the imaging that was done. We actually, if the neurologists or the neuropanel look at these, they wanna actually look at the disks, so make sure you submit those. And make sure when you're doing a neurological condition, there's a spec sheet in the guide, you can see the link here on the top under number one. It details what we need an outside treating neurologist to tell us. So again, this has been in the guide for a while. If it's a neurological brain or spinal cord AVM, you'll defer, the information we need is in the middle column. If it happens to be treated, if they've had it treated with an embolization procedure, same thing, need all the information that's in row A, any imaging after the event and hospital records. Congenital sucrase isomaltase deficiency or CSID, we're starting to see a lot more of that. Most of the cases that you're gonna see as an AME are gonna fall into row A. We want you to issue, this is not going to be a safety concern in most cases. If they're stable, if they take a medication like Sucrade, Sucrade we have a seven day wait on it right now, but if they're stable, their physician's not concerned about them, you can go ahead and just issue. Anybody who's more complicated, they have to see GI frequently, they're having complications, then you would defer and we need the progress notes from GI and any other testing they've done. So again, we're starting to see more of this when we see newer conditions and we see more pilots having these conditions, we're trying to get that information out to you so when you see it as an AME, you know what the next step is. Also osteomyelitis, so if you get a pilot who comes into your office and they had osteomyelitis a couple of years ago, single episode, it cleared up, not recurrent, no long-term problems, that's something else where you should just issue. Most of the pilots that you're gonna see are row A. Row B is anybody who has recurrent episodes, two or more, they're on antibiotics, they've got chronic infections, they should be seeing infectious disease, so we want the progress note from ID. We need to specifically know the etiology and if they have any functional limitations. On the evaluation data, the middle column, if you see a number two or something that says it must specifically include, these are call-outs that may or may not be in a normal progress note, but they're call-outs that when we develop the policy piece, these are items that we need to be able to make the safety decision. So if you see it must specifically include, please check the progress note that you're gonna send in and make sure it has this information. So if they didn't talk about the etiology, we're gonna go back and ask for that. So if you know upfront and if your pilots know upfront to identify, it must specifically include and make sure those items are in the progress note, that will speed up the certification decision. Something like any functional limitations, if the treating doc is not used to having to put something about functional limitations, you as an AME, you should be confident knowing, yes, this person has a functional limitation that might affect their flight duty ability or no, they don't. And just make a comment in item 60 for us. So again, osteomyelitis, most of the ones that you see are gonna be row A, you're gonna be able to issue. But if it was somebody who has a complication, who has recurrent disease, we'll tell you in the middle section, what information we need, you'll defer and that'll come up to the FAA for a possible special issuance. Next item is subpoena. You may occasionally get a subpoena for airman records or maybe to provide testimony about an airman. Important things are if you are given a subpoena, make sure that you call your regional flight surgeon's office, call the regional flight surgeon's office and then send them a copy of the subpoena so they can review it. Remember any of the records that are being subpoenaed belong to the FAA. You may have those records, they may be in your EMR, they may be in an old time, if you still have file boxes in your offices, but those records technically belong to the FAA and you don't release them to a third party. So if you get a subpoena, contact your regional flight surgeon's office, send them a copy, make sure you realize that those records do not belong to you or to your EMR, they belong to the FAA and the FAA will release them. The other part is make sure that you don't communicate any further with whoever filed the subpoena or any other parties of the lawsuit. And then the FAA will actually notify the office of the chief counsel. On the left-hand border of this section, you will see two links to specific AME minutes on subpoena. They're very helpful, they're a minute, minute and a half, but they kind of go over the process. One question we get from AMEs is if I get a subpoena, can the FAA attorneys represent me? And that answer is no, FAA attorneys cannot represent you as an AME. They can help you with general guidance about how the legal process works, information about how to provide testimony. But if you're not an FAA employee, the FAA legal staff cannot represent you. So just make sure you're aware of that. But again, summary on subpoenas, if for any reason you get one, the first step is to call your regional flight surgeon's office and send them that subpoena so they can help you walk through the process. Next items are updates to existing material. So COPD, we've had this out in the guide for a couple of years. COPD for row A, which in most cases is the less severe disease. We had it that if your pulse ox was 96% or higher, that would qualify for row A. And it was 96% at rest. We were asked about, is that with or without oxygen? So in order to clarify, we just wanna make sure that everybody is aware that 96% at rest is no oxygen, it's room air only. So when we get these questions that come up, we know if somebody asked it, somebody else is gonna ask it. So we've just tried to clarify that guidance here. Next item is asthma. So on the AASI for asthma, you probably don't see a lot of AASIs for asthma anymore because most of the pilots are gonna khaki. But the AASI for asthma limited the pilot to be able to take three medications for asthma. So if they're on something like Trilogy, which is a triple combo, they take Trilogy, and then they take a short acting albuterol or something like that, that's four drugs. And that would technically kick them off of the AASI and they would have to go to a regular special issuance. The update to the asthma AASI just took away the requirement for how many different meds someone could be on. So again, most of the pilots are gonna khaki. And if they khaki, they can take inhaled steroids, they can take sabas and labas. There's lots of meds on the khaki. But if they do not khaki qualify, the next option is you'll have to defer and we'll look at them for an AASI or special issuance. And we've opened up the AASI. So we no longer restrict the number of meds they're on. One other thing to pay attention to is the FEV1 for an AASI. We haven't changed it, but it's still 70%. The khaki is 80%. So that's the other difference between the two. We get that question every once in a while. Next change. On sarcoid, one of the specialists realized that we had a slightly different wording than what's used clinically. So pulmonary stage one, the pulmonary X-ray finding only of bilateral hilar lymphadenopathy. That's it. If they're bilateral hilar lymphadenopathy, follow row A and in most cases, you'll be able to issue. Low T. Low T is a high volume condition. We see lots of pilots who have low T. There's a khaki, there's an AASI, there's a special issuance, and there's a status summary to help you make the decision faster and to help the treating physician know what information we need. One thing that we have on the status summary was if their hematocrit is 54 or lower or 55 or higher. And so we had a gap between 54 and 55. So we've updated the status summary question so that it says, is a hematocrit greater than 54%? We want lower hematocrits. If they're higher than 54%, the concern is a clotting problem. So we've just realigned the wording a little bit, made it a yes, no, and removed the gap between 54 and 55. So what you need to know is if you use the low T status summary, make sure you get the updated version and give that to your pilot. Again, the way the status summary works, if everything falls in the left-hand column, in most cases, you're gonna be able to issue. If there's a khaki involved, a lot of times those are the khaki criteria. So just know that the status summary has been updated to correct for the 54 to 55% hematocrit. Next item, last month, Dr. Bergdorf talked about the new AASI for anxiety, depression, and other conditions. Remember, this is somebody who is currently on a special issuance for antidepressant use. What has changed? If somebody is currently on an AASI for the old antidepressant program, when that authorization comes due, when that research is due, you are still going to submit whatever was on that off letter, old protocol. Once we have all of that information, we'll review the case and determine if the pilot can now be followed under the new AASI. If they can be followed under the new AASI, they'll get a new off letter that tells your pilot that they can now be followed under the AASI. And really what it does is reduce the amount of information that they have to send back to us and the frequency of visits. We were getting questions about how often do they have to see their treating doc. They have to see their treating doc once a year, and it does need to be a physician, D-O-M-D-E-M-B-B-S. So treating doc once a year, but they also need to be seen by someone every six months. So they can see if there's a nurse practitioner, if there's a PA, they can see that person for the six months, but once a year, which is what most AASIs are, once a year, they have to see that physician. So make sure that they get at least once a year with a physician and make sure you do not start an AASI process until your pilot has a new authorization letter. Until they have that new auth letter, they follow the old process. Other things from last month, Dr. Bergdorf talked about removing all of the requirements. If somebody is on the AASI, nope, if somebody is on the SSRI or antidepressant protocol, we no longer need a chief pilot report. So it took us a while to take it off of all the multiple documents it was on. But now if you look in the guide, chief pilot has been removed as a requirement for antidepressant SSRI program. If the pilot is in the HIMSS program, if a pilot has a substance abuse, drug or alcohol problem, chief pilot reports may still be required and are still on the protocols. But for depression, anxiety, SSRI antidepressant use, we no longer need chief pilot reports. One final update was for drug and alcohol monitoring. We had some terminology that said HIMSS were sponsors. HIMSS are monitors that are not sponsors. So we just updated that wording, which is clarified. All right, now let's go on to some medicine. So we have an amazing pharmacist who works at the FAA. Dr. Q has been updating medications. She searches all the time for what meds can we allow that maybe we couldn't, and can we decrease the wait time or the requirements when taking certain meds and still not make any concerns about safety. So she looked at the osteoporosis medicines. She added a new one, which is a serum, S-E-R-M, and a conjugated estrogen. So that's on the allowed category as well. On migraines, the CACI migraine was two pages. It expanded due to the number of meds that we had. She's actually gone through the meds and figured out which ones no longer need as long of a wait time. So things like Frova are down to 48 hours. Zofran, we were getting a lot of questions about Zofran. Zofran's a 24-hour no-fly and it's on the CACI. And then some of the CGRPs are 24 hours. So like Ubrevaline or Nertec, those are down to 24 hours. So again, just be aware that the migraine CACI has been updated. The medication no-fly time observation period has been decreased for some of the meds, but just use the CACI worksheet and that'll help you. For the biologics page, there are biologics that come out every couple of weeks to months. She added a new biologic to the interleukin inhibitor class. Same rules apply. It has a four-hour no-fly after the dose. But again, Dr. Q is expanding the meds that are allowed. So check the guide and see if a new med has been approved. Weight loss medicines. We get lots of questions about the weight loss medicines, the GLPs specifically. When they first came out, they had a much longer wait time. And then we went down to two weeks and now it's one week. So if a pilot is taking a weight loss medication, a GLP for weight loss or prediabetes, not if they're diabetic, but weight loss or prediabetes, GLPs are now a one week downtime when they start them. And that's whether it's the injectable or the pill type. So just a one week no-fly. And if they don't have any significant problems or side effects, then they can go ahead and fly. If they change formulation, there are a lot of pilots who are now on the pill type Wigovi instead of the injections. If they change formulations, pill to injection or injection to pill, and most of what we're seeing is injection going down to pills, it's just 48 hours after they change formulation type. But that's in the guide. So again, prediabetes or weight loss management, one week on a GLP and 48 hours if they change the formulation type. All right, diabetic medications. So there's a chart in the AMI guide of acceptable diabetic medications combination. And that chart's been getting very long because there are so many different classes of medications now. So Dr. Q went through and rearranged the chart, put insulin at the top so that it doesn't get lost in the middle anywhere. One of the things with insulin is it counts as one medication. When you see the screenshot of the chart next, remember each color is a different medicine class and the pilots can only take one of each color of medicine. So one from each category. The exception is insulin. So if they take long acting or short acting or Humalog or NPH or whatever insulin, they take combinations of those and still only counts as one medication. So insulin is A1. Any combination of insulin type products is still only one medicine. Other changes. Air traffic has been 90 days. They have a specific protocol for insulin treated diabetes that's based on 3930. If there's a first or second class pilot, they have to use the CGM protocol and they have to have an observation period of 180 days. So those have stayed the same. When we get to third class pilots, some of the third class pilots were doing the old finger stick protocol and they needed to sit down for 90 days and then they could be potentially special issued. And then some of the third class started using CGM because the technology was available. Some people find it more convenient. It gives you much better, faster results and it can predict where your sugars are going. They were originally held to the 180 days of observation period like first and second class. But now that we've had time to look at those, we know that third class pilots using either the finger stick protocol or the CGM protocol, they now only have a 90 day observation period. Other item is on the acceptable combinations of diabetes medications list. There are groupings of different medications when you start one, when you change a dose or when you add to a medicine and then they have specific observation periods or downtimes. And some of those were able to be reduced from what Dr. King or what Dr. Q reviewed. And then this is just a reminder of the acceptable combinations list. Everything is color coded. Each different class of medication has a different color. The numbers have been reorganized a little bit. So when you look at group A, group A is now insulin. Group A2 is the sulfonylureas and the megalotides. And then the other groups are all different colors. At the very bottom is similin. Similin used to be a disqualifying med, but Dr. Q worked with our fast endocrine consultants and it is still a special issuance, but it does not need to be a disqualifying medication anymore. And with that, I think we are done and I will turn it back over to you, Christy. Thank you to Dr. Carter, to Leah, to Dr. Fraser for presenting this evening. I hope that everyone found this very informative. Let's go ahead and go to the next slide, please. If you have suggestions for AME guide improvement, you can send an email to ameguide at faa.gov. Keep in mind that this inbox does not answer case questions. It is only for AME guide improvement suggestions. At this time, I'd like to conclude the session of Grand Rounds. Dr. Weirich, do you have anything to add? Yeah, just once again, on behalf of Dr. Northrup, thank you for being here. And we say it often, we'll say it again though, but when you look up in the sky and you see that contrail, you played a big part of that. Thank you so much for your commitment to aviation safety and thank you for being aviation medical examiners with us.