QuickBooks Online 2022, set up inventory items. Get ready because it's go time with QuickBooks Online 2022. Here we are in our GitGridGuitars practice file that we set up with a 30 day free trial holding down control, scrolling up just a bit to get to that one, two, five percent we're currently in the home page, otherwise known as the Get Things Done page. At least within the business view that we are currently in, if you wanted to switch to the accounting view, you can do by going to the cog dropdown up top, switching to the accounting view. We're gonna stay in the business view however, and we'll probably toggle back and forth to our other file which is going to be the sample company, just to take a look at where the relevant items are in the accounting view. Going back on over, we're now gonna be thinking about the inventory items. Last time we took a look at our inventory methods, we're entering our beginning balances into the system. These are gonna be our beginning balances. We wanna set up these items before we start entering new transactions into the system. It's all about at this point in time getting the process set up so that we can then lay on top of that the transactions for the current time period which will include the items and the plus button, the invoices, the expenses, the bills and so on and so forth to do that properly. We first need our chart of accounts set up and then we need to have our items set up to properly populate our invoices and sales receipts. We also need our beginning balances if there are any beginning balances from the prior accounting system or any starting numbers that we need to set up that we currently have. And this is gonna be our inventory items. We're gonna start with the ones that are a little bit more complex. This is probably the most complex one if we're using a perpetual inventory system because we have the amount here but I can't just enter the amount into the system. In other words, you might say to enter this amount, you might say, well, that's gonna be easy to do. I'll just go on over to my accounting bookkeeping over here possibly, which is where the chart of accounts is at under the business view. Close up the hamburger, I'll find that inventory account and then I'll just enter say a beginning balance into it possibly editing it at this point seeing if they give me the option for a beginning balance, if they don't, then I'll just enter a journal entry for that account by going into the register here and just entering a transaction for it. However, you don't really want to do that or I can enter, you know, go to the form of the journal entry, the plus button. I can also enter a journal entry this way and go into the form, but you don't really wanna do that because if you have a perpetual inventory system, we also need to track the items as well. So let's get back to the home get things done page. And so we gotta enter the items that are gonna support that one here. So that's gonna be a little bit more complex. We could find those items if we go back on over. Now we need to enter the items for two reasons now. We entered the service items, not because we had any beginning balances, but because it's gonna be used to populate the invoices and the sales receipts. Now we want to enter the inventory items for two reasons because they also will be used to populate the invoices and the sales receipts. And also because we want the beginning balance to be put in place, these will also be used on the purchasing side of things when we purchase inventory for the expense forms and the bill forms and the purchase order if we're using those forms as well. So we could find the items by going to the get paid tab down here. If you were in the other view, the accounting view, it would be in the sales tab and then in the products over here in the business view, it's in the get things done. I mean, it's in the get paid tab and then it's down in the products area. We're gonna close the hamburger up top. Now you could enter this one at a time like we saw with the service items hitting a new button up top and this time going to an inventory item, the most complex item and just taking a look at the fields that would be populated. You got the name, the SKU number now being something that could be useful. You can put an image of it which actually could be useful now if you have a lot of inventory that could actually help in the processing for different people to know what you're actually talking about category. If you have multiple components of inventory it could be useful to give subcategories the quantity on hand. Now, this is something that you usually only wanna use when you first set up the accounts which we can use at this point in time. You don't typically want to do this after you first done that because then it's gonna distort your accounting because any inventory after the first point in time you most likely purchased the inventory and then the date that you put it on hand the reorder point when it gets down to a certain level it'll give you a reminder to reorder the inventory asset account. So this is the account that's gonna be used when we purchase the inventory on the balance sheet the description that's gonna be the sales description that's gonna go on the invoice and the sales receipt when we use this item to make a sale the price and then the income account sale of product income and then the purchasing information that's what's gonna show up on the purchase order expense form and or bill form when you purchase something with this item the cost that's what we pay for it as opposed to what we sell it for cost a good sold account is the account that's gonna be hit when we sell the item with an invoice or sales receipt form and the preferred vendor would be the vendor that we prefer to purchase this inventory item from. So there's a lot more information here in case you then the service items in case you didn't wrote that wasn't apparent. So then we're gonna go back on over and say let's pretend that we have all these service items or inventory items that we wanna put in place imagining their guitars now. So we're gonna say we have the item the ELP it's gonna be an Epiphone Les Paul on the sales description purchase description the same thing and then we have an Epiphone Standard Pro Epiphone Riviera Epiphone semi hollow body Gibson USA and a diamond head ukulele. I'm not a guitar expert or anything I just I have a couple guitars but I'm certainly not a connoisseur of guitars. So if I get any of this stuff wrong I apologize it's just a practice problem and then we're gonna do our diagnostics on the guitar which is kind of weird too but I in any case it'll work. So then we got the cost here the sales price caused a good sold that's the account we sell it for on the expense side the income account is gonna be sales which I might have to adjust and then the asset account is here sales tax will be applicable. So note that this is the information that you might get from like another accounting system or we might set up our own kind of items in a worksheet which would be easier to do when you're first setting them up then trying to set them up one at a time just in your mind going through line by line it would be nice to have them laid out like this either from another accounting system or just to think through it when you're thinking about multiple inventory items and then import them into the system which is what we are doing now. Notice that the cost here is what we purchased them for so if I was to figure out how does this tie into this number on the balance sheet we would take this cost times the quantity that we have on hand which I did a little worksheet on here will give us and if we add that up it gives us that two, eight, nine, six. So as we enter these inventory items on hand and assign the cost to them and tell the system how many units we have the system inventory will record the transaction to the asset account of inventory at that cost the other side will be posted to some kind of equity account profit possibly opening balance equity. Okay, so let's do that. So let's do it then enough talk I've had enough of your talk so then we're gonna go inside here and we're gonna go let's hit the dropdown and say import, import and then same kind of instructions we saw with the service items now I'm gonna pick up I'm gonna download their worksheet again cause I wanna use their headers and make the import process as easy as possible that will be as easy as possible to use their data input fields instead of guessing what they are so I'm gonna take their worksheet and see if I can copy and paste my stuff into their worksheet so let's do it I'm gonna enable the editing so I can edit it I wanna enable my editing and then I'm gonna scroll up a bit and I'm just gonna go to the right I don't need their little thing down here I don't need that do not import this file as is yeah whatever, delete okay so we need the product and service I need that tab so I'm just gonna try to copy the tabs I need here I don't want the stuff in it but I need that tab I need the sales description I want that the SKU I don't have one I don't have unit numbers so I'm gonna delete that don't need it don't need it the type it's gonna be an inventory type so I'll just say inventory and I'll copy that all the way down that's the one we want and then sales price I need that but I'm not gonna put these sales price income account that's I'll have to look that up but we do want one the purchase description I'll have to input that the purchase price cost I want that the expense account we're gonna need that cost on hand or quantity on hand we're going to need that so I'm gonna say okay and the reorder point I don't think I chose the reorder point I'm just gonna delete it I don't have a reorder point don't need it inventory account we're gonna need that and the quantity as of date we need that all right now let's just copy and paste our stuff into the proper column so I've got on the right hand side the item name so I'm gonna say item name I'm gonna copy that and go back on over here and we're gonna put that in the product service name this is gonna be the short hand kind of name that'll be easier for us to pull up and then it'll give us the description which is just gonna be these the actual name of the guitar that we have so these are the guitars that we sell we sell guitars by the way in our practice problem and then inventory and then the other side the purchase description is the same where's my purchase description over here there it is purchase description populated and then if I go back on over and say okay then I need my cost and the sales price of the cost what we purchased them for obviously less than the sales price so we're gonna say we purchase these things they're going up in price right now it's an inflationary time period but this is where we're at purchase and then the sales price the sales price is going to be here copy in the sales price where does that go that goes over here sales price income account let's just look this up in our system and see what the income account is i'm going to duplicate this tab by right clicking and duplicating it and see if there's an appropriate income account for us to put our inventory items in to the inventory items into closing up the this thing up top and we're going to go into we're going to go into the get paid area in the get paid section and then let's go up into the products and services and now that's not where i want to go i just like saying get paid i'm gonna open up get things done page and then go down into the bookkeeping area for the chart of accounts close up the hamburger and then we're scrolling down so let's look at our income accounts down here say what kind of income accounts you given me quick books what kind of income accounts we got billable refunds sales sales of product income well that's very descriptive let's use that one sales of product income is that the one that they use by default by the way if i was just to open up a new item of inventory and scroll down yes sales of product income let's use that one that's the one that's the one that they like so i'm gonna paste that one right here pasted and then copy that down uh... what in the world can i paste it just with the text only paste special text they've got some old version of excel here's the problem uh... why why is it doing that what is it what is it do that that's annoying is it too sale well whatever i don't care that it does that that's okay it's going to be like that let me copy it again let's go back in here and say inventory sale of product income i'm gonna put that over here in this old version of excel is going to do something weird to it but i don't care i don't care that's okay it's not going to mess me up alright let's go back on over and so then the cost of goods sold that again we could look that up i think that would be straightforward on the cost to get sold side of things so that would be a default here it is cost to get sold account so that looks exactly worded the same so where's that account expense account is the cost of goods sold let's paste that special with the text only copy that down copy that roger out roger that and then the sales and in the inventory we got the sales line inventory line quantity on hand so this is how many units we currently have quantity on hand and then the inventory asset account is just going to be inventory but let's just double check that in my data input field that default line should come up here it's just going to inventory assets so that's we need to call it inventory assets account that's the one they want that's what they'll get paste it inventory asset account and then the as of date we want to make sure it's before the time period that we're working in just to make sure that they don't put anything into the current income statement so twelve thirty one twelve thirty one uh... two two i'm going to say and copy that down and does that mess up their thing to put it in that excel format if i go to import so that's that date formatting can mess them up sometimes so so but i might save it as a c s v file but i think it will give it a shot we'll see what it is so there we have it there's all the stuff now we could save it as a c s v file but i'm just going to save it as this file because they say they can handle an excel file so let's go ahead and just save this on our desktop i'm just going to put it right on the top of my desk so i know where it's at my desktop as it's called and we're going to put this into the quick books and we'll put it into the new company section new company and i'm going to call this inventory items save it i don't know what it's talking about with that but i'm going to close that out maybe i should read that probably would be a good idea but no i don't need to read it i'm not reading nothing here we go so now we're going to then import this so we're back in here if i close out the x we're in the new drop down and import and now we're just going to browse to find the file that i put right on the top of my desk right on my desktop in the quick books online and we're in the new company section new company file and there it is inventory items and let's go ahead and say next and so now it's mapping this is what they call mapping the headers to our headers which should be exact because we use their headers so product item that looks perfect sku we don't have one type is to type sales description to sales for description notice if they're wrong you can hit the drop down and and find you know try to line up the descriptions but we lined them up perfect by using the exact same names purchase purchase so looks good looks good nothing here on the reorder point inventory asset uh... quantity as of date so those look good let's hit next and say this is this we're gonna sell them and we're gonna buy them we're gonna track them meaning they're going to be tracked in a perpetual inventory method this is the name that looks good the s k u don't have one type it's going to be an inventory type as opposed to a sales type we could make these a little longer if we want to sales description there's the guitars that we're going to be purchasing and selling in case you're in the market come on down actually what i don't actually have them it's just a practice problem it's just a practice problem i have like a couple guitars but they're for personal use purchase description and then purchase costs expense is going to be the cost of goods sold quantity on hand reorder point inventory and they won't give me this last one because i made the sale the sales too small uh... maybe i got a scroll down a bit scroll down inventory asset account okay i think i think it's good i think everything is good so let's go ahead and import it let's do it let's do it import six of six products in service successfully imported success let's check it out just a double check that the success is actual success i don't really trust quick books all the time so let's close this back out and say let's see what they did then scrolling down here's our items so it looks like they imported properly here's the units that we have on hand if i hit the edit button now here's the detail that has been put in in this format so you can see the same kind of data input fields have been populated that we put in you know in the excel worksheet now we will add inventory items like more like this way or as we go in the future so you can see that too but notice it also now we have something that should have populated on the financial statements as well so if i go back to the second tab list let's open a financial statement and see what they did on that site what do they do on the financials i like to start to get things done page and then move down to the business overview that's where the reports are at and the reports if you're in the accounting view the reports are located in the reports tab down here and and then the reports just a slight difference going back on over back on over to the business view we're going to open up the balance sheet let's do a range change up top from let's make it from 010121 to 123121 because we entered it in as of the end of uh... december closing up the burger so there we have it and they put the inventory at four hundred that's not right four hundreds too small so i see what happened here let's i'm going to change the date to 123122 and then run it and then i get the right number so it's a date issue and it's always a it's always a date issue most likely so what i did is i went over here and when i copied it down it copied a uh... instead of copying it i basically made a running balance i want to copy i should have copied this and had it all at 123121 so i was sloppy in that so now i'm gonna have to go back on over here and fix it so i'm gonna so i could fix it in the system by just drilling down so i'm gonna drill down on the data here and i'm gonna fix the dates notice when i drill down on this data it's not going to take me back to the same data input form it's going to take me to a different uh... you know inventory adjustment form so everything that's not 1231 i'm just gonna adjust to 1231 so i'm gonna drill down on this form and i'm gonna say let's bring it back a day for five or save it close it and do it again so this one adjusting that one going back into that one this one this is what you this is what you get for being too fast on stuff you're too fast you gotta be accurate and fast accurate then fast that's the way it goes so we're otherwise you just running circles which isn't very helpful so then we're going to go back into this one do this one again adjusted back on to the thirty-first run it run it one more time you know base malls and back to the thirty-first okay now it's good now if i run if i go back to my report and i i just the drains change again from all one all one two one all one all one two one two twelve thirty one two one and run it now it looks good on that one and that's our beginning balance number that we had here right two eight nine six year dang right it is and then down here it put the other side into opening balance equity which is kind of not the most proper account but you can see they just dumped it into the other side into equity if i go into that we can see the same transactions here so that looks good and if i go back then that looks good because that means that every if i do that to every other account they'll dump the other side somewhere into equity so equity as a total will be correct once i do this for all the other accounts which we'll see as we go so that looks good and then there's going to be a sub ledger for inventory which we can run a different report for this right click up top and duplicate the tab and see that it's tracking our inventory unit items properly by going to the reports which if i go back to the get things done page i then go down to uh... to the reports which is in the business view again reports and i want to look at the inventory reports i'm gonna say inventory valuation summary let's go into the inventory valuation summary report and so now i've got the quantity here's the here's the items that we have the s k u the quantity that we have on hand the value and then the the average item so here's the total the two eight nine six which ties out to what we have here on our report the two eight nine six we have that added detail and if we were to create one of our reports up top to to now interfinancial transactions so that we can get paid we can hit the plus button up top an invoice or form or sales receipt we can enter these items and we could have our inventory items on down below right here in our drop down and they will populate for us making the data input super simple and it will actually calculate this thing which is a fairly complex calculated calculation we're gonna add sales tax at a later point so we'll have to deal with the sales tax later that's something you need to keep in mind when you add items to uh... we're going to do sales tax kind of on its own on its own thing because it's its own little complication but it's a fairly complex transaction to enter an invoice of inventory because it's tracking the inventory items and possibly dealing with sales tax but if you set it up properly just like when you scan something yourself at a grocery store it's basically easy to do because they set up the the the back end correctly so let's close this back out and say we're gonna we do you want to do you want to leave without saving i do i'm just gonna leave it without saving it and i could also hit the plus button and when we do up an expense or when we purchase something uh... we can also be purchasing items on the expense side of things or purchase order and we want to use the items then on down below and we can purchase the items which will then pull in the proper cost amount as opposed to the sales price because the items are driving both the cost and the sales price side of things super cool that to set that up super easy one set up not so easy to set up but once you know how to do it you're a lot more valuable to the accounting system


So, we're here with Gigabyte here at the ARM press conference area, so who are you? I am Jan from Gigabyte Server Marketing Team and I'm here to present our ARM-based server systems. So, Gigabyte is doing a whole bunch of ARM servers? And now we're starting to release some, so here you can see our first kind of ARM-based servers. So, here you have a high-performance computing app based on KVM ThunderX processors. You can see this is a two-use system with four blades. Each blade is a dual-socket system with two CPUs. Each ARM processor has 48 cores, so in total on the two-use system you have 384 cores, which is like extremely high-density for parallel computing. 484 cores in the two-use system. Like, and how many SOCs? Four. Eight, sorry. Eight. Because you have two per blade and you have four blades. Four blades. So it just goes like this? Yeah, it goes in like this. All right. Is this ready for shipping or is it just prototype or what is it? Almost. We are now validating on the OS and software, but like the hardware is pretty much ready. So how big is Gigabyte with servers? For server? Yeah. It's pretty big. Pretty big. We hope so. And the pricing is good and the power consumption is low? The pricing is not fully determined yet because we are still working with partners like Kevin. What's going on here? So this is how it looks? Yeah, this is the front. This is the back side. This is the front side. So just... So we have one of those with 384, did you say? Yeah. Of course. Cool. Awesome. And what is this one? This one is a cold storage one based on the Anaporna SOC. So you can see the... What is the Anaporna? It's one of the company getting all the processors. It's based in Israel. All right. It's been one of the most secretive so far. But like here you can see the SOC. This is a four-core, very low-powered processor driving the whole system. Is this for a lot of storage? This is for cold storage like an archiving system. Or like low access with frequencies. So is this potentially towards getting towards the lowest cost storage, cloud storage system kind of solution? It's targeted for this. Is this also assumed ready? Yeah, absolutely. All right. And this one? This one is more of a commodity server system based on an APM SOC. So here you can see you have a single processor here. And then it looks like a really standard server with all kind of an expansion that you would expect. This is standard chassis. You have plenty of memory. You have 10 gates on board. So you're redefining the possible. And this one is with applied micro? Yes. It's a genuine processor. So 64 bits? Yep. 8 cores. Performance uplift and unique proposition right here. So this is a big deal. Lots of ARM servers and potentially very, very big orders, right? Yeah, because we are offering solutions for any kind of applications. And they are interesting.


Good day. I'm Dr. Steven Pomerance, and welcome to the Mentor Case Review series, and our concentration today will be the menisci with some unusual and obtuse manifestations of meniscal pathology that you might not think of. I'm here with my talented young colleague, Dr. Joseph Eugorgi, and we're going to go back and forth examining some of these unusual manifestations of meniscal pathology. Let's get started. And this first case is put up in the coronal projection. It is a 51-year-old woman who complains of right knee pain. The clinical concern was for a meniscal tear. So let's start scrolling, and we're scrolling in tandem. Now, in an adult, as we've mentioned on numerous occasions, when you're looking for meniscal pathology, you're more likely to find it in the body. So if you're trying to be efficient, which is a good idea if you want to keep your job, if you're trying to be efficient, you should go to the mid-coronal projection, and often you're going to see horizontal, cleavage, degenerative tears that run like this, inner third, right here, middle third where my rings are, and then outer third where my knuckles are. Those are nonsurgical meniscal tears. Almost everybody's got them as they advance in age. They're nonsurgical. We don't get too excited about them. But the ones that are more fresher are ones that are swollen, or edematous, or gapped, or have cysts, or have an effusion surrounding them, or the patient points to that specific locale as a site of pain. Unfortunately, though, in this case, we're in the mid-coronal plane, and we have what's known as window framing. The meniscus has a window frame of low signal around it on the water-weighted image. It has a window frame of low signal around it on the T1 fat-weighted image, and that's just peachy. That's normal. That is nothing you'd ever want to call a tear. The signal is a little brighter in the outer third. It fades in the inner third. It might slope gently downward. It might communicate with the capsular surface, but not with the inner articular surface, or upper or lower articular surfaces. It's not as bright as Highland Cartilage. In other words, it's a nothing muffin. And it has the rabbit ears that we've talked about. It does have those two little rabbit ears. The rabbit's lying on its side.  The rabbit doesn't have a body or any legs, or it looks like a Y lying on its side, and we'll make it a little brighter just so you can see it. Now, you can make just about any signal a tear. You notice if I bring up the window, there's a signal that goes all the way into the inner third. It does fade in the inner third. And what is that? That is progressive meniscal degeneration that's occurring in a 51-year-old from living. But that is not what is ailing her. There is no swelling or inflammation or cartilage disease there. But she does have a problem. Okay. Let's see if we can find it by scrolling, and we'll bring the size down to match pretty closely and start scrolling. And one thing that the water-weighted image does for you is it helps you find the hotspots. It's a detector sequence. So you're basically looking for anything that's bright. There's a little bit of an effusion. There might be a little swelling immediately. And as we move backwards, there's a little swelling right here at the back edge of the meniscus, which is also known as the meniscus root. In other words, the very tip of the meniscus has an attachment to the tibia. Now, let's see if we can make a drawing. So if we looked at the meniscus coronally, it might look something like this. It's a little thinner near the center. It's wider in the periphery. And then for it to be fixated or anchored, it has some attachments out here, which we'll call the menisco capsular attachments. And they go all the way around. They may be a little tighter on the medial side than the lateral side. But there are also ligamentous attachments that go down to the tibia. And I have this one drawn in green, but perhaps I should change my color. Maybe blue just because it's fun. So there is our root ligament. And it's the postural medial meniscus root ligament. So let's see if we can find the root ligament. So here's the meniscus. We work our way in. Let's blow it up a little bit. The meniscus looks like it's fanning out a little bit. There's a little piece right there. And then the ligament should be right here. There should be a robust, dark, straight or arcuate structure that goes right on down. I'm not seeing it. I'm not seeing it either. Looks like a little fuzzy bear right here. And then a little bit of interruption, maybe some tissue in there, maybe not. And then a little more squiggly, linear tissue. On the T1 weighted image, which is far less specific in terms of contrast resolution, all we see is a big gray blur. So perhaps it's time to turn our attention to the sagittal projection. What do you think you'd see in the sagittal projection? You know, I think it kind of looks radial-ish. So I would expect to see a gap or some kind of a disappearance. That's what I'm usually seeing when I have a radial or abrupt ending tear like that. Sure. So let's talk about that for a minute, because there are different types of root injuries. For instance, let's make a picture and let's make the medial meniscus. Axial. This is an axial view. So this can get pretty tricky. So let's assume that we had a radial tear of the root. So the radial tear, a radial tear over here, not in the root, would look a little bit like this, right? A radial tear in the root, right at the root attachment, would look like this. And if it went all the way through, it would be enter a third, middle third, post-tier third. And when you started performing your sagittal slices, what would you see? You'd see normal meniscus, normal meniscus, disappearing ghosted meniscus. And then you might even see a little sliver on the inside, depending upon how close that root tear was all the way to the free edge. In other words, if the root tear was over here, closer to the root, but not quite in it, you would see signal of the meniscus here, and then you'd lose the meniscus falling into this gap, and then you'd see a little meniscus again. So those are types of root injuries, one right up against the free tip, one a little more lateral to the free tip, sorry, a little more medial to the free tip, and then there is the actual root ligament tear. So those are all kind of the family of root injuries, and the root ligament tear is going to be a little bit different. Let's see if we can pick a different color to make it easier on us, we'll try purple. So here's our root ligament, and it is going anteriorly, but also down into the screen axially to attach on the tibia. So if this ligament ends up being transected, then you'll see the meniscus all the way out, this won't be here, we'll erase it. This tear won't be here. See if we can get our eraser to work. So we'll have a pretty good looking meniscus, and then when we get past the meniscus, we'll have a piece of ligament, a space with swelling or blood, and then another piece of ligament going down to the tibia, and that is exactly what has happened here. Let's scroll it one more time. This is a true root injury. So let's go right to it. There is the meniscus. There's the root ligament. There's the interrupted root ligament, and there's the rest of the root ligament. So this is a somewhat unusual and difficult case. Now, if we were cruising along the sagittal, which was my question to you, what would you see? And you said, well, you might see a big radial tear, which is true if the radial tear is right on the root, or you might get all the way through the meniscus. Let's do that. So you're through the meniscus, and then on the very next cut, you see swelling. And what is that swelling? It's swelling around the torn root ligament. So it's suddenly, and without warning, not only does it disappear, it disappears into a vat of inflammatory tissue. And let's see how the T1 looks as well. This is a T2. It's actually not that helpful. Let's see if we have a true T1. This looks like a true T1. Let's blow it up and get our drawing tool out of the way. And that's exactly what happens. Good looking meniscus, still pretty good. Bang. Gone. A big fluffy area of inflammatory tissue where the root would have attached. So these are kind of subtle. These are kind of subtle.  Is this something that's going to get a surgery? Is this something that surgeons don't really know much about? Or what does this mean, I guess, for the patient? Sure. Well, I'd say it's an insightful question because it's not a common, it's not a common injury. A lot of general sports medicine people don't really know about this. The folks that focus on sports medicine only and or orthopedic surgeons that go in and look at these, they are familiar with this. And many times what will happen is the root will scar down. And so surgery is not required. However, if the meniscus has other problems, the other anchoring portions of the meniscus to the capsule are damaged and the meniscus at a young age is starting to slide peripherally, then you have to do something about it. Okay. You may have to sew the meniscus to the capsule and provide other stabilization techniques. Otherwise, the meniscus will become a non functioning structure. So the answer to your question is in the majority of isolated ones, they could be managed conservatively. But if it has other complexity to it, then each case is going to have to be taken on its own merit and the position of the meniscus and its stability based on physical examination, i.e. clicking or locking and the MR appearance.


We're going to go straight to line one and we're going to letter Kenny and we're saying good morning to Adrian Monaghan. Good morning, Adrian. Hello, how are you? Good morning. Adrian, it says here you're busy doing the housework this morning. Is that right? Yeah, just how you get ready for going out later on. Right, right. Very good.  Oh, no, just a bit of cleaning up. Very good, very good. So what? Hoovering, sweeping up, clean down the work tops? No, just a wee bit of tidying up, that's all. Are you a tidy person by nature, are you? Well, most of the time, yeah. You have to say that, you're on the radio. Alright, Adrian, I have a pair of wireless earbuds I want to give you this morning. I've got a little bit of work to do. Alright, so I have a list of random items in front of me. I haven't seen them until just now and I'm going to describe as many of them as I possibly can over the space of one minute. You have to guess from my description if you can what each item is. Alright, if you don't know one, just say pass and we'll move on.  Simple as that. So are you ready? Are you up to the challenge? Yes. Alright, let's see what we can do. I want to put a minute on the clock and your time starts now. Alright, this is an item of food you might have it for breakfast, you would fry it, it comes from a pig. It comes in strips, you can get it streaky. This is an item you used to take pictures, you have them on your phone now as well. You used to have to put filament. Camera. You're probably sitting in one of these right now if you're sitting down, it has four legs, two arms. This is a liquid you would drink to keep yourself hydrated. No sugar. Water. Correct. This is an item you would use to fasten an item of clothing. It's metal, it goes up and down a runner, it can get stuck. Sometimes really annoying. Correct. This is the main ingredient in bread, you can get it in white self-raising. You might have to add bacon powder. Correct. This is a tool that you would use if you needed to pull something out of a wall. It has two handles on it, it grips something really tight in order for you to pull it out. Hammer. No, it's for pulling things out, not hammering things in. It's got two handles, you can... Pass. Okay, this is an item you would use in an after... Time is up. Alright, so you passed on one of them, it was pliers, a pair of pliers. Pliers I did, come onto my hand just after it passed. I know, I know. It's harder when you're under pressure and the clock's ticking away in the back, right? It is, yeah. But anyway, you got a good score, you got one, two, three, four, five. You got six of them, Adrian, so not too bad at all, alright? Not too shabby, but someone on the line is going to try and challenge your score now. And we are going over to the other side of the county, we're going to Duncan Neely. And we're saying good morning to Noreen Freel. Good morning, Noreen. Good morning. How are you? That's bad. How are things in Duncan Neely this morning? I don't know, half a minute's the door. You haven't put the nose outside the door yet. It says here you're sitting just drinking a cup of tea. Yeah. Is that right, very good, right? Are you still in the dressing going, are you? No, no, no, no, actually. I was going to say, if you're still in the dressing going, I like your style. I like your style. Right, okay. We want to give you a pair of wireless earbuds alright now. Adrian has set a pretty high bar. You've got six of them alright. Do you think you can beat that score? Hopefully. Hopefully you can alright. Well the same rules apply to you alright. I have a list of items here. I'm going to describe as many of them as I can. You need to guess what they are from my description. If you don't know one just say pass and we'll move on. Is that alright? Yes. Okay. If you're ready, your time starts now. Alright, this is a food item. It comes from Italy. It's long. It's stringy. You have to cook it in water to make it go all stringy. It starts off hard and it's very straight. You boil it in water and it goes all floppy and stringy. It's an Italian dish. It's made from pasta. Spaghetti? Correct. This is something you would use to put a letter into before you pop it in the post box. It's made of paper. It can be brown. It can be white. You have to stand up. Correct. This is something that would be used nowadays to generate electricity. You see them up in the mountains? They spend round and round. They have to be up high. They generate electricity. Years ago they were used to grind up corn and meal. They spend round and round. They spend round and round. They're very tall. Nowadays they're used to generate electricity. Before they were used to grind up meal and corn. Do you want to pass? Pass, yes. This is something that will be on the wall in your kitchen. You put things on it. You're out of time. You're out of time, Noreen. The one you passed on was a windmull. It was a windmull. It's easier now that you're not under pressure. You got two of them, Noreen. Not enough to beat Edwin's score today. Thanks for playing anyway. Thank you. Enjoy your day. Take care. Hey, Noreen. I'm done scoring in Don Canilly. Edwin, that makes you our winner today. With a score of 6. Thank you. Alright, so stay on the line there. We'll get your details. Thanks for playing this morning. Alright. No problem. Take care. Enjoy. All the best. That's Edwin. And, either Kenner or Kenny. He is our winner of our Rewind Wireless Earbuds for today.


administrators and users assign the course creator role arrival to add new courses.  Take the edit courses link, add a new course. So give the course a full name, short name. You put in some sort of course summary or description. You choose your course format, a variety of other settings. When done, save changes.


You're not going to lose the house. Everybody has three mortgages nowadays. And that's when I knew they were lying. I slipped in the crab. Who put that crab there? Crab. I didn't see any crab. Don't tell me there were two crabs. They were in pairs. Because perfection can't be normal? My ear canals are very sensitive. They're stainless steel. Took a bullet and corrected it. Pass straight through. Here. Look at this. I mean, by definition, perfection is far above average. Average being normal. We have these to hold down the sound, sir. Oh, good. Thanks. Let's hope they do the trick. Perfectly normal. What are you supposed to be? Some kind of a cosmonaut? No, we're exterminators. Somebody saw a cockroach up on 12. That's got to be some cockroach.  I mean, honestly, that's like trying to tell your math teacher to up your grade from a C to an A because missing all those math problems is perfectly normal. Going up. I'll take the next one. And perfection mandates an A. What is this? Obviously, you're not a golfer. It makes no sense. What has that got to do with it? Back off, man. I'm a scientist.


Ableton On Air is sponsored by Green Mountain Support Services, empowering people with disabilities to be home in the community. Washington County Mental Health, where hope and support comes together. Media sponsors for Ableton On Air include Park Chester Times, Muslim Community Report, WWW, This Is The Bronx.info, Associated Press Media Editors, New York Parrot Online Newspaper, U.S. Press Corps, Domestic and International, Anchor FM, and Spotify. Partners for Ableton On Air include The Hard New York and New England, where everyone belongs, the Orthodox Union, the Vermont Division for the Blind and Visually Impaired, the Vermont Association for the Blind and Visually Impaired, the Montpelier Sustainable Coalition. Ableton On Air has been seen in the following publications. Park Chester Times, New York Parrot Online Newspaper, Muslim Community Report, WWW, This Is The Bronx.info, and www.h.com. Ableton On Air is a member of the National Academy for Television Arts and Sciences, Boston, New England Chapter. Hello and welcome to this edition of Ableton On Air, the one and only program that focuses on the needs, concerns and achievements of the Deaf and the Abled. I've always been your host, Lauren Seiler. Before we begin our show, we would like to say special thanks to Green Mountain Support Services for this opportunity to promote their conference. And we're also sponsored by Washington County Mental Health and many many many others, including the support from the Association for the Blind and Visually Impaired of Vermont, the Division for the Blind and Visually Impaired of Vermont, the Montpelier Sustainable Coalition of Vermont, and also Habitat for Humanity of Central Vermont. That's a whole mouthful. Welcome to Ableton On Air, Josh. Joshua Smith, Executive Director of Green Mountain Support Services. Yeah, thank you for having me. I'm excited to talk to you again. Okay, good. You've been on the show before to talk about conferences and so on and so forth, and since we're in, since we are in a COVID mindset at this point, we're talking about the sixth annual, the sixth annual conference which is online, it's virtual, the sixth annual Cerebral Palsy Conference, and by the way, you can go to, for that, you can go to www.CerebralPalsyConference.org and also gmssi.org. Josh, why don't you talk a little bit, well, you have a half an hour, but why don't you talk about the conference and what you guys are doing this year? Yeah, so we're doing this in our sixth annual conference and we're super excited to do this. This is the second year we're doing it virtually this year. And so one of the things that we've done differently this year is that we're doing it, we have three tiers of registration. The first one is free. We've never been able to do it for I mean to give people free admission because ultimately what it is is that we're doing it for is for people living with cerebral palsy, for friends and family people who are living with cerebral palsy, this is a great opportunity for people to network and share education and share stories. And in order to do that, it's super important to make sure that we have the ability for people to come out of any, you know, any background, any location, because it's all virtual and all you really need is, you know, an internet connection. Now, you have your organization hasn't been able to do the conference for free before. Why is that, you know, because now during COVID people are not just people with special needs, but people in general are having issues with paying for things, you know, they got to pay for their bills and so on. Why is it important to have conferences for free sometimes? We're not doing this for the money. We're doing this to make sure that people are able to connect with each other. One of the amazing things that we saw last year, and last year was our first time doing it virtually, and we planned on doing it virtually even before COVID because we were able to get the, we were able to buy the setup back in November 2019 before COVID hit because we knew the only way for this conference to succeed is to make sure that we're open for everyone, because one of the challenges that people talk to us about when we did it in Connecticut last year is like, I can't drive to Connecticut. I don't have the ability to get on a plane or I don't have the money for that. So what we decided to do before COVID, even before I said before COVID hit, is that we wanted to do it virtually, because that's the best way to access as many people as we can all around the world. Yeah. Arlene, you want to ask questions? Go ahead. Yeah. One of the things that we did this year, from one, we are kind of like minding, you know, minding bodies. So we're doing a lot of things for mental health and all of the things for physical health for people. And the other thing we're doing this year is we're having focuses on not just for adults living cerebral palsy, but also for parents who might have children living with cerebral palsy. And the benefit for that is so we have our audiences, our speakers looking to, you know, support people with cerebral palsy, whether they're parents, guardians, or people that work at agencies. Now, explaining the history of your conferences, because I understand Jim Kavanaugh is a big, you know, he started the conferences.  So can you explain the mission of that and, you know, why the conference was started because of him? I think 2016. We chatted, he, Jim Kavanaugh is a gentleman that we provide services for. And he told us that he wanted to go to a cerebral palsy conference. And we're like, sure, that makes, sure, we'll see what we can come up with. Turns out the closest cerebral palsy conference in 2016 from Vermont was California. So what we decided to do is the whole Yankee ingenuity situation that you can find that in New England is that we decided to make our own cerebral palsy conference. And they, too, of cerebral palsy conference, and our entire agenda, as anybody can go to, is cerebral palsyconference.org. Check it out. We have an entire list of what are, who our speakers are on our agenda. And day two, it's two days long. It's October 1st and October 2nd. And on October 2nd, the morning of it is going to be, we're actually going to be showing, enabled it on air episode, where he talks about his reasons for how the cerebral palsy conference started. Okay. Now, not because I'm looking, so it's, yeah, cerebral palsyconference.org.  If you go to cerebral palsyconference.org, there's a registration button that you can click on. And you click on that, and then you register with your email address. That's all we need. And from there, you'll be sent a link to access the, you'll access the conference. That's three tiers of it. And unfortunately, as of today, that's recording the third, that the last tier is not applicable anymore. It's not available anymore, because it's for sending a physical package for that. But we have the two ones. Of course, as we said earlier, there's the free one where you can actually access for free. So you're able to attend the conference, free, no problem. The second tier, which costs $20 is a bit, it gives the attendee the ability to access the conference for 60 days afterwards. So you can see everything on demand. But the benefit to that as well is that you are able to, because here's the thing, you can show up, go for free, no, of course, to have as much fun as you want. But we have always two consecutive sessions happening at once. So you're not able to see everything for free, because there's two sessions happening at once. But for $20, you're able to then watch any of them on demand that you please for 60 days after. Plus, we're going to throw in the ability for people to look at the on demand sessions from last year. So you're talking about over 24 hours. So it's like TV, it's like a television network on demand for people with disabilities. From the CP conference. But I'm viewing it because, I'm viewing it like TV because, like television, because there's a lot of these on demand channels. Yeah, Netflix, Hulu and others. Now, talk about your the importance of your the Greenmont Support Services podcast in relation to the conference because you guys have a podcast CP conversations. So let's talk a little bit about that if we can. Sure. So what we're doing with that, that's actually with our good friend Nicole Luongo, who is a really good advocate, a really good self-advocate for folks living in cerebral palsy. She was able to house for this first year to house conversations and have speakers come on and she's been really great for us. So it's kind of a companion podcast for the cerebral palsy conference. So I'm looking on the website and it says view conference agenda. So let's see what we've got here a little bit here and go from there. How long have you been doing these conferences? This is our sixth annual so this is our sixth year doing it. Wow. So let's see. You have here and this is all online. So starting at 10 a.m. check in and visit the exhibitors. So this is this will be set up similar to a real conference but online and all people who have to do is just click the links, correct? And it goes from 10 to 4 according to this. Now explain the missions and goals. We have 15 minutes left. So we can talk about your agency as a whole. Explain the missions and goals of Green Mountain Support Services and the importance of keeping these conference going. So as I mentioned earlier, we're a mission-driven organization. So our job is to make sure that we ensure anybody living with disabilities are at home in their own community. So which means that what we need to do is we firmly believe we don't do segregated settings. We don't do congregate settings. What we do as an agency is make sure that everybody has the same access to everything that everybody else does in their own neighborhood. It doesn't matter what color your skin is, what religion you are, what background where you're from or what your level of disability is, you should still access the same things everybody else does. And part of this from what we're doing with our Super Palsy Conference, it's a stage for advocacy. It's a stage to have people be more educated and learn and being able to share stories with each other because the thing is that there's so many people that are living with Super Palsy. There's 750,000 people living with Super Palsy in the United States alone. And giving them a platform that is created, that was created by people living with Super Palsy, for people living with Super Palsy. And this is, it's only, it's a very unique and it's the only one that exists right now in the United States. Any more questions you want to ask, Arlene? Yes. Now here's the thing. What are some of the misconceptions that you say that there's a lot of people with Super Palsy around the country? What are the misconceptions around people with disabilities when like people first meet them, whether you have Super Palsy or autism or any other type of specialty? That part. Some of who's not living in Super Palsy. I don't quite know the answer to that. And, but I do know is that when we do have these events, I always see people kind of figure, oh, I didn't know that. Oh, I didn't know that. It's one of those situations where the more you learn about Super Palsy, you learn that it's not, there's not one standard thing about it. Like there's always people have, people have different anything like that. So, but yeah, I would say it's just enough for us as an agency, like our job at hosting this conference is giving people that, you know, you know, make connections, things that we keep working on to do. And make more awareness of it, you know, people, you know. Exactly. Now, your agency's been around for how long? For 30 years, correct? So yeah, over 30 years now. Yeah. Okay. And all right, so what is the future, the main future of the amount of support services and these conferences? And I think for the conference, I think what we're, you know, or what we want to do is make this as accessible to as many people as possible. And, and one of those is just, you know, creating a robust networking community for people to communicate and talk to each other and being able to be part of this community, make sure we create this, you know, minority of self advocacy and networking is super important for us. How important? I'm not quite sure because it is virtual. So they, it's, you know, be as accessible as possible as that we can do. And I guess what we could do is there's not much we can do because it is all virtual. So if somebody doesn't have a laptop or something, then would you, well, no, no, no, no, no, seriously, would you consider next year if you do another virtual conference? But those that don't, because there are some people in Vermont that probably do not have access to computer, would you consider lending tablets out for this conference or, or, you know, or computers out for that, you know, for that matter? I know we're talking with our community to try to do, if we do a hybrid, like having a physical location as well as a, a high as a virtual location as well. So that's, that's a possibility. Then you get into the, make it a question of how do people, you know, physically get to the locations as well. Okay, well, now I'm noticing here and I want something jumped up at me. There's an event going on in your virtual conference that that basically doesn't, there's like us, it says how to use your social media for self advocacy. Okay. So what exactly will that entail? So basically, I guess it's going to talk about Facebook and stuff, or is there more, there's more to so, you know, because social media basically been crazy, you know, there's a lot of things that social media people shouldn't be watching these days. But how will, how will this work? You know, or do you have like synopsys of, of, does the website have synopsys of, of what's going on in the conferences? Yes, I do. Yeah. So all you have to do is go to CerebralPalsyConference.org, click on the 2021 speakers, and then click on that for Chelsea Bear, who is really big in the social media world. And then what you do is you would just click on her, her write up and it talks about what she'll be talking about on that, on that breakout session. Is there anything that we haven't touched on that's important for this conference or your agency?  You can also see all of our past events that we've done. So it's a really good, almost a museum of the entire conference over the last several years. So yeah, you know, our previous, our previous exhibitors, our previous speakers that we've had, our previous keynote speakers that we've had, yeah, it's all there. It's a great source of all information. Arlene, any more questions? Any last questions? Dad, what if you had your own TV network to put this on TV? Yeah, will, will, will, is Green Mountain Post Services thinking about bringing the conferences more out into the open? Like you say, you said it's on demand. So would you think about maybe doing a CerebralPalsy type of TV network online with other, other speakers and other things, other presentations? Well, we kind of already have that with our, with our, with our podcasts. Because you, anybody can go and watch those on YouTube right now, go to our YouTube channel, and you can see all of our, all of our past, all of our previous conversations that we had. But as I say, the point of keeping the actual breakout sessions, we want to make sure that we want to have people who pay for those, to still have access to those. So it doesn't make sense for us to make those free, because then it's not fair to the people who paid to see those. But all of our, all I think what we have is over, you know, 10 or so, 10 or so interviews that Nicole DeWongo did for us are available to watch anytime now, just going to our, just, you know, clicking on CerebralPalsyConference.org and then going to the About Us section, and you can see the CP conversations right there. Well, we would like to thank you for joining us on this edition of Able Don't Hand. For more information on the CerebralPalsy Conference, you can go to www.CerebralPalsyConference.org. The conference is the New England CerebralPalsy Sixth Annual Conference. Again, it's www.CerebralPalsyConference.org and it is October 1st and 2nd. For more information on, and by the way, Able Don't Hand will be at the conference. You can probably click a link and see past shows of Able Don't Hand from Green Mouth Support Services or Jim Cavanaugh's interview. Also, you can, you know, pay, Josh, you said it was $20 for those that want to... Correct. $20 for anybody that wants to see it for 60 days afterwards, and plus all of our previous sessions from the year before. Okay, and we would like to thank Green Mouth Support Services and other supporters such as Washington County Mental Health, the Association for the Blind and Visually Impaired, the Division for the Blind and Visually Impaired, and many, many others. I'm Lauren Seiler. I'm Lauren Seiler. See you next time. Partners for Able Don't Hand include Yechad, New York, and New England, where everyone belongs, the Orthodox Union, the Vermont Division for the Blind and Visually Impaired, the Vermont Association for the Blind and Visually Impaired, the Montpelier Sustainable Coalition. Able Don't Hand has been seen in the following publications, Park Chester Times, New York Parrot Online Newspaper, Muslim Community Report, www.thisisabronx.info, and www.h.com. Able Don't Hand is a member of the National Academy for Television Arts and Sciences Boston, New England Chapter.


I have the pleasure of introducing Dr. Yasmeen Bhatt. She's an anatomic pathologist with subspecialty expertise in pulmonary and cardiac pathology. Her clinical focus includes interstitial lung disease, lung cancer, transplant pathology, cardiovascular pathology. She's interested in education and she is the current chair of the DLMP Education Committee and recently published a textbook, Atlas of Pulmonary Pathology, first edition of pattern-based approach. Thank you so much. So I think I know the answer to this question, but I feel like I need to ask it. Are there any other pathologists in this room? Nope, just me. Okay. Well, thank you so much for the invitation and I'm going to talk to you today about the role of biopsy. It's been mentioned in almost every lecture. So let's talk about the actual biopsies. Unlike many people here, I have no disclosures. Okay, so we'll talk about how to recognize amyloid in tissues and then the histologic differential of amyloidosis for us from the pathology side as well as some of the challenges that we face. And I'm also going to touch on light-chain deposit disease, which I think has been briefly mentioned once or twice today, and then briefly talk about hereditary TTR amyloidosis. So we've already talked about this, so I don't need to belabor this point, but amyloid is a misfolded protein that deposits in tissues and that is not a good thing. There are lots of different types. You just heard a lot about AL light-chain and that's one of the most common that you see across all organs and here are a couple of other types listed here, but there are many more amyloid types that exist. So you might think, okay, you sent the biopsy, it's easy, right?  It's actually not always the case. So sometimes it's an unexpected finding. So I think one of the themes that I have seen arising out of the lectures today is that there's lots of different clinical symptoms that may eventually lead to a diagnosis of amyloidosis, but you're not necessarily thinking about it right away. And someone may have a GI biopsy for their diarrhea, but they're not thinking about amyloid, right? So for the pathologist on the other end, especially if when you, the clinician, are seeing the patient, you're not thinking about amyloid, we might not be thinking about it either. And sometimes on the actual tissue, the finding of amyloid can be extremely focal and can just blend into the background, especially if you're thinking about something from another side. I'll use GI biopsy again as an example. You're thinking, oh, this patient has diarrhea. I'm worried about inflammatory bowel disease. I'm looking for architectural distortion. You might miss the little slips of amyloid that are in the submucosa. So amyloid can be seen, of course, in any organ or any tissue. So it can be unexpected. And there are mimics. There are things that look like amyloid. One of those is light chain deposit disease, which I'll talk at the end. And there are other things too that look like amyloid that actually aren't. And then interpretation of the special stains like congo red can actually be technically challenging, especially if you don't have experience or you're someone who only orders it once every six months, once a year, once every five years. All right, so that initial tissue diagnosis. There are a couple of stains that I wanted to mention. So the first, of course, is congo red. So when we have something that's congo red, we want to see congophilia. Okay, so we want to see this kind of pinkish red color. All right, in this particular case, this is a myocardium wrapped around the myocytes. And then when we put it under cross polarized light, we want to see apple green by refringence, okay? So here's a nice example of that. You can see that nice apple green by refringence. This is actually quite beautiful under the microscope. It's extremely challenging to take photos of, so they always look really, really dark and not very pretty. But it's actually very nice under the microscope. Another stain I wanted to talk about was sulfatedalsium blue. So this is a stain you might not hear about as much. And this will stain amyloid in this very nice teal green, almost like a toothpaste, like that old toothpaste color. And then trichrome stains will stain amyloid in a grayish blue color. This is more of a blue, but it also can sometimes have more of a grayish tint. So those are the basic special stains that we use for amyloid recognition in tissue. So let's talk about the heart. So cardiac involvement, of course, as many people have said today, is very important for the prognosis of how these patients perform. Many different types can be in the heart, AL and ATTR, of course, amongst the most common. So let's look at an example. So here's an endomyocardial biopsy. And actually, can I, does this come off? Doesn't, okay. So this is an endomyocardial biopsy. All right, so, whoops, go back. So this would be the endomyocardium, all right. So if this was still in the patient, this is where the blood would be in the chamber. And then underneath here are all the myocytes. So I've given you an inset here on the right, a little bit higher power, sorry. Laser in your eye. And these are what myocytes should look like, okay. You shouldn't have really anything in between them. But if you look at this here, you start to see, well, okay, this is a cell, this is a nucleus. And then there's all this amorphous material around it, all right. And it has this almost like a little cracked structure. It's very light, light pink color. This is one of our standard stains, is a hematoxin and eosin. Everything that comes through surgical pathology is put with this stain. And you start to see that, okay, I wonder why this patient, I don't wonder why this patient might be having trouble on cardiac symptoms, because instead of a solid sheet of myocytes, we're seeing all this material replacing those myocytes. So if we go to, and here's another piece, this is actually, I wanted to show you the second piece because this is from the same biopsy. And it's a little less obvious, I think, compared to that last biopsy, where you see more myocytes and maybe a hint of something going on. But I could see someone who wasn't used to looking at these types of biopsies. And if this was what most of the specimen looked like, looked at it really quickly, they might miss this material that's edging in around the edges there. Okay, so I'm gonna start off with a sulfated alchium blue stain, all right? And this is a very nice stain for screening. And it can pick up very small amounts of amyloid very easily. So again, so our myocytes are this orange color here. And then you're seeing the sulfated alchium blue is all of this green, which is almost completely overtaking this piece of tissue. All right, and there's that other piece you can see now. It's really obvious there's green everywhere where there shouldn't be green. So the amyloid becomes very obvious on this stain. I'll say I really like this stain. We use this at Mayo for essentially all of our cases, but not all labs have this stain or a proficient in using it for this purpose. All right, so here's the Congo red, okay? And again, it looks kind of similar to the H&E because there's so much amyloid in this particular example, but it's a little more pink, a little more pinkish red. So let's polarize that tissue there. And then now we can see all of our green there, that kind of characteristic apple green birefringence. All right, so this is a nice case because there is quite a lot of amyloid, but it's not often the case. Sometimes you see just a little bit of amyloid or your biopsy isn't as generous as those that our wonderful cardiologists send our way. And so you may have trouble seeing the little bits. And one thing I also wanted to point out here is you see the apple green birefringence. And even in this case where there's a ton of amyloid, not every piece of amyloid is actually staining. And so that's something that I think people miss sometimes. It's not every single bit, it's a polarization. It's a physical polarization of how the light is refracting through that amyloid. So you don't always see the green absolutely everywhere. And when you have small specimens, this can be incredibly challenging. Okay, so we have amyloid, now what? Typing is of course very important for patient management, has been talked about in multiple talks today. There's lots of methods. There's IHC, immunofluorescence, electron microscopy. I will say probably the two most common ones I see people use are the mass spec, which is what we do at Mayo. We send it up to Rochester and then IHC. IHC has a lot of issues associated with it. It's not always sensitive, it's not always specific. There can be a lot of background, there can be false positives, there can be false negatives. Honestly, I would advocate against using IHC in identification of amyloid typing. So if that is what your pathologist is doing in your institution or where the lab where you're sending your samples, try recommending or asking, could we actually send this for mass spec typing? I think it's a far superior system and I have seen multiple cases where the IHC led somebody down the wrong road and then when we actually typed it, you get the correct diagnosis. Very sensitive, very specific. I'm always incredibly impressed with the amount of tiny amounts of amyloid that they can pull out with their micro dissection techniques in order to run mass spec. So I'd highly recommend that you use mass spec for typing rather than IHC or some of these additional methods. All right, so I would consider this to be the gold standard. All right, so for that particular case, the patient had transcyrheating type. This patient ended up getting a lung trans, lungs on my mind, a heart transplant. And this is a cross section, a short access cross section of what we're seeing from this patient's x-planted heart. And at first glance, when you look at this, you might think, well, probably for this group, you're not gonna think this is normal. But if I'm not talking to pathology residents and other trainees, I say, oh, it looks kind of normal. But it's actually not. So you have a diffuse thickening of the myocardium here. And you might think, well, is it hypertrophic because they have coronary artery disease? But then when you look at the coronaries, they're really clear and open. There's nothing going on there. Of course, you can get amyloid deposition in vessels. So let's look at a little bit higher. Take a piece here, all right? So this is that piece and you can see, even on low power, this is where the blood would be. You can see some blood that's left there. You have this modeled look to it. Certainly not what normal myocardium should look like on HNE. And all of those lighter pink areas is our amyloid deposition. You can see just kind of wrapping around the myocytes. So really, when you get this kind of visceral look at what amyloid looks like in tissues, it doesn't surprise you that these patients have clinical symptoms. OK, so let's move to another organ. So 65-year-old man, in history of hypertension, GERD, obesity, obstructive sleep apnea, he was endorsing progressive shortness of breath. And he was found on imaging to have multiple bilateral pulmonary nodules. So they eventually decided to do a biopsy on this case. And this is the biopsy. This is a needle core biopsy of one of those nodules. All right? So when you look at this, you're like, OK, well, I don't think that's lung. Is it lung? It just looks like a solid mass of pink. There's a few giant cells. There's some inflammation of the little blue dots or lymphocytes and a little bit of more normal lung here on the side. But even that has some evidence of hemorrhage going on right there. All right, so it's a light pink mass. Not too much cellularity. It's not cancer. Always a concern with patients is a carcinoma. So what are we going to do next? So when this case comes across to my desk, I'm going to want to identify what that material is. So when we see this material, which, of course, as you all can probably guess, is going to end up being amyloid, there are other things, though, that we have to consider that are much more common. So necrosis can be very similar in appearance. Fibrosis, so collagen fibrosis, some kind of scarring. And then, of course, amyloid. And then, very rarely, you might think about light chain deposit disease. So these are some examples of what some of these deferentials might look like. So on the upper left, you have necrosis. This isn't a lung biopsy. Necrosis has a little bit more of a granular falling apart appearance in contrast to amyloid, which has more of a cracked, almost like little sheet-like look. Fibrosis in the upper right. So again, I apologize, there's a lot of lung in here. So whoops, go back. All right, so here's fibrosis. So kind of similar to amyloid in that it's pink. But you can see that collagen substructure in fibrosis. Here's an example of amyloid in the lung. And then this is what light chain deposit disease looks like. It's very similar to amyloid, but it's a little bit more eosinophilic. OK, so we'll do our next step. We'll do some stains, a Congo red, sulfated calcium blue. We'll do what I call our special stains to look for bugs. So AFB, a zeal nilson stain, we'll look for acid fast bacilli, and then GMS to look for fungus. So here's that sulfated calcium blue, showing that very characteristic teal color. And then there's our Congo red. This is a nice example of what we call congophilia. So it's not enough to see something that looks like it might be polarizing. And that's a point I want to bring out here as one of the technical challenges is collagen, for example, will give you a little bit of polarized look. It'll look kind of refractile. And you might convince yourself that, is there a little touch of green there? Maybe that's what it is. But it's important that you're actually looking at congophilic material. And then that is what polarizes to show you the apple green by refringing. So it's not just one thing. You need to see both in order to feel confident in diagnosing amyloid on using this Congo red stain. So there's our polarization. Lots and lots of apple green by refringence there. All right, so this was a patient that we diagnosed with nodular amyloid. It's a more localized form, turned out to be AL type. Here's another example. This is actually a very recent case that I had. Again, patient had a nodule in the lung and the needle core biopsy was almost completely replaced by this pale amorphous material. And one thing I hope that is coming across in the photos, now all of these photos, most of these photos are a combination of in-house cases and consultation cases. So you can see there's a variability in what the stains look like in the colors. So it's not just a reflection of how they're projecting, that's the reality. So every lab is gonna look a little bit different. And so where you train, just thinking about pathologists in general practice, where you train what the few cases of amyloid you may have seen, it may look a little bit different than when you actually go into practice or if you move jobs. So amyloid looks a little bit different depending on what lab it's being looked at in. So here's a trichrome. So I mentioned trichrome earlier and you may say, why are you doing such a general fibrosis stain? And I'll get to that in a minute. And this trichrome on that same case is gonna show you this nice blue color. And I liked this picture because it also nicely highlighted that kind of cracked look, almost like a fish scale look that you can sometimes see in amyloid. There's our sulfated alchim blue. Again, that very nice teal toothpaste color. And then our Congo red. All right, so it's not as congophilic. The other stains fit, it's not as congophilic. And you polarize it and you're like, is there a little bit of green right there? Sometimes you honestly just need to turn the lights off in your office and turn the light way up on your microscope and play around with the fine focus to actually see that apple green by refringing. So this is actually more common than not in many cases. So even in a case like this where there is so much amyloid, it's like nodular deposits of amyloid, doesn't actually refract very well. And that's not uncommon. And that's what leads to some of these false negatives or equivocal stains that you might get.  If you don't have the experience to call something, you might miss something. All right, so this patient ended up having indolent B cell lymphoma, which is often the case with the nodular amyloid deposition in the lung. Okay, so in the lung in particular, it can be quite subtle. It's important to always keep it in mind. You can have systemic or nodular forms in the lung. I won't go over this table, but essentially when you have diffuse septal amyloidosis, you're gonna think about an underlying systemic amyloidosis versus nodular. You might think more about an indolent B cell lymphoma or something associated with that. So when I talk to our trainees, I say, okay, if you find nodular amyloid deposition, the next thing you need to do is look for the lymphoma, right? So that's the second thing we do is a whole stained panel to see if there are a lymphoma around. Is it Kappa predominant, lambda predominant, what's going on? Okay, so next patient, 73-year-old man, increasing shortness of breath, and here is our biopsy, very short. Not gonna go too much into the details of the clinical side of things, but this is what his biopsy looked like. So this is lung, all right? So these empty spaces here are where air would be, and then these are those at the delicate alveolar is after where air exchange happens, all right? So this is where the magic happens, okay? I know I'm talking to a group of cardiologists, but this is where the magic happens. All right, but there's a little bit, there's something going on here. This is actually not quite as thin and delicate as you expect. This is probably closer to normal. You can see there's single red blood cells in here, nice little capillary, but there's some material that's interposing itself in between, right? That shouldn't be there. So not surprise, surprise, but here's our stains. This is sulfated calcium blue. It nicely highlights, it's actually a ton of material in there staining green, and then you can see the same thing on your congo red, and then that nicely shows you this apple green biorefringence. But again, in contrast to how much green you see here, and I just wanted to point that out again, you see there's a lot of green, right? On our calcium blue there, but then when you look at the amount of actual apple green biorefringence, just a little bit right there, maybe a little there, maybe a little there. So it can be challenging sometimes to make these diagnoses. So this patient actually did also have a history of ATTR-type cardiac amyloidosis that was previously diagnosed, and now it was in his lungs. Okay, so I wanna talk about amyloid as an incidental finding, because we mentioned sometimes there, you're not thinking about this from the clinical side, and they get a biopsy. So this is a patient who was coming in for a mitrovalve repair. It's some myxomatous mitrovalve disease. I got it as a appendage and as mitrovalve, all right? So here's his left atrial appendage. At first glance, does it look too crazy? You know, we always look to see if there's any fibrosis, any hypertrophy of the myocytes, anything along those lines. Let's look a little closer, all right? So again, a little bit of vascularization, and I wondered, is there something in there that looks a little bit off, and so decided to do a congo red on this particular one? And sure enough, there's these very wispy, wispy congophilic material in between, okay? And then if you polarize it, this one actually was a beautiful polarization. We had ton of apple-green birefringents there. I was like, okay. Then I looked at the valve, and I was like, okay, here's the valve. All right, all this deep purple stuff is calcification. There's some fibrosis here. There were some myxomatous changes and some of the other pieces, but I was like, you know, looking at some of the material, it just, I just, I worried about this case. And so I threw a congo red on this one as well. Let's look at this spot here. So this is the congo red, and it's a little hard to tell with all the calcification going on, but there actually is some congophilia, right here, right here, right here. And then when you look at the polarization, sure enough, apple-green birefringents right there. So I sent for typing on this particular case for actually both, and the left atrial appendage came back as atrial nitritic factor, ANF type amyloid, and then the mitral valve came back as an interminate type of amyloidosis. So, you know, it's probably out of the scope to talk too much about ANF type amyloid, but certainly can have some clinical implications and is important to know, but it's a different type of amyloid that was in that mitral valve. And likely what was in the mitral valve was probably just associated with a localized degenerative process. But we do see this type of amyloid. Dr. Rosen's all gonna test. I send her, end up sending patients her way by finding all this degenerative amyloid. So it's kind of interesting you can see that. But this highlights how you can have different types of amyloid in the same patient, depending on where you take the tissue in. So for this particular patient, it may or may not have had significant impact, but in other patients, for example, where you're worried about like an ATTR type and maybe you find something that's degenerative, looking at the actual organ that's impacted can be really important. So actually getting that cardiac biopsy. So you can have multiple types of amyloid. All right, so let's take a bit of a different path here. So let's look at a lung nodule in a 78 year old man. Okay, so here's his nodule, high power. So very pink kind of amorphous material. There's a couple of giant cells here and here. Okay, and you're like, okay, this looks kind of like amyloid. This was one of my consult cases actually. And so the outside pathologist said, okay, it looks kind of like amyloid. I'm gonna do a conga red. So they did a conga red, maybe conga philic, but nothing polarized, nothing there, okay? So they were like, the conga red is negative. I don't know what this material is. And so they sent it out, which is totally reasonable. So what do we do next? So this is where those other stains actually come in very helpful. So when I get cases like this, I will add a sulfated alchium blue and a trichrome. And so this is what the sulfated alchium blue look like. Now, this is not that pretty toothpaste green, right? So this is kind of like a salmon pinkish color. Very different than what we saw in amyloid. And then here's a trichrome. We're not seeing blueish gray. We're seeing this bright fire engine red color. All right, so what does this tell us? So this tells us that the patient has light chain deposition disease. So this is not amyloid, it's not amyloidogenic. It's a monoclonal Ig deposition disease. You can rarely see it in the lung and heart, but it certainly has been reported. Renal involvement tends to be more common. The nodular form is associated with chogrens, low grade lymphoma, plasma cell neoplasms. So light chain deposition disease I feel like is often missed. At least once every couple of months we get a case that comes through a consult where they're like, we don't know what this is. We're just lost because the conga red is negative. And it's one of the reasons why I really like seeing some of these additional special stains. I think I have a chart here, yes. So this is amyloid versus light chain. And what the very, very simple sulfated alchium blue trichrome, the sulfated alchium blue, not all labs have this stain available for use, but every pathology lab is gonna have trichrome. This is just a stain for fibrosis. It's used in a multitude of different scenarios. So everyone's gonna have a trichrome. So if you have a conga red and a trichrome, you can pretty reliably say if something's going to be light chain deposition disease or not. So the trichrome will give you that very distinctive crimson red in light chain in contrast to a blue-gray color that you see in amyloid.  So very different colors. No chance of sort of misdiagnosing them because they look very, very different. And then of course conga red in light chain could be vocally positive or kind of weak looking or it could just be completely negative. As a side, you can have amyloid and light chain deposition disease in the same biopsy and in the same patient. That does happen and you get a very nice mix of the two colors. If you were to do electron microscopy, not as many people do EM anymore for this, but you would see a difference in an EM. You get the nine to 10 nanometers randomly oriented fibrils for amyloid, of course. And then light chain looks more of like this kind of dense powdery deposits. Okay, so I didn't wanna talk briefly about hereditary amyloid transirite and polyneuropathy since I know that this was a topic that was being pushed a bit here. I feel like it has been talked about in better detail than what I have on here. Certainly a progressive disease, very debilitating early diagnosis is key. What I will mention from the pathology portion is that biopsy is obviously very important in identifying these patients, but the biopsy is not always of the nerve, right? And even if the patient does have a nerve biopsy that's negative, there may still be amyloid there. And so there's a lot of value in considering other biopsy sites, particularly if they do have systemic amyloidosis that's being deposited in other organs that may be affected and might be easier to get a biopsy from. So certainly you can see that there. Oftentimes though, I think, fortunately the burden on thinking about this is on you all first to figure it out. If we can find it, that's great. We can confirm it and then send it for typing. All right, so again, same thing. This was actually, this paper was talking about ATTR amyloidosis as hereditary, but I thought in their table they nicely summarized essentially everything that I wanted to talk about with the issues associated with biopsy is that you can have false negatives depending on sampling, right? So amyloid is not everywhere. So even in that picture of the explanted heart that I showed you, not every piece of the heart was involved by amyloid, even though it was quite a severe case. In fact, I took a little piece of normal appearing myocytes from that picture to use as my normal myocytes for the picture from the biopsy from that patient. So sampling is everything, right? So if we were only getting one tiny piece, you may have missed the amyloid. So consider, and then the other thing I did wanna mention too, again, coming kind of harping on that point is if you don't diagnosis a lot or the laboratory that you're sending it to doesn't see this a lot, consider asking, could you send it out or did you do any additional special stains or maybe repeat the stain because I have seen more than one case come through our service where amyloid was either missed or it was called negative and it was clearly positive, things like that. So definitely there is a level of technical skill involved both in the laboratory side of running and creating these stains and then also in the interpretation side from the pathologist of interpreting those congo red stains. All right, so I think that's my last slide. Hopefully it caught us up in a little bit of time. Thank you.