and that's what I'm going to introduce to all of you. My friend, Mike, please. My friend Mike. I'm going to introduce to all of you guys the speakers for the feeling of this talk. This talk will be done by me and my co-partners. The first person to introduce myself. My name is General Lee, and the person called me by the internet. I know what it does in here. I started working on this distribution in 2014. It doesn't become over the feeling you're local. Now I know the feeling, the technical committee members describe the feeling. The feeling community is an open source community that's about many people from different places. We are able to build an easy to use this total rating system. The image on the right is our UI over here, which has this total table in the north. And suppose we're running on X186 up and it's very architecture. And below is our home page. You can go there for more information. Respire with an image in open source instruction set up actually to offer numerous benefits, including flexibility and security. Our team is advocating that we're exploring potential applications and contributing to the development of this technology. Our team has many respire orders in world, including escalated devices and deep computing staff files, T-Heads, hyperlabel, and so on. This is a very welcome of our work on respire for the hardware to choose high-file mesh between 5 and 20. In the common layout, we object to the offline optimizes according to the hardware characteristics, including powerful managing, update display support, computing library and so on, to improve our performance. Also, we build an easy-to-use desktop environment called Mender UV-R to be re-use for rendering experience and for the application. We create an application-compatible way based on QMU or to enrich the application ecosystem in which the application of S8 and 6 architecture can run directly on the respire architecture. This is our landform architecture from source code to packaging combination to managing generation and to unite gesture. Those management and translation management are also connected to our computer. We try to automate the process as much as possible, including automating the code environment and automating the testing of the data industries. For respire-related compilation work in most tools, that's all QMU is used to lock up the devices. Since the end of last year, we have had almost 800 respire activities compiled successfully. Our goal is to build an open-killing respire version with a rich software ecosystem and seamless user preparedness. To achieve this, we are heavily focused on hardware platform, production and software ecosystem. Next time, my partner, the other one, will show our space-based work in those areas. Good afternoon, everyone. My name is Wang Wenzhu. I'm from the High Hall Library of Information Technology and Application Innovation in Tianjin, China. As a member of the open-killing technical committee and the respire of stakeholders, I'm thrilled to be here sharing our work with you. My teammate, Li Jianfeng, has already introduced the work of the open-killing community which covers software compilation and the system structure. In my part, I will elaborate our other work in the initiatives related to respire. First of all, let me talk about the hardware adaptation. For respire, it's new and promising as an architecture, but it also faces some challenges due to its early stage and lack of unified standards. This makes it difficult to adapt operating system on different respire hardware platforms. Therefore, we have been working to make our education compatible with various respire devices and the usual optimal performances. The first is to improve the power management module. This involves modifications to the device tree and the kernel driver to enable the operation of the power management chip. Then we can perform device shutdown, restart, and other functions. Secondly, we are working to optimize the system startup tool and reduce unnecessary service items. This ensures faster boot and efficient reduced boot time. Thirdly, we configure the operating system environment to ensure the normal rules for screen display network cut and USB devices. As we all know, GPU is a key factor that impacts the user experience. Therefore, we have developed a complete GPU software stack to provide seamless user experience. The first component is the driver in the latest kernel. This driver controls the GPU hardware events, managing the input and output of computing tasks. The second component involves adapting and calling GPU-related libraries including Mesa, G-Sphere, LiveGL, and other labs, which are essential for GPU. Further, we have completed the adaptation between OpenKD-UQI and the other software to ensure the normal rules of GPU in desktop environment. Finally, user-level applications such as the regional playback and the web browser are modified to utilize the GPU-level records. This results in higher performance and better visual experience for the user. So building a rich software ecosystem for this value is another key factor that we have been actively pursuing. Firstly, we have created a search of tools and resources that help developers use RISC-L more easily. This includes the comprehensive RISC-L 2-chain, that includes compilers, assemblers, debuggers, and other essential components. Additionally, we have created a software library that provides a range of calling functions and modules for RISC-L based on systems. This library includes various drivers on the utility slide, and you can quickly leverage the functionality of the RISC-L library. Also, we have built the basic user applications such as the bare-box library-based app and the OpenKD-UQI software, which can meet the basic needs for the data work. Finally, we have established the document and the support channels to help developers learn about RISC-L and address any problems they may encounter. Another way to enrich the software ecosystem is binary translation. This allows applications designed for one RISC to run on another RISC-L class. For example, I posted RISC-L 2 in both M1 and M2 chips to run x86 applications. There are also many open source projects that can achieve cross-platform software compatibility. In OpenKD, we are also working on this area to make x86 applications compatible with RISC-L. You will have many of the two technicals to improve the performance, including local library wrapping and dynamic block hatching. A local library wrapping is necessary to translate library files from the source platform to the target platform without transmitting overhead. This allows the platform to directly call the APIs of the local library, avoiding the translation process and greatly improving the system performance. This is the dynamic block hatching. It's another powerful technique as we all know, a small amount of code is executed for the majority of the time, such as the value and the order. By catching a translated code, we can award the need to retranslate each time, so instead we can use the previously translated code which saves time and improves the overhead system performance. Catching a code across can be implemented using different strategies based on specific application scenarios. So finally, let me briefly introduce our version of this work. It is very important to make OpenKD accessible and available to as many people as possible. Since we released the first OpenKD version Only.7 on July 2022, we have updated all version versions, each of which face the previous bugs and add some new features. For example, in version Only.7, we supported VLAN and adapted OpenKD's self-evaluated software. In version Only.7.5, we improved the system stability in OpenKD 9.5, we provided the latest Ukraine desktop environment. So our goal is to make OpenKD on this style a robust desktop environment system that can be used by a wide range of users from desktop users and developers to researchers and artists. So far, OpenKD can run on a five-way style platform, including HVAL iMatch, VisionDial 1 and VisionDial 2, T-Hide and also the Acubus. So the total number of downloads for all versions have reached 15,000 in under a year, from July of last year to now. And we hope to see an increasing number of research users in the future. Now I'm very excited to introduce Roma, the world's first laptop that comes with OpenKD pre-installed. We have equipped the system with basic application software and development environment to provide great use experience for experienced artists and users. So let's please welcome Mr. Liang Yun-Yin, the founder and the CEO of XCalibat, who will introduce the Roma laptop to us. Hi, everyone. Thank you for the great introduction on the OpenKD stuff and the great stuff. And I tell you the story why I started making the first laptop of my life. I run a software company called It's Terrified. We used to make compilers based on Open64. And we decided to make a laptop and to try to get it mass produced from a software guy like me and see how hard it is. It's quite hard. And this is the reason. The reason is that we want to have an experienced 886 you can carry around and play with it. And we come out of this type of storage and we don't need that close compiling. And a lot of open source is not supported but it holds compiling. And I want to try the latest on this by SOC, not only to see how many problems in manufacturing and especially mass production. I met a lot of problems especially in 2002 with the whole COVID things in China. And this is the whole from Mark this is by International. If we can get native development now we can access the software ecosystem OpenKit in all libraries and so on and so forth. And look at the laptop. This laptop is the thing is I can find and do. And we try everything hard. And it will support now OpenKit and possible Chrome OS in the future. And we make some speciality for example, we just kind of try it in the cycle and stuff and begin the box and like the stand and we make a very special hot kit close. Let's get rid of the windows. So that's the problem. And yeah, you will see if the window can show me here. So let's see where it is. It's real. So I don't know if you can see. But anyway, you can see this is a real respite things right and running on it's not joking. So let's see the R key see whether it works. R key for work on browser work. It takes a while to hold up. So you can see it's very very slow. But the point is that why we have to make the first step. Just 19 years ago when ARM has the first 64 bit it follows that now. Right. This is the first 12-inch 64 bit SOC. So and it's now in my experience I put the first ARM 64 bit on Android for Huawei. So I don't know what to think. I think now that respite is evolving with that kind of performance it's far better than ARM 10 years ago. So we look forward to another 10 years and respite will go beyond much quicker than ARM. That's all. You can see the browser is here and it's very slow. And we get better. And especially in May we have a much produced version. A lot more stable. The software looks better. So you look at now. This year we tried 12 nanometer. You will see we might have a much reduced problem. Probably might not be going through the stress testing and heat testing or stuff. But the 22 nanometers fine. And we will look in forward to the end of the year. We support 64 core very thick laptop coming up. And we have a big factory. And you can turn on and off all the cores. Whatever you like. That end. We look forward to Jim Keeler to blow out a very big FED IP coming out and probably sell nanometers. So we look forward to the older trend. And of course we cooperate with open heating. We have a lot of programs on the user the community program. So we are going to do some report for all the people contributing back to heating and our hardware products. And that's the people things. I use the thing is laptop structure. And with the high performance 12 nanometers ever in making a laptop and no experience the pain will come. And we go on through you can see this is the pictures that the SOC not designed good enough to much produce and we need a very high precision soldering just like mobile phone. Mobile phone is a lot of high voting and I can't book the capacity at all for just doing the soldering on the phone. But anyway we get it done by some good friends and this is our motherboard. So the motherboard we have we call it SOM module. And the motherboard we use. We try to use especially after a while we have our own chipset coming out the motherboard won't change. But the SOM will change according to the SOC approach. So it's a very ambitious ambition project. But it's very painful like Peter been chasing me for one. But we will get in there and we will get there. And yes we will open source our motherboard so everybody can take a look and how to make a laptop very easy, very simple. Now from our experience we can say that we will A to 10 weeks we will swap a new SOC and we can match produce a thousand laptops that quick. And yes and we will hopefully in around June we will have a push grab reviewer program. What money can we put Peter in the market. So wherever help us make him better product for RISC-5 or OpenKilling we will reward him. And yes we have a very good relationship with OpenKilling hopefully and we can run a very good international version of OpenKilling we are excited to see that we will do it over now. That's our goal. Thank you very much. RISC-5 chips is amazing to the thing going in. I'm kind of curious like where are you seeing compared to like the arm is good progression right? How do you feel like it's going to come out as far as power versus performance as it evolves? The hot ways I would say that is chicken and apple and the power and performance always a triangle balance. Hopefully the battery if I say that we are trying to compare 86 and I would think it's better but before arm I don't know right in the short term no. But we give enough time with RISC-5 and my approach and the point is we need the one thing now all the SOC companies they always have to choose the development goal. It's not the final product. That makes the the growing is hard. You got to go into a mess for the moment out of practice right? So to move people quick otherwise everybody waiting just showing off the development goal is not going to happen. But you got to test the market and if you fail and you make it better it's better. Hopefully I answer your question. Alright, all questions in the back. It's really great to see another open laptop. I'm curious about the case in the shell.  And I would say that all these in South Southern China they have a lot of common basically second of the libraries and then people can just match produce it with no copyright and blah blah blah whatever it is. And there's some fancy things there's some untested things and 90s one actually is matched producing in 886 and in the latest i7 and this year I and I did bigger screen. So we used the tested version of the structure and we just changed the board to this type. Basically I would say that anything help this type of pick up and whoever have ambitions that would be. That's why I go to all the people experience and I don't want the world to meet it again. That's why we open source it. You mentioned that you're going to match produce soon. Match produce session will be 7.0 will be DIY planning will be easy for you to replace screen replace battery change to go live. I think we will match produce this one and if the screen and all these things as not as you fit in the structure that possible. But if it's not then it's not. If it's not a modular it's not a full modular design yet. When I look at Chrome Google they do design a modular but the problem is that when you become modular and the price go up in the match produce. For example the 22 nanometer we looking down US dollar and the bone you know size whatever whatever whatever So we had to leverage the common view so we share a law component to x86 otherwise we won't get that cheap at all. Alright another question. We do that are you familiar with laptop? Yeah I heard about it but it's not going to get the price down. The price range is very weird. You have to reuse components as much as you can.  You module with your own cell phones. So you had to be sharing. Share as much as you can. Yeah and take the fancy structuring and change it and share as many components as you can and that will make much better. At the end of the day the laptop the battery basically the motherboard thing will change. Except 5.5 5.6 5.7 There's no point in changing a laptop for the motherboard. That's why we call it USB. Hopefully it will work. Yes. What supports extension standard USB and HDMI? Everything on Xtm. HDMI, Type-C Blah blah blah blah blah Type-C That means USB, USB port and audio and everything. Same as your mobile. Yeah. Okay. One more question. You mentioned about this. So then also by you think the chip is up? No, not the chip. We use in star 5. We will use all the SoC on the market and try to make it more useable.


This study developed and validated a preoperative prediction model to estimate the Omental metastasis status of locally advanced gastric cancer, LAGC. The model combines radiomic scores and clinical features to improve the accuracy of predicting Omental metastasis status. This model has been shown to have high accuracy in predicting Omental metastasis status in LAGC, which can be used as a tool to guide clinicians in making decisions regarding surgery. This article was authored by Hao Wu, Chang Lei Wu, Qing Wen Zeng, and others.


There it is. I just noticed my numbers at the top were off, so I got to reset them Mmm. You supposed to break your enemies not your stream Jokes He's got jokes chat Ha ha comedian in the house. Ha ha ha ha All right, what are we doing man, what are we doing? We got it. We got it. We got to break the dog over there Uh Yeah, let's breathe a doggo All right, we're gonna do a dark attack cuz yes. Oh That was delicious damage. I got to say chat. That was really good That was really good damage. I'm happy with that. All right, let's do a summon on linday. Is he gonna do a we Know he doesn't somebody's got to give me some money. I think it's you Yeah He's still hurting man. Well something old man. Maybe sacks. Oh Man comes through again chat.  All right boys and girls and children and dogs and puppies and cats Refreshing jam. That's my jam. Pretty sure that guy swords Pretty sure I'm wrong Please give him a turn. I need to do in sight. Thank you. I Need to look at the top see who goes. I never I always ignore that.  No There we go. You stab Letting my arrow fly in the true war dog. Come on. Give me a second. Yes Have at you indeed. Um, I Think I can do 200 health. Thank you. I'm really glad I did that cuz I just got hit for 200. I'm doing it again I'm gonna do it again All right, doggo You're up next boy and the third hit for great measure You see some dark damage on this guy Who one thousand damage look at me go? It is your turn girl. You know what you do it wait before you do still as money Indeed Wait, what happened to my insight? Oh, that was a we never mind There's still some ace SP this time. All right, let's do a Light He's already broke. So he's dark. He's weak to dark. I didn't know that I already stole from him So I was just poke him Letting your arrow fly in the true that That second serving though Well one person is to okay two people level 22 by the time I got to the boss, so I guess I'm I'm at level Yeah, I guess so Okay, I gotta go this way Okay, that's not the right way to go up. I guess It's gonna be a lot of fights. I Kind of don't want to explore cuz I'm limited on resources. Oh What were these dudes? Oh, I think it was There it is Swords come on man Bax Bax actually the one in the front is different. How about you? Are you? Yes Letting my arrow Actually, let's not do that. Let's just What next I feel him we're gonna need this Yes, I forgot to do my buff.  It's about to go down chat All right last fight before I get to him No, you can't have this dance. Don't be saying that Actually, yeah, I forgot you do this pretty much stun everybody Letting the hunt beginning You hit the wrong one, dude. How many heroes do I have just these four? If you don't count the old man Well, now that's the thing that I didn't know what happened. I had no idea that dude would do that I need to heal up the the warrior now For the next fight. I had no idea that was gonna be a thing Can I get this?  Pumpkums all right. I'm gonna be this chat Let's get right to the big dude Bigums is in the house chat Bigums is in the house Crap, that's not it Actually, I only got like two turns with them last time. Please.  Please All right, here we go Tank the damage sir with a we's we'll have to deal with dear god Man, I don't know what to do. All right. Shall I go dark damage or what man?  We got we got to get we got to get pops out here There we go pops you show them. What's up? Oh, man. Um Let's summon Killer bug Nice killer bug. You did your job Okay, I can't do a thousand spears, but I can do steel SP On one of these dudes Maybe I should there's still HP chat just saying still HP may have been a good idea.  He's got the mold dance. Oh, actually, let's do this Uh Let's buff up this mold dance Get the maximum amount of turns in here nine Old man doing his job chat. I don't know about y'all, but he's making me proud. Oh, no, he's dead Rip I've got 16 boy. You better get back up. Let's see here. Um She's dead chat. I mean, she's dead chat And the tavern guy left actually Okay, does that not do everybody? What's the difference between olive life and medium? Okay, I guess it doesn't do everybody So we're not gonna use it on that person that aoe man That one right there. Okay. Um Well, it looks like I got some more grinding to do chat Just think I went there the first time is level 17 Good thing I saved before I bought out of stuff Uh I put in three. I think right.  I have four saves Oh, no This is my grinding one. So that's the one I was gonna go back to anyway Actually, no, I want to go back to this one. I have four saves chat. What happened to him Yeah, this is this is the one right before the boss fight What happened to my four save? I want my money back I guess I'm gonna have to manually run out No, I I did a fourth save from the uh from the save thing Because there's seven slave slots say seven save slots seven save slots And I made that fourth an experimental one And it didn't Anyway, we're about to leave All right, let's go this way they're gonna give me one more fight before I get to the door watch Did they did they did they They did not They did not I guess I can grind here Yeah, see I use the four slot. It's even scrolled down for me And now it's empty because I did exit the title Earlier that that was weird. I lost a save slot That's very weird So maybe you only can keep three Yeah, let's just grind here Oh Of all the things to grind I hate this. All right, whatever Um, I think we're gonna do an offensive thing here. Wow How disappointing was that? Oh, I'm gonna I'm gonna need I I've got like all the gear So it's gonna have to be levels I'm gonna have to grain levels because Well, don't kill them That break these birds man. You saw you saw what that aoe did, right? Yeah, that hurts All right, I'm both stunned All right, we'll do a still health Have to do this night out Hold on We'll do a still health on one of these guys in the back Oh, I I'm gonna use my BP. Whoops Well, that would have been that BP would have been useful there, but whatever Let's go knock this guy out Teach him. Oh, man Uh, seal this guy What enemy are we grinding for or just getting more? Well I'm on the level for the boss. I'm trying to fight So I'm getting levels so I can actually kill them That's what I'm doing Hannah needs some healing grapes chat I just I just attempted the boss and got two shot basically It was kind of funny I gotta admit that was pretty funny. All right, give me give me a second win here Oh, no, I didn't do it. Actually she can use the health Yeah, that boss just destroyed me. See this grind here may be too slow We'll see how much XP I get Oh, no, the old man's gone chat Uh sp still I got 11 out of it. Oh no his insight wore off Ooh, that's very bad those birds man. They're so annoying gosh Using this and I actually need them. I need three more shots of uh Something on him Get rid of this armor. Why he left already man? Oh, there he is I don't know why I didn't see him 41 on the collect over it Take all of my bps Because you're about to do the ultimate of the lifestyles right now Uh, not ultimate still was good though Uh moonlight Definitely should be able to steal now 16 health he must not have a lot of life left The thrill of the fight It's kind of weird man. It's like you want to Part of me wants life bars on the enemies and part of me doesn't Right then and there I wanted life bar so I can see if it was worth it to do lifesteal I mean, I know you're supposed to get a feel for their health and stuff and Let's go ahead and do this. I almost never do this. I need to do it more often Um Let's just heal them between fights I really do it. I got a lot of healing grapes now.  Hmm Do I have a dagger like Hey, we I don't wait. I haven't checked my skills in a while Hey Guy need grapes Um Might as well just Insight Do you fast travel?  How long you've been watching me mac book?  Just just think about that for a second. How long? Okay, you've answered that now. When have you ever heard me say that I'm just gonna walk everywhere And I'm never gonna fast travel. What have you ever heard me say that? Think about it. What have you ever heard me say that ever? I've never done that. I'm fast traveling like my face off um What do here? What do here?  Uh, I can tell you what next What is these guys? What are they? What are they vulnerable to man? That middle vulnerability slot. I'm really curious. It must be like fire I've tried axe I've tried bow I've tried sword Must be something element Because they're annoying. They're very annoying and I don't have an aoe dagger skill I do have a aoe, you know, I have the aoe uh wind skill So I could take them all out like that But the dagger man The dagger Okay, well, let's do this Actually, I don't need to do that.  Look at all this money sitting here chat 97% and I failed.  They just beat them into the ground.  Oh, okay. I thought nobody was uh No, I rather do sp still 37 sp. Ooh, that's delicious Letting your arrow do his thing girl


All right. I think we'll go ahead and get started. Our presentation today is from our star VA intern, Ashley Byrne Heisel, who's been navigating mountains of paperwork and doing a great job. So we'll let her get started. All right. Today's case is about an 80-year-old man who walked in to my clinic from the VAED. His main complaint was that he had a sudden decrease in his vision in his left eye. He described that his vision loss started two days prior to presentation, and the first day it was just blurry, and then the next day it was as if a complete current had come over his left eye, and then he didn't make it in until the next day, as most of that stories go. He denied any associated flashes of light, floaters, no headache, no eye pain. His past medical history is congestive heart failure, hypertension, sleep apnea, some dermatitis, aphib, some severe left lower extremity neuropathy in which he needs a cane for COPD and hyperlipidemia. Here's his long list of medications, again, as most of our butts have. His prior ocular history is pretty minimal. He did have both cataracts done in July of 2013, about two weeks apart. He was last seen in ophthalmology clinic in August of 2013. At that time, he was given artificial tears for myelobliferitis, and his vision at that time, about a month after cataract surgery, was 2025 in the right eye and 2030 in the left. He was discharged to optometry after that point. In October 2014, so just a few months before I saw him, he was seen by optom and had 2020 vision in both eyes. So on his eye exam, his visual acuity when I saw him, he was 2015 in the right eye with correction and no light perception in the left. His pupils had a four-plus APD in the left eye, tried to measure it with the log filters, and there were not enough of them to make any difference in his APD. His sclera were normal, corneal normal, anterior chamber was clear and quiet, and his irises were normal in both eyes. On fundoscopic exam, his vitria showed no anterior vitria cell in either eye. His optic nerve, his right eye, did show a small splinter hemorrhage inferiorly. His left eye, the optic nerve was diffusely pale.  The cup-to-disc ratio was 0.5 in the right and 0.3 on the left. His macula showed some mild AMD in both eyes, and there was no red cherry red spot in either eye. His periphery in the right eye was normal, and in the left eye there were some attenuated vessels. Here is his fundoscopic exam photos. You can see in the right, you can still see the borders clearly of the optic disc, and there's just that minor splinter hemorrhage inferiorly that you actually had to look a few times to really even be able to notice. In the left eye, you can see that those borders of the optic nerve are more difficult to define, and although it is very pale, not quite chalky white, but there is a little bit of a cotton white spot inferiorly. Now the pictures kind of make it look like there is a cherry red spot, but I think it's just the way that these are developed. So the differential at this point, the biggest on my differential at first was NAION, also AEON, and really there's a large differential. It could be an infiltrate, toxic metabolic demyelinating. So walking in the diagnosis in this patient, I'd ask a few more questions. So he continued to deny any kind of headaches, no jaw claudication, no girdle weakness. He did feel like he had some loss of weight. When I initially asked him, he said, oh, yeah, I've lost some weight. It's been really slow over the last couple of years. I think it's just because I'm getting old. When asked again later, he said, oh, yeah, I guess my appetite's been pretty poor lately. So comparing his VA picture that's in the system compared to how he looked at that moment, there was quite a bit of thinning temporally. So when evaluating his temporal arteries, right anterior to his ears, he actually had pulses bilaterally. But it wasn't until I felt up more in the ocular region that you actually lost the pulsation in the left temporal artery. But there was no tenderness. So based on the severity of his vision loss, the optic nerve appearance, his weight loss, and then the loss of the pulse in the left temporal artery, we decided that this was definitely GCA. So that's what we used to decide he had GCA. However, there is no really clear classification criteria. What is available is largely based off of a 1990 study published by the American College of Rheumatology. So this study, the main point of the study was to really compare GCA to other vascularities. And it was from that study that they came up with a sensitivity and specificity of 93-91% if the patients have three of five criteria. However, it's kind of been adopted as just diagnostic criteria for temporal arthritis in general, even though that was never the intended purpose of the study. So here's that table. I call it a differentiation table because it really wasn't meant to be a classification table. So if patients either have an age over 50, a new headache or a new type of headache or head pain, ESR greater than 50, temporal artery tenderness or a loss of pulsation or a biopsy specimen, then those are the sensitivity and specificities if they have three or more. So just a little bit about temporal arthritis or GCA is now more common term. It is the most common vasculitis affecting people over the age of 50. It's most common in Caucasian females. The female to male ratio is about 2.5 to 1 and visual symptoms occur in about 30% of patients and a lot of studies have a large variety as far as what that's quoted, but 30 appears to be about the average and about half of those end up being permanent vision loss. So it tends to occur in medium to large size vessels of the head and neck and prevalent studies again are buried about 100 to 300 per 100,000 patients and incidence is about 3 to 22 per 100,000 and the median age is about 70 years. So as ophthalmologists, an important question is whether or not we can predict which patients will end up with permanent vision loss. So the answer is that if their vision is still transient, if they have double vision, if they're having a curtain come over their eye and then go away, if they're kind of in that waxing and waning stages, if you start them on a corticor storied in that time period, then you're more likely to preserve the vision. However, once they have a defect, it's pretty much going to be permanent. So what causes this disease is really poorly understood. We do know that it is an autoimmune disease. Some various studies have shown that there's seasonal and geographic variation, which makes it seem more like an autoimmune disease because it looks like infections, such as mycoplasma, chlamydia pneumonia, Parvavirus-19 might bring on sort of that autoimmune inflammatory response. There are some studies that show there might be some genetic predisposition which are in HLA types and also some gene polymorphisms in IL-6 and TNF as well as other immune system polymorphisms. So some extraocular manifestations, aortic aneurysms and aortic dissections, those usually happen not acutely, but down the line. Polymyazurumatica is associated about 30 to 50% of the time with this disease, either before, with or after the diagnosis. Scalp necrosis, as you can see in the patient, is a manifestation of this disease, although it's pretty rare. You can also get stroke and MI, and the vasculitis can cover the entire aorta and even go down into the iliac arteries. So going back to our patient, he was admitted directly from my clinic to the neurology service. He was given three days of IV steroids and due to the patient's request because he only wanted to stay two nights in the hospital, he received three doses of 1,000 milligrams of IV-solu-medrol. Current recommendations are 250 milligrams IV-Q6 hours for three days. On admission, his ESR was 16, CRP 19.5, and platelets 233. So again, those aren't super high, but based on our clinical suspicion, he underwent a temporal artery biopsy, and that biopsy was positive. So talking a little bit about pathology for this disease, it's a transmural inflammation of all three layers. There can be obliteration of the lumen, which causes the ischemic complications, which I just spoke about. Infiltrates can include T-cells, macrophages, and biopsies can show skip lesions. Giant cells for which it gets its name aren't always present and are not necessary to make the diagnosis. So here's a normal temporal artery biopsy. You can see the layers here, the adventitia on the outside. Looks like things got moved around. The arrows disappeared a little. Oh, they're just really light. So the media in the middle and the intima in between. And you can kind of see the wavy lines right here that go back and forth, and that's really important to note on these because that's the internal elastic lamina, which GCA characteristically destroys. So... Yes, yeah. So the adventitia is right here, this darker layer. The contrast isn't really good. I don't know if you can see kind of where it ends, but you can kind of see right here this is kind of a thicker layer right here, and that's the media. And then the swiggly lines right here, that's the elastic lamina and then the intima is the inner layer. Is that okay? So this is from this patient, a friend who's a path resident was able to take pictures for me, which I really appreciate. So there's the characteristic of GCA, like I said before, is that there's infiltrate in all three layers, and actually I think in this picture you can kind of see the three layers even better. They all have those blue or purple spots so it's showing that there's inflammation in all three layers, and you can see that there's a blurration of the lumen here. And actually if I go back you can kind of see where the back and forth squiggly lines end because of the infiltrate. And that's kind of the line showing where there's more inflammation so you see more of the blue and the purple in that area, and that's also where that elastic lamina is not present anymore. And this is a little closer up again, and the top left corner you can see the lamina pretty clearly waving back and forth, and then as soon as you get to kind of where the purple areas infiltrate you'll lose that back and forth wavy line. So this is not my patient, he did not have any of the classic giant cells, but this is kind of what it would look like if that were the case, and then where those giant cells are or where that is where that wavy lamina should be and has been disrupted. So as I said, a lot of these biopsies can demonstrate a skip lesion, and in this case the normal that I showed you at the beginning is actually our patients. So there is different cross sections and if the cross section had been smaller and just shown this we might not have had our diagnosis. So again that's just showing the normal skip lesion. So recommendations are again variable. They suggest at least one centimeter. A lot of publications suggest over two and a half centimeters. Our biopsy was 2.9. Should be unilateral. Studies show that by doing bilateral your yield isn't that much more. And that the use of steroids should be less than 14 days starting before you get the biopsy. A lot of recommendations are that you get it while they're hospitalized. So the main kind of clinical question I wanted to ask and bring up during this Grand Rounds is should we continue to use temporal artery biopsy as our gold standard? So temporal artery biopsy isn't without any kind of cost. There can be some pain associated with it. Facial nerve injury is the thing we kind of worry about the most. When it comes to complications and then financial it is considered a surgery. We use this as a gold standard because its specificity is really high. If it's positive it's positive. And yours 100%. However, the sensitivity is not so great. It's in some studies low as 60s and 70s and some higher ones in the 90s. But there's just a lot of variability. So this question as to whether or not we should use temporal artery biopsies was first question in 1981. There was a study that reviewed 135 specimens and only about 60% of those with clinical temporal arthritis have positive biopsies. So in this old figure down in the bottom you can see the clinical diagnosis. So this is based on clinical criteria which in this case was if they had a headache, visual symptoms and a hard tender or pulsus temporal artery as well as plus or minus an ESR which is interesting because it didn't really say if they included that in all cases or just some cases. So you can see about 41% had clinical GCA and histologically only about 25%. And these were all based on these criteria beforehand they were not followed afterwards. So incongruent results and that's just pointing out that studies came out right afterwards that showed a much higher sensitivity 90 and 95% in these two studies that I have up here. And these again, so the hard thing I have looking through all of these studies based on whether or not we should use temporal artery biopsies is that they're based on the gold standard in this case is based on clinical diagnosis and a lot of them have very different characteristics and criteria for what they include in those specifications. So in 1982 publication the three things they included were anterior ischemic optic neuropathy and ESR of 91 or greater and malice. And then in 83 this one that shows 95% sensitivity was based on pathological radiological and clinical evidence. So basically anything that convinced them of GCA was included. And these ones rather than just looking at what was thought beforehand it falls them over time and if over two years they still feel like they have GCA that was what was considered positive clinical GCA. So some of these studies in the 90s were criticized because they were in areas with high Scandinavian descendants which are known to have a higher rate of GCA. And again I criticized because they use different criteria. After 1990 things get a little bit better because I talked about how that study came out and that it changed the five criteria for what is thought to be specific for GCA. So the debate continues but the question changed a little bit which I think is actually more useful. So the question becomes who cares how sensitive the artery biopsy is to change management. So starting in the 2000s there's a lot of articles based on what if you get the biopsy back does that change whether or not they're on steroids. And these three one in 2003, one in 2005 and the most recent one and actually the largest one in 2014 which had 237 patients show a range in the 70s of patients that do not change management but still that leaves 30% that are which I think is pretty significant though a lot of these papers say only 30% are changing management and maybe that's not worth it. So another study related to this looking at changes after biopsy to management. This one only 16% of the results changed management but I thought this one was a little bit more useful because they actually provide a decision tree. So they based on the ACR criteria as to whether or not you should get a biopsy. So if you only have one of those criteria they suggest that maybe you should consider a different diagnosis and not waste your efforts or the patient's time in getting a biopsy. Whereas if you have two or three of them it might be worth getting it so you can kind of differentiate and if you have four or more it's probably you probably also don't need a biopsy because you're so clinically sure. So in our so again here are those five classifications. So in our particular patient he was over 50 and he had decreased pulsation so that would be two of the criteria which would suggest that we get a biopsy and which is positive and manages GCA. So that fits nicely with our patient and a little bit more about him so in follow-up he's maintained excellent vision and his right eye ranging from 2015 to 2020. He continues to be no light perception in his left eye. He's on a steroid taper currently over the next four months. He's following up with their ophthalmology I think in another two or three weeks and then it's been seeing primary care to manage his steroid side effects. His ESR was 60 and has decreased down to two and platelets decreased. They weren't really ever elevated but they have come down and his CRP is also decreasing. I put just a star by there because HSCRP is what we have at the VA and it actually hasn't been studied at all in temporal arthritis. All it can really give us is whether there's inflammation or not but it doesn't really have a lot of relevance especially when we have ESR which has been clinically studied. So where we are now despite 34 years of studies there's not really any clear evidence as to whether or not we should use temporal artery biopsies. There's no cochlear reviews and that's partly because again all those clinical criteria for GCA are different for the different studies and therefore there might not be enough to do a cochlear review. But I wanted to put it out there and see what you guys thought. Do you think we would have changed anything and if this was your patient not just sending it to neurophthalmology but if this was your patient and your biopsy had been negative would have you changed anything based on our clinical findings and do you think that the fact that we had a positive biopsy made us continue on steroids when we otherwise might not have any thoughts on that anyone? Yeah and that's definitely one of the reasons why this is kind of a controversial topic because not only do you not want to miss the diagnosis because the consequences are high but if you don't have the diagnosis you don't really have GCA you don't want to be on steroids for two years and these are older patients and you don't want to be on steroids. But yeah like you said potentiate the side effects from those. Yeah I mean it was interesting that the papers said that 70% of people didn't have change of management and that shouldn't really justify getting one on everyone but I think that's quite a large amount. Yeah that's true. Thank you. Yeah I didn't specifically search it when I was just doing some general searches but that would be really interesting to find out. Dr. Stagg? Yeah I did I didn't like looking to him a whole lot just but that's a new thing that's coming up is ultrasound diagnosis and I think that might be something that might be added to those. What I'd like to see is some sort of again a larger kind of diagnostic tree and maybe having that be part of it so that you know if we can make a positive or a negative diagnosis based on that maybe prevent a few people from having to get the temporal biopsy. Yeah I saw a few of those too. So another study came out actually just in January of this year but it was just I didn't think it was that strong of information so I didn't put it up but there have been a few studies done in African American populations and in Asian populations and it is there but it's just a lot more rare and they aren't really necessarily done in country they're done on descendants here in the states so there's just not a lot of information available. Does that answer your question? I mean I think yes I think most people would be less likely to follow that up but I don't think it rules them out. I don't know of hand, do you know Dr. Warner? Potentially. I don't know that either. So definitely referral to rheumatology and then they could also if any symptoms come up they could potentially refer them to us after that. Any other questions or thoughts? Comments? I didn't find anything new just you know they've tried aspirin and a bunch of other things and basically non-significant findings I don't know if you know of anything else Dr. Warner? There's always something coming out. All right. Well a special thank you to my friend Justin Karoon he's a PGY2 path resident he's the one that printed out those photos for me. Dr. Warner for helping me with this case my sister she helped with those funnest photos those weren't actually my patients she helped create them with me based on other photos the patient had and then Dr. Harry who initially saw this patient with me. Thank you.


Welcome to Frannie's Farm. I'm Frannie Fritz and you're southwest of Iroquois or southeast of Huron. A few miles out in the country, kind of out in the middle of nowhere. Well I was born and raised here. My dad died in 1973 and I had one year of high school up so I finished my, I graduated in 1974 and I had some money saved up for college so I went to SDSU and eventually I settled on animal science and I worked my way through college and got out of college with an animal science degree and a minor in dairy production. When I was in college and when I was taking my animal science classes, after about two years you start taking your major stuff, if I'd walk into a room and there was more than five women in the room, I quickly back out, check the room number, make sure I was in the right new room because there weren't women in animal science back then. If they were, they might have been there starting to get a vet degree somehow. Coming home to farm, there was bets in the community that I wouldn't last a year. It wasn't done. I was the feminist and believe me I'm so far from being a feminist that I think the truth. I just wanted to try. If I'd failed at it, then at least I tried. Mom was here with the farm and my sister and it was kind of like, come home and try since it was my major. Back then kids in college came home to farm and so I came home and I said, well, I guess if I don't try, I'm always going to regret it. That's 41 years ago. I graduated in May and I shipped my first milk the 15th of August of the same year and I milked cows for 10 years and was building a beef herd along with the cows. And pretty soon it was to the point, milk cows take a lot of time and I didn't want to do that and I wanted beef cows and switched over to beef cows and beef cows ever since. You just have to do things a different way. I probably can't use the brute force that men have because they have more strength than I have. I have to stop and think a while. Don't get me wrong when I need some serious help. I'm so blessed in this community that they've accepted me and they will come and help. But I don't abuse it. I'm more into cattle and grass. I've converted everything that used to be row crop or crop into either permanent grass or grass that's coming out and I'm trying something else. This year I planted a field of sane point. I don't know if it's going to work.  So I'd say I'm more grass simply because that's what I can handle. I don't want to invest in the planter. I don't want to invest in the inputs. I don't want to beg somebody to come and do this or that for me. I've got a baler and a hydro swing and a tractor and I got cattle. That's what I got. I love what I do. I, you know, standing out there when the heifers, I don't get to do that very much. I should but I don't. And I love what I do. But I know that when I put a stake on the table for myself or whoever, there's a fair number of people that don't understand it.  But they don't know the hours that I've spent to save a baby calf or a pair that I couldn't say. They don't understand that. These calves, they're more to you than just a commodity. Oh yeah, too much so. Talk about that. Oh no, then I cry. It's a good life, but it's a stressful life.  They have all of this. His name's Petunia. I know. It's Petunia. I didn't know he was a boy.


G'day ladies and gentlemen today, we will be reviewing the amazing Yamaha Porter sound one of my kids teachers Who is awesome and has an awesome taste in music? She will soon be retiring and her favorite band is Muse not that they're my favorite band, but it's pretty awesome that Jarvis's Teacher likes Muse. Alright, so let's switch this baby on as you can see here. No cords attached. This thing runs on batteries I will go over the hardware just to just very quickly Here is a foot pedal in Looks so weird foot pedal. It actually looks like an RCA in and out You've right next to it on the left your left is a headphone jack So we don't have to listen to the noisy kids and also a DC sub power adapter in if you do want to be attached to the wall, but this thing goes everywhere. Alright, so Let's switch it on Select the sound this camera doesn't focus too well macro. So I'm telling you it's got organ That's a bit dicky that one flute. Oh, that sounds so realistic. What do we got strings? Here we go That's strings We got clarinet next takes me back. What do we got up here piano? This will be one of the best Steinway piano samples you can get Amazing All this is coming out of here by the way Tiny little speaker on the left of the of the little keyboard here. What do we got next harpsichord? chamber musicians Eat your heart out guitar Just like a fender strap and a vibraphone Actually like that the most and it's got the sustain Button over here. That's just to the right of the tone select like that. And of course we've got the famous Yamaha portes and rhythms So we're going a bit of rock there. Let's turn the tempo down and go a bit of a wall That's how it goes Got a bit of swing. Oh, yeah All your ladies and lasses. There's the piano. Here we go. Oh, it's having a bit of a freak out Sorry, I'm just handheld in this bit of Latin. Oh, yeah Jello eat your heart out. This is my favorite part though. You can't read this but it says Single-finger chord press that now look at this magic. So basic controls are major volume Then you've got The volume of the one-finger chord Just switch it off. It still does one-finger chords Then you've got a mixy over here.  We're the fun and the kids will love it. See you tomorrow


Hello and welcome to the session. In this session we will discuss use of percentages. Let's first learn how we interpret percentages. Like for example, you have a statement which says that 30% of the total people in a party are men. Now here by 30% we mean 30 parts out of 100 and we write it as 30 upon 100. So we say that out of 100 people 30 are men. So this is how we interpret percentages. Next we discuss converting percentages to how many. We have that 10% students of a class of 50 like eating apples. We need to find out how many students like eating apples. This can be done in two ways. One we have that out of 100, 10 students like eating apples. Since we have the 10th person students like eating apples. So we say that out of 100, 10 students like eating apples. Now we need to find out that out of 50 students, students who like eating apples is given by 10 upon 100 into 50. And this is equal to 5. So we say that out of 50 students, 5 students like eating. Now the other way of doing this is that we find out 10% of the total number of students that is 50. And so this is equal to 10 upon 100 into 50 which comes out to be equal to 5. So we say that 5 students like eating apples. Next we have ratios to persons. Sometimes we are given parts in the form of ratios and we need to convert them to percentages. Let's see how we do this. Consider this figure in this. We need to find the percentage of the figure shaded red. Now as you can see we have three colors in this figure. Green, yellow and red. Now the ratio of green is to yellow is to red is given as. 2 is to 2 is to 1 since we have two parts in this figure are shaded as green. Two parts are shaded as yellow and one part is shaded as red. Now 2 plus 2 plus 1 equal to 5. This is the total of all parts. So the percentage of the figure shaded as red is equal to 1 since we have just one part is shaded as red upon the total parts of the figure that is 5 into 100% which is equal to 100 upon 5 and this is equal to 20%. So the percentage of this figure shaded as red is 20%. Next we discuss increase or decrease as percent. Sometimes we need to know the increase or decrease in a certain quantity as percentage. Let's see how we do this. We have percentage increase or percentage decrease is equal to the amount of change upon the original amount or base into 100. This is the formula that we use for finding the percentage increase or percentage decrease. Like suppose the population of a city in the year 1997 is equal to 27000. In the year 2000 the population of that city is given as 27,270. Now as you can see obviously there is increase in the population of the city from the year 1997 to the year 2000. So we have percentage increase is given by the amount of change which is given as 27,270 minus 27000 upon the original amount which is 27000 into 100 and this comes out to be equal to 1. So we say that the population of a city increased by 1%. So this completes the session. Hope you have understood the concept of percentages.