 All right, yes, thank you so much for your lecture today, Dr. Sheth. At this time, we will open the floor for any questions from our audience. You may submit a question to Dr. Sheth through the Q&A feature. Oh, someone was asking me, is pulmonary embolism less common in masona syndrome? I'm not sure, I'll be very honest with you, I'm not sure I have read any statistics, but I would think that the patient is at risk for PE just like with any other DVT. It's just that, I think, but they are the main risk for this patient is actually chronic venous inefficiency. But I have to say, I haven't read anything that they're less, they're going to be treated with anticoagulants for sure, and they also have going to be treated with a thrombolysis and then scant. Okay, the other question is, what is the difference between hemodynamic significance to noses for instigating stenosis in the partial artery? Well, it's basically when we say hemodynamically significant, in my mind, it's whether the patient needs any kind of intervention or not. And so in the peripheral arteries, it's really, so when we, it's really, it's very difficult to answer the question because a lot depend on the degree of collateral vessels the patient has. So yesterday I was reading a CTA where the patient had multiple occlusions, they had stem that were occluded, but because they had good peripheral circulation, they actually had good flow in the distal bilateral extremities. So in the peripheral, in the lower extremity in particular, it really depends on the degree of collateral arterial circulation that forms. And so I can't say I have a good answer to it. I know that in the common carotid artery, in the, I'm sorry, in the internal carotid artery, we used to say 70% or more is hemodynamic significant in that, that this patient may benefit for endoterectomy, but I think they're doing less and less endoterectomy now and managing these patients more with medical treatment. So that's the answer I have, but it really depends on particular in the lower extremity about the degree of collateral circulation. Okay. The next question is based on the appearance of the thrombus, can we write in the report thrombus is stable or not, calcification, echogenic? Okay. So, and I have more experience with the veins here, but if, but that's actually probably for us, but let me, let me talk to them because that's what I know more about. If the vein is expanded, so the diameter of the vein is increased, then that's a, that's a sign that the thrombus is likely acute and fresh thrombus can actually be anechoic. So I think that more, a lot of the thrombi we're going to see now, echogenic, which makes them easier to recognize, but I think to see if something is acute or chronic, I will first look at the, the diameter of the vein, if the vein is expanded, that's a sign that it is more acute. If there is normal or decreased diameter of the vein, if there is just wall thickening and webs, so little echogenic lines, but, but not real thrombus, then I think you can say that it leads it's sub-acute and if there are calcifications in a vein where the wall is thickened, then it's much more likely to be chronic. And now we don't say, so I think Dr. Niddleman, who is Jefferson and is really an expert on venous ultrasound, he likes to say, if you see sequela from a previous DVT, he doesn't like us to say it's chronic DVT, he likes to say it's post-hombotic changes, and in this case usually the vein will be small, you have thickened wall, you may have echogenic webs and sometimes you will see collateral veins as well around the area. So if you see a lot of collateral veins around an area, that's also an indication that this may be at least sub-acute or chronic. Can I explain the concept of systolic tick again? Okay, so it's here. Okay, let's see. So basically what happens, okay, when you have an intraaortic balloon pump, okay, you want to give as much because the heart cannot pump. I mean, the patient usually have marked decreased ejection fraction, and I'm not a cardiologist, I'm not sure I get the physiology right, but what happened is that you have the initial systolic peak with the normal peak of the order, and then there is the assisted systolic with in diastolic the balloon expands to kind of try to move more blood forward in patients with low ejection fractions. This is why you have the second systolic peak. This one is reflex diastolic augmentation when the balloon expands to push more blood forward. How do we assess deep venous insufficiency? So I don't do this routinely, so what you look for, you look for with reverse solar flow and venous, and you know, flow going in a wrong direction in a vein, but I'm sorry, I don't do this routinely, so I cannot answer any better. I apologize for that. If peripheral arteries are biophysic or monophysic flow, should we write peripheral arterial disease in the ultrasound report? Okay, so biophysic is at least if you have some flow below baseline, okay, if you have a short systolic upstroke and some flow below baseline, I think that's okay because sometimes the triphysic, the third peak, is very, very small and you can't see it. If you have monophysic flow, yes, you have to suspect that there is something else going on and we're concerned about peripheral arterial disease. Yes, if there is monophysic flow and if you have tautous perverse, that's even more of an indication that there is either an occlusion or stenosis more centrally. And so let me look at the last two questions, so please report the concept of monophysic or gel flow, okay, so that really depends where you are. So in the, we were talking about peripheral or gel systems, so in the peripheral arteries, in the arms or the legs, because we supply, they supply muscles, which is a high resistance bed, you should have a short systolic upstroke, you should have reversal of flow, transient reversal flow in diastole. If you have a more central stenosis, the theories, the flow will become very turbulent and there may be some vasodilator and other chemical phenomenon at work, which will say that the flow becomes, you have a parvastatus where you have a lack of sharp systolic upstroke, you have a more sloppy initial systole, and then you have turbulent flow because of the stenosis or the occlusion, and so you have a lot of turbulent flow, you have more flow in diastole, that's the best explanation I can give you. Okay, two more, so if there is positive upstroke in the femoral vein, does it indicate, so okay, so when you look at this positive upstroke in the femoral vein, so you should have some positivity, now sometimes you have a lot of positivity because the patient's in cardiac failure, and so again what I always do is look at the other side, if both sides look the same and there's increased spasitility, it's possible the patient has cardiac failure, and sometimes you'll see this, right, because patients came with low extremity dima, usually bilateral, and you know the question is that, is that heart failure? If it's unilateral, then I worry, and one of the things that it can be, if it's unilateral, and there is increased spasitility as opposed to decreased spasitility that I showed you, is that you may be dealing with an arterial venous fistula, you have to look at the artery, there are other signs to look at, the patient has a risk factor, does the patient have a recent procedure, etc. Okay, so it's past one o'clock, so I think I'm going to stop, I really thank you very much for attending, and I thank you for the excellent questions, I hope I was able to answer most of them at your satisfaction, thank you very much.