So I'll open it up to questions now in case anyone has a question that please come up to the mic and we can have some questions for our speakers. Um But I have with a couple of questions that her dr lears have a question. I can't help myself. PVR I know it's like being a rock star without being a rock star. Um So P V. R A. B I versus segmental Doppler waveforms, do you like to have both? Are you okay with just one? Which is better. There's not really an easy answer for that. I think there's information to be gleaned from all of them ideal in a huge lab where a lot of things have been set before I got there and they have always used PVR s. I always like analog waveforms but I think each can give you something. I think you need some segmental evaluation and that can be either segmental pressures or P. V. R. S. And you need something that will help you differentiate those inflow from outflow lesions. And at least in my experience, that's a analog waveform at the common femoral or a limited duplex. Not a full duplex has been described, but just a limited to say, okay, your common femoral is okay. And I think the important thing about all physiologic testing is a lot of art to it. This is why people are a little bit scared of it. It's you can't just put a number in and say G 230 cm. That's 70 you have to kind of put all of the information together So I think more is better actually. I don't mind having Doppler waveforms and PVR s and segmental pressures. It it never hurts. Okay, great. Um Alright, I have another question. So dr Evans, is there a question? Excellent. Yes, please go ahead and just introduce yourself. Dr Stern. I'm from Wooster Ohio. I believe it was Dr Evans who showed an image of a loosely attached rhombus in the venus system. Um The question comes to mind as to whether those are more prone to pulmonary embolism, Haitian and if so I presume that we should include that in our interpretation. Does the literature support that presumption? So I'm not aware that there is a robust body of literature on whether these Empoli's uh pulmonary embolism is incredibly common with any proximal Dvt. So up to 50% of patients with proximal DVt can have P. E. Um I think sometimes there's a kind of reflex panic when we hear that thrombosis is mobile. Um And really we should be applying that panic to all proximal DVt because these are things that need to be treated. So I tend not to call it out as much in my reporting. Um other people do. And I imagine there's a pretty wide variety of opinions on what you should do with that. Um But you know, all proximal Dvt is an emergency that needs to be treated another question. Um And I'll open this up to anyone on the panel. So um Melinda maybe you can give us a little bit insight to this part. How do you use the P. R. F. In adjusting? Um You're getting the optimal view. What's your approach or how do you think about it? Are you referred which part of you for imaging? For imaging the prof? So close repetition frequency. Especially as I get older, I like to have my spectrum build the entire window as much as possible without aliasing so that I can properly evaluate all of the flow. If you set that P. R. F. Too high you might be missing a large component of the diastolic flow. And we you won't really be able to see the window. You won't be able to determine whether that windows clean or if it's turbulent. So how do you change it from my venus evaluation to a arterial evaluation? Just maybe for some of the trainees so they understand the significance and the meaning and the utility of the P. R. F. Again, the P. R. F. On venus exam will be considerably lower and on the spectrum again like to have that filled the screen without alias scene which would be very challenging when you do an augmentation. But other than that it's always lower and as you go down in the leg, I tend to lower the P. R. F. Even further to allow the vessel to fill without any external influences. All right, any other questions. Okay if there are no questions were. Yes please. Hi. I'm saying I'm on my first year resident actually. Um My question is for dr Evans um you so say a patient comes in you know um You suspect an acute DVt. You order um Ultrasound? Uh It comes back the reed says you know uh couldn't visualize the deep veins, no evidence of cute DVt. What would you say next steps or is that good enough? So that's that's a great question. So a lot of times the report you're referring to is we couldn't see the caffeine's because there was a Dema or patient body habitants or whatever. And so there are some guidelines as to how to approach that. So if you have a strong clinical suspicion of DVT um and your imaging below the knee is negative. You probably should repeat an ultrasound at some predefined time. 5-7 days to look for propagation because that's that's how we would manage a untreated, isolated distal DVT is with serial ultrasounds. So you could apply that to those non image caffeine's. Um We don't do that in the hospital a lot. We just kind of say well they don't have a D. V. T. Um I also think a lot of times our clinical suspicion is um probably ah So so a lot of ultrasounds are negative. Let's put it that way. The vast majority of Dvt ultrasounds are negative. So we're our pretest probability. We're probably not getting it quite right. Um But yeah, if you have high suspicion you should look some more right. Excellent. Well thank you to the speakers And um we will move on to a short break and resume just about a minute or two after 950 so we can keep on schedule. Thank you very much.