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Heart Failure NCLEX Questions Class for Nurses

My name is Darius Opada, and I am a licensed nurse in the United States. In fact, I'm one of the charge nurses in one of our institutions in the Medical Oncology unit. And for today, we will be discussing a little bit about heart failure. Okay, I know this is going to be an exciting day, because besides heart failure, we will be discussing we will be revealing the winner.

The student will receive a scholarship from Connetics USA. So, actually, before I begin, I would like to thank Connetics USA and what do you call this? An Aspire RN for this wonderful opportunity. Let me just change my background real quick. I'm so sorry, guys. Okay, I think this is better. Yes. Sorry for lighting. One lucky winner will receive their NCLEX exam, paid by Connetics USA. So will your name be drawn? So if you want to know if your name is drawn, please stay tuned to find out. Okay? And again, my name is Darius, and we will be discussing a little bit of heart failure, which is part of your NCLEX exam. And I would like to encourage everybody to share this video and share your location and the time, your time zone below.

I know that this is live stream in Facebook and in some social media platforms. Please share your location, where you come from, your name, of course, that will appear as you comment and your current time zone or your time. All right, so without further ado, we will be discussing heart failure. Okay, sorry for that. All right, so I hope everybody can see me and the screen. So this is heart failure. And again.

My name is Darius Opada. I am a licensed nurse in the US. I have a double master's degree in nursing. I am a certified medical surgical registered nurse in the States, and I'm also doing my advanced degree in psychiatry. And as I mentioned, we will be having a brief discussion about heart failure today. And again, please share this video to your friends, to your Facebook, and comment your name, your location, and your time frame. Again, this discussion is sponsored by Connetics USA and Aspire RN.

So my current time right now is 08:00 P.m. In the Philippines. So welcome to all my Filipino viewers. For my international students, welcome. Thank you for joining us today. And I mentioned a while ago, too, that we will be revealing the lucky winner who will receive their NCLEX exam, paid by Connetics USA.

So, again, if you want to know if you've won, or if you want to know if your name was drawn to an end to find out. So to form a discard, that heart failure. So when you say heart failure heart failure is a clinical syndrome. That is characterized by signs and symptoms associated with high intra cardiac pressures and decreased cardiac output. So basically when you talk about heart failure, your ventricles are failing and you are having symptoms or the patients, the patient is having symptoms with decreased cardiac output and in effect they will have symptoms of decreased perfusion or oxygenation. It usually occurs when the heart or the person heart isn't able to meet the metabolic and circulatory demands of the body. In some textbooks, heart failure is either classified as either acute or chronic.

And when I say acute heart failure, acute heart failure pertains to heart failure with a sudden onset and would usually require hospitalization and parental isotropes. On the other hand, when you talk about chronic heart failure, this is the type of heart failure that occurs insidiously. So it occurs progressively overtime. But don't get me wrong, in the clinical area you will also encounter diagnosis or diagnosis such as acute on chronic heart failure because usually that is the case. Heart failure in itself is actually a chronic condition, but they can have episodes where they will have acute symptoms and they require hospitalization.

Causes of heart Failure so we have a lot of causes of heart failure and I know some of you are aware of the causes, but these are some of the causes of heart failure. So we have, of course I am sharing you a form of pneumonic or a pneumonia to memorize the cost. So we have your heart. So number one cause is usually a heart attack or an Mi. Myocardial infarction is the number one cause of heart failure, particularly your left side heart failure. We also have aortic valve or valve regurgitation or insufficiency or valve problems. We have rheumatic heart diseases.

We have T toxins, thrombus formation or cardiac tamponade. Fluid overload can also cause heart failure, AST or VST or what you call your ventricular septal defect and other cardiac anomalies in children can cause heart failure, inflammatory diseases, myocarditis dyskemia, lifestyle practices, smoking, alcoholism, of course lung diseases like your core pulmonal. Core pulmonary is a form of heart failure because of COPD or chronic obstructive pulmonary disease, uncontrolled hypertension or pulmonary hypertension, reconstructive surgeries if the patient is post cabbage or having a valve replacement, there are a trist for heart failure and of course enlargement of the heart muscles or what you call cardiomyopathy.

We will be touching a portion of cardiomyopathies later on when we will be discussing left side and right side heart failure. So these are the common causes of your heart failure, which is in short, your heart failure. And this might not be enough, but these are the usual causes of heart failure. And remember, COPD is one of the causes of right side heart failure or what we call core pulmonali and that usually comes out in the exam.

Now, we have two types of heart failure. We have what you call your left ventricular or right ventricular heart failure. So in essence, if we are going to differentiate left from right side heart failure, just remember with left side heart failure the manifestations or designs and symptoms manifested by the patient are usually pulmonary in nature. For example in left side heart failure they will havenia or difficulty breathing in any position. They have hypoxemia, low oxygen in the blood, tachycardia, increased heart rate, crackles or fluid in the lungs and they will have elevated PAOP or PAP. PAOP stands for pulmonary artery occlusion pressure or pulmonary capillary wedge pressure and your PAP stands for Archery pressure.

So these pressures, both PAP and PAOP are increased during last size heart failure. So therefore if you want to see the left side the condition of the left side of the patient then you need to monitor both PAOP and PAP and of course you will also see symptoms of cough with fraud disputing. So as you can see in the left ventricular heart failure or left side heart failure the manifestations usually are pulmonary in nature.

On the other hand, with right ventricular heart failure the manifestation usually are systemic or the signs and symptoms are usually systemic in nature. For example hepatomagle, hepatomegaly or enlargement of your liver, we have your spleenomagily, the enlargement of your screen, edema, Acetis, elevated CVP or central venous pressure and jugular vein distension.

By the way, for the record, the normal CVP is due to six millimeter mercury which is why if you want to monitor the right side function or the right side of function of your patient, then you need to monitor the CBP or the central Venus pressure. Again, it's in your slide. CVP normally due to six palp is eight to twelve P-A-P mean PAP is less than 20, systolic is PAP 15 to 25 and diastolic is eight to 13.

Now if you want it will be really nice that you can memorize these numbers because these numbers are really helpful for you to determine if the patient is having right side or left side heart failure. Just remember if you're going to look at the right side function of the heart, monitor the CVP, if you're going to monitor the left side portion of the heart then you have to monitor both PAP and PA. So basically again in summary and left side heart failure, the manifestations are usually pulmonary in nature while in right side heart failure the manifestations are usually systemic and typically heart failure.

The most common heart failure usually starts on the left ventricle. So it usually starts on the left ventricle. Your left ventricles fail first, then it will progress to right ventricular heart failure. Which is why when people come in in the hospital with heart failure, the first manifestations are usually pulmonary or left sided in nature. Okay? Then when they will have chronic heart failure or late type of heart failure in the late stages, then they will manifest systemic or right side heart failure.

Now, in the Antiques exam, the types of heart failure is not only limited to left ventricular or right ventricular in your anti exam or in the clinical setting, you will also encounter the types of left side or left ventricular heart failure. So we have two types as well of left ventricular failure. There's also what you call the systolic versus the diastolic heart failure. And if you want to pass your NCLEX exam or if you're taking your CCRN later on, or your cardiac certifications, then you should focus on systolic versus diastolic heart failure.

A lot of clinicians and doctors usually use these kinds of diagnosis to differentiate the heart failure or to diagnose the heart failure of the patient. So when you say systolic heart failure and systolic heart failure, the prominent problem is actually ejection. So it's the ejection, it's the ability of your ventricle to eject blood during systole or during contraction, which is why another term versus Polycard failure is reduce ejection fraction heart failure.

Again, another term for symbolic heart failure is reduced ejection fraction heart failure. Because basically the problem is ejection problem. So typically, signs and symptoms of systematically heart failure, we have your ejection fraction less than 40%. By the way, just for recording purposes. When you say ejection fraction, this is the volumetric measurement of the blood pumped by your ventricle in every contraction. So typically the normal ejection fraction is 50% to 60% or more for a normal person, when your ejection fraction drops below 50, then you might have systolic heart failure.

Also, another symptom of Histolic heart failure is arthritis ventricles. And usually because the heart is unable to pump so much blood or fluid. So there will be too much fluid in the heart, giving them an S Three sound or an S Three gallop, if you remember your S Three gallop. So if there is S three gallop, the implication for that is that there is too much fluid in your heart. So that's why you will have S three. And usually S Three can be heard after S two, right? If you remember your S one and S two, your love and your dog. Typically S three is heard after your S two. So when you encounter the word S three, just remember s three is because of too much fluid in your heart and it is usually associated with systolic heart failure.

Now, for the treatment of systolic heart failure, you usually treat them with positive inotropes. What are these examples of these? Positive? Iotropes. So when you say iotropes, these are the drugs that promote contraction. So what are these drugs? For example, we have your dibutamine, we have your dopamine, we have your melaminode. And these drugs usually promote contraction or ventricular ejection. We also give beta blockers if there are heart issues. We also give diuretics to reduce the fluid from their heart and from their lungs. And of course, we have to give phosphodilators. Now, the only contraindicated medication for systolic heart failure is we have to avoid negative isotropesor those drugs that lessen the contraction.

Now, what are these drugs? Examples of drugs that lessen contractions are your calcium channel blockers. Calcium channel blockers are typically avoided in systolic heart pressure insistolic heart failure rather because of their negative initial effect. So besides calcium channel blockers, any type of medication with negative inotropic effect is basically avoided in systolic heart failure because it would defeat it would exacerbate the ejection problem of the patient. And as I mentioned a while ago, because of too much fluid in your heart, so your heart tends to dilate.

So the cardiomyopathy associated with symbolic heart failure is usually dilated cardiomyopathy. So that is your systolic heart failure. Just remember, systolic heart failure, the problem is reduced ejection fraction. So because there's reduced ejection fraction, your fluid cannot get out from your lungs. So your fluid will stay sorry. Your fluid cannot get out from your heart, so it will stay in your heart. Since it will stay in your heart, typically what is\going to happen, you will have dilated heart, you will  have too much fluid and you will have street sounds.

Now, to differentiate it from diastolic failure. Sorry. So with diastolic failure, usually the problem is the filling problem or the pre load. So preload is usually the filling of the heart. So there's a problem with filling or during the payload. Why there is a problem with filling because usually your ventricles are hardened, which is why in diastolic heart failure, the most common cause of diastolic heart failure is restrictive or hypertrophic cardiomyopathy, wherein your ventricles tend to be stiffened or hardened. But if you compare it to systolic heart failure, diastolic heart failure usually has a preserved ejection fraction.

So usually if you have a diastolic heart failure, your EF is still 50 or more. Which is why another term for diastolic heart failure is heart ejection fraction. And because of the hypertrified ventricles or heart and ventricles, usually they would have an S for sound. So S four sound therefore is associated with stiff or hardened ventricles.

And like systolic heart failure, they are usually treated with beta blockers, your ace or your arms calcium channel blockers, which are negative isotropes and of course, diuretics.  The only contraindication in diastolic heart failure is of course, positive isotropes. Why? Because the more you give positive imotropes, the more you induce contraction with this kind of heart failure, the more they will have problems with filling, so there will be less cardiac output. So we are going to exacerbate the diastolic problem. And as I mentioned in the first part, this is usually associated with hypertropic and your restrictive cardiomyopathy. So actually this is a lot to remember, but just remember, heart failure usually is classified as left and right.

Left side heart failure, usually the manifestations are what, pulmonary right side heart failure, the manifestations are what? Systemic. And of course, according to many of our clinicians and some textbooks, left side heart failure is either systolic and diastolic. When you say systolic heart failure, the ejection fraction is reduced. When you say diastolic heart failure, the ejection fraction usually is preserved.

Now, what do we call sir? If there is both systolic manifestations and diastolic manifestations, then that is what you call combined systolic end by stolic heart failure. And that can also possibly happen to many patients. Okay? So I hope that you're learning with this kind of discussion. I know this is too much, but just bits and pieces for your NCLEX exam.Remember systolic versus diastolic. Remember left side versus right side heart failure. Remember, in systolic heart failure, you have to give positive isotropes, avoid negative isotropes and diastolic heart failure. Avoid positive intropes, but give negatives so that we will not be exacerbating the problem. So basically, we manage them according to the type of there what? Heart failure.

Now, diagnostic tests for your heart failure, of course. Number one, we have your beta natriuretic peptide, your BNP. So BNP is actually a peptide, which is a compensation produced by your cardiovascular. So in the event that there's too much fluid in your heart, your heart or your cardiovascular will produce a peptide you call BNP. So the more you have BNP, it means the more you have fluid in your heart or your heart is failing. And of course, your cardiac enzymes also might be elevated. Your drop I your drop b C, KMB.

But we don't usually use them as the basis for the failure. Typically, to diagnose the patient, to confirm the presence of heart failure, we have to do echocardiogram, which is either a Tte or a te. When you say Tte, this is trans thoracic echocardiogram, the noninvasive one or the esophageal, the invasive one. So in te and Tte, we will be able to see the ejection fraction of the patient, and we canalso see acknowledge or masculine problem of the patient. And we are able to measure cardiac pressures. Remember, cardiac pressures, if CVP is so high, that's usually right side. If PAOP is so high, that's usually left side heart failure.

If all of them is high, then it's usually combined. And of course, we can also do cardiac angiogram. The advantage of cardiac angiogram over your echo cardiogram is that you will be able to see internal defects or problems such as valid defects. You can see clots and we can do interventions like if we want to do angioplasty, if there's like obstruction, then we could manage it with the cardiac angioplasty because that's practically the same angiogram and angioplasty. But with Graham, we use a dye for diagnosis and Plastis an intervention. Right?

But just remember, in cardiac angiogram, two in NCLEX exam, they will ask you usually before giving the dye, you need to assess if the patient is allergic to die or not or if the patient is allergic to seafood or shelves or what have you. So usually management of heart failure, we have, of course, number one medical management, as I have discussed a while ago, with systolic and diastolic heart failure. So we usually give cardio protective measures. So these are your beta blockers, your anti lipids, your Lipidor, your antipotenceive drugs, ARB, calcium channel blockers, et cetera, to be able to protect the heart.

And usually the person has to maintain this for life because the mechanism of heart failure is usually lifetime. And the mechanism of your heart failure is usually cyclical. And the more that you will not beat them or manage them, the more it will cause damage or the more the heart failure will become severe. And of course, we need to do water management. We need to impose fluid restriction depending on ejection fraction.

And we can also give diuretics to balance their fluids. Just remember, the number one diuretic for heart failure is your Lasix, right? It is Lasix because the effect of Lasix is fast, right? And sometimes if we don't give Lasix, we could give BMX or but Tamit is an alternative. And just remember, when you're giving lazy, always monitor electrolytes, especially your potassium. And of course, we have to give oxygen. And our goal usually is 17 oxygen saturation around 94% or more.

And of course, as part of their management, we have to do dietary modifications. They usually need to follow a low salt and low fat diet to control their blood pressure because high blood pressure can exacerbate their heart failure symptoms. But in the United States right now, most heart failure patients will live because there's also what you call the LVAD. And I know this is not familiar with everybody, especially for those who are working, not working in the States. So when you say LVAD, LVAD is what you call the Left Ventricular Assistive Device, or LVAD. And this is usually indicated that when the ejection fraction of the patient is less than 25%. So when your EF is less than 25%, you're usually a candidate for LVAD. So as you can see in the picture, the LVAD, this is a left ventricular assistive device, so it will assist your left ventricle. The blood from the left ventricle enters the LVAD and it will bypass your right ventricle.

Typically, it will bypass your lungs, most of the portion of your lungs, and it will deliver blood directly to your eorta. And the purpose of that form of bypass is to help the lungs and the heart recover from the failure or decrease the stress in your cardiovascular. And when you talk about LVAD, there are two types of LVAD that you would encounter in your NCLEX. There's what you call the bridge to transplant LVAD.

So when you talk about bridge to transplant LVAD so these patients are usually Iotrobe dependent and sometimes they have cardio renal insufficiency. In layman's terms, people with bridge to transplant of us are waiting for a transplant. So they are on the list to receive a new heart because if they will not receive a new heart, they will die.

So that's what you call bridge to transplant. Alvad. Another form of alva is what you call the destination therapy or the DP. So when you talk about destination therapy or DP, these are for patients who are ineligible for heart transplant because of comorbidities or old age. Let's just say, for example, they have a DM, they have liver failure, they have heart failure, they have autoimmune diseases, and they could no longer tolerate heart transplantation. Then they will have the LVAD for life. And I have so many patients on LVAD, and I think the LVAD, according to studies, can extend their lives for ten to 15 years.

So they can return, of course, to near normal lifestyle. But of course, with this LVAD, it's connected to a battery and they need to charge the batteries from time to time because if the battery dies, they will also die, which is why that's the responsibility of the patients is to make sure that their bads have fully charged batteries or they could replace it. I just want to share that I have this one patient that she had to buy, of course, her own generator because sometimes in her area, the power shuts off and she could not charge her LVAD, and that's scary for her.

So she bought her own generator to make sure her body will continue working. And of course, surgical management for the heart failure is your what, your heart transplant is the best, but then you remember with heart transplant, with heart transplant, they will be taking anteriorjection drugs, amyuranteprolimos, azapiaprint, and the side effects of those immunosuppressant drugs is, of course, immunosuppression. And of course, there's also a tendency for them to reject the heart and when they undergo rejection, they will go back to the IC and to the ECMO and et cetera, which is why some patients just stay on the LVAD destination because they could live longer.

Actually, with destination outpat complications of your heart failure, we have your cardiogenic shock. So cardiogenic shock is conditioned. We're in signs and symptoms of heart failure which are accompanied by symptoms of low perfusion or Map, or your CPP, cerebral, cerebral perfusion pressure or mean arterial pressure. In short, there's low perfusion going to your organs or to your body.

So if you have symptoms of low perfusion with symptoms of heart failure, low BP, you're having decreased cardiac output, then you're having cardiogenic shock. Cardiogenic shock is typically treated with balloon pump, intractic balloon pump counter, pulsations, IABP or impeller and iotrop. I know impella sounds new to you because impella is not used around the world. It's used in countries like Europe and USA.

But you will encounter them if you will have alvad or if you will have patients with cardiogenic shock. And of course, another complication will be multiple organ failure. Well, it depends on the type of failure, then whatever is the failure, then we will manage them. If it's renal failure, then they will be placed on CRRT or hema dialysis and of course, arrhythmias. People with heart failure are at risk for a lot of arrhythmias, dangerous arrhythmia. So we will manage them, usually with drugs, with cardioversion, and with replacement.

So I hope that you've learned a little bit so far with that. Let's do knowledge check. So, as I mentioned in the first type of the slide, in the first part of the slide, what kind of heart failure is usually caused by COPD? You can answer below. Left side heart failure, right side heart failure. Combined right side and left side or chronic heart failure? What do you think is the answer? COPD. COPD. Chronic obstructive pulmonary disease usually leads to corporal menale. Right? What is corporate is right side heart failure caused by what? COPD.

So the answer is what? Letter B, right side heart failure. If you got the right answer. Very good. Question number two. Which of the following is not a symptom of left side heart failure? It's not a symptom of left side heart failure. So we're looking for choices not part of left side heart failure. Remember, left side heart failure. The symptoms are pulmonary right side heart failure. The symptoms are systemic pulmonary edema b, pulmonary effusion. C, hepatitis spleenomegali, tea frothy sputum, pulmonary FEMA is pulmonary. So that's left side pulmonary effusion, that's left side Hepatospino megaly, that is systemic. That is right side. And D is frothy sputum. What's the answer? Letter C. Hapato. Splino megali.

I'm sorry for that. It already showed the answer. Anyway, which of the following is not true about systolic heart failure? Remember systolic heart failure. In systolic heart failure, it is reduced ejection fraction. Right? So A, systolic heart failure manifests with reduced ejection fraction. That's true. B, positive isotropes are the preferred drug of choice. That's true. C, negative isotropes are the preferred drug of choice. That's wrong. Negative isotropes are avoided in systolic heart failure. Right. But then they are given for diastolic heart failure. D, it is usually associated with dilated cardiomyopathy, which is true. Commonly, systolic heart failures have dilated heart or dilated cardiac muscles. If you got the right answer, then that's congratulations.

Question number four. I don't know what's going on with my slides, but anyway, what does this mean? When the patient is in alvad? Bridge to Transplant a the patient is on the waitlist for heart transplant, b the patient is ineligible for heart transplant, c the patient's heart is failing, or D the patient will not survive the LVAD. Remember Bridge to transplant. They are on LVAD because they're waiting for a new heart. Correct.

So they are on the wait list. If they are ineligible for heart transplant, they are for destination therapy. Correct. Which is why B is wrong. Letter C is wrong because people with Elvis, usually they have heart failure, the patients will not survive the LVAD. Well, that's the purpose of the LVAD. The LVAD is to prolong their life. Question number five.

Last question. Which of the following intracardia pressures revealed that the patient is having arrived side heart failure? Apaop of 20. B CBP of 20, BBP of 190 over 60. Remember, right side heart failure. What pressure should you monitor for the right side? It's your correct. It's your CVP. So a CVP of 20 would mean that they have right side heart failure because both PAOP and PAP are measures of the left side heart function or left side heart failure. Correct? Correct. BP, that's not an integrated expression. So we have palp PAP and your CVP. So these are the pressures that you need to remember in your NCLEX exam questions so far.

Do you have any questions? Okay, I know you can't ask questions, but, guys, thank you so much. As I mentioned a while ago, I would like to say thank you again for Connetics USA, for giving me this opportunity to discuss a little bit about heart failure, especially for Alabama, because it's new to everybody, and this is usually used in the space right now for heart failure patients. And again, I want to thank Aspire RN for again, for giving me this wonderful opportunity.

And as I mentioned in the first part, we will be revealing the winner, the winner of the raffle that I don't know if this was done like yesterday or the other day, but we will be revealing today who is the lucky winner for that NCLEX scholarship sponsored by Connetics USA.

So, guys, if you're thinking of going to United States, choose Connetics USA as your direct hire agency. So they usually hire nurses for different parts of the state, and they are direct institutions, and they have been established for many, many years. Ms. Tanya Freedman has been known to many, many nurses, has been helpful to many, many nurses. And if you want to do your review, if you want to learn more about heart failure, not only heart failure, but about different concepts in the NCLEX, please join Aspire RN.

And after I revealed the winner, I will be giving you the next dates of the review and the fees and where to go to be able to join our next review session. So I hope that you have enjoyed my little time of discussion, and I'm so sorry that I was a little bit fast, but I hope it's all worth it. So congratulations to you, Mark Jason Sagaisai. I wish I have a background sound. Congratulations, Mark Jason Sagaisai, Connetics USA have chosen you as their Connetics USA, rather will be covering the cost of your NCLEX exam. Congratulations.

Marching I don't know who you should contact, but I'm pretty sure Kinetics USA will be in touch with you about your scholarship for NCLEX, okay? And, of course, for promotions. So we have aspire RN for Aspire RN. So. We have three kinds of review. So as the provider, we provide a starter review which is good for three months for $250. And as you can see in the screen, there are different the difference between the starter feature from the pro feature and the plus feature.

So the starter feature is $250, the pro feature is $450, and the plus feature is good for $650. It's a little bit more expensive than the pro feature because you will have a short pass guarantee and a European access good for 90 days for $650. And I know that you will expensive. So if you want to take advantage of a comprehensive review, I might as well enroll if I were you.

I will enroll in the plus feature, which is good for one year and you have two years unlimited class. You can attend a lecture online, so wherever you are, you can attend the lecture. Our lectures are recorded. If you miss the lecture, you can always go back to the website or to the page to review the recording or the lecture. This is the features or the types of what review that the Aspire RN provides. And we have upcoming schedules. Upcoming schedules. We have your July 4 to 15th, so it's currently going July 4 to 15th 2022. Our next schedule for review is August 8 to 19 and we have September 5 to 6022. So this schedule will, of course a live ten days Ed classes, high impact tutoring with rationalization, of course with over 1000 questions rationalized by our live and licensed members like me.

And we will also provide one session final coaching with two hour, one on one mentorship and individualized assessments by our mentors. We will also provide you with exclusive access to surface and text secrets, all you need to know about the exam, and of course, one month access to hundreds of hours of lecture videos in our library. And you can also get an access to our own personal student advisor that will help you focus on your review.

So, this is an NCLEX hit and final coaching review. And of course you get to meet us. You get to meet me and the rest of the teachers for Aspire. And of course with Connetics USA, you will get to meet me, Tanya Freedman, her staff, who has been trusted by many, many nurses for many, many years.

So I wish that you would choose Aspire RN for as, your review provider and Connetics USA to help you with your USA dream. So yes, you can pass your NCLEX exam and you can make your American dreams come true with Connetics USA.

If you have any questions or concerns about our review program, you can always go to Aspire RN. There's a Facebook page in our website aspirern.com. And if you have any questions about Connetics USA, you can always search them in Facebook Connetics USA and their staff will be in touch with you and ready to answer your questions. So thank you so much for this time. And again, this is Darius Opada , and thank you for attending my short review and I wish that this will be helpful even like for one or two items in the exam. And thank you so much for listening again post your name, you're location and your time in the comment section and I wish you all the best with your American dream. Pursue, pursue, pursue. Don't stop. And yes, you can. Goodbye guys.