Hello and welcome to the holiday edition of the Physician Assistant Exam Review Podcast. I just looked up and realized that this would be the last show before the new year. So I had to take a minute at the front and just say thank you. Thank you for an amazing 2023 and what is hopefully going to be an amazing 2024. Thank you for being part of the community. Thank you for letting me be part of your journey. Thank you for sharing with me your struggles, your fears, and your successes.

Thank you for letting me do what I love to do, which is to learn and teach and facilitate your growth. I’m incredibly thankful that I get to do all of this. And I had an incredible 2023 and before that 2022 as I started to work more closely and more directly with students than I ever had in the past 10 years. Through the 33 Days to Pass the PANCE program, I worked directly with hundreds of students over the last two years. I started doing more small group trainings. I was fortunate enough to get to visit and work with three different schools. I got to go to Ashland, Ohio, and work with the students there, Duquesne University in Pittsburgh, and Pace University in New York, and work with the students there.

And it was such a blast to get to meet them, to get to work with them, and to go through all of this information and help facilitate their journeys. And then it’s even better, of course, is to get the email responses telling me how scores are going up, how things are going well, how they’re implementing some of the things that I taught. It’s just so much fun and I really do appreciate it.

Now, one of the biggest ways that I can facilitate your success is through the 33 Days to Pass the PANCE program. And I want to make sure that you know that in the very beginning of January, I’m going to open registration for the February cohort, the very first cohort of 2024. I’ve had miraculous results with this program over the last two years, helping hundreds of students. I started that program in 2022 for students who had failed the PANCE more than once, honestly, or a couple of students who were struggling at the end of school with their end of rotation exams. One person in particular had failed two exams, and if he failed a third, he was out. So I wanted to do something to help these people in 2022, so I built the 33 Days to Pass the PANCE program because I didn’t believe that another cram course would help them. And one of the reasons I didn’t believe that is because of a study I came across published in the Journal of Physician Assistant Education that demonstrated cram courses have zero impact on PANCE scores.

And I wanted to help them. And I didn’t want to direct them to another course. I didn’t want to build another cram course. So I looked into what does have an impact. Learning advanced study skills. There are things you do, things students do, but there’s more. Powerful test-taking techniques, things that can improve test scores with the information you already have inside your brain.

Mastering peak performance so that you’re in control of yourself on test day and you’re in the best possible position, both mentally and physically, to take your exam. Once and for all, destroying test anxiety and the PTSD that comes from multiple attempts, those are the things that I thought could have impact on these students who are so desperate for help in their third or fourth PANCE attempt. So that’s why I put together the 33 Days to Pass Your PANCE program. But it takes time to complete the program. It’s not something you can do in a couple of days, just like you can get your black belt or learn to swim in a few days. To turn you into an amazing test taker, I can’t do it in three days. So that’s why the program is designed the way it is.

There’s a whole lot to it, I don’t want to go into every single piece here, certainly, but there’s nothing else out there like it. Nothing out there designed to make you into the best student, the best test taker, and let you get the highest score you could possibly get on your exam, or any exam for that matter. If you’re struggling at any point in PA school, then the 33 Days to Pass Your PANCE program is for you. Like I said, it was designed with the goal of turning into a learning test-taking machine, and 95% of that applies to didactic year, PACKRATs, rotations and exams, exit exams, and any other test you’re taking. Although it was designed specifically for the PANCE, the information is incredibly transferable as multiple students have shown over the last two years, taking it as early as their didactic year and all throughout their clinical years. Like I said, I’m really excited for the 2024 cohorts, as I’m just hearing back from the November 2023 cohorts, as they’re taking their PANCE now in December, actually, they’re just finishing it up. A few of them are taking it in January, but from the first two people I’ve heard back from, one person scored a 96 points higher than on their previous PANCE attempt.

And the next person I heard back from scored 97 points higher than their previous PANCE attempt. I couldn’t be more thrilled. So if you’d like to end that struggle and frustration join us in February. It’s going to be life-changing. It’s what I hear from students time and time again. And registration opens in early January, but it will fill up on a first-come, first-served basis. So I want to make sure that you’re aware of this opportunity.

And if you go to physicianassistantexamreview.com/33 Days, you can get on the waiting list there for when registration opens that you’ll be one of the first people to know when registration opens and you can jump in and start putting an end to your struggle and an end to your anxiety. I’m really excited about it. I’m really excited about what 2024 looks like. And I really hope that you join and become a part of that with us and all of the members of that cohort so we can make 2024 a heck of a lot easier than 2023. Once again, I just want to say thank you so much for being part of the community. Happy holidays. Happy New Year.

And I can’t wait to see what’s coming for you and for me.

All right, let’s go ahead and get started with episode 123. Today in episode 123, we’re going to be covering seizures and neurocognitive disorders. First, we’re going to get started with our priming questions, as always. I think that was the same music. Sorry. What is the most common cause of generalized tonic-clonic seizures in adults? Remember, you may not know this, but think through it.

What is the most common cause of generalized tonic-clonic seizures in adults? Make a guess. Which type of seizure is characterized by repetitive jerking movements? Which type of seizures characterized by repetitive jerking movements? What is the first-line medication for the urgent management of status epilepticus? I got five today, so don’t drift off on me. What is the first-line medication for urgent management of status epilepticus?

Which cognitive test is most commonly used to assess memory in mild neurocognitive disorder? Which cognitive test is commonly used to assess memory in mild neurocognitive disorder? And our fifth one: what is the characteristic clinical feature of major neurocognitive disorder? What is the characteristic clinical feature of major neurocognitive disorder? Take a minute, think about it. Again, even if you don’t know it, you can probably come up with a pretty good guess, or at least get close. Again, I’ve been using this term a lot, this idea a lot.

You want to get as close as possible to an answer. It’s almost like when someone asks you on a rotation and they ask you a question, if you’re in the neighborhood, then you’re doing fairly well. You don’t have to nail everyone. You don’t have to be right, but you need to be thinking and in the neighborhood. It’s when you’re completely off the wall that people look at you a little funny, right? So I want you to think more about spending time getting close to the right answer instead of just trying to be perfect all the time. It’s okay to be close.

All right. As we move into seizure disorders, if you are a fan of the priming questions, and I know a lot of you are, because I get emails about it, you can get more of them at physicianassistantexamreview.com/123, or any of the neuro episodes. I put together just this morning, a really cool section of 20 more questions just like this, these rapid review questions for neurology. So you can go pick that up along with the notes for this section at physicianassistantexamreview.com/123 to pick up those 20 additional neuro questions.

All right, let’s dive into seizure disorders. So we have epileptic seizures and epilepsy. Epileptic seizures are singular events of abnormal brain activity. These can happen to 5 to 10% of the population at some point, during their lives. Epilepsy is a condition characterized by recurrent seizures and only affects about 1% of the population. So just the difference between epileptic seizures and epilepsy. There can be, there’s a number of causes for these things.

Hyponatremia, hypoglycemia, strokes, TIAs, traumatic brain injuries, infections like meningitis or encephalitis or a brain abscess, congenital brain defects, metabolic disorders, brain tumors, abnormal brain blood vessels, genetic factors. There’s so many causes for these, so many possibilities out there. But if you think about anything that causes your brain to not function well, so again, hyponatremia, hypoglycemia, strokes, brain injuries, things with mass effect like brain tumors, things that mess up the blood flow to the brain like abnormal brain vessels or strokes, right? Anything that damages brain tissue, affects brain tissue can cause this. Risk factors are going to be a little similar, but I want to separate this out anyway. So a family history of seizures or epilepsy is a risk factor. Extremes of age, so very young children or very old adults.

And then again, if a person’s had a stroke or traumatic brain injury or a tumor, they’ve had brain surgery, they have Alzheimer’s or dementia. If they have active meningitis or encephalitis, they’re at increased risk, right? Cerebral palsy or multiple sclerosis can be risk factors. And then localized inflammation, all these things can be risk factors. So basically the things that we said were causes are also risk factors, right? They don’t directly cause, but they increase the risk of a seizure. So we have a couple of categories for seizures I’m going to go through here.

Types of seizures would be, first we have generalized and partial. We’re going to break those down separately. So generalized seizure, grand mal seizures, unconscious convulsions, muscle rigidity. Unconsciousness, convulsions, muscle rigidity. Absence seizures, it’s that brief loss of consciousness. So it’s not that they’re hitting the floor, it’s that they sort of freeze and they don’t realize that they’re not there anymore. Clonic seizures, repetitive jerking movements.

Myoclonic seizures are sporadic jerking movements. Tonic seizures are muscle stiffness or rigidity. And atonic seizures, well, what do you think atonic seizures are if tonic seizures are muscle stiffness and rigidity? They’re loss of muscle tone. So that’s the basis for what you need to know. It’s not every detail by any stretch, right? But it’s a starting point.

Learn that, and you’ll have a very good place to begin your study so that you understand and have a good picture of everything that’s coming. Partial seizures. In this case, there’s a preservation of consciousness, but it could move into a generalized seizure, right? So, we have a Jacksonian march, which is the seizure spreads from a distal limb to the ipsilateral face and moves in on the body. The simple seizure is a jerking muscle rigidity, spasms, head turning, unusual sensations affecting vision, hearing, smell, taste, or touch. And a complex seizure would be lip-smacking, chewing, fidgeting, walking, and other repetitive involuntary but coordinated movements. And they may have an aura present.

So simple seizures are just that, like jerking muscle spasms. They may hear or smell or taste something. The complex seizure is more of a coordinated movement, chewing, lip smacking, walking, that sort of thing. Lab studies and physical exam findings. So what are we going to do for a patient with suspected seizure activity? Again, think through this. Don’t just listen and think it’s going to stick in your head.

It’s not going to happen. It doesn’t work that way. I wish it could. It doesn’t. You have to think. You have to use your brain. What are we going to do?

What would you order on a patient who you thought was having a seizure or had just recovered from a seizure? So we’re going to get an electroencephalogram, an EEG, to determine the type of seizure and show where it’s going on. We’re going to get an MRI or a CAT scan because we’re going to be looking for structural abnormalities. So essentially, we’re going to be looking for all of those things we thought were risk factors before, right? We’re going to get some labs. We’re going to get, well, if we were worried about hypoglycemia, hyponatremia, we’re going to want some labs to prove that, right? Electrolytes, a CBC, renal and liver function, toxicology screening, right?

That makes sense. Maybe an ABG, blood cultures, if we’re concerned about infections, urinalysis, regardless, you should probably get a urinalysis because sometimes that can be subclinical with the symptoms. You might want to get a lumbar puncture for cerebral spinal fluid analysis. So think through the labs. Don’t memorize them, right? Maybe what you do is you memorize the risk factors. Maybe what you do is you memorize the causes.

But then you understand what the labs are that go along with those causes. So if I’m worried about a stroke causing this seizure, I’m going to get a CAT scan, right? If I’m concerned about a cancer or a tumor, I’m going to get a CAT scan. If I’m not clear, I’m also going to get labs because it’s just easy. But I want you to think about what you’re ordering and why, not just memorize lists of things to order. First aid and emergency protocol. So for starters, we have to make sure the patient’s safe.

If they’re in a state of having a seizure, you need to make sure that they’re safe, that they don’t fall, and that they’re not going to hurt themselves. For a prolonged seizure, you may consider things like an IV benzodiazepine or lorazepam or diazepam and to be looking for those underlying causes if you can reverse any of those. You might move on to anticonvulsants, phenobarbital, valproate, carbamazepine. And then way down the road, depending on causes, you may consider surgery if it’s a mass, right? Or something that can be removed. Neurology is not my area of expertise, but the stories that I have from this are more personal. For those of you a little closer in the community, I emailed throughout last year at this time, my brother passed away last year just after Christmas from a glioblastoma that he’d been fighting for two years.

And his very first symptoms were seizures. But he didn’t even know he was having them. They were visual and auditory. He actually saw himself inside of television shows. But it wouldn’t be while he was watching TV. It would be like walking down the street. All of a sudden, he would feel like he was in the middle of a sitcom that he had watched.

Actually, for him, it was Star Trek episodes. And he had the hallucination that he was inside of the episodes. And when he went to the doctor and to the neurologist, it turned out these were seizures, and they were the very first signs of his tumor. So there’s a lot of different causes for these things, and that they were able to control with medications and things over time, but he still had some. But I want you just to understand that seizures are a, what’s the word for it? I want to say a hallmark, a sign of something else going on. Something else is happening.

I can’t think of the right word for it at the moment, but there’s something going on, and you need to figure that out. And that’s really what’s going on here. Not necessarily on your PANCE, but in your practice.

All right, let’s move on. Status epilepticus. It’s life-threatening neurological disorder defined as a five-minute or more continuous seizure activity or multiple seizures without a return to baseline. So status epilepticus is that prolonged seizure activity. Again, our causes are pretty similar. They can be medication-related. They can be in withdrawal or interaction with new medications.

Hypoglycemia, hyponatremia. They can be alcohol-related. Or withdrawals from alcohol. They can be from strokes, TIAs, etc. Meningitis, encephalitis, or traumatic brain injuries. Just like before. So again, what are we going to do for labs and studies and physical exam findings in this section?

Well, we’re going to be looking for what’s the cause. We’re going to be running the same labs we were just talking about because we’re talking about a prolonged seizure now, right? So we’re going to be running blood glucose, electrolyte levels, CBCs, urinalysis, toxicology. We’re going to get an EEG. We’re going to get a CAT scan. We’re going to get all of these things to try to determine what’s the underlying cause. Initially, this is a major problem for these people, right?

So we need to do immediate treatment. We need to protect their airway and monitor their vital signs. We’re going to give them benzodiazepines quickly. After that, we can move on to anticonvulsants like phenytoin or valproate. And if they don’t break, we can give propofol or phenobarbital. But it all comes down to figuring out and managing that underlying cause, that underlying condition and maintaining the airway.

All right, let’s move on from seizures. Delirium, an acute state of confusion characterized by sudden onset fluctuating course and often changed in alertness. I don’t know if you guys have read or watched the Sandman. It is, I love Neil Gaiman. He’s one of my favorite authors. And it’s a… it was initially published as a comic book, and it’s fantastic in its entirety.

And then it’s on now a Netflix special they did season one, which was just absolutely did the book justice, which I couldn’t believe they could do. But Delirium is one of the characters, and she’s fantastic. And I’m hoping to see her in season two. But anyway, if you haven’t checked that out, definitely on on my short list of things to see.

All right. Causes of delirium. Kind of like before, electrolyte imbalances, advancing age, fever, infections, poor nutrition or dehydration. I always look to dehydration for a lot of problems. I feel like we can fix a lot of things. Which is getting people to drink more water or IV fluids. Multiple medical problems.

Medications that are that can cause this, like opioids, anticholinergic. Lack of sleep. Psychological stress. All sorts of things can cause this, right? You’re probably feeling a little bit of this right now. Clinical presentation. This is a rapid onset with symptom fluctuation throughout the day.

Changes in alertness, varying levels of consciousness. Disorientation to time, place for short-term memory impairment. Altered perception, including hallucinations or delusions. Emotional or personality changes, sleep disturbances, and on and on and on. Labs and studies. Again, we’re going to be looking for what’s our causes here? What’s the background image?

Why are we getting this situation? So we’re going to do a comprehensive neurological and mental examination. We’re going to run all kinds of blood tests, including glucose, electrolytes, just like before, toxicology, all the same things we’d be looking for in a seizure. Why is our brain acting funny? In fact, we’re going to get a CT and an EEG to rule out strokes and seizures. You may want to get a vitamin B1 and B12 levels, urinalysis, cerebral spinal fluid analysis, ABGs. You’re trying to figure out what the problem is.

So again, you don’t have to memorize each of these lists because it’s the same list and because the causes are the same, right? So this all kind of fits together. So please don’t spend a lot of time memorizing this list for delirium. Don’t memorize this list for partial seizures. Don’t memorize this list for epileptic, not epileptic seizures, for status epilepticus. There we go. We’re also going to be covering neurocognitive disorders, which is going to have a very similar list.

So don’t memorize it for each one of those. Understand that these are what we’re getting and ordering and thinking about when we come in with mental status changes. It’s all the same. So don’t learn them separately. Learn them together and then use them to find your diagnoses. So again, what’s our clinical presentation for delirium? And we just sort of walked through it, right?

I’m sorry, we did walk through it. I’m starting to get a little delirious myself. Sorry, that part, just thinking about my brother in this time of year has gotten me a little bit shaken up. I don’t want to start over. But forgive me for losing my place there for a minute.

Okay, treatment for delirium. Number one is going to be address the underlying causes. Right, that’s always going to be our issue. It’s the same as what we’ve just been talking about. Infections, anemia, heart issues, liver failure. Now here’s one that’s going to be a little bit different. Can we control the environmental situation?

Can we get better lighting? Can we get better sleep hygiene? That’s not going to help with seizures, right? But that will help with delirium. So those are some ways you can separate these out. You want to look through the patient’s medications and see if there’s anything that may cause them to have a problem. If they’re on polypharmacy, they’ve got tons of meds, maybe worth going through those.

Or if they’re on things like benzodiazepines. Or a whole host of other medications.

Let’s move into mild neurocognitive disorder. Mild neurocognitive disorder is characterized by a slight but noticeable decline in cognitive abilities, including memory and thinking skills, which does not significantly impair daily activities and independence. So these patients, you’re just starting to notice that maybe they’re slipping a little. Maybe they don’t quite have, they’re not quite as sharp as they were. Clinical presentation most commonly involves memory difficulties, especially in recalling recent events or information. So I find this with my parents as they’re getting older. They remember things from years ago, but something that we just did, they’ll have trouble holding on to or a conversation we had not too long ago.

Although they’ll forget more and more if they told me or my sister. They may have trouble with word finding. Problem solving or visual spatial abilities. They can function on their own. They can live independently. But they’re missing a few pieces here and there. So for lab studies and physical exam findings here, you’re going to want to do a detailed history and physical and figure out about the cognitive deficit and how it affects our daily function.

You may want to do cognitive testing, like a mini mental status exam. And you’re going to do labs to see, again, if this is just a reversible issue, if they are hypoglycemic, if they are hyponatremic, if they have some other issues. You’re going to get brain imaging. For the same reasons, right? Because you’re going to want to rule out all of those causes we talked about earlier. I’m not going to list them all again, but I want you to understand it’s all the same. They all reflect each other.

So again, treatment here. What’s going to be the treatment for mild neurocognitive disorder? How are we going to treat this? Well, just like before, just like all the other things we talked about today, we’re going to treat the underlying issue if we can find one. And if that doesn’t help, we’re going to do memory training and cognitive rehab. Some things that are extremely important for these patients, and again, I’m seeing this in my parents currently, regular physical exercise. I talk about this all the time, especially in the 33 Days program when I talk about some of the different ways to boost your studying, to boost your test-taking skills.

Exercise has been demonstrated to boost brain function over and over and over again. I don’t care if it’s a, you know, some of the studies I talk about in that program are literally a 10 minute, very mild time spent on an exercise bike. I’m not talking about running miles and miles. I’m talking about going for a short walk. Dramatic improvement in cognitive function. Cognitive engagement for these patients. Social activities.

Getting out and talking to people. Having to function in the world. Having to use your brain. I talk about this all the time as well when it comes to studying. Using your brain is a key factor in maintaining your brain. You don’t learn things. You don’t imprint memories without thinking.

So getting out into the world is very helpful for that. Social activities, cognitive engagement. And then regular follow-up to monitor for changes. Because the next step is major neurocognitive disorder. So we went from minor neurocognitive disorder to major neurocognitive disorder. So we’re making some sweeping moves today, right, from seizure disorders, talking about epilepsy, generalized seizures, partial seizures, status epilepticus, delirium, then mild neurocognitive disorder, and then major neurocognitive disorder. And again, I want to just point out to you why we’re studying these all together.

They’re all sort of, I hate to say on a spectrum for the same issues because it’s not really a spectrum, but they are related, let’s just say. Major neurocognitive disorders often synonymous with dementia. I was actually surprised when I didn’t see dementia on the blueprint until I realized that major neurocognitive disorder now includes dementia. This significantly impacts cognitive function and daily living and independence. So we move from, and this is something that you should be aware of because this is where you’re going to be asked to differentiate mild neurocognitive disorder to major neurocognitive disorder when it impacts our daily living. And we can’t be on our own anymore, or your patients can’t be on their own anymore. They have marked deficits in memory, attention, language, and executive function skills.

They may be agitated or restless. And you can definitely see signs, changes in eating habits, which can compound the issues, right? They may have depression, anxiety. They start to lose coordination and may have trouble walking and eating. These are all symptoms of major neurocognitive disorder, but the main thing is that they’re so impaired that they can’t, that it impacts their daily living and their ability to be independent. Lab studies and physical exam findings, well again, this is going to be just the same repeat and I hate to just keep saying it over and over, but it should be in your head, this shouldn’t be hard. You should be looking forward to a question about what labs to order, about what studies to get because it’s all the same so it should be pretty easy for you.

So again, you want to get a good history and physical and a neurological exam. Maybe the Montreal Cognitive Assessment or the Mini Mental Status. You’re going to want to get blood tests, right? You’re going to want to get an MRI and a CT scan. All of these things if this is the first time you’re seeing this patient. Then as far as treatment goes, you can use cholinesterase inhibitors for cognitive symptoms, maybe antipsychotics, antidepressants, anxiolytics for behavioral issues. But then again, it’s those lifestyle modifications that are going to be huge.

That exercise, the amount of light they’re getting, the socialization that they’re getting, the diet. Again, looking for signs of dehydration, other issues that might be causing this. Then the last one that’s really important for these is that caregiver support and education. Because the people who are just as much affected by this are the people who are taking care of these individuals. So those people need some help too. And that’s always important to remember. Phew.

All right. So this is a little bit of a tough episode for me, looking back at my parents’ situation and my brother’s situation. And this sort of encompassed all of that’s been going on with my family and their health issues for the past year and what made 2023 a little bit tough. But also what makes 2024 exciting because there are some progress that we’re making in some of these areas. So anyway, let’s move on from there and talk about our study tip for today.

All right. Our study tip for today is something I’ve been talking about with a couple of students and a couple of different people lately, which is questions. Loads and loads and loads of questions. I loved when I was in PA school doing questions. Anything that I did a question on would stick in my head far, far longer than things that I just read. So I feel like anytime you can be up, moving, thinking, again, I’m harping on that, thinking, using your brain, that’s when the information sticks. That’s when you get it moving.

That’s when it goes. So you just like these priming questions. That’s what gets your juices flowing, and it makes your neural networks build out stronger. Just reading over information is, or listening to me talk, quite honestly, not that helpful. You need to be working through the information, just like when you’re sitting in lectures. You need to be working on the information, not just letting it wash over you. So, one of the ways you can do that is by doing tons and tons of questions.

Now, people ask me when they’re getting ready for their PANCE, you know, should I do 50 PANCE questions a day? I’m like, wow, that seems like a lot. I don’t know that I could mentally handle 50 PANCE questions a day. But there’s certainly some number that’s a good idea to be doing. And as you’re going through the material, same thing while you’re in PA school. Like I said, while I was in school, I found once I started doing more questions, my grades started going up dramatically and it was a huge find for me. So think about how you’re incorporating questions.

I’m not just saying do more, but maybe do them better. Maybe be more involved when you do them. Consider incorporating questions regularly into how you study. And you may find that the material sticks a whole lot better. While we’re on that topic, I do just want to point you back over to the website, physicianassistantexamreview.com/123 for this episode, where you can get all of the notes, but also those 20 neuro questions to help facilitate that memory on neurology.

All right, let’s answer our priming questions. What is the most common cause of generalized tonic-clonic seizures in adults? What’s the most common cause? Strokes or TIAs. Which type of seizure is characterized by repetitive jerking movements? We didn’t spend a lot of time on this, but it was in there. Clonic seizures.

What is the first-line medication for urgent management of status epilepticus? First line. This is one you should definitely know. I feel like it’s an easy test question. What’s the first line medication for urgent management of status epilepticus? Benzodiazepines, so diazepam, lorazepam, something along those lines. Which cognitive test is commonly used to assess memory in mild neurocognitive disorder?

I gave you two today. I’m sure you can come up with others: the mini mental status exam and the Montreal Cognitive Assessment. And our last one for today. What is the characteristic clinical feature of major neurocognitive disorder? Marked deficit in memory and executive function, which keeps the patient from being able to be independent.

All right. Fantastic work. Thank you so much for hanging out with me today. Thank you so much for spending the time with me today. Thank you so much for spending the year with me. As we wrap this up, I hope you’re looking forward to 2024 in the same way that I am. Again, registration for the February cohort of the 33 Days to Pass the PANCE program, that transformative program begins in early January.

If you want to make sure that you find out right away, go to physicianassistantexamreview.com/33 Days, and you’ll be taken over to a page where you get some more information and be able to hop on the waiting list there so you don’t miss out and you get your spot early on if you’re interested in turning around your 2024 year PA journey. So again, I just want to thank you so much. Happy holidays and a happy new year. Take care. We’ll see you next time.