Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

Endocrine > Conditions > Flashcards

Conditions Flashcards

(91 cards)

Start Studying
1
Q

High risk patients for T2DM

A

AUSDRISK >=12
>=40yo + overweight
IGT/IFG
FDR
Hx CVD/PVD/CVA
ATSI, Pacific Island, Indian subcontinent
GDM hx
Antipsychotics

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

AUSDRISK

A

Assess 3 yearly from age 40yo - but screen annually if high risk
Age
Sex
Ethnicity
FDR hx diabetes
Hx of high blood glucose
use of antiHTN
Smoker
Exercise <150min per week
Waist circumference

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

DM clinical features

A

T1DM; Weight loss, Honeymoon period, DKA
Hyperglycaemia; polyuria, polydipsia, blurred vision,
Hypoglycaemia; hunger, tremor, sweating, presyncopal, tachycardia
Insulin resistance; acanthosis nigricans, skin tags, central obesity, hirsutism
Infection; candidal, cellulitis, UTI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Hypoglycaemia mx

A

BGL <4mmol/L
Cause; exercise, varied carb intake, stopping hyperglycaemic drugs (steroids), incorrect insulin dose
Mx - Rule of 15
- 15g carbs (6 jelly beans) -> wait 15min then prick -> if not rising repeat 15g- can give long acting carb (sandwich) if next meal >15min away
- monitor BSL 1hrly for next 4hrs
Mx - severe
- IM glucagon 1mg or IV glucose 50% 20ml (10% in children)
F/u
- Nil driving 6/52 until stabilised (if severe event where they were incapacitated and unable to admin tx themselves - need specialist prior to driving)
- Review trigger
- Review medication
- Review dietary intake
- Review glucose monitoring

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

DKA

A

Cause; poor adherence, stress (infection), SGLT2
Can be euglycaemic (SGLT2, pregnancy, alcohol, post-surgery)
pH <=7.3, ketone >=0.6
Sx; dehydration, lethargy, abdo pain, vomiting, acetone breath, kussmaul respiration
Mx
- Ketone 0.6-1.5; follow sick day mx plan
- IV fluids
- IV insulin infusion with glucose
- replace electrolytes
- Ix + tx precipitating factors

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

HHS

A

Severe hyperglycaemia, hyperosmolality, dehydration, little/no ketoacidosis
BSL >30, Plasma Osm >320, hypernatraemia
Mx
- IV NS 3-6L in first12hrs, and 50% of deficit in first 24hrs
- Always discuss with endocrine to avoid rapid osmolality shift
- IV K unless K >5.5
- Aim BSL 10-15 in first 24hrs
- LMWH (VTE risk with dehydration)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

HbA1C false high causes

A

Iron deficiency
Alcohol
Splenectomy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

HbA1C false low causes

A

Haemolysis
Blood loss/ transfusion
Renal/liver disease
3/12 postpartum

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

T1DM Ix

A

Antibodies; anti-islet cell, anti-glutamic acid decarboxylase - most sensitive
Non-fasting C-peptide <0.2nmol/L supports dx T1DM

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Diagnostic criteria for T2DM

A

HbA1c >=6.5%
FPG >=7mmol/L
Random >= 11.1mmol/L

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Diabetes possible

A

FPG 5.5-6.9 -> do OGTT
HbA1C 6.0-6.4% -> retest in 1 year

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

OGTT criteria

A

FPG <6.1 and 2hr <7.8 -> retest in 3 years
FPG 6.1-6.9 and 2hr <7.8 -> IFG -> retest 1 year
FPG <7.0 and 2hr >=7.8 to <11.1 -> IGT -> retest 1 yr
FPG >=7.0 and 2hr >=11.1 -> DM

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

DM management plan components

A

MDT; dietician, podiatrist, optometrist etc
Diet plan
Exercise plan
Medical mx plan
Sick-day mx plan
Schedule for screening/monitoring of complications
CVD risk mx
Plan for self management

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Insulin dosing in children/adolescents

A

Basal-bolus
- Dose; remission phase (<0.5u/kg/day), pre-adolescent (0.7-1u/kg/day), puberty (1.2-1.5u/kg/day)
- Basal; 50% of total daily (0.1-0.2u/kg evening)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Basal insulin dosing

A

Start; 0.1u/kg OR 10u at bed or morning
Titrate twice weekly
- Mean FPG 10 -> increase by 4U
- Mean FPG 8.0-9.9 -> increase by 2-4U
- Mean FPG <=4 -> reduce by 2-4U

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Bolus insulin dosing

A

Start at 10% of basal insulin dose or 4U
Titrate every 3 days
2hr glucose >=8 -> increase by 2U
2hr 4.0-5.9 -> reduce by 2U
2hr <4.0 -> reduce by 2-4U

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Biphasic insulin dosing

A

Start 10U before evening meal (or largest meal)
Titrate once per week
FPG >10 -> increase by 6U
FPG 8.0-9.9 -> increase by 4U
FPG 6.0-7.9 -> increase by 2U
FPG <4.0 -> decrease by 2U

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Insulin types

A

Bolus; insulin aspart (Novorapid)
Basal; insulin glargine (optisulin)
Premixed; insulin aspart 30% / insulin protamin 70% (Novomix 30)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Risk factors for hypos on insulin

A

Incorrect dose
Incorrect timing of insulin
Incorrect type of insulin
IM instead of subcut
Missed meals
Alcohol
Exercise
Weight loss
Renal failure (reduced insulin clearance)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Patient education for insulin

A

Self mx of timing, freq of SMBG, timing of meals, how to adjust dose
Impact of diet and carbs
Effects of fasting, weight loss on BSL
Impact of exercise
Hypoglycaemic mx
Insulin delivery technique
Sick day mx
Travel considerations
Driver license notification

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Medical examination of diabetic pt

A

BMI, waist
BP
Eyes - acuity, retinopathy
Skin; lipohypertrophy, acanthosis nigricans, infections
CVS exam + ECG
Pulses
Peripheral nerves
Feet
Mood assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Monitoring Ix for DM patients

A

HbA1c; 3-6/monthly
Lipids; 6/12ly
Urine ACR; annual if micro or macroalbuminuria
eGFR: individualised

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Glycaemic targets

A

HbA1c; <7%
FPG 4-8mmol
2hr <10mmol

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Indications for SMBG

A

Insulin / sulphonylurea
Not on insulin but difficulty achieving targets - help modify behaviours
Pre-pregnancy and pregnancy
If taking steroids / medical illness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Metformin
Pros; nil hypo, assist weight loss, improved CVD outcomes ADR; GIT effect, Dosing - MR and IR: GFR >60 (2g daily), GFR 30-60 (1g daily)
26
Sulfonylureas
Gliclazide, glibenclamide, glipizide ADR; hypo, weight gain Dosing - Gliclazide IR 40mg BD up to 320mg daily - Gliclazide MR 30-120mg daily - Avoid if GFR <30
27
T2DM lifestyle guidelines
Diet - 3x servings cereal/wholegrains - 1.5 x serves dairy - Caloric deficit Reduce sedentary exercise - don't sit for >30min etoh <2std Avoid smoking Exercise; 150min aerobic, 2-3 resistance
28
GLP-1
Pros; reduce CVD risk, weight loss, ADR; nausea, pancreatitis, worsening retinopathy can't use with DPP-4i !!! Dosing - Avoid if GFR <30 - Dulaglutide 1.5mg s/c weekly (as long as GFR >=15)
29
SGLT2
Pros; CVD/CKD benefits, weight loss Cons; UTI, euglycaemic DKA - need to avoid for procedures/fasting Can't use if eGFR <=45 Dapagliflozin 5-10mg daily
30
DPP-4 inhibitors
Pros; nil weight gain/hypo, Cons; avoid in HF (saxagliptin), avoid in pancreatitis hx, Dosing - Linagliptin 5mg daily - nil renal dosing - Sitagliptin; GFR >50 (100mg daily), GFR 30-50 (50mg), GFR <30 (25mg)
31
T2DM drug combinations
Met-SU-DDP4 -> add SGLT2 Met-DPP4-SGLT2 -> add SU or insulin If on triple therapy and still not meeting target - change one of the drugs to GLP-1 or insulin If on multidrug and GLP-1 and not meeting target - add basal or mixed insulin If not meeting target and on a GLP-1 - can switch to a different GLP-1 If on basal insulin and not meeting target, can; - add SGLT2 or GLP-1 - add bolus - basal-bolus insulin - change to BD mixed insulin regimen
32
Pneumococcal vaccination in DM
13vPCV at dx 23PPV - 1st dose 12/12 after 13vPCV or at age 4yo (whichever is later) - 2nd dose; at least 5 years later
33
Driving and diabetes
Private - OHG: 5 yearly, conditional if organ complications / severe hypo event - Insulin; Condition 2 yearly Commercial - Specialist initial review -> OHG (annual rv with doctor), insulin (annual specialist)
34
GDM diagnostic criteria
Any one of following; FPG 5.1-6.9 2hr 8.5-11.1
35
GDM BSL targets
FPG <=5 1hr <=7.4 2hr <=6.7
36
HbA1c targets
HbA1c 7-7.5% in most Complex <8% Very complex/poor health <=8.5%
37
Sick day management
Planned surgery; w/h SGLT2 3 days prior Metformin; consider withholding and restart once tolerate PO GLP-1; w/h if illness causing n/v (can worsen) Sulfonylurea; continue but w/h if BGL lowering DPP4; continue GIT illness; cease SGLT2, metformin, GLP1 - worsen dehydration Monitor BGL 2-4hrly if on insulin Educate signs of HHS/hypo/DKA Increase fluid intake If BGL >15mmol -=> use glucose free fluids
38
Withholding medications pre-op
SGLT2 - morning of if day procedure - 3 days prior if require one or more days in hospital or bowel prep Insulin - Long-acting; continue morning dose - Short; omit morning, half of normal morning dose in PM Colonoscopy - Day of; w/h all OHG - SMBG - Insulin as above - Premixed; half normal dose on day of bowel prep, on morning of do half dose with glucose infusion
39
Peripheral neuropathy
Exam; small fibre pin-prick, 10g monofilmanet plantar great toe + MTJ, ankle reflex, vibration 128Hz Ix; exclude B12/ hypothyroid/renal/alcohol Monitor; annual 10g monofilament Tx - Pregabalin - Amitriptyline 10-25mg nocte - Topical nitrate - Opioid
40
Diabetic retinopathy
Screening; annual (>15years duration, HbA1c >8%, systemic disease, ATSI) - 2 yearly for all others Risk factors for progression; poor BSL control, HTN >10yr duration, microalbuminuria, dyslipidaemia, pregnancy Features - Non-prolif; microaneurysm, haemorrhage, tortuous vessels - Prolif; abnormal vessel growth Mx - Optimise BGL - Control HTN - Add fenofbirate to reduce progression - Laser, surgery etc
41
Diabetic nephropathy
Annual eGFR + UACR Start ACEI if CKD + HTN or albuminuria to prevent progression Consider SGLT2 to prevent progression
42
Diabetic foot ulcer
Exam; annual of 6/12 if risk factors, ulcer (site, depth, size, discharge), pulses, ABI (if <0.7 then vasc surg referral) Clinical features - thick/yellow crumbling nails - Interosseous muslce wasting - Loss of achilles reflex Mx - MADADORE - Metabolic/medication; optimise BSL, lipids, HTN - Assessment; examine and grade - Debride; necrotic/unhealthy tissue - Abx; if infection - fluclox - Dressing; moist wound dressings, wound care nurse, vascular surgeon - Offloading to reduce plantar pressure - Referral; MDT team - Education; foot self care, protection
43
Diabetes cycle of care
6/12 - BMI - BP - Foot Annually - Diet, exercise, smoking - HbA1c - Monitor complications; eyes, feet, kidney, CVD health - Lipids - UACR 2 yearly - Eye
44
Metabolic syndrome dx
3/5 of; - Abdo obesity; WC >102cm men, >88cm women - TAG >1.7 - HDL <1.0 (men), <1.3 women - BP >130/85 - FPG >6.1
45
Air travel and diabetes
Hand luggage for medications Name on all medication Carry prescriptions NDSS card for proof Letter from doctor
46
Pituitary tumour types
Non-functioning adenoma - can cause mass effect- headache, VF defect, hypopituitarism Prolactinoma - tx with dopamine agonist e.g. cabergoline Acromegaly - GH -> gigantism Cushing's disease Rare; TSH/ FSH secretion
47
Acromegaly
Sx - enlarged extremities; nose, ears, jaw, hands, feet - diaphoresis - arthritis - OSA - HTN - cardiomyopathy Ix - Raised serum GH + elevated IGF- 1
48
Aetiology of HPRL
Prolactinoma Pregnancy Antipsychotics, domperidone, metoclopramide, SSRI, COCP Hypothyroidism Lactation / breast stimulation
49
HPRL tx
Dopamine agonist - 1st line; cabergoline weekly up to 3mg weekly - may take months to restore gonadal function COCP; women with microprolactinaemia who don't want fertility Pituitary surgery Radiotherapy
50
SIADH cause
Intracranial bleed Meningitis/encephalitis TB Drugs; sertraline, carbamazepine, haloperidol Malignancy; mesothelioma, GIT, lymphoma, lung Hypothyroidism
51
SIADH sx
Reduced UO Water retention
52
SIADH Ix
Na <135 Serum osm <275 Urine osm >100 TFT Morning cortisol (Addison's) CTB if considering nsurg cause CXR if suspect pulmonary cause
53
SIADH tx
FR 800ml/day
54
Diabetes insipidus
Impaired ADH secretion -> more water excretion Cause - Idiopathic - Fhx - Nsurg/trauma - Cancer - Anorexia nervosa Sx - polyuria, nocturia - polydipsia - UO 3-20L per day Tx - intranasal desmopressin
55
Evaluation of thyroid nodule
TSH - if low -> radionuclide imagine and endocrinology TSH normal/high - USS +/- FNA
56
TI-RADS classification of thyroid nodules
TR1; benign TR2; not suspicious TR3; mildly suspicious - FNA if >=2.5cm otherwise serial scans (1, 3, 5yr) TR4; moderately suspicious - FNA if >=1.5cm otherwise scans (1, 2, 3, 5yr) TR5; highly suspicious - FNA IF >=1cm otherwise scans (yearly x 5yrs)
57
Causes of thyrotoxicosis
Graves MNG Toxic adenoma Painless postpartum thyroidism Painful Subacute thyroiditis TSHoma Amiodarone induced thyroiditis
58
Causes of hypothyroidism
Hashimoto's Atrophic hypothyroidism Hypopituitarism Lithium, amiodarone
59
Ix of thyrotoxicosis
If signs of Graves (new onset orbitopathy, large non-nodular thyroid, mod-severe hyperthryoidism) - then start tx If nil signs of Graves but nodular goitre -> RAIU If nil signs of Graves and nil nodular goitre -> do TSH Antibodies (TRAb or TSI) - if positive = Graves, if negative do RAIU
60
Antithyroid mx options
Mild sx or bloods; Carbimazole 10-20mg in 3 divided doses (adjust 6/52) Significant sx (AF, weight loss), or T3/T4 >2x5x upper limit - 1st line; Carbimazole 30-45mg in 3 divided doses - 2nd line; Prophylthiouracil 300-450mg in 3 divided doses -> use if can't tolerate carbimazole, pre-conception, 1st trimester, or thyroid storm Once euthyroid - switch to once daily dosing of carbimazole for maintenance ADRs; agranulocytosis, n/v, fever, rash, liver injury Radioiodine ablation - Indication; Severe Graves + large goitre, recurrent severe Graves, toxic adenoma/MNG, Thyroidectomy - Indication same as above
61
Beta-blocker for hyperthyroidism mx
For sx of palpitation, tremor, diaphoresis Atenolol 25mg PO daily or Propranolol 10mg BD
62
Risk factors hypothyroidism
DM Coeliac Down syndrome Prior Graves Amiodarone/lithium
63
Clinical features hypothyroidism
Fatigue Cold intolerance Cognitive dysfunction Constipation Dry skin Periorbital oedema Loss of eyebrows Depression Menorrhagia Peripheral neuropathy Pregnancy; premature, low birth weight, miscarriage, impaired foetal neurocognitive development
64
TSH targets for hypothyroidism
<60yo; 0.5-2.5 >=60yo; 1-5 Pregnancy - 1st trim; 0.1 - 2.5 - 2nd trim; 0.2-3 - 3rd trim; 0.3 - 3
65
Hypothyroidism referral indication
<=18yo Unresponsive to therapy Pregnant Cardiac pt Goitre/nodule
66
Mx hypothyroidism
Thyroxine 1.6ug/kg empty stomach - titrate 4-8/52 If pregnant - increase dose by 30% and monitor 4/52 If pregnant and new dx + overt - start thyroxine immediately and await specialist input
67
Subclinical hypothyroidism mx
Asymptomatic -> repeat TSH in 4-8 weeks + test TPO - if positive TPO then likely to progress so check TFT after 3/12 - start tx if progressive rise in TSH or sx
68
Subacute thyroiditis (De Quervain thyroiditis)
Inflammation of thyroid -> transient thyrotoxicosis then hypothyroidism Sx; pain, fever, malaise and thyroid sx Ix; ESR elevated, uptake scan negative Mx - aspirin/nsaid - beta blockers for sx of thyrotoxicosis - Prednisolone for severe sx - Antithyroids don't work!!
69
Post-partum thyroiditis
Can be isolated hypo, or hyper THEN hypo, or isolated hyper Most euthyroid within 1 year Nontender - differs from De Quervains this way Ix; Anti-TPO helps dx Tx; - antithyroids don't work on hyper phase - can give thyroxine if persisting hypo or sx F/u - annual TSH 5-10 years
70
Hashimoto's
Positive anti-TPO Hashitoxicosis - rare
71
Primary hyperparathyroidism
Parathyroid adenoma Tx - surgery - If not wanting surgery; avoid high Ca diet, limit vitamin D supp, 2.5L per day water
72
Hyponatraemia causes
Hypervolaemic; HF, cirrhosis, renal failure Euvolaemic; SIADH, hypothyroidism, psychogenic polydipsia, adrenal insufficiency Hypovolaemia; GIT losses, burns, thizide drugs, hypopituitarism Drugs; chemo, antidepressants, antipsychotics, ectasy, diuretics, ACEI, sulfonylurea
73
Work up of hyponatraemia
Glucose TFT Morning cortisol – Addison's CT head if neurosurgical condition suspected CXR if pulmonary cause of SIADH considered Serum osmolality Urine osmolality
74
Hyponatraemia mx
Mild-moderate 120-135; FR 0.5-1L, monitor U+E and UO
75
Hypercalcaemia causes
Primary hyperparathyroidism Malignancy Thiazide Sarcoidosis Severe hyperthyroidism Primary adrenal insufficiency
76
Hypercalcaemia sx
Polyuria/polydipsia Renal stones Nausea/vomiting Bone pain Constipation Fatigue Bradycardia
77
Hyperkalaemia
Causes; haemolysis, renal failure, primary adrenal insuff, ACEI Tx - IV calcium gluconate - Sodium bicarbonate if acidotic - Insulin 10U IV + glucose 50% 50ml - Resonium
78
Causes of adrenal mass
Adenoma Carcinoma Phaeochromocytoma Congenital adrenal hyperplasia Nodular variant Cushing syndrome Lymphoma Amyloidosis
79
Work up of adrenal mass
Adrenal CT 1mg overnight dexamethasone suppression test Aldosterone-renin ratio Plasma metanephrines Early morning cortisol (adrenal insufficiency)
80
Primary adrenal insufficiency (Addison's disease)
Autoimmune destruction of cortex -> deficiency in cortisol, aldosterone, DHEAS Sx - Fatigue + nausea/vomiting + abdominal pain +/- skin discolouration - Pigmentation - Dizziness - Myalgia - Hypotension Ix - Positive Short synacthen test; blunted cortisol in response to tetracosactide injection - Low morning cortisol <3mcg/dL, elevated ACTH - Low Na, high K Tx - Adrenal crisis; IVF, IV hydrocortisone 100mg then 50mg QID - Hydroxycortisone to mimic circadian rhythm - Fludrocortisone - Education; increase dose during illness, educate signs of crisis, carry injectable hydrocortisone, medi-alert bracelet, action plan for crisis mx - Baseline BMD - GPMP + allied health
81
Primary aldosteronism
Primary; Conn syndrome (adenoma) or Bilateral adrenal hyperplasia Sx; weakness, headache, palpitations, cramps, paraesthesia, polyuria/dipsia Ix - Aldosterone-renin ratio 2hrs post awakening (must cease ACEI/ARB/betablockers/loop/thiaizde) - Elevated plasma aldosterone - Hypokalaemia
82
Indications to Ix for primary aldosteronism
HTN with hypokalaemia after starting diuretic HTN with adrenal incidentaloma HTN with OSA HTN + AF
83
Cushing syndrome
Sx - Reduce libido - Obesity - Plethora - Moon facies - Buffalo hump - Acanthosis nigricans - Striae - Menstrual disturbances - HTN - Hirsutism Ix - if high suspicion - do two of below; - 2x late-night salivary cortisol - 1mg overnight dexamethasone suppression test - 24hr urinary free cortisol
84
Indications to test for Cushing's
Osteoporosis or HTN ealry age Sx of cushing's Resistant HTN Adrenal incidentaloma
85
Phaeochromocytoma
Sx - Triad; headache, sweating, tachycardia - HTN - Palpitations Ix - Plasma free metanephrines and normetanephrines - OR urine total metanephrines
86
Causes of fatigue
Depression OSA Post-viral / viral / HIV / chronic infection (Lyme) CCF Anaemia Coeliac disease Fibromyalgia Menopause Pregnancy Hypokalaemia Addisons, Cushings Diabetes Thyroid
87
Carcinoid syndrome sx
Triad; flushing, diarrhoea, valvular heart disease Wheeze Telangiectasia Hypotension
88
Precocious puberty
Male <9, female <8 Cause - Idiopathic - Tumour - Tumour releasing hormones - Exogenous hormones Ix - FSH/LH - TSH - Oestradiol/testosterone - Bone age XR Tx - Urgent referral - GnRH agonist e.g. leuprorelin
89
Red flags of pubertal gynaecomastia
Outside of neonatal/pubertal age group Prepubertal and nil other secondary sex characteristics Rapid progression <4cm diametre Persistence after 17 yo
90
Male androgen deficiency signs
Micropenis/small testes Failure of enlargement of penis Failure of growth of larynx Hot flushes/sweats Low semen volume Ix - Low testosterone and normal/low LH = hypogonadotrophic hypogonadism -> measure PRL/Iron/pituitary imaging - Low test + high LH = Primary testicular failure (e.g. Klinefelter's)
91
Pre-exercise BGL targets
All pt on insulin and SU need to check BSL before, during (every 30min) Pre-exercise BGL; 5.0-12.9

Endocrine (1 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions