Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

PRE-REG-Thuri > NERVOUS SYSTEM - EPILEPSY > Flashcards

NERVOUS SYSTEM - EPILEPSY Flashcards

1
Q

what is epilepsy?

A

Seizure caused by hyper-excitable neurones firing AP.

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

What are the 3 types of seizures?

A

Focal

Generalised

Absence

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

What is 1st line drug treatment for focal seizures? (2 options)

A

Lamotrigine

Levetiracetam

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

Who is sodium valproate used in?

A

Patients who cannot have children

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

What are the 3 types of generalised seizures?

A

Tonic clonic

Myoclonic

Atonic, tonic

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

What is 1st line drug treatment for generalised seizures?

A

Sodium valproate

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

What is an absence seizure?

A

Last just a few seconds, and are characterized by a blank or “absent” stare.

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

What is 1st line drug treatment for absence seizures?

A

Ethosuximide

OR sodium valproate

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

What is a focal seizure?

A

Focal onset seizures start in ONE area and can spread ACROSS the brain and cause mild or severe symptoms

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

What is a generalised seizure?

A

Generalised seizures start as focal seizures that spread to BOTH sides of the brain.

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

What is MHRA 2017 warning regarding anti-epileptic switching?

A

Potential harm arising from switching of anti-epileptic brands.

Caused worsening SE + loss of seizure control

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

What is category 1 epilepsy medication?

A

Ensure the person is maintained on a specific manufacturer’s product.

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

List the 4 Category 1 epileptic drugs?

A

Carbamazepine

Phenytoin
Primidone
Phenobarbital

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

Phenytoin and methotrexate interaction?

A

Blood disorders

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

What are category 2 epilepsy medications? (TLCV)

A

Topiramate

Lamotrigine

Clonazepam

Valproate

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

What should we do if we need to switch category 2 anti-epileptics?

A

use clinical judgement and discuss seizure frequency and treatment history with the person and/or carer

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

What are Category 3 epileptic drugs? (LEGP)

A

Levitiracetam
Ethosuximide
Gabapentin
Pregabalin

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

Do we need to maintain same brand of category 3 epileptic drugs?

A

No need unless patient anxiety, risk of confusion or dosing errors

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

When do we keep patient on same cat 3 epileptic drug ?

A

If pt has anxiety, risk of confusion or dosing errors

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

What is Antiepileptic hypersensitivity syndrome?

A

Rare- dangerous

allergic reaction to some anti-epileptic drugs.

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

What to do if patient has Antiepileptic hypersensitivity syndrome?

A

Stop treatment

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

When does anti-epileptic hypersensitivity syndrome symptoms start?

A

Symptoms usually start between 1 to 8 weeks of exposure.

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

What 3 symptoms are common in antiepileptic hypersensitivity syndrome?

A

fever, rash, and lymphadenopathy

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

When can a decision be made about withdrawing anti-epileptic medicines?

A

Decision to withdraw antiepileptic drugs from a seizure-free patient MAY be considered after the patient has been seizure-free for at least two years

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What 2 anti-epileptic classes are withdrawal dangerous in as it can cause rebound seizures?

A

barbiturates and benzodiazepines

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What can abruptly stopping anti-epileptic medications do?

A

Cause rebound seizures

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

When does a patient STOP driving after having seizure?

A

If driver has a seizure (of any type) they must stop driving NOW + inform the (DVLA).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What 4 requirements must patients meet in order to start driving with established epilepsy?

A

No unprovoked seizures for 1 year

Seizure free

Seizure pattern + no effect on consciousness.

must NOT have a history of unprovoked seizures.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Patients who have had a 1st unprovoked epileptic seizure or a single isolated seizure CANNOT DRIVE for how many months?

A

6 months

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Can patients who have had seizure in sleep drive?

A

NOT permitted to drive for 1 year from the date of each seizure unless they meet 2 criteria.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

How long can someone drive after established epilepsy?

A

may drive a motor vehicle provided they are not a danger.

Patients must be seizure-free for at least one year

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

What are the 2 exceptions for patients with sleep seizures being able to drive?

A

Pattern of sleep seizures occurring only ever while asleep 1 year from first sleep seizure.

Established pattern of purely asleep seizures can be demonstrated over the course of 3 years if the patient has previously had seizures whilst awake.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

What does the dvla recommend about driving after medication changes or withdrawal of antiepileptic drugs

A

no driving for at least 6 months from last dose

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

If a seizure happens due to medication withdrawal or change in medication, how long is license revoked for?

A

1 year - can be given after 6 months if treatment resumed + no seizures.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

What is dosing frequency for anti-epileptic drugs?

A

twice daily

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

What are 2 carbamazepine derivatives?

A

Oxcarbazepine

Eslicarbazepine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

What is 1 MAJOR risk of using gabapentin?

A

Severe respiratory depression

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

What specific indication is gabapentin also used for aside from epilepsy?

A

Neuropathic pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

What side effect is specific to lamotrigine use?

A

Severe skin reactions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

What 2 skin reactions have developed due to use of lamotrigine?

A

Stevens-Johnson syndrome (SJS)

toxic epidermal necrolysis (TEN)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

When is it better to take lamotrigine and why?

A

Night as can make you tired

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

What is the prodrug of phenytoin called?

A

Fosphenytoin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

What anti-epileptic drug is most teratogenic?

A

Sodium valproate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

What is 1 specific side effect of topiramate?

A

Eye disorders/ cleft palate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

What is 2 specific rare SEs of vigabatrin?

A

Encephalopathy

eye disorders/ Visual field defect

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

What is the name of a carbonic anhydrase inhibitor which is also used for epilepsy?

A

acetazolamide

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

What is an example of a barbituate?

A

Phenobarbital

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

What is primidone metabolised into?

A

partially metabolised to phenobarbital

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

List 5 benzodiazepines used in epilepsy?

A

Cabazam

Clonazepman

Diazepam

Lorazepam

Midazolam

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

What is a key MHRA warning about anti-epileptic drugs?

A

Teratogenic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

What 4 anti-epileptic drugs have increasing teratogenicity?

A

Carbamazepine

Phenytoin

Phenobarbital

Pregabalin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

What do patients need when taking teratogenic drugs?

A

Highly effective contraception

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

What do do is patient planning to be pregnant and on epileptic drug?

A

Do not stop drug.

Urgent referral to specialist + give folic acid.

Join Uk epilepsy/ pregnancy register

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

What 3 drugs is teratogenicity dose dependent? (CPT)

A

carbamazepine, phenobarbital, and topiramate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

What injection minimises the risk of neonatal haemorrhage at birth?

A

Vitamin K

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

Who should be encouraged to join the UK Epilepsy and Pregnancy Register?

A

Any pregnant female with epilepsy who are and are not taking meds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

What is given to reduce the risk of neural tube defects in pregnancy?

A

Folate supplements given especially in 1st trimester

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

Can women breastfeed if on epileptic drugs?

A

If females taking monotherapy, they can.

If a female is on combination therapy or other risk factors= close monitoring is recommended

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

What 4 anti-epileptic drugs present in breastmilk? (ZELP)

A

zonisamide
Ethosuximide
Lamotrigine
Primidone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

What 2 anti-epileptic drugs if slow metabolism in infant can cause drug buildup?

A

phenobarbital + lamotrigine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

When is breastfeeding encouraged in epileptic patients?

A

When patient on monotherapy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

What is 1 particular side effect of Zonisamide?

A

Over heating - makes you sweat less

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

What 4 things should breast-fed infants be monitored for if mum taking anti-epileptic?

A

drowsiness + feeding difficulties, adequate weight gain, and developmental milestones

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q

What 3 drugs/classes cause drowsiness in breast fed babies?

A

Primidone

Phenobarbital

Benzodiazepines

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

What are 3 2nd line monotherapy drug treatment options for focal seizures?

A

Carbamazepine

Oxcarbazepine,

Zonisamide

66
Q

what are 2 unlicensed drug alternatives for generalised tonic-clonic seizures?

A

Lamotrigine or levetiracetam

67
Q

What are 4 side effects of anti-epileptic drugs?

A

Sedations + dizziness

Anti-epileptic hypersensitivity syndrome

Suicidal behaviour

Blood dyscrasias

vit D deficiency

68
Q

What is Blood dyscrasias?

A

blood disorder- imbalance of four body fluids: blood, bile, lymph, and phlegm.

69
Q

What counselling can be given for patients with Anti-epileptic hypersensitivity syndrome?

A

report any fever, rash of swollen lymph nodes

70
Q

What is there an increased risk of with anti-epileptic drugs?

A

Suicidal behaviour- report mood change/ suicidal thoughts

71
Q

What patient counselling to give for blood dyscrasias?

A

Report signs of infection or blood disorders.

e.g. fever, sore throat, mouth ulcer

72
Q

What are 3 high risk examples of respiratory depression + should be aware of before giving gabapentin?

A

pts on CNS depressants (e.g. opioids, Benzos, barbiturate)

Pt with respiratory disease

Elderly/ Neurological disease + Renal impairment

73
Q

What class of anti-epileptic drugs can cause severe respiratory depression?

A

Barbiturate

74
Q

What are 3 MHRA warnings about gabapentin?

A
  1. severe respiratory depression
  2. Abuse + dependence
  3. suicidal thoughts
75
Q

What drug class interacts with gabapentin to be fatal?

A

CNS depressants e.g. alcohol

76
Q

What class drug is gabapentin + does it require safe custody requirements?

A

Class C controlled substance and is now a Schedule 3 drug,

is EXEMPT from safe custody requirements.

77
Q

What is a risk of gabapentin use + what should healthcare professionals do before giving it?

A

risk of abuse + dependence

Do history of drug abuse before giving + observe for signs

78
Q

What is a new MHRA warning of topiramate + counselling?

A

Increased risk of neurodevelopmental disabilities

Pts need contraception

79
Q

What happens to sodium valproate during interaction?

A

Increased toxicity

80
Q

Alcohol + sodium valproate interaction?

A

Increased risk of hepatotoxicity

81
Q

Sodium valproate + azetazalomide interaction?

A

Increases the risk of toxicity when given with Valproate.

Monitor

82
Q

Cannabidiol + sodium valproate interaction?

A

Cannabidiol increases the risk of increased ALT concentrations when given with Valproate.

Manufacturer advises avoid or adjust dose.

83
Q

Sodium valproate + LMWH interaction?

A

Increases hepatoxicity

84
Q

Lamotrigine + valproate interaction?

A

valproate increases lamotrigine exposure.

Adjust lamotrigine dose , monitor rash

85
Q

Meropenem + sodium valproate interaction?

A

Meropenem decreases the concentration of Valproate. Manufacturer advises avoid.

86
Q

What 2 drugs reduce drug levels of carbamazepine, phenytoin + phernobarbital?

A

Oestrogren/ progesterogen

Warfarin

87
Q

What is phenytoin moa?

A

Reduces cortical neuronal excitability

Blocks Voltage gated Na+ channels

Prevent seizures

88
Q

What is indication of phenytoin?

A

Focal + tonic clonic seizures

89
Q

What is phenytoin therapeutic index?

A

10-20mg/L (40-80micromoles/L)

90
Q

What is the relationship between phenytoin dose and plasma-drug concentration?

A

Non linear

91
Q

What does non-linear plasma-drug concentration mean?

A

Small changes in dose = large changes in plasma concentration causing toxicity

92
Q

what happens to phenytoin protein binding?

A

Reduced protein binding so more drug in blood

93
Q

Why is plasma- phenytoin concentrations reduced in first 3 months of life

A

Reduced protein binding.

94
Q

What is optimum trough plasma concentration of phenytoin in neonate to 3 months old?

A

6–15 mg/litre (25–60 micromol/ litre)

95
Q

What should be monitored in IV phenytoin use?

A

Monitor ECG + blood pressure.

96
Q

In what 3 instances is there higher phenytoin levels in blood due to less protein binding?

A

Pregnancy

If <3Months old

Elderly

97
Q

What are 5 signs of phenytoin toxicity? (HANDS)

A

HypERglycaemia

Ataxia

Nystagmus

Diplopia

Slurred speech + confusion

98
Q

What is ataxia?

A

Co-ordination, balance + speech

99
Q

What is nystagmus?

A

eye rolling

100
Q

What is diplopia?

A

Double vision

101
Q

What deficiency can cause diplopia?

A

Low vitamin D

102
Q

100mg phenytoin sodium is equivalent to —- phenytoin base?

103
Q

What are 3 SEs of phenytoin that affects appearance?

A

couse facial hair, acne, gingival hyperplasia

104
Q

What are 3 other SE of phenytoin?

A

Skin rashes

Blood dycrasias - monitor FBC

Bone disorders - caution if immobile, no sun exposure + low calcium

105
Q

What 2 drug classes increase phenytoin levels + cause toxicity?

A

NSAIDs + Warfarin

106
Q

What other 9 enzyme inhibitors cause increased toxicity of phenytoin?

A

Amiodarone

Azoles

Cimetidine

Erythromycin

Isoniazid

Metronidazole

CCB rate limiting

SSRIs

Valproate

107
Q

What 2 anti-epileptic drugs reduce phenytoin levels?

A

Carbamazepine

Phenobarbital

108
Q

What 2 drugs (enzyme inducers) reduce phenytoin levels?

A

Rifampicin

St john’s wort

109
Q

Phenytoin is an enzyme ——?

A

Inducer = increases breakdown of the drug + lowers drug

110
Q

What happens to oestrogen + progestogen with phenytoin?

A

Reduced efficacy

111
Q

What schedule 3 drug lowers seizure threshold with phenytoin?

112
Q

What 5 drug classes reduce anti-convulsant effect with phenytoin?

A

Anti-psychotics

Quinolone

SSRI

TCA

tramadol

113
Q

What is MOA of carbamazepine?

A

Reduces cortical neuronal excitability

Blocks Voltage gated Na+ channels

Prevent seizures

114
Q

What is indication of carbamazepine?

A

Focal + tonic- clonic seizures

115
Q

What is therapeutic index of carbamazepine?

116
Q

How do we monitor therapeutic drug monitoring?

A

measure plasma conc. after 1-2 weeks

117
Q

What are 7 signs of carbamazepine toxicity? (HANDBAG)

A

HypOnatraemia - hallucination
Ataxia + anuria
Nystagmus
Drowsy, dizzy , slurred speech
Blurred vision
Arrhythmia
Gastro effect - N + V

118
Q

what is a SE of carbamazepine in patient with RI?

A

Anuria - kidney cannot produce urine

119
Q

What are 2 specific side effects of carbamazepine?

A

hepatotoxicity

HypOnatraemia

120
Q

What to monitor if patient is hepatotoxic?

A

Monitor LFT

Symptoms such as vomiting, abdominal pain, dark urine, jaundice

121
Q

What are some of the dose- related SE linked to carbamazepine?

A

Headache,

ataxia

drowsiness

N +V

Blurred vision

Dizziness

Allergic skin reactions

122
Q

What preparations can be used to reduce dose-limiting SE of carbamazepine?

123
Q

What 7 enzyme inhibitors increase carbamazepine levels?

A

Azole anti-fungals

Cimetidine

Macrolides

Rate limiting CCB

SSRIs- fluoxetine + Fluvoxamine

Grapefruit juice

Isoniazid

124
Q

What 3 drugs reduce carbamazepine levels?

A

Phenobarbital + phenytoin

St john’s wort

125
Q

Carbamazepine is an enzyme ——?

126
Q

What 4 drugs increase hypOnatremia with carbamazepine?

A

Antidepressants (SSRI, TCA + MAOI)

Desmopressin

Diuretics

NSAID

127
Q

What 8 drugs increase hepatoxicity with carbamazepine?

A

Co-amoxiclav

Flucloaxcillin

Tetracycline

Fluconazole

Isoniazid

MTX

Statin

Sulfasalazine

128
Q

What drug increases blood dyscrasias with carbamazepine?

129
Q

Carbamazepine + MTX interaction?

A

increased hepatotoxicity

130
Q

What is MOA of Sodium valproate?

A

reduces cortical neuronal excitability, blocks Na+ channels

Increases GABA levels

131
Q

What is indication for Sodium valproate?

A

Epilepsy (generalised)

Mania + migraine prophylaxis

132
Q

What to do if planning pregnancy + taking sodium valproate?

A

Contact GP/ specialist

133
Q

What is interaction between ertapenem + sodium valproate?

A

Ertapenem decreases the concentration of Valproate.

Manufacturer advises avoid.

134
Q

What 3 things are needed to be given when giving patient sodium valproate?

A

Patient guide

Patient care

ARAF

135
Q

What forms of contraception needed for females when taking sodium valproate?

A

1 user independent = IUD, implant

2 x user dependent - pill + barrier

136
Q

What 3 criteria must women meet to on pregnancy prevention programme?

A

For females of child-bearing potential

No other treatment for them

Specialist initiation

137
Q

What are 4 SE of sodium valproate?

A

Blood dyscrasias

Bone disorders

Hepatotoxicity

Pancreatitis

138
Q

What 2 things should pharmacists do when supplying sodium valproate?

A

Patient card

Give whole pack - warning label + PIL

(remind of risk + review)

139
Q

What counselling to give patients suspecting pancreatitis on valproate?

A

Report signs- abdo pain , N +V

140
Q

Sodium valproate is an enzyme —-?

A

Inhibitor - increases drug levels

141
Q

What 5 drugs decrease anticoagulant effect to cause more bleeding?

A

Anti-psychotic

Quinolone

SSRI

TCA

Tramadol

142
Q

What is status epilepticus?

A

dangerous condition

Fits follow one another without recovery of consciousness between them.

Convulsive for > 5 mins

143
Q

What to give for status epilepticus if resus facilities are available?

A

IV lorazepam

144
Q

Who to call after 1st dose of benzo for status epilepticus?

A

emergency services

145
Q

For status epilepticus, if there is NO response to 2 doses of a benzodiazepine, what to give?

A

Levetiracetam, phenytoin or valproate

If fails:

Phenobarbital or general anaesthesia

146
Q

What is 1st line tx for status epilepticus in community?

A

diazepam (rectal)

Midazolam (oromucosal)

Repeat once after 5-10 mins if needed

147
Q

What to give if alcohol abuse causing status epilepticus?

A

Also give Parenteral thiamine

148
Q

Lennox-Gastaut syndrome 1st line tx?

A

Sodium valproate

149
Q

Atonic or tonic seizures 1st line tx in males or females unable to have children?

A

Sodium valproate

150
Q

Atonic or tonic seizures 1st line tx in females who can have children?

A

Lamotrigine

151
Q

What are Myoclonic seizures?

A

sharp, uncontrollable muscle movements.

152
Q

What to give for cluster seizures?

A

clobazam or midazolam

153
Q

Which 8 antiepileptics are more prone to Antiepileptic hypersensitivity syndrome?

A

carbamazepine, lacosamide, lamotrigine, oxcarbazepine, phenobarbital, phenytoin, primidone, and rufinamide

154
Q

When can withdrawal of epilepsy meds be considered?

A

patient has been seizure-free for at least two years

155
Q

What to give patients if sodium valproate not successful in myoclonic seizures?

A

levetiracetam

156
Q

What 7 epilepsy drugs are known for causing blood disorders? (C.VET.PLZ)

A

Carbamazepine

valproate

ethuximide

topiramate

Phenytoin

Lamotrigine

Zonasamide

157
Q

What to do if patient on phenytoin has rash?

158
Q

What does MHRA recommend giving with valproate if immobile for long time or inadequate calcium?

A

vitamin D supplementation

159
Q

Which 4 anti epileptics are long acting so can be given OD at bedtime?

A

Lamotrigine
Perampanel
Phenobarbital
Phenytoin

160
Q

How long to continue contraceptives after finishing sodium valproate?

A

At least 3 months after stopping

PRE-REG-Thuri (44 decks)

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