Brainscape's Knowledge GenomeTM

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


See full index

Clin Med I - Comprehensive > Neuro > Flashcards

Neuro Flashcards

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

number one risk factor for Parkinson’s

A

aging2-4% risk >60 years

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

do males or females get Parkinson’s more

A

Males 3:2 (M:F)

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

what does Parkinson’s often start with/first sign

A

UUNILATERAL resting tremor (don’t HAVE to start our with but often do 75%)

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

when looking at brain, what is a hallmark to Parkinson’s

A

progressive Lewy Body accumulationstarts in brainstem and then goes up to frontal cortex and then works it’s way back to occipital cortex (most found in brainstem)

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

list four classical clinical features of Parkinson’s

A

Bradykinesia

Muscular Rigidity

Postural Instability

Resting Tremor

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

describe rest tremor

A

“pill-rolling”

UNILATERAL/symmetric

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

common appearance of gait in Parkinson’s

A

narrow stance, small-shuffling steps, stooped over

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

common non-motor features of Parkinson’s

A

fatigue, saliva, nocturia

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

how to tell if Parkinsonism due to Parkinson’s or drugs

A

are features presenting symmetrically or asymmetrically

symmetrically due to drugs

asymmetrically due to Parkinson’s

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

why do you want to get definitive dx of Parkinson’s when looking at neurodegenerative disorders when treatment basically the same for all of them

A

prognosisquality of lifeParkinson’s could still live 30 yearsOther neurodegenerative disorders 8-10 years

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

T/F diagnosis of Parkinson’s is clinical

A

true

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

T/F diagnosis of Parkinson’s is from good hx and physical

A

true

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

define Parkinsonism

A

bradykinesia in combination with at least 1 of rest tremor or rigidity

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

are reflexes impaired in those with Parkinson’s

A

no

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

diagnostic criteria of Parkinson’s

A

see picture

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

Parkinson’s diagnostic pearls

A

see picture

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

what best slows down the progression of Parkinson’s

A

exercise

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

goals of management of Parkinson’s

A

optimal quality of lifepatient-specific

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

T/F medication adjustment over time is the norm when treating Parkinson’s

A

true

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

Management strategies of Parkinson’s

A

see picture

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

Parkinson’s medications

A

see picture

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

rule when starting medications in Parkinson’s

A

start low and go slow

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

common side effects of selected dopaminergics

A

see picture

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

potential side effects of dopamine agonists like pramipexole (mirapex)

A

impulse controle disorders so impulsive shopping, gambling, hypersexuality, or binge eating

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

define Parkinson’s

A

neurodegenerative disorder associated with loss of dopaminergic neurons in brainstem and accumulation of Lewy bodies throughout brain

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

mainstay of pharmacotherapy for Parkinson’s motor symptoms

A

dopaminergic medications

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

mechanism of Parkinson’s

A

dopamine neurons die so less dopamineless dopamine (inhibitory) means failure to inhibit Ach (excitatory) in basal gangliathus increase GABA release (inhibitory)

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

where is loss of pigment cells seen in Parkinson’s

A

substantia nigra which projects to the striatum

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

age of onset of symptoms in Parkinson’s

A

45-65 years

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

facial involvement in Parkinson’s

A

relatively immobile face/fixed facial expressionskinda giving you the death stare

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

drug treatment of Parkinson’s

A

see picture (from pance prep pearls)

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

define tremor

A

involuntary, rhythmic, oscillating movements

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

is tremor hyperkinetic or hypokinetic

A

hyperkinetic

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

what kind of tremor occurs when the body is relaxed and supported by gravity

A

rest tremor

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

name the two types of action tremors

A

kinetic and postural

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

what kind of tremor would be seen in someone trying to complete a finger-to-nose test?

A

intention tremor (type of kinetic)

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

what kind of tremor is seen with someone that occurs when the walk forward?

A

task-specific tremor

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

what descriptors are important in determining phenomenology of a tremor (5 things)

A

locationlateralityfrequencyamplitudesituation in which it occurs

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

what is an essential tremor?

A

postural + kinetic

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

are men or women more likely to develop head tremors?

A

women

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

epidemiology of essential tremor

A

bimodal age onset5% of populationno gender preference

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

what tremor improves with alcohol

A

essential tremor

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

does essential tremor have increased mortality?

A

no, but 2-4 times the risk of developing parkinson’s

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

treatment of essential temor

A

reduce caffeinesleeppropanolol 40mg BID (can titrate up to 320mg)Primadone 12.5- 25mg (can titrate up to 250mg)

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

define dystonia

A

sustained of intermittent muscle contractions causing twitching postures, repetitive movements, or both.

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

difference between the movements in dystonia vs chorea or myoclonus

A

longer in duration, patterned

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

treatment of dystonia

A

chemodenervation, oral medications (dopaminergics, anticholinergics, dopamine depleting, muscle relaxants), and deep brain stimulation

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

define tic

A

brief, stereotyped movement or vocalization

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

3 key features of a tic

A

urgereliefsuppressible

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

when does a tic not always warrant a work up

A

in children- can be transient

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

define Tourette’s

A

multiple motor ticsat least one vocal ticstarts before age 21occurs at least daily for at least one year

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

list of drugs we have to know for hyperkinetic movement disorders (from the neuro section drug list, just an FYI)

A

RopiniroleLevodopaRisperidoneOlanzepinePropranolol

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

Rx treatment for tics

A

risperidone

olanzepine

55
Q

in restless leg syndrome what does U.R.G.E. stand for

A

urge

rest (makes worse)

getting active (makes better)

evening (makes worse)

56
Q

what are the physical exam findings with restless leg syndrome

A

none, it is normal

57
Q

what are the common secondary causes of restless leg syndrome

A

pregnancy, iron deficiency, peripheral neuropathy, ESRD, chronic lung disease, gastric surgery, parkinson’s

58
Q

what is the primary cause of restless leg syndrome

A

unknown,more common in elderlygenetic probably (3-5 times higher risk with a 1st degree relative)

59
Q

treatment of restless leg syndrome

A

iron

dopamine agonist

off-label drugs (gabapentin, levodopa, pregabalin, opiates, benzos, topiramate)

60
Q

what is wilson’s disease

A

rare, autosomal recessive disorder50% present with movement disorder50% present with liver disease

fatal if untreated

61
Q

Ischemic Stroke

A

Loss of blood supply/perfusion to an area of the brainCan be the result of hypoperfusion/hypotensionAKA “blockage stroke”

62
Q

Medical Risk Factors for Stroke

A

Hypertension

Atrial Fibrilation

Hyperlipidemia/Hypercholerestemia

DiabetesCarotid Stenosis

63
Q

Behavior Risk Factors

A

Cigarette smoking

Physical Inactivity

Illicit Drugs

Heavy Alcohol Consumption

64
Q

What are the three subtypes of ischemic strokes?

A

Large Artery Atherosclerosis

Cardioembolism

Lacunar Infarctions (Small Vessel)

65
Q

What is the significance of getting a Head CT for an ischemic stroke?

A

You want to rule out a hemorrhagic stroke. CT are good for viewing blood, but are not good at determining blockages.

66
Q

What diagnostic method is sensitive and specific for detecting an ischemic stroke?

A

Diffusion Weighted Imaging MRI

67
Q

What is a TIA

A

Transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia without acute infarction.

68
Q

Where in the arteries is atherosclerosis most commonly found?

A

In the bifurcations because there is a lot of turbulent flow.

69
Q

A 68-year old patient comes into the ER with CC of right-side facial weakness and slurred speech. You order a CT scan first, which shows no sign of a hemorrhagic stroke. What would you do next and how long do you have to act?

A

Order for the patient to have tPa and you have 3 hrs from the onset of the stroke. Giving tPa increases the likelihood of recovery at 90 days.

70
Q

A 72-year old patient comes in with stroke symptoms. You are doing your H&P and learn that he suffers from thrombocytopenia. Can he receive tPa?

A

NO. This is one of the exclusion criteria

71
Q

What is the most common cause of intraparenchymal hemorrage (IPH)?

A

HYPERTENSION

72
Q

What is an intraparenchymal hemorrhage (IPH)?

A

Bleeding into the parenchyma of the brain which may extend into the ventricular system.

73
Q

Where does IPH most commonly occur?

A

Basal ganglia, pons, cerebellum, thalamus

74
Q

Clinical presentation of IPH?

A

-Rapidly progressive focal neurological deficits-Vomiting, systolic BP >200 mmHg, severe headache, depressed mental status (not specific though)-Hard to distinguish from ischemic strokes

75
Q

Definition of Subarachnoid Hemorrhage?

A

Bleeding into the space between the arachnoid membrane and and the pia mater surrounding the brain.

76
Q

Common cause of subarachnoid hemorrhage?

A

Trauma

77
Q

Common cause of non-traumatic subarachnoid hemorrhage?

A

Rupture of cerebral aneurysm

78
Q

What are the symptoms of subarachnoid hemorrhage?

A

“Worst headache of my life”Nausea/vomiting, depressed mental status, meningeal irritation/neck stiffness

79
Q

What are the signs of subarachnoid hemorrhage?

A

The patient is often hypertensive and drowsy and exam is NON-FOCAL

80
Q

What is the common site of cerebral aneurysm?

A

Anterior communication artery

81
Q

The patient you are seeing has a CT scan that comes back negative. You highly suspect a cerebral aneurysm based on your exam findings. What do you do next?

A

Lumbar puncture

82
Q

Gold standard for diagnosing cerebral aneurysm?

A

Conventional Cerebral Angiogram

83
Q

After doing that lumbar puncture, you see that they are positive for subarachnoid hemorrhage (not due to trauma). What are two surgical options that you do for this patient

A

Coiling (endovascular approach)Clipping (surgical approach)

84
Q

This complication of SAH occurs in 25% of patients and results in ischemic stroke. What is it?

A

Vasospasm

85
Q

What drug is given to reduce the morbidity and possible mortality associated with vasospasm?

A

Prophylactic Nimodipine

86
Q

REVIEW:

What are the three layers

of the meninges and

what spaces lie between them?

A

Skull

Epidural

Dural

Subdural

Arachnoid

Subarachnoid

Pia

Brain

87
Q

Review:

What are the primary functions

of each lobe of the cerebrum?

A

Frontal: Motor functions,

behavior, emotions, higher intellect

Parietal: sensory

Temporal: hearing, speech

Occipital: Visual

88
Q

REVIEW;
What are the three components

of the brainstem and

what do they do?

A

Midbrain: visual & auditory reflex centers

Pons: connection between cortex, cerebellum and medulla

Controls chewing, biting, swallowing, facial expressions, sensation

Medulla Oblongata: cardiac, vasomotor and respiratory centers

89
Q

REVEIW:

What does the Cerebellum do?

A

Major regulator of motor activities

Integration of:

Sensory impulses from spinal cord and vestibular organ

Motor impulses of Cerebral Cortex

90
Q

REVIEW

Where is the gray matter

and white matter

in the brain and spinal cord?

A

Brain: generally gray on the outside, white on the inside (but some gray on the inside as well.

Spinal Cord: gray on the inside, white on the outside

91
Q

REVIEW:

What are key differences

between neurons and glial cells?

A

Neurons:

Nondividing, postmitotic, permanent cells

Glial Cells:

facultative, mitotic (labile), capable of dividing

92
Q

What are the six types of cells in the nervous system,

what do they do,

and what do you call their tumors?

A

Neurons: signalling/information, neuroma

Glial Cells: support, glioma

Astrocytes: support, blood brain barrier, astrocytoma

Oligodendrocytes, myelination in brain, oligodendroma

Ependymal Cells: lining ventricles, ependymoma

Schwann cells: peripheral myelination, Schwannoma

Microglia, immune response, NO tumors!

93
Q

What are the nine major types of diseases

of the nervous system?

A
  1. Developmental, genetic diseases
  2. Malformations
  3. Trauma
  4. Circulatory (vascular) disorders
  5. Infectious diseases
  6. Autoimmune diseases
  7. Metabolic, nutritional diseases
  8. Neurodegenerative and demyelinating diseases
  9. Brain tumors
94
Q

What is a dysraphic disorder?

A

Incomplete closure

of the embryonic neural tube

95
Q

What are three types of

dysraphic disorders

occuring at the hind end?

A

Spina bifida: incomplete closing of the backbone and membranes around the spinal cord. Three types:

Spina bifida occulta: outer part of vertebrae slightly open

Myelomeningocele: spinal cord and meninges protruding

Meningocele: meninges protruding

96
Q

What happens

when the head end of the neural tube

does not close properly?

A

Anencephaly: absense of a major part of the brain and skull

Encephalocele: protursions of the brain through the skull that are coverered with membrane

97
Q

What are four types of

CNS hemorrhages

and their causes?

A

Epidural Hematoma: middle meningeal artery rupture

Subdural Hematoma: bridging vein rupture

Subarachnoid Hematoma: 1. Trauma, 2. Aneurism

Intercerebral Hemorrhage: 1. Trauma, 2. HTN

98
Q

What is the fifth leading cause of death in the US?

Hint: it used to be number 3!

A

Cerebrovascular Disease

99
Q

What are the two types of stroke and their incidence?

A

Ischemic (85%)

atherosclerosis, occlusion of blood vessels

Hemorrhagic (15%)

often a complication of HTN

100
Q

REVIEW:

What are the three large cerebral arteries?

What part of the brain to they perfuse?

Where do they originate?

A

Anterior Cerebral Artery (ACA) from Internal Carotid,

perfuses medial surface of frontal and parietal lobes

Middle Cerebral Artery (MCA) from Internal Carotid

perfuses lateral surfaces of frontal, temporal, parietal lobes

Posterior Cerebral Arteries (PCA) from Vertebral Artery

perfuses posterior aspect of temporal, occipital lobes

101
Q

A patient has an MRI

showing an intracerebral hemorrhage

in the basil ganglia.

What is the likely cause?

A

Hypertension

(Trauma is most common cause

of intracerebral hemorrhage though)

102
Q

What causes cerebral herniations?

A

Cerebral Edema

103
Q

Where are the four most common locations

for cerebral herniations?

Which is most serious?

A

Tonsillar Herniation (most serious)

(cerebral tonsil exits skull through foramen magnum)

Transtentorial (uncinate) herniation

(cerebral uncus at cerebral-pontine angle)

Subfalcine herniation

(cingulate gyrus at falx)

Herniation through opening in broken skull

104
Q

Which is more serious,

a concussion or a brain contusion?

A

A contusion is more serious.

Concussion: transient loss of consciousness

Contusion: disruption of blood supply, can lose consciousness later, produce neurological deficit

105
Q

What is Coup and Counter Coup?

A

Coup (a “blow” in French) is the damage to your brain near where your head is hit

Counter Coup (on Contre Coup) is the damage where your brain hits the opposite side in response to the coup

106
Q

What are three ways

an infection can get inside the brain?

A

Penetrating trauma

Hematogenous Spread (blood vessels)

Nearby infections (otitis media, sinuses)

NOTE: if you squeez a pimple, it drains into your sinuses!

107
Q

What are the four most common organisms

causing as infection

in the nervous system?

A

Bacteria

Viruses

Fungus

Protazoa

108
Q

What bacteria

can cause an infection

in the nervous system?

A

Neisseria meningitidis,

S. pneumo,
E. coli,

H. influenza,

Treponema pallidum

(Hematogenous Route or Septic Emboli)

109
Q

What viruses

can cause an infection

in the nervous system?

A

Measles

Rubella

Adenovirus

Herpesvirus

Cytomegalovirus

Rabesvirus

(via Hematogenous Route)

110
Q

What fungi

can cause an infection

in the nervous system?

A

Candida albicans

Aspergillus flavus

Cryptococcus neoformans

(Hematogenous route)

111
Q

What protazoa

can cause an infection

in the nervous system?

A

Toxoplasma gondii

(Hematogenous route)

112
Q

Name four types of infections

of the Nervous System

A

Encephalitis:

inflammation of the brain parenchyma, usually viruses

Myelitis:

inflammation of the spinal cord, usually viruses

Cerebral Abscess:

suppurative cavitary lesion

from pyogenic bacteria, fungi or both

Meningitis:

Inflammation of meninges, viral or bacterial

113
Q

What is Multiple Sclerosis?

What is its incidence,

signs/Sx and

disease course?

A

Chronic, degenerative demyelinating disease

Incidence: women 2x men, genetic factors

Signs/Sx: loss of sense of touch, muscle weakness, unsteady gait, sphincter abnormalities

Course: exacerbation and remission

114
Q

What is the difference

between and early and late lesion

in MS?

A

Early: Lymphocytes attack myelin,

macrophages consume the debris.

Late: Astrocytes and surviving axons

115
Q

What are two congenital metabolic disorders

of enzymatic deficiency?

A

Tay-Sachs Disease

Neimann-Pick Disease

116
Q

What is a common cause

and result

of a Vitamin B1 defiency?

A

Vitamin B1 (Thiamine) deficiency:

excessive, chronic alcohol intake can cause

Wernicke-Korsakoff Syndrome

(uncoordinated movements, progressive mental deterioration, memory and concentration loss, irritability, confusion)

117
Q

What are the signs and symptoms

of Vitamin B12 (Cobalamin) deficiency?

A

Uncoordinated movements

Sensorimotor peripheral neuropathy

spinal cord disease

abnormal gait

psychiatric sx

118
Q

What are the signs/sx

of nicotinic acid deficiency?

A

Dermatitis

Diarrhea

Delirium

(The three “D”s)

119
Q

What are the effects of alcholism and B1 deficiency?

A

Wernicke Korskoff Syndrome

Subdural hematomas from falling

Pontine myelinolysis

Delirium tremens upon withdrawal

Degenerative changes to hypothalmus and mammillary bodies

Neuropathy

Myopathy

120
Q

Name four neurodegenerative Diseases

A

Alzheimer’s disease

Parkinson’s Disease

Huntingon’s Disease

Amyotrophic Lateral Sclerosis (ALS)

121
Q

Of the four key neurogenerative disorders,

what parts of the brain do they impact?

A

Alzheimer’s disease: diffuse (all over)

Parkinson’s Disease: substantia nigra

Huntingon’s Disease: cortex and subcortical nuclei (caudate, putamen)

Amyotrophic Lateral Sclerosis (ALS): motor neurons in the cerebral cortex, midbrain and spinal cord (lateral cerebrospinal pathways)

122
Q

What is Alzheimer’s Disease?

A

Progressive loss of cognitive functions and memory due to diffuse cortical atrophy caused by deposits of beta-amyloid. Genetic factors include Chromosomes 19 and 21

(Recall that Down’s Syndrome is Trisomy 21)

Note: serious diagnosis with no cure

so be sure to rule out other causes of Sx.

123
Q

What are the gross and histologic changes

in the brain of

an Alzheimer’s patient?

A

Gross: atrophic, narrowing gyri, widening sulci

Histologic: neuritic plaques, neurofibrillary tangles, granovacuolar degeneration, amyloid deposits

124
Q

What is Parkinson’s Disease?

A

Subcortical neurodegenerative disorder

affecting mainly the elderly

Decreased dopaminergic neurons in the substantia nigra

125
Q

What are the Signs/Sx

of Parkinson’s Disease?

A

Tremor/twitchin muscles

Cogwheel rigidity

Unstable walking

Depression

Dementia (10%)

126
Q

What are the gross and histologic changes

to the brain

of a patient with Parkinson’s

A

Gross: substantial nigra is pale (not black)

Histologic: loss of melanin rich neurons,

presence of Lewy bodies

127
Q

What is Huntington’s Disease?

A

Autosomal dominant neurodegenerative disease

affecting men more than women

128
Q

What are the signs/sx of

Huntington’s Disease?

A

Involuntary, gyrating movements

Progressive dementia

First Sx do not appear until midlife

Most are mentally incapacitated by 50-60 yo

129
Q

What are the gross and histological changes

to the brain

of a patient with Huntington’s

A

Gross: Atropy of cortex and subcortical nuclei,

especially the caudate and putamen

Enlarged and rounded ventricle

Histological: atrophy, degeneration, loss of neurons, reactive gliosis

130
Q

What is

Amyotrophic Lateral Sclerosis (ALS)

A

Rare neurodegenerative disease

of motor weakness and

progressive wasting

affecting older men and women

131
Q

What are the symptoms of ALS?

A

Motor weakness

progressive wasting in extremities (small hand muscles)

fasciculations

slurred speech

intact intellect!

Death in a few years.

132
Q

how to tell if Parkinsonism due to Parkinson’s or drugs

A

are features presenting symmetrically or asymmetrically

symmetrically due to drugs

asymmetrically due to Parkinson’s

133
Q
A

Clin Med I - Comprehensive (6 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions