Brainscape's Knowledge GenomeTM

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


See full index

Dermatology > Nodular Diseases > Flashcards

Nodular Diseases Flashcards

You may prefer our related Brainscape-certified flashcards:
Dermatology Board Prep flashcards
1
Q

What causes a nodule or draining lesion?**

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

What are skin nodules?

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

Where can nodules be located?

A
  • Epidermis
  • Dermis
  • SC tissue
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What does it mean to be adnexal?

A
  • Attached to a hair follicle
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

When to worry based on history about a nodule?

A
  • When did you first notice the lesion?
  • Any changes?
  • Rate of growth (remember your signalment too!)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Physical findings that might suggest a nodule isn’t benign

A
  • Poor margins
  • Depth of lesion
  • Systemic signs
  • Manipulation alters the lesion
  • Location on the body
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Things to observe about a nodule:

A
  1. Location on body
  2. Location within the skin
  3. Alopecic or haired
  4. Is the surface ulcerated?
  5. What are the margins like? (Obvious transition between normal and abnormal skin or blurred?)
  6. Remember to consider your signalment (age, breed, sex)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

WHen to worry based on cytologic findings about a nodule?

A
  • Mitoses

- Hemorrhagic aspirate

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

Basic diagnostics for nodules

A
  • FNA/cytology
  • Histopathology
  • Culture from biopsy (bacterial, fungal, mycobacterial)

He recommends taking a sample for FNA then for biopsy and culture at the same time)

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

What on cytology suggests infection?

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

How do you diagnose sterile disease?

A
  • Exclude infection and neoplasia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are more common bacterial causes of single nodules?

A
  • Staphylococcus
  • Mycobacteria
  • Nocardia/Actinomycosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Clinical signs of staphylococcus

A
  • Furunculosis

- Botryomycosis (chronic bacterial disease)

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

Etiology of canine leproid granuloma?

A
  • Mycobacteria CLG

- Novel mycobacterial species that do not grow using standard methods

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

Where are lesions restricted with canine leproid granuloma?

A
  • Head and pinnae
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Diagnosis of canine leproid granuloma

A
  • Demonstration of acid fast organisms on histopathology or cytology
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Appearance of acral lick dermatitis?

A
  • Raised ulcerated firm mass over the distal extremity
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What causes acral lick dermatitis?

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

What breeds get acral lick dermatitis?

A
  • Large breed dogs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Two rules of acral lick dermatitis?

A
  1. ALWAYS INFECTED

2. Secondary to something

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

Inciting causes of acral lick dermatitis?

A
  • Allergies**
  • infection
  • Prior surgery
  • Foreign body
  • Arthritis
  • Previous trauma
  • Neoplasia
  • Behavioral
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Diagnosis of acral lick dermatitis?

A
  1. Scrape (demodicosis is a rule out)
  2. Cytology –> biopsy
  3. Culture (from biopsy; poor man’s culture is to prep with chlorhexidine, rinse with saline and squeeze contents)
  4. Radiography
  5. Look for an underlying cause!!**
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Treatment of acral lick dermatitis

A
  • Treat underlying infection with 4-6 weeks of systemic antibiotics based on culture
  • Identify the underlying cause
  • +/- behavior modification to break the cycle
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Other treatment options for acral lick dermatitis

A
  • Cryosurgery
  • CO2 laser surgery
  • Acupuncture
  • Behavior consult
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Fungal causes of nodules

A
  • Dermatophyte
  • Saprophytic fungi
  • Pythium/lagenidium
  • Sporotrichosis
  • Blastomycosis
  • Histoplasmosis
  • Cryptoccosis
  • Coccidioidomycosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What is a kerion?

A

Dermatophyte furunculosis

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

Appearance of kerion

A
  • Usually solitary nodule often on the face
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What often causes kerions?

A
  • Microsporum gypseum, a soil dermatophyte

- Often a history of the dog sticking its face in the dirt

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

What class of fungi are pythiosis/lagenidiosis?

A
  • Oomycetes
  • Aquatic plant pathogens
  • Not true fungi but saprophyte
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Where is pythiosis or lagenidiosis found?

A
  • Decaying wood and vegetable matter
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Where is pythiosis or lagenidiosis typically found?

A
  • Gulf coast states

- WI, NJ, VA, CA, AZ KY have had diagnoses

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

Cytology of pythiosis or lagenidiosis?

A
  • Pyogranulomatous with eosinophils

- Hyphae hard to see

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

Biopsy of pythiosis or lagenidiosis?

A
  • Silver stain required for Pythium
  • Hyphae may invade blood vessels
  • Granulomatous to pyogranulomatous dermatitis with eosinophils
  • Hyphae may be found intracellularly in giant cells
  • Hyphae are broad, thick-walled, and irregularly septate
  • Hyphae of Lagenidium are larger than those of P. insidiosum
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Other diagnostic tests for pythiosis or lagenidiosis?

A
  • Culture
  • Serology, PCR, IH
  • In addition to the cytology and biopsy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Clinical signs of pythiosis?

A

Areas in contact with stagnant water most likely to be infected

  • Lesions are usually solitary draining nodules on the lower extremities
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Breed with increased incidence of pythiosis?

A
  • German SHepherds

- Lesions in cats and horses described too

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

Lagenidiosis - where have cases been identified?

A
  • FL, LA, TX, TN, and IN
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Clinical signs of lagenidiosis?

A
  • Same as those described for pythiosis

- Often quite aggressive

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

What is important to differentiate pythiosis and lagenidiosis (oomycetes) from?

A
  • Zygomycosis (true fungal infections)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Culture of pythiosis/llagenidiosis?

A
  • Isolation is difficult
  • Requires production of sexual reproductive structures for species ID, which is tough
  • Pythium can be identified on biopsy with immunoperoxidase technique
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

PCR and Pythium/Lagenidium

A
  • Can identify Pythium and differentiate it
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

Is serology better for pythiosis or lagenidiosis?

A
  • Pythiosis

- AGID and ELISA

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

Treatment of pythiosis/lagenidiosis?

A
  • Very difficult
  • WIde surgical excision treatment of choice**
  • Systemic therapy (itraconazole +/- terbinafine) for 2-4 months
  • <25% response
  • Agriculture fungicides (Caspofungin or Mefenoxam)
  • Immunotherapy with anti-pythium vaccine
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Dermatologic manifestation of Blastomycosis?

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

Appearance of blastomycosis on cytology or biopsy

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

Skin lesions with histoplasmosis?

A
  • Papular to nodular growths often located at the mucocutaneous junctions
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Appearance of histoplasmosis on cytology or biopsy?

A
  • See them within macrophages
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

Cryptococcosis appearance classic?

A
  • Bulging of the hea and bridge of the nose
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Appearance of Cryptococcus

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

What causes viral warts?

A

Papilloma virus

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

Who gets viral warts?

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

Where do viral warts occur often?

A
  • Around oral mucosa
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

Treatment for viral warts

A
  • Regress on their own (within ~3 months)
  • Azithromycin
  • Laser surgery
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Why can viral warts recur?

A
  • For the virus to take place, there has to be a penetrating trauma
  • Goes directly to the basal cell layer and invades the immune system
  • Carries with it the viral particle and grows little roots
  • has a little stalk
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

Cell type origin of histiocytomas

A
  • Langerhans cell origin
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

What are proposed theories for what a histiocytoma is?

A
  • Tumor vs reactive hyperplasia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

Who gets histiocytoma?

A
  • Common in young dogs

- Rare in cats

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

Clinical appearance of histiocytoma?

A
  • Rapid growth
  • Dome-shaped
  • Alopecic
  • 0.5 cm-1.5 cm
  • May ulcerate
59
Q

Clinical behavior of histiocytoma?

A
  • Spontaneous regression in 1-3 months

- Often looks worse just before remission

60
Q

Locations of histiocytomas?

A
  • Head, pinna, limbs, scrotum
61
Q

Treatment for histiocytoma?

A
  • Ignore or remove

- Surgically remove if it’s removing them

62
Q

Diagnosis of histiocytoma

A
  • Signalment
  • Clinical appearance
  • Cytology shows round cells (Histiocytes with mitoses or lymphocytes in regressing lesions)
  • Histopathology
63
Q

Five differentials for round cells?

A
  • Lymphoma
  • Mast cell Tumor
  • TVT
  • Histiocytoma
  • Plasmacytoma
64
Q

What is cutaneous histiocytosis?

A
  • Nodular disease of dogs
65
Q

Where do nodules occur with cutaneous histiocytosis?

A
  • Dermis or SC fat of face, neck, back and trunk

- May also occur in the nasal mucosa resulting in respiratory stridor

66
Q

Appearance of nodules with cutaneous histiocytosis?

A
  • ERythematous and nodular (raised)
67
Q

Treatment of cutaneous histiocytosis

A
  • Immunosupression (prednisone or dexamethasone)
  • Doxycycline/niacinamide
  • Cyclosporine
  • Long term treatment usually needed
68
Q

Histopath with cutaneous histiocytosis?

A
  • Infiltrates of large histiocytic cells
69
Q

What is a melanocytoma?

A
  • Benign neoplasm from melanocytes
70
Q

Who gets melanocytoma?

A
  • Dogs, higher incidence in pigmented breeds

- Rare in cats

71
Q

Locations of melanocytoma

A
  • Trunk
  • Head (eyelids, muzzle)
  • Extremities (between digits)
72
Q

Clinical appearance of melanocytoma?

A
  • Solitary
  • Circumscribed
  • Alopecic
  • Non-ulcerated
  • Dome-shaped
  • Blue-black to dark brown in color
73
Q

Clinical behavior of most melanocytomas?

A
  • Most are benign

- Can’t always predict based on histopathology

74
Q

Diagnosis of melanocytoma

A
  • Cytology and histopathology
75
Q

Treatment of melanocytoma?

A
  • Surgical removal with clean margins
76
Q

What is the cell type for trichoblastoma (basal cell tumor)?

A
  • Primitive hair germ epithelium
77
Q

Who gets trichoblastoma?

A
  • Common in dogs and cats
78
Q

What is the most common pigmented tumor of cats?

A
  • Trihoblastoma
79
Q

Where do dogs get trichoblastomas?

A
  • head and neck
80
Q

Where do cats get trichoblastomas?

A
  • Cranial half of the trunk
81
Q

Clinical appearance of trichoblastoma

A
  • SOlitary
  • Dome-shaped
  • Firm
  • 1-2cm
  • Alopecic
  • Ulcerated
  • Melanotic
82
Q

Clinical behavior of trichoblastoma

A
  • Benign
83
Q

Treatment of trichoblastoma

A
  • Observe

- Surgical excision (curative)

84
Q

Sebaceous gland tumors in dogs vs cats - how common?

A
  • Common in dogs

- Uncommon in cats

85
Q

What are the four types of sebaceous gland tumors and relative rarity of each?

A
  1. Nodular sebaceous hyperplasia (most common)
  2. Sebaceous adenoma (common)
  3. Sebaceous epithelioma (common but often ulcerates and bleeds)
  4. Sebaceous adenocarcinoma (rare)
86
Q

Location of sebaceous gland tumors

A
  • Trunk
  • Limbs
  • Eyelids
  • head
87
Q

CLinical appearance of sebaceous gland tumors

A
  • Wart-like or cauliflower like
  • Pinkish to orangish
  • may be melanotic or ulcerated
88
Q

Clinical behavior of sebaceous gland tumors

A
  • Benign
  • new adenomas or hyperplasias will develop if you might complicate them?remove
  • Adenocarcinoma and epithelioma rarely metastasize
89
Q

What can happen to sebbaceous gland tumors that might complicate them?

A
  • Can become colonized with Malassezia or bacteria
  • Can be pruritic
  • ID with surface cytology***
  • Address the infections with topical treatments
90
Q

Diagnosis of sebaceous gland tumors

A
  • Clinical appearance usually
  • Cytology
  • Histopathology (suspicious of epithelioma or adenocarcinoma)
91
Q

Treatment of sebaceous gland tumors

A
  • Observe

- Surgically excise

92
Q

When might you be more suspicious that it’s a sebaceous adenocarcinoma?

A
  • Usually more ulcerated and inflamed with poorly defined borders
93
Q

What is the doctor word for a skin tag?

A
  • Acrochordon
94
Q

What is a nevus?

A

Hamartoma

95
Q

Treatment for acrochordon

A
  • Single ones can be lasered off or excised, but if there are a lot it would take a very long time
96
Q

What is a follicular hamartoma?

A
  • Hairy mole
97
Q

Perianal adenoma?

A
  • Looks like a smooth, alopecic mass in the perianal region
98
Q

Which category of nodules do many syndromes fit?

A
  • Sterile
99
Q

What is the most likely pathogenesis of sterile nodules?

A
  • Most likely immune-mediated, but the pathogenesis is truthfully unknown
100
Q

How do you diagnose sterile causes?

A
  • Exclusion!
101
Q

What are some dfdx for pyogranulomatous inflammation?

A
  • Infectious until proven otherwise

- Could be sterile

102
Q

How do you determine if pyogranulomatous inflammation is infectious or not?

A
  • Negative tissue cultures
  • No organisms seen on histopathology
  • Lack of response to abx
103
Q

Treatment recommendations for sterile disease?

A
  • Long duration of therapy
  • Doxycycline (niacinamide)
  • Immunosuppressive steroids - prednisone or dexamethasone
  • Cyclosporine
  • Once in remission, slow taper over several months
104
Q

What to do if something you suspect is sterile disease stops improving?

A
  • Repeat cytology +/- biopsy and cultures
105
Q

Dfdx for sterile nodules?

A
  • Eosinophilic furunculosis
  • Juvenile cellulitis
  • Sterile nodular panniculitis**
  • Sterile pyogranuloma/pyogranuloma syndrome
  • Follicular cysts
  • Perianal fistulas
  • metatarsal fistulas
106
Q

What is most likely cause of eosinophilic furunculosis?

A
  • Arthropod or insect bite most likely
107
Q

Onset of canine eosinophilic furunculosis

A
  • Sudden
108
Q

Treatment of canine eosinophilic furunculosis

A
  • Often steroid responsive
109
Q

Recurrence of canine eosinophilic furunculosis

A
  • Rare
110
Q

Who gets juvenile cellulitis?

A
  • Young puppies usually, but may occur in adult dogs

- Dachshunds, Goldens, Pointers often

111
Q

Appearance of juvenile cellulitis?

A
  • Pustular to nodular disease of young puppies
112
Q

When does juvenile cellulitis tend to occur?

A
  • Following recent vaccination
113
Q

What is the cause of juvenile cellulitis

A
  • Unknown
  • It does occasionally develop following recent vaccination, but attempts to reproduce the disease with a vaccine or virus have failed
114
Q

Clinical signs of juvenile cellulitis

A
  • Pustular to nodular disease
  • Primarily affects face and head, especially muzzle and periocular region
  • Ears, anus, and prepuce may also be affected
  • Crusting on the muzzle (with a nodule underneath)
  • Often a LARGE submandibular lymphadenopathy
  • Occasionally sterile abscess at the site of vaccination
  • reports of this occurring with HOD
115
Q

Treatment for juvenile cellulitis

A
  • Immunosuppression (but usually need concurrent ABs)
  • Doxycycline/niacinamide
  • Cyclosporine
  • Slowly taper off meds once in remission
116
Q

Diagnosis of juvenile cellulitis

A
  • really needs a biopsy

- Remember you need to rule out infectious causes!

117
Q

Sterile nodular panniculitis characteristics of disease

A
  • Solitary or multiple SC nodules that ulcerate and discharge an oily, bloody exudate
  • Lesions occur anywhere
118
Q

Clinical signs of sterile nodular panniculitis

A
  • Dogs may be systemically ill (anorexia, lethargy, fever)

- Serum alkaline phosphatase may be elevated (liver process or pancreatitis associated?)

119
Q

Who is predisposed to sterile nodular panniculitis?

A
  • Dachshunds, Maltese
120
Q

Treatment for sterile nodular panniculitis

A
  • First rule out infection with cytology/culture/biopsy
  • Immunosuppression
  • Doxycycline/niacinamide
  • Cyclosporine
  • Vitamin E
  • can sometimes taper off all meds once in remission
121
Q

Dermatologic lesions with sterile nodular panniculitis

A
  • Solitary or multiple deep-seated cutaneous nodules
  • Frequently ulcerate and discharge and will leak blood yexudate
  • Lesions vary in locaiton and size, with majority occurring over the ventral lateral chest, neck, and abdomen
  • Dogs may appear systemically ill with decreased appetite, lethargy, and fever
122
Q

Major dfdx for sterile nodular panniculitis

A
  • Bacterial or fungal infection

- Need to rule out with cytology, histopathology, and sterile cultures

123
Q

What is sterile histiocytic disease?

A
  • Periadnexal multinodular granulomatous dermatosis

- Sterile pyogranuloma/granuloma syndrome

124
Q

Derm lesions with periadnexal multinodular granulomatous dermatitis

A
  • Pyogranuloma/granuloma syndrome

- Multiple nodules of the head, pinna, and paws

125
Q

Histopathologic pattern of periadnexal multinodular granulomatous dermatitis

A
  • Characteristic

- Histiocytes

126
Q

Treatment of periadnexal multinodular granulomatous dermatitis

A
  • Immunosuppression
  • after ruling out bacterial and fungal disease
  • Steroid responsive at immune suppressive doses
  • Some may respond to cyclosporine, doxycycline/niacinamide
127
Q

Follicular cyst/epidermal inclusoin cyst appearance

A
  • Dermal nodules sometimes within a pore

- Thick material inside (brown/gray thick per disease; toothpaste like)

128
Q

Complications of follicular cyst/epidermal inclusion cyst

A
  • Can create inflammatory reaction if ruptured

- Can become secondarily infected

129
Q

Diagnosis of follicular cyst/epidermal inclusion cyst

A
  • Biopsy
130
Q

Treatment of follicular cyst/epidermal inclusion cyst

A
  • Surgical excision (must pull out the lining of the cyst to be curative)
  • Retinoids/Vitamin A?
  • Could ignore
  • Sudden occurrence of many nodules - rule out endocrine!
131
Q

What is intracutaneous cornifying epithelioma?

A
  • Form of follicular cyst or epidermal inclusion cysts
  • Usually multiple and can be quite large
  • Treat with surgical incision
132
Q

Which breeds get intracutaneous cornifying epithelioma?

A
  • Keeshonds and German Shepherds
133
Q

Appearance of apocrine cysts, and what happens if you pop it?

A
  • Fluid cyst
  • Will fill back up if deflated
  • Need to remove it to prevent recurrence
134
Q

Appearance of perianal fistulas or anal furunculosis?

A
  • Draining lesions around the anus
  • Shallow, blind-ended sinuses
  • Not associated with anal sacs
  • Often very painful
135
Q

Breed predisposition for perianal fistulas?

A
  • German SHepherds or Irish Setters
136
Q

Etiology of Perianal Fistulas

A
  • Likely immune-mediated but full mechanism not well-elucidated
137
Q

Clinical signs of perianal fistulas

A
  • Clinical signs
  • Cytology
  • +/- biopsy (often quite painful and can’t suture well)
  • Rectal examination (check for anal sac involvement)
138
Q

Treatment for perianal fistulas

A
  • Cyclosporine (+/- ketoconazole)
  • Tacrolimus (better tissue penetration)
  • Prednisone
  • Food trial
  • Antibiotics
139
Q

Prognosis for perianal fistulas

A
  • Good for control
140
Q

Surgery for perianal fistulas?

A
  • Reserved for refractory cases or with secondary anal sac involvement
141
Q

Who gets focal metatarsal fistulas?

A
  • German Shepherds

- Also reported in Weimaraner, Greyhound, Doberman

142
Q

Clinical signs of focal metatarsal fistulas

A
  • Asymptomatic to lame
143
Q

Cause of focal metatarsal fistulas

A
  • Unknown
144
Q

Treatment of focal metatarsal fistulas

A
  • Response to immunosuppression
  • Steroids
  • Tacrolimus
  • Cyclosporine
  • Doxycycline/niacinamide

Dermatology (15 decks)

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