Brainscape's Knowledge GenomeTM

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


See full index

MSRA Content > Respiratory - Level 2.2 > Flashcards

Respiratory - Level 2.2 Flashcards

1
Q

Definition of sarcoidosis?

A

o Multisystem inflammatory chronic condition characterised by non-caseating epithelioid granulomata

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

Epidemiology of sarcoidosis?

A
  • Prevalence highest in Northern Europe, 20-40 years old, Afro-Caribbeans
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Symptoms of sarcoidosis - pulmonary disease?

A

o Bilateral hilar lymphadenopathy, pulmonary infiltrates or fibrosis
o Dry cough, progressive dyspnoea, decreased exercise tolerance and chest pain

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

Symptoms of sarcoidosis - skin?

A

 Papules on face
 Maculopapular rash on body or extremities
 Brownish-red infiltrative plaques on extremities or trunk
 Erythema nodosum on legs
 Lupus pernio – raised, hardened lesion affecting nose and cheeks (pathognomonic)

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

Symptoms of sarcoidosis - eye?

A 
	Granulomatous uveitis
•	Anterior & posterior
	Keratoconjunctivitis
	Dry eyes
	Glaucoma
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Symptoms of sarcoidosis - neurological?

A 
	Bell’s palsy
	Lymphocytic meningitis
	Diabetes insipidus
	Neuropathy – numbness, weakness
	Pituitary dysfunction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Symptoms of sarcoidosis - CV?

A

 Arrhythmias or heart failure in young patient – cardiomyopathy

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

Symptoms of sarcoidosis - others?

A 
	Lymphadenopathy
	Hepatomegaly, splenomegaly
	Hypercalcaemia and hypercalciuria, renal stones
	Bone marrow failure
	Lacrimal and parotid gland enlargement
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Investigations in sarcoidosis?

A 
o	Bloods
	FBC (raised WCC, lymphopenia, anaemia)
	ESR raised
	U&E
	Ca (elevated)
	LFTs (deranged)
	Serum ACE raised

o Tuberculin skin test (negative)

o If raised Ca:
 24-hour urine collection – raised calcium

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

Imaging of sarcoidosis

A

 CXR
• Bilateral hilar lymphadenopathy
 CT

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

Further testing of sarcoidosis

A 
o	Lung function tests – restrictive pattern
o	ECG (arrhythmias or BBB)
o	Bronchoalveolar Lavage
	Raised lymphocytes, raised neutrophils with pulmonary fibrosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Diagnostic testing of sarcoidosis

A

o Tissue Biopsy
 Lung, liver, lymph nodes, skin
 Non-caseating granulomas

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

Staging of sarcoidosis of CXR?

A

Staging on CXR
o Stage 0 =normal
o Stage 1= bilateral hilar lymphadenopathy (+/- paratracheal adenopathy)
o Stage 2 = Bilateral hilar adenopathy with pulmonary infiltrates
o Stage 3 = Parenchymal infiltrates without hilar adenopathy
o Stage 4 = Parenchymal involvement gives volume loss (fibrosis) and other features (calcifications, hilar retraction, cysts, bullae)

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

Management of sarcoidosis - acute sarcoidosis?

A

o Bed rest
o NSAIDs
o Remission is common
o If severe – oral prednisolone or IV Methylprednisolone

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

Management of sarcoidosis - chronic sarcoidosis - immunosuppression?

A

 Prednisolone (0.5mg/kg/day) for 4-6 weeks, then lower dose over 6 months according to response and give for 6-24 months
• NOT INDICATED IN STAGE 1, 2, 3 IF ASYMPTOMATIC
• Indications
o Parenchymal lung disease (symptomatic, progressive, static)
o Uveitis
o Hypercalcaemia
o Neurological or cardiac involvement
• Oral bisphosphonates to minimise bone loss

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

Management of sarcoidosis - chronic sarcoidosis - other therapies?

A
  • Methotrexate/azathioprine/hydroxychloroquine /ciclosporin/cyclophosphamide
  • Anti-TNF alpha
  • Rituximab
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Management of sarcoidosis - chronic sarcoidosis - lung transplant?

A

 Lung Transplant

• End stage lung disease

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

Management of sarcoidosis - chronic sarcoidosis - specific eye and skin features?

A

 Eye – Topical prednisolone

 Skin – Topical Triamcinolone or oral prednisolone

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

Management of sarcoidosis - chronic sarcoidosis - monitoring?

A 
o	Follow up every 3-6 months
o	Monitoring
	FBC
	DEXA every 2 years
	Serial lung function tests, CXR and ACE levels
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Complications of sarcoidosis?

A
  • Pulmonary – Infection, PE, fibrotic lung disease, pulmonary hypertension
  • Cardiac – arrhythmias, HF, SCD
  • Ocular – Uveitis, conjunctivitis
  • Neurological – Nerve damage, TIA/CVA, CNS impairment
  • ENT – salivary gland dysfunction, nosebleeds, obstruction
  • Others – lymphoma, hypercalcaemia, renal stones, arthritis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Prognosis of sarcoidosis?

A
  • 60% with thoracic sarcoidosis resolve over 2 years
  • 20% respond to steroids
    o If not, improvement unlikely
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Definition of cystic fibrosis?

A
  • Autosomal recessive condition causing a defective CFTR protein on chromosome 7
  • CFTR is a cAMP dependent chloride channel found in membrane of cells
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Pathology of cystic fibrosis?

A
  • Leads to excessively thick mucus in many body systems
    o Reduction in airway surface liquid layer and impaired ciliary function
    o Chronic endobronchial infection ensues
    o Thick meconium is produced
    o Pancreatic ducts also become blocked by thick secretions
    o Abnormal sweat glands
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Epidemiology of cystic fibrosis?

A
  • Incidence of 1 in 2500 live births with a carrier rate of 1 in 25
  • Average life expectancy is mid-30s
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Symptoms of infancy of cystic fibrosis?

A
  • Meconium ileus (1 in 10)
  • Prolonged neonatal jaundice
  • Failure to thrive
  • Recurrent chest infections
    o Cough, purulent sputum, chest deformity
    o Initially S.aureus, H.inflenziae
    o Pseudomonas aeruginosa, burkholderia cepacia colonisations
  • Malabsorption (ADEK), steatorrhoea – failure to thrive
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Symptoms of young child of cystic fibrosis?

A
  • Bronchiectasis
  • Rectal Prolapse
  • Nasal Polyp
  • Sinusitis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Symptoms of older child of cystic fibrosis?

A
  • Allergic bronchopulmonary aspergillosis
  • Diabetes Mellitus
  • Cirrhosis/Portal Hypertension
  • Intestinal Obstruction
  • Pneumothorax
  • Sterility in males – congenital absence of vas deferens
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Signs of cystic fibrosis?

A
  • Evidence of malnutrition, poor weight gain
  • Hyperinflation of the chest
  • Coarse inspiratory crackles
  • Expiratory wheeze
  • Finger clubbing
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Testing of cystic fibrosis - in newborns?

A
  • Screened for in Guthrie test
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Testing CF - in everyone - when to test?

A

o FHx, congenital intestinal atresia, meconium ileus, symptoms of intestinal obstruction, faltering growth, undernutrition, recurrent LRTIs, chronic cough, chronic sinus disease, obstructive azoospermia, rectal prolapse

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

Testing CF - in everyone - what test to perform?

A

o Sweat Test (children and young people) >60mmol/L
 Measuring sodium and chloride concentrations in sweat
o Gene Testing (Adults)

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

Testing CF - in everyone - when to refer to specialist?

A

o Positive or equivocal sweat test
o Assessment suggests CF but results normal
o Gene testing reveals 1 or more gene mutations

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

Management of cystic fibrosis - reviews?

A

o Annual review
 Includes pulmonary (O2 sats, CXR, FBC, aspergillus serology and serum IgE, respiratory samples, LFTs), nutrition, liver disease, complications assessment, DM test

o	Routine Reviews - O2 sats, secretion sample, LFT with spirometry
	Weekly in 1st month
	Monthly between 1-12 months
	Every 6-8 weeks between 1-5 years
	Every 8-12 weeks >5
	Every 3-6 months as adults
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Management of cystic fibrosis - prevention of cross infection?

A

o Specialist clinics are organised to prevent-cross infection – separate people individually during clinic & keep people in separate clinics depending on bacteria grown
o In-patients – individual rooms with en-suite facilities

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

Management of cystic fibrosis - exercise/physio?

A

Regular exercise improves lung function and fitness
o Individualised exercise programme and review

CT scan for under 12s or if exacerbation does not respond to treatment

Physiotherapy
o Airway clearance techniques taught to patient and carers
o Postural drainage, active cycle breathing or forced expiratory techniques

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

Management of cystic fibrosis - if lung disease?

A

o Nebulised rhDNAse (Dornase alpha) as first-line
o Add hypertonic sodium chloride if needed
o If not able to use – mannitol dry powder

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

Management of cystic fibrosis - if deteriorating lung function or repeated exacerbations?

A

o Azithromycin long-term at immunomodulatory dose

o If deteriorating – stop azithromycin and start oral prednisolone

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

Management of cystic fibrosis - treating infections?

A

o Aspergillus fumigatus – sustained antifungals only if declining pulmonary status and chronic complex
o Burkholderia cepacian – IV Antibiotic eradication, seek microbiology advice
o H.influenzae – Oral antibiotic (IV if unwell)
o S.Aureus - Oral flucloxacillin prophylaxis needed
o Pseudomonas aeruginosa – oral/IV Abx then sustained inhaled Abx (colistimethate sodium)

39
Q

Management of cystic fibrosis - nutrition?

A

o Increase calorie intake by increasing portion size/high calorie foods (150% of normal)
 If not adequate – oral nutritional support or enteral feeding
o Fat-soluble vitamins - ADEK

40
Q

Management of cystic fibrosis - pancreatic insufficiency?

A

o Test with stool elastase estimation
o Offer oral pancreatic enzyme replacement therapy (Pancreatin)
o Omeprazole helps absorption

41
Q

Management of cystic fibrosis - distal intestinal obstruction syndrome?

A

o Manage in specialist CF centre
o Oral or IV fluids offered to ensure adequate hydration
o Meglumine amidotrizoate with sodium amidotrizoate solution (oral or via enteral tube)
o 2nd line – polyethylene glycol orally or via enteral tube
o Surgery is last resort if prolonged treatment with polyethylene glycol solution not effective

42
Q

Management of cystic fibrosis - abnormal LFTs?

A

o Liver US and ursodeoxycholic acid

43
Q

Management of cystic fibrosis - diabetes?

A

o Test annually from 10 years old with CGM, serial glucose testing over days or OGTT

44
Q

Management of cystic fibrosis - osteoporosis?

A

o DEXA scan if high-risk – long-term steroids, lung disease, frequent IV Abx, undernutrition, post-menopause

45
Q

Complications of CF?

A
  • Underweight
  • Meconium ileus (1 in 7)
  • Fat-soluable deficiencies (ADEK)
  • Male infertility
  • Reduced femal fertility
  • Nasal polyps and sinusitis
  • Chronic liver disease
  • Diabetes
  • Osteoporosis
46
Q

Epidemiology of inhaled foreign body?

A
  • 75% occur in children <3

- Higher risk in learning difficulties, swallowing difficulties and boys

47
Q

Risk factors of inhaled foreign body?

A 
o	Decreased consciousness
o	<4 or >70
o	Male
o	Cerebrovascular disease
o	Dementia
48
Q

Symptoms of inhaled foreign body?

A

o Unilateral wheeze suggest partial obstruction of main or distal bronchi

49
Q

Signs of inhaled foreign body?

A

o Unilateral wheeze suggest partial obstruction of main or distal bronchi

50
Q

Investigations of inhaled foreign body?

A 
-	CXR
o	Can only see radio-opaque foreign bodies
-	Flexible bronchoscopy
o	Removal
-	If fails, rigid bronchoscopy
-	CT scan
51
Q

Management of inhaled foreign body - mild?

A

o Encourage coughing

52
Q

Management of inhaled foreign body - severe?

A 
Encourage coughing
Lean patient forwards
External Manoeuvres
	Infants (<1 years old)
•	Back blows – 5 to interscapular region
•	Chest thrusts – like chest compressions during CPR
•	Check in mouth and see if removable
•	If not – alternate two manoeuvres
	Adults and children - 5 BB then 5 ATs
•	Back blows – to interscapular region with heel of hand
•	Abdominal thrusts – stand behind, put both arms around upper abdomen, clench one fist and grasp with other, pull sharply inwards and upwards
	If unconscious:
•	Lower patient to floor
•	Call ambulance
•	Begin CPR
o	Removal with flexible/rigid bronchoscopy or surgery
53
Q

Complications of inhaled foreign body?

A
  • Pneumonia
  • Atelectasis
  • Asphyxia
  • Pneumomediastinum
  • Bronchospasm
  • Bronchiectasis
54
Q

Definition of tuberculosis?

A

An infection caused by bacteria of the Mycobacterium tuberculosis complex, predominantly Mycobacterium tuberculosis and more rarely Mycobacterium
- bovis

55
Q

Spread of tuberculosis?

A
  • Spread via respiratory route
56
Q

Definition of active disease of tuberculosis?

A

o Symptomatic or progressive disease in organs (pulmonary most common), can involve CNS, lymph nodes, bones, joints, GI, GU, skin

57
Q

Definition of latent disease of tuberculosis?

A

o Persistent immune response with no evidence of active TB (asymptomatic and not infectious)

58
Q

Epidemiology of tuberculosis?

A
  • Declining incidence and mortality in developed country
  • 10 million people developed it in world
  • Common in India, Pakistan, Romania, Bangladesh and Somalia
59
Q

Risk factors of tuberculosis?

A 
o	Being born in high prevalence areas
o	Diabetes, HIV, chronic kidney disease
o	Close-proximity
o	Immunodeficiency
o	Deprived social areas
60
Q

Symptoms of tuberculosis?

A

o The majority of patients are asymptomatic, and disease remains latent
o Lung lesion plus spread via lymph system called Ghon complex
o Fever, night sweats
o Anorexia and weight loss
o Cough
 Productive, with SOB, haemoptysis

61
Q

Extrapulmonary symptoms of tuberculosis?

A

 Lymphadenopathy (painless swelling with rubbery texture)
 Arthralgia, back pain
 Abdominal or pelvic pain, constipation, bowel obstruction
 Sterile pyuria
 Headache, vomiting

62
Q

Signs of tuberculosis?

A

o Failure to thrive, anorexia
o May affect gut, skin and lymph nodes and caseate forming a cold abscess
 Abdo pain, bowel obstruction, sterile pyuria, headache

63
Q

Investigations of tuberculosis - primary care - latent TB?

A

 Mantoux test
• Purified protein derivative of tuberculin intradermal injection
• Positive test indicates infection or previous BCG vaccine
 If positive – consider Interferon-gamma test (Quantiferon TB Gold)

64
Q

Investigations of tuberculosis - primary care - active TB?

A

 Chest X-ray
• Consolidation, cavities, miliary spread (fine white dots), calcification
• Hilar lymphadenopathy

 Three sputum samples for microscopy, culture & sensitivity for Acid-Fast Bacilli on Ziehl-Neelsen Stain
• If unable to perform, gastric washing on three consecutive mornings required to culture acid-fast bacilli

65
Q

Investigations of tuberculosis - primary care - active non-respiratory TB?

A

 CXR

 Samples – sputum, pleura, pleural fluid, urine, ascites, bone marrow, lymph node excision, CSF

66
Q

Screening of TB - when?

A

 People in contact with active pulmonary or laryngeal TB (household members, close contacts)
 Immunocompromised
 New entrants to UK from high prevalence countries
 New NHS employees working with patients and clinical specimens

67
Q

Screening of TB - What?

A

 Mantoux Test
• Tuberculin skin test infected intradermally, inspected for signs of local skin reaction after 2-3 days
• Positive if >5mm or more
 Interferon gamma release assay (Quantiferon TB Gold)
• Blood test detecting WBC response to TB antigens
 If positive - CXR

68
Q

Management of latent TB infection?

A

o Offer HIV, HepB, HepC testing before treatment

Medical therapy
 3 months isoniazid (with pyridoxine) with rifampicin OR
 6 months of isoniazid (with pyridoxine)

69
Q

Management of active TB infection - referral?

A

o Refer to specialist if suspected TB or know TB not completed treatment as planned
 CXR
 Sputum sample for microscopy culture and histology
• 3 spontaneously produced deep-cough sputum samples, preferably 1 EMU
• If not – induced sputum or bronchoscopy and lavage

70
Q

Management of active TB infection - assessment in hospital?

A

 NAAT test for Mycobacterium tuberculosis
 Other sampling techniques if needed (sputum induction, bronchoscopy and lavage, gastric aspiration, CT)
 Biopsy and needle aspiration – DO NOT PLACE IN FORMALIN WHEN SENDING FOR CULTURE (JUST IN SALINE)

71
Q

Management of active TB infection - specialist management - baseline bloods?

A

 Encourage adherence to treatment
 Stop smoking
 FBC, U&E, LFTs

72
Q

Management of active TB infection - specialist management - drug therapy?

A 
o	2 months
	Rifampicin 
	Isoniazid (with pyridoxine)
	Pyrazinamide
	Ethambutol
o	After 2 months – 6 months
	Rifampicin 
	Isoniazid (with pyridoxine)
•	If active CNS TB – 10 months
73
Q

Regimen of rifampicin in TB?

A

o 600-900mg PO 3x/week
o SE – LFT rise (stop if bilirubin rise), platelets low, orange discolouration to urine, tears and contact lenses, inactivation of pill
o Reduce dose if eGFR<50

74
Q

Regimen of isoniazid in TB?

A

o 15mg/kg PO 3x/week
o Pyridoxine given to prevent neuropathy
o Avoid tyramine rich food (cheese, salami, pickled herring, Bovril, Marmite)
o SE – LFT rise, WCC low, neuropathy

75
Q

Regimen of pyrazinamide in TB?

A

o 2.5g PO 3x/week

o SE – hepatitis, arthralgia (CI: acute gout)

76
Q

Regimen of ethambutol in TB?

A

o 30mg/kg PO 3x/week

o SE - Reversible ocular toxicity (colour vision and acuity problems)

77
Q

Management of active TB infection - specialist management - drug therapy if multiple drug resistent TB?

A

• Need prolonged treatment as risk of multiple drug resistance 18-24 months with at least 6 drugs

78
Q

Prevention of TB - what and when is given?

A

Vaccination BCG

 Neonates – in increased risk of TB before discharge from hospital
• If born in area with high incidence of TB, 1 or more parents or grandparents born in high-incidence country or FHx of TB within 5 years

 Healthcare workers

 Close Contacts if Mantoux negative:
• Not been vaccinated (no documentation or scar)
• <35 or >35 and healthcare workers with contact with patients/materials

79
Q

Complications of TB?

A

o Transmission to others
o Cor pulmonale, bronchiectasis
o Death
o Drug Resistance

80
Q

Definition of obstructive sleep apnoea?

A
  • Intermittent closure/collapse of pharyngeal airway causing apnoeic episodes during sleep
  • These are terminated by partial arousal – leading to light sleep
  • Cycle repeats itself many time throughout night
81
Q

Epidemiology of obstructive sleep apnoea?

A
  • Up to 3% of people
82
Q

Risk factors of obstructive sleep apnoea?

A 
o	Obese
o	Male
o	Middle-aged
o	Neck circumference >43cm
o	FHx
o	Smoking
o	Alcohol before bed
o	Sleeping supine
o	Hypothyroidism
83
Q

Risk factors in children of obstructive sleep apnoea??

A

o Adenotonsillar hypertrophy
o Obese
o Down’s syndrome, neuromuscular disease, Prader-Willi syndrome

84
Q

Symptoms of obstructive sleep apnoea?

A 
o	Loud snoring
o	Daytime somnolence
o	Poor sleep quality – feeling unrefreshed on waking
o	Morning headache
o	Decreased libido
o	Cognitive performance decreased
85
Q

Signs of obstructive sleep apnoea?

A

o Enlarged tonsils
o Nasal blockage
o Signs of COPD, respiratory failure, cor pulmonale

86
Q

Investigations of obstructive sleep apnoea?

A
  • Epworth sleepiness questionnaire – assess severity of symptoms
    o Refer if >10
87
Q

Management of obstructive sleep apnoea - general measures?

A

o Weight reduction
o Avoid tobacco and alcohol
o Sleep on side

88
Q

Management of obstructive sleep apnoea - driving advice?

A

 Continue to drive:
• If investigated for, or diagnosed but no symptoms of daytime sleepiness

 Inform DVLA but continue to drive if:
• Using CPAP or intra-oral device – if compliant and symptoms controlled

 Stop Driving:
• Diagnosed and symptoms impair driving

89
Q

Management of obstructive sleep apnoea - referral?

A

o To sleep centre – confirm diagnosis using sleep studies/secondary care treatments
 Urgently if hazardous occupation, driver, signs of respiratory/heart failure, COPD
 Routinely if Epworth scale >10

90
Q

Management of obstructive sleep apnoea - specialist investigations?

A

 Polysomnography – records sleep and breathing patterns
 Limited sleep study – at person home or sleep centre
 Diagnosed if >5 episodes of apnoea per hour sleep
 Severity:
• Mild 5-14, Moderate 15-30, Severe >30

91
Q

Management of obstructive sleep apnoea - non-surgical management?

A

 CPAP via nasal mask during sleep (moderate to severe disease)
• Lifelong
 Intra-oral devices (mandibular advancement)
o If mild with normal daytime alertness

92
Q

Management of obstructive sleep apnoea - surgical management?

A

o Surgical relief of pharyngeal obstruction – usually in children
 Tonsillectomy, uvulopalatopharyngoplasty, tracheostomy

93
Q

Complications of obstructive sleep apnoea?

A 
o	Pulmonary hypertension
o	Type 2 respiratory failure
o	Stroke
o	RTAs
o	Hypertension

MSRA Content (87 decks)

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