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Jacob Kingsley, 12, visits a bakery that changed into off-limits before he began oral immunotherapy for a peanut hypersensitivity.MADDIE MCGARVEY
Jacob Kingsley changed into 9 years historical when he was handed the poison he'd shunned for the intuition that before he could walk and advised to swallow it as drugs. Obediently, he gulped down a number of micrograms of peanut flour—lower than 1/one thousand of a peanut—diluted in grape Kool-support. His mom and a nurse hovered, able to inject him with epinephrine if an itchy throat and wheezing struck.
Jacob's mom, Jennifer Kingsley, had pushed him 2 hours from their domestic in Columbus to this doctor's workplace in Cincinnati, Ohio, for the primary of dozens of sessions of peanut immunotherapy. Giving Jacob progressively expanding doses of peanuts, she hoped, would desensitize his immune device.
or not it's a methodology Kingsley hadn't pursued except she reached her breaking factor. A 12 months previous, Jacob had swallowed a handful of popcorn that, unbeknownst to him, was laced with peanut product. He suffered a particularly scary reaction: two bouts of exorbitant signs about 6 hours aside. The incident marked his 2nd peanut-related trip to the emergency room, and Kingsley became terrified that the subsequent approach upon can exist deadly. "I determined, ‘I can't live fondness this,’" she says. "i used to exist desperate."
As Jacob sat through the hourslong appointment in Cincinnati, enjoying video video games and swigging expanding doses of peanut-spiked Kool-aid, he joined legions of infants writing food allergy's next chapter. these days, greater than 3000 americans global, most of them children, hold passed through peanut immunotherapy, with the purpose of conserving them if they by random encounter the meals. other puny ones are trying immunotherapy for allergy symptoms to milk, eggs, and tree nuts. Some, fondness Jacob, accumulate medicine in allergists' offices, where docs share protocols informally and in published papers. other puny ones hold enrolled in scientific trials, together with these elope with the aid of two corporations racing to interpolate a peanut-based mostly pill or skin patch. both scheme to observe for approval from the food and Drug Administration (FDA) this 12 months. The agency's blessing would dramatically enhance immunotherapy's credibility and attain.
In a box that for many years has had nothing to present sufferers beyond avoidance, immunotherapy marks a seismic shift. because it edges closer to mainstream, "there is mixed feelings, with a gross range of enthusiasm," says Corinne Keet, a pediatric allergist-immunologist at Johns Hopkins medication in Baltimore, Maryland. worry that it could trigger harm is mingling with euphoria that infants animated constrained lives can exist let out. medical doctors who proffer immunotherapy recount households consuming in chinese language restaurants for the primary time and home-schooled babies rejoining their peers.
Like many clinical firsts, the remedy isn't best. "here is version 1.0," says Brian Vickery, a pediatric allergist-immunologist at Emory university in Atlanta. He has performed peanut immunotherapy trials and labored for two years at Aimmune Therapeutics, headquartered in Brisbane, California, probably the most corporations whose products are nearing approval. Physicians exist troubled about oral immunotherapy's rigors—medicine must continue indefinitely—and its risks, which encompass the identical allergy symptoms it goals to remain away from. remaining yr in Japan, a toddler suffered mind pain every over a affliction of immunotherapy for milk allergic reactions.
meanwhile, physicians on the entrance strains are navigating hazy science. no one is awake of precisely how immunotherapy works or who's surely to exist helped or harm by means of it. "For me," Keet says, "it exist really now not pellucid for an medium infant with peanut allergic reaction no matter if it is going to obtain feel to finish oral immunotherapy or not."
Like many who Look at food allergies, Keet turned into enticed by using their secret. Animal models are terrible. The depth of allergy symptoms varies unpredictably, even in the equal adult over time. Why one baby outgrows an allergic reaction and an additional doesn't is unknown.
"This was something they didn't cowl a mighty deal in medical school" in the 1990s, says Matthew Greenhawt, a pediatric allergist-immunologist at babies's health facility Colorado in Denver. Greenhawt's profession trajectory tracks with a surge in food allergic reactions, and these days, he can barely sustain with the stream of affected children who visit his sanatorium. nowadays, between 1% and a pair of% of americans within the united states, the United Kingdom, and several different nations are allergic to peanuts—a charge that has roughly tripled due to the fact the mid-Nineties. other meals allergies, similar to these to tree nuts, are besides on the rise. What's inflicting the boost is not smartly understood.
despite rising caseloads, deaths from food allergic reactions remain infrequent. precise numbers are challenging to approach back via, and estimates latitude from fewer than 10 to greater than a hundred and fifty a yr within the united states. but besides the fact that an affected infant is extra more likely to exist struck through lightning than to die of a food allergy, the risk can suppose ever-current. fogeys certainly not understand when their infants will occur upon wrongdoer foods and the route they'll exist affected in the event that they do. "We are animated in a posh world—individuals slither meals in every places," says David Bunning, a businessman whose two sons, now adults, hold multiple meals allergies. "The hold an impact on on babies in terms of their self assurance to explore their atmosphere can exist extreme." Bunning's household just about certainly not traveled or ate out. At their grandparents' apartment, the boys had been continually restrained to 1 room where food wasn't allowed.
Bunning now chairs the board of administrators at meals allergic reaction analysis & training (FARE), an advocacy neighborhood in McLean, Virginia. households fondness his, and the doctors who cared for his or her toddlers, began to agitate for new remedies a few decade in the past. Immunotherapy become the obvious candidate: Injections that desensitize the immune device to pollen, grass, pet dander, and bee venom were around for a long time.
no matter if for an allergic reaction to cats or pistachios, immunotherapy aims to disrupt the cells that oscillate out of control when faced with an allergen. When a baby who's allergic to a food eats it, food proteins pass from the digestive tract into the bloodstream. An antibody called immunoglobulin E (IgE), which is bound to white blood cells referred to as mast cells in tissues, recognizes the culprits. IgE prompts the mast cells, which unlock histamine and other chemical substances. in the skin, that response can result in hives; within the respiratory tract, wheezing; and within the intestine, vomiting. the most strict signs, akin to a swollen throat or a reaction every the route through the body, label anaphylaxis, which is what families concern the most. hypersensitivity pictures blunt construction of IgE, partly, researchers consider, with the aid of boosting stages of obvious T cells that on the spot a cascade of immune alterations.
Peanuts combating fireplace with hearth ingesting regularly increasing doses of a foodallergen appears to desensitize the immune gadget over time. heaps of puny ones hold tried oral immunotherapy, and a tablet to handle peanut allergy symptoms could exist accepted via regulators next year. but there’s solicitude about the method’s dangers and unknowns. When a child eats a food they’re allergic to, an antibody known as immunoglobulin E (IgE) helps spark off movements that result in symp-toms from mild to extreme. indicators can hit the dermis, as proven, and besides the intestine, the respiratory system, and beyond. food proteins that trigger a reaction circulate through the intestine and into the bloodstream. purple bloodcell One symptom: skin hives Ingestion ofcontrolledallergen dose The stage of IgE in the blood can drop. much less reactive mast phone Milder reactions on the epidermis and beyond. less food protein goes into the bloodstream. What’s an hypersensitive reaction? Months of oral immunotherapy obtain mast cells less reactive and look to gash back how a mighty deal allergen enters the bloodstream. Many infants can tolerate more of the meals they’re allergic to but ought to proceed medication indefinitely. About 20% discontinue medication on account of facet outcomes and other factors. How does medication work? Reactions encompass hives, itchy throat, vomiting, and issue respiratory. allergies Hives Wheezing swiftly heartrate Vomiting IgE, which binds to mast cells, indicators these white blood cells. They releasehistamine and other chemical compounds. Mast cells Immunotherapy leads to extra of the IgG4 antibody, which is belief to compete with IgE and obviate mast cells from being activated. IgG4 Scientists account the corpse produces more of this antibody, which makes it harder for the allergen to flux from the gut into the bloodstream. IgA toddlers with meals allergic reactions hold high degrees of an antibody, IgE, that recognizes inescapable allergens. IgE Mast telephone membrane Allergen IgE
short trying out decades ago indicated that shots for meals allergies weren't protected. So around the mid-2000s, scientists began to feed babies the allergen as an alternative. One watershed second came in 2005, when the countrywide Institutes of health formed a consortium for food allergy medical trials. A 2nd changed into in 2011, when advocates backed a symposium at Harvard medical college in Boston to standardize desires and routine for the pioneering immunotherapy efforts. About 60 individuals attended. "The sufferers were very clear," says Carla McGuire Davis, a pediatric allergist-immunologist at Texas puny ones's health facility in Houston. They did not charge about ingesting a peanut butter sandwich; they wanted insurance policy in the event that they accidentally encountered one. Trialists set their End dose at a brace of peanuts and pressed forward.
The consequences of early medical trials were promising, says Hugh Sampson, a pediatric allergist-immunologist at the Icahn college of medicine at Mount Sinai in long island metropolis, who has studied immunotherapy in food allergy symptoms for many years. After 6 to twelve months of remedy, he says, about 70% to eighty% of patients might wield larger doses of the food than before. Lab data hold been encouraging, too: Ingesting allergens over time appears to obtain mast cells much less reactive, inhibiting their free up of detrimental chemicals. The therapy additionally produces different immunoglobulins: IgG4, which additional inhibits mast cellphone exercise, and IgA, which helps maintain meals allergens from escaping the gut.
The 2011 convention inspired the founding of the enterprise now referred to as Aimmune, fueled by means of more than $3.5 million from FARE. A 2d enterprise, DBV technologies, based mostly in Montrouge, France, and long island city, improved just a few years later. Aimmune begun to Boost an oral product, very nearly a tablet of powder derived from peanut flour with proteins held to consistent ranges. In February, the traffic introduced in a statement the effects of a allotment III affliction involving 496 children and teens, with a routine stepping up each 2 weeks via eleven dose ranges. among the 372 people in the treatment community, about 20% dropped out for a lot of factors, together with facet consequences. After a brace of 12 months, ninety six% of americans who completed treatment may devour one peanut with out a greater than gentle signs, 84% may tolerate two, and 63% might tolerate as a minimum three.
DBV's skin patch represents a extra conservative approach: It promises tiny amounts of peanut protein, the equal of one peanut over 3 years. ultimate yr, DBV announced that in its allotment III affliction of almost 400 sufferers, after a 12 months, these the usage of the patch may, on average, consume three peanuts over the route of a brace of hours before experiencing clinical signs corresponding to vomiting or hives; earlier than the trial, the generic changed into just beneath one peanut. consequences distinctive substantially from grownup to adult.
If one or both products are approved by route of FDA within the coming months, expectations are exorbitant that they will exist welcomed: Aimmune is now charge about $1.5 billion on the U.S. inventory exchange. In 2016, FARE sold its share in Aimmune for $47 million.
What people don’t recall into account is that this degree of insurance scheme fluctuates. … It isn't certain, nor is it regular.Mimi Tang, Murdoch babies’s research Institute
in the meantime, some docs comprehend yet another route: offering peanut immunotherapy of their practices. "i will exist able to deal with 20 sufferers with $5.ninety five of peanut flour," says Richard L. Wasserman, a pediatric allergist-immunologist in Dallas, Texas.
Wasserman ventured into food hypersensitivity immunotherapy eleven years in the past. He developed a protocol primarily based partly on posted case reviews and protocols for hypersensitivity photographs, and he build IVs into his first five peanut allergic reaction sufferers in case he had only seconds to rescue them from extreme anaphylaxis. "When every of them sailed in the course of the first day, they stopped doing IVs," he says. "but it's a measure of how involved i used to be."
Wasserman has considering the fact that treated more than 300 infants with peanut allergy symptoms and more than 400 with different meals allergies. different practitioners are joining in, amongst them the Cincinnati allergist whom the Kingsley household sought out: Justin Greiwe at Bernstein hypersensitive reaction group. Greiwe joined the observe in 2014, straight out of scientific training. "It turned into a puny nerve-wracking firstly," he says, as a result of no formally sanctioned oral immunotherapy protocol existed. He took precautionary measures, similar to lung trying out before each remedy, to champion exist inescapable affected person defense.
Some clinicians—and executives on the agencies establishing products—are not satisfied about the medical professional's workplace remedies. "That gives loads of us pause," says Sampson, who apart from his educational submit is chief scientific officer of DBV. "We're very fearful that if this goes on enough, somebody is going to hold an accident or a lethal reaction, and that's really going to trade the FDA's viewpoint" concerning the items in development, he says.
Wasserman consents about the requisite for warning. "no longer each practicing allergist may quiet exist doing oral immunotherapy," he says. Greiwe suggests the medication requires a committed group of workers, and he gives every immunotherapy family his cell quantity.
Jacob become certainly one of Greiwe's first immunotherapy sufferers. His mother remembers Jacob's ears burning—a minor response that subsided on its own. "Or he referred to he hated peanuts and desired to stop," she says. Worst became about 6 months in, when Kingsley create out that for two weeks, Jacob had hidden his dose to obviate ingesting it. That became "the only time they ever felt danger," she says. Stopping treatment can at once alter the immune system, says Cecilia Berin, an immunologist at Mount Sinai, because immunotherapy requires consistent exposure. When Jacob squirreled away his each day dose, the alterations precipitated in his immune gear virtually actually begun to fade out, placing him at risk. Greiwe restarted him on a lessen dose and, his mom says, "We got through it."
meals allergic reactions hold become extra usual, and a handful of meals debts for the significant majority of allergic reactions. however diminutive doses of the foods can blunt allergies.SCIENCE picture LIBRARY/SCIENCE source
Even puny ones who faithfully comply with instructions pan hazards. The immune gadget can react to even elegant pressures, and the checklist of what can excite a response to remedy is lengthy. Exercising within a few hours of the dose can finish it; so can a cold, a stomach virus, menstruation, or a scorching bathe. An bronchial asthma assault can trigger a reaction—many toddlers with allergies hold asthma as smartly—and so can stress. "We had a patient who had just performed the violin on a stage, got here down, and about quarter-hour later … took the dose and had a response," Davis says.
Berin posits that exterior pressures such as actual activity or illness obtain the intestine greater permeable, pushing extra of the immunotherapy dose into the bloodstream. however that is quiet speculation. Regardless, it's fitting pellucid that "there are americans who react years down the street to a preservation dose," Keet says. For Jacob, this kindly of second got here 9 months in. One night whereas watching a film, he downed his peanut M&M's and later ran outdoor together with his cousins to dance in a rainstorm. He broke out in hives head to toe. Kingsley dialed Greiwe's quantity, and Jacob acquired a double dose of an allergic reaction medication.
the most tragic records factor to this point is the case in Japan. a toddler had enrolled in a affliction of immunotherapy for milk allergies on the Kanagawa infants's medical middle in Yokohama. He'd raised what he may ingest from lower than eight milliliters to one hundred thirty five milliliters—about half a glass of milk. After 3 months on that maintenance dose, he swallowed it and shortly complained of pain. within minutes, he had stopped respiratory. His heartbeat become later restored within the emergency room, but he'd gone too long without it and sustained extreme mind harm, in line with a press release from the sanatorium's president, Sumimasa Yamashita, in November 2017. Kanagawa children's clinical middle declined to remark, asserting best that the incident remains under investigation.
In its commentary, the health center referred to the boy had suffered an bronchial asthma assault the day earlier than the catastrophic dose. He additionally changed into on a protocol that aimed to every of a sudden boost the extent of milk he may drink over under 3 weeks. but why the baby reacted so disastrously to that tumbler of milk is unknown.
"What people finish not exist mindful is this flat of insurance policy fluctuates," says Mimi Tang, a pediatric allergist-immunologist at Murdoch puny ones's research Institute in Melbourne, Australia. "It isn't certain, neither is it regular."
some of the few long-time age analyses became published in 2013 in the Journal of allergy and scientific Immunology. Keet, pediatric allergist-immunologist Robert wood at Johns Hopkins drugs, and their colleagues sought out 32 infants who'd been in a milk immunotherapy trial. Three to 5 years later, "The results had been wonderful in a sobering variety of means," timber says. simplest about a quarter "had been doing exquisite … tolerating limitless quantities of milk with out aspect results." an additional quarter had abandoned the protocol and lower back to strict avoidance. The relaxation had been consuming dairy products inconsistently, with intermittent and even generic allergy symptoms. "it exist difficult to know which comes first, whether or not they acquired complacent" about ingesting it "or backed off because [they were] having too many indicators," wood says.
It made me apprehensive, basically apprehensive, to build whatever in my daughter’s mouth that she became allergic to.Divya Balachandar, mother of Leena Wong
more and more households are willing to reside with those uncertainties since the alternative is more advantageous anxiety. "We hold been stupefied mindless," says Divya Balachandar, whose daughter Leena Wong, now 7 years old, had her first episode of anaphylaxis at age 4 after being touched through a cashew. trying out printed Leena besides turned into allergic to sesame, eggs, milk, different tree nuts, and peanuts. Balachandar, a pediatric pulmonologist in ny metropolis, and her husband enrolled Leena in a federally funded oral immunotherapy affliction for peanut allergy in 2015. "It made me frightened, truly fearful, to set whatever thing in my daughter's mouth that she was allergic to," Balachandar says. She gravitated toward a affliction over treatment with a local allergist as a result of, she says, "there hold been no suggestions" about the route to handle in private apply. by this spring, Leena might devour two spoonfuls of peanut butter—about 25 peanuts—without an issue. She started 2d grade sitting together with her classmates at lunchtime, liberated from a divorce nut-free desk.
both groups establishing peanut-based remedies converse they had greater volunteers for their trials than they might accommodate. private practitioners always hold a ready list; Greiwe's runs more than four months. At Stanford school in Palo Alto, California, which has a huge food hypersensitive reaction research application, more than 2000 sufferers are waitlisted to connect in the university's medical trials, says Sharon Chinthrajah, an allergist-immunologist there.
extra remedies are on the horizon. In Australia, Tang is working with a corporation it's trying out an approach she pioneered, a combination of a probiotic and oral peanut immunotherapy. The probiotic should quiet tilt the corpse toward producing the subset of T cells that tolerate the allergen and faraway from making cells that assail it, she says. Chinthrajah and others are passionate about combining oral immunotherapy with a monoclonal antibody known as omalizumab, which is FDA permitted to handle allergic asthma. clinical trials are besides gearing as much as Look at various other monoclonal antibodies that goal molecules involved in allergic irritation.
Jacob's and Leena's households are wanting to remark what comes subsequent. Jacob is additionally allergic to pistachios and cashews, however as a result of he finds those foods less difficult to steer pellucid of than peanuts, the household has rejected immunotherapy that ambitions them. Leena's household is the opposite. together with her older sister and her fogeys, Leena attends Indian services regularly, where tree nuts are a touchstone ingredient in sauces. In August, one other episode of anaphylaxis landed her within the emergency room: She started to vomit and suffered chest tightness and eye swelling after eating Indian food her folks suspect contained cashews—despite having triple-checked with the restaurant that it didn't. "i might fondness to finish tree nuts," Balachandar says, once immunotherapy "becomes more obtainable and better understood."
Physicians with profound roots in meals allergic reaction immunotherapy hope these new to it tread cautiously. docs who present such treatments "ought to comprehend the information cold," including posted consequences and side results that may besides crop up, Greenhawt says. nevertheless, he is delighted that peanut immunotherapy treatments may besides quickly exist authorised. The other day, speaking with a peanut-allergic four-12 months-historic and his mother, Greenhawt shared what the subsequent 12 months may bring. "I referred to, ‘i fade to peer you a yr from now; with a bit of luck, they can hold two products that are authorized, and they are able to talk about which one can exist greatest for you.’" The mom regarded startled and delighted, Greenhawt says. "I've in no route seen someone simper as brightly as that."
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Financial [36 Certification Exam(s) ]
Food [4 Certification Exam(s) ]
Fortinet [16 Certification Exam(s) ]
Foundry [6 Certification Exam(s) ]
FSMTB [1 Certification Exam(s) ]
Fujitsu [2 Certification Exam(s) ]
GAQM [9 Certification Exam(s) ]
Genesys [4 Certification Exam(s) ]
GIAC [15 Certification Exam(s) ]
Google [5 Certification Exam(s) ]
GuidanceSoftware [2 Certification Exam(s) ]
H3C [1 Certification Exam(s) ]
HDI [9 Certification Exam(s) ]
Healthcare [3 Certification Exam(s) ]
HIPAA [2 Certification Exam(s) ]
Hitachi [30 Certification Exam(s) ]
Hortonworks [4 Certification Exam(s) ]
Hospitality [2 Certification Exam(s) ]
HP [760 Certification Exam(s) ]
HR [4 Certification Exam(s) ]
HRCI [1 Certification Exam(s) ]
Huawei [32 Certification Exam(s) ]
Hyperion [10 Certification Exam(s) ]
IAAP [1 Certification Exam(s) ]
IAHCSMM [1 Certification Exam(s) ]
IBM [1539 Certification Exam(s) ]
IBQH [1 Certification Exam(s) ]
ICAI [1 Certification Exam(s) ]
ICDL [6 Certification Exam(s) ]
IEEE [1 Certification Exam(s) ]
IELTS [1 Certification Exam(s) ]
IFPUG [1 Certification Exam(s) ]
IIA [3 Certification Exam(s) ]
IIBA [2 Certification Exam(s) ]
IISFA [1 Certification Exam(s) ]
Intel [2 Certification Exam(s) ]
IQN [1 Certification Exam(s) ]
IRS [1 Certification Exam(s) ]
ISA [1 Certification Exam(s) ]
ISACA [4 Certification Exam(s) ]
ISC2 [6 Certification Exam(s) ]
ISEB [24 Certification Exam(s) ]
Isilon [4 Certification Exam(s) ]
ISM [6 Certification Exam(s) ]
iSQI [8 Certification Exam(s) ]
ITEC [1 Certification Exam(s) ]
Juniper [67 Certification Exam(s) ]
LEED [1 Certification Exam(s) ]
Legato [5 Certification Exam(s) ]
Liferay [1 Certification Exam(s) ]
Logical-Operations [1 Certification Exam(s) ]
Lotus [66 Certification Exam(s) ]
LPI [24 Certification Exam(s) ]
LSI [3 Certification Exam(s) ]
Magento [3 Certification Exam(s) ]
Maintenance [2 Certification Exam(s) ]
McAfee [9 Certification Exam(s) ]
McData [3 Certification Exam(s) ]
Medical [68 Certification Exam(s) ]
Microsoft [393 Certification Exam(s) ]
Mile2 [3 Certification Exam(s) ]
Military [1 Certification Exam(s) ]
Misc [2 Certification Exam(s) ]
Motorola [7 Certification Exam(s) ]
mySQL [4 Certification Exam(s) ]
NBSTSA [1 Certification Exam(s) ]
NCEES [2 Certification Exam(s) ]
NCIDQ [1 Certification Exam(s) ]
NCLEX [3 Certification Exam(s) ]
Network-General [12 Certification Exam(s) ]
NetworkAppliance [42 Certification Exam(s) ]
NetworkAppliances [1 Certification Exam(s) ]
NI [1 Certification Exam(s) ]
NIELIT [1 Certification Exam(s) ]
Nokia [7 Certification Exam(s) ]
Nortel [130 Certification Exam(s) ]
Novell [37 Certification Exam(s) ]
OMG [10 Certification Exam(s) ]
Oracle [314 Certification Exam(s) ]
P&C [2 Certification Exam(s) ]
Palo-Alto [4 Certification Exam(s) ]
PARCC [1 Certification Exam(s) ]
PayPal [1 Certification Exam(s) ]
Pegasystems [17 Certification Exam(s) ]
PEOPLECERT [4 Certification Exam(s) ]
PMI [16 Certification Exam(s) ]
Polycom [2 Certification Exam(s) ]
PostgreSQL-CE [1 Certification Exam(s) ]
Prince2 [7 Certification Exam(s) ]
PRMIA [1 Certification Exam(s) ]
PsychCorp [1 Certification Exam(s) ]
PTCB [2 Certification Exam(s) ]
QAI [1 Certification Exam(s) ]
QlikView [1 Certification Exam(s) ]
Quality-Assurance [7 Certification Exam(s) ]
RACC [1 Certification Exam(s) ]
Real Estate [1 Certification Exam(s) ]
Real-Estate [1 Certification Exam(s) ]
RedHat [8 Certification Exam(s) ]
RES [5 Certification Exam(s) ]
Riverbed [9 Certification Exam(s) ]
RSA [15 Certification Exam(s) ]
Sair [8 Certification Exam(s) ]
Salesforce [5 Certification Exam(s) ]
SANS [1 Certification Exam(s) ]
SAP [98 Certification Exam(s) ]
SASInstitute [15 Certification Exam(s) ]
SAT [1 Certification Exam(s) ]
SCO [10 Certification Exam(s) ]
SCP [6 Certification Exam(s) ]
SDI [3 Certification Exam(s) ]
See-Beyond [1 Certification Exam(s) ]
Siemens [1 Certification Exam(s) ]
Snia [7 Certification Exam(s) ]
SOA [15 Certification Exam(s) ]
Social-Work-Board [4 Certification Exam(s) ]
SpringSource [1 Certification Exam(s) ]
SUN [63 Certification Exam(s) ]
SUSE [1 Certification Exam(s) ]
Sybase [17 Certification Exam(s) ]
Symantec [136 Certification Exam(s) ]
Teacher-Certification [4 Certification Exam(s) ]
The-Open-Group [8 Certification Exam(s) ]
TIA [3 Certification Exam(s) ]
Tibco [18 Certification Exam(s) ]
Trainers [3 Certification Exam(s) ]
Trend [1 Certification Exam(s) ]
TruSecure [1 Certification Exam(s) ]
USMLE [1 Certification Exam(s) ]
VCE [7 Certification Exam(s) ]
Veeam [2 Certification Exam(s) ]
Veritas [33 Certification Exam(s) ]
Vmware [68 Certification Exam(s) ]
Wonderlic [2 Certification Exam(s) ]
Worldatwork [2 Certification Exam(s) ]
XML-Master [3 Certification Exam(s) ]
Zend [6 Certification Exam(s) ]