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Laying the foundation for subsequent-Gen cancer Diagnostics | 200-045 practice exam and Study Guide

foundation medication prepares to apply NGS for individualized melanoma care.   

by way of Kevin Davies   

February eight, 2012 | This summer time, groundwork medication will launch what can be described because the subsequent generation of melanoma diagnostics.

The Cambridge, Mass.-based business, established by means of a premier neighborhood of melanoma researchers and funded by using Third Rock Ventures, Kleiner Perkins Caufield & Byers and Google Ventures, will launch a finished subsequent-gen sequencing (NGS) profile screening some about 200 genes universal to be clinically imperative and actionable in cancer the use of pursuits, formalin-fixed paraffin embedded affected person cancer specimens.

“The care of oncology sufferers is on the verge of being individualized,” says CEO Michael Pellini. “The molecular make-up of every tumor is going to pressure personalized medicine. Their goal is to work with oncologists and pathologists and do nothing wanting seriously change melanoma care. They wish to trade the manner cancer patients are managed, not simply in tutorial scientific centers but in communities across the U.S. and internationally.”

“americans within the field all say, ‘If I or a pal turned into diagnosed with melanoma, here's the look at various that I’d need run.’ That’s a nearly accepted commentary,” says Pellini. “Our founders—Matthew Myerson, Levi Garraway, Todd Golub, and Eric Lander—understood the value of where cancer care and molecular diagnostics is heading and the position of next-gen sequencing.”

Pellinifoundation offers an informative genomic profile in a single extensive-based verify for all solid tumor melanoma biopsies and DNA samples using deep sequencing of about 200 genes which are clinically vital to cancer. That information—mutation analysis, central targeted medication, plus doubtlessly appropriate medical trials—should be communicated to physicians and oncologists in a consumer pleasant report, assisting e-book their therapeutic selections.

while the variety of focused therapeutics and molecular assessments for melanoma are becoming in parallel, cancer biopsies are shrinking in size. “The oncologist or pathologist has to prioritize the molecular markers. That’s a true problem,” says Pellini. “when you get beyond three-5 markers, the prices to the system grow enormously.” The groundwork strategy screens hundreds of genes concurrently whereas protecting precious affected person cloth.

Six months before full business launch, Pellini says everything is operational with specimens automatically running via billing. The enterprise is already mechanically processing specimens and producing experiences for clinical instances on a via-request basis as it ramps up to full industrial launch. “We’re doing things years forward of anybody else right now. We’re simply on the tip of the iceberg,” he says (see, “Pellini’s Pitch”).   

technology assessment

basis’s method wasn’t feasible a couple of years in the past, let alone a decade ago. “besides the fact that they had the expertise, they didn’t have the therapeutic alternatives,” says Pellini. but besides the breakthroughs which have brought us to the brink of the $1,000 genome, the contemporary FDA approval of two centered melanoma medicine—Pfizer’s Crizotinib and Plexxikon’s Venurafinib—has offered timely evidence that the oncologists’ arsenal is strengthening. hundreds greater focused anti-melanoma compounds are currently in clinical trials.

Pellini also credit the launch of the KRAS genetic assay for colon cancer in 2007 (see, “Amgen’s personalized medication Story,” Bio•IT World, April 2008) for triggering a wave of optimism that straight away unfold to medical follow. “Molecular markers had been not restrained to academic centers, they have been being ordered by using group medical doctors,” he says.

The company’s core potential extend past NGS, says Pellini. “The sequencing platform isn't irrelevant, nonetheless it’s comfortably a platform. The protocols are their protocols. the manner they suppose in regards to the application of the platform into medical diagnostics is basis medication. here's the application of NGS into the melanoma diagnostics world.”

There are 4 important pillars to foundation’s operation:• Genome technology;• melanoma biology;• advice science; and• medical oncology—the movements practice of melanoma care.

Pellini isn’t suggesting that NGS will substitute other basic methods of cancer diagnostics, such as movement cytometry and immunohistochemistry. but he thinks NGS is destined to have a significant affect. “It’s simply a query of when. here is a complementary know-how that will replace definite different molecular recommendations.”

whereas further and further tutorial centers are operating small, tumor-type based mostly cancer sequencing panels, foundation goals to peer its checking out utilized in communities throughout the U.S. “We are looking to carry this technology to the neighborhood oncologist, that’s where over eighty% of melanoma sufferers are handled,” says Pellini. “We’re investing tens of hundreds of thousands of bucks to get this appropriate… Their aim is to equipment as much as run tens of heaps of profiles a year.”   

Taking the Tour

as the man in cost of basis’s laboratory, Scotsman John Curran has to build a pipeline that satisfies not simplest in-residence needs however additionally the various regulatory organizations so that you can furnish the necessary certification. He graciously indicates me across the facility even though he’s Studying for an important state inspection.

“next week is a really large week for us,” he says. “Then they can birth processing medical samples.” bound enough, groundwork did indeed pass its Massachusetts state inspection and is now CLIA-licensed. except that element, foundation become working best on samples from tutorial collaborators together with Memorial Sloan Kettering cancer center and MD Anderson cancer middle.

The labs include a series of spotless, interjoining rooms by which samples are obtained, DNA extracted and manipulated, and sequencing performed. The technique is tied collectively by the Thermo Scientific Nautilus laboratory counsel management equipment (LIMS—see, “A scientific LIMS”).medical labs usually employ a Laboratory tips equipment (LIS), but as Curran aspects out, in basis’s atmosphere, “You need a a whole lot more complete informatics platform to address tips management, mixture counsel throughout the enterprise, and a solution to deal with a extremely dynamic company manner” where new applied sciences can be plugged in with little note.

not like a LIS, a regular LIMS isn’t designed for patient data or HIPAA certification. So Thermo Fisher partnered with a scientific consulting company to boost the functionality of its Nautilus LIMS and provide the capabilities indispensable for affected person-centric facts stream and physician-oriented interaction. “We present the best of both worlds—a traditional LIMS with the patient-centric facet of equation. They call it a medical LIMS,” says Dave Minicuci, Thermo Fisher’s director of container advertising and marketing, informatics and laboratory automation. similar methods have already been deployed at little ones’s health center (Philadelphia), Emory college, and the tuition of Miami.

The clinical LIMS no longer best tracks the receipt of samples, however a lab web portal gives an interface to alternate advice with docs, who can access the portal and order a verify. “We ship the shipping equipment with barcodes, [they] practice the barcodes to the samples and kinds, put it returned within the field and ship it right here. they are able to music it, because it’s already within the system,” says Curran. “We envisage a turnaround time that starts when the oncologist orders a look at various. With the portal, they are able to tune, call up, and ask if it’s on the style.”

After samples arrive, the barcode is scanned and the records entered into the LIMS. Tissues can arrive in lots of forms—in a block or on a slide, sparkling or a couple of years ancient—each and every requiring different processing steps. “identifying a LIMS, they vital a device that might handle varied pattern input streams that could coalesce at extraction,” says Curran.

A rigorous protocol maximizes the amount of nucleic acid extracted from tissue. “95% of the time, it will no longer be a limiting element,” says Pellini. “in case you must extract 50 nanograms (ng) for every single [sequential] gene examine, you’d run out rather instantly,” he says. The groundwork lab is geared to working with as little as 50 ng DNA, although more demo can also be requested if indispensable. within the clinical market, 15-20% of events molecular exams fail. “in spite of the fact that it's a posh NGS-based mostly look at various, they nevertheless wish to get it down less than 5% of the time they now have a failure and should make that telephone name to the ordering surgeon.”  

added CoverWhile research NGS applications usually settle for 30X genome insurance, a clinical grade verify, primarily in melanoma, requires a lot more advantageous stringency. as a result of tumor heterogeneity and the low purity of cancer samples, the frequency of critical mutations in a given pattern is regularly very low, and a medical grade examine ought to be capable of discover them at a very excessive level of sensitivity and 100% specificity.

Foundation_Curren“100X doesn't work in hobbies melanoma diagnostics, it most effective exhibits a small percent of the potentially essential mutations [at a 1-5% frequency],” says Pellini. “The common lung cancer specimen is [only] 20% tumor. To locate an alteration that happens at a frequency of 10% or much less in a lung cancer specimen, you need to ratchet that coverage up north of 400X.”

foundation’s median sequence insurance is 500-1000X on general, which Pellini believes will provide more suitable than 99% sensitivity and no false positives, which cannot be tolerated in a medical setting.

each pattern is reviewed to make certain there is enough material to proceed, noting the tumor category, dimensions, and cellularity. within the DNA extraction lab, basis extracts DNA in as little as 30 minutes. every DNA demo is graded on yield, purity, fragment size, and integrity. The tips is plugged into the LIMS, which calculates whether the demo passes or no longer. “We’ve constructed an algorithm that enables us to foretell which specimens they will’t run during the sequencer to gain the favored outcomes,” says Pellini.

The purified genomic DNA is next fragmented into 200-basepair fragments. a brief (7-bp) molecular index barcode is integrated into each sample, as a way to ultimately permit multiplexing. “we are able to song the samples with the molecular barcode, mix them all collectively, and at the conclusion computationally separate them,” says Curran. “My largest fear is demo switching and pattern contamination. That’s why the LIMS is essential. If I see a barcode I wasn’t anticipating or misplaced, i know they now have an issue.”

Following PCR and library building, the DNA is sized and normalized for hybrid seize, or what Curran calls “the meat of the assay.” basis uses proprietary RNA baits for the highest quality seize of the centered genomic content. The captured cloth is then normalized for sequencing.The LIMS creates a run sheet, detailing samples/lanes for one of the three (soon to be 4) Illumina HiSeq 2000 instruments. HiSeq might be the workhorse, however Pellini expects Ion Torrent to play a task in the future. Curran additionally anticipates a job for Illumina’s benchtop MiSeq or Ion Torrent’s own Genome computer, primarily in satisfactory handle. main foundation’s expertise building group is Alex Parker, who joined from Amgen as employee #eight (see, “Ten Billion Genotypes,” Bio•IT World, September 2008).

“We should make the most of know-how that’s capable for the scientific arena. They are looking to live chums with life Tech and with Illumina and whoever else enters the NGS field,” Pellini says diplomatically. whereas the preliminary center of attention is on DNA, Pellini expects so as to add RNA analysis to “bridge the gap” between exome analysis and a full genome/transcriptome workup.

The informatics team led via Doron Lipson and Roman Yelensky (see, “The IT Guys”), previously with Helicos and Novartis, respectively, strategies the sequence records and performs variant analysis for detection of sequence mutations, copy-number alterations and genomic rearrangements. The detected differences are fed returned to the abilities base, which in flip offers the fundamental correlation to curated scientific and scientific suggestions to generate the result report. Coming full circle, that document can also be delivered in the course of the lab net portal to the health care provider, ideally no greater than 14 days from the verify order date.  

closing replyFoundation_reportMary Pat Lancelotta, groundwork’s director of strategic advertising, shares with me a mock health care provider report (which may be provided in print or in a digital, interactive structure through a web portal), which summarizes the key mutations, principal medication and medical trials. As a diagnostics laboratory, foundation doesn’t have all of the assistance concerning the affected person and might’t recommend a particular action, however they can provide essential counsel that the general practitioner could not comprehend or have time to research.

“we are able to’t suggest a specific motion, however they are able to say, ‘listed below are the genomic changes and what they imply for this affected person, and in line with an exhaustive search of the literature, listed here are the therapeutic brokers and medical trials that you and your patient could agree with,” she says. “We’re giving the medical professional a completely informative genomic profile as a tool to support them make the subsequent treatment choice with their patient.”

The last report will have a really robust human factor, says Pellini. each file is reviewed by means of a workforce oncologist and pathologist with abilities in genomics earlier than it is shipped out. “in spite of the fact that they leap ahead a 12 months and populating the file is largely computerized, their medical director will be responsible for the accuracy of the advice. there will at all times be the involvement of an oncologist and pathologist in the ultimate file.” Pellini expects assurance organizations to reimburse for the examine “somewhere in the $4,000-5,000 latitude,” nevertheless it will be a researching procedure, he admits.

however what's going to physicians do with that counsel? groundwork faces a massive challenge to enhance health professional education. “Many pathologists and oncologists these days had no formal practicing in genetics/genomics since the field is so new,” says Lancelotta. “We’re making an attempt to provide them with a tool to aid them shift their pondering from an solely tumor-category approach of considering to a pathway model that allows you to focal point on their patients in place of molecular biology.”

commercial success hinges on more than just refined expertise and communique channels. classes can also be realized from Genomic health, the Bay enviornment business that commercialized the OncotypeDx gene expression look at various for breast cancer. Two former Genomic health executives, Maureen Cronin and Gary Palmer, have joined foundation, despite the fact Pellini doubts the Genomic health mannequin can be replicated. “It’s very complex for a diagnostics business to spend $60-90 million in advertising and marketing every 12 months. They did a masterful job and lead the way for different diagnostics groups. They get to study from what they did smartly.”

As for foundation’s fortunes, “There’s no magic here,” says Pellini. It comes right down to displays at key medical and scientific conferences, peer review publications, and academic and pharma collaborations. “We need to arm the income drive with the publications, we’ll have early adopters in educational clinical facilities. we've a scientific advisory board, and we’ll have businesses meeting around the country to [keep abreast of] the market…  Over time, they see this relocating further and further into the group the place they will advantage the top of the line number of sufferers.”

even as groundwork ramps up, the enterprise has struck agreements with a few pharma corporations, including Novartis, Celgene, and Johnson & Johnson. “As compounds go through clinical trials, we’re actively helping them understand who is responding, what they have got in average, and how will they get medication to market sooner,” explains Lancelotta. “We’re helping pharma get treatments to market faster. In flip, their check becomes extra actionable as a result of there are greater therapeutic alternatives for sufferers.”

Pellini says pharma is hunting for genomic facts upfront, no longer only to signify affected person subpopulations that respond neatly, but additionally to rescue failed trials. “a number of pharmas have instructed us that they plan to sequence every affected person that enrolls in one of their cancer-based mostly medical trials going ahead. They be aware the cost of those information,” he says. “Doing this with a clinical-grade look at various has different merits because the groups are beneath pressure to exhibit how sufferers who're certainly to reply can be routinely identified.”  

Pellini's Pitch  

Eight years ago, Pellini turned into running Genomics Collaborative, a leading biorepository delivery-up. The company was 5-10 years forward of its time, Pellini says, gathering information on more than 100,000 medical specimens (see, “Blood, Sweat and Tissue” Bio•IT World, March 2004). “We still deserve to access extraordinarily neatly characterized clinical specimens. It’s one of their brilliant challenges,”he says.

After the Genomics Collaborative property have been received with the aid of SeraCare (later transferred to BioServe), Pellini returned to Philadelphia. After a short spell within the VC world, he based and helped run a pathology business known as Lakewood Pathology. Later he became invited to join the Board of Clarient in California. “I went out there in the summer of 2007 for six weeks, and under no circumstances came domestic!”

Pellini signed on as president/COO and labored with their executive team to support Clarient construct a robust diagnostics enterprise with the suggestion of the usage of a lab to support introduce new exams into the marketplace. unless Clarient, Pellini says diagnostics organizations have been both a provider issuer/regular lab, or a biotech-like company comparable to Genomic fitness, “having a bet the farm” on a single verify or platform. There didn’t seem to be lots within the core.

Clarient routinely validated tissue blocks from cancer sufferers for businesses of typical molecular markers. “Roughly seventy five% of the time, an alteration would point out one other medication option or a medical trial choice. Their chief scientific officer would call the oncologist, and say, ‘right here’s a marker, there’s a remedy that aims this transformation.’ i will’t say what came about to the sufferers in most circumstances, however they offered further options. It was one of those ‘Aha’ moments.”

Pellini was content to reside at GE Healthcare after he helped engineer Clarient’s acquisition, however after a brief dialogue with Alexis Borisy, he turned into convinced of groundwork’s knowledge. “I consider we’ll be the company to determine this out. This technology is going to penetrate the market, there’s no doubt about it. It’s only a depend of timing.”

Pellini’s greatest shock since joining basis is huge pharma’s acceptance of the brand new rules of medical trials and molecular diagnostics. “Ten years in the past, they had blinders on; they felt threatened by the stratification of patients. I’m pleasantly stunned via pharma’s appreciation that realizing each cancer at the molecular degree is vital—on the science, clinical, and advertising facets.”   

A clinical LIMS  

The option of LIMS companion was a crucial choice for John Curran’s team at foundation drugs. After narrowing option to a few providers—Core LIMS, STARLIMS and Thermo Fisher—Curran’s team judged that Core LIMS was stronger appropriate for biochemistry labs than molecular evaluation, whereas the Thermo Scientific Nautilus LIMS edged STARLIMS in response to references and demos.

building a LIMS in apartment changed into under no circumstances a viable option, not simply on account of the time constraints but additionally the deserve to make sure future flexibility. “We obligatory whatever that wouldn’t constrain us to simply DNA processing however may deal with RNA processing or different pathology [applications],” says Curran.

Thermo Fisher’s Dave Minicuci elements to several points that made Nautilus an outstanding fit, together with reconciliation of arriving samples. “If there’s a time extend—groups don’t make cash when the samples aren’t demonstrated within the appropriate sequence.” one other abilities is the health professional-friendly customization to the core Nautilus LIMS, which still supplies “the finished information management layer, in addition to a dynamic workflow means,” says Minicuci.

One enviornment where the LIMS should shine is in aiding with a collection of state and countrywide inspections (including Massachusetts, CLIA, CAP, and long island state). “They need to make sure you’re doing a good job processing medical samples,” says Curran. An inspector will typically decide on a handful of affected person samples at random, and ask to peer the whole paper trail—requisition kinds; practicing documentation varieties (for everyone that touches the pattern); renovation documentation for all device (including pipettes) that contact the pattern; reagent logs; handle verification logs; and documentation for QC exams.

Curran customarily pulls those types and working towards facts from a submitting cupboard, but now he can enter an accession quantity, and have the counsel downloaded from the LIMS. “notwithstanding the LIMS is not a reagent administration equipment, they will catch the entire tips as they technique it via, so i will be able to get it multi function handy layout on the conclusion,” he says.   

The IT Guys 

Like a motor vehicle showroom, the records center at basis medicine is proudly displayed within the core of the company’s company headquarters. Jared White leads foundation’s application engineering effort. He sees his position as to “take the big graphic on a way to wire collectively computation so it gives you the results of the pipeline in a sturdy method. They run over 50 analysis tasks/sample, and dozens of samples per plate, so how do you wire that together in a high performance, fault-tolerant way?”

White and colleagues integrate with the LIMS and the knowledgebase, while the computational biologists work carefully on the particular person analysis components. whereas some informatics equipment came from the huge, Sanger, and different sources, several key algorithms were developed in-condominium with a view to achieve medical-level performance in detection of low-frequency mutations, White explains.

Of the ten servers, two are master/slave, and the other eight are execution hosts. as a result of they're typically saturated, a hardware function design referred to as hyperthreading is leveraged that simultaneously helps two threads of execution per core, thereby with ease doubling throughput for a given variety of rack instruments. “It’s greater than buying extra genuine cores—there’s a greener energy footprint,” White says. “each and every container has 12 physical cores, however they’re hyperthreaded so each container can aid 24 concurrent CPU-intensive jobs.”

basis at the moment uses 260 terabytes of Isilon storage, enough to shop facts on 10,000 patient samples via 2012. every rack can hang up to 1.5 petabytes, so there's a variety of headroom. Virtualization minimizes the rack footprint and the power consumed.

“The pipeline is computationally intensive, nevertheless it additionally induces lots of load on the Isilons,” says White. The CPU load on the computational cluster as smartly as the I/O load on the storage cluster influences the performance of the evaluation pipeline in alternative ways, and these need to be balanced.

“we now have a extremely exciting network,” says Sam Tran, the top of IT Infrastructure. whereas one cluster helps the primary information middle, a different offers redundancy. The complete platform is tied collectively through a collection of aggregated 10-Gigabit network connections that powers the servers and storage. The total rack is cooled via 24 heaps aircon—a chilly air aisle in the front, fanatics sucking out the scorching air within the back.

“probably the most premier elements is there are no wires in the aspect or on proper,” says Tran. “We obtain that by coming from the floor.” A strategically positioned yellow put up-It be aware demonstrates “the keenness of the fans.” 

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Dassault [2 Certification Exam(s) ]
DELL [18 Certification Exam(s) ]
DMI [1 Certification Exam(s) ]
DRI [1 Certification Exam(s) ]
ECCouncil [25 Certification Exam(s) ]
ECDL [1 Certification Exam(s) ]
EMC [134 Certification Exam(s) ]
Enterasys [13 Certification Exam(s) ]
Ericsson [5 Certification Exam(s) ]
ESPA [1 Certification Exam(s) ]
Esri [2 Certification Exam(s) ]
ExamExpress [15 Certification Exam(s) ]
Exin [42 Certification Exam(s) ]
ExtremeNetworks [3 Certification Exam(s) ]
F5-Networks [20 Certification Exam(s) ]
FCTC [2 Certification Exam(s) ]
Filemaker [9 Certification Exam(s) ]
Financial [34 Certification Exam(s) ]
Food [4 Certification Exam(s) ]
Fortinet [17 Certification Exam(s) ]
Foundry [6 Certification Exam(s) ]
FSMTB [1 Certification Exam(s) ]
Fujitsu [2 Certification Exam(s) ]
GAQM [12 Certification Exam(s) ]
Genesys [4 Certification Exam(s) ]
GIAC [17 Certification Exam(s) ]
Google [14 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 [5 Certification Exam(s) ]
Hospitality [2 Certification Exam(s) ]
HP [771 Certification Exam(s) ]
HR [4 Certification Exam(s) ]
HRCI [1 Certification Exam(s) ]
Huawei [34 Certification Exam(s) ]
Hyperion [10 Certification Exam(s) ]
IAAP [1 Certification Exam(s) ]
IAHCSMM [1 Certification Exam(s) ]
IBM [1547 Certification Exam(s) ]
IBQH [1 Certification Exam(s) ]
ICAI [1 Certification Exam(s) ]
ICDL [6 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 [5 Certification Exam(s) ]
ISC2 [7 Certification Exam(s) ]
ISEB [25 Certification Exam(s) ]
Isilon [4 Certification Exam(s) ]
ISM [6 Certification Exam(s) ]
iSQI [9 Certification Exam(s) ]
ITEC [1 Certification Exam(s) ]
ITIL [1 Certification Exam(s) ]
Juniper [68 Certification Exam(s) ]
LEED [1 Certification Exam(s) ]
Legato [5 Certification Exam(s) ]
Liferay [1 Certification Exam(s) ]
Linux-Foundation [1 Certification Exam(s) ]
Logical-Operations [1 Certification Exam(s) ]
Lotus [66 Certification Exam(s) ]
LPI [25 Certification Exam(s) ]
LSI [3 Certification Exam(s) ]
Magento [3 Certification Exam(s) ]
Maintenance [1 Certification Exam(s) ]
McAfee [9 Certification Exam(s) ]
McData [3 Certification Exam(s) ]
Medical [70 Certification Exam(s) ]
Microsoft [413 Certification Exam(s) ]
Mile2 [3 Certification Exam(s) ]
Military [1 Certification Exam(s) ]
Misc [2 Certification Exam(s) ]
Motorola [7 Certification Exam(s) ]
MuleSoft [1 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 [8 Certification Exam(s) ]
Nortel [130 Certification Exam(s) ]
Novell [38 Certification Exam(s) ]
OMG [10 Certification Exam(s) ]
Oracle [317 Certification Exam(s) ]
P&C [2 Certification Exam(s) ]
Palo-Alto [6 Certification Exam(s) ]
PARCC [1 Certification Exam(s) ]
PayPal [1 Certification Exam(s) ]
PCI-Security [1 Certification Exam(s) ]
Pegasystems [19 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 [2 Certification Exam(s) ]
PsychCorp [1 Certification Exam(s) ]
PTCB [2 Certification Exam(s) ]
QAI [1 Certification Exam(s) ]
Qlik [2 Certification Exam(s) ]
QlikView [2 Certification Exam(s) ]
Quality-Assurance [6 Certification Exam(s) ]
RACC [1 Certification Exam(s) ]
Real-Estate [2 Certification Exam(s) ]
RedHat [8 Certification Exam(s) ]
RES [5 Certification Exam(s) ]
Riverbed [9 Certification Exam(s) ]
RSA [16 Certification Exam(s) ]
Sair [8 Certification Exam(s) ]
Salesforce [13 Certification Exam(s) ]
SANS [1 Certification Exam(s) ]
SAP [98 Certification Exam(s) ]
SASInstitute [15 Certification Exam(s) ]
SAT [2 Certification Exam(s) ]
SCO [10 Certification Exam(s) ]
SCP [6 Certification Exam(s) ]
SDI [3 Certification Exam(s) ]
See-Beyond [1 Certification Exam(s) ]
ServiceNow [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) ]
Splunk [3 Certification Exam(s) ]
SpringSource [1 Certification Exam(s) ]
SUN [63 Certification Exam(s) ]
SUSE [1 Certification Exam(s) ]
Sybase [17 Certification Exam(s) ]
Symantec [137 Certification Exam(s) ]
Teacher-Certification [4 Certification Exam(s) ]
The-Open-Group [8 Certification Exam(s) ]
TIA [3 Certification Exam(s) ]
Tibco [19 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 [34 Certification Exam(s) ]
Vmware [76 Certification Exam(s) ]
Watchguard [1 Certification Exam(s) ]
Wonderlic [2 Certification Exam(s) ]
Worldatwork [3 Certification Exam(s) ]
XML-Master [3 Certification Exam(s) ]
Zend [6 Certification Exam(s) ]

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