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|Updated On||:||April 23, 2019|
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P2020-012 exam Dumps Source : IBM SPSS Data Collection Technical Support Mastery v1
Test Code : P2020-012
Test Name : IBM SPSS Data Collection Technical Support Mastery v1
Vendor Name : IBM
Q&A : 60 Real Questions
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I attended IBM’s inaugural believe adventure in Las Vegas final week. This event, IBM’s biggest (estimated 30,000+ attendees!), concentrated on making your enterprise smarter and protected keynotes and periods on such topics as artificial intelligence, information science, blockchain, quantum computing and cryptography. i was invited by using IBM as a guest to share some insights from the point of view of a data scientist. under are a number of highlights of the experience.statistics Science using IBM SPSS
IBM SPSS is IBM’s set of predictive analytics items that address the entire analytical technique, from planning to facts collection to analysis, reporting and deployment. IBM celebrated the 50th anniversary of IBM SPSS with their new beta unlock of IBM SPSS statistics 25, the biggest beta liberate in its historical past. The up to date edition comprises new developments like publication-in a position charts, MS office integration, Bayesian statistics and superior data. also, they delivered a new user interface which is relatively slick.
i used to be brought to SPSS statistics in college and have used it for every one of my research tasks in view that then. To be sincere, SPSS statistics has aged enhanced than I actually have! I actually have already began the use of the new edition and am fairly excited concerning the new points and user interface. i will file about event in a later put up. try SPSS with a free 14-day trial.improving the consumer experience
recent studies have estimated that 45% of sellers are anticipated to raise the use of artificial intelligence for client experience in the next three years, and fifty five% of agents are concentrated on optimizing the customer journey to boost customer loyalty. additionally, eighty five% of all client interactions with a company might be managed without human interaction by using 2020.
consumer adventure management (CXM) is the process of realizing and managing shoppers’ interactions with and perceptions in regards to the company/company. IBM is aware that enhancing the client adventure is increasingly becoming facts-intensive endeavor, and the usage of the mixed power of facts and these days’s processing capabilities can help organizations model the approaches that have an impact on the consumer experience. I attended a couple of periods to learn about how IBM is leveraging the vigor of IBM Watson to aid their clients with Watson Commerce and Watson customer event Analytics solutions. These solutions use the power of artificial intelligence (e.g., predictive analytics) to improve how businesses can more suitable control consumer relationships to raise consumer loyalty and flow their enterprise forward.records Science Meets superior Analytics and Augmented fact
I noticed a great demonstration of the intersection of information science, stronger analytics and augmented truth. Getting from information to insights is the purpose of data science efforts and, as information sources continue to develop, we are able to want more desirable the right way to get to those insights. Aginity is working with H2O.ai to reveal how you can enrich your predictions via augmenting public data with superior facts (with derived attributes) and enhanced analytics to make greater predictions. using baseball records, Ari Kaplan of Aginity brought up that the advancements in predictive models might translate into thousands and thousands of dollars per participant. whereas his demo concentrated on the use of these technologies in baseball facts, the concepts are generalizable to any industry vertical, together with finance, healthcare and media.
at the identical demonstration station, Alfredo Ruiz, lead of the Augmented fact software at IBM Analytics, showed me how his crew (IBM Immersive Insights) is incorporating augmented fact into records Science event to support agencies stronger understand their ever-expanding statistics sets. I’m eager for seeing how his efforts in marrying augmented reality and statistics science growth.
I had the privilege of interviewing Ari Kaplan of Aginity who talked in regards to the work he is doing to enhance how Aginity and H2O.ai is enhancing the facts science method. try what he has to say below.
Don’t miss this interview with Ari Kaplan, a true “Moneyball” and well normal round major League Baseball, as he talks in regards to the latest laptop getting to know technologies powering nowadays’s baseball selections, and take a look at the fantastic demo.
Posted through IBM records Science on Thursday, March 22, 2018statistics Science is a crew activity
I had the possibility to speak with with many trade consultants who come to records science from a distinct viewpoint than I do. while I focus essentially on the records and mathematics features of statistics science, a lot of my facts peers approach statistics science from a technological and programming attitude. basically, for an upcoming podcast, Dez Blanchfield and i were interviewed by way of Al Martin of IBM Analytics to talk about our respective roles in information science. This conversation turned into a active one, and i am longing for reliving that night once the podcast is launched. The base line is that facts science requires such a various skill set that you simply actually need to work with different individuals who can complement your talents.
This notion that records science is a team activity was put on full monitor in an wonderful session in which a couples therapist (Trisha Mahoney) helped unravel an argument between a knowledge science chief (Shadi Copty) and IT chief (Ryan Arbow). Asking probing questions, the counselor printed that the data science and IT chief have been at odds because of an absence of verbal exchange. She delivered them to IBM’s statistics Science adventure, an business facts science platform that makes it possible for them to without problems collaborate, use excellent open source equipment and get their models into creation quicker.Analytics: Your competitive potential
For me, IBM consider 2018 was all about making your business smarter via analytics. truly, analysis indicates that groups which are more advantageous in a position to deliver the vigor of analytics to bear on their company issues may be in a better position to outperform their analytics-challenged opponents. This conception become illustrated through keynotes, periods and conversations. by using bringing distinctive records science specialists collectively to leverage the tools and methods of AI and computing device/deep studying will aid you move your business forward. in case you have been unable to attend the experience, that you may watch replays of lots of the keynotes here.
(Disclosure: IBM assisted me with shuttle expenses to IBM suppose 2018.)
IBM is ending new sales its Watson classes aimed at artificial intelligence-primarily based drug discovery and construction because of negative economic returns, in keeping with a report from Stat.
The news follows huge Blue’s selections ultimate yr to stream faraway from providing Watson in clinic administration settings, not to mention the departure of the regularly occurring supervisor of the division’s health-focused unit last October.
IBM has in the past rolled out some excessive-profile partnerships, though now not fully in drug discovery, together with with Pfizer, Novartis and Illumina in cancer analysis, in addition to with Teva to discover drug repurposing. however, even with these offers, sources informed Stat the initiative turned into nevertheless no longer bringing in enough funds.
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in line with those sources, IBM employees had been currently notified of the determination and have begun reassessing Watson’s potentialities in the broader biopharma trade. greater formally, the company mentioned it will proceed working with drugmakers who currently make use of Watson for their R&D work.
“we're focusing our components within Watson fitness to double down on the adjoining box of clinical construction where we see a fair more desirable market need for our information and AI capabilities,” an IBM spokesman instructed Stat in a statement.
outdoor of drug and medical building, Watson fitness these days inked a $50 million, 10-yr funding right into a collaboration with Brigham and girls’s health center and Vanderbilt college medical center to research public fitness concerns and patient defense.
connected: IBM Watson health chief Deborah DiSanzo steps down from publish
however during the last few years, Watson has been no stranger to stumbles. A 2017 investigation with the aid of Stat discovered that IBM’s Watson for Oncology initiative—which aimed to use AI and herbal language processing of medical data to help suggest customized classes of cancer remedy—became a protracted means from being able to meet its promises.
although pitched by means of marketers as a method to generate new insight and techniques to care, the gadget has been beset by way of obstacles in interoperability and statistics assortment—namely the labor-intensive work required by using physicians and others to retain the software manually updated with medication concepts and statistics for only a handful of diverse cancers.
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Our study showed a close correlation between the CCT, including the CFCT and CVCT, and subtype of stroke in patients with MMD or MMS. The F-V ratio was inversely correlated with the possibility of hemorrhagic stroke. The model using the F-V ratio and structural metrics was more effective than the model that only used structural metrics for predicting hemorrhagic MMD or MMS.
It is generally recognized that ischemic stroke associated with MMD or MMS occurs with chronic stenosis or occlusion of the ICA or its branches, when compensatory collateral vessels cannot supply adequate blood to the brain7. Most cerebral infarction secondary to MMD or MMS is located at the ICA territory (frontal lobe is most common), while PCA involvement is present in 20–30% of MMD, resulting in PCA territory infarction23, 24. On the contrary, mainly intracranial hemorrhage occurs due to the rupture of abnormal moyamoya vessels and dilated collateral vessel such as the anterior choroidal artery, posterior communicating artery, and aneurysm5, 15,16,17,18,19. In our study, the most common region of infarction was the frontal lobe (88.0%), with 27.9% of patients having PCA involvement. The most common hemorrhagic disorder was intraventricular hemorrhage (49.3%). Hemorrhagic MMD or MMS was more common in adults than children (23:1, P = 0.128), and in females than males (1.4:1, P = 0.191), but without statistical significance. Patients with hemorrhagic MMD are most common in Suzuki stages 3 to 4, and the proportion of abnormal dilation (Grade 2) of AChA and PComA and aneurysm was significantly higher in patients with hemorrhagic MMD than in patients with ischemic MMD. ROC curve analysis of age, gender, Suzuki stage (Suzuki 3–4), dilation of AChA (Grade 2), PComA (Grade 2), and aneurysm for predicting hemorrhagic MMD or MMS showed that the AUC was 0.8748 (P < 0.0001), which is in accordance with the data from some previous studies15, 17,18,19, 23, 24. Interestingly in several patients, we noticed that the dilation of AChA, PComA and aneurysm around the AChA and PChA had regressed or disappeared after extra–intracranial revascularization surgery, which may contribute to the decreased risk of re-bleeding after revascularization (Supplementary Fig. S1).
To the best of our knowledge, a substantial proportion of the population has congenital or acquired dysplasia of the cerebral venous system, with most people exhibiting no symptoms. However, in exceptional circumstances, abnormal cerebral venous drainage can lead to increased intravascular pressure load and abnormal cerebral blood flow, resulting in brain damage. Previous studies have reported that some patients with MMD or MMS have complications of hypercoagulability, which can cause cerebral venous thrombosis and abnormal cerebral venous drainage25,26,27,28. Cerebral venous drainage in other disorders, such as cerebral hemorrhage, cerebral infarction and arteriovenous malformation, has attracted increasing attention29,30,31,32. However, the relationship between the cerebral venous system and stroke related to MMD or MMS has been rarely reported.
Previous studies about cerebral venous drainage have mainly been limited to a description of the structure or indirect signs, such as diameter and number of draining veins, or venous reflux29, 33. Although structural imaging such as CT venography (CTV), MR venography (MRV), and DSA can reflect the shape of the cerebral venous system, some diseases such as stenosis of internal jugular vein, defects of venous valves, or increased intrathoracic pressure often do not show unusual findings on structural images, but can result in increased intracranial pressure and delayed CCT, especially venous circulation time34, 35. Therefore, CCT can more accurately reflect cerebral blood flow, and CVCT is an important indicator of abnormal cerebral venous drainage36,37,38. CCT can help us further understand changes in cerebral hemodynamics in patients with MMD or MMS, which may be of great significance in clinical practice.
Due to the different methods and definitions, the normal CCT of healthy population differs accordingly35, 39, 40. In the present study, the mean CTCT (16.54 s) was prolonged in patients with MMD or MMS, compared with healthy population of previous studies35, 39. The CFCT of hemorrhagic sides was shorter than non-hemorrhagic sides, with a significant statistical difference (P < 0.001). Presumably, since hemorrhagic MMD was often in Suzuki 3 or Suzuki 4 stage, moyamoya vessels were relatively rich, and collateral arteries were dilated significantly, cerebral blood filling is faster in hemorrhagic MMD than non-hemorrhagic MMD, which coincided with above-mentioned results of this study and previous studies15, 17, 18. However, the CVCT was longer in the hemorrhagic sides than non-hemorrhagic sides, also with a significant difference (P < 0.001), suggesting poor cerebral venous drainage is probably a risk factor of hemorrhagic stroke in the patients with MMD or MMS. Subgroup analyses of different Suzuki stages, however, showed that this phenomenon was primarily apparent in the hemispheres between Suzuki 3 and Suzuki 4, with the exception of early stages (Suzuki 1 to Suzuki 2) or late stages (Suzuki 5). It is well understood that cerebral vessels of MMD are approximate to normal condition during Suzuki 1 and Suzuki 2 stages, and internal carotid arteries are approximate to occlusion during Suzuki 5 and Suzuki 6 stages, with relatively low intravascular pressure load, so it is of less possibility of bleeding during these stages.
Many other factors can affect CCT such as blood pressure, heart rate, and other parameters of angiography. In addition, CFCT and CVCT may correlate with each other. To diminish the influential factors of CCT, the F-V ratio was used to analyze the differences in CCT between hemorrhagic and non-hemorrhagic MMD or MMS. The results indicated that the F-V ratio was inversely correlated with the possibility of hemorrhagic stroke. The ROC curve analysis of the F-V ratio showed that the best cut-off point for differentiating hemorrhagic MMD or MMS from non-hemorrhagic MMD or MMS was 0.4344 (sensitivity = 81.4%, specificity = 73.2%, AUC = 0.8016), according to Youden’s index (Figs 2 and 3). The smaller the F-V ratio, the lower the sensitivity and higher the specificity for predicting hemorrhagic stroke (Table 4). The model using structural metrics and the F-V ratio was superior to the model that only used structural metrics for predicting hemorrhagic MMD or MMS (P = 0.022) (Table 5, Fig. 2).
From our perspective, this phenomenon can be attributed to two mechanisms: the rapid filling of cerebral circulation and dysfunction of cerebral venous drainage. The rapid filling is probably relevant to substantial moyamoya vessels, significantly dilated and extended collateral arteries, such as anterior choroidal artery and posterior communicating artery. For the latter mechanism, there are many factors or diseases that can lead to dysfunction of cerebral venous drainage, including intracranial and extracranial factors. Intracranial factors, such as cerebral venous sinus thrombosis and stenosis of cerebral venous sinus, can directly cause impaired outflow of intracranial blood circulation, leading to disorders of cerebral venous drainage and increased intravascular pressure load. Extracranial factors, including stenosis of internal jugular veins, defects of venous valves, or increased intrathoracic pressure, can also result in incremental intravascular pressure load by inducing increased pressure of outlet of cerebral circulation. Eventually, the incremental intravascular pressure load can increase the opportunity of rupture of fragile moyamoya vessels, dilated collateral arteries or aneurysms, which is similar with other cerebral vascular malformation29, 30, 33.
The limitations of our study should be mentioned. First, all of the patients in this study were enrolled from a single center, so potential selection bias is inevitable. However, we tried to reduce in-house selection bias as much as possible by collecting patients consecutively. Second, the nature of case-control studies necessitates further prospective cohorts or randomized studies to confirm our conclusions.
Psychological distress can affect a person’s decision-making process, leading to sub-optimal outcomes in many instances (Starcke & Brand, 2012). Amyotrophic lateral sclerosis (ALS; also referred to as motor neurone disease) is a progressive neurological disease leading to paralysis and ultimately death, most commonly as a result of respiratory failure (Bungener et al., 2005). The psychological impact on the individual can be devastating, with high levels of distress and depression being frequently reported by people with ALS (Pagnini, 2013). While there is currently no cure for the neurodegenerative process, there are intervention options available (e.g., percutaneous endoscopic gastrostomy (PEG) or non-invasive ventilation (NIV)) that have been shown to not only improve the patient’s quality of life but also potentially prolong their life (Bourke et al., 2006; Kiernan et al., 2011; Leigh et al., 2003). Despite the evidence and best-practice directives from health authorities, many ALS patients choose not to adopt these intervention options when recommended by health-care professionals (Hogden et al., 2012; Leigh et al., 2003; Orrell, 2010).
This decision-making phenomenon gives rise to further questioning regarding possible psychological factors involved. Relational frame theory (RFT) is a behaviorist approach explaining human behavior as well as internal mental processes (Barnes-Holmes et al., 2004). Research shows support for applied therapies grounded in RFT for the treatment of psychological distress in patients with long-term chronic or terminal illness, such as cancer, multiple sclerosis, and HIV (Graham et al., 2016). While there are no published randomized controlled trial results examining applied RFT and people with ALS, this paper proposes that RFT offers a viable account of understanding and acceptance of intervention options in people with ALS.Amyotrophic lateral sclerosis
The typical ALS patient endures pain and discomfort as a result of severe cramps and twitches; loss of mobility due to weakness and loss of muscle mass; loss of weight and possible malnutrition due to difficulties in getting food to his/her mouth, chewing and swallowing; loss of communication as speech muscles become increasingly affected; and trouble with breathing as diaphragmatic muscles weaken (Leigh et al., 2003). Malnutrition is a critical determinant in the prognosis of an ALS patient and patients who become malnourished increase their risk of death sevenfold (Kiernan et al., 2011; Limousin et al., 2010). Treatment for malnutrition in ALS patients involves the insertion of a small tube through the abdomen wall into the stomach, known as a PEG (Katzberg & Benatar, 2011). This enables caloric intake (liquid feeds and fluids) directly into the stomach, bypassing the mouth and throat (Katzberg & Benatar, 2011).
After a systematic review of non-randomized controlled trials, Orrell (2010) concluded that the use of PEGs in ALS patients has a positive effect on survival. PEGs prevent malnutrition in ALS patients and have been shown to increase mean survival time by 14-months (Limousin et al., 2010). The recommendation from peak health authorities to health-care-professionals caring for ALS patients is to offer a PEG to the patient if rapid weight loss is evident or the patient has difficulties swallowing (Katzberg & Benatar, 2011; Kiernan et al., 2011). It has been estimated that approximately 50% of patients in the US, and only 23% of patients in the UK, opt for a PEG (Bede et al., 2011). Bede et al. (2011) attributes these differences to variations between health care systems driven by complex local, financial, and cultural factors. Berlowitz et al. (2016) reported that 26% of patients opted for a PEG in their Australian-based study, and interestingly, 58% of patients who used NIV also opted for a PEG. It is presumed that the influence of health care systems also applies to the Australian data.
Non-invasive ventilation is an intervention offered to ALS patients suffering from respiratory insufficiency (Bourke et al., 2006; Kiernan et al., 2011; Leigh et al., 2003). Respiratory muscle function is a strong predictor of survival and quality of life in ALS patients (Bourke et al., 2006). As the ALS patient’s respiratory performance declines, the range of associated symptoms increases including headaches, disrupted sleep, fatigue, lack of mental alertness, and general decline in mental health (Bourke et al., 2006). NIV offers relief from these symptoms through the use of a small machine, called a bi-level positive airway pressure (BiPAP), enabling the patient to inhale larger volumes of air and exhale carbon dioxide more effectively (Eng, 2006).
Despite empirical support for NIV, the take-up remains relatively low, with reported rates of use in ALS patients in Australia at 23%, UK at 13%, and USA at 20% (Bede et al., 2011; Berlowitz et al., 2016). Bede et al. (2011) also cites differences between the US and the UK to the complex local, financial, and cultural drivers of the health care system. As with PEG prevalence rates, it would be presumed that these factors also apply to Australia.ALS and psychological well-being
Recent research suggests the prevalence of depressive disorders in people with ALS to be approximately 19%, and, while showing no relationship with functional impairment, depression has been shown to be strongly correlated with quality of life (Körner et al., 2015; Kurt et al., 2007; McElhiney et al., 2009; Rabkin et al., 2005).
There are no known studies investigating the relationship between general psychological well-being and decision-making in people with ALS. Depression has been shown to influence decision-making in patients with chronic illness; depressed patients being three times more likely to be non-compliant with medical advice, compared to non-depressed patients (Di Matteo, Lepper & Crogan, 2000).Relational frame theory and understanding and acceptance of interventions
Firstly, it should be noted that the terms accept and acceptance used throughout this paper are used in the context of RFT mental processes exclusively and not, for example, confirming the physical adoption of an intervention. A recent study by Greenaway et al. (2015) has elucidated important factors that influence ALS patients’ understanding and acceptance of interventions, including: (a) acceptance of the diagnosis and the course of the disease progression, (b) willingness to take action despite having a terminal illness, (c) acceptance of the physical need for an intervention, (d) specific fears relating to the intervention, and (e) timing-factors such as procrastination emanating from a lack of clarity about the likely course of symptoms. The present paper argues that the behaviors observed in the Greenaway et al. (2015) research can be explained by RFT, and that psychological flexibility, as the psychological construct targeted in applied RFT, should be a variable of interest. Furthermore, psychological flexibility could explain a significant portion of the variation between subjects in the understanding and acceptance of intervention options in people with ALS.
Relational frame theory is grounded in behaviorist principles and aims to move beyond the basic stimulus-response processes of classical and operant conditioning, providing a comprehensive theory of internal processes explaining human cognition, emotion, and behavior as well as offering an explanation for specific psychopathologies (Barnes-Holmes et al., 2004). The processes of RFT are technical in nature and far too extensive for the purpose of explanation in the present paper.
Psychological flexibility is the key construct of interest in RFT and is defined by two parts: (a) the processes of experiential avoidance and acceptance, requiring the individual to make contact with the present moment, and (b) the act of moving through unpleasant psychological reactions toward goals aligned with chosen values (Barnes-Holmes et al., 2004; Fletcher & Hayes, 2005; Hayes, 2016; Levin & Hayes, 2009).
Greenaway et al. (2015) and Hogden et al. (2012) highlighted acceptance as an influential factor for people with ALS deciding on a PEG or NIV, and the process of acceptance plays an important role in building psychological flexibility (Blackledge & Barnes-Holmes, 2009; Hayes et al., 2006; Levin & Hayes, 2009; Strosahl & Robinson, 2009). Experiential avoidance is said to present in two parts; one, the event-based unpleasant emotion; and two, the action of avoidance (Friman, Hayes & Wilson, 1998). That is, experiential avoidance manifests in actions taken to avert unpleasant emotions, thoughts, memories, or physical sensations (Levin & Hayes, 2009). RFT argues that these unwanted stimuli are a result of overly dominant comparative frames, that is, alternative mental representations or frames of reference (Levin & Hayes, 2009). RFT posits that a psychologically flexible individual has the capacity to fully accept internal events, even if unpleasant, and uses strategies (other than avoidance) to move through the discomfort.
Greenaway et al. (2015) and Hogden et al. (2012) also explained the importance of perception of choice and control in the context of this decision-making process. RFT claims that behavior can also be directed by strategic and values-based rules, explained by a frame of coordination between two relational networks (Barnes-Holmes et al., 2004), essentially whereby two or more mental representations are linked or explained to one’s self through a self-governed rule or value. Rule-governed behavior rests on the RFT notion of concept-of-self, requiring the individual not only to behave, but also to use language to assign accurate meaning to one’s own behavior (Barnes-Holmes et al., 2004). According to RFT, sound self-knowledge facilitates effective functioning but omitting the use of language to assign meaning thereby removes the process of relational framing (Barnes-Holmes et al., 2004). This would be akin to Beck’s representation of a maladaptive schema (Hulbert et al., 2011).
Psychological flexibility has been shown to have a moderate to strong relationship with general psychological well-being, including quality of life, depression, and anxiety (Hayes et al., 2006). In addition, longitudinal studies have provided support for the theory that psychological flexibility predicts mental health, and not the reverse (Hayes et al., 2006). In patients with chronic illness, Graham et al. (2016) established that applied RFT is associated with improved outcomes.
We are not aware of any published studies examining psychological flexibility in ALS patients. The only published study found of some relevance examined the longitudinal effect of mindfulness on physical functioning in people with ALS (Pagnini et al., 2015). Pagnini et al. (2015) reported that mindfulness had a positive impact on the patients’ functioning, discovering that low-mindfulness patients’ physical symptoms declined by −9.64% over a 4-month time period, while high-mindfulness patients’ physical symptoms declined by −2.88% over the same time. Mindfulness also predicted quality of life, depression, and anxiety. Relationships between quality of life, psychological well-being (depression and anxiety) and physical symptoms were reported to be non-significant.
Pagnini et al. (2015) concluded that mindfulness appeared to predict physical symptom progression in ALS patients and proposed that a mind–body interaction is the mechanism responsible. However, given that PEG and NIV interventions were not accounted for in this study, and because these interventions have been shown to influence ALS symptom progression, this proposition should be accepted with caution.The Current Study
The aim of the current study was to examine the relationship between psychological flexibility, psychological well-being, and understanding and acceptance of interventions in people with ALS, suggesting that applied RFT may have utility with this population. No previous study has investigated these relationships in people with ALS. The present study had two objectives: Firstly, we sought to examine the relationship between psychological flexibility and understanding and acceptance of interventions in people with ALS. Secondly, we set out to examine the role of psychological well-being within the abovementioned relationship, and investigate the possibility that psychological well-being moderates the relationship between psychological flexibility and understanding and acceptance of interventions.
H1: Consistent with an RFT account of feelings and behavior, we expected that high psychological flexibility would be associated with high levels of understanding and acceptance of interventions, for both PEG and NIV. In line with the literature review presented in Hayes et al. (2006), we also expected that high psychological flexibility would also be associated with high psychological well-being (i.e., high quality of life, low depression, low anxiety, and low stress).
H2: We expected that psychological flexibility and psychological well-being would predict understanding and acceptance of interventions.
H3: We expected the relationship between psychological flexibility and understanding and acceptance of interventions to be moderated by psychological well-being.Method Participants
To be eligible for this study, participants had to be aged 18-years or above and have received a diagnosis of ALS. Verification of diagnosis was not requested of the participant. The final sample consisted of 14 (40%) females and 21 (60%) males (N = 35), and participants’ ages ranged from 34 to 73 years (M = 55.80, SD = 10.48). The mean time since first symptoms was 49.14 months (SD = 32.55 months) and mean time since diagnosis was 26.74 months (SD = 21.66 months). An analysis of country of residence revealed 51.4% participants lived in Australia, 22.9% lived in the UK, 11.4% lived in the USA, 5.7% in Canada, and the remaining 8.6% in other countries. Participation was voluntary and no incentives were offered. All data for this study is available at Figshare.com (Pearlman & Thorsteinsson, 2018).Data screening Missing data
A total of 84 participants were recruited; 31 participants withdrew from the study after viewing the information sheet; 15 participants withdrew after only completing the demographic information; and three participants withdrew after only partially completing the survey (<30% of the survey was completed). The data from these 49 participants was not included in the analysis. Missing data was addressed by calculating a mean score for each subscale (as opposed to total subscale score) and setting the denominator at a minimum of x − 1, where x was the number of items on the subscale.Materials
Participants were required to complete a demographics sheet which included age, gender, country of residence, date of first symptoms and date of diagnosis. Participants were then required to complete self-report measures designed to assess psychological flexibility, quality of life, depression, anxiety, stress, and understanding and acceptance of interventions.Psychological flexibility
The 16-item version of the Acceptance and Action Questionnaire (AAQ-16) measures psychological flexibility across two factors; (a) willingness, and (b) action (Bond & Bunce, 2003). The first factor, “willingness,” includes seven items designed to measure people’s willingness to accept unwanted thoughts and feelings (e.g., “It’s ok to feel depressed or anxious”). The second factor, “action,” includes nine items assessing the participant’s ability to act in a way, that is, congruent with their goals and values, even in the presence of unwanted thoughts or feelings (e.g., In order for me to do something important, I have to have all my doubts worked out”). Participants responded to statements by indicating how true they believed the item was for them on a 7-point scale ranging from 1 (never true) to 7 (always true). A mean total score was calculated for each factor. Scores ranged from 1 to 7 where higher scores indicate greater psychological flexibility. Cronbach’s alpha reported by Bond & Bunce (2003) was 0.87. In the current study, the internal reliability was poor for willingness (Cronbach’s alpha = 0.47) and acceptable for action (Cronbach’s alpha = 0.69).Quality of life
The McGill Quality of Life Questionnaire-Revised was designed to measure quality of life in people with a terminal illness (Cohen et al., 1995). This instrument includes 14-items to form four subscales: (1) Physical (e.g., “over the past 2 days, my physical symptoms were:”); (2) Psychological (e.g., “over the past 2 days, I was nervous or worried:”); (3) Existential (e.g., “over the past 2 days, I felt good about myself as a person.”); and (4) Social (e.g., over the past 2 days, I felt the relationships with the people I care about were:). Participants were asked to indicate an option that was most true for them on a relevantly labelled 11-point scale ranging from 0 (very bad) to 10 (excellent). Subscale scores were calculated by taking the mean score across the items in that subscale. A total mean score was calculated by determining the total for each of the 4 subscale scores. Total scores range from 0 to 10 where higher scores indicate higher quality of life. Cronbach’s alpha is 0.80 (Cohen et al., 1995). Internal reliability in the current study was good (Cronbach’s alpha = 0.88).Depression, anxiety, and stress
The 21-item Depression, Anxiety, and Stress Scales was designed to assess features of depression, hyper-arousal, and tension-stress in clinical and non-clinical groups (Antony et al., 1998). Participants were presented with statements across these three subscales: (1) Depression (e.g., “I couldn’t seem to experience any positive feelings at all”); (2) Anxiety (e.g., “I was aware of dryness in my mouth”); and (3) Stress (e.g., “I found it hard to wind down”), and rate how appropriately they believed this item described them over the past week. Responses were captured on a 4-point scale ranging from 0 (never) to 3 (always). Scale scores were generated by calculating the mean total of the respective item scores, where higher scores indicate higher levels of disturbance. The Cronbach’s alphas for depression, anxiety, and stress were 0.97, 0.92, and 0.95, respectively (Antony et al., 1998). Internal reliability in the current study was good for depression and stress, with Cronbach’s alphas at 0.80 and 0.81, respectively. However, anxiety was only adequate with a Cronbach’s alpha of 0.67.Understanding and acceptance of interventions
For the purpose of the present study, a 9-item scale measuring understanding and acceptance of PEGs and a 4-item scale measuring understanding and acceptance of NIV were designed. Each item was developed from qualitative findings published in Greenaway et al. (2015). Participants were required to provide self-report responses on a 5-point scale in response to questions or statements relating to their current viewpoint or attitude toward the intervention in question (e.g., PEG—“I find the idea of a PEG tube coming from my stomach…” and NIV—“I would use a BIPAP machine if it could prolong my life.”). Response options were offered on an appropriately labelled 5-point scale ranging from 1 (highly unlikely) to 5 (highly likely). Scale scores were generated by calculating the mean total (ranging from 1 to 5), where higher scores indicate higher levels of understanding and acceptance. One item on the PEG-Scale was reverse scored. The internal reliability for both scales was good (PEG-scale Cronbach’s alpha = 0.80, NIV-scale Cronbach’s alpha = 0.82).Procedure
Following the submission of a human research ethics application and meeting all conditions in full, the University of New England Human Research Ethics Committee approved the project (approval number HE017-069). Advertisements were placed on the Motor Neurone Disease (MND) Association website, MND Association Facebook page, and international ALS online forums. Advertisements included a hyperlink, taking prospective participants directly to the study. Data collection and storage was securely managed through online software (Qualtrics, 2017). This online capability enabled participation to people with internet access via a personal computer, tablet or mobile device. The surveys could also be completed using eye-gaze assistive-technology coupled with a tablet. The surveys took approximately 15 min to complete.
The first page presented to participants was an information sheet detailing participants’ rights and addressed ethical considerations. Participation was anonymous and participants were free to withdraw from the study at any time without consequence. Participants were then presented with a page titled “Online Implied Consent for Participant,” asking the participant to confirm that they had read and understood the information sheet and explaining that clicking on the “PROCEED TO STUDY” button served as implied consent. Withdrawal at any time could be achieved simply by closing down their web browser session. At the completion of the surveys, participants were thanked for their participation and advised that their responses had been recorded.Statistical analyses
Statistical analyses were performed using IBM SPSS Statistical Software version 24. A critical alpha value of 0.05 was set to test all hypotheses. Bivariate correlational analyses were conducted using Pearson product-moment coefficient calculations. A moderation analysis was performed using PROCESS (Hayes, 2018). A power analysis using G*Power 3.1 (Faul et al., 2009) was conducted based on multiple regressions in Pagnini et al. (2015). A sample size of 37 participants was recommended based on R2 = 0.15, power = 0.80, α = 0.05, Cohen’s f = 0.176, and six predictors.
When examining understanding and acceptance of interventions the main focus was on two factors, PEG and NIV, rather than on individual items. This was consistent with the structure of the hypothesis. However, correlations of individual items from the PEG and NIV factors and other key variables are reported in Supplementary Material (i.e., Tables S1 and S2).Results Descriptive statistics and correlations
To address the possibility of lurking variables, correlations for age, time since first symptoms, and time since diagnosis were run against all variables. Participant age was not significantly correlated with any variables measured. However, psychological flexibility (action) was associated with time since diagnosis (r = 0.45, p < 0.01, two-tailed) and time since first symptoms (r = 0.36, p < 0.05, two-tailed). That is, as time passes, patients are better able to take action toward goals that are in accord with their chosen values. Descriptive statistics and correlations for all predictor and criterion variables are shown in Table 1.Table 1:
Matrix of intercorrelations, means, standard deviations and ranges for psychological flexibility, depression, anxiety, stress, quality of life, and understanding and acceptance of interventions (percutaneous endoscopic gastrostomy and non-invasive ventilation.Variable 1 2 3 4 5 6 7 8 1. Willingness – 0.17 −0.27 −0.16 −0.05 0.05 0.10 0.20 2. Action – −0.49** −0.45** −0.54** 0.40* 0.59** 0.21 3. Depression – 0.44** 0.45** −0.60** −0.32 −0.25 4. Anxiety – 0.38* −0.33 −0.32 0.19 5. Stress – −0.69** −0.45** −0.16 6. Quality of life – 0.54** 0.27 7. UAI (PEG) – 0.63** 8. UAI (NIV) – M 4.05 4.75 1.90 1.73 2.01 5.99 3.58 4.21 SD 0.82 0.79 0.52 0.46 0.49 1.68 0.82 0.87 Range possible 1–7 1–7 1–4 1–4 1–4 0–10 1–5 1–5 Range actual 2.43–5.86 3.56–5.86 1.00–3.14 1.00–2.86 1.14–3.14 1.17–9.02 1.89–5.00 1.00–5.00
The results partly supported Hypothesis 1. As expected, results showed a strong positive correlation between psychological flexibility (action) and understanding and acceptance of interventions (PEG). However, no significant relationship between psychological flexibility (action) and understanding and acceptance of interventions (NIV) was found. Similarly, there were no significant relationships between psychological flexibility (willingness) and any other variable.
It was also expected that psychological flexibility would be negatively correlated with depression, anxiety and stress, and positively correlated with quality of life. This hypothesis was supported for action, but not for willingness. Thus, these findings suggest that high psychological flexibility, specifically action, is associated with low depression, low anxiety and low stress, and high quality of life.Multiple regression
To test the second hypothesis, a multiple regression analysis was conducted to examine the extent to which psychological flexibility and psychological well-being predicted the understanding and acceptance of interventions in people with ALS, see Table 2. The model overall was a good fit with approximately 38% of the variance in understanding and acceptance of a PEG being explained by the predictors. Table 2 shows that people with ALS who scored highly on action and quality of life, were expected to have a better understanding and be more accepting of a PEG as an intervention.Table 2:
Predicting understanding and acceptance of intervention (for percutaneous endoscopic gastrostomy) from psychological flexibility and psychological well-being.Predictor b CI95% for b β r sr2 Lower Upper Psychological flexibility Willingness 0.04 −0.25 0.33 0.04 0.10 0.00 Action 0.54 0.17 0.91 0.52 0.59 0.16 Depression 0.35 −0.26 0.97 0.23 −0.32 0.03 Anxiety −0.08 −0.65 0.50 −0.04 −0.32 0.00 Stress 0.16 −0.55 0.86 0.10 −0.45 0.00 Quality of life 0.25 0.04 0.46 0.51 0.54 0.11
The second hypothesis suggested that psychological flexibility (willingness and action), depression, anxiety, stress, and quality of life would predict understanding and acceptance of NIV. The fit for the overall model was not significant. Table 3 shows that the relevant regression model was of a moderate strength, with 12% of the variance in the criterion being explained by the predictors suggesting that participants who were high in anxiety had higher understanding and acceptance of NIV.Table 3:
Predicting understanding and acceptance of intervention (for non-invasive ventilation)—raw data version from psychological flexibility and psychological well-being.Predictor b CI95% for b β r sr2 Lower Upper Psychological flexibility Willingness 0.19 −0.18 0.56 0.18 0.20 0.03 Action 0.27 −0.20 0.74 0.25 0.22 0.04 Depression −0.26 −1.04 0.52 −0.16 −0.25 0.01 Anxiety 0.86 0.14 1.59 0.36 0.19 0.15 Stress 0.11 −0.79 1.00 0.06 −0.16 0.00 Quality of life 0.14 −0.13 0.40 0.26 0.27 0.03 Moderation analysis
A moderation analysis was conducted to test the third hypothesis, that psychological well-being (moderator variable) would moderate the relationship between psychological flexibility (independent variable), and understanding and acceptance of interventions (dependent variable). We therefore expected the interaction effect between the psychological flexibility and the psychological well-being to be significant upon the understanding and acceptance of interventions.
Using the consolidated data representing the three variables, the analysis was conducted using Model 1 in PROCESS, using 5,000 bootstrapped samples (Hayes, 2018). The fit for the model overall was acceptable, R2 = 0.26, F(3, 31) = 5.06, p < 0.01. However, the interaction effect between psychological flexibility and psychological well-being on understanding and acceptance of interventions was non-significant, b = −0.01 [95% CI −0.60–0.57]. Thus, the results did not support the hypothesis.Discussion
The findings from the current study may offer some support for the position that an RFT account of behavior is tenable when evaluating the attitudes toward a PEG tube in people with ALS. Results supported the hypothesis that psychological flexibility is a significant predictor of understanding and acceptance of a PEG as an intervention for people with ALS. More specifically, the ability for an individual to take action in line with chosen goals and values appears most significant, more so than an individual’s willingness to accept unwanted thoughts or feelings. This could be helpful from a clinical perspective with results implying that applied RFT may be helpful for clients with ALS. While building acceptance and lowering experiential avoidance are generally of prime importance in applied RFT, the current study suggests that the clinician should also be cognizant of developing the client’s action skills, enabling the client to make better decisions throughout the course of their illness.
The data also suggested that a patient’s ability to take action in line with chosen goals is positively related to the time they have had ALS. This relationship may be somewhat intuitive. As time passes, patients may develop a better understanding of the nature of their disease as well as the options available to them to support their goals. Consequently, they may become better equipped to evaluate options and make decisions as time progresses. While not included in the scope of this study, the type of ALS (e.g., bulbar-onset, limb-onset) may impact the rate of symptom progression, thereby potentially exerting an influence on the point raised, and, as such, should be taken into consideration by the reader.
The results of the current research also offer some weight to the argument that the conclusions drawn in Pagnini et al. (2015)— that mindfulness predicts ALS symptoms through a mind-body interaction—may be compromised. Instead, these results offer support for the idea that mindfulness, in this case psychological flexibility, may predict a patient’s attitudes toward evidence-based treatments that prolong life. Thus, suggesting that the patient’s selection of interventions is an extraneous variable in the Pagnini (2013) research.
In line with Hayes et al. (2006), the current study found that high psychological flexibility was shown to be related to lower levels of depression, anxiety, and stress as well as higher levels of quality of life. No previous study had examined the possibility that psychological well-being moderated the relationship between psychological flexibility and understanding and acceptance of intervention options. This proposed interaction effect was shown to be non-significant and therefore offers little support for the proposed relationship. While psychological well-being did not significantly moderate this relationship, it should be noted that quality of life was a significant predictor of understanding and acceptance of a PEG in people with ALS. This relationship should be of interest to clinicians responsible for the delivery of treatment to people with ALS who may be considering intervention options.
Our parallel analysis of understanding and acceptance of NIV was less conclusive. Anxiety was the sole significant predictor, however, the direction of the relationship suggests somewhat of a paradox from an RFT perspective, with results showing a higher propensity for a participant to be more accepting of NIV when anxiety levels were high. One possible explanation for this relationship may be that the function of NIV (i.e., additional air being supplied to the patient) may be attractive to an anxious patient experiencing shortness-of-breath, hence anxiety may play a causal role. Alternatively, perhaps anxious patients are more likely to readily accept interventions that do not induce further anxiety.
Further to the analysis of understanding and acceptance of NIV, if the results observed are a true representation of this population, this would suggest that the nature of NIV decision-making may just different from PEG decision-making. Implementing NIV is: (a) far less invasive than a PEG, (b) easier to administer to the patient than a PEG, (c) a faster process and can be opted for if and when it is needed (unlike a PEG), and (d) easily reversed (unlike a PEG), should the patient wish to opt-out. On the other hand, if the results observed are not a true representation of this population, then factors including measurement error and an insufficient number of participants may also explain the phenomenon observed.Limitations
The criterion measure developed for this study had not been piloted or validated outside of the current study. Consequently, the implications that can be drawn from this research may be somewhat limited. Further to this point, readers should be aware that the generalizations made in the current study were based on the patient’s attitudes toward interventions, and in doing so, implying that this would be strongly correlated with the individual’s actual behavior to adopt an intervention. The validity of this assumption should be taken into consideration as a limitation.
The predicted effect size of the NIV-based criterion may have been over-estimated, and, as such, this segment of the current study had insufficient power. The reason for this smaller effect size may be down to the nature of NIV, as described previously. It should also be noted that the current study fell short of typical recommendations for the minimum number of participants, given six predictor variables, and therefore may have contributed to the study being under-powered.
The internal reliability of the measure of psychological flexibility (willingness) was relatively low in the current study. The relative associations may therefore have been underestimated. The literature also refers to similar shortcomings with the AAQ, and cites issues with the complexity of questions and the subtle nature of concepts addressed as potential sources of issue (Bond et al., 2011). Both of these aspects could have contributed to the internal reliability problem in the current study.
The current study recruited participants from a number of different countries. Given variation in medical practices (e.g., propensity to perform gastrostomies) and differences in patient access to resources (e.g., access to BiPAP machines though the public health system) between countries, there may be some sources of variation not accounted for in the current study design. Furthermore, the current study did not allow for any possibility that there might be some cross-cultural influence in the take-up of PEG or NIV in ALS patients. While this is an under-researched area, there is some evidence to suggest that this might be a factor (Andersen et al., 2018).
Verification of diagnosis was not sought in the current study, nor did it seek verification for type of ALS. This could potentially impact the data collected (e.g., type of ALS will be coupled with a symptom progression pattern which may, in turn, affect the patient’s decisions regarding interventions).
The scope of the current study did not include fronto temporal dementia, affecting the executive function, language and personality in 20–50% of ALS patients (Kiernan et al., 2011). Such deficits could have the potential to influence the patient’s understanding and acceptance of interventions and possibly the patient’s ability to accurately complete the questionnaire items. Finally, the cross-sectional design of this study does not allow us to make causal inferences with regard to our findings.Future Research
There are several directions that future research could take that are specific to this research question. The possible causal nature of the relationship between psychological flexibility and understanding and acceptance of interventions should be sought through a longitudinal research design. Alternatively, another possibility would be to investigate the role of psychological flexibility as a mediator of the relationship between education on PEGs and the understanding and acceptance of PEGs in people with ALS (Hayes, 2018; Muller, Judd & Yzerbyt, 2005). Finally, research to improve the validity of the criterion would be useful.
In a broader sense, further research into applied RFT in people with ALS is much needed. The COMMEND Project run by University College London in the UK is currently addressing this challenge in their two-phase study, customizing an RFT-based therapy for people with ALS and then assessing the treatment’s effectiveness within this group.Conclusion
The present study offers some support for an RFT account of behavior in explaining understanding and acceptance of intervention options in people with ALS. This research offers a first step toward developing an empirical base for applied RFT to be used with ALS patients, as it is with other chronic and terminally ill populations (Graham et al., 2016). Furthermore, the action factor of psychological flexibility has been highlighted to be of some importance, especially in relation to the decision to opt for a PEG. This study should serve as grounds for further research to elucidate the mechanisms involved, and to remind therapists who choose to use an applied RFT approach, of the importance of action skills as they formulate a strategy to improve psychological well-being and quality of life in people with ALS.Supplemental Information Matrix of Intercorrelations, Means, Standard Deviations and Ranges for Psychological Flexibility, Depression, Anxiety, Stress, Quality of Life, and Items from Understanding and Acceptance of Interventions Questionnaire (Percutaneous Endoscopic Gastrostomy. Matrix of Intercorrelations, Means, Standard Deviations and Ranges for Psychological Flexibility, Depression, Anxiety, Stress, Quality of Life, and Items from Understanding and Acceptance of Interventions Questionnaire (Non Invasive Ventilation). Intervention Understanding and Acceptance Questionnaire (NIV). Intervention Understanding and Acceptance Questionnaire (PEG).
Digital Archives | FeatureA Collaboratory for Classics
Take one part crowdsourcing and one part techno-mastery, mix in classical studies and a world-class research library, and you'll come close to understanding the ingredients that make up the Duke Collaboratory for Classics Computing or DC3, an initiative recently begun at Duke University. The DC3 is a digital classics R&D group with a mission to create new standards, services, and technology for managing and sharing scholarly information and ancient texts, starting with those written on papyrus, "antiquity's paper," and inscribed on stone.
On a grander scale, the initiative will foster global collaboration among scholars, for certain, but also ordinary folks around the world who have an interest in the ancient objects contained in their local neighborhoods, museums, and schools.
As Director Joshua Sosin explains, people from all over the world visit archaeological sites and museums taking high-quality photographs of Greek and Latin inscriptions that "get pushed to Flickr or other sites. And while they may feed the fond memories of a vacation or semester abroad, the contents can easily become lost to scholarly use." DC3 hopes to create, among other things, resources to help capture, process, and archive that material and make it available for study.
"It's not about getting ordinary people to do scholars' work. Rather, we want scholars to be able to harness this incredible stream of information and the people who are gathering it to get the chance not just to enjoy it, but also to contribute in a productive way to the progress of knowledge."
The DC3 is an initiative of Duke University Libraries funded jointly by the Andrew W. Mellon Foundation and Duke University. What's also unique is that Sosin and his small team have been "embedded" into the Duke Libraries. That's a first at the university, says Vice Provost for Library Affairs Deborah Jakubs. Typically, the embedding works the other way around -- librarians spend time within academic departments. In this case Sosin, a tenured faculty member in Classical Studies, has also been appointed to the Libraries.
It's in the Libraries where the digitizing of classical material has been going on for decades. In 1982, the Department of Classical Studies and the Duke University Libraries launched the "Duke Databank of Documentary Papyri," which now offers digital transcriptions of some 60,000 Greek and Latin texts written on wood tablets, papyrus, and pottery shards, most discovered in Egypt. Some of those came from Duke's own collection, which consists of 1,500 ancient papyri, but the bulk of these documents, dated mainly from the 3rd century before Christ to the 8th century after, come from many collections around the world. Duke's papyri are housed in the David M. Rubenstein Rare Book & Manuscript Library. Other North American collections -- such as those at the University of Michigan and the University of California Berkeley -- are larger; but Duke was the first institution to publish its entire collection online for anyone to view without restrictions.
In 1996 Duke was among the founding partners in an initiative that brought together several North American universities interested in combining their digital collections virtually under one site. The Advanced Papyrological Information System now contains nearly 35,000 records and some 20,000 images. It didn't stop there. APIS, as it's known, has now been incorporated into an international virtual collection, papyri.info, which collaborates with partners from around the world.
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Business-Objects [11 Certification Exam(s) ]
Business-Tests [4 Certification Exam(s) ]
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CPP-Institute [4 Certification Exam(s) ]
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Filemaker [9 Certification Exam(s) ]
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Food [4 Certification Exam(s) ]
Fortinet [14 Certification Exam(s) ]
Foundry [6 Certification Exam(s) ]
FSMTB [1 Certification Exam(s) ]
Fujitsu [2 Certification Exam(s) ]
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Google [4 Certification Exam(s) ]
GuidanceSoftware [2 Certification Exam(s) ]
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Hospitality [2 Certification Exam(s) ]
HP [752 Certification Exam(s) ]
HR [4 Certification Exam(s) ]
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Huawei [21 Certification Exam(s) ]
Hyperion [10 Certification Exam(s) ]
IAAP [1 Certification Exam(s) ]
IAHCSMM [1 Certification Exam(s) ]
IBM [1533 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) ]
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Intel [2 Certification Exam(s) ]
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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 [8 Certification Exam(s) ]
McData [3 Certification Exam(s) ]
Medical [68 Certification Exam(s) ]
Microsoft [375 Certification Exam(s) ]
Mile2 [3 Certification Exam(s) ]
Military [1 Certification Exam(s) ]
Misc [1 Certification Exam(s) ]
Motorola [7 Certification Exam(s) ]
mySQL [4 Certification Exam(s) ]
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NCEES [2 Certification Exam(s) ]
NCIDQ [1 Certification Exam(s) ]
NCLEX [3 Certification Exam(s) ]
Network-General [12 Certification Exam(s) ]
NetworkAppliance [39 Certification Exam(s) ]
NI [1 Certification Exam(s) ]
NIELIT [1 Certification Exam(s) ]
Nokia [6 Certification Exam(s) ]
Nortel [130 Certification Exam(s) ]
Novell [37 Certification Exam(s) ]
OMG [10 Certification Exam(s) ]
Oracle [282 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 [12 Certification Exam(s) ]
PEOPLECERT [4 Certification Exam(s) ]
PMI [15 Certification Exam(s) ]
Polycom [2 Certification Exam(s) ]
PostgreSQL-CE [1 Certification Exam(s) ]
Prince2 [6 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 [8 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 [135 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 [6 Certification Exam(s) ]
Veeam [2 Certification Exam(s) ]
Veritas [33 Certification Exam(s) ]
Vmware [58 Certification Exam(s) ]
Wonderlic [2 Certification Exam(s) ]
Worldatwork [2 Certification Exam(s) ]
XML-Master [3 Certification Exam(s) ]
Zend [6 Certification Exam(s) ]
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