Download Pass4sure 250-510 genuine questions VCE | braindumps | ROMULUS

Get our Pass4sure 250-510 study tools and boot camp with practice questions - VCE and examcollection and get ultimate success in the exam - braindumps - ROMULUS

Pass4sure 250-510 dumps | Killexams.com 250-510 true questions | http://tractaricurteadearges.ro/

250-510 Administration of SymantecTM Data Loss(R) Prevention 10.5 - BETA

Study sheperd Prepared by Killexams.com Symantec Dumps Experts

Exam Questions Updated On :



Killexams.com 250-510 Dumps and true Questions

100% true Questions - Exam Pass Guarantee with high Marks - Just Memorize the Answers



250-510 exam Dumps Source : Administration of SymantecTM Data Loss(R) Prevention 10.5 - BETA

Test Code : 250-510
Test title : Administration of SymantecTM Data Loss(R) Prevention 10.5 - BETA
Vendor title : Symantec
: 196 true Questions

in which am i able to find 250-510 dumps questions?
If you want prerogative 250-510 education on how it works and what are the tests and entire then dont squander it gradual and select killexams.com as its miles an final source of assist. I additionally desired 250-510 education and I even opted for this remarkable exam simulator and were given myself the satisfactory education ever. It guided me with each component of 250-510 exam and provided the top class questions and solutions I occupy ever seen. The study publications additionally occupy been of very much assist.


i'm very providential with 250-510 commemorate guide.
I acquire the edge of the Dumps supplied via using the killexams.com and the questions and answers wealthy with information and offers the effectual matters, which I searched exactly for my education. It boosted my spirit and provides wanted self notion to acquire my 250-510 exam. The material you supplied is so near the actual exam questions. As a non local English speaker I occupy been given a hundred and twenty minutes to complete the exam, however I genuinely took 90 5 minutes. Splendid dump. Thank you.


Where should I search to fetch 250-510 actual test questions?
To ensure the achievement in the 250-510 exam, I sought assistance from the killexams.com. I selected it for numerous motives: their evaluation on the 250-510 exam concepts and regulations turned into excellent, the material is truely consumer pleasant, first rate top class and very resourceful. most importantly, Dumps removed entire the problems on the associated topics. Your material provided generous contribution to my education and enabled me to be successful. i can firmly country that it helped me obtain my success.


actual acquire a observe at questions trendy 250-510 examination are available now.
I acquire the edge of the Dumps provided by the killexams.com and the content flush with information and offers the effectual things, which I searched exactly for my preparation. It boosted my spirit and provides needed confidence to acquire my 250-510 exam. The material you provided is so proximate to the true exam questions. As a non native English speaker I got 120 minutes to finish the exam, but I just took 95 minutes. remarkable material. Thank you.


Try out these true 250-510 Latest dumps.
Extremely helpful. It helped me pass 250-510 , especially the exam simulator. I am providential I was prepared for these tricks. Thanks killexams.com.


those 250-510 present day dumps works within the true check.
Just cleared 250-510 exam with pinnacle marks and should thank killexams.com for making it viable. I used 250-510 exam simulator as my number one statistics supply and got a tenacious passing marks on the 250-510 exam. Very dependable, Im satisfied I took a jump of religion shopping this and trusted killexams. Everything could be very professional and reliable. Two thumbs up from me.


I were given remarkable Questions pecuniary institution for my 250-510 exam.
Before I stroll to the sorting out center, i was so assured approximately my education for the 250-510 exam because of the veracity I knew i used to be going to ace it and this confidence came to me after the employ of this killexams.com for my assistance. It is brilliant at supporting college students much fancy it assisted me and i was capable of fetch desirable markss in my 250-510 test.


were given no trouble! 3 days instruction of 250-510 dumps is needed.
passed the 250-510 exam the contrary day. i might occupy by no means completed it with out your exam prep materials. some months in the past I failed that exam the first time I took it. your questions are very just fancy realone. I passed the exam very without problems this time. thank you very plenty on your assist.


determined an accurate supply for true 250-510 Questions.
Im so providential I purchased 250-510 exam prep. The 250-510 exam is tough since its very broad, and the questions cover everything you observe in the blueprint. killexams.com was my main preparation source, and they cover everything perfectly, and there occupy been tons of related questions on the exam.


tremendous source of notable actual test questions, accurate answers.
if you want to trade your future and execute inevitable that happiness is your destiny, you want to labor difficult. working hard lonesome isnt always enough to fetch to destiny, you want a few path with a purpose to lead you closer to the course. It became destiny that i institute this killexams.com in the course of my test as it lead me towards my fate. My destiny turned into getting prerogative grades and this killexams.com and its instructors made it feasible my teaching they so rightly that I couldnt in entire likelihood fail by giving me the material for my 250-510 exam.


Symantec Administration of SymantecTM Data

BT and Symantec to multiply coverage of network site visitors and Simplify security management | killexams.com true Questions and Pass4sure dumps

SAN FRANCISCO--(enterprise WIRE)--RSA conference – BT, probably the most world’s leading suppliers of communications capabilities and options, and Symantec, the realm’s leading cyber safety enterprise, today introduced the mixing of Symantec’s latest expertise into BT’s portfolio of managed security functions.

With this new contract, BT consumers will profit from enhanced visibility of incoming cyber web traffic and from simplified administration of network security and hybrid cloud infrastructure.

Two new Symantec products will complement the latest Symantec Blue Coat ProxySG carrier to bolster BT’s Managed internet protection portfolio: Symantec SSL Visibility apparatus and Symantec Cloud service.

Symantec SSL Visibility apparatus permits businesses to cost-simply dispose of blind spots that embrace the inability of perception into encrypted facts traffic on networks. on account that about half of entire web site visitors nowadays is encrypted, this can create a remarkable gap in an service provider’s safety posture. With SSL Visibility equipment, customers profit the visibility and manage they want over encrypted site visitors to aid execute inevitable compliance with their privacy, regulatory and suitable employ guidelines.

Symantec Cloud carrier offers international insurance and helps execute inevitable always-on security for consumer contraptions towards malware, viruses and advanced threats. It leverages true-time intelligence from Symantec’s global Intelligence network, the area’s largest civilian danger intelligence network, which harnesses facts from greater than 1 billion net requests, 2 billion emails, and a hundred seventy five million endpoints to update safety controls with complete probability telemetry in precise-time.

The settlement introduced nowadays besides allows entry to the Symantec management Centre platform required for the brand new Symantec SSL Visibility apparatus and Symantec Cloud service. This replaces the latest Blue Coat Director capability, to be able to continue to be supported until at the least 2020 for latest consumers.

Mike Fey, president and Chief working Officer, Symantec, noted: “increasing Symantec’s capabilities within BT’s portfolio will deliver BT consumers a finished carrier that is needed in nowadays’s cyber safety atmosphere. through offering committed SSL visibility we can fight safety threats hidden in encrypted traffic so that shoppers can heart of attention on essential commerce priorities. And the Symantec Cloud provider allows clients to lengthen their powerful Blue Coat internet security capabilities to their cell team of workers, assisting to protect users and recommendation on any apparatus and from any vicinity.”

Mark Hughes, CEO, BT protection, noted: “Monitoring community environments has become increasingly advanced over the final few years, and improving visibility of encrypted site visitors undertaking and choosing blind spots is vital for a secure and comfy business. Their contract with Symantec helps address this rigor and is a brand new step in proposing a full, complete apparatus that equips Chief counsel safety Officers with the executive tools vital to video panoply their networks.”

About Symantec

Symantec agency (NASDAQ: SYMC), the area’s leading cyber security company, helps agencies, governments and americans at ease their most essential statistics anywhere it lives. organizations across the world seem to Symantec for strategic, integrated options to guard against subtle assaults across endpoints, cloud and infrastructure. Likewise, a world community of more than 50 million individuals and families signify on Symantec’s Norton suite of products for protection at domestic and across entire of their devices. Symantec operates probably the most world’s largest civilian cyber intelligence networks, permitting it to observe and offer protection to towards the most advanced threats. For more information, delight talk over with www.symantec.com or connect with us on fb

About BT

BT’s goal is to execute employ of the vigour of communications to execute an improved world. It is one of the world’s main suppliers of communications services and solutions, serving valued clientele in a hundred and eighty nations. Its major activities embrace the availability of networked IT functions globally; local, national and international telecommunications functions to its consumers to be used at home, at labor and on the circulation; broadband, tv and web items and features; and converged fixed-mobile products and features. BT includes six consumer-dealing with lines of company: purchaser, EE, company and Public Sector, international capabilities, Wholesale and Ventures, and Openreach.

For the 12 months ended 31 March 2016, BT neighborhood’s suggested earnings become £19,042m with reported income before taxation of £3,029m.

British Telecommunications plc (BT) is a totally-owned subsidiary of BT community plc and encompasses virtually entire organizations and belongings of the BT group. BT community plc is listed on stock exchanges in London and long island.

For extra information, talk over with www.btplc.com.


Symantec: 2 Out of 3 lodges Leak Your personal particulars | killexams.com true Questions and Pass4sure dumps

are looking to location your very own records in hazard of being compromised? without rigor ebook a inn elbowroom online and await the email affirmation.

Generic Hotel Hallway

It turns out one of the crucial riskiest issues you could consequence to your personal records is engage a inn room. this is the conclusion of Symantec after reviewing more than 1,500 lodge websites spread across 54 discrete international locations.

As Reuters stories, the overview conducted by route of Symantec discovered that two out of every three motels will leak the booking particulars of guests. those details encompass complete names, e mail tackle, postal handle, cellular number, credit card particulars (ultimate four digits, card category, expiration), and passport numbers. The assistance is accessible to 3rd-party web sites, advertisers, and analytics businesses.

The obvious questions are how? and why? The own facts being leaked stems specially from the style by which resorts ship affirmation emails. They typically embrace a reference code, which links to entire of the reserving guidance and does not require a login to access. 1 / 4 of the hotel websites besides don't seem to be encrypting the hyperlink, making it a remarkable deal more convenient to intercept and entry the guidance.

in accordance with Symantec, that reference can be shared with over 30 different service providers, "together with social networks, search engines fancy google and yahoo and promoting and analytics services." From the resort's factor of view, sharing the suggestions with the client in this route is simple and light to do, however it naturally overlooks the security danger being posed.

Candid Wueest, essential danger researcher at Symantec, defined, "whereas it's no secret that advertisers are tracking clients' shopping habits, during this case, the suggestions shared may enable these third-birthday celebration functions to log into a reservation, view very own particulars and even cancel the booking altogether."

If the ease with which personal tips is being shared is never caring satisfactory, the go responses to this overview may silent set alarm bells ringing. Symantec contacted entire of them, with the regular response time with the aid of a lodge information privacy officer taking 10 days. although, 25 % did not reply within six weeks of contact. One regular response looks to be they're, "nevertheless updating their programs to be wholly GDPR-compliant."

again in November, it was institute that the personal particulars of 500 million visitors at Marriott exotic resorts had been uncovered in a database hack. Symantec did not consist of Marriott motels in the evaluation, reinforcing the reality this looks to be an industry-broad difficulty.


Two out of three hotels accidentally leak guests' very own data: Symantec | killexams.com true Questions and Pass4sure dumps

(Reuters) - Two out of three go websites inadvertently leak guests’ reserving particulars and personal information to third-birthday party websites, including advertisers and analytics businesses, in accordance with analysis released with the aid of Symantec Corp on Wednesday.

The examine, which looked at greater than 1,500 inn web sites in 54 international locations that ranged from two-celebrity to 5-big title homes, comes a few months after Marriott exotic disclosed probably the most worst records breaches in historical past.

Symantec spoke of Marriott become no longer protected within the observe at.

Compromised personal assistance comprises complete names, e mail addresses, credit card details and passport numbers of visitors that can be used through cybercriminals who're increasingly interested in the movements of influential company experts and government employees, Symantec pointed out.

“whereas it’s no secret that advertisers are tracking users’ searching habits, in this case, the tips shared could enable these third-birthday celebration functions to log prerogative into a reservation, view own details and even cancel the reserving altogether,” mentioned Candid Wueest, the primary researcher on the observe at.

The analysis confirmed compromises always happen when a hotel web page sends confirmation emails with a hyperlink that has direct booking counsel. The reference code attached to the link may well be shared with more than 30 distinctive carrier suppliers, together with social networks, serps and promoting and analytics features.  

Wueest mentioned 25 p.c of records privacy officers on the affected hotel sites did not reply to Symantec inside six weeks when notified of the problem, and those who did took a natural of 10 days to respond.

“Some admitted that they are nevertheless updating their systems to be fully GDPR-compliant,” Wueest referred to, relating to Europe’s new privacy legislations, or the ordinary information insurance policy legislation, which took repercussion a few 12 months ago and has strict instructions on how companies may silent acquire supervision of data leakage.

Reporting through Angela Moon; enhancing by means of Dan Grebler


Whilst it is very hard chore to select dependable exam questions / answers resources regarding review, reputation and validity because people fetch ripoff due to choosing incorrect service. Killexams. com execute it inevitable to provide its clients far better to their resources with respect to exam dumps update and validity. Most of other peoples ripoff report complaint clients further to us for the brain dumps and pass their exams enjoyably and easily. They never compromise on their review, reputation and character because killexams review, killexams reputation and killexams client self confidence is necessary to entire of us. Specially they manage killexams.com review, killexams.com reputation, killexams.com ripoff report complaint, killexams.com trust, killexams.com validity, killexams.com report and killexams.com scam. If perhaps you observe any bogus report posted by their competitor with the title killexams ripoff report complaint internet, killexams.com ripoff report, killexams.com scam, killexams.com complaint or something fancy this, just hold in intellect that there are always contemptible people damaging reputation of fine services due to their benefits. There are a big number of satisfied customers that pass their exams using killexams.com brain dumps, killexams PDF questions, killexams rehearse questions, killexams exam simulator. Visit Killexams.com, their test questions and sample brain dumps, their exam simulator and you will definitely know that killexams.com is the best brain dumps site.

Back to Braindumps Menu


LOT-989 questions answers | C9010-022 true questions | HP0-E01 study guide | CSM-001 rehearse test | 000-745 rehearse exam | A2010-657 brain dumps | 090-600 free pdf | HP0-512 brain dumps | 9L0-007 VCE | CAP questions and answers | 000-025 cheat sheets | HP2-K38 test prep | 000-608 rehearse questions | Rh202 mock exam | M2180-747 exam questions | 190-800 true questions | C4060-156 braindumps | 3313 free pdf | ST0-247 braindumps | EX0-007 dumps questions |


Real 250-510 questions that showed up in test today
killexams.com Symantec Certification examine guides are setup by IT specialists. Groups of understudies occupy been crying that there are an exorbitant number of questions in such a faultfinding number of preparing exams and study help, and they are as of late can not stand to deal with the expense of any more. Seeing killexams.com pros labor out this extensive interpretation while silent affirmation that entire the learning is anchored after significant research and exam.

Are you looking for Pass4sure Symantec 250-510 Dumps containing true exams questions and answers for the Administration of SymantecTM Data Loss(R) Prevention 10.5 - BETA Exam prep? They provide most updated and character source of 250-510 Dumps that is http://killexams.com/pass4sure/exam-detail/250-510. They occupy compiled a database of 250-510 Dumps questions from actual exams in order to let you prepare and pass 250-510 exam on the first attempt. killexams.com Huge Discount Coupons and Promo Codes are as under;
WC2017 : 60% Discount Coupon for entire exams on website
PROF17 : 10% Discount Coupon for Orders greater than $69
DEAL17 : 15% Discount Coupon for Orders greater than $99
DECSPECIAL : 10% Special Discount Coupon for entire Orders

Quality and Value for the 250-510 Exam: killexams.com rehearse Exams for Symantec 250-510 are composed to the most astounding benchmarks of specialized precision, utilizing just guaranteed topic specialists and distributed creators for improvement.

100% Guarantee to Pass Your 250-510 Exam: If you don't pass the Symantec 250-510 exam utilizing their killexams.com testing engine, they will give you a complete REFUND of your acquiring expense.

Downloadable, Interactive 250-510 Testing engines: Their Symantec 250-510 Preparation Material gives you entire that you should acquire Symantec 250-510 exam. Subtle elements are inquired about and created by Symantec Certification Experts continually utilizing industry tang to deliver actual, and intelligent.

- Comprehensive questions and answers about 250-510 exam - 250-510 exam questions joined by displays - Verified Answers by Experts and very nearly 100% right - 250-510 exam questions updated on general premise - 250-510 exam planning is in various determination questions (MCQs). - Tested by different circumstances previously distributing - Try free 250-510 exam demo before you select to fetch it in killexams.com

killexams.com Huge Discount Coupons and Promo Codes are as under;
WC2017: 60% Discount Coupon for entire exams on website
PROF17: 10% Discount Coupon for Orders greater than $69
DEAL17: 15% Discount Coupon for Orders greater than $99
DECSPECIAL: 10% Special Discount Coupon for entire Orders


Snap http://killexams.com/pass4sure/exam-detail/250-510

250-510 Practice Test | 250-510 examcollection | 250-510 VCE | 250-510 study guide | 250-510 practice exam | 250-510 cram


Killexams 000-588 free pdf | Killexams A6040-752 rehearse exam | Killexams 3X0-202 brain dumps | Killexams 000-M10 rehearse questions | Killexams 1Z0-061 test questions | Killexams MD0-251 test prep | Killexams 050-864 test prep | Killexams 000-283 dumps | Killexams 111-056 braindumps | Killexams RTRP bootcamp | Killexams HP3-023 brain dumps | Killexams HP2-E36 questions and answers | Killexams 7003-1 exam prep | Killexams 310-016 cram | Killexams LOT-803 rehearse test | Killexams 250-430 braindumps | Killexams 70-461 rehearse test | Killexams C2020-612 exam prep | Killexams E20-555 sample test | Killexams 3M0-331 dump |


killexams.com huge List of Exam Braindumps

View Complete list of Killexams.com Brain dumps


Killexams 3X0-203 true questions | Killexams 200-401 cheat sheets | Killexams 000-070 test questions | Killexams 000-123 braindumps | Killexams 1Z0-874 mock exam | Killexams 9L0-409 test prep | Killexams EE0-502 exam prep | Killexams COG-385 braindumps | Killexams 9A0-303 brain dumps | Killexams CAS-003 dumps questions | Killexams JN0-314 true questions | Killexams 000-854 rehearse exam | Killexams E20-598 sample test | Killexams TA12 study guide | Killexams HP3-C35 rehearse test | Killexams HP0-205 examcollection | Killexams 9L0-517 rehearse Test | Killexams 000-037 brain dumps | Killexams 922-111 dump | Killexams 1Y0-230 rehearse test |


Administration of SymantecTM Data Loss(R) Prevention 10.5 - BETA

Pass 4 confident 250-510 dumps | Killexams.com 250-510 true questions | http://tractaricurteadearges.ro/

Pathway to diabetes through attenuation of pancreatic beta cell glycosylation and glucose transport | killexams.com true questions and Pass4sure dumps

  • 1.

    Olefsky, J.M. & Courtney, C.H. ilk 2 diabetes mellitus: etiology, pathogenesis and natural history. in Endocrinology 5th edn (eds. DeGroot, L.J. et al.) 1093–1117 (W.B. Saunders, 2005).

  • 2.

    Weir, G.C. & Leahy, J.L. Pathogenesis of non-insulin dependent (type II) diabetes mellitus. in Joslin's Diabetes Mellitus (eds. Joslin, E.P., Kahn, C.R. & Weir, G.C.), Ch. 14, 240–264 (Lea and Febiger, 1994).

  • 3.

    Smyth, S. & Heron, A. Diabetes and obesity: the twin epidemics. Nat. Med. 12, 75–80 (2006).

  • 4.

    Korner, J., Woods, S.C. & Woodworth, K.A. Regulation of energy homeostasis and heath consequences in obesity. Am. J. Med. 122, S12–S18 (2009).

  • 5.

    Parillo, M. & Ricardi, G. Diet composition and the risk of ilk 2 diabetes: epidemiological and clinical evidence. Br. J. Nutr. 92, 7–19 (2004).

  • 6.

    Surwit, R.S., Kuhn, C.M., Cochrane, C., McCubbin, J.A. & Feinglos, M.N. Diet-induced ilk II diabetes in C57BL/6J mice. Diabetes 37, 1163–1167 (1988).

  • 7.

    Kahn, S.E. The relative contribution of insulin resistance and beta-cell dysfunction to the pathophysiology of ilk 2 diabetes. Diabetologia 46, 3–19 (2003).

  • 8.

    Winzell, M.S. & Ahren, B. The high-fat diet-fed mouse: a model for studying mechanisms and treatment of impaired glucose tolerance and ilk 2 diabetes. Diabetes 53 (suppl. 3) S215–S219 (2004).

  • 9.

    Leroith, D. & Accili, D. Mechanisms of disease: using genetically altered mice to study concepts of ilk 2 diabetes. Nat. Clin. Pract. Endocrinol. Metab. 4, 164–172 (2008).

  • 10.

    Saltiel, A.R. & Kahn, C.R. Insulin signaling and the regulation of glucose and lipid metabolism. Nature 414, 799–806 (2001).

  • 11.

    Schenk, S., Saberi, M. & Olefsky, J.M. Insulin sensitivity: modulation by nutrients and inflammation. J. Clin. Invest. 118, 2992–3002 (2008).

  • 12.

    Reaven, G.M. The insulin resistance syndrome: definition and dietary approaches to treatment. Annu. Rev. Nutr. 25, 391–406 (2005).

  • 13.

    Johnson, J.H. et al. Underexpression of beta cell high Km glucose transporters in noninsulin-dependent diabetes. Science 250, 546–549 (1990).

  • 14.

    Orci, L. et al. Evidence that down-regulation of β-cell glucose transporters in non-insulin-dependent diabetes may be the antecedent of diabetic hyperglycemia. Proc. Natl. Acad. Sci. USA 87, 9953–9957 (1990).

  • 15.

    Orci, L. et al. Reduced β-cell glucose transporter in new onset diabetic rats. J. Clin. Invest. 86, 1615–1622 (1990).

  • 16.

    Thorens, B., Weir, G., Leahy, J.L., Lodish, H.F. & Bonner-Weir, S. Reduced expression of the liver/beta-cell glucose transporter isoform in glucose-insensitive pancreatic beta cells of diabetic rats. Proc. Natl. Acad. Sci. USA 87, 6492–6496 (1990).

  • 17.

    Unger, R.H. Diabetic hyperglycemia: link to impaired glucose transport in pancreatic beta cells. Science 251, 1200–1205 (1991).

  • 18.

    Valera, A. et al. Expression of GLUT2 antisense RNA in β cells of transgenic mice leads to diabetes. J. Biol. Chem. 269, 28543–28546 (1994).

  • 19.

    Gremlich, S., Roduit, R. & Thorens, B. Dexamethasone induces posttranslational degradation of GLUT2 and inhibition of insulin secretion in isolated pancreatic β cells. J. Biol. Chem. 272, 3216–3222 (1997).

  • 20.

    Guillam, M.T. et al. Early diabetes and abnormal postnatal pancreatic islet evolution in mice lacking Glut-2. Nat. Genet. 17, 327–330 (1997).

  • 21.

    Guillam, M.-T., Dupraz, P. & Thorens, B. Glucose uptake, utilization, and signaling in GLUT2-null islets. Diabetes 49, 1485–1491 (2000).

  • 22.

    Reimer, M.K. & Ahrén, B. Altered β-cell distribution of pdx-1 and GLUT2 after a short-term challenge with a high-fat diet in C57BL/6J mice. Diabetes 51, S138–S143 (2002).

  • 23.

    Del Guerra, S. et al. Functional and molecular defects of pancreatic islets in human ilk 2 diabetes. Diabetes 54, 727–735 (2005).

  • 24.

    Kahn, S.E., Hull, R.L. & Utzschneider, K.M. Mechanisms linking obesity to insulin resistance and ilk 2 diabetes. Nature 444, 840–846 (2006).

  • 25.

    Ohtsubo, K. et al. Dietary and genetic control of glucose transporter 2 glycosylation promotes insulin secretion in suppressing diabetes. Cell 123, 1307–1321 (2005).

  • 26.

    Minowa, M.T. et al. cDNA cloning and expression of bovine UDP-N-acetylglucosamine:α1,3-D-mannoside β1,4-N-acetylglucosaminyltransferase IV. J. Biol. Chem. 273, 11556–11562 (1998).

  • 27.

    De Vos, A. et al. Human and rat beta cells disagree in glucose transporter but not glucokinase gene expression. J. Clin. Invest. 96, 2489–2495 (1995).

  • 28.

    Thorens, B., Guillam, M.T., Beermann, F., Burcelin, R. & Jaqueet, M. Transgenic overexpression of GLUT1 or GLUT2 in pancreatic beta cells rescues GLUT2-null mice from early death and restores natural glucose-stimulated insulin secretion. J. Biol. Chem. 275, 23751–23758 (2000).

  • 29.

    Alessi, D.R. & Cohen, P. Mechanism of activation and role of protein kinase B. Curr. Opin. Genet. Dev. 8, 55–62 (1998).

  • 30.

    White, M.F. IRS proteins and the common path to diabetes. Am. J. Physiol. Endocrinol. Metab. 283, E413–E422 (2002).

  • 31.

    Rossmeisl, M., Rim, J.S., Koza, R.A. & Kozak, L.P. Variation in ilk 2 diabetes-related traits in mouse strains susceptible to diet-induced obesity. Diabetes 52, 1958–1966 (2003).

  • 32.

    Poitout, V. & Robertson, R.P. Glucolipotoxicity: fuel excess and beta-cell dysfunction. Endocr. Rev. 29, 351–366 (2008).

  • 33.

    Kebede, M.A., Alquier, T., Latour, M.G. & Poitout, V. Lipid receptors and islet function: therapeutic implications? Diabetes Obes. Metab. 11 (suppl. 4) 10–20 (2009).

  • 34.

    Unger, R.H. Lipotoxicity in the pathogenesis of obesity-dependent NIDDM. Genetic and clinical implications. Diabetes 44, 863–870 (1995).

  • 35.

    Gremlich, S., Bonny, C., Waeber, G. & Thorens, B. Fatty acids decrease IDX-1 expression in rat pancreatic islets and reduce GLUT2, glucokinase, insulin, and somatostatin levels. J. Biol. Chem. 272, 30261–30269 (1997b).

  • 36.

    Wolfrum, C., Asilmaz, E., Luca, E., Friedman, J.M. & Stoffel, M. Foxa2 regulates lipid metabolism and ketogenesis in the liver during fasting and in diabetes. Nature 432, 1027–1032 (2004).

  • 37.

    Howell, J.J. & Stoffel, M. Nuclear export-independent inhibition of Foxa2 by insulin. J. Biol. Chem. 284, 24816–24824 (2009).

  • 38.

    Chen, Y.W. et al. The role of phosphoinositide 3-kinase/Akt signaling in low-dose mercury-induced mouse pancreatic beta-cell dysfunction in vitro and in vivo. Diabetes 55, 1614–1624 (2006).

  • 39.

    Lantz, K.A. et al. Foxa2 regulates multiple pathways of insulin secretion. J. Clin. Invest. 114, 512–520 (2004).

  • 40.

    Gao, N. et al. Foxa1 and Foxa2 maintain the metabolic and secretory features of the ripen beta-cell. Mol. Endocrinol. 24, 1594–1604 (2010).

  • 41.

    Mitchell, S.M. & Frayling, T.M. The role of transcription factors in maturity-onset diabetes of the young. Mol. Genet. Metab. 77, 35–43 (2002).

  • 42.

    Fukui, K. et al. The HNF-1 target collection controls insulin exocytosis by SNARE tangled formation. Cell Metab. 2, 373–384 (2005).

  • 43.

    Gunton, J.E. et al. Loss of ARNT/HIF1beta mediates altered gene expression and pancreatic-islet dysfunction in human ilk 2 diabetes. Cell 122, 337–349 (2005).

  • 44.

    Ohtsubo, K. & Marth, J.D. Glycosylation in cellular mechanisms of health and disease. Cell 126, 855–867 (2006).

  • 45.

    Rapoport, E.M., Kurmyshkina, O.V. & Bovin, N.V. Mammalian galectins: structure, carbohydrate specificity, and functions. Biochemistry (Mosc.) 73, 393–405 (2008).

  • 46.

    Rabinovich, G.A., Toscano, M.A., Jackson, S.S. & Vasta, G.R. Functions of cell surface galectin-glycoprotein lattices. Curr. Opin. Struct. Biol. 17, 513–520 (2007).

  • 47.

    Scarlett, J.A., Gray, R.S., Griffin, J., Olefsky, J.M. & Kolterman, O.G. Insulin treatment reverses the insulin resistance of ilk II diabetes mellitus. Diabetes supervision 5, 353–363 (1982).

  • 48.

    Revers, R.R., Kolterman, O.G., Scarlett, J.A., Gray, R.S. & Olefsky, J.M. lack of in vivo insulin resistance in controlled insulin-dependent, ilk I, diabetic patients. J. Clin. Endocrinol. Metab. 58, 353–358 (1984).

  • 49.

    Garvey, W.T., Olefsky, J.M., Griffin, J., Hamman, R.F. & Kolterman, O.G. The consequence of insulin treatment on insulin secretion and insulin action in ilk II diabetes mellitus. Diabetes 34, 222–234 (1985).

  • 50.

    Pillay, T.S., Xiao, S. & Olefsky, J.M. Glucose-induced phosphorylation of the insulin receptor. Functional effects and characterization of phosphorylation sites. J. Clin. Invest. 97, 613–620 (1996).

  • 51.

    Shafi, R. et al. The O-GlcNAc transferase gene resides on the X chromosome and is essential for embryonic arise cell viability and mouse ontogeny. Proc. Natl. Acad. Sci. USA 97, 5735–5739 (2000).

  • 52.

    Cousin, S.P. et al. Free fatty acid–induced inhibition of glucose and insulin-like growth factor I–induced deoxyribonucleic acid synthesis in the pancreatic β-cell line INS-1. Endocrinology 142, 229–240 (2001).


  • Rational employ of Opioids for Management of inveterate Nonterminal pang | killexams.com true questions and Pass4sure dumps

    Opioid prescribing for inveterate nonterminal pang has increased in recent years, although evidence for its long-term effectiveness is debilitated and its potential for harm is significant. Nonmedical employ of prescription opioids, diversion, and overdose deaths occupy besides increased sharply, sparking concern about the safety of these medications. Physicians considering initiation or continuation of opioid therapy for a patient with inveterate nonterminal pang should first employ a structured approach that includes a biopsychosocial evaluation and a treatment diagram that encourages patients to set and gain functional goals. There should be a comprehensive evaluation for the antecedent of pain, assessment for risk of opioid complications (including misuse and addiction), and a particular treatment history, including a review of medical records and data from the situation prescription monitoring program. Opioids should be prescribed on a trial basis, to be continued only if progress toward functional goals is demonstrated. Long-acting morphine is the preferred initial drug, although several alternatives are available. Ongoing monitoring for safety and effectiveness is essential, including regular review of functional progress or maintenance, urine drug testing, and surveillance of data from the situation prescription monitoring program. Ineffective, unsafe, or diverted opioid therapy should be promptly tapered or stopped.

    Chronic pang affects approximately one-third of U.S. adults, and 5 percent receive opioid treatment1; tenacious opioids are prescribed in up to 9 percent of entire office visits.2 Until the 1990s, physicians generally limited opioid treatment to patients with acute or cancer-related pain. However, studies showed that entire types of pang were undertreated; as a result, pang education, advocacy, and policy initiatives led to an multiply in opioid prescribing for patients with inveterate nonterminal pain.

    More expansive prescribing of opioids for inveterate nonterminal pang has been accompanied by increasing rates of high-dose, continuous therapy.3–6 Although some patients may profit from such treatment, others will occupy significant physiologic and functional compromise. Continuous opioid therapy for as itsy-bitsy as two weeks can bear drug tolerance in some patients. For other patients, dosages as low as 30 mg per day of morphine or its equivalent occupy been shown to lower pang thresholds and create opioid-induced hyperalgesia, in which pang paradoxically worsens as opioid doses are increased.7–9 Many patients tang nausea, vomiting, constipation, blue mood, and respiratory depression, and tolerance to these toxicities may develop slowly or not at all. A 10-year follow-up study showed that patients who acquire prescription opioids occupy a lower character of life and higher rates of depression and health supervision utilization.10

    Increased opioid prescribing has besides resulted in worrying trends of misuse, abuse, and diversion for sale. Between 1997 and 2006, sales of oxycodone (Roxicodone) increased nearly eightfold, and sales of methadone increased ninefold.11 Fifteen percent of 12th graders report that they occupy taken hydrocodone/acetaminophen (Vicodin) or oxycodone, usually obtained from family members or friends.11 From 2004 to 2008, visits to emergency departments for nonmedical employ of opioids tripled.12 The Centers for Disease Control and Prevention reported a nearly sevenfold multiply in methadone-related fatalities in 2009.12 Overall, the nonmedical employ of controlled prescription medication now exceeds illicit drug use. These statistics occupy raised sedate concerns among situation and federal law enforcement, regulatory, and legislative officials, and occupy sparked efforts to multiply prescription oversight.13,14

    In this environment, prescribers must ensure that opioid therapy is appropriate, safe, and effective. This review provides a framework for approaching opioid therapy for patients with inveterate nonterminal pain, including patient selection; structured trials of opioid therapy; monitoring; and tapering, when indicated. More details and rehearse tools are available online (http://guidelines.gov/content.aspx?id=25657&search=managing+chronic+pain).15

      Enlarge      Print

    SORT: KEY RECOMMENDATIONS FOR PRACTICE Clinical recommendation Evidence rating References

    Patients with inveterate nonterminal pang should receive a comprehensive evaluation, including assessment for potential opioid responsiveness and opioid risk.

    C

    4, 6, 18

    Chronic nonterminal pang requires treatment of physical and psychological modalities, prescription of nonopioid analgesics, treatment of comorbid mood disorders, and restoration of sleep.

    C

    18, 19

    Tricyclic antidepressants or selective serotonin-norepinephrine reuptake inhibitors should be included in patients with inveterate nonterminal pang with a neuropathic component.

    A

    13, 15, 20

    Opioid therapy should be avoided in patients with inveterate central or visceral pang syndromes such as fibromyalgia, headaches, or abdominal pain.

    C

    11, 17

    Opioids should be initiated as a trial, to be continued if progress is documented toward functional goals, and if there is no evidence of complications, including misuse or diversion.

    C

    6, 15, 18

    Opioid dosages exceeding 100 mg of morphine or its equivalent may multiply the risk of overdose, and should prompt consideration of tapering or referral to a pang subspecialist.

    C

    13, 27

    SORT: KEY RECOMMENDATIONS FOR PRACTICE Clinical recommendation Evidence rating References

    Patients with inveterate nonterminal pang should receive a comprehensive evaluation, including assessment for potential opioid responsiveness and opioid risk.

    C

    4, 6, 18

    Chronic nonterminal pang requires treatment of physical and psychological modalities, prescription of nonopioid analgesics, treatment of comorbid mood disorders, and restoration of sleep.

    C

    18, 19

    Tricyclic antidepressants or selective serotonin-norepinephrine reuptake inhibitors should be included in patients with inveterate nonterminal pang with a neuropathic component.

    A

    13, 15, 20

    Opioid therapy should be avoided in patients with inveterate central or visceral pang syndromes such as fibromyalgia, headaches, or abdominal pain.

    C

    11, 17

    Opioids should be initiated as a trial, to be continued if progress is documented toward functional goals, and if there is no evidence of complications, including misuse or diversion.

    C

    6, 15, 18

    Opioid dosages exceeding 100 mg of morphine or its equivalent may multiply the risk of overdose, and should prompt consideration of tapering or referral to a pang subspecialist.

    C

    13, 27

    Understanding inveterate Pain

    Chronic pang is different from acute pain, and must be approached differently. Acute pang is a symptom that plays a functional role in carcass defenses and resolves with tissue recovery. It is transmitted along intact neural pathways that are effectively modulated by opioids to decrease pang perception.

    In contrast, inveterate pang has no such functional role, does not resolve with tissue recovery, and can become a primary diagnosis. inveterate pang involves tangled central nervous system signaling that can be amplified by stressors such as relationship issues, pecuniary problems, or underlying psychiatric diagnoses. This can result in the perception of worse pain, and an increased likelihood of compromised social functioning.10,16,17 Thus, inveterate nonterminal pang is a biopsychosocial condition that requires a comprehensive, multidisciplinary approach to evaluation and management. Continuing typical treatments for acute pain—including opioid therapy—can be ineffective or unsafe in patients with inveterate pain.

    General Approach to the Patient with inveterate Nonterminal Pain

    Effective management of inveterate nonterminal pang requires more than prescribing medication.13,15,18 Any potential focal or treatable pang generators should be identified and treated first. Attention should then rotate to physical and psychological modalities, prescription of nonopioid and adjuvant analgesic medications, multimodal treatment of mood disorders, and restoration of sleep.18,19  Only after these measures are optimized should a trial of opioid therapy, or continuation of existing opioid therapy, be considered. A comprehensive approach is outlined in Table 1.13,15,18,20

      Enlarge      Print

    Table 1. Treatment of inveterate Pain

    Identify and handle specific local pang generators, if present

    Cutaneous stimulators (e.g., transcutaneous electrical nerve stimulation)

    Local treatment (e.g., physical therapy, manipulation, massage, heat)

    Minor interventions (e.g., anesthetic or steroid joint injection)

    Surgery

    Topical anesthetics (e.g., lidocaine ointment or patches)

    Promote vigorous behaviors

    Physical activity

    Weight control

    Restore sleep

    Depending on coexisting problems, useful agents may embrace trazodone, tricyclic antidepressants, gabapentin (Neurontin), pregabalin (Lyrica), mirtazapine (Remeron), melatonin, or quetiapine (Seroquel); employ of benzodiazepines or their analogs should be avoided because of tolerance and misuse potential

    Start adjuvant pang medications (listed in order of recommended treatments)

    Tricyclic antidepressants are indicated for neuropathic pain; nortriptyline (Pamelor), desipramine (Norpramin), amitriptyline, and doxepin are besides useful for localized or generalized pang with coexisting headache, depression, panic disorder, or tobacco addiction

    Serotonin-norepinephrine reuptake inhibitors are indicated for neuropathic pain; duloxetine (Cymbalta) and milnacipran (Savella) are most effectual for localized or generalized pang with depression or anxiety, venlafaxine (Effexor) less so; doses for treatment of pang minister to be higher than those for depression

    Pregabalin is approved by the U.S. Food and Drug Administration for neuropathic pang and fibromyalgia; gabapentin has similar effectiveness, is available generically, and is more widely used, but it is sedating, and dosing is complex; may be synergistic when combined with tricyclic antidepressants

    Anticonvulsants; carbamazepine (Tegretol) is a first-line agent for trigeminal neuralgia, but third-line (with oxcarbazepine [Trileptal] and lamotrigine [Lamictal]) for other neuropathic pain

    Migraine chemoprophylaxis (e.g., beta blockers, calcium channel blockers, tricyclic antidepressants, topiramate [Topamax])

    Treat comorbid psychiatric illness

    Use of pharmacologic and psychotherapeutic measures is essential for improvement of symptoms and function

    Commonly associated disorders embrace anxiety, depression, posttraumatic stress disorder in persons who occupy experienced physical, sexual, or emotional trauma; treatment should embrace psychotherapy, biofeedback, mindfulness training, posttraumatic stress disorder therapy, relationship counseling, social and pecuniary counseling, and gist misuse counseling

    Trial of opioid therapy (initiation or continuation)

    Patients should occupy no contraindications for opioid therapy

    Patients with diffuse, centralized pang or headache are less likely to profit from opioid therapy and may be harmed by opioid toxicities

    Select patients with specific somatic, peripheral, or neuropathic pang may profit from low-dose opioid therapy in combination with other treatments

    Treatment should bear demonstrable functional improvement, not merely a reduction in pang scores, or opioids should be tapered or discontinued

    Table 1. Treatment of inveterate Pain

    Identify and handle specific local pang generators, if present

    Cutaneous stimulators (e.g., transcutaneous electrical nerve stimulation)

    Local treatment (e.g., physical therapy, manipulation, massage, heat)

    Minor interventions (e.g., anesthetic or steroid joint injection)

    Surgery

    Topical anesthetics (e.g., lidocaine ointment or patches)

    Promote vigorous behaviors

    Physical activity

    Weight control

    Restore sleep

    Depending on coexisting problems, useful agents may embrace trazodone, tricyclic antidepressants, gabapentin (Neurontin), pregabalin (Lyrica), mirtazapine (Remeron), melatonin, or quetiapine (Seroquel); employ of benzodiazepines or their analogs should be avoided because of tolerance and misuse potential

    Start adjuvant pang medications (listed in order of recommended treatments)

    Tricyclic antidepressants are indicated for neuropathic pain; nortriptyline (Pamelor), desipramine (Norpramin), amitriptyline, and doxepin are besides useful for localized or generalized pang with coexisting headache, depression, panic disorder, or tobacco addiction

    Serotonin-norepinephrine reuptake inhibitors are indicated for neuropathic pain; duloxetine (Cymbalta) and milnacipran (Savella) are most effectual for localized or generalized pang with depression or anxiety, venlafaxine (Effexor) less so; doses for treatment of pang minister to be higher than those for depression

    Pregabalin is approved by the U.S. Food and Drug Administration for neuropathic pang and fibromyalgia; gabapentin has similar effectiveness, is available generically, and is more widely used, but it is sedating, and dosing is complex; may be synergistic when combined with tricyclic antidepressants

    Anticonvulsants; carbamazepine (Tegretol) is a first-line agent for trigeminal neuralgia, but third-line (with oxcarbazepine [Trileptal] and lamotrigine [Lamictal]) for other neuropathic pain

    Migraine chemoprophylaxis (e.g., beta blockers, calcium channel blockers, tricyclic antidepressants, topiramate [Topamax])

    Treat comorbid psychiatric illness

    Use of pharmacologic and psychotherapeutic measures is essential for improvement of symptoms and function

    Commonly associated disorders embrace anxiety, depression, posttraumatic stress disorder in persons who occupy experienced physical, sexual, or emotional trauma; treatment should embrace psychotherapy, biofeedback, mindfulness training, posttraumatic stress disorder therapy, relationship counseling, social and pecuniary counseling, and gist misuse counseling

    Trial of opioid therapy (initiation or continuation)

    Patients should occupy no contraindications for opioid therapy

    Patients with diffuse, centralized pang or headache are less likely to profit from opioid therapy and may be harmed by opioid toxicities

    Select patients with specific somatic, peripheral, or neuropathic pang may profit from low-dose opioid therapy in combination with other treatments

    Treatment should bear demonstrable functional improvement, not merely a reduction in pang scores, or opioids should be tapered or discontinued

    Opioid employ and Precautions INITIAL PATIENT SELECTION

    Safe and effectual opioid therapy requires careful patient selection. In general, inveterate somatic or neuropathic pang (e.g., musculoskeletal pain, peripheral neuropathy, postherpetic neuralgia) is at least partially responsive to opioids. However, inveterate visceral or central pang syndromes (e.g., abdominal or pelvic pain, fibromyalgia, headaches) are less responsive or nonresponsive.11,17,21,22 Patients with these conditions may occupy more adverse effects than benefits from inveterate opioid therapy.

    The patient's risk of opioid misuse or misuse must be assessed. Several validated tools are available, including the Opioid Risk utensil (Table 2).23 Risks should be acknowledged openly and managed, whenever possible, before prescribing opioids. Although no specific cutoffs occupy been established, patients with scores of 8 or more on the Opioid Risk utensil should be prescribed opioids only after entire other treatment modalities occupy been exhausted, under proximate supervision, and ideally in consultation with a pang or addiction subspecialist. Opioids should not be prescribed to patients who are actively using illicit substances, as detected during assessment or on pretreatment urine testing.

      Enlarge      Print

    Table 2. Opioid Risk Tool Item Score (females) Score (males)

    Family history of gist abuse

    Alcohol

    1

    3

    Illicit drugs

    2

    3

    Prescription drugs

    4

    4

    Personal history of gist abuse

    Alcohol

    3

    3

    Illicit drugs

    4

    4

    Prescription drugs

    5

    5

    Age 16 to 45 years

    1

    1

    History of preadolescent sexual abuse

    3

    0

    Psychological condition

    ADHD, obsessive-compulsive disorder, bipolar disorder, schizophrenia

    2

    2

    Depression

    1

    1

    Total score

    ––––

    ––––

    Table 2. Opioid Risk Tool Item Score (females) Score (males)

    Family history of gist abuse

    Alcohol

    1

    3

    Illicit drugs

    2

    3

    Prescription drugs

    4

    4

    Personal history of gist abuse

    Alcohol

    3

    3

    Illicit drugs

    4

    4

    Prescription drugs

    5

    5

    Age 16 to 45 years

    1

    1

    History of preadolescent sexual abuse

    3

    0

    Psychological condition

    ADHD, obsessive-compulsive disorder, bipolar disorder, schizophrenia

    2

    2

    Depression

    1

    1

    Total score

    ––––

    ––––

    After careful screening, opioid therapy may be initiated on a trial basis. Guidance for entire phases of opioid prescribing—decision, initiation, maintenance, and tapering—is given in Table 3.13,15,18,19,24 These steps should be followed in entire patients as portion of a universal precautions approach. Controlled medications should not be prescribed on a first visit because of pressure from the patient or a sense of duty to treat.

      Enlarge      Print

    Table 3. Phases of Opioid Prescribing

    Decision phase

    Ensure that patient understands that goal of therapy is improved function, not pang scores

    Screen for indications (prior successful multiply in function, localizable pang generator)

    Screen for precautions and contraindications in entire patients

    Evidence of multisourcing of controlled medications (check situation prescription monitoring service)

    Medical comorbidities that multiply risk (e.g., heart failure, inveterate lung disease, sleep apnea)

    Personal history of alcohol, illicit drug, or prescription drug abuse; employ CAGE Questionnaire, Opioid Risk utensil (Table 2), and urine drug testing with enzyme-linked immunoassay and gas chromatography/mass spectrometry (interpretation requires remarkable care)

    Red-flag behaviors (e.g., lost or stolen prescriptions, requests for early refills, abusive behaviors)

    Urine drug testing using enzyme-linked immunoassay for illicit drugs and gas chromatography/mass spectroscopy for prescribed medications; interpretation requires remarkable care

    Uncontrolled psychiatric comorbidities (e.g., anxiety, depression, posttraumatic stress disorder, psychosis)

    Initiation

    Consider sustained-release preparations for more consistent drug levels; patient demands for short-acting medication should be questioned; fentanyl (Duragesic) patches and oxycodone (Roxicodone) occupy high potential for misuse or diversion; methadone is potentially high risk, but easily monitored; sublingual or transdermal buprenorphine is effective, carries lower risk, and has less misuse potential

    Consolidate any other opioid therapy into one medication using an equianalgesic calculator (e.g., http://www.narculator.com); total dosages exceeding a morphine equivalent of 100 mg per day should prompt extra caution and consideration of referral to a pang management subspecialist

    Stabilize patient with one opioid; avoid polypharmacy with multiple opioids or cotreatment with benzodiazepines (may multiply risk of overdose)

    Use a controlled gist agreement; patients generally consequence not object, but doing so is a potential red flag

    Avoid continuous employ of short-acting opioids for breakthrough therapy, or restrict their employ to the initiation phase of therapy

    Maintenance phase

    Check situation prescription monitoring program before any prescription refills are issued

    Document the exact doses, pill counts, expected duration of the prescription, and circumstances under which refills are to be obtained

    Reassess goals for maintenance or improvement of function, not merely analgesia; taper therapy if functional goals are not achieved

    Repeat urine drug testing with enzyme-linked immunoassay and gas chromatography/mass spectrometry at least yearly (more often if the patient has addiction or diversion risk, or has concerning behaviors)

    Schedule face-to-face visits at least every three months (more frequently during titration or if misuse is suspected)

    Write prescriptions that attest the exact dates they can be filled

    When to stop, taper, or search consultation

    Stop prescribing immediately if patient tests positive for illicit drug employ or displays threatening behavior, or in the event of forgery or intoxication

    Taper if functional goals are not achieved, adverse effects are excessive, or medication is misused

    Consider referral if functional goals are not achieved, or for multidisciplinary pang or addiction treatment

    Table 3. Phases of Opioid Prescribing

    Decision phase

    Ensure that patient understands that goal of therapy is improved function, not pang scores

    Screen for indications (prior successful multiply in function, localizable pang generator)

    Screen for precautions and contraindications in entire patients

    Evidence of multisourcing of controlled medications (check situation prescription monitoring service)

    Medical comorbidities that multiply risk (e.g., heart failure, inveterate lung disease, sleep apnea)

    Personal history of alcohol, illicit drug, or prescription drug abuse; employ CAGE Questionnaire, Opioid Risk utensil (Table 2), and urine drug testing with enzyme-linked immunoassay and gas chromatography/mass spectrometry (interpretation requires remarkable care)

    Red-flag behaviors (e.g., lost or stolen prescriptions, requests for early refills, abusive behaviors)

    Urine drug testing using enzyme-linked immunoassay for illicit drugs and gas chromatography/mass spectroscopy for prescribed medications; interpretation requires remarkable care

    Uncontrolled psychiatric comorbidities (e.g., anxiety, depression, posttraumatic stress disorder, psychosis)

    Initiation

    Consider sustained-release preparations for more consistent drug levels; patient demands for short-acting medication should be questioned; fentanyl (Duragesic) patches and oxycodone (Roxicodone) occupy high potential for misuse or diversion; methadone is potentially high risk, but easily monitored; sublingual or transdermal buprenorphine is effective, carries lower risk, and has less misuse potential

    Consolidate any other opioid therapy into one medication using an equianalgesic calculator (e.g., http://www.narculator.com); total dosages exceeding a morphine equivalent of 100 mg per day should prompt extra caution and consideration of referral to a pang management subspecialist

    Stabilize patient with one opioid; avoid polypharmacy with multiple opioids or cotreatment with benzodiazepines (may multiply risk of overdose)

    Use a controlled gist agreement; patients generally consequence not object, but doing so is a potential red flag

    Avoid continuous employ of short-acting opioids for breakthrough therapy, or restrict their employ to the initiation phase of therapy

    Maintenance phase

    Check situation prescription monitoring program before any prescription refills are issued

    Document the exact doses, pill counts, expected duration of the prescription, and circumstances under which refills are to be obtained

    Reassess goals for maintenance or improvement of function, not merely analgesia; taper therapy if functional goals are not achieved

    Repeat urine drug testing with enzyme-linked immunoassay and gas chromatography/mass spectrometry at least yearly (more often if the patient has addiction or diversion risk, or has concerning behaviors)

    Schedule face-to-face visits at least every three months (more frequently during titration or if misuse is suspected)

    Write prescriptions that attest the exact dates they can be filled

    When to stop, taper, or search consultation

    Stop prescribing immediately if patient tests positive for illicit drug employ or displays threatening behavior, or in the event of forgery or intoxication

    Taper if functional goals are not achieved, adverse effects are excessive, or medication is misused

    Consider referral if functional goals are not achieved, or for multidisciplinary pang or addiction treatment

    If an initial evaluation raises questions about whether opioid therapy is appropriate, the physician should openly avow these concerns with the patient and entrust to handle the pang comprehensively through other means. If opioids are not appropriate in a patient who is already taking them, therapy should not be continued because of concerns about withdrawal. Although it is uncomfortable, opioid withdrawal is generally not life-threatening, and the patient can be referred to an addiction subspecialist for management.

    VISIT CHECKLISTS

    Visit checklists can be used to evaluate whether initiation or continuation of opioid therapy is appropriate. Items should embrace evidence or absence of progress toward pang relief and functional goals, evidence of red-flag behaviors (e.g., lost prescriptions, frequent early requests for refills), and the presence of uncontrolled psychiatric illness or medical comorbidities. Such checklists, if used routinely, may be especially useful in group practices where multiple physicians may supervision for the selfsame patients.

    URINE TESTING

    All patients should undergo urine drug testing before opioid therapy is initiated, and then at least yearly unless patient behavior suggests the need for more frequent testing. An enzyme-linked immunoassay for drugs of misuse (e.g., amphetamine, marijuana, cocaine) and gas chromatography/mass spectrometry to detect prescribed agents should be ordered. The opioid portion of most enzyme-linked immunoassays reliably detects only morphine or codeine, and misses hydrocodone, oxycodone, hydromorphone (Dilaudid), oxymorphone, fentanyl (Duragesic), methadone, and buprenorphine. These drugs are detected by gas chromatography/ mass spectrometry, especially if the laboratory is asked to check for these or other specific drugs in patients known to be prescribed one or more of them. Both tests may bear false-positive or false-negative results, so supervision must be taken to avoid misinterpretation of patient adherence. Concise guides to test interpretation are available.13,15,25

    PRESCRIPTION MONITORING

    Many states occupy established prescription monitoring programs (http://www.painpolicy.wisc.edu/domestic/pmp.htm). Online access is available in most states and can identify a patient's controlled prescriptions for the preceding year by drug name, strength, quantity, date of prescription, date prescription was filled, prescriber, and pharmacy used. Office staff can routinely obtain this information before visits by patients receiving opioid therapy.

    WRITTEN AGREEMENTS

    Many sample pang and controlled medication agreements are available (e.g., http://www.aapainmanage.org/literature/Articles/OpioidAgreements.pdf). These agreements silhouette appropriate intervals for follow-up, refill policies, participation in any indicated multimodal management diagram (e.g., physical therapy, psychological treatment), employ of only one prescriber and one pharmacy for entire controlled medications, and prohibition of illicit gist employ or prescription diversion. As with urine testing and prescription monitoring program reporting, written agreements should be portion of an ongoing treatment diagram for entire patients receiving inveterate opioid therapy, thereby avoiding reliance on physician judgment, suspicion, or bias.

    Selecting an Initial Opioid

    Morphine should be the first altenative for inveterate potent opioid therapy. Reliable, inexpensive, long-acting oral morphine preparations are available for patients receiving inveterate therapy. If the patient must later be switched to another medication, morphine doses are the units on which opioid equianalgesic calculations are based. Common adverse effects embrace constipation, nausea, pruritus, and drowsiness, entire of which are more common than morphine allergy. Morphine should be used with caution (especially its long-acting preparations) in patients with renal failure.

    Oxycodone is an alternative for patients with morphine intolerance or allergy. However, it may occupy a higher risk of misuse and should be used with caution in patients with higher risk scores. Long-acting oxycodone is not recommended for patients with inveterate pang because it is not truly long-acting, is expensive, and has a high street value. Transdermal fentanyl may be a better alternative, although it is expensive and can bear tolerance relatively quickly. Fentanyl is lipophilic, and absorption is affected in patients with itsy-bitsy subcutaneous bulky and in those prostrate to edema at application sites.

    Methadone can be effectual for many patients and may bear less tolerance than other opioids. It is inexpensive, long-acting, and has a combination of opioid and N-methyl-d-aspartate receptor activity that may execute it a fine altenative for patients with mixed somatic and neuropathic pain. However, physicians who prescribe methadone must be confidential with its unique pharmacokinetics: it has a very long elimination half-life, and its morphine-equivalent equianalgesic conversion ratio increases as dosages increase. Starting dosages in opioid-naive patients are 2.5 to 5 mg two or three times per day. Dosages should be titrated slowly and no more than once per week. Methadone can prolong the QT interval, especially in patients who are taking other QT-prolonging medications. Serum drug levels can be used for monitoring. Methadone does not meddle with urine testing for other opioids.

    Buprenorphine is a partial opioid agonist that is less likely to bear tolerance.26 It is effectual for treatment of pain, has lower misuse potential, and is easily monitored. However, it is expensive, and its employ requires special prescriber training (except for the transdermal patch).

    Breakthrough Dosing

    Short-acting opioids (e.g., morphine, oxycodone, hydromorphone) may be used during initiation of long-acting opioids, but should not be used continuously as primary or breakthrough treatment. Breakthrough dosing has not been shown to ameliorate outcomes and can multiply the risk of overdose, misuse, and further opioid tolerance.24 Because of the high street value of many short-acting opioids, requests for breakthrough doses should be resisted; if they are prescribed, only petite quantities should be given (e.g., 10 doses per month).

    Multiple Opioids and High-Dose Therapy

    The employ of multiple opioids should be avoided whenever possible; equianalgesic conversions can be used to consolidate therapies (a utensil is available at http://www.narculator.com). Total opioid doses exceeding 100 mg of morphine or its equivalent are associated with an increased risk of overdose and should prompt consideration of tapering or referral to a pang subspecialist.13,27 The need for such referral should be framed as an issue of medication safety and effectiveness, not suspicion or judgment of patients or their behavior.

    Tapering or Discontinuing Therapy

    Opioid therapy should be reassessed for safety and effectiveness in entire patients at least quarterly. Issues of patient safety or illegal activity should prompt discontinuation (Table 4).

      Enlarge      Print

    Table 4. Indications for Tapering or Discontinuing Opioids

    Immediate discontinuation

    Belligerent or threatening behavior toward physician or staff

    Confirmation of diversion, multisourcing, or prescription forgery

    Confirmation of illicit drug use, including marijuana

    Overdose

    Rapid tapering

    Frequent requests for early refills, despite adequate titration of long-acting opioids

    Major adverse effects or intoxication (e.g., somnolence, slurred speech, altered sensorium)

    Opioid-induced hyperalgesia

    Other nonadherence to pang medication agreement

    Gradual tapering

    Functional goals not met

    Morphine equivalent dosage greater than 100 mg per day, without clear profit to role or pain

    Persistent adverse effects despite opioid rotation (e.g., pruritus, nausea, refractory constipation)

    Table 4. Indications for Tapering or Discontinuing Opioids

    Immediate discontinuation

    Belligerent or threatening behavior toward physician or staff

    Confirmation of diversion, multisourcing, or prescription forgery

    Confirmation of illicit drug use, including marijuana

    Overdose

    Rapid tapering

    Frequent requests for early refills, despite adequate titration of long-acting opioids

    Major adverse effects or intoxication (e.g., somnolence, slurred speech, altered sensorium)

    Opioid-induced hyperalgesia

    Other nonadherence to pang medication agreement

    Gradual tapering

    Functional goals not met

    Morphine equivalent dosage greater than 100 mg per day, without clear profit to role or pain

    Persistent adverse effects despite opioid rotation (e.g., pruritus, nausea, refractory constipation)

    Before tapering, entire opioid therapy should be consolidated into a unique long-acting medication using equianalgesic calculations. Dose reduction should then proceed at a rate that avoids opioid withdrawal symptoms, loss of patient confidence, or pang escalation,28 and should continue until symptoms or role is improved. Gradual tapering can be accomplished by reducing the original total opioid dose by 10 percent every one to four weeks until 20 percent of the original total dose remains, then reducing by 5 percent of the original dose until it is discontinued. Rapid tapering can be accomplished by reducing the original dose by 25 percent every three to seven days; this will avoid strict withdrawal symptoms.

    Despite tapering, some patients may occupy withdrawal symptoms when opioids are completely discontinued. These symptoms should be managed supportively; traditional withdrawal management medications such as clonidine (Catapres), tramadol (Ultram), and muscle relaxants are generally ineffective, although temporary employ of nonbenzodiazepine sleep aids can be helpful. Follow-up visits should be scheduled frequently for ongoing multimodal pang management and encouragement that role will ameliorate over weeks to months.

    Data Sources: Searches of the human, English literature were conducted in Medline, Cochrane reports, and the National Guideline Clearinghouse for clinical trials and guidelines published from January 1, 2000, through April 25, 2011, using the major keywords of inveterate pain, non-malignant, non-cancer, and non-terminal. Terms used for specific topic searches included pang assessment, psychiatric comorbidities, addiction risk, opioid abuse, emergency department visits, pang mechanisms, opioid-induced hyperalgesia, opioid tolerance, opioid taper, long-term outcomes, and buprenorphine. Search date: January 2011 through April 2011.


    Ocrelizumab versus Interferon Beta-1a in Relapsing Multiple Sclerosis | killexams.com true questions and Pass4sure dumps

    Patients Table 1. Table 1. Demographic and Disease Characteristics of the Patients at Baseline (Intention-to-Treat Population).

    Overall, 1656 patients underwent randomization (intention-to-treat population), with 821 patients in the OPERA I trial and 835 in the OPERA II trial. The demographic and disease characteristics at baseline were similar in the assigned groups in the two trials (Table 1). In the OPERA I trial, 366 of 410 patients (89.3%) in the ocrelizumab group and 340 of 411 (82.7%) in the interferon beta-1a group completed the 96-week treatment; in the OPERA II trial, 360 of 417 patients (86.3%) and 320 of 418 (76.6%), respectively, completed the 96-week treatment (Fig. S2 in the Supplementary Appendix). There was no interaction between treatment group and trial, which allowed the pooling of data for the prespecified planned hierarchical analysis (Table S9 in the Supplementary Appendix). In the pooled analysis, which included 827 patients treated with ocrelizumab and 829 treated with interferon beta-1a, entire the primary and secondary halt points significantly favored the ocrelizumab group over the interferon beta-1a group.

    Efficacy Relapses Table 2. Table 2. Clinical and MRI halt Points during the 96-Week Trials.

    Clinical, MRI, and patient-reported outcomes are summarized in Table 2. The primary halt point, the annualized relapse rate at 96 weeks, in the OPERA I trial was 0.16 in the ocrelizumab group, as compared with 0.29 in the interferon beta-1a group (difference, 0.14 annualized relapses [differences are based on unrounded data]). In the OPERA II trial, the annualized relapse rate was 0.16 in the ocrelizumab group, as compared with 0.29 in the interferon beta-1a group (difference, 0.14 annualized relapses) (Table 2). These findings attest a 46% lower annualized relapse rate with ocrelizumab in the OPERA I trial and a 47% lower rate with ocrelizumab in the OPERA II trial (P<0.001 for both comparisons).

    Disability Figure 1. Figure 1. Key Secondary Clinical halt Points.

    Shown are the proportions of patients with disability progression confirmed at 12 weeks (first secondary halt point; Panel A) and at 24 weeks (fifth secondary halt point; Panel B) in time-to-event analyses in the pooled trial populations. Disability progression that was confirmed at 12 or 24 weeks was defined as an multiply from the baseline Expanded Disability Status Scale (EDSS) score (on a scale from 0 to 10.0, with higher scores indicating worse disability) of at least 1.0 point (or 0.5 points if the baseline EDSS score was >5.5) that was sustained for at least 12 or 24 weeks. The numbers shown on the curves portray Kaplan–Meier estimates of the risk of the event at week 96. The insets prove the selfsame data on an expanded y axis.

    In the prespecified pooled analysis, the percentage of patients with disability progression confirmed at 12 weeks was 9.1% in the ocrelizumab group, as compared with 13.6% in the interferon beta-1a group (40% lower risk with ocrelizumab; hazard ratio, 0.60; 95% confidence interval [CI], 0.45 to 0.81; P<0.001) (Figure 1A). Over the 96-week trial period, the rate of disability progression confirmed at 24 weeks was 6.9% in the ocrelizumab group, as compared with 10.5% in the interferon beta-1a group (40% lower risk with ocrelizumab; hazard ratio, 0.60; 95% CI, 0.43 to 0.84; P=0.003) (Figure 1B). The consequence of ocrelizumab on the risk of confirmed disability progression in each of the two trials was consistent with the prespecified pooled analysis (Table 2).

    In a pooled analysis, the percentage of patients with disability improvement confirmed at 12 weeks was 20.7% in the ocrelizumab group, as compared with 15.6% in the interferon beta-1a group (33% higher rate of improvement with ocrelizumab, P=0.02) (Fig. S5 in the Supplementary Appendix). The consequence of ocrelizumab on the rate of confirmed disability improvement was significant in the OPERA I trial but nonsignificant in the OPERA II trial (Table 2).

    The disagreement in the adjusted add up to change in the Multiple Sclerosis Functional Composite score from baseline to week 96 between the ocrelizumab group and the interferon beta-1a group was 0.04 in the OPERA I trial (P=0.33, which was the first nonsignificant P value in the hierarchical testing) and 0.11 in the OPERA II trial (P=0.004) (Table 2, and Fig. S6 in the Supplementary Appendix). As a result of the failure in the statistical hierarchical testing, entire the P values for the subsequent secondary efficacy halt points, including the change in the SF-36 quality-of-life physical-component summary and the measure of no evidence of disease activity, were considered to be nonconfirmatory.

    In the intention-to-treat population in the OPERA I trial, 47.9% of the patients in the ocrelizumab group had no evidence of disease activity by 96 weeks (exploratory halt point), as compared with 29.2% of those in the interferon beta-1a group. In the OPERA II trial, 47.5% of the patients in the ocrelizumab group had no evidence of disease activity by 96 weeks, as compared with 25.1% of those in the interferon beta-1a group. These findings were considered to be nonconfirmatory as a result of failure of the hierarchical analysis (Table 2, and Table S6 in the Supplementary Appendix).

    MRI-Related Secondary halt Points Figure 2. Figure 2. MRI halt Point.

    Shown are the add up to numbers of gadolinium-enhancing lesions per T1-weighted MRI scan by week 96 (second secondary halt point). The number of lesions was divided by the total number of MRI scans of the brain by week 96. In the OPERA I trial, the number of lesions on the MRI scan at 96 weeks was 94% lower in the ocrelizumab group than in the interferon beta-1a group; in the OPERA II trial, the number of lesions was 95% lower in the ocrelizumab group than in the interferon beta-1a group. Adjusted P values are shown.

    The total add up to number of gadolinium-enhancing lesions per T1-weighted MRI scan in the OPERA I trial was 0.02 with ocrelizumab versus 0.29 with interferon beta-1a (94% lower number of lesions with ocrelizumab, P<0.001). The values in the OPERA II trial were 0.02 with ocrelizumab versus 0.42 with interferon beta-1a (95% lower number of lesions with ocrelizumab, P<0.001) (Table 2 and motif 2, and Fig. S7 in the Supplementary Appendix).

    The total add up to numbers of new or newly enlarged hyperintense lesions per T2-weighted MRI scan in the OPERA I trial was 0.32 with ocrelizumab versus 1.41 with interferon beta-1a (77% lower number of lesions with ocrelizumab, P<0.001). The values in the OPERA II trial were 0.33 with ocrelizumab versus 1.90 with interferon beta-1a (83% lower number of lesions with ocrelizumab, P<0.001) (Table 2, and Figs. S8 and S13 in the Supplementary Appendix). Most of the new or newly enlarged lesion activity on T2-weighted MRI in the ocrelizumab groups occurred between baseline and week 24 (Fig. S8 in the Supplementary Appendix). From week 24 to week 48, the number of lesions was 94% lower in the ocrelizumab group than in the interferon beta-1a group in the OPERA I trial and 96% lower in the ocrelizumab group than in the interferon beta-1a group in the OPERA II trial. From week 48 to week 96 the number of lesions was 98% lower and 97% lower in the ocrelizumab group than in the interferon beta-1a group in the OPERA I trial and the OPERA II trial, respectively.

    The total add up to number of new hypointense lesions on T1-weighted MRI in the OPERA I trial was 0.42 with ocrelizumab versus 0.98 with interferon beta-1a (57% lower number of lesions with ocrelizumab, P<0.001). The values in the OPERA II trial were 0.45 with ocrelizumab versus 1.26 with interferon beta-1a (64% lower number of lesions with ocrelizumab, P<0.001) (Table 2, and Fig. S9 in the Supplementary Appendix). As a result of the failure in the statistical hierarchical testing, the differences in the percentage of brain-volume loss from week 24 to week 96 between the ocrelizumab group and the interferon beta-1a group were nonconfirmatory in the OPERA I trial (nominal P=0.004) and nonsignificant in the OPERA II trial (nominal P=0.09) (Table 2, and Fig. S10 in the Supplementary Appendix).

    Safety Adverse Events Table 3. Table 3. Adverse Events (Safety Population).

    A total of 327 of 408 patients (80.1%) in the ocrelizumab group reported an adverse event in the OPERA I trial, as compared with 331 of 409 (80.9%) in the interferon beta-1a group; the corresponding values in the OPERA II trial were 360 of 417 patients (86.3%) and 357 of 417 (85.6%) (Table 3). The most common adverse events were infusion-related reaction, nasopharyngitis, upper respiratory tract infection, headache, and urinary tract infection in patients treated with ocrelizumab and influenza-like illness, injection-site erythema, headache, urinary tract infection, and upper respiratory tract infection in patients treated with interferon beta-1a.

    Serious adverse events were reported in 6.9% of the patients treated with ocrelizumab and in 7.8% of those treated with interferon beta-1a in the OPERA I trial and in 7.0% of the patients treated with ocrelizumab and in 9.6% of those treated with interferon beta-1a in the OPERA II trial (Table 3). Three deaths occurred, including one death in the ocrelizumab group (suicide in the OPERA II trial) and two in the interferon beta-1a group (one suicide in the OPERA I trial, and one death due to mechanical ileus in the OPERA II trial).

    Infections

    Infection was reported in 232 patients (56.9%) in the ocrelizumab group and in 222 (54.3%) in the interferon beta-1a group in the OPERA I trial; the corresponding values in the OPERA II trial were 251 (60.2%) and 219 (52.5%) (Table 3). The most common infections (reported in ≥10% of the patients in either group across both trials) were upper respiratory tract infection, nasopharyngitis, and urinary tract infection. There were more reports in the ocrelizumab group than in the interferon beta-1a group of upper respiratory tract infection (15.2% vs. 10.5%) and nasopharyngitis (14.8% vs. 10.2%), whereas urinary tract infection was more frequent in the interferon beta-1a group (11.6% vs. 12.1%). The overall percentage of patients reporting a sedate infection was 1.3% in the ocrelizumab group and 2.9% in the interferon beta-1a group (Table S5 in the Supplementary Appendix). The selfsame pattern was seen when they used a broader definition of sedate infection, including nonserious infection treated with an intravenous antiinfective treatment (1.8% in the ocrelizumab group vs. 3.8% in the interferon beta-1a group). No opportunistic infections were reported in any group over the duration of either trial.

    Across the two trials, the percentage of patients reporting herpesvirus-associated infection was 5.9% in the ocrelizumab group and 3.4% in the interferon beta-1a group (Tables S3 and S4 in the Supplementary Appendix). entire these events were mild or qualify (Common Terminology Criteria for Adverse Events grade 1 or 2, as defined in Supplementary Appendix), with one exception: in the OPERA I trial, a patient treated with ocrelizumab for 1.6 years was hospitalized for a strict genital herpes simplex infection, which resolved with treatment.

    Infusion-Related Reactions

    More patients in the ocrelizumab group (34.3%) than in the interferon beta-1a group (9.7%) had at least one infusion-related reaction. Patients in the interferon beta-1a group received placebo infusions. In the OPERA I trial, at least one infusion-related reaction occurred in 30.9% of the patients in the ocrelizumab group and in 7.3% of those in the interferon beta-1a group; the corresponding values in the OPERA II trial were 37.6% and 12.0%. Most infusion-related reactions were mild to moderate, were reported at the first infusion of dose 1 (Fig. S11 in the Supplementary Appendix), and were managed with infusion adjustments and treatment of symptoms. One patient in the ocrelizumab group in the OPERA I trial had a life-threatening episode of bronchospasm during the first infusion of dose 1; the patient declined hospitalization, recovered with treatment, and was withdrawn from the trial according to the protocol. The most frequent symptoms of infusion-related reaction with ocrelizumab included pruritus, rash, throat irritation, and flushing.

    Laboratory Assessments

    CD19+ cells portray a measure of B-cell counts in anti-CD20–treated patients. The level of CD19+ cells decreased to negligible levels with ocrelizumab treatment by week 2. (See the Additional Methodology Details section and Fig. S12 in the Supplementary Appendix.)

    Antidrug-binding antibodies developed in 3 of 825 patients (0.4%) who received ocrelizumab across the two trials, with neutralizing antibodies developing in 1 patient in the OPERA II trial. Across the two trials, neutralizing anti–interferon beta-1a antibodies were detected in 21.3% of the patients.

    Neoplasms

    Across these two 96-week trials, four neoplasms (in 0.5% of patients) occurred in the ocrelizumab group (two cases of invasive ductal breast carcinoma, one case of renal-cell carcinoma, and one case of malignant melanoma), and two occurred (in 0.2%) in the interferon beta-1a group (one case of mantle-cell lymphoma and one case of squamous-cell carcinoma in the chest) (Table 3). Between the clinical cutoff dates of the two trials (April 2, 2015, in the OPERA I trial and May 12, 2015, in the OPERA II trial) and June 30, 2016, five additional cases of neoplasm (two cases of breast cancer, two cases of basal-cell skin carcinoma, and one case of malignant melanoma) were detected during the open-label extension study, during which entire the patients received ocrelizumab. As of June 30, 2016, the overall incidence rate of first neoplasm among patients treated with ocrelizumab across entire studies involving patients with multiple sclerosis was 0.40 per 100 patient-years of exposure to ocrelizumab (6467 patient-years of exposure), as compared with 0.20 per 100 patient-years of exposure in the pooled comparator groups (2053 patient-years of exposure in groups receiving interferon beta-1a or placebo). (See Table S6 in the Supplementary Appendix for the ORATORIO trial, the results of which are now published in the Journal.24)



    Direct Download of over 5500 Certification Exams

    3COM [8 Certification Exam(s) ]
    AccessData [1 Certification Exam(s) ]
    ACFE [1 Certification Exam(s) ]
    ACI [3 Certification Exam(s) ]
    Acme-Packet [1 Certification Exam(s) ]
    ACSM [4 Certification Exam(s) ]
    ACT [1 Certification Exam(s) ]
    Admission-Tests [13 Certification Exam(s) ]
    ADOBE [93 Certification Exam(s) ]
    AFP [1 Certification Exam(s) ]
    AICPA [2 Certification Exam(s) ]
    AIIM [1 Certification Exam(s) ]
    Alcatel-Lucent [13 Certification Exam(s) ]
    Alfresco [1 Certification Exam(s) ]
    Altiris [3 Certification Exam(s) ]
    Amazon [2 Certification Exam(s) ]
    American-College [2 Certification Exam(s) ]
    Android [4 Certification Exam(s) ]
    APA [1 Certification Exam(s) ]
    APC [2 Certification Exam(s) ]
    APICS [2 Certification Exam(s) ]
    Apple [69 Certification Exam(s) ]
    AppSense [1 Certification Exam(s) ]
    APTUSC [1 Certification Exam(s) ]
    Arizona-Education [1 Certification Exam(s) ]
    ARM [1 Certification Exam(s) ]
    Aruba [8 Certification Exam(s) ]
    ASIS [2 Certification Exam(s) ]
    ASQ [3 Certification Exam(s) ]
    ASTQB [8 Certification Exam(s) ]
    Autodesk [2 Certification Exam(s) ]
    Avaya [101 Certification Exam(s) ]
    AXELOS [1 Certification Exam(s) ]
    Axis [1 Certification Exam(s) ]
    Banking [1 Certification Exam(s) ]
    BEA [5 Certification Exam(s) ]
    BICSI [2 Certification Exam(s) ]
    BlackBerry [17 Certification Exam(s) ]
    BlueCoat [2 Certification Exam(s) ]
    Brocade [4 Certification Exam(s) ]
    Business-Objects [11 Certification Exam(s) ]
    Business-Tests [4 Certification Exam(s) ]
    CA-Technologies [20 Certification Exam(s) ]
    Certification-Board [10 Certification Exam(s) ]
    Certiport [3 Certification Exam(s) ]
    CheckPoint [43 Certification Exam(s) ]
    CIDQ [1 Certification Exam(s) ]
    CIPS [4 Certification Exam(s) ]
    Cisco [318 Certification Exam(s) ]
    Citrix [48 Certification Exam(s) ]
    CIW [18 Certification Exam(s) ]
    Cloudera [10 Certification Exam(s) ]
    Cognos [19 Certification Exam(s) ]
    College-Board [2 Certification Exam(s) ]
    CompTIA [76 Certification Exam(s) ]
    ComputerAssociates [6 Certification Exam(s) ]
    Consultant [2 Certification Exam(s) ]
    Counselor [4 Certification Exam(s) ]
    CPP-Institute [4 Certification Exam(s) ]
    CSP [1 Certification Exam(s) ]
    CWNA [1 Certification Exam(s) ]
    CWNP [13 Certification Exam(s) ]
    CyberArk [1 Certification Exam(s) ]
    Dassault [2 Certification Exam(s) ]
    DELL [11 Certification Exam(s) ]
    DMI [1 Certification Exam(s) ]
    DRI [1 Certification Exam(s) ]
    ECCouncil [22 Certification Exam(s) ]
    ECDL [1 Certification Exam(s) ]
    EMC [128 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 [40 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 [36 Certification Exam(s) ]
    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) ]
    GAQM [9 Certification Exam(s) ]
    Genesys [4 Certification Exam(s) ]
    GIAC [15 Certification Exam(s) ]
    Google [4 Certification Exam(s) ]
    GuidanceSoftware [2 Certification Exam(s) ]
    H3C [1 Certification Exam(s) ]
    HDI [9 Certification Exam(s) ]
    Healthcare [3 Certification Exam(s) ]
    HIPAA [2 Certification Exam(s) ]
    Hitachi [30 Certification Exam(s) ]
    Hortonworks [4 Certification Exam(s) ]
    Hospitality [2 Certification Exam(s) ]
    HP [752 Certification Exam(s) ]
    HR [4 Certification Exam(s) ]
    HRCI [1 Certification Exam(s) ]
    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) ]
    IFPUG [1 Certification Exam(s) ]
    IIA [3 Certification Exam(s) ]
    IIBA [2 Certification Exam(s) ]
    IISFA [1 Certification Exam(s) ]
    Intel [2 Certification Exam(s) ]
    IQN [1 Certification Exam(s) ]
    IRS [1 Certification Exam(s) ]
    ISA [1 Certification Exam(s) ]
    ISACA [4 Certification Exam(s) ]
    ISC2 [6 Certification Exam(s) ]
    ISEB [24 Certification Exam(s) ]
    Isilon [4 Certification Exam(s) ]
    ISM [6 Certification Exam(s) ]
    iSQI [7 Certification Exam(s) ]
    ITEC [1 Certification Exam(s) ]
    Juniper [65 Certification Exam(s) ]
    LEED [1 Certification Exam(s) ]
    Legato [5 Certification Exam(s) ]
    Liferay [1 Certification Exam(s) ]
    Logical-Operations [1 Certification Exam(s) ]
    Lotus [66 Certification Exam(s) ]
    LPI [24 Certification Exam(s) ]
    LSI [3 Certification Exam(s) ]
    Magento [3 Certification Exam(s) ]
    Maintenance [2 Certification Exam(s) ]
    McAfee [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) ]
    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 [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) ]





    References :


    Dropmark : http://killexams.dropmark.com/367904/11897645
    Wordpress : http://wp.me/p7SJ6L-258
    Dropmark-Text : http://killexams.dropmark.com/367904/12878392
    Blogspot : http://killexamsbraindump.blogspot.com/2017/12/pass4sure-250-510-practice-tests-with.html
    RSS Feed : http://feeds.feedburner.com/LookAtThese250-510RealQuestionAndAnswers
    Box.net : https://app.box.com/s/w74bsletuhskzzjh4r49ceocelwt7dt5






    Back to Main Page





    Killexams 250-510 exams | Killexams 250-510 cert | Pass4Sure 250-510 questions | Pass4sure 250-510 | pass-guaratee 250-510 | best 250-510 test preparation | best 250-510 training guides | 250-510 examcollection | killexams | killexams 250-510 review | killexams 250-510 legit | kill 250-510 example | kill 250-510 example journalism | kill exams 250-510 reviews | kill exam ripoff report | review 250-510 | review 250-510 quizlet | review 250-510 login | review 250-510 archives | review 250-510 sheet | legitimate 250-510 | legit 250-510 | legitimacy 250-510 | legitimation 250-510 | legit 250-510 check | legitimate 250-510 program | legitimize 250-510 | legitimate 250-510 business | legitimate 250-510 definition | legit 250-510 site | legit online banking | legit 250-510 website | legitimacy 250-510 definition | >pass 4 sure | pass for sure | p4s | pass4sure certification | pass4sure exam | IT certification | IT Exam | 250-510 material provider | pass4sure login | pass4sure 250-510 exams | pass4sure 250-510 reviews | pass4sure aws | pass4sure 250-510 security | pass4sure coupon | pass4sure 250-510 dumps | pass4sure cissp | pass4sure 250-510 braindumps | pass4sure 250-510 test | pass4sure 250-510 torrent | pass4sure 250-510 download | pass4surekey | pass4sure cap | pass4sure free | examsoft | examsoft login | exams | exams free | examsolutions | exams4pilots | examsoft download | exams questions | examslocal | exams practice |

    www.pass4surez.com | www.killcerts.com | www.search4exams.com | http://tractaricurteadearges.ro/