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BAS-011 - IBM SPSS Statistics Level 1 v2 - Dump Information

Vendor : IBM
Exam Code : BAS-011
Exam Name : IBM SPSS Statistics Level 1 v2
Questions and Answers : 55 Q & A
Updated On : December 14, 2018
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BAS-011 Questions and Answers

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BAS-011 IBM SPSS Statistics Level 1 v2

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BAS-011 exam Dumps Source : IBM SPSS Statistics Level 1 v2

Test Code : BAS-011
Test Name : IBM SPSS Statistics Level 1 v2
Vendor Name : IBM
Q&A : 55 Real Questions

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IBM IBM SPSS Statistics Level

IBM Wins a 2018 purple Dot Design Award for SPSS statistics | killexams.com Real Questions and Pass4sure dumps

The IBM Hybrid Cloud team is lower back at it with yet a further win for design. I’m excited to announce that our design group has been awarded the 2018 red Dot: conversation Design Award for IBM SPSS facts in the Interface Design category. This award is a continuation of the design achievements we have viewed this previous yr, including the A’Design Awards, IF Design Awards, and others. i am thrilled to see the challenging work of our designers and IBM Design continue to shine and make a change in commercial enterprise software.

First developed within the 1990’s, the purple Dot Award has been the revered foreign seal of remarkable design great. Designers, groups, and corporations from forty five distinct countries took half during this year’s competitors, totaling over eight,600 entries that underwent a 24 member jury.

“All those that development in the course of the difficult adjudication system to garner a purple Dot have each cause to be happy with themselves, because the jury offers our award simplest to creations of high design great. This makes me all the more delighted to congratulate the laureates basically on their well-merited success.” — Professor Dr. Peter Zec, founder and CEO of the red Dot Award

Receiving this award turned into particularly exciting for our crew and we're honored to be among the many winners. here's an important fulfillment for our designers who labored on this product, and that they confronted an interesting and challenging experience in engaged on this product.

what's IBM SPSS?

IBM SPSS information is a powerful records evaluation tool that is likely one of the most regular information applications. due to the fact its inception in 1968, SPSS records has been revamped and redeveloped assorted times. Now the design crew at IBM has taken on the project of growing a completely sparkling user experience.

during this newest remodel of IBM SPSS statistics, we applied design considering principles by using working carefully with our clients and making certain this modernized version of SPSS statistics aligns with their wants. Our gold standard purpose was to create a magnificent device that is not most effective easy and intuitive to make use of, but that our clients can take pleasure in.

Our group and Design strategy

The IBM SPSS design group is part of the IBM Design Studios in Boeblingen, Germany. The group consists of a various community, with many contributors originating from distinct nations and cultures. Some participants of the group had some background with information whereas others have been working during this box for the first time.

Following the principles of IBM Design thinking (examine > replicate > Make), our crew implemented a redecorate that brings a stronger center of attention on users for SPSS records. The design team conducted intensive research on the consumer base of SPSS records with a view to see how the utility can more suitable meet their wants. The existing consumer base tiers from much less skilled users reminiscent of college students to extra knowledgeable users equivalent to data scientists or company specialists. A key perception from the group’s analysis became that much less experienced users have been intimidated each through the mathematics work and the complexity of the software.

the new designs focused on simplifying workflows, reducing the typical complexity of the UI and interactions, and proposing freshmen a simple on-boarding to facts and to the product. a further important feature within the redesign become a training guide led by way of a personality named Simon, who serves as an in-application ebook, helping amateur users bear in mind distinct capabilities and achieve their desires faster.

The crew confronted some pleasing challenges in redesigning a fabricated from such complexity, and one which has additionally been around for therefore many years. a huge success of the designers become making the product accessible and attractive to new users without alienating decade-long, experienced clients.

a glance Into the Future

The preview version of our new IBM SPSS information adventure became released in March 2018, and made obtainable to the public as a trial on the IBM believe conference is Las Vegas, and due to the fact that June 26 , the new UI is frequently purchasable to all SPSS facts subscribers. This preview is barely the initial step, providing the most used statistical analyses, and basic capabilities for statistics instruction, for presentation and for reporting results. Over the following months the crew should be working to add extra features and capabilities as a way to meet journey needs of all of our person businesses.

now not simply Updating — Redesigning

i am so extremely joyful to see an additional Hybrid Cloud design group get hold of a world award for his or her work. IBM SPSS information is yet an extra example of how design is making a massive difference within the success of our items. As we proceed to use design to create more relatable and effective items, we are capable of provide our clients the experiences that they need and wish. I’m thrilled and proud to watch the change that our design crew is making on the planet of enterprise utility, and i can’t wait to look how we proceed to impact the lives of our users.

Award Winners:
  • Design supervisor: Caroline legislations
  • Design Leads: Dirk Willuhn and Eva Cochet-Weinandt
  • Design team: Christian Fritsche, Dimitri Hoffmann, Jaehee (Chloe) Lee, Oleksandr Sabov, Stephan Feger
  • thanks to these contributing designers: Katrin Ellice Heintze, Leila Johannesen, Marion Bruells, Phil Brucker, Robin Auer, Sammy Schuckert, Stefan Schwarz
  • Design interns: Mengzhu Deng, Nathalie Mader, Ting-Hao (Howard) Huang, Vanessa Ng

  • evaluating the leading large information analytics software alternate options | killexams.com Real Questions and Pass4sure dumps

    there are many providers selling items labeled as large statistics analytics utility. youngsters, or not it's challenging to...

    differentiate these products in response to performance by myself, as most of the tools share similar elements and capabilities. additionally, probably the most tools exhibit extraordinarily delicate transformations.

    That being mentioned, your key differentiating factors will likely focus on balancing ease of use, algorithmic sophistication and value in terms of your company's potential and level of maturity in analytics.

    in this article, we check products from nine massive information analytics utility providers: Alteryx Inc., IBM, KNIME AG, Microsoft, Oracle, RapidMiner Inc., SAP, SAS Institute Inc. and Teradata Corp. Some of those vendors deliver a couple of tool. See the "main companies of big facts analytics software" sidebar below for extra particulars about their selected product offerings.

    These providers signify distinctive sides of the big data analytics market. Let's compare and distinction the ways in which these products meet the company needs of user businesses.

    Analyst knowledge and knowledge 

    Some records analytics equipment are focused to novice users, some are centered to knowledgeable statistics analysts and some are engineered to attraction to each sorts of users.

    products akin to IBM SPSS Modeler, RapidMiner's equipment, Oracle superior Analytics and the automatic Analytics version of SAP BusinessObjects Predictive Analytics are often designed to allow users with a restricted heritage in facts or records analysis to research information, improve analytical models and design analytics workflows with little or no coding.

    whereas each supplier wraps its core analytics components with an intuitive user interface to e book the analyst's development in data practise, evaluation, and then mannequin design and validation, the approach taken may additionally vary, specially when comparing a stand-on my own product, akin to RapidMiner, with one it is a part of a bigger suite, such as the Oracle product.

    tools equivalent to IBM SPSS statistics, KNIME Analytics Platform, the professional Analytics module of SAP BusinessObjects Predictive Analytics, Microsoft R and the Teradata Aster Analytics platform deliver the more sophisticated functionality that skilled users are expecting. Oracle R superior Analytics for Hadoop (ORAAH), one of the add-ons within the Oracle massive records utility Connectors suite, offers an R interface for manipulating Hadoop disbursed File device statistics and writing mapper and reducer features in R. this pliability could be attractive to greater advanced records scientists.

    Alteryx and SAS business Miner present functionality tailored to the user's stage of knowledge, and practically fall into both categories. Alteryx has delivered advancements to statistics profiling to help statistics scientists stronger consider their facts sources. typical, SAS business Miner and IBM's SPSS tools stand out when it involves supporting greater advanced analytical strategies and model scoring, in addition to a broader array of evaluation functions, including neural networks, affiliation evaluation and visualization capabilities.

    Analytical variety

    counting on the use case and utility, your corporation's clients could be required to support different types of analytics capabilities with the intention to use specific types of modeling, reminiscent of regression, clustering, segmentation, habits modeling and determination timber.

    whereas this has resulted in vast aid for the a number of styles of analytical modeling at a excessive stage, some vendors have invested a long time of labor into tweaking different models of their algorithms and adding extra sophisticated performance. it's critical to take into account which models are most crucial to your company issues and to evaluate the items when it comes to how they gold standard serve your users' enterprise wants.

    it's crucial to take note which fashions are most significant to your company issues and to consider the products when it comes to how they premiere serve your users' enterprise needs.

    The more mature and higher-end -- and, for this reason, larger-priced -- equipment will exhibit the optimal analytical breadth. Oracle records Miner comprises an array of common laptop studying tactics to assist clustering, predictive mining and text mining. each versions of IBM's SPSS product provide a various set of analytical concepts and fashions. And SAS enterprise Miner helps many algorithms and recommendations, together with choice bushes, time sequence, neural networks, linear and logistic regression, sequence and net direction analysis, market basket analysis, and hyperlink analysis.

    The more recent era -- and, in some cases, lower-priced -- items assist different models, but perhaps with a narrower range of algorithmic sophistication.

    The model inventory in Alteryx Analytics Gallery includes such capabilities as regression evaluation, resolution bushes, affiliation rule analysis, classification and time series analysis. KNIME contains methods for text mining, picture mining and time sequence analysis, and additionally integrates machine getting to know algorithms from different open supply tasks, comparable to Weka and JFreeChart.

    another element of analytical range is integration with programming languages and statistical equipment, reminiscent of R, for incorporating existing libraries, in addition to consumer-described functionality. actually, integration with R may well be considered an more and more crucial differentiator.

    Alteryx fashion designer, Microsoft R, SAS enterprise Miner, Teradata Aster Analytics, Oracle's ORAAH and KNIME's Analytics Platform all interface and assist integration with R. a couple of of the companies, including IBM, Oracle, Microsoft, RapidMiner and SAP, deliver a growing to be library of extensions to R and Python, enabling users to take advantage of free libraries.

    Scope of the facts to be analyzed

    There are varied aspects of the scope of the statistics to be analyzed, including the challenge of structured vs. unstructured counsel, in addition to access to familiar on-premises databases and information warehouses, cloud-based mostly information sources, and facts managed in large data systems, corresponding to Hadoop.

    despite the fact, there are varying levels of support for information managed within much less-typical information lakes -- either managed within Hadoop or in another NoSQL records administration device supposed to deliver horizontal scaling. The components for distinguishing among the items should be in accordance with your corporation's selected requirements for having access to and processing statistics volumes and statistics range.

    In attention of the growing variety of enter sources and the diversity of underlying techniques used to residence these facts sets, an additional set of rising points that's being adopted by means of these companies contains data accessibility. IBM, RapidMiner, Alteryx, Oracle and Microsoft have all enhanced their tools' facts import, export and connectivity capabilities. These enhancements should still enable users to access a greater finished list of facts sources while simplifying and rushing up the method of loading statistics into the items.

    support for scalability and high efficiency

    The need for scalable performance is pushed by way of your organization's data volumes and urge for food for analysis. Smaller agencies with much less records may be able to tolerate items that wouldn't have efficiency traits that scale with the attainable supplies, such as the entry-degree versions of the lower-end tools, together with RapidMiner, KNIME, Microsoft R Open and Alteryx dressmaker, that can run on computing device programs and do not require additional server accessories.

    higher companies usually tend to have a better inventory of records sets to analyze, in addition to broader communities of clients. This introduces two further necessities -- high efficiency and facilitation of collaboration. The adaptability of a product to high-efficiency architectures is a great indication of scalability, and lots of the items will also be tailored to the parallelism of Hadoop or employ any other capacity of attaining quicker computation.

    all the products do have some help for Hadoop, including IBM SPSS Modeler and SPSS data; RapidMiner's business element Radoop, which connects the Studio front conclusion and Server analysis engine to facts stored in Hadoop; Oracle's big records Discovery and ORAAH equipment; and KNIME's massive records Extensions and Cluster Execution add-ins.

    IBM SPSS now additionally provides more suitable aid for a number of multithreaded analytical algorithms that may also velocity performance. Teradata Aster Analytics addresses high-performance necessities through its massively Parallel Processing architecture. SAP's skilled Analytics edition of SAP BusinessObjects Predictive Analytics can execute in-memory statistics mining for dealing with tremendous-extent information evaluation efficiently. Microsoft R Server leverages its ScaleR module, a comprehensive library of huge information analytics algorithms that guide parallelization. Scoring algorithms implemented the use of SAS business Miner can be deployed and carried out within a Hadoop ambiance.

    furthermore, integration with Apache Spark seems to be of starting to be magnitude. SPSS, KNIME, Oracle, RapidMiner and SAP all provide access to Apache Spark libraries to support analytics functions that should scale with exploding statistics volumes. This allows developed purposes to take talents of a high-efficiency cluster platform to distribute the workflow across the cluster.

    Collaboration

    As noted, the greater the firm, the extra probably there should be a need to share analyses, models and functions across distinctive agencies and among many analysts. companies which have many analysts dispensed across the enterprise may seek accelerated potential to share models and collaborate concerning the interpretation of outcomes.

    IBM's SPSS Modeler Gold edition offers collaboration capabilities, and RapidMiner's Server product offers guide for sharing and collaboration. Alteryx Analytics Gallery provides a mechanism for sharing refined analytics purposes within the cloud with participants of an extended firm. KNIME presents industrial extensions to help crew collaboration, in addition to extensions supporting operational collaboration, comparable to far flung-scheduled execution, report technology, shared data space and a workflow repository. SAS business Miner's customer-server structure allows for company clients and records analysts to work collaboratively by sharing fashions and other work products.

    Alteryx, KNIME and Teradata Aster have brought capabilities to help manage analytical workflows. additionally, one of the most companies have began to study how to allow their equipment to combine with others that may have complementary functional sweet spots. as an instance, Teradata Aster now has an extension to integrate with KNIME that enables users to leverage the KNIME workflow editor and comprise Aster Analytics features into these workflows.

    dealer size and product integration

    companies can also be compared when it comes to their measurement. One may examine and contrast what may be observed as the mega-vendors, whose large data analytics equipment are just one product among a enormous portfolio of equipment. if you work for a larger corporation that usually negotiates web page-wide, enterprise licenses for the entire suite of a seller's equipment from a mega-seller similar to IBM, SAS, SAP or Oracle may well be an inexpensive alternative.

    The huge carriers promote massive statistics analytics equipment that are a part of a an awful lot higher tool ecosystem. most likely, the products from a mega-supplier could be at the least a bit of built-in and supposed to work together. additionally, some people suppose more relaxed with larger providers, with an expectation of balance and constant client service. however, you can also handiest be able to acquire these huge statistics analytics equipment as part of a a lot greater application licensing arrangement.

    Smaller vendors, such as KNIME, Alteryx and RapidMiner, have revenues which are generally in line with licensing and aid for a small number of big facts analytics products. A smaller supplier might also deliver nearer contact with their product administration and innovation groups, and you can be able to impact the course of the product roadmap or enhanced functionality.

    A smaller supplier may even be more bendy in terms of rate and the elements protected in the licensing arrangement. You should know, despite the fact, that working with a smaller vendor does latest some risk in terms of steadiness, the elements attainable for assist and the chance that the business may well be bought, that could affect the consumer relationship.

    The larger providers are obviously aware of person needs for integration with different programs, although that often facilities on other products inside each supplier's inventory. as an example, SAP Predictive Analytics has more desirable integration with SAP HANA and BusinessObjects Cloud. SAS commercial enterprise Miner has brought nodes to execute code in a SAS open, cloud-able, in-memory Viya environment. Microsoft presents SQL Server R features, an R installation that runs alongside SQL Server and allows for users to integrate Microsoft R Server records with SQL Server and Microsoft's other business intelligence tools.

    finances for licensing and maintenance

    just about the entire vendors sell distinct versions or editions of their products, with a number prices for acquisition and total charge of operation. IBM, Oracle, RapidMiner, Teradata and Microsoft sell variations at diverse tiers, with the license cost proportional to the facets, capabilities and freedom from obstacles when it comes to the volumes of statistics to be analyzed or the variety of processing nodes the product can use.

    KNIME and RapidMiner supply free and open source versions of their products, both charging for guide functions or for variations assisting commercial enterprise-classification purposes. KNIME, RapidMiner and Alteryx have highly low licensing costs for a smaller variety of users. if you're when you consider that SAS or SAP, you should contact them for pricing alternatives.

    The industry for massive information analytics software can be a confusing place, but expectantly this text has helped you understand the advantages massive information analytics application can give your organization, and assisted you in differentiating between the specific tools examined right here.


    IBM SPSS statistics Licenses Renewed | killexams.com Real Questions and Pass4sure dumps

    Our annual license for IBM SPSS information has been renewed, and all licenses purchased between these days and may 1, 2014 will expire on July 31, 2014.

    in case you purchased a license between April 1, 2013 and these days, you have been sent renewal authorization codes by email that could be used to extend the expiration date of your software.  in case you purchased online all through that duration, you may discuss with the main OIT application web page and click on “View software you have ordered” to access your downloads and authorization code(s) at any time.

    IBM isn't renewing version 18 this year, and any person using that version (or prior) will should improve to a more recent edition.  IBM SPSS facts licenses can be found for purchase via OIT for $75 per computing device per yr.


    BAS-011 IBM SPSS Statistics Level 1 v2

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    Test Name : IBM SPSS Statistics Level 1 v2
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    Q&A : 55 Real Questions

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    IBM SPSS Statistics Level 1 v2

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    Technology Infrastructure, Graphics and Visualization, and Adaptive Technologies | killexams.com real questions and Pass4sure dumps

    Technology Infrastructure, Graphics and Visualization, and Adaptive Technologies

    Technology Infrastructure: Servers

    Acer Altos Servers

    Designed for workgroup networking, the Altos server series supports systems for file management, a department, or a LAN or WAN. Features include multiple processor support, large memory and cache possibilities, hot-swappable power supplies and storage modules, and support for multiple operating systems, including Windows NT, Novell Netware, or SCO OpenServer environments. A broad selection of scalable configurations, from basic add-in cards to key-activated Internet, Intranet, or RAID solutions, is also available. Contact: Acer America, San Jose, CA; (800) SEE-ACER; www.acer.com.

    Dell PowerEdge Servers

    The PowerEdge Server line has three different models, the PE300, PE2400, and PE4400. The PE300 has up to two Pentium III 800MHz processors and up to 1GB of ECC SDRAM. The PE2400 has up to two Pentium III 1GHz processor, 2 GB of ECC SDRAM and 144 GB of Hot Swap internal disk capacity. The PE 4400 has up to two Pentium III 1GHz processors, 4GB of PC133 SDRAM and 252GB of hot plug ultra-3SCSI internal disk capacity. Contact: Dell, Round Rock, TX; (888) 560-8324; www.dell.com.

    Gateway Ultra-Thin Server

    Gateway offers a full-featured server in a compact design, for companies with growing server requirements but limited physical space. The 7450-R supports Intel's two latest processors, 4CG of RAM and three hot-plug SCSI drives, optional RAID configurations, and two full-length 64-bit PCI slots. The components are designed for durability. Two high-powered blowers control the unit's temperature, and a tool-free chassis makes servicing convenient. Contact: Gateway, North Sioux City, IA; (800) 846-2000; www.gateway.com.

    IBM RS/6000 Model 43P-140

    The 43P-140 is an entry-level desktop/deskside system that provides a range of performance options, from drafting, design, and software development to high-definition 3D graphics and technical simulations. It includes the choice of processor speed, storage devices, and communications features, allowing users to configure the system for particular needs. With the selection of 2D or 3D graphics accelerators or 3D graphics input devices, the 43P-140 provides the necessary capability for demanding 2D or high-function 3D applications. Contact: International Business Machines, Inc., Armonk, NY; (914) 499-1900; www.ibm.com.

    Informix Dynamic Server 2000

    The Dynamic Server 2000 delivers a transaction engine for mission-critical applications while providing an upgrade path to the Internet. Capable of supporting thousands of concurrent users, it is scalable to power even the largest transaction processing systems. Features include enhanced Virtual Table Interface (VTI), which provides the ability to integrate and view legacy data from a variety of disparate systems, databases, and formats, and easy migration from previous Informix database products. Contact: Informix Software, Menlo Park, CA; (650) 926-6300; http://www-3.ibm.com/software/data/informix/ids/.


    The association between the parental perception of the physical neighborhood environment and children’s location-specific physical activity | killexams.com real questions and Pass4sure dumps

    The main aim of this study was to investigate the association between parental perceived physical environmental characteristics of the neighborhood and children’s location-specific PA. Furthermore, the association between children’s physical neighborhood environment and their overall MVPA was investigated. As expected, physical neighborhood environmental correlates of children’s PA varied by PA location and perceived physical neighborhood characteristics were unrelated to children’s overall MVPA.

    The presence of neighborhood recreation facilities was the most important condition for children to be active in public recreation spaces that were located in- or outside their neighborhood. This finding may imply that most reported PA in public recreation spaces took place in facilities that were located inside children’s neighborhood. All other perceived neighborhood characteristics were unrelated to PA in public recreation spaces that took place inside or outside the neighborhood. Proximity to recreational facilities may promote children’s activity in these facilities, as recreation facilities nearby children’s home are better accessible for children compared to recreational facilities outside the neighborhood. This indicates that intervention developers have to focus on the presence of these facilities, rather than focusing on e.g. the aesthetics along the road to these facilities, as aesthetics were unrelated to PA in recreation facilities. In a US study, small public parks, playgrounds, playfields/courts and large public parks were among the five most commonly used PA sites for children; and children were more active in smaller parks compared to larger parks [18]. This may indicate that providing sufficient public recreation spaces for children can possibly yield positive effects on children’s PA and that the presence of smaller parks nearby can be more effective in increasing PA than larger parks that are further away from children’s home. However, the present results should be interpreted with caution because reverse causality may be present. For example, it is possible that parents from children who are frequently active in a public recreation space are more aware of these facilities, compared to parents from children who are mostly active in the garden.

    It is possible that not only the presence of recreation facilities is important to explain children’s PA in these facilities, but also the presence of features in the recreation facilities and their quality may play an important role in relation to children’s PA. For example, in an Australian study, park improvements (including the establishment of a walking track, a barbecue area, a playground,..) were positively associated with the number of park users, the number of people observed walking and being vigorously active [41]. Also in the US, park renovations appeared to increase visitation and overall PA in different age groups [42]. Future research is necessary to investigate if correlates of PA in public recreation spaces inside the neighborhood differ from correlates of PA in public recreation spaces outside the neighborhood.

    Parental perceived land use mix accessibility and crime safety were positively associated with PA in nearby streets and on sidewalks. In another Belgian study that investigated the correlates of children’s active commuting to school, land use mix accessibility was also positively related to children’s active transport to school [43]. These findings may indicate that a neighborhood with a high perceived accessibility is important for children to be active in their neighborhood. The positive relation between crime safety and PA in nearby streets and on sidewalks was expected as safety concerns may cause parents to restrict their children to play outdoors [44]. Also in an Australian study, parental perceptions of safety were positively related to children’s play in their street [20]. A negative association was found between street connectivity and PA in nearby streets and on sidewalks. This negative association with street connectivity can be explained by the fact that a neighborhood with low connectivity is characterized by few intersections and more cul-de-sacs that reduce traffic volume, which results in safer places to play in the streets. The negative association between street connectivity and reported child activity in the neighborhood was also found in a US study [15] and shows that an activity friendly neighborhood for children differs from an activity friendly neighborhood for adults. In adult studies it has consistently been shown that a higher street connectivity is associated with more PA [45, 46]. The challenge for urban planners and policy makers is to develop a neighborhood in which people from different age groups are encouraged to be physically active. For example, this can be done by providing sufficient play space (e.g. small parks) in neighborhoods with a high street connectivity for walking and cycling.

    In contrast to our hypothesis that an activity unfriendly neighborhood would be associated to more garden PA, but similar to the results of an Australian study [20], none of the perceived neighborhood environmental factors were related to children’s PA in the garden. Based on these findings, it is assumed that other factors (e.g. family environmental factors such as number of siblings, parental rules, parental encouragement) explain children’s PA in the garden and that intervening in children’s neighborhood environment will not influence children’s garden PA. However, further research is necessary as it is possible that specific garden characteristics (e.g. size of the garden) mediate the association between neighborhood characteristics and children’s garden PA.

    These findings show that the physical neighborhood environment is mainly related to PA that actually takes place in children’s neighborhood (in nearby streets and on sidewalks) and is probably unrelated to PA in other contexts. This possibly explains the fact that the neighborhood physical environment was unrelated to children’s overall MVPA. As a large part of children’s overall MVPA takes place outside the neighborhood (e.g. in the sports club or at school) and only a small part of their overall PA takes place in the neighborhood or public recreation spaces, the influence of the neighborhood physical environment on children’s overall MVPA might be limited; whereas in adults, the neighborhood physical environment relates to overall MVPA in adults [47]. Also in an Australian study, the frequency children played in specific outdoor locations (i.e. their own street, their garden and in the park/playgrounds) was unrelated to overall MVPA [20]. However, in the present study, overall MVPA was measured during the school year. It is possible that the perceived neighborhood environment relates more strongly to overall MVPA during school vacations, because then children have less opportunities to be active at schools or in a sports clubs.

    More insight into the location-specific PA correlates will be very informative for policy makers or urban planners, aiming to increase children’s PA levels in specific places (e.g. recreation facilities). Therefore, in future studies the use of GPS and/or SenseCams (wearable camera that takes photos automatically) in combination with accelerometers are promising tools for investigating the association between the environment and children’s location-specific PA. By using the combination of GPS and/or SenseCams and accelerometers, children’s PA can be exactly located in the neighborhood and data will not be biased by self-report. Also the use of activity diaries in combination with accelerometers might provide valuable information (e.g. where the activity took place) to investigate the relation between the perceived neighborhood environment and overall MVPA in specific locations. In future research, also the relation between the perceived neighborhood environment and objectively measured MVPA during vacation and other specific time periods (e.g. critical window MVPA (=after school until 6 pm)) should be investigated.

    Strengths of this study were the use of the validated NEWS, the most commonly used questionnaire in the literature to assess environmental perceptions [48], the relatively large sample, the use of accelerometry to objectively determine MVPA and the use of parental perceptions of the physical environment. The cross-sectional study design is a limitation, as no causal relationships could be examined. Furthermore, no objective measures of location-specific PA were available which made it impossible to test the criterion validity of these measures. Also the neighborhood characteristics were measured by self-report. It is possible that correlated error might have influenced the association between the two self-reported measures (i.e. parental reported PA and parental reported neighborhood characteristics) to a small extent. Also the response rate of the principals was rather low, which may have limited the representativeness of the findings. For example, it is possible that the present results are not generalizable to children from schools with a lower SES, as participating schools had a slightly higher number of children with high SES compared to other schools in Ghent (e.g. 27.0 % of children’s mothers did not obtain a secondary education degree in participating schools versus 32.6 % in non-participating schools in Ghent). Besides, 7.0 % of the parents did not fill out the questionnaire after giving informed consent which can have resulted in a selection bias.


    Clinical Features and Hospital Outcomes in Thyroid Storm: A Retrospective Cohort Study | killexams.com real questions and Pass4sure dumps

    Thyroid storm (TS) is a rare manifestation of thyrotoxicosis associated with substantial morbidity and mortality and requiring prompt recognition and treatment (1–5). A complete understanding of this condition remains difficult because of its rarity, nonspecific symptomatology, and variability in the diagnostic and treatment strategies applied. Traditionally, TS has been recognized as a clinical syndrome involving thyrotoxicosis, hyperthermia, alerted mentation, and a precipitating event, along with a wide array of other signs and symptoms (6–8). However, because of significant overlap between these features and other acute medical conditions (4, 6), more objective methods have been sought for the prompt and accurate diagnosing of TS.

    Burch and Wartofsky in 1993 (5) provided a quantitative diagnostic aid that is now considered to be precise criteria for TS (9). This method assigns points for dysfunction of the thermoregulatory, central nervous, gastrointestinal (GI)-hepatic, and cardiovascular systems, with increasing points given for greater severity of dysfunction. The authors proposed that a score ≥45 is highly suspicious, and very sensitive, for TS (5), and this cutoff has been widely adopted in the literature. More recently, Akamizu et al (10) analyzed TS patients reported by physician survey and generated new diagnostic criteria for TS (designated TS1 and TS2) that largely paralleled the Burch-Wartofsky scores (BWSs). In contrast to the BWS, the Akamizu (Ak) criteria are not quantitative but instead categorize patients based on the aggregate presence of defined clinical features. The new Ak diagnostic criteria have not been widely applied to separate study populations, and neither diagnostic system has been systematically applied to a cohort of hospitalized thyrotoxic patients.

    Given the rarity of TS, most studies have collected cases over many years (1, 7, 11), likely yielding heterogeneous populations diagnosed in different ways and treated across eras with different standards of care. Additionally, comparisons made to thyrotoxic control groups from outpatient clinics may not be relevant to distinguishing TS from compensated thyrotoxicosis (CT) in the acute setting. The Los Angeles County-University of Southern California Medical Center (LAC-USC) is a public safety-net and tertiary-care hospital, serving a population lacking access to routine medical care, often due to homelessness, immigration status, and/or mental illness (12–15). Because of this, LAC-USC continues to see advanced stages of many diseases, including TS.

    In this single-center retrospective cohort study covering a 6-year period at LAC-USC, TS cases were compared with concurrently admitted thyrotoxic patients rather than an outpatient or historic population. Furthermore, patients were evaluated by the same physicians and treated in a similar manner, minimizing diagnostic and treatment heterogeneity. The purpose was to evaluate currently available diagnostic criteria and to identify the features of TS most important to hospital-based outcomes, many of which have not been addressed previously in the literature.

    Study population

    After Institutional Review Board approval, consecutive records of adult patients admitted to LAC-USC from January 1, 2008, to December 31, 2013, with any ICD-9 diagnostic code for hyperthyroidism or thyrotoxicosis and an undetectable TSH level (<0.01 mIU/L) were retrospectively reviewed. The beginning of the study period represents when the medical records became available in electronic format. Repeated admissions by a single patient were recorded separately. An undetectable TSH level was chosen as the initial screening criterion to maximize the specificity for clinically severe thyrotoxicosis and exclude other etiologies, including euthyroid sick syndrome or mild overtreatment with thyroid hormone. After initial inclusion, medical records were reviewed and patient encounters excluded if known or incident pan-hypopituitarism, pregnancy, levothyroxine treatment without thyrotoxic symptoms, or medications known to reduce TSH levels were present. Previously thyrotoxic patients treated with radioactive iodine or antithyroid medication without continued evidence of thyrotoxicosis, but in whom TSH was still suppressed consistent with a delayed pituitary response (16), were similarly excluded. Patient admissions with incomplete or inadequate medical records were excluded.

    Diagnosis of TS

    The diagnosis of TS was determined by the consulting endocrinologist at the time of initial assessment (ie, 2008–2013) without the use of a quantitative diagnostic schema. The identification of TS was based on severe thyrotoxicosis with manifestations suggesting decompensation, such as fever, altered mental status, an inciting illness, and clinical deterioration refractory to appropriate treatments. Patients were not restratified based on subsequent hospital course or retrospective assessment by the investigators. Hospitalized patients with thyrotoxicosis not diagnosed with TS, regardless of end-organ dysfunction or eventual outcome, were defined as CT.

    Data collection

    Demographic, clinical, laboratory, and outcomes data, originally recorded as part of standard medical care, were collected from the LAC-USC Electronic Medical Records system. Patients were separated by their clinical diagnosis of TS or CT. Clinical features of particular interest were those previously specified in diagnostic criteria, including hyperthermia, central nervous system (CNS) abnormalities, tachycardia, congestive heart failure (CHF), atrial fibrillation (AF), GI-hepatic dysfunction, and an identified precipitating event. All study patients were retrospectively categorized by BWS (<25, 25–44, or ≥45) and Ak categories, as previously described (5, 10) (reproduced in Supplemental Methods). The Ak categories TS1 and TS2 were combined (AkTS1/2) because their similar mortality rates suggest both define TS (10, 17). Patients not meeting criteria for AkTS1/2 were defined as AkTS0. If ambiguity with respect to a diagnostic parameter could not be resolved by a blinded second reviewer, greater severity favoring TS was assumed. Outcomes measures included hospital length of stay (LOS), intensive care unit (ICU) admission and LOS, intubation, ventilator days, and in-patient mortality.

    Data analysis and statistics

    For descriptive statistics, means ± SDs or medians with interquartile range (IQR) are shown as indicated for demographic, clinical, laboratory, and outcome data. Statistical comparisons were made between TS and CT patients, and between TS patients and only those CT patients with BWS ≥45 or AkTS1/2 (BWS ≥45/AkTS1/2), but not other subgroups. For the comparison of clinical parameters between TS and CT patients, positivity for each feature was defined as follows: 1) fever (temperature >100.4°F), 2) CNS dysfunction (Glasgow Coma Scale [GCS] <15, agitation, disorientation, delirium, psychosis, seizure, lethargy/somnolence, or coma), 3) tachycardia (heart rate >100 beats/min), 4) CHF (lower-extremity pitting edema, pulmonary edema, jugulovenous distension, or cardiogenic shock), 5) AF (irregular heart rhythm confirmed by electrocardiogram), 6) GI-hepatic dysfunction (nausea, vomiting, diarrhea, or unexplained jaundice), and 7) precipitating illness (a concurrent illness identified as complicating the patient's presentation). For complete details of the statistical analysis, see Supplemental Methods. Statistical analyses were performed using GraphPad Prism version 6.0 and SPSS Statistics version 21.0 (IBM), and graphs were created using GraphPad and Abode Photoshop software.

    Study population

    During the 6-year study period, there were 170 034 acute hospital admissions to LAC-USC. Of 906 patients with a relevant ICD-9 diagnosis, 234 had a TSH <0.01 mIU/L. After exclusion of nonthyrotoxic patients (n = 44) and those with inadequate data (n = 40), 150 thyrotoxic patients were included, of which 25 were diagnosed with TS.

    Table 1 summarizes the demographic characteristics of the 150 thyrotoxic patients. TS and CT patients were similar in age (46 ± 12.2 and 46 ± 16.4 years, respectively). Females comprised 97 of 150 patients (64.7%). The underlying etiology of thyrotoxicosis was definitively ascertained in 80 cases, with 75 (93.75%) having Graves' disease, 2 with type 2 amiodarone-induced thyroiditis, and 1 case each of toxic adenoma, subacute thyroiditis, and toxic multinodular goiter, with similar proportions of new and previous diagnoses between TS and CT groups.

    Table

    Table 1. Demographic Characteristics of Study Patients

    Table 1. Demographic Characteristics of Study Patients

    All Patients n = 150 Thyroid Storm (TS) n = 25 Thyrotoxic (CT) n = 125 CT BWS ≥45 or AkTS1/2 n = 27 Age, mean years ± sd 46 ± 15.7 46 ± 2.2 46 ± 16.4 45.0 ± 19.7 Sex     M 53 (35.3) 9 (36.0) 44 (35.2) 9 (33.3)     F 97 (64.7) 16 (64.0) 81 (64.8) 18 (66.6) Diagnosis of thyroid disorder     New presentation 69 (46.0) 10 (40.0) 59 (47.2) 12 (44.4)     Known diagnosis 71 (47.3) 14 (56.0) 57 (45.6) 13 (48.2)     Unclear 10 (6.7) 1 (4.0) 9 (7.2) 2 (7.4) Season     Winter 31 (20.7) 4 (16.0) 27 (21.6) 4 (14.8)     Spring 31 (20.7) 7 (28.0) 24 (19.2) 6 (22.2)     Summer 47 (31.3) 7 (28.0) 40 (32.0) 10 (37.0)     Fall 41 (27.3) 7 (28.0) 34 (27.2) 7 (26.0) Admitting diagnosis     Thyroid disorder 34 (22.8) 6 (24.0) 28 (22.6) 4 (14.8)     Cardiovascular 37 (24.8) 2 (8.0) 35 (28.2) 10 (37.0)     Respiratory 8 (5.4) 2 (8.0) 6 (4.8) 0 (0.0)     Gastrointestinal 18 (12.1) 2 (8.0) 16 (12.9) 3 (11.1)     Trauma/Musculoskeletal 10 (6.7) 4 (16.0) 6 (4.8) 1 (3.7)     Infection/Fever 9 (6.0) 2 (8.0) 7 (5.6) 4 (14.8)     Neurologic 14 (9.4) 3 (12.5) 11 (8.9) 1 (3.7)     Malignancy/Other 12 (12.8) 4 (16.0) 15 (12.1) 4 (14.8)

    Study patients were retrospectively categorized according to BWS and Ak criteria to evaluate the stratification of patients using these systems. As shown in Figure 1A, 44 of 150 patients (29.3%) had BWS ≥45, and an additional 55 (36.7%) had BWS of 25 to 44. Applying Ak criteria to the 150 patients, 30 (27.3%) and 11 (7.3%) were Ak TS1 and TS2, respectively. There were 47 patients who met either the BWS ≥45 or AkTS1/2 definition of TS, of whom 38 (81%) met both criteria. When comparing the clinical diagnosis of TS to the BWS and Ak designations, 20 of 25 TS patients had BWS ≥45 and AkTS1/2 criteria, whereas the remaining 5 TS patients exhibited BWS 25 to 44 and were AkTS0. Of the 125 patients clinically diagnosed as CT and not treated for TS, 27 were BWS ≥45/AkTS1/2.

    Figure 1. Presenting clinical features and laboratory data for TS and CT patients.

    A, Study patients stratified by BWSs and Ak criteria. B, Polar chart displaying the frequency of composite presenting clinical features in TS and CT patients. The scale moves from 0% to 100% from center to outer line, with divisions every 20%. All features are reported dichotomously: fever (temperature >100.4°F), tachycardia (heart rate of >100 beats/min), altered mentation (including presence of GCS <15, agitation, delirium, psychosis, lethargy, seizures, or coma), GI-hepatic signs (diarrhea, nausea, emesis, unexplained jaundice, or abdominal pain), signs of CHF (lower-extremity pitting edema, pulmonary edema, jugulovenous distension, or cardiogenic shock) AF, and a identified precipitating stressor. C and D, Frequency of traditional signs and symptoms of TS in TS and CT patients overall (C) or the subgroup of CT patients with BWS ≥45 or AkTS1/2 (D). Significantly different frequencies between TS and CT patients are indicated with asterisks: *, P < .05; **, P < .01; *** P < .001.

    Clinical features

    The presence of clinical features were compared between TS and CT patients, as shown in Figure 1C. Consistent with the criteria used to make the diagnosis, those with TS were significantly more likely to have fever (relative risk [RR] = 5.98 [95% confidence interval = 3.1–11.4], P < .001), altered mentation (RR = 8.87 [4.2–18.5], P < .001), and an identified precipitating event (RR = 4.24 [1.5–11.8], P < .05). In 18 of 25 patients classified as having altered mental status, 6 (33%) had mild agitation, 2 (11.1%) had psychosis, 4 (22.2%) had extreme lethargy, 3 (16.7%) had delirium, and 3 (16.7%) others were unresponsive.

    Although not a specific consideration, the presence of tachycardia was also significantly associated with a diagnosis of TS (RR = 10.29 [1.4–73.7], P < .01). The prevalence of GI-hepatic manifestations, CHF, and AF did not vary significantly between TS and CT patients. When comparing TS patients (n = 25) with CT patients with BWS ≥45/AkTS1/2 (n = 27), a higher rate of altered mentation in TS patients was the only factor significantly different between the 2 groups (RR = 3.08 [1.7–5.7], P < .0001) (Figure 1D).

    To better understand patient stratification, the clinical features of patients with incongruous diagnostic findings were further compared. As shown in Table 2, of the 27 CT patients with BWS ≥45/AkTS1/2, 7 of 27 (25.9%) were febrile (≥100.4°F) and 6 of 27 (22.2%) had evidence of CNS dysfunction, although no patient had both. In the 6 patients with altered mentation, 2 had psychosis likely secondary to premorbid and untreated schizophrenia. In the remaining 4 cases, in addition to absent fever, tachycardia was mild, with a median heart rate of 100.5 (range 80–125) beats/min. Clinical features of tachycardia, GI-hepatic dysfunction, AF, and CHF were present in 25, 17, 14, and 9 of these 27 patients, respectively. Conversely, in the 5 TS patients without BWS ≥45 or AkTS1/2 criteria, 2 (40%) had fever and 4 (80%) had altered mentation (agitation in 2 patients and extreme lethargy and coma in 1 case each). However, in these patients, none had AF or overt GI-hepatic manifestations, and only 1 had evidence of CHF, likely accounting for the lack of qualifying criteria under the BWS and Ak methods.

    Table

    Table 2. Clinical Features of Patients With Discordant Thyroid Storm Diagnosis

    Table 2. Clinical Features of Patients With Discordant Thyroid Storm Diagnosis

    Thyroid Storm (TS) BWS <45, AkTS0 (n,%) Thyrotoxic (CT) BWS ≥45 or AkTS1/2(n,%) Number of patients 5 27 Sex (F:M) 3:2 18:9 Age, median years (range) 44 (36–58) 40 (21–84) Fever, Temp >100.4 F (%) 2 (40) 8 (29.6) CNS dysfunction (%) 4 (80) 6 (22.2) Tachycardia, HR >100 bpm (%) 5 (100) 25 (92.6) GI-hepatic dysfunction (%) 0 (0) 17 (63) Atrial Fibrillation (%) 0 (0) 14 (51.9) Congestive Heart Failure (%) 0 (0) 9 (33.3) Precipitating event (%) 2 (40) 17 (63)

    Laboratory parameters

    To determine whether there were any biochemical markers differentiating TS from CT patients, laboratory data at the time of presentation were compared (Table 3 and Supplemental Table 1). Free T4 was assessed in all cases and median (IQR) values in TS and CT patients of 5.2 (3.53–7.49) and 3.93.0 (2.48–7.77) ng/dL, respectively, were not significantly different.

    Table

    Table 3. Selected Laboratory Measurements in Thyroid Storm and Compensated Thyrotoxicosis Patients

    Table 3. Selected Laboratory Measurements in Thyroid Storm and Compensated Thyrotoxicosis Patients

    Laboratory Study Reference Range Thyroid Storm (TS) (n = 25) Thyrotoxic (CT) (n = 125) Free Thyroxine 0.93–1.83 ng/dL 5.21 (3.53–7.49) 3.93 (2.48–7.77) Potassium 3.5–5.1 mmol/liter 4.10 (3.75–4.45) 4.00 (3.70–4.30) Glucose 65–99 mg/dL 111 (100–138) 108 (93.5–130) Corrected calcium 8.5–10.3 mg/dL 9.28 (8.88–9.80) 9.51 (9.20–9.84) BUN 8–22 mg/dL 15.0 (12.0–24.8) 14.0 (11.0–18.0)a Creatinine 0.5–1.3 mg/dL 0.57 (0.38–0.71) 0.51 (0.40–0.71) Alkaline phosphatase 40–130 U/liter 122 (82–170) 119 (86.8–164) Total bilirubin 0.0–1.0 mg/dL 0.90 (0.50–2.40) 0.60 (0.33–1.00)b INR 0.90–1.10 1.21 (1.10–1.38) 1.14 (1.05–1.26)b WBC count 3.7–10.3 K/uL 9.30 (7.40–15.3) 7.80 (6.33–10.6)a % PMN 42–78% 76.3 (54.2–80.8) 64.2 (54.4–74.9)b Post-hoc analysis     Sodium 135–145 mmol/liter 137 (135–142) 139 (136–141)     Carbon dioxide 20–30 mmol/liter 22.0 (21.5–25.0) 24.0 (22.0–26.0)     Albumin 3.5–5.0 g/dL 3.30 (2.80–3.80) 3.70 (3.30–4.00)c     AST 10–40 U/liter 42.0 (31.8–77.8) 29.0 (23.0–46.3)c     ALT 10–55 U/liter 33.0 (22.0–71.0) 31.0 (22.5–47.0)     Direct bilirubin 0.30 (0.20–1.55) 0.30 (0.13–0.40)     Hemoglobin M: 13.8–16.9 g/dL F: 11.8–14.7 g/dL 12.4 (11.2–14.0) 12.6 (11.4–13.9)     MCV 82.0–99.0 fL 85.2 (78.7–96.0) 83.4 (80.0–87.0)     Platelet count 150–350 K/uL 220 (158–280) 221 (177–275)

    Planned analyses of laboratory testing (Table 3) demonstrated a significantly greater percent neutrophil count (9.30% [7.40%–15.3%] vs 7.80% [6.33%–10.6%], P < .1) and a trend toward a greater peripheral white blood cell count (76.3 [54.2–80.8] vs 64.2 [54.4–74.9]K/μL, P < .05) in TS compared with CT patients. Evaluation of liver function revealed a significantly higher median international normalized ratio (INR) of 1.21 (1.10–1.38) and 1.14 (1.05–1.26) and a median serum bilirubin of 0.90 (0.50–2.40) and 0.60 (0.33–1.00) mg/dL in TS vs CT patients, respectively (P < .05 for each), but no difference in the proportion of patients in each group with a total bilirubin value >3 mg/dL at presentation. The planned analyses found no differences among TS and CT patients with respect to serum potassium, alkaline phosphatase, corrected calcium, glucose, creatinine, or blood urea nitrogen. Exploratory post hoc comparisons of other laboratory studies found that median serum aspartate aminotransferase (AST) was significantly higher (42.0 [31.8–77.8] vs 29.0 [23.0–46.3] IU, P < .01) and median serum albumin level significantly lower (3.30 [2.80–3.80] vs 3.70 [3.30–4.00] g/dL, P < .01) in TS compared with CT patients. All laboratory data for TS and CT patients as well as CT patients divided into BWS and Ak groups is provided in Supplemental Figure 1.

    Morbidity and mortality in patients with TS and CT

    Differences in outcomes were evaluated for TS and CT patients, followed by comparisons between TS and only those CT patients with BWS ≥45/AkTS1/2 (Figure 2 and Supplemental Table 2). Treatment for TS included a thionamide, typically propylthiouracil, β-blockade (primarily propranolol), stress-dose glucocorticoids (primarily dexamethasone), and supersaturated potassium iodine in all but 1 case. Treatment with thionamides and β-blockade only was used in CT patients. Both groups received appropriate supportive care and aggressive evaluation and treatment of potential underlying illnesses.

    Figure 2. Hospital outcome measures for patients.

    A–F, Frequency of inpatient hospital mortality (A), median (IQR) hospital LOS (B), frequency of ICU admission during hospitalization (C), median (IQR) ICU LOS (D), frequency of intubation requirement (E), and median (IQR) ventilation duration (F) in TS patients, CT patients, and the subgroup of CT patients with BWS ≥45 or AkTS1/2. Statistical comparisons are TS vs CT patients, and TS vs CT (BWS ≥45/AkTS1/2) patients. Asterisks indicate significant differences between a group and TS patients: *, P < .05; **, P < .01; ***, P < .001; ****, P < .0001.

    In-patient mortality occurred in 2 of 25 patients (8%) with TS, and no patients in any other group, yielding a mortality rate of 1.3% among all study subjects. Of mortal cases, 1 patient was a 50-year-old man with no history of thyroid disease presenting with chest pain, palpitations, lower-extremity swelling, and diarrhea. His temperature was 102.3°F and heart rate was 150 beats/min. AF and CHF with pulmonary edema were present. He did not exhibit altered mentation. The BWS was 55, and Ak TS2 criteria were met. The patient received propylthiouracil but not other TS-specific treatments because of differing physician opinions regarding treatment. During conservative treatment for non-ST elevation myocardial infarction, the patient required intubation and mechanical ventilation and hemodialysis for acute kidney injury, ultimately suffering cardiovascular arrest and death. The second case was that of a 29-year-old woman with a history of Graves' disease who was noncompliant with methimazole. She was brought in by family with fatigue, heat intolerance, dizziness, and lower-extremity edema and rapidly developed confusion progressing to somnolence that necessitated intubation. Her temperature and heart rate were 98°F, and 155 beats/min, respectively. Again, AF and CHF with pulmonary edema were present. Her BWS was 80, and Ak TS1 criteria were met. Supportive and TS-specific treatments were initiated, but after initial improvement, the patient lost a secure airway causing respiratory compromise and subsequent cardiovascular arrest. Postresuscitation efforts, including aggressive administration of vasopressive agents, were unsuccessful, and the patient died with shock and multiorgan failure.

    Hospital outcomes including inpatient LOS, ICU admission and LOS, intubation, and ventilation duration were compared between TS and CT patients. As shown in Figure 2, median hospital LOS was significantly longer in TS patients compared with all CT patients (10 [4.0–22.5] vs 4 [2.0–7.0] days, P < .0001), and CT patients with BWS ≥45/AkTS1/2 (5 [3.0–9.0] days, P < .05). The proportion of patients requiring ICU admission during hospitalization, and the median ICU LOS were also significantly greater in TS vs CT patients (100% vs 38.4%, P < .0001; and 4.5 [2.0–10.5] vs 0.0 [0.0–2.0] days, P < .0001). The higher ICU admission rate and median ICU LOS were still observed when TS patients were compared with only CT patients with BWS ≥45/AkTS1/2 (100% vs 63%, P < .001; and 4.5 [2.0–10.5] vs 2.0 [0.0–5.0] days, P < .005, respectively). Intubation was required during hospitalization in 11 of 25 TS patients (44%), with median ventilator duration of 10 (2.0–22.0) days. No patients without TS required intubation.

    Predictors of outcomes

    Total BWS and its individual components were evaluated for prognostic significance in patients with clinically diagnosed TS. After log transformation, BWS was linearly correlated with hospital LOS (r = 0.28, P = .0005) and ICU LOS (r = 0.26, P < .05) in TS patients (Figure 3), but regression analysis of clinical features included in the BWS did not identify any independent predictors of hospital outcomes in TS patients.

    Figure 3. Correlation between BWS and patient outcomes.

    A and B, The correlation between BWS and log-transformed hospital LOS (A) or log-transformed ICU LOS (B) in days are plotted for individual TS patients. Spearman rank order correlation (r) and P values are shown with each graph.

    Decompensated thyrotoxicosis, or TS, is frequently characterized by multiorgan system dysfunction and exaggerated manifestations of thyroid hormone excess (1, 6, 18), although sometimes presenting with a paucity of symptoms (19, 20). The nonspecific findings of thyrotoxicosis often overlap with those of severe illness, making the identification of TS difficult (6). To facilitate the diagnosis, Burch and Wartofsky (5) proposed a quantitative diagnostic system for thyrotoxic patients, with a score of ≥45 indicating TS. More recently, Akamizu et al (10) assembled a large multicenter case series of TS and formulated new criteria for diagnosing TS. However, these diagnostic systems are difficult to evaluate because of the rarity of TS and the absence of a true gold standard and thus far have not been independently compared in a real-world setting.

    The current single-center cohort study directly compares patients who were diagnosed with TS with a contemporary thyrotoxic control group of similar severity and acuity. Of 906 patients admitted with a diagnostic code for hyperthyroidism/thyrotoxicosis, 25 (2.75%) were diagnosed with TS, which is similar to previously reported TS rates of 1% to 7% (8, 10, 21–23). When considering only the 150 patients who presented acutely to the Emergency Department with a TSH <0.01 mIU/L and required hospitalization, the rate of TS was 16.7% (25 of 150). This high percentage may suggest a liberal clinical diagnosis of TS, although many more patients would have been classified as such using either BWS or Ak criteria. The TS rate more likely reflects severe illness within the LAC-USC patient population.

    Application of the BWS or Ak criteria to all 150 thyrotoxic subjects revealed notable differences in patient stratification. Of TS patients, 20 of 25 met the BWS ≥45 and AkTS1/2 criteria for TS, whereas the remaining 5 had BWSs of 25 to 44 (suspicious for TS) and were AkTS0. This finding suggests that Ak criteria may be less sensitive for the diagnosis of TS because there is no equivalent intermediate category. However, if all patients with a BWS of 25–44 are considered TS, 66% of thyrotoxic patients in this study would potentially have received treatment for TS, suggesting that BWSs inform but do not supplant physician judgment (24).

    Although prudent to err on the side of overdiagnosing TS to assure appropriate treatment is provided, aggressive therapy is not without possible adverse consequences. High doses of thionamide drugs may increase adverse drug reactions, such as hepatotoxicity and agranulocytosis (25), and β-blockers may cause further cardiovascular decompensation (26). Hence, unnecessary treatment for TS may entail potential harm that should be carefully weighed. A better understanding of the clinical features associated with worse outcomes in TS may help identify patients with the greatest potential to benefit from aggressive therapy.

    The clinical diagnosis of TS in this study relied heavily on the presence of fever and altered mental status in thyrotoxic patients presenting with a precipitating illness. As would be expected, these features, as well as the presence of tachycardia, were significantly more common in patients with TS compared with CT. When TS patients were compared with only those CT patients with BWS ≥45/AkTS1/2, altered mentation was the only feature more frequently found in TS. The vital importance of CNS dysfunction to the diagnosis of TS was recently recognized in Akamizu et al (10) and was incorporated as a key element to their TS1 criteria, in part explaining the closer similarity between the TS and AkTS1/2 groups in this study. The rates of GI-hepatic manifestations CHF, and AF did not differ between TS and CT patients, suggesting that in the acute hospital setting, these findings may be less informative, although small sample size may have limited the ability to detect differences in these parameters. In particular, GI-hepatic manifestations were frequent in all hospitalized thyrotoxic patients but were not associated with the clinical diagnosis of TS.

    This study also compares for the first time several hospital outcomes relevant to patient morbidity and healthcare use between TS and CT patients. Compared with CT controls, TS patients had a greater rate of ICU admission as well as greater median hospital and ICU LOS. These differences were smaller but preserved when comparing TS patients with the CT patients with BWS ≥45/AkTS1/2, and patient outcomes remained worse for 5 TS patients with BWS <45/AkTS0 compared with CT patients with BWS ≥45/AkTS1/2 (Supplemental Table 2). The frequency of altered mental status was a key clinical feature distinguishing TS patients, suggesting that CNS dysfunction identifies those at risk for worse outcomes. In support of this, Akamizu et al (10) found that a lower GCS, indicating poorer neurologic function, was associated with irreversible neurologic deficits after hospitalization and greater severity of illness (using APACHEII or SOFA scores). Additional factors associated with disease severity in TS patients in that study were advanced age, comorbid CHF, and higher total serum bilirubin. Although a serum bilirubin value >3 mg/dL was not associated with a clinical diagnosis of TS in the current study, both patients suffering in-patient mortality had a serum bilirubin >3 mg/dL, supporting the association with mortality previously reported. In this study, 2 of 25 TS patients (8%) died during hospitalization. This is consistent with the mortality rate of 7% reported by Mazzaferri and Skillman (1) and far lower than the universal mortality in early reports of TS (27, 28). Greater physician awareness, improvements in TS-specific treatments, and myriad advances in critical care medicine likely all contribute to improved TS mortality rates over time.

    The pathogenesis of TS remains uncertain, but the observed collective association of tachycardia, fever, and altered mentation with TS in this study suggests to the authors that hemodynamic decompensation may be of importance. Thyroid hormone-induced peripheral vasodilation to dissipate excess heat, and impaired ability to augment cardiac function with exertion (29–31), may produce susceptibility to cardiovascular decompensation when challenged, such as with volume depletion, sepsis, or other stress-induced adrenergic stimulation. The greater rate of tachycardia may indicate poorer perfusion of the peripheral circulation, causing heat retention and hyperthermia, and the CNS, instigating altered mentation. Furthermore, insufficient perfusion to meet the metabolic demands of the thyrotoxic liver (32) may account for the higher serum AST, total serum bilirubin, and INR found in TS cases. That cardiovascular decompensation may underlie critical aspects of TS argues that therapeutic interventions aimed at optimizing intravascular volume and cardiovascular function may be the most important components of treatment for TS.

    We recognize several limitations of the current study. Although the diagnosis and treatment of TS at a single center likely provided homogeneity in the classification and treatment of patients, the methodology for diagnosing TS may be difficult to replicate in future investigations or clinical practice. Retrospective data may contain ascertainment bias and is limited to correlative analyses. Any negative findings in this study must recognize a possible type II error given the sample size; however, the cohort design of this investigation is more robust than the case-control design most often employed in early studies of TS. This study was unable to assess many historical aspects, such as the interval from symptoms onset to TS, as has been done in other studies (1, 8, 10), because this information was not reliably documented, but given the frequency of altered mentation in TS patients, such history was unlikely to have been available at presentation to inform diagnostic judgment.

    In this study, the clinical factors associated with TS suggest decompensation of homeostatic mechanisms normally preserved in thyrotoxicosis, possibly related to cardiovascular insufficiency. However, only altered mentation distinguished TS from CT patients with BWSs ≥45 or Ak TS1 or TS2 categorization, suggesting that recognition of CNS dysfunction is of paramount importance in assessing for TS. Given the greater rate of mortality and adverse hospital outcomes observed in patients clinically diagnosed with TS at our institution, patients with suspected TS and altered mentation may derive the greatest benefit from aggressive TS-specific and supportive treatments.

    Abbreviations:

    AF

    atrial fibrillation

    Ak

    Akamizu

    AST

    aspartate aminotransferase

    BWS

    Burch-Wartofsky score

    CHF

    congestive heart failure

    CNS

    central nervous system

    CT

    compensated thyrotoxicosis

    GCS

    Glasgow Coma Scale

    GI

    gastrointestinal

    ICU

    intensive care unit

    INR

    international normalized ratio

    IQR

    interquartile range

    LOS

    length of stay

    RR

    relative risk

    TS

    thyroid storm.

    Acknowledgments

    Disclosure Summary: All authors have no conflicts of interest to declare.

    © 2017 Endocrine Society

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