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C2090-011 | IBM SPSS Statistics Level 1 v2

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C2090-011 - IBM SPSS Statistics Level 1 v2 - braindump

Vendor IBM
Exam Number C2090-011
Exam Name IBM SPSS Statistics Level 1 v2
Questions 55 Q & A
Recent Update December 11, 2018
Free PDF Download C2090-011 Brain Dump
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C2090-011 exam Dumps Source : IBM SPSS Statistics Level 1 v2

Test Code : C2090-011
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 red Dot Design Award for SPSS facts | killexams.com Real Questions and Pass4sure dumps

The IBM Hybrid Cloud crew is returned at it with yet yet another win for design. I’m excited to announce that our design team has been awarded the 2018 pink Dot: communique Design Award for IBM SPSS facts within the Interface Design category. This award is a continuation of the design achievements we have viewed this previous year, together with the A’Design Awards, IF Design Awards, and others. i am extremely joyful to see the complicated 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 pink Dot Award has been the revered overseas seal of brilliant design great. Designers, organizations, and agencies from forty five distinctive nations took part in this yr’s competition, totaling over eight,600 entries that underwent a 24 member jury.

“All those that growth through the tough adjudication method to garner a red Dot have each rationale to be happy with themselves, because the jury provides our award most effective to creations of excessive design pleasant. This makes me all the greater delighted to congratulate the laureates clearly on their well-deserved success.” — Professor Dr. Peter Zec, founder and CEO of the pink Dot Award

Receiving this award was particularly entertaining for our crew and we're honored to be among the winners. here's a major fulfillment for our designers who worked on this product, and they confronted a captivating and challenging adventure in engaged on this product.

what is IBM SPSS?

IBM SPSS information is a powerful statistics evaluation tool that is among the most commonplace information functions. considering its inception in 1968, SPSS statistics has been revamped and redeveloped diverse times. Now the design crew at IBM has taken on the assignment of growing a completely sparkling consumer experience.

during this latest redesign of IBM SPSS information, we carried out design thinking concepts by working carefully with our users and making certain this modernized edition of SPSS records aligns with their wants. Our surest intention changed into to create an impressive tool that is not best effortless and intuitive to use, but that our clients can relish.

Our group and Design approach

The IBM SPSS design crew is part of the IBM Design Studios in Boeblingen, Germany. The group consists of a various group, with many contributors originating from diverse international locations and cultures. Some individuals of the crew had some heritage with information while others had been working during this box for the primary time.

Following the principles of IBM Design pondering (study > replicate > Make), our crew carried out a redecorate that brings a better center of attention on users for SPSS data. The design team conducted intensive research on the person base of SPSS statistics with a purpose to see how the software can greater meet their needs. The current consumer base stages from less skilled clients equivalent to college students to extra expert users comparable to data scientists or enterprise gurus. A key insight from the team’s research turned into that much less experienced users have been intimidated each via the math work and the complexity of the software.

the new designs focused on simplifying workflows, cutting back the normal complexity of the UI and interactions, and featuring freshmen an easy on-boarding to records and to the product. one more vital feature within the redecorate turned into a working towards book led by using a character named Simon, who serves as an in-utility ebook, helping beginner clients take note distinctive capabilities and obtain their desires sooner.

The crew confronted some exciting challenges in redesigning a product of such complexity, and one that has additionally been round for so many years. a huge success of the designers become making the product obtainable and tasty to new users with out alienating decade-long, skilled clients.

a look Into the Future

The preview edition of our new IBM SPSS statistics journey become launched in March 2018, and made obtainable to the general public as a trial on the IBM feel conference is Las Vegas, and given that June 26 , the new UI is generally available to all SPSS statistics subscribers. This preview is just the preliminary step, offering probably the most used statistical analyses, and basic capabilities for records training, for presentation and for reporting effects. Over here months the team should be working so as to add greater elements and capabilities so as to meet event wants of all of our consumer corporations.

now not just Updating — Redesigning

i am so delighted to peer another Hybrid Cloud design team get hold of an international award for their work. IBM SPSS statistics is yet an additional instance of how design is making an incredible change in the success of our items. As we proceed to use design to create greater relatable and productive items, we are able to give our users the experiences that they want and need. I’m overjoyed and proud to observe the change that our design crew is making on this planet of enterprise utility, and i can’t wait to see how we continue to affect the lives of our users.

Award Winners:
  • Design manager: Caroline law
  • Design Leads: Dirk Willuhn and Eva Cochet-Weinandt
  • Design group: Christian Fritsche, Dimitri Hoffmann, Jaehee (Chloe) Lee, Oleksandr Sabov, Stephan Feger
  • because of 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 utility alternatives | killexams.com Real Questions and Pass4sure dumps

    there are many vendors selling products classified as huge records analytics software. despite the fact, it's challenging to...

    differentiate these products based on functionality by myself, as most of the equipment share an identical elements and capabilities. moreover, some of the tools reveal extraordinarily subtle variations.

    That being noted, your key differentiating factors will likely focal point on balancing ease of use, algorithmic sophistication and value when it comes to your organization's capability and stage of maturity in analytics.

    in this article, we check items from nine huge statistics analytics software carriers: Alteryx Inc., IBM, KNIME AG, Microsoft, Oracle, RapidMiner Inc., SAP, SAS Institute Inc. and Teradata Corp. Some of these companies supply multiple tool. See the "leading providers of big facts analytics utility" sidebar below for more particulars about their selected product choices.

    These companies characterize diverse sides of the large information analytics market. Let's examine and contrast the ways in which these items meet the business needs of consumer groups.

    Analyst potential and skills 

    Some statistics analytics equipment are centered to amateur users, some are targeted to skilled statistics analysts and some are engineered to enchantment to each types of users.

    items reminiscent of IBM SPSS Modeler, RapidMiner's equipment, Oracle advanced Analytics and the automated Analytics version of SAP BusinessObjects Predictive Analytics are often designed to enable users with a confined historical past in records or records analysis to research information, strengthen analytical models and design analytics workflows with little or no coding.

    while each vendor wraps its core analytics add-ons with an intuitive consumer interface to guide the analyst's progress in information education, analysis, and then model design and validation, the strategy taken may additionally vary, primarily when evaluating a stand-alone product, reminiscent of RapidMiner, with one it truly is a element of a bigger suite, such as the Oracle product.

    tools comparable to IBM SPSS data, KNIME Analytics Platform, the professional Analytics module of SAP BusinessObjects Predictive Analytics, Microsoft R and the Teradata Aster Analytics platform deliver the greater subtle functionality that professional clients predict. Oracle R superior Analytics for Hadoop (ORAAH), some of the add-ons within the Oracle massive information utility Connectors suite, provides an R interface for manipulating Hadoop distributed File equipment statistics and writing mapper and reducer capabilities in R. this pliability could be attractive to extra advanced facts scientists.

    Alteryx and SAS business Miner offer functionality adapted to the user's degree of advantage, and virtually fall into both classes. Alteryx has brought advancements to records profiling to aid records scientists enhanced be aware their data sources. usual, SAS enterprise Miner and IBM's SPSS equipment stand out when it involves supporting more superior analytical innovations and mannequin scoring, in addition to a broader array of evaluation capabilities, together with neural networks, association evaluation and visualization capabilities.

    Analytical range

    reckoning on the use case and application, your corporation's clients should be required to support several types of analytics capabilities that allows you to use particular types of modeling, similar to regression, clustering, segmentation, conduct modeling and resolution bushes.

    while this has resulted in extensive support for the a number of forms of analytical modeling at a high stage, some companies have invested decades of labor into tweaking distinctive versions of their algorithms and including more refined performance. it be essential to take into account which fashions are most imperative to your company complications and to evaluate the items in terms of how they most appropriate serve your clients' enterprise needs.

    it be vital to consider which models are most relevant to your business complications and to evaluate the products in terms of how they gold standard serve your users' business needs.

    The extra mature and higher-end -- and, hence, bigger-priced -- equipment will reveal the greatest analytical breadth. Oracle records Miner comprises an array of universal machine learning procedures to assist clustering, predictive mining and text mining. both versions of IBM's SPSS product give a various set of analytical concepts and fashions. And SAS business Miner supports many algorithms and strategies, including determination trees, time collection, neural networks, linear and logistic regression, sequence and web direction analysis, market basket analysis, and link evaluation.

    The more moderen era -- and, in some circumstances, lower-priced -- products assist distinct fashions, however perhaps with a narrower range of algorithmic sophistication.

    The mannequin inventory in Alteryx Analytics Gallery comprises such capabilities as regression evaluation, determination timber, association rule evaluation, classification and time collection evaluation. KNIME includes strategies for textual content mining, picture mining and time series evaluation, and also integrates laptop studying algorithms from other open source initiatives, corresponding to Weka and JFreeChart.

    a further point of analytical diversity is integration with programming languages and statistical tools, reminiscent of R, for incorporating latest libraries, as well as person-described functionality. in fact, integration with R may well be regarded an increasingly critical differentiator.

    Alteryx designer, Microsoft R, SAS business Miner, Teradata Aster Analytics, Oracle's ORAAH and KNIME's Analytics Platform all interface and guide integration with R. a few of the vendors, together with IBM, Oracle, Microsoft, RapidMiner and SAP, give a growing to be library of extensions to R and Python, enabling users to take abilities of free libraries.

    Scope of the data to be analyzed

    There are distinct sides of the scope of the facts to be analyzed, together with the difficulty of structured vs. unstructured suggestions, as well as entry to regular on-premises databases and statistics warehouses, cloud-based facts sources, and records managed in large statistics structures, comparable to Hadoop.

    despite the fact, there are various levels of support for information managed within less-ordinary records lakes -- either managed inside Hadoop or in a further NoSQL facts management gadget meant to provide horizontal scaling. The components for distinguishing among the products must be in accordance with your firm's selected requirements for having access to and processing facts volumes and information variety.

    In focus of the growing to be diversity of enter sources and the diversity of underlying systems used to residence these data units, another set of rising features that's being adopted by using these companies contains records accessibility. IBM, RapidMiner, Alteryx, Oracle and Microsoft have all enhanced their equipment' facts import, export and connectivity capabilities. These enhancements should permit clients to entry a extra finished list of records sources while simplifying and rushing up the method of loading records into the items.

    guide for scalability and high efficiency

    The need for scalable performance is driven via your company's information volumes and appetite for analysis. Smaller agencies with much less statistics could be able to tolerate items that won't have efficiency traits that scale with the attainable substances, such because the entry-degree models of the lower-end tools, together with RapidMiner, KNIME, Microsoft R Open and Alteryx fashion designer, that could run on computing device systems and do not require extra server add-ons.

    greater corporations are more likely to have a better stock of data sets to research, as well as broader communities of users. This introduces two extra requirements -- excessive performance and facilitation of collaboration. The adaptability of a product to high-performance architectures is an excellent indication of scalability, and most of the products can also be adapted to the parallelism of Hadoop or employ any other ability of attaining faster computation.

    all the products do have some guide for Hadoop, including IBM SPSS Modeler and SPSS records; RapidMiner's industrial part Radoop, which connects the Studio front end and Server evaluation engine to records saved in Hadoop; Oracle's massive information Discovery and ORAAH equipment; and KNIME's huge records Extensions and Cluster Execution add-ins.

    IBM SPSS now also gives stronger aid for a couple of multithreaded analytical algorithms that might also speed performance. Teradata Aster Analytics addresses high-efficiency necessities through its vastly Parallel Processing architecture. SAP's knowledgeable Analytics edition of SAP BusinessObjects Predictive Analytics can execute in-memory statistics mining for dealing with significant-volume information analysis efficiently. Microsoft R Server leverages its ScaleR module, a complete library of large statistics analytics algorithms that aid parallelization. Scoring algorithms applied the use of SAS business Miner may also be deployed and performed within a Hadoop environment.

    furthermore, integration with Apache Spark appears to be of starting to be importance. SPSS, KNIME, Oracle, RapidMiner and SAP all provide access to Apache Spark libraries to support analytics applications that should scale with exploding facts volumes. This makes it possible for developed applications to take competencies of a excessive-efficiency cluster platform to distribute the workflow across the cluster.


    As mentioned, the larger the corporation, the more likely there can be a need to share analyses, fashions and purposes across different corporations and among many analysts. groups that have many analysts distributed across the enterprise might also seek accelerated capability to share fashions and collaborate concerning the interpretation of consequences.

    IBM's SPSS Modeler Gold edition provides collaboration capabilities, and RapidMiner's Server product gives support for sharing and collaboration. Alteryx Analytics Gallery gives a mechanism for sharing sophisticated analytics purposes in the cloud with participants of an extended firm. KNIME presents industrial extensions to assist team collaboration, as well as extensions helping operational collaboration, equivalent to far off-scheduled execution, file era, shared data area and a workflow repository. SAS enterprise Miner's client-server structure allows for company users and statistics analysts to work collaboratively via sharing fashions and other work products.

    Alteryx, KNIME and Teradata Aster have introduced capabilities to help control analytical workflows. also, one of the providers have begun to examine tips on how to enable their tools to integrate with others that can also have complementary practical sweet spots. as an instance, Teradata Aster now has an extension to combine with KNIME that makes it possible for users to leverage the KNIME workflow editor and incorporate Aster Analytics features into those workflows.

    seller dimension and product integration

    carriers may also be compared when it comes to their size. One could compare and contrast what may well be mentioned as the mega-providers, whose big facts analytics equipment are just one product among a massive portfolio of tools. in case you work for a bigger corporation that customarily negotiates web page-vast, enterprise licenses for the whole suite of a dealer's tools from a mega-seller akin to IBM, SAS, SAP or Oracle can be an inexpensive option.

    The huge providers sell huge records analytics equipment which are a part of a tons greater tool ecosystem. presumably, the products from a mega-vendor will be at the least a bit integrated and intended to work collectively. additionally, some individuals think more relaxed with bigger vendors, with an expectation of stability and consistent client provider. however, you can also most effective be in a position to acquire these massive facts analytics tools as a part of a a good deal higher software licensing association.

    Smaller providers, corresponding to KNIME, Alteryx and RapidMiner, have revenues which are generally based on licensing and help for a small number of massive facts analytics items. A smaller vendor may additionally give closer contact with their product administration and innovation groups, and you may be in a position to impact the course of the product roadmap or enhanced performance.

    A smaller supplier could also be more bendy when it comes to fee and the points included within the licensing association. You must know, although, that working with a smaller dealer does existing some chance in terms of steadiness, the materials accessible for support and the opportunity that the company could be bought, that could have an effect on the consumer relationship.

    The larger companies are obviously conscious of consumer wants for integration with different techniques, despite the fact that regularly facilities on other products within each supplier's inventory. for instance, SAP Predictive Analytics has more desirable integration with SAP HANA and BusinessObjects Cloud. SAS business Miner has introduced nodes to execute code in a SAS open, cloud-ready, in-reminiscence Viya ambiance. Microsoft presents SQL Server R features, an R installation that runs alongside SQL Server and allows for users to integrate Microsoft R Server statistics with SQL Server and Microsoft's other business intelligence tools.

    funds for licensing and preservation

    just about all of the companies promote diverse models or variants of their products, with a number of prices for acquisition and total can charge of operation. IBM, Oracle, RapidMiner, Teradata and Microsoft sell editions at diverse tiers, with the license can charge proportional to the facets, capabilities and freedom from obstacles in terms of the volumes of records to be analyzed or the variety of processing nodes the product can use.

    KNIME and RapidMiner provide free and open supply versions of their products, either charging for guide features or for versions supporting enterprise-class purposes. KNIME, RapidMiner and Alteryx have surprisingly low licensing prices for a smaller number of clients. if you're due to the fact that SAS or SAP, you ought to contact them for pricing alternatives.

    The industry for huge statistics analytics application will also be a confusing vicinity, however with a bit of luck this article has helped you bear in mind the merits massive facts analytics utility can give your company, and assisted you in differentiating between the certain tools examined here.

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

    Our annual license for IBM SPSS data 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 nowadays, you had been sent renewal authorization codes by means of electronic mail that can be used to lengthen the expiration date of your application.  if you purchased online right through that length, you might also consult with the leading OIT software page and click “View utility you have ordered” to entry your downloads and authorization code(s) at any time.

    IBM is not renewing version 18 this 12 months, and any one using that version (or past) will should upgrade to a newer version.  IBM SPSS records licenses are available for buy via OIT for $75 per laptop per year.

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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 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 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 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.



    atrial fibrillation




    aspartate aminotransferase


    Burch-Wartofsky score


    congestive heart failure


    central nervous system


    compensated thyrotoxicosis


    Glasgow Coma Scale




    intensive care unit


    international normalized ratio


    interquartile range


    length of stay


    relative risk


    thyroid storm.


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

    © 2017 Endocrine Society

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