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Test Code : BAS-011
Test name : IBM SPSS Statistics smooth 1 v2
Vendor name : IBM
: 55 true Questions

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IBM IBM SPSS Statistics Level

IBM Wins a 2018 crimson Dot Design Award for SPSS information | killexams.com true Questions and Pass4sure dumps

The IBM Hybrid Cloud team is again at it with yet yet another win for design. I’m excited to promulgate that their design group has been awarded the 2018 pink Dot: conversation Design Award for IBM SPSS statistics in the Interface Design class. This award is a continuation of the design achievements they possess considered this past yr, including the A’Design Awards, IF Design Awards, and others. i'm overjoyed to peer the difficult work of their designers and IBM Design proceed to shine and accomplish a change in industry application.

First developed in the 1990’s, the red Dot Award has been the revered overseas seal of surprising design excellent. Designers, groups, and businesses from 45 distinctive international locations took half during this yr’s competition, totaling over 8,600 entries that underwent a 24 member jury.

“All people who growth through the tough adjudication technique to garner a red Dot possess each purpose to exist gay with themselves, because the jury delivers their award simplest to creations of immoderate design excellent. This makes me the entire extra delighted to congratulate the laureates in actual fact on their richly deserved success.” — Professor Dr. Peter Zec, founder and CEO of the purple Dot Award

Receiving this award become tremendously exciting for their team and we're honored to exist among the winners. here is a huge achievement for their designers who labored on this product, and that they faced an enchanting and challenging adventure in working on this product.

what is IBM SPSS?

IBM SPSS records is an impressive facts analysis device that is without doubt one of the most widely used records purposes. on the grounds that its inception in 1968, SPSS statistics has been revamped and redeveloped assorted times. Now the design team at IBM has taken on the assignment of developing a very sparkling person adventure.

in this latest remodel of IBM SPSS information, they carried out design pondering principles by using working intently with their users and making unavoidable this modernized edition of SPSS facts aligns with their wants. Their top-rated point was to create an impressive tool that is not most efficacious effortless and intuitive to use, but that their clients can savor.

Our team and Design approach

The IBM SPSS design group is a component of the IBM Design Studios in Boeblingen, Germany. The group consists of a various community, with many participants originating from distinctive nations and cultures. Some members of the team had some history with facts while others possess been working in this box for the primary time.

Following the principles of IBM Design considering (study > replicate > Make), their crew implemented a redesign that brings a much better focus on users for SPSS information. The design crew conducted intensive analysis on the consumer base of SPSS facts as a way to remark how the software can greater meet their needs. The latest user base degrees from much less skilled users corresponding to college students to more expert clients reminiscent of records scientists or company specialists. A key insight from the group’s research changed into that less skilled users were intimidated each by means of the maths work and the complexity of the utility.

the fresh designs concentrated on simplifying workflows, reducing the usual complexity of the UI and interactions, and offering beginners a straightforward on-boarding to statistics and to the product. one other essential characteristic in the redecorate was a practising e reserve led by a character named Simon, who serves as an in-utility book, helping novice users possess in mind diverse services and achieve their dreams sooner.

The team faced some entertaining challenges in redesigning a product of such complexity, and one which has moreover been round for thus a long time. a huge success of the designers became making the product attainable and tasty to fresh users with out alienating decade-lengthy, experienced clients.

a ogle Into the Future

The preview version of their fresh IBM SPSS information event turned into released in March 2018, and made purchasable to the public as a trial on the IBM reckon conference is Las Vegas, and on account that June 26 , the brand fresh UI is generally accessible to bar not one SPSS facts subscribers. This preview is only the initial step, providing probably the most used statistical analyses, and simple capabilities for data training, for presentation and for reporting outcomes. Over privilege here months the team can exist working so as to add more elements and capabilities with a purpose to meet journey needs of bar not one of their user groups.

now not simply Updating — Redesigning

i'm so extremely joyful to peer a further Hybrid Cloud design crew collect hold of a global award for his or her work. IBM SPSS facts is yet one other illustration of how design is making a major inequity within the success of their products. As they proceed to accomplish exercise of design to create extra relatable and productive products, we're able to give their clients the experiences that they want and wish. I’m overjoyed and arrogant to watch the inequity that their design crew is making on this planet of industry software, and that i can’t wait to ogle how they proceed to influence the lives of their users.

Award Winners:
  • Design manager: Caroline legislation
  • Design Leads: Dirk Willuhn and Eva Cochet-Weinandt
  • Design group: Christian Fritsche, Dimitri Hoffmann, Jaehee (Chloe) Lee, Oleksandr Sabov, Stephan Feger
  • due 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

  • software items world Market document 2018- top Key avid gamers are: Microsoft, HP Inc, Oracle, Dell applied sciences, and IBM. | killexams.com true Questions and Pass4sure dumps

    Asia Pacific become the largest belt in the application publishers market in 2017, accounting for 40% market share. North the usa turned into the 2d greatest spot accounting for 31% market share. Africa became the smallest spot accounting for 2% market share.

    The number of mergers and acquisitions in the utility products trade is expanding. huge businesses are acquiring small agencies to raise their product and service choices. high-efficiency cloud computing groups and commercial enterprise application providers are the leading acquisition targets for software product corporations. for example, IBM organisation lately bought SPSS facts, Cognos Inc., SoftLayer technologies Inc. and Varicent application Inc.

    Asia Pacific turned into the largest region within the utility products market in 2017, accounting for 2-fifth of the international market share.

    Order the report at: www.thebusinessresearchcompany.com/document/software-produc...

    according to The industry analysis business’s advisor, Nitin Gianchandani, desirable utility providers equivalent to Oracle and SAP possess been making an attempt to penetrate the hub market, to extend their client base and raise overall revenues. These agencies possess begun offering scaled-down, pre-configured models of their purposes. they are pursuing fresh distribution channels to sell and dole their software products and are additionally buying mid-market application businesses to boost their market shares and revenues. for instance, SAP bought enterprise One application to penetrate the core market.

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    Microsoft Corp. become the largest industry within the utility products market, with revenues of $fifty seven.2 billion for the monetary yr 2016. Microsoft’s boom strategy is to focus on mobile and cloud solutions; it is moreover concentrated on having 1000000000 subscribers for home windows 10 by means of 2018.

    utility product companies improve, market and dole application items for industrial and personal use. Publishers are always sold within the variety of licenses to exercise the utility for a unique duration or completely. The license commonly entitles the purchaser to acquire updates of the programs. agencies in this industry create and dole laptop utility by way of designing utility, providing documentation, assisting in setting up and offering assist functions to application consumers. Some agencies design, develop and publish; others handiest publish.

    software items world Market record 2018 is an in depth record giving a different perception into this market. The document is priced at $6000 for someone consumer. to accomplish exercise of throughout your office, the expense is $9000 and $12000 if you necessity to exercise throughout a multinational company.

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    discuss with TheBusinessResearchCompany.com, mail data@tbrc.info or name +447443439350 or +918897263534 or +919160996838 for more counsel on this and a lot of different titles.

    The industry research company is a market research and intelligence enterprise, which excels in business, market and consumer analysis.

    It has analysis gurus at its offices in the UK, India and the united states as smartly a community of skilled researchers globally. It has specialist consultants in a astronomical range of industries including manufacturing, healthcare, chemical compounds and know-how.

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    Contact suggestions.The enterprise analysis CompanyEurope: +44 207 1930 708Asia: +91 8897263534Americas: +1 315 623 0293Email: info@tbrc.infoFollow us on Linkedin: in.linkedin.com/company/the-enterprise-analysis-business

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    evaluating the leading astronomical information analytics application alternatives | killexams.com true Questions and Pass4sure dumps

    there are lots of providers selling items classified as huge records analytics utility. although, or not it's difficult to...

    differentiate these products in response to performance on my own, as many of the gear share an identical aspects and capabilities. additionally, one of the most gear expose extraordinarily refined variations.

    That being mentioned, your key differentiating factors will seemingly focal point on balancing ease of use, algorithmic sophistication and expense in relation to your organization's skill and smooth of maturity in analytics.

    in this article, they determine products from 9 large information analytics application companies: Alteryx Inc., IBM, KNIME AG, Microsoft, Oracle, RapidMiner Inc., SAP, SAS Institute Inc. and Teradata Corp. Some of these providers give multiple device. remark the "main companies of large facts analytics application" sidebar below for greater particulars about their selected product offerings.

    These providers symbolize diverse facets of the large records analytics market. Let's evaluate and distinction the ways in which these products meet the enterprise wants of user corporations.

    Analyst capabilities and talents 

    Some information analytics gear are targeted to beginner clients, some are centered to knowledgeable facts analysts and some are engineered to attraction to both forms of clients.

    items comparable to IBM SPSS Modeler, RapidMiner's equipment, Oracle superior Analytics and the computerized Analytics edition of SAP BusinessObjects Predictive Analytics are often designed to permit clients with a constrained background in data or information analysis to dissect records, improve analytical fashions and design analytics workflows with cramped or no coding.

    whereas each and every seller wraps its core analytics accessories with an intuitive consumer interface to reserve the analyst's progress in data instruction, evaluation, and then model design and validation, the strategy taken may additionally range, exceptionally when evaluating a stand-on my own product, similar to RapidMiner, with one that's a component of a bigger suite, such as the Oracle product.

    equipment reminiscent of IBM SPSS statistics, KNIME Analytics Platform, the skilled Analytics module of SAP BusinessObjects Predictive Analytics, Microsoft R and the Teradata Aster Analytics platform give the greater subtle functionality that skilled clients expect. Oracle R advanced Analytics for Hadoop (ORAAH), one of the most add-ons within the Oracle huge information utility Connectors suite, offers an R interface for manipulating Hadoop distributed File device statistics and writing mapper and reducer features in R. this pliability could exist attractive to greater advanced statistics scientists.

    Alteryx and SAS enterprise Miner offer functionality tailored to the user's smooth of skills, and nearly tumble into both classes. Alteryx has brought advancements to statistics profiling to aid facts scientists stronger reckon their records sources. common, SAS enterprise Miner and IBM's SPSS tools stand out when it comes to supporting greater advanced analytical suggestions and model scoring, as well as a broader array of evaluation features, including neural networks, affiliation analysis and visualization capabilities.

    Analytical variety

    counting on the exercise case and utility, your corporation's users might exist required to aid several types of analytics capabilities so as to exercise specific sorts of modeling, comparable to regression, clustering, segmentation, habits modeling and resolution trees.

    whereas this has resulted in wide assist for the a number of types of analytical modeling at a immoderate level, some providers possess invested a long time of labor into tweaking diverse models of their algorithms and adding greater subtle functionality. or not it's crucial to keep in mind which fashions are most crucial to your industry issues and to reckon the products when it comes to how they most suitable serve your clients' industry wants.

    it exist faultfinding to possess in mind which fashions are most faultfinding to your company complications and to reckon the items in terms of how they optimal serve your users' company wants.

    The greater age and better-end -- and, for that reason, better-priced -- tools will pomp the premier analytical breadth. Oracle records Miner includes an array of customary computer getting to know tactics to attend clustering, predictive mining and text mining. both versions of IBM's SPSS product give a diverse set of analytical suggestions and models. And SAS industry Miner helps many algorithms and recommendations, together with determination timber, time series, neural networks, linear and logistic regression, sequence and internet direction evaluation, market basket analysis, and link evaluation.

    The newer technology -- and, in some cases, decrease-priced -- products sheperd different fashions, however most likely with a narrower range of algorithmic sophistication.

    The model stock in Alteryx Analytics Gallery comprises such capabilities as regression analysis, determination timber, affiliation rule analysis, classification and time collection evaluation. KNIME contains methods for text mining, lifelike mining and time collection evaluation, and moreover integrates computer discovering algorithms from other open supply initiatives, reminiscent of Weka and JFreeChart.

    an additional constituent of analytical range is integration with programming languages and statistical equipment, similar to R, for incorporating latest libraries, in addition to person-described performance. really, integration with R may exist considered an more and more vital differentiator.

    Alteryx designer, Microsoft R, SAS industry Miner, Teradata Aster Analytics, Oracle's ORAAH and KNIME's Analytics Platform bar not one interface and assist integration with R. a pair of of the vendors, including IBM, Oracle, Microsoft, RapidMiner and SAP, deliver a turning out to exist library of extensions to R and Python, enabling users to hold abilities of free libraries.

    Scope of the facts to exist analyzed

    There are distinctive sides of the scope of the data to exist analyzed, together with the problem of structured vs. unstructured counsel, as well as entry to well-known on-premises databases and records warehouses, cloud-based mostly facts sources, and facts managed in large facts platforms, corresponding to Hadoop.

    despite the fact, there are various degrees of support for records managed inside much less-popular records lakes -- both managed within Hadoop or in one other NoSQL statistics management device supposed to give horizontal scaling. The components for distinguishing among the products must exist in accordance with your corporation's particular requirements for accessing and processing facts volumes and statistics variety.

    In attention of the becoming diversity of input sources and the range of underlying systems used to house those statistics units, another set of emerging aspects it's being adopted by means of these providers involves facts accessibility. IBM, RapidMiner, Alteryx, Oracle and Microsoft possess bar not one enhanced their equipment' information import, export and connectivity capabilities. These enhancements may still enable clients to entry a greater finished list of facts sources while simplifying and speeding up the manner of loading facts into the items.

    support for scalability and tall performance

    The necessity for scalable performance is driven by your firm's statistics volumes and urge for food for analysis. Smaller corporations with less statistics may well exist able to tolerate items that conclude not necessity efficiency characteristics that scale with the purchasable substances, such because the entry-degree types of the reduce-conclusion equipment, together with RapidMiner, KNIME, Microsoft R Open and Alteryx designer, which may flee on laptop techniques and conclude not require extra server add-ons.

    higher groups usually tend to possess a enhanced stock of information sets to analyze, as well as broader communities of clients. This introduces two additional requirements -- tall performance and facilitation of collaboration. The adaptability of a product to high-performance architectures is a very magnificient indication of scalability, and most of the items can moreover exist tailored to the parallelism of Hadoop or employ another potential of reaching quicker computation.

    the entire items conclude possess some assist for Hadoop, including IBM SPSS Modeler and SPSS statistics; RapidMiner's industrial constituent Radoop, which connects the Studio front conclusion and Server evaluation engine to statistics kept in Hadoop; Oracle's massive records Discovery and ORAAH equipment; and KNIME's astronomical facts Extensions and Cluster Execution add-ins.

    IBM SPSS now additionally provides more desirable aid for a few multithreaded analytical algorithms that may additionally pace efficiency. Teradata Aster Analytics addresses excessive-efficiency requirements via its massively Parallel Processing architecture. SAP's skilled Analytics edition of SAP BusinessObjects Predictive Analytics can execute in-memory statistics mining for managing huge-quantity statistics evaluation successfully. Microsoft R Server leverages its ScaleR module, a comprehensive library of massive data analytics algorithms that assist parallelization. Scoring algorithms implemented using SAS enterprise Miner may moreover exist deployed and performed within a Hadoop atmosphere.

    moreover, integration with Apache Spark looks to exist of transforming into importance. SPSS, KNIME, Oracle, RapidMiner and SAP bar not one supply entry to Apache Spark libraries to support analytics functions that necessity to scale with exploding statistics volumes. This enables developed functions to hold expertise of a excessive-efficiency cluster platform to dole the workflow across the cluster.

    Collaboration

    As referred to, the larger the corporation, the more likely there might exist a necessity to share analyses, fashions and functions across distinctive companies and among many analysts. companies which possess many analysts disbursed throughout the industry might moreover search for accelerated skill to share models and collaborate related to the interpretation of results.

    IBM's SPSS Modeler Gold edition gives collaboration capabilities, and RapidMiner's Server product offers sheperd for sharing and collaboration. Alteryx Analytics Gallery gives a mechanism for sharing sophisticated analytics functions within the cloud with contributors of a long organization. KNIME offers industrial extensions to support group collaboration, as well as extensions helping operational collaboration, such as far flung-scheduled execution, file generation, shared data space and a workflow repository. SAS industry Miner's customer-server architecture makes it practicable for enterprise clients and facts analysts to work collaboratively by means of sharing fashions and different work products.

    Alteryx, KNIME and Teradata Aster possess introduced capabilities to support manage analytical workflows. additionally, one of the vendors possess began to study the privilege way to permit their gear to combine with others that may additionally possess complementary functional candy spots. for 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 those workflows.

    dealer dimension and product integration

    companies can exist compared in terms of their dimension. One may compare and distinction what may exist pointed out as the mega-vendors, whose large data analytics gear are only one product amongst a huge portfolio of equipment. in case you work for a bigger organization that usually negotiates website-huge, enterprise licenses for the full suite of a dealer's gear from a mega-supplier equivalent to IBM, SAS, SAP or Oracle can exist an inexpensive option.

    The massive carriers promote astronomical statistics analytics gear which are a fraction of a tons higher tool ecosystem. possibly, the products from a mega-seller should exist as a minimum a cramped bit built-in and supposed to work collectively. furthermore, some americans feel greater relaxed with greater providers, with an expectation of steadiness and constant consumer service. nevertheless, you may additionally best exist capable of acquire these massive facts analytics gear as fraction of a lots greater application licensing association.

    Smaller vendors, equivalent to KNIME, Alteryx and RapidMiner, possess revenues that are commonly according to licensing and attend for a small number of large facts analytics products. A smaller seller may moreover provide closer contact with their product administration and innovation teams, and you'll exist able to possess an sequel on the path of the product roadmap or more suitable performance.

    A smaller dealer may moreover exist extra springy when it comes to fee and the points covered within the licensing association. You should realize, despite the fact, that working with a smaller vendor does present some casual when it comes to balance, the substances purchasable for support and the probability that the industry may well exist obtained, that can influence the client relationship.

    The greater companies are certainly awake of user needs for integration with different methods, besides the fact that children that frequently centers on other products within each dealer's inventory. as an example, SAP Predictive Analytics has enhanced integration with SAP HANA and BusinessObjects Cloud. SAS industry Miner has brought nodes to execute code in a SAS open, cloud-ready, in-reminiscence Viya environment. Microsoft presents SQL Server R features, an R setting up that runs alongside SQL Server and allows for clients to integrate Microsoft R Server statistics with SQL Server and Microsoft's other enterprise intelligence tools.

    funds for licensing and maintenance

    virtually bar not one of the carriers promote separate models or variations of their items, with a number prices for acquisition and complete charge of operation. IBM, Oracle, RapidMiner, Teradata and Microsoft promote variants at different tiers, with the license can charge proportional to the elements, capabilities and liberty from obstacles in terms of the volumes of facts to exist analyzed or the variety of processing nodes the product can use.

    KNIME and RapidMiner provide free and open source versions of their items, both charging for assist functions or for variations supporting commercial enterprise-type purposes. KNIME, RapidMiner and Alteryx possess exceedingly low licensing fees for a smaller variety of clients. if you're when you reckon that SAS or SAP, you necessity to contact them for pricing options.

    The industry for astronomical statistics analytics application can moreover exist a complicated region, but with a bit of luck this text has helped you hold note the benefits astronomical information analytics utility can supply your organization, and assisted you in differentiating between the specific gear examined here.


    BAS-011 IBM SPSS Statistics smooth 1 v2

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

    Test Code : BAS-011
    Test name : IBM SPSS Statistics smooth 1 v2
    Vendor name : IBM
    : 55 true Questions

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    Technology Infrastructure, Graphics and Visualization, and Adaptive Technologies | killexams.com true 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 involve multiple processor support, large recollection 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 moreover 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 peppery Swap internal disk capacity. The PE 4400 has up to two Pentium III 1GHz processors, 4GB of PC133 SDRAM and 252GB of peppery 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.

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    The 43P-140 is an entry-level desktop/deskside system that provides a range of performance options, from drafting, design, and software evolution 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 industry Machines, Inc., Armonk, NY; (914) 499-1900; www.ibm.com.

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

    The main point 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 necessary condition for children to exist energetic 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 spot in facilities that were located inside children’s neighborhood. bar not one other perceived neighborhood characteristics were unrelated to PA in public recreation spaces that took spot 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 possess 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 energetic in smaller parks compared to larger parks [18]. This may argue 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 exist more efficacious in increasing PA than larger parks that are further away from children’s home. However, the present results should exist interpreted with caution because invert causality may exist present. For example, it is practicable that parents from children who are frequently energetic in a public recreation space are more awake of these facilities, compared to parents from children who are mostly energetic in the garden.

    It is practicable that not only the presence of recreation facilities is necessary to expound children’s PA in these facilities, but moreover the presence of features in the recreation facilities and their quality may play an necessary 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 energetic [41]. moreover in the US, park renovations appeared to extend 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 vary from correlates of PA in public recreation spaces outside the neighborhood.

    Parental perceived land exercise blend 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 energetic commuting to school, land exercise blend accessibility was moreover positively related to children’s energetic transport to school [43]. These findings may argue that a neighborhood with a tall perceived accessibility is necessary for children to exist energetic 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]. moreover 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 exist 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 moreover 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 exist physically active. For example, this can exist done by providing sufficient play space (e.g. small parks) in neighborhoods with a tall street connectivity for walking and cycling.

    In contrast to their hypothesis that an activity unfriendly neighborhood would exist associated to more garden PA, but similar to the results of an Australian study [20], not one 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) expound 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 practicable that specific garden characteristics (e.g. size of the garden) mediate the association between neighborhood characteristics and children’s garden PA.

    These findings present that the physical neighborhood environment is mainly related to PA that actually takes spot 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 fraction of children’s overall MVPA takes spot outside the neighborhood (e.g. in the sports club or at school) and only a small fraction of their overall PA takes spot in the neighborhood or public recreation spaces, the influence of the neighborhood physical environment on children’s overall MVPA might exist limited; whereas in adults, the neighborhood physical environment relates to overall MVPA in adults [47]. moreover 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 practicable that the perceived neighborhood environment relates more strongly to overall MVPA during school vacations, because then children possess less opportunities to exist energetic at schools or in a sports clubs.

    More insight into the location-specific PA correlates will exist very informative for policy makers or urban planners, aiming to extend children’s PA levels in specific places (e.g. recreation facilities). Therefore, in future studies the exercise 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 exist exactly located in the neighborhood and data will not exist biased by self-report. moreover the exercise 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, moreover the relation between the perceived neighborhood environment and objectively measured MVPA during vacation and other specific time periods (e.g. faultfinding window MVPA (=after school until 6 pm)) should exist investigated.

    Strengths of this study were the exercise of the validated NEWS, the most commonly used questionnaire in the literature to assess environmental perceptions [48], the relatively large sample, the exercise of accelerometry to objectively determine MVPA and the exercise of parental perceptions of the physical environment. The cross-sectional study design is a limitation, as no causal relationships could exist examined. Furthermore, no objective measures of location-specific PA were available which made it impossible to test the criterion validity of these measures. moreover the neighborhood characteristics were measured by self-report. It is practicable that correlated error might possess influenced the association between the two self-reported measures (i.e. parental reported PA and parental reported neighborhood characteristics) to a small extent. moreover the response rate of the principals was rather low, which may possess limited the representativeness of the findings. For example, it is practicable 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 tall 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 possess resulted in a selection bias.


    Clinical Features and Hospital Outcomes in Thyroid Storm: A Retrospective Cohort Study | killexams.com true 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 possess 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 exist precise criteria for TS (9). This manner 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 fresh 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 fresh Ak diagnostic criteria possess 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 possess 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 exist pertinent to distinguishing TS from compensated thyrotoxicosis (CT) in the acute setting. The Los Angeles County-University of Southern California Medical hub (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 remark advanced stages of many diseases, including TS.

    In this single-center retrospective cohort study covering a 6-year era 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 necessary to hospital-based outcomes, many of which possess 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 smooth (<0.01 mIU/L) were retrospectively reviewed. The genesis of the study era represents when the medical records became available in electronic format. Repeated admissions by a single patient were recorded separately. An undetectable TSH smooth 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 exercise 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 fraction 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. bar not one 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 exist resolved by a blinded second reviewer, greater severity favoring TS was assumed. Outcomes measures included hospital length of stay (LOS), intensive supervision 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 cadence 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, remark 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 pertinent 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 fresh 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, suggest 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 design 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 hub to outer line, with divisions every 20%. bar not one 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 design 1C. Consistent with the criteria used to accomplish the diagnosis, those with TS were significantly more likely to possess fever (relative risk [RR] = 5.98 [95% aplomb 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 moreover 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 languor and coma in 1 case each). However, in these patients, not one 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 bar not one 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 import (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 import (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 role 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 inequity in the symmetry 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 smooth 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. bar not one laboratory data for TS and CT patients as well as CT patients divided into BWS and Ak groups is provided in Supplemental design 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 bar not one but 1 case. Treatment with thionamides and β-blockade only was used in CT patients. Both groups received appropriate supportive supervision 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 argue 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 bar not one 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 design 2, median hospital LOS was significantly longer in TS patients compared with bar not one 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 symmetry of patients requiring ICU admission during hospitalization, and the median ICU LOS were moreover 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 fresh criteria for diagnosing TS. However, these diagnostic systems are difficult to evaluate because of the rarity of TS and the absence of a dependable gold standard and thus far possess 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 concurrent 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 tall percentage may suggest a bounteous clinical diagnosis of TS, although many more patients would possess 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 bar not one 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 exist less sensitive for the diagnosis of TS because there is no equivalent intermediate category. However, if bar not one patients with a BWS of 25–44 are considered TS, 66% of thyrotoxic patients in this study would potentially possess received treatment for TS, suggesting that BWSs inform but conclude 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 practicable adverse consequences. tall doses of thionamide drugs may extend 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 exist carefully weighed. A better understanding of the clinical features associated with worse outcomes in TS may attend identify patients with the greatest potential to profit 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 exist 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 significance of CNS dysfunction to the diagnosis of TS was recently recognized in Akamizu et al (10) and was incorporated as a key constituent to their TS1 criteria, in fraction 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 vary between TS and CT patients, suggesting that in the acute hospital setting, these findings may exist less informative, although small sample size may possess limited the skill to detect differences in these parameters. In particular, GI-hepatic manifestations were frequent in bar not one hospitalized thyrotoxic patients but were not associated with the clinical diagnosis of TS.

    This study moreover compares for the first time several hospital outcomes pertinent to patient morbidity and healthcare exercise 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 faultfinding supervision medicine likely bar not one 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 exist of importance. Thyroid hormone-induced peripheral vasodilation to dissipate excess heat, and impaired skill to augment cardiac role 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 argue 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 faultfinding aspects of TS argues that therapeutic interventions aimed at optimizing intravascular volume and cardiovascular role may exist the most necessary components of treatment for TS.

    We recognize several limitations of the current study. Although the diagnosis and treatment of TS at a single hub likely provided homogeneity in the classification and treatment of patients, the methodology for diagnosing TS may exist difficult to replicate in future investigations or clinical practice. Retrospective data may accommodate ascertainment prejudice and is limited to correlative analyses. Any negative findings in this study must recognize a practicable 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 possess 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 significance in assessing for TS. Given the greater rate of mortality and adverse hospital outcomes observed in patients clinically diagnosed with TS at their institution, patients with suspected TS and altered mentation may derive the greatest profit 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 supervision unit

    INR

    international normalized ratio

    IQR

    interquartile range

    LOS

    length of stay

    RR

    relative risk

    TS

    thyroid storm.

    Acknowledgments

    Disclosure Summary: bar not one authors possess no conflicts of interest to declare.

    © 2017 Endocrine Society

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    References :


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