{"id":25247,"date":"2022-08-22T14:22:34","date_gmt":"2022-08-22T11:22:34","guid":{"rendered":"https:\/\/www.klimikdergisi.org\/?p=25247"},"modified":"2022-09-28T15:28:29","modified_gmt":"2022-09-28T12:28:29","slug":"ct-duzeyi-ile-klinik-seyir-ve-mortalite-iliskisi","status":"publish","type":"post","link":"https:\/\/www.klimikdergisi.org\/tr\/2022\/08\/22\/ct-duzeyi-ile-klinik-seyir-ve-mortalite-iliskisi\/","title":{"rendered":"SARS-CoV-2 PCR D\u00f6ng\u00fc E\u015fik (Ct) De\u011feri ile Klinik Seyir ve Mortalite \u0130li\u015fkisinin De\u011ferlendirilmesi"},"content":{"rendered":"

G\u0130R\u0130\u015e<\/h2>\n

D\u00fcnya Sa\u011fl\u0131k \u00d6rg\u00fct\u00fc (DS\u00d6) taraf\u0131ndan, Ocak 2020\u2019de daha \u00f6nce insanlarda tespit edilmemi\u015f yeni bir koronavirus (2019- nCoV) tan\u0131mlanm\u0131\u015f ve \u015eubat 2020\u2019de, hastal\u0131\u011f\u0131n ad\u0131 koronavirus hastal\u0131\u011f\u0131-2019 (COVID-19) olarak kabul edilmi\u015ftir. Virus, \u015fiddetli akut solunum yolu sendromu virusu (SARS-CoV-2) olarak adland\u0131r\u0131lm\u0131\u015ft\u0131r (1, 2). 2020 y\u0131l\u0131ndan itibaren h\u0131zla yay\u0131lan virus halen t\u00fcm d\u00fcnyay\u0131 etkilemeye devam etmektedir. SARS-CoV-2 infeksiyonunun klinik g\u00f6r\u00fcn\u00fcm\u00fc asemptomatik infeksiyondan \u00f6l\u00fcmle sonu\u00e7lanabilecek \u015fiddetli hastal\u0131\u011fa kadar de\u011fi\u015febilmektedir (1).\u00a0<\/span><\/p>\n

\u0130lk \u00e7al\u0131\u015fmalar, olumsuz klinik sonu\u00e7lar\u0131 tahmin etmek i\u00e7in konak\u00e7\u0131 risk fakt\u00f6rlerine odaklanm\u0131\u015ft\u0131r. Komorbiditeleri olan ya\u015fl\u0131 hastalar\u0131n daha k\u00f6t\u00fc prognoza sahip oldu\u011fu bilinmektedir (3). Ancak hastal\u0131\u011f\u0131n seyri ve sonucunu etkileyen ba\u015fka pek \u00e7ok fakt\u00f6r oldu\u011fundan, komorbiditesi bulunmayan hastalarda da ciddi klinik tablolar g\u00f6r\u00fclebilmektedir (4). Daha \u00f6nceki y\u0131llarda tan\u0131mlanm\u0131\u015f olan insan koronavirus t\u00fcrlerine ba\u011fl\u0131 solunum yolu hastal\u0131klar\u0131nda, y\u00fcksek virus y\u00fck\u00fcn\u00fcn daha k\u00f6t\u00fc bir klinik seyir ile ili\u015fkili oldu\u011fu g\u00f6sterilmi\u015ftir (5).<\/span><\/p>\n

COVID-19 tan\u0131s\u0131 i\u00e7in ilk tercih edilen ve alt\u0131n standart olarak kabul edilen y\u00f6ntem,\u00a0 <\/span>SARS-CoV-2 spesifik ger\u00e7ek zamanl\u0131 revers transkriptaz polimeraz zincir reaksiyonu (RT-PCR) testi ile viral n\u00fckleik asit tayinidir. RT-PCR testinde pozitif sonucun tespitini, numunedeki n\u00fckleik asidin \u00e7o\u011falmas\u0131n\u0131 floresan sinyalin toplanmas\u0131 ile g\u00f6steren sigmoidal bir amplifikasyon e\u011frisi sa\u011flar. \u201cCycle threshold\u201d (Ct); floresan sinyalin ge\u00e7mesi i\u00e7in gereken d\u00f6ng\u00fc say\u0131s\u0131 e\u015fi\u011fi olarak tan\u0131mlan\u0131r. Ct de\u011feri, y\u00fcksek ya da d\u00fc\u015f\u00fck viral y\u00fck\u00fc ay\u0131rt etmemizi sa\u011flayan semikantitatif bir de\u011ferdir ve \u00f6rnek i\u00e7indeki hedef n\u00fckleik asit miktar\u0131 ile ters orant\u0131l\u0131d\u0131r (6). Ct de\u011feri ne kadar d\u00fc\u015f\u00fckse \u00f6rnekteki viral genetik materyalin miktar\u0131 o kadar y\u00fcksektir. Klinik pratikte SARS-CoV-2 RT-PCR sonu\u00e7lar\u0131 rapor edilirken, Ct\u2019nin e\u015fik de\u011ferin alt\u0131nda veya \u00fcst\u00fcnde olu\u015funa g\u00f6re sonu\u00e7lar pozitif veya negatif olarak rapor edilmekle birlikte Ct de\u011ferinin kendisi normalde verilmemektedir. Oysa Ct de\u011feri viral y\u00fck\u00fc g\u00f6stermektedir. Viral y\u00fck\u00fcn hastal\u0131k \u015fiddeti ve prognozu a\u00e7\u0131s\u0131ndan \u00f6nemli bir belirte\u00e7 olabilece\u011fi di\u011fer solunum yolu virusleri ile ilgili \u00e7al\u0131\u015fmalarda daha \u00f6nce bildirilmi\u015ftir (7). Bug\u00fcne kadar SARS CoV-2 viral y\u00fck\u00fc ile hastal\u0131k progresyonu ve mortalite aras\u0131ndaki ili\u015fkileri ara\u015ft\u0131rm\u0131\u015f olan \u00e7al\u0131\u015fmalar\u0131n \u00e7o\u011fu; viral y\u00fck ile pn\u00f6moni derecesi, hipoksemi, \u00f6l\u00fcm riski, hematolojik, inflamatuar ve biyokimyasal belirte\u00e7ler aras\u0131nda pozitif bir korelasyonu i\u015faret etmektedir. Prognostik tahminler yapmay\u0131 sa\u011flayan g\u00f6stergeler; hastalar\u0131n klinik seyrini tahmin etmek i\u00e7in kolayla\u015ft\u0131r\u0131c\u0131 olacakt\u0131r (4).<\/p>\n

Bu \u00e7al\u0131\u015fmada, COVID-19 hastal\u0131\u011f\u0131nda RT-PCR Ct de\u011feri ile k\u00f6t\u00fc klinik seyir ve mortalite ili\u015fkisinin de\u011ferlendirilmesi ama\u00e7land\u0131.<\/p>\n

Y\u00d6NTEMLER<\/h2>\n

SARS-CoV-2 RT-PCR tan\u0131 testi, 01 A\u011fustos – 30 Kas\u0131m 2020 tarihleri aras\u0131nda hastanemiz t\u0131bbi mikrobiyoloji laboratuvar\u0131nda \u00e7al\u0131\u015f\u0131ld\u0131. Test sonucu pozitif olan ve COVID-19 ili\u015fkili semptom ve bulgularla hastaneye yat\u0131r\u0131lan, varsa ayn\u0131 g\u00fcn yoksa 7 g\u00fcn i\u00e7inde laboratuvar parametrelerine bak\u0131lan ve toraks tomografisi \u00e7ekilen eri\u015fkin 117 hasta \u00e7al\u0131\u015fmaya al\u0131nd\u0131. Hastalar yatan hasta servis kay\u0131tlar\u0131ndan geriye do\u011fru taranarak listelendi. PCR testi sonras\u0131 7 g\u00fcn i\u00e7inde yap\u0131lan ilk laboratuvar tetkikleri \u201cba\u015fvuru<\/i>\u201d tetkiki olarak kaydedildi.<\/p>\n

\u00c7al\u0131\u015fmaya dahil edilen hastalara ait t\u00fcm veriler hastane otomasyon sistemi \u00fczerinden retrospektif olarak tarand\u0131; demografik veriler, ba\u015fvurudaki laboratuvar tetkiki sonu\u00e7lar\u0131, ald\u0131\u011f\u0131 antiviral, steroid ve destek tedavileri, yat\u0131\u015f s\u00fcresi, yo\u011fun bak\u0131m (YB) ihtiyac\u0131, mekanik ventilat\u00f6r (MV) ihtiyac\u0131 ve mortalite oranlar\u0131 ile birlikte hastalar\u0131n tan\u0131 an\u0131ndaki PCR testlerindeki Ct de\u011ferleri kaydedildi.<\/p>\n

N\u00fckleik asit ekstrakte edici ve koruyucu bir s\u0131v\u0131 i\u00e7eren vNAT\u00ae<\/sup> transfer t\u00fcp\u00fcne (Bioeksen AR-GE Teknolojileri, T\u00fcrkiye) al\u0131nan nazofaringeal \u00f6rneklerin RT-PCR testleri, BioSpeedy\u00ae<\/span> SARS-CoV-2 RT-PCR kiti (Bioeksen AR-GE Teknolojileri, T\u00fcrkiye) ile rutin \u00e7al\u0131\u015fmalar dahilinde ger\u00e7ekle\u015ftirildi. Bu y\u00f6ntemde \u00fcretici firman\u0131n \u00f6nerileri do\u011frultusunda, 2.5 \u03bcL\u2019lik ekstrakt ile total 10 \u03bcL\u2019lik reaksiyon hacmi kullan\u0131ld\u0131; SARS-CoV-2\u2019ye spesifik a\u00e7\u0131k okuma b\u00f6lgesi (\u201cOpen Reading Frame, ORF\u201d) 1Ab ve N (nucleocapsid) genleri ile internal kontrol olarak insan RNase P (ribon\u00fckleaz P) geni hedeflendi. Amplifikasyon a\u015famas\u0131, Rotor-Gene (Qiagen, Almanya) cihaz\u0131 kullan\u0131larak ger\u00e7ekle\u015ftirildi. Test analizi \u00fcretici firman\u0131n \u00f6nerileri do\u011frultusunda yap\u0131ld\u0131. Viral y\u00fck Cycle Ct olarak ifade edildi ve SARS-CoV-2 gen hedefleri i\u00e7in Ct de\u011ferleri \u226433 olan sonu\u00e7lar pozitif olarak kabul edildi.<\/p>\n

Tedavi ba\u015flad\u0131\u011f\u0131 andaki pn\u00f6moninin a\u011f\u0131rl\u0131k derecesi, d\u00fc\u015f\u00fck doz kontrasts\u0131z toraks tomografisi bulgular\u0131na g\u00f6re yap\u0131ld\u0131. Daha \u00e7ok alt loblarda olmak \u00fczere tek tarafl\u0131 veya bilateral, periferik veya fiss\u00fcre kom\u015fu, k\u00fc\u00e7\u00fck, k\u0131smen yuvarlak buzlu cam opasiteleri \u201chafif<\/i>\u201d; bilateral, multifokal, akci\u011ferin \u00fcst loblar\u0131na kadar, daha geni\u015f \u00e7apl\u0131 ancak parankimin %50\u2019sinin alt\u0131nda tutulum olan tomografiler \u201corta<\/i>\u201d; bilateral akci\u011fer parankiminde %50\u2019nin \u00fczerinde yayg\u0131n tutulum, buzlu cam opasitelerine e\u015flik eden konsolidasyon veya hava bronkogram\u0131 veya \u201ccrazy-paving\u201d i\u00e7eren tomografiler \u201ca\u011f\u0131r<\/i>\u201d pn\u00f6moni olarak s\u0131n\u0131fland\u0131r\u0131ld\u0131 (8).\u00a0<\/span><\/p>\n

Oksijen ihtiyac\u0131n\u0131n miktar\u0131na ve s\u00fcresine ba\u011fl\u0131 olarak hastalara verilen steroid t\u00fcr\u00fc, dozu ve s\u00fcresi de\u011fi\u015fkenlik g\u00f6sterdi\u011fi ve farkl\u0131 dozda ba\u015flay\u0131p farkl\u0131 \u015femalarla azalt\u0131labildi\u011fi i\u00e7in standardizasyon amac\u0131yla hastalar\u0131n 10 g\u00fcn s\u00fcre ile ald\u0131\u011f\u0131 total steroid dozu kaydedildi.<\/p>\n

RT-PCR testi ile tan\u0131 sonras\u0131 28 g\u00fcn i\u00e7inde mortalite geli\u015fimi i\u00e7in \u201c28 g\u00fcn kaba mortalite<\/i>\u201d tan\u0131m\u0131 kullan\u0131ld\u0131.\u00a0<\/span><\/p>\n

Hastalar, Ct de\u011feri <20, 20-24 aras\u0131 ve >24 olanlar \u015feklinde \u00fc\u00e7 gruba ayr\u0131ld\u0131. Bu \u00fc\u00e7 grup aras\u0131nda fark olup olmad\u0131\u011f\u0131; ya\u015f, cinsiyet, komorbid hastal\u0131k varl\u0131\u011f\u0131, pn\u00f6moninin \u015fiddeti, k\u00f6t\u00fc prognostik laboratuvar parametrelerinin d\u00fczeyi (D-dimer, n\u00f6trofil\/lenfosit (N\/L) oran\u0131, C-reaktif protein (CRP), lenfosit say\u0131s\u0131), servis yat\u0131\u015f s\u00fcresi, YB ihtiyac\u0131, YB yat\u0131\u015f s\u00fcresi, MV ihtiyac\u0131 ve mortalite a\u00e7\u0131s\u0131ndan de\u011ferlendirildi.<\/p>\n

Ayr\u0131ca \u201cReceiver Operating Characteristic\u201d (ROC) analizi neticesinde belirlenen Ct de\u011feri <23.3 ve \u2265 23.3 olanlar \u015feklinde hastalar iki gruba ayr\u0131ld\u0131; bu iki grup aras\u0131nda MV ihtiyac\u0131, YB ihtiyac\u0131 ve mortalite oranlar\u0131 a\u00e7\u0131s\u0131ndan fark olup olmad\u0131\u011f\u0131 ara\u015ft\u0131r\u0131ld\u0131.\u00a0<\/span><\/p>\n

\u00c7al\u0131\u015fma i\u00e7in S.B.\u00dc. Antalya E\u011fitim ve Ara\u015ft\u0131rma Hastanesi Klinik Ara\u015ft\u0131rmalar Etik Kurulu\u2019ndan 01 Nisan 2021 tarih ve 4\/24 karar numaras\u0131yla onay al\u0131nm\u0131\u015ft\u0131r.<\/span><\/p>\n

\u0130statistiksel Analiz<\/h3>\n

Verilerin istatistiksel analizinde SPSS (\u201cStatistical Package for the Social Sciences\u201d) versiyon 22.0 program\u0131 (IBM Corp., Armonk, NY, ABD) kullan\u0131ld\u0131. \u00c7al\u0131\u015fmada yer alan kategorik de\u011fi\u015fkenler say\u0131 ve y\u00fczde ile s\u00fcrekli de\u011fi\u015fkenler ortalama, standart sapma, minimum ve maksimum de\u011ferler ile sunuldu. S\u00fcrekli de\u011fi\u015fkenlerin normal da\u011f\u0131l\u0131ma uygunlu\u011fu normalite testleri ile kontrol edildi. Gruplardaki \u00f6rneklem b\u00fcy\u00fckl\u00fc\u011f\u00fc 50 ve \u00fcst\u00fc ise normalite testi olarak Kolmogorov-Smirnov testi baz al\u0131nd\u0131. Gruplar aras\u0131nda, s\u00fcrekli de\u011fi\u015fkenlerin ortalamalar\u0131n\u0131n istatistiksel analizinde \u201cindependent samples\u201d t-testi kullan\u0131ld\u0131. Gruplar aras\u0131nda kategorik de\u011fi\u015fkenlerin istatistiksel analizinde Pearson ki-kare testi kullan\u0131ld\u0131. Hastalar Ct de\u011feri; <20,\u00a0 <\/span>20-24 ve >24 olanlar \u015feklinde \u00fc\u00e7 gruba ayr\u0131ld\u0131; ya\u015f, cinsiyet, komorbid hastal\u0131k varl\u0131\u011f\u0131, pn\u00f6moninin \u015fiddeti, k\u00f6t\u00fc prognostik laboratuvar parametrelerinin (D-dimer, N\/L oran\u0131, CRP, lenfosit say\u0131s\u0131) d\u00fczeyi, servis yat\u0131\u015f s\u00fcresi, YB ihtiyac\u0131, YB yat\u0131\u015f s\u00fcresi, MV ihtiyac\u0131 ve mortalite a\u00e7\u0131s\u0131ndan anlaml\u0131 fark olup olmad\u0131\u011f\u0131 kategorik de\u011fi\u015fkenler i\u00e7in Pearson ki-kare testi, s\u00fcrekli de\u011fi\u015fkenler i\u00e7in\u00a0 <\/span>ANOVA ve Kruskal-Wallis testi ile analiz edildi. Ayr\u0131ca RT-PCR testi ile elde edilen Ct de\u011ferleri kaydedilerek ROC analizi ile optimal duyarl\u0131l\u0131k ve \u00f6zg\u00fcll\u00fck de\u011ferlerine g\u00f6re yo\u011fun bak\u0131ma yat\u0131\u015f ve mortalite ihtimalinin \u00f6ng\u00f6r\u00fcs\u00fcnde kullan\u0131labilecek Ct e\u015fik de\u011feri hesapland\u0131. Ayr\u0131ca ROC analizi ile elde edilen Ct de\u011feri <23.3 ve \u2265 23.3 olanlar \u015feklinde hastalar iki gruba ayr\u0131ld\u0131 ve YB ihtiyac\u0131, MV ihtiyac\u0131 ve 28 g\u00fcn mortalite oranlar\u0131 a\u00e7\u0131s\u0131ndan bu iki grup aras\u0131nda fark olup olmad\u0131\u011f\u0131 ara\u015ft\u0131r\u0131ld\u0131. \u0130statistiksel olarak anlaml\u0131 kabul edilen p<\/i> de\u011feri <0.05 olarak kabul edildi.<\/span><\/p>\n

BULGULAR<\/h2>\n

\u00c7al\u0131\u015fmaya al\u0131nan 117 hastan\u0131n\u00a0 <\/span>65 (%56)\u2019i erkek, 52 (%44)\u2019si kad\u0131nd\u0131. Ya\u015f ortalamas\u0131 58.36\u00b116.18 (19-91) idi. Erkek hastalar\u0131n ya\u015f ortalamas\u0131 59.26\u00b115.37 (27-91), kad\u0131n hastalar\u0131n ya\u015f ortalamas\u0131 57.23\u00b117.21 (19-86) olarak hesapland\u0131. Erkek ve kad\u0131n hasta grubunda ya\u015f da\u011f\u0131l\u0131m\u0131 a\u00e7\u0131s\u0131ndan istatistiksel olarak anlaml\u0131 d\u00fczeyde bir fark saptanmad\u0131 (p<\/i>=0.502).<\/p>\n

Hastalar\u0131n 67 (%57)\u2019sinde en az bir komorbid hastal\u0131k mevcuttu. S\u00f6z konusu hastal\u0131klar\u0131n s\u0131kl\u0131k s\u0131ras\u0131 hipertansiyon (HT), diabetes mellitus (DM) ve koroner arter hastal\u0131\u011f\u0131 (KAH) olarak tespit edildi.\u00a0 <\/span>En s\u0131k ba\u015fvuru semptomlar\u0131 s\u0131ras\u0131 ile \u00f6ks\u00fcr\u00fck, nefes darl\u0131\u011f\u0131 ve ate\u015fti. Semptom ba\u015flang\u0131c\u0131ndan RT-PCR testi ile tan\u0131 konulmas\u0131na kadar ge\u00e7en s\u00fcre ortalama 4.65\u00b12.60 (1-14) g\u00fcn olarak saptand\u0131.\u00a0<\/span><\/p>\n

Hastalar\u0131n tamam\u0131n\u0131n antiviral tedavi olarak en az be\u015f g\u00fcn favipiravir kulland\u0131\u011f\u0131 g\u00f6r\u00fcld\u00fc. Yat\u0131\u015f g\u00fcn\u00fc oda havas\u0131nda oksijen sat\u00fcrasyonu ortalama %92.10\u00b14.06 (78-99) idi.\u00a0<\/span><\/p>\n

\u00d6rneklerin tamam\u0131 hen\u00fcz varyant su\u015f geli\u015ftirmemi\u015f ilk virusla infekte hastalara aitti. T\u00fcm hastalar\u0131n Ct de\u011feri ortalamas\u0131 22.37\u00b14.72 (11.07-34.06) olarak hesapland\u0131.<\/p>\n

\u00c7al\u0131\u015fmaya hastaneye yat\u0131r\u0131lm\u0131\u015f olan hastalar\u0131n al\u0131nmas\u0131 nedeniyle\u00a0 <\/span>pn\u00f6moni evresi \u00e7o\u011fu hastada (n=86, %74) orta-ileri evre olup pn\u00f6monisi olmad\u0131\u011f\u0131 halde yatan az say\u0131da hastan\u0131n (n=7, %6) oral al\u0131m azl\u0131\u011f\u0131, ileri ya\u015f ve genel durum d\u00fc\u015fk\u00fcnl\u00fc\u011f\u00fc gibi nedenlerle yat\u0131r\u0131ld\u0131\u011f\u0131 tespit edildi.\u00a0<\/span><\/p>\n

Hastalar\u0131n ilk yat\u0131\u015f yerleri de\u011ferlendirildi\u011finde; 112 (%96)\u2019sinin ilk yat\u0131\u015f yeri servis olup kalan be\u015f hastan\u0131n do\u011frudan yo\u011fun bak\u0131ma yat\u0131r\u0131ld\u0131\u011f\u0131 g\u00f6r\u00fcld\u00fc. Servis takibinde YB ihtiyac\u0131 geli\u015fen hastalarla birlikte YB\u2019da yatan hasta say\u0131s\u0131 toplam 58 (%50) olarak saptand\u0131. Servis yat\u0131\u015f s\u00fcresi ortalama 6.7\u00b14.4 (1-21) g\u00fcn, YB yat\u0131\u015f s\u00fcresi ise ortalama 8.21\u00b17.68 (1-28) g\u00fcn olarak hesapland\u0131. YB yat\u0131\u015f\u0131 olan hastalardan dokuz hastan\u0131n hem y\u00fcksek ak\u0131\u015fl\u0131 oksijen (\u201cHigh Flow Oxygen, HFO\u201d) tedavisi hem de s\u00fcrekli pozitif hava yolu (\u201cContinious Positive Airway Pressure, CPAP\u201d) cihaz\u0131 ile solutulmas\u0131 ihtiyac\u0131 oldu\u011fu tespit edildi. Dokuz hastan\u0131n sadece CPAP, 30 hastan\u0131n ise HFO ihtiyac\u0131 olmu\u015ftu. YB\u2019a yatan hastalardan 46 (%79)\u2019s\u0131n\u0131n MV ihtiyac\u0131 oldu\u011fu g\u00f6r\u00fcld\u00fc.<\/p>\n

Tan\u0131 sonras\u0131, 28 g\u00fcn i\u00e7inde kaba mortalite oran\u0131 %32 (n=37) olarak saptand\u0131. Mortalite g\u00fcn\u00fc ortalamas\u0131 15.65\u00b15.89 (5-27) g\u00fcn olarak hesapland\u0131.\u00a0<\/span><\/p>\n

Ba\u015fvuru s\u0131ras\u0131nda yap\u0131lan laboratuvar tetkiklerinden \u00f6zellikle CRP, D-dimer, N\/L oran\u0131 ve lenfosit say\u0131s\u0131 gibi k\u00f6t\u00fc prognostik g\u00f6stergeler de\u011ferlendirildi. D-dimer d\u00fczeyi ortalamas\u0131 754.2\u00b11288 \u00b5g\/L, CRP d\u00fczeyi ortalamas\u0131 106.83\u00b1 82.36 mg\/dL, lenfosit say\u0131s\u0131 ortalamas\u0131 1117.24\u00b1576.69\/mm3<\/sup> ve N\/L oran\u0131 ortalamas\u0131 8.79 \u00b19.93 olarak saptand\u0131.\u00a0<\/span><\/p>\n

\"\"<\/a>

Tablo 1.<\/strong> Genel Demografik ve Klinik \u00d6zellikler<\/p><\/div>\n

En az be\u015f g\u00fcn s\u00fcre ile steroid tedavisi alan hasta say\u0131s\u0131 61 (%52) olup bu hastalar\u0131n 51 (%84)\u2019inde kullan\u0131lan steroid t\u00fcr\u00fc metilprednizolon idi. On g\u00fcnl\u00fck total metilprednizolon dozu ortalamas\u0131 659.80\u00b1396.99 mg; 10 g\u00fcnl\u00fck total deksametazon dozu ortalamas\u0131 64.6\u00b128.72 mg olarak hesapland\u0131. Genel demografik ve klinik \u00f6zellikler Tablo 1\u2019de verilmi\u015ftir.<\/p>\n

YB ihtiyac\u0131 olan ve olmayan hastalar demografik veriler ve Ct de\u011ferleri a\u00e7\u0131s\u0131ndan kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131. YB ihtiyac\u0131 olan hastalar\u0131n ya\u015f ortalamas\u0131 (67.53), olmayan hastalar\u0131n ya\u015f ortalamas\u0131na (49.33) g\u00f6re daha y\u00fcksek saptand\u0131; fark istatistiksel olarak p<\/i><0.01 <\/b>de\u011feriyle <\/b>anlaml\u0131yd\u0131. YB ihtiyac\u0131 olan hastalar\u0131n 31(%53.4)\u2019i erkekti. Cinsiyetin yo\u011fun bak\u0131ma yat\u0131\u015f a\u00e7\u0131s\u0131ndan fark olu\u015fturmad\u0131\u011f\u0131 g\u00f6r\u00fcld\u00fc (p<\/i>=0.649). YB ihtiyac\u0131 olan hastalar\u0131n %65.7\u2019sinde komorbid hastal\u0131k mevcutken YB ihtiyac\u0131 olmayan hastalarda bu oran %34.3\u2019t\u00fc; fark istatistiksel olarak anlaml\u0131yd\u0131 (p<\/i><0.001).<\/b><\/p>\n

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Tablo 2.<\/strong> YB ve MV \u0130htiyac\u0131 Olan ve Olmayan Hastalar\u0131n Ortalama Ct De\u011ferleri<\/p><\/div>\n

YB ihtiyac\u0131 olan ve olmayan hastalar aras\u0131nda Ct de\u011feri ortalamalar\u0131 a\u00e7\u0131s\u0131ndan anlaml\u0131 fark saptanmad\u0131 (p<\/i>=0.482). Yo\u011fun bak\u0131ma yatan 58 hastadan, MV ihtiyac\u0131 olan ve olmayan hastalar aras\u0131nda, Ct de\u011feri ortalamalar\u0131 a\u00e7\u0131s\u0131ndan da anlaml\u0131 fark saptanmad\u0131 (p<\/i>=0.150). YB\u00dc ve MV ihtiyac\u0131 olan ve olmayan hastalar\u0131n ortalama Ct de\u011ferleri Tablo 2\u2019de g\u00f6sterilmi\u015ftir.<\/p>\n

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Tablo 3.<\/strong> Ct De\u011feri Aral\u0131klar\u0131na G\u00f6re Demografik ve Klinik \u00d6zellikler<\/p><\/div>\n

Hastalar Ct de\u011ferlerine g\u00f6re; <20 (n=37), 20-24 (n=38) aras\u0131nda ve >24 (n=42) olarak \u00fc\u00e7 gruba ayr\u0131ld\u0131. Ya\u015f, cinsiyet, komorbid hastal\u0131k, pn\u00f6moninin \u015fiddeti, k\u00f6t\u00fc prognostik laboratuvar parametrelerinin d\u00fczeyi (D-dimer, N\/L oran\u0131, CRP, lenfosit say\u0131s\u0131), servis yat\u0131\u015f s\u00fcresi, YB ihtiyac\u0131, YB yat\u0131\u015f s\u00fcresi, MV ihtiyac\u0131 ve mortalite a\u00e7\u0131s\u0131ndan bu \u00fc\u00e7 grup aras\u0131nda fark olup olmad\u0131\u011f\u0131 de\u011ferlendirildi; s\u00f6z konusu parametreler a\u00e7\u0131s\u0131ndan istatistiksel anlaml\u0131 fark saptanmad\u0131. Ct de\u011feri aral\u0131klar\u0131na g\u00f6re demografik ve klinik \u00f6zellikler Tablo 3\u2019te g\u00f6sterilmi\u015ftir.\u00a0<\/span><\/p>\n

Hastalar ba\u015fvuru pn\u00f6moni \u015fiddetine g\u00f6re; pn\u00f6moni bulgusu olmayan ve erken evre pn\u00f6monisi olanlar (n=31) ve yayg\u0131n-ileri evre pn\u00f6monisi olanlar (n=86) olarak iki ayr\u0131 grup halinde de\u011ferlendirildi\u011finde ileri evre pn\u00f6moni olan hastalarda mortalite oran\u0131 anlaml\u0131 derecede y\u00fcksek bulundu (p<\/i><0.001<\/b>). Bu iki grubun Ct de\u011ferleri a\u00e7\u0131s\u0131ndan incelenmesi sonucunda ileri evre pn\u00f6monisi olan hastalarda ortalama Ct de\u011feri 22.17 (\u00b14.65) iken pn\u00f6moni bulgusu olmayan ya da erken evre pn\u00f6monisi olanlarda ortalama de\u011fer 22.90 (\u00b14.93) olarak tespit edildi; iki grup aras\u0131nda istatistiksel olarak anlaml\u0131 d\u00fczeyde bir fark saptanmad\u0131 (p<\/i>=0.465).<\/p>\n

\"\"<\/a>

\u015eekil 1.<\/strong> Ct De\u011feri ve Yo\u011fun Bak\u0131m \u0130htiyac\u0131 \u0130li\u015fkisi<\/p><\/div>\n

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\u015eekil 2.<\/strong> Ct De\u011feri ve 28 g\u00fcn Mortalite \u0130li\u015fkisi<\/p><\/div>\n

\"\"<\/a>

Tablo 4.<\/strong> MV-YB \u0130htiyac\u0131 ve Mortalite Oranlar\u0131n\u0131n Kar\u015f\u0131la\u015ft\u0131r\u0131lmas\u0131<\/p><\/div>\n

ROC analizi ile Ct de\u011ferinin yo\u011fun bak\u0131ma yat\u0131\u015f ihtimalini tahmin etmede \u201ccut-off\u201d de\u011feri, %67.2 duyarl\u0131l\u0131k ve %49.2 \u00f6zg\u00fcll\u00fck ile 23.29 olarak hesapland\u0131 (\u015eekil 1). ROC analizi ile Ct de\u011ferinin 28 g\u00fcn mortalite ihtimalini tahmin etmede \u201ccut-off\u201d Ct de\u011feri, %70.3 duyarl\u0131l\u0131k ve %46.2 \u00f6zg\u00fcll\u00fck ile 23.29 olarak hesapland\u0131 (\u015eekil 2). ROC analizine g\u00f6re, Ct de\u011feri s\u0131n\u0131r\u0131 <23.3 ve \u2265 23.3 olarak iki gruba ayr\u0131ld\u0131\u011f\u0131nda da YB ihtiyac\u0131, MV ihtiyac\u0131, 28 g\u00fcn mortalite oranlar\u0131 a\u00e7\u0131s\u0131ndan gruplar aras\u0131nda anlaml\u0131 d\u00fczeyde bir fark saptanmad\u0131 (Tablo 4).\u00a0<\/span><\/span><\/p>\n

\u0130RDELEME<\/h2>\n

Literat\u00fcrde, COVID-19 hastal\u0131\u011f\u0131nda viral y\u00fck veya viral y\u00fck\u00fc yans\u0131tan Ct de\u011feri ile k\u00f6t\u00fc prognoz ve mortalite ili\u015fkisini inceleyen \u00e7al\u0131\u015fmalarda \u00e7eli\u015fkili sonu\u00e7lar bildirilmi\u015ftir.\u00a0<\/span><\/p>\n

Hafif seyirli hastal\u0131\u011fa k\u0131yasla agresif seyirli hastal\u0131\u011f\u0131n daha y\u00fcksek viral y\u00fck ile ili\u015fkili oldu\u011funu ve y\u00fcksek viral y\u00fck\u00fcn olas\u0131 bir prognoz g\u00f6stergesi olarak kullan\u0131labilece\u011fini g\u00f6steren \u00e7al\u0131\u015fmalar mevcuttur (9, 10).\u00a0<\/span><\/p>\n

COVID-19\u2019lu 678 hasta ile yap\u0131lan bir \u00e7al\u0131\u015fmada, hastane i\u00e7i mortalite ve Ct de\u011feri aras\u0131ndaki ili\u015fkiyi incelemek \u00fczere hastalar; Ct <25 \u201cy\u00fcksek viral y\u00fck<\/i>\u201d,\u00a0 <\/span>Ct 25-30 aras\u0131nda \u201corta viral y\u00fck<\/i>\u201d ve Ct >30 \u201cd\u00fc\u015f\u00fck viral y\u00fck<\/i>\u201d olarak \u00fc\u00e7 gruba ayr\u0131lm\u0131\u015ft\u0131r. S\u00f6z konusu \u00fc\u00e7 grup aras\u0131nda hastane i\u00e7i mortalite oranlar\u0131 s\u0131ras\u0131yla %35.0, %17.6 ve %6.2 olarak bildirilmi\u015ftir. Sonu\u00e7 olarak; y\u00fcksek viral y\u00fck \u00e7ok de\u011fi\u015fkenli modellerde ba\u011f\u0131ms\u0131z olarak mortalite ve ent\u00fcbasyon ile ili\u015fkilendirilmi\u015ftir (11).\u00a0<\/span><\/p>\n

Choudhuri ve arkada\u015flar\u0131n\u0131n (12) \u00e7al\u0131\u015fmas\u0131nda da ba\u015fvuru s\u0131ras\u0131nda al\u0131nan \u00f6rneklerdeki d\u00fc\u015f\u00fck Ct de\u011ferinin mortalite ile ili\u015fkili oldu\u011fu bildirilmi\u015ftir. Asai ve arkada\u015flar\u0131n\u0131n (13) yapt\u0131\u011f\u0131 \u00e7al\u0131\u015fmada ise Ct de\u011ferinin COVID-19 \u015fiddetini yans\u0131tmad\u0131\u011f\u0131 sonucuna var\u0131lm\u0131\u015ft\u0131r. Sadece 10 olgu i\u00e7eren bu \u00e7al\u0131\u015fmada Ct de\u011feri ve hastal\u0131k \u015fiddeti ili\u015fkili bulunmasa da mortal sonu\u00e7lanan tek olguya ait ba\u015fvuru \u00f6rne\u011finin PCR testinde Ct seviyesinin en d\u00fc\u015f\u00fck olmas\u0131 dikkat \u00e7ekicidir. \u00a0<\/span><\/span><\/p>\n

COVID-19 hastal\u0131\u011f\u0131nda SARS-CoV-2 RT-PCR Ct de\u011feri ile hastal\u0131k prognozu ve mortalite aras\u0131ndaki ili\u015fkinin incelenmesi amac\u0131yla\u00a0 <\/span>tasarlanan \u00e7al\u0131\u015fmam\u0131zda da YB ihtiyac\u0131, MV ihtiyac\u0131, pn\u00f6moninin \u015fiddeti ve mortalite ile Ct de\u011ferinin d\u00fczeyi aras\u0131nda anlaml\u0131 ili\u015fki saptanmad\u0131. Ayr\u0131ca \u00e7al\u0131\u015fmam\u0131zda yo\u011fun bak\u0131mda yat\u0131\u015f s\u00fcresi ile Ct de\u011feri aras\u0131nda da anlaml\u0131 d\u00fczeyde bir ili\u015fki saptanmad\u0131. Benzer \u015fekilde, Asai ve arkada\u015flar\u0131n\u0131n (13) ve Argyropoulos ve arkada\u015flar\u0131n\u0131n (14) \u00e7al\u0131\u015fmalar\u0131nda da viral y\u00fck ve ba\u015fvurudaki Ct de\u011feri ile hastanede yat\u0131\u015f s\u00fcresi aras\u0131nda istatistiksel olarak anlaml\u0131 ili\u015fki saptanmad\u0131\u011f\u0131 bildirilmi\u015ftir.\u00a0<\/span><\/p>\n

\u00c7al\u0131\u015fmam\u0131zda hastalar\u0131n 67 (%57)\u2019sinde en az bir komorbid hastal\u0131k mevcuttu. En s\u0131k g\u00f6r\u00fclen komorbid hastal\u0131k HT (%34) ve DM (%27) idi. Ct de\u011feri ve mortalite ili\u015fkisinin incelendi\u011fi benzer bir \u00e7al\u0131\u015fmada da en s\u0131k g\u00f6r\u00fclen komorbiditeler HT (%64.1) ve DM (%40) olarak bildirilmi\u015ftir (12). \u00a0<\/span><\/p>\n

Baz\u0131 \u00e7al\u0131\u015fmalar \u00fcst solunum yolu \u00f6rneklerinde viral y\u00fck\u00fcn infeksiyonun erken evre veya asemptomatik evrede pik yapt\u0131\u011f\u0131n\u0131 bildirirken; baz\u0131 \u00e7al\u0131\u015fmalar semptom ba\u015flang\u0131c\u0131ndan ortalama iki hafta sonra virus y\u00fck\u00fcn\u00fcn pik yapt\u0131\u011f\u0131n\u0131 bildirmi\u015ftir (9, 15-17).\u00a0<\/span><\/p>\n

Trunfio ve arkada\u015flar\u0131n\u0131n (4) \u00e7al\u0131\u015fmas\u0131nda, semptom ba\u015flang\u0131c\u0131ndan ilk PCR \u00f6rne\u011fi al\u0131nana kadar ge\u00e7en s\u00fcre 5 g\u00fcn olarak verilmi\u015ftir. Asai ve arkada\u015flar\u0131n\u0131n (13) \u00e7al\u0131\u015fmas\u0131nda, semptom ba\u015flang\u0131c\u0131ndan itibaren 8 g\u00fcnden fazla s\u00fcre ge\u00e7ti\u011fi durumlarda Ct de\u011ferleri 25-30 aral\u0131\u011f\u0131nda tespit edilmi\u015ftir.\u00a0<\/span><\/p>\n

\u00c7al\u0131\u015fmam\u0131zda, PCR i\u00e7in \u00fcst solunum yolu \u00f6rne\u011fi alma zaman\u0131 semptom ba\u015flang\u0131c\u0131ndan sonra ortalama 4.65\u00b12.60 (1-14) g\u00fcn ve Ct de\u011feri ortalamas\u0131 22.37\u00b14.72 (11.07-34.06) olarak saptand\u0131.\u00a0<\/span><\/p>\n

Baz\u0131 \u00e7al\u0131\u015fmalarda, Ct de\u011feri ile hematolojik ve biyokimyasal i\u015faretleyicilerin (\u201cmarkers\u201d) korelasyonu de\u011ferlendirildi\u011finde en az bir i\u015faretleyici ile Ct de\u011ferinin korele oldu\u011fu g\u00f6sterilmi\u015ftir (6, 17-19). \u00c7al\u0131\u015fmam\u0131zda ise, CRP, D-dimer, N\/L oran\u0131 ve lenfosit say\u0131s\u0131 gibi k\u00f6t\u00fc prognostik g\u00f6stergeler ile Ct de\u011feri ili\u015fkisi de\u011ferlendirildi\u011finde; Ct de\u011feri <20 (n=37) olanlar, Ct de\u011feri 20-24 aras\u0131nda (n=38) olanlar ve Ct de\u011feri >24 (n=42) olanlar aras\u0131nda s\u00f6z konusu laboratuvar parametreleri a\u00e7\u0131s\u0131ndan anlaml\u0131 d\u00fczeyde bir fark saptanmad\u0131.\u00a0<\/span><\/span><\/p>\n

\u00c7al\u0131\u015fmam\u0131zda, ba\u015fvurular\u0131ndaki pn\u00f6moninin \u015fiddetine g\u00f6re hastalar; \u201cpn\u00f6moni bulgusu olmayan veya erken evre pn\u00f6monisi olanlar<\/i>\u201d ile \u201cyayg\u0131n-ileri evre pn\u00f6monisi olanlar<\/i>\u201d olarak iki gruba ayr\u0131ld\u0131\u011f\u0131nda gruplar aras\u0131nda Ct de\u011ferleri a\u00e7\u0131s\u0131ndan anlaml\u0131 d\u00fczeyde bir fark saptanmad\u0131. Benzer \u015fekilde Asai ve arkada\u015flar\u0131n\u0131n (13) \u00e7al\u0131\u015fmas\u0131nda da, pn\u00f6monisi olan ve olmayan gruplar aras\u0131nda Ct de\u011feri ortalamas\u0131 a\u00e7\u0131s\u0131ndan anlaml\u0131 fark saptanmad\u0131\u011f\u0131 bildirilmi\u015ftir. Ancak Zhao ve arkada\u015flar\u0131 (20), ba\u015flang\u0131\u00e7 RT PCR Ct de\u011ferinin d\u00fc\u015f\u00fck olmas\u0131n\u0131n, takipte \u00e7ekilen tomografide pn\u00f6moni bulgular\u0131nda progresyon geli\u015fmesi a\u00e7\u0131s\u0131ndan anlaml\u0131 oldu\u011funu g\u00f6stermi\u015ftir.<\/p>\n

\u00c7al\u0131\u015fmam\u0131zda ROC analizi ile Ct de\u011ferinin yo\u011fun bak\u0131ma yat\u0131\u015f ihtimalini tahmin etmede \u201ccut-off\u201d Ct de\u011feri, %67.2 duyarl\u0131l\u0131k ve %49.2 \u00f6zg\u00fcll\u00fck de\u011feri ile 23.29 olarak hesapland\u0131. Ct de\u011ferinin 28 g\u00fcn mortalite ihtimalini tahmin etmede ise \u201ccut-off\u201d Ct de\u011feri, %70.3 duyarl\u0131l\u0131k ve %46.2 \u00f6zg\u00fcll\u00fck de\u011feri ile 23.29 olarak hesapland\u0131. Buna g\u00f6re hastalar Ct de\u011feri s\u0131n\u0131r\u0131 a\u00e7\u0131s\u0131ndan <23.3 ve \u2265 23.3 olarak iki gruba ayr\u0131ld\u0131\u011f\u0131nda, YB ihtiyac\u0131, MV ihtiyac\u0131, 28 g\u00fcn mortalite oranlar\u0131 a\u00e7\u0131s\u0131ndan gruplar aras\u0131nda anlaml\u0131 d\u00fczeyde fark saptanmad\u0131. Choudhuri ve arkada\u015flar\u0131n\u0131n (12) \u00e7al\u0131\u015fmas\u0131nda, Ct de\u011feri \u201ccut-off\u201d noktas\u0131 26 (G\u00fcven Aral\u0131\u011f\u0131 (GA): 26-27) al\u0131nd\u0131\u011f\u0131nda testin duyarl\u0131l\u0131\u011f\u0131 0.65 (GA: 0.58-0.72) ve \u00f6zg\u00fcll\u00fc\u011f\u00fc 0.64 (GA: 0.57-0.69), e\u011fri alt\u0131nda kalan alan (\u201cArea Under the ROC Curve, AUC\u201d) 0.68 (GA: 0.63-0.71) olarak bildirilmi\u015ftir. Bu \u00e7al\u0131\u015fmada da \u00e7al\u0131\u015fmam\u0131zdaki sonuca benzer \u015fekilde yatan hastalarda mortaliteyi \u00f6ng\u00f6rmede bu testin kullan\u0131m\u0131n\u0131n s\u0131n\u0131rl\u0131 oldu\u011fu sonucuna var\u0131lm\u0131\u015ft\u0131r.\u00a0<\/span><\/p>\n

Sonu\u00e7 olarak; konu ile ilgili yap\u0131lan \u00e7al\u0131\u015fmalar\u0131n \u00e7o\u011funda d\u00fc\u015f\u00fck Ct de\u011feri ve hastal\u0131k progresyonu aras\u0131nda ili\u015fki saptand\u0131\u011f\u0131 bildirilmi\u015f olmakla birlikte \u00e7al\u0131\u015fmam\u0131zda Ct de\u011feri ile k\u00f6t\u00fc klinik seyir, hastanede yat\u0131\u015f s\u00fcresi, YB ve MV ihtiyac\u0131 ve mortalite aras\u0131nda anlaml\u0131 d\u00fczeyde ili\u015fki saptanmam\u0131\u015ft\u0131r. Bununla birlikte, \u00e7al\u0131\u015fmam\u0131z\u0131n tek merkez verisi olmas\u0131 ve mutasyonlar \u00f6ncesi ilk virus tipi ile infekte hastalarla yap\u0131lmas\u0131 nedeniyle\u00a0 <\/span>tan\u0131 an\u0131ndaki Ct de\u011feri ile klinik seyir aras\u0131nda ili\u015fki olup olmad\u0131\u011f\u0131n\u0131n net belirlenebilmesi i\u00e7in, birden fazla merkezden daha fazla hasta say\u0131s\u0131 i\u00e7eren ve farkl\u0131 mutasyon tiplerinin PCR testlerindeki Ct de\u011ferlerinin kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131 \u00e7al\u0131\u015fmalara ihtiya\u00e7 olaca\u011f\u0131 kan\u0131s\u0131na var\u0131ld\u0131.<\/p>\n","protected":false},"excerpt":{"rendered":"

G\u0130R\u0130\u015e D\u00fcnya Sa\u011fl\u0131k \u00d6rg\u00fct\u00fc (DS\u00d6) taraf\u0131ndan, Ocak 2020\u2019de daha \u00f6nce insanlarda tespit edilmemi\u015f yeni bir koronavirus (2019- nCoV) tan\u0131mlanm\u0131\u015f ve \u015eubat 2020\u2019de, hastal\u0131\u011f\u0131n ad\u0131 koronavirus hastal\u0131\u011f\u0131-2019 (COVID-19) olarak kabul edilmi\u015ftir. Virus, \u015fiddetli akut solunum yolu sendromu virusu (SARS-CoV-2) olarak adland\u0131r\u0131lm\u0131\u015ft\u0131r (1, 2). 2020 y\u0131l\u0131ndan itibaren h\u0131zla yay\u0131lan virus halen t\u00fcm d\u00fcnyay\u0131 etkilemeye devam etmektedir. SARS-CoV-2 […]<\/p>\n","protected":false},"author":2,"featured_media":25593,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[5129],"tags":[5174,5476,5477,5478,2997],"class_list":["post-25247","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-ozgun-arastirma","tag-covid-19","tag-ct-degeri","tag-dongu-esigi","tag-klinik-seyir","tag-mortalite"],"acf":[],"_links":{"self":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/25247","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/comments?post=25247"}],"version-history":[{"count":3,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/25247\/revisions"}],"predecessor-version":[{"id":25737,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/25247\/revisions\/25737"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media\/25593"}],"wp:attachment":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media?parent=25247"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/categories?post=25247"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/tags?post=25247"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}