{"id":27238,"date":"2023-09-30T00:15:47","date_gmt":"2023-09-29T21:15:47","guid":{"rendered":"https:\/\/www.klimikdergisi.org\/?p=27238"},"modified":"2023-09-30T00:15:39","modified_gmt":"2023-09-29T21:15:39","slug":"covid-19-hastalarinin-ayaktan-takibi","status":"publish","type":"post","link":"https:\/\/www.klimikdergisi.org\/tr\/2023\/09\/30\/covid-19-hastalarinin-ayaktan-takibi\/","title":{"rendered":"COVID-19 Hastal\u0131\u011f\u0131 Nedeniyle Ayaktan Takip Edilen Eri\u015fkin Hastalar\u0131n 28 G\u00fcn \u0130\u00e7inde Hastaneye Yat\u0131\u015f \u0130nsidans\u0131 ve Etkileyen Fakt\u00f6rler"},"content":{"rendered":"
\"\"<\/a>

GRAF\u0130K \u00d6ZET<\/strong><\/p><\/div>\n

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

\u015eiddetli akut solunum yolu sendromu virusu (SARS-CoV-2) yeni bir koronavirus t\u00fcr\u00fc olarak 2019 y\u0131l\u0131n\u0131n sonunda \u00c7in\u2019de ortaya \u00e7\u0131kan pn\u00f6moni olgu k\u00fcmelenmesinde tan\u0131mlanm\u0131\u015f ve h\u0131zla t\u00fcm d\u00fcnyaya yay\u0131larak k\u00fcresel bir pandemiye neden olmu\u015ftur (1). Koronaviruslar s\u0131kl\u0131kla \u00fcst solunum yolu infeksiyonlar\u0131na neden olmakla birlikte SARS-CoV-2\u2019nin neden oldu\u011fu koronavirus hastal\u0131\u011f\u0131 2019 (COVID-19), asemptomatik infeksiyondan, \u015fiddetli pn\u00f6moni ve solunum yetersizli\u011fi sonucu \u00f6l\u00fcme kadar geni\u015f bir spektrumda seyredebilmektedir (2,3). Hastaneye ba\u015fvuran COVID-19 hastalar\u0131n\u0131n b\u00fcy\u00fck bir \u00e7o\u011funlu\u011fu hastaneye yat\u0131r\u0131lmadan ayaktan izlenmekte ve k\u0131sa s\u00fcre i\u00e7inde iyile\u015fmektedir (4,5). Olgular\u0131n ayaktan izlenebilmesi; hali haz\u0131rda \u00e7ok y\u00fcklenmi\u015f olan sa\u011fl\u0131k sisteminin gereksiz bir \u015fekilde me\u015fgul edilmesini \u00f6nlemenin yan\u0131 s\u0131ra sa\u011fl\u0131k i\u015f g\u00fcc\u00fcn\u00fcn, ki\u015fisel koruyucu ekipman kullan\u0131m\u0131n\u0131n ve di\u011fer sa\u011fl\u0131k harcamalar\u0131n\u0131n verimli bir \u015fekilde kullan\u0131lmas\u0131 a\u00e7\u0131s\u0131ndan son derece \u00f6nemlidir. Bununla birlikte ayaktan izlenen baz\u0131 COVID-19 olgular\u0131nda, yatan hastalara benzer \u015fekilde, klinik seyir zaman i\u00e7inde a\u011f\u0131rla\u015fabilmekte ve hastaneye yeniden ba\u015fvuru, yat\u0131\u015f ve hatta \u00f6l\u00fcm g\u00f6r\u00fclebilmektedir (6). Bu a\u00e7\u0131dan y\u00fcksek riskli bireylerin belirlenmesi hastal\u0131k seyrini, yo\u011fun bak\u0131m ve hastaneye yat\u0131\u015f riskini tahmin etmede yard\u0131mc\u0131 olabilir (7). S\u00f6z konusu hastalar\u0131n klinik seyir, komplikasyon ve hastaneye ba\u015fvuru insidans\u0131 ile ilgili olarak literat\u00fcrde yeterli d\u00fczeyde veri bulunmad\u0131\u011f\u0131 g\u00f6r\u00fclmektedir (8-15). <\/span><\/p>\n

\u00c7al\u0131\u015fmam\u0131z\u0131n amac\u0131, 18 ya\u015f ve \u00fczerindeki PCR pozitif COVID-19 hastalar\u0131nda ilk ba\u015fvurunun ard\u0131ndan 28 g\u00fcnl\u00fck d\u00f6nemdeki hastaneye yat\u0131\u015f insidans\u0131n\u0131n belirlenmesi ve hastalara ait temel sosyodemografik \u00f6zellikler (ya\u015f, cinsiyet, temas \u00f6yk\u00fcs\u00fc), komorbiditeler, ba\u015fvuru \u015fikayetleri ve klinik \u00f6zellikler ile hastaneye yat\u0131\u015f aras\u0131ndaki ili\u015fkinin anla\u015f\u0131lmas\u0131d\u0131r.<\/p>\n

Y\u00d6NTEMLER<\/h2>\n

Retrospektif kohort olarak planlanan \u00e7al\u0131\u015fmaya, 21 Mart-21 May\u0131s 2020 tarihleri aras\u0131nda ba\u015fvurup ayaktan takip karar\u0131 al\u0131nan PCR pozitif, 18 ya\u015f ve \u00fczerindeki hastalar dahil edildi; ba\u015fvuru an\u0131nda t\u00fcm hastalar semptomatikti. COVID-19 maruziyeti sonras\u0131 tarama \u00f6nerilen ve \u00f6rnek al\u0131nmas\u0131 i\u00e7in ba\u015fvuran asemptomatik hastalar ve ba\u015fvurudan sonraki ilk 24 saat i\u00e7inde yat\u0131\u015f\u0131 yap\u0131lanlar \u00e7al\u0131\u015fmaya dahil edilmedi.<\/p>\n

\u00d6rneklem b\u00fcy\u00fckl\u00fc\u011f\u00fc hesaplamalar\u0131nda Piface program\u0131 kullan\u0131ld\u0131 (16). \u00c7al\u0131\u015fman\u0131n g\u00fcc\u00fc %80 (tip II hata=0.20), tip I hata 0.05 ve komorbiditesi olan ve olmayan iki grup aras\u0131ndaki beklenen hastaneye yat\u0131\u015f insidans\u0131 fark\u0131 en az %20 (%10\u2019dan en az %30\u2019a \u00e7\u0131kmas\u0131) ve gruplar\u0131n oran\u0131 1:3 olarak kabul edildi\u011finde en az 200 hastaya ula\u015f\u0131lmas\u0131 gerekti\u011fi hesapland\u0131. S\u00f6z konusu tarih aral\u0131\u011f\u0131nda hastaneye ba\u015fvuran ve ayaktan takip karar\u0131 verilen COVID-19 hasta listesi i\u00e7indeki her iki hastadan biri sistematik \u00f6rnekleme y\u00f6ntemiyle se\u00e7ildi.<\/p>\n

Ayaktan ve yatarak tedavi g\u00f6ren COVID-19 hastalar\u0131na ait temel sosyodemografik \u00f6zellikler, ba\u015fvuru \u015fikayetleri, klinik \u00f6zellikleri, baz\u0131 laboratuvar ve radyolojik bulgular\u0131 standart bir form arac\u0131l\u0131\u011f\u0131yla kay\u0131t alt\u0131na al\u0131nd\u0131. Ba\u015fvuru an\u0131nda al\u0131nan PCR \u00f6rne\u011finin d\u00f6ng\u00fc e\u015fik (cycle threshold – Ct) de\u011feri, virus y\u00fck\u00fcn\u00fc dolayl\u0131 olarak g\u00f6steren, PCR pozitifli\u011fini saptamak i\u00e7in gerekli olan floresan sinyale ula\u015fana kadar ge\u00e7en d\u00f6ng\u00fc say\u0131s\u0131 olarak tan\u0131mland\u0131. D\u00f6ng\u00fc e\u015fik de\u011feri; y\u00fcksek (<20), orta (20-30) ve d\u00fc\u015f\u00fck (>30) olarak kategorize edildi. Yatan hasta kohortuna ait veriler ayr\u0131 bir \u00e7al\u0131\u015fma yap\u0131larak yay\u0131mland\u0131 (17). \u00c7al\u0131\u015fmadaki ba\u011f\u0131ms\u0131z de\u011fi\u015fkenler, yukar\u0131da s\u00f6z\u00fc edilen standart formdaki kay\u0131tl\u0131 verilerden elde edildi. Ba\u015fvurunun ard\u0131ndan 28 g\u00fcnl\u00fck d\u00f6nemdeki hastaneye yat\u0131\u015f ve kritik hastal\u0131k geli\u015fimi bilgilerine ise hastane kay\u0131tlar\u0131 ve Halk Sa\u011fl\u0131\u011f\u0131 Y\u00f6netim Sistemi (HSYS) yoluyla ula\u015f\u0131ld\u0131. Bu \u00e7al\u0131\u015fmada verilere kay\u0131t sisteminden ula\u015f\u0131ld\u0131\u011f\u0131 i\u00e7in hasta onam\u0131 al\u0131nmad\u0131 ve t\u00fcm de\u011ferlendirmeler anonim olarak yap\u0131ld\u0131. \u00c7al\u0131\u015fma, Marmara \u00dcniversitesi Sa\u011fl\u0131k Bilimleri Enstit\u00fcs\u00fc taraf\u0131ndan 13 Aral\u0131k 2021 ve 142 karar numaras\u0131yla onaylanm\u0131\u015ft\u0131r.<\/p>\n

\u0130statistiksel Analiz<\/h3>\n

Verilerin istatistiksel analizinde \u201cStatistical Package for the Social Sciences\u201d (SPSS) versiyon 23.0 program\u0131 (IBM Corp., Armonk, NY, ABD) kullan\u0131ld\u0131. Tan\u0131mlay\u0131c\u0131 istatistiklerde, ortalama\u00b1standart sapma, ortanca, persantil ve oranlar kullan\u0131ld\u0131. Hastaneye yat\u0131\u015f ve kritik hastal\u0131k geli\u015fimine neden olan fakt\u00f6rler tek ve \u00e7ok de\u011fi\u015fkenli istatistiksel analizlerle incelendi. Kategorik de\u011fi\u015fkenlerin kar\u015f\u0131la\u015ft\u0131r\u0131lmas\u0131, \u03c72 ve gerekti\u011fi durumlarda Fisher kesin testi ile yap\u0131ld\u0131. \u00d6l\u00e7\u00fcmsel de\u011fi\u015fkenlerin iki grup i\u00e7in kar\u015f\u0131la\u015ft\u0131r\u0131lmas\u0131nda, veriler normal da\u011f\u0131l\u0131ma uydu\u011funda Student t-testi, uymad\u0131\u011f\u0131nda Mann-Whitney U testi kullan\u0131ld\u0131.\u00a0 <\/span>\u00c7ok de\u011fi\u015fkenli analizlerde, Cox sa\u011fkal\u0131m analizi yap\u0131ld\u0131. Cox regresyon analizine, tek de\u011fi\u015fkenli analizde \u00f6ne \u00e7\u0131kan risk fakt\u00f6rleri (p<\/i><0.1) ve potansiyel kar\u0131\u015ft\u0131r\u0131c\u0131 fakt\u00f6rler dahil edildi. Analizde a\u015famal\u0131 geriye do\u011fru eleme y\u00f6ntemi kullan\u0131ld\u0131 ve etki b\u00fcy\u00fckl\u00fc\u011f\u00fc \u201chazard ratio\u201d (HR) ve %95 g\u00fcven aral\u0131\u011f\u0131 (GA) ile ifade edildi. \u0130statistiksel anlaml\u0131l\u0131k d\u00fczeyi p<\/i><0.05 olarak belirlendi.<\/p>\n

BULGULAR<\/h2>\n

Hastalar\u0131n Genel \u00d6zellikleri<\/h3>\n
\"\"<\/a>

\u015eekil 1.<\/strong> \u00c7al\u0131\u015fman\u0131n Ak\u0131\u015f \u015eemas\u0131<\/p><\/div>\n

\"\"<\/a>

Tablo 1.<\/strong> Hastalar\u0131n Demografik ve Klinik \u00d6zellikleri (n=368)<\/p><\/div>\n

\u00c7al\u0131\u015fmaya SARS-CoV-2 PCR pozitif ve semptomatik olan 368 hasta dahil edildi (\u015eekil 1). Hastalar\u0131n ortanca (25.-75. persantil) ya\u015f\u0131 36 (28-45) olup 170 (%46.1)\u2019i kad\u0131nd\u0131; 116 (%31.5)\u2019s\u0131 29 ya\u015f ve alt\u0131nda, 106 (%28.8)\u2019s\u0131 30-39 ya\u015f aral\u0131\u011f\u0131nda, 93 (%25.2)\u2019\u00fc 40-49 ya\u015f aral\u0131\u011f\u0131nda ve 53 (%14.4)\u2019\u00fc 50 ya\u015f ve \u00fczerindeydi.<\/p>\n

\"\"<\/a>

\u015eekil 2.<\/strong> Ya\u015f Kategorilerine G\u00f6re 28 G\u00fcnl\u00fck Hastaneye Yat\u0131\u015f \u0130nsidans\u0131<\/p><\/div>\n

\"\"<\/a>

Tablo 2.<\/strong> 28 G\u00fcn \u0130\u00e7inde Hastaneye Yat\u0131\u015f ile \u0130li\u015fkili Fakt\u00f6rlerin Tek ve \u00c7ok De\u011fi\u015fkenli Analizleri<\/p><\/div>\n

\"\"<\/a>

\u015eekil 3.<\/strong> Semptomlara G\u00f6re 28 G\u00fcnl\u00fck Hastaneye Yat\u0131\u015f \u0130nsidans\u0131 A) Ate\u015f ve\/veya \u00dc\u015f\u00fcme\/Titreme \u015eikayetine G\u00f6re 28 G\u00fcnl\u00fck Hastaneye Yat\u0131\u015f \u0130nsidans\u0131; B) Nefes Darl\u0131\u011f\u0131 \u015eikayetine G\u00f6re 28 G\u00fcnl\u00fck Hastaneye Yat\u0131\u015f \u0130nsidans\u0131; C) Yorgunluk\/Bitkinlik \u015eikayetine G\u00f6re 28 G\u00fcnl\u00fck Hastaneye Yat\u0131\u015f \u0130nsidans\u0131; D) Bo\u011faz A\u011fr\u0131s\u0131 \u015eikayetine G\u00f6re 28 G\u00fcnl\u00fck Hastaneye Yat\u0131\u015f \u0130nsidans\u0131; E) Kusma \u015eikayetine G\u00f6re 28 G\u00fcnl\u00fck Hastaneye Yat\u0131\u015f \u0130nsidans\u0131<\/p><\/div>\n

\"\"<\/a>

\u015eekil 4.<\/strong> Hipertansiyon Varl\u0131\u011f\u0131na G\u00f6re 28 G\u00fcnl\u00fck Hastaneye Yat\u0131\u015f \u0130nsidans\u0131<\/p><\/div>\n

Semptomlar\u0131n ba\u015flang\u0131c\u0131ndan, tan\u0131 konulmas\u0131na kadar ge\u00e7en ortanca (25.-75. persantil) s\u00fcre 2 (1-5) g\u00fcnd\u00fcr. \u0130lk ba\u015fvuru \u015fikayetleri incelendi\u011finde hastalar\u0131n 219 (%59.5)\u2019unda yorgunluk\/bitkinlik, 213 (%57.8)\u2019\u00fcnde \u00f6ks\u00fcr\u00fck, 200 (%54.3)\u2019\u00fcnde ate\u015f ve\/veya \u00fc\u015f\u00fcme\/titreme ve 182 (%49.4)\u2019sinde ba\u015f a\u011fr\u0131s\u0131 saptand\u0131.<\/p>\n

Hastalar\u0131n komorbidite da\u011f\u0131l\u0131m\u0131na bak\u0131ld\u0131\u011f\u0131nda, 97 (%26.4)\u2019sinde en az bir e\u015flik eden hastal\u0131k oldu\u011fu g\u00f6r\u00fcld\u00fc.\u00a0 <\/span>Hipertansiyon (%7.8) ve kronik akci\u011fer hastal\u0131\u011f\u0131 (%7.2) en s\u0131k rastlanan komorbiditeler aras\u0131nda idi. Hastalar\u0131n 259 (%71.2)\u2019u sigara kullanmad\u0131\u011f\u0131n\u0131, 52 (%14.3)\u2019si sigaray\u0131 b\u0131rakt\u0131\u011f\u0131n\u0131 ve kalan 53 (%14.6)\u2019\u00fc ise sigara kulland\u0131\u011f\u0131n\u0131 belirtmi\u015fti (Tablo 1).<\/p>\n

\u0130lk 28 G\u00fcn \u0130\u00e7inde Hastaneye Yat\u0131\u015f \u0130nsidans\u0131<\/h3>\n

Hastalar\u0131n 65 (HR=17.7, %95 GA=13.7-22.3)\u2019inin ba\u015fvuru an\u0131ndan sonraki ilk 28 g\u00fcn i\u00e7inde hastaneye yat\u0131r\u0131ld\u0131\u011f\u0131 tespit edildi. Ayaktan takip edilirken yat\u0131\u015f karar\u0131 verilen hastalar\u0131n 30 (%46.2)\u2019u 1-3 g\u00fcn i\u00e7inde, 24 (%36.9)\u2019\u00fc 4-7 g\u00fcn i\u00e7inde ve 11 (%16.9)\u2019i 8-28 g\u00fcn i\u00e7inde hastaneye yat\u0131r\u0131lm\u0131\u015ft\u0131 (\u015eekil 1).<\/p>\n

\u0130lk 28 G\u00fcnde Hastaneye Yat\u0131\u015f ile \u0130li\u015fkili Fakt\u00f6rler<\/h3>\n

\u0130lk 28 g\u00fcn i\u00e7inde hastaneye yat\u0131\u015fa neden olan fakt\u00f6rler tek de\u011fi\u015fkenli analizle de\u011ferlendirildi. Bu analizde, \u226429 ya\u015f referans al\u0131nd\u0131\u011f\u0131nda hastaneye yat\u0131\u015f riskinin; 30-39 ya\u015f aral\u0131\u011f\u0131nda (HR=1.8, %95 GA=0.8-4.2), 40-49 ya\u015f aral\u0131\u011f\u0131nda (HR=3.1, %95 GA=1.4-6.9) ve \u226550 ya\u015f kategorisinde (HR=5.9, %95 GA=2.6-12.9) artm\u0131\u015f oldu\u011fu tespit edildi. Ate\u015f ve\/veya \u00fc\u015f\u00fcme\/titremesi olan hastalarda hastaneye yat\u0131\u015f riski (HR=2.7, %95 GA=1.5-4.8) olmayanlara g\u00f6re daha y\u00fcksekti. Bo\u011faz a\u011fr\u0131s\u0131 olan hastalarda ise hastaneye yat\u0131\u015f riski (HR=0.5, %95 GA=0.3-1.0) olmayanlara g\u00f6re daha d\u00fc\u015f\u00fck bulundu. Komorbiditesi olan hastalarda hastaneye yat\u0131\u015f riski (HR=1.7, %95 GA=1.0-2.8) komorbiditesi olmayanlara g\u00f6re anlaml\u0131 d\u00fczeyde daha y\u00fcksekti (p=0.02). Komorbiditeler ayr\u0131 ayr\u0131 incelendi\u011finde; diabetes mellitus (DM) (HR=2.6, %95 GA=1.4-6.1), hipertansiyon (HT) (HR=3.2, %95 GA=1.7-6.0) ve kardiyovask\u00fcler hastal\u0131k (HR=3.6, %95 GA=1.3-10.1) varl\u0131\u011f\u0131n\u0131n hastaneye yat\u0131\u015f riskini art\u0131rd\u0131\u011f\u0131 saptand\u0131 (Tablo 2).<\/p>\n

\u0130lk 28 g\u00fcn i\u00e7inde hastaneye yat\u0131\u015fa neden olan fakt\u00f6rler tek de\u011fi\u015fkenli analizle de\u011ferlendirildi. Bu analizde, \u226429 ya\u015f referans al\u0131nd\u0131\u011f\u0131nda hastaneye yat\u0131\u015f riskinin; 30-39 ya\u015f aral\u0131\u011f\u0131nda (HR=1.8, %95 GA=0.8-4.2), 40-49 ya\u015f aral\u0131\u011f\u0131nda (HR=3.1, %95 GA=1.4-6.9) ve \u226550 ya\u015f kategorisinde (HR= 5.9, %95 GA=2.6-12.9) artm\u0131\u015f oldu\u011fu tespit edildi. Ate\u015f ve\/veya \u00fc\u015f\u00fcme\/titremesi olan hastalarda hastaneye yat\u0131\u015f riski (HR=2.7, %95 GA=1.5-4.8) olmayanlara g\u00f6re daha y\u00fcksekti. Bo\u011faz a\u011fr\u0131s\u0131 olan hastalarda ise hastaneye yat\u0131\u015f riski (HR=0.5, %95 GA=0.3-1.0) olmayanlara g\u00f6re daha d\u00fc\u015f\u00fck bulundu. Komorbiditesi olan hastalarda hastaneye yat\u0131\u015f riski (HR=1.7, %95 GA=1.0-2.8) komorbiditesi olmayanlara g\u00f6re anlaml\u0131 d\u00fczeyde daha y\u00fcksekti (p<\/i>=0.02). Komorbiditeler ayr\u0131 ayr\u0131 incelendi\u011finde; diabetes mellitus (DM) (HR=2.6, %95 GA=1.4-6.1), hipertansiyon (HT) (HR=3.2, %95 GA=1.7-6.0) ve kardiyovask\u00fcler hastal\u0131k (HR=3.6, %95 GA=1.3-10.1) varl\u0131\u011f\u0131n\u0131n hastaneye yat\u0131\u015f riskini art\u0131rd\u0131\u011f\u0131 saptand\u0131 (Tablo 2).<\/p>\n

\u00c7ok de\u011fi\u015fkenli analize ya\u015f, cinsiyet, ate\u015f ve\/veya \u00fc\u015f\u00fcme\/titreme, \u00f6ks\u00fcr\u00fck, nefes darl\u0131\u011f\u0131, yorgunluk\/bitkinlik, myalji, kusma, bo\u011faz a\u011fr\u0131s\u0131, e\u015flik eden hastal\u0131klardan DM, HT ve kardiyovask\u00fcler hastal\u0131k ve sigara kullan\u0131m\u0131 de\u011fi\u015fkenleri dahil edildi. Sadece 324 hastada ula\u015f\u0131lmas\u0131 nedeniyle Ct de\u011feri \u00e7ok de\u011fi\u015fkenli analize dahil edilmedi.\u00a0 <\/span>Bu analizde \u226429 ya\u015f referans al\u0131nd\u0131\u011f\u0131nda; 40-49 ya\u015f aral\u0131\u011f\u0131nda (HR=3.0, %95 GA=1.3-6.6) ve \u226550 ya\u015f kategorisinde (HR=4.1, %95 GA=1.7-9.6) hastaneye yat\u0131\u015f riski anlaml\u0131 d\u00fczeyde daha y\u00fcksekti (\u015eekil 2). Ate\u015f ve\/veya \u00fc\u015f\u00fcme\/titreme (HR=2.3, %95 GA=1.3-4.1), nefes darl\u0131\u011f\u0131 (HR=2.0, %95 GA=1.1-3.4) ve yorgunluk\/bitkinlik (HR=1.9, %95 GA=1.0-3.5) ve kusma (HR=3.0, %95 GA=1.5-5.8) hastaneye yat\u0131\u015f riskini art\u0131ran ba\u011f\u0131ms\u0131z risk fakt\u00f6rleri olarak tespit edildi (\u015eekil 3). Hipertansiyon tan\u0131s\u0131n\u0131n hastaneye yat\u0131\u015f riskini (HR=2.2, %95 GA=1.0-4.4) art\u0131rd\u0131\u011f\u0131 g\u00f6r\u00fcld\u00fc (\u015eekil 4). Bunun yan\u0131nda ilk ba\u015fvuru s\u0131ras\u0131nda bo\u011faz a\u011fr\u0131s\u0131 olmas\u0131 hastaneye yat\u0131\u015f riskini azaltan (HR=0.4, %95 GA=0.2-0.8) ba\u011f\u0131ms\u0131z bir risk fakt\u00f6r\u00fc olarak saptand\u0131 (\u015eekil 3), (Tablo 2).<\/p>\n

\u0130RDELEME<\/h2>\n

\u00c7al\u0131\u015fmam\u0131zda, COVID-19 tan\u0131s\u0131 ile hastaneye ba\u015fvurup, ayaktan takip edilen hastalar\u0131n 28 g\u00fcnl\u00fck izlem s\u0131ras\u0131nda hastaneye yat\u0131\u015f insidans\u0131 ve yat\u0131\u015flar\u0131na etki eden fakt\u00f6rler ara\u015ft\u0131r\u0131ld\u0131. Hastaneye 28 g\u00fcnl\u00fck yat\u0131\u015f insidans\u0131 %17.7 olup yat\u0131\u015f\u0131 etkileyen ba\u011f\u0131ms\u0131z risk fakt\u00f6rleri ba\u015fvuru an\u0131nda ate\u015f, nefes darl\u0131\u011f\u0131, yorgunluk\/bitkinlik, kusma ve bo\u011faz a\u011fr\u0131s\u0131, hipertansiyon varl\u0131\u011f\u0131 ve ileri ya\u015f olarak saptand\u0131.<\/p>\n

Hastaneye Yat\u0131\u015f \u0130nsidans\u0131<\/h3>\n

Ayaktan takip edilen hastalar\u0131n hastaneye yat\u0131\u015f insidans\u0131n\u0131n %6.4 ile %54.6 aras\u0131nda de\u011fi\u015fti\u011fi tespit edildi (18-23). Hacettepe \u00dcniversitesi T\u0131p Fak\u00fcltesi Hastanesi\u2019nde yap\u0131lan bir \u00e7al\u0131\u015fmada, Mart-Nisan 2020 tarihleri aras\u0131nda PCR pozitif olan 220 hastadan 41 (%18.6)\u2019inin ayaktan takibe al\u0131nd\u0131\u011f\u0131 ve 4 (%9.7)\u2019\u00fcn\u00fcn ilk 14 g\u00fcn i\u00e7inde hastaneye yat\u0131r\u0131ld\u0131\u011f\u0131 bildirilmi\u015ftir (24).<\/span><\/p>\n

Pandeminin ilk dalgas\u0131nda hastaneye yat\u0131\u015f ve taburculuk i\u00e7in \u00f6nerilerin net olmamas\u0131, \u00fclkeler ve merkezler aras\u0131nda farkl\u0131 yat\u0131\u015f endikasyonlar\u0131n\u0131n olmas\u0131 ve salg\u0131n y\u00fck\u00fcn\u00fcn co\u011frafi b\u00f6lgelere g\u00f6re de\u011fi\u015fmesi yat\u0131\u015f insidans\u0131ndaki bu varyasyonun nedeni olabilir. Ancak \u00e7al\u0131\u015fmalar\u0131n \u00f6rneklem \u00f6zelliklerinin farkl\u0131 olmas\u0131 nedeniyle s\u00f6z konusu \u00e7al\u0131\u015fmalar aras\u0131nda kar\u015f\u0131la\u015ft\u0131rma yapmak kolay de\u011fildir. \u00c7al\u0131\u015fmam\u0131za merkezimize ba\u015fvuran ve ayaktan takip edilen semptomatik SARS-CoV-2 PCR pozitif hastalar\u0131n dahil edildi\u011fi ve ara\u015ft\u0131rman\u0131n pandeminin ilk dalgas\u0131 s\u0131ras\u0131nda yap\u0131ld\u0131\u011f\u0131 g\u00f6z \u00f6n\u00fcnde bulunduruldu\u011funda ve semptomatik olan hastalar\u0131n \u00e7o\u011funun bu d\u00f6nemde hastaneye ba\u015fvurdu\u011fu d\u00fc\u015f\u00fcn\u00fcld\u00fc\u011f\u00fcnde, elde etti\u011fimiz bulgular\u0131n ger\u00e7ek ya\u015fam verilerini yans\u0131tmas\u0131 olas\u0131d\u0131r.<\/p>\n

Sun ve arkada\u015flar\u0131n\u0131n (21) yapt\u0131\u011f\u0131 \u00e7al\u0131\u015fmada, yat\u0131\u015f insidans\u0131 %26.1 olarak saptanm\u0131\u015ft\u0131r; \u00e7al\u0131\u015fmam\u0131zla kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131nda daha ya\u015fl\u0131 bir pop\u00fclasyonda y\u00fcr\u00fct\u00fclm\u00fc\u015f olmas\u0131 bu \u00e7al\u0131\u015fmada yat\u0131\u015f insidans\u0131ndaki y\u00fcksekli\u011fi a\u00e7\u0131klayabilir. Ayr\u0131ca Vila-Corcoles ve arkada\u015flar\u0131n\u0131n (22) ve Prieto-Alhambra ve arkada\u015flar\u0131n\u0131n (23) yapt\u0131klar\u0131 \u00e7al\u0131\u015fmalarda da s\u0131ras\u0131yla yat\u0131\u015f insidans\u0131 %54.6 ve %43.1 bulunmu\u015ftur. Bu iki \u00e7al\u0131\u015fmada yat\u0131\u015f insidans\u0131n\u0131n y\u00fcksek olmas\u0131 dahil edilme kriterleri aras\u0131nda daha a\u011f\u0131r hastalar\u0131n se\u00e7ilmesi ve hasta pop\u00fclasyonunun g\u00f6rece ya\u015fl\u0131 ve komorbidite y\u00fck\u00fc y\u00fcksek olan hastalardan olu\u015fmas\u0131 ile a\u00e7\u0131klanabilir. Blair ve arkada\u015flar\u0131n\u0131n (19) yat\u0131\u015f insidans\u0131n\u0131 %7.6 bulmas\u0131 ise literat\u00fcre g\u00f6re daha gen\u00e7, daha az komorbiditeye sahip, a\u011f\u0131rl\u0131kl\u0131 kad\u0131n hastalar\u0131n \u00e7al\u0131\u015fmaya dahil edilmesiyle a\u00e7\u0131klanabilir. Benzer \u015fekilde yat\u0131\u015f insidans\u0131n\u0131n %6.4 olarak hesapland\u0131\u011f\u0131 ba\u015fka bir \u00e7al\u0131\u015fmada, d\u00fc\u015f\u00fck hastane yat\u0131\u015f insidans\u0131, kronik obstr\u00fcktif akci\u011fer hastal\u0131\u011f\u0131, kardiyovask\u00fcler ve renal komorbiditelerin ara\u015ft\u0131rma pop\u00fclasyonunda d\u00fc\u015f\u00fck s\u0131kl\u0131kta g\u00f6r\u00fclmesi ile ili\u015fkilendirmi\u015ftir (18).<\/p>\n

Hastaneye Yat\u0131\u015f ile \u0130li\u015fkili Risk Fakt\u00f6rleri<\/h3>\n

Yap\u0131lan \u00e7al\u0131\u015fmalarda ayaktan takip edilen COVID-19 hastalar\u0131nda hastaneye yat\u0131\u015f ve mortalite ili\u015fkili risk fakt\u00f6rleri aras\u0131nda; ileri ya\u015f, etnisite, oksijenasyon durumu, HT ve DM gibi komorbiditeler oldu\u011fu belirlenmi\u015ftir (25,26). \u0130leri ya\u015f\u0131n ayaktan ve yat\u0131r\u0131larak takip edilen COVID-19 hastalar\u0131nda kritik hastal\u0131k riskini art\u0131rd\u0131\u011f\u0131 bilinmektedir (27). Blair ve arkada\u015flar\u0131 (19), ya\u015ftaki her bir y\u0131ll\u0131k art\u0131\u015f ile hastaneye yat\u0131\u015f riskinin 1.1 (%95 GA=1.0-1.1) kat artt\u0131\u011f\u0131n\u0131 g\u00f6stermi\u015ftir. \u00d6te yandan, Shah ve arkada\u015flar\u0131 (28) ayaktan izlenen hastalar\u0131n yedi g\u00fcnl\u00fck takibi s\u0131ras\u0131nda hastaneye yat\u0131\u015f riskini art\u0131ran fakt\u00f6rler aras\u0131nda ya\u015f\u0131 saptayamam\u0131\u015ft\u0131r. Benzer \u015fekilde \u0130spanya\u2019da yap\u0131lan tek merkezli bir \u00e7al\u0131\u015fmada da ya\u015f\u0131n tek ve \u00e7ok de\u011fi\u015fkenli analizlerde hastane yat\u0131\u015f\u0131 i\u00e7in belirleyici bir fakt\u00f6r olmad\u0131\u011f\u0131 bulunmu\u015ftur (18). S\u00f6z konusu iki ara\u015ft\u0131rmada, ya\u015f\u0131n risk fakt\u00f6r\u00fc olarak belirlenmemesi; \u00f6rneklem say\u0131s\u0131n\u0131n k\u00fc\u00e7\u00fck olmas\u0131na, \u00e7al\u0131\u015fmaya al\u0131nan hastalar\u0131n ayaktan takip kriterlerini kar\u015f\u0131layan hastalar olmas\u0131na ve bu hastalar\u0131n da g\u00f6receli olarak gen\u00e7 olmalar\u0131na ba\u011flanm\u0131\u015ft\u0131r (18).<\/p>\n

Cox regresyon analizinde, HT yat\u0131\u015f riskini art\u0131ran ba\u011f\u0131ms\u0131z risk fakt\u00f6r\u00fc olarak \u00f6ne \u00e7\u0131km\u0131\u015ft\u0131r. Pandeminin ilk dalgas\u0131nda elde edilen verilerde de yatan hastalarda kritik hastal\u0131k geli\u015fimi veya mortalite ile ili\u015fkili olarak \u00f6ne \u00e7\u0131kan komorbiditeler aras\u0131nda HT dikkat \u00e7ekmektedir (14). Teigell ve arkada\u015flar\u0131 (18), HT\u2019nin hastaneye yat\u0131\u015f i\u00e7in ba\u011f\u0131ms\u0131z bir risk fakt\u00f6r\u00fc oldu\u011funu rapor etmi\u015ftir. Vila-Corcoles ve arkada\u015flar\u0131n\u0131n (22) \u00e7al\u0131\u015fmas\u0131nda, ya\u015f ve cinsiyete g\u00f6re d\u00fczeltildi\u011finde ayaktan takip edilen hastalarda kritik hastal\u0131k geli\u015fme riskinin belirleyicileri aras\u0131nda kronik akci\u011fer hastal\u0131\u011f\u0131 ve DM yer alm\u0131\u015ft\u0131r.<\/p>\n

Ara\u015ft\u0131rmam\u0131zda ba\u015fvuru an\u0131nda sorgulanan 15 farkl\u0131 semptomdan be\u015fi olan; ate\u015f ve\/veya \u00fc\u015f\u00fcme\/titreme, nefes darl\u0131\u011f\u0131, yorgunluk\/bitkinlik, kusma ve koruyucu fakt\u00f6r olarak \u00f6ne \u00e7\u0131kan bo\u011faz a\u011fr\u0131s\u0131 Cox regresyon analizinde hastaneye yat\u0131\u015f i\u00e7in ba\u011f\u0131ms\u0131z risk fakt\u00f6rleri olarak belirlendi. Ba\u015fvuru an\u0131ndaki bulgular ile hastaneye yat\u0131\u015f riskini irdeleyen bir \u00e7al\u0131\u015fma, d\u00fc\u015f\u00fck SpO2 <\/sub>de\u011ferinin (\u2264 %92) yat\u0131\u015f riskini art\u0131ran ba\u011f\u0131ms\u0131z bir fakt\u00f6r oldu\u011fu, buna kar\u015f\u0131l\u0131k v\u00fccut \u0131s\u0131s\u0131 ve nab\u0131z de\u011ferinin hastaneye yat\u0131\u015f riski ile ili\u015fkili olmad\u0131\u011f\u0131n\u0131 g\u00f6stermi\u015ftir; ancak hastalar bulant\u0131, kusma, oral al\u0131mda g\u00fc\u00e7l\u00fck ve diyare gibi nedenlerle de hastaneye yat\u0131r\u0131ld\u0131\u011f\u0131 i\u00e7in SpO2 <\/sub>d\u00fc\u015f\u00fckl\u00fc\u011f\u00fc tek ba\u015f\u0131na hastaneye yat\u0131r\u0131lmay\u0131 tahmin ettiren bir risk fakt\u00f6r\u00fc de\u011fildir. Ayr\u0131ca s\u00f6z konusu \u00e7al\u0131\u015fmada, tek bir SpO2 <\/sub>de\u011ferinin de anlaml\u0131 olmad\u0131\u011f\u0131, g\u00fcnler i\u00e7inde takip edilmesi gerekti\u011fi de vurgulanm\u0131\u015ft\u0131r (19). \u00c7al\u0131\u015fmam\u0131zda ise yeterli veri olmad\u0131\u011f\u0131 i\u00e7in SpO2<\/sub> de\u011ferleri analizlere dahil edilemedi.<\/span><\/p>\n

\u0130spanya\u2019da yap\u0131lan retrospektif kohort \u00e7al\u0131\u015fmada, dispne ve konf\u00fczyonun yo\u011fun bak\u0131m yat\u0131\u015f veya \u00f6l\u00fcm riskini art\u0131ran ba\u011f\u0131ms\u0131z risk fakt\u00f6rleri oldu\u011fu g\u00f6sterilmi\u015f, myalji ise koruyucu bir fakt\u00f6r olarak \u00f6ne \u00e7\u0131km\u0131\u015ft\u0131r (22). Buna benzer sonu\u00e7lar ba\u015fka \u00e7al\u0131\u015fmalarda da g\u00f6sterilmi\u015ftir (29). \u00c7al\u0131\u015fmam\u0131zda, myalji varl\u0131\u011f\u0131 tek de\u011fi\u015fkenli ve \u00e7ok de\u011fi\u015fkenli analizlerde bir risk fakt\u00f6r\u00fc olarak belirlenemedi. \u00d6te yandan myalji gibi, \u00fcst solunum yolu infeksiyon belirtilerinden biri olan bo\u011faz a\u011fr\u0131s\u0131 ise hastaneye yat\u0131\u015f i\u00e7in koruyucu bir fakt\u00f6r olarak \u00f6ne \u00e7\u0131kt\u0131. Semptom k\u00fcmelerinin COVID-19 prognozuna etkisini ara\u015ft\u0131ran \u00e7ok merkezli bir \u00e7al\u0131\u015fmada, alt\u0131 farkl\u0131 semptom k\u00fcmesi incelenmi\u015f ve <\/b>myalji ile dispne\/nefes darl\u0131\u011f\u0131 gibi semptomlar\u0131n beraberli\u011finde solunum yetmezli\u011fi riskinin artt\u0131\u011f\u0131 ancak myaljinin bo\u011faz a\u011fr\u0131s\u0131, ses k\u0131s\u0131kl\u0131\u011f\u0131, ba\u015f a\u011fr\u0131s\u0131 gibi \u00fcst solunum yolu infeksiyonu semptomlar\u0131yla k\u00fcmelenmesinde solunum yetmezli\u011fi riski daha d\u00fc\u015f\u00fck izlenmi\u015ftir (30).<\/p>\n

\u00c7al\u0131\u015fmam\u0131zda, ba\u015fvuru \u015fikayetleri i\u00e7inde bo\u011faz a\u011fr\u0131s\u0131 olan hastalar\u0131n hastaneye yat\u0131\u015f riskinin neredeyse iki kat daha az oldu\u011fu g\u00f6r\u00fclmektedir. Bu durum \u00fcst solunum yolu infeksiyonu benzeri \u015fikayetleri olan hastalarda, hastal\u0131\u011f\u0131n daha hafif seyredebilece\u011fini ve hastaneye yat\u0131\u015f gereksinimi riskinin daha d\u00fc\u015f\u00fck olaca\u011f\u0131n\u0131 d\u00fc\u015f\u00fcnd\u00fcrebilir.<\/p>\n

Ayaktan \u0130zlenen Hastalar\u0131n Tedavi Karar\u0131 A\u00e7\u0131s\u0131ndan Bu \u00c7al\u0131\u015fma Katk\u0131 Sa\u011flayabilir mi?<\/h3>\n

SARS-CoV-2\u2019nin “spike”-proteinlerine kar\u015f\u0131 geli\u015ftirilen monoklonal antikor tedavileri ayaktan izlenen COVID-19 hastalar\u0131nda \u00f6zellikle erken d\u00f6nemde uyguland\u0131\u011f\u0131nda faydal\u0131 olmu\u015ftur (31-33). Erken d\u00f6nemde tan\u0131 alan hastalar\u0131n hangisinin tedavilerden fayda g\u00f6rece\u011fini kestirmek zordur. Bu nedenle ayaktan ba\u015fvuran hastalardaki prognostik risk fakt\u00f6rlerini irdeleyen \u00e7al\u0131\u015fmalar \u00f6nemlidir ve bu \u00e7al\u0131\u015fmalara halen ihtiya\u00e7 vard\u0131r. \u00c7al\u0131\u015fmam\u0131z ayaktan izlenip yat\u0131\u015f riski olan hasta pop\u00fclasyonunu belirlemesi a\u00e7\u0131s\u0131ndan \u00f6nemli olabilir. Gelecekteki ara\u015ft\u0131rmalar\u0131n hedefi, y\u00fcksek riskli oldu\u011fu belirlenen hastalarda erken tedavilerin gereklili\u011fi ve faydas\u0131n\u0131 deneysel \u00e7al\u0131\u015fmalarla g\u00f6stermek olmal\u0131d\u0131r.<\/p>\n

\u00c7al\u0131\u015fmam\u0131zda, hastalar ilk ba\u015fvuru tarihinden itibaren 28 g\u00fcn takip edilmi\u015f olup hastaneye yat\u0131\u015f i\u00e7in risk fakt\u00f6rleri sa\u011fkal\u0131m analizi ile belirlendi. \u00c7al\u0131\u015fma, pandeminin ilk dalgas\u0131nda ve etkin tedavilerin uygulamaya girmesinden \u00f6nce yap\u0131ld\u0131\u011f\u0131 i\u00e7in hastal\u0131\u011f\u0131n do\u011fal seyrini yans\u0131tacak veriler ortaya \u00e7\u0131kar\u0131ld\u0131. \u00d6rneklem, hastaneye ba\u015fvurup ayaktan takip edilen hastalar aras\u0131ndan sistematik \u00f6rnekleme y\u00f6ntemiyle se\u00e7ildi\u011fi i\u00e7in hasta grubunu temsil ederek \u00e7al\u0131\u015fman\u0131n i\u00e7 ge\u00e7erlili\u011fini g\u00fc\u00e7lendirmi\u015ftir. Di\u011fer yanda, \u00e7al\u0131\u015fmam\u0131z\u0131n tek merkezli olarak ve pandeminin ilk dalgas\u0131nda y\u00fcr\u00fct\u00fclmesi nedeniyle sonu\u00e7lar\u0131m\u0131z\u0131n, a\u015f\u0131 ve etkin antivirallerin uyguland\u0131\u011f\u0131, sonraki d\u00f6nemlerde ayaktan ba\u015fvuran hastalara genellenebilirli\u011fi k\u0131s\u0131tl\u0131d\u0131r. Ayr\u0131ca \u00e7al\u0131\u015fmam\u0131z\u0131n sonu\u00e7lar\u0131n\u0131n belirtilen tarih aral\u0131klar\u0131nda dola\u015f\u0131mda olan COVID-19 varyantlar\u0131 i\u00e7in ge\u00e7erli oldu\u011fu ak\u0131lda tutulmal\u0131d\u0131r. Radyolojik ve laboratuvar bulgular\u0131na ait verilerin yeterli olmamas\u0131 nedeniyle analize dahil edilememeleri bir di\u011fer k\u0131s\u0131tlay\u0131c\u0131 fakt\u00f6rd\u00fcr.<\/span><\/p>\n

Sonu\u00e7 olarak; ileri ya\u015f, sistemik ve alt solunum yolu infeksiyon bulgular\u0131n\u0131n varl\u0131\u011f\u0131 ve HT 28 g\u00fcn i\u00e7inde yat\u0131\u015f riskini art\u0131ran, bo\u011faz a\u011fr\u0131s\u0131n\u0131n olmas\u0131 ise yat\u0131\u015f riskini azaltan ba\u011f\u0131ms\u0131z fakt\u00f6rler olarak tespit edildi. Bo\u011faz a\u011fr\u0131s\u0131n\u0131n yat\u0131\u015f riskini d\u00fc\u015f\u00fcrmesi, hastal\u0131\u011f\u0131n hafif bir \u00fcst solunum yolu infeksiyonu olarak atlat\u0131laca\u011f\u0131 ve yat\u0131\u015f gerektirmeyece\u011fi \u015feklinde yorumlanabilir. Bu \u00e7al\u0131\u015fmada eksik veriler (radyolojik, laboratuvar ve SpO2<\/sub> verileri, vb.) nedeniyle riski art\u0131rabilecek t\u00fcm fakt\u00f6rler de\u011ferlendirilemedi. Yat\u0131\u015f riskini daha do\u011fru tahmin eden bir model olu\u015fturabilmek i\u00e7in ba\u015fvuru an\u0131ndaki klinik, laboratuvar ve radyolojik bulgular\u0131n dahil edildi\u011fi \u00e7al\u0131\u015fmalara ihtiya\u00e7 vard\u0131r. Bu \u00e7al\u0131\u015fmalardan elde edilecek verilerle ba\u015fvuru an\u0131nda yat\u0131\u015f riskini tahmin ettirmeye y\u00f6nelik bir skorlama sistemi geli\u015ftirmek m\u00fcmk\u00fcn olabilir.<\/p>\n","protected":false},"excerpt":{"rendered":"

G\u0130R\u0130\u015e \u015eiddetli akut solunum yolu sendromu virusu (SARS-CoV-2) yeni bir koronavirus t\u00fcr\u00fc olarak 2019 y\u0131l\u0131n\u0131n sonunda \u00c7in\u2019de ortaya \u00e7\u0131kan pn\u00f6moni olgu k\u00fcmelenmesinde tan\u0131mlanm\u0131\u015f ve h\u0131zla t\u00fcm d\u00fcnyaya yay\u0131larak k\u00fcresel bir pandemiye neden olmu\u015ftur (1). Koronaviruslar s\u0131kl\u0131kla \u00fcst solunum yolu infeksiyonlar\u0131na neden olmakla birlikte SARS-CoV-2\u2019nin neden oldu\u011fu koronavirus hastal\u0131\u011f\u0131 2019 (COVID-19), asemptomatik infeksiyondan, \u015fiddetli pn\u00f6moni ve […]<\/p>\n","protected":false},"author":4,"featured_media":27490,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[5129],"tags":[5736,5174,5737,5189],"class_list":["post-27238","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-ozgun-arastirma","tag-ayaktan-hasta-takibi","tag-covid-19","tag-hastaneye-yatis-insidansi","tag-sars-cov-2"],"acf":[],"_links":{"self":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/27238","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\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/comments?post=27238"}],"version-history":[{"count":3,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/27238\/revisions"}],"predecessor-version":[{"id":27441,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/27238\/revisions\/27441"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media\/27490"}],"wp:attachment":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media?parent=27238"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/categories?post=27238"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/tags?post=27238"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}