key: cord-1039577-hshlfzed authors: Simsek Yurt, Nur; Ocak, Metin; Yurt, Yusuf Can title: Epidemiological and clinical characteristics of 3334 cases with prediagnosis coronavirus disease ‐ 2019 (COVID‐19) in Turkey date: 2021-06-26 journal: Int J Clin Pract DOI: 10.1111/ijcp.14496 sha: 3b1777591aceb720a284ab9dbc8f9d0d16c69172 doc_id: 1039577 cord_uid: hshlfzed AIM: This study aims to analyse the epidemiological and clinical features of the patients admitted to the hospital with the prediagnosis of coronavirus disease 19 (COVID‐19) in Turkey. MATERIALS AND METHODS: In this retrospective study, epidemiological and clinical features, laboratory markers, radiological features, therapeutic approaches, and survival conditions of the patients with the prediagnosis of COVID‐19 from March 11th to June 30th, 2020 have been analysed and reported. The data of the cases were divided into four groups and then compared with each other: first group includes confirmed cases with positive reverse transcriptase polymerase chain reaction (RT‐PCR) and chest computed tomography (CT) imaging results considered as COVID‐19 lung involvement, second group includes the clinically diagnosed cases with negative RT‐PCR and positive CT imaging abnormalities, third group includes mild and asymptomatic cases with positive RT‐PCR and negative CT findings, fourth group includes suspected cases with negative RT‐PCR and negative CT findings. Post‐hoc analysis was performed to evaluate the differences among the groups. RESULTS: In total, 3334 patients with the prediagnosis of COVID‐19 admitted to the emergency department. Based on the post hoc analyses, significant differences were found among the four groups in terms of their test results of leukocytes, haemoglobin, platelet, neutrophils, urea and C‐reactive protein (CRP) (P < .001). Furthermore, the factors of age groups, hospitalisation, intensive care unit follow‐up and mortality rate of the four groups showed a significant difference among the groups (P = .001). CONCLUSION: The mean leukocytes, neutrophils and platelet counts of patients with positive RT‐PCR were found to be lower than the ones with negative RT‐PCR. The mean serum levels of CRP were found to be higher in patients with lung involvement compared with other patient groups. the patient diagnosis and treatment management are performed through following these guidelines in all hospitals in Turkey. The first COVID-19 case was recorded on March 11th 2020 considerably later than the COVID-19 outbreaks in neighbouring countries such as European countries and Iran. 4 WHO declared COVID-19 as a pandemic on March 11, 2020. 5 The confirmed number of cases has been continuously rising daily worldwide. The pandemic that originated from Asia spread to Europe first, and then USA and Africa continents; the highest number of cases has been so far reported in USA, Brazil, Russia, India and United Kingdom. 6 As the outbreak has been rapidly spreading all around the world, as of May 9, 2021, the number of confirmed COVID-19 cases worldwide stands at 157.289.118 and the total number of deaths is 3.277.272, while the number of cases and deaths in Turkey was reported as 5.016.141 and 42.746, respectively. 7 Identifying the epidemiological characteristics of this disease will guide appropriate decisions and thus help fighting the pandemic. This study aims to present the details of epidemiological and clinical features, laboratory markers, radiological features, therapeutic approaches and survival conditions of patients with the prediagnosis of COVID-19 retrospectively in Samsun Gazi State Hospital that is one of the pandemic hospitals authorised to apply diagnosis and treatment protocols of COVID-19 in Turkey. The study presents a retrospective evaluation of the patients admitted to the Emergency Department of Samsun Gazi State Hospital with the prediagnosis of COVID-19 between March 11, 2020 that is the date of the first reported case in Turkey and June 30, 2020. The patient data on age, symptoms, vital findings, comorbid diseases, smoking and preapplication 14-day clinical history of the patients were obtained in the triage area of the emergency department and the patients considered as a potential or confirmed COVID-19 case were directed to the isolation area in the service. A potential case is defined as a case that shows at least one of the symptoms and findings of fever or acute respiratory tract disease (coughing and shortness of breath) by the fact that his/her clinical presentation cannot be categorised as any other disease by the history of going abroad or contacting the relatives that went abroad in the 14 days before the beginning of symptoms or as a case that were in close contact with a confirmed COVID-19 patient. Moreover, the confirmed cases are defined who were found to have SARS-CoV-2 in nasopharyngeal swab samples obtained from potential cases. Laboratory tests and lung imaging scans of the patients who were taken to the isolation area were carried out, and nasopharyngeal swab samples were obtained from the people who were in close contact with a confirmed COVID-19 patient to perform SARS-CoV-2 reverse transcriptase polymerase chain reaction (RT-PCR) test. Furthermore, complete blood count, electrolytes, glucose, urea, creatinine, aspartate aminotransferase (AST), alanine aminotransferase (ALT), C-reactive protein (CRP), d-dimer, troponin tests were performed on each case. Unenhanced chest computed tomography (CT) imaging was applied for lung imaging and the acquired CT findings were categorised under two main groups. The findings considered as COVID-19 pneumonia in the foreground are occurrences of peripheral, bilateral, ground glass opacity, multifocal round ground glass opacity (they can be accompanied by other findings of organised pneumonia such as paving stone appearance, consolidation, reverse-halo) (CT +). The findings not considered as COVID-19 pneumonia in the foreground are the chest CT findings regarded as atelectasis, lobar consolidation, and parenchymal band formation (CT -). 4 In the study, the patients are categorised in four main groups. 8 The first group as confirmed cases are those admitted to the hospital with fever and acute respiratory tract symptoms, tested positive RT-PCR, and with chest CT imaging results considered as COVID-19 lung involvement (CT +). The second group as the clinically diagnosed cases are those admitted to the hospital with fever and acute respiratory tract symptoms, tested negative RT-PCR, but with chest CT imaging results considered positive in terms of COVID-19 lung involvement (CT +). The third group as the mildly symptomatic or completely asymptomatic cases, are those tested positive RT-PCR, but the chest CT imaging yielded negative results (CT -). The fourth group as the suspected cases, are patients admitted to the hospital with fever and acute respiratory tract symptoms, tested negative RT-PCR and showed no COVID-19 lung involvement in chest CT imaging (CT -). Epidemiological, demographic, clinical, laboratory, treatment data of the patients admitted to the isolation area were obtained from the electronic database of the hospital retrospectively. In cases with confirmed COVID-19 individuals over 65 years and hospitalisation rates were higher than the other groups. No deaths were found in cases with confirmed COVID-19. The chest CT imaging results of only 23% of the patients with positive RT-PCR test results showed COVID-19 pneumonia findings. Most patients with COVID-19 had normal leukocyte and lymphocyte counts in blood cell count. The mean serum levels of CRP value of the cases with lung involvement were higher. Ethics committee approval was obtained with the Ethics Committee Decision dated 30 June 2020 and No. 10 of Health Sciences University Samsun Education and Training Hospital Ethics Committee. Descriptive statistics are presented with mean and standard deviation values for continuous data; they are presented with numbers and percentages for categorical data. The compatibility of continuous data with a normal distribution was evaluated by Kolmogorov- 3334 patients were admitted to the emergency department in total, with the prediagnosis of COVID-19. 55.5% of the patients are male. Age mean of the patients is 45.46 ± 19.7; the median age is 42(6-106). While 34.7% of the patients belong to the age group 31-50 years, 19.8% is above 65 years of age. Of the total cases, 12.7% had hypertension, 7.5% had diabetes, 7.1% had chronic obstructive pulmonary disease (COPD). 28.1% of the patients were smokers. The demographic features and the comorbid diseases of the cases are given in Table 1 . The most frequent symptoms reported by patients were coughing (22.8%), shortness of breath (22.6%), muscle and joint pains (11.1%), fever (6.2%) and fatigue (6.2%). The less frequent symptoms were, in order of frequency, the complaints of sore throat, chest pain, nausea-vomiting-diarrhoea, headache-dizziness. While 22.1% of the patients were hospitalised, 2.2% were monitored in the intensive care unit (ICU). Of the total cases, 0.4% (n = 12) resulted in exitus. The mortality rate was found 0.8% (n = 7) in cases considered having COVID-19. 2.4% of the patients were referred to other health centres for various reasons ( Table 2 ). 9.8% of all cases were tested positive in RT-PCR test. 16.4% of the cases showed COVID-19 pneumonia findings in CT imaging results. 13.7% of the cases whose CT imaging results showed COVID-19 pneumonia were tested positive in RT-PCR. No pathology was found in CT results of 53.5% of the cases (Table 3) . Age groups, laboratory studies, hospitalisation, ICU monitoring and exitus condition of the cases were compared in the four groups: first group represents the confirmed cases (RT-PCR+ CT +); second group consists of the clinically diagnosed cases (RT-PCR-CT +); third group represents the mild or asymptomatic cases (RT-PCR+ CT -); fourth group consists of the suspected cases (RT-PCR-CT -). While a significant difference was found among leukocytes (P < .001), haemoglobin (P < .001), platelets (P < .001), neutrophils (P < .001), urea (P < .001), ALT (P = .007) and CRP (P < .001) values in the laboratory results between the groups based on the post-hoc analyses; no significant difference was found among lymphocytes, Na, K, Cl, serum creatinine, AST, D-dimer and troponin values. We found in the post-hoc analyses that the difference between leukocytes and neutrophils values is because of the difference between groups 1-4 (P < .001), 1-2 (P < .001), 3-4 (P < .001), 3-2 (P < .001); whereas the difference between CRP values is because of the groups 3-2 (P = .001), 4-2 (P < .001). Although no statistical difference was found in lymphocyte values among the groups (P = .017), mean lymphocyte value was found to be lower in group 1 than in other groups. Comparison of the laboratory test results among the groups is given in Table 4 We found that the doctors started treatment for 19.4% of (n = 646) the patients in total. In our analysis of the medications administered to the patients, we found that hydroxychloroquine sulphate (89.8%, n = 580) is the most preferred medication ( Table 2 ). showing COVID-19 pneumonia findings, we found that 54.3% 3334 patients were examined in the study in total in which 55.5% of the cases is male. In the meta-analysis by Wang et al on 1994 patients, the rate of males is 60%. 10 Other studies in literature report that MERS-CoV and SARS-CoV infected males more than females. 11, 12 The less susceptibility to infection among women could be attributed to the X chromosome and sex hormones, which have been reported to play a role in innate and adaptive immunity. 13 We found in our study that the most common symptoms re- 16 The positive rate of the tests in the hospital (9.8%) where we run our study is above the average of the country-wide results in RT-PCR +patients are found to be lower than those with RT-PCR. There was not any statistically significant difference in the mean of lymphocyte values among the groups. In this study, the mean value of CRP was found to be significantly higher in the second group compared with third and fourth groups (P < .001). The CRP value of the cases with lung involvement was higher. However, the mean value was found to be lower in the first group compared with other groups. In the meta-analysis by Zhu 2.2% of all cases were monitored in the ICU. 12 patients (0.4%) in total died. The case fatality rate is found in 0.8% diagnosed with COVID-19. In Turkey, the case fatality rate was reported until July 1, 2020 is 2.5%. The case fatality rate around the world is 4.9% as reported until July 1, 2020. 16 The case fatality was reported to be 2% worldwide on May 9, 2021. 7 The meta-analysis by Wang et al investigated 10 studies in the literature and reported the mortality rate to be 5%. 10 Another meta-analysis studying 3062 patients found that the case fatality rate is 5.5%. 14 In a study on 2968 patients in a single centre in Iran, the case fatality rate is reported to be 1.85%. 25 The reason for the low case fatality rate in this study can be attributed to inclusion of the asymptomatic/mild cases treated and monitored at home in addition to the hospitalised patients. Despite the important statistical learnings from our study, our study has limitations originating from the scale of the pandemic. This study includes the early stages of COVID-19 from March to June 2020. COVID-19 patient management, therapeutic strategies constantly change since the beginning of the pandemic. Therefore, new studies that include up-to-date information are needed. The case fatality rate caused by COVID-19 is found to be lower in Samsun province than the rates in Turkey and around the world. The mean of leukocytes, neutrophils and platelet count values in RT-PCR +patients are found to be lower than those of RT-PCR -patients. The mean serum levels of CRP value in patients with lung involvement are found to be higher than those of other patient groups included in the study. COVID-19 infection continues to spread across the whole world as the number of cases and mortality rates increase daily. Changes in seasonal conditions, social and economic life have a significant influence on the process, and further studies should be conducted on a broader context including a larger number of cases in the future. We declare that there is no conflict of interests. All authors have read and approved the submission. Simsek Yurt, N: protocol/project development, data collection, data analysis, writing/editing, management. Ocak, M: data collection, data analysis, manuscript reviewing. Yurt, YC: protocol/project development, data collection, manuscript reviewing. Nur Simsek Yurt https://orcid.org/0000-0002-6585-9663 Metin Ocak https://orcid.org/0000-0002-9978-0216 Yusuf Can Yurt https://orcid.org/0000-0003-0732-289X A novel coronavirus from patients with pneumonia in China Evolution of the novel coronavirus from the ongoing Wuhan outbreak and modeling of its spike protein for risk of human transmission General's remarks at the media briefing on 2019 nCoV on 11 COVID-19 (SARS-CoV-2 infection) general information [Internet]. cited 30 Director -General's opening remarks at the media briefing on COVID-19 -11 World Health Organization. Coronavirus disease (COVID-19) situation report Characteristics of COVID-19 infection in Beijing A novel coronavirus emerging in China-key questions for impact assessment COVID-19 patients' clinical characteristics, discharge rate, and fatality rate of meta-analysis Sex-based differences in susceptibility to severe acute respiratory syndrome coronavirus infection Prevalence of comorbidities in the Middle East respiratory syndrome coronavirus (MERS-CoV): a systematic review and meta-analysis Sexual dimorphism in innate immunity Clinical characteristics of 3062 COVID-19 patients: a meta-analysis Clinical characteristics of Covid-19 in New York City World Health Organization. Coronavirus disease (COVID-19) situation report -163 Correlation of chest CT and RT-PCR testing for coronavirus disease 2019 (COVID-19) in China: a report of 1014 cases Sensitivity of chest CT for COVID-19: comparison to RT-PCR CT imaging features of 2019 novel coronavirus (2019-nCoV) Chest CT for typical 2019-nCoV pneumonia: relationship to negative RT-PCR testing Value of chest computed tomography scan in diagnosis of COVID-19; a systematic review and meta-analysis Can computed tomography be a primary tool for COVID-19 detection? Evidence appraisal through meta-analysis The limited sensitivity of chest computed tomography relative to reverse transcription polymerase chain reaction for severe acute respiratory syndrome coronavirus-2 infection: a systematic review on COVID-19 diagnostics Epidemiological, clinical characteristics of cases of SARS-CoV-2 infection with abnormal imaging findings Epidemiological characteristics of coronavirus disease 2019 (COVID-19) patients in IRAN: a single center study Clinical features and treatment of COVID-19 patients in northeast Chongqing Prevalence of comorbidities and its effects in patients infected with SARS-CoV-2: a systematic review and meta-analysis Epidemiological and clinical characteristics of 3334 cases