In this study, 417 patients older than 18 years of age who were hospitalized in the internal diseases and infectious diseases wards of Ankara City Hospital due to COVID-19 were evaluated retrospectively. Patients younger than 18 years old, patients with active malignancy, and pregnant women were excluded from the study. Ethical approval of the study was obtained from the Ethics Committee of Ankara City Hospital (Date: 24/02/2021, Number: E2-21-140). The age, gender, comorbidities, and medications of the patients were recorded, as well as fever, respiratory rate, SpO2, D-dimer, fibrinogen, complete blood count, biochemical parameters, CRP, sedimentation rate, and thorax CT findings at admission to the emergency department. Demographic, clinical, laboratory, imaging examination, treatment, and outcome data were collected using a standardized case-report form. All data were checked by 2 physicians (EG and IA), and then a third researcher (SB) determined any differences in interpretation between the 2 primary reviewers.
All of the patients included in this study were tested for influenza A virus, influenza B virus, respiratory syncytial virus, and parainfluenza virus, and these infections were excluded by serological test. Nasal and/or pharyngeal swab specimens were collected from all patients, and reverse transcriptase-polymerase chain reaction assays were performed. In our tertiary medical facility, the patients received the diagnosis either by positive polymerase chain reaction (PCR) for COVID-19 or by fulfilling any 4 of 5 clinical criteria including fever, respiratory symptoms, history, compatible chest imaging findings, and decreased lymphocyte count [20, 21].
In this study, we classified the patients into two groups according to the stage of the disease (severe and non-severe) by using the slightly modified and adopted interim guidance of the World Health Organization [22, 23]. Severe cases were divided into a group of surviving patients and a group of deceased patients according to their final prognosis.
Hospitalization, treatment, management, and discharge of the patients were decided according to the guidelines of the Turkish Ministry of Health .
Five scores were included in this analysis to understand the relation between the severity groups of the COVID-19 patients, including the BCRSS, qSOFA, SOFA, MuLBSTA, and HScore. According to admission values, the BCRSS, qSOFA, SOFA, MuLBSTA, and HScore were evaluated at admission using the worst parameters available in the first 24 hours [1-3, 5, 7, 8, 10, 15, 16].
In our study, it was aimed to calculate the sensitivity and specificity values according to the cut-off values in the literature, as well as finding the best cut-off value of the scores. The cut-off values in the literature were used for these calculations, and the BCRSS, qSOFA, SOFA, MuLBSTA, and HScore values were 3, ≥2, ≥2, >12, and> 169 in the calculations, respectively [1-3, 5, 7, 8, 10, 15, 16].
The Sepsis-Related Organ Failure Assessment score was developed by the European Society of Intensive Care Medicine to define the degree of organ failure due to sepsis [1, 2, 3]. However, since its validity was determined in patients with non-sepsis organ dysfunction, it was later renamed “Sequential Organ Failure Assessment” (SOFA). Six organ systems (respiratory, cardiovascular, central nervous, renal, coagulation, and liver systems) are scored between 1 and 4 points, with a total score between 6 and 24 [1, 2, 3]. The score is based on the worst value in the last 24 hours. If there is a value that cannot be measured, scoring is performed according to the closest measurement value.
The Sepsis-3 definitions have facilitated earlier identification of patients at risk of developing sepsis for treatment . QuickSOFA (qSOFA) is a bedside clinical score to clinically categorize a septic patient. In out-of-hospital, emergency department, or general hospital ward settings, adult patients with suspected infection can be rapidly identified as being more likely to have poor outcomes typical of sepsis if they have at least 2 of the following clinical criteria of qSOFA: respiratory rate of 22/min or greater, altered mentation, or systolic blood pressure of ≤100 mmHg. This definition was later confirmed in the emergency department for patients with suspected infection .
The MuLBSTA score is a scoring system developed to predict 90-day mortality in viral pneumonia patients with multilobular infiltration, lymphopenia, bacterial coinfection, smoking history, hypertension, and age of ≥60 years [7, 8]. All parameters defined in the MuLBSTA score are clinically easy to obtain, and it is recommended that all examinations be performed on admission. The MuLBSTA score was developed as a marker that shows the risk in the clinical prediction of patients specifically diagnosed with viral pneumonia . The risk categories and death rates for each grade are suggested as follows: MuLBSTA 0-11, low risk, mortality of 5.07%; and MuLBSTA 12-22, high risk, mortality of 33.92% .
Nine variables are used for the HScore as follows: three clinical variables (high fever, organomegaly, underlying immunosuppression), five biochemical variables (triglycerides, ferritin, serum transaminases, fibrinogen, presence of cytopenia), and one cytological variable (findings of hemophagocytosis in the bone marrow) . The best cut-off value in hemophagocytic syndrome (HPS) for the HScore was 169, and it exactly classified 90% of patients with 93% sensitivity and 86% specificity .
The Brescia-COVID Respiratory Severity Scale (BRCSS) was created by sharing experiences among physicians of different specialties [15, 16]. Since the beginning of the COVID-19 pandemic in Lombardy, a daily multidisciplinary meeting has been held to coordinate patient care and transfer between units. Participants of these meetings have included intensive care, infectious diseases, chest diseases, immunology, rheumatology, and internal medicine specialists. The BRCSS uses clinical criteria to rank non-intubated patients. It assigns patients a score of 0-3 based on 4 test criteria: 1) dyspnea or staccato speech, defined as being unable to count rapidly up to 20 after a deep breath, at rest, or during minimal activity, such as sitting up in bed, standing, talking, swallowing, or coughing; 2) respiratory rate of >22 breaths/min; 3) PaO2 of <65 mmHg or SpO2 of <90% with supplemental oxygen; and 4) significant worsening of chest radiography. In intubated patients, PaO2/FiO2 below 150 mmHg determines whether the score is 5 or above, and the use of adjunctive therapies including prone positioning and neuromuscular blockade agents further increases the score [15, 16]. The BRCSS may be useful for practicing clinicians to gauge the clinical improvement or worsening of patients infected with SARS-CoV-19. It may be used in other countries, as well .
The data were analyzed using SPSS for Windows version 25.0 (IBM Corp., Armonk, NY, USA) and MedCalc 15.8 (Franz Faul, Universitat Kiel, Germany). While frequency, percentage, mean, standard deviation, median, and IQR were used as descriptive statistical methods, the chi-square (c2) test was used to compare qualitative data. The consistency of the data with normal distribution was evaluated by the Kolmogorov-Smirnov and Shapiro-Wilk tests. The Mann-Whitney U test was used to compare the data not consistent with normal distribution. While the receiver operating characteristic (ROC) curve method was used to determine the discrimination of the variables, binary logistic regression was used to determine the risk rates. The statistical significance level was considered as p < 0.05.