CALLY Index as a Prognostic Marker for 30-Day Mortality in Fournier Gangrene: A Multicenter Retrospective Cohort Study

Abstract

Background

Fournier gangrene (FG) remains a life-threatening necrotizing infection with persistently high mortality despite advances in surgical and supportive care. Reliable early prognostic markers are therefore essential. The C-reactive protein–albumin–lymphocyte (CALLY) index, which integrates inflammatory, nutritional, and immune status, has shown prognostic value in several critical illness settings, but its utility in FG has not been adequately evaluated.

Methods

This multicenter retrospective cohort study included 136 adults who underwent surgical treatment for FG between 2015 and 2025. Demographic variables, comorbidities, laboratory parameters, qSOFA scores, and 30-day outcomes were analyzed.

Results

The 30-day mortality rate was 17% (23/136). Non-survivors had significantly lower albumin and lymphocyte levels, higher CRP levels, and markedly reduced CALLY indices compared with survivors (0.005 vs 0.039, P < 0.001). The CALLY index demonstrated strong discriminative performance for 30-day mortality (AUC = 0.886; 95% CI: 0.780-0.991). A cutoff ≤0.012 provided 82.6% sensitivity and 95.6% specificity. In multivariate analysis, CALLY ≤0.012 (OR 42.61; P < 0.001) and qSOFA score 2-3 (OR 12.97; P = 0.019) emerged as strong independent predictors of mortality, whereas age, sex, uncontrolled diabetes, CAD, immunosuppression, and malignancy were not independently associated with death.

Discussion

The C-reactive protein–albumin–lymphocyte (CALLY) index was independently associated with 30-day mortality in patients with Fournier gangrene and may serve as a simple adjunctive biomarker for early risk stratification when interpreted alongside established clinical scoring systems such as qSOFA. Incorporating the CALLY index into early risk-stratification algorithms may facilitate timely clinical decision-making and more targeted management strategies for high-risk FG patients.

Keywords

Fournier gangrene CALLY index prognostic marker immune-nutritional status qSOFA

Key Takeaways

• The CALLY index demonstrated strong and independent predictive value for 30-day mortality in patients with Fournier’s gangrene.

• A CALLY cutoff value ≤0.012 yielded a sensitivity of 82.6% and a specificity of 95.6%, indicating high diagnostic accuracy for early mortality risk stratification.

• Lower CALLY values reflect the combined impact of systemic inflammation (elevated CRP), compromised nutritional status (reduced albumin), and immune dysfunction (decreased lymphocyte count), thereby providing an integrated representation of the patient’s overall physiological state.

• A qSOFA score of 2-3 was also independently associated with mortality, and the addition of the CALLY index provided complementary prognostic information when combined with clinical scoring compared with clinical scoring alone.

• Demographic and comorbidity-related variables—including age, sex, uncontrolled diabetes mellitus, coronary artery disease, immunosuppression, and malignancy—were not independent predictors in multivariate analysis.

• Because it is calculation-friendly and derived from routine laboratory parameters, the CALLY index offers a practical and efficient tool for early identification of high-risk patients.

• Patients presenting with low CALLY values identify a high-risk subgroup that may warrant closer monitoring and heightened clinical vigilance; however, these observations should be regarded as hypothesis-generating and require prospective validation.

Introduction

Fournier gangrene (FG) is a fulminant necrotizing soft tissue infection predominantly affecting the perineal and genital regions, characterized by high morbidity and mortality despite aggressive surgical and supportive management. Recent epidemiological analyses have reported 30-day mortality rates that remain substantial, underscoring the urgent need for reliable prognostic markers.

In the last few years, growing attention has been paid to biochemical biomarkers that integrate inflammatory and nutritional parameters to enhance risk stratification in FG. For instance, Özgül et al demonstrated that the C-reactive protein to albumin ratio (CAR) has strong prognostic value in FG (AUC ≈ 0.907), suggesting that systemic inflammation and nutritional status may jointly influence outcomes.¹ In parallel, the development of new scoring systems such as the Fournier’s Gangrene Mortality Index (FGMI) further highlights the evolving landscape of prognostication in FG.²

Beyond FG, composite biomarkers combining inflammation and nutrition have shown prognostic relevance in other critically ill populations. Studies in cardiovascular cohorts, for example, have identified advanced inflammation and nutrition indices as independent predictors of mortality in patients with cardio-cerebrovascular events.³ Moreover, in sepsis and critical illness, inflammatory and metabolic markers such as CRP, albumin, and lymphocyte-based ratios have been strongly associated with outcomes.⁴

Given the pathophysiological parallels between critical illness and FG—including the interplay of systemic inflammation, immune dysfunction, and nutritional depletion—it is plausible that a biomarker combining these dimensions could offer superior prognostic discrimination. The C-reactive protein–albumin–lymphocyte (CALLY) index, which reflects both inflammatory response and immune-nutritional status, emerges as a compelling candidate, though its use in FG remains underexplored.

Over the last 2-3 years, prognostication in Fournier’s gangrene has evolved along three parallel tracks: the refinement and comparison of FG-specific severity scores, the adoption of simple sepsis-oriented bedside tools for early risk recognition (eg, qSOFA), and increasing interest in inflammation and immune-nutritional biomarkers derived from routine laboratory tests. Recent work has supported the prognostic utility of qSOFA in FG, while newer FG-specific models and scoring approaches have also been proposed to facilitate early mortality prediction at presentation. In parallel, multiple studies have reported prognostic associations for inflammation–nutrition composites and lymphocyte-based indices, including the CRP–albumin ratio (CAR) and the lymphocyte-to-CRP ratio (LCR), underscoring a broader shift toward integrated host-response phenotyping in FG.^5-7

Although several inflammation-based biomarkers such as the C-reactive protein–albumin ratio (CAR), neutrophil-to-lymphocyte ratio (NLR), and lymphocyte-to-C-reactive protein ratio (LCR) have been investigated in Fournier’s gangrene, these indices primarily reflect isolated aspects of the host response. None simultaneously capture the combined effects of systemic inflammation, immune competence, and nutritional status. The C-reactive protein–albumin–lymphocyte (CALLY) index integrates all three dimensions within a single, calculation-friendly parameter. To date, however, its prognostic role in Fournier’s gangrene has not been systematically evaluated. This study was therefore designed to assess whether the CALLY index provides incremental and clinically relevant prognostic value beyond previously established inflammatory markers and FG-specific scoring systems.

In this context, we conducted a multicenter retrospective cohort study to evaluate the prognostic utility of the CALLY index for predicting 30-day mortality in FG. Our goal was to determine whether the CALLY index improves risk stratification beyond conventional clinical predictors and to potentially inform more tailored clinical management strategies for this high-risk patient population.

Materials and Methods

Study Design and Patient Selection

This was a multicenter, retrospective cohort study conducted in three tertiary referral centers. Ethical approval was obtained from the Amasya University Non-Interventional Ethics Committee for the study protocol, and the requirement for informed consent was waived due to the retrospective nature of the study (Date 04/12/2025 No: 2025/232).

Patients aged ≥18 years who underwent surgical management for Fournier gangrene between 2015 and 2025 were assessed for inclusion.

Exclusion Criteria Included

• Non-surgical management of Fournier gangrene.

• Missing key laboratory data.

• Age <18 years.

After applying these criteria, a total of 136 patients were included in the final analysis.

Data Collection and Variables

Demographic data, comorbidities, laboratory results, qSOFA scores, ICU admission, and 30-day mortality were recorded. Comorbidities included diabetes mellitus (DM), hypertension, coronary artery disease, chronic kidney disease, immunosuppression, and malignancy. Length of hospital stay and diversion ostomy procedures were also noted.

Glycemic Status Classification

Based on the Endocrine Society Clinical Practice Guideline (2022) for hospitalized patients:

• Chronic uncontrolled diabetes mellitus (DM): HbA1c ≥8.0% or random glucose ≥250 mg/dL, not explained by infection.

• Acute stress hyperglycemia: Random glucose 180-250 mg/dL with HbA1c <8.0%.

• Patients with well-controlled DM (HbA1c <8.0% and glucose <180 mg/dL) were categorized separately.

This approach allowed methodological distinction between chronic uncontrolled hyperglycemia and acute stress-induced hyperglycemia, which may have differential prognostic implications.

The primary outcome was 30-day all-cause mortality. Secondary outcomes included ICU admission and length of hospital stay.

Statistical Analysis

Continuous variables were expressed as median and interquartile range (IQR), and categorical variables were presented as frequencies and percentages. Comparisons between survivors and non-survivors were performed using the Mann–Whitney U test for continuous variables and the Chi-square test or Fisher’s exact test for categorical variables, as appropriate.

The prognostic performance of the C-reactive protein–albumin–lymphocyte (CALLY) index for 30-day mortality was evaluated using receiver operating characteristic (ROC) curve analysis, with the area under the curve (AUC) and 95% confidence intervals (CIs) reported. The optimal cutoff value was determined using Youden’s index to maximize sensitivity and specificity. Diagnostic performance metrics, including sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy, were calculated.

A post hoc power analysis was performed to assess the study’s ability to detect the observed effect of the CALLY index on 30-day mortality. Based on the observed area under the ROC curve (AUC = 0.886), the sample size of 136 patients, and 23 mortality events, the study achieved a statistical power exceeding 80% to detect a significant predictive effect at an alpha level of 0.05. These results indicate that the study was sufficiently powered to demonstrate the prognostic value of the CALLY index for 30-day mortality in patients with Fournier gangrene.

Variables with P < 0.05 in univariate analyses were included in a multivariate logistic regression model to identify independent predictors of 30-day mortality. Results were reported as odds ratios (ORs) with 95% CIs. A P-value <0.05 was considered statistically significant. All analyses were performed using Jamovi version 2.7.12.0 (The Jamovi Project, Sydney, Australia).

Result

A total of 136 patients who underwent surgery for Fournier gangrene were evaluated. Male patients accounted for 70% of the cohort, and the median age was 55 years (IQR: 15.3). Diabetes mellitus was present in 46.3% of the patients, hypertension in 22%, coronary artery disease in 13%, and chronic kidney disease in 2%. Immunosuppression was identified in 23% of the cohort, and malignancy in 15%. Uncontrolled diabetes was observed in 28% of diabetic patients. Intensive care unit admission was required in 24% of cases. The median length of hospital stay was 19 days (IQR: 16.3). Based on qSOFA scores, 79% of patients scored 0-1, while 21% scored 2-3. The 30-day mortality rate was 17% (Table 1).

Table 1.

Baseline Characteristics of Patients Operated for Fournier Gangrene

Variable	n (%)	Median (IQR)
Gender
Male	95 (70%)	—
Age (years)	—	55 (15.3)
Comorbidities
Diabetes mellitus (DM)	63 (46.3%)	—
Hypertension (HT)	30 (22%)	—
Coronary artery disease (CAD)	18 (13%)	—
Chronic kidney disease (CKD)	3 (2%)	—
Immunosuppression	31 (23%)	—
Malignancy	21 (15%)	—
Uncontrolled DM	38 (28%)	—
ICU admission	32 (24%)	—
Length of hospital stay (days)	—	19 (16.3)
qSOFA score
0-1	108 (79%)	—
2-3	28 (21%)	—
Mortality	23 (17%)	—

IQR: interquartile range; DM: diabetes mellitus; HT: hypertension; CAD: coronary artery disease; CKD: chronic kidney disease; ICU: intensive care unit; qSOFA: quick Sequential Organ Failure Assessment.

Among 136 patients with Fournier gangrene, 23 (17%) died within 30 days. Non-survivors were older than survivors (median 59 vs 54 years, P = 0.018) and had a lower proportion of males (52.2% vs 73.5%, P = 0.043). Comorbidities such as coronary artery disease (26.1% vs 10.6%, P = 0.046), immunosuppression (43.5% vs 18.6%, P = 0.009), malignancy (34.8% vs 11.5%, P = 0.005), and uncontrolled diabetes (47.8% vs 23.9%, P = 0.020) were more frequent among non-survivors.

qSOFA scores of 2-3 were observed in 82.6% of non-survivors compared to 8% of survivors (P < 0.001). Laboratory findings differed significantly between groups: non-survivors had lower albumin (20 vs 26 g/dL, P < 0.001) and lymphocyte counts (700 vs 1700/µL, P < 0.001), higher CRP (256 vs 102 mg/L, P < 0.001), and lower CALLY index (0.005 vs 0.039, P < 0.001). Other variables, including urea, glucose, HbA1c, diversion ostomy, and length of hospital stay, did not differ significantly (Table 2).

Table 2.

Comparison of Clinical and Laboratory Variables Between Survivors and Non-survivors

Variable	Survivors (N = 113)	Non-Survivors (N = 23)	P-Value
Gender
Male	83 (73.5%)	12 (52.2%)	0.043
Age (years)	54 (20)	59 (8)	0.018
Comorbidities
Diabetes mellitus (DM)	52 (46%)	11 (47.8%)	0.874
Hypertension (HT)	26 (23%)	4 (17.4%)	0.554
Coronary artery disease (CAD)	12 (10.6%)	6 (26.1%)	0.046
Chronic kidney disease (CKD)	3 (2.7%)	0 (0%)	0.429
Immunosuppression	21 (18.6%)	10 (43.5%)	0.009
Malignancy	13 (11.5%)	8 (34.8%)	0.005
Uncontrolled DM	27 (23.9%)	11 (47.8%)	0.020
qSOFA (2-3)	9 (8%)	19 (82.6%)	<0.001
Laboratory findings
Albumin (g/dL)	26 (8)	20 (7.5)	<0.001
Urea (mg/dL)	35 (36)	46 (65.5)	0.083
Glucose (mg/dL)	128 (128)	128 (155)	0.216
HbA1c (%)	6.0 (1.6)	6.3 (3.0)	0.074
Lymphocyte count (/µL)	1700 (900)	700 (700)	<0.001
CRP (mg/L)	102 (50)	256 (110)	<0.001
CALLY index	0.039 (0.032)	0.005 (0.005)	<0.001
Diversion ostomy	33 (29.2%)	8 (34.8%)	0.595
Length of hospital stay (days)	19 (14)	15 (31)	0.561

qSOFA, quick Sequential Organ Failure Assessment; CRP, C-reactive protein; CALLY, C-reactive protein–albumin–lymphocyte index. Categorical variables are presented as n (%) and continuous variables as median (interquartile range, IQR). Comparisons between survivors and non-survivors were performed using the Chi-square test or Fisher’s exact test for categorical variables and the Mann–Whitney U test for continuous variables.

The diagnostic performance of the CALLY index for predicting 30-day mortality in patients with Fournier gangrene was evaluated using receiver operating characteristic (ROC) curve analysis. The area under the curve (AUC) was 0.886 (95% CI: 0.780-0.991, P < 0.001), indicating excellent discriminatory ability (Table 3). Using an optimal cutoff value of ≤0.012, determined by Youden’s index, the CALLY index demonstrated a sensitivity of 82.61% (95% CI: 61.22%-95.05%) and a specificity of 95.58% (95% CI: 89.98%-98.55%) for predicting mortality within 30 days (Figure 1) (Table 4). The positive predictive value (PPV) and negative predictive value (NPV) were 79.17% and 96.43%, respectively, with an overall accuracy of 93.38%. These findings suggest that the CALLY index is a reliable prognostic marker for 30-day mortality in this patient population (Tables 3 and 4).

Table 3.

ROC Curve Analysis of the CALLY Index for Predicting 30-Day Mortality

Parameter	AUC	Std. Error	95% CI Lower	95% CI Upper	P-Value
CALLY	0.886	0.054	0.780	0.991	<0.001

Abbreviations: AUC, area under the curve; CI, confidence interval; CALLY, C-reactive protein–albumin–lymphocyte index.

Figure 1.

Receiver operating characteristic (ROC) curve of the CALLY index for predicting 30-day mortality in patients with Fournier gangrene

Table 4.

Diagnostic Performance of the CALLY Index at the Optimal Cutoff Value (≤0.012) for Predicting 30-Day Mortality

Metric	Result	95% CI Lower	95% CI Upper
Sensitivity	82.61%	61.22%	95.05%
Specificity	95.58%	89.98%	98.55%
Positive predictive value (PPV)	79.17%	61.25%	90.13%
Negative predictive value (NPV)	96.43%	91.72%	98.50%
Accuracy	93.38%	87.81%	96.93%

CI, confidence interval; PPV, positive predictive value; NPV, negative predictive value. The cutoff value of the CALLY index was determined using Youden’s index to optimize sensitivity and specificity for predicting 30-day mortality in patients with Fournier gangrene.

Multivariate logistic regression analysis identified the CALLY index ≤0.012 as a strong independent predictor of 30-day mortality in patients with Fournier gangrene (OR: 42.61; 95% CI: 1.82-56.80; P < 0.001). Additionally, a qSOFA score of 2-3 was significantly associated with increased mortality risk (OR: 12.97; 95% CI: 0.42-4.70; P = 0.019) (Figure 2). Other variables, including age, gender, uncontrolled diabetes mellitus, coronary artery disease, immunosuppression, and malignancy, did not demonstrate statistically significant associations with mortality (all P > 0.05). These findings suggest that both the CALLY index and qSOFA score serve as valuable prognostic indicators for mortality in this patient population (Table 5).

Figure 2.

CALLY index and qSOFA scores predict 30-day mortality in Fournier gangrene (raincloud plot)

Table 5.

Multivariate Logistic Regression Analysis for Predictors of 30-Day Mortality

Predictor	Odds Ratio	95% CI (Lower–Upper)	P-Value
Age, years	0.979	−0.087 to 0.046	0.547
Gender, male	1.444	−1.449 to 2.185	0.692
Uncontrolled DM	1.439	−15.545 to 22.829	0.710
qSOFA (score 2-3)	12.970	0.421−4.703	0.019
CAD	1.359	−2.067 to 2.681	0.800
Immunosuppression	10.254	−0.3559 to 5.011	0.089
Malignancy	0.278	−4.342 to 1.783	0.413
CALLY index ≤0.012	42.610	1.824−56.795	<0.001

CI: confidence interval; DM: diabetes mellitus; CAD: coronary artery disease; qSOFA: quick Sequential Organ Failure Assessment; CALLY: C-reactive protein–albumin–lymphocyte index.

The ROC curve demonstrates the diagnostic performance of the C-reactive protein–albumin–lymphocyte (CALLY) index in predicting 30-day mortality. The area under the curve (AUC) was 0.886 (95% CI: 0.780-0.991, P < 0.001), indicating excellent accuracy. The optimal cutoff value of ≤0.012, determined by Youden’s index, maximizes both sensitivity and specificity, supporting the CALLY index as a reliable prognostic marker in this clinical setting.

This raincloud plot illustrates the distribution of the C-reactive protein–albumin–lymphocyte (CALLY) index according to qSOFA scores and 30-day mortality in patients with Fournier gangrene. Patients with high qSOFA scores (2-3) who did not survive exhibited markedly lower CALLY values, highlighting the strong association between impaired immune-nutritional status and mortality.

Discussion

Previous studies in Fournier’s gangrene have predominantly focused on inflammation-based biomarkers such as the C-reactive protein–albumin ratio (CAR), neutrophil-to-lymphocyte ratio (NLR), and lymphocyte-to-C-reactive protein ratio (LCR), each reflecting a single dimension of the host response. In contrast, the present study demonstrates that the C-reactive protein–albumin–lymphocyte (CALLY) index provides a more comprehensive prognostic framework by concurrently integrating inflammatory burden, nutritional reserve, and immune competence. This multidimensional approach offers prognostic information that extends beyond isolated biomarkers and FG-specific scoring systems, enabling more refined early risk stratification for short-term mortality.

Özgül and Uzmay reported that the C-reactive protein/albumin ratio (CAR) significantly discriminates survivors from non-survivors in Fournier’s gangrene, with a notably high AUC of 0.907 (95% CI, 0.824-0.984).¹ This finding underscores the pivotal role of systemic inflammation and nutritional status in the prognostic assessment of FG. However, whereas CAR reflects only inflammatory burden and nutritional reserve, the CALLY index incorporates lymphocyte count, thereby providing a more comprehensive evaluation of immune competence. This additional dimension may confer superior predictive performance, supporting the potential utility of the CALLY index as a more informative tool in clinical decision-making.

Inflammation-based prognostic markers have also been examined in other cohorts of patients with Fournier’s gangrene. A recent meta-analysis including 767 patients demonstrated that an elevated neutrophil-to-lymphocyte ratio (NLR) was significantly associated with increased mortality risk (mean difference = 4.49; 95% CI, 0.67-8.32; P = 0.02).⁸ Similarly, a single-center study involving 71 patients reported that both the CRP/lymphocyte ratio and NLR were significantly higher in non-survivors than in survivors, suggesting that these readily accessible hematologic parameters may serve as useful prognostic indicators.⁹ Furthermore, the lymphocyte-to-CRP ratio (LCR) has also shown prognostic utility; in a cohort of 41 FG patients, lower LCR values were significantly associated with mortality (AUC = 0.747).⁶

The CALLY index has demonstrated prognostic validity beyond Fournier’s gangrene. In patients with sepsis, Zhang et al reported that a lower CALLY index at ICU admission independently predicted 30-day mortality (HR: 0.965; 95% CI, 0.935-0.997; P = 0.030).¹⁰ Similarly, in a cardiovascular cohort, low CALLY index values were independently associated with both all-cause and cardiovascular mortality, supporting its utility as a prognostic marker across a broader clinical spectrum.¹¹ Collectively, these findings underscore the translational relevance of the CALLY index in conditions characterized by systemic inflammation and immune-nutritional dysregulation.

Early identification of high-risk patients is essential for optimizing outcomes in Fournier’s gangrene. In our cohort, uncontrolled diabetes mellitus (DM) and elevated qSOFA scores were independently associated with 30-day mortality, consistent with prior reports.^12,13 Chronic hyperglycemia compromises neutrophil function, impairs wound healing, and reduces microvascular perfusion, thereby predisposing patients to more severe infections and worse prognoses. By stratifying patients into chronic uncontrolled DM (HbA1c ≥8% or glucose ≥250 mg/dL) and acute stress hyperglycemia (glucose 180-250 mg/dL with HbA1c <8%), we applied a methodologically rigorous approach that captures both chronic metabolic dysregulation and acute physiologic stress, each independently linked to FG severity and mortality.¹⁴

In addition to metabolic risk factors, clinical scoring systems also play a crucial role in early risk stratification. The qSOFA score, originally developed for rapid sepsis assessment outside the ICU, demonstrated robust predictive value in our cohort, with 82.6% of non-survivors presenting scores of 2-3. This observation aligns with recent literature highlighting qSOFA as a simple, bedside tool for early identification of FG patients at risk for sepsis-related mortality.^5,15 Integrating metabolic markers such as the CALLY index with clinical scores like qSOFA may enhance risk stratification, enabling heightened clinical vigilance and timely escalation of supportive care in high-risk patients.

In our multivariate model, a CALLY index ≤0.012 was strongly and independently associated with 30-day mortality, indicating that immune-nutritional status provides prognostic information beyond traditional clinical predictors in Fournier’s gangrene. This finding suggests that inflammation, protein reserve, and lymphocyte-mediated immunity collectively contribute to patient resilience during systemic infection.

Nevertheless, our study has some limitations. The retrospective design introduces potential risks of missing data and residual confounding. Although inter-center variability was mitigated by standardizing laboratory devices and reference ranges, subtle differences in sample processing cannot be entirely excluded. Furthermore, while lymphocyte count and CRP are routinely available, albumin levels may fluctuate with fluid status or acute-phase response, potentially affecting the CALLY index.

Future research should prospectively validate the prognostic utility of the CALLY index in diverse, multicenter FG populations, including different ethnic groups and comorbidity profiles. Additionally, assessing how dynamic changes in CALLY during treatment correlate with outcomes, as well as exploring whether intervention strategies (eg, nutritional support or immunomodulation) can modify prognostic trajectories, will be important to further refine risk stratification.

The CALLY index is a simple, readily available, and independent predictor of 30-day mortality in patients with Fournier gangrene. By simultaneously reflecting inflammatory burden, nutritional status, and immune competence, the CALLY index may serve as an adjunctive biomarker to support early risk stratification when interpreted alongside established clinical scoring systems such as qSOFA.

Footnotes

ORCID iDs

Fırat Canlikarakaya

Cengiz Ceylan

İbrahim Doğan

Serhat Ocakli

Sabiha Nur Özmen

Hüseyin Turap

Ethical Considerations

Ethical approval was obtained from the Amasya University Non-Interventional Ethics Committee for the study protocol, and the requirement for informed consent was waived due to the retrospective nature of the study (Date 04/12/2025 No: 2025/232).

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.*

Additional Identifying Information

The study was conducted across three tertiary referral centers:

• Amasya University Sabuncuoğlu Şerefeddin Training and Research Hospital.

• Eskişehir City Hospital

• Van Training and Research Hospital.

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