Impact of dexamethasone and tocilizumab on hematological parameters in COVID-19 patients with chronic disease

BACKGROUND AND AIM

The most effective way to control severity and mortality rate of the novel coronavirus disease (COVID-19) is through sensitive diagnostic approaches and an appropriate treatment protocol. We aimed to identify the effect of adding corticosteroid and Tocilizumab to a standard treatment protocol in treating COVID-19 patients with chronic disease through hematological and lab biomarkers.

MATERIALS AND METHODS

This study was performed retrospectively on 68 COVID-19 patients with chronic disease who were treated by different therapeutic protocols. The patients were categorized into four groups: control group represented the patients' lab results at admission before treatment protocols were applied; group 1 included patients treated with anticoagulants, Hydroxychloroquine, and antibiotics; group 2 comprised patients treated with Dexamethasone; and group 3 included patients treated with Dexamethasone and Tocilizumab.

RESULTS

The WBC and neutrophil counts were increased significantly in group 3 upon the treatment when they were compared with patients in group 1 (p = 0.004 and p = 0.001, respectively). The comparison of C-reactive Protein (CRP) level at admission was higher in group 3 than in group 1 with p = 0.030. After 10 days of treatment, CRP level was decreased in all groups, but in group 3 it was statistically significant (p = 0.002).

CONCLUSION

The study paves the way into the effectiveness of combining Dexamethasone with Tocilizumab in treatment COVID-19 patients with chronic diseases.

Impact of dexamethasone and tocilizumab on hematological parameters in COVID-19 patients with chronic disease

BACKGROUND AND AIM

The most effective way to control severity and mortality rate of the novel coronavirus disease (COVID-19) is through sensitive diagnostic approaches and an appropriate treatment protocol. We aimed to identify the effect of adding corticosteroid and Tocilizumab to a standard treatment protocol in treating COVID-19 patients with chronic disease through hematological and lab biomarkers.

MATERIALS AND METHODS

This study was performed retrospectively on 68 COVID-19 patients with chronic disease who were treated by different therapeutic protocols. The patients were categorized into four groups: control group represented the patients' lab results at admission before treatment protocols were applied; group 1 included patients treated with anticoagulants, Hydroxychloroquine, and antibiotics; group 2 comprised patients treated with Dexamethasone; and group 3 included patients treated with Dexamethasone and Tocilizumab.

RESULTS

The WBC and neutrophil counts were increased significantly in group 3 upon the treatment when they were compared with patients in group 1 (p=0.004 and p=0.001, respectively). The comparison of C-reactive Protein (CRP) level at admission was higher in group 3 than in group 1 with p=0.030. After 10 days of treatment, CRP level was decreased in all groups, but in group 3 it was statistically significant (p=0.002).

CONCLUSION

The study paves the way into the effectiveness of combining Dexamethasone with Tocilizumab in treatment COVID-19 patients with chronic diseases.

Suicide prevention actions carried out by an academic psychiatry service in Rio de janeiro city

Introduction

Description of a structured work of primary prevention, based on a survey of the prevalence of suicidal behavior in the Brazilian population throughout life, performed by an academic service of psychiatry and chemical dependence. We describe a survey of the probability of suicide attempt in an academic internment service focused on psychiatry and drug addiction in the city of Rio de Janeiro.

Objectives

Raise awareness of the need to call for help and 24-hour distress hotline phone outreach. Calculate a possible demand for mental health services to patients with severe suicidal behavior aiming at the necessary equipment to attend this population.

Methods

Clarification actions through the press, development of a suicide prevention lecture program given in schools, surveillance cameras, military institutions, companies and laws, promotion of public events with music, activities, distribution of t-shirts, booklets and leaflets.Using the mental health care implementation system: identifying the patient, raising their needs and available resources, breaking resistance, advocating and treating, we raised in this institution that from January 01, 2019 to September 01, 2019, 137 patients were hospitalized with a serious suicide attempt.

Results

According to a survey of the prevalence of suicidal behavior in the Brazilian population over the course of life, where out of 100 patients, 17 had suicidal thoughts, 5 planned, 3 attempted suicide and 1 was treated in the emergency room.

Conclusions

The suicide prevention program has been very successful as the press promotes of the telephone number for immediate relief. His survey highlighted the need to create a specific suicide treatment and prevention program.

Disclosure

No significant relationships.

Structuring of specialized treatment applied to people with suicidea ttemptin an academic psychiatric service in Rio de Janeiro city

Introduction

Description of a specialized treatment program for people attempting suicide in an academic health service focused on psychiatry and drug addiction in the city of Rio de Janeiro.

Objectives

Describe actions developed to treat suicidal behavior.

Methods

Based on a survey of the prevalence of suicidal behavior in the Brazilian population over a lifetime, reaching a total of 12,000 cases per year of the Brazilian population, this academic service of psychiatry and drug addiction established the following actions for hospitalized patients: 24-hour surveillance, reduced access to methods of committing suicide (forks and knives removal, shoelaces and ropes removal), strengthening the GVV (Life Valuation Group), strengthening the Cognitive Behavior Therapy application groups, conducting group dynamics, lectures, art therapy and physical activities.

Results

Of 370 patients admitted to this service from January 1^st, 2019 to September 1^st, 2019, 137 had suicidal behavior and only 2 died.

Conclusions

Of these two cases, one abandoned treatment and the other occurred during the treatment period.

Disclosure

No significant relationships.

Specialized Treatment applied for suicide prevention

Introduction

Suicide can be defined as a deliberate act performed by the individual, whose intention is the death, in a conscious, intentional, even if ambivalent way, using a means that he believes to be lethal. They are also part of what we usually call suicidal behavior: thoughts, plans and attempted suicide.

Objectives

Prevention is a critical step in treating suicidal behavior. Create strategies to reduce and treat the ideation, planning and suicide attempt.

Methods

Based on a large increase in the number of people who present ideas, plan and attempt suicide, the Clinic created techniques for the treatment of inpatients: Life Appreciation Group, Groups applying Cognitive Behavioral Therapy, Group Dynamics, Lectures, Art Therapy and Physical activities .

Results

The actions are developed by a multidisciplinary team that is divided by applying the various techniques and participating in all the proposed activities.

Conclusions

Patients who remained hospitalized fully complying with the suggested treatment and left with medical discharge had full benefit, unlike some cases of patients removed by the family against our indication.

Disclosure

No significant relationships.

The utilization of a creative strategy in the prevention of the use of psychoactive substances with children and adolescents

Introduction

The work describes a successful experience in the utilization of art as a tool to work the prevention of the use of drugs. The experience was developed with children and adolescents between the ages of 3 and 17 who reside in a risky area near Latin America's biggest dump, located in the city of Taguatinga, FD, Brazil.

Objectives

Create a therapeutic space to make possible the dialog with the children and adolescents, promoting the prevention and the consciousness about the harm of the use of psychoactive substances, providing clarification on the theme, through art, being the use of formal language and terms, like “illicit drugs”, unnecessary.

Methods

The children, who participated in the project, used, as expression tool, several painting items. The public was divided by age in two groups: the children received ludic approach, allowing the team nearness and interaction with them, in such a way that the former transmitted information and guidance about the harm on the use of psychoactive substances.

Results

The results were satisfactory. All the children and adolescents involved in the project demonstrated adhesion to the use of the offered tools and established a communication link, which allowed the receptivity of information about prevention in the use of psychoactive substances.

Conclusions

Through the developed activities, it was observed that the strategy utilization of art as a language had better effiency than a formal approach since the children and adolescents could have a learning space in a spontaneous way, demonstrating interest.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Dual Diagnosis and Treatment: The Experience of a Multiprofessional Team in Mental Health

Introduction

The work was developed with the people hospitalized in the period of 1 year in a psychiatric clinic in Rio de Janeiro city, Brazil. 175 patients who presented dual diagnosis were evaluated.

Objectives

The research aims to know the distribution of the most frequent psychiatric diagnosis associated with the disorders for the use of psychoactive substances. The work also has as objective to assess the treatment of patients carrying these disorders so that there is a better efficiency of the individual treatment plan.

Methods

The work consisted of the evaluation of all patients who were admitted to the clinic in the period of 1 year, using the ICD-10 for the diagnosis of dual pathologies. All the patients were assessed by the multiprofessional team, composed by general practicioner, psychiatrist, psychologist, pharmaceutic, therapist in chemical dependence, family therapist and physiotherapist. The patients were treated with the use of psychopharms, cognitive behavioral psychotherapy, 12-step program, art therapy and moderate physical activity. Family members of all patients were also interviewed.

Results

In the evaluation conducted by the team, it was found the following distribution of the most frequent diagnosis associated to disorder for the use of psychoactive substances: depression (26.3%), personality disorder (22.9%), bipolar disorder (22.3%), non-schizophrenic psychosis (12.6%), schizophrenia (9.1%), and other diagnosis (6.8%).

Conclusions

The formulation of the dual diagnosis provided a better approach of the patients on the part of the team, promoting the strengthening of the therapeutic bond and causing positive impact on the evolution of these disorders.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Most frequent clinic comorbibities in hospitalized patients in a psychiatric clinic

Introduction

Being hospitalized in a psychiatric clinic, patients present, in addition to the diseases that determine the hospitalization, clinic comorbidities, generally decompensated.

Objectives

To present the most frequent clinic pathologies in a population of hospitalized patients having diverse mental disorders and establish a protocol for investigation and their early treatment.

Aims

To know the most frequent pathologies in a population of hospitalized psychiatric patients and establish a protocol for their assesment, in a way that contributes to the global improvement of the patient health condition.

Methods

For its mission realization, the clinic counts on a multidisciplinary team. The participants were 762 patients, seen in the referred clinic, which presented a minimum period of hospitalization of 10 days and that were submitted to thorough clinic exam and complementary routine exams. The time frame referred to the period of March of 2012 to February of 2014, totalizing 24 months.

Results

In the patients that had medical release after periods of hospitalization of, 90-day average, were obtained, in the totality of the cases, excellent evolution, evidenced by the improvement of the laboratory parameters.

Conclusions

The results were achieved in the hospitalization system with careful medicament administration, differentiated diets established in agreement with the patients, supervised physical activities and psychological and psychiatric support.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

A non-smoking program in the psychiatric clinic: Eradicating tobacco from the therapeutic space

Introduction

The work describes the well-succeeded experience of the Non-Smoking Program developed in a psychiatric clinic in Rio de Janeiro city, Rio de Janeiro, Brazil.

Objective

To treat the tobacco dependence in patients with disorders for the use of substances and other psychiatric disorders. To transform the clinic therapeutic space in a free tobacco environment.

Aims

To promote the restoring of the patients’ health integrally, considering the use of tobacco is responsible for a large number of avoidable deaths, in addition to much harm to health.

Methods

In a clinic of hospitalization for diverse mental disorders treatment, especially disorders for the use of substances, in the city of Rio de Janeiro, Rio de Janeiro, Brazil, was simultaneously established a non-smoking treatment program. It was used the pharmacological therapy, associated with cognitive-behavioral therapy, occupational therapy and moderate physical activity. The average time of permanence in the non-smoking program was on average 90 days.

Results

There was significant acceptance to the proposed program. In the long-term monitoring, over 12 months, it was evidenced that most patients found themselves in tobacco abstinence.

Conclusion

The project achieved its objectives, promoting the tobacco abstinence in patients with comorbidities in hospital treatment. The study proved that it is possible to remove tobacco in patients dependent on this substance during a psychiatric hospitalization.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Substance abuse prevention during carnival in Rio de Janeiro, Brazil: “No hang over band”

Introduction

Carnival in Rio de Janeiro is one of the biggest popular events in the world, gathering millions of people from different countries, social status, beliefs and cultures. As in other events of such magnitude, there are substance abuse problems and, consequently, medical and public order issues.

Objectives

Since 2005, the “No Hang Over Band” (“Banda Alegria sem Ressaca”) is part of the Carnival schedule and parades through Copacabana beach, enhanced by dancers, celebrities, health professionals, public authorities, politicians, patients and their families, besides many supporters who join the group.

Aims

This study aims to reach a massive population with a campaign to prevent substance abuse giving information and alerts about the risks of it and, also, show professional from all around the world a way to do it.

Methods

A few months before Carnival, health professionals from Jorge Jaber Clinic present lectures about prevention quoting the preparations to the parade, as they gather supporters and sponsors. The message reaches the population through flyers, clothes and media (newspapers, T.V., radio and internet) before, during and after Carnival.

Results

The parade itself has been growing year after year, when it comes to supporters, sponsors and media exposure. Schools and other institutions have asked more often for lectures. Brazilian people have shown response to the campaign when they seek for more information and treatment.

Conclusions

With efforts from different parts of society and very little financial investment, it is possible to have real influence over a risk population even in adverse situation.

[QT interval dispersion in hypertensive diabetics and in patients with hypertension with chronic heart failure without diabetes]

AIM

Our aim was to: 1. compare QT dispersion from routine ECG in diabetic and no-diabetic patients with congestive heart failure, 2. describe associations between QT dispersion and circadian blood (BP) pressure variation in type 2 diabetic patients with congestive heart failure (CHF).

PATIENTS AND METHODS

122 patients admitted to hospital due to CHF in the period between years 2000-2001 have been divided into 2 groups: group 1:70 patients (m: 40, f: 30, mean age 64.7 +/- 9 years) with type II diabetes mellitus (DM), group 2:52 patients (m: 28, f:24, mean age 62.5 +/- 10.9 years) without DM. Diagnosis of CHF was made clinically and proved by ECG and ECHO (EF < 40%), DM was defined clinically or by using oral glucose tolerance test (75 g glucose, 2 h blood glucose > 11.1 mmol/l). The QT interval was measured from the beginning of the QRS complex to the end of the T wave from routine 12-lead ECG. QT intervals were corrected for heart rate using Bazett's formula. QT dispersion (QTd) and rate corrected QT dispersion (QTc) were defined as the difference between the maximum and minimum QT and QTc intervals, respectively. Ambulatory blood pressure (AMBP) was measured by an oscillometic technique. Diabetic patients with CHF were divided both according to below and above the median QTc dispersion (65 ms).

STATISTICAL ANALYSIS

Chi-square and Student's t-test. Significant differences were assumed of p < 0.05.

RESULTS

Both groups were matched by gender, age, duration and intensity of hypertension, the presence and intensity of obesity, hyperlipidemia (TC, TG, LDL-C, HDL-C) and smoking habits. Diabetic patients with CHF had significantly longer QTc interval (maximum and minimum), QT dispersion and QTc dispersion compared with non-diabetic patients with CHF. Diabetic patients with CHF with QTc dispersion > 65 ms had significantly higher night systolic (133 +/- 14 vs. 112 +/- 14) and diastolic (80 +/- 11 vs. 65 +/- 6) BP and significantly higher night/day ratio for both systolic (0.94 +/- 0.05 vs. 0.86 +/- 0.06) and diastolic (0.89 +/- 0.07 vs. 0.80 +/- 0.05) compared with diabetic patients with CHF with QTc dispersion < 65 ms.

CONCLUSION

Diabetic patients with CHF are higher risk than non-diabetic. Our data describe both factors related to cardiovascular risk in diabetic patients with CHF-prolongation of the QT and QTc dispersion and reduced nocturnal blood pressure.

Is left ventricular hypertrophy a risk factor in hypertensive patients?

BACKGROUND

Left ventricular hypertrophy (LVH) is supposed to be a risk factor of cardiovascular (CV) complications in hypertensive patients.

AIM

To compare clinical events in hypertensives with and without LVH.

PATIENTS AND METHODS

319 hypertensives with LVH (mean age 64.1+/-10.6 ys) and 177 hypertensives without LVH (mean age 62.5+/-11.3 ys). LVH defined by echo Penn convention as left ventricular mass index >134 g/m2 in men and >110 g/m2 in women. Clinical events--heart failure (EF<40 %), left ventricular diastolic dysfunction (echo-doppler: transmitral-flow where peak A>peak E), myocardial infarction (history, ECG, cardiac enzymes), chronic atrial fibrillation (more than 2 weeks duration), mitral regurgitation (echo) and renal involvement (creatininemia>120 micromol/l). The two groups of hypertensives were matched by demographic criteria, duration and intensity of hypertension, obesity, diabetes mellitus, lipid serum levels and smoking habits.

RESULTS

There were statistically significant at least p<0.05 more CV events (heart failure, left ventricular diastolic dysfunction, myocardial infarction, chronic atrial fibrillation, and mitral regurgitation cases) and renal involvement in LVH-positive patients than in LVH-negative patients.

CONCLUSION

LVH is a strong risk factor for clinical events in hypertensives, which necessitates their more intensive treatment, mainly with drugs producing also LVH regression. (Tab. 5, Ref. 48.)

[The electrocardiogram in primary pulmonary hypertension]

Primary pulmonary hypertension is a rare disease characterized by a rise of arterial pressure in the pulmonary artery without a known cause. The authors define, based on a case-history, the etiopathogenesis of the disease, its diagnosis and approach to treatment. They analyze the contribution of ECG examination for detection of right ventricular hypertrophy and for monitoring the therapeutic success with the finding above all of repolarization changes in the right precordium. The patient had a transplantation of the lungs.

[The role of infection and inflammation in the pathogenesis of atherosclerosis]

Pathogenesis of the atherosclerotic process is deemed as multifactorial. To the most important risk factors, besides certain family predisposition, there belongs hypercholesterolemia, arterial hypertension, obesity, diabetes mellitus, smoking and others. In the last years there are more and more data about the role of inflammation and infection in the whole development of atherosclerosis. The witness for this hypothesis is the findings of high parameters of inflammation in involved vessels as well as in the blood of atherosclerosis suffering persons. Opinions about the inflammation theory appear from the 90th. Local sterile inflammation in the subendotelium of the middle and big arteries has been proved to consist of specific immune reaction (activation of the T-lymphocytes) as well as nonspecific characteristic by elevated monocytes in the artery wall during the whole process of atherogenesis. Inflammation in the plaque can trigger and hold several factors engaged in the atherosclerotic process, such as oxidized LDL cholesterol, elevated production of various superoxides, activated macrophages, activated T-lymphocytes, cytokines (IL-1, IL-6, interferon gamma) and lipoprotein Lp (a). In this inflammation process levels of CRP (acute phase protein), fibrinogen and erythrocyte sedimentation are elevated as a reaction of the organism to nonspecific chronic infections. Because of this it is thought that elevated fibrinogen and erythrocyte sedimentation are markers of the cardiovascular risk. Some papers deal with antiinflammatory effects of statins, because these lower CRP levels so they also lower atherosclerotic risk through not only lowering of cholesterol levels. Also asprine, as an antiinflammation agent, changing the CRP levels, would be of benefit for patients with vascular disease because its antiaggregation and antiinflammatory effects. ACE inhibitors are also antiinflamatory through blocking of tissue production of angiotensin II (artery wall and atherosclerotic plaque). Enzymatic inhibitors changing angiotensin can also have a partial antiinflammatory effect. The infection theory is supported also by tracing of some microorganisms in the atherosclerotic plaque or in the blood, as e.g. Helicobacter pylori or Chlamydia pneumoniae; to the autoimmune origin is indicated the presence of the specific immunity reaction against heat shock proteins (HSP) or oxidized LDL. This infection theory offers new therapy possibilities. Therefore eradication for example by antibiotics can lead to stabilization of the atherosclerotic plaque with positive consequences, as it was discovered by many studies.

Relation of left ventricular hypertrophy to cardiovascular complications in diabetic hypertensives

The presence of diabetes mellitus and other risk factors of atherosclerosis, such as obesity, smoking and hyperlipidemia, in hypertensive patients makes the prognosis worse. Authors compared the clinical findings in diabetic hypertensive patients with and without left ventricular hypertrophy, the presence of which was diagnosed and defined by echocardiography. The study is based on the analysis of hospital records of 115 hypertensive patients treated at our department during the period 1998-1999. Left ventricular hypertrophy (LVH) was defined by echocardiography as left ventricular mass index > 134 g/m2 in men and > 110 g/m2 in women. Left ventricular hypertrophy was found in 79 patients (mean age 64.6 ys) but not in 36 patients (mean age 63.3 ys). Both groups were matched as to age and sex, intensity and duration of hypertension and diabetes, obesity, smoking and hyperlipidemia. In LVH-positive patients, there was a statistically significant incidence of heart failure, mitral regurgitation and renal involvement and a more non-significant incidence of left ventricular diastolic dysfunction, myocardial infarction, chronic atrial fibrillation and stroke than in LVH-negative ones. Left ventricular hypertrophy usually complicates the course of hypertension. Authors recommend to investigate the presence of left ventricular hypertrophy in hypertensives as it carries a much more complicated course of the disease. (Tab. 5, Ref. 28.)

[Left ventricular hypertrophy in hypertension]

Left ventricular hypertrophy LVH is supposed to be a useful marker of cardiovascular complications during the course of hypertension. Occurrence of other risk factors of atherosclerosis in these hypertensive patients such as hyperlipidemia and smoking deteriorate the prognosis too. The authors compared clinical findings in hypertensive patients with and without left ventricular hypertrophy defined by echocardiography. Hospital records of 185 hypertensive patients treated at our medical department during years 1996-1999 were analysed. Left ventricular hypertrophy was defined by echocardiography (Penn convention) as left ventricular mass index > 134 g/m2 in men and > 110 g/m2 in women. Presence of LVH was found in 109 patients (mean age 66.7 years), absence of LVH in 76 patients (mean age 64.7 years). Both groups of hypertensive patients were matched by demographic parameters by the presence of hyperlipidemia and by smoking habits. Hypertensive patients with diabetes mellitus and obesity were excluded. They were statistically significant in the incidence of heart failure, myocardial infarction, renal failure and mitral regurgitation, and non-significant in the incidence of left ventricular diastolic dysfunction. There were more cardiovascular complications in LVH-positive patients than in those with LVH-negative findings. The incidence of stroke was slightly higher in LVH-negative patients. Left ventricular hypertrophy in patients with hypertension brings usually a complicated course of the disease. The authors recommend to examine the patients with arterial hypertension for the presence of left ventricular hypertrophy as it complicates the course of the disease significantly. (Tab. 3, Fig. 2, Ref. 26.)

[Primary pulmonary hypertension]

Authors described a case of 26-year old patient with history of progressing dyspnea and repetitive syncopes. In history is intermittent hemoptysis and dyspnea from 1990. Diagnosis of thromboembolic disease was suspected. Clinical picture was dominated by dyspnea, central cyanosis, sinus tachycardia without pulmonary signs of hearth failure. On ecg there is right heart hypertrophy. Echocardiographic examination shows dilatation of right heart, systolic pressure in a. pulmonalis about 90 mmHg and tricuspidal regurgitation of the III. degree. Phlebothrombosis was not found. Complete hemocoagulation examination excluded a primary procoagulating hematologic disease. Pulmonary angiography did not confirm thromboembolic disease but found a high grade pulmonary hypertension--mean pulmonary arterial pressure of 93 mmHg. After complex pneumological examination, including HRCT, and other examinations the diagnosis of primary pulmonary hypertension was made. Patient is indicated to lung transplantation. (Fig. 4, Ref. 9.)

[QT dispersion intervals in hypertensives with left ventricular hypertrophy]

Left ventricular hypertrophy is an important risk factor of cardiovascular complications during the course of hypertension. Increased QT dispersion is associated with sudden cardiac death in congestive heart failure and in other cardiovascular diseases. Our aim was to compare QT dispersion from routine ECG in hypertensive patients with and without left ventricular hypertrophy defined by echocardiography. Authors examined 71 hypertensives treated in our medical department. Left ventricular hypertrophy was defined by echocardiography (Penn convention) as left ventricular mass index > 134 g/m2 in men and > 110 g/m2 in women. QT dispersion was defined from routine ECG (QTmax - QTmin). Presence of LVH was found in 26 patients (mean age 59.3 years), absence of LVH in 45 patients (mean age 57.8 years). Hypertensives with secondary hypertension, hypertrophic cardiomyopathy, sings of ischemia in ECG, arrhythmias, myocardial infarction, heart failure, diabetes mellitus and patients treated by antiarrhythmic drugs of the Ic and III groups were excluded. Both groups of hypertensives were matched by demographic parameters, and by the presence of hypertension, obesity, hyperlipidemia and smoking habites. There were statistically significant longer QT dispersion and QTc dispersion (59.0 +/- 20.1 ms, 64.0 +/- 23.7 ms) in LVH-positive patients than in LVH-negative once (43.2 +/- 9.5 ms, 48.4 +/- 11.1 ms). Left ventricular hypertrophy in patients with hypertension brings usually a complicated course of the disease. Authors recommend to look after left ventricular hypertrophy presence in hypertensives as it carries much more complicated course of the disease. Measurment of QT dispersion adds farther stratificational information to these patients.