8-Iso-prostaglandin F2α as a potential biomarker in patients with unipolar and bipolar depression.

OBJECTIVE: Previous studies have shown that the disturbance of redox homeostasis plays a role in the pathogenesis of mood disorders. It is currently unclear whether oxidative stress parameters can be used as biomarkers (state vs. trait). The aim of the present study was to investigate oxidative stress markers in patients with major depressive disorder (MDD) and bipolar disorder (BP) in acute depressive episodes and remission, and healthy individuals. PATIENTS AND METHODS: Thirty-two patients with a diagnosis of MDD, 32 patients with a diagnosis of BP and 32 matched healthy controls were included in the study. We measured the serum levels of markers of oxidative damage, including 8-hydroxy-2'-deoxyguanosine (8-OHdG), 8-Iso-prostaglandin F2α (8-iso-PGF2α; 8-isoprostane), and malondialdehyde (MDA), and also serum activities of superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPX), and glutathione reductase (GR) in both acute and remission phase, and in control group. RESULTS: After controlling for the effects of age, sex, body mass index, and smoking status, serum 8-iso-PGF2α levels were significantly higher in both patient groups compared to controls, regardless of disease phase. The activities of GPX and GR were significantly lower in the acute phase in MDD patients compared to controls. Serum GR activity was lower in both acute and remission phase in MDD compared to BP. CONCLUSIONS: Our results suggest that both MDD and BP are associated with a disturbed redox balance with a particularly pronounced increase in serum 8-iso-PGF2α levels in both groups and the presence of glutathione metabolism disorders in MDD patients. Further research is needed to confirm the importance of oxidative stress parameters as potential biomarkers of MDD and BP.

Long-term outcomes of spinal SBRT. Is it important to select the treatment time?

PURPOSE: SBRT (stereotactic body radiation therapy) is widely used as a curative treatment in tumoral lesions and has become a fundamental tool for the treatment of spine metastasis. In this study, we present survival and toxicity outcomes of spine SBRT after a 2-year follow-up. METHODS/PATIENTS: Data from spine SBRT treatments performed at our institution between March 2012 and February 2020 was collected. Medical records, including demographic, primary tumor, and treatment characteristics were reviewed. Patient follow-up included clinical evaluation, imaging, and blood tests. Toxicity was recorded according to CTCAE v4.0. RESULTS: We analyzed 73 consecutive spine SBRT treatments in 60 patients. 39.7% of the cases had primary breast cancer and 23.3% had prostate cancer. Most cases (87.7%) were treated with a single SBRT fraction of 16 Gy. Median follow-up was 26.1 months (range 1.7-78.6), and 1- and 2-year overall survival (OS) rates were 96.9% and 84.2%, respectively. Local control (LC) rates at 1- and 2-years were 76.3% and 70.6%, respectively. Multivariate analysis identified histology as a prognostic factor for both OS and LC. Patients who underwent spine SBRT 6 months after the spinal lesion diagnosis had LC at 2 years of 88%, vs 61.7% for those who underwent SBRT before this period. No grade III or higher toxicity was reported. The vertebral compression fracture (VCF) rate was 4.1%. CONCLUSION: Spine SBRT at our institution showed a 2-year LC of 70.6%, without G3 toxicities. Delaying SBRT at least 6 months to administer systemic treatment was related to an improvement in local control.

Adiponectin resistance parameter as a marker for high normal blood pres-sure and hypertension in patients with metabolic syndrome.

INTRODUCTION: The different degrees of adiponectin/insulin sensitivity and dysfunctional adipose tissue lead to the development of hypertension (HT). This study aimed to determine adiponectin (AD) concentration in patients with metabolic syndrome (MetS) and high-normal blood pressure or hypertension and to investigate the importance of Homeostatic Model Assessment-AD (HOMA-AD) index in assessing adiponectin/insulin resistance in hypertension. METHODS: This cross-sectional study involved 150 subjects divided into two groups: with MetS (and high-normal blood pressure, n =50; and HT, n =50), and controls without MetS (n =50). In all subjects, serum adiponectin concentration was measured by enzyme-linked immunosorbent assay method. Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) and HOMA-AD index were calculated. RESULTS: The results showed that, compared to the control group, serum AD concentrations were significantly lower in patients with MetS and high-normal blood pressure (p =0.008), and the lowest in group MetS and HT (p =0.001). High AD levels and low HOMA-AD were significantly associated with decreased blood pressure values. In patients with MetS, the value of HOMA-AD≥1.13 was associated with a higher risk of developing high-normal blood pressure. Furthermore, the value of HOMA-AD≥2.63 was associated with a higher risk of developing hypertension. CONCLUSIONS: Hypoadiponectinemia is associated with hypertension, especially in the early stages of the disease. The serum AD levels and HOMA-AD index may be useful markers for identifying patients at risk for high-normal blood pressure and hypertension. HIPPOKRATIA 2020, 24(1): 3-7.

HIV care in times of the COVID-19 crisis - Where are we now in Central and Eastern Europe?

INTRODUCTION: The SARS-CoV-2 pandemic has hit the European region disproportionately. Many HIV clinics share staff and logistics with infectious disease facilities, which are now on the frontline in tackling COVID-19. Therefore, this study investigated the impact of the current pandemic situation on HIV care and continuity of antiretroviral treatment (ART) supplies in CEE countries. METHODS: The Euroguidelines in Central and Eastern Europe (ECEE) Network Group was established in February 2016 to review standards of care for HIV in the region. The group consists of professionals actively involved in HIV care. On March 19, 2020 we decided to review the status of HIV care sustainability in the face of the emerging SARS-CoV-2 pandemic in Europe. For this purpose, we constructed an online survey consisting of 23 questions. Respondents were recruited from ECEE members in 22 countries, based on their involvement in HIV care, and contacted via email. RESULTS: In total, 19 countries responded: Albania, Armenia, Belarus, Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Estonia, Georgia, Greece, Hungary, Lithuania, Macedonia, Poland, Republic of Moldova, Russia, Serbia, Turkey, and Ukraine. Most of the respondents were infectious disease physicians directly involved in HIV care (17/19). No country reported HIV clinic closures. HIV clinics were operating normally in only six countries (31.6%). In 11 countries (57.9%) physicians were sharing HIV and COVID-19 care duties. None of the countries expected shortage of ART in the following 2 weeks; however, five physicians expressed uncertainty about the following 2 months. At the time of providing responses, ten countries (52.6%) had HIV-positive persons under quarantine. CONCLUSIONS: A shortage of resources is evident, with an impact on HIV care inevitable. We need to prepare to operate with minimal medical resources, with the aim of securing constant supplies of ART. Non-governmental organizations should re-evaluate their earlier objectives and support efforts to ensure continuity of ART delivery.

ADIPONECTIN AS A POTENTIAL BIOMARKER OF LOW BONE MINERAL DENSITY IN POSTMENOPAUSAL WOMEN WITH METABOLIC SYNDROME.

CONTEXT: Adiponectin is an abundant adipokine, which has antiinflammatory, anti-atherosclerotic and vasoprotective actions, and potential antiresorptive effects on bone metabolism. It seems to be directly involved in the improvement and control of energy homeostasis, protecting bone health and predicting osteoporotic fracture risk. OBJECTIVE: To examine the relationship between adiponectin level and bone mineral density (BMD) in post-menopausal women with metabolic syndrome (MetS) and low BMD, and to estimate the prognostic significance of adiponectin in osteoporosis. DESIGN: Clinical-laboratory cross-sectional study including 120 middle-aged and elder women (average 69.18±7.56 years). SUBJECTS AND METHODS: The anthropometric parameters were measured for all examinees. Lumbar spine and hip BMD, as well as body fat percentage, were measured using a Hologic DEXA scanner. In all subjects serum adiponectin concentration was measured by ELISA method. RESULTS: The level of adiponectin was significantly positively correlated with BMD-total, BMD of the lumbar spine and BMD of the femoral neck (r=0.618, r=0.521, r=0.567; p<0.01). Levels of adiponectin and BMD are significantly lower in post-menopausal women with MetS and osteoporosis compared to patients with osteopenia (856.87±453.43 vs. 1287.32±405.21 pg/mL, p<0.01; BMD, p<0.05), and the highest values in healthy examinees. A cut-off value of adiponectin level for osteoporosis/osteopenia was 1076.22/1392.74 pg/mL. CONCLUSIONS: Post-menopausal women with MetS have significantly lower adiponectin level and low BMD compared to healthy examinees. Adiponectin may be an early, significant and independent predictor of developing osteoporosis in women with MetS, especially in post-menopausal period.

Influence of non-dipping pattern of blood pressure in gestational hypertension on maternal cardiac function, hemodynamics and intrauterine growth restriction.

BACKGROUND: An association between gestational hypertension (GH) and changes of maternal cardiac function was previously reported. AIM: The study assessed the effect of non-dipping pattern of blood pressure (BP) in GH on haemodynamic function and intrauterine growth restriction (IUGR). METHODS: This study included 126 women (91 with GH and 35 normotensive controls). Based on the BP values measured by ambulatory blood pressure monitoring (ABPM), all hypertensive women were classified in dipper (46 women) or in non-dipper group (45 women). All participants underwent echocardiography and ABPM during the third trimester. RESULTS: Participants with GH and non-dipping pattern had significantly lower velocity of longitudinal systolic function (s') (p<0.0005), and cardiac output index (COi) compared to dippers (p<0.0005) and controls (p=0.002). Diastolic velocities at the mitral valve annulus were also lower in non-dippers e's (non-dippers vs dippers p=0.023; non-dippers vs controls p<0.0005) and e'l (non-dippers vs dippers p=0.048; non-dippers vs controls p<0.0005). There were significant differences in the index of the left ventricle filling pressure E/e' and myocardial mass index between women with GH and controls, but with no significant difference among dippers and non-dippers. Total vascular resistance was increased in non-dipping group compared to normotensives and dippers (p<0.0005). Multivariate regression analysis revealed that the peak night-time diastolic BP, left ventricular mass index and CO index were identified as independent predictors of IUGR. CONCLUSION: Changes in maternal hemodynamics, as well as IUGR, are strongly related to the non-dipping pattern of BP.

To which countries do European psychiatric trainees want to move to and why?

BACKGROUND: There is a shortage of psychiatrists worldwide. Within Europe, psychiatric trainees can move between countries, which increases the problem in some countries and alleviates it in others. However, little is known about the reasons psychiatric trainees move to another country. METHODS: Survey of psychiatric trainees in 33 European countries, exploring how frequently psychiatric trainees have migrated or want to migrate, their reasons to stay and leave the country, and the countries where they come from and where they move to. A 61-item self-report questionnaire was developed, covering questions about their demographics, experiences of short-term mobility (from 3 months up to 1 year), experiences of long-term migration (of more than 1 year) and their attitudes towards migration. RESULTS: A total of 2281 psychiatric trainees in Europe participated in the survey, of which 72.0% have 'ever' considered to move to a different country in their future, 53.5% were considering it 'now', at the time of the survey, and 13.3% had already moved country. For these immigrant trainees, academic was the main reason they gave to move from their country of origin. For all trainees, the overall main reason for which they would leave was financial (34.4%), especially in those with lower (<500€) incomes (58.1%), whereas in those with higher (>2500€) incomes, personal reasons were paramount (44.5%). CONCLUSIONS: A high number of psychiatric trainees considered moving to another country, and their motivation largely reflects the substantial salary differences. These findings suggest tackling financial conditions and academic opportunities.

Buffered Romanowsky-Giemsa method for formalin fixed, paraffin embedded sections: taming a traditional stain.

Romanowsky-Giemsa (RG) stains were devised during the 19th century for identifying plasmodia parasites in blood smears. Later, RG stains became standard procedures for hematology and cytology. Numerous attempts have been made to apply RG staining to formalin-fixed paraffin-embedded tissue sections, with varied success. Most published work on this topic described RG staining methods in which sections were overstained, then subjected to acid differentiation; unfortunately, the differentiation step often caused inconsistent staining outcomes. If staining is performed under optimal conditions with control of dye concentration, pH, solution temperature and staining time, no differentiation is required. We used RG and 0.002 M buffer, pH 42, for staining and washing sections. All steps were performed at room temperature. After staining and air drying, sections were washed in 96-100% ethanol to remove extraneous stain. Finally, sections were washed in xylene and mounted using DPX. Staining results were similar to routine hemalum and eosin (H & E) staining. Nuclei were blue; intensity depended largely on chromatin density. RNA-rich sites were purple. Collagen fibers, keratin, muscle cells, erythrocytes and white matter of the central nervous system were stained pinkish and reddish hues. Cartilage matrix, mast cell granules and areas of myxomatous degeneration were purple. Sulfate-rich mucins were stained pale blue, while those lacking sulfate groups were unstained. Deposits of hemosiderin, lipofuscin and melanin were greenish, and calcium deposits were blue. Helicobacter pylori bacteria were violet to purple. The advantages of the method are its close similarity to H & E staining and technical simplicity. Hemosiderin, H. pylori, mast cell granules, melanin and specific granules of different hematopoietic cells, which are invisible or barely distinguishable by H & E staining, are visualized. Other advantages over previous RG stains include shorter staining time and avoidance of acetone.

Correlation of the system of cytokines in moderate and severe preeclampsia.

OBJECTIVE OF THE STUDY: To study the production of pro-inflammatory (IL-1ß, IL- 2, IL-6, IL-8) and anti-inflammatory (IL-4, IL-10) cytokines in pregnancy complicated by preeclampsia in the third trimester. Institution: University Clinic of Gynecology and Obstetrics, Skopje, Republic of Macedonia. MATERIAL AND METHODS: Fifty women with pregnancies complicated by preeclampsia in the third trimester and 50 women with physiological pregnancy. Levels of IL-1ß, IL-2, IL-6, IL-8, IL-4, and IL-10 were measured by using a solid-phase enzyme immunoassay. Statistical data processing was done using the application program SPSS for Windows 13.0. To describe the distribution of analyzed variables, descriptive methods (mean, median, minim and max) were used . RESULTS: In pregnancies complicated by preeclampsia, there are increased levels of proinflammatory cytokines and a change in the behaviour of opposing pools. Most pronounced changes in the levels of proinflammatory cytokines were observed in mild preeclampsia. In severe preeclampsia there was reduction of the concentration of anti-inflammatory cytokines IL-4 and IL-10. CONCLUSION: The use of assessment cytokine profile monitoring of health status of women with preeclampsia is expedient.

Intra-amnial methotrexate in cervical pregnancy treatment.

Cervical pregnancy is an extremely rare condition with potential devastating consequences if not diagnosed and treated early enough. The authors present a case with ultrasound images of early cervical ectopic pregnancy in a woman with a history of previous cesarean section who was successfully treated with intra-amnial methotrexate (MTX).

Combination of selected biochemical markers and cervical length in the prediction of impending preterm delivery in symptomatic patients.

The pathophysiology of preterm delivery (PTD) is complex and multifactorial.It occurs in 8-12% of all deliveries, and the rate of PTD has increased during the past years in spite of intensive efforts towards early detection and prompt treatment. Fifty-eight pregnant women were eligible to join the study if they attended the University Clinic for Gynecology and Obstetrics, Skopje and were admitted to Department of High Risk pregnancy Unit with symptoms of preterm labor (PTL) (symptoms of uterine activity judged by the assessing physician to be indicative of PTL) at 24.0 to 36.6 weeks gestation.Test specimens for fetal fibronectin (fFN), phosphorylated insulin like growth factor binding protein 1 (phIGFBP-1), IL-6, and IL-2R and measuring the cervical length via transvaginal ultrasound were performed for each patient. The best statistical model for predicting PTL in the present study was to use a combination of the phIGFBP-1 test, a positive fFN test, cervical length less than 21.5 mm, levels of IL-6 higher than 1,305 pg/ml in the cervico-vaginal fluid (CVF), and serum levels of C-reactive protein (CRP) higher than 6.1 mg/L which was excellent at identifying the patients that were to deliver within 14 days of admittance.

Use of eriochrome cyanine R in routine histology and histopathology: is it time to say goodbye to hematoxylin?

Eriochrome cyanine R (ECR) is a synthetic anionic dye that forms complexes with cations such as iron. We found that an iron-ECR (Fe-ECR) mixture provided either nuclear or myelin staining depending on the differentiator used. Selective nuclear staining was obtained by differentiation in an aqueous HCl solution, pH 0.95, followed by a wash in slightly alkaline tap water; the pH difference facilitated control of differentiation. When used with an eosin B counterstain, results were nearly indistinguishable from standard hematoxylin and eosin (H & E) staining. Nuclear staining with Fe-ECR provides tinctorial features similar to regressive aluminum-hemateins as well as resistance to acidic solutions such as those of iron hemateins. Fe-ECR also stained selectively intestinal cells of the diffuse neuroendocrine system (DNES). In addition to its use as an H & E substitute, acid differentiated Fe-ECR produced acid-resistant and selective nuclear counterstaining in combination with Alcian blue, and in the Papanicolaou and van Gieson techniques. With alkali differentiation, Fe-ECR produced selective myelin staining, which was compatible with neutral red counterstaining. Myelin sheaths were stained aqua blue. Fe-ECR could be used for both cytological and histological samples, and was suitable for use in automated tissue stainers. ECR also is less expensive than hematoxylin. Hematoxylin still may be preferred as a nuclear counterstain for some immunostaining methods for which Fe-ECR mixtures probably are too acidic.

Romanowsky-Giemsa as a counterstain for immunohistochemistry: optimizing a traditional reagent.

We describe a detailed protocol for using Romanowsky-Giemsa (RG) counterstaining on formalin fixed, paraffin embedded tissue sections that are stained immunohistochemically (IHC) after antigen retrieval using hot acidic citrate buffer. RG staining is easy to perform and provides consistent results that are similar to hematoxylin and eosin (HE) staining. The counterstaining was applied after a variety of antibodies that used the DAB chromogen and the intensity of IHC stained structures was preserved. Moreover, RG counterstaining provided finer cell detail than HE, methyl green or nuclear fast red. A detailed troubleshooting guide is provided for the RG staining protocol.

Visualization of a stationary CPG-revealing spinal wave.

Central Pattern Generator (CPG) is still an elusive concept that has a visual manifestation as a rhythmic oscillation commanded from the spine, but that also has another manifestation as a train of bursts in the surface electromyographic (sEMG) signals recorded on the para-spinal muscles. This leads to the challenging problem of correlating the visually observed spinal wave with the sEMG signals recorded during the session. This paper develops a mathematical model of the spinal wave phenomenon, which, when driven by the sEMG data, yields such visually observable features as wave nodes.

CYP2D6 genotyping in patients on psychoactive drug therapy.

The polymorphic isoenzyme CYP2D6 has a major role in the oxidative metabolism of many deal of psychoactive drugs. Its six mutant alleles (null alleles *3, *4, *5, *6, *7 and *8) encode for inactive enzyme molecules. A carrier of two mutant alleles is considered a poor metabolizer phenotype, while a carrier of only one damaged allele is considered an intermediate metabolizer phenotype. The aim of the study was to assess the prevalence of null alleles in a group of psychiatric patients suffering from depression (n=49) and schizophrenia (n=86) in comparison with healthy individuals (n=145) by the method of multiplex allele specific PCR. Only CYP2D6*3,*4 and *6 mutant alleles were found in the study subjects. No significant difference between the depression and control groups was found for allele prevalence, genotype or phenotype distribution (p>0.05). However, a significant difference was observed between schizophrenic patients and controls for allele frequency (p=0.002), genotype distribution (p=0.016), and phenotype prevalence (p=0.018). The odds ratio of 2.542 for 2D6*4 suggested a significant association between this allele and schizophrenia, significantly contributing to poor metabolizer phenotype (odds ratio=5.020). The relationship between CYP2D6 gene polymorphism and side effects in schizophrenic patients undergoing long-term psychoactive drug therapy was investigated. A significant difference was obtained for allele prevalence (p=0.002), genotype (p=0.029), and phenotype (p=0.002) distribution between patients without and with side effects. A relative risk of 2.626 and 5.333 for 2D6*4 and 2D6*6, respectively, and of 7.08 for poor metabolizer phenotype suggested a significant association between the hereditary susceptibility for a particular type of drug metabolism (defect alleles) and side effects. These preliminary results suggest that the CYP2D6 genotyping appears to be useful for predicting risks for side effects of psychoactive drugs in schizophrenic patients, but their usefulness should be further explored.

Genotyping of CYP2D6 in Parkinson's disease.

Parkinson's disease is characterized by progressive degradation of dopaminergic neurons. Cytochrome P450 CYP2D6 enzyme is one of the most investigated and highly polymorphic isoforms, which metabolizes many drugs and is also involved in the metabolism of dopamine. Using allele-specific multiplex PCR, we genotyped 186 subjects for CYP2D6 *3, *4, *6, *7, and *8 alleles in order to estimate allelic, genotype and predicted phenotype frequencies in the control and patient groups, and to investigate the possible statistical difference between Parkinson's disease patients (n=41) and healthy controls (n=145). Parkinson's disease patients were further divided into two subgroups according to Hoehn and Yahr staging of the disease (HY), i.e. groups with HY stage less than 2.5 (HY <2.5; n=27) and more than 2.5 (HY >2.5; n=14). A subgroup of Parkinson's disease patients exhibiting side effects such as "on-off" phenomenon and dyskinesia (both suggesting favorable response to therapy) were compared with a subgroup of patients showing no such response. The preliminary results of this study showed that only the prevalence of CYP2D6 *4 allele differed significantly between the PD patients and control group (20.7% vs. 11.0%; p=0.027; RR=2.1, 95%CI 1.113-3.994). In the HY >2.5 subgroup, the CYP2D6*4 allelic difference was even greater (25.0% vs. 11.0% in controls; p=0.062, RR=2.69, 95%CI 1.090-6.624). Genotype frequencies differed only in the HY >2.5 subgroup, however with a level of significance of p=0.095.

The cytochrome P450 2D6 (CYP2D6) gene polymorphism among breast and head and neck cancer patients.

The prevalence of CYP2D6*3 and CYP2D6*4 alleles in normal controls and cancer patients was studied using the reliable PCR-SSCP method. In the control group (n=144), four subjects (2.8%) were found to carry CYP2D6*3 allele (heterozygote), while 30 (20.8%) subjects carried CYP2D6*4 allele (18.8% heterozygotes, 2.1% homozygotes). One (1.3%) of the breast cancer (BC) patients (n=76) carried CYP2D6*3 allele, but 24 (31.6%) carried CYP2D6*4 allele (26.3% heterozygotes, 5.3% homozygotes). In the head and neck cancer (HNC) group (n=56), two (3.6%) patients were heterozygous for CYP2D6*3 mutation and 15 (26.8%) for CYP2D6*4 mutation. Fourteen of 56 (25%) and one of 56 (1. 8%) of these patients carried heterozygous and homozygous mutations, respectively. In controls, 2.1% were identified as poor metabolizers (PM), 76.4% as extensive metabolizers (EM), and 21.5% as intermediate heterozygotes (IEM). In BC group, 5.3, 27.6 and 67.1% were classified as PM, IEM and EM, respectively. In HNC group, the incidence of PM was 1.8, but as many as 28.6% were identified as IEM phenotypes.

Detection of CYP2D6*3 and 2D6*4 allelic variants by PCR-restriction fragment length polymorphism.

The mutant of CYP2D6*3 allele with A2637 deletion in exon 5 and the mutant of CYP2D6*4 allele G1934-->A, splice site defect are among the most common polymorphic alleles of CYP2D6 gene, resulting in a decreased or no activity of CYP isoenzyme. In this study, a reliable polymerase chain reaction-restriction fragment length polymorphism method for identification of CYP2D6*3 and CYP2D6*4 alleles was used to investigate the genotype and phenotype prevalence in the groups of normal controls, and of cirrhosis and cancer patients. The results showed none of 36 controls genotyped for 2D6*3 and 2D6*4 allele to have the 2D6*3 allele with frameshift mutation in exon 5, while 33% (n=12) were found to bear the 2D6*4 allele with G to A mutation at the intron 3-exon 4 junction. In breast cancer patients (n=35) genotyped for 2D6*3 and 2D6*4 alleles, none with 2D6*3 allele was found either, but 60% (n=18) were found to bear the 2D6*4 allele. In patients with head and neck squamous cell cancer, there was only one subject with 2D6*3 allele and he was heterozygous. Among them, as many as ten (40%) patients were found to bear 2D6*4 allele. In the cirrhosis group, none of the patients was found to have the 2D6*3 allele, while the CYP2D6*4 allele was found in 23% (n=6) patients. The phenotype predicted according to the genotype was as follows: in the control group, 3% of individuals were identified as poor metabolizers, 70% as extensive metabolizers, and 27% as heterozygote extensive metabolizers. In the group of breast cancer, 7% of the patients were identified as poor metabolizer, 57% as extensive metabolizer and 36% as phenotype. In squamous cell cancer and cirrhosis patients, the incidence of poor metabolizer was zero, and of heterozygotes extensive metabolizer 42% and 31%, respectively.