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Background: Opioid utilization and related harm have increased in recent decades, notably in Australia, the United States, Canada, and some European countries. For people who are prescribed opioids, pharmacies offer an accessible, regular point-of-contact, providing a unique opportunity to address opioid prescription drugs risks., Objective: This project aimed to develop consensus-based, best practice statements for improving the safer use of prescription opioids through community pharmacy settings., Methods: The e-Delphi technique is used to obtain consensus from experts about issues where conclusive evidence is lacking, using multiple rounds of online participation. The investigator group identified an international group of potential participants with relevant expertise who were invited to the study, and asked to identify other experts for invitation. The e-Delphi process comprised three online rounds, involving (1) statement idea generation, (2) developing statement consensus, and (3) confirming and ranking statements., Results: A diverse group of 42 experts (76 % female, 6 countries) participated, comprising pharmacists (n = 24, 57 %), medical doctors of differing specialties (n = 12, 29 %), and/or researchers (n = 28, 67 %), with a mean of 15 years' professional experience (SD = 8.08). Eighty-five statements were initially developed in Round 1, and 78 were supported with amendments, with suggestions to merge and remove items in Round 2, resulting in 72 final statements which were all endorsed in Round 3. Items spanned seven themes: education, monitoring outcomes and risk, deprescribing and pain management, overdose education and naloxone, opioid agonist treatment, staff education, and overarching practices. Preferred terminology was determined in Round 2 and confirmed in Round 3., Conclusions: Community pharmacies offer a unique opportunity to support the safer use of prescription opioids. These 72 best practice statements provide practical guidance on specific practices that pharmacists can undertake to support patients' safer use of prescription opioids and prevent or reduce harms from prescribed opioid use., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Background: People who use opioids (PWUO) have an excess mortality from a range of causes. The cumulative effect of behavioral, social, and health risk factors complicates the interpretation of the effects of suitable interventions. This study explores mortality causes among a cohort of PWUO in the take-home naloxone (THN) program., Methods: This was a prospective cohort study of PWUO who received THN between 2015 and 2023. Participant data was linked with death registry data. Crude mortality rates and standardized mortality ratios (SMRs) were calculated for all causes, internal causes, and accidental opioid overdoses (AOOs). In addition to age and gender, risk factors like main route of administration, polydrug use, self-experienced overdoses, and using while alone were fitted in a Cox Regression model to explore factors associated with mortality., Results: The 2194 participants had a considerably higher mortality ratio for all causes investigated when compared to the general population (SMR=10.9, 95 % CI = 9.3,12.6). AOOs were the most prevalent cause of death (49 %). Those who reported frequent opioid use while alone had an elevated risk of dying of 2.6 (95 % CI = 1.1,6.4) compared to those who never used while alone., Conclusions: Frequent opioid use while alone was associated with elevated mortality risk, supporting the importance of overdose prevention education with naloxone distribution, and additional efforts to improve environmental and social areas for safer drug-use practices among PWUO. The variety of mortality causes found in this study illustrates the need for multifaceted and targeted interventions for people at risk of overdosing., Competing Interests: Declaration of Competing Interest No conflict declared., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Since 2010, heroin-assisted treatment (HAT) has been one of the treatment options available to people with opioid use disorder (OUD) in Denmark. This study aimed to characterize HAT patients at treatment start and compare their individual characteristics to those of patients entering traditional opioid maintenance treatment (OMT) with methadone or buprenorphine during the same period., Methods: Patients who initiated HAT or OMT with methadone or buprenorphine in Denmark from 2010 to 2018 were included (n=6798). Multiple national registers were linked to compare treatment groups in terms of socio-demographic variables, previous OUD treatment episodes, hospital-based care, and criminal conviction history., Results: Nearly all HAT patients had a history of methadone treatment (91%) and half had residential treatment experience (48%). In the year previous to admission, HAT patients recorded the highest percentages of non-fatal overdoses (12%) and chronic hepatitis C diagnoses (16%), and the lowest percentages of psychiatric disorders (11%) compared to traditional OMT patients. Criminal convictions were also common: 39% of the HAT group had committed a property crime and 18% a drug-related crime the year before HAT entry. During the study period, an overall reduction in OMT enrollments for each year was recorded. The HAT proportion to the total remained fairly stable (4%-10%), while the buprenorphine proportion increased., Conclusions: In Denmark, OMT patients exhibited numerous vulnerabilities at treatment start, and among the patient groups, HAT patients were the most burdened. HAT seems to reach the target group and adhere to formulated eligibility criteria., Competing Interests: Declaration of Competing Interest none., (Copyright © 2023. Published by Elsevier B.V.)

Introduction: Chronic pain patients may be at an increased risk for drug overdoses as a result of comorbid psychiatric disorders and treatment with risk-increasing prescription medications, such as opioids. We aimed to characterise fatal drug overdoses and investigate factors associated with the deaths among individuals who had been treated pharmacologically for chronic pain., Methods: We included all individuals who received analgesics reimbursed for chronic pain in Norway during 2010-9 (n=569 047). Among this population, we identified all individuals with drug overdoses as cause of death (cases). Extracting data from national registries on diagnoses, filled prescriptions, and socioeconomic variables, we used a nested case-control design to compare the cases with age- and sex-matched controls from the study population., Results: Overall, 623 (0.11%) individuals in the study population died of an overdose. Most, 66.8%, had overdosed accidentally, and 61.9% as a result of pharmaceutically available opioids. Compared with the controls (n=62 245), overdoses overall were associated strongly with substance use disorders (adjusted odds ratio 7.78 [95% confidence interval 6.20-9.77]), use of combinations of opioids, benzodiazepines and related drugs and gabapentinoids (4.60 [3.62-5.85]), previous poisoning with pharmaceuticals (2.78 [2.20-3.51]), and with living alone the last year of life (2.11 [1.75-2.54]). Intentional overdoses had a stronger association with previous poisonings with pharmaceuticals whereas accidental overdoses were strongly associated with substance use disorders., Conclusions: This study shows the need for better identification of overdose and suicide risk in individuals treated for chronic pain. Extra caution is needed when treating complex comorbid disorders, especially with overdose risk-increasing medications., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Among individuals receiving buprenorphine or methadone as opioid maintenance treatment (OMT), concomitant use of other central nervous system depressants, including prescription drugs, can increase risk of overdose. We aimed to 1) determine the prevalence of use of high-risk prescription drugs (opioid analgesics, benzodiazepines, benzodiazepine-related drugs, and gabapentinoids) among OMT patients, 2) calculate its associations with different mental health and pain-related diagnoses, and 3) compare prevalence of concomitant use with the general population., Methods: A national sample comprising all individuals filling at least one prescription of OMT drugs in Norway in 2019 was formed. Healthcare registry data were linked to investigate high-risk prescription drug use and different diagnoses. We calculated one-year prevalence of use, amount dispensed in defined daily doses (DDDs), and the number of prescribers for the different high-risk prescription drugs. Logistic regression was used to determine associations (adjusted odds ratios; aOR, 95% confidence intervals (CIs)) between diagnoses and use. Prevalence of use was calculated both in the OMT patient sample and the general population., Results: Among the OMT patient sample (n=7,299), 47.6% (n=3,476) filled prescriptions for benzodiazepines. For each high-risk prescription drug group, there was a median of 1-2 prescribers. Musculoskeletal diagnoses were the strongest factor for concomitant high-risk prescription drug use for both males (aOR 3.23, CI: 2.72-3.85) and females (aOR 3.07, CI: 2.42- 3.90). The 1-year prevalence of benzodiazepine use was 11.4 times higher for males and 7.1 times higher for females in OMT than the general population. The amount in DDDs was higher for every drug for OMT patients than the general population, particularly for benzodiazepines., Conclusions: OMT patients frequently filled prescriptions for high-risk drugs, and in higher dosages than the general population. However, we found little evidence of 'doctor shopping.' Given that these prescription drugs carry overdose risk, particularly when combined with OMT drugs, our findings emphasize the continued need for education and caution to both prescribers and patients on their concomitant use with OMT., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier B.V.)

Background: In 2014, the Norwegian government funded a large-scale take-home naloxone (THN) program to address high overdose mortality rates. The aims of this study are to describe characteristics among persons trained to receive THN, describe actions taken following THN use at an overdose event and to explore factors associated with naloxone use., Methods: This was a prospective cohort study of individuals who received THN from 2014 to 2021. Descriptive characteristics were collected at initial training. When returning for refill, participants reported on their previous naloxone use. In a multivariable logistic regression model exploring associations with naloxone use: gender, age, opioid use history, concomitant drug use, injecting, history of experienced or witnessed overdose were included., Results: In total, 3527 individuals were included in this study. There were 958 individuals who returned for refills 2303 times. Most participants were male (63.6%), with a history of opioid use (77.5%). Those who reported naloxone use were more likely to have a history of opioid use (aOR= 4.1; 95% CI=2.77,6.1), were younger (aOR=0.98; 95% CI=0.97,0.99) and had witnessed overdoses (aOR=3.3; 95% CI=1.98,5.34). Among current opioid users, the odds were higher for injectors (aOR=1.57; 95% CI=1.18,2.1). Naloxone use was reported 1282 times. Additional actions such as waking the person and calling the ambulance were frequently reported. Survival was reported in almost all cases (94%)., Conclusion: People who use drugs are a suitable target group for THN-programs, as they seem to be willing and capable to reverse overdoses effectively. Given their personal risk factors for overdosing, recipients will likely also benefit from overdose prevention education., Competing Interests: Declaration of Competing Interest No conflict declared., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: In March 2020, the World Health Organization declared COVID-19 a global pandemic. In the following weeks, most European countries implemented national lockdowns to mitigate viral spread. Services for people who use drugs had to quickly revise their operating procedures to rearrange service provision while adhering to lockdown requirements. Given the scarcity of literature published on overdose prevention during COVID-19 in Europe, we aimed to examine how these changes to service provision affected take-home naloxone (THN) programmes and naloxone availability across Europe., Methods: Between November 2020 and January 2021, we conducted a rapid assessment with country experts from European countries that provide THN. We sent country experts a template to report monthly THN distribution data (January 1, 2019-October 31, 2020) and a structured 6-item survey for completion., Results: Responses were received from 14 of the 15 European countries with THN provision of which 11 participated in the rapid assessment: Austria, Denmark, England, Estonia, Lithuania, Northern Ireland, Norway, Scotland, Spain (Catalonia only), Sweden, and Wales. All reported reduced organisational capacity during COVID-19, and some put into place a range of novel approaches to manage the restrictions on face-to-face service provision. In six countries, the introduction of programme innovation occurred alongside the publication of government guidelines recommending increased THN provision during COVID-19. Eight of the eleven participating countries managed to maintain 2019-level monthly THN distribution rates or even increase provision during the pandemic., Conclusion: Through programme innovation supported by public guidelines, many European THN programmes managed to ensure stable or even increased THN provision during the pandemic, despite social distancing and stay-at-home orders affecting client mobility., Competing Interests: Declarations of Interest Declaration of Competing Interest in the last 3 years (authors listed in alphabetical order): Katri Abel-Ollo: KAO has no competing interests. Lee Barnsdale: LB has no competing interests. Ben Carter: BC has received, through his university research funding from Mundipharma Research Ltd. Thomas Clausen: TC has no competing interests. Ed Day: ED has no competing interests. Desiree Eide: DE has no competing interests. Francina Fonseca: FF has no competing interests. Elin Holmén: EH has no competing interests. Kirsten Horsburgh: KH has no competing interests. Mike Kelleher: MK, in the past 3 years, has taken part in research funded by Indivior, Camurus and Mundipharma. He has received honoraria from Indivior, Gilead, and Abbvie. Martin Kåberg: MKå has received honoraria for lectures/consultancy from Abbvie, Gilead, MSD, Mundipharma, DnE Pharma, and Nordic Drugs and has received research grants from Gilead and Nordic Drugs. Martin Ladenhauf: ML has no competing interests. Andrew McAuley: AMcA has no competing interests. Rebecca McDonald: RMcD indirectly received, through her former employer King's College London, funding from Mundipharma Research Ltd that supported her position of employment (2019-21). RM was supported by the National Institute for Health Research (NIHR) Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust and King's College London. Nicola Metrebian: NM has received, through her university, King's College London, research funding from Mundipharma Research Ltd (a pharmaceutical company that produces a naloxone nasal spray). She has also received, through her university, consultancy payment from an agency for Mayne Pharma International, on another area of research not relevant to the article under consideration. Joanne Neale: JN has received, through her university, research funding from Mundipharma Research Ltd and Camurus AB for unrelated research and an honorarium from Indivior for an unrelated conference presentation. JN was supported by the National Institute for Health Research (NIHR) Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust and King's College London. Stephen Parkin: SP has received funding, as part of his employment within King's College London, funding from Mundipharma Research Ltd, and Camurus AB pharmaceutical company and The Pilgrim Trust. SP was supported by the National Institute for Health Research (NIHR) Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust and King's College London. Kevin Ratcliffe: KR has no competing interests. Chris Rintoul: CR has no competing interests. Josie Smith: JS has no competing interests. Viktorija Stifanoviciute: VS has no competing interests. John Strang: JS has been a longstanding advocate for, and research enquirer into, take-home naloxone. Through his university, JS has worked/is working with pharma and tech industries to identify new or improved interventions (including overdose crisis management) and his employer (King's College London) has received grants, travel costs and/or consultancy payments; this includes discussion and investigation of new naloxone formulations with, past 3 years, Mundipharma, Accord, dne pharma (all of whom have naloxone products). JS is currently leading a cohort study of individuals to whom a supply of take-home naloxone has been provided and who are being followed up prospectively over time, supported by an investigator-initiated grant from Mundipharma. His employer (King's College London) also earlier registered intellectual property on a buccal naloxone formulation, naming JS and colleagues, and he was previously named in a patent registration by a pharmaceutical company regarding concentrated nasal naloxone spray. JS does not receive any personal payment from these arrangements. JS was supported by the National Institute for Health Research (NIHR) Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust and King's College London. For a fuller account, see JS's web-page at http://www.kcl.ac.uk/ioppn/depts/addictions/people/hod.aspx Marta Torrens: MT has been a consultant/advisor and/or speaker for Gilead Sciences, Merck Sharp & Dohme Corp, Indivior, Mundipharma Pharmaceutics, Servier Adamed, Lundbeck, Camurus, and Rovi. Henrik Thiesen: HT has no competing interests., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objective: Little is known about burnout among European vascular surgeons (VSs). In this study, the prevalence of burnout and its associated risk factors were investigated among all VSs and vascular surgeons in training (VSTs) in Denmark., Methods: An anonymous electronic survey was distributed to all clinical active VSs and VSTs on January 1, 2020. Validated assessment tools were used to measure burnout and aspects of the psychosocial work environment., Results: A total of 104 VSs and VSTs were invited to participate, and 82% (n = 85) completed the survey. The majority of the respondents were male (60%; n = 50) and VSs (67%; n = 61). Of the respondents, 82% (n = 70) reported either light (54%; n = 46), moderate (22%; n = 19), or severe (6%; n = 5) personal burnout. More than 50% (n = 47) reported work-related burnout, light (39%; n = 33), moderate (9%; n = 8), and severe (7%; n = 6), respectively, whereas 35% (n = 30) reported patient-related burnout, light (31%; n = 26), moderate (2%; n = 2), and severe (2%; n = 2), respectively. Respondents with more than four 24-hour on-call shifts per month had significantly higher work-related burnout scores, whereas respondents with home-living children and those aged 45 to 59 years showed significantly higher personal and patient-related burnout, respectively. There were strong associations between personal and work-related burnout and the psychosocial work environment, especially work organization and interpersonal relations, but not job demands. The prevalence of burnout was unevenly distributed across departments, with the most affected department having a burnout occurrence twice the least affected department., Conclusions: Based on a national survey conducted among all clinical active VSs and VSTs in Denmark, more than 80% (n = 70) suffered from burnout, of whom 28% (n = 24) suffered from moderate to severe personal burnout. The strong association with the psychosocial work environment, and the significant differences between departments, suggest that burnout is modifiable through changes in the work environment., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The use of oral opioids as standard treatment after cesarean delivery has been linked to persistent use in opioid-naïve women in the USA. In Denmark, the use of opioids after cesarean delivery is typically restricted to in-hospital use. The aim of this study was to estimate the incidence of persistent postpartum opioid use in Denmark and compare the incidence by mode of delivery., Methods: This was a national cohort study of all women giving birth in Denmark in 2016, with one-year follow-up. Data from Danish registries were retrieved and combined using each woman's unique identification number. Persistent use of opioids was defined as ≥3 redeemed opioid prescriptions 31-365 days postpartum., Results: A total of 62 520 births were included in the cohort: 49 859 vaginal deliveries, 5310 intrapartum cesarean deliveries, and 7351 pre-labor cesarean deliveries. For all births, persistent postpartum opioid use occurred in 85 (140 in 100 000) women of whom 36 (42%) had opioid use during pregnancy. The incidence of persistent opioid use was highest in the pre-labor cesarean delivery cohort (n=27; 360 in 100 000) and lowest in the intrapartum cesarean delivery cohort (n=3, 60 in 100 000; P<0.001). Women taking opioids during pregnancy were at increased risk of persistent opioid use (odds ratio 63.3; 95% CI 43.9 to 91.4)., Conclusions: Women giving birth in Denmark, where use of post-discharge opioid treatment is generally restricted, have a low risk of developing persistent use of opioids, with very few women seeking additional analgesic treatment from their general practitioner., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Aims: The aim of the study is to present autopsy-based findings of the most prevalent opioids in overdose deaths in Norway from 2000 to 2019, as such data are lacking in the current literature., Methods: Data on cause of death obtained from the Norwegian Cause of Death Registry (NCoDR) were linked with forensic toxicological results from forensic autopsies., Results: From year 2000 the annual numbers of overdose deaths decreased, specifically during 2000-2003, thereafter a relatively stable annual number was observed. Opioids were detected in 93% of the cases. Heroin related deaths have decreased, whereas medical opioids for pain treatment have increased with time. Men in their early 40's dominate the overall numbers of deaths, but significantly different sex patterns emerge when studying the specific drugs. During the past 20 years, the mean age at overdose death has increased by 10 years (from 33 to 43 years). Overdose deaths without any illicit drugs present at autopsy have increased in recent years. These deaths, where only potentially prescription medications were detected, were more common among women and with higher age., Conclusions: In Norway during the past 20 years, we observe a dynamic shift in overdose deaths caused by heroin and illicit drugs, to include a gradually increasing trend of overdose deaths from pill based pain medications and also methadone and buprenorphine. This warrants a shift in preventive responses, as the target groups differ., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Take-home naloxone (THN) provision to people who use drugs, their family/friends, and non-medical personnel is considered a public health strategy to improve community-based naloxone access and reduce the time to antidote treatment for opioid overdose in order to prevent fatal outcome. THN programs typically report up to three performance indicators: the volume of THN kits distributed, the rate of requests for re-supply of THN kits (e.g., following naloxone use for overdose reversal), and - increasingly - THN "carriage". In this Research Methods piece, we discuss the current shortcomings in the latter measurement of THN carriage from a mixed-methods perspective and describe possible implications for public health related research and improved data analyses. We present an argument for the need to improve research methods in the case of THN "carriage" and propose a multidimensional measurement structure that takes into account: 1) the location of the THN kit relative to its owner, 2) the owner's immediate access to the kit in an emergency, 3) the type of THN device, and 4) the purpose of THN ownership (i.e., for use in self or known/unknown other/s)., Competing Interests: Declarations of Interest Declaration of Competing Interest in the last 3 years (authors listed in alphabetical order) Ben Carter: B.C. has no competing interests. Thomas Clausen: T.C. has no competing interests. Desiree Eide: D.E. has no competing interests. Rebecca McDonald: RMcD received conference-related travel funding and an honorarium from IOTOD (Improving Opioid Outcomes in the Treatment of Opioid Dependence) in 2018. RMcD's employer (King's College London) has received a research grant from Mundipharma Research Ltd for an observational cohort study of take-home naloxone provision in Europe. Separately, King's College London registered intellectual property on a novel buccal naloxone formulation, naming RMcD as co-inventor. RMcD worked as a consultant on community-based naloxone access in Central Asia and Eastern Europe for the United Nations Office on Drugs and Crime (UNODC; 2016–17). Nicola Metrebian: NM has (through her employer King's College London) received a grant from MundiPharma Research Ltd (a pharmaceutical company that produces one of the naloxone products). Joanne Neale: JN has received, through her university, research funding from Mundipharma Research Ltd and Camurus AB. Stephen Parkin: S.P. has indirectly received, through his university, funding from Mundipharma Research Ltd and Camurus AB that supports his position of employment. John Strang: JS, through his university, is working with the pharmaceutical industry to identify new or improved treatments and his employer (King's College London) has received grants, travel costs and/or consultancy payments; this includes investigation of new naloxone formulations and has included work within the past 3 years with Mundipharma Research Ltd (that produces one of the naloxone products). His employer (King's College London) has also registered intellectual property on a novel buccal naloxone formulation, naming JS as co-inventor, and he was earlier named in a patent registration by a pharmaceutical company regarding a concentrated nasal naloxone spray. JS worked as a consultant on community-based naloxone access in Central Asia and Eastern Europe for the United Nations Office on Drugs and Crime (UNODC; 2016–17). For a fuller account, see JS’ webpage at www.kcl.ac.uk/ioppn/depts/addictions/people/hod.aspx., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Opioid agonist treatment (OAT) for opioid use disorders may be delivered at treatment clinics or dispensed from pharmacies, however the type of delivery may be associated with different risks and benefits. The aim of the study was to investigate whether dispensing of methadone or buprenorphine at pharmacies during treatment for opioid use disorders was associated with adverse outcomes., Methods: Retrospective cohort study using a national, linked, population-level data set from Denmark. Patients included were between 18 and 75 years, living in Denmark, and admitted for treatment for opioid use disorders during 2000-2016 (n = 9299). Cox proportional hazards regression was estimated for convictions, non-fatal overdoses, and death, after the first dispensing of either methadone or buprenorphine from a pharmacy after starting treatment., Findings: Of all patients, 68 % had methadone and 31 % had buprenorphine dispensed at a pharmacy. Compared with the time prior to pharmacy dispension, the risk of criminal convictions increased after having methadone dispensed from a pharmacy (adjusted hazard ratio (aHR) = 1.22, 95 % confidence interval (CI) = 1.16-1.28), non-fatal overdoses (aHR = 1.55, CI 1.41-1.71), and all-cause mortality (aHR = 1.54, CI = 1.43-1.76). After having buprenorphine dispensed at a pharmacy, risk of criminal convictions increased (aHR = 1.08, CI = 1.01-1.16) and non-fatal overdoses (aHR = 1.31, CI = 1.18-1.45), but not all-cause mortality (aHR = 1.07, CI = 0.94-1.23)., Conclusions: For almost all outcomes investigated across medication type, the risk of adverse events increased following a switch from clinic dispension to pharmacy dispension of medications in OAT. Medically responsible and safe provision of OAT may often require more clinical follow-up than what is typically provided when medication is dispensed at pharmacies., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Little is known regarding what people who use drugs (PWUD) know about COVID-19 related issues and changes in the drug market due to COVID-19. We therefore conducted a survey to explore these issues., Methods: In a cross-sectional study, we interviewed 226 PWUD from three Norwegian cities in May/June 2020. Participants completed an interview-administrated questionnaire. Three separate multiple binary logistic regression models were estimated with the outcomes (no/yes): 1. Familiarity with COVID-19 symptoms, 2. Awareness of COVID-19 services tailored towards PWUD and, 3. Willingness to take a COVID-19 test., Results: The mean age was 44.1 years and 73 % were males. Fifty-four percent were injectors, and heroin/other opioids (35.8 %) and cocaine/amphetamine (25.2 %) were the most common main drugs used. Overall, 54.9 % were in opioid maintenance treatment (OMT). The majority (65.9 %) stated they knew the COVID-19 symptoms. Almost all the participants (91.2 %) reported they would take a COVID-19 test if experiencing relevant symptoms. The majority (63.7 %) were not aware of COVID-19 services available to PWUD. OMT patients were more likely to be familiar with COVID-19 symptoms (aOR = 3.4, 95 % CI 1.7; 6.8), and to be aware of COVID-19 services (aOR = 2.7, 95 % CI 1.1; 6.3). Overall, 35.4 % reported reduced drug availability, mainly for tranquilizers, while 61.5 % reported increased drug prices, mainly for cannabis., Conclusion: Drug treatment may play an important role in COVID-19 prevention, as those in OMT were more likely to be aware of symptoms and of availability of services., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Social capital in the workplace has been found to be associated with employee wellbeing and work engagement. Yet, evidence of effects of interventions to enhance the social capital are lacking. The intervention mapping method has been described as a useful tool for developing workplace interventions but it is very resource consuming. We aimed to develop an adapted version of the intervention mapping method which is more practically feasible to apply. To get insight into strengths and weaknesses of the adapted method, we applied it and conducted interviews with staff at six companies. The interviews revealed that the action plans developed using the adapted intervention mapping method were generally perceived as relevant and that the action plans had a positive effect on the social capital. However, the implementation of the action plans had been a challenge. In conclusion, the adapted intervention mapping method appears to be suitable for developing interventions to enhance the social capital in the workplace. However, more attention to the implementation of the action plans needs to be incorporated into the method. Suggestions to enhance the implementation included the involvement of the management in the implementation and monitoring of the implementation of the action plans as well as integrating the action plans into existing procedures in the workplace., (Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Drop-out is a core problem in opioid maintenance treatment (OMT), but patients' reactions to and acceptance of the various OMT medications are insufficiently investigated. In Norway, there has been vocal patient resistance to the newest medication, buprenorphine-naloxone (BNX), and complaints have focused on the side effect profile. There has been no comparison of patient satisfaction and side effects of the three most common OMT medications., Aim: To compare patient satisfaction with OMT and side effects of BNX, buprenorphine monopreparate (BUP), and methadone (MET) as reported by patients., Methods: Data were drawn from a national peer-to-peer survey developed by a patient advocacy group. The survey engaged more than 1000 OMT patients, corresponding to one seventh of OMT patients in Norway. The associations between side effects, treatment satisfaction, and patient characteristics were tested in multinomial logistic regressions., Results: High patient satisfaction with OMT overall was reported despite lower satisfaction with medication itself and widely prevalent side effects. Among each medication group, dissatisfaction with medications or OMT in general along with poor health status increased the relative risk ratio of reporting the heaviest side effect burden. MET users reported the highest side effect burden and BNX users the lightest, but BNX users were more dissatisfied with their medication., Conclusions: Side effects are a concern for nearly all OMT patients, and they do not appear to accumulate with age or length of treatment. BNX users' dissatisfaction with their medication is of particular concern, and expectations and preferences of medication may be influencing their dissatisfaction., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Aims: To investigate changes in social network and quality of life of a substance use disorder cohort as they progressed through treatment., Design: Multi-site, prospective, observational study of 338 adults entering substance use disorder treatment., Setting: Patients at 21 facilities across Norway contributed baseline data when they initiated treatment, and follow-up data was collected from them one year later., Methods: The cohort was divided into those who completed, dropped out, and remained in treatment one year after treatment initiation. For each treatment status group, general linear models with repeated measures analyzed global and social quality of life with the generic QOL10 instrument over time. The between-group factor was a change in social network variable from the EuropASI., Findings: Those who gained an abstinent network reported the largest quality of life improvements. Improvements were smallest or negligible for the socially isolated and those who were no longer in contact with the treatment system., Conclusions: Developing an abstinent network is particularly important to improve the quality of life of those in substance use disorder treatment. Social isolation is a risk factor for impaired quality of life throughout the treatment course., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Take home naloxone programs have been successful internationally in training bystanders to reverse an opioid overdose with naloxone, an opioid antagonist. A multi-site naloxone distribution program began in Norway in 2014 as part of a national overdose prevention strategy. The aim of this study was to a) describe the program, and b) present findings from the government-supported intervention., Methods: From July 2014 to December 2015, staff from multiple low-threshold facilities trained clients on how to use intranasal naloxone. Distribution occurred without an individual prescription or physician present. Questionnaires from initial and refill trainings were obtained, and distribution rates were monitored., Results: There were 2056 naloxone sprays distributed from one of the 20 participating facilities, with 277 reports of successful reversals. Participants exhibited known risks for overdosing, with injecting (p=0.02, OR=2.4, 95% CI=1.14, 5.00) and concomitant benzodiazepine use (p=0.01, OR=2.6, 95% CI=1.31, 5.23) being significant predictors for having had high rates of previous overdoses. Suggested target coverage for large-scale programs was met, with an annual naloxone distribution rate of 144 per 100,000 population, as well as 12 times the cities mean annual number of opioid-related deaths., Conclusion: A government-supported multisite naloxone initiative appears to achieve rapid, high volume distribution of naloxone to an at-risk population., (Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: In order to have a substantial impact on overdose prevention, the expansion and scaling-up of overdose prevention with naloxone distribution (OPEND) programs are needed. However, limited literature exists on the best method to train the large number of trainers needed to implement such initiatives., Methods: As part of a national overdose prevention strategy, widespread OPEND was implemented throughout multiple low-threshold facilities in Norway. Following a two-hour 'train-the trainer course' staff were able to distribute naloxone in their facility. The course was open to all staff, regardless of educational background. To measure the effectiveness of the course, a questionnaire was given to participants immediately before and after the session, assessing knowledge on overdoses and naloxone, as well as attitudes towards the training session and distributing naloxone., Results: In total, 511 staff were trained during 41 trainer sessions. During a two-month survey period, 54 staff participated in a questionnaire study. Knowledge scores significantly improved in all areas following the training (p<0.001). Attitude scores improved, and the majority of staff found the training useful and intended to distribute naloxone to their clients., Conclusion: Large-scale naloxone distribution programs are likely to continue growing, and will require competent trainers to carry out training sessions. The train-the-trainer model appears to be effective in efficiently training a high volume of trainers, improving trainers' knowledge and intentions to distribute naloxone. Further research is needed to assess the long term effects of the training session, staffs' subsequent involvement following the trainer session, and knowledge transferred to the clients., (Copyright © 2016 The Authors. Published by Elsevier Ireland Ltd.. All rights reserved.)

Strict control routines of prescribed opiate intake in opioid maintenance treatment, OMT, are used to reduce the risk of diversion and non-prescribed methadone and buprenorphine use. While maintaining a focus on aspects of control, this article explores motivations for and practices of methadone and buprenorphine use, both inside and outside of prison and among imprisoned individuals in OMT. The participants in this qualitative study were subjected to tight external control regimes in their opioid maintenance schemes in prison, as they were prior to imprisonment due to varying degrees of 'non-compliance'. We nevertheless found them to exhibit a considerable amount of self-control, self-regulation and/or self-initiation of external control. Among the participants, a ceaseless surveillance of processes associated with methadone and buprenorphine use throughout diverse situations, relations and contexts was encountered. We conclude that, in opioid maintenance treatment, some individuals might know what particular configurations of internal and external control they need in order to achieve their own treatment goals. The drug users' capacities for execution of control, as well as their delegations of control to others, may be seen as resources throughout the course of treatment., (Copyright © 2014 Elsevier B.V. All rights reserved.)

In order to fulfil the requirements of the EU Water Framework Directive nitrate load from agricultural areas to surface water in Denmark needs to be reduced by about 40%. The regulations imposed until now have been uniform, i.e. the same restrictions for all areas independent of the subsurface conditions. Studies have shown that on a national basis about 2/3 of the nitrate leaching from the root zone is reduced naturally, through denitrification, in the subsurface before reaching the streams. Therefore, it is more cost-effective to identify robust areas, where nitrate leaching through the root zone is reduced in the saturated zone before reaching the streams, and vulnerable areas, where no subsurface reduction takes place, and then only impose regulations/restrictions on the vulnerable areas. Distributed hydrological models can make predictions at grid scale, i.e. at much smaller scale than the entire catchment. However, as distributed models often do not include local scale hydrogeological heterogeneities, they are typically not able to make accurate predictions at scales smaller than they are calibrated. We present a framework for assessing nitrate reduction in the subsurface and for assessing at which spatial scales modelling tools have predictive capabilities. A new instrument has been developed for airborne geophysical measurements, Mini-SkyTEM, dedicated to identifying geological structures and heterogeneities with horizontal and lateral resolutions of 30-50 m and 2m, respectively, in the upper 30 m. The geological heterogeneity and uncertainty are further analysed by use of the geostatistical software TProGS by generating stochastic geological realisations that are soft conditioned against the geophysical data. Finally, the flow paths within the catchment are simulated by use of the MIKE SHE hydrological modelling system for each of the geological models generated by TProGS and the prediction uncertainty is characterised by the variance between the predictions of the different models., (© 2013.)

Background: Although opioid maintenance treatment (OMT) has been found to reduce crime, less is known about its associations with violent crime. This study investigates changes in violent crime convictions prior to, during, and after OMT, and examines the relationship between violent crime convictions prior to OMT with the risk of violent and non-violent crime convictions during treatment., Methods: The cohort comprised all who started OMT (n=3221) in Norway between 1997 and 2003. Treatment data were cross linked with the national Crime Registry. Convictions for violent crime 3 years prior to, during, and after treatment were studied., Results: Violent crime rates were significantly reduced during OMT compared with before treatment, for both men and women. The rate of convictions for violent crime during OMT was halved amongst those who remained in treatment. The reduction was less pronounced for those who left treatment: for this group, the rate of violent convictions after OMT was higher than before treatment. The risk of convictions for violent and non-violent crime during OMT was highest for those with violent convictions prior to treatment., Conclusions: Violent crime is reduced during OMT. Screening for violent behaviour and violence risk assessment should be implemented in the treatment system., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Aims: The primary aim of the present study is to determine the one year periodic prevalence of dispension of different analgesics to patients in long term opioid maintenance therapy (OMT). The secondary aim is to determine to which extent non-opioid analgesics are used as first line analgesics., Design: The study is a pharmacoepidemiological study with cross sectional data and cohort data. Data on patients in long term OMT in Norway were obtained from the complete national Norwegian Prescription Database (NorPD)., Findings: The analgesics with the highest one year periodic prevalence were NSAIDs (22%), codeine-paracetamol combinations (9%), paracetamol (7%) and tramadol (2.5%). During both 2007 and 2008 a total of 12% of the study population received at least one dispension of another opioid in addition to the opioid used for OMT. In 55% of the cases where OMT patients had not received an analgesic the preceding year an NSAID was the first or only dispensed analgesic whereas paracetamol-codeine was the first or only dispensed analgesic in 29% of the cases., Conclusions: This study has documented an equally high one year periodic prevalence of opioid dispensions in OMT patients as in the general population as well as a high one year periodic prevalence of dispensions of NSAIDs. Dispension of codeine-paracetamol has a relatively high one-year prevalence and is frequently used as a first line analgesic., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

The involvement of sodium/potassium-ATPase in regulating parathyroid hormone (PTH) secretion is inferred from in vitro studies. Recently, the α-klotho-dependent rapid recruitment of this ATPase to the parathyroid cell plasma membrane in response to low extracellular calcium ion was suggested to be linked to increased hormone secretion. In this study, we used an in vivo rat model to determine the importance of sodium/potassium-ATPase in PTH secretion. Glands were exposed and treated in situ with vehicle or ouabain, a specific inhibitor of sodium/potassium-ATPase. PTH secretion was significantly increased in response to ethylene glycol tetraacetic acid-induced acute hypocalcemia and to the same extent in both vehicle and ouabain groups. The glands were removed, and inhibition of the ATPase was measured by (86)rubidium uptake, which was found to be significantly decreased in ouabain-treated parathyroid glands, indicating inhibition of the ATPase. As ouabain induced systemic hyperkalemia, the effect of high potassium on hormone secretion was also examined but was found to have no effect. Thus, inhibition of the parathyroid gland sodium/potassium-ATPase activity in vivo had no effect on the secretory response to acute hypocalcemia. Hence, the suggested importance of this ATPase in the regulation of PTH secretion could not be confirmed in this in vivo model.

β-Barrel proteins are frequently found in the outer membrane of mitochondria, chloroplasts and Gram-negative bacteria. In Escherichia coli, these proteins are inserted in the outer membrane by the Bam (β-barrel assembly machinery) complex, a multiprotein machinery formed by the β-barrel protein BamA and the four peripheral membrane proteins BamB, BamC, BamD and BamE. The periplasmic part of BamA binds prefolded β-barrel proteins by a β-augmentation mechanism, thereby stabilizing the precursors prior to their membrane insertion. However, the role of the associated proteins within the Bam complex remains unknown. Here, we describe the crystal structure of BamB, a nonessential component of the Bam complex. The structure shows a typical eight-bladed β-propeller fold. Two sequence stretches of BamB were previously identified to be important for interaction with BamA. In our structure, both motifs are located in close proximity to each other and contribute to a conserved region forming a narrow groove on the top of the propeller. Moreover, crystal contacts reveal two interaction modes of how BamB might bind unfolded β-barrel proteins. In the crystal lattice, BamB binds to exposed β-strands by β-augmentation, whereas peptide stretches rich in aromatic residues can be accommodated in hydrophobic pockets located at the bottom of the propeller. Thus, BamB could simultaneously bind to BamA and prefolded β-barrel proteins, thereby enhancing the folding and membrane insertion capability of the Bam complex., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Weaning of livestock mammals is often associated with digestive problems related to profound changes in the physiology of the gastrointestinal tract. This study was undertaken to study the developmental changes in the gastrointestinal tract of mink kits during the period of 34 to 59 days of age. Twenty-four mink kits from eight litters were included in the experiment. The dams and their litters were kept under standard farm conditions. The dams and the kits were fed a diet consisting of 48.1% protein, 40.7% fat and 11.1% carbohydrate of metabolizable energy. The mink kits were weaned at 42 days of age. At 34, 47 and 59 days of age, one male mink kit from each litter was euthanized. The activity of amylase, trypsin, chymotrypsin and lipase in the pancreatic tissue increased during the experimental period, whereas the activity of carboxyl ester hydrolase remained constant. The vitamin E concentration in plasma was stable from 34 to 59 days of age, whereas the concentration decreased in the liver. The stereochemical composition of α-tocopherol showed a steep decrease in the concentration of the biologically most active natural isomer in both plasma and liver through the whole weaning period, whereas the biologically less active 2S isomers showed a clear increase. The concentration of bile salts did not change during the experimental period. The villous height increased in the proximal part of the small intestine and decreased in the distal part, whereas the crypt depth was doubled in both the proximal and distal part of the small intestine. The mucin-staining area on the villi was markedly reduced during the experimental period but no change in the mucin-staining area in the crypts was observed.

Objectives: This study investigates opioid maintenance treatment (OMT) patients found to have corrected QT (QTc) interval above 500 ms, with particular focus on past medical history, genetic testing and cardiac investigations., Methods: Detailed medical and cardiac history was obtained, with particular focus upon risk factors. Cardiac investigations, including genetic testing for the five most common long QT syndrome (LQTS) mutations, exercise electrocardiography (ECG) and 24-h ECG recordings, were performed., Results: Of 200 OMT patients assessed with ECG, seven methadone maintained patients identified with QTc interval above 500 ms participated in this study. Two were identified as heterozygous LQTS mutation carriers. Both had experienced cardiac symptoms prior to and during OMT. No other risk factors for QTc prolongation were detected among the seven patients. Six of the seven patients underwent further cardiac investigations. QTc intervals fluctuated widely over 24h and during exercise for all patients. Only one of the LQTS mutation carriers switched to buprenorphine and started on a beta-blocker. Despite strong medical advice and information, none of the other patients wanted to switch to buprenorphine or take other cardiac protective measures., Conclusion: Findings indicate the importance of recording a thorough past medical history, focusing specifically on previous cardiac symptoms, and on other known risk factors for QTc prolongation, prior to initiating patients on methadone., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

The aims of this study were to estimate the national herd prevalence and the general spatial distribution of Neospora caninum infection in Norwegian dairy cattle. Bulk milk samples from 1657 randomly selected dairy herds were analysed by iscom ELISA for the presence of N. caninum specific antibodies. The national herd prevalence was estimated to be 0.7% (95% CI: 0.3-1.2%), which is the lowest national herd prevalence reported in Europe. In addition, we included a subpopulation study in which all 400 herds in the Oslo, Akershus and Østfold counties were sampled, and we found a herd prevalence of 1.8%. In the national herd study, a significant cluster of N. caninum infected herds was identified in Jaeren, on the south west coast of Norway. Jaeren has the highest density of farm animals in the country as well as climatic conditions that favour parasite survival. Dairy herds in this region had a 52 times higher relative risk of being N. caninum positive than dairy herds in other parts of Norway. This indicates that even though N. caninum infection is of minor importance in Norway, infection might cause abortion problems in high risk areas., ((c) 2010 Elsevier B.V. All rights reserved.)

The PDZ protease DegS senses mislocalized outer membrane proteins and initiates the sigmaE pathway in the bacterial periplasm. This unfolded protein response pathway is activated by processing of the anti-sigma factor RseA by DegS and other proteases acting downstream of DegS. DegS mediates the rate-limiting step of sigma E induction and its activity must be highly specific and tightly regulated. While DegS is structurally and biochemically well studied, the determinants of its pronounced substrate specificity are unknown. We therefore performed swapping experiments by introducing elements of the homologous but unspecific PDZ protease DegP. Introduction of loop L2 of DegP into DegS converted the enzyme into a non-specific protease, while swapping of PDZ domains did not. Therefore, loop L2 of the protease domain is a key determinant of substrate specificity. Interestingly, swapping of loop L2 did not affect the tight regulation of DegS. In addition, the combined introduction of loop L2 and PDZ domain 1 of DegP into DegS converted DegS even further into a DegP-like protease. These and other data suggest that homologous enzymes with distinct activities and regulatory features can be converted by simple genetic modifications., ((c) 2010 Elsevier Ltd. All rights reserved.)

Our aim in this longitudinal study was to determine predictors of folate and cobalamin status in infancy. Data were collected from 364 mother-infant pairs with blood measurements from pregnancy ( approximately 18 wk; n = 149), newborns (cord serum; n = 361), and 6-mo-old partially or exclusively breast-fed children (n = 221). Serum/plasma folate, cobalamin, holotranscobalamin (holoTC), holohaptocorrin (holoHC), methylmalonic acid (MMA) and total homocysteine (tHcy) at birth and 6 mo were related to maternal vitamin status, parity, lifestyle variables, and anthropometry. In multivariate analyses, the strongest predictors of folate at birth and 6 mo were maternal folate and cord folate, respectively (P < 0.01). Maternal holoTC best predicted cobalamin status at birth (positively associated with cord cobalamin, holoTC, and holoHC; inversely with MMA and tHcy; P < or = 0.001), whereas maternal and cord holoHC were the strongest predictors of cobalamin status at 6 mo (positively associated with cobalamin, holoTC, holoHC; inversely with tHcy; P < 0.05). The association between cobalamin status and parity was negative at birth but positive at 6 mo. Birth weight, female sex, and smoking were associated with low cobalamin or high tHcy at birth but showed no or opposite associations at 6 mo. In conclusion, maternal folate and cobalamin status exerts a long-term positive effect on infant vitamin status. The effect of smoking, parity and female sex on cobalamin status did not persist beyond the newborn period. Maternal holoTC was the superior predictor of newborn cobalamin status, while holoHC could be a valuable marker for predicting cobalamin status later in infancy.

Two members of the widely conserved HtrA family of serine proteases, DegP and DegS, are key players in extracytoplasmic protein quality control. The underlying mechanisms of their main functions in stress sensing, regulation and protection during the unfolded protein response are discussed.

12-Oxophytodienoate reductase 3 (OPR3) is a FMN-dependent oxidoreductase that catalyzes the reduction of the cyclopentenone (9S,13S)-12-oxophytodienoate [(9S,13S)-OPDA] to the corresponding cyclopentanone in the biosynthesis of the plant hormone jasmonic acid. In vitro, however, OPR3 reduces the jasmonic acid precursor (9S,13S)-OPDA as well as the enantiomeric (9R,13R)-OPDA, while its isozyme OPR1 is highly selective, accepting only (9R,13R)-OPDA as a substrate. To uncover the molecular determinants of this remarkable enantioselectivity, we determined the crystal structures of OPR1 and OPR3 in complex with the ligand p-hydroxybenzaldehyde. Structural comparison with the OPR1:(9R,13R)-OPDA complex and further biochemical and mutational analyses revealed that two active-site residues, Tyr78 and Tyr246 in OPR1 and Phe74 and His244 in OPR3, are critical for substrate filtering. The relatively smaller OPR3 residues allow formation of a wider substrate binding pocket that is less enantio-restrictive. Substitution of Phe74 and His244 by the corresponding OPR1 tyrosines resulted in an OPR3 mutant showing enhanced, OPR1-like substrate selectivity. Moreover, sequence analysis of the OPR family supports the filtering function of Tyr78 and Tyr246 and allows predictions with respect to substrate specificity and biological function of thus far uncharacterized OPR isozymes. The discovered structural features may also be relevant for other stereoselective proteins and guide the rational design of stereospecific enzymes for biotechnological applications.

Background: Opioid maintenance treatment (OMT) is generally considered to reduce mortality in opiate dependents. However, the level of mortality reduction is still uncertain. This study investigates mortality reductions in an "intention-to-treat" perspective including all dropouts. The mortality reducing effects of OMT are examined both within treatment and post-treatment. The study separates overdose and total mortality reductions., Methods: The study is a prospective cross-registry study with up to 7 years follow-up. All opiate dependents in Norway who applied for OMT (a total of 3789 subjects) were cross-linked with data from the death registry from Statistics Norway. Date and cause of death were crossed with dates for initiation and termination of OMT, and subjects' age and gender. A baseline was established from the waiting list mortality rate. Intention-to-treat was investigated by analysing mortality among the entire population that started OMT., Results: Mortality in treatment was reduced to RR 0.5 (relative risk) compared with pre-treatment. In the "intention-to-treat" perspective, the mortality risk was reduced to RR 0.6 compared with pre-treatment. The patients who left the treatment programme showed a high-mortality rate, particularly males., Conclusions: OMT significantly reduces risk of mortality also when examined in an intention-to-treat perspective. Studies that evaluate effects of OMT only in patients retained in treatment tend to overestimate benefits. Levels of overdose mortality will influence the risk reduction. Cross-registry studies as the current one are an important supplement to other observational designs in this field.

Pyridoxine 5'-phosphate (PNP) synthase is the last enzyme in the de novo biosynthesis of vitamin B(6) catalyzing the complicated ring-closure reaction between 1-deoxy-D-xylulose-5-phosphate and 1-amino-acetone-3-phosphate. Here we present the crystal structures of four PNP synthase complexes with substrates and substrate analogs. While the overall fold of the enzyme is conserved in all complexes, characteristic readjustments were observed in the active site. The complementary structural information allowed us to postulate a detailed reaction mechanism. The observed binding mode of substrates indicates how the first reaction intermediate, the Schiff-base conjugate, is formed. The most important mechanistic features are the presence of two phosphate-binding sites with distinct affinities and the existence of a water relay system for the release of reaction water molecules. Furthermore, the complexes provide the basis to rationalize the open-closed transition of a flexible loop located on the C-terminal side of the TIM-barrel. Binding of both substrate molecules to the active site seems to be a prerequisite to trigger this transition. Highly conserved mechanistically important residues in the PNP synthase family imply a similar active site organization and reaction mechanism for all family members. Due to the exclusive presence of PNP synthase in a subset of eubacteria, including several well-known pathogens, and due to its outstanding physiological importance for these organisms, the enzyme appears to be a promising novel target for antibacterial drug design.

Background: In many pre-eclamptic women the placentation process seems to be disturbed. Our objective was to investigate if disturbed placentation in pre-eclamptic women may be recognized in early second trimester as altered plasma levels of factors involved in the formation of the uteroplacental unit., Methods: In a prospective study of 2190 pregnant women we compared plasma leptin, transforming growth factor-beta(1) (TGF-beta(1)) and plasminogen activator inhibitor type 2 (PAI-2) concentrations at 18 weeks' gestation in 71 women with subsequent pre-eclampsia and 71 controls matched for age, parity and first trimester body mass index., Results: Leptin and TGF-beta(1) concentrations were lower and PAI-2 concentration higher in women destined to develop pre-eclampsia relative to controls (leptin: median (25-75 percentiles): 19.0 (14.5-29.0) vs 25.0 (16.0-35.0) ng/ml (p =0.03), TGF-beta(1): 3.2 (2.0-6.1) vs 5.3 (3.8-7.1) ng/ml (P=0.01) and PAI-2: 78.8 (65.1-118.1) vs 67.6 (61.6-79.6) ng/ml (P=0.002)). OR (95 per cent CI) for pre-eclampsia for women in the upper quartile compared to women in the lower quartile were: leptin: 0.2 (0.03-0.7), TGF-beta(1): 0.2 (0.08-0.7) and PAI-2: 3.1 (1.2-8.2)., Conclusions: Altered plasma concentrations levels of factors involved in the process of placentation in women destined to develop pre-eclampsia, indicate that disturbed formation of the uteroplacental unit is reflected in the maternal circulation before 20 weeks' gestation., (Copyright 2002 Elsevier Science Ltd. All rights reserved.)

Cystathionine gamma-synthase catalyzes the committed step of methionine biosynthesis. This pathway is unique to microorganisms and plants, rendering the enzyme an attractive target for the development of antimicrobials and herbicides. We solved the crystal structures of complexes of cystathionine gamma-synthase (CGS) from Nicotiana tabacum with inhibitors of different compound classes. The complex with the substrate analog dl-E-2-amino-5-phosphono-3-pentenoic acid verifies the carboxylate-binding function of Arg423 and identifies the phosphate-binding pocket of the active site. The structure shows the function of Lys165 in specificity determination and suggests a role for the flexible side-chain of Tyr163 in catalysis. The importance of hydrophobic interactions for binding to the active-site center is highlighted by the complex with 3-(phosphonomethyl)pyridine-2-carboxylic acid. The low affinity of this compound is due to the non-optimal arrangement of the functional groups binding to the phosphate and carboxylate-recognition site, respectively. The newly identified inhibitor 5-carboxymethylthio-3-(3'-chlorophenyl)-1,2,4-oxadiazol, in contrast, shows the highest affinity to CGS reported so far. This affinity is due to binding to an additional active-site pocket not used by the physiological substrates. The inhibitor binds to the carboxylate-recognition site, and its tightly bent conformation enables it to occupy the novel binding pocket between Arg423 and Ser388. The described structures suggest improvements for known inhibitors and give guidelines for the development of new lead compounds., (Copyright 2001 Academic Press.)

Objective: Preeclampsia is associated with high body mass index, insulin resistance, and hypertriglyceridemia. Our objective was to investigate prospectively whether diet in the first half of pregnancy is associated with the risk for preeclampsia., Study Design: This prospective, population-based, cohort study of pregnant women investigated dietary intake early in the second trimester with a quantitative food frequency questionnaire., Results: The questionnaire was completed by 3133 women (83%). Preeclampsia developed in 85 women. Adjusted odds ratio (95% CI) for preeclampsia was 3.7 (1.5-8.9) for energy intake of >3350 kcal/d compared with < or =2000 kcal/d. Adjusted odds ratio (95% CI) for preeclampsia was 3.6 (1.3-9.8) for sucrose intake (percent of total energy) of >25% compared with < or =8.5% and 2.6 (1.3-5.4) for polyunsaturated fatty acids intake (percent of total energy) of >7.5% compared with < or =5.2%. Other energy-providing nutrients were not associated with the risk for preeclampsia., Conclusion: The current study suggests that high intakes of energy, sucrose, and polyunsaturated fatty acids independently increase the risk for preeclampsia.

The polyisoprenylated benzophenones, chamones I and II, were isolated from the trunk latex of Clusia grandiflora (Clusiaceae) growing in southeastern Venezuela. A third benzophenone, nemorosone II, was isolated from the pollinator reward resin of the female flowers of the same plant. Chamone I and nemorosone II are structurally similar, differing only in the degree of prenylation. Bioassays of chamone I and nemorosone II using the honeybee pathogens, Paenibacillus larvae and Paenibacillus alvei, demonstrate that both have potent antibacterial activity, and that their structural differences affect both their bactericidal efficacies and their aqueous mobilities.

NifS-like proteins are ubiquitous, homodimeric, proteins which belong to the alpha-family of pyridoxal-5'-phoshate dependent enzymes. They are proposed to donate elementary sulphur, generated from cysteine, via a cysteinepersulphide intermediate during iron sulphur cluster biosynthesis, an important albeit not well understood process. Here, we report on the crystal structure of a NifS-like protein from the hyperthermophilic bacterium Thermotoga maritima (tmNifS) at 2.0 A resolution. The tmNifS is structured into two domains, the larger bearing the pyridoxal-5'-phosphate-binding active site, the smaller hosting the active site cysteine in the middle of a highly flexible loop, 12 amino acid residues in length. Once charged with sulphur the loop could possibly deliver S(0) directly to regions far remote from the protein. Based on the three-dimensional structures of the native as well as the substrate complexed form and on spectrophotometric results, a mechanism of sulphur activation is proposed. The His99, which stacks on top of the pyridoxal-5'-phosphate co-factor, is assigned a crucial role during the catalytic cycle by acting as an acid-base catalyst and is believed to have a pK(a) value depending on the co-factor redox state., (Copyright 2000 Academic Press.)

Objective: The purpose of this study was to investigate whether indications of activation of the maternal endothelium were present at 18 weeks' gestation in women in whom preeclampsia eventually developed., Study Design: A total of 2190 blood samples were obtained at 18 weeks' gestation. Circulating levels of von Willebrand factor and soluble vascular adhesion molecule 1, soluble intercellular adhesion molecule 1, and E-selectin were assayed in 71 women with eventual preeclampsia and 71 control subjects., Results: E-selectin and von Willebrand factor levels were similar between the 2 groups. Soluble vascular adhesion molecule 1 concentration was significantly lower in the women with eventual preeclampsia (median, 649.0 ng/mL vs 762.4 ng/mL; P <.001), whereas soluble intercellular adhesion molecule 1 concentration was significantly higher (median, 239.8 ng/mL vs 178.3 ng/mL; P <.001)., Conclusion: We found no indications of endothelial activation at 18 weeks' gestation in women in whom preeclampsia later developed. However, decreased serum concentration of soluble vascular adhesion molecule 1 and increased serum concentration of soluble intercellular adhesion molecule 1 may reflect the disturbed placentation known to be associated with the development of preeclampsia.

Cystathionine gamma-synthase catalyses the committed step of de novo methionine biosynthesis in micro-organisms and plants, making the enzyme an attractive target for the design of new antibiotics and herbicides. The crystal structure of cystathionine gamma-synthase from Nicotiana tabacum has been solved by Patterson search techniques using the structure of Escherichia coli cystathionine gamma-synthase. The model was refined at 2.9 A resolution to a crystallographic R -factor of 20.1 % (Rfree25.0 %). The physiological substrates of the enzyme, L-homoserine phosphate and L-cysteine, were modelled into the unliganded structure. These complexes support the proposed ping-pong mechanism for catalysis and illustrate the dissimilar substrate specificities of bacterial and plant cystathionine gamma-synthases on a molecular level. The main difference arises from the binding modes of the distal substrate groups (O -acetyl/succinyl versusO -phosphate). Central in fixing the distal phosphate of the plant CGS substrate is an exposed lysine residue that is strictly conserved in plant cystathionine gamma-synthases whereas bacterial enzymes carry a glycine residue at this position. General insight regarding the reaction specificity of transsulphuration enzymes is gained by the comparison to cystathionine beta-lyase from E. coli, indicating the mechanistic importance of a second substrate binding site for L-cysteine which leads to different chemical reaction types., (Copyright 1999 Academic Press.)

Cystathionine beta-lyase (CBL) is a member of the gamma-family of PLP-dependent enzymes, that cleaves C beta-S bonds of a broad variety of substrates. The crystal structure of CBL from E. coli has been solved using MIR phases in combination with density modification. The structure has been refined to an R-factor of 15.2% at 1.83 A resolution using synchroton radiation diffraction data. The asymmetric unit of the crystal cell (space group C222(1)) contains two monomers related by 2-fold symmetry. A homotetramer with 222 symmetry is built up by crystallographic and non-crystallographic symmetry. Each monomer of CBL can be described in terms of three spatially and functionally different domains. The N-terminal domain (residues 1 to 60) consists of three alpha-helices and one beta-strand. It contributes to tetramer formation and is part of the active site of the adjacent subunit. The second domain (residues 61 to 256) harbors PLP and has an alpha/beta-structure with a seven-stranded beta-sheet as the central part. The remaining C-terminal domain (residues 257 to 395), connected by a long alpha-helix to the PLP-binding domain, consists of four helices packed on the solvent-accessible side of an antiparallel four-stranded beta-sheet. The fold of the C-terminal and the PLP-binding domain and the location of the active site are similar to aminotransferases. Most of the residues in the active site are strongly conserved among the enzymes of the transsulfuration pathway. Additionally, CBL is homologous to the mal gamma gene product indicating an evolutionary relationship between alpha and gamma-family of PLP-dependent enzymes. The structure of the beta, beta, beta-trifluoroalanine inactivated CBL has been refined at 2.3 A resolution to an R-factor of 16.2%. It suggests that Lys210, the PLP-binding residue, mediates the proton transfer between C alpha and S gamma.

Mg++ (3 and 6 mmol/L), the beta 2-adrenergic agonist terbutaline (1 and 10 mumol/L), and dibutyryl cyclic adenosine 5'-monophosphate (0.1 and 1 mmol/L) suppressed spontaneous activity and the increase in contractile activity induced by ouabain or K(+)-free buffer in isolated human pregnant myometrium. The ouabain-suppressible rubidium 86 or potassium 42 uptake was unaffected by the presence of Mg++ (3 and 6 mmol/L), the beta 2-adrenergic agonist terbutaline (1 and 10 mumol/L), or dibutyryl cyclic adenosine 5'-monophosphate (1 mmol/L). However, loading of the strips with Na+ and incubation in high K+ induced a fivefold increase in rubidium 86 uptake. On the basis of these flux rates, our previous data on the total concentration of sodium-potassium pumps in the human myometrium, and an estimated maximum transport rate of the sodium-potassium pump of 8900 K+ ions per minute at 30 degrees C, it could be calculated that the sodium-potassium pump in the Na(+)-loaded strips reached around 80% of its maximal rate. Taken together, these results showed that the relaxant effects of Mg++, terbutaline, and dibutyryl cyclic adenosine 5'-monophosphate on human myometrium are not due to a stimulation of active sodium-potassium transport.

To evaluate the effect of thyroid function on the number of Na-K pumps in skeletal muscle, the number of 3H-ouabain binding sites was measured in biopsy specimens from the vastus lateralis muscle of euthyroid subjects and patients with hypothyroidism or hyperthyroidism. In hypothyroidism there was a decrease of 50% in 3H-ouabain binding sites, and in hyperthyroidism there was an increase of 68% in 3H-ouabain binding sites. When thyroid status became normal after treatment the number of 3H-ouabain binding sites also became normal. There were significant correlations between several thyroid function tests and the number of 3H-ouabain binding sites. Free T4-index gave the highest r value (0.87). These changes may account for the variations in digitalis sensitivity associated with thyroid disorders.

Analyses of relief food used in Ethiopia showed that, because of food refinement, 6 out of 10 samples of cereals contained too little potassium and magnesium to cover daily needs. Malnutrition is often associated with gastrointestinal infections, which lead to further deficiency of these electrolytes. Potassium and magnesium are required for protein synthesis, growth, and tissue repair. Since protein supplies are often marginal, relief food should contain sufficient potassium and magnesium to allow optimum utilisation of dietary nitrogen sources. This may be achieved by using coarse qualities of cereals, by supplementing cereals with legumes, and by avoiding cooking procedures that extract these salts from the cereals.

In fifteen patients with hyperkalaemic familial periodic paralysis, inhalation of salbutamol alleviated hyperkaleamia and paralysis precipitated by exercise or oral administration of potassium chloride. In-vitro studies with rat soleus muscles indicated that the hypokalaemic effect of salbutamol is related to stimulation of the active coupled transport of sodium and potassium in muscle cells. Follow-up studies proved that the inhalation of salbutamol is a simple and adequate method for the treatment of the paralytic episodes in these patients.