Letter to the Editor: Healthy for Life: An Innovative and Collaborative Approach to COVID 19 Lockdown in New Zealand

Recently Boreskie and colleagues published an editorial in the Journal of Frailty and Aging on Preventing Frailty Progression During the COVID-19 Pandemic (1). In it they proposed the SAVE programme (Socialization, Adequate nutrition, Vitamin D, Exercise) to prevent frailty. They concluded that creative thinking and concerted efforts would be needed to disseminate health recommendations to maintain the health of pre-frail and frail older adults in unprecedented times, such as those posed by the COVID-19 pandemic.

Study protocol: older people in retirement villages. A survey and randomised trial of a multi-disciplinary invention designed to avoid adverse outcomes

Background

There is increasing interest among older people in moving into retirement villages (RVs), an attractive option for those seeking a supportive community as they age, while still maintaining independence. Currently in New Zealand there is limited knowledge of the medical, service supports, social status and needs of RV residents. The objective of this study is to explore RV facilities and services, the health and functional status of RV residents, prospectively study their healthcare trajectories and to implement a multidisciplinary team intervention to potentially decrease dependency and impact healthcare utilization.

Methods

All RVs located in two large district health boards in Auckland, New Zealand were eligible to participate. This three-year project comprised three phases: The survey phase provided a description of RVs, residents’ characteristics and health and functional status. RV managers completed a survey of size, facilities and recreational and healthcare services provided in the village. Residents were surveyed to establish reasons for entry to the village and underwent a Gerontology Nurse Specialist (GNS) assessment providing details of demographics, social engagement, health and functional status. The cohort study phase examines residents’ healthcare trajectories and adverse outcomes, over three years. The final phase is a randomised controlled trial of a multidisciplinary team intervention aimed to improve health outcomes for more vulnerable residents.

Residents who triggered potential unmet health needs during the assessment in the survey phase were randomised to intervention or usual care groups. Multidisciplinary team meetings included the resident and support person, a geriatrician or gerontology nurse practitioner, GNS, pharmacist and General Practitioner. The primary outcome of the randomised controlled trial will be first acute hospitalization. Secondary outcomes include all acute hospitalizations, long-term care admissions, and all-cause mortality.

Discussion

This paper describes the study protocol of this complex study. The study aims to inform policies and practices around health care services for residents in retirement villages. The results of this trial are expected early 2020 with publication subsequently.

Trial registration

Australia and New Zealand Clinical Trials Registry: ACTRN12616000685415. Registered 25.5.2016.

Universal Trial Number (UTN): U111–1173-6083.

The BRIGHT Trial: what are the factors associated with nutrition risk?

OBJECTIVES

To determine the nutrition risk status and factors associated with nutrition risk among older adults enrolled in the Brief Risk Identification Geriatric Health Tool (BRIGHT Trial).

DESIGN

A cluster randomised controlled trial.

SETTING

Three main centres in New Zealand.

PARTICIPANTS

A total of 3,893 older adults were recruited from 60 general practices in three of the District Health Board (DHB) regions aged 75 years and older (or 65 years and older if Māori).

MEASUREMENTS

Nutrition risk was assessed using the Australian Nutrition Screening Initiative (ANSI). Validated questionnaires were used to establish quality of life (WHOQOL-BREF), physical function (the Nottingham Extended Activities of Daily Living) and depressive symptoms (15 item Geriatric Depression Scale). Demographic, standard of living and health data were established.

RESULTS

Sixty two percent of participants were identified to be at moderate or high nutrition risk. The mean ANSI score was 4.9 (range 0-21, maximum 29). Factors which independently predicted moderate or high nutrition risk were female gender, being Māori and other ethnicities versus European, not being married, taking multiple medications, having more depressive symptoms, cardiovascular disease and diabetes. Protective factors independently related to low nutrition risk were living with others, higher physical and social health related QOL and higher functional status. WHOQOL environmental and psychological factors were not associated with nutrition risk when other predictive factors were taken into account.

CONCLUSION

Nearly two thirds of participants were identified to be at higher nutrition risk. Women, living alone, taking multiple medications, with depressive symptoms, cardiovascular disease and ndiabetes were factors associated with higher nutrition risk. Those at low nutrition risk had a better functional status and physical and social health related QOL.

Prostanoid receptors: ontogeny and implications in vascular physiology

Prostanoids exert significant effects on circulatory beds. They play a role in the response of the vasculature to adjustments in perfusion pressure and oxygen and carbon dioxide tension, and they mediate the actions of numerous factors. The role of prostanoids in governing circulation of the perinate is suggested to surpass that in the adult. Prostanoids are abundantly generated in the perinate. They have been implicated in autoregulation of blood flow as studied in brain and eyes. Prostaglandins are also dominant regulators of ductus arteriosus tone. The effects of these autacoids are mediated through specific G protein-coupled receptors. In addition to the pharmacological characterization of the prostanoid receptors, important advances in understanding the biology of these receptors have been made in the last decade. Their cloning and the development of animals with disrupted genes of these receptors have been very informative. The involvement of prostanoid receptors in the developing subject, especially on brain and ocular vasculature and on ductus arteriosus, has also begun to be investigated; the expression of these receptors changes with development. Some but not all of the ontogenic changes in these receptors are attributed to homologous regulation. Interestingly, in the process of elucidating their effects, functional perinuclear prostaglandin E2 receptors have been uncovered. This article reviews prostanoid receptors and addresses implications on the developing subject with attention to vascular physiology.

Prolonged hypercapnia-evoked cerebral hyperemia via K(+) channel- and prostaglandin E(2)-dependent endothelial nitric oxide synthase induction

Mechanisms for secondary sustained increase in cerebral blood flow (CBF) during prolonged hypercapnia are unknown. We show that induction of endothelial NO synthase (eNOS) by an increase in prostaglandins (PGs) contributes to the secondary CBF increase during hypercapnic acidosis. Ventilation of pigs with 6% CO(2) (PaCO(2 approximately)65 mm Hg; pH approximately 7.2) caused a approximately 2.5-fold increase in CBF at 30 minutes, which declined to basal values at 3 hours and gradually rose again at 6 and 8 hours; the latter increase was associated with PG elevation, nitrite formation, eNOS mRNA expression, and in situ NO synthase (NOS) reactivity (NADPH-diaphorase staining). Subjecting free-floating brain sections to acidotic conditions increased eNOS expression, the time course of which was similar to that of CBF increase. Treatment of pigs with the cyclooxygenase inhibitor diclofenac or the NOS inhibitor Nomega-nitro-L-arginine blunted the initial rise and prevented the secondary CBF increase during hypercapnic acidosis; neuronal NOS blockers 1-(2-trifluoromethylphenyl) imidazole and 3-bromo-7-nitroindazole were ineffective. Diclofenac abolished the hypercapnia-induced rise in cerebrovascular nitrite production, eNOS mRNA expression, and NADPH-diaphorase reactivity. Acidosis (pH approximately 7.15, PCO(2 approximately )40 mm Hg; 6 hours) produced similar increases in prostaglandin E(2) (PGE(2)) and eNOS mRNA levels in isolated brain microvessels and in NADPH-diaphorase reactivity of brain microvasculature; these changes were prevented by diclofenac, by the receptor-operated Ca(2+) channel blocker SK&F96365, and by the K(ATP) channel blocker glybenclamide. Acidosis increased Ca(2+) transients in brain endothelial cells, which were blocked by glybenclamide and SK&F96365 but not by diclofenac. Increased PG-related eNOS mRNA and NO-dependent vasorelaxation to substance P was detected as well in rat brain exposed to 6 hours of hypercapnia. PGE(2) was the only major prostanoid that modulated brain eNOS expression during acidosis. Thus, in prolonged hypercapnic acidosis, the secondary CBF rise is closely associated with induction of eNOS expression; this seems to be mediated by PGE(2) generated by a K(ATP) and Ca(2+) channel-dependent process.

Augmented vasoconstriction and thromboxane formation by 15-F(2t)-isoprostane (8-iso-prostaglandin F(2alpha)) in immature pig periventricular brain microvessels

BACKGROUND AND PURPOSE

Oxidant stress, especially in the premature, plays a major role in the pathogenesis of hypoxic-ischemic encephalopathies mostly manifested in the periventricular region. We studied the vasomotor mode of actions of the peroxidation product 15-F(2t)-isoprostane (15-F(2t)-IsoP) (8-iso-prostaglandin F(2alpha)) on periventricular region during development.

METHODS

Effects of 15-F(2t)-IsoP on periventricular microvessels of fetal, newborn, and juvenile pigs were studied by video imaging and digital analysis techniques. Thromboxane formation and intracellular Ca(2+) were measured by radioimmunoassay and by using the fluorescent indicator fura 2-AM.

RESULTS

15-F(2t)-IsoP-mediated constriction of periventricular microvessels decreased as a function of age such that in the fetus it was approximately 2.5-fold greater than in juvenile pigs. 15-F(2t)-IsoP evoked more thromboxane formation in the fetus than in the newborn, which was greater than that in the juvenile periventricular region; this was associated with immunoreactive thromboxane A(2) (TXA(2)) synthase expression in the fetus that was greater than that in newborn pigs, which was greater than that in juvenile pigs. 15-F(2t)-IsoP-induced vasoconstriction was markedly inhibited by TXA(2) synthase and receptor blockers (CGS12970 and L670596). Vasoconstrictor effects of the TXA(2) mimetic U46619 on fetal, neonatal, and juvenile periventricular microvessels did not differ. 15-F(2t)-IsoP increased TXA(2) synthesis by activating Ca(2+) influx through non-voltage-gated channels in endothelial cells (SK&F96365 sensitive) and N-type voltage-gated channels (omega-conotoxin sensitive) in astrocytes; smooth muscle cells were not responsive to 15-F(2t)-IsoP but generated Ca(2+) transients to U46619 via L-type voltage-sensitive channels.

CONCLUSIONS

15-F(2t)-IsoP causes periventricular brain region vasoconstriction in the fetus that is greater than that in the newborn, which in turn is greater than that in the juvenile due to greater TXA(2) formation generated through distinct stimulatory pathways, including from endothelial and astroglial cells. The resulting hemodynamic compromise may contribute to the increased vulnerability of the periventricular brain areas to oxidant stress-induced injury in immature subjects.

Localization of functional prostaglandin E2 receptors EP3 and EP4 in the nuclear envelope

The effects of prostaglandin E2 are thought to be mediated via G protein-coupled plasma membrane receptors, termed EP. However recent data implied that prostanoids may also act intracellularly. We investigated if the ubiquitous EP3 and the EP4 receptors are localized in nuclear membranes. Radioligand binding studies on isolated nuclear membrane fractions of neonatal porcine brain and adult rat liver revealed the presence of EP3 and EP4. A perinuclear localization of EP3alpha and EP4 receptors was visualized by indirect immunocytofluorescence and confocal microscopy in porcine cerebral microvascular endothelial cells and in transfected HEK 293 cells that stably overexpress these receptors. Immunoelectron microscopy clearly revealed EP3alpha and EP4 receptors localization in the nuclear envelope of endothelial cells; this is the first demonstration of the nuclear localization of these receptors. Data also reveal that nuclear EP receptors are functional as they affect transcription of genes such as inducible nitric-oxide synthase and intranuclear calcium transients; this appears to involve pertussis toxin-sensitive G proteins. These results define a possible molecular mechanism of action of nuclear EP3 receptors.

Characterization and regulation of prostaglandin E2 receptor and receptor-coupled functions in the choroidal vasculature of the pig during development

Ontogenic changes in choroidal vascular prostaglandin E2 (PGE2) receptors (EP1, EP2, EP3, and EP4), changes in receptor-coupled functions, and the possible role of high perinatal prostaglandin levels in regulating expression and function of these receptors were studied. PGE2 receptors and their functions on choroidal tissues were characterized by radioligand binding; by measurements of second messengers to receptor stimulation; and by vasomotor response to EP1, EP2, EP3, and EP4 ligands on perfused choroidal vascular beds from saline- and ibuprofen-treated (40 mg/kg every 4 every 4 hours for 48 hours) newborn pigs and from adult animals. PGE2 as well as EP2- and EP4-attributed choroidal stimulation elicited greater vasorelaxation in the saline-treated newborn and was associated with higher nitrite (oxidation product of NO, N omega-nitro-L-arginine inhibitable) production than in adult tissues. In contrast, EP1 and EP3 stimulation caused significantly more constriction in the adult than in the newborn, and this was associated with increased production of inositol 1,4,5-trisphosphate (IP3) and greater reduction of cAMP synthesis in the adult. Maximum [3H]PGE2 binding was also higher (3-fold) in adult than in newborn tissues. Competition binding studies revealed that of the PGE2 receptors in the adult choroid, approximately 55% were of the EP1 subtype, 8% were EP2, 22% were EP3, and 15% were EP4. Newborn choroid contained approximately 33% each of EP1 and EP2 receptors, 20% of EP3, and 15% of EP4. Inhibition of endogenous prostaglandin synthesis for 48 hours with ibuprofen in newborns to attain levels found in the adult resulted in an upregulation of [3H]PGE2 binding, EP1- and EP3-mediated vasoconstriction, and increases and decreases in IP3 and cAMP production, respectively, in newborn tissues compared with adult tissues. On the other hand, ibuprofen treatment of newborns led to a decrease in PGE2- and EP4-mediated vasorelaxation and nitrite synthesis (associated with decreased expression of endothelial NO synthase) to levels observed in adults: EP2-elicited responses in newborns were not affected by ibuprofen. In conclusion, fewer EP1 receptors (associated with vasoconstriction), more EP2 receptors, and greater EP4-coupled NO production (coupled to vasorelaxation) seem to be responsible for the increased vasodilation to PGE2 in the newborn. The decrease in prostaglandin levels with age appears to cause, on one hand, upregulation of EP1 and EP3 receptors and receptor-coupled vasoconstriction and, on the other hand, decreased EP4-coupled NO synthesis and choroidal vasodilation. Altogether, these factors result in increased vasorelaxation to PGE2 in the newborn compared with the adult. These findings may help to explain the inability of the newborn to autoregulate choroidal blood flow.

The role of prostaglandin receptors in regulating cerebral blood flow in the perinatal period

Prostaglandins exert significant effects on the range of cerebral blood flow autoregulation. However, the newborn exhibits a narrow cerebral blood flow autoregulatory range compared to the adult, and this apparently contributes to the susceptibility of the newborn to major perinatal complications such as intraventricular cerebral haemorrhage. Reduced vasoconstriction in response to prostaglandins due to the fewer prostaglandin receptors, especially for PGE2 (EP) and PGF2 alpha (FP), seems to contribute in part to the narrower range of cerebral blood flow autoregulation in the newborn. Evidence suggests that high levels of prostaglandins in the perinatal period are responsible for the down-regulation of neurovascular EP and FP receptors. We review the pharmacology of prostaglandin receptors, in particular PGE2 and PGF2 alpha receptors, their ontogeny on the neural vasculature, the perinatal regulation of their expression, and how these changes relate to the control of neural blood flow autoregulation.

Peroxide-cyclooxygenase interactions in postasphyxial changes in retinal and choroidal hemodynamics

To test the role of reactive oxygen species and cyclooxygenase products in the retinal hemodynamic changes induced by asphyxia, we measured retinal (RBF) and choroidal blood flows (ChBF), malondialdehyde (MDA), prostaglandin E2 (PGE2), 6-ketoprostaglandin F1 alpha (6-keto-PGF1 alpha), and thromboxane B2 (TxB2) in 1- to 3-day-old pigs treated with saline, the free radical scavengers U-74389F or high-dose allopurinol, the cyclooxygenase inhibitors ibuprofen or indomethacin, or the thromboxane synthase blocker CGS-13080 before and 5 and 60 min after a 5-min period of asphyxia. In saline-treated animals, RBF and ChBF increased 5 min after asphyxia and decreased at 60 min. The increases in RBF and ChBF at 5 min postasphyxia were slightly attenuated by cyclooxygenase blockers and free radical scavengers but not by thromboxane synthase inhibition, whereas all drugs prevented the decreases at 60 min. MDA, TxB2, PGE2, and 6-keto-PGF1 alpha increased 5 min after asphyxia; at 60 min, PGE2 and 6-keto-PGF1 alpha returned to nearly preasphyxial levels, but MDA and TxB2 continued to increase. Cyclooxygenase inhibition prevented the asphyxia-induced rise in MDA, and the free radical scavengers prevented that of prostanoids. In isolated eyecup preparations, H2O2 and cumene hydroperoxide constricted retinal arteries; this effect was blocked by cyclooxygenase and thromboxane synthase inhibitors. The data suggest that during oxidative stresses reactive oxygen species are generated from the cyclooxygenase pathway and, in turn, also activate the synthesis of thromboxane; the latter mediates the oxidative stress-induced ocular vasoconstriction that might trigger the neovascularization of retinopathy of prematurity.