A Digital Cognitive-Physical Intervention for Attention-Deficit/Hyperactivity Disorder: Randomized Controlled Trial.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders among children. Pharmacotherapy has been the primary treatment for ADHD, supplemented by behavioral interventions. Digital and exercise interventions are promising nonpharmacologic approaches for enhancing the physical and psychological health of children with ADHD. However, the combined impact of digital and exercise therapies remains unclear. OBJECTIVE: The aim of this study was to determine whether BrainFit, a novel digital intervention combining gamified cognitive and exercise training, is efficacious in reducing ADHD symptoms and executive function (EF) among school-aged children with ADHD. METHODS: This 4-week prospective randomized controlled trial included 90 children (6-12 years old) who visited the ADHD outpatient clinic and met the diagnostic criteria for ADHD. The participants were randomized (1:1) to the BrainFit intervention (n=44) or a waitlist control (n=46) between March and August 2022. The intervention consisted of 12 30-minute sessions delivered on an iPad over 4 weeks with 3 sessions per week (Monday, Wednesday, and Friday after school) under the supervision of trained staff. The primary outcomes were parent-rated symptoms of attention and hyperactivity assessed according to the Swanson, Nolan, and Pelham questionnaire (SNAP-IV) rating scale and EF skills assessed by the Behavior Rating Inventory of Executive Function (BRIEF) scale, evaluated pre and post intervention. Intention-to-treat analysis was performed on 80 children after attrition. A nonparametric resampling-based permutation test was used for hypothesis testing of intervention effects. RESULTS: Among the 145 children who met the inclusion criteria, 90 consented and were randomized; ultimately, 80 (88.9%) children completed the study and were included in the analysis. The participants' average age was 8.4 (SD 1.3) years, including 63 (78.8%) male participants. The most common ADHD subtype was hyperactive/impulsive (54/80, 68%) and 23 (29%) children had severe symptoms. At the endpoint of the study, the BrainFit intervention group had a significantly larger improvement in total ADHD symptoms (SNAP-IV total score) as compared to those in the control group (ß=-12.203, 95% CI -17.882 to -6.523; P<.001), owing to lower scores on the subscales Inattention (ß=-3.966, 95% CI -6.285 to -1.647; P<.001), Hyperactivity/Impulsivity (ß=-5.735, 95% CI -8.334 to -3.137; P<.001), and Oppositional Defiant Disorder (ß=-2.995, 95% CI -4.857 to -1.132; P=.002). The intervention was associated with significant reduction in the Metacognition Index (ß=-6.312, 95% CI -10.973 to -1.650; P=.006) and Global Executive Composite (ß=-5.952, 95% CI -10.214 to -1.690; P=.003) on the BRIEF. No severe intervention-related adverse events were reported. CONCLUSIONS: This novel digital cognitive-physical intervention was efficacious in school-age children with ADHD. A larger multicenter effectiveness trial with longer follow-up is warranted to confirm these findings and to assess the durability of treatment effects. TRIAL REGISTRATION: Chinese Clinical Trial Register ChiCTR2300070521; https://www.chictr.org.cn/showproj.html?proj=177806.

'Black African' identification and the COVID-19 pandemic in Britain: A site for sociological, ethical and policy debate.

This paper is a narrative review of the use of collective terminology in relation to race and health in Britain, with particular reference to the 'Black African' community. 'Black Africans' have been categorised in the 1991-2011 censuses with added free-text in 2021 in response to user demand. However, the UK government is increasingly reporting data for the 'Black' pan-ethnicity, especially in the even more generalised 'BAME' ('Black, Asian and Minority Ethnic') acronym in COVID-19 pandemic reports. The consequences of this practice are addressed. Firstly, with respect to ethical challenges, Black Africans find their conscription by government into the term BAME offensive and do not accept it as a self-descriptor. This labelling, which subsumes Black Africans' self-assigned ethnicity in the census, and consequent misrecognition may be interpreted as a micro-aggression (a term coined in the 1970s but used here to denote microinvalidation), as suggested in the current black activism of the 'Black Lives Matter movement'. Secondly, ONS has warned that concealed heterogeneity renders the pan-ethnicities unreliably crude, making them scientifically inaccurate. Analysts are recommended to present ethnic group data for the full census classification where possible for reasons of validity and respect for the patient as arbiter of their ethnic group.

Clinical outcomes of switching to aflibercept using a pro re nata treatment regimen in patients with neovascular age-related macular degeneration who incompletely responded to ranibizumab.

BACKGROUND: To assess the effect of switching patients previously incompletely treated with ranibizumab (RBZ) to aflibercept (AFL) using a pro re nata (PRN) treatment strategy in neovascular age-related macular degeneration (nvAMD). METHODS: A retrospective case series was conducted on patients who had persistent or recurrent intra- and/or sub-retinal fluid treated initially with RBZ and subsequently switched to AFL. The main outcome measures were best corrected visual acuity (BCVA) and central retinal thickness (CRT) measured at different stages of the study. Friedman analysis of variance and Wilcoxon test were used to examine differences in BCVA and CRT. RESULTS: Two hundred and seven eyes from 182 patients were included. BCVA and CRT improved significantly initially following 3 RBZ injections with a mean gain of 3.7 letters (p < 0.001) and a mean loss of 69 µm (p < 0.001) respectively. Following PRN RBZ therapy and immediately prior to switching to AFL (mean 129 weeks), there was a mean loss of 6.7 letters (p < 0.001) BCVA and a mean gain of 24 µm (p < 0.001) CRT. AFL loading resulted in a mean improvement of 0.7 letters (p = 0.28) BCVA and 55 µm (p < 0.001) CRT. At final follow-up following AFL PRN therapy (mean 85 weeks), there was a mean loss of 8.9 letters (p < 0.001) BCVA and a mean gain of 12 µm (p < 0.05) CRT. CONCLUSION: AFL loading resulted in a significant anatomical improvement but no significant change in visual acuity. However, the benefits of switching were gradually lost over time with AFL PRN dosing despite an increased injection rate when compared with RBZ PRN treatment. TRIAL REGISTRATION: Not applicable.

Correction to: The Aging Urban Brain: Analyzing Outdoor Physical Activity Using the Emotiv Affectiv Suite in Older People.

Please note that the legend to Fig. 1 has been modified since this article was originally published, and also that in Tables 2, 3 and 4, R[2] was corrected to (the now correct) R squared.

The Aging Urban Brain: Analyzing Outdoor Physical Activity Using the Emotiv Affectiv Suite in Older People.

This research directly assesses older people's neural activation in response to a changing urban environment while walking, as measured by electroencephalography (EEG). The study builds on previous research that shows changes in cortical activity while moving through different urban settings. The current study extends this methodology to explore previously unstudied outcomes in older people aged 65 years or more (n = 95). Participants were recruited to walk one of six scenarios pairing urban busy (a commercial street with traffic), urban quiet (a residential street) and urban green (a public park) spaces in a counterbalanced design, wearing a mobile Emotiv EEG headset to record real-time neural responses to place. Each walk lasted around 15 min and was undertaken at the pace of the participant. We report on the outputs for these responses derived from the Emotiv Affectiv Suite software, which creates emotional parameters ('excitement', 'frustration', 'engagement' and 'meditation') with a real-time value assigned to them. The six walking scenarios were compared using a form of high dimensional correlated component regression (CCR) on difference data, capturing the change between one setting and another. The results showed that levels of 'engagement' were higher in the urban green space compared to those of the urban busy and urban quiet spaces, whereas levels of 'excitement' were higher in the urban busy environment compared with those of the urban green space and quiet urban space. In both cases, this effect is shown regardless of the order of exposure to these different environments. These results suggest that there are neural signatures associated with the experience of different urban spaces which may reflect the older age of the sample as well as the condition of the spaces themselves. The urban green space appears to have a restorative effect on this group of older adults.

Establishing and sustaining health observatories serving urbanized populations around the world: scoping study and survey.

BACKGROUND: The 'health observatory' model has successfully proliferated across several world regions, this study being conducted to define the geographical and physical bases and main functions of health observatories serving largely urbanized populations and the support needed for set-up and sustainability. METHODS: A scoping study of literature and observatory websites was undertaken to identify health observatories, main functions, year established and publications, followed by a self-completion survey to further investigate these characteristics, define the help observatories would have liked at set-up and later on, and how such help might effectively be accessed. RESULTS: Of 69 health observatories contacted, 27 (39%) mainly established since 2000 completed the survey. Most responding observatories had a sub-national/regional or sub-regional/local geographical base and no one type of physical or organizational base predominated. Nearly all observatories undertook preparation of population-based health reports and intelligence, data analysis and interpretation services, and a primary commitment to working with local/regional partners to support evidence-based decision-making. Most prioritized help with deciding and defining the scope of the observatory, estimating the core resources required for establishing/developing it, addressing sustainability issues, identifying knowledge, skills and skill-mix required to undertake the health intelligence/analytic functions, accessing data/IT expertise and developing training and capacity-building programmes. The preferred means of accessing this support was a virtual network(s) of experts on particular topics to support mutual learning and toolboxes developed for specific observatory functions. CONCLUSIONS: Although the health observatory as an organizational model is maturing, the learning derived from sharing structured guidance and support is regarded as invaluable.

The urban brain: analysing outdoor physical activity with mobile EEG.

BACKGROUND: Researchers in environmental psychology, health studies and urban design are interested in the relationship between the environment, behaviour settings and emotions. In particular, happiness, or the presence of positive emotional mindsets, broadens an individual's thought-action repertoire with positive benefits to physical and intellectual activities, and to social and psychological resources. This occurs through play, exploration or similar activities. In addition, a body of restorative literature focuses on the potential benefits to emotional recovery from stress offered by green space and 'soft fascination'. However, access to the cortical correlates of emotional states of a person actively engaged within an environment has not been possible until recently. This study investigates the use of mobile electroencephalography (EEG) as a method to record and analyse the emotional experience of a group of walkers in three types of urban environment including a green space setting. METHODS: Using Emotiv EPOC, a low-cost mobile EEG recorder, participants took part in a 25 min walk through three different areas of Edinburgh. The areas (of approximately equal length) were labelled zone 1 (urban shopping street), zone 2 (path through green space) and zone 3 (street in a busy commercial district). The equipment provided continuous recordings from five channels, labelled excitement (short-term), frustration, engagement, long-term excitement (or arousal) and meditation. RESULTS: A new form of high-dimensional correlated component logistic regression analysis showed evidence of lower frustration, engagement and arousal, and higher meditation when moving into the green space zone; and higher engagement when moving out of it. CONCLUSIONS: Systematic differences in EEG recordings were found between three urban areas in line with restoration theory. This has implications for promoting urban green space as a mood-enhancing environment for walking or for other forms of physical or reflective activity.

Do changes to the local street environment alter behaviour and quality of life of older adults? The 'DIY Streets' intervention.

BACKGROUND: The burden of ill-health due to inactivity has recently been highlighted. Better studies on environments that support physical activity are called for, including longitudinal studies of environmental interventions. A programme of residential street improvements in the UK (Sustrans 'DIY Streets') allowed a rare opportunity for a prospective, longitudinal study of the effect of such changes on older adults' activities, health and quality of life. METHODS: Pre-post, cross-sectional surveys were carried out in locations across England, Wales and Scotland; participants were aged 65+ living in intervention or comparison streets. A questionnaire covered health and quality of life, frequency of outdoor trips, time outdoors in different activities and a 38-item scale on neighbourhood open space. A cohort study explored changes in self-report activity and well-being postintervention. Activity levels were also measured by accelerometer and accompanying diary records. RESULTS: The cross-sectional surveys showed outdoor activity predicted by having a clean, nuisance-free local park, attractive, barrier-free routes to it and other natural environments nearby. Being able to park one's car outside the house also predicted time outdoors. The environmental changes had an impact on perceptions of street walkability and safety at night, but not on overall activity levels, health or quality of life. Participants' moderate-to-vigorous activity levels rarely met UK health recommendations. CONCLUSIONS: Our study contributes to methodology in a longitudinal, pre-post design and points to factors in the built environment that support active ageing. We include an example of knowledge exchange guidance on age-friendly built environments for policy-makers and planners.

Decisional answer tree analysis of exudative age-related macular degeneration treatment outcomes.

The use of intravitreal ranibizumab in exudative age-related macular degeneration (eAMD) has become commonplace. We aim to investigate the early predictors of this treatment outcome. Seventy-one treatment-naive eyes of 71 patients with eAMD of all lesion subtypes who received intravitreal ranibizumab treatment and completed 12 months of follow-up were included. All patients were loaded with three injections of ranibizumab at monthly intervals. Further injections were given if clinically indicated based on logMAR best-corrected visual acuity (BCVA) and optical coherence tomography findings. Casenotes of eligible patients were reviewed retrospectively. The main outcome measure was logMAR BCVA change at month 12. The mean number of injections given over 12 months was 5.4 ± 1.9. A total of 88.7 % of the patients achieved visual stabilisation (loss of <15 letters) and 15.0 % achieved visual improvement (gain of ≥15 letters). The mean letter change at 12 months was +0.3 letters. Regression analysis showed that baseline BCVA and letter change at month 3 predicted visual acuity outcome at month 12 (baseline BCVA: t = 6.97, p < 0.001; letter change: t = 5.84, p < 0.01) but age, gender and eAMD in the fellow eye were not predictive. Finally, a decisional answer tree model demonstrated that letter change at month 3 was a strong predictor of visual outcome at month 12 with an overall accuracy of 69 %. We found that letter change from baseline at month 3 was strongly predictive of visual outcome at month 12.

Development of the Scottish Walkability Assessment Tool (SWAT).

The Scottish Walkability Assessment Tool (SWAT) was designed to objectively record aspects of the physical environment believed to be related to walking in urban Scotland. Reliability was assessed by three pairs of trained raters auditing 30 street segments on two occasions. Eighteen items were reliably audited and displayed adequate environmental variability, 25 items proved unreliable, and 69 items lacked adequate environmental variability. The large number of items that lacked environmental variability indicates a relatively uniform environment in terms of characteristics, which the literature indicates might be used to differentiate walkability; however, the 18 reliable items can potentially be used to differentiate walkability.

Enhancing Health Through Access to Nature: How Effective are Interventions in Woodlands in Deprived Urban Communities? A Quasi-experimental Study in Scotland, UK.

High prevalence of poor mental health is a major public health problem. Natural environments may contribute to mitigating stress and enhancing health. However, there is little evidence on whether community-level interventions intended to increase exposure to natural environments can improve mental health and related behaviours. In the first study of its kind, we evaluated whether the implementation of a programme designed to improve the quality of, and access to, local woodlands in deprived communities in Scotland, UK, was associated with lower perceived stress or other health-related outcomes, using a controlled, repeat cross-sectional design with a nested prospective cohort. Interventions included physical changes to the woodlands and community engagement activities within the woodlands, with data collected at baseline (2013) and post-intervention (2014 and 2015). The interventions were, unexpectedly, associated with increased perceived stress compared to control sites. However, we observed significantly greater increases in stress for those living >500 m from intervention sites. Visits to nearby nature (woods and other green space) increased overall, and moderate physical activity levels also increased. In the intervention communities, those who visited natural environments showed smaller increases in stress than those who did not; there was also some evidence of increased nature connectedness and social cohesion. The intervention costs were modest but there were no significant changes in quality of life on which to base cost-effectiveness. Findings suggest factors not captured in the study may have contributed to the perceived stress patterns found. Wider community engagement and longer post-intervention follow-up may be needed to achieve significant health benefits from woodland interventions such as those described here. The study points to the challenges in evidencing the effectiveness of green space and forestry interventions to enhance health in urban environments, but also to potential benefits from more integrated approaches across health and landscape planning and management practice.

Evaluation of quality of life and priorities of patients with glaucoma.

PURPOSE: To investigate the quality of life and priorities of patients with glaucoma. METHODS: Patients diagnosed with glaucoma and no other ocular comorbidity were consecutively recruited. Clinical information was collected. Participants were asked to complete three questionnaires: EuroQuol (EQ-5D), time tradeoff (TTO), and choice-based conjoint analysis. The latter used five-attribute outcomes: (1) reading and seeing detail, (2) peripheral vision, (3) darkness and glare, (4) household chores, and (5) outdoor mobility. Visual field loss was estimated by using binocular integrated visual fields (IVFs). RESULTS: Of 84 patients invited to participate, 72 were enrolled in the study. The conjoint utilities showed that the two main priorities were "reading and seeing detail" and "outdoor mobility." This rank order was stable across all segmentations of the data by demographic or visual state. However, the relative emphasis of these priorities changed with increasing visual field loss, with concerns for central vision increasing, whereas those for outdoor mobility decreased. Two subgroups of patients with differing priorities on the two main attributes were identified. Only 17% of patients (those with poorer visual acuity) were prepared to consider TTO. A principal component analysis revealed relatively independent components (i.e., low correlations) between the three different methodologies for assessing quality of life. CONCLUSIONS: Assessments of quality of life using different methodologies have been shown to produce different outcomes with low intercorrelations between them. Only a minority of patients were prepared to trade time for a return to normal vision. Conjoint analysis showed two subgroups with different priorities. Severity of glaucoma influenced the relative importance of priorities.

What happens to intraocular pressure at high altitude?

PURPOSE: To investigate changes of intraocular pressure on ascent to high altitude. METHODS: The Apex 2 medical research expedition provided the opportunity to measure intraocular pressure (IOP) and central corneal thickness (CCT) in 76 healthy lowlanders. They all arrived in La Paz, Bolivia (altitude, 3700 m), where they spent 4 days before being driven more than 2 hours to the Cosmic Physics Laboratory at Chacaltaya (5200 m) where they stayed for 7 days. IOP and CCT were measured with a hand-held tonometer and ultrasound pachymetry on the first, third, and seventh days at 5200 m. Pre- and postexpedition CCT and postexpedition IOP readings at sea-level were also measured. RESULTS: IOP increased significantly from baseline after acute exposure to altitude before returning to baseline with time. IOP at baseline, change in IOP from baseline, and IOP at altitude did not predict symptoms of acute mountain sickness (AMS) or development of high-altitude retinopathy (HAR). CONCLUSIONS: Acute exposure to altitude caused a statistically significant but clinically insignificant increase in IOP. This finding may be partially explained by the change in CCT. IOP returned to baseline levels and possibly lower with prolonged exposure to altitude. Changes in IOP at altitude are not predictive of symptoms of acute mountain sickness (AMS) or development of high-altitude retinopathy (HAR).

Corneal thickness at high altitude.

PURPOSE: The eye, like other organs, is affected by the hypobaric hypoxia of high altitude. Corneal swelling is known to occur under hypoxic conditions at sea level, for instance when wearing contact lenses. The aim of this study was to measure central corneal thickness (CCT) in lowlanders ascending to altitude. METHODS: The Apex 2 medical research expedition provided the opportunity to measure CCT in 63 healthy lowlanders. The subjects arrived in La Paz, Bolivia (3700 m), where they spent 4 days acclimatizing before being driven over 2 hours to the Cosmic Physics Laboratory at Chacaltaya (5200 m), where they stayed for 7 days. CCT was measured in the early afternoon by using ultrasound pachymetry on the first, third, and seventh day at 5200 m and before and after the expedition at sea level. RESULTS: Mean CCT increased significantly from 543 microm at sea level to 561 microm on the first day at 5200 m (P < 0.001). This continued to increase to 563 microm on the third day and 571 microm on the seventh day but returned to 541 microm after descent to sea level. CONCLUSIONS: This study showed that altitude caused a significant increase in CCT in a large group of healthy lowlanders with normal corneas. This finding confirms the results of previous studies and is likely to be caused by endothelial dysfunction causing stromal swelling. This could potentially cause visual problems for high-altitude mountaineers among whom refractive surgery is popular.

Coping with Stress in Deprived Urban Neighborhoods: What Is the Role of Green Space According to Life Stage?

This study follows previous research showing how green space quantity and contact with nature (via access to gardens/allotments) helps mitigate stress in people living in deprived urban environments (Ward Thompson et al., 2016). However, little is known about how these environments aid stress mitigation nor how stress levels vary in a population experiencing higher than average stress. This study used Latent Class Analysis (LCA) to, first, identify latent health clusters in the same population (n = 406) and, second, to relate health cluster membership to variables of interest, including four hypothetical stress coping scenarios. Results showed a three-cluster model best fit the data, with membership to health clusters differentiated by age, perceived stress, general health, and subjective well-being. The clusters were labeled by the primary health outcome (i.e., perceived stress) and age group (1) Low-stress Youth characterized by ages 16-24; (2) Low-stress Seniors characterized by ages 65+ and (3) High-stress Mid-Age characterized by ages 25-44. Next, LCA identified that health membership was significantly related to four hypothetical stress coping scenarios set in people's current residential context: "staying at home" and three scenarios set outwith the home, "seeking peace and quiet," "going for a walk" or "seeking company." Stress coping in Low stress Youth is characterized by "seeking company" and "going for a walk"; stress coping in Low-stress Seniors and High stress Mid-Age is characterized by "staying at home." Finally, LCA identified significant relationships between health cluster membership and a range of demographic, other individual and environmental variables including access to, use of and perceptions of local green space. Our study found that the opportunities in the immediate neighborhood for stress reduction vary by age. Stress coping in youth is likely supported by being social and keeping physically active outdoors, including local green space visits. By contrast, local green space appears not to support stress regulation in young-middle aged and older adults, who choose to stay at home. We conclude that it is important to understand the complexities of stress management and the opportunities offered by local green space for stress mitigation by age and other demographic variables, such as gender.

The Influence of Optical Coherence Tomography Measurements of Retinal Nerve Fiber Layer on Decision-Making in Glaucoma Diagnosis.

PURPOSE: To quantify the influence of spectral domain optical coherence tomography (SDOCT) on decision-making in patients with suspected glaucoma. METHODS: A prospective cross-sectional study involving 40 eyes of 20 patients referred by community optometrists due to suspected glaucoma. All patients had disc photographs and standard automated perimetry (SAP), and results were presented to 13 ophthalmologists who estimated pre-test probability of glaucoma (0-100%) for a total of 520 observations. Ophthalmologists were then permitted to modify probabilities of disease based on SDOCT retinal nerve fiber layer (RNFL) measurements (post-test probability). The effect of information from SDOCT on decision to treat, monitor, or discharge was assessed. Agreement among graders was assessed using intraclass correlation coefficients (ICC) and correlated component regression (CCR) was used to identify variables influencing management decisions. RESULTS: Patients had an average age of 69.0 ± 10.1 years, SAP mean deviation of 2.71 ± 3.13 dB, and RNFL thickness of 86.2 ± 16.7 µm. Average pre-test probability of glaucoma was 37.0 ± 33.6% with SDOCT resulting in a 13.3 ± 18.1% change in estimated probability. Incorporating information from SDOCT improved agreement regarding probability of glaucoma (ICC = 0.50 (95% CI 0.38 to 0.64) without SDOCT versus 0.64 (95% CI 0.52 to 0.76) with SDOCT). SDOCT led to a change from decision to "treat or monitor" to "discharge" in 22 of 520 cases and a change from "discharge" to "treat or monitor" in 11 of 520 cases. Pre-test probability and RNFL thickness were predictors of post-test probability of glaucoma, contributing 69 and 31% of the variance in post-test probability, respectively. CONCLUSIONS: Information from SDOCT altered estimated probability of glaucoma and improved agreement among clinicians in those suspected of having the disease.

Seasonal Differences in Light Exposure and the Associations With Health and Well-Being in Older Adults: An Exploratory Study.

OBJECTIVE: This article reports summer verses winter seasonal variations across a suite of blue light, illuminance levels and health and well-being indicators. BACKGROUND: The quality of lighting in care homes has been assessed previously, yet seasonal comparisons and the associations with sleep quality are limited. This exploratory study investigates light exposure in two seasons to determine the changes over time and the associations with health and well-being. METHODS: In a repeated measures design, 16 older people (aged 72-99 years) living in a care home had their personal light exposure and sleep/wake patterns monitored for 4 days. Cognitive ability, mental well-being, daytime physical activity, and visual function were assessed. Mean light levels at preset times across the day, duration in light exposure over 1,000 lux, and sleep parameters were computed. Statistical investigations included correlations exploring associations and paired means tests to detect the changes between seasons. RESULTS: The mean morning illuminance level in summer was 466 lux and 65 lux in winter. Duration in bright light over 1,000 lux was 46 min in summer and 3 min in winter. Light measures were significantly higher in summer. There was no statistical difference in sleep quality parameters between seasons, but there were significant difference in daytime physical activity level (i.e., this was higher in summer). CONCLUSION: The findings indicate low level of light exposures experienced in both seasons, with exposure levels being particularly low in winter. This provides new insights into the limited amount of light older people receive independent of season and the possible impacts on sleep and daytime physical activity level.

Migrants and HIV stigma: findings from the Stigma Index Study (UK).

This paper is based on data collected in 2009 for the international Stigma Index Study which measured the experiences of stigma among participants living with HIV in the UK. Data were collected using a self-completed survey questionnaire and focus group discussions. Quantitative data were analysed using SPSS, while qualitative data were subjected to thematic analysis. The Stigma Index attempts to establish a baseline for documenting the experience of stigma and discrimination by people living with HIV while also acting as an advocacy tool whose power lay in the involvement of people living with HIV in the design of study instruments and data collection. Participants were recruited through collaborations with a broad range of UK HIV support organisations. The ethics protocols used were those described in the Stigma Index guidebook. A total of 867 people living with HIV took part, of whom 276 described themselves as 'immigrants'. Most of this 'migrant' subsample (70%) was women. Nearly, all (91%) identified as heterosexual, while 9% were attracted to someone of the same sex as them. Socioeconomic deprivation was a key theme and they reported other stigmatised chronic conditions in addition to HIV. It is not possible to ascertain from the questionnaire, the migrants' countries of origin and length of stay in the UK. Control of information about HIV was critically managed, with respect to family and partners. Felt stigma increased anxieties about personal safety, particularly among men. Strategies for safeguarding against the negative impact of stigma included avoiding social gatherings, intimacy, and clinical and HIV social care settings. Most participants were unaware of policies and declarations that protected them as persons living with HIV. Specific recommendations include creating awareness about rights as enshrined in various legal frameworks that protect the right of people living with HIV, which has been reconfigured as a 'disability'.

The eye at altitude.

High altitude retinopathy (HAR) was first described in 1969 as engorgement of retinal veins with occasional papilloedema and vitreous hemorrhage. Since then various studies have attempted to define the incidence, etiology and significance of this phenomenon, usually with small numbers of subjects. Recently studies on relatively large groups of subjects in Nepal, Bolivia and Tibet have confirmed that the retinal vasculature becomes engorged and tortuous in all lowlanders ascending above 2500m. Sometimes this leads to hemorrhages, cotton wool spots and papilloedema, which is the pathological state better known as high altitude retinopathy. These studies have also shown a significant change in both corneal thickness and intraocular pressure at altitude. The retinal blood vessels are the only directly observable vascular system in the human body and also supply some of the most oxygen-demanding tissue, the photoreceptors of the retina. New techniques are being applied in both hypobaric chamber and field expeditions to observe changes in retinal function during conditions of hypobaric hypoxia. This work allows better advice to be given to lowlanders traveling to altitude either if they have pre-existing ocular conditions or if they suffer from visual problems whilst at altitude. This especially applies to the effect of altitude on refractive eye surgery and results of recent studies will be discussed so that physicians can advise their patients using the latest evidence. Retinal hypoxia at sea level accounts for the developed world's largest cause of blindness, diabetic retinopathy. The investigation of retinal response to hypobaric hypoxia in healthy subjects may open new avenues for treatment of this debilitating disease.