Peter Aspinall

Green Space and Stress: Evidence from Cortisol Measures in Deprived Urban Communities

Contact with green space in the environment has been associated with mental health benefits, but the mechanism underpinning this association is not clear. This study extends an earlier exploratory study showing that more green space in deprived urban neighbourhoods in Scotland is linked to lower levels of perceived stress and improved physiological stress as measured by diurnal patterns of cortisol secretion. Salivary cortisol concentrations were measured at 3, 6 and 9 h post awakening over two consecutive weekdays, together with measures of perceived stress. Participants (n = 106) were men and women not in work aged between 35–55 years, resident in socially disadvantaged districts from the same Scottish, UK, urban context as the earlier study. Results from linear regression analyses showed a significant and negative relationship between higher green space levels and stress levels, indicating living in areas with a higher percentage of green space is associated with lower stress, confirming the earlier study findings. This study further extends the findings by showing significant gender differences in stress patterns by levels of green space, with women in lower green space areas showing higher levels of stress. A significant interaction effect between gender and percentage green space on mean cortisol concentrations showed a positive effect of higher green space in relation to cortisol measures in women, but not in men. Higher levels of neighbourhood green space were associated with healthier mean cortisol levels in women whilst also attenuating higher cortisol levels in men. We conclude that higher levels of green space in residential neighbourhoods, for this deprived urban population of middle-aged men and women not in work, are linked with lower perceived stress and a steeper (healthier) diurnal cortisol decline. However, overall patterns and levels of cortisol secretion in men and women were differentially related to neighbourhood green space and warrant further investigation.

Patients' perception of visual impairment in glaucoma: a pilot study.

BACKGROUND/AIMS There is a paucity of useful information on the level of visual disability suffered by glaucoma patients. The aims of this study were to determine and rank the frequency of self reported visual disability in daily tasks performed by glaucoma patients; to examine the interrelation between disabilities using factor analysis; to study the relation between perceived visual difficulty and a measure of the severity of visual field loss; to develop a glaucoma specific subgroup of questions; and examine the validity and reliability of this subgroup of questions. METHODS 63 glaucoma patients completed a questionnaire containing 62 questions covering 10 broad aspects of daily life activities using a five point answer scale. Patients were classified into three groups as having mild, moderate, and severe field loss on the basis of the perimetric results. The relation between a measure of the severity of visual field loss and subjective visual disability in the three groups was examined. RESULTS Using factor analysis, the most frequently reported problems were grouped into the following four categories: outdoor mobility, glare and lighting conditions and activities demanding functional peripheral vision, household tasks, and personal care. These four factors accounted for 72% of the variability in the patients’ questionnaire responses. With increasing severity of binocular visual field loss there was an increase in the number of self reported visual problems. A loss of confidence in performing some routine daily tasks tended to precede self reported specific visual disabilities. The factor “glare and lighting and activities demanding functional peripheral vision” was found to have a significant relation with a measure of visual field loss and was used to create a glaucoma specific subset of questions. Cronbach’s α showed a high degree of reliability and internal consistency (α =0.96) in this glaucoma specific subset of questions. Furthermore, the validity of this new subset of questions was shown to be significant (r=0.037, p<0.05) for the correlation between a measure of the severity of binocular visual field loss and the mean score of the variables used in the glaucoma specific subgroup of questions. CONCLUSIONS Outcome measures and quality of life issues need to be addressed in glaucoma. This pilot study identified common problems encountered by patients which at the present time are not assessed in routine glaucoma care. It also identified a subgroup of questions that seems to be specific for glaucoma. Further research is required if a significant impact on the quality of life of glaucoma patients is to be achieved.

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 individuals 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.

The restorative benefits of walking in urban and rural settings in adults with good and poor mental health.

People differ in their potential for psychological restoration but there is little evidence on the role of varying mental health state or settings in the process. This paper reports two quasi-experiments which compare the restorative benefits of walking in urban and rural settings in two groups of adults with good and poor mental health. Two aspects of restoration are examined, firstly mood, the other using personal project techniques (Little, 1983) to capture an under-explored aspect of cognitive restoration through reflection on everyday life tasks. Results are consistent with a restorative effect of landscape: the rural walk was advantageous to affective and cognitive restoration in both health groups when compared to an urban walk. However, beneficial change took place to a greater extent in the poor health group. Differential outcomes between health groups were found in the urban setting, which was most advantageous to restoration in the poor mental health group. This study extends restorative environments research by showing that the amount of change and context for restoration can differ amongst adults with variable mental health.

Is cataract surgery justified in patients with age related macular degeneration? A visual function and quality of life assessment

AIMS To determine whether patients with age related macular degeneration (ARMD) benefit from cataract surgery in terms of visual function and quality of life measures, and to assess the impact of surgery on the progression of ARMD. METHODS A prospective study was carried out of patients with and without ARMD undergoing cataract surgery. Data were collected from 187 patients at the Princess Alexandra Eye Pavilion, Edinburgh and the Oxford Eye Hospital, Oxford. The patients were divided into three groups: (1) a control group with ARMD and no surgery (n=41), (2) a study group of patients with ARMD who underwent cataract surgery (n=90), and (3) a second control group of patients without ocular comorbidities who underwent cataract surgery (n=56). Visual function and quality of life assessments were carried out at baseline and 3–5 months after baseline or surgery. RESULTS There were significant improvements both in terms of quality of life and visual function measures in the study group. Benefits were greater in patients with moderate cataract irrespective of the degree of ARMD. No increased incidence in progression to the “wet” form of ARMD was found. Improvements in quality of life measures and visual function were more pronounced in patients with no ocular comorbidities. CONCLUSIONS Patients with mild and moderate degrees of ARMD do benefit from cataract surgery and the benefits are greater in patients with moderate degrees of lens opacity. Longer follow up is required to assess the risk of increased ARMD progression.

Cataract surgery in patients with age-related macular degeneration One-year outcomes

Purpose: To determine whether patients with age‐related macular degeneration (ARMD) benefit from cataract surgery and to assess the risk of progression of preexisting maculopathy 4 and 12 months postoperatively. Setting: Princess Alexandra Eye Pavilion, Royal Infirmary of Edinburgh, Edinburgh, Scotland. Methods: Two groups of patients were evaluated prospectively. The study group comprised patients with ARMD scheduled to have cataract surgery (n = 40). The control group comprised patients with ARMD not having cataract surgery (n = 43). Patients were assessed at baseline (preoperatively) and 4 and 12 months postoperatively. Assessment included visual function tests and quality of life (QoL) measures. The mean values for each item tested were obtained for each group at each visit, and comparisons between visits were done using the Wilcoxon signed rank test. Results: There were significant benefits of cataract surgery in terms of visual function and QoL measures at 4 and 12 months. There was no increased risk of progression of maculopathy in the study group. There were no significant differences in the items tested in the control group. Conclusions: One year postoperatively, QoL benefits were maintained in the study group and there was no increased risk of progression of maculopathy in patients with mild and moderate degrees of ARMD. Larger numbers of patients must be assessed prospectively for longer periods to determine the relative risk of progression of different stages of ARMD after cataract surgery.

Safety and efficacy of a dexamethasone anterior segment drug delivery system in patients after phacoemulsification

Purpose: To compare the safety and efficacy of the Surodex® dexamethasone anterior segment drug delivery system (Oculex Pharmaceuticals, Inc.) and dexamethasone 0.1% eyedrops (Maxidex®) in patients with inflammation after cataract surgery. Setting: Cataract Service, Department of Ophthalmology, Lothian University Hospitals, Edinburgh, United Kingdom. Methods: This comparative single‐masked parallel‐group study comprised 1 eye of 19 patients having phacoemulsification cataract extraction and posterior chamber intraocular lens implantation. The Surodex group had the dexamethasone drug delivery system inserted into the anterior chamber (AC) angle during surgery and was treated with saline eyedrops (Isopto Plain®) for 4 weeks. The control group had no drug delivery system or a placebo inserted at surgery and were treated with dexamethasone 0.1% eyedrops for 4 weeks. A Kowa FM‐500 laser flare meter was used to objectively measure AC flare, the main outcome measure. Slitlamp biomicroscopy to grade AC flare and cells, intraocular pressure measurement, and corneal endothelial specular microscopy, performed up to 60 days after surgery, were the secondary outcome measures. The Surodex group had safety follow‐ups after completion of the initial study period. Results: Both groups had a steady increase in laser flare meter readings postoperatively. The readings peaked at 3 days in the control group and at 7 days in the Surodex group. This was followed by a gradual decline toward baseline values up to 28 days, after which the values remained at a similar level to 60 days in both groups. There were no significant differences in flare meter readings between the groups throughout the study. There were also no significant between‐group differences in subjective assessment of intraocular inflammation and in impact on corneal endothelial cell count (P = .67). Surodex remnants persisted up to a mean of 22.0 months ± 2.5 (SD) postoperatively in 6 eyes (54%). Neither group had a severe adverse event. Conclusion: Surodex appeared to be as effective as dexamethasone 0.1% eyedrops in controlling intraocular inflammation after cataract surgery by phacoemulsification, and both methods had a similar safety profile.

Sensitivity and specificity of frequency-doubling technology, tendency-oriented perimetry, and Humphrey Swedish interactive threshold algorithm-fast perimetry in a glaucoma practice.

PURPOSE To evaluate the sensitivity and specificity of the screening mode of the Humphrey-Welch Allyn frequency-doubling technology (FDT), Octopus tendency-oriented perimetry (TOP), and the Humphrey Swedish Interactive Threshold Algorithm (SITA)-fast (HSF) in patients with glaucoma. DESIGN A comparative consecutive case series. METHODS This was a prospective study which took place in the glaucoma unit of an academic department of ophthalmology. One eye of 70 consecutive glaucoma patients and 28 age-matched normal subjects was studied. Eyes were examined with the program C-20 of FDT, G1-TOP, and 24-2 HSF in one visit and in random order. The gold standard for glaucoma was presence of a typical glaucomatous optic disk appearance on stereoscopic examination, which was judged by a glaucoma expert. The sensitivity and specificity, positive and negative predictive value, and receiver operating characteristic (ROC) curves of two algorithms for the FDT screening test, two algorithms for TOP, and three algorithms for HSF, as defined before the start of this study, were evaluated. The time required for each test was also analyzed. RESULTS Values for area under the ROC curve ranged from 82.5%-93.9%. The largest area (93.9%) under the ROC curve was obtained with the FDT criteria, defining abnormality as presence of at least one abnormal location. Mean test time was 1.08 +/- 0.28 minutes, 2.31 +/- 0.28 minutes, and 4.14 +/- 0.57 minutes for the FDT, TOP, and HSF, respectively. The difference in testing time was statistically significant (P <.0001). CONCLUSIONS The C-20 FDT, G1-TOP, and 24-2 HSF appear to be useful tools to diagnose glaucoma. The test C-20 FDT and G1-TOP take approximately 1/4 and 1/2 of the time taken by 24 to 2 HSF.

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.

“It Gets You Away From Everyday Life”: Local Woodlands and Community Use—What Makes a Difference?

This paper explores who uses woodlands near their homes, why they visit, what benefits they believe they obtain and what makes the difference between them choosing to visit or not. In the research, supported by the Forestry Commission, a multi-method, user-led approach was used, based on focus groups, questionnaire surveys and on-site observation in relation to five different communities in the central belt of Scotland. The conclusions demonstrate the overriding importance of childhood woodland visits as predictors of adult patterns of use. Proximity of woodlands is important for regular woodland users and freedom from rubbish is the physical quality people care most about. The physical qualities that make a difference as to whether people visit woodlands or not include directional signs, good information boards, variety of trees and tidiness of appearance. Perceptions of woodlands differ according to age and sex but are predominantly positive across all groups sampled: most people feel at peace in a woodland.