Framing effectiveness in impact assessment: Discourse accommodation in controversial infrastructure development

There is ongoing debate about the effectiveness of impact assessment tools, which matters both because of the threat to future practice of the tools which are frequently perceived to be ineffective, and because of the disillusionment that can ensue, and controversy generated, amongst stakeholders in a decision context where opportunities for meaningful debate have not been provided. In this article we regard debate about the meaning of effectiveness in impact assessment as an inevitable consequence of increased participation in environmental decision-making, and therefore frame effectiveness based on an inclusive democracy role to mean the extent to which impact assessment can accommodate civil society discourse. Our aim is to investigate effectiveness based on this framing by looking at one type of impact assessment - environmental impact assessment (EIA) - in two controversial project proposals: the HS2 rail network in England; and the A4DS motorway in the Netherlands. Documentary analysis and interviews held with key civil society stakeholders have been deployed to identify discourses that were mobilised in the cases. EIA was found to be able to accommodate only one out of four discourses that were identified; for the other three it did not provide the space for the arguments that characterised opposition. The conclusion in relation to debate on framings of effectiveness is that EIA will not be considered effective by the majority of stakeholders. EIA was established to support decision-making through a better understanding of impacts, so its ineffectiveness is unsurprising when its role is perceived to be broader. However, there remains a need to map discourses in different decision contexts and to analyse the extent to which the range of discourses are accommodated throughout the decision process, and the role of impact assessment in those processes, before recommendations can be made to either improve impact assessment effectiveness, or whether it is simply perceptions of effectiveness that need to be improved

Microvascular function in non-insulin-dependent diabetes mellitus

Epidemiological studies suggest differences in the prevalence and natural history of microvascular complications between subjects with insulin dependent (IDDM) and non-insulin dependent (NIDDM) diabetes. The haemodynamic hypothesis proposes that early functional changes in the microcirculation result in the eventual development of diabetic microangiopathy. There is now a large body of experimental evidence in support of this hypothesis in patients with IDDM, with abnormalities in blood flow, capillary pressure and permeability having been demonstrated. In contrast, there have been few studies investigating microvascular function in NIDDM; however, preliminary work has identified a profound limitation in microvascular vasodilation at an early stage, while capillary pressure does not appear to be elevated. The aim of this thesis was to further investigate functional changes in the skin microcirculation in patients with NIDDM and impaired glucose tolerance (IGT). 1. Using a sensitive plethysmographic system, no difference was found in microvascular fluid permeability between patients with NIDDM and control subjects (5.3 (3.2-9.1) x 10-3 ml.min-1.100g tissue-1.mmHg-1 vs 5.4 (3.5-8.0) x 10-3 ml.min-1. 100g tissue-1 .mmHg-1 median and range; p = 0.98, Mann-Whitney). 2. In confirmation of previous studies, reduced microvascular hyperaemia in response to local heating of the skin was found (using laser Doppler fluximetry) in NIDDM patients with large vessel disease excluded (0.82 (0.42-1.41) V vs 1.40 (0.89-2.13) V control subjects; p<0.005). Limited vasodilation correlated with fasting plasma insulin (Rg =-0.63, p<0.04) but not glycaemic control. Microvascular hyperaemia increased after one year of improved glycaemic control in recently diagnosed patients (1.20 (0.51-3.93) V vs 0.97 (0.22-2.17) V at baseline; p<0.05). In hypertensive NIDDM patients, there was no further reduction in microvascular vasodilation (1.05 (0.70-1.42) V vs 1.04 (0.79-1.63) V normotensive NIDDM, p = 0.82), although there was an increase in calculated resistance to blood flow (127.2 (87.5-181.3) mmHg.V-1 vs 84.7 (61.9-123.0) mmHg.V-1 normotensive patients, p < 0.02). 3. Reduced microvascular hyperaemia was found in subjects with IGT (1.01 (0.71-1.57) V vs 1.41 (1.32-2.13) V control subjects, p < 0.001), and also insulin resistant patients with acromegaly (0.96 (0.56-1.70) V vs 1.46 (1.24-2.13) V control subjects, p < 0,05). In subjects with IGT, limited vasodilation was found to correlate with fasting plasma insulin (Rg = -0.7; p < 0.001) and insulin sensitivity (Rs = 0.52; p < 0.02), but not with β-cell function, plasma glucose or serum lipid concentrations. 4. Using iontophoresis and laser Doppler fluximetry, defective endothelium-dependent vasodilation was found in subjects with IGT (518 (410-905) AU-min-l vs 1236 (875-1588) AU.min-1 control subjects, median and range; p < 0.003). In contrast there was no significant difference in myogenic (683 (301-1175) AU.min-1 vs 898 (303-998) AU.min-1 control subjects; p = 0.5) or neurogenic vasodilation ( 61 (31-109) AU vs 46 (37-146) control subjects; p = 0.8). 5. No differences in skin capillary density were found between patients with NIDDM, subjects with IGT and control subjects under basal conditions (112 (71-144) caps.mm-2 vs 107 (76-140) caps.mm-2 vs 112 (76-138) caps.mm-2 respectively; p= 0.9, Kruskal Wallis), or after venous occlusion (122 (87-157) caps.mm-2 vs 121 (90-143) caps.mm-2 IGT vs 123 (81-147) caps.mm-2; p= 0.9). In light of the above results, a unifying hypothesis has been proposed to explain the differences in epidemiology and pathophysiology of microvascular disease between IDDM and NIDDM

Vignettes:an innovative qualitative data collection tool in Medical Education research

This article describes how to make use of exemplar vignettes in qualitative medial education research. Vignettes are particularly useful in prompting discussion with participants, when using real-life case examples may breach confidentiality. As such, using vignettes allows researchers to gain insight into participants’ thinking in an ethically sensitive way.</p

Measuring differential attainment:a longitudinal analysis of assessment results for 1,512 medical students at four Scottish medical schools

Funding The Scottish Medical Education Research Consortium (SMERC) provided funding to allow the research project to take place. The funding was used to pay for administrator and researcher time to collate and analyse the data. The funder had no direct input into the analyses chosen or the reporting of the results. The researchers were independent from the funder, and all researchers had access to the data and can take responsibility for the integrity of the data and the accuracy of the data analysis.Peer reviewedPublisher PD

Learning Vision-Based Bipedal Locomotion for Challenging Terrain

Reinforcement learning (RL) for bipedal locomotion has recently demonstrated robust gaits over moderate terrains using only proprioceptive sensing. However, such blind controllers will fail in environments where robots must anticipate and adapt to local terrain, which requires visual perception. In this paper, we propose a fully-learned system that allows bipedal robots to react to local terrain while maintaining commanded travel speed and direction. Our approach first trains a controller in simulation using a heightmap expressed in the robot's local frame. Next, data is collected in simulation to train a heightmap predictor, whose input is the history of depth images and robot states. We demonstrate that with appropriate domain randomization, this approach allows for successful sim-to-real transfer with no explicit pose estimation and no fine-tuning using real-world data. To the best of our knowledge, this is the first example of sim-to-real learning for vision-based bipedal locomotion over challenging terrains

Medical student assessments-frequency of radiological images used : a national study

Assessments are a key part of life for medical students at University. We know there is variation in these assessments across Universities. The aims of this study were to expatiate summative assessments in Scottish Medical Schools and to examine how frequently radiological images feature in them. All Scottish medical schools were invited to participate in the study. Data on objective structured clinical examinations (OSCEs; 5 years) and written assessments (3 years) were retrospectively collected for each university and results were collated. Each University was randomly assigned a letter from A to E and anonymised for data presentation. 10,534 multiple choice questions (MCQ) and 1083 OSCE stations were included in this study. There was wide variation in the number, type and timing of assessments across Scottish medical schools. There were highly significant differences in the number of OSCE stations and the number of MCQs set over the study period ( <0.0001). Radiological images were used on average 0.6 times (range 0-1.1) in each OSCE examination and 2.4 times (range 0.1-3.7) for written assessments. In this detailed study, we demonstrated significant differences in medical student assessments across Scottish Universities. Given the importance of Radiology in modern medicine, the frequency and differences in which radiological images were used in assessments across Universities should be addressed. This is the first national longitudinal study to quantify the role of radiological images in summative Medical Student Assessments. Great variability exists in the extent and how (clinical versus written assessments) radiological images are used to assess Scottish medical students. Radiological images are used infrequently in clinical assessments, but are present in every written assessment. These findings could help inform medical schools and academic radiologists as they prepare medical students for the imminent unified medical licensing examination, where Clinical Imaging is a subject with one of the highest number of associated conditions examinable. [Abstract copyright: © 2020 The Authors. Published by the British Institute of Radiology.]Publisher PDFPeer reviewe

Metabolic, inflammatory and haemostatic effects of a low-dose continuous combined HRT in women with type 2 diabetes: potentially safer with respect to vascular risk?

BACKGROUND Conventional hormone replacement therapy (HRT) containing conjugated equine oestrogen (CEE) and medroxyprogesterone acetate (MPA) increases triglyceride, C- reactive protein (CRP) and coagulation Factor VII concentrations, potentially explaining their increased coronary heart disease (CHD) and stroke risk. OBJECTIVE To assess the metabolic effects of a continuous combined HRT containing 1 mg oestradiol and 0.5 mg norethisterone or matching placebo. DESIGN Double-blind, randomized placebo-controlled trial. PATIENTS Fifty women with type 2 diabetes. MEASUREMENTS Classical and novel risk factors for vascular disease. RESULTS Triglyceride concentration was not altered (P = 0.31, change in active arm relative to placebo) and low-density lipoprotein (LDL) cholesterol concentration declined 13% (P = 0.018). IL-6 concentration (mean difference -1.42 pg/ml, 95% CI: -2.55 to - 0.29 IU/dl, P = 0.015), Factor VII (-32 IU/dl, -43 to -21 IU/l, P lt 0.001) and tissue plasminogen activator antigen (by 13%, P = 0.005) concentrations fell, but CRP was not significantly altered (P = 0.62). Fasting glucose (P = 0.026) also declined significantly, but there are no significant effects on HBA1c, Factor IX or APC resistance. CONCLUSIONS HRT containing 1 mg oestradiol and 0.5 mg norethisterone may avoid the adverse metabolic effects potentially implicated in the elevated CHD and stroke risk induced by conventional higher dose HRT. This type of preparation may therefore be more suitable than conventional HRT for women at elevated CHD risk such as those with type 2 diabetes. Large randomized controlled trials of such low dose preparations, powered for cardiovascular end points, are now needed

Stage-Specific Inhibition of MHC Class I Presentation by the Epstein-Barr Virus BNLF2a Protein during Virus Lytic Cycle

gamma-herpesvirus Epstein-Barr virus (EBV) persists for life in infected individuals despite the presence of a strong immune response. During the lytic cycle of EBV many viral proteins are expressed, potentially allowing virally infected cells to be recognized and eliminated by CD8+ T cells. We have recently identified an immune evasion protein encoded by EBV, BNLF2a, which is expressed in early phase lytic replication and inhibits peptide- and ATP-binding functions of the transporter associated with antigen processing. Ectopic expression of BNLF2a causes decreased surface MHC class I expression and inhibits the presentation of indicator antigens to CD8+ T cells. Here we sought to examine the influence of BNLF2a when expressed naturally during EBV lytic replication. We generated a BNLF2a-deleted recombinant EBV (ΔBNLF2a) and compared the ability of ΔBNLF2a and wild-type EBV-transformed B cell lines to be recognized by CD8+ T cell clones specific for EBV-encoded immediate early, early and late lytic antigens. Epitopes derived from immediate early and early expressed proteins were better recognized when presented by ΔBNLF2a transformed cells compared to wild-type virus transformants. However, recognition of late antigens by CD8+ T cells remained equally poor when presented by both wild-type and ΔBNLF2a cell targets. Analysis of BNLF2a and target protein expression kinetics showed that although BNLF2a is expressed during early phase replication, it is expressed at a time when there is an upregulation of immediate early proteins and initiation of early protein synthesis. Interestingly, BNLF2a protein expression was found to be lost by late lytic cycle yet ΔBNLF2a-transformed cells in late stage replication downregulated surface MHC class I to a similar extent as wild-type EBV-transformed cells. These data show that BNLF2a-mediated expression is stage-specific, affecting presentation of immediate early and early proteins, and that other evasion mechanisms operate later in the lytic cycle