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Referrals for adult autism assessment to the Cambridgeshire Lifespan Autism Spectrum Service (CLASS) have increased from 430 in 2019 to 887 in 2023, with demand exceeding capacity. The team enrolled in the Royal College of Psychiatrists’ Quality Improvement (QI) Demand, Capacity and Flow (DCF) Collaborative. The agreed aim was to increase the number of diagnostic assessments by 51% per month.
Methods
Participants included the CLASS multi-disciplinary team (MDT), referrers, the provider improvement advisor and an autistic adult. Using the NHS Quality Service Improvement and Redesign (QSIR) six-step approach, a process map identified five key stages of the CLASS pathway. A project driver diagram was then used to identify change ideas in the referral, screening, pre-assessment, assessment and post-diagnostic stages.
Change ideas in the screening and assessment stages were prioritised and two Plan-Do-Study-Act (PDSA) cycles designed: PDSA 1) To reduce screening time by removing the first screening of referrals; PDSA 2) To increase the number of assessments conducted and completed in a single face-to-face appointment.
Data collected for PDSA 1 included: number of working days from date of referral to date added to waiting list and total screening time (minutes) per referral. Data were compared in a sample of 133 referrals from the two-stage screening process and 68 referrals from the one-stage process. Data collected for PDSA 2 included: average assessment time (minutes), average duration of open assessments, and the number of assessments completed within the same month. The data at Time 1 (before introducing PDSA 2) were compared with Time 2 (after PDSA 2) in a sample of 10 and nine referrals, respectively.
Results
PDSA 1) Statistical Process Control (SPC) charts show a reduction in mean working days from 160 to 30 working days. The mean screening time per referral reduced from 33 minutes to 23 minutes. PDSA 2) SPC charts show that between Time 1 and Time 2 there was (i) a reduction in clinician time in minutes per assessment (m = 236.8 to m = 210), (ii) a reduction in working days assessment remained open (m = 39.4 to m = 6.4), (iii) a reduction in number of assessments involving multiple appointments (6 of 10 to 3 of 9), (iv) an increase in the number of assessments completed in the same month (3 of 10 to 7 of 9).
Conclusion
These results show promise towards increasing DCF across the pathway, but further PDSAs (e.g., digitalising reporting, refining the post-diagnostic pathway) need to be implemented to achieve the overall aim.
Geoarchaeological research as part of the AHRC funded Living with Monuments (LwM) project investigated the upper Kennet river system across the Avebury World Heritage landscape. The results demonstrate that in the early–mid-Holocene (c. 9500–1000 bc) there was very low erosion of disturbed soils into the floodplain, with floodplain deposits confined to a naturally forming bedload fluvial deposit aggrading in a shallow channel of inter-linked deeper pools. At the time of the Neolithic monument building in the 4th–early 3rd millennium bc, the river was wide and shallow with areas of presumed braid plain. Between c. 4000 and 1000 bc, a human induced signature of soil erosion became a minor component of fluvial sedimentation in the Kennet palaeo-channel but it was small scale and localised. This strongly suggests that there is little evidence of widespread woodland removal associated with Neolithic farming and monument building, despite the evidently large timber requirements for Neolithic sites like the West Kennet palisade enclosures. Consequently, there was relatively light human disturbance of the hinterland and valley slopes over the longue durée until the later Bronze Age/Early Iron Age, with a predominance of pasture over arable land. Rather than large Neolithic monument complexes being constructed within woodland clearings, representing ancestral and sacred spaces, the substantially much more open landscape provided a suitable landscape with areas of sarsen spreads potentially easily visible. During the period c. 3000–1000 bc, the sediment load within the channel slowly increased with alluvial deposition of increasingly humic silty clays across the valley floor. However, this only represents small-scale landscape disturbance. It is from the Late Bronze Age–Early Iron Age when the anthropogenic signal of human driven alluviation becomes dominant and overtakes the bedload fluvial signal across the floodplain, with localised colluvial deposits on the floodplain margins. Subsequently, the alluvial archive describes more extensive human impact across this landscape, including the disturbance of loessic-rich soils in the catchment. The deposition of floodplain wide alluvium continues throughout the Roman, medieval, and post-medieval periods, correlating with the development of a low-flow, single channel, with alluvial sediments describing a decreasing energy in the depositional environment.
Neuropsychological criteria for mild cognitive impairment (MCI) more accurately predict progression to Alzheimer’s disease (AD) and are more strongly associated with AD biomarkers and neuroimaging profiles than ADNI criteria. However, research to date has been conducted in relatively healthy samples with few comorbidities. Given that history of traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) are risk factors for AD and common in Veterans, we compared neuropsychological, typical (Petersen/Winblad), and ADNI criteria for MCI in Vietnam-era Veterans with histories of TBI or PTSD.
Method:
267 Veterans (mean age = 69.8) from the DOD-ADNI study were evaluated for MCI using neuropsychological, typical, and ADNI criteria. Linear regressions adjusting for age and education assessed associations between MCI status and AD biomarker levels (cerebrospinal fluid [CSF] p-tau181, t-tau, and Aβ42) by diagnostic criteria. Logistic regressions adjusting for age and education assessed the effects of TBI severity and PTSD symptom severity simultaneously on MCI classification by each criteria.
Results:
Agreement between criteria was poor. Neuropsychological criteria identified more Veterans with MCI than typical or ADNI criteria, and were associated with higher CSF p-tau181 and t-tau. Typical and ADNI criteria were not associated with CSF biomarkers. PTSD symptom severity predicted MCI diagnosis by neuropsychological and ADNI criteria. History of moderate/severe TBI predicted MCI by typical and ADNI criteria.
Conclusions:
MCI diagnosis using sensitive neuropsychological criteria is more strongly associated with AD biomarkers than conventional diagnostic methods. MCI diagnostics in Veterans would benefit from incorporation of comprehensive neuropsychological methods and consideration of the impact of PTSD.
Alterations in cerebral blood flow (CBF) are associated with risk of cognitive decline and Alzheimer’s disease (AD). Although apolipoprotein E (APOE) ε4 and greater vascular risk burden have both been linked to reduced CBF in older adults, less is known about how APOE ε4 status and vascular risk may interact to influence CBF. We aimed to determine whether the effect of vascular risk on CBF varies by gene dose of APOE ε4 alleles (i.e., number of e4 alleles) in older adults without dementia.
Participants and Methods:
144 older adults without dementia from the Alzheimer’s Disease Neuroimaging Initiative (ADNI) underwent arterial spin labeling (ASL) and T1-weighted MRI, APOE genotyping, fluorodeoxyglucose positron emission tomography (FDG-PET), lumbar puncture, and blood pressure assessment. Vascular risk was assessed using pulse pressure (systolic blood pressure -diastolic blood pressure), which is thought to be a proxy for arterial stiffening. Participants were classified by number of APOE ε4 alleles (n0 alleles = 87, m allele = 46, n2 alleles = 11). CBF in six FreeSurfer-derived a priori regions of interest (ROIs) vulnerable to AD were examined: entorhinal cortex, hippocampus, inferior temporal cortex, inferior parietal cortex, rostral middle frontal gyrus, and medial orbitofrontal cortex. Linear regression models tested the interaction between categorical APOE ε4 dose (0, 1, or 2 alleles) and continuous pulse pressure on CBF in each ROI, adjusting for age, sex, cognitive diagnosis (cognitively unimpaired vs. mild cognitive impairment), antihypertensive medication use, cerebral metabolism (FDG-PET composite), reference CBF region (precentral gyrus), and AD biomarker positivity defined using the ADNI-optimized phosphorylated tau/ß-amyloid ratio cut-off of > 0.0251 pg/ml.
Results:
A significant pulse pressure X APOE ε4 dose interaction was found on CBF in the entorhinal cortex, hippocampus, and inferior parietal cortex (ps < .005). Among participants with two e4 alleles, higher pulse pressure was significantly associated with lower CBF (ps < .001). However, among participants with zero or one ε4 allele, there was no significant association between pulse pressure and CBF (ps > .234). No significant pulse pressure X APOE ε4 dose interaction was found in the inferior temporal cortex, rostral middle frontal gyrus, or medial orbitofrontal cortex (ps > .109). Results remained unchanged when additionally controlling for general vascular risk assessed via the modified Hachinski Ischemic Scale.
Conclusions:
These findings demonstrate that the cross-sectional association between pulse pressure and region-specific CBF differs by APOE ε4 dose. In particular, a detrimental effect of elevated pulse pressure on CBF in AD-vulnerable regions was found only among participants with the e4/e4 genotype. Our findings suggest that pulse pressure may play a mechanistic role in neurovascular unit dysregulation for those genetically at greater risk for AD. Given that pulse pressure is just one of many potentially modifiable vascular risk factors for AD, future studies should seek to examine how these other factors (e.g., diabetes, high cholesterol) may interact with APOE genotype to affect cerebrovascular dysfunction.
White matter hyperintensity (WMH) burden is greater, has a frontal-temporal distribution, and is associated with proxies of exposure to repetitive head impacts (RHI) in former American football players. These findings suggest that in the context of RHI, WMH might have unique etiologies that extend beyond those of vascular risk factors and normal aging processes. The objective of this study was to evaluate the correlates of WMH in former elite American football players. We examined markers of amyloid, tau, neurodegeneration, inflammation, axonal injury, and vascular health and their relationships to WMH. A group of age-matched asymptomatic men without a history of RHI was included to determine the specificity of the relationships observed in the former football players.
Participants and Methods:
240 male participants aged 45-74 (60 unexposed asymptomatic men, 60 male former college football players, 120 male former professional football players) underwent semi-structured clinical interviews, magnetic resonance imaging (structural T1, T2 FLAIR, and diffusion tensor imaging), and lumbar puncture to collect cerebrospinal fluid (CSF) biomarkers as part of the DIAGNOSE CTE Research Project. Total WMH lesion volumes (TLV) were estimated using the Lesion Prediction Algorithm from the Lesion Segmentation Toolbox. Structural equation modeling, using Full-Information Maximum Likelihood (FIML) to account for missing values, examined the associations between log-TLV and the following variables: total cortical thickness, whole-brain average fractional anisotropy (FA), CSF amyloid ß42, CSF p-tau181, CSF sTREM2 (a marker of microglial activation), CSF neurofilament light (NfL), and the modified Framingham stroke risk profile (rFSRP). Covariates included age, race, education, APOE z4 carrier status, and evaluation site. Bootstrapped 95% confidence intervals assessed statistical significance. Models were performed separately for football players (college and professional players pooled; n=180) and the unexposed men (n=60). Due to differences in sample size, estimates were compared and were considered different if the percent change in the estimates exceeded 10%.
Results:
In the former football players (mean age=57.2, 34% Black, 29% APOE e4 carrier), reduced cortical thickness (B=-0.25, 95% CI [0.45, -0.08]), lower average FA (B=-0.27, 95% CI [-0.41, -.12]), higher p-tau181 (B=0.17, 95% CI [0.02, 0.43]), and higher rFSRP score (B=0.27, 95% CI [0.08, 0.42]) were associated with greater log-TLV. Compared to the unexposed men, substantial differences in estimates were observed for rFSRP (Bcontrol=0.02, Bfootball=0.27, 994% difference), average FA (Bcontrol=-0.03, Bfootball=-0.27, 802% difference), and p-tau181 (Bcontrol=-0.31, Bfootball=0.17, -155% difference). In the former football players, rFSRP showed a stronger positive association and average FA showed a stronger negative association with WMH compared to unexposed men. The effect of WMH on cortical thickness was similar between the two groups (Bcontrol=-0.27, Bfootball=-0.25, 7% difference).
Conclusions:
These results suggest that the risk factor and biological correlates of WMH differ between former American football players and asymptomatic individuals unexposed to RHI. In addition to vascular risk factors, white matter integrity on DTI showed a stronger relationship with WMH burden in the former football players. FLAIR WMH serves as a promising measure to further investigate the late multifactorial pathologies of RHI.
Three volumes of detailed description of Bedfordshire parish churches, presented with text from five important nineteenth-century sources; Appendices and Index complete the set.
This is to be a series of three volumes covering Bedfordshire churches in the nineteenth century. The volumes will contain descriptions of churches “on the eve of restoration” together with contemporary illustrations –most of which will be published for the first time.
For each church, there will be extracts from original records amplified by a commentary and explanatory footnotes. The main source material consists of:
1. Extracts from church inventories – mainly 1822
2. Antiquarian notes on churches by Archdeacon Bonney, c.1840
4. Articles on churches by W.A. – John Martin, the librarian at Woburn Abbey - 1845-1854
5. Church descriptions by Sir Stephen Glynne 1830-1870
There is considerable value in having these key sources, with illustrations and commentary, in one place. The descriptions by Bonney and Glynne are purely factual, but John Martin’s articles, highlighting abuses and neglect, make colourful and at times controversial reading. Bonney’s visitation notes - and the supporting evidence from contemporary records such as churchwardens’ accounts – give a clear indication that church buildings were far from neglected in the opening decades of the nineteenth century. Together these sources document features that can still be seen today, and provide information on others that have been lost.
The aim has been to present the text of contemporary sources in their original state, to convey a feeling for the times as well as to provide information. It is recognised that most of the sources could have been condensed by editing - for instance the lists of registers in the glebe terriers and the quotations in the articles by W.A. – but the Editorial Group felt that they should nevertheless be published in extenso.
The introductory commentary for each church includes a summary of the history of the building, focusing especially on eighteenth and nineteenth century restoration and alterations. These introductory notes are generally brief, but may be longer where differences between present and past external appearance merit detailed discussion. Detailed footnotes explain and amplify features mentioned in the text of the original sources and so lead the reader to additional research material.
Bedfordshire churches on the eve of restoration are well documented in a number of sources. First, there are a great many pictures of churches by artists such as Thomas Fisher and George Shepherd dating from the early Cl9th. Secondly, there are the manuscript sources which describe the condition of church buildings and ornaments in the years leading up to “the age of restoration”.
These sources are described and discussed in detail below. In outline, however, they include the glebe terriers for 1822 which describe the plan of each church and list the ornaments and furnishings. As Archdeacon of Bedford from 1821 to 1844, Dr. Henry Kaye Bonney compiled two notebooks on the churches in his care. In the one, he made detailed architectural notes on each church and its fittings, and in the other he kept a record of the orders made at his archidiaconal visitations between 1823 and 1839. Another commentator was John Martin, the Librarian at Woburn Abbey, who using the signature W.A. wrote a series of pithy articles on Bedfordshire churches for the Northampton Mercury and Bedfordshire Times between 1845 and 1854. Lastly, there are the notebooks of Sir Stephen Glynne who visited over a third of the churches in the County between 1830 and 1870.
Together these sources provide a colourful image of the appearance, condition and atmosphere of Bedfordshire churches at a time when on the one hand they were nearer their mediaeval state than they are today but when on the other they were arguably in their greatest need of attention.
Glebe Terriers (extracts) 1822
After the Reformation, the ecclesiastical authorities became increasingly aware of the need to keep proper records of church possessions. The documents known as glebe terriers fulfil this purpose, and include terriers (recording property and endowments) and inventories (listing goods and chattels). The existence of such records helped to prevent the loss and misappropriation of church property.
Terriers had been compiled for purely parochial purposes in mediaeval times, but in compliance with an archiepiscopal order or canon of 1571 it became a requirement for copies of these documents to be lodged in diocesan registries for safe-keeping.
Although the present church dates chiefly from the Cl4th and Cl5th, the foundations of the Cl2th church were discovered during excavations in 1975. The later church has a chancel, nave with north and south aisles, south porch and west tower. It retains its Cl5th roof with angels and shields (though the painted decoration is modem) and there is a ceilure above the former rood.
In 1696 a private pew was constructed for Lord Ashbumham of Ampthill Park in the south aisle of the church. Sir Christopher Wren and his pupil Nicholas Hawksmoor were involved in the design, and the pew was built by Alexander Fort, the King’s joiner. There was a heated legal dispute between Lord Ashburnham and Lord Ailesbury of Houghton House about this pew, which was eventually removed in 1847. The entrance through the east wall of the south aisle is shown in Buckler’s drawing dated 1835 (Plate 2). Lord Ailesbury had his own pew in the church, and there are faculties and papers regarding other Cl8th pews. In 1827 Boissier described the church as “crowded with pews & galleries”. Between 1823 and 1839 Bonney ordered several improvements to the pews, and in 1845 W.A. was highly critical of the arrangement of the church interior.
A faculty was obtained in 1728 to replace the pulpit, take down the chancel screen, and alter various windows. It was probably at this date that the pulpit was placed centrally in the chancel arch where it remained until 1847. Other repairs and alterations in the Cl8th and early Cl9th are recorded in the churchwardens’ accounts from 1718, vestry minutes from 1767, and churchwardens bills from 1823 (listed individually by Andrew Underwood) in the parish records.
Restoration came in 1847-8 under James Tacy Wing of Bedford, who provided new seats and galleries in the nave (Plate 3) and renewed the east window, repaired the roof and stonework, and added a small vestry on the north side of the chancel. In 1851-2 the church was lit by gas.
The tracery of the windows in the south aisle was renewed in 1872-3. Further work followed in 1877 when the vestry on the north side of the chancel was enlarged under James Piers St. Aubyn, although not all the work authorised by the faculty was carried out.
The parish churches of England are among the most noble and conspicuous of the nation’s architectural monuments. Their survival, however, owes more to chance than to good stewardship. Neglect, decay, and deliberate destruction are as much a part of their history as the work of dedicated benefactors and parishioners who strove to make our churches worthy for Christian worship.
As the sources selected for inclusion in this series demonstrate all too clearly, many Bedfordshire churches were in a dilapidated state in the opening decades of the nineteenth century. Others, whilst structurally sound and decently furnished for the worship of the day, needed “restoration” – a term meaning much more than just repair. This was the situation facing the Victorians who – far from vandalising our heritage – sought to restore these precious buildings from years of neglect and adapt them to suit the new liturgical arrangements of the time.
The coming of the ecclesiological movement in the 1840s brought a new concern for the ceremonial aspects of worship – the ministry of the sacraments instead of the ministry of the word. This entailed a change in the arrangement of church buildings, the old “preaching boxes” of the Cl8th giving way to churches in which all attention focused on the chancel and the holy table in the sanctuary. The reformers often exaggerated the poor state of church buildings as a means of drawing attention to the need for change, and the Victorians were invariably critical of alterations and repairs carried out in previous centuries when utility had been regarded as more important than sanctity.
Between about 1840 and 1914 virtually every parish church in England was in some measure restored, and vast sums of money were spent on what was seen to be one of the most worthy causes of the Victorian era. Many churches were rescued from the brink of collapse and given a new lease of life. Some were restored to their former glory. Others were mutilated beyond recognition or wholly rebuilt. Churches viewed by the Victorians as “tainted by classical alterations” were gothicised. Sound buildings were “improved” to suit the needs of a new religious age.
Churches remaining “unrestored” in appearance are to be seen at Chaigrave, Dean, Knotting, Odell, Shelton and Wymington (to name a few of the more rewarding examples in the County), but sadly the phrase “over restored” is all too common in the Bedfordshire volume of Dr. Nikolaus Pevsner’s Buildings of England series.
A brief general survey of post-Reformation church work in the County will be useful as an introduction to the subject. It seems sensible to frame the review round the work of architects - the designers of buildings and of furnishing schemes - who worked at different periods and in different styles. In this way, it is possible to view the changes in ecclesiastical taste in the County in their broader national context.
Post-Reformation church building to 1800
In general terms, church building activity came to an abrupt end at the time of the Reformation. There are, however, exceptions and recent studies in the neighbouring county of Huntingdonshire have demonstrated the extent of building work and improvements to churches into the seventeenth century. This may be untypical of the general picture, and Bedfordshire lacks any particularly distinguished examples of churches dating from the period between 1550 and 1800. Those mentioned below are all relatively minor when compared with the treasures in neighbouring counties, such as:
In Bedfordshire, Hulcote church was rebuilt by the Chemocke family in the late sixteenth century. It is gothic in form, but with a distinctly Renaissance feel. The tower at Blunham was rebuilt in 1583. At Odell there is a fine screen and ringing gallery of 1637 in the tower arch. At Campton, the north aisle dates from 1649. Whipsnade church was rebuilt in 1719. Melchboume has a seventeenthcentury porch brought, it is said, from Woodford in Northamptonshire. The body of the church was rebuilt in the classical style in about 1770. Shillington tower, destroyed in a storm in 1701, was rebuilt in brick in 1750. The 1783 black basalt Wedgwood font at Cardington - another formerly existed at Melchboume - is a particularly memorable example of eighteenth-century church furnishing. In every one of these cases the identity of the architect is unknown.
Having lived and worked in Bedfordshire for the past sixteen years, I have visited every church in the County in the course of my work. While on the staff of the Bedfordshire County Record Office I have been responsible for surveying and listing all the church records, and I am fortunate that this has enabled me to develop an intimate knowledge of the churches and their history.
It is my hope that in preparing these volumes I may be able to pass on some of this knowledge for the benefit of people interested either in specific churches or in the subject generally. I should like to thank the Society for publishing this book. I also wish to thank Gordon Vowles, the General Editor, and my colleagues on the Editorial Group for their constructive comments and suggestions throughout its gestation period.
Formal acknowledgment is due to the authorities and owners who have allowed the publication of their material. The 1822 glebe terriers are published here by kind permission of Lincoln Diocesan Record Office. Archdeacon Bonney’s church notes were among the manuscripts transferred to the County Record Office from the old Bedford Library, while Bonney’s visitation notes appear by kind permission of the present Archdeacon of Bedford, the Ven. Malcolm Lesiter. Sir Stephen Glynne’s Bedfordshire church notes are published by kind permission of Sir William Gladstone. Thanks are also due to Geoffrey Veysey, the Clwyd County Archivist, for providing information on the notes and for allowing me to quote from his article about Sir Stephen Glynne. The sources of illustrations are acknowledged separately.
Material for this volume has been gathered from several record repositories and institutions. My first debt of gratitude is to my colleagues in the Bedfordshire County Record Office, but I must also thank the staff at the British Library, the British Newspaper Library, the library of the Society of Antiquaries of London, the Bedfordshire County Library Service, Lambeth Palace Library, Cambridge University Library, Lincolnshire Archives, and the Hertfordshire County Record Office for their help and advice.
Thanks are also due to all those who have typed parts of the text including Deborah Blake and Ellen Collier, but especially to Pauline Newbery on whom the main body of the work has fallen.
Recent shifts in political support to populist parties worldwide have been linked to the changing preferences of “left behind communities.” Based on apparently growing “left behind” support for populists, some commentators have argued for policy changes including tightened immigration rules coupled with increasing investment in economically deprived areas, particularly in health care. However, left behind communities’ policy preferences are unclear from existing research due to a series of methodological challenges associated with researching polarization and stigmatization. We complement existing research with an innovative photo elicitation methodology covering five field sites in the United Kingdom during 2019, focusing on left behind communities’ policy preferences concerning Brexit. Photo elicitation overcomes methodological challenges associated with emotional attachment and stigmatization. Drawing on 418 interviews with 489 participants, we find that interviewees rejected elite framings suggesting a logical link between Brexit and health care investment, instead articulating policy preferences for health care investment drawing on personal experiences.