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Welford J, Rafferty R, Hunt K, Duncan L, Richardson O, Ward A, Rushton C, Short D, Greystoke A. CN14 The utility of a brief clinical frailty scale (CFS) in predicting prognosis and discharge destination in oncology inpatients. Ann Oncol 2020. [DOI: 10.1016/j.annonc.2020.08.2119] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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2
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Greystoke A, Ward A, Welford J, Rushton C, Short D, Todd A, Rafferty R, Hunt K, Duncan L, Tanner L, Gardiner J. Implementation of the Rockwood Clinical Frailty Score (CFS) into the Newcastle upon Tyne NHS Trust lung cancer practice. Lung Cancer 2020. [DOI: 10.1016/s0169-5002(20)30220-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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3
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Rushton C, Burton CS, Goddard K, Basran AK, Alfred A. Monitoring lung function in patients with chronic graft versus host disease: a pilot study. ACTA ACUST UNITED AC 2019; 28:1196-1200. [PMID: 31597050 DOI: 10.12968/bjon.2019.28.18.1196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Bronchiolitis obliterans syndrome (BOS) following allogenic haematopoietic stem cell transplant is considered the manifestation of chronic graft versus host disease (cGvHD) in the lung, and affects about 14% of patients with cGvHD, mainly in the first 2 years after transplant. Despite advances in assessment, diagnosis and treatment, the clinical prognosis remains poor for patients with pulmonary manifestations of cGvHD. A pilot study of 50 patients was devised to establish whether a relationship exists between forced expiratory volume in 1 second (FEV1) via pulmonary function test (PFT) and the equivalent peak expiratory flow (PEF) via peak flow handheld spirometry in cGvHD patients receiving extracorporeal photopheresis (ECP). Only PEF observed within 2 days of PFT could be compared with data at month 3, 6, 9 and 12. This pilot study illustrated that monitoring via handheld peak flow readings has the potential to become an acceptable method of monitoring lung function longitudinally in cGvHD patients.
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Affiliation(s)
- Cherie Rushton
- at time of writing was Clinical Nurse Specialist Photopheresis, The Rotherham NHS Foundation Trust, Rotherham
| | | | - Kathryn Goddard
- Consultant Haematologist, The Rotherham NHS Foundation Trust, Rotherham
| | | | - Arun Alfred
- Consultant Haematologist, The Rotherham NHS Foundation Trust, Rotherham
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4
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Rushton C, Bacon E, Jennings E, Marchetti P, Alfred A. Adrenal insufficiency of patients with graft versus host disease treated with extracorporeal photopheresis. ACTA ACUST UNITED AC 2019; 28:698-701. [PMID: 31188658 DOI: 10.12968/bjon.2019.28.11.698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Graft versus host disease (GvHD) is a serious and common complication of allogenic haematopoietic stem cell transplant. Corticosteroids are considered the standard care for initial treatment of GvHD but a significant proportion of patients will need long-term steroid treatment for control of GvHD. Extracorporeal photopheresis (ECP) is a cell-based immunomodulatory therapy that is an accepted second line treatment in patients with steroid refractory, dependent or intolerant GvHD and has shown efficacy in allowing steroid dose reduction and discontinuation in this cohort of patients. Adrenal cortical insufficiency is defined by the inability of the adrenal cortex to produce sufficient amounts of glucocorticoids and/or mineralocorticoids leading to a severe and potentially life-threatening condition. The most common cause of drug-induced adrenal insufficiency is the suppression of the hypothalamic-pituitary-adrenal axis by exogenous glucocorticoid doses ≥5 mg prednisolone equivalent for more than 4 weeks. The aim of the study was to ascertain the number of patients with GvHD receiving ECP that are affected by adrenocortical insufficiency.
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Affiliation(s)
- Cherie Rushton
- Specialist Nurse Photopheresis, The Rotherham NHS Foundation Trust, Rotherham
| | - Elizabeth Bacon
- Specialist Nurse Photopheresis, The Rotherham NHS Foundation Trust, Rotherham
| | - Emma Jennings
- Research Assistant, The Rotherham NHS Foundation Trust, Rotherham
| | - Paula Marchetti
- Consultant Clinical Scientist, The Rotherham NHS Foundation Trust, Rotherham
| | - Arun Alfred
- Consultant Haematologist, The Rotherham NHS Foundation Trust, Rotherham
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Arthur S, Mottok A, Cojocaru R, Jiang A, Grande B, Alcaide M, Rushton C, Ennishi D, Kumar Lat P, Davidson J, Bushell K, Audas T, Unrau P, Sen D, Gascoyne R, Marra M, Connors J, Morin G, Scott D, Steidl C, Morin R. FUNCTIONAL CHARACTERIZATION OF NFKBIZ
3′ UTR MUTATIONS IN DIFFUSE LARGE B-CELL LYMPHOMA. Hematol Oncol 2019. [DOI: 10.1002/hon.43_2629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- S.E. Arthur
- Molecular Biology & Biochemistry; Simon Fraser University; Burnaby Canada
| | - A. Mottok
- Centre for Lymphoid Cancer; BC Cancer; Vancouver Canada
| | - R. Cojocaru
- Molecular Biology & Biochemistry; Simon Fraser University; Burnaby Canada
| | - A. Jiang
- Molecular Biology & Biochemistry; Simon Fraser University; Burnaby Canada
| | - B.M. Grande
- Molecular Biology & Biochemistry; Simon Fraser University; Burnaby Canada
| | - M. Alcaide
- Molecular Biology & Biochemistry; Simon Fraser University; Burnaby Canada
| | - C. Rushton
- Molecular Biology & Biochemistry; Simon Fraser University; Burnaby Canada
| | - D. Ennishi
- Centre for Lymphoid Cancer; BC Cancer; Vancouver Canada
| | - P. Kumar Lat
- Molecular Biology & Biochemistry; Simon Fraser University; Burnaby Canada
| | - J. Davidson
- Molecular Biology & Biochemistry; Simon Fraser University; Burnaby Canada
| | - K.R. Bushell
- Molecular Biology & Biochemistry; Simon Fraser University; Burnaby Canada
| | - T. Audas
- Molecular Biology & Biochemistry; Simon Fraser University; Burnaby Canada
| | - P. Unrau
- Molecular Biology & Biochemistry; Simon Fraser University; Burnaby Canada
| | - D. Sen
- Molecular Biology & Biochemistry; Simon Fraser University; Burnaby Canada
| | - R.D. Gascoyne
- Centre for Lymphoid Cancer; BC Cancer; Vancouver Canada
| | - M.A. Marra
- Genome Sciences Centre; BC Cancer; Vancouver Canada
| | - J.M. Connors
- Centre for Lymphoid Cancer; BC Cancer; Vancouver Canada
| | - G.B. Morin
- Genome Sciences Centre; BC Cancer; Vancouver Canada
| | - D.W. Scott
- Centre for Lymphoid Cancer; BC Cancer; Vancouver Canada
| | - C. Steidl
- Centre for Lymphoid Cancer; BC Cancer; Vancouver Canada
| | - R.D. Morin
- Molecular Biology & Biochemistry; Simon Fraser University; Burnaby Canada
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Rushton C, Alcaide M, Cheung M, Thomas N, Arthur S, Michaud N, Daigle S, Davidson J, Bushell K, Yu S, Jain M, Shepherd L, Crump M, Mann K, Kuruvilla J, Assouline S, Johnson N, Scott D, Morin R. IDENTIFYING MUTATIONS ENRICHED IN RELAPSED-REFRACTORY DLBCL TO DERIVE GENETIC FACTORS UNDERLYING TREATMENT RESISTANCE. Hematol Oncol 2019. [DOI: 10.1002/hon.4_2629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- C. Rushton
- Molecular Biology and Biochemistry; Simon Fraser University; Burnaby Canada
| | - M. Alcaide
- Molecular Biology and Biochemistry; Simon Fraser University; Burnaby Canada
| | - M. Cheung
- Molecular Biology and Biochemistry; Simon Fraser University; Burnaby Canada
| | - N. Thomas
- Molecular Biology and Biochemistry; Simon Fraser University; Burnaby Canada
| | - S. Arthur
- Molecular Biology and Biochemistry; Simon Fraser University; Burnaby Canada
| | | | | | - J. Davidson
- Molecular Biology and Biochemistry; Simon Fraser University; Burnaby Canada
| | - K. Bushell
- Molecular Biology and Biochemistry; Simon Fraser University; Burnaby Canada
| | - S. Yu
- Molecular Biology and Biochemistry; Simon Fraser University; Burnaby Canada
| | - M. Jain
- Department of Medical Oncology and Hematology; Princess Margaret Cancer Centre; Toronto Canada
| | - L. Shepherd
- Canada Cancer Trials Group; Queen's University; Kingston Canada
| | - M. Crump
- Department of Medical Oncology and Hematology; Princess Margaret Cancer Centre; Toronto Canada
| | - K. Mann
- Department of Medicine; McGill University; Montreal Canada
| | - J. Kuruvilla
- Department of Medical Oncology and Hematology; Princess Margaret Cancer Centre; Toronto Canada
| | - S. Assouline
- Department of Oncology; McGill University; Montreal Canada
| | - N. Johnson
- Department of Medicine; McGill University; Montreal Canada
| | - D.W. Scott
- Genome Sciences Centre; BC Cancer; Vancouver Canada
| | - R.D. Morin
- Molecular Biology and Biochemistry; Simon Fraser University; Burnaby Canada
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7
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Rushton C, Anderson V, Walton A. Assess the benefits of Implementing regular nutritional screening for patients with a lung cancer diagnosis. Lung Cancer 2019. [DOI: 10.1016/s0169-5002(19)30163-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Rushton C, Jackson A, Goddard K, Alfred A. A case review of a patient experience of photopheresis using a peripherally inserted central catheter. J Clin Apher 2018; 34:73-74. [PMID: 30414332 DOI: 10.1002/jca.21674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 07/26/2018] [Accepted: 10/18/2018] [Indexed: 11/05/2022]
Abstract
Extracorporeal photopheresis (ECP) is a cell based immunomodulatory therapy in which the patient is attached intravenously to a cell separating machine. During ECP a patient's blood is collected via either a central venous access device (CVAD) or a peripherally inserted 16G arterial venous fistula needle in either one or both antecubital fossa. However, patients presenting for ECP with GVHD repeatedly present a challenge to the ECP team due to poor venous access resulting from previous therapies and skin changes. The use of peripherally inserted central venous catheters (PICCs) offers an alternative route of vascular access for this cohort of patients. Here we present a case report of a patient successfully treated with ECP following the insertion of a PICC line.
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Affiliation(s)
- Cherie Rushton
- Photopheresis, Rotherham Foundation Trust, Rotherham, United Kingdom
| | - Andrew Jackson
- Vascular Access, Rotherham Foundation Trust, Rotherham, United Kingdom
| | - Kathryn Goddard
- Photopheresis, Rotherham Foundation Trust, Rotherham, United Kingdom
| | - Arun Alfred
- Photopheresis, Rotherham Foundation Trust, Rotherham, United Kingdom
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Rushton C, Goodgrove R, Robertson L, Taylor T, Taylor P, Alfred A. The introduction and evaluation of a pressure ulcer risk assessment tool for photopheresis outpatients. ACTA ACUST UNITED AC 2017. [PMID: 28640721 DOI: 10.12968/bjon.2017.26.12.s16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Chronic graft-versus-host disease (cGVHD) patients are at high risk of compromised skin integrity, and of developing pressure ulcers, which may bleed and/or become infected. The Rotherham Outpatient Screening Tool (ROST) was adapted from the Waterlow score and the Malnutrition Universial Screening Tool (MUST) to suit patients attending an outpatient unit for photopheresis. A review of the screening tool highlighted patients at a higher risk of developing pressure damage during treatment and therefore the unit was able to reduce this risk by the provision of a pressure-relieving cushion (Repose).
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Affiliation(s)
- Cherie Rushton
- Specialist Nurse in Photopheresis, The Rotherham NHS Foundation Trust
| | - Rachel Goodgrove
- Specialist Nurse in Photopheresis, The Rotherham NHS Foundation Trust
| | - Leeah Robertson
- Specialist Nurse in Photopheresis, The Rotherham NHS Foundation Trust
| | - Tracie Taylor
- Photopheresis/Pathology Clinical Services Manager, The Rotherham NHS Foundation Trust
| | - Peter Taylor
- Consultant Haematologist, The Rotherham NHS Foundation Trust
| | - Arun Alfred
- Consultant Haematologist, The Rotherham NHS Foundation Trust
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Rushton C, Robertson L, Taylor T, Taylor P, Alfred A. Implementation and evaluation of a pre-assessment telephone triage system in an outpatient photopheresis service. ACTA ACUST UNITED AC 2017; 26:400-404. [PMID: 28410041 DOI: 10.12968/bjon.2017.26.7.400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The prompt assessment of patients as fit for photopheresis is imperative to ensure delivery of a safe and efficient service. Before January 2015 the photopheresis unit was reliant on patients contacting the department directly to cancel their appointment if they were unwell or were suffering from any pre-defined exclusion criteria. Methods to reduce the number of cancellations and patients arriving unwell were therefore examined. The authors combined aspects of patient pre-assessment with telephone triage to develop a system that could provide better care and improve the use of resources within the department. The pre-assessment telephone triage system successfully reduced cancellations and increased patient awareness of conditions that would prevent delivery of photopheresis treatment. Subsequently the quality improvement initiative established that the pre-assessment telephone triage system saved the photopheresis unit over £33 000 over a 12-month period.
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Affiliation(s)
- Cherie Rushton
- Specialist Nurse in Photopheresis, The Rotherham NHS Foundation Trust
| | - Leeah Robertson
- Specialist Nurse in Photopheresis, The Rotherham NHS Foundation Trust
| | - Tracie Taylor
- Photopheresis/Pathology Clinical Services Manager, The Rotherham NHS Foundation Trust
| | - Peter Taylor
- Consultant Haematologist, The Rotherham NHS Foundation Trust
| | - Arun Alfred
- Consultant Haematologist, The Rotherham NHS Foundation Trust
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Rushton C, Robertson L, Taylor T, Taylor P, Button P, Alfred A. Improving the service for patients receiving extracorporeal photopheresis using Lean principles. ACTA ACUST UNITED AC 2016; 25:917-21. [DOI: 10.12968/bjon.2016.25.16.917] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Cherie Rushton
- Specialist nurse in Photopheresis, The Rotherham NHS Foundation Trust
| | - Leeah Robertson
- Specialist Nurse in Photopheresis, The Rotherham NHS Foundation Trust
| | - Tracie Taylor
- Photopheresis/Pathology Clinical Services Manager, The Rotherham NHS Foundation Trust
| | - Peter Taylor
- Consultant in Photopheresis, The Rotherham NHS Foundation Trust
| | | | - Arun Alfred
- Consultant in Photopheresis, The Rotherham NHS Foundation Trust
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Puntillo KA, Benner P, Drought T, Drew B, Stotts N, Stannard D, Rushton C, Scanlon C, White C. End-of-life issues in intensive care units: a national random survey of nurses' knowledge and beliefs. Am J Crit Care 2001; 10:216-29. [PMID: 11432210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
OBJECTIVE To investigate the knowledge, beliefs, and ethical concerns of nurses caring for patients dying in intensive care units. METHODS A survey was mailed to 3000 members of the American Association of Critical-Care Nurses. The survey contained various scenarios depicting end-of-life actions for patients: pain management, withholding or withdrawing life support, assisted suicide, and voluntary and nonvoluntary euthanasia. RESULTS Most of the respondents (N = 906) correctly identified the distinctions among the end-of-life actions depicted in the scenarios. Almost all (99%-100%) agreed with the actions of pain management and withholding or withdrawing life support. A total of 83% disagreed with assisted suicide, 95% disagreed with voluntary euthanasia, and 89% to 98% disagreed with nonvoluntary euthanasia. Most (78%) thought that dying patients frequently (31%) or sometimes (47%) received inadequate pain medicine, and almost all agreed with the double-effect principle. Communication between nurses and physicians was generally effective, but unit-level conferences that focused on grief counseling and debriefing staff rarely (38%) or never (49%) occurred. Among the respondents, 37% had been asked to assist in hastening a patient's death. Although 59% reported that they seldom acted against their consciences in caring for dying patients, 34% indicated that they sometimes had acted against their conscience, and 6% had done so to a great extent. CONCLUSIONS Intensive care unit nurses strongly support good pain management for dying patients and withholding or withdrawing life-sustaining therapies to allow unavoidable death. The vast majority oppose assisted suicide and euthanasia. Wider professional and public dialogue on end-of-life care in intensive care units is warranted.
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Puntillo KA, Benner P, Drought T, Drew B, Stotts N, Stannard D, Rushton C, Scanlon C, White C. End-of-life issues in intensive care units: a national random survey of nurses' knowledge and beliefs. Am J Crit Care 2001. [DOI: 10.4037/ajcc2001.10.4.216] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE: To investigate the knowledge, beliefs, and ethical concerns of nurses caring for patients dying in intensive care units. METHODS: A survey was mailed to 3000 members of the American Association of Critical-Care Nurses. The survey contained various scenarios depicting end-of-life actions for patients: pain management, withholding or withdrawing life support, assisted suicide, and voluntary and nonvoluntary euthanasia. RESULTS: Most of the respondents (N = 906) correctly identified the distinctions among the end-of-life actions depicted in the scenarios. Almost all (99%-100%) agreed with the actions of pain management and withholding or withdrawing life support. A total of 83% disagreed with assisted suicide, 95% disagreed with voluntary euthanasia, and 89% to 98% disagreed with nonvoluntary euthanasia. Most (78%) thought that dying patients frequently (31%) or sometimes (47%) received inadequate pain medicine, and almost all agreed with the double-effect principle. Communication between nurses and physicians was generally effective, but unit-level conferences that focused on grief counseling and debriefing staff rarely (38%) or never (49%) occurred. Among the respondents, 37% had been asked to assist in hastening a patient's death. Although 59% reported that they seldom acted against their consciences in caring for dying patients, 34% indicated that they sometimes had acted against their conscience, and 6% had done so to a great extent. CONCLUSIONS: Intensive care unit nurses strongly support good pain management for dying patients and withholding or withdrawing life-sustaining therapies to allow unavoidable death. The vast majority oppose assisted suicide and euthanasia. Wider professional and public dialogue on end-of-life care in intensive care units is warranted.
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Griffiths S, Chipperfield B, Todd S, Rushton C, McCarthy M. Dietary beliefs, practices and attitudes of adults in an inner city population. J Hum Nutr Diet 1994. [DOI: 10.1111/j.1365-277x.1994.tb00275.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Rushton C. Cindy Rushton: big advocacy, little world. Interview by Michael Villaire. Crit Care Nurse 1994; 14:106-13. [PMID: 7882679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Rushton C. Cindy Rushton: big advocacy, little world. Interview by Michael Villaire. Crit Care Nurse 1994. [DOI: 10.4037/ccn1994.14.2.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Rushton C. Irritable bowel syndrome. Br J Gen Pract 1991; 41:437. [PMID: 1777314 PMCID: PMC1371845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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Rushton C, Kipps A, Quarmby V, Whitehead PH. The distribution and significance of amylase-containing stains on clothing. J Forensic Sci Soc 1979; 19:53-8. [PMID: 469498 DOI: 10.1016/s0015-7368(79)71251-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Abstract
The development of a 42-item measure of a number of personality features derived from the theory of psychological reversals is reported. These personality features are (a) the extent to which a person is serious-minded, (b) the extent to which a person plans ahead and organizes himself in the pursuit of goals, and (c) the extent to which a person seeks to avoid arousal. These features together are seen to constitute a personality trait which is described as telic dominance. Data concerning the test-retest reliability, criterion-related and construct validity of the Telic Dominance Scale are presented, together with the scale and scoring key.
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Abstract
The effects of the subcutaneous injections of 50 000 i.u. of vitamin D on 25-hydroxy-vitamin D levels were measured in young controls, old people living at home, and in elderly in-patients. Responses were substantially reduced in both groups of old people, particularly in those living at home. This phenomenon may be due to the effects of ageing or disease on 25-hydroxylase activity.
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