Targeting systemic and gut microbial metabolism in ER+ breast cancer

Estrogen receptor-positive (ER+) breast tumors have a better overall prognosis than ER- tumors; however, there is a sustained risk of recurrence. Mounting evidence indicates that genetic and epigenetic changes associated with resistance impact critical signaling pathways governing cell metabolism. This review delves into recent literature concerning the metabolic pathways regulated in ER+ breast tumors by the availability of nutrients and endocrine therapies and summarizes research on how changes in systemic and gut microbial metabolism can affect ER activity and responsiveness to endocrine therapy. As targeting of metabolic pathways using dietary or pharmacological approaches enters the clinic, we provide an overview of the supporting literature and suggest future directions.

Gestational Diabetes Is Characterized by Decreased Medium-Chain Acylcarnitines and Elevated Purine Degradation Metabolites across Pregnancy: A Case-Control Time-Course Analysis

Gestational Diabetes Mellitus (GDM) results in complications affecting both mothers and their offspring. Metabolomic analysis across pregnancy provides an opportunity to better understand GDM pathophysiology. The objective was to conduct a metabolomics analysis of first and third trimester plasma samples to identify metabolic differences associated with GDM development. Forty pregnant women with overweight/obesity from a multisite clinical trial of a lifestyle intervention were included. Participants who developed GDM (n = 20; GDM group) were matched with those who did not develop GDM (n = 20; Non-GDM group). Plasma samples collected at the first (10-16 weeks) and third (28-35 weeks) trimesters were analyzed with ultra-performance liquid chromatography-mass spectrometry (UPLC-MS). Cardiometabolic risk markers, dietary recalls, and physical activity metrics were also assessed. Four medium-chain acylcarnitines, lauroyl-, octanoyl-, decanoyl-, and decenoylcarnitine, significantly differed over the course of pregnancy in the GDM vs Non-GDM group in a group-by-time interaction (p < 0.05). Hypoxanthine and inosine monophosphate were elevated in the GDM group (p < 0.04). In both groups over time, bile acids and sorbitol increased while numerous acylcarnitines and α-hydroxybutyrate decreased (p < 0.05). Metabolites involved in fatty acid oxidation and purine degradation were altered across the first and third trimesters of GDM-affected pregnancies, providing insight into metabolites and metabolic pathways altered with GDM development.

Identification of potential biomarkers and metabolic insights for gestational diabetes prevention: A review of evidence contrasting gestational diabetes versus weight loss studies that may direct future nutritional metabolomics studies

Gestational diabetes mellitus (GDM) significantly increases maternal health risks and adverse effects for the offspring. Observational studies suggest that weight loss before pregnancy may be a promising GDM prevention method. Still, biochemical pathways linking preconception weight changes with subsequent development of GDM among women who are overweight or obese remain unclear. Metabolomic assessment is a powerful approach for understanding the global biochemical pathways linking preconception weight changes and subsequent GDM. We hypothesize that many of the alterations of metabolite levels associated with GDM will change in one direction in GDM studies but will change in the opposite direction in studies focusing on lifestyle interventions for weight loss. The present review summarizes available evidence from 21 studies comparing women with GDM with healthy participants and 12 intervention studies that investigated metabolite changes that occurred during weight loss using caloric restriction and behavioral interventions. We discuss 15 metabolites, including amino acids, lipids, amines, carbohydrates, and carbohydrate derivatives. Of particular note are the altered levels of branched-chain amino acids, alanine, palmitoleic acid, lysophosphatidylcholine 18:1, and hypoxanthine because of their mechanistic links to insulin resistance and weight change. Mechanisms that may explain how these metabolite modifications contribute to GDM development in those who are overweight or obese are proposed, including insulin resistance pathways. Future nutritional metabolomics preconception intervention studies in overweight or obese are necessary to investigate whether weight loss through lifestyle intervention can reduce GDM occurrence in association with these metabolite alterations and to test the value of these metabolites as potential diagnostic biomarkers of GDM development.

Autism-related language preferences of English-speaking individuals across the globe: A mixed methods investigation

Over the past two decades, there have been increasing discussions around which terms should be used to talk about autism. Whilst these discussions have largely revolved around the suitability of identity-first language and person-first language, more recently this debate has broadened to encompass other autism-related terminology (e.g., 'high-functioning'). To date, academic studies have not investigated the language preferences of autistic individuals outside of the United Kingdom or Australia, nor have they compared levels of endorsement across countries. Hence, the current study adopted a mixed-methods approach, employing both quantitative and qualitative techniques, to explore the linguistic preferences of 654 English-speaking autistic adults across the globe. Despite variation in levels of endorsement between countries, we found that the most popular terms were similar-the terms 'Autism', 'Autistic person', 'Is autistic', 'Neurological/Brain Difference', 'Differences', 'Challenges', 'Difficulties', 'Neurotypical people', and 'Neurotypicals' were consistently favored across countries. Despite relative consensus across groups, both our quantitative and qualitative data demonstrate that there is no universally accepted way to talk about autism. Our thematic analysis revealed the reasons underlying participants' preferences, generating six core themes, and illuminated an important guiding principle-to respect personal preferences. These findings have significant implications for informing practice, research and language policy worldwide.

Predictive Gestational Diabetes Biomarkers with Sustained Alterations Throughout Pregnancy: A Scoping Review

Gestational diabetes mellitus (GDM) results in an increased risk of pre- and postpartum health complications for both mother and child. Metabolomics analysis can potentially identify predictive biomarkers and provide insight into metabolic alterations associated with GDM pathogenesis and progression, but few metabolomics studies investigate alterations observed across the first and third trimester. We hypothesize that metabolites altered in first-trimester GDM that remain altered in late pregnancy may best inform interventions. Metabolomic studies comparing plasma and serum metabolite alterations in GDM vs non-GDM pregnancies were retrieved by searching PubMed, Medline, and CINAHL Plus databases. The present scoping review summarizes the metabolites found to be consistently altered throughout the course of GDM and proposes mechanisms that explain how these metabolic perturbations relate to GDM development and progression. Metabolites involved in fatty acid metabolism, reductive carboxylation, branched-chain amino acid metabolism, cell membrane lipid metabolism, purine degradation, and the gut microbiome were found to be altered throughout GDM pregnancies, with many of these pathways showing mechanistic links to insulin resistance, inflammation, and impaired cell signaling. Future studies are required to investigate if normalization of these perturbed pathways can be the targets of interventions.

Metabolites involved in purine degradation, insulin resistance, and fatty acid oxidation are associated with prediction of Gestational diabetes in plasma

INTRODUCTION

Gestational diabetes mellitus (GDM) significantly increases maternal and fetal health risks, but factors predictive of GDM are poorly understood.

OBJECTIVES

Plasma metabolomics analyses were conducted in early pregnancy to identify potential metabolites associated with prediction of GDM.

METHODS

Sixty-eight pregnant women with overweight/obesity from a clinical trial of a lifestyle intervention were included. Participants who developed GDM (n = 34; GDM group) were matched on treatment group, age, body mass index, and ethnicity with those who did not develop GDM (n = 34; Non-GDM group). Blood draws were completed early in pregnancy (10-16 weeks). Plasma samples were analyzed by UPLC-MS using three metabolomics assays.

RESULTS

One hundred thirty moieties were identified. Thirteen metabolites including pyrimidine/purine derivatives involved in uric acid metabolism, carboxylic acids, fatty acylcarnitines, and sphingomyelins (SM) were different when comparing the GDM vs. the Non-GDM groups (p < 0.05). The most significant differences were elevations in the metabolites' hypoxanthine, xanthine and alpha-hydroxybutyrate (p < 0.002, adjusted p < 0.02) in GDM patients. A panel consisting of four metabolites: SM 14:0, hypoxanthine, alpha-hydroxybutyrate, and xanthine presented the highest diagnostic accuracy with an AUC = 0.833 (95% CI: 0.572686-0.893946), classifying as a "very good panel".

CONCLUSION

Plasma metabolites mainly involved in purine degradation, insulin resistance, and fatty acid oxidation, were altered in early pregnancy in connection with subsequent GDM development.

Search for Lepton Number and Flavor Violation in K^{+} and π^{0} Decays

Searches for the lepton number violating K^{+}→π^{-}μ^{+}e^{+} decay and the lepton flavor violating K^{+}→π^{+}μ^{-}e^{+} and π^{0}→μ^{-}e^{+} decays are reported using data collected by the NA62 experiment at CERN in 2017-2018. No evidence for these decays is found and upper limits of the branching ratios are obtained at 90% confidence level: B(K^{+}→π^{-}μ^{+}e^{+})<4.2×10^{-11}, B(K^{+}→π^{+}μ^{-}e^{+})<6.6×10^{-11} and B(π^{0}→μ^{-}e^{+})<3.2×10^{-10}. These results improve by 1 order of magnitude over previous results for these decay modes.

Postprandial Dried Blood Spot-Based Nutritional Metabolomic Analysis Discriminates a High-Fat, High-Protein Meat-Based Diet from a High Carbohydrate Vegan Diet: A Randomized Controlled Crossover Trial

BACKGROUND

Due to the challenges associated with accurate monitoring of dietary intake in humans, nutritional metabolomics (including food intake biomarkers) analysis as a complementary tool to traditional dietary assessment methods has been explored. Food intake biomarker assessment using postprandial dried blood spot (DBS) collection can be a convenient and accurate means of monitoring dietary intake vs 24-hour urine collection.

OBJECTIVE

The objective of this study was to use nutritional metabolomics analysis to differentiate a high-fat, high-protein meat (HFPM) diet from a high-carbohydrate vegan (HCV) diet in postprandial DBS and 24-hour urine.

DESIGN

This was a randomized controlled crossover feeding trial.

PARTICIPANTS/SETTING

Participants were healthy young adult volunteers (n = 8) in California. The study was completed in August 2019.

INTERVENTION

The standardized isocaloric diet interventions included an HFPM and an HCV diet. Participants attended 2 intervention days, separated by a 2-week washout.

MAIN OUTCOME MEASURES

During each intervention day, a finger-prick blood sample was collected in the fasting state, 3 hours post breakfast, and 3 hours post lunch. Participants also collected their urine for 24 hours. DBS and urine samples were analyzed by ultra-performance liquid chromatography mass spectrometry to identify potential food intake biomarkers.

STATISTICAL ANALYSES PERFORMED

Principal component analysis for discriminatory analysis and univariate analysis using paired t tests were performed.

RESULTS

Principal component analysis found no discrimination of baseline DBS samples. In both the postprandial DBS and 24-hour urine, post-HFPM consumption had higher (P < 0.05) levels of acylcarnitines, creatine, and cis-trans hydroxyproline, and the HCV diet was associated with elevated sorbitol (P < 0.05). The HFPM diet had higher concentrations of triacylglycerols with fewer than 54 total carbons in DBS, and 24-hour urine had higher nucleoside mono- and di-phosphates (P < 0.05).

CONCLUSIONS

Nutritional metabolomics profiles of postprandial DBS and 24-hour urine collections were capable of differentiating the HFPM and HCV diets. The potential use of postprandial DBS-based metabolomic analysis deserves further investigation for dietary intake monitoring.

Investigation of an Alternative Collection Method for Food Intake Biomarkers Discriminates a High Fat-High Protein Meat-Based Diet from a High Carbohydrate Vegan Diet

Objectives

Due to the challenges associated with accurate monitoring of dietary intake in humans, the use of food intake biomarker (FIB) analysis as a complement to dietary questionnaires has been explored. However, numerous limitations exist including the requirement of 24-hour urine collection, currently the best method of FIB assessment. As a potentially more convenient and accurate means of monitoring dietary intake, we explored the utility of postprandial dried blood spot (DBS) collection. The hypothesis of this study was that metabolic profiles in both DBS and urine under controlled feeding conditions would similarly reflect differences in diets of varying food type and macronutrient distribution.

Methods

This was a randomized controlled trial with a crossover design including healthy volunteers (n = 8) from the San Luis Obispo, CA. The standardized isocaloric diet interventions included a high fat, high protein meat diet (HFPM) versus a high carbohydrate vegan (HCV) diet. Participants attended two intervention days, separated by a two-week washout. During each intervention day, a finger-prick blood sample was collected one hour before each meal (at 8 am, 12 pm, and 4 pm). Participants also collected their urine for 24-hours. DBS and urine samples were analyzed by LC-MS in order to identify diet-discriminatory biomarkers.

Results

Both the DBS and urine sample analysis identified biomarkers that differentiated the HFPM and HCV diets (P &lt; 0.05). Most notably, in both the DBS and urine, post-HFPM consumption had higher levels of amino acids and creatine while the HCV diet was associated with elevated sorbitol and hippuric acid (P &lt; 0.05). Unique to DBS, the HFPM diet had higher ketone bodies and triacylglycerols with &lt;54 total carbons while post-HCV diets had higher levels of triacylglycerols with ≥54 total carbons (P &lt; 0.05). Exclusive to urine sample metabolite changes, post-HFPM had elevated cis-trans hydroxyproline and several nucleoside mono- and di-phosphates (P &lt; 0.05).

Conclusions

DBS and urine collections were similarly capable of differentiating the diets consumed in this study. The potential use of DBS as a more efficient method of FIB identification deserves further investigation.

Funding Sources

Cal Poly CAFES SURP and the Department of Food Science and Nutrition.

NA62 and NA48/2 results on search for Heavy Neutral Leptons

In this paper we present new results on upper limits for the search of Heavy Neutral Leptons (HNL) with data collected by NA48/2 (2003-2004), NA62-RK (2007) and NA62 (2015) CERN experiments. The data collected with different trigger configuration allow to search for both long and short living heavy neutrinos in the mass range below the kaon mass. In addition the status of the search for K+ → π+vv with the NA62 detector will be briefly presented.

Safeguarding vulnerable older people in hospital

Safeguarding vulnerable older people is the responsibility of all healthcare professionals, but what this means in reality and how it can be achieved in practice is not always well understood. This article provides guidance on how government initiatives can be used by nurses to improve the care of older people. The article identifies criteria for determining when a concern should be raised as a safeguarding alert and when neglect may be occurring. A positive culture encompassing zero tolerance of poor care in the hospital setting is advocated.

Excess post-exercise oxygen consumption in untrained men following exercise of equal energy expenditure: comparisons of upper and lower body exercise

AIM

This study assessed excess post-exercise oxygen consumption (EPOC) following continuous 200- kcal bouts of upper body exercise (UBE) and lower body exercise (LBE).

METHODS

Ten untrained men (age: 25.7 +/- 5.83 years; arm VO(2peak): 2.2 +/- 0.25 l/min; 21.5 +/- 4.35 ml/kg/min; leg VO(2peak): 3.1 +/- 0.38 l/min; 30.7 +/- 7.79 ml/kg/min) exercised at 60% mode-specific VO(2) peak using either an arm crank or a leg cycle protocol (counterbalanced order with 48 h between). Baseline VO(2) was monitored for 30 min. EPOC was measured until baseline was re-established.

RESULTS

EPOC magnitude and duration were significantly greater (p < 0.05) following LBE (2.93 +/- 1.4 l/min; 16.5 +/- 7.4 min) compared with UBE (1.89 +/- 0.7 l/min; 11.5 +/- 6.1 min).

CONCLUSIONS

Results indicate that leg exercise elicited a greater EPOC magnitude and duration compared with arm exercise of the same relative intensity and energy expenditure.

HRPT2, encoding parafibromin, is mutated in hyperparathyroidism-jaw tumor syndrome

We report here the identification of a gene associated with the hyperparathyroidism-jaw tumor (HPT-JT) syndrome. A single locus associated with HPT-JT (HRPT2) was previously mapped to chromosomal region 1q25-q32. We refined this region to a critical interval of 12 cM by genotyping in 26 affected kindreds. Using a positional candidate approach, we identified thirteen different heterozygous, germline, inactivating mutations in a single gene in fourteen families with HPT-JT. The proposed role of HRPT2 as a tumor suppressor was supported by mutation screening in 48 parathyroid adenomas with cystic features, which identified three somatic inactivating mutations, all located in exon 1. None of these mutations were detected in normal controls, and all were predicted to cause deficient or impaired protein function. HRPT2 is a ubiquitously expressed, evolutionarily conserved gene encoding a predicted protein of 531 amino acids, for which we propose the name parafibromin. Our findings suggest that HRPT2 is a tumor-suppressor gene, the inactivation of which is directly involved in predisposition to HPT-JT and in development of some sporadic parathyroid tumors.

Mechanism of action of estrogens and selective estrogen receptor modulators

Estrogen, one of several sex steroid hormones, mediates its actions through the estrogen receptor. The estrogen receptor (ER) has two subtypes, ER alpha and ER beta, each of which predominates in specific tissues and organs. Cofactor proteins interact with the ER to maximize ligand-dependent transactivation of target-gene promoters. The estrogen response element is the final step in estrogen-mediated gene regulation, and current research is focused on alternate response elements. The resulting biologic action can vary according to the specific type of ER, cofactor milieu, response element, and ligand. Selective estrogen receptor modulators (SERMs) exhibit tissue-specific estrogen agonist or antagonist activity. The SERM raloxifene, which binds to ER and targets a distinct DNA element, may distinguish agonist vs antagonist activity by ER subtype and has unique activity among other SERMs because of its molecular conformation. Phytoestrogens, a potential alternative to hormone replacement therapy and for cancer prevention, do not consistently mimic estrogen's activity. Different types of phytoestrogens have different potencies, and taking high-dose supplements after menopause may not emulate the apparent benefits of lifelong consumption of phytoestrogen-rich diets. In conclusion, the complexity of estrogen action--through different ER subtypes, with various cofactors, on alternate response element--is further enhanced by ligands with selective estrogen activity. Additional research is needed to elucidate these pathways and the resulting biological effects.

C-C chemokine receptor 4 expression defines a major subset of circulating nonintestinal memory T cells of both Th1 and Th2 potential

CCR4, a chemokine receptor for macrophage-derived chemokine (MDC) and thymus and activation-regulated chemokine (TARC), has been implicated as a preferential marker for Th2 lymphocytes. Following in vitro polarization protocols, most Th2 lymphocytes express CCR4 and respond to its ligands TARC and MDC, whereas Th1 lymphocytes express CXC chemokine receptor 3 and CCR5 (but not CCR4). We show in this study that CCR4 is a major receptor for MDC and TARC on T lymphocytes, as anti-CCR4 mAbs significantly inhibit the migration of these cells to MDC and TARC. CCR4 is also highly expressed in most single-positive CD4(+) thymocytes and on a major fraction of blood nonintestinal (alpha(4)beta(7)(-)) memory CD4 lymphocytes, including almost all skin memory CD4(+) cells expressing the cutaneous lymphocyte Ag (CLA), but weakly or not expressed in other subsets in thymus and blood. Interestingly, major fractions of circulating CCR4(+) memory CD4 lymphocytes coexpress the Th1-associated receptors CXC chemokine receptor 3 and CCR5, suggesting a potential problem in using these markers for Th1 vs Th2 lymphocyte cells. Moreover, although production of Th2 cytokines in blood T cells is associated with CCR4(+) CD4 lymphocytes, significant numbers of freshly isolated circulating CCR4(+) memory CD4 lymphocytes (including both CLA(+) and CLA(-) fractions) readily express the Th1 cytokine IFN-gamma after short-term stimulation. Our results are consistent with a role for CCR4 as a major trafficking receptor for systemic memory T cells, and indicate that the patterns and regulation of chemokine receptor expression in vivo are more complex than indicated by current in vitro models of Th1 vs Th2 cell generation.

Long-term effects of raloxifene on bone mineral density, bone turnover, and serum lipid levels in early postmenopausal women: three-year data from 2 double-blind, randomized, placebo-controlled trials

BACKGROUND

In postmenopausal women, raloxifene hydrochloride has favorable effects on bone and lipid metabolism and does not stimulate reproductive tissues. The studies reported herein evaluated the long-term (3-year) effects of raloxifene treatment on bone mineral density (BMD), serum lipid levels, and drug tolerability in healthy postmenopausal women.

METHODS

A total of 1145 healthy European and North American postmenopausal women aged 45 through 60 years were enrolled in 2 parallel, double-blind, randomized, placebo-controlled trials of identical design and randomly assigned to receive raloxifene hydrochloride, 30, 60, or 150 mg, or placebo daily; all groups received 400 to 600 mg of elemental calcium. Assessments included measurements for BMD by dual-energy x-ray absorptiometry, markers of bone turnover, and serum lipid levels.

RESULTS

Lumbar spine BMD changed from baseline to 36 months as follows: placebo (mean percentage change + SE), -1. 32% +0.22%; raloxifene, 30 mg, 0.71% +0.23%; raloxifene, 60 mg, 1. 28% +0.23%; and raloxifene, 150 mg, 1.20% +0.24%. Comparable BMD changes were observed in the hip and total body. Biochemical markers of bone turnover were suppressed by raloxifene to normal premenopausal ranges through 3 years. Serum low-density lipoprotein cholesterol was reduced 7% to 12% below baseline through 3 years. Study withdrawals due to any reason (37%) and withdrawals due to adverse events (14%) were not different among groups. The only significant adverse effect of therapy was hot flashes (25% in the 60-mg raloxifene group vs 18% in the placebo group); hot flashes were typically reported as mild and were not associated with study withdrawal (1.7% for 60-mg raloxifene vs 2.4% for placebo).

CONCLUSIONS

Raloxifene preserves BMD at important skeletal sites, lowers serum low-density lipoprotein cholesterol levels, and has a tolerability profile comparable to placebo. These results indicate a favorable benefit-risk profile of raloxifene for long-term use in healthy postmenopausal women. Arch Intern Med. 2000;160:3444-3450.

Clinical supervision as an emancipatory process: avoiding inappropriate intent

As clinical supervision becomes more widely implemented in the United Kingdom with concerns and resistances being eroded as practitioners discover its benefits, it is important that potential limitations and perhaps failures are avoided. This paper utilizes Johns' (1996) intent-emphasis axis to explore how a technical interest, misunderstanding of expert practice, and confusion of self awareness with counselling, can detract from the supervisory process. Several of the criticisms of reflective practice will be examined to demonstrate where concerns are valid and where they may be based on misunderstandings and the need to control clinical supervision. Greater awareness of inappropriate emphasis and intent should enable even relatively inexperienced supervisors to help their supervisees move towards independence, emancipation and evolving expertise.

Living environments and older people

The influence of care environments on patients has long been a fundamental concern for nurses. Considerations of how environments might be defined, particularly how multiple aspects of environments might impact on any individual, are complex. This article aims to unpick some of the complexities and to offer ideas on how nurses can positively influence environments, particularly in settings where older people live and are offered care.

Hyperparathyroidism-jaw tumor syndrome: the HRPT2 locus is within a 0.7-cM region on chromosome 1q

Hyperparathyroidism-jaw tumor syndrome (HPT-JT) is an autosomal dominant disease characterized by the development of multiple parathyroid adenomas and multiple fibro-osseous tumors of the maxilla and mandible. Some families have had affected members with involvement of the kidneys, variously reported as Wilms tumors, nephroblastomas, and hamartomas. The HPT-JT gene (HRPT2) maps to chromosome 1q25-q31. We describe further investigation of two HPT-JT families (K3304 and K3349) identified through the literature. These two expanded families and two previously reported families were investigated jointly for linkage with 21 new, closely linked markers. Multipoint linkage analysis resulted in a maximum LOD score of 7.83 (at recombination fraction 0) for markers D1S2848-D1S191. Recombination events in these families reduced the HRPT2 region to approximately 14.7 cM. In addition, two of these four study families (i.e., K3304 and K11687) share a 2.2-cM length of their (expanded) affected haplotype, indicating a possible common origin. Combining the linkage data and shared-haplotype data, we propose a 0.7-cM candidate region for HRPT2.

Keeping a reflective practice diary: a practical guide

Reflective practice aims to enhance client care via the professional development and growing expertise of practitioners. This paper offers practical guidelines for writing diaries that may form the basis for reflective practice, while acknowledging the skills that practitioners already use to examine their nursing actions and interactions. There is an emphasis on the outcomes of reflection as well as the reflections themselves, as this is seen as important if professional development is to be recognized and clients benefit. Time constraints that may make frequent formal reflection difficult are recognized by the format that allows deeper reflection where time permits and as skills develop. While ideas presented have been influenced by the literature on reflection, the paper owes as much to the continuing education students of the Homerton School of Health Studies who studied the reflective practice module during 1996. Without listening to their discussions, becoming aware of their difficulties and sharing their growing ability to reflect on practice, this article would not have been possible.

Paradigm dialogues and dogma: finding a place for research, nursing models and reflective practice

Debates within nursing can take the form of useful discussion and critique or verbal conflict generated from inflexible paradigm positions intolerant of differing stances perceived to be of no value. It is suggested that the most profitable process is debate that generates understanding of the strengths and limitations of various tools and techniques and helps identify suitable usage rather than uncritical advocacy or outright rejection. Suggested uses will thus themselves become subject to further debate and practitioners will be encouraged to adopt a use that suits their practice setting and role. The quantitative-qualitative research debate, criticisms of the nursing process and nursing models and reflective practice are examined. Dogmatic positions are highlighted and uses that are potentially controversial are identified.