Amelioration of arterial properties with a perindopril-indapamide very-low-dose combination

BACKGROUND

Epidemiological studies have shown that increased arterial stiffness and wave reflections, major determinants of systolic and pulse pressure, are associated with morbidity and mortality. Therapeutic trials based on cardiovascular mortality have recently shown that reduction of systolic blood pressure (SBP) requires normalization of both large-artery stiffness and wave reflections.

AIMS

To compare the antihypertensive effects of the very-low-dose combination of perindopril (2 mg) and indapamide (0.625 mg) (one or two tablets per day) with the beta-blocking agent atenolol (50 mg; one or two tablets per day) in order to determine whether the combination decreased SBP and pulse pressure more than did atenolol, and whether this decrease occurred in relation to a reduction in arterial stiffness [aortic pulse wave velocity (PWV)] or a decrease in the intensity of, or delay in, wave reflections (augmentation index, measured by applanation tonometry) or a combination of both.

MATERIAL AND METHODS

This was a double-blind randomized study in 471 individuals with essential hypertension followed for 12 months. Arterial pressure was measured in the brachial artery (mercury sphygmomanometer) and in the carotid artery (applanation tonometry).

RESULTS

For the same reduction in diastolic blood pressure (DBP), the combination of perindopril and indapamide decreased brachial SBP and pulse pressure significantly more than did atenolol (adjusted differences between groups -6.2 +/- 1.5 and -5.5 +/- 1.0 mmHg, respectively; P < 0.001). This difference was even more pronounced for the carotid than for the brachial artery. Whereas both antihypertensive agents similarly decreased PWV, only the combination significantly attenuated wave reflections.

CONCLUSION

Normalization of SBP, pulse pressure and arterial function--a haemodynamic profile known to improve survival significantly in hypertensive populations at high cardiovascular risk--was achieved to a greater extent with a very-low-dose combination of perindopril and indapamide than with atenolol.

Improvement in blood pressure, arterial stiffness and wave reflections with a very-low-dose perindopril/indapamide combination in hypertensive patient: a comparison with atenolol

International guidelines recommend that antihypertensive drug therapy should normalize not only diastolic (DBP) but also systolic blood pressure (SBP). Therapeutic trials based on cardiovascular mortality have recently shown that SBP reduction requires normalization of both large artery stiffness and wave reflections. The aim of the present study was to compare the antihypertensive effects of the very-low-dose combination indapamide (0.625 mg) and perindopril (2 mg) (Per/Ind) with the beta-blocking agent atenolol (50 mg) to determine whether Per/Ind decreases SBP and pulse pressure (PP) more than does atenolol and, if so, whether this decrease is predominantly due to reduction of aortic pulse wave velocity (PWV) (automatic measurements) and reduction of wave reflections (pulse wave analysis, applanation tonometry). In a double-blind randomized study, 471 patients with essential hypertension were followed for 12 months. For the same DBP reduction, Per/Ind decreased brachial SBP (-6.02 mm Hg; 95% confidence interval, -8.90 to -3.14) and PP (-5.57; 95% confidence interval, -7.70 to -3.44) significantly more than did atenolol. This difference was significantly more pronounced for the carotid artery than for the brachial artery. Whereas the 2 antihypertensive agents decreased PWV to a similar degree, only Per/Ind significantly attenuated carotid wave reflections, resulting in a selective decrease in SBP and PP. The very-low-dose combination Per/Ind normalizes SBP, PP, and arterial function to a significantly larger extent than does atenolol, a hemodynamic profile that is known to improve survival in hypertensive populations with high cardiovascular risk.

Decision making and prostate cancer treatment selection: a review

OBJECTIVES

To review the issues surrounding decision making regarding prostate cancer treatment.

DATA SOURCES

Journal articles, abstracts, and selected findings from one prospective grounded theory research study.

CONCLUSIONS

Multiple factors are involved in the selection of prostate cancer treatment, such as individual disease-specific data, age, personal values, vicarious and personal cancer experiences, and the physician-patient relationship.

IMPLICATIONS FOR NURSING PRACTICE

Accurate information regarding each treatment option delivered by experts in their respective fields is necessary for informed decision making. A more multidisciplinary approach regarding discussion of treatment options is needed. Nurses play a pivotal role in facilitating discussion among family members and assisting patients to make a decision that balances their personal values with accurate information regarding treatment outcomes.

Expectant management of prostate cancer

OBJECTIVES

To discuss the role of expectant management in the treatment of clinically localized prostate cancer.

DATA SOURCES

Published research and review articles, textbooks, and pending research publications.

CONCLUSIONS

Expectant management is a viable option for the treatment of clinically localized prostate cancer in carefully selected men.

IMPLICATIONS FOR NURSING PRACTICE

Nursing personnel along with physicians must work together to develop coping strategies for these men to deal with the continual uncertainty of this treatment program.

Cutaneous paraneoplastic syndromes

Paraneoplastic syndromes are caused by hormones or other substances produced by cancer cells and may be the first sign of cancer. A wide range of paraneoplastic syndromes, including endocrine, neurologic, and cutaneous disorders, occurs in patients with cancer. More than 30 cutaneous paraneoplastic syndromes have been identified; this article reviews some of the more common syndromes--acanthosis nigricans, Paget's Disease, acquired ichthyosis, telangiectasia, hypertrichosis lanuginosa acquisita, erythroderma, Bazex's Syndrome, and necrotizing migratory erythema. When these syndromes are diagnosed during the course of a malignancy, professional caregivers may misinterpret them as indicative of metastatic disease or other disorders and patients may be misdiagnosed and not receive optimal treatment. Paraneoplastic syndromes also compromise quality of life by often causing skin impairment and discomfort. Therefore, nurses must be aware of the signs and symptoms of these cutaneous disorders and know how to care for patients with paraneoplastic syndromes.

Urinary incontinence as a factor in prostate cancer treatment selection

Urinary incontinence is a common adverse effect associated with treatment for early stage prostate cancer. The influence of this factor on treatment selection decisions by patients and their partners has been explored only minimally in the literature. Data regarding the actual incidence of incontinence associated with prostate cancer treatment are confusing because of the lack of standardized definitions of incontinence. Radical prostatectomy is associated with higher rates of urinary adverse effects than is radiation therapy. Brachytherapy appears to be associated with a low risk of incontinence, whereas cryosurgery is associated with significant urinary adverse effects. Including incontinence, urethral sloughing, and bladder neck obstruction. The influence of these adverse effects on decision making regarding prostate cancer treatment selection is difficult to ascertain. Research indicates that both men and their partners appear to have difficulty processing information presented to them regarding the probability of urinary adverse effects and the degree to which these adverse effects may have an impact on their daily lives.

Narrowing the options: the process of deciding on prostate cancer treatment

Prostate cancer is a pressing health concern in the United States and one surrounded by continual controversy. Currently there is no consensus regarding the efficacy of routine screening, nor has one treatment modality been demonstrated as superior. Patients and spouses are asked to choose from several options: radical prostatectomy, radiation therapy, or the "watch and wait" approach. A grounded theory design was used to examine the actual treatment decision-making process as it occurred over time among 18 newly diagnosed prostate cancer patients and their wives in western North Carolina. Couples were interviewed conjointly and individually to explore their perceptions of the decision process. All interviews were audiotaped, transcribed verbatim, and analyzed using content analysis techniques. Couples negotiated decisions through their common and unique personal and family histories, biases, and individual coping styles. They narrowed the options based on these factors. Most couples received their counseling regarding treatment options exclusively from the surgeon who narrowed the options based on age and physiologic status. Most couples chose surgery believing it to be the only treatment promising cure. Distinct misconceptions about radiation therapy were noted. Concern about potential side effects did not deter men from selecting surgery, although men and their wives differed in their willingness to accept treatment "at any cost." Information regarding potential for cure and risk of recurrence were highly important factors in the decision process. The decision was incomparable with any other life decisions the couples had faced.

Prostate cancer treatment decisions: a focus group exploration

PURPOSE/OBJECTIVES

To explore the decision-making process as retrospectively described by patients with prostate cancer and their spouses and to test the feasibility of a larger scale prospective examination of decision making in this same population.

DESIGN

A qualitative study using focus group methodology.

SAMPLE/SETTING

Twelve patients with prostate cancer and six spouses were recruited purposefully from a newly organized prostate cancer support group in an urban North Carolina community.

METHODS

Using an interview guide, an experienced facilitator conducted two 90-minute focus groups. Sessions were audiotaped, transcribed verbatim, and analyzed using thematic content analysis techniques.

MAIN RESEARCH VARIABLES

Decision making, prostate cancer treatment, spousal participation.

FINDINGS

Six themes were derived from the data: (a) Finding Out, (b) Prostate Specific Antigen Talk, (c) (Getting the Story, (d) Who Decides, (e) Treatment Options, and (f) Looking Back. The data corroborated American Cancer Society findings that national cancer resources are not being used effectively by this population and reinforced the need for a multidisciplinary approach to the management of prostate cancer.

CONCLUSIONS

Additional prospective studies are needed to explore the decision process from a family perspective. Studies focusing on the unique needs of older patients with prostate cancer and their spouses also are needed.

IMPLICATIONS FOR NURSING PRACTICE

Nurses must assess informal information sources and work toward a more comprehensive presentation of treatment options. Misconceptions about surgery and radiotherapy hamper informed decision making. Nurses are in a unique position to educate families regarding prostate cancer treatment options.