Treatments for Patients with Prostate Cancer

Treatments for Patients with Prostate Cancer EFFECTIVE TREATMENT FOR PATIENTS WITH PROSTATE CANCER TO ACHIEVE A BIOCHEMICAL RECURRENCE FREE SURVIVAL Mariam O. Akinwale MEDICAL UNIVERSITY OF THE AMERICAS Mentor: Dr. Akintola Odutola Manuscript word count: 4205 HYPOTHESIS: In the treatment of aggressive and metastatic prostate cancer, patients who undergo radical prostatectomy with additional radiation therapy and/or hormonal therapy have less recurrence rate in comparison to those who receive radical prostatectomy alone due to its additive curative effect. ABSTRACT (word count: 275) Hypothesis: In the treatment of aggressive and metastatic prostate cancer, patients who undergo radical prostatectomy with additional radiation therapy and/or hormonal therapy have less recurrence rate in comparison to those who receive radical prostatectomy alone due to its additive curative effect. Method: The articles reviewed in this studies were obtained from PubMed. The database search combined terms from three themes: men above the age of 50, radical prostatectomy, radiation therapy or hormonal therapy and prostate cancer remission. This search yielded 72 articles after inclusion criteria were considered. A total of 32 articles were used for final review after excluding 40 articles that did not compare management options for treatment of prostate cancer. Result: Better life-expectancy have been indicated in patient treated with radiotherapy with hormonal therapy compared to patient treated with radical prostatectomy only. However, radical prostatectomy and radiotherapy with hormonal therapy are far more efficient compared to radiotherapy with hormonal therapy. The use of hormonal therapy for treatment of prostate cancer has always been frowned at because of its life-threating side effects but its patient-survival rate supersedes that of radical prostatectomy as a monotherapy. Conclusion: Combination therapy of radical prostatectomy with radiotherapy and hormonal therapy for treatment of patients with either benign or metastatic prostate cancer have a longer life-expectancy than radiotherapy with hormonal therapy, while patients treated with radiotherapy and hormonal therapy have a longer life-expectancy than those with radical prostatectomy with radiotherapy even after considering the side effects of hormonal therapy. Screening tests may help with early detection of biochemical recurrence and also prevent overtreatment with radiotherapy and/or hormonal therapy after radical prostatectomy. Keywords: radical prostatectomy, adjuvant radiation therapy, hormonal therapy, biochemical recurrence, prostates cancer INTRODUCTION Prostate cancer (PCa) is the second commonest cancer in males above age 60. African- Americans have the highest prevalence in the US. Risk factors include diets high in beef and milk. Two hundred and thirty-three thousand new cases are diagnosed yearly with 29,480 mortality reported in 2014. (American Cancer Society, 2014) Given these statistics, it is very important to diagnose and treat PC early in order to reduce the risk of high mortality. Several treatments options are available in the management of PCa. Low- risk prostate cancer is managed by active surveillance in order to prevent unnecessary exposure to radiation or surgery. Intermediate or high- risk non-metastatic prostate cancer is treated with prostatectomy or radiation therapy (Zietman et al., 2010). Aggressive and metastatic prostate cancers are treated with variable combinations of radical prostatectomy (RP), radiation therapy (RT), chemotherapy, cryosurgery, hormonal therapy (HT) and bisphosphates. These combination therapeutic options address the tendency of aggressive PCa to metastasize to neighbouring structures/organs. This study is designed to evaluate a specific combination of treatment option in the management of aggressive and metastatic PCa. It is hypothesized that patients with aggressive PCa who undergo radical prostatectomy and adjuvant radiotherapy have less recurrence rate compared to those who receive radical prostatectomy alone due to its additive curative effect (Thompson et al., 2013). This study is significant because evidence suggests that different combination treatments of aggressive PCa are associated with different recurrence rate. The identification of the combination therapy with the lowest recurrence rate and longer life-expectancy is essential in this study. I chose this topic because it is important for family practice physicians to have accurate information to give to their patients regarding best treatment options for aggressive metastatic PCa. METHOD The articles reviewed in this studies were obtained from PubMed. The database search combined terms from four themes: specific population (older men OR men above 50 OR prostate cancer patient OR post prostatectomy patient OR recurrent prostate cancer patient), intervention (prostate cancer adjuvant therapy OR prostate cancer adjuvant radiotherapy OR prostate cancer adjuvant chemotherapy), comparison (radical prostatectomy) and possible outcomes (prostate cancer recurrence OR prostate cancer remission OR prostate cancer curative OR prostate cancer life span OR prostate cancer prognosis OR prostate cancer quality of life). Boolean operators used were OR and AND. OR was used to capture each term within a theme and AND was used to link each theme within parentheses. Filters used were: article types (randomized controlled trial), text availability (free full text), publication dates (5 years), and limited to human. Inclusion criteria Articles that were included in the systematic review of this study had to meet the following criteria: used randomised clinical trials, cohort studies and meta-analysis; prostate cancer population; radical prostatectomy with adjuvant radiotherapy and hormonal therapy as intervention; radical prostatectomy only as comparison; and prostate cancer recurrence, prostate cancer remission, prostate cancer curative, prostate cancer life span, prostate cancer prognosis, prostate cancer quality of life as outcome. Localized and high risk prostate cancer management were included in the study. Exclusion criteria Population of women and men below the age of 50 were excluded. Articles published prior to 2011 and were not written in English language were excluded. Articles that were not free full text were excluded. Articles that did not compare RP+RT+HT with radical prostatectomy only were excluded. RESULTS This search yielded 72 articles after inclusion criteria were considered. A total of 27 articles were used for final review after excluding articles that did not compare management options for treatment of prostate cancer. Treatment of Prostate Cancer with Radical Retropubic Prostatectomy (RRP) And Pelvic Lymph Node Dissection (PLND) Before we can lay emphasises on other possible treatments to prevent biochemical recurrence (BCR) after RP, we have to talk about RRP and PLND. According to one of the studies cited in this systematic review, ten of 11 patients with histologically confirmed lymph node metastasis (LNM) showed a PSA response (Winter et al., 2015). Three of 10 patients with single LNM had a complete biochemical remission (median follow-up 72months, range 31.0-83) (Winter et al., 2015). In five cases with single LNM PSA decreased et al., 2015). All of the additionally removed 30 LNs were completely negative (Winter et al., 2015). Treatment of Prostate Cancer with Radical Prostatectomy (RP), PLND and Hormonal Therapy (HT) The above combination therapies have been reported to be commonly used for the treatment of metastatic PCa to lymph nodes and other neighboring tissues than localized PCa due to its higher efficacy and potency for the treatment of metastatic PCa. The first article I will be talking about under this subtopic had a mean follow-up of 5.3 years and LNM occurred in 140 patients. An average of 10.9 lymph nodes was dissected from patient with pN1 through a method known as extended sentinel lymph node dissection (eSLND) (Muck et al., 2015). After the surgery, 121 patients with pN1 patients received adjuvant ADT for a sort period of time (Muck et al., 2015). Average survival year for; recurrence-free survival (RFS), RFS after secondary treatment, case-specific survival (CSS), and overall survival (OS) were 4.7, 7.0, 8.8, and 8.1 years, respectively (Muck et al., 2015). RFS, CSS, and OS were significantly correlated with tumor staging (Muck et al., 2015). The second article focuses on the 67 Chinese patients with lymph node metastasis (LNM) after RP and extended PLND, and these patients received continuous adjuvant ADT. The median follow-up of this study was 46.7 months and two patients were lost to follow-up. BCR-free survival was recorded annually indicating 52%, 40%, 22% for the first 3 years respectively and a more significant survival was observed in patients with 5-year BCR free-survival which shows a 93% free-local recurrence, 83% free-systemic metastasis and 96% cancer death-free (Qin et al,2015). Postoperative BCR-free survival was 27.5 months (Qin et al.,2015). Even though a lot of articles support the positive effect of HT as a treatment for PCa, we also have to consider the adverse effect of HT including depression. According to Lee et al, 2015, patients who are treated with ADT have shown to a significant prolonged depressive state (pet al.,2016). The depressive state in correlation to ADT is confirmed when compared to a control by indicating a p value less than 0.001 (Lee et al.,2016) Apart from the adverse effect associated with HT, metastasis have been reported after adjuvant ADT has been used for treatment of both localized and high-risk PCAa (Taguchi et al., 2014). Taguchi et al. reported 9 (4.6%) patients developed metastasis and 6 (3.0%) died from PCa. Eight of nine metastatic patients had a GS greater than 9 and developed a metastasis to the bone, while the remaining one had a GS greater than 7 and developed lymphatic spread (Taguchi et al.,2014). Based on the findings above, optimal timing of salvage ADT for BCR after RP is crucial. According to a study by Taguchi et al., biochemical recurrence was seen in one patients (2.0%) in the ultra-early group and seen in 12 patients (17.1%) in the early salvage ADT group (Taguchi et al.,2014). Only one patient in the early salvage ADT group developed metastasis to a left supraclavicular lymph node, and no patient died from PCa during follow-up (Taguchi et al.,2014). Treatment of prostate cancer with Radical Prostatectomy (RP) and Radiation Therapy (RT) In order to examine the effect of RT after RP, an article which compared outcome of patients treated with radiotherapy after radical prostatectomy and patients who were under active surveillance after radical prostatectomy (Petruzzeillo et al., 2014). Patients who were under surveillance had a longer follow-up but higher recurrence rate and short life-expectancy (Petruzzeillo et al.,2014). Another article was able to back-up this finding, indicating significant longer life-expectancy and lower risk of recurrence (Gandaglia et al.,2014). However, the earlier administration of radiotherapy after RP is very essential. Studies had if indicated that patients who had ultra-early radiotherapy after RP had lower recurrence and longer life-expectancy (Azelie et al.,2012). A number of reports have associated early RT after RP to decrease risk of BCR and longer overall survival (OS). According to Gandaglia et al, patients with high risk score benefitted more from early radiotherapy compared to patients with lower risk scores (Gandaglia et al.,2014). The risk scores were determined based on its association to increasing 5- to 10- year prostates cancer mortality rates with a p value less than 0.001 (Gandaglia et al.,2014). the risk score was associated with increasing 5- and 10-year cancer-specià ¯Ã‚ ¬Ã‚ c mortality rates (P et al., 2014). However, adjuvant RT after RP have shown to present with gastrointestinal and genitourinary toxicities. A study indicating the use of real-time tumor-tracking intensity-modulate radiation therapy (RT-IMRT) as a much preferable RT for treatment of PCa with less adverse effects (Shinohara et al.,2013). In patient treated with RT-IMRT have shown to have better quality of life with little or no risk of urinary and sexual dysfunction (Shinohara et al., 2013). No patients treated with RT-IMRT after RP have gastrointestinal discomfort (Azelie et al.,2012). An article has indicated that earlier RT can lower the risk of adverse effect such as gastrointestinal and urinary dysfunction (Hegarty et al.,2015). Another concern is excessive treatment of PCa with RP+RT using standardized guideline. Patients who underwent RT after RP using this standard guideline 27 patients out of 163 patients had recurrence and 3 out 87 with PSAet al.,2014). Hence the other patients were over treated and therefore exposing them to preventable adverse effects. Treatment of Prostate Cancer with Radical Prostatectomy(RP), Radiation Therapy(RT) and Hormonal Therapy (HT) For the treatment of high-risk prostate cancer (PCa) different evidence-based therapies exist such as (RT+HT), (RP+RT), and (RP+RT+HT). RT + HT resulted in a longer life-expectancy which is always greater than 1 compared to RP+RT (Parikh et al.,2012). However, RP+RT+HT combination have a greater than 0.5 longer life-expectancy compared to RT+HT after considering their side effects (Parikh et al.,2012). Treatment of Prostate Cancer with Radical Prostatectomy (RP), Radiation Therapy (RT), Hormonal Therapy (HT) and Neoadjuvant Chemotherapy (NCHT). Patients with local and metastatic PCa are prone to recurrence after RP. Hence adjuvant therapies are required to reduce biochemical failure and also prolong life-expectancy. Therefore, it is important to study the adverse effect of these combination therapies (RP+RT+HT+NCHT). The major adverse effect associated with these combinations are gastrointestinal and urinary dysfunction while leucopenia and neutropenia mainly for NCHT (Guttilla et al.,2014) and (Thalgotti et al.,2014). Gastrointestinal and urinary dysfunction are seen in low grade pathologically (Guttilla et al.,2014). Thalgotti et al.,2014 reviewed the percentile of blood toxicity after patients have been administered the combination therapies; 90% had neutropenia and 53.8% leucopenia in the studied patients (Thalgotti et al.,2014). Effective Screening Test to Aid Prevention of Biochemical Recurrence (BCR) Eighty-eight miRNAs were identified to be significantly (p36months) (Bell et al.,2015). Nine miRNAs were identified to be significantly (pet al.,2015). Based on the efficacy of the above result a new prognostic stick has been created, composed of miRNA-4516 and miRNA-601, Gleason score and lymph node status (Bell et al.,2015). A study was done to assess which patients would benefit the most from RT after RP using 11C-choline PET/CT. In order to identify which patients would benefit the most from restaging 11C-choline PET/CT before RT, 11C-choline PET/CT was positive in 28.4% of patients (172/605) (Castellucci et al, 2016). Castellucci et al.,2016 categorized these patients based on staging: Eighty-three of 605 patients were positive locally, 72 of 605 patients had systemic metastasis, and 17 of 605 patients had both local recurrence and systemic metastasis (Catellucci et al., 2016). At multi-analysis; PSA, PSA doubling time (PSAdt), and ADT were signià ¯Ã‚ ¬Ã‚ cant predictors for positive scan results, whereas PSA and PSAdt were signià ¯Ã‚ ¬Ã‚ cantly related to distant recurrence detection (Pet al.,2016). Genomic classifier (GC) used to predict biochemical recurrence and distant metastasis in men receiving radiotherapy (RT) after radical prostatectomy (RP). Illustrating Den et al.,2015, the measurement of GC was used to predict recurrence of PCA at 5 years after receiving RT (Den et al.,2015). A multi-analysis was done which no correlation between GC and PSA before RP. However, patients with low GC had no significance recurrence at 5 years after RT while patients with high GC had recurrence at 5 years after RT (Den et al.,2015). DISCUSSION This reviews attempted to answer the question: Can adjuvant therapy be used in patients that have undergone radical prostatectomy to prevent local recurrences? The general collective consensus of articles included in this review supported the hypothesis that in the treatment of aggressive and metastatic prostate cancer, patients who undergo radical prostatectomy and adjuvant radiotherapy with hormonal therapy have less recurrence rate in comparison to those who receive radical prostatectomy alone due to its additive curative effect (Parikh et al.,2012; Kyrdalen et al.,2012; Hayachi et al., 2012; Shinohara et al.,2013; Kaplan et al.,2013; Linder et al.,2013; Azelie et al.,2012; Miyake et al.,2014; Taguchi et al.,2014; Muck et al.,2014; Gandaglia et al,2015; Den et al.,2014; Castellucci et al.,2014; Lee M. et al., 2015; Kang et al.,2014; Thalgotti et al.,2014; Sato et al.,2014; Gutilla et al.,2014; Kim et al.,2016; Rosenkrantz et al.,2015; Petruzzeillo et al.,2014;Den et al.,2014; Lee J. et al.,2015; Qin et al.,2015; Mizowaki et al,2015; Winter et al.,2015; Bell et al,2015; Hegarty et al.,2015; Den et al., 2015; Taguchi et al.,2014). Only one article concluded that patient with High Gleason score (GS) carry a risk of bone metastasis and cancer specific-death after RP with ADT (Taguchi et al.,2014). Seven articles laid more emphasise on the combination therapys adverse effects such as gastrointestinal, genitourinary toxicities and sexual dysfunction (Shinohara et al.,2013) and specifically; diabetes mellitus, heart disease, osteoporosis (Parikh et al.,2012) and depression for HT (Lee M. et al.,2015). However, few articles addressed these adverse effects by recommending ultra-early RT after RP (Azelia et al.,2012 and Hegarty et al.,2015) and early HT after RP (Taguchi et al.,2014 and Sato et al., 2014). However, early RT after RP does not only reduce gastrointestinal and gastrourinary toxicities but it also prolongs quality-adjusted life expectancy (QALE) and lowers biochemical recurrence (BCR) (Azelie et al.,2012, Sato et al.,2014 and Gandgalia et al.,2014). Radiotherapy such as Real-time tumor-tracking intensity-modulated RT (RT-IMRT) may be a better treatment for localized PCa even though it has a similar effect as RP because of the adverse effects associated with RP such as urinary incontinence and erectile dysfunction (Azelie et al.,2012). Hence, better quality of life with RT compared to RP (Shinohara et al.,2013). An article compared RT after RP with observation alone (OA) after RP which reviewed 87.1% to 30% biochemical progression-free survival, respectively (Petruzzeillo et al.,2014). This result lays further emphasises on the efficacy of RT after RP. Despite all the articles emphasizing the efficacy of adjuvant RT and androgen deprivation therapy (ADT) after RP, there is concern for excessive treatment of PCa using AUA/ASTRO guideline on adjuvant RT. A particular article stretched on the concern by concluding that patients treated with RT who met the AUA/ASTRO guideline should be carefully considered to prevent excessive treatment (Kang et al., 2014). This is because in the article, among 163 patients with high risk BCR according to AUA/ASTRO guideline, only 27 patients developed BCR and treated with RT (Kang et al., 2014). In addition, in 87 patients with pre-operative PSAet al., 2014). Some articles (Gutilla et al,2014; Gutilla et al,2014 and Thalgott et al.,2014) considered the effectiveness of screening test on predicting biochemical failure in order to prevent BCR after RP. Several screening test were considered and tested. Specific miRNA (miR-4516 and miR-601), 11C-Choline PET/CT, Genomic Classifier (GC) and whole-lesion histogram apparent diffusion coefficient (ADC) metric have sensitivity and specificity for BCR after RP (Bell et al.,2015; Castellucci et al.,2015; Den et al.,2015; Den et al.,2014 and Rosenkrantz et al.,2015). These screenings can help to identify specific treatment for BCR, for example, patients with low GC scores are best treated with RT only, whereas those with high GC scores beneà ¯Ã‚ ¬Ã‚ t from additional therapies (Den et al., 2014). Some studies verified that the trimodality therapy (RP+RT+HT) has shown an increase in quality of life expectancy (QALE) (Parikh et al.,2012; Guttilla et al.,2014; Kyradalen et al.,2012 and Den et al.,2014). Limitations of the search strategy include searching only one database (PubMed), only one source of information is used (database), only published data is included, only data from the last 5 years is included, only articles published in the English language are included, and only one reviewer is reviewing the abstracts. The major limitation of this systematic review is use of more retrospective cohort than clinical trials and use of only free-full articles and also broad question covering several treatment options such as different types of adjuvant radiation therapies, hormonal therapies and inclusion of some chemotherapies. Future research may consider comparing multiple interventions in a single randomized clinical trial with several approaches to allow for better comparison across clinical outcome measures. Further research may consider more screening test to prevent overtreatment. APPENDICES First Author Date of Publication Study Design Level of Evidence Study Population Therapy Outcome Azelie C. 2012 Randomized Clinical trial 1b 178 patients were referred for daily exclusive image guided IMRT (IG-IMRT) and 69 patients were the control group IG-IMRT vs RP+IMRT Patients with low risk PCa treated with IG-IMRT had a more significant outcome compared to the control group (patient treated with RP + IMRT) Bell E. March, 2015 Prospective Cohort Study without controls 4 43 patients who undergone RT after RP miRNAs miRNA signatures (Notably, two novel miRNAs: miR-4516 and miR-601) can be used as a diagnostic tool to determine patients who will benefit from additional therapy after RP. Castellucci P. Nov., 2015 Case series 4 605 patients treated with RT after RP. RT+RP vs ADT at the time of 11C-choline PET/CT At the early stage of BCr after RP 11C-choline PET/CT should be suggested before ADT is administered. Den R. March, 2015 Randomized Clinical Trials 1b 188 patients with positive margin of PCa at Thomas Jefferson University and Mayo Clinic between 1990 and 2009 were considered. Neoadjuvant HT, IMRT, salvage RT, ART In patients treated with RT after RP,genomic classifier (GC) was a good prognostic tool for determining metastasis. Den R. August, 2014 Randomized Clinical trial 1b 139 patients who underwent RT after RP that were identified with pT3 or positive prostate margin. Using genetic classifier to predict biochemical failure after RP+RT The genetic classifier (GC) predicted biochemical failure and metastasis after RP +RT. Patients with lower GC may benefit from delayed RT, as opposed to those with higher GC. Gandaglia G. August, 2014 Randomized Clinical trial 1b 7616 prostate cancer patients treated with RP. Early treatment with RT after RP vs not receiving early RT after RP Patients with two or more adverse pathological characteristics at RP might beneà ¯Ã‚ ¬Ã‚ t the most from adjuvant RT in terms of reduced cancer specific mortality. Guttilla A. 2014 Randomized Clinical Trial 1b 35 patients with newly diagnosed high-risk localized prostate cancer IMRT, RP, ADT, docetaxel-based chemotherapy This treatment phase for high-risk PCa indicated an acceptable oncological outcome. Hayashi S. July, 2012 Retrospective Cohort Study without controls 4 41 patients were treated with external beam RT as salvage RT because of increasing PSA levels following RP. RT after radical prostatectomy Lymphatic invasion is reported after RT+RP Vascular invasion is not associated with biochemical failure in PCa treatment. Hegarty S. February, 2015 Prospective Cohort Study without controls 4 Using the Surveillance, Epidemiology, and End Results-Medicare linked database, we identified 6,137 prostate cancer patients diagnosed during 1995-2007 who had one or more adverse pathological features after prostatectomy. RT after RP RT after RP is associated with adverse effects such as gastrointestinal and genitourinary toxicities while early treatment with RT is not associated with these adverse effects. Kaplan J. 2013 Retrospective Cohort Study without controls 4 577 men with LN metastases discovered during RP and 177 men underwent ART with no distant metastases Adjuvant RT, RP ART after RP in men with LN-positive prostate cancer was associated recurrence free-survival. Kang J. 2014 Retrospective Cohort Study without controls 3b 163 men who had pT2-3 with undetectable PSA level after RP who had metastasis. Adjuvant RT (ART) after RP ART in patient who met the ASTRO/AUA criteria should be applied more selectively to avoid overtreatment. Kyrdalen A. 2012 Randomized Clinical Trial 1b 771 compliers were divided into four groups (i) no treatment, (ii) RP, (iii)RT without HT and (iv) RT+HT No treatment vs RP vs RT vs RT+HT No treatment group: had the highest level of moderate/severe bladder outlet-obstruction. RP group: reported more urinary incontinent compared to other treatment groups and also the highest prevalence of poor erectile functions. RT group: reported highest gastrointestinal dysfunction and fecal leakage compared to RP and no treatment group. Bladder outlet obstruction and poor sexual drive were significantly associated with low quality of life. Lee J. July, 2015 Prospective Cohort Study without controls 4 307 patients who underwent RP at Seoul National University Hospital between January,2006 and July,2007. RP According to this finding, SHBG may be useful in selection of candidate for adjuvant treatment following RP. Lee. M 2015 Observational studies with controls 3b 61 men with prostate cancer and their match control group (n=61) without cancer ADT This article indicates an association with PCa patient developing depression after receiving ADT. Linder B. 2013 Retrospective Cohort Study without controls 4 419 patients who received additional HT Adjuvant HT after RP Adjuvant HT after RP with high-risk PCa does not increase non-prostate cancer (such as cardiovascular disease) mortality, even in patient with multiple comorbidities. Mizowaki T. April, 2015 Observational Study with controls 3b Patients with localized PCa from the Japanese Radiation Oncology Study (JROSG) who were treated with RP before 2005 and those who received RT in 2007.. HT, RT Hormonal therapy was combined with radiotherapy which resulted in a longer life- expectancy. Muck A. March, 2014 Retrospective Cohort Study without controls 4 819 patients with localized prostate cancer (PCa) Extended sentinel lymph node dissection (eSLND) and RP. The use of ESLND and RP in patients with low risk can serve serve as complete cure for BCR. Parikh R. Jan., 2012

Has Slavery Changed since Ancient Times? :: Slavery Essays

Has Slavery Changed since Ancient Times? Slavery has always been a large issue and possibly always will. The issues of today are often negative but did you know that back in ancient Roman times they were all for it? Well they were! The question that will be answered in this assessment is "In what ways, if any, has slavery changed from ancient to modern times?" I believe that slavery has changed very much from the past. Not that there may be more or less of it, but that it may be harsher and have worse conditions. In the ancient times slavery was a common and normal thing. In 70 A.D it was estimated that there were slaves in Rome. There were no troubles or controversies over it. Slavery was widespread and most families owned at least one slave. Today there is only one real way to become a slave but in Roman Times (rise of Rome) there were three. 1=Slavery due to crime committed. 2=Not being a Roman citizen. 3=Taken prisoner by Romans. An example is war. Some of these may seem unfair but it was the Romans belief in their superiority. There were many types of slaves that were good at different types of jobs. Often, rich families had so many slaves that they didn't really have to do any work around the house at all! There were other types of slaves apart from the above. These were Statuliberi = Slaves freed by their master's will. Servi sub unsufructu manumissi =Slaves made free by will remaining as slaves. Bona fide servientes = Freemen acting as slave to master Auctorati = Free men who were gladiators, under a contract to their gladiatorial master. Redempti = Freemen captured in war and ransomed back to non-relatives. They worked until they paid off their debt. Coloni adscripti glebae = Free persons who were tenant farmers. These slaves were not treated as a person but as an impersonal asset although they did have their rights. These were dismal rights but they were important for the slaves well-being. The rights were as follows: the slave was allowed his personal items (like money etc.), he could not be killed without a good reason. Masters had rights too of course. They could treat a slave anyway they wanted to. They could be abusive, friendly or do anything they wanted to the slave. They could defend themselves against slaves and could kill him/her if the master provided the courts with a good reason.

Pagan Christianity by Frank Viola Essay

The book â€Å"Pagan Christianity† by Frank Viola and George Barna leads readers into the world of religion, religious customs and rituals, sermons and religious clothing. The authors show how the church has changed over times and what new practices and beliefs it has adapted. Frank Viola is known to be an American writers and speaker who has published a series of books devoted to problems with church calling people to return to the biblical principles. Therefore, the central thesis of the book is that people should get back to biblical principles in their religious beliefs because modern church practices are rooted in secular or Pagan practices which have nothing to do with the Bible and God’s commandments, as well as the church doesn’t resemble the early church which was described in the book of Acts. Modern church is based on hierarchical structure; whereas the author claims Jesus came with the strong intent to put an end to legalism, structure and hierarchy. The book is very interesting from historical viewpoint and I think that it is broadly accurate offering us new insights and facts from religious past. Pagan Christianity The authors start their narration with strong claim that modern churches have little resemblance with the early centuries churches described in the New Testament. With the partaking of the Traditional Church the author became very interested trying to reveal what we went on. The first chapter is reflection of authors’ inquiries on the subject of interest. For example, Viola questions whether there was a need to turn down light and to wait when the Spirit would move on to another church. The author thinks we are the ‘Children of Lights’, although he admits that he doesn’t agree with any theologian and preacher offering his unbiased review. It is said that the word ‘pagan’ is a part of book’s title and it is applied to the churches being discussed. However, even the authors agree that often this term is not applicable. In the second chapter the author discusses the issue of the Church Building and ‘modern’ church-goerselievers. It is emphasized that the Church has built itself. The original meaning of the word refers to the Greek language ‘ekklesia’ and it means a group assembled. Viola argues that time and words are describing the gradual development of Holy Places and things which are considered important parts of religious world. The authors discuss Constantine as he was one of the first Christians who gave legitimacy to the Christian Religion. Constantine promoted and supported grand displays of religious architecture. Further, the authors review religious clothing, music, steeples, architecture, thrones borrowed from other cultures along with customs and rituals. In the third chapter Viola provides overview of the order of traditional Worship and description of Sunday morning sets. He argues that standard order should be held in all churches with only slight differences. For example, he writes: â€Å"You can scour your Bible from beginning to end, and you will never find anything that remotely resembles our order of worship†. Further, the authors describe contributions of historical Church leaders – Luther, the Puritans, the Pentecostals, etc. In the fourth chapter they describe the sermon abandoning principles of Protestantism. The authors argue that the early churches were not the sermons; instead, they were places for gathering and Jesus functioned as its Head. In the fifth chapter Viola and Barna introduce the Pastor which is viewed as an obstacle to functioning of every member. The pastor is the fundamental figure in Protestantism and he â€Å"is often better known, more highly raised, and more heavily relied on than Jesus Christ Himself†. (p. 65) And it is a serious mistake. It is noted that the word ‘pastor’ isn’t a tile – instead, it is a function. Viola notes that the word ‘pastor’ is referred to in Ephesians 4:11 only one time: â€Å"a scanty piece of evidence on which to hang the Protestant Faith. In this regard there seems to be more biblical authority for snake handling than there is for the present-day pastor†. p. 66) In the sixth chapter there is a detailed description of Sunday morning costumes. The authors describe dressing up for church, what clothing is appropriated and why. The next chapter is devoted to the origins of Music Ministry and description of the hierarchy of clergy. The eighth chapter analyzes Tithing stressing that it is used in the New Testament and Clergy Compensation, althou gh it is never used by the Christians. Further, the authors specify Baptism, its core principles and fundamentals. They explain that Baptism has replaced the Sinner’s Prayer. The Lord’s Supper was firstly a festive banquet and, therefore, lost its concrete picture of ‘The Body and Blood’. The final chapters are devoted to religious education and how it is possible to receive the qualification to Minister the gospel. Viola and Barna provide new insight into the New Testament offering so-called second glance at Jesus, churches, pastor functioning, religious customs and education. Conclusion: Strengths & Weaknesses Frank Viola and Geroge Barna offer new ideas and facts about religious order, customs, traditional music and dressing. The book is very informative, innovative and well-organized. Moreover, it is very interesting from historical perspective as it is challenging and thought-provoking. The authors incorporate many references about the culture of time, adaptation of church, etc. I like their idea about church building that church is not the place – it is the people. Nevertheless, there were several controversial moments I can’t agree with. I see that Viola offers his own version of organized empire and it seems that he is supreme speaker and the founder of knowledge. It is evidence of hierarchy which he manages to escape. Moreover, he claims that such situation shouldn’t happen in church, although he puts himself on superior position. Viola calls people to leave their church as all of them don’t follow Biblical principles. However, he tells we are the Body of Christ contradicting himself. I think that we shouldn’t worry about such doctrinal issues. Despite certain weaknesses, the book is very informative and fresh.

Hypertension In Nursing - 1340 Words

Introduction The National Council of State Boards of Nursing (NCSBN) is the organization that creates the examination that is required to obtain a nursing license. The NCSBN categorizes the content of the examination into four different categories: assurance of a safe and effective care environment, health promotion and maintenance of health, preservation of patient psychosocial and physiological health (National Council of State Boards of Nursing, 2015). Health promotion and maintenance includes subcategories of growth and development, disease and illness prevention and early detection, and includes strategies to improve or optimize health. The purpose of this paper is to research current evidence based practices for treating and†¦show more content†¦It is imperative to find ways for patients to manage hypertension which prescribed medication therapies and lifestyle changes to limit negative outcomes. Potential Negative Effect Left Unresolved. Potential negative outcomes if hypertension is left uncontrolled can become fatal. Uncontrolled hypertension can cause organ damage, renal failure, myocardial infarction, cerebrovascular accident, retinopathy, aneurysm, or encephalopathy (High Blood Pressure Dangers: Hypertensions effects on your body, 2016). Due to the negative effects associated with unresolved hypertension, it is extremely important to improve the clinical problem of uncontrolled hypertension through medication compliance and lifestyle changes as advised by medical providers. Patient Population The patient population for hypertension varies greatly, but some groups of individuals are more at risk than others. Medication treatments also differ based on demographic criteria. The JNC 8 makes medication recommendations based on age and race. For example, JNC 8 recommends thiazide diuretics in combination with calcium channel blockers but suggests angiotensin-converting enzyme inhibitor, angiotensin receptor blockers, calcium channel blockers, or thiazide-type diuretics in populations that are non-African American, even with confirmed diagnoses of diabetes (James etShow MoreRelatedChapter 33 Nursing Management Hypertension3539 Words   |  15 PagesChapter 33: Nursing Management: Hypertension Test Bank MULTIPLE CHOICE 1. Which action will the nurse in the hypertension clinic take in order to obtain an accurate baseline blood pressure (BP) for a new patient? a. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second. b. Have the patient sit in a chair with the feet flat on the floor. c. Assist the patient to the supine position for BP measurements. d. Obtain two BP readings in the dominant arm and average the results. 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