Treatment of advanced hepatocellular carcinoma with very low levels of amplitude-modulated electromagnetic

BACKGROUND: Therapeutic options for patients with advanced hepatocellular carcinoma (HCC) are limited. There is emerging evidence that the growth of cancer cells may be altered by very low levels of electromagnetic fields modulated at specific frequencies. METHODS: A single-group, open-label, phase I/II study was performed to assess the safety and effectiveness of the intrabuccal administration of very low levels of electromagnetic fields amplitude modulated at HCC-specific frequencies in 41 patients with advanced HCC and limited therapeutic options. Three-daily 60-min outpatient treatments were administered until disease progression or death. Imaging studies were performed every 8 weeks. The primary efficacy end point was progression-free survival X6 months. Secondary efficacy end points were progression-free survival and overall survival. RESULTS: Treatment was well tolerated and there were no NCI grade 2, 3 or 4 toxicities. In all, 14 patients (34.1%) had stable disease for more than 6 months. Median progression-free survival was 4.4 months (95% CI 2.1 -5.3) and median overall survival was 6.7 months (95% CI 3.0 -10.2). There were three partial and one near complete responses. CONCLUSION: Treatment with intrabuccally administered amplitude-modulated electromagnetic fields is safe, well tolerated, and shows evidence of antitumour effects in patients with advanced HCC. British Journal of Cancer (2011Cancer ( ) 105, 640 -648. doi:10.1038Cancer ( /bjc.2011 Published online 9 August 2011 & 2011 Cancer Research UK Keywords: hepatocellular carcinoma; phase II study; radiofrequency electromagnetic fields; tumour-specific modulation frequencies; 27.12 MHz Treatment of inoperable or metastatic solid tumours is a major challenge in oncology, which is limited by the small number of therapeutic agents that are both well tolerated and capable of longterm control of tumour growth. Hepatocellular carcinoma (HCC) is the second most common cause of cancer death in men and the sixth in women worldwide Therapies for HCC are limited. Resections of the primary tumour or liver transplantation are the preferred therapeutic approaches in patients who are surgical candidates The intrabuccal administration of low and safe levels of electromagnetic fields, which are amplitude-modulated at disease-specific frequencies (RF AM EMF) PATIENTS AND METHODS Patients The study was aimed at offering treatment to patients with ChildPugh A or B advanced HCC and limited therapeutic options. Patients were classified as having advanced disease if they were not eligible for surgical resection or had disease progression after surgical or locoregional therapies or had disease progression after chemotherapy or sorafenib therapy. Patients with measurable, inoperable HCC were eligible for enrolment. Previous local or systemic treatments were allowed as long as they were discontinued at least 4 weeks before enrolment. Inclusion criteria included Eastern Cooperative Oncology Group performance status of 0, 1, or 2 and biopsy-confirmed HCC. Also allowed were patients with no pathological confirmation of HCC with a level of a-fetoprotein higher than 400 ng ml À1 and characteristic imaging findings as assessed by multislice computer tomography (CT) scan or intravenous contrast ultrasound (US). As per the University of São Paulo Department of Transplantation and Liver Surgery guidelines, liver biopsies are avoided in patients eligible for transplant or with severely impaired liver function. Exclusion criteria included confirmed or suspected brain metastasis, Child -Pugh C, previous liver transplant, and pregnancy. Study design This was an investigator-initiated, single centre, uncontrolled phase I/II trial in patients with advanced HCC. The trial was approved by the local human investigation committee and conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from each patient. The protocol was registered: clinicaltrial.gov identifier no. NCT00534664. Translational Therapeutics Administration of AM EMFs The generator of AM EMFs consists of a battery-driven radiofrequency (RF) EMF generator connected to a 1.5 m long 50 O coaxial cable, to the other end of which a stainless-steel spoonshaped mouthpiece is connected via an impedance transformer ( We have previously reported the discovery of HCC-specific modulation frequencies in 46 patients with HCC using a patientbased biofeedback approach and shown the feasibility of using AM EMFs for the treatment of patients with cancer The treatment method consists of the administration of AM EMFs by means of an electrically conducting mouthpiece, which is Translational Therapeutics in direct contact with the oral mucosa ( Efficacy end points and disease assessment The primary end point of this trial was the proportion of patients progression-free at 6 months. Secondary end points were progression-free survival (PFS) (first day of treatment until progression of disease or death) and overall survival (OS) (first day of receiving treatment to death). Objective response was assessed using the Response Evaluation Criteria in Solid Tumours group classification for patients with disease assessed by either helical multiphasic CT (Therasse et al, 2000). Whenever contrastenhanced US radiological assessment was used, it was performed and reviewed by the same radiologist specialised in HCC (MCC) as this imaging modality is investigator dependent. Tumour measurements were performed at baseline and every 8 weeks. Only patients with at least one repeat tumour measurement during therapy were considered for response analysis. Throughout the study, lesions measured at baseline were evaluated using the same technique (CT or contrast-enhanced US). Overall tumour response was scored as a complete response (CR), partial response (PR), or stable disease (SD) if the response was confirmed at least 4 weeks later. Alpha-fetoprotein (AFP) levels were measured every 8 weeks in all patients throughout the study, but changes in AFP were not an end point for assessment of response. Pain was assessed according to the NCI-CTCAE v.3.0 (http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/ctcaev3.pdf). Statistical analyses and efficacy assessment All eligible patients who began treatment were considered assessable for the primary and secondary end points. A Simon two-stage phase II minimax design was used (Simon, 1989) to evaluate the rate of progression-free survival at 6 months. The interim analysis was performed once enrolment into the first stage was completed. In the first stage, 23 patients were observed. If two or fewer patients had progression-free survival X6 months, the trial would be terminated early for lack of efficacy. If the progression-free survival of 3 or more of the first 23 patients was equal or greater than 6 months, then an additional 18 patients would be enrolled to a maximum of 41 patients. If eight or more of the 41 had PFS of at least 6 months, we would conclude that the treatment was efficacious. This design had a Type I error rate of 5% and a Type II error rate of 10% for the null hypothesis of a 6-month PFS rate of 10% vs the alternative of 27.5%. KaplanMeier estimates of survival, PFS, and duration of response were calculated with standard errors based on Greenwood's formula. These calculations were performed using the Proc Lifetest in SAS 9.2 (SAS Institute Inc., Cary, NC, USA). RESULTS Patient recruitment and follow-up From October 2005 to July 2007, 267 patients were assessed for eligibility ( Translational Therapeutics A total of 31 patients (75.6%) had radiological evidence of disease progression at the time of enrolment as defined by comparison of baseline imaging studies, with imaging studies obtained within the previous 6 months; 34 (82.9%) patients had received therapy before enrolment, five (14.6%) of them systemic chemotherapy or sorafenib Treatment efficacy Six of the first 23 patients (26.1%) had progression-free survival X6 months, which led us to continue enrolling patients up to the preplanned total of 41 patients A total of 28 patients were evaluable for tumour response Translational Therapeutics patients without biopsy-proven disease subsequently withdrew consent after 4.9 months to undergo liver transplantation. The patient died of progression of disease 9.4 months later before undergoing liver transplantation. One patient with Child -Pugh B disease had a partial response lasting 11.7 months and died of gastrointestinal bleeding. One patient died of disease progression at 44.6 months. Overall, there were six long-term survivors with an OS greater than 24 months and four long-term survivors with an OS greater than 3 years. Importantly, five of the six (83%) long-term survivors had radiological evidence of disease progression at the time of study enrolment In all, 11 patients reported pain before treatment initiation, 3 patients reported grade 3, 5 patients reported grade 2, and 3 patients grade 1. Five patients reported complete disappearance of pain and two patients reported decreased pain shortly after treatment initiation. Two patients reported no changes and two patients reported increased pain. There were no treatment-related grade 2, 3, or 4 toxicities. The only treatment-related adverse events were grade 1 mucositis (one patient) and grade 1 somnolence (one patient) over a total of 266.8 treatment months. DISCUSSION Treatment with AM EMFs did not show any significant toxicity despite long-term treatment. The lack of toxicity experienced by the 41 patients presented in this report as well as the 28 patients from our previous report These data are comparable to recent phase II studies evaluating the effectiveness of standard chemotherapy as well as novel targeted therapies in HCC The majority of patients enrolled in this study had either failed standard treatment options or had severely impaired liver function that limited their ability to tolerate any form of systemic or intrahepatic therapy. Indeed, 16 patients (39.0%) had Child -Pugh B8 or B9 disease. Among these patients, the median progressionfree survival was 4.4 months (95% CI 1.6 -7.6 months), which is identical to that of the entire group. Five of these 16 patients (31.3%) received therapy for more than 7.5 months, which indicates that this therapy is well tolerated even in patients with severely impaired liver function. Previous treatment with standard chemotherapy or sorafenib does not seem to impact the effectiveness of AM EMFs in the treatment of HCC. Indeed, three of the four patients who had a Translational Therapeutics partial response while receiving AM EMFs had received previous systemic therapies (chemotherapy and sorafenib) and one had received intrahepatic therapy with 131 I-lipiodol. Tumour shrinkage as assessed by radiological imaging as well as changes in AFP levels were documented in patients with advanced HCC receiving RF EMF modulated at HCC-specific frequencies administered by an intrabuccal probe. Antitumour activity in patients with advanced HCC was exemplified by partial responses observed in four patients (9.8%) and decreases in AFP levels greater than 20% in four patients. A total of 18 patients (43.9%) either had objective response or SD X6 months. Importantly, this therapeutic approach has long-lasting therapeutic effects in several patients with metastatic cancer. Two of these patients, one with recurrent thyroid cancer metastatic to the lungs Our phase I/II study has several limitations. First, only 19 of the 41 patients had biopsy-proven HCC, and the others were diagnosed by clinical criteria, an approach similar to that used in a recently reported phase II trial evaluating the clinical and biological effects of bevacizumab in unresectable HCC (Siegel et al, 2008). Importantly, analysis restricted to these 19 patients shows rates of progression-free survival at 6 months, median progression-free survival and OS that are similar to those without biopsyproven HCC Antitumour response is considered the primary end point for phase II studies to proceed to further investigations. Studies applying Cox proportional hazards analysis indicate that this end point is consistently associated with survival in trials of locoregional therapies for HCC (Llovet et al, 2002) and a recent consensus article suggests that randomised studies are necessary to capture the true efficacy of novel therapies in HCC (Llovet et al, 2008a). In summary, the encouraging findings from this study warrant a randomised study to determine the impact of AM EMFs on OS and time to symptomatic progression. ACKNOWLEDGEMENTS We thank Drs Al B Benson III, Northwestern University and Leonard B Saltz, Memorial Sloan-Kettering Cancer Center for reviewing the manuscript. There is clinical evidence that very low and safe levels of amplitude-modulated electromagnetic fields administered via an intrabuccal spoon-shaped probe may elicit therapeutic responses in patients with cancer. However, there is no known mechanism explaining the anti-proliferative effect of very low intensity electromagnetic fields. METHODS: To understand the mechanism of this novel approach, hepatocellular carcinoma (HCC) cells were exposed to 27.12 MHz radiofrequency electromagnetic fields using in vitro exposure systems designed to replicate in vivo conditions. Cancer cells were exposed to tumour-specific modulation frequencies, previously identified by biofeedback methods in patients with a diagnosis of cancer. Control modulation frequencies consisted of randomly chosen modulation frequencies within the same 100 Hz -21 kHz range as cancer-specific frequencies. RESULTS: The growth of HCC and breast cancer cells was significantly decreased by HCC-specific and breast cancer-specific modulation frequencies, respectively. However, the same frequencies did not affect proliferation of nonmalignant hepatocytes or breast epithelial cells. Inhibition of HCC cell proliferation was associated with downregulation of XCL2 and PLP2. Furthermore, HCC-specific modulation frequencies disrupted the mitotic spindle. CONCLUSION: These findings uncover a novel mechanism controlling the growth of cancer cells at specific modulation frequencies without affecting normal tissues, which may have broad implications in oncology. Conflict of interes

Scientific production on workplace bullying/harassment in dissertations and theses in the Brazilian scenario

OBJECTIVE To analyze scientific production about workplace bullying and harassment in dissertations and theses in Brazil, with emphasis on the year of publication; educational institution; area of knowledge; professional and academic background of the authors; keywords used; and concept map organization. METHOD Bibliometric study with a quantitative approach with a sample consisting of 57 papers, 5 theses and 52 dissertations, published between 2002 and 2012. RESULTS It was found that 2012 was the year with the highest number of publications in this topic area. The region that stood out was the Southeast. The institution with the highest number of publications was the Federal University of Santa Catarina. There was a predominance of dissertations and most publications were produced by researchers focused on a multidisciplinary perspective. CONCLUSION Expanding the views regarding bullying in order to disseminate scientific production was proposed, promoting further advancement of debates and raising pertinent questions

Permanent education in health: a review

OBJECTIVE : To undertake a meta-synthesis of the literature on the main concepts and practices related to permanent education in health. METHODS : A bibliographical search was conducted for original articles in the PubMed, Web of Science, LILACS, IBECS and SciELO databases, using the following search terms: “public health professional education”, “permanent education”, “continuing education”, “permanent education health”. Of the 590 articles identified, after applying inclusion and exclusion criteria, 48 were selected for further analysis, grouped according to the criteria of key elements, and then underwent meta-synthesis. RESULTS : The 48 original publications were classified according to four thematic units of key elements: 1) concepts, 2) strategies and difficulties, 3) public policies and 4) educational institutions. Three main conceptions of permanent education in health were found: problem-focused and team work, directly related to continuing education and education that takes place throughout life. The main strategies for executing permanent education in health are discussion, maintaining an open space for permanent education, and permanent education clusters. The most limiting factor is mainly related to directly or indirect management. Another highlight is the requirement for implementation and maintenance of public policies, and the availability of financial and human resources. The educational institutions need to combine education and service aiming to form critical-reflexive graduates. CONCLUSIONS : The coordination between health and education is based as much on the actions of health services as on management and educational institutions. Thus, it becomes a challenge to implement the teaching-learning processes that are supported by critical-reflexive actions. It is necessary to carry out proposals for permanent education in health involving the participation of health professionals, teachers and educational institutions.OBJETIVO : Realizar metasíntesis de la literatura sobre los principales conceptos y prácticas relacionados con la educación permanente en salud. MÉTODOS : Se realizó búsqueda bibliográfica de artículos originales en las bases de datos PubMed, Web of Science, Lilacs, IBECS y SciELO, utilizando los siguientes descriptores: “ public health professional education”, “permanent education”, “continuing education”, “permanent education health ”. De un total de 590 artículos identificados, posterior a los criterios de inclusión y exclusión, fueron seleccionados 48 para análisis, los cuales fueron sometidos al análisis individual, análisis comparativo, análisis con criterios de agrupamiento de elementos-clave y sometidos a metasíntesis. RESULTADOS : Los 48 artículos originales fueron clasificados como elementos-clave en cuatro unidades temáticas: 1) Concepciones; 2) Estrategias y dificultades; 3) Políticas públicas e 4) Instituciones formadoras. Se encontraron tres concepciones principales de educación permanente en salud: ubicación del problema y enfocarlo en el trabajo en equipo, directamente relacionado con la educación continua y educación que se da a lo largo de la vida. Las principales estrategias para efectivar la educación permanente fueron la ubicación del problema, mantenimiento de espacios para la educación permanente y polos de educación permanente. El mayor factor limitante estuvo relacionado con la gerencia directa o indirecta. Fueron mencionadas la necesidad de implementación y mantenimiento de políticas públicas, así como la disponibilidad de recursos financieros y humanos. Las instituciones formadoras tendrían la necesidad de articular educación y servicio para la formación de egresados críticos-reflexivos. CONCLUSIONES : La articulación educación y salud se encuentra pautada tanto en las acciones de los servicios de salud, cuanto en la gestión y de instituciones formadoras. Así, se torna un desafío implementar procesos de educación-aprendizaje que sean respaldados por acciones crítico-reflexivas. Es necesario realizar propuestas de educación permanente en salud con la participación de profesionales de los servicios, profesores y profesionales de las instituciones de educación.OBJETIVO : Realizar metassíntese da literatura sobre os principais conceitos e práticas relacionados à educação permanente em saúde. MÉTODOS : Foi realizada busca bibliográfica de artigos originais nas bases de dados PubMed, Web of Science, Lilacs, IBECS e SciELO, utilizando os seguintes descritores: “ public health professional education ”, “ permanent education”, “continuing education ”, “ permanent education health ”. De um total de 590 artigos identificados, após os critérios de inclusão e exclusão, foram selecionados 48 para análise, os quais foram submetidos à análise individual, análise comparativa, análise com critérios de agrupamentos de elementos-chave e submetidos à metassíntese. RESULTADOS : Os 48 artigos originais foram classificados como elementos-chave em quatro unidades temáticas: 1) Concepções; 2) Estratégias e dificuldades; 3) Políticas públicas; e 4) Instituições formadoras. Foram encontradas três concepções principais de educação permanente em saúde: problematizadora e focada no trabalho em equipe, diretamente relacionada à educação continuada e educação que se dá ao longo da vida. As principais estratégias para efetivação da educação permanente foram a problematização, manutenção de espaços para a educação permanente e polos de educação permanente. O maior fator limitante foi relacionado à gerência direta ou indireta. Foram indicadas a necessidade de implementação e manutenção de políticas públicas, além de disponibilidade de recursos financeiros e de recursos humanos. As instituições formadoras teriam necessidade de articular ensino e serviço para a formação de egressos críticos-reflexivos. CONCLUSÕES : A articulação educação e saúde encontra-se pautada tanto nas ações dos serviços de saúde, quanto de gestão e de instituições formadoras. Assim, torna-se um desafio implementar processos de ensino-aprendizagem que sejam respaldados por ações crítico-reflexivas. É necessário realizar propostas de educação permanente em saúde com a participação de profissionais dos serviços, professores e profissionais das instituições de ensino

Children's health care assistance according to their families: a comparison between models of Primary Care

OBJECTIVE To compare the health assistance models of Basic Traditional Units (UBS) with the Family Health Strategy (ESF) units for presence and extent of attributes of Primary Health Care (APS), specifically in the care of children. METHOD A cross-sectional study of a quantitative approach with families of children attended by the Public Health Service of Colombo, Paraná. The Primary Care Assessment Tool (PCA-Tool) was applied to parents of 482 children, 235 ESF units and 247 UBS units covering all primary care units of the municipality, between June and July 2012. The results were analyzed according to the PCA-Tool manual. RESULTS ESF units reached a borderline overall score for primary health care standards. However, they fared better in their attributes of Affiliation, Integration of care coordination, Comprehensiveness, Family Centeredness and Accessibility of use, while the attributes of Community Guidance/Orientation, Coordination of Information Systems, Longitudinality and Access attributes were rated as insufficient for APS. UBS units had low scores on all attributes. CONCLUSION The ESF units are closer to the principles of APS (Primary Health Care), but there is need to review actions of child care aimed at the attributes of APS in both care models, corroborating similar studies from other regions of Brazil

Knowledge, attitude and practice of condom use by women of an impoverished urban area

OBJECTIVE Assessing the adequacy of knowledge, attitude and practice of women regarding male and female condoms as STI/HIV preventive measures. METHOD An evaluative Knowledge, Attitude and Practice (KAP) household survey with a quantitative approach, involving 300 women. Data collection took place between June and August 2013, in an informal urban settlement within the municipality of João Pessoa, Paraiba, Northeast Brazil. RESULTS Regarding the male condom, most women showed inadequate knowledge and practice, and an adequate attitude. Regarding the female condom, knowledge, attitude and practice variables were unsatisfactory. Significant associations between knowledge/religious orientation and attitude/education regarding the male condom were observed. CONCLUSION A multidisciplinary team should be committed to the development of educational practices as care promotion tools in order to improve adherence of condom use