Cetuximab plus radiotherapy for the treatment of locally advanced squamous cell carcinoma of the head and neck

This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of cetuximab plus radiotherapy for the treatment of locally advanced squamous cell carcinoma of the head and neck (LA SCCHN) considered inappropriate for chemoradiotherapy but appropriate for radiotherapy, based upon the evidence submission from Merck Pharmaceuticals to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The manufacturer's submission was generally of good quality and was an accurate representation of the original reference data. One good-quality randomised controlled trial comparing radiotherapy plus cetuximab with radiotherapy alone in patients with stage III or IV non-metastatic LA SCCHN was included, demonstrating that the duration of locoregional control was significantly longer with radiotherapy plus cetuximab than with radiotherapy alone; also, overall and progression-free survival were significantly longer and the overall response rate was significantly better with the combination therapy. Cetuximab did not exacerbate the common toxic effects associated with radiotherapy of the head and neck. No supporting evidence for these findings are available. The patient population in the trial included a high proportion of patients who would be expected to be suitable for chemoradiotherapy and therefore does not match the population described in the submission's decision problem. Also, the radiotherapy regimens used in the trial are not typical of current UK practice. The ERG considered the manufacturer's economic evaluation to comprise the only relevant evidence to consider for the purposes of this STA. The economic model was considered appropriate for the decision problem. The results suggested that cetuximab plus radiotherapy was cost-effective compared with radiotherapy alone under a broad range of different assumptions on the basis of a cost-effectiveness threshold of 20,000 pounds. In the base case the incremental cost-effectiveness ratio of cetuximab plus radiotherapy compared with radiotherapy alone in the treatment of patients with LA SCCHN was 6390 pounds per additional QALY. Simple sensitivity analyses to examine the robustness of the results were undertaken, suggesting that areas of uncertainty that emerged in the modelling are unlikely to have a material effect on the conclusions. The guidance issued by NICE in May 2007 as a result of the STA states that cetuximab in combination with radiotherapy is not recommended for patients with LA SCCHN.

Fludarabine phosphate for the first-line treatment of chronic lymphocytic leukaemia

This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of fludarabine phosphate or fludarabine plus cyclophosphamide for the first-line treatment of chronic lymphocytic leukaemia,based upon the evidence submission from Schering Health Care (SHC) to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process.The submission was of good quality with no major errors or omissions in the clinical evidence.Two published studies and seven abstracts were included in the company submission, which showed improvements in overall response and progression-free survival (PFS) and a higher complete response rate in the fludarabine containing arms; however, until the complete data are made available for evaluation these results must be interpreted with caution. The manufacturer's decision-analytic Markov model to estimate the cost-effectiveness of treatment with fludarabine monotherapy, fludarabine plus cyclophosphamide and chlorambucil was considered to be the most relevant source for informing this STA;it was appropriate for the decision problem and the data sources used to inform the model were appropriate from a UK NHS perspective.The incremental cost-effectiveness ratio of fludarabine plus cyclophosphamide compared with chlorambucil from the revised model presented in the manufacturer's addendum was pounds 3244 per additional quality-adjusted life-year.The results were robust to a range of subgroup and sensitivity analyses. Additional sensitivity and survival analyses were carried by the ERG to investigate possible bias in the results. This brought into question the validity of the assumptions underpinning the extrapolation of data over a lifetime time horizon and showed that the ICER estimates submitted by the manufacturer were notcalculated correctly and uncertainty surrounding the decision problems was not expressed fully.Based on these analyses the ERG suggests that further evidence is needed to enable an accurate assessment to be made of the clinical and cost effectiveness of fludarabine as first-line treatment for chronic lymphocytic leukaemia. The guidance issued by NICE in December 2006 as a result of the STA states that fludarabine monotherapy,within its licensed indication, is not recommended for the first-line treatment of chronic lymphocytic leukaemia; no recommendations have been made with respect to fludarabine plus cyclophosphamide combination therapy because the current marketing authorisation does not specifically provide a recommendation that fludarabine should be used concurrently with other drugs for the treatment of chronic lymphocytic leukaemia.

A qualitative study of teacher's perceptions of an intervention to prevent conduct problems in Jamaican pre-schools

BACKGROUND

There is a growing evidence base showing the efficacy of school-based interventions to prevent conduct problems but few evaluations have addressed teachers' perceptions of these programmes. Teachers' views on the acceptability, feasibility and usefulness of an intervention will influence implementation fidelity and programme sustainability and can help further our understanding of how the intervention works and how it may be improved.

METHODS

A pilot study of the Incredible Years Teacher Training Programme supplemented by a curriculum unit on social and emotional skills was conducted in inner-city pre-schools in Kingston, Jamaica. Three pre-schools comprising 15 classrooms participated in the intervention which involved seven monthly teacher workshops and 14 weekly child lessons in each class. At the end of the intervention in-depth individual interviews were conducted with each intervention teacher.

RESULTS

Teachers reported benefits to their own teaching skills and professional development, to their relationships with children and to the behaviour, social-emotional competence and school readiness skills of the children in their class. Teachers also reported benefits to teacher-parent relationships and to children's behaviour at home. A hypothesis representing the teachers' perceptions of how the intervention achieved these benefits was developed. The hypothesis suggests that intervention effects were due to teachers' gains in skills and knowledge in three main areas: (1) a deeper understanding of young children's needs and abilities; (2) increased use of positive and proactive strategies; and (3) explicitly teaching social and emotional skills. These changes then led to the variety of benefits reported for teachers, children and parents. Teachers reported few difficulties in implementing the majority of strategies and strongly recommended wider dissemination of the intervention.

CONCLUSIONS

The intervention was valued by Jamaican pre-school teachers and teachers felt they were able to successfully integrate the strategies learned into their regular practice.

A pilot study of the Incredible Years Teacher Training programme and a curriculum unit on social and emotional skills in community pre-schools in Jamaica

BACKGROUND

School-based interventions involving teacher and/or child training have been shown to benefit teacher practices and to prevent conduct problems and improve children's social and emotional competence in developed countries; however, we are aware of no reports from a developing country. We conducted a pilot study of the Incredible Years Teacher Training programme and a curriculum unit on social and emotional skills based on concepts and activities drawn from the Incredible Years Dina Dinosaur Classroom Curriculum to determine if this approach is appropriate for use with Jamaican pre-school teachers and children.

METHODS

Five pre-schools in Kingston, Jamaica were randomly assigned to an intervention (3 pre-schools with 15 classrooms) or control (2 pre-schools with 12 classrooms) condition. Intervention involved seven whole-day teacher workshops using the Incredible Years Teacher Training programme supplemented by 14 child lessons in each class. The project was evaluated through structured observations of four categories of teacher behaviour and four observer ratings: two rating scales of child behaviour and two rating scales of classroom atmosphere.

RESULTS

Significant intervention benefits were found to teachers' behaviour with increased positive behaviour [b = 7.9; 95% confidence interval (CI): 3.5, 12.3], reduced negative behaviour (b =-3.5; 95% CI: -6.6, -0.2) and increases in the extent to which teachers promoted children's social and emotional skills (b = 46.4; 95% CI: 11.0, 81.7). The number of teacher commands was not significantly reduced (b =-2.71; 95% CI: -6.01, 0.59). Significant intervention benefits were found to ratings of child behaviour with an increase in children's appropriate behaviour (b = 5.7, 95% CI: 1.0, 10.8) and in children's interest and enthusiasm (b = 7.2, 95% CI: 0.9, 13.5). Intervention also benefited classroom atmosphere with increases in opportunities provided for children to share and help each other (b = 1.3, 95% CI: 0.5, 2.1) and in teacher warmth (b = 1.3, 95% CI: 0.9, 1.8).

CONCLUSION

This is a promising approach for improving the emotional climate of Jamaican pre-school classrooms and for improving child behaviour and participation.

A randomised controlled trial to compare minimally invasive glucose monitoring devices with conventional monitoring in the management of insulin-treated diabetes mellitus (MITRE)

OBJECTIVES

To evaluate whether the additional information provided by minimally invasive glucose monitors results in improved glycaemic control in people with poorly controlled insulin-requiring diabetes, and to assess the acceptability and health economic impact of the devices.

DESIGN

A four-arm randomised controlled trial was undertaken.

SETTING

Participants were recruited from secondary care diabetes clinics in four hospitals in England.

PARTICIPANTS

404 people aged over 18 years with insulin-treated diabetes mellitus (types 1 or 2) for at least 6 months who were receiving two or more injections of insulin daily were eligible. Participants had to have had two glycosylated haemoglobin (HbA1c) values > or = 7.5% in the last 15 months.

INTERVENTIONS

Participants were randomised to one of four groups. Two groups received minimally invasive glucose monitoring devices [GlucoWatch Biographer or MiniMed Continuous Glucose Monitoring System (CGMS)]. These groups were compared with an attention control group (standard treatment with nurse feedback sessions at the same frequency as those in the device groups) and a standard control group (reflecting common practice in the clinical management of diabetes in the UK).

MAIN OUTCOME MEASURES

Change in HbA1c from baseline to 3, 6, 12 and 18 months was the primary indicator of short- to long-term efficacy in this study. Perceived acceptability of the devices was assessed by use and a self-report questionnaire. A health economic analysis was also performed.

RESULTS

At 18 months all groups demonstrated a decline in HbA1c levels from baseline. Mean percentage changes in HbA1c were -1.4 for the GlucoWatch group, -4.2 for the CGMS group, -5.1 for the attention control group and -4.9 for the standard care control group. At 18 months the relative percentage reduction in HbA1c in each of the intervention arms was less than that in the standard care control group. In the intention to treat analysis no significant differences were found between any of the groups at any of the assessment times. There was no evidence that the additional information provided by the devices resulted in any change in the number or nature of treatment recommendations offered by the nurses. The health economics analysis indicated no advantage in the groups who received the devices; a lower cost and higher benefit were found for the attention control arm. Assessment of device use and acceptability indicated a decline in use of both devices, which was most marked in the GlucoWatch group by 18 months (20% still using GlucoWatch versus 57% still using the CGMS). The GlucoWatch group reported more side effects, greater interference with daily activities and more difficulty in using the device than the CGMS group.

CONCLUSIONS

Continuous glucose monitors do not lead to improved clinical outcomes and are not cost-effective for improving HbA1c in unselected individuals with poorly controlled insulin-requiring diabetes. On acceptability grounds the data suggest that the GlucoWatch will not be frequently used by individuals with diabetes because of the large number of side effects.

Fludarabine phosphate for the first-line treatment of chronic lymphocytic leukaemia

This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of fludarabine phosphate or fludarabine plus cyclophosphamide for the first-line treatment of chronic lymphocytic leukaemia, based upon the evidence submission from Schering Health Care (SHC) to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The submission was of good quality with no major errors or omissions in the clinical evidence. Two published studies and seven abstracts were included in the company submission, which showed improvements in overall response and progression-free survival (PFS) and a higher complete response rate in the fludarabinecontaining arms; however, until the complete data are made available for evaluation these results must be interpreted with caution. The manufacturer’s decision-analytic Markov model to estimate the cost-effectiveness of treatment with fludarabine monotherapy, fludarabine plus cyclophosphamide and chlorambucil was considered to be the most relevant source for informing this STA; it was appropriate for the decision problem and the data sources used to inform the model were appropriate from a UK NHS perspective. The incremental cost-effectiveness ratio of fludarabine plus cyclophosphamide compared with chlorambucil from the revised model presented in the manufacturer’s addendum was £3244 per additional quality-adjusted life-year. The results were robust to a range of subgroup and sensitivity analyses. Additional sensitivity and survival analyses were carried by the ERG to investigate possible bias in the results. This brought into question the validity of the assumptions underpinning the extrapolation of data over a lifetime time horizon and showed that the ICER estimates submitted by the manufacturer were not calculated correctly and uncertainty surrounding the decision problems was not expressed fully. Based on these analyses the ERG suggests that further evidence is needed to enable an accurate assessment to be made of the clinical and cost-effectiveness of fludarabine as first-line treatment for chronic lymphocytic leukaemia. The guidance issued by NICE in December 2006 as a result of the STA states that fludarabine monotherapy, within its licensed indication, is not recommended for the first-line treatment of chronic lymphocytic leukaemia; no recommendations have been made with respect to fludarabine plus cyclophosphamide combination therapy because the current marketing authorisation does not specifically provide a recommendation that fludarabine should be used concurrently with other drugs for the treatment of chronic lymphocytic leukaemia.

Cetuximab plus radiotherapy for the treatment of locally advanced squamous cell carcinoma of the head and neck

This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of cetuximab plus radiotherapy for the treatment of locally advanced squamous cell carcinoma of the head and neck (LA SCCHN) considered inappropriate for chemoradiotherapy but appropriate for radiotherapy, based upon the evidence submission from Merck Pharmaceuticals to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The manufacturer’s submission was generally of good quality and was an accurate representation of the original reference data. One good-quality randomised controlled trial comparing radiotherapy plus cetuximab with radiotherapy alone in patients with stage III or IV non-metastatic LA SCCHN was included, demonstrating that the duration of locoregional control was significantly longer with radiotherapy plus cetuximab than with radiotherapy alone; also, overall and progression-free survival were significantly longer and the overall response rate was significantly better with the combination therapy. Cetuximab did not exacerbate the common toxic effects associated with radiotherapy of the head and neck. No supporting evidence for these findings are available. The patient population in the trial included a high proportion of patients who would be expected to be suitable for chemoradiotherapy and therefore does not match the population described in the submission’s decision problem. Also, the radiotherapy regimens used in the trial are not typical of current UK practice. The ERG considered the manufacturer’s economic evaluation to comprise the only relevant evidence to consider for the purposes of this STA. The economic model was considered appropriate for the decision problem. The results suggested that cetuximab plus radiotherapy was cost-effective compared with radiotherapy alone under a broad range of different assumptions on the basis of a cost-effectiveness threshold of £20,000. In the base case the incremental cost-effectiveness ratio of cetuximab plus radiotherapy compared with radiotherapy alone in the treatment of patients with LA SCCHN was £6390 per additional QALY. Simple sensitivity analyses to examine the robustness of the results were undertaken, suggesting that areas of uncertainty that emerged in the modelling are unlikely to have a material effect on the conclusions. The guidance issued by NICE in May 2007 as a result of the STA states that cetuximab in combination with radiotherapy is not recommended for patients with LA SCCHN.

Randomized controlled trial to assess the impact of continuous glucose monitoring on HbA(1c) in insulin-treated diabetes (MITRE Study)

AIMS

To determine whether continuous glucose information provided through use of either the GlucoWatch G2 Biographer or the MiniMed continuous glucose monitoring system (CGMS) results in improved glycated haemoglobin (HbA(1c)) for insulin-treated adults with diabetes mellitus, relative to an attention control and standard care group.

METHODS

Four hundred and four adults taking at least two daily insulin injections and with two consecutive HbA(1c) values > or = 7.5% were recruited to this randomized controlled trial (RCT). All were trained at baseline to use the same monitor for traditional capillary glucose testing throughout the 18-month study. The CGMS group were asked to wear the device three times during the first 3 months of the trial and on another three occasions thereafter. The GlucoWatch group wore the device a minimum of four times per month and a maximum of four times per week during the first 3 months and as desired for the remainder of the trial. Trained diabetes research nurses used downloaded data to guide therapy adjustments. Proportional reduction in HbA(1c) from baseline to 18 months was the primary outcome measure.

RESULTS

Neither an intention-to-treat nor per-protocol analysis showed improvement in HbA(1c) in the device groups compared with standard care. For the intention-to-treat analysis, when the standard care group was compared with each of the other groups, this equated to differences in mean relative HbA(1c) reduction (95% confidence interval) from baseline to 18 months of 3.5% (-1.3 to 8.3; GlucoWatch), 0.7% (-4.1 to 5.5; CGMS), and -0.1% (-4.6 to 4.3; attention control).

CONCLUSIONS

The additional information provided by these devices did not result in improvements in HbA(1c) in this population.

200 REPROGRAMMING OF Oct-4 FOLLOWING EQUINE SOMATIC CELL NUCLEAR TRANSFER

Oct-4, a POU domain-containing transcription factor encoded by Pou5f1, is selectively expressed in pre-implantation embryos and pluripotent stem cells, but not in somatic cells. Because of such a unique expression feature, Oct-4 can serve as a useful reprogramming indicator in somatic cell nuclear transfer (SCNT). Compared with data of Oct-4 expression in mouse and bovine cloned embryos, little is known about this gene in equine nuclear transfer. In the present study, we investigated Oct-4 expression in donor cells, oocytes, and SCNT embryos to evaluate reprogramming of equine somatic cells following nuclear transfer. Horse ovaries were obtained from a local slaughterhouse and the oocytes collected from the ovaries were matured in vitro in an M199-based medium (Galli et al. 2003 Nature 424, 635) for 24 h. Donor cells were derived from biopsy tissue samples of adult horses and cultured for 1 to 5 passages. Standard nuclear transfer procedures (Zhou et al. 2008 Mol. Reprod. Dev. 75, 744–758) were performed to produce cloned embryos derived from equine adult somatic cells. Cloned blastocysts were obtained after 7 days of in vitro culture of reconstructed embryos. Total RNA were extracted using Absolutely RNA Miniprep/Nanoprep kits (Stratagen, La Jolla, CA) from oocytes (n = 200), donor cells, and embryos (n = 5). DNase I treatment was included in the procedure to prevent DNA contamination. Semiquantitative RT-PCR was performed with optimized cycling parameters to analyze Oct-4, GDF9, and β-actin in equine donor cells, oocytes, and cloned blastocysts. The RT-PCR products were sequenced to verify identity of the genes tested. The relative expression abundance was calculated by normalizing the band intensity of Oct-4 to that of β-actin in each analysis. No transcript of Oct-4 was detected in equine somatic cells used as donor nuclei, consistent with its expression patterns in other animal species, whereas Oct-4 was abundantly expressed in equine SCNT blastocysts derived from the same donor cell line. Oct-4 transcripts were also detected in equine oocytes and whether any maternally inherited Oct-4 mRNA persisted up to the blastocyst stage was unclear in this study. We selected GDF9 to address this question; GDF9 was abundantly detected in equine oocytes, consistent with its expression pattern in mouse and bovine, but not detected in donor cells and cloned blastocysts, suggesting that the GDF9 mRNA from the oocyte was degraded at least by the blastocyst stage. The results from this study imply occurrence of Oct-4 reprogramming in equine SCNT blastocysts, and future analysis for more developmentally important genes is needed to better understand reprogramming at molecular levels in this species.

Writing your postgraduate dissertation: a basic framework

This paper provides a basic framework for those embarking upon a postgraduate dissertation. The dissertation experience can offer many opportunities for self and academic development once ethical approval has been obtained. A good dissertation is the result of a sound methodological framework, where some thought has been given to the strengths and weaknesses of qualitative and quantitative methods of inquiry. The research question needs to be given careful consideration so that the aims and objectives of the postgraduate research project are fulfilled.

When it is better to estimate a slope with only one point

When investigating the change in a biomarker, it is often believed that at least two measurements are needed from each participant, and that those with only one measurement should be excluded. In this short note, we explain why this could lead to imprecise and biased estimates. Furthermore, we discuss a standard statistical method that handles such issues.

Comparison of Campylobacter jejuni genotypes from dairy cattle and human sources from the Matamata-Piako District of New Zealand

AIMS

To identify the prevalence and types of Campylobacter jejuni carried by dairy cattle and the extent of overlap of these types with those causing disease in humans.

METHODS AND RESULTS

Faecal samples from 410 dairy cattle were collected from 36 farms in the Matamata-Piako district in New Zealand. Campylobacter jejuni was isolated on all 36 farms, with a prevalence of 51% (95% CI 45-57) in dairy cattle and 65% (95% CI 58-72) in calves. Eighty-nine of these isolates were typed using Penner serotyping and pulsed field gel electrophoresis and were compared with 58 human C. jejuni isolates from people resident within this study area.

CONCLUSIONS

Campylobacter jejuni were found in the faeces of over half of the dairy cows and calves examined. Twenty-one per cent of the bovine isolates and 43% of the human isolates formed indistinguishable clusters of at least one bovine and one human isolate.

SIGNIFICANCE AND IMPACT OF THE STUDY

While a direct link between bovine isolates and human cases was not demonstrated, the finding of indistinguishable genotypes among C. jejuni isolates from bovine and human sources confirms that dairy cows and calves are a potential source of human campylobacteriosis. Barriers to separate bovine faecal material from the general public are therefore important public health measures.

64-Slice computed tomography angiography in the diagnosis and assessment of coronary artery disease: systematic review and meta-analysis

CONTEXT

Coronary artery disease (CAD) is a major cause of mortality and ill health.

OBJECTIVE

To assess whether 64-slice CT angiography might replace some coronary angiography (CA) for diagnosis and assessment of CAD.

DATA SOURCES

Electronic databases, conference proceedings and reference lists of included studies.

STUDY SELECTION

Eligible studies compared 64-slice CT with a reference standard of CA in adults with suspected/known CAD, reporting sensitivity and specificity or true and false positives and negatives.

DATA EXTRACTION

Two reviewers independently extracted data from included studies.

RESULTS

Forty studies were included; 28 provided sufficient data for inclusion in the meta-analyses, all using a cut off point of >/=50% stenosis to define significant CAD. In patient-based detection (n = 1286) 64-slice CT pooled sensitivity was 99% (95% credible interval (CrI) 97% to 99%), specificity 89% (95% CrI 83% to 94%), median positive predictive value (PPV) across studies 93% (range 64-100%) and negative predictive value (NPV) 100% (range 86-100%). In segment-based detection (n = 14 199) 64-slice CT pooled sensitivity was 90% (95% CrI 85% to 94%), specificity 97% (95% CrI 95% to 98%), median PPV across studies 76% (range 44-93%) and NPV 99% (range 95-100%).

CONCLUSIONS

64-Slice CT is highly sensitive for patient-based detection of CAD and has high NPV. An ability to rule out significant CAD means that it may have a role in the assessment of chest pain, particularly when the diagnosis remains uncertain despite clinical evaluation and simple non-invasive testing.

What evidence is there that the UK should tackle the potential emerging threat of methamphetamine toxicity rather than established recreational drugs such as MDMA ('ecstasy')?

BACKGROUND

There is increasing interest in whether methamphetamine is an emerging recreational drug in the UK.

AIM

To determine what evidence is there that methamphetamine use is an emerging drug in the UK compared to established recreational drugs such as MDMA.

DESIGN AND METHODS

We undertook a retrospective study collating data on the number of enquiries to both our poisons centre and the UK National Poisons Information Service (NPIS) relating to all recreational drugs, methamphetamine and MDMA; presentations to our Emergency Department (ED) with acute methamphetamine toxicity and the frequency of positive urine tests for methamphetamine and MDMA in workplace drug screening programmes.

RESULTS

There was a small increase in the number of methamphetamine-related calls to our poisons centre, but it remained uncommon (0.1% of all recreational drugs cases in 2000 to 1.23% in 2006) compared to MDMA (17.3-42.7% of all recreational drugs cases). The number of 2005/6 enquiries to the UK NPIS for methamphetamine was 12, compared to 455 MDMA enquiries (0.014 and 0.52% of all enquiries, respectively). There were five presentations to our ED relating to methamphetamine over a 15-month period compared to 171 for MDMA. Of the 254 440 urine samples screened for the presence of drugs in the workplace (2000-06), three were positive for methamphetamine and 147 for MDMA.

CONCLUSION

There is no evidence of increasing use of methamphetamine or that acute methamphetamine poisoning is a significant clinical problem compared to established recreational drugs such as MDMA. In our opinion, healthcare, educational and law enforcement resources should be proportionally directed towards tackling drugs that pose an immediate and continuing healthcare risk to the population rather than emerging recreational drugs.

Primary prevention of type-2 diabetes and heart disease: action research in secondary schools serving an ethnically diverse UK population

BACKGROUND

Escalating rates of childhood obesity are likely to have an impact on the prevalence of coronary heart disease and type-2 diabetes. We aimed to identify barriers to healthy lifestyles and evaluate the effectiveness of an action research approach to lifestyle modification in secondary schools.

METHODS

An action research partnership between schools and university researchers involved pupils aged 11-15 in five inner-city secondary schools serving a predominantly South Asian population in Leicester, UK. Data collection included baseline and follow-up diet and physical activity questionnaires. Focus groups and observational visits were used to identify barriers, assist with developing tailored interventions and review the impact of the study.

RESULTS

Working with secondary schools presented challenges but a useful partnership was sustained. Qualitative feedback suggested that this had raised awareness of healthy lifestyle issues in participating schools. Barriers in pupils included low prioritization of health when making lifestyle choices. Sub-optimal diet and activity habits were identified at baseline. Overall, these persisted at follow-up, although some limited positive changes were identified.

CONCLUSIONS

Using action research methods in this context is challenging but can facilitate useful data collection and may have a modest impact on lifestyle behaviours.

Proportion of injury deaths with unspecified external cause codes: a comparison of Australia, Sweden, Taiwan and the US

BACKGROUND

The proportion of injury deaths with unspecified external cause codes has been used as an indicator of the level of comprehensiveness and specificity of information on death certificates provided by certifiers.

OBJECTIVE

To compare the proportion of unspecified external cause codes across countries.

METHODS

Multiple-cause-of-death mortality data for people who died in 2001 due to external causes in Australia, Sweden, Taiwan and the USA were used for this international comparison study. The proportion of injury deaths coded as due to an unspecified external cause (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, ICD-10, chapter XX) to all injury deaths in each block was calculated.

RESULTS

Sweden (33%) had the highest proportion of use of the least specific code (ICD-10 code X59 exposure to unspecified factor), followed by Australia (17%), Taiwan (13%) and the USA (7%). More than two-thirds of the deceased for whom an ICD-10 code X59 was assigned in Sweden and Australia were those aged > or =65 years, and more than half of them had femoral fractures. The percentage of use of the unspecified codes within specific groups of external causes was relatively high for falls and unintentional drowning.

CONCLUSIONS

Caution should be used in examining the compensatory effects of the unspecified external event code (ICD-10 code X59) on specific external causes (especially falls) when making international comparisons. Efforts are needed to educate certifiers to report sufficient information for specific coding so as to provide more useful information for injury prevention.

Proton-dependent transporter gene lndJ confers resistance to landomycin E in Streptomyces globisporus

Sequence analysis of 2 kb BamHI-SmaI fragment of landomycin E (LaE) gene cluster in S. globisporus 1912 revealed one complete ORF marked as lndJ. Analysis of putative LndJ aminoacid sequence allowed us to suppose that it is proton-dependent antiporter which could be involved in resistance to LaE in the producing strain. Although disruption of lndJ had no significant influence on LaE production and resistance, it's overexpression in wild type and LaE overproducing strains led to qualitative changes in landomycins biosynthesis and increased resistance to LaE. These data support the hypothesis about involvement of lndJ gene in landomycins export.

A normative value pilot study: levels of uranium in urine samples from UK civilians

A normative study of the levels of urinary uranium in the general UK population is needed for comparison with levels in UK military and ex-military personnel who served where munitions containing depleted uranium (DU) were used. As preparation, this pilot study trialled the process of collecting 24-h samples from adult male civilians, and compared the measurements from 24-h samples with those from spot samples taken over the subsequent 24h. The purpose was to assess the relative utility of the two types of samples. Twenty-five convalescent hospital in-patients were recruited as participants. Uranium concentrations in the 24-h samples ranged from 1 to 10.6 ng l(-1); in the spots, from not detectable to 38.1 ng l(-1). Normalised to creatinine, concentrations in the 24h samples ranged from approximately 100 to 800 ng mol(-1) creatinine; in the spot samples, from not detectable to approximately 4000 ng mol(-1) creatinine. The ranges appear similar to those reported for residents of the US. The distribution of spot sample results indicated that 95% of a participant's creatinine-adjusted concentrations from spot samples would be within the range 40-250% of his mean. Adjusting for creatinine almost entirely eliminated a slight indication of diurnal variation in urinary uranium concentration in spot samples. All the 24-h samples and 131 out of the 133 spot samples showed ratios of isotopes (238)U to (235)U consistent with natural uranium (i.e. neither enriched nor depleted). Slightly elevated ratios in two spot samples were not supported by other samples from the same participants, indicating that slightly elevated ratios may be recorded on very low concentration (<1 ng l(-1)) samples. In the main, quantification of this isotope ratio from spot samples was only slightly more variable than from 24-h samples. Complete 24-h urine samples gave better precision than spot samples in estimating uranium concentrations at these low levels, but presented more logistic difficulties in the collection of the samples. Clarification of the relative merits of alternative sampling strategies enables the design of a wider study to be optimised.

Ex vivo monitoring of human cytomegalovirus-specific CD8+ T-cell responses using QuantiFERON�-CMV

We have developed a novel diagnostic technology to monitor the human cytomegalovirus (HCMV)-specific CD8+ T-cell responses that is based on the detection of secreted interferon-gamma (IFN-gamma) in the whole blood (referred to as QuantiFERON -CMV). Evaluation of QuantiFERON -CMV in healthy individuals revealed that this technology was at least as sensitive and with some HCMV epitopes more sensitive than the ELISPOT for detecting ex vivo IFN-gamma. Results from QuantiFERON -CMV assays showed 97% (36/37 individuals) agreement with the anti-HCMV serology test in healthy individuals. Furthermore, we also show that this technology can be used to assess HCMV-specific T-cell responses in transplant patients. This study shows that QuantiFERON -CMV is a simple, reproducible, and reliable test for the detection of IFN-gamma in response to HCMV CD8+ T-cell epitopes, and may be a valuable diagnostic test for the detection of HCMV infection and a useful clinical tool for monitoring the immune response in immunosuppressed patients during therapy.

Diet and overweight and obesity in populations of African origin: Cameroon, Jamaica and the UK

OBJECTIVES

To determine the relationship of diet to overweight and obesity among populations of African origin.

DESIGN AND SETTING

Cross-sectional data were obtained from adults aged 25-74 years in rural Cameroon (n = 686), urban Cameroon (n = 975), Jamaica (n = 924) and Afro-Caribbeans in the UK (n = 257). Dietary data were collected using food-frequency questionnaires specifically designed for each site. Body mass index (BMI) was used as a measure of overweight.

RESULTS

The expected gradient in the distribution of overweight across sites was seen in females (rural Cameroon, 9.5%; urban Cameroon, 47.1%; Jamaica, 63.8%; UK, 71.6%); however, among males overweight was less prevalent in Jamaica (22.0%) than urban Cameroon (36.3%). In developing countries increased risks of overweight (BMI > or = 25 kg m(-2) were influenced by higher energy (urban Cameroonian men) and protein (Jamaican women) intakes. No dietary variables were associated with obesity (BMI > or = 30 kg m(-2) in Cameroon or Jamaica. In the UK, energy intakes were inversely related with overweight whereas increased risks of being overweight were associated with higher protein (men) and fat (women) intakes. Similarly, whereas higher protein and fat intakes in UK men and women were associated with obesity, carbohydrate intakes were associated with decreased risks of obesity in men.

CONCLUSIONS

Diet and overweight were associated in the UK but few dietary variables were related to overweight in Jamaica and the Cameroon. These findings suggest that associations between diet and overweight/obesity are not generalisable among populations.

The effectiveness and cost-effectiveness of computed tomography screening for coronary artery disease: systematic review

OBJECTIVES

To assess the clinical and cost-effectiveness of computed tomography (CT) screening for asymptomatic coronary artery disease; also to establish whether coronary artery calcification (CAC) predicts coronary events and adds anything to risk factor scores, and whether measuring CAC changes treatment.

DATA SOURCES

Main electronic databases were searched up to 2005, with a MEDLINE update in February 2006.

METHODS

A systematic review of screening studies and economic evaluations was carried out. Studies were included in the review if screening for coronary heart disease was the principal theme of the study, and if data were provided that allowed comparison of CT screening with current practice, which was taken to be risk factor scoring. Mismatches between CAC scores and risk factor scoring were of particular interest. A review of the case for screening against the criteria used by the National Screening Committee (NSC) for assessing screening programmes was also undertaken.

RESULTS

No randomised control trials (RCTs) were found that assessed the value of CT screening in reducing cardiac events. Seven studies were identified that assessed the association between CAC scores on CT and cardiac outcomes in asymptomatic people and included 30,599 people. Six used electron-beam CT. The relative risk of a cardiac event was 4.4 if CAC was present, compared to there being no CAC. As CAC score increased, so did the risk of cardiac events. The correlation between CAC and cardiac risk was consistent across studies. There was evidence that CAC scores varied among people with the same Framingham risk factor scores, and that within the same Framingham bands, people with higher CAC scores had significantly higher cardiac event rates. This applied mainly when the CAC scores exceeded 300. There was little difference in event rates among the groups with no CAC, and scores of 1-100 and 101-300. In one study, CAC score was a better predictor of cardiac events than the Framingham risk scores. No studies were found that showed whether the addition of CAC scores to standard risk factor assessment would improve outcomes. There were reports from two observational studies that lowering of low-density lipoprotein cholesterol to about 3 mmol/l; or below with statin treatment modestly reduced CAC scores, but this was not confirmed in two RCTs. In three studies examining whether knowledge of CAC scores would affect compliance with lifestyle measures, perception of risk was affected, but it did not improve smoking cessation rates, although it did increase anxiety. There were a few economic studies of CT screening for heart disease, which provided useful data on costs of scans, other investigations and treatment, but relied on a number of assumptions, and were unable to provide definitive answers. One modelling study estimated that adding CT screening to risk factor scoring, and only giving statins to those with CAC score over 100, would save money, based on a cost per CT screen of US$400 and statin costs of US$1000 per annum per patient. However, the arrival of generic statins has reduced the price dramatically, and these savings no longer apply.

CONCLUSIONS

CT examination of the coronary arteries can detect calcification indicative of arterial disease in asymptomatic people, many of whom would be at low risk when assessed by traditional risk factors. The higher the CAC score, the higher the risk. Treatment with statins can reduce that risk. However, CT screening would miss many of the most dangerous patches of arterial disease, because they are not yet calcified, and so there would be false-negative results: normal CT followed by a heart attack. There would also be false-positive results in that many calcified arteries will have normal blood flow and will not be affected by clinically apparent thrombosis: abnormal CT not followed by a heart attack. For CT screening to be cost-effective, it has to add value over risk factor scoring, by producing sufficient additional information to change treatment and hence cardiac outcomes, at an affordable cost per quality-adjusted life-year. There was insufficient evidence to support this. Most of the NSC criteria were either not met or only partially met. It would be useful to have more data on the distributions of risk scores and CAC scores in asymptomatic people, and the level of concordance between risk factor and CAC scores, the risk of cardiac events per annum according to CAC score and risk factor scores, information on the acceptability of CT screening, after information about the radiation dose, and an RCT of adding CT screening to current risk factor-based practice.

Standardized training for healthcare professionals and its impact on patients with perennial rhinitis: a multi-centre randomized controlled trial

BACKGROUND

Perennial rhinitis is common and often results in substantial, potentially avoidable, impairment of quality of life. Quality of rhinitis care has been shown to be sub-optimal in general practice. Rigorous evaluation of educational interventions for healthcare professionals using randomized controlled trials is very uncommon.

OBJECTIVE

To evaluate the effectiveness of standardized allergy training for healthcare professionals on patients' disease-specific quality of life.

METHODS

Patients with clinician diagnosed perennial rhinitis and/or a prescription for relevant nasal medication were recruited from general practice. Following baseline measurement of quality of life using the validated rhino-conjunctivitis questionnaire (RQLQ), patients were centrally randomized to receive care from an allergy-trained primary healthcare professional or routine care. RQLQ was measured again at 13 months after randomization.

RESULTS

Process measures revealed that the training was well received. 202 patients were included in the intention-to-treat analysis and 157 in the per-protocol analysis. There was a 0.23 greater mean improvement in quality-of-life scores in the intervention group when compared with controls (P=0.08) in the intention-to-treat analysis, this increasing to a 0.3 greater mean improvement if confined to a per-protocol analysis (P=0.05). The intention-to-treat analysis showed that 39/101 (39%) in the intervention group showed a clinically significant > or =0.5 improvement in RQLQ compared with 28/101 (28%) of controls (risk difference=11%, number needed to treat=9, P=0.1).

CONCLUSIONS

Standardized allergy education given to primary healthcare professionals leads to modest improvements in disease-specific quality of life in patients with perennial rhinitis.

Determinants of response to first HAART regimen in antiretroviral-naïve patients with an estimated time since HIV seroconversion

OBJECTIVE

To study the determinants of immunological and virological response to highly active antiretroviral therapy (HAART) in naïve patients, adjusting for time since HIV-1 seroconversion.

DESIGN

Data from HIV-cohort studies where dates of seroconversion have been reliably estimated. Methods In previously untreated patients, short- and long-term marker responses from HAART initiation (three or more antiretroviral drugs) to the end of follow-up or any treatment modification were considered using mixed effects models accounting for undetectable HIV viral load and informative dropout.

RESULTS

In total, 943 patients were treated with a first HAART regimen for a median of 29 months. In adjusted analyses, compared with a reference group of homosexual men without AIDS initiating treatment 4 years after seroconversion, injecting drug users (IDUs) were treated at similar CD4 and HIV RNA levels but had poorer short-term virological response (2.54 vs 2.13 log(10) HIV-1 RNA copies/mL at 1.5 months, P=0.03) and poorer long-term immunological response (522 vs 631 cells/microL at 24 months, P<0.0001). Although individuals with AIDS at HAART initiation had lower CD4 counts (206 vs 382 cells/microL, P<0.0001), their immunological responses were similar to those of individuals without AIDS. Similarly, individuals further from seroconversion started HAART at lower CD4 counts (e.g. 311 vs 382 cells/microL at vs before 9 years from seroconversion, P<0.0001), but had similar CD4 responses. However, they experienced poorer long-term virological response (0.67 log(10) copies/mL/year smaller decline, P<0.0001) compared to those treated before 9 years from seroconversion.

CONCLUSION

Taking into account the time elapsed since seroconversion, this study suggests that careful choices of initial treatment should be made and intensive follow-up carried out in high-risk subgroups such as IDUs who have poorer responses.

The clinical effectiveness and cost-effectiveness of computed tomography screening for lung cancer: systematic reviews

OBJECTIVES

The aim of this review is to examine the clinical and cost-effectiveness of screening for lung cancer using computed tomography (CT) to assist policy making and to clarify research needs.

DATA SOURCES

Electronic databases and Internet resources.

REVIEW METHODS

A systematic review was undertaken and selected studies were assessed using the checklists and methods described in NHS Centre for Reviews and Dissemination (CRD) Report 4. Separate narrative summaries were performed for clinical effectiveness and cost-effectiveness. Cost-effectiveness analysis resulting in a cost per quality-adjusted life-year was not feasible, therefore the main elements of such an appraisal were summarised and the key issues relating to the existing evidence base were discussed.

RESULTS

Twelve studies of CT screening for lung cancer were identified, including two randomised controlled trials (RCTs) and ten studies of screening without comparator groups. The quality of reporting of these studies was variable, but the overall quality was adequate. The two RCTs were of short duration (1 year) and therefore there was currently no evidence that screening improves survival or reduces mortality. The proportion of people with abnormal CT findings varied widely between studies (5-51%). The prevalence of lung cancer detected was between 0.4% and 3.2% (number need to screen to detect one lung cancer = 31-249). Incidence rates of lung cancer were lower (0.1-1% per year). Detection of stage I and resectable tumours was high, 100% in some studies. Adverse events, as a result of investigation or surgery, or the screening process per se were poorly reported. Incidental findings of other abnormalities requiring medical follow-up were reported to be as high as 49%. Six full economic evaluations of population CT screening programmes for lung cancer were included in the review. The magnitude of cost-effectiveness ratios reported varied widely. None was set in the UK and generalisation was complicated by wide variation in the data used in different countries and a paucity of UK data for comparison. All six made the fundamental assumption that screening with CT for lung cancer reduced mortality. At the current time, there is no evidence to support that assumption. In the absence of evidence of health gains from screening for lung cancer, in terms of either quantity or quality of life, and faced with a range of uncertainties, from the frequency of abnormal screening findings within a population to the natural history of screening detected lung cancers, it is not feasible at the current time to develop accurately and meaningfully an economic argument for CT screening for lung cancer in the UK. For subgroups, in particular certain occupational groups, there is evidence of increased risk of lung cancer, but the role of screening has not been demonstrated by the current studies.

CONCLUSIONS

The accepted National Screening Committee criteria are not currently met, with no RCTs, no evidence to support clinical effectiveness and no evidence of cost-effectiveness. RCTs are needed to examine the effect of CT screening on mortality, either with whole-population screening or for particular subgroups; to determine the rate of positive screening and detected lung cancers. Research is also needed to understand better the natural history and epidemiology of screening-detected lung cancers, particularly small, well-differentiated adenocarcinomas; as well as the impacts on quality of life. Increased collection is needed of UK health service data regarding resource use and safety data for lung cancer management and services. Research is also needed into the feasibility and logistics of tracing people who have in the past worked in industry where there was exposure to lung carcinogens.

A prospective survey evaluating the use of soy products in breast cancer

10562

Background: Many studies have evaluated the potential role of soy in the prevention of breast cancer. A number of components in soy appear to have anticancer properties, including isoflavones, genistein and daidzein. The use of soy by women with breast cancer is now being questioned because of the estrogen-like effects of isoflavones and possible interactions with tamoxifen. Clinicians providing nutrition counseling to these women are concerned because the availability of soy foods has increased dramatically in the past few years. The goal of this study was to quantify the intake of isoflavones in women with breast cancer to determine if their intake is of clinical significance. Methods: We evaluated a consecutive case series of 100 women with breast cancer treated at Cancer Treatment Centers of America between 09/03 and 02/04. After obtaining informed consent, each patient was asked to complete a soy food frequency questionnaire (FFQ) that was scored by Fred Hutchinson Cancer Research Center, the institute that developed and validated FFQ. Results: Mean age was 50.5 years (std. dev. = 9.4; range 31–70) and mean BMI was 27.3kg/m2 (std. dev. = 6.75; range 17–59). Table 1 shows detailed characteristics of our patients. Genistein and Daidzein consumption was limited to 65 patients with a mean intake of 81.5 mg/week (std. dev. = 153; range 0.02–682) and 52.9 mg/week (std. dev. = 98.8; range 0.02–482) respectively. Soy foods with highest reported consumption were soy sauce (37%), soy milk (23%), soy bars (18%), roasted soy nuts (13%) and tofu (13%). Conclusions: Our study suggests that the isoflavone intake of breast cancer patients at our hospital was quite variable. Thirty-five patients reported no soy intake. The mean daily intake translates into 11.6 mg genistein and 7.4 mg daidzein, which is equivalent of less than ¼ cup of tofu per day. This amount is slightly higher than what has been previously reported in non-Asian American women.

[Table: see text]

No significant financial relationships to disclose.

Anti-IgE for chronic asthma in adults and children

BACKGROUND

Omalizumab is a recombinant humanised monoclonal antibody directed against immunoglobulin E (anti-IgE) to inhibit the immune system's response to allergen exposure. Omalizumab is directed against the binding site of IgE for its high affinity Fc receptor. It prevents free serum IgE from attaching to mast cells and other effector cells and prevents IgE mediated inflammatory changes.

OBJECTIVES

To determine the efficacy of anti-IgE compared with placebo in patients with allergic asthma

SEARCH STRATEGY

We searched the Cochrane Airways Group Asthma trials register for potentially relevant studies (February 2006).

SELECTION CRITERIA

Randomised controlled trials examining anti-IgE administered in any manner for any duration. Trials with co-interventions were included as long as they were the same in each arm.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed study quality and extracted and entered data. Three modes of administration were identified from the published literature (inhaled, intravenous and subcutaneous injection). Subgroup analysis was performed by asthma severity. Data were extracted from published and unpublished sources.

MAIN RESULTS

Fourteen trials (15 group comparisons) were included in the review, contributing a total of 3143 mild to severe allergic asthmatic participants with high levels of IgE. Treatment with intravenous and subcutaneous Omalizumab significantly reduced free IgE compared with placebo. Omalizumab led to a significant reduction in inhaled steroid (ICS) consumption compared with placebo (-119 mcg/day (95% CI -154 to -83, three trials)). There were significant increases in the number of participants who were able to reduce ICS by over 50% (odds ratio (OR) 2.50, 95% confidence interval (CI) 2.02 to 3.10 (four trials)); or completely withdraw their daily ICS intake (OR 2.50 (95%CI 2.00 to 3.13; four trials)). Participants treated with Omalizumab were less likely to suffer an asthma exacerbation with treatment as an adjunct to ICS (OR 0.52, 95%CI 0.41 to 0.65, five trials), or as an ICS tapering agent (OR 0.47, 95% CI 0.37 to 0.60, four trials).

AUTHORS' CONCLUSIONS

Omalizumab was significantly more effective than placebo at increasing the numbers of patients who were able to reduce or withdraw their inhaled steroids, but the clinical value of the reduction in steroid consumption has be considered in the light of the high cost of Omalizumab. The impressive placebo effects observed in control groups bring into question the true effect of Omalizumab. Omalizumab was effective in reducing asthma exacerbations as an adjunctive therapy to inhaled steroids, and during steroid tapering phases of clinical trials. Omalizumab was generally well tolerated, although there were more injection site reactions with Omalizumab. Patient and physician assessments of the drug were positive. Further assessment in paediatric populations is necessary, as is direct double-dummy comparison with ICS.

99 EFFECT OF CYSTEAMINE ON SURVIVAL OF BOVINE AND OVINE OOCYTES VITRIFIED USING THE MINIMUM VOLUME COOLING (MVC) CRYOTOP METHOD

The addition of cysteamine to maturation (IVM) media increases glutathione (GSH) synthesis in bovine oocytes and improves embryo development and quality (de Matos et al. 1995 Mol. Reprod. Dev. 42, 432–436). This study assesses the effect of adding cysteamine to IVM media on the survival of bovine and ovine oocytes following vitrification using the MVC cryotop method (Kuwayama and Kato 2000 J. Assist. Reprod. Genet. 17, 477 abst.). Abattoir-sourced bovine and ovine cumulus–oocyte complexes (COC) were matured in IVM media with or without 100 μM cysteamine for 24 h. After maturation, the COC were partially denuded and a proportion vitrified. Oocytes were equilibrated with 10% ethylene glycol (EG) and 10% dimethyl sulfoxide (DMSO) for 30 s and then exposed to 20% EG, 20% DMSO, 0.5 M sucrose, and 20% FCS for 15 s. Oocytes were loaded onto a MVC plate (Cryotop, Kitazato Supply, Tokyo), and plunged into liquid nitrogen. After 5 days, oocytes were thawed directly into 1.25 M sucrose solution at 38.5°C, followed by stepwise dilution of the cryoprotectants. Ova were subsequently fertilized (Day 0) and cultured in modified SOF. Oocyte survival was assessed by cleavage and development to Day 8 compared with the development of fresh oocytes. Main effects, interactions and individual treatment differences were tested using procedure CATMOD in SAS. Cleavage rate was higher (P < 0.001) for fresh oocytes than for vitrified oocytes and it increased (P < 0.05) only for fresh ovine oocytes when cysteamine was added to maturation media. Blastocyst development was influenced by a significant (P < 0.001) interaction between species and whether or not oocytes were vitrified. This interaction occurred because cysteamine improved blastocyst rate in fresh ovine and vitrified bovine oocytes but not in other treatments. These results show that bovine oocytes (38.3% blastocyst rate) can be vitrified successfully when maturation occurs in the presence of cysteamine; however, a comparable result did not occur in ovine oocytes (10.6% blastocyst rate) despite >70% cleavage. Table

The effect of early stimulation on maternal depression: a cluster randomised controlled trial

AIM

To determine the effect of early childhood stimulation with undernourished children and their mothers on maternal depression.

METHODS

Mothers of 139 undernourished children (weight for age < or =-1.5 z-scores) aged 9-30 months were recruited from 18 government health centres in the parishes of Kingston, St Andrew, and St Catherine, Jamaica. They received weekly home visits by community health aides for one year. Mothers were shown play activities to do with their child using home made materials, and parenting issues were discussed. Frequency of maternal depressive symptoms was assessed by questionnaire. Child development was also measured.

RESULTS

Mothers in the intervention group reported a significant reduction in the frequency of depressive symptoms (b = -0.98; 95% CI -1.53 to -0.41). The change was equivalent to 0.43 SD. The number of home visits achieved ranged from 5 to 48. Mothers receiving > or =40 visits and mothers receiving 25-39 visits benefited significantly from the intervention (b = -1.84, 95% CI -2.97 to -0.72, and b = -1.06, 95% CI -2.02 to -0.11, respectively) while mothers receiving <25 visits did not benefit. At follow up, maternal depression was significantly negatively correlated with children's developmental quotient for boys only.

CONCLUSIONS

A home visiting intervention with mothers of undernourished children, with a primary aim of improving child development, had significant benefits for maternal depression. Higher levels of maternal depression were associated with poorer developmental levels for boys only.