On 2019-02-16 20:45:24, user GuyguyKabundi Tshima wrote:
Patients with a thick negative drop were excluded from the small sample taken to explain HIV-malaria coinfection.
These excluded patients interested me later with the performance of the diagnosis of malaria by PCR which could detect positive the negative cases of the thick drop even asymptomatic cases which are then treated to reduce the parasite biomass.
The positive slope means that the weight loss under ART is accompanied by the number<br />
malaria episodes and if we do not want to see the weight gain won under ART be erased in case of malaria, it was necessary to set in motion all necessary means (clinical, paraclinical, therapeutic and nutritional) to prevent HIV positive subjects to do Malaria-disease.
In 2013, I interacted again with a reader's questions.
Q. A reader writes: For my part, I would have liked the data of this work are supported by laboratory results from your own investigations:
A. At variance. I know my answer is LOW: "For my part, I've been recommended by the original supervisor to collect existing data at AMOCONGO, I was authorized by the Vice-Dean in charge of Research, Specialization and Aggregation, and I received the approval of the Ethics Committee of the national program of struggle against AIDS and sexually transmitted infections (PNLS/ IST). The essence of the question is the guarantee of the integrity of the data: what I can attest by having myself collected the data on the medical files.
Q. A reader writes: Can we present a work of thesis of aggregation on a base as held as the one you present us: the medical files!<br />
Comments : In this case, the elements of the cards used have been designed by others. You have analyzed this data from a perspective that you have set for yourself. Hence, the poverty in the material presented for your subject: the medical files!
A. At variance. I know that my answer is still LOW, same reason that in 1: evoking the original supervisor is not a "scientific" argument. Here also the background of<br />
the question is the integrity of the data.<br />
The medical forms were used to finalize a process in which the original Promoter advocated for the collection of the data necessary for the finalization of the thesis project.
Q. A reader writes: What do we mean by prospective study?<br />
Comments: In my opinion, shared by most researchers, a prospective study is one in which the researcher masters the essential stages of research from beginning to end. He establishes his program of study: he foresees the statistical methods, then, collects himself or with the collaborators his data in the laboratory or in the field. Then it analyzes the data collected and identifies the conclusions
A. At variance. I know my answer is in MIDDLE: "In my opinion, shared by the late Dr. Mulumba Madishala Paul (Biomedical research: methodological bases and elements of biostatistics. Biométrix Editions, Kinshasa. 74 pages, 1994, 200l), it is right and wrong that most researchers consider any study conducted on the basis of medical records as retrospective. In our article, this is an authentic prospective study because the data collected there are of a longitudinal nature (weight at admission, at 3, 6 and 12 months under ART) ". I plan to add 2 or 3 other articles references as this is a great criticism of my methodology. So far I have noted that this prospective / retrospective definition is not consensual, and modern epidemiologists therefore recommend that they no longer use this terminology: it is the reference of a course of biostatistics which one can see on the site of the Faculty of Medicine of Pierre and Marie-Curie University (http://www.chups.jussieu.fr... consultation of the<br />
28.10.2015).
Q.4. A reader writes: you talk about a search prospective in the case of a study conducted on the basis of the rereading of medical records. It is therefore in a prospective vision relating to the first year of putting patients under triple therapy that this study was conducted.
A.4. In agreement. My answer is GOOD, but I have to take out the limitations on my<br />
results. I mention that the limitations of the thesis should be emphasized and well defined.
Q.5. A reader writes: Compared to the work (ANTERRETROVIRAL FLOODING AND INTERACTIONS WITH MALARIA), what is the original contribution of this work?
A.5. In agreement. This work had this conclusion: "there is on average no change in weight in the first year under ART". The original contribution of this work is that it must be understood that the link between Selenium and NADPH oxidase was not formally established. And I did not study it with data, but through articles.
The subject WEIGHT FLUCTUATION UNDER ART AND POTENTIAL INTERACTIONS WITH MALARIA
"Weight loss under ART and potential interactions with malaria"
Problematic<br />
Rapid increase in access to antiretroviral therapy in developing countries brought new challenges. These include the unprecedented need for perpetual treatment for an illness<br />
infectious for life, and the pressure this will place on health services [Khoo S., 2004]. Gaps in current knowledge urgently require emphasis on the change in body weight on antiretroviral therapy and the different interactions with other drugs, including antimalarials [Khoo S., 2004]. Malaria is spread across areas of the world where resources are limited,<br />
and most of these sectors have also been shaken by the HIV pandemic.
Research hypotheses<br />
There are potentially many different ways in which both diseases act each other at the political, social and public health levels, as well as new evidence of how one can affect the pathogenesis and the results of the other [Khoo S., 2004].As access to antiretroviral drugs increases, and new combinations of antimalarials are evaluated. It is important that potential interactions between therapies for these two infections are also reviewed [Khoo S., 2004].
Main objective
Contribute to the fight against HIV / AIDS infection and malaria, two major diseases<br />
in the Democratic Republic of Congo with scary figures:<br />
- Malaria: 10% of global mortality<br />
- HIV: 3,000,000 Congolese are infected (?)
Specific objectives
- This study was undertaken to evaluate the evolution of the mass index (BMI) or quetelet index of patients living with HIV / AIDS (PVV) under the antiretroviral therapy in a malaria endemic area.
- Provide clinicians with a nutritional monitoring tool in a malaria endemic area<br />
for people living with HIV
Methods
- A simple random sample of 72 medical records of patients followed in Kinshasa<br />
been taken to the medical center of ACS / AMOCONGO, a specialized N.G O. in the Democratic Republic of Tthe Congo, but data not available in the variable size in many cases forced us to consider only the variable weight in order to evaluate the evolution of the nutritional status of PVV under ART.
- The CD4 lymphocyte variable before treatment was also taken. For the latter, there were also missing data. In fact, CD4 lymphocytes were considered as confounders.
- At ACS / AMOCONGO all patients' medical records are listed from A to Z:<br />
at random we chose the letter D and took the first 72 patient records in<br />
which the following variables were found: age, weight before and after<br />
ART (weight at the date of the last visit), malaria (suspected clinically and confirmed by a thick blood thin smear), antimalarials (quinine, sulfadoxine-pyrimethamine, arthemeter-amodiaquine) and ART (all patients were under Triomune - stavudine, lamivudine and<br />
nevirapine)
Results
The percentage of PVV with high CD4 lymphocyte levels:<br />
- compared with that of PVV with the levels of collapsed CD4 lymphocytes was<br />
15.79% vs. 84.21%, or in a ratio of 1/5 (patients with<br />
CD4 cells collapsed 5 times more than those with high CD4).<br />
The percentage of PVV with high CD4 lymphocyte levels:<br />
- and its correlation with malaria compared to that of PVV with lymphocyte levels<br />
CD4 collapsed and its correlation with malaria was 5.26% and 31.58%, respectively, in a ratio of 1/6 (patients with collapsed CD4 cells were 6 times more likely to be malaria patients than those with high CD4 ).<br />
Quinine was prescribed first-line followed by Sulfadoxine Pyrimethamine and<br />
artemisinin-amodiaquine.<br />
• The weight gain was 16.67% compared to the weight loss which was 61.11%<br />
in a ratio of ¼ (1 in 4 patients gained weight during HIV-malaria co-infection)
Discussion
All of these results should be considered with the following confounding factors:<br />
- the level of CD4 lymphocytes (generally classified as collapsed if less than 410 and elevated if higher than 410 CD4 cells / mm3)<br />
- patient income (which can determine the quality of the diet),<br />
- the duration of ARV treatment<br />
- associated opportunistic infections.<br />
72 patients: small sample? But representative because calculated according to the formula: n≥ Z2αpq / d2<br />
n: sample p: HIV prevalence<br />
d: precision of 95% so d = 5% Zα = Z0.05 = 1.96<br />
Z0.05 = 1.96 = 2<br />
p = 0.046 = 4.6%<br />
q = 1-p = 1-.046 = .954<br />
d = 0.05<br />
n≥4 * 0.046 * 0.954 / 0.0025 = 70<br />
Nevertheless, this being an exploratory study, we will complete our data to arrive at a sample of at least 200 patients. The information gathered corroborated the results of the work on more than one point presented by Saye Khoo, David Back and Peter Winstanley in June 2004 at WHO in Geneva on interactions between HIV and malaria (1)<br />
The results obtained will allow integration of care.
Conclusion
In conclusion, this study has shown that attention can be highlighted in cases of HIV-malaria coinfection:<br />
- malaria is an aggravating factor that with fever induces catabolism and requires<br />
energy<br />
- to this we must also add its symptoms and the side effects of antimalarials<br />
(anorexia,…) that can lead to decreased dietary intake and weight loss.
Recommendation
For weight monitoring, we recommend using the "Body-Check System"<br />
(KORONA) originally planned for fitness, we think with the agreement of our<br />
promoter, this can be adopted for the nutritional monitoring of subjects living with HIV because they can:<br />
- measure body fat (energy source)<br />
- indicate the body water rate<br />
- display BMI or body mass index<br />
- display the consumption in Kcal
Key words: antiretrovirals, antimalarials, body mass index, weight gain, weight loss, Kinshasa (Democratic Republic of Congo)
Bibliography
- Khoo S., Back D., Winstanley P. The potential for interactions between antimalarial and<br />
antiretroviral drugs. In AIDS 2005, 19: 995-1005.
- Back D., Gatti G., Fletcher C., Garaffo R., Haubrich R., Hoetelmans R., et al. Therapeutic drug monitoring in HIV infection: current status and future directions. AIDS 2002; 16 (Suppl 1): S5-S37.
Q. A reader writes: Viral load: Reason advanced: it was not our database (missing data). This reason is not valid: Because the real reason is that, at the time, no laboratory in Kinshasa still had equipment for measuring of this viral load.
A. In agreement.
Q. A reader writes: Do different ART regimens have any effect?
A. In agreement. They have effects, but in our sample, all patients were under the same ART regimen in first-line treatment with triomune-40.
Q.A reader writes: We know that some ART train more easily resistances than others.
A.15. In agreement.
Q. A reader writes: Opportunistic diseases and comorbidities: not take into account, is this a valid hypothesis?
A. According to our collect of routinely data, the model that does not exclude another model that can hold account of this valid hypothesis. The important thing for a model is its interpretation:<br />
- Our model is limited to weight on admission and 12 months under ART.<br />
- However, its interpretation takes into account opportunistic diseases and co-morbidities.<br />
And it is obvious that co-infection with severe malaria-HIV / AIDS should be cited first<br />
in a tropical area.<br />
It is this explanation that our model has brought. With the exception of severe malaria<br />
causing weight loss, there are:<br />
- HIV itself which is supposed to be inactive under ART<br />
- other opportunistic diseases that are eliminated as and when e of the recovery of<br />
CD4 lymphocytes with ART.<br />
- other comorbidities such as cirrhosis or diabetes that can be controlled,<br />
But malaria that is often severe in immunocompromised patients is overlooked, no lines<br />
guidelines for the treatment of HIV-Malaria co-infection on a global scale according to<br />
Flateau's review of the literature which states that because of the lack of criteria<br />
rigorous diagnostics to prove malaria, the precise assessment of the effect of<br />
Malaria in HIV-infected patients is limited (Flateau CG: 2011).
Q. A reader writes: Civil status: he was not mentioned on the health data consulted?
A. In agreement. Yes, it was missing on some medical records consulted.
Q. A reader writes: Absence of control with HIV (-).
A. In agreement. The study focused on the medical records of HIV + patients under ART.
Q. A reader writes: Some limitations could have been overcome.
A. In agreement.
Q. A reader writes: Targets of insulin: hepatocyte, adipocyte, myocyte,... there is also the neuron!
A. In agreement.
Q. A reader writes: p.44 (6th line): ... .TNFα increases what catabolism:<br />
hat of proteins, carbohydrates or lipids?
A. The proteins.
Q.A reader writes: It can be understood that the excess of the production of SOD which releases H2O2 precursor hydroxyl radical HO ° according to the reaction it<br />
catalysis: 2 O2 + 2H + H2O2 + O2 May exacerbate oxidative stress. But how to integrate in this exacerbation the opposite phenomenon of insufficient production of SOD.
A. In agreement. It is the excessive production of SOD that demands the organism to use another non-enzymatic pathway with NADPH oxidase which involves the Selenium in its composition. This is the key to the thesis: fever (malaria or HIV) activates NADPH oxidase. HIV is blocked by ARVs. So if there is fever in an HIV subject on ARV, the HIV factor is eliminated, while the severe malaria factor due to the endemic area is always present. Which makes us say that this fever is mostly of malaria origin. NADPH oxidase fights oxidative stress (SOD). Selenium intake goes into the sense to increase the role of antioxidant played by NADPH oxidase.
Q.A reader writes: As non-enzymatic antioxidants, there is no that selenium, we must also mention Vit C and Vit E.
A. In agreement, but selenium is powerful non-enzymatic antioxidant, more powerful<br />
that Vit C and Vit E together.
Q.A reader writes: introduction of a parameter different from previous ones: 200 CD4 / μl whereas everywhere else in the work it is 50 CD4 / μl you speak. How to reconcile this change of cell count?
A. In agreement. I remember that the cut-off for ARV is less than 200 CD4 / μl whereas in the cards consulted, the patients had a quarter of this number less than 50 CD4 / μl so on admission, patients had very compromised immunity so naive to make a serious malaria.
Q. A reader writes: The title of table 4 is not precise: it is actually about<br />
analysis of variance for the four moments of weight: 0, 3, 6 and 12 months.
A. In agreement.
Q.A reader writes: You write: HIV infection increases the repetition of episodes of severe malaria.
A. In agreement.
Q.A reader writes: Will weight loss be associated with HIV or repeat episodes of severe malaria?
A. In agreement. HIV is inactive on ARVs, so weight loss would be associated with<br />
repetition of severe malaria episodes that activate the enzyme NADPH oxidase.
Q. A reader writes: We know that HIV is already associated with a loss weight. So?
A. In agreement. HIV is inactive on ART, so weight loss would be associated with<br />
repetition of severe malaria episodes that activate the enzyme NADPH oxidase.
Q. A reader writes: the variance analysis table shows the test of non-significance of the weights on admission, after 3, 6 and 12 months?
A. I agree
Q. A reader writes: Apparently from your statistical results, you only have 2 variables: response variable (Y) ; Predictive variable 1 (X1). Finally, the equation used would be: Y = a + b1X1.
A. In agreement. Weight loss can be adequately modeled at 12 months on ART<br />
(y), the diagnosis of severe malaria on admission (x) as y = ax + b; where "a" is<br />
a constant and "b" is the slope of the linear regression.
Q. A reader writes: The binary logistic regression. We read ... Using Minitab software, we calculate the binary logistic regressi we have follows: Severe malaria = Number of CD4 <50 cells / μl (no separation) Weight (in) on admission(no separation) Weight (in) 12 months later ...It would have been clearer to systematize your model: Y = severe malaria; X1 = CD4; X2 = initial weight; X3 = Weight after 12 months. What would have given as equation:<br />
Y = a + b1x1 + b2X2 + b3X3.
A. In agreement.
Q. A reader writes: it is necessary to begin by exposing the complete model with Y = Initial weight, X1 = CD4 / μl, X2 = Weight after 12 months, X3 = severe Malaria, X4 = severe HIV / malaria coinfection, X i + j = diabetes, cirrhosis, etc ...
A. In agreement.
Q. A reader writes: This raises the question of how many predictive variables (2, 3, 4, 5, etc ...) have been incorporated into your initial model of logistic regression: (1) CD4 / μl, (2) Weight after 12 months, (3) severe malaria, (4) HIV / severe malaria coinfection, (5) diabetes, (6) cirrhosis, (7) tuberculosis, (8) ) cancer, (9) age ... etc. .. This is not explicit in your text. Because from 9, 10, 11 variables predictives poses the conceptual problem of the utility of each of these variables for include in the model. This problem needs to be explained clearly. Because we would have to show the table drawn for the Khi-Carré of each variable predictive so that we realize its meaning.
A. In agreement: 3 predictor variables were incorporated in the initial model of<br />
Logistic regression: (1) CD4 / μl <50 cells, (2) Initial weight, (3) Weight after 12 months.<br />
The logistic regression was not significant however, she had shown<br />
in the cards consulted a link between the diagnosis of severe malaria and<br />
admission (y) and a number of CD4 / μl <50 cells (x1).<br />
So, I switched to linear regression to adequately model weight loss<br />
at 12 months on ARV (y), diagnosis of severe malaria on admission (x)<br />
y = ax + b; where "a" is a constant and "b" is the slope of the linear regression.<br />
y = Weight after 12 months, x1 = Diagnosis of severe malaria at admission, x2 = co-infection<br />
HIV / severe malaria, x i + j = diabetes, cirrhosis.
Q. A reader writes: No evaluation of the accuracy or the reproducibility and the reliability of counting CD4 in the laboratory of AMOCONGO. For good reason: retrospective study!
A. At variance. Good reason: AMOCONGO is a social structure, not for the scientific purpose. The laboratory is living with limited time subsidies.
Q. A reader writes: Your Conceptual Model is not well explained: in the box beginning with ... 72 medical ... all the text included in this box should be reduced to a bare minimum, returning the rest in the text.
A. In agreement. Here is the conceptual model well explained ; Evolution of the weight of HIV-positive subjects on antiretroviral treatment in an area of malaria endemic
Q.A reader writes: BMI or IMC (Body Mass Index in French).<br />
This index is calculated by the formula: BMI = Weight (kg) / [Size (m)] 2. Your work is titled: "Evolution of BMI ..." in addition, your sample is limited to adults (age≥18 years). Under these conditions, within 12 months, can the size of a subject undergo significant variation to the point of affecting BMI?
A. No. In agreement.
Q. A reader writes: Of course, BMI is a report that changes when one terms: numerator or denominator changes. The analysis of the medical records of your sample suggest this change in subject size ??
A. No. In agreement.
Q. A reader writes: If this is not the case, then replace Evolution of BMI by Evolution of weight ...
A. I agree
Q. A reader writes: You evoke Eastern DRC as an unstable malaria and Kinshasa as a stable malaria area. Have you determined the workforce patients from that area who were eventually included in your sample of 72 patients?
A. No. In agreement. However, this work draws our attention to the vulnerability of a<br />
HIV + who leaves an unstable malaria area and comes for treatment in an area stable malaria: it runs the risk of making more severe forms of malaria. And we know that the war would have increased the number of HIV-positive women in Eastern DRC with the rapes suffered by girls and sons in this part of the country during atrocities, this is no longer to be demonstrated with all the African forces who had elected home during the war of liberation.
Q. A reader writes: MATERIEL. You're saying: Toshiba Computer,<br />
medical fislands, sheets of paper, pens. Is it really worth aligning sheets of paper<br />
and bics among the material used? Why not add chairs and tables too! In<br />
finally, your material consisted only of patients' medical files!
R. In agreement.
Q. A reader writes: Admit it's simple!
A. In disagreement. The medical forms were used for the finalization of the thesis to be included in the whole of the global theme which is POVERTY with 5 PREPRINT<br />
published articles and 2 in peer-review submission. And talking about POVERTY is not lean. Regarding weight loss, there are 10 key messages:<br />
- 1. HIV-AIDS and malnutrition are interdependent.<br />
- 2. HIV affects nutrition through multiple mechanisms. Its impact starts early<br />
during asymptomatic infection and continues throughout the life cycle.<br />
-3. HIV exposure and HIV infection worsen malnutrition issues<br />
infantile<br />
-4. Infants who are not breastfed because of maternal choice, illness or<br />
mortality are particularly vulnerable to malnutrition.<br />
-5. Nutritional interventions benefit HIV patients<br />
-6. Nutritional education can improve adherence or adherence to ARVs and<br />
other drugs to treat opportunistic infections.<br />
-7. The objectives for nutrition education vary at different stages of infection<br />
Asymptomatic HIV HIV and AIDS and post-mortem HIV<br />
surviving members of the family.<br />
-8. Priority actions include nutrition for a positive life, management of<br />
disease nutrition, management of interactions between ARVs and foods,<br />
Therapeutic feeding for HIV seropositive moderately and severely malnourished,<br />
children and adults, infants and young children, and the elderly in<br />
accommodation or palliative care.<br />
-9. Nutrition interventions for people living with HIV / AIDS<br />
include the food supply and the assessment of nutritional status,<br />
support tips, targeted nutritional supplements, and links to programs<br />
supply and food security.<br />
-10. Nutrition education, care and support are important elements of<br />
in charge of HIV and should be considered initially when planning<br />
programs.
Q. A reader writes: In a real environment, can we observe a phenomenon<br />
with p = 0.00? No.
A. In agreement.
Q.A reader writes: The probability that you score 0.000 is indeed a very low probability that it should be indicated 0.0003 .... 0.00005 ... At least indicate that it is inferior to such value and not to affirm that it is 0.000!
A. In agreement.
Q. A reader writes: Where do you plan to present the research question?
A. In agreement. The research question is presented in the introduction.
Q. A reader writes: A summary should summarize the essence of the work: a<br />
brief introduction with objective of the subject: methods used in a few words, results<br />
essentials and conclusion and not to exceed a certain number of words: 250 words! That's not what we find in your summary.
A. In agreement.
Q. A reader writes: The title of the project is too long for nothing. We can<br />
shorten by replacing it with: PROSPECTIVE STUDY ON BMI EVOLUTION OF<br />
HIV / AIDS SUBJECTS UNDER ART IN MALARIA ENDEMIC AREA.
A. In agreement.
Q. A reader writes: The whole page and the ¾ of the page are devoted to the mechanisms of oxidative stress in the progression of HIV and malaria. Is it in the acknowledgments the appropriate place to talk about these mechanisms?
A. In agreement. No, it's in the generalities.
Q. A reader writes: Can it be understood that these are febrile patients with diagnosis of severe malaria with a CD4 count <50 cells / μl ... is not better, so expressed?
A. In agreement.
Q. A reader writes: ... confounding factors as opportunistic infections (OI), helminths, poverty, diabetic, cirrhosis, ... In this line, what is the grammatical role diabetic : adjective or noun? If adjectiof, how do you list it with nouns: infections, poverty, etc ...? Replace diabetic by diabetes.
A. In agreement.