BackgroundVerbal autopsy (VA) is one method to obtain valid estimates of causes of death in the absence of valid medical records. We tested the reliability and validity of a VA questionnaire developed for a cohort study in Golestan Province in northeastern Iran.MethodA modified version of the WHO adult verbal autopsy was used to assess the cause of death in the first 219 Golestan Cohort Study (GCS) subjects who died. The GCS cause of death was determined by two internists who independently reviewed all available medical records. Two other internists (“reviewers”) independently reviewed only the VA answers and classified the cause of death into one of nine general categories; they repeated this evaluation one month later. The reliability of the VA was measured by calculating intra-reviewer and inter-reviewer kappa statistics. The validity of the VA was measured using the GCS cause of death as the gold standard.ResultsVA showed both good validity (sensitivity, specificity, PPV, and NPV all above 0.81) and reliability (kappa>0.75) in determining the general cause of death independent of sex and place of residence. The overall multi-rater agreement across four reviews was 0.84 (95%CI: 0.78–0.89). The results for identifying specific cancer deaths were also promising, especially for upper GI cancers (kappa = 0.95). The multi-rater agreement in cancer subgroup was 0.93 (95%CI: 0.85–0.99).ConclusionsVA seems to have good reliability and validity for determining the cause of death in a large-scale adult follow up study in a predominantly rural area of a middle-income country.
Background: More than 350 million people are chronic carriers of hepatitis B virus (HBV) and because of the high HBV-related morbidity and mortality, the global disease burden of HBV is substantial. In patients with HBeAg-negative chronic hepatitis B (CHB) with serum alanine aminotransferase (ALT) levels, 1-2 × upper limit of normal (ULN) and HBV DNA load of 10000 to 100000 copies/mL, liver biopsy should be considered and treatment may be initiated if liver biopsy shows moderate/severe necro-inflammation or significant fibrosis. A dynamic balance between viral replication and host immune response is pivotal for the pathogenesis of liver disease in HBV infection. Due to immune response variability, there is thought to be a considerable difference in the histopathologic status of liver biopsy samples present in various populations. Objectives: Liver histopathology in asymptomatic patients with greater than 10000 DNA copies/mL despite negative Hbe Ag was studied to determine, the number of people that will benefit from a liver biopsy, and variables that will significantly be affected by viral load changes. Patients and Methods: Eighty-two symptomless hepatitis B patients, identified during screening tests, were entered into the study. All candidates were HBS Ag Positive, Hbe Ag negative, Hbe Ab positive, HDV Ab, HIV Ab 1, 2, and HCV Ab negative. In all cases HBV DNA virus load was greater than 10000 copies/mL (2000 U/mL). Liver biopsy was done after obtaining a written consent. Liver histopathology was reported based on the histological activity index (HAI). Results: Both HBV DNA load and serum ALT levels significantly correlated with the grade score. Both stage and grade significantly correlated with age. Stage score of liver specimens was significantly lower in women than men. Logistic regression analysis indicated that the baseline ALT and HBV DNA levels and age were independent predictors of the HAI score. Conclusions: In 10% of the patients, liver biopsy changed the treatment plan and treatment was started despite ALT levels being less than twice the normal level.
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