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Are there valid proxy measures of clinical behaviour?
Background: Accurate measures of health professionals' clinical practice are critically important to guide health policy decisions, as well as for professional self-evaluation and for research-based investigation of clinical practice and process of care. It is often not feasible or ethical to measure behaviour through direct observation, and rigorous behavioural measures are difficult and costly to use. The aim of this review was to identify the current evidence relating to the relationships between proxy measures and direct measures of clinical behaviour. In particular, the accuracy of medical record review, clinician self-reported and patient-reported behaviour was assessed relative to directly observed behaviour.
Methods: We searched: PsycINFO; MEDLINE; EMBASE; CINAHL; Cochrane Central Register of Controlled Trials; science/social science citation index; Current contents (social & behavioural med/clinical med); ISI conference proceedings; and Index to Theses. Inclusion criteria: empirical, quantitative studies; and examining clinical behaviours. An independent, direct measure of behaviour (by standardised patient, other trained observer or by video/audio recording) was considered the 'gold standard' for comparison. Proxy measures of behaviour included: retrospective self-report; patient-report; or chart-review. All titles, abstracts, and full text articles retrieved by electronic searching were screened for inclusion and abstracted independently by two reviewers. Disagreements were resolved by discussion with a third reviewer where necessary.
Results: Fifteen reports originating from 11 studies met the inclusion criteria. The method of direct measurement was by standardised patient in six reports, trained observer in three reports, and audio/video recording in six reports. Multiple proxy measures of behaviour were compared in five of 15 reports. Only four of 15 reports used appropriate statistical methods to compare measures. Some direct measures failed to meet our validity criteria. The accuracy of patient report and chart review as proxy measures varied considerably across a wide range of clinical actions. The evidence for clinician self-report was inconclusive.
Conclusion: Valid measures of clinical behaviour are of fundamental importance to accurately identify gaps in care delivery, improve quality of care, and ultimately to improve patient care. However, the evidence base for three commonly used proxy measures of clinicians' behaviour is very limited. Further research is needed to better establish the methods of development, application, and analysis for a range of both direct and proxy measures of behaviour
Specific inhibition of mouse oocyte nuclear protein phosphatase-1 stimulates germinal vesicle breakdown
Okadaic acid (OA)-induced germinal vesicle breakdown (GVBD) and localization of protein phosphatase-1 (PP1) in oocyte nuclei are suggestive of PP1's role in regulating oocyte GVBD. To explore this possibility, we microinjected protein phosphatase (PP) inhibitors OA, anti-PP1 antibody (anti-PP1), PP1 inhibitor I2, and anti-PP2A antibody (anti-PP2A) into nuclei of roscovitine (ROSC)-arrested mouse oocytes. Oocytes were also injected with recombinant PP1 in the absence of ROSC. Oocytes were assessed for GVBD and metaphase II (MII) development at 2 and 18 hr post-injection. Data were analyzed using Cochran-Mantel-Haenszel Statistics adjusted for time. Microinjection of OA significantly enhanced GVBD in comparison to controls at 2 and 18 hr ( P  < 0.01), yet had no effect on MII development. Similarly, microinjection of anti-PP1 resulted in significantly higher levels of GVBD compared to controls at 2 and 18 hr ( P  < 0.01). Interestingly, anti-PP1 microinjection also tended to enhance MII development at 18 hr in comparison to controls ( P  < 0.09). Microinjection of I2, anti-PP2A, and PP1 had no effect on GVBD or MII development. If reduction of PP1 activity was important for GVBD, one would anticipate an endogenous means of regulating PP1 activity at this developmental stage. In somatic cells, phosphorylation of PP1 at Thr320 causes PP1 inactivation. Germinal vesicle-intact oocytes did not contain phosphorylated PP1, as determined using a specific Thr320-Phospho-PP1 antibody, Western blot analysis, and confocal immunocytochemistry. At or around the time of GVBD, oocyte PP1 became phosphorylated at Thr320, which remained phosphorylated through MII development. These data indicate that inhibition of intra-nuclear PP1, through specific antibody neutralization, mimics OA-stimulated GVBD, providing the first direct evidence that nuclear PP1 is involved in regulation of oocyte nuclear membrane integrity. In addition, phosphorylation of PP1 occurs at/or around GVBD indicating that inactivation of PP1 is an important intracellular event in regulation of nuclear envelope dissolution at GVBD. Mol. Reprod. Dev. 65: 96–103, 2003. © 2003 Wiley-Liss, Inc.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/35087/1/10258_ftp.pd