The experience and professional development of medical appraisers

This article explores the experiences of General Practitioner (GP) appraisers working in a unfamiliar setting (Jersey) with appraisees new to the process. Findings were interpreted using the learning theory, 'situated cognition', to shed light on the experience of appraisers working with new appraisees more generally and contribute to new understandings of workplace learning. Rich qualitative data derived from transcripts of nine in-depth interviews with GP appraisers were analysed thematically in a rigorous and iterative manner process. GP appraisers working in an unfamiliar environment shared a common sense of culture shock and discomfort. Initially, they needed to work much harder than usual to establish rapport and credibility, but by the second round of appraisals, appraisers were reminded of the power of appraisal. The innovative application of 'situated cognition' helps to explain why appraisers felt like 'novices' in Jersey and how they were required to reconstruct their professional knowledge. This is the first time appraiser development has been considered in this way and appraisers can be helped to develop professionally if they are offered a mix of appraisal-related activities in new places and with new people. Such implications for educational support apply internationally where doctors are involved in a process of peer review as part of on-going professional development.

The benefits of appraisal: a critical (re)view of the literature

It has been acknowledged that little is known about the impact of general practice (GP) appraisal on clinical and professional practice, as may be demonstrated by identifiable or 'hard' outcomes, and further, that the way in which appraisal informs professional development is unclear. In spite of this acknowledgement and the existence of a substantial number of studies about GP appraisal, to date an overview of the field of enquiry which maps what is known, has been lacking. In this leading article we present the first extensive thematic narrative synthesis of the literature on appraisal. In it we highlight the issues and tensions around research into appraisal, based on what we found (or didn't find) in our review. Key conclusions concern the focus of existing research - which has tended to report the perceptions of change from individual appraisees, rather than specific examples of change captured from other sources and perspectives - and the scope of research - which has been limited to certain data collection methods. Based upon our review, we draw out implications for research and researchers in the future.

The bipolar disorder risk allele at CACNA1C also confers risk of recurrent major depression and of schizophrenia

Molecular genetic analysis offers opportunities to advance our understanding of the nosological relationship between psychiatric diagnostic categories in general, and the mood and psychotic disorders in particular. Strong evidence (P=7.0 × 10(-7)) of association at the polymorphism rs1006737 (within CACNA1C, the gene encoding the α-1C subunit of the L-type voltage-gated calcium channel) with the risk of bipolar disorder (BD) has recently been reported in a meta-analysis of three genome-wide association studies of BD, including our BD sample (N=1868) studied within the Wellcome Trust Case Control Consortium. Here, we have used our UK case samples of recurrent major depression (N=1196) and schizophrenia (N=479) and UK non-psychiatric comparison groups (N=15316) to examine the spectrum of phenotypic effect of the bipolar risk allele at rs1006737. We found that the risk allele conferred increased risk for schizophrenia (P=0.034) and recurrent major depression (P=0.013) with similar effect sizes to those previously observed in BD (allelic odds ratio ∼1.15). Our findings are evidence of some degree of overlap in the biological underpinnings of susceptibility to mental illness across the clinical spectrum of mood and psychotic disorders, and show that at least some loci can have a relatively general effect on susceptibility to diagnostic categories, as currently defined. Our findings will contribute to a better understanding of the pathogenesis of major psychiatric illness, and such knowledge should be useful in providing an etiological rationale for shaping psychiatric nosology, which is currently reliant entirely on descriptive clinical data.

No evidence for developmental plasticity of color patterns in response to rearing substrate in pygmy grasshoppers

Color polymorphisms in animals may result from genetic polymorphisms, developmental plasticity, or a combination where some phenotypic components are under strong genetic control and other aspects are influenced by developmental plasticity. Understanding how color polymorphisms evolve demands knowledge of how genetic and epigenetic environmental cues influence the development and phenotypic expression of organisms. Pygmy grasshoppers (Orthoptera, Tetrigidae) vary in color pattern within and among populations. Color morphs differ in morphology, behavior, and life history, suggesting that they represent alternative ecological strategies. Pygmy grasshoppers also show fire melanism, a rapid increase in the frequency of black and dark-colored phenotypes in populations inhabiting fire-ravaged areas. We examined the influence of plasticity on color polymorphism in the pygmy grasshopper Tetrix subulata (L., 1761) using a split-brood design. Individuals were experimentally raised in solitude on either crushed charcoal or white aquarium gravel. Our analyses uncovered no plasticity of either color pattern or overall darkness of coloration in response to rearing substrate. Instead, we find a strong resemblance between maternal and offspring color patterns. We conclude that pygmy grasshopper color morphs are strongly influenced by genetic cues or maternal effects, and that there is no evidence for developmental plasticity of coloration in response to rearing conditions in these insects.

Genetic utility of broadly defined bipolar schizoaffective disorder as a diagnostic concept

BACKGROUND

Psychiatric phenotypes are currently defined according to sets of descriptive criteria. Although many of these phenotypes are heritable, it would be useful to know whether any of the various diagnostic categories in current use identify cases that are particularly helpful for biological-genetic research.

AIMS

To use genome-wide genetic association data to explore the relative genetic utility of seven different descriptive operational diagnostic categories relevant to bipolar illness within a large UK case-control bipolar disorder sample.

METHOD

We analysed our previously published Wellcome Trust Case Control Consortium (WTCCC) bipolar disorder genome-wide association data-set, comprising 1868 individuals with bipolar disorder and 2938 controls genotyped for 276 122 single nucleotide polymorphisms (SNPs) that met stringent criteria for genotype quality. For each SNP we performed a test of association (bipolar disorder group v. control group) and used the number of associated independent SNPs statistically significant at P<0.00001 as a metric for the overall genetic signal in the sample. We next compared this metric with that obtained using each of seven diagnostic subsets of the group with bipolar disorder: Research Diagnostic Criteria (RDC): bipolar I disorder; manic disorder; bipolar II disorder; schizoaffective disorder, bipolar type; DSM-IV: bipolar I disorder; bipolar II disorder; schizoaffective disorder, bipolar type.

RESULTS

The RDC schizoaffective disorder, bipolar type (v. controls) stood out from the other diagnostic subsets as having a significant excess of independent association signals (P<0.003) compared with that expected in samples of the same size selected randomly from the total bipolar disorder group data-set. The strongest association in this subset of participants with bipolar disorder was at rs4818065 (P = 2.42 x 10(-7)). Biological systems implicated included gamma amniobutyric acid (GABA)(A) receptors. Genes having at least one associated polymorphism at P<10(-4) included B3GALTS, A2BP1, GABRB1, AUTS2, BSN, PTPRG, GIRK2 and CDH12.

CONCLUSIONS

Our findings show that individuals with broadly defined bipolar schizoaffective features have either a particularly strong genetic contribution or that, as a group, are genetically more homogeneous than the other phenotypes tested. The results point to the importance of using diagnostic approaches that recognise this group of individuals. Our approach can be applied to similar data-sets for other psychiatric and non-psychiatric phenotypes.

Sub-threshold manic symptoms in recurrent major depressive disorder are a marker for poor outcome

OBJECTIVE

A small but significant proportion of patients with major depressive disorder (MDD) report mild manic symptoms which are below the diagnostic threshold for a hypomanic episode.

METHOD

We tested for an association between sub-threshold manic symptoms and clinical outcome in almost 600 patients with recurrent MDD who also had no known family history of bipolar disorder.

RESULTS

9.6% of this large sample had a life-time history of sub-threshold manic symptoms. These patients were significantly more likely to have a history of poor response to antidepressants (OR 2.84; 95% CI 1.23-6.56; P < 0.02) and more likely to have experienced psychosis (OR 2.07; 95% CI 1.05-4.09; P < 0.04). They had also experienced more depressive episodes on average (P = 0.006) and were more likely to have been admitted to hospital (P < 0.03).

CONCLUSION

Sub-threshold manic symptoms in patients with recurrent MDD may be a useful clinical marker for poor response to antidepressants and a more morbid long-term clinical course.