Utility of pharmacogenetic testing to optimise antidepressant pharmacotherapy in youth: a narrative literature review

Pharmacogenetics (PGx) is the study and application of how interindividual differences in our genomes can influence drug responses. By evaluating individuals' genetic variability in genes related to drug metabolism, PGx testing has the capabilities to individualise primary care and build a safer drug prescription model than the current "one-size-fits-all" approach. In particular, the use of PGx testing in psychiatry has shown promising evidence in improving drug efficacy as well as reducing toxicity and adverse drug reactions. Despite randomised controlled trials demonstrating an evidence base for its use, there are still numerous barriers impeding its implementation. This review paper will discuss the management of mental health conditions with PGx-guided treatment with a strong focus on youth mental illness. PGx testing in clinical practice, the concerns for its implementation in youth psychiatry, and some of the barriers inhibiting its integration in clinical healthcare will also be discussed. Overall, this paper provides a comprehensive review of the current state of knowledge and application for PGx in psychiatry and summarises the capabilities of genetic information to personalising medicine for the treatment of mental ill-health in youth.

Chronic non-cancer pain management - insights from Australian general practitioners: a qualitative descriptive study

BACKGROUND

The study explored the experiences and perceptions of GPs regarding the management of chronic non-cancer pain (CNCP). Specifically, participants were asked to identify perceived enablers and barriers to CNCP care and how the care of patients with CNCP may be improved.

METHODS

The study utilised a qualitative descriptive methodology. General practice in Western Australia. The sample was purposive with 12 Australian GPs from predominantly metropolitan locations and with experience in managing CNCP. Semi structured interviews were conducted. Each interview was of 45-60min duration. All interviews were audio recorded and transcribed using a secure transcription service. Thematic analysis developed themes inductively and deductively.

RESULTS

Themes emerged regarding: the importance of a holistic and personalised approach; the important role of a coordinating GP; the need for an evidence-based approach to opioid management; concerns relating to access to multidisciplinary services; the importance of clinician and patient education regarding CNCP; and an acknowledgement of the challenges for doctors and patients in managing CNCP.

CONCLUSIONS

Currently, the management of CNCP in Australia is challenging. Notable challenges include: difficulties with continuity of patient care; challenges with patient expectations of treatment, in particular opioid medications; difficulty with access to the health services required to enable holistic care; and the need for improved pain education in the community. The breadth of these challenges suggests there is a need for supportive organisational and structural considerations in the healthcare system to enable optimal care of CNCP in the community.

Disruption caused by the COVID-19 pandemic response from a Western Australian metropolitan general practice perspective: a qualitative descriptive study

BACKGROUND

In 2020 and 2021, Western Australia (WA) was an early adopter of the 'COVID zero' policy, eliminating community transmission and pursuing vaccine roll out to enable a 'soft landing' once coronavirus disease 2019 (COVID-19) infiltrated the community in 2022. Optimisation and augmentation of general practice services were at the forefront of policies. This study explores metropolitan general practice responses to the resulting disruption caused.

METHODS

Qualitative descriptive methodology, purposive sampling and template analysis were used. Semi-structured interviews were undertaken from March to June 2021 with teams from six general practices in metropolitan WA; six general practitioners, four practice nurses and three practice managers.

RESULTS

Staff at all levels responded rapidly amid uncertainty and workload challenges with marked personal toll (anxiety and fear of exposure to risks, frustrations of patients and balancing work and family life). Self-reliance, teamwork and communication strategies built on inclusivity, autonomy and support were important. Responding to changes in general patient behaviour was to the fore. Increasing use of telehealth (telephone and video) became important to meet patient needs. Lessons learned from what was implemented in early-stage lockdowns provided practices with preparedness for the future, and smoother transitions during subsequent lockdowns.

CONCLUSION

The study demonstrates the self-reliance, teamwork and adaptability of the general practice sector in responding to a sudden, unexpected major disruption, yet maintaining ongoing service provision for their patients. Although the COVID-19 landscape has now changed, the lessons learned and the planning that took place will help general practice in WA adapt to similar future situations readily.

Teaching and assessment of clinical diagnostic reasoning in medical students

BACKGROUND

Teaching diagnostic reasoning and giving feedback has an important role in medical education. Clinicians who teach may recognise errors, but be unfamiliar with the terminology used to describe them, leading to a lack of consistent and useful student feedback.

OBJECTIVE

This prospective project evaluation study aimed to develop an examiner training package regarding errors in diagnostic reasoning, utilising consistent language and feedback tool, and report on diagnostic reasoning errors in second year medical students over the transition from preclinical to early clinical training at objective structured clinical exams (OSCEs).

RESULTS

Likert questionnaire regarding examining, assessment and feedback pre- and post-training showed improvement in all measures, including examiner feedback confidence post training (p < .001). Students (n = 235) within the cohort were examined at the first preclinical OSCE 12 weeks into the teaching year and 236 students at the end of year OSCE. A range of 0-6 diagnostic reasoning errors were reported for individual students. When comparing mean history station scores at the preclinical OSCE for students who were observed to have diagnostic reasoning errors, students with 'poor pattern recognition' had a 4.2% lower score than those without this error type (p = .04, 95% CI of difference .14, 8.32), while those with 'unfocused data collection' error had a station score 7.7% lower than those without this error (p < .001, 95% CI of difference 3.50, 11.99). At the end of teaching year clinical OSCE, all common error types were associated with poorer performance. Error pattern shifted through the two longitudinal assessments, resulting in 'poor pattern recognition' having reduced and 'too narrow' and 'premature closure' increased rates.

CONCLUSIONS

Incorporating the identification and feedback of common diagnostic reasoning errors into existing clinical assessments was feasible and easy to implement. Understanding, identifying and providing consistent feedback on common errors assists educators and could guide curriculum design.