ObjectiveTo synthesise qualitative studies that explore prescribers’ perceived barriers and enablers to minimising potentially inappropriate medications (PIMs) chronically prescribed in adults.DesignA qualitative systematic review was undertaken by searching PubMed, EMBASE, Scopus, PsycINFO, CINAHL and INFORMIT from inception to March 2014, combined with an extensive manual search of reference lists and related citations. A quality checklist was used to assess the transparency of the reporting of included studies and the potential for bias. Thematic synthesis identified common subthemes and descriptive themes across studies from which an analytical construct was developed. Study characteristics were examined to explain differences in findings.SettingAll healthcare settings.ParticipantsMedical and non-medical prescribers of medicines to adults.OutcomesPrescribers’ perspectives on factors which shape their behaviour towards continuing or discontinuing PIMs in adults.Results21 studies were included; most explored primary care physicians’ perspectives on managing older, community-based adults. Barriers and enablers to minimising PIMs emerged within four analytical themes: problem awareness; inertia secondary to lower perceived value proposition for ceasing versus continuing PIMs; self-efficacy in regard to personal ability to alter prescribing; and feasibility of altering prescribing in routine care environments given external constraints. The first three themes are intrinsic to the prescriber (eg, beliefs, attitudes, knowledge, skills, behaviour) and the fourth is extrinsic (eg, patient, work setting, health system and cultural factors). The PIMs examined and practice setting influenced the themes reported.ConclusionsA multitude of highly interdependent factors shape prescribers’ behaviour towards continuing or discontinuing PIMs. A full understanding of prescriber barriers and enablers to changing prescribing behaviour is critical to the development of targeted interventions aimed at deprescribing PIMs and reducing the risk of iatrogenic harm.

A new brief questionnaire, the Bulimic Investigatory Test, Edinburgh (BITE), for the detection and description of binge-eating is described. Data from two separate populations demonstrate satisfactory reliability and validity. The scale has measures of both symptoms and severity. All items in the DSM-III definition of bulimia and Russell's definition of bulimia nervosa are covered but the questionnaire is more than just an operationalised checklist of these diagnostic criteria.

The use of multiple medicines, known as polypharmacy, poses a risk of harm that is greatest in older adults with multimorbidity. Deprescribing aims to improve health outcomes through ceasing medicines that are no longer necessary or appropriate due to changing clinical circumstances and patient priorities. General practitioners (GPs) and consultant pharmacists (CPs) are well positioned to facilitate deprescribing in primary care in partnership with older adults who present with inappropriate polypharmacy. In this article, we explore GPs' and CPs' views about inappropriate polypharmacy, the reasoning they apply to deprescribing in primary care, and identify factors that support or inhibit this process. Using focus group methodology and the Framework Method for thematic analysis, two major themes were discerned from the data-working through uncertainty and risk perception as a frame of reference. The findings provide important insights when devising methods for advancing and supporting deprescribing in primary care.

Background: Pharmacists are viewed as highly trained yet underutilised and there is growing support to extend the role of the pharmacist within the primary health care sector. The integration of a pharmacist into a general practice medical centre is not a new concept however is a novel approach in Australia and evidence supporting this role is currently limited. This study aimed to describe the opinions of local stakeholders in South-East Queensland on the integration of a pharmacist into the Australian general practice environment. Methods: A sample of general practitioners, health care consumers, pharmacists and practice managers in SouthEast Queensland were invited to participate in focus groups or semi-structured interviews. Seeding questions common to all sessions were used to facilitate discussion. Sessions were audio recorded and transcribed verbatim. Leximancer software was used to qualitatively analyse responses. Results: A total of 58 participants took part in five focus groups and eighteen semi-structured interviews. Concepts relating to six themes based on the seeding questions were identified. These included positively viewed roles such as medication reviews and prescribing, negatively viewed roles such as dispensing and diagnosing, barriers to pharmacist integration such as medical culture and remuneration, facilitators to pharmacist integration such as remuneration and training, benefits of integration such as access to the patient's medical file, and potential funding models. Conclusions: These findings and future research may aid the development of a new model of integrated primary health care services involving pharmacist practitioners.

The physical complications of anorexia nervosa are common and can be life threatening, but psychiatrists and the increasing number of non-medical therapists involved in treatment programmes often overlook these complications. Cardiovascular complications are the most common, and the most likely to result in fatalities, particularly in those patients who vomit, purge or abuse diuretics, because of the electrolyte abnormalities induced. Osteoporosis is an early and perhaps irreversible consequence of severe weight loss. Further, there are dangers in rapid intravenous hyperalimentation.

Inappropriate polypharmacy in older patients imposes a significant burden of decreased physical functioning, increased risk of falls, delirium and other geriatric syndromes, hospital admissions and death. The single most important predictor of inappropriate prescribing and risk of adverse drug events in older patients is the number of prescribed medications. Deprescribing is the process of tapering or stopping drugs, with the goal of minimising polypharmacy and improving outcomes. Barriers to deprescribing include underappreciation of the scale of polypharmacy-related harm by both patients and prescribers; multiple incentives to overprescribe; a narrow focus on lists of potentially inappropriate medications; reluctance of prescribers and patients to discontinue medication for fear of unfavourable sequelae; and uncertainty about effectiveness of strategies to reduce polypharmacy. Ways of countering such barriers comprise reframing the issue to one of highest quality patient-centred care; openly discussing benefit-harm trade-offs with patients and assessing their willingness to consider deprescribing; targeting patients according to highest risk of adverse drug events; targeting drugs more likely to be non-beneficial; accessing field-tested discontinuation regimens for specific drugs; fostering shared education and training in deprescribing among all members of the health care team; and undertaking deprescribing over an extended time frame under the supervision of a single generalist clinician.

The primary drug related problem reported in the practice pharmacist phase was Additional therapy required as compared to Precautions in the external pharmacist phase. The practice pharmacist most frequently recommended to add drug with Additional monitoring recommended most often in the external pharmacists. During the practice pharmacist phase 71 % of recommendations were implemented and was significantly higher than the external pharmacist phase with 53 % of recommendations implemented (p < 0.0001). Two of the 23 drug related problem domains differed significantly when comparing medication reviews conducted in the patient's home to those conducted in the medical centre.

For an eating disorder study over a period of 1 year, we measured total-body bone mineral using a Hologic QDR 1000W in a total of 157 subjects and observed anomalies that questioned the accuracy of such measurements. Using the recommended Enhanced software, a change in total bone mineral content (⌬BMC) correlated positively with a change in weight (⌬W; r ‫؍‬ 0.66), but a loss of weight was associated with an increase in bone mineral areal density (BMD; r ‫؍‬ 0.58), arising from a reduction in bone area (AREA). Both regressions were highly significant. The dominant factor in this relationship was a strong correlation between ⌬AREA and ⌬BMC, for all parts of the skeleton, r > 0.9, with a slope close to 1. This is implausible because bone area would not be expected to change. When Standard software was used, the slope of the ⌬BMC/⌬W correlation was steeper, but the ⌬BMD/⌬W regression became positive. An artefact of dual-energy X-ray absorptiometry processing was suspected, and phantom measurements were made. The phantom consisted of tissue-equivalent hardboard cut and stacked to form cylinders corresponding to the head, trunk, arms, and legs of a standard man. The skeleton was constructed from layers of aluminium sheet as an approximation of the average shape, BMD, BMC, and AREA in each region. When aluminium thickness was varied, BMD thresholds were found, approximately 0.4 g/cm 2 for the legs and 0.2 g/cm 2 for the arms. Above these, bone area rose fairly rapidly toward a plateau. At higher skeletal densities, the relationships between measured and true BMDs were close to linear, but slopes were less than unity, so that changes would be underestimated by 10 -30%. Increases of thickness of the soft tissue of the phantom lowered AREA slightly. Uniform fat proportion increases led to decreases in BMC and AREA, but lard wrapped in an annulus around the limbs led to spurious increases in BMC and AREA of a similar magnitude to those observed in vivo, while BMD fell slightly, although there had been no true change of bone variables. Similar results were obtained with lard around the limbs of a volunteer. Reanalysis of phantom scans using Standard software confirmed the software differences noted in vivo. The phantom measurements offer an explanation of the anomaly in vivo and demonstrate that, under different circumstances, change in both BMC and BMD can be wrongly recorded. We believe that no valid conclusions can be drawn from measurements by the Holgic QDR 1000W of bone changes during weight