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This is the first study with acceptable inter-rater reliability to examine specific therapeutic techniques related to change in anxiety disorder patients during short-term psychodynamic psychotherapy. The study first examined the effectiveness of short-term psychodynamic psychotherapy and results showed significant and positive pre-/post-treatment changes on both patient and independent clinical ratings for anxiety, global symptomatology, relational, social, and occupational functioning. Likewise, the majority of patients (76%) reported anxiety symptoms within a normal distribution at termination. Importantly, psychodynamic interventions rated early in treatment (third/fourth session) were positively related to changes in anxiety symptoms. Further, results showed that several individual psychodynamic techniques were meaningfully related to outcome including (1) focusing on wishes, fantasies, dreams, and early memories; (2) linking current feelings or perceptions to the past; (3) highlighting patients' typical relational patterns; and (4) helping patients to understand their experiences in new ways. Clinical applications are discussed. [ABSTRACT FROM AUTHOR]

The article describes the investigative methods and surgical technique of trochleoplasty for the treatment of patella instability. Trochleoplasty is an option for patients with trochlear dysplasia who have failed appropriate nonoperative management or previous operative treatment. The article offers information on multiple imaging modalities used to investigate the patellofemoral joint, as well as the general complications associated with open knee surgery.

Background: Noise exposure during surgery is a known occupational hazard, impacting staff hearing and surgical outcomes. Despite guidelines such as the Australian Work Health and Safety Act, noise safety remains largely neglected in orthopaedic surgery. Anecdotally, the introduction of robotic-assisted arthroplasty has contributed to increased noise production. This research article aims to investigate the role of robots in noise levels during arthroplasty., Methods: In this prospective observational study, we collected noise exposure data during total knee arthroplasty with and without robotic assistance. Noise levels were measured using a smartphone placed in the surgeon's breast pocket. Patient demographics and surgical details were collected for subgroup analysis. Mean (LAeq), time-weighted average, and peak noise levels, as well as dose equivalent were calculated to quantify the exposure., Results: A total of 65 knee arthroplasty sound recordings were included with a mean noise level of 82.0 dB (standard deviation [SD]: 3.9). Robotic-assisted surgeries exhibited significantly higher levels than using the conventional technique: 82.4 (SD: 3.2) vs 78.4 dB (SD: 3.8) (<0.0001). These values exceed some of the recommended guidelines. Peak exposure levels were similar in both categories at 109.6 (SD: 2.7) and 110.7 dB (SD: 4.3), remaining below the safety threshold., Conclusions: This study highlights the potential for harmful noise exposure in orthopaedic surgery, emphasizing the contribution of robotic-assisted procedures. Our findings indicate noise levels approximate or exceed international safety guidelines. The results support the wearing of personal protective hearing equipment, and other preventative strategies. Our study provides insights into an underappreciated aspect of orthopaedic surgery., (© 2024 The Authors.)

Purpose: To explore participant experiences for people on an arthroplasty waitlist, randomised to an exercise and behaviour-change counselling program (ENHANCE). The ENHANCE program for arthroplasty patients was led by an accredited exercise physiologist who delivered an individually tailored and structured exercise program. Included in the exercise program were up to five in-person counselling sessions, based on the Health Action Process Approach (HAPA) applied specifically to people with osteoarthritis. Nine adults (mean 69.4 years) who were on the waiting list for a total hip or knee arthroplasty and who had completed a 12-week program (ENHANCE) as part of a randomised controlled trial were recruited for this study., Methods: Two focus groups were conducted to explore participant experiences of ENHANCE. Data were analysed using inductive thematic analysis with constructs of the HAPA (motivational and volitional factors) as a framework., Results: We identified three themes (1) 'The structured program addressed inactivity and improved feelings of wellness and preparation for the operation'. The benefits were not only physical, but psychological and were contextualised in terms of preparation for the upcoming surgery. (2) 'People as enablers of participation': Participants identified that the attitude, and skill of the experienced instructor were supportive and motivating, especially in tailoring the intervention. Within the program, the support of the group was considered a positive attribute (3) 'Improved awareness changed attitudes to self-efficacy and perceived self-control'. Participants described an increased awareness of their condition and a better understanding of health expectations. They felt more control and ownership over their health journey., Conclusion: Goal setting and social support were identified factors in a behaviour-change counselling program, delivered in conjunction with structured exercise that led to a positive experience. Improved psychological and physical health were described. Participants were better prepared for their upcoming surgery, with increased self efficacy and mastery to support long-term physical-activity engagement.

Background: The addition of vancomycin to beta-lactam prophylaxis in arthroplasty may reduce surgical-site infections; however, the efficacy and safety are unclear., Methods: In this multicenter, double-blind, superiority, placebo-controlled trial, we randomly assigned adult patients without known methicillin-resistant Staphylococcus aureus (MRSA) colonization who were undergoing arthroplasty to receive 1.5 g of vancomycin or normal saline placebo, in addition to cefazolin prophylaxis. The primary outcome was surgical-site infection within 90 days after surgery., Results: A total of 4239 patients underwent randomization. Among 4113 patients in the modified intention-to-treat population (2233 undergoing knee arthroplasty, 1850 undergoing hip arthroplasty, and 30 undergoing shoulder arthroplasty), surgical-site infections occurred in 91 of 2044 patients (4.5%) in the vancomycin group and in 72 of 2069 patients (3.5%) in the placebo group (relative risk, 1.28; 95% confidence interval [CI], 0.94 to 1.73; P = 0.11). Among patients undergoing knee arthroplasty, surgical-site infections occurred in 63 of 1109 patients (5.7%) in the vancomyin group and in 42 of 1124 patients (3.7%) in the placebo group (relative risk, 1.52; 95% CI, 1.04 to 2.23). Among patients undergoing hip arthroplasty, surgical-site infections occurred in 28 of 920 patients (3.0%) in the vancomyin group and in 29 of 930 patients (3.1%) in the placebo group (relative risk, 0.98; 95% CI, 0.59 to 1.63). Adverse events occurred in 35 of 2010 patients (1.7%) in the vancomycin group and in 35 of 2030 patients (1.7%) in the placebo group, including hypersensitivity reactions in 24 of 2010 patients (1.2%) and 11 of 2030 patients (0.5%), respectively (relative risk, 2.20; 95% CI, 1.08 to 4.49), and acute kidney injury in 42 of 2010 patients (2.1%) and 74 of 2030 patients (3.6%), respectively (relative risk, 0.57; 95% CI, 0.39 to 0.83)., Conclusions: The addition of vancomycin to cefazolin prophylaxis was not superior to placebo for the prevention of surgical-site infections in arthroplasty among patients without known MRSA colonization. (Funded by the Australian National Health and Medical Research Council; Australian New Zealand Clinical Trials Registry number, ACTRN12618000642280.)., (Copyright © 2023 Massachusetts Medical Society.)

Importance: Ischemic heart disease remains the leading cause of mortality following hip and knee arthroplasty. Due to its antiplatelet and cardioprotective properties, aspirin has been proposed as an agent that could reduce mortality when used as venous thromboembolism (VTE) prophylaxis following these procedures., Objective: To compare aspirin with enoxaparin in reducing 90-day mortality for patients undergoing hip or knee arthroplasty procedures., Design, Setting, and Participants: This study was a planned secondary analysis of the CRISTAL cluster randomized, crossover, registry-nested trial performed across 31 participating hospitals in Australia between April 20, 2019, and December 18, 2020. The aim of the CRISTAL trial was to determine whether aspirin was noninferior to enoxaparin in preventing symptomatic VTE following hip or knee arthroplasty. The primary study restricted the analysis to patients undergoing total hip or knee arthroplasty for a diagnosis of osteoarthritis only. This study includes all adult patients (aged ≥18 years) undergoing any hip or knee arthroplasty procedure at participating sites during the course of the trial. Data were analyzed from June 1 to September 6, 2021., Interventions: Hospitals were randomized to administer all patients oral aspirin (100 mg daily) or subcutaneous enoxaparin (40 mg daily) for 35 days after hip arthroplasty and 14 days after knee arthroplasty procedures., Main Outcomes and Measures: The primary outcome was mortality within 90 days. The between-group difference in mortality was estimated using cluster summary methods., Results: A total of 23 458 patients from 31 hospitals were included, with 14 156 patients allocated to aspirin (median [IQR] age, 69 [62-77] years; 7984 [56.4%] female) and 9302 patients allocated to enoxaparin (median [IQR] age, 70 [62-77] years; 5277 [56.7%] female). The mortality rate within 90 days of surgery was 1.67% in the aspirin group and 1.53% in the enoxaparin group (estimated difference, 0.04%; 95% CI, -0.05%-0.42%). For the subgroup of 21 148 patients with a nonfracture diagnosis, the mortality rate was 0.49% in the aspirin group and 0.41% in the enoxaparin group (estimated difference, 0.05%; 95% CI, -0.67% to 0.76%)., Conclusions and Relevance: In this secondary analysis of a cluster randomized trial comparing aspirin with enoxaparin following hip or knee arthroplasty, there was no significant between-group difference in mortality within 90 days when either drug was used for VTE prophylaxis., Trial Registration: http://anzctr.org.au Identifier: ACTRN12618001879257.

Surgical coaching is a new approach to continuous professional development (CPD). Advocates claim that coaching improves surgical and non-technical skills, leading to enhanced performance and reduced stress and burnout. Widespread acceptance of coaching in the surgical community is limited due to a paucity of evidence, surgery-specific obstacles and lack of resources. This narrative review introduces what 'surgical coaching' is and describes its origins. Coaching techniques are based on live or video observation of procedures, followed by collaborative analysis, reflection and goal planning in a non-competitive setting aided by an expert, peer or lay coach. Technical skills improvements have been reported using coaching techniques, yet long-term influence on non-technical competencies, overall performance and surgeon wellbeing are largely hypothetical. There are clear potential benefits in the application of surgical coaching to daily surgical practice. However, significant knowledge gaps remain. Dedicated research into the short-term applicability and the long-term effects of surgical coaching are required., (© 2023 Royal Australasian College of Surgeons.)

Background : Treatment outcomes in studies on prosthetic joint infection are generally assessed using a dichotomous outcome relating to treatment success or failure. These outcome measures neither include patient-centred outcome measures including joint function and quality of life, nor do they account for adverse effects of treatment. A desirability of outcome ranking (DOOR) measure can include these factors and has previously been proposed and validated for other serious infections. We aimed to develop a novel DOOR for prosthetic joint infections (PJIs). Methods : The Delphi method was used to develop a DOOR for PJI research. An international working group of 18 clinicians (orthopaedic surgeons and infectious disease specialists) completed the Delphi process. The final DOOR comprised the dimensions established to be most important by consensus with > 75  % of participant agreement. Results : The consensus DOOR comprised four main dimensions. The primary dimension was patient-reported joint function. The secondary dimensions were infection cure and mortality. The final dimension of quality of life was selected as a tie-breaker. Discussion : A desirability of outcome ranking for periprosthetic joint infection has been proposed. It focuses on patient-centric outcome measures of joint function, cure and quality of life. This DOOR provides a multidimensional assessment to comprehensively rank outcomes when comparing treatments for prosthetic joint infection., Competing Interests: The contact author has declared that none of the authors has any competing interests., (Copyright: © 2022 Brenton P. Johns et al.)

Objective: This study aimed to determine if a novel intervention that combined individualised exercise training with behaviour change counselling based on Health Action Process Approach (HAPA) constructs could elicit long-term increase in physical activity (PA) and reduce comorbidity development among people requiring hip or knee arthroplasty., Method: A pre-registered two arm, parallel group, randomised controlled trial comparing the effect of a 12-week individualised exercise program combined with behavioural counselling delivered by accredited exercise physiologists, versus usual care to Osteoarthritis (OA) patients on public surgery waitlists. Participants were followed up at 6 months after baseline (pre-surgery) and again at 6 months post-surgery. Within and between group differences in post-surgery PA (as measured by ActivPal accelerometer), pain, function, quality of life, HAPA-based behavioural and psychological constructs, and health risk factors were analysed., Results: 63 participants (34 Female; Mean age ​= ​66.4 ​± ​7.2 ​yrs) consented to participate in this study. At 6 months post baseline and 6 months post-surgery there were significant improvements in PA, pain, function, and quality of life, however there were no significant differences in the between group responses. Significant between group changes were observed in several psychological constructs related to volition at 6 months post baseline; however, these had disappeared by 6 months post-surgery., Conclusions: An exercise program and HAPA guided counselling intervention can improve psychological constructs related to exercise behaviour; however, these did not result in significant between group changes in PA at the timepoints measured. Further research with larger sample size is required. Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN 12617000357358) Date of registration: 08/03/2017., Competing Interests: The authors declare they have no competing interests., (© 2022 The Authors.)

Importance: There remains a lack of randomized trials investigating aspirin monotherapy for symptomatic venous thromboembolism (VTE) prophylaxis following total hip arthroplasty (THA) or total knee arthroplasty (TKA)., Objective: To determine whether aspirin was noninferior to enoxaparin in preventing symptomatic VTE after THA or TKA., Design, Setting, and Participants: Cluster-randomized, crossover, registry-nested trial across 31 hospitals in Australia. Clusters were hospitals performing greater than 250 THA or TKA procedures annually. Patients (aged ≥18 years) undergoing hip or knee arthroplasty procedures were enrolled at each hospital. Patients receiving preoperative anticoagulation or who had a medical contraindication to either study drug were excluded. A total of 9711 eligible patients were enrolled (5675 in the aspirin group and 4036 in the enoxaparin group) between April 20, 2019, and December 18, 2020. Final follow-up occurred on August 14, 2021., Interventions: Hospitals were randomized to administer aspirin (100 mg/d) or enoxaparin (40 mg/d) for 35 days after THA and for 14 days after TKA. Crossover occurred after the patient enrollment target had been met for the first group. All 31 hospitals were initially randomized and 16 crossed over prior to trial cessation., Main Outcomes and Measures: The primary outcome was symptomatic VTE within 90 days, including pulmonary embolism and deep venous thrombosis (DVT) (above or below the knee). The noninferiority margin was 1%. Six secondary outcomes are reported, including death and major bleeding within 90 days. Analyses were performed by randomization group., Results: Enrollment was stopped after an interim analysis determined the stopping rule was met, with 9711 patients (median age, 68 years; 56.8% female) of the prespecified 15 562 enrolled (62%). Of these, 9203 (95%) completed the trial. Within 90 days of surgery, symptomatic VTE occurred in 256 patients, including pulmonary embolism (79 cases), above-knee DVT (18 cases), and below-knee DVT (174 cases). The symptomatic VTE rate in the aspirin group was 3.45% and in the enoxaparin group was 1.82% (estimated difference, 1.97%; 95% CI, 0.54%-3.41%). This failed to meet the criterion for noninferiority for aspirin and was significantly superior for enoxaparin (P = .007). Of 6 secondary outcomes, none were significantly better in the enoxaparin group compared with the aspirin group., Conclusions and Relevance: Among patients undergoing hip or knee arthroplasty for osteoarthritis, aspirin compared with enoxaparin resulted in a significantly higher rate of symptomatic VTE within 90 days, defined as below- or above-knee DVT or pulmonary embolism. These findings may be informed by a cost-effectiveness analysis., Trial Registration: ANZCTR Identifier: ACTRN12618001879257.

Importance: Distal radius fractures are common and are managed with or without surgery. Current evidence indicates surgical treatment is not superior to nonsurgical treatment at 12 months., Objective: Does surgical treatment for displaced distal radius fractures in patients 60 years or older provide better patient-reported wrist pain and function outcomes than nonsurgical treatment at 24 months?, Design, Setting, and Participants: In this secondary analysis of a combined multicenter randomized clinical trial (RCT) and a parallel observational study, 300 patients were screened from 19 centers in Australia and New Zealand. Of these, 166 participants were randomized to surgical or nonsurgical treatment. Participants who declined randomization (n = 134) were included in the parallel observational group with the same treatment options and follow-up. Participants were followed up at 3, 12, and 24 months by a blinded assessor. The 24-month outcomes are reported herein. Data were collected from December 1, 2016, to December 31, 2020, and analyzed from February 4 to October 21, 2021., Interventions: Surgical treatment consisting of open reduction and internal fixation using a volar-locking plate (VLP group) and nonsurgical treatment consisting of closed reduction and cast immobilization (CR group)., Main Outcomes and Measures: The primary outcome was patient-reported function using the Patient-Rated Wrist Evaluation (PRWE) questionnaire. Secondary outcomes included health-related quality of life, wrist pain, patient-reported treatment success, patient-rated bother with appearance, and posttreatment complications., Results: Among the 166 randomized and 134 observational participants (300 participants; mean [SD] age, 71.2 [7.5] years; 269 women [89.7%]), 151 (91.0%) randomized and 118 (88.1%) observational participants were followed up at 24 months. In the RCT, no clinically important difference occurred in mean PRWE scores at 24 months (13.6 [95% CI, 9.1-18.1] points for VLP fixation vs 15.8 [95% CI, 11.3-20.2] points for CR; mean difference, 2.1 [95% CI, -4.2 to 8.5]; P = .50). There were no between-group differences in all other outcomes except for patient-reported treatment success, which favored VLP fixation (33 of 74 [44.6%] in the CR group vs 54 of 72 [75.0%] in the VLP fixation group reported very successful treatment; P = .002). Rates of posttreatment complications were generally low and similar between treatment groups, including deep infection (1 of 76 [1.3%] in the CR group vs 0 of 75 in the VLP fixation group) and complex regional pain syndrome (2 of 76 [2.6%] in the CR group vs 1 of 75 [1.3%] in the VLP fixation group). The 24-month trial outcomes were consistent with 12-month outcomes and with outcomes from the observational group., Conclusions and Relevance: Consistent with previous reports, these findings suggest that VLP fixation may not be superior to CR for displaced distal radius fractures for patient-rated wrist function in persons 60 years or older during a 2-year period. Significantly higher patient-reported treatment success at 2 years in the VLP group may be attributable to other treatment outcomes not captured in this study., Trial Registration: ANZCTR.org Identifier: ACTRN12616000969460.

Aims: Platelet-rich plasma (PRP) intra-articular injections may provide a simple and minimally invasive treatment for early-stage knee osteoarthritis (OA). This has led to an increase in its adoption as a treatment for knee OA, although there is uncertainty about its efficacy and benefit. We hypothesized that patients with early-stage symptomatic knee OA who receive multiple PRP injections will have better clinical outcomes than those receiving single PRP or placebo injections., Methods: A double-blinded, randomized placebo-controlled trial was performed with three groups receiving either placebo injections (Normal Saline), one PRP injection followed by two placebo injections, or three PRP injections. Each injection was given one week apart. Outcomes were prospectively collected prior to intervention and then at six weeks, three months, six months, and 12 months post-intervention. Primary outcome measures were Knee Injury and Osteoarthritis Outcome Score (KOOS) and EuroQol five-dimension five-level index (EQ-5D-5L). Secondary outcomes included visual analogue scale for pain and patient subjective assessment of the injections., Results: A total of 102 patients were recruited. The follow-up period was 12 months, at intervals of six weeks, 12 weeks, six months, and 12 months. KOOS-Total significantly improved in all groups at these time intervals compared to pre-injection. There was an improvement in EQ-5D-5L index scores in saline and single injection groups, but not in the multiple injection group. Comparison of treatment groups showed no additional beneficial effect of single or multiple PRP injections above that displayed in the saline injection group. Subjective patient satisfaction and recommendation of treatment received demonstrated a similar pattern in all the groups. There was no indication of superiority of either single or multiple PRP injections compared to saline injections., Conclusion: There is no evidence that single or multiple PRP had any additional beneficial effect compared to saline injection up to 12 months, follow-up after treatment of early stage symptomatic OA of the knee. Cite this article: Bone Joint J  2022;104-B(6):663-671.

The Alternative Model for Personality Disorders (AMPD) in Section III of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5 ; American Psychiatric Association, 2013) conceptualizes personality pathology as a combination of impairment (Criterion A) and traits (Criterion B). One measure used to develop Criterion A was the Social Cognition and Object Relations Scale - Global Rating Method (SCORS-G), which is a multidimensional, object-relational clinician-rated measure of personality functioning. Although there are conceptual links between the AMPD and SCORS-G dimensions, there exists no research examining the relationship. To address this, we examined associations between the SCORS-G dimensions and measures of the AMPD constructs in a large, archival dataset of outpatients and inpatients. More pathological scores on SCORS-G dimensions reflecting self- and interpersonal functioning were associated with greater pathological traits and impairment. Overall, results support further investigation into SCORS-G as a useful measure in AMPD research and assessment.

Importance: The burden of injury and costs of wrist fractures are substantial. Surgical treatment became popular without strong supporting evidence., Objective: To assess whether current surgical treatment for displaced distal radius fractures provided better patient-reported wrist pain and function than nonsurgical treatment in patients 60 years and older., Design, Setting, and Participants: In this multicenter randomized clinical trial and parallel observational study, 300 eligible patients were screened from 19 centers in Australia and New Zealand from December 1, 2016, until December 31, 2018. A total of 166 participants were randomized to surgical or nonsurgical treatment and followed up at 3 and 12 months by blinded assessors. Those 134 individuals who declined randomization were included in a parallel observational cohort with the same treatment options and follow-up. The primary analysis was intention to treat; sensitivity analyses included as-treated and per-protocol analyses., Intervention: Surgical treatment was open reduction and internal fixation using a volar-locking plate (VLP). Nonsurgical treatment was closed reduction and cast immobilization (CR)., Main Outcomes and Measures: The primary outcome was the Patient-Rated Wrist Evaluation score at 12 months. Secondary outcomes were Disabilities of Arm, Shoulder, and Hand questionnaire score, health-related quality of life, pain, major complications, patient-reported treatment success, bother with appearance, and therapy use., Results: In the 300 study participants (mean [SD] age, 71.2 [7.5] years; 269 [90%] female; 166 [81 VLP and 85 CR] in the randomized clinical trial sample and 134 [32 VLP and 102 CR] in the observational sample), no clinically important between-group difference in 12-month Patient-Rated Wrist Evaluation scores (mean [SD] score of 19.8 [21.1] for VLP and 21.5 [24.3] for CR; mean difference, 1.7 points; 95% CI -5.4 to 8.8) was observed. No clinically important differences were found in quality of life, wrist pain, or bother at 3 and 12 months. No significant difference was found in total complications between groups (12 of 84 [14%] for the CR group vs 6 of 80 [8%] for the VLP group; risk ratio [RR], 0.53; 95% CI, 0.21-1.33). Patient-reported treatment success favored the VLP group at 12 months (very successful or successful: 70 [89%] vs 57 [70%]; RR, 1.26; 95% CI, 1.07-1.48; P = .005). There was greater use of postoperative physical therapy in the VLP group (56 [72%] vs 44 [54%]; RR, 1.32; 95% CI, 1.04-1.69; P = 0.02)., Conclusions and Relevance: This randomized clinical trial found no between-group differences in improvement in wrist pain or function at 12 months from VLP fixation over CR for displaced distal radius fractures in older people., Trial Registration: http://anzctr.org.au identifier: ACTRN12616000969460.

The Social Cognition and Object Relations Scale-Global Rating Method (SCORS-G) measures the quality of object relations in narrative material. The reliability and validity of this measure have been well established. However, a psychometric oddity of this scale is that default ratings are given to select dimensions when the relevant construct is not present. This can result in narrative 'blandness' and may impact clinical findings. The aim of these two studies is to understand these phenomena both psychometrically and clinically. In the first study, we identified 276 outpatients who had SCORS-G ratings for TAT Cards 1, 2, 3BM, and 14, set criteria for narrative 'blandness' across all eight dimensions, and examined group differences. In Study 2, we used a subset (N = 99) of Study 1 and examined how percentage of formal default ratings for Emotional Investment in Values and Moral Standards (EIM), Experience and Management of Aggressive Impulses (AGG), Self-Esteem(SE), and Identify and Coherence of Self (ICS) impacted robustness of correlations across tests of intelligence, psychopathology, and normal personality functioning. Taken together, we identified clinical characteristics of patients who are more likely to produce 'bland' narratives and increased percentages of formal default ratings. Also, an excess of default ratings per protocol impacts robustness of correlations and weakens significant correlations. As cut-off scores increase (>25% and >28.12%), the likelihood of being able to interpret EIM, AGG, SE, and ICS decreases. Psychometric and clinical implications are discussed., (© 2020 John Wiley & Sons, Ltd.)

The goal of the present study was to explore how self-disclosure (SD) and immediacy relate to trainee therapists' personal characteristics. A prospective multitrait multimethod assessment approach was utilized to assess a wide range of trainee characteristics at the beginning of graduate school. Results showed a significant, positive relationship between trainee interpersonal problems and SD for trainees ( n = 33) in their third psychotherapy session with their first patient. Moreover, greater use of SD correlated with less session depth, as rated by the trainee. Greater use of immediacy was positively related to trainee undergraduate grade point average and trainee-reported post-session arousal. Notably, all statistically significant findings had a moderate magnitude of effect. Finally, qualitative analyses of the SDs and immediacy statements were included to aid the discussion of potential reasons for the results. Overall, our findings provide preliminary conclusions about which trainees utilize SD and immediacy, what types of SDs and immediacy interventions they tend to use, and how trainees and patients perceived the session in which SD and immediacy were implemented. Implications for supervision and training are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The aim of this study is to investigate the clinical effectiveness of an advanced practice physiotherapist triaging patients referred from primary care to the orthopaedic clinic with chronic hip and knee pain. An exploratory study design was used to assess 87 consecutive patients referred from general practice in Northern Tasmania. Patients were assessed by both an advanced practice physiotherapist and a consultant orthopaedic surgeon. Diagnostic and treatment decisions were compared, with the orthopaedic consultant decision defined as the gold standard. By using these decisions, over and under referral rates to orthopaedics could be calculated, as well as the surgical conversion rate. Conservative care of patients referred to the orthopaedic clinic with hip and knee pain was limited. The diagnostic agreement between the advanced scope physiotherapist and the orthopaedic surgeon was almost perfect (weighted kappa 0.93 (95% CI 0.87-1.00)), with treatment agreement substantial (weighted kappa 0.75 (95% CI 0.62-0.89)). Under a physiotherapist-led triage service, the surgical conversion rate doubled from 38% to 78%. An advanced physiotherapist assessing and treating patients with chronic hip and knee pain made decisions that match substantially with decisions made by an orthopaedic consultant. A model of care utilising an advanced physiotherapist in this way has the potential to support high-quality orthopaedic care in regional centres.

To facilitate patient growth, therapists must immerse themselves in the patient's world while also being able to see what is needed for change. This process requires finding a delicate balance between supporting and pushing patients. Therapists in training are additionally tasked with incorporating supervisors' suggestions with their own views on what is needed to help their patients. Beginning therapists with tendencies to be overly accommodating may struggle to reconcile these competing demands. Thus, the aim of the present work is to explore how trainee friendly submissiveness (FS) interfaces with psychotherapy. Prior to training, clinical graduate trainee ( n = 35) FS was assessed using the Inventory of Interpersonal Problems-32. Process and outcome data were then collected from each therapist's first training case. Specifically, each trainee was assigned an undergraduate student volunteer with whom they had four non-manualized therapy sessions over the academic semester. After the third session, patients and trainees completed questionnaires assessing session impact and the working alliance, and two expert raters coded third session videotapes for techniques. Following termination, patients rated the overall helpfulness of the therapy. Trainee FS was significantly negatively associated with patient-rated depth, alliance, and overall helpfulness with moderate effects. Findings from a mediation analysis further suggested that trainees with higher FS struggled to focus the therapy in a way that felt productive to patients. Implications for clinical training are discussed., Competing Interests: Conflict of interest: the authors report grants from Society for Psychotherapy Research, grants from American Psychological Association, Division 29, during the conduct of the study., (©Copyright L. Cain et al., 2018.)

Background: Osteoarthritis often results in prolonged periods of reduced physical activity and is associated with adverse health outcomes, including increased risk of cardiovascular and metabolic diseases. Exercise interventions for patients on the waiting list for arthroplasty can reduce the risk of long-term adverse outcomes by increasing activity levels. However, uptake and ongoing positive rates of physical activity in this population are low and the impact of pre-operative behaviour counselling on exercise is not known., Method/design: The exercise and behaviour change counselling (ENHANCE) trial is a two-arm assessor-blind randomised controlled trial to assess the effectiveness of a 12-week exercise intervention designed to improve long-term physical activity and functional abilities for people awaiting arthroplasty. Participants on the waiting list for hip and knee arthroplasty are recruited from one clinical site in Australia. After collection of baseline data, participants are randomised to either an intervention or control group. The control group receive usual care, as recommended by evidence-based guidelines. The intervention group receive an individualised programme of exercises and counselling sessions. The 12-week exercise programme integrates multiple elements, including up to five in-person counselling sessions, supported by written materials. Participants are encouraged to seek social support among their friends and self-monitor their physical activity. The primary outcome is physical activity (daily step count and percentage of day spent in sedentary activities). Secondary outcomes include pain ratings, physical function, psychosocial factors and changes in clinical markers linked with potential common chronic diseases (diabetes and cardiovascular disease). All outcomes are assessed at baseline and 26 weeks later and again at 26 weeks post-surgery., Discussion: This study seeks to address a significant gap in current osteoarthritis management practice by providing evidence for the effectiveness of an exercise programme combined with behaviour counselling for adults waiting for hip and knee arthroplasty. Theory-driven evidence-based strategies that can improve an individual's exercise self-efficacy and self-management capacity could have a significant impact on the development of secondary chronic disease in this population. Information gained from this study will contribute to the evidence base on the management of adults waiting for hip and knee arthroplasty., Trial Registration: Australian New Zealand Clinical Trials Registry, ACTRN12617000357358 . Registered on 8 March 2017.

The Social Cognition and Object Relations Scales-Global Rating Method (SCORS-G) contains 8 scales for coding narrative content. This study explores the factor structure of this measure using college (n = 171), outpatient (n = 239), and inpatient (n = 78) samples. Participants told stories to the Thematic Apperception Test (TAT; Murray, 1943) cards. Stories were transcribed and coded by blind raters using the SCORS-G. Cases were randomly assigned to an exploratory or validation group. Exploratory factor analysis with the exploratory group suggested 2- and 3-factor models. The Emotional Investment in Relationships (EIR) scale did not obtain a primary loading on any factor and was not included in subsequentmodels. After modifications, confirmatory factor analysis indicated good-to-adequate fit for 2- and 3-factor models. Both models showed good fit in the validation group and met criteria for invariance across models. Findings indicated that some SCORS-G scales tap cognitive-structural elements, whereas others assess affective-relational components of narratives. We found mild support separating the affective-relational scales in terms of internal representations for the self and others and relationships. The results reported here indicate that clinicians and researchers can calculate a separate cognitive-structural composite score and an affective-relational composite score when using the SCORS-G to rate TAT stories.

The Social Cognition and Object Relations Scale-Global Rating Method (SCORS-G; Stein, Hilsenroth, Slavin-Mulford, & Pinsker, 2011 ; Westen, 1995b ) reliably measures the quality of object relations in narrative material. It assesses 8 dimensions (on a continuum from maladaptive to adaptive) that mediate interpersonal functioning. The 8 dimensions can be averaged to create a global or composite score to represent a person's overall object relational functioning. This study aimed to create levels of personality organization using the SCORS-G global score ratings of Thematic Apperception Test (TAT) narratives and to explore the construct validity of these levels using a multimethod approach (i.e., psychopathology, normal personality, and life-event data). Meaningful relationships were found between the SCORS-G level of personality organization and aspects of psychopathology (Personality Assessment Inventory; Morey, 1991 ), regulation and control (NEO Five-Factor Inventory; Costa & McCrae, 1989, 1992b ), and number of psychiatric hospitalizations, suicide attempts, and educational level. Overall, this study demonstrates the potential value of creating levels of personality organization (LPO) using the SCORS-G composite or global ratings as a supplement to the psychological assessment process and further highlights the utility of this measure in the field of personality assessment. Clinical and research-related implications as well as limitations are discussed.

This study contributes to the convergent and discriminant validity of the Psychiatric Diagnostic Screening Questionnaire (PDSQ) by investigating its correlations with the relevant clinical scales of the Personality Assessment Inventory (PAI) and life space variables, such as relationship status, education level, job loss, and history of suicide attempts. Bivariate correlations were calculated for a sample of 254 psychiatric outpatients. The results indicated that the PDSQ scales demonstrated good to excellent convergent and discriminant validity with target scales from the PAI. They were also found to be meaningfully associated with a variety of life space variables. For example, five of the subscales and the Total Score correlated positively with a recent job loss, and eight of the subscales were negatively associated with education and/or employment status. Some incongruence with hypothesized relationships was discovered for life correlates classified as markers of psychiatric severity. Overall, these findings add to the emerging body of evidence corroborating the convergent and discriminant validity of the PDSQ., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Fractures of the distal radius are common and occur in all age groups. The incidence is high in older populations due to osteoporosis and increased falls risk. Considerable practice variation exists in the management of distal radius fractures in older patients ranging from closed reduction with cast immobilisation to open reduction with plate fixation. Plating is currently the most common surgical treatment. While there is evidence showing no significant advantage for some forms of surgical fixation over conservative treatment, and no difference between different surgical techniques, there is a lack of evidence comparing two of the most common treatments used: closed reduction and casting versus plating. Surgical management involves significant costs and risks compared with conservative management. High-level evidence is required to address practice variation, justify costs and to provide the best clinical outcomes for patients., Methods and Analysis: This pragmatic, multicentre randomised comparative effectiveness trial aims to determine whether plating leads to better pain and function and is more cost-effective than closed reduction and casting of displaced distal radius fractures in adults aged 60 years and older. The trial will compare the two techniques but will also follow consenting patients who are unwilling to be randomised in a separate, observational cohort. Inclusion of non-randomised patients addresses selection bias, provides practice and outcome insights about standard care, and improves the generalisability of the results from the randomised trial., Ethics and Dissemination: CROSSFIRE(Combined Randomised and Observational Study of Surgery for Fractures In the distal Radius in the Elderly) was reviewed and approved by The Hunter New England HREC (HNEHREC Reference No: 16/02/17/3.04). The results of the trial will be published in a peer-reviewed journal and will be disseminated via various forms of media. Results will be incorporated in clinical recommendations and practice guidelines produced by professional bodies., Registration: CROSSFIRE has been registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR: ACTRN12616000969460)., Competing Interests: Competing interests: All authors have completed the ICMJE COI form. Completed forms are held by the corresponding author. There were no COIs declared by any of the authors., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

The content of Thematic Apperception Test (TAT) cards can, in some cases, influence how respondents form narratives. This study examines how imagery from select TAT cards affects the narratives of respondents from a nonclinical setting. The Social Cognition and Object Relations Scale-Global Rating Method (SCORS-G; Stein, Hilsenroth, Slavin-Mulford, & Pinsker, 2011 ; Westen, Lohr, Silk, Kerber, & Goodrich, 1989) was used to rate narratives. Forty-nine college students provided narratives to 6 TAT cards. Narratives were rated by two expert raters using the SCORS-G. Consistent with prior research, Card 2 exhibited the most pull for adaptive ratings on SCORS-G scales, and 3 BM exhibited the most pull for maladaptive ratings. Findings for other cards were mixed. Although raters were highly reliable, internal consistency estimates were lower than desirable for 6 of the 8 SCORS-G scales. Variance component estimates indicated that card by person interactions accounted for the largest amount of variance in person-level scores. Results and limitations are discussed in light of prior research. We also make suggestions for further lines of research in this area.