human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background Patient aggression is a common problem in acute psychiatric wards and calls for preventive measures . The timely use of preventive measures presupposes a preceded risk assessment . The Norwegian Brøset-Violence-Checklist ( BVC ) is one of the few instruments suited for short-time prediction of violence of psychiatric in patients in routine care . Aims of our study were to improve the accuracy of the short-term prediction of violence in acute inpatient setting s by combining the Brøset-Violence-Checklist ( BVC ) with an overall subjective clinical risk- assessment and to test the application of the combined measure in daily practice . Method We conducted a prospect i ve cohort study with two sample s of newly admitted psychiatric patients for instrument development ( 219 patients ) and clinical application ( 300 patients ) .  Risk of physical attacks was assessed by combining the 6-item BVC and a 6-point score derived from a  Visual Analog Scale . Incidents were registered with the Staff Observation of Aggression Scale-Revised SOAS-R. Test accuracy was described as the area under the receiver operating characteristic curve ( AUCROC ) . Results The AUCROC of the new VAS-complemented BVC-version ( BVC-VAS ) was 0.95 in and 0.89 in the derivation and validation study respectively . Conclusion The BVC-VAS is an easy to use and accurate instrument for systematic short-term prediction of violent attacks in acute psychiatric wards . The inclusion of the VAS-derived data did not change the accuracy of the original BVC OBJECTIVE To examine factors associated with physical restraint in psychiatric emergency rooms . METHOD We extracted variables likely to predict use of physical restraints from a large r and omised trial undertaken in three psychiatric emergency rooms in Rio de Janeiro . We fitted a Bayesian binary multivariate model using only variables clearly preceding the restraints . RESULTS Of 301 agitated , aggressive people admitted to emergency rooms , 73 ( 24 % ) were restrained during the first 2 h of admission . In Rio , younger people ( OR=1.03 for each year younger ) , exhibiting intense ( OR=2.53 ) or extreme agitation ( OR=7.71 ) , thought to result from substance misuse ( OR=1.75 ) or diagnoses other than psychosis ( OR=1.88 ) , arriving in the morning ( OR=1.64 ) were at greater risk of  physical restraints  than older , less severely aggressive or agitated people , arriving at the hospital during the afternoon or night . Hospital , gender , first admission to hospital and medication were not associated with risk of being restrained . CONCLUSION Restraint practice s in Rio are predictable and based on a limited clinical assessment . Predictive factors for physical restraint may vary worldwide , but should be monitored and studied to assist training , and to establish programs to evaluate and refine this controversial practice BACKGROUND Psychiatric emergency situations ( PES ) are of high importance to the German prehospital physician-based emergency medical system . So far , however , no prospect i ve studies regarding the incidence of PES have been performed , neither have effects of training programs on diagnostic and therapeutic accuracy been studied . METHOD The protocol s of two emergency medical services ( EMS ) were collected and analyzed prospect ively .  Emergency physicians ( EPs ) in Kaiserslautern ( KL ) attended a st and ardized educational program and underwent daily supervision .  EPs in Homburg ( HOM ) had not been informed about the study . In KL , sociodemographic variables were collected . An investigator who was not involved in the individual EMS mission assessed the correct classification of PES . RESULTS Among all calls for an EP , 11.8 % were classified as PES . There was no difference between the two centers . Correct classification of PES in KL was significantly higher than that in HOM ( 94.3 % vs. 80.6 % ) . Documentation of suicidal behavior was deficient in both centers . EPs in KL gave verbal crisis intervention significantly more often , administered less medication overall , and dispensed more specific drugs in psychotic disorders and significantly less drugs in substance abuse disorders . Patients were more often treated at the scene and were less often transported to a hospital . Some sociodemographic variables were associated with psychiatric morbidity of treatment . CONCLUSION Accounting for 12 % of all missions , psychiatric emergencies are a frequent reason for calls for EPs , equaling trauma-related and neurological emergencies . The most frequent reasons for calls were alcohol intoxication , states of agitation and suicidal behavior . The diagnostic and therapeutic accuracy of EPs may be improved with a concise st and ardized teaching program This study determined the inter-rater reliability of the  Sedation-Agitation Scale ( SAS ) when used by staff in a tertiary level general intensive care unit ( ICU ) . The study was design ed to answer the question in the ' real world ' , with minimum patient exclusion criteria , do nurses and doctors rate ICU patient 's sedation levels using the SAS similarly ? A convenient sample of 35 nursing and seven medical staff and a r and omly selected sample of 69 patients were used . A nurse and a doctor rated each patient simultaneously using the SAS , with a systematic five-stage arousal process . The results showed that there was exact agreement between the nurses ' and doctors ' scores in 74 % of assessment s. The weighted kappa finding of 0.82 indicates very good agreement ( reliability ) . The mean SAS scores recorded for nurses ( 2.33+/-1.21 ) and doctors ( 2.36+/-1.35 ) were similar . Intraclass correlations for single measures ( r=.921 , p<.001 ) and average measures ( r=.959 , p<.001 ) indicated individuals who completed multiple ratings did not introduce bias . Where there was a difference between the paired ratings , these were only one level of the SAS away from each other . This research indicates nurses and doctors rate patients ' levels of sedation similarly using the SAS . It also provides support for the use of the instrument in general ICUs outside the USA . Research is now needed to determine the value of the SAS in guiding clinical decision-making related to sedation management PURPOSE To describe  physical restraint ( PR ) rates and context s in U.S. hospitals . DESIGN This 2003 - 2005 descriptive study was done to measure PR prevalence and context s ( census , gender , age , ventilation status , PR type , and rationale ) at 40 r and omly selected acute care hospitals in six U.S. metropolitan areas . All units except psychiatric , emergency , operative , obstetric , and long-term care were included . METHODS On 18 r and omly selected days between 0500 and 0700 ( 5:00 am and 7:00 am ) , data collectors determined PR use and context s via observation and nurse report . FINDINGS PR prevalence was 50 per 1,000 patient days ( based on 155,412 patient days ) . Preventing disruption of therapy was the chief reason cited . PR rates varied by unit type , with adult ICU rates the highest obtained . Intra- and interinstitutional variation was as high as 10-fold . Ventilator use was strongly associated with PR use . Elderly patients were over-represented among the physically restrained on some units ( e.g. , medical ) but on many unit types ( including most ICUs ) their PR use was consistent with those of other adults . CONCLUSIONS Wide rate variation indicates the need to examine administratively mediated variables and the promotion of unit-based improvement efforts . Anesthetic and sedation practice s have contributed to high variation in ICU PR rates . Determining the types of units to target to achieve improvements in care of older adults requires study of PR sequelae rate by unit type OBJECTIVE The objective of the study was to evaluate the effectiveness of the  sedation assessment tool ( SAT ) in assessing patient response to treatment for acute behavioural disturbance ( ABD ) . METHODS The SAT is a simplified version of the altered mental status score ( AMSS ) and is a 7-point scale assessing levels of agitation and sedation using only two descriptors . To assess the SAT we firstly compared plots of the SAT and the  AMSS  versus time in patients with ABD recruited to a clinical trial . AMSS were converted to the SAT for this comparison . Second , the sensitivity and specificity were calculated for an increase in the SAT to + 2 or + 3 as a predictor of whether additional sedation was required in a prospect i ve cohort of 138 patients . Third , interrater reliability was assessed using two individuals to score the same patient at two different time points and finally the time to record the score was measured . RESULTS Plots of AMSS and  SAT  for 91 patients in the clinical trial illustrated similar trends in agitation/sedation . Seventeen of 138 patients in the second cohort had an increase in the SAT .  Fifteen of 17 ( 88 % ) received additional sedation . The sensitivity and specificity of the SAT for additional sedation was 100 % ( 95 % CI 75 - 100 % ) and 98 % ( 95 % CI 94 - 100 % ) , respectively . The median time for staff to assign the SAT was 10 s ( range 3 - 15 s ) . Interrater reliability was high with a kappa of 0.87 . CONCLUSION The SAT is a simple , rapid and useful measure of the level of agitation/sedation in patients with ABD . Increases in the score reliably indicated the need for further sedation Introduction : Studies of aggressive behaviors in a nonforensic mental health setting have focused primarily on the inpatient ward and , on event prediction , using behavior-based clinical rating scales . Few studies have specifically targeted aggressive behaviors in the psychiatric emergency service or determined whether assessing the demographic and clinical characteristics of such patients might prove useful for their more rapid identification . Methods : We used a prospect ively acquired data base of over 20,900 visits to four services in the province of Quebec , Canada , over a two-year period from September 2002 onwards . A maximum of 72 variables could be acquired per visit . Visits with aggression ( any verbally or physically intimidating behavior ) , both present and past , were tagged . Binary logistic regressions and cross-tabulations were used to determine whether the profile of a variable differed in visits with aggression from those without aggression . Results : About 7 % of visits were marked by current aggression ( verbal 49 % , physical 12 % , verbal and physical 39 % ) . Including visits with a “ past only ” history of aggression increased this number to 20 % . Variables associated with aggression were gender ( male ) , marital status ( single/separated ) , education ( high school or less ) , employment ( none ) , judicial history ( any type ) , substance abuse ( prior or active ) , medication compliance ( poor ) , type of arrival to psychiatric emergency services ( involuntary , police , judiciary , l and lord ) , reason for referral ( behavioral dyscontrol ) , diagnosis ( less frequent in anxiety disorders ) , and outcome ( more frequently placed under observation or admitted ) . Conclusion : Our results suggest that many state-independent variables are associated with aggressive behaviors in the psychiatric emergency service . Although their sum may not add up to a specific patient profile , they can nevertheless be useful in service planning , being easily integrated alongside state-dependent rating scales in a triage and /or observation instrument for daily use in the psychiatric emergency service OBJECTIVE To describe the Psychiatric Emergency Research Collaboration ( PERC ) , the methods used to create a structured chart review tool and the results of our multicenter study . METHOD Members of the PERC Steering Committee created a structured chart review tool design ed to provide a comprehensive picture of the assessment and management of psychiatric emergency patients . Ten primary indicators were chosen based on the Steering Committee 's professional experience , the published literature and existing consensus panel guidelines . Eight emergency departments completed data abstract ion of 50 r and omly selected emergency psychiatric patients , with seven providing data from two independent raters . Inter-rater reliability ( Kappas ) and descriptive statistics were computed . RESULTS Four hundred patient charts were abstract ed . Initial concordance between raters was variable , with some sites achieving high agreement and others not . Reconciliation of discordant ratings through re- review of the original source documentation was necessary for four of the sites . Two hundred eighty-five ( 71 % ) subjects had some form of laboratory test performed , including 212 ( 53 % ) who had urine toxicology screening and 163 ( 41 % ) who had blood alcohol levels drawn . Agitation was present in 220 ( 52 % ) , with 98 ( 25 % ) receiving a medication to reduce agitation and 22 ( 6 % ) being physically restrained . Self-harm ideation was present in 226 ( 55 % ) , while other-harm ideation was present in 82 ( 20 % ) . One hundred seventy-nine ( 45 % ) were admitted to an inpatient or observation unit . CONCLUSION Creating a common st and ard for documenting , abstract ing and reporting on the nature and management of psychiatric emergencies is feasible across a wide range of health care institutions OBJECTIVE Assessing risk for violence is a complex task often based on not objective or structured clinical evaluations . HCR-20 Assessing Risk for Violence has been used in several countries to increase the accuracy of this exam . The purpose of this study was to inform on central aspects of this instrument , as well as the results of the reliability assessment of the HCR-20 Assessing Risk for Violence in a Brazilian inpatient criminal population . METHOD Two examiners independently assessed a r and om sample of 30 patients that were under criminal commitment at the Mauricio Cardoso Forensic Psychiatric Institute RESULTS Mean consensus values means were as follows : Historical = 13.1 ; Clinical = 4.8 and Risk management = 5.8 . The value 
    Output:
    
agent
Verbal de-escalation techniques have been shown to decrease agitation and reduce the potential for associated violence in the emergency setting .
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background Patient aggression is a common problem in acute psychiatric wards and calls for preventive measures . The timely use of preventive measures presupposes a preceded risk assessment . The Norwegian Brøset-Violence-Checklist ( BVC ) is one of the few instruments suited for short-time prediction of violence of psychiatric in patients in routine care . Aims of our study were to improve the accuracy of the short-term prediction of violence in acute inpatient setting s by combining the Brøset-Violence-Checklist ( BVC ) with an overall subjective clinical risk- assessment and to test the application of the combined measure in daily practice . Method We conducted a prospect i ve cohort study with two sample s of newly admitted psychiatric patients for instrument development ( 219 patients ) and clinical application ( 300 patients ) .  Risk of physical attacks was assessed by combining the 6-item BVC and a 6-point score derived from a  Visual Analog Scale . Incidents were registered with the Staff Observation of Aggression Scale-Revised SOAS-R. Test accuracy was described as the area under the receiver operating characteristic curve ( AUCROC ) . Results The AUCROC of the new VAS-complemented BVC-version ( BVC-VAS ) was 0.95 in and 0.89 in the derivation and validation study respectively . Conclusion The BVC-VAS is an easy to use and accurate instrument for systematic short-term prediction of violent attacks in acute psychiatric wards . The inclusion of the VAS-derived data did not change the accuracy of the original BVC OBJECTIVE To examine factors associated with physical restraint in psychiatric emergency rooms . METHOD We extracted variables likely to predict use of physical restraints from a large r and omised trial undertaken in three psychiatric emergency rooms in Rio de Janeiro . We fitted a Bayesian binary multivariate model using only variables clearly preceding the restraints . RESULTS Of 301 agitated , aggressive people admitted to emergency rooms , 73 ( 24 % ) were restrained during the first 2 h of admission . In Rio , younger people ( OR=1.03 for each year younger ) , exhibiting intense ( OR=2.53 ) or extreme agitation ( OR=7.71 ) , thought to result from substance misuse ( OR=1.75 ) or diagnoses other than psychosis ( OR=1.88 ) , arriving in the morning ( OR=1.64 ) were at greater risk of  physical restraints  than older , less severely aggressive or agitated people , arriving at the hospital during the afternoon or night . Hospital , gender , first admission to hospital and medication were not associated with risk of being restrained . CONCLUSION Restraint practice s in Rio are predictable and based on a limited clinical assessment . Predictive factors for physical restraint may vary worldwide , but should be monitored and studied to assist training , and to establish programs to evaluate and refine this controversial practice BACKGROUND Psychiatric emergency situations ( PES ) are of high importance to the German prehospital physician-based emergency medical system . So far , however , no prospect i ve studies regarding the incidence of PES have been performed , neither have effects of training programs on diagnostic and therapeutic accuracy been studied . METHOD The protocol s of two emergency medical services ( EMS ) were collected and analyzed prospect ively .  Emergency physicians ( EPs ) in Kaiserslautern ( KL ) attended a st and ardized educational program and underwent daily supervision .  EPs in Homburg ( HOM ) had not been informed about the study . In KL , sociodemographic variables were collected . An investigator who was not involved in the individual EMS mission assessed the correct classification of PES . RESULTS Among all calls for an EP , 11.8 % were classified as PES . There was no difference between the two centers . Correct classification of PES in KL was significantly higher than that in HOM ( 94.3 % vs. 80.6 % ) . Documentation of suicidal behavior was deficient in both centers . EPs in KL gave verbal crisis intervention significantly more often , administered less medication overall , and dispensed more specific drugs in psychotic disorders and significantly less drugs in substance abuse disorders . Patients were more often treated at the scene and were less often transported to a hospital . Some sociodemographic variables were associated with psychiatric morbidity of treatment . CONCLUSION Accounting for 12 % of all missions , psychiatric emergencies are a frequent reason for calls for EPs , equaling trauma-related and neurological emergencies . The most frequent reasons for calls were alcohol intoxication , states of agitation and suicidal behavior . The diagnostic and therapeutic accuracy of EPs may be improved with a concise st and ardized teaching program This study determined the inter-rater reliability of the  Sedation-Agitation Scale ( SAS ) when used by staff in a tertiary level general intensive care unit ( ICU ) . The study was design ed to answer the question in the ' real world ' , with minimum patient exclusion criteria , do nurses and doctors rate ICU patient 's sedation levels using the SAS similarly ? A convenient sample of 35 nursing and seven medical staff and a r and omly selected sample of 69 patients were used . A nurse and a doctor rated each patient simultaneously using the SAS , with a systematic five-stage arousal process . The results showed that there was exact agreement between the nurses ' and doctors ' scores in 74 % of assessment s. The weighted kappa finding of 0.82 indicates very good agreement ( reliability ) . The mean SAS scores recorded for nurses ( 2.33+/-1.21 ) and doctors ( 2.36+/-1.35 ) were similar . Intraclass correlations for single measures ( r=.921 , p<.001 ) and average measures ( r=.959 , p<.001 ) indicated individuals who completed multiple ratings did not introduce bias . Where there was a difference between the paired ratings , these were only one level of the SAS away from each other . This research indicates nurses and doctors rate patients ' levels of sedation similarly using the SAS . It also provides support for the use of the instrument in general ICUs outside the USA . Research is now needed to determine the value of the SAS in guiding clinical decision-making related to sedation management PURPOSE To describe  physical restraint ( PR ) rates and context s in U.S. hospitals . DESIGN This 2003 - 2005 descriptive study was done to measure PR prevalence and context s ( census , gender , age , ventilation status , PR type , and rationale ) at 40 r and omly selected acute care hospitals in six U.S. metropolitan areas . All units except psychiatric , emergency , operative , obstetric , and long-term care were included . METHODS On 18 r and omly selected days between 0500 and 0700 ( 5:00 am and 7:00 am ) , data collectors determined PR use and context s via observation and nurse report . FINDINGS PR prevalence was 50 per 1,000 patient days ( based on 155,412 patient days ) . Preventing disruption of therapy was the chief reason cited . PR rates varied by unit type , with adult ICU rates the highest obtained . Intra- and interinstitutional variation was as high as 10-fold . Ventilator use was strongly associated with PR use . Elderly patients were over-represented among the physically restrained on some units ( e.g. , medical ) but on many unit types ( including most ICUs ) their PR use was consistent with those of other adults . CONCLUSIONS Wide rate variation indicates the need to examine administratively mediated variables and the promotion of unit-based improvement efforts . Anesthetic and sedation practice s have contributed to high variation in ICU PR rates . Determining the types of units to target to achieve improvements in care of older adults requires study of PR sequelae rate by unit type OBJECTIVE The objective of the study was to evaluate the effectiveness of the  sedation assessment tool ( SAT ) in assessing patient response to treatment for acute behavioural disturbance ( ABD ) . METHODS The SAT is a simplified version of the altered mental status score ( AMSS ) and is a 7-point scale assessing levels of agitation and sedation using only two descriptors . To assess the SAT we firstly compared plots of the SAT and the  AMSS  versus time in patients with ABD recruited to a clinical trial . AMSS were converted to the SAT for this comparison . Second , the sensitivity and specificity were calculated for an increase in the SAT to + 2 or + 3 as a predictor of whether additional sedation was required in a prospect i ve cohort of 138 patients . Third , interrater reliability was assessed using two individuals to score the same patient at two different time points and finally the time to record the score was measured . RESULTS Plots of AMSS and  SAT  for 91 patients in the clinical trial illustrated similar trends in agitation/sedation . Seventeen of 138 patients in the second cohort had an increase in the SAT .  Fifteen of 17 ( 88 % ) received additional sedation . The sensitivity and specificity of the SAT for additional sedation was 100 % ( 95 % CI 75 - 100 % ) and 98 % ( 95 % CI 94 - 100 % ) , respectively . The median time for staff to assign the SAT was 10 s ( range 3 - 15 s ) . Interrater reliability was high with a kappa of 0.87 . CONCLUSION The SAT is a simple , rapid and useful measure of the level of agitation/sedation in patients with ABD . Increases in the score reliably indicated the need for further sedation Introduction : Studies of aggressive behaviors in a nonforensic mental health setting have focused primarily on the inpatient ward and , on event prediction , using behavior-based clinical rating scales . Few studies have specifically targeted aggressive behaviors in the psychiatric emergency service or determined whether assessing the demographic and clinical characteristics of such patients might prove useful for their more rapid identification . Methods : We used a prospect ively acquired data base of over 20,900 visits to four services in the province of Quebec , Canada , over a two-year period from September 2002 onwards . A maximum of 72 variables could be acquired per visit . Visits with aggression ( any verbally or physically intimidating behavior ) , both present and past , were tagged . Binary logistic regressions and cross-tabulations were used to determine whether the profile of a variable differed in visits with aggression from those without aggression . Results : About 7 % of visits were marked by current aggression ( verbal 49 % , physical 12 % , verbal and physical 39 % ) . Including visits with a “ past only ” history of aggression increased this number to 20 % . Variables associated with aggression were gender ( male ) , marital status ( single/separated ) , education ( high school or less ) , employment ( none ) , judicial history ( any type ) , substance abuse ( prior or active ) , medication compliance ( poor ) , type of arrival to psychiatric emergency services ( involuntary , police , judiciary , l and lord ) , reason for referral ( behavioral dyscontrol ) , diagnosis ( less frequent in anxiety disorders ) , and outcome ( more frequently placed under observation or admitted ) . Conclusion : Our results suggest that many state-independent variables are associated with aggressive behaviors in the psychiatric emergency service . Although their sum may not add up to a specific patient profile , they can nevertheless be useful in service planning , being easily integrated alongside state-dependent rating scales in a triage and /or observation instrument for daily use in the psychiatric emergency service OBJECTIVE To describe the Psychiatric Emergency Research Collaboration ( PERC ) , the methods used to create a structured chart review tool and the results of our multicenter study . METHOD Members of the PERC Steering Committee created a structured chart review tool design ed to provide a comprehensive picture of the assessment and management of psychiatric emergency patients . Ten primary indicators were chosen based on the Steering Committee 's professional experience , the published literature and existing consensus panel guidelines . Eight emergency departments completed data abstract ion of 50 r and omly selected emergency psychiatric patients , with seven providing data from two independent raters . Inter-rater reliability ( Kappas ) and descriptive statistics were computed . RESULTS Four hundred patient charts were abstract ed . Initial concordance between raters was variable , with some sites achieving high agreement and others not . Reconciliation of discordant ratings through re- review of the original source documentation was necessary for four of the sites . Two hundred eighty-five ( 71 % ) subjects had some form of laboratory test performed , including 212 ( 53 % ) who had urine toxicology screening and 163 ( 41 % ) who had blood alcohol levels drawn . Agitation was present in 220 ( 52 % ) , with 98 ( 25 % ) receiving a medication to reduce agitation and 22 ( 6 % ) being physically restrained . Self-harm ideation was present in 226 ( 55 % ) , while other-harm ideation was present in 82 ( 20 % ) . One hundred seventy-nine ( 45 % ) were admitted to an inpatient or observation unit . CONCLUSION Creating a common st and ard for documenting , abstract ing and reporting on the nature and management of psychiatric emergencies is feasible across a wide range of health care institutions OBJECTIVE Assessing risk for violence is a complex task often based on not objective or structured clinical evaluations . HCR-20 Assessing Risk for Violence has been used in several countries to increase the accuracy of this exam . The purpose of this study was to inform on central aspects of this instrument , as well as the results of the reliability assessment of the HCR-20 Assessing Risk for Violence in a Brazilian inpatient criminal population . METHOD Two examiners independently assessed a r and om sample of 30 patients that were under criminal commitment at the Mauricio Cardoso Forensic Psychiatric Institute RESULTS Mean consensus values means were as follows : Historical = 13.1 ; Clinical = 4.8 and Risk management = 5.8 . The value 
    Output:
    