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Daily variations in ambient fine particulate matter (PM 2.5 ) could contribute to the morbidity of anxiety disorders in children and adolescents, but has not yet been studied longitudinally at a daily level. We tested this association using repeated weekly measures of anxiety symptom severity in a group of 23 adolescents with generalized anxiety disorder. After estimating ambient PM 2.5 concentrations using a validated model, we found that increased concentrations were significantly associated with increased anxiety symptom severity and frequency two, three, and four days later. PM 2.5 may be a novel, modifiable exposure that could inform population level interventions to decrease psychiatric morbidity., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Objective: To characterize executive function in adolescents with generalized anxiety disorder (GAD) and its relationship to treatment. Methods: Using data from a double-blind, placebo-controlled trial of escitalopram in adolescents ( N  = 51) 12-17 years of age with GAD, we used the self-report version of the Behavior Rating Inventory of Executive Function (BRIEF-SR) to assess executive function, at baseline, and examined its relationship to treatment response as measured by the Pediatric Anxiety Rating Scale (PARS). Results: For all baseline subscores of the BRIEF-SR, T-scores were significantly elevated in adolescents with GAD compared to an age- and sex-matched normative healthy sample. In escitalopram-treated patients, baseline BRIEF-SR scores for Emotional Control ( β  = 0.256, 95% credibility interval [CrI]: 0.367 to 0.146, p  < 0.001), Working Memory ( β  = 0.204, CrI: 0.2952 to 0.1134, p  < 0.001), Planning/Organizing ( β  =  - 0.223, CrI: -0.1021 to -0.3436, p  = 0.004), and Task Completion ( β  = -0.152, CrI: 0.075 to 0.228, p  = 0.002) predicted the trajectory of improvement in PARS score over the 8-week trial. For youth who received placebo, only the Inhibit score was significantly, but weakly, associated with response trajectory ( β  = -0.081, CrI: -0.0167 to -0.1461, p  = 0.015). For adolescents who had clinically significant impairment in Emotional Control, Working Memory, Planning/Organizing, and Task Completion (i.e., T-score >65), the trajectory of improvement significantly differed from patients without scores in the clinically significant range. Conclusions: Taken together, these findings point to the potential value of assessing executive function in youth with anxiety disorders as one strategy for guiding treatment selection. These data suggest that executive function may predict treatment response to psychopharmacologic treatment and point to numerous avenues for further personalizing treatment.

Current pharmacologic treatments for pediatric anxiety disorders (e.g., selective serotonin reuptake inhibitors (SSRIs)) frequently use "one size fits all" dosing strategies based on average responses in clinical trials. However, for some SSRIs, including escitalopram, variation in CYP2C19 activity produces substantial variation in medication exposure (i.e., blood medication concentrations). This raises an important question: would refining current SSRI dosing strategies based on CYP2C19 phenotypes increase response and reduce side effect burden? To answer this question, we designed a randomized, double-blind trial of adolescents 12-17 years of age with generalized, separation, and/or social anxiety disorders (N = 132). Patients are randomized (1:1) to standard escitalopram dosing or dosing based on validated CYP2C19 phenotypes for escitalopram metabolism. Using this approach, we will determine whether pharmacogenetically-guided treatment-compared to standard dosing-produces faster and greater reduction in anxiety symptoms (i.e., response) and improves tolerability (e.g., decreased risk of treatment-related activation and weight gain). Secondarily, we will examine pharmacodynamic variants associated with treatment outcomes, thus enhancing clinicians' ability to predict response and tolerability. Ultimately, developing a strategy to optimize dosing for individual patients could accelerate response while decreasing side effects-an immediate benefit to patients and their families. ClinicalTrials.gov Identifier: NCT04623099.

Objective: to verify Burnout Syndrome prevalence among nursing technicians of an adult Intensive Care Unit and associate prevalence with sociodemographic and clinical data., Method: a cross-sectional study carried out in an adult Intensive Care Unit of a large public hospital in southern Brazil, between March and April/2018. Prevalence was assessed using the Maslach Burnout Inventory., Results: 122 nursing technicians participated (aged 39±2.5 years), 76% being women. Burnout Syndrome prevalence was 19.7% and 62.9%. There was a significant association between Burnout Syndrome and depression (p=0.004), as well as Burnout Syndrome and comorbidities (p=0.033), when less conservative criteria were adopted., Conclusion: the findings are relevant to professionals in this area and may contribute to adopting strategies to combat Burnout Syndrome.

Objective: To describe the incidence and to report the cases of falls in a cohort of critical adults., Method: A prospective cohort study, conducted in 2018 at an adult Intensive Care Unit (ICU) in the south of Brazil. The patients were followed up from admission to discharge; observations were made in the morning and afternoon. The clinical and care variables were evaluated. The descriptive analysis was performed followed by the reporting of the cases., Results: 551 patients were monitored during 6 [3-12.7] days of hospitalization, generating 7,839 observations. There were four cases of falls, with an incidence rate of 5.1/10.000 observations/day - confidence interval of 99% [0.9 to 16] and density of incidence of 7/10.000 observations/day - confidence interval of 99% [1.2 to 22]. No serious harms were observed., Conclusion: Falls occur less in the ICU, which can be explained by the use of safe care practices.

Importance: The effects of intensive care unit (ICU) visiting hours remain uncertain., Objective: To determine whether a flexible family visitation policy in the ICU reduces the incidence of delirium., Design, Setting and Participants: Cluster-crossover randomized clinical trial involving patients, family members, and clinicians from 36 adult ICUs with restricted visiting hours (<4.5 hours per day) in Brazil. Participants were recruited from April 2017 to June 2018, with follow-up until July 2018., Interventions: Flexible visitation (up to 12 hours per day) supported by family education (n = 837 patients, 652 family members, and 435 clinicians) or usual restricted visitation (median, 1.5 hours per day; n = 848 patients, 643 family members, and 391 clinicians). Nineteen ICUs started with flexible visitation, and 17 started with restricted visitation., Main Outcomes and Measures: Primary outcome was incidence of delirium during ICU stay, assessed using the CAM-ICU. Secondary outcomes included ICU-acquired infections for patients; symptoms of anxiety and depression assessed using the HADS (range, 0 [best] to 21 [worst]) for family members; and burnout for ICU staff (Maslach Burnout Inventory)., Results: Among 1685 patients, 1295 family members, and 826 clinicians enrolled, 1685 patients (100%) (mean age, 58.5 years; 47.2% women), 1060 family members (81.8%) (mean age, 45.2 years; 70.3% women), and 737 clinicians (89.2%) (mean age, 35.5 years; 72.9% women) completed the trial. The mean daily duration of visits was significantly higher with flexible visitation (4.8 vs 1.4 hours; adjusted difference, 3.4 hours [95% CI, 2.8 to 3.9]; P < .001). The incidence of delirium during ICU stay was not significantly different between flexible and restricted visitation (18.9% vs 20.1%; adjusted difference, -1.7% [95% CI, -6.1% to 2.7%]; P = .44). Among 9 prespecified secondary outcomes, 6 did not differ significantly between flexible and restricted visitation, including ICU-acquired infections (3.7% vs 4.5%; adjusted difference, -0.8% [95% CI, -2.1% to 1.0%]; P = .38) and staff burnout (22.0% vs 24.8%; adjusted difference, -3.8% [95% CI, -4.8% to 12.5%]; P = .36). For family members, median anxiety (6.0 vs 7.0; adjusted difference, -1.6 [95% CI, -2.3 to -0.9]; P < .001) and depression scores (4.0 vs 5.0; adjusted difference, -1.2 [95% CI, -2.0 to -0.4]; P = .003) were significantly better with flexible visitation., Conclusions and Relevance: Among patients in the ICU, a flexible family visitation policy, vs standard restricted visiting hours, did not significantly reduce the incidence of delirium., Trial Registration: ClinicalTrials.gov Identifier: NCT02932358.

This is a report about a 12 year old boy with mosaic of trisomy 8 syndrome and with average intelligence. He has been treated about three years because of specific learning disabilities. There are indications in the literature about cases with similar development.