Objective: The purpose of this article is to present a brief review of the effects of excessive sleepiness on driving performance, and to emphasize the importance of the subject. Methods: Bibliographic review of national and international literature, including original articles and official publications from the American Thoracic Society and the American Sleep Apnea Association. Results: There is growing evidence that excessive sleepiness may be an important factor related to the occurrence of motor vehicle accidents. Difficulties regarding the identification of sleepiness as a preceding factor related to motor vehicle crashes are discussed on the text. There are many causes for excessive sleepiness. Fortunately most of them are easy to recognize and have specific treatment. Conclusions: A better understanding of the problem is fundamental to promote a better approach for patients with excessive sleepiness and perhaps encourage the discussion about the current motor vehicle legislation and the physicians' legal obligations.

Keywords: sleepiness; motor vehicle accidents

Objective: There are many ways of assessing sleepiness, which has many dimensions. In patients presenting a borderline apnea-hypopnea index (AHI, expressed as events/hour of sleep), the mechanisms of excessive daytime sleepiness (EDS) remain only partially understood. In the initial stages of sleep-disordered breathing, the AHI might be related to as-yet-unexplored EDS dimensions. Methods: We reviewed the polysomnography results of 331 patients (52% males). The mean age was 40 ± 13 years, and the mean AHI was 4 ± 2 (range, 0-9). We assessed ten potential dimensions of sleepiness based on polysomnography results and medical histories. Results: The AHI in non-rapid eye movement (NREM) stage 1 sleep (AHI-N1), in NREM stage 2 sleep (AHI-N2), and in REM sleep (AHI-REM) were, respectively, 6 ± 7, 3 ± 3 and 10 ± 4. The AHI-N2 correlated significantly with the greatest number of EDS dimensions (5/10), including the Epworth sleepiness scale score (r = 0.216, p < 0.001). Factor analysis, using Cronbach's alpha, reduced the variables to three relevant factors: QUESTIONNAIRE (α = 0.7); POLYSOMNOGRAPHY (α = 0.68); and COMPLAINTS (α = 0.55). We used these factors as dependent variables in a stepwise multiple regression analysis, adjusting for age, gender, and body mass index. The AHI-N1 correlated significantly with POLYSOMNOGRAPHY (β = −0.173, p = 0.003), and the AHI-N2 correlated significantly with COMPLAINTS (β = −0.152, p = 0.017). The AHI-REM did not correlate with any factor. Conclusions: Our results underscore the multidimensionality of EDS in mild sleep apnea.

Keywords: Disorders of excessive somnolence; Sleep apnea syndromes; Sleep, REM; Polysomnography.

Objective: To evaluate the usefulness of simple motor tasks such as hand grasping and tongue protrusion as predictors of extubation failure in critically ill neurological patients. Methods: This was a prospective cohort study conducted in the neurological ICU of a tertiary care hospital in the city of Porto Alegre, Brazil. Adult patients who had been intubated for neurological reasons and were eligible for weaning were included in the study. The ability of patients to perform simple motor tasks such as hand grasping and tongue protrusion was evaluated as a predictor of extubation failure. Data regarding duration of mechanical ventilation, length of ICU stay, length of hospital stay, mortality, and incidence of ventilator-associated pneumonia were collected. Results: A total of 132 intubated patients who had been receiving mechanical ventilation for at least 24 h and who passed a spontaneous breathing trial were included in the analysis. Logistic regression showed that patient inability to grasp the hand of the examiner (relative risk = 1.57; 95% CI: 1.01-2.44; p < 0.045) and protrude the tongue (relative risk = 6.84; 95% CI: 2.49-18.8; p < 0.001) were independent risk factors for extubation failure. Acute Physiology and Chronic Health Evaluation II scores (p = 0.02), Glasgow Coma Scale scores at extubation (p < 0.001), eye opening response (p = 0.001), MIP (p < 0.001), MEP (p = 0.006), and the rapid shallow breathing index (p = 0.03) were significantly different between the failed extubation and successful extubation groups. Conclusions: The inability to follow simple motor commands is predictive of extubation failure in critically ill neurological patients. Hand grasping and tongue protrusion on command might be quick and easy bedside tests to identify neurocritical care patients who are candidates for extubation.

Keywords: Ventilator weaning; Airway extubation/adverse effects; Critical care; Neurosurgery.

Objective: The aim of this study was to develop a Portuguese-language version of the Epworth sleepiness scale (ESS) for use in Brazil. Methods: The steps involved in creating the ESS in Brazilian Portuguese (ESS-BR) were as follows: translation; back-translation; comparison (by a committee) between the translation and the back-translation; and testing in bilingual individuals. The ESS-BR was applied to a group of patients who were submitted to overnight polysomnography in order to identify obstructive sleep apnea-hypopnea syndrome (OSAHS), insomnia and primary snoring. A control group was composed of subjects with a history of normal sleep habits, without reported snoring. Results: A total of 114 patients and 21 controls were included. The 8-item scores of the ESS-BR had an overall reliability coefficient of 0.83. The study group was composed of 59 patients with OSAHS, 34 patients with primary snoring and 21 patients with insomnia. One-way ANOVA demonstrated significant differences in ESS-BR scores among the four diagnostic groups (p < 0.001). Post-hoc tests between groups showed that the ESS-BR scores of the patients with insomnia did not differ from those of the controls (p > 0.05). The ESS-BR scores were significantly higher for OSAHS patients and for primary snorers than for controls (p < 0.05). In addition, the scores for OSAHS patients were significantly higher than were those for primary snorers (p < 0.05). Conclusions: The results of the present study demonstrate that the ESS-BR is a valid and reliable instrument for the assessment of daytime sleepiness, equivalent to its original version when applied to individuals who speak Brazilian Portuguese.

Keywords: Validation studies; Sleep disorders; Cross-cultural comparison; Disorders of excessive somnolence.

Smoking among women has drawn increasing attention because of the increase (or less pronounced decrease) in its prevalence when compared with that observed for men, as well as because of the specific effects that smoking has on women's health. For the 2010 "World No Tobacco Day", the World Health Organization chose the theme "Gender and tobacco with an emphasis on marketing to women", with the aim of encouraging policies to combat marketing strategies employed by the tobacco industry and to curb the epidemic of smoking among women. In this article, we discuss the characteristics of smoking among women, addressing factors such as smoking prevalence, nicotine dependence, the role of the tobacco industry, health risks, approaches to smoking cessation, treatment strategies, and prevention measures.

Keywords: Smoking; Women's health; Tobacco industry.

Silicosis, the most prevalent of the pneumoconioses, is caused by inhalation of crystalline silica particles. Silica-exposed workers, with or without silicosis, are at increased risk for tuberculosis and nontuberculous mycobacteria-related diseases. The risk of a patient with silicosis developing tuberculosis is higher (2.8 to 39 times higher, depending on the severity of the silicosis) than that found for healthy controls. Various regimens for tuberculosis chemoprophylaxis in patients with silicosis have been studied, all of which present similar efficacy and overall risk reduction to about one half of that obtained with placebo. Long-term regimens have potential side effects (particularly hepatotoxicity). In addition, the use of such regimens can jeopardize adherence to treatment. The current guidelines recommend that tuberculin skin tests be performed, and, if positive, that chemoprophylaxis be instituted. There are several possible regimens, varying in terms of the drugs prescribed, as well as in terms of treatment duration. We recommend the use of isoniazid at 300 mg/day (or 10 mg/kg/day) for six months for patients with silicosis, as well as for healthy patients with periods of exposure to silica longer than 10 years and strongly positive tuberculin skin test results (induration ≥ 10 mm). Nevertheless, further studies are necessary so that indications, drugs, doses and duration of chemoprophylaxis regimens can be more properly defined.

Keywords: Silicosis; Tuberculosis; Diagnostic techniques and procedures; Chemoprevention.

The human body is exposed to different environmental aggressions; accidents, physical, chemical, and microbiological agents are a permanent risk. The respiratory system is particularly exposed to environmental aggressions and is frequently ground of alterations with greater or lesser intensity and danger. The authors review the consequences of air pollution on the respiratory system. They define air pollution, indoor and outdoor pollution, and primary and secondary pollution. They briefly review respiratory system defense mechanisms and describe harmful actions of different air pollutants to airways: SO2, NO2, CO, O3, aerosols and particles. They point to the consequences of tobacco smoking due to its importance to health. They conclude with comments on the intervention that Pneumology and Pneumologists should have in this matter, drawing the attention of the community and authorities to the risks of pollution to health in general and to the respiratory system in particular.

We report the case of a 25-year-old woman with Churg-Strauss syndrome, the symptoms of which had first appeared soon after she began taking oral contraceptive at the age of sixteen. The clinical profile evolved rapidly to severe persistent asthma, nasal polyposis, perennial obstructive rhinitis, eosinophilia (peripheral/tissue) and mononeuritis. Churg-Strauss syndrome is the type of disease that demands early detection, accurate diagnosis, aggressive treatment and periodic monitoring. It should be considered in the differential diagnosis of moderate and severe persistent asthma. The case reported calls attention to possibility that there is a hormonal component and that the disease can present early onset.

Keywords: Asthma; Churg-Strauss syndrome; Eosinophilia; Nasal polyps; Vasculitis; Case reports [publication type]

The relationship between cancer and coagulopathy was suggested by Trousseau nearly 150 years ago. Later, it became more evident that oncologic patients are at a higher risk of experiencing thromboembolic events. This can be due to activation of the coagulation system either by neoplastic cells or by prescribed therapies (chemotherapy or surgical procedures). In fact, these events can constitute the first manifestation of cancer, and their recurrence, despite efficient anticoagulation, has been described. The coagulation system is normally activated in order to provide healing. In the presence of neoplasms, this complex system is activated as a response to multiple stimuli and seems to contribute to cancer progression. Activation of the coagulation system has a greater effect on metastatic foci than on the primary tumor. However, most cancer victims die from complications caused by metastasis, which underscores the importance of this theme. In this area, various mechanisms have been described, creating promising perspectives for future treatments. The current success in using low-molecular-weight heparins against small cell lung cancer is encouraging. Although the knowledge of those mechanisms is relatively incipient, many basic research and clinical studies are underway.

Keywords: Lung neoplasms; Thrombophilia.

Recurrent pleural effusion, which is commonly seen in clinical practice, compromises patient quality of life, especially in patients with advanced malignant disease. The therapeutic approach to the pleural space involves a wide range of techniques, including aggressive procedures such as pleurectomy. Among such techniques, pleurodesis is the most frequently used. Pleurodesis can be induced through the insertion of pleural catheters, as well as through major surgical procedures (such as thoracotomy). There are various recommended sclerosing agents, including talc (which is the most widely used), silver nitrate and, recently, proliferative cytokines. This article summarizes the principal approaches to the treatment of recurrent pleural effusion, pleurodesis in particular, addressing the indications for, as well as the advantages and disadvantages of, their application in daily pulmonology practice.

Keywords: Pleural effusion, malignant/prevention & control; Pleural neoplasms; Pleura/surgery; Pleurodesis/methods; Silver nitrate; Talc; Recurrence

Objective: To evaluate the frequency of the real association between paracoccidioidomycosis (PCM) and tuberculosis (TB) as well as the rate of previous TB misdiagnosis in individuals with PCM among the patients treated in the Pulmonology Division of the State University of Campinas Hospital das Clínicas, Campinas, Brazil. Methods: A retrospective study of 227 adult patients with PCM (chronic form) treated between 1980 and 2005. Results: Of the 227 patients studied, 36 (15.8%) had been previously treated for TB. However, only 18 (7.9%) presented positive sputum smear microscopy results. The remaining 18 (7.9%) neither presented positive sputum smear microscopy nor showed improvement after receiving specific anti-TB treatment. Conclusion: Although the existence of an association between PCM and TB has been documented in the literature, misdiagnosis is common due to the superimposition of and the similarity between their clinical and radiographic presentations, thereby warranting the need for bacteriological diagnosis before initiating specific treatment.

Keywords: Paracoccidioidomycosis; Tuberculosis, pulmonary; Diagnosis, differential.