Ventilator-associated pneumonia (VAP) is the most frequent nosocomial infection in the intensive care unit (ICU), with an incidence ranging from 8% to 38%. Patients who acquire VAP have higher mortality rates and longer ICU and hospital stays. Because there are other potential causes of fever, leukocytosis, and pulmonary infiltrates, clinical diagnosis of VAP is overly sensitive. The only alternative approach to the clinical diagnosis of VAP is the Clinical Pulmonary Infection Score (CPIS). Employing quantitative cultures of respiratory secretions in the diagnosis of VAP leads to less antibiotic use and probably to lower mortality. With respect to microbiologic diagnosis, however, it is not clear that the use of invasive sampling using bronchoscopy is associated with better outcomes. Delayed administration of antibiotic therapy is associated with an increased mortality, and inadequate antibiotic therapy is also associated with higher mortality. Therefore, prompt initiation of adequate antibiotic therapy is a cornerstone of the treatment of VAP. The initial antibiotic therapy should be based on the most common organisms in each hospital and the most likely pathogens for that specific patient. When final cultures and susceptibilities are available, de-escalation to less broad spectrum antibiotics should be done. Since clinical improvement usually takes 2 to 3 days, clinical responses to the initial empirical therapy should be evaluated by day 3. A short course of antibiotic therapy appears to be equivalent to a traditional course of more than 14 days, except when treating non-fermenting gram-negative organisms. If patients receive initially adequate antibiotic therapy, efforts should be made to shorten the duration of therapy to as short as 7 days, provided that the etiologic pathogen is not a non-fermenting gram-negative organism.

Social welfare services for respiratory-disabled persons in Korea are offered based on the respiratory impairment grade, which is determined by 3 clinical parameters; dyspnea, forced expiratory volume in 1 second ($FEV_1$), and arterial oxygen tension. This grading system has several limitations in the objective assessment of respiratory impairment. We reviewed several guidelines for the evaluation of respiratory impairment and relevant articles. Then, we discussed a new grading system with respiratory physicians. Both researchers and respiratory physicians agreed that pulmonary function tests are essential in assessing the severity of respiratory impairment, forced vital capacity (FVC), $FEV_1$ and single breath diffusing capacity ($DL_{co}$) are the primarily recommended tests. In addition, we agreed that arterial blood gas analysis should be reserved for selected patients. In conclusion, we propose a new respiratory impairment grading system utilizing a combination FVC, $FEV_1$ and $DL_{co}$ scores, with more social discussion included.

Background: Transcription factor FOXP3 characterizes the thymically derived regulatory T cells. FOXP3 is expressed by cancer cell itself and FOXP3 expression was induced by TGF-${\beta}$ treatment in pancreatic cancer cell line. However, the expression of FOXP3 expression is not well known in patients with lung cancer. This study was conducted to investigate the expression of FOXP3 in patients with lung cancer and to investigate the regulation of FOXP3 expression by the treatment of TGF-${\beta}$ and DNA methyltransferase inhibitor in lung cancer cell lines. Methods: FOXP3 expression in the tissue of patients with resected non-small cell lung cancer (NSCLC) was evaluated by immunohistochemistry. The regulation of FOXP3 expression was investigated by Western blot and RT-PCR after lung cancer cell lines were stimulated with TGF-${\beta}1$ and TGF-${\beta}2$. The regulation of FOXP3 expression was also investigated by RT-PCR and flow cytometry after lung cancer cell lines were treated with DNA methyltransferase inhibitor (5-AZA-dC). Results: FOXP3 expression was confirmed in 27% of patients with NSCLC. In NCI-H460 cell line, TGF-${\beta}2$ decreased FOXP3 mRNA and protein expressions. In A549 cell line, both TGF-${\beta}1$ and TGF-${\beta}2$ decreased FOXP3 mRNA and protein expressions. 5-AZA-dC increased FOXP3 mRNA expression in NCI-H460 and A549 cell lines. Moreover, 5-AZA-dC increased intracellular FOXP3 protein expression in A549 cell lines. Conclusion: It was shown that FOXP3 is expressed by cancer cell itself in patients with NSCLC. Treatment of TGF-${\beta}2$ and DNA methyltransferase inhibitor seems to be associated with the regulation of FOXP3 expression in lung cancer cell lines.

Background: We investigated whether curcumin and genistein affect the MUC5AC mucin production from human airway epithelial cells that is induced by phorbol 12-myristate 13-acetate (PMA) or tumor necrosis factor-${\alpha}$ (TNF-${\alpha}$). Methods: Confluent NCI-H292 cells were pretreated with each agent for 30 min and then stimulated with PMA or TNF-${\alpha}$ for 24 hours. MUC5AC mucin production was measured by an ELISA. Results: (1) Curcumin dose-dependently inhibited the production of MUC5AC mucin that was induced by PMA or TNF-${\alpha}$; (2) Genistein inhibited PMA-induced MUC5AC mucin production. However, it did not decrease TNF-${\alpha}$-induced MUC5AC mucin production. Conclusion: These results suggest that curcumin and genistein inhibit the production of airway mucin induced by PMA.

Background: Little data is available regarding hospitalized patients with nursing home-acquired pneumonia (NHAP). This is unfortunate because there is an increasing number of elderly persons who are living in nursing homes in Korea. The aim of this study was to compare clinical characteristics and treatment responses of NHAP with community-acquired pneumonia (CAP). Methods: Patients with pneumonia who were admitted from eight nursing homes or from their own homes were enrolled between May 2007 and April 2009. Their clinical characteristics and treatment responses were reviewed retrospectively, and differences between the two groups were analyzed. Results: Of 110 Patients with pneumonia, 66 (60%) were from nursing homes and their median age was 84. In the NHAP group, functional performance status was significantly poorer, classical symptoms of pneumonia were less severe, and multi-lobe involvement (on chest radiographs) was more frequent than in the CAP group. Patients with NHAP more frequently showed lymphocytopenia, anemia, hypoalbuminemia, hypoxemia, and elevated blood urea nitrogen on admission. The mean CURB-65 score was 2.2 in the NHAP group, higher than 1.7 in the CAP group (p=0.004), and multi-drug resistant pathogens were also highly identified in NHAP group (39% vs. 10%, p=0.036). The mean duration of antibiotic therapy was greater for the NHAP (12.6 days) than for the CAP group (6.6 days) (p<0.001). The mortality rate was 23% in NHAP group, which was significantly higher than 5% in the CAP group (p=0.014). Conclusion: NHAP should be more intensively investigated because of the higher frequency of multi-drug resistant pathogens and mortality than the CAP.

Background: The rising prevalence of asthma may be associated with the rising prevalence of obesity in developed nations. There are several studies showing that obesity increases the risk of asthma in adults. We investigated the association of each body composition scale and bronchial hyper-responsiveness. Methods: This study involved a retrospective review of the existing records for 279 subjects with respiratory symptoms, who underwent a pulmonary function test, a methacholine challenge test and a body composition test between May 2007 and June 2009. Results: Of the 279 subjects, 179 (64%) were female. There was a statistically significant difference in fat free mass and in fat free mass index between the normal bronchial responsiveness group and bronchial hyper-responsiveness group (p=0.036; p=0.000). There was no significant differences in body mass index, in fat mass and fat free mass index in the normal bronchial responsiveness group and bronchial hyper-responsiveness group in males. However in females, body mass index and fat free mass index were increased in the bronchial hyper-responsiveness group (p=0.044; p=0.000). Total body water (kg), fat free mass (kg) and soft lean mass (kg) were significantly different between the normal bronchial responsiveness group and bronchial hyper-responsiveness group (p=0.002; p=0.000; p=0.000). Conclusion: This study showed significant differences in fat free mass and in fat free mass index between the normal bronchial responsiveness group and the bronchial hyper-responsiveness group. In females, BMI, soft lean mass, and total body water showed significant differences between the normal bronchial responsiveness group and the bronchial hyper-responsiveness group. We concluded that bronchial hyper-responsiveness was associated with not only body mass index but also fat free mass index in female bronchial asthma.

Pulmonary capillary hemangiomatosis (PCH) is a rare disease of unknown etiology that is characterized by nodules composed of infiltrating capillary blood vessels. Herein, we describe a case of a PCH-like lesion that was detected by chest computed tomography. Transthoracic needle aspiration resulted in life-threatening hemorrhage. The patient was followed for seven years. He remained in good health and a follow up image showed little interval change.

The pandemic (H1N1) 2009 influenza outbreak coincided with the typical Scrub typhus season, which can lead to diagnostic difficulties due to their similar and non-specific symptoms. Here we describe a case of laboratory confirmed co-infection of Pandemic (H1N1) 2009 influenza and Scrub typhus and discuss the difficulties in distinguishing the two illnesses clinically.

The prevalence of multi-drug resistant tuberculosis (MDR-TB), which is resistant to isoniazid and rifampin, has been increasing in Korea. And the side effects of 2nd line anti-tuberculosis medications, including drug-induced hepatitis, are well known. Although prothionamide (PTH) is one of the most useful anti-TB medications and although TB medication-induced acute hepatitis is a severe complication, there are only a few published case reports about prothionamide induced hepatitis. In this case report, a 22 year old male was diagnosed with pulmonary MDR-TB and was administered 2nd line anti-TB mediations, including PTH. Afterwards, he had a spiking fever and his liver enzymes were more than 5 times greater than the upper limit of the normal range. He was then diagnosed with drug-induced hepatitis by liver biopsy. His symptoms and liver enzyme elevation were improved after stopping PTH. Accordingly, we report this case of an association between PTH and acute hepatitis.

A 65-year-old woman was admitted due to poor oral intake and a dry cough over the previous 3 months. The physical examination was remarkable for bibasilar crackles, and plain chest radiography showed reticulation in both lower lung fields. A pulmonary function test demonstrated a restrictive pattern with a reduced diffusing capacity of the lung for carbon monoxide. High resolution computed tomography showed reticulation and honey-combing in both peripheral lung zones, which was consistent with usual interstitial pneumonia pattern. Her skin showed livedo reticularis. The erythrocyte sedimentation rate and C-reactive protein level were elevated, and hematuria was noted on urinary analysis. A serologic test for auto-antibodies showed seropositivity for Myeloperoxidase-Anti-neutrophil cytoplasmic antibody (MPO-ANCA). A kidney biopsy was performed and showed focal segmental glomerulosclerosis. She was diagnosed as having pulmonary fibrosis with microscopic polyangiitis (MPA) and treated with high dose steroids. Here we report a case of pulmonary fibrosis coexistent with microscopic polyangiitis.

Cholethorax is a bilious pleural effusion caused by a pleurobiliary fistula or leakage of bile into the pleural space. Most cases of cholethorax arise from a complication of abdominal trauma, hepatobiliary infection, or invasive procedures or surgery of hepatobiliary system. However, we experienced a case of a patient with cholethorax of unknown origin. There was no evidence of pleurobiliary fistula or leakage of bile from the hepatobiliary system although we examined the patient with various diagnostic tools including chest and abdominal computed tomography, endoscopic retrograde cholangiopancreatography, tubography, bronchofiberscopy, hepatobiliary scintigraphy and video-assisted thoracoscopic surgery. Herein we report a case of cholethorax for which the specific cause was not identified. The patient was improved by percutaneous drainage of pleural bile.