High-dose Sulbactam Treatment for Ventilator-Associated Pneumonia Caused by Carbapenem-Resistant Acinetobacter Baumannii / 대한구급학회지

BACKGROUND: Several antibiotics can be used to treat ventilator-associated pneumonia caused by carbapenem-resistant A. baumannii (CRAB-VAP) including high-dose sulbactam. However, the effectiveness of high-dose sulbactam therapy is not well known. We report our experience with high-dose sulbactam for treatment of CRAB-VAP. METHODS: Medical records of patients with CRAB-VAP who were given high-dose sulbactam between May 2013 and June 2015 were reviewed. RESULTS: Fifty-eight patients with CRAB-VAP were treated with high-dose sulbactam. The mean age was 72.0 ± 15.2 years, and the acute physiology and chronic health evaluation II (APACHE II) score was 15.1 ± 5.10 at the time of CRAB-VAP diagnosis. Early clinical improvement was observed in 65.5% of patients, and 30-day mortality was 29.3%. Early clinical failure (odds ratio [OR]: 8.720, confidence interval [CI]: 1.346-56.484; p = 0.023) and APACHE II score ≥ 14 at CRAB-VAP diagnosis (OR: 10.934, CI: 1.047-114.148; p = 0.046) were associated with 30-day mortality. CONCLUSIONS: High-dose sulbactam therapy may be effective for the treatment of CRAB-VAP. However, early clinical failure was observed in 35% of patients and was associated with poor outcome.

High-dose Sulbactam Treatment for Ventilator-Associated Pneumonia Caused by Carbapenem-Resistant Acinetobacter Baumannii / 대한중환자의학회지

BACKGROUND: Several antibiotics can be used to treat ventilator-associated pneumonia caused by carbapenem-resistant A. baumannii (CRAB-VAP) including high-dose sulbactam. However, the effectiveness of high-dose sulbactam therapy is not well known. We report our experience with high-dose sulbactam for treatment of CRAB-VAP. METHODS: Medical records of patients with CRAB-VAP who were given high-dose sulbactam between May 2013 and June 2015 were reviewed. RESULTS: Fifty-eight patients with CRAB-VAP were treated with high-dose sulbactam. The mean age was 72.0 ± 15.2 years, and the acute physiology and chronic health evaluation II (APACHE II) score was 15.1 ± 5.10 at the time of CRAB-VAP diagnosis. Early clinical improvement was observed in 65.5% of patients, and 30-day mortality was 29.3%. Early clinical failure (odds ratio [OR]: 8.720, confidence interval [CI]: 1.346-56.484; p = 0.023) and APACHE II score ≥ 14 at CRAB-VAP diagnosis (OR: 10.934, CI: 1.047-114.148; p = 0.046) were associated with 30-day mortality. CONCLUSIONS: High-dose sulbactam therapy may be effective for the treatment of CRAB-VAP. However, early clinical failure was observed in 35% of patients and was associated with poor outcome.

A 45-Year-Old Man With Recurrent Dyspnea and Hemoptysis during Exercise: Exercise-Induced Pulmonary Hemorrhage/Edema / 결핵및호흡기질환

A 45-year-old man presented with dyspnea and hemoptysis during exercise. A chest computed tomography (CT) revealed multifocal diffuse patchy ground glass opacity and interlobular septal thickening in both the lungs. Permeability pulmonary edema or pulmonary hemorrhage was suspected. Serologic studies for autoimmune disorders and vasculitis were negative. There was no laboratory evidence of coagulopathy, other hematopoietic disease or infectious disease. Considering correlation with exercise, we diagnosed exercise-induced pulmonary hemorrhage (EIPH) or exercise-induced pulmonary edema (EIPE). The patient was managed with antifibrinolytics, antibiotics, and antitussive agent. After a week, follow-up chest CT revealed completely resolved pulmonary hemorrhage. About 2 months after the first event, he visited again with dyspnea and hemoptysis during running. In the present study, we report a case of recurrent pulmonary hemorrhage after exercise.

Diagnostic Tools of Pleural Effusion / 결핵및호흡기질환

Pleural effusion is not a rare disease in Korea. The diagnosis of pleural effusion is very difficult, even though the patients often complain of typical symptoms indicating of pleural diseases. Pleural effusion is characterized by the pleural cavity filled with transudative or exudative pleural fluids, and it is developed by various etiologies. The presence of pleural effusion can be confirmed by radiological studies including simple chest radiography, ultrasonography, or computed tomography. Identifying the causes of pleural effusions by pleural fluid analysis is essential for proper treatments. This review article provides information on the diagnostic approaches of pleural effusions and further suggested ways to confirm their various etiologies, by using the most recent journals for references.

Successful Removal of Endobronchial Lipoma by Flexible Bronchoscopy Using Electrosurgical Snare / 결핵및호흡기질환

A 62-year-old man with a chronic cough presented with atelectasis of the left upper lobe on chest X-ray. Chest computed tomography showed an atelectasis in the left upper lobe with bronchial wall thickening, stenosis, dilatation, and mucoid impaction. We performed bronchoscopy and found a well-circumscribed mass on the left upper lobe bronchus. The mass was removed by flexible bronchoscopy using an electrosurgical snare and diagnosed with lipoma. An endobronchial lipoma is a rare benign tumor that can be treated by a surgical or endoscopic approach. We report the successful removal of endobronchial lipoma via flexible bronchoscopic electrosurgical snare.

Tracheal Stenosis after Tracheostomy Treated Successfully with Papillotome Electrocautery / 결핵및호흡기질환

A 39-year-old woman presented with symptoms of dyspnea. Ten years previously, she had received a tracheostomy because of the decision to not continue taking an anticonvulsant drug. Presently, chest computed tomography showed diffuse stenosis and focal web at the cervical trachea. We performed bronchoscopy and found a two-thirds reduction of the upper trachea due to the web-like fibrotic stenosis. Papillotome electrocautery removed the stenotic lesion. Endobronchial electrocautery is a valuable tool with potential for therapy of an endobronchial obstructing airway lesion. We report this case to introduce the successful treatment with papillotome electrocautery.

Role of Microbiologic Culture Results of Specimens Prior to Onset of Ventilator-Associated Pneumonia in the Patients Admitted to Intensive Care Unit / 결핵및호흡기질환

BACKGROUND: Patients with ventilator-associated pneumonia (VAP) in intensive care unit (ICU) have a high mortality rate. The routine surveillance cultures obtained previously or an ATS guideline for hospital-acquired pneumonia was used in selecting initial antimicrobials. The object of this study was to compare the respiratory samples before VAP and bronchoalveolar lavage (BAL) culture. METHODS: 54 patients underwent fiberoptic bronchoscopy to obtain BAL samples. We reviewed microbiologic specimen results of prior respiratory specimens (pre-VAP) and BAL. RESULTS: Among 51 patients with 54 VAP episodes, 52 microorganisms of pre-VAP and 56 BAL samples were isolated. Pre-VAP included 21.2% of MRSA, and 32.6% of multidrug resistant-Acinetobacter baumannii (MDR-AB). BAL samples comprised 25.0% of MRSA, 26.7% of MDR-AB, 14.3% of Stenotrophomonas maltophilia and 3.6% of Klebsiella pneumonia in order. In pre-VAP samples compared to BAL samples, only 35.2% were identical. In BAL samples compared to pre-VAP samples obtained in 5 days before the onset of VAP, only 43.6% were identical. However, among BAL samples compared to pre-VAP samples obtained after more than 5 days, 13.3% were identical (p=0.037). CONCLUSION: Based on these data, pre-VAP samples obtained prior to 5 day onset of VAP may help to predict the causative microorganisms and to select appropriate initial antimicrobials.

The Effect of Tissue Plasminogen Activator on TGF-beta1 Pre-Treated Human Mesothelial Cell Line / 결핵및호흡기질환

BACKGROUND: In an effort to find alternative therapeutic agents to prevent excessive fibrosis as a sequela to complicated parapneumonic effusion or empyema, we examined the effect of tissue plasminogen activator (tPA) as a fibrinolytic agent combined with talc or transforming growth factor (TGF)-beta1 in a human pleural mesothelial cell line, MeT-5A. METHODS: MeT-5A cells were stimulated with various doses of talc, doxycycline or TGF-beta1 for 24 h and then were treated with tPA for an additional 24 h. Cell viability was measured by MTT assay. The production of interleukin (IL)-8 and vascular endothelial growth factor (VEGF) in the culture supernatants was measured by ELISA. Real-time PCR was carried out for measurement of type I collagen mRNA. RESULTS: MeT-5A cells treated with talc showed a dose-dependent increase in production of IL-8. Talc also increased production of type I collagen mRNA at low doses, but talc did not influence the induction of VEGF. Addition of tPA to talc-stimulated cells showed further increases in the production of IL-8, but tPA did not influence the production of VEGF or type I collagen mRNA. TGF-beta1 increased the production of both VEGF and collagen type I mRNA, both of which were effectively inhibited by additional tPA treatment in MeT-5A cells. CONCLUSION: TGF-beta1 is a potent inducer of collagen synthesis without induction of IL-8 in MeT-5A cells. Addition of tPA after TGF-beta1 stimulation inhibited further fibrosis by direct inhibition of collagen mRNA synthesis as well as by inhibition of VEGF production.

MicroRNA-23a: A Novel Serum Based Diagnostic Biomarker for Lung Adenocarcinoma / 결핵및호흡기질환

BACKGROUND: MicroRNAs (miRNAs) have demonstrated their potential as biomarkers for lung cancer diagnosis. In recent years, miRNAs have been found in body fluids such as serum, plasma, urine and saliva. Circulating miRNAs are highly stable and resistant to RNase activity along with, extreme pH and temperatures in serum and plasma. In this study, we investigated serum miRNA profiles that can be used as a diagnostic biomarker of non-small cell lung cancer (NSCLC). METHODS: We compared the expression profile of miRNAs in the plasma of patients diagnosed with lung cancer using an miRNA microarray. The data from this assay were validated by quantitative real-time PCR (qRT-PCR). RESULTS: Six miRNAs were overexpressed and three miRNAs were underexpressed in both tissue and serum from squamous cell carcinoma (SCC) patients. Sixteen miRNAs were overexpressed and twenty two miRNAs were underexpressed in both tissue and serum from adenocarcinoma (AC) patients. Of the four miRNAs chosen for qRT-PCR analysis, the expression of miR-23a was consistent with microarray results from AC patients. Receiver operating characteristic (ROC) curve analyses were done and revealed that the level of serum miR-23a was a potential marker for discriminating AC patients from chronic obstructive pulmonary disease (COPD) patients. CONCLUSION: Although a small number of patients were examined, the results from our study suggest that serum miR-23a can be used in the diagnosis of AC.

Comparison of spirometry with cardiopulmonary exercise test of chronic obstructive pulmonary disease / 대한내과학회지

BACKGROUND/AIMS: Chronic obstructive pulmonary disease (COPD) is characterized by an incompletely reversible airflow limitation. Pulmonary function test (PFT) has been considered the gold standard test for diagnosis and severity evaluation in COPD. However, PFT by spirometry does not provide information about exercise performance in COPD patients. Therefore, the present study was performed to compare pulmonary function determined by spirometry with exercise function determined by cardiopulmonary exercise test (CPET) for grading of COPD. METHODS: A total of 105 patients with airway obstruction were examined. The patients' mean age was 65 years, and the mean smoking history was 27 pack-years. The patients underwent spirometry and CPET. The results were analyzed by categorical statistical comparison, based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) and American Thoracic Society guidelines. RESULTS: The two methods agreed on the classification of only 44 patients (42%). Of the remaining patients, 21 (20%) were found to be less severe according to CPET than according to PFT, whereas 40 (38%) were more severe. Those who were more severe according to CPET had significantly low maximal minute ventilation, low anaerobic threshold, low oxygen pulse, and high breathing reserve. CONCLUSIONS: The present study revealed the large disagreement between the results of resting and exercise pulmonary function tests, and therefore suggests the need for a novel approach or guideline. Additional cardiological evaluation may be needed in patients classified as more severe according to CPET, who are assumed to have a greater degree of impairment of cardiovascular function.

A Case of Miliary Tuberculosis Misdiagnosed as Pneumonia and ARDS Due to the Transient Improvement after Intravenous Injection of Levofloxacin / 결핵및호흡기질환

Miliary tuberculosis is quite a rare but serious cause of acute respiratory distress syndrome (ARDS). Therefore, the early detection of military tuberculosis as the underlying cause of ARDS is very important for the prognosis and survival of the patient. We report a case of military tuberculosis mimicking ARDS. A female patient was admitted due to repeated fever and dyspnea. The initial chest CT scan showed diffuse ground glass opacity, without a miliary pattern. The case was considered to be ARDS caused by pneumonia. She showed improvement after being treated with levofloxacin. However, she was re-admitted with fever seven days after discharge. The follow up chest CT scan showed micronodules in both lungs. An open lung biopsy confirmed the diagnosis of military tuberculosis.

MicroRNA Expression Profiles in Korean Non-Small Cell Lung Cancer / 결핵및호흡기질환

BACKGROUND: MicroRNAs (miRNAs) play an important role in the regulation of cell proliferation, apoptosis, development and differentiation. Several studies have shown that aberrant expression of miRNAs is involved in cancer development and progression by regulating the expression of proto-oncogenes or tumor suppressor genes. In this study, we investigated miRNA expression profiles in Korean patients with non-small cell lung cancer (NSCLC). METHODS: We performed miRNA microarray analysis containing 60~65 bp oligonucleotide probes representing human 318 miRNAs and validated the results of the microarray with Northern blot analysis or quantitative RT-PCR. Next, we examined the correlation between miRNA expression and the target gene transcriptional profile using a human whole-genome-expression microarray. RESULTS: We showed that 35 miRNAs were expressed differentially in the NSCLCs and corresponding non-malignant lung tissues. We showed that 35 miRNAs were expressed differentially in the NSCLCs and corresponding non-malignant lung tissues. Thirteen of the 35 differentially expressed miRNAs were newly identified in the present study. Of the 35 miRNAs, 2 (miR-371 and miR-210) were over-expressed in lung cancers, and 33 miRNAs, including miR-145, were under-expressed in lung cancers. miR-99b expression consistently showed a negative correlation with FGFR3 expression. CONCLUSION: Albeit a small number of patients were examined, these results suggest that miRNA expression profiles in Korean lung cancers may be somewhat different from the expression profiles reported on lung cancers in Western populations. The findings suggest that miR-99b might be a tumor suppressor through its up-regulation of FGFR3.

MicroRNA Expression Profiles in Korean Non-Small Cell Lung Cancer / 결핵및호흡기질환

BACKGROUND: MicroRNAs (miRNAs) play an important role in the regulation of cell proliferation, apoptosis, development and differentiation. Several studies have shown that aberrant expression of miRNAs is involved in cancer development and progression by regulating the expression of proto-oncogenes or tumor suppressor genes. In this study, we investigated miRNA expression profiles in Korean patients with non-small cell lung cancer (NSCLC). METHODS: We performed miRNA microarray analysis containing 60~65 bp oligonucleotide probes representing human 318 miRNAs and validated the results of the microarray with Northern blot analysis or quantitative RT-PCR. Next, we examined the correlation between miRNA expression and the target gene transcriptional profile using a human whole-genome-expression microarray. RESULTS: We showed that 35 miRNAs were expressed differentially in the NSCLCs and corresponding non-malignant lung tissues. We showed that 35 miRNAs were expressed differentially in the NSCLCs and corresponding non-malignant lung tissues. Thirteen of the 35 differentially expressed miRNAs were newly identified in the present study. Of the 35 miRNAs, 2 (miR-371 and miR-210) were over-expressed in lung cancers, and 33 miRNAs, including miR-145, were under-expressed in lung cancers. miR-99b expression consistently showed a negative correlation with FGFR3 expression. CONCLUSION: Albeit a small number of patients were examined, these results suggest that miRNA expression profiles in Korean lung cancers may be somewhat different from the expression profiles reported on lung cancers in Western populations. The findings suggest that miR-99b might be a tumor suppressor through its up-regulation of FGFR3.

Successful Embolization in the Patient with Hemoptysis Due to Right Inferior Phrenic Artery-pulmonary Artery Anastomosis and Pseudoaneurysm / 결핵및호흡기질환

The primary cause of hemoptysis is the bronchial artery. However, it should be noted that pulmonary artery and other vessels can cause hemoptysis. If the source of the bleeding is not determined after embolization, other evaluations are needed. Systemic-pulmonary anastomosis and pulmonary artery pseudo-aneurysm are rare vascular abnormalities with varying etiologies. An accurate and rapid diagnosis is needed in hemoptysis, since the cause may be life-threatening. We report a case of a 77-years-old man with persistent hemoptysis due to the right inferior phrenic artery - pulmonary artery anastomosis and pseudoaneurysm. After the embolization of the inferior phrenic artery, the hemoptysis was successfully treated.

Molecular Epidemiology and Antimicrobial Resistance of Methicillin-resistant Staphylococcus aureus Isolated from Nasal Swab at Intensive Care Unit / 결핵및호흡기질환

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is the most common organism associated with nosocomial infections. MRSA infections are becoming increasing important because they have emerged no only as healthcare-associated (HA) infections but also as community-associated (CA) ones. This study examined the moleculo-epidemiology of MRSA, which was isolated from nasal swabs in the intensive care unit (ICU) at Konyang University Hospital. MRSA are classified into HA-MRSA and CA-MRSA. METHODS: From June to September 2006, 353 patients who were admitted to the ICU in Konyang University Hospital were enrolled in this study. Single nasal swabs were obtained for culture in the ICU on the 1st day. Pulsed-field gel electrophoresis and the antimicrobial resistant patterns were analyzed between HA- and CA-MRSA. An antimicrobial sensitivity test was also performed. RESULTS: Forty two strains of MRSA were isolated from 353 patients (11.9%). Among the 42 isolates, HA-MRSA and CA-MRSA were found in 33 (78.6%), and 9 (21.4%), respectively. Eleven different PFGE types (type A to K) were identified. Types A (n=9) and B (n=7) were the most common for HA-MRSA, and types A (n=2) and B (n=2) were identified in CA-MRSA. The proportion of types A and B in CA-MRSA (44.4%) was similar to that in HA-MRSA (48.5%). The rates of resistance rates to erythromycin and ciprofloxacin were higher in HA-MRSA than in CA-MRSA. CONCLUSION: The rate of isolation of MRSA in an ICU setting was 11.9%. HA-MRSA was isolated more frequently than CA-MRSA. The rate of resistance of HA-MRSA to erythromycin and ciprofloxacin was higher than that of CA-MRSA. Despite the small number of subjects, the main isolates (type A and B) of CA-MRSA were similar to those of HA-MRSA.

Synchronous Roentgenographically Occult Lung Carcinoma Treated with Argon Plasma Coagulation in a Patient with Resectable Primary Lung Cancer / 결핵및호흡기질환

We treated synchronous double primary lung cancers, where one site resulted from CIS disease, with lobectomy and argon plasma coagulation (APC) in a patient who couldn't tolerate pneumonectomy, which resulted in a reduction of the extent of surgery. APC could be a reasonable alternative for CIS disease of lung in inoperable patients.

A Case of Double Primary Lung Cancer that was Diagnosed by Percutaneous Localization with using a Hook Wire

With the progress of computed tomography (CT), the detection of small pulmonary nodules has been increased. The conventional diagnostic modalities for tissue confirmation, such as bronchoscopic biopsy or transthoracic needle biopsy, may not be successful in some cases. Too small a nodule or the nodules located far from the pleural surface can be marked and localized with device preoperatively and then this tissue can be obtained surgically. CT-guided hook wire fixation is useful in marking pulmonary nodules and there are few complications with this procedure. We report here on a case of double primary lung cancer that was diagnosed by percutaneous localization with using a hook wire

A Case of Pneumatosis Intestinalis Induced by Chemotherapy in a Patient with Lung Cancer

Pneumatosis intestinalis is an uncommon condition that is characterized by the presence of gas within the bowel wall. We experienced a case of pneumatosis intestinalis after cession of chemotherapy and we herein report on this case. A 58-year old man was admitted to our hospital for the evaluation of incidentally recognized pneumatosis intestinalis. He was diagnosed as having non small cell lung cancer in August 2006 and he received radiation therapy for concomitant brain metastasis and SVC syndrome in September 2006. He achieved a partial response after completing 6 cycles of chemotherapy with gemcitabine and cisplatin. Newly enlarged lymph nodes were observed on the follow-up CT, and chemotherapy with paclitaxel and carboplatin was started in July 2007. Due to the lack of a response, the therapeutic regimen was switched to oral erlotinib. After 1 month of treatment, the follow-up CT for response evaluation revealed pneumatosis intestinalis in the ascending colon without any subjective symptoms such as fever or abdominal pain. The laboratory results were within the normal range except for a slight increase of leukocytes. He underwent right hemicolectomy, but he didn't survive his postoperative acute renal failure and pneumonia

Identification of DNA Methylation Markers for NSCLC Using Hpall-Mspl Methylation Microarray / 결핵및호흡기질환

BACKGROUND: Epigenetic alterations in certain genes are now known as at least important as genetic mutation in pathogenesis of cancer. Especially abnormal hypermethylation in or near promoter region of tumor suppressor genes (TSGs) are known to result in gene silencing and loss of gene function eventually. The authors tried to search for new lung cancer-specific TSGs which have CpG islands and HpaII sites, and are thought to be involved in carcinogenesis by epigenetic mechanism. METHODS: Tumor tissue and corresponding adjacent normal tissue were obtained from 10 patients who diagnosed with non small cell lung cancer (NSCLC) and underwent surgery in Konyang university hospital in 2005. Methylation profiles of promoter region of 21 genes in tumor tissue & non-tumor tissue were examined with HpaII-MspI methylation microarray (Methyl-Scan DNA chip(R), Genomic tree, Inc, South Korea). The rates of hypermethylation were compared in tumor and non-tumor group, and as a normal control, we obtained lung tissue from two young patients with pneumothorax during bullectomies, methylation profiles were examined in the same way. RESULTS: Among the 21 genes, 10 genes were commonly methylated in tumor, non-tumor, and control group. The 6 genes of APC, AR, RAR-b, HTR1B, EPHA3, and CFTR, among the rest of 11 genes were not methylated in control, and more frequently hypermethylated in tumor tissue than non-tumor tissue. CONCLUSION: In the present study, HTR1B, EPHA3, and CFTR are suggested as possible novel TSGs of NSCLC by epigenetic mechanism.

Efficacy and Safety of Weekly Low Dose Paclitaxel and Cisplatin as First Line Therapy in Advanced NSCLC of Elderly Patients

PURPOSE : Anti-cancer chemotherapeutic agents act by inhibiting tumor cell proliferation through cytotoxic action, therefore the generally tolerated maximum dose is administered to patients. However, this often results in the production of undesirable toxicities, such as bone marrow suppression, and a long interruption of treatment is necessary for recovery to occur before additional cycles of treatment are administered. Paclitaxel and cisplatin are well known effective chemotherapeutic agents used for the treatment of Non-Small Cell Lung Cancer (NCSLC), however, they have substantial toxicities. To evaluate efficacy and safety of a therapy consisting of a weekly low dose of paclitaxel and therapy in elderly patients with advanced NSCLC. MATERIALS AND METHODS : Thirteen treatment-naive, elderly patients over 65 years old who were diagnosed with stage IV NSCLC at Konyang University from April 2005 to October 2006 were enrolled in the present study. Paclitaxel at a dose of 55 mg/m2 in combination with cisplatin at a dose of 20 mg/m2 was administered intravenously on day 1, 8, and 15 with 1 week of interruption for a total of six cycles of chemotherapy. RESULTS : The mean age of the ten patients included in this study was 69.5 years. Following treatment, 50 % of the patients exhibited a partial response to treatment, whereas the disease remained stable in 40% of the patients, and progressed in 10% of the patients. The median survival time (Kaplan-Meier method) was 15 months (4~24 months), and the 6-month, 1-year, and 2-year survival rates were 80%, 50%, and 10%, respectively. The median progression survival time was 8 months (2~14 months) and the 6- and 12-month progression free survival rates were 60% and 10%, respectively. Grade 3 neutropenia occurred in only 1 case (10%). CONCLUSION : The results of this study indicated that chemotherapy consisting of a weekly low dose of paclitaxel and cisplatin could be more effective and have lesser toxicity when administered to elderly patients with advanced NSCLC. In addition, this treatment regimen showed a promising response rate