Pneumonia is frequently encountered in the clinical fields, both as a cause for admission and as a complication of the underlying disorder or as the course of treatment. Pneumonia is the second most common hospital-acquired infection and is associated with the highest morbidity and mortality rates among hospital-acquired infections. The guidelines for the management of hospital-acquired pneumonia by the American Thoracic Society include identifying individuals who have recently received antibiotics therapy or have been in medical facilities; these individuals are at higher risk for infection with multiple drug resistant organisms. Individuals, who have acquired pneumonia according to this clinical scenario, have what is known as healthcare-associated pneumonia (HCAP). Patients with HCAP should be considered to have potentially drug-resistant pathogens and should receive broad spectrum empiric antibiotic therapy directed at the potentially resistant organisms. In this paper, the diagnosis, risk factors, and treatment of HCAP are discussed.

Background: Macrophages are one of the most important inflammatory cells in innate immunity. PU.1 is a macrophage-specific transcription factor. Ubiquitins are the ultimate regulator of eukaryotic transcription. The ubiquitination process for PU.1 is unknown. This study investigated the lipopolysaccharide (LPS)-induced activation of PU.1 and its relation to ubiquitins in the macrophages. Methods: Raw264.7 cells, the primary cultured alveolar, pulmonary, and bone marrow derived macrophages were used. The Raw264.7 cells were treated with MG-132, $NH_4Cl$, lactacytin and LPS. Nitric oxide and prostaglandin D2 and E2 were measured. Immunoprecipitation and Western blots were used to check ubiquitination of PU.1. Results: The PU.1 ubiquitination increased after LPS ($1{\mu}g$/mL) treatment for 4 hours on Raw264.7 cells. The ubiquitination of PU.1 by LPS was increased by MG-132 or $NH_4Cl$ pretreatment. Two hours of LPS treatment on macrophages, PU.1 activation was not induced nor increased with the inhibition of proteasomes and/or lysosomes. The ubiquitination of PU.1 was increased in LPS-treated Raw264.7 cells at 12- and at 24 hours. LPS-treated cells increased nitric oxide production, which was diminished by MG-132 or $NH_4Cl$. LPS increased the production of $PGE_2$ in the alveolar and peritoneal macrophages of wild type mice; however, $PGE_2$ was blocked or diminished in Rac2 null mice. Pretreatment of lactacystin increased $PGE_2$, however it decreased the $PGD_2$ level in the macrophages derived from the bone marrow of B57/BL6 mice. Conclusion: LPS treatment in the macrophages ubiquitinates PU.1. Ubiquitination of PU.1 may be involved in synthesis of nitric oxide and prostaglandins.

Background: The clinical manifestation of $M.$ $tuberculosis$ infection ranges from asymptomatic latent infection, to focal forms with minimal symptoms and low bacterial burdens, and finally to advanced tuberculosis (TB) with severe symptoms and high bacillary loads. We investigated the diagnostic sensitivity of the whole-blood interferon-${\gamma}$ release assay according to the wide spectrum of clinical phenotypes. Methods: In patients diagnosed with active TB that underwent $QuantiFERON^{(R)}$ (QFT) testing, the QFT results were compared with patients known to be infected with pulmonary tuberculosis (P-TB) and extra-pulmonary TB (EP-TB). In addition, the results of the QFT test were further analyzed according to the radiographic extent of disease in patients with P-TB and the location of disease in patients with EP-TB. Results: There were no statistical differences in the overall distribution of QFT results between 177 patients with P-TB and 84 patients with EP-TB; the positive results of QFT test in patients with P-TB and EP-TB were 70.1% and 64.3%, respectively. Among patients with P-TB, patients with mild extents of disease showed higher frequency of positive results of QFT test than that of patients with severe form (75.2% vs. 57.1%, respectively; p=0.043) mainly due to an increase of indeterminate results in severe P-TB. Patients with TB pleurisy showed lower sensitivity by the QFT test than those with tuberculous lymphadenitis (48.8% vs. 78.8%, respectively; p=0.019). Conclusion: Although QFT test showed similar results between overall patients with P-TB and EP-TB, individual sensitivity was different according to the radiographic extent of disease in P-TB and the location of disease in EP-TB.

Background: Maspin (mammary serine protease inhibitor) is a member of the serpin superfamily. A few studies have examined the role of maspin in tumor suppression of non-small cell lung cancer (NSCLC); however, its role in the development and progression of NSCLC still remains controversial. We evaluated the immunohistochemical expression of maspin in order to elucidate its clinical significance in NSCLC. Methods: We analyzed 145 patients with pathologically confirmed NSCLC, including 66 cases of squamous cell carcinomas (SCCs) and 79 cases of adenocarcinomas (ADCs). We performed a immuno-histochemical stain with maspin and PCNA (proliferating cell nuclear antigen) using tissue microarray blocks. Results: There were 108 men and 37 women in the study population. The mean age of patients in the study was 63.7 years (range, 40.0~82.0; median, 65.0). The proportion of maspin expression was significantly higher in SCCs (52/66, 78.8%; p<0.01) than in ADCs (17/79, 21.5%; p<0.01). Maspin expression was not associated with PCNA (p=0.828), lymph node involvement (p=0.483), or tumor stage (p=0.216), but showed correlation with well-to-moderate tumor differentiation (p=0.012). There was no observed correlation between maspin expression and survival with NSCLC (p=0.218). Conclusion: The present study suggests that maspin expression was significantly higher in SCCs than in ADCs and was associated with low histological grade. However, maspin expression was not an independent factor to predict a prognosis in NSCLC.

Background: Lung cancer is responsible for substantial proportions of cutaneous metastasis from internal malignancies. The aim of this study was to evaluate the clinical manifestations and outcomes of cutaneous metastasis in Korean lung cancer patients. Methods: On a retrospective basis, we analyzed medical records of all patients diagnosed with lung cancer from 2000 to 2006. Results: Cutaneous metastases were found in 10 of 4,385 patients. The number of cases was highest for squamous cell carcinoma. However, there was no metastasis from 754 cases of small cell carcinomas. Cutaneous metastasis was detected during staging work-up in 4 patients and it was the presenting sign of recurrence post-operative in 2 patients. Average time from the diagnosis to discovery of cutaneous metastasis was 16.3 months and median survival was 8.5 months (range, 1.8~19.1 months). Conclusion: Physicians should be acquainted with clinical manifestations and outcomes of cutaneous metastasis from lung cancer to detect new, recurrent cancer, or disease progression, and to administer appropriate and prompt management.

Background: Stopping medical treatment by tuberculosis (TB) patients prior to completing treatment period is a major concern in private hospitals. We evaluated the impact of public-private mix (PPM) project on increasing treatment success rate of TB in a private tertiary hospital in Korea. Methods: Starting in February 2009, TB patients treated at Dankook University Hospital received health education and case monitoring activities by specially trained public health nurses (PPM project). On a retrospective basis, we reviewed medical records and compared the treatment outcome of TB patients treated under the PPM project (PPM group) to patients treated without the PPM project (control group) between January 2008 and June 2010. In addition, we also evaluated the risk factors treatment non-completion. Results: The number of patients in the PPM group and control group were 123 (85 pulmonary TB and 38 extrapulmonary TB) and 146 (101 pulmonary TB and 45 extra-pulmonary TB), respectively. The PPM group had demographic and clinical findings comparable to those of control group. The PPM group showed a significantly higher treatment success rate (93.5%) compared to the control group (77.9%). However, development of complications, proximity to the hospital, and presence of co-morbid disease did not influence the treatment success rate. Conclusion: The PPM project was effective at increasing the TB treatment success rate. An effort to improve and to expand the PPM project is needed in private Korean hospitals.

We report a case of Caplan's Syndrome, which presented as multiple pulmonary nodules. A 58-year-old male was admitted to hospital due to multiple pulmonary nodules. In addition, the patient presented with multiple arthritis, and dyspnea on exertion. Rheumatoid arthritis had been diagnosed 35 years ago. The patient had worked as a stonemason for 20 years. Computed Tomography (CT) revealed numerous well-defined tiny nodules scattered in both lungs, which was suspicious of miliary tuberculosis or malignancy. The patient was started on antituberculous medications and referred to our hospital. First, a transbronchial lung biopsy was performed, which showed no evidence of granuloma. It was our opinion that the biopsy was insufficient, and a follow-up video-associated thoracoscopy was performed. The pathological report determined necrotizing granulomatous inflammation and silicosis on background. According to imaging studies, pathologic reports, and clinical symptoms, we concluded that the patient had Caplan's syndrome. We controlled his rheumatic medications, and instructed him to avoid exposure to hazardous dust.

Recently, a novel influenza A (H1N1) has been recognized as the cause of a worldwide respiratory infection outbreak. Although the symptoms of a novel influenza A (H1N1) are usually mild, the disease can cause severe illness and death. A complication of novel influenza A (H1N1) is pneumomediastinum, a rarely reported condition. We report a case of influenza A (H1N1) complicating pneumomediastinum with subcutaneous emphysema, which had initially presented with blood tinged sputum and chest pain. In addition, we demonstrate bronchoalveolar lavage in influenza A (H1N1).

Paraneoplastic neurologic syndrome is a group of assorted disorders resulting from damage to the nervous system in cancer, remote from primary site, and not related to metastasis, infection, or metabolic disorder associated with cancer. Patient with small cell lung cancer sometimes shows various neurological syndromes, but patient with non-small cell lung cancer rarely shows neurologic syndromes and few antineuronal antibodies have been found. Here, we report a case of 53-year-old male patient who developed ptosis and extraocular muscular limitation of left eye due to third and forth cranial nerve palsy in non-small cell lung cancer without brain metastasis. These neurologic symptoms improved after lobectomy without any other treatment immunotherapy.

Pheochromocytomas are neuroendocrine tumors of chromaffin cell that originate in the paraganglia of the adrenal medulla. Approximately 10% of pheochromocytomas are found in the extra-adrenal paraganglia and are called paragangliomas. However, cases of middle mediastinal paragangliomas are very rare. In this case, the patient presented with a voice change and a headache. A middle mediastinal soft tissue mass with marked enhancement was detected on computed tomography of the chest. The 24-hour urine catecholamine level was markedly elevated. The middle mediastinal mass was biopsied via mediastinoscopy and the resulting immunohistochemical staining was compatible with a diagnosis of middle mediastinal paraganglioma. The mass was resected surgically and the symptoms were relieved.