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And so to the web summit and the thrusting new face of Ireland. On entering the RDS, we were greeted by three men of restricted height dressed as leprechauns and offering us the chance to win a pot of gold ? which turned out not be a pot of gold at all, but a free pint of Guinness at the pub across the road. The little people in green, phoney financial offers, and booze ? welcome to Ireland 2.0, or as Enda Kenny excitedly dubbed it: “The new digital capital of the planet.” Well, it would have been the digital capital of the planet if the wifi was working at the venue ? but who needs wifi at a web summit? The centrepiece of the day was a transatlantic hook-up which saw the Taoiseach press a button at the RDS which rang the bell to begin trading on New York’s Nasdaq stock exchange. Enda has form with this sort of thing after managing to ring the bell on Wall St once ? though attempts by his handlers at the time to big it up as a major honour were somewhat undermined by the fact that the Smurfs had been awarded the prestigious gig before him. But half of Silicon Valley appeared to be crowded onto the stage at the RDS to see Mr Kenny ring once again as futuristic eerie sounds pumped out from the speakers ? even if there was some confusion about who he actually was. One Californian accent was heard saying: “I’m loving this Star Wars music, it’s soooo dramatic! Who are we waiting for? The T-Shock? Oh my god, is that like an ewok?” And then there was Enda, not from a galaxy far, far away, but from back stage, in a haze of dry ice and resplendent in the type of microphone headset so beloved by the likes of Madonna. As the RDS crowd burst into spontaneous cheers and whoops ? exactly when ordered to do so by the MC ? giant screens showed the scenes being flashed onto giant screens on the side of the Nasdaq building in New York. A New Year’s Eve-style countdown then ensued until bell ringer extraordinaire Enda delivered the goods and sent New York into a spending frenzy. But, unfortunately, back home he was silencing wedding bells for same-sex couples after putting off a Cabinet decision on a referendum to extend marriage rights to same-sex couples until next week. Though, in an ironic touch, the footmark taped onto the floor by TV technicians so the Taoiseach knew where to stand for the cameras at the press conference after he opened Nasdaq was a big pink X shape, which he shuffled on awkwardly as he denied putting off the Cabinet decision on the gay marriage referendum. It was one of several slightly confusing moments at the RDS as non-techy types must have wondered if the stern “No Tethering” signs dotted about the place were left-overs from the Dublin Horse Show rather than warnings not to create your own “personal hot spot”. But Enda was in a hot spot all of his own as king of the bell ringers, or campanologists as they are officially known ? and it must be said he did look a tad camp with the headset, dry ice, and scary music. In a parting shot, Mr Kenny told the web summit delegates to enjoy the delights of Dublin during their stay ? but failed to warn them to remember to take a shower before 8pm, as that was when the water was being turned off across the city. Welcome to the new digital capital of the planet. Digital clubbing is characterized by a focal bulbous enlargement of the terminal segments of the fingers and/or toes due to proliferation of connective tissue between nail matrix and the distal phalanx. It results in increase in both anteroposterior and lateral diameter of the nails.[1] Clubbed fingers are also known as watch-glass nails, drumstick fingers, and Hippocratic fingers/nails. It was first described by Hippocrates[2] nearly 2500 years ago in a patient with empyema. Because of this, it is often described as Hippocratic finger and is regarded to be the oldest sign in clinical medicine.[3] Later on, it was found to be associated with a variety of clinical conditions including bronchiectasis, lung cancer, cirrhosis of liver, cyanotic congenital heart disease, etc. Although clubbed fingers are mostly asymptomatic, it often reflects the presence of dreadful internal illness like lung cancer, idiopathic pulmonary fibrosis, or underlying suppurative conditions. Digital clubbing may occur as isolated finding or is often part of the syndrome of hypertrophic osteoarthropathy (HOA) which is characterized by periostosis of the long bones and occasional painful joint enlargement. It was initially known as hypertrophic pulmonary osteoarthropathy (HPOA) based on the fact that majority of cases of HOA are due to malignant thoracic tumors. The term “pulmonary” was later abandoned as it was realized that the skeletal syndrome may occur in several non-pulmonary diseases and even may occur without any underlying illness. In the later condition, it is known as primary hypertrophic osteoarthropathy (PHO) or pachydermoperiostotis.[4] PHO or pachydermoperiostosis is a rare hereditary disorder inherited in an autosomal dominant pattern or recessive pattern. It is characterized by digital clubbing, subperiosteal new bone formation, mainly from the ends of long bones, acro-osteolysis, hypertrophy of soft tissues and glands, particularyly in the face and scalp resulting in wrinkling of skin on the face and scalp.[5,6] Skin involvement differentiates it from the secondary form.[7] Secondary form is the more common one and is associated with variety of clinical conditions. A majority of cases of secondary HOA (>90%) are associated with malignancies or chronic suppurative pulmonary diseases and can even predate the diagnosis of an underlying disease.[8,9] Pulmonary malignancies including primary, metastatic lung cancer, and intrathoracic lymphoma account for 80% cases of secondary HOA.[10] Adenocarcinoma lung is the most frequent histopathological type of lung cancer associated with HOA, whereas small cell carcinoma is the least frequently occurred lung cancer.[11] HOA is present in 10-20% cases of digital clubbing. In adults, malignant neoplasm of the lung is the predominant pulmonary cause of clubbing, contributing to nearly 90% of cases.[26] Among the different types of thoracic malignancy, lung cancer is responsible for 80% cases of clubbing, whereas pleural tumors and other intrathoracic and mediastinal growth contribute to 10% and 5% cases, respectively.[27] On the other hand, the prevalence of clubbing in lung cancer patient ranges from 5% to 15%.[26] Clubbing in lung cancer is a paraneoplastic manifestation and is also the most common paraneoplastic syndrome in lung cancer patients.[28] A majority of clubbing in lung cancer patient involves non-small cell variety.[26] Clubbing is relatively uncommon in small cell lung carcinoma because of its aggressive course and poor prognosis, thereby leading to early death. However, contrary to this classical view, Findik and Baughman et al.'s[29] series reported similar incidence of clubbing in both SCLC and NSCLC patients. Most studies did notice a male predominance of clubbing in lung cancer patients[26] except Sridhar et al.[30] who found a female predominance of clubbing in lung cancer patients. The megakaryocyte/platelet hypothesis appears quite reliable in explaining digital clubbing in lung cancer patients. Hirakata et al.[31] also reported increased serum transforming growth factor (TGF s1) level in primary lung cancer patients with clubbing. Therefore, large megakaryocyte or platelet clumps may release TGF s1 level locally which may increase local accumulation of extra cellular matrix protein. There are few case reports of digital clubbing occurrence in malignant mesothelioma, pleural fibroma, and metastatic osteogenic sarcoma.[32] McGavin et al.[33] noticed finger clubbing based on abnormal fluctuation of nail bed in 30% of the mesothelioma and 14% of benign asbestos pleural disease, respectively. The incidence of clubbing in malignant pleural mesothelioma is high enough to be included in the list of digital clubbing. Solitary fibrous tumor of pleura is less common than malignant mesothelioma. Moreover, they are mesenchymal in origin unlike mesothelial origin of mesothelioma. They often develop characteristic paraneoplastic syndrome of clubbing, HOA, and hypoglycemia, not typically seen with mesothelioma.[34] Inflammatory pseudo-tumor is a rare benign lung tumor of uncertain etiology, occurring more commonly in younger patients. Vandemergel et al.[35] reported the first association of inflammatory pseudo tumor with digital clubbing in an adult patient. Pulmonary metastases from extrathoracic neoplasms are rare cause of clubbing and HPOA. Most of the reported cases have been sarcomas, mainly of bone and soft tissues; among the rest are tumors of the nasopharynx and uterus and cervix and renal cell carcinoma.[36,37] Renal cell carcinoma has been usually associated clubbing in the presence of pulmonary metastases.[36,38] However, in the Vandemergel et al. series renal cell carcinoma patient with digital clubbing did not have evidence of lung metastasis.[35] Hodgkin's lymphoma is rarely associated with digital clubbing. Characteristically, clubbing is mainly seen in the presence of intrathoracic involvement and in children and adolescents. In patients of Hodgkin's lymphoma, the presence of clubbing requires searching for an underlying intrathoracic neoplasm.
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