Digital clubbing is an ancient and important clinical signs in medicine. Although clubbed fingers are mostly asymptomatic, it often predicts the presence of some dreaded underlying diseases. Its exact pathogenesis is not known, but platelet-derived growth factor and vascular endothelial growth factor are recently incriminated in its causation. The association of digital clubbing with various disease processes and its clinical implications are discussed in this review.

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Synovial sarcoma is highly malignant tumor of soft tissues, occurring chiefly in the extremities and limb girdle with a propensity for local recurrence and sometimes metastases to the lungs. Primary synovial sarcoma arising in the lungs is rare and brain metastasis as presentation is further uncommon. We report a case of primary monophasic synovial sarcoma lung presenting with brain metastasis in a 35-year-old male patient. The diagnosis was made on percutaneous transthoracic needle aspiration from left-sided pulmonary mass and later confirmed by immunohistochemistry. The utility of preoperative diagnosis by percutaneous aspiration cytology is also stressed.

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Leptospirosis has a spectrum of presentation which ranges from mild disease to a severe form comprising of jaundice and renal failure. Involvement of the lung can vary from subtle clinical features to deadly pulmonary hemorrhage and acute respiratory distress syndrome. Of late, it has been identified that leptospirosis can present atypically with predominant pulmonary manifestations. This can delay diagnosis making and hence optimum treatment. The purpose of this review is to bring together all the reported pulmonary manifestations of leptospirosis and the recent trends in the management.

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Kartagener's syndrome is a rare, autosomal recessive genetic ciliary disorder comprising the triad of situs inversus, chronic sinusitis, and bronchiectasis. The basic problem lies in the defective movement of cilia, leading to recurrent chest infections, ear/nose/throat symptoms, and infertility. We hereby report three unusual cases of this rare entity - an infertile male with azoospermia in whom Bochdalek's diaphragmatic hernia coexisted, another case of an infertile female, and a third of an infertile male with oligospermia. The need for a high index of suspicion to make an early diagnosis cannot be overemphasized in such patients so that wherever possible, options for timely treatment of infertility may be offered and unnecessary evaluation of symptoms is avoided.

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Introduction: Tuberculosis is a public health problem in India. The patients of Tuberculosis hide their disease from family, relatives, and community due to the presence of stigma. This study was conducted to assess the knowledge, awareness, and perception regarding social variables of tuberculosis among patients and to associate the awareness with their literacy status. Materials and Methods: Type of study was observational, descriptive, and epidemiological. Study design was cross-sectional. Study setting was general out-patient department of tertiary care hospitals of West Bengal. Sample size was 464 (Four hundred sixty four) patients. The collected data were tabulated, analyzed, and interpreted by proper statistical methods (by percentage and Z test). Results: 60.34% of study population was male. More than one third was illiterate (37.93%). Majority (91.38%) had heard about tuberculosis (TB). Correct answer on cause (infection) was responded by 16.81% patients. About 72.41% had heard about TB from an informal contact. The correct response on mode of spread of TB was told by 31.47% patients. About 62.07% correctly answered that cough was the commonest symptom. 82.76% knew about curability of the disease. Isolation of patient (08.62%) and avoidance of sharing of food (06.03%) were reported as preventive measures. The literacy status had a significant influence on awareness about TB. Conclusion: An attempt could be made in future to improve awareness among illiterates to remove myths and misconceptions, to allay the social stigma attached with it, to decrease TB transmission.

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Background: Pulmonary tuberculosis (TB) is caused by Mycobacterium tuberculosis (M. tb). In lungs, alveolar macrophages and type II alveolar epithelial cells serve as a replicative niche for this pathogen. Secretory proteins released by actively replicating tubercle bacilli are known to interact with host cells at the initial stages of infection. To understand the role of these cells in TB pathogenesis, it is important to identify the mycobacterial components involved in interaction with alveolar epithelial cells. Materials and Methods: We fractionated the whole secretory proteome of M. tb H ₃₇ Rv into 10 narrow molecular mass fractions (A1-A10; <20 kDa to >90 kDa) that were studied for their binding potential with A549; type II alveolar epithelial cell line. We also studied the consequences of this interaction in terms of change in epithelial cell viability by MTT assay and cytokine release by ELISA. Results: Our results show that several mycobacterial proteins bind and confer cytolysis in epithelial cells. Amongst all the fractions, proteins ranging from 35-45 kDa (A5) exhibited highest binding to A549 cells with a consequence of cytolysis of these cells. This fraction (A5) also led to release of various cytokines important in anti-mycobacterial immunity. Conclusion: Fraction A5 (35-45 kDa) of mycobacterial secretory proteome play an important role in mediating M. tb interaction with type II alveolar epithelial cells with the consequences detrimental for the TB pathogenesis. Further studies are being carried out to identify the candidate proteins from this region.

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Background: The quality of sleep in chronic obstructive pulmonary disease (COPD) patient from India has not been studied. Aim of this study was evaluation of subjective assessment of sleep quality in stable COPD patients and its relationship with associated depression. Materials and Methods: Forty clinically stable COPD patients were recruited from outpatient department and their disease status was classified as per Global Initiative for Chronic Obstructive Lung Disease guideline. Presence of depression was assessed by administering Patient Health Questionnaire (PHQ)-9 and subjective quality of sleep was measured by Pittsburgh Sleep Quality Index (PSQI). Results: All study subjects were male and mean age of study population was 62.2 ± 9.2 years, 12 patients (30%) in stage II, 19 patients (47.5%) in stage III and 9 patients (22.5%) in stage IV were enrolled. All subjects had poor sleep quality with the median global Pittsburgh Sleep Quality Index score 11. PHQ-9 score was significantly correlated with daytime function and global PSQI score (P<0.01). No correlation of global PSQI score with severity of COPD was observed. Conclusion: The prevalence of poor sleep quality among COPD patients is high. Irrespective of severity of airflow obstruction, the presence of depression in COPD is a risk factor for poor sleep quality.

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Aim: To assess the prevalence and correlates of current smoking, awareness of hazards, and quitting behavior among smokers 30 years and above. Materials and Methods: Study design: Cross-sectional; Setting: Gokulpuri, a resettlement colony in East Delhi, India; Sample size: 911, persons aged 30 years and above using systematic random sampling; Study tools: Semi-structured questionnaire. Results: Prevalence of current smoking was found to be 24.6% (95% CI 21.90 - 27.49). Majority 198 (88.4%) of current smokers smoked bidi exclusively, and on an average 13.5 bidi/cigarette were smoked per day. Multivariate analysis showed the factors associated with current smoking as male sex, advancing age, illiteracy, skilled occupation, low socio-economic status, and low BMI (P < 0.001). 64.2% were aware of the hazards of smoking. 63 (21.9%) had quit smoking in the past, majority due to the health problems. Low educational status was associated with poor hazard awareness and quitting behavior. Conclusion: Smoking is a significant problem among poor and illiterate males, shows an increasing trend with an advancing age and is directly associated with skilled occupation and low BMI. There are significant gaps in knowledge regarding hazards of smoking.

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The pulmonary venous abnormalities are very rare and are difficult to diagnose. We present a case of middle age male who presented with cough and chest pain. Chest radiograph showed abnormal tortuous vessel in right lung. Computed tomographic angiography of chest demonstrated meandering anomalous right superior pulmonary vein.

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Bronchogenic cysts are generally asymptomatic and are detected incidentally by radiographic imaging as a smooth homogeneous mediastinal/pulmonary lesion. We present a case of a large bronchogenic cyst in the posterior mediastinum mimicking ischemic heart disease in a 70-year-old man with unknown heart disease. In patients with chest pain the rare case of a bronchogenic cyst has to be considered for management of atypical angina pectoris.

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Bochdalek hernia is a congenital diaphragmatic defect that allows abdominal viscera to herniate into the thorax. Intrathoracic kidney is a very rare finding representing less than 5% of all renal ectopias. A 20 year old female presented with complaints of dry cough since 15 days and intermittent fever of 4 days duration. As part of routine investigation chest X-ray was done which showed a left retro-cardiac homogenous opacity, rest of the lung field appeared normal. Abdominal ultrasound showed the right kidney to be normal, left kidney was not visualized. Computed tomography scan demonstrated left-sided Bochdalek hernia with the left kidney within the thorax. An IVP was done to confirm the diagnosis. Many a times intrathoracic kidney is confused with a thoracic mass and the patient undergoes a battery of unnecessary investigations, surgical interventions and image guided biopsies for the same, hence to avoid this we are reporting this case.

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Paradoxical reaction during antituberculosis treatment (ATT) is commonly seen as tuberculous lymphadenitis of peripheral lymph node, cerebral tuberculomas, pulmonary infiltrates, and pleural disease. This phenomenon is more commonly associated with extrapulmonary tuberculosis and disseminated tuberculosis. Respiratory distress, as presentation of paradoxical reaction, is rare. We report an 8-month-old child with primary progressive tuberculosis without mediastinal adenopathy, who developed paradoxical reaction with extensive mediastinal adenopathy within 15 days of ATT and presented with severe respiratory distress. The child responded to short course of high-dose steroids.

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Context: The treatment of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis (TB) is consistently difficult. Besides resistances, drug availability can be problematic and costs for therapy are high. Aims: Our aim was to evaluate alternatives in treatment of MDR and XDR TB other than using second-line drugs. Materials and Methods: We analyzed retrospectively the minimal inhibitory concentrations (MICs) of first-line drugs for 44 multidrug-resistant Mycobacterium tuberculosis isolates determined in our institute over a period of 20 years (1990 - 2010, n = 44). Drug susceptibility testing (DST) was performed using the proportion method on Lowenstein-Jensen Medium or Middlebrook 7H10 agar. MICs were defined as the lowest drug concentration after two-fold serially diluted concentration of the drugs that inhibits growth of more than 99.0% of a bacterial proportion of the tested M. tuberculosis within 14 to 21 days of incubation at 37΀C. Statistical Analysis Used: Summation. Results: The MICs of isoniazid and ethambutol were equal or slightly above the critical concentration in most of the strains (92% and 84%, respectively), defined as "low-level resistance". Rifampicin and streptomycin exhibited very high MICs in most of the strains (100% and 77%, respectively), indicating a "high-level resistance". Conclusion: Our results indicate that isoniazid and ethambutol could still play a role in treating MDR and XDR TB patients if low-level resistance is detected. Quantitative DST seems to be promising for the recognition of residual drug activity, but has to be confirmed by clinical studies.

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Aluminium phosphide (ALP) is a common agrochemical pesticide poisoning with high mortality rate. Primary manifestations are due to myocardial and gastrointestinal involvement. Pleural effusion in ALP poisoning is occasionally reported. We report a case of pleural effusion that developed after ALP ingestion and resolved along with recovery from poisoning.

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Carcinoid tumors are rich in somatostatin receptors and show high uptake of radiotracer on octreotide scintigraphy. 68Ga-DOTATATE could be of great help at initial staging and during follow-up of these patients. We describe a patient with avid 68Ga-DOTATATE and poor F18-FDG uptake.

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Context : Compliance for non-pharmaceutical interventions for containment of Influenza A H1N1 is determined by community understanding and accurate information by appropriate risk commu­nication strategy. Aims: To assess the baseline awareness of public regarding Influenza A H1N1 and its existing risk communication strategy; and to assess public expressed willingness to comply with containment measures. Materials and Methods: Sample of 300 subjects (>18 years) coming to primary health centre (PHC) in Delhi was interviewed using a semi-structured questionnaire. The data was collected from 1 ^st July to 1 ^st Sept 2009 by systematic random sampling. Statistical Analysis Used: Chi-square test and binary logistic regression. Results: Only 66 (22%) individuals had complete knowledge about the spread, symptoms, risk groups, and method of prevention for Influenza A H1N1 infection. Knowledge was significantly higher among males and literates. Only 45 (15%) individuals thought that information given by government on H1N1 is complete and understandable. Conclusions: Majority of the respondents were willing to comply with containment measures, if implied by government. It was significantly high among literates.

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Objective : Appearance of hypoxia in a patient may be an indicator of a serious medical condition that can have grave consequences. Clinical evaluation fails to detect majority of the patients of hypoxia, and therefore, it may remain unnoticed in the wards. We planned to assess the magnitude of hypoxia in different wards of our tertiary care hospital. Materials and Methods: We studied all the patients admitted in various medical and surgical wards during 1 week of study. Oxygen saturation (SpO ₂ ) was measured with the help of a pulse oximeter in all the patients who remained admitted for at least 24 h. Hypoxia was diagnosed in a patient when he had SpO ₂ less than 90%. Results: During the study period, 1167 patients were admitted in various wards of the hospital. Hypoxia was detected in 121 patients (10.36%). Among them, 7 (0.59%) patients were already having a diagnosis of respiratory failure, but were not on oxygen therapy while 5 (0.42%) patients were having SpO ₂ less than 90% despite of oxygen therapy. In 109 (9.34%) patients, hypoxia was detected incidentally. Conclusion: Unnoticed hypoxia was detected in a significant number of the patients admitted in the wards of the hospital. Therefore, it is concluded that oxygen saturation measurements should be included with other vital parameters like pulse, temperature, and blood pressure, in the monitoring chart of all the admitted patients.

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Background : Mexico's National Institute of Respiratory Diseases (NIRD) is a third-level national reference center. Primary adenoid cystic carcinoma (PACC) is an uncommon neoplastic disorder; hence improvements in the description of this disease are needed. Materials and Methods: This is a retrospective clinical study based on all consecutive patients with pathological diagnoses of PACC seen at the NIRD between January 1, 2000 and December 31, 2009. Results: We identified 9 cases of PACC (67% female) out of a total of 2,634 patients with lung cancer seen during the period analyzed. The mean age of those 9 patients was 41 years (IQR 36-57), and the frequency of PACC at our center was 0.3%. It is important to note that 67% of those patients had a history of smoking and that 6 of the 9 had the antecedent of previous exposure to biomass fuel smoke. Baseline arterial blood gas analyses revealed a median of 61 mmHg for pO ₂ and 28.5 mmHg for pCO ₂ . Median FVC was 78%, while FEV ₁ was 77% with an FEV ₁ /FVC ratio of 78. Death occurred in 56% of cases, and the median survival time was 17 months (IQR 6-26) after the initial diagnosis. Conclusions: The frequency of tracheobronchial PACC among patients with lung cancer was similar to that previously reported (0.3%). According to our results, lung function has no specific phenotype in this disease; however, some abnormalities could be related to potential risk factors such as tobacco use and exposure to biomass fuel smoke.

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