Diarrhea and cholera surveillance for early warning and preparedness to prevent epidemics among Rohingya Myanmar nationals in Cox's Bazar, Bangladesh.

Diarrheal diseases, especially cholera, can be a serious threat to Rohingya refugees in Cox's Bazar due to overcrowding and inadequate hygiene infrastructure. Assessing the risk, cholera surveillance network was established with the aim to identify the outbreak of diarrhea and cholera and help to take appropriate preventive measures including a vaccination campaign. The surveillance network has been ongoing for 6 years (2017-2023) in 17 health facilities. Diarrhea patients from Rohingya Myanmar nationals matched with case definition were enrolled and stool samples were tested by Rapid diagnostic test (RDT) for early cholera detection Multiple Logistic regression models were fitted to examine the associations of risk factors among cholera cases. A total of 17,252 stool samples were collected through surveillance. Among the tested samples, 588 (3.5 %) were detected positive by RDT, and 239 (1.4 %) Vibrio cholerae were isolated by microbiological culture. Between 2021 and 2023, the number of culture-confirmed cases exceeded that in the period from 2017 to 2020. In addition to V. cholerae; high positivity was identified for ETEC (11.8 %) followed by Salmonella (3.9 %) and Shigella (2.7 %). Most of the cholera cases were presented with vomiting, dehydration and loose watery and rice watery nature of stool (p value = <0.001). Major risk factors for cholera were 2-4 years age group (OR = 5.72; 95 % CI, 3.84-8.53.14; P = .001), process of water treatment (OR = 1.54; 95 % CI, 1.01-2.37; P = .046) and hand washing with soap before taking meals (OR = 0.6; 95 % CI, 0.39-0.92; P = .020. This study highlights the epidemiology of cholera among the Rohingya population and underscores the effectiveness of integrating surveillance data with early warning, alert, and response systems (EWARS) system, along with oral cholera vaccine (OCV) campaigns, in preventing major cholera outbreak.

Common pediatric surgical conditions and associated health-seeking behaviors in Pakistan: An urban and rural comparative assessment.

Approximately five billion people do not have access to necessary surgical treatment globally and up to 85% of children in LMICs are affected with conditions requiring surgical care by the age of 15 years. It is crucial to identify common surgical conditions in children in Pakistan to inform healthcare professionals and policymakers for effective resource allocation. This representative cross-sectional household survey conducted on children aged 5-10 years assessed existing surgical diseases and healthcare-seeking behaviors in the two largest provinces (Sindh and Punjab) of Pakistan. The data was collected through a validated cross-sectional survey tool [Surgeons OverSeas Assessment of Surgical Need (SOSAS)]. Caregivers were asked about their child's recent and past surgical conditions in six distinct anatomical regions and pictures were taken of identified conditions after appropriate consent for further diagnosis. Health-seeking behaviors including the kind of treatment sought, the nature of care received, and the reasons for not receiving care were noted. 13.5% of children surveyed reported a surgical condition, with a similar distribution across urban (13.2%) and rural (13.7) areas and the most common cause was trauma. The greatest number of surgical conditions were found to be on the head and neck region (57.7%), while the back accounted for the least number of conditions (1.7%). Our results outline a need for organizing all entities (governmental, non-governmental, and private) involved in child health to ensure efficient resource allocation to cater to existing surgical problems.

Identification, mapping, and self-reported practice patterns of village doctors in Sitakunda subdistrict, Bangladesh.

Background: Informally trained health care providers, such as village doctors in Bangladesh, are crucial in providing health care services to the rural poor in low- and middle-income countries. Despite being one of the primary vendors of antibiotics in rural Bangladesh, village doctors often have limited knowledge about appropriate antibiotic use, leading to varied and potentially inappropriate dispensing and treatment practices. In this study, we aimed to identify, map, and survey village doctors in the Sitakunda subdistrict of Bangladesh to understand their distribution, practice characteristics, clinical behaviours, access to technologies, and use of these technologies for clinical decision-making. Methods: Using a 'snowball' sampling method, we identified and mapped 411 village doctors, with 371 agreeing to complete a structured survey. Results: The median distance between a residential household and the closest village doctor practice was 0.37 km, and over half of the practices (51.2%) were within 100 m of the major highway. Village doctors were predominately male (98.7%), with a median age of 39. After completing village doctor training, 39.4% had completed an internship, with a median of 15 years of practice experience. Village doctors reported seeing a median of 84 patients per week, including a median of five paediatric diarrhoea cases per week. They stocked a range of antibiotics, with ciprofloxacin and metronidazole being the most prescribed for diarrhoea. Most had access to phones with an internet connection and used online resources for clinical decision-making and guidance. Conclusions: The findings provide insights into the characteristics and practices of village doctors and point to the potential for internet and phone-based interventions to improve patient care and reduce inappropriate antibiotic use in this health care provider group.

Assessing Barriers to Primary Prevention of Cardiovascular Diseases in Low and Middle-Income Countries: A Systematic Review.

The incidence of cardiovascular diseases (CVDs) in low- and middle-income countries (LMICs) has greatly increased. Previously dominated by infectious diseases, LMICs are the new epicentre of CVDs. CVD is a common problem amongst the population in the African continent; however, many countries in LMICs lack the resources to stem the rise of CVDs. A systematic review was conducted between March and July 2023 to assess barriers to the primary prevention of CVDs in studies conducted in LMICs. Online databases, such as Embase, Cochrane, Scopus, and MEDLINE, were consulted. Keywords included primary prevention, cardiovascular diseases, diabetes, weight loss, and physical fitness, all of which focused on LMICs. To enrich the literature review, efforts were made to check other listed references and more papers were retrieved. The inclusion criteria were countries in LMICs, CVD, full-text, and peer-reviewed journals. Qualitative and quantitative studies were included. Exclusion criteria included high-income countries, secondary prevention, and research unrelated to CVDs, such as barriers in oncology or mental health. A total of 1089 papers were retrieved from the search engines. After applying the exclusion criteria for LMICs, only 186 papers were retained. A further search for quality, relevance, and duplicity reduced the qualifying number to 50 papers. Further efforts to retrieve the data and examine the quality of the studies resulted in 18 final selected studies. Three categories emerged based on the type of barriers: physician barriers, patient barriers, and health system barriers. Evidently, in several LMICs, guidelines for CVD prevention were lacking, and too much emphasis was placed on secondary prevention at the expense of primary prevention, a lack of human resources, and inadequate infrastructure. Overworked healthcare providers were unable to allocate adequate time to the patients. There was no shared decision-making process. Patient barriers included lack of motivation, no symptoms, low level of education, no insurance, long physical distances to the facilities, and inadequate medication or stock out. Some of the major barriers included closing and opening hours, poor operating space, inadequate funding from the government or donors, and lack of electronic medical services. There are many barriers to accessing primary prevention services for CVDs. These barriers can be divided into patient, physician, or health system barriers. More research needs to be conducted in LMICs to address the increasing risk factors for CVDs. Greater investment is required by national governments to provide more resources. Task shifting and shared decision-making are some of the quick wins.

An Interesting Case of Wolf-Parkinson-White Syndrome in a Young Patient With Sensorineural Deafness.

Wolff-Parkinson-White (WPW) syndrome is a condition associated with tachycardia due to accessory pathways in the heart, and it is one of the most common causes of tachycardia in infants and children. WPW may also be associated with mitochondrial encephalomyopathy, lactic acidosis, stroke-like episodes (MELAS syndrome) or LEOPARD syndrome (LS). We report a case of pre-excitation WPW syndrome in a 17-year-old man who was brought to the hospital by ambulance following the collapse. WPW syndrome type A was diagnosed from precordial leads. Electrocardiography (ECG) revealed a short PR interval, delta waves, and positive waves with dominant R in all pericardial leads. Blood test results showed an isolated elevated ALT level. Subsequent echocardiography was unremarkable, with an ejection fraction of 55%, apart from septal and inferior wall dyssynchrony. With regard to the past medical history, he had sensorineural deafness (SND) since childhood and had a family history of SND. Consequently, the patient was transferred to the cardiac electrophysiology department at another hospital after consultation and underwent ablation. A successful post-ablation electrocardiogram revealed the resolution of the WPW syndrome signs and post-ablation features, such as peak T waves.

A Systematic Review and Meta-Analysis on the Role of Bempedoic Acid in Cardiovascular Outcomes for Patients With Statin Intolerance.

Atherosclerosis, a multifaceted pathogenic process affecting the arteries and aorta, poses a significant threat because of its potential to impede or entirely obstruct blood flow by narrowing blood vessels. This intricate progression involves various factors such as dyslipidemia, immunological responses, inflammation, and endothelial dysfunction. The initial phase manifests as the formation of fatty streaks, considered a pivotal hallmark in the inception of atherosclerotic plaques, a process that can commence as early as childhood. Over time, this process evolves, characterized by the thickening of the arterial inner layer (intima) and accumulation of lipid-laden macrophages, commonly known as foam cells, along with the buildup of the extracellular matrix. Subsequent stages witness the proliferation and aggregation of smooth muscle cells, culminating in the formation of atheroma plaques. As these lesions progress, apoptosis can occur in the deeper layers, further recruiting macrophages, which may undergo calcification and transform into atherosclerotic plaques. Notably, mechanisms such as arterial remodeling and intraplaque hemorrhage also contribute significantly to the progression of atherosclerotic cardiovascular disease, although these facets fall beyond the scope of this article. This study aimed to systematically review and conduct a meta-analysis of randomized controlled trials investigating the efficacy and safety of bempedoic acid in statin-intolerant patients with hyperlipidemia and to provide conclusions and recommendations accordingly. A systematic search of databases, such as PubMed, Web of Science, and Embase, will be performed. Only randomized trials will be included comparing bempedoic acid with placebo in statin-intolerant patients. This study aimed to provide a comprehensive understanding of the role of bempedoic acid in managing hyperlipidemia in statin-intolerant patients. In primary prevention, for patients unable to tolerate recommended statins, bempedoic acid was associated with a significant reduction in major adverse cardiovascular events (MACE) as the primary endpoint.

Acute Large Pericardial Effusion With Haemodynamic Compromise Secondary to Undiagnosed Tuberculosis.

Tuberculous pericardial effusion is uncommon in the developed countries. However, it remains one of the main causes of presentation with a pericardial presentation with pericardial effusion in the developing world. We present the case of a 24-year-old male patient who presented with a weekly history of diarrhoea, vomiting, shortness of breath and feeling hot. Chest computed tomography revealed a large pericardial effusion with significant haemodynamic compromise. The patient underwent emergency pericardiocentesis, and the pericardial fluid interferon-gamma assay result was positive for tuberculosis. He was unable to tolerate endobronchial biopsy under ultrasound despite heavy sedation and was commenced on anti-tuberculous therapy following a discussion in a multidisciplinary team meeting. He was started on four standard anti-tuberculosis medications, including rifampicin, isoniazid, pyrazinamide, ethambutol and prednisolone. The patient had re-accumulation of pericardial fluid on repeat echocardiography in the first few weeks, which eventually resolved with anti-tuberculous therapy.

Effect of Dietary Simulating Solvents on the CAD-CAM Provisional Restorative Materials' Microhardness and Color Stability Properties: An in vitro Study.

Purpose: This in vitro study investigated the effects of dietary solvents on the microhardness and color stability of CAD/CAM provisional restorations compared to conventional materials. Methods: Disc-shaped specimens (n=200) were fabricated from self-cured acrylic resin, two 3D-printing resins (FormLabs, NextDent), and a milled material (TelioCAD). Randomization assigned specimens (n=10/group) to immersion solutions: artificial saliva, citric acid, heptane, coffee, and tea. Microhardness and color stability were evaluated. One-way and three-way ANOVA with Tukey's post hoc test analyzed the data. Results: Dietary solvents significantly reduced the surface microhardness of all tested materials (p<0.05). Unpolished surfaces exhibited greater color changes compared to polished ones (p<0.05) across all materials. Coffee and tea induced the most substantial reductions in hardness and the most significant color alterations (p<0.05), whereas saliva and citric acid had minimal effects. Conclusion: Milled provisional restorations exhibited superior hardness and color stability. Dietary solvents significantly affected material properties over time, highlighting the importance of material selection for clinical applications.

Recurrent Pericardial Effusion Secondary to Cardiac Angiosarcoma.

Cardiac angiosarcoma is a malignant cardiac tumour. We present the case of a young patient in his mid-30s with recurrent pericardial effusion. He had flu-like symptoms a month earlier and had shortness of breath, lethargy, and tightness in his throat for the past ten days. Echocardiography demonstrated global pericardial effusion > 4 cm with tamponade features, and the patient was blue-lighted to our hospital. He underwent emergency pericardiocentesis, and > 1 litre of pericardial fluid was drained. Computed tomography of the chest, abdomen, and pelvis revealed small-volume ascites and moderate right-sided pleural effusion, with associated lobar collapse. The patient presented to the hospital with global pericardial effusion requiring emergency pericardiocentesis three weeks later and underwent cardiac magnetic resonance imaging demonstrating global pericardial effusion and a 48 × 26 mm pericardial space mass adjacent to the right atrium. He underwent surgical resection of the tumour, followed by chemotherapy, and tolerated the treatment well. The patient is currently under follow-up.

Advancements in intrusion detection: A lightweight hybrid RNN-RF model.

Computer networks face vulnerability to numerous attacks, which pose significant threats to our data security and the freedom of communication. This paper introduces a novel intrusion detection technique that diverges from traditional methods by leveraging Recurrent Neural Networks (RNNs) for both data preprocessing and feature extraction. The proposed process is based on the following steps: (1) training the data using RNNs, (2) extracting features from their hidden layers, and (3) applying various classification algorithms. This methodology offers significant advantages and greatly differs from existing intrusion detection practices. The effectiveness of our method is demonstrated through trials on the Network Security Laboratory (NSL) and Canadian Institute for Cybersecurity (CIC) 2017 datasets, where the application of RNNs for intrusion detection shows substantial practical implications. Specifically, we achieved accuracy scores of 99.6% with Decision Tree, Random Forest, and CatBoost classifiers on the NSL dataset, and 99.8% and 99.9%, respectively, on the CIC 2017 dataset. By reversing the conventional sequence of training data with RNNs and then extracting features before applying classification algorithms, our approach provides a major shift in intrusion detection methodologies. This modification in the pipeline underscores the benefits of utilizing RNNs for feature extraction and data preprocessing, meeting the critical need to safeguard data security and communication freedom against ever-evolving network threats.

A Young Patient With Acute Ostial Right Coronary Artery Aneurysm Presenting As ST Elevation Myocardial Infarction.

A coronary artery aneurysm (CAA) is a localized dilatation of a coronary artery segment >1.5 times the diameter of the adjacent normal segment. CAA is more common in men than women and has multiple etiologies, including genetic causes, infections, and atherosclerotic diseases. Kawasaki disease is the most common cause of CAA in children, whereas atherosclerosis is the most common etiology in adults. We present the case of a male in his 30s who presented with sudden-onset chest pain and inferior ST segment elevation on an ECG. Echocardiography revealed preserved left ventricular function and mild hypokinesia. The patient underwent an emergency coronary angiogram that showed an ostial right CAA with thrombi. He was initially managed with a glycoprotein IIb/IIIa inhibitor tirofiban infusion, followed by triple therapy with aspirin, clopidogrel, and rivaroxaban. The patient underwent magnetic resonance imaging of his head, which was normal, and he did not attend outpatient computed tomography coronary angiography. The patient was discharged with lifelong rivaroxaban 20 mg once daily.

Statins As Anti-Hypertensive Therapy: A Systematic Review and Meta-Analysis.

Hypertension is the most prevalent condition in clinical practice. Hypertension, diabetes, and hypercholesterolaemia are major contributing factors to cardiovascular diseases. They commonly coexist in a single patient. Statins have been used as prominent medicines for the reduction of cardiovascular events. Statins have been shown to reduce blood pressure in patients with hypertension and have lipid-lowering properties in recent articles. Statins reduce blood pressure because of their impact on endothelial function, their interactions with the renin-angiotensin system, and their influence on major artery compliance. This meta-analysis aimed to ascertain the effectiveness and efficacy of statins for managing hypertension in patients with hypertension. Systematic searches were conducted on PubMed, Science Direct, Embase, Cochrane Library, and Google Scholar. Randomized controlled trials, systematic trials, and cohort studies were retrieved using keywords on statins and their use in patients with hypertension. Exclusion criteria included studies that were not in the English language, studies that did not include patients on statins with hypertension, studies that did not provide enough information, technical reports, opinions, or editorials, and studies involving patients < 18 years old. The inclusion criteria were randomized controlled trials, meta-analyses, adult patients aged > 18 years old, and studies that were freely available or through institutional login. This meta-analysis scrutinized 9361 randomized controlled trials, clinical trials, meta-analyses, and systematic reviews, of which 32 articles including 25 randomized controlled trials and seven meta-analyses were included in the final analysis. This meta-analysis of the role of statins in hypertensive patients aimed to determine the outcome of hypertension control along with antihypertensive medication. Our study showed that statins are useful in reducing both systolic and diastolic blood pressure. We used a heterogeneous model for analysis due to variations in the study characteristics. The I2 value was 0.33 (0.76, 0.10) for systolic blood pressure and 0/88 (0.86, 0.90) for diastolic blood pressure. The I2 value for the seven meta-analyses included in the study was 1.79 (2.88, 0.69).

Stimulatory effects of smoke solution and biogas digestate slurry application on photosynthesis, growth, and methylation profiling of solanum tuberosum.

Biostimulants are obtained from various sources like plants, animals, microorganisms, and industrial by-products as well as waste material. Their utilization in agriculture practices is being increased that is giving positive results. The purpose of the current study was to use plant-derived smoke (SMK) solution and biogas digestate (BGD) slurry as biostimulant to elucidate their impact on potato (Solanum tuberosum) performance. The experiment was conducted in lab as well as field conditions, and SMK and BGD solutions were prepared in varying concentrations such as SMK 1:500, SMK 1:250, BGD 50:50, and BGD 75:25. Foliar applications were performed thrice during experiments and data were collected related to photosynthesis, growth, pigments, and genome-wide methylation profiling. Net photosynthesis rate (A) and water use efficiency (WUE) were found higher in SMK- and BGD-treated lab and field grown plants. Among pigments, BGD-treated plants depicted higher levels of Chl a and Chl b while SMK-treated plants showed higher carotenoid levels. Alongside, enhancement in growth-related parameters like leaf number and dry weight was also observed in both lab- and field-treated plants. Furthermore, DNA methylation profile of SMK- and BGD-treated plants depicted variation compared to control. DNA methylation events increased in all the treatments compared to control except for SMK 1:500. These results indicate that smoke and slurry both act as efficient biostimulants which result in better performance of plants. Biostimulants also affected the genome-wide DNA methylation profile that resultantly might have changed the plant gene expression profiling and played its role in plant responsiveness to these biostimulants. However, there is need to elucidate a possible synergistic effect of SMK and BGD on plant growth along with gene expression profiling.

The Role of MRI Scan in Sports-Related Anterior Cruciate Ligament Injuries: A Case Report-Based Literature Review.

Sports-related knee injuries are a common presentation in general practice in Australia among patients of the adolescent age group. A complete understanding of the anatomy, mechanism of injury, history, focused clinical examination of the knee joint, and proper investigations can help make a proper diagnosis. Injuries can be prejudicial to ligaments, tendons, muscles, and bones. Here, we present a case of rupture of the anterior cruciate ligament (ACL) following a fall while playing football. The patient visited the emergency department where an initial radiography was performed, which was unremarkable, and was consequently discharged from the emergency department on painkillers. Later, he presented with swelling and worsening pain in general practice, and magnetic resonance imaging (MRI) confirmed a diagnosis of ACL rupture. Therefore, he was referred to an orthopedic surgeon for further treatment and management. The patient was managed conservatively and underwent physiotherapy.

Osteosarcoma in a Teenage Athlete With a Swollen Knee Joint.

Osteosarcoma is a malignant mesenchymal tumour. This primarily manifests in the formation of immature osteoid cells by tumour cells. Osteosarcoma is the most common primary bone tumour in children and adolescents. It tends to occur in the metaphysis of long shafts, shows osteoblastic differentiation, and produces malignant osteoid material. We present the case of a 17-year-old male who presented to our clinic who had left knee pain for a few days. An initial radiograph of the knee joint revealed a lytic lesion in the proximal tibia and further imaging was advised. During a follow-up visit, the patient had worsening pain and had a computerized tomography scan of the left knee, confirming osteosarcoma on the lateral side of the left tibia. He was referred to the orthopaedic department, where a biopsy was performed, to confirm the diagnosis of osteosarcoma. The patient was commenced on chemotherapy due to metastatic disease and has so far tolerated therapy well.

A transformer-based approach empowered by a self-attention technique for semantic segmentation in remote sensing.

Semantic segmentation of Remote Sensing (RS) images involves the classification of each pixel in a satellite image into distinct and non-overlapping regions or segments. This task is crucial in various domains, including land cover classification, autonomous driving, and scene understanding. While deep learning has shown promising results, there is limited research that specifically addresses the challenge of processing fine details in RS images while also considering the high computational demands. To tackle this issue, we propose a novel approach that combines convolutional and transformer architectures. Our design incorporates convolutional layers with a low receptive field to generate fine-grained feature maps for small objects in very high-resolution images. On the other hand, transformer blocks are utilized to capture contextual information from the input. By leveraging convolution and self-attention in this manner, we reduce the need for extensive downsampling and enable the network to work with full-resolution features, which is particularly beneficial for handling small objects. Additionally, our approach eliminates the requirement for vast datasets, which is often necessary for purely transformer-based networks. In our experimental results, we demonstrate the effectiveness of our method in generating local and contextual features using convolutional and transformer layers, respectively. Our approach achieves a mean dice score of 80.41%, outperforming other well-known techniques such as UNet, Fully-Connected Network (FCN), Pyramid Scene Parsing Network (PSP Net), and the recent Convolutional vision Transformer (CvT) model, which achieved mean dice scores of 78.57%, 74.57%, 73.45%, and 62.97% respectively, under the same training conditions and using the same training dataset.

COVID-19 vaccine coverage, determinants and inequity amongst refugees and migrants in Pakistan: a cross-sectional study.

OBJECTIVE: Migrants and refugees are at a disadvantage in accessing basic necessities. The objective of this study is to assess the inequity in access, needs and determinants of COVID-19 vaccination among refugees and migrant populations in Pakistan. DESIGN: We conducted a mixed-method study comprising a cross-sectional survey and a qualitative study. In this paper, we will only report the findings from the cross-sectional survey. SETTING: This survey was conducted in different cities of Pakistan including Quetta, Karachi and Hyderabad. PARTICIPANTS: A total of 570 participants were surveyed including refugees and migrants, both in regular and irregular situations. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome of the study was to estimate the proportion of refugees and migrants, both in regular and irregular situations vaccinated against COVID-19 and assess the inequity. The χ2 test and Fisher's exact test were used to determine the significant differences in proportions between refugees and migrants and between regions. RESULTS: The survey showed that only 26.9% of the refugee and migrant population were tested for COVID-19, 4.56% contracted coronavirus, and 3.85% were hospitalised due to COVID-19. About 66% of the refugees and migrants were fully vaccinated including those who received the single-dose vaccine or received all two doses, and 17.6% were partially vaccinated. Despite vaccination campaigns by the government, 14.4% of the refugee and migrant population remained unvaccinated mostly because of vaccines not being offered, distant vaccination sites, limited access, unavailability of COVID-19 vaccine or due to a difficult registration process. Vaccination rates varied across provinces, genders and migrant populations due to misconceptions, and several social, cultural and geographical barriers. CONCLUSION: This study highlights the COVID-19 vaccine coverage, access and inequity faced by refugees and migrants during the pandemic. It suggests early prioritisation of policies inclusive of all refugees and migrants and the provision of identification documents to ease access to basic necessities.

Aberrant Left Coronary Artery Origin in a Patient Presenting With Acute Coronary Syndrome.

A congenital anomalous origin of the coronary artery is a rare cardiovascular malformation that includes the left circumflex artery arising from the right sinus of Valsalva (RSV), both coronary arteries arising from RSV, the left anterior descending (LAD) artery arising from the respiratory sinus arrhythmia, and a single coronary artery arising from the left sinus of Valsalva. We present the case of a 72-year-old patient presenting with chest pain to his local hospital while cycling. Troponin levels peaked from 90 to 360 ng/L, and electrocardiography showed normal sinus rhythm and left bundle branch block. Echocardiography showed good left ventricular function with an ejection fraction of 55% and no regional wall motion abnormalities. The patient underwent coronary angiography, which revealed a severe proximal right coronary artery (RCA) lesion and an aberrant LAD artery. He underwent primary percutaneous coronary angioplasty of the RCA and was discharged home with dual antiplatelet therapy and high-dose statins. CT coronary angiography revealed an aberrant LAD and patent RCA stent with mild to moderate disease in the distal vessel, and he was reviewed in the outpatient clinic.

Bronchogenic cyst: a rare cause of palpitations and atrial fibrillation.

Bronchogenic cysts are rare congenital lesions found primarily in the mediastinum. Most patients are asymptomatic and can be treated with minimally invasive resection. We present a case of a middle-aged patient who presented to a district general hospital with palpitations and shortness of breath. She underwent a computerised tomographic pulmonary angiogram that showed a likely bronchogenic cyst and was subsequently transferred to our hospital. She developed atrial fibrillation during admission requiring therapy with beta-blockers and digoxin. Cardiac MRI revealed a large cyst posterior to the left atrium, a moderate circumferential pericardial effusion and bilateral pleural effusions. There was significant left atrial compression. The patient underwent surgical removal of the cyst and was discharged. She returned to the hospital within a week with palpitations and was treated with intravenous antibiotics for sepsis. She was discharged a week later and remained clinically stable.