COVID-19-induced atypical pneumonia in an unseparated adult conjoined twin in a remote setup of developing country: management by telemedicine. Illustrative case

BACKGROUND

Telemedicine is the use of wireless communications and Web-based technologies to provide healthcare and services. The coronavirus disease 2019 (COVID-19) pandemic has posed an unprecedented challenge to healthcare providers, who have been forced to change their usual mode of service delivery and have been given an opportunity to adopt the concept of telemedicine.

OBSERVATIONS

A 40-year-old underprivileged and unseparated conjoined twin (pygopagus) had dorsal spine tuberculosis and was on a regular follow-up through telemedicine due to the ongoing COVID-19 pandemic and embarrassment they had to face in public appearances. After a few months, they contracted COVID-19 infection after which they were shifted to our tertiary care center. Several unique challenges were encountered during the 4-day course of management. Ultimately, they died and left us with questions of whether we are really prepared to tackle these challenges.

LESSONS

The general public should be made aware of such groups of patients and to encourage them to follow COVID-appropriate behavior. Vaccinations should be given on a priority basis to these subsets. A more robust approach of telemedicine consultation is required for management of patients in remote areas at the time of a pandemic. Ventilator management of these patients is still intriguing.

Minimally Jointed Symmetrical Pygopagus Twins - Successful Surgical Separation

Conjoined pygopagus accounts for about 17% of all conjoined twins and commonly share the gluteal region, terminal spine, lower gastrointestinal, urological, and reproductive tracts. This makes their separation a very challenging task. We report herein pygopagus twins who had minimal fusion in coccygeal region and could be separated without a complicated procedure. The case is being reported to add to the literature and emphasize that simple fusion in conjoined twins can be relatively easy to manage.

The growth of pediatric neurosurgery in southern Vietnam and the first separation of pygopagus twins: case report

Conjoined twins are a rare congenital abnormality with an estimated incidence of 1:50,000 pregnancies and 1:200,000 live births. Pygopagus twins are characterized by sacrococcygeal fusion that is commonly associated with perineal and spinal abnormalities. Management of this complex disease requires a well-developed surgical system with multidisciplinary capacity and expertise.A decade ago there were no dedicated pediatric neurosurgeons in southern Vietnam. This has changed within a few short years; there are now 10 dedicated pediatric neurosurgeons with continually expanding technical capacity. In August 2017 a multidisciplinary surgical and anesthetic team successfully separated female pygopagus twins with fused sacrum and spinal cord with associated myelomeningocele defect.The authors present here the first successful separation of pygopagus twins in Vietnam as a representative case of gradual and sustainable pediatric neurosurgical scale-up.

Two is a Crowd: Two is a Crowd: On the Enigmatic Etiopathogenesis of Conjoined Twinning

In this article, we provide a comprehensive overview of multiple facets in the puzzling genesis of symmetrical conjoined twins. The etiopathogenesis of conjoined twins remains matter for ongoing debate and is currently cited-in virtually every paper on conjoined twins-as partial fission or secondary fusion. Both theories could potentially be extrapolated from embryological adjustments exclusively seen in conjoined twins. Adoption of these, seemingly factual, theoretical proposals has (unconsciously) resulted in crystallized patterns of verbal and graphic representations concerning the enigmatic genesis of conjoined twins. Critical evaluation on their plausibility and solidity remains however largely absent. As it appears, both the fission and fusion theories cannot be applied to the full range of conjunction possibilities and thus remain matter for persistent inconclusiveness. We propose that initial duplication of axially located morphogenetic potent primordia could be the initiating factor in the genesis of ventrally, laterally, and caudally conjoined twins. The mutual position of two primordia results in neo-axial orientation and/or interaction aplasia. Both these embryological adjustments result in conjunction patterns that may seemingly appear as being caused by fission or fusion. However, as we will substantiate, neither fission nor fusion are the cause of most conjoined twinning types; rather what is interpreted as fission or fusion is actually the result of the twinning process itself. Furthermore, we will discuss the currently held views on the origin of conjoined twins and its commonly assumed etiological correlation with monozygotic twinning. Finally, considerations are presented which indicate that the dorsal conjunction group is etiologically and pathogenetically different from other symmetric conjoined twins. This leads us to propose that dorsally united twins could actually be caused by secondary fusion of two initially separate monozygotic twins. An additional reason for the ongoing etiopathogenetic debate on the genesis of conjoined twins is because different types of conjoined twins are classically placed in one overarching receptacle, which has hindered the quest for answers. Clin. Anat. 32:722-741, 2019. © 2019 Wiley Periodicals, Inc.

Conjoined twins: From conception to separation, a review

Conjoined twins are suggested to result from aberrant embryogenesis. The two main theories proposed to explain the phenomena are fission and fusion. The incidence rate is 1 in 50,000 births; however, since about 60% of the cases are stillborn, the true incidence is approximated at 1 in 200,000. There is a higher predisposition towards female than male gender with a ratio of 3:1. Conjoined twins are classified based upon the site of attachment. The extent of organ sharing, especially the heart, determines the possibility and prognosis of a separation procedure. Meticulous preoperative evaluation, planning, and preparedness of the team are crucial for a successful separation. Separation of conjoined twins poses several technical, legal, and ethical issues. Clin. Anat. 30:385-396, 2017. © 2017 Wiley Periodicals, Inc.