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.

Impact of Timing of Tocilizumab Use in Hospitalized Patients With SARS-CoV-2 Infection.

BACKGROUND: SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) continues to be a global challenge due to the lack of definitive treatment strategies. We sought to determine the efficacy of early administration of anti-interleukin 6 therapy in reducing hospital mortality and progression to mechanical ventilation. METHODS: This was a retrospective chart review of 11,512 patients infected with SARS-CoV-2 who were admitted to a New York health system from March to May 2020. Tocilizumab was administered to subjects at the nasal cannula level of oxygen support to maintain an oxygen saturation of >88%. The Charlson comorbidity index was used as an objective assessment of the burden of comorbidities to predict 10-year mortality. The primary outcome of interest was hospital mortality. Secondary outcomes were progression to mechanical ventilation; the prevalence of venous thromboembolism and renal failure; and the change in C-reactive protein, D-dimer, and ferritin levels after tocilizumab administration. Propensity score matching by using a 1:2 protocol was used to match the tocilizumab and non-tocilizumab groups to minimize selection bias. The groups were matched on baseline demographic characteristics, including age, sex, and body mass index; Charlson comorbidity index score; laboratory markers, including ferritin, D-dimer, lactate dehydrogenase, and C-reactive protein values; and the maximum oxygen requirement at the time of tocilizumab administration. Mortality outcomes were evaluated based on the level of oxygen requirement and the day of hospitalization at the time of tocilizumab administration. RESULTS: The overall hospital mortality was significantly reduced in the tocilizumab group when tocilizumab was administered at the nasal cannula level (10.4% vs 22.0%; P = .002). In subjects who received tocilizumab at the nasal cannula level, the progression to mechanical ventilation was reduced versus subjects who were initially on higher levels of oxygen support (6.3% vs 18.7%; P < .001). There was no improvement in mortality when tocilizumab was given at the time of requiring non-rebreather, high-flow nasal cannula, noninvasive ventilator, or invasive ventilator. CONCLUSIONS: Early use of anti-interleukin 6 therapy may be associated with improved hospital mortality and reduction in progression to more severe coronavirus disease 2019.

A 44-Year-Old Man With Dyspnea and a Pulmonary Artery Filling Defect.

CASE PRESENTATION: A 44-year-old man with a history of coronary artery disease, type 2 diabetes mellitus, and OSA reported progressively worsening dyspnea on exertion over a 6-week period. Outpatient CT angiogram revealed a pulmonary artery filling defect. He was sent to the ED where he was started on a heparin drip for unprovoked pulmonary embolism (PE). Echocardiogram revealed normal cardiac function without evidence of right heart strain. Lower extremity ultrasound was negative for DVT. He improved symptomatically, and no risk factors for PE were identified. He was discharged on apixaban. Five weeks later, the patient returned to the ED with hemoptysis. He reported compliance with anticoagulation and improvement of his dyspnea on exertion. History remained negative for recent travel, trauma, surgery, clotting disorders, thromboembolic disease, and alcohol or drug use. He had a 60 pack-year cigarette smoking history and quit 3 months prior.