Tawam Hospital

Avelumab, pembrolizumab, and enfortumab vedotin (EV) demonstrated efficacy in mUC following platinum-based chemotherapy. However, real-world data in patients with urothelial carcinoma with squamous differentiation (UCSD) are limited. The aim of this study is to assess the real-world clinical outcomes of avelumab, pembrolizumab, or EV in mUCSD patients. The ARON-2EV study is a retrospective, international, multicenter analysis in patients with mUC treated with avelumab, pembrolizumab, or EV across 79 centers in 21 countries. Patients were divided into three cohorts: 1 (avelumab), 2 (pembrolizumab), and 3 (EV). Primary endpoints were overall survival (OS) and time on treatment (ToT). Secondary objectives included evaluating clinical factors associated with outcomes and exploring the impact of UCSD histology on response to therapy. Statistical methods included Kaplan-Meier estimates, log-rank tests, Fisher's exact and chi-square tests, and Pearson's correlation coefficients. A total of 1918 patients, 1696 with advanced pure UC (pUC) and 222 with mUCSD (36 in cohort 1, 111 in cohort 2, and 75 in cohort 3), were included. Median OS was shorter in patients with UCSD compared to patients with pUC histology in the three cohorts (1: 13.0 vs 26.8months, HR 2.66,p = 0.003; 2: 10.2 vs 18.5months, HR 1.52,p = 0.008; and 3: 7.6 vs 13.1months, HR 1.68,p = 0.011). Median ToT was shorter in patients with UCSD compared to patients with pUC histology in cohort 1 (3.5 vs 5.6months, HR 1.57,p = 0.044) and 3 (7.6 vs 13.6months, HR 1.83,p = 0.005) but not in cohort 2 (3.7 vs 4.7months, HR 1.19,p = 0.177). Response to therapy was negatively correlated with UCSD histology in cohorts 2 (correlation coefficient 0.094,p = 0.008) and 3 (correlation coefficient 0.107,p = 0.021), while response to avelumab was not correlated with UCSD (correlation coefficient 0.072,p = 0.263). UCSD is a histology with a poor prognosis and response to treatments compared to pUC. Treatments activity and effectiveness in divergent differentiations should be addressed in dedicated prospective studies. NCT05290038.

Malignant middle cerebral artery infarction is associated with high mortality and severe disability despite decompressive craniectomy. The thalamus plays a central role in arousal and sensorimotor integration and may be vulnerable to early compression from cerebral mass effect. This study evaluates whether preoperative ipsilateral thalamic volume reduction predicts functional outcomes following decompressive craniectomy. This retrospective cohort study included 41 adult patients with malignant middle cerebral artery infarction who underwent decompressive craniectomy between April 2017 and September 2022. Preoperative computed tomography scans were analysed for infarct volume, midline shift, herniation markers, and percentage ipsilateral thalamic volume reduction. Functional outcomes were assessed at discharge and 90 days using the Full Outline of UnResponsiveness score, National Institutes of Health Stroke Scale, modified Rankin Scale, Barthel Index, and Disability Rating Scale. Logistic regression and receiver operating characteristic analyses were performed. Mean ipsilateral thalamic volume reduction was 15.1%. Each 1% increase in thalamic volume loss independently increased the odds of poor functional outcome, defined as modified Rankin Scale scores of 5-6, at discharge and 90 days. Greater thalamic distortion was associated with higher National Institutes of Health Stroke Scale scores. Receiver operating characteristic analysis demonstrated good discrimination, with optimal thresholds of 14% at discharge and 19% at 90 days. Increased thalamic compression was associated with postoperative infections and longer hospital stays. Preoperative ipsilateral thalamic volume reduction is a strong imaging biomarker for predicting outcomes after decompressive craniectomy in malignant middle cerebral artery infarction.

Neuromyelitis optica spectrum disorder (NMOSD) is a severe autoimmune disorder affecting the central nervous system, often misdiagnosed as multiple sclerosis. The identification of aquaporin-4-IgG (AQP4-IgG) has improved diagnostic precision and enabled targeted therapies. Given the unique regional challenges in healthcare delivery across the Middle East and North Africa (MENA) region, the Middle East and North Africa Committee for Treatment and Research in Multiple Sclerosis (MENACTRIMS) convened an expert panel to develop evidence-based, region-specific consensus recommendations for diagnosis and management. These guidelines endorse the 2015 International Panel for NMO Diagnosis (IPND) criteria, emphasizing AQP4-IgG testing via cell-based assays. Differential diagnosis should consider multiple sclerosis, myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), and acute disseminated encephalomyelitis (ADEM). For acute treatment: initiate high-dose intravenous methylprednisolone promptly and use plasma exchange early for severe or steroid-refractory attacks. For long-term immunotherapy, monoclonal antibodies (rituximab, inebilizumab, eculizumab, ravulizumab, satralizumab, or tocilizumab) are recommended according to availability and patient factors; conventional immunosuppressants remain alternatives when biologics are inaccessible. Guidance is provided for pediatric patients and for pregnancy and breastfeeding, including planning after ≥ 12 months of disease stability and early postpartum treatment resumption. These MENACTRIMS guidelines aim to improve NMOSD outcomes across the region by promoting accurate diagnosis and timely, effective therapy.

Diabetic ketoacidosis (DKA) is a severe diabetic emergency usually triggered by an infection or missed insulin doses. Concurrent myocardial infarction, though an uncommon precipitating factor, complicates diagnosis and management due to overlapping clinical features and contradictory management challenges. We report the case of a 51-year-old male patient with type 2 diabetes mellitus, hypertension, and dyslipidemia, who presented with a two-day history of central chest pain radiating to the left arm, associated with nausea, vomiting, exertional dyspnea, and orthopnea. On examination, he was hypotensive, tachycardic, and clinically dehydrated. Initial investigations revealed sinus tachycardia with ST-segment depression in leads V4, V5 and V6 on ECG, severe hyperglycemia (glucose 20.1 mmol/L), ketonemia (>7 mmol/L), and high anion gap metabolic acidosis (pH 7.06, bicarbonate 9 mmol/L), confirming DKA.Management was initiated with intravenous fluid resuscitation and insulin infusion. Troponin T was elevated at 56.2 ng/L, raising concern for non-ST-elevation myocardial infarction (NSTEMI). The cardiology team recommended conservative management with dual antiplatelet therapy, statins, beta-blockers, ACE inhibitors, and low molecular weight heparin. The patient required non-invasive ventilation in the ICU due to oxygen desaturation and pulmonary congestion. Serial troponins peaked at 429 ng/L. Coronary angiography revealed multi-vessel coronary artery disease. Transthoracic echocardiography showed regional wall motion abnormalities with an ejection fraction (EF) of 40-45%. The patient subsequently underwent coronary artery bypass grafting (CABG) at an external center and has since shown favorable recovery. This case underscores the rare but clinically significant presentation of NSTEMI-induced DKA. The systemic inflammatory state and catecholamine surge during myocardial infarction may precipitate metabolic decompensation in patients with diabetes. Co-management requires a careful balance between aggressive fluid resuscitation for DKA and the risk of exacerbating cardiac dysfunction. Early recognition, multidisciplinary coordination, and risk stratification are essential for optimizing outcomes.

Background: This study investigated how static postural parameters influence dynamic spinopelvic balance across varying walking speeds. One hundred healthy young adults (aged 18-25) underwent rasterstereographic assessment (DIERS 4Dmotion®) to quantify static global alignment metrics including craniovertebral angle (CVA), Q-angle, sagittal and coronal imbalance, pelvic rotation, torsion, obliquity, vertebral rotation, thoracic kyphosis, lumbar lordosis, and pelvic tilt, followed by dynamic spinopelvic analysis during treadmill walking at 1, 2, 4, and 5 km/h. Methods: Multiple linear regression models were used to determine the predictive value of static postural measures for dynamic outcomes at each speed. At slower walking speeds (1-2 km/h), static alignment variables significantly predicted dynamic spinopelvic parameters (adjusted R2 = 0.53-0.73; RMSE = 0.59-0.81), with CVA, sagittal imbalance, and pelvic torsion emerging as the most consistent predictors. Results: At higher speeds (4-5 km/h), predictive strength declined substantially (adjusted R2 = 0.04-0.34), indicating a shift from posture-driven to neuromuscular-governed gait control. The Q-angle showed limited and inconsistent predictive value across all conditions. Conclusions: Overall, static postural alignment, particularly CVA, sagittal imbalance, and pelvic torsion, serves as a moderate predictor of spinopelvic dynamics at slow to moderate gait speeds but loses explanatory power as velocity increases, emphasizing the growing role of neuromuscular control in maintaining dynamic balance. These findings highlight the clinical relevance of integrating both static and dynamic assessments to comprehensively evaluate postural and locomotor function.

( Anesth Analg . 2025;140(5):1230-1232. doi: 10.1213/ANE.0000000000007287) Acetaminophen (also known as paracetamol) is widely used for pain relief in various clinical settings. Introduced as an intravenous (IV) medication in Europe in 2002 and in the United States in 2010, it offers quick analgesic effects. However, the IV administration process carries significant risk for errors, including mistakes in dosage, rate, and particularly route of administration. Misconnections between IV and epidural lines can lead to serious complications, especially during perioperative care when neuraxial devices are in use. This study reviewed documented incidents where acetaminophen was mistakenly administered through an epidural catheter.

Background: Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting women of reproductive age, characterized by insulin resistance, hyperandrogenism, and menstrual irregularities, which contribute to both metabolic and psychological challenges. Yoga therapy, as a holistic mind–body intervention, may provide benefits, although the evidence requires updating. This study aimed to assess the impact of yoga therapy on metabolic, endocrine, reproductive, and psychological outcomes in women with PCOS through a systematic review and meta analysis of randomized controlled trials (RCTs). Methods: Following the PRISMA 2020 guidelines, we searched PubMed, Embase, Cochrane, Scopus, and Google Scholar from January 2020 to May 2025 for RCTs on yoga for PCOS. Two reviewers screened the data, extracted the data, and assessed the risk of bias (RoB). Random-effects meta-analysis pooled outcomes and grading of recommendations assessment, development, and evaluation was used to evaluate certainty. Results: Eight RCTs involving 632 participants were included (median n = 52; moderate RoB). Yoga reduced metabolic homeostatic model assessment of insulin resistance (mean difference [MD] −0.58, 95% confidence interval [CI] −1.05–−0.11; I2 = 0%; moderate certainty), fasting insulin (MD −15.2 pmol/L, 95% CI −25.4–−5.0; I2 = 15%), testosterone (MD −10.44 ng/dL, 95% CI −14.12–−6.76; I2=19%), and depression (MD −4.69, 95% CI −5.63–−3.76; I2 = 75%; low certainty). Menstrual regularity improved (RR 1.45, 95% CI 1.10–1.92; I2 = 20%; moderate certainty). The effects on BMI and glucose levels were modest and uncertain. The subgroups showed greater benefits at ≥12 weeks/≥150 min/week. No adverse events. Conclusion: Yoga has demonstrated modest improvements in outcomes for individuals with PCOS, with moderate certainty regarding its metabolic and endocrine benefits. As a safe adjunctive therapy, it merits consideration for integration into patient care in the future. To confirm these findings over the long term, large multicenter RCTs with standardized protocols are required.

IntroductionDiabetic ketoacidosis (DKA) is a potentially fatal diabetes complication marked by hyperglycemia, ketonemia, and acidosis that remains a major global healthcare burden despite advances in diabetes management. The aim of this study was to quantify the healthcare costs of DKA admissions at a tertiary hospital in the United Arab Emirates (UAE), and evaluate cost-effective preventative strategies.MethodsA retrospective electronic record analysis of all DKA admissions from 2019 to 2023 at Tawam Hospital, Al Ain, was conducted after ethical approval from Tawam Human Research Ethics Committee, approval number MF2058-2023-916. Clinical characteristics, precipitating factors, length of stay, insurance status, and total inpatient costs were analyzed for all consecutive adult (≥ 16 years) DKA admissions over this period. The cost of DKA-related admission was compared to the price of insulin therapy in underinsured patients who are unable to afford insulin.ResultsThere were 134 patients admitted with DKA (157 admissions) over 5 years (one DKA admission every 11.6 days). The mean hospitalization cost per DKA admission was 12,274 ± 10,213 USD (45,461 ± 37,826 AED), with an average length of stay of 10.2 ± 11.7 days (1203 USD [4,457 AED] per day). Insulin unaffordability, a preventable factor, led to 13.4% (21 cases) of admissions, incurring a total cost of 257,765 USD (954,686 AED). Underinsured patients demonstrated significantly higher ICU utilization (76.8% vs 52.5%, p < 0.01) and mean costs (14,269 USD [52,847 AED] vs 11,133 USD [41,235 AED], p = 0.07) compared to adequately insured patients. In comparison, the average cost of insulin is 38 USD (139.5 AED) per patient/month, indicating that the cost of one preventable DKA admission equals 27 years of insulin therapy. The overall mortality rate of DKA admissions was 4.5%.ConclusionDKA imposes a substantial economic and clinical burden in the UAE, with mean hospitalization costs of 12,274 USD per admission. While insulin unaffordability accounts for 13.4% of admissions (costing 257,765 over 5 years), infections represent the largest precipitating factor at 49.0%. Comprehensive DKA prevention requires a multifaceted approach: infection management education, ensuring insulin access for underinsured patients, and structured diabetes education. Our analysis suggests that addressing insulin affordability could be economically favorable, as preventing one DKA admission would offset 27 years of insulin costs. However, optimal resource allocation requires addressing all major precipitating factors to achieve meaningful reductions in DKA burden.Graphical abstract available for this article.Graphical Supplementary InformationThe online version contains supplementary material available at 10.1007/s13300-025-01812-w.