Persistent Peril: Recurrent Deep Vein Thrombosis and Pulmonary Embolism in a Patient With Protein S Deficiency Despite Optimal Anticoagulation Therapies.

The clotting system has evolved as an adaptive mechanism to prevent blood loss during vascular damage. However, the intricate nature of the clotting cascade and the complexities of human life can sometimes lead to the unnatural activation of this delicate cascade. This can result in blood clot formation within the cardiovascular system, contributing to a wide range of pathological conditions. Abnormal intravascular coagulation most commonly occurs in the deep veins of the lower extremities, and can emboli to other organs, hence, it is termed "venous thromboembolism" (VTE). In this report, we introduce a challenging case of VTE that poses a dilemma for current medical management. The patient with possible protein S deficiency underwent various guideline-directed medical treatments, yet experienced recurrent VTE episodes, including deep vein thrombosis (DVT) and pulmonary embolism (PE), leading to hospital readmissions. This case report sheds light on our challenges in effectively treating VTE.

Anti-N-Methyl-D-Aspartate Receptor Encephalopathy in a Young Female.

Widely distributed in the central nervous system (CNS), N-methyl-D-aspartate receptors (NMDARs) are believed to be involved in long-term potentiation, essential in regulating and forming memory. This condition primarily occurs in young females because of autoantibodies forming against the N-methyl-D-aspartate receptor-1 (NR1) or N-methyl-D-aspartate receptor-2 (NR2) subunits of NMDAR in the CNS, ultimately portraying a unique psychoneurological phenomenon. Patients with antibodies against NMDAR present with a combination of neurological and psychiatric signs and symptoms. This article presents a case of a young female with no significant past medical, psychological, or surgical history. While being previously diagnosed with acute psychosis, upon arrival at the emergency department (ED), she also displayed an acute decline in judgment, hallucinations, severe agitation, and peculiar behavior, prompting family members to seek medical attention. Consequently, she was evaluated for metabolic and infectious encephalopathy. Following a thorough examination and extensive laboratory imaging, the patient was found to have NMDAR antibody encephalopathy. After dedicated treatment, her two-month follow-up presented a complete resolution of symptoms.

Clinical and functional outcomes of 405 Achilles tendon ruptures after a minimum follow-up of 1 year.

OBJECTIVE: The results of surgical versus conservative treatment of acute Achilles tendon ruptures are still controversial. The objective of this study was to compare surgical and conservative treatment at a minimum follow-up of 1 year in terms of the complications, functional outcomes and clinical results. HYPOTHESES: There is no difference in the complications, clinical results and functional outcomes between the two treatment groups. There is no difference in the occurrence of complications or the clinical results due to the immobilization or rehabilitation protocols. METHODS: This was a retrospective comparative, multicenter, non-randomized study of acute Achilles tendon ruptures treated between 01/01/2018 and 31/12/2019 at 21 study sites in France. All patients who received surgical or conservative treatment were included. The demographics, sports participation, nature of treatment, immobilization parameters (type, duration, position) and rehabilitation protocol were collected. Rerupture, general and specific complications, clinical results (heel-rise test, single-leg hop, calf circumference, ankle dorsiflexion) and the functional outcomes (ATRS, VISA-A, EFAS, SF-12) were collected at the final review. RESULTS: Four hundred five patients were reviewed at a mean follow-up of 24 (±7) months. Surgical treatment was done in 372 patients (92%) and conservative treatment in 33 patients (8%), with these two sets of patients having comparable preoperative characteristics. There was a similar number of reruptures in the conservative group (3 cases, 9%) as in the surgical group (15 cases, 4%) (p=0.176). There were more general complications in the conservative group (24%) than in the surgical group (11%) (p=0.04). There was a 9% rate of surgery-related complications (infection, nerve damage, anesthesia after-effects). The ATRS (p=0.017), EFAS Total (p=0.013), EFAS daily living (p=0.008), and SF-12 physical (p=0.01) were better in the surgical group. Strict then relative immobilization provided the best balance between functional recovery (EFAS total of 33, p<0.01) and tendon lengthening (0°, p=0.01) without increasing the occurrence of rerupture (2%, p=0.18). Early weightbearing accompanied by immobilization and rehabilitation within 30 days did not lead to more reruptures than if it was started beyond 30 days (p=0.082 and p=0.07). CONCLUSIONS: This study found no differences in the number of reruptures between surgical treatment and conservative treatment of acute Achilles tendon ruptures. Surgical treatment led to better clinical results but had a variable effect on improving the functional scores. No matter which treatment is used, in the ideal case, 3 weeks of strict immobilization in equinus should be followed by progressive reduction over the next 3 weeks. Early weightbearing and mobilization within 30 days did not increase the risk of rerupture; it actually optimized the clinical and functional outcomes. LEVEL OF EVIDENCE: III; retrospective comparative, non-randomized.

Designing, implementation and evaluation of story reading: a solution to increase general empathy in medical students.

BACKGROUND: Communication and mutual understanding among healthcare providers is a significant concern within the healthcare system, and enhancing empathy is one way to foster effective communication and mutual understanding. The aim of this research is to evaluate and compare the impact of story reading on the level of empathy in medical students at Mazandaran University of Medical Sciences. METHODS: The study employed an intervention educational design (a quasi-experimental), with a convenience sample of 51 medical students selected as the statistical population. The process of story reading was conducted over six two-hour virtual sessions in the students' classroom, spanning six weeks. Selected stories were discussed in an online virtual class under the supervision of an instructor, focusing on story elements. To assess students' empathy in this educational program, the Davis General Empathy Questionnaire was administered before each of the six sessions, after, and one week later at the end of the course. Statistical analysis of the collected data was performed using repeated measures analysis of variance and Bonferroni's post hoc test through SPSS version 28 software, with a significance level set at 0.05. RESULTS: The findings revealed that 27 participants (58.7%) were female students, with the remaining being male students, having an average age of 19.5 ± 0.86 years. The level of general empathy among the students significantly increased after the intervention compared to before the intervention (P<0.001). Furthermore, the analysis of variance with repeated measures indicated a significant effect of the story reading program on enhancing empathy in terms of emotional and cognitive transfer among students in the intervention group (P<0.001). CONCLUSIONS: The research findings suggest that the story reading program effectively enhances the overall sense of empathy among medical students at the University of Medical Sciences. Therefore, implementing this method in universities, higher education centers, libraries, and psychology centers for teaching empathy can be valuable in fostering empathy skills and improving healthcare.

Takotsubo Cardiomyopathy Induced by Stress From Amyotrophic Lateral Sclerosis and a Mechanical Fall.

Named after the Japanese octopus trap, Takotsubo cardiomyopathy is an acute myocardial condition characterized by a reversible ventricular dysfunction with ballooning of the left ventricle (LV) during systole. A catecholamine surge is likely the primary mechanism responsible for myocardial damage in this condition. The association between amyotrophic lateral sclerosis (ALS) and Takotsubo cardiomyopathy has not been well established. We present a unique case of Takotsubo cardiomyopathy diagnosed in a patient with ALS who presented after a fall with shortness of breath, generalized weakness, and hypotension. She was found to have troponinemia, elevated brain natriuretic peptide, and Osborn waves without ST-segment changes noted on electrocardiography (EKG). The diagnosis of Takotsubo cardiomyopathy was confirmed via transthoracic echocardiography (TTE), which revealed reduced left ventricular ejection fraction, apical ballooning of the LV, akinesis of the ventricular apex, and hyperkinesis of the base of the heart. Coronary angiography revealed no coronary artery disease. She was managed medically and was hemodynamically stable at the time of discharge.

Enhancing residents' neonatal resuscitation competency through team-based simulation training: an intervention educational study.

BACKGROUND: Neonatal resuscitation training in a simulated delivery room environment is a new paradigm in pediatric medical education. The purpose of this research is to highlight team-based simulation as an effective method of teaching neonatal resuscitation to senior pediatric residents. METHODS: In an intervention educational study, we evaluated the impact of team-based simulation training in the development of neonatal resuscitation. A team consisting of a three-person group of senior pediatric residents performed neonatal resuscitation on a low-fidelity newborn simulator based on the stated scenario. Video-based structured debriefing was performed and followed by the second cycle of scenario and debriefing to evaluate the feasibility of conducting team-based simulation training in a lesser-resourced environment. Evaluation criteria included megacode scores which is a simulation performance checklist, pre-and post-test scores to evaluate residents' knowledge and confidence, the survey checklist as a previously developed questionnaire assessing residents' satisfaction, and debriefing from live and videotaped performances. Four months after the end of the training course, we measured the behavioral changes of the residents by conducting an OSCE test to evaluate post-training knowledge retention. Mean ± SD was calculated for megacode, satisfaction (survey checklist), and OSCE scores. Pre- and post-program gains were statistically compared. The first three levels of Kirkpatrick's training effectiveness model were used to evaluate the progress of the program. RESULTS: Twenty-one senior residents participated in the team-based simulation. The mean ± SD of the megacode score was 35.6 ± 2.2. The mean ± SD of the overall satisfaction score for the evaluation of the first level of the Kirkpatrick model was 96.3 ± 3.7. For the evaluation of the second level of the Kirkpatrick model, the pre-posttest gain in overall confidence score had a statistically significant difference (P = 0.001). All residents obtained a passing grade in OSCE as an evaluation of the third level. CONCLUSIONS: Team-based simulation training in neonatal resuscitation improves the knowledge, skills, and performance of pediatric residents and has a positive effect on their self-confidence and leadership skills. There is still a need to investigate the transfer of learning and abilities to real-life practice, and further research on cost-effectiveness and impact on patient outcomes is warranted.

CICIoT2023: A Real-Time Dataset and Benchmark for Large-Scale Attacks in IoT Environment.

Nowadays, the Internet of Things (IoT) concept plays a pivotal role in society and brings new capabilities to different industries. The number of IoT solutions in areas such as transportation and healthcare is increasing and new services are under development. In the last decade, society has experienced a drastic increase in IoT connections. In fact, IoT connections will increase in the next few years across different areas. Conversely, several challenges still need to be faced to enable efficient and secure operations (e.g., interoperability, security, and standards). Furthermore, although efforts have been made to produce datasets composed of attacks against IoT devices, several possible attacks are not considered. Most existing efforts do not consider an extensive network topology with real IoT devices. The main goal of this research is to propose a novel and extensive IoT attack dataset to foster the development of security analytics applications in real IoT operations. To accomplish this, 33 attacks are executed in an IoT topology composed of 105 devices. These attacks are classified into seven categories, namely DDoS, DoS, Recon, Web-based, brute force, spoofing, and Mirai. Finally, all attacks are executed by malicious IoT devices targeting other IoT devices. The dataset is available on the CIC Dataset website.

CapsRule: Explainable Deep Learning for Classifying Network Attacks.

Despite the potential deep learning (DL) algorithms have shown, their lack of transparency hinders their widespread application. Extracting if-then rules from deep neural networks is a powerful explanation method to capture nonlinear local behaviors. However, existing rule extraction methods suffer from inefficiency, incomprehensibility, infidelity, and not scaling well. Concerning security applications, they are not optimized regarding the decision boundary, data types and ranges, classification tasks, and dataset size. In this article, we propose CapsRule, an effective and efficient rule-based DL explanation method dedicated to classifying network attacks. It extracts high-fidelity rules from the feed-forward capsule network that explains how an input sample is classified. Using precomputed coupling coefficients, the training phase overlaps the rule extraction process to increase efficiency. The activation vector of a capsule can represent semantic intelligence about the attributes of the input sample. The rules extracted from CapsRule address the major concerns of network attack detection. The rules: 1) approximate the nonlinear decision boundary of the underlying data; 2) reduce the number of false positives significantly; 3) increase transparency; and 4) help find errors and noise in the data. We evaluate CapsRule on the CICDDoS2019 dataset that contains over a million of the most advanced Distributed Denial-of-Service (DDoS) attacks. The extensive evaluation shows that it generates accurate, high-fidelity, and comprehensible rules. CapsRule achieves an average accuracy of 99.0% and a false positive rate of 0.70% for reflection-and exploitation-based attacks. We verify that the learned features from the rulesets match our domain-specific knowledge. They also help find flaws in the dataset generation process and erroneous patterns caused by attack simulators.

Liquefaction Potential of Saturated Sand Reinforced by Cement-Grouted Micropiles: An Evolutionary Approach Based on Shaking Table Tests.

Cement-grouted injections are increasingly employed as a countermeasure material against liquefaction in active seismic areas; however, there is no methodology to thoroughly and directly evaluate the liquefaction potential of saturated sand materials reinforced by the cement grout-injected micropiles. To this end, first, a series of 1 g shaking table model tests are conducted. Time histories of pore water pressures, excess pore water pressure ratios (ru), and the number of required cycles (Npeak) to liquefy the soil are obtained and modified lower and upper boundaries are suggested for the potential of liquefaction of both pure and grout-reinforced sand. Next, adopting genetic programming and the least square method in the framework of the evolutionary polynomial regression technique, high-accuracy predictive equations are developed for the estimation of rumax. Based on the results of a three-dimensional, graphical, multiple-variable parametric (MVP) analysis, and introducing the concept of the critical, boundary inclination angle, the inclination of micropiles is shown to be more effective in view of liquefaction resistivity for loose sands. Due to a lower critical boundary inclination angle, the applicability range for inclining micropiles is narrower for the medium-dense sands. MVP analyses show that the effects of a decreasing spacing ratio on decreasing rumax are amplified while micropiles are inclined.

Dental Infection Causing Methicillin-Resistant Staphylococcus aureus Bacteremia and Spinal Infection: A Case Report.

Poor dentition as a source of infection causing bacteremia and spinal infections (such as paraspinal abscess, and discitis) should be considered even in the absence of recent dental surgery. The case presents a patient found to have an infection in the cervical and thoracic spine, methicillin-resistant Staphylococcus aureus bacteremia, and poor dentition. Although the patient had a history of drug use, he denied a history of intravenous drug use. He had Crohn's disease that resulted in periodontal and endodontal tooth disease. The patient was found to have poor dentition with erythematous gums. He had not been to the dentist in over 24 years and had active dental caries. Since he presented with bacteremia and a spinal infection, it is likely the patient had an infection in the oral cavity that spread hematogenously to the blood, and then the spine. This report highlights the importance of considering tooth infections as the source of bacteremia and spinal infections.

Perceived Challenges Caused by Covid-19 Outbreak in Students of Medical Sciences.

Background: Students of medical sciences are a highly vulnerable group during COVID-19 pandemic who may experience a wide range of challenges and stresses. The aim of this study was to investigate the perceived challenges caused by COVID-19 outbreak in students of medical sciences. Materials and Methods: A qualitative study was carried out based on conventional qualitative content analysis following Graneheim and Lundman from December 2020 to February 2021. The participants were 17 students of medical sciences and data gathering was done through semistructured interviews. Results: Data analyses revealed 5 categories and 12 subcategories. The extracted categories were perceived fear of contracting coronavirus, social limitation, changes in education, neglecting health protocols, and worrying news and information overload. Conclusions: The findings indicated that students of medical sciences had been facing challenges and the COVID-19 had affected the psychological, social, and academic functioning of the health-care students. It is important to take measures to improve their mental health. These measures can prevent medical complications in these students, especially during clinical internship.

The impact of intra-sacroiliac joint methylprednisolone injection in the recovery of patients with spondyloarthropathy: a randomized controlled trial.

Introduction: Spondyloarthropathies are a group of chronic inflammatory diseases with specific clinical symptoms in rheumatic diseases. These patients suffer from pain in the joints. Physicians have tried several ways to decrease the pain in these patients. This study aimed to evaluate the effect of intra-sacroiliac joint methylprednisolone injection under the guidance of ultrasonography in spondyloarthropathy patients. Material and methods: In this randomized control trial we studied 60 patients with spondyloarthropathy (30 patients in the intervention group and 30 patients in the control group) from January 2020 to December 2020. The intervention group patients received 40 mg of intra-sacroiliac joint (SIJ) methylprednisolone injection at the beginning in addition to treatment with nonsteroidal anti-inflammatory drugs (inflammatory dose) and sulfasalazine (2 to 3 g/day). Patients' pain intensity and symptoms were assessed in the 2nd, 4th, 6th, and 8th weeks after glucocorticosteroid injection. Quantitative factors were compared by independent Student's t-test. Data analysis was performed using SPSS version 22.0 software. A p-value < 0.005 was considered significant. Results: There were no statistically significant differences in Visual Analogue Scale (VAS) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) criteria and finger-to-floor (FTF) levels in the intervention and control groups. There were significant differences in VAS and BASDAI criteria and FTF levels 2 weeks after the injection, and this difference remained the same until the end of the 8th week. The p-value was significant (p-value < 0.0001). Conclusions: The sacroiliac joint methylprednisolone injection approach with ultrasound guidance seems to be effective in pain relief and function, and patient satisfaction scores. Additionally using the guidance of ultrasonography in this approach is without the risk of radiation exposure.

Desmopressin Acetate in Percutaneous Ultrasound-Guided Native Kidney Biopsy in Patients with Reduced Kidney Function: A Double-Blind Randomized Controlled Trial.

INTRODUCTION: Bleeding events are the most common complications after kidney biopsy. This study aims to evaluate the effect of desmopressin administration on bleeding complication, in native kidney biopsy candidates with reduced kidney function. METHODS: This double-blind randomized clinical trial enrolled 18 to 80 years old patients with 15 < eGFR < 90 mL/min/ 1.73m² from July 2017 to August 2020. Patients were randomly assigned to receive either 3 µg/kg of intranasal desmopressin acetate or 1 mL/kg of intranasal sodium chloride 0.65%, one hour before ultrasound-guided, percutaneous native kidney biopsy. The primary outcome was the post-biopsy bleeding complications, and secondary outcomes were the volume of perirenal hematoma, and changes of post-biopsy hemoglobin and hematocrit level, plasma sodium and blood pressure (Clinical Trial Registration ID: IRCT20090701002112N3). RESULTS: A total of 120 patients (58 men and 62 women), 60 patients in each group, were analyzed. The mean age and eGFR of the patients were 45.29 ± 15.95 years and 51.77 ± 18.02 ml/min/ 1.73m², respectively. Desmopressin administration significantly decreased post-biopsy perirenal hematoma compared to placebo (7/60 [11.6%]) vs. 33/60 [40%]; P < .05), and the hematoma volume was significantly smaller in the desmopressin group, in case of hematoma formation (2.31 ± 1.17 vs. 7.72 ± 5.45 mm³, P < .05). CONCLUSION: Desmopressin administration before kidney biopsy is a safe and effective strategy to prevent bleeding complications. Considering absolute risk reduction of about 28%, the number needed to treat is about 4 procedures. We recommend considering desmopressin administration before percutaneous native kidney biopsy.  DOI: 10.52547/ijkd.6966.

Exploration the role of a clinical supervisor to improve the professional skills of medical students: a content analysis study.

BACKGROUND AND PURPOSE: Clinical supervision supports learners and paves the way for effective and efficient learning in clinical settings. This study aimed to explain the responsibilities of clinical supervisors in clinical education wards to improve the professional skills of medical students. MATERIALS AND METHODS: In this qualitative study, we used the conventional content analysis approach. The sample consisted of 16 faculty members of medical sciences and medical graduates of Iranian universities. Purposeful sampling and semi-structured interviews were used to collect data. The Graneheim and Lundman method (2004) analyzed the data. RESULTS: From the analysis of interviews, 2 themes, 8 categories, and 18 subcategories were obtained. "Clinical supervisor responsibilities" as a theme includes the categories: "Creating motivation in learner", "Learner's need recognition", "Performance evaluation", "Creating learning opportunities", and "Professional ethics education". And, the sub-categories were: "Creating a supportive atmosphere", "Task assignment","Understanding training needs", "Understanding individual needs", "Periodic evaluation", "Proper feedback', "Reduce work stress", "Learner engagement' , "Learning Facilitation", "Attention to the patient's treatment", and "Ethical observance in relation to patients". As the second theme "Clinical supervisor characteristics" included the categories of: "Scientific competence", "Leading role", and "Ethical model". Their sub-categories are clustered as: "Knowledge of educational concepts", "Mastery of professional concepts", "Effective communication skills", "Understanding managerial concepts", "High resilience", "Career commitment ", and "social commitment" . CONCLUSIONS: The clinical supervisor will improve the professional skills of medical students, which will improve the quality of services provided, train efficient graduates, and provide a safe and relaxing environment that leads to patient satisfaction.

Towards the third generation universities: The core innovative function approach.

Background: Undoubtedly, economic and social value added depends on the functions of universities. Moving toward third-generation universities (3rd GU) is an inevitable process. These universities need different functions than traditional ones; therefore, identifying and determining their functions is essential. The purpose of this study is to collect, match and explore the functions of universities in the transition to 3rd GU and ultimately offer a functional model of the 3rd GU for the use of professors, academics and policymakers in order to evaluate and promote universities. Methods: A critical review method was adapted. Literature was included based on their relevant empirical data to research objectives and referral rates, and texts with more conceptual richness entered the study without time limitations. Results: A total of 20 texts were included in the final analysis. While presenting the basic model, extracts the overarching concepts associated with the success of 3rd GU. These key concepts include the 7 core functions of innovative and entrepreneurial activities, supportive activities (financial and non-financial), entrepreneurial education ( curriculum and academic workforce empowerment), creation and provide applied knowledge, boundary-spanning function or communications and interactions with other elements of the national innovation system (state and industry), develop innovative and entrepreneurial culture and institutional governance and leadership in the direction of economic growth and development. Conclusion: Using new functions at universities would be a move toward 3rd GU, economic growth and development in the country. So, these functions are a practically useful guide to policymakers to estimate the rate of success in each university and deliver the necessary suggestions to provide the mechanisms for the establishment of a successful university.

Vowel duration measurement in school-age children with cochlear implant.

OBJECTIVES: Normal hearing system is an essential factor for accurate production of speech segments. It seems that cochlear implant prosthesis helps children with hearing impairment to speak more accurately than before receiving prosthesis. The current research aimed to compare the vowel duration in school-aged children with cochlear implants and that in children with normal hearing. Additionally, the performance of girls and boys in two groups were investigated. METHODS: A cross-sectional and descriptive-analytical study was carried out to compare the vowel duration in 9- to 12-year-old children with cochlear implant and those with normal hearing. Participants were 52 children who were matched by age and sex. We asked the children to read the target words with each word including one vowel and then participants' voice samples were recorded. Then, vowel duration was measured using Praat software. Finally, the vowel duration was compared between the two groups running independent sample t-test. The level of significance was (P < 0.05). RESULTS: There was no statistically significant difference observed between the two groups in the mean values of the vowel duration for the six Persian vowels (P > 0.05). Also, no significant difference was found between boys and girls in the mean value of the vowel duration between the two groups (P > 0.05). CONCLUSION: Persian vowels in school-aged children with cochlear implant and with typical hearing are produced with similar durations. This finding is probably related to the increased duration of using prosthesis in this age range and speech mode used to measure vowel duration in the present study.

Structural Requirements of the Third-Generation University: The Case of Medical Sciences Universities in Iran.

INTRODUCTION: Given the social, economic, environmental and internal developments of universities, the necessity for medical universities to move to being third-generation universities has been demonstrated. These universities, along with the requirements of entrepreneurship and commercialization of research, are in need of structural requirements. This study was conducted with the aim to identify and introduce the structural requirements of medical sciences universities in Iran in the transition to the third-generation universities. MATERIALS AND METHODS: This study was a qualitative approach using a conventional content analysis method. The contributors comprised 16 faculty members working in medical universities in Iran who were purposefully recruited and interviewed face to face in semi-structured interviews between October 2018 and March 2019. RESULTS: Two wide classifications containing macro-structural requirements (institutional requirements) and micro-structural requirements (organizational requirements) were developed. Institutional requirements included four subcategories including redefining the university as a holding of knowledge business units, redefining academic units as a strategic business unit (SBU) which refer to the mission of the universities and eliminate bureaucracy, independence, and 'Competition in recruitment and contracts' which refer to the administrative requirements of the universities. The organizational requirements included units and offices, centers, and parks that are grouped because of similarities in internal processes. CONCLUSION: Medical universities need structural requirements to move to third-generation universities and improve infrastructure. These requirements, which develop in a spiral over time, must be appropriate and tailored to the capacity of each university.

Hy-Bridge: A Hybrid Blockchain for Privacy-Preserving and Trustful Energy Transactions in Internet-of-Things Platforms.

In the current centralized IoT ecosystems, all financial transactions are routed through IoT platform providers. The security and privacy issues are inevitable with an untrusted or compromised IoT platform provider. To address these issues, we propose Hy-Bridge, a hybrid blockchain-based billing and charging framework. In Hy-Bridge, the IoT platform provider plays no proxy role, and IoT users can securely and efficiently share a credit with other users. The trustful end-to-end functionality of blockchain helps us to provide accountability and reliability features in IoT transactions. Furthermore, with the blockchain-distributed consensus, we provide a credit-sharing feature for IoT users in the energy and utility market. To provide this feature, we introduce a local block framework for service management in the credit-sharing group. To preserve the IoT users' privacy and avoid any information leakage to the main blockchain, an interconnection position, called bridge, is introduced to isolate IoT users' peer-to-peer transactions and link the main blockchain to its subnetwork blockchain(s) in a hybrid model. To this end, a k-anonymity protection is performed on the bridge. To evaluate the performance of the introduced hybrid blockchain-based billing and charging, we simulated the energy use case scenario using Hy-Bridge. Our simulation results show that Hy-Bridge could protect user privacy with an acceptable level of information loss and CPU and memory usage.

Evaluating the Relationship Between Serum Level of Interleukin-6 and Rheumatoid Arthritis Severity and Disease Activity.

AIM: The aim of this study was to evaluate the relationship between Interleukin-6 (IL-6) serum level and the severity and activity of Rheumatoid Arthritis (RA). METHODS: In this cross-sectional study, 120 RA patients referred to the rheumatology clinic, the patients were diagnosed by rheumatologists according to ACR / EULAR 2010 criteria. Based on DAS28 score the patients were divided into 4 groups: Remission, Mild, Moderate and Severe. Each group contained 30 patients. Serum levels of Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP), anti-Cyclic Citrullinated Peptide (anti-CCP) and Rheumatoid Factor (RF) and serum levels of IL-6, were measured. The relationship between these factors was measured and compared to the relationship between IL-6 and these factors, and the activity of the disease was evaluated based on DAS-28. RESULTS: This study showed that the serum level of IL-6 has a significant relationship with RA activity according to DAS-28 (P value <0.001). There is also a significant relationship between the ESR level, the number of painful joints, and the number of swollen joints, and the severity of the disease based on VAS. CONCLUSION: Generally the findings of this study indicate that serum level of IL-6 plays an important role in the severity and activity of RA disease and can be considered as a determining factor in evaluating the severity of RA in RA patients and it is a good guide for a step up or down of treatment.

Prevention of Contrast-induced Nephropathy in Patients with Chronic Kidney Disease Undergoing Elective Coronary Angioplasty or Angiography with Sodium Potassium Citrate Solution, a Double Blind Randomized Clinical Trial.

INTRODUCTION: Contrast-induced nephropathy (CIN) is a frequent complication of contrast exposure. A recent study suggested that Na/K citrate might have a preventive role. We investigated the efficacy of Na/K citrate to prevent CIN in patients with renal dysfunction undergoing coronary intervention. METHODS: The randomized, double-blind, placebo-controlled trial included 201 patients with estimated creatinine clearance < 90 mL/ min, randomized to receive oral Na/K citrate plus saline infusion (treatment group, 104 patients) or oral water plus saline infusion (placebo group, 97 patients). CIN was defined as an absolute increase of serum creatinine ≥ 0.5 mg/dL or a relative increase ≥ 25% or a relative decrease of estimated GFR ≥ 25% within 5 days. RESULTS: CIN occurred in 22 patients (12.29%); 10 (11%) in treatment group and 12 (13.6%) in placebo group (P > .05). Post-exposure Cr values were not significantly different between the two groups (1.18 ± 0.28 mg/dL in the placebo vs. 1.15 ± 0.29 mg/dL in the treatment group, P > .05). CIN-negative patients in the treatment group showed a significantly higher increase in urine pH than that of CIN-positive patients (1.642 ± 0.577 vs. 1.20 ± 0.422, P < .05). CONCLUSION: Na/K citrate solution is not effective for prophylaxis of CIN in patients with renal dysfunction. However, a probable preventive effect might exist in a subgroup of patients with at least 1.6 units increase in urine pH values following Na/K citrate administration.