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In this paper, a survey of the state of the art, challenges, and possibilities for aquatic surface robots is presented. To this end, a survey and classification of aquatic surface robots is first outlined. Then, different levels of autonomy are identified for this typology of robots and categorised into environmental complexity, mission complexity, and external system independence. From this perspective, a step-wise approach is adopted on how to increment aquatic surface robots abilities within guidance, navigation, and control in order to target the different levels of autonomy. Possibilities and challenges for designing aquatic surface robots as carriers for conducting research activities are discussed. The main goal of this paper is to further increase global efforts to realise the wide range of possible applications offered by aquatic surface robots and to provide an up-to-date reference as a benchmark for new research and development in this field.

Purpose Septic induced cardiomyopathy has a wide spectrum of presentation, being associated with systolic and/or diastolic dysfunction. There is currently no evidence of association between left ventricular (LV) systolic dysfunction and mortality in septic patients. Methods We conducted a systematic review and meta-analysis to investigate the association between systolic wave (s') obtained with Tissue Doppler Imaging (TDI) and mortality in septic patients. Secondary outcome was the association of LV ejection fraction with mortality. Results In the primary analysis we included a total of 13 studies (1197 patients, mortality 39.9%); overall s' wave was not significantly different between survivors and non-survivors (Standardized Mean Difference 0.20, 95%Confidence-Interval − 0.18, 0.59). This result was confirmed also in sub-groups analyses according to regional criteria of TDI sampling. A post-hoc analysis including only septic shock patients confirmed that s' wave was not associated with mortality. Several sensitivity analyses confirmed these results. We found no evidence of publication bias. The secondary analysis (11 studies, 1081 patients, mortality 36.7%) showed that LV ejection fraction was not associated with mortality (Mean Difference 0.98, 95% Confidence-Interval − 1.79,3.75). Conclusions There is no association between mortality and LV systolic function as evaluated by TDI s' wave in septic patients.

Purpose: Echocardiography is a common tool for cardiac and hemodynamic assessments in critical care research. However, interpretation (and applications) of results and between-study comparisons are often difficult due to the lack of certain important details in the studies. PRICES (Preferred Reporting Items for Critical care Echocardiography Studies) is a project endorsed by the European Society of Intensive Care Medicine and conducted by the Echocardiography Working Group, aiming at producing recommendations for standardized reporting of critical care echocardiography (CCE) research studies.Methods: The PRICE panel identified lists of clinical and echocardiographic parameters (the "items") deemed important in four main areas of CCE research: left ventricular systolic and diastolic functions, right ventricular function and fluid management. Each item was graded using a critical index (CI) that combined the relative importance of each item and the fraction of studies that did not report it, also taking experts' opinion into account.Results: A list of items in each area that deemed essential for the proper interpretation and application of research results is recommended. Additional items which aid interpretation were also proposed.Conclusion: The PRICES recommendations reported in this document, as a checklist, represent an international consensus of experts as to which parameters and information should be included in the design of echocardiography research studies. PRICES recommendations provide guidance to scientists in the field of CCE with the objective of providing a recommended framework for reporting of CCE methodology and results.

International audience; Haptic technology for human augmentation provides gains in ability for different applications, whether the aim is to enhance "disabilities" to "abilities", or "abilities" to "super-abilities". Commercially-available devices are generally expensive and tailored to specific applications and hardware. To give researchers a haptic feedback system that is economical, customisable, and fast to fabricate, our group developed a low-cost immersive haptic, audio, and visual experience built by using off-the-shelf (COTS) components. It is composed of a vibrotactile glove, a Leap Motion sensor, and an head-mounted display, integrated together to provide compelling immersive sensations. This paper proposes a higher technology readiness level (TRL) for the system to make it modular and reliable. To demonstrate its potential, we present two human subject studies in Virtual Reality. They evaluate the capability of the system in providing (i) guidance during simulated drone operations, and (ii) contact haptic feedback during virtual objects interaction. Results prove that the proposed haptic-enabled framework improves the performance and illusion of presence.

This review focuses on fluid management of critically ill patients. The topic is addressed based on 10 single questions with simplified answers that provide clinicians with the basic information needed at the point of care in treating patients in the Intensive Care Unit. The review has didactic purposes and may serve both as an update on fluid management and as an introduction to the subject for novices in critical care. There is an urgent need to increase awareness regarding the potential risks associated with fluid overload. Clinicians should be mindful not only of the indications for administering fluid loads and of the type of fluids administered, but also of the importance to set safety limits. Lastly, it is important to implement proactive strategies seeking to establish negative fluid balance as soon as the clinical conditions are considered to be stable and the risk of deterioration is low.

Highly-compliant elastic actuators have become progressively prominent over the last years for a variety of robotic applications. With remarkable shock tolerance, elastic actuators are appropriate for robots operating in unstructured environments. In accordance with this trend, a novel elastic actuator was recently designed by our research group for Serpens, a low-cost, open-source and highly-compliant multi-purpose modular snake robot. To control the newly designed elastic actuators of Serpens, a two-feedback loops position control algorithm was proposed. The inner controller loop is implemented as a model reference adaptive controller (MRAC), while the outer control loop adopts a fuzzy proportional-integral controller (FPIC). The performance of the presented control scheme was demonstrated through simulations. However, the efficiency of the proposed controller is dependent on the initial values of the parameters of the MRAC controller as well as on the effort required for a human to manually construct fuzzy rules. An alternative solution to the problem might consist of using methods that do not assume a priori knowledge: a solution that derives its properties from a machine learning procedure. In this way, the controller would be able to automatically learn the properties of the elastic actuator to be controlled. In this work, a novel controller for the proposed elastic actuator is presented based on the use of an artificial neural network (ANN) that is trained with reinforcement learning. The newly designed control algorithm is extensively compared with the former approach. Simulation results are presented for both methods. The authors seek to achieve a fair, non-biased, risk-aware and trustworthy comparison.

Objective We performed a systematic review to summarize the knowledge regarding the prevalence of burnout among intensive care unit physicians. Methods We conducted a systematic review of the MEDLINE and PubMed® databases (last update 04.02.2019) with the goal of summarizing the evidence on burnout among intensive care unit physicians. We included all studies reporting burnout in intensive care unit personnel according to the Maslach Burnout Inventory questionnaire and then screened studies for data on burnout among intensive care unit physician specifically. Results We found 31 studies describing burnout in intensive care unit staff and including different healthcare profiles. Among these, 5 studies focused on physicians only, and 12 others investigated burnout in mixed intensive care unit personnel but provided separate data on physicians. The prevalence of burnout varied greatly across studies (range 18% - 49%), but several methodological discrepancies, among them cut-off criteria for defining burnout and variability in the Likert scale, precluded a meaningful pooled analysis. Conclusion The prevalence of burnout syndrome among intensive care unit physicians is relatively high, but significant methodological heterogeneities warrant caution being used in interpreting our results. The lower reported levels of burnout seem higher than those found in studies investigating mixed intensive care unit personnel. There is an urgent need for consensus recommending a consistent use of the Maslach Burnout Inventory test to screen burnout, in order to provide precise figures on burnout in intensive care unit physicians.

Cristina Santonocito,1 Alberto Noto,2 Claudia Crimi,3 Filippo Sanfilippo1 1Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy; 2Department of Anesthesia and Intensive Care, Messina University, Messina, Italy; 3Department of Respiratory Medicine, AOU “Policlinico-Vittorio Emanuele”, University of Catania, Catania, Italy Abstract: The use of remifentanil in clinical practice offers several advantages and it is used for a wide range of procedures, ranging from day-surgery anesthesia to more complex procedures. Nonetheless, remifentanil has been consistently linked with development of opioid-induced hyperalgesia (OIH), which is described as a paradoxical increase in sensitivity to painful stimuli that develops after exposure to opioid treatment. The development of OIH may cause several issues, delaying recovery after surgery and preventing timely patient’s discharge. Moreover, it causes patient’s discomfort with higher pain scores, greater use of analgesics, and associated side effects. Remifentanil is the opioid most convincingly associated with OIH, and hereby we provide a review of remifentanil-induced hyperalgesia, describing both the underlying mechanisms involved and the available studies investigating experimental and clinical pharmacologic approaches aiming at reducing its incidence and degree. Keywords: opioid-induced hyperalgesia, pain, opioid consumption, opioid tolerance

A benchmark framework for advanced control methods of maritime cranes is presented based on the use of the functional mockup interface. The system integrates different manipulator models, all the corresponding hydraulic systems, various vessels, and the surrounding environment for visualization. Different control methods can be transparently implemented and tested. A set of routine tests, different cost functions, and metrics are provided—taking into account several factors, including position accuracy, energy consumption, quality, and safety for both the cranes and the surrounding environment. The concept of operational profiles is introduced, allowing for definition of different standard transporting and lifting operations. By considering task-oriented routines, this benchmark suite allows the comparison of different control methods independently from the specific crane model to be controlled. Two alternative control methods for maritime cranes based on the use of artificial intelligence are extensively compared. The first method is based on the use of genetic algorithms, while the second method involves the use of particle swarm optimization. Simulation results are presented for both methods. © 2017 IEEE. Personal use of this material is permitted. Permission from IEEE must be obtained for all other uses, in any current or future media, including reprinting/republishing this material for advertising or promotional purposes, creating new collective works, for resale or redistribution to servers or lists, or reuse of any copyrighted component of this work in other works.

Purpose To evaluate the characteristics and practice of predatory journals in critical care medicine (CCM). Methods We checked a freely accessible online and constantly updated version of the Beall lists of potential predatory publishers/journals in the field of CCM. We checked the journals' websites to retrieve the following data such as: 1) Country and address (checked by Google maps); 2) Article processing charges (APC); 3) Indexing; 4) Editor-in-chief and the Editorial Board (EB) members; 5) Number of published articles; 6) Review time (lapse submission-acceptance); 7) English form. Results We identified 86 CCM journals from 48 publishers. Most journals' reported address was in the US (52%). The address was unreliable in 43%. English form was low/very-low in 72% of cases. Three journals were indexed in PubMed. Several journals reported false indexing in the Committee on publication ethics (COPE), International Committee of Medical Journal Editors (ICMJE), Directory of Open Access Journals (DOAJ) and Google Scholar. Median APCs for research article was 909.5 USD. Name of the Editor-in-chief and EB lists were reported by 29% and 81%, respectively. Median lapse submission-acceptance for published articles was 32 days. Conclusions We found a relevant number of probable predatory CCM journals. Scientists should carefully check journal's characteristics to avoid selecting predatory journals as editorial target.

Background Myocardial dysfunction may contribute to circulatory failure in sepsis. There is growing evidence of an association between left ventricular diastolic dysfunction (LVDD) and mortality in septic patients. Utilizing echocardiography, we know that tissue Doppler imaging (TDI) variables e′ and E/e′ are reliable predictors of LVDD and are useful measurements to estimate left ventricular (LV) filling pressures. Methods We conducted a systematic review and meta-analysis to investigate the association of e′ and E/e′ with mortality of patients with severe sepsis or septic shock. In the primary analysis, we included studies providing transthoracic TDI data for e′ and E/e′ and their association with mortality. Subgroup analyses were conducted according to myocardial regional focus of TDI assessment (septal, lateral or averaged). Three secondary analyses were performed: one included data from a transoesophageal study, another excluded studies reporting data at a very early ( 48 h) stage following diagnosis, and the third pooled data only from studies excluding patients with heart valve disease. Results The primary analysis included 16 studies with 1507 patients with severe sepsis and/or septic shock. A significant association was found between mortality and both lower e′ [standard mean difference (SMD) 0.33; 95% confidence interval (CI): 0.05, 0.62; P=0.02] and higher E/e′ (SMD –0.33; 95% CI: –0.57, –0.10; P=0.006). In the subgroup analyses, only the lateral TDI values showed significant association with mortality (lower e′ SMD 0.45; 95% CI: 0.11, 0.78; P=0.009; higher E/e′ SMD –0.49; 95% CI: –0.76, –0.22; P=0.0003). The findings of the primary analysis were confirmed by all secondary analyses. Conclusions There is a strong association between both lower e′ and higher E/e′ and mortality in septic patients.

Background: Respiratory complications are common after cardiac surgery and the use of extracorporeal circulation is one of the main causes of lung injury. We hypothesized a better postoperative respiratory function in off-pump coronary artery bypass grafting (OPCABG) as compared with “on-pump coronary artery bypass grafting” (ONCABG). Methods: This is a retrospective, single-center study at a cardiothoracic intensive care unit (ICU) in a tertiary university hospital. Consecutive data on 339 patients undergoing elective CABG (n = 215 ONCABG, n = 124 OPCABG) were collected for 1 year from the ICU electronic medical records. We compared respiratory variables (Pao2, Pao2/Fio2 ratio, Sao2, and Paco2) at 7 predefined time points (ICU admission, postoperative hours 1, 3, 6, 12, 18, and 24). We also evaluated time to extubation, rates of reintubation, and use of noninvasive ventilation (NIV). We used mixed-effects linear regression models (with time as random effect for clustering of repeated measures) adjusted for a predetermined set of covariates. Results: The values of Pao2 and Pao2/Fio2 were significantly higher in the OPCABG group only at ICU admission (mean differences: 9.7 mm Hg, 95% confidence interval [CI] 3.1-16.2; and 27, 95% CI 6.1-47.7, respectively). The OPCABG group showed higher Paco2, overall ( P = .02) and at ICU admission (mean difference 1.8 mm Hg, 95% CI: 0.6-3), although mean values were always within normal range in both groups. No differences were seen in Sao2 values, time to extubation, rate of reintubation rate, and use of postoperative NIV. Extubation rate was higher in OPCABG only at postoperative hour 12 (92% vs ONCABG 82%, P = .02). Conclusion: The OPCABG showed only marginal improvements of unlikely clinical meaning in oxygenation as compared to ONCABG in elective low-risk patients.

Indoor positioning based on the Wireless Fidelity (WiFi) protocol and the Pedestrian Dead Reckoning (PDR) approach is widely exploited because of the existing WiFi infrastructure in buildings and the advancement of built-in smartphone sensors. In this work, a hybrid algorithm that combines WiFi fingerprinting and PDR to both exploit their advantages as well as limiting the impact of their disadvantages is proposed. Specifically, to build a probability map from noisy Received Signal Strength (RSS), a Gaussian Process (GP) regression is deployed to estimate and construct the RSS fingerprints with incomplete data. Mean and variance of generated points are used to estimate WiFi fingerprinting position by K-nearest weights from the probability of visible RSS measurements of the online phase. In addition, a particle filter is applied to fuse PDR and WiFi fingerprinting by using the information from RSS, inertial sensors and features of indoor maps. To demonstrate the potential of the proposed framework, two case studies are considered. In the first case, a comparison is made between GP regression with K-Nearest Neighbours (KNN) method to show the improvement with a sparse input data set. In the second case, the proposed framework is compared to both the fingerprinting approach as well as the PDR algorithm. The results show significant improvements from our proposed framework. The average positioning accuracy of our proposed system can be lower than 1.2 m, which was reduced by 48% and 70% compared with the WiFi fingerprinting and the PDR method, respectively.

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. “© 2019 IEEE. Personal use of this material is permitted. Permission from IEEE must be obtained for all other uses, in any current or future media, including reprinting/republishing this material for advertising or promotional purposes, creating new collective works, for resale or redistribution to servers or lists, or reuse of any copyrighted component of this work in other works.” Even though a few examples of elastic snake robots exist, they are generally expensive and tailored to custom-made hardware/software components that are not openly available. In this work, Serpens, a newly-designed low-cost, open-source and highly-compliant modular snake robot with series elastic actuators (SEA) is presented. Serpens features precision torque control and stereoscopic vision. Only low-cost commercial-off-the-shelf (COTS) components are adopted. The robot modules can be 3D-printed by using Fused Deposition Modelling (FDM) manufacturing technology, thus making the rapid-prototyping process very economical and fast. A screw-less assembly mechanism allows for connecting the modules and reconfiguring the robot in a reliable and robust manner. By using a low-cost sensing approach, functions for torque sensing at the joint level, sensitive collision detection and joint compliant control are possible. The concept of modularity is also applied to the system architecture on both the software and hardware sides. The software architecture is based on the Robot Operating System (ROS). This paper describes the design of Serpens and presents preliminary simulation and experimental results which illustrate its potential.

Snake robot locomotion in a cluttered environment where the snake robot utilises a sensory-perceptual system to perceive the surrounding operational environment for means of propulsion is defined as perception-driven obstacle-aided locomotion (POAL). From a control point of view, achieving POAL with traditional rigidly-actuated robots is challenging because of the complex interaction between the snake robot and the immediate environment. To simplify the control complexity, compliant motion and fine torque control on each joint is essential. Accordingly, intrinsically elastic joints have become progressively prominent over the last years for a variety robotic applications. Commonly, elastic joints are considered to outperform rigid actuation in terms of peak dynamics, robustness, and energy efficiency. Even though a few examples of elastic snake robots exist, they are generally expensive to manufacture and tailored to custom-made hardware/software components that are not openly available off-the-shelf. In this work, Serpens, a newly-designed low-cost, open-source and highly-compliant multi-purpose modular snake robot with series elastic actuator (SEA) is presented. Serpens features precision torque control and stereoscopic vision. Only low-cost commercial-off-the-shelf (COTS) components are adopted. The robot modules can be 3D-printed by using Fused Deposition Modelling (FDM) manufacturing technology, thus making the rapid-prototyping process very economical and fast. A screw-less assembly mechanism allows for connecting the modules and reconfigure the robot in a very reliable and robust manner. The concept of modularity is also applied to the system architecture on both the software and hardware sides. Each module is independent, being controlled by a self-reliant controller board. The software architecture is based on the Robot Operating System (ROS). This paper describes the design of Serpens and presents preliminary simulation and experimental results, which illustrate its performance.

Background Acute respiratory distress syndrome (ARDS) survivors are affected with long-term physical/mental impairments, with improvements limited mostly to the first year after intensive care (ICU) discharge. Furthermore, caregivers of ICU patients exhibit psychological problems after family-member recovery. We evaluated the long-term physical and mental recovery of ARDS survivors treated with veno-venous extracorporeal membrane oxygenation (VV-ECMO), and the long-term psychological impact on their caregivers. Methods Single-center prospective evaluation of a retrospective cohort of 75 ARDS patients treated with VV-ECMO during a seven-year period (25.10.2009-11.08.2016). Primary outcomes were the 36-Item Short-Form Health-Survey (SF-36, patients only), and risks of depression, anxiety or post-traumatic stress disorder (PTSD), both for patients and their caregivers. We investigated correlations between outcomes and population characteristics. Results Of 50 ICU-survivors, seven died later and five were not contactable. Among 38 living patients, 33 participated (87%, 31 with their caregiver) with 2.7 years of median follow-up. Physical and mental SF-36 component scores were 42 (inter-quartile range, IQR:22) and 52 (IQR:18.5), respectively. The worst domains of the SF-36 were physical-role limitations (25, IQR:100) and general-health perception (56, IQR:42.5). Psychological tests highlighted high risk of depression (39-42%, patients; 39-52%, caregivers), anxiety (42%, patients; 39%, caregivers), and PTSD (47%, patients; 61%, caregivers). Patient depression or anxiety scores were correlated to age and to the outcome reported by caregivers. Conclusions At almost three-year follow-up, ARDS survivors treated with VV-ECMO showed reduced health-related quality-of-life and high risk of psychological impairment, in particular PTSD. Caregivers of this population were at high psychological risk as well.

Purpose The role of high-flow nasal therapy (HFNT) as compared to conventional oxygen therapy (COT) in immunocompromised patients admitted to intensive care unit (ICU) with acute respiratory failure (ARF) remains unclear. We conducted a systematic review and meta-analysis in order to address this issue. Methods We searched PubMed, Medline and Embase until November 7th, 2018. Randomized controlled trials (RCTs), non-randomized prospective and retrospective evidence were selected. Observational studies were considered for sensitivity analysis. Primary outcome was mortality rate; intubation rate was a secondary outcome. Results We included four studies in the primary analysis: one RCT, two RCT's post-hoc analyses and one retrospective study. We found no significant difference in short-term mortality comparing HFNT vs. COT: 1) ICU: n = 872 patients, odds ratio (OR) = 0.80 [0.44,1.45], p = 0.46, I2 = 30%, p = 0.24; 2) 28-day: n = 996 patients, OR = 0.79 [0.45,1.38], p = 0.40, I2 = 52%, p = 0.12). Conversely, we found a reduction of intubation rate in the HFNT group (n = 1052 patients, OR = 0.74 [0.55,0.98], p = 0.03, I2 = 7%, p = 0.36). The inclusion of one observational study for sensitivity analysis did not grossly change results. Conclusions We found no benefit of HFNT over COT on mortality in immunocompromised patients with ARF. However, HFNT was associated with a lower intubation rate warranting further research.

Background Continuous noninvasive blood pressure (CNBP) measurement using the volume-clamp method is a less invasive alternative compared with invasive intra-arterial monitoring for awake patients during carotid endarterectomy (CEA) under regional anaesthesia. Objective We investigated the agreement of blood pressure (BP) recorded with invasive and CNBP methods during awake CEA. Design A prospective observational study for assessing agreement with Bland-Altman plots, agreement-tolerability indices (ATI), concordance and interchangeability. Setting Azienda Ospedaliera Universitaria G. Martino, Messina, a University tertiary referral centre in Italy. Patients In 30 consecutive patients, we recorded continuously ipsilateral invasive and noninvasive BPs, from 3 min before carotid cross-clamping to 5 min after unclamping. Main outcome measures Primary outcome was bias, 95% limits of agreement, ATI, concordance and interchangeability for mean arterial pressure (MAP). Secondary outcomes were agreements for systolic arterial pressure and diastolic arterial pressure. Tracking of changes was assessed with four-quadrant polar plots and the trend interchangeability method. Optimal bias was defined as 5 mmHg or less. Results A total of 2672 invasive and CNBP paired measurements (93% of overall data) were analysed, with a median of 92 readings per patient [IQR 76 to 100]. Mean (SD) bias for MAP, systolic arterial pressure and DAP were -6.8 (6.7), -3.0 (9.7) and -9.0 (5.4) mmHg, respectively. The ATIs were 0.88, 0.95 and 0.71, respectively, where ATI of 1.0 or less and at least 2.0 defined acceptable, marginal and unacceptable agreements. The four-quadrant plot analysis for beat-to-beat differences showed concordance rates of 97.3%, 99.98% and 96.4%, respectively. Polar plot analysis showed 95% limits of agreement of -3 to 3, -2 to 2 and -2 to 2 mmHg respectively. Trend interchangeability method showed an interchangeability rate of 95% for MAP. Conclusion During CEA performed under regional anaesthesia, CNBP offers a less invasive approach for BP monitoring. We found acceptable agreement for MAP defined by an ATI of 0.88 and an excellent 95% global interchangeability rate. A suboptimal bias of 7 mmHg was found with CNBP for MAP.

Braitenberg vehicles are simple models of animal motion towards, or away from, a stimulus (light, sound, chemicals, etc). They have been widely used in robotics to implement target reaching and avoidance behaviors based on different types of sensors. While the seminal work of Braitenberg used wheeled vehicles to illustrate the principles of animal steering, few attempts have been made at combining these steering level controllers with locomotion mechanism other than actuated wheels. This paper presents the first implementation of this biologically inspired steering controller in a snake-like robot with non-actuated wheels and actuated joints. The sinusoidal gait of the snake is modulated following the principles of the Braitenberg vehicle 3a using two sensors symmetrically located on the head. The effectiveness of this bio-inspired controller is shown through simulations where the snake orients its head and body with the direction of the stimulus gradient, and reaches the stimulus maximum within some range. This paper represents one of the first steps towards connecting bio-inspired sensor-based steering mechanisms and bio-inspired locomotion, and shows that existing theoretical results of Braitenberg vehicles with actuated wheels also apply to a snake-like robot with non-actuated wheels.

In the original article [1], the authors noticed a typographical error in Figure 2. The top left box should have included “E/A

Guidelines for treatment of out-of-hospital cardiac arrest (OOH-CA) with shockable rhythm recommend amiodarone, while lidocaine may be used if amiodarone is not available. Recent underpowered evidence suggests that amiodarone, lidocaine or placebo are equivalent with respect to survival at hospital discharge, but amiodarone and lidocaine showed higher hospital admission rates. We undertook a systematic review and meta-analysis to assess efficacy of amiodarone vs lidocaine vs placebo.We included studies published in PubMed and EMBASE databases from inception until May 15th, 2016. The primary outcomes were survival at hospital admission and discharge in OOH-CA patients enrolled in randomized clinical trials (RCT) according to resuscitation with amiodarone vs lidocaine vs placebo. If feasible, secondary analysis was performed including in the analysis also patients with in-hospital CA and data from non-RCT.A total of seven findings were included in the metanalysis (three RCTs, 4 non-RCTs). Amiodarone was as beneficial as lidocaine for survival at hospital admission (primary analysis odds ratio-OR 0.86-1.23, p=0.40) and discharge (primary analysis OR 0.87-1.30, p=0.56; secondary analysis OR 0.86-1.27, p=0.67). As compared with placebo, survival at hospital admission was higher both for amiodarone (primary analysis OR 1.12-1.54, p0.0001; secondary analysis OR 1.07-1.45, p0.005) and lidocaine (secondary analysis only OR 1.14-1.58, p=0.0005). With regards to hospital discharge there were no differences between placebo and amiodarone (primary outcome OR 0.98-1.44, p=0.08; secondary outcome OR 0.92-1.33, p=0.28) or lidocaine (secondary outcome only OR 0.97-1.45, p=0.10).Amiodarone and lidocaine equally improve survival at hospital admission as compared with placebo. However, neither amiodarone nor lidocaine improve long-term outcome.

The Offshore Simulator Centre AS (OSC) is the world's most advanced provider of simulators for demanding offshore operations. However, even though the OSC provides very powerful simulation tools, it is mainly designed for training purposes and it does not inherently offer any flexible methods concerning the control methodology. In fact, each crane model is controlled with a dedicated control algorithm that cannot be modified, accessed, or replaced at runtime. As a result, it is not possible to dynamically switch between different control methods, nor is it possible to easily investigate alternative control approaches. To overcome these problems, a flexible and general control system architecture that allows for modeling flexible control algorithms of maritime cranes and more generally, robotic arms, was previously presented by our research group. However, in the previous work, a generic game engine was used to visualize the different models. In this work, the flexible and general control system architecture is integrated with a crane simulator developed by the OSC taking full advantage of the provided domain-consistent simulation tools. The Google Protocol Buffers protocol is adopted to realize the communication protocol. This integration establishes the base for the research of alternative control algorithms, which can be efficiently tested in a realistic maritime simulation environment. As a validating case study, an alternative control method based on particle swarm optimization (PSO) is also presented. Related simulations are carried out to validate the efficiency of the proposed integration.

Patients resuscitated from cardiac arrest develop a pathophysiological state named "post-cardiac arrest syndrome." Post-resuscitation myocardial dysfunction is a common feature of this syndrome, and many patients eventually die from cardiovascular failure. Cardiogenic shock accounts for most deaths in the first 3 days, when post-resuscitation myocardial dysfunction peaks. Thus, identification and treatment of cardiovascular failure is one of the key therapeutic goals during hospitalization of post-cardiac arrest patients. Patients with hemodynamic instability may require advanced cardiac output monitoring. Inotropes and vasopressors should be considered if hemodynamic goals are not achieved despite optimized preload. If these measures fail to restore adequate organ perfusion, a mechanical circulatory assistance device may be considered. Adequate organ perfusion should be ensured in the absence of definitive data on the optimal target pressure goals. Hemodynamic goals should also take into account targeted temperature management and its effect on the cardiovascular function.

There is growing evidence both in the perioperative period and in the field of intensive care (ICU) on the association between left ventricular diastolic dysfunction (LVDD) and worse outcomes in patients. The recent American Society of Echocardiography and European Association of Cardiovascular Imaging joint recommendations have tried to simplify the diagnosis and the grading of LVDD. However, both an often unknown pre-morbid LV diastolic function and the presence of several confounders—i.e., use of vasopressors, positive pressure ventilation, volume loading—make the proposed parameters difficult to interpret, especially in the ICU. Among the proposed parameters for diagnosis and grading of LVDD, the two tissue Doppler imaging-derived variables e′ and E/e′ seem most reliable. However, these are not devoid of limitations. In the present review, we aim at rationalizing the applicability of the recent recommendations to the perioperative and ICU areas, discussing the clinical meaning and echocardiographic findings of different grades of LVDD, describing the impact of LVDD on patients’ outcomes and providing some hints on the management of patients with LVDD.

Predatory publishing is an exploitative fraudulent open-access publishing model that applies charges under the pretense of legitimate publishing operations without actually providing the editorial services associated with legitimate journals. The aim of this study was to analyze this phenomenon in the field of anesthesiology and related specialties (intensive care, critical and respiratory medicine, pain medicine, and emergency care). Two authors independently surveyed a freely accessible, constantly updated version of the original Beall lists of potential, possible, or probable predatory publishers and standalone journals. We identified 212 journals from 83 publishers, and the total number of published articles was 12,871. The reported location of most publishers was in the United States. In 43% of cases (37/84), the reported location was judged as "unreliable" after being checked using the 3-dimensional view in Google Maps. Six journals were indexed in PubMed. Although 6 journals were declared to be indexed in the Directory of Open Access Journals, none were actually registered. The median article processing charge was 634.5 US dollars (interquartile range, 275-1005 US dollars). Several journals reported false indexing/registration in the Committee on Publication Ethics and International Committee of Medical Journal Editors registries and Google Scholar. Only 32% (67/212) reported the name of the editor-in-chief. Rules for ethics/scientific misconduct were reported in only 24% of cases (50/212). In conclusion, potential or probable predatory open-access publishers and journals are widely present in the broad field of anesthesiology and related specialties. Researchers should carefully check journals' reported information, including location, editorial board, indexing, and rules for ethics when submitting their manuscripts to open-access journals.

International audience; A sensor-fusion wearable health-monitoring system with integrated haptic feedback was previously introduced by our research group. The system's components are the following: a chest-worn device with an embedded controller board, an electrocardiogram (ECG) sensor, a temperature sensor, an accelerometer, a vibration motor, a colour-changing light-emitting diode (LED) and a pushbutton. This multi-sensor device makes possible to collect biometric and medical monitoring data from its wearer. The data provide a real-time indication of the wearer's health state and can also be further analysed later for medical diagnosis. The embedded vibration motor can actuate distinctive haptic feedback patterns according to the wearer's health state. The embedded colour-changing LED provides the wearer with an additional intuitive visual feedback of the current health state, and the wearer can report a potential emergency condition by using the pushbutton. In this paper, a conceptual case study is presented concerning possible applications for the health monitoring of elderly people in smart cities. The proposed system aims at reducing risk by assessing individual and overall potentially-harmful situations. A data collection and analysis are also presented to demonstrate that the system can provide compelling vibrotactile feedback.

Objective There is increasing burnout incidence among medical disciplines, and physicians working in emergency settings seem at higher risk. Cardiac anesthesiology is a stressful anesthesiology subspecialty dealing with high-risk patients. The authors hypothesized a high risk of burnout in cardiac anesthesiologists. Design National survey conducted on burnout. Setting Italian cardiac centers. Participants Cardiac anesthesiologists. Interventions The authors administered via email an anonymous questionnaire divided into 3 parts. The first 2 parts evaluated workload and private life. The third part consisted of the Maslach Burnout Inventory test with its 3 constituents: high emotional exhaustion, high depersonalization, and low personal accomplishment. Measurements and Main Results The authors measured the prevalence and risk of burnout through the Maslach Burnout Inventory questionnaire and analyzed factors influencing burnout. Among 670 contacts from 71 centers, 382 cardiac anesthesiologists completed the survey (57%). The authors found the following mean Maslach Burnout Inventory values: 14.5 ± 9.7 (emotional exhaustion), 9.1 ± 7.1 (depersonalization), and 33.7 ± 8.9 (personal accomplishment). A rate of 34%, 54%, and 66% of respondents scored in “high” or “moderate-high” risk of burnout (emotional exhaustion, depersonalization, and personal accomplishment, respectively). The authors found that, if offered to change subspecialty, 76% of respondents would prefer to remain in cardiac anesthesiology. This preference and parenthood were the only 2 investigated factors with a protective effect against all components of burnout. Significantly lower burnout scores were found in more experienced anesthesiologists. Conclusion A relatively high incidence of burnout was found in cardiac anesthesiologists, especially regarding high depersonalization and low personal accomplishment. Nonetheless, most of the respondents would choose to remain in cardiac anesthesiology.

Background Sepsis-induced myocardial dysfunction is associated with poor outcomes, but traditional measurements of systolic function such as left ventricular ejection fraction (LVEF) do not directly correlate with prognosis. Global longitudinal strain (GLS) utilizing speckle-tracking echocardiography (STE) could be a better marker of intrinsic left ventricular (LV) function, reflecting myocardial deformation rather than displacement and volume changes. We sought to investigate the prognostic value of GLS in patients with sepsis and/or septic shock. Methods We conducted a systematic review (PubMed and Embase up to 26 October 2017) and meta-analysis to investigate the association between GLS and mortality at longest follow up in patients with severe sepsis and/or septic shock. In the primary analysis, we included studies reporting transthoracic echocardiography data on GLS according to mortality. A secondary analysis evaluated the association between LVEF and mortality including data from studies reporting GLS. Results We included eight studies in the primary analysis with a total of 794 patients (survival 68%, n = 540). We found a significant association between worse LV function and GLS values and mortality: standard mean difference (SMD) − 0.26; 95% confidence interval (CI) − 0.47, − 0.04; p = 0.02 (low heterogeneity, I 2 = 43%). No significant association was found between LVEF and mortality in the same population of patients (eight studies; SMD, 0.02; 95% CI − 0.14, 0.17; p = 0.83; no heterogeneity, I 2 = 3%). Conclusions Worse GLS (less negative) values are associated with higher mortality in patients with severe sepsis or septic shock, while such association is not valid for LVEF. More critical care research is warranted to confirm the better ability of STE in demonstrating underlying intrinsic myocardial disease compared to LVEF.

Biological snakes are capable of exploiting roughness in the terrain for locomotion. This feature allows them to adapt to different types of environments. Snake robots that can mimic this behaviour could be fitted with sensors and used for transporting tools to hazardous or confined areas that other robots and humans are unable to access. Snake robot locomotion in a cluttered environment where the snake robot utilises a sensory-perceptual system to perceive the surrounding operational environment for means of propulsion can be defined as perception-driven obstacle-aided locomotion (POAL). The initial testing of new control methods for POAL in a physical environment using a real snake robot imposes challenging requirements on both the robot and the test environment in terms of robustness and predictability. This paper introduces SnakeSIM, a virtual rapid-prototyping framework that allows researchers for the design and simulation of POAL more safely, rapidly and efficiently. SnakeSIM is based on the Robot Operating System (ROS) and it allows for simulating the snake robot model in a virtual environment cluttered with obstacles. The simulated robot can be equipped with different sensors. Tactile perception can be achieved by using contact sensors to retrieve forces, torques, contact positions and contact normals. A depth camera can be attached to the snake robot head for visual perception purposes. Furthermore, SnakeSIM allows for exploiting the large variety of robotics sensors that are supported by ROS. The framework can be transparently integrated with a real robot. To demonstrate the potential of SnakeSIM, a possible control approach for POAL is considered as a case study. © 2018 IEEE. Personal use of this material is permitted. Permission from IEEE must be obtained for all other uses, in any current or future media, including reprinting/republishing this material for advertising or promotional purposes, creating new collective works, for resale or redistribution to servers or lists, or reuse of any copyrighted component of this work in other works.

Aim The prediction of return of spontaneous circulation (ROSC) during resuscitation of patients suffering of cardiac arrest (CA) is particularly challenging. Regional cerebral oxygen saturation (rSO 2 ) monitoring through near-infrared spectrometry is feasible during CA and could provide guidance during resuscitation. Methods We conducted a systematic review and meta-analysis on the value of rSO 2 in predicting ROSC both after in-hospital (IH) or out-of-hospital (OH) CA. Our search included MEDLINE (PubMed) and EMBASE, from inception until April 4th, 2015. We included studies reporting values of rSO 2 at the beginning of and/or during resuscitation, according to the achievement of ROSC. Results A total of nine studies with 315 patients (119 achieving ROSC, 37.7%) were included in the meta-analysis. The majority of those patients had an OHCA ( n =225, 71.5%; IHCA: n =90, 28.5%). There was a significant association between higher values of rSO 2 and ROSC, both in the overall calculation (standardized mean difference, SMD –1.03; 95%CI –1.39,–0.67; p 2 at the beginning of resuscitation: SMD –0.79; 95%CI –1.29,–0.30; p =0.002; averaged rSO 2 value during resuscitation: SMD –1.28; 95%CI –1.74,–0.83; p Conclusions Higher initial and average regional cerebral oxygen saturation values are both associated with greater chances of achieving ROSC in patients suffering of CA. A note of caution should be made in interpreting these results due to the small number of patients and the heterogeneity in study design: larger studies are needed to clinically validate cut-offs for guiding cardiopulmonary resuscitation.

Background: Acupuncture treatment has been employed in China for over 2500 years and it is used worldwide as analgesia in acute and chronic pain. Acupuncture is also used in general anesthesia (GA). The aim of this systematic review and meta-analysis was to assess the efficacy of electroacupuncture (EA) in addition to GA in patients undergoing cardiac surgery. Methods: We searched 3 databases (Pubmed, Cochrane Library, and Web of Science—from 1965 until January 31, 2017) for randomized controlled trials (RCTs) including patients undergoing cardiac surgery and receiving GA alone or GA + EA. As primary outcomes, we investigated the association between GA + EA approach and the dosage of intraoperative anesthetic drugs administered, the duration of mechanical ventilation (MV), the postoperative dose of vasoactive drugs, the length of intensive care unit (ICU) and hospital stay, and the levels of troponin I and cytokines. Results: The initial search yielded 477 citations, but only 7 prospective RCTs enrolling a total of 321 patients were included. The use of GA + EA reduced the dosage of intraoperative anesthetic drugs ( P < .05), leading to shorter MV time ( P < .01) and ICU stay ( P < .05) as well as reduced postoperative dose of vasoactive drugs ( P < .001). In addition, significantly lower levels of troponin I ( P < .01) and tumor necrosis factor α ( P < .01) were observed. Conclusion: The complementary use of EA for open-heart surgery reduces the duration of MV and ICU stay, blunts the inflammatory response, and might have protective effects on the heart. Our findings stimulate future RCT to provide definitive recommendations.

Purpose: We describe an approach for anticoagulation and transfusions in veno-venous–extracorporeal membrane oxygenation (VV-ECMO), evaluating factors associated with higher transfusion requirements, and their impact on mortality. Methods: Observational study on consecutive adults supported with VV-ECMO for acute respiratory distress syndrome (ARDS). We targeted an activated partial thromboplastin time of 40 to 50 seconds and a hematocrit of 24% to 30%. Univariate and multiple analyses were done to evaluate factors associated with transfusion requirements and the influence of increasing transfusions on mortality during ECMO. Results: In a cohort of 82 VV-ECMO patients (PRedicting dEath for SEvere ARDS on VV-ECMO [PRESERVE] score: 4, Interquartile range [IQR]: 3-5, Respiratory Extracorporeal Membrane Oxygenation Survival Prediction [RESP] score: 2, IQR: 2-4), 76 (92.7%) patients received at least 1 unit of packed red blood cells (PRBCs) during the intensive care unit stay related to ECMO (median PRBC/d 156 mL, IQR: 93-218; median ECMO duration 14 days, IQR: 8-22). A higher requirement of PRBC transfusions was associated with pre-ECMO hematocrit, and with the following conditions during ECMO: platelet nadir, antithrombin III (ATIII), and stage 3 of acute kidney injury (all P < .05). Sixty-two (75.6%) patients survived ECMO. Pre-ECMO hospital stay, PRBC transfusion, and septic shock were associated with mortality (all P < .05). The adjusted odds ratio for each 100mL/d increase in PRBC transfusion was 1.9 (95% confidence interval [CI]: 1.1-3.2, P = .01); for the development of septic shock it was 15.4 (95% CI: 1.7-136.8, P = .01), and for each day of pre-ECMO stay it was 1.1 (95% CI: 1-1.2, P = .04). Conclusion: Implementation of a comprehensive protocol for anticoagulation and transfusions in VV-ECMO for ARDS resulted in a low PRBC requirement, and an ECMO survival comparable to data in the literature. Lower ATIII emerged as a factor associated with increased need for transfusions. Higher PRBC transfusions were associated with ECMO mortality. Further investigations are needed to better understand the right level of anticoagulation in ECMO, and the factors to take into account in order to manage personalized transfusion practice in this select setting.

Background Weaning-induced pulmonary oedema (WiPO) is a well-recognised cause of failure of weaning from mechanical ventilation, but its incidence and risk factors have not been reliably described. We wanted to determine the incidence and risk factors in a population of critically ill patients. In addition, we wanted to describe the effects of diuretics when they are administered in this context. Methods We monitored 283 consecutive spontaneous breathing trials (SBT; T-piece trial) performed in 81 patients. In cases with cardiac output monitoring (n = 85, 29 patients), a passive leg raising (PLR) test was performed before SBT. Three experts established the diagnosis of WiPO based on various patient characteristics. Results SBT failed in 128 cases (45 % of all SBT). WiPO occurred in 59 % of these failing cases. Compared to patients without WiPO (n = 52), patients with at least one WiPO (n = 29) had a higher prevalence of chronic obstructive pulmonary disease (COPD) (38 % vs. 12 %, respectively; p

BACKGROUND Thoracic epidural anesthesia (TEA) is widely used for major surgery, but studies assessing its impact on left ventricular (LV) systolic and diastolic function are limited, and such studies have assessed patients already under general anesthesia and/or receiving volume expansion between examinations. METHODS Observational study at a secondary university hospital including consecutive awake patients undergoing major abdominal surgery without significant pre-existing cardiac disease. Patients received a pre-emptive intravenous volume loading before epidural catheter placement with puncture between T6-T7 and T8-T9. Hemodynamic and trans-thoracic echocardiography (TTE) parameters were assessed before and after establishing TEA with a 10 mL bolus of 2% lidocaine. Changes in heart rate (HR), mean arterial pressure (MAP), stroke volume (SV), cardiac output (CO), LV systolic function (as evaluated by fractional shortening [FS]; ejection fraction [EF]; Simpson; S prime [S`]), and LV diastolic function were recorded. RESULTS Twenty-four awake patients were included. After TEA, HR, MAP, SV and CO significantly decreased (15.0%, 29.3%, 6.8% and 22%, respectively; all P

Background. Burnout syndrome has reached epidemic levels among physicians (reported around 50%). Anesthesiology is among the most stressful medical disciplines but there is paucity of literature as compared with others. Analysis of burnout is essential because it is associated with safety and quality of care. We summarize evidence on burnout in anesthesiology. Methods. We conducted a systematic review (MEDLINE up to 30.06.2017). We included studies reporting burnout in anesthesiology with no restriction on role or screening test used. Results. Fifteen surveys/studies described burnout in anesthesiology, including different workers profiles (nurses, residents, consultants, and directors). All studies used the Maslach Burnout Inventory test but with significant differences for risk stratification. Burnout prevalence greatly varied across studies (10%–41% high risk, up to 59% at least moderate risk). Factors most consistently associated with burnout were strained working pattern, working as younger consultant, and having children. There was no consistent relationship between burnout and hospital characteristics, gender, or marital status. Conclusions. Burnout prevalence among anesthesiologists is relatively high across career stages, and some risk factors are reported frequently. However, the small number of studies as well as the large differences in their methodology and in reporting approach warrants further research in this field.

Introduction The central venous pressure (CVP) is the most commonly used static marker of preload for guiding fluid therapy in critically ill patients, though its usefulness remains controversial. Centrally inserted central catheters (CICCs) are the gold-standard devices for CVP monitoring but peripherally inserted central catheters (PICCs) may represent a valid alternative. We undertook a systematic review and meta-analysis with the aim to investigate whether the difference between PICC- and CICC-measured CVP is not significant. Methods We searched for clinical studies published in PubMed and EMBASE databases from inception until December 21st 2016. We included studies providing data on paired and simultaneous CVP measurement from PICCs and CICCs. We conducted two analyses on the values of CVP, the first one according to the total number of CVP assessments, the second one considering the number of patients recruited. Results Four studies matched the inclusion criteria, but only three of them provided data for the meta-analyses. Both analyses showed non-significant differences between PICC-measured and CICC-measured CVP: 1489 paired simultaneous CVP assessments (MD 0.16, 95%CI −0.14, 0.45, p = 0.30) on a total of 57 patients (MD 0.22, 95%CI −1.46, 1.91, p = 0.80). Both analyses showed no heterogeneity (I2 = 0%). Conclusions Available evidence supports that CVP monitoring with PICCs is accurate and reproduces similar values to those obtained from CICCs. The possibility to monitor CVP should not be used among clinical criteria for preferring a CICC over a PICC line.

In nature, snakes can gracefully traverse a wide range of different and complex environments. Snake robots that can mimic this behaviour could be fitted with sensors and transport tools to hazardous or confined areas that other robots and humans are unable to access. In order to carry out such tasks, snake robots must have a high degree of awareness of their surroundings (i.e., perception-driven locomotion) and be capable of efficient obstacle exploitation (i.e., obstacle-aided locomotion) to gain propulsion. These aspects are pivotal in order to realise the large variety of possible snake robot applications in real-life operations such as fire-fighting, industrial inspection, search-and-rescue, and more. In this paper, we survey and discuss the state of the art, challenges, and possibilities of perception-driven obstacle-aided locomotion for snake robots. To this end, different levels of autonomy are identified for snake robots and categorised into environmental complexity, mission complexity, and external system independence. From this perspective, we present a step-wise approach on how to increment snake robot abilities within guidance, navigation, and control in order to target the different levels of autonomy. Pertinent to snake robots, we focus on current strategies for snake robot locomotion in the presence of obstacles. Moreover, we put obstacle-aided locomotion into the context of perception and mapping. Finally, we present an overview of relevant key technologies and methods within environment perception, mapping, and representation that constitute important aspects of perception-driven obstacle-aided locomotion © 2017 The Authors. This is an open access article distributed under the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. (CC BY 4.0).