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In this paper, the configuration of a five-limbed modular robot is introduced. A specialised locomotion gait is designed to allow for omni-directional mobility. Due to the large diversity resulting from various gait sequences, a criteria for selecting the best gaits based on their stability characteristics is proposed. A series of simulations is then performed to evaluate the various gaits in different walking directions. A gait arrangement scheme toward omni-directional locomotion is finally derived. Lastly, Experiments are also carried out on our pentapedal robot prototype in order to validate the results of simulation. The experiments confirm the gait analysis and selection is highly accurate in the evaluation of gait stability.

This paper introduces a new modular approach to robotic grasping that allows for finding a trade off between a simple gripper and more complex human like manipulators. The modular approach to robotic grasping aims to understand human grasping behavior in order to replicate grasping and skilled in-hand movements with an artificial hand using simple, robust, and flexible modules. In this work, the design of modular grasping devices capable of adapting to different requirements and situations is investigated. A novel algorithm that determines effective modular configurations to get efficient grasps of given objects is presented. The resulting modular configurations are able to perform effective grasps that a human would consider “stable”. Related simulations were carried out to validate the efficiency of the algorithm. Preliminary results show the versatility of the modular approach in designing grippers.

To the Editor: Khemasuwan et al. retrospectively evaluated a cohort of 211 patients admitted to intensive care units (ICUs) with acute pulmonary embolism (PE). The investigators examined the correlation between echocardiographic parameters and clinical outcomes, in particular ICU, hospital, and long-termmortality. Several simple echocardiographic parameters were associated with ICU, hospital, and long-termmortality in this group of patients, while right ventricular (RV) strain analysis was not, although optimal data were available for only 54% of the patients. However, the study findings are partly flawed. The investigators performed adjusted analyses for Acute Physiology and Chronic Health Evaluation score (ICU mortality), Pulmonary Embolism Severity Index score (hospital mortality), or age and gender (longterm mortality), but they did not consider two important issues. First, intravenous thrombolytic therapy was administered to 9% of the study population. Thrombolytic therapy has been previously associated with significant early improvements in echocardiographic parameters of RV function compared with heparin alone in patients with acute massive or submassive PE. Therefore, patients receiving thrombolysis may have had more pronounced improvement in all or some of the parameters that were positively correlated with clinical outcomes in this study. Unfortunately, the investigators did not present a subgroup analysis of the echocardiographic findings in the subgroup of patients who received thrombolysis, and thrombolysis was not considered in the regression analysis. Second, absence of $50% inferior vena cava (IVC) collapsibility was correlated with ICU and hospital mortality. Nonetheless, 26% of the patients in this study required mechanical ventilation, which in turn significantly influences changes in IVC diameter (IVC distensibility for ventilated patients) and its value as an indicator of RV preload. The investigators did not adjust for this variable in the binary logistic regression analyses, and this can introduce a degree of bias when considering IVC collapsibility as predictor of outcome. Therefore, before the data can be correctly interpreted, an adjustment of the analysis for such variables (thrombolysis and mechanical ventilations) is needed. Finally, it would be interesting if the investigators could look into the echocardiographic follow-up of survivors, evaluating both early (within weeks) and late (after a few months) improvements in RV function and looking for predictors of good functional RV recovery. By reporting these data, the investigators would greatly contribute in providing further valuable insight on this interesting topic.

Quint and colleagues recently published the results of their investigation into the role of β blockers in patients with chronic obstructive pulmonary disease (COPD) having a first myocardial infarction.1 They obtained data from the UK national registry of myocardial infarction between 2003 and 2008. The primary outcome of all …

In May, 2012, a 46year-old woman reported chest pain before having an out-of-hospital cardiac arrest. Para medics successfully resuscitated her. The pre-arrest rhythm strip showed a sinus tachycardia only. A 12-h troponin I was raised at 5·9 μg/L (normal values 0–0·04 μg/L) A year earlier, she had been admitted with a similar history of chest pain, which had developed after taking sumatriptan for a migraine. A 12-lead electrocardiograph (ECG) showed transient inferior and lateral ST elevation. A 12-h troponin was negative. At this time, coronary angiography showed a normal left coronary system and a dominant right coronary artery, with minor ostial spasm and slow fl ow. A bubble study was negative for right to left shunting. She was diagnosed with vasospastic angina and started oral diltiazem. On advice, she stopped smoking and sumatriptan was discontinued. She continued to have occasional episodes of chest pain responsive to sublingual glycerol trinitrate. At the time of her cardiac arrest, her regular medications were oral diltiazem, nicorandil, lansoprazole, and a beclometasone inhaler. In the 48 h after the cardiac arrest she had fi ve additional pulseless electrical activity (PEA) arrests while intubated and ventilated in the intensive care unit. These were characterised by transient ST elevation (fi gure) and progressive hypotension, cul minating in loss of car diac output. Each episode responded to about 15–25 min of resuscitation. In between episodes, left ven tricular size and function was normal on echocardi ography. Electro cardiography was unremarkable. Repeat coronary angi ography showed normal coronary arteries, though of smaller luminal diameter than a year earlier. An intra-aortic balloon pump and a temporary tunnelled dual cham ber pacemaker were placed, which permitted potent vaso dilator therapy (intra venous glyceryl trinitrate and verapa mil, with nifedipine via a nasogastric tube) to be estab lished without the need for prolonged use of ino tropes. During this time, one episode of ST elevation and brady cardia was ter minated with a bolus of intravenous verapamil. The patient had a full neurological recovery; however it was complicated by the development of compartment syndrome in her left leg which necessitated removal of the intra-aortic balloon pump and a fasciotomy. She was converted to oral medications and underwent a cardiac magnetic resonance scan which was normal. At review in July, 2013, she remains entirely well. Although ventricular arrhythmia is recognised as the main cause of cardiac arrest in these patients, isolated cases of PEA have been reported. However, only one case has been described fully and did not feature the type of aggressive disease, with recurrent PEA arrests, detailed here. Patients with vasospastic angina are at higher risk of cardiac arrest than the background population. In a recent study of 1429 patients with vaso spastic angina, 35 (2·4%) had an out-of-hospital arrest and were younger (mean age 58 years) and more likely to have spasm of the left anterior descending coronary artery than were patients who had not had cardiac arrest. Since predicting which patients will have recurrent events is diffi cult, one suggestion is that all patients with vasospastic angina and a history of life-threatening arrhyth mia could benefi t from an automated implantable cardioverter-defi brillator alongside calcium channel blockers. In the absence of ventricular arrhythmias in our patient, an implantable cardioverter-defi brillator was not felt to be benefi cial. That this patient developed compart ment syndrome with no history of peripheral vascular disease is note worthy. We postulated that this was directly related to vasospasm provoked by the intra-aortic balloon pump. This case also highlights the value of intravenous calcium channel blockade to abort ST elevation and progression to PEA arrest. Our patient has been reminded to treat any further chest pain promptly with sublingual glyceryl trinitrate and seek immediate medical attention. Maintenance of vasodilator therapy has been strongly recommended.

This study aimed to estimate the incidence of hospital transmission of influenza A subtype H1N1 [A(H1N1)], to identify high-risk areas for such transmission and to evaluate common characteristics of affected patients. In this single-centre retrospective cohort study, 10 patients met the criteria for hospital-acquired A(H1N1) infection over a three-month period. All affected patients required an escalation of their care and the mortality rate was 20%. Clinicians should be aware of the risk of nosocomial A(H1N1) infection that exists despite routine infection control measures and should consider additional control measures including vaccination of hospital inpatients and healthcare staff.

The perioperative use of beta-blockers (BBs) with the aim of decreasing perioperative adverse cardiac events has been strongly supported, especially after the publication of two small trial (McSPI and DECREASE I) that showed major benefits. However, some later trials did not confirm these benefits. The POISE trial, with 8351 patients, showed reduced primary outcomes (cardiac death, non-fatal myocardial infarction, non-fatal cardiac arrest) at the expense of significant harm, increasing all-cause and sepsis-related deaths, and doubling the incidence of stroke. These results led to revised American and European guidelines. The American guideline recommended a substantial narrowing of indication for perioperative BBs, while the European guideline remained far more liberal. Since the publication of the results of POISE, meta-analyses and new studies have been published. In this review the most recent available evidence, the changes in the guidelines and the criticism on POISE results are discussed together with reasons why recent meta-analyses may not have greater certainty. This is explained by the huge numeric influence of the POISE trial and the heterogeneity in the design of the trials on perioperative BBs. Thus all the evidence available must now be taken into consideration to develop more appropriate guidelines to minimise the risks and enhance the benefits of perioperative beta-blockade.

This paper demonstrates rapid prototyping of a stroke rehabilitation system consisting of an interactive 3D virtual reality computer game environment interfaced with an EEG headset for control and interaction using brain waves. The system is intended for training and rehabilitation of partially monoplegic stroke patients and uses low-cost commercial-off-the-shelf products like the Emotiv EPOC EEG headset and the Unity 3D game engine. A number of rehabilitation methods exist that can improve motor control and function of the paretic upper limb in stroke survivors. Unfortunately, most of these methods are commonly characterised by a number of drawbacks that can limit intensive treatment, including being repetitive, uninspiring, and labour intensive; requiring one-on-one manual interaction and assistance from a therapist, often for several weeks; and involve equipment and systems that are complex and expensive and cannot be used at home but only in hospitals and institutions by trained personnel. Inspired by the principles of mirror therapy and game-stimulated rehabilitation, we have developed a first prototype of a game-like computer application that tries to avoid these drawbacks. For rehabilitation purposes, we deprive the patient of the view of the paretic hand while being challenged with controlling a virtual hand in a simulated 3D game environment only by means of EEG brain waves interfaced with the computer. Whilst our system is only a first prototype, we hypothesise that by iteratively improving its design through refinements and tuning based on input from domain experts and testing on real patients, the system can be tailored for being used together with a conventional rehabilitation programme to improve patients’ ability to move the paretic limb much in the same vain as mirror therapy. Our proposed system has several advantages, including being game-based, customisable, adaptive, and extendable. In addition, when compared with conventional rehabilitation methods, our system is extremely low-cost and flexible, in particular because patients can use it in the comfort of their homes, with little or no need for professional human assistance. Preliminary tests are carried out to highlight the potential of the proposed rehabilitation system, however, in order to measure its efficiency in rehabilitation, the system must first be improved and then run through an extensive field test with a sufficiently large group of patients and compared with a control group. Published by ECMS European Council for Modelling and Simulation

Sepsis is a modern medicine icon and the onset of organ dysfunction is one of the worst scenario. More than 100 distinct molecules have been proposed as useful biological markers of sepsis. TNF-alpha, IL-6, chemokines and cytokines are considered the first line factors able to drive the dynamic process of sepsis. The PIRO scheme is a new classification of different aspects, used to stage sepsis. Resuscitation bundles must be started within 6 hours of presentation (serum lactate measured; blood cultures obtained before antibiotic therapy; broad-spectrum antibiotics within 3 hours from emergency admission and 1 hour from ICU admission; in case of hypotension and/or lactate higher than 4 mmol/L deliver an initial 20 ml/kg of crystalloid or colloid solution or apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure above 65 mmHg). A management bundle should be implemented within 24 hour (low-dose steroids administered for septic shock; recombinant human activated protein C; glucose control maintained at less than 8.3 mmol/L; inspiratory plateau pressures maintained at less than 30 cm H2O).

Cardiac arrest (CA) is the primary cause of death in industrialized countries. Successful resuscitation rate is estimated of about 40%, but a good neurological outcome remains difficult to achieve. The majority of resuscitated victims suffers of a pathophysiological entity termed as "post resuscitation disease". Today's efforts are mainly pointed to the chain of survival, often devoting less attention to post-resuscitation care. Resuscitated patients are often victims of nihilistic therapeutic approach, with clinicians failing to promptly institute strategies that mitigate the ischemia-reperfusion injury to vital organs. Only after 72 hours prognostication can be realistically attempted. Neurological evaluation relies on a combination of clinical, instrumental and laboratoristic parameters, since no one alone holds a specificity of 100%. Biochemical markers, such as neuron specific enolase and S-100b, may contribute to predict prognosis after CA. To the contrary, when used individually the necessary precision remains poorly characterized. Biochemical studies suffer from substantial methodological differences hampering attempts to summarize their findings. We review the information available on biochemical markers of brain damage for neurological prognostication after CA.

This paper introduces ModGrasp, an open-source virtual and physical rapid-prototyping framework that allows for the design, simulation and control of low-cost sensorised modular hands. By combining the rapid-prototyping approach with the modular concept, different manipulator configurations can be modelled. A real-time one-to-one correspondence between virtual and physical prototypes is established. Different control algorithms can be implemented for the models. By using a low-cost sensing approach, functions for torque sensing at the joint level, sensitive collision detection and joint compliant control are possible. A 3-D visualization environment provides the user with an intuitive visual feedback. As a case study, a three-fingered modular manipulator is presented. Related simulations are carried out to validate efficiency and flexibility of the proposed rapid-prototyping framework. © 2014 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.