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In this paper, a novel performance index for the kinematic optimization of robotic manipulators is presented. The index is based on the condition number of the Jacobian matrix of the manipulator, which is known to be a measure of the amplification of the errors due to the kinematic and static transformations between the joint and Cartesian spaces. Moreover, the index proposed here, termed global conditioning index (CGI), is meant to assess the distribution of the aforementioned condition number over the whole workspace. Furthermore, the concept of a global index is applicable to other local kinematic or dynamic indices. The index introduced here is applied to a simple serial two-link manipulator, to a spherical three-degree-of-freedom serial wrist, and to three-degree-of-freedom parallel planar and spherical manipulators. Results of the optimization of these manipulators, based on the GCI, are included.

In this paper, the design of a spherical three-degree-of-freedom parallel manipulator is considered from a kinematic viewpoint. Three different design criteria are established and used to produce designs having optimum characteristics. These criteria are (a) symmetry (b) workspace maximization, and (c) isotropy. The associated problems are formulated and their solutions, one of them requiring to resort to a numerical method, are provided. Optimum designs are thereby obtained. A discussion on singularities is also included.

This article has an accompanying continuing medical education activity, also eligible for MOC credit, on page e18 (https:// www.gastrojournal.org/cme/home). Learning Objective: Upon completion of this CME activity, successful learners will be able to explain measures of disease severity in children with nonalcoholic fatty liver disease (NAFLD) and identify factors in the intestinal microbiome that associate with disease severity.

IMPORTANCE Pediatric guidelines for the management of nonalcoholic fatty liver disease (NAFLD) recommend a healthy diet as treatment. Reduction of sugary foods and beverages is a plausible but unproven treatment. OBJECTIVE To determine the effects of a diet low in free sugars (those sugars added to foods and beverages and occurring naturally in fruit juices) in adolescent boys with NAFLD. DESIGN, SETTING, AND PARTICIPANTS An open-label, 8-week randomized clinical trial of adolescent boys aged 11 to 16 years with histologically diagnosed NAFLD and evidence of active disease (hepatic steatosis >10% and alanine aminotransferase level Ն45 U/L) randomized 1:1 to an intervention diet group or usual diet group at 2 US academic clinical research centers from August 2015 to July 2017; final date of follow-up was September 2017. INTERVENTIONS The intervention diet consisted of individualized menu planning and provision of study meals for the entire household to restrict free sugar intake to less than 3% of daily calories for 8 weeks. Twice-weekly telephone calls assessed diet adherence. Usual diet participants consumed their regular diet. MAIN OUTCOMES AND MEASURES The primary outcome was change in hepatic steatosis estimated by magnetic resonance imaging proton density fat fraction measurement between baseline and 8 weeks. The minimal clinically important difference was assumed to be 4%. There were 12 secondary outcomes, including change in alanine aminotransferase level and diet adherence. RESULTS Forty adolescent boys were randomly assigned to either the intervention diet group or the usual diet group (20 per group; mean [SD] age, 13.0 [1.9] years; most were Hispanic [95%]) and all completed the trial. The mean decrease in hepatic steatosis from baseline to week 8 was significantly greater for the intervention diet group (25% to 17%) vs the usual diet group (21% to 20%) and the adjusted week 8 mean difference was −6.23% (95% CI, −9.45% to −3.02%; P < .001). Of the 12 prespecified secondary outcomes, 7 were null and 5 were statistically significant including alanine aminotransferase level and diet adherence. The geometric mean decrease in alanine aminotransferase level from baseline to 8 weeks was significantly greater for the intervention diet group