High Technical Skills Research Articles

CNC Learning Innovation: Improving Students' Self-Efficacy and Creativity through Peer-PBL

The demand for increasingly diverse product designs and specifications in the manufacturing industry requires CNC machine operators to have high technical skills and strong self-efficacy and creativity. High self-efficacy allows operators to be more confident in applying their technical skills, while creativity helps them solve problems and challenges during the production process. This study aims to improve students' self-efficacy and creativity by applying the Peer-Project Based Learning (Peer-PjBL) model, which combines aspects of project-based learning with peer-to-peer learning. The method used in this research is Classroom Action Research (PTK), which consists of two implementation cycles. Each cycle involves planning, implementation, observation, and reflection stages. The subjects of this study were 20 students who took the CNC Machining Technology course at Yogyakarta State University. Data were collected using a questionnaire that measured self-efficacy and student creativity indicators and then analyzed descriptively. The results showed that applying the Peer-PjBL method significantly increased students' self-efficacy and creativity in each research cycle. This improvement can be seen in students' ability to face new challenges independently, as well as their ability to generate diverse creative ideas in solving problems. This research makes an important contribution to the development of learning methods in vocational education by emphasizing the improvement of technical abilities and non-technical skills, such as self-efficacy and creativity, which are needed in the modern world of work.

Design of Moringa Leaf Dryer Based on Programmable Logic Control Laboratory Scale

Moringa plants can be found in most tropical and subtropical climates. In some parts of Indonesia, the plant is called kelor or marungga. People need the tree as a source of protein, vitamins, minerals, and carbohydrates. The plant contains more than 90 nutrients, antioxidants, and 8 essential amino acids, called the ‘elixir tree’. The problem with this plant is that its leaves are easily damaged when picked. One way to avoid this is to perform a drying process. This Moringa dryer consists of an inner cabinet made of aluminum and an outer side made of zinc. The cabinet measures 40 cm long, 35 cm wide, and 35 cm high, has three shelves arranged horizontally, and each shelf can dry between 100 grams to 200 grams of moringa leaves simultaneously. In addition, it has a heater consisting of two 125-watt heaters and two upper and lower fans. In the first experiment, Moringa leaves were dried for 9 hours at 40°C, yielding 30g of dried leaves from 100g of fresh leaves. The second experiment lasted 6 hours at 50 °C, yielding 30 g of dried leaves from 100 g of fresh leaves. Finally, the leaves were dried for 3 hours at 60°C, yielding 30g of dried leaves from the initial 100g. These results also show a large weight loss at various temperatures and durations. After calculating the percentage of weight loss, it was found that the leaves lost 70% of their weight. Outseal PLC can automatically control the drying process according to the pre-programmed program. Temperature and humidity sensors maintain the nutritional quality and texture of the moringa leaves produced by controlling the dryer environment appropriately. This tool can be used easily by users without requiring high technical skills.

Surgeon Skill and Perioperative Outcomes in Robot-Assisted Partial Nephrectomy

Technical skill in complex surgical procedures may affect clinical outcomes, and there is growing interest in understanding the clinical implications of surgeon proficiency levels. To determine whether surgeon scores representing technical skills of robot-assisted kidney surgery are associated with patient outcomes. This quality improvement study included 10 urological surgeons participating in a surgical collaborative in Michigan from July 2021 to September 2022. Each surgeon submitted up to 7 videos of themselves performing robot-assisted partial nephrectomy. Videos were segmented into 6 key steps, yielding 127 video clips for analysis. Each video clip was deidentified and distributed to at least 3 of the 24 blinded peer surgeons from the collaborative who also perform robot-assisted partial nephrectomy. Reviewers rated technical skill and provided written feedback. Statistical analysis was performed from May 2023 to January 2024. Reviewers scored each video clip using a validated instrument to assess technical skill for partial nephrectomy on a scale of 1 to 5 (higher scores indicating greater skill). For all submitting surgeons, outcomes from a clinical registry were assessed for length of stay (LOS) greater than 3 days, estimated blood loss (EBL) greater than 500 mL, warm ischemia time (WIT) greater than 30 minutes, positive surgical margin (PSM), 30-day emergency department (ED) visits, and 30-day readmission. Among the 27 unique surgeons who participated in this study as reviewers and/or individuals performing the procedures, 3 (11%) were female, and the median age was 47 (IQR, 39-52) years. Risk-adjusted outcomes were associated with scores representing surgeon skills. The overall performance score ranged from 3.5 to 4.7 points with a mean (SD) of 4.1 (0.4) points. Greater skill was correlated with significantly lower rates of LOS greater than 3 days (-6.8% [95% CI, -8.3% to -5.2%]), EBL greater than 500 mL (-2.6% [95% CI, -3.0% to -2.1%]), PSM (-8.2% [95% CI, -9.2% to -7.2%]), ED visits (-3.9% [95% CI, -5.0% to -2.8%]), and readmissions (-5.7% [95% CI, -6.9% to -4.6%]) (P < .001 for all). Higher overall score was also associated with higher partial nephrectomy volume (β coefficient, 11.4 [95% CI, 10.0-12.7]; P < .001). In this quality improvement study on video-based evaluation of robot-assisted partial nephrectomy, higher technical skill was associated with lower rates of adverse clinical outcomes. These findings suggest that video-based evaluation plays a role in assessing surgical skill and can be used in quality improvement initiatives to improve patient care.

Current genetic models for studying congenital heart diseases: Advantages and disadvantages.

Congenital heart disease (CHD) encompasses a diverse range of structural and functional anomalies that affect the heart and the major blood vessels. Epidemiological studies have documented a global increase in CHD prevalence, which can be attributed to advancements in diagnostic technologies. Extensive research has identified a plethora of CHD-related genes, providing insights into the biochemical pathways and molecular mechanisms underlying this pathological state. In this review, we discuss the advantages and challenges of various In vitro and in vivo CHD models, including primates, canines, Xenopus frogs, rabbits, chicks, mice, Drosophila, zebrafish, and induced pluripotent stem cells (iPSCs). Primates are closely related to humans but are rare and expensive. Canine models are costly but structurally comparable to humans. Xenopus frogs are advantageous because of their generation of many embryos, ease of genetic modification, and cardiac similarity. Rabbits mimic human physiology but are challenging to genetically control. Chicks are inexpensive and simple to handle; however, cardiac events can vary among humans. Mice differ physiologically, while being evolutionarily close and well-resourced. Drosophila has genes similar to those of humans but different heart structures. Zebrafish have several advantages, including high gene conservation in humans and physiological cardiac similarities but limitations in cross-reactivity with mammalian antibodies, gene duplication, and limited embryonic stem cells for reverse genetic methods. iPSCs have the potential for gene editing, but face challenges in terms of 2D structure and genomic stability. CRISPR-Cas9 allows for genetic correction but requires high technical skills and resources. These models have provided valuable knowledge regarding cardiac development, disease simulation, and the verification of genetic factors. This review highlights the distinct features of various models with respect to their biological characteristics, vulnerability to developing specific heart diseases, approaches employed to induce particular conditions, and the comparability of these species to humans. Therefore, the selection of appropriate models is based on research objectives, ultimately leading to an enhanced comprehension of disease pathology and therapy.

Integration and Non-Integration of Life Skills: is There an Influence on the Development of Basketball Shooting Skills?

Lack of integration of life skills in training can result in athletes having high technical skills but lacking the ability to adapt and cooperate in everyday life. This study aims to analyze the impact of integration and non-integration of life skills in training on improving shooting skills in basketball. This experimental research was conducted involving 20 basketball players as samples. The collected data will be analyzed using descriptive and inferential statistics. This research uses an independent t-test and ANOVA. The study showed a significant increase in shooting accuracy and technique in the experimental group, which received integrated life skills, compared to the control group. These findings indicate that a holistic training approach that includes aspects of life skills can positively improve technical abilities in basket ball sports. Based on these results, this study recommends that trainers consider integrating life skills into training programs. This supports improving the athlete's technical skills and contributes to a more holistic development of the athlete, which includes aspects of valuable life skills. The implications of this research can help deepen understanding of how the integration of life skills can influence various aspects of sports performance.

Early Experience with EndoRobotic Submucosal Dissection (ERSD): Pathologic and Short-term Outcomes in the First 28 Patients.

To evaluate the safety and feasibility of single-port endorobotic submucosal dissection (ERSD) using the Da Vinci SP platform for the management of rectal neoplasms. Endoscopic submucosal dissection (ESD) offers a potential organ-sparing treatment for advanced colorectal neoplasms but demands high technical skill and a steep learning curve. Advances in semiflexible robotic platforms, such as the Da Vinci SP, promise to simplify this procedure, potentially offering improved outcomes for patients with benign rectal neoplasms. A retrospective analysis of 28 patients who underwent ERSD using the Da Vinci SP platform between 2020 and 2023 was performed. Patient demographics, lesion characteristics, procedure details, outcomes, and complications were reviewed. The primary endpoint was successful en-bloc resection. The cohort had a median age of 60.5 years and a median BMI of 28.2kg/m², predominantly male(67.8%) with ASA categories 2 or 3(82%). Lesions had a median size of 38mm and were located a median of 9cm from the anal verge. The median procedure time was 87.5 minutes. En-bloc resection was achieved in all cases(100%), with no intraoperative complications or mortality. One patient experienced urinary retention, and one had late bleeding requiring blood transfusion. Pathology outcomes included 46.4% tubulovillous adenomas, 21.4% adenocarcinomas, and high-grade dysplasia in 53.6% of patients. Single-port ERSD using the Da Vinci SP platform is safe and feasible for the management of colorectal neoplasia, ensuring a high rate of en-bloc resection. It potentially offers advantages over conventional ESD, including shorter dissection times, although further studies are necessary for a definitive comparison.

Robotic Surgical Techniques in Transplantation: A Comprehensive Review

In the field of surgery, the idea of performing organ transplants in a minimally invasive fashion has always been a significant technical challenge. The advent of the robotic approach facilitated the overcoming of difficulties in highly complex surgical procedures that demand high technical skill. Furthermore, robotic transplants are showing significant benefits in patient outcomes, particularly in the obese population. The purpose of this review is to provide an overview of the current state of robotics applications for transplant surgery. Kidney transplants were the first to be performed using a fully robotic approach. Since then, robotic surgery has gradually been applied to other organ transplants, with very recent reports of fully robotic lung and liver transplants. Further experiences and studies will be needed to verify their effectiveness and to satisfy some concerns regarding the longer warm ischemia time related to the robotic approach in comparison with open surgery.

Novel gastric endoscopic submucosal dissection training model enhances the endoscopic submucosal dissection skills of trainees: a multicenter comparative study.

Endoscopic submucosal dissection (ESD) requires high endoscopic technical skills, and trainees should develop effective training methods. In collaboration with KOTOBUKI Medical, we developed the G-Master, which is a non-animal training model that can simulate various parts of gastric ESD. We aimed to clarify the usefulness of the G-Master for inexperienced ESD trainees. We collected data from the first 5 gastric ESD cases conducted by 15 inexperienced ESD trainees at 5 participating centers between 2018 and 2022. The participants were divided into two groups: the G-Master training and non-G-Master training groups. Outcome measurements, such as procedural speed, perforation rate, self-completion rate, and en bloc resection rate, were compared between the two groups retrospectively. A total of 75 gastric ESD cases were included in this study. The G-Master training group included 25 cases performed by 5 trainees, whereas the non-G-Master training group included 50 cases performed by 10 trainees. The median procedural speed for all cases was significantly faster in the G-Master training group than in the non-G-Master training group. Moreover, the procedural speed was linearly improved from the initial to the last cases in the lower location in the G-Master training group compared with the non-G-Master training group. In addition, although there was no significant difference, the G-Master training group showed lower rates of perforation and a lesser need to transition to expert operators than the non-G-Master training group. The G-Master could improve the ESD skills of inexperienced ESD trainees.

End-User Assessment of the Graduate Performance From Islamic Bank Department, Faculty of Islamic Studies, Universitas Ahmad Dahlan: A Survey

It is undeniable that external factors drive the development and growth of the Islamic bank industry in Indonesia. One of them is the supply of Islamic Human Resources (IHR) from various universities (PT), both private and public, that have opened Islamic banking study programs. However, the increasing availability of IHR from PT still needs to improve, including; link and math curriculum, absorption of graduates in the Islamic bank industry, competence, and performance of PT graduates. Therefore, this study aims to assess the performance of graduates of Islamic banking study programs who have worked in the Islamic banking and finance/islamic banking industry with an approach of technical competence, conceptual competence, and interpersonal ability. This type of research is descriptive quantitative. The sample is all alums of the Islamic banking study program who have worked in Islamic banks and finance/islamic for 2019-2021 with snowball sampling techniques. The sampling method uses questionnaires distributed to company leaders. The findings showed that most alums of Islamic banking study programs who work in the financial industry show high technical skills, conceptual abilities, and interpersonal skills.

Clinical and Radiological Outcomes after Surgical Stabilization of Craniovertebral Junction – A Single-center Experience

Abstract Background and Objectives: Craniovertebral instability and its surgical management require a thorough knowledge of the anatomy and dynamics of the craniovertebral junction (CVJ). Due to the wide range of mobility and proximity of vital neurovascular structures, these surgeries demand high technical skill and precision. It is very difficult to suggest a single good technique for CVJ stabilization as each procedure has got its own indications and benefits. Novel techniques and gadgets like neuro navigation and robotic arms help surgeons to minimize complications, thereby improving the overall functional outcome. In this study, we are analyzing the retrospective data of CVJ instabilities surgically managed by freehand technique in our institute. Materials and Methods: We did a retrospective analysis of 33 patients operated on for craniocervical junction instability for 7 years from January 1, 2015, to December 31, 2021. We analyzed the clinical and radiological presentations and postoperative outcomes at 3 weeks, 6 months, and after 1 year. The distribution of clinical presentation in terms of neck pain, myelopathy, restricted neck movements, and lower cranial nerve palsy was evaluated and correlated with the demographic parameters. The paired “t”- test was used to correlate the clinical and radiological outcomes after surgery. Results: The paired “t” value of the clinical improvement assessed with the preoperative and postoperative Japanese Orthopedic Association (JOA) myelopathic scores was − 4.376 with P &lt; 0.001, which indicates a significant clinical improvement 6 months after surgery. Among the 33 patients evaluated, only three patients developed a slight reduction in the JOA score after surgery, which was improved within 1 year. All the patients achieved satisfactory trabecular bone formation at the graft site and decorticated joint facets without any clinical or radiological evidence of implant failure. Among the C2 pedicle screws, 3 (7.5%) were having vertebral foraminal impingement, and 2 (5%) were having medial cortical violation and spinal canal impingement. All the patients with radiological evidence of implant malposition were clinically intact and did not show any deterioration of the studied myelopathic score (JOA). Conclusions: As the bony anatomy and the vascular course of the CVJ vary from patient to patient, thorough preoperative planning is mandatory for the surgical management of CVJ instability. In our study, the clinical and radiological improvement after surgical stabilization of craniovertebral instability by freehand technique is comparable with the available data. The overall risk of screw malposition and associated lethal complications may be minimized by adding modern technologies such as neuronavigation, robotic arms, and three-dimensional C-arm in the armamentarium.

The decision-making in dribbling: a video analysis study of U10 soccer players' skills and coaches' quality evaluation.

Dribbling is an important soccer skill that, when effective, allows players to overcome opponents. It can provide a strong tactical advantage; for this reason, all of its components (sprint, speed, and ball control) are fundamental to the development of young players. Dribbling can also be considered a decision-making process, and due to its characteristics, it is not always easy to study ecologically. Using a video analysis study, this research aimed to determine whether dribbling skills, specifically dribbling choice (i.e., decision-making), were related to U10 soccer players' quality. Several outcomes measures, divided into three categories, were taken during video analyses: (i) measures related to the efficacy of dribbling skill; (ii) measures related to the ability of players without the ball to support the player in possession; and (iii) measures related to ball circulation. These data were retrospectively assessed to whether the coaches had formed the teams in training through an implicit knowledge of the players' dribbling skills. The percentage of accurate dribbling (that is, the ability to perform correct passes after a successful dribble) was found to be the variable that coaches may have implicitly used in creating the three groups differentiated by technical skills (p < 0.05). In fact, this percentage was 12.9%, 24.0%, and 48.1% for the groups with lower, average, and higher technical skills, respectively. Overall, the results demonstrate that dribbling accuracy has an important weight in the coach's evaluation of the technical skills level of young soccer players.

Surgical Approaches to Pancoast Tumors.

Pancoast tumors, also defined as superior sulcus tumors, still represent a complex clinical condition requiring high technical surgical skills within more articulated multimodality treatment. The morbidity and mortality rates after Pancoast tumor treatments range from 10 to 55% and 0 to 7%, respectively, and the 5-year survival rate has significantly improved in recent years thanks to the advancement of treatments. Although a multimodality approach combining chemotherapy, radiotherapy, and surgery allows for radical resection and effective local control in the vast majority of patients, many patients cannot receive surgical resection or complete the whole programmed therapeutic regimen. Systemic relapse, particularly cerebral recurrence, still poses a significant issue in this cohort of patients. Surgical resection still plays a pivotal role within the multimodality approach. Here, we focus on surgical approaches to both anterior and posterior Pancoast tumors: the anterior transclavicular approach (Dartevelle); the anterior transmanubrial approach (Grunenwald-Spaggiari); the anterior trap-door approach (Masaoka, Nomori); the posterior approach (Shaw-Paulson); the hemiclamshell approach; and hybrid approaches. Global clinical condition, tumor histology, and long-term perspectives should always be taken into consideration when embarking on such a demanding oncologic scenario.

Building technical, human and conceptual skills: implications for Vietnamese librarians

PurposeThis study examines the working skills of Vietnamese librarians in terms of technical, human and conceptual skills. Then, this study suggests recommendations to improve their working skills.Design/methodology/approachTo attain this objective, the study surveyed 243 Vietnamese librarians. Several statistical tests, including analysis of variance (ANOVA) and the paired t-test, were used to investigate differences in respondents' responses based on demographic variables such as gender, age, education and managerial level.FindingsGender appears to impact the working skill of Vietnamese librarians. In detail, the findings indicate that male librarians have higher technical skills than female librarians.Research limitations/implicationsThis study opens the scope of working skill literature, particularly in the library sector. Notably, this is the first study investigating this issue in Vietnam. Given the current circumstances, suggesting practical recommendations to enhance the working skills of Vietnamese libraries is essential.Originality/valueThis is the first study examining Vietnamese librarians in technical, human and conceptual skills. Therefore, this research is essential in this field.

Hudozhestvennaya cennost' i istoricheskoe znachenie risovaniya kist'yu ot ruki v figurnoj zhivopisi dinastii Sun

As the pinnacle of the development and evolution of Chinese classical painting art, the painting art of the two Song dynasties is famous for its high technical skills, detailed subjects. This paper analyzes the artistic value and historical meaning of Yi Yi figurepaintingfrom the background study and style analysis of Yi Yipaintings in the two Song dynasties, combining two works, “Painting of Immortals with Ink” and “Tai Bai Xing Yin”.

Designing Modern Japan

The design disciplines that Teasley addresses in her book—such as graphic and product design—took root in the wake of the Meiji-era (1868–1912), when social, political, and economic transformations upended local cottage industries and prompted the makers of luxury and craft goods to consider how to apply existing design and production practices to make new types of objects for new markets, both at home and overseas. The Arita vases displayed at the Philadelphia Centennial Exposition of 1876, for example, exemplified high technical skill while also promoting a particular image of “Japan” that responded to Western tastes. Artisans across various industries, from ceramics to textiles to lacquerware, began to shift their attention to Western markets and expand their product lines (to include such things as lacquered hairbrushes and glove boxes), developing new patterns, motifs, and color palettes and experimenting with new production techniques and technologies.

Pelvic anatomy in laparoscopic surgery for pelvic organ prolapse: dissect your success.

Laparoscopic surgery for pelvic organ prolapse is a complex procedure, requiring high technical skills and great knowledge of the anatomy to perform a safe dissection and achieve the best clinical and surgical outcomes. To highlight the anatomical landmarks during dissection in this procedure and give tips for a safer and more effective performance. Surgical videos of the dissection involved in laparoscopic surgery for pelvic organ prolapse in a stepwise approach. Identification of the most important anatomical landmarks involved in the dissection of the promontory, the para-rectal space, the recto-vaginal space, and the vesico-vaginal space. Advice for acquiring better exposure and the right cleavage planes. Presentation of some difficult cases during dissection. Step-by-step overview of the different steps of dissection involved in laparoscopic surgery for pelvic organ prolapse, specifying the most important anatomical landmarks for reference and at risk of damage and presenting tips to correctly perform the dissection. Besides the great surgical technical skills required, deep knowledge of pelvic anatomy is key for performing laparoscopic surgery for pelvic organ prolapse safely, minimising complications and recurrence and improving quality of life and the overall success of surgery.

Reusable carbon dot/chitin nanocrystal hybrid sorbent for the selective detection and removal of Cr(VI) and Co(II) ions from wastewater

The last few decades have seen a dramatic increase in heavy metal ions in industrial wastewater, especially Cr6+ and Co2+ ions, which have been shown to adversely affect human health; thus, there is a great need for their removal. Existing removal methods are time-consuming, expensive, and require high technical skills; therefore, there exists a need for a quick, simple, and cost-effective method. Chitin was selected from natural materials (shrimp waste), and an inexpensive, biodegradable, fluorescent carbon dot/chitin nanocrystal (C-dot/ChNC) sorbent for the simultaneous detection and removal of heavy metal ions from wastewater was synthesized from it. C-dot/ChNC shows high selectivity and sensitivity to Cr6+ and Co2+ ions and has high chromium(VI) and cobalt(II) adsorption capacities. These ions are weakly adsorbed on the C-dot/ChNC surface and are easily removed during regeneration, showing high cyclability. Thus, C-dot/ChNC is a viable sorbent for the removal of heavy metal ions during wastewater treatment.

Ultra-Low Detection of Infectious Disease Nucleic Acid Biomarkers By a Visual Colorimetric Sensor

The gold standard method for detecting nucleic acid markers is the polymerase chain reaction. However, this method demands high technical skills, labor-intensive, time-consuming, and expensive. Many resource-limited countries around the globe do not have access to such laboratory-based PCR tests. To address the global test needs of virus and other pathogen infections, as well as address the early biomarker detection of diseases. We have developed an affordable nanoparticle colorimetric sensor approach. In our system, the virus RNA marker is captured by the complementary oligonucleotide attached to low fouling gold-coated iron oxide nanoparticles. Further specificity is achieved through a second complementary hybridization probe conjugated with streptavidin-horseradish peroxidase labels. Visual colorimetry is performed using a chromogenic substrate allowing the visual conversion of the colorless solution to a blue color confirming a positive test. The intensity of the color is in direct correlation to the concentration of the virus RNA marker. We have successfully demonstrated attomolar detection in buffer and picomolar detection in real undiluted biofluids such as in neat human serum. Our ongoing efforts focus on saliva-based non-invasive detection with ultra-low capabilities, optimization of the assay, repeatability, and expanding this work for a multiplex detection format

S2890 A Case for Endoscopic Ultrasound-Directed TransGastric ERCP (EDGE) Procedure: Removal of Choledocholithiasis in Gastric Bypass Patient

Introduction: Due to rise in obesity, there has been an increased number of gastric bypass surgeries. Around 36% morbidly obese patient develop cholelithiasis or choledocholithiasis (CDL) in their lifetime. Due to the anatomy, a conventional Endoscopic Retrograde Cholangio Pancreatography (ERCP) is often challenging and not possible. We present a case of an altered anatomy ERCP in a patient with CDL and Roux-en-Y gastric bypass (RYGB) who underwent Endoscopic ultrasound Directed trans-Gastric ERCP(EDGE) procedure. Case Description/Methods: A 69-year-old female with a history of RYGB admitted for Hartmann’s procedure. During the hospitalization, she complained of RUQ pain and CT abdomen showed a distended gallbladder with cholelithiasis and CBD dilation of 8.3mm; MRCP confirmed five or more CDL. A traditional attempt at an ERCP using a pediatric colonoscope was unsuccessful in reaching the papilla. She underwent cholecystectomy with an intraoperative cholangiogram re-demonstrating the CDL. Options were to do a laparoscopy assisted ERCP v/s double balloon assisted ERCP v/s EDGE. Due to already multiple surgeries patient opted for EDGE procedure. For stage 1 of the EDGE, the excluded stomach was identified under EUS and punctured using a 19-gauge-needle followed by a radiocontrast dye injection into the excluded stomach confirmed under fluoroscopy. Subsequently, a guidewire was advanced through the needle into the pylorus and duodenum to verify the patency of pylorus. After confirming access to the excluded stomach, a 20 x 10 mm (AXIOSTM) lumen apposing metal stent (LAMS) was placed and a gastro-gastric fistula between the gastric pouch and the excluded stomach was formed. The lumen of the stent was subsequently dilated using a CRE balloon confirming the direct visualization of the gastric rugae. (Figure). The LAMS was left for 4 weeks for the tract to mature. Stage 2 of the EDGE procedure was then completed by passing the duodenoscope through the LAMS and completion of the traditional ERCP followed by removal of the LAMS. Overall patient did well. Discussion: EDGE is a minimally invasive EUS guided technique for doing an ERCP in patients with RYGB. Comparison studies have shown EDGE to have similar or better technical success when compared to laparoscopy-assisted ERCP and balloon Enteroscopy-assisted ERCP. Due to the high technical skill required in doing an EDGE, it is best advisable to offer this at institutions where a trained advanced endoscopist well versed with a therapeutic EUS is available.Figure 1.: A: EGD showing gastric pouch post-RYGB B: EUS suggests decompressed excluded stomach C: Injecting contrast into the excluded stomach - to make cystic cavity D: 20 x 10 mm(AXIOS) lumen apposing metal stent placement E: CRE Baloon dilation of LAMS F: Confirmed visualization of excluded gastric mucosa - gastrogastric fistula

O tiro de polícia: decisão irreversível em ambientes complexos

In dynamic environments with a high degree of uncertainty, the response time is shorter, as the anticipatory process simplifies the selection of information, focuses on the target and simultaneously uses strategies to control the environment, where intuition or instinct, whenever resorting to long-term working memory and allied to greater experience, practice and expertise, they increase the efficiency of the decision, whose success is all the greater, the closer the “scanning environment” is (Tenenbaum, 2004). Considering some complex and stressful police environments (eg, searches, arrests of criminals, brawls), the criminal investigator is required to be able to manage the unpredictability and associated risk, and to decide quickly from the selection and treatment of situational information, only possible if there are organizationally high levels of training and frequent training, with a focus on simulator shooting exercises because they are closer to reality. The police decision-making process is, for the reasons invoked, complex and conditioned by psychophysiological, environmental and task variables (Davies, 2015). Complex social systems require high technical skills at the level of police shooting and inherently the TD of criminal investigators of the PJ, whose performance, through the only known study in Portugal with these variables, should be the object of reflection as it shows data that is not in line with the socially intended results of excellence.