Tactical Modifications Research Articles

A cognitive task analysis of expert surgeons performing the robotic roux-en-y gastric bypass.

The safe and effective performance of a robotic roux-en-y gastric bypass (RRNY) requires the application of a complex body of knowledge and skills. This qualitative study aims to: (1)define the tasks, subtasks, decision points, and pitfalls in a RRNY; (2)create a framework upon which training and objective evaluation of a RRNY can be based. Hierarchical and cognitive task analyses for a RRNY were performed using semi-structured interviews of expert bariatric surgeons to describe the thoughts and behaviors that exemplify optimal performance. Verbal data was recorded, transcribed verbatim, supplemented with literary and video resources, coded, and thematically analyzed. A conceptual framework was synthesized based on three book chapters, three articles, eight online videos, nine field observations, and interviews of four subject matter experts (SME). At the time of the interview, SME had practiced a median of 12.5years and had completed a median of 424 RRNY cases. They estimated the number of RRNY to achieve competence and expertise were 25 cases and 237.5 cases, respectively. After four rounds of inductive analysis, 83 subtasks, 75 potential errors, 60 technical tips, and 15 decision points were identified and categorized into eight major procedural steps (pre-procedure preparation, abdominal entry & port placement, gastric pouch creation, omega loop creation, gastrojejunal anastomosis, jejunojejunal anastomosis, closure of mesenteric defects, leak test & port closure). Nine cognitive behaviors were elucidated (respect for patient-specific factors, tactical modification, adherence to core surgical principles, task completion,judicious technique & instrument selection, visuospatial awareness, team-based communication, anticipation & forward planning, finessed tissue handling). This study defines the key elements that formed the basis of a conceptual framework used by expert bariatric surgeons to perform the RRNY safely and effectively. This framework has the potential to serve as foundational tool for training novices.

Understanding How Experts Do It: A Conceptual Framework for the Open Transversus Abdominis Release Procedure.

The safe and effective performance of a posterior component separation via a transversus abdominis release (TAR) requires intraoperative judgement and decision-making skills that are difficult to define, standardize, and teach. We herein present the first qualitative study which builds a framework upon which training and objective evaluation of a TAR can be based. Hierarchical and cognitive task analyses for a TAR procedure were performed using semi-structured interviews of hernia experts to describe the thoughts and behaviors that exemplify optimal performance. Verbal data was recorded, transcribed, coded, and thematically analyzed. A conceptual framework was synthesized based on literary sources (4 book chapters, 4 peer-reviewed articles, 3 online videos), 2 field observations, and interviews of 4 hernia experts (median 66 minutes [44-78]). Subject matter experts practiced a median of 6.5 years [1.5-16] and have completed a median of 300 [60-500] TARs. After 5 rounds of inductive analysis, 80 subtasks, 86 potential errors, 36 cognitive behaviors, and 17 decision points were identified and categorized into 10 procedural steps (midline laparotomy, adhesiolysis, retrorectus dissection, etc.) and 9 fundamental principles: patient physiology and disease burden; tactical modification; tissue reconstruction and wound healing; task completion; choice of technique and instruments; safe planes and danger zones; exposure; ergonomics, environmental limitations; anticipation and forward planning; and tissue trauma and handling. This is the first study to define the key tasks, decisions, and cognitive behaviors that are essential to a successful TAR procedure.

Hepatocyte Growth Factor-Preconditioned Neural Progenitor Cells Attenuate Astrocyte Reactivity and Promote Neurite Outgrowth.

The astroglial scar is a defining hallmark of secondary pathology following central nervous system (CNS) injury that, despite its role in limiting tissue damage, presents a significant barrier to neuroregeneration. Neural progenitor cell (NPC) therapies for tissue repair and regeneration have demonstrated favorable outcomes, the effects of which are ascribed not only to direct cell replacement but trophic support. Cytokines and growth factors secreted by NPCs aid in modifying the inhibitory and cytotoxic post-injury microenvironment. In an effort to harness and enhance the reparative potential of NPC secretome, we utilized the multifunctional and pro-regenerative cytokine, hepatocyte growth factor (HGF), as a cellular preconditioning agent. We first demonstrated the capacity of HGF to promote NPC survival in the presence of oxidative stress. We then assessed the capacity of this modified conditioned media (CM) to attenuate astrocyte reactivity and promote neurite outgrowth in vitro. HGF pre-conditioned NPCs demonstrated significantly increased levels of tissue inhibitor of metalloproteinases-1 and reduced vascular endothelial growth factor compared to untreated NPCs. In reactive astrocytes, HGF-enhanced NPC-CM effectively reduced glial fibrillary acidic protein (GFAP) expression and chondroitin sulfate proteoglycan deposition to a greater extent than either treatment alone, and enhanced neurite outgrowth of co-cultured neurons. in vivo, this combinatorial treatment strategy might enable tactical modification of the post-injury inhibitory astroglial environment to one that is more conducive to regeneration and functional recovery. These findings have important translational implications for the optimization of current cell-based therapies for CNS injury.

Defining the competencies for laparoscopic transabdominal adrenalectomy: An investigation of intraoperative behaviors and decisions of experts

BackgroundSafe performance of laparoscopic transabdominal adrenalectomy requires the application of a complex body of knowledge and skills, which are difficult to define, teach, and measure. This qualitative study aims to characterize expert behaviors, decisions, and other cognitive processes required to perform laparoscopic transabdominal adrenalectomy. MethodHierarchical and cognitive task analyses for right and left laparoscopic transabdominal adrenalectomy were performed using semi-structured interviews and field observations of experts. Verbal data was supplemented with published literature, coded and thematically analyzed using constructivist grounded-theory by 2 independent reviewers. ResultsA conceptual framework was synthesized. Sixty-eight tasks, 46 cognitive behaviors, and 52 potential errors were identified and categorized into 8 procedural steps and 8 fundamental principles: anticipation, exposure, teamwork or communication, physiology, dissection techniques, oncologic margins, tactical modification, and error recovery. Experts emphasized the importance of creating a 3-dimensional mental model of the anatomy or pathology (eg, aberrant vessels, tumor location) that is consistently fine-tuned throughout the operation, with conscious awareness of danger zones (eg, medial arc). Despite variations in dissection techniques, experts highlighted 2 themes: macrodissection and microdissection, with emphasis on nonlinear motions and effective transitions between the 2 when appropriate. ConclusionThis study defines behaviors and competencies that are essential to performing laparoscopic transabdominal adrenalectomy effectively and safely.

Tactical modification of pseudo-SILAR process for enhanced quantum-dot deposition on TiO2 and ZnO nanoparticles for solar energy applications

Pseudo successive ionic layer adsorption and reaction (p-SILAR) process is a unique route to develop quantum-dot (QD) sensitized nanocomposites (NCs) via QDs deposition on metal oxide nanoparticles (NPs). In this work, we have successfully increased the deposition of PbS and CdS QDs on TiO2 as well as ZnO NPs using a simple wet chemical modification of p-SILAR. An optimal fluorination treatment of both NPs with 0.1 M aqueous solution of NH4F was carried out under centrifugation. Consequent increase in deposition of PbS and CdS QDs was affirmed using scanning electron microscopy, EDX, UV–vis spectroscopy and XRD. Eventually, solar paint based photovoltaics and photocatalysis were carried out to show that modification of p-SILAR enabled TiO2-PbS NC to exhibit ˜30% increase (from 6.5 mA/cm2 to 8.5 mA/cm2) in the photocurrent density (JSC) of solar cells and more than 11% increase (from 81% to 92%) in the degradation of congo red (CR) dye.

A IMPORTÂNCIA DO GOLEIRO E SUA PARTICIPAÇÃO TÁTICA COM A BOLA NOS PÉS

Modern football has become faster and more dynamic due to changes in rules. In this way, with all the tactical modifications, the goalkeeper startedto have even greater importance within his team. This study aimed to analyze the importance of the goalkeeper in professional football matches. Thirteen football matches were analyzed, divided into two groups. Group 1 was comprised of the analysis of ninematches played during the 2014 FIFA World Cup. Group 2 was formed by four matches of other competitions, selected from the participation of goalkeepers with greater skill in the feet, according to the ranking of goal of the International Federation of Football History & Statistics(IFFHS). The games were downloaded on the public domain site of Youtube and then analyzed through the software SKOUT, regarding the tactical positioning and quantification of the numbers of each goalkeeper (technical part) during the matches. The Shapiro-Wilk normality test was used for normality analysis and then the Student's t-test for independent samples (p<0.05). It was verified that the goalkeepers of Group 2 presented greater participation in the fundamentals of pass, reception, finishing, hand replacement, driving and scored goals (p<0.05). However, in the mean of errors in the pass, reception and driving fundamentals the differences were not significant. It is concluded that the goalkeepers of Group 2 presented greater participation in the fundamentals that required skill with the possession of ball.

Charlottesville and the alt-right: a turning point?

ABSTRACTThis article argues that education and exposure are essential tools in the fight against the alt-right movement. While the alt-right has flourished by disguising its core racist ideology, the August 2017 “Unite the Right” rally in Charlottesville VA revealed the movement's white supremacist leanings and affiliations. Building on this public unmasking, I outline what I see as the eight central white supremacist concepts that animate alt-right thinking: the Jewish Question, the 14 words, white genocide, white nationalism, identitarianism, race realism, misogyny, and the ethno-state. These concepts connect the alt-right to more traditional white power groups and organizations, and it is essential that educators, parents, students, and administrators understand and publicize those connections. The tragedy and chaos of the Charlottesville rally certainly forced alt-right leaders to make strategic and tactical modifications: public exposure intensified existing schisms and led to doubts about the efficacy of large-scale public rallies. But the central white supremacist tenets that emboldened far-right advocates to march through Charlottesville continue to motivate the movement, and anti-racist activists must understand and fight those ideas in both the real and virtual worlds.

An empirically grounded agent based simulator for the air traffic management in the SESAR scenario

In this paper we present a simulator allowing to perform policy experiments relative to the air traffic management. Different SESAR solutions can be implemented in the model to see the reaction of the different stakeholders as well as other relevant metrics (delay, safety, etc). The model describes both the strategic phase associated to the planning of the flight trajectories and the tactical modifications occurring in the en-route phase. An implementation of the model is available as an open-source software and is freely accessible by any user.More specifically, different procedures related to business trajectories and free-routing are tested and we illustrate the capabilities of the model on an airspace which implements these concepts. After performing numerical simulations with the model, we show that in a free-routing scenario the controllers perform less operations but the conflicts are dispersed over a larger portion of the airspace. This can potentially increase the complexity of conflict detection and resolution for controllers.In order to investigate this specific aspect, we consider some metrics used to measure traffic complexity. We first show that in non-free-routing situations our simulator deals with complexity in a way similar to what humans would do. This allows us to be confident that the results of our numerical simulations relative to the free-routing can reasonably forecast how human controllers would behave in this new situation. Specifically, our numerical simulations show that most of the complexity metrics decrease with free-routing, while the few metrics which increase are all linked to the flight level changes. This is a non-trivial result since intuitively the complexity should increase with free-routing because of problematic geometries and more dispersed conflicts over the airspace.

Trends in Technical and Tactical Modifications Among Competitors of Various Nationalities Based on Research Conducted During the 2009 World Youth Championship in Greco-Roman Style Wrestling in Turkey

Abstract Introduction . This paper discusses the relationship between the technique implemented during competition and the end result including an attempt to evaluate the technical and tactical preparation of different nationality competitors in Greco- Roman wrestling. The research was conducted during the 2009 Junior World Cup in Turkey. Material and methods. The research material included a video recording posted by the International Federation of Associated Wrestling Styles (FILA) on their website. The material contained recordings of 240 matches. An analysis of 212 matches with competitors from 49 countries was conducted; each team selected one competitor in each weight category (up to 8 competitors in total). Results and conclusions . During the competition there was strong correlation between victory and the execution of the roll-through and the combat zone and result defence, also in the ground position. Competitors from Russia and Iran, who were most successful, winning 6 and 4 medals respectively, obtained an average of 3.18 technical points in each match. Among the sample analysed this was the lowest score, indicating the optimal use of technical and tactical skills by the competitors resulting in a victory.

The Appendiceal Stump Closure During Laparoscopy

During a laparoscopic appendectomy, the closure of the appendiceal stump is an important step because of postoperative complications from its inappropriate management. The development of life-threatening events such as stercoral fistulas, postoperative peritonitis, and sepsis is feared and unwanted. The tactical modification of the appendiceal stump closure with a single endoligature, replacing the invaginating suture, adjusted very well to laparoscopic appendectomy, and nowadays is the procedure of choice, whenever possible. Among the alternatives that do not make use of an invaginating suture, studies advocate the use of an endostapler, endoligature (endo-loop), metal clips, bipolar endocoagulation, and polymeric clips. All alternatives have advantages and disadvantages against the different clinical stages of acute appendicitis, and it should be noted that the different forms of appendiceal stump closure have never been assessed in prospective randomized studies. Knowledge about and appropriate use of all of them are important for a safe and more cost-effective procedure.

Replantation of Thumb Avulsion Injuries

To point out detailed technical considerations and tactical modifications within the experience of 59 replantations of thumb avulsion injuries, to clarify the indications of replantation, and to evaluate the long-term results. Seventy-two thumb avulsions of 510 thumb amputations were treated at our centre between 1986 - 2002. Sixty-two of them were male and 10 were female. The average age of the patients was 27 years. Fifty-nine avulsed thumbs were replanted, and 13 were considered as "not replantable" and operated using other reconstructive procedures. Since the main goal of thumb replantation is survival with sensitivity and good function, all the injured tissues were repaired or primarily reconstructed. As a main principle, we always aimed for a one-stage reconstruction including vein grafts for the arterial injury, direct vein repair or vein transfer to establish venous outflow, tendon transfers to restore movement, and nerve transfer to restore sensation. Overall survival rate was 84.7 %. The average follow-up time was 65.2 months. 80 percent of the patients returned to their original work within an average of 4 months after replantation. The patients were generally satisfied with the outcome and ability to use their thumb. The average range of movement of the interphalangeal joint was 75 % of the normal side. On average, key pinch strength was 65 % of contralateral hand. Two-point discrimination was less than 10 mm in 60 % of the cases. Semmes-Weinstein monofilament testing evaluation showed 2.83 in 35 patients, 3.61 in 20, and 6.68 in 4 patients. In replantation of avulsion amputation of the thumb, functional success depends on repair or reconstruction of all damaged tissues, if necessary, using nerve transfers and tendon transfers. If these could be done primarily as a one-stage reconstruction, the costs would be less, the patients would return to their work when the one-stage treatment and rehabilitation is finished, and would also eliminate the technical difficulties encountered in secondary reconstructions.

Northeast Asia Policy Under George W. Bush: Doctrine in Search of Policy

IntroductionThe Bush Doctrine stipulates that unilateral action, regime change, and preemptive attack now define U.S. foreign policy. In Northeast Asia, however, the doctrine has run up against unpleasant realities that ought to be causing-but so far do not appear to have caused-its abandonment. Instead, the doctrine's new realism, embellished with strong ideological predispositions, has made the United States odd man out in Asia. This paper critically examines the Bush administration's policy toward the People's Republic of China (PRC; China), the Korean peninsula, and Japan. It concludes that, contrary to the view of some observers (Rose 2005) and notwithstanding tactical modifications, the Bush Doctrine remains the essential underpinning of U.S. policy in George W. Bush's second administration. Northeast Asia's present and future look very different to Chinese, North Korean, Japanese, and U.S. officials. Reconciling those perspectives will have great bearing on prospects for security in the region, but there must also exist the will to reconcile them. Domestic political factors come into play here-the roles, for example, of bureaucratic selfinterest, party alignments, interpretations of history, and ideological preconceptions. In the Bush administration, these factors have lent themselves to a worldview that is unprecedented exceptionalist and hegemonic in its approach to national security affairs. The predominant influence behind this worldview is the group of so-called neoconservatives-people such as Vice President Dick Cheney, Secretary of Defense Donald Rumsfeld, and former Deputy Secretary of Defense Paul Wolfowitz who held national security posts in the Ronald Reagan and George H. W. Bush administrations. Even so-called realists around the president, such as Condoleezza Rice, seem to subscribe to the neoconservatives' belief that the unipolar moment for the United States has arrived.The Bush Doctrine dubs this new realism a distinctly American internationalism. The doctrine asserts that the United States should take advantage of its enormous and unchallengeable power in world affairs to shape the new century (White House 2002; Gurtov 2006; Ikenberry 2002; and Hendrickson 2002). The 9/11 attacks have provided the opportunity to do so. No state can effectively challenge the United States militarily; nor is there any other viable political or economic model that can pose an alternative to the American way of life. In sustaining superiority, Bush administration officials have said, the use and threat to use force-preventively if necessary-must have wider application than in the past; however, diplomacy-multilateral diplomacy in particular-must operate on a shorter leash than previously. A sustained military buildup, with new capabilities to match wider missions, is crucial to implementing the new doctrine. The help and advice of allies, friendly countries, and international organizations of all kinds are useful only so long as they serve U.S. purposes; otherwise, they are dispensable. International law and cooperation must serve the larger objective of restoring order in the international system.If the above summary has merit, its implications for U.S. policy in Northeast Asia are considerable. First, it means that the Pentagon plays a key role in shaping national security policy. Second, neoconservative domination of the policy process means that intelligence findings run a considerable risk of being politicized to serve ideological predispositions. Third, the overall thrust of U.S. policy is to seek to impose U.S. will by relying on military preponderance to send a message to rival states, with scant appreciation for their security concerns and historical sensitivities. But, as seems to have happened in the second George W. Bush administration, such predilections may be undercut by other developments: the high costs of counterinsurgency in Iraq and the accompanying revelations of illegalities and false pretenses in that war, the resistance to U. …

The use of laparoscopic sacrocolpopexy in the management of pelvic organ prolapse

This paper aims to review and comment on the developments in laparoscopic sacrocolpopexy published during the last year. We classified the findings reported recently in the literature for laparoscopic sacrocolpopexy as technical or tactical findings. Technical findings concern the material of the mesh, the methods of mesh fixation, the use of adapted vaginal retractors and the interest in robotic assistance. Tactical findings consist of specific modifications to the standard surgical procedure aimed at reducing the side effects and complications and ameliorating the effectiveness of this intervention. These modifications include the possibility of avoiding the placement of a posterior mesh and the fixation of the posterior mesh to the puborectal muscles or the perineal body instead of the posterior vaginal wall. A specific section has been dedicated to reviewing and commenting on those interventions associated routinely with laparoscopic sacrocolpopexy. Laparoscopic sacrocolpopexy is a safe surgical procedure in constant evolution which allows excellent results in the treatment of utero-vaginal prolapse. Large prospective, randomized studies comparing the different technical and tactical modifications recently introduced are needed in order to further enhance the effectiveness of this intervention.

Tactical modifications in the Skoog reduction mammoplasty.

Some modifications of the Skoog reduction mammoplasty are presented, with the aims of greater safety, longer lasting results, and a better shape of the breast. These modifications are lengthening and thickening of the flap that carries the nipple-areolar complex and a dermal flap in the lower part of the breast, to prevent the sliding of the gland in a late follow-up.

Sweden's Postwar Diplomacy: Some Problems, Views, and Issues

HE CONCEPT OF NEUTRALITY is so firmly planted in Swedish national consciousness that no Swedish Government could long remain in power which does not unconditionally subscribe to the doctrine that neutrality is the best policy for Sweden. Indeed, a Swedish Government that would oppose this doctrine would be unthinkable. Government and people, regardless of politics, seem to have a secret understanding, or gentlemen's agreement, that anything but strict adherence to this Weltanschauung would be intolerable; and seem to have signed a secret pact to stop anybody with a different concept from getting into a position where he might change the course that was chartered almost 150 years ago by the first Bernadotte king. There is so little difference between the Swedes with regard to this fundamental basis for their foreign policy that strangers talking to them get the impression that they have been briefed by their Foreign Office what to tell visitors from other countries. This does not mean, however, that there are no nuances in the policy of neutrality. It is not an inflexible strategy; it allows for tactical modifications, depending on time and circumstance. During World War II, the policy bent one way to adjust to the pressures from Germany in the beginning of the war, and bent in another direction later on to accommodate the demands from the Western Powers. Sweden emerged unscathed from the war, and gave its policy of neutrality almost the entire credit for it.