Oral hygiene is an integral part of general health of a person. Nurses qualified about oral care can play an important role in improving the quality of oral health in hospitalized patients. This study investigated the educational needs of nurses in the field of oral health of hospitalized patients.The study used the modified Delphi method in three rounds. Fifty faculty members of the School of Dentistry and Nursing were selected via purposive sampling. The data collection tool was a demographic form and an open-ended questionnaire in the first round and a structured questionnaire in the next rounds. The analysis was performed using both content and descriptive analysis techniques.The top ten oral health education priorities for nurses were greater than 75% with a consensus level: oral anatomy and physiology, learning the signs and symptoms of common oral diseases, learning of oral medications and administration, learning the drugs that cause damage to the mouth and teeth, training in managing dental emergencies, patient education for tooth brushing and taking care of the mouth, especially in the elderly patient, providing oral and dental care, training for unconscious and fasting patients, undergoing chemotherapy and radiotherapy, and hospitalization in intensive care unit.The findings of the study emphasized the need for interdisciplinary cooperation between nursing and dental professionals for the development of an oral health curriculum for nurses to promote and improve oral health and prevent dental diseases in hospitalized patients and the community.The online version contains supplementary material available at 10.1186/s12912-020-00517-8. Oral hygiene is an integral part of general health that should be maintained throughout life, as the mouth is considered the mirror of the body and the gateway to health , 2. NumeThe study by Carrilho Neto et al. 2011) showed most of the patients had poor oral hygiene, gingivitis, periodontal disease, and dental decay . This ha showed mNurses are one of the largest healthcare group  that plaIn general, studies have shown that nurses need to improve their knowledge about OH , 20. TheThis study was performed using the modified Delphi method over three rounds. The Delphi method is a forecasting process framework based on the results of multiple rounds of questionnaires sent to a panel of experts that seeks to reach a correct response through consensus on a particular topic , 24. TheData collection tool was a questionnaire. In each round, a summary of the results of the previous round was evaluated by the panelists. In the first round, an unstructured questionnaire was sent to the participants by e-mail, and they were requested to complete the demographic information including age, gender, level of education, work experience and an open-ended question: “In your opinion, what are the educational priorities of nurses in the field of improving the OH of hospitalized patients?” Participants were free to express any ideas and opinions about the educational needs of OH nurses and write a list of topics of interest. The items obtained from the first round were analyzed. Also, at the end of this round, the literature was reviewed for finding related issue, the categories extracted from the first round as a structured questionnaire to be used as tools for the second round. In the second round, the participants were asked to answer the items on a Likert scale . Therefore, about the importance of ranking, only items were accepted that scored above 75% and were ranked as important and very important. In the third round, all items that were accepted in the second round were sent to the experts to express their agreement or disagreement with the items. The items were accepted that obtained an agreement score above or equal to 75%. In most Delphi studies, the criterion for consensus was percentage of agreement by 75% . The rem. In conventional content analysis, coding categories are derived directly from the text data. In this study, conventional content analysis was done based on the Lundman & Graneheim method in which codes, category, and themes are compared for similarity and differences [The analysis was performed using both quantitative and qualitative methods. Data analysis was performed in the first round of this study with conventional content analysis approach . Qualitaferences . IBM SPSThis study was the second phase of a project of the designing, implementation and evaluation of a specific nursing educational program in OH of hospitalized patients, which was approved by the Committee of Ethics in Human Research at Shahid Sadoughi University of Medical Sciences in Yazd. In this study, an informed consent was obtained from the participants. Eligible participants were informed about the aim of the study, the method, and confidentiality of their responses by e-mail.In this study, 25 nurses and 25 dentists participated in the first round.  was above 75% and the rest were removed. The removed 6 items were: introducing drugs that affect oral disorders , how to use dental consultation and refer to a dentist, teaching children periodic oral examinations, brushing training for special patients, and teeth fluoride varnish training. In the third round, the items approved in the second round were sent to experts in the agreed/disagreed format to prioritize nurses’ educational needs in the OH of in-patients. Items for which the panelists reached an agreement above 75% were accepted for the last round and the rest were eliminated. So, 5 items on “the relationship between diseases such as respiratory diseases, diabetes, heart disease, etc. and OH problem”, “problems with wearing dentures and how to remove them”, “familiarity with interventions for controlling halitosis (bad breath)”, “providing oral and dental care for patients under d. Table .Table 3Finally, the 10 approved items were confirmed as educational priorities for OH in nursing Table .Table 4In this study, the educational needs of nurses in oral and dental health of hospitalized patients were identified. According to some studies, nurses are not satisfied with the health of the mouth and there is a need for training , 31. TheAccording to the findings, there were ten educational priorities of the nurses in the field of OH for hospitalized patients. Of course, each has been a topic and the educational content must be developed for each of them.Based on the findings, nurses who want to provide oral care for their patients in hospital must know the oral anatomy and physiology and the signs and symptoms of common oral diseases. They should have enough information about the medications that are prescribed to fight oral and dental diseases or about the medicines which can cause dry mouth (xerostomia) and increase the risk of tooth decay and drug administration route. Nurses need to learn what to do when a patient has tooth pain or swollen gums due to toothache.Based on important findings of the study, that nurses need to learn about delivery of oral care to hospitalized patients is that the elderly are more often hospitalized and with longer hospital stays compared to other age groups; so, nurses must learn how to brush their teeth and take care of the mouth, especially in the elderly patient. Haresaku et al. (2018) showed almost half the nurses performed OH check-ups for elderly patients .Another important finding is that nurses need to learn is concerned with delivery of oral care to hospitalized patients. It was emphasized that nurses should be able to provide OH care in this particular group of patients, because they form a greater number of patients requiring hospitalization. These groups of patients include NPO and unconscious, admitted to critical care unit and undergoing chemotherapy and radiotherapy, critically ill patients with an artificial airway. Lee et al. (2019) indicated most participants considered that there is a need for evidence-based protocol for oral care for hospitalized patients, and nurses employed in the critical care unit are much more responsible in this regard compared to nurses working in the public ward .Review of the related literature showed insufficient research to determine the educational requirements of OH for nurses, especially hospitalized patients. Moreover, the studies have been conducted about basic OH. Rwakatema et al.(2015) declared nursing students had insufficient knowledge about basic oral hygiene . HoweverOn the basis of findings, the nurse requires more attention to assess the status of OH and offer the related care. In particular, mouth/oral care should be done for elderly, high-risk patients, and in hospitalized patients in Intensive Care Unit. In this regard, interdisciplinary cooperation between nurses and dentists must be enhanced to develop an OH care curriculum. Then, nurses should be educated about in-patients’ oral care needs. In the future, well-qualified nursing workers can promote OH and prevent dental disease in hospitalized patients.One of the limitations of the present study was the lack of participation of nursing and dental specialists from other universities and throughout the country. It is suggested that this shortcoming be considered in future studies.In this study, ten topics were noted as the most important educational needs of nurses in the field of OH care. The educational needs assessment of nurses about OH of in-patients can lead to the designing, implementation and evaluation of the special nursing OH curriculum for training of undergraduate and graduate courses and nurses retraining.Additional file 1. Delphi First Round QuestionnaireAdditional file 2. Delphi Second Round QuestionnaireAdditional file 3. Delphi Third round questionnaire


The development of the online to offline business has accelerated the growth of the online food ordering market in China. The widespread use of disposable takeaway containers has resulted in a large amount of waste, which seriously affects the ecological environment. This paper studied the collection modes of reusable takeaway containers and the preferences of consumers and merchants. First, after two rounds of discussion and revision, four takeaway container collection modes were designed. Second, based on the survey results of consumers and merchants, a binary logistic regression model was applied to analyze the preferences of consumers and merchants. The results showed that the consumers’ delivery requirements and the current disposal of takeaway containers had a significant impact on consumers’ preferences. Consumers were more concerned about the hygienic status of the containers, food health and safety, while the merchants were more concerned about the increased costs. The promotion of collection modes requires the special consideration of the locations of dishwashing facilities and increased costs. Finally, according to the preferences and concerns of consumers and merchants, several suggestions on promoting the collection mode, such as the use of different promotion strategies for different people, the short distance of dishwashing facilities, reward systems, and food safeguard measures were proposed. This research provides guidance for decision making regarding the sustainable consumption and the promotion of reusable takeaway containers, which will contribute to resource conservation, ecological environmental improvement and sustainability. With the rise of the online to offline (O2O) business, the restaurant industry has undergone major changes, and the takeaway industry is growing rapidly in China. As the pace of life accelerates, work pressure is greater, and as people seek quick and convenient ways to eat, takeaway has become almost a necessity of life for the majority of office workers and students. According to an analysis of Chinese catering takeaway businesses, the takeaway market is growing , as show3 of takeaway garbage is generated per day [With the rapid growth in the online food ordering market, such a large amount of takeaway orders has resulted in a large amount of takeaway packaging waste, which is collected in large piles and difficult to handle. The impact of this waste on the environment is a matter of concern ,4,5,6,7. per day . In Chin per day ,14,15,16 per day . The proCountries are looking for ways to decrease takeaway waste, and they are focusing on the use of environmentally friendly degradable containers. Expanded polystyrene (EPS) containers have the lowest impacts due to the lower material and electricity requirements in their manufacture . HoweverThe use of reusable and non-disposable takeaway containers has become more widespread. That is, takeaway merchants provide reusable containers for consumers to use, and consumers return the containers to a collection point, thus enabling the reuse of the containers. In Japan, the reusable and non-disposable containers, such as porcelain bowls or lacquer bowls, have been implemented through two recycling modes. One mode involves consumers paying a deposit, washing the containers, and placing the containers in a fixed location where the merchants collect the containers. The second mode involves consumer washing the takeaway containers and then delivering them to a collection center. The containers are then uniformly packaged and sent to a collection center. At the collection center, the containers will be washed, disinfected and then provided for reuse .Some research has been conducted on the promotion of the use of reusable takeaway containers. In an investigation of the collection of disposed containers in a Japanese university campus, it was concluded that offering a cash reward improved the collection rate of wasted containers . In JapaAt present, in the Chinese catering market, reusable containers have not been used in takeaway meals, but have been applied for dinners in the restaurant. Some scholars have studied the collection modes, which means the complete system, including the collection and processing. Yiran et al. applied for an invention patent for a collection system of reusable containers . Sanwu eFurther research on how to promote reusable takeaway containers is needed. It is unclear whether merchants and consumers are willing to accept reusable containers and whether collection modes conflict with merchants’ interests and consumers’ need for convenience or others . It is nThe goal of this study was to better explain what the consumers’ and merchants’ preferences for collection modes of reusable takeaway containers were and explore the factors influencing their preferences. To achieve this goal, from September 2018 to June 2019, in four cities, i.e., Nanjing, Jiangyin, Yixing and Yulin, the authors conducted a face-to-face questionnaire survey to analyze the demand, preferences, concerns and suggestions of merchants and consumers for reusable takeaway containers. Four experts were invited to provide decision support and advice on research items. We proposed effective collection modes to get more people involved. Furthermore, a logistic model was applied to analyze the consumers’ and merchants’ preferences and the influencing factors of collection modes. In combination with the concerns and suggestions, the promotion suggestions were proposed. In general, this research contributed to the promotion of the sustainable consumption of takeaway containers in China. The widespread use of disposable takeaway containers resulted in a large amount of waste, which seriously affects the ecological environment. Not only China has these problems, but maybe other countries around the world are also having similar problems. This research provides scholars in more countries with guidance for decision making regarding the sustainable consumption and the promotion of reusable takeaway containers, which will contribute to resource conservation, ecological environmental improvement and sustainability on a broader scale.The content of the rest of this paper is organized as follows. The following is an analysis of the advantages of promoting reusable takeaway containers compared to promoting the recycling of biodegradable single-use food containers.The difficulties with recycling of biodegradable single-use food containers exist in China. First, the coated paper bowl in degradable containers has poor extrusion resistance, as soup leaks easily; thus, these containers are not suitable for Chinese foods with liquids and high temperatures. Second, the price of biodegradable containers is higher than that of non-biodegradable containers, and merchants are more inclined to choose disposable plastic containers due to their low cost. Third, the low recycling rate of biodegradable food containers is also a problem that cannot be ignored . The bioAt present, in China, the reusable melamine containers have not been used in takeaway meals, but have been applied for dinners in restaurants. There are corresponding dishwashing centers to provide dishwashing and disinfection services, therefore, these centers can be used for reusable takeaway containers. From the perspective of cost and environmental protection, food containers made of low-cost straw materials and ceramics are recommended .Thus, promoting reusable takeaway containers have the following advantages compared to the biodegradable single-use food containers in China. First, the reuse of reusable takeaway containers can fundamentally reduce the waste of takeaway packaging. Second, the reusable containers can hold all categories of Chinese food. Third, the dishwashing centers established in the Chinese catering market provide an infrastructure for promoting the use of reusable takeaway containers. Fourth, in the short term, the cost of reusable containers is bound to be higher than that of biodegradable containers. However, in the long term, the cost advantages of reusable meal containers will gradually become apparent based on their reusability.This paper followed a two-step research process. First, the collection modes of reusable takeaway containers were designed. Second, the consumers’ and merchants’ preferences for collection modes were analyzed, and the suggestions on the promotion of sustainable consumption was proposed. A flow chart of this two-step research process is shown in The design of the collection modes of reusable takeaway containers was studied and modified over several rounds. A preliminary design was first developed based on expert interviews and international experiences. Then, the questionnaire surveys were conducted to assess preferences. Questionnaires were distributed to takeaway merchants and consumers to determine their activity, the reasons for their selections, concerns and suggestions. The feasibility and reasonability of the preliminary proposal were analyzed. If it was not reasonable, the preliminary design would be modified, and a new round of design was initiated. Then, a new questionnaire was conducted until the proposal was determined to be appropriate.The second step of this research involved the analysis of the respondents’ preferences for collection modes. Based on the final round questionnaire results, a binary logistic regression model was applied to determine the factors that influence the consumers’ and merchants’ preferences. According to the results, some suggestions on promoting collection modes were proposed.A panel invited four experts, including a professor from Nanjing Forestry University, a professor from the Southeast University, two senior managers from the takeaway platforms of Meituan takeaway and Eleme. These experts each had more than 10 years of respective field experience, which could make the judgments more consistent and reliable.The expert interviews were completed in September 2018, December 2018, and June 2019 to provide decision support and advice on five research items: the guidelines for the collection mode; the criteria for judging the reasonableness of the collection mode; several feasible collection modes; a list of questionnaire questions for the questionnaire survey; and the specific survey process.Taking into account the recommendations of the experts and the literature review ,18,24,29The design of the collection mode was mainly based on national and international cases, the literature review and the experience of experts. There is currently a delivery rider immediate retrieval mode in China. This mode is therefore included in the first round of collection modes. Others are mainly based on the Japanese case and the literature review, in which consumers bring their food containers to a collection point, where they are later picked up by the merchants ,26,27,28In the first round, four collection modes were designed as follows.Mode 1. The takeaway consumer places the food in their own containers, and returns the empty reusable containers to the delivery driver. Then, the delivery driver returns the containers to the merchants for dishwashing.Mode 2. The consumer simply washes the containers after a meal, and make an appointment on the app. Then, a delivery driver makes an appointment to pick up the containers and return them to the original takeaway merchant for deep dishwashing.Mode 3. The consumer simply washes the containers and then brings them to a collection bin for simple automatic dishwashing. Then, a delivery driver picks up the containers and brings them to the merchants for dishwashing.Mode 4. The consumer brings the food containers to a collection bin for simple automatic dishwashing, and a delivery driver brings them to a dishwashing center for deep dishwashing. The containers are washed and sanitized before being distributed to the merchants.The experts suggested the probability of the consumers’ and merchants’ choice of collection mode as a criterion for judging the reasonableness of the collection mode. If the selection probability of a collection mode was small relative to several other modes, then this mode can be largely ruled out.Mode 2, Mode 3 and Mode 4 from the first round were retained, and a new mode was added. The second round of the collection modes were as follows.Mode A–M. The retained previous Mode 2. Here, the A in Mode A–M is the initial capitalization of the word app and the M is the initial capitalization of the word merchant.Mode A–W. A new added mode. The consumer simply washes the containers after a meal, and makes an appointment on the app. Then, a driver makes an appointment to pick up the containers and bring them to a dishwashing center for deep dishwashing. Here, the W in Mode A–W is the initial capitalization of the word wash, which means dishwashing center.Mode B–M. The retained previous Mode 3. The B in Mode B–M is the initial capitalization of the word bin, which means collection bin.Mode B–W. The retained previous Mode 4.This paper uses the well established field questionnaire method. This method is simple and effective and has been adopted by the majority of scholars ,34,35. IThe questionnaires for the consumers were collected from takeaway consumers, with answers about their essential information, their ordering takeaway behavior, and their opinions on the preference, concerns and suggestions of promoting reusable takeaway containers . The essThe questionnaires for merchants were collected from takeaway merchants, with answers about their essential information, their business characteristics of takeaway and their opinions on the preference, concerns and suggestions of promoting reusable takeaway containers. The essential information of the merchants included gender, age and education level. Their business characteristics of takeaway were surveyed in perspective of catering classification, major forms of catering, daily business hours, number of in-store dinners at peak time, online orders at peak time, the existing distribution mode, number of delivery drivers, and the selection standard of existing containers. Their opinions on the preference, concerns and suggestions of promoting reusable takeaway containers were collected in the same way as that of the consumers’ questionnaire.Previous studies have used questionnaires, field surveys, and interview surveys. Some have preferred to use mailing questionnaires to identify target respondents, but due to the low return rate , the results are always poor ,48,49. SIn order to fully understand the consumers’ and merchants’ preferences in reusable takeaway containers, the target respondents are selected among restaurants with high takeaway sales, whose opinions are based on real experience. This questionnaire survey was conducted in four cities, i.e., Nanjing, Jiangyin, Yixing and Yulin. When designing the first-round mode, the responses were collected from 137 consumers and 112 merchants during the second half of 2018. The second-round questionnaire was carried out in the same cities during the first half of 2019. The content of the questionnaire was essentially the same as the first round of the questionnaires, except that the options for several collection modes were modified. A total of 393 consumer questionnaires and 112 merchant questionnaires were collected.k independent variables was constructed as follows [iP represents the probability of choosing this mode. β0, β1k…β represent the regression coefficients. x1, x2k…x represent the variables. Because the dependent variable is binary, the error term of the logistic regression model should obey a binomial distribution, and the maximum likelihood method is used to estimate and test the model. It is noteworthy that the significance of each model parameter is less than 0.05, and the parameter modification is effective.This paper explores the factors that influence the consumers’ and merchants’ preferences for collection modes by a binary logistic regression model. When the dependent variables are categorical, the linear regression method is not suitable for analyzing the probability of selecting each mode. Therefore, we used a logistic regression model. The dependent variable studied in this paper was “whether to choose a certain mode”, which was divided into “yes” and “no” . Assuming that the random variables follow the logical probability distribution, a binary logistic regression model with  follows :(1)Pi=eβ2 [SPSS can be used to filter the independent variables according to forward or backward and stepwise regression. There are three criteria for eliminating independent variables, namely conditional parameter estimation, maximum likelihood estimation, and Wald χ2 .A first-round questionnaire survey was conducted. A total of 91% of consumers were aware of the impacts of the disposal of takeaway waste. A total of 77% of consumers supported the use of reusable food containers, but they were concerned about dishwashing and disinfection. A total of 70% of consumers used takeaway services because it is convenient and saves time. However, returning the containers to the collection bins requires additional time; a total of 57% of consumers were not willing to spend time on this. Consumers were more inclined to support collection modes that take less time. According to the results of the first round of the performance survey, which are shown in A second-round questionnaire survey was carried out. The preferences for the second round of the modes are shown in For the consumers, there were two preferences, namely make an appointment on the app  or bring the containers to a collection bin for dishwashing . For the merchants, there were two preferences, namely return the containers to the merchants  or bring the containers to a dishwashing center .The SPSS 25.0 was used to filter the independent variables according to forward or backward and stepwise regression. Thirteen variables were defined, and the statistical results of the consumers’ survey sample are shown in 2 value is, the better the fit of the model is [2 and Nagelkerke’s R2 were larger than 0.05, indicating that the model fits well [The likelihood ratio test and the Hosmer–Lemeshow test were used for the goodness-of-fit analysis, and the results are shown in model is . The valits well . The Hosits well . In thisThe SPSS 25.0 was used to filter the independent variables according to forward or backward and stepwise regression. Fourteen independent variables were defined, and the statistical results of the merchant survey sample are shown in The likelihood ratio test and the Hosmer–Lemeshow test were used for the goodness-of-fit analysis, and the results are shown in As can be seen from The consumers’ suggestions on promoting reusable takeaway containers were collected from the questionnaire, and focused on the distance of dishwashing facilities and acceptable increased costs.The consumers’ preferences for the distance of collection bins is shown in Compared to the disposable takeaway containers, the purchase and collection of reused containers and the operation of dishwashing facilities are all direct contributors to the increased costs of takeaway businesses. Indirectly, they contribute to the increased cost of ordering takeout for consumers. Both the consumers and merchants are concerned about the increased cost. As shown in In this study, we found the impacts of the independent variables on the consumers’ and merchants’ preferences. The independent variables of the consumers’ preferences, shown in red in Consumers under the age of 20 were more likely to select Mode B. Most of them were university students or young workers who did not find it convenient to wash dishes, and therefore, they preferred to send the containers to a small dishwashing bin. Consumers aged between 21 and 50 preferred Mode A, as it was easier for these individuals to wash their dishes.Consumers who ordered takeaway 1–2 times and 3–4 times a week preferred Mode A. The average amount spent per meal was mostly in the CNY 15 and CNY 15–30 categories. Consumers spending less than CNY 15 per meal were more likely to select Mode B, but those spending between CNY 30–50 per meal were less likely to select Mode B.Consumers who chose Mode B were more concerned about hygiene and the distance of small automatic dishwashing centers.The impacts of the independent variables on the merchants’ preferences were shown in Merchants offering burgers, pizza and dessert drinks preferred Mode M. Hamburgers and pizzas are packaged in simple disposable paper bags, which essentially eliminates the need for reusable containers. Therefore, these merchants preferred Mode M due to its lower cost. Our goal, of course, is to promote the use of reusable containers or the packaging of all types of food, thus preventing packaging waste, even if the packaging is easily discarded. Foods such as pizza and hamburgers can also use reusable containers or packages.The longer the business hours were, the more likely it was that merchants would choose Mode W. The more consumers there were in the restaurant at peak dining hours, the more likely it was that the merchants would choose Mode M, probably to avoid running out of containers in the restaurant. The more consumers there were ordering online at peak time, the more likely it was that the merchants would choose Model W. When there were high numbers of both online ordering consumers and in-store dining consumers, the merchants were more likely to choose Mode W. A dishwashing center ensures both hygiene and the timely turnover of containers.According to the above discussion, consumers and merchants of different ages, genders and consumption levels have different preferences for the modes. Several factors influence the consumers’ and merchants’ choices. Therefore, different collection modes should be promoted for different crowds. Considering the high cost of setting up collection bins, it is recommended that these bins be set up where the takeaway consumers are concentrated.For consumers, collection modes can be promoted depending on the number of takeout times, the average amount spent per meal and age. Consumers who order takeaway more often and spend more preferred Mode B. For consumers who are young students, Mode B should be promoted in dormitories on campuses. If it is convenient for consumers to wash their dishes, such as in residential areas, Mode A should be promoted.For takeaway merchants, collection modes can be promoted depending on the categories of catering and the number of consumers. Mode M is recommended for merchants who sell food with simple packaging, such as hamburgers, pizza and dessert drinks. Mode M is also recommended for merchants with low-peak dining attendance; conversely, Mode W is recommended for those with high-peak dining attendance.To promote the collection mode of reusable takeaway containers, some issues need to be addressed, namely, the locations of dishwashing facilities, the increased costs and the hygienic status of takeaway containers.It is recommended that the collection bin be within 500 m of the consumers and the dishwashing center be within 5 km of the merchant.In response to the increased operation costs, a reward system is recommended based on the experience in Japan . TakeawaIn addition, it is recommended to seek some support and help from the government administrative departments. The promotion of relevant policies requires all parties to effectively participate in the use of reusable containers to ensure the smooth implementation of the collection process. The tax bureau can provide a certain degree of benefits to merchants in terms of tax revenue. The environmental protection bureau can implement a carbon credit system for merchants to offset part of the tax so that the operation costs of merchants can be reduced.To implement the collection modes of reusable takeaway containers, the government regulatory departments and takeaway platforms need to formulate a series of articles of association and publicity. Thus, the merchants and consumers would have no doubts about the hygiene and costs and would actively participate in the use and promotion of reusable takeaway containers.It is suggested that the health supervision department be transparent in establishing strict regulations and evaluation mechanisms to standardize the production and disinfection process of containers. The food safety office needs to strengthen the supervision and spotcheck process, cooperating with the administration of the industry and commerce to punish manufacturers who illegally produce low-quality containers and those who neglect the dishwashing and disinfection process. It is important that consumers trust the reusable containers and their sanitation and that they are easily able to use the containers.This paper presented designs for collection modes for reusable takeaway containers, and analyzed the takeaway consumers’ and merchants’ preferences for collection modes. Based on the preferences and concerns of consumers and merchants, we proposed promotion strategies and guarantee measures, such as different promotion strategies for different people, suggestions on the locations of dishwashing facilities, reward systems and food safeguard measures.It is recommended that different collection modes should be promoted for different people. For takeaway merchants, collection modes can be promoted depending on the categories of catering and the number of consumers. For the consumers, collection modes can be promoted depending on the number of takeout times and the average amount spent per meal and age. It is also recommended that the collection bin be within 500 m of the consumers and the dishwashing center be within 5 km of the merchant. In response to the increased operation costs, a reward system is recommended. The environmental protection bureau can implement a carbon credit system for the merchants to offset part of the tax so that the operation costs of merchants can be reduced. It is suggested that the health supervision department be transparent in establishing strict regulations and evaluation mechanisms to standardize the production and disinfection process of reusable food containers.However, there are still some limitations. The number of merchants surveyed herein was too small, which led to deviations in the fit of the model. In the future, we will continue to identify the influencing factors and conduct in-depth research to develop models with better fit. In addition, since takeaway consumers do not typically go to in-store dinner, this study did not consider the possibility of consumers bringing the reusable food containers back to the merchants. However, when promoting the collection of all food containers in the future, the feasibility of this mode will need to be considered.


Zeff at 24 months.Explosives detection systems (EDS) based on X-ray are used at airports to screen baggage for the presence of explosives. Once EDS are installed in airports, however, it can be challenging to test the EDS equipment and verify that it continues to perform at the highest level, because of the impracticality of introducing bulk explosives into civil aviation airports. The problem is particularly acute for sensitive homemade explosives, such as triacetone triperoxide (TATP). This paper describes our work to develop a safe, accurate and stable simulant for TATP for EDS based on X-ray transmission. Bulk quantities of TATP were synthesised and characterised especially for this project, and we describe the unique challenges and safety considerations of collecting this data. Our calculations show that the expanded measurement uncertainty with a coverage factor of k = 2 is 5.7% for bulk density and 1.0% for  In Europe, civil aviation security is regulated at EU level under Framework Regulation 300/2008  and its In aviation security, explosives detection systems (EDS) is a specific term that refers to X-ray equipment with the functionality to automatically detect  the presence of explosives in screened baggage. EU legislation requires that all baggage has to be screened before being loaded onto the aircraft hold. Although multiple screening solutions are permitted by legislation, the sheer number of bags and the limited time available for screening mean that in practice almost all items of hold baggage are screened by EDS. In Europe and the United States, EDS equipment is tested extensively by specialist test centres ,5 prior 9H18O6 and its molecule is sketched in TATP was discovered in 1895 by Richard Wolffenstein . It beloZeff. It was also considered important that—just like actual TATP—the simulant is in a powder form.The purpose of this work was to develop high-quality explosives simulants for TATP that can be used as standardised testing materials to verify the detection performance of EDS. The simulants had to be inert, non-toxic and mimic the relevant properties of explosives. For transmission X-ray systems, those properties are bulk density and effective atomic number, This paper describes the development of TATP powder bulk simulants for EDS carried out at the European Commission’s Joint Research Centre (JRC) in Geel, Belgium. The target parameters were determined from highly specialised measurements of several hundred grams of TATP that were synthesised and characterised especially for this project by the Instituto Nacional de Técnica Aeroespacial (INTA), in Spain. We describe the unique challenges and safety considerations of collecting such characterisation data. To the best of our knowledge, our characterisation data of bulk quantities of TATP using dual-energy, computer tomography (DECT) equipment is the first such data collected in Europe. The project was safely executed, and the synthesis and characterisation steps were successful. However, the measures required to minimise the hazards of working with sensitive primary explosives in large quantities illustrate the need amongst the testing community for safe alternatives. We conclude that our simulants described in this paper are fit for purpose for the safe testing of the detection of TATP by explosives detection systems based on X-ray transmission.Finally, we mention that this paper complements a recent paper by the authors on the development of solid, polymer-bonded simulants of other explosives , in whicWe identified two main formulations for producing TATP simulants. Initial formulations were based on vanillin, caffeine, malic acid and sodium bicarbonate. Although the simulants based on these formulations had the required values of bulk density and effective atomic number, they suffered from a couple of drawbacks. The most obvious issue was the strong vanilla odour, which could be somewhat mitigated by tightly sealed containers. More unsatisfactory, however, was the unexpected tendency of the vanillin part of the simulant to partly recrystallize and go from free-flowing powder to a semi-hard powdered matrix. This issue could be partly reversed by input of mechanical energy to the simulant.A second formulation was conceived based on stearates, caffeine and benzoates. The stearate-based formulations did not suffer from the drawbacks of the vanillin-based formulations, so we decided to focus on only the stearate formulations for further optimisation. The advantage of simulants based on stearates is that the amount of stearate present in the simulant and the level of compression of the mixture can be varied to manipulate the bulk density of the resulting simulant. Photos of the stearate-based TATP simulants are shown in Zeff and bulk mass density, and this data provided us with target parameters to develop a TATP simulant. The sample of real TATP measured at INTA using DECT equipment had a bulk density of 0.66 g/cm3 and an effective atomic number, Zeff, of 7.10. The repeatability of the TATP measurements in terms of relative standard deviation (RSD) was 0.6% and 0.1% for density and Zeff respectively. The accuracy of six different TATP simulants relative to the measured values of real TATP is indicated in The accuracy of our stearate-based simulants of TATP was determined by comparing their density and effective atomic number to that of real TATP, as measured on the same equipment. Characterisation data was acquired using DECT X-ray equipment. This equipment has passed ECAC testing for so-called standard EDS-C2 . The meaZeff data exhibit very little variation across the simulants, and the measurements are very repeatable. Expressed as relative standard deviation (RSD), intermediate precision for Zeff was 0.3%. This confirms the efficacy of the mixing and homogenisation, as all six simulants were produced from the same batch of ingredients.We can see that the The density data exhibits greater variability, which reflects both the variation in the final density of the simulants, and the increased uncertainty inherent in measurements of powder densities using X-ray transmission equipment. Expressed as relative standard deviation (RSD), intermediate precision for bulk mass density was 1.5%.Stability testing is necessary to establish conditions for storage as well as conditions for dispatch to customers. A stability study was carried out using a standard design model where samples are measured at various time points and the linear regression analysis is used at the end to calculate the stability of the samples. The measurements at each time point were performed under repeatability conditions, and the data is shown in Zeff. These parameters were systematically followed for nine months at room temperature (21 °C). Stabilities at lower and elevated temperatures were not tested. Volume integrity stability testing of powder simulants shows no significant self-compaction over the test period. In Zeff. These results show acceptable long-term stability of the simulants.To determine the stability of the simulants, we followed the volume integrity of the simulants along with bulk density and Zeff at 24 months.To estimate the measurement uncertainty, we followed the Guide to the Expression of Uncertainty in Measurement . We idenZeff of TATP and our simulants were determined using commercial explosives detection systems (EDS), namely the XT2080SI Kylin , with a nominal energy of 160 keV. This EDS has passed testing by the European Civil Aviation Conference [The density and nference . In geneA bulk amount of real TATP (around 400 g) was synthesised and subsequently characterised using DECT equipment. This part of the work was co-ordinated and carried out by INTA at the facilities in Cuadros, Leon (Spain). To the best of our knowledge, this was the first time ever that bulk amounts of TATP were characterised with DECT equipment in Europe. The data collection of bulk TATP samples with the EDS equipment required several phases: synthesis, transport, handling, testing and destruction. There was no readily available information on safety protocols for handling and transporting hundreds of grams of dry bulk samples, nor information on how to test these samples with DECT equipment. Thus, a risk assessment was carried out that led to the development of specific safety protocols before the start of the project. All phases were only performed by highly qualified personnel, under the use of the appropriate safety measures. Strategies were established in all the phases to minimise risks from electrostatic discharge, friction, impact, temperature, etc. During all steps involving bulk TATP, a medical team and ambulance were present. Work-up tests were carried out before the main test in order to train personnel in the various tasks to be performed, minimising the risk of possible errors and identifying improvements to the protocols.For safety reasons, the synthesis of the TATP was carried out as close as possible to the testing bunker where the EDS was located. For this reason, INTA personnel specialized in the synthesis of energetic materials were deployed to INTA’s facilities in Leon. The test site at Leon did not have any synthesis laboratory, so one of the buildings was conditioned to accommodate an in situ laboratory with all the safety measures in place, as well as all the necessary instrumentation and equipment.There are numerous references in the literature on the synthesis of TATP ,11,12. AFor handling and transport, all relevant safety measures were provided to the personnel  and EOD  or military protection equipment . The handling and transport of the synthesized sample was carried out by military personnel with EOD qualifications by INTA see b. The TAThere are numerous published studies on the detection of TATP with various technologies with bulk, diluted, trace, or vapour TATP samples. In those studies, the detection is performed on very small amounts (less than one gram) of TATP ,18,19,20Testing comprised 15 sequential screenings of the TATP using DECT equipment (Nuctech XT2080SI Kylin) installed inside a bunker at INTA’s facilities in Leon, Spain. High-purity reference materials were also scanned before and after the measurements of TATP, for calibration and stability testing purposes. The TATP samples had to be placed in trays and these placed at the entrance to the EDS for analysis. Measures were taken in order to improve the entry and exit of the trays with the TATP, and a trolley was built for the placement and handling of the TATP in the trays. Once outside the measuring tunnel, they had to be collected. This process was carried out manually by the EOD personnel. The manufacturer was consulted on the possible effects that the EDS system could have on the TATP explosive. An improvised control centre was deployed outside the bunker and the EDS had to be adapted to allow it to be controlled from a greater distance than usual. From the control centre, the work of the different teams was co-ordinated, and the EDS equipment was operated. A remote video monitoring system was used to verify in real time the correct execution of the test inside the bunker. Once the runs were completed, the data generated by the system was analysed to verify the successful acquisition of data, thus marking the completion of the testing phase.There are different methods of destroying TATP ,24,25,26Disclaimer: Cyclic acetone peroxides are sensitive to accidental detonation from impact, friction, electric discharge and flame. The synthesis, transportation, handling and measurement of TATP described in this paper are dangerous operations that should only be performed by highly qualified personnel using the strictest safety precautions for handling primary explosives. Neither the European Commission nor the Instituto Nacional de Técnica Aeroespacial shall be responsible for any damage, loss, harm of any kind suffered by third parties attempting to replicate the work described in this paper.Ze (to differentiate from Zeff) has several advantages, namely that it is based on a physical model instead of an empirical one, that it comprises one fixed algorithm over a range of materials and energy spectra of interest, and that each value of the parameter corresponds to a well-defined x-ray absorption behaviour. At the heart of the Ze approach is the calculation of energy-dependent photon cross-sections σ(Ex), based on the sum of the cross sections of the constituent atoms in compounds and mixtures, weighted according to the relative electron fraction, ia:ia is given by:in is the number atoms, iZ is the atomic number for each element, i, in the mixture, and N is the number of constituent elements in the mixture.Effective atomic number is a critical concept for the automated detection of explosives using dual-energy x-ray equipment. Along with density, these two parameters are the primary features used by software algorithms to detect explosives in scanned baggage. However, effective atomic number is a (semi-) empirical parameter, and there are multiple definitions in literature . In thisZe. We used this software to screen substances for their potential use as simulants ingredients. Ingredients were systematically screened and checked based on their Zeff values, C:H:N:O ratios, potential toxicity and aggregate state, and the necessary proportions of ingredients to achieve the required effective atomic number of the resulting mixture were determined.We developed our own implementation  using MiChemicals used for synthesis of TATP explosive used to obtain reference values were concentrated sulphuric acid , hydrogen peroxide at 30%  synthesis-grade acetone  and sodium bicarbonate . Chemicals used for preparation and development of simulant formulations were as follows: vanillin, caffeine, lithium stearate, sodium stearate, calcium stearate , malic acid, glucose, sorbitol, xylitol, ascorbic acid, cyanuric acid , sodium bicarbonate, sodium benzoate, acetylsalicylic acid , 1,6 hexanediol and TRIS . All simulants described in this paper were in powder form and were initially contained in plastic bags, but in order to gain better control over powder volume packaging was changed to cylindrical PVC transparent tubes with a diameter of 70 ± 0.1 mm. The height of the cylindrical containers and the size of the bags depended on the mass of the simulant. For long-term stability studies and calibration purposes of EDS, pure polyoxymethylene , polytetrafluoroethylene (PTFE), graphite, silicon and aluminium rods with the diameter of 60 mm and length of 200 mm, from American Elements  were used.® benchtop 3D mixer ). For drying of the mixture slurries, a temperature-controlled drying cabinet was used . For grinding of the powders, a cryo-grinding vibrating mill was used . For compacting of the powder mixtures, a vibratory feeder Laborette 24 was used .The TurbulaZeff, and physical properties of the material. The powder mixture was then mixed in a 3D mixer for one hour to homogenize the distribution of the different powder fractions. Finally, the simulant powder mixture was packed into a PVC tube of 70 × 500 mm, and a thickness of 15 µm, and vibrated to the desired volume. The excess of tube material was cut and the ends were sealed, to ensure the bulk density remained matched with the target one.The process of bulk powder explosive simulant production required that the simulant components were weighed according to calculated proportions and dissolved in deionized water to generate a slurry, which was then homogenized by mixing. The slurry was dried in a temperature-controlled oven. The mixture was then frozen overnight in liquid nitrogen in a stainless-steel container and subsequently milled using a cryo-grinding vibrating mill. The mill was maintained below −120 °C throughout the process. This was a necessary because milling at room temperature would cause melting due to friction created during the milling process. Milling served two goals. Firstly, it ensured all particles were approximately the same average size in order to prevent stratification during mixing and compression. Secondly, milling controls the bulk volume and electrostatic interaction between particles, which in turn affect the bulk density of the resulting simulant. The smaller the particles, the bigger the electrostatic forces between them. The mixture was then slowly brought to room temperature in a dry atmosphere (this was achieved by displacing air with dry nitrogen gas) in order to avoid water condensation on the powder. This prevented the contamination of the simulant by water, which can change the density, Explosives detection systems (EDS) play a key role in aviation security, and they represent the last line of defence in preventing explosives from being brought on board aircraft in baggage. There is a need to verify the detection performance of EDS during their operational lifetime, but working with explosives in an operational environment is challenging. The situation is particularly acute for sensitive homemade explosives like TATP.We acquired characterization data of bulk density and effective atomic number of several hundred grams of TATP using dual-energy, computer-tomography EDS. The challenges and safety precautions employed to minimise the risk of this kind of work are described in this paper. We used the characterization data to develop simulants for TATP based on a formulation comprising stearates, caffeine and benzoates. Compared to solid simulants, controlling and the bulk density of powders is more challenging. We described the material processing steps used to produce our simulants.Zeff, composition, or stability, and hence do not have sufficient quality control or quality assurance to be used during formal testing in aviation security. Based on the comparison of bulk density and effective atomic number of our simulants with the real TATP sample measured with the same equipment, we conclude that our simulants are fit for purpose as a safe alternative for verifying the detection of TATP in baggage screening equipment based on X-ray transmission. The process described in this paper is adaptable, and additional TATP simulants can be produced with different properties if deemed appropriate, for example, in the light of intelligence on specific recipes.To the best of our knowledge, our material is the first one that was designed using actual measurements of bulk amounts  of TATP explosive, and the material is accompanied by reliable test data. Our experience is that commercial TATP simulants are not supplied with much, or even any, information on accuracy of density or A patent linked to this work has been filed with the European Patent Office in 2019.


To present new endoscopic robotic devices in the context of minimally invasive procedures with high precision and automation. Review of the literature by December 2018 on robotic endoscopy. We present the studies and investments for robotic implementation and flexible endoscopy evolution. We divided them into forceps manipulation platforms, active endoscopy and endoscopic capsule. They try to improve forceps handling and stability and to promote active movement. The implementation and propagation of robotic models depend on doing what the endoscopist is unable to. The new devices are moving forward in this direction. Endoscopy began as a gastrointestinal (GI) diagnosis method and became an important treatment method for GI pathologies nowadays. The equipment is in constant evolution, since the implementation of the electrical lamp, from the coming of flexible endoscopes, incorporation of ultrasonography and the recent development of robotic methods.Endoscopic instruments had already been used for the urethra, bladder and uterine cervix. However, it was Adolf Kussmaul, in 1868, who performed the first direct esophagogastroscopy. After attending a sword-swallower performance, he demonstrated that it was possible to introduce a rigid tube to the stomach if head and neck hyperextended, yet without enough illumination. Joseph Leiter, in 1882, included an electrical lamp on the tip of the endoscope.2 .Endoscopy as known today is due to the invention of the flexible endoscope by Wolf and Schindler in 1932, spreading the diagnostic endoscopy use. The emergence of videoendoscopy expanded its use in the GI pathologies treatmentWith the evolution and propagation of endoscopy, two major dilemmas emerged. Both the endoscopic submucosal dissection (ESD), resecting lesions each time wider and more complex, and the willingness to perform Natural Orifice Transluminal Endoscopic Surgeries (NOTES) bring the need of platforms that promote stability and forceps manipulation that conventional equipment does not. Adding up to that, there is the pursuit of automation for equipment to do what, nowadays, only the endoscopist physician is capable of.Thereby, the endoscopic robotic techniques can be divided into those developed to improve forceps handling and stability and those with active movement.3 . However, with the advance of its therapeutic purpose, the time and complexity of procedures have been drastically increasing, highlighting the operational limitations of flexible endoscopes. They have limitations regarding stability and forceps movement, with little possible angulation.Flexible endoscopy is widely used for GI diagnosis and therapy, as it is little invasive and fast. Done by only one endoscopist and, most times, without general anesthesia4 . Degrees of freedom are specific, defined modes in which a mechanical device or system can move. The number of degrees of freedom is equal to the total number of independent displacements or aspects of motion. Beyond that, it is necessary to keep searching for lower adverse events rates, pain and discomfort while the exam to promote higher patient acceptance.Robotics has more degrees of freedom to improve triangulation and traction precision for dissections and NOTESThe larger researches and investments in robotic endoscopy are directed to:5 .Platforms capable of high degrees of freedom on forceps manipulation for ESD and NOTES9 .Active introduction of the endoscopes to reduce the influence of the operator ability and to reduce the discomfort and pain referred by the patients11 .Endoscopic capsule evolution to use it as screening for GI pathologies and as a therapeutic method12 ; metallic clips tied to strings14 and forceps attached to external channels16 . However, each one has its limitations. The cap-assisted technique reduces the vision field and sometimes does not promote the necessary traction. The clip is not possible to be pushed. Forceps in external channels can only perform traction in the same axis as the endoscope17 .For ESD, it is necessary an adequate mucosal traction towards the lumen to expose the submucosal layer. The submucosal layer is dissected carefully, with hemostasis, until complete resection of the lesion. Mucosal traction needs to be constantly reallocated, due to angles and curves, especially in larger lesions. Those steps can take hours and bring technical difficulty. A range of instruments was developed to help the dissection, as different types of endoscopic knives and techniques to promote traction as cap-assisted3 . We will describe some of the devices that are being carried out and improved.The robotic systems facilitate the techniques described above. The main principle of the majority is two attached arms in the tip of the endoscope, enabling the forceps manipulation to various directions with better triangulation, traction, exposure and dissection of the tissue18 . Animal studies demonstrated effectiveness on ESD, full-thickness gastric resection and hepatic resection18 . This system was used on human for a few gastric, one esophageal and one colon ESDs24 .Developed by the Nanyang Technological University and the National University of Singapore, the MASTER system consists of two attached arms to a conventional double-channel endoscope with a forceps and an electrocautery hook. It allows nine degrees of freedom   . It is et al .23 evaluated five early gastric lesions restricted to the body or antrum. The mean time of margin free resection was 18 min (3-50 min), without adverse events. Although its viability, the MASTER has a few limitations. It is not possible to change the forceps, it is necessary to insert an overtube in the esophagus and the external control unit is big and restricts its displacement25 . The MASTER development continues to improve flexibility, precision and to promote kinetic sensation26 .The narrow space interferes with the forceps manipulation, but en bloc resection was possible without major complications. Phee TM. Developed by the Research Institute against Digestive Cancer (IRCAD) with Karl-Storz, it is a modular system with a 16mm diameter endoscope. It has two 4,3mm diameter channels and one 3,2mm central channel. Specific forceps are capable of bounding at the tip, promoting rotation and translation with 10 degrees of freedom25 . A trocar like the tip of the endoscope protects the esophagus during the insertion and opens like a shell when it is in place. External traction wires electronically control the instruments, eliminating the resistance sensation of the initial Anubiscope, which had mechanical control27 . NOTES cholecystectomy was performed successfully by AnubiscopeTM in one patient28 . AnubiscopeTM needs good cooperation and synchrony between at least two physicians who share the workspace at the platform. In this sense, the robotics and telemanipulation provide the possibility of only one person controlling the entire equipment  for the use in NOTES. It is a system composed by a main body (command console) and the tube. The tip has two articulated arms with five degrees of freedom , besides a conventional work channel. The tube has 15mm diameter and the articulated arms have 2.8mm diameter. An exclusive overtube is required for the insertion of the tube. Two endoscopists are required for its manipulation, one at the tube and one at the command console managing the two articulated arms. The application in humans still needs validation, although its use has been demonstrated in ex vivo studies29   and 6 .30  are constantly measured and transmitted to the workstation. A computer algorithm adjusts the three pressures to advance the vehicle balloon and to avoid perforations. Once the system is in the cecum, the pressures are changed to maintain the colon distended for evaluation and the balloon regression to the rectum. The camera provides a circumferential view of 360º32 . Gluck et al .33 reported a cecal intubation rate of 98.2%  or externally by magnetismWe present the researches and investments in the implementation of robotics and the evolution of flexible endoscopy. There is a search for systems that bring stability and greater controllability of the instruments for complex ESDs and NOTES. However, the new models presented have not yet been tested in large and challenging lesions, where they would show their full capacity and initial purpose, reducing technical difficulty and procedure time. For the implementation and diffusion of the robotic models, they must perform tasks that the endoscopist is incapable of, not only to reproduce what is already widely done. To move in this direction, the available models need to be constantly developed. Now to improve handling and stability; decrease the caliber and size of parts; and promote tactile sensation. However, this mission is not simple. Improved handling means increasing degrees of freedom, increasing the number of parts and instruments, making it harder to reduce the size of models.Regarding active endoscopy, it is still necessary to develop models that prove safe and effective progression of the devices. The ability to perform small therapies, such as forceps polypectomies, also needs to be incorporated into these models. The endoscopic capsule is still far from being able to carry out self-propulsion and therapy. However, with external handling modules, the diagnostic exam of the stomach is already feasible and may be an alternative for screening tests. The idea of performing exams without the need of the endoscopist is still far from being materialized. In some cases, the need for the skilled professional has even increased, as in distance manipulation forceps models, where two endoscopists are necessary: one at the tube and another at the control console. The association of artificial intelligence with the processing and interpretation of computer images will certainly increase the autonomy of endoscopy, but the models currently available are still in research and this is not a reality for the near future.


The Prospecting Boundaries project explores the Mazaro river corridor from a landscape archaeological perspective, using integrated prospection techniques to recover traces of past human activity and environmental contexts. One key research area is Guletta, a zone of dense multiperiod activity situated on the rocky plain above the river. In this paper, we detail results from recent work at Guletta, which has revealed numerous previously undocumented archaeological settlement features that appear to have been built in successive phases. Artifact analysis from corresponding surface survey indicates a mixture of locally produced and imported materials dating from the Middle Bronze to Archaic periods. Using these new results together with existing archaeological and environmental information, we present an initial interpretation of the occupation sequence of the settlement and explore the concept of Guletta as a connecting point between emerging indigenous, colonial, coastal, and interior interdependencies and interests in later pre- and protohistory. The zone between coastal and interior western Sicily contains a rich matrix of archaeological resources indicative of its changing importance and functions at various periods in history. Nowhere is this in greater evidence than along the banks of the Mazaro River, a spring-fed perennial stream that flows from the hilly western interior near modern-day Salemi for more than 25 km southwest to the Mediterranean port city of Mazara del Vallo. The inland section of the river flows in a wide and gentle valley, but as it approaches Mazara del Vallo, it cuts into shallow sandstone, forming a deep-sided gorge whose rocky outcrops have provided resources and shelter for both the living and the dead for millennia. Existing information about archaeological resources in the region indicate a diversity of archaeological sites and isolated finds from the Upper Palaeolithic to the modern era and a complex spatiotemporal relationship with the river and surrounding lands  on a 1:50.000 series Istituto Geografico Militare (IGM) topographic map from 1896, likely indicating one of the more prominent later period funerary structures dug into the side of the gorge  and later rural central fortified farmhouses . Soils that are thicker and more fertile are found in areas with Pliocene and Holocene sediments. In terms of climate, the region today is characterized by a Mediterranean climate of dry summers with mean annual temperatures of 18°C and a mean annual precipitation of less than 600 mm  in the spring of 2016. Roughly 9 ha of magnetic data was collected across the central portion of the settlement . Using the magnetometry results as a guide, six areas of interest totaling 2.5 ha within the survey area were chosen for the GPR survey. Surface survey was conducted in early April 2016 by members of the Prima Archeologia (PA). An area corresponding roughly to the area covered by the geophysical prospection was divided into 28 units of 100 × 100 m, from which artifacts were collected, yielding over 300 ceramic, metal, and stone objects. Diagnostic artifacts were point-located using a handheld GNSS device. Ground surface visibility was variable, with most of the site being covered by patchy low grasses and scrub vegetation. Results from these surveys, detailed below, were then combined with the existing cartographic and remote sensing datasets for further interpretation. The resulting dataset represents several different scales and resolutions of information  and small quantities of EIA material (3%) were also recovered. Curiously, artifacts from later periods (excluding modern debris associated with the former vineyard activity) seem to be entirely absent, although earlier surveys have noted significant amounts of Roman material ca. 300 m to the north of the current survey area  and is not related to longer distance soil transportation, redeposition or manuring. Thus, although variable surface visibility and subsequent land use modification may be affecting the recovery of artifacts, we can nevertheless be reasonably certain that the artifacts recovered have not been transported a significant distance since their initial deposition.Together, the prospection and survey data collected at Guletta have provided critical insight into the structural composition of the site and its surroundings. Components of many features can be observed in multiple datasets, while some datasets provide unique insights into structures and features at the site. In particular, analysis of materials recovered from the surface survey currently provides our strongest link to the timeframe of activities in the area, and it is worth noting that the bulk of the surface finds were recovered from three main loci around features indicated in the prospection data . The larb.c. Above all else, it seems likely that the central portion of the area surveyed contained a pre- and protohistoric indigenous settlement of moderate size, with an occupation sequence of at least 1000 years. Materials recovered from the site are indicative of domestic activity and trade, linking Guletta with regional activities and settlements on the coast and in the interior. The superpositioning and distinctive alignments of various features also indicate that they may belong to distinct phases of construction. The dissimilar nature of the inner and outer ditch and possible remodelling further support the interpretation of different construction phases and spans of use. Additionally, the cross-cutting of several exposed features at Guletta, particularly the mortuary features along the sides of the inner ditch and the ditch construction evidence from the GPR data, provide additional support for multiple periods of occupation at Guletta. It seems clear that people were occupying and reusing this space, if not continuously, then at least repeatedly over a long period of time.What is emerging from the analysis of data gathered at Guletta is evidence of a complex cycle of activities in the area between the mid-2nd and mid-1st millennia Although disturbed by later activity, the main structures present at Guletta that we believe to be largely of pre/protohistoric origin include the outer enclosure surrounding the site, the two ditches enclosing the settlement area, the pit structures within the settlement area, and the rectilinear structure to the northwest of it. Additionally, mortuary features of various types are cut into the cliff face overlooking the gorge. Open quarries, some of which may have origins contemporary to Guletta’s occupation sequence, are located in areas where the bedrock substrate is particularly close to the ground surface . AlthougThe outermost visible structure at the site is the outer enclosure : A. BaseThe dissimilar nature of the ditches surrounding the main settlement area suggests distinct periods of development : B. The The inner and outer ditches connect in the southwest, where the geophysical prospection results give the impression of a large access way to the inner portion of the settlement, somewhat obscured by construction of the modern vineyard. Interpretation of the lower GPR depth slices indicates the dissimilar nature of the outer and inner ditch construction. This is particularly apparent where the structures connect. In these lower depth slices, there are additional indications that the inner ditch may have once stretched across the open area of the south entrance and that a smaller entrance may have once stood in its place (From the data available, we can consider at least three clusters of activity on the slope within the inner ditch, and some of these features may be superimposed on others. This is additional support for interpreting multiple phases of occupation, or that each area may consist of multiple, contemporary clusters of informally arranged structures : C. In eb.c. (The remnants of the rectangular structure to the northwest of the ditched settlement bear morphological similarities to later rural habitation structures that begin to appear in this part of western Sicily in the later part of the 1st millennium b.c. : D (e.g.b.c. . The larThe known funerary structures present near the ditched settlement are of various forms. Some of them either intersect or are intersected by the inner ditch of the settlement, providing clues to the relative stratigraphy of some of the site structures : E. SomeGiven the timespan indicated by surface survey material from Guletta and the dissimilar nature of the features, it is unlikely that all features at this site represent a single construction phase. While the bulk of the material collected appears to be from the indigenous Iron Age, current knowledge about the spatial layout of contemporary indigenous settlements in western Sicily suggests that the discrete construction of a multi-ditched structure for settlement purposes would be unique. It is therefore reasonable to conclude that activity from more recent phases of occupation have partially obliterated traces from earlier periods. Furthermore, Guletta shares similarity with other MBA sites in terms of topographic position, although the ditches at Guletta are not particularly characteristic of known MBA settlement layouts in the region. Although significant material evidence for settlement at Guletta prior to the MBA is currently lacking, we can see some morphological and topographical similarities between the inner ditch at Guletta and older ditched settlements, such as those at Neolithic sites (Stintenello, Stretto Partanna, and Megara: Leighton Leaving aside the later period activity, our current interpretation of the pre- and protohistoric sequencing at the site indicates at least four phases of activity, possibly punctuated by periods of disuse . A possib.c. Evidence for multiple phases of activity allows us to approach the question of how the site is situated within the framework of known regional activity, despite limiting chronological considerations of materials collected during the surface survey. MBA material places Guletta in the wider context of similar period sites in the region. This includes other sites along the banks of the Mazaro, such as Contrada Archi, located just a few kilometers downstream (Calafato, Tusa, and Mammina facis. We currently have no material that specifically indicates a later Bronze Age occupation at Guletta, and it may be that subsequent occupation is masking LBA activity on the site or that diagnostic materials from this period are simply difficult to identify. Alternatively, the site may have been abandoned for a period, in keeping with suggested regional trends of aggregation to larger, better-defended sites as long-distance trade contact declined (Kolb Building a likely scenario for Guletta’s development is key to understanding not only the site but its place in the regional cultural landscapes of the 2nd–1st millennium ned Kolb . This pob.c. community that had trade contact with Phoenician and Greek interests in the west. This would make Guletta one of the westernmost of the known settlements of this type during this period (Though present, EIA material from Guletta is of an extremely low density, and it is possible that Guletta’s occupational hiatus extended into the early part of the Iron Age, or that later activity is again masking the presence of diagnostic materials. Previous authors have noted similar chronological gaps in their survey work and have questioned whether this is due to an actual occupational hiatus, continuity in material types from the LBA, discipline-based issues surrounding the study of the period, or similar difficulties in identifying distinctive EIA material culture in survey assemblages Leighton , 9, 25. s period , perhapss period , 985. Fus period , 986.Fib.c. as part of a network of contact points with new groups settling in the region. Greek settlers in the west would have benefited from local knowledge about agricultural practices and environmental exploitation, even if some of these settlers came from other parts of Sicily (De Angelis Assuming that Guletta was unoccupied or did not serve as a significant focal site during the earliest Iron Age, it may have been established in the 7th century b.c., possibly as a response to changes in social structures brought about by a growing trade economy and resulting social stratification. Environmental changes in the western Sicilian landscape, such as deforestation and the potential beginnings of ecological change in what is today the sciara may also have played a role in the changing structure and function of the site. Whatever the reason, the 6th–5th century b.c. occupants of Guletta may have joined people from other sites in the region in migrating, forcibly or otherwise, to sites that would become regional centers (Kolb b.c. (Bernardini et al. , such as San Miceli (Mosca Abandonment of the settlement at Guletta may have been a part of wider regional trends during the mid-1st millennium ers Kolb . There ili Mosca , as actib.c. This could be related to a change in land use practices in the hinterlands of Selinunte and the eventual reorganization of agricultural practices in the coastal hinterlands of western Sicily (Blake and Schon b.c.Around the time of the presumed abandonment of the indigenous Iron Age settlement at Guletta, Phoenician interests in western Sicily were also changing. Subsequent to the Carthaginian conquest of Selinous, an increased Punic presence can be inferred from evidence of reoccupation at sites such as Monte Polizzo and other formerly indigenous inland hilltop settlements, which seem to be reoccupied in a limited manner, possibly as military outposts (Morris et al. The cycle of material culture at Guletta may be reflective of wider trends between the MBA and Archaic/Classical periods in western Sicily. At Montagnola della Borrania, 15 km to the north of Guletta, similar patterns of occupation and abandonment seem to have occurred, particularly at site 28 Lauro , 238–242The sequences of abandonment and reoccupation at Guletta may be evidence of direct occupation by new cultural groups in the transition zone between coast and interior, internal socio-political struggle, or merely a change in material culture as local inhabitants engaged with new cultural and socioeconomic influences. We currently lack fine-grained contexts at the site to determine which of these is most likely and what these changes meant for local people. Nevertheless, we can infer possible connections between Guletta and other regional sites and reasons for changes in the spatial layout at Guletta based on structural evidence and the distribution and density of surface artifacts. The occupation and abandonment of Guletta fits well within general reorganizational trends in western Sicily during this period. Thus, it is likely that the occupational sequences we are seeing at Guletta reflect a wider movement from relative cultural stability to a landscape restructured by a socio-political shift from cooperation to competition.While we currently only have enough information to speculate over such a transition, we do have evidence of a sequence of apparent habitation structures and both locally produced and imported materials that seem to come from multiple regional centers. These observations lead us to tentatively assess Iron Age Guletta as a gateway site (Rivers, Knappett, and Evans Our investigations have produced a wealth of new information at Guletta, casting it as a node of both local and regional activity in later pre- and protohistoric western Sicily. Through integrated interpretation of historic and modern remote sensing, geophysical prospection, and survey data, several previously unknown features were identified and placed chronologically between the Middle Bronze and later Archaic/Early Classical periods. In particular, prior to our investigation, settlement activity dating to the indigenous phase of the late Iron Age and Archaic period was largely unknown within our project area. Importantly, none of the features identified in the prospection data which we consider to be pre/protohistoric in origin align with any subsequent later historic period land use.b.c. A lack of locally produced materials after the 6th–5th century b.c. and an eventual transition to the construction of a rectilinear structure could be tied to regional patterns of abandonment, aggregation, and changing land use. We see the multiple types of locally produced and imported material at the site as indicating that Guletta was, for a time, a point of interaction between different cultural groups, occupying a possible frontier zone in the transitional area between coast and interior, acting as a sociocultural/socioeconomic gateway in the region.Changes in structure and material culture at the site may be related to a confluence of environmental and sociocultural changes and shifting land use practices in the middle of the 2nd and the latter part of the 1st millennium The comprehensive spatial nature of the information we have already obtained will allow us to target certain areas of the site and surrounding landscape for excavation and further testing to investigate specific questions related to feature dating, construction, and sequencing in a minimally destructive manner. Due to the steady amount of new material brought to the surface when firebreaks are plowed, we expect that the remnants of secure contexts persist below the surface in several places, particularly within the area bounded by the innermost ditch. Although we anticipate that our assessment of Guletta’s sequence and connections to other sites in the region will be strengthened by new information from the ongoing analysis of ceramic materials from the site, securing dates for the various features revealed by prospection would be an obvious next step in understanding site sequencing. A better understanding of the cycles and types of activity on the site will help to better situate Guletta in the context of the regional discussions about movement and interaction.The results of our research at Guletta have provided further evidence with which to question traditional models about movement and interaction in the region. Specifically, evidence of indigenous period occupation at Guletta has redrawn the boundaries of later Iron Age settlements in the west and clearly indicates that absence of evidence was the basis of previous assumptions of regional movement in all periods. Previous intensive surveys in our project area have found little to no evidence of pre/protohistoric material beyond funerary monuments carved into the walls of the Mazaro gorge. Our findings, based on non- and minimally invasive area-based data collection approaches, indicate that evidence is certainly there. Using the information we have collected as a basis for intensive regional survey, spatial analysis, environmental testing, and further geophysical prospection, we aim to fill in more knowledge gaps about archaeological landscapes from all periods in the region.In western Sicily and beyond, an iterative analysis of multiple types of data collected through non-invasive means, such as those employed in this study, provide us with new ways to examine past land use at multiple scales. These data can completely change our conceptions of landscapes in the past and their remains in the present. Along the Mazaro River, these data are contributing to evolving models of local and regional interaction, continuity, and change.


Surgical site infection (SSI) is recognized as an important quality indicator for patient safety. In Korea, the use of prophylactic antibiotics for surgery is conducted as a national quality measures related to SSI prevention. The objective of the present study was to investigate physicians’ perceptions of hospital quality measures for SSI as well as identify obstacles that might hinder its implementation in South Korea.Online-based questionnaires were administered twice. Twenty physician experts who were members of the Healthcare Review and Assessment Committee that was constituted for the “Assessment of prophylactic use of antibiotics for surgery” participated in the study. The first survey comprised open-ended questions that were designed to elicit the physician who could hinder the implementation of SSI indicators. The second survey, which was developed on the basis of the initial survey’s results, consisted of 10 closed-ended questions about the feasibility of objective perception and the need for subjectivity, with regard to SSI.From among the 20 physicians, we collected data from 16 respondents in the first survey (response rate of 80%) and 15 respondents in the second survey (response rate of 75%).Thirty-one percent of the respondents supported hospital SSI evaluations, and 69% expressed objections. The obstacles that were perceived as being able to hinder hospital SSI evaluations pertained to difficulties in collecting data, unavailability of information, possibility of underreporting, and redundancy of the inquiry undertaken by the Korean National Healthcare-associated Infections Surveillance System-SSI. Physician experts provide significantly higher ratings for the clinical indicator, rate of readmission due to SSI, both in terms of feasibility and need, when evaluating the results of SSI prevention in hospitals.The results of this study show that physicians perceive the need for QI development of hospital SSI measurements to prevent nation-wide SSIs in Korea. However, the feasibility of hospital SSI measurements is low. To develop QIs of hospital SSIs using health insurance claims data, it is necessary to develop a methodology for claims data-based surveillance systems and a data collection system in order to increase the sensitivity and validity of post-operative SSI detection. Infections that are absent and not latent at the time of admission but emerge during the hospital stay are known as healthcare-associated infections (HAIs) , One sucThe World Health Organization reports that the incidence of SSI is 6.0% in low-income countries and 7.8% in Southeast Asian countries, both of which are higher than those of countries such as the United States and Australia where the incidence rates are 0.9 and 2.8%, respectively [To decrease the likelihood of SSI, it is important to first identify risk factors before developing the necessary measures for its prevention and management. Most SSI are caused by normal skin flora at the surgical incision site. Therefore, the risk of infection is higher when the surgical site is open, from the time of skin incision until the wound is sutured. Other external causes of SSI include contaminated surgical environments and instruments . FurtherThe administration of prophylactic antibiotics is an effective strategy to lower the risk of SSI caused by normal skin flora. It also ensures an appropriate use of antibiotics, reduction of misuse or abuse of antibiotics, and prevention of multi-resistant bacteria. To this end, an appropriate selection of antibiotics based on the type of surgery, and measures to maintain permissible levels of antibiotics in blood and tissue during a surgery will be helpful. It is noteworthy that, since 2007, the Health Insurance Review and Assessment Service’s (HIRA) National Quality Assessment Program, which has been assessing the prophylactic use of antibiotics for surgeries in the prevention of SSI, has managed to decrease the abuse and misuse of antibiotics. As a result of this program, the administration of prophylactic antibiotics, within 1 h of surgical incision, improved from 70% (in the first assessment) to 88.2% (in the seventh assessment). Additionally, the administration of aminoglycoside, one of the antibiotics that should only be used sparingly recorded a decrease in its usage, dropping from 30 to 3% .Meanwhile, it has been suggested that the assessment should measure the outcomes of QI activities in healthcare organizations in a manner that it is inclusive of the various factors that affect SSI. In other words, it should address, the limitations of current assessments, which are largely focused on the prophylactic use of antibiotics for surgery . AlthougTwenty physician expert members, who were members of the Healthcare Benefits Review and Assessment Committee that was constituted for the ‘Assessment of prophylactic use of antibiotics in surgery’, were recruited as per the recommendations of each academic society. The HIRA sent official letters to academic societies to solicit recommendations from committee members with knowledge and expertise in the assessment of prophylactic use of antibiotics for surgery.The expert panel included 13 surgeons as recommended by The Korean Surgical Society, The Korean Neurosurgical Society, The Korean Orthopedic Association, and the Korean Society for Thoracic and Cardiovascular Surgery. An additional 2 internists were recommended by The Korean Society of Infectious Diseases and The Korean Association of Internal Medicine, and 5 additional surgeons were recommended by The Korean Society of Otorhinolaryngology-Head and Neck Surgery, The Korean Society of Gynecologic Oncology, The Korean Ophthalmological Society, and The Korean Urological Association.Two rounds of online surveys were carried out to investigate physicians’ perceptions of SSI assessment indicators and factors that could hinder its use. In the first-round survey, expert opinions were obtained by administering an open-ended questionnaire to physicians. In the second round, the opinions collected in the first round were used to design a closed-ended questionnaire, to investigate the survey objective and subjective perceptions. This study was approved by the Institutional Review Board (IRB No.2018–029) at the HIRA, after considering the ethical problems that may arise during the study.“What is the possibility and limitations of assessing SSI incidence based on outcome indicators (obstacles to be overcome)?”“Which factors should be considered in developing items for quality measures for SSI?”“Which existing indicators, other than SSI, can that be used as outcome measures?”Based on a consensus among the members of the department assessing the prophylactic use of antibiotics for surgery and experts in the first survey, the following contents about the SSI indicator assessment were administered as open-ended questions:In the second round, opinions collected from the first round were used to design 10 close-ended questions, and participants were asked to rate the feasibility and need, for each item on the of SSI indicator assessment. The feasibility of an SSI indicator is rated on a five-point scale, to measure physicians’ decisions and opinions, whereas the need for an SSI indicator assessment is rated on a four-point scale  to measure physicians’ perceptions irrespective of factual information.The frequency of responses on the Likert scale, ranging from 1 to 5, was converted to percentages (%), as shown in Table From July 30, 2018 to August 17, 2018, data were collected from 16 participants in the first survey (response rate of 80%) and 15 participants in the second survey (response rate of 75%). Table n = 5) were found to have positive opinions about the implementation of SSI indicators; the remaining 69% (n = 11) were found to have negative opinions. Participants perceived difficulties in obtaining accurate information, collecting data, possible underreporting, and redundant monitoring systems by the KONIS to be some of the factors that could hinder the implementation of SSI indicators. Further, rate of readmission due to SSI was suggested as an alternative indicator.In the first open-ended survey, 31% of the participants  definition, SSI includes cases that occur up to 30 days after surgery and up to 1 year after surgery, if artificial devices have been inserted into the human body . On the Second, there is a need for efficient data collection measures that could increase the sensitivity and validity of SSI data. For instance, the assessment checklist for the prophylactic use of antibiotics in surgery is a self-reported survey of SSI events that occur in each hospital. Similarly, the KONIS, which was implemented in 2007, is an internet-based prospective surgical site monitoring system that collects data based on medical records. A limitation of this system is that SSI may be under-reported when relevant information is not entered in medical records . Data arThird, to develop a severity adjustment model, more studies are needed to investigate those SSI risk factors that are specific to the demographic features of Korea. This is significant because, in studies that examined hospital readmission and SSI predictors, the identified SSI risk factors were found to differ depending on whether American, Danish, or Japanese databases were used . AlthougIn consideration of the above limitations, there may be a few short-term strategies to measure SSI. First, the survey can be limited to types of surgeries that require the patient to visit the hospital for follow-up care after discharge. Follow-up is more feasible in the cases of surgeries in which patients are highly likely to visit the same hospital for post-surgical complications and infections. Second, additional codes should be developed, and computer systems should be updated to enable monitoring of SSI, based on health insurance claims data. Further, claims data and medical records data should be compared; once the validity of the data is established, they can be used as assessment indicators. Third, measures to integrate the KONIS-SSI system and health insurance claims data should be considered. As previously mentioned, detection of SSI that relies on integrated data derived from health insurance claims and detailed KONIS medical records is likely to create a more efficient and robust information collection system. Since January 2018, medical institutions are required to participate in KONIS, which is operated by the Korean CDC, to request for infection prevention and management fees. In 2019, this requirement will be expanded to hospitals; therefore, it is possible that SSI-related data can be interlinked across hospitals that participate in KONIS.This study has a number of limitations. The first limitation is the small number of respondents, although they are experts recommended by academic societies. The second limitation is the use of the Likert scale. We used a 5-point scale in the first online survey and a 4-point scale for the second survey, as we decided to exclude neutral opinions. This, however, can be problematic in regard of coherence. Nevertheless, this study is the first attempt at the perceptions of SSI indicators and hindering factors. The study can provide basic data for the development of outcome indicators for national hospital quality measures for SSI.Even if both claims data and medical records data are used, it is difficult to resolve the issue of short-term follow-up of SSI after discharge. In our survey, more than two-thirds of the experts held negative opinions about the implementation of SSI indicators because of inaccurate data collection, underreporting, and overlapping data collection with KONIS. However, SSI readmission rates evidenced a higher score for physicians’ objective perception of feasibility and subjective need, when compared to other SSI indicators. Thus, SSI readmission indicator appears to be more practical and feasible in the short-term because relatively accurate information can readily be obtained from claims data and medical records. Furthermore, because readmission due to SSI is a serious adverse event in terms of patient safety, monitoring and management of this parameter by medical institutions are crucial.Monitoring of SSI incidence and hospital-led QI activities must take precedence so that data about SSI indicators can be used to assess the quality of healthcare organizations and establish financial incentives based on performance.