The emotional experience brought about by failure, especially the important roles of negative emotions in learning behavior after failure, has received increasingly more attention from organization management scholars. Research on the impact of employees’ sense of failure-induced shame is still controversial. Based on the Chinese context, according to the process model of emotion regulation theory, we have studied the influence of failure-induced shame on employees’ learning from failure and the conditions that have boundary effects on this process. Through a questionnaire analysis of 776 samples from Chinese high-tech enterprises, the results show the following: (1) shame has a negative relationship with learning from failure (2) project commitment alleviates the negative relationship between shame and learning from failure, and (3) restoration orientation alleviates the negative relationship between shame and learning from failure while loss orientation cannot. Our results further enrich the research on negative emotions related to failure and provide a theoretical basis for the failure management of Chinese companies. In a complex and ever-changing business environment, it is common for enterprises to encounter project failure. Studies have shown that failure experiences can encourage organization members to find effective problem solutions and challenge old concepts to innovate . LearninAfter the failure of a project, the most common emotional responses are guilt and shame . These tShame can lead employees to fall into a vicious circle of negative behavior responses and negative emotions . WhetherIn addition, the cognition of the goal and value of a project will also affect the emotional and behavioral results after failure. Project commitment, which is an individual’s recognition of the value of a project and their desire to realize the project, affects individuals’ enthusiasm and initiative in work and learning . IndividTherefore, we construct a theoretical framework, as shown in Shame is a type of self-awareness of the negative emotional reactions that often occur in moral situations  or nonmoral situations , and the other is to proactively address secondary stressors  as research objects. We randomly selected 400 companies from the list of high-tech companies reported in Beijing and phoned them to invite them to participate in our research. When communicating with the companies, we explained the purpose of the research, emphasized the confidentiality of the data, and promised to share the research results with the company leaders. For companies that agreed to participate in the survey, with the help of an internal coordinator appointed by the CEO, the research assistant, after identifying participants, distributed the questionnaire and asked team members to complete the questionnaire before regular team meetings. For the absentees, research assistants obtained their contact information from the internal coordinator and ensured that they returned the questionnaire through follow-up communication. In addition, in order to improve the response rate of the questionnaire, we asked the CEO to leave an endorsement and distribute a small gift with the questionnaire.Finally, we obtained completed questionnaires from the full sample of 776 participants. The average age of these participants was 31.65 , of which 77.1% were men, and approximately 92.4% of the participants had a bachelor’s degree or above.All items in the questionnaire came from extant research. To ensure the accuracy of the translation, we used the back translation method  with twoWe used a five-item scale  to measure shame . Sample We used the six-item scale developed by We used a five-item scale  to measure project commitment . Sample We used an eight-item scale  to measure learning from failure . Sample We controlled not only demographic variables, such as sex , age, education level , and tenure in the firm and project team, but also oscillation orientation, which is parallel to restoration and loss orientation . AdditioWe used a three-item scale developed by We used a five-item scale developed by We used Amos 24.0 for confirmatory factor analysis (CFA) to check the validity of the model and SPSS 25.0 for correlation analysis and multiple regression analysis to test the hypothesis. Our data were collected at the same time, which may lead to common method bias (CMB). Following In order to test the degree of model fit, we first conducted CFA. As shown in b=−0.098, p<0.01), which supports hypothesis 1.The descriptive statistics and correlation coefficients in We adopt the stepwise linear regression method to further test the relationships between the variables. Specifically, we use learning from failure as a dependent variable to conduct a regression in six steps . When exb=−0.072, p<0.01, Model 2). Therefore, hypothesis 1 is supported. Hypothesis 2 and hypothesis 3 address the moderating effects of project commitment and negative emotion coping orientation (loss orientation and restoration orientation), respectively. As shown in b=0.076, p<0.01, Model 4). There is also a significant positive relationship between the interaction item of shame and loss orientation and learning from failure . Furthermore, there was a significant positive relationship between the interaction item of shame and restoration orientation and learning from failure . However, when the three moderators were put into the model at the same time, the moderating effects of project commitment and restoration orientation are still significant , indicating that the moderating effect of the two moderators is stable; however, the moderating effect of loss orientation becomes nonsignificant . Therefore, the moderating effects of project commitment and restoration orientation are supported while the moderating effect of loss orientation is not supported by the data.Hypothesis 1 states that shame will impede an individual’s learning from failure behavior. In order to better explain the moderating effects of project commitment and restoration orientation, we take the data higher than (or lower than) the average value of a standard deviation as the value of the moderating variable at a high (or low) level  and draw the relevant schematic diagrams, as shown in Project failures are common in the workplace. They have not only visible financial costs and interruptions in project progress but also consequential psychological costs to employees . In this paper, we investigate the influence mechanism of individual negative emotions caused by failure on subsequent learning from failure behavior and identify the affective and cognitive factors that may affect this relationship as moderators. Specifically, this paper constructs a theoretical framework, taking feelings of shame after failure as an antecedent variable and negative emotion coping orientation and project commitment as moderators, to explain how and to what extent negative emotions affect people’s learning from failure events. Through the empirical analysis of questionnaire data from high-tech enterprises in Beijing, we draw the following conclusions: (1) Failure-induced shame has a negative relationship with employees’ learning from failure; (2) restoration orientation negatively moderates the relationship between failure-induced shame and learning from failure, and the higher the restoration orientation level is, the weaker the negative relationship is, but the moderating effect of loss orientation on this relationship is not significant; and (3) project commitment negatively moderates the relationship between shame and learning from failure, and the higher the level of project commitment is, the weaker the negative relationship.This paper enriches the research on the antecedent variables of individual learning from failure. Learning from failure has been shown to have significant beneficial effects on individuals  to enhance the sense of belonging of employees so as to improve the level of project commitment of employees and their enthusiasm for study and work. Furthermore, enterprises and managers can inform employees of project goals and project values and improve their sense of identity for their work.This paper has drawn relevant conclusions through empirical research, but there are still some limitations as follows. First, the data in this paper are cross-sectional data, which have an impact on the measurement of variables such as emotion coping orientation that may change over time. This may also be a reasonable explanation for the insignificant moderating effect of loss orientation in this study. Therefore, future research can use other methods, such as experience sampling, to collect individual response information at multiple time points and capture the changes in the impacts of loss orientation and restoration orientation on employees’ emotions and learning from failure behaviors. Second, since the scale used in this paper is from the mature scale of foreign countries, there may also be differences in shame as there are differences between Eastern and Western cultural situations. Therefore, future studies can use local scales to verify the results of this study and explore the universality and differences of the results of this model under different cultural situations. Finally, this paper only focuses on the moderating effects of emotion coping orientation and project commitment on the relationship between shame and learning from failure. Whether there are other moderating factors is unknown, and whether there is an interaction between these two factors is also unclear. Therefore, future studies can also further explore the effects of other moderating variables on the model and whether there is an interaction between the moderating variables.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements. Written informed consent was not obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.WW and SS substantially contributed to the conception and the design of the work as well as in the analysis and interpretation of the data. JW, QL, LH, and XC prepared the draft and reviewed it critically. All the authors contributed to the article and approved the submitted version.This research was supported by MOE (Ministry of Education in China) Project of Humanities and Social Sciences (Grant No. 19YJA630082).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The Breast Cancer Clinical Practice Guidelines, 2018 edition, written in Japanese and organized by the Japanese Breast Cancer Society, were published in Japanese in May 2018. The process of making these guidelines, as well as the content, was largely changed and compared with previous editions. The concept of these guidelines is to act as a support tool for shared decision making between doctor and patient. The procedure of creating the guidelines referred to Minds Handbook for Clinical Practice Guideline Development 2014. This guideline, written in Japanese, consists of two booklets: (1) the epidemiology and diagnosis booklet covering screening, radiological, and pathological diagnosis and (2) the treatment booklet covering surgical therapy, radiation therapy, and systemic therapy. This review article consists of five parts, including the history of the Breast Cancer Clinical Practice Guidelines, the concept, process, content, and recommendation grade. I believe this brief summary concerning the Breast Cancer Clinical Practice Guidelines 2018 edition in English will be helpful for both Japanese and foreign investigators. The “Science-Based Breast Cancer Practice Guidelines” were prepared as a research report on a grant from the Ministry of Health, Labor, and Welfare in 2002 and formed the beginning of the current Breast Cancer Clinical Practice Guidelines. After that, the development of the guidelines was transferred to the Japanese Breast Cancer Society. The first edition was published as five booklets, covering 1) epidemiology and prevention, (2) screening and diagnosis, (3) surgical therapy, (4) radiation therapy, (5) systemic therapy, released in 2004 and 2005. Since then, several revised versions have been published. Previous guidelines were based on scientific evidence such as review data of many clinical trials. Their credibility was based on the “level of evidence ” of the data as described in a previous review [ epidemioIn recent years, in the process of standardization of global guideline development, the procedure for preparing the Breast Cancer Clinical Practice Guidelines has become somewhat outdated. The guidelines up to the previous edition decided on important subjects in daily clinical practice to be posed as clinical questions, comprehensively searched the literature related to this, created the text after critical review of the literature, and recommended it after review by committee members. We have taken the steps to determine the recommended grade and complete the final version. Clinical questions (CQs) with positive results in randomized controlled trials (RCTs) and meta-analyses were often "strongly recommended" for the presence of Level 1 evidence in previous guidelines. Of course, the guidelines for breast cancer treatment up to the previous edition are also highly regarded as largely complete guidelines and it is true that they have contributed significantly to the standardization of breast cancer treatment in Japan. However, there is a point of view that "the balance of benefit and harm" was not adequately covered in the description of the previous guidelines.Guidelines are not only a guide to standard practice, but also a tool to provide the reader with the materials, which need to be considered when encountering a problem. Our daily practice is a series of interventions  and when deciding which method to use, we should be unconsciously choosing means in consideration of benefits and harms. However, when deciding the intervention means, it is important to decide on the intervention means, while sharing the balance of benefits and harms with the patient, as well as the judgment of the individual physician (shared decision making). Therefore, in this revision of the guidelines for breast cancer medical care, we proceeded with the concept of creating guidelines as a tool for doctors and patients to make shared decisions. The concept of the 2018 Breast Cancer Clinical Practice Guidelines is to provide a support tool for both doctor and patient to use shared decision making. Minds Handbook for Clinical Practice Guideline Development 2014  was usedIn this 2018 edition, we set multiple outcomes (both in terms of benefits and harms) for each clinical question (CQ) (about 3–6) and determined the clinical importance (1–9) for each outcome. Then, after the literature search/extraction from keywords related to the CQ, a quantitative or qualitative systematic review was conducted for each one of multiple outcomes and the strength of the recommendation for the CQ was then taken into consideration at each small board meeting, regarding the balance between benefit and harm. Finalized recommendations from each session were confirmed through discussion and voting at the recommendation decision meeting, which included doctors, nurses, pharmacists, and patients. Based on this final decision, the responsible committee member wrote a commentary and completed the final version after mutual review.BQ (background question)Content that is regarded as a standard treatment with old guidelines with which you should comply even if you are not a specialist, and content that should be treated originally as a CQ with content that is routinely lost in clinical judgment, but only old data are included. In addition, any contents that are expected to have no new evidence in the future are also regarded as BQ and outlined.∗Structure: BQ sentence, statement, and commentary.CQ The subject of daily clinical questioning is taken up, a quantitative or qualitative systematic review is carried out, proposals are put to a vote at a recommendation decision meeting, the strength of recommendations is decided, and commentary about the recommendations is provided. We comment on points of discussion at the decision meeting.∗Structure: CQ sentence, recommendation, strength of recommendation, consensus rate, strength of evidence and commentary.FQ (future research question)Although there is insufficient data on these subjects to be taken up as a CQ, it explains the current thinking about the CQ that is considered to be an important issue in the future.∗Structure: FQ sentence, statement, and commentary.Recommendation grade is shown in Table A guideline is not an absolute rule book. Even if you explain that an interpretive sentence is read and what this means in terms of recommendation for a patient, the decision of each particular patient may change according to the patient's sense of values. Each valued judgment in such a patient should be respected with the premise that patients are given the right information. We believe that more accurate medical examination and treatment will be spread via the utilization of this guideline at clinical sites, and as a result, many patients would like to gain more benefit in daily practice.


Ergonomics in interventional radiology has not been thoroughly evaluated. Like any operators, interventional radiologists are exposed to the risk of work-related musculoskeletal disorders. The use of lead shielding to radiation exposure and the lack of ergonomic principles developed so far contribute to these disorders, which may potentially affect their livelihoods, quality of life, and productivity. The objectives of this review were to describe the different situations encountered in interventional radiology and to compile the strategies both available to date and in development to improve ergonomics. Interventional radiology is now considered an effective option for treating a wide range of conditions ,2. It prTo further optimize the performance and well-being of IRs, and meet the needs and demands of the patients and care, research in ergonomics is now mandatory in interventional radiology . ErgonomA literature search was performed on MEDLINE/PubMed focused on articles published between January 2000 and March 2021. The terms ‘‘interventional radiology’’ OR ‘‘surgery’’ AND ‘‘ergonomics’’ were used. The search was limited to the English language and covered all studies available until the search date. Study titles and abstracts were screened by the primary author, with studies of potential relevance progressing to full text screening. Where there was uncertainty regarding a study’s eligibility for inclusion, two additional authors were consulted and, through discussion, a decision was made on whether to include the study. A total of 84 articles were identified. Finally, 25 original articles were selected based on their relevance. Additionally, all cited references were analyzed to include additional papers related to the search and previously excluded by the initial review. A total of 62 articles were included in this review article, which follows the Scale for the Assessment of Narrative Review Articles . All datInjuries occur when the load placed on a tissue exceeds the capacity of that tissue or when repeated exposure to lower loads, or risk factors, interferes with the ability of the body to recover ,14,15,16In interventional radiology, the use of anti-X aprons, in association with awkward postures and non-ergonomic working conditions, might cause the onset of MSDs . The prep = 0.024), higher burnout (p = 0.005), and significantly higher callousness toward people (p < 0.001) than those not fearing loss of career longevity [Work-related MSDs can cause pain and physical discomfort during procedures as well as time off work ,14,15,16ongevity . There iThe awkward postures of the trunk, neck, and upper extremities used to perform ultrasound-guided procedures, as well as sustained or forceful gripping and downward force applied with the transducer, contribute to symptoms of discomfort and risk of injury . An assoIn the angio suite, IRs must comply with recommendations to limit the radiation exposure to themselves ,38. A ceSpecial attention should also be paid to the position of the cervical spine, which is often extended and rotated in the angio suite due to the positions of devices and monitors. Ideally, the screen should be in front of the operator to avoid the combined stress of rotation and extension . The monAmong the items particularly important in the angio suite, the height of the table must be adjusted to allow the elbow joint to remain in a neutral position for most of the operating time to avoid the operator bending forward A. SurgicComputed tomography (CT) is used to guide a wide range of interventional procedures in various locations ranging from biopsies to ablations . LikewisPerforming procedures under magnetic resonance (MR) guidance eliminates the need for protective lead aprons. Compared with CT scan, open field magnets can facilitate the procedure by providing wide access to the bore, improving the position of IRs . HoweverThere is a lack of evidence for scientifically proven methods for the prevention of MSDs, not only in interventional radiology . HoweverThe effects of training on the occurrence of musculoskeletal pain and discomfort has been demonstrated but need to be further evaluated in interventional radiology. A better knowledge of ergonomics can considerably reduce MSDs and must be implemented early in the career . To prevIn interventional radiology, the integration of ergonomics in the workplace must balance the ergonomic disadvantages of shielding . SpecifiThe development of robotics can improve the accuracy of procedures while limiting radiation exposure to staff . This maThe prevalence and impact of MSDs on IR practice requires increased awareness and prevention. Improvements in the ergonomics of interventional radiology have the potential to alleviate these symptoms, improve productivity and performance, reduce time off work, extend careers, and ultimately improve patient care. Training programs focused on ergonomics are now mandatory as is an evolution in the design of medical devices and interventional suites.


Treatment of patients with a burn injury is a complex process involving multicomponent multidirectional intensive therapy of the majority of organs and systems damaged by thermal effects on the skin, alternating with repeated surgical interventions aimed at removing nonviable tissues with subsequent plastic closure of wound defects. After the recovery from the burn shock, local infectious complications are considered to be the leading problem that decelerates the process of recovery and is the main cause of lethal outcomes. Since the skin integrity is broken, microorganisms penetrate readily into the internal environment of the human organism resulting in a septic state with multiple organ failure. A widespread and often uncontrollable use of antibacterial drugs in medical practice has led to the emergence of multiple drug resistance (MDR) in microorganisms.Introduction of drugs made on the basis of bacteriophages into practice is presently becoming increasingly important. This is confirmed by the growing interest in this field of pharmacology, the development of special programs aimed at studying the processes of phage and bacterial cell interaction.This review presents the main types of bacteria pertaining to MDR pathogens, principles of their classification, and the risk factors for infecting patients. The mechanisms of the selective action of phage particles on a bacterial cell and the possibility of using phage therapy in the treatment of burn injury  based on the analysis of foreign literature are demonstrated as well as new positive properties of phages related to the changes in the macroorganism immune status caused by the interaction with bacteriophage particles. For the last decades the lethality from burn trauma has been gradually decreasing which is mainly connected with the development of new medical equipment, achievements in the field of intensive therapy, and improvements of surgical techniques such as necrectomy and autodermotransplantation –3. NonetSince the time of their discovery at the beginning of the last century, antibiotics have been the main and often a single means of treating bacterial infections. However, eight decades of a wide and often nonselective use have led to general reduction of their efficacy. Currently, bacteria with multiple drug resistance (MDR) present a serious problem. Resistance to drugs which became known for the first time soon after the penicillin invention turned currently into a serious obstacle in the struggle against infection worldwide. According to foreign statistics, about 25,000 patients die in the European Union annually from infections caused by MRD bacteria , 12.Staphylococcus aureus resistant to methicillin, or enterococci resistant to vancomycin, and/or microorganisms resistant to extended-spectrum β-lactamases (ESBL) are isolated during inoculation [In clinical practice, wound defects are considered colonized by MDR microorganisms if cultures of culation .Patients colonized by MDR bacteria are sources of nosocomial infection and become its potential transmitters in a hospital setting. Bearing this in mind, the American researchers  have stuIrrational application of antibiotics , 17 and All the above said explains the following rule: if patients with a burn wound survive during the first 72 h, the most frequent cause of death at a later time is local and general infectious complications. According to the published reports –35, gramBurn wounds are especially sensitive to infection for several reasons. Destruction of the epidermal barrier in combination with denaturation of proteins and lipids creates a favorable medium for microbial growth , 37. SinPseudomonas aeruginosa [S. aureus, and Acinetobacter baumannii [S. aureus remains the most widespread microorganism colonizing the burn wounds in the early period. At the same time, P. aeruginosa is known as the most frequent cause of life-threatening infection in these patients. Both agents, especially P. aeruginosa, are known for their natural and acquired resistance to many antibiotics. Antibiotic-resistant strains of P. aeruginosa were reported to cause hospital infection outbreaks in the burn units [ruginosa –42, S. aaumannii –45 are eaumannii , S. aurern units –50.A steady growth of resistance of infective agents to antibiotics associated with rendering medical aid in combination with a high susceptibility of burn wounds to infection and difficulty of systemic use of antibiotics for injured tissue debridement made the development of new effective antimicrobial medications for the treatment of burn infections one of the rapidly evolving fields of medicine. Application of bacteriophages to fight infections looks very promising , 52.Bacteriophages, or phages, are the most common organisms on the Earth and natural controllers of bacteria abundance. They are “viruses” for bacteria and are capable of lysing, among others, the strains of virulent microorganisms irrespective of sensitivity of these strains to antibiotics. This property allows one to use bacteriophages as an alternative means of fighting infection which may be combined or interleaved with antibiotic therapy and which is able to improve the results of treating bacterial infections –55.Treatment of all types of bacterial infection with bacteriophages started as early as the 20s years of the XX century. Since that time, they have been used in Russia, Georgia, Poland, and other countries , 57. RusBesides, in the Western medicine there are serious obstacles preventing introduction of clinical applications of phages. In the EU and the USA, discussions between the small and medium-sized pharmaceutical enterprises and the competent authorities have resulted in classifying bacteriophages as medicinal agents  regulated, in particular, by the European Community Code relating to medicinal products for human use . After this step, the way to licensing bacteriophages as medical products became difficult and expensive. Difficulty to obtain funding for the development of phages as medicinal agents is also a serious factor, as the problem of intellectual property protection for the types of phages (products of nature) has not been regulated. And finally, no less important is a negative perception of phage therapy which is associated with a false perception of viruses: phages are often identified (without any nuances) as “killers” and “enemies of life” .According to the data presented by Cooper , until rVillareal  believesP. aeruginosa, S. aureus, Escherichia coli, Klebsiella spp. and/or Proteus spp. 42 patients recovered completely and the condition of the rest 7 patients improved notably. Jikia et al. [P. aeruginosa infection [P. aeruginosa from the wound was not isolated and subsequent autodermotransplantation was successful.Despite the above-mentioned complexities, the number of cases of phage applications is increasing worldwide. In Egypt, physicians treated 30 patients with burn wounds for 5–17 days using dressings with bacteriophage solution. From 15 to 47 dressings were required for each patient . This ina et al.  have shoa et al. . In the nfection . The tra(www.nf-phagen.de) [Presently, the therapeutic use of phages experiences the revival of renaissance in the Western world as well due to the pandemic of MDR bacteria . There aagen.de) .The participants of this Symposium believe that the following factors may serve as the “pro phage” arguments :high phage specificity allows for avoiding dysbiosis in the treated media;toxic side-effects are absent;self-replication is restricted;emergence of resistance to one phage does not cause generalized resistance to other phages;phage-resistant bacteria are often less virulent;phage reserves in nature are practically inexhaustible;phages are effective even against MDR/ESKAPE bacteria;phage protein-lysines can be used as an alternative;phages are not expensive;various ways of phage introduction are possible;specific phage preparations can be prepared within a reasonable time.According to the concept of personalized medicine, phage therapy is considered as the treatment responding to the concrete parameters of the human microbiome.The following is referred to the “contra phage” arguments, i.e. probable drawbacks:microorganisms, causative agents of the infectious process, must be uniquely identified, in the mixed infections as well;microorganism immune system may create problems for phages;phages reach intracellular pathogens with difficulty;effective life/stability may vary from phage to phage which requires a regular phage titer control;physicians must acquire new knowledge to use phage therapy in their work;some parts of the human body may be difficult for phage application .P. aeruginosa and K. pneumoniaе [A number of experimental works on phagotherapy of burn wounds are presented in the scientific literature which suggests a potentially successful effect of bacteriophage application in this pathology. The experiment on mice showed that in deep burns, phage application can reduce lethality from infection caused by eumoniaе , 80.P. aeruginosa infection of the split-skin graft was investigated on the experimental model [P. aeruginosa destroys them while a specific lytic bacteriophage prevents the destruction during closure of the contaminated burn wound.The efficacy of employing bacteriophages in skin transplantation complicated by al model  of a burK. pneumoniaе has been compared with that of silver nitrate and gentamycin. In the experiment in vivo, a deep burn was modeled and the wound infected with K. pneumoniae. After the development of the infection process, the tested preparations were applied topically on the burn wound. Lethality served as a criterion for the efficacy. The results have shown that a single phage dose led to a significant lethality reduction (р<0.001). Multiple application of silver nitrate and gentamycin at a dose of 0.5% and 1000 mg/L, respectively, provided also significant protection (р<0.001). However, the level of defense provided by these two agents was lower than that of phagotherapy. The results indicate that the phage is perspective for the treatment of burn wound infections since its single topical application could reduce lethality in mice caused by K. pneumoniae infection compared to the multiple use of silver nitrate and gentamycin.In the recent study by Kumari et al. , the effP. aeruginosa with multiple drug resistance. Holguín et al. [in vivo on the mouse model of the burn wound. The results obtained demonstrated that the phage in relation to plankton cells and biofilms reduced considerably the bacterial population. In the main group, the survival of the animals was from 80 to 100%, being significantly different from the control (0%).It was shown on the model of the burn wound in mice  that then et al.  have perStaphylococcus and Streptococcus were isolated two times and Proteus spp. 1.5 times less frequently, while E. coli was not isolated at all. The number of positive hemocultures also decreased. Immune status evaluation showed statistically significant normalization of the immune response at a cellular level. The phagocytosis level remained unchanged whereas in the control group (without bacteriophage application) it became lower.An established high specificity of phages to a bacterial cell means that in order to achieve a wide spectrum of their action, it is reasonable to use a mixture of phages . In the In another investigation , a phagePolish researchers Górski et al.  performeScientists from Portugal  presentein vivo [Investigators from Egypt compared in the experiment in vivo  the matein vitro the sensitivity of resistant microorganisms, isolated from patients with complicated infections of soft tissues, to the standard bacteriophage (phage) cocktails. The results demonstrate a high potential of topical bacteriophage therapy in the management of complicated soft tissue infections.A group of scientists from Turkey  has studin vivo could decrease cellular infiltration of the skin allograft. The data presented in work [The specialists from the Institute of Transplantation of the Warsaw Medical University (Poland) believe that the administration of phage viruses to the patients with transplantation is safe because they, unlike other viruses, do not increase the risk of transplant rejection. There is evidence that phage viruses may cause immunosuppressive effect increasing the probability of transplant engrafting. Bacteriophages inhibit considerably the T cell activation and proliferation as well as the activation of nuclear transcription factor NF-kB in response to a viral pathogen. The introduction of phage  in work  have sho in work .(www.phagoburn.eu) which was funded by the European Commission and was launched in 2013 with participation of France, Belgium, and Switzerland. The project allowed the scientists to evaluate the phage therapy efficacy in the treatment of burn wounds infected with P. аeruginosa [An interesting project for investigating the potentials of using bacteriophages for burn wounds is a randomized controlled study PhagoBurn ruginosa .in vitro and in vivo, and is oriented in many respects to the expert opinion. It seems extremely important to continue investigations of the possibility of application and efficacy of phagotherapy in the treatment of burn wound infections within the frames of epidemiological and clinical studies with a more sophisticated design.Bacteriophages are confidently taking one of the leading places in the row of antibacterial preparations and phagotherapy becomes a component of successful management of patients with MDR infections. The increasing number of publications undoubtedly reflects a growing interest of specialists from different countries to the application of bacteriophages in the treatment of complicated wounds including those in burn patients. The available data illustrate both significant advances of the Russian scientists in the exploration and application of bacteriophages in clinics and accelerated development of investigations of our western colleagues. Presently, the evidence base in relation to a therapeutic potential of bacteriophages in treating burn patients has been formed primarily by the described cases of their successful applications in clinical practice, experimental studies


In the last decade, vegetable safety issues have received growing attention from both consumers and public authorities in China, as vegetable safety hazards pose a serious threat to public health. In 2017, the Industry & Trade Bureau in China implemented a “Market Renovation Program”. This program includes the renovation of wholesale and wet markets, the formal registration of all stallholders in these markets and the introduction of a rapid test for pesticides residues. We apply the co-regulation framework to assess the implementation and results of the renovation program on the safety of vegetables. A mixed methods approach is used to investigate the effects of the renovation program. The qualitative study elaborates on the implementation of the renovation program and the behavioural changes of stakeholders in handling vegetables through interviews and field observations. The quantitative results confirm that the renovation program has a positive impact on vegetable safety. In conclusion, this study shows that the key factor for the success of the renovation program is the transition of authority from the local, public authority to the market management. In the last decades, consumer demand for food safety has increased dramatically in China due to urbanization and a rising middle class. Vegetables are among the most important food items for Chinese consumers. Vegetable safety has therefore received growing attention, as vegetable safety hazards pose a serious threat to public health. Recent studies show that pesticides residues are the most prevalent safety hazard in fresh vegetables ,2. Many Nong Chan Pin Zhi Liang An Quan Ren Zheng)” in China, which classifies vegetables into three standards: hazard-free, green and organic. In Europe and North America, food certification and classification have proven to be an effective way of controlling food safety hazards [Public authorities have also attempted to improve food safety by labelling agri-food products and by restructuring the food supply chain. In 2003, the Ministry of Agriculture introduced the “Food certification label policy  food safety standards ,14. To aThe amendment of the “Food Safety Law” in 2015, is the most recent regulation concerning food safety control in China ,18. RuraIn comparison to China, the European Union and the United Kingdom have developed regulatory frameworks that enable public-private collaboration to oversee food safety controls. In 2002, the EU introduced the General Food Law and established the European Food Safety Authority (EFSA) ,20. UndeSince 2006, the EU Commission and member states have developed strategies to reduce the impact of pesticides application on consumer health and the environment. Regulation of the market for plant protection products and the directive on the sustainable use of pesticides provide the regulatory framework and practical guidance for farmers to improve the quality and efficacy of pesticide application equipment, to ensure better training and education of users and to develop integrated pest management schemes .Gui Fan Hua Nong Mao Shi Chang)” (known as the renovation policy). This policy aimed to improve food safety in wholesale and wet markets by renovating their infrastructure.To mitigate the potential for food safety crises in China, public authorities have started to intervene at the market side of the vegetable supply chain in 2017. The main regulator for urban food provision is the State Administration for Industry and Trade (ITB). The bureau has subdivisions at the provincial, city and county level. In 2017, the Industry and Trade Bureau of China introduced the “Wholesale and Wet Market Renovation and Upgrade Policy  before and after the implementation of the market renovation program to determine the impact. The rest of the paper starts with further introducing the conceptual framework of co-regulation, followed by a discussion of the research methods. A food safety crisis is acknowledged as a threat to public health. Therefore, public authorities are considered responsible for overseeing the safety of food. Nevertheless, food is produced and supplied by the private sector through markets. Public authorities endeavour to reduce food safety hazards by reinforcing controls and regulations ,24,26. H“the process by which the government and companies cooperate to construct an effective food safety system to ensure better food safety…, under the premise that all stakeholders in the food supply chain (from production to consumption) can benefit from improved governance efficiency” . Generally, co-regulation consists of four stages in the regulatory process: (i) setting food safety standards; (ii) implementation; (iii) enforcement; and (iv) monitoring . First, This study applies a mixed method approach with a focus on in-depth qualitative research. The fieldwork was implemented in Shandong Province. Shandong province is one of the main vegetables producing and consuming provinces in China. The economic development of Shandong  is slightly above average in China (8643 U.S Dollar) and ranks tenth out of the 31 provinces. Shandong province has a population of 98 million people, of which 57% live in urban areas [http://samr.cfda.gov.cn/WS01/CL1667/index_5.html accessed on 31 December 2017). The data are the result of a systematic collection of monitoring data and related information on foodborne diseases, food contamination and food hazards from food samples at the market and retail level. The officially published reports contain detailed information on the type of food safety hazard, maximum residue levels (MRL) and inspection results. Like the European Food Safety Authority (EFSA), the CFDA applies a general default MRL of 0.01 mg/kg [To estimate the results of the renovation program, four cities in Shandong province  were selected. Data was gathered from the food safety risk monitoring system on the official website of the Chinese Food and Drug Administration (CFDA) (further information can be found at CFDA reports contain the following information: food safety status (contamination detected or unsafe/no contamination detected or safe), name and address of the seller as recorded during the inspection, and date of purchase. We establish a dataset by retrieving all observations on vegetable tests from wholesale and wet markets in the four cities in Shandong province. Our dataset contains 2784 samples of tested vegetables, and each observation is the outcome of one test on a specific vegetable in a specific market. We define food safety as a binary variable: the sample is reported as unsafe if the pesticide residue exceeds the MRL and is considered safe otherwise. The dataset was retrieved from the CFDA reports in 2016, 2017 and 2018. The renovation program was implemented in October 2017. The reports from 2016 and from 2017 between Jan. to Sept are categorized as “before renovation”. The reports in 2018 are considered as “after renovation”. We used the list of renovated markets released by the ITB to identify which markets in the dataset were renovated and which were not. We found that 1191 observations came from these renovated markets. Further information can be found in the We select two cities: Jinan and Qingdao, for qualitative investigation using in-depth interviews and field observation. We expect that the implementation of the renovation program, and hence its effects, differ between cities. Considering that the renovation policy was issued by the central government but implemented by the city-level ITB, it is expected that the provincial capital city will receive more attention. In addition, the ITB in the capital city might possess more financial and human resources to implement the renovation program. The peripheral cities may lack resources and pressure to renovate markets. Thus, the renovation may have a smaller impact on the peripheral cities. Before we can claim that the renovation program has succeeded, we need in-depth interviews and field observation to verify the results and to clarify the mechanism behind this renovation.In Jinan, 16 markets were selected for renovation. These 16 renovated markets consisted of eight wholesale markets and eight wet markets. Qingdao is a coastal city, where 14 markets were renovated . In these two cities, 14 markets were visited during the research. The differences between renovated and non-renovated markets were observed. The differences in market infrastructure before and after renovation were recorded by interviewing staff. Wholesalers and retailers were interviewed to assess their behavioural change due to the renovation. In total, we randomly selected 56 wholesalers and stallholders and conducted interviews with them. As shown in To secure the external validity of this study, we visited markets in different cities. The type, size and location of the markets vary, as well as the size and background of the wholesalers and retailers that were interviewed. For internal validity, a clear narrative from the policy document to safety inspection was created. The steps were elucidated following this structure: the announced renovation plan, the change in infrastructure following the plan, the behavioural change due to the new infrastructure, and the change in food safety levels brought by the change in behaviour.The market management should provide training for tenants. Tenants are required to learn the Food Quality and Safety Protocol before they enter the market. The protocol indicates the food safety standards and penalties for food safety hazards.Tenants must register with the market management if they want a place in the renovated market. The market management requires tenants to provide a copy of their ID card for traceability.Tenants are required to provide certification of the origin of the vegetables (including details of the producer and harvest time) for traceability.The market management should set up a rapid testing room with specialized staff. Vegetables in the market should be regularly tested.The market should keep records of the test results and set a display screen to announce the test results for consumers.The formal document of the renovation program considers the market management and tenants of wholesale and wet markets as key stakeholders. The renovation program for wholesale and wet markets that was released by the State Administration for Industry and Trade in 2016 includes five measures:The renovation program was implemented under the instruction of the city administration of industry and trade. The city ITB selected the markets to be renovated by the end of 2017.Generally, the renovation program of markets in China involves three actors: the local policy maker as overseer of the market, the wholesale and wet market management, and the wholesalers and stallholders as tenants of the market. In practice, the renovation program can be seen as an intervention guided by the local ITB, implemented by the wholesale and wet market management and modifying the behaviour of the wholesaler and stallholder. This section discusses the role played by these actors. Conventional markets in urban China can be distinguished into wet markets and wholesale markets. A wet market is a location for the public gathering of buyers and sellers at a known time. Wet markets contain a limited number of stallholders (10–30) and provide fresh food for consumers living nearby. Wet markets involve a large number of transactions of relatively small quantities of goods on a face-to-face basis between a seller and buyer. Sellers in a wet market are commonly designated as stallholders because they rent a market stall to display, advertise and store their goods. Stallholders in wet markets normally operate independently on an individual or family basis. The types and quantity of vegetables are decided by the stallholders themselves. In the 1990s, the stallholder and market owner (enterprise or collective) maintained a simple tenant-landlord relationship . In the Wholesale markets are usually located in urban areas. The wholesale market provides space for hundreds of wholesalers to display and store their goods. Normally, stallholders from the wet market and other retailers visit the wholesale market in the morning and buy in bulk. Without wholesalers, retailers would need to purchase directly from farmers, which would involve many minor transactions . ThroughAs tenants, wholesalers and stallholders are both regulated by tenancy agreements with the market management. These tenancy agreements are publicly accessible in the market. Furthermore, tenancy agreements have similar terms in different markets, emphasizing fire drills, fair trade and fraud prevention. Sanctions such as penalties for violating these clauses are announced publicly. To enforce market regulation, market management has the power to punish and reward tenants in the market. In the interviews, stallholders, wholesalers and market personnel mentioned that sanctions such as a penalty or cancellation of the tenancy agreement are rarely implemented in practice. Nevertheless, the market management holds many tools to reward tenants and can thereby influence their behaviour. For instance, the stall closest to the market entry is preferred by tenants because of the higher turnover. Some tenants are offered better and larger positions in the market because they comply with the market rules. In addition, tenants are offered rent discounts in the following year if they can continuously comply with the market rules in the current year.Market management and tenants are expected to provide agri-food products free of food safety hazards. In every wholesale and wet market, the market management demands tenants to guarantee the safety of their agri-food products. The importance of food hygiene and absence of food safety hazards are emphasized in the tenant agreement. Agri-food products are exposed to chemical contamination during production, transportation and storage. Vegetables can be contaminated at any stage before they reach the consumer. Thus, vegetable safety requires engagement of the wholesaler, stallholder and market management. Nevertheless, without institutional guarantees, tenants and market management lack the tools and incentives to ensure food safety.The ITB Department of Market Regulation is responsible for supervising wholesale and wet markets and other food trading entities. This department controls general market transactions in China, through drafting and implementing measures regarding the market order, regulating online transactions in goods and services, administrating supervision over contract execution, investigating and punishing illegal acts such as contractual fraud, taking charge of chattel mortgage registration, regulating brokers and auctions, organizing and instructing the credit rating of commodity transaction markets, and initiating special campaigns to address ongoing marketplace problems.http://www.samr.gov.cn/spscs/ accessed on 31 December 2017). However, neither the ITB nor the market management had an inspection plan and protocol to survey and control food safety and quality before the market renovation policy in 2017. Until then, wholesalers and retailers had to apply for a food trade license to be permitted to trade food. However, due to the large number and the flexibility of the retailer and wholesaler, the bureau had difficulties controlling the quality and safety of their goods.Within this extensive domain of the ITB, food safety issues were not their primary concern in the past. The relationship between markets and the bureau has changed dramatically in recent decades. In the 1980s and 1990s, most markets were established and managed by the local ITB and local municipalities. Later, markets were privatized and transferred to private corporations . BecauseIn 2016, the state administration released the executive order for a wholesale and wet market renovation program. Early 2017, the city-level ITB started approaching market management and selected the markets to be renovated. Later, in October 2017, the top-down renovation program was implemented. The wholesale and wet markets were required to maintain a high standard of food hygiene, employ their own staff of inspectors and establish a fully equipped and staffed laboratory. In the next section, we discuss the implementation of the renovation program in more detail.In general, the market management actively participated in the implementation and enforcement of the renovation program, leaving the standard setting and monitoring to the ITB. The infrastructure of the wholesale market and wet market has significantly improved after the renovation following the standards set by the ITB. As part of the implementation, large-scale wholesale markets, such as Qilipu, established special rooms and hired staff for rapid testing of food safety hazards. The room is at the entry of the market, and the staff takes samples from every vehicle that enters the market gate. The market management of Qilipu hired at least five people for the inspections while the smaller wholesale market, Huazhong, has only one inspector. Although the ITB provided equipment and instruction for staff, the market management is required to implement the renovation program and cover the costs. Large-scale wholesale markets can afford the costs of renovation and payment for additional staff. Smaller wholesale markets may lack the resources to comply with the requirements of the renovation program.“if the vegetables are contaminated and the contamination is detected, the whole batch of goods cannot be sold in the market. In addition, staff will ask us to remove the goods out of the market”. This answer implies that the enforcement of the renovation program is the obligation of the market management. The stallholders in the wet market describe the procedure to be similar as in the wholesale market. The market management also mentioned penalties for selling contaminated food. However, none of the display screens in the markets that were visited actually worked. The management mentioned: “the test results are recorded yet not accessible for external visitors”.During the interviews, wholesalers were asked about what would happen if pesticides residues were found in the sample. The wholesalers in different markets provided similar answers: “the cabbage was produced by a local farmer; the onion was delivered from Hebei province”, etc. In addition, the sellers have received no training or instructions about vegetable safety or pesticides residues. The market management and staff for safety tests hardly communicate with the sellers. They believe that sellers sometimes spray illegal chemicals on vegetables to keep them fresh. One CFDA document also indicates that sellers were found to be using fungicides on vegetables during transport and storage.The vegetables in the renovated markets are still not traceable. The wholesalers and stallholders can only provide general answers such as The standard for the food safety hazards rapid test was issued by the State ITB without consulting the market management. The rapid test room aims to directly detect food safety hazards. The main threat for vegetable safety is pesticides residues. Thus, the rapid test aims primarily at detecting pesticides. Moreover, heavy metal pollution and other chemical contamination can also trigger the rapid test alarm. Pesticides include fungicides, herbicides, and insecticides. To detect pesticides residues, gas chromatography, high-performance liquid chromatography, capillary electrophoresis and mass spectrometry methods have been developed . These mHowever, the enzymatic method has been criticized for its low accuracy. The official maximum tolerance level for pesticides is 0.01 mg/L. The enzymatic method can achieve a lower accuracy depending on the pre-test concentration and the skills of the staff. Hence, the enzymatic method can provide false negative results in practice, i.e., contaminated vegetables are likely to be omitted and considered as safe. However, the enzymatic method is unlikely to provide false positive results, i.e., mistaking safe vegetables as contaminated because only a high volume of pesticides will trigger the enzyme-based biosensor .In conclusion, we find that three out of the five measures from the renovation program have been implemented. By following the standard issued by the ITB, market management set up a food safety hazards rapid test room and tests goods that enter the market. The test results are recorded for the local ITB. In every renovated market, the sellers are required to register with their ID card and pay the rent in advance.2-coefficient is 341.331 (p < 0.001). This indicates that the renovation has significantly improved the safety level in renovated markets.In short, we found that the most significant measure of this renovation is the establishment of a rapid test room and the implementation of the comprehensive test. This rapid test was enforced and resulted in a lower detection rate of food safety hazards in wholesale markets. The success of the renovation is mainly the result of the collaboration between the ITB and market managements. First, the ITB offered clear instruction on the standard setting and training for the food safety test staff. Although we cannot confirm that the market management was consulted in standard setting, the city ITB selected the least complex and time-consuming test method, the enzymatic method, to ensure the renovation can be implemented and enforced. The main barrier for the ITB to enforce the food safety standards by inspecting every wholesaler directly is the mobility of wholesalers. Nevertheless, market management enforced the standard by using the dependency of the wholesaler on the market. In addition, the successful enforcement is the result of the authority transition from ITB to the market management. After the renovation, the market management was granted the authority to force the wholesaler to dispose of contaminated vegetables. Whereas the market management closely monitored the rapid test results, it remains unknown whether the monitor data was delivered to the ITB as well. At last, we found that the wholesaler was excluded from every process of the renovation program. The participation of the actors in the four co-regulation processes is presented in “the wholesalers are required to stop at the entry. Their vehicles are weighted, and they need to pay the rent according to the weight of their goods. After the renovation, samples will be taken from their vehicle while the vehicle is being weighted. The driver is asked to park nearby the entry temporarily until the rapid test result comes out. If the result is positive, vegetables in this vehicle are not allowed to be sold in this market. The wholesaler must remove the goods”. Buyers drive empty vehicles into the wholesale market to purchase vegetables. They can enter and leave the market without inspection because their vehicles are much smaller than the wholesalers’ and easy to distinguish.Whereas the wholesalers were not consulted in the standard setting and received no food safety knowledge or training, their behaviour and routines were modified. Comprehensive inspection, meaning that every batch of vegetables is tested, results in significant changes for wholesalers. In wholesale markets, the tests can cover all goods because the wholesalers drive their vehicle into the marketplace through the market entrance. The market personnel describe the procedure before and after the renovation as follows: “we always dispose of the goods as formally required”. The risk for wholesalers seems too high if they try to find buyers outside of the wholesale market. The market staff believed that “the wholesaler attempts to sell the rejected goods to retailers to avoid loss”. Nonetheless, the staff also acknowledged the difficulty of trading outside of the market. Typical stallholders in wet markets or retailers sell 20 to 30 types of vegetables in small quantities (10 to 20 kg) in their stall or store. However, a wholesaler sells one type or a few types of vegetables in large quantity (more than 1000 kg). Thus, a retailer needs to visit more than ten wholesalers to find all vegetable types and, likewise, a wholesaler must trade with dozens of retailers until all the goods are completely sold out. Thus, it is beneficial for retailers and wholesalers to assemble in a certain location to complete their transactions. Outside the formal wholesale market, it is impossible to find such a location in urban or suburban areas .Officially, the rejected vegetables are being disposed. However, the market management has no authority to oversee wholesalers’ activities outside the market. The interviews revealed several possibilities with respect to the rejected goods. The wholesaler has the right to apply for a reassessment. Their vegetables will be sent to a third-party inspection institute to acquire more accurate results. However, the staff of the market mentioned that they have never encountered this situation, possibly because the rapid test is likely to provide false negative results but unlikely to provide false positive results. Wholesalers are aware that the third-party test is very likely to reveal more hidden hazards such as the use of prohibited pesticides. When asked about the rejected goods, wholesalers claimed: “we consider the issue of food safety more when buying vegetables from the producer”. Before the renovation, wholesalers considered merely the price and freshness of the vegetables. As they know that contaminated vegetables will be rejected by the market, they have adjusted their buying behaviour to minimize the risk of rejection. In the interviews, wholesalers vaguely mentioned: “we purchase from a ‘reliable source’ or a ‘local source’; we know which vegetables are safe for we have experience in producing vegetables”. The personnel in the market agreed that “many of the wholesalers used to be vegetable farmers themselves”. Wholesalers may prefer to buy local vegetables because they are more familiar with local farmers and can check whether the farmer has a reputation of pesticides overuse, when the vegetables were harvested, and what the length of the post-harvest interval was. Pesticides residues on vegetables depend on the pesticide type, the amount that was applied and the post-harvest interval. If more information is available, the experienced wholesaler can select the vegetables that are most likely hazard-free. However, tracing the vegetables in the wholesale market back to the producer may not be possible due to the lack of information. In addition, another hidden activity was revealed by the market personnel: “to avoid food loss, many wholesalers sprayed fungicides and other chemical stuff on the vegetables. After the rapid test was established, wholesalers stopped or at least reduced spraying fungicides on vegetables, for the risk of being detected is too high”.In response to the renovation, wholesalers have changed their behaviour to avoid being rejected at the market entrance. Wholesalers mentioned: Not all wholesalers are equally dependent on the market and we observed clear differences between wholesalers. Large-scale wholesalers possessed sufficient human resources and equipment to maintain the safety of the vegetables that they sell even before the renovation. Small-scale wholesalers, on the other hand, may lack the resources and capacity to control food safety. The additional safety inspection established by the renovation program helped small wholesalers to detect contaminations and thereby enhanced their food safety level.“stallholders will normally comply because the value and quantity of one vegetable type in their stall is low”.In addition to wholesale markets, the renovation program was also implemented in wet markets. Although both types are included in the renovation program, the impact of renovation might be different. The safety control in wet markets differs slightly from the control in the wholesale market because the stallholders have a different daily routine. Stallholders drive small vehicles to transport vegetables from the wholesale market to the wet market. After arriving at the wet market, they need to move their goods from the vehicle to their stall as quickly as possible. Unlike the large-scale wholesale market, most wet markets are located in urban areas with a high population density. Thus, asking stallholders to wait outside the market is impractical. The market personnel visit every stallholder’s stall and randomly take one or two types of vegetables to test. If the result is positive, the retailer is asked to dispose of this type of vegetable. The staff claims that: “we buy and sell vegetables as we used to, with or without the rapid test”. When the staff comes to collect samples for the rapid test, the stallholders simply comply. One staff member in the wet market said that “some of the stallholders buy vegetables from the vehicles parked in the street for lower prices. The vegetables in these vehicles did not enter the wholesale market due to either low safety degree or to avoid paying the market fee. However, fewer stallholders choose to buy from the “street parking vehicles” nowadays thanks to the rapid test”. The CFDA data supports our observation. p = 0.291). However, the renovation successfully changed the safety level in wholesale markets (p < 0.001).The interviews with stallholders failed to find any remarkable change in behaviour: The renovation program involves the public authority, market management and tenants. The program was implemented mainly by the ITB with the participation of market management. After the state administration issued the renovation plan in 2016, the city-level ITB was required to implement the policy. First, the city-level ITB selected some of the markets in the city and provided guidance on how to build the rapid safety check, the equipment for rapid testing, and instructions for the staff. The market management is required to build the safety check, display screen and entry control, and pay the staff’s salary. The wholesalers and stallholders were not consulted in the renovation policy. Nevertheless, the behaviour of the wholesalers has changed because of the recently established infrastructure.This study reveals the important role of the wholesaler and the wholesale market in guaranteeing vegetable safety. We highlight that the vegetable safety level can be enhanced by developing a co-regulation strategy between private market management and local public authority. This study reveals that the key factors for the success of the renovation are the commitment of the local public authority, expansion of the market management domain, and the dependency of the wholesaler on the market. The conclusion of this study is relevant for the rest of China as well as for the Global South. In urbanizing areas, consumers raise higher demands for food safety. By reinforcing inspection and control in the marketplace, food safety hazards can be reduced. For the municipality, this study provides an additional solution for food safety issues besides retail modernization. Supermarketization is not the only possibility for developing the food retail sector. By transferring certain responsibilities to the market management, the local municipality can enhance the food safety level. The high dependency on the market for food retailers and wholesalers in cities in the Global South gives the management leverage to secure the quality and safety of the food they sell despite their flexibility and small scale. This strategy is particularly effective in wholesale markets.Moreover, this study highlights the role of the “market management” as a relevant actor in the public-private co-regulation framework. In previous research, conventional wholesale and wet markets have been treated as an assembly of stallholders. However, the local municipality has empowered market management and supported its expansion in the regulatory domain. This has made the market management a comprehensive regulator that controls crucial resources for the provision of vegetables. The provider of such a location for trading holds an essential resource. For markets in urban China, this resource is the authorization given by the municipality. The permission of transactions in urban areas is a privilege granted to certain markets. If wholesalers and retailers need to trade agri-food products, they must trade in these markets. Any transaction outside the market location will be ceased by the security office. After the renovation, market management reinforced the control over wholesalers and retailers.In addition, the renovation has expanded the domain of market management. By expanding the power of the market management, the ITB successfully established a rapid test room and entry controls in markets. In this study, we did not have the chance to interview policymakers in the local or central ITB. Nevertheless, the local ITB used to own and run the wholesale and wet markets until the 2000s. With privatization, most markets are transferred to people close to the local, public authority. From a practical perspective, for the local ITB, reaching a few market management teams is much easier than locating thousands of wholesalers and retailers. Controlling products, i.e., maintaining traceability, or controlling the producer is almost impossible for the urban ITB. Ensuring that all transactions happen in renovated markets and controlling the entry of the market seems to be a practical alternative. In addition, consumers were not consulted, and thereby they were excluded from the renovation. Because consumers were not treated as a relevant stakeholder, transparency, i.e., setting screens for the test results, was not guaranteed.Our results show that larger wholesale markets are more successful in improving the food safety level in urban markets. We therefore recommend further concentration in the wholesale sector and increasing the scale of wholesale markets to allow a more targeted and controlled roll-out of the market renovation program. Furthermore, we have shown that successful wholesale markets benefit from close collaboration between the market management and the market regulatory administration. Hence, co-regulation is therefore recommended as a guideline for future reforms of food safety regulations, especially in Southeast Asia and South Asia, where public concerns over food safety have been growing rapidly.This study is limited by a focus on a single province in China (Shandong) and a single class of agricultural product, vegetables. We suggest implementing similar research in other regions and for other food items. Another limit of this study is that we did not interview policymakers. Therefore, we did not have access to in-depth information about the decision-making process and the reasons for the selection of markets in the renovation program. Regarding the public authority, we have interviewed four members of the safety control staff in the markets. In this way, we obtained insights in the behavioral changes at the individual level, but not at the higher administrative level. Finally, this study revealed several limits of the renovation policy. Because the vegetable production sector is highly fragmented, the traceability of products remains elusive. The renovation program might be able to leverage the preferences of wholesalers for food quality and safety. Nevertheless, this policy is unlikely to modify farmers’ behaviour. This study also reveals that the general safety level of vegetables and the main safety hazards remain problematic because still over 13% of the vegetables in wholesale and wet markets are contaminated. Although the renovation has significantly enhanced the safety level in some of the markets, the overall share of unsafe vegetables in the renovated markets has merely been reduced to 7%. This means that vegetable safety is still worrisome in urban China.


The lack of an efficient approach in managing pharmaceutical prices in the procurement system led to a substantial burden on government budgets. In Thailand, although the reference price policy was implemented to contain the drug expenditure, there have been some challenges with the price dispersion of medicines and pricing information transparency. This phenomenon calls for the development of a potential algorithm to estimate appropriate prices for medical products. To serve this purpose, in this paper, we first developed the model by the sequential minimal optimization (SMO) algorithm for predicting the range of the prices for each medicine, using the Waikato environment for knowledge analysis software, and applying feature selection techniques also to examine improving predictive accuracy. We used the dataset comprised of 2424 records listed on the procurement system in Thailand from January to March 2019 in the application and used a 10-fold cross-validation test to validate the model. The results demonstrated that the model derived by the SMO algorithm with the gain ratio selection method provided good performance at an accuracy of approximately 92.62%, with high sensitivity and precision. Additionally, we found that the model can distinguish the differences in the prices of medicines in the pharmaceutical market by using eight major features—the segmented buyers, the generic product groups, trade product names, procurement methods, dosage forms, pack sizes, manufacturers, and total purchase budgets—that provided the highest predictive accuracy. Our findings are useful to health policymakers who could employ our proposed model in monitoring the situation of medicine prices and providing feedback directly to suggest the best possible price for hospital purchasing managers based on the feature inputs in their procurement system. The cost of pharmaceutical products is one of a considerable proportion of total healthcare expenditure in many countries, resulting in between 20% and 60% . AdditioThe limitations of procurement procedures in the pharmaceutical market could be different from country to country. In Thailand, pharmaceutical procurement is a complex system that relates to several agencies, organizations, and manufacturers. The pharmaceutical procurement data are gathered to estimate a reference price of each medicine. The reference price is determined as the maximum price that hospitals can procure their product. However, this strategy has not been successful in controlling the price dispersion for pharmaceuticals which have been routinely encountered . As descAccordingly, a model that can effectively predict the range of the prices for each medicine should be explored. The choice between the statistical and machine learning (ML) methods may seem fuzzy but it can be considered on the primary objective . In someTo assist policymakers to monitor the prices of medicines, in this study, we focused on investigating the performance of the model of the SMO algorithm for predicting the range of the prices for each medicine. We expected that our findings can be useful to health policymakers who could employ this model as an application in monitoring the situation of medicine prices and providing feedback directly to suggest the best possible price for hospital purchasing managers based on their feature inputs in the procurement system.Pharmaceutical procurement represents a considerable part of the expenditure of the healthcare sector. It is important for operational performance . The maiOne of the policies used to control drug expenditure in many countries is price regulation policy through reference prices. Reference drug pricing can be applied to different levels of medicine groups , as drugWhile there have been various implementations of support vector machine (SVM) algorithms in the past years ,21, in tThe SMO algorithm has been used in many fields ,23,24 anAccording to the recent literature, there are several factors related to the pricing of each medicine . In the We now define all the variables used in our paper. The output variable used in our paper is PRICE which is the price per unit of medicine that discretized into eight class labels of price ranges for medicine, as shown in We use other eight procurement features as the input variables, including DEPT, GPU, TPU, METHOD, UNIT, SIZE, WINNER, and TOTAL. DEPT is variable of purchasing department that consists of thirteen departments to make the decision to purchase medicines for hospitals, GPU is the name of the generic product used in this study under Anatomical Therapeutic Chemical Classification (ATC) code A02BC01  which involves two different labels: omeprazole 40 mg and omeprazole 20 mg, TPU is the trade product name that includes twenty-two different names, METHOD is the procurement method that includes two different methods: bidding method and specific selection method, UNIT is the dosage form that includes two different forms, SIZE is the pack size that has seven different sizes; WINNER is the variable of winning supplier that consists of six different firms who are selected to sell the medical product to hospitals, and TOTAL is the total purchase budget that discretized into eighty-four different labels. These eight features are used in developing the model to predict the price ranges for medicine.The study procedures are listed in the conceptual framework exhibited in In this study, we use the software of the Waikato environment for knowledge analysis   which isx, y) is a vector of training dataset such that during the training process, a nonlinear classification problem with a dataset ith input pattern of the selected input variables , and Q depends on a set of Lagrange multipliers Sequential minimal optimization (SMO) is developed by employing the principle that the original quadratic programming problem produced when using the support vector machines (SVM) algorithm that can be decomposed into a series of the smallest possible sub-problems . In our by Platt , a quadrfunction . This prConsidering the Lagrange multipliers k, Equation (5) becomesReplacing U and lower bound L limits, as mentioned in Platt [The SMO first optimizes the quadratic programming problem by determining a Lagrange multiplier in Platt :(7)α1={UA similar procedure can be used to find other optimal Lagrange multipliers nditions  are satiIn the study, we employ the SMO classifier implemented in the Waikato environment for knowledge analysis (WEKA) software, as shown in However, the SMO algorithm still cannot handle large amounts of irrelevant features. To circumvent the limitation, efficient feature selection, the process of selecting a subset of essential features for the algorithm used, is recommended to circumventing the difficulty.In our analysis, we assumed that eight features, namely, the segmented buyers, the generic product groups, trade product names, procurement methods, dosage forms, pack sizes, manufacturers, and total purchase budgets can be used in developing the model to predict the prices for each medicine effectively. These features were examined by using the feature selection method , the proThis study applied the option of 10-fold cross-validation, which was widely adopted to test the prediction accuracy and error of a model. Cross-validation has been extensively used for estimating the performances of different classification models ,36. In tAfter the model was developed and validated by a 10-fold cross-validation test, we can obtain feedback from metrics that can explain the performance of the model. Generally, accuracy constitutes the traditional metric for performance evaluation and comparison among different prediction models; accuracy can be expressed as the difference between the predicted class and the true class of data . HoweverThis section discusses the empirical analysis of our study. We first present the descriptive statistics of variables used in this study. We then discuss the results of the feature analysis, followed by discussing the performance analysis, including accuracy, precision, recall, F-measure, receiver operating characteristic (ROC) area, and the Kappa coefficient. We also represent the results of the confusion matrix in this section.All medications listed on the procurement system in Thailand were classified according to the Anatomical Therapeutic Chemical Classification (ATC) system . The druThe omeprazole 40 mg powder for solution for injection drug, resulting in a high range of unit price from 8.05 to 62.06 Thai Baht (THB). If we classified by trade names or brands of this drug as shown in The choice of different methods of feature selections depends on both the algorithms being used and the type of given data. To examine whether the method of feature selection is suitable for the sequential minimal optimization (SMO) algorithm and pharmaceutical price data, we examined four popular feature selection methods implemented in the Waikato environment for knowledge analysis (WEKA) software, involving the correlation-based feature subset selection (CFS), information gain, gain ratio, and wrapper subset evaluation methods. Major features selected by these methods were ordered by the most relevant and compared to determine which of them can provide the greatest predictive accuracy. As presented in The work can be useful for health authorities or policymakers to estimate the prices of each medicine based on their procurement conditions. As described in In another work of this analysis, we can compare the prices for different sets of feature inputs such as comparing between brand A and brand B from different suppliers on the same pack size at 10 vials/box that will be procured by hospitals in the public health region 1 by using the specific selection procedure under the budget of 50,000 THB. The proposed model can predict the prices of both option inputs in a different range of prices. The price of brand A was about 3 times less than that of brand B. Thus, policymakers can monitor and analyze the prices of medicine from different options of feature inputs and provide this information to suggest the best choice for hospital purchasing managers in order to get the right medicine product at the optimal price.In our feature analysis, we used all eight condition features in developing the model for classifying the price of medicine corresponding to the eight class labels described in The decisions made by the classification model over a set of input data could be presented in the form of a confusion matrix, with each entry representing the numbers of both correct and incorrect predictions. This study involved a classification problem with eight classes, corresponding to an 8 × 8 confusion matrix, as shown in It is important to control the prices of medicine products and expenditure in the pharmaceutical sectors. Policymakers in many countries are currently considering and discussing a range of approaches intended to reduce drug prices and enhance the best options in the pharmaceutical marketplace. Pharmaceutical procurement data over time contribute useful insights when evaluating the need for new approaches and planning the policies . HoweverSMO is one of the most widely used optimization algorithms among all effective algorithms in supporting vector learnings . Platt dIn this study, we employed the pharmaceutical price data listed on Thailand’s government procurement system. Although some approaches have been developed to measure the change of the price for each medicine in Thailand, there is still no proper technique to determine the appropriate price and to control the distribution of the procurement price for drug products. Presently, policymakers collect the procurement data of medicine and estimate a reference price or benchmark for each medicine. This benchmark is set as the maximum price of the medicine group which consists of the same generic name and dosage form. For example, if the reference price of the omeprazole 40 mg drug, injection form, is estimated to be 62.06 Thai Baht (THB), inferring that all trade product names of this type of medicine must be purchased at lower or equal 62.06 THB for each vial. However, in our study, we found that under the price regulation policy through reference prices, drug products of the same generic name can be procured at different prices and showed high price dispersion. Meanwhile, different brands of the same chemical substance were also purchased at different ranges of prices see . More imTo improve predictive accuracy, we incorporated the SMO algorithm with feature selection tools. We found that our proposed model of SMO algorithm with gain ratio selection method outperforms other models by providing the highest accuracy rate, followed by the information gain, wrapper subset evaluation, and CFS methods. This can explain the second hypothesis; the gain ratio can be the best choice of feature selection method that was suitable for the SMO algorithm and pharmaceutical price data in our study. For measuring model performance for predicting the range of the prices for medicine products presented in Our proposed model has some limitations. First, our results were based on the accuracy of the procurement data and the procurement prices of some types of medicines procured in the given time period. Different types of medicines could yield different findings. Thus, academics and practitioners can use more data and more types of products to examine the algorithms and compare the performance of our proposed model with other algorithms. Moreover, there could be a challenge in class distribution when using enormous differential types of medicines with complex purchasing conditions. Therefore, future analysis could also investigate the relationship between class distributions and classification effectiveness.In conclusion, the model derived using the SMO algorithm is useful for enhancing data analysis in pharmaceutical procurement tasks. This study explicitly demonstrated the benefits of using this approach. One of them is that the model has useful analytics, and is sensitive and dependable ,50. Anot