This paper presents the results of research aimed at finding the possible ways of disposing of ceramic waste material, focusing mainly on the possibility of using it as aggregates in concretes exposed to an aggressive chemical environment . The research part presents the preparation method and investigation of waste ceramic aggregates . A suitable ratio of coarse to fine aggregates was selected, and their density, absorptivity and crushing strength were examined. All examined aggregates were also subjected to SEM analysis. Red ceramic aggregate is characterized by a greater degree of crushing compared to glazed and sanitary ceramic aggregate, by 205.7% and 439.4%, respectively. Another part of the research was to compare the properties of concrete with traditional aggregate  and with ceramic waste aggregate. The tested parameters included consistency, apparent density, absorptivity, flexural and compressive strengths of concretes. The study proved that the absorptivity of recycled composites is higher than that of traditional composites by 20.8–24.7%. The concrete based on sanitary ceramic waste has the highest strength parameters. Its compressive strength is higher by 10.5% and flexural strength by 5.9% compared with the basalt aggregate concrete. The compressive strength of sanitary ceramics concrete is higher by 42% and by 59% compared with concrete based on glazed ceramic and red ceramic aggregate, respectively. The last part of the research was to examine the resistance of concrete to aggressive environment. The scope of the work included the preparation of the research environment in the form of solutions with an increased concentration of aggressive agents . Among the concretes with ceramic aggregate, the highest decrease in the compressive strength was demonstrated by the concrete based on red ceramics (128.2%), while the smallest was demonstrated by the concrete based on sanitary ceramics (aggregate from sanitary ceramics (15.4%). The mass loss at different time intervals and compressive strength loss of samples stored in solutions were tested. The smallest weight loss caused by aggressive environment attack was recorded in the concrete based on ceramic sanitary and glazed aggregate . The research on the reuse of waste substances carried out to date has brought many positive results, which have been successfully implemented for industrial activities. An example is fly ash being used as a pozzolanic material in concrete  or as a Gonzalez et al.  manufactOther research results present the work carried out on the concretes made from precious white ceramic ,30,31,32Ceramic waste is also used in powder form. Kannan et al.  used it 2S. After oxidation of this compound by aerobic bacteria, sulfuric acid is formed, which destroys concrete surfaces. [2 produced during the hydration of the cement; therefore, it was proved [An important issue related to the durability of concretes is its resistance to aggressive chemical environments. Under the influence of external factors, concrete is often exposed to the destruction associated with the impact of harmful chemical compounds. Harmful environments may be related to the presence of gaseous pollutants , mineral acids  or organic acids  ,37,38. Turfaces. . There aurfaces. , making urfaces. , or incrurfaces. . Li et aurfaces.  proved ts proved  that thes proved  investigs proved  proved ts proved  showed ts proved  proved ts proved . These ss proved , on the s proved  tested ts proved  proved tThis work is a continuation of the previously conducted research, in which attention was focused on the waste ceramic matter obtained from sanitary ware products . The artThe analysis of the results allowed the authors to identify the technical and environmental aspects of recycling ceramic waste material.The selection of material for the study was made by segregating the waste deposited in illegal building material landfills. Among the ceramic waste, the largest percentage of waste included red ceramic waste in the form of crushed bricks, ceramic blocks and shards of roof tiles. Another chemical substance found among the other waste was ceramic floor and wall tiles—broken or in scraps. A less sizeable group consisted of sanitary ceramics fragments.The aggregate used in the authors’ own research was collected from landfills and grouped according to the type and classification of ceramic waste into three groups, i.e., red ceramics, glazed ceramics and sanitary ceramics . The same aggregates were also used in our own previous studies ,51. SandUsing an Energy Dispersive Spectrometer (EDS) detector Phenom G2 Pro , elemental analysis was performed. The chemical compositions of the aggregates used in the investigation are shown in 2 (over 54%), Al2O3 (over 24%), and K2O (over 3%) were found. High silica content also occurred in the basalt aggregate. Gravel contained mainly MgO (40.85%) and CaO (31.78%). The content of CaO was a feature of both traditional aggregates. There was no CaO in the recycled aggregates.As indicated in the experiment, the chemical compositions of the ceramic aggregates are very similar. In all ceramic aggregates, high amounts of SiOThus, the obtained waste was subjected to crushing in MAKRUM 4015 jaw crushers . The use of the crushing machine enabled the segregation of aggregate grading into two types: fine grain size 0–4 mm and thick grain size 4–8 mm. Shards of ceramics with a diameter greater than 8 mm were placed in the crusher again. The ceramic waste generated from landfills and ceramic aggregate obtained by crushing are shown in A series of studies was carried out for the aggregate obtained this way, corresponding to the examination of natural aggregates that are commonly used in concrete ,53. Exam3. By measuring the weight, bulk densities were calculated as well. Obtaining the tightest plastic stack is beneficial to ensuring adequate load bearing. Therefore, the selection of grains in which the finer grains will tightly fill the spaces between the thicker grains is the goal. To determine the optimum ratio of coarse to fine grain size, a trial was carried out on the aggregates obtained from sanitary wares. Mixes of different proportions were poured into a dish with a volume of 1.69 dmThe study on the grain composition of the aggregate mixture with this ratio was performed according to the PN-EN 933-1:2012 standard  after drThe optimization test results are shown in On subsequent measurements, bulk density increased, and then it dropped. The point at which the bulk density was highest was considered to be the optimal ratio of fine aggregate to coarse, and this amounted to 1:0.4. The test results for the grain composition of aggregates mixture are presented in the diagram below .The composition of grain size was not the same for all aggregates. Red ceramic aggregate contained many more fine grains than the other ceramic aggregates. The probable cause for this is that red ceramics have lower strength parameters. It was crushed by the jaw crusher to a greater extent than the other ceramic waste. The aforementioned supposition is confirmed by the degree of crushing test results. This parameter is much higher for red ceramics than for other aggregates. The test method for the rate of crushing and the process of crushing in crushers is similar. In this process, for aggregates of lower strength, during the crushing of large-sized material, it is possible to obtain a larger number of silt particles and particles of smaller diameters, but for the materials with higher strength, the particles will be greater in size. The different particle size distributions of the different types of aggregates can affect the concrete parameters. The effect of using aggregates with different particle size distributions in individual concretes will be a difference in density, which affects other properties, such as mechanical strength.The content of particles smaller than 0.063 mm was evaluated using Horiba LA-300 laser diffraction particle size analyzer  for a separated pile of grain size lesser than 0.25 mm. In the case of sanitary ceramics , the conThe specific density was determined using the method provided in the PN-EN 1097-7 standard . The tesThe apparent density and water absorption of the aggregates were determined according to the PN-EN 1097-6 standard . From thThis test was performed in accordance with the PN-B-06714-40: 1978 standard  on the aThe crushing indicator was established as a percentage (by mass) of grains that did not pass through a 1 mm sieve after crushing. Three tests for each type of aggregate were conducted.On the basis of the reference recipe for concrete C35/45, the main ingredient of which was basalt aggregate, a concrete was prepared in which the sand was replaced with crushed waste from ceramic of fine particle size, whereas ceramic aggregate of coarse grain size constituted the substitute for basalt grit. Aggregates were replaced by mass. In each formula, the weight ratios of the ingredients were the same.Portland cement CEM I 42.5N/SR3/NA , was used as a cement in the concrete in accordance with PN-EN 197-1 standard . It is cThree concrete formulas were designed in which the aggregate was exclusively ceramic aggregate , as well as two recipes using only traditional aggregates: gravel, sand and basalt. Despite the different absorbability of the aggregates used, the same W/C ratio = 0.37 was used in all formulas. The purpose of this was to determine the effect of only one variable factor (type of aggregate) on the tested concrete properties. The composition of the starting basalt concrete is shown in For comparison of results, besides the samples of basalt aggregate, the samples with gravel aggregate were prepared as well. Due to the fact that the largest dimensions of the aggregates in the presented concrete composites were 8 mm, the samples for strength tests were prepared in the form of beams with dimensions of 40 × 40 × 160 mm; in an amount of 9 pieces per recipe, in accordance with the literature data . After fThe consistency was tested by concrete slump test in accordance with PN-EN 12350-2 . The meaThe apparent density was tested for the samples with the dimensions of 40 × 40 × 160 mm. The tests were carried out on 6 samples from each recipe. The study was conducted in accordance with the PN-EN 12390-7 standard . The appThe samples were subjected to a flexural strength test by three-point bending, and then half of the trabeculae were subjected to the compressive strength test. The study was conducted in a Controls Advantest 9 testing machine  in line with the PN-EN 12390-5  and PN-E2SO4, HCl, HNO3), weak acids  and organic acids . Degradation is the formation of readily soluble salts as a result of the reactions described in the literature [Deterioration mechanisms vary depending on the type of factors that cause them. The adverse effect of acidic destruction applies to all concrete components, including aggregates  . It is iterature .Acidic destruction leads to an increased porosity of the concrete and lowering of its strength. The mechanism of sulfate deterioration is based on the reaction of sulfate ions with the components of hardened cement paste. The corrosion products are insoluble compounds that attach to water in the crystallization process, resulting in a significant increase in volume. Initially, calcium hydroxide reacts by turning into hydrated calcium sulfate, in accordance with the reactions described in the literature . In the During magnesium deterioration, as a result of the reaction with calcium hydroxide, the magnesium ions replace the calcium ions. The product of the reaction is a slightly soluble magnesium hydroxide, which does not have binding properties, resulting in a weakening of the concrete structure. As in the case of the magnesium corrosion, the calcium ions are exchanged for the ammonium cations. The product are volatile ammonia and easily soluble salts, and as a result, the porosity of the concrete increases .H3O+ (pH), sulfate ions SO42−, ammonium ions NH4+ and magnesium ions Mg2+.To imitate the chemically aggressive exploitation environment of pipes intended for the construction of municipal sewage systems, the concrete samples were placed in aqueous solutions of aggressive substances. Four types of aggressive agents were adopted, hydronium ions The work assumes a procedure for testing resistance to aggressive environments in accordance with the abovementioned literature ,66,67,68Test samples were placed in plastic containers containing the solution. For comparison purposes, some of the samples were placed in a container with tap water, containing no harmful agents. All samples of CC1, CC2, CC3, TC1, and TC2 composites for chemical resistance tests were cut out from the concrete samples with the dimensions of 150 × 150 × 150 mm. The samples were completely immersed in the test solutions, and their upper surface was about 20 mm below the table of the solutions to exclude the influence of hydrostatic pressure. The samples placed in research and comparison environments are shown in The first criterion for assessing the resistance of composites to chemically aggressive environments was to test the compressive strength of samples after 40 days of immersing them in the solution. Another criterion for assessing chemical resistance was the loss of mass of samples caused by the solution. Before the start of the experiment, all samples were weighed in a dry state using a laboratory scale with an accuracy of 0.01 g. Subsequent measurements of mass change were carried out after 14, 30, 60, 90, 120 and 240 days. The research procedures  were proposed by the authors. They resulted mainly from continuous observation of samples and visual assessment of samples during solution exchange.The test results were compared to the literature results  for the 3. Ceramic sanitary wares with density of 2390 kg/m3, in turn, showed an absorptivity equal to 0.55% [to 0.55% ,27The effect of high water absorption of the material and exposing it to the subsequent of freezing and thawing processed in the landfill were probably responsible for a significant weakening of the structure throughout the whole material. Due to the relatively low water absorption of other ceramic materials and the more coherent structure, the material was more unified, even after crushing. Using the scanning microscope Phenom G2 Pro , the structure of the surface of recycled aggregates and comparative aggregates was analyzed as well. The structure of grain surface is shown in On the basis of the presented scanning images, it can be observed that the structure of all the tested materials is very diverse. The image showing the surface of the red ceramics grain proves that this material has numerous pores, constituting the majority of its volume. This structure is the reason for the high absorbability of the red ceramics and their low mechanical strength.Glazed ceramics also have numerous pores in their volume (visible on the surface); however, they are closer to the images obtained for sanitary ceramics. In both cases, the pores constitute a much smaller percentage of the material volume than in the red ceramics, while at the same magnification (1000×), a smaller number of them can be observed in sanitary ceramics. The “glassy” surface of both recycling materials is important. This effect is probably obtained by firing of clays at much higher temperatures, which causes melting of the material and its solidifying during cooling. This glazing may improve the technical parameters of aggregates, and may ultimately affect their increased resistance to chemical attack. Numerous pores in the space of both materials are the cause of their high absorbability.The images of grain of comparative gravel aggregates indicate their irregular structure, the occurrence of numerous hollows, cracks and irregular pores. Such a structure causes their relatively high absorbability as well as low strength parameters. Basalt grains, on the other hand, show a smooth, homogeneous surface without pores, which explains their low absorbability and high strength parameters.The test results for crushing strength  are presented in 3, and [3.Certain differences in the characteristics of aggregates can be analyzed during the crushing step. Sanitary and glazed ceramic materials behave similarly in the crusher; their fragmentation came in the form of brittle fracture, whereas the grains of obtained aggregate had a stocky form. Similar observations are described in . Crushed3, and ,9 22.8% The results of testing the consistency of concrete mixes are presented in The different consistency results with the same amount of water and plasticizer in all recipes proved that in terms of workability of the mixture, more favorable parameters were obtained using traditional aggregates. Ceramic aggregates are characterized by high open porosity and high absorptivity, which contributes to the absorption of certain amounts of cement paste. A smaller amount of cement paste surrounding the aggregate grain resulted in lowering both the fluidity of the mix and the consistency class. Similar observations are described in other studies . AlreadyThe results of the apparent density and absorptivity of tested composites are presented in The results of the apparent density test showed that despite the same concrete components used (apart from aggregates), different values of apparent density of composites were noted. The differences within composites based on ceramic aggregate did not differ significantly between each other and this difference was about 2%. The apparent density of the composites containing traditional aggregates was higher, and for the composite with basalt aggregate, TC2 was about 14% higher than CC1. Cabrera-Covarrubias et al.  proved tThe absorptivity of the composites varied and, similarly to the density tests, the results were similar in the samples with ceramic aggregates. Vieira et al.  proved tThe average flexural and compressive strengths of the tested concrete samples are shown in the diagrams below . Error b3). The concrete made with the participation of glaze aggregate had lower performance than a comparative concrete with basalt aggregate, by 17 and 35%, respectively. However, its parameters were almost identical to the parameters obtained for the concrete with gravel aggregate. The improvement in the strength of concrete resulting from the use of ceramic aggregate, compared to the usage of basalt aggregates, could be related to the quality of contact between the aggregates and the binder. The surfaces of basalt aggregates are smooth, and despite the fact that the aggregate is very robust during the strength tests, destruction occurs in places where the binder is connected to aggregate. Ceramic aggregates have the added advantage of an open microscopic structure [The flexural strength of ceramic concretes ranges from 2.90 to 7.10 MPa, and compressive strength ranges from 34.40 to 84.60 MPa. In addition to various aggregates, the particle size distribution of aggregates would be a source of differences in strength results. The results of concrete strength tests showed a clear improvement in the characteristics of the obtained concrete by replacing the original aggregate with the ceramic aggregate obtained from crushed ceramic sanitary waste. Similar observations are described in the literature ,28,29,30No relation was found between crushing strength of ceramic aggregates and the strength parameters of concrete, because red ceramic aggregates are characterized by the highest crushing strength, and concrete based on this aggregate has the lowest flexural and compressive strength among concretes based on ceramic aggregates.Considering the results of the aggregate granulometry test and the content of grains smaller than 0.063 mm, a high content of dust in the aggregate may be the reason for low strength parameters of the composite with red ceramics. Covering the aggregate grains with dust hinders the access of cement paste to their surface. The result is that the grain-paste contact zone was weakened. The content of fine grains, with a diameter smaller than 0.063 mm, proved to be unfavorable from the point of view of concrete composite quality.The results of the compressive strength test of concrete samples exposed to a chemically aggressive environment are shown in the graph below . The val2SO4 was about 43.86%. Gireesh [2SO4) was in the range of 1.78–5.11%.For all the tested samples immersed in an aggressive environment, lower strength values were observed than for the samples immersed in water. The form of destruction of the samples also showed the effect of aggressive environment. All tested samples were destroyed in the first phase by splitting off the surface layers directly affected by the solution. The lowest values were found for the samples CC1 (15.6 MPa) and TC2 (18.7 MPa). The highest strength was exhibited by the sample CC3 (77.7 MPa). Compared with the strength of a high-quality basalt aggregate composite (56.7 MPa), the strength of the composite made of sanitary ceramics was 27% higher. The decrease in compressive strength of basalt concrete and concrete based on sanitary ceramic aggregate was 27.8% and 13.4%, respectively. After 40 days of testing, the cement matrix weakened in the samples (aforementioned chipping of the surface layers during the compression test), which appeared to be particularly intensive in the case of the composites with non-porous aggregates . As a result of the weakening of the cement matrix, the adhesion force of the aggregate grains to the matrix weakened. In this case, the mechanical bonds between the cement matrix and the pores of the open construction aggregates proved to be more advantageous. The analysis of loose grains from the surface layers of basalt aggregate during destructive tests proved that the bond ceased to exist (the weakened paste was washed out under the stream of water). In the case of the ceramic aggregate grains, the cement paste remained in the pores of the aggregate. Weakening of the structure of composites based on red ceramics and gravel was caused by the fact that after 40 days of the experiment, the solution started to have a destructive effect on the aggregate grains. For comparison, in other studies , the red Gireesh , in turnThe results of the measurements pertaining to the percentage change in mass of concrete samples are presented in In the initial period of the experiment, mass gain was observed in all of the tested composites, which resulted from the appearance of crystalline reaction products on the surface of the samples. Then, from the 14th day after the experiment started, decreases in the mass of the samples caused by aggressive environment attack were recorded. Already in this period, exposed aggregate was observed on the surfaces of all samples. During the analysis of the results, it was found that the fastest mass losses occurred in the samples with gravel aggregate and red ceramics. The weight drops that progressed the least were observed in the composites with sanitary and glazed ceramics. The mass decreases of the samples recorded after 120 days of immersion in the solution were chosen as reference values for the comparison purposes. The weight loss of the CC1 composite was 78.4%. The CC1 sample was destroyed to such an extent that only its core remained. A similar observation was found for the TC2 composite sample. The weight loss value of this sample was 70.6%. The samples of the CC2, CC3 and TC1 composites lost 34.45%, 20.21% and 57.9% of their mass, respectively. The smallest impact of the aggressive environment on concrete based on sanitary ceramic aggregate could be related to the lowest absorptivity of this aggregate from among ceramic aggregates. Red ceramics, in turn, are characterized by the highest absorptivity, and concrete based on this aggregate is the least resistant to aggressive environments. Both in these and the previous samples, it was noticed that the cause of the destruction, mainly of the cement matrix, was an aggressive environment, although in the case of gravel aggregate, red ceramics and basalt, the aggregate was also deteriorated. The grains made of sanitary ceramics did not deteriorate. Their appearance indicated that the aggregate was a kind of protection (shield) against the chemical deterioration of the matrix due to the aggressive environment. This could also be due to the specific types of bonding between aggregate and cement paste mentioned above, which, apart from adhesion, were defined as mechanical. The destruction of composites, i.e., samples after 240 days of saturation in the solution, is shown in 2SO4 was about 5.24%. Gireesh [2SO4) was in the range of 1.06–2.23%. After 30 days of immersion in the solution, the decrease in the mass of the samples was almost zero. For comparison, in other studies , the red Gireesh , in turnConsidering both the first and the second criterion, the research demonstrated the beneficial effect of the presence of ceramic aggregates (in particular derived from sanitary ceramics) on the resistance to aggressive environments. A substitute for traditional aggregate in the form of crushed waste sanitary wares resulted in lower losses of composite mass and higher compressive strength compared to traditional composites. It was therefore concluded that the use of recyclate from the sanitary cullet was the most advantageous for the production of concrete resistant to aggressive environments, and is recommended for the production of sewerage pipes.There was no relationship between the results of chemical deterioration resistance tests and the results of chemical composition of aggregates tests. Similar chemical composition of recycled aggregates and various images of their destruction showed a greater impact on the examined feature of physical parameters. Features such as glazing of the surface and diversified structure probably had a greater impact on the chemical resistance than the chemical composition of the ceramic aggregates.This research presents the possibilities of using three types of ceramics as concrete aggregate. The basic parameters of the aggregates were investigated. The use of recycled aggregates from ceramic construction waste is possible, although the analyses conducted prove that there are many factors which determine the characteristics of the final composite.Recycled ceramic aggregates present relatively lower apparent density and higher absorptivity compared to traditional aggregates . Other ceramic aggregates are characterized by higher, but similar, absorptivity to traditional aggregates.Red ceramic aggregate is characterized by a greater degree of crushing compared to glazed and sanitary ceramic aggregate, by 205.7% and 439.4%, respectively.Depending on the type of recycled aggregate used, the technical properties of the concretes obtained from it are different.The consistency of composites with ceramic recycled aggregates was lower than in the case of traditional composites, despite the same cement paste ingredients being used.The apparent density of composites with recycled aggregates was lower than in traditional composites; absorptivity of recycled composites was higher than that of traditional composites. All these characteristics result from the examined aggregate features, i.e., low density and high absorptivity.The concrete based on sanitary aggregate is characterized by 22% higher flexural strength and 42% higher compressive strength than concrete based on glazed ceramic aggregate and flexural and compressive strength 59% higher than that of concrete based on the red ceramic aggregate.The study proved that sanitary ceramic concrete is characterized by greater strength than concrete based on basalt aggregate, by 10.5% and by 5.9% for the compressive and the flexural strength, respectively. The parameters of the concretes made with glazed ceramic can constitute a substitute for gravel concrete. The concretes based on a glazed ceramic aggregate are characterized by similar strength properties to the properties of concrete based on gravel.The concrete based on red ceramic aggregate is characterized by the flexural strength lower by 10% and the compressive strength lower by 20% than the strength of the gravel-based concrete.The lowest drop in strength after the impact of a chemically aggressive environment was observed in the concrete based on sanitary ceramics aggregate (13.4%). Among the concretes based on traditional aggregates, the lowest compressive strength loss was observed in the basalt concrete (27.8%).The smallest weight loss caused by aggressive environment attack was recorded in the concrete based on ceramic sanitary and glazed aggregate . Among the concretes based on traditional aggregates, the lowest weight loss was observed in the basalt concrete (57.9%).The use of sanitary ceramic cullet as aggregate is the most advantageous in the production of the concrete resistant to aggressive environments and is recommended for the production of concrete sewage pipes.A thorough analysis of the obtained results enabled to formulate the following conclusions:


Immunoglobulin G4-related disease (IgG4-RD) is regarded as an immune-mediated systemic fibroinflammatory disease. Several studies have linked IgG4-RD to infections such as tuberculosis and actinomycosis. However, the coexistence of IgG4-RD and non-tuberculous mycobacterium (NTM) in a single pulmonary nodule has not been reported yet.A 76-year-old male patient presented with cough and sputum. A solitary pulmonary nodule suspicious of lung cancer was found on chest CT.Through video-assisted thoracoscopic biopsy, a diagnosis of co-existing NTM and IgG4-RD in a single nodule was made.Antibiotic treatment was applied for pneumonia developed after surgery. The patient was also supported by extracorporeal membrane oxygenation and mechanical ventilation since his pneumonia was refractory to medical treatment.The patient expired on the 60th postoperative day due to multiple organ failure.IgG4-RD can occur singularly or accompanied by other diseases. We report a solitary pulmonary nodule caused by NTM and concurrent IgG4-RD, suggesting a possible association between these 2 entities. Immunologic relations between IgG4-RD and accompanying infection should be further investigated. Although this disease forms a distinct clinical entity, its pathogenesis is not clearly understood yet. Diseases occurring in association with IgG4-RD, either synchronously or metachronously, has been suggested as an etiologic trigger for abnormal IgG4-related immunological reactions.Immunoglobulin G4-related disease (IgG4-RD) is newly defined as a fibroinflammatory process. It has been reported in various organs with different names such as Mikulicz's syndrome, Küttner's tumor, Riedel's thyroiditis, and idiopathic retroperitoneal fibrosis.We report a case that highlights radiology-pathology correlation of solitary pulmonary nodule due to concurrent diagnosis of NTM and IgG4-RD that suggests a possible link between the 2 diseases.29/L). His body temperature was 36.5°C. His blood pressure was 135/75 mmHg with pulse rate of 67/minute.This study was approved by our institutional review board. The patient's family members provided consented to publish this case. A 76-year-old male patient presented cough and sputum. He was a 30 pack-years ex-smoker. He had unstable angina and received stent insertion in right coronary artery 2 years ago. His complete blood count showed no leukocytosis -4, IL-5, IL-10, and IL-13, and transforming growth factor β can be overexpressed. These cytokines contribute to eosinophilia, elevated serum IgG4 and IgE concentrations, and progression of fibrosis that are characteristics of IgG4-RD.M tuberculosis and IgG4-RD in pulmonary/ extrapulmonary organs have been reported.–8 Concurrent IgG4-related lymphadenopathy was reported in a patient with disseminated NTM infection. However, co-occurrence of NTM and IgG4-RD in a pulmonary lesion has not been reported before. In the present case, his immunologic response to NTM might have precipitated the development of IgG4-related lesions. On pathologic examination, fibroinflammatory tissues suggesting IgG4-RD existed at the periphery of caseation necrosis and granulomatous area, creating irregular wall thickening and pleural invasion. We postulate that NTM in this patient might have activated a type 2 helper T cell response that in turn leads to overexpression of interleukins and transforming growth factor.Several studies linking  Key pathological features are dense lymphoplasmacytic infiltrate, storiform fibrosis, obliterative phlebitis, and eosinophilic infiltration. IgG4/IgG-positive cell ratio > 40% and/or >10 IgG4-positive cells/high power field are required. A definitive diagnosis of IgG4-RD can be made in patients who fulfill all of the following 3 criteria:Diagnosis of IgG4-RD can be made using comprehensive diagnostic criteria combined with organ-specific criteria.1)organ involvement,2)a serum IgG4 concentration >135 mg/dl, and3)histopathological findings of >10 IgG4 cells/HPF and IgG4/IgG-positive cell ratio >40%.We presented a solitary pulmonary nodule due to NTM and concurrent IgG4-RD, suggesting a possible association between the two entities. Further investigations and more proof from clinical cases are needed to clarify the relationship between infection and IgG4-RD.Conceptualization: Kyung Nyeo Jeon.Data curation: Kyungsoo Bae, Hyo Jung An, Kyung Nyeo Jeon, Sung Hwan Kim, Ho Cheol Kim.Formal analysis: Hyo Jung An, Dae Hyun Song.Methodology: Hyo Jung An, Dae Hyun Song, Ho Cheol Kim.Resources: Sung Hwan Kim.Writing – original draft: Kyungsoo Bae, Kyung Nyeo Jeon.Writing – review & editing: Kyung Nyeo Jeon.


Antimicrobial resistance (AMR) is a serious public health problem and a global concern. The inappropriate use of antibiotics has been identified by the World Health Organization as a major risk factor for AMR.The purpose of this research study is to assess the prevalence of inappropriate antibiotic use among Qatar University students and their family members, detect sociodemographic factors associated with inappropriate use, evaluate the knowledge and attitude towards antibiotic use, and assess respondents’ opinions on healthcare providers’ antibiotic prescription practices. Participants (N = 596) completed a self-administered questionnaire. Descriptive analysis, the Pearson chi-squared test, and multivariate logistic regression analyses were performed.The major inappropriate antibiotic use practices followed by the respondents were using antibiotics without prescription (82%), not completing the antibiotic course (45%), and obtaining antibiotics from the pharmacy without prescription (23%). The chi-square test results showed that age (p = 0.031) and nationality (p = 0.041) were associated with using antibiotics without prescription. In addition, respondents less than 21 years of age (p<0.001), who had only a secondary education (p = 0.007), and who lived in one of the large and crowded cities in Qatar (p = 0.011) had higher odds of stopping the antibiotic before completing the course. Our study also revealed that almost 60% of the respondents had inadequate knowledge and a negative attitude towards antibiotic use. Nationality and municipality were the independent factors associated with having appropriate knowledge of antibiotic use. Univariate logistic regression analyses in our study demonstrated that older (>26 years), married and university-graduated participants were more likely to have a positive attitude towards antibiotic use than others. Respondents also reported that neither doctors nor pharmacists were providing adequate patient education about appropriate antibiotic use. The Socio-Ecological Model was applied to interpret the findings and frame implications.The findings shed light on various factors shaping antibiotic use practices and provide evidence to design multilevel behavioral interventions to improve public practices of antibiotic use. Antibiotics are drugs used to stop and manage bacterial infections, either by killing the infectious bacteria inside the host body or by preventing their multiplication and spread, allowing the host’s own defense to contain and eliminate it . AntibioAccording to the World Health Organization’s new global antimicrobial surveillance system, ABR is widely spread, existing among 500,000 people in 22 countries; it kills thousands of individuals every year . In deveFew studies have reported on the emergence of ABR in the Gulf Cooperation Council (GCC) countries , 8. DuriAn increase in consumption, longer duration and multiple courses of antibiotics have been associated with the development of resistance , 12. EacSelf-medication/prescription of antibiotics is another issue associated with the risk of inappropriate drug use. In the Middle East region, a recent systematic review showed that the prevalence of self-medication and self-prescription with antibiotics ranges from 19% to 82% across studies . PenicilAt the community level, previous research found extensive problems in knowledge, attitudes, beliefs and behaviors that influence antibiotic use –24. PatiA systematic review conducted in Qatar to explore antibiotic use in upper respiratory tract infections for patients visiting healthcare settings revealed overprescribing of antibiotics in all health care settings . For insIn Qatar, a country with highly mobile inhabitants, one of the reasons for inappropriate use of antibiotics is that residents can purchase antibiotics without prescription when traveling and bring them back to Qatar . A QatarInappropriate antibiotic use is driven by individuals’ behaviors and practices. A better understanding of these practices will contribute to achieving a positive change for the benefit of patients and community members’ health. There is a paucity of studies regarding antibiotic use practices among community members in Qatar and the factors influencing these practices. Our study will be the first of its kind in assessing antibiotic use practices among college students in Qatar. This study will provide baseline data for future studies and provide insight into the development of behavioral interventions with the aim of optimizing appropriate antibiotic use among the public, which will, in turn, help in the implementation of the antibiotic stewardship program in Qatar and thus decrease the rate of ABR.The purpose of this study is to assess public practices on antibiotic use among specific communities represented by Qatar University students and their family members. More specifically, the study objectives are to measure the degree of antibiotic prescribing; assess knowledge, attitudes and practices on antibiotic use; evaluate participants’ opinions on healthcare provider antibiotic prescription practices; and quantify how all these factors are associated with the study population characteristics.This is a cross-sectional study that was conducted between September 2018 and March 2019. Using a convenience-sampling design, three colleges out of nine in the university were chosen to recruit participants: the College of Engineering, the College of Arts and Sciences, and the College of Health Sciences. Next, students expected to have diverse fields of study and nationalities were recruited from two main female buildings as well as from the female students’ dormitory at the university. Participants were eligible to be included in the study if they were ≥18 years old, were aware of the term “antibiotic” and understood English or Arabic. Additionally, in order to enhance external validity, one family member of each selected student was asked to complete the questionnaire. The family member was also chosen using a convenience-sampling method. The study was approved by the Qatar University Institutional Review Board .Participants and their family members completed a total of 596 questionnaires. Using an anticipated prevalence of 73% of antibiotic self-medication  and a 4%Six senior public health students from the College of Health Sciences (CHS) at Qatar University were the main data collectors, who invited other students to participate in the study. Participants who agreed to participate in the study were provided an anonymous self-administered questionnaire to be completed by themselves and by one of their family members. Data collectors assured participants of confidentiality and provided them with written consent to participate in the study. No incentives were offered for participation.The questionnaire was adapted from the ABR: Multi-Country Public Awareness Survey  and a vaThe questionnaire included four sections: demographics; antibiotic prescription history and antibiotic self-medication; knowledge and attitude towards antibiotic use; and opinion on healthcare providers’ antibiotic prescription practices.The first section of the questionnaire consisted of the sociodemographic questions. The first two questions identified the participant as a student or a family member and their relationship to the student. There were questions about gender, age, marital status, nationality, highest educational level completed, employability status, area of residence, and total household income. These questions were adapted from the Kuwaiti study  and WHO The second section covered antibiotic prescriptions, antibiotic use practices and self-medication with 14 close-ended questions. The first eight questions asked: if they had been prescribed antibiotics within the last year; the frequency of being prescribed antibiotics during the last year; if they had finished the last antibiotic prescribed; if not, they were asked about the reasons; whether they had used an antibiotic without being prescribed it by a doctor or dentist within the last year (self-medication); frequency of self-medication with an antibiotic during the last year; conditions for which the antibiotics were self-prescribed; and if they completed these self-prescribed antibiotics. Additionally, a question listed seven conditions for which antibiotics were used without prescription, and respondents were asked to check all the conditions for which they had self-medicated with antibiotics. Other questions asked if the participant used antibiotics that were originally prescribed for an infection that recurred later, originally prescribed for another type of infection, obtained from a pharmacy abroad without a prescription, obtained from a pharmacy within Qatar without a prescription, originally prescribed for another family member, or prescribed for someone else who was not a family member. These questions were mainly adapted from the Kuwaiti study. The questions about antibiotic prescription, the conditions for which antibiotics were used, and where participants usually obtained antibiotics were also included in the WHO survey.In the third section, there were 16 statements about knowledge and attitudes regarding antibiotic use. A 5-point Likert scale, which started from strongly disagree to strongly agree, was used to assess the participants’ responses. The first nine statements assessed knowledge about antibiotic use among the participants. Participants were asked if they agreed with these statements or not: Different antibiotics are needed to cure different diseases; antibiotics are effective against bacteria; Antibiotics can kill the bacteria that normally live on the skin and in the gut; Antibiotics speed up the recovery from most coughs and colds; antibiotics work on most coughs and colds; Antibiotics are effective against viruses; If they get side effects during a course of antibiotic treatment, they should stop taking them as soon as possible; If they get some kind of skin reaction when using an antibiotic, they should not use the same antibiotic again; and Antibiotic use can cause imbalance in the body’s own bacterial flora. These statements were adapted from the Kuwaiti study.The remaining seven statements in this section assessed the participants’ attitudes towards antibiotic use. Participants were asked if they agreed with these statements or not: I always complete the course of treatment with antibiotics even if I feel better; It is good to be able to get antibiotics from relatives or friends without having to see a medical doctor; I prefer to be able to buy antibiotics from the pharmacy without a prescription; I prefer to keep antibiotics at home in case there may be a need for them later; If I feel better after a few days, I sometimes stop taking my antibiotics before completing the course of treatment; I prefer to use an antibiotic if I have a cough for more than a week; and If I have a sore throat, I prefer to use an antibiotic. These questions were mainly adapted from the Kuwaiti study. The two questions on attitudes about obtaining antibiotics from relatives and friends and stopping antibiotics before completing the course of treatment were also included in the WHO survey.Section four included four statements to assess participants’ opinions regarding healthcare providers’ antibiotic prescription practices. They were asked if they agreed with these statements or not: Pharmacists often tell you how antibiotics should be used; Doctors often take time to inform the patient during the consultation how antibiotics should be used; Doctors often prescribe antibiotics because the patient expects it; and Doctors often take time to consider carefully whether antibiotics are needed or not. A 5-point Likert scale, which started from strongly disagree to strongly agree, was used to assess the participants’ responses. All questions were adapted from the Kuwaiti study, and the question on the role of doctors and pharmacists in explaining how a patient should use an antibiotic was also included in the WHO survey.The main objectives of the study were to measure the degree of antibiotic prescribing, assess inappropriate antibiotic use practices, assess knowledge and attitudes on antibiotic use, evaluate respondents’ opinions on healthcare providers’ antibiotic prescription practices, and evaluate how all these factors are associated with the respondents’ characteristics.The main outcome variable to measure the degree of antibiotic prescribing was being prescribed antibiotics 1 or more times within the last year . Inappropriate antibiotic use and self-medication were measured using three variables: Using an antibiotic without prescription , not completing the last prescribed or unprescribed antibiotic course  and obtaining an antibiotic without a prescription from a pharmacy abroad or in Qatar .Two outcome variables, capturing knowledge and attitude towards antibiotic use, were derived using a scoring system. The system assigned scores of 1 or zero to each participant response to the relevant statements. A continuous total score was computed for each respondent as the sum of their 0/1 scores. This total score was further categorized into a binary variable using the median of the total score as a cutoff point.Knowledge on antibiotic use was based on responses to the nine knowledge statements asked. A participant who responded to a correct statement with “strongly agree” or “agree” was given a 1 score and zero otherwise. For wrong statements, a score of 1 was given to participants who responded “strongly disagree” or “disagree” and zero otherwise. The total score (range 0–9) was categorized as acceptable knowledge for total scores equal to or greater than the median and unacceptable knowledge otherwise.The attitude towards antibiotic use was derived from participants’ responses to the seven attitude statements. Positive statements with “strongly agree” or “agree” were given a 1 score and zero otherwise, while negative statements were given a score of 1 to participants who responded “strongly disagree” or “disagree” and zero otherwise. The total score (range 0–7) was categorized as a positive attitude for total scores equal to or greater than the median and a negative attitude otherwise.Furthermore, opinions on healthcare provider antibiotic prescription practices was captured using six opinion statements. Additionally, the basic characteristics of the participants, such as age, gender, nationality, marital status, highest educational level completed, employability status, area of residence, and total household income , were coepidata entry program*. To ensure data entry quality, the data entry program was designed to perform range calculations, consistency checks, field validations and data-type restrictions. Data were then exported into the Stata data format for analysis.After data collection, data were checked in the paper questionnaires for potential mistakes and inconsistencies. Each questionnaire was given a unique identification. Data were then entered into the Stata version 15. Means and standard deviations were used to summarize continuous data, while proportions and percentages were used for categorical variables. Association of respondents’ characteristics with antibiotic prescribing, inappropriate antibiotic use and self-medication, and knowledge and attitudes towards antibiotic use were evaluated using univariate logistic regression. All variables with a global Wald test p < 0.25 in the univariate analysis were included in an initial multivariable logistic regression analysis to determine the factors that were independently associated with each outcome variable. Based on this model, a final model was built, considering a global test p-value of 0.05 to be statistically significant.Entered data were cleaned and analyzed using the Statistical Package A total of 600 subjects were approached to participate in the study, and 596 of them completed the questionnaire. The majority of the respondents were females (86.2%). Approximately two-thirds of the respondents were students (64.4%), and 23.2% were aged 26 years or above. Among these respondents, 73.8% were single, and only 3.7% were non-Arab. Key characteristics of the respondents are presented in Of all respondents, 64% had received at least one prescription for antibiotics within the last year prior to our study, 34% of whom had used antibiotics once, and 12% had used them three times or more. During the same period, the majority of the respondents (82%) used antibiotics without prescription, 37% of whom used antibiotics that were prescribed for another family member or someone else and 27% of whom used antibiotics that were prescribed for them for a previous illness when they had similar symptoms later on. In addition, 45% of the respondents did not complete the last course of antibiotics, and 23% obtained the antibiotic without prescription from any pharmacy .Slight significant differences in using antibiotics with prescription among the respondents in relation to age were reported (p = 0.048). Respondents with older age (>26 years old) had higher odds ratios of using antibiotics with prescriptions than youngsters . HoweverThe chi-square test results showed that nationality (p = 0.041) and age (p = 0.031) were associated with using antibiotics without prescription among the respondents . HoweverConcerning adherence to the recommended antibiotic regimen, forty-five percent of the study population reported that they did not complete their last course of antibiotics . Table 4Regarding the nonprescription supply of antibiotics from pharmacies, 23% of our study population declared that they obtained antibiotics without a prescription from a pharmacy, 12% of whom got them from pharmacy in Qatar . There wThe questionnaire revealed that respondents had inadequate knowledge about antibiotic use, since the percentage of full agreement (“strongly agree” and “agree”) on the unacceptable knowledge statements was almost 56%. As demonstrated in The chi-square test results showed that nationality (p = 0.010) and municipality (p = 0.048) were the independent factors associated with having appropriate knowledge of antibiotic use. Approximately 64% of Non-Arab respondents had adequate knowledge about antibiotic use, compared to 41.5% of Qatari respondents. Only 37% of the study population who lived in Al-Rayan municipality had acceptable knowledge of antibiotic use, compared to 45% of those living in Doha. The univariate logistic regression revealed that there were no significant predictors among the demographic factors regarding knowledge of antibiotic use.Regarding the respondents’ attitude towards antibiotic use, the questionnaire also showed that a significant proportion of respondents had a negative attitude towards antibiotic use (59.73%). Interestingly, only 14% of the respondents agreed with the need for a prescription to buy antibiotics from a pharmacy, and 35% declared that they would complete the antibiotics course even if they started to feel better. Three quarters of them claimed that it is good to have the ability to obtain antibiotics from friends or relatives without seeking proper medical advice. Half of the respondents believed that using antibiotics is an effective treatment for coughs, while 35% also believed that it is an appropriate treatment for sore throat .Chi-square test results revealed that respondents’ attitude towards antibiotic use was significantly associated with age (p = 0.003), marital status (p = 0.010), nationality (p = 0.001) and level of education (p = 0.003). Multivariate analyses demonstrated that older (age>26), married and university-graduated participants had higher odds of having a positive attitude towards antibiotic use than others . Nationality was also significantly associated with respondents’ attitude towards antibiotic use. Compared with Qataris, other GCC respondents had lower odds of having a positive attitude towards antibiotic use .Respondents’ reported that neither doctors nor pharmacists were providing adequate patient education regarding appropriate antibiotic use. Approximately half of the respondents claimed that doctors do not allocate enough time to explain appropriate antibiotic use, and 75% reported the same issue with pharmacists. In addition, 46% of the respondents mentioned that doctors are not cautious when considering whether antibiotics are needed, and 28% reported that doctors often prescribe antibiotics because the patients expect it .This study aimed to assess the prevalence of inappropriate antibiotic use among Qatar University students and their family members and the different factors associated with this behavior. Our results showed that more than 60% of the respondents had received at least one prescription for antibiotics within the last year prior to our study, which is less than what was reported by a previous study among the public in Qatar (96%) , yet stiThe major inappropriate antibiotic use practices followed by the respondents were using antibiotics without prescription, not completing the antibiotic course, and obtaining antibiotics from a pharmacy without prescription. Our study revealed a high prevalence of inappropriate antibiotic use among the respondents, with 82% reported using antibiotics without prescription, 37% of whom used antibiotics that were prescribed for another family member or someone else and 27% of whom used the same antibiotics that were prescribed for them for a previous illness. A study conducted in Peru in 1000 college students showed that approximately 70% of the participants used antibiotics without medical consultation . A high Another finding was about the nonprescription supply of antibiotics from pharmacies: 23% of our study population declared that they obtained antibiotics without a prescription from a pharmacy, 12% of whom got them from a pharmacy in Qatar. Given that people cannot obtain an antibiotic without a medical prescription from pharmacies in Qatar , it was On adherence to the recommended antibiotic regimen, 45% of the population in our study reported that they did not complete their last course of antibiotics. The range of percentages of not completing the course of antibiotics across studies in GCC countries is between 30 and 72, with a 40% median, which may expose the patients to ABR . The metIn our study, nationality and age were associated with using antibiotics without prescription. Qataris and respondents aged less than 21 years reported the highest percentage of inappropriate antibiotic use. The age factor, which was diluted when performing a logistic regression, could be explained by the fact that the young generation does not have appropriate knowledge about antibiotic use. On the contrary, a study reported that older age is a factor negatively affecting the perceived need for antibiotics . As for Our study revealed that the respondents had inadequate knowledge about antibiotic use, since the percentage of their full agreement (“strongly agree” and “agree”) on the unacceptable knowledge statements was almost 56%. The majority of the respondents (73%) believed that antibiotics are effective against bacteria; almost half claimed that antibiotics are effective against viral infections, and approximately 60% of the respondents reported that antibiotics speed up the recovery from most coughs and colds. A study reported that although approximately 70% of the participants acknowledged the value of antibiotics in treating bacterial infections, half of the participants thought that they could also use antibiotics for non-bacterial infections . MoienzaThe chi-square test results in our study showed that nationality and municipality were the independent factors associated with having appropriate knowledge of antibiotic use. This reinforces our previous findings that Qatari respondents living in Doha have inadequate knowledge about antibiotic use. Results from antibiotic awareness surveys have shown that although individuals would have good knowledge of when antibiotics should be used, they would still obtain antibiotics without prescription –49. ThusPrevious research points to the crucial role that family members play as sources of antibiotic information, recommendations and supply . Qatar hThe last finding is about the respondents’ opinion regarding the healthcare providers’ antibiotic prescription practices. Respondents reported that neither doctors nor pharmacists provide adequate patient education about appropriate antibiotic use. Approximately half of the respondents claimed that physicians do not allocate enough time to explain appropriate antibiotic use, and 75% reported the same issue with pharmacists. A recent Australian study reported that detailed information about appropriate antibiotic use was not voluntarily provided by either the GP or community pharmacist if not asked for by the patients , and somAny effort to tackle antibiotic resistance must include patient education and counseling, as patient demands are a major driver of overuse and misuse of antibiotics. Health organizations must consider social media within their communication strategy to promote appropriate antibiotic-related information seeking in the general population. A recent study demonstrated that the Internet is a resource for disseminating quality health information that has the potential to improve the stewardship of antibiotics in the community . AndersoOur study has some strengths. To the best of our knowledge, this study is the first to assess inappropriate antibiotic use practices among university students and their family members and the factors influencing this behavior in the State of Qatar. Understanding how some factors shaping public practices of antibiotic use are embedded in the different layers of the ecological model would help address the behavior comprehensively and tailor the findings towards evidence-based, multifactorial, effective interventions.Study limitations: The limitations of this study include the cross-sectional design, which limits our ability to infer causation between the various factors and antibiotic use practices. The small sample size and the use of convenience sampling, which may not truly represent the overall population being studied , limits the generalization of the findings to the study population level. Other potential limitations include the social desirability bias of respondents, which may have led them to offer favorable answers, and the use of a self-administered survey, which may have led to recall bias.An Action Plan was developed in Qatar to reduce the inappropriate antibiotic use that causes the spread of ABR. The Action Plan is supposed to implement antimicrobial stewardship in all healthcare settings, aiming to improve public antibiotic use through promotion programs and interventions . A few sThis study showed that antibiotic use is a multifactorial behavior shaped by demographic, individual (knowledge and attitude), and organizational factors. Young Qatari individuals with a secondary educational who live in large and crowded cities in Qatar (Doha and Al Rayan) are at high risk of following inappropriate antibiotic use practices, such as using antibiotics without prescription, not completing the antibiotic course, and obtaining antibiotics from a pharmacy without prescription. Health educators should design awareness campaigns to educate the public, especially young adults, about the appropriate antibiotic use practices and the consequences of their misuse. Educational sessions can focus on school children and adolescents. Sharing educational messages through social media about appropriate antibiotic use, the difference between bacterial and viral infections and how antibiotics should not be used for viral infections, antibiotics’ side effects, and ABR could be an effective health promotion method for the young generation. Awareness campaigns should involve different family members since family is considered an important source of both antibiotics and health information regarding antibiotic use. Health educators should work not only on providing knowledge but also on changing the attitudes and behaviors regarding antibiotic use through different behavioral interventions.At the organizational level, the healthcare system in the public and private sectors should offer training for professionals who have the authority to prescribe antibiotics, such as physicians and pharmacists, to enhance awareness about antibiotic prescribing guidelines and the patient- health care provider communication process regarding appropriate antibiotic use. There should be an emphasis on applying the guidelines and laws when prescribing and dispensing antibiotics.S1 Questionnaire(DOCX)Click here for additional data file.S2 Questionnaire(DOCX)Click here for additional data file.


Around the world, millions of people are impoverished due to health care spending. The highest catastrophic health expenditures are found in countries in transition. Our study analyzes the extent of financial protection by estimating the incidence of catastrophic health care expenditure in Myanmar and its association with sociodemographic factors.We performed a secondary analysis of data from the household surveys conducted by the Livelihoods and Food Security Trust Fund (LIFT) in 2013 and 2015 in Myanmar. To estimate the magnitude of catastrophic health care expenditure, we applied the definition of catastrophic payment proposed by the World Health Organization (WHO); a household’s out-of-pocket payment for health care is considered catastrophic if it exceeds 40% of the household capacity to pay. We also examined the changes in catastrophic payments at three different threshold levels  with one equation allowing for a negative capacity to pay (modified WHO approach) and another equation with adjusted negative capacity to pay (standard WHO approach).In 2013, the incidence of catastrophic expenditure was 21, 13, 7% (standard WHO approach) and 48, 43, 41% (modified WHO approach) at the 20, 30, 40% threshold level respectively, while in 2015, these estimates were 18, 8, 6% (standard WHO approach) and 47, 41, 39% (modified WHO approach) respectively. Geographical location, gender of the household head, total number of household members, number of children under 5, and number of disabled persons in the household were statistically significantly associated with catastrophic health care expenditures in both studied years 2013 and 2015. Education of household head was statistically significantly associated with catastrophic health expenditure in 2013. We found that the incidence of catastrophic expenditures varied by the approach used to estimate expenditures.Although the level of catastrophic health care expenditure varies depending on the approach and threshold used, the problem of catastrophic expenditures in Myanmar cannot be denied. The government of Myanmar needs to scale up the current Social Security Scheme (SSS) or establish a new financial protection mechanism for the population. Vulnerable groups, such as households with a household head with a low-level of education, households with children under the age of 5 years or disabled persons, and low-income households should be prioritized by policymakers to improve access to essential health care.The online version of this article (10.1186/s12939-019-1018-y) contains supplementary material, which is available to authorized users. Around the world, millions of people are impoverished due to health care spending or have to spend catastrophic amounts of money for health care. Catastrophic payments impede access to health care. Catastrophic expenditure can occur in every country at all stages of development, even in countries with well-developed financial risk protection mechanisms, e.g., in Australia, the lowest income group had a 15 times higher chance of having catastrophic health expenditure compared to the highest income group . HoweverIn Myanmar, out-of-pocket payments (OOPPs) are the main source of health care financing, representing 74% of the total health expenditures in 2015. This percentage ranks Myanmar as the country with the highest OOPPs for health care among the Association of Southeast Asian Nations (ASEAN) . OOPPs fThere are only a small number of studies that have estimated catastrophic health care expenditure in Myanmar. The studies that have investigated this expenditure find that catastrophic payments range between 10 and 40%, depending on the method applied –12. HoweOur study explores not only the extent of financial protection conferred by estimating the incidence of catastrophic health care expenditure in Myanmar and its association with sociodemographic factors but also highlights the share of OOPPs that is spent on each type of service such as pharmaceuticals, outpatient care, and others. We performed a secondary analysis of data from the household surveys conducted by the Livelihoods and Food Security Trust Fund (LIFT) in 2013 and 2015 in Myanmar. The LIFT was initiated in 2010 to assist the poor with food availability and income. The LIFT program provides inputs for agriculture  and non-agricultural livelihood , as well as advice on natural resource management  and support to develop effective social protection measures, especially for the chronically poor. The LIFT household survey was conducted among all population groups  in the country’s main agro-ecological zones: Hilly zone, Dry zone, and Delta zone.Our study is important because it examines the level of financial protection, which is one of the monitoring indicators for health financing arrangements in a country. We use regionally representative data provided by the LIFT survey . EvidencThe LIFT household survey was conducted as part of the evaluation of LIFT activities described above. Three survey waves were carried out in 2011, 2013, and 2015 respectively in the main agro-ecological zones: Hilly zone, Dry zone, and Delta zone. These zones cover 76 townships in 8 of 15 states/regions in Myanmar. However, data on expenditures were only collected in 2013 and 2015, so data from those years were only used in our analysis. The surveys were carried out among 200 villages. Although the survey was conducted among 16 households in each village, data on expenditures were only collected among 5 households in each village. Overall, the sampling procedure for the two years was comparable. The total sample for the expenditure part of the survey was 1000 in 2013 and 1165 in 2015 .The expenditure survey questions were adapted from the 2009–2010 Integrated Household Living Conditions Assessment survey conducted in Myanmar, which was based on the World Bank’s Living Standards Measurement Study surveys. The questions were adapted to the Myanmar context by replacing local foods and other goods consumed in the country. We did not participate in the design of the survey and in the data collection process. The data from the expenditure module that we used for our analysis were anonymized before being provided to us.Food consumption expenditures over the last 7 days at home: pulses, beans, nuts, and seeds; meat, dairy, eggs; fish and other seafood; roots and tubers; vegetables; fruits; spices and condiments; other food products except tobacco and alcohol.Other food consumption expenditures during the last 7 days: alcoholic beverages consumed at home or outside of home; food and beverages taken outside homeFood consumption expenditures during the last 30 days: rice and cereals; oil and fats; milk products; other food itemsNonfood consumption expenditures during the last 30 days: Energy for household use ; water; personal apparel; medicines/drugs ; local transport ; other nonfood itemsNonfood consumption expenditures during the last 6 months: clothing and other apparel; home equipment; house rent and repair; health ; education (including preschool and adult education); travel/trips ; otherValue of assets: household items; agricultural itemsThe expenditure dataset is divided into six sections:The estimation of total expenditures was done based on the daily expenditures after recalculating the various timeframes. The variables used in the calculations and their definitions are described in Table To measure financial protection, two main indicators, namely, catastrophic spending and the impoverishing effects of payment for health care, are used in the literature .The sustainable development goal method: when a household’s OOPPs for receiving health care exceeds certain share of household income or consumption .The method proposed by the World Health Organization (WHO): when a household’s OOPPs for health care exceeds certain share of household’s capacity to pay .Two definitions are widely used to estimate catastrophic health care expenditure:The impoverishing effects of health care spending was defined as total expenditures falling below the poverty line after paying for receiving health care . In our To identify households with catastrophic health care spending, we applied the WHO method mentioned above, which is based on a food-based basic need line to estimate household’s capacity to pay. We used the standard WHO approach and the modified WHO approach . The twoWe first calculated the incidence of catastrophic expenditures using the two WHO approaches described above (standard and modified), and three thresholds, namely, 20, 30, and 40% of the household’s capacity to pay. We counted the number of households that exceeded the given thresholds. Results are presented for the total sample in 2013 and 2015. We also present the distribution of catastrophic OOPPs by consumption quintiles: poorest, second, third, fourth, and the richest quintile. In addition, regression analyses were carried out to identify the relation between sociodemographic characteristics and catastrophic health care expenditures at all three thresholds using both approaches. Sociodemographic characteristics included households’ LIFT intervention status; region; age, gender, and education of the household head; total number of household members; number of children under 5 years old; number of disabled persons in the household; and the total monthly household income. These sociodemographic variables are in line with the determinants of catastrophic health care expenditure described in the background paper of the Bulletin of the WHO . The conThe incidence of catastrophic expenditures for the two approaches at the 20, 30, and 40% threshold levels is shown in Table The distribution of catastrophic expenditures by income quintiles are shown in Table The average levels of OOPPs in each income quintile are shown in Table The percentage of daily health expenditures per capita in each income quintile that was spent on each service  based on the two WHO approaches are shown in Tables The data on catastrophic health care expenditures were further analyzed by logistic regression analysis to determine the association between sociodemographic characteristics and catastrophic health care expenditures at the three threshold levels using both approaches for data from 2013 and 2015.Geographical location, gender and education of the household head, total number of household members, number of children under 5, and number of disabled persons in the household were statistically significantly associated with catastrophic health care expenditures in 2013. In 2013, the geographical location of households was significantly associated with catastrophic health care expenditures at the 20% (OR = 0.57) and 30% (OR = 0.51) thresholds using the WHO standard approach and among all three thresholds levels using the WHO modified approach  using the WHO standard approach, and at the 30% (OR = 0.83) and 40% (OR = 0.81) threshold levels using the WHO modified approach. Larger household sizes were associated with greater likelihood of facing catastrophic expenditures at all three threshold levels  using the WHO modified approach. Having more children in the family under 5 years old was associated with a greater the likelihood of catastrophic expenditures, with odds ratios ranging from 1.3 to 1.7 times at the 20 and 30% threshold levels using the WHO standard approach and the 30 and 40% threshold levels using the WHO modified approach. The number of disabled persons living in the household also increased the chance of catastrophic expenditures by 1.78 to 1.73 times and 1.68 to 1.70 times at the 20 and 30% threshold levels using the WHO standard and modified approaches, respectively. Detailed results are provided in Table 2 using tGeographical location, gender of the household head, total number of the household members, the number of children under 5, the number of disabled persons in the household, and total household income were significantly associated with catastrophic health care expenditures in 2015. Using the WHO modified approach, households living in the hilly region were nearly two times  more likely to have catastrophic expenditures at the 20, 30, and 40% threshold levels. Female-headed households had a 1–2% greater likelihood of catastrophic expenditures at the 20 and 30% threshold levels using the WHO standard method. Larger households were associated with a 1.85, 2.12, and 2.22 times greater likelihood of having catastrophic expenditures at the 20, 30, and 40% threshold levels using the WHO modified approach. Having more children under 5 was associated with a 37% increased likelihood of having catastrophic expenditures at the 20% threshold level using the WHO standard approach. Having disabled persons in the household increased the odds of catastrophic payments by 1.76, 1.79, and 1.77 at 20, 30, and 40% threshold levels using the WHO standard approach, and by 2.21, 1.91, and 1.93 using the WHO modified approach. Finally, higher household incomes were associated with a reduced likelihood of catastrophic expenditures, with OR = 0.85, 0.82, and 0.81 at 20, 30, and 40% threshold levels using the WHO modified approach. Detailed results are provided in Table Using the standard WHO approach, our findings show that the incidence of catastrophic health care expenditure ranged from 7 to 21% in 2013 and from 6 to 18% in 2015, depending on the threshold used. This incidence is lower than what was observed in previous Myanmar studies conducted in Magway region (23.6%), selected states and regions (32.9%), and among poor families living in two mountainous states (26%), all of which applied the 40% threshold and the WHO standard approach , 11. TheOverall, our findings show that in Myanmar, the incidence of catastrophic health care expenditure was lower in 2015 compared to that in 2013, although the percent contribution of OOPPs to the total health expenditure was higher in 2015 (74%) than in 2013 (64%) . The issOur study also found that the mean OOPPs expenditure per capita per day in 2015 was nearly double that observed in 2013. There was 1.2 times inflation of the exchange rate between the two studied years, but alone this trend does not explain the increase in mean OOPPs. Rather, this may have been due to increases in health care costs other than inflation since mean OOPPs expenditures increased in USD value at this time as well. Alternatively, it could be due to increased household wealth. In addition, country level data show that OOPPs per capita was increased from 15 USD in 2013 to 44 USD in 2015,although the percent contribution of OOPPs to total health expenditures decreased [Analyses of the distribution of catastrophic health care expenditures across income quintiles found that the share of catastrophic expenditures among the poorest households decreased with increasing thresholds in both studied years. Moreover, the share of catastrophic expenditures in the poorest quintile was at the lowest across all income quintiles at the 40% threshold using the WHO standard approach. This finding was similar to that reported in a study conducted in China and another study conducted in 8 countries . However, it differs from trends observed in Thailand, where the share of catastrophic OOPPs did not vary by income quintile , 23. In We found that pharmaceutical costs are the highest spending area for both the poorest and the richest quintile using the WHO standard approach and across all income quintiles using on the WHO modified approach. This finding is consistent with a study of eight countries in the WHO South-East Asia Region, which found that the proportion of total OOPPs attributable to pharmaceutical costs is 34.05–81.89% . One stuSociodemographic factors associated with catastrophic expenditures include: geographic location; gender and education of household head; household size, number of children under 5 years old and disabled persons in the household; and total household income. These findings are consistent with a study conducted in China showing that female-headed households, those with low education, and households with elderly or chronically ill family members are more likely to experience catastrophic health expenditures . SimilarWe found that the incidence of catastrophic expenditures varied by the approach used to estimate expenditures. These variations emphasize the importance of being consistent in catastrophic health care expenditure analyses. Specifically, our study applied two different approaches, which yielded considerably different incidence rates. The standard WHO approach controls for negative results in calculating capacity to pay. Therefore, it produces a lower incidence of catastrophic expenditures than the modified WHO approach. However, the standard WHO approach better reflects the real-world situation because it uses the actual food-spending costs if the representing household basic needs spending is greater than the actual food spending. The choice of the threshold in a catastrophic expenditure study is also important. As shown by our results, the lower threshold level of 20% of capacity to pay captures up to three times more catastrophic expenditure cases than those captured at the 40% threshold level. There are also other approaches for estimating catastrophic health care expenditures. For example, the WHO European regional office considers not only food but also rent and utilities spending as a basic need . HoweverOur study has some limitations. First, data were only available for the LIFT intervention area for two rounds of the LIFT survey, which means that these are subnational data and also that they cannot be used to study trends. Therefore, the results are not nationally representative and can not be used for causal inferences. Second, no information about the insurance or social protection status of the studied population was available, which could have been an important explanatory variables as suggested in other studies , 30, 31.Our study findings provide a base for key policy conclusions as the magnitude of the catastrophic health expenditure is an indicator of the effectiveness of the current health financing arrangements. Although the level of catastrophic health care expenditure varies depending on the approach and threshold used, the problem of catastrophic expenditures in Myanmar cannot be denied. The government of Myanmar needs to scale up the current SSS or establish a new financial protection mechanism for the population. Vulnerable groups, such as households with a low educated household head, households with children under the age of 5 years or disabled persons, and low-income households should be a priority in the improvement of access to essential health care. The incidence of catastrophic expenditures that we captured in our study, might only be the tip of the iceberg as our data only represent subnational trends. Additionally, the uneven distribution of catastrophic expenditures across wealth quintiles may also show another major problem: individuals not seeking needed care because of OOPPs. This problem is not visible in catastrophic health care expenditure research and requires a separate investigation.Additional file 1:Calculation of catastrophic health expenditure. (DOCX 23 kb)


Concrete made from ordinary Portland cement is one of the most widely used construction materials due to its excellent compressive strength. However, concrete lacks ductility resulting in low tensile strength and flexural strength, and poor resistance to crack formation. Studies have demonstrated that the addition of graphene oxide (GO) nanosheet can effectively enhance the compressive and flexural properties of ordinary Portland cement paste, confirming GO nanosheet as an excellent candidate for using as nano-reinforcement in cement-based composites. To date, the majority of studies have focused on cement pastes and mortars. Only limited investigations into concretes incorporating GO nanosheets have been reported. This paper presents an experimental investigation on the slump and physical properties of concrete reinforced with GO nanosheets at additions from 0.00% to 0.08% by weight of cement and a water–cement ratio of 0.5. The study demonstrates that the addition of GO nanosheets improves the compressive strength, flexural strength, and split tensile strength of concrete, whereas the slump of concrete decreases with increasing GO nanosheet content. The results also demonstrate that 0.03% by weight of cement is the optimum value of GO nanosheet dosage for improving the split tensile strength of concrete. Concrete made from ordinary Portland cement is one of the most widely used construction materials . As a stOrdinary Portland cement is the principal binder holding sand and coarse gravels or crushed rocks together to produce concrete when water is added to initiate the hydration. It is reported that the global production of cement has exceeded 3600 million tonnes annually with more than 55% from China since 2011 . The cemAdvancements in nanotechnology can generate opportunities to improve the properties and performance of cement by incorporating nanomaterials . StudiesIn this study, the effects of GO nanosheets on the slump and physical properties of concrete are experimentally investigated. The GO nanosheet content is at additions of 0.00%, 0.02%, 0.03%, 0.04%, 0.06%, and 0.08% by weight of cement under a water–cement ratio of 0.5. The evaluated physical properties of concrete include the compressive strength, flexural strength, and split tensile strength. Additionally, the optimum value of GO nanosheet dosage for improving the split tensile strength of concrete is also discussed.Ordinary Portland cement (OPC) type 42.5R was used for all the concrete mixes, and its chemical composition is shown in 3, which included the mixing water, GO nanosheet water dispersion solution, and PCs solution.Six concrete mixes were prepared. The concrete mix proportions are shown in Both the fine aggregate (FA) and coarse aggregate (CA) were air dried in the laboratory environment. Cement was first mixed with the fine aggregate in a twin shaft concrete mixer for two minutes, and then the coarse aggregate was added before mixing for a further two and a half minutes at moderate speed. The potable mix water was pre-mixed in a separate vessel with the PCs solution and mechanically stirred for one and half minutes using a hand-mixer, which was followed by adding the GO nanosheet water dispersion solution and further stirring for another one and half minutes at a moderate speed. The pre-mixed solution was added to the dry mixed cement and aggregates and then mixed for two and a half minutes at moderate speed. The freshly mixed concrete was poured into pre-oiled molds and compacted on an electric concrete vibration table after which the specimens were covered with a polyethylene sheet and cured in the laboratory for twenty-four hours. Finally, the specimens were demolded and cured at a relative humidity greater than 95% and a temperature of 21 ± 2 °C until tested.The compressive strength, flexural strength, and split tensile strength of specimens were measured on day 7, day 14, and day 28. The concrete specimens were tested in accordance with the GB/T50081-2002, Standard for Test Method of Mechanical Properties on Ordinary Concrete . The speThe results obtained from the slump test are shown in The results of the compressive strength tests for concrete specimens with ages of 7, 14, and 28 days under the different GO contents are shown graphically in The trend in the compressive strength of the concrete specimens with age is shown in The flexural strength results of the concrete specimens at 7, 14, and 28 days under the different GO contents are shown graphically in It is widely accepted that the compressive and flexural strengths of concrete are related. Various empirical relationships for predicting the flexural strength have been proposed, such as the European  and Chinr2 = 0.9345 was developed:cf is the compressive strength at 28 days and ff is the flexural strength at 28 days. It should be noted that this relationship may be subject to update when more data become available.Empirical models for predicting the flexural strength of concrete containing GO nanosheets based on its compressive strength have not been reported in previous studies. Building on the experimental data of the flexural and compressive strengths listed in The split tensile strength results for the concrete specimens at 7, 14, and 28 days are shown in (1)The slump of concrete containing GO nanosheets decreases with the addition of GO nanosheets from 0.02% to 0.80% by weight of cement under a water to cement ratio of 0.5. However, the workability of concrete is affected by both the additive and the GNPs. Therefore, further study is needed to better understand the influence of GO nanosheets on the workability of concrete.(2)The compressive strength of the concrete is enhanced by an increase at the level of GO nanosheets from 0.02% to 0.08% for the water–cement ratio of 0.5. It may be associated with many factors, such as the promotion of the hydration process, the “bridging effect” of GO nanosheets for microcracks, etc. This will be subjected to further examination by SEM.(3)The addition of GO nanosheets improves the flexural strength of concrete in a range from 2.77% to 15.60% at 28 days when the content of GO nanosheets increases from 0.02% to 0.08%. However, the rate of increase in the flexural strength is generally less than that of the compressive strength.(4)The split tensile strength of the specimens with a water–cement ratio of 0.5 generally increases with increasing GO nanosheets content. The results also indicate that 0.03% is the optimum value of GO nanosheet dosage for improving the split tensile strength of the concrete specimens with a water–cement ratio of 0.5.The present study has led to the following conclusions:


As we seek to prepare the next generation of researchers, teachers, and service providers in the field of aging, it is vital that students garner experience interacting directly and appropriately with older adults. Community engagement and service-learning (CE/SL) are high impact pedagogical practices associated with enhanced learning, retention, and student success and can facilitate positive interactions across generations. Creating CE/SL opportunities requires authentic relationships with community members and organizations, allowing faculty, staff, and students the opportunity to network with a variety of individuals and agencies. In this presentation, we define CE/SL, examine the role of networks in creating CE/SL opportunities, and discuss challenges and threats to effective CE/SL projects. Tools and resources will be highlighted to provide guidance to those wishing to harness the power of networks to teach gerontology content while also working to have positive, lasting, and measurable impact on the communities in which they serve.


The Caregiver Reaction Scale (CRS) is a comprehensive measure of the family caregiving experience that assesses burden, family strains and positive aspects of caregiving (PAC). The CRS has been validated in sample of older adult help-seeking caregivers, but its validity and reliability in a non-help-seeking sample of caregivers was unknown. This study aimed to explore how well the CRS assesses the full caregiving experience in a younger non-help-seeking sample of family caregivers and to further evaluate the validity of the PAC subscales. A sample of non-help-seeking caregivers  completed online questionnaires of burden, positive aspects of caregiving, and psychological well-being. All subscales of the CRS demonstrated very good internal consistency reliability (α ≤ .88). The PAC subscales of the CRS demonstrated medium to large positive correlations with a measure of positive aspects of caregiving (r ≥ .44) and small to medium positive correlations with psychological well-being (.25 ≥ r ≤ .42). Burden subscales of the CRS had large positive correlations with another measure of burden (r ≥ .66). Medium positive correlations were also found between family and job conflict subscales of the CRS and the burden measure (r ≥ .35). CRS PAC subscales were negatively correlated with the burden measure (r ≤ -.13). The CRS is a valid and reliable measure of the caregiving experience as evidenced by convergent and discriminant validity of CRS subscales and well validated measures of burden and positive aspects of caregiving.