Respondents were asked whether they thought antibiotics were effective for ILI and about their antibiotic use. Proportions and 95% confidence intervals (CI) were calculated for each question and interactions with respondent characteristics were tested using logistic regression. Over the three surveys, the proportion of respondents who believed antibiotics would “definitely/probably” help an ILI fell from 37% (95% CI 35–39%) to 28% (95% CI 26–29%). Those who would “definitely/probably” visit a doctor in this situation fell from 48% (95% CI 46–50%) to 36% (95% CI 34–37%), while those who would request antibiotics during a consultation fell from 39% (95% CI 37–41%) to 30% (95% CI 29–32%). The percentage of respondents who found the information we provided about AMR “new/surprising” fell from 34% (95% CI 32–36%) to 28% (95% CI 26–31%). Awareness improved more among black, Asian and minority ethnic (BAME) than white people, with little other evidence of differences in improvements between subgroups. Whilst a degree of selection bias is unavoidable in online survey samples, the results suggest that awareness of AMR and appropriate antibiotic use has recently significantly improved in the United Kingdom, according to a wide range of indicators.Influenza-like illnesses (ILI) account for a significant portion of inappropriate antibiotic use. Patient expectations for antibiotics for ILI are likely to play a substantial role in ‘unnecessary’ antibiotic consumption. This study aimed to investigate trends in awareness of appropriate antibiotic use and antimicrobial resistance (AMR). Three sequential online surveys of independent representative samples of adults in the United Kingdom investigated expectations for, and consumption of, antibiotics for ILI (May/June 2015 ( Antibiotic use is a key driver of antibiotic resistance ,2. In EnPrior to the timeframe for our study (May 2015–March 2017), a large proportion of the United Kingdom (UK) population believed that antibiotics were effective for ILI, about one third saying they would expect their GP to prescribe antibiotics . Using tThree web-based surveys were conducted in which members of the general public were asked questions about antibiotics and AMR ,14. The The 1st survey , conductHere we focused on 9 key questions and corresponding variables that were common to all 3 surveys and thus permitted analyses of trends over time in awareness of AMR and attitudes towards the use of antibiotics for ILIs.The surveys see  asked reA temperature,Aching muscles,A headache,A dry chesty cough,A sore throat,And you feel weakHealth state A was described symptomatically because individuals are likely to interpret terms like “flu” or “virus” differently. Moreover, some respondents may know that antibiotics are not required for viral conditions but not realise that these symptoms are more consistent with a viral infection. Respondents were asked how they would respond in the hypothetical situation of having experienced Health State A for 5 days. They were asked whether they thought they would go to see a GP about these symptoms. Except for those who said, ‘Definitely not’, respondents were then asked whether if they did see a GP, they thought they would ask for antibiotics. Respondents were also asked whether they thought antibiotics would be likely to help these symptoms and whether they had taken antibiotics for similar symptoms in the last 12 months. Participants with dependent children then answered analogous questions regarding their youngest child being ill with ILI symptoms, consulting a GP and requesting antibiotics. To assess AMR-awareness, respondents were given the information in Together, the questions provided 9 indicators of awareness of AMR and attitudes towards antibiotic use for ILI . The surBox 1Information wording in Survey 1“Antibiotic resistance occurs when an antibiotic loses its ability to effectively control or kill growing bacteria. It is an increasingly serious threat to public health. Without effective antibiotics, many routine treatments will become increasingly dangerous. Setting broken bones, and even basic operations, rely on access to antibiotics that work. Antibiotic resistance is believed to be caused by unnecessary use of antibiotics, and inappropriate use, such as not taking them as prescribed, skipping doses, or saving them for later use.”  Information wording in Surveys 2 and 3“Antibiotic resistance happens when an antibiotic no longer kills or controls growing bacteria. It is an increasingly serious threat to public health. Without antibiotics that work well, many routine treatments will become increasingly dangerous. Setting broken bones, and even basic operations, rely on access to antibiotics that work. Antibiotic resistance is believed to be caused by unnecessary use of antibiotics, and inappropriate use, such as not taking them as prescribed, skipping doses, or saving them for later use.”  NOTE: The wording in Surveys 2 and 3 was intended to have exactly the same meaning as that in Survey 1. Minor changes in wording were made to the first and third sentences to make them easier to read and understand.Box 2All Respondents“At this point [5 days of ILI symptoms], do you think you would go to see a GP about these symptoms?” [Definitely/Probably/Probably not/Definitely not/Don’t know]  “If you went to see a GP about these symptoms, do you think you would ask for antibiotics?” [Definitely/Probably/Probably not/Definitely not/Don’t know]  “Do you think antibiotics would be likely to help these symptoms?”  [Definitely/Probably/Probably not/Definitely not/Don’t know]  “To the best of your knowledge, have you taken antibiotics for symptoms similar to these in the last 12 months?” [Yes/No]  “To what extent is this information Text in  new . For the first survey, SSI was commissioned to obtain a sample of at least 2000 completed responses, representative of adult members of the general public in terms of gender, age, ethnicity and geographic region. For the second and third surveys, SSI was commissioned to obtain samples of 4000 completed responses, again representative of the UK-resident adult members of the general public (the larger sample sizes needed to support a randomized experiment with three arms reported elsewhere ). In totRespondents were offered a small incentive to complete the surveys in the form of ‘Nectar points’ , worth a total of approximately £0·60.Chi-squared tests were used to test whether the 9 indicators of AMR-awareness and attitudes towards antibiotics were the same in Survey 1 (May–June 2015) and Survey 3 (March 2017). Indicators were also reported for Survey 2 (Oct–Nov 2016) for full disclosure, but we did not test for differences between Surveys 1 and 2 or Surveys 2 and 3. This was because attitudes may be different before (Survey 2) and after (Surveys 1 and 3) the seasonal peak in ILI incidence . Confidep-values of the interaction terms were plotted for each regression model. All statistical analyses were done using R version 3.5.1. To explore whether awareness/attitudes improved more/less in certain subgroups, we used logistic regression models that allowed for interaction terms between time and respondent characteristics. Because the surveys were not equally spaced in time, and, as above, because attitudes may be different before and after the seasonal peak in ILI incidence , we onlySurvey 1 was completed by 2064 respondents. Surveys 2 and 3 were each completed by 4000 respondents . Awareness of AMR and appropriate antibiotic use improved over time . While 4In total, 37% of respondents from Survey 1 thought that antibiotics would help if they experienced ILI, and 53% thought antibiotics would be effective for their child with ILI. By Survey 3, these figures had decreased to 28% and 43%, respectively. The percentage of respondents who indicated that the AMR information  was new/The percentage of respondents who had used antibiotics for ILI in the 12 months before the survey also declined over time, from 21% in Survey 1 to 14% in Survey 3. Although past antibiotic use for ILI was higher in children across the surveys, a similar decline in use was observed between Surveys 1 and 3 from 25% to 20%. p < 0.05 for interaction with time) for multiple indicators that improvement in awareness differed by subgroup was ethnicity. Awareness improved more among BAMEs than whites for the following three indicators: (1) Going to GP with child with ILI, (2) asking for antibiotics when going to GP with ILI, and (3) finding the AMR information that was provided new/surprising. Effectively, awareness among BAMEs and whites became more similar over time for these indicators. For most indicators, there was little evidence of subgroups for which awareness improved less than for others . The onlThe findings from these surveys suggest that awareness of AMR and appropriate antibiotic use have improved over time. In the most recent survey, respondents were substantially more likely to be aware of AMR and appropriate antibiotic use. Moreover, the number of adults, and their children, who had taken antibiotics for ILI in the previous 12 months declined. Just as diseases often cluster within certain populations according to sociodemographic factors , so too Encouragingly, in this study, we found generally little evidence that the observed trends in improving awareness were restricted to or were weaker in any particular population subgroups. The exception was ethnicity, where some AMR and appropriate antibiotic use awareness indicators improved more among BAMEs. However, this is also encouraging as the indicators in Survey 1 suggest that awareness of AMR and appropriate antibiotic use was initially poorer among BAMEs than whites . NeverthA key limitation of this study is that only members of the online survey panels participated. A degree of selection bias is unavoidable in online survey samples as persons with no interest in completing surveys, no internet-access or no basic computer literacy cannot be included. Nevertheless, the panels were broadly representative of the general UK population in terms of age, gender, ethnicity, region and unemployment, though, as is common in online surveys, the percentage with higher education was relatively high . Respondents’ answers may not reflect what they will actually do in practice. However, it seems likely that the observed changes in expectations and attitudes are likely to support desirable consultation behaviour in future.The surveys were not explicitly designed to investigate changes in attitudes over time and there was limited scope to include further questions that might have helped with interpreting the results. For example, additional questions might have sought to ascertain awareness of media campaigns or news about AMR around the time the surveys were in the field. The three surveys were conducted during a period in which the need to tackle AMR was gaining increasing prominence in the UK. In particular, the Review on Antimicrobial Resistance, commissioned by the UK government in July 2014, produced an initial report  in DecemThe three surveys differed with respect to their timing in relation to the seasonal peak in ILI incidence. Moreover, the severity of the influenza seasons during the study period also varied . AttitudThe setting for this study was the UK, and a further limitation is that trends in awareness of appropriate antibiotic use are likely to vary across countries. For example, a meta-analysis of cross-sectional studies published during 2000 to 2013, stratified by continents, found that an inappropriate answer to the statement “Antibiotics are useful for cold and flu,” was given by 69.0% of respondents in Oceania but only 28.0% in Europe .During the study period, antibiotic prescribing in primary care in England declined by approximately 8% between the respective second quarters of 2015 and 2017 . This deWhile changes in attitudes may lead to fewer antibiotics being prescribed, reducing antibiotic prescribing has also been shown to reduce GP consultation rates for both upper and lower RTIs ,37. ThisPublic perceptions of AMR and appropriate use of antibiotics in primary care have been surveyed in previous studies ,38,39,40Although we found an improvement in awareness of AMR and appropriate antibiotic use, there remains a substantial proportion of the UK general population who think that antibiotics would help ILI symptoms, and who would ask their GP for antibiotics in a consultation. There is an urgent need for further research that evaluates how such beliefs might be successfully challenged, for example, in public health campaigns. One promising avenue shown to have the potential for improving the indicators in our surveys is to provide people with fear-based messages about AMR together with empowering information on how to effectively self-manage symptoms without antibiotics .


Determining whether antibiotic prescriptions are inappropriate requires knowledge of patients’ underlying conditions. In low-income and middle-income countries (LMICs), where misdiagnoses are frequent, this is challenging. Additionally, such details are often unavailable for prescription audits. Recent studies using standardised patients (SPs) offer a unique opportunity to generate unbiased prevalence estimates of antibiotic overuse, as the research design involves patients with predefined conditions.Secondary analyses of data from nine SP studies were performed to estimate the proportion of SP–provider interactions resulting in inappropriate antibiotic prescribing across primary care settings in three LMICs . In all studies, SPs portrayed conditions for which antibiotics are unnecessary , angina and asthma). We conducted descriptive analyses reporting overall prevalence of antibiotic overprescribing by healthcare sector, location, provider qualification and case. The WHO Access–Watch–Reserve framework was used to categorise antibiotics based on their potential for selecting resistance. As richer data were available from India, we examined factors associated with antibiotic overuse in that country through hierarchical Poisson models.Across health facilities, antibiotics were given inappropriately in 2392/4798  interactions in India, 83/166  in Kenya and 259/899  in China. Prevalence ratios of antibiotic overuse in India were significantly lower in urban versus rural areas  0.70, 95% CI 0.52 to 0.96) and higher for qualified versus non-qualified providers , and for presumptive TB cases versus other conditions . Access antibiotics were predominantly used in Kenya (85%), but Watch antibiotics  were highly prescribed in India (47.6%) and China (32.9%).Good-quality SP data indicate alarmingly high levels of antibiotic overprescription for key conditions across primary care settings in India, China and Kenya, with broad-spectrum agents being excessively used in India and China. A recent systematic review and meta-analysis showed that, across 48 studies from 27 low-income and middle-income countries including China, India and Kenya, approximately half of all patients evaluated in outpatient primary care received an antibiotic prescription.Methods used to assess inappropriateness of antibiotic prescription, such as prescription audits, medical records and patient exit interviews, have multiple limitations.Standardised patients (SPs) offer a unique opportunity to explore prescribing practices and accurately estimate overprescription because case presentations are fixed by design, thus allowing comparisons across settings and providers.In this secondary analysis of data from nine SP studies carried out in India, Kenya and China, we provide a more unbiased prevalence estimate of antibiotic overprescription for selected clinical conditions ) across a range of primary healthcare providers.About 30% of SP–provider interactions in China and 50% of those performed in India and Kenya resulted in inappropriate antibiotic prescription.Watch antibiotics  were very commonly prescribed in India (about 50%) and China (over 32%), and some patients (0.8%) even received last-resort antibiotics belonging to the ‘Reserve’ group.In India, the average prevalence of antibiotic prescribing was 30% lower in urban versus rural areas, 55% higher among qualified providers compared with non-qualified ones and 19% higher for patients presenting with presumptive TB versus other conditions.Our findings indicate alarming levels of antibiotic overprescription for conditions that are frequently encountered in primary care, potentially leading to toxic effects and diagnostic delays.The choice of antibiotics given to patients is concerning, as several agents with high potential for resistance selection are often inappropriately prescribed.The SP methodology could prove useful to further investigate antibiotic prescribing practices and its underlying determinants, using other case presentations across a range of different contexts.Antibiotic stewardship is critical for tackling antimicrobial resistance (AMR), especially in the context of the ongoing COVID-19 pandemic.However, determining inappropriate prescription in LMICs is a challenge, and a standardised tool for its assessment is currently unavailable. Inappropriate antibiotic prescribing can derive from a range of failings: (1) prescription in the absence of clinical indication , which not only produces zero benefit to the patient but can also be harmful ; (2) failure to prescribe antibiotics when necessary ; (3) suboptimal antibiotic choice with respect to aetiology (confirmed or presumptive), site, severity of infection and patient characteristics ; (4) prescription of wrong dosage and/or duration of antibiotic treatment as compared with national and international guidelines.Methods used to assess inappropriateness, such as prescription audits, medical records and patient exit interviews, have multiple limitations.A less biased method is the use of standardised patients (SPs), also known as ‘simulated’ or ‘mystery’ patients, that is, healthy individuals recruited from local communities and extensively trained to portray a standardised clinical condition to a healthcare provider.Considering the aforementioned advantages, we performed a secondary analysis of prescription data from previously conducted SP studies in three LMICs  with two objectives: (1) to estimate the overall proportion of SP–provider interactions  that resulted in prescription or dispensing of at least one antibiotic in the absence of clinical indication  and (2) to identify factors associated with antibiotic overprescribing in health facilities.Data on SP–provider interactions  from studies conducted by members of our team (India and Kenya) or had used SP cases developed by our team or obtained from publicly accessible sources (China) were gathered to compile a pooled dataset for secondary analyses.Among studies carried out in India, four involved primary health facilities across five sites ,Information regarding medications prescribed by healthcare providers were collected in these published SP studies but were not analysed in depth, especially with regard to inappropriate use. This is because, in most instances, the primary publications focused on overall quality of care, rather than the specific components of care.Sampling approaches adopted in each primary study from which our data were drawn are summarised in Tracer conditions  were defined similarly across SP studies, thus allowing comparisons across settings. Cases ranged from presumptive or confirmed tuberculosis (TB) (which requires specific anti-TB treatment as per WHO recommendations) to self-limiting infections, such as watery diarrhoea or upper respiratory tract illness , to non-communicable diseases like asthma or chest pain indicative of angina (these should be referred to a higher level of care). Importantly, none of such conditions requires antibiotics, which means that any antibiotic prescribed to SPs is deemed inappropriate by indication .Raw data from original studies were harmonised and recoded as needed. We used the available information on medications that were prescribed or dispensed during each SP–provider interaction to categorise individual drugs. Antibacterial agents were further classified using both the ATC  Index and the WHO Access–Watch–Reserve (AWaRe) framework.The primary outcome measure was expressed as the proportion of SP–provider interactions that resulted in antibiotic prescription or dispensing. Secondary outcomes were proportions of specific groups of antibiotics that were prescribed or dispensed both overall and across strata of key variables of interest. These proportions provide a direct measure of antibiotic overuse.For studies carried out in health facilities, we conducted country-level descriptive analyses and reported the crude proportion of SP–provider interactions that resulted in antibiotic prescription or dispensing. The overall proportion of prescribed or dispensed antibiotics, along with ATC-class and AWaRe group-specific proportions, was calculated across strata defined by key variables of interest, such as healthcare sector (public/private), facility location , provider qualification  and tracer conditions. For all prevalence proportions, we computed 95% CIs using bootstrapping in order to account for clustering at the study level.In order to examine the factors associated with antibiotic prescribing in health facilities in India, we fit a hierarchical Poisson regression model that allows direct estimation of adjusted prevalence ratios (aPRs) even if the outcome is common as in this case. Our model included a random intercept for studies and dummy variables for facility location, healthcare sector, provider qualification and tracer conditions as predictors.10.1136/bmjgh-2020-003393.supp1Supplementary dataData from pharmacies were not pooled because contexts and tracer conditions were highly heterogeneous in the two available studies. Therefore, we only calculated prevalence proportions and 95% CIs of dispensed antibiotics, both overall and in stratified analyses.All analyses were performed using Stata 16.It was not possible to involve patients or the public in the design, conduct, reporting or dissemination plans of our research because this is a secondary analysis of previously conducted studies.The main features of SP studies that were included in our analyses are summarised in In India, 2392 of 4798  SP–provider interactions resulted in at least one antibiotic prescription . SimilarIn most instances, only one antibiotic was given during an individual SP–provider interaction; less than 5% of interactions across all settings resulted in two or more antibiotics prescriptions. Crude analyses of data from India indicate that antibiotic overprescription was more common among healthcare providers in urban areas, among those working in the private sector and among qualified professionals. Furthermore, antibiotics were largely overprescribed to patients presenting with a diverse range of clinical conditions in all countries . In IndiAcross studies performed in India, 2768 antibiotics were given to 2392 patients. The top 10 most prescribed antibiotics across SP–provider interactions in India were azithromycin , amoxicillin+beta-lactamase inhibitor , amoxicillin , levofloxacin , cefixime , ofloxacin , ofloxacin+ornidazole , norfloxacin+tinidazole , ciprofloxacin  and cefpodoxime . Broad-spectrum agents with higher potential for selecting resistance (Watch antibiotics) were disproportionately represented , and even more so in urban areas  . This reDiscouraged antibiotics, that is, FDCs other than antimycobacterial drugs (such as norfloxacin+tinidazole or ofloxacin+ornidazole) accounted for 12.1%, of which all but one were given for child diarrhoea. Anti-TB medications represented 8.3% of antibiotics in India; almost all of them were given by healthcare providers in urban areas; and none could be considered appropriate based on the expected correct management of such cases.About one-quarter of drugs prescribed in studies from China could not be categorised based on the AWaRe framework because only the drug class was reported. These were mainly cephalosporins, most likely second or higher generation, and therefore the overall proportion of Watch-group antibiotics is expected to be greater than 32.9% . UndefinSubgroup analyses of antibiotic prescription patterns among SP–provider interactions that took place in Nairobi were limited by the small sample size. However, 85.4% (76/89) of all antibiotics prescribed were first-line and narrow-spectrum agents from the ‘Access’ group, while the remaining belonged to the ‘Watch’ group.Prevalence ratios of antibiotic overuse and their 95% CIs estimated through mixed-effects Poisson regression analysis are reported in The hierarchical Poisson model did not show any significant difference between public and private providers, but this is in contrast with what emerged from alternative models as described in Our secondary analysis of data from two pharmacy-based SP studies showed that over-the-counter antibiotic dispensing is also a common problem in various parts of India .In Udupi district (Karnataka state) the proportion of SP—pharmacist interactions that resulted in antibiotic dispensing was 3.6% (95% CI: 2.6 to 4.6), with a similar pattern in both urban and rural areas. In contrast, at least one antibiotic was dispensed in 319/1,200 interactions performed across Delhi, Mumbai and Patna, corresponding to 26.6% (95% CI: 24.2 to 29.2) of the total. However, a direct comparison between these two studies is not possible owing to the very different contexts involved and particularly to the different types of cases that were examined. As observed in studies from healthcare facilities, subjects presenting to pharmacies with symptoms suggestive of TB were generally more likely to receive an antibiotic as compared with other conditions.The average proportion of Watch-antibiotics  dispensed across the three cities was 49.4% (95% CI: 43.9 to 54.4), ranging from 24.0% (95% CI: 15.0 to 32.0) in Mumbai to 60.9% (95% CI: 55.1 to 67.1) in Patna. A deeper evaluation of antibiotic dispensing in Udupi district is limited by the small sample size. Only 55 antibiotics were dispensed across 1522 interactions, thus making subgroup analyses less meaningful. Yet, it is worth highlighting that nearly half of these antibiotics were discouraged FDCs of two antibiotics, whereas the remaining were almost equally distributed among Access- and Watch-groups. More details regarding the types of antibiotics dispensed across pharmacies in both studies are presented in 10.1136/bmjgh-2020-003393.supp2Supplementary dataOur analysis of past SP studies involving 4798 SP–provider interactions in India showed that healthcare providers in primary care settings prescribed antibiotics to about half (49.9%) of patients presenting with clinical conditions that do not require antibiotics. Antibiotic overprescribing was found to be similar (50% of SP–provider interactions) in a small SP study carried out in Nairobi, Kenya. Pooled data from two studies conducted in China showed lower levels of antibiotic overuse (28.8%), but it should be noted that percentages differed substantially across individual studies, likely reflecting the different type of cases being involved. In fact, SP–provider interactions involving presumptive TB cases were more likely to result in antibiotic prescription as compared with other clinical conditions. Among the two pharmacy-based SP studies done in India,Although our focus was on LMICs, the overuse of antibiotics is not confined to LMICs. Large population-based cohort data have shown that antibiotic overuse in ambulatory settings across the United States was 30% among children and 17% among adults with certain respiratory tract illnesses for which antibiotics are not indicated .Nearly 50% of all antibiotics prescribed in the context of India SP studies belonged to the ‘Watch’ list, with a peak of 80% among patients presenting with symptoms suggestive of TB, which is consistent with national antibiotic sales.Discouraged FDCs of antibiotics were commonly given in India but not in other settings, accounting for 10.4% of the total. FDCs were finally banned in India in September 2018, thus leaving hope for a change in the near future.Alarmingly, we observed the use of some ‘Reserve’ antibiotics in primary care settings. In India, oral colistin was prescribed for paediatric diarrhoea, and faropenem was given to one patient with presumptive TB. This is very concerning as parenteral colistin is the last resort drug for treatment of extremely drug-resistant Gram-negative infections,According to our findings from India, antibiotic overuse was particularly common in rural areas, among qualified providers and for patients presenting with presumptive TB. Besides leading to potentially dangerous diagnostic delays,While normative boundaries may partly explain why qualified providers prescribed more antibiotics than non-qualified ones as observed in our analyses for India, the widespread overuse of antibiotics suggests that important training gaps likely exist. However, prescribing behaviours among healthcare providers also depend on a number of other factors, including financial incentives from pharmaceutical companies, patient expectations and requests, or just old habits that are hard to die.The biggest strength of our study lies in the nature and quality of the data used to investigate the extent and patterns of antibiotic overprescribing. Although previous research had already highlighted that Watch group antibiotics are highly prescribed across India and China, such studies could not provide a clear picture of inappropriate antibiotic use owing to the limited amount of clinical information available from prescription audits and evaluations of drug sales data.Furthermore, representative samples of healthcare providers from public and/or private sectors were selected in all SP studies conducted in India, with the only exception of one relatively small pilot study in Delhi. In this pooled dataset, private practitioners were much more represented than public providers, but we lacked statistical power to make appropriate comparisons between the two groups. Yet, this distribution well reflects the fact that about 75% of outpatient visits in India take place in the private sector, with nearly 70% of primary care in the country being delivered by informal providers.Of note, available data originated from a range of geographical areas with different sociocultural and economic profiles and could be generalisable to similar contexts in India. For all these reasons, the representativeness of our findings is very good, and selection bias is likely negligible due to the robust mapping and sampling approach used across all SP studies.There are limitations in our study. First, the SP study data from China and Kenya were limited and lacked generalisability. Second, our analyses were restricted to overprescription and to a limited number of clinical scenarios. Third, we could not investigate other important forms of inappropriate antibiotic use, such as the choice of the incorrect drug and dosage to treat a given infection. This is an intrinsic limitation that arises from the type of tracer conditions used across SP studies so far. Although the SP methodology was initially implemented to assess overall quality of care in LMICs and to evaluate educational/behavioural programmes in high-income countries, this approach is being increasingly adopted to gain insight into medication use, and especially drug dispensing practices among pharmacists. Data recording systems in SP studies are therefore improving in order to facilitate the collection of key details regarding medications that were harder to capture from studies whose main objective was not related to drug use.In conclusion, the prevalence of antibiotic overprescribing estimated from SP studies ranged from 29% in China to 50% in India and Kenya, and Watch antibiotics accounted for a large proportion of antibiotics prescribed in both India and China. Combining the SP methodology with new tracer conditions would allow overcoming many of the typical limitations of most studies aimed at evaluating inappropriate antibiotic use in greater detail. SPs represent a unique opportunity to further explore prescription practices among healthcare providers, including the management of common infectious diseases, such as pneumonia or urinary tract infections, that contribute substantially to the overall antibiotic use in primary care. Future studies also need to focus on untangling the channels for antibiotic overprescription and better understand the determinants of such practice among public and private healthcare providers in various contexts.The extent of antibiotic overuse in primary care across LMICs is a serious concern and requires targeted antimicrobial stewardship interventions aimed at improving rational and locally adapted prescribing practices. An active involvement of private providers in all such interventions would be essential to ensure uptake, particularly in countries where the private sector plays a major role in healthcare. Greater efforts are also necessary to develop and scale up accurate point-of-care tests that could guide therapeutic choices where resources are scarce. Additional research is also required to evaluate whether antibiotic use  will dramatically increase as a consequence of the COVID-19 pandemic, and concerns have already been raised about the implications for AMR.


The aim of the research presented in this paper is to evaluate the feasibility of using hydrophobic agents based on organosilicon compounds for surface protection of lightweight concrete modified with waste polystyrene. The experimental part pertains to the physical and mechanical properties of polystyrene-modified lightweight concrete. The concrete samples were prepared with the following ingredients: CEM I 42.5 R cement, recycled polystyrene (0–2 mm), quartz sand (0–2 mm), coarse river aggregate (2–16 mm), and water. Silane and tetramethoxysilane were employed for surface hydrophobization. Concrete with 20% polystyrene exhibits high porosity (25.22%), which is related to an increase in absorptivity (14.75%) compared to the reference concrete. The hydrophobized concrete is characterized by the lowest surface free energy (SFE) value, which is 7 or 11 times lower than the value of reference concrete, depending on the agents. The test on the contact angle (CA) was performed before and after the frost-resistance test (F–T test). Lower SFE translates into lower adhesive properties, higher resistance of the material to the infiltration of water and corrosive compounds, e.g., salts, and higher resistance to freezing and thawing cycles. Silane and tetramethoxysilane coating raised frost resistance by 54–58% compared to the reference samples. This agent reduced absorptivity by 30%. Recycled polystyrene can be successfully used to produce lightweight concrete (LC) with high durability provided by hydrophobic/icephobic coatings. Construction and demolition waste is rapidly increasing in developed countries. The low biodegradability of polymers, the base of numerous building materials, has triggered numerous economic and ecological problems. One of the EU’s priorities is reaching 50% recycling by 2025. Significant financial fees are threatened in the case of failure . RecentlIn comparison to the standard concrete, LC has very good characteristics, such as lower density and thermal conductivity and higher energy absorption due to the partial or total replacement of standard aggregates with lightweight coarse aggregates . The lig3 [Recycled polystyrene may be also used as aggregate in LC production. Expanded polystyrene (EPS), thermoplastic resin, is a type of artificial aggregate of density 10–30 kg/m3 , which m3 . Thus, iCompared to a very low density of polystyrene, the concrete mixture is prone to component segregation. There have been several studies that have focused on the elimination of this problem, including the addition of silica powder to improve adhesion between EPS aggregates and cement paste. Roy et al.  used supRecycled Styrofoam may partially solve this problem, due to its unique pitted, strongly rough, uneven structure, obtained during mechanical fragmentation, which may significantly increase the adhesion of concrete to Styrofoam. Additionally, Styrofoam shows good sorption characteristics and may accumulate enough ice and salt in its structure. However, porous Styrofoam in open structures may cause increased water absorptivity by concrete . MoreoveSurface hydrophobization is one of the protection methods for concrete against frost corrosion and salts dissolved in water ,26,27. OIt was showed that the hydrophobization of LC composites containing recycled polyurethane foam increased frost resistance by over 80%, compared to the reference samples . HoweverHydrophobization of concrete results in a shift of the ice crystallization zone into the depth of the material. Thus, the adhesion of coating to the concrete base ensures the efficiency of hydrophobization ,35. RegaThe negative effects of hydrophobization on the physico-mechanical characteristics of LC causes the need for further studies concerning this problem. In this paper, the problem of building material recycling, including Styrofoam, is considered. As a result, the application of Styrofoam aggregates in LC is proposed. To the best of our knowledge, there are no examples available in the literature of a hydrophobizing agent such as silane and a new-generation agent such as tetramethoxysilane being applied in LC with polystyrene aggregates from recycling. There are papers presenting the use of polystyrene in concrete, but not recycled polystyrene, which has a different, rough, and jagged structure. So far, we have been unable to find any paper reporting surface hydrophobization of such concretes. Therefore, this study focuses on the evaluation of the concrete with recycled polystyrene surface modification.This paper presents the physico-mechanical characteristics of lightweight concrete with the addition of recycled Styrofoam, and comparative analysis of the effect of hydrophobic/icephobic coatings based on organosilicon compounds (silane and tetramethoxysilane) on the properties of heat LC with polystyrene aggregates from recycling. The influence of hydrophobization agents on CA and frost resistance were tested particularly carefully. The values of the contact angle of concrete by the singular test liquid were determined before and after frost-resistance tests. Then, surface free energy (SFE), characterizing wetting and water adhesion to hydrophobic coatings under standard conditions and after cyclic exposure to low temperatures, was determined by the Neumann method. The structure of LC and the adhesion of cement paste to the polystyrene aggregates were presented with the application of the scanning electron microscope (SEM) technique. As a result, the hydrophobization efficiency of LC containing polystyrene is determined. ® WS 405; A2—Protectosil® WS 808. The manufacturer does not provide data on A1—water emulsion based on organofunctional silanes. Silane is an inorganic compound with chemical formula SiH4, making it a Group 14 hydride. Surface hydrophobization was carried out by applying the agent twice with a brush using the “wet-on-wet” method.The presented studies covered three concrete specimens: reference concrete without recycled polystyrene (LC0), concrete with 10% (LC10), and 20% (LC20) addition by volume of recycled polystyrene (EPS). The addition, which was used to partially replace the volume of sand according to its particle size distribution, was assessed as the waste aggregate of particle size 0–2 mm. All studied concrete samples underwent surface hydrophobization with two different agents: silane (A1) and tetramethoxysilane (A2). Both applied hydrophobizing agents were produced by CFI World S.A. 62-023 Robakowo, Poland, based on ingredients from Evonik Industries, Business Line Silanes, Rodenbacher Chaussee 4 63457 Hanau-Wolfgang, Germany. Trade names of used preparations are as follows: A1—ProtectosilThe properties of applied hydrophobizing agents are presented in 2 95.3%, Al2O3 1.9%, Fe2O3 0.7%, and CaO 0.35% [Natural washed quartz sand, 0–2 mm, of particle sizes compliant to applied waste aggregate (EPS), and natural gravel, 2–16 mm, was used in the concrete sample preparation. The main component of the applied waste aggregate (EPS) is polystyrene. The chemical composition of the quartz sand is SiOaO 0.35% . 3, while the bulk density of the EPS addition was definitely lower, i.e., 0.018 kg/dm3. Portland cement CEM I 42.5 R from a cement plant in Chełm, Poland (CEMEX Polska sp. z o.o.) was used in all the studied concrete samples. The cement producer also delivered detailed characteristics of the supplied cement. Chemical composition of the used cement clinker is presented in Natural gravel quartz from sandstone and minerals in gravel grains was derived from plutonic rocks—orthoclase and albite—minerals in the grains were derived from sedimentary rocks—calcite, dolomite, and illite. The bulk density of the used sand and gravel was the same, i.e., 2.65 kg/dm3 of concrete was assumed across all tested mixtures. The particle size distribution of the fine and coarse aggregates is shown in To compare influence of waste aggregate content on the properties of concrete, the same volume of fine aggregates in 1 mAll concrete mixtures used in this study had the same water/cement ratio, i.e., w/c = 0.40. The comparable consistency of all concrete samples was obtained due to the application of superplasticizer based on polycarboxylic ether. First, the dry components were mixed slowly in a mixer for 2 min. Then, slowly and gradually, water was added to the mixture to obtain accurate connection and to avoid segregation of the mixture components. The mixing continued for 5 min. The concrete mixture was compacted in molds on the vibration table with oscillations frequency 50 Hz to obtain full compaction, without excessive segregation and excretion of cement milk. The samples after demolding were cured in water of temperature 20 ± 5 °C. The performed concrete slump test for all concrete mixtures indicated 12 ± 2 cm, which reflects consistency class S3 . The comThe volumetric density of the tested concretes was determined according to EN 12390-7:2019 standard  on 6 cubThe compressive strength of tested specimens was determined on 6 cubic samples with edges 150 mm long according to EN 12390-3 . The fleThe mass absorptivity of water was determined on cubic samples of edge length 150 mm, according to PN-B-06250 . The conTo determine the frost resistance of the studied concretes, F–T tests were performed, according to PN-B-06250 , based o4)2HPO4. The samples were regularly weighted due to a loss of moisture until reaching a state of equilibrium. The experiment took 8–10 days, regarding water vapor permeability of the tested material.The water vapor permeability of the tested concrete samples was determined by the cup method according to EN ISO 7783:2012 . Cylindr3 were applied on the surface of each sample by pipette. SFE was determined by Neumann method [wθ—water contact angle (°), 2), and 2).The measurements of the contact angle, describing characteristics of liquid drop, were performed by goniometer  and camera for the precise photography of drops on the surface of concrete samples. All the studied concretes were included in the measurements, before and after frost-resistance tests. The measurements were conducted in distilled water, because of its high polarity, at a temperature of 22 ± 2 °C. Six drops of distilled water of volume approximately 2 mmn method ,18,35 usn method .(1)cosθResearch concerning the resistance of concrete against salt crystallization was conducted according the standard PN-EN:12370 . 14% solThe microstructure of the tested concretes was observed with a scanning electron microscope (SEM Quanta FEG 250 microscope by Field Electron and Ion (FEI), Hillsboro, OR, USA). The working distance was set as 10–13 mm. Next, to achieve conductivity on the surface of the samples, they were covered with a 45 nm layer of carbon. Such treatment excludes the possibility of micro-defects due to concrete surface and cracking. Low vacuum and low beam energy were applied during observations to avoid the possibility of other defects of the sample surface. The results of basic physical and strength tests of the considered LCs are presented in 3 for LC20 with 20% EPS content to 2250 kg/m3 for LC0. The volumetric porosity is 2 and 3.9 times greater after partial replacement of sand by EPS in the amount of 10 and 20% by volume, respectively. The above is reflected in the results of compressive and flexural tensile strength measurements for tested samples. According to the EPS content, the tested concrete samples showed different values of volumetric density, starting from 2080 kg/mfc,cube#150 after EPS addition decreased by 10.2% and 18.4% for LC10 and LC20, respectively. However, the flexural tensile strength fct,flex decreased by 13.5% for LC10 and by 32.3% for LC20. Cadere et al. [The compressive strength e et al.  noticed e et al. . Research by Ranjbar and Mousavi  showed tfc,cube#150 and flexural tensile strength fct,flex as well as the correlation between compressive strength and total porosity are shown in The correlation between the compressive strength 2 − 0.004x − 24.01. Values of both analyzed strength characteristics decrease with the increase in EPS content in concrete. On the other hand, the opposite relationship was observed between compressive strength of concrete and its total porosity: the higher porosity, the lower compressive strength. In this case, a very strong correlation  was observed. As can be observed in nw by weight values after 1, 7, and 14 days of testing. As can be noted, the applied surface hydrophobization clearly reduced concrete absorptivity. The best results of absorptivity reduction were obtained for concretes LC0-A1 and LC0-A2. After the first day of testing, absorptivity decreased by 11 times and after 14 days by 2.6 times, compared to the standard LC0 samples. The highest value of determined absorptivity was noted for LC20 concrete, containing a greater amount of EPS, also after hydrophobization. The absorptivity of LC20-A1 is 5 times, and of LC20-A2 is 6 times higher than for the hydrophobized standard concrete samples LC0-A1 and LC0-A2. Higher hydrophobization efficiency for all tested series of concrete was obtained due application of A2, a macromolecular tetramethoxysilane compound. This formulation probably created an impervious coating on the surface of the concrete. The efficiency of the hydrophobization process is mainly dependent on the porosity of the concrete. Along with the increase in porosity, the absorptivity of LC increases, and hydrophobization becomes more effective because the applied agent may penetrate the structure of the concrete. As presented by Błaszczyński et al. , efficieWater absorption is strongly related to the water vapor permeability of LC, which is greatest for the LC20 samples. The results of measurements of the LC water vapor permeability, before and after hydrophobization, are presented in The structure of the tested concrete samples was slightly sealed during the applied hydrophobization process. The diffusion of water vapor was most strongly distorted by tetramethoxysilane (A2). In the cases of LC10-A2 and LC20-A2, the water vapor permeability is twice as low as that for the standard concrete samples. The above is related to the size of the resin particles, which sealed the fine surface pores of concrete. Sabatini et al.  reportedThe strongly sealed coating, significantly reducing the water vapor permeability of concrete, may trigger damage in the material structure, mainly due to salt and ice crystallization ,32,35. TThe other characteristic related to water absorption and water vapor permeability is the water CA. The values of CA measured using a goniometer before and after the F–T cycles are shown in The results of the tests presented in The clear decrease in determined values of water CA was visible after F–T tests indicated reduced efficiency of hydrophobization under the influence of frost. The decrease in CA was in the range 23–23% for LC0-A2 and LC10-A2, respectively. In the case of the reference concrete L0, the applied coating kept its hydrophobic properties, and the determined CAs values were equal to 103° and 110° for A1 and A2, respectively. All the tested concrete samples containing EPS lost their hydrophobic properties. Thus, in practice, highly absorptive concrete surfaces should be cyclically hydrophobized each year or every few years as needed, just as in the case of the analyzed LC10 and LC20. Najduchowska and Pichniarczyk  proved iThe SFE is a key factor in the assessment of the physico-chemical properties of a solid’s surface. The surface may present a dispersive (dispersive component) or polar (polar component) character. According to characteristics of the impregnating agents, it is possible to increase or decrease the SFE, and therefore the surface tension of the materials causing their non-wettability, which is related to resistance to chemical corrosion and frost. The greatest decrease in SFE may be caused by coatings with the highest degree of hydrophobization of the surface ,28,35. T2 for LC0, LC10, and LC15, respectively, before frost-resistance tests, and 17.11, 29.87, and 38.56 mJ/m2 after frost-resistance tests). In the case of LC0-A2 the determined value of SFE is 92% lower than for LC0-S. After frost-resistance tests, all values of SFE increased, which was related to the decrease in measured CA , which, after hydrophobization, dropped to 15.1 mJ/m2. The highest decrease in SFE, 70%, was observed for mortar containing 10% waste polyurethane foam, PVC, and wood chips after hydrophobization by a nanopolymer-based agent. Król et al. [2, while in the studies performed by Barnat-Hunek et al. [2 were obtained for polysiloxane coatings. An increase in SFE values after frost-resistance tests was observed, which indicates a decrease in hydrophobization efficiency and damage to the hydrophobic coatings. The lowest values of SFE tested in  charactel et al.  used silk et al.  a value The determined values of SFE increased by 73%, 77% 64%, and 87% for LC0-A2, LC10-A2, LC10-A1, and reference concrete LC0, respectively. Crystallization of ice under the hydrophobic coating caused damage in its continuity, which leads to greater wettability (affected CA and SFE). The similar observations were reported by  after te2SO4 is presented in To assess the durability of hydrophobized concrete samples containing EPS, the research concerning the negative influence on tested concrete of frost and salts dissolved in water was performed. The determined decrease in mass of concrete samples after 50 F–T cycles is presented in The determined results of the frost resistance of the tested concrete samples allowed the determination of the relationship between mass loss and the other characteristics of concrete. The susceptibility of LC to damages caused by F–T cycles is related to concrete composition, its porosity, and, primarily, the type of applied hydrophobizing agent. The EPS content, decreasing sealing, and frost resistance seems to have a significant influence. The freezing water increasing its volume tends to fill the empty pores of concrete. According to Fagerlund , this prAs predicted, significant damage in the EPS concrete structure was observed. The frost resistance of LC10 and LC20 after 50 cycles of F–T decreased by 18 and 25 times, respectively. Similar observations were reported by Barnat-Hunek et al.  after teA significant improvement was obtained after application of A1 and A2 coatings on all the tested concrete types. The studies showed that surface hydrophobization significantly slows the creation of damage, microcracks etc. and protects the concrete against destruction during F–T cycles see a. The teThe best frost resistance was determined by  for a na2SO4 × 10H2O and Na2SO4 × 7H2O). Damage is usually caused by direct mirabilite crystallization or by the dissolving of heptahydrate [The other factor influencing the strength and durability of concrete is resistance to aggressive ion penetration ,59. Sodiahydrate .Scherer  and MancHydrophobization of the LC surface was unable to protect the samples from salt outgrowth, which can be observed from visible white coating on the sample surfaces d,f. The Studies performed by Szafraniec et al.  showed tMorphologic (SEM) observations of selected LC samples were performed to show their structure, ITZ between EPS and cement paste, and the possible cracks. SEM research by Ranjbar and Mousavi  showed lThe calcium silicate hydrate C–S–H phase, of different forms , is a veThe very good distribution of hydrophobic coatings inside the concrete structure was observed in SEM pictures see . ParticlSimilar differences in particle size of polysiloxane gel in the structure of mortar containing light aggregate waste were also observed . ParticlThe main purpose of this study was to determine the efficiency of hydrophobization of EPS concrete with the application of coating agents based on silane and tetramethoxysilane. Both applied hydrophobic agents are commercially available; however, due to their different chemical base and properties, they present different influences on securing the coated surfaces and structures of LC composites. Our studies aimed to indicate which of the two tested agents would be more efficient in the protection of LCs against severe environmental conditions, compared to standard concrete. The EPS addition to concrete influences the properties of the tested concrete samples. Application of EPS reduces strength characteristics, density, and frost resistance. The frost resistance of LC10 and LC20 after 50 F–T cycles decreases by 18 and 25 times compared to reference concrete. The EPS also increases porosity, absorbability, and water vapor permeability.Hydrophobization allows the effective protection of all tested types of concrete, using both silane and tetramethoxysilane.Application of EPS and organosilicon affects the wettability and adhesive properties of concrete, defined by SFE and CA. The lowest value of SFE, thus the weakest adhesive characteristics, is determined for LC hydrophobized by tetramethoxysilane.A significant decrease in wettability and adhesive properties (SFE) is observed after surface hydrophobization of concrete, which indicates the high efficiency of the hydrophobization process.Hydrophobization by silane agent results in significantly higher mass loss than after the application of tetramethoxysilane, after tests of reference concrete resistance against salt crystallization. These specimens contain porous additions in which pore crystallization of salt occurred. No visible damages of EPS concrete were observed.Very good distribution of hydrophobic coatings inside the concrete structure was observed in SEM pictures. The size of particle generated from tetramethoxysilanes is greater than that from silane, and varies between 2 μm and 14 μm. However, particles of gel generated from silane (A1) have dimensions in the range 0.4–3 μm. Such arrangements and sizes of hydrophobic coating sufficiently protect LCs with EPS from frost and chemical corrosion.The highest efficiency of EPS concrete hydrophobization was obtained after tetramethoxysilane application, while the performance of silane coating was weaker.Based on the analysis of the obtained results, the following conclusions are proposed:


This study is aimed at exploring the changes and significance of circulating Th and Tfh cell subsets in glucocorticoid-treated IgG4-RD patients.  39 glucocorticoid-treated IgG4-RD patients and 22 healthy controls (HC) were enrolled. Peripheral blood mononuclear cells were separated, and circulating Th and Tfh cell subsets were examined by flow cytometry according to the surface and intranuclear markers. Disease activity was accessed by the IgG4-RD responder index (RI) score. Correlation analyses were conducted between Th/Tfh subset numbers and clinical indicators. The receiver operating characteristic (ROC) curve was used to evaluate the efficacy of Th and Tfh subsets to distinguish active IgG4-RD patients from remission IgG4-RD patients.  Circulating Th1, Th17, Tfh1, and Tfh17 cells were significantly increased in active IgG4-RD patients compared with HC. Th1 and Tfh1 numbers were positively correlated with serum IgG4 levels in patients with IgG4-RD. Meanwhile, the absolute numbers of circulating Th1 and Tfh1 cells were positively correlated with IgG4-RD RI scores. The areas under the curve (AUC) were 0.8276 for Th1 and 0.7310 for Tfh1, 0.5862 for Tfh2, and 0.6810 for Tfh17.  Increased circulating Th1 and Tfh1 subsets are related to elevated serum IgG4 levels in active IgG4-RD patients during glucocorticoid treatment, which may play an important role in the course of IgG4-RD disease, and could be potential biomarkers for monitoring disease activity of IgG4-RD. The maj IgG4-RD .+ cytotoxic T lymphocytes (CTLs) and follicular helper T (Tfh) cells that infiltrated tissue lesions were the main CD4+ T cells at disease sites in IgG4-RD [+ CTLs and Tfh cells were found to be expanded in patients with IgG4-RD [+CCR6−), Th2 plus naïve CD4+ cells , and Th17 cells (CXCR3−CCR6+) [+ CTLs, which express the transcription factors of ThPOK, Runx3, and T-bet, are mainly differentiated from Th1 cells [+ CTLs may lead to elevated Th1 cells in the peripheral blood of IgG4-RD patients. Tfh cells represent a distinct CD4+ T cell subset providing key signals to B cells for their differentiation into plasma cells which secrete high-affinity antibodies in the germinal center [+CXCR5+ T cells are considered to be a circulating pool of memory Tfh cells, which can be divided into Tfh1 (CXCR3+CCR6−), Tfh2 (CXCR3−CCR6−), and Tfh17 (CXCR3−CCR6+) cells, and they have different capabilities to help the differentiation of B cell subsets [+ T cell subsets in IgG4-RD. However, most previous studies have focused on untreated IgG4-RD patients. Few studies have explored the relationship between circulating CD4+ T cell subsets and disease activity in treated IgG4-RD patients.Previous studies have reported that CD4 IgG4-RD . Circula IgG4-RD , 6, 9. C3−CCR6+) , 11. CD4h1 cells , 13. Accl center , 15. Per subsets , 17. SomIn this study, we aim to determine the relationship between circulating Th and Tfh cell subsets and serum IgG4 levels as well as disease activity in glucocorticoid-treated IgG4-RD patients. We intend to clarify the changes and clinical significance of circulating Th and Tfh cell subsets in treated IgG4-RD patients.n = 25), possible (n = 12), and probable (n = 2) IgG4-RD diagnosis results, and the clinical and demographic characteristics of the patients are described in Supplementary Table n = 29) and remission (n = 10) IgG4-RD patients according to RI scores.We involved 39 patients with IgG4-RD including the diagnosis of definite . Similarly, IgE was significantly elevated in active IgG4-RD patients compared with HC and remission patients . In contrast, serum C4 levels were significantly decreased in patients with active IgG4-RD compared with HC . We also analyzed levels of lymphocytes and CD4+ T cell percentages and found elevated lymphocyte concentrations and CD4+ T cell percentages in active IgG4-RD patients compared to HC or remission patients (not shown).We measured and compared levels of IgG4, IgG, IgE, C3, C4, and CRP in the serum of active IgG4-RD patients, remission IgG4-RD patients, and HC. As shown in Supplementary Figure +CD4+CXCR5−Foxp3− cells because we want to exclude the influence of Foxp3+ regulatory T cells. Th1, Th2 plus naïve CD4, and Th17 cell subsets were defined as CXCR3+CCR6− cells, CXCR3−CCR6− cells, and CXCR3−CCR6+ cells within the CD3+CD4+CXCR5−Foxp3− Th cells, respectively. As shown in μL) of circulating Th1 cells was significantly increased in active IgG4-RD patients compared with HC and remission patients . Moreover, the absolute numbers (per μL) and frequencies of circulating Th17 cells were significantly higher in patients with active IgG4-RD than in HC . Interestingly, the absolute numbers (per μL) of circulating Th2 plus naïve CD4 cells were significantly lower in remission IgG4-RD patients than in active patients and HC . The frequencies of circulating Th2 plus naïve CD4 cells were significantly lower in active IgG4-RD than in HC .We next measured Th cell levels in IgG4-RD patients and HC according to surface markers. Circulating Th cells were defined as CD3+CD4+CXCR5+Foxp3− cells. Foxp3+ cells were also excluded because we want to exclude the influence of follicular regulatory T cells. Tfh1, Tfh2, and Tfh17 cell subsets were defined as CXCR3+CCR6− cells, CXCR3−CCR6− cells, and CXCR3−CCR6+ cells within CD3+CD4+CXCR5+Foxp3− Tfh cells, respectively. As shown in μL) of circulating Tfh1 cells was significantly increased in active IgG4-RD patients compared with HC . Moreover, the absolute numbers (per μL) and frequencies of circulating Tfh17 cells were also significantly increased in patients with active IgG4-RD compared with HC . Conversely, the frequencies of circulating Tfh2 cells were significantly decreased in active IgG4-RD patients compared with HC and remission patients .We next analyzed circulating Tfh cell changes in these IgG4-RD patients. Circulating Tfh cells were defined as CD3μL) of Th1 cells was found to be positively correlated with serum IgG4 levels and IgG4-RD RI scores . Similarly, the correlations of Tfh cell subsets with serum IgG4 and RI scores in IgG4-RD patients were also analyzed, respectively .To determine the associations of Th cell subsets with clinical indicators, the correlations of Th cell subsets with serum IgG4 and RI scores in IgG4-RD patients were conducted. As shown in ectively . InteresSince Th1 and Tfh1 subset numbers are significantly increased in active IgG4-RD patients and have significant positive correlations with disease activity, we further explored whether they could be used as potential markers for IgG4-RD disease activity monitoring. As shown in In this research, we studied the changes and significance of circulating Th and Tfh cell subsets in glucocorticoid-treated IgG4-RD patients. We found that circulating Th1 and Tfh1 subsets were increased and were related to serum IgG4 levels and RI scores in active IgG4-RD patients, which may play an important role in IgG4-RD, and could be potential biomarkers for monitoring disease activity of IgG4-RD during treatment.IgG4-RD is often featured by elevated levels of serum IgG4 , 19. Ser+ CTLs have been reported to play an important role in the pathogenesis of IgG4-RD [+ CTLs differentiate mainly from Th1 cells. Accordingly, we investigated circulating Th subsets in patients with IgG4-RD. The numbers of circulating Th1 cells were significantly increased in active IgG4-RD patients. In line with our results, increased circulating Th1 cells in IgG4-related sialadenitis patients have already been reported by Ohta et al. and Higashioka et al. [+ CTLs in lesion tissues from patients with IgG4-related dacryoadenitis and sialoadenitis was positively correlated with serum IgG4 concentrations [+ CTLs will result in the production of more IFN-γ, and excessive IFN-γ is thought to lead to the pathogenic accumulation of Tfh cells, which in turn leads to the formation of abnormal germinal centers and the production of autoantibodies [γ, etc.) and cytolytic molecules (perforin and granzyme), which were associated with the disease activity.Expanded CD4 IgG4-RD –23. CD4+a et al. , 25. Hertibodies . This in+ Tfh cell subsets were expanded in IgG4-related sclerosing cholangitis and pancreatitis, but only activated Tfh2 cells were associated with disease activity [+ Tfh cells were reported to be significantly increased in secondary lymphoid organs and lesion tissues in IgG4-RD [+ Tfh cells express BATF, rather than GATA-3, which was identified as a master transcriptional factor of circulating Tfh2 [+ Tfh cells in lesion tissues of IgG4-RD patients [+ Tfh and CCR6+ Tfh cells. Here, we found that the number of circulating Tfh1 cells was significantly higher in patients with active IgG4-RD. Moreover, the number and proportion of circulating Tfh17 cells were significantly higher in patients with active IgG4-RD than in HC. In contrast, the proportion of circulating Tfh2 cells was significantly decreased in active IgG4-RD patients. Also, the numbers of circulating Tfh1 cells were positively correlated with serum IgG4 levels and IgG4-RD RI scores, which suggests that increased Tfh1 cells may be associated with the elevated IgG4 and might contribute to IgG4-RD.Previous studies investigated the role of Tfh cell subsets in IgG4-RD. However, the results remain controversial. Akiyama et al. reported that activated circulating Tfh1 and Tfh2 cells were increased in IgG4-RD and the number of Tfh2 cells was associated with serum IgG4 levels , 28. Cheactivity . IL-4+ T IgG4-RD , and theing Tfh2 . CXCR3 aOne of the reasons for the inconsistent conclusions is the different criteria for the inclusion of patients. We included patients in this study who were undergoing glucocorticoid therapy. The changes in Th and Tfh subpopulations in these patients during the treatment process were very different from those of new onset or after treatment. Since most IgG4-RD patients are often in the state of starting treatment, it is difficult to collect new-onset patients, but our results are more of reference significance because it reflects the situation of most patients who come to the hospital. This is also the first time to systematically study the changes of Th and Tfh subsets in patients treated with glucocorticoid. We suspect that glucocorticoid can have an effect on circulating T cell subsets, and changes in T cell subsets can also reflect the effects of treatment.Based on this, we also conducted a preliminary exploration of the diagnostic value of the Th and Tfh subsets and used ROC curves to evaluate the effectiveness of these subsets for distinguishing the active from remission status of IgG4-RD patients during glucocorticoid treatment. According to our results, the areas under the curve (AUC) were 0.8276 for Th1 and 0.7310 for Tfh1, suggesting that Th1 and Tfh1 numbers could be potential diagnosis makers in monitoring IgG4-RD disease activity. Our research uses flow cytometry to detect molecules on the surface of peripheral blood cells. If it can achieve the purpose of evaluating the treatment of patients, it will have a good application prospect. However, because the sample size is not large enough, it is necessary to expand the sample size in the future to clarify the diagnostic value of Th1 and Tfh1.In summary, our study demonstrates that active IgG4-RD is characterized by circulating T cell polarization toward Th1/Tfh1 and Th17/Tfh17 during glucocorticoid treatment. Circulating Th1 and Tfh1 levels positively correlate with serum IgG4 levels and disease activity in patients with IgG4-RD, which might play an important role in the course of IgG4-RD, and could be the potential biomarkers for disease activity monitoring in IgG4-RD.A total of 39 patients with IgG4-RD  and 22 healthy controls (HC)  were recruited from outpatient and inpatient sections of Peking University People's Hospital between December 2018 and May 2019. The diagnosis of IgG4-RD was performed according to the 2011 comprehensive diagnostic criteria . All IgGSerum levels of IgG4 were measured by nephelometry using a Siemens BN II Nephelometer  and Siemens reagents. Serum concentrations of IgG, C3, and C4 were measured by nephelometry using a Beckman Coulter Immage 800 Nephelometer  and Beckman Coulter reagents. CRP in serum was tested by immunoturbidimetry using a Beckman Coulter Chemistry Analyzer AU5800  and Beckman Coulter reagents. Serum IgE levels were tested by a Cobas e601 Electrochemiluminescence Immunoassay Analyzer . WBC and lymphocyte counts were determined by Sysmex XE-2100 .μL) of each subgroup was calculated.Peripheral blood mononuclear cells (PBMCs) were separated by gradient centrifugation with a human lymphocyte separation medium  and then washed twice with PBS. Enriched PBMCs were immediately stained for 30 minutes with the following antibodies: CD3-APC, CD4-PerCP/Cy5.5, CXCR5-APC/Cy7, CXCR3-PE, and CCR6-PE/Cy7. Intracellular staining for Foxp3 was performed using a transcription factor staining buffer kit , according to the manufacturer's instructions. After fixation and permeabilization, cells were incubated with anti-Foxp3 allophycocyanin for 30 minutes. All fluorescent antibodies were purchased from BioLegend . Samples were analyzed on FACSCanto using Diva software . Based on the number of lymphocytes in the complete blood count and the proportion of each subgroup of lymphocytes determined by flow cytometry, the absolute count  curve analyses were performed to explore the efficiency of parameters in evaluating IgG4-RD disease activity and the AUC values were determined. Statistical significance was determined using GraphPad Prism software V.7.0 . Statistics with P values less than 0.05 were considered to be significant.Continuous variables are shown as median with 25


Surgical treatment of tibial plateau fracture (TPF) is common. Surgical site infections (SSI) are among the most serious complications of TPF. This multicentre study aimed to evaluate the effect of fracturoscopy on the incidence of surgical site infections in patients with TPF.We performed a retrospective multicentre study. All patients with an AO/OTA 41 B and C TPF from January 2005 to December 2014 were included. Patients were divided into three groups: those who underwent arthroscopic reduction and internal fixation (ARIF), and those who underwent open reduction and internal fixation (ORIF) with fracturoscopy, and those treated with ORIF without fracturoscopy. The groups were compared to assess the effect of fracturoscopy. We characterised our cohort and the subgroups using descriptive statistics. Furthermore, we fitted a logistic regression model which was reduced and simplified by a selection procedure (both directions) using the Akaike information criterion (AIC). From the final model, odds ratios and inclusive 95% confidence intervals were calculated.p = 0.37). Regression analyses indicated a potential positive effect of fracturoscopy .Overall, 52 patients who underwent fracturoscopy, 48 patients who underwent ARIF, and 2000 patients treated with ORIF were identified. The rate of SSI was 0% (0/48) in the ARIF group and 1.9% (1/52) in the fracturoscopy group compared to 4.7% (93/2000) in the ORIF group (OR = 0.40, Our study shows that fracturoscopy is associated with reduced rates of SSI. Further studies with larger cohorts are needed to investigate this.Level III. The surgical treatment of tibial plateau fractures (TPF) is common and surgical site infections (SSI) remain one of the most serious complications . The ratRecently, fracturoscopy has been used in TPF to help improve intraoperative fracture reduction –7. FurthWe conducted a retrospective multicentre study at 7 level-1 trauma centres in Germany and Switzerland. This study was performed in line with the principles of the Declaration of Helsinki. The study was approved by the leading ethical committee (Reference number: 098/15-ff) and by the corresponding ethics committees of all the participating hospitals. The requirement for informed consent from patients was waived due to the retrospective nature of the study. Both ARIF  and ORIF   were performed at three centres while ORIF with or without fracturoscopy was performed at four centres . In contrast to ARIF, with arthroscopy applied in conventional ways and a typical water pressure between 35 and 55 mmHg, fracturoscopy does not require increased water pressure as it is introduced into the joint through an open surgical approach.All patients who were surgically treated for proximal tibia fractures in the participating hospitals from January 2005 to December 2014 were identified by querying the hospitals’ databases using the International Classification of Disease (ICD) code for tibial plateau fractures. The medical record of each patient was manually screened to avoid the inclusion of patients who were improperly coded, were primarily operated on in another hospital or did not fit in our inclusion criteria.The inclusion criteria were as follows: age > 18 years, primarily treated in a participating hospital, and proximal tibial fracture classified as AO 41 B or C. Exclusion criteria were as follows: AO 41 A fractures and primary treatment with arthroplasty. The cohort was divided into three groups: ARIF, fracturoscopy, and ORIF.In addition to standard parameters , pre-existing conditions were categorised into four groups according to the number of comorbidities: no comorbidity, 1–3 comorbidities, 4–5 comorbidities, and ≥ 6 comorbidities. Diabetes mellitus, nicotine abuse, alcohol/drug abuse, as well as intake of immunosuppressive drugs were listed separately at the nominal scale level. Other concomitant injuries were categorised as none, not relevant , and relevant  . PatientFracture morphology was classified according to the AO/OTA Fracture and Dislocation Classification . We recoSSI were recorded according to the definition proposed by the current protocol of the National Healthcare Safety Network, Centres for Disease Control and Prevention –15. ThisWe characterised our cohort and the subgroups using descriptive statistics: Mean  for continuous variables and number (%) for categorical variables. As a measure for the association between the groups with/without fracturoscopy, the standardised mean difference (SMD) was calculated for continuous variables and odds ratio for binary variables.Further, we examined if fracturoscopy remained a relevant and significant factor when the effect is adjusted by known covariates. With this aim, we fitted a binary logistic regression model for infection with fracturoscopy and 13 additional baseline and peri-operative covariates. The model was reduced and simplified by a selection procedure (both directions) using the Akaike information criterion (AIC). From the final model, odds ratios including 95% confidence intervals were calculated.Data preparation and descriptive statistics were analysed using IBM SPSS Statistics, version 26. Using the R software, multiple models were fitted, and graphs were generated. The significance level was set at 5% for two-tailed testing.n = 52) or ARIF (n = 48) were identified. The rate of SSI was 1.9% (1/52) in the fracturoscopy group compared to 0% in the ARIF (0/48) and 4.7% (93/2000) in the ORIF group . Tables Of the 2100 patients who underwent surgery for TPF, 100 patients who underwent fracturoscopy (nd 4.7% 9/2000 in nd 4.7% 9/2000 in n = 1) or a double plate (n = 3).Screw osteosynthesis was used in all the patients treated by ARIF. A comparison between ORIF and fracturoscopy revealed that there were differences in the primary application of the external fixator and the combination of screws and plates. Patients with fracturoscopy and ORIF were most frequently treated by plate osteosynthesis Table . Four pap = 0.69). However, only low statistical evidence was observed for this effect likely due to confounding by several covariates that were not possible to control. Figure Multiple regression analysis showed an increased risk of SSI related to various factors Table . Furtherp = 0.69). However, the large confidence interval and the p value indicates that this effect is statistically uncertain. This can be traced back to the single case of infection in the fracturoscopy group. To the best of our knowledge, this is the first study to focus on the association between fracturoscopy and SSI. In comparison with previously published studies, it was observed that patients treated by ARIF rarely had an SSI. Verona et al. compared 19 ARIF cases with 21 ORIF cases for Schatzker I–III fractures where one case of SSI was found in the ORIF group [This study evaluated potential factors associated with fracturoscopy that may be good indicators of SSI reduction. Analysis of our data showed that the rate of SSI in the group with fracturoscopy was 1.9% which was substantially lower compared to the ORIF group 4.7%). Furthermore, the regression analysis indicated the positive effect of fracturoscopy on SSI  that could influence the occurrence of SSI were not evaluated in this study.


The calcium stearate content used in the concrete here consists of 0, 1, 5, and 10 kg per m3 of concrete volume, or alternatively, 0 to 2.85% by the weight of cement. We have performed several tests for each of the contents, namely, compressive strength, water absorption, chloride ion infiltration, and accelerated corrosion tests. According to the testing, we have found that with the addition of calcium stearate at 1 kg/m3 in self-compacting concrete (SCC) with 10% fly ash, the mechanical and physical properties of SCC can be improved significantly when compared to the SCC without fly ash and calcium stearate, resulting in a stable compressive strength, lower water absorption, lower chloride ion infiltration, and lower degree of corrosion attack.This work aims to study the effect of Ca(C Portland composite cement (PCC) is a hydraulic binder that is milled together with clinker, gypsum, and one or more inorganic materials, or is the result of mixing Portland cement powder and other inorganic powders. These inorganic materials include blast furnace slag, pozzolan, silicate compounds, and limestone, with a total content of inorganic material of 6–35% of the mass of Portland composite cement . PCC is 2 content in fly ash greatly contributes to the increase in the compressive strength of concrete. Silica oxide (SiO2) in fly ash reacts with calcium hydroxide (Ca(OH)2) to form the additional calcium silicate hydrate mineral referred to as C-S-H (tobermorite) [2O). The use of fly ash in concrete as a substitute for cement further increases the amount of C-S-H/calcium silicate hydrate (tobermorite) formed during the cement hydration process. It can reduce cement the consumption by 3.2–5 kg·m−3·MPa−1 [2 gas (a pollutant) is released because of combustion to make clinker. Reducing cement consumption in concrete consequently decreases the CO2 emissions. Besides that, the appearance of fly ash in concrete also raises the alkalinity of concrete [Fly ash is the ash that results from burning coal which is used as fuel in steam power plants. This material can be used as a partial replacement for cement in concrete. Fly ash has a particle size that is smaller than the particle size of cement. Because of this physical condition, the use of fly ash in concrete contributes many advantages in improving the physical and mechanical properties of concrete. The physical and mechanical properties of concrete that can be improved include a lower permeability , lower wrmorite) . Calcium−3·MPa−1 . In the concrete . The higNot only additives such as fly ash, slag, and silica fumes, but superplasticizers such as water reducers  in concrA large contact angle makes it more difficult for water to seep into concrete . As a re18H35O2)2  in self-compacting concrete (SCC) with PCC as a binder have been carried out by Maryoto et al. in 2018 [3 of concrete reduces the corrosion attack of steel bars by around 8%. Although the effect of calcium stearate on concrete with a PCC binder is well-known, the effect of calcium stearate in concrete using PCC and fly ash as a binder has not yet been studied. Therefore, this study aims in determining the effect of calcium stearate on concrete with a PCC binder, combined with fly ash and a superplasticizer.Millions of reinforced concrete structures are located in corrosive environments. This is a problem throughout the world. To avoid corrosion attack on steel bars in concrete, some studies must be carried out to increase the resistance properties of concrete. Studies on the use of Ca to analyze the chloride ion content, the coating material, sodium chloride, sandpaper, cables, steel bars of a 12-mm diameter, an ammonium citrate solution, copper plates, duct tape, a Whatman filter , bromic-phenol blue indicator , HNO3, and Hg(NO3)2. The crushed stone utilized in this study had a maximum size of 20 mm and was produced from granite cobblestone. The physical properties of calcium stearate are presented in The materials used include PCC, crushed stone, sand, water, a superplasticizer, fly ash, calcium stearate, chemical materials , a cylinder molding (polivinyl chloride pipe), that was 75-mm in diameter and 150-mm tall a cube molding (cast iron) with 150-mm sides, a beam molding of a 100 mm × 100 mm × 200 mm (multiplex wood) size, a direct current power supply (China), a Los Angeles machine , and a universal testing machine .Based on the physical properties of the cement, fly ash, sand, and crushed stone, the concrete mixtures were designed as shown in 3 of concrete, respectively. When converted into percentages by the weight of cement, the values are 0.28, 1.43, 2.85, 0.24, 1.20, 2.40, 0.19, 0.93, and 1.86%.The superplasticizer content used was 0.25% by weight of cement, and the amount of fly ash used was 10% by weight of cement. In The tests conducted in the laboratory include compressive strength, water absorption, infiltration of chloride ions, and accelerated corrosion tests. The number of specimens for each code mix proportion was three pieces. Specifically, for the infiltration of chloride ion specimens, each specimen was investigated for the chloride ion content at depths of 1, 2, 4, 6, and 8 cm from the surface of the test specimen, and each test was taken with three samples. The compressive strength specimen was cylindrical, with a diameter of 150 mm and a height of 300 mm. The water absorption specimens were cylinders with a diameter of 75 mm and a height of 150 mm. The infiltration of chloride ions and the accelerated corrosion test specimens were cubes side lengths of 150 mm and beams with a size of 100 × 100 × 200 mm, respectively. The number of specimens for each code for the compressive strength, water absorption, and accelerated corrosion tests was 3 pieces. Meanwhile, the number of specimens for the infiltration of chloride ions test was 15 pieces.The crushed stone and sand used in the production of the fresh concrete were kept in saturated surface dry conditions. They were weighed according to the mix design and were put in a concrete mixer and then mixed. The next step was that cement and fly ash (for concrete using fly ash) were inserted and mixed again with a concrete mixer. The next step was to add water to the concrete mixer and mix it again, such that the fresh concrete became homogeneous. For concrete using a superplasticizer, after the fresh concrete was quite homogeneous, the superplasticizer was put into the fresh concrete and then mixed again. Workability testing was then carried out with a slump test before the fresh concrete was poured into a mold. The average workability of concrete without the superplasticizer was around 10 cm. Further, the concrete with the superplasticizer had a workability of 3 cm before the superplasticizer added, and a 65-cm diameter for workability after the superplasticizer was added a–c. EspeAfter the concrete was one day old, the molds were removed, and all specimens were treated by immersing them in water, except for the accelerated corrosion specimen . The acc2 per second. The maximum force that was applied when the test object ruptured was noted. The compressive strength can be calculated by dividing the maximum force by the area of the test object.The compressive strength test was conducted based on the ASTM C39-94 standard . The comAfter the water absorption specimens were 28 days old, the specimens were dried in an oven for 3 days at a temperature of 100 ± 5 °C . The speAfter the test subjects were treated in water for 27 days, the 150 × 150 × 150 mm cube specimens were removed from the water pond. When the specimens had dried, five surfaces of each specimen were coated with a waterproof coating. Only one surface was left without a waterproof surface coating. The next step was to soak the specimens in sea water containing 3% sodium chloride with water depths as high as 3 cm from the top concrete surface for 90 days after the waterproof coating was dry. The specimens were removed from the sea water pond when they were 90 days old and were then left to dry in an open space. The specimens were then drilled at distances of 1, 2, 4, 6, and 8 cm from the surface of the unprotected surface in a dry condition, as in 3 was added until the color of the solution was green and the pH was around 3.2 (see 3)2 at 0.14 N until the color changed to purple 2 and Cl− (mg Hg(NO3)2/ cc Cl−) and V is the volume of a titrant (volume (in drops) of Hg(NO3)2 subtracted by blank volume (in drops) of Hg(NO3)2.The powder was then analyzed for its chloride ion content using the wet chemical analysis method, which is one of the methods used to analyze the chemical elements in materials using a chemical reaction, usually the decomposition of the sample using a reagent. On the other hand, to analyze the chemical elements, one may also utilize X-ray diffraction (XRD) or dry chemical analysis. Because no liquids are used in the XRD process, it is known as a dry chemical analysis. The procedure for testing the chloride ion content is as follows. Total of 5 grams of powder was weighed and put into a glass beaker a. Then 1 3.2 see c. The soo purple d. The chW2)  before corrosion. The corrosion level calculation was carried out using Equation (3).The accelerated corrosion test was carried out when the concrete was 28 days old. The process for the accelerated corrosion testing is listed as follows. The specimens were immersed in water containing 3% sodium chloride. The water level was 90 mm from the bottom surface of the specimen or 10 mm lower than the top concrete surface. For example, six pieces of 20 MPa quality concrete specimens with the G2S0F0C0, G2S1F0C0, G2S1F1C0, G2S1F1C1, G2S1F1C5, and G2S1F1C10 codes were connected in parallel with one direct power supply see a. This wW2) d. The amIt is important to note here that we use a red box in the figures below to identify a concrete test result where calcium stearate has been involved. The first two symbols of G2, G3, and G3 are omitted in the figures and have been replaced by the symbol “--“, and the legends show explanations of 20, 30, and 40 MPa with different line colors. The results of compressive strength testing are shown in The water absorption results are shown in The accelerated corrosion specimens were then broken down and the corroded reinforcement was removed. Both the amount of corrosion that occurred in the specimens for each code and the quality of the concrete are shown in 3 of fresh concrete. So, this content may still safely be used in concrete with a binder in the form of SCC added with fly ash and a superplasticizer as well.The compressive strength of specimens --S1F1C1, --S1F1C5, and --S1F1C10 began to decrease when compared to specimen number --S1F1C0. This is due to the addition of calcium stearate at 1, 5, and 10 kg in the concrete. Calcium stearate reacts with cement and water to form a wax-like constituent. This compound has a weaker bond than the bond formed by the C-S-H compound. Therefore, the wax-like constituents in the concrete cause the compressive strength to decrease . This reBy comparing SCC  without fly ash, in this case the code is --S1F0C0, the compressive strength of the SCC with calcium stearate and fly ash  is not significantly different. This shows that the presence of calcium stearate in SCC with fly ash has a good impact in the compressive strength of SCC.3 as an additive material. It can be observed that water absorption decreases significantly compared to concrete without calcium stearate . This decrease occurred in all qualities of concrete here when using calcium stearate. This could be explained by the possibility that calcium stearate reacts with cement and water to form a wax-like compound. This wax-like compound coats the surface of capillaries during the evaporation process. This compound is hydrophobic. As a result of this hydrophobic nature, the contact angle that forms between water and cement becomes large. The contact angle of water and concrete is usually lower than 180°. SCC with calcium stearate has a contact angle of more than 180°, as shown in 3 of concrete decreases water absorption by around 20% after 30 minutes of immersion in water.Specimens --S1F1C1, --S1F1C5, and --S1F1C10 are concrete specimens using calcium stearate at 1, 5, and 10 kg per m3 of concrete . Calcium stearate has a high degree of swelling when it contacts water and forms a gel. The gel functions as a power blocker and blocks capillaries when other liquids, together with chloride ions, penetrate into the concrete. Another influence is that the addition of calcium stearate makes the surfaces of capillaries have a hydrophobic effect [c effect .The concrete without a superplasticizer, fly ash, and calcium stearate (code --S0F0C0) had the highest degree of corrosion attack, contrary to the specimen of concrete with a superplasticizer as a water reducer, fly ash, and calcium stearate . The addition of calcium stearate clearly can significantly reduce corrosion attack in concrete with a PCC binder, fly ash, and a superplasticizer. This result is in accordance with the work of Quraishi et al. from 2011 . It is bThe diagram in When compared with concrete with PCC as a binder at 20, 30, and 40 MPa qualities, the following conclusions can be made based on the fresh concrete without calcium stearate. First, the compressive strength of the concrete when adding calcium stearate is relatively stable. The compressive strength of concrete containing calcium stearate is not significantly different when compared to concrete without a superplasticizer, fly ash, and calcium stearate. Moreover, the use of calcium stearate will clearly reduce the water absorption capability of concrete and the infiltration of chloride ions. Finally, our tests have revealed that corrosion of concrete can be reduced by using calcium stearate. Hence, calcium stearate is a good candidate to improve the mechanical and physical properties of concrete. Overall, the use of calcium stearate in SCC-containing fly ash has a beneficial effect on its properties; the use of calcium stearate increases compressive strength, reduces water absorption, decreases the infiltration of chloride ions, and diminishes the degree of corrosion attack. In the next study we will discuss the effect of calcium stearate on the bonding force between steel bars and concrete.


To first describe and estimate the potential pathogenic role of Ig4 autoantibodies in complement-mediated thrombotic microangiopathy (TMA) in a patient with IgG4-related disease (IgG4-RD).® Complement System assays. Human complement factor H levels, anti-complement factor H auto-antibodies were analyzed by ELISA, using HRP-labeled secondary antibodies specific for human IgG, IgG4, and IgA, respectively. Genetic analyses were performed by exome sequencing of 14 gens implicated in complement disorders, as well as multiplex ligation-dependent probe amplification looking specifically for CFH, CFHR1-2-3, and 5.This study is a case report presenting a retrospective review of the patient’s medical chart. Plasma complement C3 and C4 levels, immunoglobulin isotypes and subclasses were determined by nephelometry, the complement pathways’ activity  using WIESLABCFHR 1 and CFHR 4 genes deletions, and inhibitory anti-complement factor H autoantibodies of the IgG4 subclass. Remission was achieved with plasmaphereses, corticosteroids, and cyclophosphamide. Following remission, the patient was diagnosed with lymphocytic meningitis and SARS-CoV-2 pneumonia with an uneventful recovery.Our brief report presents the first case of IgG4-RD with complement-mediated TMA originating from both pathogenic CFHR1 and CFHR4 gene deletions enhance the susceptibility to the formation of inhibitory anti-Factor H IgG4 antibodies.IgG4-RD can be associated with pathogenic IgG4 autoantibodies. Genetic predisposition such as  IgG4-related disease (IgG4-RD) is a protean fibro-inflammatory condition characterized by tumefactive and hyperplastic lesions with storiform fibrosis and dense lymphoplasmocytic infiltrates rich in IgG4-positive plasma cells . DependiThrombotic microangiopathy (TMA), also known as atypical hemolytic uremic syndrome, is characterized by hemolytic anemia, thrombocytopenia, and organ failure  related to vascular damage provoking arteriolar and capillary thrombosis , 6. CompA 45-year-old woman, born in Cameroon, presented in December 2019 at the Emergency Department (ED) with a three-day history of epigastric abdominal pain, nausea, vomiting, and macroscopic hematuria. The patient had a clinical history of IgG4-RD diagnosed in 2015 with elevated serum IgG4 (5.3 g/l), plasmablast counts , and tubulointerstitial nephritis with more than 10/HPF IgG4+ plasma cells. She was treated with corticosteroids and rituximab but had multiple relapses, as summarized in ® Complement System assay (SVAR life science AB.SE.) in the serum. Human Complement factor H levels were determined using ELISA-Hycult biotech. Com. in the plasma and anti-CFH antibodies were measured using ELISA-VIDITEST from VIDIA.CZ in the serum.On admission, blood tests revealed hemolytic anemia (hemoglobin 100 g/l) with undetectable haptoglobin, increased LDH levels at 992 U/l, 2% of schistocytes on the blood smear, thrombocytopenia (35 G/l), and acute kidney injury with creatinine measured at 369 µmol/l for a baseline value of 77 µmol/l (KDIGO stage 3). Leucocyturia, glomerular hematuria, and nephrotic range glomerular proteinuria (estimated over 6.6 g/day) were present. Blood albumin levels were 28 g/l. Specific coagulation parameters  were in the normal range. ADAMTS13  activity was normal (78%), and antiphospholipid antibodies were absent. Antinuclear antibodies (ANA) titers were at 1/5,000 with homogenous and nucleolar pattern without anti-nucleoprotein or -nucleosome specificities. Total IgG and IgG4 levels were at normal range, 11.1 and 1.2 g/l, respectively. Plasma complement C3 was significantly decreased, 0.14 g/l (0.66–1.35), with normal plasma C4 levels 0.16 g/l (0.08–0.34); the results of the last control two years earlier were 1.19 and 0.21 g/l, respectively. Activity of all three complement pathways, classical, alternative and lectin, was decreased: CH50 25% , AP50 0% , MBL 27% . Detectable complement factor H (CFH) levels were low at 49 µg/ml  by fresh frozen plasma twice the plasma volume and corticosteroids  with gradual tapering until May 2020 . Deletions in the genes of CFHR 1 and CFHR 4, GRCh37/hg19 chr.1:g.(196789032_196794607)_(196887536_196913011)del, were identified that are known risk factors for complement-mediated TMA  balanced by B-lymphocytes, as well as T helper lymphocytes (Th-2) and regulatory T cells (Treg) that also regulate B-cell differentiation and TGF-β-mediated tissue fibrosis. IgG4 overexpression and accumulation could be inflammatory leftovers of chronic inflammation that results from massive plasma cell production. IgG4 antibodies are supposed to be nonpathogenic in IgG4-RD . HoweverOn the other hand, pathogenic autoreactive IgG4 antibodies have been observed in other autoimmune diseases such as myasthenia gravis, directed against muscle-specific tyrosine kinase (MuSK) receptor subtype, pemphigus vulgaris, directed against desmoglein 1, and idiopathic membranous glomerulonephritis, directed against M-type phospholipase A2 receptor , 13. Intvia competing with complement factor B in binding to C3b, and dissociates the alternative C3 convertase with formation of C3b and Bb. CFH-related protein 1 (CFHR1) is likely to inhibit the formation of C5 convertase and may compete with CFH for binding to C3b. Deficiency of CFHR1 can arise from homozygote CFHR1/4 gene deletions  converting C3b to an inactive form, as a decay-accelerating factor ated TMA , 17.Therapeutic strategies for complement-mediated TMA are evolving with the recent introduction of complement inhibitors in particular eculizumab, a monoclonal antibody that binds complement component C5 and prevents its cleavage by C5 convertases and formation of the membrane attack complex (MAC) . In our Severe infections such as HIV, influenza, and pneumococcus are known causes of TMA and related to relapse . In our CFHR1/4 gene deletion.In conclusion, we describe for the first time a pathogenic role of IgG4 autoantibodies directed against CFH causing complement-mediated TMA in a patient with IgG4-RD and a genetic predisposition with homozygote Ethical review and approval were not required for the study on human participants in accordance with the local legislation and institutional requirements. The patient provided their written informed consent to participate in this study.Conceptualization and design of the study: GB, IZ, BP, and JS. Acquisition and analysis of data: GB, IZ, SS. Drafting of a significant portion of the manuscript or figures: GB, IZ. Correction of the manuscript: GB, IZ, CS, BP, JS. All authors contributed to the article and approved the submitted version.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.