ProVate is a novel, disposable, collapsible self-inserted vaginal device for the nonsurgical management of pelvic organ prolapse (POP). We assessed possible vaginal microflora changes and POP reduction using ProVate and a commercially available ring pessary (control).We performed post-hoc analysis of data obtained from an interventional, prospective, multicenter, open-label, randomized, controlled, statistically powered (noninferiority), home-use, cross-over study conducted at seven sites. Safety and performance data collected for both devices were analyzed to compare objective POP reduction (employing the Pelvic Organ Prolapse Quantification System [POP-Q]), safety (assessed by the incidence of adverse events [AEs]), and the rates of certain AEs.Eighty-five women with symptomatic POP were screened; 71 were randomized, and 58 completed the study per protocol. Forty-nine (90.7%) ProVate users experienced complete prolapse reduction (stage 0), 3 (5.6%) experienced reductions to POP-Q stage 1, and 2 (3.7%%) experienced reductions to stage 2. Collectively, 52/54 (96.3%) ProVate users experienced prolapse reduction to stage 0 or 1. In all, 47/57 (82.5%) control users experienced complete prolapse reduction, while 5 (8.8%), 4 (7.0%), and 1 (1.8%) experienced reductions to stage 1, 2, and stage 3, respectively. Collectively, 52/57 (91.2%) control users experienced reductions to either stage 0 or 1. In 53/54 (98.1%) ProVate and 55/57 (96.5%) control users, there was at least 1 POP-Q stage prolapse reduction, and in 32 (91.4%) ProVate and 31 (83.8%) control users who had stage ≥3 prolapse, there were at least three POP-Q stage reductions. In total, 26/71 (36.6%) ProVate and 22/64 (34.4%) control users in the safety population experienced AEs. The incidence of device-related AEs was 17/71 (23.9%) for ProVate and 13/64 (20.3%) for the control. Most AEs were minor, mild, and anticipated.Our analysis demonstrated that ProVate and the control are highly effective in reducing POP, and both are associated with comparably low numbers of AEs. However, ProVate has the advantage of being more user-friendly, suitable for home use, and expected to allow women with POP to practice better and easier self-care. OnlyCurrently available ring pessaries are the most widely used type of pessary, considered effective, and safe, but also associated with substantial downsides  which liThe huge gap between existing cumbersome pessary management, and women’s wish for a more pleasant and comfortable home-use POP control and for unhindered intercourse, dictated the development of a new device, ProVate, which retains the upsides of a ring pessary while substantially reducing or eliminating its major downsides. The device was designed to be used by lay women, while the applicator leads the device into the correct position within the vagina, thus eliminating the need for constant replacement appointments. Notably, some women, primarily the elderly frail, will not be able to insert a ProVate device by themselves and will continue using the existing ring pessaries.ProVate  was desiThe objective of the study was to confirm that ProVate does not alter the vaginal microflora in a clinically significant manner compared to the commercially available ring pessary (control). We also evaluated the effectiveness and safety of ProVate and the control.2.2.1.The study was designed as an interventional, prospective, multicenter, open-label, randomized, controlled, statistically powered (non-inferiority), home-use trial, testing ProVate, and the control in a sequential cross-over fashion. The study was conducted in seven outpatient gynecology/urogynecology clinics (six in the US and one in Israel) over 14 months between August 2017 and September 2018.The study received ethical approval from the Institutional Review Board Service in the US (#Pro 00022375), and from Assuta Medical Ethics Committee in Israel (#2016028), and all participants gave their written informed consent.According to the study’s usage period, each participant received either a clean sealed disposable ProVate , or a new reusable ring pessary (not using their used device) made by a single US manufacturer .After the screening phase, the first usage phase  started in situ during the entire study period. During each clinic visit, participants were examined vaginally to assess the stage of prolapse according to the POP-Q scale, with or without the device, and to check for the presence of AEs.If the device was either too small (expulsion) or too large (discomfort), it was refitted. During the ProVate usage period, participants were instructed to use as many devices as they wished for 1–7 days and fill in a daily diary, documenting each device’s usage length, functionality, and AEs. The ProVate usage period was at least 18 consequent or non-consequent usage days in the PP set, while the control ring pessary remained 2.2.We included females aged 21–80 years who were diagnosed with POP-Q stage 2–4 vaginal prolapse in one or more sites along their vaginal walls, women who previously used a vaginal ring pessary, women who could use both hands and insert a device into their vaginas, and women in whom a 61-91-mm pessary  could be well-fitted and retained.We excluded patients with previous inability to accommodate tampons or vaginal pessaries, women who were currently participating in another clinical study, patients with a comorbid condition(s) or severe systemic diseases that could limit their ability to participate in the study, pregnant women, women with suspected pregnancies, or the intention to get pregnant during the study period, women with abnormal vaginal bleeding in the previous six months, women who underwent vaginal surgery during the preceding three months, women with severely atrophic vaginas, existing vaginal or vulvar lacerations, and symptomatic vaginal, or urinary tract infections as determined by physical examinations and lab results, women who used medications  and had medical conditions that may have compromised their immune systems, and women with recurrent urinary tract infections and abnormal cervical cytology.All participants were instructed to avoid activities or the use of commercial products that may modify the vaginal flora, such as vulvar., or intimate cosmetics, medications, contraceptives, and wipes. They were also to avoid any vaginal devices other than the study devices and use only the menstrual supplies and condoms provided by the study site.2.3.Data collection at baseline (no device) and at the final visit included the Pelvic Organ Prolapse Quantification (POP-Q) staging for each subject and AE recording. These data were further analyzed post-hoc with two objectives: (I) to show that the objective reduction of POP while using ProVate is high and comparable to the control; and (II) to show that safety, as assessed by the rate of AEs for both ProVate and control, is comparable and that the rates of certain AEs are expected to remain low once insertion and removal are in small dimensions and a disposable device with a limited usage period is used.Efficacy was assessed using two performance indicators:The proportion of participants who had their prolapse reduced to POP-Q stage 0/1/2/3 while using ProVate or the control, regardless of the initial POP-Q stage (the first objective efficacy outcome).The proportion of participants who had 1, 2, or 3 POP-Q stage reductions while using ProVate or the control, compared to baseline, using the PP analysis set (the second objective efficacy outcome).POP-Q staging was determined at baseline as well as at the last visit with each of the studied devices. The percentage of participants who had their prolapse reduced to POP-Q stage 0/1/2/3 while using ProVate or the control, regardless of the initial POP-Q stage, while using the PP analysis set, was determined. The percentages of participants who had, 1, 2, or 3 POP-Q stage reductions while using ProVate or the control, were also evaluated.de novo urinary incontinence, and constipation.Safety was assessed by recording the incidence of anticipated and unanticipated AEs. Anticipated AEs included vaginal wall trauma, vaginal/urine infections, pain, spotting, discomfort, AEs were obtained and reported using all of the following methods: daily diaries, direct questioning, and vaginal examination during all routine study visits, scheduled weekly telephone calls to participants, and non-scheduled calls from participants.2.4.The safety analysis set (SA) was defined as all randomized subjects who used at least one device (ProVate or the control) for any duration [Full Analysis set (FA)].The Per-Protocol analysis set (PP) included all randomized participants who (I) used ProVate and the control for at least 16 days out of each device usage portion of the study, (II) had no major protocol deviation, and (III) had no evidence of vaginal infection at enrollment. Safety analyses were conducted on the safety/FA population and efficacy analyses were conducted on the PP population.Statistical analyses were performed using SAS v 9.4  software. All statistical tests and confidence intervals were two-sided and tests were performed using a 5% significance level.p-values and 95% confidence intervals (CI) of rate differences. The percentage rate differences and 95% CI of the differences based on the Farrington-Manning Score tests are presented in the results section.Categorical analyses of the percentage of POP-Q responders were performed using Fisher’s exact test. The post-hoc analyses presented here show analyses of differences between the groups with 3.Symptomatic participants accustomed to using ring pessaries were recruited from seven community gynecology/urogynecology clinics. Eighty-five women with symptomatic POP were screened ; 73 wereThe general characteristics of our study participants are summarized in Participants were allowed to use as many ProVate devices as they wanted for at least 24 h and up to seven days; however, they were encouraged to use ProVate for as long as possible within those limits. In total, 383 ProVate devices were used in the safety population, a mean value of 5.7 ± 1.6 devices per user, and 350 ProVate devices in the PP population, a mean value of 6.0 ± 1.1 devices per user. In 62.8% of the participants, a single ProVate device was used for at least four days, whereas a single reusable control remained in the vagina during the entire control phase (≥23 days) in 89.6% of the participants. The total number of usage days was 1,647 for ProVate and 1,734 days for the control (PP population).p = 0.325), suggesting the lack of a sequence effect and allowing the pooling of the results for each device from both sequences in all analyses.No significant effect of sequence randomization was observed . However, POP reduction while using ProVate or the control was not limited to a specific site . Furthermore, the upward distension of the vaginal apex caused flattening of the vaginal walls as well as prolapse reduction at other sites.The objective efficacy outcomes for both ProVate & the control are further presented in p = 0.4391). The difference between the ProVate and control groups was 5.1%.The first objective efficacy outcome relates to the proportion of participants who had either POP-Q stage 0, 1, or 2 prolapses at the final visit, while using the ProVate, or the control, using the PP analysis set. While using ProVate, 49 participants (90.7%) experienced complete prolapse reduction (to stage 0), 3 participants (5.6%) experienced prolapse reduction to POP-Q stage 1, and 2 participants (3.7%) experienced prolapse reduction to stage 2 . Collectp = 1.00). In the ProVate and control groups, there were at least 2 POP-Q stages of prolapse reduction in 94.4 and 87.7% cases, respectively. The difference between the ProVate and control groups was 6.7 % . Of the 35 ProVate and 37 control participants who had POP-Q stage 3 or 4 during the screening, 32 ProVate (91.4%) and 31 control (83.8%) participants had at least 3 POP-Q stages of prolapse reduction. The difference between the groups was 7.6% . No statistically significant differences  were found between the ProVate and control groups for 1, 2, or 3 POP-Q stage reductions.The second objective efficacy outcome relates to the proportion of participants who had 1, 2, or 3 POP-Q stage reductions while using ProVate or the control. Following the insertion, in 53/54 (98.1%) of ProVate users and 55/57 (96.5%) of control users, there was at least a one-POP-Q-stage prolapse reduction. The difference between the ProVate and control groups was 1.7%  ProVate participants and 22 out of 64 (34.4%) control participants in the safety population who experienced any AE. A summary of the categorization of AEs is shown in The most common AEs with ProVate were vaginal discomfort and vaginal spotting (eight cases in six participants for each complaint during the study), which are anticipated for all devices that are used vaginally. The most common AE with the control was vaginal discharge (five cases in five participants), which is also anticipated for many devices that are used vaginally for long periods.With ProVate, there were no signs nor symptoms of vaginal or urinary tract infections (UTIs), by both self-report, and vaginal examinations, during the study. With the control, there was one case of vaginal infection, two cases of bothersome vaginal complaints, and one case of UTI requiring treatment with antibiotics.There were five cases of vaginal wall trauma in four women using ProVate and two cases in two women using the control, again, a nonsignificant difference.4.The aim of this post-hoc analysis of data from a randomized controlled trial was to demonstrate the substantial objective efficacy and safety of ProVate in the non-surgical management of POP and compare it to the efficacy and safety of a commercially available ring pessary (the control). ProVate and the control reduce POP in the same manner ; yet, ProVate has the following upsides: it is an all-disposable device, can be self-inserted and removed by the user, can be used anywhere, and at any time, has small dimensions, exists within an applicator, and comes with no dependency on the clinic (other than routine checkups); thus, it is expected to improve user’s experience and substantially reduce the discontinuation rate  while enThere is no common definition for “success” in POP reduction either with surgery or with non-surgical methods. Barber et al.  defined This definition of treatment success, when a woman still has a POP-Q-stage-2 prolapse, may be too lenient; thus, attempts should be made to reduce the prolapse to POP-Q stage 1 or even 0, which, in most cases, is asymptomatic. Therefore, we propose that objective treatment success reports should follow ProVate is a disposable flexible vaginal ring pessary designed to overcome many downsides of existing ring pessaries. This study demonstrates that ProVate, once deployed, reduces POP as much as the control. Both devices (ProVate and the control) function as a mechanical intravaginal scaffold with an immediate lift-up of the vaginal apex and distension of its lateral walls; therefore, it also reduces any prolapse at other vaginal sites . In other words, both devices are expected to provide similar support and uplift to all vaginal walls; however, ProVate also provides its unique qualities, allowing women to manage their POP with a home self-use disposable device that has a tampon-like applicator for self-insertion.A search of the literature revealed only scarce previous evidence on objective ring pessary efficacy, as demonstrated by the proportion of POP-Q stage reduction(s) , and by eventual POP-Q stage achievement with a pessary . Many reports use parameters such as the discontinuation rate, quality of life, and subjective efficacy questionnaires as indicators of efficacy . In a prThe results of the current study add new evidence as to the objective efficacy of ring pessaries. With ProVate, in 96.3% of participants, there was prolapse reduction to POP-Q stage 0 or 1, over 98% of them had a one-stage prolapse reduction, and in over 91% of them, there was even a three-stage reduction. Similar results were found with the control, whereby in 91.2% of patients, there was prolapse reduction to POP-Q stage 0 or 1, over 96% of patients had a one-stage prolapse reduction, and in over 83% of them, there was even a three-stage reduction.p-value = 0.8578). The rate of device-related AEs for both devices was rather low when compared to the literature [citing up to 73.1% of AEs  with ProVate and 31 AEs in 22 participants (22/64 = 34.3%) with the control , and the design of the study where strict patient follow-up was employed, with frequent interactions between patients and the research team, allowing for the early, strict and accurate detection of specific AEs  and prompt implementation of corrective measures .The main limitation of this report is the rather short follow-up period of as little as 33 usage days, which is certainly sufficient to demonstrate efficacy and safety but may not reflect the long-term usage habits of participants. This study was designed only to demonstrate that the efficacy and safety of ProVate are comparable to those of the control; however, it did not attempt to look into the specific advantages of each device over the other.This post-hoc analysis demonstrates that ProVate and the control are both effective in reducing POP and are both associated with a (comparable) low number of AEs. However, ProVate has the advantage of easy self-handling  and allows women to resolve their POP issues by themselves.This analysis also raises the question as to the correct way of reporting the success of POP treatments, where the current definition of objective POP reduction may not be relevant anymore. The objective success rate should be defined as the number of POP-Q stages reduced, and the final POP-Q stage achieved.5.ProVate is expected to provide a useful & beneficial solution to women, enabling them to self-manage their POP issues and have autonomy over their intimate behavior , with a single-use small-size device at insertion & removal, and without the frequent dependency on the clinic. Many healthcare organizations intend to manage certain medical conditions at home. In an era where clinic visits are avoided by many women (due to reasons such as pandemics), and where treatment avoidance may lead to complications, ProVate is an example of a simple and available self-use home management modality. Moreover, this new management modality for POP may increase POP treatment compliance among untreated patients with POP. Further studies will be required to learn more about other characteristics of this device.eziv@contipi.com.The data analyzed in this study is subject to the following licenses/restrictions: The data that support the findings of this study are confidential assets of ConTIPI Medical Ltd. Restrictions apply to the availability of these data as they are the company’s confidential and restricted data; therefore, they are not publicly available. However, data may be available from the corresponding author upon reasonable request and with the permission of ConTIPI Medical Ltd. Requests to access these datasets should be directed to The studies involving humans were approved by the Institutional Review Board Service in the US (#Pro 00022375), and Assuta Medical Ethics Committee in Israel (#2016028). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.EZ: conceptualization, methodology, data collection as the PI, data analysis, and writing – original draft. TE: conceptualization, methodology, data analysis, and writing – original draft. All authors contributed to the article and approved the submitted version.ConTIPI Medical Ltd.  funded this study as part of its R&D/regulatory process. EZ and TE designed the study and contributed as employees and members of the research team. However, the study was conducted by an external CRO, and the statistical analysis was done by an external firm. Therefore, the funder had no involvement in these activities. ConTIPI Medical Ltd. also funded all costs associated with the writing and publication of this manuscript.EZ has a conflict of interest as he is an employee and shareholder of ConTIPI Medical, the company that developed the studied device. EZ took part in the design of the study, data collection, interpretation of the results, and manuscript writing. TE has a conflict of interest as she is a consultant and optionee at ConTIPI Medical, the company that developed the studied device. TE took part in the design of the study, interpretation of results, and manuscript writing.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


To evaluate the economic impact of treating severe infectious keratitis (IK) at one tertiary referral center in Thailand by analyzing the direct costs of treatment and estimating the indirect costs, and to determine whether cultured organisms had any effect on treatment expenditure.A retrospective study was conducted of patients with severe IK who had been hospitalized between January 2014 and December 2021 in Rajavithi Hospital. Data from medical records were collected from the time of the patients’ admission until the point at which they were discharged and treated in the outpatient department and their IK was completely healed, or until evisceration/enucleation was performed. The direct costs of treatment included fees for services, medical professionals and investigation, as well as for operative and non-operative treatment. The indirect costs consisted of patients’ loss of wages, and costs of travel and food.A total of 335 patients were studied. The median direct, indirect and total costs were US$65.2, range US$ 6.5–1,119.1, US$314.5, range US$50.8–1,067.5, and US$426.1, range 57.5–1,971.5 respectively. There was no statistically significant difference between direct, indirect, or total treatment costs for culture-negative and culture-positive patients. Among those who were positive, fungal infections entailed the highest total cost of treatment, and this difference was statistically significant (p<0.001). In terms of direct and indirect costs, patients with fungal infections had the greatest direct costs, and this figure was statistically significant (p = 0.001); however, those with parasitic infections had the highest indirect treatment costs, and this was also statistically significant (p<0.001).Severe IK can cause serious vision impairment or blindness. Indirect costs represented the majority of the expense at 73.8%. There was no difference between direct, indirect, and total treatment costs for patients who were culture-negative or positive. Among the latter, fungal infections resulted in the highest total cost of treatment. Infectious keratitis (IK) is a serious problem which can cause vision impairment or blindness , 2. The Kampitak K, et al.,  a study th Revision, Clinical Modification Codes (ICD-10-CM). The study included patients with a diagnosis of corneal ulcer (H160) who had been hospitalized with IK treatment as the primary indication. We excluded cases with insufficient data for evaluation as well as patients who had multiple hospitalizations during the same disease episode. We collected data on all eligible patients from the time they were admitted to the hospital to the time of their discharge and treatment in the outpatient department until the point when their IK was completely healed or evisceration/enucleation was performed. Corneal scraping was routinely taken from each patient’s affected eye upon admission to the hospital in order to culture the samples in blood, chocolate, and thioglycolate broth. In addition, PCR tests for herpes and non-nutrient agar with E. coli lawn were performed if there was suspicion of viral or parasitic infection. We defined healed IK as an epithelial defect that was completely closed, with all corneal infiltration having turned to corneal scar. When a therapeutic corneal transplantation was performed, final follow-up was considered when there was no epithelium defect and no recurrence of infection on the corneal graft. The following data were reviewed and analyzed: gender; age on admission date; duration of symptoms onset before presenting at our hospital; region of residence; length of stay (LOS); BCVA on first admission date and on final follow-up visit; duration of follow-up period; medical treatment; surgical intervention; number of visits to the outpatient clinic; and microbial culture results.The study protocol followed the ethical guidelines regarding human subjects given by the Declaration of Helsinki and was approved by the Ethics Committee of Rajavithi Hospital (No. 65100) on 11 July 2022. The need for informed consent from participants was waived by the Ethics committee of Rajavithi Hospital due to the retrospective nature of our study. We included all patients presenting with severe IK who had been hospitalized in Rajavithi Hospital between January 2014 and December 2021. Each case in this study was classified as severe IK, according to modification of Jones’ grading criteria. Severe IK is defined by a diameter greater than 5 mm, a depth greater than 50%, dense infiltrates reaching the deep layers of the corneal stroma, and possibly scleral involvement [https://costingmenu.hitap.net/), were patients’ loss of wages, travel expenses incurred in order to access care, and food expenditure. The estimated food costs and loss of wages were calculated using the number of days of work missed during hospitalization (LOS) and the number of hospital visits to the outpatient department following discharge. The estimated travel expenses incurred to access care were calculated by multiplying the standard cost of travel from the patient’s region of residence and the number of hospital visits. The cost data were converted to the year 2021 values using the Thailand Consumer Price Index (CPI) for medical care [Thailand now provides universal health coverage to all Thais through one of three major public health insurance systems: the Civil Servants Medical Benefit Scheme (CSMBS), which provides medical coverage to government employees and their families, including parents; the national Social Security Scheme (SSS), which provides medical coverage to employees in the private sector; and the National Health Security Scheme, also known as the Universal Coverage System (UCS), which provides medical coverage to all Thais who are not members of the other two groups mentioned above . The coscal care , and theDescriptive results were summarized for continuous variables using mean, median and range, and for categorical variables utilizing frequencies and percentages. Nonparametric testing with Kruskal Wallis test was employed for comparisons between groups of culture organisms, age on admission date, cost of treatment, gender, direct costs, and indirect costs. Statistical significance was set at p-value<0.05, and SPSS V.22.0 was used in all statistical analyses (IBM SPSS Statistics for Windows).A total of 335 patients who had been admitted to the inpatient department were included, and their medical records from the inpatient and outpatient department relating to the same disease episode were analyzed. The majority of patients were male . Age at presentation ranged from 7 to 88 years with a mean of 54.12 years (SD 17.7 years), and just under half  were aged between 30 and 60 years. All patients had received topical medications from their primary/secondary care provider before presenting at our hospital. After classifying the infections based on clinical findings at presentation, out of the total 335 eyes revealed that 47.2% (158 eyes) were treated for bacterial infections, 37.9% (127 eyes) for fungal infections, 10.4% (35 eyes) for mixed bacterial and fungal infections, 2.7% (9 eyes) for viral infections, and only 1.8% (6 eyes) for parasitic infections. The classification of mixed bacterial and fungal infectious keratitis was based on the clinical history and findings of polymicrobial keratitis, which included the use of contact lenses, advanced age, the use of steroids, indistinct edges of the infiltrate, and the presence of ring infiltrate [When cultured, 118 patients (35.2%) were found to have no growth for all organisms, 119 patients (35.5%) had positive culture for bacteria, 91 patients (27.2%) had fungal infections, 4 patients (1.2%) had positive culture for virus, 3 patients (0.9%) had parasitic infections which were all Acanthamoeba species. Prior to presenting at our hospital, patients’ median duration of symptom onset was 14.0 days (range 1–180 days). Median LOS was 15 days (range 1–74 days); median clinical visits after discharge from hospital until final follow-up of disease episode was 4 (range 1–16); and median treatment duration was 152 days (range 7–2328 days). At first presentation, 6 patients (1.8%) had vision better than 20/60, 18 (5.4%) had vision ranging from 20/60 to 20/200, 8 (2.4.%) had vision range worse than 20/200 to 20/400, 277 (82.7%) had vision worse than 20/400 to light perception (PL), and 26 patients (7.8%) had vision with no light perception in the affected eye. At final follow-up, 48 patients (14.3%) had vision better than 20/60, 28 (8.4%) had vision range from 20/60 to 20/200, 7 (2.1%) had vision range worse than 20/200 to 20/400, 149 (44.5%) had vision worse than 20/400 to PL, and 103 (30.7%) had vision with no light perception in the affected eye.Almost half of the patients  did not receive TPK or evisceration/enucleation. Evisceration/enucleation was performed on 79 patients (23.5%) who had severe corneal infections that did not respond to treatment. TPK was performed on 101 patients (30.1%), while 7 individuals who had previously undergone TPK surgery required evisceration/enucleation due to recurrent infection on the corneal graft. The most common causative pathogen for evisceration/enucleation was bacteria , but the most prevalent pathogen in patients who had evisceration/enucleation after previous therapeutic keratoplasty was fungus . Eleven patients had undergone more than one TPK, and most of these had bacterial infections. The duration of symptom onset before presentation at the hospital, LOS, and number of follow-up visits according to cultured organisms. There was no statistically significant difference between these three factors in patients with negative and positive culture, p-value 0.432, 0.446, and 0.054 respectively. Among culture-positive patients, those with parasitic infections had the longest duration of onset of symptoms before hospital presentation, and this figure was statistically significant at p-value 0.004. Patients with fungal infection had the longest LOS among the culture-positive cases, and this was statistically significant at p-value 0.007. There was no significant difference between the number of follow-up visits required by culture-positive patients and their negative counterparts. Among the former, type of infection was not a significant factor. There was a statistically significant difference in the number of surgical treatments, BCVA at presentation, and BCVA at final follow-up visits between patients with negative and positive culture, with p-values of <0.001, <0.001, and <0.001, respectively. The median direct cost was US$65.2, range US$ 6.5–1,119.1 . Median indirect cost was US$314.5, range US$50.8–1,067.5 , and median total cost was US$426.1, range US$57.5–1,971.5 . Among all age groups, people in the age range 30–60 years old had the highest direct, indirect, and overall total cost of treating severe IK, and these figures were statistically significant . There was no statistically significant difference between males and females in terms of direct and indirect costs , but overall total cost was significantly higher in males than in females with p-value 0.035.This study is the first to analyze the direct and indirect costs of treating severe IK patients in Thailand who require hospitalization. As a secondary objective, it aimed to determine whether type of organism had any effect on treatment costs. In our research, more than half of the patients were male, with a median age of 55 years (range 7–88 years), which is similar to that of a previous ACSIKS study of subjects in 8 Asian countries, including Thailand, which found that the majority of IK patients were male, with a median age of 46.0 years (range 0.08–95 years) . Using aA review of 20 studies found that the overall median culture positivity rate from clinically diagnosed cases of IK was 50.3%. (range 32.6%–79.4%) . Even thSome studies have found differences in BCVA between patients with culture-positive and culture-negative IK at presentation. The study by Ting DSJ et al. , which wOther studies have been conducted to assess the economic impact of IK , 23, 24.The median indirect cost of having one episode of severe keratitis was US$314.5, range US$50.8–1,067.5 . There was no difference between indirect costs for patients with negative and positive culture. Among culture-positive patients, parasite infections led to the highest median total indirect cost, primarily resulting from costs incurred during the follow-up period in the outpatient department. Patients with parasite infection had the highest median costs in all categories during the follow-up period in the outpatient department, even though it was not statistically significant in each category. Of the culture-positive cases, those with fungal infections incurred the highest median indirect inpatient care cost. The main financial factor was LOS, probably because patients with fungal infections had the highest LOS in our study . This finding was consistent with those of a study in the UK, where the LOS for fungal keratitis was found to be 18.9 days (SD 16.3 days)  found thBesides the burden placed on patients by their loss of wages during hospitalization, prolonged LOS is also a drain on hospital resources. The number of hospitalizations is an important factor when calculating direct costs such as service and medical professionals’ disbursements. When assessing the indirect cost of patients’ loss of wages, the LOS and number of hospital visits during the follow-up period were significant multipliers; therefore, reductions in these two areas are important factors in lowering the financial burden shouldered by patients. However, indirect cost is thought to be a factor that is determined by the patient’s residential area, occupation, and socioeconomic circumstances rather than disease characteristics. As a result, each patient’s actual expense would be more detailed and represent the actual indirect costs of severe IK treatment rather than the average standard indirect costs from HITAP. This is additionally one of the important considerations.Our results indicate that patients with lower initial BCVA at presentation tend to have higher treatment costs, with cases of initial BCVA of less than 20/400 to PL incurring the highest direct, indirect, and overall costs. Patients with initial BCVA of NPL had the lowest treatment costs in this study; however, this does not necessarily imply an improvement in their IK. It is more probably attributable to the fact that these patients had severe infections and required evisceration/enucleation early in their treatment, resulting in a shorter LOS , and also fewer medications, surgical interventions, and follow-up visits. The BCVA at initial and final follow-up, together with the costs associated with each BCVA group level, provides us with an insight into the costs associated with treating every disease episode of severe IK in each BCVA category. The majority of patients in the study had initial and final BCVA at follow-up of 20/400 to PL, and this group had the highest treatment costs; however, the treatment effort and costs did not improve the patients’ BCVA, but rather merely maintained their level of vision.The median total cost was US$426.1, range US$57.5–1,971.5 , with indirect costs representing by far the largest proportion of expenditure at 73.8%. There was no difference between total costs incurred by patients with negative and positive cultures, but among the latter, those with fungal cultures accounted for the highest total cost . The World Data Atlas shows that annual health expenditure per capita in Thailand was US$296 in 2019 . This meThe data also show that Thailand’s general government health expenditure to current health expenditure ratio was 71.7%. This reflects the government’s primary concern regarding controlling healthcare costs, particularly by reducing the incidence of preventable diseases such as IK. Increasing public awareness and knowledge of the risk factors, early signs, and symptoms of IK is essential, as is encouraging the wearing of safety equipment while working in industry, driving, doing construction work, gardening, or engaging in sport. Other desirable measures include informing people how to properly wear and care for contact lenses, developing and effectively implementing teleophthalmology between regional and local health care systems, as well as between medical professionals and patients, in order to aid in early diagnosis, timely treatment, and monitoring of diseases. All of these interventions may result in lower overall healthcare costs throughout the treatment process.This economic burden study was solely focused on treating episodes of severe IK and did not take into account the concomitant consequences of patients’ impaired vision, such as depression, which should not be overlooked. Rasendran C, et al.  showed tThis study has some limitations. First, the data were collected in a single tertiary care hospital in the central region of Thailand, so the findings are not representative of hospitals in other parts of the country. Since all these patients were referred from elsewhere after failing to respond to medications, they were more likely to have complicated and severe conditions that required additional management, potentially resulting in an overestimation of normal expenditure in our study. Second, we focused on patients with severe IK only and did not attempt to reflect the cost of treatment for all levels of severity. Clearly, mild and moderate cases of IK would be less expensive to manage because there would be no hospitalization and little surgical intervention required, so that the average cost of treatment of IK of other severity levels might be lower. Third, the indirect costs in this study were estimations rather than actual expenses because they were derived from the HITAP website’s average standard cost list rather than directly from each patient, and the loss of wages of accompanying persons was not calculated as part of the indirect care cost because the number of accompanying persons was not recorded. Fourth, 17 patients who had multiple hospitalizations during the same IK episode were excluded from the study. Such patients with multiple hospitalizations frequently have complicated diseases requiring more investigation and treatment than usual; therefore, the estimated cost of treatment in this study might be underestimated.Severe IK can cause serious vision impairment or blindness. This study provides information on the economic burden of treating severe IK in Thailand. There was no difference between direct, indirect, and total costs of treatment of severe IK for patients with negative or positive culture; however, among the culture-positive cases, fungal infections entailed the highest total cost of treatment.


Childhood obesity is a global public health problem. Worldwide, 41 million children under 5 years and 340 million children and adolescents between 5 and 19 years are overweight. In addition, the recent COVID-19 epidemic has further amplified this social phenomenon. Obesity is a condition associated with various comorbidities, such as nonalcoholic fatty liver disease (NAFLD). The pathophysiology of NAFLD in obesity is intricate and involves the interaction and dysregulation of several mechanisms, such as insulin resistance, cytokine signaling, and alteration of the gut microbiota. NAFLD is defined as the presence of hepatic steatosis in more than 5% of hepatocytes, evaluated by histological analysis. It can evolve from hepatic steatosis to steatohepatitis, fibrosis, cirrhosis, hepatocellular carcinoma, and end-stage liver failure. Body weight reduction through lifestyle modification remains the first-line intervention for the management of pediatric NAFLD. Indeed, studies suggest that diets low in fat and sugar and conversely rich in dietary fibers promote the improvement of metabolic parameters. This review aims to evaluate the existing relationship between obesity and NAFLD in the pediatric population and to assess the dietary patterns and nutritional supplementations that can be recommended to prevent and manage obesity and its comorbidities. The spread of obesity is reaching increasingly alarming proportions, both among adults and children ,2. ChildThis review aims to evaluate the existing relationship between obesity and NAFLD in the pediatric population and to assess the dietary patterns and nutritional supplementations  that can be adopted to prevent and manage childhood obesity and its comorbidities.We searched for human clinical studies published in English from January 2012 up to December 2022 in children (<18 years old) with obesity and NAFLD. The research was conducted through the PubMed database, with the following keywords: “NAFLD”; “childhood and steatosis”; and “childhood obesity”. Studies were firstly evaluated on the abstract and then included in the paper if they met our inclusion criteria. Then, a further search was conducted through citations of included articles to identify other suitable works.2) [Childhood obesity is one of the most serious public health challenges affecting every country in the world. The WHO defines obesity as a clinical condition characterized by excessive body weight due to fatty tissue accumulation to an extent that adversely affects the health status. To define if a subject is underweight, normal weight, overweight, or affected by obesity, the BMI calculation is used. It derives from a mathematical ratio between weight (expressed in kilograms) and height (expressed in meters square) (kg/m2) . General2) . At olde2) . DiagnosTo assess a child’s proper growth and weight status, it is necessary to take into consideration anthropometric parameters such as weight, length up to age 2, and height from then on .The measurement of waist circumference is useful too, based on the strong correlation between the distribution of body fat and metabolic complications. Thus, it is a good practice to determine the ratio between waist circumference and height in overweight children older than 5 years old. A value higher than 0.5 irrespective of sex, age, BMI, and ethnic group is associated with increased cardiovascular risk factors . In addiThe United Nations Sustainable Development Goals aim at eradicating hunger and all three forms of malnutrition  everywhere in the world by 2030 . UnfortuData published in 2019 by the OECD “Organization for Economic Cooperation and Development” showed that in 2016 the rates of pre-obesity and obesity in children and adolescents (5–19 years old) in OECD countries were 18.7% and 9.9%, respectively. In particular, the United States had the highest prevalence of pre-obesity (20.4%) and obesity (21.4%) followed by New Zealand, Greece, and Italy .Italy is a member of the WHO’s project called “Childhood Obesity Surveillance Initiative” (COSI), which collected data from 411 thousand children between 6 and 9 years old during the three-year period 2018–2020 . The oveData from the Italian survey “Okkio alla salute”, published in 2019, showed that overweight children were 20.4% and children affected by obesity were 9.4%. This survey confirmed that boys have a slightly higher obesity rate than girls . A geographical distinction was also observed; in fact, southern Italian regions showed higher rates of excess of weight in both genders than northern regions .Childhood obesity is associated with numerous comorbidities, such as type 2 diabetes mellitus (T2DM), dyslipidemia, obstructive sleep apnea (OSA), and hepatic steatosis, which were formerly considered as “adult” diseases. The risk of developing these comorbidities is typically related to the severity of obesity .One of the repercussions of the epidemic spread of obesity is an increase in the prevalence of a condition known as “fatty liver” or hepatic steatosis. Currently, the term NAFLD seems to be not adequate for children because it cannot be associated with alcohol consumption, thus the new term “pediatric fatty liver disease (PeFLD)” seems to be more correct . HoweverIt comprises a wide spectrum of liver diseases, ranging from triglyceride accumulation in the hepatocytes (simple hepatic steatosis or NAFLD) to various degrees of inflammation and fibrosis  to cirrhosis .Pediatric NAFLD is defined as chronic hepatic steatosis in children (<18 years old), not dependent on genetic or metabolic disorders, infection, steatogenic drug use, alcohol consumption, or malnutrition .In both adults and children, NAFLD is frequently associated with all the manifestations related to insulin resistance , such asThe prevalence of this condition in children is very heterogeneous and varies according to the degree of obesity, ranging from 9.6% in normal-weight children to 38% in those affected by obesity ,25.NAFLD is more prevalent in males than females, both before and during puberty . The difTo simplify the pathogenesis of NAFLD, the multiple-hits hypothesis is used . Indeed,Several genes that encode proteins and regulate lipid metabolism are associated with pediatric NAFLD. These genes include Patatin-like phospholipase domain containing 3 (PNPLA3), glucokinase regulatory protein (GCKR), and transmembrane 6 superfamily member 2 (TM6SF2) ,33, and Hepatic steatosis is reversible, and in its pathogenesis four mechanisms are involved: (1) increased absorption of fatty acids by the liver; (2) reduced transport of fat as triglycerides in the very low-density lipoprotein (VLDL); (3) decreased β-oxidation of free fatty acids; and (4) increased de novo lipogenesis (DNL) in the liver .It has been observed that the accumulation of triglycerides and insulin resistance are central features in the development of hepatic steatosis ,33. SubjIn addition, the hypertrophy and increased size of fat cells facilitates the infiltration of macrophages into the fat that produce pro-inflammatory cytokines/chemokines, such as Tumor Necrosis Factor-α (TNF-α), Interleukin-6 (IL-6), and Monocyte Chemoattractant Protein-1 (MCP-1) . These mOxidative stress, or “REDOX imbalance”, also plays an active role in the development of NAFLD and its progression into NASH . It denoThe liver is an organ involved in numerous activities, for instance it regulates micronutrient metabolism, the modification of which can lead to the onset of NAFLD . Indeed,Physiologically, to ensure the oxidation of toxins and facilitate their excretion, biotransformation processes produce ROS. However, an overload of toxins and a deficiency of antioxidants  results in tissue damage and inflammation .n-3 PUFA supplementation, reduces oxidative stress, the onset of NAFLD, and progression to hepatocellular carcinoma [In fact, in some clinical studies it is shown how the use of antioxidant molecules, such as vitamin E and hydroxytyrosol  and n-3 arcinoma .The adipose tissue normally secretes adipokines, specifically leptin and adiponectin . ExcessiDuring puberty, the prevalence of hepatic steatosis is twice as high in males as in females with obesity. It depends on several factors: exogenous influences (diet) and levels of sex hormones (androgens and estrogens) and adipokines (leptin and adiponectin) . RegardiAdipokines show a sex-dependent pattern too. In boys and girls with obesity, leptin is elevated throughout puberty with a tendency to increase in girls and decrease in boys, probably due to the effect of androgens. In contrast, adiponectin levels are similar in males and females at the beginning of puberty, but decrease significantly through puberty. In males, however, there is a more severe adiponectin reduction due to elevated androgen levels, which are inversely proportional to adiponectin concentrations. Hence, in males, lower levels of estrogen, higher levels of androgens, and lower levels of both leptin and adiponectin, in respect to female concentrations of these hormones, tend to comprehensively promote greater progression of NAFLD .Thus, as a preventive measure, children with obesity should undergo instrumental or laboratory screening to identify NAFLD . As recoIn addition, the finding of liver hyper-echogenicity (bright liver) on ultrasonography (US), with or without increased transaminases, raises suspicion of NAFLD .It is also important to exclude other causes of hepatopathy . In selected cases by the pediatric gastroenterologist/hepatologist, liver biopsy should be indicated, although it has its contraindications due to its invasiveness .In addition, as evidenced by studies in children with histologically confirmed NAFLD diagnosis, the use of serum markers such as retinol-binding protein 4, cytokeratin 18, and hyaluronic acid, which is related to the degree of liver damage and fibrosis, is promising ,52.Non-invasive investigations  are also promising, but their use is not still recommended in children .There is evidence that NAFLD is influenced by the gut microbiota. To describe the link between the gut and the liver, the term “gut-liver axis” has been coined. Through the portal vein, the liver receives most of its blood supply from the intestine after nutrient digestion and absorption and is therefore one of the organs most exposed to potentially toxic factors. Thus, quantitative and qualitative variations in the microbiota composition can actively contribute to the pathogenesis of several liver diseases, including NAFLD, alcoholic steatohepatitis, and cirrhosis ,55.Indeed, patients with NAFLD exhibit small intestinal bacterial overgrowth (SIBO) and increased intestinal permeability that exposes the liver to toxic microbial metabolites ,57. FurtBradirizobium, Anaerococcus, Peptoniphilus, Propionibacterium acnes, Dorea, and Ruminococcus and reduced proportions of Oscillospira and Rikenellaceae compared to healthy controls.Del Chierico et al. evaluated gut microbiota changes in pediatric patients with NAFLD using targeted metagenomics and metabolomics . OverallFaecalibacterium, Akkermansia, and Bifidobacterium adolescentis), while harmful bacteria  were numerous [In addition, a recent case–control study of 75 children aged 7–16 years evaluated the role of the gut microbiota in the development of NAFLD. Through 16S ribosomal RNA amplicon sequencing, the composition of the fecal microbiota was assessed . It was numerous .Clostridia and Bacteroidia , has been seen. These bacteria are associated with glucose, lipid, and water electrolyte metabolism  [In children with NASH, an abundance of butyrate-producing bacteria, r, etc.) . This coIn addition, several studies on fecal microbiota in children and adolescents with NAFLD have shown intestinal dysbiosis  ,62. In pThe disruption of intracellular tight junctions causes an increased gut permeability and it determines the passage of lipopolysaccharides (LPSs) from the gut to the circulation . LPSs, dThe process that leads to the onset of steatosis with the passage of bacterial endotoxins to the liver via the portal vein is defined as “endotoxemia” .Diet may alter the gut microbiota. An increased consumption of processed foods has caused a rise in the ingestion of fructose from 30% to 500% in the last 40 years . Indeed,Following a healthy, balanced diet is essential to receive an adequate amount of micronutrients, which can also influence the immune system . PatientVitamin E is a free radical scavenger, so it plays a protective role against oxidative stress that can lead to the progression from NAFLD to NASH. Since vitamin D absorption depends on the gut’s ability to absorb dietary fat, individuals with fat malabsorption associated with diseases such as certain forms of liver disease, cystic fibrosis, celiac disease, and inflammatory bowel disease  are more vulnerable to vitamin D deficiency. In addition, subjects with obesity (BMI ≥ 30) may have blood vitamin D (25-hydroxyvitamin D) values lower than normal-weight subjects because an excess of subcutaneous fat sequesters most of the vitamin and alters its release into the circulation . FurtherIn fact, Nobili et al. demonstrated a negative correlation between vitamin D levels and the severity of NAFLD and fibrosis in 73 children with high aminotransferase levels and hyperechogenic liver on ultrasonography . AdditioIn the literature, there are no studies regarding omega 3 deficiency in children with NAFLD. In general, omega 3 is important for an efficient insulin action. In fact, a decreased concentration of PUFAs could be associated with a reduced insulin sensitivity, especially in the muscle cell membranes .From a therapeutic point of view, the primary treatment for pediatric NAFLD is lifestyle modification: improved eating habits and increased physical activity ,85. GradSome dietary interventions have been evaluated in the pediatric population with obesity, such as the control of portion sizes, the glycemic load reduction, low-carbohydrate diets, meal replacement and time-restricted feeding, as well as very-low-calorie diets and protein-sparing modified fasting for cases of more severe obesity ,88,89,90Ramon-Krauel et al. compared, in a 6-month study, two different dietary patterns: a low-glycemic diet and a low-fat diet in 17 children with obesity and hepatic fat fraction (HFF) > 9%. Both nutritional protocols were effective in significantly reducing ALT and HFF, without differences between the two groups .It is clear, however, that to manage the excess of body weight in children, as well as in adults, a dietary plan is effective if it can be sustained over a long period of time ,93. Thusn-3 polyunsaturated fatty acids (PUFAs) [According to the international guidelines, NAFLD management requires a reduced intake of calories, fats , and fructose and, conversely, an increased intake of proteins , dietary fibers, and  (PUFAs) .At present, although the type of dietary pattern recommended in cases of NAFLD has not yet been defined, some studies suggest that a “diet low in free sugars”  ,99 and aThe current WHO guidelines suggest that the daily intake of free sugars should be limited to less than 10% for all people and less than 5% in specific circumstances .Several recent studies suggest that a high intake of added sugars , included in the preparation of food and beverages, plays a role in the onset of NAFLD because they contribute to increasing glucose and fructose intake in the diet. Children tend to consume added sugars through sugar-sweetened beverages (SSBs) .Sullivan et al. demonstrated that children with NAFLD are able to absorb and metabolize fructose more efficiently than lean subjects . SchwimmMager et al. conducted a study on 7- to 18-year-old subjects with NAFLD and healthy controls, evaluating the effects of a modest reduction in fructose intake  and of load and glycemic index on improving plasma markers of hepatic dysfunction and cardiometabolic risk . SpecifiIn another study, Schwarz et al. evaluated for 9 days the effect of a reduced fructose consumption in 41 nondiabetic Latino and African American children with obesity and metabolic syndrome identified as habitual high sugar consumers  regardless of calories consumed . On day The Mediterranean diet (MD) was first coined by Dr. Ancel Keys and in 2010 it became an intangible heritage of humanity by UNESCO. This nutritional pattern has been and currently is the meeting point between cultures and populations around the Mediterranean basin . This nuIn fact, Della Corte et al. evaluated the impact of the Mediterranean diet on children with obesity and NAFLD. Specifically, 243 patients with obesity were enrolled and they underwent abdominal ultrasonography and laboratory analysis; a subgroup of 100 children also underwent biopsy . A cliniAlthough in the literature there is a lack of trials in the last 10 years on the use of supplements in children with NAFLD; various trials based on the use of antioxidants (particularly vitamin E), vitamin D, docosahexaenoic acid (omega-3), and probiotics have been tested with different results on NAFLD or NASH in children.-The anti-inflammatory response is promoted by the vitamin’s action in reducing the expression of cytokines such as (TNF-α), interleukin (IL)-1, IL-2, IL-4, IL-6, and IL-8, and in increasing the levels of adiponectin, which suppresses hepatic fatty acid synthesis, reduces liver fibrosis, and prevents cirrhosis ,117,118.-The antioxidant effect is enhanced by an increased production of superoxide dismutase (SOD) and acts as a scavenger of hydroxyl, peroxyl, and superoxide radicals, protecting against lipid and low-density lipoprotein (LDL) peroxidation. Thus, increased consumption of vitamin E limits the increased oxidative stress typical of patients with NAFLD. In addition, vitamin E also stimulates the action of antioxidant enzymes, including catalase and glutathione peroxidase ,119.-The antiapoptotic effect is due to increased levels of the antiapoptotic protein BCL-2 and decreased levels of the proapoptotic proteins BCL-2 associated-X (BAX) and p53. Furthermore, vitamin E limits the activity of caspase-9 and cytochrome C, which regulate mitochondrial apoptosis, and caspases-8 and 3, involved in the apoptotic pathway .Oxidative stress plays a crucial role in the progression from NAFLD to NASH, and consequently the use of antioxidant molecules that can modulate stress is being evaluated. Alpha-tocopherol (vitamin E) is the most widely studied antioxidant in cases of liver disease in the pediatric age group ,114 becaVitamin E has been suggested to manage liver disease alone or in combination, but a limitation of its use is its bioavailability when administered with oral preparations, the dosage, and the lack of long-term studies .Ghergherehchi et al. conducted a double-blind placebo study on 33 children with obesity and NAFDL and allocated them to either a lifestyle modification + vitamin E (400 IU) group or a lifestyle modification + placebo group for 6 months. Both groups followed a hypocaloric diet and 2 h of physical activity every day. In both groups, significant changes in BMI, ALT, AST triglycerides, and total and LDL cholesterol were observed and the mean difference between the two groups were not significant, except for LDL cholesterol. Thus, they declared that vitamin E supplementation was not more efficient than placebo in improving steatosis in children with obesity and NAFLD .D’adamo et al. conducted a 6-month study on 42 prepubertal children with obesity and NAFLD that were equally allocated to either a vitamin E supplementation intervention group (group 1) and a control group (group 2). Both groups received nutritional and physical activity recommendations and only group 1 also received 600 mg/day of vitamin E. The results showed a significant reduction in BMI, waist circumference, and fasting glucose in both groups compared to baseline. Only in group 1 were a significant decrease in HOMA-IR, insulin, total cholesterol, LDL-cholesterol, and ALT and an increase in HDL cholesterol observed. Obviously, only in the treated group, a significant increase in the concentration of vitamin E levels (es-RAGE) and a decrease in the concentration of the marker of oxidative stress (PGF-2α) were assessed. Moreover, variations in vitamin E were associated with changes in ALT, HOMA IR, and total cholesterol independently of BMI reduction. Thus, vitamin E has determined a reduced level of oxidative stress and of LDL cholesterol, and an improvement in insulin and lipid profile . The redVitamin E supplementation has also been evaluated in addition to hydroxytyrosol (HXT) or to ursodeoxycholic acid (UDCA). The first one is a phenol found in extra virgin oil and, in addition to vitamin E, it has been seen to improve oxidative stress, insulin resistance, and steatosis in children ,125. NobTwo years later, the same group of authors published an article on the same population evaluating the effects of HXT+VitE on systemic inflammation . At the Regarding the role of the ursodeoxycholic acid (UDCA), it has been seen that it is able to antagonize the progression of NAFLD/NASH  through Vitamin D is a fat-soluble hormone and it is synthetized in the skin by solar exposure and it is converted to a biologically active form firstly in the liver and then in kidneys.Thus, hepatic dysregulation may also be involved in the impaired vitamin D metabolism. It regulates bone metabolism and calcium homeostasis, but it also has a role in hepatic fibrogenesis ,78.Currently, there are no FDA-approved drugs for the treatment of NAFLD. However, vitamin D, because of its good insulin-sensitizing and anti-inflammatory properties, could be a good treatment option for patients with NAFLD .The only study that evaluated the effects of vitamin D supplementation in children was the one of El Amrousy et al. They conducted a 6-month randomized controlled clinical trial on 100 children with biopsy-proven NAFLD to assess the effectiveness of vitamin D supplementation. Patients were randomly assigned into two groups: a treatment group (2000 IU/day of vitamin D) and a placebo group. They evaluated anthropometric parameters, vitamin D and serum calcium levels, AST, ALT, total cholesterol, triglycerides, LDL and HDL cholesterol, fasting glycemia and insulinemia, and HOMA-IR. At the end of the study, significant improvements in hepatic steatosis and lobular inflammation by liver biopsy and a decrease in AST, ALT, triglycerides, LDL, fasting insulin, and glycemia and HOMA-IR were observed. Moreover, vitamin D levels and HDL cholesterol significantly increased in the treated group. This study suggests that vitamin D supplementation may be useful for children with NAFLD .Polyunsaturated fatty acids (PUFAs) comprise the ω-3 series: α-linolenic acid , eicosapentaenoic acid , and docosahexaenoic acid  and the ω-6 series: linoleic acid , g-linolenic acid (18:3), and arachidonic acid (20:4 ARA). They are essential, in fact human cells are able to synthetize them in small amounts, the majority must be provided by an adequate nutritional intake . The ω-3Pacifico et al., in a double-blind, parallel-group, placebo-controlled randomized trial, evaluated the effect of a six-month DHA treatment in the pediatric population compared to a placebo group in reducing hepatic and visceral fat and associated cardiovascular disease (CVD) risk factors . ChildreJanczyk et al. observed, in a 6-month randomized multicenter double-blind placebo-controlled trial, the effect of omega 3  supplementation compared to placebo (sunflower oil in the same dose) in 76 children aged 6–19 with NAFLD. All patients were invited to follow a hypocaloric diet and to increase physical activity. ALT and GGT significantly decreased but no changes were observed in ALT levels compared to baseline .In another study, DHA supplementation (250 mg/day and 500 mg/day) in 60 children with NAFLD allocated to three groups for 1 year reduced both triglyceride and ALT levels and improved steatosis compared to the placebo group. The different dosage was equally effective in reducing liver fat content .n-6 FAs after the treatment [Spahis et al. conducted a 6-month double-blind, one-way, crossover randomized trial in 2015 on 30 children aged 8–18 years with obesity and NAFLD. They were randomly assigned to two groups. The first phase of the study consisted of administering an omega 3 supplementation (2 g of fish oil/daily providing 1.2 g of omega 3) to a group and a placebo (sunflower oil) to the other group for 3 months, while in the second phase both groups received the omega 3 supplementation for the last 3 months. The supplementation was provided by four capsules containing 500 mg of fish oil (300 mg of omega 3 with 3.75 U vitamin E), while the placebo was composed of 500 mg of sunflower oil with 3.75 U vitamin E. Only 21 out of 30 subjects completed the study. NAFLD children presented higher values of ALT, fasting insulin levels, HOMA-IR index, C-reactive protein, TG levels, and lower levels of HDL cholesterol at baseline compared to 33 healthy children. The 21 NAFLD children showed an increase in the proportion of EPA and DHA at the expense of reatment .n = 20), the severity of disease by assessing transaminase levels, liver ultrasound, NAFLD activity score, and fatty liver index (FLI) across two groups: 9 with mNAFLD (moderate fatty liver) and 11 with sNAFLD (severe fatty liver) [n-3 PUFAs for 6 months. At the end of the n-3 PUFA treatment, there was a significant increase in EPA and DHA concentrations in red blood cells and a reduction in FLI, ALT, and ALT/AST ratio, with signs of improvement of hepatic steatosis. In addition, an improvement was observed in both carotid intima thickness and lipid profile with reduction in TG, LDL-C, and Apo B, as well as Apo B/AI, total cholesterol/HDL-C, LDL-C/HDL-C, and Apo B/TG ratios, without improvement in HDL-C, Apo A-I, and Apo family members. In treated patients, reductions in serum oxLDL, leptin, and acyl ghrelin, and an increase in adiponectin (signs of improvement in oxidative stress and inflammation associated with the disease) were also detected [n-3 PUFA in patients with these metabolic abnormalities is useful not only in reducing NAFLD, but also in preventing serious complications such as diabetes and cardiovascular disease [Some years later, the same group evaluated, on the same subjects (y liver) . The mNAdetected . Thus, t disease .One hundred and eight children (9–17 years old) with NAFLD were included in the double-blind treatment of Boyraz et al. and they were randomly assigned to either a PUFA group (diet + 1000 mg dose of PUFA) or a placebo group (diet + placebo) for 12 months + a dietary lifestyle intervention. The PUFA intervention determined higher HDL levels and lower Triglycerides, insulin, glycemia, and HOMA-IR .Regarding omega 3 consumption, the studies’ results provide a strong recommendation that children with NAFLD should consume the appropriate quantity of fish per week or they have to be supplemented with omega-3 . HoweverOnly one study in the literature compared DHA + vitamin D in 41 children (4–16 years) with NAFLD and vitamin D deficiency (<20 ng/dL). The children were randomized to the treatment arm or the placebo arm. Treatment consisted of a mixture of vitamin D + DHA orally once daily versus placebo for 24 weeks. For the dosage of DHA, the aforementioned study by Nobili et al. was taken into account, while for that of vitamin D, the American Academy of Pediatrics’ recommendation of administering between 600 and 1000 IU/day in adolescents at risk of vitamin D deficiency was used. Treatment improved insulin resistance, lipid profile, and ALT compared to placebo, and biopsies showed an improvement in liver damage (NAFLD activity score) .Probiotics are nonpathogenic living micro-organisms which may affect the health of the host by regulating the intestinal microbiota, producing antibacterial substances, improving epithelial barrier function, and reducing intestinal inflammation ,147,148.Although the molecular mechanism of probiotics is still not completely understood, it is clear that they can be used in the treatment of NAFLD as they modulate the gut microbiota. They also improve intestinal mucosal permeability and inhibit the inflammatory response .Certainly, a better knowledge about the various bacterial species that populate the gut of individuals with NAFLD warrants a selection of appropriate probiotics to improve liver status. Commercially available probiotics are Bifidobacterium and Lactobacillus. Furthermore, it would appear that Bifidobacteria play an active role in the management of NAFLD and obesity . Thus, tBifidobacteria and Lactobacilli in the feces of four groups: (1) children with obesity, (2) children with obesity and NAFLD, (3) children with obesity and NASH, and (4) healthy children. This study showed an increase in Lactobacillus spp. in NAFLD, NASH, and only obesity groups compared to healthy controls. In particular, the L. mucosae strain was significantly higher in the subjects with obesity, NAFLD, and NASH than in the healthy subjects. On the contrary, healthy controls had an abundance of Bifidobacterium spp., indicating their beneficial activity in liver disease [Nobili et al. observed the distribution of intestinal  disease .Lactobacillus acidophilus ATCC B3208, 3 × 109 colony-forming units (CFU); Bifidobacterium lactis DSMZ 32269, 6 × 109 CFU; Bifidobacterium bifidum ATCCSD6576, 2 × 109 CFU; and Lactobacillus rhamnosus DSMZ 21690, 2 × 109 CFU. The 64 patients (10–18 years) had a BMI > 85th percentile. They were equally divided into two groups: intervention and placebo. Although there were no significant changes in weight and body mass index, there was a significant decrease in mean ALT (from 32.8 ± 19.6 to 23.1 ± 9.9 U/L) and AST levels (from 32.2 ± 15.7 to 24.3 ± 7.7 U/L) and waist circumference (from 82.2 ± 14.7 to 80.3 ± 15.1) following the intervention. Finally, an improvement in liver ultrasound was also observed in both the intervention and placebo groups: it was normal in 17 (53.1%) subjects taking probiotics and in 5 (16.5%) of the placebo group [The effectiveness of probiotic compound administration in improving weight and liver ultrasound is also confirmed by another randomized triple-blind study conducted in 64 children with obesity and with NAFLD . In factbo group .Streptococcus thermophilus, Bifidobacteria , Lactobacillus acidophilus, L. plantarum, L. paracasei, and L. delbrueckii subsp. bulgaricus) [An additional study conducted by Alisi et al. evaluated the beneficial effect of VSL#3 in children with obesity and steatohepatitis . VSL#3 igaricus) . The stugaricus) .Furthermore, the study by Goyal et al. evaluated the effects of VSL#3 in 116 children and adolescents (5–18 years old) with obesity and NAFLD. They divided them into four groups: (1) VSL#3 + lifestyle modification, (2) VSL#3, (3) lifestyle modification, and (4) placebo for 4 months. They assessed anthropometrical parameters  and also biochemical parameters to evaluate lipid profile, fasting glycemia, high-sensitivity C-reactive protein, uric acid, and obesity hormones. The results showed that group 1 had better results both on anthropometric and biochemical parameters compared to probiotic and lifestyle modification alone .n = 43) or a placebo (n = 41) group. Both groups received a structured diet and physical activity advice. After 6 months, BMI decreased in both groups [Rodrigo et al. conducted a double-blind randomized placebo-controlled trial to evaluate the effects of probiotics on metabolic condition in 84 children (5–15 years old) with obesity and NAFDL. They were randomized either into a probiotic (h groups . Strangeh groups .Although NAFLD is one of the most common pediatric diseases and is now considered the hepatic manifestation of metabolic syndrome, a lack of recent clinical trials is present in the literature . InterveHowever, to date, it has not been defined which type of dietary treatment is most suitable in coping with this condition. There is a consensus in the literature that both the low-free-sugar diet and the Mediterranean diet are beneficial ,100. In In addition, the use of vitamin E, vitamin D, omega-3, and probiotics represents a good option to counteract NAFLD, blocking the development of fibrosis and the progression of liver disease ,157. IndAs there is a lack of trials in the pediatric population, further studies are needed to deeply evaluate which nutritional treatment and supplements are the most suitable in the management of NAFLD in children.


Bronchiolitis is the most common lower respiratory tract infection (LRTI) in children and is mainly caused by the Respiratory Syncytial Virus (RSV). Bronchiolitis presents seasonally and lasts about five months, usually between October to March, with peaks of hospitalizations between December and February, in the Northern Hemisphere. The burden of bronchiolitis and RSV in primary care is not well understood.This retrospective analysis used data from Pedianet, a comprehensive paediatric primary care database of 161 family paediatricians in Italy. We evaluated the incidence rates (IR) of all-cause bronchiolitis , all-cause LRTIs, RSV-bronchiolitis and RSV-LRTIs in children from 0 to 24 months of age, between January 2012 to December 2019. The role of prematurity  as a bronchiolitis risk factor was evaluated and expressed as odds ratio.Of the 108,960 children included in the study cohort, 7,956 episodes of bronchiolitis and 37,827 episodes of LRTIs were recorded for an IR of 47 and 221 × 1,000 person-years, respectively. IRs did not vary significantly throughout the eight years of RSV seasons considered, showing a seasonality usually lasting five months, between October and March, while the peak of incidence was between December and February. Bronchiolitis and LRTI IRs were higher during the RSV season, between October and March, regardless of the month of birth, with bronchiolitis IR being higher in children aged ≤12 months. Only 2.3% of bronchiolitis and LRTI were coded as RSV-related. Prematurity and comorbidity increased the risk of bronchiolitis; however, 92% of cases happened in children born at term, and 97% happened in children with no comorbidities or otherwise healthy.Our results confirm that all children aged ≤24 months are at risk of bronchiolitis and LRTI during the RSV season, regardless of the month of birth, gestational age or underlying health conditions. The IRs of bronchiolitis and LRTI RSV-related are underestimated due to the poor outpatient epidemiological and virological surveillance. Strengthening the surveillance system at the paediatric outpatient level, as well as at the inpatient level, is needed to unveil the actual burden of RSV-bronchiolitis and RSV-LRTI, as well as to evaluate the effectiveness of new preventive strategies for anti-RSV. Respiratory Syncytial Virus (RSV) is the leading cause of hospitalization in children aged ≤12 months due to lower respiratory tract infection (LRTI), such as pneumonia and bronchiolitis, and represents a significant public health challenge worldwide .Almost every child is infected by RSV at least once by the second year of life. Children with an RSV infection require a medical visit at the paediatric practice in more than 20% of cases; 6% of them need medical assistance at the emergency department, and almost 4% require hospitalization , 4, 5.The yearly global cost of inpatient and outpatient RSV in children <5 years of age was estimated to be €4.82 billion, with 55% of global costs accounting for hospitalizations and 45% for outpatient costs (2017 estimates) .RSV presents seasonally, with outbreaks of infection in the Northern Hemisphere usually lasting five months and occurring between October and March, while the peak of infections may vary between December and February , 4, 5.The nature of RSV disease is unpredictable, and it is challenging to identify in advance which child will develop severe disease . Major rRSV-bronchiolitis lacks etiological prevention and treatment effective for all children. Clinical management is focused on supportive care, while pharmacological treatment with medicines such as bronchodilators, corticosteroids, and antibiotics have limited use in reducing disease severity and are currently not recommended by national guidelines –22. HoweSeveral environmental and behaviour measures are effective in the prevention of RSV-bronchiolitis. Among the most relevant: washing hands before touching the child; cleaning and disinfecting toys, utensils and other frequently touched surfaces; keeping a smoke-free home, car and any space near the child; keeping the child away from people with colds; wearing masks during the RSV season . In addiAlthough there is currently no licensed vaccine or monoclonal antibody to protect all children against RSV available in routine medical practice, there are several candidates in the final phases of clinical trials and the European Medicines Agency recently recommended and authorized nirsevimab to protect all children at their first RSV season , 31. FurThe present study aims to investigate the epidemiologic burden of bronchiolitis in Italy and to describe the seasonality using electronic paediatric primary care data.Pedianet is a national population database that contains anonymous patient-level data of more than 500,000 children since 2004, corresponding to around 4% of the annual paediatric population in Italy , 36–38. Società Servizi Pediatrici, the legal owner of Pedianet, in Padova, Italy. Informed consent is required from children's parents to enter the data in the database and to have Pedianet data linked to other databases, such as the vaccine registry database or the hospitalization database, using unique patient identifiers. Data are manually validated for study-specific conditions, and the accuracy of diagnosis data was verified  of bronchiolitis were expressed as the number of episodes per 1,000 person-years with the appropriate 95% confidence intervals (CI) and were stratified by age group, sex, calendar month, the month of birth, depending on RSV seasonality as in-season cases (October-March) vs. out of season (April-September) and by the four seasons of the year . The Mann-Kendall trend test was used to analyze the trend over time of bronchiolitis incidence. RSV-bronchiolitis prevalence was estimated by dividing the number of RSV-bronchiolitis by the total number of bronchiolitis; RSV-LRTIs prevalence was estimated by dividing the number of RSV-LRTIs by the total number of LRTIs.The role of prematurity in bronchiolitis' onset was investigated and expressed as odds ratio with the appropriate 95% CI.p < 0.05.All analyses were performed using the Statistical Analysis System software . Statistical significance was set at Out of 108,960 children aged ≤24 months included in the study cohort, 7,956 episodes of bronchiolitis were recorded among 6,955 (6.4%) children with at least one episode of bronchiolitis for an IR of 46.6 × 1,000 person-years (95% CI: 45.6–47.6). Of the total bronchiolitis episodes, 388 (5%) were defined as RSV-bronchiolitis for an IR of 2.3 × 1,000 person-years (95% CI: 2.1–2.5). However, the total number of bronchiolitis tested for pathogens is unknown . The IR In children aged ≤24 months, the IR of bronchiolitis was higher during the winter season, January-March  and lower during the summer season, July-September ; higher during the months in the RSV seasonality, October-March  and lower during the months out of the RSV seasonality, April-September  .Considering the month of birth in children aged ≤24 months, IR slightly increased from March  to November ; considering the calendar month, IR sharply increased from August  to January  .N = 6,961) were in children aged ≤12 months . In this population, the IR of bronchiolitis was higher during the winter season, January-March  and lower during the summer season, July-September . IR bronchiolitis was higher during the months in the RSV seasonality, October-March  and lower during the months out of the RSV seasonality, April-September . The IRs in children aged ≤12 months were higher and almost doubled the relative IRs in children ≤24 months of age  (87% of bronchiolitis episodes (.6–47.6) .Out of 108,960 children aged ≤24 months included in the study cohort, 37,753 episodes of LRTIs  were recorded for an IR of 221.4 × 1,000 person-years (95% CI: 219.2 to 223.7); of these, 394 (1%) were caused by RSV. However, the total number of bronchiolitis tested for pathogens is unknown . SimilarN = 18,487) were in children aged ≤12 months . In this group, the IR of LRTIs was higher during the winter season, January-March  and lower during the summer season, July-September . LRTI IR was higher during the months in the RSV seasonality, October-March  and lower during the months out of the RSV seasonality, April-September . All-season and seasonality IRs in children aged ≤12 months were similar to the relative IRs in children ≤24 months of age  (49% of LRTI episodes (2–223.7) .97.5% of bronchiolitis episodes  happened in children with no comorbidities, while 196 episodes (2.5%) happened in children with comorbidities: the most frequent underlying clinical condition was a concomitant cardiovascular disease, present in 107 (1.3%) of the bronchiolitis episodes .Regarding gestational age, 92.2% of bronchiolitis episodes  happened in children born at term, while 624 episodes (7.8%) happened in children born at <37 gestational weeks: in 486 cases (6.1%) children were born moderate to late preterm, having a gestational age between 33 and 37 weeks, while in 138 cases (1.7%) children were born with ≤32 gestational weeks.Being born preterm increased the odds of having bronchiolitis: children with a gestational age between 33 and 37 weeks showed an OR 1.41 (95% CI: 1.27–1.57); children with a gestational age between 28 and 32 weeks showed an OR 1.90 (95% CI: 1.52–2.37); while children with a gestational age ≤27 weeks showed an OR 1.89 (95% CI: 1.20–2.98).This study assessed the burden of bronchiolitis and LRTI in Italy over eight consecutive years using a large paediatric database. Our results show that bronchiolitis and LRTI are responsible for a significant burden in children aged ≤24 months, while bronchiolitis IR are twofold higher in children aged ≤12 months. IRs of both bronchiolitis and LRTI were higher in the winter season and lowered in the summer season; higher in RSV seasonality, October-March, and lower out the RSV seasonality, April-September. None to little variation was seen in the IRs of bronchiolitis and LRTI by the month of birth.Our results are coherent with other epidemiological studies, recently conducted both in Italy and in the Northern hemisphere, that showed that most children with RSV infection requiring a medical visit at a paediatric practice or hospitalization were born at term and healthy –11: thisRegarding RSV infection, only 388 of the 7,956 bronchiolitis episodes were coded as RSV-related (5%). However, the total number of bronchiolitis tested for pathogens is unknown. RSV is well known to be the most common infecting agent in bronchiolitis among children ≤5 years old, and it accounts for 50% to 80% of hospitalization for bronchiolitis in children aged 0–5, and it rises to 80% in children aged ≤12 months .A gestational age ≤35 weeks is considered an eligibility criterion for RSV bronchiolitis prevention with the specific anti-RSV monoclonal antibody palivizumab in the Italian and Spanish guidelines, although many Regions of both countries have restricted the eligibility to 32 and 29 gestational weeks , 41, 42,Our study confirms that all children in their first RSV season are at risk of bronchiolitis and LRTI, regardless of the month of birth, and would support strategies to protect all children against RSV disease. Although, to date, there is no available vaccine or monoclonal antibody in the routine medical practice to protect all children against RSV, several preventive products are in the final stages of clinical trials, while a new long-acting anti-RSV monoclonal antibody, nirsevimab, was recently recommended and authorized by EMA to protect all children at their first RSV season , 31. TheTo our knowledge, this is the first study assessing the burden of bronchiolitis and LRTI with insights into the RSV seasonality at the outpatient level in Italy. The strengths of our study are its size, generalizability and representative coverage of paediatric patients in Italy.There are limitations in estimating RSV incidence due to the poor RSV testing available at the outpatient level. Currently, there is no systematic national surveillance of RSV available in Italy, although a project to include it within the National influenza-like illness Surveillance System (INFLUNET) is ongoing  and a pr2. Strengthening RSV surveillance at the outpatient and inpatient level may unveil the actual burden of RSV disease in children, supporting policymakers in implementing appropriate preventive strategies to protect all children against RSV.In conclusion, our study supports the evidence that bronchiolitis and LRTI waves in Italy usually last five months and present seasonally, between October and March, with a peak between December and February. The major risk factors of bronchiolitis and LRTI are age ≤12 months and age ≤24 months, respectively, and seasonality, with all children being at risk at their first RSV season within October-March, regardless of the month of birth. Although children born preterm and those with comorbidities had a higher risk of bronchiolitis, most cases happened in those born at term (92.2%) and in children with no comorbidities or otherwise healthy (97.5%). Information on RSV-bronchiolitis and RSV-LRTI in the outpatient setting is still lacking, and the actual burden is not fully recognized and may be underestimated by health policy makersInterventions aimed at preventing RSV disease, including introducing anti-RSV vaccines and long-acting monoclonal antibodies, would impact the incidence of bronchiolitis and LRTI in our setting. In order to facilitate universal access to protecting all children from RSV, WHO and ECDC recommended that the National Immunization Advisory Group (NITAGs) consider including these preventive tools within the routine immunization calendar. Further studies focused on the burden of RSV at outpatient and inpatient levels are needed to unveil the true burden of this disease and its impact in the post-Covid19 era. Indeed, having a surveillance system of respiratory pathogens, including RSV, will support health policymakers in implementing and evaluating the effectiveness of those new preventive strategies when they are finally available to protect all children against RSV.