Osteoporosis is a disease characterized by low bone mass and alterations of bone microarchitecture, with an increased risk of fractures. It is a multifactorial disorder that is more frequent in postmenopausal women but can be associated to other diseases (inflammatory and metabolic diseases). At present, several options are available to treat osteoporosis trying to block bone reabsorption and reduce the risk of fracture. Anyway, these drugs have safety and tolerance problems in long-term treatment. Recently, gut microbiota has been highlighted to have strong influence on bone metabolism, becoming a potential new target to modify bone mineral density. Such evidences are mainly based on mouse models, showing an involvement in modulating the interaction between the immune system and bone cells. Germ-free mice represent a basic model to understand the interaction between microbiota, immune system, and bone cells, even though data are controversial. Anyway, such models have unequivocally demonstrated a connection between such systems, even if the mechanism is unclear. Gut microbiota is a complex system that influences calcium and vitamin D absorption and modulates gut permeability, hormonal secretion, and immune response. A key role is played by the T helper 17 lymphocytes, TNF, interleukin 17, and RANK ligand system. Other important pathways include NOD1, NOD2, and Toll-like receptor 5. Prebiotics and probiotics are a wide range of substances and germs that can influence and modify microbiota. Several studies demonstrated actions by different prebiotics and probiotics in different animals, differing according to sex, age, and hormonal status. Data on the effects on humans are poor and controversial. Gut microbiota manipulation appears a possible strategy to prevent and treat osteopenia and/or osteoporosis as well as other possible bone alterations, even though further clinical studies are necessary to identify correct procedures in humans.

Background and aims:The COVID-19 pandemic represents a source of stress and potential burnout for many physicians. This single-site survey aimed at assessing perceived stress and risk to develop burnout syndrome among physicians operating in COVID wards.Methods: This longitudinal survey evaluated stress and burnout in 51 physicians operating in the COVID team of Gemelli Hospital, Italy.Participants were asked to complete the Maslach Burnout Inventory (MBI) and the Perceived Stress Questionnaire on a short run (PSQs) (referring to the past 7 days) at baseline (T0) and then for four weeks (T1-T4). Perceived Stress Questionnaire on a long run (PSQl) (referring to the past 2 years) was completed only at T0. Results:Compared with physicians board-certified in internal medicine, those boardcertified in other disciplines showed higher scores for the Emotional Exhaustion (EE) score of the MBI scale (P < .001). Depersonalisation (DP) score showed a reduction over time (P = .002). Attending physicians scored lower than the resident physicians on the DP scale (P = .048) and higher than resident physicians on the Personal Accomplishment (PA) scale (P = .04). PSQl predicted higher scores on the EE scale (P = .003), DP scale (P = .003) and lower scores on the PA scale (P < .001). PSQs showed a reduction over time (P = .03). Attending physicians had a lower PSQs score compared with the resident physicians (P = .04).

Endoscopic orbital surgery has become a highly evolving multidisciplinary surgical field thanks to development in technical skills of ophthalmologists and otolaryngologists. These advances expanded the clinical application of orbital decompression, with a growing body of literature describing the multidisciplinary management of thyroid eye disease and compressive optic neuropathy, since 1990. Although techniques have improved considerably, only few Randomized Control Trials (RCT) provide evidence to support recommendations in clinical practice. This review provides an overview of the current knowledge of orbital decompression to clarify which is the most standardized therapeutic strategy. In the literature, we observed several approaches with contradicting results and the comparison of different surgical techniques was biased by inclusion of patients at different stage of disease (active or inactive), different surgical indications (dysthyroid neuropathy or disfiguring proptosis) and measures of outcomes (such as different system for ocular motility evaluation). The timing of surgical decompression is one of the debated issues. One RCT focusing on Graves' orbitopathy showed how intravenous corticosteroids achieve better visual recovery than surgical orbital decompression; but in case of absent or poor response to medical therapy the patient should undergo surgery within two weeks. There is slight evidence that the removal of the medial and lateral wall (so-called balanced decompression) with or without fat removal could be the most effective surgical technique, with low complication rate, but an increasing number of authors are promoting, for selected cases, a pure endoscopic surgical approach (with removal of medial and infero-medial orbital wall), less invasive than the balanced one; the latter indicated to more severe proptosis or diplopia after endoscopic procedure. Three-wall decompression is chosen for high degrees of proptosis, but complications are more frequent. Timing of surgical orbital decompression, in particular when a concomitant optic neuropathy is present, is still to be determined. Additional ophthalmological procedures are needed to restore normal eye function and cosmesis. Strabismus surgery to address diplopia and lowering the position of the upper eyelid represent some of the additional steps for the final rehabilitation of Graves' orbitopathy. The main clinical outcomes including visual acuity, proptosis, and new-onset diplopia are changing. Recent studies focused on the development of imaging measurements in order to objectively evaluate the surgical results and QOL questionnaires are gaining increasing importance. KEY WORDS: nasal endoscopy, orbital decompression, thyroid eye disease, compressive optic neuropathy RIASSUNTO La chirurgia endoscopica orbitaria rappresenta un ambito multidisciplinare in costante evoluzione grazie allo sviluppo delle tecniche sia in ambito oftalmologico che otorinolaringoiatrico. Tali progressi hanno esteso le applicazioni cliniche della decompressione orbitar...

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