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We present a 10-17 Degrees of Freedom (DoF) sensory gloves for Smart Healthcare implementing an energy harvesting architecture, aimed at enhancing the battery lasting when powering the electronics of the two different types of gloves, used to sense fingers movements. In particular, we realized a comparison in terms of measurement repeatability and reliability, as well as power consumption and battery lasting, between two sensory gloves implemented by means of different technologies. The first is a 3D printed glove with 10 DoF, featuring low-cost, loweffort fabrication and low-power consumption. The second is a classical Lycra® glove with 14 DoF suitable for a more detailed assessment of the hand postures, featuring a relatively higher cost and power consumption. An electronic circuitry was designed to gather and elaborate data from both types of sensory gloves, equipped with flex sensors, differing for number of inputs only. Both gloves allow the control of hand virtual limbs or mechanical arts in surgical, military, space and civil applications. The proposed gloves were already individually evaluated in terms of repeatability, reproducibility and reliability, but in this work their performances are compared also in terms of power consumption, because a particular effort was devoted in this case to increase battery lasting for both systems, developing an Energy Harvesting (EH) system with the electronics relaying on Radio Frequency, Piezoelectric and Thermoelectric harvesters, and applying it to the gloves for the first time. The harvesting part was built and tested as a prototype discrete element board, that is interfaced with an external microcontroller and a radiofrequency transmitter board. Measurement results demonstrated a meaningful improvement in battery operation time up to 25%, considering different operating scenarios, for both glove systems, which exhibited not very different power consumption and therefore battery duration, in spite of different DoF measuring capabilities. [ABSTRACT FROM AUTHOR]

The purpose of this study was to quantify the metabolic equivalents (METs) of resistance exercise in obese patients with type 2 diabetes (T2DM) and healthy young subjects and to evaluate whether there were differences between sessions executed at low- versus high-intensity resistance exercise. Twenty obese patients with T2DM (62.9±6.1 years) and 22 young subjects (22.6±1.9 years) performed two training sessions: one at vigorous intensity (80% of 1-repetition maximum (1RM)) and one at moderate intensity (60% of 1RM). Both groups carried out three strength exercises with a 2-day recovery between sessions. Oxygen consumption was continuously measured 15 min before, during and after each training session. Obese T2DM patients showed lower METs values compared with young healthy participants at the baseline phase (F= 2043.86; P<0.01), during training (F=1140.59; P<0.01) and in the post-exercise phase (F=1012.71; P<0.01). No effects were detected in the group x intensity analysis of covariance. In this study, at both light-moderate and vigorous resistance exercise intensities, the METs value that best represented both sessions was 3 METs for the obese elderly T2DM patients and 5 METs for young subjects. [ABSTRACT FROM AUTHOR]

The purpose of this study was to quantify the metabolic equivalents (METs) of resistance exercise in obese patients with type 2 diabetes (T2DM) and healthy young subjects and to evaluate whether there were differences between sessions executed at low- versus high-intensity resistance exercise. Twenty obese patients with T2DM (62.9±6.1 years) and 22 young subjects (22.6±1.9 years) performed two training sessions: one at vigorous intensity (80% of 1-repetition maximum (1RM)) and one at moderate intensity (60% of 1RM). Both groups carried out three strength exercises with a 2-day recovery between sessions. Oxygen consumption was continuously measured 15 min before, during and after each training session. Obese T2DM patients showed lower METs values compared with young healthy participants at the baseline phase (F= 2043.86; P<0.01), during training (F=1140.59; P<0.01) and in the post-exercise phase (F=1012.71; P<0.01). No effects were detected in the group x intensity analysis of covariance. In this study, at both light-moderate and vigorous resistance exercise intensities, the METs value that best represented both sessions was 3 METs for the obese elderly T2DM patients and 5 METs for young subjects. [ABSTRACT FROM AUTHOR]

Rationale: Screening for lung cancer with modern imaging technology may decrease lung cancer mortality, but encouraging results have only been obtained in uncontrolled studies. Objectives: To explore the effect of screening with low-dose spiral computed tomography (LDCT) on lung cancer mortality. Secondary endpoints are incidence, stage at diagnosis, and resectability. Methods: Male subjects, aged 60 to 75 years, smokers of 20 or more pack-years, were randomized to screening with LDCT or control groups. All participants underwent a baseline, once-only chest X-ray and sputum cytology examination. Screening-arm subjects had LDCT upon accrual to be repeated every year for 4 years, whereas controls had a yearly medical examination only. Measurements and Main Results: A total of 2,811 subjects were randomized and 2,472 were enrolled (LDCT, 1,276; control, 1,196). After a median follow-up of 33 months, lung cancer was detected in 60 (4.7%) patients receiving LDCT and 34 (2.8%) control subjects (P = 0.016). Resectability rates were similar in both groups. More patients with stage I disease were detected by LDCT (54 vs. 34%; P = 0.06) and fewer cases were detected in the screening arm due to intercurrent symptoms. However, the number of advanced lung cancer cases was the same as in the control arm. Twenty patients in the LDCT group (1.6%) and 20 controls (1.7%) died of lung cancer, whereas 26 and 25 died of other causes, respectively. Conclusions: The mortality benefit from lung cancer screening by LDCT might be far smaller than anticipated. [ABSTRACT FROM AUTHOR]

Objective: The COVID-19 pandemic has disrupted educational systems worldwide, raising concerns about its impact on academic performance, particularly among developmental age students., Methods: A systematic review with meta-analysis aimed to evaluate the association between the COVID-19 pandemic and the academic performance in this population was performed according to PRISMA 2020 guidelines. PubMed/MEDLINE, Scopus and Embase were searched on December 2023 to identify relevant studies. Both fixed and random effect models were performed. The Effect size was reported as Cohen's d with a 95% Confidence Interval. Studies' quality was assessed using the Newcastle-Ottawa scale. The protocol was registered in PROSPERO., Results: A total of 30 studies met the inclusion criteria, but only 13 could be combined in the meta-analysis. Based on a sample size of 4,893,499 students, pooled Cohen's d was -0.07 [(95% CI = -0.10; -0.03); p-value <0.001]. Subgroup analyses by subject suggested that performance in math was affected the most, Cohen's d= -0.14 [(-0.18; -0.10); p-value <0.001]., Conclusion: The findings revealed a significant negative association between the COVID-19 pandemic and academic performance among developmental age students. Interventions to mitigate the adverse effects of the pandemic on educational outcomes in this population are needed.

Background: Postoperative seroma is most frequent after mastectomy (ME) in combination with axillary lymph node dissection (ALND), and its reported incidence varies from 15.5% up to 90%. Seromas can be responsible for discomfort, infections and can lead to reconstruction failure. Therefore, many ways of seroma prevention have been studied, although from a recent overview it has become clear that no single method is reliably successful. Mechanical closure of the dead space, however, was consistently found to be significantly effective. The aim of our study is to evaluate if quilting of the axilla, in patients undergoing ME, immediate prosthetic breast reconstruction and ALND reduces the duration of drain maintenance, the incidence of seromas that require aspiration (clinically significant seromas, CSS) and reconstruction failure rate., Materials and Methods: In our study population we analyzed a total of 81 patients divided into two groups: 27 consecutive patients undergoing mastectomy, axillary lymph node dissection (ALND), breast reconstruction and quilting of the axilla. We subsequently randomly picked up a double number of patients (54) undergoing the same oncological and reconstructive procedures without undergoing axillary quilting, matched for clinical characteristics in order to analyze efficacy of the procedure while reducing any bias. Our observational retrospective data was collected from October 2016 to July 2020 in one single high-volume center. Our median follow-up time was of 40.6 months., Results: In the case group we observed a reduced time of drain maintenance: 16 vs. 20 days observed in the non-quilted group ( p  < 0.05). Incidence of seromas that required aspiration was 11% in the control group, while 3,7% in the case group. In addition to that, we observed 6 cases of implant removal in the control group, while in the quilted group we only observed a single case., Conclusion: Previous literature and our results confirm that quilting of the axilla with flap fixation significantly decreases time of drain maintenance, allowing the earlier removal of the drains as well as decreasing the incidence of seroma, its eventual associated complications and related social costs. Moreover, our work suggests how quilting sutures decrease the incidence of seroma in patients undergoing immediate reconstruction, probably reducing the risk for implant removal., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Lisa, Bozzo, Vinci, Klinger, Errico, Tinterri, Klinger and Testori.)

Luminal-like breast cancer (BC) constitutes the majority of BC subtypes, but, differently from highly aggressive triple negative BC, is poorly infiltrated by the immune system. The quality of the immune infiltrate in luminal-like BCs has been poorly studied, thereby limiting further investigation of immunotherapeutic strategies. By using high-dimensional single-cell technologies, we identify heterogeneous behavior within the tissue-resident memory CD8+ T (Trm) cells infiltrating luminal-like tumors. A subset of CD127- CD39 hi Trm cells, preferentially present in the tumor compared to the adjacent normal breast tissue or peripheral blood, retains enhanced degranulation capacity compared to the CD127+ CD39 lo Trm counterpart ex vivo, and is specifically associated with positive prognosis. Nevertheless, such prognostic benefit is lost in the presence of highly-suppressive CCR8 hi ICOS hi IRF4+ effector Tregs. Thus, combinatorial strategies aiming at boosting Trm function and infiltration while relieving from Treg-mediated immunosuppression should be investigated to achieve proper tumor control in luminal-like BCs., (© 2021. The Author(s).)

Background: Silicon migration after rupture is an adverse event of breast implant, whose risk increases with the aging of prosthesis. The exact prevalence of this complication remains unclear and reported data are inconsistent. In addition, microscopic diffusion of silicone gel through intact implant, known as gel bleeding, might verify thus complicating diagnosis. Although high cohesive gel has reduced the occurrence of gel bleeding, this phenomenon is still possible and its occurrence rate remains underestimated. If silicon droplets migrate in locoregional lymph node, a swelling that mimics recurrence can arise. Therefore, a risk of overdiagnosis is possible when clinicians rely only on imaging techniques. The aim of this study is to evaluate the actual prevalence of metastasis in internal mammary lymph node (IMLN) in presence of PET positive uptake and no prosthesis rupture., Methods: We retrospectively evaluated our patient's records and selected those with intact breast implants and suspected relapse in IMLN that underwent biopsy, either surgical or imaging guided. All patients performed PET/CT scan showing pathological uptake in IMLNs. A breast magnetic resonance (MRI) or ultrasound (US) imaging confirmed a suspicious adenopathy and excluded prosthesis rupture. From 2015 to 2019 a total of nine patients underwent biopsy of the IMLN and only six of them met inclusion criteria., Results: Four biopsies were CT-guided, two were surgical. Three patients (50%) were diagnosed with breast cancer relapse while two (33.3%) were found with siliconoma and one (16.7%) was inflammatory., Conclusions: Siliconoma can occur even without evidence of capsule rupture, challenging the clinicians and leading to a risk of relapse over diagnosis. Echographic, MRI and nuclear medicine imaging criteria may be not sufficient in differential diagnosis. To overcome the issue, we suggest introducing into the clinical practice the biopsy of suspicious enlarged IMLN with minimally invasive technique., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://dx.doi.org/10.21037/gs-20-860). The authors have no conflicts of interest to declare., (2021 Gland Surgery. All rights reserved.)

Direct metal laser deposition (DMLD) is an additive manufacturing technique suitable for coating and repair, which has been gaining a growing interest in 3D manufacturing applications in recent years. However, its diffusion in the manufacturing industry is still limited due to technical challenges to be solved-both the sub-optimal quality of the final parts and the low repeatability of the process make the DMLD inadequate for high-value applications requiring high-performance standards. Thus, real-time monitoring and process control are indispensable requirements for improving the DMLD process. The aim of this study was the optimization of deposition strategies for the fabrication of thin walls in AISI 316L stainless steel. For this purpose, a coaxial monitoring system and image processing algorithms were employed to study the melt pool geometry. The comparison tests carried out highlighted how the region-based active contour algorithm used for image processing is more efficient and stable than others covered in the literature. The results allowed the identification of the best deposition strategy. Therefore, it is shown how this monitoring methodology proved to be suitable for designing and implementing the right building strategy for DMLD manufactured 3D components. A fast and stable image processing method was achieved, which can be considered for future closed-loop monitoring in real-time applications.

Triple negative breast cancer (TNBC), usually presenting with a very aggressive phenotype, is a heterogeneous entity. We aim to discuss new biomarkers, suitable for prognostic and predictive purposes. We retrospectively collected clinical variables and immunohistochemical characteristics of early TNBCs, specifically focusing on the prognostic and predictive significance of tumor infiltrating lymphocytes (TILs) and androgen receptor (AR) expression, assessing their correlation with clinical variables. Among 159 patients, TILs were significantly higher in younger patients and with lower BMI, and in tumors with higher ki-67 and greater nodal involvement; conversely, AR was significantly higher in older patients and in tumors with lower ki-67. Interestingly and in line with literature, both TILs level and ARs expression were lower within metastatic sites, in patients who developed distant metastases, compared to those found in the primary site. Small (pT1) and node negative tumors were highly represented and no correlation of either TILs or AR with prognosis could be observed. Our findings support the use of stromal TILs to identify a more aggressive, but chemo-sensitive phenotype, mostly represented in younger women, while AR may identify a less aggressive, slow-growing luminal TNBC subtype, more common among older patients. TILs and AR are worth implementing in routine clinical practice to refine prognosis even if, in our case series, we couldn't identify a significant correlation of the two variables with either disease-free and overall survival.

We propose a sign language recognition system based on wearable electronics and two different classification algorithms. The wearable electronics were made of a sensory glove and inertial measurement units to gather fingers, wrist, and arm/forearm movements. The classifiers were k-Nearest Neighbors with Dynamic Time Warping (that is a non-parametric method) and Convolutional Neural Networks (that is a parametric method). Ten sign-words were considered from the Italian Sign Language: cose, grazie, maestra, together with words with international meaning such as google, internet, jogging, pizza, television, twitter, and ciao. The signs were repeated one-hundred times each by seven people, five male and two females, aged 29-54 y ± 10.34 (SD). The adopted classifiers performed with an accuracy of 96.6% ± 3.4 (SD) for the k-Nearest Neighbors plus the Dynamic Time Warping and of 98.0% ± 2.0 (SD) for the Convolutional Neural Networks. Our system was made of wearable electronics among the most complete ones, and the classifiers top performed in comparison with other relevant works reported in the literature.

Small food businesses, because of their limited resources, are hard pressed to comply with the requirements of a conventional food safety management system (FSMS). To overcome it, the European legislation provides some flexibility in the application of FSMS. With this study, we evaluated the change in the perception and awareness of hazards in food production and in the attitudes of food business operators (FBOs) after a regional regulation was introduced to allow flexibility and a campaign of training activities on the FSMS simplification opportunities. Training activities targeting various stakeholders have been carried out in Piedmont region since 2014. A total of 283 FBOs from the dairy and the meat supply chains were recruited for a two-round survey. Overall, the majority of the FBOs believed that application of an FSMS helps to overcome official controls, to produce healthy foods, to better manage the production process, and for staff training; its usefulness for enhancing customer trust was judged of limited value. FBO knowledge on the possibility of simplifying the FSMS activities increased significantly between surveys, suggesting the success of the information campaigns. Over time, simplification increased in the meat but not in the dairy supply chain, where it involved nearly 70% of FBOs. The cost of FSMS (mainly due to microbiological analysis) and the time it takes were the main reasons for FBO resistance to its application. Simplification of FSMS procedures were welcomed by the vast majority (>90%) of FBOs. The perception of hazards was low and generic, suggesting the need for targeted training activities., Competing Interests: Conflict of interests: The authors declare no potential conflict of interests., (©Copyright: the Author(s).)

Mucinous carcinoma (MC) is a rare breast cancer characterized by the presence of large extracellular mucin amount. Two main subtypes can be distinguished: pure (PMC) and mixed (MMC). We conducted a retrospective MC analysis in our prospective maintained database, calculating disease-free survival (DFS) and 5-year overall survival (OS). We found a global 92.1% OS (higher in MMC group and statistically significative) and a DFS of 95.3% (higher in MMC group but not statistically significative)., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest in relation to this work., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

In Italy, the Banco Alimentare Onlus manages a network of 8,000 charitable organizations that distribute 67,000 tons of foodstuffs to 1.6 million needy persons. To provide their volunteers with the required food safety knowledge, the Banco Alimentare del Piemonte Onlus commissioned the Istituto Zooprofilattico Sperimentale del Piemonte, Liguria e Valle d'Aosta to hold training courses in food safety. Before and after each session, the participants completed a questionnaire to evaluate their knowledge on the topic of food safety. The responses were entered in a dedicated database and analyzed using STATA ver. 15.1. Comparison of the scores for each participant before and after training revealed a considerable discordance [ICC 0.06, 95% confidence interval (CI) 0.00-0.18]. Analysis of the post-training questionnaires showed that the number of questions left unanswered decreased and the number of correct answers increased. The difference between the percentage of correct and incorrect responses before and after the training course was statistically significant (P<0.001). Comparison of responses to the pre- and post-training questionnaires provided the data for statistical evaluation of the efficacy of the training course., Competing Interests: Conflict of interest: The authors declare no potential conflict of interest., (©Copyright: the Author(s), 2019.)

Introduction: Type 2 diabetes (T2D) is associated with an increased fracture risk despite normal-to-increased bone mineral density, suggesting reduced bone quality. Exercise may be effective in reducing fracture risk by ameliorating muscle dysfunction and reducing risk of fall, though it is unclear whether it can improve bone quality., Methods and Analysis: The 'Study to Weigh the Effect of Exercise Training on BONE quality and strength (SWEET BONE) in T2D' is an open-label, assessor-blinded, randomised clinical trial comparing an exercise training programme of 2-year duration, specifically designed for improving bone quality and strength, with standard care in T2D individuals. Two hundred T2D patients aged 65-75 years will be randomised 1:1 to supervised exercise training or standard care, stratified by gender, age ≤ or >70 years and non-insulin or insulin treatment. The intervention consists of two weekly supervised sessions, each starting with 5 min of warm-up, followed by 20 min of aerobic training, 30 min of resistance training and 20 min of core stability, balance and flexibility training. Participants will wear weighted vests during aerobic and resistance training. The primary endpoint is baseline to end-of-study change in trabecular bone score, a parameter of bone quality consistently shown to be reduced in T2D. Secondary endpoints include changes in other potential measures of bone quality, as assessed by quantitative ultrasound and peripheral quantitative CT; bone mass; markers of bone turnover; muscle strength, mass and power; balance and gait. Falls and asymptomatic and symptomatic fractures will be evaluated over 7 years, including a 5-year post-trial follow-up. The superiority of the intervention will be assessed by comparing between-groups baseline to end-of-study changes., Ethics and Dissemination: This study was approved by the institutional ethics committee. Written informed consent will be obtained from all participants. The study results will be submitted for peer-reviewed publication., Trial Registration Number: NCT02421393; Pre-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Luminal B breast cancers (BC) have a more aggressive behavior associated with a higher rate of tumor relapse and worse prognosis compared to luminal A tumors. In this study, we evaluated the involvement of specific epithelial-to-mesenchymal transition- (EMT-) and immune-related pathways in the dissemination of luminal B BC cells. The expression of 42 EMT- and immune-related genes was evaluated in matched sentinel lymph nodes (SLNs) analyzed by the one-step nucleic acid amplification assay (OSNA) and primary tumors of 40 luminal B BC patients by gene array and immunohistochemistry. The results were validated in an independent group of 150 luminal B tumors by immunohistochemistry and immunofluorescence and using gene expression data from 315 luminal B BC patients included in the Metabric dataset. We found that the expression of CXCR4 ( p = 3.28 E - 02) and CD163 ( p = 6.92 E - 03) was significantly upregulated in SLNs of recurrent luminal B BC patients. Luminal B primary tumors overexpressing CXCR4 were characterized by an increased expression of vimentin and a high content of CD163-positive macrophages. Bioinformatics analysis confirmed the correlation of CXCR4 with CXCL12 , VIM , and CD163 expression and LN involvement. Our results suggest that the upregulation of the CXCR4/CXCL12 pathway and the presence of protumor macrophages in the primary tumor and SLNs sustain the aggressiveness of an important subgroup of luminal B BC.

In May 2016, two separate clusters of febrile gastroenteritis caused by Listeria monocytogenes were detected by the local health authority in Piedmont, in northern Italy. We carried out epidemiological, microbiological and traceback investigations to identify the source. The people affected were students and staff members from two different schools in two different villages located in the Province of Turin; five of them were hospitalised. The epidemiological investigation identified a cooked beef ham served at the school canteens as the source of the food-borne outbreak. L. monocytogenes was isolated from the food, the stools of the hospitalised pupils and the environment of the factory producing the cooked beef ham. All isolates except one were serotype 1/2a, shared an indistinguishable PFGE pattern and were 100% identical by whole genome sequencing (WGS). By combining a classical epidemiological approach with both molecular subtyping and WGS techniques, we were able to identify and confirm a Listeria gastroenteritis outbreak associated with consumption of sliced cold beef ham.

A 67-year-old patient presented for persistent cough. Computed tomography showed right lower lung opacity associated with mediastinal adenopathy. On suspicion of metastatic pulmonary neoplasm, the patient was submitted to right lower lobectomy with lymphadenectomy. Postoperative histopathology led to the diagnosis of multicentric Castleman's disease.

Objective: Adherence to physical activity (PA) recommendations is hampered by the lack of effective strategies to promote behavior change. The Italian Diabetes and Exercise Study 2 (IDES&#95;2) is a randomized controlled trial evaluating a novel behavioral intervention strategy for increasing PA and decreasing sedentary time (SED-time) in patients with type 2 diabetes., Research Design and Methods: The study randomized 300 physically inactive and sedentary patients with type 2 diabetes 1:1 to receive theoretical and practical counseling once yearly for 3 years (intervention group [INT]) or standard care (control group [CON]). Here, we report the 4-month effects on objectively (accelerometer) measured daily light-intensity PA (LPA), moderate-to-vigorous-intensity PA (MVPA), and SED-time, and cardiovascular risk factors., Results: LPA and MVPA both increased, and SED-time decreased in both groups, although changes were significantly more marked in INT participants (approximately twofold for LPA and SED-time and approximately sixfold for MVPA). A significant reduction in HbA 1c was observed only in INT subjects. An increase in LPA >0.92 h · day -1 and in MVPA >7.33 min · day -1 and a decrease in SED-time >1.05 h · day -1 were associated with an average decrease in HbA 1c of ∼1% and also with significant improvements in fasting glucose, body weight, waist circumference, and hs-CRP. Changes in PA and SED-time were independent predictors of improvements in HbA 1c ., Conclusions: This behavioral intervention is effective in the short term for increasing LPA and MVPA and reducing SED-time. Significant improvements in cardiometabolic risk profiles were observed in subjects experiencing the most pronounced changes in PA and SED-time, even if below the recommended level., (© 2017 by the American Diabetes Association.)

Background: Pseudoangiomatous stromal hyperplasia is an uncommon mesenchymal breast neoplasm., Case Presentation: Here we present a case of an 11-year old hispanic girl affected by bilateral mammary nodular pseudoangiomatous stromal hyperplasia, an uncommon breast disease, with a review of the literature related to diagnostic workup, differential diagnosis, and management. A rapidly growing mass in the breast may be stressful for both parents and child as the suspicion of malignancy arises. Multiple wide excisions of both breasts were performed., Conclusions: The purpose of this case report is to draw attention to the fact that most emerging lesions of the breast in girls during puberty are benign diseases.

The robotic system has several technical advantages over the manual video thoracoscopic approach. It offers a high definition three-dimensional view and robotic arms are more comfortable to use, because they allow more precise, flexible, and intuitive movements. This case report describes a locally advanced thymoma in a 75-year-old male patient, excised through a robotic-assisted thymectomy with atypical resection of the infiltrated left upper lobe, the preservation of the left phrenic nerve and partial resection of the left anonymous vein involved, without necessity of reconstruction. Clinical staging was thymoma T3 B1-2, while the postoperative histological classification and radiation was thymoma T3, B3, Masaoka-Koga stage IIB. The postoperative course was uneventful and the patient was discharged in second postoperative day. This case remarks that robotic devices are of great help in the intraoperative recognition and precise management of infiltrated structure, like important vessels and nerves, avoiding conversion to an open approach, which until now was the main surgical indication in these situations., Competing Interests: G Veronesi is a consultant for ABI Medica SpA and Medtronic. Other authors have no conflicts of interest to declare.