A modular approach to the specification and management of time duration constraints in BPMN

The modeling and management of business processes deals with temporal aspects both in the inherent representation of activity coordination and in the specification of activity properties and constraints. In this paper, we address the modeling and specification of constraints related to the duration of process activities. In detail, we consider the Business Process Model and Notation (BPMN) standard and propose an approach to define re-usable duration-aware process models that make use of existing BPMN elements for representing different nuances of activity duration at design time. Moreover, we show how advanced event-handling techniques may be exploited for detecting the violation of duration constraints during the process run-time. The set of process models specified in this paper suitably captures duration constraints at different levels of abstraction, by allowing designers to specify the duration of atomic tasks and of selected process regions in a way that is conceptually and semantically BPMN-compliant. Without loss of generality, we refer to real-world clinical working environments to exemplify our approach, as their intrinsic complexity makes them a particularly challenging and rewarding application environment

Integrated Exploration of Data-Intensive Business Processes

Modeling and reasoning over business processes require enterprises to manage and integrate large amounts of information. Despite process designers and engineers may benefit from a unified view of process and data models, integrating these two perspectives is challenging, especially when considering conceptual models. In this paper, we provide a uniform formal representation of a process model, the schema of a related database, and the data operations connecting them. Then, we show how we can use such a formal representation to identify interesting information during the integrated conceptual modeling and analysis of processes and related databases, from a process (re-)design and improvement perspective. Finally, we discuss the evaluation of the proposed approach through a controlled experiment and a proof-of-concept implementation that considers both relational and XML database technologies

A Methodological Framework for the Integrated Design of Decision-Intensive Care Pathways\u2014an Application to the Management of COPD Patients

Healthcare processes are by nature complex, mostly due to their multi-disciplinary character that requires continuous coordination between care providers. They encompass both organizational and clinical tasks, the latter ones driven by med- ical knowledge, which is inherently incomplete and distributed among people having different expertise and roles. Care pathways refer to planning and coordination of care processes related to specific groups of patients in a given setting. The goal in defining and following care pathways is to improve the quality of care in terms of patient satisfaction, costs reduction, and medical outcome. Thus, care pathways are a promising methodological tool for standardizing care and decision-making. Business process management techniques can successfully be used for representing organiza- tional aspects of care pathways in a standard, readable, and accessible way, while supporting process development, analysis, and re-engineering. In this paper, we intro- duce a methodological framework that fosters the integrated design, implementation, and enactment of care processes and related decisions, while considering proper rep- resentation and management of organizational and clinical information. We focus here and discuss in detail the design phase, which encompasses the simulation of care pathways. We show how business process model and notation (BPMN) and decision model and notation (DMN) can be combined for supporting intertwined aspects of decision-intensive care pathways. As a proof-of-concept, the proposed methodology has been applied to design care pathways related to chronic obstructive pulmonary disease (COPD) in the region of Veneto, in Italy

Male Bilateral Risk-Reducing Mastectomy: Report of a Case

Male prophylactic mastectomy is described only in sporadic cases and always performed in men with BRCA mutation with a contralateral breast cancer diagnosis. This case may suggest that we need to tailor counseling and decision‐making process for males carrying BRCA mutation and take into consideration risk‐reduction surgery when wished and strongly motivated by the consultant or in the presence of multiple risk factors in addition to gene mutation

Bridging the Gap between Processes and Data -- Proposing and Evaluating Activity Views

Business processes constantly generate, manipulate, and consume data that are managed by organizational databases. Despite being central to business process modeling, the link between processes and data is often handled by developers during process implementation, thus leaving the connection unexplored during conceptual design. However, supporting process designers in understanding the structure and semantics of the conceptual data related to a process may result in better communication with stakeholders and improved data-aware process models. In this paper, we introduce, formalize, and experimentally evaluate a novel conceptual view that bridges the gap between process and data models, and show some kinds of interesting insights that can be derived when reasoning about such connection

Management of PALB2-associated breast cancer: A literature review and case report

Key Clinical Message Germline pathogenic variants (PV) of the PALB2 tumor suppressor gene are associated with an increased risk of breast, pancreatic, and ovarian cancer. In previous research, PALB2-associated breast cancer showed aggressive clinicopathological phenotypes, particularly triple-negative subtype, and higher mortality regardless of tumor stage, type of chemotherapy nor hormone receptor status. The identification of this germline alteration may have an impact on clinical management of breast cancer (BC) from the surgical approach to the systemic treatment choice. We herein report the case of a patient with a germline PV of PALB2, diagnosed with locally advanced PD-L1 positive triple-negative BC, who progressed after an immune checkpoint inhibitor (ICI)-containing regimen and then experienced a pathologic complete response after platinum-based chemotherapy. This case report hints a major role of the germline PALB2 alteration compared to the PD-L1 expression as cancer driver and gives us the opportunity to extensively review and discuss the available literature on the optimal management of PALB2-associated BC. Overall, our case report and review of the literature provide additional evidence that the germline analysis of PALB2 gene should be included in routine genetic testing for predictive purposes and to refine treatment algorithms

Axillary Ectopic Carcinoma of the Breast. Report of Two Cases with Different Clinical Presentation and Review of the Literature.

Aims: Primary ectopic breast cancer (PEBC) is a rare and often misdiagnosed condition. Through the discussion of two clinical cases, we want to focus on clinical presentation, outcomes and treatment of PEBC, to lead clinicians to awareness and optimal management. Methods: We present the case of a 47-year-old patient, with a 30 mm axillary mass, that was diagnosed as a PEBC (infiltrating lobular carcinoma, triple negative). The patient underwent systemic staging: diffuse metastatic bone lesions and leptomeningeal metastasis were found. The second patient is a 73-year-old woman with personal history of right breast tumor. She came to our attention for a 9 mm left axillary mass, suspicious for a metastatic lymph node. A fine-needle cytology revealed the absence of lymphoid cells but the presence of atypical epithelial cells, as in a primary breast carcinoma. She was treated with local excision and sentinel node biopsy. Results: The first patient presented with metastatic disease at the time of diagnosis and she deceased after three months from the diagnosis, despite systemic chemotherapy. The diagnosis was performed at an early stage in the second patient. She underwent surgery, complementary endocrine therapy and radiotherapy. She has no evident disease after two years from surgery. Conclusion: Primary ectopic breast cancer is a rare clinical entity, often misdiagnosed or diagnosed with a long delay. The treatment of PEBC is analogous to that of orthotopic breast cancer, but we strongly recommend to approach the patient with a multidisciplinary team to provide the best staging workout and therapie

“Wake-up time activation” in older adults: first randomized experimental clinical trial

Balance main rely on vestibular, proprioceptive and visual apparatus integrity. In elderly, postural control fails also due to deficit of sensory functions, atrophy of the musculoskeletal system and neuronal reduction. Deterioration of these functions finally lead to abnormality in performing voluntary muscle movements, subjective feeling of vulnerability, insecurity and depression. Besides, physical inactivity (hypokinesia) is a major risk factor for developing coronary artery disease and stroke, contributing to obesity, high blood pressure, hypercholesterolemia and diabetes. For these reasons, especially in elderly, it is important to include physical activity as part of a regular routine. Aim of this randomized controlled trial was to demonstrate that daily subministration of “Wake-up Time Activation” protocol allow individual recovery of balance and tensile properties of periarticular and intra-articular structures, so preventing morning stiffness and reduction of the Range Of Motion (R.O.M.), mainly in the Vertebral Columna. Therefore, we propose to 50 Healthy individuals (age 45-86) of both sexes a peculiar sequence of movements that allow individual recovery of balance and tensile properties of periarticular and intra-articular structures, so preventing morning stiffness and reduction of the Range Of Motion (R.O.M.), mainly in the Vertebral Columna. To verify the effectiveness of this exercises, we scientifically detected, by mean of validated test and instruments, different parameters at tifferent time, for each individual, for two months. Tests were detected at T0 (before starting daily exercises), T1 (after one month of daily exercises), T2 (at the end of the second month of exercises). At each time, on every person, we performed: Cervical Test, Spinal motility, Pelvic motility (mobility); Standing one leg Test (balance); Get up and Go (reactivity); SF-36 (mood/depression); Paint Rating Scales (joint pain). Statistical analysis of obtained results, discussed in detail in the Postrer, scientifically demonstrate that performing of “Wake-up Time Activation” protocol of adapted fisical activity lead to immediate and persistent back pain reduction, articular R.O.M. increase, recovery of balance and coordination, improved autonomy and mood, also in elderly

Impact of COVID-19 Pandemic on Surgical Breast Cancer Patients Undergoing Neoadjuvant Therapy: A Multicentric Study

Background/Aim: Due to the SARS-CoV-2 pandemic, many scientific committees proposed neoadjuvant therapy (NACT) bridging treatment as a novel strategy and indication. The aim of the study was to evaluate the impact of COVID-19 pandemic on breast cancer patients undergoing NACT. Patients and Methods: All breast cancer patients referred to two Breast Units during COVID-19-pandemic were enrolled. Results: Out of 814 patients, 43(5.3%) were enrolled in the COVID-19-group and compared with 94 (7.9%) similar Pre-COVID-19 patients. We observed a reduction in the number of patients undergoing NACT, p=0.0019. No difference was reported in terms of clinical presentation, indications, and tumor response. In contrast, a higher number of vascular adverse events was reported (6.9% vs. 0% p=0.029). Immediate breast cancer reconstructions following invasive surgery suffered a significant slowdown (5.9% vs. 47.7%, p=0.019). Conclusion: COVID-19 caused a reduction in the number of patients undergoing NACT, with no changes in terms of indications, clinical presentation, and tumor response. Furthermore, there was an increased incidence of vascular events

Development of a novel nomogram-based online tool to predict axillary status after neoadjuvant chemotherapy in cN+ breast cancer : A multicentre study on 1,950 patients

Background Type of axillary surgery in breast cancer (BC) patients who convert from cN + to ycN0 after neoadjuvant chemotherapy (NAC) is still debated. The aim of the present study was to develop and validate a preoperative predictive nomogram to select those patients with a low risk of residual axillary disease after NAC, in whom axillary surgery could be minimized. Patients and methods 1950 clinically node-positive BC patients from 11 Breast Units, treated by NAC and subsequent surgery, were included from 2005 to 2020. Patients were divided in two groups: those who achieved nodal pCR vs. those with residual nodal disease after NAC. The cohort was divided into training and validation set with a geographic separation criterion. The outcome was to identify independent predictors of axillary pathologic complete response (pCR). Results Independent predictive factors associated to nodal pCR were axillary clinical complete response (cCR) after NAC (OR 3.11, p < 0.0001), ER-/HER2+ (OR 3.26, p < 0.0001) or ER+/HER2+ (OR 2.26, p = 0.0002) or ER-/HER2- (OR 1.89, p = 0.009) BC, breast cCR (OR 2.48, p < 0.0001), Ki67 > 14% (OR 0.52, p = 0.0005), and tumor grading G2 (OR 0.35, p = 0.002) or G3 (OR 0.29, p = 0.0003). The nomogram showed a sensitivity of 71% and a specificity of 73% (AUC 0.77, 95%CI 0.75–0.80). After external validation the accuracy of the nomogram was confirmed. Conclusion The accuracy makes this freely-available, nomogram-based online tool useful to predict nodal pCR after NAC, translating the concept of tailored axillary surgery also in this setting of patients