Abstract
Introduction. The study of the clinical workflows and information flows in healthcare institutions is of vital importance to improve its effectiveness and efficiency. At Hospital Sao Joao, Oporto Portugal, a Diagnostic Breast Unit (DBU) was recently created. The implementation of a new Electronic Patient Record (EPR) called Breast.Care triggered the need to better understand the DBU processes and suggest improvements. Aim. To describe clinical workflows and information flows in DBU, detect problems and propose solutions for better communication among different actors. Methods. The study started with a direct observation period with a total of 24 hours. The observed processes and flows were transcribed into free text and then into structured text, tables and Unified Modeling Language (UML) diagrams (activity and partition-activity). The structured text and diagrams were analysed to find possible improvements. Results. Seven main processes were identified representing how different actors (humans and computers) work together. Three communication process improvements between humans were detected (e.g. changing timing of patient data insertion to facilitate reading access to others), three human machine improvements (e.g. changing computer medical forms) and one between machines (creating specific links between information systems). Discussion. Analysing workflow and information flow in DBU allowed the detection of communication problems and the improvement of those through changes in EPR and in DBU current processes.

Abstract
Oncoplastic Breast Surgery (OPBS) is becoming an integral part of breast cancer management, but few surgeons have received formal training in these techniques. An International Symposium has recently debated the key issues which impact on training and specialisation in OPBS, as well as patient access to these procedures. The Symposium concluded that increasing the availability of OPBS is a major challenge, which demands much closer collaboration and cooperation between breast and plastic surgeons, backed up by new training schemes, new curricula and new guidelines.

Abstract
Background. To analyze the relationship of objective and subjective evaluation tools of breast aesthetics, we compare the results of the BCCT.core (breast cancer conservative treatment.cosmetic results) software, a semiautomated objective symmetry evaluation tool, with those of the Aesthetic Status of the BCTOS (Breast Cancer Treatment Outcome Scale) patient questionnaire. Materials and Methods. We included 128 patients with one-sided, primary breast cancer, treated conservatively in a prospective, exploratory study in order to assess the inter-rater reliability of the BCCT.core and the agreement between the BCCT.core and the BCTOS preoperatively, shortly and 1 year after surgery. Therefore, we use agreement rates, multiple (mk), and weighted (wk) kappa coefficients as statistical methods. Furthermore, we analyzed patient-, tumor-, and therapy-related variables as possible covariates to explain agreement. Results. The inter-rater reliability for the semiautomated BCCT.core is very good with agreement rates up to 84% (mk = 0.80). The agreement rates of the BCCT.core and the BCTOS Aesthetic Status range between 35 and 44% subject to the different times of assessment (wk = 0.34 at best). Moreover, the patients judge their aesthetic outcome more positively than the software. None of the considered patient-, tumor-, and therapy-related covariates turned out to explain agreement. Conclusion. The BCCT.core is a reliable instrument that shows fair agreement with patient's perspective.

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Abstract
Two programs were recently developed for the aesthetic evaluation of results in breast cancer conservative treatment: the Breast Cancer Conservative Treatment cosmetic results (BCCT.core) and the Breast Analyzing Tool (BAT). Both make use of a face-only photographic view of the patient and were developed to overcome the lack of reproducibility observed with subjective visual evaluation. The BCCT.core analyses several parameters related to asymmetry, color differences and scar appearance, while the BAT considers only asymmetry measurements. The purpose of this study was to compare the performance of these two methods. Material and methods Digital pictures of 59 patients from Porto and 60 from Vienna were evaluated subjectively by two panels using the four-class Harris scale. The Porto photographs had a similar backlight and better quality, and were evaluated by an international panel of 23 experts. The Vienna photographs had different backlight and lower quality, and were evaluated by four students and two breast cancer specialists. All 119 cases were submitted to analysis using the BCCT.core and BAT. Agreement between the software programs and the subjective evaluation was calculated using kappa (k), weighted kappa statistics (wk) and error rate (er). Results In overall analysis, BCCT.core program obtained a better agreement with the subjective evaluation (k = 0.56; wk = 0,64; er = 0.20) than the BAT software (k = 0.39; wk = 0.46; er = 0.42) (P < 0.0007). Results were again better for the BCCT.core program, when analysing the photographs obtained in Porto (k = 0.71; wk = 0.78; er = 0.14) than for the BAT (k = 0.35; wk = 0.41; er = 0.51) (P < 0.0003) while no significant differences in agreement were obtained regarding the Vienna images (P > 0.1). Conclusions The results suggest that the inclusion of multiple parameters in image analyses of aesthetic results has the potential to improve results. However, picture quality is probably important for analysis of other features besides asymmetry.

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