Electronic Documentation of Intraoperative Observation of Cystoscopic Procedures Using the cMDX Information System

PURPOSE

Accurate documentation of lesions during transurethral resection of bladder tumors (TURBT) is essential for precise diagnosis, treatment planning, and follow-up care. However, optimizing schematic documentation techniques for bladder lesions has received limited attention.

MATERIALS AND METHODS

This prospective observational study used a cMDX-based documentation system that facilitates graphical representation, a lesion-specific questionnaire, and heatmap analysis with a posterization effect. We designed a graphical scheme for bladder covering bladder landmarks to visualize anatomic features and to document the lesion location. The lesion-specific questionnaire was integrated for comprehensive lesion characterization. Finally, spatial analyses were applied to investigate the anatomic distribution patterns of bladder lesions.

RESULTS

A total of 97 TURBT cases conducted between 2021 and 2023 were included, identifying 176 lesions. The lesions were distributed in different bladder areas with varying frequencies. The distribution pattern, sorted by frequency, was observed in the following areas: posterior, trigone, lateral right and anterior, and lateral left and dome. Suspicious levels were assigned to the lesions, mostly categorized either as indeterminate or moderate. Lesion size analysis revealed that most lesions fell between 5 and 29 mm.

CONCLUSION

The study highlights the potential of schematic documentation techniques for informed decision making, quality assessment, primary research, and secondary data utilization of intraoperative data in the context of TURBT. Integrating cMDX and heatmap analysis provides valuable insights into lesion distribution and characteristics.

[Perception and mindfulness-based occupational therapy in people with mental disorders-A retrospective observational study on the SELWA-treatment]

During occupational therapeutic treatment of clients with mental disorders, perception and mindfulness-based techniques are used. However, little is known regarding relevant outcomes. Aim of the present study is to describe the results of a perception and mindfulness-based occupational therapeutic intervention (self-control techniques using perception-based methods (SELWA®) by S. Thielen) regarding the outcomes occupational performance and satisfaction in self-care, productivity and leisure, as well as concentration. The data of 28 clients (22 ♀, 6 ♂; mean age = 42.8 (±SD 14.7) years) with mental disorders, that were collected before and after prescribed occupational therapeutic treatment, were analyzed. The outcomes were quantified using the Canadian Occupational Performance Measure (COPM) and the revision test, respectively. Significance of changes after the intervention was tested using the Wilcoxon-Signed Rank Test (p < 0.05). Effect sizes Cohen's d_z and r were determined to evaluate the meaningfulness of changes. The occupational performance as well as the satisfaction in the COPM improved significantly after the therapeutic intervention (p < 0.001; d_z = 2.37, r = 0.77 and d_z = 2.24, r = 0.75). Moreover, the clients improved significantly in the revision test after the therapeutic intervention (p < 0.001; d_z = 0.65, r = 0.31). Clients with mental disorders seem to benefit meaningfully from the SELWA®-treatment by S. Thielen regarding occupational performance and satisfaction in self-care, productivity and leisure. Furthermore, a moderate improvement of concentration seems to occur after the therapeutic intervention.

Artificial Intelligence-Based Prognostic Model for Urologic Cancers: A SEER-Based Study

Simple Summary

We describe a risk profile reconstruction model for cancer-specific survival estimation for continuous time points after urologic cancer diagnosis. We used artificial intelligence (AI)-based algorithms, a national cancer registry data, and accessible clinical parameters for the risk-profile reconstruction. We derived a risk stratification model and estimated the minimum follow-up duration and the likelihood for risk stability in prostate, kidney, and testicular cancers. The estimated follow-up duration was in alignment with recognized clinical guidelines for these cancers. Moreover, the estimated follow-up duration was differed by the cancer origin and the disease dissemination status. Overall, the reconstruction of the population’s risk profile for the cancer-specific prognostic score estimation is feasible using AI and has potential application in clinical settings to improve risk stratification and surveillance management.

Abstract

Background: Prognostication is essential to determine the risk profile of patients with urologic cancers. Methods: We utilized the SEER national cancer registry database with approximately 2 million patients diagnosed with urologic cancers (penile, testicular, prostate, bladder, ureter, and kidney). The cohort was randomly divided into the development set (90%) and the out-held test set (10%). Modeling algorithms and clinically relevant parameters were utilized for cancer-specific mortality prognosis. The model fitness for the survival estimation was assessed using the differences between the predicted and observed Kaplan–Meier estimates on the out-held test set. The overall concordance index (c-index) score estimated the discriminative accuracy of the survival model on the test set. A simulation study assessed the estimated minimum follow-up duration and time points with the risk stability. Results: We achieved a well-calibrated prognostic model with an overall c-index score of 0.800 (95% CI: 0.795–0.805) on the representative out-held test set. The simulation study revealed that the suggestions for the follow-up duration covered the minimum duration and differed by the tumor dissemination stages and affected organs. Time points with a high likelihood for risk stability were identifiable. Conclusions: A personalized temporal survival estimation is feasible using artificial intelligence and has potential application in clinical settings, including surveillance management.

How Does Mental Workload Influence the Adoption of Clinical Information Systems: An Exploratory Study

Mental workload and technology acceptance are relevant factors that relate to use behavior and performance. Studies show a potential moderating effect of mental workload on predictors of technology acceptance. Aim of this study was the investigation of predictors of technology acceptance (UTAUT) related to clinical information systems and their relation to mental workload. This quasi-experimental study with 48 participants used the following measures: NASA TLX and UTAUT questionnaire. Participants had to perform three tasks on a clinical information system as well as four task-levels of the n-back task with increasing difficulty. Analyses show a high level of technology acceptance (M=3.82, SD=.76) and confirm performance expectancy as the most relevant predictor of behavioral intention (β=.48, p<.001). A linear regression showed that a high level of mental workload has an influence on performance expectancy (F1,46=8.438, p<.05). The study shows an influence of mental workload on acceptance, the strength and role of which (e.g. moderation) needs to be further investigated, especially in the context of other determinants.

Comparing the Acceptance of Mobile Hypertension Apps for Disease Management Among Patients Versus Clinical Use Among Physicians: Cross-sectional Survey

Background

High blood pressure or hypertension is a vastly prevalent chronic condition among adults that can, if not appropriately treated, contribute to several life-threatening secondary diseases and events, such as stroke. In addition to first-line medication, self-management in daily life is crucial for tertiary prevention and can be supported by mobile health apps, including medication reminders. However, the prescription of medical apps is a relatively novel approach. There is limited information regarding the determinants of acceptance of such mobile health (mHealth) apps among patients as potential users and physicians as impending prescribers in direct comparison.

Objective

The present study aims to investigate the determinants of the acceptance of health apps (in terms of intention to use) among patients for personal use and physicians for clinical use in German-speaking countries. Moreover, we assessed patients’ preferences regarding different delivery modes for self-care service (face-to-face services, apps, etc).

Methods

Based on an extended model of the unified theory of acceptance and use of technology (UTAUT2), we performed a web-based cross-sectional survey to explore the acceptance of mHealth apps for self-management of hypertension among patients and physicians in Germany. In addition to UTAUT2 variables, we measured self-reported self-efficacy, eHealth literacy, previous experiences with health apps, perceived threat to privacy, and protection motivation as additional determinants of mHealth acceptance. Data from 163 patients and 46 physicians were analyzed using hierarchical regression and mediation analyses.

Results

As expected, a significant influence of the unified theory of acceptance and use of technology (UTAUT) predictors on intentions to use hypertension apps was confirmed, especially for performance expectancy. Intention to use was moderate in patients (mean 3.5; SD 1.1; range 1-5) and physicians (mean 3.4, SD 0.9), and did not differ between both groups. Among patients, a higher degree of self-reported self-efficacy and protection motivation contributed to an increased explained variance in acceptance with R²=0.09, whereas eHealth literacy was identified as exerting a positive influence on physicians (increased R²=0.10). Furthermore, our findings indicated mediating effects of performance expectancy on the acceptance among patients but not among physicians.

Conclusions

In summary, this study has identified performance expectancy as the most important determinant of the acceptance of mHealth apps for self-management of hypertension among patients and physicians. Concerning patients, we also identified mediating effects of performance expectancy on the relationships between effort expectancy and social influence and the acceptance of apps. Self-efficacy and protection motivation also contributed to an increase in the explained variance in app acceptance among patients, whereas eHealth literacy was a predictor in physicians. Our findings on additional determinants of the acceptance of health apps may help tailor educational material and self-management interventions to the needs and preferences of prospective users of hypertension apps in future research.

Examining the Mental Workload Associated With Digital Health Technologies in Health Care: Protocol for a Systematic Review Focusing on Assessment Methods

BACKGROUND

The workload in health care is high; physicians and nurses report high stress levels due to a demanding environment where they often have to perform multiple tasks simultaneously. As a result, mental health issues among health care professionals (HCPs) are on the rise and the prevalence of errors in their daily tasks could increase. Processes of demographic change are partly responsible for even higher stress levels among HCPs. The digitization of patient care is intended to counteract these processes. However, it remains unclear whether these health information systems (HIS) and digital health technologies (DHT) support the HCPs and relieve stress, or if they represent a further burden. The mental construct that describes this burden of technologies is mental workload (MWL). Work in the clinic can be viewed as working in safety-critical environments. Particularly in this sensitive setting, the measurement methods of MWL are relevant, mainly due to their strongly differing levels of intrusiveness and sensitivity. The method of eye tracking could be a useful way to measure MWL directly in the field.

OBJECTIVE

The systematic review aims to address the following questions: (1) In which manner do DHT contribute to the overall MWL of HCPs? (2) Can we observe a direct or indirect effect of DHT on MWL? (3) Which aspects or factors of DHT contribute to an increase in MWL? (4) Which methods/assessments are applied to measure MWL related to HIS/DHT? (5) What role does eye tracking/pupillometry play in the context of measuring MWL? (6) Which outcomes are being assessed via eye tracking?

METHODS

Following the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) statement, we will conduct a systematic review. Based on the research questions, we define keywords that we then combine in search terms. The review follows the following steps: literature search, article selection, data extraction, risk of bias assessment, data analysis, and data synthesis.

RESULTS

We expect results as well as a finalization of the review in the summer of 2021.

CONCLUSIONS

This review will evaluate the impact of DHT on the MWL of HCPs. In addition, assessment methods of MWL in the context of digital technologies will be systematically analyzed.

TRIAL REGISTRATION

PROSPERO (International Prospective Register of Systematic Reviews) CRD42021233271; https://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42021233271.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/29126.

[Awareness and Use of Digital Health Services in Germany: A Cross-sectional Study Representative of the Population]

OBJECTIVES

In light of the current efforts of health policy to implement eHealth, the question arises which sections of the population already use online self-help in order to tailor them to users' needs. The present study aims to determine the differences in the use of health information and psychological online counseling based on socio-demographic variables, health status and previous illnesses.

METHODS

The basis for the cross-sectional data analyses using logistic regression analysis was the innovation sample of the German socio-economic panel. Data were collected from September 2016 to February 2017, with 4802 participants aged between 17-95 years.

RESULTS

Fifty-five percent of the sample searched for health information on the Internet, while 1.1% had experience with online counseling. Logistic regression analyses showed that online search for information was significantly determined by age (Odds Ratio (OR)=0.96; 95-%-CI=0.96-0.97), gender (OR=1.20; 95-%-CI=1.05-1.36), awareness of Internet therapy (OR=2.57; 95-%-CI=2.20-3.00), experience with psychotherapy (OR=1.40; 95-%-CI=1.16-1.69) and the diagnosis of asthma (OR=1.14; 95-%-CI=1.01-1.29) or stroke (OR=0.66; 95-%-CI=0.52-0.84). Regarding the use of online counseling, awareness of Internet therapy and experience with face-to-face psychotherapy proved to be significant determinants.

CONCLUSION

For the first time, a reliable picture has become available of the determinants of the awareness of internet therapy and online self-help utilization among the German public that should enable target-group-specific strategies to improve the care situation.

Acceptance and Commitment Therapy for Major Depressive Disorder: Insights into a New Generation of Face-to-Face Treatment and Digital Self-Help Approaches

Major depressive disorder (MDD) represents a key contributor to the global burden of mental illness given its relatively high lifetime prevalence, frequent comorbidity, and disability rates. Evidence-based treatment options for depression include pharmacotherapy and psychotherapy, such as cognitive behavioral therapy (CBT). Beyond traditional CBT, over 15 years ago, Hayes proclaimed a new generation of contextualistic and process-orientated so-called third wave of CBT interventions, including acceptance and commitment therapy (ACT). Using mindfulness and acceptance as well as commitment and behavior change processes, the transdiagnostic ACT approach aims to increase psychological flexibility as universal mechanism of behavior change and to build a value-driven orientation in life. ACT for MDD can be provided as either stand-alone individual, group, or self-help formats (e.g., apps) or combined with other approaches like behavioral activation. To date, a steadily growing empirical support from outcome and process research suggests the efficacy of ACT, which appears to work specifically through the six proposed core processes involved in psychological flexibility, such as defusion. In view of an ongoing interest of clinicians in "third-wave" CBTs and the important role of clients' preferences in providing therapy choices that work, the purpose of this chapter is to give a brief overview on the application of ACT in the treatment of MDD in adults.

Exploring User-Related Drivers of the Early Acceptance of Certified Digital Stress Prevention Programs in Germany

Electronic mental health services represent innovative instruments to increase the dissemination of stress programs in primary prevention. However, little is known about facilitators of their uptake. This study aimed to explore determinants of the acceptance of centrally certified digital stress coping programs and preferences for service delivery modes among adult members of German statutory health insurances. Participants completed a multi-construct 45-item questionnaire covering acceptance of digital stress prevention (behavioral use intention) and potential predictors we assessed using hierarchical regression analysis-(1) socio-demographic variables and time spent online, (2) openness to experience, (3) perceived stress, and (4) attitudes toward e-mental health. Preferences in terms of the willingness to use online, face-to-face and blended programs were analyzed using paired t-tests. Participants (N = 171, 66% female, 18-69 years) reported a moderate acceptance of digital stress management (M = 2.76, SD = 1.16, range: 1-5). We identified younger age (ß = -0.16, P = .009), openness to experience (ß = 0.17, P = .003), and positive attitudes (ß = 0.61, P < .001) as predictors of acceptance (R ² = .50, P < .001). Face-to-face was preferred over online (d = 0.40) and blended (d = 0.33), and blended over stand-alone online delivery mode (d = 0.19; all P < .001). Our findings indicate that promoting favorable attitudes toward digital stress prevention through tailored information may be a starting point to facilitate their adoption.

Determinant Factors of Public Acceptance of Stress Management Apps: Survey Study

BACKGROUND

Chronic stress is a major public health concern. Mobile health (mHealth) apps can help promote coping skills in daily life and prevent stress-related issues. However, little is known about the determinant factors of public acceptance of stress management in relation to preferences for psychological services.

OBJECTIVE

The aim of this survey study was to (1) assess determinant factors of public acceptance (behavioral use intention) of stress management apps based on an adapted and extended version of the Unified Theory of Acceptance and Use of Technology (UTAUT) model and (2) explore preferences for mHealth apps compared with other mental health services.

METHODS

Using convenience sampling, participants completed a multiscale 54-item Web-based survey. Based on significant correlations with acceptance, hierarchical stepwise regression analysis was performed within three blocks: (1) background and stress-related control variables, (2) beliefs and attitudes toward using mHealth, and (3) the core UTAUT determinants. The preference for mHealth apps in comparison with nine other mental health services (operationalized as readiness to use) was analyzed using paired t tests.

RESULTS

Of 141 participants, nearly half (69/141, 48.9%) indicated prior mHealth use. Acceptance of stress coping apps was moderate (mean 3.10, SD 1.03, range 1-5). Hierarchical stepwise regression including four of 11 variables (R²=.62; P=.01, f²=1.63) identified positive attitudes toward using mHealth for stress coping (beta=0.69, P<.001, 46% R² increase above block 1, f²=0.85), skepticism/perceived risks (beta=-0.14, P=.01, f²=0.16), and stress symptoms (beta=0.12, P=.03, f²=0.14) as significant predictors of acceptance. UTAUT determinants added no predictive contribution beyond attitudes (all P>.05, R² increase of 1%), whereas post hoc analysis showed significant R² increases of attitudes and skepticism/perceived risks beyond UTAUT determinants (all P<.001, R² increase of 13%). The readiness to use apps was equivalent to or significantly higher than most service types, but lower than information websites.

CONCLUSIONS

Attitudes may be at least as predictive for the acceptance of stress management apps as for more elaborated outcome beliefs. Efforts aimed at improving the public adoption of mHealth could put more emphasis on the pleasant aspects of app use, address misconceptions, offer stress screening tools on health websites, and increase options to try high-quality apps.

Diagnostic Classification of Cystoscopic Images Using Deep Convolutional Neural Networks

PURPOSE

The recognition of cystoscopic findings remains challenging for young colleagues and depends on the examiner's skills. Computer-aided diagnosis tools using feature extraction and deep learning show promise as instruments to perform diagnostic classification.

MATERIALS AND METHODS

Our study considered 479 patient cases that represented 44 urologic findings. Image color was linearly normalized and was equalized by applying contrast-limited adaptive histogram equalization. Because these findings can be viewed via cystoscopy from every possible angle and side, we ultimately generated images rotated in 10-degree grades and flipped them vertically or horizontally, which resulted in 18,681 images. After image preprocessing, we developed deep convolutional neural network (CNN) models (ResNet50, VGG-19, VGG-16, InceptionV3, and Xception) and evaluated these models using F1 scores. Furthermore, we proposed two CNN concepts: 90%-previous-layer filter size and harmonic-series filter size. A training set (60%), a validation set (10%), and a test set (30%) were randomly generated from the study data set. All models were trained on the training set, validated on the validation set, and evaluated on the test set.

RESULTS

The Xception-based model achieved the highest F1 score (99.52%), followed by models that were based on ResNet50 (99.48%) and the harmonic-series concept (99.45%). All images with cancer lesions were correctly determined by these models. When the focus was on the images misclassified by the model with the best performance, 7.86% of images that showed bladder stones with indwelling catheter and 1.43% of images that showed bladder diverticulum were falsely classified.

CONCLUSION

The results of this study show the potential of deep learning for the diagnostic classification of cystoscopic images. Future work will focus on integration of artificial intelligence-aided cystoscopy into clinical routines and possibly expansion to other clinical endoscopy applications.

Mental Workload Relating Health Information System - A Literature Review

BACKGROUND

Assessing Mental Workload related to Health Information Systems can help to analyze weak points of the use of Health Information Systems and in health care work processes. Our objectives were to give an overview of current research and applied measurement methods as well as gaining insights into influencing factors of mental workload on the use of health information systems and vice versa.

METHODS

We applied a structured literature research by searching for "mental workload" on PubMed. Studies were included into our review if they assessed related to Health Information Systems.

RESULTS

The research in PubMed led to 124 articles, resulting in 17 papers taken into in-depth analyses. We identified three categories referring to different study design types. Additionally, articles showed that mental workload was influenced by using health information systems and vice versa.

DISCUSSION

The review was limited to only one database but revealed that future research with sociotechnical focus including mental workload is necessary.

CONCLUSION

In contrast to the high relevance only a few articles address mental workload in Health Information systems. The quality of the studies in terms of evidence and external validity appears to be largely in need of development and should be improved in ongoing research.

Acceptance of mHealth Apps for Self-Management Among People with Hypertension

BACKGROUND

Mobile health applications (mHealth apps) have the potential to help patients with chronic conditions such as hypertension by supporting self-management activities in daily life. However, the uptake of mHealth apps remains poor among patients. To improve the utilization of mHealth apps for hypertension, the analysis of the behavioral intention to use such applications must consider personality traits and illness-related perceptions.

METHOD

Adults with hypertension in Germany and Austria filled out a self-administered questionnaire in a cross-sectional study based on the UTAUT-model in order to identify potential predictors for the behavioral intention to use mHealth applications as an indicator for their early acceptance. Beyond the four core determinants of acceptance of the UTAUT (performance expectancy, effort expectancy, social influence and facilitating conditions), self-efficacy, openness to experience and perceived health threat were analyzed as predictors.

RESULTS

145 participants (mean age 52.51 years, SD 14.33; 60% female) completed the survey. Acceptance was moderate on average (M = 3.26, SD = 1.07, min 1 to max 5). In a multiple hierarchical regression, performance expectancy and effort expectancy were confirmed as significant predictors of acceptance (step 1, R2 = .57, p < .001), while self-efficacy could not be confirmed (step 2, p = .87). In addition, perceived health threat (β = .12, p < .05) and openness to experience (β = .22, p < .001) had a significant influence on acceptance of mHealth apps for hypertension (step 3, overall model with R2 = .62). Age showed a negative association with the intention to use (β = .22, p = .005) while no influence of gender could be found (p = .06).

CONCLUSION

Above expectations regarding effectiveness and usability, openness to experience and perceived health threat make a significant contribution in predicting the acceptance of mHealth solutions in the field of chronic diseases.

Relating Factors for Acceptance of Health Care Technology: Focus on Mental Workload

Medical information systems and care robots are two typical examples of human computer interaction in health care. Although used in a stressful environment, effects on mental workload and acceptance are hardly evaluated. We conducted an experimental design including collaborative robotics and eye tracking in a nursing situation to test the practicability and plausibility of eye tracking as a measuring method for workload. Results showed that eye tracking is feasible if context factors are adjusted. Data reduction and classification of tasks are necessary.

Combination possibility and deep learning model as clinical decision-aided approach for prostate cancer

This study aims to introduce as proof of concept a combination model for classification of prostate cancer using deep learning approaches. We utilized patients with prostate cancer who underwent surgical treatment representing the various conditions of disease progression. All possible combinations of significant variables from logistic regression and correlation analyses were determined from study data sets. The combination possibility and deep learning model was developed to predict these combinations that represented clinically meaningful patient's subgroups. The observed relative frequencies of different tumor stages and Gleason score Gls changes from biopsy to prostatectomy were available for each group. Deep learning models and seven machine learning approaches were compared for the classification performance of Gleason score changes and pT2 stage. Deep models achieved the highest F1 scores by pT2 tumors (0.849) and Gls change (0.574). Combination possibility and deep learning model is a useful decision-aided tool for prostate cancer and to group patients with prostate cancer into clinically meaningful groups.

[Use of the S3 guidelines for early detection of prostate cancer in urological practices]

OBJECTIVES

The German S3 guideline on prostate cancer gives recommendations on early detection of prostate cancer. In this study we analyzed the adherence of urologists in private practice from the administrative district of Münster, Germany to this guideline.

METHODS

Data were collected through a semistructured survey of 22 urologists based on the COREQ checklist (Consolidated criteria for reporting qualitative research) in four focus groups consisting of five or six urologists in private practice. We developed 23 questions relating to 12 recommendations of the paragraphs of the S3 guidelines dealing with early detection of prostate cancer and prostate biopsy. The recommendations of the guideline are subdivided in nine "strong", one "optional recommendation" and two "statements". The adherence to the guideline was investigated by using frequency and qualitative content analysis (Mayring) based on a mixed methods design.

RESULTS

The urologists follow six of the nine "strong recommendations" of the guideline and deviate from three. Reasons for deviations from "strong recommendations" are the following: information about advantages and disadvantages of early detection for prostate cancer, recommendation of a prostate biopsy in case of PSA level ≥4 ng/ml, and indication for repeat biopsy.

CONCLUSION

Most of the "strong recommendations" are followed by the interviewed urologists of the administrative district of Münster. Contextually relevant deviations from "strong recommendations" are justified, e. g., the only limited transferability of the PSA threshold of 4 ng/ml derived from population-based studies of asymptomatic men to men presenting in a urologist's office.

Samply.MDR - A Metadata Repository and Its Application in Various Research Networks

Collaboration in medical research is becoming common, especially for collecting relevant cases across institutional boundaries. If the data, which is usually very heterogeneously formalized and structured, can be integrated, such a collaboration can facilitate research. An absolute prerequisite for this is an extensive description about the formalization and exact meaning of every data element contained in a dataset. This information is commonly known as metadata. Various research networking projects tackle this challenge with the development of concepts and IT tools. The Samply Metadata Repository (Samply.MDR) is a solution for managing and publishing such metadata in a standardized and reusable way. In this article we present the structure and features of the Samply.MDR as well as its flexible usability by giving an overview about its application in various projects.

Expectancy, usage and acceptance by general practitioners and patients: exploratory results from a study in the German outpatient sector

Objective

The study’s objective was to assess factors contributing to the use of smart devices by general practitioners (GPs) and patients in the health domain, while specifically addressing the situation in Germany, and to determine whether, and if so, how both groups differ in their perceptions of these technologies.

Methods

GPs and patients of resident practices in the Hannover region, Germany, were surveyed between April and June 2014. A total of 412 GPs in this region were invited by email to participate via an electronic survey, with 50 GPs actually doing so (response rate 12.1%). For surveying the patients, eight regional resident practices were visited by study personnel (once each). Every second patient arriving there (inclusion criteria: of age, fluent in German) was asked to take part (paper-based questionnaire). One hundred and seventy patients participated; 15 patients who did not give consent were excluded.

Results

The majority of the participating patients (68.2%, 116/170) and GPs (76%, 38/50) owned mobile devices. Of the patients, 49.9% (57/116) already made health-related use of mobile devices; 95% (36/38) of the participating GPs used them in a professional context. For patients, age (P < 0.001) and education (P < 0.001) were significant factors, but not gender (P > 0.99). For doctors, neither age (P = 0.73), professional experience (P > 0.99) nor gender (P = 0.19) influenced usage rates. For patients, the primary use case was obtaining health (service)-related information. For GPs, interprofessional communication and retrieving information were in the foreground. There was little app-related interaction between both groups.

Conclusions

GPs and patients use smart mobile devices to serve their specific interests. However, the full potentials of mobile technologies for health purposes are not yet being taken advantage of. Doctors as well as other care providers and the patients should work together on exploring and realising the potential benefits of the technology.

From a Content Delivery Portal to a Knowledge Management System for Standardized Cancer Documentation

Heterogeneous tumor documentation and its challenges of interpretation of medical terms lead to problems in analyses of data from clinical and epidemiological cancer registries. The objective of this project was to design, implement and improve a national content delivery portal for oncological terms. Data elements of existing handbooks and documentation sources were analyzed, combined and summarized by medical experts of different comprehensive cancer centers. Informatics experts created a generic data model based on an existing metadata repository. In order to establish a national knowledge management system for standardized cancer documentation, a prototypical tumor wiki was designed and implemented. Requirements engineering techniques were applied to optimize this platform. It is targeted to user groups such as documentation officers, physicians and patients. The linkage to other information sources like PubMed and MeSH was realized.

Does single-source create an added value? Evaluating the impact of introducing x4T into the clinical routine on workflow modifications, data quality and cost-benefit

OBJECTIVES

The first objective of this study is to evaluate the impact of integrating a single-source system into the routine patient care documentation workflow with respect to process modifications, data quality and execution times in patient care as well as research documentation. The second one is to evaluate whether it is cost-efficient using a single-source system in terms of achieved savings in documentation expenditures.

METHODS

We analyzed the documentation workflow of routine patient care and research documentation in the medical field of pruritus to identify redundant and error-prone process steps. Based on this, we established a novel documentation workflow including the x4T (exchange for Trials) system to connect hospital information systems with electronic data capture systems for the exchange of study data. To evaluate the workflow modifications, we performed a before/after analysis as well as a time-motion study. Data quality was assessed by measuring completeness, correctness and concordance of previously and newly collected data. A cost-benefit analysis was conducted to estimate the savings using x4T per collected data element and the additional costs for introducing x4T.

RESULTS

The documentation workflow of patient care as well as clinical research was modified due to the introduction of the x4T system. After x4T implementation and workflow modifications, half of the redundant and error-prone process steps were eliminated. The generic x4T system allows direct transfer of routinely collected health care data into the x4T research database and avoids manual transcription steps. Since x4T has been introduced in March 2012, the number of included patients has increased by about 1000 per year. The average entire documentation time per patient visit has been significantly decreased by 70.1% (from 1116±185 to 334±83 s). After the introduction of the x4T system and associated workflow changes, the completeness of mandatory data elements raised from 82.2% to 100%. In case of the pruritus research study, the additional costs for introducing the x4T system are €434.01 and the savings are 0.48ct per collected data element. So, with the assumption of a 5-year runtime and 82 collected data elements per patient, the amount of documented patients has to be higher than 1102 to create a benefit.

CONCLUSION

Introduction of the x4T system into the clinical and research documentation workflow can optimize the data collection workflow in both areas. Redundant and cumbersome process steps can be eliminated in the research documentation, with the result of reduced documentation times as well as increased data quality. The usage of the x4T system is especially worthwhile in a study with a large amount of collected data or a high number of included patients.

Preoperative prostate-specific antigen isoform p2PSA ≤ 22.5 pg/ml predicts advanced prostate cancer in patients undergoing radical prostatectomy

BACKGROUND

The prediction value of prostate-specific antigen (PSA) isoform [-2]proPSA (p2PSA) for detecting advanced prostate cancer (PCa) remains unclear. Our objective was to evaluate the additional clinical utility of p2PSA compared with total PSA (tPSA), free PSA (fPSA), and preoperative Gleason score (Gls) in predicting locally advanced PCa (pT3/T4) with high-accuracy discrimination. The aim was to develop a novel classification based on p2PSA and preoperative Gls for predicting advanced PCa.

MATERIALS AND METHODS

In 208 consecutive men diagnosed with clinically localized PCa who underwent radical prostatectomy, we determined the predictive and discriminatory accuracy of serum tPSA, fPSA, percentage of fPSA to tPSA, p2PSA, p2PSA density, percentage of p2PSA to fPSA, and the Prostate Health Index. The cutoff level of p2PSA with best accuracy was estimated. The novel classification was developed by analyzing the interaction between p2PSA and Gls in predicting pathologic outcomes using a chi-square automatic interaction detection analysis. Decision curve analysis was applied to test the clinical consequences of using the novel classification.

RESULTS

On univariate analyses, p2PSA, p2PSA density, percentage of p2PSA to fPSA, and Prostate Health Index were accurate but were not independent predictors by multivariate analysis. The p2PSA cutoff level of 22.5 pg/ml showed the best accuracy level for predicting and discriminating advanced diseases (area under the curve [AUC] = 0.725, sensitivity = 51.4%, specificity = 81.8%). By chi-square automatic interaction detection, univariate and multivariate analysis, a p2PSA level > 22.5 pg/ml was significantly associated with an increased frequency and risk of advanced disease. In patients with a p2PSA level ≤ 22.5 pg/ml, 91.8% of Gleason sum 6 PCa was organ confined. The combination of p2PSA and Gls enhanced slightly but significantly the predictive and discriminatory accuracy for advanced disease (0.6%-3.6%).

CONCLUSIONS

The p2PSA cutoff level of 22.5 pg/ml can accurately discriminate between organ-confined and advanced PCa. The additional use of p2PSA enhanced slightly the predictive accuracy for advanced PCa (pT3/pT4) and has limited additional predictive value in identifying aggressive PCa (Gls > 7a).

Analyses of medical data models - identifying common concepts and items in a repository of medical forms

One year ago the portal of Medical Data Models (http://medical-data-models.org) was presented as a resource for the scientific community. As of November 2012 there are approximately 3,300 forms with 102,000 items available in the CDISC ODM format. First descriptive analyses regarding form metadata demonstrate the capability of such a repository to identify commonly used medical concepts. Most common items are administrative attributes which indicates that more clinical information are needed to increase the secondary use of data documented within these forms.

Patient recruitment workflow with and without a patient recruitment system

In clinical trials (CTs), the process of patient recruitment (PR) is one of the main risk factors, as almost half of all trial delays are caused by problems in PR. To our knowledge, no publication in this field describes the process of PR. Therefore, weak spots and potential benefits cannot be identified. By interviewing six domain experts and modeling the workflow in a standardized way, we describe the actors, tasks and tools within PR. We compare the current workflow with Patient Recruitment System (PRS)-supported PR. The identification of eligible participants is the most complex part, but adding a PRS simplifies it by automating repetitive tasks and taking work off the Investigators' hands. This work contributes to a common understanding of the PR process.

[Assessment of pruritus - current standards and implications for clinical practice : consensus paper of the Action Group Pruritus Parameter of the International Working Group on Pruritus Research (AGP)]

With a prevalence of 20%, chronic pruritus is a symptom of many diseases with major impact on healthcare costs. The lack of specific therapeutic measures makes the development of new drugs and their testing in clinical trials urgent. It is not possible to measure pruritus in an objective way. For these reasons, it is necessary to have a series of standardized measures to characterize pruritus in a reliable way. Intensity scales such as the visual analog scale (VAS) are most frequently used to document the course of the symptoms. However, for assessing pruritus intensity, VAS is not an optimal instrument, although it cannot be dispensed with. The VAS should be combined with other scales in clinical studies in order to internally test the consistency of data. Other instruments for assessing intensity and course of pruritus are in the process of development. Presently scratch activity and scratch-associated lesions can be documented in a descriptive fashion. There are some studies that have employed devices to document scratch activity; however, methodological studies are not yet available. The patient-benefit index is an indispensable tool in clinical trials. A questionnaire for gathering data on the history and some pruritus-specific parameters has been developed and published. Questionnaires on patient quality of life, anxiety and depression are helpful in obtaining data on other cost-relevant parameters. A questionnaire on the quality of life, for instance, can provide important help in the assessment of the burden of the disease. The results of these questionnaires can be correlated with data on pruritus intensity scales. The relevant questionnaires have been partially digitalized so that they are available immediately as part of patient care. Additional methodological developments and studies are required in order to define a robust set of instruments for measuring pruritus in daily practice and in clinical studies.

Multilingual Medical Data Models in ODM Format: A Novel Form-based Approach to Semantic Interoperability between Routine Healthcare and Clinical Research

BACKGROUND

Semantic interoperability between routine healthcare and clinical research is an unsolved issue, as information systems in the healthcare domain still use proprietary and site-specific data models. However, information exchange and data harmonization are essential for physicians and scientists if they want to collect and analyze data from different hospitals in order to build up registries and perform multicenter clinical trials. Consequently, there is a need for a standardized metadata exchange based on common data models. Currently this is mainly done by informatics experts instead of medical experts.

OBJECTIVES

We propose to enable physicians to exchange, rate, comment and discuss their own medical data models in a collaborative web-based repository of medical forms in a standardized format.

METHODS

Based on a comprehensive requirement analysis, a web-based portal for medical data models was specified. In this context, a data model is the technical specification (attributes, data types, value lists) of a medical form without any layout information. The CDISC Operational Data Model (ODM) was chosen as the appropriate format for the standardized representation of data models. The system was implemented with Ruby on Rails and applies web 2.0 technologies to provide a community based solution. Forms from different source systems - both routine care and clinical research - were converted into ODM format and uploaded into the portal.

RESULTS

A portal for medical data models based on ODM-files was implemented (http://www.medical-data-models.org). Physicians are able to upload, comment, rate and download medical data models. More than 250 forms with approximately 8000 items are provided in different views (overview and detailed presentation) and in multiple languages. For instance, the portal contains forms from clinical and research information systems.

CONCLUSION

The portal provides a system-independent repository for multilingual data models in ODM format which can be used by physicians. It serves as a platform for discussion and enables the exchange of multilingual medical data models in a standardized way.

Qualitative and quantitative evaluation of EHR-integrated mobile patient questionnaires regarding usability and cost-efficiency

OBJECTIVES

The objective of this evaluation study is to assess a web-based application, currently available on iPad, to document questionnaires regarding patient reported outcomes such as quality of life. Based on the single source approach, the results of these questionnaires are available in the electronic health record to be used for treatment and research purposes. The assessment focuses on the usability and efficiency of the system.

METHODS

The system usability scale questionnaire with seven additional items was used to rate the usability by the patients. It was formally validated by a Cronbach Alpha test. In addition, semi-structured interviews were conducted with patients and medical staff. Time and cost measures, based on official tables of costs, were taken through workflow observations. This study was conducted in the department of dermatology at the University Hospital of Münster, Germany from April to June 2011.

RESULTS

Using the web-based application questionnaire, results about patient reported outcomes like quality of life are immediately available in the electronic health record and can be used for treatment or research purposes. 118 patients and four staff members participated in the study. The usability score reached 80 from 100 points and patients as well as medical staff stated in the interviews that the usability of the web-based system was high, and they preferred it to the previously used paper-based questionnaires. In the setting of our pilot department the mobile devices amortized their costs after 6.7 months. In general, depending on the professional group who are going to post process the paper-based forms, the earliest break-even point to use mobile questionnaires is at 1737 paper sheets per year.

CONCLUSION

The mobile patient questionnaires, integrated into the electronic health record, were well accepted in our pilot setting with high usability scores from patients and medical staff alike. The system has also proved to be cost-efficient compared to the paper-based workflow, given that a certain number of questionnaires is used per year.

Semantic enrichment of medical forms - semi-automated coding of ODM-elements via web services

Semantic interoperability is an unsolved problem which occurs while working with medical forms from different information systems or institutions. Standards like ODM or CDA assure structural homogenization but in order to compare elements from different data models it is necessary to use semantic concepts and codes on an item level of those structures. We developed and implemented a web-based tool which enables a domain expert to perform semi-automated coding of ODM-files. For each item it is possible to inquire web services which result in unique concept codes without leaving the context of the document. Although it was not feasible to perform a totally automated coding we have implemented a dialog based method to perform an efficient coding of all data elements in the context of the whole document. The proportion of codable items was comparable to results from previous studies.

Interoperability in clinical research: from metadata registries to semantically annotated CDISC ODM

Planning case report forms for data capture in clinical trials is a labor-insensitive and not formalized process. These CRFs are often neither standardized nor using defined data elements. Metadata registries as the NCI caDSR provide the capability to create forms based on common data elements. However, an exchange of these forms into clinical trial management systems through a standardized format like CDISC ODM is currently not offered. Thus, our objectives were to develop a mapping model between NCI forms and ODM. We analyzed 3012 NCI forms and included common data elements regarding their frequency and uniqueness. In this paper, we have created a mapping model between both formats and identified limitations in the conversion process: Semantic codes requested from the caDSR registry did not allow a proper mapping to ODM items and information like the number of module repetitions got lost. Summarized, it can be stated that our mapping model is feasible. However, mapping of semantic concepts in ODM needs to be specified more precisely.

Designing and implementing a biobanking IT framework for multiple research scenarios

This paper presents a biobanking IT framework, comprising a set of integrated biobanking information technology components. It provides adaptable and scalable IT support for varying biobanking scenarios, workflows and projects, while avoiding redundancy in data and technology. Feasibility of this approach is illustrated by implementations for four different biobanking projects at Erlangen University Hospital and with cooperating partners in Münster and Lübeck.

Mapping turnaround times (TAT) to a generic timeline: a systematic review of TAT definitions in clinical domains

BACKGROUND

Assessing turnaround times can help to analyse workflows in hospital information systems. This paper presents a systematic review of literature concerning different turnaround time definitions. Our objectives were to collect relevant literature with respect to this kind of process times in hospitals and their respective domains. We then analysed the existing definitions and summarised them in an appropriate format.

METHODS

Our search strategy was based on Pubmed queries and manual reviews of the bibliographies of retrieved articles. Studies were included if precise definitions of turnaround times were available. A generic timeline was designed through a consensus process to provide an overview of these definitions.

RESULTS

More than 1000 articles were analysed and resulted in 122 papers. Of those, 162 turnaround time definitions in different clinical domains were identified. Starting and end points vary between these domains. To illustrate those turnaround time definitions, a generic timeline was constructed using preferred terms derived from the identified definitions. The consensus process resulted in the following 15 terms: admission, order, biopsy/examination, receipt of specimen in laboratory, procedure completion, interpretation, dictation, transcription, verification, report available, delivery, physician views report, treatment, discharge and discharge letter sent. Based on this analysis, several standard terms for turnaround time definitions are proposed.

CONCLUSION

Using turnaround times to benchmark clinical workflows is still difficult, because even within the same clinical domain many different definitions exist. Mapping of turnaround time definitions to a generic timeline is feasible.

CIS-based registration of quality of life in a single source approach

Background

Documenting quality of life (QoL) in routine medical care and using it both for treatment and for clinical research is not common, although such information is absolutely valuable for physicians and patients alike. We therefore aimed at developing an efficient method to integrate quality of life information into the clinical information system (CIS) and thus make it available for clinical care and secondary use.

Methods

We piloted our method in three different medical departments, using five different QoL questionnaires. In this setting we used structured interviews and onsite observations to perform workflow and form analyses. The forms and pertinent data reports were implemented using the integrated tools of the local CIS. A web-based application for mobile devices was developed based on XML schemata to facilitate data import into the CIS. Data exports of the CIS were analysed with statistical software to perform an analysis of data quality.

Results

The quality of life questionnaires are now regularly documented by patients and physicians. The resulting data is available in the Electronic Health Record (EHR) and can be used for treatment purposes and communication as well as research functionalities. The completion of questionnaires by the patients themselves using a mobile device (iPad) and the import of the respective data into the CIS forms were successfully tested in a pilot installation. The quality of data is rendered high by the use of automatic score calculations as well as the automatic creation of forms for follow-up documentation. The QoL data was exported to research databases for use in scientific analysis.

Conclusion

The CIS-based QoL is technically feasible, clinically accepted and provides an excellent quality of data for medical treatment and clinical research. Our approach with a commercial CIS and the web-based application is transferable to other sites.

HIS-based Kaplan-Meier plots--a single source approach for documenting and reusing routine survival information

BACKGROUND

Survival or outcome information is important for clinical routine as well as for clinical research and should be collected completely, timely and precisely. This information is relevant for multiple usages including quality control, clinical trials, observational studies and epidemiological registries. However, the local hospital information system (HIS) does not support this documentation and therefore this data has to generated by paper based or spreadsheet methods which can result in redundantly documented data. Therefore we investigated, whether integrating the follow-up documentation of different departments in the HIS and reusing it for survival analysis can enable the physician to obtain survival curves in a timely manner and to avoid redundant documentation.

METHODS

We analysed the current follow-up process of oncological patients in two departments (urology, haematology) with respect to different documentation forms. We developed a concept for comprehensive survival documentation based on a generic data model and implemented a follow-up form within the HIS of the University Hospital Muenster which is suitable for a secondary use of these data. We designed a query to extract the relevant data from the HIS and implemented Kaplan-Meier plots based on these data. To re-use this data sufficient data quality is needed. We measured completeness of forms with respect to all tumour cases in the clinic and completeness of documented items per form as incomplete information can bias results of the survival analysis.

RESULTS

Based on the form analysis we discovered differences and concordances between both departments. We identified 52 attributes from which 13 were common (e.g. procedures and diagnosis dates) and were used for the generic data model. The electronic follow-up form was integrated in the clinical workflow. Survival data was also retrospectively entered in order to perform survival and quality analyses on a comprehensive data set. Physicians are now able to generate timely Kaplan-Meier plots on current data. We analysed 1029 follow-up forms of 965 patients with survival information between 1992 and 2010. Completeness of forms was 60.2%, completeness of items ranges between 94.3% and 98.5%. Median overall survival time was 16.4 years; median event-free survival time was 7.7 years.

CONCLUSION

It is feasible to integrate survival information into routine HIS documentation such that Kaplan-Meier plots can be generated directly and in a timely manner.

The single source architecture x4T to connect medical documentation and clinical research

Clinical trials often require large and redundant documentation efforts, because information systems in patient care and research are separated. In two clinical trials we have assessed the number of study items available in the clinical information system for re-use in clinical research. We have analysed common standards such as HL7, IHE RFD and CDISC ODM, regulatory constraints and the documentation process. Based on this analysis we have designed and implemented an architecture for an integrated clinical trial documentation workflow. Key aspects are the re-use of existing medical routine data and the integration into current documentation workflows.

Populating the i2b2 database with heterogeneous EMR data: a semantic network approach

In an ongoing effort to share heterogeneous electronic medical record (EMR) data in an i2b2 instance between the University Hospitals Münster and Erlangen for joint cancer research projects, an ontology based system for the mapping of EMR data to a set of common data elements has been developed. The system translates the mappings into local SQL scripts, which are then used to extract, transform and load the facts data from each EMR into the i2b2 database. By using Semantic Web standards, it is the authors' goal to reuse the laboriously compiled "mapping knowledge" in future projects, such as a comprehensive cancer ontology or even a hospital-wide clinical ontology.

Steps towards single source--collecting data about quality of life within clinical information systems

Information about the quality of life from patients being treated in routine medical care is important for the attending physician. This data is also needed in research for example to evaluate the therapy and the course of the disease respectively. Especially skin diseases often negatively affect the quality of life. Therefore we aimed to design a concept to collect such data during treatment and use it for both medical care and research in the setting of dermatology. We performed a workflow analysis and implemented a designated form using the tools of the local clinical information system. Quality of life data is now collected within the clinical information system during treatment and is used for discharge letters, progress overviews as well as research about the treatment and course of disease. This concept which contributes to the single source approach was feasible within dermatology and is ready to be expanded into other domains.

Multidisciplinary education in medical informatics--a course for medical and informatics students

Design and implementation of healthcare information systems affect both computer scientists and health care professionals. In this paper we present our approach to integrate the management of information systems in the education of healthcare professionals and computer scientists alike. We designed a multidisciplinary course for medical and informatics students to provide them with practical experience concerning the design and implementation of medical information systems. This course was implemented in the curriculum of the University of Münster in 2009. The key element is a case study that is performed by small teams of medical and informatics students. A practical course on management of information systems can be useful for medical students who want to enhance their knowledge in information systems as well as for informatics students with particular interests in medicine.

Estimation of patient accrual rates in clinical trials based on routine data from hospital information systems

BACKGROUND

Delayed patient recruitment is a common problem in clinical trials. According to the literature, only about a third of medical research studies recruit their planned number of patients within the time originally specified.

OBJECTIVES

To provide a method to estimate patient accrual rates in clinical trials based on routine data from hospital information systems (HIS).

METHODS

Based on inclusion and exclusion criteria for each trial, a specific HIS report is generated to list potential trial subjects. Because not all information relevant for assessment of patient eligibility is available as coded HIS items, a sample of this patient list is reviewed manually by study physicians. Proportions of matching and non-matching patients are analyzed with a Chi-squared test. An estimation formula for patient accrual rate is derived from this data.

RESULTS

The method is demonstrated with two datasets from cardiology and oncology. HIS reports should account for previous disease episodes and eliminate duplicate persons.

CONCLUSION

HIS data in combination with manual chart review can be applied to estimate patient recruitment for clinical trials.

HIS-based electronic documentation can significantly reduce the time from biopsy to final report for prostate tumours and supports quality management as well as clinical research

Background

Timely and accurate information is important to guide the medical treatment process. We developed, implemented and assessed an order-entry system to support documentation of prostate histologies involving urologists, pathologists and physicians in private practice.

Methods

We designed electronic forms for histological prostate biopsy reports in our hospital information system (HIS). These forms are created by urologists and sent electronically to pathologists. Pathological findings are entered into the system and sent back to the urologists. We assessed time from biopsy to final report (TBF) and compared pre-implementation phase (paper-based forms) and post-implementation phase. In addition we analysed completeness of the electronic data.

Results

We compared 87 paper-based with 86 electronic cases. Using electronic forms within the HIS decreases time span from biopsy to final report by more than one day per patient (p < 0.0001). Beyond the optimized workflow we observed a good acceptance because physicians were already familiar with the HIS. The possibility to use these routine data for quality management and research purposes is an additional important advantage of the electronic system.

Conclusion

Electronic documentation can significantly reduce the time from biopsy to final report of prostate biopsy results and generates a reliable basis for quality management and research purposes.

Transferring HIS data to population-based cancer registries - concept and first implementations

Cancer is the second leading cause of death worldwide and in focus of epidemiological research. In Germany the cancer registration law stipulates an electronic report to the population-based cancer registry (PBCR). In this context the Comprehensive Cancer Centre Münster (CCCM) required a new concept to support the obligation to register cancer diseases. We analysed Hospital Information System (HIS) data structures related to cancer documentation and PBCR documents. Our main idea was to export available data items from the HIS and to convert them into the import format of the PBCR. We analysed HIS data and developed an XML-based converter to support an electronic reporting procedure. Using available HIS data can avoid redundant data entry and supports information workflow within the CCCM. HIS data can provide a secondary use beyond clinical routine in form of reporting, quality assurance and clinical research.

Single source information systems to connect patient care and clinical research

Currently documentation processes for routine patient care and clinical research are kept separate (dual source). Due to overlaps between routine and research documentation, a single source approach provides opportunities to improve efficiency of medical documentation given the large workload of physicians related to documentation. Organisational, technical and regulatory conditions need to be considered for the design of single source systems. We present a single source architecture for clinical studies and provide results from pilot implementations.

A newly discovered gene, tfuA, involved in the production of the ribosomally synthesized peptide antibiotic trifolitoxin

Trifolitoxin (TFX) is a gene-encoded, posttranslationally modified peptide antibiotic. Previously, we have shown that tfxABCDEFG from Rhizobium leguminosarum bv. trifolii T24 is sufficient to confer TFX production and resistance to nonproducing strains within a distinct taxonomic group of the alpha-proteobacteria (E. W. Triplett, B. T. Breil, and G. A. Splitter, Appl. Environ. Microbiol. 60:4163-4166, 1994). Here we describe strain Tn5-2, a Tn5 mutant of T24 defective in the production of TFX, whose insertion maps outside of the tfx cluster. It is not altered in growth compared with T24, nor does it inactivate TFX in its proximity. The wild-type analog of the mutated region of Tn5-2 was cloned. Sequencing, transcriptional fusion mutagenesis, and subcloning were used to identify tfuA, a gene involved in TFX production. On the basis of computer analysis, the putative TfuA protein has a mass of 72.9 kDa and includes a peroxidase motif but no transmembrane domains. TFX production studies show that extra copies of the tfxABCDEFG fragment increase TFX production in a T24 background while additional copies of tfuA do not. Lysate ribonuclease protection assays suggest that tfuA does not regulate transcription of tfxA. Upstream of tfuA are two open reading frames (ORFs). The putative product of ORF1 shows high similarity to the LysR family of transcriptional regulators. The putative product of ORF2 shows high similarity to the cytosine deaminase (CodA) of Escherichia coli.