Response of heart rate variability and cardiorespiratory phase synchronization to routine bronchodilator test in patients with asthma.

Heart rate variability (HRV) and cardiorespiratory phase synchronization (CRPS) were employed to study the cardio- and respiratory interactions in patients with asthma receiving inhalation of beta2-agonist (Berotec 200 mcg) for routine bronchodilator test. Both time- and frequency-domain parameters were used to analyze the HRV. A weighted G-index was introduced to study the quality of the CRPS. The HRV parameters, in both the time and frequency domains, exhibited significant changes pointing to a sympathetic activation of the autonomic balance immediately after the inhalation. On the other hand, the CRPS index barely changed throughout the entire process. This indicates that inhalation of beta2-agonist does not alter the CRPS appreciably, and that the CRPS, in contrast to HRV, is relatively stable in response to the inhalation of beta2-agonist in patients with asthma.

Web-Based Experience Sharing Platform on Medical Device Incidents for Clinical Engineers in Hospitals.

The aim of this study was to establish a web-based platform for exchanging medical device management and maintenance experiences to enhance the professional competency of clinical engineers (CEs), which ensures the quality of medical devices and increases patients' satisfaction with medical services. Medical devices play an essential role in diagnosis and disease management. CEs are responsible for providing functional medical devices that contribute worthwhile functions to a medical service to improve patients' health and safety. The purpose of the platform is to facilitate collection and sharing of medical device incidents experiences to improve CEs' capability. To provide useful and practical information for CEs, an event review committee, composed of experts with more than 20 years of clinical engineering experience who were recruited as reviewers, was established under the platform. Cases submitted to the platform were required to have comprehensive descriptions of the device and events. Each case was evaluated by at least two reviewers based on five evaluation indices: (1) severity, (2) breadth, (3) frequency, (4) insidiousness, and (5) correctness. After being reviewed, each final report was published on the platform to be shared with the event submitters and other members. The results show that 116 staffs from 32 different hospitals, registered to join this platform. From January 2015 to December 2016, 70 events were submitted with 56 reports. This study also assessed the platform's benefits for CEs. A total of 93 respondents completed a questionnaire survey: 93% of the CEs agreed that the information from the platform helped them do their job. The web-based platform has high value as an experience-sharing interface for medical devices. The CEs obtained extremely useful information from the platform for medical device management and their daily duties. This study provided an online training model with systematic methods to improve the quality and effectiveness of medical device management.

Respiratory Rate Estimation by Using ECG, Impedance, and Motion Sensing in Smart Clothing.

The needs for light-weight and soft smart clothing in homecare have been rising since the past decade. Many smart textile sensors have been developed and applied to automatic physiological and user-centered environmental status recognition. In the present study, we propose wearable multi-sensor smart clothing for homecare monitoring based on an economic fabric electrode with high elasticity and low resistance. The wearable smart clothing integrated with heterogeneous sensors is capable to measure multiple human biosignals (ECG and respiration), acceleration, and gyro information. Five independent respiratory signals (electric impedance plethysmography, respiratory induced frequency variation, respiratory induced amplitude variation, respiratory induced intensity variation, and respiratory induced movement variation) are obtained. The smart clothing can provide accurate respiratory rate estimation by using three different techniques (Naïve Bayes inference, static Kalman filter, and dynamic Kalman filter). During the static sitting experiments, respiratory induced frequency variation has the best performance; whereas during the running experiments, respiratory induced amplitude variation has the best performance. The Naïve Bayes inference and dynamic Kalman filter have shown good results. The novel smart clothing is soft, elastic, and washable and it is suitable for long-term monitoring in homecare medical service and healthcare industry.

A prospective and randomized comparison of limited versus extensive atrial substrate modification after circumferential pulmonary vein isolation in nonparoxysmal atrial fibrillation.

INTRODUCTION: The optimal substrate ablation approach in patients with persistent atrial fibrillation (Per AF) remains unclear. This was a prospective randomized study comparing the efficacy of limited (continuous complex fractionated atrial electrogram, CFAE: <60 milliseconds) versus extensive (continuous CFAE plus variable CFAE: <120 milliseconds) atrial substrate modification in Per AF patients. METHODS AND RESULTS: We enrolled 120 Per AF patients in the study, and 30 patients with AF termination after pulmonary vein isolation (PVI) were excluded. In the remaining 90 patients, 45 were treated with limited approach (Group 1) and 45 with an extensive approach (Group 2). The end point of the study was the incidence of an atrial arrhythmia recurrence postblanking period. The patients were followed up for 15 months with 3-month clinical reviews, electrograms (ECGs), Holter recordings, and echocardiographic monitoring. Procedural AF termination and the single procedural efficacy were statistically comparable between the 2 groups (48.9% vs. 63.4% in Groups 1 and 2, respectively, P = 0.289). During the follow-up, patients who received limited ablation had a lower incidence of recurrent AFL (P = 0.04), and better reverse remodeling of the left atrium (LA, P = 0.04). After 2 procedures, the freedom from any atrial arrhythmia was better in Group 2 (62.2% vs. 87.8%, P = 0.009). Those with longstanding AF and a larger baseline LA size responded better to the extensive ablation. CONCLUSIONS: In the Per AF patients who failed to achieve AF termination after PVI alone, a specific atrial substrate modification approach targeting only continuous CFAEs could be considered as an initial ablation strategy.

Realizing digital signatures for medical imaging and reporting in a PACS environment.

According to Taiwan's legislation pertaining to the protection of electronic data, the creators of electronic medical records (EMR) are solely responsible for the security of EMR. However, actual implementations that fulfill the security standards and requirements for electronic medical record systems are still lacking. Most EMR created from picture archive and communication system are not considered secure, as security protection mechanisms have not yet been granted legal status. This paper describes the details of establishing a digital signature system using Taiwan health professional cards. A digital signature system has been included to ensure quality assurance (QA) operations are controlled by technicians, and reporting capabilities have been provided for radiologist. Six imaging modalities and eight types of radiology reports have also been included in the system. Results indicate that the process of creating QA signatures does not have an adverse effect on the workflow of the facility, requiring less time for the signing and verification of radiology reports. This system has already been used routinely online in a real clinical setting for more than 2 years.

A prospective, randomized comparison of modified pulmonary vein isolation versus conventional pulmonary vein isolation in patients with paroxysmal atrial fibrillation.

INTRODUCTION: Pulmonary vein isolation (PVI) is the primary ablation therapy in patients with atrial fibrillation (AF). We hypothesized that high dominant frequency (DF) sites (AF nests during sinus rhythm [SR]) adjacent to the PV ostia are associated with the atrial substrate that maintains AF, and PVI incorporating the high-frequency AF nests may have a higher efficacy. METHODS AND RESULTS: In a prospective and randomized comparison, 126 symptomatic paroxysmal AF patients that underwent PVI were enrolled. We compared the efficacy of a modified PVI (ablation line: 1.0-1.5 cm from the PV ostium with encircling the AF nests [spectral analysis with DF >70 Hz during SR, Group II]) versus the anatomy-guided conventional PVI (Group I). In Group II, the DF value along the PV ostium was lower than 70 Hz after the PVI. The primary endpoint was the freedom from symptomatic atrial arrhythmias after a single procedure. We also followed the autonomic function by a time-domain analysis of the heart rate variability. In both groups, AF nests were observed and electric isolation was successfully obtained in all patients. With a mean duration of 16 ± 6.1 months of follow-up, Group II had a higher single procedure efficacy without drugs (78.7% vs 66.1%, log-rank test: P = 0.02), and fewer repeat procedures (6.6% vs 23%; P = 0.04), as compared to Group I. CONCLUSION: PVI incorporating the high frequency AF nests adjacent to the PV ostia had a better single procedure efficacy.

"Altered Short-Term Dynamics of Cardio-Respiratory Interaction during Propofol-Induced Yawning".

"Cardiac and respiratory oscillations have been shown to interact with each other. This interaction could reflect autonomic nervous system functionality. Propofol-induced yawning during anesthesia induction seems to be associated with sympathetic activation. Presumptively, there is high linearity among interaction of different physiologic system behaviors. Recently, investigators used coherence analysis to quantify the existence and strength of linearity between system signals for study of cardio-respiratory interaction under different physiological conditions. In this investigation, we used a method of time-frequency coherence function to analyze ECG and respiration signals to investigate the linearity of cardio-respiratory dynamics in patients undergoing routine propofol induction procedures for elective surgery. In this prospective, observational clinical study, a total of 84 eligible patients were enrolled. The patients were categorized into yawning and no-yawning groups during propofol induction. During induction, both groups demonstrated significant reduction in high frequency coherence (coh-HF) with simultaneously significant increase in very low frequency coherence (coh-VLF) compared to the pre-induction period. As yawning occurred, the yawning group had more significant changes of cardio-respiratory coherences than the no-yawning group at coh-LF and coh-VLF bands. The yawning group also showed loss of linearity at high frequency band (coh-HF > 0.5) as compared with the pre-induction period, and also showed increases in linearity at low (coh-LF > 0.5) and very low (coh-VLF > 0.5) frequency bands compared with the no-yawning group. Propofol-induced yawning alters cardio-respiratory dynamics with changes of linearity between cardio-vascular and respiratory system behaviors."

Applying a presentation content manifest for signing clinical documents.

In this paper, we demonstrate how to digitally sign a content manifest of a presentable clinical document that contains multiple clinical data with presentations. Only one signature is needed for an entire clinical document with multiple data resources, which can reduce the computation time during signing and verifying processes. In the radiology field, a report may contain text descriptions, images, and annotations that are stored separately in different data resources. The manifest signature would be a proper means for integrity checking for all the clinical data within the manifest. The manifest signature can be extended with a trusted third party to add a digital time signature for long-term verifiability. The performance of the manifest signing compared with that of a traditional digital signing was evaluated. The new manifest signature can be used for signing different types of presentable clinical documents, such HL7 CDA documents and DICOM image reports.

Efficacy of additional ablation of complex fractionated atrial electrograms for catheter ablation of nonparoxysmal atrial fibrillation.

BACKGROUND: The efficacy of ablation of complex fractionated atrial electrograms (CFEs) in the single ablation procedure for nonparoxysmal atrial fibrillation (AF) patients is not well demonstrated. The aim of this study was to compare the ablation strategies of pulmonary vein isolation (PVI) plus linear ablation with and without additional ablation ofCFEs in these patients. METHODS: Consecutive 60 patients (49 +/- 11 years old, 50 male, 10 female) with nonparoxysmal AF underwent catheter ablation guided by a NavX mapping system. A stepwise approach included a circumferential PVI and left atrial (LA) linear ablation followed by either the additional ablation of continuous CFEs in the LA/coronary sinus (the first 30 patients) or not (the second 30 patients), detected by an automatic algorithm. RESULTS: There was no difference in the baseline characteristics between the two groups. Complete PVI eliminated some continuous CFEs and altered the distribution of CFEs. Following PVI and linear ablation,the remaining continuous CFEs were identified in 7.9 +/-10% mapping sites of the LA and CS, and were ablated successfully with a procedural AF termination rate of 53%. With a follow-up of 19 +/-11 months, a Kaplan-Meier analysis showed that the patients with additional ablation of the CFEs had a higher rate of sinus rhythm maintenance. Multivariate analysis showed the single procedure success could be predicted by the procedural AF termination and the additional ablation of continuous CFEs in the LA/CS. CONCLUSIONS: Ablation of continuous CFEs after PVI and LA linear ablation had a better long-term efficacy based on the results of single-ablation procedure.

Consistency of complex fractionated atrial electrograms during atrial fibrillation.

BACKGROUND: Temporal variation in complex fractionated atrial electrograms (CFAEs) exists during atrial fibrillation (AF). OBJECTIVE: This study sought to quantify the variation in CFAEs using a fractionation interval (FI) algorithm and to define the shortest optimal recording duration required to consistently characterize the magnitude of the fractionation. METHODS: Twenty-seven patients undergoing AF mapping in the left atrium were studied. The FI and frequency analysis were performed at each mapped site for recording durations of 1 to 8 seconds. The magnitude of the fractionation was quantified by the FI algorithm, which calculated the mean interval between multiple, discrete deflections during AF. The results from each duration were statistically compared with the maximal-duration recording, as a standard. The FI values were compared with the dominant frequency values obtained from the associated frequency spectra. RESULTS: The FIs obtained from recording durations between 5 and 8 seconds had a smaller variation in the FI (P < .05) and, for those sites with a FI < 50 ms, the fractionation was typically continuous. The fast-Fourier Transform spectra obtained from the CFAE sites with recording durations of >5 seconds harbored higher dominant frequency values than those with shorter recording durations (8.1 +/- 2.5 Hz vs. 6.8 +/- 0.98 Hz, P < .05). The CFAE sites with continuous fractionation were located within the pulmonary veins and their ostia in 77% of patients with paroxysmal AF, and in only 29% of patients with nonparoxysmal AF (P < .05). CONCLUSION: The assessment of fractionated electrograms requires a recording duration of > or =5 seconds at each site to obtain a consistent fractionation. Sites with the shortest FIs consistently identified sites with the fastest electrogram activity throughout the entire left atrium and pulmonary veins.

Frequency analysis of the fibrillatory activity from surface ECG lead V1 and intracardiac recordings: implications for mapping of AF.

AIMS: Fibrillatory waves observed in the surface electrograms may be a direct reflection of the electrophysiologic mechanism of the atrial fibrillation (AF). This study compared the fibrillatory waves in the surface ECG and the individual intracardiac mapping sites in different types of paroxysmal AF. METHODS AND RESULTS: Thirty patients with paroxysmal AF originating from the pulmonary veins (PVs) or superior vena cava (SVC) were enrolled. Frequency analysis was performed on the intracardiac electrograms recorded from various mapping sites in both atria sequentially with simultaneous surface electrogram recordings. The SVC-AF patients had a trend toward a higher DF in ECG lead V1 when compared with the PV-AF patients (7.35 +/- 2.09 vs. 5.89 +/- 0.79 Hz, P = 0.018). The mean dominant frequency (DF) of the LA mapping sites in the PV-AF patients was higher than that in the SVC-AF patients (7.06 +/- 0.66 vs. 6.13 +/- 0.96 Hz, P = 0.009), whereas the mean DF of the RA mapping sites was similar between the two groups (5.84 +/- 0.80 vs. 6.26 +/- 1.11 Hz, P = NS). The intra-class correlation coefficient (ICC) between the mean DF of the RA sites and V1 was higher (r = 0.21, P = 0.02) when compared with the mean DF of the LA sites (r = -0.007, P > 0.05). Furthermore, the maximal ICC was observed in the anterolateral RA free wall (r = 0.84, P < 0.001) and not the other anatomic sites of the RA and LA. CONCLUSION: The fibrillatory activity observed in ECG lead V1 correlated primarily with the activity of the anterolateral RA free wall and thus may be useful for detecting the AF source if it is close to that area.

Clinical assessment of propofol-induced yawning with heart rate variability: a pilot study.

STUDY OBJECTIVES: To investigate the proportion of propofol-induced yawning and sympathovagal balance during propofol-induced yawning. DESIGN: Prospective, observational, clinical study. SETTING: University hospital and 2400-bed tertiary medical center. PATIENTS: 546 ASA physical status I and II patients undergoing elective surgery with general anesthesia. INTERVENTIONS: Standard induction of anesthesia was performed with intravenous (IV) propofol two to four mg/kg (group P), or pretreatment with atropine 0.1 mg/kg (group AP) or with fentanyl 1 to 3 microg/kg (group FP) before propofol. Continuous standard electrocardiogram for heart rate variability (HRV) was performed in another 20 patients to investigate sympathovagal balance during propofol-induced yawning. MEASUREMENTS AND MAIN RESULTS: The proportions of yawning were 53.5% (207/386), 61.1% (55/90), and 0% (0/50) in the P, AP, and FP groups, respectively. Propofol-induced yawning could be dramatically decreased by pretreatment with IV fentanyl (P < 0.001, chi2 test). Significant increased ratio of low-frequency/high-frequency power was detected during HRV monitoring in 9 patients with yawning in comparison with 11 patients without yawning (P < 0.05, Wilcoxon signed-rank test). CONCLUSIONS: Pretreatment with fentanyl may inhibit propofol-induced yawning. Fluctuations in autonomic function have been noted during propofol-induced yawning.

Validation of the frequency spectra obtained from the noncontact unipolar electrograms during atrial fibrillation.

INTRODUCTION: Noncontact mapping (NCM) can record virtual unipolar electrograms (Egs) from multiple sites simultaneously; therefore, it has the potential to perform simultaneous frequency mapping during atrial fibrillation (AF). The aim of this study was to validate the frequency spectra of the noncontact unipolar Egs in both atria. METHODS: This study enrolled 12 patients (age = 61 +/- 16 years) with paroxysmal or persistent AF who underwent catheter ablation guided by NCM. Noncontact and contact unipolar Egs were recorded simultaneously. The cross-correlation of the Eg morphology, activation time difference of the time-domain signals, and resultant frequency spectra were compared via dominant frequency (DF) and magnitude-squared coherence (MSC). RESULTS: A total of 159 sites were analyzed during AF. The variables that independently predicted a higher correlation between the contact and noncontact electrogram morphology were a smaller activation timing difference P < 0.01), smaller distance of the mapping sites to the array center (P = 0.01), and higher atrial voltage (P = 0.03). However, the average MSC of the frequency band within the physiologic range of AF (2 to 15 Hz) was only affected by the activation timing difference (P = 0.002). The DF value between the contact and noncontact unipolar signals correlated well with each other throughout the right atria and left atria in 94% of the mapping sites (r = 0.87, P < 0.001). CONCLUSION: The accuracy of the noncontact unipolar Eg morphology decreased when the mapping sites harbored a smaller atrial voltage and longer distance to the array center. The DF difference between the contact and noncontact unipolar Eg was not affected by the distance to the array center.

Electrophysiological characteristics and catheter ablation in patients with paroxysmal right atrial fibrillation.

BACKGROUND: Catheter ablation of the right atrial (RA) substrate has had variable efficacy in curing paroxysmal atrial fibrillation (PAF), suggesting that RA substrate ablation can play an important role in the treatment of atrial fibrillation (AF) in some patients. The aim of this study was to investigate the electrophysiological characteristics and ablation strategy and its results in a specific group of patients with paroxysmal RA-AF. METHODS AND RESULTS: The study population consisted of 13 patients (8 men; age, 64+/-15 years) with drug-refractory (2+/-1 drugs), frequent episodes of PAF. Provocation maneuvers did not reveal any ectopic beat-initiating AF. However, rapid atrial pacing easily induced AF. Activation mapping during sinus rhythm, atrial pacing, and AF was visualized by using a noncontact mapping system. Noncontact mapping revealed RA reentry (6 patients with single-loop circuits and 7 with double-loop circuits) with conduction through channels between lines of block, crista terminalis gaps, and the cavotricuspid isthmus, which could be identified during sinus rhythm and atrial pacing, resulting in fibrillatory conduction in other parts of the RA. The consistency of wavefront activation was confirmed by frequency analysis from equally distributed mapping sites in the RA. Short lines of ablation lesions were aimed at the conduction channels between the lines of block, crista terminalis gaps, and the cavotricuspid isthmus, resulting in bidirectional block. AF was eliminated in 11 (85%) of 13 patients, and those 11 patients with acute success were free of AF without any antiarrhythmic drugs during the long-term follow-up period (16+/-6 months). CONCLUSIONS: RA ablation still can cure selected patients with PAF. Linear ablation of the RA substrate guided by the electrophysiological characteristics of RA-AF is an effective approach for treating this specific group of patients with AF.

The influence of mean heart rate on measures of heart rate variability as markers of autonomic function: a model study.

Some studies have demonstrated that the assessments of autonomic activities from the alterations of heart rate variations (HRVs) after autonomic blockade and during exercise of high intensity by the spectral analysis of HRV seemed inconsistent with actual situation. The inconsistency is probably caused by the contributions of fluctuating magnitudes and mean levels of autonomic activities on HRV having not been clarified. The alterations of HRV after autonomic blockade and during exercise of high intensity using a mathematical model were simulated. The autonomic activity in normal condition was assumed first according to some experimental evidence. Then autonomic activities after sympathetic blockade, vagal blockade and during exercise of high intensity were appropriately adjusted accordingly. The HRVs in response to these given autonomic activities were simulated. We found that the effect on HRV influenced by the mean level of autonomic activity is helpful to explain alterations of HRV in these conditions. After vagal blockade, a largely reduced low frequency (LF) power could be caused by the reduced mean heartbeat interval induced by a decreased mean level of vagal activity. Increased low and high frequency powers after sympathetic blockade could be caused by the increased mean heartbeat interval induced by a decreased mean level of sympathetic activity. A decreased LF power during exercise of high intensity, in addition to the withdrawal of vagal activity, could also be caused by the decreased mean heartbeat interval induced by an increased mean level of sympathetic activity.

Education of biomedical engineering in Taiwan.

Biomedical Engineers (BME) play an important role in medical and healthcare society. Well educational programs are important to support the healthcare systems including hospitals, long term care organizations, manufacture industries of medical devices/instrumentations/systems, and sales/services companies of medical devices/instrumentations/system. In past 30 more years, biomedical engineering society has accumulated thousands people hold a biomedical engineering degree, and work as a biomedical engineer in Taiwan. Most of BME students can be trained in biomedical engineering departments with at least one of specialties in bioelectronics, bio-information, biomaterials or biomechanics. Students are required to have internship trainings in related institutions out of campus for 320 hours before graduating. Almost all the biomedical engineering departments are certified by IEET (Institute of Engineering Education Taiwan), and met the IEET requirement in which required mathematics and fundamental engineering courses. For BMEs after graduation, Taiwanese Society of Biomedical Engineering (TSBME) provides many continue-learning programs and certificates for all members who expect to hold the certification as a professional credit in his working place. In current status, many engineering departments in university are continuously asked to provide joint programs with BME department to train much better quality students. BME is one of growing fields in Taiwan.

Characteristics of fibrillatory activities during spontaneous termination of paroxysmal atrial fibrillation: new insight from high-density right atrium frequency mapping.

BACKGROUND: Sinus node (SN) activity is difficult to assess during atrial fibrillation (AF). The aim of the present study was to investigate SN activity by frequency analysis during AF. METHODS: Thirteen patients with paroxysmal AF and atrial flutter in the right atrium (RA) underwent 3-dimensional noncontact mapping. The fibrillatory activity was recorded from a multielectrode array in the RA. A frequency analysis with 2- and 6-second time-segment lengths was performed. Spectral characteristics (dominant frequency and harmonic index) and isopotential activation maps were used to investigate the spatiotemporal activity of the SN region and the rest of the RA (crista terminalis, septum, and free wall) during the initiation, while ongoing, and before the termination of AF. RESULTS: With duration of 6 seconds, the whole RA had similar trends of frequency distribution. With duration of 2 seconds prior to termination, the SN region exhibited a trend of low-frequency pattern and high-organization distribution, compared with the segments for the 2 to 4 and 4 to 6 seconds before termination. The isopotential activation maps showed the spontaneous earliest activities had wave front propagation patterns similar to those during sinus rhythm (after termination). CONCLUSIONS: The fibrillatory activity of the SN region was organized, and slow activation was detected, by frequency analysis and isopotential mapping, within 2 seconds just prior to AF termination.

A reliable transmission protocol for ZigBee-based wireless patient monitoring.

Patient monitoring systems are gaining their importance as the fast-growing global elderly population increases demands for caretaking. These systems use wireless technologies to transmit vital signs for medical evaluation. In a multihop ZigBee network, the existing systems usually use broadcast or multicast schemes to increase the reliability of signals transmission; however, both the schemes lead to significantly higher network traffic and end-to-end transmission delay. In this paper, we present a reliable transmission protocol based on anycast routing for wireless patient monitoring. Our scheme automatically selects the closest data receiver in an anycast group as a destination to reduce the transmission latency as well as the control overhead. The new protocol also shortens the latency of path recovery by initiating route recovery from the intermediate routers of the original path. On the basis of a reliable transmission scheme, we implement a ZigBee device for fall monitoring, which integrates fall detection, indoor positioning, and ECG monitoring. When the triaxial accelerometer of the device detects a fall, the current position of the patient is transmitted to an emergency center through a ZigBee network. In order to clarify the situation of the fallen patient, 4-s ECG signals are also transmitted. Our transmission scheme ensures the successful transmission of these critical messages. The experimental results show that our scheme is fast and reliable. We also demonstrate that our devices can seamlessly integrate with the next generation technology of wireless wide area network, worldwide interoperability for microwave access, to achieve real-time patient monitoring.

Embedding a hiding function in a portable electronic health record for privacy preservation.

The objective of this study was to develop a method to hide information in a portable electronic health record (PEHR). In compliance with HIPAA guidelines, a hiding function for personal identifiers in a PEHR was implemented by recognizing and hiding techniques. The method emphasizes the feasibility of embedding a hiding function in a PEHR. The hiding function could be executed to hide identifiers in offline mode. The present study showed that embedding the hiding function in a PEHR is a practical way not only satisfies data confidentiability needs, but also meets patient's personal privacy requirements. The effects of executing the hiding function would be the same as through de-identification or anonymization process.

Can temperament be understood at birth? The relationship between neonatal pain cry and their temperament: a preliminary study.

This study investigated the relationship between the pain cries of neonates at 3-5 days and temperament at 1 month of age, as rated by mothers. A total of 68 healthy neonates' pain cries elicited by injection of the hepatitis B virus vaccine were analyzed and were categorized into "pre-part" and "post-part" cry by the determination of a regulatory point by observers, with a high consensus on spectrogram profiles. Differences in parameters between the pre-part and post-part of the pain cries and their association with the dimensions of temperament were analyzed. The results indicated that neonates who exhibited greater intensity pre-part crying had a more positive mood quality at 1 month, and those with shorter breath intervals after the regulatory point had a higher activity temperament score at 1 month. Moreover, the higher the pitch or the shorter the duration of the cry sounds in the post-part, the lower the adaptability score at 1 month. This study demonstrates that neonatal pain cry parameters could be used to understand subsequent temperament behavioral styles.