Integration of Prior Expectations and Suppression of Prediction Errors During Expectancy-Induced Pain Modulation: The Influence of Anxiety and Pleasantness.

Pain perception arises from the integration of prior expectations with sensory information. Although recent work has demonstrated that treatment expectancy effects (e.g., placebo hypoalgesia) can be explained by a Bayesian integration framework incorporating the precision level of expectations and sensory inputs, the key factor modulating this integration in stimulus expectancy-induced pain modulation remains unclear. In a stimulus expectancy paradigm combining emotion regulation in healthy male and female adults, we found that participants' voluntary reduction in anticipatory anxiety and pleasantness monotonically reduced the magnitude of pain modulation by negative and positive expectations, respectively, indicating a role of emotion. For both types of expectations, Bayesian model comparisons confirmed that an integration model using the respective emotion of expectations and sensory inputs explained stimulus expectancy effects on pain better than using their respective precision. For negative expectations, the role of anxiety is further supported by our fMRI findings that (1) functional coupling within anxiety-processing brain regions (amygdala and anterior cingulate) reflected the integration of expectations with sensory inputs and (2) anxiety appeared to impair the updating of expectations via suppressed prediction error signals in the anterior cingulate, thus perpetuating negative expectancy effects. Regarding positive expectations, their integration with sensory inputs relied on the functional coupling within brain structures processing positive emotion and inhibiting threat responding (medial orbitofrontal cortex and hippocampus). In summary, different from treatment expectancy, pain modulation by stimulus expectancy emanates from emotion-modulated integration of beliefs with sensory evidence and inadequate belief updating.

Electroencephalographic spectrogram-guided total intravenous anesthesia using dexmedetomidine and propofol prevents unnecessary anesthetic dosing during craniotomy: a propensity score-matched analysis.

BACKGROUND: The bispectral index (BIS) may be unreliable to gauge anesthetic depth when dexmedetomidine is administered. By comparison, the electroencephalogram (EEG) spectrogram enables the visualization of the brain response during anesthesia and may prevent unnecessary anesthetic consumption. METHODS: This retrospective study included 140 adult patients undergoing elective craniotomy who received total intravenous anesthesia using a combination of propofol and dexmedetomidine infusions. Patients were equally matched to the spectrogram group (maintaining the robust EEG alpha power during surgery) or the index group (maintaining the BIS score between 40 and 60 during surgery) based on the propensity score of age and surgical type. The primary outcome was the propofol dose. Secondary outcome was the postoperative neurological profile. RESULTS: Patients in the spectrogram group received significantly less propofol (1585 ± 581 vs. 2314 ± 810 mg, P < 0.001). Fewer patients in the spectrogram group exhibited delayed emergence (1.4% vs. 11.4%, P = 0.033). The postoperative delirium profile was similar between the groups (profile P = 0.227). Patients in the spectrogram group exhibited better in-hospital Barthel's index scores changes (admission state: 83.6 ± 27.6 vs. 91.6 ± 17.1; discharge state: 86.4 ± 24.3 vs. 85.1 ± 21.5; group-time interaction P = 0.008). However, the incidence of postoperative neurological complications was similar between the groups. CONCLUSIONS: EEG spectrogram-guided anesthesia prevents unnecessary anesthetic consumption during elective craniotomy. This may also prevent delayed emergence and improve postoperative Barthel index scores.

Comparisons on the intraoperative desaturation and postoperative outcomes in non-intubated video-assisted thoracic surgery with supraglottic airway devices or high-flow nasal oxygen: A retrospective study.

BACKGROUND: Few studies have compared intraoperative oxygenation and perioperative outcomes between non-intubated video-assisted thoracic surgery (NIVATS) with supraglottic airway devices (SADs) and NIVATS with high flow nasal oxygenation (HFNO). The aim of this retrospective study was to compare the intraoperative desaturation rate and postoperative outcomes between NIVATS with SADs and NIVATS with HFNO. METHODS: Data regarding NIVATS performed for lung cancer from January 2020 to December 2021 were collected. Intraoperative anesthetic results, post-anesthetic adverse effects, and surgical outcomes for patients who received SAD or HFNO were analyzed using propensity score-matched and unmatched analysis. RESULTS: In total, 199 patients with i-gel™ and 95 patients with HFNO were included. Significantly more female patients (91.6 vs. 82.4%, p = 0.0378) and fewer wedge resections (78.9 vs. 85.4%, p = 0.0258) were observed in the HFNO group. Among 250 patients who underwent NIVATS wedge resections under total intravenous anesthesia, those who received HFNO had a significantly higher desaturation event rate (19.8% vs. 7.9% in i-gel™ group; p = 0.0063), lower nadir SPO2 (94.0% vs. 96.1% in i-gel™ group; p = 0.0012), and longer hospitalization (4.0 ± 0.8 vs. 3.6 ± 0.6 in i-gel™ group; p < 0.0001). However, propensity score matching analysis revealed no significant between-group difference in the desaturation rate. A log-rank test revealed that smoking (p = 0.0005) and HFNO (p = 0.0074) were associated with intraoperative desaturation. CONCLUSION: The rate of SAD use in NIVATS was twice the rate of HFNO use, especially for wedge resections. There is uncertain airway patency and limited flow through HFNO during one-lung ventilation, whereas SADs like i-gel™ presented a significantly less intraoperative desaturation rate over time and similar postoperative outcomes.

Synergistic symptom-specific effects of ketorolac-tramadol and ketorolac-pregabalin in a rat model of peripheral neuropathy.

BACKGROUND: Although current neuropathic pain treatment guidelines do not recommend the use of nonsteroidal anti-inflammatory drugs (NSAIDs), whether NSAIDs can serve as a useful adjuvant to conventional multimodal therapy remains unclear. METHODS: The spared nerve injury (SNI) rats rapidly developed profound and long-lasting spontaneous and evoked pain behaviors, including mechanical and cold allodynia of the ipsilateral hind paw. At day 5, we first characterized the nociceptive responses to ketorolac, tramadol, pregabalin, and their combinations. RESULTS: We found that tramadol and pregabalin exerted dose-dependent analgesic effects on both spontaneous and evoked behaviors. However, ketorolac alone did not suppress any behaviors regardless of the dose. Ketorolac-tramadol and ketorolac-pregabalin produced variable degrees of additive suppression of spontaneous and evoked behavioral responses. Cold allodynia was profoundly diminished after ketorolac was added to ineffective pregabalin or tramadol. Mechanical allodynia was markedly attenuated by ketorolac-pregabalin but less so by ketorolac-tramadol mixtures. CONCLUSION: Our data demonstrated that an NSAID alone failed to relieve spontaneous or evoked pain behaviors in the rat SNI model, but when combined with a weak opioid and α-2-δ-ligand produced a profound synergistic analgesic effect on cold allodynia and discrepant efficacy for mechanical allodynia and spontaneous pain.

Effects of Positive and Negative Expectations on Human Pain Perception Engage Separate But Interrelated and Dependently Regulated Cerebral Mechanisms.

Expectations substantially influence pain perception, but the relationship between positive and negative expectations remains unclear. Recent evidence indicates that the integration between pain-related expectations and prediction errors is crucial for pain perception, which suggests that aversive prediction error-associated regions, such as the anterior insular cortex (aIC) and rostral anterior cingulate cortex (rACC), may play a pivotal role in expectation-induced pain modulation and help to delineate the relationship between positive and negative expectations. In a stimulus expectancy paradigm combining fMRI in healthy volunteers of both sexes, we found that, although positive and negative expectations respectively engaged the right aIC and right rACC to modulate pain, their associated activations and pain rating changes were significantly correlated. When positive and negative expectations modulated pain, the right aIC and rACC exhibited opposite coupling with periaqueductal gray (PAG) and the mismatch between actual and expected pain respectively modulated their coupling with PAG and thalamus across individuals. Participants' certainty about expectations predicted the extent of pain modulation, with positive expectations involving connectivity between aIC and hippocampus, a region regulating anxiety, and negative expectations engaging connectivity between rACC and lateral orbitofrontal cortex, a region reflecting outcome value and certainty. Interestingly, the strength of these certainty-related connectivities was also significantly associated between positive and negative expectations. These findings suggest that aversive prediction-error-related regions interact with pain-processing circuits to underlie stimulus expectancy effects on pain, with positive and negative expectations engaging dissociable but interrelated neural responses that are dependently regulated by individual certainty about expectations.SIGNIFICANCE STATEMENT Positive and negative expectations substantially influence pain perception, but their relationship remains unclear. Using fMRI in a stimulus expectancy paradigm, we found that, although positive and negative expectations engaged separate brain regions encoding the mismatch between actual and expected pain and involved opposite functional connectivities with the descending pain modulatory system, they produced significantly correlated pain rating changes and brain activation. Moreover, participants' certainty about expectations predicted the magnitude of both types of pain modulation, with the underlying functional connectivities significantly correlated between positive and negative expectations. These findings advance current understanding about cognitive modulation of pain, suggesting that both types of pain modulation engage different aversive prediction error signals but are dependently regulated by individual certainty about expectations.

Mirtazapine, in orodispersible form, for patients with preoperative psychological distress: A pilot study.

BACKGROUND: Perioperative psychological distress is associated with preoperative anxiety, depression, and postoperative pain. Mirtazapine is effective as an antidepressant, anxiolytic agent, and sleep enhancer. Moreover, mirtazapine can be made as orodispersible tablets with a fast onset for patients in nil per os status. This study is to determine whether mirtazapine can help psychologically distressed patients reduce perioperative anxiety, depression, and postoperative pain. MATERIALS AND METHODS: Patients with preoperative psychological distress, undergoing major abdominal surgery, were inquired and assigned to two groups according to their own choice. In the treatment group, patients could choose to take orodispersible mirtazapine 30 mg at each night from Preoperative Day 0 to Postoperative Day 3. There was no other intervention in the nontreatment group. Hospital Anxiety and Depression Scale (HADS), Athens Insomnia Scale (AIS), and pain scores were accessed on the day before operation (Day 0), and on the 1(st) day (Day 2) and 3(rd) day (Day 4) after operation. We compared the HADS, AIS, and pain scores, and morphine consumptions between the two groups on a daily basis. Marginal regression models were fitted to our correlated longitudinal data alone with the generalized estimating equations method to estimate the population average effects of time-varying mirtazapine usage on the mean values of HADS, AIS, and pain scores, and daily morphine consumptions. RESULTS: From September 2007 to December 2008, 86 patients agreed to be enrolled and 79 of them completed the study. Propensity scores and multivariate analysis showed that mirtazapine reduced HADS scores of patients in 2 days. Trial results indicated that mirtazapine lowered the AIS day index and tended to decrease night index as well. Mirtazapine may reduce patients' morphine consumption, but this effect was not statistically significant (p = 0.2). CONCLUSION: Mirtazapine helps reduce anxiety, depression, and insomnia scores for patients with perioperative psychological distress.

Fast Track ultrasound protocol to detect acute complications after totally implantable venous access device placement.

BACKGROUND: The role of ultrasound examination in detection of postprocedure complications from totally implantable venous access devices (TIVAD) placement is still uncertain. In a cohort of 665 cancer outpatients, we assessed a quick ultrasound examination protocol in early detection of mechanical complications of catheterization. METHODS: Immediately after TIVAD placement, an ultrasound examination and chest radiography were performed to detect hemothorax, pneumothorax, and catheter malposition. The two methods were compared. RESULTS: Of the 668 catheters inserted, 628 were placed into axillary veins and 40 into internal jugular veins. The ultrasound examination took 2.5 ± 1.1 min. No hemothorax was detected, and neither pneumothorax nor catheter malposition was evident among the 40 internal jugular vein cannulations. Ultrasound and chest radiography examinations of the 628 axillary vein cannulations detected five and four instances of pneumothorax, respectively. Ultrasound detected all six catheter malpositions into the internal jugular vein. However, ultrasound failed to detect two out of three malpositions in the contralateral brachiocephalic vein and one kinking inside the superior vena cava. Without revision surgery, the operating time was 34.1 ± 15.6 min. With revision surgery, the operating time was shorter when ultrasound detected catheter malposition than when chest radiography was used (96.8 ± 12.9 vs. 188.8 ± 10.3 min, p < 0.001). CONCLUSIONS: Postprocedure ultrasound examination is a quick and sensitive method to detect TIVAD-related pneumothorax. It also precisely detects catheter malposition to internal jugular vein thus reduces time needed for revision surgery while chest radiography remains necessary to confirm catheter final position.

Evident cognitive impairments in seemingly recovered patients after midazolam-based light sedation during diagnostic endoscopy.

BACKGROUND/PURPOSE: Midazolam is a widely used sedative agent during colonoscopy, with cognitive toxicity. However, the potential cognitive hazard of midazolam-based light sedation has not been sufficiently examined. We aimed to examine the cognitive safety and vulnerability profile under midazolam light sedation, with a particular focus on individual variations. METHODS: We conducted a prospective case-controlled study in an academic hospital. In total, 30 patients undergoing sedative colonoscopy as part of a health check-up were recruited. Neuropsychological testing on the full cognitive spectrum was evaluated at 15 minutes and 120 minutes after low-dose midazolam administration. The modified reliable change index (RCI) was used for intrapersonal comparisons and controlling for practice effects. RESULTS: Midazolam affected psychomotor speed (48%), memory (40%), learning (32%), working memory (17%), and sustained attention (11%), while sparing orientation and the fluency aspect of executive function at the acute stage. Residual memory (10%) and learning (10%) impairments at 2 hours after administration were evidenced in some patients. The three object recall and digit symbol coding tests can serve as useful screening tools. CONCLUSION: Midazolam-based light sedation induced selective cognitive impairments and prolonged cognitive impairments occurred in patients with advanced age. A longer observation time and further screening were recommended for patients due to their at risk state.

Injury Location and Mechanism for Complex Regional Pain Syndrome: A Nationwide Population-Based Case-Control Study in Taiwan.

BACKGROUND: Few studies have investigated the relationship between injury location, mechanism and their association with complex regional pain syndrome (CRPS). We conducted a nationwide database survey to explore this issue. METHODS: This was a population-based case-control study. Five hundred and eighty-nine patients with at least one ambulatory visit or admission with a principal diagnosis of CRPS from 2004 to 2009 were selected. For each CRPS patient, ten age- and sex-matched non-CRPS subjects were randomly selected. The odds ratios (PLoS One. 2013;8:e57205) and 95% confidence intervals (95% CIs) of risk factors for CRPS were derived from multivariate logistic regression models. RESULTS: Injury was a risk factor for CRPS (OR, 2.96; 95% CI, 2.18 to 4.02) independent of age and sex. In adjusted models, open wound on the upper limbs (OR 1.25, 95% CI 1.02 to 1.54) conferred higher CRPS risk. Injury mechanisms including nerve and spinal cord injury (OR 2.42, 95% CI 1.44 to 4.08), muscle and joint sprain and strain (OR 1.69, 95% CI 1.40 to 2.03), superficial injury (OR 1.23, 95% CI 1.00 to 1.51), and contusion (OR 1.44, 95% CI 1.20 to 1.74), but not fracture, increased the risk of CRPS. CONCLUSION: Injury in the extremities rather than the trunk is an important risk factor for CRPS. Certain injury mechanisms confer higher risk of CRPS. This nationwide study demonstrated that injury increased CRPS nearly threefold. Open wound, sprain and strain, superficial injury, contusion, and nerve and spinal cord injury are main injury mechanisms. Injury in the extremities confers a higher risk of CRPS.

The Alaris auditory evoked potential monitor as an indicator of seizure inducibility and duration during electroconvulsive therapy: an observational study.

BACKGROUND: Precise control of anesthetic depth during electroconvulsive therapy (ECT) is crucial because most intravenous anesthetics have anticonvulsant effects. In this study, we investigated the association between anesthetic depth measured by the Alaris auditory evoked potential index (AAI) and seizure inducibility and seizure duration during ECT. METHODS: Sixty-four ECTs were evaluated in 12 consecutive patients. General anesthesia was performed with a thiopental-based method. The relationship between the pre-ictal AAI, seizure activity and seizure duration was analyzed, and a possible threshold pre-ictal AAI to induce a seizure duration of at least 25 seconds was calculated. RESULTS: Forty-one of the 64 ECT stimuli successfully induced seizure activity that lasted longer than 25 seconds. Pre-ictal AAI was significantly correlated to seizure duration (r = 0.54, p < 0.001) and the threshold pre-ictal AAi value was calculated to be 26 (area under curve: 0.76, sensitivity: 70.3% and specificity: 73.9%, p < 0.001). ECT with a pre-ictal AAI ≧ 26 had a higher incidence of successful seizure activity ( p < 0.001) and a longer seizure duration (55 ± 35 v.s. 21 ± 27 seconds, p < 0.001). CONCLUSION: Maintenance of a pre-ictal AAI value ≧ 26 was associated with an increased incidence of successful seizure activities and a longer seizure duration. This is the first report to investigate Alaris AEP monitoring during ECT.

New 6% hydroxyethyl starch 130/0.4 does not increase blood loss during major abdominal surgery - a randomized, controlled trial.

BACKGROUND/PURPOSE: Ideal fluid management during surgery still poses a clinical dilemma gauging the benefits and adverse effects. This randomized controlled trial compared the tissue perfusion and coagulation profiles under clinically equivalent hydroxyethyl starch (HES 130/0.4) and lactated Ringer's solution (LR). METHODS: Eighty-four patients undergoing major abdominal surgery were randomized to receive either HES or LR. Tissue perfusion parameters using heart rate, arterial blood pressure, central venous pressure, cardiac index, stroke volume index, and central venous oxygen saturation were measured at T0 (baseline), T1 (start of surgery), T2 (1 hour after start of surgery), and T3 (end of surgery). Coagulation parameters using thrombelastography (TEG) were measured at T0 (baseline), T4 (after 15 mL/kg fluid transfused), and T5 (24 hours after baseline). RESULTS: The total amount of fluid administrated was 1547.9 ± 424.0 mL in HES group and 2303.1 ± 1033.7 mL in LR group (p < 0.001). The parameters of tissue perfusion and TEG did not differ significantly between groups at any time point except for a transient decrease in clot kinetic and clot strength at T4 for HES group. There was no significant difference in blood loss and consumption of blood products between the two fluids. CONCLUSION: HES 130/0.4 is a more efficient intravascular volume expander to maintain tissue perfusion than conventional crystalloid. Transient hypocoagulability induced by HES 130/0.4 does not warrant excessive blood loss and blood transfusion.

Analgesic efficacy of tramadol/acetaminophen and propoxyphene/acetaminophen for relief of postoperative wound pain.

BACKGROUND/PURPOSE: Weak opioid combined with acetaminophen (APAP) has been proven to provide better analgesic efficacy and cause fewer complications than either drug alone. However, there are questions about whether different opioids, tramadol and propoxyphene, provide similar efficacy or safety. Thus, we investigated Ultracet (37.5 mg tramadol/325 mg APAP) and Depain-X (65 mg propoxyphene/650 mg APAP). The primary aims of this study were to compare the analgesic efficacy and adverse effects of single-dose oral Ultracet versus Depain-X in acute postoperative pain. MATERIALS AND METHODS: This was a randomized, open-label, active-controlled parallel study on patients with postsurgical pain. Sixty patients who sustained moderate postsurgical pain (visual analog scale(3)3 cm) after undergoing implantation of venous access were randomized to two groups to receive either Ultracetor Depain-X for postoperative analgesia. Assessment items included pain intensity and pain relief ratings at the first 4 hours, and adverse events. RESULTS: There were initially 107 patients who were enrolled in this trial, but up to 45 (42.1%) of them were withdrawn during the study. In these 62 patients who complied with treatment (Ultracet: Depain-X = 29: 33), pain relief scale indicated that Ultracet could provide a better analgesic effect than Depain-X provided at 1 hour (p < 0.05). At 4 hours, the pain score in the Ultracet group was significantly lower than that in the Depain-X group (p < 0.05). Adverse events, such as drowsiness, dizziness, and skin itching did not differ in both groups. CONCLUSION: Among patients with mild to moderate postoperative wound pain, single-dose Ultracet can provide slightly better analgesic efficacy than Depain-X in terms of onset and duration. Depain-X is no longer marketed in Europe, America, Taiwan and other countries, therefore, Ultracet can serve as a good substitute for treating postoperative pain.

Efficacy of intrathecal drug delivery system for refractory cancer pain patients: a single tertiary medical center experience.

BACKGROUND/PURPOSE: Between 10% and 20% of cancer pain patients fail to obtain adequate pain relief despite comprehensive medical management. The totally implantable programmable intrathecal drug delivery system (IDDS) is an attractive option for managing refractory cancer pain. In suitable patients, IDDS can provide reliable long-term analgesia without any permanent nerve or plexus destruction. IDDS can also allow patient care on an outpatient basis. In Taiwan, however, the experience of using IDDS in terminally ill cancer patients is very limited. METHODS: This retrospective study, describes experience of managing totally implantable programmable IDDS in 6 refractory cancer pain patients including patient selection, intraspinal morphine trial, surgical techniques, complications, and drug adjustment. Pain scores and functional status were compared before and after IDDS. RESULTS: By delivering liberal dose of intrathecal morphine, patients' pain scores decreased from 10 to 3.5. Due to much better pain control and improved quality of life, Eastern Cooperative Oncology Group performance status also improved in 4/6 patients. During the mean 5 ± 4.1 months of follow-up, two patients experienced pocket seroma, and resolved spontaneously after short-term abdominal binder compression. Otherwise, no serious complication was noted. CONCLUSION: Intrathecal morphine delivery by using totally implantable programmable IDDS is an effective method to relieve refractory cancer pain.

Intravenous electrocardiography helps inexperienced operators to place totally implantable venous access device more accurately.

BACKGROUND: Proper tip position is a major determinant of totally implantable venous access device (TIVAD) outcome. The aim of this study is to analyze the potential utilization of intravenous electrocardiography (IV-ECG) to help inexperienced operators for TIVAD placement. PATIENTS AND METHODS: This is a retrospective, observational, uni-institutional study. 331 patients receiving TIVAD implantation from July 2008 to December 2008 were recruited. In IV-ECG group, IV-ECG was used to help decide catheter tip location and catheter length. In Landmark group, catheter length was decided by surface landmarks. Catheter tip position was confirmed by post-operative supine chest X-ray. RESULTS: There were 153 patients in IV-ECG group, and 178 patients in Landmark group. No immediate reoperation due to catheter mal-position was noted in IV-ECG group, but it happened in eight patients in Landmark group. In IV-ECG group, 97.3% of the catheter tip located at proper position (within 2 cm from junction of right atrium and superior vena cava, as compared to 88.8% of the tip position in Landmark group was proper. The difference was statistically significant (P < 0.05). There was no complication associated with the use of IV-ECG. CONCLUSION: IV-ECG is a safe and convenient method to help inexperienced operators placing TIVAD.

The role of transesophageal echocardiography in transplantation of an adult-sized kidney to a small child.

Transplantation of adult-sized kidneys to pediatric patients weighing less than 10 kg is a challenge to both surgical and anesthetic management. For survival of the graft, a large-size kidney graft transferred to a pediatric patient needs extraphysiological cardiac output to compensate for adequate renal blood flow. We report here a boy weighing 8.4 kg who received transplantation of a kidney donated by his 56.4-kg mother. Since monitoring of the central venous pressure was not accurate enough and Swan-Ganz catheterization was not feasible in this patient for monitoring the fluid status and cardiac function, we used transesophageal echocardiography to guide intravascular volume expansion and to titrate inotropic support during the surgery. It was demonstrated to be a useful tool for optimization of renal perfusion in this scenario. The transplanted graft served its function well.

Modified lightwand intubation in a child with spondyloepiphyseal dysplasia congenita.

This is the case report on a 1-year 9-month-old boy suffering from spondyloepiphyseal dysplasia congenita who was successfully intubated with our modified lightwand intubation procedure for general anesthesia to undergo bilateral herniorrhaphy despite the great likelihood of facing a difficult airway because of unstable cervical spine. We bent the pediatric wand after it was encased in an endotracheal (ET) tube of appropriate diameter. The light tip of the wand was let to protrude just out of the bevel of the ET tube. Once the light bulb properly transilluminated the trachea, the ET tube was threaded gently into the trachea. The patient recovered from anesthesia smoothly and was discharged on the next day. This maneuver can facilitate both visual and tactile confirmations of the position and proper tube size. The effectiveness and safety of our modified lightwand intubation procedure is well demonstrated.

User inspection of National Taiwan University Hospital's telehealth care information system.

The telehealth care system has been important in the healthcare world for several decades; however, Taiwan only began work on telehealth care this past year. This paper outlines the effectiveness of the telehealth care system developed by the National Taiwan University Hospital (NTUH). The usability of the integrated telehealth care system was analyzed through of heuristic evaluation and its usefulness. By using the heuristic evaluation form as developed by Nielsen, it is possible to examine the telehealth care system from the user's perspective. In addition, in assessing the usefulness through lists of criteria, system developers can determine the pros and the cons of the database. Ultimately, the heuristic evaluation revealed several violations on the system, but are not prohibitive to the development of such as system. Similarly, evaluation of the usefulness comes out positive; despite the fact that the suggested changes proposed by the users can be said are the main weaknesses of the system. With some improvements, the telehealth care system can be used efficiently in NTUH's healthcare system.