Patent Publication Number: US-2022225945-A1

Title: Health monitoring systems and methods

Description:
BACKGROUND 
     Advances in software, electronics, sensor technology and materials science have revolutionized patient monitoring technologies. In particular, many devices and systems are becoming available for a variety of health monitoring applications. However, improvements may yet be desired for health monitoring devices and systems that provide one or more of effective data collection and/or manipulation for parameter determination. 
     Further alternatives for patients and their physicians may then be developed to include robust and convenient monitors that in some instances may collect and transfer short-term or long-term data and/or monitor events in real-time, and in some cases may include multi-variable parameter determination. 
     SUMMARY 
     Described herein are several alternative medical monitoring devices, systems and/or methods for parameter determination, in some instances for long-term sensing and/or recording of cardiac and/or respiratory and/or temperature data of one or more individuals, such as a neonate, infant, mother/parent, athlete, or patient. A number of alternative implementations and applications are summarized and/or exemplified herein below and throughout this specification. 
     In one alternative aspect, the developments hereof may include an implementation wherein a health device is configured for monitoring one or a plurality of physiological parameters of one or more individuals from time-concordant measurements collected by one or a plurality of sensors, including one or a variety of one or more of, but not limited to, electrodes for measuring ionic potential changes for electrocardiograms (ECGs), and/or one or more light sources and one or more photodetectors, in some cases including LED-photodiode pairs, for optically based oxygen saturation measurements, and/or one or more temperature sensors, and/or one or more xyz accelerometers for movement and exertion measurements, and the like. In some implementations, methods and devices of the developments hereof may be used to generate a respiration waveform. Other implementations may include a circuit that mimics a driven right-leg circuit (sometimes referred to herein as “a proxy driven right-leg circuit”) that may permit reduction in common mode noise in a small-footprint device conveniently adhered or having the capacity to be adhered to an individual. 
     In another alternative aspect hereof, a blood pressure determination may in some cases be made from a determination of pulse transit time. The pulse transit time is the time for the cardiac pressure wave to travel from the heart to other locations in the body. Measurements of pulse transit time may then be used to estimate blood pressure. Heart beat timing from ECG or otherwise and photoplethysmogram (aka PPG) signals can be used to generate pulse transit time. Note, such signals may be generated from conventional or other to-be-developed processes and/or devices or systems; or, such signals may be taken from one or more wearable health monitoring devices such as those also described hereinbelow. 
     In another alternative aspect, the developments hereof may include in some instances one or more methods and/or devices for measuring and/or determining oxygen saturation parameters from time concordant pulse oximetry signals and ECG signals. In some implementations, ECG signals may be used to define intervals, or “frames” of pulse oximetry data that are collected and averaged for determining the constant and main periodic components (e.g., DC and AC components) of the pulse oximetry signals from which, in turn, values for oxygen saturation may be determined. Patient-wearable devices of such implementations with pulse oximetry and ECG sensors may be particularly useful when placed on a patient&#39;s chest for such signal acquisition. 
     These as well as other alternative and/or additional aspects are exemplified in a number of illustrated alternative and/or additional implementations and applications, some of which are shown in the figures and characterized in the claims section that follows. However, as will be understood by the ordinarily skilled artisan, the above summary and the detailed description below do not describe the entire scope of the inventions hereof and are indeed not intended to describe each illustrated embodiment or every possible implementation of the present inventions nor provide any limitation on the claims or scope of protection herein set forth below. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       The drawings include: 
         FIG. 1 , which includes and is defined by sub-part  FIGS. 1A-1R , illustrates several alternatives of the present developments, including a variety of isometric, top and bottom plan and elevational views of devices and alternative conductive adhesive structures. 
         FIG. 2 , which includes and is defined by sub-part  FIGS. 2A-2D , provides circuit diagrams of alternatives to, in  FIGS. 2A-2C , a driven right leg circuit, and in  FIG. 2D , pulse oximetry. 
         FIG. 3  is a flow chart including alternative methods of use. 
         FIG. 4  illustrates an exemplary computer system or computing resources with which implementations hereof may be utilized. 
         FIG. 5 , which includes and is defined by sub-part  FIGS. 5A-5D , provides alternative screenshots of alternative software implementations according hereto. 
         FIGS. 6A and 6B  illustrate features of one embodiment for measuring oxygen saturation using pulse oximetry signals and electrocardiogram signals. 
         FIG. 6C  is a flow chart showing steps of one embodiment for determining oxygen saturation values. 
         FIGS. 6D and 6E  illustrate an embodiment for determining depth of respiration values. 
         FIGS. 7A, 7B and 7C  set forth flow diagrams for alternative methodologies hereof. 
     
    
    
     DETAILED DESCRIPTION 
     While the inventions hereof are amenable to various modifications and alternative forms, specifics hereof have been shown herein by way of non-limitative examples in the drawings and the following description. It should be understood, however, that the intention is not to limit the inventions to the particular embodiments described. The intention is to cover all modifications, equivalents, and alternatives falling within the spirit and scope of the inventions whether described here or otherwise being sufficiently appreciable as included herewithin even if beyond the literal words or figures hereof. 
     In one aspect, a system hereof may include a device for monitoring physiological parameters such as one or more or all of electrocardiogram (aka ECG or EKG), photoplethysmogram (aka PPG), pulse oximetry, temperature and/or patient acceleration or movement signals. 
     Moreover, systems hereof may be established to measure and/or process such signals of a patient using or including any one or more of the following elements: (a) a circuit, sometimes flexible as in or on or forming a flexible or flex circuit board, embedded in or on a flat elastic substrate or board having a top surface and a bottom surface, the circuit having one or more of (i) at least one sensor mounted in or on or adjacent the bottom surface of the flat elastic substrate, the at least one sensor being capable of electrical or optical communication with the patient. In some implementations, a circuit may include (ii) at least one signal processing module for receiving and/or accepting signals from the at least one sensor in some implementations also providing for transforming such signals for storage as patient data; and/or (iii) at least one memory module for receiving and/or accepting and storing patient data, and/or (iv) at least one data communication module for transferring patient data, stored or otherwise to an external device, and/or (v) a control module for controlling the timing and operation of the at least one sensor, one or more of the at least one signal processing module, the at least one memory module, the at least one data communication module, and/or the control module capable of receiving commands to implement transfer of patient data by the at least one data communication module and to erase and/or wipe patient data from the at least one memory module. In some implementations, a system hereof may include (b) a conductive adhesive removably attached to the bottom surface of the flat elastic substrate, the conductive adhesive capable of adhering to skin of the patient or other user and in some non-limiting examples a system hereof may be capable of conducting an electrical signal substantially only in a direction perpendicular to the bottom surface of the flat elastic substrate, and/or in some implementations may include a conductive portion adjacent the sensor or sensors and a non-conductive portion. In some implementations, the conductive adhesive is an anisotropically conductive adhesive in that it comprises regions of material that conducts current substantially only in a direction perpendicular to the skin (i.e. “z-axis” conduction). 
     In some implementations, devices hereof will be for comprehensive long-term cardiac monitoring, inter alia. Features of such may but not necessarily include any one or more of a Lead  1  ECG, PPG, pulse oximeter, accelerometer, temperature sensor and/or a button or other indicator for manual patient event marking. Such a device may be adapted to store up to, for example, about two weeks of continuous data (though more or less will also be feasible in alternative implementations), which may in some implementations be downloaded to a clinic or other computer in a short time period, as for one example, in only about 90 seconds (though more or less time will be viable in alternative implementations) via computer connection, whether wireless or wired as in one example by USB or other acceptable data connection. A companion software data analysis package may be adapted to provide automated event capture and/or allow immediate or delayed, local data interpretation. 
     Intermittent cardiac anomalies are often difficult for physicians to detect and/or diagnose, as they would typically have to occur during a physical examination of the patient. A device hereof may address this problem with what in some implementations may be a continuous or substantially continuous monitoring of one or a number of vital signs. 
     Some alternative features may include but not be limited to one or more of (i) a driven “Right Leg” circuit with electrodes located only on the chest, and/or (ii) a “z-Axis” or anisotropic conductive adhesive electrode interface that may permit electrical communication only between an electrode and a patient&#39;s skin immediately beneath the electrode, and/or (iii) data transmission to and interpretation by a local computer accessible to CCU/ICU personnel, and/or (iv) a unique combination of hardware that may allow correlation of multiple data sources in time concordance to aid in diagnosis. 
     In some alternative non-limiting implementations, devices and systems hereof may provide 1) reusability (in some cases near or greater than about 1000 patients) that may allow recouping cost of the device in just about 10-15 patient tests; and/or 2) one or more of ECG waveform data, inertial exertion sensing, manual event marking, temperature sensing and/or pulse oximetry, any one or all of which in time concordance to better detect and analyze arrhythmic events; and/or 3) efficient watertightness or waterproofing (for the patient/wearer to be able to swim while wearing the device); and/or 4) a comprehensive analysis package for typically immediate, local data interpretation. An alternative device may be adapted to take advantage of flex-circuit technology, to provide a device that is light-weight, thin, durable, and flexible to conform to and move with the patient&#39;s skin during patient/wearer movement. 
       FIGS. 1 and 2  illustrate examples of alternative implementations of devices that may be so adapted. 
       FIG. 1 , which is defined by and includes all of sub-part  FIGS. 1A-1P , shows a device  100  that has a component side or top side  101 , patient side or circuit side  102 , and one or more inner electrical layer(s), generally identified by the reference  103  and an elongated strip layer  105 . The strip layer  105  may have electronics thereon and/or therewithin.  FIG. 1A  shows isometrically these in what may in some non-limitative implementations be considered a substantially transparent device together with some other elements that may be used herewith.  FIG. 1B  is more specifically directed to a top side  101  plan view and  FIG. 1C  to an underside, patient side  102  plan view and  FIG. 1D  a first elevational, side view. 
     Many of the optional electronics hereof may be disposed in the electronics layer or layers  103 , and as generally indicated here, the electronics may be encapsulated in a material  104  (see  FIGS. 1A, 1B, 1D and 1K  for some examples, and see  FIGS. 1N, 1O, 1P and 1Q  described further below, e.g.), medical grade silicone, plastic or the like, or potting material, to fix them in operative position on or in or otherwise functionally disposed relative to the elongated strip layer  105 . The potting or other material may in many implementations also or alternatively provide a waterproof or watertight or water resistant coverage of the electronics to keep them operative even in water or sweat usage environments. One or more access points, junctions or other functional units  106  may be provided on and/or through any side of the encapsulation material  104  for exterior access and/or communication with the electronics disposed therewithin, or thereunder.  FIGS. 1A, 1B and 1D  show four such accesses  106  on the top side. These may include high Z data communication ports and/or charging contacts, inter alia. This upper or component side  101  of device  100  may be coated in a silicone compound for protection and/or waterproofing, with only, in some examples, a HS USB connector exposed via, e.g., one or more ports  106 , for data communication or transfer and/or for charging. 
     The elongated strip layer  105  may be or may include a circuit or circuit portions such as electrical leads or other inner layer conductors, e.g., leads  107  shown in  FIG. 1D , for communication between the electronics  103  and the electrically conductive pads or contacts  108 ,  109  and  110  described further below ( 108  and  109  being in some examples, high impedance/high Z silver or copper/silver electrodes for electrocardiograph, ECG, and  110  at times being a reference electrode). In many implementations, the strip layer  105  may be or may include flex circuitry understood to provide acceptable deformation, twisting, bending and the like, and yet retain robust electrical circuitry connections therewithin. Note, though the electronics  103  and electrodes  108 ,  109 ,  110  are shown attached to layer  105 ; on top for electronics  103 , and to the bottom or patient side for electrodes  108 ,  109 ,  110 ; it may be that such elements may be formed in or otherwise disposed within the layer  105 , or at least be relatively indistinguishably disposed in relative operational positions in one or more layers with or on or adjacent layer  105  in practice. Similarly, the leads or traces  107  are shown embedded (by dashed line representation in  FIG. 1D ); however, these may be on the top or bottom side, though more likely top side to insulate from other skin side electrical communications. If initially top side (or bottom), the traces may be subsequently covered with an insulative encapsulant or like protective cover (not separately shown), and/or in many implementations, a flexible material to maintain a flexible alternative for the entire, or majority of layer  105 . 
     On the patient side  102 , the ECG electrodes  108 ,  109  and  110  may be left exposed for substantially direct patient skin contact (though likely with at least a conductive gel applied therebetween); and/or, in many implementations, the patient side electrodes  108 ,  109  and/or  110  may be covered by a conductive adhesive material as will be described below. The electrodes may be plated with or may be a robust high conductive material, as for example, silver/silver chloride for biocompatibility and high signal quality, and in some implementations may be highly robust and, for one non-limiting example, be adapted to withstand over about one thousand ( 1000 ) alcohol cleaning cycles between patients. Windows or other communication channels or openings  111 ,  112  ( FIG. 1C ) may be provided for a pulse oximeter, for example, for LEDs and a sensor. Such openings  111 ,  112  (e.g.,  FIG. 1C ) would typically be disposed for optimum light communication to and from the patient skin. An alternative disposition of one or more light conduits  111   a / 112   a  (and  111   b / 112   b ) is shown in a non-limiting example in  FIG. 1D  more nearly disposed and/or connected to the electronics  103 . A variety of alternative placements may be usable herein/herewith, some of which further described below. 
     In some implementations, sampling of the ambient light (with the LEDs off) may be provided, and then subtracting this from each of the pulse-ox signals in order to cancel out the noise caused by sunlight or other ambient light sources. 
     The LEDs and one or more photodiode sensors may also and/or alternatively be covered with a layer of silicone to remove any air gap between the sensor/LEDs and the patient skin. Some examples of such are set forth in respective  FIGS. 1H and/or 1K and/or 1L and/or 1M and/or 1N, 1O, 1P and 1Q ; where a silicone layer or covering  121  and/or  121   a  and/or  121   b  and/or  121   c  and/or  121   d  is shown covering/surrounding the light conduits and/or sensors/LEDs  111   c / 111   d / 112   c . LED  111   c  ( FIGS. 1H and/or 1K  and/or one or more of  1 L,  1 M,  1 N,  1 O,  1 P and/or  1 Q) might be a Red LED, LED  111   d  ( FIGS. 1H and/or 1K  and/or one or more of  1 L- 1 Q) might be an IR (infrared) LED and the device  112   c  ( FIGS. 1H and 1K  and/or one or more of  1 L- 1 Q)) might be a sensor. Alternative and/or additional LEDs might be provided; for a first example, one or more additional or alternative colors of LEDs (not shown) might be provided not unlike those shown in  FIGS. 1H and/or 1K  and/or one or more of  1 L- 1 Q, as for example a Green LED (not shown) for additional and/or alternative functionality as described further below. 
     Other alternative LED and sensor arrays or arrangements are shown in  FIGS. 1L and 1M  wherein one or more LEDs are more centrally disposed within epoxy/light-pipe  121   c  on a substrate  105   a  and one or more sensors or photodiodes are more peripherally disposed. In  FIG. 1L  two LEDs  111   c  and  111   d  (not unlike LEDs  111   c  and  111   d  of  FIGS. 1H and/or 1K , but for positioning/geometry) are shown relatively centrally disposed relative to one or more sensors, here, two sensors or photodiodes  112   c  and  112   d . As above-described for  FIGS. 1H and/or 1K , LED  111   c  might be a Red LED, and LED  111   d  might be an IR (infrared) LED and the devices  112   c  and/or  112   d  might be one or more sensors, here two sensors or photodiodes  112   c  and  112   d . In  FIG. 1M , four LEDs  111   c ,  111   d ,  111   e  and  111   f  (not unlike LEDs  111   c  and  111   d  of  FIGS. 1H and/or 1K and/or 1L , but for number, positioning and/or geometry) are shown relatively centrally disposed relative to one or more sensors, here, four sensors or photodiodes  112   c ,  112   d ,  112   e  and  112   f . As above-described for  FIGS. 1H and/or 1K and/or 1L , LED  111   c  might be a Red LED, and LED  111   d  might be an IR (infrared) LED, and/or  111   e  might also be a Red LED, and LED  111   f  might be an IR (infrared) LED and the devices  112   c ,  112   d ,  112   e  and/or  112   f  might be one or more sensors, here four sensors or photodiodes  112   c ,  112   d ,  112   e  and  112   f.    
     Placing the LEDs in the more centrally disposed positioning of  FIGS. 1L and 1M  and surrounding those more centrally disposed LEDs with sensors or photodiodes, as opposed to the more or relatively conventional method of a central sensor or photodiode surrounded by LEDs, provides a geometry that may be disposed to capture a much greater percentage of the emitted light, emitted from the LEDs. In the more or relatively conventional geometry, substantially all of the emitted light facing away from the photodiode is wasted. In the geometries of and/or described for  FIGS. 1L and 1M , much more light, perhaps as much as virtually all of the emitted light may be captured by the sensors or photodiodes, or in some cases, a significantly higher efficiency capture than conventional. Due to the higher efficiency light capture, fewer LEDs might thus be required than conventional Multi-LED integrated sensors. This may contribute to significantly reducing power consumption and yet achieve similar or better measurement results. In sum, a geometry of LEDs, such as the red and IR combinations described above, combined with an array of photodiodes (or sensors) is shown and described that may enable a higher concentration of light into the subcutaneous region of the subject (patient/infant/neonate/mother/athlete, e.g.). The combination of LEDs and photodiodes/sensors might also be referred to in some implementations as a High-Efficiency Integrated Sensor. This arrangement may be implemented in determination of SpO2 (peripheral capillary oxygen saturation). Note, in some practical implementations, the sensors shown in  FIGS. 1L and 1M , e.g., may be about 5 mm 2  and the diameter of the exterior circle encompassing the sensors and LEDs might be a corresponding about 8 mm. In some implementations, it may be that about 3.2 mm red may be set for a preferred distance from the center of the red LED light source to the center of the corresponding sensor or sensors, and may be a preferred distance of about 3.7 mm set from the center of the IR LED light source to the corresponding sensor or sensors therefor. 
     This silicone layer or covering  121 / 121   a / 121   b / 121   c / 121   d / 121   e  may reduce the light lost to reflection off the skin, and thereby greatly increase the signal and reduce the noise caused by motion of the skin relative to the sensor. In some implementations this silicone might be referred to as a light pipe and in some situations may be clear, colorless, and/or medical grade silicone. As described further below, the silicone layer or covering  121  and/or  121   a  and/or  121   b  and/or  121   c  and/or  121   d  and/or lens surface  121   e  (sometimes referred to herein in short by  121 / 121   a / 121   b / 121   c / 121   d / 121   e  but having the same meaning hereof) may also/alternatively be referred to as a light pipe or lens  121 / 121   a / 121   b / 121   c / 121   d / 121   e  herein inasmuch as how it may be involved in light transmitting or to be transmitted therethrough, whether upon emission or received upon reflection or both. 
     In one or more implementations, an encapsulant and/or lens  121 / 121   a / 121   b / 121   c / 121   d / 121   e  hereof may be made from a medical grade silicone that is one or more of clear, colorless, soft, low durometer. Exemplars of such specialized silicones that may be used herewith are known as “tacky gels” (several suppliers), and typically have very high-tack adhesives, preferably embedded on both sides. A low durometer silicone combined with double-sided adhesive on the tacky gel allows the construction of a lens  121 / 121   a / 121   b / 121   c / 121   d / 121   e  that may be both conforming to the electronic sensors and skin, as well as, in some implementations, exhibiting properties of motion artifact reduction by limiting movement between the skin-lens-sensor interface. A lens according hereto may also/alternatively be specially shaped such that it can be trapped between layers of the composite adhesive strip (see e.g., alternatives of  FIGS. 1D, 1G and 1I and 1J ), and in some implementations, with a raised portion the size of the opening, often a rectangular opening, in the adhesive strip that allows the lens to protrude slightly on the patient side of the adhesive strip (see further detail relative to  FIG. 1K , described below). 
     In  FIG. 1K  an implementation of a further alternative silicone covering or encapsulant  121   a  for the LEDs and sensor  111   c / 111   d / 112   c , may include a convex lens at or adjacent the covering external surface  121   b . In many implementations, the external surface and lens are one and the same and/or the lens may be defined by the surface  121   b  of the encapsulant material  121   a . What this provides is a structure and method for interfacing pulse oximetry LED emitters  111   c / 111   d  and one or more photodiode sensors  112   c  with the skin surface, whether chest or forehead (e.g., infant or neonate) or otherwise mounted on the patient or user body. 
     More particularly, as otherwise described herein, a system and/or device  100  hereof may utilize one or multiple LED emitters  111   c / 111   d  (and/or  111   e  and/or  111   f ) of selected wavelengths and one or multiple photodiode sensors. However, In order to maximize coupling of the LED/sensor combination to the skin  1001  of a wearer  1000 , an encapsulant and/or lens  121 / 121   a / 121   b / 121   c / 121   d / 121   e  comprised of optically clear, medical grade silicone may be molded onto or molded such that it may be later attached in covering relationship on the LED/sensor combination  111   c / 111   d / 112   c . In many implementations, as for example in  FIG. 1K , the lens  121   b  may be partially spherical or perhaps hemispherical in nature, though it need not be; see e.g.,  FIGS. 1N-1Q , described below. Curvature of other shapes may be useful as well. Curvature may reduce loss of skin contact when the device  100  may be moved, whether by wearer motion or otherwise. I.e., motion of the wearer  1000  or the device  100  relative to the wearer  1000  in  FIG. 1K  can result in a quasi-rolling contact of the lens on and in relation to the skin  1001 . Better maintained skin contact means better data acquisition without interruption and/or with reduced noise. In some implementations, including those above and below (though not directly shown therein, i.e., alternatively included or not included therewith), or as described with specific reference to  FIG. 1Q  below, a thin silicone adhesive  113   e  may be used on and between the silicone layer  121 / 121   a / 121   b / 121   c / 121   d / 121   e  to assist with maintenance of the skin contact relative to the silicone encapsulant  121 / 121   a / 121   b / 121   c / 121   d / 121   e . See description of  FIG. 1Q  below, e.g. 
     Moreover, related to the function of maintaining contact is the light piping effect that may be achieved when LEDs and sensors, even of different heights are communicating substantially with little or substantially without air gap interruption through the light pipe of the encapsulant material  121   a / 121   c / 121   d / 121   e  from the emission to the skin and back from the skin to the sensors. With no air gap from emitter to and through the light pipe  121   a / 121   c / 121   d / 121   e  and/or sometimes including a curved surface  121   b  substantially constant contact with the skin, there is thus no air gap or with little or substantially no air gap interruption in transmission into and through and reflected back on return from within the skin and back to the sensor via the same light pipe material  121   a / 121   c / 121   d / 121   e  (transmission and reflection both referring to light travel). This reduces inefficiencies caused by light wave scattering at air gap interfaces (air gaps allow for light to bounce off the skin or other surface). I.e., encapsulation of the LEDs and the sensor; provides no air-gap and a light pipe effect to and the curved surface provides high quality low scattering transmission into the skin and reception of reflection from the skin and bone. The light pipe and curved lens surface maintain uninterrupted contact skin and lens reduces lost signals due skin reflection. The signal to noise ratio goes down and data acquisition goes up in quality. 
     Such an encapsulant  121 / 121   a / 121   c / 121   d  and/or a lens  121   b / 121   e  may thus serve one or multiple purposes, including in some instances, inter alia: 1) providing a “light-pipe” effect to assure equal or otherwise high quality coupling of the different height LEDs and sensors, as well as substantially constant coupling to the skin to reduce motion artifact; 2) focusing of emitted light through the skin to the bone; and, 3) focusing of reflected light through the skin to the photodiode sensors. 
     As a further note, for a curved lens  121   b  option as from  FIG. 1K , the radius of the lens may be designed to maximize 1) through 3). The height of the lens may be designed to allow it to protrude above composite adhesive  113  of the device  100  and into the skin, but not deep enough to disturb the capillary bed which would also result in bad data. Moreover, the radius of curvature and the angles of LED lightwave emission are not necessarily highly controlled and need not be because the LEDs used to penetrate the skin, e.g., the red and infra-red and/or green LEDs; provide a very wide array of angles of emission, and thus a large number of reflected array of lightwaves will be focused back to the sensor by a large variety of curved surfaces. I.e., the curved surface is helpful for maintaining contact through movement (accidental or on purpose), and is less important to the angles of transmission through the skin and reflection back to the sensor. In other words, many different radii of curvature will be effective with very little difference in data/wave transmission and reflection; the wide angle emission of LED takes care of what might be a variety of radii. Rather, the curvature may have more limitation in the maintenance of contact due to movement of the device  100 —e.g., flatter curvatures won&#39;t roll readily, and very small radii of curvature will not transmit or receive as much data. 
     In some implementations, a radii of curvature found useful have been between about 20 and 40 (both 20.34 mm and 39.94 mm radii of curvature have been found useful) for a device having LEDs and sensors in a compartment of about 12.6 mm by 6.6 mm. It may be noted further that LEDs may be on one side or another or on two opposing sides or perhaps at four or more substantially equi-distant points around a sensor and may provide desirable results. 
     Note further, pulse oximetry hereof may be with multiple light sources and/or sensors as may be one interpretation of the dispositions of  FIGS. 1H and 1K , and/or any one or more of  1 L- 1 Q, e.g. Typical pulse oximetry circuitry uses one light source (LED) per wavelength (typically red, infrared, and sometimes others including green or long time averages of red/IR for further examples as described below). However, devices and/or methods hereof may make use of multiple light sources for each wavelength. This may allow for interrogation of a wider area of capillary bed in/on the patient/wearer in order to reduce the effects of a local motion artifact. Similarly, multiple sensors may be used for the same or similar purpose or advantage. 
     Furthermore, a combination of driven right leg and/or proxy driven right leg together with pulse oximetry can provide additional benefits. The right leg circuit, proxy right leg and/or driven right leg, whether for chest or forehead or other electrode placement, can remove common mode and power line noise that would/might otherwise be capacitively-coupled into the pulse oximetry sensor and reduce effectiveness thereof. A combination of driven right leg and/or proxy driven right leg and improved pulse oximetry with a lens as described in and for  FIG. 1K  and/or the light pipes of  FIGS. 1  H and/or any one or more of  FIGS. 1L-1Q  may significantly reduce such noise, and thereby enhance data acquisition. For driven electrodes see further detail below. 
     Thus, measurement of arterial blood oxygen content can be made using optical signals (sometimes also referred to as heart beat optical signals), typically from Red and Infra-Red pulsed sources, which exhibit different optical absorptions dependent on oxy-haemoglobin presence or absence. In sum, a transmissive system is used with light sources and optical detectors. In many implementations as described following, a light pipe that encapsulates either or both the light source or sources and the one or more sensors may be employed, particularly a light pipe encapsulating, meaning having substantially no air gaps, may be used for providing either or both increased efficiency in light emission to the skin and/or capturing otherwise lost photons upon collection. 
     Herein, reflective systems are typical, and these often have some advantages being less intrusive, and perhaps being more portable. As described herein, such reflective systems typically employ a red and an infra-red source and a photo-diode sensor or detector, or multiple arrangements of these components. Also as described, one implementation/method employs one or more central large area photo-diodes/sensors/detectors, with one or more LED sources, often one or more of each of a red, and an infra-red LED sources adjacent to the photo-diode or in an array around it. Also as described, an alternative arrangement uses a central LED set of one or more light sources, with one or more of each wavelength type (Red, InfraRed, Green, etc.), and multiple large area photo-diodes or light sensors surrounding the central LEDs. Such an arrangement might use two or three or four such detectors around the LEDs to collect more light scattering from the LEDs through the skin and other tissues; see e.g.,  FIGS. 1L and/or 1M . 
     A further alternative implementation may employ structural enhancements to and/or around the light sources and/or the one or multiple photo-diodes. Described first are one or more such enhancements disposed in relation to the central LED arrangement described above, though the following could be used with or relative to the prior described central sensor arrangement as well. The optical enhancing structures may provide minimal intrusion in the collection area and may reduce photo-diode areas or reduce numbers of photodiodes. Cost benefits and/or increased efficiency may thus result. 
     In  FIGS. 1N, 1O, 1P and 1Q , in the light pipe  121   d , the central LED sources  111   c  and  111   d  are isolated from the peripheral photo-detectors  112   c ,  112   d ,  112   e  and  112   f  on the substrate  105   a  by a surrounding barrier wall  122  (here also identified by the alternative reference B 1 ). A further optional external barrier  123  surrounding the sensor area is also shown. The barrier wall  122  (or B 1 ) and/or wall  123  (or B 2 ) is/or preferably opaque and/or reflective to both red and IR (or to whatever other color or wavelength of light is being used, e.g., green etc.) in order to prevent crosstalk between the LEDs and the sensors. i.e., preferably want all of the light leaving the LED area to go into the skin rather than some of the light rays finding a path to enter the sensors directly. A preferable surface for the barrier would be diffuse-reflective (as opposed generally to relative absorptive and/or mirror-shiny). An example may be clear anodized aluminum. Another would be textured white paint. Operation is shown and described relative to  FIGS. 1P and/or 1Q ; see below. 
     The shape and size of the wall  122  can be chosen appropriate to the shape and size of the LED sources, here sources  111   c  and  111   d . For example, the wall  122  could be, as shown, a circle, or could be a square or rectangular shape or otherwise (not shown) around the LEDs  111   c ,  111   d  (noting here also that more or fewer light sources might be included within or enclosed by the wall  122 ). The width or thickness of and the material used for the barrier wall  122  can be variable or varied as needed or desired as well; indeed, the width may depend upon the material and/or vice versa in that the relative opacity of any particular material may mean less or more width necessary to provide a particular level of opacity or relative diffuse reflectivity. The particular wavelengths of light, i.e., type of light used, and/or the type or types of sensors and/or the relative and/or overall geometrical relationships (sensors to light sources, sensors to sensors, and/or light sources to light sources) may also figure into the relative dimensions and/or material used for and/or due to the relative opacity in relation to the particular wavelengths. There may be situations where the relative thicknesses may have more to do with the type of material of the wall, or the opacity or relative diffuse reflectivity thereof. In some implementations, the barrier/wall may be machined, anodized aluminum, or other similar material, but other implementations are of plastic, e.g., a molded plastic. For Red and Infra-Red usage, a driving consideration can be that the material would perhaps preferably be opaque or reflective or diffuse reflective to both 660 and 940 nanometers. Thus, in many situations, very thin aluminum meets this criteria, and thicker plastic does as well. 
     The options for wall  122  will primarily be for the provision of an optical barrier to sideways propagation of either the radiation from the LEDs (e.g., as here thus far, the Red or the Infra-Red light from, e.g., LEDs  111   c / 111   d ), and the wall  122  is preferably level or slightly higher than the optical exit window of the LEDs. It is preferred that the barrier wall  122  also has a width sufficient to prevent optical crosstalk of light rays that never enter the skin or scattering material, but not so wide that light from the LEDs that is scattered from the skin or other flesh material, is prevented from reaching the photo-diode detectors outside the barrier wall. 
     An optional external barrier wall  123  might also be employed. This one assisting with collection of light reflected from the patient or user. Similar considerations for size and thickness and material may be employed with wall  123 ; the difference being primarily in collection as opposed to light generation. 
     Where these developments may provide improvement with external detectors as described here,  FIGS. 1N / 1 O, and/or  1 P/ 1 Q, is that an optical collecting structure is added that can collect light from other regions where detector diodes are not present, and conduct or reflect some of that radiation in such a way as to reach one or more of the detectors. Note, central detectors with otherwise separately isolated light sources (not shown) may also have similar improvements. 
     Preferred structures of this type may include a transparent optical medium, here the light pipe material  121   d . This light pipe material may be molded into a shape within and/or surrounding the relatively opaque barrier wall  122  (see e.g.,  FIG. 1Q , described further below), and contain sources  111   c  and  111   d  (and/or others if/when present) within the wall  122  and/or contain outside the wall  122  (between wall  122  and wall  123 ) the diode detectors  112   c ,  112   d ,  112   e  and/or  112   f  (and/or others if/when present) embedded in that structure  121   d  with little or substantially no air gaps between the detectors and the light pipe material. The detector devices  112   c ,  112   d ,  112   e  and/or  112   f  may be molded into the optical medium, i.e., light pipe material, itself, or could be inside premolded cavities in that optical medium. Optical structures of this type, could be generally referred to as “light pipes”. 
     The shape of the light pipe structure  121   d  and/or surface  121   e  can be chosen in a variety of ways, depending on the number and size or shape of the detector diodes, and may be designed in such a way as to capture scattered light received from the skin or flesh material not directly in contact or above any detector diode, and contain it by means of total internal reflection, and using scattering reflective surfaces, to redirect rays in a direction towards one or more of the photo diodes. In this way, light that would be lost in previous designs, is captured by devices of these present implementations. In  FIGS. 1N and 1O , the epoxy (light pipe)  121   d  is relatively flat, i.e., presenting a relatively flat surface  121   e , not concave or convex, though it may be that curvature will work with the barrier wall or walls hereof. In  FIG. 1Q , also a relatively or substantially flat surface  121   e  is shown. 
     Shown also in  FIG. 1Q  is an optional thin silicone adhesive  113   e  on surface  121   e  which may be used to relatively adhere the device to the skin (not shown here) to reduce movement of the device relative to the skin and enhance light transmission and reception. If used, such an adhesive may preferably be as thin as operably possible so as not to interfere with or provide refraction of light waves passing therethrough. A 0.2 mm thickness may be so operable. Also, it may be that a similar refractive index of the adhesive to the expoxy/encapsulant/light pipe  121 / 121   a / 121   b / 121   c / 121   d / 121   e  might be preferred. This choosing of a similar refractive index may be of assistance or may be related to thickness as well as material of adhesive to be used. E.g., an appropriate refractive index similarity may result from or lead to an operable 0.2 mm thickness. 
       FIGS. 1P and 1Q  show some operative examples and/or alternatives. In  FIG. 1P , where no light pipe is shown for simplicity, though could be an operable alternative example, light wave emissions A, B and C are shown emanating from the exemplar LED  111   c . Wave A is a relative direct emission meeting no obstacle on its way from the device to the skin (not shown), whereas wave B is shown as reflected off the wall  122  (note though waves are sometimes described, it is understood that light energy in whatever form is intended herewithin, whether for example it is or may better be understood as photons which are more particularly as understood as emitted and/or collected). Less preferred is a wave C shown not reflected off wall  122 ; here shown merely for highlighting the preference toward most if not all waves leaving the LED finding a way to be reflected to exit the LED area and enter the skin of the user (not shown here). Light collection is shown relative to the exemplar sensors  112   c  and  112   d , where in  FIG. 2P , relatively direct waves D are shown as they might enter the sensor area and be captured by the sensors  112   c  and/or  112   d . Reflected waves E are also shown as they might be reflected off the walls  122  and/or  123 . Note, the floor or top surface of the substrate  105   a  might also be diffuse reflective to the waves and assist in reflecting these ultimately for sensor collection. 
     In  FIG. 1Q , the light pipe/s  121   d  are shown as is an optional thin adhesive  113   e . The relative refractive indices of these materials may or may not affect, or largely affect the light passing therethrough. Preference is for similarity of refractive indices to minimize refraction. Even so, some refraction may occur as shown for example by emitting light wave B in  FIGS. 1Q and 1   n  collected waves E and F, F differing from E by not also being reflected of the walls  122  and/or  123  as is light wave E. Light wave B is shown both reflected and refracted. Choice of materials and sizes and shapes of relative structures can assist in management of relative reflection and/or refraction toward increasing efficiency in light emission and/or capture. 
     Returning to the adhesive alternatives,  FIG. 1D  provides a first example of an adhesive  113  that may be used herewith. The adhesive layer  113  is here a double-sided adhesive for application to the bottom side  102  of the device  100 , and a second side, perhaps with a different type of adhesive for adhering to the skin of the human patient (not shown). Different types of materials for adhesion might be used in that the material of choice to which the adhesive layer is to be attached are different; typically, circuit or circuit board material for connection to the device  100 , and patient skin (not separately shown) on the patient side. A protective backing  114  may be employed on the patient side until application to the patient is desired. Note, in many applications, the adhesive  113  is anisotropic in that it may preferably be only conductive in a single or substantially a single direction, e.g., the axis perpendicular to the surface of adhesive contact. Thus, good electrically conductive contact for signal communication can be had through such adhesive to/through the adhesive to the electrical contacts or electrodes,  108 ,  109  and  110 . Note, a corresponding one or more light apertures  111   b / 112   b  are shown in the adhesive of  113  of the example of  FIG. 1D  to communicate light therethrough in cooperation with the light conduit(s)  111   a / 112   a  in/through layer  105  for communication of light data typically involved in pulse oximetry. 
     The adhesive may thus be placed or disposed on the device  100 , in some implementations substantially permanently, or with some replaceability. In some implementations, the device as shown in  FIGS. 1A-1D and/or 1G  without (or with in some implementations) the adhesive may be reusable. In many such cases, the adhesive layer  113  may be removed and replaced before each subsequent use, though subsequent re-use of and with a layer  113  is not foreclosed. In a first or subsequent use with a replaceable adhesive layer  113 , it may be that the user applying the device to the patient, e.g., the physician or technician or even the patient, him/herself, applies the conductive transfer adhesive  113  to the patient side  102  of the device  100 . The protective backing  114  may then be removed, and the device adhered to the patient and activated. 
     Activation of the device after application to a patient/wearer may occur in a number of ways; in some, it may be pre-set that an affirmative activation interaction may not be necessary from the doctor or patient or like due to either an inertial and/or a pulse oximeter activation which may be substantially automatically activating, e.g., upon receiving sufficient minimum input (movement in case of inertial system or light reflection of blood flow for pulse oximetry); however, a button may be provided at an access  106  or in some other location adjacent the electronics to allow the patient to start or stop the device or otherwise mark an event if desired. In one exemplar implementation the device may be worn for a period such as two weeks for collection of data substantially continuously, or at intervals as may be preferred and established in or by the systems hereof. 
     After a monitoring period is over, a physician, technician, patient or other person may then remove the device from the patient body, in some instances remove the adhesive, in some instances with alcohol, and may establish a data communication connection for data transfer, e.g., by wireless communication or by insertion/connection of a USB or like data connector to download the data. The data may then be processed and/or interpreted and in many instances, interpreted immediately if desired. A power source on board may include a battery and this can then also be re-charged between uses, in some implementations, fully recharged quickly as within about 24 hours, after which the device could then be considered ready for the next patient or next use. 
     Some alternative conductive adhesives may be used herewith.  FIGS. 1E, 1F and 1G  show one such alternative conductive adhesive  113   a ; a bottom plan view in  FIG. 1E  and elevational side views thereof in  FIGS. 1F and 1G  (as being connected to a device  100  in  FIG. 1G ). In some implementations, the conductivity may be anisotropic as introduced above; in some conductive primarily if not entirely in the direction of the Z-Axis; perpendicular to the page (into and/or out of the page) in  FIG. 1E , and/or vertically or transversally relative to the long horizontal shown axis of device  100  in the implementation view of  FIG. 1F . 
     The implementation of this particular example includes a composite adhesive  113   a  which itself may include some non-conductive portion(s)  113   b  and some one or more conductive portions  113   c . The adhesive composite  113   a  may, as described for adhesive  113  above be double sided such that one side adheres to the patient while the other side would adhere to the underside  102  of the device  100  (see  FIG. 1G ) so that one or more conductive portions  113   c  may be disposed or placed in electrically communicative and/or conductive contact with the integrated electrodes on the electronic monitoring device  100 . Since the electrodes would operate better where they may be electrically isolated or insulated from each other, yet each making electrical contact or communication with the patient&#39;s skin, the adhesive may further be more specifically disposed in some implementations as follows. 
     As shown in  FIGS. 1E and 1F , three isolated conductive portions  113   c  may be disposed separated from each other by a body portion  113   b  which may be non-conductive. These could then correspond to the electrodes  108 ,  109 ,  110  from the above-described examples, and as more particularly shown schematically in  FIG. 1G  (note the scale is exaggerated for the adhesive  113   a  and thus, exact matching to the electrodes of device  100  is not necessarily shown). In some examples, the electrode areas  113   c  may be a conductive hydrogel that may or may not be adhesive, and in some examples, may be made of a conductive an adhesive conductive material such as 3M Corporation 9880 Hydrogel adhesive (3M Company, St. Paul, Minn.). These areas  113   c  may then be isolated from each other by a non-conductive material  113   b  such as 3M Corporation 9836 tape or 3M double-sided Transfer Adhesive 9917 (3M, St. Paul, Minn.) or equivalent. The additional layer  113   d , if used, might be a 3M 9917 adhesive together with the  113   b  of a 9836 material. These constructs may provide the effect of creating a low electrical impedance path in the Z-axis direction (perpendicular to page for  FIG. 1E  and vertically/transversally for  FIGS. 1F and 1G ) for the electrode areas  113   c , and high electrical impedance path between the electrodes in the X/Y directions. (See  FIGS. 1E, 1F and 1G ; coplanar with the page in  FIG. 1E  and horizontal and perpendicular to the page in  FIGS. 1F and 1G ). Thus, a composite adhesive strip can ensure not only device adhering to the patient, but also that the electrodes whether two or as shown three electrodes are conductively connected by conductive portions of the adhesive strip, where the combination of conductive and non-conductive portions can then reduce signal noise and/or enhance noise free characteristics. Electrodes that move relative to skin can introduce noise; that is, electrodes electrically communicative/connected to the skin via a gel may move relative to the skin and thus introduce noise. However, with one or more conductive adhesive portions in a composite adhesive connected to respective electrodes and then substantially securely connected to the skin will keep the respective electrodes substantially fixed relative to the skin and thereby reduce or even eliminate electrode movement relative to the skin. Removal of such movement would then remove noise which would thereby provide a clean signal that can allow for monitoring cardiac P waves which enhances the possibility to detect arrhythmias that couldn&#39;t otherwise be detected. Further description is set forth below. 
     In some implementations, a further optional connective and/or insulative structure  113   d  may be implemented as shown in  FIGS. 1F and/or 1G , to provide further structural and insulative separation between electrodes with connected to a device  100  on the underside  102  thereof (see  FIG. 1G ). Though shown separate in  FIGS. 1F and 1G , it may be contiguous with the insulative adhesive  113   b  of these views. 
     Further alternatives related to the adhesive may be used. In some implementations, a composite adhesive strip may be used having properties to reduce one or more motion artifacts. Typical ECG attachment systems use a conductive gel located over the electrode. Here, however, a hydrogel adhesive may be used which is embedded in a continuous sheet of laminated adhesives that cover the selected regions or the entire footprint of the device. The fact that the hydrogel itself has strong adhesive properties coupled with the complete coverage of the device with adhesives may assure a strong bond between the device and the patient&#39;s skin. Contributing to motion artifact reduction may be an alternative vertical placement of the device on the sternum which results in reduced motion artifacts for one or more of ECG signals, photoplethysmography waveforms, and oxygen saturation signals. 
     In some implementations, composite adhesive improvements may include water-proof encapsulation of the hydrogel adhesive to prevent ohmic impedance reduction resulting in reduction of signal amplitude. This may also help prevent hydrocolloid adhesive degradation. In particular, as shown the non-limitative alternative exemplar in  FIGS. 1I and 1J ; several layers may be used. Herein, Layer 1 may be a hydrocolloid that is an adhesive designed for long term skin contact by absorbing sweat and cells. Layer 2 may then also be a layer designed for long-term skin contact, however, this layer 2 isolates Layer 3 from contacting the skin. The smaller dimensions of Layer 2 create a gap between Layers  1  and  3 . When Layer 1 and 3 bond together, it forms a water-tight seal around Layer 2. This layer, Layer 2, also isolates the Hydrocolloid from the Hydrogel Adhesive, protecting the adhesive properties of the Hydrocolloid. Layers  3  and  5  would then generally be waterproof layers that are electrically isolating, double-sided adhesives. These two layers encapsulate the hydrogel adhesive, preventing a “short circuit” described relative to layer 4 below. Layer 4 is the hydrogel adhesive that is the conductive element hereof. The three islands of hydrogel adhesive of Layer 4 must be kept electrically isolated from each other. However as the hydrocolloid in layer 1 absorbs sweat, it too becomes conductive and creates a potential “short circuit” between the three islands of hydrogel adhesive in Layer 4, reducing signal amplitude. Nevertheless, this “short circuit” may be prevented by layers 3 and 5, described above. 
     In some one or more additional alternative implementations, temperature may be a parameter determined hereby. This may be by a single sensor or plural sensors as described herein. In some temperature implementations, infant or neonate temperature may be sought data for capture hereby, or temperature may be used with other users, adult or otherwise. 
     Infant and/or neonate temperature sensing can be of significant assistance in health monitoring. Forehead or other use may be one such application. Another set of possible applications may include methods and apparatuses for sensing the temperature of both an infant and a mother engaged in so-called “Kangaroo Care”. There is evidence that pre-mature infants may benefit more from constant contact with a parent&#39;s or the mother&#39;s skin than from being placed in an incubator. There is also evidence of lower mortality rates. 
     An apparatus  100   a  for dual temperature sensing, the infant wearer  1000  and the mother  1010  or ambient air  1011 , is shown in the accompanying figure,  FIG. 1R . The substrate  1105  is preferably a small, flexible circuit board, in some examples, approximately twenty (20) mm X thirty (30) mm. The board  1105  may be disposed to contain circuitry  1103  for, for example, sensing relative X-Y-Z position and/or acceleration, and/or Bluetooth or other wireless data/signal connectivity, as well as, in many examples, a replaceable and/or rechargeable battery for extended use, as for example, seven (7) days of continuous monitoring (circuit element alternatives not all separately shown in  FIG. 1R ). The apparatus  100   a  may be held to the infant with an adhesive, such as the composite adhesive  1113  shown in  FIG. 1R , which may further be, for example, a disposable, medical grade, double-sided adhesive. 
     Each of two temperature sensors  1111   a  and  1111   b  may be disposed on alternative opposing sides  1101 ,  1102  of the apparatus  100   a , and may be thermally isolated from each other, as well as often being waterproof, water tight or water resistant. A thermally insulating or isolation layer  1103   a  may provide the thermal isolation of the electronics  1103  and/or sensors  1111   a  and  1111   b . A further spacer  1103   b  may be disposed through the insulating/isolating layer  1103   a  to provide a throughway for electronic communication of the sensor  1111   b  to the electronics layer  1103 . A silicone bead  1104  may be provided for isolating and assisting in giving a waterproof or water-resistant seal on the “infant side”  1102 , and a silicone cover  1121  may provide a waterproof or waterproof barrier on the “mother side”  1101 . The sensor  1111   b  on the “mother side” or top or exterior side  1101  may be slightly protruding relative to the cover  1121  with in many implementations a thin/thinner layer of covering material and/or silicone thereover. The sensor  1111   a  on the child side or patient or circuit side  1102  may be protruding past, or through the adhesive and/or disposed exposed or also/alternatively covered with a thin protectant layer for water proofness, or tightness or resistance. 
     The thermally insulating layer may provide one or two or more functions. It may provide for or allow the “infant side” sensor  1111   a  to reach equilibrium, thus providing an accurate “core temperature” of the infant. It may also or alternatively isolate the infant&#39;s temperature reading from the mother&#39;s or ambient. The “mother side” sensor  1111   b  does not have to provide an accurate core temperature for the mother. Typically, the function of sensor  1111   b  would be to differentiate whether or not the infant is in the correct direct contact with the mother&#39;s skin; i.e., to provide a relative measurement for determining whether the infant is in relative contact or not in relative contact with the mother. If the infant is facing the wrong way, but is still in the “pouch” the sensor will read that environment&#39;s ambient temperature. If the infant is out of the pouch, it will read the room ambient temperature. The relative differences would be interpretable to provide an indication of what position the infant is in; whether in contact, or in close association in a controlled “pouch” environment (but not in contact), or outside the pouch in a further removed environment. 
     An alarm from a Bluetooth or otherwise wirelessly connected device may be used to alert the mother (or health care professional) that the infant is no longer in the correct desired position, or no longer in the “pouch”. 
     Some alternative implementations hereof may include a driven right leg ECG circuit with one or more chest only electrodes (“Driven Chest Electrode”). In addition to the electrodes used to measure a single or multiple lead electrocardiogram signal, a device  100  may use an additional electrode, as for example the reference electrode  110  (see  FIGS. 1A, 1C, 1D and 1G , e.g.) to reduce common mode noise. Such an electrode may function in a manner similar to the commonly-used driven right leg electrode, but may here be located on the patient&#39;s chest rather than on the patient&#39;s right leg but nevertheless this third/reference electrode may play the role of the leg electrode. This chest electrode may thus mimic a right leg electrode and/or be considered a proxy driven right leg electrode. A circuit, or portion of an overall circuit, adapted to operate in this fashion may include a number of amplifier stages to provide gain, as well as filtering to ensure circuit stability and to shape the overall frequency response. Such a circuit may be biased to control the common mode bias of the electrocardiogram signal. This driven chest electrode implementation may be used in conjunction with a differential or instrumentation amplifier to reduce common mode noise. In this case, the sense electrode may be used as one of the electrocardiogram electrodes. Alternatively, a single-ended electrocardiogram amplifier may be used where the differential electrocardiogram signal is referenced to ground or to some other known voltage. 
     A circuit or sub-circuit  200  using a transistor  201  as shown in  FIG. 2  may be such a circuit (aka module) and may thus include as further shown in  FIG. 2A , a sense electrode  202 , a drive electrode  203 , and an amplifier  204 . Both the sense and drive electrodes  202 ,  203  are placed on the patient&#39;s chest such that they provide an electrical connection to the patient. The amplifier  204  may include gain and filtering. The amplifier output is connected to the drive electrode, the inverting input to the sense electrode, and the non-inverting input to a bias voltage  205 . The amplifier maintains the voltage of the sense electrode at a level close to the bias voltage. An electrocardiogram signal may then be measured using additional electrodes. Indeed, as was the case for the improved conductivity through use of anisotropic adhesive portions above, here also or alternatively, the use of this third electrode as a proxy for a right leg electrode (i.e., proxy driven right leg electrode) can provide signal reception otherwise unavailable. Clean signals may thus allow for receiving cardiac P waves which enhances the possibility to detect arrhythmias that couldn&#39;t otherwise be detected. 
     Further alternative descriptions of circuitry include that which is shown in  FIGS. 2B and 2C ; in which are shown non-limiting alternatives in which three adjacent electrodes E 1 , E 2 , and E 3  may be used to pick up the ECG signal, one of which electrodes playing the role of the distant limb electrode of traditional ECG monitors. Because the electrode-patient interface has an associated impedance (Re 1  and Re 2 ), current flowing through this interface will cause a difference in voltage between the patient and the electrode. The circuit may use a sense electrode (E 1 ) to detect the patient voltage. Because this exemplar circuit node has a high impedance to circuit ground (GND), very little current flows through the electrode interface, so that the voltage drop between the patient and this node is minimized. The first of these alternative, non-limiting circuits ( FIG. 2B ) also contains an amplifier (U 1 ) whose low-impedance output is connected to a separate drive electrode (E 2 ). The amplifier uses negative feedback to control the drive electrode such that the patient voltage (as measured by the sense electrode E 1 ) is equal to the bias voltage (V 1 ). This may effectively maintain the patient voltage equal to the bias voltage despite any voltage difference between the driven electrode (E 2 ) and the patient. This can include voltage differences caused by power line-induced current flowing between the drive electrode and the patient (through Re 2 ). This arrangement differs from a traditional ‘driven-right-leg’ circuit in at least two ways: the driven electrode is placed on the patient&#39;s chest (rather than the right leg), and the ECG signal is a single-ended (not differential) measurement taken from a third electrode (E 3 ). Because all electrodes are located on the patient&#39;s chest in a chest-mounted example, a small device placed there may contain all the necessary electrodes for ECG measurement. One possible benefit of the single-ended measurement is that gain and filtering circuitry (U 2  and associated components ( FIG. 2C )) necessary to condition the ECG signal prior to recording (ECG Output) requires fewer components and may be less sensitive to component tolerance matching. The examples of  FIGS. 2A, 2B and 2C  are non-limiting examples and not intended to limit the scope of the claims hereto as other circuits with other circuit elements can be formed by skilled artisans in view hereof and yet remain within the spirit and scope of claims hereof. 
     In many implementations, a system hereof may include other circuitry operative together with the ECG electrodes, which may thus be accompanied by other sensors to provide time concordant traces of: i) ECG p-, qrs-, and t-waves; ii) O2 Saturation, as measured by Pulse Oxymetry; and/or iii) xyz acceleration, to provide an index of physical activity. Such circuitry may be implemented to one or more of the following electrical specifications. The overall system might in some implementations include as much as two weeks (or more) of continuous run time; gathering data during such time. Some implementations may be adapted to provide as many or even greater than 1000 uses. Alternatives may include operability even after or during exposure to fluids or wetness; in some such examples being water resistant, or waterproof, or watertight, in some cases continuing to be fully operable when fully submerged (in low saline water). Other implementations may include fast data transfer, as for an example where using an HS USB for full data transfer in less than about 90 seconds. A rechargeable battery may typically be used. 
     A further alternative implementation may include an electronic “ground”: In a device hereof, mounted entirely on a flexible circuit board, the ground plane function may be provided by coaxial ground leads adjacent to the signal leads. The main contribution of this type of grounding system may be that it may allow the device the flexibility required to conform and adhere to the skin. 
     For electrocardiograph; EKG or ECG, some implementations may include greater than about 10 Meg Ohms input impedance; some implementations may operate with a 0.1-48 Hz bandwidth; and some with an approximate 256 Hz Sampling Rate; and may be implementing 12 Bit Resolution. For PPG and Pulse Oximeter, operation may be with 660 and 940 nm Wavelength; about 80-100 SpO2 Range; a 0.05-4.8 Hz Bandwidth; a 16 Hz Sampling Rate; and 12 bit resolution. For an accelerometer: a 3-Axis Measurement may be employed, and in some implementations using a ±2 G Range; with a 16 Hz Sampling Rate; and a 12 Bit Resolution. 
     For pulse oximetry, an option for PPG ambient light subtraction may be included. A method and circuitry for reducing errors in pulse oximetry caused by ambient light is described and a circuitry option shown in  FIG. 2D . Here a correlated double sampling technique is shown for use to remove the effect of ambient light, photo-detector dark current, and flicker noise. 
     The schematic shown in  FIG. 2D  may be used where, first, the noise signal may be measured. The light sources are turned off, switch S 1  is closed, and switch S 2  is open. This allows charge proportional to the noise signal to accumulate on C 1 . Then switch S 1  is opened. At this point the voltage on C 1  is equal to the noise signal voltage. Next, the light signal may be measured. The light source is turned on, switch S 2  is closed, and charge is allowed to flow through C 1  and C 2  in series. Then, S 2  is opened, and the voltage is held on C 2  until the next measurement cycle when the whole process is repeated. 
     If C 1  is much larger than C 2 , nearly all the voltage will appear on C 2 , and the voltage on C 2  will be equal to the noise-free signal (s). Otherwise, the voltage on C 2  will be a linear combination of the previous C 2  voltage (p) and the noise-free signal: (C 2 *s+C 1 *p)/(C 1 +C 2 ). This has the effect of applying a first-order, low-pass, IIR discrete-time filter to the signal. If this filtering effect is not desired, the voltage on C 2  may be discharged to zero before the signal is measured each cycle, so that the signal held on C 2  is simply: (C 2 *s)/(C 1 +C 2 ). 
     This circuit may be used with a trans-impedance amplifier in place of resistor R, a phototransistor in place of the photodiode, and FETs in place of the switches. The output may be followed by additional buffering, amplification, filtering and processing stages. 
     Some summary methodologies may now be understood with relation to  FIG. 3 , though others may be understood through and as parts of the remainder of the disclosure hereof. A flow chart  300  as in  FIG. 3  may demonstrate some of the alternatives; where an initial maneuver  301  might be the application of the device  100  to the patient. Indeed, this might include some one or more of the alternatives for adhesive application as described here above, whether by/through use of an adhesive such as that  113  of  FIG. 1D , or that of  FIGS. 1E , IF and/or  1 G. Then, as shown, in moving by flow line  311 , a data collection operation  302  may be implemented. Note, this might include a continuous or substantially continuous collection or an interval or periodic collection or perhaps even a one-time event collection. This may depend upon the type of data to be collected and/or be dependent upon other features or alternatives, as for example whether a long term quantity of data is desired, for ECG for example, or whether for example a relative single data point might be useful, as in some cases of pulse oximetry (sometimes a single saturation point might be of interest, as for example, if clearly too low, though comparison data showing trending over time, may indeed be more typical). 
     Several alternatives then present in  FIG. 3 , flow chart  300 ; a first such might be the following of flowline  312  to the transmission of data operation  303 , which could then involve either wireless or wired (e.g., USB or other) data communication from the device  100  to data analysis and/or storage devices and/or systems (not separately shown in  FIG. 3 ; could include computing devices, see e.g.,  FIG. 4  described below, or the like). Options from this point also appear; however, a first such might include following flow line  313  to the data analysis operation  304  for analyzing the data for determination of the relative health and/or for condition diagnosis of a patient. Computing systems, e.g., a computer (could be of many types, whether hand-held, personal or mainframe or other; see  FIG. 4  and description below) could be used for this analysis; however, it could be that sufficient intelligence might be incorporated within the electronics  103  of device  100  such that some analysis might be operable on or within device  100  itself. A non-limiting example, might be a threshold comparison, as for example relative to pulse oximetry where when a low (or in some examples, perhaps a high) threshold level is reached an indicator or alarm might be activated all on/by the electronics  103  of the device  100 . 
     A similar such example, might be considered by the optional alternative flow path  312   a  which itself branches into parts  312   b  and  312   c . Following flow path  312  a, and then, in a first example path  312   b , a skip of the transmit data operation  303  can be understood whereby analysis  304  might be achieved without substantial data transfer. This could explain on board analysis, whether as for example according to the threshold example above, or might in some instances include more detailed analysis depending upon how much intelligence is incorporated on/in the electronics  103 . Another view is relative to how much transmission may be involved even if the transmission operation  303  is used; inasmuch as this could include at one level the transmission of data from the patient skin through the conductors  108 ,  109  and/or  110  through the traces  107  to the electronics  103  for analysis there. In other examples, of course, the transmission may include off-board downloading to other computing resources (e.g.,  FIG. 4 ). In some cases, such off-loading of the data may allow or provide for more sophisticated analysis using higher computing power resources. 
     Further alternatives primarily may involve data storage, both when and where, if used. As with intelligence, it may be that either some or no storage or memory may be made available in/by the electronics  103  on-board device  100 . If some storage, whether a little or a lot, is made available on device  100 , then, flow path  312   a  to and through path  312   c  may be used to achieve some storing of data  305 . This may in many cases then, though not necessarily be before transmission or analysis (note, for some types of data multiple paths may be taken simultaneously, in parallel though perhaps not at the same time or serially (e.g., paths  312   b  and  312   c  need not be taken totally to the exclusion of the other), so that storage and transmission or storage and analysis may occur without necessarily requiring a completion of any particular operation before beginning or otherwise implementing another). Thus, after (or during) storage  305 , flow path  315   a  may be followed for stored data which may then be transmitted, by path  315   b  to operation  303 , and/or analyzed, by path  315   c  to operation  304 . In such a storage example, which in many cases may also be an on-board storage example, data can be collected then stored in local memory and later off-loaded/transmitted to one or more robust computing resources (e.g.,  FIG. 4 ) for analysis. Frequently, this can include long term data collection, e.g., in the manner of days or weeks or even longer, and may thus include remote collection when a patient is away from a doctor&#39;s office or other medical facilities. Thus, data can be collected from the patient in the patient&#39;s real world circumstances. Then, after collection, the data can be transmitted from its storage on device  100  back to the desired computing resource ( FIG. 4 , e.g.), and such transmission might be wireless or wired or come combination of both, as for example a blue tooth or Wi-Fi connection to a personal computer ( FIG. 4  for one example) which might then communicate the data over the internet to the designated computer for final analysis. Another example might include a USB connection to a computer, either to a PC or a mainframe ( FIG. 4 ), and may be to the patient computer or to the doctor computer for analysis. 
     If little or no storage or memory is resident on device  100  (or in some examples even where there may be a large amount of resident memory available), then, relatively soon after collection, the data would need to or otherwise might desirably either or both be transmitted and then stored, see path  313   a  after operation  303 , and/or transmitted and analyzed, paths  312  and  313 . If path  313   a  is used, then, more typically, the data storage may be in/on computing resources (not shown in  FIG. 3 , but see  FIG. 4  described below) off-board (though on-board memory could be used as well), and then, any of paths  315   a ,  315   b  and  315   c  may be used. 
     A feature hereof may include an overall system including one or more devices  100  and computing resources (see  FIG. 4 , for example) whether on-board device(s)  100 , or separate, as for example in personal or mobile or hand-held computing devices (generally by  FIG. 4 ), the overall system then providing the ability for the physician or doctor to have immediate, in-office analysis and presentation of collected test data. This would in some implementations allow for on-site data analysis from the device without utilization of a third party for data extraction and analysis. 
     Alternative implementations hereof may thus include one or more hardware and software combinations for multiple alternative data source interpretations. As noted above, a device  100  hereof includes hardware that monitors one or more of various physiologic parameters, then generates and stores the associated data representative of the monitored parameters. Then, a system which includes hardware such as device  100  and/or the parts thereof, and software and computing resources ( FIG. 4 , generally) for the processing thereof. The system then includes not only the collection of data but also interpretation and correlation of the data. 
     For example, an electrocardiogram trace that reveals a ventricular arrhythmia during intense exercise may be interpreted differently than the same arrhythmia during a period of rest. Blood oxygen saturation levels that vary greatly with movement can indicate conditions that may be more serious than when at rest, inter alia. Many more combinations of the four physiologic parameters are possible, and the ability of software hereof to display and highlight possible problems will greatly aid the physician in diagnosis. Thus, a system as described hereof can provide beneficial data interpretation. 
     Some of the features which can assist toward this end may be subsumed within one or more of operations  303  and  304  of  FIG. 3 , wherein data collected on a device  100  can rather simply be communicated/transmitted to computing resources (again, whether on-board device  100  or discrete therefrom as e.g.,  FIG. 4 ). For an example, when a patient having had a device applied (operation  301 ) may return to a physician&#39;s office after a test period wherein data was collected (operation  302 ) the device is connected via one or more data transmission alternatives, as for example, USB to a computer (Windows or Mac) (generally with reference to  FIG. 4  and description thereof) in the office, allowing immediate analysis by the physician while the patient waits (note, the device  100  may first have been removed from the patient or might remain thereon pending transmission and analysis for determination of whether more data may be desired). In some implementations, data analysis time may be relatively quick, at approximately 15 minutes in some implementations, and might be achieved with a user-friendly GUI (Graphic User Interface) to guide the physician through the analysis software. 
     The analysis/software package may be disposed to present the physician with results in a variety of formats. In some implementations, an overview of the test results may be presented, either together with or in lieu of more detailed results. In either case, a summary of detected anomalies and/or patient-triggered events may be provided, either as part of an overview and/or as part of the more detailed presentation. Selecting individual anomalies or patient-triggered events may provide desirable flexibility to allow a physician to view additional detail, including raw data from the ECG and/or from other sensors. The package may also allow data to be printed and saved with annotations in industry-standard EHR formats. 
     In one implementation, patient data may be analyzed with software having the one or more of the following specifications. Some alternative capabilities may include: 1. Data Acquisition; i.e., loading of data files from device; 2. Data Formatting; i.e., formatting raw data to industry standard file formats (whether, e.g., aECG (xml); DICOM; or SCP-ECG) (note, such data formatting may be a part of Acquisition, Storage or Analysis, or may have translation from one to another (e.g., data might be better stored in a compact format that may need translation or other un-packing to analyze)); 3. Data Storage (whether local, at a clinic/medical facility level or e.g., in the Cloud (optional and allows offline portable browser based presentation/analysis); 4. Analysis which inter alia, may include, e.g., noise filtering (High pass/Low pass digital filtering); and/or QRS (Beat) detection (in some cases, may include Continuous Wave Transform (CWT) for speed and accuracy); and/or  5 . Data/Results Presentation, whether including one or more graphical user interface(s) (GUIs) perhaps more particularly with an overall Summary and/or General Statistics and/or Anomaly Summary of Patient triggered event(s); presentation of additional levels of detail whether of Strip view(s) of anomaly data by incident (previous, next) Blood Oxygen saturation, stress correlation or the like; and/or allowing care provider bookmarking/annotations/notes by incident and/or Print capability. 
     Further, on alternative combinations of hardware with proprietary software packages: I) One on-device software package may be adapted to store the measurements from the data signals acquired from one or more of EKG/ECG (whether right leg and/or p-, qrs- and/or t-waves), or O2 saturation, or xyz acceleration, in a time concordant manner, so that a physician may access a temporal history of the measurements (say, in some examples, over a 1-2 week interval), which would provide useful information on what the patient&#39;s activity level was prior to, during, and after the occurrence of a cardiac event. ii) an alternative to alternately manage the real-time transmission of the real-time measured parameters to a nearby station or relay. And/or; iii) an off-device ECG analysis software aimed at recognizing arrhythmias. 
     The software mentioned above may be industry understood software provided by a 3rd party, or specially adapted for the data developed and transmitted by and/or received from a wearable device  100  hereof. Thorough testing using standard (MIT-BIH/AHA/NST) arrhythmia databases, FDA  510 ( k ) approvals preferred. Such software may be adapted to allow one or more of automated ECG analysis and interpretation by providing callable functions for ECG signal processing, QRS detection and measurement, QRS feature extraction, classification of normal and ventricular ectopic beats, heart rate measurement, measurement of PR and QT intervals, and rhythm interpretation. 
     In many implementations, the software may be adapted to provide and/or may be made capable of supplying one or more of the following measurements: 
                         TABLE 1                  1.   Heart Rate Min, Max and Average       2.   QRS duration average       3.   PR interval average       4.   QT interval average       5.   ST deviation average                    
and, may be adapted to recognize a broad range of arrhythmias such as those set forth here:
 
     
       
         
           
               
               
             
               
                 TABLE 2A 
               
               
                   
               
             
            
               
                 1. 
                 SINUS RHYTHM 
               
               
                 2. 
                 SINUS RHYTHM + IVCD 
               
               
                 3. 
                 SINUS BRADYCARDIA 
               
               
                 4. 
                 SINUS BRADYCARDIA + IVCD 
               
               
                 5. 
                 SINUS TACHYCARDIA 
               
               
                 6. 
                 PAUSE 
               
               
                 7. 
                 UNCLASSIFIED RHYTHM 
               
               
                 8. 
                 ARTIFACT 
               
               
                   
               
            
           
         
       
     
     This first group of 8 given above are arrhythmia types that may be recognizable even if there is no discernible P wave. They are the ones typically recognized by existing products in the outpatient monitoring market that we propose to address. 
     A second set or group of arrhythmias; below, may require a discernible and measurable P wave. Some implementations hereof may be adapted to be able to detect and recognize them, as device  100  may be able as described above to detect P waves, depending of course, and for example, on whether the strength of the P wave which may be affected by device  100  placement or patient physiology. 
     
       
         
           
               
               
             
               
                 TABLE 2B 
               
               
                   
               
             
            
               
                 9. 
                 ATRIAL FIBRILLATION/FLUTTER SVR (slow) 
               
               
                 10. 
                 ATRIAL FIBRILLATION/FLUTTER CVR (normal rate) 
               
               
                 11. 
                 ATRIAL FIBRILLATION/FLUTTER RVR (rapid 
               
               
                 12. 
                 FIRST DEGREE AV BLOCK + SINUS RHYTHM 
               
               
                 13. 
                 FIRST DEGREE AV BLOCK + SINUS TACHYCARDIA 
               
               
                 14. 
                 FIRST DEGREE AV BLOCK + SINUS BRADYCARDIA 
               
               
                 15. 
                 SECOND DEGREE AV BLOCK 
               
               
                 16. 
                 THIRD DEGREE AV BLOCK 
               
               
                 17. 
                 PREMATURE ATRIAL CONTRACTION 
               
               
                 18. 
                 SUPRAVENTRICULAR TACHYCARDIA 
               
               
                 19. 
                 PREMATURE VENTRICULAR CONTRACTION 
               
               
                 20. 
                 VENTRICULAR COUPLET 
               
               
                 21. 
                 VENTRICULAR BIGEMINY 
               
               
                 22. 
                 VENTRICULAR TRIGEMINY 
               
               
                 23. 
                 IDIOVENTRICULAR RHYTHM 
               
               
                 24. 
                 VENTRICULAR TACHYCARDIA 
               
               
                 25. 
                 SLOW VENTRICULAR TACHYCARDIA 
               
               
                   
               
            
           
         
       
     
     Further in alternative software implementations; some sample screenshots are shown in  FIG. 5 . A first such alternative is shown in  FIG. 5A , which is an example screenshot showing ECG and Oxygen Saturation data taken by using a patch device such as a device  100  hereof. An extremely clean signal is shown (no filtering or smoothing has been done on this data). Distinct p-waves are also shown (3 of which are shown as an example with arrows). P wave detection can be extremely important for ECG anomaly detection. Oxygen Saturation, as measured by Pulse Oxymetry, is shown on the bottom plot. This is data taken by a device on the chest, and is taken in time concordance with the ECG data. 
     Another alternative is shown in  FIG. 5B , which is an example screenshot of Analysis Software. This is a sample of ECG data taken from the MIT-BIH Arrhythmia Database, Record  205 . As analyzed by the Analysis system hereof, we see in the Event Occurrences Summary list (top, left) five (5) anomaly types (plus normal sinus rhythm). This list also shows the number of occurrences of each anomaly, total duration of the anomaly in the complete ECG, and the percent time this anomaly occurs in the complete ECG. To view specific instances of each anomaly, the user double clicks the specific row in the Event Occurrences Summary list, as shown in  FIG. 5C . 
     As introduced,  FIG. 5C  is an example screenshot showing specific instance of Ventricular Tachycardia. The ECG plot automatically navigates to the specific time in the ECG waveform, and marks the beginning and end of the event. More detailed data about this specific event is now shown in the Occurrence Details: HR Average, HR Max, etc. for the duration of this event. To show the instances of another anomaly in this ECT, the user can click on the Premature Ventricular Contraction (PVC) row of the Event Occurrences Summary, as shown  FIG. 5D . 
     As introduced,  FIG. 5D  is an example screenshot showing specific instance of Premature Ventricular Contraction. This shows occurrences of the PVC. The Start Times list (middle top) shows all instances of PVC occurrences in this ECG, and lists the start time for each occurrence. In this case, the user can click on the PVC that starts at 00:15:27 (the 11 th  occurrence). The ECG plot is automatically taken to this point in time to show and indicate the PVC instances in the waveform. Since there are 3 instances of a PVC in this timeslot, all 3 occurrences are marked. 
     As mentioned above, in one aspect of the developments hereof, ECG signals collected in time concordance with pulse oximetry signals may be used to reduce the noise in the pulse oximetry signals and to permit the calculation of values for oxygen saturation, particularly in circumstances where sensors pulse oximetry data are placed on noise-prone locations of a patient, such as the chest. In some embodiments, this aspect may be implemented by the following steps: (a) measuring an electrocardiogram signal over multiple heart beats; (b) measuring one or more pulse oximetry signals over multiple heart beats such that the electrocardiogram signal and the one or more pulse oximetry signals are in time concordance over one or more heart beats; (c) comparing a portion of the electrocardiogram signal and the one or more pulse oximetry signals in time concordance over one or more heart beats to determine a constant component and a primary periodic component of each of the one or more pulse oximetry signals; and (d) determining oxygen saturation from the constant components and primary periodic components of the one or more pulse oximetry signals. Measurement of the ECG signals and pulse oximetry signals may be implemented by embodiments of devices hereof. In particular, pulse oximetry signals may be a reflective infrared signal and a reflective red light signal collected by a photodetector in a device hereof. Alternatives may include other colors, as for example green in addition to or in lieu of one or both of red and infrared. Such alternatives are described further below. 
     Intervals of pulse oximetry signals corresponding to heart beats may be determined by comparing such signals to the time concordant ECG signals. For example (not intended to be limiting), successive R-wave peaks of a time concordant ECG signal may be used to identify such intervals, although other features of the ECG signal may be used as well. Once such intervals are identified, values at corresponding times within the intervals may be averaged to reduce signal noise and to obtain more reliable values for the constant components (sometimes referred to as the “DC components”) and the main periodic components (sometimes referred to as the “AC components”) of the pulse oximetry signals, e.g. Warner et al, Anesthesiology, 108: 950-958 (2008). The number of signal values recorded in an interval depends on the signal sampling rate of the detectors and processing electronics employed. Also, as the intervals may vary in duration, the averaging may be applied to a subset of values in the intervals. As described below, oxygen saturation values may be computed from such DC and AC components using conventional algorithms. The number of heart beats or intervals over which such averages may be computed may vary widely, as noted below. In some embodiments, signals from one or more heart beats or intervals may be analyzed; in other embodiments, signals from a plurality of heart beats or intervals may be analyzed; and in some embodiments, such plurality may be in the range of from 2 to 25, or in the range of from 5 to 20, or in the range of from 10 to 20. 
     As described, a method of pulse oximetry measures photoplethysmogram signals at red and infrared wavelengths. The DC or mean value is estimated and subtracted, and the ratio of AC or pulsatile signal is estimated and/or averaged. Linear regression between the two signals can be used as described below. However, performance is limited because similar noise exists in both the red and infrared signals. Photoplethysmography taken using green light (˜550 nm) is more resilient to motion noise because the light is absorbed much more by blood than by water or other tissue. However, the difference between oxygenated and deoxygenated blood in the green region of the spectrum is much less than red. In an alternative, a green PPG signal (or long time average of red/IR (see below)) may be used to determine the shape of the pulsatile signal. A weighted average of any number of different wavelengths (such as green, red and infrared) may be used to estimate the shape of the pulsatile waveform. 
     In further alternative implementations, a linear regression algorithm for Oxygen Saturation may be used. As such, either or both the patient&#39;s ECG signal and/or a green (or other color) LED PPG signal may be used. For a first example, an ECG signal may be used to determine when heart beats occur. The beat locations allow correlated time averaging of each of the two photoplethysmogram signals. A linear regression of the ensemble averages may then be used to determine the linear gain factor between the two signals. This gain factor can be used to determine the patient oxygen saturation. 
     If/when in the alternative and/or in addition, photoplethysmography (PPG) using green light (˜550 nm) is implemented, the PPG signal may be used determine the shape of the pulsatile signal. This lower-noise signal may then be used as the independent variable for linear regression with both the red and infrared signals. The ratio of these two regression results is an estimate of the correlation between the red and infrared signals. Noise can be reduced by ensemble averaging over multiple heart beats as disclosed herein (see e.g., description of frames below). In addition to or instead of using an ECG signal to determine beat timing, the green wavelength PPG signal may be used. Alternatively, a weighted average of any number of different wavelengths (such as green, red and infrared or long time average of red/IR (see below)) may be used. The ensemble averaging may be improved by detecting and removing outlier beats, possibly by discarding beats that have less correlation to the estimated ensemble average than others, or by estimating noise and weighting beats from areas of high noise less. Noise can also be improved through longer averaging periods. 
     As such, included may be a method for health monitoring comprising: determining from either or both a user&#39;s ECG and/or a first photoplethysmogram PPG signal and/or a weighted combination of wavelengths when heart beats occur; time averaging the first photoplethymogram PPG signal to generate a first pulse shape template or dataset; time averaging each of two additional photoplethysmogram signals correlated to the beat locations; one of the additional signals being red, the other additional signal being IR; generating ensemble averages for each of the red and IR signals; comparing each of the red and IR ensemble averages to the first pulse shape template or dataset; using a linear regression of each of the red and IR ensemble average-comparisons to the first pulse template or dataset to determine the linear gain factor between the two signals; determining from the gain factor the patient oxygen saturation. 
     In a similar view; included may be a method for determining pulse oxygenation; comprising: a) detecting heart beats; using ECG, using green, or using a weighted combination of wavelengths; b) generating one or more of a first pulse shape template or a dataset representing a first pulse shape, including using green wavelengths, an ensemble average of green over approximately the same amount of time as for either red or IR, an ensemble average of multiple wavelengths over approximately the same amount of time as for either red or IR, or an ensemble average of multiple wavelengths over significantly longer than the amount of time as for either red or IR; can use ensemble average gives beat shape; or a long time average of a single wavelength of any color; c) obtaining a red pulse shape template or dataset representing same and an IR pulse shape template or dataset representing same, and compare each of these to the first pulse shape above; and, d) correlating via linear regression between red ensemble average with the first pulse shape template or dataset to the IR ensemble average with the first pulse shape or dataset, where the ratio of these correlations is then used as the AC ratio for oxygen saturation. 
     The pulse shape template or dataset is in some implementations similar to the reference frame template described herein as well in that the pulse shape template represents a long-term ensemble average of the PPG signal. However, a difference is that the reference frame template described herein elsewhere was there designated for pulse transit time, while in the present description related to a first pulse shape or dataset or the like, is for oxygen saturation. 
     While a first method may be one where green light is used for the beat detection, other methods will be viable as well, as where ECG is used for beat detection. Further, the alternatives include green or a long red and IR average used for the first pulse shape, and a shorter red and IR is used for the oxygen saturation comparisons to the first pulse shape. It may be helpful to understand that a long red and IR average used for the first pulse waveform shape (or dataset) is in relation to the relatively shorter red/ir signals used for the oxygen saturation measurement. Because the shape is expected to change slower than the oxygen saturation, a long average can be used for the shape, while still using a shorter average (and thus getting faster response times) for the oxygen saturation part. 
     Note, green has been found desirable because it has a high signal to noise ratio; the pulse signal is strong relative to other possible motion noise. However, other wavelengths could be used instead of green, i.e. green could be replaced by other colors in the spectrum of light, keeping in mind, some colors will behave better or other colors worse in the relationship of signal to noise. Note, other colors, even without a desirable signal to noise ratio can be used herein or herewith. Similarly, the preference for red and/or IR wavelengths has been that it has been found that red and/or IR have provided good relative reflectivity to the particular oxygenation of hemoglobin blood in a test subject. Each of oxygenated blood reflects an effective amount comparatively of red light and de-doxygenated blood reflects an effective amount comparatively of infrared, IR, light. Other colors can be used instead of red and IR throughout, though the other colors may have less (or more) effectiveness in particular applications. It should also be noted that as understood in the art, whenever any particular color of light is described, a number of discrete wavelengths may be understood as falling within such definition, and that utility may fall within or outside the definition, though preferences may be identified by general color. Thus colors other than green or red or IR are understood to be used and/or such color selection may be limited only by minimal effectiveness in either signal to noise ratio and/or reflectiveness related to oxygenation or other utility. 
     ECG or green PPG (or like) or long time average of red/IR (see below) data may be recorded in time-concordance with two or more photoplethysmographs of different light wavelengths. The heart beats are detected in the ECG or green PPG signal. These heart beats allow for definition of a ‘frame’ of photoplethysmogram data for the time between two adjacent heart beats. Two or more of these frames can then be averaged together at each point in time to create an average frame for the time interval. Because the photoplethysmogram is correlated with the heartbeat, the photoplethysmograph signal is reinforced by this averaging. However, any motion artifact or other noise source that is uncorrelated in time with the heartbeat is diminished. Thus, the signal-to-noise ratio of the average frame is typically higher than that of the individual frames. 
     Having constructed an average frame for at least two photoplethysmographs of different light wavelengths, linear regression can then be used to estimate the gain between the two average frame signals. This gain value may be used to estimate blood oxygen saturation information or other components present in the blood such as hemoglobin, carbon dioxide or others. The process may be repeated for additional and/or alternative light wavelengths in order to do so. 
     Exemplar/alternative methods hereof may include determining the gain between particular signals, as between the red and IR and/or green frame signals, if/when such may be used. These may be found by averaging the two frames together first. This may result in a signal with reduced noise. The gain is found by performing linear regression of the red versus combined and IR versus combined and then finding the ratio of these two results; or linear regression of the red versus combined with green and IR versus combined with green and then finding the ratio of these two results; or linear regression of red versus green and IR versus green and then finding the ratio of these two results; or by linear regression of combining green with each of red and IR and using the ratio of these results. 
     Another method involves selecting a possible gain value, multiplying the average frame signal by it, and determining the residual error with respect to an average frame of a different wavelength. This process may be repeated for a number of potential gain values. While simple linear regression finds the global minimum gain value, this method allows for finding local minima. Thus, if it is likely that the global minimum represents correlation caused by motion artifact, venous blood movement or another noise source, it may be ignored, and a local minimum may be selected instead. 
     Yet another method uses an ensemble average of the red and/or IR signals over a much longer time to determine the pulse waveform shape, then fitting shorter time averaged signals to that waveform shape. Basically, we replace the green light signal or ECG signal described above with a long time average of red/IR. 
     As mentioned above, patient wearable devices hereof for implementing the above aspects may be particularly useful for monitoring oxygen saturation in noisy regions for such measurements, for example, where there is significant local skin movement, such as the chest location. 
     One embodiment of the above aspect hereof is illustrated in  FIGS. 6A-6C . In  FIG. 6A , curve A ( 600 ) illustrates time varying output of the photodiode of a device hereof for infrared (IR) reflection and curve B ( 602 ) illustrates time varying output of the photodiode of the device for red light reflection. In some embodiments, the skin is alternatively illuminated by the red and IR LEDs to generate the signals collected by the same photodiode. In  FIG. 6B , time synchronized (i.e. time concordant) ECG data (or alternatively/additionally green PPG data or long time average of red/IR as introduced above), illustrated by curve C ( 604 ), is added to the plot of  FIG. 6A . Peak values in the ECG data (e.g. peaks  606  and  608 ) (or green PPG or long time average of red/IR data, see above) may be used to define frames or intervals of pulse oximetry data. Additional consecutive frames or intervals are indicated by  612  and  614 , and further frames may be similarly determined. In accordance with this aspect, pulse oximetry data from a plurality of frames is collected. The magnitude of the plurality may vary widely depending on particular applications. In some embodiments, the plurality of frames collected is from 5 to 25; in one embodiment, a plurality is between 8 and 10 frames. Typically, frames or intervals of pulse oximetry data contain different numbers of signal samples. That is, output from the sensors may be sampled at a predetermined rate, such a 32 samples per second. If the time between ECG (or green PPG or long time average of red/IR) peaks varies, then the number of samples per frame will vary. In one embodiment, features in the ECG (or green PPG or long time average of red/IR) data serving as the starting points of a frame are selected so that an associated peak in the pulse oximetry data is approximately in the mid-point, or center, of the frame, after which a predetermined number of signal samples are recorded for each frame. Preferably in this embodiment, the predetermined number is selected to be large enough to ensure that the pulse oximetry signal peak is roughly mid-frame. Sample values corresponding to time points above the predetermined value are not used. After a plurality of frames of data is collected, averages of the values at corresponding time points of the frames are computed. The values from such averages AC and DC components of the pulse oximetry data are determined and are then used to compute relative oxygen saturation by conventional methods, such as the ratio-of-ratios algorithm, e.g. Cypress Semiconductor document No. 001-26779 Rev A (Jan. 18, 2010). This basic procedure is summarized in the flow chart of  FIG. 6C . Frame size (in terms of number of samples) is determined ( 620 ). Values of samples at corresponding time points within each frame are summed ( 622 ), after which average values for each time point are computed which, in turn, give the AC and DC components of IR and red and/or green light reflection with reduced noise. In some embodiments, values for these components can be used to compute oxygen saturation using conventional algorithms ( 626 ). Relative values for oxygen saturation may be converted into absolute values by calibrating the measurements for particular embodiments. Calibration may be carried out in controlled environments where individuals are exposed to varying atmospheric concentrations of oxygen and measured oxygen saturation values are related to corresponding oxygen levels. 
     In addition to the above embodiment for comparing ECG and/or green PPG or long time average of red/IR signals with pulse oximetry signals, a range of other embodiments for such comparing is within the comprehension of those of ordinary skill in the art. For example, in order to find peaks of the AC component of pulse oximetry signals in the presence of noise, features of the time concordant ECG signal that are located at characteristic times preceding and succeeding the pulse oximetry maximum and/or minimum values may be used to reliably determine the pulse oximetry peak and minimum values when averaged over a plurality of heart beats (without the need to average all values of the pulse oximetry signal over the heart beats). For example, if, within an interval, the R wave peak of an ECG signal characteristically preceded a pulse oximetry signal maximum by x milliseconds and trailed a pulse oximetry signal minimum by y milliseconds, then the essential information about the AC component of the pulse oximetry signal may be obtained by repeated measurements of just two values of pulse oximetry signals. 
     In some embodiments, values for IR or red reflection measured by the photodiode may be used to estimate depth and/or rate of respiration. In  FIG. 6D , a curve ( 630 ) of Red or IR or green values over time is illustrated. In  FIG. 6E , maximum values and minimum values of curve ( 630 ) are shown by dashed curves ( 632 ) and ( 634 ), respectively. The difference between the maximum and minimum values at a time point is monotonically related to the depth of breath in an individual being monitored. Thus, as illustrated, breaths at time ( 636 ) are shallower than those at time ( 638 ). In some embodiments, depth of breath versus time may be computed and monitored in an individual. Over time, the rate of respiration can be evaluated from the curve of maximum and minimum values over time. 
     Moreover, moving from an appreciation of a derivation of a respiration waveform from ECG R-S amplitude and/or R-R intervals, it has been found that a PPG and/or pulse oximeter as described herein can be used to relatively directly estimate a respiration waveform. As the chest expands and contracts during breathing, the motion hereof shows up as a wandering baseline artifact on the PPG signals. The respiration signal may be isolated by filtering out the PPG data to focus on the breathing/respiration signal. This may be particularly so with a chest-mounted PPG. 
     In addition, a chest mounted accelerometer may also or alternatively be used to measure the respiration waveform, especially when the user is lying on his/her back. As the chest expands and contracts, the chest accelerates up and down (or transversely, or otherwise depending upon orientation), which can be measured by the accelerometer. 
     Either of these, PPG and/or accelerometer, devices and/or methods may be used discretely or in combination with each other and/or with the above-described ECG-based respiration estimation technique. Using multiple methods may improve accuracy when compared to estimates based on a single method. Respiration rate and depth may then be estimated from the respiration signal using time-domain and/or frequency domain methods. 
     In some implementations, heart beat timing (e.g., from ECG) and PPG signals can be used to determine pulse transit time; i.e., the time for the pressure wave to travel from the heart to other locations in the body. Measurements of pulse transit time may then be used to determine or estimate blood pressure. Note, the heartbeat timing, ECG and/or PPG signals may be generated by conventional or other to-be-developed methods, systems or devices, or may be developed by wearable devices such as those otherwise described herein. I.e., the algorithms hereof may be separately usable, as well as being usable in the wearable cardiac device. 
     As disclosed herein elsewhere, the PPG signals of several heart beats may be averaged by correlating each with a respective heartbeat. The result is a PPG frame where the heart rate-correlated PPG signal is reinforced while uncorrelated noise is diminished. Moreover, because the PPG frame is already correlated to the timing of the heartbeat, pulse transit time may be estimated by determining the location of either the peak or minimum with respect to either the beginning or end of the frame itself. This may be done either by finding the minimum and/or maximum sample(s), or by interpolating the signal to find points between measured samples. For example, interpolation may be done with a quadratic fit, a cubic spline, digital filtering, or many other methods. 
     The pulse transit time may also be estimated by correlating the PPG frame with a sample signal. By shifting the two signals with respect to each other, the time shift resulting in the maximum correlation may be determined. If the sample signal is an approximation of the expected PPG frame, then the time shift with maximum correlation may be used to determine the pulse transit time. 
     An exemplar methodology or algorithm herefor is described here and shown in the drawing  FIGS. 7A, 7B and 7C . Initially, such a method  710  (which includes and/or is defined by parts  710   a ,  710   b  and/or  710   c ) takes at least one heartbeat (typical ECG) signal  712  and at least one PPG signal  711  as input as shown in  FIG. 7A , e.g. The heartbeat timing information/signal  712  is used to generate heartbeat timing information by detecting the R-wave or other ECG feature from each beat; multiple ECG signals (i.e. different leads from locations on the body) may be used to obtain a better estimate of the heartbeat timing information. The PPG  711  may use a single light wavelength or signals from multiple light wavelengths. Using the corresponding heartbeat timing information related to each PPG signal  711 , each PPG signal  711  is segmented into “frames,” see PPG Frame  1 , PPG Frame  2  and PPG Frame N in  FIG. 7A , where each frame contains the PPG signal of a single wavelength for the duration of one corresponding beat of the heart. 
     Optionally, but, typically, a PPG signal quality estimate may also be performed. An example of this is shown as method part  710   b  in  FIG. 7B . This estimate may consider the variance of the PPG signal, the estimated signal-to-noise ratio of the PPG signal, PPG signal saturation, patient motion information from an accelerometer or gyroscope, an ECG or impedance measurement noise estimate, or other information about the PPG signal quality. Shown in  FIG. 7B  is an exemplar using accelerometer signal  713  in conjunction with PPG signal  711  to generate a PPG Signal Quality Value/Estimate  714 . This signal quality estimate  714  may then be used in conjunction with the heartbeat timing information  712  to generate the gain for each frame, see PPG Frame  1  Gain, PPG Frame  2  Gain and PPG Frame N Gain in  FIG. 7B , where lower signal quality results in a lower gain. To reduce computation time, the signal quality estimate  714  may be omitted and a constant may be used for the gain information. 
     As shown in  FIG. 7C , the gain information (PPG Frame  1  Gain, PPG Frame  2  Gain and PPG Frame N Gain from  FIG. 7B ) may be used (here shown as combined/manipulated) with the frame information (PPG Frame  1 , PPG Frame  2  and PPG Frame N from  FIG. 7A ) to create a weighted, n-sample moving-average frame  715 , where the PPG signal that is correlated with the heartbeat timing is reinforced while the uncorrelated noise is reduced. The number of samples included in the frame (n)  715  may be adapted to reduce noise or decrease response time. The frames may be additionally weighted by time in order to increase the contribution of recent or near-future frames with respect to frames that are further away and potentially less-relevant. This additional weighting by time may be implemented using an IIR or FIR filter. 
     Once the average frame  715  has been produced for a given instant in time, the pulse transit time  716  may be determined by finding the shift in the frame signal with respect to the heartbeat. This may be done simply by finding the sample index  717  where the signal is at a minimum or maximum and comparing it with the frame boundary (heartbeat timing) to determine the pulse transit time. For a more precise result, the signal may be interpolated  718  using a spline or polynomial fit around the minimum or maximum values, allowing the minimum or maximum to be determined with greater precision than the sample rate. Finally, the frame may be compared  719  to a reference frame template, where the average frame is shifted with respect to the template. The shift with the highest correlation between the average frame and the template indicates the transit time  716 . This reference template may be a predetermined signal, or it may be allowed to adapt by using a long-term frame average with a known transit time. 
     Note, such methodologies may be used with PPG and heartbeat timing information obtained from a variety of sources, including but not limited to conventional and/or to-be-developed technologies; or, may be obtained one or the other alone or together and/or together with quality signal (PPG variance, estimated PPG signal-to-noise ratio, PPG signal saturation, patient motion accelerometer or gyroscope data, an ECG or impedance measurement noise estimate, or other information about the PPG signal quality) obtained from a wearable device and/or system as described further hereinbelow. 
     Some further alternatives may include data transmission and/or interpretation by local medical facilities, whether physician or doctor offices or e.g., ICU/CCU (Intensive Care/Coronary Care Units). Accordingly, a device  100  hereof that will measure one or more of a variety of physiologic signals, possibly including electrocardiogram, photoplethysmogram, pulse oximetry and/or patient acceleration signals will be placed on the patient&#39;s chest and held with an adhesive as described herein. The device transmits the physiologic signals wirelessly or by wire (e.g., USB) to a nearby base station for interpretation and further transmission, if desired. The wireless transmission may use Bluetooth, Wi-Fi, Infrared, RFID (Radio Frequency IDentification) or another wireless protocol. The device may be powered by wireless induction, battery, or a combination of the two. The device  100  monitors physiological signals and/or collects data representative thereof. The collected data may then be transmitted wirelessly or by wire connection, in real time, to the nearby base station. The device may be wirelessly powered by the base station or by battery, removing the need for wires between the patient and the station. 
     Relatedly and/or alternatively, patients or wearers may be monitored wirelessly in a hospital, including an ICU (Intensive Care Unit) or other facility. As such, an ECG signal may be measured on a patient using a small, wireless patch device hereof. The signal is then digitized and transmitted wirelessly to a receiver. The receiver converts the signal back to analog, such that it approximates the original ECG signal in amplitude. This output is then presented to an existing hospital ECG monitor through the standard electrode leads. This allows the patient to be monitored using existing hospital infrastructure without any lead wires necessarily connecting the patient to the monitor. Patient chest impedance may be measured as well, allowing the reconstructed signal to approximate the ECG signal not only in amplitude, but in output impedance as well. This can be used to detect a disconnected patch. The output impedance may be continuously variable, or it may have discrete values that may be selected (e.g. one low value for a connected device and one high value to signify the patch has come loose). The impedance may also be used to signify problems with the wireless transmission. 
     Other alternative implementations may include coupling one or multiple sensors mounted to the forehead of an infant. Initially, a method of obtaining oxygen saturation data by mounting a device in the forehead of an infant might be used as introduced. However, an expansion or alternative may include coupling oxygen saturation sensors with relative position and temperature sensors on the same forehead-mounted device. The combined data can be utilized to ascertain if an infant is in any danger of suffocation due to a face-down position. 
     Thus, some of the alternative combinations hereof may include one or more of: 1) medical grade adhesives (from many possible sources) selected for their ability to maintain in intimate contact with the skin without damaging it, for several days (up to, say 10 days or two weeks in some examples), as well as operability with different types of sensors; 2) conductive electrodes or photo-sensitive detectors able to supply electrical signals from the skin or from the photo-response of cutaneous or subcutaneous tissues to photo-excitation; 3) amplifiers, microprocessors and memories, capable of treating these signals and storing them; 4) power supply for the electronics hereof with stored or with wirelessly accessible re-chargeability; 5) flex circuits capable of tying the above elements together within a flexible strip capable of conforming to a cutaneous region of interest. 
     Examples of physiological parameters that may be subject to monitoring, recordation/collection and/or analyzing may include one or more of: electrocardiograms, photo responses of photo-excited tissues for e.g., oxygen saturation of blood; pulse rates and associated fluctuations; indications of physical activity/acceleration. One or more of these may be used in monitoring ambulatory cardiac outpatients over several days and nights, which could thereby provide for recording, for post-test analysis, several days&#39; worth of continuous ECG signals together with simultaneous recording of O2 saturation and an index of physical exertion. Similarly, one or more of these may be used in monitoring ambulatory pulmonary outpatients over several days and nights for recording, for post-test analysis, O2 saturation together with simultaneous recording of an index of physical activity. Alternatively and/or additionally, one or more of these could be used for monitoring in-patients or other patients of interest, as for example neonates, wirelessly (or in some cases wired), whether in clinics, emergency rooms, or ICUs, in some instances detecting the parameters of EKG, O2 and/or physical exertion, but instead of storing them would transmit them wirelessly to either a bedside monitor or a central station monitor, thus freeing the patient from attachment to physical wires. In particular, devices hereof may be adhered to the forehead of a neonate for monitoring respiration and oxygen saturation. In further alternatives, devices hereof may be used to monitor respiration and ECG of patients suffering from sleep apnea. 
     An exemplary computer system or computing resources which may be used herewith will now be described, though it should be noted that many alternatives in computing systems and resources may be available and operable within the reasonably foreseeable scope hereof so that the following is intended in no way to be limiting of the myriad possible computational alternatives properly intended within both the spirit and scope hereof. 
     Some of the implementations of the present developments include various steps. A variety of these steps may be performed by hardware components or may be embodied in machine-executable instructions, which may be used to cause a general-purpose or special-purpose processor programmed with the instructions to perform the steps. Alternatively, the steps may be performed by a combination of hardware, software, and/or firmware. As such,  FIG. 4  is an example of computing resources or a computer system  400  with which implementations hereof may be utilized. According to the present example, a sample such computer system  400  may include a bus  401 , at least one processor  402 , at least one communication port  403 , a main memory  404 , a removable storage media  405 , a read only memory  406 , and a mass storage  407 . More or fewer of these elements may be used in a particular implementation hereof. 
     Processor(s)  402  can be any known processor, such as, but not limited to, an Intel® Itanium® or Itanium 2® processor(s), or AMD® Opteron® or Athlon MP® processor(s), or Motorola® lines of processors. Communication port(s)  403  can be any of an RS-232 port for use with a modem based dialup connection, a 10/100 Ethernet port, a Universal Serial Bus (USB) port, or a Gigabit port using copper or fiber. Communication port(s)  403  may be chosen depending on a network such a Local Area Network (LAN), Wide Area Network (WAN), or any network to which the computer system  400  connects or may be adapted to connect. 
     Main memory  404  can be Random Access Memory (RAM), or any other dynamic storage device(s) commonly known in the art. Read only memory  406  can be any static storage device(s) such as Programmable Read Only Memory (PROM) chips for storing static information such as instructions for processor  402 . 
     Mass storage  407  can be used to store information and instructions. For example, hard disks such as the Adaptec® family of SCSI drives, an optical disc, an array of disks such as RAID, such as the Adaptec family of RAID drives, or any other mass storage devices may be used. 
     Bus  401  communicatively couples processor(s)  402  with the other memory, storage and communication blocks. Bus  401  can be a PCI/PCI-X or SCSI based system bus depending on the storage devices used. 
     Removable storage media  405  can be any kind of external hard-drives, floppy drives, IOMEGA® Zip Drives, Compact Disc-Read Only Memory (CD-ROM), Compact Disc-Re-Writable (CD-RW), Digital Video Dis-Read Only Memory (DVD-ROM). 
     The components described above are meant to exemplify some types of possibilities. In no way should the aforementioned examples limit the scope of the inventions hereof, as they are only exemplary embodiments. 
     Embodiments of the present inventions relate to devices, systems, methods, media, and arrangements for monitoring and processing cardiac parameters and data, inter alia. While detailed descriptions of one or more embodiments of the inventions have been given above, various alternatives, modifications, and equivalents will be apparent to those skilled in the art without varying from the spirit of the inventions hereof. Therefore, the above description should not be taken as limiting the scope of the inventions, which is defined by the appended claims.