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Our results show that the artificial addition of between 1 and 6% missed beat artefact did induce progressive amounts of bias into the calculation of DFA a1. Using either the AC or MC methods from Kubios Software at the 1 or even 3% level produced similar results in the median DFA a1 index with small amounts of bias in the Bland Altman analysis. Even at the 6% level, AC methodology produced reasonable results, albeit with some proportional bias and more outliers. However, at 6% MC, both a large number of outliers and substantial proportional bias was seen. It should be noted that previous reports showing high levels of bias in non-linear HRV during exercise used the medium threshold correction method [11]. As the level of artefact rose, AC methodology demonstrated both less bias as well as a reduction in scatter between the differences. Review of the regression analysis for each artefact level and correction method also confirms the trivial effects of 1% artefact especially with AC usage. However, at higher artefact levels, artefact correction falsely raised the DFA a1 index, particularly across its low, uncorrelated and anticorrelated range (interbeat random behavior). Calculation of the HRVT was minimally affected by either 1 or 3% artefact using either correction method. At the 6% artefact level, both AC and MC had similar results, although with small degrees of bias reaching just over 1 bpm. It is interesting to speculate why large amounts of the proportional bias seen with the 6% MC group, had marginal effects on the HRVT. The HRVT is calculated for DFA a1 values between 1 and 0.5, however even with 6% artefact, values just under 1 are minimally affected, values near 0.5 moderately affected, with most of the bias below this point. After reviewing the Bland Altman analysis for the 2-min window comparisons, one could conclude that the addition of 3% missed beat artefact would have minimal, if any effect on the HRVT unless the index was skewed by a random outlier value. At the 6% artefact level, one would also expect reasonable concordance with artefact free data. However, there was a higher occurrence of outliers, especially using MC which could indicate the need to repeat the HRVT assessment for confirmation.
The findings of the above studies were based on univariate analysis. In addition, most research regarding TBI and HRV was only carried out with periodic calculations (5 min or 10 min recordings), within the acute phase of brain injury (72 h post ictus) and free of interventions and confounding medication. This study aimed to investigate the aspects of continuous HRV collection from admission across the first 24 h of stay in the ICU in severe TBI patients and utilize the continuous HRV measurement to develop a patient outcome prediction system. The advantages of using HRV analysis is that it utilises cardiovascular bio-signals that are readily available, pre-existing standards of care, patient specific and inexpensive, which means that earlier identification of outcome in these patients may be improved without an increase in cost of care. 2b1af7f3a8