Longitudinal trajectories and psychological predictors of weight loss and quality of life until 3 years after metabolic and bariatric surgery.

OBJECTIVE: This study aimed to describe longitudinal trajectories of Total Weight Loss (%TWL), and mental and physical health related quality of life (HRQOL), as well as to identify preoperative psychological predictors of these trajectories. METHODS: A prospective observational study including Dutch patients treated with metabolic and bariatric surgery (n = 420, age 44.8 ± 10.3 years, 78.6% females) was performed. Trajectories of %TWL and HRQOL from screening to 1-, 2-, and 3-years post-surgery were described using growth mixture modelling. Multivariable and lasso regression models were used to identify predictors. RESULTS: Three trajectories described %TWL, varying in the degree of first-year weight loss. No pre-surgical psychological factors were associated with %TWL trajectories. We identified four physical and five mental HRQOL trajectories. Approximately 25-30% of patients exhibited patterns of initial improvements followed by decline, or persistently low levels of HRQOL. Higher depressive symptoms were associated with these unfavourable physical HRQOL trajectories (OR 1.20, 95%CI 1.04-1.39), adjusted for confounders. Unfavourable mental HRQOL trajectories were predicted by depressive and anxiety symptoms, neuroticism, insecure attachment, and maladaptive coping. In contrast, self-esteem, extraversion, and conscientiousness were associated with favourable mental HRQOL trajectories. DISCUSSION: Psychological factors did not predict weight loss, but they significantly impacted patient's HRQOL after metabolic and bariatric surgery. A subgroup with unsuccessful HRQOL after surgery was identified, who would benefit from tailored preoperative counselling to optimize surgery outcomes. Metabolic and bariatric surgery may not be universally beneficial for all patients, challenging the conventional approach to surgical interventions for severe obesity and advocating for a more nuanced, individualized assessment of potential candidates.

The effect of an animation video on consultation time, anxiety and satisfaction in women with abnormal cervical cytology: Animation video reduces colposcopy time.

The objective was to assess whether supplementing hospital-dependent standard information with a hospital-independent animation video might reduce consultation time, pre-colposcopy anxiety levels and increase post-colposcopy satisfaction. Between November 2016 and May 2018, women were included if they were referred to the department of Obstetrics and Gynaecology in one of the three participating hospitals in the Netherlands due to an abnormal cervical smear. Exclusion criteria were colposcopy in the medical history or inability to understand, speak or read Dutch. Two consecutive cohorts were created: a control group that received standard information and an intervention group that received the same plus the animation video. Outcome measures were consultation time, pre-colposcopy anxiety level and post-colposcopy satisfaction. Consultation time was measured using stopwatch. Anxiety was measured using the State-Trait Anxiety Inventory (STAI) and the Hospital Anxiety and Depression Scale (HADS). Satisfaction was measured with the Patient's Experience and Attitude Colposcopy Eindhoven questionnaire (PEACE-q). In total, 122 women were included, 61 in each group. Baseline characteristics were similar between the two groups. Pre-colposcopy consultation time was significantly reduced in the intervention group (median 140 s) compared to the control group (median 269 s). However, overall consultation time was not reduced. The outcome measures anxiety and satisfaction were not significantly different. A hospital-independent animation video did significantly reduced pre-colposcopy consultation time but did not reduce anxiety or increase satisfaction in women with abnormal cervical cytology. Further research should focus on the effects of animation video in a primary care setting.

Somatic depression predicts mortality in chronic heart failure: can this be explained by covarying symptoms of fatigue?

OBJECTIVE: Somatic symptoms of depression predict mortality in chronic heart failure (CHF), but symptoms of fatigue that are common to both conditions may confound this association. We therefore examined the contribution of fatigue to the association between somatic depression and increased risk of mortality in patients with CHF. METHODS: At baseline, 380 consecutive patients with CHF were assessed for symptoms of depression, exertion fatigue, and general fatigue. Demographic and clinical data were obtained from the patients' medical records or the treating cardiologist. The primary end point was mortality after a median follow-up of 2.3 years (range = 0.15-4.76 years). RESULTS: At follow-up, 63 patients (16.6%) had died. Exertion fatigue (hazard ratio [HR] = 1.04, 95% confidence interval [CI] = 1.01-1.06, p = .003), not general fatigue, was associated with an increased risk of mortality in CHF. Multivariate Cox regression analysis revealed that somatic symptoms of depression (HR = 1.41, 95% CI = 1.05-1.88, p = .02) were independently associated with increased mortality risk and that this association could not be explained by exertion fatigue (HR = 1.02, 95% CI = 0.97-1.05, p = .31). CONCLUSIONS: The adverse effect of somatic depression on prognosis in CHF was not confounded by exertion fatigue. Behavioral interventions should focus not only on fatigue but also on other somatic manifestations of depression in patients with CHF.

Psychological distress and mortality in systolic heart failure.

BACKGROUND: Depression, anxiety, and type D ("distressed") personality (tendency to experience negative emotions paired with social inhibition) have been associated with poor prognosis in coronary heart disease, but little is known about their role in chronic heart failure. Therefore, we investigated whether these indicators of psychological distress are associated with mortality in chronic heart failure. METHOD AND RESULTS: Consecutive outpatients with chronic heart failure (n=641; 74.3% men; mean age, 66.6+/-10.0 years) filled out a 4-item questionnaire to assess mixed symptoms of anxiety and depression and the 14-item type D scale. End points were defined as all-cause and cardiac mortality. After a mean follow-up of 37.6+/-15.6 months, 123 deaths (76 due to cardiac cause) were recorded. Cumulative hazard functions for elevated anxiety/depression symptoms differed marginally for all-cause (P=0.06), but not cardiac, mortality (P=0.43); type D personality was associated with neither all-cause mortality (P=0.63) nor cardiac mortality (P=0.87). In multivariable analyses, neither elevated anxiety/depression symptoms nor type D personality was associated with all-cause mortality (hazard ratio [HR]=1.18; 95% CI, 0.76 to 1.84; P=0.45 and HR=1.09; 95% CI, 0.67 to 1.77; P=0.73, respectively) or cardiac mortality (HR=1.13; 95% CI, 0.63 to 2.04; P=0.65 and HR=1.16; 95% CI, 0.62 to 2.18; P=0.67). In secondary analyses, a 1-point increase in anxiety/depression (range, 0 to 16) was associated with an 8% increase in risk for all-cause mortality (HR=1.08; 95% CI, 1.01 to 1.15; P=0.02). CONCLUSIONS: Neither elevated anxiety/depression symptoms nor type D personality was associated with an increased risk for all-cause or cardiac mortality. Future studies with adequate power and a longer follow-up duration are needed to further elucidate the role of psychological distress in chronic heart failure.

Type D personality and cardiac mortality in patients with chronic heart failure.

BACKGROUND: Clinical predictors of cardiac mortality in chronic heart failure (CHF) are established, but less is known about chronic psychological predictors. Therefore, we examined the prognostic value of Type D personality (tendency to experience negative feelings and inhibit self-expression) in CHF patients. METHODS AND RESULTS: Consecutive systolic CHF outpatients (n=232) filled in the Type D Scale (DS14) at baseline. Socio-demographic and clinical data were obtained from the medical record/cardiologist. The primary endpoint was total cardiac mortality (follow-up=30.7+/-11.1 months). Late (>6 months) cardiac mortality was the secondary endpoint. Type D patients had a higher incidence of total cardiac mortality (15/48=31.3%) as compared to non Type D patients (32/184=17.4%), OR=2.16;95%CI:1.05-4.43, p=.04. Type D personality was a near significant independent predictor of total cardiac mortality (OR=1.40;95%CI:0.93-4.29, p=.08), and a significant independent predictor of late cardiac mortality, adjusting for sex, age and left ventricular ejection fraction (OR=2.34;95%CI:1.05-5.26, p=.04). CONCLUSIONS: Type D personality was a near-significant independent predictor of total cardiac mortality, and a significant independent predictor of late cardiac mortality, adjusting for socio-demographics and disease-severity. These findings suggest that Type D personality, a chronic psychological risk factor, is of importance in long-term prognosis in CHF.

Inadequate consultation behavior modulates the relationship between type D personality and impaired health status in chronic heart failure.

BACKGROUND: Psychological risk factors for impaired health outcomes have been acknowledged in chronic heart failure (CHF), with Type D personality being such a risk factor. Inadequate consultation behavior, a specific aspect of self-management, might be one mechanism in explaining the adverse effect of Type D on health outcomes. In this study we examined the relationship between Type D personality, impaired disease-specific health status, and inadequate consultation behavior. METHODS AND RESULTS: CHF outpatients (n=313) completed the Type D Scale (DS14) at baseline, and the European Heart Failure Self-care Behaviour Scale (EHFScBS) and the Minnesota Living with Heart Failure Questionnaire (MLWHFQ) at 6-month follow-up. Type D personality independently predicted inadequate consultation behavior (OR=1.80, 95%CI [1.03-3.16], p=.04) and impaired health status (OR=3.61, 95%CI [1.93-6.74], p<.001) at 6-month follow-up, adjusting for demographic and clinical variables. Inadequate consultation behavior (OR=1.80, 95%CI [1.11-2.94], p=.02) and NYHA-class (OR=2.83, 95%CI [1.17-4.71], p<.001) were associated with impaired health status, after controlling for demographics, clinical variables, and Type D personality. Post-hoc multivariable analysis pointed out that Type D patients who displayed inadequate consultation behavior were at a 6-fold increased risk of reporting impaired health status, compared to the reference group of non-Type D patients who displayed adequate consultation behavior (OR=6.06, 95%CI [2.53-14.52], p<.001). CONCLUSIONS: These findings provide evidence for inadequate behavior as a mechanism that may explain the link between Type D personality and impaired health status. Future studies are warranted to elaborate on these findings.

Somatic versus cognitive symptoms of depression as predictors of all-cause mortality and health status in chronic heart failure.

OBJECTIVE: Depression is a predictor of adverse health outcomes in chronic heart failure (CHF), but it is not known whether specific symptoms drive this relationship. We examined the impact of somatic/affective, cognitive/affective, and total depressive symptoms on all-cause mortality and health status in CHF. METHOD: Consecutive CHF outpatients (n = 366) completed the Beck Depression Inventory. The primary endpoint was all-cause mortality; the secondary endpoint was disease-specific health status, as measured by the Minnesota Living with Heart Failure Questionnaire (n = 285) at inclusion and 1-year follow-up. The study was conducted between October 2003 and March 2007. RESULTS: There were 68 (18.6%) deaths (mean +/- SD follow-up, 37.2 +/- 10.6 months). Patients high on somatic/affective depressive symptoms had a greater incidence of mortality compared to patients low on somatic/affective depressive symptoms (31% vs 15%; hazard ratio [HR] = 2.3; 95% CI, 1.38-3.69; P = .001). There was no significant difference in the incidence of mortality between patients high versus low on cognitive/affective depressive symptoms (23% vs 18%; HR = 1.4; 95% CI, 0.80-2.40; P = .25), but there was a significant difference between patients high versus low on total depressive symptoms (24% vs 16%; HR = 1.6; 95% CI, 1.01-2.63; P < .05). After adjusting for demographic and clinical characteristics, we found that somatic/affective depressive symptoms predicted all-cause mortality (HR = 1.8; 95% CI, 1.03-3.07; P = .04), while cognitive/affective and total depressive symptoms did not. Both dimensions of depressive symptoms predicted disease-specific health status at 1 year. CONCLUSIONS: Only somatic/affective depressive symptoms significantly predicted all-cause mortality in CHF. In the context of diagnosing and intervening, awareness of subtypes of depressive symptoms is important.

Response to cardiac resynchronization therapy: is it time to expand the criteria?

BACKGROUND: Cardiac resynchronization therapy (CRT) is a promising treatment for a subgroup of patients with advanced congestive heart failure and a prolonged QRS interval. Despite the majority of patients benefiting from CRT, 10-40% of patients do not respond to this treatment and are labeled as nonresponders. Given that there is a lack of consensus on how to define response to CRT, the purpose of this viewpoint is to discuss currently used definitions and their shortcomings, and to provide recommendations as to how an expansion of the criteria for CRT response may be useful to clinicians. METHODS AND RESULTS: Analysis of the literature and case reports indicates that the majority of established measures of CRT response, including New York Heart Association functional class and echocardiographic, hemodynamic, and neurohormonal parameters, are poor associates of patient-reported symptoms and quality of life. Moreover, the potential moderating role of psychological factors in determining health outcomes after CRT has largely been neglected. CONCLUSIONS: It is recommended to routinely assess health status after CRT with a disease-specific questionnaire in standard clinical practice and to examine its determinants, including psychological factors such as personality traits and depression. This may lead to improved (secondary) treatment and prognosis in CHF patients treated with CRT.

Usefulness of Type D personality and kidney dysfunction as predictors of interpatient variability in inflammatory activation in chronic heart failure.

Tumor necrosis factor-alpha (TNF-alpha), soluble TNF-alpha receptors 1 and 2 (sTNFR1/2), and interleukin (IL)-6 are powerful predictors of mortality in chronic heart failure (CHF). Little is known, however, about the origins of proinflammatory cytokine production or the determinants of substantial interpatient variability in inflammatory activation. We prospectively examined kidney dysfunction and Type D personality (tendency to experience and inhibit emotional distress) as predictors of interpatient variability in these markers of inflammatory activation. At baseline, 125 patients with CHF were assessed for kidney dysfunction and Type D. Serum levels of proinflammatory cytokines (TNF-alpha, sTNFR1, sTNFR2, IL-6), the anti-inflammatory cytokines IL-10, and IL-1 receptor antagonist were measured at 1-year follow-up. Type D patients had higher levels of sTNFR1 (p = 0.009) and sTNFR2 (p = 0.001) and lower levels of IL-10 (p = 0.006) than patients without Type D and kidney dysfunction. Patients with kidney dysfunction also had elevated levels of sTNFR1 and sTNFR2 (p <0.0001), but their IL-10 level was not decreased. Type D personality and kidney dysfunction predicted increased sTNFR1/IL-10 and sTNFR2/IL-10 ratios (p < or =0.007); Type D also predicted an increased IL-6/IL-10 ratio (p = 0.013). Other predictors were spironolactone and older age. After adjusting for these variables, the odds for elevated ratios (highest 20%) were still increased in Type D patients (all odd ratios >3.00). In conclusion, Type D personality and kidney dysfunction independently predicted unfavorable cytokine profiles in patients with CHF and may enhance our understanding of interpatient variability in inflammatory activation in these patients.

Patient-rated changes in fatigue over a 12-month period predict poor outcome in chronic heart failure.

AIMS: Little is known about the factors that are associated with changes in fatigue in chronic heart failure (CHF). Moreover, it is unclear whether these changes have prognostic impact. The aim of this study was to examine these issues. METHODS AND RESULTS: Three hundred and eighty-seven CHF patients were assessed twice (at baseline and at 12-month follow-up) for exertion and general fatigue. Regression models were developed to assess whether baseline characteristics predicted changes in fatigue and to assess the effect of changes in fatigue on cardiac events occurring beyond 12-months of follow-up. An increase in exertion fatigue over a 12-month period was predicted by higher left ventricular ejection fraction (P = 0.02) and cognitive-affective depressive symptoms (P = 0.03) at baseline, and not having a biventricular pacemaker shortly after baseline (P = 0.02), whereas an increase in general fatigue was only predicted by cognitive-affective depressive symptoms (P = 0.002). One hundred and forty-three patients (37%) experienced an event (readmitted, 117; death, 26). An increase in exertion fatigue was associated with a near two-fold increased risk of events beyond 12-months of follow-up (hazard ratio = 1.78; 95% confidence interval 1.18-2.68, P = 0.006), while controlling for standard cardiac risk factors. CONCLUSION: Baseline clinical and psychosocial factors predicted changes in fatigue. Increased exertion fatigue independently predicted an increased risk of cardiac re-admission or death.

Type D personality and depressive symptoms are independent predictors of impaired health status in chronic heart failure.

OBJECTIVE: To examine whether Type D personality exerts a stable, independent effect on health status in CHF over time, adjusted for depressive symptoms. SUBJECTS: CHF outpatients (n = 166; 75% men; mean age 66 years) completed the Type D Scale and Beck Depression Inventory (baseline) and the Minnesota Living with Heart Failure Questionnaire and Short-Form Health Survey (baseline and 12 months). RESULTS: There was a general improvement in disease-specific physical (p = .029) and mental (p < .001) health over time, but Type D patients scored significantly lower on both outcomes (p < or = .001). The interaction effects Type D x time were not significant, indicating stability of the personality effect. Type D patients also scored significantly lower on all generic physical (p values between .001 and .04) and mental (all p values < or = .01) health status subdomains; these effects were also stable over time. Type D was an independent predictor of disease-specific mental health (p < .001), social functioning (p = .04), role emotional functioning (p < .001), bodily pain (p = .05), and general health (p = .04), adjusted for depressive symptoms, baseline health status and clinical characteristics. Depressive symptoms was an independent predictor of role physical functioning and bodily pain. CONCLUSIONS: Type D personality and depressive symptoms were independent predictors of impaired health status in CHF.

Type D personality and depressive symptoms are independent predictors of impaired health status in chronic heart failure.

OBJECTIVE: To examine whether Type D personality exerts a stable, independent effect on health status in CHF over time, adjusted for depressive symptoms. SUBJECTS: CHF outpatients (n=166; 75% men; mean age 66 years) completed the Type D Scale and Beck Depression Inventory (baseline) and the Minnesota Living with Heart Failure Questionnaire and Short-Form Health Survey (baseline and 12 months). RESULTS: There was a general improvement in disease-specific physical (p=.029) and mental (p<.001) health over time, but Type D patients scored significantly lower on both outcomes (p

Health status in patients treated with cardiac resynchronization therapy: modulating effects of personality.

BACKGROUND: Cardiac resynchronization therapy (CRT) is a promising treatment in chronic heart failure (CHF). However, a subgroup of patients still report impaired health status, cardiac symptoms, and feelings of disability following CRT. The aims of this study were to examine (1) whether CHF patients treated with CRT improved in patient-centered outcomes and functional capacity, and (2) whether personality traits exert a stable effect on these outcomes over two months. METHODS: Analyses are based on 31 patients (65% male; mean age 70 +/- 8) with CHF treated with CRT. Two weeks before and two months after CRT, patients completed the Type-D Scale (negative affectivity, i.e., tendency to experience negative emotions, and social inhibition, i.e., tendency to inhibit self-expression), the Minnesota Living with Heart Failure Questionnaire (disease-specific health status), and the Health Complaints Scale (cardiac symptoms and perceived disability), and performed the six-minute walking test (functional capacity). RESULTS: There was an improvement in disease-specific health status (P< 0.001), cardiac symptoms (P = 0.001), perceived disability (P< 0.001), and functional capacity (P = 0.007) in all patients over two months. However, high negative affectivity patients reported significantly lower disease-specific health status (P = 0.046), and more cardiac symptoms (P = 0.035), and perceived disability (P = 0.015) as compared to low negative affectivity patients. There was no significant main effect for negative affectivity on functional capacity. High negative affectivity patients still reported lower disease-specific health status (P = 0.06) and significantly more perceived disability (P = 0.04) when adjusting for left ventricular ejection fraction, gender, and age. The effects of negative affectivity on patient-centered outcomes, as measured by Cohen's effect size index, were moderate to large. CONCLUSIONS: Patient-centered outcomes improved over a two-month period in patients treated with CRT, but negative affectivity exerted a stable, negative effect on health status, cardiac symptoms, and perceived disability. Personality traits should be taken into account when evaluating effects of CRT.

Type-D personality but not depression predicts severity of anxiety in heart failure patients at 1-year follow-up.

BACKGROUND: Chronic heart failure (CHF) is a debilitating condition associated with poor outcome, including increased anxiety. However, anxiety and its determinants have not yet been studied systematically in CHF. We examined whether type-D personality and depressive symptoms would predict clinically significant anxiety at 1-year follow-up. METHODS: Consecutive patients with systolic CHF (n=149; 79% men; mean age 66+/-8.6) completed the type-D Scale (DS14), the Beck Depression Inventory, and the Anxiety Sensitivity Index at baseline. A clinical interview (Hamilton Anxiety Rating Scale) was used to assess clinically significant anxiety at 1-year follow-up. RESULTS: At 12 months follow-up, 26% (9/35) of type-D patients had clinically significant anxiety versus only 6% (7/114) of the non type-Ds (p=0.001). In univariable analyses, type-D personality (OR=5.3; p=0.002) and anxiety sensitivity (OR=4.5; p=0.009), but not depressive symptoms (p=0.27) predicted clinically significant anxiety. Type-D remained an independent predictor of anxiety at 1 year (OR=5.7; p=0.01), controlling for depressive symptoms, anxiety sensitivity, socio-demographic and clinical variables. Adding type-D in a hierarchical logistic regression model, comprising standard and psychological risk factors, enhanced the level of prediction of clinically significant anxiety substantially (-2LL=75.16 chi(2)=26.46; p=0.009). CONCLUSIONS: Type-D personality, but not depressive symptoms predicted 1-year clinically significant anxiety. The type-D scale could be used to identify CHF patients at high risk of anxiety, as these patients may be at an increased risk of adverse prognosis and impaired quality of life.

Symptoms of fatigue in chronic heart failure patients: clinical and psychological predictors.

OBJECTIVE: To examine the role of clinical and psychological characteristics as predictors of fatigue in CHF. BACKGROUND: Little is known about predictors of fatigue in CHF. Next to heart failure characteristics, depressive symptoms and type-D personality may explain individual differences in fatigue. METHODS: At baseline, 136 CHF outpatients (age

Failure to consult for symptoms of heart failure in patients with a type-D personality.

BACKGROUND: Self-management and adequate consultation behaviour are essential for the successful treatment of chronic heart failure (CHF). Patients with a type-D personality, characterised by high social inhibition and negative affectivity, may delay medical consultation despite increased symptom levels and may be at an increased risk for adverse clinical outcomes. AIM: To examine whether type-D personality predicts poor self-management and failure to consult for evident cardiac symptoms in patients with CHF. Design/methods/ PATIENTS: 178 outpatients with CHF (aged < or =80 years) completed the type-D Personality Scale at baseline, and the Health Complaints Scale (symptoms) and European Heart Failure Self-care Behaviour Scale (self-management) at 2 months of follow-up. Medical information was obtained from the patients' medical records. RESULTS: At follow-up, patients with a type-D personality experienced more cardiac symptoms (OR 6.4; 95% CI 2.5 to 16.3, p<0.001) and more often appraised these symptoms as worrisome (OR 2.9; 95% CI 1.3 to 6.6, p<0.01) compared with patients with a non-type-D personality. Paradoxically, patients with a type-D personality were less likely to report these symptoms to their cardiologist/nurse, as indicated by an increased risk for inadequate consultation behaviour (OR 2.7; 95% CI 1.2 to 6.0, p<0.05), adjusting for demographics, CHF severity/aetiology, time since diagnosis and medication. Accordingly, of 61 patients with CHF who failed to consult for evident cardiac symptoms, 43% had a type-D personality (n = 26). Of the remaining 108 patients with CHF, only 14% (n = 16) had a type-D personality. CONCLUSION: Patients with CHF with a type-D personality display inadequate self-management. Failure to consult for increased symptom levels may partially explain the adverse effect of type-D personality on cardiac prognosis.

The distressed (type D) personality is independently associated with impaired health status and increased depressive symptoms in chronic heart failure.

BACKGROUND: Chronic heart failure (CHF) is a serious condition that is associated with impaired health status and a high prevalence of depressive symptoms. To date, little is known about the determinants of health status and depressive symptoms in CHF. Therefore, the aim of this study was to assess whether Type D personality is associated with impaired health status and increased depressive symptoms in heart failure patients, independent of disease characteristics. METHODS: Eighty-four patients (63 men and 21 women, mean age=65.9+/-12.1 years) with systolic CHF completed four questionnaires to assess Type D personality (14-item Type D Personality Scale [DS14]), health status (Minnesota Living with Heart Failure Questionnaire [MLWHFQ]), depressive symptoms (Center for Epidemiological Studies Depression Scale [CES-D]) and mood status (Global Mood Scale [GMS]) when visiting an outpatient heart failure clinic. Information on clinical variables was obtained from patients' medical records. RESULTS: Type D patients were more likely to experience impairment in health status (18/38=47%) as compared to non-Type Ds (11/46=24%), P=0.027. They also more often reported symptoms of depression; namely 18 of 38=47% versus 6 of 46=13%, P=0.001. When controlling for severity and etiology of CHF, age and gender, Type D remained a significant associate of impaired health status [odds ratio (OR) 3.0, 95% confidence interval (CI) 1.12-7.78] and depressive symptoms (OR 6.3, 95% CI 2.08-19.12). CONCLUSIONS: Type D was associated with impaired health status and increased depressive symptoms in CHF patients. These preliminary findings demonstrate the value of including personality factors in CHF research.