Situational Analysis of Malaria Incidence Under Integrated Malaria Service in Hotspot Township - Minbya Township, Rakhine State, Myanmar, 2017-2020.

Introduction: Malaria is a significant public health concern and tropical disease, particularly affecting Myanmar within the Greater Mekong Subregion. The annual parasite index (API) exceeds 1 per 10,000 population in the northern seven townships of Rakhine State, with Minbya Township designated as a high-burden area for malaria by the World Health Organization (WHO) Myanmar and the National Malaria Control Programme (NMCP). Since 2017, the Malaria reduction intensification plan has been in place in this township to combat the high disease transmission rates. This study aims to assess the malaria epidemiology in Minbya Township from 2017 to 2020 under the intensification plan for elimination, as well as to evaluate the effectiveness of the integrated strategy in reducing cases in hotspot areas. Methods: The study utilized a surveillance study design to collect secondary data from the Malaria surveillance system (MSS) and the epidemiologic monitoring dashboard of Minbya Township, Maruk-U District, located in Rakhine State. Results: Since 2017, the Malaria prevention and control (P&C) Program in Minbya Township has successfully decreased malaria morbidity, eliminated malaria-related deaths, and bolstered malaria testing capabilities through the participation of village health volunteers (VHVs). Approximately 87% of malaria prevention and control services are executed by the township's malaria elimination and disease control programs, with additional support from stakeholders. The API dropped from 13 in 2017 to 2.5 in 2020, with Plasmodium vivax being the most prevalent malaria species, accounting for 55% of cases. Conclusions: The study suggests that early diagnosis and promotion of artemisinin-based combination treatment (ACT), along with strategic planning including expanding active case detection in rural health centers and implementing a community-based integrated healthcare approach, are effective and efficient strategies for malaria elimination.

Adherence to COVID-19 preventive measures among residents in selected townships, Yangon Region, Myanmar: a community-based cross-sectional study.

BACKGROUND: To fight the current coronavirus disease (COVID-19) pandemic, many countries have implemented various mitigation measures to contain the spread of the disease. By engaging with health service providers, the community's participation in adherence to preventive measures is certainly required in the implementation of COVID-19 mitigation strategies. Therefore, this study aimed to assess the level of adherence to COVID-19 preventive measures and its associated factors among the residents, Yangon Region, Myanmar. METHODS: A community-based cross-sectional study was carried out among 636 residents in Yangon Region, Myanmar, from October to December 2021. A multistage non-probability sampling method, purposively selected for three townships in Yangon Region and convenience sampling for 212 participants from each township, was applied and the data were collected by face-to-face interviews using structured and pretested questionnaires. Data were entered, coded, and analyzed using IBM SPSS version 25.0. Simple and multiple logistic regression analysis were performed to identify the significant variables of adherence to COVID-19 preventive measures. RESULTS: As a level of adherence to COVID-19 preventive measures, the proportion of residents who had good adherence was 39.3% (95% CI 35.5-43.2%), moderate adherence was 37.6% (95% CI 33.8-41.5%), and poor adherence was 23.1% (95% CI 19.9-26.6%). The age group of 31-40 years (AOR: 3.13, 95% CI 1.62-6.05), 30 years and younger (AOR: 3.22, 95% CI 1.75-5.92), Burmese ethnicity (AOR: 2.52, 95% CI 1.44-4.39), own business (AOR: 3.19, 95% CI 1.15-8.87), high school education level and below (AOR: 1.64, 95% CI 1.02-2.69), less than 280.90 USD of monthly family income (AOR: 1.51, 95% CI 1.01-2.29), low knowledge about COVID-19 (AOR: 1.90, 95% CI 1.26-2.88) were significantly associated with poor adherence to COVID-19 preventive measures. CONCLUSIONS: In this study, nearly one-fourth of the residents were experiencing poor adherence to COVID-19 preventive measures. Therefore, building up the risk communication through the community using widely used mainstream media, the continuation of disease surveillance and announcement of updated information or advice for the public to increase awareness towards COVID-19, and enforcement to follow the recommended directions and regulations of health institutions are vital to consider for improving the adherence to preventive measures against COVID-19 among the residents.

Job satisfaction among Myanmar working population, a cross-sectional study.

The gap between expectations and reality could lead to low job satisfaction. Although much literature has been described on job satisfaction among different categories of people, more research is needed to acknowledge the judgment of job satisfaction among some of the Myanmar working population. The study aims to find out the satisfaction level of a job and the factors related to it. The cross-sectional study was conducted in January 2019 by calling for face-to-face interviews with 536 respondents selected using a convenient sampling technique using a pre-tested questionnaire. The highest satisfied respondents were >50 years age group (86.11%), females (71.89%), higher officials (90.53%), and more than three years of service (78.35%). In the adjusted analysis, having 41-50 year age group (AOR 2.72; 95% CI: 1.08-6.83), part-time job nature (AOR 2.16; 95% CI: 1.17-3.99), and the higher official (AOR 5.71; 95% CI: 2.48-13.13) were significantly associated with job satisfaction. Relationships with the direct executive and, organization and management were the main determinants of job satisfaction. Moreover, the respondents with higher positions were more likely to have higher job satisfaction in the study.

Prevalence of G6PD deficiency and diagnostic accuracy of a G6PD point-of-care test among a population at risk of malaria in Myanmar.

BACKGROUND: Over the past decade, the incidence of malaria has steadily declined in Myanmar, with Plasmodium vivax becoming predominant. The resilience of P. vivax to malaria control is attributed to the parasite's ability to form hypnozoites in the host's liver, which can cause relapse. Primaquine is used to eliminate hypnozoites but can cause haemolysis in glucose-6-phosphate dehydrogenase (G6PD)-deficient individuals. It is thus necessary to estimate the frequency and variant types of G6PD deficiency in areas where primaquine will be widely used for P. vivax elimination. METHODS: In this study, a descriptive cross-sectional survey was conducted to determine the prevalence of G6PD deficiency in a population residing in Nay Pyi Taw, Myanmar, using a standard spectrophotometric assay, a rapid diagnostic test (RDT), Biosensor, and by genotyping G6PD variants. RESULTS: G6PD enzyme activity was determined from 772 leukocyte-depleted samples, with an adjusted male median G6PD activity value of 6.3 U/g haemoglobin. Using a cut-off value of 30% enzyme activity, the overall prevalence of G6PD deficiency was 10.8%. Genotyping of G6PD variants was performed for 536 samples, of which 131 contained mutations. The Mahidol variant comprised the majority, and males with the Mahidol variant showed lower G6PD enzyme activity. The G6PD Andalus variant, which has not been reported in Myanmar before, was also identified in this study. CONCLUSION: This study provides a G6PD enzyme activity reference value for the Myanmar population and further information on the prevalence and variants of G6PD deficiency among the Myanmar population; it also evaluates the feasibility of G6PD deficiency tests.

Polymer types and additive concentrations in single-use plastic products collected from Indonesia, Japan, Myanmar, and Thailand.

Marine debris comprising single-use plastic products (SUPs) is ubiquitous in Asian coastal waters, but there is little information on the types of polymers and the concentrations of plastic additives such waste products contain. In this study, 413 SUPs randomly collected from 4 Asian countries between 2020 and 2021 were analyzed to obtain specific polymer and organic additive profiles. Polyethylene (PE), coupled with external polymers, was prominent in the inside of the SUPs, whereas polypropylene (PP) and polyethylene terephthalate (PET) were prevalent in both the insides and outsides of the SUPs. The use of different polymers in the insides and outsides of PE SUPs implies specific and complicated recycling systems are required to maintain the purity of the products. Phthalate plasticizers including dimethyl phthalate (DMP), diethyl phthalate (DEP), diisobutyl phthalate (DiBP), dibutyl phthalate (DBP), and di(2-ethylhexyl) phthalate (DEHP), and the antioxidant butylated hydroxytoluene (BHT) were prevalent in the SUPs (n = 68). High concentrations of DEHP were detected in PE bags from Myanmar (820,000 ng/g) and Indonesia (420,000 ng/g), which were an order of magnitude greater than the concentrations in PE bags collected in Japan. SUPs containing high concentrations of organic additives may be the primary source of harmful chemicals in the environment, and should be responsible for their ubiquitous distribution in ecosystems.

Exposure to diverse sarbecoviruses indicates frequent zoonotic spillover in human communities interacting with wildlife.

BACKGROUND: Sarbecoviruses are a subgenus of Coronaviridae that mostly infect bats with known potential to infect humans (SARS-CoV and SARS-CoV-2). Populations in Southeast Asia, where these viruses are most likely to emerge, have been undersurveyed to date. METHODS: We surveyed communities engaged in extractive industries and bat guano harvesting from rural areas in Myanmar. Participants were screened for exposure to sarbecoviruses, and their interactions with wildlife were evaluated to determine the factors associated with exposure to sarbecoviruses. RESULTS: Of 693 people screened between July 2017 and February 2020, 12.1% were seropositive for sarbecoviruses. Individuals were significantly more likely to have been exposed to sarbecoviruses if their main livelihood involved working in extractive industries (logging, hunting, or harvesting of forest products; odds ratio [OR] = 2.71, P = 0.019) or had been hunting/slaughtering bats (OR = 6.09, P = 0.020). Exposure to a range of bat and pangolin sarbecoviruses was identified. CONCLUSION: Exposure to diverse sarbecoviruses among high-risk human communities provides epidemiologic and immunologic evidence that zoonotic spillover is occurring. These findings inform risk mitigation efforts needed to decrease disease transmission at the bat-human interface, as well as future surveillance efforts warranted to monitor isolated populations for viruses with pandemic potential.

Pursuing Investigations Establish the Challenging Diagnosis of Primary Aldosteronism.

Primary aldosteronism is one of the causes of secondary hypertension. The most sensitive screening test for primary aldosteronism is the measurement of the plasma aldosterone concentration and plasma renin activity to calculate the aldosterone/renin ratio. We report a case of hypertension and hypokalemia with a negative plasma aldosterone/renin ratio, inconclusive confirmatory saline infusion test. Subsequently, the patient was diagnosed with primary aldosteronism secondary to adrenal adenoma. If there is a high index of clinical suspicion of primary aldosteronism, it is important to evaluate further to establish the diagnosis for initiation of specific treatment because failure to identify primary aldosteronism can lead to aldosterone-specific adverse cardiovascular diseases and events.

Readmissions, Death and Its Associated Predictors in Heart Failure With Preserved Versus Reduced Ejection Fraction.

Background Data on rehospitalizations for heart failure (HF) in Asia are scarce. We sought to determine the burden and predictors of HF (first and recurrent) rehospitalizations and all-cause mortality in patients with HF and preserved versus reduced ejection fraction (preserved EF, ≥50%; reduced EF, <40%), in the multinational ASIAN-HF (Asian Sudden Cardiac Death in Heart Failure) registry. Methods and Results Patients with symptomatic (stage C) chronic HF were followed up for death and recurrent HF hospitalizations for 1 year. Predictors of HF hospitalizations or all-cause mortality were examined with Cox regression for time to first event and other methods for recurrent events analyses. Among 1666 patients with HF with preserved EF (mean age, 68±12 years; 50% women), and 4479 with HF with reduced EF (mean age, 61±13 years; 22% women), there were 642 and 2302 readmissions, with 28% and 45% attributed to HF, respectively. The 1-year composite event rate for first HF hospitalization or all-cause death was 11% and 21%, and for total HF hospitalization and all-cause death was 17.7 and 38.7 per 100 patient-years in HF with preserved EF and HF with reduced EF, respectively. In HF with preserved EF, consistent independent predictors of these clinical end points included enrollment as an inpatient, Southeast Asian location, and comorbid chronic kidney disease or atrial fibrillation. The same variables were predictive of outcomes in HF with reduced EF except atrial fibrillation, and also included Northeast Asian location, older age, elevated heart rate, decreased systolic blood pressure, diabetes, smoking, and non-usage of beta blockers. Conclusions One-year HF rehospitalization and mortality rates were high among Asian patients with HF. Predictors of outcomes identified in this study could aid in risk stratification and timely interventions. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01633398.

Evolving Challenges in Diagnosis of Renal Vasculitis.

Renal-limited vasculitis is a rare anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis that presents only with a renal manifestation in the absence of other organs involvement. In this report, a 50-year-old female presented with nonspecific symptoms and anemia, who was subsequently discovered to have renal-limited vasculitis. After receiving a combination of steroid and immunosuppressive therapy, she recovered uneventfully without further relapse. A wide range of nonspecific presenting symptoms and the insidious nature of renal disease often delay in early recognition of renal-limited vasculitis. Keeping a lower threshold of initiating vasculitis workup helps detect the earlier diagnosis which is crucial in management with improved renal outcome.

A survey of visual impairment and blindness in children attending eight schools for the blind in Myanmar: An update.

Purpose: To determine the causes of visual impairment (VI) and blindness among children in schools for the blind in Myanmar; to identify the avoidable causes of VI and blindness; to provide spectacles, low-vision aids, and ophthalmic treatment where indicated; to provide an update of the 2007 survey performed and identify any major epidemiological changes. Methods: Two hundred and ninety children under 16 years of age from all eight schools for the blind in Myanmar were examined and the data entered into the World Health Organization Prevention of Blindness Examination Record for Childhood Blindness. Results: In total, 271 children (93.4%) were blind (visual acuity [VA] <3/60 in the better eye) and 15 (5.17%) had severe visual impairment (SVI = VA <6/60 to 3/60 in the better eye). Most children had whole globe as the major anatomical site of SVI or blindness (105, 36.6%). The cause was unknown in the majority of these (155, 54.0%). One hundred and twelve children had avoidable causes of blindness and SVI (39.0%). Forty children (13.9%) required an optical device and 10.1% required surgical or medical attention, with a potential for visual improvement through intervention in 3.48%. Conclusion: In all, 39.0% of children had potentially avoidable causes of SVI and blindness with cataracts and measles being the commonest causes. This follow-up survey performed after the first one completed in Myanmar in 2007 demonstrates a change in the major site of abnormality from the cornea to whole globe and a reduction in avoidable blindness but highlights the ongoing burden of measles.

Seroepidemiologic Survey of Crimean-Congo Hemorrhagic Fever Virus in Logging Communities, Myanmar.

Crimean-Congo hemorrhagic fever virus (CCHFV) is endemic in Asia, infecting many animal hosts, but CCHFV has not been reported in Myanmar. We conducted a seroepidemiologic survey of logging communities in Myanmar and found CCHFV exposure was common (9.8%) and exposure to wild animal blood and body fluids was associated with seropositivity.

Financial difficulties and patient-reported outcomes among patients with advanced heart failure.

PURPOSE: Management of congestive heart failure (CHF) is associated with high health care costs and financial difficulties for patients. We aimed to comprehensively assess the association between financial difficulties and patients' quality of life (QOL) (physical, emotional, social and spiritual), perceived health care quality, and perception of being a burden to the family among patients with CHF; and to assess whether perceived control over stress moderated these associations. METHODS: This was a cross-sectional study of 250 patients using the baseline data of the Singapore Cohort of Patients with Advanced Heart Failure (SCOPAH). Patients had class 3 or 4 CHF symptoms based on the New York Heart Association and were recruited between July 2017 and August 2019. We used a 3-item questionnaire to measure financial difficulties among patients. We used multivariable linear/ordered logistic regressions to test associations between financial difficulties and each dependent variable. RESULTS: 41% of participants reported financial difficulties. A higher financial difficulties score (range: 0-6, higher score indicating greater difficulty) was associated with lower QOL (emotional, social, and spiritual) and perceived health care coordination, and a higher likelihood of patients perceiving themselves to being a burden to family (all p < 0.05) CONCLUSION: Patients with financial difficulties are vulnerable to poor outcomes. Heart failure clinics should directly assess patients' financial difficulties to help guide treatment-related discussions and to identify patients vulnerable to poor QOL.

Prevalence and Prognostic Significance of Frailty in Asian Patients With Heart Failure: Insights From ASIAN-HF.

Background: Frailty is common in patients with heart failure (HF) and can adversely impact outcomes. Objectives: This study examined the prevalence of frailty among Asian patients with HF, its association with 1-year outcomes, and if race-ethnicity, HF subtypes, and sex modify this relationship. Methods: In the multinational ASIAN-HF (Asian Sudden Cardiac Death in Heart Failure) registry, a baseline frailty index (FI) was constructed using a cumulative deficits approach with 48 baseline variables, and patients were followed for the 1-year primary outcome of all-cause death or HF hospitalization. Results: Among 3,881 participants (age 61 ± 13 years, 27% female), the mean FI was 0.28 ± 0.11, and 69% were frail (FI >0.21). Higher FI was associated with older age, Malay ethnicity, and Southeast Asian residency. While comorbidities were more frequent in frail patients (by definition), body mass index was not different across frailty classes. Compared with FI class 1 (<0.21, nonfrail), FI class 2 (0.21-0.31) and FI class 3 (>0.31) had increased risk of the 1-year composite outcome (hazard ratios of 1.84 [95% confidence interval (CI): 1.42-2.38] and 4.51 [95% CI: 3.59-5.67], respectively), even after multivariable adjustment (adjusted hazard ratios of 1.49 [95% CI: 1.13-1.97] and 2.69 [95% CI: 2.06-3.50], respectively). Race-ethnicity modified the association of frailty with the composite outcome (P interaction = 0.0097), wherein the impact of frailty was strongest among Chinese patients. The association between frailty and outcomes did not differ between men and women (P interaction = 0.186) or for HF with reduced ejection fraction versus HF with preserved ejection fraction (P interaction = 0.094). Conclusions: Most Asian patients with HF are frail despite relatively young age. Our results reveal specific ethnic (Malay) and regional (Southeast Asia) predisposition to frailty and highlight its prognostic importance, especially in Chinese individuals. (ASIAN HF Registry, A Prospective Observational Study [ASIANHF]; NCT01633398).

Assessment of Noise Exposure and Hearing Loss Among Workers in Textile Mill (Thamine), Myanmar: A Cross-Sectional Study.

BACKGROUND: In a wide range of industries, noise-induced hearing loss remains one of the most prevalent occupational problems. This study aimed to assess the noise exposure level and associated factors of hearing loss among textile workers in Yangon Region, Myanmar. METHODS: A cross-sectional study was conducted at a Textile mill (Thamine), Yangon Region, from April to December 2018. In total, 226 workers who were randomly selected from 3 weaving sections participated in face-to-face interviews using a structured questionnaire. A digital sound level meter and pure-tone audiometer were used for the assessment of noise exposure level and hearing loss, respectively. Logistic regression analysis was performed to assess the associated factors of hearing loss. RESULTS: In total workers, 66.4% were exposed to ≥85 dB(A) of noise exposure, and the prevalence of hearing loss was 25.7%. Age ≥35 years, below high school education, hearing difficulty, tinnitus, hypertension, > 9 years of service duration in a textile mill were positively associated with hearing loss. After adjusting confounding factors, age ≥35 years (adjusted odds ratio = 6.90, 95% confidence interval = 3.45-13.82) and tinnitus (adjusted odds ratio = 2.88, 95% confidence interval = 1.13-7.37) were persistently associated with hearing loss. CONCLUSION: Providing occupational hazard education and enforcement of occupational safety regulations should be taken to decrease the noise exposure level. The regular audiometry test should be conducted for assessment of hearing threshold shift. The employer needs to implement a hearing conservation program in workplace when noise exposure reaches or exceeds 85 dB(A) for 8 hours.

Global Retinoblastoma Presentation and Analysis by National Income Level.

Importance: Early diagnosis of retinoblastoma, the most common intraocular cancer, can save both a child's life and vision. However, anecdotal evidence suggests that many children across the world are diagnosed late. To our knowledge, the clinical presentation of retinoblastoma has never been assessed on a global scale. Objectives: To report the retinoblastoma stage at diagnosis in patients across the world during a single year, to investigate associations between clinical variables and national income level, and to investigate risk factors for advanced disease at diagnosis. Design, Setting, and Participants: A total of 278 retinoblastoma treatment centers were recruited from June 2017 through December 2018 to participate in a cross-sectional analysis of treatment-naive patients with retinoblastoma who were diagnosed in 2017. Main Outcomes and Measures: Age at presentation, proportion of familial history of retinoblastoma, and tumor stage and metastasis. Results: The cohort included 4351 new patients from 153 countries; the median age at diagnosis was 30.5 (interquartile range, 18.3-45.9) months, and 1976 patients (45.4%) were female. Most patients (n = 3685 [84.7%]) were from low- and middle-income countries (LMICs). Globally, the most common indication for referral was leukocoria (n = 2638 [62.8%]), followed by strabismus (n = 429 [10.2%]) and proptosis (n = 309 [7.4%]). Patients from high-income countries (HICs) were diagnosed at a median age of 14.1 months, with 656 of 666 (98.5%) patients having intraocular retinoblastoma and 2 (0.3%) having metastasis. Patients from low-income countries were diagnosed at a median age of 30.5 months, with 256 of 521 (49.1%) having extraocular retinoblastoma and 94 of 498 (18.9%) having metastasis. Lower national income level was associated with older presentation age, higher proportion of locally advanced disease and distant metastasis, and smaller proportion of familial history of retinoblastoma. Advanced disease at diagnosis was more common in LMICs even after adjusting for age (odds ratio for low-income countries vs upper-middle-income countries and HICs, 17.92 [95% CI, 12.94-24.80], and for lower-middle-income countries vs upper-middle-income countries and HICs, 5.74 [95% CI, 4.30-7.68]). Conclusions and Relevance: This study is estimated to have included more than half of all new retinoblastoma cases worldwide in 2017. Children from LMICs, where the main global retinoblastoma burden lies, presented at an older age with more advanced disease and demonstrated a smaller proportion of familial history of retinoblastoma, likely because many do not reach a childbearing age. Given that retinoblastoma is curable, these data are concerning and mandate intervention at national and international levels. Further studies are needed to investigate factors, other than age at presentation, that may be associated with advanced disease in LMICs.

Isolated complete unilateral ptosis with intact extraocular eye movements.

An 88-year-old woman presented with a 2-day history of inability to open her left eye with no ocular discomfort or blurred vision. She had a long-standing history of diabetes mellitus, hypertension and stroke disease. Examination revealed an isolated complete left eye ptosis with no pupillary involvement and intact extraocular movements. There were no other neurological deficits and fatigability was not elicited. Magnetic resonance imaging of the brain showed an acute infarct of the left red nucleus. Oculomotor nerve fascicles are widely separated in the midbrain before they exit at the interpeduncular fossa. A discrete lesion involving the most caudal fibres of the levator palpebrae is the most likely explanation. Although uncommon, this should be considered in patients with underlying cardiovascular risk factors.

Starvation-induced diplopia and weakness: a case of beriberi and Wernicke's encephalopathy.

A 56-year-old teetotaller man with hypertension and gout presented with a week duration of painless worsening diplopia on a background of loss of weight and appetite, generalised lethargy and weakness for 1 year. On examination, he was noted to be hypothermic and tachycardic with generalised muscle wasting. Proximal myopathy, lower limb fasciculations and areflexia, restricted bilateral eye abduction and nystagmus were observed. Blood investigations demonstrated compensated lactic acidosis, acute kidney injury and leucocytosis. A nerve conduction study showed severe length-dependent axonal sensorimotor polyneuropathy. This was a diagnostic dilemma until an MRI brain revealed symmetrical signal abnormality and enhancement in the periaqueductal area indicative of Wernicke's encephalopathy, caused by thiamine deficiency from poor nutrition. Beriberi, also caused by thiamine deficiency, accounted for his tachycardia, polyneuropathy, areflexia, hypothermia and biochemical abnormalities. Both beriberi and Wernicke's encephalopathy are medical emergencies, which were treated with intravenous thiamine to good effect.

Study protocol for a cohort study of patients with advanced heart failure in Singapore.

INTRODUCTIO: Understanding the symptom and health expenditure burden among patients with advanced congestive heart failure (CHF) and their family caregivers is essential to reform policy and practice needed to provide quality care to these patients at affordable prices. The proposed cohort study titled Singapore Cohort of Patients with Advanced Heart Failure aims to describe trajectories of quality of life among patients and their primary informal caregivers, quantify healthcare utilisation and expenditures, assess changes in patient and caregiver awareness of and preferences for knowing diagnostic and prognostic information, awareness and utilisation of palliative care services, preferences for treatments and decision making, perceived quality of care, self-care, caregiver psychological distress and caregiver burden. METHODS: This cohort study will recruit 250 patients with New York Heart Association Classification class III and IV CHF from inpatient wards at two public tertiary healthcare institutions in Singapore. Patients and their primary informal caregiver are being surveyed every 4 months until patients' death; caregivers are followed until 8 weeks postpatient death. Medical and billing records of patients are obtained and merged with patients' survey data. ETHICS AND DISSEMINATION: The study has been approved by an ethics board. Results from the study will be disseminated through publications and presentations targeting researchers, policy makers and clinicians interested in understanding and improving care for patients with advanced CHF. TRIAL REGISTRATION NUMBER: NCT03089034.