The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Hemoadsorption Using CytoSorb® in Patients with Infective Endocarditis: A German-Based Budget Impact Analysis

A considerable number of infective endocarditis (IE) patients require cardiac surgery with an increased risk for postoperative sepsis. Intraoperative hemoadsorption may diminish the risk of postoperative hyperinflammation with potential economic implications for intensive care unit (ICU) occupation. The present study aimed to theoretically investigate the budget impact of a reduced length of ICU stay in IE patients treated with intraoperative hemoadsorption in the German healthcare system. Data on ICU occupation were extrapolated from a retrospective study on IE patients treated with hemoadsorption. An Excel-based budget impact model was developed to simulate the patient course over the ICU stay. A base-case scenario without therapy reimbursement and a scenario with full therapy reimbursement were explored. The annual eligible German IE patient population was derived from official German Diagnostic-Related Group (DRG) volume data. One-way deterministic sensitivity analysis and multivariate analysis were performed to evaluate the uncertainty over the model results. The use of intraoperative hemoadsorption resulted in EUR 2298 being saved per patient in the base-case scenario without therapy reimbursement. The savings increased to EUR 3804 per patient in the case of full device-specific reimbursement. Deterministic and probabilistic sensitivity analyses confirmed the robustness of savings, with a probability of savings of 87% and 99% in the base-case and full reimbursement scenario, respectively. Intraoperative hemoadsorption in IE patients might have relevant economic benefits related to reduced ICU stays, resulting in improved resource use. Further evaluations in larger prospective cohorts are warranted.

Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

The Cost-effectiveness of Watch and Wait for Rectal Cancer

The existing literature suggests with a high degree of certainty that watch and wait is more cost-effective than initial total mesorectal excision. However, it is heavily reliant on poor-quality health-related quality of life data. Furthermore, the cost-effectiveness of organ preservation from a broader societal perspective has not been studied. Finally, the cost-effectiveness of emerging adjuncts to watch and wait for organ preservation, such as contact X-ray brachytherapy, local excision and total neoadjuvant therapy, need to be characterised.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

Use of CytoSorb© Hemoadsorption in Patients on Veno-Venous ECMO Support for Severe Acute Respiratory Distress Syndrome: A Systematic Review

Acute respiratory distress syndrome (ARDS) is associated with high morbidity and mortality. Adjunct hemoadsorption is increasingly utilized to target underlying hyperinflammation derived from ARDS. This article aims to review available data on the use of CytoSorb© therapy in combination with V-V ECMO in severe ARDS, and to assess the effects on inflammatory, laboratory and clinical parameters, as well as on patient outcomes. A systematic literature review was conducted and reported in compliance with principles derived from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. When applicable, a before-and-after analysis for relevant biomarkers and clinical parameters was carried out. CytoSorb© use was associated with significant reductions in circulating levels of C-reactive protein and interleukin-6 (p = 0.039 and p = 0.049, respectively). Increases in PaO2/FiO2 reached significance as well (p = 0.028), while norepinephrine dosage reductions showed a non-significant trend (p = 0.067). Mortality rates in CytoSorb© patients tended to be lower than those of control groups of most included studies, which, however, were characterized by high heterogeneity and low power. In an exploratory analysis on 90-day mortality in COVID-19 patients supported with V-V ECMO, the therapy was associated with a significantly reduced risk of death. Based on the reviewed data, CytoSorb© therapy is able to reduce inflammation and potentially improves survival in ARDS patients treated with V-V ECMO. Early initiation of CytoSorb© in conjunction with ECMO might offer a new approach to enhance lung rest and promote recovery in patients with severe ARDS.

711 Effect of Roux-En-Y Gastric Bypass on HbA1c As Well As Number of Medications in Diabetic Patients

Aim

Roux en Y gastric bypass (RYGB) is known to ameliorate Type 2 Diabetes Mellitus (T2DM) in morbidly obese patients. We aimed to determine both the reduction in the glycosylated haemoglobin (HbA1c) and the number of anti-diabetic medications (including insulin) in diabetic patients undergoing RYGB over a five-year period.

Method

We reviewed data of diabetic patients (n = 530) who underwent RYGB from January 2012 – December 2017, including those with a minimum of a 2-year post-operative follow up (n = 47). Preoperatively, BMI, HbA1c and the number of anti-diabetic medications and the duration of T2DM since diagnosis were recorded. These measurements were repeated at the end of the two year follow up.

Results

At the time of enrolment in the bariatric programme, the median BMI was 42.5 (range, 31.7-61.5) kg/m2, mean duration of T2DM was 58 months and median HbA1c was 59 (37-118) mmol/mol. The mean number of anti-diabetic medications taken, including insulin, was 2. At the end of 2-year follow-up, the median BMI was 32 (range, 24-41) kg/m2 and HbA1c was 41(range, 33-91) mmol/mol. 15 patients (31.9%) still required anti-diabetic medication, 12 of whom had a diagnosis of T2DM for 3 years or more at time of enrolment.

Conclusions

RYGB is strongly associated with a resolution of T2DM in morbidly obese patients. In those who were not resolved, the number of anti-diabetic medications taken and HbA1c were reduced. The impact of the surgery is dependent on the duration of T2DM since diagnosis preoperatively.

Is the Management of Rectal Cancer Using a Watch and Wait Approach Feasible, Safe and Effective in a Publicly Funded General Hospital?

AIMS

Although there is emerging evidence to suggest equivalent oncological outcomes using a watch and wait approach compared with primary total mesorectal excision surgery, there is a paucity of evidence about the safety and efficacy of this approach in routine clinical practice. Here we report the long-term outcomes and quality of life from patients managed with watch and wait following a clinical complete response (cCR) to neoadjuvant therapy.

MATERIALS AND METHODS

Patients with adenocarcinoma of the rectum with cCR following neoadjuvant therapy managed using watch and wait were retrospectively identified. Demographic data, performance status, pretreatment staging information, oncological and surgical outcomes were obtained from routinely collected clinical data. Quality of life was measured by trained clinicians during telephone interviews.

RESULTS

Over a 7-year period, 506 patients were treated for rectal cancer, 276 had neoadjuvant therapy and 72 had a cCR (26.1%). Sixty-three were managed with watch and wait. Thirteen patients had mucosal regrowth. There was no significant difference in the incidence of metastatic disease between the surgical and watch and wait cohorts (P = 0.38). The 13 patients with mucosal regrowth underwent salvage surgery. Eleven of the patients who underwent surgical resection had R0 resections. There was also a statistically and clinically significant improvement in the Functional Assessment of Cancer Therapy - Colorectal (FACT-C) trial outcome index (P = 0.022).

CONCLUSION

This study shows that watch and wait is safe and effective outside of tertiary referral centres. It suggests that an opportunistic cCR is durable and when mucosal regrowth occurs it can be salvaged. Finally, we have shown that quality of life is probably improved if a watch and wait approach is adopted.

Effect of the SARS-CoV-2 pandemic on mortality related to high-risk emergency and major elective surgery

These data show large reductions in both elective and emergency activity that are concerning for unmeasured morbidity and mortality within the community. The risk of mortality following high-risk EGS and major elective surgery during the first wave of the pandemic did not differ when compared with date-matched patient cohorts from 2019. The prevalence of concomitant SARS-CoV-2 infection in this surgical population is low.

The Potential Role of Extracorporeal Cytokine Removal in Hemodynamic Stabilization in Hyperinflammatory Shock

Hemodynamic instability due to dysregulated host response is a life-threatening condition requiring vasopressors and vital organ support. Hemoadsorption with Cytosorb has proven to be effective in reducing cytokines and possibly in attenuating the devastating effects of the cytokine storm originating from the immune over-response to the initial insult. We reviewed the PubMed database to assess evidence of the impact of Cytosorb on norepinephrine needs in the critically ill. We further analyzed those studies including data on control cohorts in a comparative pooled analysis, defining a treatment effect as the standardized mean differences in relative reductions in vasopressor dosage at 24 h. The literature search returned 33 eligible studies. We found evidence of a significant reduction in norepinephrine requirement after treatment: median before, 0.55 (IQR: 0.39-0.90); after, 0.09 (0.00-0.25) μg/kg/min, p < 0.001. The pooled effect size at 24 h was large, though characterized by high heterogeneity. In light of the importance of a quick resolution of hemodynamic instability in the critically ill, further research is encouraged to enrich knowledge on the potentials of the therapy.

Contact X-ray Brachytherapy as an Adjunct to a Watch and Wait Approach is an Affordable Alternative to Standard Surgical Management of Rectal Cancer for Patients with a Partial Clinical Response to Chemoradiotherapy

AIMS

Emerging evidence suggests that contact X-ray brachytherapy (CXB) may increase the clinical complete response rate and durability when administered after standard chemoradiotherapy in patients with rectal cancer. The addition of CXB in partial responders is therefore probably cost-effective. The affordability of widening access to CXB in the UK, however, has not been evaluated.

MATERIALS AND METHODS

Decision analytical modelling with Monte Carlo simulation was used to evaluate long-term costs for the management of patients with rectal cancers who were given a CXB boost when a clinical complete response was not initially achieved following chemoradiotherapy in order to facilitate a watch and wait approach. A third-party payer (National Health Service) perspective was adopted, probabilistic sensitivity analysis was carried out and a scenario analysis was performed to investigate the effect of the number of referral centres and number of patients treated with CXB.

RESULTS

We estimate that 818 (95% confidence interval 628-1021) patients per year are eligible for CXB as an adjunct to a watch and wait approach in England and Wales. As this management is less costly than surgical management for each individual patient, the more patients treated, the more affordable the technology. Even if as few as 125 patients are treated nationally in 15 centres, the cost of implementing this technology would be less than £4 million. If the average number of patients treated in each centre is 30, this technology would be cost saving within 5 years.

CONCLUSIONS

The cost of CXB is not prohibitive according to the National Institute for Health and Care Excellence threshold for implementation of new technology and may even be cost saving within 5 years compared with standard surgical management, depending on the uptake of the technology and the number of referral centres.

An evaluation of cause-of-death trends from recent decades based on registered deaths in Turkey

OBJECTIVES

Although cause-of-death analyses are very important to define public health policy priorities and to evaluate health programs, there is very limited knowledge about mortality profiles and trends in Turkey. The aim of this study was to measure the trends in mortality within three broad cause-of-death groups and their distribution by age groups and gender and to describe the changes of leading causes of death between 1980 and 2013 in Turkey.

STUDY DESIGN

Descriptive study.

METHODS

In the study, data on the number of deaths by year, gender, age and cause was obtained from the Turkish Statistical Institute. The causes of death were classified as group I: communicable, maternal, perinatal, and nutritional conditions; group II: non-communicable diseases (NCDs); and group III: injuries. Unknown or ill-defined causes of death were distributed within group I and group II. The percentage distribution of the cause-of-death groups by gender and age groups between 1980 and 2013 was identified. Age-standardized mortality rates (ASMRs) per 100,000 of broad causes-of-death groups were calculated using European Standard Population 1976 between 1980 and 2008. Changes in mortality rates per hundred were calculated using the formula ([the rate of last year of the period-the rate of the first year of the period]/the rate of the first year of the period). Gender and age-specific data were analyzed using the Joinpoint software to examine trends and significant changes in trends of mortality rates.

RESULTS

Crude death rates for group I, group II, and group III were 157.3, 147.2, and 21.4 per 100,000 in 1980 and 35.3, 377.5, and 15.8 in 2008 for males; 161.8, 120.2, and 5.8 in 1980 and 38.6, 318.4, and 6.4 in 2008 for females, respectively. ASMRs for group I, group II, and group III were 146.3, 394.3, and 29.3 per 100,000 in 1980 and 49.7, 723.6, and 18.8 in 2008 for males; 138.0, 291.5, and 7.6 per 100,000 in 1980 and 47.7, 478.8, and 7.2 in 2008 for females, respectively. The mortality rates of group I for almost all age groups particularly below 5 years of age decreased significantly.

CONCLUSION

This study indicates that Turkey is at an advanced stage in the epidemiological transition, with the majority of the causes of death from NCDs. Considering the regional differences, it is necessary to carry out studies on the specific details of epidemiological transition and the social determinants of deaths in Turkey.

Inhibition of DNA2 nuclease as a therapeutic strategy targeting replication stress in cancer cells

Replication stress is a characteristic feature of cancer cells, which is resulted from sustained proliferative signaling induced by activation of oncogenes or loss of tumor suppressors. In cancer cells, oncogene-induced replication stress manifests as replication-associated lesions, predominantly double-strand DNA breaks (DSBs). An essential mechanism utilized by cells to repair replication-associated DSBs is homologous recombination (HR). In order to overcome replication stress and survive, cancer cells often require enhanced HR repair capacity. Therefore, the key link between HR repair and cellular tolerance to replication-associated DSBs provides us with a mechanistic rationale for exploiting synthetic lethality between HR repair inhibition and replication stress. DNA2 nuclease is an evolutionarily conserved essential enzyme in replication and HR repair. Here we demonstrate that DNA2 is overexpressed in pancreatic cancers, one of the deadliest and more aggressive forms of human cancers, where mutations in the KRAS are present in 90–95% of cases. In addition, depletion of DNA2 significantly reduces pancreatic cancer cell survival and xenograft tumor growth, suggesting the therapeutic potential of DNA2 inhibition. Finally, we develop a robust high-throughput biochemistry assay to screen for inhibitors of the DNA2 nuclease activity. The top inhibitors were shown to be efficacious against both yeast Dna2 and human DNA2. Treatment of cancer cells with DNA2 inhibitors recapitulates phenotypes observed upon DNA2 depletion, including decreased DNA double strand break end resection and attenuation of HR repair. Similar to genetic ablation of DNA2, chemical inhibition of DNA2 selectively attenuates the growth of various cancer cells with oncogene-induced replication stress. Taken together, our findings open a new avenue to develop a new class of anticancer drugs by targeting druggable nuclease DNA2. We propose DNA2 inhibition as new strategy in cancer therapy by targeting replication stress, a molecular property of cancer cells that is acquired as a result of oncogene activation instead of targeting currently undruggable oncoprotein itself such as KRAS.

Femoral cortical index: an indicator of poor bone quality in patient with hip fracture

BACKGROUND

Osteoporosis is a common disease in elderly, characterized by poor bone quality as a result of alterations affecting trabecular bone. However, recent studies have described also an important role of alterations of cortical bone in the physiopathology of osteoporosis. Although dual-energy X-ray absorptiometry (DXA) is a valid method to assess bone mineral density, in the presence of comorbidities real bone fragility is unable to be evaluated. The number of hip fractures is rising, especially in people over 85 years old.

AIMS

The aim is to evaluate an alternative method so that it can indicate fracture risk, independent of bone mineral density (BMD). Femoral cortical index (FCI) assesses cortical bone stock using femur X-ray.

METHODS

A retrospective study has been conducted on 152 patients with hip fragility fractures. FCI has been calculated on fractured femur and on the opposite side. The presence of comorbidities, osteoporosis risk factors, vitamin D levels, and BMD have been analyzed for each patient.

RESULTS

Average values of FCI have been 0.42 for fractured femurs and 0.48 at the opposite side with a statistically significant difference (p = 0.002). Patients with severe hypovitaminosis D had a minor FCI compared to those with moderate deficiency (0.41 vs. 0.46, p < 0.011). 42 patients (27.6%) with osteopenic or normal BMD have presented low values of FCI.

DISCUSSION AND CONCLUSION

A significant correlation among low values of FCI, comorbidities, severe hypovitaminosis D. and BMD in patients with hip fractures has been found. FCI could be a useful tool to evaluate bone fragility and to predict fracture risk even in the normal and osteopenic BMD patients.

Selective hydrophilic modification of Parylene C films: a new approach to cell micro-patterning for synthetic biology applications

We demonstrate a simple, accurate and versatile method to manipulate Parylene C, a material widely known for its high biocompatibility, and transform it to a substrate that can effectively control the cellular microenvironment and consequently affect the morphology and function of the cells in vitro. The Parylene C scaffolds are fabricated by selectively increasing the material's surface water affinity through lithography and oxygen plasma treatment, providing free bonds for attachment of hydrophilic biomolecules. The micro-engineered constructs were tested as culture scaffolds for rat ventricular fibroblasts and neonatal myocytes (NRVM), toward modeling the unique anisotropic architecture of native cardiac tissue. The scaffolds induced the patterning of extracellular matrix compounds and therefore of the cells, which demonstrated substantial alignment compared to typical unstructured cultures. Ca(2+) cycling properties of the NRVM measured at rates of stimulation 0.5-2 Hz were significantly modified with a shorter time to peak and time to 90% decay, and a larger fluorescence amplitude (p < 0.001). The proposed technique is compatible with standard cell culturing protocols and exhibits long-term pattern durability. Moreover, it allows the integration of monitoring modalities into the micro-engineered substrates for a comprehensive interrogation of physiological parameters.

Corrigendum: Systematic review and meta-analysis of the effect of North American working hours restrictions on mortality and morbidity in surgical patients

No

Molecular markers as intermediate end-points in chemoprevention of colon-cancer - modulation of ras activation by sulindac and phenylhexylisothiocyanate during colon carcinogenesis

Recent evidence suggests that activation of ras proto-oncogenes and inactivation of suppressor genes induce malignant phenotype in colonic cells. Thus the identification of clonal population of cells expressing activated ras may lead to a valuable intermediate biomarker to detect premalignant lesions amenable to chemoprevention. Previously, we demonstrated that sulindac inhibited the carcinogen-induced colon tumor development whereas phenylhexylisothiocyanate (PHITC) promoted the tumor outcome. The present study was conducted to investigate the effect of sulindac and PHITC on azoxymethane (AOM)induced activation of ras proto-oncogenes in order to explore the plausibility of using ras as an intermediate biomarker in chemoprevention of colon cancer. Male F344 rats were fed the AIN-76A diet containing 0, 320 ppm sulindac or 640 ppm PHITC and administered s.c. AOM dissolved in normal saline at a dose rate of 15 mg/kg body wt/week for 2 weeks. Vehicle control groups received s.c. equal volume of normal saline. Animals were sacrificed 52 weeks after AOM or saline treatment and their colonic mucosa and tumors were analyzed for mutations in codon 12 and 13 of K-ras and the expression of ras p21. As an alternative non-invasive approach, we developed a simple and sensitive one-step mutant-enriched PCR method to detect these genetic lesions in stools collected at 16, and again at 24 weeks after AOM treatment. AOM-induced G to A transitions were observed at the second nucleotide of 12th codon of K-ras substituting amino acid asp with wild-type gly. Sulindac not only suppressed the selective amplification of initiated cells possessing AOM-induced mutated K-ras codon 12, but significantly inhibited the AOM-induced expression of total and mutant ras-p21. PHITC did not exert any inhibitory effect on AOM-induced ras activation. Results indicated a strong correlation between ras activation and tumor outcome. Data suggest that ras activation may be a useful intermediate molecular marker in chemoprevention of colon cancer.

Safety of training and assessment in operating theatres--a systematic review and meta-analysis

OBJECTIVE

Procedural outcomes can be used to assess the performance of specialists and trainees. This article establishes a systematic evidence base for the safety of training in the operating theatre. It also explores the possibility of using early, intermediate and late procedural outcomes of cardiac surgical operations to evaluate the performance of the clinicians and the healthcare system.

METHODS

Medline, EMBASE and PsycINFO databases were searched. Comparative studies evaluating quality indicators of cardiac surgical procedures (coronary artery bypass grafting (CABG) and valve surgery) were included. guidelines from the preferred reporting items for systematic reviews and meta-analyses (PRISMA) were used.

RESULTS

Fourteen studies met the inclusion criteria. For CABG, meta-analysis of outcomes did not show any significant differences between the technical and non-technical skills of trainees versus specialists apart from bypass time (less for specialists) and intensive care unit (ICU) length of stay (less for trainees). Studies reporting outcomes on valve surgery also did not report any statistically significant differences amongst the outcomes.

CONCLUSION

This systematic review did not discern any significant differences between the procedural outcomes of trainees and specialists, which indicates that trainees are safe to operate under senior supervision. In addition, this article recommends that various procedural outcomes can be used to evaluate the performance of clinicians and healthcare systems. Prospective studies need to be performed, taking into account the specific contribution of trainees and specialists during the procedure. This will give a clearer indication of safety and performance of trainees and specialists in the operating theatre.

Access to health services and early age mortality in Ende, Indonesia

OBJECTIVE

Improvements in child survival to achieve Millennium Development Goal 4 require highly accessible and effective maternal and child health (MCH) services. This article seeks to fill the gap in information for local government in Indonesia about early age mortality and access to appropriate care to inform the evaluation and planning of MCH services.

METHODS

The Ende Child Mortality Survey (ECMS) was conducted in the district of Ende in Nusa Tenggara Timur (NTT), one of the poorest provinces in Indonesia. The ECMS is a cross-sectional household survey, providing information on child survival, MCH service utilisation, and socio-economic characteristics of the population. Multivariate logistic regression was conducted to examine the association of mortality, health service utilisation and socio-economic variables.

RESULTS

Use of an unskilled birth attendant (45% of births) and giving birth at home are most common among the poorest and least educated women. The children of these women have the highest risk of infant mortality. The infant mortality rate differs greatly by region within Ende. Time to the preferred provider of child health care is longest in regions with the highest under-five mortality risk.

CONCLUSIONS

Many women in Ende do not receive vital interventions during labour to reduce infant mortality. The ECMS demonstrates the feasibility in implementing a low cost survey to provide evidence for MCH investments to improve accessibility to appropriate health services and reduce mortality risk.