Evidence based policy making during times of uncertainty through the lens of future policy makers: four recommendations to harmonise and guide health policy making in the future

The Covid-19 pandemic has not only outlined the importance of using evidence in the healthcare policy making process but also the complexity that exists between policymakers and the scientific community. As a matter of fact, scientific data is just one of many other concurrent factors, including economic, social and cultural, that may provide the rationale for policy making. The pandemic has also raised citizens' awareness and represented an unprecedented moment of willingness to access and understand the evidence underpinning health policies.This commentary provides policy recommendations to improve evidence-based policy making in health, through the lens of a young generation of public policy students and future policymakers, enrolled in a 24-hour course at Sciences Po Paris entitled "Evidence-based policy-making in health: theory and practice(s)".Four out of 11 recommendations were prioritised and presented in this commentary which target both policymakers and the scientific community to make better use of evidence-based policy making in health. First, policy makers and scientists should build trusting partnerships with citizens and engage them, especially those facing our target health care issues or systems. Second, while artificial intelligence raises new opportunities in healthcare, its use in contexts of uncertainty should be addressed by policymakers in terms of liability and ethics. Third, conflicts of interest must be disclosed as much as possible and effectively managed to (re) build a trust relationship between policymakers, the scientific community and citizens, implying the need for risk management tools and cross border disclosure mechanisms. Last, well-designed and secure health information systems need to be implemented, following the FAIR (findable, accessible, interoperable and reusable) principles for health data. This will take us a step further from data to 'policy wisdom'.Overall, these recommendations identified and formulated by students highlight some key issues that need to be rethought in the health policy cycle through elements like institutional incentives, cultural changes and dialogue between policy makers and the scientific community. This input from a younger generation of students highlights the importance of making the conversation on evidence-based policy making in health accessible to all generations and backgrounds.

[Epidemic of Staphylococcus aureus nosocomial infections resistant to methicillin in a maternity ward]

Methicillin-resistant Staphylococcus aureus (MRSA) nosocomial infections frequently occur in the hospital environment, but their incidence is less often observed in neonates. In the present investigation, seventeen cases were recorded over a nine-week period (two cases per week). Pulsed field gradient gel electrophoresis confirmed the clonal character of the strain. The hypothesis of manually-transmitted infection due to contamination from multiple sources was reinforced by the fact the epidemic persisted in spite of the elimination of the main human infectious source and an absence of risk factors determined by the case-control study. The role of environmental factors in the persistence of this outbreak of MRSA infection has been considered.

[Colloid osmotic pressure and neonatal respiratory distress syndrome]

BACKGROUND

The interest of studying colloid osmotic pressure (COP) in neonates is based on a possible relation between low COP and severity of neonatal respiratory distress.

POPULATION AND METHODS

Because this relation has not been accurately established, COP was prospectively measured at birth in 84 infants: 35 with respiratory distress syndrome treated with mechanical ventilation (group RD+: GA = 34.5 +/- 3.5 weeks; BW = 2,190 +/- 830 g); 49 free of severe respiratory disease (group RD-: GA = 37.5 +/- 2.5 weeks; BW = 2,720 +/- 655 g).

RESULTS

On day one after birth COP was significantly lower in the RD+ group (15.0 +/- 2.2 mmHg) as compared with that in the RD- group (17.9 +/- 2.5 mmHg), and was negatively correlated with mean oxygenation index (OI) on day one, with the highest OI over the first five days of life, and with total duration of oxygen support (P < 0.05). COP was significantly reduced in the neonates with systemic hypotension on day one (P < 0.05).

CONCLUSIONS

These results confirm a correlation between COP at birth and incidence and severity of neonatal respiratory distress. The relationship between low COP and systemic hypotension suggests an important role of COP in the ability of maintaining volemia. This study stresses the strong relationship between water homeostasis and neonatal respiratory distress. Nevertheless, it does not allow to conclude that modifying COP is necessary to improve neonatal respiratory disease.

[Congenital tracheal agenesis. Apropos of 2 cases]

BACKGROUND

Tracheal agenesis is an uncommon, and lethal malformation. It can combine with other malformations.

CASE REPORT

Two cases of congenital tracheal agenesis were seen in preterm infants (GA: 36 and 34 weeks, respectively). Diagnosis was suggested at birth when tracheal intubation failed in those asphyxic patients. One infant presented with the Vacter association; karyotype was normal in both cases.

CONCLUSION

Antenatal diagnosis of tracheal agenesis is difficult but is desirable to favor a well-adapted management of the newborn at birth and give valuable information to parents.

Urea removal by neonatal hemo(dia)filters in hyperazotemic rabbits

OBJECTIVE

Comparison of three neonatal hemo(dia)filters (FH22, Gambro; Minifilter Plus, Amicon; Miniflow 10, Hospal) for removal of urea by venovenous hemofiltration (HF) and venovenous hemodiafiltration (HDF).

DESIGN

Filters were successively used for HF with two different blood flows (Qb = 8.3 and 16.6 ml/ min) and for HDF with the two different blood flows and four dialysate flows (Qd = 0.5, 1.0, 2.0, and 3.0 l/h).

SUBJECTS

21 anesthetized adult New Zealand White rabbits infused with urea.

MAIN RESULTS

Urea clearance was significantly increased by HDF compared to HF regardless of blood flow, dialysate flow, and the hemo (dia)filter type except in the FH22 group, when blood flow was high and dialysate flow was 0.5 or 1.0 l/h. The FH22 filter allowed the best urea clearance during HF at high blood flow. During the HDF procedures, the Miniflow 10 allowed the highest urea clearance regardless of blood flow and dialysate flow.

Salt depletion and dehydration in hypertensive preterm infants

Three preterm infants presented with both severe or moderate arterial hypertension and dehydration due to increased water and sodium urinary excretion. In patient 1, water and sodium wasting were extremely severe and peaked at 575 ml/kg per day and 73 mEq/kg per day, respectively. In all infants, urinary water and sodium excretion dramatically decreased when hypertension resolved. The overall clinical data suggest a pressure natriuresis phenomenon.

Intravenous nicardipine in hypertensive preterm infants

Eight preterm infants were given intravenous nicardipine, a calcium channel blocker, to treat systemic hypertension (renal artery thrombosis (n = 3); dexamethasone for management of bronchopulmonary dysplasia (n = 2); unexplained (n = 3). Nicardipine doses ranged from 0.5 to 2.0 micrograms/kg/min and were given for three to 36 days (mean (SD) 15.9 (10.3) days). Systolic blood pressure had significantly decreased after 12 and 24 hours of nicardipine treatment (-17 (17)% and -21 (10)%, respectively). Diastolic blood pressure significantly decreased after 24 hours of treatment (-22 +/- 16%). The decrease in blood pressure remained significant over the subsequent days of treatment. No hypotension or other clinical side effects were observed. It is concluded that intravenous nicardipine could be a first line treatment for hypertension in preterm infants.

Hemodynamics and oxygenation changes induced by the discontinuation of low-dose inhalational nitric oxide in newborn infants

OBJECTIVE

To assess changes associated with nitric oxide (NO) discontinuation in neonates receiving inhalational NO therapy as a treatment for pulmonary hypertension of the neonate (PPHN).

DESIGN

Prospective study.

SETTING

A pediatric PICU in a university hospital.

PATIENTS AND METHODS

Ten neonates were included. NO discontinuation was attempted when the oxygenation index fell below 10. The mean NO concentration was 4.9 +/- 0.8 ppm. Each infant was studied over three successive 5-min periods and was assigned to either group 1 (NO1+, NO2+, NO-) or group 2 (NO1+, NO-, NO2+).

MEASUREMENTS AND RESULTS

Postductal transcutaneous PO2 (tcPO2), postductal oxygen saturation with pulse oxymetry (SpO2), systolic and diastolic blood pressure (BP), heart rate (HR), left ventricular shortening fraction (LVSF), cardiac output (CO), and ratio of pulmonary artery time to peak velocity and right ventricular ejection time (TPV/RVET) were similar during the two successive NO+ periods (group 1), thus demonstrating that the measurements were reproducible. NO removal (groups 1 and 2) did not modify systolic or diastolic BP, HR, CO, or LVSF but did induce a significant decline in SpO2, tcPO2 (- 25 +/- 5%) and TPV/RVET ratio (- 25 +/- 3%). No reinstitution reversed the effects of NO withdrawal on tcPO2, SpO2 and TPV/RVET ratio (group 2) without any changes in systemic hemodynamics.

CONCLUSION

The shut-off of low-dose NO induced in each patient a decrease in oxygen delivery that may be due to increased pulmonary vascular resistances and/or redistribution of pulmonary blood flow with ventilation-perfusion mismatching. The optimum weaning-off procedure of inhalational NO remains to be determined.

Inhaled cigarette smoke selectively reverses human hypoxic vasoconstriction

The acute effects of the inhaled gas phase of cigarette smoke on pulmonary (PAP) and systemic (SAP) arterial pressures and on plasma arterial cGMP content were compared with those of inhaling 10, 20 and 80 ppm nitric oxide (NO) in one healthy adult volunteer spontaneously breathing a hypoxic gas mixture. Hypoxia (FIO2 0.12) induced a sustained, stable pulmonary vasoconstriction. Inhaled NO induced a dose-dependent fall in PAP; plasma cGMP rose from 39.4 (hypoxia) to 164 pmol/ml (hypoxia plus 80 ppm NO). Exposure to cigarette smoke induced a rapid, consistent and reversible fall in PAP; plasma cGMP rose from 45.5 (hypoxia) to 138 pmol/ml (hypoxia plus cigarette smoke). Neither NO nor cigarette smoke inhalation induced any change in SAP. These data suggest that exposure to cigarette smoke is able selectively to reverse acute hypoxic vasoconstriction in humans without causing systemic vasodilation, an effect likely mediated through the NO-cGMP pathway.

[Necrotizing tracheobronchitis in ventilated newborn infants]

BACKGROUND

Necrotizing tracheobronchitis is a severe complication observed in some mechanically ventilated neonates.

CASE REPORT

A twin premature (GA = 31 weeks), weighing 1,500 g required oral endotracheal intubation for mechanical ventilation because he suffered from respiratory distress syndrome. He was given indomethacin on day 4 for patent ductus arteriosus. Progressive weaning of ventilation on day 9 was dramatically complicated by hypoxia, respiratory acidosis and right pneumothorax. Immediate endoscopy showed total obstruction of trachea by necrotic secretions the suction of which was followed by rapid improvement of the respiratory condition. Bacterial examination of secretions showed coagulase-negative staphylococcus. The patient was given steroids + antibiotics. Prolonged ventilation resulted in bronchopulmonary dysplasia and the patient was only extubated at week 12 after a normal endoscopic control.

CASE REPORT

A premature girl (GA = 32 weeks), weighing 1,800 g required oral endotracheal intubation for mechanical ventilation because she suffered from respiratory distress syndrome. The respiratory condition worsened on day 3, requiring tracheography which showed distal tracheal obstruction. Immediate endoscopy showed thin, adherent and necrotic membranes which were removed by suction. The patient was given steroids +antibiotics and was extubated on day 14 after a normal endoscopic control.

CONCLUSIONS

This iatrogeneous complication must be recognized in a ventilated infant when the respiratory condition dramatically worsens. Emergency bronchoscopy permits endotracheal suction of necrotic secretions.

[Use of tissue plasminogen activator in the treatment of aortic thrombosis in newborn infants]

BACKGROUND--Aortic thrombosis is more frequent since the use of umbilical artery catheters in neonatal intensive care units. Some drugs or surgery are proposed to prevent complications; experience with tissue plasminogen activator (tPA) is still limited. CASE REPORT NO 1--A neonate, weighing 2400 g, developed respiratory distress requiring insertion of a catheter into her umbilical artery at H12. Ultrasonography on day 3 showed aortic thrombosis extending to the right renal artery which was confirmed by angiography. tPA 0.1 mg/kg was administered through the catheter, followed by 0.3 mg/kg/h for 3 hours and heparin, 100 IU/kg/hour for 54 hours. Angiography, performed 18 hours later, showed complete disappearance of the thrombosis. CASE REPORT NO 2--A neonate, weighing 2520 g suffered at 12 hours of life from seizures, apnea and bradycardia which required insertion of a catheter into her umbilical artery. Cyanosis of the right leg with weakening of femoral pulsations, 14 hours later, lead to the diagnosis of aortic thrombosis which was confirmed by aortography. The patient was given tPA 0.1 mg/kg followed by 0.3 mg/kg/h for 3 hours and heparin 100 IU/kg/hour for 6 hours. Amplitude of femoral pulsations strikingly increased within 6 hours with the disappearance of cyanosis. CONCLUSION--These results suggest that tPA can be useful in neonates presenting with aortic thrombosis.

[Ultrasonographic survey of the effect of umbilical arterial catheterization in newborn infants]

BACKGROUND

Incidence of aortic thromboses in the neonatal period is significantly increased after umbilicar artery catheterization.

POPULATION AND METHODS

Fourty neonates (GA: 34.7 +/- 7.2 wks and birth weight: 2377 +/- 786 g) were prospectively studied in order to assess frequency and natural history of aortic thromboses due to umbilical artery catheterization. Investigation was based on serial real-time ultrasonography (2.3 times/week). Presence of aortic thrombus was correlated with the existence of clinical complications and the results of biological findings (prothrombin and fibrinogen levels; hematocrit) and platelet number.

RESULTS

Aortic thrombosis was found in six patients (15%); it was clinically asymptomatic in two (5%). A vascular wall-fixed catheter was shown in ten infants (25%); this finding was associated with thrombosis in five cases and preceded thrombosis in one other. The presence of thrombus and/or abnormal position of the catheter was not correlated with gestational age, birth weight, duration of catheterization, blood hemostasis and results of bacteriological cultures of the tip of the catheter.

CONCLUSIONS

Ultrasonographic control must be repeated after umbilical artery catheterization. It permits evaluation of renal flux and can lead to removal of catheter and/or peculiar therapeutic measures.

[Renal effects of prolonged indomethacin therapy in premature infants]

BACKGROUND

Indomethacin therapy for large patent ductus arterious would be more effective when it is prescribed for 5 or 6 days vs 2 or 3 days. Effects on renal function of such prolonged therapy is still debated.

PATIENTS AND METHODS

Seven preterm infants (gestational age: 28.6 +/- 0.9 weeks; birth-weight: 1,169 +/- 267 g) with symptomatic patent ductus arterious were given indomethacin, 0.1 mg/kg/day for 6 days (four patients) and 5 days (three patients). Urinary water excretion, water output/input ratio, creatinine clearance and body weight were measured before and every day during therapy.

RESULTS

Urinary water excretion, water output/input ratio and creatinine clearance were significantly decreased after 5 days of treatment, -40 +/- 30%, -42 +/- 27% and -48 +/- 31%, respectively. Creatinemia and body weight were significantly increased, + 34 +/- 36% and + 9 +/- 7%, respectively. Mean sodium plasma level and fractional excretion of sodium, potassium and chloride remained stable.

CONCLUSION

Prolonged therapy with indomethacin does not avoid the renal side effects seen with shorter administration.

[Removal of amino acids by continuous hemofiltration and hemodiafiltration]

BACKGROUND

Continuous hemodiafiltration is potentially more efficient than hemofiltration for removing low molecular metabolites.

CASE REPORT

A newborn (2100 g) was admitted suffering from acute distress with statuts epilepticus, liver failure with generalized hyperaminoacidemia, hypoglycemia and oligo-anuria. Peritoneal dialysis, performed on the 17th day of life, was ineffective and the patient was treated by continuous hemofiltration alternating with hemodiafiltration. Clearance of amino-acids was studied for 15 minutes under each technique. The amino-acid concentrations were measured in the infused fluid and in the ultrafiltrate. The baby died on the 20th day despite this treatment.

RESULTS

Amino acid clearance by hemodiafiltration was 181 +/- 176% greater than by hemofiltration. The mean improvement for all amino acids was 148%, with extremes of +43% for citrulline and 941% for glutamic acid.

CONCLUSION

Continuous hemodiafiltration is an efficient method of removing amino acids; it could be used to treat severe inborn errors of metabolism such as leucinosis.

Vasodilators in persistent pulmonary hypertension of the newborn: a need for optimal appraisal of efficacy

Tolazoline hydrochloride is usually the first choice pulmonary vasodilator in persistent pulmonary hypertension of the neonate (PPHN). The analysis of 26 articles including 467 tolazoline-treated infants has been hindered by many methodological drawbacks. Tolazoline has always been administered to infants suffering refractory hypoxemia, but, unfortunately, pulmonary hypertension has not usually been investigated. Moreover, 80% of the tolazoline-treated neonates had an underlying pulmonary parenchymal disease as a potential cause of severe hypoxemia. Noteworthy is that similar comments apply to all studies dealing with the use of other pulmonary vasodilators in PPHN. Pulsed Doppler echocardiography (PDE) should allow a qualitative and quantitative approach for PPHN and an analysis of both success and failure of vasodilator therapeutics. In the meantime, the use of PDE requires more intense investigation prior to wide application in PPHN.

[Hypersensitivity pneumopathies ("bird fancier's lung") in children. Diagnostic value of bronchoalveolar lavage]

A current view of "pigeon fancier's lung" in children is reported through a familial case presenting as a severe denutrition in a 9 year-old boy. Cellular and biochemical analysis of broncho-alveolar lavage fluid is essential to proper diagnosis. Treatment is based upon the eviction of inhaled antigenic organic materials issued from pigeon's droppings, corticosteroid treatment being only additional. Pulmonary fibrosis is a rare but possible complication in the outcome of the disease.