Effectiveness of Mechanisms and Models of Coordination between Organizations, Agencies and Bodies Providing or Financing Health Services in Humanitarian Crises: A Systematic Review.

BACKGROUND: Effective coordination between organizations, agencies and bodies providing or financing health services in humanitarian crises is required to ensure efficiency of services, avoid duplication, and improve equity. The objective of this review was to assess how, during and after humanitarian crises, different mechanisms and models of coordination between organizations, agencies and bodies providing or financing health services compare in terms of access to health services and health outcomes. METHODS: We registered a protocol for this review in PROSPERO International prospective register of systematic reviews under number PROSPERO2014:CRD42014009267. Eligible studies included randomized and nonrandomized designs, process evaluations and qualitative methods. We electronically searched Medline, PubMed, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, PsycINFO, and the WHO Global Health Library and websites of relevant organizations. We followed standard systematic review methodology for the selection, data abstraction, and risk of bias assessment. We assessed the quality of evidence using the GRADE approach. RESULTS: Of 14,309 identified citations from databases and organizations' websites, we identified four eligible studies. Two studies used mixed-methods, one used quantitative methods, and one used qualitative methods. The available evidence suggests that information coordination between bodies providing health services in humanitarian crises settings may be effective in improving health systems inputs. There is additional evidence suggesting that management/directive coordination such as the cluster model may improve health system inputs in addition to access to health services. None of the included studies assessed coordination through common representation and framework coordination. The evidence was judged to be of very low quality. CONCLUSION: This systematic review provides evidence of possible effectiveness of information coordination and management/directive coordination between organizations, agencies and bodies providing or financing health services in humanitarian crises. Our findings can inform the research agenda and highlight the need for improving conduct and reporting of research in this field

Impact of Antioxidant Therapy on Natural Pregnancy Outcomes and Semen Parameters in Infertile Men: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Purpose: Seminal oxidative stress (OS) is a recognized factor potentially associated with male infertility, but the efficacy of antioxidant (AOX) therapy is controversial and there is no consensus on its utility. Primary outcomes of this study were to investigate the effect of AOX on spontaneous clinical pregnancy, live birth and miscarriage rates in male infertile patients. Secondary outcomes were conventional semen parameters, sperm DNA fragmentation (SDF) and seminal OS. Materials and methods: Literature search was performed using Scopus, PubMed, Ovid, Embase, and Cochrane databases. Only randomized controlled trials (RCTs) were included and the meta-analysis was conducted according to PRISMA guidelines. Results: We assessed for eligibility 1,307 abstracts, and 45 RCTs were finally included, for a total of 4,332 infertile patients. We found a significantly higher pregnancy rate in patients treated with AOX compared to placebo-treated or untreated controls, without significant inter-study heterogeneity. No effects on live-birth or miscarriage rates were observed in four studies. A significantly higher sperm concentration, sperm progressive motility, sperm total motility, and normal sperm morphology was found in patients compared to controls. We found no effect on SDF in analysis of three eligible studies. Seminal levels of total antioxidant capacity were significantly higher, while seminal malondialdehyde acid was significantly lower in patients than controls. These results did not change after exclusion of studies performed following varicocele repair. Conclusions: The present analysis upgrades the level of evidence favoring a recommendation for using AOX in male infertility to improve the spontaneous pregnancy rate and the conventional sperm parameters. The failure to demonstrate an increase in live-birth rate, despite an increase in pregnancy rates, is due to the very few RCTs specifically assessing the impact of AOX on live-birth rate. Therefore, further RCTs assessing the impact of AOX on live-birth rate and miscarriage rate, and SDF will be helpful

Controversy and consensus on indications for sperm DNA fragmentation testing in male infertility: a global survey, current guidelines, and expert recommendations.

PURPOSE: Sperm DNA fragmentation (SDF) testing was recently added to the sixth edition of the World Health Organization laboratory manual for the examination and processing of human semen. Many conditions and risk factors have been associated with elevated SDF; therefore, it is important to identify the population of infertile men who might benefit from this test. The purpose of this study was to investigate global practices related to indications for SDF testing, compare the relevant professional society guideline recommendations, and provide expert recommendations. MATERIALS AND METHODS: Clinicians managing male infertility were invited to take part in a global online survey on SDF clinical practices. This was conducted following the CHERRIES checklist criteria. The responses were compared to professional society guideline recommendations related to SDF and the appropriate available evidence. Expert recommendations on indications for SDF testing were then formulated, and the Delphi method was used to reach consensus. RESULTS: The survey was completed by 436 experts from 55 countries. Almost 75% of respondents test for SDF in all or some men with unexplained or idiopathic infertility, 39% order it routinely in the work-up of recurrent pregnancy loss (RPL), and 62.2% investigate SDF in smokers. While 47% of reproductive urologists test SDF to support the decision for varicocele repair surgery when conventional semen parameters are normal, significantly fewer general urologists (23%; p=0.008) do the same. Nearly 70% would assess SDF before assisted reproductive technologies (ART), either always or for certain conditions. Recurrent ART failure is a common indication for SDF testing. Very few society recommendations were found regarding SDF testing. CONCLUSIONS: This article presents the largest global survey on the indications for SDF testing in infertile men, and demonstrates diverse practices. Furthermore, it highlights the paucity of professional society guideline recommendations. Expert recommendations are proposed to help guide clinicians

Controversy and consensus on the management of elevated sperm DNA fragmentation in male infertility: a global survey, current guidelines, and expert recommendations

PURPOSE: Sperm DNA fragmentation (SDF) has been associated with male infertility and poor outcomes of assisted reproductive technology (ART). The purpose of this study was to investigate global practices related to the management of elevated SDF in infertile men, summarize the relevant professional society recommendations, and provide expert recommendations for managing this condition. MATERIALS AND METHODS: An online global survey on clinical practices related to SDF was disseminated to reproductive clinicians, according to the CHERRIES checklist criteria. Management protocols for various conditions associated with SDF were captured and compared to the relevant recommendations in professional society guidelines and the appropriate available evidence. Expert recommendations and consensus on the management of infertile men with elevated SDF were then formulated and adapted using the Delphi method. RESULTS: A total of 436 experts from 55 different countries submitted responses. As an initial approach, 79.1% of reproductive experts recommend lifestyle modifications for infertile men with elevated SDF, and 76.9% prescribe empiric antioxidants. Regarding antioxidant duration, 39.3% recommend 4-6 months and 38.1% recommend 3 months. For men with unexplained or idiopathic infertility, and couples experiencing recurrent miscarriages associated with elevated SDF, most respondents refer to ART 6 months after failure of conservative and empiric medical management. Infertile men with clinical varicocele, normal conventional semen parameters, and elevated SDF are offered varicocele repair immediately after diagnosis by 31.4%, and after failure of antioxidants and conservative measures by 40.9%. Sperm selection techniques and testicular sperm extraction are also management options for couples undergoing ART. For most questions, heterogenous practices were demonstrated. CONCLUSIONS: This paper presents the results of a large global survey on the management of infertile men with elevated SDF and reveals a lack of consensus among clinicians. Furthermore, it demonstrates the scarcity of professional society guidelines in this regard and attempts to highlight the relevant evidence. Expert recommendations are proposed to help guide clinicians

Technical aspects and clinical limitations of sperm DNA fragmentation testing in male infertility: a global survey, current guidelines, and expert recommendations.

PURPOSE: Sperm DNA fragmentation (SDF) is a functional sperm abnormality that can impact reproductive potential, for which four assays have been described in the recently published sixth edition of the WHO laboratory manual for the examination and processing of human semen. The purpose of this study was to examine the global practices related to the use of SDF assays and investigate the barriers and limitations that clinicians face in incorporating these tests into their practice. MATERIALS AND METHODS: Clinicians managing male infertility were invited to complete an online survey on practices related to SDF diagnostic and treatment approaches. Their responses related to the technical aspects of SDF testing, current professional society guidelines, and the literature were used to generate expert recommendations via the Delphi method. Finally, challenges related to SDF that the clinicians encounter in their daily practice were captured. RESULTS: The survey was completed by 436 reproductive clinicians. Overall, terminal deoxynucleotidyl transferase deoxyuridine triphosphate Nick-End Labeling (TUNEL) is the most commonly used assay chosen by 28.6%, followed by the sperm chromatin structure assay (24.1%), and the sperm chromatin dispersion (19.1%). The choice of the assay was largely influenced by availability (70% of respondents). A threshold of 30% was the most selected cut-off value for elevated SDF by 33.7% of clinicians. Of respondents, 53.6% recommend SDF testing after 3 to 5 days of abstinence. Although 75.3% believe SDF testing can provide an explanation for many unknown causes of infertility, the main limiting factors selected by respondents are a lack of professional society guideline recommendations (62.7%) and an absence of globally accepted references for SDF interpretation (50.3%). CONCLUSIONS: This study represents the largest global survey on the technical aspects of SDF testing as well as the barriers encountered by clinicians. Unified global recommendations regarding clinician implementation and standard laboratory interpretation of SDF testing are crucial

27 Cost Analysis of Online Telehealth Platforms Offering Testosterone Therapy

ABSTRACT Introduction Online telehealth platforms are becoming increasingly common across several areas of medicine, including those related to men's health conditions. These ventures now offer virtual services for the evaluation of testosterone deficiency and treatment via the online sale of testosterone therapy (TTh). Objective We sought to compare the cost of undergoing virtual evaluation and treatment with TTh via online telehealth platforms, as compared to what may be offered by a board-certified urologist following the American Urologic Association (AUA) guidelines at a tertiary care center. Methods Google was queried to identify platforms that offer an online consultation and prescription service for TTh. Platforms that did not provide transparency of services including details of the initial consultation, laboratory work, type of medication offered, and associated fees on the company website were excluded. Information regarding the type of providers used, services and laboratory work included in the initial consultation, and price for the evaluation and three months of treatment with TTh were gathered. These were compared to the services and prices that a board-certified urologist at a tertiary care center may offer while following the AUA guidelines for the evaluation and management of testosterone deficiency. Costs for services at the tertiary care center were estimated using a single institution's online cost estimator1 for a patient with no insurance, a patient with basic employee insurance, and a patient with Medicare. Results A total of three online platforms met inclusion criteria: Hone, Regenex Health, and TRT Nation. The services provided for the initial evaluation and for follow up of patients on TTh were similar between the online platforms and those suggested by AUA guidelines (Table 1). The cost of the initial consultation including laboratory services were lowest for the patient with Medicare at a tertiary center ($0) and via the online platform, Hone ($45.00) (Table 2). The estimated cost for three months of treatment with TRT including follow up was lowest among the patient with Medicare ($32.79) and the patient with basic employee insurance ($192.58) at the tertiary center (Table 3). The cost of three months of treatment and follow up was highest via the online platform Regenex Health ($1,059.00). Conclusions While online telehealth platforms may offer a cost benefit in the initial consultation and evaluation for TRT for some patients, the cost of ongoing treatment greatly exceeds that which may be obtained at a tertiary care center for patients with basic insurance plans or Medicare. Patients without insurance may encounter a high cost of initial evaluation at a tertiary center, however, ongoing follow up and medication costs for these patients is likely similar between select online platforms and a tertiary center. Disclosure No </jats:sec

138 Is Reddit a Reliable Source for Information on Erectile Dysfunction Treatment?

ABSTRACT Introduction Men commonly turn to the internet for information prior to seeing a physician about erectile dysfunction (ED)[1]. Reddit is a popular and influential social media platform consisting of over 52 million users engaged in discussions regarding a vast array of topics[2]. Reddit can serve as a source of information for urologic conditions[3], but social media has been shown to contain unreliable information when it comes to erectile dysfunction[4]. References: 1. Ferguson, Tom, and Gilles Frydman. "The first generation of e-patients." (2004): 1148-1149. 2. Reddit by the Numbers.” Reddit, www.redditinc.com/press. 3. Du, Chris, et al. "I leaked, then I Reddit: experiences and insight shared on urinary incontinence by Reddit users." International urogynecology journal 31.2 (2020): 243-248. 4. Fode, Mikkel, et al. "Quality of information in YouTube videos on erectile dysfunction." Sexual Medicine 8.3 (2020): 408-413. Objective We sought to identify and characterize the types of ED therapies being discussed by users of the highly influential Reddit website. Methods Two sub-reddit pages, “Ask Men” and “erectile dysfunction”, were chosen for analysis. Posts within the erectile dysfunction sub-reddit were sorted by most popular over all time, and the top 50 threads discussing ED management with at least 2 comments were chosen for analysis. Within the Ask Men sub-reddit, the posts were filtered to include the words “erectile dysfunction”. Of these threads, 35 were found to contain discussions relevant to ED treatment, and were thus selected for analysis. Each thread was evaluated for any recommendations for an ED therapy made by the users within the comments, and each therapy was evaluated for congruence with the American Urologic Associated (AUA) guidelines statements for the treatment of ED. Results The “erectile dysfunction” and “Ask Men” sub-reddit forums consist of 8,100 and 2.7 million members, respectively. A total of 57 different ED therapies were recommended within the 85 posts that were analyzed. Recommendations for changing sexual habits were the most common (29.8%), followed by seeking assistance from a medical professional or use of medications (21.2%), lifestyle changes (17.0%), and exercise practices (13.4%) (Figure 1). Less commonly recommended therapies included the use of supplements (10.7%), herbal remedies (3.9%), and dietary changes (3.9%). Specific therapies that were recommended most often included counseling from a physician, lowering anxiety or stress reduction, reducing porn, reducing masturbation, and discussing ED openly with a partner. Of the 57 specific treatments that were discussed, only 14 (24.6%) were in line with current AUA guidelines for the treatment of ED (Table 1). Conclusions ED treatments are commonly discussed on Reddit, with a wide range of therapies being self-reportedly successful among users. Most of the treatments discussed are not supported by strong clinical evidence. An understanding of commonly discussed treatments is valuable for the physician, as this may represent an opportunity to educate the population and guide patient counseling. Disclosure No </jats:sec

Estimation of global case fatality rate of coronavirus disease 2019 (COVID-19) using meta-analyses: Comparison between calendar date and days since the outbreak of the first confirmed case

Abstract Since the outbreak of the coronavirus disease 2019 (COVID-19) in December of 2019 in China, the estimation of the pandemic’s case fatality rate (CFR) has been the focus and interest of many stakeholders. In this manuscript, we prove that the method of using the cumulative CFR is static and does not reflect the trend according to the daily change per unit of time. A proportion meta-analysis was carried out on CFR in every country reporting COVID-19 cases. Based on the results, we performed a meta-analysis for global COVID-19 CFR. Each analysis was performed on two different calculations of CFR: according to calendar date and according to days since the outbreak of the first confirmed case. We thus explored an innovative and original calculation of CFR concurrently based on the date of the first confirmed case as well as on a daily basis. For the first time, we showed that using meta-analyses, according to calendar date and days since the outbreak of the first confirmed case were different. We propose that CFR according to days since the outbreak of the first confirmed case might be a better predictor of the current CFR of COVID-19 and its kinetics