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Boutros P, Kassem N, Nieder J, Jaramillo C, von Petersdorff J, Walsh FJ, Bärnighausen T, Barteit S. Education and Training Adaptations for Health Workers during the COVID-19 Pandemic: A Scoping Review of Lessons Learned and Innovations. Healthcare (Basel) 2023; 11:2902. [PMID: 37958046 PMCID: PMC10649637 DOI: 10.3390/healthcare11212902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/25/2023] [Accepted: 11/02/2023] [Indexed: 11/15/2023] Open
Abstract
Introduction: The COVID-19 pandemic has considerably impacted the clinical education and training of health workers globally, causing severe disruptions to learning environments in healthcare facilities and limiting the acquisition of new clinical skills. Consequently, urgent adaptation measures, including simulation training and e-learning, have been implemented to mitigate the adverse effects of clinical education. This scoping review aims to assess the impact of COVID-19 on medical education and training, examine the implemented adaptation measures, and evaluate their effectiveness in improving health workers' education and training during the pandemic. Methods: Employing the PRISMA-ScR framework and Arksey and O'Malley's methodological guidance, we conducted a scoping review, systematically searching PubMed, medRxiv, Google, and DuckDuckGo databases to account for the grey literature. The search included studies published between 1 December 2019 and 13 October 2021, yielding 10,323 results. Of these, 88 studies focused on health worker education and training during the pandemic. Results: Our review incorporated 31,268 participants, including physicians, medical trainees, nurses, paramedics, students, and health educators. Most studies (71/88, 81%) were conducted in high-income and lower-middle-income countries. The pandemic's effects on health workers' clinical skills and abilities have necessitated training period extensions in some cases. We identified several positive outcomes from the implementation of simulation training and e-learning as adaptation strategies, such as enhanced technical and clinical performance, increased confidence and comfort, and an expanded global educational outreach. Conclusions: Despite challenges like insufficient practical experience, limited interpersonal interaction opportunities, and internet connectivity issues, simulation training, e-learning, and virtual training have proven effective in improving clinical education and training during the COVID-19 pandemic. Further research is required to bolster preparedness for future pandemics or similar situations.
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Affiliation(s)
- Perla Boutros
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine, Heidelberg University Hospital, Heidelberg University, 69120 Heidelberg, Germany
| | - Nour Kassem
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine, Heidelberg University Hospital, Heidelberg University, 69120 Heidelberg, Germany
| | - Jessica Nieder
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine, Heidelberg University Hospital, Heidelberg University, 69120 Heidelberg, Germany
| | - Catalina Jaramillo
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine, Heidelberg University Hospital, Heidelberg University, 69120 Heidelberg, Germany
| | - Jakob von Petersdorff
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine, Heidelberg University Hospital, Heidelberg University, 69120 Heidelberg, Germany
| | - Fiona J Walsh
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine, Heidelberg University Hospital, Heidelberg University, 69120 Heidelberg, Germany
| | - Till Bärnighausen
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine, Heidelberg University Hospital, Heidelberg University, 69120 Heidelberg, Germany
- Africa Health Research Institute (AHRI), Somkhele, Mtubatuba 3935, KwaZulu-Natal, South Africa
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Sandra Barteit
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine, Heidelberg University Hospital, Heidelberg University, 69120 Heidelberg, Germany
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Patient Preferences for Treatment of Bacillus Calmette-Guérin-unresponsive Non-muscle-invasive Bladder Cancer: A Cross-country Choice Experiment. EUR UROL SUPPL 2023; 49:92-99. [PMID: 36874596 PMCID: PMC9974996 DOI: 10.1016/j.euros.2022.12.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2022] [Indexed: 02/04/2023] Open
Abstract
Background Patients with non-muscle-invasive bladder cancer (NMIBC) that is unresponsive to bacillus Calmette-Guérin (BCG) immunotherapy face a difficult choice. Immediate radical cystectomy (RC) is effective but might represent overtreatment. Continuing bladder preservation with medical therapy is an alternative, but it risks progression to muscle-invasive bladder cancer (MIBC) and a reduction in survival. Objective To understand the trade-offs patients are willing to make in selecting treatments for BCG-unresponsive NMIBC. Design setting and participants Adults with NMIBC from the UK, France, Germany, and Canada who reported current receipt of BCG, disease unresponsive to BCG, or receipt of RC in the previous 12 mo after failure of BCG were recruited to participate in an online choice experiment. Patients were asked to make repeated choices between two hypothetical medical treatments and the option to undergo immediate RC. The medical treatments required trade-offs between the time to RC, the mode and frequency of administration, the risk of experiencing serious side effects, and the risk of disease progression. Outcome measurements and statistical analysis Error component logit models were used to calculate relative attribute importance (RAI) scores as the maximum percentage contribution to a preference and acceptable benefit-risk trade-offs. Results and limitations Most of the 107 participants (average age 63 yr) never selected RC (89%) as their preferred option in the choice experiment. Preferences were most affected by time to RC (RAI 55%), followed by risk of progressing to MIBC (RAI 25%), medication administration (RAI 12%), and the risk of serious side effects (RAI 8%). To increase the time to RC from 1 yr to 6 yr, patients accepted a 43.8% increase in the risk of progression and a 66.1% increase in the risk of serious side effects. Conclusions Patients with BCG-treated NMIBC valued bladder-sparing treatments and were willing to make substantial benefit-risk trade-offs to delay RC. Patient summary Adults with bladder cancer not invading the bladder muscle completed an online experiment in which they chose between hypothetical medications and bladder removal. The results show that patients would be willing to accept different risks associated with medications to delay bladder removal. Patients considered disease progression the most important risk of medicinal treatment.
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Amir I, Golan S, Frumer M, Sternberg IA, Gildor OS, Hoffman A, Shashar R, Mano R, Savin Z, Haifler M, Zilberman DE, Dotan ZA, Rosenzweig B. Association between COVID-19 Burden, Population Vaccination Status, and Urologic Oncology Surgery Volume: A National Multicenter Cross-Sectional Study. J Clin Med 2022; 11:jcm11237071. [PMID: 36498646 PMCID: PMC9738532 DOI: 10.3390/jcm11237071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/24/2022] [Accepted: 11/27/2022] [Indexed: 12/03/2022] Open
Abstract
Initial deleterious effects of the COVID-19 pandemic on urologic oncology surgeries are well described, but the possible influence of vaccination efforts and those of pandemic conditions on surgical volumes is unclear. Our aim was to examine the association between changing vaccination status and COVID-19 burden throughout the pandemic and the volume of urologic oncology surgeries in Israel. This multi-center cross-sectional study included data collected from five tertiary centers between January 2019 and December 2021. All 7327 urologic oncology surgeries were included. Epidemiological data were obtained from the Israeli Ministry of Health database. A rising trend in total urologic oncology surgery volumes was observed with ensuing COVID-19 wave peaks over time (X2 = 13.184, df = 3, p = 0.004). Total monthly surgical volumes correlated with total monthly hospitalizations due to COVID-19 (R = -0.36, p = 0.015), as well as with the monthly average Oxford Stringency Index (R = -0.31, p = 0.035). The cumulative percent of vaccinations and of new COVID-19 cases per month did not correlate with total monthly urologic surgery volumes. Our study demonstrates the gradual acclimation of the Israeli healthcare system to the COVID-19 pandemic. However, hospitalizations due to COVID-19, as well as restriction stringency, correlate with lower volumes of urologic oncological surgeries, regardless of the population's vaccination status.
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Affiliation(s)
- Ido Amir
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Shay Golan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Section of Urology, Rabin Medical Center, Petah Tikva 4941492, Israel
- Israeli Urologic Oncology Collaboration (IUOC)
| | - Michael Frumer
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Section of Urology, Rabin Medical Center, Petah Tikva 4941492, Israel
| | - Itay A. Sternberg
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Israeli Urologic Oncology Collaboration (IUOC)
- Department of Urology, Meir Medical Center, Kfar Saba 4428164, Israel
| | - Omri Schwarztuch Gildor
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Department of Urology, Meir Medical Center, Kfar Saba 4428164, Israel
| | - Azik Hoffman
- Israeli Urologic Oncology Collaboration (IUOC)
- Department of Urology, Rambam Health Center, Haifa 3109601, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, The Technion-Israel Institute of Technology, Haifa 3200003, Israel
| | - Reut Shashar
- Department of Urology, Rambam Health Center, Haifa 3109601, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, The Technion-Israel Institute of Technology, Haifa 3200003, Israel
| | - Roy Mano
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Israeli Urologic Oncology Collaboration (IUOC)
- Department of Urology, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Ziv Savin
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Department of Urology, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Miki Haifler
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Israeli Urologic Oncology Collaboration (IUOC)
- Department of Urology, Chaim Sheba Medical Center, Ramat Gan 5262000, Israel
| | - Dorit E. Zilberman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Department of Urology, Chaim Sheba Medical Center, Ramat Gan 5262000, Israel
| | - Zohar A. Dotan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Department of Urology, Chaim Sheba Medical Center, Ramat Gan 5262000, Israel
| | - Barak Rosenzweig
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Israeli Urologic Oncology Collaboration (IUOC)
- Department of Urology, Chaim Sheba Medical Center, Ramat Gan 5262000, Israel
- Correspondence: or ; Tel.: +972-3-5302221
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van Hoogstraten LM, Kiemeney LA, Meijer RP, van Leenders GJ, Vanneste BG, Incrocci L, Smilde TJ, Siesling S, Witjes JA, Aben KK. The impact of the COVID-19 pandemic on bladder cancer care in the Netherlands. Bladder Cancer 2022. [DOI: 10.3233/blc-211608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: The COVID-19 pandemic has disrupted regular health care with potential consequences for non-COVID diseases like cancer. To ensure continuity of oncological care, guidelines were temporarily adapted. OBJECTIVE: To evaluate the impact of the COVID-19 outbreak on bladder cancer care in the Netherlands. METHODS: The number of bladder cancer (BC) diagnoses per month during 2020-2021 was compared to 2018-2019 based on preliminary data from the Netherlands Cancer Registry (NCR). Additionally, detailed data were retrieved from the NCR for the cohort diagnosed between March 1st-May 31st 2020 (first COVID wave) and 2018-2019 (reference cohort). BC diagnoses, changes in age and stage at diagnosis, and time to first-line treatment were compared between both periods. Changes in treatment were evaluated using logistic regression. RESULTS: During the first COVID wave (week 9–22), the number of BC diagnoses decreased by 14%, corresponding with approximately 300 diagnoses, but increased again in the second half of 2020. The decline was most pronounced from week 13 onwards in patients≥70 years and patients with non-muscle invasive BC. Patients with muscle-invasive disease were less likely to undergo a radical cystectomy (RC) in week 17–22 (OR = 0.62, 95% CI = 0.40–0.97). Shortly after the start of the outbreak, use of neoadjuvant chemotherapy decreased from 34% to 25% but this (non-significant) effect disappeared at the end of April. During the first wave, 5% more RCs were performed compared to previous years. Time from diagnosis to RC became 6 days shorter. Overall, a 7% reduction in RCs was observed in 2020. CONCLUSIONS: The number of BC diagnoses decreased steeply by 14% during the first COVID wave but increased again to pre-COVID levels by the end of 2020 (i.e. 600 diagnoses/month). Treatment-related changes remained limited and followed the adapted guidelines. Surgical volume was not compromised during the first wave. Altogether, the impact of the first COVID-19 outbreak on bladder cancer care in the Netherlands appears to be less pronounced than was reported for other solid tumors, both in the Netherlands and abroad. However, its impact on bladder cancer stage shift and long-term outcomes, as well as later pandemic waves remain so far unexamined.
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Affiliation(s)
- Lisa M.C. van Hoogstraten
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, the Netherlands
| | - Lambertus A. Kiemeney
- Department of Urology, Radboud University Medical Centre, Nijmegen, the Netherlands
- Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Richard P. Meijer
- Department of Oncological Urology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Ben G.L. Vanneste
- Department of Radiation Oncology, MAASTRO-clinic, GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Luca Incrocci
- Department of Radiation Oncology, Erasmus MCCancer Institute, Rotterdam, the Netherlands
| | - Tineke J. Smilde
- Department of Medical Oncology, Jeroen Bosch Hospital, ‘s-Hertogenbosch, the Netherlands
| | - Sabine Siesling
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, the Netherlands
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, Netherlands
| | - J. Alfred Witjes
- Department of Urology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Katja K.H. Aben
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, the Netherlands
- Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
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Guerrieri R, Rovati L, Dell’Oglio P, Galfano A, Ragazzoni L, Aseni P. Impact of the COVID-19 Pandemic on Urologic Oncology Surgery: Implications for Moving Forward. J Clin Med 2021; 11:171. [PMID: 35011911 PMCID: PMC8745246 DOI: 10.3390/jcm11010171] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 12/21/2021] [Accepted: 12/28/2021] [Indexed: 12/17/2022] Open
Abstract
The COVID-19 pandemic has caused the destruction of routine hospital services globally, leading to an increase in the backlog of elective surgery cases. The aim of the study was to retrospectively investigate the pandemic's impact on the urologic oncology surgical activity of a high-volume center located in Milan, Italy. The number and type of procedures performed in 2020 during the COVID-19 pandemic was evaluated using 2019 data as control. Waiting times for each surgical procedure were compared, on a bimonthly basis, between the two different years. Overall, a 26.7% reduction in the number of urologic oncology surgeries between 2019 and 2020 was observed (2019: 720, 2020: 528). Both the main indication for surgery and the type of procedure performed significantly differed between 2019 and 2020 (all p < 0.0001), with a decrease in the number of radical prostatectomies and an increase in the number of radical cystectomies and radical nephrectomies/nephroureterectomies performed in 2020. Waiting time decreased by 20% between 2019 and 2020, with the most significant reduction seen after the first wave of the COVID-19 pandemic (July-October 2020), in particular for partial nephrectomy and radical prostatectomy, possibly due to the underdiagnosis of cases. In conclusion, in accordance with recommendations by international urological societies on prioritization strategies for oncological procedures, a higher proportion of surgeries for high-risk tumors was performed in 2020 at our center at the expense of procedures for lower risk diseases; however, future implications for patients' prognosis still need to be determined.
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Affiliation(s)
- Rossella Guerrieri
- Emergency Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (R.G.); (P.A.)
| | - Lucrezia Rovati
- Emergency Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (R.G.); (P.A.)
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy
| | - Paolo Dell’Oglio
- Department of Urology, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (P.D.); (A.G.)
| | - Antonio Galfano
- Department of Urology, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (P.D.); (A.G.)
| | - Luca Ragazzoni
- CRIMEDIM—Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università del Piemonte Orientale, 28100 Novara, Italy;
| | - Paolo Aseni
- Emergency Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (R.G.); (P.A.)
- Department of Biomedical and Clinical Sciences “L. Sacco”, Università degli Studi di Milano, 20157 Milano, Italy
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Bersanelli M, Porta C. Impact of SARS-CoV-2 Pandemic on Kidney Cancer Management. KIDNEY CANCER 2021. [DOI: 10.3233/kca-210112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: The SARS-CoV-2 pandemic still has a huge impact on the management of many chronic diseases such as cancer. Few data are presently available reagarding how the management of renal cell carcinoma (RCC) has changed due to this unprecedented situation. OBJECTIVE: To discuss the challenges and issues of the diagnosis and treatment of RCC in the COVID-19 era, and to provide recommendations based on the collected literature and our personal experience. METHODS: Systematic review of the available Literature regarding the management of RCC during the SARS-CoV-2 pandemic. RESULTS: Our review showed a prevalence of narrative publications, raising the issue of the real relevance of the evidence retrieved. Indeed, the only original data about RCC and COVID-19 found were a small retrospective case series and two surveys, providing either patients’ or physicians’ viewpoints. CONCLUSIONS: The expected delayed diagnosis of RCC could lead to an increase of advanced/metastatic cases; thus, proper therapeutic choices for patients with small renal masses should be carefully evaluated case by case, in order to avoid negative effects on long-term survival rates. The controversial interaction between immune checkpoint blockade and COVID-19 pathogenesis is more hypothetical than evidence-based, and thus immunotherapy should not be denied, whenever appropriate. To avoid treatments which won’t have an impact on patients’ survival, a honest and accurate evaluation of the cost/benefit ratio of each treatment option should be always performed. Finally, SARS-CoV-2 swab positivity should not prevent the continuation of ongoing active treatments in asymptomatic cases, or or after symptoms’ resolution.
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Affiliation(s)
- Melissa Bersanelli
- Medicine and Surgery Department, University of Parma and Medical Oncology Unit, University Hospital of Parma, Parma, Italy
| | - Camillo Porta
- Department of Biomedical Sciences and Human Oncology, University of Bari ‘A. Moro’ and Division of Medical Oncology, A.O.U. Consorziale Policlinico di Bari, Bari, Italy
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Fallara G, Sandin F, Styrke J, Carlsson S, Lissbrant IF, Ahlgren J, Bratt O, Lambe M, Stattin P. Prostate cancer diagnosis, staging, and treatment in Sweden during the first phase of the COVID-19 pandemic. Scand J Urol 2021; 55:184-191. [PMID: 33913376 DOI: 10.1080/21681805.2021.1910341] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The first case of COVID-19 in Sweden was diagnosed in late January 2020, the first recommendations against the spread of the virus were released in mid-March, and the peak of the first wave of the pandemic was reached in March-June. The aim of this cross-sectional study was to assess the short-term effects of the first wave of the COVID-19 pandemic on prostate cancer (PCa) diagnosis, staging, and treatment. MATERIALS AND METHODS Data in the National Prostate Cancer Register (NPCR) of Sweden on newly diagnosed PCa cases and on the number of diagnostic and therapeutic procedures performed between 18 March 2020 and 2 June 2020 were compared with those in the corresponding time periods in 2017-2019, as reported until January 31 of the year after each study period. RESULTS During the study period in 2020, 36% fewer PCa cases were registered in NPCR compared with the corresponding time period in previous years: 1458 cases in 2020 vs a mean of 2285 cases in 2017-2019. The decrease in new PCa registrations was more pronounced in men above age 75 years, down 51%, than in men aged 70-75, down 37%, and in men below age 70, down 28%. There was no decrease in the number of radical prostatectomies and number of radical radiotherapy courses increased by 32%. CONCLUSIONS During the peak of the first phase of the COVID-19 pandemic, the number of men diagnosed with PCa in Sweden decreased by one third compared with previous years, whereas there was no decrease in the number of curative treatments.
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Affiliation(s)
- Giuseppe Fallara
- Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy.,Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Fredrik Sandin
- Regional Cancer Centre, Uppsala/Örebro, Uppsala University Hospital, Uppsala, Sweden
| | - Johan Styrke
- Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden
| | - Stefan Carlsson
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden
| | - Ingela Franck Lissbrant
- Department of Oncology Institute of Clinical Sciences, the Sahlgrenska Academy, University of Göteborg, Göteborg, Sweden
| | - Johan Ahlgren
- Regional Cancer Centre, Uppsala/Örebro, Uppsala University Hospital, Uppsala, Sweden
| | - Ola Bratt
- Department of Urology, Institute of Clinical Science, the Sahlgrenska Academy, Gothenburg University, Sweden.,Department of Urology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mats Lambe
- Regional Cancer Centre, Uppsala/Örebro, Uppsala University Hospital, Uppsala, Sweden
| | - Pär Stattin
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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