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OBJECTIVES: To describe the organization of a hospital during the COVID-19 pandemic, paying attention to both organizational and leadership aspects, and considering all hospital areas, including the operating room.MATERIAL AND METHODS: Review of the literature regarding the organizational councils for hospital management within the pandemic. In addition, the recommendations of societies, institutions such as the WHO, the CDC, the ECDC, the National Ministry of Health and the Ministry of Health of Madrid and the center’s own experience have been taken into account.RESULTS: Description of the key elements for the organization, as well as the different areas of action within a hospital: emergencies, consultations, hospitalization and operating rooms.CONCLUSIONS: Management during a pandemic requires a high degree of agility in response and plasticity in people. All hospital structures must adapt to a situation for which they have not been conceived and all staff must place themselves at the service of a disease that conditions all decisions. Being able to adapt and try to anticipate what is going to happen are the keys to success.
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INTRODUCTION: On 11th March 2020 the WHO declared COVID19 a global pandemic, a challenge previously unseen for sanitary systems, including the activity in Urology departments. MATERIAL AND METHODS: Web and PubMed search using the keywords “SARS-CoV-2”, “COVID19”, “COVID Urology”, “COVID surgery”, “consensus methods”, “nominal group”, “Delphi method”. A narrative revision of the literature until the 20th May 2020, including articles and documents in English and Spanish.RESULTS: Medical practice in Spain has been forced to rapidly adapt to the pandemic, dedicating most of its material and human resources to the care of patients infected by SARS-CoV-2. This has meant a significant reduction of the routine practice in Urology, as in other medical specialities, limiting the medical attention to urgent and emergent cases. Programmed activity has been reserved for selected cases in which a delayed attention could compromise survival.Different scientific associations have made a significant effort to adapt their recommendations to the pandemic, prioritizing high-risk oncologic cases, and reducing the use of ventilators and hospital stays to the minimum.These restrictions must be dynamic, adapting to the de-escalating phases as the pandemic is more controlled, widening the range of services available. In this de-escalate there is an additional challenge, being the difficulty in generating quality scientific evidence. In order to obtain such evidence, consensus methods have been used, such as the nominal group technique or the Delphi method.CONCLUSIONS: The COVID19 pandemic has meant a complete disruption in the routine activity in Urology in Spain, with a need for prioritizing the attention of urgent and high-risk oncologic pathology. These restrictions must be progressively modified according to the de-escalating process in the general population.
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The COVID-19 pandemic has required drastic measures for an attempt in controlling its spread. Health resources and facilities are being destined for the treatment of critically ill infected patients. During the past weeks, we, as urologists have faced increasingly difficult changes in practice, as outpatient activity and elective surgeries must be postponed in order to save resources and limit the mobilization of patients and faculty. During this conflictive situation, telehealth medicine can provide adequate support using technological tools and trying to simulate face-to-face consults with the use of video or telephone calls. However, many outpatient clinics and facilities are not ready yet for telehealth as their experience in this area is low. The benefits for telemedicine in urology are continuing urologic outpatient follow-up, providing recommendations and prescriptions, and the triage of patients who will need urgent procedures. Urology residency training has suffered an abrupt disruption nowadays as outpatient, surgical and academic meetings are cancelled. In this scenario, virtual strategies and “smart learning” activities are being used to continue education. We provide a review of the latest published literature regarding the use of telehealth medicine or telemedicine for the modern urology practice, alongside our recommendations and conclusions.
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INTRODUCTION: The crisis in the SARS-CoV-2 coronavirus causing COVID-19 is putting health systems around the world to the test. In a great effort to standardize the management and treatment guidelines, the different health authorities and scientific associations have tried to issue recommendations on how to act in this new and complex scenario.OBJECTIVE: To synthesize the existing evidence and recommendations about urological emergency surgery during the COVID-19 pandemic situation. Furthermore, we propose a general action protocol for these patients.MATERIAL AND METHODS: The document is based on the scarce evidence on SARS/Cov-2 and the experi-ence of the authors in the management of COVID-19 in their institutions, including specialists from Andalusia, Cantabria, Madrid and the Basque Country. A web and PubMed search was performed using the key-words “SARS-CoV-2”, “COVID19”, “COVID Urology”, “COVID19 surgery” and “emergency care”. A narrative review of the literature was carried out until April 30, 2020, including only articles and documents written in Spanish and English. After the nominal group tech-nique modified due to the extraordinary restrictions, a first draft was made to unify criteria. Finally, a definitive version was made, agreed by all the authors on May 12, 2020.RESULTS: General principles of action are set out, as well as specific recommendations for the most frequent urgent urological procedures.CONCLUSIONS: Given the exceptional nature of the situation, there is a lack of evidence regarding the op-timal management of the patient with urgent urological pathology. The information is changing, as the epidemi-ological knowledge of the disease advances. The es-tablishment of multidisciplinary surgical committees that develop and implement action protocols appropriate to the different resources and particular situations of each center is recommended. Likewise, these committees must individually assess each possible urological surgical emergency situation and ensure compliance with pro-tective measures for the patient and other healthcare personnel.
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The COVID-19 pandemic caused by SARS-CoV-2 virus has caused an important health im-pact that has affected renal cell carcinoma manage-ment, among other urology areas. The high cancellation rate of surgeries, including those related to renal can-cer, will cause an inevitable healthcare overload and probably a potential negative impact on its oncological outcomes, especially in locally advanced and metastatic renal cancer.Kidney cancer scenarios are quite different depend-ing on their stage, distinguishing mainly between low priority of localized disease or high priority of locally advanced and metastatic under active treatment. The unknown pandemic duration and possibly fluctuating prevalence of the virus are likely to force an adaptation in the management of renal cell carcinoma among urolo-gy and oncology departments, ideally individualized on a case-by-case basis within multidisciplinary units. To this end, we present algorithms and tables regarding renal cell carcinoma management adapted to the COVID-19 period and stratified according to oncological stage, which might be useful for specialists dedicated to this uro-oncology area.
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OBJECTIVE: The objective of this publi-cation is to provide recommendations in the manage-ment of prostate cancer (PC) in a new reality framework based on the presence of COVID-19 disease.MATERIAL AND METHODS: The document is based on the scarce evidence on SARS/Cov-2 and the experi-ence of the authors in handling COVID-19 in their insti-tutions, including specialists from Andalusia, Cantabria, Catalonia, Madrid and the Valencian Community. RESULTS: The authors defined different priorities for the different clinical situations in PC. Emergency/urgency (life-threatening or urgent even in normal situation), high priority/elective urgency (potentially dangerous if post-poned for more than 1 month), intermediate/elective priority (it is recommended not to delay more than 6 months), low priority/delayed (can be postponed more than 6 months). According to this classification, the working panel agreed on the distribution of the different diagnostic, therapeutic and follow-up scenarios for PC. The risk of severe morbidity as a result of SARS-CoV-2 infection may outweigh the risk of PC morbidity/mortal-ity in many men; therefore, in the short term it is unlikely that delays in diagnosis or treatment can led to worse cancer outcomes.CONCLUSIONS: The COVID-19 pandemic has result-ed in a challenge for our health system, which raises several considerations in the treatment of patients with PC. The redistribution of surgical procedures according to the degrees of priority is essential during the period of the pandemic and the transition to the new normality. The change of the out-clinics with the adequate security measures for healthcare practitioners and patients, and the development of a telemedicine program is highly recommended.
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OBJECTIVES: The guidelines and rec-ommendations of good clinical practice have been disrupted by new and urgent policies, marked by the COVID-19 pandemic. Urothelial carcinoma has a signif-icant prevalence in Spain, whose population has been greatly affected by COVID-19, directly by the disease and indirectly by the confinement. The objective of this work is to offer recommendations on protocols and guidelines adjusted to different phases of the pandemic.MATERIAL AND METHODS: This document on the man-agement of bladder carcinoma is based on few evi-dence on urological oncological practice during the first months of the pandemic and on the authors’ experience in this pathology during the crisis of COVID-19. Hospi-tal experts in infectious disseases and radiology have participated to design a common strategy to reorganize the activity.RESULTS: Different proposals for treatment and follow-up of patients diagnosed with bladder cancer adjusted for oncological risk and the different phases of the pandem-ic are presented.CONCLUSIONS: The pandemic’s spread was unimag-inable just a few months ago. Health systems have been shaken by the disease in the most critical phases. It is necessary, at this time, to make an additional effort to develop tools that can facilitate the care of bladder car-cinoma and minimize the impact and risks for patients and health professionals in the future.
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INTRODUCTION: First cases of COVID-19 were reported in China on December 2019 and rapidly spread globally. The explosive increase in number of cases requiring hospitalization has led to a delay in a big number of surgical interventions, including oncologic surgeries. Collateral effects of this increase means a challenge for urologists, who have been forced to redistribute their resources. Due to its poor pronostic, patients suffering from by upper tract urinary tumours will be negatively affected by this pandemic. METHODS: A non sistematic review was performed us-ing literature published until May 23, 2020, using “Up-per tract urothelial tumours”, “COVID-19” and “nephro-ureterectomy”. as keywords. The resulting manuscript was critically revised by national authors in order to es-tablish common criteria about treatment and follow up.EVIDENCE SYNTHESIS: Four studies were identified that assessed the impact of delaying radical nephroure-trectomy as curative treatment. These studies showed that surgery delays decrease overall survival and cancer specific survival rates in high-risk groups. On the other hand, delaying radical nephrouretrectomy due to ure-teroscopy did not affect survival in cohorts of patients with predominately low-grade disease. CONCLUSIONS: A delay in curative treatment of upper tract urothelial tumours for more than three months re-sults in adverse outcomes as overal survival and cancer specific survival. Hence, it is important to prioritize the timely care of this group of patients as far as COVID-19 pandemic allows it.
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OBJECTIVES: To provide a priority algo-rithm for determinate diagnostic, therapeutic and fol-low-up procedures regarding at testicular cancer, adjust-ed by institutional requirements. Testicular cancer patient assessment during COVID-19 Pandemia. MATERIAL AND METHODS: Review of relevant man-uscript published up to date, draft creation corrected though modified nominal group until final corrected man-uscript.RESULTS: A lack of scientific evidence exists through a large amount of manuscripts. The authors support pri-oritizing diagnostic and therapeutic procedures. Once priorities have been established, that will facilitate pro-viding each patients the limited resources. Initial diag-nostic procedures for testicular cancer such as scrotal US, orchiectomy, staging CT and adjuvant treatment (if required) are priority. Reducing the usage of chemother-apy with respiratory toxicity and increasing the usage of growth factors during chemotherapy treatment are the main stakeholders of treatment. Besides, providing ac-tive surveillance on non-risk factor clinical stage I is also a priority. In case of positive COVID-19, it is important to highlight that the vast majority of patients are tenta-tively cured.CONCLUSIONS: During de-escalation phases, patients diagnosed with testicular cancer should receive priority care during initial assessment. The follow-ups of patients with low -risk and without recurrence for a long time, might be delayed.
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PURPOSE: The COVID-19 pandemic which has affected Spain since the beginning of 2020 compels us to determine recomendations for the practice of Andrology in present times. MATERIALS AND METHODS: A web search is carried out in English and Spanish and a joint proposal is de-fined by experts in Andrology from different regions of Spain. RESULTS: Most diagnostic and therapeutic proce-dures in Andrology can be safey postponed during the COVID-19 pandemic. Online consultations and outpatient surgeries must be encouraged. Andrologic emergencies and penile cancer management should be considered high priority, and should be diagnosed and treated promptly even in the most severe phases of the pandemic.
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OBJECTIVES: The pandemic caused by the new SARS / Cov-2 Coronavirus represents an un-precedented scenario in modern medicine that affects many aspects of daily healthcare. Lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH) has a high prevalence and is related to high consump-tion of health resources. For this reason, we performed a revision of the management of LUTS and HBP during and after COVID-19 pandemic.MATERIAL AND METHODS: A group of experts in benign prostatic hyperplasia from different regions of Spain were selected to design a strategy to reorganize the management of benign prostatic hyperplasia and lower urinary tract symptoms during the pandemic. A comprehensive review of the literature was undertaken and a set of recommendations are generated.RESULTS: Recommendations for the management of LUTS-BPH during and after the SARS/CoV2 coronavirus pandemic outbreak consist of promoting telemedicine and developing joint protocols with Primary Care Atten-tion. Clear diagnostic and treatment criteria and referral criteria must be established. Referral of patients for risk complications such as kidney failure, recurrent hematuria and obstructive uropathy are a priority. Surgeries due to BPH are generally potentially delayed until phases I and II of the pandemic, in which the percentage of hospi-talized patients with COVID-19 does not exceed 25%, and it is necessary to determine COVID19 negativity. The surgical technique that associates the least compli-cations and the shortest stay should be selected.CONCLUSIONS: The diagnosis and prescription of treatment for BPH during the COVID-19 pandemic should be based on telemedicine and joint protocols for primary care attention and urology. Elective surgical treatment can be delayed until we are in phases I or II, individualizing the surgical and anaesthetic technique of choice to minimize risks.
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OBJECTIVES: Offer some recommenda-tions or guidelines during the evolution of the COVID-19 pandemic in terms of diagnosis, treatment and follow-up in the field of Reconstructive Urology.MATERIAL AND METHOD: The document is based on the evidence on SARS/Cov-2 and the authors’ expe-rience in managing COVID-19 in their institutions, in-cluding specialists from Andalusia, Madrid, Cantabria, the Valencian Community and Catalonia. A web and PubMed search was performed using “SARS-CoV-2”, “COVID-19”, “COVID-19 Urology”, “COVID19 urolo-gy complications”, “COVID-19 reconstructive surgery”. A narrative review of the literature was carried out (5/17/2020) and after the nominal group technique modified due to the extraordinary restrictions, a first draft was made to unify criteria and reach a quick consensus. Finally, a definitive version was made, agreed by all the authors (5/22/2020).RESULTS: The authors defined the following surgical pri-orities for Urological Reconstructive Surgery: Emergen-cy/Urgency (life-threatening or emergencies still in a normal situation), Elective Urgency/High priority (poten-tially dangerous pathology if postponed for more than 1 month), Elective Surgery/Intermediate priority (patholo-gy with little probability of being dangerous but it is rec-ommended not to delay more than 6 months), Delayed surgery/Low priority (non-dangerous pathology if it is postponed for more than 6 months). According to this classification, the Working Group agreed on the distri-bution of the different surgical scenarios of Reconstruc-tive Urology. In addition, consensus was reached on rec-ommendations regarding the diagnosis and follow-up of pathology in the field of Reconstructive Urology.CONCLUSIONS: Tools should be implemented to fa-cilitate the gathering of the medical visit and diagnos-tic tests. Redistribution of surgical procedures based on priority degrees is necessary during the pandemic and transition period. The use of telemedicine is essential for follow-up, by computer, telephone or videoconference.
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OBJECTIVES: Due to the COVID-19 Pandemic, all surgical activity that was not life threat-ening was cancelled , as well as most face-to-face con-sultations. Currently the beginning of the de-escalation phases that will led us to a new normal, forces us to establish some degree of priority in the interventions as well as in the medical consultations. Our objective is to establish some recommendation on Functional Urology office visits and surgical interventions that serve as a tool to facilitate decision-making.MATERIAL AND METHODS: Experts in Functional Urol-ogy from different autonomous communities of Spain were contacted to design a strategy to reorganize the activity of both, diagnosis and treatment. A modified nominal group technique has been used due to the ex-traordinary restrictions of assembly and mobility during the COVID pandemic. The first signer (EMC) made the first draft with the measures adopted and the strategy to be followed during the evolution of the COVID-19 pandemic. The proposal was sent to the rest of the au-thors, in order to unify criteria and experiences to reach a quick consensus on the relative priority of the different activities, problems and solutions. A final version was approved by all authors May 27, 2020.RESULTS: Tables of recommendation have been pre-pared for outpatient consultation, surgical and technical interventions, according to de-escalation phases pro-posed by the Spanish Associations of Surgeons.CONCLUSIONS: The change that COVID-19 Pandem-ic has involved in our clinical practice force us to seek alternative methods to treat our patients, some of which may already be established. Meanwhile, a consensus in decision making is necessary. Documents such as the current one, are intended to guide the management of patients with urological functional pathology in excep-tional situations. Logically, it should be adapted to ma-terial and human availability, and to the idiosyncrasy of each Urology service.
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OBJECTIVES: To report the recommen-dations of an expert panel to reorganize Neurourology units and to prioritize examinations and both conserva-tive and surgical treatments during the COVID-19 pan-demic.MATERIALS AND METHODS: Non-systematic review of the literature and national experts’ opinion summa-rizing the recommendations in the diagnosis, manage-ment, and follow-up of neurourological patients during the COVID-19 pandemic. A modified nominal group technique was used due to extraordinary meeting and mobility restrictions during COVID-19 pandemic. RESULTS: Neurourological patients have special physio-logical and pathological characteristics that make them more vulnerable to SARS-CoV-2 infection. For prioritiza-tion purposes, they encompass in Functional Urology patients and their management is considered non-urgent or delayable with no specific deadline of recovery from normality. However, it is important to identify individual situations jeopardising the upper urinary tract, urinary retention or predisposing to urinary infections/sepsis. A classification is provided prioritizing conservative/out-patient management and the surgical treatment of the events occurring in neurourological patients during the COVID-19 pandemic.CONCLUSIONS: In neurourological patients we can find exceptional clinical situations in which a delayed treatment could develop irreversible changes in the up-per urinary tract, advocating a more urgent treatment in specific scenarios.
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INTRODUCTION: The health crisis caused by COVID-19 pandemic has led to a restruc-turing of urological activity in order not to delay priority situations. An important part to prioritize within Urology is Urolithiasis. The objective of this article is to establish strategies and recommendations for the treatment and follow-up in COVID-19 pandemic in phases I, II and III, based on available scientific evidence and the consen-sus of a group of experts in these pathologies. MATERIAL AND METHODS: The document is based on the evidence available in the literature so far on SARS-CoV-2 and the experience of the authors in the manage-ment of COVID-19 in their institutions. A narrative review of the literature was conducted, and a modified nominal group technique was used due to the extraordinary re-strictions of assembly and mobility during the pandemic.RESULTS: Recommendations are made regarding the epidemiological evaluation of patients before surgery, the management of positive patients, the epidemiologi-cal measures for healthcare personnel, the management of renal colic, the type of anesthesia, endourological surgery, shockwave lithotripsy, hospitalization, clinical tests, out-patient service and priorities on the surgical waiting list.CONCLUSION: Treatment of Urolithiasis in COVID-19 pandemic calls for prioritization of patients, maximum ef-ficiency in treatments, adequate protection of healthcare personnel, and the implementation of telemedicine as a measure to reduce patient attendance to the hospital.
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INTRODUCTION: The COVID-19 pandemic poses significant challenges in the area of kidney donation and transplantation. The objective of this arti-cle is to establish general recommendations for surgical teams to manage the kidney transplant program during the COVID-19 era. MATERIAL AND METHODS: This document is based on the scientific evidence available on the infection caused by SARS-CoV-2 and the experience of authors during the COVID-19 pandemic. A web and Pubmed search was performed using the keywords “SARS-CoV-2”, “COVID-19”, “COVID Urology”, “COVID-19 surgery”, and “kidney transplantation.” A modified nominal group technique was used. RESULTS: When health system saturation occurs, kidney transplants should be deferred, except in patients with low transplant possibilities and an optimal kidney available, combined transplants or life-threatening situations. Screening for the SARS-CoV-2 virus should be done in all those donors and recipients with clinical symptoms consistent with COVID-19, who have visited or live in high-risk areas, or who have been in close contact with confirmed cases of COVID-19. Donation and transplantation will not proceed in confirmed cases of COVID-19. Surgeries should be based on general recommendations in the COVID-19 era and will be efficient, short, and focused on those with the shortest hospital stay. In emergencies, protective measures will be taken with personal protection equipment. Surgical staff will be only the strictly necessary, and permanence in the OR should be minimized. Transplant urology consultations will be conducted by teleconsultation when possible. CONCLUSION: The safety of potential donors and recipients must be guaranteed, adopting individual protection measures and screening for SARS-CoV-2. Kidney transplant surgery must be efficient in terms of health, human resources, and clinical benefit. All non-urgent transplant activities should be delayed until the improvement of the local condition of each center.
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Medical and surgical priorities have changed dramatically following the COVID-19 pan-demic declaration. The rapid spread of the virus and the high number of cases has saturated the health system in our country and has forced many hospitals to redistribute resources to care for infected patients. This has led to a significant reduction in surgical activity, in some cases reaching the point of delaying all elective interventions by performing only urgent interventions. The decrease in the number of infections with the progressive desat-uration of hospitals has currently allowed us to enter a new phase of “de-escalation” or transition in order to recover our surgical activity in pediatric urology, which was practically canceled. It is proposed how surgical care activities such as outpatient care should be dealt with, in addition to the different circuits that patients must maintain and, above all, their and professional safety.
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OBJECTIVE: SARS-CoV-2 pandemic has high repercussion on urologic minimally invasive surgery (MIS). Controversy about safety of MIS procedures during COVID-19 pandemic has been published. Nowadays, our priority should be create agreement in order to restart and organize MIS with safety conditions for patients and healthcare workers. METHODS: Pubmed and web search was conducted with following terms: “SARS-CoV-2”, “COVID19”, “COVID19 Urology”, COVID19 Surgery”, “COVID19 transmission”, “SARS-CoV-2 transmission”, “COVID19 and minimally invasive surgery” “SARS-CoV-2 and CO2 insuflation”. A narrative review of available literature and scientific evidence summary was done. A modify nominal group technique was used to achieve an expert consensus. First draft was circulated amongst authors. Definitive document was approved in May 26th. RESULTS: Non evidence supports higher risk of SARS-CoV-2 healthcare workers infection with MIS compared to open surgery. MIS is associated with shorter hospital stay than open surgery. Modify MIS indications to open surgery, with no scientific evidence, could spend valuable resources in detriment to COVID-19 patients. MIS indications should be prioritized attending to available resources and pandemic intensity. SARS-CoV-2 screening 72 hours prior to surgery by clinical and epidemiological questionnaire and nasopharyngeal PCR is recommended, in order to prevent nosocomial transmission, professional infections and to minimize post-operative complications. Intraoperative steps should be established to reduce professional exposure to surgical aerosols, including: surgical room reorganization, adequate personal protective equipment, surgical technique optimization and management of CO2 and surgical smoke. CONCLUSIONS: In COVID-19 pandemic de-escalation, MIS carried out with optimal safety measurements, could contribute to reduce hospital resources utilization. With current evidence, MIS should not be limited or reconverted to open surgery during COVID-19 pandemic.
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The COVID-19 pandemic has seriously disrupted the day-to-day running of hospitals, affecting the activity of all medical and surgical departments. It has also affected urology residents, depriving them of training at their usual workplaces and forcing them to support COVID units. This has implied not only the loss of daily activities, but also the uncertainty of job opportunities for the final year residents. In addition, the cancellation of numerous events such as congresses, exams, or courses has affected the annual planning of the specialty. A review of the current literature on the impact of the COVID-19 pandemic, as well as the de-escalation process, on resident training has been carried out using web search and PubMed. The situation of the residents has been analyzed, both through the information generated by recent literature and by the personal experience of the authors, from different areas: evaluation systems, educational and surgical aspects, as well as healthcare work.As a result of this review, the negative impact of the crisis on urology resident training can be observed, especially in the surgical field, but new learning opportunities or new forms of communication with the patient can also be observed. These educational and healthcare resources invite the urology resident in particular, and the medical society in general, to reinvent themselves.The aim of this article is to analyse the training of the urology resident in the de-escalation phase. Similarly, the emerging educational resources during the pandemic are synthesized, inviting the reader, and especially the urology resident, to continue their training and learning in these times of uncertainty.
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The Goddess of Health had two daugh-ters, Panacea and Higinia, the fruit of the first is diagno-sis, prognosis and treatment, and the fruit of the second is health management, prevention, and statistics. Human beings are unexpectedly subjected to:1. Happenings: they belong to the plane of the per-sonality, crisis, the Age of the virus appears that had already been announced. The ideological support is not sustained, causing a bankruptcy in the system of our life. The subject acts unconsciously, does not believe in the advent of the catastrophe, does not follow logical rules, is unable to transcend, fear-anguish appears and this requires a lot of protection. Those who remain free from personal decomposition skewer him and put a project called “person” with his sense of life, his lifestyle and life project, which is the conjunction of body and spirit, which with the agony struggles against life itself. 2. Events: they belong to the plane of nature, catastro-phes. The use of the word catastrophe is not synonymous with unavoidable natural disaster, accident, although it is used by the health authorities this can have a great impact on those affected by the virus. This word has the final nuance of Greek tragedies. False arrogance ap-pears, true madness. In the case of the Covid-19 there is something else, a dialectical position with oneself. They lived and we lived on a volcano. The example of the Apocalypse and its three plagues, epidemics and post-war neuroses, etc. The most striking neuropsychiat-ric symptomatology is the appearance of “ageusia” and “anosmia”, abruptly and totally, which disappears slow-ly, as well as sleep disturbances with ignagogic images post-traumatic stress charts appear.
