To the Editor: We read with great interest the Correspondence by Burke et al,1 “The Coronavirus Disease 2019 Global Pandemic: A Neurosurgical Treatment Algorithm”, which appeared online in Neurosurgery in April 2020. In this interesting work, the authors proposed a set of algorithms concerning different aspects of the management of the SARS-CoV-2 disease from the neurosurgical viewpoint (scheduling of surgical cases, scheduling of clinic cases, contingency planning for intensive care unit (ICU) utilization and research directives) with the intention to help neurosurgeons in developing local protocols to manage the sanitary crisis. SARS-CoV-2 represents the last pandemic in a long line. As a matter of fact, there are many examples of pandemics that drastically changed the course of history, such as Spanish Flu and European Plague. What distinguish SARS-CoV-2 from other pandemics is its rapid diffusion in developed countries. Treatment of infected patients is requiring resources that, although considered as “available”, are actually limited as a consequence of the temporal case concentration with the risk of not being able to guarantee the appropriate care to everyone. Lombardy region was the first to be heavily hit in Italy. Actually, hospitals are overwhelmed and health workers are overstressed. In this difficult scenario, although SARS-CoV-2 represents the major concern, the population keeps suffering also from other acute and chronic pathologies, complicating themanagement and allocation of the limited economical and sanitary resources. As a natural consequence, criteria of choice and priorities must be set by the different health systems. Answers are related to the political philosophy of different countries: an individualistic approach, where each patient a priori is always worthy of treatment, or a “society-first” policy, where sanitary, economical, and sociological aspects are weighted on the ground of the common interest. Looking at our country, the 32nd article of the Italian Constitution states that “the Republic safeguards health as a fundamental right of the individual and as a collective interest, and guarantees free medical care to the indigent”.2 The Italian Government was focused first on the protection of any single citizen at any cost. At the moment, in fact, Italy decided to allocate any possible resources to retrieve respirators, doctors, nurses, and whatever is needed to be loyal to the promise of the 32nd Article. Following such ideals, the Lombardy Government tried to slow down the diffusion of the virus (lock-down since March 8th), incremented ICU units, and reorganized hospitals, identifying COVID-19 and COVID-19-free wards, re-defining priorities, re-allocating resources based upon necessities, but always trying to take care of everyone.3,4 Looking at our daily practice, the COVID-19 outbreak forced neurosurgeons to review their priorities. While life-threatening conditions such as the great majority of traumatic and hemorrhagic events represent clear and obvious urgencies (exactly on the same level of SARS-CoV-2), the treatment priorities for elective patients created controversy. May neoplastic and noturgent vascular pathologies be considered disease that can be postponed, if they are not associated with rapid neurologic deterioration? In other words, is it actually ethical to tell a patient that a surgery for a brain tumor needs to be postponed because ICUbed and sanitary operators are totally committed and dedicated to COVID-19 management? Is it ethical to treat a COVID-19 interstitial pneumonia and postpone the treatment of a low-grade glioma, for which malignant transformation is unpredictable in terms of time? Should we operate unruptured aneurysms at this moment? How shall we consider a glioblastoma (average life expectancy after surgery and adjuvant treatment of 15-18 mo)5 in comparison to a SARS-CoV-2 patient who is reasonable to suppose that can be discharged home with an apparently untouched life expectancy after intensive care?6 May we consider the actual pandemic in the same way as an overwhelming event causing multiple injured, where resuscitation councils guidelines advise to privilege patients with greater survival chances?7,8 Lombardy Government identified 4 neurosurgical “hubs” and dedicated the other neurosurgical facilities to SARS-CoV-2 patients.9,10 Such an organization guaranteed free most effective treatments for everyone, despite COVID-19 disease (private practice was stopped). Hence, in a Country that safeguards life above all, the question of surgery on 70-yr-old patient affected by a life-threatening edematous supratentorial meningioma, has just one simple answer: yes, up to the last bed, nurse, respirator, surgeon is available. As a last food for thought, we truly feel that what deserves attention is how to dedicate resources to patients who really benefit from the investment. Hence, what COVID-19 pandemic made clear to our eyes is the need for predictors that may help in a decisional process. Machine learning on Big Data is a powerful instrument to investigate the future.11 In this view, it appears of paramount importance the creation of medical registries supported by single Nations and World Health Organization to collect factors enabling to create predictive models useful for the future. An example of the use of registries and machine learning to predict functional impairment after intracranial tumor surgery is in press.12 Along with such mathematical approaches, the other side of the moon is represented by consensus reached among experts, through elements of quick reference and discussion (Delphi studies, Consensus Conferences, and internet-based surveys). At this regard, many surveys and guidelines have been shared in the medical community since virus outbreak, with the purpose to share clinical

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回复：2019 年冠状病毒病全球大流行：一种神经外科治疗算法

致编辑：我们饶有兴趣地阅读了 Burke 等人的信函，1“2019 年全球大流行：一种神经外科治疗算法”，该信函于 2020 年 4 月在线发表于 Neurosurgery。在这项有趣的工作中，作者提出了一组从神经外科的角度（手术病例安排、临床病例安排、重症监护病房 (ICU) 使用的应急计划和研究指令）涉及 SARS-CoV-2 疾病管理的不同方面的算法，旨在帮助神经外科医生制定当地协议来管理卫生危机。SARS-CoV-2 代表了最后一次大流行。事实上，有许多大流行病彻底改变了历史进程的例子，例如西班牙流感和欧洲瘟疫。SARS-CoV-2 与其他流行病的区别在于它在发达国家的快速传播。受感染患者的治疗需要资源，尽管这些资源被视为“可用”，但由于时间上的病例集中，可能无法保证为每个人提供适当的护理，因此实际上是有限的。伦巴第大区是意大利第一个遭受重创的地区。实际上，医院不堪重负，卫生工作者压力过大。在这种困难的情况下，尽管 SARS-CoV-2 是主要问题，但人们还不断患有其他急性和慢性疾病，这使得有限的经济和卫生资源的管理和分配变得复杂。自然的结果是，不同的卫生系统必须制定选择标准和优先事项。答案与不同国家的政治哲学有关：一种个人主义的方法，其中每个患者的先验总是值得治疗，或“社会第一”的政策，其中卫生、经济和社会学方面的权重取决于共同利益。纵观我们的国家，意大利宪法第 32 条规定“共和国保障健康是个人的基本权利和集体利益，并保证为贫困者提供免费医疗服务”。2 意大利政府首先关注的是不惜任何代价保护任何一个公民。此刻，事实上，意大利决定分配任何可能的资源来取回呼吸器、医生、护士以及忠于第 32 条承诺所需的一切。遵循这样的理想，伦巴第政府试图减缓病毒的传播（自 3 月 8 日起封锁），增加 ICU 病房，并重组医院，确定 COVID-19 和无 COVID-19 病房，重新定义优先事项，重新分配资源基于必需品，但始终努力照顾每个人。3,4 从我们的日常实践来看，COVID-19 的爆发迫使神经外科医生重新审视他们的优先事项。虽然绝大多数创伤性和出血性事件等危及生命的情况都代表了明确而明显的紧迫性（与 SARS-CoV-2 完全相同），但选择性患者的治疗优先级引起了争议。如果肿瘤性和非急迫性血管病变与快速神经功能恶化无关，是否可以将其视为可以推迟的疾病？换句话说，告诉患者脑瘤手术需要推迟，因为 ICUbed 和卫生操作员完全致力于并致力于 COVID-19 管理，这实际上是否合乎道德？治疗 COVID-19 间质性肺炎并推迟治疗恶性转化在时间上无法预测的低级别胶质瘤是否合乎道德？这个时候我们应该手术未破裂的动脉瘤吗？与 SARS-CoV-2 患者相比，我们应该如何考虑胶质母细胞瘤（手术和辅助治疗后的平均预期寿命为 15-18 个月）5 6 我们是否可以将实际的流行病视为造成多人受伤的压倒性事件，复苏委员会的指南建议在哪些方面给予患者更大生存机会的特权？7,8 伦巴第政府确定了 4 个神经外科“中心”，并将其他神经外科设施专门用于 SARS-CoV-2 患者。9,10 这样的组织保证免费为患者提供最有效的治疗每个人，尽管有 COVID-19 疾病（私人诊所已停止）。因此，在一个以生命为首要保障的国家，对患有危及生命的水肿性幕上脑膜瘤的 70 岁患者进行手术的问题只有一个简单的答案：是的，直到最后一张床，护士，呼吸器，外科医生可用。作为最后的思考，我们真正感到值得关注的是如何将资源投入到真正从投资中受益的患者身上。因此，COVID-19 大流行让我们清楚地看到，需要可能有助于决策过程的预测因素。基于大数据的机器学习是研究未来的有力工具。 11 在这种观点下，建立由单一国家和世界卫生组织支持的医疗登记机构以收集能够创建对未来有用的预测模型的因素，这一点至关重要。使用注册和机器学习来预测颅内肿瘤手术后功能障碍的一个例子正在印刷中。 12 与这些数学方法一起，月亮的另一面由专家达成的共识代表，通过快速参考和讨论的元素（德尔福研究、共识会议和基于互联网的调查）。在这方面，