May we deliver neuro oncology in difficult times (e.g. COVID 19)
Italy has been hit hard by COVID 19, ranking #2 after the USA when it comes to patients who have been infected by this virus. Surprisingly, in our country we are also seeing an extraordinarily high mortality rate 10.6% (https /bing.com/ covid retrieved on March 28th 2020 Fig. 1 top) which has not been explained yet, and may be partially related to the high percentage of elderly people in the Italian population or to the underrepresented figure of the real COVID 19 positive, yet asymptomatic patients/carriers. Hospitals workload has become hectic. This poses a threat to the everyday work of a neuro oncology unit. The main limiting factor is represented by ICU's, which are stuck, since ~10% of the patients need intensive care at a certain point [1] As neurosurgical oncology often demands for ICU admission in the early post op, it is clear how such an epidemic can affect this neurosurgical subspecialty, on top of others. Besides, neuro oncological patients may be immunocompromised, presenting the ethical dilemma of having them at the same hospital where COVID 19 patients are. As per the epidemic spreading curves (Fig. 1 middle) it is foreseeable that other countries may experience similar emergency situations in the near future. Lombardy is the Italian region which has been most heavily affected by this epidemic. The C. Besta Neurological Institute has a long standing tradition as a national largevolume center mainly committed to neuro oncology; it does not have an A&E Dept. so far, we managed to keep it as a COVID 19 free hospital, enforcing a strict control policy for all admitted patients, relatives, and visitors. Because of these peculiar features, in an effort to preserve the availability of ICU beds for COVID 19 patients as much as possible, the C. Besta Institute has been designated as the regional centralizing neurosurgery HUB for neuro oncology [2] while all other Centers' activity has been progressively quenched, according to a Hub and Spoke organizational scheme. This operative network became effective on March 16th, allowing SPOKE neurosurgical equipes from Lombardy to come to our Institute and to operate themselves on their patients. We provide them with the entire neuro oncological infrastructure, taking care of patients before admission (pre op studies) during hospitalization (including radiation and oncological therapy inpatient assessment, when appropriate) and at discharge (either home or rehab) In the first three weeks of HUB implementation, despite the expected decrease of global activity as compared to normal times, we managed to take care of all the neuro oncology patients that were referred to our Institute and deemed urgent (not amenable to be postponed) In particular, we have seen 159 brain tumor out patients, operated on 67 patients (18 operated by SPOKE neurosurgical equipes at our Institute) and delivered in hospital chemotherapy to 27 patients. Of course, the main challenge was represented by maintaining the Hub as a COVID19 free Hospital. The algorithm that served to this purpose was based on a tight control of admissions, early recognition of any signs or symptoms of infection, and a rigid protection for any health professionals. More specifically, all patients were deeply screened with body temperature, O2 saturation, C reactive protein, transamineses levels, complete cell blood count, chest radiography, pharyngeal SARS CoV 2 swab, and a thorough interview. In case of SARS CoV 2 positivity, surgical indication was re discussed, based on some preliminary unpublished data (Fontanella et al. manuscript in preparation) suggesting a higher risk of morbidity and lethality. So far, this new paradigm has worked smoothly, implementing a new way of close interaction via weekly teleconferences (Fig. 1 bottom) Neurosurgeons and Francesco DiMeco francesco.dimeco@istituto besta.it
Journal of Neuro Oncology