LAUSR

We considered the review by Fasano and colleagues a stimulating document. The article defines a decisional algorithm on advanced therapies of Parkinson’s Diseases (PD) and addresses the clinical needs caused by the severe acute respiratory syndrome coronavirus 2 outbreak. To some extent, the article left open questions on possibly differential needs for each procedure. Our center, invested by coronavirus disease 2019 (COVID19) emergency, organized different modalities of health care and adjusted medical activity for patients with PD. To overcome the inability to perform scheduled visits (March 8 to June 3), we administered a specific survey to identify critical issues in patients with PD in device-related therapy (DrT). Of the 54 patients with PD in DrT interviewed, 21 were treated with deep brain stimulation (DBS) onto the subthalamic nucleus (1–5 years previously), 32 were on levodopa–carbidopa intestinal gel therapy and (for at least 18 months), and 2 were in continuous subcutaneous apomorphine infusion. The interview was structured in 1 parts: the first investigated symptoms and any COVID-19-related diagnostic processes, the presence of epidemic-related concerns, and precautionary measures taken by patients; the second part evaluated the presence of motor/nonmotor worsening and the impact of the severe acute respiratory syndrome coronavirus 2 outbreak on DrT. We studied the possible clinical deterioration requiring a device adjustment, the possibility of remote intervention, and finally, if the COVID-19 emergency changed the patients’ relationships with the device. Our survey suggests that there are substantial differences between different DrT. Among the 32 patients on levodopa– carbidopa intestinal gel, only 4 required an active intervention on the pump consisting of a dosage modulation, successfully performed using a smartphone video call with the help of a caregiver (Video S1). No urgency was found in 2 patients on apomorphine (such a small number does not allow any inference). Conversely, DBS patients presented greater difficulties (6 of 21). Two required a large increase in the levodopa daily dosage (>20%) in the absence of significant worsening of motor performance as judged by smartphone video call; a similar event had never occurred during their prolonged clinical history, probably implying a sort of “nocebo effect” related to the lack of empathic interaction with clinicians and to the reduced possibility of intervention on the device. Two patients developed an anxiety disorder with a false belief of low battery that could not be resolved by remote intervention and that required dedicated access to our clinic in a clean dedicated path. Finally, 2 patients dissatisfied with their motor condition independently increased the levodopa intake with the unmasking of dyskinesias otherwise controlled until then. Preliminary survey analysis shows that patients on levodopa– carbidopa intestinal gel maintained good confidence in DrT; nevertheless, patients with DBS, while acknowledging that without DBS they would be worsened, accrued a greater mistrust toward their therapy. DBS therapy requires special attention during a crisis when routine personnel dedicated to psychological interventions or rehabilitation practices are not available. Developing dedicated clinical pathways for patients with DBS is extremely important, considering the possible psychopathological vulnerability and the relevance of the placebo/nocebo-effect. To this aim, it is necessary to implement telemedicine tools that allow large-scale remote intervention with patients with DBS, knowingly taking into account that patients with PD in DrT are not a homogeneous cohort.■