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Mishra B, Sudheer P, Rajan R, Agarwal A, Srivastava MVP, Nilima N, Vishnu VY. Bridging the gap between statistical significance and clinical relevance: A systematic review of minimum clinically important difference (MCID) thresholds of scales reported in movement disorders research. Heliyon 2024; 10:e26479. [PMID: 38439837 PMCID: PMC10909673 DOI: 10.1016/j.heliyon.2024.e26479] [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: 11/08/2023] [Revised: 01/16/2024] [Accepted: 02/14/2024] [Indexed: 03/06/2024] Open
Abstract
Background Minimum clinically important difference (MCID) is the smallest change in an outcome measure that is considered clinically meaningful. Using validated MCID thresholds for outcomes powers trials adequately to detect meaningful treatment effects, aids in their interpretation and guides development of new outcome measures. Objectives To provide a comprehensive summary of MCID thresholds of various symptom severity scales reported in movement disorder. Methods We conducted systematic review of the literature and included studies of one or more movement disorders, and reporting MCID scales. Results 2763 reports were screened. Final review included 32 studies. Risk of bias (RoB) assessment showed most studies were of good quality. Most commonly evaluated scale was Unified Parkinson's Disease Rating Scale (UPDRS) (11 out of 32). Four studies assessing MDS-UPDRS had assessed its different sub-parts, reporting a change of 2.64,3.05,3.25 and 0.9 points to detect clinically meaningful improvement and 2.45,2.51,4.63 and 0.8 points to detect clinically meaningful worsening, for the Part I, II, III and IV, respectively. For Parts II + III, I + II + III and I + II + III + IV, MCID thresholds reported for clinically meaningful improvement were 5.73, 4.9, 6.7 and 7.1 points respectively; while those for clinically meaningful worsening were 4.7, 4.2, 5.2 and 6.3 points, respectively. MCID thresholds reported for other scales included Abnormal Involuntary Movement Scale (AIMS), Toronto Western Spasmodic Torticollis Rating Scale (TWSRS), and Burke-Fahn-Marsden Dystonia Scale (BFMD). Conclusion This review summarizes all the MCID thresholds currently reported in Movement disorders research and provides a comprehensive resource for future trials, highlighting the need for standardized and validated MCID scales in movement disorder research.
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Affiliation(s)
- Biswamohan Mishra
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Pachipala Sudheer
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Roopa Rajan
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ayush Agarwal
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - M V Padma Srivastava
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Nilima Nilima
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Venugopalan Y Vishnu
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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Gozes I, Shapira G, Lobyntseva A, Shomron N. Unexpected gender differences in progressive supranuclear palsy reveal efficacy for davunetide in women. Transl Psychiatry 2023; 13:319. [PMID: 37845254 PMCID: PMC10579238 DOI: 10.1038/s41398-023-02618-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 09/28/2023] [Accepted: 10/03/2023] [Indexed: 10/18/2023] Open
Abstract
Progressive supranuclear palsy (PSP) is a pure tauopathy, implicating davunetide, enhancing Tau-microtubule interaction, as an ideal drug candidate. However, pooling patient data irrespective of sex concluded no efficacy. Here, analyzing sex-dependency in a 52 week-long- PSP clinical trial (involving over 200 patients) demonstrated clear baseline differences in brain ventricular volumes, a secondary endpoint. Dramatic baseline ventricular volume-dependent/volume increase correlations were observed in 52-week-placebo-treated females (r = 0.74, P = 2.36-9), whereas davunetide-treated females (like males) revealed no such effects. Assessment of primary endpoints, by the PSP Rating Scale (PSPRS) and markedly more so by the Schwab and England Activities of Daily Living (SEADL) scale, showed significantly faster deterioration in females, starting at trial week 13 (P = 0.01, and correlating with most other endpoints by week 52). Twice daily davunetide treatments slowed female disease progression and revealed significant protection according to the SEADL scale as early as at 39 weeks (P = 0.008), as well as protection of the bulbar and limb motor domains considered by the PSPRS, including speaking and swallowing difficulties caused by brain damage, and deterioration of fine motor skills, respectably (P = 0.01), at 52 weeks. Furthermore, at 52 weeks of trial, the exploratory Geriatric Depression Scale (GDS) significantly correlated with the SEADL scale deterioration in the female placebo group and demonstrated davunetide-mediated protection of females. Female-specific davunetide-mediated protection of ventricular volume corresponded to clinical efficacy. Together with the significantly slower disease progression seen in men, the results reveal sex-based drug efficacy differences, demonstrating the neuroprotective and disease-modifying impact of davunetide treatment for female PSP patients.
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Affiliation(s)
- Illana Gozes
- Elton Laboratory for Molecular Neuroendocrinology, Department of Human Molecular Genetics and Biochemistry, Faculty of Medicine, Adams Super Center for Brain Studies and Sagol School of Neuroscience, Tel Aviv University, 69978, Tel Aviv, Israel.
| | - Guy Shapira
- Department of Cell and Developmental Biology, Faculty of Medicine, Sagol School of Neuroscience, Edmond J Safra Center for Bioinformatics, Tel Aviv University, 69978, Tel Aviv, Israel
| | - Alexandra Lobyntseva
- Elton Laboratory for Molecular Neuroendocrinology, Department of Human Molecular Genetics and Biochemistry, Faculty of Medicine, Adams Super Center for Brain Studies and Sagol School of Neuroscience, Tel Aviv University, 69978, Tel Aviv, Israel
| | - Noam Shomron
- Department of Cell and Developmental Biology, Faculty of Medicine, Sagol School of Neuroscience, Edmond J Safra Center for Bioinformatics, Tel Aviv University, 69978, Tel Aviv, Israel
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Abate F, Russo M, Ricciardi C, Tepedino MF, Romano M, Erro R, Pellecchia MT, Amboni M, Barone P, Picillo M. Wearable sensors for assessing disease severity and progression in Progressive Supranuclear Palsy. Parkinsonism Relat Disord 2023; 109:105345. [PMID: 36868037 DOI: 10.1016/j.parkreldis.2023.105345] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 02/20/2023] [Accepted: 02/23/2023] [Indexed: 02/26/2023]
Abstract
INTRODUCTION Progressive supranuclear palsy (PSP) is an atypical parkinsonism characterized by prominent gait and postural impairment. The PSP rating scale (PSPrs) is a clinician-administered tool to evaluate disease severity and progression. More recently, digital technologies have been used to investigate gait parameters. Therefore, object of this study was to implement a protocol using wearable sensors evaluating disease severity and progression in PSP. METHODS Patients were evaluated with the PSPrs as well as with three wearable sensors located on the feet and lumbar area. Spearman coefficient was used to assess the relationship between PSPrs and quantitative measurements. Furthermore, sensor parameters were included in a multiple linear regression model to assess their ability in predicting the PSPrs total score and sub-scores. Finally, differences between baseline and three-month follow-up were calculated for PSPrs and each quantitative variable. The significance level in all analyses was set at ≤ 0.05. RESULTS Fifty-eight evaluations from thirty-five patients were analyzed. Quantitative measurements showed multiple significant correlations with the PSPrs scores (r between 0.3 and 0.7; p < 0.05). Linear regression models confirmed the relationships. After three months visit, significant worsening from baseline was observed for cadence, cycle duration and PSPrs item 25, while PSPrs item 10 showed a significant improvement. CONCLUSION We propose wearable sensors can provide an objective, sensitive quantitative evaluation and immediate notification of gait changes in PSP. Our protocol can be easily introduced in outpatient and research settings as a complementary tool to clinical measures as well as an informative tool on disease severity and progression in PSP.
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Affiliation(s)
- Filomena Abate
- Center for Neurodegenerative Diseases (CEMAND), Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", University of Salerno, 84131, Salerno, Italy
| | - Michela Russo
- University of Naples Federico II, Department of Electrical Engineering and Information Technology, 80125, Naples, Italy
| | - Carlo Ricciardi
- University of Naples Federico II, Department of Electrical Engineering and Information Technology, 80125, Naples, Italy; Istituti Clinici Scientifici Maugeri IRCCS, 27100, Pavia, Italy
| | - Maria Francesca Tepedino
- Center for Neurodegenerative Diseases (CEMAND), Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", University of Salerno, 84131, Salerno, Italy
| | - Maria Romano
- University of Naples Federico II, Department of Electrical Engineering and Information Technology, 80125, Naples, Italy
| | - Roberto Erro
- Center for Neurodegenerative Diseases (CEMAND), Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", University of Salerno, 84131, Salerno, Italy
| | - Maria Teresa Pellecchia
- Center for Neurodegenerative Diseases (CEMAND), Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", University of Salerno, 84131, Salerno, Italy
| | - Marianna Amboni
- Center for Neurodegenerative Diseases (CEMAND), Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", University of Salerno, 84131, Salerno, Italy; IDC Hermitage-Capodimonte, 80131, Naples, Italy
| | - Paolo Barone
- Center for Neurodegenerative Diseases (CEMAND), Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", University of Salerno, 84131, Salerno, Italy
| | - Marina Picillo
- Center for Neurodegenerative Diseases (CEMAND), Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", University of Salerno, 84131, Salerno, Italy.
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Kidwell KM, Roychoudhury S, Wendelberger B, Scott J, Moroz T, Yin S, Majumder M, Zhong J, Huml RA, Miller V. Application of Bayesian methods to accelerate rare disease drug development: scopes and hurdles. Orphanet J Rare Dis 2022; 17:186. [PMID: 35526036 PMCID: PMC9077995 DOI: 10.1186/s13023-022-02342-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 04/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background Design and analysis of clinical trials for rare and ultra-rare disease pose unique challenges to the practitioners. Meeting conventional power requirements is infeasible for diseases where sample sizes are inherently very small. Moreover, rare disease populations are generally heterogeneous and widely dispersed, which complicates study enrollment and design. Leveraging all available information in rare and ultra-rare disease trials can improve both drug development and informed decision-making processes. Main text Bayesian statistics provides a formal framework for combining all relevant information at all stages of the clinical trial, including trial design, execution, and analysis. This manuscript provides an overview of different Bayesian methods applicable to clinical trials in rare disease. We present real or hypothetical case studies that address the key needs of rare disease drug development highlighting several specific Bayesian examples of clinical trials. Advantages and hurdles of these approaches are discussed in detail. In addition, we emphasize the practical and regulatory aspects in the context of real-life applications.
Conclusion The use of innovative trial designs such as master protocols and complex adaptive designs in conjunction with a Bayesian approach may help to reduce sample size, select the correct treatment and population, and accurately and reliably assess the treatment effect in the rare disease setting. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02342-5.
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Affiliation(s)
- Kelley M Kidwell
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA.
| | | | | | - John Scott
- Food and Drug Administration, Washington, DC, USA
| | | | - Shaoming Yin
- Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
| | | | | | | | - Veronica Miller
- Forum for Collaborative Research, University of California School of Public Health, Berkeley, CA, USA
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Pereira MF, Buchanan T, Höglinger GU, Bogdanovic M, Tofaris G, Prangnell S, Sarangmat N, FitzGerald JJ, Antoniades CA. Longitudinal changes of early motor and cognitive symptoms in progressive supranuclear palsy: the OxQUIP study. BMJ Neurol Open 2022; 4:e000214. [PMID: 35128403 PMCID: PMC8785161 DOI: 10.1136/bmjno-2021-000214] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 12/19/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Progressive supranuclear palsy (PSP) is a rare neurodegenerative condition characterised by a range of motor and cognitive symptoms. Very little is known about the longitudinal change in these symptoms over time. Moreover, the effectiveness of clinical scales to detect early changes in PSP is still a matter of debate. OBJECTIVE We aimed to determine longitudinal changes in PSP features using multiple closely spaced follow-up time points over a period of 2 years. Methods 28 healthy control and 28 PSP participants, with average time since onset of symptoms of 1.9 years, were prospectively studied every 3 months for up to 24 months. Changes from baseline scores were calculated at each follow-up time point using multiple clinical scales to identify longitudinal progression of motor and cognitive symptoms. RESULTS The Montreal Cognitive Assessment, but not the Mini-Mental State Examination, detected cognitive decline at baseline. Both scales revealed poor longitudinal sensitivity to clinical change in global cognitive symptoms. Conversely, the Movement Disorders Society Unified Parkinson's disease Rating Scale - part III and the PSP Rating Scale (PSPRS) reliably detected motor decline less than 2 years after disease onset. The 'Gait/Midline' PSPRS subscore consistently declined over time, with the earliest change being observed 6 months after baseline assessment. CONCLUSION While better cognitive screening tools are still needed to monitor cognitive decline in PSP, motor decline is consistently captured by clinical rating scales. These results support the inclusion of multiple follow-up time points in longitudinal studies in the early stages of PSP.
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Affiliation(s)
- Marta F Pereira
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | | | - Günter U Höglinger
- Department of Neurology, Technische Universität München & Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), Munich, Germany
| | - Marko Bogdanovic
- Department of Neurology, Oxford University Hospitals, Oxford, UK
| | - George Tofaris
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Simon Prangnell
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | | | - James J FitzGerald
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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Affiliation(s)
- Nikolaos Giagkou
- Parkinson’s disease and Movement Disorders Department, Hygeia Hospital, Athens, Greece
| | - Maria Stamelou
- Parkinson’s disease and Movement Disorders Department, Hygeia Hospital, Athens, Greece
- Neurology Clinic, Philipps-University, Marburg, Germany
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Rodríguez-Blázquez C, Forjaz MJ, Kurtis MM, Balestrino R, Martinez-Martin P. Rating Scales for Movement Disorders With Sleep Disturbances: A Narrative Review. Front Neurol 2018; 9:435. [PMID: 29951032 PMCID: PMC6008651 DOI: 10.3389/fneur.2018.00435] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 05/23/2018] [Indexed: 12/11/2022] Open
Abstract
Introduction: In recent years, a wide variety of rating scales and questionnaires for movement disorders have been developed and published, making reviews on their contents, and attributes convenient for the potential users. Sleep disorders are frequently present in movement disorders, and some movement disorders are accompanied by specific sleep difficulties. Aim: The aim of this study is to perform a narrative review of the most frequently used rating scales for movement disorders with sleep problems, with special attention to those recommended by the International Parkinson and Movement Disorders Society. Methods: Online databases (PubMed, SCOPUS, Web of Science, Google Scholar), related references from papers and websites and personal files were searched for information on comprehensive or global rating scales which assessed sleep disturbances in the following movement disorders: akathisia, chorea, dystonia, essential tremor, myoclonus, multiple system atrophy, Parkinson's disease, progressive supranuclear palsy, and tics and Tourette syndrome. For each rating scale, its objective and characteristics, as well as a summary of its psychometric properties and recommendations of use are described. Results: From 22 rating scales identified for the selected movement disorders, only 5 included specific questions on sleep problems. Movement Disorders Society-Unified Parkinson's Disease Rating scale (MDS-UPDRS), Non-Motor Symptoms Scale and Questionnaire (NMSS and NMSQuest), Scales for Outcomes in Parkinson's Disease (SCOPA)-Autonomic and Progressive Supranuclear Palsy Rating Scale (PSPRS) were the only rating scales that included items for assessing sleep disturbances. Conclusions: Despite sleep problems are frequent in movement disorders, very few of the rating scales addresses these specific symptoms. This may contribute to an infra diagnosis and mistreatment of the sleep problems in patients with movement disorders.
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Affiliation(s)
| | - Maria João Forjaz
- National School of Public Health and REDISSEC, Institute of Health Carlos III, Madrid, Spain
| | - Monica M. Kurtis
- Movement Disorders Unit, Neurology Department, Hospital Ruber International, Madrid, Spain
| | - Roberta Balestrino
- Department of Neuroscience “Rita Levi Montalcini, ” University of Turin, Turin, Italy
| | - Pablo Martinez-Martin
- National Center of Epidemiology and CIBERNED, Institute of Health Carlos III, Madrid, Spain
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Rojas JC, Bang J, Lobach IV, Tsai RM, Rabinovici GD, Miller BL, Boxer AL. CSF neurofilament light chain and phosphorylated tau 181 predict disease progression in PSP. Neurology 2017; 90:e273-e281. [PMID: 29282336 DOI: 10.1212/wnl.0000000000004859] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 10/16/2017] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To determine the ability of CSF biomarkers to predict disease progression in progressive supranuclear palsy (PSP). METHODS We compared the ability of baseline CSF β-amyloid1-42, tau, phosphorylated tau 181 (p-tau), and neurofilament light chain (NfL) concentrations, measured by INNO-BIA AlzBio3 or ELISA, to predict 52-week changes in clinical (PSP Rating Scale [PSPRS] and Schwab and England Activities of Daily Living [SEADL]), neuropsychological, and regional brain volumes on MRI using linear mixed effects models controlled for age, sex, and baseline disease severity, and Fisher F density curves to compare effect sizes in 50 patients with PSP. Similar analyses were done using plasma NfL measured by single molecule arrays in 141 patients. RESULTS Higher CSF NfL concentration predicted more rapid decline (biomarker × time interaction) over 52 weeks in PSPRS (p = 0.004, false discovery rate-corrected) and SEADL (p = 0.008), whereas lower baseline CSF p-tau predicted faster decline on PSPRS (p = 0.004). Higher CSF tau concentrations predicted faster decline by SEADL (p = 0.004). The CSF NfL/p-tau ratio was superior for predicting change in PSPRS, compared to p-tau (p = 0.003) or NfL (p = 0.001) alone. Higher NfL concentrations in CSF or blood were associated with greater superior cerebellar peduncle atrophy (fixed effect, p ≤ 0.029 and 0.008, respectively). CONCLUSIONS Both CSF p-tau and NfL correlate with disease severity and rate of disease progression in PSP. The inverse correlation of p-tau with disease severity suggests a potentially different mechanism of tau pathology in PSP as compared to Alzheimer disease.
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Affiliation(s)
- Julio C Rojas
- From the Memory and Aging Center, Department of Neurology (J.C.R., R.M.T., G.D.R., B.L.M., A.L.B.), and Department of Epidemiology and Biostatistics, Division of Biostatistics (I.V.L.), University of California, San Francisco; and Department of Neurology (J.B.), Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Jee Bang
- From the Memory and Aging Center, Department of Neurology (J.C.R., R.M.T., G.D.R., B.L.M., A.L.B.), and Department of Epidemiology and Biostatistics, Division of Biostatistics (I.V.L.), University of California, San Francisco; and Department of Neurology (J.B.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Iryna V Lobach
- From the Memory and Aging Center, Department of Neurology (J.C.R., R.M.T., G.D.R., B.L.M., A.L.B.), and Department of Epidemiology and Biostatistics, Division of Biostatistics (I.V.L.), University of California, San Francisco; and Department of Neurology (J.B.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Richard M Tsai
- From the Memory and Aging Center, Department of Neurology (J.C.R., R.M.T., G.D.R., B.L.M., A.L.B.), and Department of Epidemiology and Biostatistics, Division of Biostatistics (I.V.L.), University of California, San Francisco; and Department of Neurology (J.B.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Gil D Rabinovici
- From the Memory and Aging Center, Department of Neurology (J.C.R., R.M.T., G.D.R., B.L.M., A.L.B.), and Department of Epidemiology and Biostatistics, Division of Biostatistics (I.V.L.), University of California, San Francisco; and Department of Neurology (J.B.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bruce L Miller
- From the Memory and Aging Center, Department of Neurology (J.C.R., R.M.T., G.D.R., B.L.M., A.L.B.), and Department of Epidemiology and Biostatistics, Division of Biostatistics (I.V.L.), University of California, San Francisco; and Department of Neurology (J.B.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Adam L Boxer
- From the Memory and Aging Center, Department of Neurology (J.C.R., R.M.T., G.D.R., B.L.M., A.L.B.), and Department of Epidemiology and Biostatistics, Division of Biostatistics (I.V.L.), University of California, San Francisco; and Department of Neurology (J.B.), Johns Hopkins University School of Medicine, Baltimore, MD
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Young VN, Jeong K, Rothenberger SD, Gillespie AI, Smith LJ, Gartner‐Schmidt JL, Rosen CA. Minimal clinically important difference of voice handicap index‐10 in vocal fold paralysis. Laryngoscope 2017; 128:1419-1424. [DOI: 10.1002/lary.27001] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 09/13/2017] [Accepted: 10/16/2017] [Indexed: 01/14/2023]
Affiliation(s)
- VyVy N. Young
- Department of Otolaryngology, University of Pittsburgh Voice CenterUniversity of Pittsburgh School of MedicinePittsburgh Pennsylvania U.S.A
| | - Kwonho Jeong
- Department of MedicineCenter for Research on Health Care Data CenterUniversity of Pittsburgh School of MedicinePittsburgh Pennsylvania U.S.A
| | - Scott D. Rothenberger
- Department of MedicineCenter for Research on Health Care Data CenterUniversity of Pittsburgh School of MedicinePittsburgh Pennsylvania U.S.A
| | - Amanda I. Gillespie
- Department of Otolaryngology, University of Pittsburgh Voice CenterUniversity of Pittsburgh School of MedicinePittsburgh Pennsylvania U.S.A
| | - Libby J. Smith
- Department of Otolaryngology, University of Pittsburgh Voice CenterUniversity of Pittsburgh School of MedicinePittsburgh Pennsylvania U.S.A
| | - Jackie L. Gartner‐Schmidt
- Department of Otolaryngology, University of Pittsburgh Voice CenterUniversity of Pittsburgh School of MedicinePittsburgh Pennsylvania U.S.A
| | - Clark A. Rosen
- Department of Otolaryngology, University of Pittsburgh Voice CenterUniversity of Pittsburgh School of MedicinePittsburgh Pennsylvania U.S.A
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