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Staying Active With Arthritis: RCT of Physical Activity for Older Adults With Osteoarthritis and Hypertension (STAR)

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details.
 
ClinicalTrials.gov Identifier: NCT01280903
Recruitment Status : Completed
First Posted : January 21, 2011
Results First Posted : January 31, 2018
Last Update Posted : January 31, 2018
Sponsor:
Collaborator:
National Institute of Nursing Research (NINR)
Information provided by (Responsible Party):
Elizabeth Schlenk, University of Pittsburgh

Tracking Information
First Submitted Date  ICMJE December 17, 2010
First Posted Date  ICMJE January 21, 2011
Results First Submitted Date  ICMJE December 13, 2016
Results First Posted Date  ICMJE January 31, 2018
Last Update Posted Date January 31, 2018
Study Start Date  ICMJE January 2012
Actual Primary Completion Date April 2015   (Final data collection date for primary outcome measure)
Current Primary Outcome Measures  ICMJE
 (submitted: January 2, 2018)
  • Performance of Lower Extremity Exercise at 25 Weeks [ Time Frame: At the end of the 6-month intervention period (week 25) ]
    Measured by the electronic-diary in terms of the total volume of lower extremity exercise (i.e., the number of days the participant reports completing a lower extremity exercise session and the total number of lower extremity exercises per day performed [repetitions x sets] over a 7-day period).
  • Participation in Fitness Walking at 25 Weeks [ Time Frame: At the end of the 6-month intervention period (week 25) ]
    Measured by the ActiGraph accelerometer in terms of mean daily activity minutes of none to very low, light, and moderate-to-vigorous activity counts summarized over a 7-day period.
  • Objective Functional Status by the 6-minute Walk at 25 Weeks [ Time Frame: At the end of the 6-month intervention period (week 25) ]
    Measured by the 6-minute walk (yards) as part of the performance-based functional status assessment.
  • Objective Functional Status by the Short Physical Performance Battery at 25 Weeks [ Time Frame: At the end of the 6-month intervention period (week 25) ]
    Measured by the Short Physical Performance Battery (total scale score) as part of the performance-based functional status assessment; subscale scores are summed for a total scale score; the scale score range is 0-13; higher scores are better.
  • Systolic Blood Pressure at 25 Weeks [ Time Frame: At the end of the 6-month intervention period (week 25) ]
    Measured by the OMRON HEM-907XL automatic professional digital blood pressure monitor in mm Hg.
  • Diastolic Blood Pressure at 25 Weeks [ Time Frame: At the end of the 6-month intervention period (week 25) ]
    Measured by the OMRON HEM-907XL automatic professional digital blood pressure monitor in mm Hg.
  • Performance of Lower Extremity Exercise at 52 Weeks [ Time Frame: 6 months after the intervention period ends (week 52) ]
    Measured by the electronic-diary in terms of the total volume of lower extremity exercise (i.e., the number of days the subject reports completing a lower extremity exercise session and the total number of lower extremity exercises per day performed [repetitions x sets] over a 7-day period).
  • Participation in Fitness Walking at 52 Weeks [ Time Frame: 6 months after the intervention period ends (week 52) ]
    Measured by the ActiGraph accelerometer in terms of mean daily activity minutes of none to very low, light, and moderate-to-vigorous activity counts summarized over a 7-day period.
  • Objective Functional Status by the 6-minute Walk at 52 Weeks [ Time Frame: 6 months after the intervention period ends (week 52) ]
    Measured by the 6-minute walk (yards) as part of the performance-based functional status assessment.
  • Objective Functional Status by the Short Physical Performance Battery at 52 Weeks [ Time Frame: 6 months after the intervention period ends (week 52) ]
    Measured by the Short Physical Performance Battery (total scale score) as part of the performance-based functional status assessment; subscale scores are summed for a total scale score; the scale score range is 0-13; higher scores are better.
  • Systolic Blood Pressure at 52 Weeks [ Time Frame: 6 months after the intervention period ends (week 52) ]
    Measured by the OMRON HEM-907XL automatic professional digital blood pressure monitor in mm Hg.
  • Diastolic Blood Pressure at 52 Weeks [ Time Frame: 6 months after the intervention period ends (week 52) ]
    Measured by the OMRON HEM-907XL automatic professional digital blood pressure monitor in mm Hg.
Original Primary Outcome Measures  ICMJE
 (submitted: January 19, 2011)
  • Change from Baseline in Performance of Lower Extremity Exercise at 25 weeks [ Time Frame: Baseline and at the end of the 6-month intervention period (week 25) ]
    Measured by the electronic-diary in terms of the total volume of lower extremity exercise (i.e., the number of days the participant reports completing a lower extremity exercise session and the total number of lower extremity exercises per day performed [sets x repetitions] over a 7-day period).
  • Change from Baseline in Participation in Fitness Walking at 25 weeks [ Time Frame: Baseline and at the end of the 6-month intervention period (week 25) ]
    Measured by the ActiGraph accelerometer in terms of total activity counts per minute and minutes per day of light, moderate, and vigorous physical activity summarized over a 7-day period.
  • Change from Baseline in Objective Functional Status at 25 weeks [ Time Frame: Baseline and at the end of the 6-month intervention period (week 25) ]
    Measured by the 6-minute walk and Short Physical Performance Battery as part of the performance-based functional status assessment.
  • Change from Baseline in Systolic Blood Pressure at 25 weeks [ Time Frame: Baseline and at the end of the 6-month intervention period (week 25) ]
    Measured by the sphygmomanometer in mm Hg.
  • Change from Baseline in Diastolic Blood Pressure at 25 weeks [ Time Frame: Baseline and at the end of the 6-month intervention period (week 25) ]
    Measured by the sphygmomanometer in mm Hg.
  • Change from Baseline in Performance of Lower Extremity Exercise at 52 weeks [ Time Frame: Baseline and 6 months after the intervention period ends (week 52) ]
    Measured by the electronic-diary in terms of the total volume of lower extremity exercise (i.e., the number of days the subject reports completing a lower extremity exercise session and the total number of lower extremity exercises per day performed [sets x repetitions] over a 7-day period).
  • Change from Baseline in Participation in Fitness Walking at 52 weeks [ Time Frame: Baseline and 6 months after the intervention period ends (week 52) ]
    Measured by the ActiGraph accelerometer in terms of total activity counts per minute and minutes per day of light, moderate, and vigorous physical activity summarized over a 7-day period.
  • Change from Baseline in Objective Functional Status at 52 weeks [ Time Frame: Baseline and 6 months after the intervention period ends (week 52) ]
    Measured by the 6-minute walk and Short Physical Performance Battery as part of the performance-based functional status assessment.
  • Change from Baseline in Systolic Blood Pressure at 52 weeks [ Time Frame: Baseline and 6 months after the intervention period ends (week 52) ]
    Measured by the sphygmomanometer in mm Hg.
  • Change from Baseline in Diastolic Blood Pressure at 52 weeks [ Time Frame: Baseline and 6 months after the intervention period ends (week 52) ]
    Measured by the sphygmomanometer in mm Hg.
Change History
Current Secondary Outcome Measures  ICMJE
 (submitted: January 2, 2018)
  • Subjective Functional Status at 25 Weeks [ Time Frame: At the end of the 6-month intervention period (week 25) ]
    Measured by the Physical Function subscale of the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index; the subscale score range is 0-68; lower scores are better.
  • Quadriceps Strength at 25 Weeks [ Time Frame: At the end of the 6-month intervention period (week 25) ]
    Measured by the MicroFET2 hand-held dynamometer in terms of mean maximum pounds over two trials.
  • Pain by the Pain Subscale of the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index at 25 Weeks [ Time Frame: At the end of the 6-month intervention period (week 25) ]
    Measured by the Pain subscale of the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index; the subscale score range is 0-20; lower scores are better.
  • Pain by the Bodily Pain Subscale of the Short Form-36v2 at 25 Weeks [ Time Frame: At the end of the 6-month intervention period (week 25) ]
    Measured by the Bodily Pain subscale of the Short Form-36v2; the subscale score range is 0-100; higher scores are better.
  • Fatigue at 25 Weeks [ Time Frame: At the end of the 6-month intervention period (week 25) ]
    Measured by the Brief Fatigue Inventory, which assesses fatigue severity; the scale score range is 0-10; lower scores are better.
  • Health-Related Quality of Life at 25 Weeks [ Time Frame: At the end of the 6-month intervention period (week 25) ]
    Measured by the Short Form-36v2 in terms of the following: Mental Component: this summary scale is composed of eight subscale scores primarily derived from the mental health, role functioning-emotional, and social functioning scores; the scale score range is 0-100; higher scores are better Physical Component: this summary scale is composed of eight subscale scores primarily derived from the physical functioning, role functioning-physical, and bodily pain scores; the scale score range is 0-100; higher scores are better
  • Self-Efficacy at 25 Weeks [ Time Frame: At the end of the 6-month intervention period (week 25) ]
    Measured by the Self-Efficacy Scale in terms of the following: Exercise Barriers Self-Efficacy subscale: the subscale score range is 0-100; higher scores are better Exercise Self-Efficacy subscale: the subscale score range is 0-100; higher scores are better
  • Arthritis Self-Efficacy at 25 Weeks [ Time Frame: At the end of the 6-month intervention period (week 25) ]
    Measured by the Arthritis Self-Efficacy Scale in terms of the following: Pain subscale: the subscale score range is 10-100; higher scores are better Function subscale: the subscale score range is 10-100; higher scores are better Other Symptoms subscale: the subscale score range is 10-100; higher scores are better
  • Outcome Expectancy at 25 Weeks [ Time Frame: At the end of the 6-month intervention period (week 25) ]
    Measured by the Perceived Therapeutic Efficacy Scale in terms of the following: Exercise and Arthritis: the scale score range is 0-100; higher scores are better Exercise and Hypertension: the scale score range is 0-100; higher scores are better
  • Subjective Functional Status at 52 Weeks [ Time Frame: 6 months after the intervention period ends (week 52) ]
    Measured by the Physical Function subscale of the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index; the subscale score range is 0-68; lower scores are better.
  • Quadriceps Strength at 52 Weeks [ Time Frame: 6 months after the intervention period ends (week 52) ]
    Measured by the MicroFET2 hand-held dynamometer in terms of mean maximum pounds over two trials.
  • Pain by the Pain Subscale of the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index at 52 Weeks [ Time Frame: 6 months after the intervention period ends (week 52) ]
    Measured by the Pain subscale of the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index; the subscale score range is 0-20; lower scores are better.
  • Pain by the Bodily Pain Subscale of the Short Form-36v2 at 52 Weeks [ Time Frame: 6 months after the intervention period ends (week 52) ]
    Measured by the Bodily Pain subscale of the Short Form-36v2; the subscale score range is 0-100; higher scores are better.
  • Fatigue at 52 Weeks [ Time Frame: 6 months after the intervention period ends (week 52) ]
    Measured by the Brief Fatigue Inventory, which assesses fatigue severity; the scale score range is 0-10; lower scores are better.
  • Health-Related Quality of Life at 52 Weeks [ Time Frame: 6 months after the intervention period ends (week 52) ]
    Measured by the Short Form-36v2 in terms of the following: Mental Component: this summary scale is composed of eight subscale scores primarily derived from the mental health, role functioning-emotional, and social functioning scores; the scale score range is 0-100; higher scores are better Physical Component: this summary scale is composed of eight subscale scores primarily derived from the physical functioning, role functioning-physical, and bodily pain scores; the scale score range is 0-100; higher scores are better
  • Self-Efficacy at 52 Weeks [ Time Frame: 6 months after the intervention period ends (week 52) ]
    Measured by the Self-Efficacy Scale in terms of the following: Exercise Barriers Self-Efficacy subscale: the subscale score range is 0-100; higher scores are better Exercise Self-Efficacy subscale: the subscale score range is 0-100; higher scores are better
  • Arthritis Self-Efficacy at 52 Weeks [ Time Frame: 6 months after the intervention period ends (week 52) ]
    Measured by the Arthritis Self-Efficacy Scale in terms of the following: Pain subscale: the subscale score range is 10-100; higher scores are better Function subscale: the subscale score range is 10-100; higher scores are better Other Symptoms subscale: the subscale score range is 10-100; higher scores are better
  • Outcome Expectancy at 52 Weeks [ Time Frame: 6 months after the intervention period ends (week 52) ]
    Measured by the Perceived Therapeutic Efficacy Scale in terms of the following: Exercise and Arthritis: the scale score range is 0-100; higher scores are better Exercise and Hypertension: the scale score range is 0-100; higher scores are better
Original Secondary Outcome Measures  ICMJE
 (submitted: January 19, 2011)
  • Change from Baseline in Subjective Functional Status at 25 weeks [ Time Frame: Baseline and at the end of the 6-month intervention period (week 25) ]
    Measured by the Physical Function subscale of the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index.
  • Change from Baseline in Quadriceps Strength at 25 weeks [ Time Frame: Baseline and at the end of the 6-month intervention period (week 25) ]
    Measured by the MicroFET2 hand-held dynamometer.
  • Change from Baseline in Pain at 25 weeks [ Time Frame: Baseline and at the end of the 6-month intervention period (week 25) ]
    Measured by the Bodily Pain subscale of the Short Form-36v2 and the Pain subscale of the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index.
  • Change from Baseline in Fatigue at 25 weeks [ Time Frame: Baseline and at the end of the 6-month intervention period (week 25) ]
    Measured by the Brief Fatigue Inventory.
  • Change from Baseline in Health-Related Quality of Life at 25 weeks [ Time Frame: Baseline and at the end of the 6-month intervention period (week 25) ]
    Measured by the Short Form-36v2.
  • Change from Baseline in Self-Efficacy at 25 weeks [ Time Frame: Baseline and at the end of the 6-month intervention period (week 25) ]
    Measured by the Self-Efficacy Scale (Barriers Self-Efficacy subscale and Exercise Self-Efficacy subscale) and the Arthritis Self-Efficacy Scale (Pain subscale, Function subscale, and Other Symptoms subscale).
  • Change from Baseline in Outcome Expectancy at 25 weeks [ Time Frame: Baseline and at the end of the 6-month intervention period (week 25) ]
    Measured by the Perceived Therapeutic Efficacy Scale (Exercise and Arthritis version and Exercise and High Blood Pressure version).
  • Change from Baseline in Subjective Functional Status at 52 weeks [ Time Frame: Baseline and 6 months after the intervention period ends (week 52) ]
    Measured by the Physical Function subscale of the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index.
  • Change from Baseline in Quadriceps Strength at 52 weeks [ Time Frame: Baseline and 6 months after the intervention period ends (week 52) ]
    Measured by the MicroFET2 hand-held dynamometer.
  • Change from Baseline in Pain at 52 weeks [ Time Frame: Baseline and 6 months after the intervention period ends (week 52) ]
    Measured by the Bodily Pain subscale of the Short Form-36v2 and the Pain subscale of the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index.
  • Change from Baseline in Fatigue at 52 weeks [ Time Frame: Baseline and 6 months after the intervention period ends (week 52) ]
    Measured by the Brief Fatigue Inventory.
  • Change from Baseline in Health-Related Quality of Life at 52 weeks [ Time Frame: Baseline and 6 months after the intervention period ends (week 52) ]
    Measured by the Short Form-36v2.
  • Change from Baseline in Self-Efficacy at 52 weeks [ Time Frame: Baseline and 6 months after the intervention period ends (week 52) ]
    Measured by the Self-Efficacy Scale (Barriers Self-Efficacy subscale and Exercise Self-Efficacy subscale) and the Arthritis Self-Efficacy Scale (Pain subscale, Function subscale, and Other Symptoms subscale).
  • Change from Baseline in Outcome Expectancy at 52 weeks [ Time Frame: Baseline and 6 months after the intervention period ends (week 52) ]
    Measured by the Perceived Therapeutic Efficacy Scale (Exercise and Arthritis version and Exercise and High Blood Pressure version).
Current Other Pre-specified Outcome Measures Not Provided
Original Other Pre-specified Outcome Measures Not Provided
 
Descriptive Information
Brief Title  ICMJE Staying Active With Arthritis: RCT of Physical Activity for Older Adults With Osteoarthritis and Hypertension
Official Title  ICMJE Promoting Physical Activity in Older Adults With Comorbidity
Brief Summary The purpose of the Staying Active with Arthritis (STAR) research study is to determine if a 6-month program will improve leg exercise, fitness walking, and clinical outcomes (function, blood pressure, leg strength, pain, fatigue, and health-related quality of life) in older adults with osteoarthritis of the knee and high blood pressure.
Detailed Description Over 9 million Americans have symptomatic osteoarthritis (OA) of the knee, a chronic disease associated with frequent joint pain, functional limitations, and quadriceps weakness that intrude upon everyday life. At least half of those with OA of the knee are diagnosed with hypertension or high blood pressure (HBP), one of the most prevalent risk factors for cardiovascular disease. Many other individuals with OA of the knee unknowingly have HBP and remain untreated. Our own work and that of others suggest that persons with OA of the knee experience reductions in BP when they participate in a regular regimen of physical activity. Even small decreases in systolic and diastolic BP found with physical activity are clinically significant, e.g., a 2 mm Hg decrease reduces the risk of stroke by 14% - 17%, and the risk of coronary heart disease is reduced by 6% - 9%. Yet, only 15% of persons with OA and 47% with HBP engage in regular physical activity. The purpose of this study is to investigate how the individually delivered, home-based, 6-month modified Staying Active with Arthritis (STAR) intervention, guided by self-efficacy theory and modified to address comorbid HBP, affects lower extremity exercise (flexibility, strengthening, and balance), fitness walking, functional status, BP, quadriceps strength, pain, fatigue, and health-related quality of life (HRQoL) in a convenience sample of 224 adults age 50 years or older with OA of the knee and HBP. Using a randomized controlled, 2-group design, we (1) hypothesize that at the end of the 6-month intervention period and 6 months after the intervention period ends those who receive the modified STAR intervention will be more likely to perform lower extremity exercise, participate in fitness walking, show improvements in objective functional status, and demonstrate reductions in BP than those who receive attention-control. Secondarily, we will (2) evaluate the impact of the modified STAR intervention, compared to attention-control, on subjective functional status, quadriceps strength, pain, fatigue, and HRQoL at both time points; (3) explore the impact of the modified STAR intervention, compared to attention-control, on self-efficacy and outcome expectancy at both time points; (4) explore the relationship between self-efficacy and outcome expectancy; and (5) explore the extent to which self-efficacy and outcome expectancy mediate the relationship between the modified STAR intervention and performance of lower extremity exercise and participation in fitness walking. Data will be analyzed using repeated measures modeling.
Study Type  ICMJE Interventional
Study Phase  ICMJE Not Applicable
Study Design  ICMJE Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary Purpose: Treatment
Condition  ICMJE
  • Osteoarthritis, Knee
  • Hypertension
Intervention  ICMJE
  • Behavioral: STAR Intervention
    The 24-week modified Staying Active with Arthritis (STAR) intervention, guided by self-efficacy theory and modified to address comorbid hypertension, consists of 6 weekly individual face-to-face exercise sessions by a licensed physical therapist, 9 biweekly telephone counseling sessions by a registered nurse to continue the use of self-efficacy strategies, and lower extremity exercise and fitness walking being carried out at home between sessions. There will be no contact with participants during weeks 7, 9, 11, 13, 15, 17, 19, 21, and 23. During the 6-month follow-up period, the participants will be contacted briefly by telephone by a registered nurse at weeks 30, 36, and 48 for a general check-up.
  • Behavioral: Attention-Control
    Attention-Control is a 24-week general health education program for older adults that consists of 6 weekly telephone sessions by a registered nurse followed by 9 biweekly telephone sessions by a registered nurse. There will be no contact with participants during weeks 7, 9, 11, 13, 15, 17, 19, 21, and 23. Topics include cancer screenings; immunizations; osteoporosis; low vision; hearing loss; talking with your primary care provider; eating healthy (two parts); sleep and aging; injury prevention (two parts: balance problems and falls); oral health; foot care; and mental health (depression). During the 6-month follow-up period, the participants will be contacted briefly by telephone by a registered nurse at weeks 30, 36, and 48 for a general check-up.
Study Arms  ICMJE
  • Experimental: STAR Intervention
    Staying Active with Arthritis Intervention
    Intervention: Behavioral: STAR Intervention
  • Placebo Comparator: Attention-Control
    Senior Health Information Intervention
    Intervention: Behavioral: Attention-Control
Publications * Schlenk EA, Sereika SM, Martire LM, Shi X. Older adults' social network and support and its association with physical activity. Geriatr Nurs. 2021 Mar-Apr;42(2):517-523. doi: 10.1016/j.gerinurse.2020.09.006. Epub 2020 Oct 7.

*   Includes publications given by the data provider as well as publications identified by ClinicalTrials.gov Identifier (NCT Number) in Medline.
 
Recruitment Information
Recruitment Status  ICMJE Completed
Actual Enrollment  ICMJE
 (submitted: January 13, 2016)
182
Original Estimated Enrollment  ICMJE
 (submitted: January 19, 2011)
224
Actual Study Completion Date  ICMJE April 2015
Actual Primary Completion Date April 2015   (Final data collection date for primary outcome measure)
Eligibility Criteria  ICMJE

Inclusion Criteria:

  • Age 50 years or older.
  • Is community dwelling.
  • Has osteoarthritis of the knee.
  • Has hypertension for which monotherapy or combination pharmacological treatment is prescribed.
  • Able to complete a behavioral run-in consisting of completing questionnaires, using a 7-day electronic-diary, and wearing an ActiGraph accelerometer at the waist for 7 days.
  • Has written permission to participate from the physician.

Exclusion Criteria:

  • Reports currently doing lower extremity exercise => 2 times/week.
  • Reports currently fitness walking => 90 minutes/week.
  • Incapable of managing their own treatment regimen.
  • Does not have, or cannot use, a telephone or is unwilling to provide a telephone number.
  • Has received cortisone or Synvisc injections in the knee, angioplasty, stents, or a pacemaker in the past 6 months.
  • Reports unstable cardiovascular, pulmonary, or metabolic disease or signs and symptoms suggestive of cardiovascular, pulmonary, or metabolic disease that restrict activity.
  • Has resting systolic blood pressure => 160 mm Hg or diastolic blood pressure => 100 mm Hg.
  • Reports other conditions, such as osteoarthritis of the hip, spinal stenosis, inflammatory arthritis, foot drop, diabetes treated with insulin, or diabetic complications that may affect performance of lower extremity exercise and participation in fitness walking.
  • Reports current knee conditions, such as meniscus tears and knee ligament ruptures.
  • Reports major depression that may impact the ability to fully participate in this study.
  • Is scheduled to undergo a major surgical procedure in the next 13 months.
  • Is concurrently participating in a drug or psychoeducational trial that may confound, or be confounded by, participation in this study.
Sex/Gender  ICMJE
Sexes Eligible for Study: All
Ages  ICMJE 50 Years and older   (Adult, Older Adult)
Accepts Healthy Volunteers  ICMJE No
Contacts  ICMJE Contact information is only displayed when the study is recruiting subjects
Listed Location Countries  ICMJE United States
Removed Location Countries  
 
Administrative Information
NCT Number  ICMJE NCT01280903
Other Study ID Numbers  ICMJE 1R01NR010904-01A1( U.S. NIH Grant/Contract )
R01NR010904-01A1 ( U.S. NIH Grant/Contract )
Has Data Monitoring Committee Yes
U.S. FDA-regulated Product Not Provided
IPD Sharing Statement  ICMJE
Plan to Share IPD: No
Responsible Party Elizabeth Schlenk, University of Pittsburgh
Study Sponsor  ICMJE University of Pittsburgh
Collaborators  ICMJE National Institute of Nursing Research (NINR)
Investigators  ICMJE
Principal Investigator: Elizabeth A. Schlenk, PhD, RN University of Pittsburgh
PRS Account University of Pittsburgh
Verification Date January 2018

ICMJE     Data element required by the International Committee of Medical Journal Editors and the World Health Organization ICTRP