Эта страница была переведена автоматически, точность перевода не гарантируется. Пожалуйста, обратитесь к английской версии для исходного текста.

Exercise-facilitated Neurorehabilitation in Diabetic Neuropathy

20 сентября 2019 г. обновлено: VA Office of Research and Development

Exercise-Facilitated NeuroRehabilitation in Diabetic Neuropathy

This study will determine the type and combination of exercise needed to rehabilitate the neuro-compromised diabetic Veteran. Guided exercise protocols may prove to be practical therapeutic options for the prophylactic management of diabetic subjects with neuropathy.

Обзор исследования

Статус

Завершенный

Подробное описание

Purpose: A single-site, randomized, blinded, prospective clinical trial is proposed to determine the significance of a combined isokinetic strength and aerobic exercise training program on the rehabilitation of peripheral nerve function in Type 2 diabetic veterans and non-veterans with neuropathy. Background and Significance: Obesity is a major factor in the increasing rates of diabetes and its related complications. Diabetes affects greater than 7% of the population. Veterans are at even greater risk, with approximately 16% currently receiving treatment at Department of Veterans Affairs Medical Centers for diabetes. More than half of affected veterans experience debilitating complications of diabetes, including peripheral neuropathy (PN). Exercise training, in combination with pharmacologic intervention, is now recognized as a cornerstone of management for diabetes. Therapeutic interventions currently available for the treatment of PN in diabetic patients are limited, however, to pain management and stringent glycemic control. Exercise is reported to significantly decrease peripheral nerve microvascular complications common among chronic diabetics. Our preliminary findings demonstrate that exercise intervention improves peripheral nerve function in the diabetic veteran with PN. Intervention strategies, such as proposed in this application, offer a unique and novel therapeutic option for the rehabilitation of the neuro-compromised Type 2 diabetic veterans and non-veterans. Methods & Research Plan: One-hundred subjects will be recruited for this 24-week study. Subjects each will be randomly assigned to aerobic, isokinetic strength training, combined aerobic and strength training, or non-exercise (control) intervention groups. Isokinetic strength training (Biodex System 3), aerobic exercise training (treadmill), or the combination of strength and aerobic training will be administered 3x per week for the initial 12 weeks. Control subjects will receive 12 clinical visits over the course of the initial 12 weeks. The effects of exercise training type, compared with control subjects, on recovery of peripheral nerve function will be rigorously determined from baseline, 12- and 24-week testing using electrodiagnostic primary outcome measures, Quantitative Sensory Testing, and a battery of validated qualitative and quantitative secondary outcome measures that include an incremental symptom-limited treadmill test, peak torque, Total Neuropathy Score, visual analogue pain scale, and quality of life SF-36V Health Survey. Sustainability of effect will be determined at 24-weeks.The individual effects of exercise training type, compared with control subjects, on tissue oxygenation will be determined from baseline, 12- and 24-week testing by non-invasive quantitated infrared spectroscopy using an InSpectraTM Tissue Spectrometer. Expected Outcomes: This study will objectively and critically determine the type and combination of exercise needed to rehabilitate the neuro-compromised diabetic Veteran. Guided exercise protocols may prove to be practical therapeutic options for the prophylactic management of diabetic subjects with neuropathy.

Тип исследования

Интервенционный

Регистрация (Действительный)

45

Фаза

  • Непригодный

Контакты и местонахождение

В этом разделе приведены контактные данные лиц, проводящих исследование, и информация о том, где проводится это исследование.

Места учебы

Критерии участия

Исследователи ищут людей, которые соответствуют определенному описанию, называемому критериям приемлемости. Некоторыми примерами этих критериев являются общее состояние здоровья человека или предшествующее лечение.

Критерии приемлемости

Возраст, подходящий для обучения

От 45 лет до 80 лет (Взрослый, Пожилой взрослый)

Принимает здоровых добровольцев

Нет

Полы, имеющие право на обучение

Все

Описание

Inclusion Criteria:

  • Clinical diagnosis of type 2 diabetes mellitus
  • stable blood glucose control
  • clinical findings consistent with length-dependent sensorimotor polyneuropathy, stage N2a

Exclusion Criteria:

  • foot ulceration
  • unstable heart disease
  • co-morbid conditions limiting exercise
  • disorders of the central nervous system causing weakness or sensory loss
  • received treatment with medications known to have neuropathy as a prominent side effect including vincristine, vinblastine, cis-platin, and paclitaxel
  • medical conditions that may be associated with neuropathies such as alcoholism, liver disease, kidney disease, toxic exposure, vitamin deficiency, autoimmune disorders, cancer, or hypothyroidism

Учебный план

В этом разделе представлена ​​подробная информация о плане исследования, в том числе о том, как планируется исследование и что оно измеряет.

Как устроено исследование?

Детали дизайна

  • Основная цель: Уход
  • Распределение: Рандомизированный
  • Интервенционная модель: Факторное присвоение
  • Маскировка: Одинокий

Оружие и интервенции

Группа участников / Армия
Вмешательство/лечение
Без вмешательства: Arm 1
Sedentary Control Group
Экспериментальный: Arm 2
Aerobic Exercise Group
Structured aerobic exercise (treadmill).
Structured isokinetic strength exercise (dynameter).
Экспериментальный: Arm 3
Isokinetic Strength Exercise Group
Structured aerobic exercise (treadmill).
Structured isokinetic strength exercise (dynameter).
Экспериментальный: Arm 4
Combined Aerobic and Isokinetic Strength Exercise Group
Structured aerobic exercise (treadmill).
Structured isokinetic strength exercise (dynameter).

Что измеряет исследование?

Первичные показатели результатов

Мера результата
Мера Описание
Временное ограничение
Sural Nerve Amplitude
Временное ограничение: Baseline, 12, and 24 weeks
Maximal responses were obtained using percutaneous electrical stimuli. Sensory nerve action potentials were recorded from sural (antidromic), median (antidromic to second digit), and ulnar nerves (antidromic to fifth digit).To minimize inter-examiner variability and maximize neurophysiologic test/retest reliability, the same experienced neurologist conducted all nerve conduction studies on days separate from all other testing activities. A dedicated TECA Synergy electromyograph system was used for all nerve conduction studies. The patients dominant side was chosen. In patients with definable differences between the two sides, the side with the most prominent clinical findings was chosen. In all cases, the same limb was used for all three (baseline, 12-weeks, 24-weeks) conduction studies.
Baseline, 12, and 24 weeks
Sural Nerve Latency
Временное ограничение: Baseline, 12 wks, 24 wks
Maximal responses were obtained using percutaneous electrical stimuli. Sensory nerve action potentials were recorded from sural (antidromic), median (antidromic to second digit), and ulnar nerves (antidromic to fifth digit).To minimize inter-examiner variability and maximize neurophysiologic test/retest reliability, the same experienced neurologist conducted all nerve conduction studies on days separate from all other testing activities. A dedicated TECA Synergy electromyograph system was used for all nerve conduction studies. The patients dominant side was chosen. In patients with definable differences between the two sides, the side with the most prominent clinical findings was chosen. In all cases, the same limb was used for all three (baseline, 12-weeks, 24-weeks) conduction studies.
Baseline, 12 wks, 24 wks
Sural Nerve Conduction Velocity
Временное ограничение: Baseline, 12 wks, 24 wks
Maximal responses were obtained using percutaneous electrical stimuli. Sensory nerve action potentials were recorded from sural (antidromic), median (antidromic to second digit), and ulnar nerves (antidromic to fifth digit).To minimize inter-examiner variability and maximize neurophysiologic test/retest reliability, the same experienced neurologist conducted all nerve conduction studies on days separate from all other testing activities. A dedicated TECA Synergy electromyograph system was used for all nerve conduction studies. The patients dominant side was chosen. In patients with definable differences between the two sides, the side with the most prominent clinical findings was chosen. In all cases, the same limb was used for all three (baseline, 12-weeks, 24-weeks) conduction studies.
Baseline, 12 wks, 24 wks
Tibial Nerve Amplitude
Временное ограничение: Baseline, 12 weeks, 24 weeks
Maximal responses were obtained using percutaneous electrical stimuli. Distal motor nerve evoked compound muscle action potential (CMAP) potentials were recorded from tibial and peroneal nerves.To minimize inter-examiner variability and maximize neurophysiologic test/retest reliability, the same experienced neurologist conducted all nerve conduction studies on days separate from all other testing activities. A dedicated TECA Synergy electromyograph system was used for all nerve conduction studies. The patients dominant side was chosen. In patients with definable differences between the two sides, the side with the most prominent clinical findings was chosen. In all cases, the same limb was used for all three (baseline, 12-weeks, 24-weeks) conduction studies.
Baseline, 12 weeks, 24 weeks
Tibial Nerve Latency
Временное ограничение: Baseline, 12 weeks, 24 weeks
Maximal responses were obtained using percutaneous electrical stimuli. Distal motor nerve evoked compound muscle action potential (CMAP) potentials were recorded from tibial and peroneal nerves.To minimize inter-examiner variability and maximize neurophysiologic test/retest reliability, the same experienced neurologist conducted all nerve conduction studies on days separate from all other testing activities. A dedicated TECA Synergy electromyograph system was used for all nerve conduction studies. The patients dominant side was chosen. In patients with definable differences between the two sides, the side with the most prominent clinical findings was chosen. In all cases, the same limb was used for all three (baseline, 12-weeks, 24-weeks) conduction studies.
Baseline, 12 weeks, 24 weeks
Tibial Nerve Conduction Velocity
Временное ограничение: Baseline, 12 weeks, 24 weeks
Maximal responses were obtained using percutaneous electrical stimuli. Distal motor nerve evoked compound muscle action potential (CMAP) potentials were recorded from tibial and peroneal nerves.To minimize inter-examiner variability and maximize neurophysiologic test/retest reliability, the same experienced neurologist conducted all nerve conduction studies on days separate from all other testing activities. A dedicated TECA Synergy electromyograph system was used for all nerve conduction studies. The patients dominant side was chosen. In patients with definable differences between the two sides, the side with the most prominent clinical findings was chosen. In all cases, the same limb was used for all three (baseline, 12-weeks, 24-weeks) conduction studies.
Baseline, 12 weeks, 24 weeks
Sensory Median Nerve Amplitude
Временное ограничение: Baseline, 12, and 24 weeks
Maximal responses were obtained using percutaneous electrical stimuli. Sensory nerve action potentials were recorded from sural (antidromic), median (antidromic to second digit), and ulnar nerves (antidromic to fifth digit).To minimize inter-examiner variability and maximize neurophysiologic test/retest reliability, the same experienced neurologist conducted all nerve conduction studies on days separate from all other testing activities. A dedicated TECA Synergy electromyograph system was used for all nerve conduction studies. The patients dominant side was chosen. In patients with definable differences between the two sides, the side with the most prominent clinical findings was chosen. In all cases, the same limb was used for all three (baseline, 12-weeks, 24-weeks) conduction studies.
Baseline, 12, and 24 weeks
Sensory Median Nerve Latency
Временное ограничение: Baseline, 12wks, 24 wks
Maximal responses were obtained using percutaneous electrical stimuli. Sensory nerve action potentials were recorded from sural (antidromic), median (antidromic to second digit), and ulnar nerves (antidromic to fifth digit).To minimize inter-examiner variability and maximize neurophysiologic test/retest reliability, the same experienced neurologist conducted all nerve conduction studies on days separate from all other testing activities. A dedicated TECA Synergy electromyograph system was used for all nerve conduction studies. The patients dominant side was chosen. In patients with definable differences between the two sides, the side with the most prominent clinical findings was chosen. In all cases, the same limb was used for all three (baseline, 12-weeks, 24-weeks) conduction studies.
Baseline, 12wks, 24 wks
Sensory Median Nerve Conduction Velocity
Временное ограничение: Baseline, 12 wks, 24 wks
Maximal responses were obtained using percutaneous electrical stimuli. Sensory nerve action potentials were recorded from sural (antidromic), median (antidromic to second digit), and ulnar nerves (antidromic to fifth digit).To minimize inter-examiner variability and maximize neurophysiologic test/retest reliability, the same experienced neurologist conducted all nerve conduction studies on days separate from all other testing activities. A dedicated TECA Synergy electromyograph system was used for all nerve conduction studies. The patients dominant side was chosen. In patients with definable differences between the two sides, the side with the most prominent clinical findings was chosen. In all cases, the same limb was used for all three (baseline, 12-weeks, 24-weeks) conduction studies.
Baseline, 12 wks, 24 wks
Sensory Ulnar Nerve Amplitude
Временное ограничение: Baseline, 12 wks, 24 wks
Maximal responses were obtained using percutaneous electrical stimuli. Sensory nerve action potentials were recorded from sural (antidromic), median (antidromic to second digit), and ulnar nerves (antidromic to fifth digit).To minimize inter-examiner variability and maximize neurophysiologic test/retest reliability, the same experienced neurologist conducted all nerve conduction studies on days separate from all other testing activities. A dedicated TECA Synergy electromyograph system was used for all nerve conduction studies. The patients dominant side was chosen. In patients with definable differences between the two sides, the side with the most prominent clinical findings was chosen. In all cases, the same limb was used for all three (baseline, 12-weeks, 24-weeks) conduction studies.
Baseline, 12 wks, 24 wks
Sensory Ulnar Nerve Latency
Временное ограничение: Baseline, 12 wks, 24 wks
Maximal responses were obtained using percutaneous electrical stimuli. Sensory nerve action potentials were recorded from sural (antidromic), median (antidromic to second digit), and ulnar nerves (antidromic to fifth digit).To minimize inter-examiner variability and maximize neurophysiologic test/retest reliability, the same experienced neurologist conducted all nerve conduction studies on days separate from all other testing activities. A dedicated TECA Synergy electromyograph system was used for all nerve conduction studies. The patients dominant side was chosen. In patients with definable differences between the two sides, the side with the most prominent clinical findings was chosen. In all cases, the same limb was used for all three (baseline, 12-weeks, 24-weeks) conduction studies.
Baseline, 12 wks, 24 wks
Sensory Ulnar Nerve Conduction Velocity
Временное ограничение: Baseline, 12 wks, 24 wks
Maximal responses were obtained using percutaneous electrical stimuli. Sensory nerve action potentials were recorded from sural (antidromic), median (antidromic to second digit), and ulnar nerves (antidromic to fifth digit).To minimize inter-examiner variability and maximize neurophysiologic test/retest reliability, the same experienced neurologist conducted all nerve conduction studies on days separate from all other testing activities. A dedicated TECA Synergy electromyograph system was used for all nerve conduction studies. The patients dominant side was chosen. In patients with definable differences between the two sides, the side with the most prominent clinical findings was chosen. In all cases, the same limb was used for all three (baseline, 12-weeks, 24-weeks) conduction studies.
Baseline, 12 wks, 24 wks
Peroneal Nerve Amplitude
Временное ограничение: Baseline, 12 wks, 24 wks
Maximal responses were obtained using percutaneous electrical stimuli. Distal motor nerve evoked compound muscle action potential (CMAP) potentials were recorded from tibial and peroneal nerves.To minimize inter-examiner variability and maximize neurophysiologic test/retest reliability, the same experienced neurologist conducted all nerve conduction studies on days separate from all other testing activities. A dedicated TECA Synergy electromyograph system was used for all nerve conduction studies. The patients dominant side was chosen. In patients with definable differences between the two sides, the side with the most prominent clinical findings was chosen. In all cases, the same limb was used for all three (baseline, 12-weeks, 24-weeks) conduction studies.
Baseline, 12 wks, 24 wks
Peroneal Nerve Latency
Временное ограничение: Baseline, 12 wks, 24 wks
Maximal responses were obtained using percutaneous electrical stimuli. Distal motor nerve evoked compound muscle action potential (CMAP) potentials were recorded from tibial and peroneal nerves.To minimize inter-examiner variability and maximize neurophysiologic test/retest reliability, the same experienced neurologist conducted all nerve conduction studies on days separate from all other testing activities. A dedicated TECA Synergy electromyograph system was used for all nerve conduction studies. The patients dominant side was chosen. In patients with definable differences between the two sides, the side with the most prominent clinical findings was chosen. In all cases, the same limb was used for all three (baseline, 12-weeks, 24-weeks) conduction studies.
Baseline, 12 wks, 24 wks
Peroneal Nerve Conduction Velocity
Временное ограничение: Baseline, 12 wks, 24 wks
Maximal responses were obtained using percutaneous electrical stimuli. Distal motor nerve evoked compound muscle action potential (CMAP) potentials were recorded from tibial and peroneal nerves.To minimize inter-examiner variability and maximize neurophysiologic test/retest reliability, the same experienced neurologist conducted all nerve conduction studies on days separate from all other testing activities. A dedicated TECA Synergy electromyograph system was used for all nerve conduction studies. The patients dominant side was chosen. In patients with definable differences between the two sides, the side with the most prominent clinical findings was chosen. In all cases, the same limb was used for all three (baseline, 12-weeks, 24-weeks) conduction studies.
Baseline, 12 wks, 24 wks

Вторичные показатели результатов

Мера результата
Мера Описание
Временное ограничение
Symptom-Limited TMT Blood Glucose Response
Временное ограничение: Initial entry into study, 12 and 24 weeks
Changes in blood glucose in response to modified Bruce Protocol treadmill test (TMT)
Initial entry into study, 12 and 24 weeks
Short Form-36V: Physical Component Score
Временное ограничение: Initial entry into study, 12 and 24 weeks
The short form-36Veterans (SF-36V) health survey questionnaire was used to measure health-related quality of life. This survey is comprised of eight subscales and two overall component scores, all of which have demonstrated high levels of internal consistency and discriminate validity when administered to groups of medically stable individuals. Patient aggregate responses for the eight distinct summary subscales and two component scores were compiled as a percentage of total points possible using the RAND 36-item health survey table. Data shown are expressed as a percentage of total possible score ranging from 0%-100% with 100% considered relatively good health and 0% considered poor health. Physical Component scores reflect perceived changes in physical health relative to the previous year.
Initial entry into study, 12 and 24 weeks
Voluntary Duration of Symptom-Limited TMT
Временное ограничение: baseline, 12-wks, 24-wks
Total time subjects voluntarily exercised while undergoing a modified Bruce Protocol treadmill test (TMT)
baseline, 12-wks, 24-wks
Symptom-Limited TMT Maximum Heart Rate
Временное ограничение: baseline, 12-wks, 24-wks
Peak heart rate achieved while undergoing a modified Bruce Protocol treadmill test (TMT)
baseline, 12-wks, 24-wks
Symptom-Limited TMT Maximum Systolic Blood Pressure
Временное ограничение: Baseline, 12-wk, 24-wk
Peak systolic BP achieved while undergoing a modified Bruce Protocol treadmill test (TMT)
Baseline, 12-wk, 24-wk
Symptom-Limited TMT Maximum Minute Ventilation (VE)
Временное ограничение: Baseline, 12-wks, 24-wks
Peak volume of air exchanged per minute achieved while undergoing a modified Bruce Protocol treadmill test (TMT)
Baseline, 12-wks, 24-wks
Symptom-Limited TMT Maximum Oxygen Uptake (VO2)
Временное ограничение: Baseline, 12-wks, 24-wks
Peak Oxygen uptake achieved while undergoing a modified Bruce Protocol treadmill test (TMT)
Baseline, 12-wks, 24-wks
Maximum Respiratory Exchange Ratio (RER) During TMT
Временное ограничение: Baseline, 12-wks, 24-wks
Peak RER achieved while undergoing a modified Bruce Protocol treadmill test (TMT). This is a mathematical ratio of maximally achieved (peak) VCO2 divided by maximally achieved (peak) VO2.
Baseline, 12-wks, 24-wks
Symptom-Limited TMT Maximum Carbon Dioxide Expelled (VCO2)
Временное ограничение: Baseline, 12-wks, 24-wks
Peak Carbon Dioxide expelled achieved while undergoing a modified Bruce Protocol treadmill test (TMT)
Baseline, 12-wks, 24-wks
Symptom-Limited TMT Maximum METS Achieved (MET)
Временное ограничение: Baseline, 12-wks, 24-wks
Peak metabolic rate equivalents (METS) achieved while undergoing a modified Bruce Protocol treadmill test (TMT). One MET is defined as the metabolic rate observed at rest, quantified as resting oxygen consumption of 250 ml/min (Male) or 200 ml /min (female). A value of 5 METS would represent a metabolic rate that is 5x that at rest and is considered an indicator of how hard a given individual is exercising. Data shown are expressed as a ratio at peak of exercise of oxygen consumed relative to normalized values for men or women at rest.
Baseline, 12-wks, 24-wks
Short Form-36V: Mental Component Score
Временное ограничение: initial entry into study, and at 12-wks and 24-wks
The short form-36Veterans (SF-36V) health survey questionnaire was used to measure health-related quality of life. This survey is comprised of eight subscales and two overall component scores, all of which have demonstrated high levels of internal consistency and discriminate validity when administered to groups of medically stable individuals. Patient aggregate responses for the eight distinct summary subscales and two component scores were compiled as a percentage of total points possible using the RAND 36-item health survey table. Data shown are expressed as a percentage of total possible score ranging from 0%-100% with 100% considered relatively good health and 0% considered poor health. Mental Component scores reflect perceived changes in emotional health relative to the previous year.
initial entry into study, and at 12-wks and 24-wks

Другие показатели результатов

Мера результата
Мера Описание
Временное ограничение
Height
Временное ограничение: baseline
Height of subjects upon entry into study
baseline
Weight
Временное ограничение: Baseline, 12-wks, 24-wks
Weight of subjects at baseline, 12-weeks, and 24-weeks
Baseline, 12-wks, 24-wks
Body Mass Index (BMI)
Временное ограничение: Baseline, 12-wk, 24-wk
BMI is calculated as a ratio of subject body mass (kg) divided by the square of subject height (m).
Baseline, 12-wk, 24-wk
Duration of Diabetes Mellitus
Временное ограничение: Baseline
Duration, in years, since first diagnosed with Diabetes Mellitus upon entry into study
Baseline
HbA1C Laboratory Values
Временное ограничение: Baseline, 12-wk, 24-wk
Laboratory values of subject HbA1C levels at Baseline, 12-wk, 24-wk
Baseline, 12-wk, 24-wk
Triglyceride Laboratory Values
Временное ограничение: Baseline
Laboratory triglyceride values at baseline entry into study
Baseline
Cholesterol Laboratory Values
Временное ограничение: Baseline
Laboratory total cholesterol, HDL-cholesterol, and LDL-cholesterol levels at baseline entry into study
Baseline
Creatinine Laboratory Values
Временное ограничение: Baseline
Laboratory creatinine values at baseline entry into study
Baseline
Blood Urea Nitrogen (BUN) Laboratory Values
Временное ограничение: Baseline
Laboratory Blood Urea Nitrogen levels at baseline entry into study
Baseline
Aspartate Aminotransferase Laboratory Values
Временное ограничение: Baseline
Laboratory values for Aspartate Aminotransferase (AST) at baseline entry into study
Baseline
Thyroid Stimulating Hormone Laboratory Values
Временное ограничение: Baseline
Laboratory values for Thyroid Stimulating Hormone (TSH) at baseline entry into study
Baseline
Age
Временное ограничение: at baseline
Age of participants at entry into study.
at baseline

Соавторы и исследователи

Здесь вы найдете людей и организации, участвующие в этом исследовании.

Следователи

  • Главный следователь: Evan Stubbs, Edward Hines Jr. VA Hospital, Hines, IL

Публикации и полезные ссылки

Лицо, ответственное за внесение сведений об исследовании, добровольно предоставляет эти публикации. Это может быть что угодно, связанное с исследованием.

Даты записи исследования

Эти даты отслеживают ход отправки отчетов об исследованиях и сводных результатов на сайт ClinicalTrials.gov. Записи исследований и сообщаемые результаты проверяются Национальной медицинской библиотекой (NLM), чтобы убедиться, что они соответствуют определенным стандартам контроля качества, прежде чем публиковать их на общедоступном веб-сайте.

Изучение основных дат

Начало исследования (Действительный)

14 января 2010 г.

Первичное завершение (Действительный)

14 ноября 2014 г.

Завершение исследования (Действительный)

14 ноября 2014 г.

Даты регистрации исследования

Первый отправленный

6 августа 2009 г.

Впервые представлено, что соответствует критериям контроля качества

7 августа 2009 г.

Первый опубликованный (Оценивать)

10 августа 2009 г.

Обновления учебных записей

Последнее опубликованное обновление (Действительный)

2 октября 2019 г.

Последнее отправленное обновление, отвечающее критериям контроля качества

20 сентября 2019 г.

Последняя проверка

1 сентября 2019 г.

Дополнительная информация

Эта информация была получена непосредственно с веб-сайта clinicaltrials.gov без каких-либо изменений. Если у вас есть запросы на изменение, удаление или обновление сведений об исследовании, обращайтесь по адресу register@clinicaltrials.gov. Как только изменение будет реализовано на clinicaltrials.gov, оно будет автоматически обновлено и на нашем веб-сайте. .

Подписаться