Colorado-Oregon Altitude Study
Phase: PHASE4
Conditions: Acute Mountain Sickness
Sponsor: University of Oregon

Colorado-Oregon Altitude Study Research and Statistical Analysis Plan 
NCT: Not yet assigned 
June 2, 2022 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Research Plan 
IMPORTANT: When completing this outline, please use the Research Plan Guidance for the 
content necessary to develop a comprehensive yet succinct Research Plan. Using the guidance to 
complete this outline will help facilitate timely IRB review. 
 
Study Title: Colorado Oregon Altitude STudy (COAST) 
Protocol Number: TBD 
Principal Investigator: Andrew T. Lovering, PhD 
 
A.  Introduction and Background 
Rapid and prolonged exposure to high altitude presents a serious threat to the health of people. 
Unfortunately, no major advances have been made in promoting health and performance at high 
altitude in the last 25 years. To remedy this problem, we propose to test three new ideas to rapidly 
advance human performance at high altitude.  
  
While a two-week period of acclimatization to high altitude substantially improves physical and 
cognitive function (2), this strategy is clearly impractical for many people who travel from low 
altitude to high altitude quickly. Pharmacological countermeasures to offset the negative effects of 
high altitude are thus attractive to ensure optimal health and performance at high altitude. 
Unfortunately, current pharmacological strategies only work moderately well, or are fraught with 
side effects and risks (1, 3). Our team has recently conducted a series of Department of Defense 
(DoD) funded studies aimed at understanding the molecular and genetic basis of human adaptation 
to high altitude as a means to identify novel ways to promote acclimatization. Based in part on our 
research and research from their labs, we have identified two compounds that we believe will 
improve human health and performance at high altitude: iron and erythropoietin. Moreover, we 
will study the molecular biomarkers of natural exposure and acclimatization in a placebo group and 
the two intervention groups to discover how these interventions aid performance, and to look for 
markers of use of each compound to aid detection of illicit use in the face of high altitude exposure. 
In addition, we propose to study the effect of these drugs on altitude acclimatization in those with 
and without a patent foramen ovale (PFO), a small hole in the atrial septum present in ~30% of the 
population. The PFO has been shown to alter ventilatory responses to hypoxia and increase 
susceptibility to acute mountain sickness, although the mechanism remains unclear. 
  
Iron and erythropoietin are linked by each playing a role in the oxygen sensing pathway regulated by 
hypoxia inducible factor (HIF). We know that HIF plays a key role in sensing low oxygen, and thus 
plays a key role regulating human’s response to low oxygen during acute and chronic exposure to 
high altitude. By using these compounds to modulate the HIF pathway we propose to discover the 
most important components of the pathway for overcoming hypoxia exposure in healthy, fit 
humans.  
 
B.   Specific Aims/Study Objectives 
 
The overarching goal of the study is to determine the effect of iron and erythropoietin (EPO) 
supplementation on acute and chronic physiological responses to high altitude. 
 
Specific aims 
 

1. To determine the effects of iron and EPO on exercise performance acutely (first 3 days), 
during acclimatization (days 7-8), and chronically (days 13-14) at altitudes of 10,000 to 14,000 
feet in PFO- and PFO+ subjects. 
2. To determine the effects of iron and EPO on acute and chronic changes in hemoglobin (Hb) 
mass, cognitive performance, ventilation, and molecular markers of hypoxia exposure at 
altitudes of 10,000 to 14,000 feet in PFO- and PFO+ subjects. 
3. To determine the effects of iron and EPO on development of acute mountain sickness (AMS) 
at altitudes of 10,000 to 14,000 feet in PFO- and PFO+ subjects. 
 
Please note that all baseline studies will provide novel data on men and women with and without a 
patent foramen ovale (PFO) so that even if the altitude studies become unfeasible, new 
information will be gained from these studies. 
 
C.   Methods, Materials and Analysis 
Overview: The initial components of the study will be performed over 6 days at baseline to 1) screen 
subjects for inclusion in the study and 2) obtain baseline measurements, with all studies 
conducted at the Cardiopulmonary Lab, Eugene, OR. These screening and baseline studies will 
be followed by 4 weeks of placebo or drug interventions (Cardiopulmonary Lab, Eugene, OR) and 
14 days living at high altitude (Breckenridge or Leadville, CO). Within 1 week after returning to 
Eugene, OR, post-altitude measures will be made. Refer to Figure 1 below for a schematic 
representation of the timing and location of measurements. Each subject, regardless of 
intervention arm, will perform all protocols described below. All screening in Eugene, OR is 
scheduled for 6 days, but screening could take up to 10 days in the case of equipment 
malfunction or if the subject prefers to spread tests out over additional days.  

 
Baseline measures
APFTs
Informed Consent
Menstrual history Q
Medical history Q
Physical Exam
Blood draw 
BL Day 1
BL Day 4
PFTs
Cardiac Screening
HCVR & ventilation
AMS Q/SPO2
Cog Fxn
Pregnancy test
VO2max
BL Day 2
BL Day 5
Pregnancy test 
Hb mass & p50
Blood draw 
Dried blood spot
BL Day 3
Performance 
stabilization
(5k run)
Sea Level: Eugene, OR
Drug Treatment, 4 weeks (10 visits)
Blood draw on both iron infusion days
Early Altitude measures
AMS Q/SpO2
5K run
Cog Fxn
Hb mass & p50
Blood draw
Dried blood spot
Pregnancy test
Alt Day 1
Alt Day 2
AMS Q/SpO2
Rucksack carry
Cog Fxn
Ultrasound *
HCVR & ventilation *
AMS Q/SpO2
Cog Fxn
Ultrasound *
HCVR & ventilation *
Alt Day 3
Mid Altitude measures
AMS Q/SpO2
5K run
Cog Fxn
Hb mass & p50
Blood draw
Dried blood spot
Pregnancy test
Ultrasound *
HCVR & ventilation *
Rucksack carry
Ultrasound *
HCVR & ventilation *
Alt Day 7
Alt Day 8
Late Altitude measures
Alt Day 13
Rucksack carry
Alt Day 14
Return to OR
Arrive in CO
Altitude: COLORADO
Post-Altitude measures
5K run 
Blood draw
Sea Level: Eugene, OR
BL Day 6
* Indicates protocol 
that will be done on 
either day listed in early 
or mid altitude 
measures
AMS Q/SpO2
5K run
Cog Fxn
Hb mass & p50
Blood draw
Dried blood spot
Pregnancy test
Ultrasound
HCVR & ventilation

 
What follows is a detailed description of each study day: 
BASELINE: EUGENE, OR RESEARCH SITE 
All studies done in Eugene will be done in either laboratory space within Pacific Hall and/or on 
running tracks and trails within the Eugene/Springfield metropolitan area or very close to this 
community. 
 
Any subject with childbearing potential will be required to take a pregnancy test on VO2max days 
and Hemoglobin mass testing days (both at baseline and altitude) as the other testing days will not 
involve any activity that would otherwise affect the fetus.  
 
Day 1 – Informed consent, medical History, blood draw: Cardiopulmonary Lab, Eugene, OR 
(~60 min) 
Subjects who express interest in the study will have any initial questions answered on the phone or 
over email, depending on subject preference. Those interested in continuing with the study will 
arrive to the lab, and subjects will undergo informed consent and a complete a self-report health 
history questionnaire, and complete a menstrual cycle history questionnaire (biological women only) 
(~30 min). Subjects will have the option to undergo informed consent remotely prior to arriving to 
the lab (see ‘Informed Consent Process’ below) but will complete all other paperwork, including 
signing the informed consent, upon arrival to the lab. Menstrual cycle history will be documented for 
control purposes for blood biomarker analysis, although subjects will not be required to be in a 
certain phase for testing, nor will they be excluded for contraceptive use.  
 
After completing paperwork, subjects will undergo physical examinations by either a Nurse 
Practitioner or Physician Assistant 25 mL blood draw for iron, ferritin, transferrin, basic metabolic 
panel, and complete blood count measurements to be analyzed by QUEST. Subjects will be asked to 
either give or deny permission to the Lovering Lab to re-contact them after the end of the study. 
Lastly, subjects will be asked to use an online Qualtrics survey, which will be emailed to every 
consenting subject, to log daily exercise activity for the duration of the study. (~30 min).  
 
Day 2 – Army Physical Fitness Tests (APFTs): Cardiopulmonary Lab, Eugene, OR (~60 min) 
Subjects will perform a modified version of the Army Physical Fitness Tests (APFTs) outdoors at the 
University of Oregon. The APFT will include 2 minutes of push-ups and sit-ups and a 5k run. Total 
time ~1 hour.  
 
Day 3 – Lung function. cardiac screening, blood draw, Acute Mountain Sickness (AMS) 
questionnaire with finger saturation, and cognitive function testing: Cardiopulmonary 
Lab, Eugene, OR (~125 min) 
Subjects will perform pulmonary function testing (~15 minutes) and cognitive function testing (~20 
minutes). 
 
Subjects will have an intravenous catheter (IV) placed. Subjects will then undergo comprehensive 
ultrasound screening. Amount of blood flow travelling through the PFO/ASD and IPAVA will be 
graded using saline contrast echocardiography while the subject is breathing room air. Pulmonary 
artery pressure, cardiac output, and TAPSE will also be measured using ultrasound (~60 minutes).   
 
 

Subjects will complete the Lake Louise Questionnaire (LLQ) and Environmental Symptoms 
Questionnaire (ESQ) to determine acute mountain sickness (AMS). Subjects will be instrumented 
with a pulse oximeter to measure oxygen saturation (~15 minutes).  
Lastly, subjects will have resting ventilation and HCVR measured (~15 minutes). 
 
Day 4 – VO2max testing day: Cardiopulmonary Lab, Eugene, OR (~30 min) 
Subjects will perform a VO2max test (~30 minutes). Additionally, resting, exercise, and post-exercise 
heart rate and systemic blood pressure will be measured. Any subject with child bearing potential 
will be required to take a pregnancy test prior to the VO2max test.  
 
All subjects will arrive at the Cardiopulmonary lab and will be given a telemetric core temperature 
pill to take 5-10 hours before arriving for Day 5 testing.  If subjects do not take the pill the night prior 
to exercise testing, they will have to take the temperature pill as a suppository the morning of 
testing. 
 
To take the core temperature pills, subjects will be told to swallow with a glass of water or other 
beverage. There are no restrictions for fluid or food consumption after the pill has been ingested 
and subjects will be told not to chew the telemetric pill. In order to insert the pill as a suppository, 
subjects will be instructed to insert the pill past the first digit of your finger and given lubricant and a 
glove to assist with the insertion process. Research staff will be available to give additional 
information about the insertion process if subjects have more questions. These directions apply to 
every time subjects take the core temperature pills. 
 
 
Day 5 – Performance Stabilization, Eugene, OR (occurs ~30 days before departure for 
Colorado) (~30 min) 
To further ensure accurate baseline measurements of physical performance, the top 80 subjects 
(and 20 alternates) with the most similar physical characteristics will repeat the 5K. This strategy will 
minimize the influence of learning effects associated with the tests and facilitate matching between 
groups. (~30 min).  
 
Day 6 – Hemoglobin mass, Eugene, OR (occurs ~30 days before departure for Colorado) (~75 
min) 
Subjects will perform hemoglobin mass (Hb mass) and p50 measures (~75 minutes). This 
measurement involves placing an IV and drawing an additional 10 mL of venous blood. Any subject 
with child bearing potential will be required to take a pregnancy test prior to Hb mass testing. In 
addition, subjects will have baseline venous blood drawn (60 mL of venous blood will be analyzed 
for various biomarkers and 5 mL for sickle cell screening to be analyzed by QUEST). Dried Blood Spot 
samples will be taken utilizing a commercially available dried blood spot sampling device (80 uL) 
(TASSO, Tasso Inc, Seattle, USA).  Dried blood will be analyzed for HGB, CD71/Band3, ESAs, and 
reticulocytes. Total Blood drawn for this day of ~76 mL. 
 
 
Drug intervention, Eugene, OR 
For the 4 weeks immediately prior to the scheduled departure date, subjects will arrive at the 
Cardiopulmonary Lab as required by their intervention schedule (see ‘Drug Intervention’ below for 
details) to receive their assigned intervention via a sub-cutaneous injection and/or intravenous 

injection. After the last dose, subjects will have venous blood drawn (~60 mL) prior to departure to 
Colorado for measurements of various biomarkers. A dried blood drop sample (80 uL) will also be 
taken. 
 
COLORADO FIELD SITE:  
All studies performed in Colorado will happen in laboratory space created by the investigators 
and/or on running tracks and trails in or very near Leadville or Breckenridge, CO. 
 
Early high-altitude measures: Days 1-3 
Subjects will fly from Eugene, OR to Denver, CO and be driven from Denver to the field site (~10,000 
ft) where they will be housed and fed for 2 weeks. Upon arrival, subjects will fill out AMS 
questionnaires and have saturation measured. Prior to departure from Eugene, a research staff 
member will meet subjects at the airport and they will be given a telemetric core temperature pill to 
take 5-10 hours prior to the 5k time trial in Colorado.  If subjects do not take the pill the night prior 
to exercise testing, they will have to take the temperature pill as a suppository before testing. After, 
subjects will run the 5k time trial, perform cognitive function tests, and then will be taken to preview 
the course for the rucksack carry to be performed on day 2. Dried Blood Spot samples will be taken 
utilizing a commercially available dried blood spot sampling device (80 uL) (TASSO, Tasso Inc, Seattle, 
USA).  Dried blood will be analyzed for HGB, CD71/Band3, ESAs, and reticulocytes.  In the evening, 
subjects will have an IV placed and venous blood drawn, and will perform Hb mass & p50 
measurements (10 mL blood draw). Venous blood (60 mL) will be analyzed for various biomarkers. 
Total blood drawn for this day of ~71 mL. Subjects will fill out AMS questionnaires and have 
saturation measured before going to sleep. Any subject with child bearing potential will be required 
to take a pregnancy test on this day.  
 
On day 2, AMS scores will be taken and saturation measured (morning and night), and subjects will 
participate in the rucksack carry. Cognitive function will also be measured. 
 
On day 3, AMS scores will be taken and saturation measured (morning and night). Cognitive function 
will also be measured. 
 
Subjects will also undergo ultrasound measurements and have resting ventilation and HCVR 
measured on either day 2 or 3.  
 
Mid high altitude measures: Days 7-8 
On day 7, AMS scores will be taken and saturation measured (morning and night), and subjects will 
run the 5k time trial, perform cognitive function tests, perform Hb mass & p50 measurements (10 
mL blood draw), and have venous blood drawn (60mL). Venous blood will be analyzed for various 
biomarkers. Dried blood spot samples will also be taken (80 uL). Total blood drawn for this day of 
~71 mL. This day will be a repeat of day 1 at altitude. Any subject with child bearing potential will be 
required to take a pregnancy test on this day. Subjects  will be given a telemetric core temperature 
pill to take 5-10 hours prior to the 5k time trial on day 7/8. If subjects do not take the pill the night 
prior to exercise testing, they will have to take the temperature pill as a suppository before testing. 
 
On day 8, subjects will participate in the rucksack carry.  
 

Subjects will also undergo ultrasound measurements and have resting ventilation and HCVR 
measured on either day 7 or 8.  
 
Late high altitude measures: Days 13-14 
On day 13, AMS scores will be taken and saturation measured (morning and night), and subjects will 
undergo ultrasound measurements, run the 5k time trial, perform cognitive function tests, perform 
Hb mass & p50 measurements (10 mL blood draw), and have venous blood drawn (60mL). Dried 
blood spot samples will also be taken (80 uL). Venous blood will be analyzed for various biomarkers. 
Total blood drawn for this day of ~71 mL. This day will be a repeat of day 1 at altitude. Any subject 
with child bearing potential will be required to take a pregnancy test on this day. Subjects will be 
given a telemetric core temperature pill to take 5-10 hours prior to the 5k time trial on day 7/8. If 
subjects do not take the pill the night prior to exercise testing, they will have to take the temperature 
pill as a suppository before testing. 
 
Subjects will also undergo ultrasound measurements and have resting ventilation and HCVR 
measured on day 13. 
  
On the morning of day 14, subjects will participate in the rucksack carry. Subjects will be driven back 
to Denver, CO where they will fly back to Eugene, OR.  
 
Post-altitude measures, Eugene, OR 
Within 1 week of returning to Eugene, OR, subjects will return to the Cardiopulmonary Lab (Eugene, 
OR) to repeat the 5k run and blood draw only. Tests will be performed over post-Altitude days 3-5. 
The 5k run will be done either on the same day as the other tests, or on a separate day depending 
on subject availability. Total blood draw 60 mL.  
 
Note: During the 14 days at high altitude, subjects will be involved in data collection on days 1, 2, 3, 
7, 8, 13 and 14. On all other days, there will be group activities and the possibility for subjects to hike 
or bike ride in small groups.  They will not participate in any research activities during these “off” 
days, and they will be reminded frequently to follow CDC guidelines for COVID-19 risk mitigation 
(see ‘COVID-19 exposure scenario’ below).  
 
 
Description of Data Collection Procedures: 
Pulmonary Function Tests:  Subjects will perform standard non-invasive spirometry to measure a 
maximal inspiratory and expiratory flow-volume loop, forced vital capacity (FVC), slow vital capacity 
(SVC), forced expiratory volume in 1 sec (FEV1), and mid expiratory flow (FEF25-75%). These tests will 
require the subject to blow in and out of a mouthpiece connected to a computerized flowmeter 
(pneumotachometer). This is a routine clinical test.  
 
VO2max tests: The VO2max test will be an incremental test to volitional exhaustion on a cycle 
ergometer. Subjects will breathe through a mouthpiece and will begin cycling at a low resistance (50 
W), with the resistance increasing every minute by 25 W. The test will continue until the subject 
reaches volitional exhaustion or a plateau in VO2 as measured by our metabolic cart (Medgraphics 
Ultima CPX) is reached. During the entire protocol, subjects will breathe room air through a 2-way 
non-rebreathing small sampling flowmeter (pneumotachometer), which will allow us to measure 

ventilation (VE), VO2, and breath-by-breath metabolic data. Subjects will be instrumented with a 
forehead oxygen sensor to measure heart rate and SpO2 at rest and during exercise.  
 
Army physical fitness tests (APFTs): The Army Physical Fitness Test (APFT) is used by the military to 
assess the fitness of soldiers. The test consists of the maximum number of push ups in 2 minutes, 
then the maximum number of sit ups in 2 minutes, and finally the fastest time possible for a 2 mile 
run. The entire protocol must be completed within 2 hours. No strict cut offs for push ups or sit ups 
will be used as screening criteria, however, to meet the higher standards required of the Special 
Operations Forces (SOF), the run has been extended from 3.2 km (2 miles) to 5.0 km, and more 
stringent selection criteria will be applied. Specifically, all participants must be able to achieve at 
least 80% of the age adjusted minimum performance level on each of the three APFT criteria, but 
preference will be given to those who complete the criteria at 100% or more.  For example, 100% 
passing for males (age 18-21), means they are  able to complete 42 push ups in 2 minutes, 53 sit-ups 
in 2 minutes, and 5k run <24:42 (7:57 per mile pace). 100% passing for females (age 18-21), means 
they are able to complete 19 push ups in 2 minutes, 53 sit-ups in 2 minutes, and 5k run < 29:22 (9:27 
per mile pace). The APFT will be performed once at baseline for all subjects and possibly twice for 
performance stabilization. Below is the table with the 100% passing criteria for all age groups 
included in the study. 
 
 
Male APFT Standards 
Female APFT Standards 
Age 
Group 
Push Up 
Sit Up 
Run 
(Pace) 
Run Time 
(min) 
Push Up 
Sit Up 
Run 
(Pace) 
Run Time 
(min) 
18-21 
42 
53 
7:57 
24.42 
19 
53 
9:27 
29.22 
22-26 
40 
50 
8:18 
25.47 
17 
50 
9:48 
30.27 
27-31 
39 
45 
8:30 
26.25 
17 
45 
10:15 
31.51 
32-36 
36 
42 
8:51 
27.29 
15 
42 
10:51 
33.43 
37-40 
34 
38 
9:09 
28.26 
13 
38 
11:21 
35.15 
 
 
Measurements of Core Temperature: Core temperature (Tcore) will be measured using a Vital 
Sense Monitor and a telemetric pill (JonahTM ingestible temperature sensor, Mini Mitter Inc, Bend 
OR). The sterile telemetric pill will be activated by study staff then will be taken orally (with liquid) the 
5-10 hours prior to testing or the volunteer will self-insert the pill into the rectum the morning of 
testing. Core temperature will be measured during the 5k runs (performance stabilization at 
baseline), and approximately days 1, 7, and 13 at high altitude). 
 
 
Intravenous catheter and venous blood draw: We will place a 20-22 gauge (small diameter) IV 
into a vein in the subject’s arm. This IV will be used to for various tests – blood draws for Hb mass & 
p50, blood draws to measure various biomarkers in the blood, iron/saline infusion during drug 
treatment, and for contrast bubble injections during ultrasound measures at sea level.  
 
Venous blood draw: Blood for measuring biomarkers will be drawn from an IV (60 mL per blood 
draw) and centrifuged, and de-identified plasma and serum stored at -80°C until assayed. 
Additionally, blood will be drawn for baseline iron, transferrin, ferritin, complete blood count, and 
basic metabolic panel analysis (via QUEST diagnostics, 25 mL) on baseline day 1, and blood will be 
drawn for sickle cell screening on baseline day 6 (via QUEST diagnostics, 5 mL). Intravenous blood 
for biomarker analysis will be drawn on baseline 6, and on the second day of iron or saline infusion 

to minimize the number of needle sticks. Blood will also be drawn days 1, 7, and 13 at high altitude, 
and at sea-level post altitude. 60 mL of blood will be drawn for biomarker analysis on each of these 
blood draw days.  
 
Hypercapnic ventilatory response: We will use a published, well-established method (Duffin method) 
for assessing chemo sensitivity to carbon dioxide (MacKay et al., Adv Physiol Education, 2016). Subjects 
will be fitted with a nose-clip and breathe room air through a two-way rebreathing valve that can be 
directed between a filtered 6L non-diffusing bag filled with a mixture of CO2 and O2, with values 
dependent on whether studies are being conducted at baseline or altitude (CO2 range: 3% to 7%, O2 
range: 60% to 97%) (medical grade), and room air. If O2 and CO2 do not equal 100%, the tank will be 
balanced with nitrogen. Ventilation, end tidal CO2 (PETCO2), end tidal O2 (PETO2) and saturation will be 
measured continuously throughout this test (Medgraphics).  To establish a baseline before hypercapnic 
testing using the modified rebreathing protocol, subjects will breathe room air for 5 min. Subjects will 
then be coached to hyperventilate by increasing the lung volume and frequency of breathing for 1 
minute to reach a target PETCO2 of ~20-25 mm Hg (~40-45 mm Hg is normal); this part of the test is 
required to reduce CO2 stores in the body. After 1 minute the subject will be asked to take a full breath 
in and out then they will be switched to the bag filled with the hyperoxic O2 and hypercapnic CO2 
mixture and will be coached to take 3 large breaths then resume normal breathing until: 1) their 
breathing increases so much that it becomes in tolerable and they signal to quit; 2) the PETCO2 = 55 mm 
Hg or 3) the rebreathing bag becomes deflated. Subjects will be informed of what to expect with this 
test prior to performing it, i.e they will be told that we will coach them through it and that when they 
start to breathe out of the bag they will initially have very little urge to breathe but as the rebreathing 
progresses they will have a very strong urge to breathe. 
Comprehensive ultrasound screening: Ultrasound screening will be performed using a previously 
placed IV (see above).  Subjects will sit in the left lateral decubitis position for ultrasound screening.  
An agitated saline contrast injection will be made while transthoracic saline contrast 
echocardiography (TTSCE) is performed on the subject to evaluate extent of blood flow through 
IPAVA and PFO/ASD (see below).  Subjects will be asked to perform a Valsalva maneuver while 
breathing room air. This maneuver enhances blood flow across the PFO/ASD. Multiple saline 
contrast injections (up to 3) may be performed to verify bubble grades/presence of a PFO/ASD. 
Pulmonary artery systolic pressure (PASP), cardiac output, and TAPSE (tricuspid annular plane 
systolic excursion) will be measured with ultrasound. Comprehensive measurements will be done 
on baseline 3, and PASP, cardiac output, and TAPSE will be measured on days 1, 3, 7, and 13 at high 
altitude.  
 
Transthoracic Saline Contrast Echocardiography (TTSCE): Echocardiography requires a medical 
sonographer to place a small probe against the subject's ribcage, which transmits and receives 
sound waves to produce images that are captured and stored on a computer. Saline contrast is 
made by manually agitating (mixing) 3-5 ml of sterile saline and 1 ml of air to create a suspension 
(mixture of liquid and gas) of very small bubbles called microbubbles. This suspension is injected 
through an IV, which allows us to detect the transpulmonary passage of microbubbles. 
 
Cognitive Function: We will use the Defense Automated Neurobehavioral Assessment (DANA) to 
assess neurocognitive function across the study. We have recently documented decrements in 
several components of the DANA during a simulated rapid deployment to high altitude that 
improved with acclimatization (2) and thus believe the tests are sensitive and specific to the 

cognitive challenges SOF face in this environmental extreme. Using a handheld computer, the 
following nine cognitive function tests will be administered:  
1. Simple Reaction Time-1 (measured at the beginning of neurocognitive testing to gain an 
understanding of pure visual-motor response);  
2. Simple Reaction Time-2, repeated at the end of neurocognitive testing to assess diminished 
reserve of cognitive effort on reaction time;  
3. Procedural Reaction Time, a measure of choice reaction time and accuracy;  
4. Go-No-Go, a measure of speed, accuracy and impulsivity;  
5. Code Substitution—Simultaneous, a measure of visual scanning and attention, learning, and 
immediate recall of digit-symbol pairings;  
6. Code Substitution—Delayed Recall, a measure of short-term memory for digit-symbol 
pairings;  
7. Spatial Discrimination, a measure of visuospatial analytic ability;  
8. Matching to Sample, an assessment of attention and memory for visuospatial discrimination;  
9. Sternberg’s Memory Search, a measure of working memory for letters.  
  
The total time required to complete the battery of tests is ~20 minutes. DANA will be administered 
once at sea level (baseline day 3) and in the evening of days 1, 3, 7, and 13 at high altitude. 
 
Acute Mountain Sickness (AMS) and oxygen saturation (SpO2): The severity of AMS symptoms 
will be determined using a subset of the Environmental Symptoms Questionnaire (ESQ) and the 
Lake Louise AMS Questionnaire (LLQ), the two most common and accepted measures of AMS. 
  
The ESQ is a self-reported, 68-question inventory used to document symptoms induced by high 
altitude and other stressful environments. A weighted average of scores from 9 symptoms 
(headache, lightheaded, dizzy, etc.) designated AMS-C will be calculated. AMS-C scores greater than 
0.7 are considered positive for AMS (77). 
  
The LLQ consists of a six question self-reported assessment of AMS symptoms, with a score of ≥ 3, 
including headache, defined as AMS. The high altitude-illness assessment questionnaires will be 
administered on paper forms and tabulated in digital format at the end of each day (78).  
 
After completing the AMS assessment forms, arterial saturation will be monitored by pulse oximetry. 
Each AMS assessment and pulse oximetry measurement will take ~10 minutes to complete. These 
measurements will be made once at baseline, immediately upon arrival at high altitude, and every 
night and morning of days 1, 2, 3, 7, and 13 at high altitude. Based on our previous study of 164 
subjects, this ascent profile induced symptoms of AMS in ~50% of the subjects on the first evening at 
high altitude. 
 
Hemoglobin mass (Hb mass) and p50: Determination of blood volume is done by measuring 
hemoglobin mass using the carbon monoxide (CO) rebreathing method and doing some calculations 
(see below). Prior to the test the rebreathing circuit is flushed and prefilled with 100% oxygen and 
sealed. Upon arriving to the laboratory subjects will have an IV placed into their arm by an 
investigator as described above. Prior to any measurements, subjects rest in the supine position, 
quietly for ~20 minutes. Then, we obtain 1 blood sample (2 mL) for p50 measurements. After, using 
a noseclip and mouthpiece, subjects will breathe 100% oxygen for 4 minutes. At the end of this 4 
minute period, another 2 mL blood sample will be taken to measure hemoglobin concentration, 

hematocrit, baseline proportion of hemoglobin bound with CO (HbCO), and baseline proportion of 
hemoglobin bound with oxygen (HbO2). HbCO is typically 1.5 to 2.0% in nonsmoking city dwellers. 
Once the baseline blood sample has been taken, subjects will be instructed to breathe out 
completely. Then they take a slow breath from the rebreathe circuit prefilled with 100% oxygen to 
completely fill their lungs while a bolus of 99.9% pure CO is injected into the circuit. The bolus 
volume of CO is calculated from body mass (1.0 mL/kg body mass for men; 0.8 mL/kg body mass for 
women). This dose of CO is expected to raise HbCO by ~6% to ~8%, which is below the levels 
associated with side effects (>15%; see below). After CO administration the subjects begin breathing 
normally for 10 minutes. At the end of this 10-minute period, subjects expire all of their air back into 
the spirometer and the spirometer is sealed and a post-rebreathe blood sample of 2mL is taken to 
measure the above-mentioned blood parameters (with the exception of p50, which is measured 
once prior to Hb mass testing). Subjects then goes back to resting while breathing ambient air. 
Finally, we obtain the total volume of gas in the rebreathe circuit and determine the concentration of 
CO left in the rebreathe circuit after the test. Using established formulas, we calculate hemoglobin 
mass and then use the following equations to obtain red cell volume (Red Cell Volume = hemoglobin 
mass x hematocrit x hemoglobin-1 x 100-1) and then blood volume (Blood Volume = red cell volume 
x 100 x hematocrit-1 x 0.91-1). Subjects will then repeat the above procedures within 10 minutes 
after completion. Procedures, including volume of CO injected and blood withdrawn, are identical, 
with the exception of p50 measurements, which will only be done once prior to CO inhalation. The 
second test is performed to establish a low test-retest variable as it minimizes biological variation 
that would occur between days. If these two tests yield results within 3% then the test is complete. If 
greater than 3% we will repeat the 2 tests on a different day once CO levels in the blood have 
returned to baseline (~48 hours). In total, 10 mL of blood will be taken (8mL for Hb mass - 4mL for 
each test, and 2mL for p50). CO level in the blood is not expected to exceed 20% following the 
second test. If it does, subjects will breathe 100% oxygen for 10 minutes. p50, the partial pressure of 
oxygen when Hb is 50% saturated with oxygen, is calculated using pre-rebreathe values for pH, 
PvO2, PvCO2, Hb concentration, HbO2, and HbCO. Hb mass will be measured in this manner, i.e., 
duplicate tests, at baseline day 6 and on days 1, 7, and 13 at high altitude. p50 will be measured on 
every day Hb mass is measured, as well as on baseline day 3 and day 3 at high altitude when Hb 
mass is not measured. On p50 only days, one 2mL blood sample will be taken to measure p50, but 
no Hb mass measurement will be made.  
 
Blood measures: Blood samples will be used to measure biomarkers such as soluble transferrin 
receptor, ferritin, hepcidin, erythropoietin, C-reactive protein, erythropoiesis agents (ESAs), 
hemoglobin, hematocrit, red blood cell count, reticulocyte number, reticulocyte percentage, mean 
corpuscular volume, mean corpuscular hemoglobin, CD71/Band3, cytokines including interleukins 
(IL) -1, 6, 8, 10, 12p (70), 17A, 18, 23, and 33, interferons -2 and -, tumor necrosis factor-, 
monocyte chemoattractant protein-1, nitric oxide synthase, endothelin-1, myoglobin, matrix 
metalloproteinases 2 and 9, cystatin C, myeloid-related protein 8/14, osteopontin, neutrophil 
gelatinase-associated lipocalin, myeloperoxidase, serum amyloid A, insulin like growth factor binding 
protein 4, intracellular adhesion molecule 1, and vascular cell adhesion protein 1. Serum will also be 
collected for Luminex analysis of genetics and metabolism regarding inflammation which will 
include many of the previously mentioned markers. Additionally, serum will be saved for cell culture 
experiments in which endothelial and vascular smooth muscle cells will be exposed to serum, these 
cells will be analyzed for mechanistic changes involving inflammation and health status change of 
the cells. 
 

Plasma, buffy coat, and serum samples will all be stored for later use; however, these samples will 
be unidentifiable, only stored with an ID number that will indicate which treatment the sample had 
been exposed to. 
 
Abnormal blood test results will be shared with participants with a recommendation to see their 
physician. 
 
Dried Blood Spot Sampling: We will use a commercially available and FDA-approved for patient use 
blood spot single-use disposable sampling device (TASSO, TASSO Inc, Seattle, USA).  The device 
adheres to skin which has been cleaned with isopropyl alcohol with a light adhesive.  Upon 
activation, a vacuum forms and a lancet pricks the surface of the skin.  The vacuum draws blood out 
of the capillaries and into the sample pod attached to the bottom of the device, collecting 4 samples 
of 20 microliters (0.020 mL) each over the course of 5 minutes and storing the samples on a dried 
blood spot card contained within the device.  After collection, the device is removed from the skin, 
the sample card separates from the device and is submitted for analysis. Samples will be taken 
every time a venous blood draw is taken at sea level (baseline 6, and post dosing) and altitude (day 
1, 7, and 13).  
 
5k run: The 5-kilometer run will be performed as part of the APFTs at baseline (see above) and on its 
own on days 1, 7 and 13 in Colorado. The run will be performed on a 400 m track or local running 
trail (Pre’s trail) in Eugene, OR and on the high school track or local paved trails near the research 
site in Colorado. Subjects will be asked to complete the run as fast as possible while being timed. 
 
Drug intervention: In a single-blind, randomized, placebo-controlled design, subjects will receive a 
placebo (saline placebo), iron, or erythropoietin.  
 
Iron. Volunteers will receive an intravenous injection of Fe(III)-hydroxide sucrose (200 mg) or 
placebo twice before high altitude exposure, once 4 weeks and once within several days before 
traveling to high altitude. All subjects will report to the lab as if they are receiving iron, but only those 
randomly assigned to the iron arm will receive iron. The remaining subjects will receive intravenous 
saline. This is infused over the course of approximately 2-5 minutes.  This is the same dose shown to 
prevent AMS, and to block hypoxia-induced pulmonary hypertension28. All subjects, regardless of 
whether they receive iron or placebo, will remain in the lab for an additional 15 minutes after 
administration to ensure they do not have an allergic reaction (see risks below) and to ensure 
placebo subjects are blinded to the treatment.  
 
EPO. Volunteers will receive a sub-cutaneous injection of epoetin alpha 150 IU/kg injections given 
weekly (50 IU/kg 3 x week) for three consecutive weeks prior to high altitude exposure. This dose 
and timing match the AMS prevention study protocol of Heo et al.11  
 
To ensure subjects are blinded to the intervention, all subjects will have the same intervention 
schedule. For those in the iron group, they will come to the lab 3x per week as required by the EPO 
intervention schedule, for example, and receive saline interventions. For those in the EPO group, 
they will come to the lab one time 4 weeks prior to departing to Colorado to receive a placebo 
injection while the iron group receives their iron injection. The placebo group will receive saline at all 
visits.  
 

The table below provides the intervention schedule for each group. Blue indicates the placebo 
group, red indicates the iron group, and green indicates the EPO group.  
 
 
Sunday 
Monday 
Tuesday 
Wednesday 
Thursday 
Friday 
Saturday 
4 weeks 
until 
departure 
 
 
 
Saline 
Iron 
Saline 
 
 
 
3 weeks 
until 
departure 
 
Saline 
Saline 
EPO 
 
Saline 
Saline 
EPO 
 
Saline 
Saline 
EPO 
 
2 weeks 
until 
departure 
 
Saline 
Saline 
EPO 
 
Saline 
Saline 
EPO 
 
Saline 
Saline 
EPO 
 
1 week 
until 
departure 
 
Saline 
Saline 
EPO 
 
Saline 
Iron 
EPO 
 
Saline 
Saline 
EPO 
Departure 
 
Rucksack carry: Subjects will be instructed to complete a 3.1-mile uphill hike as fast as possible 
while carrying a 35-pound backpack. We previously developed this test to simulate military style field 
operations for another DoD funded study. The course follows a rugged hiking/jeep trail that begins 
in a wooded area at ~10,500 feet and ends on a ridge above tree line at ~12,500 feet. Subjects will 
hike the course as a group after the 5k run first day at high altitude to familiarize themselves with 
the terrain. The following morning (2nd day) they will be asked to complete the course as fast as 
possible while being timed. Subjects will also run the course on days 8 and 14. Fit subjects, free of 
AMS, can finish the course in ~60 minutes. 
 
Traveling and accommodations:  
Subjects will be transported to Denver, Colorado in groups of 10-20 by commercial airlines or bus 
and then immediately driven to Leadville or Breckenridge, Colorado by charter buses. The total 
travel time from baseline to high altitude will be ~8 hours. Subjects will follow a strict regimen of 
tasks designed to simulate a high level of physical activity at high altitude (10,000 to 14,000 feet) over 
three days and two nights (acute) followed by 11 additional days of residence at high altitude 
(chronic exposure) before returning to Oregon on the 14th day.  
  
Subjects will be housed and fed in condominiums in the Leadville or Breckenridge area. All meals 
will be cooked and served communally. Omnivorous and vegetarian options will be provided. 
Subjects will sleep in individual beds, but will share quarters and bathrooms (see note below about 
COVID management in ‘COVID-19 exposure scenario’). Caffeine intake will be limited to the 
equivalent of two cups of coffee per day. Subjects will refrain from taking any non-study related 
supplements (over-the-counter, prescription, and recreational) or other non-study drugs or alcohol 
for the duration of the study beginning with baseline studies through the completion of the study. 
Violation of these policies will yield a subject’s data invalid for the whole study, and thus will result in 
expulsion from the study and prorated payment. 
 
D.  Research Population & Recruitment Methods 
 

Participant population 
We will study civilians who are recreational athletes who meet the basic health and physical fitness 
eligibility standards as evaluated using the modified Army Physical Fitness Test (APFT). We use the 
APFT because of its standard of use across all US Armed Forces, and our experience with it 
successfully selecting broadly fit students, i.e. a specialized runner might struggle, but a male or 
female with overall high aerobic fitness and strength will do well. Subjects will be matched and 
assigned to either the placebo or the two intervention groups to achieve the necessary statistical 
power to detect meaningful changes in health and performance at high altitude. Our team has 
extensive experience in recruiting and screening subjects on college campuses to achieve this goal 
(4-64). 
  
Up to 300 volunteers will be screened in Eugene, Oregon to identify 100 subjects meeting the 
inclusion and exclusion criteria (see below). 
  
Inclusion criteria 
Exclusion criteria 
Ages 18 to 40 
 
Recreational athletes able to pass the APFTs 
 
Men and women of any ethnic background 
 
Medical and dental insurance 
 
Able to read and speak English 
 
Fully vaccinated against COVID-19 
 
*If a subject is taking medication that is 
deemed safe and will not interfere with the 
main outcome measurements of the study as 
determined by clinical research staff, they will 
be included.  
 
*If a subject had a previous mild to moderate 
COVID-19 infection but is deemed safe for all 
research activities by clinical research staff, 
then they will be included in the study.  
 
Smokers 
 
Previous severe COVID infection or contraction 
of any COVID infection occurring during the 
study. Previous mild to moderate COVID 
infections will be considered for the study on a 
case-by-case basis as determined safe by 
clinical research staff (see inclusion criteria).  
 
Carboxyhemoglobin values (HbCO) 3% or 
greater at baseline 
 
Diseases or disorders known to be affected by 
hypoxia or the drugs used in this study, 
including but not limited to hypotension, 
anemia, sickle cell trait or disease, and 
diabetes. 
 
Anyone unable to receive the investigational 
drugs used in this protocol (EPO or iron).  
  
Those with a history of significant head injury, 
migraines or seizures. 
 
Anyone that is pregnant or trying to become 
pregnant. 
  

Any medication determined by the clinical 
research staff to be unsafe or to interfere with 
the outcome measurements of the study.  
  
Those with inability to be headache-free when 
consuming the amount of caffeine in two six-
ounce cups of coffee or less per day. 
  
Extended exposure (>6 hours) to high altitude 
above 1000m in the month leading up to 
departure to Colorado. 
  
Those who have been on an airline flight over 
six hours (the lowered cabin pressure for an 
extended period of time approximates 
exposure to high altitude) within the month 
leading up to departure to Colorado. 
  
Those who are unable to achieve the minimum 
physical criteria as outlined above. 
 
Anyone with lung function below the lower 
limit of normal per GLI standards.  
 
Previous diagnosis of high altitude pulmonary 
edema or high altitude cerebral edema upon 
altitude exposure. 
 
Failure to get fully vaccinated against COVID-
19. Choosing not to be vaccinated will result in 
exclusion. 
 
Family history of clotting disorders, anemia or 
venous thrombosis. 
 
Plans for professional competition during or 
within 1 week after participation in this study 
as participation may enhance your aerobic 
performance 
 
Presence or absence of a PFO once we have 
enrolled a sufficient number of each group 
representation in the general population (e.g., 
~40% of population has a PFO and ~60% does 
not). However, all subjects will be allowed to 

complete all baseline screening to assure that 
we will have enough subjects to go to Colorado 
 
Biological sex once we have enrolled a 
sufficient number of males and/or females as 
we are aiming to enroll ~50% of each sex. 
However, all subjects will be allowed to 
complete all baseline screening to assure that 
we will have enough subjects to go to 
Colorado. 
 
Subjects will be excluded from telemetric pill 
ONLY if they have a history of obstructive 
diseases of the gastrointestinal tract including 
diverticulosis, diverticulitis, inflammatory 
bowel disease, peptic ulcer disease, Crohn's 
disease, ulcerative colitis, or previous GI 
surgery.  
 
Detailed recruitment methods 
Recruitment of participants will begin immediately following IRB approval. Participants will be 
solicited through flyers posted locally (posted in Eugene and on University of Oregon’s campus), 
online, via word of mouth, through directly contacting UO students, faculty, and staff using the list 
maintained by the lab of potentially participants who have expressed interest in future 
participation, and through newspaper and radio ads. Screening will be conducted at University of 
Oregon, under the direction of Dr. Andy Lovering, and University of Oregon personnel will seek 
informed consent. 
 
The PI (Andy Lovering) and graduate students will be responsible for actively recruiting participants 
and seeking informed consent. 
 
Potential subjects responding to advertisements will be given a basic description of the study over 
either phone or email (depending on personal preference) and given a chance to ask any initial 
questions. Questions in the phone and email script will be used to ensure those most likely to 
qualify present for the comprehensive screening days.  If the subjects wish to participate in the 
study, we will schedule their first visit.  
 
During subject recruitment, we will give examples of exclusion criteria to enable participant self-
identification for exclusion.  For example, “have you ever had a blood clot, or been told that you are 
anemic?” 
 
Compensation 
In return for the time and effort, subjects will be compensated for the study visits completed as 
follows: 
•        
Baseline Screening: $75  
•        
Performance Stabilization: $25 

•        
Colorado Week 1: $400 
•        
Colorado Week 2: $400 
•        
Post-study visits: $100 
 
All expenses (airfare, lodging and food) will be paid for the subject's trip to Colorado. Subjects will 
receive a check for a total of $1000, if they complete the entire study. Subjects will be mailed a check 
for $600 by Research Logistics LLC, the study sponsor, approximately 2 weeks after completion of 
the study and they will receive a separate check for $400 from the University of Oregon’s 
Cardiopulmonary and Respiratory Physiology Laboratory. If subjects do not complete all study 
procedures or violate the study rules (such as drinking alcohol or excess caffeine or violating CDC 
guidelines for lessening COVID-19 exposure risks), payment will be prorated based on the above 
compensation schedule, e.g., if subjects complete baseline screening and performance stabilization 
before dropping out they will be paid $100. Subjects who do not comply with the study rules will be 
housed until they are able to be sent home on the next available flight without excessive costs to the 
investigators and will be paid only for the portions of the study they have completed before they 
were removed from the study.  
 
E.   Informed Consent Process 
Informed consent will be administered to each subject by the PI and colleagues. The PI is well versed 
in the process of informed consent and has trained his co-investigators thoroughly on how to best 
perform this procedure. The PI will ensure that all investigators obtaining consent have experience 
in the informed consent procedure and are capable of adequately discussing the related physiology, 
study procedure and potential risks. 
 
The researcher will first verbally explain the study in its entirety and in doing so walk through the 
informed consent in person or via an online video conferencing service. Subjects will then be given a 
sufficient length of time to read through the informed consent form privately and 
instructed/encouraged to write down or remember any questions/concerns they may have. 
Afterward, the researcher will rejoin the subject and address any question or concern they may have 
while subsequently going back through the informed consent form with the subject and obtaining 
any needed initials and signature at the end of the document. Furthermore, the investigator will 
verbally address any questions the subject may have regarding the seriousness and/or likelihood for 
the occurrence of the risks described in the Informed Consent Form.  The research team will 
address probability and severity of any adverse reactions with the subject by carefully explaining the 
statements regarding probability and severity contained within the Informed Consent.  The 
investigator will also provide appropriate statistics (where available) regarding the probability of 
adverse reactions.  The investigator also advises the subject of what he/she can expect to feel during 
a particular procedure, for example, during contrast injection.  Investigator further explains any 
questions regarding physiology or reason for a particular procedure in plain language. 
 
This process will be done either in person when they arrive for their physical exam and informed 
consent visit or done via an online video conferencing service prior to coming to the lab for their 
physical exam. Remote informed consent via an online video conferencing service will be conducted 
in groups sized 1-20, and we will allow individual subjects to ask questions privately in breakout 
rooms. Subjects will be asked to sign the informed consent once they arrive for their first visit to the 
lab. 
 

Before all tests, the subject will be telephoned or e-mailed (depending on preference) or told in 
person (while in Colorado) to confirm participation, remind them of the activities that will take place, 
checking for questions, and confirming continued interest and as a reminder to: 1) stay hydrated by 
drinking at least 2 liters of water a day, and 500 ml the morning of the test day; 2) to limit caffeine 
intake to the equivalent of two 8 oz cups of coffee a day; 3) limit exercise to that prescribed in the 
study design; with no exercise the day before the VO2Max, APFT and 5K tests; and 4) for exercise 
tests to time their eating so 1-2 hrs elapse between last meal and heavy exercise (VO2Max, 5K run or 
ruck hike). In addition, subjects will be emailed (while in Oregon) or reminded in person (while in 
Colorado) to complete their COVID-19 compliance survey prior to arriving to the lab.  
 
A copy of the consent will be posted after the trial is closed to recruitment and no later than 60 days 
after the last visit by any subject in this study. 
 
F.   Provisions for Participant Privacy and Data Confidentiality 
Each subject folder will be stored in locking file cabinets inside the primary investigators’ locking 
offices (Dr. Andrew Lovering, Dr. Robert Roach, Dr. Andrew Subudhi, or Dr. Joseph Duke). All other 
computer files associated with the subject will be identified only through their unique subject ID and 
stored on password protected lab computers. The de-identified data will be kept for at least 7 years 
after publication, per NIH guidelines. In the unlikely event the data are not published, they will be 
kept for at least 10 years after collection. This will ensure sufficient time for publication after data 
have been collected considering some trainees take up to 6 years to graduate, and often publication 
does not occur until many years after graduation. 
 
Each subject will be assigned an ID using a random number code system consisting of three to five 
letters describing the study (e.g., COAST) and a random, non-repeating number (1-1000). This ID will 
be associated with their data folder, which will contain all study documents and data collected 
including all associated forms (i.e. informed consent document). 
 
The PI will maintain a subject ID key capable of identifying subject IDs to subject names and contact 
information to provide us with the ability to identify subjects as additional questions or research 
findings arise. This ID key will be kept in a locked filing cabinet also within the office of the primary 
investigator. No contact information will be stored with subject data.  
 
De-identified data may potentially be shared with other investigators for research purposes. 
 
Specimens collected for research will be de-identified using the subject’s unique ID and stored at the 
University of Oregon until future analysis. Blood collected to be analyzed by a third party (QUEST 
diagnostics) will be labeled with the subject’s ID and birthdate, as required by QUEST, and results 
from those tests will be available only to members of the Lovering lab who have access to the 
password protected QUEST Quanum online platform. No subject names are included online or on 
their specimens, and all specimens get destroyed after analysis.  
 
G.   Potential Research Risks or Discomforts to Participants 
Confidentiality: 
If data is lost or stolen, subjects could experience invasion of privacy. To minimize the potential 
invasion of privacy, we are not collecting social security numbers so that the potential economic 
impact is greatly minimized. All of our files will be kept in a locked filing cabinet to prevent theft and 

data will be de-identified. Data acquired on computers will be password protected. As such, the 
probability of the adverse outcomes discussed above is low, and the severity is minimal. 
 
Psychological: 
For the echocardiography tests, female subjects will need to have no sports bra on to allow for 
imaging of the heart and the placement of small electrodes on the chest to record heart rate. To 
avoid any discomfort, subjects will be given a large, loose-fitting shirt (provided by researchers) to 
cover up. Male subjects will either go shirtless or be given a loose-fitting shirt. As such, the 
probability of the adverse outcomes discussed above is low, and the severity is minimal. 
 
Physiological: 
Travel: All subjects will be transported between Eugene and Colorado by automobiles and 
airplanes. Travel by road or air, carries the risk of injury or death. According to the National 
Transportation Safety Board, there are 0.0003 fatal accidents for every 1,000,000 miles flown by US 
carriers. The National Highway Traffic Safety Administration reports a fatality rate of 1.13 per 
100,000,000 miles driven on US roads. To minimize this risk, only commercial, US carriers will be 
used for air travel and all traffic laws will be strictly obeyed. 
 
Pulmonary Function Tests: Risks associated with pulmonary function testing include shortness of 
breath, cough, dizziness, and possible loss of consciousness. To minimize risks, the co-investigators 
will administer all pulmonary function tests and allow subjects to rest between measurements.  
Lung function testing performed in our lab is a routine assessment performed in pulmonary 
function labs all over the world according to American Thoracic Society and European Respiratory 
Society standards. Subjects can stop the test at any time if they feel any of the above symptoms.  
The probability and severity of these risks is very low. 
 
VO2MAX testing: Subjects will perform a VO2max test where they exercise to volitional exhaustion.  
Criteria for terminating a VO2max include achieving: 1) heart rate >85% of age-predicted max (220-
age), 2) a plateau in oxygen consumption and/or a respiratory exchange ratio >1.15; all of these 
criteria are continuously monitored on our metabolic system and Nellcor pulse oximeter. This 
carries the rare risk of dizziness, confusion, nausea, fatigue, difficulty breathing, abnormal heart 
rhythms, stroke, heart attack, and sudden death. In subjects less than 35 years old, the risk of 
sudden death of all causes is estimated to be 1 in 133,000 for men (Van Camp et al MSSE 1995).  In 
this study only 100 of 136 deaths with identifiable causes were caused by cardiac events, so this 
estimate of risk may overestimate incidence of cardiac events.  In the event of a cardiac event, 
research personnel will respond in a manner appropriate to their level of training. All graduate 
students, study coordinators, and PIs are minimum CPR/AED/first aid certified and will therefore 
immediately call emergency services and perform CPR if appropriate. The overall risk of sudden 
death caused by a heart problem for all ages and sexes is estimated to be 1 in 15,000 to 18,000. 
(Source: American College of Sports Medicine - ACSM). As such, the probability of the adverse 
reactions discussed above is low, and the severity is very low (e.g. dizziness) to very high (e.g. 
sudden death). 
 
Additional exercise tests (APFTs, 5k run, and rucksack carry): Hard exercise has inherent risks 
associated with it, including stroke and heart attack. These risks are very low in young, healthy 
individuals (less than 0.00006%). Subjects may also feel dizzy, lightheaded, or unusually winded. 
These symptoms can be worse during exercise at high altitude. If subjects feel faint or feel like they 

can’t get enough oxygen, subjects will be instructed to tell study personnel as soon as possible. For 
field exercise tests, like the rucksack carry, research personnel will be stationed at various points 
along the course, including the start point, turn-around point, and various mid-way points. All 
research personnel will be equipped with subject lists, and each subject will wear an identifiable 
running number on their clothing. Therefore, if a subject feels feint during this test, they will be close 
to the aid of research personnel and easily identifiable to the research team. Subjects may 
experience muscle injury and stiffness following exercise. Proper warm-up and cool-down 
procedures will minimize the chances of this occurring. 
 
 Risks associated with core temperature pill: The risks of using the temperature pills include 
mechanical injury to the mucus membranes if adequate care is not used. Risks of the temperature 
pill will be minimized by explaining the procedures to the volunteers. Additionally, ample lubricant 
(suppository) or water (oral) will be provided to the volunteer. Volunteers with history of obstructive 
diseases of the gastrointestinal tract including diverticulosis, diverticulitis, inflammatory bowel 
disease, peptic ulcer disease, Crohn's disease, ulcerative colitis, or previous GI surgery will not use a 
telemetric pill. 
Hypercapnia during rebreathing tests: Risks associated with breathing hypercapnia (high carbon 
dioxide) at rest include feeling light-headed, headache, fatigue, dizziness, shortness of breath. Subjects 
will be monitored with a peripheral estimate of arterial oxygen saturation using a forehead monitor to 
ensure you are well oxygenated and we will continuously monitor inspired and expired oxygen and 
carbon dioxide levels.  As such, the probability of the adverse reactions discussed above is moderate, 
and the severity is minimal. 
 Intravenous catheter:  Risks associated with placement of an IV include pain and/or bleeding 
during placement, vasovagal syncope, hematoma (pooling of blood under the skin), infection, and 
vessel blockage. The placement of the IV may cause some discomfort with rare bleeding or bruising 
at the puncture site. It also carries the risk of infection. To mitigate risks associated with vasovagal 
syncope, the subject will be safely positioned upright and sitting in an IV chair, and the subject will 
be continually monitored by Dr. Lovering and colleagues, all of whom are trained to place IVs. As 
such, the probability of the adverse reactions discussed above is low, and the severity is minimal. 
 
Blood Removal: Risks associated with the removal of blood include an aversion to seeing blood that 
could result in nausea, vasovagal syncope, increased stress, and/or feeling faint. To mitigate these 
potential risks, the subject is continually monitored by Andrew Lovering PhD and colleagues. In 
addition, the subject is safely and comfortably positioned on a gurney or cot. In this way, the 
potential risk of vasovagal syncope (i.e., fainting) is mitigated.  
 
 A total of ~435-465 mL of blood will be drawn throughout the study. The range up to 465ml is 
included in case extra samples are required for screening metabolic panels due to abnormalities in 
findings or compromised samples. Of that volume, 25mL will be drawn baseline day 1 as part of the 
physical examination. In total, ~162 mL will be drawn prior to departure to Colorado for metabolic 
panels, biomarker analysis, dried blood spots, Hb mass, and p50. An additional ~213 mL will be 
drawn during the 2 weeks at high altitude (max volume of ~71mL per day), and ~60 mL will be drawn 
as part of post-altitude testing. 1 pint of blood, the normal volume of blood donated on a given day, 
is ~473mL. Throughout the entire study, we will be taking less than that, and the maximum volume 
for a given day does not exceed ~76 mL. As such, the probability of the adverse reactions discussed 
above is low, and the severity is minimal. 

 
The following table is meant to breakdown the volume of venous blood that will be drawn on a given 
day, as well as what it will be used for:  
 
 
  
 Saline Contrast Echocardiography:  The PI has been using saline contrast echocardiography since 
2003 to detect blood flow through intracardiac and intrapulmonary shunts.  Risks: transient 
dizziness associated with agitated sterile saline injection in patients with cardiac shunting. With 
respect to exercise, the Principal Investigator has >10 years of experience using TTSCE in a research 
setting. In 4 years (2003-2007) at the University of Wisconsin Madison, approximately 60 human 
(male and female) subjects (including 8 subjects with a patent foramen ovale) were tested without a 
single adverse event related to TTSCE. Additionally, research done at the University or Oregon 
between 2008 and 2016 has involved >100 subjects using TTSCE at rest and during exercise without 
incident related to the TTSCE. We will use agitated sterile saline without preservatives. Furthermore, 
we will use a minimal volume (3-5 mL) of sterile saline. Dr. Lovering and colleagues will perform 
saline contrast injections, while a trained ultrasonographer will perform echocardiography. Mixed 
saline (saltwater), either alone or with 5% sugar in water has been used to help see the 
ultrasound pictures (echocardiogram) for over thirty years.  Saline contrast bubble injections 
are routinely used to screen for the presence of a patent foramen ovale in the clinic.  The American 
Society of Echocardiography Guidelines (2014) state that “…life threatening reactions are rare (<1 in 
10,000)” when using contrast injections (including bubbles with protein shells) and The European 
Association of Echocardiography (2009) has stated that “… the evidence shows that contrast 
echocardiography is very safe in clinical practice.” And this includes using stabilized bubbles with 
protein shells and we only use non-stabilized saline contrast bubbles in our lab.  We only use a small 
amount of air mixed with saline, thus the probability of any severe adverse reaction is very low. 
Given the evidence presented above, the probability of the adverse reactions discussed above is 
low.  Although the severity of arterial gas emboli is high, given the amount of air used and the short 
life span of intravascular bubbles of this size, the likelihood of the constellation of unfortunate 
events required for a serious adverse reaction to occur is very small. 
 
Hb mass measurement: Risks associated with CO determination of blood volume include exposure 
to carbon monoxide.  Most non-smoking city dwellers have 1.5-2.0% CO in their blood and the 
duplicate tests will increase it to ~15%.  The level most commonly associated with symptoms is 
>15%, with no symptoms reported at 10% or lower. Minor symptoms are present when CO levels 
rise to 30%. These symptoms may include: confusion, headache, fatigue, nausea, shortness of 
breath, dizziness, cough, and cherry-colored lips. To protect against an excessive increase in CO we 
 
Informed consent 
Baseline 6 
Post Treatment 
Altitude 1 
Altitude 7 
Altitude 13 
Post-altitude 
Screening panels 
25 mL 
5mL 
None 
None 
None 
None 
None  
Biomarkers 
None 
60 mL 
60 mL 
60 mL 
60 mL 
60 mL 
60 mL  
Hb Mass & p50 
None 
10 mL 
None 
10 mL 
10 mL 
10 mL 
None 
Dried blood spot 
None 
0.08 mL 
0.08 mL 
0.08 mL 
0.08 mL 
0.08 mL 
None  

will only test individuals whose baseline CO level is 3% or less.  Further, if an individual’s post-CO 
rises to 20% or higher following the duplicate test we will initiate oxygen therapy. This will have 
subjects breathe 100% oxygen for 10 min, which reduces the CO half-life from 5 hours to 80 minutes 
and is the approved therapy used in a clinical setting to treat CO poisoning.  In the unlikely event 
that a subject’s CO bound to hemoglobin is excessive and does not appear to be responding to O2 
therapy we will call appropriate police dispatch, depending on the location of the incident (Eugene, 
OR or Colorado). This method has been in use in research in a wide variety of populations to 
measure Hb mass including elite athletes (male and female), untrained individuals (male and 
female), adolescents (11-15 year old boys and girls), elderly subjects, and pregnant women with no ill 
effects reported. The use of CO as a marker for measuring blood volume has been in use for over 
100 years without notable complications. Subjects will be verbally reminded of the symptoms 
associated with increased carbon monoxide levels prior to their participation in the CO uptake test 
and will be asked to notify researchers if they are experiencing any of the side effects of carbon 
monoxide during or after the test. 
  
Altitude associated risks: Staying at high altitude causes systemic hypoxia. This decreased 
oxygenation can lead to several things depending on how high one goes, how fast one goes there, 
and how well adjusted to high altitude one is. The consequences can range from mild to severe.  
  
The most common symptoms of high altitude exposure are feeling lightheaded, dizzy, or short of 
breath during exercise.  We expect up to 40% of people to feel one of these things while at high 
altitude. A smaller number of people will develop acute mountain sickness (AMS). AMS is a name for 
the combination of headache and lack of appetite, difficulty sleeping, upset stomach, throwing up, 
or feeling weak. These symptoms are usually temporary and manageable. They typically do not 
threaten peoples' health. Participants will not be treated for AMS symptoms and AMS should be 
gone by day 3 at the altitudes studied and therefore very unlikely to overlap with COVID symptoms 
and COVID testing will occur 4-5 days after arrival to Colorado to confirm the presence or absence of 
COVID infection.  In addition, while PFO+ subjects have shown to have increased susceptibility to 
AMS, this illness is non-life threatening and does not increase risks for those with a PFO traveling to 
altitude. More severe altitude illness will be identified and treated as outlined below. 
  
Traveling from sea level to high altitude can, in rare occasions, lead to more serious conditions. Two 
of these include high altitude pulmonary edema (HAPE) and high altitude cerebral edema (HACE). 
Both of these conditions are potentially fatal if left untreated. HAPE is a serious disorder that 
sometimes occurs with a fast change in altitude (going up). It occurs in less than 1% of people going 
from baseline to altitudes used in this study. The APFT will be at 9,075 feet above baseline. The 
uphill hike will start at 10,627 feet and go to 12,595 feet. Subjects will sleep at 10,570 feet. This 
sleeping altitude is not expected to produce HAPE. HAPE symptoms are treatable if found early. 
They usually show up 2-3 days after ascent to high altitude. HAPE may be preceded by AMS. The 
inability to breathe while resting is the hallmark of HAPE. Subjects may also have a bad cough, blue 
lips, fever, or fast heart beat. Subjects will be instructed to immediately notify study personnel if they 
feel out of breath at rest. Suspected HAPE cases will be treated by a doctor familiar with the 
condition.  
  
The other serious complication of high altitude is HACE. HACE is very rare. The possibility of seeing 
HACE is extremely low. In our previous studies involving >150 volunteers at these altitudes in 
Colorado, HAPE and HACE have never been seen. As with HAPE, it is treatable if recognized early. 

Loss of coordination and mental confusion are the major symptoms of HACE. HACE victims typically 
show AMS or HAPE first. If a subject starts to behave irrationally or appear very uncoordinated, they 
will be treated by a doctor immediately.  
  
To protect subjects during their stay in Colorado, we will monitor them in several ways. Their oxygen 
levels will be monitored with a standard finger oximetry (Nellcor N-200). Subjects will also fill out a 
questionnaire designed to quantify the level of AMS they are experiencing, if any. Furthermore, 
subjects will be monitored for other signs that they are proceeding down a path that may threaten 
their health. These include severe AMS symptoms: a severe headache that does not go away, 
uncontrolled vomiting, extreme dizziness, or excessive weakness. Other signs include: blue 
fingernails, trouble breathing while resting, unsteady walk, extreme paleness, or incoherent or 
bizarre behavior. In the event that the research team notices these signs and symptoms, they will 
call emergency services immediately so that appropriate medical personnel can treat these 
symptoms. The research being done in Colorado, whether in Leadville or Breckenridge, will occur in 
and around town and will never be far from hospital care or quick emergency transport. Oxygen and 
transportation back to Denver will be available at all times. In the event of a life-threatening 
emergency, we will call 911. Although we do not expect most of these symptoms to develop, we 
cannot rule out the possibility. It is important to note that the combined experience of the research 
team amounts to over a century of doing this type of study with no severe adverse events in that 
time. 
 
During the rucksack carry, there is cell phone service throughout the hikes. Subjects are 
accompanied with research teams ahead of and behind the subjects, with research assistants setup 
along the trail with radios (walkie talkies) to contact the teams ahead of and behind the runners with 
updates on participant status. The Colorado group has completed over 300 runs with research 
subjects in these exact same conditions with no medical adverse events to date. Any of the vehicles 
we will be driving can transport a subject to the Frisco medical center within 15-20 minutes. In 
Leadville, St. Vincent Health Hospital is 1.4 miles from College Mountain College (where subject’s will 
be staying) and subjects can be transported within 5-10 minutes. A physician will be on the course 
with a vehicle, with supplemental medical oxygen, and a full field first aid kit at all times subjects are 
on the course. 
 
There are also risks of being in the mountains. The most significant environmental risks include 
lightning strikes, traumatic injury from falls in rough mountain terrain, and sunburn from the higher 
UV-light exposure. These risks will be minimized by requiring subjects to remain in the vehicle or 
indoors during electrical storms; by prohibiting subjects from any rock climbing activity, and by 
making subjects aware of the sunburn risk and supplying them with sunscreen. Finally, the 
investigators have more than three decades of experience conducting field research and dealing 
with these challenges,4-64 including recent experience with an identical protocol in identical 
mountain setting with nearly identical testing procedures and with no serious unanticipated 
outcomes. 
 
Risks associated with drug interventions: Some of the known risks associated with EPO are joint/ 
muscle/bone pain, fever, cough, rash, nausea, vomitting, soreness of mouth, itching, headache, 
redness and pain in the skin where EPO shots are given, myocardial infarction, stroke, venous 
thromboembolism, thrombosis of vascular access, and tumor progression or recurrence. Some of 
the known risks associated with iron are pain and swelling at the site of injection. In order to 

minimize these risks, all precautions and warning labels will be followed, and dosing volumes will be 
strictly adhered to. Serious allergic reactions to this drug are unlikely, but may include: rash, 
itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing. Subjects 
will be excluded from the study for any health problems that may negatively effect their reaction to 
these drugs (see table of inclusion and exclusion criteria and drug appendices for specific exclusion 
criteria). FDA recall lists for drugs being administered to participants will be checked weekly 
beginning with the initiation of drug administration. 
 
Risks for subjects who are pregnant: Potential risks to subjects who are pregnant (beyond the 
risks outlined above for the general population) include exercising beyond than what is 
recommended by their doctor (see ‘VO2max testing’ and ‘additional exercise testing’ above) and 
potential unknown risks to the child bearer or fetus from carbon monoxide inhalation (see ‘Hb mass 
measurement’ above). None of the additional risks described above are greater in those who are 
pregnant. Due to the increased risk of exercise testing and Hb mass measurements, any subject 
with childbearing potential will be required to take a pregnancy test on a day that involves maximal 
exercise testing (VO2max) and Hb mass testing while at baseline and in Colorado, and if such a test 
comes back positive, they will be immediately excluded from the study. Therefore, there is no added 
risk to the child bearer or the fetus from any of the above-mentioned protocols, as they will not 
undergo those procedures. As such, the probability of an adverse reaction is zero, and the severity 
of an adverse reaction is zero. 
 
COVID-19 related risks: Due to the SARS-Cov2 pandemic, there is the added risk of COVID-19 
infection for subjects and staff in this study. To mitigate this risk, all research personnel will be 
fully vaccinated before the initiation of any study (see below).  Additionally, per standard 
protocol, all mouthpieces will be disinfected with Cidex and all surfaces wiped with disinfecting 
wipes between participants. Researchers will wear appropriate PPE, including masks, lab coats or 
scrubs, safety glasses, and gloves. Additionally, proper social distancing can be done with the most 
protocols described above, i.e. maintaining 6 feet between participants and researchers. When 
possible, testing will be performed outdoors to maximize social distancing (i.e. during 5km and 
uphill rucksack tests).  While the severity of COVID-19 infection has the potential to be severe even in 
our young subject population, the measures described to mitigate this risk make the likelihood of an 
event low. Subjects will also be reminded during the consent process and throughout the study that 
failure to comply with these precautions will result in their removal from the study. Subjects will be 
cohabitating in Colorado so to minimize COVID outbreaks subjects will be assigned to research 
groups of 4-5 so that if one subject develops COVID, we can minimize transmission within our other 
groups.  Subjects will wear masks, wash hands frequently and will have hand sanitizer in each room 
while cohabitating. In addition, we have created a COVID-19 plan outlined below, including 
additional precautions during travel, exposure scenarios, vaccination requirements, etc.  
 
COVID-19 plan 
All research team members and subjects will be required to be fully vaccinated prior to beginning 
the study. Subjects’ vaccination cards will be scanned, and identifiable data (name, birthday, etc.) will 
be blacked out prior to photocopied vaccine card being added to subject folders. Subjects will be 
considered fully vaccinated to the extent that is recommended by the CDC and University of Oregon 
(for example, if a booster shot is recommended and available, subjects and researchers must 
receive it).  
 

Prior to departure to Colorado, subjects will self-monitor symptoms and be told to not come in to 
the lab if they experience any symptoms of COVID and get tested if recommended by current CDC 
and University of Oregon guidelines. While in Colorado, research team members will screen all 
participants daily for symptoms and signs of COVID. If subjects report symptoms that suggest they 
have COVID, transportation will be provided to the closest COVID testing center. The subject or the 
subject’s insurance company will be responsible for costs related to the COVID test, if there are costs 
incurred. If the subject’s COVID test is positive prior to or while in Colorado, they will be withdrawn 
from the study and they will be treated by local medical personnel according to CDC guidelines. The 
subject or the subject’s insurance company will be responsible for any costs related to medical care 
for COVID. Research team members will check on subjects closely and will work to arrange safe 
transportation back to Oregon when the medical personnel tell us it is safe for them to travel.  
 
Compensation for an injury or assistance with medical bills resulting from the subject’s participation, 
including contracting COVID, in the course of this research is not available from the University of 
Oregon or Research Logistics LLC.  If subjects get sick or injured as part of your participation in this 
study, the subject or the subject’s insurance provider will be charged for the cost of the care.  
 
COVID Compliance protocol 
Compliance to CDC guidelines for minimizing risk of exposure to COVID-19 must be adhered to by 
all participants for the duration of the study. In order to hold participants accountable, subjects will 
be emailed a Qualtrics survey to check ‘yes, I have been following appropriate COVID protocols’, or 
‘no, I have not been following appropriate COVID protocols’ in their reminder email prior to every lab 
visit in Oregon. Subjects will also be required to fill this survey out starting weekly 30 days prior to 
departure to Colorado. Participants will be required to fill out this survey daily while in Colorado 
reporting that they are following CDC guidelines and will have the opportunity to report pod mates 
who are no following guidelines. Additionally, each week the participants will be updated on any 
changes to CDC guidelines which will be included as part of the survey. 
 
COVID transportation protocol 
Participants will be given a “covid-19 travel bag” which will include one 4 oz bottle of hand sanitizer 
(minimum 60% alcohol), 3 KN95 masks, and several alcohol wipes. We will ask the participants to do 
the following while traveling:  
• 
Before walking into the airport: put KN95 mask on, this will stay on the entire duration of 
airplane travel 
• 
When seated on airplane use alcohol wipes to disinfect all touch surfaces by the seat 
including the lap tray, buckle, arm rests, overhead light/air controls, and if in window seat, 
the window screen pull. Then, use hand sanitizer to clean hands. 
• 
After exiting the airport in Colorado trash the first KN95 mask and replace with a fresh one, 
this mask will be used for the duration of the bus ride to Leadville or Breckenridge. Use hand 
sanitizer. 
• 
When seated in the bus, use alcohol wipes to disinfect all touch surfaces by the seat. Use 
hand sanitizer. 
• 
Upon arrival to Leadville or Breckenridge, trash the bus KN95 and replace with a fresh mask. 
Use hand sanitizer.  
• 
Participants will be given a new “covid-19 travel bag” when they depart from Colorado so 
that their travel back may be as safe as possible. They will be expected to follow the same 
protocol for traveling to Eugene as they did while traveling to Colorado. 

 
COVID testing protocol 
If at any time during a subject’s stay in Colorado they experience symptoms of COVID, they will be 
given a COVID test and their pod will be quarantined.  
 
Safety Equipment available in the Cardiopulmonary and Respiratory Physiology Laboratory 
(where all testing and screening will be performed):  Phillips FRx AED, a spare AED battery, and 
spare AED pads, bottled oxygen and face masks, all necessary equipment to run ACLS algorithms 
(suction, masks, breathing bag, etc.) and ACLS drugs such as chewable aspirin, and oxygen will be 
administered as required by AHA and ACLS guidelines. Additionally, a standard first aid kit is also 
available.   
 
Emergency Procedures:  According to American Heart guidelines, in the event of an adverse 
cardiopulmonary event, we will begin CPR, call 911 (as directed by U of O EH&S), and will continue 
CPR as required until emergency medical personnel arrive. Epinephrine auto-injectors (Epi Pens) will 
be available if the PI and colleagues judgement and/or 911 operator supported a decision to use an 
Epi Pen. In addition, a separate emergency procedure document is included.  
 
Safety Monitoring: Subjects will be given clear instructions that they should notify the investigators 
immediately if they experience any of the above-mentioned risk symptoms.  During the VO2max test and 
recovery procedures, all subjects will be non-invasively and continuously monitored for vital signs 
using a forehead monitor to monitor arterial oxygen saturation and heart rate. During all other 
procedures subjects will be visually monitored for any signs of discomfort, distress or problems.  
During both exercise and resting procedures, the investigators will continuously ask the subjects 
how they are feeling and how they are doing. If subjects have ingested a core temperature pill they 
will be given an orange safety bracelet (no MRI) to wear until the study staff can ensure the pill has 
been passed. 
Medical Monitor: Dr. Bill Cornwell, MD, University of Colorado, Colorado Springs (UCCS) will serve 
as the medical monitor for this study. Dr. Cornwell will receive regular reports on volunteer status. 
He will also evaluate adverse event reports and monitor study progress. He will discuss research 
progress with the PI on a weekly basis. He will promptly report discrepancies or problems to the IRB 
of record and the HRPO. He shall have the authority to stop this research study in progress, remove 
individual subjects from a study, and take whatever steps are necessary to protect the safety and 
wellbeing of research subjects until the IRB can assess their report. The medical monitor is required 
to review all unanticipated problems involving risk to subjects or others, serious adverse events and 
all subject deaths associated with the protocol and provide an unbiased written report of the event. 
At a minimum, the medical monitor will comment on the outcomes of the event or problem and in 
case of a serious adverse event or death, comment on the relationship of the event to participation 
in the study. The medical monitor will also indicate whether he concurs with the details of the report 
provided by the PI. Reports for events determined by either the PI or medical monitor to be possibly 
or definitely related to participation and reports of events resulting in death will be promptly 
forwarded to the USAMRMC ORP HRPO. 
H.  Potential Benefits of the Research 

This study will not improve the health of subjects and is only being done to gather information. This 
study will not improve the health of the general subject population. Completing the aims of this 
study will have the benefit of contributing to generalizable knowledge. 
 
I.   Investigator Experience 
The PI and Co-Investigators colleagues have been performing cardiopulmonary and respiratory 
physiology investigations at rest and during exercise in healthy and diseased populations at the 
University of Oregon for ~10 years. Dr. Lovering’s CV is on file. Notably, Drs. Lovering, Subudhi and 
Roach successfully completed the 2012 AltitudeOmics research project which was also based in 
Oregon and Colorado, and also involved the safe transport and study of 21 research subjects to very 
high altitude in Bolivia. That study resulted in no serious adverse events in any research subject, and 
in more than 20 research publications. 
 
The PI trains all graduate and undergraduate personnel on all laboratory procedures and protocols. 
Ultrasound technician Eben Futral, RDCS has worked with Dr. Lovering’s group for years as well 
(Futral ~5 years). Futral, a registered diagnostic cardiac sonographers (RDCS), has performed 
thousands of resting and stress echoes in patients and research subjects. 

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