Safety and Efficacy of the Noxsano Wound Care Bandage: A First in Human Study
Phase: NA
Conditions: Wound Heal, Peripheral Artery Disease, Ulcer, Leg, Ulcer Foot, Diabetic Foot Ulcer, Arterial Insufficiency
Sponsor: OhioHealth

Study Title:  Safety and Efficacy of the Noxsano Wound Care Bandage: A First-
in-Human Study 
 
Protocol Approval Date: September 21, 2021  
 
NCT Number: NCT04123093 

STUDY TITLE: 
Safety and Efficacy of the Noxsano Wound 
Care Bandage: A First-in-Human Study
PRINCIPAL INVESTIGATOR:
Mitch Silver, DO, FACC, FSVM, RPVI
OhioHealth
Heart & Vascular Physicians
614-262-6772
Mitch.Silver@ohiohealth.com
EXTERNAL INVESTIGATOR:
Brad Mehl, DPM, FACFAS
Step Lively Foot & Ankle Centers
Podiatrist
614-891-9994
Bmehl99@gmail.com
Eric Anderson, DPM
Complete Foot and Ankle Specialists
Podiatrist
937-599-4852
Ftdoc18@gmail.com
SPONSOR: 
Mitch Silver, DO, FACC, FSVM, RPVI 
SUPPORT/FUNDING:
            Noxsano, Inc.
SUPPLIED DEVICE:
Noxsano Bandage
VERSION NUMBER:
6.0 
VERSION DATE:
February 23, 2021
IRB NUMBER:
1331496
IRB# 1331496
Page 1
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

SUMMARY OF CHANGES
Protocol 
Date
Section
Change
Initial IRB approval
07/11/2019
1.3.5, 3.3
Spelling and grammatical errors corrected
07/11/2019
5.5
Specified that any member of study staff can shave posterior leg area
0711/2019
5.6
Removed reference to Dr. Mehl and specified that the principal 
investigator or sub-investigator may apply and remove the study 
device for Healthy Volunteers.
7/19/19
4.1.2
Inclusion of OhioHealth associates in the healthy volunteer study 
population
7/19/2019
5.12
Removal of mechanism of payment from compensation language
9/24/19
5.1
Location change for the baseline visit for Healthy Volunteers
9/24/19
7.3, 8.7
Updated IRB reporting requirements 
12/17/19
5.1, 5.7
Updated Visit Requirements
12/17/2019
5.6
Removed  reference  to  Dr.  Mehl  and  specified  that  principal 
investigator  or  sub-investigator  may  apply  or  remove  the  study 
device for wound care patients
12/17/19
4.1.1
Location change for the baseline visit for Healthy Volunteers
12/17/19
5.3, 5.6
Removed  reference  to  Dr.  Mehl  taking  all  measurements  for 
consistency  and  specified  that  current  procedures  used  by  the 
Critical Limb Heart and Vascular Clinic nursing staff will be used to 
ensure consistency of all wound measurements.
12/17/19
5.3
Defined  minimum  standard  wound  measurements  completed  by 
nursing staff per Critical Limb Heart and Vascular Clinic protocol
02/23/2021
Protocol 
Summary, 
2.2,  3.3, 
5.1, 5.8, 
Changed the study visit schedule for Group 2 from once weekly 
visits during the first four weeks of the treatment period to two times 
per week for up to 4 weeks. 
02/23/2021
4.4, 4.5
Clarification to Group 2 inclusion and exclusion criteria was made to 
specify which criteria are specific to the wound to be treated with the 
Noxsano bandage. 
02/23/2021
4.5
Separated  Group  2  exclusion  criteria  for  patients  with  arterial 
insufficiency and diabetes
02/23/2021
5.0
Renumbered sub-headings to align with the order presented in the 
schedule of events in section 5.1
02/23/2021
5.3
Clarification  that  wound  photographs  are  also  taken  during  the 
treatment period
02/23/2021
5.4
Edited to add that wound measurements will be collected in the 
REDCap  data  collection  tool.  Removed  reference  to  other 
measurements and descriptors performed per standard of care that 
will not be collected in the REDCap data collection tool. 
IRB# 1331496
Page 2
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

Protocol 
Date
Section
Change
02/23/2021
5.1,  5.5, 
5.8,  5.9, 
5.10
Edited to add study assessment of percent granulation tissue
02/23/2021
5.7
Edited to add that shape of the wound can also be used to determine 
the size device to be used 
02/23/2021
5.8, 5.10
Edited to add after hours contact number for Dr. Anderson 
02/23/2021
5.11
Clarified  language  that  wound  healing  is  evidenced  by  a  50% 
decrease in wound surface area.
02/23/2021
5.11
Edited to add that missing two consecutive follow-up visits for 
Group 2 subjects will result in efforts to contact the subject and 
establish if they are lost to follow-up. 
02/23/2021
5.11
Edited to add that subjects may be offered the option to have data 
collected on wound progression after they withdraw from the study. 
02/23/2021
10.0
An addendum was added to the protocol to describe two adverse 
events related to the Noxsano study device and outcomes from the 
OhioHealth Institutional Board review of these events. Information 
included about bandage updated to have softer edges. 
IRB# 1331496
Page 3
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

STUDY SCHEMA
IRB# 1331496
Page 4
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

PROTOCOL SUMMARY
STUDY TITLE
Safety and Efficacy of the Noxsano Wound Care Bandage: A 
First-in-Human Study
STUDY PHASE
Safety and efficacy 
DEVICE
Noxsano Bandage
OBJECTIVES
Group 1 (Safety): Healthy Volunteers.  The initial phase of the 
study is designed to determine the safety of the study device in 
healthy volunteers without wounds. If there are no issues with 
tolerance, side effects, and/or adverse reactions in healthy 
volunteers, the second phase of the study will proceed with 
active wound care subjects.
Group 2 (Efficacy): Wound Care Subjects. The second phase of 
the study is designed to determine the effectiveness of the study 
device on wound healing in subjects with active wounds (see 
Primary Endpoint below), and to determine if the study device 
is equivalent to standard and established techniques (standard 
techniques demonstrate 50% wound healing at 2 months).
STUDY DESIGN
This study is a prospective, interventional, non-randomized, 
sequential phase study designed to assess the safety and 
efficacy of the Noxsano Bandage (study device) in subjects 
with a diabetic lower extremity ulceration and/or arterial 
insufficiency lower extremity ulceration.
SUBJECT 
POPULATION
Group 1: Initial subjects will be limited to healthy volunteers 
without wounds. Five (5) white subjects and 5 black or African 
American subjects will be enrolled to evaluate skin differences.  
Group 2: Ten (10) wound care subjects with lower extremity 
ulceration attributed to diabetes and/or arterial insufficiency. 
NUMBER OF 
SUBJECTS
20 subjects will be included in the analysis (10 healthy 
volunteers for Group 1, and 10 active wound care subjects for 
Group 2).  
NUMBER OF SITES
One site located at Riverside Methodist Hospital.
PRIMARY 
ENDPOINT
The primary endpoint for this study is wound healing (Group 
2), as defined by the percent change in wound surface area 
(surface area is calculated in cm2) from baseline through the 
active treatment period. 
SUBJECT FOLLOW-
UP
Group 1: The initial healthy volunteer safety study will last a 
total of 4.5 weeks.  Healthy volunteers will have the study 
device applied for 3 consecutive days (up to 72 hours), 
followed by weekly visits for 4 weeks of observation for 
tolerance, side effects, and adverse reactions. 
Group 2: The wound care subject treatment period will consist 
of up to 3 consecutive months of study device application to a 
specific ulceration. The study device will be changed two times 
per week for up to 4 weeks from the start of treatment and then 
IRB# 1331496
Page 5
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

weekly for the remainder of the study treatment period. At the 
conclusion of the treatment period, subjects will be followed 
every 3 months for 12 consecutive months for observation of 
late side effects and/or adverse reactions (up to 3 months of 
active treatment, 12 months of follow-up observation, 15 
months total participation).
TIMELINE
Anticipated Enrollment Timeframe: 6 months
Anticipated Study Timeframe: 21 months
IRB# 1331496
Page 6
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

TABLE OF CONTENTS
1.0 
INTRODUCTION 
1.1
Background
1.2
Study Rationale
1.3 
Device Description
2.0
STUDY OBJECTIVES AND ENDPOINTS
2.1
Primary Objective
2.2 
Primary Endpoint
2.3
Secondary Objective
2.4
Secondary Endpoint
3.0
STUDY DESIGN
3.1
Study Design Overview
3.2
Subject Population and Sites
3.3
Expected Study Duration and Subject Participation
4.0 
SUBJECT SELECTION
4.1
Subject Identification and Recruitment
4.2 
Informed Consent
4.3
Enrollment
4.4
Inclusion Criteria
4.5
Exclusion Criteria
5.0
STUDY PROCEDURES AND ASSESSMENTS
5.1
Schedule of Events
5.2
Concomitant Medications
5.3
Photographs
5.4
Wound Measurements
5.5 
Granulation Tissue 
5.6
Baseline Procedures
5.7
Initial Study Device Application Visit
5.8
Treatment Visits and Assessments
5.9
Required Follow-Up Visits and Assessments
5.10
Unscheduled Visits
5.11
Subject Withdrawal or Discontinuation
5.12
Lost to Follow-Up
5.13
Compensation
6.0
PRODUCT DESCRIPTION
6.1
General 
6.2
Manufacturer
6.3 
Packaging
6.4
Intended Population
6.5
Product Training Requirements
IRB# 1331496
Page 7
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

6.6
Product Receipt and Tracking
6.7
Product Storage and Accountability
6.8
Product Return or Destruction
7.0
SAFETY REPORTING
7.1
Definitions
7.2
Documentation
7.3
Reporting of Adverse Events
8.0
STUDY ADMINISTRATION 
8.1
Data Management
8.2
Clinical and Safety Monitoring
8.3
Regulatory and Ethical Considerations
8.4
Record Retention
8.5
Audits and Inspections
8.6
Subject Confidentiality
8.7
Protocol Deviations
9.0
STATISTICAL CONSIDERATIONS
10.0
ADDENDUM
11.0
REFERENCES
 
12.0
APPENDICES 
APPENDIX A: Safety and Adverse Reactions (SAR) Questionnaire
APPENDIX B: Recruitment Materials (Healthy Volunteers): Flyer
APPENDIX C: Recruitment Materials (Healthy Volunteers): ResearchMatch
APPENDIX D: Informed Consent Form (Healthy Volunteers)
APPENDIX E: Informed Consent Form (Wound Care Patients)
APPENDIX F: Screening and Enrollment Log
APPENDIX G: Noxsano Bandage Information Sheet
APPENDIX H: Device Tracking Log Template
 
IRB# 1331496
Page 8
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

1.0
INTRODUCTION
1.1
Background 
Wound repair is a very complex and highly coordinated pathway that includes a series of 
overlapping  phases:  inflammation,  cell  proliferation,  matrix  deposition,  and  tissue 
remodeling.  This  pathway includes  a complex,  changing series  of events  including 
clotting, inflammation, granulation tissue formation, epithelialization, neovascularization, 
collagen synthesis, and wound contraction [1]. Impairment of this pathway of wound 
healing  often  leads  to severe  disabilities.  Accordingly,  chronic,  non-healing  wound 
conditions represent a situation of major clinical importance, and a large burden to the 
health care system. There are several well-described disease states that ultimately cascade 
into impaired wound healing [2]. Among those, the most prominent chronic wound 
impairments include decubitus or pressure ulcers, venous ulcers, diabetic ulcers, and 
ischemic  ulcers  from concomitant  peripheral  arterial  disease (PAD). The advent of 
molecular and cellular biology and the use of different modeling systems, most notably 
genetically engineered animals, have greatly extended our knowledge of wound repair. 
Inflammation, re-epithelialization, and granulation tissue formation are driven in part by 
a complex mixture of growth factors and cytokines, which are released coordinately into 
the wounds [1, 2].  Besides these protein-type factors and mitogens, emerging evidence 
suggests the importance of small diffusible molecules, such as nitric oxide (NO) in 
wound repair [3].
As a testimony to the rapidly expanding knowledge about its multiple biological roles, 
NO, after its discovery in 1987, was named molecule of the year in 1992 [4].  There is 
increasing evidence for a functional role of NO in wound healing. Inhibition of the 
inducible isoform of NO, iNOS, by competitive inhibitors decreases collagen deposition 
and breaking strength of incisional wounds and impairs the healing of other wound 
models [5-7]. The use of NO donors has also been shown to improve incisional and 
excisional wound healing in rats [8-10]. Inhibition of iNOS by competitive inhibitors, 
either applied to the wound surface [11] or given systemically [6], decreases collagen 
deposition and breaking strength of incisional wounds and impairs the healing. Finally, 
there are strong correlations between reduced cutaneous NO levels and impaired wound 
healing under disease conditions such as diabetes [6, 12-14], malnutrition [15], and 
chronic steroid treatment [11].
Angiogenesis, the process of forming new micro-vessels, is an important component of 
normal wound repair. NO plays  a central  role in this  process  [16] as  it increases 
angiogenesis in ischemic murine tissues [17]. NO is also vital to the activity of pro-
angiogenic cytokines. Vascular endothelial growth factor (VEGF) is a potent angiogenic 
factor which involves the modulation of NO generation [18].
1.2 
Study Rationale
Wound  dressings  and  devices  form  an  important  segment  of  the  medical  and 
pharmaceutical wound care market worldwide. The last two decades have witnessed the 
introduction of many dressings, with new ones becoming available each year. These 
modern dressings are based on the concept of creating an optimum environment to allow 
IRB# 1331496
Page 9
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

epithelial  cells  to  move  unimpeded,  for  the  treatment  of  wounds.  Such  optimum 
conditions include a moist environment around the wound, effective oxygen circulation 
to aid regenerating cells and tissues, and a low bacterial load.  The active ingredients used 
in wound management have evolved alongside the pharmaceutical agents and dressings 
used to deliver them. The use of topical pharmaceutical agents in the form of solutions, 
creams and ointments to wound sites has been the mainstay of wound dressings for the 
past decade.
Controlled delivery dressings can provide an excellent means of delivering drugs to 
wound sites in a consistent and sustained fashion over long periods of time without the 
need for frequent dressing change [19]. This form of a local drug delivery dressing is 
potentially useful in the treatment of wounds where it may be beneficial to have increased 
local concentrations of the active drug while avoiding high systemic doses, and thus 
minimizing  systemic  side  effects.  Improvement  of  patient  compliance  is  another 
advantage with local drug delivery dressings especially in chronic wound management 
where patients usually undergo long treatments and frequent changing of dressings that 
can lead to noncompliance. A dressing that will deliver an active substance to a wound 
site in a controlled fashion for a sustained period could help solve or minimize this 
problem.
1.3
Device Description
1.3.1 Preclinical Data
 
Nitric Oxide and Wound Healing. The process of wound healing is complex and involves 
a multitude of signaling pathways, effector molecules, and response phases.  In certain 
circumstances such as diabetes, disability, old age, and obesity, wound healing can be 
delayed, and result in a non-healing (chronic) wound. Infection is a significant risk in 
chronic wounds, and can be difficult to treat as chronic wounds are associated with 
restricted blood flow (ischemia), which limits efficacy of systemic antibiotics. If an 
infection cannot be controlled, amputation of the affected limb is required to prevent 
death from sepsis. The mortality rate in people who must receive an amputation is 
startlingly high, greater than the mortality rate of several major cancers combined. [20] 
NO is the key molecule controlling many signaling cascades in wound healing and 
insufficient  production  is  a  primary  cause  of  chronic  wounds  [21]. NO  is  present 
throughout healing (weeks) and its level varies as healing progresses (Fig. 1).
IRB# 1331496
Page 10
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

Figure 1.  Nitric Oxide Levels during the Healing Process.
Noxsano  Bandage  Device. The  Noxsano  Bandage  (study  device)  is  designed  to 
exogenously replace the deficient NO in wounds and restore normal signaling required 
for wounds to heal.  The Noxsano Bandage uses an electrochemical reaction to generate 
highly controlled doses of NO for wound healing. The electrochemical reaction reduces 
sodium nitrite (meat tenderizer) to NO. To achieve this efficiently, an electrochemical 
mediator is used that ‘shuttles’ electrons from the anode to the nitrite. The dressing (Fig. 
2)  has  a  battery,  two electrodes,  electrical  connectors,  and  a hydrogel  formulation 
containing  the  sodium  nitrite  and  electrochemical  mediator.   Each  component  is 
described in greater detail below.
Figure 2.  Diagram of the Noxano Bandage Dressing.
IRB# 1331496
Page 11
                  Version 6.0
x-axis: Time (weeks)
y-axis: NO levels (µM)
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1


Specifications – The device sizes available are small (4 x 4 cm), medium (6 x 6 cm), 
and large (6 x 8 cm), and are all 1-2 cm in thickness (1 cm at the ends and 2 cm in the 
center, i.e., the location of the battery). The size used will depend on the size of the 
wound in the wound care subject population (the device must cover the entire area of 
the wound) and could vary over time, while the healthy volunteers will all receive the 
small (4 x 4 cm) device size.

Electrodes – Non-woven conductive carbon fiber cloth. The carbon fiber allows 
efficient reaction with the mediator and prevents galvanic corrosion of the electrode 
that would occur with a metal electrode.

Connectors – 3M non-metallic conductive tape.

Battery – Three volt (3V) lithium ion battery. The battery is similar to standard coin 
cell watch batteries such as the CR2032, but has a higher operating temperature 
allowing for steam sterilization.

Hydrogel  formulation –  Medical  grade  cross-linked  poly-(acrylic  acid),  sodium 
nitrite, buffer (pH 7.5-8.0), and an electrochemical mediator. The formulation is 
‘activated’ by soaking the dressing in sterile water.  The final concentration of sodium 
nitrite in the wet hydrogel is 1-4%, depending on the NO level being delivered.  The 
mediator is a derivative of benzophenone (sunscreen) and is used at 100 ppm in the 
wet hydrogel.
The generation of NO from the Bandage has been quantified in vitro using a gel (gelatin) 
containing a colorimetric sensor, 1,2-diaminoanthroquinone, (DAQ) which selectively 
reacts with NO to form a colorless product.  The flux of NO (moles per minute) was 
calculated  by  following  the  loss  of  the  DAQ  from  the  gel.  A  formulation/device 
combination  generating  the  appropriate  NO  flux  to  promote  granulation  tissue 
development (0.5-1.5 x 10-7 moles per minute = 50-150 nM per minute) during healing 
was identified and used in porcine wound healing studies [22].
Ischemic Wound Healing. Noxsano is collaborating with Prof. Valerie Bergdall (Ohio 
State University Laboratory Animal Resource, ULAR). Prof. Bergdall has extensive 
experience  [23-27]  in  the  development  and  application  of  wound  models  for  the 
evaluation of wound healing technologies. Based on Prof. Bergdall’s advice, Noxsano 
undertook the Bandage evaluation using a porcine ischemic wound model, a good model 
for wound healing in chronic wounds [31].  The ischemic wound model involves creating 
a 12.5 cm x 5.0 cm flap with reduced blood flow (ischemia). In the center of the flap an 8 
mm full thickness wound is created, and this wound is used to evaluate ischemic wound 
healing. The first ischemic wound study sought to validate our hypothesis that restoring 
approximately 1 x 10-7 moles per minute of NO delivered to an ischemic wound would 
promote granulation and therefore speed healing time.  
Wound  healing  was  evaluated  visually  and  via  histology.  Results  indicated  that 
investigators could indeed heal an ischemic wound significantly faster than a similar 
wound treated  with conventional  care  (Tegaderm™).  The ultimate  objective  of the 
Noxsano Bandage is to restore ‘normal healing’ to an ischemic (chronic) wound. This 
was demonstrated in the porcine wound model by comparing the healing of an ischemic 
IRB# 1331496
Page 12
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

wound on the pig to that of a normal wound; an 8 mm full-thickness wound without the 
‘flap.’  The healing was evaluated visually and using transepidermal water loss (TEWL), 
which measures the movement of water through the skin.  If the skin is compromised, the 
movement of water is significantly increased; TEWL therefore provides a very sensitive 
measure of when a wound has healed (skin integrity restored).  The control (normal) 
wound was treated with a simple Tegaderm™ dressing.  The ischemic wound was treated 
with a Noxsano dressing delivering between 0.8 and 1.2 x 10-7 moles per minute NO. 
The dressing was changed every 3-4 days and delivered NO continuously between 
Bandage changes.  At day 21 the TEWL assessment of the ischemic wound indicated it 
was healed.  The TEWL  was similar or equivalent to normal skin indicating normal 
barrier function (Fig. 3).  In contrast, the normal wound was still an ‘open wound.’ The 
TEWL was significantly higher than normal skin indicating that the barrier function had 
not been restored and the wound was still prone to infection (Fig. 3).
Figure 3.  Transepidermal Water Loss (TEWL) as an Assessment for Wound Healing 
[proprietary data].
Biofilm Control. A third porcine study was used to evaluate the Noxsano Bandage’s 
control of a wound biofilm. In order to establish a stable biofilm, a second-degree burn 
was applied and the burn infected with a non-pathogenic, biofilm-forming bacteria (P. 
aeruginosa). Once the biofilm had stabilized (3 days) an 8 mm full-thickness punch 
wound was created in the center of the burn wound. The infected burn wound was treated 
with either Tegaderm™ (control) or a Noxsano dressing delivering approximately 1 x 10-
7 moles per minute of NO. As with the previous tests, the dressing was changed every 3-4 
IRB# 1331496
Page 13
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

days. The biofilm was evaluated by taking punch biopsies. After 7 days, the control 
biofilm remained intact. In comparison, the biofilm had been reduced by ~3 orders of 
magnitude to a bio-burden with the Noxsano Bandage. The test was continued and 
showed accelerated healing of both the burn and punch wounds (original and punch 
biopsies) (Fig. 4).
Figure 4.  Wound Healing between the Noxsano Bandage and Control (Tegaderm™) 
[proprietary data].
1.3.2
Clinical Data
The proposed study will be the first clinical study for the Noxsano Bandage.
1.3.3
Clinical Pharmacokinetics
As mentioned,  NO is  involved  in the wound healing  process at all stages  and its 
mechanism of action is not yet completely understood.  The following outline of the role 
of NO is summarized further from a review by Luo et al [28]. 
Nitric Oxide and Angiogenesis. Angiogenesis, the process of forming new micro vessels, 
is an important component of normal wound repair.  NO is vital to the activity of pro-
angiogenic cytokines. Vascular endothelial growth factor (VEGF) is a potent angiogenic 
factor controlled by NO. VEGF depends on NO for control of VEGF-induced endothelial 
cell proliferation and mitogen-activated protein (MAP) kinase. In addition, NO plays a 
role in controlling monocyte-induced angiogenesis, substance P, and transforming growth 
factor  (TGF)-β1.  Taken  together,  NO  clearly  plays  a  crucial  role  in  post-wound 
angiogenesis.
Nitric  Oxide  and  Inflammation. NO  has  been  shown  to  modulate  chemoattractant 
cytokines that initiate post-wound inflammation, including interleukin (IL)-8, TGF-β1, 
monocytes, and neutrophils. Because IL-1 is a potent chemoattractant for keratinocytes, 
IRB# 1331496
Page 14
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

the modulation of IL-1 by NO may usher keratinocyte recruitment, proliferation, and 
differentiation. Taken together, NO modulation of inflammation-associated cytokines 
may affect the inflammatory phase of wound healing.
Nitric  Oxide  and  Cell  Proliferation,  Differentiation,  and  Apoptosis.  NO  affects 
proliferation, differentiation, and apoptosis in key cell types involved in wound healing. 
Low levels of NO increase keratinocyte proliferation. NO has been shown to stimulate 
the proliferation of endothelial cells, protect endothelial cells from apoptosis, and mediate 
VEGF production. Together these effects suggest NO is critical during the proliferative 
phase of healing.
Nitric Oxide and Matrix Deposition and Remodeling.  The final phases of healing require 
increased  collagen  synthesis  and deposition.  NO  increases  collagen  formation  in 
fibroblasts derived from both normal and wound skin. Conversely, inhibition of NO 
synthesis has been shown to decrease collagen formation and deposition. 
All the effects described above are dependent on delivery of the correct concentration. 
At the  extreme,  very  high levels  of NO  become  cytotoxic.  To create  the  benefits 
described above a low, carefully controlled level of NO must be delivered continuously 
to the wound. The Noxsano Bandage achieves this as it generates a controlled flux of NO 
during use, restoring the normal biological processes required for wound healing.
1.3.4    Device Regulatory Pathway
Under 21 CFR 812.3(m), a significant risk device means an investigational device that:
1. Is intended as an implant and presents a potential for serious risk to the health, 
safety, or welfare of a subject, 
2. Is purported or represented to be for use supporting or sustaining human life and 
presents a potential for serious risk to the health, safety, or welfare of a subject, 
3. Is for a use of substantial importance in diagnosing, curing, mitigating, or treating 
disease, or otherwise preventing impairment of human health and presents a 
potential for serious risk to the health, safety, or welfare of a subject, and/or
4. Otherwise presents a potential for serious risk to the health, safety, or welfare of a 
subject.
The Noxsano Bandage is not an implantable device nor is it designed to sustain life; in 
this regard it is clearly not a significant risk device as defined by the FDA. The Noxsano 
Bandage also does not treat a disease, but does treat wounds which certainly could be 
considered an impairment of human health. The Bandage does not, in the manufacturer’s 
opinion however, represent a serious risk to the health, safety, or welfare of the study 
subjects. The study subjects already have non-healing wounds that impair their health. 
The objective of the study will be to show improved healing relative to established 
techniques. Subjects will be monitored and returned to established techniques if the 
Noxsano Bandage fails to improve their healing. No preclinical evidence of significant 
risk has been demonstrated, and therefore significant risk is not anticipated or expected:

NO is a naturally-occurring species produced by the body during healing as a bio-
signal, but is absent in chronic wounds. 
IRB# 1331496
Page 15
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1


Exogenous  delivery  replaces  the  missing  NO  at  levels  equivalent  to  those 
generated naturally, restoring the wound to its ‘natural state.’ 

NO  is  short  lived  (1-2  seconds)  and  therefore  does  not  become  systemic. 
Biological activity is limited to the wound.

The  level  of  NO  is  highly  controlled  by  the  electrochemical  reaction,  thus 
preventing any risk of overdose.

The  level  delivered  to  the  wound  is  fixed  by  the  battery  voltage  and  the 
formulation and cannot be altered by the patient.

The dressing is powered by a 3V battery commonly found in a wide range of 
consumer electronics.  It presents no risk for electric field exposure, electrical 
shock, or electrocution.

The dressing contains a safe, stable precursor to NO, sodium nitrite. Sodium 
nitrite  is  commonly  used  to  tenderize  and  cure  meats,  and  can  safely  be 
consumed.

The mediator is a benzophenone derivative present at very low levels (100 ppm), 
and is similar in structure to a common sunscreen ingredient.  It has no known 
adverse toxicological effects.

The hydrogel is a medical grade supersorber, essentially the same material used in 
baby diapers.  It has no known adverse toxicological effects.

The hydrogel formulation  does not directly  contact  the patient’s  skin.  The 
formulation is contained in a medical grade nonwoven dressing material.
The factors described above lead Noxsano to the view that the proposed study device is 
‘non-significant risk’ (NSR) as defined by the FDA in 21 CFR 812.3(m).  In addition, the 
protocol has been designed to ensure that the subjects’ health and safety is not imperiled. 
1.3.5
Group 1 (Healthy Volunteers) Rationale
Group 1 healthy volunteers are not dysfunctional in the generation of NO due to chronic 
wound healing, and therefore their endothelium will contain ‘normal levels.’ As such, use 
of the Bandage will represent an increase above physiologically normal levels in the 
endothelium of the healthy volunteers. In contrast, Group 2 subjects have wounds that are 
known to be dysregulated in NO.  In this instance, the treatment returns their endothelium 
to  physiologically  normal  levels  of  NO.  Although  the  porcine  study  demonstrated 
efficacy, it could not indicate if irritation occurred as a side effect. As a result, a healthy 
volunteer group was included in this study to assess irritation from the use of the 
Bandage. As NO is a biologically-active species involved in a number of pathways in the 
endothelium,  the  manufacturer  recommends  a  short  ‘acute  exposure’  of  72  hours. 
Longer-term overexposure could lead to artifacts as the body reacts to elevated levels of 
this biosignal. 
The founders of Noxsano have worn devices for up to 72 hours with no apparent negative 
effects.  The  excess  NO  did  appear  to  cause  melanogenesis  (skin  darkening)  and 
hyperemia (increased local blood flow). A period of 72 hours for Group 1 is therefore 
believed to be sufficient to determine if irritation occurs but short enough to avoid any 
potential artifacts from NO above physiological levels. Longer-term exposure to the 
Group 2 subject population is, in the opinion of the manufacturer, justified by the 
IRB# 1331496
Page 16
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

preclinical data from porcine studies. These studies demonstrate that long-term (weeks) 
NO  exposure  to  chronic  wounds  leads  to  improved  wound  healing  without  any 
identifiable negative physiological effects (upon observation or histology). 
2.0
STUDY OBJECTIVES AND ENDPOINTS
2.1 
Primary Objective 
Group 1 (Safety): Healthy Volunteers. The initial phase of the study is designed to 
determine the safety of the study device in healthy volunteers without wounds.  If there 
are no issues with tolerance, side effects, or adverse reactions in healthy volunteers, the 
second phase of the study will proceed with active wound care subjects.
For the purposes of this study, if two subjects experience an unacceptable adverse 
reaction warranting discontinuation of treatment in the opinion of the Investigators during 
the initial phase of the study, the study will be halted and the second phase (and the 
remainder of the initial phase, if applicable) will not be completed. Allergic reactions and 
infections at the bandage site will be considered unacceptable at any clinical severity; 
other adverse reactions will be deemed “unacceptable” by the Investigators on a case-by-
case basis dependent upon clinical severity (App. A).
Group 2 (Efficacy): Wound Care Subjects. The second phase of the study is designed to 
determine the effectiveness of the study device in wound healing in subjects with active 
wounds (see Primary & Secondary Endpoints below).
2.2
Primary Endpoint
The primary endpoint for this study is wound healing (Group 2), as defined by the 
percent change in wound surface area (surface area is calculated in cm2) from baseline 
through the active treatment period. Specifically, wound care subjects will have the study 
device applied at baseline then re-applied two times per week for up to 4 weeks from the 
start of the active treatment period. Device reapplication will change to weekly when the 
principal or sub-investigator determines it is permissible or when a maximum of 4 weeks 
of treatment is reached. Device re-application will continue weekly until the wound is 
judged to be healed by the wound care practitioner or up to 3 months, whichever comes 
first. If after 2 consecutive months of treatment with the study device the wound does not 
exhibit healing, evidenced by a decrease in surface area (cm2), the subject will be 
returned to standard and established techniques of treatment consistent with the wound 
etiology. 
2.3 
Secondary Objective (Group 2 only)
Group 2 (Efficacy): Wound Care Subjects. The secondary endpoint of the study is to 
determine  if  the  study  device  is  equivalent  to  standard  and  established  techniques 
(standard techniques demonstrate 50% wound healing at 2 months) in subjects with 
active wounds.
IRB# 1331496
Page 17
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

2.4
Secondary Endpoint (Group 2 only)
Standard  wound  healing  techniques  generally  demonstrate  50%  wound  healing  at 
2 months. Therefore, the secondary endpoint for this study is the proportion of wound 
care patients that have at least 50% improvement in surface area within 2 months of 
treatment. This information will be used to describe if the study device is equivalent to 
standard and established techniques.
IRB# 1331496
Page 18
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

3.0
STUDY DESIGN
3.1 
Study Design Overview 
This  study is  a prospective,  interventional,  non-randomized,  sequential  phase study 
designed to assess the safety and efficacy of the Noxsano Bandage (study device) in 
subjects with a diabetic lower extremity ulceration and/or arterial insufficiency lower 
extremity ulceration.
3.2
Subject Population and Sites
Group 1: Initial subjects will be limited to healthy volunteers with intact skin on their 
lower extremities. Five (5) white subjects and 5 black or African American subjects will 
be enrolled to evaluate skin differences. Group 1 (healthy volunteers without wounds) 
will have all follow-up completed and the results assessed before the investigators initiate 
prior to proceeding to Group 2 (wound care subjects).
Group 2: The subsequent wound care subject study will include 10 subjects from the 
patient population treated at the OhioHealth Riverside Methodist Hospital Critical Limb 
Care  Center  for  lower  extremity  ulceration  attributed  to  diabetes  and/or  arterial 
insufficiency. 
 3.3
Expected Study Duration and Subject Participation
Group 1: The initial healthy volunteer safety study will last a total of 4.5 weeks. Healthy 
volunteers will wear the study device for 3 consecutive days (up to 72 hours), followed 
by weekly visits for 4 weeks of observation for tolerance, side effects, and/or adverse 
reactions.  
For the purposes of this study, if 2 subjects experience an unacceptable adverse reaction 
warranting discontinuation of treatment in the opinion of the Investigators during the 
initial healthy volunteer phase, the study will be halted and Group 2 (and the remainder 
of the initial phase, if applicable) will not be completed. Allergic reactions and infections 
at the study device application site will be considered unacceptable at any clinical 
severity; other adverse reactions will be deemed “unacceptable” by the Investigators on a 
case-by-case basis dependent upon clinical severity (App. A).
Group 2: The wound care subjects will have twice per week study device applications to 
a specific ulceration for up to the first 4 weeks of treatment and then weekly re-
application thereafter. For subjects that exhibit any reduction in wound surface area, this 
application will occur until the wound is healed, or for up to 3 months (whichever occurs 
first).  For  subjects  that  do  not  exhibit  any  reduction  in  wound  size  at  2  months, 
application will stop and standard treatment protocols will be pursued. At the conclusion 
of the treatment window (up to 3 months), subjects will be followed every 3 months for 
12 consecutive months for observation of late side effects or adverse reactions (3 months 
of active treatment, 12 months of follow-up observation, 15 months total).
IRB# 1331496
Page 19
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

4.0
SUBJECT SELECTION
4.1
Subject Identification and Recruitment 
4.1.1 Research Match 
ResearchMatch.org is a national electronic, web-based recruitment tool that was created 
through  the  Clinical  &  Translational  Science  Awards  Consortium  in  2009  and  is 
maintained at Vanderbilt University Medical Center. There is no cost for researchers at 
participating institutions in the ResearchMatch Network to use ResearchMatch for the 
purposes of conducting recruitment feasibility analysis or participant recruitment. The 
Vanderbilt University Medical Center IRB provides oversight for ResearchMatch as a 
recruitment tool). However, individual requests to use ResearchMatch as a recruitment 
tool are required to be approved by the participating institution’s IRB. OhioHealth is an 
approved ResearchMatch institution. 
ResearchMatch© consists of a registry of volunteers that have signed up to receive 
notifications  about  potential  research  studies.  ResearchMatch© provides  standard 
notification language that will be received by all ResearchMatch© volunteers who may be 
eligible for a given study. When a volunteer is sent a notification about a study, they will 
reply (“yes” or “no”) using the appropriate notification quick links. When volunteers 
select “yes” to affirm their interest in participating, ResearchMatch© will release their 
contact information through the online portal to the Principal Investigator (PI) or research 
team. All information will be managed per strict ResearchMatch© Guidelines. Research 
staff will then call volunteers to prescreen for medical history pertaining to the study and 
determine eligibility. If the volunteer is interested, the consent will be sent via email for 
review, and the Baseline visit will be scheduled at the OhioHealth Research Institute.
4.1.2 Identification and Recruitment 
Group 1: Healthy volunteers will be identified from the community using recruitment 
flyers  posted  at  OhioHealth  hospital  campuses  (App.  B)  and  notifications  in 
ResearchMatch© (App.  C). ResearchMatch©  notifications  will  be  limited  to  registry 
participants located within a 25 mile radius of OhioHealth Riverside Methodist Hospital. 
OhioHealth associates can be included in the healthy volunteer cohort. 
Group 2: Patients presenting to the OhioHealth Riverside Methodist Hospital Critical 
Limb Care Center with a diabetic lower extremity ulceration and/or arterial insufficiency 
lower extremity ulceration will be pre-screened for possible inclusion in the study. If 
determined preliminarily eligible, a research staff member will either approach the patient 
at their visit to the Critical Limb Care Center, or contact them by phone following their 
visit, if necessary.
4.2
Informed Consent
Written informed consent using the most current Institutional Review Board (IRB)-
approved informed consent form (ICF) will be obtained from all subjects prior to any 
study-specific tests or procedures performed (App. D & E).  This does not include those 
procedures or tests that are obtained in the normal course of the subject’s routine care.
IRB# 1331496
Page 20
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

4.3
Enrollment
Subjects will be considered enrolled once signed informed consent has been obtained. 
Subjects that do not present for the initial Noxsano Bandage application appointment will 
be withdrawn from the study and replaced. 
All subjects who have been consented will be registered in the Research Electronic Data 
Capture (REDCap™) database and will be assigned a unique subject study number.  
The screening and enrollment log will also be completed to document the outcome of all 
subjects who underwent screening (App. F). The screening and enrollment log will 
contain the enrollment and study number of subjects who were enrolled, or the reason for 
non-enrollment of subjects who did not meet inclusion/exclusion criteria.
Group 1 and Group 2 subjects will be screened according to the protocol inclusion and 
exclusion criteria.  Each of the criteria in sections 4.4 and 4.5 must be met in order for a 
subject to be considered eligible for this study. 
4.4
Inclusion Criteria
Group 1: Subjects must meet all of the following criteria to be eligible for enrollment:
1. Subject is ≥ 18 and < 80 years of age.   
2. Subject is white, black or African American
3. Subject has provided written informed consent.
4. Subject is willing to comply with study follow-up requirements.
5. Subject has intact skin on lower extremities.
Group 2: Subjects must meet all of the following criteria to be eligible for enrollment:
1. Subject is ≥ 18 and < 80 years of age.   
2. The wound to be treated with the Noxsano bandage has a baseline wound surface 
area of < 25 cm2.
3. Subject has provided written informed consent.
4. Subject is willing to comply with study follow-up requirements. 
5. Subject with at least one of the following: 
a.
Diabetic lower extremity ulceration with a hemoglobin A1c (HgbA1c) value ≤ 
9.0, drawn within 3 months prior to study participation1, and/or
b. Arterial insufficiency lower extremity ulceration with a post-revascularization 
ankle-brachial index (ABI) value of ≥ 0.40 and ≤ 0.80 on the involved 
extremity, performed within 3 months prior to study participation1, and/or
1 Baseline measures of HgbA1c or ABI (within 3 months prior to consent) must be available for inclusion. 
IRB# 1331496
Page 21
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

c.
Diabetic and/or arterial insufficiency lower extremity ulceration deemed in-
eligible for revascularization with 3 months prior to study participation
4.5
Exclusion Criteria
Group 1: Subjects will be excluded from the trial if any of the following criteria are met:
1. Subject is < 18 or ≥ 80 years of age.
2. Subject has a history of diabetes, arterial insufficiency, or osteomyelitis.
3. Subject has a known hypersensitivity to adhesives.
4. Subject is on any prescription medications, including contraceptives. Due to the 
short duration of the procedure period (3 days), subjects who initiate prescription 
medications during study participation will continue in the study.
5. Subject is pregnant, plans to become pregnant during the study period, or is 
breastfeeding.
6. Subject is non-English speaking or reading.
7. Subject is unable to give informed consent.
Group 2: Subjects will be excluded from the trial if any of the following criteria are met:
1. Subject is < 18 or ≥ 80 years of age.
2. The wound to be treated with the Noxsano bandage has a baseline wound surface 
area of ≥ 25 cm2.
3. The wound to be treated with the Noxsano bandage is a plantar wound. 
4. Subject with diabetes with an HgbA1c value of > 9.0, drawn within 3 months 
prior to study participation2. 
5. Subject with arterial insufficiency with an ABI value of < 0.40 or > 0.80, 
performed within 3 months prior to study participation3. 
6. The wound to be treated with the Noxsano bandage has osteomyelitis contiguous 
with the treatment site.
7. Subject with peripherally-inserted central catheter (PICC) line antibiotic treatment 
within the previous 6 months.
2 Hemoglobin A1c is known to be significantly associated with wound healing rates, making it an important 
marker in the prediction of wound healing in diabetic patients [29].  A cutoff of 9.0% was chosen to 
exclude those with uncontrolled diabetes at highest risk for poor healing outcomes, as well as surgical 
complications including wound infections [30].
3   Patients with a normal-to-borderline ABI (> 0.80) are not characterized or diagnosed as having arterial 
insufficiency and are not referred to a vascular specialist; on the opposite end of the spectrum, those with 
severe arterial disease (< 0.40) typically proceed directly to hyperbaric treatment. 
IRB# 1331496
Page 22
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

8. Subject requiring any type of amputation on the treatment limb within 3 months 
prior to study participation.
9. Subject with a known hypersensitivity to adhesives.
10. Subject is on active steroid therapy (does not include inhaled steroids).
11. Subject is pregnant, plans to become pregnant during the study period, or is 
breastfeeding. 
12. Subject is non-English speaking or reading. 
13. Subject is unable to give informed consent.
14. Subject is currently enrolled in another interventional study.
IRB# 1331496
Page 23
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

5.0 
STUDY PROCEDURES AND ASSESSMENTS
5.1
Schedule of Events
Group 1 (Healthy Volunteers):
The  initial healthy  volunteer  safety  study  will  last  a  total  of  4.5  weeks.  Healthy 
volunteers will have the study device applied for 3 consecutive days (up to 72 hours), 
followed by weekly visits for 4 weeks of observation for tolerance, side effects, and 
adverse reactions. Weekly visits will occur every 7 ± 2 days after the Day 3 visit. 
Assessment
Screening (via phone)
Baseline
Study Device 
tion: Day 0
Treatment: 
3 ± 0 days  
Follow-Up: 
y 7 ± 2 days4 
Unscheduled Visit
Informed Consent
x
Medical history 
x
Concomitant medications
x
x
x
x
x
x
OhioHealth Research Institute Clinic Visit 
(Research Only)
x
Critical Limb Care Center (Riverside Methodist 
Hospital Wound Center) visit (research-only)
x
x
x
Shaving of left posterior calf
x
Photograph
x
x5
x
Noxsano Bandage application
x
SAR Questionnaire
x
x
x
Group 2 (Wound Care Subjects): 
The wound care subject treatment period will consist of twice per week study device 
applications to a specific ulceration for up to the first 4 weeks of treatment and then 
weekly re-application thereafter. When deemed permissible by the clinical judgment of 
the principal or sub-investigator or when 4 weeks is reached, re-application of the study 
device will change to weekly. This weekly re-application will occur until the wound is 
healed, or for up to 12 weeks (whichever occurs first). For subjects that do not exhibit 
any reduction in wound size at 2 months, application will stop and standard treatment 
protocols will be pursued.
At the conclusion of the treatment period (maximum of 3 months), subjects will be 
followed every 3 months for 12 consecutive months for observation of late side effects or 
adverse  reactions  (up  to  3  months  of  active  treatment,  12  months  of  follow-up 
observation, 15 months maximum).
4 Day 10, 17, 24, and 31
5 Photograph and compensation are given on Day 3 only during Treatment Period
IRB# 1331496
Page 24
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

Assessment
Screening / Baseline
Initial Study Device 
Day 0
Treatment: 
very 3 ± 2 days6
Treatment: 
ery 7 ± 2 days7 
Follow-Up: 
3mo ± 14 days8 
Unscheduled Visit
Informed Consent
x
Routine medical history / physical exam
x
x
Concomitant medications
x
x
x
x
x
x
HgbA1c (subjects with diabetes)
x
ABI (subjects with arterial insufficiency)
x
Critical Limb Care Center visit (Riverside 
Methodist Hospital Wound Center)
x
x
x
x
x
x
Photograph (i.e., wound image)
x
x
x
x
x
x
Wound measurements
x
x
x
x
x
x
Percent granulation tissue
x
x
x
x
x
x
Noxsano Bandage application
x
x
x
SAR Questionnaire
x
x
x
x
x
5.2
Concomitant Medications
A list of all prescription and over the counter medications, including topical treatments, 
will be recorded for all subjects at each visit.  
Although subjects are excluded from Group 1 if they are on any prescription medications 
at the time of study initiation, due to the short duration of the procedure period (3 days), 
subjects  who initiate  prescription and/or over the counter medications  during study 
participation will continue in the study.
5.3 
Photographs
Photographs of the study device application site and wounds (Group 2) will be taken 
using  a  digital  camera,  an  FDA  Class  1  510(k)  exempt  medical  device.  Digital 
photographs are routinely taken in the OhioHealth Riverside Methodist Hospital Critical 
Limb Care Center, therefore, their equipment will be utilized for the study.
Group 1(Healthy Volunteers): A photograph will be taken on Day 0 of the shaved area on 
the left posterior calf prior to study device placement. A photograph of the site where the 
study device was applied will also be taken on Day 3, following removal of the study 
device, and at each follow-up visit (Days 10, 17, 24, and 31). All photographs will be 
6 Weeks 1-4, 2 times per week study device changes or until change to weekly is permitted by investigator.
7 Weeks 5-12, weekly study device changes until wound has healed or 3 months is reached.
83, 6, 9, and 12 months post-treatment
IRB# 1331496
Page 25
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

uploaded into the study electronic case report forms (eCRFs) by a member of the study 
staff. 
Group 2 (Wound Care Subjects): Photographs of the wound with a conventional ruler in 
place will be obtained at baseline, Day 0 (Initial Device Application), treatment, and 
follow-up visits. Photographs will be taken by a wound care nurse and uploaded in the 
study eCRFs by a member of the study staff. 
5.4 
Wound Measurements
The standard measurement per the current protocol at the Center for Critical Limb Care is 
a vertical and horizontal measurement taken in centimeters using a conventional ruler. 
These  measurements  are  used  to  calculate  the  wound  area  (cm2).  All  wound 
measurements for this study will be performed according to The OhioHealth Heart and 
Vascular Wound Care Center protocol  to ensure consistency visit  to visit.  Current 
protocol involves trained nursing wound care staff obtaining photographic images with 
standard conventional ruler. Wound length, width, and surface area will be reported in the 
REDCap data collection tool. Sub-investigators will review the photographs to ensure in 
agreement with correct measurements. 
5.5
Granulation Tissue
Percentage  of granulation  tissue present  in the  wound being  treated  with  Noxsano 
bandage will be recorded in the REDCap data collection tool at each study visit. 
5.6
Baseline Procedures
Group 1(Healthy Volunteers):  If the subject meets inclusion/exclusion criteria and the 
informed consent is signed, a 4 x 4 cm segment of healthy, intact skin on the left 
posterior calf will be shaved by study staff. Study device application will occur within 1-
3 days after the Baseline visit in the event that shaving causes irritation.
Group 2 (Wound Care Subjects):  Baseline data will be collected, including a routine 
medical history and physical examination pertaining to study eligibility. The most recent 
documented baseline HgBa1c and/or ABI values will be collected from the subject’s 
medical record. A baseline photograph and the standard wound measurement using a 
conventional ruler will be obtained as described in section 5.3. Baseline photographs will 
be taken with the conventional ruler in place. When possible subjects may proceed 
immediately to the initial study device application once baseline assessments have been 
completed. 
5.7
Initial Study Device Application Visit
The device sizes available are small (4 x 4 cm), medium (6 x 6 cm), and large (6 x 8 cm), 
and are all 1-2 cm in thickness (1 cm at the ends and 2 cm in the center, i.e., the location 
of the battery). The size used will depend on the size and shape of the wound to be 
treated (the device must cover the entire area of the wound) and could vary over time. 
Healthy volunteers will all receive the small (4 x 4 cm) device size.
IRB# 1331496
Page 26
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

All subjects will be given a Noxsano Bandage Information Sheet (App. G), which will 
reiterate conversations from the Informed Consent process, including, but not limited to 
the following:

“Troubleshooting” the Noxsano Bandage, including device malfunctions and 
frequently asked questions;

Reporting safety issues, side effects, and adverse reactions.
Group 1 (Healthy Volunteers): A photograph will be taken on Day 0 of the shaved area 
where the device will be place prior to study device application. The study device will be 
applied by the Principal Investigator or delegated Sub-Investigator to the shaved area of 
skin on the left posterior calf. The study device will not be changed over the 3-day 
treatment period in order to complete an uninterrupted application of 3 total days (up to 
72 hours). A photograph of the site where the study device was applied will also be taken 
on Day 3, following removal of the study device, and at each follow-up visit. 
The  SAR  questionnaire  will  be  administered  by  study  staff  immediately  following 
application of the study device to assess tolerance, side effects, and/or adverse reactions 
(App. A). For the purposes of this study, if 2 subjects experience an unacceptable adverse 
reaction warranting discontinuation of treatment in the opinion of the Investigators during 
the initial phase of the study, the study will be halted and the second phase (and the 
remainder of the initial phase, if applicable) will not be completed.. Allergic reactions 
and infections at the device application site will be considered unacceptable at any 
clinical  severity;  other  adverse  reactions  will  be  deemed  “unacceptable”  by  the 
Investigators on a case-by-case basis dependent upon clinical severity (App. A).
Group 2 (Wound Care Subjects): The initial device application visit (Day 0) may be 
combined  with  the  screening/baseline  visit.  Group  2  subjects  will  be  limited  to  a 
maximum wound surface area of < 25 cm2, to allow for complete coverage with the 
largest device size of 6 x 8 cm.  Those with wounds ≥ 25 cm2, comprising less than 5% of 
the wound care population, will be excluded. Conversely, we are not limiting minimum 
wound size, as some of the most complicated wounds are actually under 1 cm2.
The standard wound measurement in centimeters using a conventional ruler will be 
obtained according the The OhioHealth Heart and Vascular Wound Care Center standard 
protocol prior to the initial device application at Day 0. The standard measurement per 
the current protocol at the Center for Critical Limb Care will be implemented and a 
photograph with the conventional ruler in place will be taken. 
The  study device  will  be applied  to the lower extremity  wound site  by a trained 
investigator or sub-investigator. Routine wound care techniques such as debridement will 
be performed in the usual standard fashion prior to application of the Noxsano Bandage. 
The  SAR  questionnaire  will  be  administered  by  study  staff  immediately  following 
application of the Noxsano Bandage to assess tolerance, side effects, and/or adverse 
reactions (App. A).
5.8
Treatment Visits and Assessments
IRB# 1331496
Page 27
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

Group 1 (Healthy Volunteers): Healthy volunteers will be seen in the Critical Limb Care 
Center on Day 0 for Application (± 0 days) and Day 3 for Removal (± 0 days) during the 
study treatment period. Subjects will be instructed to call the Critical Limb Care Center 
(614-566-2682) during regular business hours (0700-1600), and the Study Investigators 
will be available after-hours (614-738-8938 for Dr. Mehl, 614-404-7512 for Dr. Silver, 
937-599-4852 for Dr. Anderson)for concerns regarding adverse reactions or other general 
questions. Contact numbers for the study investigators will be provided in the informed 
consent document. The following evaluations and processes will be completed and data 
recorded in the REDCap eCRF:

SAR Questionnaire (App. A)

Concomitant medications 

Photograph (Day 3 only after the removal of the study device)
Group 2 (Wound Care Subjects): Subjects will be seen in the Critical Limb Care Center 
twice a week (every 3 days ± 2 days) for up to 4 weeks. Clinical judgment of the 
principal or investigator will permit a subject to discontinue twice weekly bandage 
changes prior to the end of 4 weeks. After the first 4 weeks of treatment or when deemed 
permissible by the investigator, subjects will be seen in the Critical Limb Care Center 
weekly (7 days ± 2 days) for a total treatment period of up to 3 months. The following 
evaluations will be completed and data recorded in the REDCap eCRF:

Study device application 

Photograph of the study device application site (on Day 0 prior to study device 
application; following the removal of the old device and prior to application of the 
new device on subsequent treatment visits)

Wound measurements

Percent granulation tissue

SAR Questionnaire (App. A)

Concomitant medications 
5.9
Required Follow-Up Visits and Assessments
Group 1 (Healthy Volunteers): Healthy volunteers will be seen in the Critical Limb Care 
Center once a week (every 7 days ± 2 days) for a total of 4 weeks of follow-up. The 
following evaluations will be completed and data recorded in the REDCap eCRF:

Photograph of the study device application site 

SAR Questionnaire (App. A)
Group 2 (Wound Care Subjects): After completion of  treatment (completed when wound 
has healed or 3 months is reached), subjects will be seen by the principal or sub-
investigator in the Critical Limb Care Center every 3 months ± 14 days for 12 months to 
evaluate for any late-term issues of tolerance, side effects, and/or adverse reactions. The 
following evaluations will be completed and data recorded in the REDCap eCRF:

Photograph of the study device application site

Wound measurements

Percent granulation tissue 

SAR Questionnaire (App. A)

Concomitant medications
IRB# 1331496
Page 28
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

5.10
Unscheduled Visits
A critical limb wound care podiatrist will be on call at all times.  
Subjects will be instructed to call the Critical Limb Care Center (614-566-2682) during 
regular business hours (0700-1600), and the Study Investigators will be available after-
hours (614-738-8938 for Dr. Mehl, 614-404-7512 for Dr. Silver, 937-599-4852 for Dr. 
Anderson) for concerns regarding adverse reactions or other general questions. Subjects 
will be seen on an urgent basis as-needed based on podiatrist recommendation during 
regular business hours at the Critical Limb Care Center.
Unscheduled visits are additional visits that occur at times other than the protocol pre-
determined required visits during study participation. If an unscheduled visit occurs, the 
following will be collected from the subject’s medical record and entered in the REDCap 
eCRF:

Routine physical examination by a podiatrist, including assessment of the lower 
extremities

Concomitant medications

Photograph of the study device application site 

Wound Measurements

Percent granulation tissue

Bandage re-application if necessary

SAR Questionnaire (App. A)
5.11
Subject Withdrawal or Discontinuation
Subjects have the right to withdraw from the study at any time and for any reason without 
penalty or loss of benefits to which the subject is otherwise entitled.  If a subject decides 
to withdraw, all study assessments, tests, and procedures  will  be stopped.  An exit 
interview will be requested to understand why the subject chose to withdraw. The subject 
will also be offered the option to have data collection from the electronic medical record 
to continue in order to track wound progression.  The Investigators may withdraw the 
subject at any time to protect the health, safety, or welfare of the subject. At the last point 
of contact, the date and reason for discontinuation will be documented, and every effort 
should  be  made  to  follow-up  the  status  of  any  ongoing  adverse  events  prior  to 
withdrawal.
Subjects that do not present for the initial Noxsano Bandage application appointment will 
be withdrawn from the study and replaced. 
Study participation may continue per the Schedule of Events (section 5.1) until one of the 
following criteria applies:
Group 1: 

Unacceptable adverse reactions warranting discontinuation of treatment in the 
opinion  of  the  Investigators: Subjects  experiencing  any  allergic  reaction  or 
infection at the device application site will be removed from study treatment.
IRB# 1331496
Page 29
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

Group 2: 

Unacceptable adverse reactions warranting discontinuation of treatment in the 
opinion  of  the  Investigators:  Subjects  experiencing  any  allergic  reaction  or 
infection at the device application site will be removed from study treatment.

Missed weekly treatment visits and discontinuation from study treatment: Weekly 
treatment visits will be indicated as “missed” if the deviation from the planned 
date is > 2 days (i.e., 3 or 7 days ± 2 days, during the 3 month study period).  If a 
subject misses 2 consecutive treatment visits, they will be removed from study 
and not replaced. 

Missed study follow-up visits: Subjects who miss two consecutive follow-up visits 
will be contacted as described in section 5.12 in order to determine whether they 
wish to withdraw for the study or re-establish regular study follow-up visits. If 
subjects are able to re-establish study follow-up visits they may remain on the 
study. If the subject is unable to be contacted through the procedures outlined in 
section 5.12 data collection from the electronic medical record may continue, but 
the subject will be considered “lost to follow-up”. 

Wound healing and discontinuation from study treatment: Clinical benefit may be 
determined during the treatment process by documentation of a healed ulceration, 
at  which  time  the  study device  application  will  be  discontinued.  The  post-
treatment follow-up period will then begin for observation of late side effects and/
or adverse reactions.

No evidence of wound healing at 2 months. If a subject has no evidence of 
decreased wound surface area at 2 months (8 week treatment visit), the patient 
will be returned to standard and established techniques consistent with the wound 
etiology, and study follow-up will be discontinued.

Wound < 50% healed at the completion of the study treatment period and 
discontinuation from study follow-up: If after 3 consecutive months (12 weeks) of 
treatment with the study device the wound does not exhibit at least a 50% 
decrease in surface area (cm2), the subject will be returned to standard and 
established techniques consistent with the wound etiology, and study follow-up 
will be discontinued. Clinical benefit experienced after the three-month treatment 
period, but not during the treatment period is not anticipated  
In the absence of discontinuation due to adverse reactions (for both Groups 1 and 2) or 
wound healing outcomes (for Group 2 only) as indicated above, treatment may continue 
per the Schedule of Events (section 5.1) until one of the following criteria applies:

Subject decision to withdraw from treatment (partial consent) or from the study 
(full consent),

Death, or

Funder reserves the right to temporarily suspend or prematurely discontinue this 
study.
5.12
Lost to Follow-Up
The subject may be lost to follow-up after 3 documented phone calls and a certified letter 
has been mailed to the subject in order to obtain compliance with study requirements. 
These subjects will not be replaced.  
IRB# 1331496
Page 30
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

5.13
Compensation
Participant compensation will be done using a method approved by OhioHealth 
Research  Institute (OHRI) Research  Business Services.   OhioHealth  Associates 
enrolled in the healthy cohort will not be compensated.
Group 1: Compensation for healthy volunteers will be disbursed for the Baseline visit, 
the completion of the treatment period on Day 3, and the weekly 4 week follow-up period 
resulting in up to $150 in total compensation (see compensation milestones below).  
Time Point
Compensation Amount
Baseline
$25
Completion of treatment
$25
Week 1 follow-up
$25
Week 2 follow-up
$25
Week 3 follow-up
$25
Week 4 follow-up
$25
Subjects who discontinue study participation in Group 1 or Group 2 due to unacceptable 
adverse reactions per section 7.0 will receive a one-time discontinuation payment of $25. 
Those subjects that discontinue, withdraw, or are lost to follow-up will not receive any 
further compensation.
Group 2: Compensation for wound care subjects will be disbursed for the completion of 
the treatment  period (completed when wound has healed, subject is transitioned to 
standard  of  care  techniques,  or  3  months  is  reached,  whichever  comes  first),  and 
disbursed for each completed follow-up visit during the 12 month follow-up period 
resulting in up to $125 in total compensation (see compensation milestones below).  
Time Point
Compensation Amount
Completion of treatment
$25
3-month follow-up
$25
6-month follow-up
$25
9-month follow-up
$25
12-month follow-up
$25
Subjects who discontinue study participation due to unacceptable adverse reactions per 
section 7.0 will receive a one-time discontinuation payment of $25. Those subjects that 
discontinue, withdraw, or are lost to follow-up will not receive any further compensation 
IRB# 1331496
Page 31
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

6.0
PRODUCT DESCRIPTION
6.1
General
The Noxsano Bandage (study device) uses an electrochemical reaction to generate highly 
controlled doses of NO for wound healing. The electrochemical reaction reduces sodium 
nitrite (meat tenderizer) to NO. To achieve this efficiently, an electrochemical mediator is 
used that ‘shuttles’ electrons from the anode to the nitrite. The dressing has a battery, two 
electrodes, electrical connectors, and a hydrogel formulation containing the sodium nitrite 
and electrochemical mediator. Each component is described in Figure 2 (section 1.3.1) 
above.
6.2
Manufacturer
The Noxsano Bandage is manufactured by:
Noxsano, Inc.
1275 Kinnear Rd.
Columbus, OH 43212
6.3
Packaging
The Noxsano Bandage is assembled by Noxsano, Inc., autoclave sterilized and supplied 
to OhioHealth Research Institute (OHRI). The hydrogel formulation in the dressing is 
‘activated’ by soaking the device in 25-50 ml (depending on dressing size) of sterile 
water  for  5  minutes.  This  process  ‘connects’  the  electrodes  and  initiates  the 
electrochemical generation of NO. NO delivery continues until the dressing is removed 
(3-5 days). The dressing delivers 0.8-1.2 x 10-7 moles of NO per minute to the wound 
continuously during use. This level of NO mimics the level the body would generate 
during normal wound healing. The dressing will be packaged in a sterile container and 
delivered in-person by the manufacturer (staff from Noxsano, Inc.) to OHRI.
6.4
Intended Population
The Noxsano Bandage is intended for use in patients with chronic and non-healing 
wounds.
6.5
Product Training Requirements
Investigators, wound care practitioners, and research staff will be trained by Noxsano, 
Inc. staff in an onsite in-service at the Critical Limb Care Center at OhioHealth Riverside 
Methodist Hospital on the usage of the Noxsano Bandage, including, but not limited to 
the following:

Clinical aspects of packaging, handling, application, and mechanism of action of 
the Noxsano Bandage;

“Troubleshooting” the Noxsano Bandage, including device malfunctions and 
frequently asked questions;

Reporting and advising on patient safety issues, side effects, and adverse 
reactions.
6.6
Product Receipt and Tracking
IRB# 1331496
Page 32
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

The study device will be delivered in-person by the manufacturer (staff from Noxsano, 
Inc.) and stored in a secure area at the offices of OHRI or in a locked storage room 
accessible only to OHRI staff at the OhioHealth Riverside Methodist Hospital Critical 
Limb Care Center.  
Study device receipt will be tracked by research staff at each delivery using Device 
Tracking Logs (App H).  
6.7
Product Storage and Accountability
The device will be labeled and stored in a secure area at the offices of OHRI or in a 
locked storage room accessible only to OHRI staff at the OhioHealth Riverside Methodist 
Hospital Critical Limb Care Center. Device storage and accountability will be controlled 
only by the assigned, trained research staff at the site. Each device will be labeled with 
the following: 

Company name

Company contact information

Device identification number

Date of sterilization

Shelf life (6 months)
Study device usage and administration will be tracked by research staff at each subject 
visit using Device Tracking Logs (App H). Per the manufacturer, there are no special 
storage requirements (shelf-stable at room temperature).
6.8
Product Return or Destruction
Any unused or expired product will be retrieved in-person by the manufacturer (staff 
from Noxsano, Inc.) upon study closure. 
Study device return will be tracked by research staff at the conclusion of study enrollment 
using Device Tracking Logs (App. H).  
IRB# 1331496
Page 33
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

7.0
SAFETY REPORTING
7.1
Definitions 
7.1.1
Adverse Event  
An adverse  event (AE)  is  any  unfavorable  or  unintended  event,  physical  or 
psychological,  associated  with a research study, which causes harm or injury to a 
research participant as a result of the participant’s involvement in a research study.  The 
event can include abnormal laboratory findings, symptoms, or disease associated with the 
research study.  The event does not necessarily have to have a causal relationship with the 
research, any risk associated with the research, the research intervention, or the research 
assessments. 
Adverse events may be the result of the interventions and interactions used in the 
research; the collection of identifiable private information in the research; an underlying 
disease, disorder, or condition of the subject; and/or other circumstances unrelated to the 
research or any underlying disease, disorder, or condition of the subject. 
Subjects will be followed in terms of tolerance/side effects/adverse reactions:

Tolerance: pruritus (itchy skin), dermatitis (dry skin), pain

Side effects: erythema (red skin), edema (swollen skin), pressure ulcer (skin 
breakdown), melanogenesis (skin darkening), hyperemia (increased local blood 
flow)

Adverse reactions: any systemic side effect, including (but not limited to) fever, 
nausea, vomiting, or hypotension (low blood pressure)
Group 1 healthy volunteers are not dysfunctional in the generation of NO due to chronic 
wound healing, and therefore their endothelium will contain ‘normal levels.’ As such, use 
of the Bandage will represent an increase above physiologically normal levels in the 
endothelium of the healthy volunteers.  In contrast, Group 2 subjects have chronic 
wounds that are known to be dysregulated in NO.  In this instance, the treatment returns 
their endothelium to physiologically normal levels of NO (see section 1.3.5).  
Therefore, Group 1 healthy volunteers are more likely to experience adverse events 
related to hypersensitivity and skin reactions, and are thus being limited to 3 days (up to 
72) hours of Bandage wear. It is anticipated that symptoms will manifest within 24-72 
hours of application and resolve within 7-10 days of removal, but could take as long as 
30 days or more depending on individual skin regeneration. Regarding Group 2 wound 
care subjects, we expect manifestation and resolution of symptoms on the same timeline, 
but cannot state decisively as this is the first study in this population. Finally, as itching is 
a normal consequence of wound healing, we expect this to occur in the majority of Group 
2 subjects. No preclinical evidence of significant risk has been demonstrated with the 
Noxsano Bandage, and therefore is not anticipated or expected during this study. 
IRB# 1331496
Page 34
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

7.1.2
Adverse Device Effect
An adverse device effect (ADE) is defined as any AE that is related to the use of the 
investigational medical device.  
7.1.3
Device Deficiency, Malfunction, and User Error
Investigators are instructed to report all possible device deficiencies, malfunctions or user 
errors during the course of the trial. These incidents will be documented in the eCRF as 
follows:

Device  Deficiency (ISO  14155:2011): Inadequacy  of a  medical  device  with 
respect to its identity, quality, durability, reliability, safety, or performance

Device Malfunction: Failure of a device to meet its performance specifications or 
otherwise perform as intended [21 CFR 803.3].  

User Error: Device-related error or mistake made by the person using the device.
7.1.4  Serious Adverse Events 
A  serious adverse event  (SAE) is any adverse experience occurring at any dose that 
results in any of the following outcomes: 

Results in death. 

Is a  life-threatening adverse experience. The term “life-threatening” in the 
definition of “serious” refers to an adverse event in which the subject was at 
risk of death at the time of the event. It does not refer to an adverse event 
which hypothetically might have caused death if it were more severe. 

Requires
 inpatient  hospitalization  or  prolongation  of  existing 
hospitalization. Any adverse event leading to hospitalization or prolongation 
of hospitalization will be considered as Serious, UNLESS at least one of the 
following expectations is met:
o
The admission results in a hospital stay of less than 24 hours; OR
o
The admission is pre-planned (e.g., elective or scheduled surgery 
arranged prior to the start of the study); OR
o
The admission is not associated with an adverse event (e.g., social 
hospitalization for purposes of respite care.
However it should be noted that invasive treatment during any hospitalization 
may fulfill the criteria of “medically important” and as such may be reportable as 
a serious adverse event dependent on clinical judgment. In addition, where local 
regulatory authorities specifically require a more stringent definition, the local 
regulation takes precedent. 

Results in persistent or significant disability/incapacity. The definition of 
disability is a substantial disruption of a person’s ability to conduct normal 
life’s functions.

Is a congenital anomaly/birth defect. 

Is an important medical event. Important medical events that may not result 
death, be life-threatening, or require hospitalization may be considered a 
serious adverse experience when, based upon appropriate medical judgment, 
they  may  jeopardize  the  subject  and  may  require  medical  or  surgical 
IRB# 1331496
Page 35
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

intervention to prevent one of the outcomes listed in this definition.  Examples 
of such medical events include allergic bronchospasm requiring intensive 
treatment in an emergency room or at home, blood disease or disorders, or 
convulsions that do not result in inpatient hospitalization, or the development 
of drug dependency or drug abuse. The development of a new cancer is 
always considered an important medical event.
7.1.5
Serious Adverse Device Effect
A serious adverse device effect (SADE) is any ADE that has resulted in any of the 
consequences characteristic of an SAE.
7.1.6
Unanticipated Adverse Device Effect
An unanticipated device effect (UADE) is defined in 21 CFR 812.3 as any serious AE on 
health or safety or any life-threatening problem or death caused by, or associated with, a 
device, if that effect, problem, or death was not previously identified in nature, severity or 
degree of incidence in the protocol, or any other unanticipated serious problem associated 
with a device that relates to the rights, safety, or welfare of a subject.
7.1.7
Unexpected
Any AE that  is  not consistent  in specificity  or severity  with the  current  protocol, 
including all amendments, is considered unexpected.
7.2
Documentation
Adverse  events  will  be  documented  on  the  appropriate  eCRF.  All  AEs  will  be 
characterized by the following criteria:

Seriousness

Intensity or severity

Relatedness to the device and procedure

Outcome

Treatment or action taken

Determination to continue study participation
7.2.1
Intensity or Severity
Intensity or severity will be recorded as mild, moderate, or severe using the following 
definitions:

Mild: Minor signs/symptoms; no specific medical intervention required; 
asymptomatic laboratory findings only; marginal clinical relevance Subject is 
aware of symptoms, but symptoms are easily tolerated. 

Moderate: Requiring minimal, local, or noninvasive intervention only. 
Symptoms interfere with normal daily activities. 

Severe: Significant symptoms requiring hospitalization or invasive intervention. 
Symptoms are incapacitating. 
7.2.2
Relatedness
Relatedness to the device and procedure will be recorded as unrelated, possibly related, 
or related.
IRB# 1331496
Page 36
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

7.2.3
Outcome
Outcome will be recorded as ongoing, resolved with sequelae, or resolved without 
sequelae (with the date resolved).
7.3
Reporting of Adverse Events
The Principal Investigator or designee is responsible for ensuring that all AEs (both 
serious and non-serious) observed by the clinical team or reported by the subject which 
occur after the subject has signed the informed consent are fully recorded in the subject’s 
medical record.  Source documentation must be available to support all adverse events. 
A critical limb wound care podiatrist is on call 24/7/365.  Subjects will be instructed to 
call the Critical Limb Care Center, and will be seen on an urgent basis as needed based 
on podiatrist recommendation. The adverse event will be immediately reported to the 
study Principal Investigator.
7.3.1
Reporting of Serious Adverse Events
Reporting of SAEs includes reporting of any SAE, any medical device deficiency that 
might have led to an SAE, and any new finding / update in relation to already reported 
events.
It is the responsibility of the Principal Investigator or designee to report all SAEs to 
Noxsano, Inc. (the study device manufacturer) within 2 business days of discovery or 
notification of the event.  
It is the responsibility of the Principal Investigator or designee to report all SAEs 
according to the IRB of record’s policies and procedures.  
7.3.2 Reporting of Unanticipated Adverse Device Effects
If a complication occurs that the Principal Investigator believes may be a potential 
UADE, the site should immediately contact the device supplier to determine reporting 
requirements.
It is the responsibility of the Principal Investigator or designee to report all UADEs 
according to the IRB of record’s policies and procedures.
IRB# 1331496
Page 37
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

8.0
STUDY ADMINISTRATION 
8.1
Data Management
The Principal Investigator is required to prepare and maintain adequate and accurate case 
histories designed to record all observations and other data pertinent to the investigation.
The Research Electronic Data Capture (REDCap™) system will be utilized, as required 
by OHRI, for data collection for both accrual entry and trial data management.  REDCap 
is an electronic data capture (EDC) system housed on secure servers maintained at 
OhioHealth.  Access to data through REDCap is restricted by user accounts and assigned 
roles. Once logged into the REDCap system with a user ID and password, REDCap 
defines roles for each user which limits access to appropriate data. User information and 
passwords can be obtained by contacting the REDCap Administrator.
REDCap is designed with the capability for study setup, activation, tracking, reporting, 
data monitoring and review, and eligibility verification.  This study will utilize electronic 
case report form (eCRF) completion in the REDCap database.  A calendar of events and 
required eCRFs are available in REDCap.
8.2
Clinical and Safety Monitoring
Qualified monitors from CSSi LifeSciences representing the Funder (Noxsano, Inc.) will 
conduct on-site monitoring visits to ensure that all Investigators conduct the study in 
compliance with the protocol.
8.2.1
Background
The purpose of the Clinical Monitoring Plan for the Safety and Efficacy of the Noxsano 
Wound Care Bandage: A First-in Human Study, protocol number 1331496, is to ensure 
compliance with the Principles of International Conference on Harmonization - Good 
Clinical Practice (ICH-GCP).
8.2.2
Objectives  
The main objectives of the Monitoring Plan are to:

Ensure that the rights and well-being of human subjects are protected.

Ensure that key reported trial data are accurate, complete, and verifiable from 
source documentation.

Assure the study site is familiar with and follows the protocol.

Assure  the  site  is  GCP  compliant  and compliant  with applicable  regulatory 
requirements.
“Safety and Efficacy of the Noxsano Wound Care Bandage: A First-in Human Study” is 
designed to determine the safety and effectiveness of the Noxsano device. The initial 
safety assessment will be conducted in healthy volunteers as part of an IRB-approved 
study. Once safety has been established, the efficacy and safety of the Noxsano device 
will be evaluated in subjects with an active wound as part of an IRB-approved study.
IRB# 1331496
Page 38
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

8.2.3
Monitoring Plan
A site initiation visit will be conducted. At this visit, the regulatory binder will be 
reviewed to ensure that it contains all necessary documents. The monitor will ascertain 
that the Principal Investigator and study staff are knowledgeable about the protocol and 
proper use of the Noxsano device. The initial monitoring visit will be conducted within 
the first month of patient enrollment. Thereafter, interim visits will be conducted every 6-
8 weeks. Additional visits will be scheduled to address unanticipated issues which require 
training, remediation, or site assistance.
During the monitoring visits, the Clinical Research Associate (CRA) will ensure that the 
trial is conducted and documented properly. The CRA will perform the monitoring tasks 
in accordance with the protocol specific requirements, ICH/GCP Guidelines, and other 
applicable regulatory requirements. The CRA will verify that written informed consent 
was obtained before each subject participated in the trial. The CRA will verify the 
accuracy and completeness of the Case Report Forms (CRFs) and source documents for 
every subject enrolled in the trial. During the course of monitoring visits, the CRA will 
ensure that the regulatory binder is complete and up to date.
8.3
Regulatory and Ethical Considerations
The  study  will  be  conducted  in  compliance  with  International  Conference  on 
Harmonization (ICH) guidelines and with all applicable federal (including 21 CFR parts 
56 & 50), state, or local laws.
8.3.1
Role of the Principal Investigator
The Principal Investigator has the overall responsibility for the conduct of the study, 
including  assurance  that  the  study  meets  and  is  conducted  within  the  regulatory 
requirements specified by each reviewing regulatory authority. The Principal Investigator 
is responsible for ensuring informed consent is obtained, proper quality monitoring is 
performed, and quality data is collected and reported. 
Provision of written  informed  consent  must be obtained  prior  to any study-related 
procedures. The Principal Investigator will ensure that the subject is given full and 
adequate oral and written information about the nature, purpose, possible risks, and 
possible benefits of the study as well as the subject’s financial responsibility. Subjects 
must also be notified that they are free to discontinue/withdraw from the study at any 
time.  The subject should be given the opportunity to ask questions and be allowed time 
to consider the information provided. 
8.4 
Record Retention
The Principal Investigator supervises the retention of all study documentation and will 
maintain study records and reports for a minimum of 3 years after the study is terminated 
or completed.  Electronic files will be stored on password-protected computers, and paper 
files will be stored in a secure facility with limited access at the offices of OHRI.
IRB# 1331496
Page 39
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

8.5 
Audits and Inspections 
Authorized representatives of the sponsor, OhioHealth Research Compliance (ORC), or a 
regulatory authority may visit the site to perform audits or inspections, including source 
data  verification.  The  purpose  of  an  audit  or  inspection  is  to  systematically  and 
independently examine all study-related activities and documents to determine whether 
these  activities  were  conducted,  and  data  were  recorded,  analysed,  and  accurately 
reported  according  to  the  protocol,  Good  Clinical  Practice  (GCP)  guidelines,  ICH 
guidelines, and any applicable regulatory requirements.   
8.6
Subject Confidentiality
Subject confidentiality will be maintained throughout the clinical study to ensure that 
data can always be tracked to the source. For this purpose, a unique subject study number 
will be used that allows identification of all data reported for each subject.
Protected Health Information (PHI) will be treated and maintained in compliance with the 
Healthy Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule on 
the protection of individuals with regard to the processing of personal data.
8.7
Protocol Deviations
The Investigators and research staff will not deviate from the protocol without prior 
written approval of the Institutional Review Board except in medical emergencies.  
It is the responsibility of the Principal Investigator or designee to report all protocol 
deviations according to the IRB of record’s policies and procedures. 
IRB# 1331496
Page 40
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

9.0 STATISTICAL CONSIDERATIONS
Primary Objective. 
Group 1 (Safety): Healthy Volunteers. The initial phase of the study is designed to 
determine the safety of the study device in normal healthy volunteers without wounds.  If 
there are no issues with tolerance, side effects, and/or adverse reactions in normal healthy 
volunteers, the second phase of the study will proceed with active wound care subjects.
Group 2 (Efficacy): Wound Care Subjects. The second phase of the study is designed to 
determine the effectiveness of the study device in wound healing in subjects with active 
wounds (see Primary Endpoint below), and to determine if the study device is equivalent 
to standard and established techniques (standard techniques demonstrate 50% wound 
healing at 2 months).
Primary Endpoint.
The primary endpoint for this study is wound healing (Group 2), as defined by the 
percent change in wound surface area (surface area is calculated in cm2) from baseline 
through the active treatment period.  Wound care subjects will have the study device 
applied (and re-applied weekly) until the wound is judged to be healed by the wound care 
practitioner, for up to 3 months total duration. If after 2 consecutive months of treatment 
with the study device the wound does not exhibit at least 50% improvement in surface 
area (cm2), the subject will be returned to standard and established techniques consistent 
with the wound etiology. We will also determine if the study device is equivalent to 
standard  and  established  techniques  (standard  techniques  demonstrate  50%  wound 
healing at 2 months).
Statistical Analysis Plan.
Descriptive  statistics  will  comprise  the  bulk  of  the  statistical  analysis.  Continuous 
variables will be reported as means and standard deviations, along with median and 
minimum/maximum values and compared between baseline and follow-up times using 
paired t-tests and/ or repeated measures ANOVA. Dichotomous and categorical variables 
will be reported as frequencies with percentages and compared between follow-up times 
using Chi-square tests or Kruskal Wallis tests. Imputation techniques will be used to 
account for missing data. Statistical significance will be set at p<0.05 for all the tests.
IRB# 1331496
Page 41
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

10.0 ADDENDUM
The first two subjects enrolled in the Group 2, wound care subjects cohort experienced 
adverse events which were promptly reported to the OhioHealth Institutional Review 
Board. 
One subject experienced skin erosion around the site of the Noxsano bandage application. 
The skin around the borders of the bandage had redness and breakdown which was 
attributed to the stiffness of the bandage. This event was determined by the OhioHealth 
Institutional Review Board to be unexpected and related. The Board acknowledged the 
event as a minor adverse event that did not increase risk to the subject or others. 
One subject experienced an increase in wound size at the site of the Noxsano bandage 
application. This event was determined by the OhioHealth Institutional Review Board to 
be expected, related, and did not suggest that participants or others were at greater risk of 
harm. 
To address the aforementioned adverse events, the informed consent will be edited to 
include information regarding the potential for increased pain consistent with treatment 
of these types of wounds and the wound may appear worse before looking better. 
Additionally, a continuing review report will be submitted to the OhioHealth Institutional 
Review Board 3 months after study enrollment activities resume. The makers of the 
Noxsano bandage have also updated the design of the device to reduce stiffness of the 
bandage edges. The study schedule has also been updated so that Noxsano bandage 
changes will be done twice a week up to the first 4 weeks of treatment to assess for 
adverse events and wound healing. 
IRB# 1331496
Page 42
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

11.0
REFERENCES
1. Singer AJ, Clark RA. Cutaneous wound healing. N Engl J Med 1999; 341: 738–46.
2. Bello YM, Phillips TJ. Recent advances in wound healing. JAMA 2000; 283: 716–8.
3. Frank S, Kampfer H, Wetzler C, Pfeilschifter J. Nitric oxide drives skin repair: novel 
functions of an established mediator. Kidney Int 2002; 61: 882–8.     
4. Koshland DE. Molecule of the year. Science 1993;262:1953.    
5. Schaffer MR, Tantry U, Thornton FJ, et al. Inhibition of nitric oxide synthesis in 
wounds: pharmacology and effect on accumulation of collagen in wounds in mice. 
Eur J Surg 1999;165:262–7.
6. Schaeffer MR, Tandry U, Gross SS, et al. Nitric oxide regulates wound healing. J 
Surg Res 1996;63:237–40.
7. Murrell GA, Szabo C, Hannafin JA, et al. Modulation of tendon healing by nitric 
oxide. Inflamm Res 1997;46:19–27. 
8. Witte MB, Thornton FJ, Kiyama T, et al. Nitric oxide enhances wound collagen 
deposition in diabetic rats. Surg Forum 1997;48: 665–7.
9. Shabani M, Pulfer SK, Bulgrin JP, et al. Enhancement of wound repair with a 
topically applied nitric oxide-releasing polymer. Wound Rep Reg 1996;4:353–62.
10. Bauer JA, Rao W, Smith DJ. Evaluation of linear polyethyleneimine/nitric oxide 
adduct on wound repair: therapy versus toxicity. Wound Rep Reg 1998;6:569–77.
11. Bulgrin JP, Shabani M, Chakravarthy D, Smith DJ. Nitric oxide synthesis is 
suppressed in steroid-impaired and diabetic wounds. Wounds 1995; 7: 48–57.
12. Schaffer MR, Tantry U, Efron PA, Ahrendt GM, Thornton FJ, Barbul. Diabetes-
impaired healing and reduced wound nitric oxide synthesis: a possible 
pathophysiologic correlation. Surgery 1997; 121:513–9.
13. Luo JD, Wang YY, Fu W, Wu J, Chen AF. Gene therapy of eNOS and MnSOD 
restores delayed wound healing in type 1 diabetic mice. Circulation 2004; 110: 2484–
93.
14. Stallmeyer B, Anhold M, Wetzler C, Kahlina K, Pfeilschifter J, Frank S. Regulation 
of eNOS in normal and diabetes-impaired skin repair: implications for tissue 
regeneration. Nitric Oxide 2002; 6: 168–77.
15. Schaffer MR, Tantry U, Ahrendt GM, Wasserburg HL, Barbul A. Acute protein-
calorie malnutrition impairs wound healing: a possible role of decreased wound nitric 
oxide synthesis. J Am Coll Surg 1997; 184: 37–43.
IRB# 1331496
Page 43
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

16. Donnini S, Ziche M. Constitutive and inducible nitric oxide synthase: role in 
angiogenesis. Antioxid Redox Signal 2002; 4: 817–23.
17. Murohara T, Asahara T, Silver M, Bauters C, Masuda H, Kalka C, et al. Nitric oxide 
synthase modulates angiogenesis in response to tissue ischemia. J Clin Invest 1998; 
101: 2567–78.
18. Zhang R, Wang L, Zhang L, Chen J, Zhu Z, Zhang Z, et al. Nitric oxide enhances 
angiogenesis via the synthesis of vascular endothelial growth factor and cGMP after 
stroke in the rat. Circ Res 2003; 92: 308–13.
19. Lisa B P.
‐
 1997. Biomaterials: Polymers in controlled drug delivery. Med Device 
Link, Los Angeles, CA: Med Plastics Biomater. November 1997.
20. Robbins, J. M. et al. Mortality rates and diabetic foot ulcers: is it time to 
communicate mortality risk to patients with diabetic foot ulceration? J. Am. Podiatr. 
Med. Assoc. 98, 489–93.
21. Frank, S., Kämpfer, H., Wetzler, C. & Pfeilschifter, J. Nitric oxide drives skin repair: 
Novel functions of an established mediator. Kidney Int. 61, 882–888 (2002).
22. Coneski, P. N. & Schoenfisch, M. H. Nitric oxide release: Part III. Measurement and 
reporting. Chem. Soc. Rev. 41, 3753 (2012).
23. B Fries, R. et al. Dermal excisional wound healing in pigs following treatment. 
Mutation research 579, (2005).
24. Gordillo, G. et al. Protocols for Topical and Systemic Oxygen Treatments in Wound 
Healing. Methods in enzymology 381, (2004).
25. Roy, S. et al. Characterization of a preclinical model of chronic ischemic wound. 
Physiological genomics 37, (2009).
26. Elgharably, H. et al. Development of a Preclinicl Model to Study Biofilm in Full-
Thickness Cutaneous Swine Burn Wound. Wound Repair and Regeneration 20, 
(2012).
27. Elgharably, H. et al. A Modified Collagen Gel Dressing Promotes Angiogenesis in a 
Pre-Clinical Swine Model of Chronic Ischemic Wounds. Wound Repair and 
Regeneration 22, (2014).
28. Luo, J., Chen, A. F. & Chen P, A. F. Nitric oxide: a newly discovered function on 
wound healing. Acta Pharmacol. Sin. 26, 259–264 (2005).
29. Christman AL, Selvin E, Margolis DJ, et al. Hemoglobin A1c is a Predictor of 
Healing Rate In Diabetic Wounds. J Invest Dermatol. 2011 Oct; 131(10):2121–2127.
30. Underwood P, Askari R, Hurwitz S, et al. Preoperative A1C and Clinical Outcomes 
in Patients With Diabetes Undergoing Major Noncardiac Surgical Procedures. 
Diabetes Care. 2014 Mar; 37(3): 611–616.
IRB# 1331496
Page 44
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1

31. Sullivan TP, Eaglstein WH, Davis SC, Mertz P. The pig as a model for human wound 
healing. Wound Repair Regen 9: 66–76, 2001.
IRB# 1331496
Page 45
                  Version 6.0
 
Approved Date: September 21, 2021
Expiration Date: July 20, 2022
OhioHealth Corporation
Institutional Review Board 1