MicroRNA Activation of LOX-1 Mechanisms in Endometriosis
Phase: PHASE4
Conditions: Endometriosis
Sponsor: Penn State University

 
 
 
 
 
 
 
 
 
 
MicroRNA Activation of LOX-1 Mechanisms in Endometriosis 
NCT05331053 
04/18/2018 
Study Protocol and Statistical Analysis Plan 

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HRP-592 - Protocol for Human Subject 
Research with Use of Test Article(s)
Protocol Title:
Provide the full title of the study as listed in item 1 on the “Basic Information” page in CATS IRB (http://irb.psu.edu). 
Role of microRNA activation of lectin-like oxidized LDL receptor (LOX-1) mechanisms in microvascular dysfunction in 
women with endometriosis (IRB# 9584)
Principal Investigator:
Name: Lacy M. Alexander, Ph.D.
Department:  Kinesiology
Telephone: 814-867-1781
E-mail Address: lma191@psu.edu
Version Date:
Provide the date of this submission. This date must be updated each time the submission is provided to the IRB office 
with revisions.  
4/18/18
Clinicaltrials.gov Registration #:
Provide the registration number for this study, if applicable.
NA
Important Instructions for Using This Protocol Template:
1.
Add this completed protocol template to your study in CATS IRB (http://irb.psu.edu) on the “Basic Information” 
page, item 7. 
2.
This template is provided to help investigators prepare a protocol that includes the necessary information needed 
by the IRB to determine whether a study meets all applicable criteria for approval. 
3.
Type your protocol responses below the gray instructional boxes of guidance language.  If the section or item is 
not applicable, indicate not applicable.
4.
For research being conducted at Penn State Hershey or by Penn State Hershey researchers only, delete the 
instructional boxes from the final version of the protocol prior to upload to CATS IRB (http://irb.psu.edu).  For all 
other research, do not delete the instructional boxes from the final version of the protocol.
5.
When making revisions to this protocol as requested by the IRB, please follow the instructions outlined in the Study 
Submission Guide available in the Help Center in CATS IRB (http://irb.psu.edu) for using track changes. 
If you need help…
University Park and other campuses:
Office for Research Protections Human Research Protection Program
The 330 Building, Suite 205
University Park, PA 16802-7014
Phone: 814-865-1775
Fax: 814-863-8699
Email: irb-orp@psu.edu
College of Medicine and Hershey Medical Center:
Human Subjects Protection Office
90 Hope Drive, Mail Code A115, P.O. Box 855
Hershey, PA 17033
(Physical Office Location: Academic Support Building Room 1140)
Phone: 717-531-5687
Fax number: 717-531-3937
Email: irb-hspo@psu.edu
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Table of Contents
1.0
Objectives
2.0
Background
3.0
Inclusion and Exclusion Criteria
4.0
Recruitment Methods
5.0
Consent Process and Documentation
6.0
HIPAA Research Authorization and/or Waiver or Alteration of Authorization
7.0
Study Design and Procedures
8.0
Subject Numbers and Statistical Plan
9.0
Confidentiality, Privacy and Data Management
10.0
Data and Safety Monitoring Plan
11.0
Risks
12.0
Potential Benefits to Subjects and Others
13.0
Sharing Results with Subjects
14.0
Subject Stipend (Compensation) and/or Travel Reimbursements
15.0
Economic Burden to Subjects
16.0
Resources Available
17.0
Other Approvals
18.0
Multi-Site Research
19.0
Adverse Event Reporting
20.0
Study Monitoring, Auditing and Inspecting
21.0
Future Undetermined Research: Data and Specimen Banking
22.0
References
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1.0
Objectives
1.1
Study Objectives
Describe the purpose, specific aims or objectives.  State the hypotheses to be tested. Describe the 
treatment that is considered standard of care (i.e., indicate how patients would be treated in a non-
investigational setting). Indicate if the study test article(s) is available to patients without taking part in 
the study.
Epidemiologic data demonstrate a clear association between endometriosis, reproductive risk factors, 
inflammation and cardiovascular (CV) risk 5, 8-11.  Circulating factors, Low-density lipoprotein (LDL) and oxidized 
LDL (oxLDL), are two of many biomarkers of cardiovascular and inflammatory disease of endometriosis 9, 10.  An 
important signaling mechanism through which circulating LDL and oxLDL act is the lectin-like oxidized LDL 
receptor (LOX-1).  LOX-1 signal transduction functionally results in pronounced endothelial dysfunction, a 
hallmark of CV.  We hypothesis that one factor mediating the elevated risk of cardiovascular disease in 
endometriosis is microRNA (miRNA) activation of LOX-1 receptor mechanisms.
Specific Aim 1. To test the hypothesis that LOX-1 receptor activation is increased leading to endothelial 
dysfunction in endometriosis.  
Hypothesis 1A.  In women with endometriosis, LOX-1 receptor activation is increased resulting in endothelial 
dysfunction mediated through oxidant stress, endothelial NO-synthase uncoupling, and disruptions of 
intracellular trafficking. 
Specific Aim 2. To test the hypothesis that decreased microRNAs (i.e. let7-a, let7-b, let7-g, MiR98, Mi590-p) are 
driving increased LOX-1 receptor expression and function in endometriosis.  
In women with endometriosis: 
Hypothesis 2A.  MicroRNAs will be negatively related to LOX-1 receptor expression; 
Hypothesis 2B.  MicroRNAs will be negatively related to endothelial function.  
1.2
Primary Study Endpoints
State the primary endpoints to be measured in the study.  Clinical trials typically have a primary 
objective or endpoint. Additional objectives and endpoints are secondary.  The endpoints (or outcomes), 
determined for each study subject, are the quantitative measurements required by the objectives.  
Measuring the selected endpoints is the goal of a trial (examples: response rate and survival).
Skin blood flow (cutaneous vascular conductance)
1.3
Secondary Study Endpoints
State the secondary endpoints to be measured in the study.
LOX-1 receptor activation (soluble LOX receptor), microRNAs (i.e. let7-a, let7-b, let7-g, MiR98, Mi590-p), OxLDL, 
LDL, blood pressure, heart rate
2.0
Background
2.1
Scientific Background and Gaps
Describe the scientific background and gaps in current knowledge.
Endometriosis is an estrogen-dependent gynecological disorder associated with considerable chronic pelvic pain, 
pain during intercourse, and is a major cause of infertility 1, 2.  This disorder affects 6% - 10% of reproductive age 
women and can be as high as 35-50% in women experiencing pain or infertility 3-6   Endometriosis derives from 
the presence of endometrium-like tissue in sites outside the uterine cavity.  While endometriosis is a local 
inflammatory syndrome, the inflammatory process is systemic 7. 
Endometriosis is associated with higher risk of hypercholesterolemia and hypertension 8.  Epidemiologic 
data demonstrate a clear association between endometriosis, reproductive risk factors, inflammation and 
cardiovascular (CV) risk 5, 8-11. 
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Endometriosis and Endothelial Dysfunction: Circulating factors including LDL and oxidized LDL are two 
of many biomarkers of cardiovascular and inflammatory disease of endometriosis 9, 10.  An important signaling 
mechanism through which circulating LDL and oxLDL act is the lectin-like oxidized LDL receptor (LOX-1).  LOX-1 is 
a ubiquitously expressed scavenger receptor, stimulated by oxLDL, Ang II, and other inflammatory cytokines, and 
inhibited by estrogen12. LOX-1 is the upstream signaling initiator of mechanisms including increased oxidant 
production, reduced nitric oxide (NO) metabolism, and impaired intracellular trafficking 13. Thus, LOX-1 signal 
transduction functionally results in pronounced endothelial dysfunction.
2.2
Previous Data
Describe any relevant preliminary data.
Cell culture and rodent data implicate miRNAs from the let7 family in regulating LOX-1 expression and 
activation, and these LOX-1-specific miRNAs are similarly dysregulated in endometriosis.  We propose to 
interrogate a direct association between endometriosis-specific miRNAs and elevated LOX-1-mediate 
endothelial dysfunction.
2.3
Study Rationale
Provide the scientific rationale for the research.
Cardiovascular disease (CVD) is the leading cause of death in women.  Endometriosis is associated with higher 
risk of hypercholesterolemia and hypertension 8.    Epidemiologic data demonstrate a clear association between 
endometriosis, reproductive risk factors, inflammation and cardiovascular (CV) risk 5, 8-11.  Our scientific premise 
is that in women with endometriosis, elevated cardiovascular disease risk is the result of endothelial dysfunction 
and chronic systemic inflammation through LOX-1 receptor activation.  We will explore microRNA (miRNA) 
activation of LOX-1 receptor mechanisms as one factor mediating the elevated risk of CVD in endometriosis.
Lipitor is a commonly used statin that has pleotropic effects. One of those is to inhibit the LOX receptor and 
decrease the microRNAs that stimulate the LOX receptor. We will test this on an acute (receptor activation level) 
with microdialysis and on a systemic level.  Additionally, statins have been proposed and tested in animals to 
decrease the endometriosis associated inflammatory and microRNAs we hypothesize to be driving the 
accelerated CVD risk. The short term oral statin will help us delineate this putative effect/mechanism.”
The current application comprises pilot experiments designed to yield data for the development of the final 
protocol.  Modifications (e.g. doses of some of the investigational substances, number of subjects needed to 
complete study, etc.) to this protocol will be made in the future based on the results of the pilot experiments.
3.0
Inclusion and Exclusion Criteria
Create a numbered list below in sections 3.1 and 3.2 of criteria subjects must meet to be eligible for study 
enrollment (e.g., age, gender, diagnosis, etc.). Indicate specifically whether you will include any of the 
following vulnerable populations: (You may not include members of these populations as subjects in your 
research unless you indicate this in your inclusion criteria.) Review the corresponding checklists to ensure that 
you have provided the necessary information.

Adults unable to consent
o
Review “CHECKLIST: Cognitively Impaired Adults (HRP-417)” to ensure that you have 
provided sufficient information. HRP-417 can be accessed by clicking the Library link in 
CATS IRB (http://irb.psu.edu).

Individuals who are not yet adults (infants, children, teenagers)
o
If the research involves persons who have not attained the legal age for consent to 
treatments or procedures involved in the research (“children”), review the “CHECKLIST: 
Children (HRP-416)” to ensure that you have provided sufficient information. HRP-416 
can be accessed by clicking the Library link in CATS IRB (http://irb.psu.edu).

Pregnant women
o
Review “CHECKLIST: Pregnant Women (HRP-412)” to ensure that you have provided 
sufficient information. HRP-412 can be accessed by clicking the Library link in CATS IRB 
(http://irb.psu.edu).
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
Prisoners
o
Review “CHECKLIST: Prisoners (HRP-415)” to ensure that you have provided sufficient 
information.  HRP-415 can be accessed by clicking the Library link in CATS IRB 
(http://irb.psu.edu).

Neonates of uncertain viability or non-viable neonates
o
Review “CHECKLIST: Neonates (HRP-413)” or “CHECKLIST: Neonates of Uncertain Viability 
(HRP-414)” to ensure that you have provide sufficient information.  HRP-413 and HRP-414 
can be accessed by clicking the Library link in CATS IRB (http://irb.psu.edu).
3.1
Inclusion Criteria
List the criteria that define who will be included in your study.

Healthy women between the ages of 18 and 45 years (Controls), taking oral contraceptive or with regular 
menses every 26-34 days

Women between the ages of 18 and 45 years with endometriosis (diagnosis by prior laproscopy by subject’s 
own physician, and reported by the subject to the researchers)

Tylenol if the subject has acute pain is allowed

Contraceptive use is allowed
3.2
Exclusion Criteria
List the criteria that define who will be excluded in your study.

Use of nicotine-containing products (e.g. smoking, chewing tobacco, etc.)

Diabetes (HbA1C .6.5%)

BP>140/90 

Taking pharmacotherapy that could alter peripheral vascular control (e.g. insulin sensitizing, cardiovascular 
medications)

Pregnancy

Breastfeeding

Taking illicit and/or recreational drugs

Abnormal liver function

Abnormal creatine phosphokinase (CPK)

Rash, skin disease, disorders of pigmentation, known skin allergies

Diagnosed or suspected metabolic or cardiovascular disease

Persistent unexplained elevations of serum transaminases

Known allergy to latex or investigative substances (including Lipitor)

Previous adverse reaction to Lipitor or statin
3.3
Early Withdrawal of Subjects
3.3.1
Criteria for removal from study
Insert subject withdrawal criteria (e.g., safety reasons, failure of subject to adhere to protocol 
requirements, subject consent withdrawal, disease progression, etc.).
Participants may withdraw at any time.  We may end the participant’s role if we determine that her/his health 
or behavior adversely affects the study or increases the risks beyond those approved by the Institutional Review 
Board and agreed upon by the subject in the informed consent.
3.3.2
Follow-up for withdrawn subjects
Describe when and how to withdraw subjects from the investigational product or study; the 
type and timing of the data to be collected for withdrawal of subjects; whether and how 
subjects are to be replaced; the follow-up for subjects withdrawn from investigational 
treatment.
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The study team will not contact subjects who voluntarily withdraw. The study team contacts subjects who 
withdraw due to an untoward or adverse event within 5 days of the withdrawal for follow-up and feedback.
4.0
Recruitment Methods
4.1
Identification of subjects
Describe the methods that will be used to identify potential subjects or the source of the subjects.  If not 
recruiting subjects directly (e.g., database query for eligible records or samples) state what will be 
queried, how and by whom.
StudyFinder:  If you intend to use StudyFinder (http://studyfinder.psu.edu) for recruitment purposes, 
please indicate this in section 4.1 along with any other methods for identifying subjects. Note that 
information provided in this protocol should be consistent with information provided on the 
StudyFinder page in your CATS IRB study.
For Penn State Hershey submissions using Enterprise Information Management (EIM) for recruitment, 
attach your EIM Design Specification form on the Basic Information page in CATS IRB (irb.psu.edu). See 
HRP-103 Investigator Manual, “What is appropriate for study recruitment?” for additional information.
We recruit subjects from Centre County, PA and surrounding regions utilizing CTSI resources at University Park.  
Also, we advertise for subjects (see below).  Interested persons contact us.  We also avail ourselves of lists of 
potential subjects maintained by the CRC and our lab.  People on these lists have screened for other studies and 
indicated that they wished to be maintained on a list of potential subjects to be contacted in the event that they 
may qualify for additional studies.  We will use StudyFinder.
4.2
Recruitment process
Describe how, where and when potential subjects will be recruited (e.g., approaching or providing 
information to potential subjects for participation in this research study).
We advertise for subjects.  Interested persons contact us.  We discuss the study’s purpose and protocol as well 
as the qualifications for the study with the potential subject.  We discuss the informed consent with them.  We 
invite potential subjects to tour the lab, and ask questions.  
4.3
Recruitment materials
List the materials that will be used to recruit subjects. Add recruitment documents to your study in CATS 
IRB (http://irb.psu.edu) on the “Consent Forms and Recruitment Materials” page. For advertisements, 
upload the final copy of printed advertisements. When advertisements are taped for broadcast, attach 
the final audio/video tape. You may submit the wording of the advertisement prior to taping to preclude 
re-taping because of inappropriate wording, provided the IRB reviews the final audio/video tape.
StudyFinder:  If you intend to use StudyFinder (http://studyfinder.psu.edu) for recruitment purposes, 
you do not need to upload a separate recruitment document for information placed on the STUDYfinder 
site to your study in CATS IRB.  Necessary information will be captured on the StudyFinder page in your 
CATS IRB study. 
Study Finder
Newspaper/magazine ads  
Letters/Emails to potential participants  
Flyers/posters    
Web Sites
Listserv  
Script – Verbal (i.e., telephone, face-to-face, classroom)
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Note:  We advertise through various listservs on and off campus that target under-represented groups (e.g. 
FOBA) as well as listservs belonging groups (e.g. endometriosis support/info groups) and others as we become 
aware of them. 
Note:  We use the information from the uploaded ad and/or the phone script in other forms of recruitment (e.g. 
emails, listservs, websites).
4.4
Eligibility/screening of subjects
If potential subjects will be asked eligibility questions before obtaining informed consent, describe the 
process. Add the script documents and a list of the eligibility questions that will be used to your study in 
CATS IRB (http://irb.psu.edu) on the “Consent Forms and Recruitment Materials” page.
StudyFinder:  If you intend to use StudyFinder (http://studyfinder.psu.edu) for recruitment purposes, 
any scripts (phone, email, or other) used when contacting StudyFinder participants as well as any 
eligibility screening questions must be added to your study in CATS IRB (http://irb.psu.edu) on the 
“Consent Forms and Recruitment Materials” page. 
An interview using the phone questionnaire assesses likelihood of eligibility before obtaining informed consent. 
Subjects are informed that the information they provide is kept confidential. The data from individuals who 
qualify or do not qualify are kept and stored until the end of the study, then destroyed. Permission to maintain 
the information for subjects who qualify and contact them for future studies is requested. See Screening under 
“Study Design and Procedures” for screening information.
5.0
Consent Process and Documentation
Refer to “SOP: Informed Consent Process for Research (HRP-090)”, for information about the process of 
obtaining informed consent from subjects.  HRP-090 can be accessed by clicking the Library link in CATS IRB 
(http://irb.psu.edu).
5.1
Consent Process 
5.1.1
Obtaining Informed Consent
5.1.1.1
Timing and Location of Consent
Describe where and when the consent process will take place.
We obtain a consent via telephone for the subject to fast before coming to the lab for the screening.
The subject reports to Noll lab for the consenting process. The subject signs an informed consent before any 
screening procedures are performed. 
5.1.1.2
Coercion or Undue Influence during Consent
Describe the steps that will be taken to minimize the possibility of coercion or 
undue influence in the consent process.
Subjects are informed throughout the study that their participation is voluntary, and they may discontinue their 
participation at any time. It is possible that a person enrolled in the study could be a student or employee. They 
are advised that participation in the study is voluntary and no aspect of their participation or non-participation 
has an effect on their class, grade, employment, or salary. Subjects are informed that participation or 
withdrawal from the study does not affect the quality of their medical care, payment or enrollment in health 
plans, or affect eligibility for benefits.
5.1.2
Waiver or alteration of the informed consent requirement
If you are requesting a waiver or alteration of consent (consent will not be obtained, required 
information will not be disclosed, or the research involves deception), describe the rationale 
for the request in this section.  If the alteration is because of deception or incomplete 
disclosure, explain whether and how subjects will be debriefed. Add any debriefing materials or 
document(s) to your study in CATS IRB (http://irb.psu.edu) on the “Supporting Documents” 
page.  NOTE: Review the “CHECKLIST: Waiver or Alteration of Consent Process (HRP-410)” to 
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ensure you have provided sufficient information for the IRB to make these determinations. 
HRP-410 can be accessed by clicking the Library link in CATS IRB (http://irb.psu.edu). 
Subject may arrived to consenting-session fasted if subject wishes to give informed consent and have the 
medical screening on the same day.
5.2
Consent Documentation
5.2.1
Written Documentation of Consent
Refer to “SOP: Written Documentation of Consent (HRP-091)” for information about the process 
to document the informed consent process in writing.  HRP-091 can be accessed by clicking the 
Library link in CATS IRB (http://irb.psu.edu).
If you will document consent in writing, describe how consent of the subject will be documented 
in writing. Add the consent document(s) to your study in CATS IRB (http://irb.psu.edu) on the 
“Consent Forms and Recruitment Materials” page. Links to Penn State’s consent templates are 
available in the same location where they are uploaded and their use is required.
The potential subject signs the informed consent. A copy of the signed consent is given to the 
subject.
5.2.2
Waiver of Documentation of Consent (Implied consent, Verbal consent, etc.)
If you will obtain consent (verbal or implied), but not document consent in writing, describe how 
consent will be obtained. Add the consent script(s) and/or information sheet(s) to your study in 
CATS IRB (http://irb.psu.edu) on the “Consent Forms and Recruitment Materials” page. Links to 
Penn State’s consent templates are available in the same location where they are uploaded and 
their use is required. Review “CHECKLIST: Waiver of Written Documentation of Consent (HRP-
411)” to ensure that you have provided sufficient information. HRP-411 can be accessed by 
clicking the Library link in CATS IRB (http://irb.psu.edu).
If your research presents no more than minimal risk of harm to subjects and involves no 
procedures for which written documentation of consent is normally required outside of the 
research context, the IRB will generally waive the requirement to obtain written documentation 
of consent.
i.
The written script of the information will be provided orally (if verbal consent is to be 
obtained) and will include all required elements of consent disclosure.
ii.
The research presents no more than minimal risk of harm to subjects (this is for the 
screening fasting procedure only)
iii.
The research involves no procedures for which written consent is normally required 
outside of the research context.
iv.
Written information describing the research is to be provided to the subject (option to 
print the consent form for their records).
5.3
Consent – Other Considerations 
5.3.1
Non-English Speaking Subjects
Indicate what language(s) other than English are understood by prospective subjects or 
representatives.
If subjects who do not speak English will be enrolled, describe the process to ensure that the 
oral and written information provided to those subjects will be in that language. Indicate the 
language that will be used by those obtaining consent.
Indicate whether the consent process will be documented in writing with the long form of the 
consent documentation or with the short form of the consent documentation.  Review the 
“SOP: Written Documentation of Consent (HRP-091)” and the “Investigator Manual (HRP-103)” 
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to ensure that you have provided sufficient information. HRP-091 and HRP-103 can be accessed 
by clicking the Library link in CATS IRB (http://irb.psu.edu).
Not Applicable
5.3.2
Cognitively Impaired Adults
Refer to “CHECKLIST: Cognitively Impaired Adults (HRP-417)” for information about research 
involving cognitively impaired adults as subjects. HRP-417 can be accessed by clicking the Library 
link in CATS IRB (http://irb.psu.edu).
5.3.2.1 Capability of Providing Consent
Describe the process to determine whether an individual is capable of consent.
Not Applicable
5.3.2.2
Adults Unable To Consent
Describe whether and how informed consent will be obtained from the legally 
authorized representative.  Describe who will be allowed to provide informed 
consent. Describe the process used to determine these individual’s authority to 
consent to research.
For research conducted in the state, review “SOP: Legally Authorized 
Representatives, Children and Guardians (HRP-013)” to be aware of which 
individuals in the state meet the definition of “legally authorized 
representative”. HRP-013 can be accessed by clicking the Library link in CATS IRB 
(http://irb.psu.edu).
For research conducted outside of the state, provide information that describes 
which individuals are authorized under applicable law to consent on behalf of a 
prospective subject to their participation in the procedure(s) involved in this 
research.  One method of obtaining this information is to have a legal counsel or 
authority review your protocol along with the definition of “children” in “SOP: 
Legally Authorized Representatives, Children, and Guardians (HRP-013).” HRP-
013 can be accessed by clicking the Library link in CATS IRB (http://irb.psu.edu).
Not Applicable
5.3.2.3 Assent of Adults Unable to Consent
Describe the process for assent of the subjects.  Indicate whether assent will be 
required of all, some or none of the subjects.  If some, indicate which subjects will 
be required to assent and which will not. 
If assent will not be obtained from some or all subjects, provide an explanation of 
why not.
Describe whether assent of the subjects will be documented and the process to 
document assent.  The IRB allows the person obtaining assent to document assent 
on the consent document and does not routinely require assent documents and 
does not routinely require subjects to sign assent documents.
Not Applicable
5.3.3
Subjects who are not yet adults (infants, children, teenagers) 
5.3.3.1 Parental Permission
Describe whether and how parental permission will be obtained. If permission 
will be obtained from individuals other than parents, describe who will be 
allowed to provide permission.  Describe the process used to determine these 
individual’s authority to consent to each child’s general medical care.
For research conducted in the state, review “SOP: Legally Authorized 
Representatives, Children and Guardians (HRP-013)” to be aware of which 
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individuals in the state meet the definition of “children”. HRP-013 can be 
accessed by clicking the Library link in CATS IRB (http://irb.psu.edu).
For research conducted outside of the state, provide information that describes 
which persons have not attained the legal age for consent to treatments or 
procedures involved in the research, under the applicable law of the jurisdiction 
in which research will be conducted.  One method of obtaining this information 
is to have a legal counsel or authority review your protocol along with the 
definition of “children” in “SOP: Legally Authorized Representatives, Children, 
and Guardians (HRP-013).” HRP-013 can be accessed by clicking the Library link 
in CATS IRB (http://irb.psu.edu).
Not Applicable
5.3.3.2 Assent of subjects who are not yet adults
Indicate whether assent will be obtained from all, some, or none of the children. If 
assent will be obtained from some children, indicate which children will be 
required to assent. When assent of children is obtained describe whether and how 
it will be documented.
Not Applicable
6.0
HIPAA Research Authorization and/or Waiver or Alteration of Authorization
This section is about the access, use or disclosure of Protected Health Information (PHI). PHI is individually 
identifiable health information (i.e., health information containing one or more 18 identifiers) that is transmitted 
or maintained in any form or medium by a Covered Entity or its Business Associate. A Covered Entity is a health 
plan, a health care clearinghouse or health care provider who transmits health information in electronic form.  
See the “Investigator Manual (HRP-103)” for a list of the 18 identifiers.  HRP-103 can be accessed by clicking the 
Library link in CATS IRB (http://irb.psu.edu).
If requesting a waiver/alteration of HIPAA authorization, complete sections 6.2 and 6.3 in addition to section 
6.1. The Privacy Rule permits waivers (or alterations) of authorization if the research meets certain conditions. 
Include only information that will be accessed with the waiver/alteration. 
6.1
Authorization and/or Waiver or Alteration of Authorization for the Uses and Disclosures of PHI
Check all that apply:
X 
Not applicable, no identifiable protected health information (PHI) is accessed, used or 
disclosed in this study. [Mark all parts of sections 6.2 and 6.3 as not applicable]
Authorization will be obtained and documented as part of the consent process. [If this is the 
only box checked, mark sections 6.2 and 6.3 as not applicable]
Partial waiver is requested for recruitment purposes only (Check this box if patients’ medical 
records will be accessed to determine eligibility before consent/authorization has been 
obtained). [Complete all parts of sections 6.2 and 6.3]
Full waiver is requested for entire research study (e.g., medical record review studies). 
[Complete all parts of sections 6.2 and 6.3]
Alteration is requested to waive requirement for written documentation of authorization 
(verbal authorization will be obtained). [Complete all parts of sections 6.2 and 6.3]
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6.2
Waiver or Alteration of Authorization for the Uses and Disclosures of PHI
6.2.1
Access, use or disclosure of PHI representing no more than a minimal risk to the privacy of the 
individual
6.2.1.1 Plan to protect PHI from improper use or disclosure
Include the following statement as written – DO NOT ALTER OR DELETE unless this 
section is not applicable because the research does not involve a waiver of 
authorization. If the section is not applicable, remove the statement and indicate 
as not applicable. 
Not Applicable
6.2.1.2 Plan to destroy identifiers or a justification for retaining identifiers 
Describe the plan to destroy the identifiers at the earliest opportunity consistent 
with the conduct of the research. Include when and how identifiers will be 
destroyed. If identifiers will be retained, provide the legal, health or research 
justification for retaining the identifiers.
Not Applicable
6.2.2
Explanation for why the research could not practicably be conducted without access to and 
use of PHI
Provide an explanation for why the research could not practicably be conducted without access 
to and use of PHI.
Not Applicable
6.2.3
Explanation for why the research could not practicably be conducted without the waiver or 
alteration of authorization
Provide an explanation for why the research could not practicably be conducted without the 
waiver or alternation of authorization.
Not Applicable
6.3
Waiver or alteration of authorization statements of agreement
By submitting this study for review with a waiver of authorization, you agree to the following statement 
– DO NOT ALTER OR DELETE unless this section is not applicable because the research does not involve a 
waiver or alteration of authorization. If the section is not applicable, remove the statement and indicate 
as not applicable.
Not Applicable
7.0
Study Design and Procedures
7.1
Study Design
Describe the type/design of trial to be conducted (e.g., double-blind, placebo controlled, parallel design, 
etc.). Provide a schematic diagram of study design, procedures and stages, if appropriate.
Two groups of women complete this study: 1) healthy women between the ages of 18 and 45 years (Controls); 
2) women between the ages of 18 and 45 years with endometriosis.  Each subject participates in a cutaneous 
microdialysis (MD) experiment before and after 6-9 days of oral atorvastatin (Lipitor) therapy (10mg/day).  Each 
MD experiment includes a blood draw (e.g. miRNA, soluble LOX receptor, OxLDL, IL6, IL17, TNFα).  The 
microdialysis experiments combine an acetylcholine dose response, perfusion of investigational agents, and 
local heating of the skin to explore the role of microRNA (miRNA) activation of LOX-1 receptor mechanisms in 
endothelial dysfunction associated with endometriosis.
7.2
Study Procedures
Provide a description of all research procedures being performed and when they are being performed 
(broken out by visit, if applicable), including procedures being performed to monitor subjects for safety 
or minimize risks.  Include any long-term follow-up procedures and data collection, if applicable. 
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Describe where or how you will be obtaining information about subjects (e.g., medical records, school 
records, surveys, interview questions, focus group topics, audio or video recordings, data collection 
forms, and collection of specimens through invasive or non-invasive procedures to include the amount 
to be collected and how often). Add any data collection instruments that will be seen by subjects to your 
study in CATS IRB (http://irb.psu.edu) in the “Supporting Documents” page.
7.2.1
EXAMPLE: Visit 1 or Day 1 or Pre-test, etc. (format accordingly)
Provide a description as defined above and format accordingly.
Screening
1.  The participants drink only water and do not eat for 12 hours before the screening.  
2.  The research nurse conducts the screening that includes pregnancy test for women who are not post-
menopausal, 12-lead resting ECG, heart rate (HR), blood pressure (BP), height, waist circumference, weight, health 
history, creatine phosphokinase (CPK), and standard venipuncture to obtain blood (30 ml, 2 Tbsp) for complete 
blood count (CBC), chemistry analysis, lipid profile, protein kinase, and other substances of interest.  
3.  If participant takes thyroid medication, the nurse obtains thyroid stimulating hormone (TSH) level from 
participant.  If TSH level is not available and/or has not been measured within 6 months, TSH is also measured from 
the blood sample.  
4.  We do not perform genetic analyses on the blood nor look for presence of disease (e.g. HIV).  
5.  We give subjects a note that informs her/his physician that the subject takes Lipitor as part of this study.
If the research nurse is unavailable for an extended period, the Clinical Research Center CRC staff performs her 
screening tasks.  The CRC uses their admission form to admit potential participants for screening at the CRC.
7.2.2
EXAMPLE: Visit 2 or Day 2 or Post-test, etc. (format accordingly)
Provide a description as defined above and format accordingly.
Note: Subjects perform a pre- and post-statin therapy experiment.
1.
Preparation for experiments
a.
We give printed and verbal instructions outlining what the subjects need to do before they come to the lab.  
b.
Subjects continue with their normal diet except:
i.
 They refrain from consuming alcohol and caffeine (ex. coffee, tea, Coca Cola, chocolate) for 12 hours 
before the experiment.
c.
On the day of the experiment, 
i.
Subjects refrain from activity that causes them to exert themselves more than a leisurely walk.
ii.
We measure HR, BP, and oral temperature.  Women who are not postmenopausal undergo a urine 
pregnancy test if they have not been tested within 2 weeks.   
iii.
The nurse draws 10 ml blood for analysis of relevant substances of interest such as miRNA, soluble LOX 
receptor, OxLDL, IL6, IL17, and TNFα.  
iv.
Microdialysis probe insertion:  The subject washes the ventral forearm with antimicrobial soap.  We 
place a tight band around the arm so we can visualize veins.  For each MD site, we make pairs of pen-
marks on the arm 2.5 cm (1 inch) apart and away from veins.  We remove the tight band.  The MD 
tubing enters and exits the skin at the marks.  We clean the arm with povidone iodine and alcohol.  We 
place an ice bag on the arm for 5 minutes to numb the skin.  Then we insert a thin needle into the skin 
at each entry mark.  The needle’s tip travels between the layers of skin for 2.5 cm (1 inch) and leaves 
the skin at the matching exit mark. We thread the MD tubing through the needle.  Next, we withdraw 
the needle leaving the tubing in the skin.  Any redness of the skin subsides in about 60 – 120 minutes.  
v.
We initiate lactated Ringer’s perfusion in all MD probes at 2 µl/min.
vi.
We attach 3 ECG leads to measure heart rate, and place a cuff on the upper arm sans the MD probes to 
measure blood pressure.  We place a local skin heater and laser Doppler probe over each MD site.  We 
measure heart rate, local temperature, and skin blood flow (SkBF) throughout the MD experiments.  
We also measure blood pressure every 5-7 minutes (brachial osculation and/or critical care monitor).
2.
MD Experiment – Pre-Statin Therapy
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a.
Acetylcholine (ACh) Dose Response
We prepare 5 MD sites:
Probe 1. Lactated Ringer’s only (control)
Probe 2. Lactated Ringer’s + LNAME
Probe 3. Lactated Ringer’s + Poly I:C
Probe 4. Lactated Ringer’s + atorvastatin
Probe 5. Lactated Ringer’s + (LNAME + Poly I:C) or (LNAME + atorvastatin)*
*Note:  Pilot experiments lead to development of the final protocol.  Two treatments are explored at MD 
Probe 5 during pilot experiments.  Pilot experiments also determine final doses of investigational agents.
We clamp the temperatures of the local heaters at 34°C (93°F).  We add Poly I:C or atorvastatin to probes 3, 
4, and 5 as indicated above.  After 30 minutes, we add LNAME to Probes 2 and 5.  Twenty minutes later, we 
record a 10-minute baseline.  After the baseline, we add the first concentration of ACh to the perfusate at 
each probe.  Each site receives 6 increasing concentrations of ACh (10^-10M to 10^-1M) each concentration 
is perfused for 5 minutes.  As SkBF stabilizes with the addition of each concentration of ACh, we proceed to 
the next concentration.  After the last concentration of ACh, we switch perfusates at all sites to Ringer’s only 
for about 30 minutes while increasing the local temperature to 43°C.  We add SNP to lactated Ringer’s for 10 
minutes at each site.  Heating and SNP perfusion causes maximum vasodilation.
b.
Then the experiment is over, and we remove the MD tubing from the skin and place sterile bandages over 
the sites.  If the subject desires, we can also place a bag of ice on the site for 10 minutes to reduce any 
bruising that may occur.  We measure blood pressure and heart rate before the subject departs.
3.
Subjects take 10 mg/day atorvastatin for 6-9 days.  Women who are not postmenopausal undergo a urine 
pregnancy test before beginning the atorvastatin.   
4.
Venous blood may be drawn for Chem 24 analysis if a subject experiences side effects from the statin therapy 
(e.g. dark urine, muscle myalgia).
5.
MD Experiment – Post-Statin Therapy
a.
The subjects return to the lab to repeat the MD experiment within days 6-9 of atorvastatin therapy.
b.
On the morning of the experiment, the subjects take their final dose of atorvastatin.
c.
All other preparation and procedures are the same as described for the Pre-statin Therapy MD Experiment.
Equipment:
Laser Doppler Flowmetry:  The Laser Doppler Flowmeter (Moor Instruments, Inc.) non-invasively provides a 
qualitative measure of skin blood flow to a depth of about 1 mm in the skin using a weak laser light.  This measure 
is a dimensionless value called “flux” that reflects the speed and number of blood cells moving through the 
microvasculature in an area of skin.  The flowmeter continuously measures skin blood flow using a fiber optic probe 
that fits into holders taped to the skin.  Approved by the FDA
  
Blood Pressure, ECG (Heart rate):  The critical care monitor measures blood pressure via a cuff inflated every 5-7 
minutes on the upper arm and heart rate via 3-lead ECG probes taped to the skin of the chest.  Approved by the 
FDA
12-lead ECG:  The critical care monitor measures standard 12-lead ECG during screening via electrodes taped to the 
skin.  Approved by the FDA
7.3
Duration of Participation
Describe the duration of an individual subject’s participation in the study.
Screening (1 Visit) 
less than 1.5 hour
MD Experiments (2 Visits)
5 hours
Total: ~11.5 Hours
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7.4
Test Article(s) (Study Drug(s) and/or Study Device(s))
7.4.1
Description
Provide a brief description of all test articles (drugs (including any foods and dietary 
supplements), devices and/or biologics used in the research including the purpose of their use 
and their approval status with the Food and Drug Administration (FDA). Include information 
about the form of the drug product (e.g., tablets, capsules, liquid).
Investigative Substances:  Microdialysis
Acetylcholine
ACh
Form: solid
Role in Current Study:  The local perfusion of endothelial agonist, acetylcholine, specifically examines the 
attenuated endothelium-dependent vasodilation associated with endometriosis.
Atorvastatin
Form: solid
Role in Current Study:  Atorvastatin is a LOX inhibitor.
Lactated Ringer’s
Ringer’s
Form: Liquid
Role in current study:  Lactated Ringer’s acts as the vehicle for the other research substances and as a flush.
LNAME 
NG-nitro-L-arginine methyl ester
Form: solid
Role in current study:  A nitric oxide synthase inhibitor.  L-NAME is an analog to the amino acid, L-arginine.  L-
NAME is a non-specific inhibitor for nitric oxide synthases, thereby inhibiting the production of nitric oxide that 
causes vasodilation.  
Polyinsinoic Acid
Poly I:C
Form: solid
Role in Current Study:  Polyinosinic Acid is a LOX-1 receptor antagonist.
Sodium Nitroprusside     
SNP
Form: solid
Role in Current Study:  SNP, acting as an NO donor, dilates blood vessels maximally thereby, combined with local 
heating, achieving maximal skin blood flow (SkBF).  Maximal SkBF is a reference point for other measures of skin 
blood flow.
Investigative Substances:  Oral
Atorvastatin
Brand name:  Lipitor
Form:  tablet
Role in Current Study:  Atorvastatin acts as a systemic LOX inhibitor.
7.4.2
Treatment Regimen
Describe dose, route of administration and treatment duration. Include information about dose 
adjustments.
Investigative Substances:  Microdialysis
The following is a table of the research agents used with intradermal microdialysis.  Based upon research 
literature, we use 14% for calculating maximum delivery of the research agents for all IND applications for our 
MD studies.  
Research Agent
14% delivery (mg)
ACh
0.025
Atorovastatin
0.00061
L-NAME
0.091
Poly I:C
0.1
SNP
0.023
Investigative Substances:  Oral
Atorovastatin
10 mg/day for 6-9 days
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7.4.3
Method for Assigning Subject to Treatment Groups
Describe the randomization process and how the associated treatment assignment will be 
made.
Not Applicable
7.4.4
Subject Compliance Monitoring
Insert the procedures for monitoring subject compliance.
We note remaining atorvastatin tablets when subject returns for post-treatment experiment.
7.4.5
Blinding of the Test Article
Describe how the test article is blinded.
Not Applicable
7.4.6
Receiving, Storage, Dispensing and Return 
7.4.6.1
Receipt of Test Article 
Describe how the test article will be obtained and from what source. Describe 
how the study test article will be packaged along with amounts (e.g., number of 
tablets/capsules or volume of liquid) and labeling. If drug kits are used, describe 
all the contents of the kit and associated labeling.
See uploaded Physician Oversight SOP.
Investigative Substances:  Microdialysis
Detailed records are kept in laboratory log books.  The containers of the substances are dated upon receipt and 
when opened. 
   
Investigative Substance
Source(s) 
ACh
USP
Atorvastatin
USP
L-NAME
EMD, Tocris
Lactated Ringer’s
McKesson, Moore Medical
Poly I:C
Invivogen
SNP
USP
From uploaded Physician Oversight SOP:  
The investigative agents are purchased by the lab members from reputable sources as indicated in the IRB and 
the FDA IND applications and in accordance with the standards and guidelines imposed by the FDA.
A license from the CRC physician, the nurse manager, or the overseeing physician is filed with vendors (e.g. 
VWR, Owens and Minor) requiring the documentation for the purchase of some investigative agents (e.g. 
Lactated Ringer's).
The investigative agents are shipped to the Noll Lab or picked up from the pharmacy by lab personnel.
Copies of the prescriptions and orders are maintained in the laboratory's files.
Investigative Substances:  Oral
A prescription, written by a study physician, for the Atorvastatin (10mg/tablet, 9 tablets) is filled by the 
Boalsburg Apothecary for each study participant.  Detailed records are kept in laboratory log books and in 
individual subjects' charts.  All medications will be double-checked by two people to ensure correctness.  
Atorvastatin (Lipitor)
Boalsburg Apothecary
From uploaded Physician Oversight SOP:  
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Some of the investigative agents are prescription drugs... The lab personnel obtain prescriptions from a CRC 
physician, the research nurse manager, or the overseeing physician for the investigative agents that are 
prescription drugs and forward the prescriptions to the pharmacy….  The investigative agents are shipped to the 
Noll Lab or picked up by lab personnel.
A license from the CRC physician, the research nurse manager, or the overseeing physician is filed with 
reputable vendors requiring the documentation for the purchase of some investigative agents.
Copies of the prescriptions and orders are maintained in the laboratory's files.
7.4.6.2
Storage
Describe the plans to store, handle the test article so they will be used only on 
subjects and only by authorized investigators. Describe storage temperature 
requirements and how temperature will be monitored and recorded.
Investigative Substances:  Microdialysis
The investigational substances are stored under environmental conditions according to manufacturers’ 
instructions in cabinets, refrigerators, or freezers located in Room 229 or 224A Noll Laboratory.  The room is 
locked when unoccupied.  Each location has a thermometer.  The temperatures are recorded daily during 
weekdays.  The temperature of the room is also monitored by the Central Control System of the Environmental 
Systems at PSU.
Investigative Substances:  Oral
We store the drugs in a locked cabinet in Room 229 under environmental conditions according to 
manufacturers’ instructions.  The room is locked when unoccupied.  The location has a thermometer.  The 
temperatures are recorded daily during weekdays.  The temperature of the room is also monitored by the 
Central Control System of the Environmental Systems at PSU.
7.4.6.3
Preparation and Dispensing
Describe how the test article will be assigned to each subject and dispensed. 
Describe the steps necessary to prepare the test article. Include where the test 
article preparation will be done and by whom. Fully describe how the study 
treatment is to be administered and by whom.
Investigative Substances:  Microdialysis
None of the microdialysis drugs are dispensed to the participant; rather we use them in the experiment, as 
outlined in the Standard Operating Procedures (Phys Ovrsght SOP).  The physician providing oversight approves 
the laboratory standard operating procedure for the obtainment, preparation, and administration of all 
investigational agents for MD and other procedures in experiments.
The following procedures have been examined and approved by the FDA.
Trained lab personnel prepare the perfusates in accordance with the procedure described in the IRB and FDA 
IND applications. When mixing the perfusates, the experienced technician washes the hands, wears protection 
(e.g. gloves, lab coat), and uses glassware that has been washed with cleaner (designed for use with healthcare 
instruments, pharmaceutical process equipment , tissue culture apparatus , etc.), and rinsed multiple times in 
tap and then doubly- distilled water and air-dried.  Most of the investigational agents are obtained in ultra-pure 
solid form. The solid investigational agents are weighed on a microbalance and then mixed with sterile 
pharmaceutical-grade Lactated Ringer's solution to the desired concentration.  The solution is drawn into the 
syringe through a 0.2 µm filter.  Prior to injecting a solution into or withdrawing solution from a sterile container 
through a sterile hypodermic needle, the stopper of the sterile container is cleaned thoroughly with alcohol.  
Most perfusates are used within minutes or hours after preparation.  Stock solutions are made for some 
investigational agents.  The stock solutions are drawn into sterile 1-cc syringes through 0.2 µm filters for storage.  
The sterile stock solutions are labeled accordingly (e.g. content, date), and protected from light.   Stock solutions 
are not used beyond 1 week (refrigerated) and 6 months (frozen) after mixing.  Stock solutions are diluted with 
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sterile Lactated Ringer's when preparing the perfusate.  The final dilutions of the perfusates are drawn into 
sterile syringes through 0.2 µm filters within minutes or hours of their use in the experiment.
The protocol that includes the administration of the investigative substances has been examined and approved 
by the FDA.
The administration of the investigative substances is performed by the trained and approved lab personnel as 
described in the protocol included in the IRB and FDA IND applications.  The overseeing physician has observed 
and approved the microdialysis technique as performed by Dr. Lacy Alexander.  The lab personnel performing 
microdialysis have been trained and approved to perform the technique by Dr. Lacy Alexander, approved by the 
overseeing physician, and approved by the IRB.  Letters of approval from the overseeing physician for each 
member of the lab who performs microdialysis in the research project have been submitted to the IRB.
Investigative Substances:  Oral
The Boalsburg Apothecary places the pills into bottles labeled with the subject ID number, strength (mg), dosing 
instructions, date, etc.  Each bottle contains the number of pills as prescribed by a study physician. All 
medications will be double-checked by two people to ensure correctness.  The research nurse gives the bottle of 
pills to the subject along with handouts that contain detailed information and dosing instructions pertinent to 
their assigned drug.  Detailed records are kept in laboratory log books and in individual subjects ' charts.
7.4.6.4
Return or Destruction of the Test Article
Describe the procedures for final reconciliation of the test article supply at the 
end of the study and whether the test article is to be shipped back to a source 
or destroyed on site.
Subjects are required to return unused pills to investigators. The pills are disposed of in accordance with policies 
of the Penn State’s Environmental Health and Safety Department at University Park.
7.4.6.5
 Prior and Concomitant Therapy
Describe what prior and/or concomitant medical therapy will be collected. 
Describe which concomitant medicines/therapies are permitted during the 
study. Describe which concomitant medicines are not permitted during the 
study.
Subjects are excluded if they are currently taking chronic medications that may affect vascular function or are 
contraindicated for the atorvastatin pharmacotherapy. Medications that are not specifically mentioned in 
exclusion criteria may be excluded on a case by case basis upon review by the research clinicians or PI.
8.0
Subject Numbers and Statistical Plan
8.1
Number of Subjects
Indicate the total number of subjects to be accrued. 
If applicable, distinguish between the number of subjects who are expected to be enrolled and 
screened, and the number of subjects needed to complete the research procedures (i.e., numbers of 
subjects excluding screen failures.)
Anticipated number of subjects to be screened:  10
Needed to complete:  6
The pilot experiments will enable the determination of the number of subjects needed for completion of the 
study.  A future modification to this study will update number of subjects.
8.2
Sample size determination
If applicable, provide a justification of the sample size outlined in section 8.1 – to include reflections on, 
or calculations of, the power of the study.
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The pilot experiments will enable the determination the number of subjects needed for completion of the study.  
A future modification to this study will add that number of subjects.
8.3
Statistical methods
Describe the statistical methods (or non-statistical methods of analysis) that will be employed.
Descriptive statistics will be calculated and the variance will be noted for a full power analysis.  If appropriate, 
three-way repeated measures ANOVA (ANCOVAs) will be performed to examine group differences (healthy 
control vs. endometriosis) or systemic treatment differences (pre-treatment vs. post-treatment), and local 
microdialysis treatment differences across the doses of pharmacological stimuli with the primary outcome 
variable of cutaneous vascular conductance.  Appropriate post-hoc analyses with corrections for multiple 
comparisons will be performed when main effects are identified, in all cases including potential confounding 
variables as covariates.
9.0
Confidentiality, Privacy and Data Management 
For research being conducted at Penn State Hershey or by Penn State Hershey researchers only, the research 
data security and integrity plan is submitted using “HRP-598 – Research Data Plan Review Form Application 
Supplement”, which is available in the Library in CATS IRB (http://irb.psu.edu).  Refer to Penn State College of 
Medicine IRB’s “Standard Operating Procedure Addendum: Security and Integrity of Human Research Data”, 
which is available on the IRB’s website. In order to avoid redundancy, for this section state “See the Research 
Data Plan Review Form” in section 9.0 if you are conducting Penn State Hershey research and move on to 
section 10. 
For all other research, in the sections below, describe the steps that will be taken to secure the data during 
storage, use and transmission.
9.1
Confidentiality
9.1.1
Identifiers associated with data and/or specimens
List the identifiers that will be included or associated with the data and/or specimens in any way 
(e.g., names, addresses, telephone/fax numbers, email addresses, dates (date of birth, 
admission/discharge dates, etc.), medical record numbers, social security numbers, health plan 
beneficiary numbers, etc.).  
If no identifiers will be included or associated with the data in any way, whether directly or 
indirectly, please indicate this instead.  
Most of the data are coded and do not contain personal identifying information.  Some data will temporarily 
contain the subject’s name, address, and/or telephone number (Phone Interview Form).  Documents allowing 
identification of participants do not leave our labs and are only available to authorized persons.  Only authorized 
personnel may access the lab computer.  Data forms containing identifiable information are shredded when no 
longer needed (within 5 years after publication of results).
9.1.1.1 Use of Codes, Master List
If identifiers will be associated with the data and/or specimens (as indicated in 
section 9.1.1 above), describe whether a master record or list containing a code 
(i.e., code number, pseudonyms) will be used to separate the data collected 
from identifiable information, where that master code list will be stored, who 
will have access to the master code list, and when it will be destroyed. 
If identifiers are included or associated with the data as described in section 
9.1.1 above, but no master record or list containing a code will be used, it will be 
assumed by the IRB that the investigator plans to directly link the identifiers 
with the data.   
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We keep data in the laboratory in locked cabinets, the password-protected folder on the secured PSU server, 
and on password-protected computers maintained in a locked room.  Only authorized personnel have access.  
Coded data shared with unauthorized persons cannot be traced to individuals.  The list linking code numbers to 
participants is not shared with unauthorized persons and destroyed when project is completed and published.  
The code is destroyed within 5 years of publication of the data.
9.1.2
Storage of Data and/or Specimens
Describe where, how and for how long the data (hardcopy (paper) and/or electronic data) 
and/or specimens will be stored. NOTE: Data can include paper files, data on the internet or 
websites, computer files, audio/video files, photographs, etc. and should be considered in the 
responses.  Refer to the “Investigator Manual (HRP-103)” for information about how long 
research records must be stored following the completion of the research prior to completing 
this section. HRP-103 can be accessed by clicking the Library link in CATS IRB 
(http://irb.psu.edu). 
Please review Penn State’s Data Categorization Project for detailed information regarding the 
appropriate and allowable storage of research data collected according to Penn State Policy 
AD71. Although the IRB can impose greater confidentiality/security requirements (particularly 
for sensitive data), the IRB cannot approve storage of research data in any way or using any 
service that is not permissible by Penn State Policy AD71.  
We maintain data in the laboratory in locked cabinets and on password-protected computers 
located in rooms that are locked when unoccupied.  Most of the data are coded and do not 
contain personal identifying information.  Documents allowing identification of participants do 
not leave the investigator’s labs and are only available to authorized persons.  Coded data 
shared with unauthorized persons cannot be traced to individuals.  We store any list linking the 
code to participants’ identity in locked cabinets and on password-protected computers located 
in rooms that are locked when unoccupied.  Hard copy data forms containing identifiable 
information are shredded when no longer needed (within 5 years after publication of results).  
Screening data from subjects who are not accepted into the study are shredded when the 
project ends.  Subjects may give permission to have their contact information retained in the 
investigator’s secured files if they wish to be considered for participation in future studies.  After 
we complete the study, we remove all identifiers from the study’s data and store the data 
indefinitely.  Individual data may be used without identifying the subject to illustrate 
representative responses.
Biological specimens are stored at University Park and Quest Labs, (Chantilly, VA).  At University 
Park, the specimens are stored in a -80°C freezer in Noll first floor hallway.  All specimens not 
exhausted upon analysis are maintained no longer than 5 years after publication.
9.1.3
Access to Data and/or Specimens
Identify who will have access to the data and/or specimens. This information should not conflict 
with information provided in section 9.1.1.1 regarding who has access to identifiable 
information, if applicable.   
Only authorized personnel have access.
9.1.4
Transferring Data and/or Specimens
If the data and/or specimens will be transferred to and/or from outside collaborators, identify 
the collaborator to whom the data and/or specimens will be transferred and how the data 
and/or specimens will be transferred. This information should not conflict with information 
provided in section 9.1.1.1 regarding who has access to identifiable information, if applicable.
Some specimens are mailed or transported by lab members or couriers outside labs for analysis.  
The outside labs are the Biomarker Core Lab (PSU, University Park) and Quest Diagnostics 
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(Chantilly, VA).  All specimens are coded and do not contain identifiers.  We do not share the 
code with unauthorized persons.  
9.2
Subject Privacy
This section must address subject privacy and NOT data confidentiality.
Indicate how the research team is permitted to access any sources of information about the subjects. 
Describe the steps that will be taken to protect subjects’ privacy interests. “Privacy interest” refers to a 
person’s desire to place limits on whom they interact with or to whom they provide personal information.
Describe what steps you will take to make the subjects feel at ease with the research situation in terms 
of the questions being asked and the procedures being performed. “At ease” does not refer to physical 
discomfort, but the sense of intrusiveness a subject might experience in response to questions, 
examinations, and procedures.
Only authorized personnel have access (e.g. computer passwords, keys to locked cabinets/labs) to sources 
of information about subjects.  We tell participants that they may decline to answer questions and decline 
to participate in the study.  Only authorized personnel are present during screening and experiments.  On 
occasion (e.g. educational visit, visiting colleague, site visit) participants may give permission for visitors 
to observe a procedure or experiment.
10.0 Data and Safety Monitoring Plan
This section is required when research involves more than Minimal Risk to subjects. As defined in “SOP: 
Definitions (HRP-001)”, available in the Library in CATS IRB (http://irb.psu.edu), Minimal Risk is defined as the 
probability and magnitude of harm or discomfort anticipated in the research that are not greater in and of 
themselves than those ordinarily encountered in daily life or during the performance of routine physical or 
psychological examinations or tests.  For research involving prisoners, Minimal Risk is the probability and 
magnitude of physical or psychological harm that is normally encountered in the daily lives, or in the routine 
medical, dental, or psychological examination of healthy persons. Please complete the sections below if the 
research involves more than minimal risk to subjects OR indicate as not applicable.  
10.1
Periodic evaluation of data
Describe the plan to periodically evaluate the data collected regarding both harms and benefits to 
determine whether subjects remain safe.
NA
10.2
Data that are reviewed
Describe the data that are reviewed, including safety data, untoward events, and efficacy data.
NA
10.3
Method of collection of safety information
Describe the method by which the safety information will be collected (e.g., with case report forms, at 
study visits, by telephone calls and with subjects).
NA
10.4
Frequency of data collection
Describe the frequency of data collection, including when safety data collection starts.
NA
10.5
Individuals reviewing the data
Identify the individuals who will review the data. The plan might include establishing a data and safety 
monitoring committee and a plan for reporting data monitoring committee findings to the IRB and the 
sponsor.
NA
10.6
Frequency of review of cumulative data
Describe the frequency or periodicity of review of cumulative data.
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NA
10.7
Statistical tests
Describe the statistical tests for analyzing the safety data to determine whether harms are occurring.
NA
10.8
Suspension of research
Describe any conditions that trigger an immediate suspension of research.
NA
11.0 Risks
List the reasonably foreseeable risks, discomforts, hazards, or inconveniences to the subjects related the 
subjects’ participation in the research.  For each potential risk, describe the probability, magnitude, duration, 
and reversibility. Consider all types of risk including physical, psychological, social, legal, and economic risks. If 
applicable, indicate which procedures may have risks to the subjects that are currently unforeseeable. If 
applicable, indicate which procedures may have risks to an embryo or fetus should the subject be or become 
pregnant. If applicable, describe risks to others who are not subjects.
Please keep in mind that loss of confidentiality is a potential risk when conducting human subject research and 
should be addressed as such. 
General note:  The research group’s members are trained and competent in their duties.  The group, led by Dr. 
Alexander, evaluates the effectiveness and safety of protocols and procedures in an ongoing fashion.  They 
discuss the protocol with candidates, invite questions, and offer tours of the laboratory.  Prior to medical 
screening, candidates read and sign informed consent forms detailing protocols, procedures, risks, sensations, 
compensation, etc.  We give candidates witnessed copies of the signed consent forms.  After accepting 
participants into the study, we discuss and review the procedures and protocols with them generally and at each 
step throughout the project.  They frequently remind participants of the option to withdraw from the study at 
any time. Restricting access to experiments, data, and coding to authorized personnel maintains confidentiality.  
The Noll Lab’s electronics technician certifies the electrical devices for human use.  Lists of emergency numbers 
remain by lab telephones.  At least one cell phone is present at each experiment.  A hospital and emergency 
medical services are within 1-2 miles of the lab.  All lab members who are graduate students, post docs, or staff 
have current American Heart Association (AHA) Basic Life Support (BLS) with automated external defibrillator 
(AED) training.  A cardiopulmonary resuscitation (CPR) mask hangs in each lab room.  An AED hangs nearby in 
the hallway.
Microdialysis:  We insert a 23 g needle horizontally into and then out of the layers of the skin of the ventral 
forearm.  The needle’s entry and exit are about 2.5 cm apart.  They thread the microdialysis “probe,” comprising 
a tube of membrane (320 um OD) with tubing attached at both ends (650 um OD), through the needle.  Then 
they withdraw the needle leaving the membrane under the skin.  They perfuse the probe with sterile saline 
using a syringe pump.
Cutaneous microdialysis commonly causes some pain and bruising similar to that experienced during 
venipuncture.  There is usually no pain after the probe is in place.  The participant may experience mild pain 
while we remove the probe.  Minor bleeding may occur.  As with routine venipuncture, a participant who is 
nervous about needles could have increased heart rate and blood pressure, become lightheaded or nauseated, 
or could faint.
As with venipuncture or any event that breaks the skin, infection is possible.  However, no participants in any of 
the researchers’ experiments have reported infection.  We place a sterile bandage on the site after the 
experiment.
Although rare, if the membrane should break in half during removal, they remove the remaining half by gently 
pulling the attached tubing.  This presents no additional risk to the participant.  In the unlikely event in which the 
membrane breaks during removal leaving an isolated piece of membrane under the skin, they treat the piece of 
membrane in a manner similar to that for a splinter in the skin.  In this case, they have to make a superficial 
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incision for removal.  Such an event has not occurred in projects that have used MD in this lab (over 1,000 MD 
probes have been placed by Dr. Alexander, alone).  
The persons performing MD have been trained in proper technique and procedure by Dr. Alexander and had 
their technique witnessed / approved by Robert Mooney, D.O. and/or Sarah Ferguson, M.D. (see uploads under 
respective “CV”s).  Ice numbs the skin and the small needle reduces pain during insertion.  We stop any bleeding 
by applying mild pressure to the site with sterile gauze.  In the unlikely event that the individual has an allergic 
reaction, we stop microdialysis immediately.  If the reaction becomes severe, we seek emergency medical 
assistance.  Infection is possible, but proper aseptic technique and sterile solutions / supplies keep the risk 
minimal.  They place a sterile bandage on the site after the experiment.  
Perfusate:  Lactated Ringer’s solution flows through the microdialysis probes.  An allergic reaction to this 
physiological saline solution is highly unlikely.
All substances (ACh, Atorvastatin, L-NAME, Poly I:C, SNP) added to the lactated Ringer’s perfusing the 
microdialysis probes have been used previously clinically and/or during research in humans:
Microdialysis delivers small amounts of the substances to a nickel-sized area of the skin.  The small quantities 
used and the extremely localized administration during microdialysis is unlikely to produce systemic effects.  To 
our knowledge, there are no reports of long side effects of these substances administered through microdialysis. 
The chance of adverse reactions to these substances is extremely small given the minute amount delivered to 
the a very small area of skin, the lack of adverse reactions to similar amounts delivered via MD in many other 
studies, and lack of adverse effects in human cell cultures.  There is a slight chance of a sensitivity or allergic 
reaction to these substances that could produce redness, itching, rash, and/or swelling.  A severe reaction 
(anaphylactic shock) could also cause fever, difficulty in breathing, changes in pulse, convulsions, and/or loss of 
consciousness.  Although rare, it is possible that a subject could experience lightheadedness, flushing, nausea, 
“pounding heart” sensation, and/or vomiting.  We end the perfusion in the event of these signs and symptoms.
The perfusate is sterile.  We prepare the perfusate in the laboratory using sterile techniques and supplies 
commonly used for this purpose in research laboratories.  The Ringer’s solution is sterile as purchased.  We add 
other solutions aseptically to the sterile bag of Ringer’s solution through 0.2 micron Gelman Sterile Acrodisc 
syringe filters.  We mix the perfusate for same-day use and discard excess perfusate after the experiment.   
During the IND application process, the FDA accepted our technique for preparing perfusates.  Although 
unlikely, in the case of a severe reaction to the perfusate, we call 911.
Laser Doppler Flowmetry:   The probe attaches to the skin with double-sided tape and measures skin blood flow 
in a 1mm3 volume of skin.  Weak lasers can hurt the eye if one should stare into the light for a long time.  The 
red light seen on the surface of the skin is harmless.  We do not turn on the laser until the probes are taped to a 
surface.  We remove the tape afterward carefully.  We have used this technique in the lab with IRB approval for 
many years without incident.   
Blood pressure (manual and critical care monitor (e.g. CardioCap5):  The manual method and critical care 
monitor use a cuff that inflates on the upper arm.  The cuff slowly deflates while we listen to pulse-sounds at the 
inside of the elbow with a stethoscope, or the critical care monitor takes a measurement.  The inflated cuff may 
make the arm feel tingly and numb, and the cuff may temporarily bruise the arm.  Efficient and competent 
measurement technique minimizes the duration of cuff inflation.
Povidone Iodine:  Hospitals and researchers use povidone iodine to clean and sterilize the skin.  Participants 
could be allergic to iodine.   An allergic reaction could cause redness, itching, rash, and/or swelling.  A worse 
reaction could also cause fever, breathing problems, changes in pulse and/or blood pressure, convulsions, shock, 
and/or loss of consciousness.  Staff use only alcohol on participants with iodine allergy as identified during 
screening.
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Blood draw:  Blood draws can cause anxiety (with increased heart rate and blood pressure), mild pain, swelling, 
nausea, lightheadedness, fainting, or bleeding.  There is a slight chance of infection.  A competent nurse 
performs blood draws using standard venipuncture-procedure and techniques that minimize the chance of 
infection.  Participants may recline for the procedure.
Tape and adhesive disks:   Participants could be sensitive to the adhesive of the tape and double-sided adhesive 
disks used in the study causing redness, rash, tenderness, and/or itching.  We remove the tape and adhesive 
disks carefully.  Ointment is available, if needed.  
Screening:  The screening includes blood sample, height, waist circumference, weight, heart rate, blood 
pressure, pregnancy test, and history performed by the competent research staff.  Participants may be 
uncomfortable giving medical information or being measured.  The participants may decline to answer questions 
or participate in measurements.  We conduct screenings professionally and privately.
Initial Screening Form:  We use the form to initially determine a candidate’s suitability for the study.  The initial 
interview gathers minimally invasive personal data that is kept confidential.  They used similar interviews in the 
past without problem.  Candidates may complete the form at the lab group’s web site via the Qualtrics 
commercial survey website.  The participant may decline to answer questions.  We conduct phone interviews 
professionally and privately.  Only authorized personnel may access completed forms.
Local Heating:  The local heating control unit (Moor Instruments) precisely controls and monitors the 
temperature of the heated probe holders used with the Laser Doppler Flowmeter.  To determine the maximal 
SkBF, we increase the temperature of the heating units slowly (about 0.1°C every 1 second).   The skin feels very 
warm but not painful.  Local heating causes temporary redness of the skin that subsides within several hours.  
This technique is very unlikely to produce long-term ill effects.  The local heating controllers (Moor Instruments) 
precisely control and monitor the temperature of the heated probe holders.  The system has programmed 
maximum temperature limits.  This technique is unlikely to cause long-term ill effects.
ECG:  We attach three to ten electrodes to the participant’s chest and then attach the electrode wires to an ECG 
machine.  The machine records the electrical activity of the heart. There are no adverse effects from this 
measure.  A participant may be shy about electrodes applied to the chest.  The staff carefully remove the tape 
afterward. They conduct the test professionally and privately.
Atorvastatin Therapy:  Atorvastatin is a synthetic lipid-lowering agent. Atorvastatin is an inhibitor of 3-hydroxy-
3-methylglutaryl-coenzyme A (HMG-CoA) reductase. This enzyme catalyzes the conversion of HMG-CoA to 
mevalonate, an early and rate-limiting step in cholesterol biosynthesis.  Atorvastatin is generally well-tolerated.  
Adverse reactions have usually been mild and transient. In controlled clinical studies of 2502 patients, <2% of 
patients were discontinued due to adverse experiences attributable to atorvastatin. The most frequent adverse 
events thought to be related to atorvastatin were muscle pain, nausea, constipation, flatulence, dyspepsia, and 
abdominal pain.  Statins have been associated with abnormalities in liver function.  Persistent elevations in 
serum transaminases occurred in 0.7% of patients who received atorvastatin in clinical trials. The incidence of 
these abnormalities was 0.2%, 0.2%, 0.6%, and 2.3% for 10, 20, 40, and 80 mg doses, respectively.  The low dose 
and short duration of the therapy used in this study reduces the likelihood of adverse event even more.  The 
therapy is under the direction of the GCRC clinician with Urs Leuenberger, M.D., Professor of Medicine, Milton S. 
Hershey Medical Center (see attached letter) consulting.  Subjects receive verbal and written information 
concerning the therapy.  Creatine phosphokinase (CPK) is measured during screening and before each 
experiment.  If the subject experiences symptoms of possible adverse response to atorvastatin, blood is drawn 
for CPK and/or Chem 24 analysis when the subject reports symptoms to the study team or study nurse.  If 
increased transaminase develops, we monitor levels until increase resolves.  If subjects develop increased CPK, 
ALT (alanine aminotransferase) or AST (aspartate aminotransferase), they discontinue atorvastatin and their 
participation in the study.  We exclude subjects having contraindications to statin therapy including active liver 
disease or persistent unexplained elevations of serum transaminases.
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12.0 Potential Benefits to Subjects and Others
12.1
Potential Benefits to Subjects
Describe the potential benefits that individual subjects may experience from taking part in the research. 
If there is no direct benefit to subjects, indicate as such. Compensation is not considered a benefit. 
Compensation should be addressed in section 14.0.
Subjects receive a medical screening and the results of their medical tests that could inform them about their 
health.  In particular, they learn their blood pressure and blood cholesterol levels.  This is important knowledge.  
High blood pressure and blood cholesterol contribute to many serious health problems.  We advise those with 
high blood pressure or blood cholesterol to follow-up with a health care provider.  Benefits also include the 
satisfaction derived from participating in a research program exploring a mechanism underlying the increased 
risk for CVD in women with endometriosis.  
12.2
Potential Benefits to Others
Include benefits to society or others. 
Cardiovascular disease (CVD) is the leading cause of death in women.  Epidemiologic data demonstrate a clear 
association between endometriosis, reproductive risk factors, inflammation and cardiovascular (CV) risk.  
Endometriosis impacts 5-10% of women in the US, and its cardiovascular effects are usually left untreated.  We 
hope to gain an improved understanding of one of mechanisms underlying the increased risk for CVD in women 
with endometriosis.   The causes and effects of endometriosis are understudied.  We also hope that this study 
will become part of a body of work that increases interest in the examination of endometriosis and its effects on 
the health of women.  Also, the project provides valuable experience, education and partial fulfillment of 
degree-work for graduate and undergraduate students of The Pennsylvania State University.
13.0 Sharing Results with Subjects
Describe whether results (study results or individual subject results, such as results of investigational diagnostic 
tests, genetic tests, or incidental findings) will be shared with subjects or others (e.g., the subject’s primary care 
physicians) and if so, describe how it will be shared.
We give participants copies of their individual lab results.  
14.0 Subject Stipend (Compensation) and/or Travel Reimbursements
Describe the amount and timing of any subject stipend/payment or travel reimbursement here. If there is no 
subject stipend/payment or travel reimbursement, indicate as not applicable. 
If course credit or extra credit is offered to subjects, describe the amount of credit and the available alternatives. 
Alternatives should be equal in time and effort to the amount of course or extra credit offered.
If an existing, approved student subject pool will be used to enroll subjects, please indicate as such and indicate 
that course credit will be given and alternatives will be offered as per the approved subject pool procedures. 
MD Experiments:        ($  15.00 / MD probe inserted + $20.00 completing MD experiment.)
        
Experiment
$   95.00 each
(5 MD probes; 2 experiments: 1 pre-treatment, 1 post-treatment)
Total
$ 190.00
Subjects can receive payment for experiments not completed.  We pay an amount of money equal to the part 
completed.  For instance, if a subject completes half of Experiment 1, the subject receives $15.00 for each probe 
inserted plus $10.00. ($10.0 is one-half of $20.00).  We may ask subjects to repeat a trial.  If subjects agree to 
repeat a trial, they receive payment for the repeated trial as stated above. They are reimbursed for gasoline if 
they live more than 20 miles from Noll Lab.
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15.0 Economic Burden to Subjects
15.1
Costs 
Describe any costs that subjects may be responsible for because of participation in the research.
None
15.2
Compensation for research-related injury
If the research involves more than Minimal Risk to subjects, describe the available compensation in 
the event of research related injury.
If there is no sponsor agreement that addresses compensation for medical care for research subjects 
with a research-related injury, include the following text as written - DO NOT ALTER OR DELETE:
It is the policy of the institution to provide neither financial compensation nor free medical treatment 
for research-related injury. In the event of injury resulting from this research, medical treatment is 
available but will be provided at the usual charge. Costs for the treatment of research-related injuries 
will be charged to subjects or their insurance carriers. 
For sponsored research studies with a research agreement with the sponsor that addresses 
compensation for medical care for research-related injuries, include the following text as written - DO 
NOT ALTER OR DELETE:
It is the policy of the institution to provide neither financial compensation nor free medical treatment 
for research-related injury. In the event of injury resulting from this research, medical treatment is 
available but will be provided at the usual charge. Such charges may be paid by the study sponsor as 
outlined in the research agreement and explained in the consent form.
It is the policy of the institution to provide neither financial compensation nor free medical treatment for 
research-related injury. In the event of injury resulting from this research, medical treatment is available but will 
be provided at the usual charge. Costs for the treatment of research-related injuries will be charged to subjects 
or their insurance carriers.
16.0 Resources Available
16.1
Facilities and locations
Identify and describe the facilities, sites and locations where recruitment and study procedures will be 
performed. 
If research will be conducted outside the United States, describe site-specific regulations or customs 
affecting the research, and describe the process for obtaining local ethical review. Also, describe the 
principal investigator’s experience conducting research at these locations and familiarity with local 
culture.
The Noll laboratory is a 4-floor (35,000 sq. ft.) free-standing building devoted to basic, clinical, and applied 
physiological research.  Biochemistry laboratories are available for sample processing and analyses.  Available 
equipment includes centrifuges, critical care monitors, osmometer, assay plate reader, shaker,  washer, NA/K 
analyzer, spectrophotometer, i-Stat analyzer, refractometer, hemocue, hematocrit system, fraction collector, 
hydrogen sulphide analyzer, sonicator, microbalances, laser doppler flowmeters, full-field laser perfusion 
imager, mini-syringe pumps/ controllers,  sweat rate monitoring systems, hospital beds, medical infusion chair, 
ECG analysis system, finipres, plethysmograph, refrigerators, pharmaceutical refrigerator,  -20 C and -80 C 
freezers, heated/refrigerated circulators, water-perfused suits, local skin cooling/ heating systems, critical care 
monitors, blood pressure monitors, metabolic cart, gas sterilization equipment, and autoclave facilities.  In 
addition to ample office and laboratory laptop or desktop computers for research and student use, Noll 
Laboratory has two available servers and a trunk line connection to the University’s mainframe computer 
system.  Internal, office and laboratory computers are linked.  The laboratory has four PC-based data acquisition 
systems equipped with Dataq hardware driven by Windaq software, two of which are located in computer 
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controlled environmental chambers equipped with treadmills and bikes.   A Clinical Research Center is 
contiguous to the Noll Laboratory in the 14,000 sq. ft. Elmore wing, and available for the proposed studies.  Up 
to 12 subject beds for overnight (or longer) stays, a metabolic kitchen, medical examination rooms, and several 
specialized procedure rooms are available.  Because the CRC is contiguous with existing laboratory space, it is 
readily available for research support, e.g., pre-test subject screening.  Noll Laboratory has exceptional in-house 
support facilities including machine and electronics shops.
16.2
Feasibility of recruiting the required number of subjects
Indicate the number of potential subjects to which the study team has access.  Indicate the percentage 
of those potential subjects needed for recruitment.
We are using recruiting methods that will reach a large percent of the general population.  We have employed 
these methods successfully for earlier projects that targeted specialized groups that have similar or rarer 
incidence in the US population.  1 in 10 women in the US have endometriosis.  Utilizing targeted recruitment we 
believe we can meet our subject number goals. 
16.3
PI Time devoted to conducting the research
Describe how the PI will ensure that a sufficient amount of time will be devoted to conducting and 
completing the research. Please consider outside responsibilities as well as other on-going research for 
which the PI is responsible.
We have been conducting similar experiments for many years and are familiar with the duration of the 
procedures/protocols/projects and the amount of staffing required to complete the project while maintaining 
their other obligations.
16.4
Availability of medical or psychological resources
Describe the availability of medical or psychological resources that subject might need as a result of 
their participation in the study, if applicable.
The CRC is located within the same building as the Noll Lab.  A hospital and emergency medical services are 
within 1-2 miles of the lab.  An AED hangs near the labs in the hallway.  A CPR mask hangs in each lab.  The 
faculty, staff, grad students, and post docs in the lab group have current AHA BLS with CPR training.
16.5
Process for informing Study Team
Describe the training plans to ensure members of the research team are informed about the protocol 
and their duties, if applicable.
The PI and senior lab members train new members in the necessary procedures.  We conduct weekly lab 
meetings.  They review any applicable changes or issues.
17.0 Other Approvals
17.1
Other Approvals from External Entities
Describe any approvals that will be obtained prior to commencing the research (e.g., from cooperating 
institutions, community leaders, schools, external sites, funding agencies).
We are modifying IND# 78954 with the FDA.
17.2
Internal PSU Committee Approvals
Check all that apply:
  Anatomic Pathology – Hershey only – Research involves the collection of tissues or use of pathologic 
specimens. Upload a copy of HRP-902 - Human Tissue For Research Form on the “Supporting 
Documents” page in CATS IRB. This form is available in the CATS IRB Library.
  Animal Care and Use – All campuses – Human research involves animals and humans or the use of 
human tissues in animals
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X  Biosafety – All campuses – Research involves biohazardous materials (human biological specimens in 
a PSU research lab, biological toxins, carcinogens, infectious agents, recombinant viruses or DNA or gene 
therapy). 
  Clinical Laboratories – Hershey only – Collection, processing and/or storage of extra tubes of body 
fluid specimens for research purposes by the Clinical Laboratories; and/or use of body fluids that had 
been collected for clinical purposes, but are no longer needed for clinical use. Upload a copy of HRP-901 
- Human Body Fluids for Research Form on the “Supporting Documents” page in CATS IRB. This form is 
available in the CATS IRB Library.
X  Clinical Research Center (CRC) Advisory Committee– All campuses – Research involves the use of CRC 
services in any way.  
  Conflict of Interest Review – All campuses – Research has one or more of study team members 
indicated as having a financial interest.
  Radiation Safety – Hershey only – Research involves research-related radiation procedures. All 
research involving radiation procedures (standard of care and/or research-related) must upload a copy 
of HRP-903 - Radiation Review Form on the “Supporting Documents” page in CATS IRB. This form is 
available in the CATS IRB Library.
X  IND/IDE Audit – All campuses – Research in which the PSU researcher holds the IND or IDE or intends 
to hold the IND or IDE.
  Scientific Review – Hershey only – All investigator-written research studies requiring review by the 
convened IRB must provide documentation of scientific review with the IRB submission. The scientific 
review requirement may be fulfilled by one of the following: (1) external peer-review process; (2) 
department/institute scientific review committee; or (3) scientific review by the Clinical Research Center 
Advisory committee.  NOTE: Review by the Penn State Hershey Cancer Institute Scientific Review 
Committee is required if the study involves cancer prevention studies or cancer patients, records and/or 
tissues. For more information about this requirement see the IRB website at: 
http://www.pennstatehershey.org/web/irb/home/resources/investigator 
18.0 Multi-Site Research
If this is a multi-site study (i.e., the study will be conducted at other institutions each with its own principal 
investigator) and you are the lead investigator, describe the processes to ensure communication among sites in 
the sections below.
18.1
Communication Plans
Describe the plan for regular communication between the overall study director and the other sites to 
ensure that all sites have the most current version of the protocol, consent document, etc.  Describe the 
process to ensure all modifications have been communicated to sites. Describe the process to ensure 
that all required approvals have been obtained at each site (including approval by the site’s IRB of 
record).   Describe the process for communication of problems with the research, interim results and 
closure of the study.
NA
18.2
Data Submission and Security Plan
Describe the process and schedule for data submission and provide the data security plan for data 
collected from other sites.  Describe the process to ensure all engaged participating sites will safeguard 
data as required by local information security policies.
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NA
18.3
Subject Enrollment
Describe the procedures for coordination of subject enrollment and randomization for the overall 
project.
NA
18.4
Reporting of Adverse Events and New Information
Describe how adverse events and other information will be reported from the clinical sites to the overall 
study director. Provide the timeframe for this reporting.
NA
18.5
Audit and Monitoring Plans
Describe the process to ensure all local site investigators conduct the study appropriately. Describe any 
on-site auditing and monitoring plans for the study.
NA
19.0 Adverse Event Reporting
19.1
Adverse Event Definitions
For drug studies, incorporate the following definitions into the below responses, as written:
Adverse event
Any untoward medical occurrence associated with the use of the drug in 
humans, whether or not considered drug related
Adverse reaction
Any adverse event caused by a drug
Suspected adverse 
reaction
Any adverse event for which there is a reasonable possibility that the drug 
caused the adverse event.  Suspected adverse reaction implies a lesser degree 
of certainty about causality than “adverse reaction”.

Reasonable possibility.  For the purpose of IND safety reporting, 
“reasonable possibility” means there is evidence to suggest a causal 
relationship between the drug and the adverse event.
Serious adverse 
event or Serious 
suspected adverse 
reaction
Serious adverse event or Serious suspected adverse reaction: An adverse event 
or suspected adverse reaction that in the view of either the investigator or 
sponsor, it results in any of the following outcomes: Death, a life-threatening 
adverse event, inpatient hospitalization or prolongation of existing 
hospitalization, a persistent or significant incapacity or substantial disruption 
of the ability to conduct normal life functions, or a congenital anomaly/birth 
defect. Important medical events that may not result in death, be life-
threatening, or require hospitalization may be considered serious when, based 
upon appropriate medical judgment, they may jeopardize the patient or 
subject and may require medical or surgical intervention to prevent one of the 
outcomes listed in this definition. 
Life-threatening 
adverse event or 
life-threatening 
suspected adverse 
reaction
An adverse event or suspected adverse reaction is considered “life-
threatening” if, in the view of either the Investigator (i.e., the study site 
principal investigator) or Sponsor, its occurrence places the patient or research 
subject at immediate risk of death.  It does not include an adverse event or 
suspected adverse reaction that had it occurred in a more severe form, might 
have caused death.
Unexpected 
adverse event or 
Unexpected 
suspected adverse 
reaction.  
An adverse event or suspected adverse reaction is considered “unexpected” if 
it is not listed in the investigator brochure, general investigational plan, clinical 
protocol, or elsewhere in the current IND application; or is not listed at the 
specificity or severity that has been previously observed and/or specified.
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For device studies, incorporate the following definitions into the below responses, as written:
Unanticipated 
adverse device 
effect
Any serious adverse effect 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 investigational plan or IDE application (including a supplementary plan 
or application), or any other unanticipated serious problem associated with a 
device that relates to the rights, safety, or welfare of subjects.
19.2
Recording of Adverse Events
Address the frequency and process for eliciting adverse event information from research subject, e.g., 
“Research subjects will be routinely questioned about adverse events at study visits.”
In the response, incorporate the following as written:
All adverse events (serious or non-serious) and abnormal test findings observed or reported to study 
team believed to be associated with the study drug(s) or device(s) will be followed until the event (or 
its sequelae) or the abnormal test finding resolves or stabilizes at a level acceptable to the 
investigator.
An abnormal test finding will be classified as an adverse event if one or more of the following criteria 
are met:

The test finding is accompanied by clinical symptoms

The test finding necessitates additional diagnostic evaluation(s) or medical/surgical 
intervention; including significant additional concomitant drug treatment or other therapy
NOTE: Simply repeating a test finding, in the absence of any of the other listed criteria, does 
not constitute an adverse event.

The test finding leads to a change in study drug dosing or discontinuation of subject 
participation in the clinical research study

The test finding is considered an adverse event by the investigator.
In the case of untoward events, those lab members present during the event are included in a debriefing and 
notes of the meeting are taken.  The participant involved in an untoward event is interviewed in person or via 
telephone concerning the event and the responses are included into the notes for that event.
All adverse events (serious or non-serious) and abnormal test findings observed or reported to study team 
believed to be associated with the study drug(s) or device(s) will be followed until the event (or its sequelae) or 
the abnormal test finding resolves or stabilizes at a level acceptable to the investigator.
An abnormal test finding will be classified as an adverse event if one or more of the following criteria are met:

The test finding is accompanied by clinical symptoms

The test finding necessitates additional diagnostic evaluation(s) or medical/surgical intervention; including 
significant additional concomitant drug treatment or other therapy
NOTE: Simply repeating a test finding, in the absence of any of the other listed criteria, does not constitute 
an adverse event.

The test finding leads to a change in study drug dosing or discontinuation of subject participation in the 
clinical research study

The test finding is considered an adverse event by the investigator.
The CRC clinicians will be notified of any reported adverse reactions.
19.3
Causality and Severity Assessments
By submitting this study for review, you agree to the following statement – DO NOT ALTER OR DELETE: 
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The investigator will promptly review documented adverse events and abnormal test findings to determine 1) if 
the abnormal test finding should be classified as an adverse event; 2) if there is a reasonable possibility that the 
adverse event was caused by the study drug(s) or device(s); and 3) if the adverse event meets the criteria for a 
serious adverse event.
If the investigator’s final determination of causality is “unknown and of questionable relationship to the study 
drug(s) or device(s)”, the adverse event will be classified as associated with the use of the study drug(s) or 
device(s) for reporting purposes.  If the investigator’s final determination of causality is “unknown but not 
related to the study drug(s) or device(s)”, this determination and the rationale for the determination will be 
documented in the respective subject’s case history.
19.4
Reporting of Adverse Reactions and Unanticipated Problems to the FDA  
19.4.1 Written IND/IDE Safety Reports
For a drug study under an IND, incorporate the following from 21 CFR 312.32 as written – DO 
NOT ALTER OR DELETE: 
The Sponsor-Investigator will submit a written IND Safety Report (i.e., completed FDA Form 
3500A) to the responsible new drug review division of the FDA for any observed or volunteered 
adverse event that is determined to be a serious and unexpected, suspected adverse reaction.  
Each IND Safety Report will be prominently labeled, “IND Safety Report”, and a copy will be 
provided to all participating investigators (if applicable) and sub-investigators.
Written IND Safety Reports will be submitted to the FDA as soon as possible and, in no event, 
later than 15 calendar days following the Sponsor-Investigator’s receipt of the respective 
adverse event information and determination that it meets the respective criteria for reporting.
For each written IND Safety Report, the Sponsor-Investigator will identify all previously 
submitted IND Safety Reports that addressed a similar suspected adverse reaction experience 
and will provide an analysis of the significance of newly reported, suspected adverse reaction in 
light of the previous, similar report(s) or any other relevant information.
Relevant follow-up information to an IND Safety Report will be submitted to the applicable 
review division of the FDA as soon as the information is available and will be identified as such 
(i.e., “Follow-up IND Safety Report”).
If the results of the Sponsor-Investigator’s follow-up investigation show that an adverse event 
that was initially determined to not require a written IND Safety Report does, in fact, meet the 
requirements for reporting; the Sponsor-Investigator will submit a written IND Safety Report as 
soon as possible, but in no event later than 15 calendar days, after the determination was made.
For a device study under an IDE, incorporate the following from 21 CFR 812.150 as written – 
DO NOT ALTER OR DELETE: 
The Sponsor-Investigator will submit a completed FDA Form 3500Ato the FDA’s Center for 
Devices and Radiological Health for any observed or volunteered adverse effect that is 
determined to be an unanticipated adverse device effect.  A copy of this completed form will be 
provided to all participating sub-investigators.
The completed FDA Form 3500Awill be submitted to the FDA as soon as possible and, in no 
event, later than 10 working days after the Sponsor-Investigator first receives notice of the 
adverse effect.
If the results of the Sponsor-Investigator’s follow-up evaluation show that an adverse effect that 
was initially determined to not constitute an unanticipated adverse device effect does, in fact, 
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meet the requirements for reporting; the Sponsor-Investigator will submit a completed FDA 
Form 3500Aas soon as possible, but in no event later than 10 working days, after the 
determination was made.
For each submitted FDA Form 3500A, the Sponsor-Investigator will identify all previously 
submitted reports that that addressed a similar adverse effect experience and will provide an 
analysis of the significance of newly reported adverse effect in light of the previous, similar 
report(s). 
Subsequent to the initial submission of a completed FDA Form 3500A, the Sponsor-Investigator 
will submit additional information concerning the reported adverse effect as requested by the 
FDA.
The Sponsor-Investigator will submit a written IND Safety Report (i.e., completed FDA Form 3500A) to the 
responsible new drug review division of the FDA for any observed or volunteered adverse event that is 
determined to be a serious and unexpected, suspected adverse reaction.  Each IND Safety Report will be 
prominently labeled, “IND Safety Report”, and a copy will be provided to all participating investigators (if 
applicable) and sub-investigators.
Written IND Safety Reports will be submitted to the FDA as soon as possible and, in no event, later than 15 
calendar days following the Sponsor-Investigator’s receipt of the respective adverse event information and 
determination that it meets the respective criteria for reporting.
For each written IND Safety Report, the Sponsor-Investigator will identify all previously submitted IND Safety 
Reports that addressed a similar suspected adverse reaction experience and will provide an analysis of the 
significance of newly reported, suspected adverse reaction in light of the previous, similar report(s) or any other 
relevant information.
Relevant follow-up information to an IND Safety Report will be submitted to the applicable review division of the 
FDA as soon as the information is available and will be identified as such (i.e., “Follow-up IND Safety Report”).
If the results of the Sponsor-Investigator’s follow-up investigation show that an adverse event that was initially 
determined to not require a written IND Safety Report does, in fact, meet the requirements for reporting; the 
Sponsor-Investigator will submit a written IND Safety Report as soon as possible, but in no event later than 15 
calendar days, after the determination was made.
19.4.2 Telephoned IND Safety Reports – Fatal or Life-threatening Suspected Adverse Reactions
For a drug study under an IND, incorporate the following from 21 CFR 312.32 into the 
response, as written:
In addition to the subsequent submission of a written IND Safety Report (i.e., completed FDA 
Form 3500A), the Sponsor-Investigator will notify the responsible review division of the FDA by 
telephone or facsimile transmission of any unexpected, fatal or life-threatening suspected 
adverse reaction. 
The telephone or facsimile transmission of applicable IND Safety Reports will be made as soon 
as possible but in no event later than 7 calendar days after the Sponsor-Investigator’s receipt of 
the respective adverse event information and determination that it meets the respective criteria 
for reporting.
In addition to the subsequent submission of a written IND Safety Report (i.e., completed FDA Form 3500A), the 
Sponsor-Investigator will notify the responsible review division of the FDA by telephone or facsimile 
transmission of any unexpected, fatal or life-threatening suspected adverse reaction. 
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The telephone or facsimile transmission of applicable IND Safety Reports will be made as soon as possible but in 
no event later than 7 calendar days after the Sponsor-Investigator’s receipt of the respective adverse event 
information and determination that it meets the respective criteria for reporting.
19.5
Reporting Adverse Reactions and Unanticipated Problems to the Responsible IRB
By submitting this study for review, you agree to the following statement – DO NOT ALTER OR DELETE: 
In accordance with applicable policies of The Pennsylvania State University Institutional Review Board (IRB), the 
investigator will report, to the IRB, any observed or reported harm (adverse event) experienced by a subject or 
other individual, which in the opinion of the investigator is determined to be (1) unexpected; and (2) probably 
related to the research procedures. Harms (adverse events) will be submitted to the IRB in accordance with the 
IRB policies and procedures.
19.6
Unblinding Procedures
Describe the procedures for unblinding study therapy on a subject, including documentation of this in 
the subject’s source document. Include example(s) here why someone might unblind a study. In most 
cases, the unblinding will be part of managing a serious adverse reaction and will be reported with the 
serious adverse event. However, in cases where unblinding was not associated with a serious adverse 
event, such actions should be reported in a timely manner.
NA
19.7
Stopping Rules
In studies with a primary safety endpoint or studies with high risk to study subjects, provide the rules 
that define the circumstances and procedures for interrupting or stopping the study. If an independent 
Data and Safety Monitoring (DSMB) or Committee (DSMC) is set up for the study, the same stopping 
rules should be incorporated into the safety analysis plan as well.
Although such events are extremely unlikely to occur, we are prepared to immediately stop experiments and 
seek medical assistance if the subjects should experience the more serious reactions described in the informed 
consents, and IRB applications such as signs and symptoms of an allergic reaction, anaphylactic shock, etc.  As 
always, our subjects are reminded throughout the protocol that they may stop the experiment at any time. Also, 
we exercise the discretion to end a subject’s participation if the subject should engage in behavior that could 
jeopardize his/her own health and well-being or that of others.  
We end the experiments if the subject experiences:

Systolic or diastolic blood pressures exceed 220 or 110 mmHg, respectively, or
•
Systolic or diastolic blood pressures are less than 90 or 50 mmHg, respectively or 

Heartrate <40 bpm or > 120 bpm.  
20.0 Study Monitoring, Auditing and Inspecting
20.1
Study Monitoring Plan
20.1.1 Quality Assurance and Quality Control
Include this section if FDA regulations apply to this study (see “WORKSHEET: Drugs (HRP-306)” 
and “WORKSHEET: Devices (HRP-307)”. HRP-306 and HRP-307 can be accessed by clicking the 
Library link in CATS IRB (http://irb.psu.edu). 
Describe how you will ensure that this study is conducted and that the data are generated, 
documented (recorded) and reported in compliance with this protocol, with institutional and 
IRB policies, with Good Clinical Practice guidelines and any other applicable regulatory 
requirements.
Indicate who is responsible for monitoring the conduct of the study and specify how often the 
study will be monitored. 
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For single-site studies with low risk, it may be appropriate for the principal investigator to 
monitor the study.
For multi-center studies or single site studies involving significant risk, an independent monitor 
may be required (e.g., monitoring by the staff of the PSU quality assurance program office(s) or 
by a clinical research organization).
Dr. Lacy M. Alexander is responsible for the conduct and monitoring of the study for its compliance with this 
protocol, with institutional and IRB policies, with Good Clinical Practice guidelines and any other applicable 
regulatory requirements.  She is assisted by members of her lab group.  The monitoring is ongoing.
20.1.2 Safety Monitoring
Include this section if FDA regulations apply to this study (see “WORKSHEET: Drugs (HRP-306)” 
and “WORKSHEET: Devices (HRP-307)”. HRP-306 and HRP-307 can be accessed by clicking the 
Library link in CATS IRB (http://irb.psu.edu). 
Indicate the process for identifying, recording and reporting adverse events.
Specify roles for adverse event recording and monitoring. Indicate each staff member’s role in 
the adverse event reporting process. Include the following if applicable:
The Principal Investigator will confirm that all adverse events (AE) are correctly entered into the 
AE case report forms by the coordinator; be available to answer any questions that the 
coordinators may have concerning AEs; and will notify the IRB, FDA, sponsor and/or DSMB of all 
applicable AEs as appropriate. All assessments of AEs will be made by a licensed medical 
professional who is an investigator on the research.
The Research Coordinator will complete the appropriate report form and logs; assist the PI to 
prepare reports and notify the IRB, FDA and/or DSMB of all Unanticipated Problems/SAE’s.
The Monitor will confirm that the AEs are correctly entered into the case report forms. The 
Monitor will also confirm that the adverse events are consistent with the source documents and 
are reported to the appropriate regulatory bodies as required.
The Principal Investigator will confirm that all adverse events (AE) are correctly entered into the AE case report 
forms by the coordinator; be available to answer any questions that the coordinators may have concerning AEs; 
and will notify the IRB, FDA, sponsor and/or DSMB of all applicable AEs as appropriate. All assessments of AEs 
will be made by a licensed medical professional who is an investigator on the research.
The Research Coordinator will complete the appropriate report form and logs; assist the PI to prepare reports 
and notify the IRB, FDA and/or DSMB of all Unanticipated Problems/SAE’s.
21.0 Future Undetermined Research: Data and Specimen Banking
If this study is collecting identifiable data and/or specimens that will be banked for future undetermined 
research, please describe this process in the sections below. This information should not conflict with 
information provided in section 9.1.1 regarding whether or not data and/or specimens will be associated with 
identifiers (directly or indirectly).
21.1
Data and/or specimens being stored
Identify what data and/or specimens will be stored and the data associated with each specimen.
NA
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21.2
Location of storage
Identify the location where the data and/or specimens will be stored.
NA
21.3
Duration of storage
Identify how long the data and/or specimens will be stored.
NA
21.4
Access to data and/or specimens
Identify who will have access to the data and/or specimens.
NA
21.5
Procedures to release data or specimens
Describe the procedures to release the data and/or specimens, including: the process to request a 
release, approvals required for release, who can obtain data and/or specimens, and the data to be 
provided with the specimens.
NA
21.6
Process for returning results
Describe the process for returning results about the use of the data and/or specimens.
NA
22.0 References
List relevant references in the literature which highlight methods, controversies, and study outcomes.
Objectives and Background
1.
Donnez J, Binda MM, Donnez O, Dolmans M-M. Oxidative stress in the pelvic cavity and its role in the pathogenesis 
of endometriosis. Fertility and Sterility. 2016;106:1011-1017
2.
Bulun SE. Endometriosis. The New England journal of medicine. 2009;360:268-279
3.
Burney RO, Giudice LC. Pathogenesis and pathophysiology of endometriosis. Fertility and Sterility. 2012;98:511-519
4.
Giudice LC, Kao LC. Endometriosis. Lancet. 2004;364:1789-1799
5.
Missmer SA, Hankinson SE, Spiegelman D, Barbieri RL, Marshall LM, Hunter DJ. Incidence of laparoscopically 
confirmed endometriosis by demographic, anthropometric, and lifestyle factors. Am J Epidemiol. 2004;160:784-796
6.
Meuleman C, Vandenabeele B, Fieuws S, Spiessens C, Timmerman D, D'Hooghe T. High prevalence of endometriosis 
in infertile women with normal ovulation and normospermic partners. Fertility and sterility. 2009;92:68-74
7.
Alderman MH, 3rd, Yoder N, Taylor HS. The systemic effects of endometriosis. Seminars in reproductive medicine. 
2017;35:263-270
8.
Mu F, Rich-Edwards J, Rimm EB, Spiegelman D, Forman JP, Missmer SA. Association between endometriosis and 
hypercholesterolemia or hypertension. Hypertension. 2017
9.
May KE, Conduit-Hulbert SA, Villar J, Kirtley S, Kennedy SH, Becker CM. Peripheral biomarkers of endometriosis: A 
systematic review. Hum Reprod Update. 2010;16:651-674
10. Agic A, Xu H, Finas D, Banz C, Diedrich K, Hornung D. Is endometriosis associated with systemic subclinical 
inflammation? Gynecologic and obstetric investigation. 2006;62:139-147
11. Teng SW, Horng HC, Ho CH, Yen MS, Chao HT, Wang PH, Taiwan Association of Gynecology Systematic Review G. 
Women with endometriosis have higher comorbidities: Analysis of domestic data in taiwan. J Chin Med Assoc. 
2016;79:577-582
12. Balin M, Celik A, Kobat MA, Baydas A. Pregnancy followed by delivery may affect circulating soluble lectin-like 
oxidized low-density lipoprotein receptor-1 levels in women of reproductive age. Mediators of inflammation. 
2012;2012:837375
13. Mehta JL, Chen J, Hermonat PL, Romeo F, Novelli G. Lectin-like, oxidized low-density lipoprotein receptor-1 (lox-1): 
A critical player in the development of atherosclerosis and related disorders. Cardiovasc Res. 2006;69:36-45
14. Pahk K, Joung C, Jung SM, Young Song H, Yong Park J, Woo Byun J, Lee YS, Chul Paeng J, Kim C, Kim S, Kim WK. 
Visualization of synthetic vascular smooth muscle cells in atherosclerotic carotid rat arteries by f-18 fdg pet. Sci Rep. 
2017;7:6989
L-NAME, SNP, ACh
1.
Buxton, I. L., D. J. Cheek, D. Eckman, D. P. Westfall, K. M. Sanders, and K. D. Keef. NG-nitro L-arginine methyl ester 
and other alkyl esters of arginine are muscarinic receptor antagonists. Circ Res. 72:387-395, 1993.
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2.
Chauhan, A., R. S. More, P. A. Mullins, G. Taylor, C. Petch, and P. M. Schofield. Aging-associated endothelial 
dysfunction in humans is reversed by L-arginine. J Am Coll Cardiol. 28:1796-1804, 1996.
3.
Holowatz, L. A., C. S. Thompson, and W. L. Kenney. L-Arginine supplementation or arginase inhibition augments 
reflex cutaneous vasodilatation in aged human skin. J Physiol. 574:573-581, 2006.
4.
Holowatz, L. A., C. S. Thompson, C. T. Minson, and W. L. Kenney. Mechanisms of acetylcholine-mediated 
vasodilatation in young and aged human skin. J Physiol. 563:965-973, 2005.
5.
Houghton, B. L., L. A. Holowatz, and C. T. Minson. Influence of progestin bioactivity on cutaneous vascular 
responses to passive heating. Med Sci Sports Exerc. 37:45-51; discussion 52, 2005.
6.
Kakoki, M., A. P. Zou, and D. L. Mattson. The influence of nitric oxide synthase 1 on blood flow and interstitial nitric 
oxide in the kidney. Am J Physiol Regul Integr Comp Physiol. 281:R91-97, 2001.
7.
Kellogg, D. L., Jr., Y. Liu, I. F. Kosiba, and D. O'Donnell. Role of nitric oxide in the vascular effects of local warming of 
the skin in humans. J Appl Physiol. 86:1185-1190, 1999.
8.
Luscher, T. F., V. Richard, M. Tschudi, Z. H. Yang, and C. Boulanger. Endothelial control of vascular tone in large and 
small coronary arteries. J Am Coll Cardiol. 15:519-527, 1990.
9.
Parnell, M. M., J. P. Chin-Dusting, J. Starr, and D. M. Kaye. In vivo and in vitro evidence for ACh-stimulated L-
arginine uptake. Am J Physiol Heart Circ Physiol. 287:H395-400, 2004.
10. Sokolnicki, L. A., S. K. Roberts, B. W. Wilkins, A. Basu, and N. Charkoudian. Contribution of nitric oxide to cutaneous 
microvascular dilation in individuals with type 2 diabetes mellitus. Am J Physiol Endocrinol Metab. 292:E314-318, 
2007.
11. Taddei, S., A. Virdis, L. Ghiadoni, A. Magagna, and A. Salvetti. Cyclooxygenase inhibition restores nitric oxide activity 
in essential hypertension. Hypertension. 29:274-279, 1997.
12. Taddei, S., A. Virdis, L. Ghiadoni, G. Salvetti, G. Bernini, A. Magagna, and A. Salvetti. Age-related reduction of NO 
availability and oxidative stress in humans. Hypertension. 38:274-279, 2001.
13. Thuraisingham, R. C., N. B. Roberts, M. Wilkes, D. I. New, A. C. Mendes-Ribeiro, S. M. Dodd, and M. M. Yaqoob. 
Altered L-arginine metabolism results in increased nitric oxide release from uraemic endothelial cells. Clin Sci 
(Lond). 103:31-41, 2002.
14. Weller, R. Nitric oxide: a key mediator in cutaneous physiology. Clin Exp Dermatol. 28:511-514, 2003.
15. Wennmalm, A., A. Edlund, E. F. Granstrom, and O. Wiklund. Acute supplementation with the nitric oxide precursor 
L-arginine does not improve cardiovascular performance in patients with hypercholesterolemia. Atherosclerosis. 
118:223-231, 1995.
16. Wessagowit, V., R. Mallipeddi, J. A. McGrath, and A. P. South. Altered expression of L-arginine metabolism pathway 
genes in chronic wounds in recessive dystrophic epidermolysis bullosa. Clin Exp Dermatol. 29:664-668, 2004.
17.
Yamamori, T., A. R. White, I. Mattagajasingh, F. A. Khanday, A. Haile, B. Qi, B. H. Jeon, A. Bugayenko, K.  Kasuno, 
D. E. Berkowitz, and K. Irani. P66shc regulates endothelial NO production and endothelium-dependent 
vasorelaxation: implications for age-associated vascular dysfunction. J Mol Cell Cardiol. 39:992-995, 2005.
Atorvastatin
1.
Biocca S, Iacovelli F, Matarazzo S, Vindigni G, Oteri F, Desideri A, Falconi M. Molecular mechanism of statin-mediated 
LOX-1 inhibition. Cell Cycle. 2015;14(10):1583-95. 
2.
Bruni F1, Pasqui AL, Pastorelli M, Bova G, Cercignani M, Palazzuoli A, Sawamura T, Gioffre WR, Auteri A, Puccetti L. 
Different effect of statins on platelet oxidized-LDL receptor (CD36 and LOX-1) expression in hypercholesterolemic 
subjects. Clin Appl Thromb Hemost. 2005 Oct;11(4):417-28.
3.
Bruni F, Pasqui AL, Pastorelli M, Bova G, Cercignani M, Palazzuoli A, Sawamura T, Gioffre WR, Auteri A, Puccetti L. 
Different effect of statins on platelet oxidized-LDL receptor (CD36 and LOX-1) expression in hypercholesterolemic 
subjects. Clin Appl Thromb Hemost. 2005 Oct;11(4):417-28.
4.
Matarazzo S, Quitadamo MC, Mango R, Ciccone S, Novelli G, Biocca S. Cholesterol-lowering drugs inhibit lectin-like 
oxidized low-density lipoprotein-1 receptor function by membrane raft disruption. Mol Pharmacol. 2012 
Aug;82(2):246-54.
5.
Puccetti L, Sawamura T, Pasqui AL, Pastorelli M, Auteri A, Bruni F. Atorvastatin reduces platelet-oxidized-LDL 
receptor expression in hypercholesterolaemic patients. Eur J Clin Invest. 2005 Jan;35(1):47-51.
6.
Puccetti L, Pasqui AL, Bruni F, Pastorelli M, Ciani F, Palazzuoli A, Pontani A, Ghezzi A, Auteri A. Lectin-like oxidized-
LDL receptor-1 (LOX-1) polymorphisms influence cardiovascular events rate during statin treatment. Int J Cardiol. 
2007 Jun 25;119(1):41-7.
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Polyinsinoic Acid
1.
Morse MA, Chapman R, Powderly J, Blackwell K, Keler T, Green J, Riggs R, He LZ, Ramakrishna V, Vitale L, Zhao B, 
Butler SA, Hobeika A, Osada T, Davis T, Clay T, Lyerly HK. Phase I study utilizing a novel antigen-presenting cell-
targeted vaccine with Toll-like receptor stimulation to induce immunity to self-antigens in cancer patients. Clin Cancer 
Res. 2011 Jul 15;17(14):4844-53..
2.
Alfaro C, Perez-Gracia JL, Suarez N, Rodriguez J, Fernandez de Sanmamed M, Sangro B, Martin-Algarra S, Calvo A, 
Redrado M, Agliano A, Gonzalez A, Rodriguez I, Bolaños E, Hervás-Stubbs S, Perez-Calvo J, Benito A, Peñuelas I, 
Vigil C, Richter J, Martinez-Forero I, Melero I. Pilot clinical trial of type 1 dendritic cells loaded with autologous tumor 
lysates combined with GM-CSF, pegylated IFN, and cyclophosphamide for metastatic cancer patients. J Immunol. 
2011 Dec 1;187(11):6130-42. Epub 2011 Nov 2.
3.
Rosenfeld MR, Chamberlain MC, Grossman SA, Peereboom DM, Lesser GJ, Batchelor TT, Desideri S, Salazar AM, 
Ye X. A multi-institution phase II study of poly-ICLC and radiotherapy with concurrent and adjuvant temozolomide in 
adults with newly diagnosed glioblastoma. Neuro Oncol. 2010 Oct;12(10):1071-7. Epub 2010 Jul 8.
4.
Okada H, Kalinski P, Ueda R, Hoji A, Kohanbash G, Donegan TE, Mintz AH, Engh JA, Bartlett DL, Brown CK, Zeh H, 
Holtzman MP, Reinhart TA, Whiteside TL, Butterfield LH, Hamilton RL, Potter DM, Pollack IF, Salazar AM, Lieberman 
FS. Induction of CD8+ T-cell responses against novel glioma-associated antigen peptides and clinical activity by 
vaccinations with {alpha}-type 1 polarized dendritic cells and polyinosinic-polycytidylic acid stabilized by lysine and 
carboxymethylcellulose in patients with recurrent malignant glioma. J Clin Oncol. 2011 Jan 20;29(3):330-6. Epub 2010 
Dec 13.
5.
Ewel CH, Urba WJ, Kopp WC, Smith JW 2nd, Steis RG, Rossio JL, Longo DL, Jones MJ, Alvord WG, Pinsky CM, et 
al. Polyinosinic-polycytidylic acid complexed with poly-L-lysine and carboxymethylcellulose in combination with 
interleukin 2 in patients with cancer: clinical and immunological effects. Cancer Res. 1992 Jun 1;52(11):3005-10.
6.
Feldman S, Hughes WT, Darlington RW, Kim HK. Evaluation of topical polyinosinic acid-polycytidylic acid in treatment 
of localized herpes zoster in children with cancer: a randomized, double-blind controlled study. Antimicrob Agents 
Chemother. 1975 Sep;8(3):289-94.
7.
Freeman AI, Al-Bussam N, O'Malley JA, Stutzman L, Bjornsson S, Carter WA. Pharmacologic effects of polyinosinic-
polycytidylic acid in man. J Med Virol. 1977;1(2):79-93.
8.
Butowski N, Lamborn KR, Lee BL, Prados MD, Cloughesy T, DeAngelis LM, Abrey L, Fink K, Lieberman F, Mehta M, 
Ian Robins H, Junck L, Salazar AM, Chang SM.  A North American brain tumor consortium phase II study of poly-
ICLC for adult patients with recurrent anaplastic gliomas. J Neurooncol. 2009 Jan;91(2):183-9. 
9.
Butowski N, Chang SM, Junck L, DeAngelis LM, Abrey L, Fink K, Cloughesy T, Lamborn KR, Salazar AM, Prados 
MD. A phase II clinical trial of poly-ICLC with radiation for adult patients with newly diagnosed supratentorial 
glioblastoma: a North American Brain Tumor Consortium (NABTC01-05). J Neurooncol. 2009 Jan;91(2):175-82. 
10. Salazar AM, Levy HB, Ondra S, Kende M, Scherokman B, Brown D, Mena H, Martin N, Schwab K, Donovan D, 
Dougherty D, Pulliam M, Ippolito M, Graves M, Brown H, Ommaya A. Long-term treatment of malignant gliomas with 
intramuscularly administered polyinosinic-polycytidylic acid stabilized with polylysine and carboxymethylcellulose: an 
open pilot study. Neurosurgery. 1996 Jun;38(6):1096-103; discussion 1103-4.
Atorvastatin
Microdialysis
1.
Bennett, L. A., J. M. Johnson, D. P. Stephens, A. R. Saad, and D. L. Kellogg, Jr. Evidence for a role for vasoactive 
intestinal peptide in active vasodilatation in the cutaneous vasculature of humans. J Physiol. 552:223-232, 2003.
2.
Boutsiouki, P., S. Georgiou, and G. F. Clough. Recovery of Nitric Oxide from Acetylcholine-Mediated 
Vasodilatation in Human Skin In Vivo. Microcirculation. 11:249-259, 2004.
3.
Clough, G. and M. Noble. Microdialysis--a model for studying chronic wounds. Int J Low Extrem Wounds. 2:233-
239, 2003.
4.
Clough, G. F., P. Boutsiouki, M. K. Church, and C. C. Michel. Effects of blood flow on the in vivo recovery of a 
small diffusible molecule by microdialysis in human skin. J Pharmacol Exp Ther. 302:681-686, 2002.
5.
Holowatz, L. A., C. S. Thompson, C. T. Minson, and W. L. Kenney. Mechanisms of acetylcholine-mediated 
vasodilatation in young and aged human skin. J Physiol. 563:965-973, 2005.
6.
Houghton, B. L., J. R. Meendering, B. J. Wong, and C. T. Minson. Nitric oxide and noradrenaline contribute to the 
temperature threshold of the axon reflex response to gradual local heating in human skin. J Physiol. 572:811-
820, 2006.
7.
Kellogg, D. L., Jr., Y. Liu, I. F. Kosiba, and D. O'Donnell. Role of nitric oxide in the vascular effects of local warming 
of the skin in humans. J Appl Physiol. 86:1185-1190, 1999.
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8.
Kellogg, D. L., Jr., J. L. Zhao, U. Coey, and J. V. Green. Acetylcholine-induced vasodilation is mediated by nitric 
oxide and prostaglandins in human skin. J Appl Physiol. 98:629-632, 2005.
9.
Minson, C. T., L. T. Berry, and M. J. Joyner. Nitric oxide and neurally mediated regulation of skin blood flow 
during local heating. J Appl Physiol. 91:1619-1626, 2001.
10.
Minson, C. T., L. A. Holowatz, B. J. Wong, W. L. Kenney, and B. W. Wilkins. Decreased nitric oxide- and axon 
reflex-mediated cutaneous vasodilation with age during local heating. J Appl Physiol. 93:1644-1649, 2002.
11.
Schnetz, E. and M. Fartasch. Microdialysis for the evaluation of penetration through the human skin barrier - a 
promising tool for future research? Eur J Pharm Sci. 12:165-174, 2001.
12.
Shastry, S. and M. J. Joyner. Geldanamycin attenuates NO-mediated dilation in human skin. Am J Physiol Heart 
Circ Physiol. 282:H232-236, 2002.
13.
Thompson, C. S., L. A. Holowatz, and W. L. Kenney. Cutaneous vasoconstrictor responses to norepinephrine are 
attenuated in older humans. Am J Physiol Regul Integr Comp Physiol. 288:R1108-1113, 2005.
14.
Thompson, C. S. and W. L. Kenney. Altered neurotransmitter control of reflex vasoconstriction in aged human 
skin. J Physiol. 558:697-704, 2004.
15.
Ungerstedt, U. Microdialysis--principles and applications for studies in animals and man. J Intern Med. 230:365-
373, 1991.
16.
Wilkins, B. W., L. A. Holowatz, B. J. Wong, and C. T. Minson. Nitric oxide is not permissive for cutaneous active 
vasodilatation in humans. J Physiol. 548:963-969, 2003.
17.
Wong, B. J. and C. T. Minson. Neurokinin-1 Receptor Desensitisation Attenuates Cutaneous Active Vasodilatation 
in Humans. J Physiol, 2006.
 Pyrogens
1.
Brown, S., and A.C. Fuller, “Depyrogenation of Pharmaceutical Solutions Using Submicron and Ultrafilters,” J. 
Parenteral Sci. & Tech., Vol. 47, No. 6, 1993, pp. 285-288.
The effect of varying the pH and ionic strength on endotoxin removal (depyrogenation) from Water for 
Injections (WFI) was investigated. Studies using submicron filters showed that endotoxin aggregation and 
filter retention increased with increasing molarity and decreasing pH. Using a Sartorius 0.01 micron filter, 
greater than 98% endotoxin retention could be achieved with 10 endotoxin units (EU)/ml bulk solution, and 
greater than 97% endotoxin retention with the 500 EU/ml bulk solution. Depyrogenation of active and 
placebo solutions of the radiopaque, Iohexol (350 mgI/ml), using ultrafilters of varying nominal molecular 
weight limit (NMWL 10,000-300,000) and a Pall Posidyne 0.2 micron filter was also investigated. Results with 
the ultrafilters showed that it was possible to increase the molecular weight cut-off of an ultrafilter from 
10,000 to 100,000, without affecting the efficiency of endotoxin removal, thereby increasing flow rate and 
reducing filtration time. The Posidyne filter was able to depyrogenate Iohexol active and placebo product. The 
use of submicron filtration in place of ultrafiltration would provide significant cost benefits in terms of 
filtration time and equipment costs, and they have been shown to be capable of efficient depyrogenation of 
these pharmaceutical products.
2.
McCormick J, Pragman A, Stolpa J, Leung D, Schlievert P, “Funtional Characterization of Streptococal Pyrogenic 
Exotoxin J, a Novel Superantigen” Infection and Immunity, Vol. 69, No. 3: p. 1381-1388, 2001.
3.
Orwin P, Leung D, Tripp T, Bohach G, Earhart C, Ohlendorf D, Schlievert P. 2002.
Characterization of a novel staphylococcal enterotoxin-like superantigen, a member of the group V subfamily of 
pyrogenic toxins. Biochemistry 41:14033-14040, 2002.
Staphylococcus aureus is an important human pathogen, causing a variety of diseases. Major virulence 
factors of this organism include staphylococcal enterotoxins (SEs) that cause food poisoning and toxic shock 
syndrome. Our study identified a novel enterotoxin-like protein that is a member of the new subfamily 
(group V) of pyrogenic toxin superantigens (PTSAgs) and examined its biochemical and immunobiological 
properties. The gene encoding the SE-like protein is directly 5‘ of another recently identified PTSAg, SEK. The 
SE-like protein had a molecular weight of 26000 and an experimentally determined isoelectric point between 
7.5 and 8.0. We demonstrated that the PTSAg had many of the biological activities associated with SEs, 
including superantigenicity, pyrogenicity, and ability to enhance endotoxin shock, but lacked both lethality in 
rabbits when administered in subcutaneous miniosmotic pumps and emetic activity in monkeys. 
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Recombinant protein stimulated human CD4 and CD8 T cells in a T cell receptor variable region, β chain 
(TCRVβ) specific manner. T cells bearing TCRVβ2, 5.1, and 21.3 were significantly stimulated.
4.
Orwin P, Fitzgerald JR, Leung D, Gutierrez J, Bohach G, Schlievert P,  “Characterization of Staphylococcus aureus 
Entertoxin L, “Infection and Immunity, Vol. 71, No. 5p.: 2916-2919, 2003.
5.
Weber C, Linsberger I, Rafiee-Tehrani M, Falkenhagen D: Permeability and adsorption capacity of dialysis 
membranes to lipid A. Int J Artif Organs 20: 144-152, 1997.
Hemodialysis membranes were tested in vitro for possible penetration by low molecular weight endotoxins 
containing lipid A. Using lipid A from Escherichia coli as a model substance for this kind of pyrogen, different 
dialyzers (F4, E3. Acepal 1300, Altraflux, F 40, Polyflux 110, Filtral 12, F 60) were challenged by tangential 
filtration in aqueous medium. All membranes exhibited impermability to lipid A (as well as to LPS from 
Pseudomonas aeruginosa), which was proved by additional experiments using culture filtrates of 
Pseudomonas aeruginosa in bicarbonate dialysis fluid, as well as by employing miniaturized dialyzers with 
synthetic lipid A as a contaminant. Furthermore, the highest adsorption capacities were found for 
polysulfone and polyamide membranes.
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Approval: 2/16/2022