Modulating Physiologic Effects Of Phospholipid Metabolism In Obesity And Diabetes; AIM 4: Composition and Function of Sarcoplasmic Reticulum in Persons With the Metabolic Syndrome
Conditions: Metabolic Syndrome
Sponsor: Washington University School of Medicine

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             Aim 4: Composition and Function of Sarcoplasmic Reticulum in persons with the Metabolic Syndrome 
 
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Modulating Physiologic Effects Of Phospholipid Metabolism In 
Obesity And Diabetes 
 
AIM 4:  Composition and Function of Sarcoplasmic Reticulum in 
persons with the Metabolic Syndrome 
 
 
 
Comp-SR 
Version 6 
HRPO201311099 
01/FEB/2021 
 
 
Principal Investigator 
Clay Semenkovich, MD 
Professor of Medicine 
 
 
Sub-Investigators 
Janet McGill, MD 
Professor of Medicine 
 
Alexis McKee, MD 
Andrea Cedeno, MD 
Samantha Adamson, MD 
Mei Zhang, MD 
 
 
 
Administrative Coordinator 
Mary Jane Clifton, BA, CCRP 
 
 
 
 
 
 
 
 
 
 

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ROLE OF SARCOPLASMIC RETICULUM IN INSULIN SENSITIVITY AND THE 
METABOLIC SYNDROME 
 
INTRODUCTION, BACKGROUND AND SIGNIFICANCE 
 
Global death rates fell for most diseases over the last two decades. Diabetes is a glaring 
exception, with a 93% increase in the absolute number of deaths (second only to HIV/AIDS) and 
a 70% increase in global years of life lost between 1990 and 2010 1. With at least 1.5 billion 
overweight people in the world, a third of whom are obese 2, diabetes and premature death are 
certain to accelerate.   While exercise has been shown to prevent diabetes and is a proven 
treatment for the metabolic derangements that occur in diabetes3, persons with the metabolic 
syndrome, pre-diabetes and diabetes often have poor exercise tolerance4.  While overall lack of 
fitness is multi-factorial, reduced exercise performance may be related to fuel metabolism in 
skeletal muscle in susceptible individuals, including those with diabetes5-7.  Exercise has been 
shown to improve metabolism of glucose and reduce insulin resistance in skeletal muscle, but 
the role of lipid metabolism to insulin sensitivity and exercise performance is not well 
understood. This study is a pilot that will explore the role of lipid metabolism in key metabolic 
pathways in skeletal muscle.  The overall goal is to understand the abnormalities that occur in 
lipid metabolism in sedentary persons with the metabolic syndrome compared to controls 
without the metabolic syndrome who are normal weight and sedentary.  This study will add to 
our understanding of how lipid metabolism contributes to insulin sensitivity and function in 
skeletal muscle.   
 
The sarcoplasmic reticulum (SR) is the muscle cell's production and function center.  It is made 
mostly of a phospholipid (fatty) layer that is also integral to its function.  Fatty acid synthase 
(FAS) and choline/ethanolamine phosphotransferase 1 (CEPT1) are two proteins involved in the 
production of this phospholipid layer.  Depending on the activity of these proteins, this 
phospholipid layer can assimilate more of certain types of phospholipids, mainly 
phosphatidylethanolamine (PE) and phosphatidylcholine (PC).  Phosphatidylethanolamine is the 
phospholipid species assimilated when FAS and CEPT1 are active. The more active these 
proteins, the more PE is present in the SR layer.  The main alternative to PE is 
phosphatidylcholine. More of this phospholipid species is assimilated into the SR when the 
above proteins are not active.  Each of these phospholipids carries a different structure and with 
it, different functional properties, so depending on which type of phospholipid is more abundant, 
the overall structure and function of the SR is varied. 

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Interestingly, our new data show that high fat 
feeding leads to increased fatty acid synthase 
activity in mice.  In humans, we have found that 
FAS is increased in the skeletal muscle of 
obese, yet healthy subjects, while it is 
decreased in metabolically compromised 
obese subjects (Fig 1).  Furthermore, we have 
found that surgically induced weight loss 
decreases both FAS and CEPT1 (Fig 2). These 
results suggest that FAS and CEPT1 are part 
of a phospholipid production pathway brought 
on by high fat feeding or obesity to preserve 
the function of the sarcoplasmic reticulum. This 
fails in those who progress to metabolic 
decompensation (the obese ‘abnormal’ in Fig 
1A).   
 
Given the function of these proteins, these studies suggest that the phospholipid composition 
may also be altered in metabolically compromised individuals when compared with normal 
subjects.  Indeed, this hypothesis was supported by our findings of altered phospholipid 
composition in mice with artificially lowered activity of these proteins. There was more PC than 
PE in the sarcoplasmic reticulum of these mice when fed a high fat diet. 
 
But what does the sarcoplasmic reticulum have to do 
with blood sugar control?  It turns out that insulin 
sensitivity is related to the activity of a protein that 
interacts with the sarcoplasmic reticulum, called 
sarco/endoplasmic reticulum ATPase (SERCA). The 
main function of SERCA is to store calcium in the 
sarcoplasmic reticulum in order to allow the muscle to 
relax. This resets the muscle to allow for repeated 
muscle contraction. However, SERCA is only functional 
when actively associated with the phospholipid layer of 
the SR. Calcium also seems to regulate insulin 
sensitivity in the muscle cell through the proteins 
CaMKKβ, AMPK, and AS160 (Fig 4).  When SERCA is 
not active and therefore calcium is not stored in the SR, 
muscle cells are more insulin sensitive.  When SERCA 
is active and therefore calcium is stored away and not 
available in the cytosol of the cell, muscle cells are more 
insulin resistant.   
 
Fig 1. FAS mRNA levels in human skeletal muscle. 
*P<0.05 vs. obese abnormal by Tukey’s post hoc 
test. B. FAS mRNA in mice from Fig 1A of 
reference 4.   
Fig 2. FAS and CEPT1 protein in 
skeletal muscle biopsies from 16 
obese human subjects before 
and after 20% weight loss 
induced by gastric bypass. 

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How do these findings relate to the composition of the sarcoplasmic reticulum?  Our studies 
have shown that SERCA has lower activity when the composition of the sarcoplasmic reticulum 
is comprised of more PC than PE.  Mice that are artificially induced to have this altered SR 
composition through inactivation of FAS are found to have muscle weakness, but this is in 
exchange for improved blood sugar control.  In normal mice with functioning FAS, the PE to PC 
ratio is preserved and muscle strength is normal, but at the cost of reduced insulin sensitivity.  
This suggests that insulin sensitivity may be determined by the ratio of PC to PE in muscle 
tissue, based upon the activity of SERCA.  When there is more PC than PE, the activity of 
SERCA is lower and thus muscle function is compromised, but the cell’s sensitivity to insulin is 
higher.  Conversely, when there is more PE than PC, the activity of SERCA is higher and thus 
muscle function is 
preserved, but the 
cell’s sensitivity to 
insulin is lower. Our 
conclusion from 
these observations 
is that the muscle 
cell sacrifices insulin 
sensitivity for muscle 
function when called 
upon to do so.  The 
muscle cell’s first 
priority is to contract, 
not to be sensitive to 
insulin. 
 
But does this insulin-
desensitizing phospholipid ratio apply to humans?  For example, we know that FAS and CEPT1 
activity apply to humans, but does the activity of these proteins affect the ratio of PC to PE in 
humans as well?  To see if the findings in mouse muscle can translate to human muscle, we 
analyzed skeletal muscle biopsies from four humans.  We found that the human sarcoplasmic 
reticulum phospholipid composition was similar to that of the sarcoplasmic reticulum from mice 
(Fig 3). These results established the feasibility for studying the muscle of humans with the 
metabolic syndrome.   
 
If indeed we do find that insulin sensitivity in humans can be predicted by the phospholipid ratio 
in skeletal muscle, this would verify the involvement of phospholipids in insulin sensitivity.  This 
study will help to create a new context in our understanding how diabetes works, and how we as 
a medical community can combat it. Specifically, therapy could be guided by utilizing non-
invasive imaging, such as MRI to identify specific skeletal muscle phospholipid signatures.  
Drugs could be developed or even repurposed to alter the structure and function of the 
sarcoplasmic reticulum and offer new options for the treatment of obesity and diabetes.  This 
would be paradigm shifting in our understanding of how muscle contributes to overall insulin 
resistance or sensitivity, and would pave the way to further studies and possible therapeutics 
that target muscle in ways not previously thought of.   
 
 
Fig 3. A. Human muscle PC/PE ratio (0.97±0.088). B. PC species. C. PE 
species. As in mouse, 16:0/22:6 is the most abundant PE species in human 
muscle.  

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SPECIFIC AIMS 
 
 
The specific aims of this study are to determine if the composition and function of the 
sarcoplasmic reticulum is altered in persons with the metabolic syndrome compared to lean 
controls.  Long-term goals are to deliver new understanding of impediments to effective therapy, 
novel biomarkers of disease progression, and innovative treatment targets for diabetes.  
 
PROTOCOL PLAN 
 
Study Design. We will perform a cross-sectional study of age-matched, sedentary lean controls 
and individuals with the metabolic syndrome, recruited in part from a large database of subjects 
screened for our recently completed clinical trial (manuscript in preparation) involving metabolic 
syndrome (NCT00455403). 
 
Eligibility Criteria 
 
 
Control subjects 
Inclusion: 
1. Sedentary: No routine exercise; walking <10,000 steps per day   
2. Age >18 and <65 
3. Body Mass Index (BMI) <32 
4. Healthy by physical exam (patient is devoid of major acute or chronic illness) 
5. No significant abnormality in screening labs 
 
Fig 4. Increased cytosolic calcium after FAS inactivation likely impairs 
relaxation of the actin-myosin junction at the sarcomere, promoting 
muscle weakness. Calcium also likely activates a signaling cascade 
involving CaMKKβ, AMPK, and AS160 that enhances insulin-stimulated 
glucose uptake in muscle. (Taken from reference 5) 

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Exclusion: 
1. Currently on any significant prescription medications other than oral 
contraceptives in women  
2. Currently Pregnant  
3. Current Tobacco use 
 
Subjects with the Metabolic Syndrome 
 
Inclusion 
1. Sedentary: No routine exercise; walking <10,000 steps per day   
2. Age >18 and <65 
3. Body Mass Index (BMI) >30  
4. Meet at least three of the following ATP III criteria for the metabolic 
syndrome: 
a. waist circumference > or = 40 inches in men, > or = 35 inches in 
women 
b. blood triglycerides > or = 150 mg/dL 
c. blood HDL cholesterol <40 mg/dL in men, <50 in women 
d. blood pressure > or = 130 mmHg systolic, or > or = 85 mmHg diastolic 
e. fasting blood sugar > or = 100 mg/dL 
Exclusion 
1. Diagnosed with Type 2 diabetes, coronary artery disease, cancer, liver, lung, 
or kidney disease or any other major illness 
2. Currently on any significant prescription medications other than: 
a. oral contraceptives in women  
b. More than two standard medications for stage 1 hypertension in men 
or women (blood pressure 140-159/90-99) 
3. Currently Pregnant 
4. Current Tobacco use 
 
Study Plan and Procedures 
Screening.  Potential subjects will be interviewed, the protocol will be explained in detail, then 
risks and benefits of involvement will be discussed. Those subjects interested in participating 
will be given ample time to review the informed consent, to ask questions of any member of the 
study team, and will sign the informed consent prior to any study procedures being conducted.  
Subjects will have a complete history and physical examination (including measurement of 
blood pressure according to a standard protocol and determination of height, weight and waist 
circumference, all performed by experienced personnel in the Washington University IRU) or the 
study coordinator. A CBC, CMP, HBA1c, and a lipid panel will be performed to determine 
whether the patient meets the inclusion criteria and does not meet any exclusion criteria.  
Individuals who have one or more exclusions will be informed of their test results but will not 
proceed further.  If the patient meets the inclusion and does not meet the exclusion criteria 
specified above at the screening visit, he or she will be scheduled for three subsequent visits, as 
depicted in the schedule of events.  
Rescreening Visit. If potential subject fails screening based upon a single criterion, i.e. a lab 
result or blood pressure that is thought not to be reflective of prior results based on history, at 
the discretion of the investigator the screening procedure may be repeated once.   
Study procedures. Patients who provide informed consent, and who meet the inclusion criteria 
and do not meet the exclusion criteria will received 2 phone calls (Visits 2 and Visit 3) 
approximately 1 week apart and will return to the study site for a final subsequent visit.  At visits 
2 and 3 study staff will be verifying no change in eating or exercising habits, as well as no 
change in medications or health status. Visit 4 will interview subjects to determine no changes in 

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eating or exercising habits, no changes in medications or health status and the following 
procedures: lab work (HBA1c, Lipid panel, fasting glucose and insulin levels, as well as 3 vials 
of blood for future use), an oral glucose tolerance test including an insulin level with each draw, 
a DEXA scan, and a muscle biopsy.  The schedule of events, as well as explanations of each 
procedure is outlined below.   
 
Comp-SR Schedule of Events 
Procedure 
Screening  
 
*Rescreen 
Phone   
visit 
Phone 
visit 
Final 
visit 
Week 1 
 
Week 
2 
Week 
3  
Week 
4 
Fasting (10-12 hours) 
X 
X 
 
 
X 
Informed consent 
X 
 
  
  
  
H&P 
X 
 
  
  
  
Vital signs (BP, HR, Temp) 
X 
X 
 
 
X 
Weight 
X 
X 
 
 
X 
Waist circumference and Height 
X 
 
Urine Pregnancy test in women of childbearing 
potential 
X 
X 
 
 
X 
Verify no change in exercise 
X 
X 
X 
X 
Verify no change in eating habits 
X 
X  
X  
X  
Verify no change in medications or health status 
 
X 
X 
X 
X 
CBC, CMP, HBA1c, Lipid panel 
X 
X 
  
  
  
HBA1c, Lipid panel, fasting glucose and insulin 
levels, as well as 3 vials of blood for future use (All 
drawn 5 min prior to OGTT) 
 
 
 
 
X 
OGTT:  0, 30, 60, 90, 120 minutes 
with insulin levels also drawn at each time marker 
  
 
  
X  
DEXA scan  
  
 
  
X  
Leg Muscle biopsy 
  
 
  
X 
*Subject will only have the failed test repeated.  
Blood tests.  Most determinations will be performed by the Washington University Core Lab for 
Clinical Studies, a CLIA-certified facility that has served as the reference lab for landmark 
clinical trials including the Coronary Primary Prevention Trial and the CARE trial. The lab will 
measure CBC, CMP, HBA1c, and Lipid panel at first visit and HBA1c, Lipid panel, and glucose 
and insulin levels, as well as 3 more vials of blood for future research at the final visit.     
Oral Glucose Tolerance Test (OGTT).  This test will be performed on the final visit.  Study 
patients will be asked to arrive fasting for 10-12 hours ahead of time.  An intravenous catheter 
will be placed, labs including Hemoglobin A1C, lipid panel, and blood glucose and insulin levels 
will be obtained 5 minutes prior to the start of the OGTT. Blood will be drawn for blood glucose 
and insulin levels at the start of the OGTT.  The patient will then be asked to consume 75 grams 
of glucose.  Blood will be drawn again for blood glucose and insulin levels at 30, 60, 90 and 120 
minutes after consuming the glucose.  This visit will take approximately 4-6 hours.   
DEXA scan. This test will be performed on the final visit.  We will ask the patient to lie on a table 
while they are scanned by a special machine.  The DEXA scan takes about 30 minutes. DEXA 
images taken during the study are for specific research purposes and are not being used to 

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evaluate the patient’s health or find medical abnormalities.  These images will not be reviewed 
by a radiology physician to diagnose existing abnormalities. 
Muscle Biopsy. This procedure will be performed on the final visit.  A member of the study team 
will obtain a sample of muscle tissue from the patient’s thigh (vastus lateralis muscle).  This 
involves numbing the skin with a local anesthetic (lidocaine), making a small (approximately the 
size of the dotted line ------ ; 1 cm) incision and removing a small (approximately 1/15th of an 
ounce) piece of muscle tissue.  Each incision will be closed with a piece of sterile tape or a 
stitch, if necessary.         
Sample Size Estimates and Statistical Analyses 
There are no published data to guide estimates; to our knowledge, this type of study has never 
been done. If SERCA activity is 25% less in the metabolic syndrome, based on a standard 
deviation of 0.445 (Fig 14), 17 subjects per group are required (80% power, α=0.05). We will 
enroll 25 for each group to account for assay problems and to increase power. For the mouse 
and cell culture studies, primary endpoints are clearly defined. Differences and variances from 
the first experiments will be used to estimate sample size (80% power, α=0.05). All comparisons 
will use appropriate tests for parametric and nonparametric data. Suitable posttests will be used 
for multiple groups.   
Anticipated Results, Alternative Approaches, Potential Problems and Benefits  
Anticipated results of the study are lower SERCA activity and higher SR PC/PE ratio in people 
with metabolic syndrome compared to lean controls. We expect to find higher FAS and CEPT1 
in metabolic syndrome skeletal muscle, reflecting activation of a phospholipid synthetic pathway 
attempting to replenish SR membrane composition disrupted by the obesity/high fat state.  
Predicting relationships between insulin sensitivity and SERCA activity is difficult based on our 
mechanistic studies. The most insulin resistant could have the highest levels of FAS and CEPT1 
despite lower SERCA activity in the setting of a higher PC/PE ratio. This would reflect the 
inability to synthesize key PE molecules due to the stress of lipid overload despite induction of 
the FAS-CEPT1 pathway.  
An alternative approach could include euglycemic insulin clamps, but the Matsuda index is 
highly correlated with glucose disposal and much less invasive than a clamp.  
Potential problems in this study include patient lost to follow up, rarely loss of confidentiality, 
drawing of blood may cause minor discomfort, bruising, bleeding, chance of infection or blood 
clotting associated with the insertion of the needle and rarely infection or fainting.  
The patient could experience blood sugar fluctuations during the OGTT causing discomfort; 
sweating, shaking, nausea. However, blood sugar is carefully monitored throughout the OGTT 
to decrease the risk.  
Risk associated with the placement of catheter is similar to blood drawing, infection or injury 
from the muscle biopsy, reaction to the local anesthetic (lidocaine/xylocaine), or exposure of a 
developing fetus to the DEXA scan.  Careful precautions will be taken and proper procedures 
are in place to avoid these complications, participants are under constant medical supervision 
(i.e. proper training of staff and physicians to perform blood drawing, muscle biopsies, 
questioning subject about prior allergic reaction to lidocaine/xylocaine, pregnancy tests prior to 
DEXA scanning and review of medical history, including history of radiation exposure for 
research testing.)  
To protection patient confidentiality all data, forms, and specimens will be labeled with each 
study participant’s unique study identifier.  The optional stored biologic samples are coded (with 
initials, DOB, gender & race) and stored in a locked lab with access to study staff. Biologic 

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samples will not have identifiers but only a study code - the lab will not have access to the link. 
Only Washington University study staff will have the link between the biologic sample code and 
the subject identifiers.  
Stored Samples will be kept at the Washington University Core Lab for Clinical Studies and/or 
Dr. Clay Semenkovich’s lab. Access to the storage area is restricted by pass card swipe; 
samples are kept in a locked room and in a locked cabinet. Only authorized staff will have 
access to the samples. Electronic stored data (may contain subject initial and/or DOB) and 
study identifier maintained on WUSM secure computer network on a password protected 
database with access restricted to designated study staff only. Any information maintained in 
electronic format that includes identifiable information will be stored on the secure network, 
password protected and restricted to WU study staff only.  
Study source documents will contain subject name, date of birth and other identifying 
information. Study data collection documents may contain subject identifier (initials and/or 
assigned #). Subject identifiers will be collected and maintained for internal (WU) use only. 
Confidential binders and study files with the subject info will be kept in a restricted access area 
in a locked office and a locked cabinet when not in the possession of study staff. 
Withdrawal of research subjects from the protocol may occur.  Research subjects will be 
withdrawn if any of the following occurs: 
• The patient withdraws consent for any reason 
• An adverse event occurs related to study procedures (i.e. severe infection from muscle 
biopsy) 
• An adverse event that would impact any of the study results occurs.  An example would be 
a patient who develops poison ivy during the study and requires oral steroids for control of 
the rash.  This would disrupt their weight steady state as steroids are known to cause 
weight gain.  Efforts will be made to adjust the study schedule to permit recovery, but if 
that is not possible or likely, the patient will be withdrawn. 
The PI and/or sub-I will monitor each subject’s lab results and visit data at each study visit. 
Possible benefits to study patients would be satisfaction of altruistic values alone. 
Adverse Event  
An Adverse Event (AE) is any untoward medical occurrence in a study participant regardless of 
its relationship to study treatment.   
A Serious Adverse Event (SAE) is any untoward medical occurrence that results in death, is life-
threatening, requires hospitalization or prolongation of an existing hospitalization, results in 
persistent or significant disability, or is a congenital anomaly/birth defect.  Important medical 
events that do not fall into the above categories may also be considered an SAE when, based 
on medical judgment, such events may jeopardize the patient’s safety and require 
medical/surgical intervention to prevent one of the outcomes listed in the SAE definition.  The 
term SAE is not intended as a measure of severity or intensity. 
Adverse Events Reporting 
All AEs will be reported on the Adverse Events form that will be completed by the study staff at 
each regular follow-up visits.  Forms will include standardized questions relating to specific 
events of import in patients as well as any significantly abnormal physical finding identified on 
examination and any significantly abnormal laboratory results obtained on the patient between 
visits or at the time of the visit.  AEs reported or ascertained between clinic visits will be 
captured and reported at the time of the next schedule visit.  Pre-existing conditions (that is, 
conditions present prior to randomization) will not be considered or recorded as AEs unless the 

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condition worsens in intensity or frequency after randomization.  Likewise, continuing AEs will 
not be reported as AEs at subsequent visits unless they increase in severity or frequency 
between visits, they results in criteria for a SAEs, and/or they resolve between visits.  The study 
staff will report all AE's to HRPO according to its AE reporting policy and procedures.   
Assessment of Causality and Severity 
The seriousness of adverse events will be ascertained by investigator and the need for further 
evaluation, follow-up, or referral.  The relationship between study participation and AEs will be 
determined according to the following criteria:  
Not related – temporal relationship of the onset of the event, relative to study participation, is not 
reasonable or another cause can by itself explain the occurrence of the event. 
Possibly related – temporal relationship of the onset of the event, relative to study participation, 
is reasonable but the event could have been due to another, equally likely cause. 
Probably related – temporal relationship of the onset of the event, relative to study participation, 
is reasonable and the event is more likely explained by the study treatment than by another 
cause. 
Definitely related – temporal relationship of the onset of the event, relative to study participation, 
is reasonable and there is no other cause to explain the event. 
Study Data Monitoring and Safety  
The study will be reviewed for safety, privacy and data integrity by the investigator(s) at regular 
intervals during the course of the study and at least annually by a designated Safety Officer 
The purpose of the safety officer’s oversight is to evaluate accumulating data and provide 
continual safety oversight of trial subjects and recommendations. The Safety Officer will review 
data annually with ad hoc meetings reviews as necessary. The purpose of the annual review is 
to review safety information, to review factors relating to quality of trial conduct, and to ensure 
proper implementation of procedures for the trial. 
The Safety Officer will be an independent, senior faculty member having pertinent expertise in 
the management of patients in the conduct and monitoring clinical trials and free from interest 
conflicts.  The Safety Officer will submit a written report of patients reviewed, any pertinent 
findings, and decision about continuation or stopping the study annually.  The report will be 
submitted to the Human Research Protection Office.   
Data Collection and Quality Assurances  
In accordance with applicable regulations, GCP, and HRPO requirements the PI will review with 
the study staff   the protocol, study requirements, and their duties and responsibilities to satisfy 
regulatory, ethical, and HRPO requirements.  
Study personnel will enter demographic data and study results into a database and/or 
spreadsheet for analysis. Subjects will be de-identified and assigned a subject number for the 
analysis data set.  Information entered into databases will be stored on a secured server, which 
is password protected and accessible only to authorized study staff. 
When reviewing data collection procedures, the discussion will include identification, agreement, 
and documentation of data items for which a paper chart will serve as the source document. 
The PI and sub-Is, will monitor the study to ensure that the: 
• 
Data are authentic, accurate, and complete 
• 
Safety and rights of subjects are being protected 
• 
Study is conducted in accordance with the currently approved protocol, GCP, and all 
applicable regulatory requirements.  (Faculty sponsor is only when the PI is in training.) 

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Subjects will be requested to contact study staff if any adverse event occurs between clinic 
visits.  All adverse events, whether incurred at a study visit or between study visits, will be 
reviewed by PI, and submitted to HRPO in accordance with HRPO policy.  The PI or Dr. McGill 
will remove any subject at his or her discretion based upon his judgment or in the event of 
undue AE’s.  New risks will be added or the risk language adjusted in the informed consent per 
HRPO policy and participants will be notified of any and all changes, in particular those that 
might affect their decision to participate. 
Safety and tolerability assessments include the following: 
• AEs and SAEs  
• Physical examinations, laboratory evaluations, vital sign measurements (blood 
pressure and pulse rate) 
All safety data will be available in data listing in the clinical protocol report. Data will be 
described in terms of descriptive statistics reviewed on a continuous basis by study staff and the 
Safety Officer. The number of patients screened, enrolled, and completing the study will be 
summarized.  
Study safety will be monitored by PI and sub-Is.  PI will review all reported AE’s and report to 
HRPO, as per HRPO requirements.  The PI may halt the study participation or the study if 
determined to be in the best interest of participants.  Safety Reports will be generated ad hoc 
and reported as per HRPO policy and at least annually at the time of HRPO renewal.  Since this 
study does not involve an intervention, i.e., is purely observational, a DSMB will not be 
convened.   
Study Termination 
The study will be terminated if it is determined that continuing the study would pose an 
unacceptable risk to subjects.  
 
 

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