A Single Dose Pharmaco-Diagnostic for Peripheral Nerve Continuity After Trauma
Phase: PHASE2
Conditions: Nerve Injury
Sponsor: Milton S. Hershey Medical Center

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,.
                                                                                       
HRP-592 - Protocol for Human Subject 
Research with Use of Test Article(s)
Protocol Title:
A Single Dose Pharmaco-Diagnostic for Peripheral Nerve Continuity After Trauma
Principal Investigator:
Name: Kenneth Taylor, MD 
Department:  Orthopaedics & Rehabilitation
Telephone: 717-531-2948
E-mail Address: ktaylor3@pennstatehealth.psu.edu
Version Date:
03/31/2022
Clinicaltrials.gov Registration #:
NCT04026568
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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
Data and Safety Monitoring Plan
10.0
Risks
11.0
Potential Benefits to Subjects and Others
12.0
Sharing Results with Subjects
13.0
Subject Payment and/or Travel Reimbursements
14.0
Economic Burden to Subjects
15.0
Resources Available
16.0
Other Approvals
17.0
Multi-Site Study
18.0
Adverse Event Reporting
19.0
Study Monitoring, Auditing and Inspecting
20.0
Future Undetermined Research: Data and Specimen Banking
21.0
References
22.0
Confidentiality, Privacy and Data Management
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1.0
Objectives
1.1
Study Objectives
The purpose of this study is to evaluate the role of single dose 4-aminopyridine (4-AP) on the diagnosis of 
severing vs non-severing nerve injury after peripheral nerve traction and/or crush injury. The investigational 
treatment will be used to test the hypothesis that 4-aminopyridine can speed the determination of nerve 
continuity after peripheral nerve traction and/or crush injuries allowing the identification of incomplete injuries 
earlier than standard electrodiagnostic (EDX) and clinical assessment.
1.2
Primary Study Endpoints
Primary Aim and Study Endpoint:  Return of voluntary function and subjective sensation not present after 
trauma.
Summary of Specific Aims:  This proposal contains two distinct aims to be investigated in two similar but distinct 
groups of patients.  This will be measured by sensory, motor and sudomotor (electrical conduction tests), and 
electrodiagnositc (EDX) testing.  
 
Aim 1: To examine the mechanistic effect of 4AP on the return of sensorimotor function and EDX sensitivity in 
the setting of nerve dysfunction from orthopaedic trauma. This aim tests the hypothesis that oral one-time 
administration of 4AP provides transient return of function and EDX sensitivity to the traumatically denervated 
limb in alert patients with known limb injuries not involving the central nervous system.
Aim 2: To examine the mechanistic effect of 4AP on the return of sensorimotor function and EDX sensitivity in 
the setting of iatrogenic nerve injury after surgical intervention. This aim tests the identical hypothesis as in Aim 
1 in a distinct group of patients, whose nerve dysfunction is the result of a clinical intervention, and whose 
function before that intervention was intact.
1.3
Secondary Study Endpoints
Not applicable.
2.0
Background 
2.1
Scientific Background and Gaps
Neurological injury in the form of traction or crush to nerves that control muscles and sensory function is common.  
Because an understanding of these injuries is only now beginning to emerge, research on potential treatments is 
an important next step. Through experiments performed on animals with the Acorda Therapeutics, Inc. version of 
the drug (AMPYRA®), 4-aminopyridine (4-AP) has been strikingly effective in ameliorating the effect of a 
standardized peripheral nerve crush injury.  The peripheral nerve injury used in our experiments was a standard 
model of peripheral nerve injury used to measure recovery in animals and is a model of peripheral nerve traction 
and crush injury that has been studied for over thirty years.  We have found that: 
(1) 4-AP administration in a single dose given on day three after the injury led to a drastic reduction in the 
dysfunction afforded by a crush injury just days after the crush itself.  
(2) 4-AP treatment’s effect was short-lived after a single dose and was, in effect, diagnostic of the potential to 
recover in a nerve that was crushed but not shattered.  
(3) Severed nerves show no capacity to recover even with 4-AP treatment.  
(4) The treatment in a daily regimen led to profound, lasting, permanent improvement in the speed of recovery 
in these animals.  
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4-AP is used in some of the most fragile of neurologically-ailing patients and is currently a mainline treatment in 
the setting of multiple sclerosis (1).  Multiple sclerosis patients suffer a demyelinating disorder that causes the 
stripping of the myelin sheath from around neurons in the peripheral and central nervous system.  The myelin 
covering allows for normal conduction of impulses and, without such covering, impulses are small, impaired, 
impeded, and ineffective.  The recognition that crush injuries to nerves do not simply sever the axonal fibers but 
also demyelinate some population of nerve cells has led to the idea to study the treatment of peripheral nerve 
traumatic injuries in humans using 4-AP.  
2.2
Previous Data
4-AP has been studied in humans since the early 1980s, and principles of safe usage are extremely well 
established.  For the purposes of this proposal, the immediate release formulation of 4-AP, sometimes called 
fampridine will be referred to as IR 4-AP.  The proposed version of the drug used in this study is an extended 
release formulation of 4-AP, called dalfampridine, which was marketed under the trade name AMPYRA, by Acorda 
Therapeutics.  Recently, this extended release formulation has become available as a generic, which will be 
referred to as generic AMPYRA or dalfampridine.  Essentially identical principles apply whether 4-AP is provided 
in an orally available immediate release formulation (IR 4-AP) or an orally available sustained release formulation 
(dalfampridine).  The safety of 4-AP appears to be determined solely by serum levels.  
It has long been recognized that the most significant safety concern regarding 4-AP is an increased frequency in 
seizures, which occurs in a small percentage of patients if serum levels exceed 100 ng/ml.  Therefore, dosages are 
chosen to maintain serum levels that do not exceed 50-60ng/ml.  In prior studies, 5mg of study drug were 
administered once every six hours, for a total dosage per day of 20 mg.   This total dose, as indicated by multiple 
previous studies on immediate release 4-AP, has an excellent safety profile even in the fragile population of 
patients with multiple sclerosis.  A sustained release formulation of 4-AP (AMPYRA®) at this same dose is FDA 
approved for use in the multiple sclerosis population even with a known risk of seizure activity in these patients.
It is important to note that multiple studies on 4-AP also include patients with chronic stroke, chronic spinal cord 
injury, transverse myelitis, primary lateral sclerosis, Lambert-Eaton myasthenic syndrome, ocular nystagmus, 
nonarteritic anterior ischemic optic neuropathy, spinal muscular atrophy, chronic Guillan-Barre syndrome, 
episodic ataxia Type 2, obstructive sleep apnea and spinocerebellar ataxias.  Over 45 clinical trials have been 
conducted in the US alone (as listed on the Clinicaltrials.gov website).  There are also 49 primary publications on 
clinical trials outcomes on 4-AP, which include patients with multiple sclerosis, chronic spinal cord injury, 
spinocerebellar ataxias and chronic stroke. 
The many trials on 4-AP have been conducted using both immediate release 4-AP and sustained release 4-AP.  The 
difference between the immediate release and sustained release formulations are that the sustained release 
formulation helps to decrease the peaks and troughs in serum levels that can occur with larger doses of immediate 
release formulations.  
In respect to the use of immediate release formulations of 4AP (not proposed for use in this study but relevant for 
evaluation of safety), the following studies on multiple sclerosis patients are the most pertinent: 
1. 4-Aminopyridine in patients with multiple sclerosis: dosage and serum level related to efficacy and safety. Van 
Diemen HA, Polman CH, Koetsier JC, Van Loenen AC, Nauta JJ, Bertelsmann FW. Clin Neuropharmacol. 1993 
Jun;16(3):195-204.
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In these studies, nonenteric-coated capsules containing 4-AP or placebo were administered orally for 12 weeks, 
the starting dosage was 10-20 mg orally per day in 2-3 divided doses. The daily dosage was elevated with 5-15 mg 
at week two and week six. Blood samples, to determine serum levels at the end of the first and second oral 
treatment, were taken 1.5-2.5 hours after the latest intake of medication.  
Side effects were minimal in these studies and mostly were confined to paresthesias and/or 
dizziness/lightheadedness and nausea/vomiting and were not considered to be significant by the patients.
The mean dosage given to patients was 31.2 mg per day and ranged from 10-50 mg per day.  Thus, the 
average dose was higher than we have proposed. 
Capsules were divided in 2-4 doses and ranged from 0.17- 0.55 mg/ kg. On average, 4AP serum levels increased 
1.3 ng/ml per mg 4- AP/day. Side effects were less frequent with oral dosing than with intravenous dosing. When 
side effects occurred, they mostly occurred within 30-45 minutes after taking the medication and generally 
resolved within 2-5 hours, with half the patients not experiencing any side effects.
The rapid resolution of side effects with orally administered 4-AP in an immediate release formulation 
was very favorable.
One patient, who received three oral doses daily at twice the concentration that are proposed (i.e., 10mg per 
capsule instead of 5 mg/capsule), was closely studied at multiple time intervals in this very early study. Following 
an initial rapid climb in serum levels to 114 ng/ml, subsequent doses caused increases to lower levels of 60 ng/mL 
or 80 ng/ml. 
 In general, restlessness, confusion and generalized tonic-clonic seizures have been reported at doses higher than 
0.8 mg/kg bodyweight, and such symptoms were not seen when doses of 0.5 mg/kg bodyweight or less were 
used.  
For this IND application, we are assuming a body weight of 70kg, the dosages proposed are <0.3 mg/kg, distributed 
in 1 dose of 10mg/capsule.  No subject will receive a dose greater than 0.5 mg/kg bodyweight. Patients will receive 
only one pill for the course of the study.  
2. The effect of 4-aminopyridine on clinical signs in multiple sclerosis: a randomized, placebo-controlled, double-
blind, cross-over study. van Diemen HA, Polman CH, van Dongen TM, van Loenen AC, Nauta JJ, Taphoorn MJ, van 
Walbeek HK, Koetsier JC. Ann Neurol. 1992 Aug;32(2):123-30.
In this study, patients reported side effects (which were mild when they occurred at all) that occurred within 30-
45 minutes after taking the medication, and generally resolved within 2 -5 hours. Severe side effects were not 
encountered which was thought to be due to the fact that the maximum daily dose was only 0.5 mg/kg of body 
weight.  
3. 4-Aminopyridine improves clinical signs in multiple sclerosis. Stefoski, D., Davis, F.A., Faut, M., Schauf, C.L., 
1987.. Ann Neurol 21, 71-77.
In these patients, single doses up to 15 mg 4-AP were administered in an immediate release oral formulation. In 
this single-dose administration, 70% of the improvements lasted 7 to 10 hours and usually became apparent one 
hour post-4-AP and culminated three hours or so later.  
Serum samples were taken from a heparin lock placed in a peripheral arm vein before 4-AP initiation and at 0.5, 
1.0, 1.5, 2, 3, 4, 6, and 8 hours after the dose. Analysis of serum concentrations of levels of 4-AP showed a terminal 
half-life of approximately 3 ± 1 hours. There was no detectable serum 4-AP in the majority of patients on the 
morning following the test day, although 7/17 patients had varying carryover levels. These carryover levels were 
lower than any from the previous day and clinical improvements had reversed to baseline by this time. 
Side effects of this dosage (which is three times higher than we propose) seen were mild to moderate consistently 
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lasted no more than 60-90 minutes. These were generally well tolerated and patients did not consider them 
disturbing.
4. Orally administered 4-aminopyridine improves clinical signs in multiple sclerosis. Davis FA, Stefoski D, Rush J. 
Ann Neurol. 1990 Feb;27(2):186-92.
In these studies, 4 AP was delivered orally in a single dose and no serious or bothersome side effects were 
observed with single oral doses of up to 25 mg. These dosages were up to 2 times greater than any used in this 
proposal. 
5. The effects of 4-aminopyridine in multiple sclerosis patients: results of a randomized, placebo-controlled, 
double-blind, concentration-controlled, crossover trial. Bever CT Jr, Young D, Anderson PA, Krumholz A, Conway 
K, Leslie J, Eddington N, Plaisance KI, Panitch HS, Dhib-Jalbut S, et al. Neurology. 1994 Jun;44(6):1054-9.
In patients given anywhere from 5-10 mg of 4-AP after various time points(i.e., q12h, q8h, q6h) serum levels only 
once exceeded 64 ng/ml in one patient and 56 ng/ml in one patient and otherwise were all between 35-51 ng/ml 
at the Cmax analysis point. The only time seizures were seen was in a patient where the serum level reached, with 
high dosage administration, greater than 100 ng/ml. The conclusion of this study was that peak serum levels above 
100 ng/ml should be avoided but that at lower levels side effects are minimal.
The studies on multiple sclerosis define the dosages to be used in this proposal, even though the traumatically 
injured patients are not considered to be a fragile population. The following studies on patients with spinal cord 
injuries are also relevant, as these patients, like peripheral nerve injury patients, do not have the central nervous 
system lesions that are prominent in patients with multiple sclerosis. 
6. Safety and efficacy of 4-aminopyridine in humans with spinal cord injury: a long-term, controlled trial. Segal 
JL, Pathak MS, Hernandez JP, Himber PL, Brunnemann SR, Charter RS. Pharmacotherapy. 1999 Jun;19(6):713-23.
In these patients with chronic spinal cord injuries, dosages provided in immediate release oral formulations of 4-
AP were 30 mg per day and demonstrated efficacy in multiple patients. Clinically significant adverse effects or 
measurable toxicity did not occur. Nervousness, giddiness or dizziness, and gastrointestinal upsets manifesting as 
mild abdominal cramping or nausea were the most frequent side effects. Side effects were transient, self-limiting 
and seizures or seizure-like activity was not observed. 
The authors stated that they have administered an oral formulation in amounts of up to 40 mg/day to more than 
60 patients with no significant toxicities or adverse reactions that warranted discontinuing a subject.  This is 
generally the case, and patients with spinal cord injury have been studied at dosages higher than those used in 
patients with multiple sclerosis. 
7. Effect of 4-aminopyridine on gait in ambulatory spinal cord injuries: a double-blind, placebo-controlled, 
crossover trial.  DeForge, D., Nymark, J., Lemaire, E., Gardner, S., Hunt, M., Martel, L., Curran, D., Barbeau, H., 
2004.. Spinal cord 42, 674-685.
15 chronic, ambulatory SCI patients were randomized to an initial 2 weeks of 40mg/day, oral medication of 
either placebo or immediate-release 4-AP and subsequently crossed over to the alternate medication for the 
following 2 weeks.  The study treatment (placebo or 4-AP) started at 5 mg twice daily for 3 days, increased to 10 
mg twice daily for 3 days and finally 10 mg four times daily. The subjects were on the full dosage of 40 mg/day 
within 1 week.  Side effects consisted of nausea, dizziness and sleeping difficulties but did not include seizures 
even though dosages were twice those studied in patients with multiple sclerosis.
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8. Sustained improvements in neurological function in spinal cord injured patients treated with oral 4-
aminopyridine: three cases.  Potter, P.J., Hayes, K.C., Hsieh, J.T., Delaney, G.A., Segal, J.L., 1998.. Spinal cord 36, 
147-155.
Potter and colleagues examined three patients with SCI who were administered oral (capsule) IR-4AP (10 mg 
b.i.d. or t.i.d.) over a 4 month interval. Only trivial side effects (transient light- headedness) were observed.  
2.3
Study Rationale
More research is needed to evaluate the role of 4-aminopyridine (4AP) in the course of assessment of nerve 
continuity after peripheral nerve traction and/crush injuries.  The investigational treatment will be used to test 
the hypothesis that 4AP allows the identification of incomplete injuries earlier than standard electrodiagnostic 
(EDX) and clinical assessment and may have a role in faster triage.
3.0
Inclusion and Exclusion Criteria
3.1
Inclusion Criteria

Patients with trauma involving two or less limbs where the continuity of a given peripheral nerve or 
nerves is unclear on presenting physical examination.

Closed soft tissue envelope obscuring direct observation of the continuity of the affected nerve.

Cognitive ability to report sensory and motor deficit during examination.

Able to complete single day dosing within seven days (168 hours) of nerve injury diagnosis.

Eligible for standard of care plan of monitoring vs surgical exploration of the nerve.

Adults subject aged 18-90

Known limb trauma which resulted in nerve injury (aim 1) or post-operative/post intervention nerve 
injury (aim 2).

Ability to give written informed consent.

Capable of safely undergoing electrodiagnostic testing (EDX).

Availability for all testing days and main trial day.
3.2
Exclusion Criteria
                            

Not able to complete dosing within seven days (168 hours) of nerve injury diagnosis

Distracting injury which prevents adequate examination.

Plan for surgical exploration of the nerve during the ensuing 48 hours.

Plan for surgical exploration of the nerve as part of another surgical procedure within 48 hours of 
evaluation.

Intoxication during examination or evidence of cognitive deficit that emerges during examination.

History of multiple sclerosis, stroke or any other diagnosed neurological disorder

History of hypersensitivity to AMPYRA® or 4-aminopyridine

Current use of aminopyridine medications, including other compounded 4-AP 

Renal impairment based on calculated GFR (GFR<80 mL/min). This laboratory value is measured in all 
inpatient trauma patients as part of the standard of care.  

History of difficult compliance with timely follow up or plan to seek care at another institution closer to 
home. 

Patients outside the age range or unable to consent.

Patients with a known history of a seizure disorder (4AP overdose can, in selected cases, result in limited 
seizure activity).

Patients with a concomitant traumatic brain injury.
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•
Patients unable to communicate return or loss of sensation.
•
Patients unable to exhibit motor control on the affected limb at baseline.
•
Patients unwilling to complete the study requirements.
•
Patients with injuries too extensive to isolate a single nerve(s) for testing.
•
Patients currently taking organic cat-ion transporter 2 (OCT2) inhibitors, e.g. Cimetidine.
•
Pregnancy, breastfeeding or incarcerated individuals.   
3.3
Early Withdrawal of Subjects
3.3.1 Criteria for removal from study
•
If the subject is unable or unwilling to take the study drug they will be withdrawn from the 
study. 
•
Subjects who experience a seizure while taking study medication will be withdrawn from the 
study. 
•
The Safety Monitor may withdraw any subject at increased risk using best medical opinion 
based on reported AEs/SAEs. 
•
Subjects will be advised in the written informed consent form that they have the right to 
withdraw from the study at any time without prejudice.
3.3.2 Follow-up for withdrawn subjects
In order to maintain a sample size of 25-34 subjects per aim (note that there are two aim target 
groups), those withdrawn from the study will be replaced. Subjects withdrawn for safety reasons 
will be followed up by regular checking up with them over the phone (and or other tests if 
necessary).
4.0
Recruitment Methods
4.1
Identification of subjects
The patients will be identified as potential subjects by a co-investigator on the study team while in the 
emergency department at Hershey Medical Center or during consultation as inpatients. Traumatic peripheral 
nerve injury (TPNI) patients rarely escape consultation on the orthopaedic or neurosurgical services as patients 
do not tolerate paralysis without explanation or the initiation of a treatment plan. Clinic (office) presentation is 
also theoretically possible however, patients presenting to clinics within the 7 day window of inclusion are 
exceedingly rare in our system. Nonetheless, we will allow inclusion of such patients from orthopaedic surgery, 
neurosurgery, or neurology clinics of the co-investigators should these rare presentations arise.
4.2
Recruitment process
4.2.1 How potential subjects will be recruited.
Patients will all be consented in face to face interviews inside the Penn State Milton S. Hershey Medical 
Center. To minimize the opportunity for coercion a study coordinator listed on the study will conduct the 
consent process, when available.  The subject will be told about the study and given ample time to ask questions 
and review the consent form before deciding about participation.  All subjects will provide written informed 
consent before beginning study measures or receiving study medications and all will be given a copy of the 
signed consent form.  
4.2.2 Where potential subjects will be recruited.
As patients in Hershey Medical Center as described in section 4.1
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4.2.3 When potential subjects will be recruited.
At time of treatment from one of the co-investigators listed on the study.
4.2.4 Describe the eligibility screening process and indicate whether the screening process will 
occur before or after obtaining informed consent. Screening begins when the investigator 
obtains information about or from a prospective participant in order to determine their 
eligibility.  In some studies, these procedures may not take place unless HIPAA Authorization 
is obtained OR a waiver of HIPAA Authorization when applicable for the screening procedures 
is approved by the IRB.  [For FDA regulated studies, consent for any screening activities would 
need to be obtained prior to screening unless specifically waived by the IRB.]
No further eligibility questions will be asked in addition to verification of the inclusion and 
exclusion criteria. The study team will screen the EHR to confirm inclusion and exclusion criteria 
prior to consent. 
5.0
Consent Process and Documentation 
5.1
Consent Process:
Check all applicable boxes below:
Informed consent will be sought and documented with a written consent form [Complete Sections 
5.2 and 5.6] 
Implied or verbal consent will be obtained – subjects will not sign a consent form (waiver of 
written documentation of consent) [Complete Sections 5.2, 5.3 and 5.6] 
  Informed consent will be sought but some of the elements of informed consent will be omitted or 
altered (e.g., deception). [Complete section 5.2, 5.4 and 5.6]
Informed consent will not be obtained – request to completely waive the informed consent 
requirement. [Complete Section 5.5]
5.2
Obtaining Informed Consent 
5.2.1 Timing and Location of Consent 
Patients will all be consented in face to face interviews inside the Penn State Milton S. Hershey 
Medical Center.  This can take place in the ER, inpatient, and possibly clinics of investigators 
listed on the study.
5.2.2 Coercion or Undue Influence during Consent 
To minimize the opportunity for coercion a non-conflicted study coordinator or co-
investigator will conduct the consent process, when available.  Because of potential 
conflicts, Dr. Elfar will only participate in the explanation of the protocol, risks and benefits, 
answering potential subject’s questions about the study, and reviewing if the potential 
subject meets criteria for the study.  The subject will be told about the study and given 
ample time to ask questions and review the consent form before deciding about 
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participation.   It will be reviewed that deciding not to participate in the research will not 
affect treatment.
5.3
Waiver of Written Documentation of Consent 
5.3.1 Indicate which of the following conditions applies to this research:
  The research presents no more that minimal risk of harm to subjects and involves no 
procedures for which written consent is normally required outside of the research context.
OR
  The only record linking the subject and the research would be the consent document and the 
principal risk would be potential harm resulting from a breach of confidentiality. Each subject 
will be asked whether the subject wants documentation linking the subject with the research, 
and the subject’s wishes will govern. (Note: This condition is not applicable for FDA-regulated 
research. If this category is chosen, include copies of a consent form and /or parental 
permission form for participants who want written documentation linking them to the 
research.)
OR
  If the subjects or legally authorized representatives are members of a distinct cultural group 
or community in which signing forms is not the norm, that the research presents no more 
than minimal risk of harm to subjects and provided there is an appropriate alternative 
mechanism for documenting that informed consent was obtained.  (Note: This condition is not 
applicable for FDA-regulated research.)
Describe the alternative mechanism for documenting that informed consent was obtained:
NA
5.3.2 Indicate what materials, if any, will be used to inform potential subjects about the research 
(e.g., a letter accompanying a questionnaire, verbal script, implied consent form, or summary 
explanation of the research)
 NA
5.4
Informed consent will be sought but some of the elements of informed consent will be omitted or 
altered (e.g., deception).
5.4.1 Indicate the elements of informed consent to be omitted or altered
NA
5.4.2 Indicate why the research could not practicably be carried out without the omission or 
alteration of consent elements
NA
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5.4.3 Describe why the research involves no more than minimal risk to subjects.
NA
5.4.4 Describe why the alteration/omission will not adversely affect the rights and welfare of 
subjects.
NA
5.4.5 If the research involves using identifiable private information or identifiable biospecimens, 
describe why the research could not be practicably be carried out without using such 
information or biospecimens in an identifiable format.
NA
5.4.6 Debriefing
NA
5.5
Informed consent will not be obtained – request to completely waive the informed consent 
requirement
5.5.1 Indicate why the research could not practicably be carried out without the waiver of consent
NA
5.5.2 Describe why the research involves no more than minimal risk to subjects.
NA
5.5.3 Describe why the alteration/omission will not adversely affect the rights and welfare of 
subjects.
NA
5.5.4 If the research involves using identifiable private information or identifiable biospecimens, 
describe why the research could not be practicably be carried out without using such 
information or biospecimens in an identifiable format.
NA
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5.5.5 Additional pertinent information after participation
NA
5.6
Consent – Other Considerations 
5.6.1 Non-English-Speaking Subjects
Not applicable.
5.6.2 Cognitively Impaired Adults
5.6.2.1 Capability of Providing Consent
The PI will determine if there is a possibility of incapability to provide consent.
5.6.2.2
Adults Unable to Consent
Not applicable.
5.6.2.3 Assent of Adults Unable to Consent
Not applicable.
5.6.3 Subjects who are not yet adults (infants, children, teenagers) 
5.6.3.1 Parental Permission
Not applicable.
5.6.3.2 Assent of subjects who are not yet adults
Not applicable.
6.0
HIPAA Research Authorization and/or Waiver or Alteration of Authorization
6.1
Authorization and/or Waiver or Alteration of Authorization for the Uses and Disclosures of PHI
Check all that apply:
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
Information is included in the “Confidentiality, Privacy and Data Management” section of this protocol.
6.2.1.2
Plan to destroy identifiers or a justification for retaining identifiers 
Identifiers will be destroyed at the closure of the study by the PI.
6.2.2 Explanation for why the research could not practicably be conducted without access to and 
use of PHI
During treatment an investigator will review the inclusion and exclusion criteria with the 
potential subject to verify they meet criteria for enrollment. Information must be obtained from 
the patient’s electronic medical record during recruitment to determine eligibility and, in some 
cases, to confirm information discussed with the subject in regards to their medical history.
6.2.3 Explanation for why the research could not practicably be conducted without the waiver or 
alteration of authorization
PHI will need to be accessed to review the medical record to verify the subject meets criteria for 
enrollment.  This is necessary to protect the safety of the subjects
The waiver is requested only for recruitment to determine subject eligibility to ensure that no 
medical conditions that fall into the exclusion criteria are present and would thus preclude 
enrollment. This waiver will minimize the enrollment of subjects’ who may ultimately fail to 
meet the study inclusion/exclusion criteria.
6.3
Waiver or alteration of authorization statements of agreement
Protected health information obtained as part of this research will not be reused or disclosed to any 
other person or entity, except as required by law, for authorized oversight of the research study, or for 
other permitted uses and disclosures according to federal regulations. 
The research team will collect only information essential to the study and in accord with the ‘Minimum 
Necessary’ standard (information reasonably necessary to accomplish the objectives of the research) per 
federal regulations. 
Access to the information will be limited, to the greatest extent possible, within the research team. All 
disclosures or releases of identifiable information granted under this waiver will be accounted for and 
documented.
7.0
Study Design and Procedures
7.1
Study Design
This is a pilot, single-center study that will be conducted at the Penn State College of Medicine at Hershey.  It is a 
double-blind trial design.  Group A will receive the study drug on the main trial day, and Group B will receive 
placebo.  These groups will exist for both aims (both types of included patients). 
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Rationale for Study Design
Both subject and provider will be blinded to group assignment to avoid selection bias. 
The timing of the design comes from the treatment of trauma patients with nerve continuity which is 
ambiguous.  Currently no test for nerve continuity is available for 6 weeks post injury. This allows the proposed 
intervention to occur in a time when diagnostics are not available (within days of the injury).  
Animal models also reveal lasting positive effects beyond presence of 4-AP on myelin. Demyelination and 
myeloprotection after injury is poorly understood in any model.  We have seen changes in mice which evolve 
over weeks to months with treatment.  This has provided support for continuing treatment for our chosen 
timeline.  
Rationale for Dosage
Both the 4-AP and the placebo treatments will be administered orally. In order to conduct the trial according to 
the strictest safety concerns, the 4-AP dosage will be a one-time dose of 10mg/day which reflects current FDA 
recommendations for 4-AP (in the form of AMPYRA®) taken by individuals with multiple sclerosis.  This dose has 
also been found to be effective in previous trials on chronic spinal cord injury but is below dosages that have 
caused increased dropout rates due to side effects38.  Our initial trial approval is sought for the single dose of 
10mg which is well within the range of approved dosages for 4AP.   
In order to maintain serum levels in a safe range in this proposal the dosage in any individual capsule has been 
set to the starting dose used in the more fragile (and therefore susceptible to side effects) group of patients 
currently treated with MS.  The dose is therefore set to a single dose of 10mg and the dosage is trialed based on 
our initial work at a one-time dose of 10mg (one pill). The tablet will be taken whole, without food, in the 
Clinical Research Center.  
7.2
Study Procedures
This is a pilot, single-center, inpatient Clinical Research Center study that will be conducted at Penn State 
Hershey.  Subjects will be randomized to treatment or placebo for each aim.  Both the subject and investigator 
will be blinded to group assignment for the duration of the trial.  
Study Participant Source:  Study participants will come from two sources. The first will be traumatized patients 
presenting with nerve dysfunction.  These study participants are referred to as study participants for aim 1 of 
this trial. These patients often have concomitant orthopaedic injuries, which require stabilization. If the nerve 
was dysfunctional before intervention, then the patient will be included as a recruit for aim 1. The second source 
is patients who suffer nerve dysfunction after a surgery or intervention where nerve injury may not have been 
expected, as is the case with routine fracture fixation or joint arthroplasty procedures.  In such cases, post-
intervention examination may reveal a loss of nerve function where the continuity of the nerve again cannot be 
established. These patients, owing to their intact nerve function before the intervention, will be included as 
recruits to aim 2. In point of fact, both groups of patients have the same phenotypic condition, namely the loss 
of nerve function where the continuity of the nerve is not demonstrable. However, they are grouped into 
differing aims because the latter group suffers nerve dysfunction as the result of an intervention or surgical 
procedure and critically, these patients will have a clear pre-intervention examination without any nerve 
dysfunction.
Study participant screening procedures include the interview and chart review of patients to ensure that they 
match the inclusion and exclusion criteria listed in section 3.1 and 3.2.  This will be performed on first interview 
with the patient on presentation for both Aim 1 and Aim 2 in the hospital (either inpatient ward or emergency 
department).  
Potential study participants will be pre-screened for eligibility by reviewing the EMR to confirm inclusion and 
exclusion criteria. Study participants meeting pre-screening criteria will be presented with the study 
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opportunity. After obtaining informed consent, patients will be provided a research diary and instructed on its 
use.
Research study participant randomization for this trial is segregated by aim. Aim 1 research study participants 
are randomized to treatment or placebo separately from aim 2 research study participants. Each study 
participant for each aim is randomly assigned to either treatment or placebo using permuted block 
randomization.  
       
Testing
Blood Tests for the circulating level of 4AP will be performed using standard high-performance liquid 
chromatography. This testing is performed after optimizing conditions with serum samples spiked with either 
isotope labeled 4AP (Penn State Mass Spec method) or 3,4-diaminopyridine (URMC Mass Spec Method) 24. 
These samples will be tested after the optimization process (to begin prior to funding this proposal). Samples 
will be tested at the Penn State Mass Spectroscopy Laboratories at the Milton S. Hershey Medical Center, which 
is a laboratory currently involved with several on site clinical trials. The test, which is not CLIA certified, will 
nonetheless allow us to verify our test results in two different methodologies so that future CLIA applications 
will benefit from work done in this proposal. Samples will be verified at the Penn State College of Medicine Mass 
Spectroscopy Resource Center, where we have optimized parameters for this specific test in both human and 
murine serum samples. The effective range of concentrations which we have measured is 5nM to 50mM which 
spans an order of magnitude below (ineffective) and above (toxic) doses of 4AP in the literature. Each sample 
will be 5 ml (1 tsp).
Sensory functional testing: The most complete set of clinical examination tests must be employed to achieve 
our aims at understanding the mechanism of 4AP mediated return of function (or lack thereof). Each nerve in 
the body contains an expected sensory nerve dermatomal distribution on the skin 25. Sensory testing of this 
distribution is performed to test every type of fiber in the sensory portion of the nerve including:  Semmes-
Weinstein monofilament responses 26,27,39; static and moving two-point discrimination 5,28; light-touch sensation 
(a commonly used subjective assessment used in trauma patients5); and subjective reports of sensation both 
inside and outside the dermatome. These reports will be scored to reflect 2:1 weight of objective (e.g., 
monofilament) over subjective (e.g. reported sensation, light touch sensation), according to the same protocols 
used previously 26-30. In the hand, individual sides of each finger (e.g., for ulnar, median, and radial nerve 
distributions) will be tested as in our previous work 26,28-30. Patients will also be objectively graded on the 
withdrawal from a pin-prick using a sterile needle 27-guage needle in the nerve distribution which is absent (8 
pricks per patient). Patients will also have any relevant (well established) deep-tendon reflexes measured, 
although these are not available for every possible affected nerve, in contrast with the rest of the tests we 
employ.
Motor functional testing: As with sensory testing (above), a complete motor assessment which includes all the 
voluntary motor function tests used in the routine assessment of these patients must be here applied to our trial 
patients within the 1 hour testing periods in between serum tests. Each potentially traumatized nerve whose 
continuity is in question has expected muscles which will not function. Each muscle under the control of the 
nerve in question will be tested using standard muscle strength testing paradigms 5,7. Muscle strength is 
assessed by the rater using standard strength testing scales used elsewhere in the literature (1=no firing, 2=firing 
but no antigravity strength, 3=antigravity strength only, 4=more strength than gravity but less than the rater, 
5=equal to rater strength testing).These tests focus on strength, which may be too high a bar for a nerve whose 
continuity is in question. Therefore we will also have two independent observers observe six trials at voluntary 
movement in two muscle groups innervated by the nerve in question and score the observations using standard 
inter-rater statistics 31-33.
Sudomotor functional testing: We will attempt to obtain electrical conductance measurements 34-36 in skin areas 
known to be innervated by the injured nerve at all time points during muscle testing. This is done by measuring 
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the resistance using a standard volt meter (no current involved) across skin scores from this test will be 
compared (as controls) against the same measurements in non-denervated and from clothing and or hair (non-
innervated). These are not primarily used in TPNI patients and, when used are chiefly performed on the hands 
and feet of patients. Several test methods have been used, including industrial rigs with the capability to 
measure secreted biomarkers from skin patches 37. This notwithstanding, the applicability of these tests to a 
nerve injury where the dermatome affected is not enriched with sweat glands (like the hands and feet), is not 
established.
EDX testing: Patients enrolled in the trial will undergo serial EDX testing by a trained member of the study team 
to specifically assess the continuity of the injured limb nerves. For patients with known single-nerve lesions 
below the plexus trunk level, the testing will include nerve conduction studies (NCS) and electromyography 
(EMG).  The NCS will include one sensory and one motor nerve (if indicated) with needle exam of two muscles 
supplied by the motor nerve. EMG will show motor units which will allow for assessment of their size and 
recruitment, and the presence or absence of active denervation (fibrillation potentials and positive sharp waves) 
depending on the timeline.  It should be noted that our early testing phase is within four days of injury and that 
these findings of chronic denervation should only be present at 6 and 12 week testing. The NCS will be assessed 
for latencies, amplitudes, and conduction velocities values. Of particular note is the natural difficulties with the 
use of EDX in this setting.  The presence of non-recordable or absent responses on NCS can be interpreted as 
abnormal or inconclusive depending on multiple factors including technical limitations.  The presence of active 
denervation and motor unit size and recruitment abnormalities are time-dependent.  These do not usually 
manifest prior to 10-14 days.  As such, we expect most of these studies to be inconclusive on the trial day.  If, 
the nerve is believed to be continuous by this test, then the result will be saved and sealed for analysis post-hoc. 
This test will be performed at baseline before challenge with 4AP or placebo and then hourly for five hours after 
challenge. There will therefore be a total of six tests performed over the course of the testing day (Figure 1, blue 
arrows with the 5th post-test being done in conjunction with the Return to Baseline test). Clear indications of 
continuity will be shared with the main study coordinator at the end of the day and the patient will be informed 
of the result of the EDX test at the conclusion of the day (but not which group their allocation). 
7.2.1
Visit 1 in Clinical Research Center (CRC) and/or Inpatient setting~8 hours
 Trial Logistics and Organizing framework:  Patients for this trial are divided into two aims.  Patients enrolled for one 
aim, are excluded from the other aim, because the causes of the injury, which define the aim, are exclusive.  Aim 1 is 
for post traumatic neuropathy.  Aim 2 is for post surgical or post intervention neuropathy.  Within each aim, there 
are treated patients and placebo patients.  Only one patient will be evaluated at a time.  Evaluation takes one day.  
Patients will be randomized in the Penn State University Clinical Research Center (CRC) or at the bedside, where 
they will stay for a period of analysis afterwards that lasts a few hours.  
Eligible, consented patients will present for testing from one of three locations (emergency department, inpatient 
ward, or home).  Patients will undergo testing in the CRC and/or bedside under the direction of trial personnel. 
Testing will be initiated by patients undergoing a thorough sensory and motor evaluation and establishing an 
intravenous line for blood sampling.  A baseline blood sample and EDX study (prior to drug or placebo) and 
sensorimotor examination will be performed. These tests comprise part of a standardized array of tests performed 
hourly. This array of tests (serum 4AP level, EDX study, and sensorimotor examination) will be repeated every hour 
after treatment for five hours (Figure 1) during which the drug will have decreased to a level low enough to have no 
expected effect. The final hourly test is the return to baseline test.  It is likely going to occur at the fifth hourly 
posttest, but is depicted separately for clarity.  Only five tests after dosing will be necessary, based on our 
expectations from known pharmacokinetic data. 
Finally, testing is concluded at the end of this period. Research subjects will be provided a diary and asked to record 
symptoms as instructed.  The subjects will be asked to maintain the diary for 20 weeks and the diaries will be 
reviewed at each follow up visit and collected at or after the final 20 week visit.
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Figure 1 Legend: Planned admission to Penn State Clinical Research Center for testing and monitoring in proposed 
trial design. Each patient will complete testing in one arm (either 4-AP or placebo) before discharge. Note, standard 
measures of nerve continuity like EDX are not usually obtained at this period of time because they typically yield no 
usable information. They are performed during this portion of a trial as a control on our results. Note that the return 
to baseline test timing is not currently known.  As such, this test may not be necessary.  We are currently planning 
on having the final hourly test be the return to baseline test.  It is depicted as a separate test to note that we will 
ensure that the patient has returned to baseline before discharged from the CRC.  Based on pharmacokinetic data, 
we expect that this will occur between the fourth and fifth hourly posttest. 
7.2.2
Follow up visits                              
Following the initial testing, subjects will be seen for a period of 20 weeks after injury to monitor recovery and 
progress. Subjects will return for follow-up visits at 2, 6, 12, 18, and 20 weeks post injury. The 2 week visit will 
coincide with the initial post-operative visit with the treating provider as part of standard of care. The 6, 12, and 18 
week visits will be completed in the neurology clinic and EDX testing will be completed as part of standard of care 
(the current gold standard for continuity and recovery diagnosis). The 20 week visit will be completed in the CRC. 
Subjects will receive a physical exam at all follow-up visit. EDX testing will be completed at 6, 12, and 18 week visits 
only. Subjects will complete a telephone interview at 9 and 15 weeks post injury at which time subjective motor and 
sensory function will be assessed by asking 1) Can you move your (affected extremity)?  Yes or No 2) Can you feel 
your (affected extremity)? Yes or No. Review of the subject diary will also be completed.  The 9, 15, and 20 week 
visits are not part of standard of care and are being done for research purposes only. Each visit or phone interview 
will last approximately 30 minutes. Subjects will be instructed to bring the research diary to their follow-up 
appointments and will be reviewed and evaluated by study personnel. At the final 20 week visit the diary will be 
collected. Additional follow up might be considered beyond standard of care for diary completion if required.
Testing Day 1:
Consent verification
Line placement
baseline testing
*Test Panel (for each time point):
1. Serum for 4AP level
2. EDX study
3. Sensory-motor examination
Baseline tests
Group 2 (placebo)
Group 1 (4AP)
Post tests (hourly)
8:00 AM
Return to Baseline test
4:00 PM – Discharge Home
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Figure 2 Legend: General timeline of trial for single patient. Note that enrolled patients are allowed to proceed with 
standard of care exploration of injured nerves at their own discretion (with consultation of their surgeons) all 
throughout this 20-week period. If the continuity or lack thereof is verified, they continue with assessments as 
planned.  In the figure, week 1 starts after testing day (which is visit 1 in the CRC.  The first follow up visit is after 
testing day.  
7.3
Duration of Participation
Enrolled Subjects will be followed for a 20 week period.
7.4
Test Article(s) (Study Drug(s) and/or Study Device(s))
7.4.1 Description
Generic dalfampridine (4-aminopyridine extended release formulation): 4-AP is an organic compound with the chemical 
formula C5H4N–NH2. The molecule is one of the three isomeric amines of pyridine. It is primarily used to manage some of 
the symptoms of multiple sclerosis,[3][4] and is indicated for symptomatic improvement of walking in adults with several 
variations of the disease.[4]  4-AP works as a potassium channel blocker. Electrophysiological studies of demyelinated axons 
show that augmented potassium currents increase extracellular potassium ion concentration which decreases action 
potential duration and amplitude which may cause conduction failure. Potassium channel blockade reverses this effect. A 
study has shown that 4-AP is a potent calcium channel activator and can improve synaptic and neuromuscular function by 
directly acting on the calcium channel beta subunit.[3]
Subjects will receive one dose of oral dalfampridine 10 mg extended release tablets or an identical appearing placebo 
pill(see drug insert packet for formulation and testing information). The tablets will be over-encapsulated using Coni-
Snap Empty Gelatin Capsules manufactured by Capsugel. USP grade methylcellulose will be used as filler for the active 
capsules and as the placebo. Placebo capsules will consist of the Con-Snap Empty Gelatin Capsule manufactured by 
Capsugel and the methylcellulose filler. Both pills will be formulated and tested in conformity with the FDA mandated 
guidelines for this trial.   
7.4.2 Treatment Regimen
Investigational Treatment – Group A and group B will both receive the same treatment with active ingredient listed 
below.  Group A will receive the active drug and Group B will receive the placebo.  This is a single-dose study.
Active Ingredient: 4-aminopyridine (4-AP) 10 mg pill per dose
Inactive Ingredient: See package insert
Dosing schedule = 1 capsule.  
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Other Agent(s): Placebo 
7.4.3 Method for Assigning Subject to Treatment Groups
Subjects in both aims will be assigned to Group A or Group B using a randomization scheme. Each study participant for 
each aim is randomly assigned to either treatment or placebo using permuted block randomization.  
This randomization will be done using redcap. This is a single-dose, pilot study.
7.4.4 Subject Compliance Monitoring
Not applicable.  Study medication will be administered under observation.
7.4.5 Blinding of the Test Article
Blinding will be performed by the IDS service at Penn State.  
7.4.6
Receiving, Storage, Dispensing and Return 
7.4.6.1
Receipt of Test Article 
The study drug and placebo will be maintained by Penn State Investigational Drug Service (IDS).  They will store, dispense 
and monitor all investigational supplies.
7.4.6.2
Storage
The study drug and placebo will be maintained by Penn State Investigational Drug Service (IDS).  They will store, dispense 
and monitor all investigational supplies.  IDS will prepare and dispense study drug and placebo after randomization upon 
receipt of a valid prescription from the study director, which will be transported to IDS after consent.  
7.4.6.3
Preparation and Dispensing
Dalfampridine (extended release 4-aminopyridine) 10mg tablets will be obtained from Accord Pharmaceuticals by the 
Investigational Drug Service (IDS) Pharmacy at Penn State Health Milton S. Hershey Medical Center. IDS will then 
prepare blinded capsules of over-encapsulated Dalfampridine tablets and matching placebo.
7.4.6.4
Return or Destruction of the Test Article
One 10 mg study capsule will be taken by mouth, whole in the setting of the Clinical Research Center or at the bedside. 
In case there is unused product if a subject chooses to withdraw after the med is dispensed, the CRC or research 
coordinator will return the unused product to the IDS.
Investigational product that remains at end of study will be destroyed by IDS according to Institutional policy.
7.4.6.5
Prior and Concomitant Therapy
The study drug may not be taken together with other aminopyridine medications, including other compounded 4-AP 
(sometimes called 4-aminopyridine or dalfampridine).
8.0
Subject Numbers and Statistical Plan
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8.1
Number of Subjects
This is a pilot study. The purpose is to gain preliminary data and refine infrastructure and establish finalized 
routines associated with our work. We hope to recruit 50 patients to this pilot study based on our previous 
statistical analysis.  
8.2
Sample size determination
We cannot provide sample size based on the pilot nature of this study. Our purpose is to generate preliminary 
data that can further inform our biostatisticians.  We also have found that defining our protocol procedures in 
the CRC will help us define statistical groups for regulatory approval of the crossover trial currently planned.  
8.3
Statistical methods
Consultation with the biostatistical team included separate discussions with Dr. Vernon Chinchilli and Dr. 
Shaohow Zhou. This trial is a pilot study in preparation for an NIH funded randomized controlled trial which is 
currently in preparation. 
Our methods will be to stratify nerve injuries based on injury severity and compare placebo to drug patients 
using the methods listed below:
This proposal contains two distinct aims to be investigated in two similar groups of patients.
Aim 1: To examine the effect of 4AP on the return of sensorimotor function and EDX sensitivity in the setting of 
nerve dysfunction from orthopaedic trauma. This aim tests the hypothesis that oral one-time administration of 
4AP provides transient return of function and EDX sensitivity to the traumatically denervated limb in alert 
patients with known limb injuries not involving the central nervous system.
Aim 2: To examine the effect of 4AP on the return of sensorimotor function and EDX sensitivity in the setting of 
iatrogenic nerve injury after surgical intervention. This aim tests the identical hypothesis as in Aim 1 in a distinct 
group of patients, whose nerve dysfunction is the result of a clinical intervention, and whose function before 
that intervention was intact.
Statistical planning was performed in the design of this trial with a qualified biostatistician, who also sits on the 
Data Safety Monitoring Board for this study.  Statistical methods will be used to evaluate both the effect of 
treatment as well the effects of injury type (either aim 1 or aim 2).  Groups will be analyzed separately within 
each aim.  
Categorical variables (as in the presence or absence of sensation) will be compared (between treated and 
untreated groups for each aim) using Chi-squared testing.  Continuous data (as in nerve conduction velocity 
from EDX) will be compared with standard student’s T testing.  Grouped data variables will be first compared in 
linear models (accounting for mixed effects of multiple variables as indicated).  Formal recommendations for the 
statistical methods to be used for posthoc comparisons will be made by the biostatistician designee of the DSMB 
(Dr. Vernon Chinchilli), who has aided in the planning of this trial and is a non-conflicted member of the trial 
team.  
  
Information provided by the biostatistician collaborator:  
Data analysis for both of these aims is identical, and involves a generalized linear mixed-effects model with a 
logit link function (118). The separation of these aims is based on the source of the injury, the likelihood of a 
severed nerve (less likely in aim 2), and the patient’s need for an answer to the question. In aim 1, patients may 
suffer additional harm to a nerve for necessary care but fundamentally, aim 1 contains patients for whom the 
question of nerve continuity is not the result of a surgical intervention.
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Patients will undergo clinical testing for both subjective (return of feeling, motor control) and objective 
(withdrawal from painful stimuli, deep-tendon reflexes, sudomotor function, muscle firing) measures of function 
before and after administration of 4AP and placebo (all patients will receive both treatments in random order). 
Standard monitoring will include clinical observation for voluntary movement, electrodiagnostic testing, and 
serum tests to correlate circulating 4AP concentrations to diagnostic thresholds and compare those thresholds 
to those used for therapeutic efficacy in the current approved patient populations. The diagnostic information, 
in conjunction with formalized inclusion and exclusion criteria, will not affect the current standard treatment 
paradigm, but will inform our decisions on suspected nerve continuity and surgical exploration.
Patients with intact function prior to operative procedures often suffer trauma to a nerve iatrogenically as a 
result of a procedure. In these patients, the trauma is often our surgery to correct a fracture or other deformity. 
We will investigate the possibility of administration of oral 4AP in patients with nerve dysfunction after surgical 
intervention in the limb. Despite the belief that the nerve is not severed, dysfunction in these patients is 
indistinguishable from cases where the nerve is later discovered to be iatrogenically severed as part of the 
procedure. Their testing will be performed identically as in the case of aim 1, with the exception that these 
patients will have documented presurgical examination of the limb showing function to be intact prior to the 
index procedure. 
9.0
Data and Safety Monitoring Plan
9.1
Periodic evaluation of data
The study Medical Monitor will be named by the DSMB.  Dr. Kenneth Taylor and Dr. John Elfar, MD, Professor in 
the Department of Orthopaedics and Rehabilitation, will be responsible for reporting to the study monitor.  A 
separate study monitor from neurology will be assigned to monitor functional outcomes.  This neurologist will be 
familiar with the study parameters and intervention proposed and will assess EDX outcomes.   
For the entire study trial day in the CRC, subjects will be continuously monitored (see trial logistics section above). 
 Thereafter, serial follow-up with phone call backup will be instituted per the protocol depicted in Figure 2 (above). 
 Alternative contacts will be instituted and maintained to allow direct interaction between the study coordinator, 
principal investigator and patients so that all interactions (in person, by phone or by email) are possible should 
the need arise.  Patients will also keep a diary (distributed at the time of consent) to monitor any symptoms, signs, 
illnesses or experiences which develop or worsen, whether or not the event is considered related to the study 
drug.  After the first two weeks and for the following 18 weeks, each subject will be queried about any potential 
AEs at the time of standard visits with the neurologist and study principal investigator.  
All subject reports of events that develop or worsen will be reported as Adverse Events and sent to the Safety 
Monitor (same as the medical monitor), the PI and the neurologist to ensure on-going subject safety. Any adverse 
medical experience that meets the definition of an SAE will be monitored and reported in the same way.  The 
Adverse Event Tracking Form will be used to document safety monitoring and reporting.
Estimated glomerular filtration rate (GFR) is assessed in trauma patients and will be known before initiating 
treatment with 4-AP.  The relationship between 4AP dosage and estimated GFR levels is based on the 
importance of renal function in removing 4AP from the system.  In patients with mild renal impairment 
(estimated GFR 51–80 mL/min), 4-AP plasma levels may approach those seen at a dose of 15 mg twice daily, a 
dose that may be associated with an increased risk of seizures. As mild renal impairment is common after age 
50, estimating GFR is particularly important in such patients. Patients with renal impairment (estimated GFR≤80 
mL/min) will be excluded from the study based on the fact that this level of impairment is contraindicated
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9.2
Data that are reviewed
All clinical outcomes data will be reviewed. 
9.3
Method of collection of safety information
Patients will also keep a diary to monitor any symptoms, signs, illnesses or experiences which develop or worsen, 
whether or not the event is considered related to the study drug.  After the first two weeks and for the following 
18 weeks, each subject will be queried about any potential AEs at the time of standard visits with the neurologist 
and study principal investigator.  
9.4
Frequency of data collection
Data will be collected at each study visit as outlined in Sections 7.2.1 and 7.2.2 of the protocol.
9.5
Individuals reviewing the data
The Data Safety Monitoring Board will be reviewing the data a minimum of twice per year unless there is an 
adverse event reported and then a meeting will be convened to review the adverse event unless a meeting has 
already been scheduled within a week. 
9.6
Frequency of review of cumulative data
Twice per year. 
9.7
Statistical tests
Harm will be determined based on standard comparison of response to placebo with response to the drug.  Each 
test, provided data from that test is normally distributed, which the data from each of our clinical and 
diagnostics are, is tabulated and compared with the same response when no active drug is in the system.  Since 
all variables in our outcomes are continuous, the appropriate tests are standard t-tests.  Theoretically, ordinal 
tests will be assayed with the chi-squared method.
9.8
Suspension of research
An adverse event where the patient has an unexpected reaction to the drug will suspend this study.  An example 
of such an event would be a seizure or a drastic increase in pain in the limb after administration of a single dose 
of the active drug.  One other way to stop the trial is by an objection by a member of the data safety monitoring 
board, which exists to monitor all adverse events in this trial.  
10.0  Risks
Loss of confidentiality:
One potential risk is the possible consequences of breach of confidentiality.
Venipuncture:
There is a venipuncture risk drawing blood of a slight pinch or pin prick when the sterile needle enters the skin. The risks 
include mild discomfort and/or bruising at the site of the puncture. Less common risks include a small blood clot, infection 
or bleeding at the puncture site, and on rare occasions fainting during the procedure.
4-AP study drug:
In addition, serious risks associated with allergic reaction to the study medicine including shortness of breath or trouble 
breathing, swelling of the throat or tongue or hives are possible.  There is also a serious risk of kidney or bladder infection 
and seizure.  
 
The following information will be included in the consent form to make sure that the subjects understand the risks:

The research participant could have a seizure even if they never had a seizure before.
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
The chance of having a seizure is higher if too much study medication is taken or if the participant’s kidneys have 
a mild decrease of function, which is common after age 50.

The participant’s kidneys will be checked before start of study medication to determine how well they are 
working. 

Before taking study medication, the participant should tell the doctor if they have kidney problems. 
The study medication can also cause dizziness, confusion and balance problems.  Therefore, prior to leaving the CRC, 
patients planning on driving or operating machinery, should be familiar with how the study medication affects them.
Risks of EDX tests: The EDX tests that will be performed are low-risk procedures, and complications are rare. There's a 
small risk of pain (although rarely encountered), bleeding, infection and nerve injury where a needle electrode is 
inserted. 
The member of the study team trained to conduct the EMG will need to know if the participant has certain medical 
conditions. The participant must tell the study team member and other EMG lab personnel if the subject:

Has a pacemaker or any other electrical medical device

Takes blood-thinning medications

Has hemophilia, a blood-clotting disorder that causes prolonged bleeding
Risks of Randomization: The primary risk of randomization is that the treatment the subjects receive may prove to be 
less effective or to have more side effects than the other study treatment(s) or other available treatments.  A secondary 
risk of randomization is that the randomization process is somehow in error, and the patient is assigned to the wrong 
group.  This would result in a patient exposed to treatment and labelled as having been exposed to placebo.  The only 
negative effect of this error would be to mask the truly beneficial effects of the treatment.  The same masking would 
occur if a patient assigned to treatment, being given instead placebo.  This would have the same masking effect.  Neither 
effect exposes patients in this trial to harm.  
 
Protection Against Risks
Breaches of confidentiality will be reduced by storing the data on secure share drives within Penn States Trial Data Center 
(part of the Department of Public Health Sciences).  Access will be restricted to the investigators, the study coordinator, 
and any agency legally empowered to demand access to the data and only encrypted, password-protected computers will 
be used.
 
Potential risks and discomforts from taking the study medication will be minimized to the greatest extent possible by 
closely monitoring subjects for the most common side effects including allergic reactions and the less common side effect 
of seizure while in the CRC and after discharge (see above).  Study subjects will be asked by study personnel after the CRC 
day about any potential symptoms and any evidence of difficulty or adverse event will be evaluated.
 
Estimated glomerular filtration rate (GFR) is assessed prior to inclusion in this study and in trauma patients as standard of 
care and will be known before initiating the trial with 4-AP.  In patients with mild renal impairment (estimated GFR 51-80 
mL/min), 4-AP plasma levels may approach those seen at a dose of 15 mg twice daily, a dose that may be associated with 
an increased risk of seizures. As mild renal impairment is common after age 50, estimating GFR is particularly important 
in these subjects. Patients with renal impairment (estimated GFR≤80 mL/min) will be excluded from the study based on 
the fact that this level of impairment is contraindicated in the use of 4-AP.
4-AP has never been shown to definitively exacerbate renal function in humans and studies in animals only reveal 
alterations at doses several-fold higher than are used in our proposed study.  The relationship between 4AP dosage and 
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estimated GFR levels is based on the importance of renal function in removing 4AP from the system.  Therefore, the risk 
of 4-AP use in this patient population is directly linked to the risk of changes in estimated GFR.  To be on the safe side of 
renal clearance issues, however, we have taken two specific steps with regards to issues with 4-AP in renal toxicity.  
First, we have excluded patients with estimated GFR <= 80 mL/min based on the fact that this level of impairment is 
contraindicated in the use of the study drug.  This criteria means that we even have excluded patients whose estimated 
GFR levels actually met criteria for inclusion in earlier 4-AP trials.  Second, we are using lower doses of 4-AP in this study 
than were used in initial studies for 4-AP for a variety of neurological maladies to further ensure we do not run into 
toxicity issues.  The specific dose we have selected is the starting dose used in multiple sclerosis patients prior to dose 
escalation.
Randomization errors are protected against in this trial by double checking the randomization protocol in IDS and use of 
redcap.  Further checking and oversight is planned at the DSMB level prior to initiating the trial and after the 80% mark 
is achieved.  
11.0
Potential Benefits to Subjects and Others 
11.1
Potential Benefits to Subjects
A known risk in nerve injury is a delay in recovery of function attributable to inability to correctly diagnose a nerve 
laceration without EDX, which only becomes sensitive to the continuity of the nerve weeks after the injury.  It is 
well known that early surgical exploration and repair of lacerations of the nerve is best in patients with known 
nerve lacerations and detrimental for patients found at surgery to have an unsevered nerve.  As this trial offers 
no change in the overall standard of care for nerve patients other than a trial of a drug to see if it returns function 
or sensation (clear indications that the nerve is not severed), this trial does not alter the standard of care for these 
patients.  The benefits are a clear indication of the status of the nerve weeks before the gold standard test can 
reveal the same information – but this benefit is only realized in the drug group and only if return of function is 
demonstrated.  4-AP is a known neuro-enhancing agent we hypothesize will potentially return function transiently 
but long enough to reveal those patients whose nerves are intact but not working.  Furthermore, we predict this 
diagnostic intervention will also limit the difficulty and stigma associated with not knowing if their nerve has been 
cut, again a direct benefit only realized when continuity is demonstrated.  This trial only affects patient decisions 
to pursue further treatment if return of function is clearly demonstrated.  Otherwise, patients might have no 
return of function either because their nerve was indeed severed in the trauma or if they received placebo.  As 
such, no direct conclusions or alterations in patient care will be based on these results for trial patients.  Also, 
since there are additional research visits included at two week intervals in this trial, recovery will be followed with 
greater accuracy over time.
11.2
Potential Benefits to Others
Currently in the literature there is no consensus as to the right way to diagnose a nerve with ambiguous continuity. 
 There is agreement that patients must wait until EDX studies become sensitive, but even within the literature, 
the time for the first use of this test varies from three to eight weeks with most practitioners agreeing with a 
standard six week first EDX study.  The current evidence is not sufficient to support the routine use of surgical 
exploration or watch-and-wait strategies for these injuries.  Practitioners simply choose which option for a nerve 
injury based on their clinical guess as to the status of the nerve.  This strategy represents the alternative to 
participation.  
We, therefore, propose to allow the current standard of care to be the alternative to participation.  In this case, 
a patient would be treated as all patients with this injury and differs from trial patients only in the fact that trial 
patients may have more information about the state of their nerve with which to make a more informed 
treatment decision with their treating surgeon.
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12.0
Sharing Results with Subjects
The results of this study include both subjective and objective measures.   It is impossible to hide the subjective 
measures from the patients given the nature of our measurements.  We will prevent active discussion of 
objective measures until final follow up at 20 weeks.  Patients will be free to use their subjective assessments of 
the return of function in their standard-of-care treatment decisions.  We will not inform other physicians except 
at the express consent of patients to do so.  Subjective responses to treatment can be discussed, again at the 
patient’s request, with treating physicians before final follow up.  Objective test results will not be discussed 
with treating physicians until 20 weeks, again, only with patient consent to do so.  In cases where the patient’s 
decision to seek further surgical exploration of an injured peripheral nerve based on subjective return of 
function (or lack of return) seems ill-advised to members of the study team, a patient conference will be 
arranged in conjunction with the ethicist and DSMB.  Such cases where the patient intends to monitor a nerve 
where our subjective findings suggest clear evidence that the nerve requires surgical exploration, are expected 
to be rare.  Other such cases, where the patient intends to elect for surgical exploration of a nerve which is 
believed, based on the results of the study, to be in continuity, may be slightly more common.  In both of these 
cases, the patient’s decision in conjunction with the treating surgeon (who is purposefully excluded from the 
study team to avoid any conflicts) is held to be paramount.  Conferences of the type described above will be 
held in selected cases where the evidence from the trial is deemed to be clearly in conflict with the decision 
taken by the patient – only to ensure adequate education, again with prior consultation with the DSMB.  
Unblinding will be discussed at this time as well.  
13.0
Subject Payment and/or Travel Reimbursements
Subjects will be compensated $80 after completion of Visit 1. This is based on the standard hourly rate ($10 per 
hour).  Subjects completing visit 1 in the CRC will be provided with a $10 meal card.  This will be done through 
Greenphire ClinCard. 
14.0
Economic Burden to Subjects
14.1
Costs 
The subject will not incur any additional costs as a result of participation in this study.  The study drug 
and placebo will be provided to the subject at no charge. The subject or the subject’s insurance will be 
responsible for all standard of care costs associated with treatment for the nerve injury.  Testing 
completed in the CRC for visit 20 weeks will be covered by study funding and will not impact insurance 
coverage.  The EDX testing done on visit 1 and 6, 12, and 18 weeks post injury are considered standard 
of care and will be changed to the subject’s insurance accordingly.  
14.2
Compensation for research-related injury
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.
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15.0
Resources Available 
15.1
Facilities and locations
This research will be conducted at the Penn State Milton S. Hershey Medical Center.  Specifically, the 
trial day (when patients are given 4AP or placebo and monitored) is conducted in the Penn State 
Hershey Clinical Research Center (https://research.med.psu.edu/research-support/crc).  Patients will be 
followed in the Penn State Hershey Outpatient Clinics in both the Orthopaedic Surgery and Neurology 
Departments.  No patients will be treated, seen or recruited at any site outside of the Penn State 
Hershey Facility.  
15.2
Feasibility of recruiting the required number of subjects
We have undertaken several different forms of analysis aimed assessing the feasibility of this study.  
These efforts combine in-depth studies of patient selection, sources, availability and estimates of the 
likelihood of recruitment if a patient is found.  
Patient Selection: Patients eligible for this trial must exhibit the loss of nerve function from 
recent trauma or post-operative state (within 7 days of injury) where the state of nerve continuity is 
unknown. These patients do not currently qualify for objective EDX because of known limitations of 
that electrophysiologic testing. We will, as part of the trial perform these tests nonetheless to ensure 
that they are still not usable with and without 4AP treatment. Patients may have multiple nerves 
effected with at least one, defined and EDX testable nerve among them. Patients must have a functional 
loss that they themselves can appreciate at the time of enrollment because some of the employed tests 
are subjective. Patients must report the capacity to use and sense with that nerve before trauma, and 
must be willing to undergo a test which may expose only some functions and not others (see below). 
Moreover, patients must be willing to have a test of a return of function which, in all likelihood will be 
fleeting – lasting only so long as the circulating level of 4AP, allows the impulse conduction in the 
traumatized nerve before being cleared and excreted. 
Patient Source: Patients will come from two sources. The first will be traumatized patients presenting 
with nerve dysfunction. These patients often have concomitant orthopaedic injuries, which require 
stabilization. If the nerve was dysfunctional before intervention, then the patient will be included as a 
recruit for aim 1. The second source is patients who suffer nerve dysfunction after a surgery or 
intervention where nerve injury may not have been expected, as is the case with routine fracture 
fixation or joint arthroplasty procedures. In such cases, post-intervention examination may reveal a loss 
of nerve function where the continuity of the nerve again cannot be established. These patients, owing 
to their intact nerve function before the intervention, will be included as recruits to aim 2. In point of 
fact, both groups of patients have the same phenotypic condition, namely the loss of nerve function 
where the continuity of the nerve is not demonstrable. However, they are grouped into differing aims 
because the latter group suffers nerve dysfunction as the result of an intervention or surgical procedure 
and critically, these patients will have a clear pre-intervention examination without any nerve 
dysfunction. 
Splitting aims is necessary because of the differing means by which the patient is injured and the 
different circumstances of injury. Surgeons will often tell patients who would qualify for aim 2 that they 
are absolutely sure that the nerve is not severed, altering the pre-test/pre-trial likelihood that the 
patient may feel a return of function even if exposed to the placebo. We therefore intend to keep the 
recruitment and counselling of aim 2 patients separate from those who present after traumatic, non-
iatrogenic nerve injury.
Patient Selection and Availability Patient Availability and Cohort Query Analytics: Ambiguous nerve 
continuity is common in our medical center. Initial estimates, based on stakeholder provider interviews, 
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indicate that there are sufficient cohorts to conduct this trial in our single institution with matched 
cohorts divided into sub-categories based on the extent of nerve involvement. Annually, presenting 
patients (aim 1) with nerve deficits and those whose nerve continuity becomes obscure after 
intervention (aim 2) number at least 24 and 50 respectively. Our proposed recruitment estimates, 
corrected for exclusion criteria and inability to consent, indicate that diagnostic trials on 4AP can be 
completed in 24 months with full follow up for our gold standard electrodiagnostic endpoint (10 weeks). 
Thus, within two years, we can answer this highly relevant clinical question unambiguously in our single 
center. 
15.3
PI Time devoted to conducting the research
Dr. Taylor is allotted time to work on his research in agreement with his contract in the Department of 
Orthopaedics.
15.4
Availability of medical or psychological resources
Medical or psychological care will be referred to resources here at Penn State Hershey Medical Center.
15.5
Process for informing Study Team
As detailed in the team composition/budget justification, our team is composed of several different types of 
clinicians and scientists. This entire team will be housed at a single medical center (not at satellite facilities).  In 
addition to quarterly meetings, the entire team will attend a yearly retreat to discuss issues surrounding this 
trial.  
This communication time notwithstanding, the investigators will also communicate regularly, either by phone or 
in person, to discuss study progress, updates, and responsibilities. Communication will occur weekly during the 
first six months of the project to facilitate successful implementation of the project protocol. After six months, 
communication will be bi-weekly for the duration of the project period. Both investigators and the principal 
investigator will share their respective research results with key personnel. The study team will work together to 
discuss any changes in the direction of the research projects. 
16.0
Other Approvals
16.1
Other Approvals from External Entities
Not applicable
16.2
Internal PSU Committee Approvals
Check all that apply:
  Anatomic Pathology – Penn State Health only – Research involves the collection of tissues or use of 
pathologic specimens. Upload a copy of “HRP-902 - Human Tissue For Research Form” in CATS IRB. 
  Animal Care and Use – All campuses – Human research involves animals and humans or the use of 
human tissues in animals
  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).
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  Clinical Laboratories – Penn State Health 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” in CATS IRB. 
  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 – Penn State Health 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” in CATS IRB. 
  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 – Penn State Health 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 Health Cancer 
Institute (PSCI) Protocol Review Committee or the PSCI Disease Team 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.
17.0
Multi-Site Study
17.1
Other sites 
                             not applicable
17.2
Communication Plans
not applicable
17.3
Data Submission and Security Plan
not applicable
17.4
Subject Enrollment
not applicable
17.5
Reporting of Adverse Events and New Information
not applicable
17.6
Audit and Monitoring Plans
not applicable
18.0
Adverse Event Reporting
18.1
Adverse Event Definitions
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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.
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.
18.2
Recording of Adverse Events
Adverse events will be assessed at every visit after consent is obtained.
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
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•
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.
18.3
Causality and Severity Assessments
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.
Data collected and events reviewed by Dr. Elfar will also be reviewed by a non-conflicted investigator on 
the study.
18.4
Reporting of Adverse Reactions and Unanticipated Problems to the FDA  
18.4.1 Written IND/IDE Safety Reports
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.
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18.4.2 Telephoned IND Safety Reports – Fatal or Life-threatening Suspected Adverse Reactions
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.
18.5
Reporting Adverse Reactions and Unanticipated Problems to the Responsible IRB
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.
18.6
Unblinding Procedures
In the case of a medical emergency the un-blinded IDS can disclose the randomization group.  Contact 
information will be listed in the subject’s electronic medical record (EMR).  If such action is necessary, the 
Investigator and Safety Monitor will review the incident to determine if the subject should be withdrawn 
from the study. All emergency drug disclosures will also be reviewed at DSMC meetings to assure the 
continuing safety of research subjects.
18.7
Stopping Rules
Our safety analysis plan includes routine review (urgently within 48 hours) of every adverse event to the 
data safety monitoring board.  The board will render a decision on suspension of the trial based on the 
available data in an unbiased manner.  Examples of reasons for such a stoppage include adverse events 
that are not explainable, and patient dissatisfaction with the trial progression.  The rules for stopping are 
not confined to adverse events, as defined by the drug information insert.  The data safety monitoring 
board has the power to stop the trial for any reason surrounding safety, even if that includes 
investigating a particular patient’s response to the trial drug or evaluation of the circulating levels of the 
drug at the time of an adverse event.  Stopping rules include:  Seizure, increased pain not treatable in 
the clinical research center, clear demonstration of a positive result which alters the statistical numbers 
for the trial, clear indications of deviations from the protocol, inadequate reporting by the trial team, 
and incomplete documentation of results.  
19.0
Study Monitoring, Auditing and Inspecting
19.1
Study Monitoring Plan
19.1.1 Quality Assurance and Quality Control
This is a single site study with low risk.  4AP is an FDA approved drug used in a patient 
population known to be more susceptible to its side-effect profile than the currently proposed 
study population.  Nonetheless, we are implementing a full data and study monitoring 
apparatus to ensure study compliance within our single institution.  
Elements of this monitoring body are a fully functional and active Data Safety Monitoring Board 
including a bio-ethicist to review each consented patient as well as a standardized system for 
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the reporting of adverse events (see explanation of each of these features below).  Furthermore, 
we expect, invite and encourage institutional as well as outside monitoring of our trial execution 
through standardized means to ensure quality study execution.  
The PI will monitor the study and 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.   
The study will be monitored by the Clinical Trial Monitoring Team from the Department of 
Public Health Sciences at Penn State Hershey College of Medicine. The monitors will provide an 
independent review of the regulatory and subject records and the data collected to assure 
compliance with the protocol, GCP, and applicable federal regulations. The monitoring will occur 
at regular bimonthly intervals after the enrollment of the first subject and the times will be 
predetermined by the monitoring plan developed by the Clinical Trial Monitoring Team.
19.1.2 Safety Monitoring
A Data Safety Monitoring Board (DSMB) will be constructed of individuals with varying 
backgrounds to allow for a holistic approach to data monitoring.  One of the goals will be to 
completely and comprehensively capture any adverse events and process information to the 
FDA and regulatory bodies at Penn State in a straightforward manner.  
We intend to include an ethicist as a lay member of the DSMB as well as key members of the 
Clinical and Translational Science Institute (CTSI).  The CTSI places the highest priority on 
ensuring the safety of patients participating in clinical trials. The initial review of trial protocol 
lies with the CTSI Scientific Review Committee (SRC) to ensure that the trial, regardless of 
sponsorship or support, contains adequate plans for data and safety monitoring. The CTSI is 
therefore a natural component of our Data and Safety Monitoring Board (DSMB), which will be 
responsible for monitoring this investigator-initiated trial (IIT). 
The DSMB has the responsibility for continuing review and monitoring of the study. The DSMB’s 
review and oversight are written in to the IRB-approved protocol for such trials. The DSMB 
provides oversight of study progress and safety by review of the following information:
                                          •
Rates of accrual and retention.
•
Frequency and severity of adverse events (AEs) and serious adverse events (SAEs).
•
Response rates, where appropriate.
•
New information related to the trial, i.e., published scientific reports or other 
developments that may affect subject safety or ethical concerns.
•
Any changes to the anticipated risk/benefit ratio of the study that would affect its 
continuation.
•
Protocol deviations and violations (although this is the subject of independent audits by 
the IRB as well). 
•
Matters that pertain to serious errors or potential misconduct by any of the 
investigators or research staff, i.e., breaches in confidentiality, research fraud.
•
Subject complaints.
•
Conflicts of interest.
The DSMB will be empowered to recommend a halt of the study should there be deviations 
from established gender or race metrics of presenting patients in this “consecutive consent” 
design.  The timeline for review of trials by the DSMB is determined at the outset of the study 
with approval by the SRC. The frequency of DSMB review required for this protocol at six 
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months but will include an additional review after every ten patients recruited (whichever is 
most frequent).  These details are recorded by the clinical coordinator, who prepares the 
skeleton of the report of the DSMB, which then adds the interpretation and evaluation sections 
of the report and then submits that to the IRB and study PI at least once yearly (but likely twice, 
depending on recruitment). 
Roles in the reporting of adverse event(s) (AE(s)): 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 Data 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 ethicist will review every proposed consenting trial patient and report results monthly to 
the balance of the DSMB. Accrual will be monitored monthly by the DSMB based on this report. 
Data Management and Monitoring: Monthly monitoring by the co-investigator (from the 
Department of Public Health Sciences) will also be performed as per the mechanism offered by 
the Penn State Clinical Trial Data Management Center (housed within the same department). 
Trial outcome data will be held in a secure server within that department and an interim 
statistical analyses will be undertaken at the approximate midpoint for each specific aim (13 
patients) via the Obrien-Fleming group sequential method to monitor the trial data. Early 
achievement of the trial result will be identified by this mechanism and written reports of 
progress towards this achievement will be relayed to the DSMB by this co-investigator. Quality 
control of serum data will be ensured through dual laboratory certification of serum results. The 
same control of clinical data will be ensured through dual independent assessment of each test 
on the patient during testing periods, and interpretation of EDX results by a qualified specialized 
blinded participating clinician. Analysis for any given patient’s data will be contained to the 
timeline in Figure 2. 
20.0
Future Undetermined Research: Data and Specimen Banking
20.1
Data and/or specimens being stored
not applicable
20.2
Location of storage
not applicable
20.3
Duration of storage
not applicable
STUDY00012040
Approval: 4/21/2022

Page 34 of 35 (V.01/21/2019) 
20.4
Access to data and/or specimens
not applicable
20.5
Procedures to release data or specimens
not applicable
20.6
Process for returning results
not applicable
21.0
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22.0
Confidentiality, Privacy and Data Management 
               See the Research Data Plan Review Form
STUDY00012040
Approval: 4/21/2022