Conditions: Inflammation Cognitive Deterioration
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 36
Healthy volunteers: no

Brief summary:
The purpose of this study is to investigate how recombinant human lactoferrin (rhLF) which is a partially iron saturated form of lactoferrin produced and purified from rice grain may improve mobility and memory in older adults with chronic inflammation. Lactoferrin, is a known multifunctional protein, and has been shown to have anti-inflammatory effects. A recombinant human version of this protein was recently developed and produced from rice. This is now available from the Ventria Bioscience Company in a controlled, pharmaceutical grade capsule. As part of this double blinded and randomized study, participants will take daily dosages of recombinant human lactoferrin (rhLF) or its matched placebo; to measure the effects of rhlactoferrin on chronic inflammation and its association with improving mobility and memory over a 6 month time period. During the study all participants will be asked to provide blood samples and will have physical and cognitive tests administered to them. By measuring biomarkers in the blood as well as changes in physical and cognitive measures, the investigators will gain an understanding of how rhlactoferrin may safely improve measures of chronic inflammation in older adults. As well as a better understanding of whether it has the potential to meaningfully influence important measures of physical and cognitive function known to be influenced by Chronic Inflammation (CI).

Detailed description:
The primary objective of this study is to examine in a double blinded and randomized trial the efficacy of Recombinant Human lactoferrin (rhLF) in reducing chronic inflammation as measured by IL-6 and sTNFR1 in the bloodstream. The primary end point is to gather information about the tolerability of and adherence to oral rhlactoferrin (rhLF) among older adults with CI over a six-month period. The exploratory objective is to assess the efficacy of rhlactoferrin (rhLF) in attenuating cognitive decline as measured by the Digit Symbol Substitution Test and Trail Making Test, as well as improving physical mobility as measured by performance on 4 meter and six-minute walk tests. Further physical and functional measurement data will be gather using an Acti-graph link Activity monitor, the raw data collected will be used to : (i) characterize cumulative daily activity, (ii) assess daily circadian patterns of activity, (iii) assess physical activity variability, (iv) model patterns of daily activity, and (iv) estimate walking speed. This additional data will complement mobility measures by describing function enacted in daily life

Arms:
arm 1: rH lactoferrin will be provided by Ventria Biosciences. Each capsule will contain 250 mg of rH lactoferrin as active ingredient. Subjects will receive 1500 mg of lactoferrin in capsule form twice a day. Dosing will be six 250 mg capsules twice a day for six months. arm 2: Matching placebo capsule will be provided by Ventria Biosciences and six capsules twice a day will be provided to the subjects in this arm.

Interventions: intervention 1: rhLactoferrin intervention 2: Placebo
Intervention descriptions: intervention 1: Eligible participants will be provided with Recombinant Human lactoferrin (rhLF) in 250 mg capsules along with detailed instructions for taking the study drug and they will be asked to take six 250 mg capsules twice a day and to keep a daily dosing dairy. intervention 2: Eligible participant will be provided with placebo in capsules of 250 mg along with detailed instructions for taking the placebo. Participants will be asked to take six 250 mg capsules twice a day and to keep a daily dosing dairy.

Protocol document:
Prot_SAP_001.pdf: 
 
 
JHMIRB eForm A 01 
Version 3 Dated:   05/2016 
 
Page 1 of 15 
 
 
 
Effects of Lactoferrin on Chronic Inflammation in the 
Elderly (ELCIE) 
 
NCT number:  NCT02968992 
12/15/2017 
 


 
 
JHMIRB eForm A 01 
Version 3 Dated:   05/2016 
 
Page 2 of 15 
 
 
 
 
 
 
 
Date: December 15, 2017 
Principal Investigator: Jeremy Walston, M.D. 
Application Number: IRB_00094982  
 
 
 
JHM IRB - eForm A – Protocol 
 
 
 
*************************************************************************************************** 
 
 
1. 
Abstract 
Mild persistent activation of inflammatory pathways, often termed chronic inflammation (CI) is observed in 
up to 30% of older adults (1;2).  Dozens of population studies have identified significant associations 
between serum-based pro-inflammatory measures and functional decline, frailty, worsening chronic 
illness, cognitive decline, mortality and reduced gait speed (2).  Serum markers of CI such as interleukin 6 
(IL6) and soluble TNF-alpha receptor 1 (sTNFR1) are increasingly recognized as pathologic and in part 
causal in many of age-associated processes such as sarcopenia and neurodegeneration that in turn drive 
functional and cognitive decline and worsening chronic disease states in older adults (3;4).  The etiology of 
the chronic elevation of these mediators in older adults is complex and includes chronic disease states, 
increased free radical production, senescent cells, altered microbiome, and decreased barrier function of 
GI epithelium (4-6). Despite the increased understanding of etiologies and consequences of CI in older 
adults, few options have been tested for reducing CI and associated adverse health outcomes.  This is in 
part because of lack of specific biological targets and because of safety concerns regarding presently 
utilized anti-inflammatory drugs in older adults (7).  In response, this research aims to test the effects of 
lactoferrin (recombinant human lactoferrin {rhLF)), a known anti-inflammatory agent, on reducing low 
grade CI, mobility limitations, and cognitive decline in older adults.   
 
After careful consideration of potential etiologies of CI that could be safely attenuated, and of multiple 
pharmaceutical and non-pharmaceutical agents that are both safe and biologically plausible to be effective 
against CI, our team has identified lactoferrin as an important potential treatment for CI and related 
declines in functional consequences in older adults.  Lactoferrin is a basic glycoprotein found in most 
exocrine secretions and in neutrophil granules that has a pleiotropic impact on innate immune system 
activation (8-10). It binds to invading organisms and bacterial cellular wall products rendering them less 
immunogenic and easier to degrade, modulates the adaptive immune system, and it directly suppresses 
inflammation via NfKB mechanisms, especially in the GI tract (9-15). A prior study of oral bovine lactoferrin 
administration in post-menopausal women demonstrated significant reductions of CRP and IL-6 level (16).  
Given this background, we hypothesize that oral lactoferrin will attenuate inflammatory signaling in adults 
with CI. We further hypothesize that the lactoferrin induced CI attenuation will attenuate decline or 
facilitate measureable improvement in specific functional and cognitive measures in older adults.  
 
To test these hypothesizes, a randomized, placebo controlled pilot trial of rhlactoferrin (rhLF) in adults over 
age 70 is proposed that aims to assess the efficacy of this potent anti-inflammatory nutrient on CI and 
restricted mobility.  This study will enroll 60 patients (30 randomized to rhlactoferrin (rhLF) and 30 
randomized to placebo).  
 


 
 
JHMIRB eForm A 01 
Version 3 Dated:   05/2016 
 
Page 3 of 15 
 
At the conclusion of this pilot study, we will have determined whether recombinant human lactoferrin 
(rhLF) can safely reduce measures of CI in older adults, and if it has the potential to meaningfully influence 
important measures of physical and cognitive function known to be influenced by CI.  This information will 
in turn be utilized to develop a more definitive clinical trial of rhlactoferrin (rhLF) for CI and adverse health 
outcomes in older adults.   
 
 
2. 
Objectives  
The primary objective of this study is to examine in a double blinded and randomized trial the efficacy of 
Recombinant Human lactoferrin (rhLF) in reducing chronic inflammation as measured by IL-6 and sTNFR1 
in the bloodstream.  Secondary objectives include assessing the efficacy of rhlactoferrin (rhLF) in 
attenuating cognitive decline as measured by the Digit Symbol Substitution Test and Trail Making Test, as 
well as improving physical mobility as measured by performance on 4 meter and six-minute walk tests.  
The tertiary objective of this study is to gather information about the tolerability of and adherence to oral 
rhlactoferrin (rhLF) among older adults with CI over a three-month period.    
  
 
3. 
 Background 
Chronic Inflammation and Biological Mediators:  
Chronic inflammation (CI) as defined by chronic elevation in serum inflammatory measures is a known risk 
factor for a host of adverse health outcomes in older adults (3;17;18).  The etiology of CI is complex with 
increased chronic disease burden, fat mass, free radicals, and senescent cells, dysfunctional 
mitochondria, altered microbiome, and decreased GI tract barrier function all potentially contributing (19-
25).  Dozens of population studies have detailed significant associations between pro-inflammatory 
measures and functional and mobility decline, frailty, worsening chronic illness, cognitive decline, mortality 
and reduced gait speed (1;2;26;27;28).  Although these relationships were often considered to be 
epidemiological phenomena rather than causal, evidence suggests that chronic exposure to some 
inflammatory mediators can lead directly to molecular and tissue changes that contribute to the observed 
adverse outcomes (29;30-34).  Specifically, evidence suggests that IL-6, sTNFR1 and other molecules 
directly and negatively impact skeletal muscle and neurologic tissue through impairment of satellite cells, 
through the triggering of cell death pathways, and through other mechanisms (35-44). Figure 1 provides a 
conceptual overview for a biologically plausible pathway between CI and health-related declines; 
lactoferrin is hypothesized to impact inflammatory mediators and their downstream effects.      
 
 
 
Chronic Inflammation and Cognitive Decline:  
A range of studies has explored how inflammation may contribute to cognitive dysfunction in an aging 
population (45; 46).  Connections between inflammatory associated measures and cognitive declines are 
observed in patients with Parkinson’s disease, Alzheimer’s disease, and mild cognitive impairment (45).  A 
defining feature of Alzheimer’s disease is the buildup of beta-amyloid into plaques; examinations of 
patients with Alzheimer’s disease reveals the presence several inflammatory proteins, such as cytokines 
and chemokines, within cerebrospinal fluid and beta-amyloid plaques (46).  To target inflammation in 
those with neurodegenerative diseases and attenuate the effects of cognitive decline, nonsteroidal anti-
Possible CI Etiologies
Fat mass, senescent cells, 
GI tract, microbiome
- free radicals
Chronic Diseases
- DM                   - CHF
- COPD               - Depression
Tissue Changes that 
Impede Function
Skeletal muscle
CNS/Neurologic
Hematologic (anemia)
CI Mediators
IL-6
TNFR1
Figure 1: Conceptual overview connecting age-related increases in CI to adverse health outcomes seen in older adults.  
Rhlactoferrin is proposed as an intervention that can potentially target several of the mechanisms that cause and sustain CI in 
older adults. 
Diseases that Impede 
Function
OA, RA             CHF/CVD
Parkinson’s      CVA
COPD
Outcomes
Mobility
Cognitive & functional decline
Worsening chronic disease


 
 
JHMIRB eForm A 01 
Version 3 Dated:   05/2016 
 
Page 4 of 15 
 
inflammatory drugs (NSAIDS) are frequently prescribed (46).  As a nutrient with known-anti-inflammatory 
effects, it is anticipated that administration of lactoferrin will result in some improvement of cognitive 
function.           
 
Diagnosing and Treating Chronic Inflammation:  
To date, no clear method for diagnosing CI has been accepted. Although dozens of inflammatory 
measures have been used to identify associations between adverse outcomes and CI in older adults, IL6 
and sTNFR1, stand out as especially relevant in part because of their known biological relevance to 
muscle loss (36;47-52).    
 
Most prior studies linking CI to adverse health in older 
adults have relied on single serum-based biomarkers 
such as IL6 or C-reactive protein (CRP). Studies have 
emerged that demonstrate that elevations in ≥2 
inflammatory markers are more strongly associated 
with adverse outcomes (53-57). Approaches to 
aggregate markers can be categorized into 
“unsupervised” and “supervised”, with unsupervised 
aggregation being a summary of markers obtained 
based only on their joint distribution, e.g. by z-scores, 
principal component analysis or exploratory factor 
analysis (58;60) and supervised aggregation also 
considering biological understanding, or externally 
validating response (e.g., mortality(26)) for an 
“optimally” predicting response. Our group has made 
key contributions to work on supervised aggregation 
of inflammatory markers; including the first study 
applying latent variable (LV) modeling to summarize 
markers in accordance with biology understanding 
(61). Subsequently, we demonstrated that an 
inflammatory index (IIS) combining serum levels of IL6 
and sTNFR1 provided superior prediction of 10-year 
mortality in the Cardiovascular Health Study 
(N=5,177) (26) over many other cytokines. As 
rationale for the use of these measures for diagnosis 
of CI in this project over other markers, we performed 
additional analyses (table 1) using the likelihood ratio 
test that shows that IL-6, TNFR1, and combined 
measure IIS are superior predictors of gait speed 
declines over 10 years when compared to CRP and 
interleukin 1 receptor antagonist (IL1RA).  The cutoff 
point for the study inclusion criteria for IL6 was identified based on a published threshold serum value 
above which adverse outcomes are much more common; the value for sTNFR1 was identified using a 
loess curve generated from data analyzed from the Cardiovascular Health Study (17;18;26).  This 
background research provides strong rationale for the use of these measures to identify CI and to monitor 
treatment efficacy of lactoferrin on CI. 
 
 
4. 
Study Procedures 
Prescreening Contact: Subjects will be recruited from a registry of older adults who have consented to be 
re-contacted for studies related to aging as well as from other populations of community-dwelling older 
adults.  Sixty individuals age 70 and over who can walk without assistance at least four meters will be 
studied. Study coordinators will review basic information available from the registry and make a 
determination on potential eligibility based on the inclusion and exclusion criteria; this information includes 
participants’ age, ambulatory ability, and medical and neurological conditions that may exclude 
participation.  Subjects who satisfy entry criteria will be contacted by the study coordinator or the 
Table 1:  Differences in mean gait 
speed (top tertile of CI marker vs 
other), differences in rates of 
walking speed decline between 
highest / lower CI tertiles 
(marker*Time),  and rates of gait 
speed decline among those with 
lower CI (Time), using linear 
mixed-effects models  in CHS 
(n=5091) 
Likelihood ratio 
test (LRT) 
statistic 
comparing linear 
mixed-effects 
models with and 
without 
cytokines for 
predicting gait 
speed. 
Models  
Estimatea 
LRT statistic 
(p-value)    
IIS (top tertile)      -0.047  ±0.0058 
220.0 (2.8e-49) 
IIS*Time 
-0.005 ± 0.0009 
Time 
-0.010 ± 0.0005 
  
IL6 (top tertile)      -0.041 ± 0.006 
150.0 (4.4e-34) 
  
IL6*Time 
-0.004 ± 0.001 
Time 
-0.010 ± 0.0005 
 
TNFR1 (top 
tertile)      
-0.038 ± 0.0060 
130.0 (2.8e-28) 
TNFR1*Time 
-0.005 ± 0.0010 
Time 
-0.010 ± 0.0005 
  
ILR1a (top 
tertile)      
-0.034± 0.0059 
53.0 (2.9e-12) 
  
ILR1a*Time 
-0.0002± 0.0009 
Time 
-0.011± 0.0005 
  
CRP (top 
tertile)      
-0.021 ± 0.006 
48.0 ( 4.3e-11) 
  
CRP*Time 
-0.002 ± 0.001 
Time 
-0.010 ± 0.0005 
  


 
 
JHMIRB eForm A 01 
Version 3 Dated:   05/2016 
 
Page 5 of 15 
 
investigators, who will explain the study, its purpose, and its potential benefits and risks.  Individuals will 
then be scheduled to visit Johns Hopkins Bayview for informed consent and the formal screening visit.   
 
Screening Visit (SV): The screening visit will consist of   the administration and review of the informed 
consent, completion of a demographic questionnaire, a medical history questionnaire, physical activity, 
fatigue and weight loss questionnaire,   a MMSE, a physical exam, and measurements of vital signs  
(Height, weight, blood pressure, temperature and respiration) and two timed 4 meter walks. Blood will be 
drawn to measure CMP and CBC/w Diff; additionally a 10 cc tube of blood will be drawn, serum will be 
processed and stored at -80 C in the Primary Investigator’s laboratory for cytokine measurement.   If the 
cytokine levels are above the threshold for either IL-6 or TNF-R1, we will retest the prospective participant 
again within four weeks to confirm chronic inflammation after screening visit. This will be done at the ABT 
visit. (17; 18; 26).  If they remain eligible by elevation of either cytokine, they will be included in the 
study.  If eligible, the participant will be randomized to either active or placebo treatment group.  After 
confirming eligibility the JHU Pharmacy will generate the randomization schedule, and the appropriate 
numbered treatment kit for that participant will be assigned.  
 
Baseline Visit (BV): Individuals meeting eligibility criteria (described below) will be scheduled for a baseline 
visit.  This visit will consist of a brief medical history review and blood draw, along with outcome 
measurements described thoroughly below.  At the end of the visit, the pharmacy or site coordinator will 
distribute the randomized study product with instructions.  A structured walking program and 
encouragement of physical activity for participants in all treatment arms will be included.  Participants will 
also receive an accelerometer for home mobility measurement along with detailed instructions for use.        
 
Follow up visit (FUV):  Monthly in person visits will take place, with telephone contact every two weeks 
by study staff between visits to help maintain adherence and assess for adverse effects.  Pill counts 
and side effect assessments will take place at FU1, FU2, and FU3.  FU6 will include measures checked 
in Table 2 and described below. 
 
Table 2 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
All 
laboratory results will be reviewed by study physicians during the study and there will be frequent review 
PSC 
SV 
ABT 
BV 
FU1 
FU2 
FU3 
 
 
FU6. 
Phone Screen 
X 
 
 
 
 
 
 
 
 
 
Medical History 
 
X 
 
 
 
 
 
 
 
Brief Medical History Review 
 
 
 
X 
X 
X 
X 
 
 
X 
Informed Consent 
 
X 
 
 
 
 
 
 
 
 
Demographics 
 
X 
 
 
 
 
 
 
 
 
Randomization 
 
 
 
X 
 
 
 
 
 
 
Frailty Assessment 
 
 
 
X 
 
 
X 
 
 
X 
Activity Assessment 
 
 
 
X 
 
 
X 
 
 
X 
Vital Signs (BP, HR, Hgt,Wgt. 
Temp, Resp.) 
 
X 
 
X 
 
X 
X 
X 
X 
 
 
X 
Short Physical Performance 
Battery 
 
 
 
X 
 
 
X 
 
 
X 
Side Effect Assessment 
 
 
 
 
X 
X 
X 
 
 
 
4 meter walk 
 
X 
 
X 
 
 
X 
 
 
X 
Six-minute walk test 
 
 
 
X 
 
 
X 
 
 
X 
Blood Draw 
 
X 
X 
X 
X 
 
X 
 
 
X 
Physical Exam  
 
X 
 
 
 
 
 
 
 
 
MMSE 
 
X 
 
 
 
 
 
 
 
 
Cognitive measures (Trail 
Making Test and Digit 
Symbol Substitution Test) 
 
 
 
X 
 
 
X 
 
 
X 
Accelerometry 
 
 
 
X 
 
 
X 
 
 
X 
Pill Calendar 
Marked Dailyto end of Month 3 
Abbreviations: PSC: Prescreening contact; SV: Screening visit; ABT Additional Blood test (to  
further determine eligibility for those whose cytokine levels are above threshold);  BV: Baseline 
visit; FU1-6: Follow up months 1-6 of pilot study 


 
 
JHMIRB eForm A 01 
Version 3 Dated:   05/2016 
 
Page 6 of 15 
 
of adverse and/or other unexpected events.  Following study protocol, all adverse events will be reported 
to the IRB and National Institute on Aging (NIA) as per requirements.  Participants will be able to report 
issues at study contacts but will also be provided with a number to call ad hoc as needed if issues related 
to study participation arise.  If participants choose to withdraw from the study, their medical care will not be 
affected in any way.   
 
Measurements Performed at Visits:  
Phlebotomy (primary outcome measure): Primary outcome will be serum IL-6 and sTNFR1 as measured 
by ELISA as previously performed in the PI’s laboratory by an experienced laboratory technician.  
Blood will also be measured for CBC w/Diff, and CMP, these measures will be made from blood drawn 
at SV, ABT, BV, FU1, FU3 and FU6. Rationale for the choice of these measures are provided above in 
the background section.   
 
A Physical Exam will be taken at SV.  A Medical History will be taken at SV and a Brief Medical History 
Review at BV and all subsequent FUV.  These are to assess eligibility or contraindicate the intervention, 
detect new conditions or complications and other safety signals, and to measure important covariates (i.e. 
demographics, past medical history, current activity levels, routine medication, and vitamin use).      
 
4 meter walk: Speed of walking at usual pace over 4 meters will be measured at the SV, BV, FU3, and 
FU6. 
 
Six-minute walk: This is performed at the BV, FU3, and FU6 by having the participant walk along a straight 
hallway for six minutes and measuring the distance walked and the sensation of leg fatigue and dyspnea.  
The participant is given scripted prompts at one-minute intervals, but the test is largely self-directed and 
self-limited.   
 
Short Physical Performance Battery (SPPB): This is an assessment of lower extremity functioning 
comprised of gait speed, balance, and leg strength and is performed at the BV and FU6.  As part of the 
SPPB, participants will complete a balance test assessing their ability to stand without assistance and a 
chair stand test.   
 
Cognitive Function Measures: The Digit Symbol Substitution Test (DSST) is a sensitive measure in 
cognitively normal older adults. It measures attentional control and switching, and more broadly executive 
processes and thus is not sensitive to impairment in particular brain regions. It is a highly precise measure 
across the range from cognitively normal to mildly impaired older adults and takes about 90 seconds to 
administer (75).  The DSST will be conducted at BV, FU3, and FU6.  The Trail Making A and B Test 
measures executive functioning and task-switching, is highly sensitive to change and takes 5-10 minutes 
to administer (76).  This test will be performed at BV, FU3, and FU6.  An MMSE (a mini-mental state 
exam) will also be performed at the BV.     
 
Side Effect Assessment:  A Side Effect Assessment will be conducted at FU1, FU2, and FU3.   The 
purpose of this assessment is to monitor participants’ responses to lactoferrin and to assess for any 
adverse side effects.   
 
Activity Assessment: Participants will answer questions about their physical activity and energy levels.  
This assessment is conducted at BV, FU3, and FU6.     
 
Frailty Assessment: This assessment is completed at BV, FU3, and FU6.  This assessment measures 
participants’ walking speed and grip strength, and includes questions about weight loss.   
 
Vital Signs: Participants’ vital signs will be measured at every study visit.  These measurements include 
height, weight, blood pressure, respiratory rate, and temperature.     
 
Additional Physical and Functional Measurements: 
Home Mobility Measurement: An Acti-Graph® Link Activity monitor will be placed on the participant’s 
non-dominant wrist at the end of the BV. This model includes an ambient light designed to provide 
environmental information and a gyroscope and magnetometer to capture position and rotational data. 
Accelerometry counts will be measured at a sampling frequency of 80 hertz for 7 days immediately 


 
 
JHMIRB eForm A 01 
Version 3 Dated:   05/2016 
 
Page 7 of 15 
 
after completing the BV, 3-month, and 6-month visits.  Participants will be asked to wear the device at 
all times except when swimming for >30 minutes.  Monitors will be mailed via pre-addressed express 
mail packets where all raw data will be downloaded using commercial software (ACTLIFE, v6) to derive 
activity data in g force and counts/min. The JHU Statistical Methods for Applications and Research in 
Technology (“SMART”-stats) group, developers of the “movelets” technology that enables the use of raw 
data (62), will use collected data to: (i) characterize cumulative daily activity, (ii) assess daily circadian 
patterns of activity, (iii) assess physical activity variability, (iv) model patterns of daily activity, and (iv) 
estimate walking speed (62, 63, 64). These measurements greatly extend what is normally available from 
accelerometers and will complement mobility measures by describing function enacted in daily life.   
 
5. 
Inclusion/Exclusion Criteria 
Inclusion: Age 70 and older; able to complete 4- meter timed walk; walking speed <1.0 m/sec; serum IL-
6 level ≥ 2.5 pg/ml or TNFR1 level ≥1500 pg/ml.   Consistent with NIH guidelines, both genders and 
minority persons are enrolled.  Participants will be followed for 6 months to investigate the effects of the 
treatments on gait speed and other outcomes.   
 
Exclusion criteria: Participants with IL-6 levels above 30.0 pg /ul. Daily anti-inflammatory drug use 
(prednisone, Advil, Aleve, Remicade, Enbrel, methotrexate, standing NSAID, aspirin greater than 325 
mg per day), lower extremity mobility disability caused by Parkinson’s disease, CVA with residual motor 
deficit, severe osteo or rheumatoid arthritis, symptomatic claudication, hospitalization within 3 months 
for MI, angina, infection requiring antibiotics, or joint replacement, and for other reasons that markers 
may be elevated  such as active or chronic malignancies  MMSE < 21.  
6. 
Drugs/ Substances/ Devices 
Lactoferrin is a basic glycoprotein initially identified in milk but subsequently identified in most exocrine 
secretions and in granules secreted from neutrophils (8).  It has pleiotropic anti-inflammatory effects 
that range from the coating and degradation of invading organisms and their antigenic cellular 
components, to the sequestration of free iron needed by invading organisms to thrive, to the  
suppression of inflammatory (NFkB) signaling, and the modulation of the adaptive immune system (8-
10;12) .  A recent study that characterized a lactoferrin knock out mouse demonstrated a colonic 
inflammatory phenotype which suggests an important role for lactoferrin at the interface between the 
colon and the immune system (11). Given the evidence for altered immunogenic intestinal flora in frail 
older adults, and the decreasing barrier function of the aging intestinal epithelium, and the known anti-
inflammatory functions of lactoferrin, the use of oral lactoferrin for CI suppression in older adults is 
highly biologically plausible. (13-15;65-68). Beyond this mechanistic rationale, oral lactoferrin has 
demonstrated to safely and significantly reduce the incidence of neonatal sepsis in prior studies (69) 
and post-antibiotic diarrhea in older nursing facility residents (70). In older adults, lactoferrin was well 
tolerated in late stage cancer patients and increased overall survival in a study that did not include 
inflammatory measures (71, 72).  A prior study of bovine lactoferrin demonstrated significant reductions 
of CRP and IL-6 levels in post-menopausal women treated for 6 months with minimal or no side effects 
(16).  Lactoferrin has previously been used as a chronic diarrhea intervention in other vulnerable 
populations with minimal safety concerns and few if any adverse outcomes related to lactoferrin 
(70;73,74).  
 
For this study, Recombinant Human lactoferrin (rhLF) a partially iron saturated form of lactoferrin in  250 
mg capsules and matching placebo capsules will be provided by Ventria Bioscience Biotech company 
at bulk pricing.  Each capsule will contain 250 mg of rhlactoferrin (rhLF) as active ingredient and 
cellulose, magnesium stearate, and silicon dioxide as inert ingredients.  Subjects will receive either 
1500 mg of rhlactoferrin in capsule form twice a day or a placebo in exact matching capsules.  Dosing 
will be six 250 mg capsules twice a day based on prior dosing used safely in studies of diarrhea in a 
nursing home population (70).  This treatment will take place for approximately 3 months (87 days).    
Recombinant human lactoferrin (rhLF) is produced through standard methods of genetic modification 
and plant transformation.  The rice grain in which the protein accumulates is stable and well suited as a 
production system Recombinant human lactoferrin has been purified from transgenic rice using 
standard food industry procedures and current good manufacturing practices.  Each placebo capsule 
will contain cellulose, magnesium stearate, and silicon dioxide, manufactured in full compliance with all 
pharmaceutical regulation.   


 
 
JHMIRB eForm A 01 
Version 3 Dated:   05/2016 
 
Page 8 of 15 
 
 
7. 
Study Statistics 
Based on a two-sided two-sample t-test with a Type I error of 0.05, a sample size of 23 subjects per group 
(46 in total) will achieve 80% power to detect  a difference of 0.86 SD or greater in logIL-6 between the 
treatment group and the placebo group at the end of the 6-month trial. Secondarily, we will compare the 
linear rate of change in logIL-6 between the treatment and the placebo groups by modeling the individual 
trajectories of the outcome. With 20 subjects per group, three repeated measurements of IL-6 assessed at 
baseline, 3, and 6 months, and a correlation of 0.54 between measurements, we will have 80% power to 
detect a difference of 1.3 SD units (equivalent to a cross-sectional between-group difference of 0.65SD 
different at 6 months) or greater in the yearly rate of change in logIL-6 between the treatment and the 
placebo group. The within subject between-measurement correlation of 0.54 was estimated using 
longitudinal data from the Women’s Health and Aging Study II. Therefore, using longitudinal data, we will 
have adequate power to detect a difference similar to the 0.63 SD (or 2.5 pg/mL) difference observed at 
the end of a 6-month, randomized clinical study of a ribonuclease-enriched lactoferrin supplement in post-
menopausal women (16).  Given these calculations, we are aiming to recruit up to 60 individuals, 30 in 
each group, in order to maximize our ability to detect differences between treatment and placebo groups.  
This increased number beyond what are calculated here will  take into account anticipated drop outs 
during the treatment period and leave us with an estimated ‘complete completer’ group of 46 total.   In 
addition, we are estimating that we will need to have at least 250 individuals recruited into the protocol in 
order to identify those eligible by inflammatory mediator criteria listed above.   
 
8. 
Risks 
Six Minute Walk Test: This is performed by having the participant walk along a straight hallway for six 
minutes and measuring the distance walked and the sensation of leg fatigue and dyspnea.  The participant 
may stop at any time if they feel uncomfortable.  As with any exercise test, there is a theoretical risk that a 
participant could suffer cardiac risk from arrhythmia or ischemia, or orthopedic risk from falling or 
stumbling.  Risks are minimized by conducting the test in a medically supervised environment with trained 
personnel. 
 
4-meter Walk Test: This is performed by having the participant walk a distance of 4 meters while being 
timed.  The associated risk is minimal, as the participant may stop at any time if they feel uncomfortable.   
 
Phlebotomy: Blood draw is performed by taking blood from a vein in the forearm or antecubital fossa.  This 
may cause pain during the insertion of the needle or slight bruising afterward.  This risk is minimized by 
the use of disposable single needles, trained personnel, and application of pressure after the blood draw.   
 
Questionnaires, Health History, and Physical Examination: This information is routinely collected in the 
process of medical care of patients.  Here are not any significant physical risks from these procedures.  As 
with all medical information, there is always the psychological distress if personal health information is not 
held confidential within the wishes of the participant.  In order to protect participants’ privacy and 
confidentiality, all data collected will be maintained through the use of unique study identification (ID) 
numbers, rather than patient names, in the study database. Blood samples will be labeled only with study 
ID information when transmitted or stored. No information will be disclosed in an individually identifiable 
form in any type of presentation or publication. Participants will be given contact information for the PI and 
Project Manager to answer questions or to report problems.  Patients can withdraw from the study at any 
time without any effect on their medical care.     
 
Data and Safety Monitoring Plan: Because this is a human intervention study, we have a Data and 
Safety Monitoring Board (DSMB).  The DSMB has already been constituted as part of ongoing clinical 
studies of the Johns Hopkins Older Americans Independence Center (OAIC).   
     
The DSMB is responsible for safeguarding the interests of participants enrolled in intervention studies, 
assessing the safety and efficacy of study procedures, and for monitoring the overall conduct of 
intervention studies supported by the Johns Hopkins OAIC.  
The DSMB is an independent advisory group to the Director of NIA, and is required to provide 
recommendations about starting, continuing, and stopping OAIC intervention studies. Selected 


 
 
JHMIRB eForm A 01 
Version 3 Dated:   05/2016 
 
Page 9 of 15 
 
observational studies may come under the purview of the DSMB if deemed by the OAIC Leadership, in 
consultation with NIA, to have non-negligible risks. In addition, the DSMB is asked to make 
recommendations, as appropriate, to the NIA about: 
 
Efficacy of the study intervention 
 
Benefit/risk ratio of procedures and participant burden 
 
Selection, recruitment, and retention of participants 
 
Adherence to protocol requirements 
 
Completeness, quality, and analysis of measurements 
 
Amendments to the study protocol and consent forms 
 
Performance of individual centers and core labs 
 
Participant safety 
 
Notification and referral for abnormal findings 
All adverse events, regardless of severity, are monitored by the (DSMB) and reviewed by the Steering 
Committee during their regularly scheduled meetings.  Adverse events judged by a study physician to be 
both serious and unexpected and related to study participation will be reported via the study form and a 
narrative to the IRB and NIA program official in a timely manner.  An event narrative will be sent to the 
DSMB and to the clinical centers, with instructions for reporting to their IRB.  The DSMB will decide if a 
teleconference is needed to discuss the event and recommend actions to the NIA.  If the event is judged 
to be related to a study drug, the NIA will report the event to the FDA.  Any unexpected fatal or life-
threatening adverse events associated with the study drug will be reported to the FDA within 7 days of 
initial receipt; adverse events that are serious, unexpected, and associated with study drug will be 
reported within 15 days of initial receipt. 
 
9. 
Benefits 
There may be no direct benefit to participants.  Study participation may involve more intensive clinical 
follow-up than the standard of care, and participants may benefit from this.  Some participants may gain 
psychological satisfaction by contributing to research that may improve the outcomes for older adults with 
chronic inflammation.  
 
Becoming disabled from physical or memory losses are a significant burden for older adults and to society.  
This project has the potential to advance knowledge toward identifying a safe and effective strategy to 
treat chronic inflammation that might improve both mobility and memory among older adults. We expect 
that results will be directly relevant to public health and clinical guidelines, and will influence policy.  The 
risk/benefit ratio for the trials will be evaluated and every protocol will be designed so that the risks 
associated with participation are reasonable in relation to the important knowledge to be gained.  Overall, 
the risks of participating in this trial are small, and the potential information gained will likely add critical 
knowledge that will be used to guide a definitive trial to reduce chronic inflammation and impact mobility 
and memory among older adults. 
 
10. 
Payment and Remuneration 
Participants will be reimbursed for their time, effort and related expenses (i.e. parking and transportation) 
in the amount of $350.00 per person.  The first payment will be of $35.00 for completing the Screening 
Visit. The second payment will be $15.00 after completion of the ABT (additional blood draw visit).  The 
remaining amount will be divided into three increments of $100.00 each.  The third payment will be 
dispensed to study participants after the completion of their Baseline Visit.  The next reimbursement will 
be given after the completion of the 3-month Follow up Visit.  The final reimbursement will be given after 
the completion of the 6-month Follow up Visit.      
 
11. 
Costs 
There will be no cost to the participants for enrolling in the study as the costs associated with the study are 
covered by grant funds.   
 
 
 


 
 
JHMIRB eForm A 01 
Version 3 Dated:   05/2016 
 
Page 10 of 15 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Reference List 
 
 
1  Walston J, McBurnie MA, Newman, A., Tracy R, Kop WJ, Hirsch CH, Gottdiener JS, and Fried, L. 
P. 2002. Frailty and activation of the inflammation and coagulation systems with and without clinical 
morbidities: Results from the Cardiovascular Health Study. Arch Intern Med 162:2333-2341. 
 
2  Singh, T. and Newman, A. B. 2011. Inflammatory markers in population studies of aging. Ageing 
Res. Rev. 10:319-329. 
 
3  Cohen, H. J., Harris, T., and Pieper, C. F. 2003. Coagulation and activation of inflammatory 
pathways in the development of functional decline and mortality in the elderly. Am. J. Med. 114:180-187. 
 
4  Franceschi, C. and Campisi, J. 2014. Chronic inflammation (inflammaging) and its potential 
contribution to age-associated diseases. J. Gerontol. A Biol. Sci. Med. Sci. 69 Suppl 1:S4-S9. 
 
5  Meehan, C. J., Langille, M. G., and Beiko, R. G. 2015. Frailty and the Microbiome. Interdiscip. Top. 
Gerontol. Geriatr. 41:54-65. 
 
6  Zapata, H. J. and Quagliarello, V. J. 2015. The microbiota and microbiome in aging: potential 
implications in health and age-related diseases. J. Am. Geriatr. Soc. 63:776-781. 
 
7  Javed, Q. and Murtaza, I. 2013. Therapeutic potential of tumour necrosis factor-alpha antagonists 
in patients with chronic heart failure. Heart Lung Circ. 22:323-327. 
 
8  Vogel, H. J. 2012. Rhlactoferrin, a bird's eye view. Biochem. Cell Biol. 90:233-244. 
 
9  Jenssen, H. and Hancock, R. E. 2009. Antimicrobial properties of rhlactoferrin. Biochimie 91:19-29. 
 
10  Berlutti, F., Pantanella, F., Natalizi, T., Frioni, A., Paesano, R., Polimeni, A., and Valenti, P. 2011. 
Antiviral properties of rhlactoferrin--a natural immunity molecule. Molecules. 16:6992-7018. 
 
11  Ye, Q., Zheng, Y., Fan, S., Qin, Z., Li, N., Tang, A., Ai, F., Zhang, X., Bian, Y., Dang, W., Huang, 
J., Zhou, M., Zhou, Y., Xiong, W., Yan, Q., Ma, J., and Li, G. 2014. Rhlactoferrin deficiency promotes 
colitis-associated colorectal dysplasia in mice. PLoS. One. 9:e103298. 
 
12  Berkhout, B., Floris, R., Recio, I., and Visser, S. 2004. The antiviral activity of the milk protein 
rhlactoferrin against the human immunodeficiency virus type 1. Biometals 17:291-294. 
 
13  Frioni, A., Conte, M. P., Cutone, A., Longhi, C., Musci, G., di Patti, M. C., Natalizi, T., Marazzato, 
M., Lepanto, M. S., Puddu, P., Paesano, R., Valenti, P., and Berlutti, F. 2014. Rhlactoferrin differently 


 
 
JHMIRB eForm A 01 
Version 3 Dated:   05/2016 
 
Page 11 of 15 
 
modulates the inflammatory response in epithelial models mimicking human inflammatory and infectious 
diseases. Biometals 27:843-856. 
 
14  Zheng, Y., Qin, Z., Ye, Q., Chen, P., Wang, Z., Yan, Q., Luo, Z., Liu, X., Zhou, Y., Xiong, W., Ma, 
J., and Li, G. 2014. Rhlactoferrin suppresses the Epstein-Barr virus-induced inflammatory response by 
interfering with pattern recognition of TLR2 and TLR9. Lab Invest. 
 
15  Choe, Y. H. and Lee, S. W. 1999. Effect of rhlactoferrin on the production of tumor necrosis factor-
alpha and nitric oxide. J. Cell Biochem. 76:30-36. 
 
16  Bharadwaj, S., Naidu, T. A., Betageri, G. V., Prasadarao, N. V., and Naidu, A. S. 2010. 
Inflammatory responses improve with milk ribonuclease-enriched rhlactoferrin supplementation in 
postmenopausal women. Inflamm. Res. 59:971-978. 
 
17  Ferrucci, L., Harris, T. B., Guralnik, J. M., Tracy, R. P., Corti, M. C., Cohen, H. J., Penninx, B., 
Pahor, M., Wallace, R., and Havlik, R. J. 1999. Serum IL-6 level and the development of disability in older 
persons [see comments]. J Am Geriatr. Soc 47:639-646. 
    18    Ferrucci, L., Penninx, B. W., Volpato, S., Harris, T. B., Bandeen-Roche, K., Balfour, J., Leveille, S. 
G., Fried, L. P., and Md, J. M. 2002. Change in muscle strength explains accelerated decline of physical 
function in older women with high interleukin-6 serum levels. J. Am. Geriatr. Soc. 50:1947-1954. 
 
19  Little, J. P., Simtchouk, S., Schindler, S. M., Villanueva, E. B., Gill, N. E., Walker, D. G., Wolthers, 
K. R., and Klegeris, A. 2014. Mitochondrial transcription factor A (Tfam) is a pro-inflammatory extracellular 
signaling molecule recognized by brain microglia. Mol. Cell Neurosci. 60:88-96. 
 
20  Campisi, J. 2005. Senescent cells, tumor suppression, and organismal aging: good citizens, bad 
neighbors. Cell 120:513-522. 
 
21  Hill, S. and Van, R. H. 2014. Mitochondrial stress signaling in longevity: a new role for 
mitochondrial function in aging. Redox. Biol. 2:936-944. 
 
22  Freund, A., Orjalo, A. V., Desprez, P. Y., and Campisi, J. 2010. Inflammatory networks during 
cellular senescence: causes and consequences. Trends Mol. Med. 16:238-246. 
 
23  Tchkonia, T., Zhu, Y., Van, D. J., Campisi, J., and Kirkland, J. L. 2013. Cellular senescence and 
the senescent secretory phenotype: therapeutic opportunities. J. Clin. Invest 123:966-972. 
 
24  Hotamisligil, G. S., Shargill, N. S., and Spiegelman, B. M. 1993. Adipose expression of tumor 
necrosis factor-alpha: direct role in obesity-linked insulin resistance. Science 259:87-91. 
 
25  Zinovkin, R. A., Romaschenko, V. P., Galkin, I. I., Zakharova, V. V., Pletjushkina, O. Y., Chernyak, 
B. V., and Popova, E. N. 2014. Role of mitochondrial reactive oxygen species in age-related inflammatory 
activation of endothelium. Aging (Albany. NY) 6:661-674. 
 
26  Varadhan, R., Yao, W., Matteini, A., Beamer, B. A., Xue, Q. L., Yang, H., Manwani, B., Reiner, A., 
Jenny, N., Parekh, N., Fallin, M. D., Newman, A., Bandeen-Roche, K., Tracy, R., Ferrucci, L., and 
Walston, J. 2014. Simple Biologically Informed Inflammatory Index of Two Serum Cytokines Predicts 10 
Year All-Cause Mortality in Older Adults. J. Gerontol. A Biol. Sci. Med. Sci. 69:165-173. 
    27    Schaap, L. A., Pluijm, S. M., Deeg, D. J., Harris, T. B., Kritchevsky, S. B., Newman, A. B., Colbert, 
L. H., Pahor, M., Rubin, S. M., Tylavsky, F. A., and Visser, M. 2009. Higher inflammatory marker levels in 
older persons: associations with 5-year change in muscle mass and muscle strength. J Gerontol A Biol Sci 
Med Sci 64:1183-1189. 


 
 
JHMIRB eForm A 01 
Version 3 Dated:   05/2016 
 
Page 12 of 15 
 
 
28  Chang, S. S., Weiss, C. O., Xue, Q. L., and Fried, L. P. 2012. Association between inflammatory-
related disease burden and frailty: results from the Women's Health and Aging Studies (WHAS) I and II. 
Arch. Gerontol. Geriatr. 54:9-15. 
 
29  Freund, A., Orjalo, A. V., Desprez, P. Y., and Campisi, J. 2010. Inflammatory networks during 
cellular senescence: causes and consequences. Trends Mol. Med. 16:238-246. 
    30  Sikka, G., Miller, K. L., Steppan, J., Pandey, D., Jung, S. M., Fraser, C. D., III, Ellis, C., Ross, D., 
Vandegaer, K., Bedja, D., Gabrielson, K., Walston, J. D., Berkowitz, D. E., and Barouch, L. A. 2013. 
Interleukin 10 knockout frail mice develop cardiac and vascular dysfunction with increased age. Exp. 
Gerontol. 48:128-135. 
 
31  Binkley, N. C., Sun, W. H., Checovich, M. M., Roecker, E. B., Kimmel, D. B., and Ershler, W. B. 
1994. Effects of recombinant human interleukin-6 administration on bone in rhesus monkeys. Lymphokine 
Cytokine Res. 13:221-226. 
 
32  Akki, A., Yang, H., Gupta, A., Chacko, V. P., Yano, T., Leppo, M. K., Steenbergen, C., Walston, J., 
and Weiss, R. G. 2013. Skeletal muscle ATP kinetics are impaired in frail mice. Age (Dordr. ). 
 
33  Ko, F., Yu, Q., Xue, Q. L., Yao, W., Brayton, C., Yang, H., Fedarko, N., and Walston, J. 2011. 
Inflammation and mortality in a frail mouse model. Age (Dordr). 2011 Jun 2. [Epub ahead of print] 34:705-
715. 
 
34  Walston J, Fedarko N, Yang H, Leng S, Beamer B, Espinoza S, Lipton A, Zheng H, and Becker K 
2008. The Physical and Biological Characterization of a Frail Mouse Model. Journal of Gerontology 
63:391-398. 
    35    Degens, H. 2010. The role of systemic inflammation in age-related muscle weakness and wasting. 
Scand. J. Med. Sci. Sports 20:28-38. 
 
36  Pistilli, E. E., Jackson, J. R., and Alway, S. E. 2006. Death receptor-associated pro-apoptotic 
signaling in aged skeletal muscle. Apoptosis. 11:2115-2126. 
 
37  Langen, R. C., Van Der Velden, J. L., Schols, A. M., Kelders, M. C., Wouters, E. F., and Janssen-
Heininger, Y. M. 2004. Tumor necrosis factor-alpha inhibits myogenic differentiation through MyoD protein 
destabilization. FASEB J. 18:227-237. 
 
38  Guttridge, D. C., Mayo, M. W., Madrid, L. V., Wang, C. Y., and Baldwin, A. S. 2000. NF-kappaB-
induced loss of MyoD messenger RNA: possible role in muscle decay and cachexia. Science 289:2363-
2366. 
 
39  Langen, R. C., Schols, A. M., Kelders, M. C., Wouters, E. F., and Janssen-Heininger, Y. M. 2001. 
Inflammatory cytokines inhibit myogenic differentiation through activation of nuclear factor-kappaB. 
FASEB J. 15:1169-1180. 
 
40  Chabi, B., Ljubicic, V., Menzies, K. J., Huang, J. H., Saleem, A., and Hood, D. A. 2008. 
Mitochondrial function and apoptotic susceptibility in aging skeletal muscle. Aging Cell 7:2-12. 
 
41  Marzetti, E., Calvani, R., Cesari, M., Buford, T. W., Lorenzi, M., Behnke, B. J., and Leeuwenburgh, 
C. 2013. Mitochondrial dysfunction and sarcopenia of aging: From signaling pathways to clinical trials. Int. 
J. Biochem. Cell Biol. 
 
42  Beenakker, K. G., Duijnisveld, B. J., Van Der Linden, H. M., Visser, C. P., Westendorp, R. G., 
Butler-Brown, G., Nelissen, R. G., and Maier, A. B. 2012. Muscle characteristics in patients with chronic 
systemic inflammation. Muscle Nerve 46:204-209. 


 
 
JHMIRB eForm A 01 
Version 3 Dated:   05/2016 
 
Page 13 of 15 
 
 
43  Degens, H. and Alway, S. E. 2006. Control of muscle size during disuse, disease, and aging. Int. J. 
Sports Med. 27:94-99. 
 
44  Ferrucci, L., Penninx, B. W., Volpato, S., Harris, T. B., Bandeen-Roche, K., Balfour, J., Leveille, S. 
G., Fried, L. P., and Md, J. M. 2002. Change in muscle strength explains accelerated decline of physical 
function in older women with high interleukin-6 serum levels. J. Am. Geriatr. Soc. 50:1947-1954. 
    45   Simen, A. A., Bordner, K. A., Martin, M. P., Moy, L. A., & Barry, L. C. (2011).            
           Cognitive Dysfunction with Aging and the Role of Inflammation. Therapeutic     
           Advances in Chronic Disease, 2(3): 175–195.  
 
   46    Gorelick, P.  Role of inflammation in cognitive impairment: results of observational   
           trials epidemiological studies and clinical trials.  Annals of the New York       
           Academy of Sciences 1207:  155-162.  
 
   47    Tsujinaka, T., Kishibuchi, M., Yano, M., Morimoto, T., Ebisui, C., Fujita, J., Ogawa, A., Shiozaki, H., 
Kominami, E., and Monden, M. 1997. Involvement of interleukin-6 in activation of lysosomal cathepsin and 
atrophy of muscle fibers induced by intramuscular injection of turpentine oil in mice. J. Biochem. 122:595-
600. 
 
48  Maggio, M., Guralnik, J. M., Longo, D. L., and Ferrucci, L. 2006. Interleukin-6 in aging and chronic 
disease: a magnificent pathway. J. Gerontol. A Biol Sci. Med. Sci. 61:5-584. 
 
49  Fujita, J., Tsujinaka, T., Ebisui, C., Yano, M., Shiozaki, H., Katsume, A., Ohsugi, Y., and Monden, 
M. 1996. Role of interleukin-6 in skeletal muscle protein breakdown and cathepsin activity in vivo. Eur. 
Surg. Res. 28:361-366. 
 
50  Tsujinaka, T., Fujita, J., Ebisui, C., Yano, M., Kominami, E., Suzuki, K., Tanaka, K., Katsume, A., 
Ohsugi, Y., Shiozaki, H., and Monden, M. 1996. Interleukin 6 receptor antibody inhibits muscle atrophy 
and modulates proteolytic systems in interleukin 6 transgenic mice. J. Clin. Invest 97:244-249. 
 
51  Ebisui, C., Tsujinaka, T., Morimoto, T., Kan, K., Iijima, S., Yano, M., Kominami, E., Tanaka, K., and 
Monden, M. 1995. Interleukin-6 induces proteolysis by activating intracellular proteases (cathepsins B and 
L, proteasome) in C2C12 myotubes. Clin. Sci. (Lond) 89:431-439. 
 
52  White, J. P., Puppa, M. J., Sato, S., Gao, S., Price, R. L., Baynes, J. W., Kostek, M. C., Matesic, L. 
E., and Carson, J. A. 2012. IL-6 regulation on skeletal muscle mitochondrial remodeling during cancer 
cachexia in the ApcMin/+ mouse. Skelet. Muscle 2:14. 
 
53  Harris, T. B., Ferrucci, L., Tracy, R. P., Corti, M. C., Wacholder, S., Ettinger, W. H., Jr., Heimovitz, 
H., Cohen, H. J., and Wallace, R. 1999. Associations of elevated interleukin-6 and C-reactive protein 
levels with mortality in the elderly. Am J Med. 106:506-512. 
 
54  Cesari, M., Penninx, B. W., Newman, A. B., Kritchevsky, S. B., Nicklas, B. J., Sutton-Tyrrell, K., 
Rubin, S. M., Ding, J., Simonsick, E. M., Harris, T. B., and Pahor, M. 2003. Inflammatory markers and 
onset of cardiovascular events: results from the Health ABC study. Circulation 108:2317-2322. 
 
55  McDermott, M. M., Ferrucci, L., Liu, K., Criqui, M. H., Greenland, P., Green, D., Guralnik, J. M., 
Ridker, P. M., Taylor, L. M., Rifai, N., Tian, L., Zheng, J., Pearce, W. H., Schneider, J. R., and Vonesh, E. 
2005. D-dimer and inflammatory markers as predictors of functional decline in men and women with and 
without peripheral arterial disease. J. Am. Geriatr. Soc. 53:1688-1696. 
 
56  Hsu, F. C., Kritchevsky, S. B., Liu, Y., Kanaya, A., Newman, A. B., Perry, S. E., Visser, M., Pahor, 
M., Harris, T. B., and Nicklas, B. J. 2009. Association between inflammatory components and physical 
function in the health, aging, and body composition study: a principal component analysis approach. J. 
Gerontol. A Biol. Sci. Med. Sci. 64:581-589. 


 
 
JHMIRB eForm A 01 
Version 3 Dated:   05/2016 
 
Page 14 of 15 
 
 
57  Bautmans, I., Njemini, R., Lambert, M., Demanet, C., and Mets, T. 2005. Circulating acute phase 
mediators and skeletal muscle performance in hospitalized geriatric patients. J. Gerontol. A Biol. Sci. Med. 
Sci. 60:361-367. 
 
58  Hsu, F. C., Kritchevsky, S. B., Liu, Y., Kanaya, A., Newman, A. B., Perry, S. E., Visser, M., Pahor, 
M., Harris, T. B., and Nicklas, B. J. 2009. Association between inflammatory components and physical 
function in the health, aging, and body composition study: a principal component analysis approach. J. 
Gerontol. A Biol. Sci. Med. Sci. 64:581-589. 
    59    Bautmans, I., Njemini, R., Lambert, M., Demanet, C., and Mets, T. 2005. Circulating acute phase 
mediators and skeletal muscle performance in hospitalized geriatric patients. J. Gerontol. A Biol. Sci. Med. 
Sci. 60:361-367. 
 
60  Brinkley, T. E., Hsu, F. C., Beavers, K. M., Church, T. S., Goodpaster, B. H., Stafford, R. S., Pahor, 
M., Kritchevsky, S. B., and Nicklas, B. J. 2012. Total and abdominal adiposity are associated with 
inflammation in older adults using a factor analysis approach. J. Gerontol. A Biol. Sci. Med. Sci. 67:1099-
1106. 
 
61  Bandeen-Roche, K., Walston, J. D., Huang, Y., Semba, R. D., and Ferrucci, L. 2009. Measuring 
systemic inflammatory regulation in older adults: evidence and utility. Rejuvenation. Res. 12:403-410. 
 
62  Bai, J., Goldsmith, J., Caffo, B., Glass, T. A., and Crainiceanu, C. M. 2012. Movelets: A dictionary 
of movement. Electron J. Stat. 6:559-578. 
 
63  He, B., Bai, J., Zipunnikov, V. V., Koster, A., Caserotti, P., Lange-Maia, B., Glynn, N. W., Harris, T. 
B., and Crainiceanu, C. M. 2014. Predicting human movement with multiple accelerometers using 
movelets. Med. Sci. Sports Exerc. 46:1859-1866. 
    64  Schrack, J. A., Zipunnikov, V., Goldsmith, J., Bai, J., Simonsick, E. M., Crainiceanu, C., and 
Ferrucci, L. 2014. Assessing the "physical cliff": detailed quantification of age-related differences in daily 
patterns of physical activity. J. Gerontol. A Biol. Sci. Med. Sci. 69:973-979. 
 
65  Guigoz, Y., Dore, J., and Schiffrin, E. J. 2008. The inflammatory status of old age can be nurtured 
from the intestinal environment. Curr. Opin. Clin. Nutr. Metab Care 11:13-20. 
 
66  He, F., Ouwehand, A. C., Isolauri, E., Hosoda, M., Benno, Y., and Salminen, S. 2001. Differences 
in composition and mucosal adhesion of bifidobacteria isolated from healthy adults and healthy seniors. 
Curr. Microbiol. 43:351-354. 
 
67  van Tongeren, S. P., Slaets, J. P., Harmsen, H. J., and Welling, G. W. 2005. Fecal microbiota 
composition and frailty. Appl. Environ. Microbiol. 71:6438-6442. 
 
68  Bertuccini, L., Costanzo, M., Iosi, F., Tinari, A., Terruzzi, F., Stronati, L., Aloi, M., Cucchiara, S., 
and Superti, F. 2014. Rhlactoferrin prevents invasion and inflammatory response following E. coli strain 
LF82 infection in experimental model of Crohn's disease. Dig. Liver Dis. 46:496-504. 
    69  Pammi, M. and Abrams, S. A. 2015. Oral rhlactoferrin for the prevention of sepsis and necrotizing 
enterocolitis in preterm infants. Cochrane. Database. Syst. Rev. 2:CD007137. 
     70   Laffan, A M., Mckenzie, R., Forti, J., Conklin, D., Marcinko, R., Shrestha, R., Bellantoni, M., and 
Greenough, W.B., III 2011.  Rhlactoferrin for the prevention of post-antibiotic diarrhoea.  J. Health Popul. 
Nutr. 29:57-551.   
 
71  Hayes, T. G., Falchook, G. S., and Varadhachary, A. 2010. Phase IB trial of oral tarhlactoferrin in 
the treatment of patients with metastatic solid tumors. Invest New Drugs 28:156-162. 


 
 
JHMIRB eForm A 01 
Version 3 Dated:   05/2016 
 
Page 15 of 15 
 
 
72  Parikh, P. M., Vaid, A., Advani, S. H., Digumarti, R., Madhavan, J., Nag, S., Bapna, A., Sekhon, J. 
S., Patil, S., Ismail, P. M., Wang, Y., Varadhachary, A., Zhu, J., and Malik, R. 2011. Randomized, double-
blind, placebo-controlled phase II study of single-agent oral tarhlactoferrin in patients with locally advanced 
or metastatic non-small-cell lung cancer that progressed after chemotherapy. J. Clin. Oncol. 29:4129-
4136. 
 
73  Ochoa, T. J., Chea-Woo, E., Baiocchi, N., Pecho, I., Campos, M., Prada, A., Valdiviezo, G., 
Lluque, A., Lai, D., and Cleary, T. G. 2013. Randomized double-blind controlled trial of bovine rhlactoferrin 
for prevention of diarrhea in children. J. Pediatr. 162:349-356. 
 
74  Maccio, A., Madeddu, C., Gramignano, G., Mulas, C., Sanna, E., and Mantovani, G. 2010. Efficacy 
and safety of oral rhlactoferrin supplementation in combination with rHuEPO-beta for the treatment of 
anemia in advanced cancer patients undergoing chemotherapy: open-label, randomized controlled study. 
Oncologist. 15:894-902. 
  75 
Ryan JJ and Lopez SJ 2001. Wechsler adult intelligence scale- III. In Dorfman  WI and Hersen M, 
eds., Understanding Psychological Assessment, Perspectives on Individual Differences, p. 23. Kluwer 
Academic/Plenum Publishers, New York. 
  76   Reitan RM 1958. Validity of Trail Making Test as an indicator of organic brain damage. Perceptual 
and Motor Skills 8:271-276.