does propranolol attenuate inflammatory responses to a ...interestingly, propranolol is also...

DoesPropranololAttenuateInflammatoryResponsestoaPsychologicalStressor?

NCT02972554 10/12/2016

Beta-Blockers&StressStudyProtocol

CompleteTitle:Theeffectsofpropranololonpsychologicalandphysiologicalresponsestoacutestress

ShortTitle:Beta-BlockersandStressStudy

DrugorDeviceName(s):Propranolol

Sponsor:Dr.MuscatellUNClaboratorystart-upfunds

ProtocolDate:9/26/2016

Amendment1Date:10/12/16

StudyPrincipalInvestigator:

KeelyA.Muscatell,Ph.D.

AssistantProfessor

DepartmentofPsychology&Neuroscience

328DavieHall

235EastCameronStreet

ChapelHillNC27599

Phone919-843-9113

email:[email protected]

PROTOCOLTITLE: Beta-BlockersandStress

LeadInvestigator:

KeelyA.Muscatell,Ph.D

UniversityofNorthCarolinaatChapelHill

ProtocolVersion2

VersionDate:October12,2016

IconfirmthatIhavereadthisprotocolandunderstandit.

PrincipalInvestigatorName: KeelyMuscatell

Date: October12,2016

TABLEOFCONTENTS

TableofContents.......................................................................................................................3

AbbreviationsandDefinitionsofTerms.....................................................................................4

ProtocolSynopsis........................................................................................................................5

1 BACKGROUNDANDRATIONALE........................................................................................................................8

2 STUDYOBJECTIVES...........................................................................................................................................10

3 INVESTIGATIONALPLAN...................................................................................................................................10

4 STUDYPROCEDURES.........................................................................................................................................12

5 STUDYEVALUATIONSANDMEASUREMENTS..................................................................................................14

6 STATISTICALCONSIDERATIONS........................................................................................................................16

7 STUDYINTERVENTION(DEVICEOROTHERINTERVENTION)...........................................................................17

8 STUDYINTERVENTIONADMINISTRATION........................................................................................................18

9 SAFETYMANAGEMENT....................................................................................................................................18

10DATACOLLECTIONANDMANAGEMENT..........................................................................................................18

11 RECRUITMENTSTRATEGY.................................................................................................................................19

12 CONSENTPROCESS...........................................................................................................................................19

13 PUBLICATION....................................................................................................................................................19

14 REFERENCES......................................................................................................................................................19

ABBREVIATIONSANDDEFINITIONSOFTERMS

Abbreviation Definition

SNS Sympatheticnervoussystem;partoftheautonomicnervoussystemthatisengaged

duringphysiologicalarousal

CTRC ClinicalandTranslationalResearchCenter;centeratUNC-CHthatprovidesinvestigators

withresearchsupportservices,includingon-locationnursingservicesutilizedinthe

presentstudy

TSST TrierSocialStressTask;acommonly-used,acute,laboratorystressparadigmforinducing

physiologicalandpsychologicalstressinparticipants

IDS InvestigationalDrugServices

MLM MultilevelModeling

PEP Pre-EjectionPeriod;ameasureofsympatheticnervoussystemactivationderivedfrom

electrocardiogramandimpedancecardiography.

RSA RespiratorySinusArrhythmia;ameasureofparasympatheticnervoussystemactivation

derivedfromelectrocardiogram.

PROTOCOLSYNOPSIS

LIMITSYNOPSIStonomorethan2-3pages.Thesynopsisshouldprovideanoverviewofthestudy.

Keepbriefandusebulletpoints.

StudyTitle BetaBlockersandStress

Funder Dr.Muscatell’slaboratorystart-upfundsprovidedbyUNC-CH

ClinicalPhase PhaseIV

StudyRationale Thisrandomized,double-blind,placebo-controlledstudyof

propranololwillshedimportantlightonhowsympatheticnervous

system(SNS)activationinfluencespsychologicalandinflammatory

responsestoacutestress.Resultsfromthisstudywillinformboth

thebasicscienceliteraturethatisattemptingtomapthe

physiologicalmechanismsbywhichpsychologicalstressmayleadto

poormentalandphysicalhealth,andmayalsoultimatelyhave

therapeuticrelevanceforindividualswhoareexperiencinghigh

levelsofstressthatisputtingtheirhealthatrisk.Utilizinga

psychopharmacologicalapproachallowsforthecircumventionof

manyofthechallengesofconductingthisresearchinhuman

populations,andwillallowforconclusionsregardingcausality,given

thatSNSactivationwillbeexperimentallymanipulated,ratherthan

relyingoncorrelationalmeasuresofSNSactivitythataredifficultto

assessandarenotappropriateforaskingifSNSactivitycauseschangesinpsychologyandbiology.

StudyObjective(s) PrimaryObjective1.Todetermineifblockingbeta-adrenergic

receptorswiththedrugpropranololwillattenuateinflammatory

responses(i.e.,interleukin-6;IL-6)toanacute,laboratorystressor.

SecondaryObjective1.Toexamineifblockingbeta-adrenergic

receptorswiththedrugpropranololwillattenuatecortisol

responsestoanacute,laboratorystressor.


receptorswiththedrugpropranololwillattenuatesalivaryalpha

amylaseresponsestoanacute,laboratorystressor.

SecondaryObjective3.Toevaluateifblockingbeta-adrenergic

receptorswiththedrugpropranololwillattenuatesympathetic

nervoussystemresponses(i.e.,pre-ejectionperiod;PEP)toan

acute,laboratorystressor.


receptorswiththedrugpropranololwillchangeparasympathetic

nervoussystemresponses(i.e.,respiratorysinusarrhythmia;RSA)

toanacute,laboratorystressor.


receptorswiththedrugpropranololchangesself-reportedaffective

responses(i.e.,negativeaffect)toanacutelaboratorystressor.

TestArticle(s) Propranolol(FDAapproved)

(IfApplicable)

StudyDesign

Thisisarandomized,doubleblind,placebo-controlledstudyofthe

effectsofpropranololonpsychologicalandphysiologicalresponses

tostress.Itwillconsistofatelephonescreening,aninitialin-person

sessionwhenconsentwillbeobtained,andasubsequentlonger,

interventionsession.

SubjectPopulation

keycriteriaforInclusion

andExclusion:

InclusionCriteria

1. HealthyindividualsfromtheUNC-ChapelHillcommunity

2. Ages18-25.

3. FluentinEnglish(spokenandwritten)

4. Ingoodoverallhealth.

ExclusionCriteria

1)Presenceorhistoryofchronicphysicalillness(especially

disorderswithaninflammatorycomponent,suchasrheumatoid

arthritis,asthma,allergies,orissuesthatcanaffecttheheart,

includinglow-bloodpressureorotherheartconditions)

2)Presenceorhistoryofpsychiatricillness(depression,anxiety)

3)Anycurrentprescriptionmedicationuse

4)Currentlypregnantorplanningtobecomepregnant(self-

reported)

5)Engagementinanumberofhealth-compromisingbehaviorsthat

mayaffectlevelsofpro-inflammatorycytokines,includingcigarette

smoking,excessivecaffeineintakeandsleepdisturbance(e.g.,

workingnightshifts)

6)BodyMassIndex(BMI)greaterthan30,giventhatadiposityis

knowntorelatetobaselinelevelsofinflammation;

7)Anxietyaboutorprevioushistoryofproblemswithblooddraws

(e.g.,fainting)

8)Anyreportedheartconditions

NumberOfSubjects

95(45percondition;wewillrun5“extra”subjectsinthecaseof

dataloss)

StudyDuration Eachsubject’sparticipationwilllast5-6hours.

Theentirestudyisexpectedtolast1-2years.

StudyPhases

Screening

StudyTreatment

Follow-Up

(1)Screening:screeningforeligibilitywilloccurviatelephone

interview,andconsentwillbeobtainedin-personduringafirst

studysession.

(2)Intervention:studyintervention/experimentaltreatmentwill

occurduringasecondstudysession.Participantswillberandomly

assignedtotakeeitherasingle,40mgdoseofpropranolol,ora

placebo,andwillgothroughastandardizedpsychologicalstress

task.Blooddrawsandsalivasampleswillbetakenthroughout,and

willbeassayedforinflammationandhormones,respectively.

(3)Follow-Up:n/a

EfficacyEvaluations Thisdoesnotapply,asthisisnotatrueinterventionaltrial.These

arehealthyparticipants.

SafetyEvaluations Thesafetyoftheparticipantswillbeensuredbytrainedresearch

staffandnursesfromtheUNCClinicalandTranslationalResearch

Center(CTRC),whowillbeon-handfortheinterventionsessions,

withthesupervisionofthePI.Theco-investigatingphysician

(SamanthaMeltzer-Brody)willbeon-callduringallsessions,andthe

investigationaldrugserviceatUNCisavailableforconsultation.A

singledoesofpropranololisexpectedtobeverywell-toleratedin

thisyoung,healthypopulation.

StatisticalAndAnalytic

Plan

Toaddressourprimaryaim,wewillconductmultilevelmodel

(MLM)analysesexamininglevelsofinflammation,withtime

(baseline,pre-stress,30-,60-,90-minpost-stress)asawithin-

subjectsfactorandcondition(propranololvs.placebo)asa

between-subjectsfactor.Wehypothesizethatindividualsinthe

placeboconditionwillshowanincreaseinlevelsofthe

inflammatorymarkerIL-6frompre-topost-stress,whilethosein

thepropranololconditionwillshowsignificantlylowerlevelsof

inflammationovertimecomparedtotheplacebocondition(i.e.,no

stress-relatedincreaseininflammatorymarkers).

Wewillalsoconductsimilarmultilevelmodellinganalysesonour

othersecondaryendpoints(i.e.,cortisol,salivaryalphaamylase,

PEP,RSA,negativeaffect).

DATAANDSAFETY

MONITORINGPLAN

ThePIandtheprojectcoordinatorwillberesponsiblefordata

qualitymanagementandongoingassessmentofsafety.Alldata

collectedforthestudywillbestoredonsecure,password-protected

serversmaintainedbytheDepartmentofPsychologyand

Neuroscience(oronsecure,password-protectedcomputersinthe

laboratory.SafetymonitoringwillbeprovidedbythePIandthe

studyphysician,togetherwithnursesfromtheUNCCTRCandthe

studycoordinator.

1 BACKGROUNDANDRATIONALE

1.1 Introduction

Psychologicalstressisimplicatedintheonsetandprogressionofmanycommonandcostlychronic

diseases,includingcardiovasculardisease,chronicpainconditions,andmajordepressivedisorder(Cohenetal.,

2007;Kendleretal.,1999;SteptoeandKivimäki,2012).Anemergingbodyofevidencesuggeststhat

inflammation,indexedvialevelsofpro-inflammatorycytokinesandreactiveproteins,maybeakeybiological

mechanismbywhichstressaffectshealth(Bakeretal.,2012;Milleretal.,2009;Slavichetal.,2010).Indeed,

psychologicalstressorscaninduceincreasesininflammation(SlavichandIrwin,2014;Kiecolt-Glaseretal.,

2003;Rohleder,2014;Steptoeetal.,2007),andgreaterlevelsofinflammationmaycontributetothe

developmentofdisease(CapuronandMiller,2004;ChoyandPanayi,2001;DellaGiolaandHannestad,2010;

RaisonandMiller,2013;TheEmergingRiskFactorsCollaboration,2010).Despitethisgrowingliteraturelinking

stress,inflammation,andpoorhealth,littleisknownabouttheprecisephysiologicalmechanismslinking

psychologicalstressandincreasesininflammation.

Onehypothesizedmechanismthatmaytranslatepsychologicalstressintoincreasesinlevelsof

inflammationisactivationofthesympatheticnervoussystem(SNS).TheSNSispartoftheautonomicnervous

systemandisprimarilyindexedbyreleaseofthecatecholaminesepinephrine(adrenaline)andnorepinephrine

(noradrenaline).Priorresearchinnon-humananimalmodelshasshownthatstress-inducedSNSactivation

leadstoincreasesinlevelsofpro-inflammatorycytokinesinflammation(Bierhausetal.,2003;DeRijketal.,

1994;Kopetal.,2008;vanGooletal.,1990),whilepharmacologicallyblockingsympatheticactivation

attenuatestheinflammatoryresponsetostress(Bierhausetal.,2003).However,noknownhumanstudiesto

datehaveexaminedtherelationshipbetweenpsychologicalstress,SNSactivation,andinflammation.The

presentstudyisdesignedtoaddressthismajorgapinourknowledgeofthephysiologicalmechanismsthatmay

linkstressanddisease.

Apotentialreasonforthelackofhumanresearchlinkingstress,SNSactivation,andinflammationisthat

SNSactivityisdifficulttomeasure.Indeed,adrenalineandnoradrenalinearereleasedintothebloodstream

veryrapidlyduringastressor,makingtheirkineticsdifficulttocaptureduringtypicallaboratory-basedstress

paradigms.IndirectmeasuresofSNSactivitymaybeacquiredusingpsychophysiologicalapproachesthat

involveperipheralmeasuresofelectricalactivityandefficiencyoftheheart;however,thesemethodsprovide

onlyindirectindicatorsofSNSactivity,makingthemsubjecttocriticisminthepsychoneuroimmunology

community.

TocircumventtheseissueswithassessmentofSNSactivity,thepresentstudywillemploya

psychopharmacologicalapproachtoexperimentallyblockSNSactivityusingthedrugpropranolol.Propranololis

abeta-blockermedicationthatisverycommonlyprescribedbyphysiciansintheUnitedStatesforthe

treatmentofhypertension,giventhatitblockedadrenergicreceptorsthatleadtorelaxationofthecardiac

muscleandsmoothmuscletissue.Interestingly,propranololisalsosometimesprescribedtoindividualswho

haveperformanceanxiety(i.e.,publicspeakinganxiety),asreducingSNSactivity(i.e.,eliminatingtheincreased

heartrate,bloodpressure,sweatypalms,etc.,thattypicallyaccompanyanxiety-provokingsituations)hasbeen

anecdotallyobservedtodecreaseperceptionsofstressduringthesesituations.Psychologicalscientistshave

recentlybecomemoreinterestedintheroleSNSactivitymayplayintheformationandreconsolidationoffear

memories,andanumberofstudieshavenowusedpropranololtoinvestigateifblockingSNSactivitymayhelp

treatindividualswithPost-TraumaticStressDisorder(PTSD;Pitmanetal.,2002;Vaivaetal.,2003).However,

onlyoneknownstudytodatehasinvestigatedifpropranololreducesstress-inducedimmunesystemactivation

(Benschopetal.,1994),andthis(nowdated)studydidnotspecificallyexploreifpropranololreduces

inflammatoryresponsestostress.Furthermore,noknownstudieshaveexaminedifblockingSNSactivitywith

propranololchangesindividuals’appraisalsofthestressfulsituation,ortheiraffectiveresponsestostress.

ResultsfromthisstudywillcomplementandextendtheexistingworkonhowSNSactivityaffectsfear

memoriesandstressbyfocusingonhowpropranololaffectsinflammatoryandpsychologicalresponsestoa

stressor.

Inadditiontotheseprimarygoalsofthepresentstudy,wewillalsoexploretheroleofSNSactivationin

anumberofadditionaltasksthatarehypothesizedtobeaffectedbysympatheticarousal.Morespecifically,we

willexamineifexposuretopropranololeliminatesimplicitbiasestowardout-groupmembers(inthiscase,

AfricanAmericans),giventhataverylargeliteraturesuggeststhatmanyWhiteAmericansholdimplicitbiases

againstAfricanAmericans(Witenberketal.,1997;Noseketal.,2002).Whileithasbeenhypothesizedthat

sympatheticarousalbasedonculturalstereotypesassociatingAfricanAmericanswithnegativitymaybeleading

totheseimplicitbiases,noknownstudieshaveinvestigatedthisissue.WewillalsoexploreofSNSactivationis

criticalforempathy,orourabilitytounderstandtheemotionalstatesofothers,foravoidingriskydecisions,and

formoraljudgments.Thus,thisstudywillalsoansweranumberofimportant,unansweredquestionsinsocial

psychologyregardingtherolethatsympatheticarousalplaysinsomeofourmostfundamentalpsychological

processes.

Insum,thisrandomized,double-blind,placebo-controlledstudyofpropranololwillshedimportantlight

onhowSNSactivationinfluencesourpsychologicalandinflammatoryresponsestostress.Resultsfromthis

studywillinformboththebasicscienceliteraturethatisattemptingtomapthephysiologicalmechanismsby

whichpsychologicalstressmayleadtopoormentalandphysicalhealth,andmayalsoultimatelyhave

therapeuticrelevanceforindividualswhoareexperiencinghighlevelsofstressthatisputtingtheirhealthat

risk.Byutilizingpsychopharmacologicalapproaches,wewillcircumventmanyofthechallengesofconducting

thisresearchinhumanpopulations,andwewillalsobeinaplacetodrawstrongconclusionsregarding

causality,giventhatwewillhaveexperimentallymanipulatedSNSactivation,ratherthanrelyingon

correlationalmeasuresofSNSactivitythataredifficulttoassessandarenotappropriateforaskingifSNS

activitycauseschangesinpsychologyandbiology.1.2 NameandDescriptionofInvestigationalProductorIntervention

Thisstudyentailsaone-time,40mgdoseofshort-actingpropranololtoassessitsimmediate/short-term

effectsoninflammation,stresshormones,autonomicphysiology,andpsychologicalresponsestoanacute

stressor.Propranololistypicallyprescribedtotreathypertensionandotherheart-relatedconditions,butit

sometimesusedtotreatperformanceanxiety.Theparticipantsenrolledinthisstudyaremedication-naïve,thus

theadministrationofpropranololdepartsfromtheparticipant’sroutineclinicalcare.

1.3 Non-ClinicalandClinicalStudyFindings

Propranololblockstheeffectsofepinephrineandnorepinephrinebycompetitivelybindingtobothβ1-

andβ2-adrenergicreceptorsinboththeperipheralandcentralnervoussystem.Itwasoriginallyusedtotreat

hypertension,approvedbytheFDAin1965.SincethenithasbeenFDA-approvedforavarietyofother

indications,includingmigraineprevention,andessentialtremor.Itisevenapprovedforcertainpediatric

conditions.Propranololisoneofthehistoricallymostcommonly-usedprescriptionmedications,anditis

generallyviewedasasafe,nontoxicmedicationinthedailydosagerangeofupto640mg,dividedinto2-4

dosesperday.The40mgdosetobegivenhereisexpectedtobewell-tolerated,withthemostadverseside

effectanticipatedbeingthepossibilityofallergicreaction.Propranololrarelycausessideeffects,including:

hypotension,insomnia,fatigue,light-headedness,nausea,brochospasm,dizziness,headache,hyperglycemia,

andmuscleweakness.Eachofthesesideeffectsisuncommonatthelow,singledosagebeingutilizedinthese

studies.Moreover,thesesideeffectsarenotonlyrare,butalsoquitemildandrarelyprolonged(i.e.<1-2

hours)whentheydooccur.Ifanyofthesesideeffectsdooccur,thesubjectswillbegivenacomfortableplace

toliedownuntilthesymptomspass,andwillbemonitoredbytheCTRCnurseandtheprojectcoordinator.

Studiesofthepharmacokineticsofpropranololsuggestthatpeakplasmaconcentrationsfollowinga40

mgdoseoccur1-2hoursafteradministration;assuch,wewillhaveparticipantsrestquietlyfor1hourfollowing

administrationofthemedicationbeforethestartthestresstask.Plasmahalf-lifeofpropranololis3-6hours,

andassuch,wewillexamineourmoreexploratoryaimsattheendofthesession,whichisstillwithinthehalf-

lifeofthedrug.

ThestudyMDwillbeon-callduringallinterventionsessionstoassessanysideeffectsandprescribe

appropriatemanagementasneeded,andaCTRCnursewillbepresentthroughoutthemajorityofstudy

procedures.Giventhatwedonotanticipateanyserioussideeffectstooccurandthatthereiscurrentlynodata

tosuggestthatanacutedoseofpropranololleadstoserioussideeffectsinhealthypopulations,webelievethe

facilitiesatHowellHallaresufficienttomanagethemild,transientsideeffectsthatmayoccurinresponseto

takingpropranolol.

1.4 RelevantLiteratureandData

SeeSection1.1(Introduction)aboveandreferencesattheconclusionofthisproposalforaliterature

reviewandreferences.

2 STUDYOBJECTIVE

ThepurposeofthisstudyistodetermineifSNSactivationisakeyphysiologicalmechanismlinking

psychologicalstressandinflammation.Thus,wewillexperimentally-blockSNSactivationusingpropranolol,a

beta-blocker,andexamineifexposuretopropranololattenuatesinflammatoryresponsestoapsychological

stressor.

2.1. PrimaryObjective

PrimaryObjective1.Toexamineifblockingsympatheticnervoussystemactivityviathebeta-blocker

propranololwillattenuateinflammatoryresponsestostress.

2.2 SecondaryObjectives

SecondaryObjective1.Toexamineifblockingbeta-adrenergicreceptorswiththedrugpropranololwill

attenuatecortisolresponsestoanacute,laboratorystressor.


attenuatesalivaryalphaamylaseresponsestoanacute,laboratorystressor.

SecondaryObjective3.Toevaluateifblockingbeta-adrenergicreceptorswiththedrugpropranololwill

attenuatesympatheticnervoussystemresponses(i.e.,pre-ejectionperiod;PEP)toanacute,laboratory

stressor.


changeparasympatheticnervoussystemresponses(i.e.,respiratorysinusarrhythmia;RSA)toanacute,

laboratorystressor.

SecondaryObjective5.Toexamineifblockingbeta-adrenergicreceptorswiththedrugpropranolol

changesself-reportedpsychologicalresponses(i.e.,negativeaffect)toanacutelaboratorystressor.

3 INVESTIGATIONALPLAN(briefoverview)

3.1 StudyDesign

Thisisadoubleblind,randomized,placebo-controlledtrialoftheeffectsofpropranololon

inflammatoryresponsestopsychologicalstressinhealthyparticipants.Wewilluseabetween-subjects

manipulation,giventhatrepeatedexposurestothestresstaskmayleadtohabituationinbothpsychological

andphysiologicalresponses,introducingapotentialconfoundinorder-effects.Itconsistsofthreestages:1)

telephonescreening2)in-personSessionIand3)inpersonSessionII.

Telephonescreening.Thetelephonescreeningwillbeconductedbytrainedresearchassistantsinthe

CarolinaSocialNeuroscienceandHealthLaboratory,underthesupervisionofthePI.Inclusionandexclusion

criteriawillbeassessed,andstudyprocedureswillbedescribed.Ifparticipantsmeetinclusioncriteriaandare

interestedinparticipants,theywillscheduledforSessionI.

StudySessionI.SessionIwilllastapproximately30-60minutes.ParticipantswillenterthelabinHowell

HallatUNC-ChapelHill,meettheresearchassistantwhoisrunningthesession,andreadthroughtheconsent

form.Onceparticipantshavebeengivenachancetoaskanyquestionsabouttheconsentformanditisclear

thattheyunderstandtheprotocolandarecomfortablewithproceeding,theywillsignacopyoftheGeneral

ConsentForm.Next,subjectsareinformedingreaterdetailabouttheprocedureforaheartbeatdetectiontask

asameasureoftheirinteroceptiveorinnerbodilyawareness.Taskdescriptions,instructions,andan

opportunitytoaskquestionswillbeprovidedtoeachparticipant.Theheartbeatdetectiontaskwilltakeabout

20minutestocomplete,andwillbeadministeredbytrainedresearchassistants.Followingcompletionofthe

heartbeatdetectiontask,theexperimenterwillreiteratetotheparticipantthegeneralpurposeofSessionII

andremindparticipantsoftheirscheduleddateforSessionII.

StudySessionII.SessionIIwilllastapproximately5hoursandwilltakeplaceintheemotioninduction

laboratoryinHowellHallatUNC-CH.Whentheparticipantarrivesforthesession,theywillmeetthelab

managerandthenursesuppliedbyCTRC.Thelabmanagerwillgivetheparticipantachancetoreviewthe

consentformthesignedduringSessionI,andwillthenremindtheparticipantoftheprotocolandtasksin

SessionII.Oncetheparticipantunderstandstheprotocolandiscomfortablewithproceeding,thenursewill

insertacatheterintotheparticipant’snon-dominantforearm,whichwillbeusedtodrawallthebloodsamples.

Overthecourseofthefivehours,therewillbefiveblooddraws,foursalivasamples,andaseriesof

questionnaires.TheparticipantswillalsocompletetheTrierSocialStressTaskduring.Forthis,theparticipant

willgiveashortspeech(10minutes)whiletheyareevaluatedbytrainedresearchassistants.Participantswill

alsocompleteanumberofcomputerizedtasksdesignedtoassessoursecondaryaims.Participantswillbefully

debriefedattheendofthestudy.

3.2 AllocationtoTreatmentGroupsandBlinding

TheUNCInvestigationalDrugService(IDS)willrandomlyassignpatientstotheexperimentalgroup

(propranolol)ortheplacebogroup.Therandomizerwillbeinstructedthatgroupsshouldbematchedonage,

gender,andracialcomposition,andwillthusbeinformedoftheparticipant’sdemographicinformationin

advanceofrandomization.Researchstaffwhohavedirectcontactwiththeparticipantwillbeblindtothe

conditionoftheparticipant.Thepsychiatristwhoismonitoringsafetyandpossibleadverseeventswhilethe

participantsareonpropranololorplacebowillbeunblindedduringthestudyandthereforeabletoidentify

whichpillwastakenifthereareanysignificantadverseeffectsfeltbytheparticipantaftertakingthepill.The

psychiatristwillnothavedirectcontactwithparticipantsduringtheexperimentalvisitsunlesstheparticipantis

experiencingadverseside-effects.Thus,nostudyteammemberwhointeractswithparticipantsonthe

propranolol/placeboSessionIIvisitwillknowwhetheraparticipantisonplaceboorpropranolol.Afterdata

collectionforthestudyiscompleted,thepharmacistwhomadeorderassignmentswillrevealwhichgroup

participantswerein(propranololvs.placebo)soappropriateanalysescanbeconducted.

3.3 StudyDuration,EnrollmentandNumberofSubjects

Thestudyisexpectedtobeactivefor1-2years,whileweenroll95subjects(45intheplacebocondition,

45inthepropranololcondition;withsomepotentialfordataloss).

Eachsubject’sparticipationwilllastapproximatelysevenhoursoverthecourseofapproximatelytwo

weeks.Theywillcompleteatelephonescreeningforeligibility(~15-20minutes),anin-personsessionfinalizing

eligibility,consentandcompletingameasureofinteroceptivesensitivity(~30-60minutes),andtheintervention

session,whichwillinvolvetakingthestudymedication,blooddraws,salivasamples,thepsychologicalstress

task,andcomputerizedtasksandquestionnaires(~5hours).Weexpectapproximately1weektopassbetween

SessionIandSessionII.

3.4 StudyPopulation

Participantsinthisstudywillbehealthy,undergraduatestudentsfromtheUNC-ChapelHillcommunity,

betweentheagesof18-25whoarefluentinEnglish(spokenandwritten)andingoodoverallhealth.

ExclusionCriteria

1)presenceorhistoryofchronicphysicalillness(especiallydisorderswithaninflammatorycomponent,suchas

rheumatoidarthritis,asthma,allergies,orissuesthatcanaffecttheheart,includinglow-bloodpressureorother

heartconditions)

2)presenceorhistoryofpsychiatricillness(depression,anxiety)

3)anycurrentprescriptionmedicationuse

4)currentlypregnantorplanningtobecomepregnant;

5)engagementinanumberofhealth-compromisingbehaviorsthatmayaffectlevelsofpro-inflammatory

cytokines,includingcigarettesmoking,excessivecaffeineintakeandsleepdisturbance(e.g.,workingnight

shifts);

6)bodymassindex(BMI)greaterthan30,giventhatadiposityisknowntorelatetobaselinelevelsof

inflammation;

7)anxietyaboutorprevioushistoryofproblemswithblooddraws(e.g.,fainting)

8)anyreportedheartconditions

4 STUDYPROCEDURES(whatwillbedone)

4.1 ScreeningProceduresandBaselineVisit

ProspectiveparticipantswhoemailtheSocialNeuroscienceandHealthLabregardingparticipationwill

firstbescreenedviatelephonebythelabmanagerorothertrainedresearchassistantinthelabtoensurethey

meeteligibilityrequirements.EligibleparticipantswillthenbescheduledforSessionI.Participantswhoendorse

oneormoreexclusionarycriteriawillbenotifiedthattheyarenoteligibleforthepresentstudy,butwillbe

encouragedtokeepaneyeoutforflyersandannouncementsregardingotherresearchprojectsinourlabif

theyareinterestedinparticipatinginotherstudies.Seeattachedtelephonescreeningscriptformore

information.

SessionIwilllastapproximately30-60minutes.Participantswillenterthelab,meettheresearch

assistantwhoisrunningthesession,andreadthroughtheconsentform.Onceparticipantshavebeengivena

chancetoaskanyquestionsabouttheconsentformanditisclearthattheyunderstandtheprotocolandare

comfortablewithproceeding,theywillsignacopyoftheGeneralConsentForm.Theywillthenfollowthe

experimentertoaprivatetestingroominourlabinHowellHall,whereourpsychophysiologicalequipmentfor

theheartbeatdetectiontaskislocated(Howell119).There,subjectsareinformedingreaterdetailaboutthe

procedurefortheheartbeatdetectiontaskasameasureoftheirinteroceptiveorinnerbodilyawarenessand

alsotheconceptualknowledgequestionnaires.Taskdescriptions,instructions,andanopportunitytoask

questionswillbeprovidedtoeachparticipant.Theheartbeatdetectiontaskwilltakeabout20minutesto

complete,andwillbeadministeredbytrainedresearchassistants.Followingcompletionoftheheartbeat

detectiontask,theexperimenterwillreiteratetotheparticipantthegeneralpurposeofSessionIIandremind

participantsoftheirscheduleddateforSessionII.Participantsaretoldthattheydonothavetocomplete

SessionIIiftheydonotwish,andthattheywillstillreceive$20forSessionI.Thoseparticipantswhodonotwishtocontinuethestudywillbepaidanddismissed.ParticipantswhoAREcontinuingwithSessionIIwillbe

remindedtogetagoodnight’ssleepbeforethenextsession,tonotexerciseoruseover-the-counter

medicationthemorningofthesession,andtonotintakeanycaffeineinthetwohoursbeforethebeginningof

thesession.Theseinstructionsaregivenbecausesleep,exercise,anti-inflammatoryuseandcaffeineintakeare

allknowntoimpactlevelsofinflammation.Participantswillalsobeaskedtoeatasatisfyingmealandtobe

well-hydratedbeforecomingtothelabforSessionII,tolessenthelikelihoodoffaintingduringblooddrawsor

fatigueduringthesession.

4.1 Intervention/Treatmentprocedures(byvisits)

SessionII(theintervention/treatmentvisit)willlastapproximately5hoursandwilltakeplaceinthe

emotioninductionlaboratoryinHowellHallatUNC-CH.Whentheparticipantarrivesforthesession,theywill

meetthelabmanagerandthenursesuppliedbyCTRC.Thelabmanagerwillgivetheparticipantachanceto

reviewtheconsentformthesignedduringSessionI,andwillthenremindtheparticipantoftheprotocoland

tasksinSessionII.Oncetheparticipantunderstandstheprotocolandiscomfortablewithproceeding,thenurse

willinsertacatheterintotheparticipant’snon-dominantforearm,whichwillbeusedtodrawalltheblood

samples.Weusethecathetermethodsothatparticipantsdonothavetobestuckwithneedlesmultipletimes

throughouttheexperiment.Oncethecatheterisplaced,theparticipantwillbegivenatleast45minutesto

acclimatetothecatheter,duringwhichtimetheywillbepreparedforpsychophysiologicaldatacollection.We

arecollectingHeartRate,RespiratorySinusArrhythmia,CardiacImpedance,andBloodPressuremeasuresfrom

participantsthroughoutthesessionand,whichwillallowustogetagoodindexofparticipants'autonomic

nervoussystemresponsestothestresstask,andwillprovideabiological“manipulationcheck”toensurethat

thepropranololhashadtheintendedeffect(itshouldlowerheartrateandbloodpressure).Again,aswith

Session1,femaleresearchassistantswillbeassignedtofemaleparticipants,whilebothmaleandfemale

researchassistantswillbeassignedtomaleparticipants,inanefforttoreduceparticipantdiscomfortwiththe

procedureofattachingthesensors.Oncesensorshavebeenattached,wewillcollect5minutesofbaseline

datawhiletheparticipantjustrestsandrelaxes.

Uponcompletionofthebaselinepsychophysiologicalmeasures,participantswillcompletetrait

questionnairemeasureswhiletheycontinuetoacclimatetothecatheterandthelaboratoryenvironment.Once

45minuteshaspassed(around1:15PM),thenursewilldrawthefirst(baseline)bloodsample,andparticipants

willbeaskedtoprovidethefirst(baseline)salivasample.Next,theoraltabletofpropranololorplacebowillbe

administeredtotheparticipantbythenurse.Participantswillcontinuecompletingtraitquestionnairesand

oncefinished,theywillbegivenneutralreadingmaterial(magazines)toreadwhiledrugactivationtakesplace.

Onehourafteradministrationofthemedication(orplacebo),thenursewilldrawasecondbloodsample,and

participantswillbeaskedtoprovideasecondsalivasample.Wewillalsocollectanother5minutesof

psychophysiologicaldata.

Next,theTrierSocialStressTask(TSST;Kirschbaum,Pirkem,&Hellhammer)procedureswillbe

explainedtoparticipants.TheTSSTisacommonly-usedacutestresstesttomeasurepsychologicaland

biologicalresponsestostressinthelaboratory.Inthistask,participantswillbeaskedtoprepareforandgivea

10-minutespeechandcompleteadifficultmentalarithmetictaskastheyareevaluatedbytrainedinterviewers.

Thenatureofthetaskisstressfulandparticipantsmayexperiencevaryinglevelsofstress,anxiety,andpossibly

embarrassment.Theconsentformatthebeginningofthestudydescribesthattheywilltakepartina“role

play”duringacognitiveperformancetask(seeConsentForm).Wedescribethetaskinthisvaguewayinthe

initialconsentbecausewewanttoensurethatthebaselinephysiologydataiscleanandnotimpactedby

participants'anticipatorystressabouttheupcomingtask.Additionally,priortotheparticipant'sparticipationin

theTSST,participantswillinformedingreaterdetailabouttheprocedureforTSST,andtheywillbeaskedifthey

wouldliketocontinue.Iftheydocontinue,butwishtostopatanytime,theywillberemindedthattheycan.

Afterbeinginformedoftheproceduresandconfirmingparticipantswouldliketocontinue,the

experimenterwillintroducetwomoreresearcherswhowillactastheinterviewers/judges.Participantswill

have2minutestoprepareforthespeech,inwhichtheywillbeaskedtoanswerwhytheyaretheperfect

candidatefortheirdreamjob.Participantswillthengivea10minutespeechinfrontofthetwointerviewers

andavideocamera.Afterthe10minutespeech,participantswillcompleteaverbalmathtaskfor5minutes.

Whileparticipantsarecompletingthetasks,interviewerswillremainneutral(giveneitherpositivenornegative

feedback).TheexperimenterleadingSessionIIwillalsobepresentthroughout,tohelpwithtimingthetasks,

etc.

FollowingcompletionoftheTSSTprocedures,participantswillcompleteasecondroundof

questionnairestomeasuretheiraffectiveresponses,somaticresponses,andinterpersonalappraisalsduring

andaftertheTSST.FifteenminutesafterterminationoftheTSST,athirdsalivasamplewillbetaken,and30

minutesaftertheterminationoftheTSST,afourth(andfinal)salivasample,andthirdbloodsample,willbe

taken.Additionalbloodsampleswillbetaken60minutes(sample#4)and90minutes(sample#5)following

terminationoftheTSST.Inbetweenbloodsamplings,participantswillbegivenneutralreadingmaterial.

Followingcollectionofthefinalbloodsample,thenursewillremovethecatheterandchecktheparticipant’s

vitalsigns.ThenursewillthenbedismissedbacktotheCTRC.

Fortheremaining60minutesofthesession,participantswillcompletefourcomputerizedtasks

designedtomeasureotherpsychologicalprocesses(besidesstress)thoughttobeinfluencedbysympathetic

nervoussystemactivation.Alistoftasksandquestionnairesisincludedbelow.

Inaddition,atthecompletionofthestudy,participantswillbefullydebriefed.Contactinformationfor

thePI,StudyPhysician,andIRBisprovidedontheconsentformanddebriefingform(whichparticipantscan

keep)iftheywishtoaddressanyconcernstheyhad.

4.2 Follow-upprocedures

Therewillbenoscheduledfollow-up;however,participantswillbegiventhecontactinformationofthe

PIandstudyphysicianandinstructedtocontactusiftheyexperienceanysideeffectsordiscomfortfollowing

thestudy.

4.3 SubjectCompletion/Withdrawalprocedures

Ifaparticipantwishestodiscontinuetheirparticipationinthestudybeforeitends,theywillreceive$25

foreachhourthattheyparticipated.Uponcompletionofthestudy,theywillreceive$125.

5. STUDYEVALUATIONSANDMEASUREMENTS(howmeasurementswillbemade)

DetailsofHeartbeatDetectionTask:Wewillusethewell-validatedHeartbeatDetectionTask(Barrettetal.,

2004;Kleckneretal.,2016)toprovideanindexofparticipants’interoceptivesensitivity(i.e.,howawarethey

areofphysiologicalchangesinthebody).Todoso,wewillfirstpreparetheparticipantforpsychophysiology

datacollection.Participantsaregiventhechancetogototherestroomifneedbeandgetcomfortablebefore

weattachthesensors.Femaleresearchassistantswillbeassignedtofemaleparticipants,whilebothmaleand

femaleresearchassistantswillbeassignedtomaleparticipants,inanefforttoreduceparticipantdiscomfort

withtheprocedureofattachingthesensors.Onlythreesensorswillbeattachedforthistaskasisstandardfor

basicEKGmeasurement.Onesensorwillgoontheparticipant’srightcollarbone,andtwomoresensorsright

belowtheirribs.Oncesensorshavebeenattached,wewillcollect5minutesofbaselinedatawhilethe

participantsitsandrelaxes.Thisbaselineisimportantforustohelpgenerateparticipant-specifictrialsforthe

heartbeatdetectiontaskitself.Next,participantswilleithercompletetheheartbeatdetectiontaskorour

questionnairemeasuresofconceptualknowledge.Thesetwotasksarecounterbalancedbecausewesuspect

thattheactivationofinteroceptiveconceptknowledgecouldtemporarilyelevateinteroceptivesensitivity--and

likewise,interoceptivesensitivitycouldactivateinteroceptiveconceptknowledge.Therefore,counterbalancing

eachtaskshouldhelpreduceordereffects.Fortheheartbeatdetectiontask,weuseMATLABtoautomatically

generateaperson-specificheartbeattaskbasedontheirbaselinecardiacdata.Participantsputonheadphones

andfollowtheon-screeninstructionsprovidedtothem.Theyareinstructedtolistenforaseriesof3beepsin

theirheadphonesthenmustindicateonthecomputerwhetherthesebeepsoccurredbetweentheircurrentheartbeatsorduringtheircurrentheartbeat.Participantsalsoratehowconfidenttheyareintheirresponse.Participantshave2practicetrialswiththeresearchassistanttoensuretheyunderstandthetask,andthen

completethe60targettrialsontheirownintheprivate,quietlabroom.Accuracyiscomputedbycomparing

participant'shitsandmisses,anddeterminingiftheywereaccurateabovechance.Afterboththeheartbeat

detectionandconceptualknowledgetasksaredone,theexperimenterwillhelptheparticipantremovethe

psychophysiologysensors.Thesensorsmuststayonacrossbothtaskssincetheyarecounterbalancedandwe

wishtokeepallpsychologicalfactorsasequalaspossible.

DetailsoftheTrierSocialStressTask(TSST).TheTSSTisacommonly-usedacutestresstesttomeasure

psychologicalandbiologicalresponsestostressinthelaboratory.Inthistask,participantswillbeaskedto

prepareforandgivea10-minutespeechandcompleteadifficultmentalarithmetictaskastheyareevaluated

bytrainedinterviewers.Thenatureofthetaskisstressfulandparticipantsmayexperiencevaryinglevelsof

stress,anxiety,andpossiblyembarrassment.Theconsentformatthebeginningofthestudydescribesthatthey

willtakepartina“roleplay”duringacognitiveperformancetask.Wedescribethetaskinthisvaguewayinthe

initialconsentbecausewewanttoensurethatthebaselinephysiologydataiscleanandnotimpactedby

participants'anticipatorystressabouttheupcomingtask.Additionally,priortotheparticipant'sparticipationin

theTSST,participantswillbeinformedingreaterdetailabouttheprocedureforTSST,andtheywillbeaskedif

theywouldliketocontinue.Iftheydocontinue,butwishtostopatanytime,theywillberemindedthatthey

can.

Afterbeinginformedoftheproceduresandconfirmingparticipantswouldliketocontinue,the

experimenterwillintroducetwomoreresearchassistantswhowillactastheinterviewers/judges.Participants

willhave2minutestoprepareforthespeech,inwhichtheywillbeaskedtoanswerwhytheyaretheperfect

candidatefortheirdreamjob.Participantswillthengivea10-minutespeechinfrontofthetwointerviewers

andavideocamera.Afterthe10-minutespeech,participantswillcompleteaverbalmathtaskfor5minutes.

Whileparticipantsarecompletingthetasks,interviewerswillremainneutral(giveneitherpositivenornegative

feedback).TheexperimenterleadingSessionIIwillalsobepresentthroughout,tohelpwithtimingthetasks,

etc.

BiomarkerInformation:

SalivaSamples.Wewilltake4salivasamplesduringthestudyviathepassivedroolmethod.Passive

droolisasalivacollectionmethodforcollectingwholesaliva.Passivedroolisconsideredbymany

researcherstobethegoldstandardwhencollectingsalivasamplesforbiologicaltesting,becauseit

providesthepurestsamplepossibleandallowsresearchersto“biobank”samplesfortesting.

Participantsallowsalivatopoolinmouth,then,withheadtiltedforward,gentlyforcesalivathrougha

smallstrawandintothevial.Participantswillbeaidedbytrainedresearchassistantswearingrubber

gloves.About2mlofsalivawillbecollectedateachsamplingtime.Salivasampleswillbeassayedfor

levelsofthestresshormone,cortisol,aswellasanotherHPAaxisbyproductsincludingACTHand

testosterone.

BloodSamples.Wewilldraw10mLofbloodintovacutainerEDTAtubesateachtimepoint,whichwill

bestoredoniceforthedurationofthestudy,andthencentrifugedtoisolateplasmaandstoredin1mL

aliquotsincryovialsina-80degreefreezeruntilthestudyiscomplete.Sampleswillthenbeassayedfor

levelsofpro-inflammatorycytokines(i.e.,interleukin-6,tumornecrosisfactoralpha,interleukin-1)using

multiplexbead-basedassays.

Psychophysiology.Wewillcollectelectrocardiogramandimpedancecardiographydatafrom

participantstoexaminehowpropranololandexposuretotheTSSTinfluenceautonomicphysiology.

Questionnaires(forexploratorymoderatoranalyese):

Demographics.Weaskparticipants'age,gender,race/ethnicity,weight/height(tocalculateBMI),perceivedSES,and

alsoaboutparticipants'comfortwithgivingspeeches/beingthecenterofattention.

HealthBehavioralQuestionnaire(Muscatell,2016).Thisasksaseriesofquestionstomakesurethat

participantsfollowedinstructionspriortothesessionandarestilleligibletoparticipate.Itincludes

items“Whichmedicationshaveyoutakeninthelast48hours?”

UCLALonelinessScale:(Russell,D.,Peplau,L.A.,andFerguson,M.L1978)Thisisacommonlyused,10

item,measureofloneliness.

ThePHQ-9:(Spitzer,1999)Thisamultipurpose,validatedinstrumentforscreening,diagnosing,

monitoringandmeasuringtheseverityofdepression.

PerceivedStressScale:(Cohen,1994)Thisisawidelyusedpsychologicalinstrumentformeasuringthe

perceptionofstress;i.ethedegreetowhichsituationsinone’slifeareappraisedasstressful.

SocialProvisionsScale(Cutrona,C.E.andRussell,D.,1987).Thisexaminesthedegreetowhich

respondent’ssocialrelationshipsprovidevariousdimensionsofsocialsupport.

FearofEvaluationScale(Leary1983).Thisisaisa30-item,self-ratedscaleusedtomeasuresocial

anxiety.

State-TraitAnxietyInventory(Spielberger1983)thisinventoryhas40self-reportitemspertainingto

anxietyaffect.

TheMacArthurScaleofSubjectiveSocialStatus:(Adler,1984)Thisisacommonlyusedmeasure

subjectivesocialstatus.Inaneasypictorialformat,itpresentsa"socialladder"andasksindividualsto

placean"X"ontherungonwhichtheyfeeltheystand.Therearetwoversionsoftheladder,onelinked

totraditionalSESindicatorsandthesecondlinkedtostandinginone'scommunity,inthiscaseUNC.We

willgivethemboth.ItisusefultobeabletomakecomparisonsbetweenobjectiveandsubjectiveSES.

ParentSES:Thisisasixitemquestionnairetoassessthesocioeconomicstatusoftheparticipantand

theirfamily.ItwillbeusedtomakecomparisonsbetweenobjectiveandsubjectiveSES.

PANAS-circumplexquestionnaire.ParticipantsratewhichemotionstheyfeltduringtheTSSTandalso

howtheyarefeelingcurrently.ParticipantsratehowintenselytheyfeltthoseemotionsusingaLikert

scale.Additionally,participantsreporthowcleartheiremotionswereduringtheTSST.Thisisour

measureofdiscreteemotion,perceivedemotionalintensity,andperceivedemotionalclarity.

SomaticSensationsquestionnaire.ParticipantsratewhichsomaticsensationstheyfeltduringtheTSST

andalsoratehowclearly/distinctlytheyexperiencedthosebodilychanges.ParticipantsuseLikert

scalesfortheirratings.Wewillalsoassesstheparticipants’feelingsabouttheinterviewersusing

standardizedmeasures.

Challengethreatappraisals:Blascovich,J.&Mendes,W.B.(2000).Thisquestionnairetapsintothe

degreetowhichtheparticipantviewsnewexperiencesasapotentialchallengeorthreat.

6. STATISTICALCONSIDERATION

Dr.Muscatellandhertraineeswillberesponsibleforstatisticalcomputationsanddataanalysis.Shewill

consultwithcolleaguesintheQuantitativePsychologyareaoftheDepartmentofPsychologyandNeuroscience

asneeded.Allhypothesistestswillbeevaluatedusing95%confidenceintervals,correspondingtoapvalueor.05.Onlyteststhatindicateapvalueof.05orlesswillbeconsideredstatisticallysignificant;testsabovethispvaluewillnotbeinterpreted.

6.1 PrimaryEndpoint-StatisticalMethods

PrimaryObjective1.Toexamineifblockingsympatheticnervoussystemactivityviathebeta-blocker

propranololwillattenuateinflammatoryresponsestostress.

AnalysisPlan.Toaddressthisaim,wewillfirstexamineiftherewasachangeininflammationsimplyas

aneffectoftakingthepropranolol(beforestressinduction).Assuch,wewillconductamultilevelmodel

(MLM)examininglevelsofinflammation(IL-6),withtime(BLvs.pre-TSST)asawithin-subjectsfactorand

condition(propranololvs.placebo)asabetween-subjectsfactor.Iftheresultofthistestshowsasignificant

interaction,thenwewillonlyincludethepre-TSSTtimepointinsubsequentmodels.Ifnon-significant,we

willusebothbaselinetimepointsinsubsequentanalyses.Next,wewillconductanMLMexamininglevels

ofinflammation,withtime(BLand/orpre-TSST,30-,60-,90-minpost-TSST)asawithin-subjectsfactorand

condition(propranololvs.placebo)asabetween-subjectsfactor.Wehypothesizethatindividualsinthe

placeboconditionwillshowanincreaseinlevelsofinflammatorymarkersfrompre-topost-TSST,while

thoseinthepropranololconditionwillshowsignificantlylowerlevelsofinflammationovertimecompared

totheplacebocondition(i.e.,nostress-relatedincreaseininflammatorymarkers).

Alloutcomeswillfirstbeexaminedusinghistogramandscatterplotforassumptionsofnormalityand

homoscedasticity.Anyvariablesthatneedtobelog-transformed(e.g.,cortisol,sAA,IL-6)willbebefore

analysesarerun.Acrossallmodels,wewillevaluateifweneedtocontrolforsex,BMI,andobjectiveSES.

Priortoanalyses,wewillalsoexamineeachoutcomeforoutliersexisting+/-3SDsfromthemean

withineachtimepointwithineachcondition.Outliersareexcludedonlywithinthetimepointwherethey

wereproblematicbutretainedelsewheretoreducedataloss.

AlldatawillbeanalyzedinRusingthelme4package.Astimepointsarenestedwithinindividuals,we

takeamultilevelmodellingapproachwiththeinclusionofarandomintercepttomodelindividual

differencesineachoutcome.

6.2 SecondaryEndpoints-StatisticalMethods

AnalysisPlan.Toaddresssecondaryobjectives,wewillfollowtheidenticalprocedureoutlinedabove,

butwillswapintherelevantoutcomeasthedependentvariable(i.e.,cortisol,salivaryalphaamylase,PEP,

RSA,psychologicalresponses).Wewillfirstexamineiftherewasachangeintheoutcomesimplyasan

effectoftakingthepropranolol(beforestressinduction).Assuch,wewillconductamultilevelmodel

(MLM)examininglevelsoftheoutcome,withtime(BLvs.pre-TSST)asawithin-subjectsfactorand

condition(propranololvs.placebo)asabetween-subjectsfactor.Iftheresultofthistestshowsasignificant

interaction,thenwewillonlyincludethepre-TSSTtimepointinsubsequentmodels.Ifnon-significant,we

willusebothbaselinetimepointsinsubsequentanalyses.Next,wewillconductanMLMexamininglevels

ofeachrelevantoutcome,withtime(BLand/orpre-TSST,post-TSSTtime-points)asawithin-subjectsfactor

andcondition(propranololvs.placebo)asabetween-subjectsfactor.

6.4 SampleSizeandPower

Weareplanningtoenroll45participantsperconditioninourstudy,foratotalof90participants.The

samplesizewasselectedbasedonathoroughliteraturereviewofpriorstudiesthathaveexaminedtheeffects

ofpropranololonpsychologicaltasksinhealthyparticipants(similartothoseinthepresentstudy)revealedthe

averagesamplesizeofeachconditiontobe21participants(22inthepropranololcondition,21intheplacebo

condition).Thus,byrandomizing45participantstoeachcondition,wearesufficientlypoweredtoachieveour

aims.Wehaveincludedmoreparticipantsthanpriorworkinthisareabecauseweareinterestedinexamining

moderatorsofourmaineffectsofinterest,andsuchanalysesrequiregreatersamplesizetobesufficiently-

powered.Wealsoconsideredavailabilityofpossibleeligibleparticipantswhenmakingthisdecision;wedonot

anticipatesignificantdifficultyinfindingparticipantswhomeetourinclusion/exclusioncriteria,giventhatthey

arerelativelyopenandshouldberelativelyprevalentinourtargetrecruitmentpopulation(i.e.,primarily

healthy,undergraduatestudents).Finally,wealsoconsideredpracticalconstraintsintermsoffundsandtime

availabletocompletethestudy.AstheprojectwillbefundedoffofDr.Muscatell’slaboratorystart-upfunds,

wedonotcurrentlyhavegrantfundstoenrolladditionalparticipants.Wearealsohopingtocompletethe

projectwithinoneyearsothatwecanusethedatageneratedbytheprojectaspreliminarydataforagrantto

besubmittedtoNIHtorunasimilarstudyincludinganeuroimaging(fMRI)component.

7. STUDYINTERVENTION(drug,deviceorotherinterventiondetails)

Description.Propranololblockstheeffectofepinephrineandnorepinephrinebycompetitivelybindingtoon

bothβ1-andβ2-adrenergicreceptorsinboththeperipheralandcentralnervoussystem.Itwasoriginallyusedto

treathypertension,approvedbytheFDAin1965.SincethenithasbeenFDAapprovedforavarietyofother

indications,includingmigraineprevention,andessentialtremor.Itisevenapprovedforcertainpediatric

conditions.Propranololisoneofthehistoricallymostcommonly-usedprescriptionmedications,anditis

generallyviewedasasafe,nontoxicmedicationinthedailydosagerangeofupto640mg,dividedinto2-4

dosesperday.

Receipt/Storage.TheprojectmanagerwillpickupthemedicationatIDSthedaypriortotheparticipantssecond

session.AllmedicationtabletswillbestoredinaroomtemperaturelockedcabinetintheMuscatellLabin

HowellHallatUNC.OnlytheprojectcoordinatorandthePIwillhaveakeyforthiscabinet.

Packaging/Labeling.MedicationwillbepackagedandlabeledinaccordancewithIDSprotocol.

Dosing.Eachparticipantwillreceive40mgofpropranolol,oratabletofequivalentsizeofaplacebo.

TreatmentcomplianceandAdherence.Thisisaone-timedosage,sonotapplicable.

DrugReturn/Destruction.Ifaparticipantdoesnotshowupfortheirappointment,wewillreturnthedrugtoIDS

andtheywilldestroyitinaccordancewiththeirprotocol.

8. STUDYINTERVENTIONADMINISTRATION(ifapplicable)

Thisisadoubleblind,randomizedclinicaltrial.IDSwillrandomlyassignpatientstotheexperimentalgroup

(propranolol)ortheplacebogroup.Researchstaffwhohavedirectcontactwiththeparticipantwillbeblindto

theconditionoftheparticipant.Thepsychiatristwhoismonitoringsafetyandpossibleadverseeventswhile

theparticipantsareonpropranololorplacebowillbeunblindedduringthestudyandthereforeabletoidentify

whichpillwastakenifthereareanysignificantadverseeffectsfeltbytheparticipantaftertakingthepill.The

psychiatristwillnothavedirectcontactwithparticipantsduringtheexperimentalvisitsunlesstheparticipantis

experiencingadverseside-effects.Thus,nostudyteammemberwhointeractswithparticipantsonthe

propranolol/placeboSessionIIvisitwillknowwhetheraparticipantisonplaceboorpropranolol.Afterdata

collectionforthestudyiscompleted,thepharmacistwhomadeorderassignmentswillrevealwhichgroup

participantswerein(propranololvs.placebo)soappropriateanalysescanbeconducted.

9. SAFETYMANAGEMENT

The40mgdoseofpropranololtobegiveninthisstudyisexpectedtobewell-toleratedinthisyoung,

healthypopulation.Thegreatestrisktoparticipantstakingthismedicationisallergicreaction,andwewill

assessallmedicationallergiespriortostudyenrollment.Propranololrarelycausessideeffects,including:

hypotension,insomnia,fatigue,light-headedness,nausea,brochospasm,dizziness,headache,hyperglycemia,

andmuscleweakness.Eachofthesesideeffectsisuncommonatthelow,singledosagebeingutilizedinthese

studies.Moreover,thesesideeffectsarenotonlyrare,butalsoquitemildandrarelyprolonged(i.e.<1-2

hours)whentheydooccur.Ifanyofthesesideeffectsdooccur,thesubjectswillbegivenacomfortableplace

toliedownuntilthesymptomspass,andwillbemonitoredcloselybythenursesandresearchstaff.

ThestudyMDwillbeon-calltoassessanysideeffectsandprescribeappropriatemanagementasneeded,

andaCTRCnursewillbepresentthroughoutthemajorityofstudyprocedures.Giventhatwedonotanticipate

anyserioussideeffectstooccurandthatthereiscurrentlynodatatosuggestthatanacutedoseof

propranololleadstoserioussideeffectsinhealthypopulations,webelievethefacilitiesatHowellHallare

sufficienttomanagethemilder,transientsideeffectsthatmayoccurinresponsetotakingpropranolol.

TheMDwhoismonitoringsafetyandpossibleadverseeventswhiletheparticipantsareonpropranololor

placebowillbeun-blindedduringthestudyandthereforeabletoidentifywhichpillwastakenifthereareany

significantadverseeffectsfeltbytheparticipantaftertakingthepill.Thepsychiatristwillnothavedirect

contactwithparticipantsduringtheexperimentalvisitsunlesstheparticipantisexperiencingadverseside-

effects.Althoughtheyarenotanticipated,anyadverseeventswillbeimmediatelyreportedtotheUNCIRB.

10. DATACOLLECTIONANDMANAGMENT

Thestudycoordinator,EmmaArmstrong-Carter,willberesponsiblefordatamanagement,withsupervision

fromthePI.DataentrywillbecapturedandmanagedusingtheREDCapsoftwareprovidedbytheNCTraCS

Institute,whichisHIPPAcompliantandprovidesastate-of-the-artsystemfordataentryandmanagement,

especiallyforastudysuchasthatproposedinthepresentprotocolthatincludesmeasuresofmultiple

endpoints.AllInformationanddatacollectedforthepurposeofthisresearchstudywillbekeptconfidentialas

requiredbylaw.Telephonenumbersande-mailaddresseswillbeusedforschedulingstudysessions.These

identifierswillbestoredseparatelyfromanydata.Allcopiesoftestrecordsandresultswillbekeptin

computerfilesthatrequireapasswordtoopen.Allinformationwillbeaccessibleonlytoauthorizedpersonnel.

Codeswillbeusedonalldatasheetsinplaceofnames.Nosubjectswillbeidentifiedinanyreportor

publicationaboutthisstudy.Asinglefilewilllinktheidentifyinginformationtoparticipant’ssubjectIDcode

andthatwillonlybestoredontheLabManager’scomputeranditwillbepasswordprotected.OnlytheLab

ManagerandthePIwillhaveaccesstothepasswordforthisfile.

DataqualitywillbeensuredwithprecisedocumentationthroughoutSessionII.Specifically,boththeCTRC

nursesandthestudycoordinatorwillhave“flowsheets”createdbythePIthatspecifywhensamplesshouldbe

taken,whenthemedicationshouldbeadministered,andwhenthequestionnairesandcomputertasksshould

takeplace.Thestudycoordinatorandnursewilldocumenttheprecisetimethatsamplesaretakenduringthe

session,recordingreasonsforanydeviationfromtheplannedtimingontheflowsheet.Theywillalsorecord

whentasksandquestionnairesareadministered,andanyotherdetailsrelevanttothesession.Followingthe

session,alltiminginformationanddetailsaboutthesessionwillbetransferredtoREDCApandlinkedtothe

restoftheparticipant’sdata.QuestionnairemeasureswillbeadministeredinREDCap,andwhileparticipants

canelecttoskipanyquestiontheydonotfeelcomfortableanswering,apromptwillappearonscreennotifying

participantsiftheyhaveskippedaquestion,toensurethattheyhaveintentionallynotansweredthequestion

ratherthanaccidentallyleavingitblank.

11. RECRUITMENTSTRATEGY

ParticipantswillberecruitedthroughpostingofIRB-approvedflyersaroundUNCandtheneighboringareas

(FranklinStreet,Carrboro,etc.),announcementsmadeinclassesatUNC,andemaillist-servesatUNC.All

recruitment-relatedmaterialswillbeapprovedbytheIRB,includingflyers,e-mails,andannouncementsscripts.

Wedonotanticipatehavinganydifficultyrecruitingtheprojectednumberofsubjectsidentified.

12. CONSENTPROCESSAllsubjectswillparticipateintheinformedconsentprocess.Participantswillbefamiliarizedwiththe

protocolbythePIorqualifiedstudypersonnel,includingitsrisksandbenefits,andinformedconsentwillbe

documentedaccordingtotheregulationsgoverninghumansubjectresearchattheUniversityofNorthCarolina,

ChapelHill,whichmeetthestandardsoftheNIH.

UponarrivaltoparticipateinSessionI,participantswillreadandhaveexplainedtothemtheinformed

consentdocument.Informedconsentisobtainedinacomfortable,privateareainHowellHalldesignedforthis

purpose.Participants’questionsabouttheprotocolwillbethoroughlyansweredpriortoobtainingconsent,

withnotimelimittothisprocedure.Uponconsent,thesubjectisfreetowithdrawthatconsentatanytime,

whichwillbeemphasizedtothesubject.Consentwillbeobtainedbyapprovedstudystaff.

13. PLANSFORPUBLICATIONWeplantosubmittheresultsfromthisstudytopeer-reviewedpsychologyandneurosciencejournals.

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does propranolol attenuate inflammatory responses to a ...interestingly, propranolol is also...

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