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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:kmuscatell@unc.edu
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.
SecondaryObjective2.Toexamineifblockingbeta-adrenergic
receptorswiththedrugpropranololwillattenuatesalivaryalpha
amylaseresponsestoanacute,laboratorystressor.
SecondaryObjective3.Toevaluateifblockingbeta-adrenergic
receptorswiththedrugpropranololwillattenuatesympathetic
nervoussystemresponses(i.e.,pre-ejectionperiod;PEP)toan
acute,laboratorystressor.
SecondaryObjective4.Toexamineifblockingbeta-adrenergic
receptorswiththedrugpropranololwillchangeparasympathetic
nervoussystemresponses(i.e.,respiratorysinusarrhythmia;RSA)
toanacute,laboratorystressor.
SecondaryObjective5.Toexamineifblockingbeta-adrenergic
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.
SecondaryObjective2.Toexamineifblockingbeta-adrenergicreceptorswiththedrugpropranololwill
attenuatesalivaryalphaamylaseresponsestoanacute,laboratorystressor.
SecondaryObjective3.Toevaluateifblockingbeta-adrenergicreceptorswiththedrugpropranololwill
attenuatesympatheticnervoussystemresponses(i.e.,pre-ejectionperiod;PEP)toanacute,laboratory
stressor.
SecondaryObjective4.Toexamineifblockingbeta-adrenergicreceptorswiththedrugpropranololwill
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.
14. REFERENCES:1. Barrett,L.F.(2004).FeelingsorWords?UnderstandingtheContentinSelf-ReportRatingsof
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