key: cord-0320322-s9bwfplf authors: Demetriou, L.; Coxon, L.; Krassowski, M.; Rahmioglu, N.; Arendt-Nielsen, L.; Aziz, Q.; Becker, C. M.; Birch, J.; Cruz, F.; Hoffman, A.; Horne, A. W.; Hummelshoj, L.; McMahon, S.; Meijlink, J.; Pogatzki-Zahn, E.; Sieberg, C. B.; Tracey, I.; Treede, R.-D.; Missmer, S. A.; Zondervan, K. T.; Nagel, J.; Vincent, K. title: Deep phenotyping of women with endometriosis-associated pain and bladder pain syndrome: the TRiPP (Translational Research in Pelvic Pain) study protocol date: 2022-05-16 journal: nan DOI: 10.1101/2022.05.16.22274828 sha: 31e84c7691533dcbb83b9bdf725d0ca3b31d9588 doc_id: 320322 cord_uid: s9bwfplf Chronic pelvic pain is common, poorly understood, and many women suffer for years without proper diagnosis and effective treatment. The Translational Research in Pelvic Pain (TRiPP) project takes a phenotyping approach, with a particular focus on endometriosis-associated pain (EAP) and bladder pain syndrome (IC/BPS), to improve our fundamental understanding of chronic pelvic pain. We believe that reconceptualising these conditions in the context of the multisystem dysfunction known for other chronic pain conditions rather than as end-organ pathologies has the potential to improve our understanding of the conditions. Our approach combines clinical, biological, physiological and psychological data to establish perturbations in the functions of pain-relevant systems that are specific to EAP and IC/BPS, and those that overlap both conditions and chronic pelvic pain more generally and associated quantitative biomarker profiles. We believe that TRiPPs novel methodological approach will produce clinical data to aid our understanding of pelvic pain and identify underlying pathways for the development of refined animal models and targeted therapeutic treatments. Chronic pelvic pain (CPP) is common, affecting 5-26.6% of women (1) (2) (3) (4) . It has significant impact on quality of life and high associated costs for individuals, society and healthcare providers (5) . Yet, CPP is neglected and underfunded in both pain and women's health research fields. Translational Research in Pelvic Pain (TRiPP) project (https://www.imipaincare.eu/PROJECT/TRIPP/) is a collaboration between academics in the UK, Europe and the USA, European Pharma companies, a small-medium sized enterprise (SME) and patient partners. It focusses on endometriosis-associated pain (EAP) and interstitial cystitis/bladder pain syndrome (IC/BPS) in women, two conditions where CPP is highly prevalent and for which current treatments predominantly target the periphery (ectopic tissue for endometriosis and the bladder for IC/BPS) and are often ineffective (6) . Our hypothesis is that the pain symptoms in these conditions are generated and maintained by mechanisms similar to those found in other chronic pain conditions but occur in combination with specific pathological lesions and symptoms (8, 9) . We believe that reconceptualising these conditions in the context of the multisystem dysfunction known for other chronic pain conditions rather than as solely end-organ pathologies has the potential to improve our understanding of the conditions, allow us to identify meaningful subgroups of patients, develop better preclinical models and thus ultimately facilitate research and drug development in this field. The present project takes a deep-phenotyping approach, combining clinical, biological, physiological and psychological data, to improve our understanding of CPP in women. The primary objective is to establish perturbations in the function of pain-relevant systems/mechanisms that are specific to EAP and IC/BPS, and those that overlap both conditions (EABP) and CPP more generally. The secondary objectives are to: a) establish biomarker profiles that are specific to EAP and IC/BPS and those that overlap both conditions and CPP more generally; b) determine whether women with pelvic pain can be stratified based on clinical data, the function of pain-relevant systems and their biomarker profile and identify any key pathways/processes underlying pain in these subgroups that may point to novel therapeutic targets; and c) explore whether any subgroups identified during the study relate to response to previous treatment. TRiPP is an observational cohort study being conducted in phases and includes five groups of participants (10, 11) who meet our inclusion/exclusion criteria to form the TRiPP cohort. From this cohort we aimed to recruit 200 participants to undergo psychophysiological testing and of these, 100 who would also undergo a neuroimaging scan. Data from each study phase will be analysed separately initially, with subsequent multi-modal analysis integrating the different datasets. Data collection is conducted at the University of Oxford, Boston Childrens Hospital, Brigham and Women's Hospital and IBMC Porto. The study commenced in April 2018 and is still ongoing, with TRiPP . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 16, 2022. ; specific recruitment having commenced in September 2019 after all regulatory approvals were gained. All recruitment is now complete. Participants forming the TRiPP cohort were selected according to the following criteria: All groups: • Aged 18-50 years (acknowledging some will have been younger when they first contributed data to ENDOx/BCE) • Not pregnant, lactating or planning pregnancy during the course of the study EAP: • surgical diagnosis of endometriosis; • at least one pelvic pain score of >4/10 on numerical ratings scales (NRS) • no urinary symptoms (e.g. urge, frequency) . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) • pain not perceived as arising from the bladder. • surgical diagnosis of endometriosis; • at least one pelvic pain score of >4/10 on NRS • urinary symptoms • pain perceived as arising from the bladder and from other area(s) of the pelvis. • no history of endometriosis; • at least one pelvic pain score of >4/10 on NRS • urinary symptoms • pain perceived as arising from the bladder. • surgical confirmation of no endometriosis; • at least one pelvic pain score of >4/10 on NRS • no urinary symptoms • pain not perceived as arising from the bladder. • no history of endometriosis; • no pelvic pain, all scores <3/10 on NRS • no urinary symptoms . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 16, 2022. Regretfully, due to the COVID-19 pandemic recruitment of new IC/BPS participants had to be halted in March 2020 and therefore the majority of the BPS group was also identified from the existing studies. Participants who agreed to participate in TRiPP specific phases of the study could choose which part(s) of the study they wished to be involved in as long as they are able to give informed consent for their participation. For phase IV (fMRI) they need to meet appropriate inclusion/exclusion criteria regarding MRI magnet safety. Our full cohort comprises 786 participants, with 158 having completed additional questionnaires and 85 the physiological testing paradigm. fMRI data collection is ongoing. The sample size of the omics biomarker discovery analyses in the main cohort was chosen to maximise power of discovery within the most easily back translatable biospecimen (blood), allowing selection of promising, robust signals that can be targeted for further analysis as per existing literature (12) . The sample size for the subsequent phases of the study were determined on the basis of previous literature, however, a pragmatic decision about closing recruitment was required in the light of the COVID-19 pandemic to allow time to complete all analyses. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 16, 2022 All women identified from ENDOx and BCE had already completed the baseline questionnaire (10) and these data have been harmonised in a REDCap database. This questionnaire provides a comprehensive profile of the participants including gynaecological, obstetric and medical history; detailed assessment of their pelvic pain now and previously; and important demographic variables. Participants recruited at IBMC completed the baseline and additional questionnaires once consented and these data were entered in the database. Women recruited to phase II from Oxford and BCH completed additional questionnaires on paper or directly into the database. Data entered by hand from paper versions was double entered to reduce error for a minimum of ~20% for each participant. All questionnaires were available in English and Portuguese. For the Portuguese versions, validated translations were used where available, otherwise forward and back translation was used. Physiological Testing Somatosensory testing: Quantitative sensory testing (QST) Visceral sensitivity testing: Non-invasive bladder testing Central sensitization assessment: Temporal summation (within QST paradigm) Assessment of descending brainstem control: Conditioned pain modulation (CPM) HPA axis integrity assessment: salivary cortisol profile How are you today? questionnaire at each visit . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The questionnaires for Phase II of the study were selected by the TRiPP consortium with additional input from members of IMI-PainCare (EPZ, RDT). They were chosen to allow a wide understanding of CPP in the context of what is known about other chronic pain conditions (e.g.mood, catastrophizing, sleep disturbances) (13) (14) (15) . Some of these domains have been assessed previously in endometriosis and/or IC/BPS (e.g. gastrointestinal symptoms) but not in combination with the variety of other measures collected here, whilst other areas have not been assessed before (e.g. a detailed characterisation of flares in endometriosis). Table 2 illustrates the domains being assessed and tools that are used for phase II. Very little is known about the neurophysiology of women with CPP. The Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Network has undertaken many of these tests in those with Urologic Chronic Pelvic Pain Syndrome (an overarching term that includes IC/BPS), however their cohorts comprise both men and women (https://www.mappnetwork.org). Data from this group and others looking at women only do support the idea that these conditions are similar to other chronic pain conditions (16, 17) ; however, to date this has not been comprehensively assessed by combining multiple assessments in a deeply phenotyped cohort and in combination with endometriosis. The TRiPP paradigm was designed with input from pain researchers within the TRiPP consortium (LAN, QA, SM, CS, KV) and IMI-PainCare project (EPZ, RDT). We aim to assess all relevant systems whilst keeping the paradigm an acceptable length and avoiding invasive procedures. Patient partners (JB, LH, JM) were key to designing an acceptable paradigm ( Table 2) . A questionnaire assessing state measures considered important covariates for the analysis of these physiological data is completed prior to each experimental session ("How are you today?" questionnaire). To ensure reproducibility between the centres, researchers collecting physiological data attended a coordinated training session in Heidelberg, Germany in September 2019 and subsequent post-COVID virtual refresher sessions. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 16, 2022. ; https://doi.org/10.1101/2022.05.16.22274828 doi: medRxiv preprint Omics EDTA plasma from biobanks (stored for a maximum of 8 years) and newly recruited patients was used to obtain genotypes of participants and quantify the relative abundance of proteins and metabolites. 182 proteins were measured using Olink's proximity extension assay inflammation and neurology panels (18) and ~1200 metabolites were quantified using ultra-high performance liquid chromatography-tandem mass spectrometry run in four different modes by Metabolon. Neuroimaging will be used to further understand the central processes underlying observations from the physiological testing and explore whether MRI markers observed in other chronic pain conditions are present in CPP. The scanning protocol includes structural and functional sequences (see Table 1) and is aligned to the fMRI protocol of the BioPain subproject of IMI-PainCare. Punctate stimuli will be used for the "pain task" as they have been previously demonstrated to give robust activation of key pain-related areas in hyperalgesic states (both experimental (19) (20) (21) and clinical (22) ) and in women with endometriosis-associated pain without hyperalgesia (KV unpublished data). Derived variables will be calculated from all validated scales and physiological testing paradigms according to published methodology. The TRiPP pain and omics data-analysis groups regularly review all plans before commencing analysis and the overall TRiPP statistical-analysis plan is maintained as a live document. Appropriate statistical software will be used to analyse the large volumes of data collected. Omics modelling will be performed using base R, rms and easystats packages, Stan or PyMC3, and multiple Python packages including pingouin. QST data will be analysed in MATLAB. fMRI data will be analysed with FSL (FMRIB's Software Library; www.fmrib.ox.ac.uk/fsl), and other analysis will be conudcted in SPSS. An integration analysis will be undertaken to combine all the different . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 16, 2022. modalities, allowing comparisons of the biomarker profiles between patient groups and controls and an exploration of different phenotypic presentations. The TRiPP consortium benefits from global interdisciplinary co-operations between clinicians and basic scientists from a wide variety of backgrounds working both in academia and the pharmaceutical industry, as well as three active patient organisations who have been involved with the study since inception. We believe that our novel approach, both in terms of deep phenotyping and the use of methodologies not usually applied to these conditions, has the potential to improve our understanding of pelvic pain. We hope to be able to produce novel clinically relevant data (e.g. an understanding of the prevalence and impact of both widespread pain and flares in CPP), identify underlying pain pathways and thus potential new therapeutic targets or opportunities to repurpose treatments from other conditions. Moreover, other work-packages within the project will backtranslate our findings to refine existing rodent models (41) of endometriosis and IC/BPS with the hope of improving the drug development capabilities. The use of existing bioresources, whilst allowing this project to proceed relatively rapidly, means that the time between biospecimen collection and analysis varied for each participant and resulted in sample aging of relevance to the omics data. Common to most recent studies, the COVID-19 pandemic and related restrictions severely delayed recruitment and data collection for phases III and IV. Additionally, it limited our ability to recruit a new IC/BPS cohort of adequate size. Whilst we could mitigate against this to an extent by using participants within the bioresources who met the BPS recruitment criteria, this group is not of the size we had originally planned and the majority of participants were identified from gynaecology rather than urology clinics. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 16, 2022 Written informed consent is obtained from all the participants at each phase of the study, and they were informed that they are free to withdraw from the study at any time. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 16, 2022. ; https://doi.org/10.1101/2022.05.16.22274828 doi: medRxiv preprint Direct access will be granted to authorised representatives from the Sponsor and host institution for monitoring and/or audit of the study to ensure compliance with regulations. All study data will be stored for 10 years after the end of the study. Once the study and all follow up analyses are complete de-identified data will be deposited in a publicly accessible repository as required by the funders. Physiological Testing Somatosensory testing: Quantitative sensory testing (QST) Visceral sensitivity testing: Non-invasive bladder testing Central sensitization assessment: Temporal summation (within QST paradigm) Assessment of descending brainstem control: Conditioned pain modulation (CPM) HPA axis integrity assessment: salivary cortisol profile How are you today? questionnaire at each visit Biospecimens Blood -genotype (* only 2/16 in Porto) -metabolomics -proteomics Urine Saliva . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) (40) Other symptoms and experiences II . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 16, 2022 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 16, 2022. ; https://doi.org/10.1101/2022.05.16.22274828 doi: medRxiv preprint Epidemiology of endometriosis The community prevalence of chronic pelvic pain in women and associated illness behaviour Prevalence of chronic pelvic pain among women: an updated review Chronic pelvic pain in women Surgical outcomes in patients with endometriosis: a systematic review Surgical removal of superficial peritoneal endometriosis for managing women with chronic pelvic pain: time for a rethink? 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Health Qual Life Outcomes Neuro-QOL: brief measures of health-related quality of life for clinical research in neurology Disclosure of traumas and psychosomatic processes Preclinical models of endometriosis and interstitial cystitis/bladder pain syndrome: an Innovative Medicines Initiative-PainCare initiative to improve their value for translational research in pelvic pain The authors wish to acknowledge Allison Vitonis and Kurtis Garbutt for their work in harmonising databases between Boston and Oxford and identifying participants suitable for the TRiPP cohort. All authors read and approved the final manuscript.