Metabolomic Profiling Based on Nuclear Magnetic Resonance in Fibromyalgia Patients

1. Full name of the study: Nuclear Magnetic Resonance Based Metabolomic Profiling in Fibromyalgia Patients
2. Aim and importance of the study (primary aim, secondary aims, if any): Determination and quantitation of metabolites and enzyme activities by NMR in fibromyalgia patients, changes in citrate, isocitrate, alpha ketoglutarate, alpha ketoglutarate, succinyl CoA, fumarate, malate, glutamate, G-6 PD, phosphogluconate, glyceraldehyde 3 P and oxaloacetate values, especially in energy metabolism in these patients and evaluation of their clinical usefulness will be investigated.
3. Expected benefits and risks of the research: Fibromyalgia is defined as a chronic syndrome of unknown cause characterized by widespread body pain, fatigue, sleep disturbance, impaired cognitive functioning and anxiety, and possible causes include genetic, neurological, psychological, sleep-related and immunological factors. The disease is 6-9 times more common in women. The diagnosis of fibromyalgia, which has been defined as a true syndrome since the publication of the 1990 classification criteria of the American College of Rheumatology (ACR), is difficult due to the subjectivity of the symptoms, the fact that the evaluation is based on patient reports and the lack of objective diagnostic tests to confirm the diagnosis. The diagnostic criteria for fibromyalgia, which was first described in the 19th century and is the most common rheumatic disease after osteoarthritis, are in constant change. In addition to the difficulty in the diagnosis of the disease, the physiopathology is not fully understood and a specific target for treatment has not been determined. The number of metabolomic studies in serum and urine analyses of patients with fibromyalgia is limited and in order to fill this gap, we will use Bruker 500 MHertz NMR device with an experienced team to examine metabolite determination and quantitation, enzyme activities and especially energy metabolism in Fibromyalgia patients. Thus, it will be investigated whether there is a predisposition to degenerative or proliferative diseases due to acceleration or decrease in energy metabolism in Fibromyalgia patients. According to our literature review, there are no studies investigating both enzymes and metabolites together in fibromyalgia patients. In the published work of researchers, NMR is often used for structure analysis. Quantitative NMR (qNMR), on the other hand, is under development to expand the range of metabolites it can detect in body fluids (to capture low concentrations of substances). qNMR started with very old studies and sub-techniques are being optimized to provide high sensitivity. With the developing technology, this spectrum will expand and in the future, hundreds of metabolites can be determined using a single reference. Although NMR equipment is available in a limited number of universities in our country, we have determined that there is no group working for quantitative analysis as a result of our research. We aim to put our theoretical knowledge into practice with the experience and knowledge of the faculty members of Bezmi Alem Vakıf University Faculty of Medicine within our project. As a starting point for our qNMR studies, we chose fibromyalgia disease, where the number of daily samples reaching our hospital is quite high. In addition, we found that clinical studies on the subject are quite limited. In this sense, the investigators is unique in that it will provide a holistic metabolic profiling in fibromyalgia patients and provide data on adults. The most important problem with the NMR technique is the high costs during the installation of the device, then with low operating costs, the desired analyzes can be performed easily and at low cost in the presence of reference materials and software required for data analysis. We aim to perform quantification of metabolites in body fluids on the NMR device, which has already been installed and is currently in operation at Bezmi Alem Vakıf University. As a starting point, we chose fibromyalgia disease, for which quantitative NMR analysis is very rare in the literature. In terms of sample preparation/analysis procedure for quantitative NMR analyses, it is planned to study serum and urine, which are the first standardized body fluid samples, and samples belonging to the patient population and healthy volunteers. According to the peaks obtained in the NMR spectrum, metabolite identification will be made and quantitation of these metabolites will be performed with the software to be provided for the study.
4. Type, scope and design of the planned study: In this prospective two-group study, metabolite identification will be performed according to the peaks obtained in the NMR spectrum in 50 patients with clinically diagnosed fibromyalgia and 50 healthy volunteers and it is aimed to perform the quantitation of these metabolites with the software to be provided for the study.
5. Number of patients and volunteers to be included in the study, their qualifications and rationale for selection: The investigators will be conducted between January 1, 2024 and December 1, 2024 with 50 patients with a diagnosis of fibromyalgia between the ages of 18-65 who meet the inclusion and exclusion criteria of the investigatorsand 50 healthy volunteers. The prior power analysis of the study was performed using the "G. Power-3.1.9.2" program. Means in calculations: Wilcoxon singed-rank test (one sample case) effect size 0.50, alpha 0.05, power 0.90, number of groups 1, number of measures:2, total sample was calculated as 38. A total of 38 patients were planned to be included in the study
6. Parameters to be analyzed: Measurement of citrate, isocitrate, alpha ketoglutarate, succinyl CoA, fumarate, malate, glutamate, G-6 PD, phosphogluconate, glyceraldehyde 3 P and oxaloacetate levels by NMR technique
7. Where and by whom the parameters will be checked: The study will be conducted by Specialist Dr. Hatice Kübra Aşık in the outpatient clinic of the Physical Medicine and Rehabilitation Clinic of Private Beykent Hospital. Dr. Hatice Kübra Aşık and biochemical tests will be performed by Prof. Dr. Yıldız Atamer at the Biochemistry Department of Private Beykent Hospital.
8. Which of the parameters to be used in the study are routine for that disease group and which are specific to the study: Measurement of citrate, isocitrate, alpha ketoglutarate, succinyl CoA, fumarate, malate, glutamate, G-6 PD, phosphogluconate, glyceraldehyde 3 P and oxaloacetate levels by NMR technique not routine for this disease but will be studied in this group for scientific research purposes
9. Projected duration of work, start and end dates: March 1, 2024 - December 1, 2024
10. Inclusion, exclusion and withdrawal criteria: Inclusion criteria: Female patients aged 18-65 years Patients with clinical complaints of fibromyalgia (widespread pain, weakness, fatigue, sleep problems, anxiety, restriction of movement, etc.) among the patients applying to the outpatient clinic Exclusion criteria: Viral or bacterial infections, Systemic diseases (diabetes mellitus, hypertension, chronic renal failure, hypo-hyperthyroidism) Patients taking antidepressants or medication, Patients with abnormal laboratory results (erythrocyte sedimentation rate, biochemical or serologic parameters, and thyroid function tests), Smokers and alcohol users, Patients with rheumatic arthritis and systemic lupus erythematosus were excluded. Those who received treatment for tumor
11. Study termination criteria: The study is planned to be terminated after the completion of the 50 patients and 50 healthy volunteers required for the study.
12. In the evaluation of the data to be obtained as a result of the research statistical methods to be used:

IBM SPSS (Statistical Package for the Social Sciences) Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp. will be used. In the descriptive statistics of the data, mean and standard deviation values will be used in parametric tests; median values, minimum and maximum values will be used in nonparametric tests.

The distribution of variables will be checked by Kolmogorov-Smirnov test. Paired t test will be used for repeated measurements with normal distribution, while Wilcoxon test will be used for non-normally distributed data. Results will be evaluated at 95% confidence interval and p<0.05 is defined as statistical significance.

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