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. 2024 Oct 4;25(19):10686.
doi: 10.3390/ijms251910686.

Multimodal Identification of Molecular Factors Linked to Severe Diabetic Foot Ulcers Using Artificial Intelligence

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Multimodal Identification of Molecular Factors Linked to Severe Diabetic Foot Ulcers Using Artificial Intelligence

Anita Omo-Okhuasuyi et al. Int J Mol Sci. .

Abstract

Diabetic foot ulcers (DFUs) are a severe complication of diabetes mellitus (DM), which often lead to hospitalization and non-traumatic amputations in the United States. Diabetes prevalence estimates in South Texas exceed the national estimate and the number of diagnosed cases is higher among Hispanic adults compared to their non-Hispanic white counterparts. San Antonio, a predominantly Hispanic city, reports significantly higher annual rates of diabetic amputations compared to Texas. The late identification of severe foot ulcers minimizes the likelihood of reducing amputation risk. The aim of this study was to identify molecular factors related to the severity of DFUs by leveraging a multimodal approach. We first utilized electronic health records (EHRs) from two large demographic groups, encompassing thousands of patients, to identify blood tests such as cholesterol, blood sugar, and specific protein tests that are significantly associated with severe DFUs. Next, we translated the protein components from these blood tests into their ribonucleic acid (RNA) counterparts and analyzed them using public bulk and single-cell RNA sequencing datasets. Using these data, we applied a machine learning pipeline to uncover cell-type-specific and molecular factors associated with varying degrees of DFU severity. Our results showed that several blood test results, such as the Albumin/Creatinine Ratio (ACR) and cholesterol and coagulation tissue factor levels, correlated with DFU severity across key demographic groups. These tests exhibited varying degrees of significance based on demographic differences. Using bulk RNA-Sequenced (RNA-Seq) data, we found that apolipoprotein E (APOE) protein, a component of lipoproteins that are responsible for cholesterol transport and metabolism, is linked to DFU severity. Furthermore, the single-cell RNA-Seq (scRNA-seq) analysis revealed a cluster of cells identified as keratinocytes that showed overexpression of APOE in severe DFU cases. Overall, this study demonstrates how integrating extensive EHRs data with single-cell transcriptomics can refine the search for molecular markers and identify cell-type-specific and molecular factors associated with DFU severity while considering key demographic differences.

Keywords: OCHIN database; diabetic foot ulcer; electronic health records; healthcare analytics; machine learning; risk factors.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Workflow illustrating the stages of the multimodal approach. The pipeline consists of data sourcing, preprocessing, and classification/feature extraction, and feature translational studies, culminating in bulk RNA sequencing and single-cell RNA sequencing analyses.
Figure 2
Figure 2
Flowchart of patient selection for study on diabetic patients by Hispanic origin.
Figure 3
Figure 3
Feature importance rankings for laboratory tests in predicting the DFU outcomes in the Hispanic population using a Random Forest model.
Figure 4
Figure 4
Box plots illustrating significant differences in Albumin/Creatinine Ratio: (a) demonstrates statistical difference between Hispanic and non-Hispanic groups as indicated by p-value of; (b) ACR differences between surviving and deceased individuals within the Hispanic and non-Hispanic population.
Figure 5
Figure 5
Uniform Manifold Approximation and Projection (UMAP) plot of single-cell RNA sequencing dataset. (a) UMAP plot of the integrated dataset, and (b) UMAP plot split by sample type.
Figure 6
Figure 6
(a) UMAP projection showing the distribution of various cell types across the non-healing DFU sample. Different colors represent distinct cell types, demonstrating the distribution and clustering of cell populations across the dataset. (b) Bar plot representing the cell type composition in cluster 10, with keratinocytes forming the majority, followed by epithelial cells. (c) UMAP plots showing the expression of APOE across the different tissues. Higher APOE expression was observed in non-healing DFU samples, particularly in specific clusters, as indicated by the intensity of the red color. (d) UMAP highlighting APOE expression, specifically in Cluster 10. Increased APOE expression was prominently visible in non-healing DFU tissues, suggesting its potential role in disease pathology.
Figure 7
Figure 7
Workflow of integrating EHR data and transcriptomics analysis for diabetic foot ulcer study.

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