Abstracts and Posters

Posterior tibial translation (PTT) on posterior kneeling stress radiographs is commonly used to objectively assess for PCL tears with a PTT of 8-11 mm being described as an indicator of isolated PCL tears, while PTT ≥12 is associated with combined injuries. A retrospective study was performed using radiographs of posterior cruciate ligament (PCL) kneeling stress x-rays for patients with a posterior cruciate ligament (PCL) tear, with or without concomitant knee injuries. Preoperative standing lateral knee and PCL stress radiographs were evaluated to measure anatomic posterior tibial slope (PTS) and posterior tibial translation (PTT). PTT and PTS were averaged between the two raters to determine an average measurement for both variables. Linear regression analysis was used to assess the correlation. Significance was set at P<0.05. 53 patients met the inclusion criteria for this study. When analyzing posterior tibial slope (PTS) and injured knee posterior tibial translation (PTT), a significant regression with low negative correlation for the entire cohort (Figure 1, P=0.001, R2=0.192) and the isolated cohort (Figure 2, P=0.005, R2=0.270) was found. As posterior tibial slope increased in the injured knee, posterior tibial translation decreased. PTS and injured knee PTT demonstrated a significant negative correlation for the entire cohort and the isolated PCL cohort, indicating an important relationship. 

The goal of this project is to identify patients with recurrent ketoacidosis without diabetes and genetically test them to look for a Monocarboxylate Transporter 1 (MCT1) mutation. Normally, under fasting conditions, the liver will break down fatty acids and produce ketone bodies as a source of energy. Ketoacidosis occurs when ketone bodies are overproduced usually due to a failure in insulin regulation such as diabetes mellitus. The main hypothesis of this project is that patients with recurrent ketoacidosis without diabetes may have a defect in MCT1. In the astrocytes in the brain, MCT1, encoded by SLC16A1 gene, acts as a transmembrane transporter for molecules with one carboxylate group such as lactate, pyruvate, and ketone bodies. Defects in this transporter could result in overproduction of ketone bodies, thus leading to ketoacidosis, neurodegeneration, and cognitive defects. Working with Fairview Health Systems, patients will be screened for ketoacidosis without a previous diagnosis of diabetes. Patients will be recruited for the study, asked to give a DNA sample, and analyzed for MCT1 mutations. 

Cystic fibrosis (CF), caused by biallelic inactivating mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene, is highly associated with the development of colon polyps and increased risk of colorectal cancer (CRC). Various evidence suggests that CFTR acts as a tumor suppressor in the development of CRC: 1) CF patients and heterozygous carriers of CFTR mutations develop disease at an increased rate when compared to cohorts with fully functional CFTR; 2) Cftr knockout mice develop more intestinal tumors than Cftr wild-type mice; 3) Sporadic CRC patients with lower expression of CFTR in their tumors demonstrate poorer survival rates. Further, BRAF V600E mutations are known to be oncogenic drivers of CRC through constitutive activation of the MAPK pathway that regulates proliferation. To investigate the interaction between CFTR and BRAF V600E in the growth and proliferation of CRC, we examined activation of ERK1 and ERK2 as measured by phosphorylation in CFTR wild-type and knockout human Caco2 CRC cell lines in the presence or absence of overexpression of a plasmid encoding BRAF V600E. Our results demonstrate no significant difference in ERK activity between CFTR knockout and wild-type controls. However, further investigation is necessary to characterize interactions of CFTR and BRAF V600E under more physiologic conditions.

Breast cancer is the 2nd most common cancer and cause of cancer death in women in the United States. As such, screening via mammogram and breast exams is critical in diagnosing breast cancers before significant growth or metastasis occurs. However, not all populations have equal access to this preventative care. Rural populations tend to live farther away from healthcare facilities, making cancer screening more difficult to obtain. As a result, rural populations have been shown to suffer from increased mortality from breast cancer compared to their urban counterparts. To further investigate these disparities between rural and urban populations, we examined how average cancer stage at diagnosis and method of cancer detection differed between rural and urban populations in four Nebraska cancer treatment centers using diagnosis data from the Breast Cancer Collaborative Registry. Individuals were placed into urban density categories based on the Frontier and Remote (FAR) area codes. At this time, the data have been visualized but not statistically analyzed. Visual inspection of the data suggest that individuals in more rural areas may be diagnosed at a later stage than those in urban areas. The data may also suggest that individuals in rural areas are less likely to detect their breast cancer through screening. However, we are unable to provide any conclusions as of yet.

The Duluth Family Medicine Clinic (DFMC) has low cancer screening rates for colon, breast, and cervical cancer. Previous initiatives were ineffective. Thus, we wanted to better understand what specific barriers prevent DFMC patients from getting screened for cancer to create more targeted interventions. Extensive research exists on barriers to cancer screening, but there is limited data on patient populations the DFMC serves, low-income, uninsured, and unhoused people. A survey was conducted of all DFMC staff including physician residents. The survey asked participants to identify the barriers their patients encountered and why cancer screening rates were low. We obtained 34 responses (13 residents) with a 52.3% response rate. 82% of participants were in a patient-facing role. “Not motivated/not important” was the most reported reason for why a patient was not up to date on colon and breast cancer screening. For cervical cancer, “embarrassed/uncomfortable/modest” was the biggest barrier. The “Personal” reasons category was greatest for all 3 cancer screenings. This suggests that DFMC staff believe the individual patient has the most control over their healthcare and less significance is given to social and structural drivers of health. However, responses indicated that DFMC patients have many priorities that are more important than cancer screenings, suggesting “other health problems limit ability or are a greater priority” may more accurately describe patient barriers.

Individuals who do not attend their scheduled appointment as well as not calling to cancel the appointment beforehand create difficulty for health systems at many levels including patient experience. Many departments are affected causing administrative burden, lost revenue, provider time strain, and lost opportunities for learning in residency program clinics. Residency programs may struggle with appointment attendance due to frequency of provider turnover, patient population, or insurance reimbursement availability. The Duluth Family Medicine Clinic (DFMC) had 5244 appointments that were no call no showed from July 1, 2022 to June 30, 2023, averaging 20 per day. The 30-40 year old age group had the largest number of unique individuals completing the most visits at DFMC. Ironically, the 30-40 age group also had the highest number of individuals who had no call no show appointments and made up the largest quantity of no call no show appointments by age. The 30-40 year-old age group most frequently seeking healthcare is a unique finding not well described in literature. Designing and implementing interventions for this age group could include technology, since these individuals should be comfortable and provided reliable internet is accessible.

ATV and snowmobile use is a common recreational activity for many people in the United States. Use of these machines for Minnesota residents has had increase in recent years, where registered all-terrain vehicles increased in 2022 by a significant amount. ATV accidents have been shown to cause serious harm to both drivers and riders, especially for the pediatric population. All-terrain-vehicle-related injuries among children younger than age 15 years result in hospitalization at a rate nearly seven times greater than that of all other pediatric trauma. Injuries in the pediatric population can be extensive, with the most prevalent being orthopedic traumas, and the second most common injury being head injuries. In this study, we will be retrospectively evaluating the charts of patients 16 years old and from existing data in the Essentia Health Trauma Registry to compare pediatric patients in two groups: 1) those admitted to EH-SMMC Trauma with helmeted or non-helmeted ATV accidents and 2) a comparison group of those admitted for car accidents. This data will be used to evaluate the outcome disparities in patients that were helmeted versus non-helmeted during the accident, RUCA code to determine rural prevalence, whether the accident occurred on a roadway or recreational trail, and if the patient was driving or a passenger when the accident occurred.  

Key words: TBI (traumatic brain injury), pediatrics, ATV, AIShead (abbreviated injury score, head)

Helicopter-Based Emergency Medical Services (HEMS) has become a mainstay of prehospital emergency trauma care and has the potential to improve timely trauma care in rural areas. Rapid transport of patients via HEMS to a designated trauma center may improve outcomes after traumatic brain injury (TBI). We evaluated how HEMS affects pre-hospital times and outcomes of TBIs in a rural trauma system. All TBI patients transported by EMS (ground or air) to Saint Mary’s Medical Center (SMMC) were retrospectively reviewed between 2016 and 2021. SMMC is a level 1 trauma center in Duluth, MN. Injury severity, mode of prehospital transport, and duration of transport were obtained. Severity of injury was defined by head abbreviated injury score (AIS) and the injury severity score (ISS). Based on our results most patients transported by HEMS were injured in rural areas and many were severely injured. However, transport times were prolonged even with HEMS, and in this study we did not find improved outcomes with HEMS transport. The long transport times must be interpreted in the setting of a vast rural trauma system that this Level 1 Trauma center serves, but the long delays to trauma center are still notable. This study points out the need for limited prehospital resources (HEMS) to be used effectively and additional protocols may be needed to target patients that will benefit most from HEMS transportation.

Rural communities face many obstacles when it comes to accessible healthcare. Over 25% of the population in Minnesota is considered rural under the census tract rural-urban commuting area (RUCA) codes. The delay in care due to rurality may have detrimental effects on outcomes for individuals who sustain traumatic brain injuries (TBI). We aimed to evaluate how injuries in rural locations affect outcomes after TBI. We performed a retrospective review of all individuals who presented with a TBI between 1/2016-4/2021 to our Level 1 Trauma Center: Essentia Health-Saint Mary’s Medical Center. RUCA code and distressed communities index (DCI) (a zip code based social determinant of health score) were collected for all injuries. In our review, 1116 patients sustained a TBI during the study period and had pre-hospital data available. Overall, the patient data we pulled suggested patients from rural communities are more likely to sustain more severe head injuries and have worse outcomes. More research will need to be conducted to identify additional correlational data, but this study serves as a starting point for identifying outcomes in relation to rurality.

It has been established that rates of emergency department visits are higher for adults with dementia in rural vs urban regions of Minnesota. In order to further analyze the perceptions of rural physicians about what served to enhance or prevent referral to dementia care, we performed a qualitative, secondary thematic analysis with data collected by interviews with 8 providers in northern MN. Line by line coding using gerunds; then, focused codes were used to develop preliminary themes. Factors identified to enhance provider referrals included valuing early diagnosis and using strategies to open conversations about memory loss. Factors found to prevent provider referrals included devaluing early diagnosis, caring for patients who dismiss healthcare services, and stigma surrounding a dementia diagnosis. These findings highlight how rural cultural factors influence effective dementia care in Northern Minnesota and how both physician and patient beliefs and understandings of the illness are a critical factor in diagnosis. 

Cannabis legalization will likely result in some degree of de-stigmatization and increased use. Previous studies have shown separate links between heavy cannabis use with early life adversity (ELA), impulsivity, and younger age of first use of cannabis. This study sought to combine these measures in examining their links with heavy cannabis use by testing the mediating role of impulsivity, as measured by delayed discounting (DD) and age of first use as a method of exploring the mechanism for later life addiction. 576 people were recruited using an online survey and answered questions pertaining to social history and drug use. Participants were then classified into four cannabis use categories based on level and frequency of consumption. ELA, Age of first cannabis use, and delay discounting all predicted heavy cannabis use. While age of onset mediated the link between ELA and heavy cannabis use, the mediating effect of delayed discounting was not significant. Our results show that early life adversity is associated with increased risk for heavy cannabis use, and this association is mediated by early use of this substance. Overall, data supports higher likelihood of ELA causing earlier experimentation and use of cannabis, and both factors are likely to contribute to heavy use later in life. Although delayed discounting predicted heavy cannabis use it did not mediate effects of ELA on this use.

Multiple studies since 2020 have demonstrated that Black patients, as compared to White patients, have increased rates of occult hypoxemia, using patient-reported races as comparator groups. To better understand how skin pigmentation may introduce bias into the estimation of oxygen saturation using pulse oximetry, it is important to use an objective measure of skin tone in place of non-specific categories of race. This prospective cohort study will build on past research by using an electronic skin colorimeter device to evaluate if darker skin pigmentation, as compared to lighter skin pigmentation, is associated with underestimation of the true oxygen saturation as measured from arterial blood. Adult patients in the ICU and emergency department with an arterial blood gas (ABG) being drawn as part of routine clinical care with a pulse oximeter reading > 92% and appropriate plethysmograph waveform will be included. Simultaneous SpO2 readings at time of ABG draw will be collected. Informed consent will be acquired from patients to acquire quantitative skin pigmentation readings by a noninvasive skin colorimeter and a qualitative classification on the Monk Skin Tone Scale. The primary endpoint will be the relative risk of occult hypoxemia according to 6 skin pigmentation groups by colorimeter, and 10 skin tone groups, spanning very light skin to dark skin. The primary analysis will use a Mantel-Haenszel chi-square test. Enrollment period will be from March 2023 until March 2024.

Racial disparities persist in obstetric care, with minorities, especially African Americans, having higher cesarean rates (Buckley et al., 2022). The VBAC calculator, designed to help with vaginal birth after cesarean (VBAC), unintentionally reinforced these disparities due to embedded racial bias (Vyas et al., 2019). Despite efforts to eliminate race-based factors (Grobman et al., 2021), underlying racism impacts VBAC outcomes, affecting patient autonomy and informed consent. This study analyzed 2019-2021 data from the CDC, revealing significant racial disparities in VBAC utilization, even after adjusting for other factors. Inadvertent racial bias in the VBAC calculator, potentially from historical biases in medical algorithms or unintended inclusion of demographic variables, seems to contribute to these persistent disparities. Equitable access to VBAC is crucial. Eliminating race from medical prediction tools is essential to reduce disparities and improve outcomes. Collaboration among policymakers, healthcare professionals, and organizations is vital to dismantle biases, establish equitable care, and overcome racial barriers. Addressing these issues can promote patient-centered care and reduce disparities in obstetric outcomes. Rectifying these disparities is a public health imperative. A comprehensive, patient-centered approach will enhance outcomes for all, regardless of race or ethnicity, ultimately benefiting society as a whole.

COVID-19 vaccination provides critical protection, but vaccine hesitancy persists despite the benefits. Understanding perceptions of boosters within Minnesota can inform the work of public health institutions and healthcare providers when promoting vaccine utilization. We surveyed Minnesota fairgoers regarding their thoughts on COVID-19 vaccination boosters to gain insight into themes that are important in vaccine perception. Participants were asked how many doses of COVID-19 vaccination they had received in addition to an open-ended question about their thoughts on COVID-19 boosters. Responses were coded by general attitude (positive, negative, neutral) and by theme. Some themes, such as utility and efficacy, were common across all vaccination statuses. Others, such as safety, personal liberty, and mistrust were top themes for those with 0 or 1-2 doses of COVID-19 vaccine. Notably, neutral responses accounted for ~15% of participants who had received 0 or 1-2 doses. This demonstrates a proportion of people who may be more receptive to messaging promoting vaccine utilization than those who do have a negative perception. These trends can be used to help inform approaches to increasing vaccine utilization among Minnesotans with various vaccination statuses.

COVID-19 affected patient access to cardiac intervention and cardiac surgery; however, cardiac surgical volumes continued at the usual pace at St. Luke’s Hospital (SLH) in Duluth, MN; whereas, most other surgeries saw a decline. Given the known adverse effects COVID and associated inflammation have on cardiac physiology, previous studies have found increases in emergent and urgent cardiac surgery cases as well as an increase in postoperative complications. Given that little of this research has been conducted in or focused on rural communities, our study aims to fill this literature gap and explore how cardiac surgery outcomes in rural communities were affected by COVID-19. We conducted a retrospective chart review of all patients admitted to SLH between 1/1/2018 and 12/31/2021 who underwent cardiac, surgical, or percutaneous interventions (n=609). Our data shows that individuals who underwent a Coronary Artery Bypass Graft Surgery (CABG) between 1/2020-12/2021 had significantly different postoperative outcomes when compared against the pre-COVID cohort (1/2018-12/2019). Importantly, rural identity did not significantly influence patient outcomes. The initial analyses suggest that postoperative procedures were expedited during the COVID-19 pandemic, likely due to unprecedented demand placed on hospital systems for ICU space and ventilators. Further analyses exploring long term outcomes are needed to evaluate whether expedition of these processes compromised patient health. 

Intravenous drug use (IVDU) is a chronic, steadily rising dilemma that is striking the heart of America. With IVDU on the rise, rates of IVDU associated diseases, such as infectious endocarditis (IE) have also been increasing. While current literature has focused on national trends, we aim to investigate the incidence of IE and compare features of infection, management, and outcomes of individuals with intravenous drug associated (IVDA) IE and non-IVDA-IE presenting to a single hospital in Duluth, MN between 2008 and 2022. Hospitalized patients with a diagnosis of IE at St. Luke’s Hospital from 2008 to 2022 were included in the study based on the International Classification of Diseases, Ninth and Tenth Revisions (ICD-9, ICD-10). A total of 197 cases were identified and included in a preliminary analysis. Of the 197 total cases of IE, 87 were associated with IVDU (110 non-IVDU). Rates of both IVDA- and non-IVDA-IE appear to have increased from 2008 to 2022. Of the patients with non-IVDA-IE, 98% were White and 2% were American Indian/Alaska Native. Additionally 70% of the patients with non-IVDA-IE were male (30% female). Of the patients with IVDA-IE, 55% were White, 43% were American Indian/Alaska Native, and 2% Other. 48% of the patients with IVDA-IE were male (52% female). Although these results are preliminary, it is apparent that public health level actions and associated interventions by health care systems are needed to better treat and prevent cases of IVDA-IE. 

Atrial fibrillation (AF) is a chronic disease that affects millions of individuals and the prevalence of the disease is projected to reach 12.1 million in the United States by 2030. The risk of developing AF has been attributed to many factors including underlying chronic diseases such as hypertension, obesity, and diabetes. The objective of our study was to determine whether neighborhood characteristics and the Area Deprivation Index (ADI) are associated with outcomes in patients with atrial fibrillation in a Midwest community. We used the Expanded Rochester Epidemiology to identify patients with new-onset AF from January 1, 2013, through December 31, 2017. Patients with AF were identified using an algorithm requiring both a diagnosis code ECG or Holter monitor. To identify Neighborhood Characteristics, we used publicly available data linked to addresses, including rural-urban commuting area and area deprivation index. Patients were divided into Urban, Micropolitan, Small Rural, and Isolated and four ADI Quartiles using nationally ranked data. Results showed that hose in urban areas having a significantly lower risk of mortality compared to those in isolated areas while those living in ADI Quartile 1 were at significantly lower risk of death compared to ADI Quartile 4. This is consistent with trends seen in other cardiovascular diseases. Future research is needed to ascertain how both neighborhood characteristics and ADI affect treatment and other outcomes in those living with AF. 

One in 4 high stroke risk (males with a CHA2DS2-VASC score of ≥2 and females with a score of ≥3) atrial fibrillation (AF) patients are not being treated with oral anticoagulation. Essentia Health developed and implemented a novel electronic Care Gap alert (AF Care Gap), based on the CHA2DS2-VASc score to identify high-risk patients not on anticoagulation. An electronic survey was sent to 490 providers to evaluate the usability, acceptability, and obtain feedback from providers on the AF Care Gap. Our survey response rate was 25% (N=121); 51% reported prior use of the AF Care Gap (N=62) with majority (73%) in family medicine. Of respondents, 67% report using the health maintenance section; 57% have seen the AF Care Gap and 51% have used it. Majority of users and nonusers reported when alerted they were “likely” or “extremely likely” to start a conversation about anticoagulation and use it in their future practice (84%). Of those who have used it, 75% of providers were “likely” or “extremely likely” to prescribe anticoagulation. Majority of users would recommend it to others (67%). On the system usability scale, the AF Care Gap scored 72.45 of 100. The acceptance was 27 of 35 using the theory-informed questionnaire. Survey respondents report high usability and acceptability of AF Care Gap. Future evaluation of the AF Care Gap utilization and gaps in management are still needed to improve anticoagulation management for high-risk AF patients. 

In 2023, federal legislation was enacted to increase the Federal Medical Assistance Percentage (FMAP) for Guam and other US territories, presenting an opportunity to offset local program spending and facilitate program improvement. Through this legislation, the government of Guam was required to create and submit a strategic plan and evaluation to the Health and Human Services department (HHS). The strategic plan and evaluation consists of 21 areas of program improvement and are all organized into four sections: Workforce Development, Financing, Systems Implementation and Operation, Program Integrity and Transparency. This research aims to review this document and to use existing literature to contextualize and report its components. 

Residencies across the country have come to recognize the stress, anxiety, depression, and burnout residents face. The Duluth Family Medicine Residency Program (DFMRP) noted a need for an evidence-based wellness curriculum. A literature review of the evidence-based interventions was used to guide future wellness curriculum. A total of 10 reviews were identified, with a total of 64 unique outcome studies. Many studies were unable to draw definitive conclusions about the type and intensity of interventions that are effective due to small sample size or limitations in research methodology. Multiple studies recommended implementing resilience interventions and mindfulness training. At DFMRP, surveys were distributed to all residents from May 2022 to May 2023 following each wellness activity in the current curriculum. DFMRP wellness activities were grouped into 4 categories: resilience, nature-based mindfulness, unstructured time, and resident well-being discussions (with a non-faculty family medicine physician). Majority of residents found wellness activities to be useful or very useful across all 4 disciplines. Some proposed topics by residents include dealing with mistakes in medicine, mindfulness, and handling the unknown. Resident suggestions on topics will be incorporated into the proposed curriculum and will be provided to faculty and residents for feedback. Surveys should continue to be provided to assess resident perceptions and guide future curriculum.

The authors’ central goal was to design a plan for the anticipated physician deficit in the North Midwest region of the United States. We analyzed the Association of American Medical Colleges’ (AAMC) 2019 projections, which have forewarned of a significant shortage by 2034. This study addresses this challenge by proposing targeted plans to augment medical student and resident capacity in Iowa, Minnesota, North Dakota, South Dakota, and Wisconsin. The purpose was to develop targeted, state-specific plans to ensure an adequate supply of physicians to meet the growing demands on the healthcare systems. The calculations identified the approximate balance between the growing healthcare needs of the North Midwest region and the capacity of the existing medical education and residency training programs. We suggested the incremental expansion of medical student seats and residency positions over the next 10 years and outlined how to bridge the physician gap while avoiding any undue stress on the existing systems. The application of these state-specific strategies could establish a robust physician workforce that meets the unique healthcare demands of each North Midwest state. Ultimately, the overarching goal was to ensure equitable access to healthcare services across the regions while safeguarding the health and well-being of all constituents.