Publications by authors named "Rebecca Vitale"

9 Publications

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A new interventional home care model for COVID management: Virtual Covid IP.

Diabetes Metab Syndr 2021 Jul 23;15(5):102228. Epub 2021 Jul 23.

Department of Diabetology, Jothydev's Diabetes Research Centers, Kerala, India.

Aim: Amidst COVID-19 pandemic, the health care delivery in India faces major challenges owing to the overwhelming hospitals, exhausted healthcare workers, and shortage of crucial medical supplies such as ventilators and oxygen. The study aims to propose a novel successful interventional home care model, the Virtual COVID In-Patient (VCIP) care for effective COVID management.

Methods: The Covid-19 positive patients enrolled in VCIP were chosen for the study. A 24/7 active multidisciplinary WhatsApp group was created for each patient, for remote monitoring of temperature, blood pressure, blood glucose, respiratory and pulse rate along with the symptoms. Advice on sleep and exercises were given along with the medication via video-audio consultations. Lab facility was provided at the doorstep. Training on various devices, medications including steroids, delivering subcutaneous injections etc were given via video platforms.

Results: Among the 220 patients who availed the VCIP facility, only two were hospitalized, yielding a 99.5 % success rate in preventing hospitalizations and patients enrolled have been immensely satisfied with their experience.

Conclusions: With similar pandemics anticipated in near future, VCIP model may be considered for successful domiciliary treatment and overcoming the challenges.
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July 2021

Euglycemic Diabetic Ketoacidosis With COVID-19 Infection in Patients With Type 2 Diabetes Taking SGLT2 Inhibitors.

AACE Clin Case Rep 2021 Jan-Feb;7(1):10-13. Epub 2020 Dec 28.

Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.

Objective: Diabetes mellitus is associated with poor outcomes in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Diabetic ketoacidosis (DKA) has also been reported to occur with this virus. A cluster of cases of euglycemic DKA (euDKA) was identified in patients with type 2 diabetes mellitus using sodium-glucose cotransporter-2 inhibitors (SGLT2is) who developed SARS-CoV-2 infection.

Methods: The cases were identified by the authors while providing clinical care, and details were collected.

Results: Five cases of euDKA, presenting with glucose levels <300 mg/dL, were identified over the course of 2 months by the endocrinology consult service. All patients had a history of type 2 diabetes mellitus with no known history of DKA. All were taking SGLT2is. Oral antihyperglycemic medications were stopped for all patients on admission. All received intravenous insulin infusion to treat DKA before being transitioned to a subcutaneous insulin regimen. SGLT2i use was discontinued for all patients who were discharged.

Conclusion: EuDKA has been seen in the setting of acute illness in patients using SGLT2is, but this cluster of cases suggests that there is a specific association with SARS-CoV-2 infection. In addition to the known risk of euDKA with SGLT2i use, coronavirus disease 2019-specific mechanisms may include a direct toxic effect of the virus on the pancreatic islets, an accelerated inflammatory response promoting ketosis, and the diuretic effect of SGLT2i in conjunction with anorexia and vomiting. It is crucial to counsel patients to stop SGLT2is when sick, especially if SARS-CoV-2 infection is suspected.
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December 2020

Improving patient satisfaction through improved telephone triage in a primary care practice.

Fam Med Community Health 2019 2;7(4):e000208. Epub 2019 Dec 2.

Department of Internal Medicine and Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA.

Objective: The objective of this study was to improve the telephone communication experience for patients in a primary care practice.

Design: An exploratory survey was conducted that revealed suboptimal patient satisfaction with clinic access due to the telephone triage system. Several interventions were designed: a monthly quality meeting was established among clinic staff, all phone interactions were recorded in the electronic medical record (EMR) and clinic appointments were made available several months in advance. A follow-up survey was conducted to evaluate these interventions.

Setting: The study was conducted in a multispecialty, urban-based, resident-faculty practice from November 2016 to November 2017.

Participants: Subjects were recruited in a convenience sample from the waiting room. 200 subjects participated in the initial survey and 215 in the second survey.

Results: After the interventions, patients felt that their questions were answered more frequently than before (p<0.01). They also felt that appointments were easier to make (p=0.03). A similar number of patients reported seeking emergency care because they were unable to reach a provider (33.8% vs 31.9%, p=0.68). The percentage of patients who received a call back within 24 hours increased, but it was not statistically significant (38.6% vs 44%, p=0.13).

Conclusion: Improving telephone triage through implementing a monthly quality improvement meeting, optimising use of the EMR and opening schedules several months in advance resulted in several improvements in the patient experience, but did not change use of emergency services. Further interventions, including increased resource allocation, are needed to optimise patient experience.
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December 2019

A resident-led project to improve documentation of overweight and obesity in a primary care clinic.

J Community Hosp Intern Med Perspect 2019 1;9(5):377-383. Epub 2019 Nov 1.

Departments of Internal Medicine and Pediatrics, Yale University School of Medicine, New Haven, CT, USA.

: Although the prevalence of overweight and obesity (OW/OB) has increased in the last three decades, studies show that these conditions are sub-optimally documented by physicians. Health information technology tools have varying effects on improving documentation of OW/OB but often have to be complemented with other interventions to be effective. : Upon identifying low rates of documentation of diagnoses of overweight and obesity by resident and attending physicians, despite the use of an electronic health record (EHR) with automated BMI calculations, we performed a quality improvement (QI) project to improve documentation of these diagnoses for patients in our community hospital primary care clinic. : The EHR was reviewed to determine documentation rates by resident and attending physicians between 1 March 2018 and 31 September 2018. We collected pre-intervention data, developed interventions, and implemented tests of change using Plan-Do-Study-Act (PDSA) cycles to improve documentation of OW/OB. : Documentation of overweight and obesity diagnoses increased from a baseline of 46% to 79% over a 20-week period after initiation of our project. : We demonstrate the successful implementation of resident-led, multi-faceted interventions in a team-based QI project to optimize documentation of OW/OB in the EHR.
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November 2019

An Effective Diabetic Ketoacidosis Prevention Intervention in Children With Type 1 Diabetes.

SAGE Open Nurs 2018 Jan-Dec;4:2377960818804742. Epub 2018 Nov 26.

Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA.

The objective of this study was to evaluate the effectiveness of a brief, office-based educational intervention to increase parent or patient recognition of the early warning signs and symptoms of diabetic ketoacidosis (DKA). Forty-two patients aged > 13 years and 34 parents of children aged ≤ 13 years were given a pretest questionnaire about their knowledge of signs and symptoms of DKA and sick day management practices. They received a brief refresher course on sick day management specific to their treatment modality (pump vs. injection) and were given a take-home flow sheet of guidelines for diabetes sick day management. Subjects were retested with the same knowledge questionnaire after 6 to 12 months. Patients or parents scored higher on the posttest than the pretest and called the emergency line for assistance more frequently ( = .032) following the intervention. Emergency department visits were significantly reduced in adolescents ( = .024). A short educational intervention and printed management tool is effective in improving sick day and DKA knowledge and appears to be effective in reducing emergency department visits by increasing utilization of a diabetes emergency line for early outpatient intervention.
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November 2018

Developing an evidence-based program sustainability training curriculum: a group randomized, multi-phase approach.

Implement Sci 2018 09 26;13(1):126. Epub 2018 Sep 26.

Center for Public Health System Science, Brown School at Washington University in St Louis, St Louis, MO, USA.

Background: The emergence of dissemination and implementation (D&I) science has driven a rapid increase in studies of how new scientific discoveries are translated and developed into evidence-based programs and policies. However, D&I science has paid much less attention to what happens to programs once they have been implemented. Public health programs can only deliver benefits if they reach maturity and sustain activities over time. In order to achieve the full benefits of significant investment in public health research and program development, there must be an understanding of the factors that relate to sustainability to inform development of tools and trainings to support strategic long-term program sustainability. Tobacco control programs, specifically, vary in their abilities to support and sustain themselves over time. As of 2018, most states still do not meet the CDC-recommended level for funding their TC program, allowing tobacco use to remain the leading cause of preventable disease and death in the USA. The purpose of this study is to empirically develop, test, and disseminate training programs to improve the sustainability of evidence-based state tobacco control programs and thus, tobacco-related health outcomes.

Methods: This paper describes the methods of a group randomized, multi-phase study that evaluates the empirically developed "Program Sustainability Action Planning Training" and technical assistance in US state-level tobacco control programs. Phase 1 includes developing the sustainability action planning training curriculum and technical assistance protocol and developing measures to assess long-term program sustainability. Phase 2 includes a group randomized trial to test the effectiveness of the training and technical assistance in improving sustainability outcomes in 24 state tobacco control programs (12 intervention, 12 comparison). Phase 3 includes the active dissemination of final training curricula materials to a broader public health audience.

Discussion: Empirical evidence has established that program sustainability can improve through training and technical assistance; however, to our knowledge, no evidence-based sustainability training curriculum program exists. Therefore, systematic methods are needed to develop, test, and disseminate a training that improves the sustainability of evidence-based programs.

Trial Registration: NCT03598114 . Registered 25 July 2018-retrospectively registered.
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September 2018

The two levels of care for diabetes in a developing country: Mechanisms for improved intermediate health outcomes.

Diabetes Metab Syndr 2016 Jan-Mar;10(1 Suppl 1):S90-4. Epub 2015 Oct 8.

Department of Diabetes, Jothydev's Diabetes Research Centre, Trivandrum, Kerala, India. Electronic address:

India has over 70 million citizens with diabetes, the second-most of any country worldwide. Disparities in learning skills, resources, education, and physician practices make it difficult to practically implement the diabetes management guidelines recommended by international scientific organizations. In its guidelines, the International Diabetes Federation advocates for three different levels of care based on availability of resources. This study investigates the differences in intermediate health outcomes between two diabetes care programs: one a comprehensive diabetes centre, the other a limited care setting. The comprehensive centre offers telemedicine and periodic diabetes education, empowering patients and providing 24-hour advice on lifestyle modifications, diet, and exercise. All patients of this centre practice self-monitoring of blood glucose. The subjects in the limited care setting receive minimal investigations and periodic physical follow-ups, and few patients have access to home glucose monitoring. The results showed that HbA1c (7.62 vs. 8.58, p=0.003), cholesterol (134.4 vs. 173.4, p<0.001), and diastolic blood pressure (72.9 vs. 77.0, p=0.016) were significantly lower in patients receiving comprehensive care, while the reductions in systolic blood pressure (134.6 vs. 138.7, p=0.202) did not achieve statistical significance. These reductions, which remained significant after correcting for confounding factors, could be attributed to more aggressive treatment regimens in the comprehensive care centre, as well as the real-time, frequent communication with medical professionals in the telemedicine program.
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January 2017

Adjuvant induced glucose uptake by activated T cells is not correlated with increased survival.

Adv Exp Med Biol 2008 ;614:65-72

Institute for Cellular Therapeutics, University of Louisville School of Medicine, 570, S. Preston Street, Louisville, KY 40202, USA.

Authors contributed equally to this manuscript Natural adjuvants, such as bacterial lipopolysaccharide (LPS), activate antigen presenting cells via Toll-like receptors and, indirectly, increase the survival of antigen-activated T cells. The molecular mechanisms leading to increased survival remain poorly defined. Because T cell clonal expansion leads to high energy demands, we hypothesized that increased glucose uptake and/or utilization in adjuvant-activated T cells could be important molecular event(s) that would lead to adjuvant-associated T cell survival advantage. Using a fluorescent analog of 2-deoxyglucose, 2-NBDG, we measured glucose accumulation and rate of uptake in T cells from mice treated with antigen in the absence or presence of LPS. Although adjuvant activated T cells increased the accumulation of 2-NBDG, the rate of uptake was unchanged compared to cells activated with only antigen. Furthermore, glucose transport inhibitors, cytochalasin B or phloretin, decreased the accumulation of glucose in adjuvant-treated T cells, but this decrease did not impair adjuvant-associated survival advantages. Together, these data indicate that increased glucose uptake through glucose transporters is not required for increased survival of activated T cells.
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April 2008