Browsing by Author "Raman, Maitreyi"
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Item Open Access A Mixed Methods Study on the Effect of Flipping the Undergraduate Medical Classroom(2017-11-14) Burak, Kelly W.; Raman, Maitreyi; Paget, Michael; Busche, Kevin; Coderre, Sylvain; McLaughlin, KevinThe flipped classroom model is increasingly being adopted in healthcare education, despite the fact that recent systematic reviews in the nursing and medical education literature suggest that this method of instructional design is not inherently better or worse than the traditional classroom. In this study, we used a sequential, explanatory mixed methods design to assess the impact of flipping the hepatology classroom for preclinical medical students. Compared to students in the traditional classroom, students in the flipped classroom had significantly lower mean (SD) ratings of their learning experiences (3.48 (1.10) vs. 4.50 (0.72), p < 0.001, d = 1.10), but better performance on the hepatology content of the end-of-course examination (78.0% (11.7%) vs. 74.2 (15.1%), respectively, p < 0.01, d = 0.3). Based upon our qualitative data analyses, we propose that the flipped classroom induced a change in the learning process of students by requiring increased preparation for classroom learning and promoting greater learner autonomy, which resulted in better retention of learned material, but reduced enjoyment of the learning experience. This dissonance in outcomes is captured in the words of one flipped classroom student: “…I hated it while I was learning it, but boy did I remember it…”. Based upon our dissonant outcomes and the inconsistent findings in the literature, we feel that there is still equipoise regarding the effectiveness of the flipped classroom, and further studies are needed to describe ways of making the flipped classroom a more effective (±more enjoyable) learning experience.Item Open Access Assessment of Blood-Derived Macrophages from Individuals with Crohn's Disease: Potential Role of Diet and Selenium(2024-01-04) Sousa, James Amedeo; Raman, Maitreyi; McKay, Derek; Ferraz, Jose; Canton, JohnathanThere is growing evidence of the role of diet in modulating immune function in inflammatory conditions such as inflammatory bowel disease (IBD). Specifically, there are alterations in macrophage populations and function found in patients with IBD such as reduced polarization to the M(IL-4) phenotype. Moreover, there are specific micronutrients such as selenium (Se) that patients with IBD are commonly deficient in and can also affect macrophage function and polarization. However, whether dietary intervention or Se intake can impact macrophage polarization and function in patients with Crohn’s disease (CD) is unknown. Therefore, utilizing a selenium rich Mediterranean therapeutic diet intervention (TDI) in patients with active CD, I addressed the following hypotheses: 1) there are innate differences in macrophages derived from healthy donor and patients with CD that can be modified by diet intervention and 2) that macrophages derived from patients with active CD are more prone to H2O2-induced cytotoxicity through the ferroptosis pathway. This is the first study that I am aware of to show reduced selenoprotein expression in monocyte-derived macrophages from patients with CD. This suggests reduced antioxidant defence and is further supported by increased H2O2-induced cytotoxicity compared with healthy macrophages. The TDI was beneficial with improvement in biomarkers of disease activity and dietary habits. However, there was no significant effect on the Se status of the patients. There was, however, a relationship between the M(IL-4) CD206 mRNA response and change in CRP concentration after diet intervention. Despite being able to increase GPx1 expression, Se supplementation in vitro had no significant effect on macrophage polarization to the M(IL-4) phenotype. Lastly, markers of ferroptosis were increased in healthy and patient-derived macrophages treated with H2O2, indicating that H2O2-induced cell death through the ferroptosis pathway. The differences found in selenoprotein expression and reduced antioxidant defence between healthy volunteer and patient-derived macrophages highlights the role of oxidative stress in IBD. In terms of the TDI, there is evidence of its therapeutic effect and positive impact on macrophages. Lastly, the increased cytotoxicity in CD derived-macrophages further evokes the need to study the physiological impacts of macrophage ferroptosis in IBD pathophysiology.Item Open Access Characterization of Hepatitis B Virus (HBV) and Host Cytokine Patterns in a Multiethnic Cohort of Patients with Non-alcoholic Fatty Liver Disease (NAFLD) and Chronic Hepatitis B (CHB)(2020-01-06) Lucko, Aaron Michael; Coffin, Carla S.; Chadee, Kris C.; Raman, MaitreyiStudies have reported conflicting data on the relationship between non-alcoholic fatty liver disease (NAFLD) and chronic hepatitis B (CHB). We aimed to identify how metabolic factors associated with NAFLD (diabetes, hypertension, central obesity and dyslipidemia) affects the hepatitis B virus (HBV) in patients with CHB. Patients with CHB and NAFLD were prospectively enrolled from 3 Canadian liver clinics. Patients underwent standardized liver tests (liver stiffness measurement [LSM] by transient elastography, controlled attenuation parameter [CAP]) and HBV clinical tests (quantitative [q] HBV surface antigen [HBsAg], HBeAg). Plasma levels of HBV DNA and RNA were measured by quantitative (q)PCR. Viral genotype was identified by population and next generation sequencing of the precore (C)/C and presurface (S)/S genes and analyzed using MEGA 7. Peripheral blood mononuclear cells (PBMCs) were stimulated ex vivo for 72h by HBV core antigen (HBcAg) or HBsAg peptides. PBMC supernatant and serum were analyzed for cytokine/chemokine markers using a 13-plex immunoassay. Kruskal-Wallis, multiple linear regression, Chi-square, and Fischer’s exact tests were performed using R commander. Of 48 subjects enrolled (median age 44.5 [IQR 16.8]), most were male (n=31), of Asian descent (n=29), and HBeAg negative (n=45). In HBeAg negative patients, the mean CAP was 30652 dB/m, ALT was 4026 IU/mL, and LSM was 5.82.0 kPa, indicating high steatosis without fibrosis. In all patients, the HBV genotypes were 13% A, 16% B, 46% C, 17% D, 6% E. Mutations associated with severe liver disease, anti-viral drug resistance, immune escape, and HBeAg negativity were identified in all subjects. Obese patients had increased qHBsAg levels, while diabetic patients had increased S gene diversity. Hepatic steatosis severity did not relate to viral factors analyzed. Ex vivo PBMC responses to HBcAg or HBsAg stimulation were not different to unstimulated controls. In this study, a multi-ethnic cohort of CHB and NAFLD patients were prospectively evaluated with novel virologic and host immunological markers. We found that metabolic factors associated with NAFLD correlated to inflammatory cytokine levels, viral genetic characteristics, and HBV replication markers. These viral and host factors can influence the risk of liver disease progression in patients with both NAFLD and CHB, warranting further study.Item Open Access Colorectal Endoscopic Mucosal Resection Curriculum Development(2021-10-24) Kayal, Ahmed; Heitman, Steven J; Coderre, Sylvain; Raman, Maitreyi; McLaughlin, KevinABSTRACTBackground and aimsEndoscopic mucosal resection (EMR) is a commonly performed procedure that is not systematically taught during most training programs. The aim of this study was to evaluate the effectiveness of a one-day didactic and simulation-based EMR curriculum for practicing endoscopists without prior formal training in advanced endoscopic tissue resection.MethodsWe designed a one-day lecture and simulation-based EMR course. Twelve participants completed the course. Effectiveness and clinical utility were evaluated using sequential explanatory mixed methods. All participants completed a pre-course multiple-choice-question (MCQ) examination followed by a different, but thematically similar, post-course MCQ examination. A survey was also conducted to assess cognitive fatigue, perceived benefit, and potential for change in EMR practice. Finally, a delayed MCQ examination was administered 10-14 weeks later to assess knowledge retention and qualitative data were sequentially collected from three candidates via semi-structured interviews.ResultsThe mean pre-course score was 47.8% (SD 12.4%). The mean post-course score was 75% (9.9%) and mean delayed score 70.8% (13.6%), both significantly higher than the mean pre-course score (P <0.001; Cohen’s d = 1.86 and P <0.001; Cohen’s d = 1.47, respectively). There was no significant difference between the mean post- and delayed-course test scores (P =130.2). Three themes emerged from the interviews: (1) a need for EMR training, (2) improved knowledge evaluating polyps and (3) changed or refined EMR technique after the course.ConclusionsThis study highlights the need for formal education in EMR and demonstrates significant knowledge acquisition and retention of EMR cognitive skills.Item Open Access Evaluating Yoga Therapy for Irritable Bowel Syndrome(2022-06-21) D'Silva, Adrijana; Raman, Maitreyi; Marshall, Deborah; Nasser, Yasmin; Vallance, JeffBackground: Irritable bowel syndrome (IBS) is a chronic disease of the brain-gut axis. Mind-body therapies such as yoga target the central nervous system, autonomic nervous system, immune and endocrine systems involved in the brain-gut axis to improve IBS symptoms and other patient outcomes such as mental health and quality of life. Virtually delivered yoga programming has not been tested nor have the experiences of participants in these programs been explored. Further, we are unaware of the beliefs and attitudes of IBS patients and gastroenterologists towards yoga. Objectives: This thesis had four objectives and they were to: 1) identify patients’ attitudes, subjective norms, perceived behavioural control for yoga, and underlying beliefs and intentions to practice yoga; 2) identify gastroenterologists’ attitudes, perceived supports, barriers and facilitators and intention to recommend a yoga program as part of routine medical care for patients with IBS; 3) explore the feasibility and efficacy of an eight-week virtual yoga program on IBS symptom severity and other patient-reported outcomes compared to an advice-only control group; and 4) explore and describe participants’ experiences in a virtual yoga program, and its impact. Methods: Using mixed-methods, cross-sectional surveys were used to answer aims 1 and 2. A randomized clinical trial answered objective 3 and semi-structured interviews answered objective 4. Results: Patients (N=109) reported controllability, self-efficacy, and affective attitude predicted their intention to practice yoga. Gastroenterologists (N=79) reported they were ten times more likely to recommend yoga if they agreed yoga improves IBS symptoms, however, most were not recommending yoga due to lack of confidence and scientific evidence. The randomized controlled trial (N=79) found virtually delivered yoga was safe, feasible, and efficacious in improving IBS symptoms, quality of life, stress, and fatigue. The interviews revealed the participants had overwhelmingly positive experiences in the program. Conclusions: Virtually delivered yoga programming is acceptable, safe, feasible, and efficacious in the treatment of IBS. Future research is needed to explore how virtually delivered yoga may be positioned as a therapy in the management of IBS.Item Open Access Gut microbiota manipulation with prebiotics in patients with non-alcoholic fatty liver disease: a randomized controlled trial protocol(BMC Gastroenterology, 2015-12-03) Lambert, Jennifer E.; Parnell, Jill A.; Eksteen, Bertus; Raman, Maitreyi; Bomhof, Marc R.; Rioux, Kevin P.; Madsen, Karen L.; Reimer, Raylene A.Background Evidence for the role of the gut microbiome in the pathogenesis of non-alcoholic fatty liver disease (NAFLD) is emerging. Strategies to manipulate the gut microbiota towards a healthier community structure are actively being investigated. Based on their ability to favorably modulate the gut microbiota, prebiotics may provide an inexpensive yet effective dietary treatment for NAFLD. Additionally, prebiotics have established benefits for glucose control and potentially weight control, both advantageous in managing fatty liver disease. Our objective is to evaluate the effects of prebiotic supplementation, adjunct to those achieved with diet-induced weight loss, on heptic injury and liver fat, the gut microbiota, inflammation, glucose tolerance, and satiety in patients with NAFLD. Methods/design In a double blind, placebo controlled, parallel group study, adults (BMI ≥25) with confirmed NAFLD will be randomized to either a 16 g/d prebiotic supplemented group or isocaloric placebo group for 24 weeks (n = 30/group). All participants will receive individualized dietary counseling sessions with a registered dietitian to achieve 10 % weight loss. Primary outcome measures include change in hepatic injury (fibrosis and inflammation) and liver fat. Secondary outcomes include change in body composition, appetite and dietary adherence, glycemic and insulinemic responses and inflammatory cytokines. Mechanisms related to prebiotic-induced changes in gut microbiota (shot-gun sequencing) and their metabolic by-products (volatile organic compounds) and de novo lipogenesis (using deuterium incorporation) will also be investigated. Discussion There are currently no medications or surgical procedures approved for the treatment of NAFLD and weight loss via lifestyle modification remains the cornerstone of current care recommendations. Given that prebiotics target multiple metabolic impairments associated with NAFLD, investigating their ability to modulate the gut microbiota and hepatic health in patients with NAFLD is warranted.Item Open Access Hyperglycemia in Hospitalized Patients Receiving Parental Nutrition Is Associated with Increased Morbidity and Mortality: A Review(2010-08-03) Kumar, Puja Rajender; Crotty, Pam; Raman, MaitreyiParenteral Nutrition (PN) is a valuable life saving intervention which can improve the nutritional status of hospitalized malnourished patients. PN is associated with complications including the development of hyperglycemia. This paper aims to provide a descriptive systematic review regarding the effects of PN-induced hyperglycemia in hospitalized patients, either in the intensive care unit or ward, while formulating and complementing existing guidelines on the administration of PN and glucose monitoring in hospitalized patients. Medline and Pubmed were searched for relevant articles describing complications arising from the development of hyperglycemia in patients receiving PN; four relevant studies were identified in the search. These articles had different glycemic targets and patient populations, and their protocols varied with regards to glycemic control. However, there was consistency regarding the association between hyperglycemia and mortality in patients receiving PN. These studies highlight the need for guidelines regarding monitoring and initiation of therapy in hyperglycemic patients. Unfortunately, all the currently available studies are retrospective in design; a large, prospective, randomized controlled trial regarding glycemic control in patients receiving PN is required for the development of standardized protocols.Item Open Access Implementation strategies for hospital-based probiotic administration in a stepped-wedge cluster randomized trial design for preventing hospital-acquired Clostridioides difficile infection(2023-12-11) Bresee, Lauren C.; Lamont, Nicole; Ocampo, Wrechelle; Holroyd-Leduc, Jayna; Sabuda, Deana; Leal, Jenine; Dalton, Bruce; Kaufman, Jaime; Missaghi, Bayan; Kim, Joseph; Larios, Oscar E.; Henderson, Elizabeth; Raman, Maitreyi; Fletcher, Jared R.; Faris, Peter; Kraft, Scott; Shen, Ye; Louie, Thomas; Conly, John M.Abstract Background Clostridioides difficile infection (CDI) is associated with considerable morbidity and mortality in hospitalized patients, especially among older adults. Probiotics have been evaluated to prevent hospital-acquired (HA) CDI in patients who are receiving systemic antibiotics, but the implementation of timely probiotic administration remains a challenge. We evaluated methods for effective probiotic implementation across a large health region as part of a study to assess the real-world effectiveness of a probiotic to prevent HA-CDI (Prevent CDI-55 +). Methods We used a stepped-wedge cluster-randomized controlled trial across four acute-care adult hospitals (n = 2,490 beds) to implement the use of the probiotic Bio-K + ® (Lactobacillus acidophilus CL1285®, L. casei LBC80R® and L. rhamnosus CLR2®; Laval, Quebec, Canada) in patients 55 years and older receiving systemic antimicrobials. The multifaceted probiotic implementation strategy included electronic clinical decision support, local site champions, and both health care provider and patient educational interventions. Focus groups were conducted during study implementation to identify ongoing barriers and facilitators to probiotic implementation, guiding needed adaptations of the implementation strategy. Focus groups were thematically analyzed using the Theoretical Domains Framework and the Consolidated Framework of Implementation Research. Results A total of 340 education sessions with over 1,800 key partners and participants occurred before and during implementation in each of the four hospitals. Site champions were identified for each included hospital, and both electronic clinical decision support and printed educational resources were available to health care providers and patients. A total of 15 individuals participated in 2 focus group and 7 interviews. Key barriers identified from the focus groups resulted in adaptation of the electronic clinical decision support and the addition of nursing education related to probiotic administration. As a result of modifying implementation strategies for identified behaviour change barriers, probiotic adherence rates were from 66.7 to 75.8% at 72 h of starting antibiotic therapy across the four participating acute care hospitals. Conclusions Use of a barrier-targeted multifaceted approach, including electronic clinical decision support, education, focus groups to guide the adaptation of the implementation plan, and local site champions, resulted in a high probiotic adherence rate in the Prevent CDI-55 + study.Item Open Access Isha yoga practices, vegan diet, and participation in Samyama meditation retreat: impact on the gut microbiome & metabolome – a non-randomized trial(2023-04-05) Raman, Maitreyi; Vishnubhotla, Ramana; Ramay, Hena R.; Gonçalves, Maria C. B.; Shin, Andrea S.; Pawale, Dhanashri; Subramaniam, Balachundhar; Sadhasivam, SenthilkumarAbstract Background Growing evidence suggests a role for gut bacteria and their metabolites in host-signaling responses along the gut-brain axis which may impact mental health. Meditation is increasingly utilized to combat stress, anxiety, and depression symptoms. However, its impact on the microbiome remains unclear. This study observes the effects of preparation and participation in an advanced meditation program (Samyama) implemented with a vegan diet including 50% raw foods, on gut microbiome and metabolites profiles. Methods There were 288 subjects for this study. Stool samples were collected at 3-time points for meditators and household controls. Meditators prepared for 2 months for the Samyama, incorporating daily yoga and meditation practices with a vegan diet including 50% raw foods. Subjects were requested to submit stool samples for 3 time points – 2 months before Samyama (T1), right before Samyama (T2), and 3 months following Samyama (T3). 16 s rRNA sequencing was used to study participants' microbiome. Alpha and beta diversities along with short-chain fatty acid (SCFA) were assessed. Metabolomics were performed on a mass spectrometer coupled to a UHLPC system and analyzed by El-MAVEN software. Results Alpha diversity showed no significant differences between meditators and controls, while beta diversity showed significant changes (padj = 0.001) after Samyama in meditators’ microbiota composition. After the preparation phase, changes in branched short-chain fatty acids, higher levels of iso-valerate (padj = 0.02) and iso-buytrate (padj = 0.019) were observed at T2 in meditators. Other metabolites were also observed to have changed in meditators at timepoint T2. Conclusion This study examined the impact of an advanced meditation program combined with a vegan diet on the gut microbiome. There was an increase in beneficial bacteria even three months after the completion of the Samyama program. Further study is warranted to validate current observations and investigate the significance and mechanisms of action related to diet, meditation, and microbial composition and function, on psychological processes, including mood. Trial registration Registration number: NCT04366544 ; Registered on 29/04/2020.Item Open Access Pregnant Women with Inflammatory Bowel Disease (IBD) are More Likely to be Vitamin D Insufficient than Pregnant Women without IBD(2017) Lee, Sangmin; Seow, Cynthia H.; Kaplan, Gilaad G.; Metcalfe, Amy; Raman, MaitreyiVitamin D insufficiency is associated with adverse pregnancy outcomes. Since individuals with inflammatory bowel disease (IBD) are at risk for vitamin D insufficiency, studying vitamin D status in women with IBD is of importance as the peak incidence of IBD occurs between 18-35 years of age. Currently there is no literature that evaluates vitamin D status in pregnant women with IBD. Therefore, the prevalence of vitamin D insufficiency in pregnant women with IBD was assessed. This study demonstrated that pregnant women with IBD are more likely to be vitamin D insufficient than those without IBD. Further, the current recommended daily dosage of vitamin D supplements for all pregnant women is not appropriate to achieve vitamin D sufficiency, particularly for those with IBD. Appropriate clinical practice guidelines for vitamin D supplementation during pregnancy are needed for optimal prenatal care of pregnant women with IBD to improve their pregnancy outcomes.