Medicine and Health Sciences Commons^™

Climate, Environmental And Socio-Economic Change: Weighing Up The Balance In Vector-Borne Disease Transmission, Paul E. Parham, Joanna Waldock, George K. Christophides, Deborah Hemming, Folashade Agusto, Katherine J. Evans, Nina Fefferman, Holly Gaff, Abba Gumel, Shannon Ladeau

Biological Sciences Faculty Publications

Arguably one of the most important effects of climate change is the potential impact on human health. While this is likely to take many forms, the implications for future transmission of vector-borne diseases (VBDs), given their ongoing contribution to global disease burden, are both extremely important and highly uncertain. In part, this is owing not only to data limitations and methodological challenges when integrating climate-driven VBD models and climate change projections, but also, perhaps most crucially, to the multitude of epidemiological, ecological and socio-economic factors that drive VBD transmission, and this complexity has generated considerable debate over the past 10-15 …

Patient-Reported Outcomes In Male And Female Collegiate Soccer Players During An Athletic Season, Johanna M. Hoch, Beth Druvenga, Brittany A. Ferguson, Megan N. Houston, Matthew C. Hoch

Rehabilitation Sciences Faculty Publications

Context: Clinicians are urged to document patient-based outcomes during rehabilitation to measure health-related quality of life (HRQOL) from the patient's perspective. It is unclear how scores on patient-reported outcome instruments (PROs) vary over the course of an athletic season because of normal athletic participation.

Objective: Our primary purpose was to evaluate the effect of administration time point on HRQOL during an athletic season. Secondary purposes were to determine test-retest reliability and minimal detectable change scores of 3 PROs commonly used in clinical practice and if a relationship exists between generic and region-specific outcome instruments.

Design: Cross-sectional study.

Setting: Athletic facility. …

Gadolinium Modifies The Cell Membrane To Inhibit Permeabilization By Nanosecond Electric Pulses, Elena C. Gianulis, Andrei G. Pakhomov

Bioelectrics Publications

Lanthanide ions are the only known blockers of permeabilization by electric pulses of nanosecond duration (nsEP), but the underlying mechanisms are unknown. We employed timed applications of Gd³⁺ before or after nsEP (600-ns, 20 kV/cm) to investigate the mechanism of inhibition, and measured the uptake of the membrane-impermeable YO-PRO-1 (YP) and propidium (Pr) dyes. Gd³⁺ inhibited dye uptake in a concentration-dependent manner. The inhibition of Pr uptake was always about 2-fold stronger. Gd³⁺ was effective when added after nsEP, as well as when it was present during nsEP exposure and removed afterward. Pores formed by nsEP in …

Measures Of Functional Performance And Their Association With Hip And Thigh Strength, Roger Kollack, Bonnie L. Van Lunen, Stacie I. Ringleb, James M. Oñate

Rehabilitation Sciences Faculty Publications

Context: Insufficient hip and thigh strength may increase an athlete's susceptibility to injury. However, screening for strength deficits using isometric and isokinetic instrumentation may not be practical in all clinical scenarios.

Objective: To determine if functional performance tests are valid indicators of hip and thigh strength.

Design: Descriptive laboratory study.

Setting: Research laboratory.

Patients or Other Participants: Sixty-two recreationally athletic men (n = 30, age = 21.07 years, height = 173.84 cm, mass = 81.47 kg) and women (n = 32, age = 21.03 years, height = 168.77 cm, mass = 68.22 kg) participants were recruited.

Intervention(s): During session 1, …

Patient-Reported Outcome Measures In Individuals With Chronic Ankle Instability: A Systematic Review, Megan N. Houston, Johanna M. Hoch, Matthew C. Hoch

Rehabilitation Sciences Faculty Publications

Context: A comprehensive systematic literature review of the health-related quality-of-life (HRQOL) differences among individuals with chronic ankle instability (CAI), ankle-sprain copers, and healthy control participants has not been conducted. It could provide a better indication of the self-reported deficits that may be present in individuals with CAI.

Objective: To systematically summarize the extent to which HRQOL deficits are present in individuals with CAI.

Data Sources: We searched for articles in the electronic databases of EBSCO Host and PubMed Central using key words chronic, functional, mechanical, coper, instability, sprains, and patient-assessed. We also performed a hand search of reference lists, authors, …

Perceptions Of Support Networks During The Graduate Assistant Athletic Trainer Experience, Stephanie M. Mazerolle, Stephanie Clines, Christianne M. Eason, William A. Pitney

Rehabilitation Sciences Faculty Publications

Context: The graduate-assistant position can be a highly influential experience because it is often the first time novice athletic trainers (ATs) are practicing autonomously.

Objective: To gain an understanding of how graduate-assistant ATs (GAATs) perceive professional socialization and mentorship during their assistantships.

Design: Semistructured phone interviews. Setting: Graduate-assistant ATs in various clinical settings.

Patients or Other Participants: Twenty-five GAATs (20 women, 5 men) studying in 1 of 3 academic tracks (postprofessional athletic training = 8, athletic training-based curriculum = 11, non-athletic training-based curriculum = 6). Median age was 24 years.

Data Collection and Analysis: Phone interviews were digitally recorded and …

Preparation Of The Professional Athletic Trainer: A Descriptive Study Of Undergraduate And Graduate Degree Programs, Julie M. Cavallario, Bonnie L. Van Lunen

Rehabilitation Sciences Faculty Publications

Context: The examination of the appropriate professional degree for preparation as an athletic trainer is of interest to the profession. Descriptive information concerning universal outcomes is needed to understand the effect of a degree change.

Objective: To obtain and compare descriptive information related to professional athletic training programs and a potential degree change and to determine if any of these factors contribute to success on existing universal outcome measures.

Design: Cross-sectional study.

Setting: Web-based survey.

Patients or Other Participants: We contacted 364 program directors; 178 (48.9%; 163 undergraduate, 15 postbaccalaureate) responded.

Intervention(s): The survey consisted of 46 questions: 45 questions …

Hip Strengthening Compared With Quadriceps Strengthening In Conservative Treatment Of Patients With Patellofemoral Pain: A Critically Appraised Topic, Chyrsten L. Regelski, Brittany L. Ford, Matthew C. Hoch

Rehabilitation Sciences Faculty Publications

Clinical Scenario: Patellofemoral pain is a common injury that affects both athletic and sedentary populations. Clinicians may treat patellofemoral pain more effectively through a comprehensive understanding of the most effective exercise protocols. Clinical Question: In patients with patellofemoral pain, are hip abductor and external rotator muscle strengthening exercises more effective in reducing pain and improving patient-reported function compared with isolated quadriceps strengthening? Summary of Key Findings: A comprehensive and systematic database search was conducted for studies of level 2 evidence or higher. The search yielded 253 studies; of these studies, four randomized control trials and one comparative control trial fit …

You Are What You Tweet: Connecting The Geographic Variation In America's Obesity Rate To Twitter Content, Ross J. Gore, Saikou Diallo, Jose Padilla

VMASC Publications

We conduct a detailed investigation of the relationship among the obesity rate of urban areas and expressions of happiness, diet and physical activity on social media. We do so by analyzing a massive, geo-tagged data set comprising over 200 million words generated over the course of 2012 and 2013 on the social network service Twitter. Among many results, we show that areas with lower obesity rates: (1) have happier tweets and frequently discuss (2) food, particularly fruits and vegetables, and (3) physical activities of any intensity. Additionally, we provide evidence that each of these results offer different and unique insight …

Diseases, Patients And The Epistemology Of Practice: Mapping The Borders Of Health, Medicine And Care, Michael Loughlin, Robyn Bluhm, Jonathan Fuller, Stephen Buetow, Kirstin Borgerson, Benjamin R. Lewis, Brent M. Kious

Philosophy Faculty Publications

Last year saw the 20th anniversary edition of JECP, and in the introduction to the philosophy section of that landmark edition, we posed the question: apart from ethics, what is the role of philosophy at the bedside'? The purpose of this question was not to downplay the significance of ethics to clinical practice. Rather, we raised it as part of a broader argument to the effect that ethical questions - about what we should do in any given situation - are embedded within whole understandings of the situation, inseparable from our beliefs about what is the case (metaphysics), what it …

Therapeutic Targeting Of Replicative Immortality, Paul Yaswen, Karen L. Mackenzie, W. Nicol Keith, Patricia Hentosh, Francis Rodier, Jiyue Zhu, Gary L. Firestone, Ander Matheu, Amancio Carnero, Alan Bilsland

School of Medical Diagnostics & Translational Sciences Publications

One of the hallmarks of malignant cell populations is the ability to undergo continuous proliferation. This property allows clonal lineages to acquire sequential aberrations that can fuel increasingly autonomous growth, invasiveness, and therapeutic resistance. Innate cellular mechanisms have evolved to regulate replicative potential as a hedge against malignant progression. When activated in the absence of normal terminal differentiation cues, these mechanisms can result in a state of persistent cytostasis. This state, termed “senescence,” can be triggered by intrinsic cellular processes such as telomere dysfunction and oncogene expression, and by exogenous factors such as DNA damaging agents or oxidative environments. Despite …

Urinary Dna Lesions As A Biomarker For Assessing Male Reproductive Health, Hueiwang Anna Jeng, Chih-Hung Pan, Chao Mu-Rong

Community & Environmental Health Faculty Publications

The study aimed to examine whether urinary 8-hydroxy-2’-deoxyguanosine (8-OHdG) could serve as a biomarker for assessing sperm DNA integrity. Urine and semen samples were collected from 124 coke-oven workers, who had chronically been exposed to polycyclic aromatic hydrocarbons (PAHs), from a steel plant in Kaohsiung, Taiwan. The coke-oven workers were divided into two subgroups: topside-oven workers and side-oven workers. Sperm DNA integrity was assessed in terms of DNA fragmentation and 8-oxo-7,8-dihydro-2’-deoxyguanosine (8-oxodGuo). Urine samples were used to detect 1-hydroxypyrene (1-OHP) and urinary 8-OHdG, which served to assess exposure to PAHs and the whole body oxidative stress, respectively. Urinary 1-OHP concentrations …

Are Semen Quality Parameters Sufficient For Biomonitoring Spermatozoa Dna Integrity And Oxidatively Damaged Dna, Hueiwang Anna Jeng, Ruei-Nian Li, Wen-Yi Lin

Community & Environmental Health Faculty Publications

The present study aimed to investigate the relationship between semen quality parameters and DNA integrity, and determine whether semen quality parameters could serve as a reliable biomarker for monitoring sperm DNA damage. Conventional semen parameters from a total of 202 male human subjects were analyzed. DNA fragmentation and 8-oxo-7,8-dihydro-2′- deoxyguanosine (8-oxoGuo) were used to assess sperm DNA integrity. DNA fragmentation was analyzed by the terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay and sperm chromatin structure assay (SCSA), while 8-oxodGuo was quantified by the liquid chromatography/tandem mass spectrometry (LC-MS/MS) coupled with an on-line solid phase system. The levels of …

The Use Of Immersive Visualization For The Control Of Dental Anxiety During Oral Debridement, Carmelo Padrino-Barrios, Gayle B. Mccombs, Norou Diawara, Gianluca De Leo

Dental Hygiene Faculty Publications

Purpose: The purpose of this study was to evaluate the effects of Immersive Visualization (IV) eyewear on anxious, adult patients during oral debridement.

Methods: Thirty adult volunteers (n=23 females n=7 males) were enrolled in the study. Participants were required to be 18 years or older, exhibit at least moderate anxiety (score 9 or higher) on the Corah's Dental Anxiety Scale-Revised (DAS-R), and be generally healthy. Individuals were excluded from participation if they presented with severe dental calculus, periodontal disease, or dental caries, were taking psychotropic drugs, had a history of convulsive disorders, vertigo, or equilibrium disorders, or required antibiotic premedication. …

Weight-Bearing Dorsiflexion Range Of Motion And Landing Biomechanics In Individuals With Chronic Ankle Instablity, Matthew C. Hoch, Kelley E. Farwell, Stacey L. Gaven, Joshua T. Weinhandl

Rehabilitation Sciences Faculty Publications

Context: People with chronic ankle instability (CAI) exhibit less weight-bearing dorsiflexion range of motion (ROM) and less knee flexion during landing than people with stable ankles. Examining the relationship between dorsiflexion ROM and landing biomechanics may identify a modifiable factor associated with altered kinematics and kinetics during landing tasks.

Objective: To examine the relationship between weight-bearing dorsiflexion ROM and single-legged landing biomechanics in persons with CAI.

Design: Cross-sectional study.

Setting: Laboratory.

Patients or Other Participants: Fifteen physically active persons with CAI (5 men, 10 women; age = 21.9 ± 2.1 years, height = 168.7 ± 9.0 cm, mass = 69.4 …

Mass Fatality Incidents And The Role Of The Dental Hygienist: Are We Prepared?, Tara L. Newcomb, Ann M. Bruhn, Bridget Giles

Dental Hygiene Faculty Publications

Dental hygienists can fill critical roles during mass fatality incidents in the area of disaster victim identification, providing much needed support to forensic odontologists. The purpose of this paper is to bring awareness that research is needed to assess current dental hygiene programs, continuing education opportunities and the type of approach being used to develop and implement pedagogy in the forensic specialty area, specifically mass fatality preparedness and response for the dental hygienist. Because of the threat of terrorism in the U.S. and natural disasters like hurricanes, the need to prepare dental professionals in disaster response and fatality management is …

Killing Adherent And Nonadherent Cancer Cells With The Plasma Pencil, Mounir Laroussi, Soheila Mohades, Nazir Barekzi

Electrical & Computer Engineering Faculty Publications

The application of low temperature plasmas in biology and medicine may lead to a paradigm shift in the way various diseases can be treated without serious side effects. Low temperature plasmas generated in gas mixtures that contain oxygen or air produce several chemically reactive species that have important biological implications when they interact with eukaryotic or prokaryotic cells. Here, a review of the effects of low temperature plasma generated by the plasma pencil on different cancerous cells is presented. Results indicate that plasma consistently shows a delayed killing effect that is dose dependent. In addition, there is some evidence that …

Liver Perilipin 5 Expression Worsens Hepatosteatosis But Not Insulin Resistance In High Fat-Fed Mice, Michelle B. Trevino, David Mazur-Hart, Yui Machida, Timothy King, Joseph Nadler, Elena V. Galkina, Arjun Poddar, Sucharita Dutta, Yumi Imai

Mathematics & Statistics Faculty Publications

Perilipin 5 (PLIN5) is a lipid droplet (LD) protein highly expressed in oxidative tissues, including the fasted liver. However, its expression also increases in nonalcoholic fatty liver. To determine whether PLIN5 regulates metabolic phenotypes of hepatosteatosis under nutritional excess, liver targeted overexpression of PLIN5 was achieved using adenoviral vector (Ad-PLIN5) in male C57BL/6J mice fed high-fat diet. Mice treated with adenovirus expressing green fluorescent protein (GFP) (Ad-GFP) served as control. Ad-PLIN5 livers increased LD in the liver section, and liquid chromatography with tandem mass spectrometry revealed increases in lipid classes associated with LD, including triacylglycerol, cholesterol ester, and phospholipid classes, …

Increased Tissue Temperature Improves Electro-Transfer Mediated Gene Delivery To Skin, Anna Bulysheva, Amy Donate, Chelsea Edelblute, Derrick Jung, Karl Schoenbach, Richard Heller

Bioelectrics Publications

[Introduction] Developing an optimal gene electro-transfer system for delivery of plasmid DNA to the skin in vivo has been challenging with expression often confined in the epithelium requiring high voltage electric fields, which can cause cellular and tissue damage. Minimizing such damage, while optimizing gene expression profiles, are highly desirable for therapeutic applications of gene delivery to the skin. Cell membrane fluidity is temperature dependent, thus moderate temperature elevation can increase membrane fluidity. Utilizing this concept, we developed a novel gene electro-transfer electrode for in vivo applications with ability to heat tissue with a laser integrated into a four pin …

Performance Of Dental Hygiene Students In Mass Fatality Training And Radiographic Imaging Of Dental Remains, Tara L. Newcomb, Ann M. Bruhn, Loreta H. Ulmer, Norou Diawara

Dental Hygiene Faculty Publications

Purpose: Mass fatality incidents can overwhelm local, state and national resources quickly. Dental hygienists are widely distributed and have the potential to increase response teams' capacity. However, appropriate training is required. The literature is void of addressing this type of training for dental hygienists and scant in dentistry. Hence, the purpose of this study was to assess one facet of such training: Whether the use of multimedia is likely to enhance educational outcomes related to mass fatality training.

Methods: A randomized, double-blind, pre- and post-test design was used to evaluate the effectiveness of comparable educational modules for 2 groups: a …

Creating A Foundation For The Causal Relationship Between Libraries And Learning: A Proposed Application Of Nursing And Public Health Research Methods, Marcia A. Mardis, Sylvia K. Norton, Gail K. Dickinson, Shana Pribesh, Allison Cline, Sue Kimmel, Jody Howard

Teaching & Learning Faculty Publications

Thomas Cook, a renowned causal research expert and professor of sociology, psychology, education, and social policy at Northwestern University (USA), called for school library researchers to parallel causality determination efforts in health-related fields. In this paper, we respond to Dr. Cook’s challenge with a proposed research design centered on Mixed Research Synthesis (MRS) as part of process validated by the U.S. Department of Education and National Science Foundation’s Common Guidelines for Education Research and Development. MRS studies, often used in nursing and public health research to develop causal theories, enable researchers to develop evidence summaries; identify and adjudicate rival and …

Application And Histology-Driven Refinement Of Active Contour Models To Functional Region And Nerve Delineation: Towards A Digital Brainstem Atlas, Nimal Patel, Sharmin Sultana, Tanweer Rashid, Dean Krusienski, Michel A. Audette

Electrical & Computer Engineering Faculty Publications

This paper presents a methodology for the digital formatting of a printed atlas of the brainstem and the delineation of cranial nerves from this digital atlas. It also describes on-going work on the 3D resampling and refinement of the 2D functional regions and nerve contours. In MRI-based anatomical modeling for neurosurgery planning and simulation, the complexity of the functional anatomy entails a digital atlas approach, rather than less descriptive voxel or surface-based approaches. However, there is an insufficiency of descriptive digital atlases, in particular of the brainstem. Our approach proceeds from a series of numbered, contour-based sketches coinciding with slices …

Designing A Broad-Spectrum Integrative Approach For Cancer Prevention And Treatment, Keith I. Block, Charlotte Gyllenhaal, Leroy Lowe, Amedeo Amedei, A.R.M. Ruhul Amin, Amr Amin, Katia Aquilano, Jack Arbiser, Alexandra Arreola, Alla Arzumanyan, Patricia Hentosh

School of Medical Diagnostics & Translational Sciences Publications

Targeted therapies and the consequent adoption of “personalized” oncology have achieved notable successes in some cancers; however, significant problems remain with this approach. Many targeted therapies are highly toxic, costs are extremely high, and most patients experience relapse after a few disease-free months. Relapses arise from genetic heterogeneity in tumors, which harbor therapy-resistant immortalized cells that have adopted alternate and compensatory pathways (i.e., pathways that are not reliant upon the same mechanisms as those which have been targeted). To address these limitations, an international task force of 180 scientists was assembled to explore the concept of a low-toxicity “broad-spectrum” therapeutic …

Bioactive Lipid Coating Of Bone Allografts Direct Engraftment And Fate Determination Of Bone Marrow-Derived Cells In Rat Gfp Chimeras, Anusuya Das, Claire E. Segar, Yihsuan Chu, Tiffany W. Wang, Yon Lin, Chunxi Yang, Roy C. Ogle

School of Medical Diagnostics & Translational Sciences Publications

Bone grafting procedures are performed to treat wounds incurred during wartime trauma, accidents, and tumor resections. Endogenous mechanisms of repair are often insufficient to ensure integration between host and donor bone and subsequent restoration of function. We investigated the role that bone marrow-derived cells play in bone regeneration and sought to increase their contributions by functionalizing bone allografts with bioactive lipid coatings. Polymer-coated allografts were used to locally deliver the immunomodulatory small molecule FTY720 in tibial defects created in rat bone marrow chimeras containing genetically-labeled bone marrow for monitoring cell origin and fate. Donor bone marrow contributed significantly to both …

Minority Stress, Depression, Relationship Quality, And Alcohol Use: Associations With Overweight And Obesity Among Partnered Young Adult Lesbians, Tyler B. Mason, Robin J. Lewis

Psychology Faculty Publications

Purpose: Although lesbian women are more likely to be obese compared to heterosexual women, relatively little research has examined correlates of overweight and obesity among lesbians. The purpose of this study was to examine the association of minority stress and depression, relationship quality, and alcohol-use variables to overweight and obesity among lesbians in relationships.

Method: Self-identified lesbians (n = 737) in current relationships completed measures of demographics, minority stress, depressive symptoms, relationship variables, and alcohol use.

Results: Overweight and obesity were associated with more public identification as a lesbian, more depressive symptoms, increased heavy drinking, longer relationship length, and lower …

Testing A Model Of Caffeinated Alcohol-Specific Expectancies, Ashley N. Linden-Carmichael, Cathy Lau-Barraco, Amy L. Stamates

Psychology Faculty Publications

Introduction- The present study sought to further understand the association between caffeinated alcoholic beverage (CAB) use and alcohol-related risks. In particular, we focused on the role of two identified expectancies specific to CAB use: intoxication enhancement and avoidance of negative consequences. Although outcome expectancies are consistent predictors of substance use, limited research has examined expectancies related to CAB use and their association with alcohol-related behaviors, such as protecting themselves from alcohol-related harms. Consequently, the present study examined CAB-specific expectancies and protective behavioral strategies (PBS) as mediators of CAB use and negative consequences.

Methods- Participants were 322 (219 women) college drinkers …

Global Analysis Of Gene Expression And Projection Target Correlations In The Mouse Brain, Ahmed Fakhry, Tao Zeng, Hanchuan Peng, Shuiwang Ji

Computer Science Faculty Publications

Recent studies have shown that projection targets in the mouse neocortex are correlated with their gene expression patterns. However, a brain-wide quantitative analysis of the relationship between voxel genetic composition and their projection targets is lacking to date. Here we extended those studies to perform a global, integrative analysis of gene expression and projection target correlations in the mouse brain. By using the Allen Brain Atlas data, we analyzed the relationship between gene expression and projection targets. We first visualized and clustered the two data sets separately and showed that they both exhibit strong spatial autocorrelation. Building upon this initial …

A Comparative Study Of Two Prediction Models For Brain Tumor Progression, Deqi Zhou, Loc Tran, Jihong Wang, Jiang Li, Karen O. Egiazarian (Ed.), Sos S. Agaian (Ed.), Atanas P. Gotchev (Ed.)

Electrical & Computer Engineering Faculty Publications

MR diffusion tensor imaging (DTI) technique together with traditional T1 or T2 weighted MRI scans supplies rich information sources for brain cancer diagnoses. These images form large-scale, high-dimensional data sets. Due to the fact that significant correlations exist among these images, we assume low-dimensional geometry data structures (manifolds) are embedded in the high-dimensional space. Those manifolds might be hidden from radiologists because it is challenging for human experts to interpret high-dimensional data. Identification of the manifold is a critical step for successfully analyzing multimodal MR images.

We have developed various manifold learning algorithms (Tran et al. 2011; Tran et al. …

The Multimodal Brain Tumor Image Segmentation Benchmark (Brats), Bjoern H. Menze, Andras Jakab, Stefan Bauer, Jayashree Kalpathy-Cramer, Khan M. Iftekharuddin, Syed M.S. Reza

Electrical & Computer Engineering Faculty Publications

In this paper we report the set-up and results of the Multimodal Brain Tumor Image Segmentation Benchmark (BRATS) organized in conjunction with the MICCAI 2012 and 2013 conferences. Twenty state-of-the-art tumor segmentation algorithms were applied to a set of 65 multi-contrast MR scans of low-and high-grade glioma patients-manually annotated by up to four raters-and to 65 comparable scans generated using tumor image simulation software. Quantitative evaluations revealed considerable disagreement between the human raters in segmenting various tumor sub-regions (Dice scores in the range 74%-85%), illustrating the difficulty of this task. We found that different algorithms worked best for different sub-regions …

An Intersectional Perspective On Stigma As A Barrier To Effective Hiv Self-Management And Treatment For Hiv-Infected African American Women, Kimberly Adams Tufts

Ellmer School of Nursing Faculty Publications

Among those who are HIV-infected and striving to live well with HIV, African American women have poorer health outcomes and represent a higher portion of those women who die from HIV-related causes. Those health inequalities have been associated with the presence of social determinants of health such as stigma. This analytical review asserts that stigmas precipitated by gender, race, and class in the context of HIV-related stigma constitute substantial barriers to active engagement in HIV self-management, care, and treatment for HIV-infected African American women. The utility of the intersectionality framework for analyzing how these various stigmas interact to create unique …