Medicine and Health Sciences Commons^™

Modulation Of Hippocampal Protein Expression By A Brain Penetrant Biologic Tnf-Α Inhibitor In The 3xtg Alzheimer’S Disease Mice, Nataraj Jagadeesan, G. Chuli Roules, Devaraj V. Chandrashekar, Joshua Yang, Sanjana Kolluru, Rachita K. Sumbria

Pharmacy Faculty Articles and Research

Background

Biologic TNF-α inhibitors (bTNFIs) can block cerebral TNF-α in Alzheimer’s disease (AD) if these macromolecules can cross the blood–brain barrier (BBB). Thus, a model bTNFI, the extracellular domain of type II TNF-α receptor (TNFR), which can bind to and sequester TNF-α, was fused with a mouse transferrin receptor antibody (TfRMAb) to enable brain delivery via BBB TfR-mediated transcytosis. Previously, we found TfRMAb-TNFR to be protective in a mouse model of amyloidosis (APP/PS1) and tauopathy (PS19), and herein we investigated its effects in mice that combine both amyloidosis and tauopathy (3xTg-AD).

Methods

Eight-month-old female 3xTg-AD mice were injected intraperitoneally with …

Delayed Diagnosis Of Mycobacterium Bovis Bacillus Calmette-Guérin Periprosthetic Joint Infection Following Total Knee Arthroplasty, Christopher E. Pelt, Salika Shakir, Michael J. Cahill, Jakrapun Pupaibool, Barbara C. Cahill

SKMC Student Presentations and Publications

Periprosthetic joint infection (PJI) can present challenges in diagnosis and treatment, particularly in the setting of atypical causative organisms such as fungi and mycobacteria. Herein, we present a case and provide a review of the diagnosis and treatment of an unusual PJI caused by bacillus Calmette-Guérin, administered during the treatment of bladder cancer 3 years prior to total knee arthroplasty and subsequent PJI. Although the patient's history of bladder cancer was known, neither his Bacillus Calmette-Guérin treatment nor its potential for distant site spread that could lead to PJI were appreciated, leading to a prolonged diagnostic evaluation and treatment course.

The Prevalence Of Gram-Negative Bacteria With Difficult-To-Treat Resistance And Utilization Of Novel Β-Lactam Antibiotics In The Southeastern United States, Y. Vivian Tsai, P. Brandon Bookstaver Pharm.D., Joseph Kohn, Julie Ann Justo, Darrell Childress, Stefanie Stramel, Douglas Slain, Patrick Tu, Mary Joyce B. Wingler, Bruce M. Jones, Daniel T. Anderson, Megan M. Seddon, David A. Cretella, Joshua Eudy, Hana Winders, Kayla Antosz Pharm.D., Pamela Bailey, Majdi N. Al-Hasan

Faculty Publications

Objective:

To evaluate temporal trends in the prevalence of gram-negative bacteria (GNB) with difficult-to-treat resistance (DTR) in the southeastern United States. Secondary objective was to examine the use of novel β-lactams for GNB with DTR by both antimicrobial use (AU) and a novel metric of adjusted AU by microbiological burden (am-AU). Design:

Retrospective, multicenter, cohort. Setting:

Ten hospitals in the southeastern United States. Methods:

GNB with DTR including Enterobacterales, Pseudomonas aeruginosa, and Acinetobacter spp. from 2015 to 2020 were tracked at each institution. Cumulative AU of novel β-lactams including ceftolozane/tazobactam, ceftazidime/avibactam, meropenem/vaborbactam, imipenem/cilastatin/relebactam, and cefiderocol in days of therapy (DOT) …

Brain-Specific Serine/Threonine-Protein Kinase 1 Is A Substrate Of Protein Kinase C Epsilon Involved In Sex-Specific Ethanol And Anxiety Phenotypes, Michael P. Dugan, Rajani Maiya, Caleb Fleischer, Michal Bajo, Angela E. Snyder, Ashwin Koduri, Sathvik Srinivasan, Marisa Roberto, Robert O. Messing

School of Graduate Studies Faculty Publications

Protein kinase C epsilon (PKCε) regulates behavioural responses to ethanol and plays a role in anxiety-like behaviour, but knowledge is limited on downstream substrates of PKCε that contribute to these behaviours. We recently identified brain-specific serine/threonine-protein kinase 1 (BRSK1) as a substrate of PKCε. Here, we test the hypothesis that BRSK1 mediates responses to ethanol and anxiety-like behaviours that are also PKCε dependent. We used in vitro kinase assays to further validate BRSK1 as a substrate of PKCε and used Brsk1−/− mice to assess the role of BRSK1 in ethanol- and anxiety-related behaviours and in physiological responses to ethanol. We …

Gut Feelings: A Literature Review On The Gut-Brain Axis And Its Potential Influence On Mood, Grace Johnson

University Honors Theses

In recent decades, research on the gut-brain axis has evolved due to an increasing interest in the connection between gut health and mental health. The gut-brain axis presents a new frontier of health for both medical professionals and psychologists as there is expanding evidence illustrating the comorbidity of gut disorders and mood disorders. Due to the complex nature of studying the gut-brain axis and the myriad of influences on mood disorders such as depression, research has yet to find significant results definitively tying the two together. Nonetheless, the current body of literature on the topic provides a promising outlook on …

03.18.2024 Orsp Connect, Liz Williamson

ORED Newsletter

SPAN and ARC form training, Nature Masterclasses, Glisto Rice, Useful Links

What Do Cervical Cancer Patients Know, How Do They Learn, And Who Do They Tell? A Pilot Study, Sharon Larson, Brian Mcanany, Ilene Ladd, Radhika Gogoi

College of Population Health Faculty Papers

BACKGROUND: This study explored what patients identified with cervical cancer know about the link between human papillomavirus (HPV) and cervical cancer and where they learned this information. Patients share a great deal of information with family, friends and colleagues and we were interested in the accuracy and sources of information they are sharing.

METHODS: Patients identified through the EHR of a health system who had a history of cervical cancer were invited to participate in a brief survey of their experience. The sample represents an opportunity sample of patients who responded.

RESULTS: Generally, these patients, drawn from the Geisinger Health …

Most Recent Advances And Applications Of Extracellular Vesicles In Tackling Neurological Challenges, Mandeep Kaur, Salvatore Fusco, Bram Van Den Broek, Jaya Aseervatham, Abdolmohamad Rostami, Lorraine Iacovitti, Claudio Grassi, Barbara Lukomska, Amit K. Srivastava

Cardeza Foundation for Hematologic Research

Over the past few decades, there has been a notable increase in the global burden of central nervous system (CNS) diseases. Despite advances in technology and therapeutic options, neurological and neurodegenerative disorders persist as significant challenges in treatment and cure. Recently, there has been a remarkable surge of interest in extracellular vesicles (EVs) as pivotal mediators of intercellular communication. As carriers of molecular cargo, EVs demonstrate the ability to traverse the blood-brain barrier, enabling bidirectional communication. As a result, they have garnered attention as potential biomarkers and therapeutic agents, whether in their natural form or after being engineered for use …

American Association For Anatomy Recommendations For The Management Of Legacy Anatomical Collections, Jon Cornwall, Thomas H. Champney, Carlina De La Cova, Dominic Hall, Sabine Hildebrandt, Jason C. Mussell, Andreas Winkelmann, Valerie B. Deleon

School of Medicine Faculty Publications

Collections of human remains in scientific and private institutions have a long tradition, though throughout history there has often been variable regard for the respect and dignity that these tissues demand. Recent public scandals around the use of human remains, coupled with an increasing community awareness around accountability in such instances, forces scholars to confront the ethical and moral concerns associated with these collections. This includes specific focus on the acquisition, storage, use, and disposition of these remains, which were often collected with no consent and with little knowledge, or concern, about the individual or their respective culture and practices …

Reliability And Validity Of The Patient Health Questionnaire-4 Scale And Its Subscales Of Depression And Anxiety Among Us Adults Based On Nativity, David Adzrago, Timothy J Walker, Faustine Williams

Faculty, Staff and Student Publications

BACKGROUND: The burdens of anxiety and depression symptoms have significantly increased in the general US population, especially during this COVID-19 epidemiological crisis. The first step in an effective treatment for anxiety and depression disorders is screening. The Patient Health Questionnaire-4 (PHQ-4, a 4-item measure of anxiety/depression) and its subscales (PHQ-2 [a 2-item measure of depression] and Generalized Anxiety Disorder [GAD-2, a 2-item measure of anxiety]) are brief but effective mass screening instruments for anxiety and depression symptoms in general populations. However, little to no study examined the psychometric properties (i.e., reliability and validity) of the PHQ-4 and its subscales (PHQ-2 …

Fungi Of The Order Mucorales Express A “Sealing-Only” Trna Ligase, Khondakar Sayef Ahammed, Ambro Van Hoof

Faculty, Staff and Student Publications

Some eukaryotic pre-tRNAs contain an intron that is removed by a dedicated set of enzymes. Intron-containing pre-tRNAs are cleaved by tRNA splicing endonuclease, followed by ligation of the two exons and release of the intron. Fungi use a "heal and seal" pathway that requires three distinct catalytic domains of the tRNA ligase enzyme, Trl1. In contrast, humans use a "direct ligation" pathway carried out by RTCB, an enzyme completely unrelated to Trl1. Because of these mechanistic differences, Trl1 has been proposed as a promising drug target for fungal infections. To validate Trl1 as a broad-spectrum drug target, we show that …

Cns-Associated Macrophages Contribute To Intracerebral Aneurysm Pathophysiology, Martina Glavan, Ana Jelic, Damien Levard, Juhana Frösen, Sara Keränen, Bart A A Franx, Ana-Rita Bras, Estelle R Louet, Ádám Dénes, Mario Merlini, Denis Vivien, Marina Rubio

Faculty, Staff and Student Publications

Simple Summary

Vestibular schwannoma (VS), benign cranial nerve sheath tumors of the vestibulocochlear nerve, lack efficacious systemic therapies, especially if they develop in a NF2-related schwannomatosis (NF2) background. They cause hearing loss, tinnitus and balance problems. Metastasis associated in colon cancer 1 (MACC1) is a key driver of metastasis. Although MACC1 expression is associated with highly malignant tumors and VS are considered benign, both are attached to the HGF/MET signaling pathway and MACC1 is a candidate gene localized at a hearing loss-related gene locus. Therefore, it was investigated whether MACC1 might be involved in VS pathogenesis. Surprisingly, MACC1 expression …

Cd69 Signaling In Eosinophils Induces Il-10 Production And Apoptosis Via The Erk1/2 And Jnk Pathways, Respectively, Dan Van Bui, Linh Manh Nguyen, Akira Kanda, Hanh Hong Chu, Nhi Kieu Thi Le, Yasutaka Yun, Yoshiki Kobayashi, Kensuke Suzuki, Akitoshi Mitani, Akihiro Shimamura, Kenta Fukui, Shunsuke Sawada, David Dombrowicz, Hiroshi Iwai

Faculty, Staff and Student Publications

INTRODUCTION: Eosinophils contribute to the pathogenesis of allergic diseases, including asthma, allergic rhinitis, and atopic dermatitis. We previously reported that human tissue eosinophils have high CD69 expression compared to blood eosinophils, and its expression is correlated with disease severity and the number of infiltrated eosinophils. However, biological CD69 signaling activity in eosinophils remains unclear.

METHODS: CD69 expression on lung tissue eosinophils obtained from mice with ovalbumin-induced asthma was measured using flow cytometry. CD69 crosslinking was performed on eosinophils purified from the spleen of IL-5 transgenic mice to investigate CD69 signaling and its function in eosinophils. Then, qPCR, Western blot, enzyme-linked …

Hematopoietic Stem Cells With Granulo-Monocytic Differentiation State Overcome Venetoclax Sensitivity In Patients With Myelodysplastic Syndromes, Juan Jose Rodriguez-Sevilla, Irene Ganan-Gomez, Feiyang Ma, Kelly Chien, Monica Del Rey, Sanam Loghavi, Guillermo Montalban-Bravo, Vera Adema, Bethany Wildeman, Rashmi Kanagal-Shamanna, Alexandre Bazinet, Helen T Chifotides, Natthakan Thongon, Xavier Calvo, Jesús María Hernández-Rivas, Maria Díez-Campelo, Guillermo Garcia-Manero, Simona Colla

Faculty, Staff and Student Publications

The molecular mechanisms of venetoclax-based therapy failure in patients with acute myeloid leukemia were recently clarified, but the mechanisms by which patients with myelodysplastic syndromes (MDS) acquire secondary resistance to venetoclax after an initial response remain to be elucidated. Here, we show an expansion of MDS hematopoietic stem cells (HSCs) with a granulo-monocytic-biased transcriptional differentiation state in MDS patients who initially responded to venetoclax but eventually relapsed. While MDS HSCs in an undifferentiated cellular state are sensitive to venetoclax treatment, differentiation towards a granulo-monocytic-biased transcriptional state, through the acquisition or expansion of clones with STAG2 or RUNX1 mutations, affects HSCs' …

Neoadjuvant Chemotherapy Alone Or Combined With Egfr-Directed Targeted Therapy Or Anti-Pd-1 Immunotherapy For Locally Advanced Lacrimal Sac And Nasolacrimal Duct Carcinomas, Jeremy Goldfarb, Janet Fan, Luana Guimaraes De Sousa, Neal Akhave, Jeffrey Myers, Ryan Goepfert, Krish Manisundaram, Jiawei Zhao, Steven J Frank, Amy Moreno, Renata Ferrarotto, Bita Esmaeli

Faculty, Staff and Student Publications

Background/aims: We describe our findings in patients with locally advanced lacrimal sac and nasolacrimal duct (NLD) carcinoma who received neoadjuvant systemic therapy.

Methods: We identified patients with locally advanced primary lacrimal sac/NLD carcinoma treated with neoadjuvant systemic intravenous therapy at our institution during 2017-2019.

Results: The study included seven patients, four men and three women; the mean age was 60.4 years (range: 43-76). All patients had locally advanced disease with significant orbital soft tissue invasion with or without skull base invasion making eye-sparing surgery not feasible as an initial step. Three patients had poorly differentiated squamous cell carcinoma; two, invasive …

Ultrasound Biomicroscopy As A Novel, Potential Modality To Evaluate Anterior Segment Ophthalmic Structures During Spaceflight: An Analysis Of Current Technology, Benjamin Soares, Joshua Ong, Daniela Osteicoechea, Cihan Mehmet Kadipasaoglu, Ethan Waisberg, Prithul Sarker, Nasif Zaman, Alireza Tavakkoli, Gianmarco Vizzeri, Andrew G Lee

Faculty, Staff and Student Publications

Ocular health is currently a major concern for astronauts on current and future long-duration spaceflight missions. Spaceflight-associated neuro-ocular syndrome (SANS) is a collection of ophthalmic and neurologic findings that is one potential physiologic barrier to interplanetary spaceflight. Since its initial report in 2011, our understanding of SANS has advanced considerably, with a primary focus on posterior ocular imaging including fundus photography and optical coherence tomography. However, there may be changes to the anterior segment that have not been identified. Additional concerns to ocular health in space include corneal damage and radiation-induced cataract formation. Given these concerns, precision anterior segment imaging …

Prophylactic Defunctioning Stomas Improve Clinical Outcomes Of Anastomotic Leak Following Rectal Cancer Resections: An Analysis Of The Us Rectal Cancer Consortium, Katherine Hrebinko, Vincent P Anto, Katherine M Reitz, Adriana C Gamboa, Scott E Regenbogen, Alexander T Hawkins, M Benjamin Hopkins, Aslam Ejaz, Philip S Bauer, Paul E Wise, Glen C Balch, Jennifer Holder-Murray

2020-Current year OA Pubs

PURPOSE: Anastomotic leak (AL) is a complication of low anterior resection (LAR) that results in substantial morbidity. There is immense interest in evaluating immediate postoperative and long-term oncologic outcomes in patients who undergo diverting loop ileostomies (DLI). The purpose of this study is to understand the relationship between fecal diversion, AL, and oncologic outcomes.

METHODS: This is a retrospective multicenter cohort study using patient data obtained from the US Rectal Cancer Consortium database compiled from six academic institutions. The study population included patients with rectal adenocarcinoma undergoing LAR. The primary outcome was the incidence of AL among patients who did …

Htra1 Disaggregates Α-Synuclein Amyloid Fibrils And Converts Them Into Non-Toxic And Seeding Incompetent Species, Sheng Chen, Anuradhika Puri, Braxton Bell, Joseph Fritsche, Hector H Palacios, Maurie Balch, Macy L Sprunger, Matthew K Howard, Jeremy J Ryan, Jessica N Haines, Gary J Patti, Albert A Davis, Meredith E Jackrel

2020-Current year OA Pubs

Parkinson's disease (PD) is closely linked to α-synuclein (α-syn) misfolding and accumulation in Lewy bodies. The PDZ serine protease HTRA1 degrades fibrillar tau, which is associated with Alzheimer's disease, and inactivating mutations to mitochondrial HTRA2 are implicated in PD. Here, we report that HTRA1 inhibits aggregation of α-syn as well as FUS and TDP-43, which are implicated in amyotrophic lateral sclerosis (ALS) and frontotemporal dementia. The protease domain of HTRA1 is necessary and sufficient for inhibiting aggregation, yet this activity is proteolytically-independent. Further, HTRA1 disaggregates preformed α-syn fibrils, rendering them incapable of seeding aggregation of endogenous α-syn, while reducing HTRA1 …

Medical School Watercooler Newsletter - March 17, 2024, Lindsey Lyle

Watercooler Newsletter

This is the March 17, 2024 edition of the Frederick P. Whiddon College of Medicine’s newsletter - Watercooler.

Contents Include

• It's a match! Class of 2024 celebrate residency placements
• Meet a Med Student: Emily Hartsell
• Internal medicine residents hone nonverbal skills with unlikely subjects
• USA Research Mixer set for April 3

Healthcare For Undocumented People In America, Richard Pazer

Graduate Student Research Symposium

Millions of undocumented people live in America and roughly a million have entered every year since 2021. This is a hot-button issue in mainstream politics for a variety of reasons. However, there is an issue that tends to get overlooked which is their health care. In most states, undocumented people do not qualify for healthcare coverage of any kind. This leaves them reliant on EMTALA and emergency departments (ED). Through an examination of the various state and federal policies that pertain to undocumented people’s healthcare coverage, we can see that these people are in desperate need of assistance. It becomes …

The Impact Of Telecritical Care On Length Of Stay In A Critical Care Setting, Mallory Oberts

Student Scholarly Projects

Practice Problem: At a major metropolitan VA hospital, there was a lack of adherence by the nursing staff to the TeleCritical Care program for adult patients in the critical care setting.

PICOT: The PICOT question guiding this project was: In adult patients admitted to critical care (P), does the implementation of TeleCritical Care (I) compared to standard critical care without telemedicine (C) decrease length of stay (O) within 8 weeks (T)?

Evidence: The literature review identified improved quality of care delivery, decreased length of stay, and reduced mortality rates as key benefits of implementing TeleCritical Care in …

Evidence-Based Practice For Terminal Extubation: A Guideline Development For Critical Care, Heather Marica

Student Scholarly Projects

Practice Problem: In the critical care unit it was identified that providers utilized various practices in managing patients who were to be terminally extubated (TE). The variations in TE practice resulted in healthcare providers engaging in the TE process feeling unsure of the care they were providing and questioning if best practice measures were being implemented.

PICOT: The PICOT question guiding this project was: “In acute care adult patients who are to be TE (P), how does the development of an evidence-based TE guideline (I) compared to current TE practices (C) improve critical care healthcare workers perception and ability to …

Laryngeal Cancer Presenting As An Anterior Glottic Web., Razmig Garabet, Lauren E Melley, Omar Ramadan, Robert T Sataloff

Otolaryngology (ENT) Resident Research

No abstract available

A Representative Clinical Course Of Progression, With Molecular Insights, Of Hormone Receptor-Positive, Her2-Negative Bone Metastatic Breast Cancer, Elizabeth Magno, Karen M. Bussard

Department of Pharmacology, Physiology, and Cancer Biology Faculty Papers

Despite treatment advances, breast cancer remains a leading cause of death of women in the United States, mostly due to metastatic disease. Bone is a preferential site for breast cancer metastasis, and most metastatic breast cancer patients experience bone involvement at the time of death. The majority of patients with bone metastatic breast cancer are first diagnosed with and treated for early-stage disease, and from development of early-stage breast cancer to the recurrence of cancer in the bones, up to 30 years may elapse. Throughout this timeframe, a typical patient undergoes many treatments that have effects on the bone microenvironment. …

How To Build And Sustain A Transdisciplinary Community-Based Exercise Program For Older Adults, Stephen D. Ball Phd, Kristin Miller Ms, Kelsey J. Weitzel Ms, Breanne S. Baker Phd

Journal of Extension

We have built a community-based program called Stay Strong, Stay Healthy, which helps older adults improve muscle strength and flexibility while reducing fall risk. This report details lessons learned and keys to success for Extension practitioners. First, maximize the potential of your state’s Extension framework by building a program that centers around your target population and is fun and easy to implement. Second, partner with researchers who can help to improve program effectiveness and logistical feasibility on larger scales. Lastly, continue to evaluate and adapt based on feedback from those who utilize and implement the program.

Extending Knowledge On Biosecurity In Small-Scale And Backyard Systems In The United States, Juliette Di Francesco, Amber Itle, Craig Mcconnel, Ragan Adams, Roselle Busch, Richard Van Vleck Pereira, Terry W. Lehenbauer, Beatriz Martínez-López, Alda F. A. Pires

Journal of Extension

The number of small-scale and backyard operations has increased in the United States during the past decade, but there is currently a lack of outreach efforts and readily-available educational materials targeting these farming systems. We developed a webinar series on biosecurity to provide training for small-scale and backyard producers, and training tools that can be used by local veterinarians and extension educators to disseminate knowledge and consistent recommendations more effectively. Fewer people attended the webinars than registered, suggesting a gap between interest in biosecurity and commitment to the topic. Participants in the webinar series reported a high level of satisfaction …

Actions To Improve In-Patient Communication On Medication Teaching, Tracy Wei

Student Scholarly Projects

Practice Problem: Medication education is a national and global patient safety challenge. Healthcare organizations often lack consistent and effective medication teaching policies. Studies have found that the teach-back method is an effective interactive communication practice of medication teaching to achieve optimal patient outcomes.

PICOT: In direct care nursing staff (P), How does an evidence-based medication teaching bundle (I) compared to the current medication teaching practice(C) affect staff adherence to the dissemination of medication teaching to hospitalized patients (O) in 12 weeks (T)?

Evidence: A review and appraisal of 12 research studies demonstrated that the teach-back method was …

Differential Effects Of Fucus Vesiculosus Fucoidan On Fibroblast And Macrophage Cell Lines Inflammatory Activation, Aleksandra Augustyniak, Joanna Przyborska, Helena Mcmahon

Publications

It is estimated that more than one-third of people aged over 16 reported living with inflammation-related chronic illness. Fucoidan, sulfated polysaccharide, has been proven to modulate immune response and inhibit inflammation in both in vitro and in vivo research. In the present study the effect of commercially available fucoidan from Fucus vesiculosus (with purity 97%) on immune response was investigated. Two cell lines, human fibroblasts (HDFa) and mouse macrophages (J774A.1) were used in the study. Cells were activated with pro-inflammatory stimulus (LPS/IFN-γ or PMA) and treated with fucoidan. Results of NO inhibition assay revealed that fucoidan has anti-inflammatory activity and …

Automated Seizure Detection Based On State-Space Model Identification, Zhuo Wang, Michael Sperling, Dale Wyeth, Allon Guez

Department of Neuroscience Faculty Papers

In this study, we developed a machine learning model for automated seizure detection using system identification techniques on EEG recordings. System identification builds mathematical models from a time series signal and uses a small number of parameters to represent the entirety of time domain signal epochs. Such parameters were used as features for the classifiers in our study. We analyzed 69 seizure and 55 non-seizure recordings and an additional 10 continuous recordings from Thomas Jefferson University Hospital, alongside a larger dataset from the CHB-MIT database. By dividing EEGs into epochs (1 s, 2 s, 5 s, and 10 s) and …

Seeking Sufficient And Appropriate Care During The First Year After Spinal Cord Injury: A Qualitative Study, Anne M. Bryden, Brian Gran

Faculty Scholarship

Study design: Longitudinal qualitative study, based on a constructivist grounded theory and transformative approach. Objectives: This study investigated experiences of individuals with spinal cord injury (SCI) while navigating rehabilitation, resources for recovery, and community reintegration during the first year after injury. Setting: An acute inpatient rehabilitation facility in the Midwest United States. Methods: In-depth, semi-structured interviews were conducted with 20 individuals with newly-acquired SCI. Interviews were conducted approximately every other month for one year, beginning at acute inpatient rehabilitation. Data were analyzed and interpreted using a constructivist grounded theory approach and transformative paradigm, which examines power and social structures within …