Functional ectopic thyroid tissue may rarely be present within the walls of a thyroglossal duct cyst, and these may be the only functional thyroid tissue. We described one such case of ectopic thyroid within the thyroglossal duct cyst and its surgical management. A 12-year-old girl presented to us with a gradually increasing, painless midline neck mass that moved with swallowing and tongue protrusion. Ultrasonography showed a well-defined spongiform midline lesion measuring 3.2*1.4 cm in the upper neck. The thyroid scan showed focal increased tracer uptake in the midline upper neck corresponding to the clinically palpable swelling. A Sistrunk procedure was carried out, and the patient was started on thyroid hormone replacement.
Introduction: Polycystic ovarian syndrome (PCOS) is a common hormonal disorder affecting 1 in 10 women of reproductive age, causing irregular periods, ovarian cysts, weight gain and fertility issues. Due to inadequate awareness, many women remain undiagnosed. This study aimed to assess the effectiveness of structured teaching programme on polycystic ovarian syndrome among undergraduate female students in colleges of Pokhara. Methods: A pre-experimental one group pre-test post-test research design was used among 141 undergraduate female students in selected colleges under Tribhuvan University of Pokhara by using probability stratified random sampling technique. Data were collected through structured self-administered questionnaire where pre-test and post-test was done on in a gap of 28 days of teaching programme. Analysis was performed using SPSS Version 16, employing descriptive statistics (frequency, percentage, mean, standard deviation) and inferential statistics (paired t-test and chi-square test). Results: The findings of the study revealed that 47(33.3%) of students had inadequate knowledge before teaching programme, which improved to 67(47.5%) with adequate knowledge after teaching programme. The mean knowledge score before and after teaching programme was 43.81±9.31 and 56.20±12.47 respectively. The alternative hypothesis was accepted, indicating a significant improvement. Furthermore, a significant association was also found between students’ knowledge levels and their faculty (p = 0.032 pretest). Conclusions: The study concluded that structured teaching programme on polycystic ovarian syndrome was effective, as it significantly improved students' knowledge. To enhance students’ understanding of Polycystic Ovarian Syndrome (PCOS), the college authorities can incorporate PCOS education into the college curriculum, organize regular educational programs, video-assisted teaching sessions, lectures and interactive discussions.
Plagiarism is a form of intellectual theft that occurs when an individual uses another person's ideas, words, or work without giving proper credit to the original source. It is a serious violation of academic integrity and ethical standards, often resulting in significant academic, professional, and legal consequences. Understanding plagiarism and its various forms is essential for maintaining honesty and credibility in both academic and professional settings.
Introduction: Nurses, as the largest and most diverse group of healthcare professionals, often experience significant work-related stress that affects their physical, emotional, and mental well-being, as well as patient care. The objective of this study was to assess the level of work-related stress among nurses in a teaching hospital of Pokhara. Methods: A descriptive cross-sectional research design was adopted for this study which was conducted among nurses working in inpatient department of Gandaki Medical College Teaching Hospital and Research Centre (GMCTHRC), Kaski, Nepal. Probability simple random sampling technique was used to select 123 nurses. Structured standard tool i.e. Expanded Nursing Stress Scale (ENSS) was used for data collection and the data were collected using self-administered structured questionnaire. Descriptive statistics (frequency, percentage, mean, median and standard deviation) and inferential statistics (chi-square test) were used to analyze the data. Results: Among 123 respondents, 48.8% of them had moderate level of stress, 31.7% of respondents had mild stress and 19.5% of respondents had severe level of stress. The level of stress is statistically associated with the age (p=0.026), religion (p=0.012) and working unit (p=0.031). Conclusions: Nurses working in the hospital have some degree of stress. It is essential for hospital administration to identify its underlying causes and implement appropriate stress management strategies.
Introduction: Sexual harassment is a form of discrimination that includes unwelcome and inappropriate sexual advances, requests for sexual favors, or verbal, non-verbal, or physical conduct of a sexual nature. The research aimed to identify the different forms of sexual harassment experienced by nurses at work place. Methods: A descriptive cross-sectional study was conducted in a tertiary hospital of Kathmandu from January to June 2025. Purposive sampling technique was used for the selection of hospital. To ensure representation from all wards, a disproportionate stratified random sampling technique was used to select nurses for the study. Data was collected from 150 nurses through a structured self-administered questionnaire. Collected data was entered and analyzed in SPSS; descriptive statistics were used. Results: The findings revealed that 39.4% nurses reported experiencing verbal sexual harassment, 25.4% experienced non-verbal sexual harassment, 15.9% encountered physical sexual harassment, and 9.3% faced cyber sexual harassment during their lifetime. In addition, 20.7% of nurses reported being subjected to persistent staring while 14.7% reported feeling awkward due to sexually inappropriate comments at the workplace. Of total, 5.3% faced the sending of explicit messages or images via electronic platforms. Notably, 24.7% of the perpetrators were relatives of patients or clients. Conclusions: The study concluded that nearly two fifths of the nurses reported experiencing verbal sexual harassment, one-fourth experienced non-verbal sexual harassment, and nearly one in ten nurses faced cyber sexual harassment at workplace during their lifetime. The nurses recommend for establishing clear policies and protocols to prevent and control sexual harassment.
Introduction: Dengue fever is a self-limiting acute illness that occurs with dengue virus, whose vector is mosquitoes Aedes aegypti and Aedes albopictus. Dengue spread from person to person via infected mosquito, the primary vector being Aedes aegypti. Clinical features ranges from febrile phase to clinical phase and finally recovery phase. Warning signs of dengue fever are pain abdomen, persistent vomiting, fluid accumulation states like ascites or pleural effusion, bleeding from mucosa, lethargy, hepatomegaly greater than 2 cm, increase in hematocrit, including leukopenia and thrombocytopenia. Hence, this study aimed to evaluate clinical profile of dengue patients. Methods: This was a cross-sectional study where dengue fever was diagnosed based on serology (Ns1). The clinical parameters and laboratory findings were recorded after obtaining verbal and written consent. Results: Out of 170 dengue patients, mean age were 38.21(±16.5) years with a female:male ratio of 1.1:1. Majority had fever 164(96.5%) followed by headache 91(53.5%), retro-orbital pain 80(47.1%) and myalgia 112(65.9%). Most common feature of warning sign was abdominal pain 33(60%). Our study showed 91(53.5%) dengue patient had thrombocytopenia. This study showed the statistically significance between warning signs and thrombocytopenia(p<0.001). Conclusions: Majority of dengue patients had fever, with abdominal pain as a common feature signifying warning sign. Majority had thrombocytopenia and leukopenia; this also showed statistically significant difference between thrombocytopenia and warning sign.
Introduction: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Acute exacerbations frequently lead to emergency visits and worsen patient outcomes. This study aimed to assess the clinical presentation, precipitating factors, and predictors of severity among patients with AECOPD (Acute exacerbation of chronic obstructive pulmonary disease). Methods: A descriptive cross-sectional study was conducted among 150 patients presenting with AECOPD to the emergency department of a tertiary care center in Pokhara, Nepal. Data on clinical features, risk factors, and investigations were collected and analyzed using SPSS 25.0. Multivariable logistic regression was used to identify predictors of ICU admission. Results: The mean age was 75.6±9.8 years, with female predominance 92(61.3%). Shortness of breath 147(98%) and cough 125(83.3%) were the most common symptoms. Recent upper respiratory tract infection 38(25.3%) was the most frequent trigger. ICU admission was required in 42(28%) of patients. Increased respiratory rate, lower oxygen saturation, cyanosis, and accessory muscle use were associated with severity. Respiratory rate, PaO₂, and serum creatinine were independent predictors of ICU admission. Conclusions: AECOPD mainly affects elderly patients and is commonly triggered by infections. Simple clinical and laboratory parameters can help identify severe cases early, allowing timely management and improved outcomes.
Gastrointestinal stromal tumors (GISTs) are rare malignant tumors, rarely found in jejunum. Diagnosis mainly relies on histopathological examination and immunohistochemistry. Management typically includes surgery and chemotherapy. Herein, we present a case of an older adult female with abdominal pain and a palpable lump and managed by small bowel resection and adjuvant imatinib therapy. The excised tumor showed positive immunoreactivity for CD117, DOG-1 and SMA. This case report highlights the importance of considering GISTs in abdominal masses and the role of CT imaging and Immunohistochemistry in diagnosis and management.
Introduction: Psoriasis is a chronic immune-mediated inflammatory dermatosis associated with significant cardiovascular comorbidity. Population-specific data on lipid abnormalities in Nepalese psoriasis patients are limited. This study aimed to determine the association of psoriasis with serum lipid profiles. Methods: This hospital-based case-control study enrolled 73 confirmed psoriasis cases and 73 age and sex-matched healthy controls. Fasting serum triglycerides, total cholesterol, low-density lipoprotein cholesterol, very low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol were measured. Disease severity was graded by the Psoriasis Area and Severity Index. Results: Psoriasis vulgaris was the commonest clinical pattern 40 (54.8%). Cases had significantly elevated median triglycerides (145.0 vs. 122.0 mg/dl; p<0.001) and very low-density lipoprotein cholesterol (37.0 vs. 21.0 mg/dl; p<0.001), and significantly lower high-density lipoprotein cholesterol (60.40 vs. 72.73 mg/dl; p<0.001) and low-density lipoprotein cholesterol (p<0.001). Total cholesterol did not differ significantly (p=0.703). Elevated very low-density lipoprotein cholesterol (odds ratio [OR] 9.06; p<0.001), low high-density lipoprotein cholesterol (OR 6.30; p=0.017), and hypertriglyceridemia (OR 3.03; p=0.003) were more prevalent among cases. No significant correlation was found between Psoriasis Area Severity Index and lipid parameters. Conclusions: Psoriasis is associated with a proatherogenic lipid profile. Routine fasting lipid profiling at diagnosis is recommended for early cardiovascular risk assessment.
Introduction: Changes in dental anatomy resulting from hereditary and environmental influences during tooth development are known as anomalies. Abnormalities in tooth number, shape, size and structure result from disturbances during different stages of tooth development. This study was conducted to assess the prevalence of dental anomalies among patients visiting a dental teaching hospital in Kathmandu. Methods: In this descriptive cross-sectional study, dental anomalies affecting tooth shape, number, and position were evaluated on digital orthopantomograms. Data was analyzed in SPSS version 24. Mean, standard deviation, frequency, and percentage were calculated for descriptive data analysis. Results: Among 200 radiographs observed, 20(10.00%) had at least one dental anomaly present. Anomaly affecting shape was observed in 9(4.50%), and anomaly affecting number in 12(6.00%). Impacted tooth was present in 150(75%). The third molar impaction was seen in 89(44.50%). Only 3(1.5%) of patients’ radiographs showed canine impaction. Five (2.5%) teeth with dilaceration and 4(2.0%) peg-shaped laterals were observed. Eight (4.0%) patients had at least one missing tooth. Paramolar, distomolar, mesiodens and multiple supernumerary teeth were present in 1(0.5%). Conclusions: The findings of this study revealed that dental anomalies were present in a small yet notable proportion in radiographs of patients visiting a dental teaching hospital. Impaction was the most prevalent anomaly affecting tooth position, present in three-fourths of the radiographs, predominantly involving third molars. Routine radiographic evaluation, particularly panoramic radiographs, should be considered in young adults to detect impaction and other anomalies at an early stage.
Reflection has been recognized, during the recent years as a vital skill to improve the clinical and professional performances of nurses. It involves the precise analysis of a clinical situation or condition, through careful and detailed review of feelings, actions, thoughts and behaviors. Different nursing programmes should encourage the development and use of reflective practices among the students. Administrators should consider constructing and designing the curriculum which enhances this skill among the students, thus improving their self learning and efficacy. Students should be encouraged to write and practice reflective exercises, which should be integrated with the development of other competencies. The instructors should address the gaps and encourage the students to work on the areas that need improvement. Mentorship can be planned for the students with weaker reflective capacity.
Introduction: Topical delivery was selected to enhance localized drug concentration at the site of infection while minimizing systemic side effects. Itraconazole makes the fungal cell membrane weak, leading to leakage of cell contents and ultimately fungal cell death. The present study focused on the formulation and evaluation of a topical antifungal gel containing itraconazole for the effective treatment of superficial fungal infections. Methods: The gel was prepared using suitable gelling agents such as Carbopol 940 and HPMC K4M, with Dimethyl Sulfoxide as a solvent and propylene glycol as a co-solvent. The formulation was optimized based on parameters including pH, spreadability, drug content and in vitro drug release. Antifungal efficacy was assessed using the agar well diffusion method against Candida albicans. The optimized formulation showed desirable physiochemical properties, sustained release, and significant antifungal activity, suggesting its potential as an effective topical treatment for fungal skin infections. Results: The results showed that the F7 formulation was found to be optimal, showing a skin-compatible pH of 6.43±0.025, good spreadability (10.84±0.1035), high drug content, and a sustained drug release profile reaching up to 93.07% over 240 minutes. Conclusions: The study successfully developed an optimized Itraconazole topical gel using Carbopol 940 and HPMC K4M. Among the formulations, F7 exhibited the best physicochemical properties and in vitro drug diffusion. These results confirmed23 that the developed gel is an effective delivery system for treating and preventing fungal infections.
Introduction: Zygomaticomaxillary complex (ZMC) fractures are among the most common facial fractures and can be managed either conservatively or surgically depending on severity and clinical presentation. However, the optimal approach remains debated, particularly in terms of functional and aesthetic outcomes. Hence, this study aimed to compare the clinical outcomes and complications associated with conservative versus surgical management of ZMC fractures and to identify predictors of favorable recovery. Methods: A comparative study was conducted on 60 patients diagnosed with isolated ZMC fractures, divided equally into conservative (n=30) and surgical (n=30) management groups. Demographic characteristics, fracture patterns, treatment outcomes, and complications were recorded. Clinical outcomes were categorized as excellent, good, fair, or poor. Multivariable logistic regression analysis was performed to identify factors associated with favorable recovery. Results: Patients in the surgical group were older on average than those managed conservatively. Excellent outcomes were more frequent in the surgical group (50.0%) compared to the conservative group (33.3%), while poor outcomes were less common (3.3% vs. 10.0%). Enophthalmos and cosmetic deformity were notably higher in the conservative group, affecting 26.7% and 36.7% of patients, respectively, compared to 6.7% and 13.3% in the surgical group. The incidence of nerve paresthesia, trismus, and diplopia was similar across both groups. Although surgical patients demonstrated better outcomes, surgical management was not an independent predictor of favorable recovery in multivariable analysis (p = 0.21). Cosmetic deformity was the only significant predictor of poorer recovery (p = 0.04). Conclusions: Surgical management of ZMC fractures appears to provide better clinical and aesthetic outcomes with fewer complications compared to conservative treatment. Cosmetic deformity negatively impacts recovery, highlighting the importance of appropriate treatment selection for optimal patient outcomes.
Introduction: Large immature cells (LICs) are myeloid or lymphoid cells normally present in bone marrow which may be released in peripheral blood in various conditions. The automated hematology analyzers though have good correlation with microscopy for mature cells, give flag messages when immature cells are present and manual microscopy remains the reference method. The objective of this study was to find types of immature cells comprising LICs and see correlation of automated and manual Differential leukocyte count (DLC) in presence of such cells. Methods: This cross-sectional study was conducted in the Central Clinical Laboratory, College of Medical Sciences, after ethical approval. A total of 100 EDTA-anticoagulated blood samples with LIC >3% on automated DLC using the Horiba Yumizen H550 analyzer were included. Repeat CBC samples and leukopenic cases without automated DLC were excluded. CBC and DLC parameters including Hb, TLC, platelet count, and differential counts were recorded. Pearson correlation was used to assess relationship, with p<0.05 considered significant. Results: Total leukocyte count ranged from 790 to 479190/cumm. Myeloblasts were seen in 6%, promyelocytes in 6%, myelocytes in 41%, metamyelocytes in 73%, bands in 84%, lymphoblasts in 2%, atypical lymphocytes in 30% and atypical monocytes in 5%. There was strong correlation between automated and manual DLC for neutrophils, lymphocytes and eosinophils, fair correlation for monocytes (p<0.001) and no correlation for basophils (p=0.175). Conclusions: Manual microscopy is required to evaluate all the cases in presence of LIC more than reference range.
Introduction: Difficult laryngoscopy remains a significant challenge in anesthetic practice, occurring in 1.5% to 13% of cases. Point-of-care ultrasound has emerged as a potential tool for predicting difficult laryngoscopy. This study evaluated the utility of ultrasound measurements of anterior neck soft tissue thickness in predicting difficult laryngoscopy. Methods: This prospective observational study included 140 adult patients (ASA I-II) undergoing elective surgery requiring general anesthesia and endotracheal intubation. Modified Mallampati Grade, thyromental distance, inter-incisor gap, neck circumference, and body mass index were recorded and ultrasound measurements of distance from skin to hyoid bone (DSHB), skin to epiglottis midway between hyoid and thyroid cartilage (DSEM), and skin to anterior commissure (DSAC) were obtained preoperatively. Laryngoscopy view was graded using the Modified Cormack-Lehane classification. Receiver operating characteristic curve analysis was performed to determine the diagnostic accuracy of each parameter. Results: Out of 140 patients, 33(23.6%) had difficult laryngoscopy. DSEM demonstrated superior predictive performance with an area under the curve (AUC) of 0.867, sensitivity of 90.9%, and specificity of 79.4% at a cutoff of 1.69 cm (p<0.001). DSHB showed an AUC of 69.8% with moderate sensitivity (51.5%) and specificity (74.8%). Among clinical parameters, neck circumference (p=0.016), thyromental distance (p=0.007), inter-incisor gap (p=0.005), and Modified Mallampati grading (p=0.006) were significantly associated with difficult laryngoscopy. Conclusions: Ultrasound measurement of DSEM is a reliable predictor of difficult laryngoscopy with excellent sensitivity and good specificity. The high negative predictive value (96.6%) makes DSEM particularly useful for ruling out difficult airways in routine cases.
Background: There have been significant advancements in the scope of anesthesia, however, it has been misconceived as a behind the screen specialty. Patients are not aware of anesthesiologist as a qualified health professional, especially in under-developed countries. This knowledge gap may adversely affect informed consent and perioperative anxiety management. Hence, this study aimed to assess patient`s knowledge and perception regarding anesthesia, evaluate concerns about surgical interventions and determine associations between educational level and previous anesthetic exposure with awareness about anesthesia types. Methods: An institutional based cross- sectional study was conducted from November 2025 to January 2026 in patients aged 18 to 75 years. Around 370 patients were interviewed with a structured questionnaires with 12 items to assess patients’ knowledge, perception and concerns of anesthesia. Descriptive statistics and Chi-square tests were used for analysis. Results: Out of 370 patients, only 80(21.60%) correctly identified anesthesiologists as the health care professionals responsible for administering anesthesia. Most patients 283(76%) lacked knowledge about anesthetic types. A statistically significant association was found between education level and awareness of anesthetic types (p<0.001) and between previous anesthetic exposure and awareness of anesthetic types (p<0.0001). Conclusions: Patient awareness regarding anesthesia and the peri-operative role of anesthesiologists was limited. Higher educational attainment and previous anesthetic exposure were associated with improved awareness.
Chronic kidney disease (CKD) affects approximately 10–13% of the global population and is associated with substantial morbidity, mortality, cardiovascular complications, and healthcare costs. Effective self-management is increasingly recognized as a cornerstone of CKD care. This narrative review synthesizes current evidence on self-management in adults with CKD by examining its core components, effectiveness, influencing factors, and clinical implications. A literature search of PubMed, CINAHL, Embase, Scopus, and Web of Science included studies published up to 2025, including randomized controlled trials, systematic reviews, clinical guidelines, and observational studies. The evidence indicates that self-management interventions improve patient knowledge, self-efficacy, medication adherence, lifestyle behaviours, blood pressure control, psychological well-being, and health-related quality of life. Nurse-led education, behavioural counselling, family support, and digital health approaches have shown promising outcomes, although effectiveness varies according to health literacy, patient engagement, socioeconomic conditions, and healthcare access. Future research should focus on standardized, culturally appropriate, and sustainable self-management interventions, particularly in resource-limited settings.
Introduction: Coloboma is a congenital ocular defect affecting various ocular structures and can make cataract surgery more challenging. Evidence on surgical outcomes from developing regions remains limited. This study evaluated the outcomes of manual small incision cataract surgery (M-SICS) in colobomatous eyes at a tertiary center. Methods: This prospective analytical study included 46 eyes with congenital coloboma and visually significant cataract managed at a tertiary referral center. Preoperative assessment included visual acuity, slit lamp examination, and biometry. The surgical technique was primarily M-SICS. Patients were followed on postoperative day 1, at 2 weeks, and 6 weeks. Outcomes assessed included visual acuity, intraoperative events, and postoperative complications. Statistical analysis included paired t-test and repeated measures ANOVA. Results: The mean age was 43.37±1.7 years, with 52.2% females. Bilateral involvement was present in 56.5%. Microcornea was observed in 39.1% and macula sparing coloboma in 65.2%. Preoperative mean visual acuity was 1.528±0.614 LogMAR, with 65.2% presenting with BCVA ≤1/60. Intraoperative challenges included poor pupillary dilatation in 45.7% and zonular weakness in 32.6%. Posterior capsular rent occurred in 23.9%. Intraocular lens implantation was achieved in 80.4%. Postoperatively, visual acuity improved significantly to LogMAR 0.996 on day 1, 0.720 at 2 weeks, and 0.696 at 6 weeks. Significant improvement was seen at all time points, p < 0.001. Good visual outcome was achieved in 58.7%. Corneal edema resolved by 6 weeks. Conclusions: M-SICS provides effective visual rehabilitation in colobomatous eyes despite intraoperative challenges.
Introduction: Short lesion-pleural distance allows little space for manipulation of biopsy needle with high risk of needle dislodgement into pleural space causing air leak and subsequently pneumothorax. This study compared short trans-pulmonary biopsy approach with long trans-pulmonary approach for small sub-pleural pulmonary nodule to determine approach with lesser complication and better diagnostic yield. Methods: A total of 65 patients who were undergoing CT guided biopsy for small (≤20 mm) sub-pleural (≤10 mm) pulmonary nodules were divided into two groups depending upon biopsy approach, i.e., long trans-pulmonary biopsy approach (group A, n=34) and short trans-pulmonary biopsy approach (group B, n=31). Diagnostic accuracy and complication rate between the groups were compared. Results: No significant difference was found between two groups in case of diagnostic accuracy (Group A vs Group B: 91.2% vs 87.1%; p=0.59). Pneumothorax rate was higher in group B (29.0%) compared to group A (14.7%), however, difference was not statistically significant (p=0.16). Among risk factors for pneumothorax, smaller lesion size (5-10 mm), short lesion-pleural distance (≤ 5 mm) and number of pleural passes (>1) was associated with significantly higher pneumothorax rate in group B compared to group A (71.4 vs 40% p=0.02; 85.7% vs 16.6% p=0.01; 100% vs 57.1% p=0.01 respectively). Conclusions: Smaller sub-pleural pulmonary nodules render high risk of pneumothorax with the use of short trans-pulmonary pathway. If the nodule is very close to pleura and relatively smaller where one could not ensure access with single puncture, long trans-pulmonary pathway serves as safer option to avoid pneumothorax.
Introduction: Physical activity during pregnancy affects multiple aspects of a woman’s life. Attitudes, values, experiences, and socio-cultural contexts play an important role in participation in physical activity. This study aimed to explore pregnant women lived experiences and perceptions of physical activity. Methods: A qualitative phenomenological study was conducted among women attending obstetrics outpatient department of Gandaki Medical College Teaching Hospital and Research Centre. Purposive sampling was used to recruit participants meeting inclusion criteria. The researchers performed semi-structured interviews, audio recorded them, transcribed the verbatim, and used thematic analysis. This approach focused on capturing the essence of participants lived experiences while organizing data into meaningful patterns. Results: Three major experiential themes emerged. 1) Perceptions of Pregnancy and Physical Activity: Women recognized the benefits of exercise but had limited knowledge of safe types, intensity, and frequency, often equating physical activity with household chores. 2) Experiences and Influences on Physical Activity: Participation was influenced by perceived benefits, fear of harming the foetus, fatigue, and social or cultural restrictions. Support from spouses, family, peers, and community resources facilitated engagement. 3) Experiences with Healthcare Providers and Recommendations: Guidance from healthcare professionals was often inadequate, leaving women uncertain about safe practices. Participants suggested structured counselling, practical demonstrations, family support, and accessible community programs to promote safe physical activity during pregnancy. Conclusions: Pregnant women recognize the benefits of physical activity but possess limited understanding of appropriate exercises, frequency, and safety. Interventions promoting physical activity should address informational gaps and take sociocultural circumstances into account.
