Patient outcome tools not defined, limiting consistent comparisons.

No legal or consent guidance for acetylcholine use in testing.

Lacks training and certification standards for test operators.

Relies on expert opinion without supporting clinical trial data.

Noor Ul Huda: Conceptualization, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing. Sanhia Maheshwari: Conceptualization, Methodology, Writing – original draft, Writing – review & editing. Syeda Fatima Hassnain: Conceptualization, Methodology, Writing – original draft, Writing – review & editing.

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