Limited Experience Research Articles

Treatment of glucocorticoid-induced osteoporosis with concurrent denosumab and romosozumab: a case report.

Osteoporosis is a metabolic bone disorder for which treatment options include antiresorptive therapies (e.g., bisphosphonates, denosumab); anabolics (e.g., teriparatide, abaloparatide); and dual mechanisms (e.g., romosozumab). Management of osteoporosis with concurrent antiresorptive and anabolic agents may be superior to monotherapy, as demonstrated in the DATA trial with the combination of denosumab and teriparatide. However, there is limited experience with the combination of denosumab and romosozumab, which may be an alternative antiresorptive/anabolic regimen for individuals who are not candidates for PTH receptor agonists. In this case, we present a young man with glucocorticoid-induced osteoporosis who could not tolerate a daily injectable anabolic and who experienced improvement in bone mineral density with concurrent denosumab and off-label romosozumab administration.

Deep-learning generated B-line score mirrors clinical progression of disease for patients with heart failure

BackgroundUltrasound can detect fluid in the alveolar and interstitial spaces of the lung using the presence of artifacts known as B-lines. The aim of this study was to determine whether a deep learning algorithm generated B-line severity score correlated with pulmonary congestion and disease severity based on clinical assessment (as identified by composite congestion score and Rothman index) and to evaluate changes in the score with treatment. Patients suspected of congestive heart failure underwent daily ultrasonography. Eight lung zones (right and left anterior/lateral and superior/inferior) were scanned using a tablet ultrasound system with a phased-array probe. Mixed effects modeling explored the association between average B-line score and the composite congestion score, and average B-line score and Rothman index, respectively. Covariates tested included patient and exam level data (sex, age, presence of selected comorbidities, baseline sodium and hemoglobin, creatinine, vital signs, oxygen delivery amount and delivery method, diuretic dose).ResultsAnalysis included 110 unique subjects (3379 clips). B-line severity score was significantly associated with the composite congestion score, with a coefficient of 0.7 (95% CI 0.1–1.2 p = 0.02), but was not significantly associated with the Rothman index.ConclusionsUse of this technology may allow clinicians with limited ultrasound experience to determine an objective measure of B-line burden.

Video-Guided Optimization of Stimulation Settings in Patients with Parkinson's Disease and Deep Brain Stimulation.

Deep brain stimulation (DBS) for Parkinson's disease (PD) often necessitates frequent clinic visits for stimulation program optimization, with limited experience in remote patient management. Due to the resource-intensive nature of these procedures, we investigated a way to simplify stimulation optimization for these patients that allows for the continuous monitoring of symptoms while also reducing patient burden and travel distances. To this end, we prospectively recruited ten patients treated with DBS for PD to evaluate the feasibility of telemedicinal optimization in a home-based setting. Patients recorded daily videos of a modified Unified Parkinson's Disease Rating Scale (UPDRS) III, which experienced DBS physicians located at the clinic assessed to provide instructions on adjusting stimulation settings using a handheld programmer with previously set programs as well as patient amplitude control. This study concluded with significant improvements in participants' motor status as measured by the UPDRS-III (p = 0.0313) compared to baseline values. These findings suggest that remote video-guided optimization of DBS settings is feasible and may enhance motor outcomes for patients.

Predictor of Surgical Failure Following Transvaginal Mesh Repair Using Minimally Invasive Prolapse System Device (MIPS).

Background: The Minimally Invasive Prolapse System (MIPS) device, a novel single-incision transvaginal mesh, represents recent advancements in mesh technology, providing lightweight, biocompatible support for pelvic organ prolapse while reducing erosion, allowing for customization and improving surgical outcomes. This study aimed to identify factors associated with pelvic organ prolapse (POP) recurrence after transvaginal mesh (TVM) repair using the Minimally Invasive Prolapse System device. Methods: Two hundred and eighteen women with symptomatic stage II to IV POP underwent TVM. Preoperative and postoperative assessments included urinalyses and pelvic examinations using the POP quantification (POP-Q) staging system. Results: During a follow-up period of 12-46 months, 7 of 218 (3.2%) women experienced POP recurrence. Univariate analysis was conducted to identify predictors of surgical failure, revealing no significant differences in body mass index, POP stage, or preoperative urinary symptoms between the recurrence and success groups (p > 0.05). However, functional urethral length <20 mm based on urodynamics (p = 0.011), ICI-Q scores ≥7 (p = 0.012), and the first 60 surgical cases (p = 0.018) were significant predictors of surgical failure. Multivariate logistic regression confirmed these findings. Conclusions: Functional urethral length <20 mm, ICI-Q scores ≥7, and limited surgical experience were significant predictors of TVM failure using the Minimally Invasive Prolapse System kit. POP recurrence after mesh repair is less likely beyond the learning curve.

Exploring clinical practice education for student midwives: Hospital and community opportunities and challenges

Understanding the experiences of student midwives during clinical training is crucial amid evolving midwifery practices in the Philippines. This training is a vital component of their education, offering real-world experience in hospital and community settings. Although existing literature covers various aspects of midwifery training, detailed accounts of the specific challenges and opportunities faced by Filipino student midwives are limited. This study explores the experiences of student midwives across different levels of training in public and private institutions, focusing on the opportunities and challenges they encountered. A qualitative descriptive research design was conducted with 26 purposively selected student midwives. Data collected through in-depth interviews were analyzed to identify recurring themes. Key themes included the importance of a supportive learning environment, exposure to diverse cases, and the acquisition of practical skills. Challenges such as hierarchical barriers and communication challenges, role confusion, resource limitations and adaptation struggles, balancing autonomy and supervision, emotional toll of challenging situations and limited community experiences were highlighted. The findings stress the need for a more supportive and resourceful training environment. Addressing these challenges through targeted interventions could enhance the learning experience and better prepare student midwives for their professional roles. Collaborative efforts with other healthcare professionals and continuous learning opportunities are also essential for their development. This study offers valuable insights for educators and healthcare institutions to optimize midwifery training programs, ultimately fostering the holistic growth of future midwives.

Preparing Early Education Leaders: An Analysis of UCEA Principal Preparation Programs

Purpose: Recently, a confluence of factors has focused elementary school leaders on early education. One factor is that nearly 60 percent of all public elementary schools in the U.S. today have a Pre-K program in the building. Yet, prior research reveals that leaders are often not prepared to effectively lead early education programs. This study assesses the current state of early education leadership preparation among UCEA-affiliated programs. Method: Using a sequential explanatory mixed-methods approach, our study draws on survey data from 232 principal preparation faculty members at UCEA-affiliated programs, follow-up interviews with 20 purposively sampled survey respondents, and content analysis of 113 program web pages. Findings: We found that preparation programs currently afford little attention to early education leadership coursework and content, despite faculty expressing it as an important goal. Only four percent of faculty from the survey reported that their program required a course focused on child development and/or early education—a finding corroborated by the website analysis. Last, our interviews reveal reasons for the limited engagement with early education leadership, including time constraints, limited faculty experience, and licensure and accreditation requirements. Implications: Policymakers aiming to improve early education leadership may revise principal certification requirements that could prompt revisions in principal preparation programs. Principal preparation programs, similarly, could revise their programming to intentionally expose principal candidates to key topics in early education leadership. A bi-directional and concerted reform effort is likely needed to meaningfully advance change in this area.

Exploring team creativity: The nexus between freshness and experience

Scientific collaborations are widely acknowledged as a key factor in advancing contemporary science. Using the absence of prior collaboration relationships among all team members of a focal paper to assess team freshness, previous studies demonstrated strong associations between team freshness and the ability to generate original and multidisciplinary papers. However, the intricate interplay between team freshness and the experiences of new members remains less explored. For example, individuals can be classified based on their experiences or ages, distinguishing between newcomers with limited experience and incumbents with a track record of publications. Using the existing definition of team freshness, we focus on categorizing fresh teams into two distinct types: those consisting of fresh incumbents and those with fresh newcomers. Utilizing a comprehensive dataset comprising over 5 million articles, we systematically investigate the relationship between team freshness, the freshness of incumbents, and the freshness of newcomers on various creativity measurements. Our analysis yields several key findings. Firstly, both team freshness and the freshness of newcomers display a declining trend over time, whereas the freshness of incumbents remains stable. Secondly, we observe strong positive associations between team freshness, the freshness of incumbents, and the freshness of newcomers with regard to various creativity indicators. Strikingly, we emphasize substantial promotional powers of the freshness of incumbents on creativity, even after adjusting for overall team freshness. Our results have important policy implications related to the formation of creative teams.

Comparison of deep learning models to detect crossbites on 2D intraoral photographs

BackgroundTo support dentists with limited experience, this study trained and compared six convolutional neural networks to detect crossbites and classify non-crossbite, frontal, and lateral crossbites using 2D intraoral photographs.MethodsBased on 676 photographs from 311 orthodontic patients, six convolutional neural network models were trained and compared to classify (1) non-crossbite vs. crossbite and (2) non-crossbite vs. lateral crossbite vs. frontal crossbite. The trained models comprised DenseNet, EfficientNet, MobileNet, ResNet18, ResNet50, and Xception.FindingsAmong the models, Xception showed the highest accuracy (98.57%) in the test dataset for classifying non-crossbite vs. crossbite images. When additionally distinguishing between lateral and frontal crossbites, average accuracy decreased with the DenseNet architecture achieving the highest accuracy among the models with 91.43% in the test dataset.ConclusionsConvolutional neural networks show high potential in processing clinical photographs and detecting crossbites. This study provides initial insights into how deep learning models can be used for orthodontic diagnosis of malocclusions based on intraoral 2D photographs.

Problems of Waqf Management in Indonesia: A Review of Positive Law

The implementation of waqf has been happening in many regions in Indonesia. The essence of waqf as a form of worship that brings great rewards and community welfare should be managed properly by professional nadzirs, not the other way around. Various problems have occurred in various regions, resulting in the management of waqf not maximizing and not achieving common goals. This research uses a normative juridical approach that is descriptive analytical by using various theories in legal science related to the process of implementing waqf within the framework of positive legal development in Indonesia. The problems of waqf management in Indonesia so far have been caused by the lack of socialization about waqf by a less aggressive government, waqf management and management that is not in accordance with the rules, limited human resources (nadzir) who meet the requirements and weak control systems in supervision to be less effective in its application in society. The problems that exist so far show that they arise from external factors, namely legal subjects who have not experienced limitations and sufficient knowledge in managing waqf properly and correctly according to the rules of law and Islamic religious law. For this reason, it is necessary to supervise the management of waqf by the government and society so that strict supervision is expected that waqf in Indonesia can be managed properly so that the results can be utilized to empower the quality of life of the people.

Biophilia and Adolescents’ Sense of Place in Australian Vertical Schools

This article describes the place relationships adolescents have with natural elements in recently developed ‘vertical schools’ in Australia: a relatively new school typology in the country, generally considered to be over four storeys high. Vertical schools are being built in Australia’s largest cities in response to the need for new schools where land is scarce. Drawing on qualitative research into the place relationships that adolescents have with their learning environments in two Australian vertical schools, this article explores the ways young people seek closer associations with nature in multi-storey educational settings. The research adopted a phenomenological approach to ‘place research’, asking what makes a place a place? Further, it recognised that places have the capacity to shape the ‘becoming’ of a person, that ‘becoming’ happens when there is a certain resonance between a place’s cycles, and that identity is created out of difference. As such, ‘place as complex adaptive assemblage theory’ was employed to study the interplay between location and experience in selected vertical schools, also drawing on the earlier theoretical work of Relph (1976), who suggested that the essence of a place lies in the unselfconscious intentionality that defines places as profound centres of human existence. Photovoice was employed as a method to elicit insights into the relationships adolescents have with their school as place. Students created photo essays to document their place relationships, revealing deeply insightful personal reflections on their school as place and the meanings they associate with it. Specifically, the article reports on what thirteen adolescent students communicated about the biophilic experiences afforded by their vertical school, including how it influenced their ‘becoming’. The findings demonstrated that the participating students not only valued relationships with natural elements, but actively sought biophilic experiences on a regular basis. The desire for more frequent and more significant interactions with natural materials and cycles was common across most students, indicating that the relatively limited biophilic experiences available to students in vertical schools is a challenge that should be addressed in future multi-level educational environments.

223.3: Successful implementation of pure laparoscopic right donor hepatectomy in a small center with limited experience: The role of proctorship program.

223.3: Successful implementation of pure laparoscopic right donor hepatectomy in a small center with limited experience: The role of proctorship program.

Model-Informed Assessment of Probability of Phase 3 Success for Ritlecitinib in Patients with Moderate-to-Severe Ulcerative Colitis.

Ritlecitinib, an oral Janus kinase 3/tyrosine kinase expressed in hepatocellular carcinoma family inhibitor, was evaluated in patients with ulcerative colitis (UC) in a phase 2b trial. Model-informed drug development strategies were applied to bridge observations from phase 2b to predictions for a proposed phase 3 study design to assess the probability of achieving the target efficacy outcome. A longitudinal exposure-response model of the time course of the 4 Mayo subscores (rectal bleeding, stool frequency, physician's global assessment, and endoscopic subscore) in patients with UC receiving placebo or ritlecitinib was developed using population modeling approaches and an item response theory framework. The quantitative relationships between the 4 Mayo subscores accommodated the prediction of composite endpoints such as total Mayo score and partial Mayo score (key endpoints from phase 2b), and modified clinical remission and endoscopic remission (proposed phase 3 endpoints). Clinical trial simulations using the final model assessed the probability of candidate ritlecitinib dosing regimens (including those tested in phase 2b and alternative) and phase 3 study designs for achieving target efficacy outcomes benchmarked against an approved treatment for moderate-to-severe UC. The probabilities of achieving target modified clinical remission and endoscopic improvement outcomes at both weeks 8 and 52 for ritlecitinib 100 mg once daily was 74.8%. Model-based assessment mitigated some of the risk associated with proceeding to pivotal phase 3 trials with dosing regimens of which there was limited clinical experience.

Reflections on ethnic diversity within a dental desert.

The demographics of the dental workforce have changed significantly in recent years, with regard to both gender and ethnicity. Ethnic diversity within dentistry does not align with UK population data, with some groups less well-represented than others, such as those of Black or Afro-Caribbean heritage. Although multiculturalism has developed throughout the UK, it is much less advanced within rural areas. Rural communities have a less ethnically diverse population and this has been identified as a challenge when looking to recruit dentists and other dental care professionals from a Black, Asian or minority ethnic (BAME) background.Recruitment and retention of dentists to rural areas is a major issue and it is vitally important to ensure that all members of the dental profession feel adequately supported and welcome. Addressing the shortage of dental professionals in rural areas is crucial in improving dental access. However, this task becomes more complex when considering the increasing number of BAME students and graduates from a metropolitan background, and a continuing lack of multi-culturalism within rural communities. Identifying and understanding the factors which influence BAME dental professionals' decisions to relocate to rural areas is vital for developing effective strategies to attract and retain diverse talent within these communities.This opinion article considers existing literature, while drawing upon personal experiences as a Black student in the South West of England, in order to explore the barriers to working in rural areas as an individual from a minority ethnic group. Socioeconomic challenges, cultural isolation and limited rural experience are identified as factors that can deter Black and other minority ethnic dentists from living and working in rural areas.

Typical Mathematical Education Cannot Predict Non‐Verbal Number Sense

ABSTRACTFormal education would promote symbolic number processing ability, but the relationship between non‐symbolic number sense and mathematical education remains controversial. The current investigation hypothesized that non‐symbolic number sense is independent from the limited human experience of mathematical education, while symbolic number processing could be influenced by related closely to mathematical education. Experiment 1 compared both non‐symbolic number sense and arithmetic computation of undergraduates majoring in STEM fields and humanities. Experiment 2 compared homologous undergraduates from China and Kyrgyzstan in non‐symbolic number sense and mathematical cognitive processing. Both of two experiments found that mathematical education was significantly associated with symbolic mathematics, but not with non‐symbolic number sense. The results suggest that while mathematical education might improve symbolic mathematics, it does not alter non‐symbolic number sense.

The Role of QR Code Applications in Enhancing Customer Satisfaction at Restaurants: A Conceptual Study

This paper aims to analyse the application of QR codes in enhancing customer satisfaction within the restaurant industry. Specifically, the study identifies the impact of QR code usage on customer satisfaction by reviewing existing literature. Data is gathered by reviewing journals, articles, and research studies using argumentative techniques. In today's world, characterized by a shift towards contactless interactions, the restaurant industry has embraced QR codes for seamless, contactless payments and operations. This study addresses the need for a deeper understanding of QR code applications by determining three critical elements: usefulness, acceptability, and feasibility. The findings are expected to guide industry professionals and researchers in identifying the most effective QR code implementations, thereby enhancing customer satisfaction. Through this exploration, the study contributes to bridging the knowledge gap and fostering improved practices in the restaurant industry, ultimately promoting the wide-spread adoption of QR codes as a valuable tool for customer engagement and satisfaction. However, this study profound a limitation with the suggested model leading from limited participant perspectives and experiences. This restricts the ability to form a comprehensive and solid view, potentially affecting the study's findings. Future research should involve a more diverse group of participants with varied experiences to enhance the understanding and application of the model.

Keinen Verfasser, nur eine Verfasserin? Literarische agency schreibender und ‘geschriebener’ Frauen in Prag (1770–80)

ABSTRACT This article deals with the characteristics of female authorship in Prague in the 1770s. The moral weeklies Die Unsichtbare (1771) and Die Sichtbare (1771) highlight the differences between the Prague reading public's expectations for female writers to focus on superficial, feminine topics and the complex and sophisticated writing of the female authors themselves. Experiences of limitation due to writing in Bohemia, in less valued genres such as novels, and because of their gender in fact led to women writers such as Viktorie Rupp and Maria Anna Sager developing self-confidence as authors. A central aspect of this paper is the juxtaposition of male and female writing patterns and their contrasts, as illustrated by Sager in her novels Die verwechselten Töchter (1771) and Karolinens Tagebuch (1774). Finally, her contributions as a female writer are contextualized within the framework of contemporary literary criticism and the academic aesthetics surrounding the Prague professor Karl Heinrich Seibt.

Working practices and integration of primary health care doctors in remote rural areas in Brazil: a qualitative study

Health care challenges in remote rural municipalities (RRMs) emphasize the importance of primary health care (PHC) and require an expanded scope of practice. Doctors are key actors in this context. The aim of this study was to explore the level of integration of doctors in RRMs and working practices. We conducted a qualitative study involving semi-structured interviews with 46 PHC doctors working in 27 RRMs in Brazil. Content analysis was performed, resulting in the identification of categories of analysis grouped under three core dimensions: doctor training and experience; comprehensive care and timely access; and the community-based approach. Doctors working in RRMs were mainly recent graduates with limited experience who had undertaken their degree outside Brazil, and care was focused on the individual. The findings also revealed weak sociocultural adaptation and a harsh working environment and issues related to social status that reinforced prejudice against rurality and poverty. Practice was limited in scope and care tended to be oriented towards acute problems, disease-centered and focused on the biomedical model of medicine. Barriers to the delivery of comprehensive care include both structural constraints, such as poor facilities and centralization of services in administrative centers, and the lack of professional competencies necessary for PHC in these areas. The findings point to the need to promote an expanded scope of practice in PHC delivery in RRMs, with major public investment in the promotion of training and strengthening career pathways in these areas.

Efficacy of Dry Needling in Enhancing Hand Function and Reducing Spasticity in MCA Stroke Patients: A Prospective Case Report

Stroke, particularly involving the middle cerebral artery (MCA), often leads to persistent disability, significantly impairing hand function and inducing severe spasticity in the forearm flexors due to complex motor pathway involvement. This case report evaluates the effectiveness of combining dry needling therapy (DNT) with task-oriented training (TOT) in reducing spasticity and improving hand function in a post-MCA stroke patient. A 61-year-old male with right-side hemiplegia following a left MCA stroke, compounded by a history of diabetes, hypertension, and recent kidney stone diagnosis, participated in this study. The patient experienced severe functional limitations due to spasticity (grade 3 on the Modified Ashworth Scale) and scored 31 on the CAHAI-13, indicating significant hand dysfunction. DNT was applied to key forearm muscles (flexor carpi radialis, flexor carpi ulnaris, flexor digitorum superficialis, flexor digitorum profundus, and pronator teres), followed by TOT targeting daily tasks. Post-intervention, the patient demonstrated significant improvements: spasticity was reduced (Modified Ashworth Scale score decreased from grade 3 to grade 2), and muscle hypertonicity, as measured by EMG, was reduced in all targeted muscles. Functional hand use improved markedly, with the CAHAI-13 score increasing from 31 to 45. These improvements led to enhanced independence in daily activities. This case report highlights the clinical relevance of integrating DNT with TOT in stroke rehabilitation. The combined intervention not only reduced spasticity and improved neuromuscular function but also led to meaningful gains in hand function, enhancing the patient’s ability to perform daily activities independently. Given the promising results, this combined approach could serve as a practical and effective strategy for improving motor recovery and functional independence in post-stroke patients. Further studies with larger sample sizes are necessary to confirm these findings and explore the broader application of this approach in clinical practice.

Patient-Oriented Questionnaires and Machine Learning for Rare Disease Diagnosis: A Systematic Review.

Background: A major challenge faced by patients with rare diseases (RDs) often stems from delays in diagnosis, typically due to nonspecific clinical symptoms or doctors' limited experience in connecting symptoms to the underlying RD. Using patient-oriented questionnaires (POQs) as a data source for machine learning (ML) techniques can serve as a potential solution. These questionnaires enable patients to portray their day-to-day experiences living with their condition, irrespective of clinical symptoms. This systematic review-registered at PROSPERO with the Registration-ID: CRD42023490838-aims to present the current state of research in this domain by conducting a systematic literature search and identifying the potentials and limitations of this methodology. Methods: The review adheres to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was primarily funded by the German Federal Ministry of Education and Research under grant no. 16DHBKI056 (ki4all). The methodology involved a systematic search across the databases PubMed, Semantic Scholar and Google Scholar, covering articles published until June 2023. The inclusion criteria encompass examining the use of POQs in diagnosing rare and common diseases. Additionally, studies that focused on applying ML techniques to the resulting datasets were considered for inclusion. The primary objective was to include English as well as German research that involved the generation of predictions regarding the underlying disease based on the information gathered from POQs. Furthermore, studies exploring identifying predictive indicators associated with the underlying disease were also included in the literature review. The following data were extracted from the selected studies: year of publication, number of questions in the POQs, answer scale in the questionnaires, the ML algorithms used, the input data for the ML algorithms, the performance of these algorithms and how the performance was measured. In addition, information on the development of the questionnaires was recorded. Results: This search retrieved 421 results in total. After one superficial and two comprehensive screening runs performed by two authors independently, we ended up with 26 studies for further consideration. Sixteen of these studies deal with diseases and ML algorithms to analyse data; the other ten studies provide contributing research in this field. We discuss several potentials and limitations of the evaluated approach. Conclusions: Overall, the results show that the full potential has not yet been exploited and that further research in this direction is worthwhile, because the study results show that ML algorithms can achieve promising results on POQ data; however, their use in everyday medical practice has not yet been investigated.

Mobile-linked point-of-care diagnostics in community-based healthcare: a scoping review of user experiences

BackgroundWhile mobile-linked point-of-care diagnostics may circumvent geographical and temporal barriers to efficient communication, the use of such technology in community settings will depend on user experience. We conducted a scoping review to systematically map evidence on user experiences of mobile-linked point-of-care diagnostics in community healthcare settings published from the year 2016 up to the year 2022.MethodologyWe conducted a comprehensive search of the following electronic databases: Scopus, Web of Science, and EBSCOhost (Medline, CINAHL, Africa-wide, Academic Search Complete). The inter-reviewer agreement was determined using Cohen’s kappa statistic. Data quality was appraised using the mixed method appraisal tool version 2018, and the results were reported according to the preferred reporting items for systematic reviews and meta-analyses for scoping reviews (PRISMA-ScR).ResultsFollowing the abstract and full article screening, nine articles were found eligible for inclusion in data extraction. Following the quality appraisal, one study scored 72.5%, one study scored 95%, and the remaining seven studies scored 100%. Inter-rater agreement was 83.54% (Kappa statistic = 0.51, p < 0.05). Three themes emerged from the articles: approaches to implementing mobile-linked point-of-care diagnostics, user engagement in community-based healthcare settings, and limited user experiences in mobile-linked point-of-care diagnostics. User experiences are key to the sustainable implementation of mobile-linked point-of-care diagnostics. User experiences have been evaluated in small community healthcare settings. There is limited evidence of research aimed at evaluating the usability of mobile-linked diagnostics at the community level.ConclusionMore studies are needed to assess the user experience of mobile-linked diagnostics in larger communities. This scoping review revealed gaps that need to be addressed to improve user experiences of mobile-linked diagnostics, including language barriers, privacy issues, and clear instructions.