Assessment of internal exposure risk from metals pollution of occupational and non-occupational populations around a non-ferrous metal smelting plant.

Non-ferrous metal smelting poses significant risks to public health. Specifically, the copper smelting process releases arsenic, a semi-volatile metalloid, which poses an emerging exposure risk to both workers and nearby residents. To comprehensively understand the internal exposure risks of metal(loid)s from copper smelting, we explored eighteen metal(loid)s and arsenic metabolites in the urine of both occupational and non-occupational populations using inductively coupled plasma mass spectrometry with high-performance liquid chromatography and compared their health risks. Results showed that zinc and copper (485.38 and 14.00 µg/L), and arsenic, lead, cadmium, vanadium, tin and antimony (46.80, 6.82, 2.17, 0.40, 0.44 and 0.23 µg/L, respectively) in workers (n=179) were significantly higher compared to controls (n=168), while Zinc, tin and antimony (412.10, 0.51 and 0.15 µg/L, respectively) of residents were significantly higher than controls. Additionally, workers had a higher monomethyl arsenic percentage (MMA%), showing lower arsenic methylation capacity. Source appointment analysis identified arsenic, lead, cadmium, antimony, tin and thallium as co-exposure metal(loid)s from copper smelting, positively relating to the age of workers. The hazard index (HI) of workers exceeded 1.0, while residents and control were approximately at 1.0. Besides, all three populations had accumulated cancer risks exceeding 1.0 × 10-4, and arsenite (AsIII) was the main contributor to the variation of workers and residents. Furthermore, residents living closer to the smelting plant had higher health risks. This study reveals arsenic exposure metabolites and multiple metals as emerging contaminants for copper smelting exposure populations, providing valuable insights for pollution control in non-ferrous metal smelting.

Giant strong coupling in a Q-BICs' tetramer metasurface.

Due to their ultrahigh Q-factor and small mode volume, bound states in the continuum (BICs) are intriguing for the fundamental study of the strong coupling regime. However, the strong coupling generated by BICs in one metasurface is not always strong enough, which highly limits its efficiency in applications. In this work, we realize a giant strong coupling of at most 60 meV in a quasi-BICs' (Q-BICs) tetramer metasurface composed of four Si cylinders with two different sets of diagonal lengths. The Q-BICs are induced from two types of electric quadrupole (EQ), for which detuning can be flexibly controlled by manipulating the C4v symmetry breaking Δd. The giant Rabi splitting in our proposed metasurface performs more than 15 times of the previous works, which provides more possibilities for important nonlinear and quantum applications, such as nanolaser and quantum optics.

Preoperative albumin-bilirubin score predicts short-term outcomes and long-term prognosis in colorectal cancer patients undergoing radical surgery.

BACKGROUND: The albumin-bilirubin (ALBI) score is a serum biochemical indicator of liver function and has been proven to have prognostic value in a variety of cancers. In colorectal cancer (CRC), a high ALBI score tends to be associated with poorer survival. AIM: To investigate the correlation between the preoperative ALBI score and outcomes in CRC patients who underwent radical surgery. METHODS: Patients who underwent radical CRC surgery between January 2011 and January 2020 at a single clinical center were included. The ALBI score was calculated by the formula (log10 bilirubin × 0.66) + (albumin × -0.085), and the cutoff value for grouping patients was -2.8. The short-term outcomes, overall survival (OS), and disease-free survival (DFS) were calculated. RESULTS: A total of 4025 CRC patients who underwent radical surgery were enrolled in this study, and there were 1908 patients in the low ALBI group and 2117 patients in the high ALBI group. Cox regression analysis revealed that age, tumor size, tumor stage, ALBI score, and overall complications were independent risk factors for OS; age, tumor stage, ALBI score, and overall complications were identified as independent risk factors for DFS. CONCLUSION: A high preoperative ALBI score is correlated with adverse short-term outcomes, and the ALBI score is an independent risk factor for OS and DFS in patients with CRC undergoing radical surgery.

Does aortic calcification really affect anastomotic leakage after rectal cancer surgery?

The purpose of the current study was to analyze whether aortic calcification had impact on the anastomotic leakage (AL) after rectal cancer (RC) surgery. We collected patients' information from January 2011 to January 2020 in a single teaching hospital. Preoperative computed tomography images were obtained. Abdominal aortic calcification (AAC), superior mesenteric aortic calcification, and inferior mesenteric aortic calcification were recorded. The difference of AL and grade C AL was calculated. A total of 2412 RC patients were included in this study. Ninety-seven (4.0%) RC patients experienced AL and 47 (1.9%) RC patients experienced grade C AL. The amount of AAC, superior mesenteric aortic calcification, and inferior mesenteric aortic calcification was 1546 (64.1%), 128 (5.3%), and 31 (1.3%). The AL group had higher portion of AAC (P = .019) than the no AL group, and the grade C AL group had higher portion of AAC (P = .016) than the no grade C AL group. In univariate logistic regression analysis, AAC was a significant potential factor for AL (P = .021, OR = 1.739, 95% CI = 1.088-2.779) and grade C AL (P = .019, OR = 2.339, 95% CI = 1.115-4.986). However, in multivariate logistic regression, AAC was not an independent predictive factor for AL (P = .157, OR = 1.443, 95% CI = 0.871-2.358) or grade C AL (P = .064, OR = 2.055, 95% CI = 0.960-4.399). AAC was associated with higher amount of AL and grade C AL, however, AAC was not an independent predictive factor for AL or grade C AL.

Comparative Cytological and Gene Expression Analysis Reveals That a Common Wild Rice Inbred Line Showed Stronger Drought Tolerance Compared with the Cultivar Rice.

Common wild rice (Oryza rufipogon Griff.) is an important germplasm resource containing valuable genes. Our previous analysis reported a stable wild rice inbred line, Huaye3, which derives from the common wild rice of Guangdong Province. However, there was no information about its drought tolerance ability. Here, we assessed the germination characteristics and seedling growth between the Dawennuo and Huaye3 under five concentrations of PEG6000 treatment (0, 5%, 10%, 15%, and 20%). Huaye3 showed a stronger drought tolerance ability, and its seed germination rate still reached more than 52.50% compared with Dawennuo, which was only 25.83% under the 20% PEG6000 treatment. Cytological observations between the Dawennuo and Huaye3 indicated the root tip elongation zone and buds of Huaye3 were less affected by the PEG6000 treatment, resulting in a lower percentage of abnormalities of cortical cells, stele, and shrinkage of epidermal cells. Using the re-sequencing analysis, we detected 13,909 genes that existed in the genetic variation compared with Dawennuo. Of these genes, 39 were annotated as drought stress-related genes and their variance existed in the CDS region. Our study proved the strong drought stress tolerance ability of Huaye3, which provides the theoretical basis for the drought resistance germplasm selection in rice.

Survival Analysis of Antiretroviral Treatment for PLWH in Sichuan Province, China, 2003-2022: A Large Retrospective Cohort Study.

Background: Sichuan Province was severely affected by the HIV, and there was a scarcity of data regarding the survival time and influencing factors for People Living with HIV/AIDS (PLWH) in Sichuan Province who have received Antiretroviral Therapy (ART). Therefore, it is necessary to conduct a survival analysis for PLWH receiving ART. Methods: A retrospective cohort study was conducted on PLWH who had received ART≥6 months in Sichuan Province from January 1, 2003, to December 31, 2022. The Kaplan-Meier method was used to calculate median survival time and plot survival curves, while a Cox proportional hazards regression model was applied to analyze factors affecting survival time. Bilateral tests were performed, with P≤0.05 considered statistically significant. Results: The cumulative survival rates at 1, 3, 5, and 10 years for the 223,386 subjects were 94.54%, 89.07%, 84.82%, and 76.44%, respectively. Multivariate analysis using the Cox regression model indicated lower mortality risks for females (HR=0.59, 95% CI: 0.54-0.65), homosexual transmission (HR=0.43, 95% CI: 0.33-0.55), and baseline BMI≥24 (HR=0.81, 95% CI: 0.72-0.90). Higher mortality risks were associated with age≥50 years at diagnosis (HR=3.21, 95% CI: 2.94-3.50), being unmarried or divorced (HR=1.23, 95% CI: 1.11-1.37), living separately (HR=1.32, 95% CI: 1.22-1.43), baseline BMI <18.5 (HR=1.27, 95% CI: 1.13-1.41), presence of single-drug resistance (HR=1.25, 95% CI: 1.15-1.36), baseline WHO stage IV (HR=1.27, 95% CI: 1.09-1.47), and a diagnosis-to-treatment interval >12 months (HR=1.27, 95% CI: 1.15-1.41). Compared to those with CD4(+) T cell count of 200-350cells/µL, 350-500cells/µL, and >500cells/µL at baseline, individuals with <200cells/µL had higher mortality risks (HR=0.73, 95% CI: 0.67-0.79; HR=0.57, 95% CI: 0.51-0.64; and HR=0.58, 95% CI: 0.51-0.66, respectively). Conclusion: The survival rate for PLWH receiving ART in Sichuan Province was relatively high. Male gender, age over 50 at diagnosis, being unmarried, divorced, or living separately, presence of single-drug resistance, low baseline BMI, baseline CD4+ T cell <200cells/µL, baseline WHO stage IV, and a diagnosis-to-treatment interval >12 months were risk factors for the survival of PLWH.

A multi-classifier system integrated by clinico-histology-genomic analysis for predicting recurrence of papillary renal cell carcinoma.

Integrating genomics and histology for cancer prognosis demonstrates promise. Here, we develop a multi-classifier system integrating a lncRNA-based classifier, a deep learning whole-slide-image-based classifier, and a clinicopathological classifier to accurately predict post-surgery localized (stage I-III) papillary renal cell carcinoma (pRCC) recurrence. The multi-classifier system demonstrates significantly higher predictive accuracy for recurrence-free survival (RFS) compared to the three single classifiers alone in the training set and in both validation sets (C-index 0.831-0.858 vs. 0.642-0.777, p < 0.05). The RFS in our multi-classifier-defined high-risk stage I/II and grade 1/2 groups is significantly worse than in the low-risk stage III and grade 3/4 groups (p < 0.05). Our multi-classifier system is a practical and reliable predictor for recurrence of localized pRCC after surgery that can be used with the current staging system to more accurately predict disease course and inform strategies for individualized adjuvant therapy.

Alkaline absorbents for SO2 and SO3 removal: A comprehensive review.

Injection of an alkaline absorbent into the flue gas can significantly reduce SO2 and SO3 emissions. The article presents alkaline absorbents employed in industrial processes to remove SO2 and SO3 from flue gases, detailing their characteristics and applications across various process conditions. It summarizes the mechanisms and influencing factors behind SO2 and SO3 removal, outlines the impact of multi-component gases, particularly SO2, on SO3 removal in actual flue gases, and elucidates this competitive phenomenon from a theoretical standpoint. The article compares the application scenarios and efficiencies of alkaline absorbents across different processes, identifies the optimal combinations of various absorbents and processes, and proposes a synergistic approach for the removal of SO2 and SO3. The findings demonstrate that by injecting calcium- or sodium-based absorbents into dry processes, SO2 and SO3 can be removed efficiently and cost-effectively, with process optimization and absorbent modifications further enhancing the SOx removal efficiency. In the future, by blending two or more absorbents and applying them to dry processes, a synergistic removal of SO2 and SO3 can be achieved.

The impact of sleep quality on emotion regulation difficulties in adolescents: a chained mediation model involving daytime dysfunction, social exclusion, and self-control.

OBJECTIVE: Previous studies have revealed associations between sleep quality and mental health, yet the comprehensive role of sleep quality, daytime dysfunction, social exclusion, and self-control in difficulties with emotion regulation remains unclear. This study aimed to elucidate how sleep quality affects emotion regulation difficulties among middle school students through pathways involving daytime dysfunction, social exclusion, and self-control, thereby providing a more comprehensive theoretical basis for mental health interventions. METHODS: Utilizing the pittsburgh sleep quality index, the adolescent social exclusion scale, the brief self-control scale, and emotion regulation scale-short form, we assessed 1067 students randomly selected from four middle schools from October to November 2023. After the removal of extreme values (those exceeding 3 standard deviations), 806 students were retained for data analysis. RESULTS: Our findings indicate that poor sleep quality significantly contributes to increased daytime dysfunction(ß = 0.86, SE = 0.07, p < .001), which in turn affects social exclusion(ß = 0.60, SE = 0.16, p < 0 0.001), self-control abilities(ß = 1.27, SE = 0.16, p < .001) and emotion regulation difficulties(ß = 1.56, SE = 0.30, p < .001). Social exclusion mediates the relationship between sleep quality and emotion regulation difficulties(Estimate = 0.11, SE = 0.04, 95% CI [0.04, 0.20] ). CONCLUSION: The aim of this study is to provide new insights into the development of effective intervention measures to improve sleep and mental health in adolescents.

Development of a novel staging classification for Siewert II adenocarcinoma of the esophagogastric junction after neoadjuvant chemotherapy.

BACKGROUND: Stage classification for Siewert II adenocarcinoma of the esophagogastric junction (AEG) treated with neoadjuvant chemotherapy (NAC) has not been established. AIM: To investigate the optimal stage classification for Siewert II AEG with NAC. METHODS: A nomogram was established based on Cox regression model that analyzed variables associated with overall survival (OS) and disease-specific survival (DSS). The nomogram performance in terms of discrimination and calibration ability was evaluated using the likelihood-ratio test, Akaike information criterion, Harrell concordance index, time-receiver operating characteristic curve, and decision curve analysis. RESULTS: Data from 725 patients with Siewert type II AEG who underwent neoadjuvant therapy and gastrectomy were obtained from the Surveillance, Epidemiology, and End Results database. Univariate and multivariate analyses revealed that sex, marital status, race, ypT stage, and ypN stage were independent prognostic factors of OS, whereas sex, race, ypT stage, and ypN stage were independent prognostic factors for DSS. These factors were incorporated into the OS and DSS nomograms. Our novel nomogram model performed better in terms of OS and DSS prediction compared to the 8th American Joint Committee of Cancer pathological staging system for esophageal and gastric cancer. Finally, a user-friendly web application was developed for clinical use. CONCLUSION: The nomogram established specifically for patients with Siewert type II AEG receiving NAC demonstrated good prognostic performance. Validation using external data is warranted before its widespread clinical application.

α-Carbonyl Rh-Carbenoid Initiated Cascade Assembly of Diazobarbiturates with Alkylidene Pyrazolones for Synthesis of Spirofuropyrimidines.

Catalyzed by Rh2(esp)2 (10 mol%) and (±)-BINAP (20 mol%) in DCE at 80 °C, the cascade assembly between diazobarbiturates and alkylidene pyrazolones proceeded readily and produced spiro-furopyrimidines in 38-96% chemical yields. The chemical structure of the prepared spirofuro-pyrimidines was firmly confirmed by X-ray diffraction analysis.

An ex vivo method to evaluate vasoactivity induced by hemoglobin-based oxygen carriers in resistance vessels.

Red blood cell substitutes offer a solution to the problem of blood shortage and side effects of blood transfusion. Hemoglobin-based oxygen carriers (HBOCs) are one of the promising substitutes for red blood cells. Vasoactivity, which refers to the side effect of HBOCs that causes vasoconstriction and subsequent hypertension, limits the clinical application of HBOCs. In this study, an ex vivo method for the evaluation of vasoactivity induced by HBOCs was established based on isolated rat mesenteric artery vessels and the DMT120CP system. The DMT120CP system, equipped with a flowmeter, permits the control of intravascular pressure, pressure gradient, and flow conditions with high accuracy, simulating the physiological conditions for isolated vessels. The concentration of noradrenaline was optimized to 1 × 10-6∼3 × 10-6 M. PEGylated bovine hemoglobin (PEG-bHb) was synthesized and perfused into the vessel for vasoactivity evaluation, with bHb as the positive control and PSS buffer solution as the negative control. PEG-bHb showed a hydration diameter of 15.5 ± 1.4 nm and a P50 value of 6.99 mmHg. PEG-bHb exhibited a colloid osmotic pressure of 64.1 mmHg and a viscosity of 1.73 cp at 40 mg/mL. The established vasoactivity evaluation method showed significant differences in samples (bHb or PEG-bHb) with different vasoactivity properties. The vasoconstriction percentage induced by PEG-bHb samples synthesized in different batches showed coefficients of variation less than 5%, indicating good applicability and repeatability. The established evaluation method can be applied to study the vasoactivity induction and elimination strategies, promoting the clinical application of HBOCs.

Exercise-Induced Central Fatigue: Biomarkers, and Non-Medicinal Interventions.

Fatigue, commonly experienced in daily life, is a feeling of extreme tiredness, shortage or lack of energy, exhaustion, and difficulty in performing voluntary tasks. Central fatigue, defined as a progressive failure to voluntarily activate the muscle, is typically linked to moderate- or light-intensity exercise. However, in some instances, high-intensity exercise can also trigger the onset of central fatigue. Exercise-induced central fatigue often precedes the decline in physical performance in well-trained athletes. This leads to a reduction in nerve impulses, decreased neuronal excitability, and an imbalance in brain homeostasis, all of which can adversely impact an athlete's performance and the longevity of their sports career. Therefore, implementing strategies to delay the onset of exercise-induced central fatigue is vital for enhancing athletic performance and safeguarding athletes from the debilitating effects of fatigue. In this review, we discuss the structural basis, measurement methods, and biomarkers of exercise-induced central fatigue. Furthermore, we propose non-pharmacological interventions to mitigate its effects, which can potentially foster improvements in athletes' performances in a healthful and sustainable manner.

Mechanistic insights into phosphoactivation of SLAC1 in guard cell signaling.

Stomata in leaves regulate gas (carbon dioxide and water vapor) exchange and water transpiration between plants and the atmosphere. SLow Anion Channel 1 (SLAC1) mediates anion efflux from guard cells and plays a crucial role in controlling stomatal aperture. It serves as a central hub for multiple signaling pathways in response to environmental stimuli, with its activity regulated through phosphorylation via various plant protein kinases. However, the molecular mechanism underlying SLAC1 phosphoactivation has remained elusive. Through a combination of protein sequence analyses, AlphaFold-based modeling and electrophysiological studies, we unveiled that the highly conserved motifs on the N- and C-terminal segments of SLAC1 form a cytosolic regulatory domain (CRD) that interacts with the transmembrane domain(TMD), thereby maintaining the channel in an autoinhibited state. Mutations in these conserved motifs destabilize the CRD, releasing autoinhibition in SLAC1 and enabling its transition into an activated state. Our further studies demonstrated that SLAC1 activation undergoes an autoinhibition-release process and subsequent structural changes in the pore helices. These findings provide mechanistic insights into the activation mechanism of SLAC1 and shed light on understanding how SLAC1 controls stomatal closure in response to environmental stimuli.

Probing the effect of protein corona on SERS signals: insights from melamine detection in milk matrix.

Matrix effects limit the application of surface-enhanced Raman scattering (SERS) technology in the field of food safety. This study elucidated it from the perspective of protein corona by employing a model system for melamine SERS detection in milk. Compared with the melamine standard solution, higher detection limits (1 mg/L and 10 mg/L) are observed in milk matrix. The melamine signal exhibits an 80% reduction in whey protein solution, suggesting that protein has a significant impact on SERS signals. The changes in particle size, zeta potential and UV-vis spectra indicate the AuNPs interact with whey protein. Forming protein corona inhibits the melamine-induced AuNPs aggregation, reducing the number of 'hot spot' and the adsorption of melamine on AuNPs (from 0.28 mg/L to 0.07 mg/L), which may be responsible for signal loss. The found matrix effect from protein corona provides new insights for developing strategies about reducing matrix effect in SERS application.

Microwave-assisted preparation of yellow fluorescent graphitic carbon nitride quantum dots for trace tetracycline-specific detection.

Tetracycline (TC) is extensively utilized in livestock breeding, aquaculture, and medical industry. TC residues seriously harm food security, the environment, and human health. There is an urgent need to exploit a highly efficient and sensitive testing method to monitor TC residue levels in aquatic environments. In this study, graphitic carbon nitride quantum dots (g-CNQDs) were successfully synthesized by a one-step microwave-assisted method using citric acid and urea as precursors. The as-prepared g-CNQDs with size of 1.25-3.75 nm exhibited bright yellow fluorescence at 523 nm when excited at 397 nm. Interestingly, this characteristic fluorescence emission of g-CNQDs could be selectively and efficiently quenched by TC. Based on this phenomenon, for TC detection was successfully explored and applied in real water samples. Wide linear scope of 7-100 µM, low detection limit (LOD) of 0.48 µM, satisfactory recovery of 97.77%-103.4%, and good relative standard deviation (RSD) of 1.05-5.87% were obtained. Mechanism investigations revealed that the static quenching and the inner filter effect (IFE) were responsible for this fluorescence quenching between g-CNQDs and TC. This work not only provided a facile approach for g-CNQDs synthesis but also constructed a g-CNQDs-based fluorescent sensor platform for the highly sensitive and selective detection of TC in aquatic environments.

Biomarkers to predict efficacy of immune checkpoint inhibitors in colorectal cancer patients: a systematic review and meta-analysis.

Immune checkpoint inhibitors (ICIs) are approved to treat colorectal cancer (CRC) with mismatch-repair gene deficiency, but the response rate remains low. Value of current biomarkers to predict CRC patients' response to ICIs is unclear due to heterogeneous study designs and small sample sizes. Here, we aim to assess and quantify the magnitude of multiple biomarkers for predicting the efficacy of ICIs in CRC patients. We systematically searched MEDLINE, Embase, the Cochrane Library, and Web of Science databases (to June 2023) for clinical studies examining biomarkers for efficacy of ICIs in CRC patients. Random-effect models were performed for meta-analysis. We pooled odds ratio (OR) and hazard ratio (HR) with 95% confidence interval (CI) for biomarkers predicting response rate and survival. 36 studies with 1867 patients were included in systematic review. We found that a lower pre-treatment blood neutrophil-to-lymphocyte ratio (n=4, HR 0.37, 95%CI 0.21-0.67) predicts good prognosis, higher tumor mutation burden (n=10, OR 4.83, 95%CI 2.16-10.78) predicts response to ICIs, and liver metastasis (n=16, OR 0.32, 95%CI 0.16-0.63) indicates resistance to ICIs, especially when combined with VEGFR inhibitors. But the predictive value of tumor PD-L1 expression (n=9, OR 1.01, 95%CI 0.48-2.14) was insignificant in CRC. Blood neutrophil-to-lymphocyte ratio, tumor mutation burden, and liver metastasis, but not tumor PD-L1 expression, function as significant biomarkers to predict efficacy of ICIs in CRC patients. These findings help stratify CRC patients suitable for ICI treatments, improving efficacy of immunotherapy through precise patient management. (PROSPERO, CRD42022346716).

Association of the PCSK6 rs1531817(C/A) polymorphism with the prognosis and coronary stenosis in premature myocardial infarction patients: a prospective cohort study.

BACKGROUND: Proprotein convertase subtilisins/kexin 6 (PCSK6) polymorphisms have been shown to be associated with atherosclerosis progression. This research aimed to evaluate the relationship of PCSK6 rs1531817 polymorphisms with coronary stenosis and the prognosis in premature myocardial infarction (PMI) patients. METHODS: This prospective cohort analysis consecutively included 605 PMI patients who performed emergency percutaneous coronary intervention (PCI) at Tianjin Chest Hospital sequentially between January 2017 and August 2022, with major adverse cardiovascular events (MACEs) as the outcome. Analyses assessed the relationships among PCSK6 rs1531817 polymorphism, Gensini score (GS), triple vessel disease (TVD), and MACEs. RESULTS: 92 (16.8%) patients experienced MACEs with an average follow-up of 25.7 months. Logistic analysis revealed that the PCSK6 rs1531817 CA + AA genotype was an independent protective factor against high GS and TVD. Cox analysis revealed that the PCSK6 rs1531817 CA + AA genotype was an independent protective factor against MACEs. The mediation effect results showed that apolipoprotein A1/apolipoprotein B (ApoA1/ApoB) partially mediated the association between PCSK6 rs1531817 polymorphism and coronary stenosis and that total cholesterol/high-density lipoprotein (TC/HDL) and TVD partially and in parallel mediated the association between the PCSK6 rs1531817 polymorphism and MACEs. CONCLUSION: Patients with the PCSK6 CA + AA genotype have milder coronary stenosis and a better long-term prognosis; according to the mediation model, ApoA1/ApoB and TC/HDL partially mediate. These results may provide a new perspective on clinical therapeutic strategy for anti-atherosclerosis and improved prognosis in PMI patients.

Ischaemia with no obstructive coronary arteries: a review with focus on the Asian population.

ABSTRACT: Ischaemia with no obstructive coronary arteries (INOCA) has been a diagnostic and therapeutic challenge for decades. Several studies have demonstrated that INOCA is associated with an increased risk of death, adverse cardiovascular events, poor quality of life and high healthcare cost. Although there is increasing recognition of this entity in the Western population, in the Asian population, INOCA remains elusive and its prevalence uncertain. Despite its prognostic significance, diagnosis of INOCA is often delayed. In this review, we identified the multiple barriers to its diagnosis and management, and proposed strategies to overcome them.