Combinatorial effect of calcium chloride and polyethylene glycol on efficient isolation of small extracellular vesicles.

Small extracellular vesicles (sEVs) are cargo-carrying cellular nano-vesicles that have been explored for developing organic drug delivery modalities (DVM), an alternative to synthetic liposomes. However, scaled-up production of sEVs is a notable challenge in bringing sEV-based DVMs from the bench to the clinic. Ultracentrifugation is the most accepted isolation approach, but the cumbersome logistical issues and aftereffects of intense 'g' force hinder their applicability. In this study, we developed a new amenable isolation strategy for sEVs using a combinatorial treatment of calcium chloride and polyethylene glycol (PEG). An equivalent volume of cell culture medium from growing lung cancer A549 and H1299 cells was incubated overnight at 4 °C with different formulations (0.1 M CaCl2, 8% PEG, 12% PEG, 0.1 M CaCl2 + 8% PEG, and 0.1 M CaCl2 + 12% PEG) and centrifuged at 4000g to purify the precipitated sEVs as a pellet. Next, the extra CaCl2 was chelated out and the buffer was exchanged with PBS. The sEV number and protein content were assessed using the NTA (nanoparticle tracking analysis) and the BCA assay, respectively. Finally, transmission electron microscopy (TEM) was used to visualize the sEVs. The data from the present study demonstrated that the combination of 8% PEG and 0.1 M CaCl2 produced comparable numbers of sEVs with the ultracentrifugation technique. The sEV characteristics and structural integrity also remained intact, as evident from the TEM images and western blot assay. Thus, here we report an efficient technique for sEV isolation that can be easily scaled up.

No-stain protein labeling as a potential normalization marker for small extracellular vesicle proteins.

Western blot analysis of relative protein expression relies on appropriate reference proteins for data normalization. Small extracellular vesicles (sEVs), or exosomes, are increasingly recognized as potential indicators of the physiological state of cells due to their protein composition. Therefore, accurate relative sEVs protein quantification is crucial for disease detection and prognosis applications. Currently, no documented ubiquitous reference proteins are identified for precise normalization of a protein of interest in sEVs. Here we showed the use of total protein staining method for sEVs protein normalization in western blots of samples where conventional housekeeping proteins like ß-actin and glyceraldehyde 3-phosphate dehydrogenase (GAPDH) are not always detected in the sEVs western blots. The No-Stain™ Protein Labeling (NSPL) method showed high sensitivity in sEVs-protein labeling and facilitated quantitative evaluation of changes in the expression pattern of the protein of interest. Further, to show the robustness of NSPL for expression analysis, the results were compared with quantitative mass spectroscopy analysis results. Here, we outline a comprehensive method for protein normalization in sEVs that will increase the value of protein expression study of therapeutically significant sEVs.

Extracellular Vesicle (EVs) Associated Non-Coding RNAs in Lung Cancer and Therapeutics.

Lung cancer is one of the most lethal forms of cancer, with a very high mortality rate. The precise pathophysiology of lung cancer is not well understood, and pertinent information regarding the initiation and progression of lung cancer is currently a crucial area of scientific investigation. Enhanced knowledge about the disease will lead to the development of potent therapeutic interventions. Extracellular vesicles (EVs) are membrane-bound heterogeneous populations of cellular entities that are abundantly produced by all cells in the human body, including the tumor cells. A defined class of EVs called small Extracellular Vesicles (sEVs or exosomes) carries key biomolecules such as RNA, DNA, Proteins and Lipids. Exosomes, therefore, mediate physiological activities and intracellular communication between various cells, including constituent cells of the tumor microenvironment, namely stromal cells, immunological cells, and tumor cells. In recent years, a surge in studying tumor-associated non-coding RNAs (ncRNAs) has been observed. Subsequently, studies have also reported that exosomes abundantly carry different species of ncRNAs and these exosomal ncRNAs are functionally involved in cancer initiation and progression. Here, we discuss the function of exosomal ncRNAs, such as miRNAs and long non-coding RNAs, in the pathophysiology of lung tumors. Further, the future application of exosomal-ncRNAs in clinics as biomarkers and therapeutic targets in lung cancer is also discussed due to the multifaceted influence of exosomes on cellular physiology.

Efficacy and Safety of Turmeric Extracts for the Treatment of Knee Osteoarthritis: a Systematic Review and Meta-analysis of Randomised Controlled Trials.

PURPOSE OF THE REVIEW: Finding appropriate pharmacological options to treat osteoarthritis (OA) remain challenging. We aimed to determine the efficacy and safety of all types of turmeric extracts for the management of knee OA. RECENT FINDINGS: Sixteen RCTs of up to 16 weeks duration including 1810 adults with knee OA were included. Eleven RCTs compared the efficacy of turmeric extracts with placebo and five with active comparators (NSAIDs). The overall risk bias of included RCTs was moderate. Turmeric extracts significantly reduced knee pain (SMD - 0.82, 95% CI - 1.17 to - 0.47, I2 = 86.23%) and improved physical function (SMD - 0.75, 95% CI - 1.18 to - 0.33, I2 = 90.05%) compared to placebo but had similar effects compared to NSAIDs. BMI was the major contributor to heterogeneity in the placebo-controlled studies (explained 37.68% and 67.24%, respectively, in the models) and modified the effects of the turmeric on pain and physical function with less improvement with higher BMI (SMD 0.26 95% CI 0.04 to 0.48; SMD 0.48 95% CI 0.21 to 0.74). No significant between-group differences were reported for either biochemical markers or imaging outcomes. Turmeric extracts had 12% fewer adverse events than NSAIDs and similar rates to placebo. Turmeric extract is a safe and effective option for the symptomatic management of knee OA, compared to placebo or NSAIDs. However, current evidence from short-term studies is heterogeneous and has moderate risk of bias leading to some uncertainty about the true effect.

Association of Vitamin D Receptor (FokI and BsmI) Gene Polymorphism with Bone Mineral Density and Their Effect on 25-Hydroxyvitamin D Level in North Indian Postmenopausal Women with Osteoporosis.

Osteoporosis is a systemic disease with a strong genetic component. Vitamin D receptor (VDR) has been suggested as a candidate gene for osteoporosis. Therefore the present study was aimed to investigate the pattern of allelic variants of VDR gene polymorphism (FokI and BsmI), its influence on vitamin D levels and bone mineral density (BMD) in North Indian postmenopausal women with osteoporosis for possible genetic association. 254 postmenopausal osteoporotic women and 254 postmenopausal non osteoporotic women were included in the study. VDR FokI and BsmI gene polymorphism gene were assessed by the PCR-RFLP method. Serum 25-hydroxyvitamin D was measured by the ELISA. BMD at the L1-L4 lumbar spine, hip, forearm and femoral neck was assessed by dual energy X-ray absorptiometry. The average BMD at spine and hip in postmenopausal women with bb and spine, hip, femoral neck and forearm with ff genotype had significantly low BMD. The frequency of ff genotype and f allele was significantly higher in postmenopausal osteoporotic women when compared with postmenopausal non osteoporotic women. However, no significant association was found between the genotypes and vitamin D levels. Our study reveals that VDR gene FokI and BsmI polymorphism is significantly associated with low bone mineral density. Therefore the ff genotype and f allele of VDR FokI gene may be used as an important risk factor for osteoporosis.

Osteoporosis in Postmenopausal Females with Primary Knee Osteoarthritis in a Vitamin D Deficient Population.

AIM AND OBJECTIVE: To find prevalence of osteoporosis (OP) in postmenopausal females with primary knee osteoarthritis (OA) in India, where there is widespread Vitamin D deficiency (VDD). MATERIAL AND METHODS: 75 postmenopausal women (PMW) fulfilling ACR criteria for Knee OA between 40 - 60 years of age, having OA grade 2 or more as per Kellgren Lawrence grade on anterior- posterior radiograph of the right knee were enrolled. 34 PMW of the same age with normal right knee radiograph were taken as controls. Bone mineral density (BMD) of lumber spine (L1- L4), total hip and left forearm was performed using DXA in all patients and controls. The results were expressed in absolute values (g/cm2) and as per WHO criteria - Osteoporosis: T score < -2.5, Osteopenia: T score between -1 and -2.5. Vitamin D Level was done by ELISA. RESULTS: Body mass index (BMI) of patients was significantly higher than controls (p 0.006). There was no difference in BMD between patients and controls at any site. Forty percent patients and 53% controls had osteopenia (p ns), while 34.6% patients and 41.1% controls had osteoporosis at any site (p ns). When this comparison was made at each site there was no difference between patients and controls. CONCLUSION: Prevalence of osteoporosis in PMW with primary knee OA is similar to that in general population.

Osteocalcin HindIII gene polymorphism not associated with bone mineral density­A study in North Indian postmenopausal osteoporotic women.

Osteoporosis is an important health problem in India owing to the prevalence of vitamin D deficiency across all ages, low level of awareness and higher risk of complications. This disease is characterized by decreased bone mass, bone strength and higher risk of bone fracture. Here, we investigated association between osteocalcin HindIII gene polymorphism and bone mineral density (BMD) in postmenopausal osteoporotic and postmenopausal healthy North Indian women, possibly the first study of this kind in the aforesaid population. We investigated Polymerase Chain Reaction (PCR) and Restriction Fragment Length Polymorphism (RFLP) of osteocalcin HindIII in 254 postmenopausal osteoporotic (56.12±7.004 years) and 254 postmenopausal healthy (55.27±5.93 years) North Indian women. BMD at lumbar spine (L1-L4), femoral neck, hip and forearm was measured by dual energy X-ray absorptiometry (DEXA). The results showed no significant correlation between osteocalcin HindIII gene polymorphism and BMD and we conclude that osteocalcin HindIII gene polymorphism may not have major effects on BMD variation in postmenopausal North Indian women.

Problem-focused coping and self-efficacy as correlates of quality of life and severity of fibromyalgia in primary fibromyalgia patients.

OBJECTIVES: Patients with fibromyalgia syndrome (FMS) often experience problems such as poor quality of life (QoL), loss of self-efficacy (SE), inappropriate coping behavior, and chronic widespread pain along with other symptoms. Recent studies have indicated that sense of SE and effective coping strategies (CSs) are the crux on which the management of chronic pain and enrichment of QoL of FMS patients depend. Realizing the importance of this subject for the rehabilitation of the people with FMS, this study aimed at analyzing the correlation between severity of FMS, and QoL, SE, and CSs among the patients of FMS. METHODS: One hundred patients with fibromyalgia (FM) and 100 control subjects were studied. Fibromyalgia Impact Questionnaire-Revised, Quality of Life Scale, Arthritis Self-efficacy Scale, and COPE Scales for CSs were administered to both the groups. RESULTS: Significantly lower SE, poor QoL, and less use of CSs were reported by FM patients (P < 0.01) vis-à-vis healthy people. Problem-focused coping (r = 0.27, P < 0.01) and SE (r = 0.20, P < 0.05) were found to be significantly and positively associated with QoL. Components of Fibromyalgia Impact Questionnaire-Revised, namely, pain, function, and symptoms, were found to be significantly and negatively associated with problem-focused coping (P < 0.05), SE (P < 0.01), and QoL (P < 0.01). CONCLUSIONS: This study confirms that problem-focused CSs and SE are important correlates of QoL and severity of FM in Indian as well as other populations.

A Long-Term Study on Recurrence, Chronic Pain, and Quality of Life in Obese Patients with Groin Hernia undergoing Laparoscopic Total Extraperitoneal Hernia Repair: Comparison between Mesh Fixation and Nonfixation Techniques.

Introduction: "Laparoscopic Total Extraperitoneal (TEP)" repair of hernia is a common surgical procedure for treating groin hernias. This study focused on the long-standing assessment of "quality of life (QoL)," chronic pain, and recurrence to compare the effectiveness of TEP hernia surgery with "mesh fixation (MF)" against "nonfixation (NF)" in patients who are obese with a BMI of 35 kgs/m2 or higher. Methods: In this study's randomized controlled experiment, 73 obese individuals with groin hernias underwent total extraperitoneal hernia repair with either MF (n = 35) or NF (n = 38). A check-up was conducted 1, 3, and 5 years after the operation. Recurrence, chronic pain, and QoL were assessed using a physical examination and validated questionnaires. Results: There were no changes between the subjects of either group in baseline characteristics, hernia recurrence rate, chronic pain rate, or QoL. There were neither significant variations in surgical complications nor hospital stay duration. Conclusion: The results suggest that treating TEP hernias among people with a BMI of 35 kgs/m2 or above with mesh NF may be successful. The recurrence rates among the subject groups were not substantially different; however, NF was linked with reduced rates of chronic pain which would be beneficial for patient satisfaction and recovery. To decide the optimal technique for MF in TEP hernia repair, these findings need to be verified by additional studies.

Acute Necrotizing Pancreatitis Following Intragastric Balloon Insertion.

Obesity has become a widespread global issue, particularly in the developed world. One popular weight loss technique is the intragastric balloon placement due to its simplicity of insertion and safe nature. While some side effects have been linked to its use, most are benign. However, severe complications do occur in some cases. One such rare complication is pancreatitis due to compression of the pancreas or the pancreatic duct. We encountered an interesting case of necrotizing pancreatitis following gastric balloon insertion, about which scarce data is available in the literature; its incidence is also unknown currently. Our patient was a 22-year-old male with a gastric balloon inserted for obesity eight months before his presentation. The mechanism of the inflammation, the age of the patient, and the progression to necrosis are the compelling aspects of this case.

Efficacy of Individualized Homeopathic Medicines in the Treatment of Sciatica Pain: Double-Blind, Randomized, Placebo-Controlled Trial.

Objectives: Sciatica is a debilitating condition that causes pain in its distribution or in the lumbosacral nerve root that is connected to it. Although there are claims that homeopathy can reduce sciatica pain, systematic scientific proof is currently lacking. The objective of the trial was to determine whether individualized homeopathic medicines (IHMs) were as effective as identical-looking placebos in treating sciatica pain. Design: This is a double-blind, randomized (1:1), two parallel arms, placebo-controlled trial. Setting: The study was conducted at Mahesh Bhattacharyya Homoeopathic Medical College and Hospital, Howrah, West Bengal, India. Subjects: Sixty participants with sciatica pain were included in this study. Interventions: Verum (n = 30; IHMs plus concomitant care) versus control (n = 30; placebos plus concomitant care). Outcome measures: Primary-Sciatica Bothersome Index (SBI) and Sciatica Frequency Index (SFI) scores and secondary-Roland Morris Pain and Disability Questionnaire (RMPDQ), Short Form McGill Pain Questionnaire (SF-MPQ), and Oswestry Low Back Pain Questionnaire (OLBPQ) scores: all of them were measured at baseline, and every month, up to 3 months. Results: Intention-to-treat sample (n = 60) was analyzed. Group differences were examined by two-way (split-half) repeated measure analysis of variance, primarily accounting for between groups and time interactions, and additionally, by unpaired t tests comparing the estimates obtained individually every month. The level of significance was set at p < 0.025 and <0.05 two tailed for the primary and secondary outcomes, respectively. Group differences could not achieve significance in SBI (p = 0.044), SFI (p = 0.080), and RMPDQ scores (p = 0.134), but were significant for SF-MPQ (p = 0.007) and OLBPQ (p = 0.036). Gnaphalium polycephalum (n = 6; 10%) was the most frequently prescribed medicine. No harm, serious adverse events, or intercurrent illnesses were recorded in either of the groups. Conclusions: The primary outcome failed to demonstrate evidently that homeopathy was effective beyond placebo, and the trial remained inconclusive. Independent replications are warranted to confirm the findings. Clinical Trial Registration Number: CTRI/2020/10/028617.

Induction of Ferroptosis by an Amalgam of Extracellular Vesicles and Iron Oxide Nanoparticles Overcomes Cisplatin Resistance in Lung Cancer.

Extracellular vesicles (EVs) hold potential as effective carriers for drug delivery, providing a promising approach to resolving challenges in lung cancer treatment. Traditional treatments, such as with the chemotherapy drug cisplatin, encounter resistance in standard cell death pathways like apoptosis, prompting the need to explore alternative approaches. This study investigates the potential of iron oxide nanoparticles (IONP) and EVs to induce ferroptosis-a regulated cell death mechanism-in lung cancer cells. We formulated a novel EV and IONP-based system, namely 'ExoFeR', and observed that ExoFeR demonstrated efficient ferroptosis induction, evidenced by downregulation of ferroptosis markers (xCT/SLC7A11 and GPX4), increased intracellular and mitochondrial ferrous iron levels, and morphological changes in mitochondria. To enhance efficacy, tumor-targeting transferrin (TF)-conjugated ExoFeR (ExoFeR TF ) was developed. ExoFeR TF outperformed ExoFeR, exhibiting higher uptake and cell death in lung cancer cells. Mechanistically, nuclear factor erythroid 2-related factor 2 (Nrf2)-a key regulator of genes involved in glutathione biosynthesis, antioxidant responses, lipid metabolism, and iron metabolism-was found downregulated in the ferroptotic cells. Inhibition of Nrf2 intracellular translocation in ExoFeR TF -treated cells was also observed, emphasizing the role of Nrf2 in modulating ferroptosis-dependent cell death. Furthermore, ExoFeR and ExoFeR TF demonstrated the ability to sensitize chemo-resistant cancer cells, including cisplatin-resistant lung cancer patient-derived tumoroid organoids. In summary, ExoFeR TF presents a promising and multifaceted therapeutic approach for combating lung cancer by intrinsically inducing ferroptosis and sensitizing chemo-resistant cells.

Oxidative stress and antioxidative parameters and metal ion content in patients with fibromyalgia syndrome: implications in the pathogenesis of the disease.

Fibromyalgia syndrome (FMS) is characterised by diffuse muscle pain, poor sleep and unrelenting fatigue. Individuals with FMS may also experience headaches, anxiety, depression, poor memory, numbness and tingling in the extremities, cold hands and feet, irritable bowel syndrome and lowered immune function. FMS is a common chronic pain syndrome of unknown etiology and limited treatment options. Previous studies have reported oxidative stress in FMS patients, but the results were inconsistent. Oxidative stress and nitric oxide is involved in FMS pathophysiology, however, it is still not clear whether oxidative stress abnormalities are the cause of FMS. There are several studies indicating oxidative stress in patients with FMS. Oxidant (Malondialdehyde) and antioxidant (Superoxide dismutase) balances were found to be changed in FMS patients. Furthermore, increased free radical levels may be responsible for the development of FMS and free radical-mediated oxidative stress including inflammatory cytokines may also play important roles in its pathogenesis. Moreover, oxidative stress is supposed to be increased in patients with FMS which is related to the severity of FMS symptoms. Therefore, it is important to understand whether the oxidative stress parameters are involved in FMS and what is the relationship between these and antioxidants in FMS patients. In this review we will elucidate the importance of oxidative stress and antioxidants and its possible relationship with FMS. Moreover, as metal toxicity is also reported to be involved in the pathogenesis of FMS, therefore we will also try to establish the role of toxic metals in the pathogenesis of FMS.

Circadian rhythm of serum cortisol in female patients with fibromyalgia syndrome.

Fibromyalgia syndrome (FMS) patients have disturbed sleep patterns which may lead to altered circadian rhythm in serum cortisol secretion. The aim of this study was to assess circadian changes, if any, in serum cortisol levels in female patients with FMS. Cortisol levels were estimated every 6 h during 24 h period; in 40 female patients satisfying ACR criteria for FMS (Age 36.4 ± 9.9), and 40 healthy females without FMS (Age 33.8 ± 11.1). A significant difference in the night time serum cortisol level was observed among the patients and control groups (patients, 12.9 ± 9.7 controls 5.8 ± 3.0; p < 0.01). However, no significant difference was found in serum cortisol levels in patients and control groups in the morning (patients, 28.4 ± 13.2 controls, 27.6 ± 14.5; p > 0.05), afternoon (patients, 14.4 ± 5.6 controls, 14.0 ± 6.6; p > 0.05) and evening hours (patients, 10.9 ± 5.8 controls, 8.9 ± 3.6; p > 0.05). It could be concluded that there is an abnormality in circadian secretion of cortisol in female FMS patients.

Unraveling the Enigma: A Report on a Rare Case of Cutaneous Horn, an Extraordinary Dermatological Occurrence.

A cutaneous horn is a rare, hyperkeratotic, projecting lesion that can be mostly found in sun-exposed areas of the skin. The base of the lesions can reveal an underlying malignancy. They can also be associated with several benign or pre-malignant dermatologic conditions. A biopsy of the base of the lesion and histopathological analysis are needed to confirm the diagnosis. Management depends on the underlying disease; however, surgical excision is the preferred treatment method.

Phyllodes Tumor of the Breast Complicated With Mastitis.

One of the rarest fibro-epithelial neoplasms of the breast during pregnancy is the phyllodes tumor (PT). It is typically a painless, bi-phasic, and rapidly growing neoplasm that resembles fibroadenomas. It is still unclear if the neoplasm is hormone-dependent during pregnancy. It is often challenging to diagnose and treat PT. Herein, we report a case of a 30-year-old female at 31 weeks gestation who was diagnosed with a benign phyllodes tumor of her breast with concurrent mastitis. She was first seen during her third trimester where the neoplasm was around 5 cm as reported by the ultrasound (US) examination. Her biopsy report was suggestive of a PT and she was advised surgery with excision of the tumor margin, but she refused. Ten days after her delivery she presented to the emergency department with a fever and a hard, engorged, erythematous, and tender left breast. She was diagnosed with mastitis of the left breast. She then underwent incision and drainage of the left breast that drained purulent milk; additionally, large necrotic grape-like tissues were removed and were confirmed by the histopathology report as a benign phyllodes tumor of the breast.

Investigating Skin Rashes Associated With Pantoprazole Medication: Causes and Clinical Implications.

Pantoprazole is a proton-pump inhibitor mainly used in treating various gastroesophageal disorders and frequently as prophylaxis for stress ulcers and gastrointestinal bleeding in most patients admitted for in-hospital management. Hypersensitivity reactions to this medication have been reported, although the exact incidence and prevalence are unknown. Further studies on proton-pump inhibitor allergic reactions should be conducted to enable physicians to safely select and prescribe an alternative type of medication within the same drug class, confidently avoiding the allergenic molecular compound that the patient reacted to previously. We present a case of a 35-year-old male postoperative bariatric patient with no significant allergy history who developed an allergic skin rash a week after being discharged on pantoprazole 40 mg. His rash was itchy and distributed mainly over the torso and lower limbs, without any additional respiratory or gastrointestinal symptoms.

Post-appendectomy Adhesive Small Intestine Obstruction With Gangrene: A Sinister Case.

Intestinal adhesions are fibrotic bands of scar tissue that develop intra-abdominally due to serosal or peritoneal irritation caused during surgery or by severe infections. It may also occur congenitally. It can lead to serious complications such as small bowel obstruction, which is then termed adhesive small bowel obstruction. In this scenario, it can constrict the bowel wall and cause ischemia and necrosis of the affected intestinal segment. Computed tomography imaging may show characteristic signs, such as the "whirl sign" or "fat-bridging sign." Diagnostic laparoscopy or laparotomy can confirm the diagnosis and presence of adhesions. Management of this condition is either conservative or surgical, the latter of which is necessary in the case of intestinal strangulation. While the literature supports the laparoscopic method of adhesiolysis, practically, it may present technical difficulties. Surgeons should employ their clinical judgment in cases where an open procedure may be more beneficial. We present a case of this very occurrence and discuss the risk factors, pathogenesis, diagnostic evaluation, and, finally, the approaches to surgical management of this condition.

Intentional Ingestion of Foreign Bodies: A Physician's Agony.

Intentional foreign body ingestion is the phenomenon wherein one swallows a non-digestible object with the intent to cause self-injury. It is intentional in adult patients with a positive psychiatric history and can be a recurrent issue. Although the incidence of this condition is increasing, there are few existing articles on the subject that highlight its importance. This case report aims to present a unique patient encounter to emphasize the multispecialty approach required for management and provide an overview of the literature available on the subject regarding types of objects swallowed, selection of appropriate imaging modalities, and plans of management.

Strangulated Bochdalek Hernia in Adults: Timely Recognition and Surgical Intervention Can Prevent a Lethal Outcome.

Bochdalek hernias are rare diaphragmatic hernias most commonly seen in pediatric populations. Adults with this condition may be asymptomatic or present with gastrointestinal symptoms such as abdominal pain, pressure, choking, or dysphagia. Computed tomography imaging is a gold standard in diagnosing the condition. The definitive treatment is surgery, recommended and encouraged for asymptomatic patients as well to reduce the risk of future complications. Whilst the approach to surgical management differs on a case-by-case basis, the main goal is to reduce the herniating organ and repair the defect. It is important to note that in severe cases, intestinal obstruction and strangulation may occur. We present a unique case of this very phenomenon in a patient diagnosed and treated as a case of strangulated Bochdalek hernia. We aim to highlight the importance of diagnosing this condition as clinical symptoms may be non-specific, and rapid surgical intervention is necessary.