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data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1000_en.txt

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+On July 10, 2022, a 40-year-old woman was admitted to the first affiliated hospital of Xi’an Jiaotong University due to intermittent fever for 2 months. Two months prior, her temperature fluctuated between 37.4 and 38.4°C in the afternoons, and chills and a dry cough accompanied this symptom. She had previously undergone examination and symptomatic treatment at a regional hospital. However, the treatment was ineffective. Furthermore, arthralgia and fatigue gradually appeared, with no chest pain and tightness, or rash. A month and a half prior, she was diagnosed with depression and treated with escitalopram oxalate, and magnesium valproate sustained-release tablets at a hospital. The symptoms slightly improved after treatment. Half a month prior, a B-ultrasonic examination showed lymphadenopathy throughout her body. Therefore, lymphoma was suspected but she did not get any treatment. One day prior to her arrival at our hospital, the patient suddenly developed hemoptysis of approximately 2 ml, which occurred four times for no reason. Past medical history revealed that she was diagnosed with chronic hepatitis B (CHB) in 2014 and developed cirrhosis a year later. Her CHB was well-controlled by a long-term oral antiviral treatment with Entecavir. In addition, she had lost 5 kg over the past 3 months.
+On admission, her temperature was 37°C, respiratory rate was 19 breathe⋅min–1, heart rate was 70 beat⋅min–1, and blood pressure was 103/72 mmHg. The liver, spleen, lymph nodes of the neck, and axillary lymph nodes were enlarged with moderate activity and no tenderness. Rough breath sounds were detected in both lungs with dry and wet rales. All other clinical examination results were negative.
+Laboratory examination revealed inflammation and liver dysfunction: red cell count, 4.27 × 1012/L (4–4.5 × 1012/L); white cell count, 4.87 × 109/L (5–12 × 109/L); platelet count 89 × 109/L (125–350 × 109/L), hypersensitive C-reactive protein 9.81 mg/L (0–3 mg/L), direct bilirubin 6.2 μmol/L (0–3.4 μmol/L), aspartate aminotransferase, 54 U/L (13–45 U/L); alanine aminotransferase, 20 U/L (7–40 U/L); alkaline phosphatase, 164 U/L (35–100 U/L); γ-glutamyl transpeptidase, 82 U/L (7–45 U/L), albumin 33.8 g/L (40–55 g/L).
+B-scan ultrasonography revealed bilateral cervical and axillary lymphadenopathies. Chest computed tomography (CT) revealed multiple pulmonary nodules in both lungs, with a small amount of pleural effusion and enlarged lymph nodes in the bilateral axilla. To effectively confirm the nature of the lesion, we performed needle biopsies of pulmonary nodules and lymph nodes. The results implied an infectious disease, while the detection of T cells in tuberculosis infection was negative. Therefore, suspicions of tumors and tuberculosis were excluded.
+Interestingly, we noticed that the patient came from Ningxia province, which is famous for animal husbandry. The patient reluctantly informed us that she raised cattle and had come into contact with neighboring sheep without vaccination. Consequently, Brucella infection was suspected. On the fourth day of admission, the serum agglutination test (SAT) result was 1:800, and the rose-bengal plate agglutination test (RBPT) result was positive. Furthermore, the blood culture for Brucella melitensis was positive on the tenth day after admission. Characteristic rod-shaped gram-negative bacteria could be observed under a microscope. Subsequently, the patient was definitively diagnosed with brucellosis.
+Following the brucellosis diagnosis, she received antibiotic therapy with rifampicin (600 mg/dose, once a day) and doxycycline (100 mg/dose, twice a day) for 3 months from the fourth day of the course. Furthermore, due to the poor medical conditions of the patient’s residence and excessive complications, including multipulmonary nodules, arthralgia, hepatosplenomegaly, and lymphadenopathy, moxifloxacin and ceftriaxone sodium were added from the sixth day of the course to prevent the possibility of developing drug-resistant brucellosis after discharge. During treatment, the patient and her family were highly cooperative. At discharge, fever, cough, arthralgia, depression and fatigue were relieved. After 2 months of follow-up, the fever and cough were gone, as was fatigue and arthralgia. In addition, the number of multiple nodules in both lungs was reduced. At the same time, liver function test results also indicated that the patient was recovering well. After 3 months of follow-up, her weight had increased and her depression symptoms were alleviated. The entire process of diagnosis, treatment, and outcomes is shown in .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1018_en.txt

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+A previously healthy 12-year-old girl presented with a 2-year history of chronic progressive bilateral knee pain, worsening in the preceding 6 months. Her symptoms were episodic and variable in duration and severity, with difficulty participating in sports. She had a 2.5 kg weight loss over 2 months and low BMI of 14 kg/m2. She denied any gastrointestinal symptoms, oral ulcers, skin changes, or ocular symptoms. She had not tried any specific treatments or interventions. She is of South Asian background and the product of a non-consanguineous relationship. There is no relevant family history of CRMO, autoinflammatory disease, or IBD. Examination showed fullness and tenderness in both medial femoral condyles. Her abdominal and perianal examinations were benign.
+Initial investigations showed a normocytic anemia (Hb 112 g/L, MCV 79 fL), raised transaminases (ALT 84, AST 81, ALP 227, GGT 146 U/L), and raised inflammatory markers (ESR 94 mm/hr., CRP 15 mg/L). X-rays of the hips, femur, and knees showed distal femoral metaphyseal lytic lesions with surrounding sclerosis, and MRI of the lower limbs revealed multifocal distal femoral bone marrow abnormalities with regional edema pattern, cortical thickening, and periostitis . A whole-body MRI revealed additional bone marrow edema pattern involving bilateral medial clavicular heads and right acromion.
+The patient was treated with a single dose of intravenous zoledronic acid (0.0125 mg/kg) with significant clinical improvement and improved mobilization, but demonstrated persistently abnormal liver enzymes (AST 71, ALT 67, GGT 124 U/L), anemia (Hb 106 g/L), and raised inflammatory markers (ESR 82 mm/hr) and gamma globulins (IgG 30.1 g/L, IgM 3.3 g/L). Conjugated bilirubin was < 0.2umol/L, albumin was 42 g/L, and INR was 1.0. The patient remained asymptomatic without abdominal pain or bowel alterations, jaundice, or pale stools.
+Further workup with pediatric gastroenterology was concerning for Type 1 Autoimmune Hepatitis (AIH) with Anti-Smooth muscle > 1:640, ANA negative, Anti-LKM negative, and ANCA negative. Abdominal ultrasound showed mildly heterogeneous liver echotexture but a normal biliary tree; magnetic resonance cholangiopancreatography was normal. Transient elastography showed increased liver stiffness (8.8 kPa, IQR/median of 7%). Liver biopsy showed features of both small-duct PSC and AIH, with interface hepatitis with plasma cells, concentric fibrosis of bile ducts, grade 3–4 hepatitis and stage 3–4 fibrosis. Other diagnoses including hepatitis B/C and tuberculosis, Wilson disease and celiac disease were excluded.
+Although the patient was asymptomatic, given the strong association between PSC and IBD, the patient’s fecal calprotectin was measured. This was elevated at 615 μg/g, and so she underwent gastroscopy and colonoscopy. This showed chronic mildly active colitis (non-granulomatous) from cecum to rectum with normal terminal ileum, and normal upper endoscopy, leading to a diagnosis of ulcerative colitis.
+The patient’s liver and gastrointestinal disease was treated with oral prednisone (35 mg oral daily), azathioprine (75 mg oral once daily), and ursodeoxycholic acid (250 mg oral daily) with sufficient adherence. No reported adverse effects were reported. There was normalization of liver biochemistry and liver stiffness (5.5 kPa with IQR/median 19%) within 6 months. The patient’s musculoskeletal symptoms remain inactive 11 months since initial therapy with zoledronic acid.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1025_en.txt

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+The patient was a 34-year-old Turkish woman, gravida 2 para 1 with a normal vaginal delivery 15 years previously. Although she had not used any contraceptive method afterwards, she had not become pregnant. She was transferred to our hospital from her local clinic at the gestation stage of 13 weeks because of pain in the lower abdomen and slight vaginal bleeding. She did not know when her last menstrual period had been, due to irregular periods. At admission, she presented with a history of abdominal distention together with steadily increasing abdominal and back pain, weakness, lack of appetite, and restlessness with minimal vaginal bleeding. She denied a history of pelvic inflammatory disease, sexually transmitted disease, surgical operations, or allergies. Blood pressure and pulse rate were normal. Laboratory parameters were normal, with a hemoglobin concentration of 10.0 g/dl and hematocrit of 29.1%. Transvaginal ultrasonographic scanning revealed an empty uterus with an endometrium 15 mm thick. A transabdominal ultrasound examination demonstrated an amount of free peritoneal fluid and the nonviable fetus at 13 weeks without a sac; the placenta measured 58 × 65 × 67 mm. Abdominal-Pelvic MRI (Philips Intera 1.5T, Philips Medical Systems, Andover, MA) in coronal, axial, and sagittal planes was performed especially for localization of the placenta before she underwent surgery. A non-contrast SPAIR sagittal T2-weighted MRI strongly suggested placental invasion of the sigmoid colon .
+Under general anesthesia, a median laparotomy was performed and a moderate amount of intra-abdominal serohemorrhagic fluid was evident. The placenta was attached tightly to the mesentery of sigmoid colon and was loosely adhered to the left abdominal sidewall . The fetus was localized at the right of the abdomen and was related to the placenta by a chord. The placenta was dissected away completely and safely from the mesentery of sigmoid colon and the left abdominal sidewall. Left salpingectomy for unilateral hydrosalpinx was conducted. Both ovaries were conserved. After closure of the abdominal wall, dilatation and curettage were also performed but no trophoblastic tissue was found in the uterine cavity. As a management protocol in our department, we perform uterine curettage in all patients with ectopic pregnancy gently at the end of the operation, not only for the differential diagnosis of ectopic pregnancy, but also to help in reducing present or possible postoperative vaginal bleeding.
+The patient was awakened, extubated, and sent to the room. The patient was discharged on post-operative day five with the standard of care at our hospital.

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+A previously healthy, 33-year-old white female was presented with headache and fever for 3 days. She did not used to smoke or consume alcohol. She gave 3 live healthy births and 1 year ago bilateral leg swellings and high blood pressure were noticed close to her last delivery, but medical investigation was not performed and her symptoms disappeared soon after the delivery. Her mother succumbed to a sudden disease, which was characterized by acute renal and neurological injuries, but further information was not available.
+On physical examination, she was good on appearance, and temperature, blood pressure, and pulse rate were 38°C, 160/100 mmHg, and 110 bpm, respectively. Bilateral minimal pretibial edema was noticed.
+The laboratory tests were consistent with thrombotic microangiopathy and severe renal dysfunction (leukocytes 5800 cells/mm3, urea 255 mg/dL, creatinine 11.8 mg/dL, uric acid 8.7 mg/dL, Na 133 mEq/L, K 4.9 mEq/L, AST 43 U/L, ALT 105 U/L, LDH 1248 U/L, total bilirubin 0.03 mg/dL, CPK 37 U/L, C-reactive protein <3 mg/L, 2–3 leukocytes and 8–10 erythrocytes per high power field and 3+ proteinuria in urinalysis, 24 hours proteinuria 2.4 g, serum haptoglobin <10 mg/dL, Coomb tests negative, reticulocytes 3.68%, and 5% schistocytes per field in peripheral blood film). Plasma ADAMTS13 levels and activity were within the normal limits. Antinuclear antibody was negative, C3 level was 80 mg/dL (85–200), and C4 level was within the normal range. Left renal agenesis and enlarged right kidney (145 × 55 mm) were detected by urinary ultrasonography.
+Genetic analysis revealed a novel mutation in exon 21 of complement factor H (CFH) (c.3454T>A; p.C1152S), and the same mutation was later identified in her asymptomatic 3 (males) of 4 siblings.
+Daily plasma exchange using 40 mL/kg fresh frozen plasma and on-demand hemodialysis were started. Markers of thrombotic microangiopathy did not consistently normalize during 22 sessions of plasma exchange; therefore, PE was replaced by eculizumab within 2 weeks of vaccination against Neisseria meningitides (900 mg/week for 4 weeks, 1200 mg every other week from the 5th week on). Thrombocytopenia and elevated LDH normalized within 1 month along with gradual improvement in renal functions and the need for dialysis was eliminated within 2 months of eculizumab treatment . Eculizumab was discontinued after 1 year of treatment, during which creatinine nadir was 1.35 mg/dL, and the patient was set to follow-up. Thrombocytes dropped and remained below the lower limit of normal from the 7th month (January 6, 2015) of follow-up on, but LDH levels remained around the upper limit of normal . Multiple peripheral blood films, serum haptoglobin levels, and reticulocyte counts were found normal, except for thrombocytopenia, since detection of thrombocytopenia. Levels of creatinine slightly increased but remained <2 mg/dL except for a few occasions, whereas the levels of proteinuria remained <0.5 g/day (385 mg/day at last visit) . Informed consent was obtained from the patient.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1040_en.txt

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+Our patient was a 75-year-old Iranian man, admitted to hospital with recurrent upper abdominal pain for the past 18 months. A common bile duct plastic stent had been inserted based on the results of diagnostic investigations, including an obstructive pattern of liver enzyme elevation, dilatation of extra- and intrahepatic bile ducts revealed through ultrasonography and heterogeneity of the pancreatic head (likely due to cancer) in an abdominal spiral CT scan with oral- and venous-contrast media . No abnormalities were found during a physical examination, with the exception of mild upper abdominal tenderness and vitiligo patches on his neck and hands .
+An upper gastrointestinal endoscopy, aimed at controlling the presence of occult blood in his stool, iron deficiency anemia and heartburn, showed lower esophageal ulcers associated with diaphragmatic herniation. A pathologic evaluation of the ulcer biopsy specimens confirmed reflux esophagitis. A colonoscopy was normal. Mild dilatation of his extra- and intrahepatic bile ducts was seen in repeated abdominal ultrasonography procedures. However, an endoscopic ultrasound showed a hypoechoic area, 2 cm in size, in the head of his pancreas. The pathological and cytological results of an aspiration biopsy of the lesion revealed fibrosis and inflammatory cell infiltration without evidence of malignancy .
+Once AIP had been diagnosed, prednisolone was administered. Two months after treatment, a reevaluation of the pancreas head by means of an abdominal spiral CT scan with oral and venous contrast media did not show any abnormality, and the common bile duct stent was removed because of the positive therapeutic response.

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+We evaluated a Comorian girl aged 3 years 6 months with neuroregression and seizures. The child was third born to second-degree consanguineous parents by lower-segment cesarean section due to cephalopelvic disproportion. Birth weight was 3.1 kg with uneventful perinatal history. There was maternal history of normal healthy live birth in the first pregnancy and spontaneous miscarriages in second and fourth pregnancies in early trimesters. The fourth pregnancy was associated with Down syndrome. The mother was given antenatal progesterone for excess bleeding in the first trimester.
+From 2 weeks of age, she presented with lethargy, sweating, and breathlessness on feeding. Later on, she presented with recurrent episodes of aspirations with severe lower respiratory infections. Cardiac examination revealed a holosystolic murmur suggestive of ventricular septal defect (VSD). Chest X-ray revealed cardiomegaly with features suggestive of pneumonia . Echocardiography (ECHO) showed moderate VSD (6–7 cm subaortic perimembranous VSD), dilated left atrium and left ventricle, trivial aortic regurgitation with aortic cusp collapse, dilated pulmonary artery system with flow acceleration across pulmonary valve, and half-systemic pulmonary artery pressure with normal left ventricular systolic function . There was no pericardial effusion or right ventricular outflow tract obstruction. She was managed medically with decongestive medications and antibiotics for lower respiratory infections. She was noted to have laryngomalacia. At 3 months of age, decreased motor movements were noted. She was gaining weight till 5 months of age, after which there was flattening of the growth curve and failure to thrive. At 6 months, she had developmental arrest followed by progressive neuroregression. She also had severe startle response since 8 months of age. Then, she started having generalized recurrent seizures from 9 months onward. The epileptic episodes were mostly focal with secondary generalization, with the most severe event reported as having frequency of ten seizure episodes within 2 hours time period despite anticonvulsant therapy. She had also macrocephaly with coarse facial features, persistent laryngomalacia, and hyperacusis. There was no muscle atrophy. Central hypotonia, peripheral hypertonia, and a positive Babinski reflex were elicited. Organomegaly was absent. Ophthalmological examination showed bilateral macular cherry-red spots and an inability to fixate the eyes. At 12 months, she developed gastroesophageal reflux disease (GERD) as well as reactive airway disease. Gastrostomy tube feeding was also commenced. She had frequent episodes of hospitalizations due to repeated aspiration pneumonia, reactive airway diseases, and other central nervous system complications.
+History and physical examinations pointed toward the diagnosis of GM2 gangliosidosis (Tay–Sachs disease, SD, AB variant). In view of cherry-red spots and coarse facies, GM1 gangliosidosis was also considered. No significant abnormality was noted in complete blood count, electrolytes, or renal and liver function tests. Ultrasonography of abdomen did not reveal any hydronephrosis or other anatomic abnormalities. Computerized tomography scan of brain without contrast was suggestive of mild bilateral symmetric hyperdensity of thalami . Electroencephalogram (EEG) showed slowing of delta frequencies associated with drowsiness. Video-fluoroscopic assessment for swallowing function was suggestive of aspiration on both fluoroscopic runs. Magnetic resonance imaging (MRI) of brain revealed extensive high signal within the supratentorial white matter involving subcortical and deep white matter structures. There was evidence of T1-increased signal in the thalamus and a relatively large head shape. Bilaterally, the thalami demonstrated symmetric reduction of T2 signal and increase in the T1-weighted signal. There was marked delay in myelination as demonstrated on T1-weighted imaging. The corpus callosum was markedly thinned in its anterior body and genu. There was mild hypoplasia of the posterior arch of the C1 vertebra causing minimal narrowing at the upper cervical spinal canal .
+Magnetic resonance spectroscopy (MRS) trace did not reveal high creatinine or N-acetyl aspartate (NAA) peaks. No significant lactate level was demonstrated .
+Metabolic workup revealed a serum finding of trace-to-absent total serum HEX A and HEX B (0.0 nmol/min/ml; reference value > 20 nmol/min/ml) explaining the deficiency of the β subunit of HEX and consequent deficiency of HEX B. The serum HEX A percentage was 100% (reference value 20–90%). This biochemical findings of low total HEX and deficient HEX B activities, with high percentage of HEX A/total HEX activity suggested the diagnosis of SD. Oligosaccharide urine screen was positive in the urine sample, and genetic testing confirmed the diagnosis of SD with homozygous deletion c.(445+1_512-1)_(669+1_1170) in the HEXB gene. The parents were advised to consent to genetic analysis, but they refused.
+The patient was maintained on decongestive therapy (captopril, frusemide, spironolactone, and digoxin) and antiepileptics (levetiracetam and phenobarbitone). Fundoplication was done owing to her symptomatic GERD during infancy, and she was started on regular esomeprazole and domperidone, after which she was fed through gastrostomy tube. Fluticasone, ipratropium bromide and salbutamol nebulizations were continued in view of reactive airway disease. Iron supplementation was started in view of anemia. The clinical course is complicated with recurrent aspiration pneumonia warranting frequent hospital admissions. She also underwent multiple bronchoscopies. At 3 years of age, she had adenoviral infection on respiratory BioFire assay and then developed Pseudomonas pneumonia. Despite treatment with piperacillin–tazobactam, ciprofloxacin, tobramycin, and clindamycin antibiotics, her cardiorespiratory status worsened and she became ventilator dependent. Tracheostomy was performed at 3 years of age. However, despite the multimodality care with cardiology, neurology, pulmonology, physiotherapy, and nutritional and ventilatory support, she died at 3 and half years of age .

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+A 72-year-old man (height 168.5 cm, weight 72.4 kg, and body mass index 25.5 kg/m2) had type 2 diabetes mellitus and stage 4 chronic kidney disease (estimated glomerular filtration rate [eGFR] 28.0 mL/min/1.73 m2) before X-47 years. Other medical history included heart failure with reduced ejection fraction due to acute myocardial infarction, right lower extremity atherosclerosis obliterans, cataracts, and osteoporosis. He had no family history of diabetes, and no history of allergies and side reactions.
+He underwent an emergent percutaneous coronary intervention at Mie University Hospital in X-5 years but did not achieve good glycemic control despite taking glimepiride 3 mg once daily, sitagliptin 50 mg once daily, and metformin 250 mg twice daily (fasting blood glucose level 327 mg/dL and hemoglobin A1c [HbA1c] 7.8%). His primary physician changed his antidiabetic medication to sitagliptin 50 mg once daily, mitiglinide 10 mg three times daily, and insulin glargine 10 units once daily, and he was subsequently discharged from the hospital for regular visits.
+The patient’s daily dose of insulin glargine was increased from 10 to 12 units because of poor glycemic control (X-4 years; HbA1c 7.9%). Nevertheless, he did not obtain good glycemic control in X-3 years (HbA1c 8.2%). His primary physician confirmed negative findings of anti-glutamic acid decarboxylase antibody, C-peptide level of 2.9 ng/mL, and C-peptide index of 1.6. In X-2 years, voglibose 0.2 mg three times daily was added to the present regimen (HbA1c 8.1%). In X year (day 0), he orally received vadadustat 300 mg once daily with a diagnosis of renal anemia (hemoglobin 9.9 g/dL and HbA1c 7.4%). His eGFR was approximately 30 mL/min/1.73 m2 during the follow-up . The blood glucose mean (± standard deviation) over the last two weeks (days -14 to -1) was 108 ± 14 mg/dL before breakfast, 122 ± 24 mg/dL before lunch, and 158 ± 39 mg/dL before dinner . The prescribed medications on day 0 were sitagliptin 50 mg once daily, mitiglinide 10 mg three times daily, voglibose 0.2 mg three times daily, insulin glargine injection 12 units once daily, aspirin enteric tablets 100 mg once daily, rosuvastatin 10 mg once daily, esomeprazole 20 mg once daily, furosemide 20 mg once daily, carvedilol 10 mg twice daily, eplerenone 25 mg once daily, perindopril 2 mg once daily, and minodronic acid 50 mg every 4 weeks. There were no significant changes in medication history and lifestyle habits, such as diet and exercise, during treatment with vadadustat. Self-monitoring of blood glucose showed a decreasing tendency on day 18 after the start of vadadustat administration. He developed asymptomatic hypoglycemia on day 23 . The blood glucose level of the concomitant vadadustat period (days 0 to 23) was 94 ± 16 mg/dL before breakfast, 109 ± 20 mg/dL before lunch, and 126 ± 30 mg/dL before dinner . He called his outpatient attending physician and visited the hospital on the same day. This phenomenon was considered to be a result of the drug–drug interaction between sitagliptin and vadadustat via OAT3 inhibition, resulting in an enhanced hypoglycemic effect of sitagliptin and mitiglinide.
+The blood glucose recovered to 121 ± 25 mg/dL before breakfast, 147 ± 38 mg/dL before lunch, and 161 ± 36 mg/dL before dinner after discontinuation of vadadustat (days 24 to 37) . On day 56, at the regular clinic visit, his medication was changed to the alternative HIF-PHD inhibitor, daprodustat 2 mg once daily, and dipeptidyl-peptidase-4 (DPP-4) inhibitor, linagliptin 5 mg once daily, which is not transported by OAT3. Thereafter, the blood glucose remained stable at 111 ± 19 mg/dL before breakfast, 119 ± 13 mg/dL before lunch, and 134 ± 32 mg/dL before dinner (days 57 to 70). On the drug interaction probability scale (DIPS), the drug–drug interaction between sitagliptin and vadadustat was scored at 5 points, classified as “probable” .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1062_en.txt

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+A 66-year-old man had symptoms of abdominal pain, distension, and weight loss (from 62 to 47 kg within 6 mo).
+The patient complained of abdominal distension and weight loss and had visited the hospital previously. Esophagogastroduodenoscopy (EGD) was performed, and an advanced type 3 lesion was detected on the lower part of the gastric body with stenosis, causing resistance to passage of the scope. He was then admitted to our hospital and underwent a detailed medical examination and treatment.
+He had no specific past illness but had a current active smoking status [Brinkman Index: 920 (20 × 46 years)].
+No family history to note.
+Mild tenderness was noted in the upper abdomen.
+Initial laboratory data revealed a hemoglobin level of 11.0 g/dL, white blood cell count of 9700 cells/µL, and platelet count of 3.17 × 105/μL. The creatinine level was 0.81 mg/dL, total bilirubin level was 0.3 mg/dL, direct bilirubin level was 0.1 mg/dL, aspartate aminotransferase level was 43 IU/L, alanine aminotransferase level was 72 IU/L, and albumin level was 3.5 g/dL. Tumor marker level of the carcinoembryonic antigen was 23.00 ng/mL, and carbohydrate antigen 19-9 level was 53.20 U/mL.
+EGD identified stenosis caused by a large tumor . Computed tomography (CT) showed lymph node (LN) metastases at the station of the lesser curvature (#3 LN; 11.8 mm × 8.5 mm, Figure ), right greater curvature nodes along the right gastroepiploic artery (#4d LN; 10.3 mm × 8.4 mm, Figure ), infrapyloric nodes (#6 LN; 21.6 mm × 14.7 mm, Figure ), anterosuperior LNs along the common hepatic artery (#8a; 14.0 mm × 13.4 mm, Figure ), and suspicion of metastatic #6 LN invasion to the pancreatic head (the names of the LN station are provided in Table ). There were no findings of distant metastasis.
+Biopsies were taken, and the histological examination led to a diagnosis of adenocarcinoma (papillary and well-differentiated adenocarcinoma; Figure ). Additional pathological examination revealed human epidermal growth factor receptor 2 (HER2) positivity based on an immunohistochemical score of 3 + .
+The clinical diagnosis was gastric cancer LD circ cType3 cT4b (panc) N2M0 cStageIVA according to the Union for International Cancer Control Tumor, Node Metastasis Classification of Malignant Tumors, Eighth Edition. The lymph node station was defined according to the Japanese Classification of Gastric Cancer, 15th Edition.

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+A 72-year-old man visited our hospital complaining of gross hematuria. There were no GI illnesses in his medical history. Cystoscopy revealed multiple bladder tumors. CT and MRI showed stage cT1N0M0 disease. The patient underwent transurethral resection of the bladder tumors. Complete resection of the bladder tumors was not achievable because of the extensive lesions. The pathological result was high-grade pT1 urothelial carcinoma. After pathological diagnosis, the patient was treated with two cycles of a gemcitabine and cisplatin regimen as neoadjuvant chemotherapy. The patient then underwent laparoscopic radical cystectomy with the creation of a U-shaped ileal neobladder and limited dissection of the lymph node. Pathological examination showed high-grade pT2 urothelial carcinoma with negative resection margins and pN0 (two lymph nodes). Recurrence evaluation after surgery was determined by FDG-PET-CT due to reduced renal function. Three months after surgery, FDG-PET-CT taken to evaluate the effect of initial postoperative treatment revealed a new appearance of abdominal lymph node metastasis . Due to reduced renal function, combination chemotherapy with gemcitabine and carboplatin was administrated. However, enlargement of lymph node metastases was identified on FDG-PET-CT after two cycles . The patient began treatment with pembrolizumab (200 mg/body administrated every 3 weeks) as second-line treatment. FDG-PET-CT after three cycles of pembrolizumab showed a marked response with the disappearance of FDG accumulation in all metastatic lesions .
+The patient had no adverse effects, but after 10 months complained of anorexia and upper abdominal pain. EDG demonstrated diffusely erythematous and edematous gastric mucosa covered with a whitish, fibrin-like membrane . In addition, diffuse erosions were found in the gastric antrum .
+Biopsy specimens revealed inflammatory cell infiltration and apoptosis in the epithelium. High numbers of lymphocytes and plasma cells were observed infiltrating into the lamina propria . In addition, T cell infiltration and apoptotic bodies were observed in the gastric epithelium . Immunostaining identified these lymphocytes as CD3+ and CD8+ T-cells in the epithelium. No histological or immunohistochemical evidence of Helicobacter pylori or cytomegalovirus was apparent. However, the serum H. pylori antibody concentration was elevated (15 U/mL; normal <10 U/mL). The clinical and pathological findings were comparable with lymphocytic gastritis induced by pembrolizumab. The patient received eradication therapy combined with the administration of a PPI, amoxicillin, and clarithromycin for 1 week. Eradication therapy and cessation of pembrolizumab led to improvement of clinical symptoms and findings on EDG without steroid therapy in 4 months . The patient has since resumed and continued pembrolizumab administration while maintaining CR for 28 months to date.

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+We introduced a 34-year-old man with a definitive diagnosis of KS from two years ago, with a history of trauma to the ankle from 18 days ago. His family history of venous thromboembolism (VTE) was negative. He was hospitalized in the cardiology ward to treat chest pain and dyspnea, with the New York Heart Association Classification of Heart Failure (NYHA) class III. The clinical examination at the time of admission in OR exposed a drowsy patient with a history of twice syncope from the day before, palpitation (PR = 120), sweating, chest pain, blood pressure at 80/55 mmHg (with invasive blood pressure monitoring IBP), SpO2at 85% in ambient air and 92% under oxygen, and two-sided crackles on chest auscultation. In paraclinical findings, a D-dimer test was 1700 mg/mL, ECG revealed tachycardia with RBBB, transthoracic echocardiography presented a D-shape septum due to high RV pressure, moderate to severe RV enlargement, moderate to severe RV systolic dysfunction, hypertrabeculated RV apex, at least moderate TR, TRG = 40 mmHg, severe PAH, PAP = 55 mmHg, dilated IVC with respiratory variation < 50%, visible fresh cloth in main PA, and proximal part of branches in suprasternal view. On computed tomography angiography (CTA) of the lungs, a massive embolus was reported in the main pulmonary artery as well as in the right and left main branches. The troponin was negative. The lower extremities venous Doppler ultrasound revealed normal flow and no thrombosis. Because of this massive pulmonary embolism, the patient was a candidate for surgical embolectomy. After general anesthesia and placement on the hypothermic cardiopulmonary bypass (CPB) in the 28-degree centigrade, pulmonary embolectomy was done . After rewarming, weaning off from the CPB was easily done, without the need for inotrope. After four hours, the patient was extubated and weaning off the ventilator with a stable hemodynamic condition. The congestive signs were retreated well using diuretic treatment. The patient was discharged from the hospital in good general condition after one week with a warfarin prescription.

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+A 71-year-old female with a history of acid reflux presented to the emergency department following a syncopal episode, along with progressive diarrhea, weight loss, worsening jaundice, and fatigue. She had been undergoing outpatient evaluation for elevated liver enzymes over the past 2 years prior to admission. She was trialed on ursodiol and low-dose prednisone without much benefit prior to arrival.
+In the emergency department, her vitals were remarkable for hypotension with a blood pressure of 72/53 mm Hg and a nadir HR of 62. Physical exam was significant for jaundice and cachexia. Blood work demonstrated leukocytosis 27.7 × 109/L (normal 3.4–9.6 × 109/L) with neutrophilic predominance. Hepatic function panel showed an aspartate transaminase level of 85 U/L (normal 8–43 U/L), alanine aminotransferase 85 U/L (normal 7–45 U/L), bilirubin 9.3 mg/dL (normal <1.2 mg/dL), and alkaline phosphatase of 2262 U/L (normal 35–104 U/L). Gamma-glutamyl transferase was elevated to 494 U/L (normal 5–36 U/L). C-reactive protein was 52 mg/L (normal <8 mg/L). TSH was elevated to 22.8 mL U/L (normal 0.3–4.2 mlU/L) with undetectable T3 and T4 levels. Review of a 6-month prior outside liver biopsy was consistent with periportal fibrosis with lymphocytic and scattered neutrophilic infiltrates in the portal tracts. No infiltrating histiocytes were noted in the biopsy.
+The patient was admitted to the intensive care unit for vasodilatory shock, requiring vasopressors and chronotropic agents along with antibiotics. Computed tomography (CT) of the abdomen and pelvis with contrast illustrated diffusely heterogenous liver parenchymal enhancement without ductal dilatation, duodenitis, and diffuse colonic thickening concerning pancolitis (shown in a). CT chest was performed which showed centrilobular ground glass opacities bilaterally with mild pulmonary edema. Echocardiogram did not reveal any cardiac abnormality. Brain magnetic resonance imaging (MRI) with contrast revealed abnormal enhancement and thickening of the pituitary infundibulum and stalk most consistent with lymphocytic hypophysitis (shown in b).
+Given the cholestatic nature of liver injury, magnetic resonance cholangiopancreatography was performed which showed multifocal nodular hepatic steatosis and hepatomegaly without any focal liver abnormality; in addition, multiple indeterminate bony lesions were read as non-specific focal sclerosis and cystic lesions. Autoantibody screening including anti-nuclear antibody, SS-A and SS-B antibodies, and anti-smooth muscle antibody were negative. IgG4 subclass levels were normal. A bone marrow biopsy showed 40% cellularity and reactive marrow changes without any blasts or infiltrate. Subcutaneous fat aspirate was negative for amyloid deposition on Congo red staining.
+The patient was being optimized for a possible esophagogastroduodenoscopy and colonoscopy once more stable. A repeat liver biopsy revealed histiocytes infiltrating the biliary tree with chronic biliary tract injury. Tissue stained positive for CD1a and S100, markers of Langerhans cells, and BRAFV600E-mutated protein, commonly found in various malignancies (shown in ). No evidence of IgG4 sclerosing cholangitis was observed. A diagnosis of secondary sclerosing cholangitis and cirrhosis secondary to multisystem LCH was confirmed.
+Treatment was initiated with hydrocortisone and levothyroxine for panhypopituitarism. The patient was eventually started on dose reduced b-rapidly accelerator fibrosarcoma (BRAF) inhibitor, vemurafenib, after multidisciplinary discussion. The patient’s hospital course was also complicated by acute necrotizing pancreatitis, poorly controlled blood sugars, and new onset central diabetes insipidus that required treatment with desmopressin. Repeated hospitalizations in the following 3 months prompted her to opt for comfort care with palliative measures.

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+An 18-year-old male, healthy collegiate sprinter, presented with a chronic tear of his right rectus femoris tendon. A year prior, he was running high school track when he felt a pop in his right thigh and developed an obvious deformity. Physical therapy was attempted with incomplete recovery and continued thigh and groin pain, resulting in an occasional antalgic gait. He also felt subjective limitation in his athletic ability. Due to his continued symptoms, he sought a second opinion with the primary investigator.
+Physical examination of the thigh demonstrated an obvious subcutaneous deformity, similar to a “Popeye” type sign seen in the proximal biceps, with a palpable defect in the quadriceps tendon. Knee range of motion was 0–120° and he was tender to palpation along the distal tendon stump. Hip range of motion was 110° of flexion, 15° of extension, 35° of internal rotation, and 45° of external rotation. Internal impingement sign was positive reproducing the patient’s pain in his groin.
+MRI of the right lower extremity and MR arthrogram of the right hip demonstrated a complete tear of the rectus femoris tendon without atrophic changes, a CAM lesion with an alpha angle of 70°, and anterior-superior labrum tearing.
+A trial of conservative management was attempted with activity modification, physical therapy, and an intra-articular hip injection for both diagnostic and therapeutic purposes. With the injection, we attempted to isolate the patient’s symptoms as coming from intra-articular hip pathology or from the rectus femoris rupture. The injection relieved his groin pain for approximately 1 week with continued irritation in the thigh, especially isolated around the tendon stump. An attempt was made with the patient to elucidate the true nature of the symptoms. He sincerely felt that the groin pain, which was temporarily relieved from the injection, was significant and independent pain from the pain, he experienced at the region of the tendon stump. The pain at the tendon stump continued to bother him during the week of relief from the groin pain. Furthermore, after the initial response to the injection, the patient felt that both areas of pain were significant to his overall limitations and symptoms. At this point, the patient had failed conservative therapy with both the intra-articular pathology and rectus femoris rupture deemed significant sources of his persistent symptoms. Surgery was recommended for both hip and tendon pathologies.
+The primary surgeon and patient jointly decided to address the rectus femoris rupture with reconstruction and the intra-articular hip pathologies through hip arthroscopy. For the rectus femoris, the patient was positioned supine on a traction table. A midline incision, in line with the quadriceps tendon, was made at the site of tendon rupture from the tendon stump to the proximal patella. The distal stump of the rectus femoris was isolated circumferentially. There was approximately 4 mm of relatively thin rectus femoris tendon stump remaining. The tendon stump was sutured with multiple loops of Fiberwire (Arthrex, Naples, FL). The Achilles allograft was then obtained and sutured medially and laterally in a running Krackow fashion. The Achilles graft was fanned out and tacked to the rectus femoris muscle belly utilizing approximately 15 simple interrupted #2 Ethibond (Ethicon, Cincinnati, OH) sutures. Fiberwire (Arthrex, Naples FL) was utilized to connect the tendon graft to the remaining rectus femoris tendon stump in a Krakow fashion medially and laterally. Attempting to balance anatomic location versus graft/tendon tension, the rectus femoris complex was pulled over the distal intact quadriceps tendon. While maintaining tension, #2 Fiberwire (Arthrex, Naples, FL) was passed in a running Krakow fashion medially and laterally through the graft and quadriceps tendon from musculotendinous margin to the proximal patella and back. Once completed, the graft and rectus femoris had excellent stability throughout knee range of motion.
+For the hip arthroscopic procedure, the hip was placed under traction. Three portals were utilized: Anterolateral, mid-anterior, and distal anterolateral accessory. Diagnostic arthroscopy demonstrated a labral tear from the 12:30 to 3:00 position. The acetabular rim was decorticated. For the 1:00 position and 2:30 position, knotless Cinchlock anchors (Stryker, Kalamazoo, MI) were utilized to affix the labrum. Traction was then released and restoration of the suction seal nature of the labrum was confirmed. Attention was then turned to the arthroscopic femoroplasty. The convex protuberance of bone consistent with a CAM lesion was noted at the 1–3 o’clock position. A burr was used to recontour the femoral head-and-neck junction to a concave structure. This was confirmed by direct visualization and intraoperative radiographs.
+Following the arthroscopic procedure, the rectus femoris reconstruction was rechecked and intact. All skin incisions were then closed and dressed.
+Postoperatively, the patient was placed in a locked knee immobilizer and recommend toe-touch weightbearing for 3 weeks. Physical therapy was initiated after 2 weeks with a gradual progression of weightbearing after 3 weeks. Knee flexion was initiated at 2 weeks with 15 degrees per week until full motion. No quadriceps resistance was allowed until 3 months. Six months following the operation, the patient was cleared to return to sports. There were no complications encountered.

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+A 64-year-old woman was admitted to hospital because of dehiscence of a sternal wound, after a mitral valve replacement that was performed 2 months earlier due to severe insufficiency. She presented a clinical history of rheumatic mitral stenosis, which was treated with closed mitral valvulotomy 35 years previously, resulting in a mitral insufficiency. Twenty-three years previously she had suffered a bacterial endocarditis due to viridans group streptococci that led to cerebral embolism.
+On examination, a white material was found to be exuded from the sternal wound when pressed over the wound margins. A computed tomography scan of the chest showed a dehiscence of the surgical wound, with swelling of soft tissue above the sternum and osteitis of the sternal bone. Apart from a C-reactive protein level of 2.6 mg dl−1 and an albumin level of 3.1 g dl−1, laboratory studies were unremarkable.
+Empirical treatment with clindamycin (300 mg/6h i.v.) and ceftazidime (2 g/8h i.v.) was started. The treatment was changed to imipenem (500 mg/6h i.v.) and ciprofloxacin (750 mg/12h p.o.) after a preliminary microbiology laboratory report of growth of an actinomycete with presumed susceptibility to several antimicrobials. Surgical debridement of the wound was performed. This treatment was maintained for 3 weeks, but successive wound cultures continued showing the presence of the actinomycete organism. Because the symptoms did not improve, sternal cerclage was removed and antibiotic therapy was shifted to teicoplanin (400 mg/24h i.v.) plus ciprofloxacin (750 mg/12h p.o.) and rifampin (600 mg/24h p.o.) for 2 weeks, followed by ciprofloxacin plus rifampin for an additional6 weeks, resulting in wound healing.
+Culture of wound samples on chocolate and blood agar plates for 72 h at 37 °C in aerobic conditions yielded creamy-white, dry, wrinkled and non-haemolytic colonies. After these 3 days, a colour change was observed in the colonies from white to yellowish. Colony appearance showed synnemata and no aerial hyphae (see ). Gram staining yielded Gram-positive short coryneform rods without branching. Modified Ziehl–Neelsen staining confirmed slight acid-fastness. Both conventional Ziehl–Neelsen and auramine stains were negative. The micro-organism was non-spore-forming, and catalase and urease positive. Casein, hypoxanthine, tyrosine and gelatine were not decomposed. Arylsulfatase production was negative within 3 days. Nitrate was not reduced to nitrite and indole was not produced. With the API NH strip (bioMérieux) acid was produced from glucose, fructose and sucrose. 16S rRNA gene sequence analysis using the blast algorithm showed 99.9 % similarity to G. bronchialis strain DSM 43247 (GenBank accession no. ).
+An antimicrobial-susceptibility assay was performed using Etest strips (bioMérieux) on Mueller–Hinton agar with 5 % defibrinated horse blood and 20 mg β-NAD l−1 (MH-F; Oxoid). Readings were taken after 48 h of incubation, and susceptibility categories were defined according to Clinical and Laboratory Standards Institute (CLSI) guidelines for mycobacteria, nocardiae and other actinomycetes . The isolate was resistant to clindamycin (MIC=8 mg l−1), and susceptible to amoxicillin/clavulanic (0.016 mg l−1), ceftriaxone (0.5 mg l−1), imipenem (0.008 mg l−1), ciprofloxacin (0.06 mg l−1), amikacin (0.06 mg l−1), tobramycin (0.12 mg l−1), clarithromycin (2 mg l−1), minocycline (0.25 mg l−1), linezolid (1 mg l−1) and co-trimoxazole (0.03 mg l−1). Although no susceptibility breakpoints have been established for vancomycin and teicoplanin by the CLSI, MIC values were low (0.25 and 1 mg l−1, respectively).
+The isolate was analysed by two MALDI-TOF MS-based systems, a Bruker Biotyper (Bruker Daltonics) and a Vitek MS (bioMérieux). Identification of G. bronchialis (99.9 % identity) was obtained with the Vitek MS (saramis 3.0 software) following the procedure recommended by the manufacturer. Briefly, target slides were inoculated into the spots by picking a freshly grown overnight colony and overlaid with 1 µl matrix solution, α-cyano-4-hydroxycinnamic acid. The same result was attained with the Bruker Biotyper (version 3.1 software), using a complete protocol of protein extraction with formic acid and acetonitrile, following the Bruker Biotyper instructions, but the score value (1.72) was lower than the one defined in the manufacturer’s criteria (≥2.00) for acceptance of identification at the species level.

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+A 25-year-old primigravida with no significant past medical history at 22 weeks and 0 days gestation presented to a local hospital with sudden onset of right-sided back pain radiating to her right lower quadrant that had persisted for less than one day. She denied nausea, vomiting, fevers, vaginal bleeding, and dysuria. Her pregnancy had been otherwise uncomplicated. Her pain became uncontrollable with intravenous medication and localized solely to her right lower quadrant. She was transferred to a tertiary care center for further management, given concern for appendicitis and possible need for surgical intervention.
+Her pain worsened on transport, and on arrival to the tertiary care center, she demonstrated severe right lower quadrant tenderness with rebound and voluntary guarding without costovertebral angle tenderness. She was hemodynamically stable, but intravenous hydromorphone only provided transient and mild improvement in her pain. Her cervix was found to be closed on digital exam, and no abnormalities were noted on speculum exam. Initial laboratory evaluation demonstrated a normal comprehensive metabolic panel and coagulation studies. Hemoglobin was 10.7 gm/dL and white blood cell count was not elevated (9.9 × 103/μL). Urinalysis was negative.
+She underwent an abdominal MRI showing a normal appendix. However, in a verbal read from the on-call radiologist, concern was communicated for right forniceal rupture given the constellation of radiologic findings of hydroureter combined with perinephric and retroperitoneal fluid, highlighted in . Her left kidney and collecting system were normal in appearance. Renal ultrasound was therefore performed, and it revealed right ureteral tapering between the gravid uterus and right iliac artery with no right ureteral jet visualized. Given these findings, the patient was subsequently managed by a multidisciplinary team consisting of maternal-fetal medicine, urology, and interventional radiology. Three strategies were discussed and included conservative management with close follow-up, placement of a ureteral stent, and placement of a percutaneous nephrostomy (PCN) tube. Patient preference was for PCN placement. Of note, urine culture collected prior to PCN placement was negative.
+Following its placement by interventional radiology, her pain was relieved, and she was discharged with follow-up with maternal-fetal medicine and interventional radiology. Her pregnancy was subsequently complicated by readmission for recurrent pain and pyelonephritis with culture isolation of Enterobacter cloacae resistant to both nitrofurantoin and trimethoprim/sulfamethoxazole (TMP-SMX). She required placement of a midline IV for daily infusion of ertapenem at her local hospital. Her pregnancy was also complicated by fetal growth restriction, diagnosed at 35 weeks. Uncomplicated vaginal delivery occurred at 37 weeks and 1 day. Her PCN was removed postpartum at which point antibiotics were also discontinued.

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+The patient was a 66-year-old man who underwent rectal resection and postoperative chemotherapy for rectal cancer. Bile duct obstruction due to a liver metastasis caused obstructive jaundice and acute cholangitis, which resulted in emergency hospitalization. On magnetic resonance imaging , a 3.5 cm mass in the biliary hilum caused type IV biliary obstruction according to the Bismuth-Corlette classification of hilar cholangiocarcinoma. Despite several attempts at biliary drainage (branch of B3 and B2, B5, B7) via ERCP, obstructive jaundice was not improved. The patient was emergently hospitalized again because of acute cholangitis with a 39 °C fever and epigastric pain, although bile duct plastic stents (PS) had been placed in the left intrahepatic bile duct (branch of B3 and B2) and right intrahepatic bile duct (B5 and B7) . Repeated ERCP and biliary drainage were performed, had no effect as shown on the CT . In this case, many of biliary branches were divided by the obstruction at hilar biliary. Only by 2D image, it was hard to identify the relation between dilated biliary branches and drainage tube placed. Given that selective bile duct drainage had proven extremely difficult with the conventional procedures, 3D images were created from preoperative CT image data using a 3D image reconstruction system (SYNAPSE VINCENT version 5, FUJIFILM Corporation, Tokyo, Japan). We used the 3D images for preoperative planning and performed biliary drainage using them as an intraoperative reference.
+Residual dilation was observed in the left intrahepatic bile duct (B3). Although the PS was allowing slight decompression of the left intrahepatic bile duct (B2), marked biliary dilation persisted; thus, the PS was deemed ineffective for B3, while no biliary dilation was found around the PSs placed in B5 and B7, so these were deemed to be effective. Marked dilation of B6 and B8 was noted, and drainage was deemed necessary . On the basis of the above findings, we planned preoperatively that an additional PS would be placed in the deep part of B3 and several other PSs would be replaced (B6 and B8). The entire ERCP procedure was performed under the combination of fluoroscopic images of a standard side-view duodenoscope (EDT-580, FUJIFILM, Tokyo, Japan) and the 3D images. This procedure was performed using a multipurpose imaging system incorporating a C-arm (VersiFlex Apla, HITACHI corporation Tokyo, Japan). During the actual ERCP procedure, endoscopists could see the endoscope video (a), the 3D image of the bile ducts that rotate freely (b), and the 2D fluoroscopic image (c) at the same time . With the 3D images for preoperative planning and intraoperative reference, biliary drainage was successfully performed without complications . Postoperatively, the patient had no further cholangitis or need for stent replacement up to his death.

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+A 75-year-old Japanese man was found to have a pancreatic cyst in 2006 while undergoing postoperative evaluation for colorectal cancer. The pancreatic cyst increased in size, and surgery was recommended, but the patient declined . In 2015, the cyst ruptured, and he was treated conservatively . In 2017, he began dialysis for chronic renal failure. The same year, he fell down on a road with a fever of 40 °C and was transported emergently to a nearby hospital. Laboratory tests showed elevated levels of C-reactive protein. Serum levels of carcinoembryonic antigen and carbohydrate antigen 19-9 were 5.8 ng/ml and 131.3 U/ml, respectively .
+The patient was treated with new quinolone-based antibiotics for 3 weeks as a conservative treatment after hospitalization. Bacteria were not detected by blood culture examination at admission. Enhanced computed tomography (CT) revealed a cystic lesion in the body of the pancreas measuring 119 mm × 100 mm and an adjacent left renal cyst measuring 63 mm in diameter. The wall of the pancreatic cyst was thickened. The pancreatic ducts were not dilated . Magnetic resonance imaging (MRI) demonstrated a liquid surface in the pancreatic cyst . Magnetic resonance cholangiopancreatography (MRCP) did not show pancreatic duct dilation . Endoscopic ultrasound (EUS) showed a liquid surface in the pancreatic cyst and did not show nodules in the cyst . Gastroscopy showed an elevated mass in the posterior wall of the body of the stomach with intact mucosa . In addition, colonoscopy performed 5 months before admission showed an elevated mass in the descending colon with intact mucosa .
+Pancreatic cyst infection was diagnosed as the source of infection. However, identification of the organism was difficult. Furthermore, due to the increase in the size and wall thickness of the cyst, it was unclear whether the cystic mass was neoplastic with malignant potential. For these reasons, the patient underwent distal pancreatectomy and splenectomy, with deroofing of the left renal cyst. Intraoperatively, the pancreatic cyst strongly adhered to the descending colon, so partial resection of the colon was added.
+Pathologic analysis of the resected cyst demonstrated a simple cyst lined by mucinous epithelium . There was no underlying stromal condensation or epithelial dysplasia, and communication with the native pancreatic ducts was not observed. Pathological analysis of the resected colon adhesive pancreatic wall revealed a fistula-like depression on the mucosal side of the colon . Bacteroides fragilis and Streptococcus sanguinis were detected as a result of culture examination of the pancreatic cyst contents. On the basis of the operative and histological findings, a final diagnosis of MNNC with colon communication was made . The small colonic fistula was presumed to be the source of infection.
+Postoperatively, the patient was treated for a grade B pancreatic fistula. On postoperative day 12, emergency surgery was performed for thrombotic descending colon perforation. On postoperative day 94, the patient was discharged on foot.

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+A 3-months-old female was referred to our department because of suspicion of child physical abuse. She was born at term, a product of uneventful gestation. At birth her weight was 3310 gm, length of 51 cm and her occipito-frontal circumference was 33.5 cm. No irritability, feeding or pulmonary abnormalities, and fever were recorded. The mother was 29-year-old-gravida 2, married to a 33-year-old-unrelated man. She had no history of spontaneous abortions, stillbirths, prematurity and or polyhydramnios. No maternal use of medications or antenatal illnesses was reported. Physical examination of the baby showed normal facial features, no blue sclerae, normal nose but swelling of the mandible was noted. There were swellings of some of the long bones (right leg, and radius). Neither feeding abnormalities nor fever was present. Her chest was noted to be symmetrical and of normal appearance. Hands and feet were normal. There were no associated signs of abnormal skin stigmata such as fragility/extensibility and or ligamentous hyperlaxity was noted. Hearing, vision and neurological examinations were all normal. Laboratory studies including metabolic tests, which aimed to tests calcium, phosphorus, and vitamin D metabolism were normal. No specific genetic test has been done for this baby.
+Anteroposterior radiograph of the skull showed massive sclerosis of the skull bone associated with significant cortical hyperostosis and enlargement of the mandible secondary to cortical new bone formation . Lateral skull radiograph showed sclerosis of the skull base (arrow) and hyperostosis of the calvaria . Coronal MRI imaging showed significant calvarial/facial and mandibular hyperostosis . Anteroposterior radiograph of the radius showed cortical new bone formation associated with subperiosteal thickening. Note marked bloating along the diaphysis with sparing of the epi-metaphyseal components associated with expansion of the bone marrow cavity and a persistent-like deformity . Anteroposterior radiograph of the tibia showed a thick and broad ballooning occupies the diaphyses (proximally and distally) there is gaining in the diameter comes from subperiosteal new bone apposition by intramembraneous bone formation .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1140_en.txt

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+A 55-year-old man started to receive hemodialysis because of diabetic renal failure 2 years previously. He underwent renal transplantation 1.5 years previously, and had been receiving immunosuppressants since then. Eight months after transplantation, the serum creatinine level increased to 4.4 mg/dl. He had CMV enteritis with occult blood in the stool and an elevated CMV pp65 (C7-HRP) antigen level in blood mononuclear cells. Intravenous ganciclovir (150 mg/day) was administered for 11 days, followed by valganciclovir (450 mg/day). Because the enteritis was very severe, ganciclovir and valganciclovir were not reduced to maintenance doses, which are generally half of starting doses. Two days after starting valganciclovir, he had unsteady gait, but could walk unaided. On the next day, the patient needed assistance with walking. His consciousness was mildly disturbed (E3, V5, and M6 on the Glasgow Coma Scale). One day later, he became delirious intermittently. Two days later, he was found on the floor after falling, without major injuries. He was suspected to be irritated and exhausted because of severe enteritis. Nine days after starting valganciclovir, his level of consciousness worsened (E3, V3, and M5), and he could not receive oral drugs, including valganciclovir. Neurologists were consulted. Encephalitis was unlikely, since no meningeal signs or fever was noted; the cell count was normal (0.33 cells/μl) in the CSF, and the protein concentration marginally elevated (54 mg/dl). CMV, herpes simplex virus, varicella-zoster virus, and Epstein-Barr virus DNA was later found to be negative in the CSF. Ganciclovir-induced encephalopathy was suspected, and the drug was withdrawn. Because of the risk of further falls, hemodialysis using a VPS-15HA membrane, a vitamin E-coated polysulfone membrane (Asahi Kasei Kuraray Medical, Japan) was performed twice in 2 days. His consciousness improved considerably after the first session of dialysis (E3, V4, and M6) and was completely restored on the next morning after the second session (E4, V5, and M6). The trough levels of ganciclovir in the serum and CSF were retrospectively measured and are shown in table .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1147_en.txt

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+A 5-year-old Persian, female cat was brought for investigation of progressive behavioral changes (loss appetite, loss weight, imbalance, and lethargy) at Albaittar clinic in Tripoli, Libya. The cat was mated 1 month before it was brought to the clinic. It showed vigorous behavior in a male during estrus. The cat’s owner visited the clinic for suspecting pregnancy. At presentation, the cat had a body weight of 2.5 kg and a body temperature of 38°C. Physical examination revealed an enlargement of the abdomen, with a palpable irregular-shaped mass on the right side of the mesogastric region. Abdominal Ultrasound examination (DRAMIŃSKI ANIMALprofi L, DRAMIŃSKI, Poland) revealed the presence of an echogenic irregular mass in the right ovary.
+The cat subsequently underwent therapeutic ovariohysterectomy (OHE). Ovaries, uterus, contralateral ovary, and fallopian tube were fixed in 10% neutral buffered formalin within 48 hours and submitted for macroscopic and histopathological examination. The cat received 20 mg/kg of long-acting Amoxicillin for five consecutive days after the operation and the wound was dressed with wound disinfectant and antibiotic powder every 2 days. The cat started to eat on the next day of the operation.
+Macroscopic examination revealed a uterus measured 11 cm in length, convoluted with corkscrew appearance, soft in consistency, and intact serosal layer . The right ovary showed an attached ovarian cystic tissue mass measured 6 × 5 × 3 cm, rounded in shape, dark red to tan in color, soft to firm in consistency with multilobulation and intact capsule . The specimen was inked and serially cut. The contralateral ovary measured 0.9 cm and fallopian tube measured 0.5 cm in length.
+On cut section of the ovarian tissue mass, a well-circumscribed multilobular tumor mass, solid heterogeneous, greyish white to tan in colored areas with multiple foci of necrosis and cystic spaces were detected. The capsule is intact grossly. The uterine cavity showed thickened wall with variable cystic dilatations. The other ovary and fallopian tube showed no obvious pathological abnormality.
+For histopathological examination, serial sections were taken from the ovarian tumor mass and from the uterus, as well as, from the contralateral ovary and fallopian tube, and were fixed in 10% buffered formalin for later processing and examination. All histological procedures were performed according to . The tissue sections were stained with hematoxylin and eosin (H&E) following the standard procedures. The stained tissue sections were examined under a light microscope (ZEISS, Germany).
+Histopathological examination of the ovarian tumor mass revealed a malignant tumor composed of diffuse atypical granulosa cells with spherical to oval nuclei, distinct nucleoli, and scant eosinophilic cytoplasm arranged in different patterns (micro follicles, small nests, acinar formation, and alveolar-like) . Regions of the tumor exhibited Sertoli-pattern (Luteinization), while others showed sarcomatous spindle cells arranged in tight fascicles . The cells were separated by connective tissue septa along with areas of hemorrhage and necrosis . Mitotic count according to active foci of the tumor showed 2–3 mitosis / 10 hpF. The fibroconnective tissue capsule (FCC) revealed evidence of vascular invasion which showed blood vessels lined by endothelial cells .
+The endometrium examination revealed thickened endometrial lining with elongated glands and prominent stroma. There was also a dilatation of glands with formation of variable sized cysts . No cytological atypia was seen, nor evidence of complexity or tumor deposits or invasion. The contralateral ovary and fallopian tube showed normal histological findings, with no evidence of malignant infiltrations.
+Based on histological findings, the GCT of the ovary with evidence of vascular invasion associated with CEH was made and the contralateral ovary and fallopian tube were free.
+The surgical intervention resulted in the complete resolution of clinical signs. However, 6 months following surgery the cat was brought to the Albittar clinic again with complaints of weakness, cachexia, ascites, off food, and lethargy with the presence of abdominal mass. Sings of pain were determined on palpation of the right abdominal region and ultrasonography examination was performed. According to the ultrasonography examination, a clear mass at the mesogastric region attached to the right kidney was determined and was suspected as a sequela of past tumor metastasis. Since the poor prognosis surgery was not performed, the cat had paralysis in hind limbs and massive weight loss after one week and eventually died. The owner of the cat rejected the euthanized decision and the postmortem examination.

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+A 50-year-old man presented with positive fecal occult blood test results. He denied any previous medical or surgical history. On digital examination, a solid tumor 5 cm from the anal verge on the posterior side of the rectum was palpated, and there were no anal fistulas or abscesses. Colonoscopy revealed a rectal tumor below the peritoneal reflection, occupying three-quarters of the circumference . A pathological diagnosis of the biopsy specimen indicated a well-to-moderately differentiated tubular adenocarcinoma. Computed tomography (CT) and magnetic resonance imaging (MRI) showed no significant regional lymphadenopathy or distant metastasis. Therefore, the clinical diagnosis was rectal cancer cT3N0M0, cStage IIa (UICC TNM classification 8th edition) .
+We indicated preoperative chemoradiation therapy (CRT), comprising 45 Gy in 25 fractions; tegafur/gimeracil/oteracil potassium (S-1), 80 mg/m2/day at days 1–14 and 21–35 (2 cycles). The patient did not experience any significant adverse events. Four weeks after completion of CRT, a follow-up CT and MRI showed that the primary tumor had shrunk with a partial response as defined by the Japanese Society for Cancer of the Colon and Rectum (JSCCR) , but a small liver mass highly indicative of metastasis was also detected. This was later diagnosed as cavernous hemangioma using gadolinium ethoxybenzyl-diethylenetriaminepentaacetic acid-enhanced MRI 3 months after CRT initiation. We then indicated consolidation chemotherapy, consisting of capecitabine combined with oxaliplatin (XELOX regimen: intravenous oxaliplatin 130 mg/m2 [day 1] followed by oral capecitabine 1000 mg/m2 twice daily [day 1, evening to day 15, morning]). His tolerance to chemotherapy gradually declined due to peripheral sensory neuropathy (CTCAE Grade 1 to 2 ) after three cycles. As such, we excluded oxaliplatin and continued consolidation chemotherapy with three cycles of capecitabine alone (1000 mg/m2 twice daily [day 1, evening to day 15, morning]). Four weeks after completing consolidation chemotherapy, follow-up colonoscopy showed that the primary tumor achieved a complete response based on the JSCCR guidelines . Since a follow-up CT simultaneously showed thickening of the edematous rectal wall, we planned to perform low anterior resection as a radical surgery after neoadjuvant therapy.
+However, he presented with persistent anal pain 2 weeks after the last chemotherapy session. Anorectal examination revealed tenderness and rigidity around the posterior side of the anus, which was distant from the primary tumor. MRI revealed a high-intensity mass behind the anus, suggestive of an anal fistula . We considered the differential diagnosis of a benign anal fistula or implantation metastasis into the anal fistula. Coring-out fistulectomy was performed, and the resected fistula was pathologically diagnosed as tubular adenocarcinoma, which has similar morphological characteristics to rectal cancer . The resection margin was deemed positive because of the cauterized margin of cancer cells. This result suggested an implantation metastasis to the anal fistula. Therefore, instead of low anterior resection, abdominoperineal resection was performed to resect the primary rectal tumor and metastatic lesion simultaneously.
+Twelve weeks after completing consolidation chemotherapy, we performed laparoscopic abdominoperineal resection. The postoperative course was complicated by a perineal abscess requiring percutaneous drainage. Otherwise, it was uneventful, and the patient was discharged on the 25th postoperative day. Histopathological examination revealed a well-differentiated adenocarcinoma, ypT2, INFb, Ly0, V0, Pn0, pPM0, pDM0, ypN0 . The therapeutic effect was grade 2 according to the definition of the JSCCR .
+Subsequently, we investigated the origin of the tubular adenocarcinoma from the resected anal fistula by immunohistochemistry and found that it was CDX-2-positive, CK20-positive, CK7-negative, and GCDFP-15-negative . These findings implied that the anal fistula adenocarcinoma was consistent with metastasis and intraluminally implanted rectal cancer. The patient declined to undergo postoperative adjuvant chemotherapy. No recurrence was detected until his last follow-up 21 months after the surgery.

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+A 40-year-old male presented in casualty with a history of seizures that let to fall from 10 feet height resulting in injury to both hips and left shoulder. He was diagnosed with cerebral venous thrombosis and started on heparin. On X-rays & CT scan (, ), he was diagnosed to have bilateral acetabular fracture and three part left proximal humerus fracture. He was operated for bilateral acetabular fracture using modified Stoppa’s approach and fixed with buttress plate in true pelvis on both sides . On post op day 3, he had fever & discharge from suture site, dressing was done and pus culture and sensitivity done. Wound wash was done to eradicate infection. Culture showed growth of Klebsiella and anaerobes sensitive to cefoperazone sulbactum, clindamycin and amikacin. The pus discharge resumed again after 3 days of wound wash and antibiotics. This time culture sensitivity tests showed resistance to cefoperazone sulbactum so chloremphenical was started which decreased the pus discharge but could not stop it. Based on the sensitivity tests, meropenem was started which stopped the discharge for 5 days then again the discharge started. At this time about 2 weeks after the first surgery, it was decided to start irrigation with Qurion solution for an hour and then continue Vacumn assisted suction (VAS). At both ends of the suture line single stitches were removed, at one end infant feeding tube was put for irrigation with qurion solution and at the other end infant feeding tube inserted for vacuum assisted suction . Daily Qurion irrigation was done in morning and evening for one hour during which vacuum assisted suction was stopped. After one hour again vacuum assisted suction was started. After 2 days of starting Qurion irrigation & vacuum assisted suction therpy (QiVAS), the suture site became dry. We continued QiVAS therapy for 2 weeks with antibiotic meropenem. Blood counts and CRP were within normal range after 2 weeks of QiVAS therapy and patient was discharged. Patient was followed up at 3 months and 6 months with no evidence ofinfection .

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+A 61-year-old female, known to suffer from chronic hepatitis C (Child Pugh A), presented in Jan 2001 to another hospital complaining of abdominal pain. CT-Scan of the abdomen showed a solitary 5 × 5 cm mass in segment VII of the liver. Fine needle aspiration cytology (FNAC) showed features consistent with HCC. AFP level at the time was normal 2.23 ng/ml (normal < 5.6 ng/ml). She traveled abroad (outside Kuwait), underwent resection of the tumor and returned back to Kuwait. A brief report stated that the tumor was resected from segment VII with about 1.5 cm safety margin with an uneventful postoperative course. Histopathology of the original tumor proved to be a well differentiated HCC with clear margins and no vascular invasion.
+Upon return to Kuwait, she was under the care of the hepatologist who treating her chronic hepatitis with Pegelated Interferon and Ribaverin for 6 months. Unfortunately she remained HCV positive.
+In Oct. 2004, three years following her original surgery, she was referred to the Liver Unit, Mubarak Al-Kabeer Hospital with an abdominal wall mass of one-year duration. On physical examination an obvious 7 × 5 cm smooth oval mass was seen in the right upper quadrant at the lateral border of her previous right subcostal scar. Clinically the mass seemed to be within the abdominal wall and the skin over it was free. CT scan of the abdomen showed a round well defined enhancing soft tissue density mass measuring 11 × 5 × 5 cm within the anterior abdominal wall with no intra-abdominal extension or skin infiltration . The liver was free except from signs of previous surgery in segment VII. Tumor markers were: AFP 6.23 ng/ml (normal < 5.6 ng/ml), CEA 1.5 ng/ml (normal < 6.9 ng/ml) and CA19-9 15.9 (normal < 43 ng/dl). FNAC from this mass, was consistent with metastatic HCC . En-bloc resection of the mass (including the mass, overlying skin, abdominal wall muscles and peritoneum) was performed under general anesthesia with primary closure. Histopathology of the removed specimen confirmed implantation of HCC in the abdominal muscles with free surgical margin and no peritoneal penetration . The patient had an uneventful recovery and was discharged home on the 7th postoperative day.
+To date, 20 months since resection of the metastatic mass, she remains well with normal AFP and liver functions and no evidence of recurrence in the liver or abdominal wall.

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+A 35-year-old woman from Haryana presented with generalized tonic-clonic seizures. She was treated with antiepileptics and became seizure-free. She had also noticed swellings all over her body which had gradually increased in number and size over the previous year, and there was proptosis of her right eyeball. She also had fever and arthralgia. On examination there was symmetrical generalized hypertrophy of the limbs, most prominent in the calf muscles, and also affecting trunk, neck and facial muscles. There was muscle tenderness with increased pain on movement of the joints.
+Investigations revealed hemoglobin of 12.5 gm%, total lymphocyte count (TLC) of 12,800 and differential leucocyte count (DLC) of P80%:L20%. The erythrocyte sedimentation rate (ESR) was 40 mm/hour. The level of serum creatinine phosphokinase was 150 (normal value 200). In addition, urine tests showed the presence of proteinuria without any active sediment on microscopy. Routine biochemical investigations revealed normal glucose, renal and liver function tests. The tests for rheumatoid arthritis (RA) factor and antinuclear antibodies were positive but the patient did not have any other symptoms to suggest a diagnosis of rheumatoid arthritis or lupus. Tests for HIV using enzyme-linked immunosorbent assay (ELISA) were negative for both HIV 1 and 2. Electrocardiogram (ECG) examination revealed a right bundle branch block and a right axis deviation. An echocardiogram failed to show cysticerci in the heart. X-rays of the skull and extremities were normal. There was no radiographic evidence of calcification in the muscles. Ultrasound examination of the orbit and neck was performed, revealing multiple swellings in the orbit, thyroid gland and strap muscles of the neck. Fundus examination was normal. Perimetry was also within normal limits. Magnetic resonance imaging (MRI) scan showed multiple cysts in the brain, scalp tissue, orbit and neck muscles. There was no evidence of hydrocephalus. Biopsy of a subcutaneous swelling was taken from the right forearm. Cysts poured out as soon as the skin was incised. Histopathological examination confirmed that the cysts were of C. cellulosae.
+The patient was treated with prednisolone 1 mg/kg of body weight 1 week prior to the initiation of albendazole therapy instituted at a dose of 15 mg/kg. The patient was observed for 5 days prior to discharge. The symptoms improved and albendazole was continued for a total duration of 30 days. There was objective evidence of improvement with reduction in the size of the swellings. There was no deterioration in neurological or intellectual status and no appearance of new crops of cysticerci. To our surprise her fever and arthralgia disappeared without the use of anti-inflammatory agents. This improvement lasted for 6 months, at which time there was an increase in the size of existing swellings plus development of new crops of swelling. The fever and arthralgia reappeared. The patient was again primed with steroids and given praziquantel therapy. The patient responded and was discharged after 10 days of observation in hospital. Antiepileptic treatment was continued.
+On followup after 1 year, no new swellings or any apparent increase in the size of the residual swellings were reported, there was no further fever or arthralgia and the patient remained seizure-free.

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+A 27-year-old male, victim of aggressive, blunt trauma with a 4-day history of symptoms was admitted to our surgery unit. The patient presented abdominal pain, was hypotensive (100/50 mmHg), perspiring, and drowsy. The abdominal examination revealed diffuse tenderness and rebound tenderness to palpation, 2 periumbilical ecchymoses of 2/2 cm, many others within the left deltoid area and on the lower limbs. Abdominal sonography revealed peritoneal fluid in all spaces with fibrin, chest X-rays unremarkable. Laboratory investigation showed hemoglobin and white blood cell count with normal values, creatinine 4.04 mg/dL, urea 209 mg/dL, mild acidosis, lactate 21 mmol/L, creatinine-kinase 1910 U/L, lactate-dehydrogenase 451 U/L, and ethanol 34 mg/dL. During laparotomy, we discovered 2 perforations on the ileum and general peritonitis with pus. We performed an enterectomy, about 20 cm of ileum, and an end-ileostomy with a mucous fistula on the distal ileum, saline lavage, four drainages, and a laparostomy. Following surgery, the patient was admitted to the intensive care unit (ICU) with septic shock and multiple organ dysfunction syndrome (MODS). We initiated empirical therapy with broad-spectrum antibiotics with ertapenem and vancomycin. The antibiogram from the peritoneal liquid revealed S. putrefaciens, S. cerevisiae, and Candida species susceptible to amikacin, gentamicin, ciprofloxacin, third-generation cephalosporins, and fluconazole. On the second day following surgery, we intervened again, and we discovered multiple intraperitoneal abscesses. We washed the patient once more, drained, and treated him surgically with a laparostomy. From the peritoneal liquid, Acinetobacter baumannii developed that were susceptible to colistin, and the same bacteria was discovered within the tracheal secretion. The patient remained on mechanical ventilation, inotropic support, and sedated. Fever (38.5 ºC), leukocytosis (22850/μL), high lactate (31.5), very high inflammatory markers (presepsin, procalcitonin, C-reactive protein), and higher inotropic support (from 10 to 25 μg/hour of norepinephrine) convinced us to repeat the intervention including both washing and laparostomy with negative pressure. Until the 11th day following surgery, the patient remained intubated, with inotropic support, had high fever (38 ºC), and very grave general status-MODS. He also had septic shock, with a positive antibiogram from the venous catheter for Klebsiella pneumoniae susceptible to sulfamethoxazole with trimethoprim, and for Staphylococcus hominis susceptible to vancomycin and levofloxacin. From the tracheal secretion, the bacteria found in the peritoneal liquid (A. baumannii) was sampled analogously. Every other day, we repeated the intervention to change the kit for intra-abdominal negative pressure. On the 12th day following surgery, the general status of the patient had improved. Thus, he no longer remained intubated, was hemodynamically stable, without inotropic support, with spontaneous respirations, and had a functional ileostomy. We changed 6 kits of negative abdominal pressure, the antibiogram from the peritoneal cavity was positive once again for Klebsiella and Acinetobacter with antibiotic therapy . During the last 3 interventions, we progressively closed the abdomen, and upon the 10th repeated intervention, we closed the entire abdomen, after which the patient was discharged from the ICU after 20 days where he had been administered many doses of antibiotherapy. The patient was discharged from the surgery unit on the 30th day after admission and had completely recovered.
+After 6 months, the patient returned to close the ileostomy, and after another 8 months, he returned with a median postoperative hernia . Given both the large defect and due to the weight gained, we chose to resolve the hernia with an intraperitoneal mesh. This method was unsuccessful, and even the antibiogram was negative; the patient developed ulceration of the skin which was resolved surgically. We removed the mesh and performed a muscular-cutaneous flap . Written informed consent was obtained from the patient who participated in this case.

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+A 40-year old woman was referred to our clinic in 2003 after detection of multiple lesions in both hepatic lobes during routine ultrasound examination. The patient did not report weight loss, night sweats or fever. She had no flush symptoms or diarrhea, only a slight postprandial discomfort in the right upper quadrant. Apart from a moderate hepatomegaly, physical examination was unremarkable. Routine laboratory findings were within normal limits without indication of liver disease or advanced malignancy. Likewise, chromogranin A, serotonin and 5-HIAA were within normal range. Sonographically the lesions were of high echogenicity with a hypoechoic halo. The largest lesion found in segment VI had a diameter of 6.8 cm. Multiple additional hepatic lesions were spread throughout both lobes with a size of approximately 1 cm. A CT-guided core biopsy was performed to establish histopathological diagnosis. Histological analysis of the biopsy material showed a G1 neuroendocrine neoplasm (NEN) with a low proliferation rate (Ki-67 < 1%) .
+For tumor staging, abdominal imaging by MRI and a chest CT scan were performed which confirmed multiple bilobular hepatic lesions with no option for complete surgical removal. Somatostatin receptor scintigraphy (SRS) showed a positive receptor status of the hepatic lesions. Colonoscopy identified the primary tumor in the rectum: 5 cm from the anus a polyp with 1 cm diameter was found and endoscopically removed by snare biopsy. Microscopical analysis confirmed a G1 NEN with similar histological appearance as seen in the hepatic metastases . Due to the positive somatostatin (SMS) receptor status treatment with octreotide was started. 6 months later, however, a restaging revealed progression of the liver metastases. As there was no evidence of extrahepatic manifestation we decided to perform a transarterial chemoembolization (TACE) of the hepatic lesions. The patient received in total 7 TACE interventions without complications over a period of 2 years. Over a follow-up period of 7 years without further anti-cancer therapy up to the present, MRI revealed stable disease according to RECIST criteria.
+In 2013, however, the patient presented to the general practitioner with hoarseness as well as tenderness on palpation and stabbing pain in the right lower jaw, the mandibular joint and the right part of the tounge. During the course of several weeks, additional symptoms like palsy of the tongue and dysarthria emerged and the patient was put on an empiric antibiotic treatment with a cephalosporine. With increasing numbness of the tongue and on the inner surface of the cheek, pain of the tongue, worsening dysarthria and dysphagia the patient presented to the emergency department of our hospital. A thorough neurological examination including cranial computed tomography, MRI with MR-angiography and a time of flight (TOF)-imaging as well as ENT examination was not instrumental to establish a diagnosis. However, a lumbar cerebrospinal fluid (CSF) puncture revealed a pleocytosis (19 cells/μl) as well as an intrathecal protein synthesis (IgG), both in accordance with an inflammatory process in the brain. Unremarkable CSF parameters included negative PCR’s for herpes simplex I and II virus, Epstein Barr virus, cytomegalovirus, varicella zoster and toxoplasma as well as negative bacterial cultures, cryptococcus antigen, and cytology examination for malignant cells. Transcranial magnetic stimulation showed an increased latency between the primary motor cortex and the left arm, whereas the right arm and both legs showed normal conduction. Serologic investigation of onconeural antibodies showed a highly positive titer for anti-Ri (1:2560, normal <80). The positive indirect immunofluorescence technique (IIFT) was validated with immunoblotting, which substantiated the isolated presence of the Ri-antibodies . As a result of this the diagnosis paraneoplastic brainstem encephalitis was established. An intravenous methylprednisolone therapy with 500 mg for 5 days led to rapid improvement of the patients neurological symptoms with concomitant decline of the anti-Ri titer from 1:2560 to 1:320. On follow-up 3 months after steroid therapy, the patient is currently completely asymptomatic. A regular methylprednisolone therapy for 5 days intravenously every 8 weeks is planned over a treatment period of at least 2 years. Since brainsteam encephalitis as paraneoplastic neurological syndrom have not been described in patients with metastatic rectum NEN before, other tumors were ruled out including a normal gynecological examination and a FDG-PET-CT without evidence for a lung tumor.

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+A 38-year-old illiterate housewife from rural southeast Mexico, with bilateral urolithiasis attended a urology consultation at a highly specialized public hospital in Yucatan Mexico, as she had had a fever between 38 ℃ and 40 ℃ for the previous 2 d, accompanied by severe pain in the right flank irradiating to the ipsilateral suprapubic region and reported changes in frequency and quality of urination.
+She was admitted for in-hospital care, and abdominal computerized axial tomography was performed, along with blood and urine tests, including cultures. Tomography indicated the presence of gas in the right kidney indicating EPN Huang IV and confirmed the presence of a nonfunctional left kidney . Blood culture was unremarkable, while urine culture reported S. fonticola as a single pathogen, sensitive to most antibiotics but resistant to trimethoprim and nitrofurantoin.
+Antecedents included that she debuted with symptomatic bilateral urinary lithiasis in 2015, and she was diagnosed with chronic kidney disease Class Kidney Diseases Global Outcomes 3A that same year. Left renal exclusion was confirmed using radiotracer mercaptoacetyltriglycine gammagraphy.
+In 2016 and 2017 second look percutaneous nephrolithotomy was performed, finding right ureteral stenosis due to lithiasis; JJ catheters were temporarily placed in the right kidney and removed after treatment.
+Fever and right flank pain irradiating to the ipsilateral suprapubic region persisted.
+Diabetes and hypertension had been ruled out at every hospitalization, as the patient only registered normal values of fasting glucose and blood pressure. The patient was treated with piperacillin/ tazobactam; a combined endoscopic intrarenal surgery was performed to place a metallic catheter and to treat with percutaneous drainage. After 3 d of antibiotic, she became afebrile. The gas presence due to anaerobic bacteria reduced according to imaging, and a new culture was performed on day 4, which was reported negative. Her white blood cell count improved markedly. However, after 8 d her fever relapsed, and new studies were performed, finding Pseudomonas aeruginosa as a single pathogen in her urine culture along with an increase in neutrophils and white blood cell count in general. She was therefore treated with meropenem .
+After 10 d of treatment, with tomographic and laboratory evidence for the resolution of the acute signs and symptoms, she was discharged.

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+A 40-year-old white American woman presented to primary care with a chief concern of nontraumatic umbilical bleeding that began 2 days prior; she woke up and noticed her shirt soaked in blood from her umbilicus. Upon applying pressure with a rag, she was able to stop the bleeding. The patient continued to experience intermittent umbilical bleeding associated with nonradiating periumbilical pain that was exacerbated by movement and associated with nausea and emesis. She had been seen for non-painful umbilical bleeding 5 years prior when she had been occasionally cleaning her umbilicus in the shower with a cotton swab and peroxide; this would sometimes leave small spots of blood on the cotton swab. At that time, no imaging was performed; she was prescribed bacitracin and told to apply Vaseline for what was presumed to be superficial irritation. She had no interim symptoms and discontinued cleaning her umbilicus with a cotton swab.
+Past medical history included hypertension, gastroesophageal reflux disease, class III obesity with BMI 45, major depression, and generalized anxiety. Patient is a G1P1001. Surgical history was notable only for elective caesarean section 12 years prior without complications. The patient was divorced and worked in retail. She did not smoke, use illicit drugs, or drink alcohol. Family history included diabetes, Crohn’s disease, diverticulitis, and breast, lung, and prostate cancer. The patient was taking multiple long-term prescription medications, including losartan 50 mg tablet by mouth daily, propranolol 60 mg tablet by mouth twice daily, escitalopram 20 mg tablet by mouth daily, bupropion 450 mg tablet by mouth daily, gabapentin 300 mg capsule by mouth three times daily, norethindrone-ethinyl estradiol 1 mg–35 µg tablet by mouth daily, trazodone 100 mg tablet by mouth daily, and diclofenac 1% gel topically four times daily as needed.
+On the day of presentation, the patient’s blood pressure was 125/81 mmHg with a pulse of 65 beats per minute. She was afebrile. Inspection revealed a non-distended abdomen and completely normal skin without erythema, fissuring, or visible discharge, though there was some dried blood. There was mild periumbilical tenderness with deep palpation. Deep palpation around the umbilicus produced a thin, watery, serosanguinous fluid directly from the umbilicus. The remainder of the physical examination including cardiac, pulmonary, and neurologic examinations, which were normal.
+The patient was referred for CT of the abdomen/pelvis the same day, which revealed a small fat-containing umbilical hernia with a likely small area of fat necrosis just superior to the umbilical hernia . Laboratory workup was notable for a mildly elevated high-sensitivity CRP at 13.8. The remainder of labs, including complete blood count (CBC) with differential, electrolytes, renal function, and liver function were within normal limits. No coagulation parameters were checked. Four weeks later, the patient underwent outpatient open umbilical hernia repair without mesh and umbilectomy with open wound packing. Dissection was performed down to the level of the fascia, and a 4.2-by-3.5-by-2.6 cm specimen consisting of the hernia sac and urachal remnants was excised and sent for pathologic interpretation. No cultures were sent since there was low suspicion for infection. She had complete resolution of symptoms and bleeding on follow-up 30 days postoperation. She did not receive any antibiotics or other prescription medications for this condition. Surgical pathology interpretation revealed ulcerated skin with abscess, umbilical remnant, granulation tissue, and foreign body suture material. At 1-month and 2-month wound check visits, the patient denied any pain, nausea, or vomiting. At next follow-up 6 months postoperation, the patient continued to do well without recurrence of her symptoms. A timeline of the patient’s history and care is presented in Fig. .

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+A 66 year old woman with floor of mouth squamous cell carcinoma (SCC) presented to our institution after her second relapse. Originally diagnosed in 2006, she had undergone a composite resection with a flap reconstruction and bilateral neck dissections followed by post-surgical adjuvant radiotherapy for stage IVa (T4aN0M0) disease. Immunohistochemistry (IHC) staining for p16 was negative. In May of 2009, a resectable locoregional recurrence was detected and consequently treated with a composite resection utilizing a pectoralis flap reconstruction. In November of 2013, she presented with a second non-resectable locoregional relapse. She received carboplatin and paclitaxel for 4 cycles with a partial response (PR) after 2 cycles. The patient subsequently developed regional progression and was treated with weekly methotrexate and cetuximab and she achieved stable disease (SD) for 6 months. Later, she progressed locally and was enrolled into a trial utilizing single agent pembrolizumab. She had SD for 6 cycles , and then suffered from local progression with a significant increase in the size of her neck mass, with painful ulceration and bleeding. Pembrolizumab was therefore discontinued. At this time restaging studies revealed no evidence of distant metastasis. She required multiple transfusions secondary to tumor hemorrhage and as a result was treated palliatively with radiation therapy to a total dose of 30 Gy directed at the mass. The patient experienced an excellent clinical response. Bleeding had resolved and her pain had greatly improved. A significant radiographic response was also noted on computed tomography (CT) scan, with tumor dimensions decreasing by 60 %, from 7.1 × 7.2 cm pre-radiation, to 5.9 × 3.4 cm, 6 weeks post-radiation.

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+A 37-year-old woman was admitted to our hospital on September 15, 2020 due to recurrent cough for more than 10 mo.
+The patient developed a paroxysmal cough accompanied by a small amount of white sputum 10 mo ago. She had no chills, fever, chest pain, hemoptysis, or shortness of breath. She received symptomatic treatment such as anti-infection at a local hospital but her symptoms persisted during this period. The above symptoms recurred 1 mo ago with a little yellow sputum. Fever and hemoptysis were absent. The patient was admitted to our hospital for further treatment.
+The patient was thin and weighed only 40 kg (Body mass index: 15.6). Her temperature was 37.4 °C, pulse rate was 99 bpm, respiratory rate was 19 breaths/min, and blood pressure was 100/63 mmHg. No clubbing of fingers, icterus, or generalized lymphadenopathy were observed. Clinical examinations of the cardiovascular, gastrointestinal, and nervous systems were normal, but crackles were found in the lower lobe of the left lung during lung auscultation.
+Laboratory studies showed normal white blood cells (8.6 × 109/L), and the neutrophil ratio was 83.0%. Erythrocyte sedimentation rate was 26 mm/h (normal value < 15 mm/h), and high-sensitivity C-reactive protein was 8.2 mg/L (normal value < 8.0 mg/L). Arterial partial pressure of oxygen was 91 mmHg (partial pressure of oxygen/fraction of inspiration O2 433.3 mmHg), and arterial partial pressure of carbon dioxide was 41 mmHg. The 1,3-β-D-glucan test and galactomannan test were both negative.
+Enhanced computed tomography images revealed a honeycomb lesion in the lower lobe of the left lung, and an enhanced vascular shadow was seen in the descending aorta, which was consistent with pulmonary sequestration .
+We also performed bronchoscopic alveolar lavage in the posterior basal segment of the left lower lobe. Gram-positive bacilli were detected in the bronchoalveolar lavage fluid (BALF) . The modified acid-fast staining of BALF was weakly positive, and the possible presence of Nocardia species was considered. Following culture of BALF, N. cyriacigeorgica was identified , which was confirmed by matrix-assisted laser desorption ionization-time of flight mass spectrometry (matrix-assisted laser desorption/ ionization-time of flight; VITEK MS, bioMérieux, Craponne, France) .

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+A 62-year-old male patient, known to have primary hypertension and type 2 diabetes mellitus, presented with a brutal onset of loss of consciousness, muscle pain in the upper limbs accompanied by increased movement impairment. In the emergency department a rapid antigen test for SARS-CoV-2 was performed which was found to be positive. The patient had not been vaccinated against SARS-CoV-2. Clinical assessment showed no significant changes: BMI = 32.41 kg/m2; BP = 140/85 mmHg; HR = 95 bpm with normal rhythmic heart beats; SpO2 = 97% (room air); no fever; no pulmonary rales. Initial lab values showed increased inflammation (CRP = 59.5 mg/L), increased values of cardiac enzymes (hsTnI = 8248 ng/L) and possible sepsis (procalcitonin = 68.03 ng/L). The ECG showed no acute ischemic changes. A CT angiography of the pulmonary arteries was performed with the following result: cardiomegaly with contrast refluxed into the hepatic veins, pulmonary arteries with dimensions at the upper limits for normal values, homogeneously opacified, without acute pulmonary lesions. Considering these data, the patient underwent a standard cardiac ultrasound examination revealing concentric hypertrophy of the left ventricle, severe hypokinesia of the interventricular septum, of the anterior and antero-lateral wall, and hypokinesia of the inferior and posterior wall with an estimated ejection fraction of the left ventricle to be approximately 34% ; global strain was −7.7% ; systolic pressure in the pulmonary artery was 50 mmHg. Approximately 2 h after admission, the dynamics of myocardial necrosis was entertained, enzymes registered an increasing trend (hsTnI = 9755 ng/mL; CK = 51432 U/L; CK-MB = 189 U/L). As a result of the accumulated data, an acute coronary syndrome without ST segment elevation was suspected. The patient underwent coronary angiography using the right radial artery approach, in which the coronary arteries revealed no significant angiographic lesions. and show the dynamics of hsTnI, CK and CK-MB.
+Considering possible sepsis of unknown origin, antibiotics were initiated with ceftriaxone. A sputum culture was positive for Klebsiella pneumoniae spp pneumoniae, and ceftriaxone was continued according to the antibiogram. Blood cultures taken consecutively were negative. During day 3, a thorax CT scan was performed, which showed fine areas of ground glass arranged peripherally and classified as minimal lung damage and small bilateral areas of pleurisy with a maximum thickness of 10 mm in the right costo-phrenic recess. Methylprednisolone was given, with progressive decreasing of the dose over time. Standard medication for heart failure with a reduced ejection fraction was given . The serum level of interleukin-6 was 2.32 pg/mL, which was considered to be normal . The evolution was favorable: cardiac enzymes, inflammatory markers and procalcitonin continued to decrease and eventually were normalized. Kidney function was preserved. The muscle pain in the upper limbs subsided, with full recovery of functionality. Patient tested negative for SARS-CoV-2 infection on day 14 (RT-PCR).
+Corroborating the clinical, paraclinical and biological context, the panel of IgG antibodies specific for myositis was observed, with a positive result for anti-PL-7 antibodies. We consider that the episode of myocarditis and extensive myositis was clinically triggered by the SARS-CoV-2 infection, possibly linked to his autoimmune status, which was unknown to the patient.

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+An 8-year-old girl fell from a height of around 1.5 m and injured her left elbow. She was examined by a physician in her village and diagnosed as having an elbow sprain for which limb was immobilized in a plaster cast for 3 weeks. The child sustained another injury to the same elbow following fall on her outstretched hand 4 weeks after removal of the cast. Again the elbow was immobilized in a long arm cast for 3 weeks. After removal of the cast, the child complained of persistent pain and discomfort in the elbow. She was then referred to our hospital 3 months after the initial injury.
+Examination revealed a stiff elbow with a painless range of motion from 45° to 90°, with only terminal limitation of pronation and supination. The ununited fragment was palpable separately from the rest of the distal humerus and freely mobile. Valgus instability was also noted. There were no signs of ulnar nerve irritability or deficit. An anteroposterior and lateral radiographs revealed a displaced fragment of the medial condyle involving the trochlea .
+To address the limitation of movement, articular incongruity and elbow instability, open reduction, and fixation of the fracture was planned. After obtaining consent from the parents, the patient was administered general anesthesia and positioned supine on the operating table with arm abducted on arm board. Limb was exsanguinated and surgery was commenced under tourniquet. Incision was made directly over the medial condyle fragment. The ulnar nerve was identified and protected with plastic tube. The medial condyle fragment was found displaced proximally and anteriorly. The fragment was rotated with its cancellous surface lying anteriorly. This surface was freshened with a curette. Fracture surface on the humeral side was identified and freshened. Medial articular edge of distal humerus was identified for accurate reduction. Without any undue soft tissue stripping, the fractured fragment was reduced to the best possible position with approximation of articular surfaces. Fixation with three smooth Kirschner (K) wires was done followed by suturing of surgical wound. Long arm cast was applied with elbow at 90° and forearm in mid-prone position. There were no post-operative complications.
+Considering that the fracture was already 3 months old at the time of surgery, we anticipated that a longer duration of immobilization would be required; hence, the cast and K-wires were removed at 6 weeks under local anesthesia. Active and active-assisted elbow range of motion exercises were started after K-wire removal. Radiographs taken at 3-month follow-up show union of the fracture, with an irregular medial condyle. The patient regained an active flexion arc of 25° to 95°, with complete pronation and supination . Passively 20° to 100° arc of motion had been restored. At 6-month follow-up range from 10° to 120° had been restored and there was no coronal plane deformity.

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+A 53-year-old man (85 kg and 170 cm) was admitted for rupture of spleen caused by an accidental fall.
+Emergency splenectomy was planned under general anesthesia. Preoperative emergency ultrasound examination including the heart, chest, and abdomen were performed, and it was found that spleen had been ruptured and was accompanied by active bleeding, complicated with progressive hemochrome reduction, which was the main reason for the patient to undergo emergency surgery. Preoperative ultrasound showed no heart or chest abnormalities. The patient did not complain of dyspnea preoperatively, and preoperative CT showed no hemothorax or pneumothorax . Initial vital signs before anesthesia were a blood pressure of 126/82 mm Hg, heart rate of 75 bpm, and an oxygen partial pressure (SpO2) of 95% while inhaling air. Anesthesia was induced with sufentanil 0.3 µg/kg, rocuronium 0.1 mg/kg, and propofol 3 mg/kg. Tracheal intubation was successfully performed with video laryngoscopy, and positive pressure ventilation was performed with an airway peak pressure of 14 cm H2O. Because the patient's thick chest wall, breath sounds were difficult to auscultate. About 2 min after tracheal intubation, it was difficult to ventilate. The airway peak pressure increased progressively, reaching a maximum of 50 cm H2O and SpO2 dropped, reaching a minimum of 70%. Because of obesity and the thick chest wall, the cause of respiratory failure could not be determined by traditional auscultation. Following the BLUE protocol, a recommended area of the chest was scanned by bedside ultrasound. The pleural slide sign disappeared in the upper and lower blue points of the left lung, and in M-mode, an obvious parallel line sign could be seen below the pleura. The boundary of pneumothorax (lung points) was rapidly confirmed by ultrasound. To avoid lung injury and secondary pneumothorax, a closed thoracic drainage tube was placed in the area guided by ultrasound. The interval from suspicion of pneumothorax to placement of the drainage tube was less than 3 min. After many bubbles had emerged from the water seal bottle, the airway pressure dropped to 20 cm H2O and the SpO2 returned to 96%-100%. After the patient's vital signs stabilized, the splenectomy continued and was successfully completed. The patient was sent to the intensive care unit (ICU) with a endotracheal tube for further treatment after surgery. On day 1 after surgery, the endotracheal tube was removed. On day 6, the closed thoracic drainage tube was removed. On day 9, the patient was discharged from the hospital without any complications.
+Anemia (hemoglobin 85 g/L).
+Focused assessment with sonography in trauma (FAST) has been extensively utilized and studied in blunt and penetrating trauma. Following the FAST protocol, organ damage can be rapidly evaluated by the amount of free fluid in the chest, abdominal, and pelvic cavities. In this case, preoperative emergency ultrasound examination of the heart, chest and abdomen found that spleen had been ruptured and active bleeding was complicated by progressive hemochrome reduction, which was also the main reason for the patient to undergo emergency surgery. Preoperative ultrasound showed no abnormalities in the heart or chest. Following the BLUE protocol, LUS confirmed that the pleural slide sign had disappeared in the recommended area of the left lung, and in M-mode, an obvious parallel line sign was seen below the pleura . The boundary of the pneumothorax (lung points) was rapidly confirmed by ultrasound .

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+A 53 year old Pakistani lady presented to the Medicine clinic of a local hospital in 2004 with a history of heel pain and lower back pain for 5 months. In this period, the patient had sustained a rib fracture and left humeral fracture. There was no history of diabetes, hypertension or any other chronic disease. She had not been on any form of medication, including steroids and traditional drugs widely available and prescribed in the region, prior to the onset of pain. At the time of the fractures, she had been placed on non steroidal anti inflammatory agents, acetaminophen and tramadol. There was no history of illicit drug use and she was a non smoker. Family history was unremarkable, particularly in the context of bone disease, and malignancy.
+Initial laboratory investigations had shown a mildly elevated total calcium level of 10.8 mg/dL {2.7 mmol/L}-(no albumin level result available from that time for correction). Parathormone levels (PTH) had not been determined. There was no vitamin d or renal function report available from that time. X-Ray pelvis revealed lytic lesions in the right iliac bone . A magnetic resonance imaging (MRI) of the lumbosacral spine showed some signal changes. The differentials based on the MRI were metastatic bone disease or multiple myeloma.
+Serum protein electrophoresis was normal. The patient then got lost to follow-up. Her work up was resumed 4 years later when her bone pains had started flaring up. Bone marrow examinations done back in 2007, and later in 2009, were negative for multiple myeloma. A bone scan in November 2009 showed generalized increased tracer uptake over the skull and both the axial and appendicular skeletons- findings in favor of metabolic bone disease . An initial planar parathyroid sestamibi scan requested by a general practitioner in November 2009 was negative for any functioning parathyroid adenoma in the neck or superior mediastinum. No serum PTH report was available from this time either. Following this workup, the patient was treated empirically for bone pains with calcium supplements, an empiric vitamin d injection, and intravenous zoledronic acid 5 mg (without prior bone mineral density assessment via DXA scan). This empiric treatment was instituted by an orthopedic surgeon whom she had been referred to. The patient experienced only a slight improvement in bone pains with this treatment and also developed nausea, vomiting and anorexia. Subsequently, she sought care at the National Institute of Diabetes and Endocrinology, Dow University Health Sciences, Karachi, Pakistan.
+At presentation, the patient was well oriented and of functional class 3 (wheel chair bound, able to walk only with support). Her blood pressure was 110/70 mmHg. Neck examination revealed no mass or lymphadenopathy. She had a significant proximal myopathy as well as curved thighs. She had shortened fingers, and spinal scoliosis was evident. Severe generalized bone tenderness was elicited. There was no focal deficit. Laboratory investigations at this time showed a calcium level of 15.1 mg/dL{3.775 mmol/L}, (corrected for albumin of 3.6 mg/dL{36 g/L}); Vitamin D3 level of 33.92 ng/mL{84.664 nmol/L}; phosphorus 2.3 mg/dL {0.743 mmol/L}and alkaline phosphatase of 1298 IU/L {21.633 µkat/L}. Her 24 h urine calcium was 155 mg/day {3.875 mmol/day}, with urine calcium to creatinine ratio of 0.02. Her creatinine level was 1.3 mg/dL {114.92 µmol/L}. The estimated glomerular filtration rate (calculated through Cockcroft-Gault equation) was 50 mL/min {0.835 mL/second).
+Following these tests, the patient’s PTH level was ordered and determined to be 2105 pg/mL {2105 ng/L} [Table ]. Ultrasonography of the neck showed a solid hypo echoic, well-circumscribed mass lesion, measuring 1.8 × 1.2 cm at the lower pole of the right lobe of thyroid. There were no calcifications or lymphadenopathy. Appearances were suggestive of parathyroid adenoma. Both lobes of the thyroid appeared normal. A repeat planar sestamibi scan, (requested from a different institute in the city), revealed areas of tracer retention over upper and lower poles of the right lobe of thyroid. The intensity of retained tracer was more over the right inferior parathyroid gland. The findings were highly suggestive of hyperparathyroidism .
+A bone mineral density scan showed a T score of − 2.9 in the spine, − 3.8 in the hip and − 4.5 in the distal forearm, consistent with severe osteoporosis. The Z scores at the spine, hip and distal forearm were − 2.0, − 3.1 and − 3.6, respectively .
+Ultrasonography of the kidneys revealed a single renal stone (0.6 cm) and no neprocalcinosis.
+Based on the biochemistry results of hypercalcemia, associated with elevated PTH levels, a diagnosis of primary hyperparathyroidism was made. Subsequent sestamibi scan and neck imaging facilitated us to localize the abnormal parathyroid gland. The DXA scan was useful for evaluation of the bone mineral density. In view of the phenomenally high levels of parathyroid hormone, (more than 10 times upper limit of normal), the pre-operative suspicion of parathyroid cancer was high [, ]. The patient was rehydrated with intravenous fluids. Subcutaneous calcitonin injections at a dose of 4 units/kg every 12 h were administered to tide her over until the surgery. Once her calcium levels had come down to 10.5 mg/dL {2.625 nmol/L}L, she was operated upon. At surgery, right hemithyroidectomy and inferior parathyroidectomy with level six lymph node resection was done. The lymphadenectomy was performed as there was evidence of enlarged lymph nodes at neck exploration. The size of the lesion was measured as 2.5 × 1.5 × 1 cm. Histopathology showed features consistent with parathyroid cancer . Capsular invasion and focal vascular invasion were noted. However, margins of excision were tumor free. The excised lymph nodes did not show evidence of tumour infiltration. The patient was not given external radiation therapy postoperatively. Literature review revealed that post operative adjuvant radiation therapy may only have a role in the management of patients with a histologically positive margin following en bloc resection, or in those with lymph node metastases [, , ].
+Postoperative PTH level, performed on the second day of surgery, was 59 pg/mL {59 ng/L} (16–87). On the third postoperative day, the patient’s serum corrected calcium declined to 6 mg/dL {1.5 mmol/L}. This was associated with paresthesias around her mouth and carpo-pedal spasm. There were no seizures, although there was some confusion in terms of time and place. Intravenous calcium (2 g calcium gluconate, equivalent to 180 mg elemental calcium, in 50 mL 5% dextrose water) was infused over 20 min. Re-monitoring of calcium levels revealed persistent hypocalcemia. A slow infusion of calcium was initiated at an initial rate of 50 mL/h. This was prepared by adding 100 mL of 10% calcium gluconate (equivalent to 900 mg elemental calcium) to 1000 mL 5% dextrose water. The infusion rate was adjusted, with a goal to maintain calcium levels at lower end of normal range. On the fifth post-operative day, the calcium level had risen to 9.0 mg/dL {2.25 nmol/L}. Neurologic examination was normal and she was tolerating oral diet. Oral calcium supplementation was initiated (Qalsan D four times daily-equivalent to 2 g elemental calcium per day). She was discharged on oral calcium and vitamin D supplementation with active vitamin D, (calcitriol) 0.25 µg twice daily, in a stable condition.
+At follow-up, her appetite and mobility had improved significantly, although she continued to experience bone pains. Corrected calcium was 9.5 mg/dL {2.375 nmol/L}. A repeat skeletal scintigraphy done 3 months after parathyroidectomy did not demonstrate a significant change in the lytic lesions . A repeat DXA scan 2 years down the line revealed a significant improvement in bone mineral density at all sites, though more so at the spine and hip, than at the forearm . Thereafter, we followed her clinically, as she was not keen to have further radiologic testing done. We have been monitoring her calcium and PTH levels on an annual basis. They have remained within their normal range till date (2018). She is now functional class 2, (no longer wheel chair bound), and on regular calcium and vitamin D supplements (patient perspective, attached as Additional file ).

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+A 39-year-old male patient with MEN-1 who had an anterior mediastinal mass was referred to our hospital. The patient had undergone total parathyroidectomy and auto-transplantation of a partial parathyroid for hyperparathyroidism 6 years ago. His vital signs showed no abnormalities. He had a temperature of 37.2 °C, blood pressure of 117/72 mmHg, heart rate of 100 bpm, respiratory rate of 16 breaths per minute, and oxygen saturation of 98% in room air. Laboratory data revealed a serum antiacetylcholine receptor binding antibody level below 0.2 nmol/L (normal, below 0.2 nmol/L), serum cancer antigen level 5 U/mL (normal, below 35 U/mL), serum α-fetoprotein level 3 ng/mL (normal, below 10 ng/mL), serum human chorionic gonadotropin β subunit level below 0.5 mIU/mL (normal, below 0.5 mIU/mL), and serum soluble interleukin-2 receptor level 292 U/mL (normal, below 475 U/mL).
+Chest computed tomography revealed an isolated anterior mediastinal mass on the thymic gland with a maximum diameter measuring 22 mm and without invasion into the surrounding tissues . Thymic carcinoid is classified as MEN-1 and has a poor prognosis; thus, we decided to remove the tumor. The patient was intubated with a double-lumen endotracheal tube for one-lung ventilation under general anesthesia and positioned in the left lateral decubitus position. A 5-cm skin incision was made at the fifth intercostal space (ICS) in the anterior axillary line, and a wound protector (Gel POINT Mini Advanced Access Platform, Applied Medical, Rancho Santa Margarita, CA, USA) was placed at the subcutaneous muscular layer . Through the wound protector, an 8-mm camera port was placed at the fifth ICS in the anterior axillary line as the second arm. Two 8-mm assisted ports were inserted at the fourth and sixth ICS on the anterior side as the first and third arms, respectively . The distance between each port was about 3 cm. After the da Vinci® Xi (Intuitive Surgical, Sunnyvale, CA, USA) was positioned; a robotic arm was mounted to each port with a bipolar fenestrated grasping forceps on the first arm and a monopolar spatula on the third arm. The rigid 30° oblique viewing endoscope was used. Carbon dioxide (CO2) was insufflated at a set pressure of 5 mmHg. Depending on the situation, the robotic instruments on the left and right arms were replaced and da Vinci® Vessel Sealer Extend (Intuitive Surgical) instruments were also used. Part of the thymic and pericardial fat including the tumor was dissected from the inferior side, and complete dissection was performed from the cranial side, resulting in the removal of the tumor. To prevent robotic arm collisions, the left and right forceps were moved vertically with the endoscope in between . The final histopathologic examination diagnosed the tumor as a thymic carcinoid tumor . Hematoxylin and eosin staining revealed the presence of a number of atypical pleomorphic cells. Immunohistochemical staining showed the presence of neuroendocrine markers chromogranin A, synaptophysin, cytokeratin AE1/3, and Ki-67 (5–10%) . Thus, confirmation of a thymic carcinoid tumor was obtained. The postoperative course was uneventful.

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+This 28-year-old and 20-week pregnant Chinese woman with genetically confirmed alpha-thalassemia trait and a current obstetric record of gravida 3, para 0, artificial abortion 1 and ectopic pregnancy 1 (G3P0AA1E1 by Gravida/para/abortus (GPA) system) presented to our emergency unit (EU) due to headache, chills, fever and general soreness for one day. At our EU, her physical examination revealed a fever up to 38.5°C, mild tachypnea with a respiratory rate up to 21 breaths/min and bilateral lower back knocking pain. Her obstetric ultrasound revealed 20 weeks gestational age, normal placenta location and a fetal heart beat between 140 and 150/min. No vaginal bleeding was noted.
+Her laboratory data showed pyuria (urine white blood cell count 30 to 50/high power field) and severe peripheral blood pancytopenia: white blood cell (WBC) count 2200/mm3 with an absolute neutrophil count (ANC) of 1780/mm3, hemoglobin 5.5g/dL, mean corpuscular volume (MCV) 119.4fl and platelet count 116,000/mm3. Aggregation of erythrocytes and low reticulocyte percentage (0.1%) were detected in peripheral blood smear. Both direct and indirect antiglobulin tests were strongly positive for antibodies against erythrocytes. The autoantibody was found to be of the cold type. A subsequent laboratory investigation revealed 1:32(+) of cold hemagglutinin titer, raised lactate dehydrogenase (314U/L) and low levels of complement 3 (55.5mg/dL) and complement 4 (10mg/dL).
+Her initial bone marrow cytology showed myeloid hyperplasia and only very few erythroid precursors with erythroblasts in abnormal megaloblastic change , some of which presented with pseudopods or ‘dog ears’ , and almost no erythroid maturation beyond basophilic normoblasts. Her bone marrow biopsy revealed scattered erythroblasts displaying homogeneous ground glass intranuclear viral inclusions and positive nuclear immunostaining of B19 virus . Polymerase chain reaction for B19 virus DNA was positive in specimens from her bone marrow, plasma and nasal cavity. Antibodies against Epstein-Barr virus (EBV) were not checked because she did not present with the symptoms and signs of infectious mononucleosis or lymphoproliferative disorders present in most reported cases of EBV-associated hemolytic anemia.
+TAC caused by B19 virus infection in a pregnant woman with cold antibody autoimmune hemolytic anemia (AIHA) was diagnosed. She received intravenous immunoglobulin (IVIG) injection (CSL Limited, Parkville, Australia), 0.4gm/Kg/day for five days, for eradication of viremia and prophylaxis of occurrence of hydrops fetalis. Although her peripheral blood reticulocyte percentage increased dramatically after IVIG treatment , her hemolytic anemia did not improve much. In order to control her autoimmune hemolysis, intravenous high dose dexamethasone (Astar Chem. & Pharm., Hsinchu, Taiwan), 40mg/day for four days, was prescribed. This treatment was repeated every two weeks for four cycles and then shifted to a monthly oral schedule. She was discharged in a stable condition after the fourth intravenous treatment and received careful follow-up study in our outpatient clinic. No more erythrocytes were transfused after the fifth course of high dose dexamethasone in spite of persistent mild anemia. During her hospitalization and subsequent outpatient clinic visits, obstetric ultrasound did not reveal any evidence of fetal anemia and hydrops fetalis. Four months later, a normal looking healthy baby boy (Apgar score 8 at one minute and 9 at five minutes, body weight 3240gm) was naturally delivered with vacuum extraction aid. After delivery of the baby, her AIHA quickly resolved.

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+A 25-year-old woman, without previous medical history, presented for infertility lasting for more than one year. Clinical examination was normal but abdominal and pelvic computed tomodensitometry (CT) revealed a cyst of the left ovary associated with abundant peritoneal ascites that could correspond to mucinous material. Pelvic magnetic resonance imaging (MRI) confirmed ascites and showed a heterogeneous mass of the left ovary measuring 8.4 × 6.8 cm with adipose, solid and cystic regions that were suggestive of a dermoid cyst. The right ovary and uterus seemed normal. No other lesion was seen in the rest of the body, notably in the digestive system. In this context, surgery by left oophorectomy with appendicectomy and omentectomy was performed 3 months after the first consultation, without resorting to additional hyperthermic intraperitoneal chemotherapy (HIPEC). Intra-operative examination revealed mucinous material inside the peritoneal cavity and a normal digestive tract with a normal appendix. There was no complication of the surgery. The 5-month follow-up based on clinical and imaging surveillance revealed no complaints. Without relapse, the patient was able to pursue her plan to have a child.
+Macroscopically, the left ovary was cystic measuring 9.5 × 7 × 7 cm and weighing 305 g. It was ruptured on 4 cm. Its cut section revealed a heterogeneous and viscous mass with hair. The appendix, measuring 6 cm in length, and the omentum were macroscopically normal. Histologically, the ovarian cyst corresponded to a mature pluritissular teratoma with intermingled skin and pilosebaceous annexes, serous and mucinous glands, respiratory epithelium, adipose tissue and smooth muscle . The organoid areas with the aspect of a colon, representing about 20% of the ovarian cyst, were composed of colonic mucosa, muscularis mucosae, and submucosa from the surface to the depth. A thick muscularis propria was also observed. In the colonic mucosa, some glands were elongated and layered with moderate proliferating epithelial cells with minimal atypia, near to mucin pools stained with Alcian blue. The colonic epithelial cells were immunohistochemistry stained with CK20 and CDX2, and showed heterogeneous staining for CK7. These cells were negative for estrogen and progesterone receptors . The ovarian surface was covered with hyperplastic mesothelial cells and presented acellular mucinous pools, also found in the omentum. The left fallopian tube was normal. The appendix examined in totality was histologically normal besides mucin deposits on the surface of the serosa. It did not present any mucocele or LAMN/HAMN. All together, these data suggested a diagnosis of acellular PMP (according to Carr classification ) caused by a ruptured appendiceal-like mucocele associated with LAMN, in a left ovarian teratoma.
+Next generation sequencing of the LAMN of the teratomatous mucocele revealed an activating mutation of KRAS gene c.35G > A corresponding to the p.(Gly12Asp) substitution . Complementary molecular analysis by SNaPshot showed an associated mutation of GNAS c.602G > A resulting in p.(Arg201His). No mutation was found by these two techniques on the other tissues of the ovarian teratoma (squamous, respiratory, adipose or smooth muscle elements) or in the normal appendix and ovarian parenchyma .

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+A 71-year-old man was scheduled to undergo total hip replacement surgery under general anesthesia to fix malunion of the right hip joint. Two months before the scheduled procedure, he had undergone left bipolar hip arthroplasty and right acetabular fracture fixation due to bilateral acetabular cartridge fractures. After the fractures, the patient had been prescribed oral polystyrene sulfonate calcium because of hyperkalemia. He was diagnosed to have PNH at the age of 60, and the oral administration of prednisolone was initiated. The therapy with eculizumab was not initiated.
+The preoperative blood examination showed pancytopenia [white blood cells, 2.100/μl; hemoglobin (Hb), 12.7 g/dl; and platelets, 100 × 103/μl]. We suspected a hemolytic reaction due to the presence of a slightly increased aspartate aminotransferase, although bilirubin and lactase dehydrogenase level were within the normal limits. The hyperkalemia improved with the polystyrene sulfonate calcium. The irregular antibody screening was positive. Therefore, 6 units of packed RBCs and a blood salvage device (electa™; Sorin Group Italia, Italy) were prepared. No other abnormal results in the cardiac, liver, or renal functions were observed.
+Figure a depicts the intraoperative progress course. The Hb and potassium (K+) levels after the anesthesia induction were 11.5 g/dL and 4.6 mmol/L, respectively. An hour after the operation started, the same levels became 9.6 g/dL and 5.4 mmol/L, respectively, due to unexpected bleeding and presumably intravascular hemolysis. We initiated blood salvage procedures and started transfusion of 2 units of prepared packed RBCs using a potassium adsorption filter. After that, 190 ml of the first salvaged autologous RBCs were re-infused. Blood examination results to check K+ concentration levels in the transfer bag showed a high level of 6.2 mmol/L in the salvaged RBCs. Because the patient’s Hb became 7.6 g/dL due to continuous bleeding, we transfused two more units of packed RBCs and re-infused 90 ml of the second salvaged autologous RBCs using a potassium adsorption filter. The value of K+ in the transfer bag of the second salvaged autologous RBCs batch was also high at 6.0 mmol/L. The patient’s Hb level recovered to 10.5 g/dL after the RBC transfusion. However, the hyperkalemia progressed to 6.8 mmol/L of K+, and we administered 850 mg of calcium gluconate and initiated glucose-insulin therapy. Although the operation was close to being finished, we transfused two more units of packed RBCs anticipating the possibility of intravascular hemolysis after the operation. The surgery was performed without complications. The value of K+ at the end of the operation was 4.9 mmol/L. The amount of bleeding during the operation was 1900 ml, and the infusion volume during the operation was 2400 ml of crystalloids, 6 units of packed RBCs, and 280 ml of salvaged autologous RBCs. The duration of surgery and anesthesia was 140 and 215 min, respectively. Postoperatively, the patient was transferred to the intensive care unit (ICU).
+Figure b indicates the patient’s progress after the operation. Glucose-insulin therapy was continued until the postoperative day (POD) 1. The patient left the ICU and restarted the oral intake of polystyrene sulfonate calcium at POD 3 because the K+ increased again. At POD 18, the patient was transferred to another hospital for rehabilitation.

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+A 77-years-old Caucasian male with past medical history of hypertension, iron deficiency anemia and gout was admitted to our hospital with scrotal and bilateral leg swelling along with a blood pressure of 257/117. Labs showed a BUN of 29, serum creatinine of 1.96 and hemoglobin of 10.2. Further testing revealed a low serum albumin of 1.9 and 4.2 gm/day of proteinuria with no RBC casts in urine analysis. Upper GI endoscopy with small bowel biopsy done for evaluation of anemia revealed villous atrophy with intraepithelial lymphocytic infiltrate consistent with celiac disease . Anti-endomysial antibody was positive whereas ANA, C3 and C4 were normal. Hepatitis B and C serologies were also negative. No monoclonal protein was detected in serum and urine immunofixation electrophoresis examination.
+Renal biopsy subsequently revealed stage II-III membranous nephropathy. Immunofluorescence studies showed granular global subepithelial deposits which stained 3+ for IgG, 1+ for IgM/T/IgA, 3+ for C3, +/− for C1, 3+ for kappa and 3+ for lambda; supporting the diagnosis of membranous nephropathy. Electron microscopy showed 2-3+ global subepithelial/T/intramembranous electron dense deposits, 100% foot process effacement, 1-2+ segmental subendothelial fluff and 1+ segmental GBM duplication consistent with membranous nephropathy . Review of patient's medication list did not reveal any drugs causing membranous nephropathy. Patient was put on a gluten free diet and started on amlodipine, hydralazine and clonidine for blood pressure control. He was started on irbesartan to control the proteinuria and furosemide for the edema, along with allopurinol for gout prophylaxis. The patient was initiated on steroids (prednisone 60 mg/day) as well as an additional immunosuppressive agent (cyclophosphamide 75 mg/day). However, within a period of 2 to 3 months of starting therapy, patient died due to myocardial infarction.

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+Our patient is a 39-year-old Caucasian woman, with family history of hypertension and with hypertension herself since her late 20s, well controlled on amlodipine 10 mg once daily. In addition, her non-cardiac history includes keratosis follicularis (Darier disease), with frequent skin infections, treated empirically with minocycline. She suffered an acute aortic dissection type A 3.5 years ago and underwent surgery for aorta repair with a 34 mm Dacron graft. Her immediate post-operative course was uncomplicated and she was discharged a week later.
+Twenty-five days after surgery she presented to our institution with fever; clinical examination was remarkable for red keratotic papules of forehead, neck, and presternal area, in addition, fine left lower lobe crackles were present. Her fundi were normal. Leucocytosis with granulocytosis was observed; renal and liver functions tests were within normal limits. A chest X-ray revealed left lower lobe pneumonia with ipsilateral pleural effusion and an echocardiogram showed moderate pericardial effusion. Her blood cultures and Bronchoalveolar Lavage were positive for staph hominis and ciprofloxacin 500 mg BID was administered for 4 weeks. One week after completion of antibiotic therapy, she was re-admitted with fever and malaise and had negative blood cultures, but PCR was positive for Coagulase Negative Staphylococci and ciprofloxacin 500 mg BID and vancomycin 1 g IV BID were given for 4 weeks. With the suspicion of graft infection,—relapse of fever, despite previous appropriate antibiotic treatment, soon after urgent surgery, in a patient with skin disease—an 18F-fluorodeoxyglucose Positron Emission Tomography Computerized Tomography (FDG PET-CT scan) was done and showed uptake in the aortic graft . Daptomycin 500 mg IV OD was initiated for another 6 weeks and fever and inflammatory markers subsided. During a 6-month period, however, multiple relapses occurred, each time following completion of antibiotics and a subsequent FDG PET-CT scan showed increased metabolic activity in the graft, pleura, pericardium, sternum and substernal fat, lymph nodes and spleen . The decision to re-operate was then made; the infected Dacron graft was removed and a bovine pericardium graft was inserted, 9 months after the first operation. Methicillin Resistant Staphylococcus epidermidis (MRSE) was isolated in graft’s cultures and IV daptomycin was administered for 6 weeks post-operatively. Patient remained asymptomatic at 22 months follow-up after second surgery and 18F-FDG PET/CT scan showed significant reduction in FDG uptake.

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+An 81-year-old Caucasian woman presented to the outpatient clinic of our hospital with nasal obstruction, headache and diplopia. She had experienced nasal obstruction for over ten years and her headache had worsened for three months. She did not have epistaxis or epiphora. She had been treated medically with antibiotics, nasal decongestants, and nasal steroids. However, her complaints were not alleviated. Her otorhinolaryngological history was unremarkable.
+An endoscopic examination revealed a massively large middle turbinate on the left side. The mucosa was normal and no infection signs were detected in the nasal passage. The enlarged middle turbinate contacting the lateral nasal wall and the septum was the only endoscopic finding. Our patient has proptosis, but her ophthalmic examination revealed 20/20 visual acuity in both eyes and normal intraocular pressures.
+Computed tomography (CT) scans showed a homogenous fluid or soft tissue density lesion surrounded by a bony shell in the left nasal cavity. Erosion of lamina papyracea and ethmoid roof was determined from the CT scans . Neoplasia and mucocele of CB were considered in the differential diagnosis, and a biopsy was planned under local anesthesia.
+Intraoperatively, when we removed the lateral part of the CB for biopsy, a yellow-white colored mass was found inside the CB cavity . The mass was totally excised. The lamina papyracea was found to be defective but no erosion was detected at the ethmoid roof. No further treatment was performed, and the cavity was left open without packing. A histopathological examination showed submucosal chronic inflammation and squamous epithelium with keratinized debris and diagnosis of cholesteatoma was made . Diplopia and proptosis healed after surgery. A follow-up examination 14 months after surgery showed no recurrence of the disease.

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+A 65-year-old male farmer was admitted to the dermatology department of Lishui Central Hospital in April 2016 with the chief complaint of erythema, pruritus, and ulceration of the perianal skin combined with cough, which lasted for 1 year. One year ago, patient had perianal erythema, accompanied by pruritus, ulceration, exudation, and pain. Further questioning revealed that the patient had been coughing several times a day. The patient occasionally had white sputum, without any hemoptysis, chest pain, low grade fever, night sweats, or any other discomfort. The patient had applied a variety of ointments for external use, without improvement. The erythema gradually expanded, affecting half of the hip on both sides of the crissum; an ulcer developed at the center of the erythema. Past medical history included hepatitis B for more than 10 years, and hypertension for about 3 years. The patient had surgical history of cholecystectomy at 39 years of age and denied previous history of TB, tumor, being engaged in risky sexual behaviors, or similar family history. Physical examinations included body temperature of 36.9°C, blood pressure 133/86 mm Hg, pulse rate 86 beats/min, breathing 20 times/min, double pulmonary breath sounded rough without obvious rales. Physical examination by specialist showed a large erythematous plaque of about 20 cm × 15 cm around the anus, skin ulcers could be seen nearly 4 cm range at the perianal area, and the base could be seen with fresh granulation, and few purulent secretions (See Fig. ). Blood routine test, liver and kidney function tests, treponema pallidum particle agglutination assay (TPPA), toluidine red unheated serum test (TRUST), combined detection of human immunodeficiency virus (HIV) antibodies, and HIV antigens were all negative or within normal ranges. The detection and screening of alpha-fetoprotein (AFP) tumor marker, carcinoembryonic antigen (CEA), squamous cell carcinoma antigen (SCC), total prostate specific antigen (TPSA), and free prostate-specific antigen (FPSA) were all normal. Blood sedimentation rate was 50.0 mm/h, TB DNA was positive, and TB antibody was positive. Acid-fast bacillus detection in sputum samples was ++++. Histological examination of perianal skin showed an ulcerative and necrotic area in the perianal skin, and peripheral epidermis had keratosis and hyperkeratosis. The stratum spinosum was proliferated, accompanied by intercellular edema. The whole dermis had epithelial-like cell mass, Langerhans giant cells could be seen, a large number of infiltrating lymphocytes were observed, and anti-acid staining was positive. Pathological diagnosis demonstrated (perianal skin) necrotic granulomatous lesions (TB). Special staining demonstrated acid-fast bacilli using acid-fast staining, periodic acid-Schiff stain (PAS) was negative (−), silver hexosamine stain was negative (−) (See Fig. ). Chest computed tomography (CT) scan showed symmetrical thorax, trachea moved to the right, and double lung marking increased and disordered. Diffuse nodular, flocculent, and striped high-density shadow could be seen in both the lungs, the edges were blurred, and the density was uneven. The partial lung tissues in both the upper lungs were consolidated and the cavity was formed. Hilus of the lung and mediastinal lymph nodes were not enlarged. The shape of the heart was not abnormal. There was no pleural effusion in the bilateral pleural cavity. Intrahepatic bile duct showed dilatation. Chest CT scan showed secondary pulmonary TB with cavitation in both upper lobes, and part of the right upper lung was damaged (See Fig. ). The results of abdominal enhanced CT showed intrahepatic bile duct dilatation and pneumobilia, gallbladder was not shown; splenomegaly, and multiple renal cysts in both the kidneys; possibility of duodenal descending diverticulum, and a little pneumatosis as a partial small intestinal obstruction. Admitting diagnosis showed perianal ulcerative skin TB, secondary bilateral pulmonary TB with possible cavity formation in the 2 upper lungs, TB bacillus was positive (+) in sputum smear. The patient was transferred to the infectious disease department for treatment, and was given with regular anti-TB treatment, which included isoniazid tablets 0.1 g/time, 3 times/day; rifampicin capsules 0.45 g/time, 1 time/day; ethambutol tablets 0.75 g/time, 1 time/day; pyrazinamide tablets 0.75 g/time, 2 times/day. The patient was discharged after 8 days of hospital treatment. M. tuberculosis in sputum smear was negative (−) at the time of discharge. Flushing and exudation of perianal skin were better than before. The patient was recommended to take regular anti-TB drugs for 6 months after discharge. After 6 months of discharge, the patient was followed up through telephone and replied that the ulcer had healed.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1286_en.txt

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+A 26-year-old black African male health care worker was admitted to the clinic on 21 July 2022, with a significant chief complaint of headache, loss of appetite, and watery diarrhea. The admitted patient presented with a 2-day history of hyperthermia, headache, loss of appetite, and watery diarrhea, as well as back pain, joint weakness, and insomnia. The patient traveled to Malarious area for his education 5 years ago; once upon a time, he bought overripe mangoes from a vegetable vendor on the street and ate them there. The patient ate mangoes at 4:00 a.m. and began experiencing diarrhea at noon, at 10:00 a.m. The patient had taken ciprofloxacillin at 11:00 a.m. from the student clinic without any clinical investigations based on his clinical manifestations due to the inaccessibility of laboratory investigations and diagnostic equipment, and he recovered totally from the illness after 2 days. No one in his family had previously been diagnosed with typhoid fever.
+Recently, the patient traveled to a desert environment and malarious area for work and stayed there for 1 year. When he returned home after 1 year, he bought pineapple from the vegetable seller on the street, ate it after 3 days without putting it in the refrigerator, and experienced the above clinical manifestations after 12 hours. The patient said, ‘I was suspecting typhoid fever because the pineapple I ate was overripe’, and then the physician decided to identify the disease type through laboratory investigations and diagnostic criteria and started undergoing it. First, the physician had performed a laboratory investigation to identify malarial parasites in peripheral blood via thin and thick smears, and no malarial parasites were detected in the patient.
+Second, a physical examination was performed and revealed a high-grade fever (40.3°C/107.4°F) (normal value: 37°C/98.6°F), slight dehydration, tachycardia, or a heart rate of 114 beats per minute (normal value: 60–100 beats per minute), a respiratory rate of 15 breaths per minute (normal value: 12–16 breaths per minute), and a blood pressure of 112/71 mm Hg (normal value: 120/80 mm Hg).
+Third, laboratory investigations were performed and showed a white blood cell (WBC) count of 3160 cells /mm3 (normal value: 3200–9800 cells/mm3), neutrophils of 47% (normal value: 54–62%); eosinophils of 2.1% (normal value: 1–3%), monocytes of 4.8% (normal value: 3–7%), basophils of 0.3% (<1%), and lymphocytes of 43% (normal value: 25–33%), a platelet count of 125 000/mm3 (normal value: 130 000–400 000 cells/mm3), a serum creatinine level of 0.9 mg/dl (normal value: 0.6–1.2 mg/dl), an aspartate aminotransferase/serum glutamic oxaloacetic transaminase level of 68 units/l (normal value: 0–35 units/l), an (alanine aminotransferase/serum glutamic-pyruvic transaminase) alanine aminotransferase level of 95 units/l (normal value: 0–35 units/l), an erythrocyte sedimentation rate of 9 mm/h (normal value: 0–20 mm/h), 45% hematocrit (normal value: 39–49%), hemoglobin of 15.9 g/dl (normal value: 14–17.5 g/dl), mean corpuscular volume of 79.8 fl/cell (normal value: 80–97.6 fl/cell), mean corpuscular hemoglobin of 31 pg/cell (normal value: 27–33 pg/cell), and mean corpuscular hemoglobin concentration of 35 g/dl (normal value: 32–36 g/dl).
+Finally, the physician performed the Widal agglutination test to find that the patient had active or previous typhoid fever. According to the Widal test, the H antigen titer was 1 : 189 and the O antigen titer (TO) was 1 : 137 (normal value: 1 : 20–1 : 80). Herein, the admitted patient had a past history of S. typhi and no detection of active infection with S. typhi because the patient was discharged after 5 days from the onset of fever, and O agglutinins can usually be detected 6–8 days after the onset of fever. The H antigen titer was positive, which was 1 : 189 greater than the normal range and showed the past history of S. typhi infection. Because active typhoid fever infection is not detected until 6 days after the onset of fever, laboratory investigations are used to identify it. The above TO titer value detected was a false negative result because it was done before the 6-day onset of fever.
+On admission, ciprofloxacillin 500 mg was given orally twice a day for 7 days to treat typhoid by inhibiting the deoxyribonucleic acid replication in S. typhi and preventing S. typhi deoxyribonucleic acid topoisomerase and deoxyribonucleic acid gyrase. On the same day, paracetamol 500 mg was given orally three times a day for 5 days to control the fever by inhibiting prostaglandin E2 secretion, which elevates heat secretion and lowers heat loss. The following day, 22 July 2022, the patient was free of all clinical manifestations except fever and sent home with ciprofloxacin and paracetamol.
+The admitted patient recovered from a typhoid fever infection and was discharged back home with prescribed medications.

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+A 32-year-old woman, gravida 3, para 1, was referred to our center at 26 + 3 weeks of gestation for further fetal cardiac examination for suspected cardiac anomalies. The patient was in good health without any maternal complications or high-risk factors (e.g. diabetes, hypertension, amniotic disorders). A detailed echocardiogram was performed to find any potential cardiac anomalies using transverse and sagittal scanning. Conventional 2DE was used to show fetal anatomical structures. Color Doppler flow imaging (CDFI), together with HDFI was used to show fetal hemodynamics. The sound beam was continuously moved upward along the vertical axis of the fetal thorax to perform the transverse scanning. The four-chamber view (4CV) showed a symmetrical left and right heart. The left and right outflow tract views showed normal ventriculoarterial connections. However, a small-sized ventricular septal defect (VSD) was identified at the 4CV and the left outflow tract view with the communication clearly shown by CDFI . An additional movie file shows this in more detail (See Additional file : Video). The pulmonary valve annulus (PVA) was apparently wider in comparison with the aortic valve annulus (AVA). The ratio of PVA/AVA was 1.6 in diameter. The size of the pulmonary artery (PA) was also larger than the aorta (AO) and the ratio of PA/AO was 2.1 in diameter. At the three-vessel trachea (3VT) view, the widened pulmonary trunk continued to be the ductus, which was connected with the descending aorta. At the same time, a tiny vessel was found located at the right side of the pulmonary trunk, with no convergence with the ductus . An additional movie file shows this in more detail (See Additional file : Video). Under normal conditions, the aortic arch joins with the ductus to form proximal descending aorta in a characteristic “V” shape at the 3VT view . The echocardiographic manifestations in the current case thus suggest the possibility of an IAA. Sagittal planes were also scanned to obtain more information. The arch did not present, instead, the ascending aorta was visualized going straight upward and then branching three brachiocephalic arteries in a “W” shape . An additional movie file shows this in more detail (See Additional file : Video). A preliminary diagnosis of IAA type A was then reached. The 3DE with STIC technology was then used to obtain 3D images of the great arteries to confirm the 2D diagnosis. A 3D motorized transducer (4–8 MHz) was used to acquire cardiac volumes when scanning the sagittal planes using HDFI. The acquisition time was set to 12.5 s and the sweep angle was set to 30°. Cardiac volumes were acquired automatically and then reconstructed to display in a cine loop in multiplanar mode. Volume post-analysis was then performed using an off-line software (4D viewer, version 14.0) to obtain the 3D reconstructed images. This could be achieved by properly adjusting the direction and size of the region of interest (ROI) and the rotation of the images in three orthogonal planes in the volume. A combination of smooth surface and gradient light algorithms was also used to enhance the 3D effect of the reconstructed images. The 3D image demonstrated an abnormal angle of attachment of the aortic arch to the ductus and descending aorta via a slim isthmus . An additional movie file shows this in more detail (See Additional file : Video). The final diagnosis was CoA at the isthmus.
+The patient refused a chromosomal examination and did not go back to the following-up echo four weeks later for personal reasons. She came to the hospital at 31 gestational weeks as she could not feel fetal movement. Intra-uterine fetal death was demonstrated by fetal echo and proofs of intra-uterine infection were found during the induction of the labor. An autopsy was then performed and showed the great arteries in detail. The spatial relationships of the aorta and the pulmonary artery were normal. The size of the ascending aorta was approximately half of that of the pulmonary trunk while it went straight upward and gave off the innominate artery, left common carotid artery and the left subclavian artery, in turn. An abnormal angle of the connection between the aortic arch and the slim isthmus could be appreciated . In addition, a perimembranous VSD about 4 mm in diameter was also found. The gross findings confirmed the prenatal diagnosis.

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+A 42-year-old Caucasian woman was admitted to our hospital because of fluctuating diplopia, ptosis, dysphagia, dysarthria and fatigable chewing at the end of meals or at the end of the day. Also, she would not answer the phone anymore because of her fear of not being able to finish a conversation. Her medical history included APS (that had led to three spontaneous abortions) and transitory hypothyroidism. She took acetylsalicylic acid 81mg daily.
+On examination she had dysarthria and weakness of facial muscles, tongue and neck. She displayed progressive fatigability in upward gaze during the Simpson test. Repetitive ulnar nerve stimulation showed abnormal (>10%) decrement. The results of tests to detect antibodies against AChR, MuSK and titin were negative. A generalized MG was diagnosed. Her thoracic computed tomography scan was normal. Thromboplastin time and activated partial thromboplastin time were high, as an expression of the APS; anticardiolipin and anti-β2 glycoprotein-I antibodies were elevated. Laboratory findings are shown in Table .
+She had a good clinical response when treated with pyridostigmine, prednisone and azathioprine.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1338_en.txt

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+We describe a 57-year-old right-handed female presenting to a neurology outpatient clinic with a chief complaint of weakness. She initially began to experience hypophonia, weakness and subsequent difficulty walking approximately one year prior, with hoarseness of speech starting even earlier. Initial onset of symptoms also involved bradykinesia, including speech and ambulation. She noted that her left upper and lower extremities were predominantly affected at onset, with subsequent spread to the right upper and lower extremities. In particular, she had difficulty typing, especially with her left hand, and over time developed micrographia with somewhat illegible handwriting. She experienced impaired gait and balance with a tendency to fall backwards and reported difficulty lifting her legs getting in and out of vehicles. She also endorsed stiffness and cramping in her legs.
+Review of systems was notable for vague lightheadedness, which she described as a "fuzzy feeling" or slowed mental processing. She had a history of constipation with infrequent bowel movements for several years and exhibited frequent episodes of yelling out at night for which the patient was amnestic. Remarkably, within about six months of disease onset she developed laughing involuntarily out of context. Throughout her symptomatic progression, she did not experienced fevers, chills, or other constitutional symptoms. Past medical history was limited to a diagnosis of shingles several years earlier without residual symptoms, and family history was negative for neurologic disorders including motor neuron disease and movement disorders.
+Physical exam included normal orthostatics. Hypomimia was observed with no abnormalities of eye movements. Cognition was normal by Montreal Cognitive Assessment, but speech was hypophonic, slow and mildly dysarthric with hoarse monotone quality. Jaw jerk was absent, and there was no evidence for tongue atrophy or fasciculations. Power was normal without muscle atrophy or fasciculations. Hyperreflexia with Hoffmann's and suprapatellar reflexes were noted bilaterally. Mild bilateral lower extremity spasticity was slightly greater on the left with bilateral extensor plantar responses present. Gait was slow en bloc with bilaterally decreased arm swing. Mild bradykinesia was seen in the upper extremities but without cogwheeling or resting tremor appreciated. Subsequent further evaluation showed severely impaired finger tapping bilaterally and moderate postural instability.
+Laboratory studies including routine blood work and other testing were negative for autoimmune and paraneoplastic processes, vitamin deficiency, and metabolic disorders . Genetic analysis revealed a variant of uncertain significance in the PSEN2 gene . Electromyography was completely negative for lower motor neuron findings. Magnetic resonance imaging (MRI) of the brain both at nine months and two years from disease onset revealed atrophy mildly greater than expected for the patient’s age, particularly in the frontal and parietal cortices bilaterally symmetrical with a normal-appearing brainstem, including pons. Neither a hot cross bun nor putaminal rim sign was visualized . MRI of the cervical spine was essentially normal with minimal disc bulging and no intrinsic cord findings. A DaTscan roughly one year from symptom onset was markedly abnormal with no activity in the putamen bilaterally and diminished uptake in the caudate bilaterally, moderate on the right and mild on the left, confirming nigrostriatal dysfunction .
+Follow-up 2.5 years after initial symptom onset, the patient’s clinical course has been a very slow progression. She continues to have pathologically brisk reflexes with spasticity limiting functionality and increased tone impacting her dexterity and gait. Neuropsychological testing reveals normal cognition with exception of mild slowing in verbal construction and cognitive processing. Ocular motor function remains normal. She continues to exhibit mild asymmetry with both spasticity and bradykinesia slightly worse on the left, still without tremor. She ambulates independently and functions well in her job though challenged by hypophonia and difficulty typing. She has not developed orthostatic hypotension or other signs of autonomic failure. Treatment with tizanidine has helped symptoms of stiffness and cramping, and her bradykinesia has subjectively responded to levodopa titrated up to tolerance.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1342_en.txt

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+A 25-year-old woman, gravida 1 para 0 with satisfactory antenatal progress was admitted for an elective cesarean delivery by maternal request at 39+ 1 weeks of gestation. She denied any medical history of chronic disease. As requested by the patient, combined spinal-epidural anesthesia was administered for cesarean delivery. Fifteen milligrams of 0.5% ropivacainehydro chloride injection (AstraZeneca AB, Sweden) was injected into the subarachnoid space and 5 mL of 2% lidocaine (Shanxi Shiyao Yinhu, China) was injected into the epidural space. Cefathiamidine (1.0 g, Shandong Luoxin, China) was administered intravenously as a prophylactic antibiotic. During the surgery, the patient started shivering, but the vital signs remained stable. The operation was completed successfully, and she was monitored in an anesthetic resuscitation room.
+In the anesthetic resuscitation room, she continued to shiver and complained of general numbness and breathlessness. She was febrile with a temperature of 40.7 °C. Her blood pressure dropped to its lowest point of 78/44 mmHg, she had tachycardia with a maximum heart rate of 177 bpm, and she had intermittent vaginal bleeding. However, her oxygen saturation remained at 98%. Hence, septic shock was suspected, but we were unable to rule out anaphylactic shock. Resuscitation was initiated with massive fluid replacement, intravenous dexamethasone (Sinopharm, China), and a uterotonic agent, namely, 250 μg of intramuscular carboprost tromethamine (Pharmacia and Upjohn company, America). Concurrently, a Bakri Postpartum Balloon (Cook, America) was placed. Despite these treatments, her blood pressure remained unstable (< 90/60 mmHg). The blood investigations revealed metabolic acidosis (a pH of 7.252 [7.35–7.45], a serum lactic acid concentration of 6.52 mmol/L [0.36–1.25]), a raised procalcitonin of 94.5 ng/mL [0.0–0.5], an increased white blood cell count of 15 × 109/L [4–10 × 109], increased neutrophilia of 96.1% [50–70%], decreased platelets of 83 × 109/L [100–450 × 109], a hemoglobin concentration of 105 g/L [110–155], a hematocrit of 30.7% [35–45%], coagulopathy with a prolonged activated partial thromboplastin time (APTT) of 91.3 s [22.3–32.5] with low fibrinogen (FIB) < 0.25 G/L[2-4], and hypokalemia of 3.26 mmol/L [3.5–5.5]. The sequential organ failure assessment (SOFA) score was above 2 (oxygenation index ≤400 mmHg, platelet count≤150,000/uL and mean arterial pressure < 70 mmHg). A central venous catheter and a femoral artery catheter were inserted, red blood cell concentrates and fresh frozen plasma were transfused, low-dose noradrenalin (Grandpharma, China) was administered, and the antibiotic was changed to 2.0 g of ceftriaxone sulbactam sodium (Pfizer, America) at 12-h intervals. Five hours after surgery, all vital signs except her body temperature stabilized. Eighteen hours after surgery, her temperature decreased to 37.8 °C, with a raised white blood cell count of 23.13 × 109/L, neutrophilia of 91.7%, procalcitonin above 100 ng/mL, a decreased platelet count of 64 × 109/L, hemoglobin of 71 g/L and hematocrit of 19.8%. The antibiotic dose was altered to 500 mg of intravenous imipenem/cilastatin sodium (Merck Sharp &Dohme, America) at 6-h intervals. Five days after surgery, the results of the blood culture and microbe identification confirmed R. mannitolilytica. At that time, the patient’s body temperature had fluctuated to approximately 37.4 °C, and the hemogram decreased significantly (white blood cell count, 10.43 × 109/L; neutrophilia, 76.9%; procalcitonin, 11.6 ng/mL). Treatment with imipenem/cilastatin sodium was continued because the drug sensitivity test of the bacteria could not be carried out in our laboratory. Eight days after surgery, the patient’s body temperature returned to normal. Blood analysis showed a white blood cell count of 12.09 × 109/L, neutrophilia of 76.6% and procalcitonin of 2.26 ng/mL. The antibiotic was changed to 2.0 g of intravenous cefoperazone sulbactam sodium at 6-h intervals for 6 days. All the blood results had returned to normal, the repeated blood culture was negative on day 14 postoperatively and she was discharged well on day 15. No abnormality was found during follow-up at half a year after discharge.

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+A 65-year-old white male was referred to our Vitreo-Retinal Surgery Service for a retinal detachment (RD) in his right eye. On examination, his best-corrected visual acuity (BCVA) was 20/63 in the right eye (RE) and 20/20 in the left eye (LE), with a small refractive error. Intraocular pressure was 15 mmHg OU. Slitlamp examination revealed quiet anterior chambers and slight nuclear sclerosis in both eyes. Dilated fundus examination of the right eye showed an inferior bullous RD involving the macula with no evidence of retinal breaks, while a large RPE tear was detected in the temporal quadrant . There was no sign of uveitis or vitreitis. Fundus examination of the LE was unremarkable, except for slight RPE distrophic alterations at the posterior pole with RPE mottling. Enhanced depth imaging optical coherence tomography (EDI-OCT) revealed a pachychoroid pattern in both eyes . Moreover, OCT scans of the right eye showed sub-retinal fluid (SRF) reaching the macular area from the inferior quadrants. No SRF was detected in the LE. Ocular ultrasound showed no mass lesion . Upon questioning his medical history, the patient referred a history of central serous chorioretinopathy (CSC) in the RE and the recent use of intravenous corticosteroids for bronchitis. Fluorescein angiography (FA) and Indocyanine green angiography (ICGA) were performed, revealing hyperpermeable and dilated choroidal vessels and multifocal and diffuse leakage in the late angiograms of the RE . No disc leak or vasculitis were detected. Swept-Source OCT angiography (SS-OCT-A) confirmed the pachychoroid pattern and clearly demonstrated the mid-pheripheral RPE tear in the inferotemporal quadrant . Axial lengths were 23.63 mm (RE) and 23.35 mm (LE).
+Based on the clinical features, a diagnosis of bullous variant of CSC with RPE tear was made. Oral therapy with eplerenone at a dose of 50 mg/day was initiated. However, no improvement was detected. In fact, two months later, the exudative RD increased with a worsening of the BCVA to 20/80 , despite the continuing therapy with eplerenone. To prevent irreversible photoreceptor damage, management with observation or eplerenone treatment continuation were excluded, and alternative therapeutic procedures were discussed. Laser therapy was deemed inappropriate because the leakage was multifocal and diffuse, with multiple “ink blot” focal areas of leakage at the superior margin of the detached retina and other poorly defined leakage areas in the attached retina. Photodynamic therapy (PDT) was not applicable because of the extension and elevation of the RD. Therefore, the opportunity for surgical treatment was considered.
+Written informed consent was given by the patient, after a comprehensive explanation of the procedures. Under general anesthesia, the patient’s eye was prepared with povidone-iodine and draped. After 180° inferior conjunctival peritomy, bridle suture was passed under the inferior, medial and lateral rectus muscles with 3–0 ticron, and the sclera was exposed. Two 4 × 4 mm almost full scleral thickness sclerectomies were done in the inferior quadrants, taking care to avoid the areas close to exit sites of the vortex veins. Finally, the conjunctiva was approximated with 8–0 Vicryl suture. The treatment resulted in complete RD resolution as of the first day after surgery. Upon follow-up six months after surgery- complete SRF resolution was confirmed and BCVA was stable at 20/80 .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1356_en.txt

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+A 47-year-old man (body weight 62.1 kg and height 166.8 cm) was reported in our hospital with a past medical history of tongue cancer that was operable. The preoperative spirometry test, electrocardiography, and transthoracic echocardiogram were normal. He is a non-smoker with no history of cerebrovascular disease. In his thirties, he had undergone resection of the mandibular area with plate reconstruction for treatment of tongue cancer; however, the site became infected and the plate was removed 8 months before presentation. The patient returned for reoperation involving a free abdominal muscle flap with vascular anastomosis and partial mandibular resection with tracheostomy. After surgery, the patient was in the ICU for deep sedation and ventilator management for 48 h, until the vascular anastomosis stabilized. Initially, the iASV ventilator mode was selected to change only the percentage minute volume (%MV) automatically. On the postoperative day 3, the patient’s oxygenation worsened, and purulent sputum increased; fiberoptic suctioning of sputum was performed once along with sputum culturing. Although no significant organism was detected with sputum Gram staining, Klebsiella pneumoniae and Pseudomonas otitidis were detected in the sputum culture test. We therefore arrived at a diagnosis of VAP and changed the patient’s antibiotic from ampicillin/sulbactam 1.5 g per 6 h to meropenem 0.5 g per 8 h. At the time of entering the ICU, his PaO2/FiO2 ratio was 462, which indicated a good oxygenation capacity; this decreased to 171.5 at the time of VAP diagnosis. At the same time, the other patient entered the ICU with a severe respiratory emergency. We continued the iASV mode as we judged that the respiratory condition could be improved. PEEP and FiO2 were selected as additional automatic settings in iASV, %MV was automatically set, and the delta P (ΔP) approximating the driving pressure did not exceed 10 cm H2O. .
+Arterial blood gas (PaO2, PaCO2, and pH) was measured every 6 h to confirm that his respiratory condition was within the expected range.
+Once the patient’s oxygenation capacity started improving, the INTELLiVENT®-ASV started to show a decline in FiO2, first until it reached 0.3, and then reduced PEEP from 14 to 5 cm H2O based on the lung protective ventilation strategy. Two days after changing the antibiotics to treat VAP, his WBC, CRP, and the sputum secretion from the lungs decreased, indicating resolution of VAP. Therefore, mechanical ventilation was successfully withdrawn. During this time, the ΔP obtained by subtracting PEEP from the inspiratory plateau pressure was kept below 10 cm H2O .
+We used dexmedetomidine (0.2γ to 0.5γ) and propofol (1 mg/kg/h to 3 mg/kg/h) for sedation during his admission in ICU. We continued the same sedation dosage after VAP diagnosis, and after stopping ventilator usage, the propofol administration was also stopped. Dexmedetomidine was continued after extubation at night for the purpose of sleeping.
+Two days after stopping ventilator usage, the patient’s respiratory condition was stable and he was transferred to the general ward.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1374_en.txt

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+An 87-year-old Asian woman in good general health presented with a progressively enlarging mass located in her left preauricular region. Fine needle aspiration (FNA) cytology analysis performed in the clinic suggested malignant cells of uncertain origin, but the tumors showed a rapid and consistent regression after FNA. During six months of observation, the tumor regrew and the patient was referred to our hospital.
+A physical examination revealed a 55-mm tumor located in the parotid with extension to the retroparotid area, and swelling of her left laterocervical lymph node. A computed tomography scan showed a peripheral enhanced mass in her right parotid gland. Magnetic resonance imaging revealed low signal intensity on T1-weighted images and iso-high signal intensity on T2-weighted images. The images showed the lesion to be clearly circumscribed, with homogeneous hypo-iso signal intensity on T1-weighted images and heterogeneous high signal intensity on T2-weighted images. The tumor demonstrated circumscribed and heterogeneous enhancement on gadolinium-enhanced T1-weighted images . Computed tomography scans of her thorax and abdomen did not reveal involvement of other sites.
+FNA was performed again and a cytological examination revealed a Papanicolaou classification of Class V, suggesting SmCC. A total parotidectomy and modified neck dissection were performed. On histopathology, the tumor showed diffuse growth with confluent necrosis in the salivary gland. The tumor cells had scant cytoplasm and hyperchromatic nuclei without prominent nucleoli. Mitotic figures were frequently observed . Neoplasmic elements reveal positivity for cluster of differentiation 56, neuron specific enolase, synaptophysin and a dotted staining pattern with cytokeratin 20 . Based on our histopathological findings, a diagnosis of a Merkel-cell-like SmCC of the parotid gland was made. Additional studies were positive for Maspin.
+Our patient’s postoperative course was uneventful, and no postoperative radiotherapy was administered. The nine-year clinical follow-up, which is the longest follow-up of head and neck SmCC in our knowledge, revealed no locoregional recurrence or distant metastasis.

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+A 30-year-old woman visited the hospital due to right lower quadrant pain over the period of 1 week. A laparoscopic myomectomy was performed 4 years ago because of a broad ligament leiomyoma, which was about 10 cm in size. Laboratory findings included a routine blood examination, and a C-Reactive Protein (CRP) test, with tumor markers all found to be within normal ranges. The pelvic Magnetic Resonance Imaging (MRI) scan showed some nodules at the posterior margin of the bladder that were considered to be endometriosis, and some pelvic effusion that was significant on the right side. It was also noted that there was a mass shadow at the lower right ureter (medial to the iliopsoas muscle), with distention of the lower right ureter . The patient also underwent computed tomography (CT) scans to enable the practitioners to observe the size of the abdominal mass and its surroundings. The CT images revealed a region occupying the middle right ureter that was considered to be a retroperitoneal aggressive fibroma, which led to severe hydronephrosis on the right kidney and upper ureter, and a right pelvic effusion . After more detailed examinations were conducted, there were no obvious abnormalities detected in the brain, heart, liver, gallbladder, spleen, pancreas or blood. The color Doppler ultrasound demonstrated that there was a hypoechoic mass next to the right iliac vessels that was closely related to the adjacent ureter. This resulted in severe hydronephrosis of the right kidney and a right upper ureteral dilatation . Ndzengue et al. reported a case of a pelvic desmoid tumor simulating a uterine leiomyoma recurrence. The patient that presented at our hospital had a history of uterine leiomyoma. We subsequently organized a multidisciplinary consultation to determine the next stage of her treatment plan. According to the patient’s surgical history, the next step would be determined after reviewing the results of the last surgical pathological wax, because the pathological nature of the retroperitoneal mass was uncertain.
+Consequently, a laparoscopic pelvic tumor resection with assistance from a Da Vinci robot was successfully conducted. A local peritoneal protuberance was observed in the right iliac vascular area. The parietal peritoneum was incised above the mass and it was carefully freed along the edge of the mass. The size of the tumor was about 6.0 cm × 5.0 cm × 3.0 cm. It had invasively grown and it was wrapped around the right ureter and the right ovarian arteries and veins. It was stuck to the psoas muscle and the iliac vessels. According to preoperative preparations and intraoperative conditions, a decision was made to cut off the right ureter, the right ovarian arteries and veins, and completely remove the tumor and the two masses that were located in front of the broad ligament on the right hand side of the uterus. The sizes of the masses were approximately 1.5 cm × 1.0 cm × 1.0 cm. The right ureter was anastomosed and put into a double J tube. A pathological diagnosis of an intraoperative frozen sample determined that it was a spindle cell soft tissue tumor, and the two masses were leiomyomas. Postoperative pathology tests of the pelvic mass determined that it was aggressive fibromatosis that had invaded the ureteral wall . The uterine surface nodules were also leiomyomas. Microscopically, the tumor cells were arranged sparsely in a spindle shape with blood vessels of different sizes found in the interstitial tissue. Immunohistochemical findings were found to be partially positive for smooth muscle actin (SMA) and desmin, and less than 5% ki-67 of positive cells were seen in the lesion. A detailed re-examination was performed 3 months after the initial surgery, to determine the structure and function of the ovaries. The transvaginal color Doppler ultrasonography was able to determine that the ovaries were normal in size with several follicular echoes. The blood supply to the right ovary was good. There were no obvious abnormalities in the uterus or pelvic cavity . The pelvic MRI and the CT scan of the whole abdomen determined that there were no abnormal lesions in the pelvis. Simultaneously, the endocrine function of the patient’s ovaries was found to be normal, and she was able to self-maturate after removing the double J tube.