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data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_101_en.txt

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+A 32-year-old man presented to the emergency room with repetitive episodes of syncope and intermittent dyspnea within 7 d.
+The patient complained of chest distress on February 15, 2019. Then he had a transient, self-limited loss of consciousness lasting for 3-5 min, followed by prompt recovery. The syncope happened four times. The trigger of the attacks included physical exertion or inhaling cold air. There is no prodromal or accompanied symptom. He went to our hospital by himself on February 22, 2019 because of another onset of syncope.
+The patient had no medical history nor family history of blood clotting disorders, but he had a sedentary lifestyle due to his job as a news editor.
+His vital signs were stable at the time of the first medical contact. Physical examination results were as follows: Pulse rate: 96 beats/min; respiratory rate: 20 breaths/min; blood pressure: 15.5/10.1 kPa; body mass index: 23.1 kg/m2; pupils: Symmetric and responsive to light; prominent P2; symmetrical breath sounds without rales or wheezing; and warm extremities without edema. The neurological examination was negative.
+Initial laboratory test showed elevated serum D-dimer at 4150 ng/mL (reference < 500 ng/mL). Arterial blood gas analysis showed PaO2 of 79 mmHg while he was breathing ambient air. N-terminal pro-B-type natriuretic peptide was 4460 pg/mL (reference < 450 pg/mL). The levels of serum cardiac enzyme series were normal.
+The electrocardiogram showed sinus tachycardia. Doppler ultrasound revealed a deep venous thrombosis in the right popliteal vein . Transthoracic echocardiography showed a mass thrombus straddling a PFO concomitant dilated right atrium and moderate pulmonary hypertension . The size of the thrombus was 3 mm × 20 mm in the left atrium, 8 mm × 25 mm in the right atrium. Computed tomography angiography confirmed bilateral peripheral PE . The brain computed tomography scan was normal.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1030_en.txt

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+A 42-year-old man, previously healthy, was living with his step father and other members of an extended family in a small farm. He presented with a first episode of a motor seizure that started on the left side of his body before becoming generalized. Shortly afterwards, he noticed left hemiparesis and dysarthria; he was admitted to our institution through the emergency department.
+After a physical examination, magnetic resonance imaging (MRI) of the patient revealed a well-defined, spherical lesion, located in the superior aspect of the anterior limb of the internal capsule and right striatum, with surrounding edema . Laboratory studies found no systemic compromise and no underlying immunocompromise. We decided to excise and analyze the aforementioned lesion. Performing an image-guided frontal craniotomy, using the Leksell Stereotactic G-Frame (Elekta Instruments AB, Stockholm, Sweden), we planned the trajectory to avoid the head of the caudate nucleus, the genu of the internal capsule, the putamen, and other critical structures. The mass was completely excised and the thalamostriate vein, which was adhered to the mass, was preserved. Craniotomy was performed, instead of a stereotactic biopsy, because we suspected the lesion to be a high-grade glioma that was accessible to surgical resection.
+In the pathological analysis, there was an evident atypical T and B infiltrate; morphological and phenotypical characteristics of Grade 1 lymphomatoid granulomatosis. The patient was subjected to thoracic and abdominal screening, which revealed paratracheal, jugular, and inguinal adenopathies, but no other masses.
+After consulting with the hematology group, the patient received a four-cycle medical treatment with rituximab and prednisone. Clinically, he recovered almost completely with strength of 4/5 and complete reintegration to his daily activities, which involved bimanual work. Six months after his diagnosis, a new MRI showed the absence of new or residual lesions.
+Two years after the surgery the patient continued to be free of seizures, and his MRI showed no evidence of new lesions, areas of restriction of diffusion, or anomalous enhancements that could indicate residual or recurrent tumor .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1035_en.txt

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+A 9.3-kg 7-month-old girl with congenital biliary atresia presented for living-donor liver transplantation. At 6 months of age, she developed hepatic dysfunction and was treated with symptomatic therapy. Her preoperative hemoglobin (Hb) was 77 g/L, albumin was 30.7 g/L, total bilirubin was 430.4 μmol/L, and prothrombin time was 17.3 s, with no electrocardiograph (ECG) abnormality or prominent heart murmur. Her preoperative blood pressure was 90/50 mmHg and the heart rate was 130 bpm.
+On arrival in the operating room, ECG leads and a pulse oximeter were placed and continuously monitored. General anesthesia was induced by inhalation of sevoflurane 8% (vol) with transvenous midazolam 1 mg, sufentanyl 5 μg, and rocuronium 10 mg, followed by intubation with an endotracheal tube. Subsequently, a 24G left radial arterial catheter was inserted for continuous invasive arterial blood pressure (IABP) monitoring. A 4F double-lumen intravenous catheter was placed in the right internal jugular vein for continuous central venous pressure (CVP) monitoring. Anesthesia was maintained with expiratory sevoflurane 2% (vol), sufentanyl 10 μg/h, and rocuronium 5 mg/h. Arterial blood gas values after intubation were pH 7.300, arterial oxygen pressure (PaO2) 154 mmHg, Hb 5.5 g/L, and potassium 2.6 mmol/L during intermittent positive-pressure ventilation with a fraction of inspired oxygen 0.6. The patient received 20% human serum albumin 50 ml and red blood cells 1U. Vital signs were stable at 25 min of the hepatic-free stage, and arterial blood gas values 20 min after portal occlusion were pH 7.310, base excess −6.8 mmol/L, Hb 8.8 g/L, and potassium 3.4 mmol/L, while core body temperature was maintained at 37°C. She received 5% sodium bicarbonate 30 ml.
+Immediately after reperfusion, IABP, especially systolic blood pressure, steeply decreased to 64/45 mmHg, followed by a heart rate decrease to 117 bpm. IABP quickly returned to 80/50 mmHg without treatment. However, the ST segment began to increase to 3.0 mm and gradually reached 13.2 mm within 45 min . The patient's blood pressure (BP), heart rate (HR), and SpO2 were in the normal range during this period.
+For further diagnostic workup, the respiratory circuit, tracheal tube, and anesthesia machine were also checked as soon as possible to confirm that all processes were normal. A full-lead ECG was monitored at the surgical bedside, showing the ST-segment elevation (STE) in II, III, and Augmented Voltage Foot (EKG lead) (aVF) leads, and ST-segment depression in I and Augmented Voltage Left Arm (EKG lead) (aVL) leads, consistent with subendocardial and inferior subepicardial myocardial injuries . Arterial blood gas was detected, and values were in normal range except for potassium 3.1 mmol/L. Myocardial infarction markers were also detected, which showed that cardiac troponin (cTnl), creatine kinase-MB (CK-MB), and myoglobin (MYO) had all increased to more than 2 times the normal values. After 2 h of nitroglycerin infusion at a dosage of 2 μg/kg/min and potassium chloride at a dosage of 0.5 mg/kg/min, STE gradually reduced to 1.6 mm .
+The procedure was completed 3 h after reperfusion, with consistently stable vital signs. A full-lead ECG was monitored immediately after admission to the transplantation intensive care unit, showing slight ST-segment elevation in II, III, and aVF leads . Markers of myocardial infarction gradually decreased to almost normal levels during the first few days after the procedure . The patient was successfully discharged from the hospital 12 days after surgery. An echocardiogram showed a patent foramen ovale with a left-to-right shunt tract width of 2.7 mm. No sequela related to air embolism was identified postoperatively.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1036_en.txt

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+A 46-year-old male was admitted with the chief complaints of nasal bleeding and nasal obstruction since 4 months. His blood profile for biochemistry and hematology was within normal limits. Tests for human immunodeficiency virus (HIV), hepatitis B surface antigen (HBsAg), and hepatitis C virus were negative.
+Contrast-enhanced computed tomography scan (CECT) and contrast-enhanced magnetic resonance imaging (CEMRI) of the brain and paranasal sinuses were suggestive of a large heterogeneous mass in the left superior nasal cavity (causing its expansion) with intense heterogeneous post-contrast enhancement. The lesion was extending posteriorly into the nasopharynx, medially into the right nasal cavity and right maxillary antrum with deviation of the nasal septum to the right side, and laterally into the left maxillary sinus with blockage of the osteomeatal complex. Superiorly, the lesion was seen to erode the cribriform plate and extend into the anterior cranial fossa. There was evidence of peritumoral cysts at the tumor–brain interface with perilesional edema. The lesion involved bilateral ethmoidal and sphenoidal sinuses also . The patient underwent a combined bifrontal osteoplastic craniotomy and excision of the intracranial part of the tumor from above and transnasal endoscopic removal of the mass in the nasal cavities and paranasal sinuses from below. Postoperative CECT scan of the brain and paranasal sinuses was suggestive of gross complete excision of the mass .
+On histopathological examination (HPE), the tumor was composed of lobules, sheets, and nest of primitive cells which were displaying high nuclear: cytoplasmic (N:C) ratio, pleomorphism, round hyperchromatic nuclei with inconspicuous nucleoli, and scanty cytoplasm. On immunohistochemistry (IHC), the tumor cells were positive for neuron-specific enolase (NSE), synaptophysin, chromogranin, CD56, and peripherally for S100 and were negative for CD99. True rosette formation was noted. Large areas of necrosis and brisk mitotic activity were seen. Neurofibrillary matrix was absent. The tumor cells were seen infiltrating the adjacent brain parenchyma. Some areas showed epithelial differentiation in the form of glandular, squamous, and respiratory epithelium. On IHC, these areas were positive for cytokeratin (CK) and epithelial membrane antigen (EMA). CK 5/6 was positive in the squamous morules and CK 7 focally in the glandular component. Intervening stroma was positive for vimentin. The final histopathological report was “mixed olfactory neuroblastoma-carcinoma (squamous and glandular differentiation) Hyams grade IV” .
+The patient was discharged after removal of stitches on postoperative day 7. He was advised to take adjuvant radiotherapy, which the patient did not take due to personal reasons. Two months later, he presented to us again with nasal bleeding and nasal obstruction. CECT scan and CEMRI of the brain and paranasal sinuses were suggestive of a large recurrence of esthesioneuroblastoma with similar extensions as before . Metastatic work up of the patient was normal. The patient is now planned for salvage surgery followed by adjuvant chemoradiation.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1042_en.txt

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+A 76-year-old male patient [body mass index (BMI), 21.5 kg/m2] was admitted to the General Surgery Department of our institution due to local abdominal distension in the left lower flank and intermittent abdominal pain for one year.
+Before admission, the patient had undergone laparoscopic rectal resection one year ago in our institution. During the operation, five trocars were used in this patient, including a 10 mm trocar inserted at the umbilical site, two 5 mm trocars in the left flank, a 12 mm trocar and a 5 mm trocar in the right flank, respectively. Fascia layers were closed by an absorbable suture at the ≥ 10 mm trocar site. A 20 FR soft rubber tube was inserted in the left lower quadrant stoma port to drain excessive blood and exudates. The drainage tube was removed five days postoperatively following gastrointestinal function recovery, and the drainage liquid was ≤ 20 mL/d. The fascia layer at the drain site was not closed due to a tiny defect. The postoperative period was uneventful and the patient was discharged on the ninth day after the operation. The patient reported no discomfort postoperatively. However, one month later, there was abdominal bulging in the left lower flank in the standing position, which disappeared in the supine position. Little attention was paid to this initially; however, the patient felt a gradual progression of the abdominal bulge, accompanied by occasional dull abdominal pain over time.
+The patient had a history of chronic bronchitis combined with intermittent cough without regular medical treatment. He also has a history of hypertension, coronary heart disease, and a laparoscopic cholecystectomy. The patient showed well controlled blood pressure without cardiovascular system symptoms. There were no restrictions on his daily activities.
+The patient had no remarkable personal and family history.
+According to the physical examination after admission, the patient was found to have a local palpable mass (3 cm in length) in the left lower flank above the former drain-site and an abdominal wall defect (2 cm in length). Tenderness and rebound tenderness were not observed in the abdomen.
+Routine serological examinations were performed without obvious abnormalities.
+A preoperative computed tomography scan confirmed the diagnosis and showed an abdominal wall hernia at the drainage site in the left lower quadrant, and the content consisted of the omentum majus . The detected abdominal wall fascial defect was 2 cm in diameter.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1049_en.txt

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+The patient was a 29-year-old man admitted to the hospital four years ago (June 2009) due to hematemesis. The problem was diagnosed as esophageal variceal bleeding and the proper treatment was provided. He had no history of alcohol consumption or diabetes mellitus. Moreover, the tests were negative for all types of viral hepatitis (B, C), EBV (Epstein–Barr virus), herpes, CMV (Cytomegalovirus), autoimmune hepatitis, HIV, celiac and Wilson’s disease. The colonoscopy result was normal. On April 2010, liver biopsy showed cirrhotic changes and the patient was diagnosed with cryptogenic cirrhosis. His name went to the list of liver transplantation candidates and the academic management for cirrhotic patients was started for him.
+The patient first visited Behesht Clinic of Tehran University of Medical Sciences in Tehran for Iranian traditional medicine on September 2011, about 17 months after being diagnosed. At the time, his medicinal prescription included spironolactone, propranolol, prednisolone and doxepin. The patient stopped taking all the medications after one month.
+His height was 173 cm and his weight was 57 kg. In his first visit, he had flatulence, dyspepsia, and heartburn. He was generally thirsty and drank up to eight glasses of cold water a day. He also had severe itching sensation of skin and would not sweat even during intense physical activities. His sclera was icteric.
+From his first visit to Behesht Clinic on September 2011 till February 2013, the patient was visited 16 times and each time, considering his general state and by performing physical examinations, the necessary traditional medication was prescribed for him. After three weeks of treatment, his itching sensation was significantly reduced, he felt energetic, and his flatulence and heartburn decreased. During four months of treatment, the patient gained 6 kg without any sign of ascites in abdominal ultrasonography. From the first admission (June 2009) until the end of study (February 2013), the alpha-fetoprotein (AFP) level was always in the normal range. The traditional medicine preparations used for this patient were based on the book “Al-Qanoon fi al-Tibb” by Avicenna. What follows is a list of different medicines used at different stages of the treatment:
+Monzeje soda, kabed capsuls, sekanjebine-bozoori, sekanjebine-sadri, samgh capsuls, eksir syrup, khabasolhadid, goleghand, habolroman, javareshe amole, aftimoon syrup, araghe-kasni shahtare, araghe-zenyan. and show the changes in the patient’s test results before and after the traditional medication. At the moment, the patient is in a good general condition and there is no need for liver transplantation.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1071_en.txt

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+We present a case of a 46-year-old Asian woman who was usually fit and well except for a 1-year history of menorrhagia prior to her initial presentation in our emergency department (ED). Her menorrhagia was due to multiple fibroids diagnosed via transvaginal ultrasound of the pelvis in 2018, which showed a multifibroid uterus with normal-appearing ovaries and no obvious adnexal cysts/masses. She was then started on TXA (1 g three times daily as required) and mefenamic acid (500 mg three times daily as required) to be taken during her menstrual period to reduce excessive bleeding and pain, respectively. She claimed she did not have to take the TXA (and mefenamic acid) during all her menstrual periods, because she believed the TXA was not required on many occasions. She was physically healthy, of normal weight (body mass index of 22 kg/m2), never smoked cigarettes or drank alcohol, and had no previous history of DVT or PE. She also denied using any form of contraception and had no significant family history of clotting disorders or cancer, but she claimed her mother had type 2 diabetes mellitus and had died of myocardial infarction.
+Our patient presented to our ED with a 2-week history of noncardiac-type central chest pain that was nonradiating, pleuritic, and intermittent with occasional shortness of breath on exertion. She had no history of diaphoresis, nausea, vomiting, cough, fever, or any infective symptoms. She had no history of recent long-distance journey or any other significant risk factors suggestive of VTE.
+Except for a fast heart rate (119 beats/minute), her vital signs, including blood pressure and physical examination, were within normal limits. Her chest x-ray was normal, and her Electrocardiogram (ECG) showed no dynamic changes except for sinus tachycardia. Her D-dimer was marginally raised at 0.66 μg/ml (normal range, 0.05 to 0.50 μg/ml), whereas her cardiac troponin I finding was negative. Other routine blood test results, including electrolytes, complete blood count, inflammatory markers, and clotting screen, were within normal limits. She was diagnosed with possible anxiety/musculoskeletal pain and sent home with analgesics and a planned follow-up review of her symptoms in the emergency ambulatory clinic (EAC) after 1 week.
+About 2 weeks after her initial presentation, the patient came back for follow-up review in the EAC as planned. She claimed she still experienced pleuritic chest pain on and off in addition to a new intermittent interscapular pain. A repeat D-dimer test result came back negative (0.35 μg/ml; normal range, 0.05 to 0.50 μg/ml). Likewise, results of her physical examination and recheck of her routine blood tests, including troponin I, clotting screen, and inflammatory markers, were all within normal limits. She was reassured and discharged to home after a (repeat) normal chest x-ray finding. She was informed that a computed tomographic (CT) pulmonary angiogram (CTPA) or ventilation/perfusion measurement was not required.
+About 2 months after the follow-up review, our patient re-presented to our ED with symptoms of pleuritic central chest pain and intermittent shortness of breath on moderate exertion. She claimed her symptoms were similar to her previous presentations. Further history was taken to exclude infection, cardiac-related problems, and common risk factors for PE, among other illnesses, but the findings were unremarkable. The patient said she last took her TXA for 2 days before the index presentation. Her physical examination results, including respiratory and cardiovascular examinations, were as usual within normal limits. Her vital signs were normal except for tachycardia (pulse rate of 113 beats/minute). Her blood workup showed slightly raised D-dimer (0.93 μg/ml), but other routine blood results for infection, thyroid function, electrolytes, clotting screen, complete blood count, and cardiac biomarkers were again all within normal limits. Her ECG showed sinus tachycardia, but her chest x-ray finding again was normal. Wells Score for PE was 4.5. We had a high suspicion to exclude PE in view of her symptoms and TXA use. So, a therapeutic dose of enoxaparin was started, and we placed an order for CTPA. The CTPA report 2 days later demonstrated filling defects in the distal subsegmental branches of the left lower and right upper segments that confirmed bilateral subsegmental PE (see Figs. and ).
+Following the confirmation of PE diagnosis on the basis of imaging, our patient’s treatment dose of enoxaparin was changed to apixaban. The planned duration of treatment with apixaban was 3 months; however, this is usually subject to evaluation during patient follow-up in the anticoagulation clinic. Our patient was then advised to stop TXA and informed to use other painkillers, such as paracetamol and/or codeine phosphate, for pain control instead of mefenamic acid due to increased risk of bleeding caused by drug–drug interactions with apixaban.
+An outpatient CT scan of the patient’s abdomen and pelvis (CT-AP) was arranged and obtained within 2 weeks after PE diagnosis to rule out any occult malignancy. The CT-AP scan report finding was normal. The patient was subsequently referred for routine follow-up in the anticoagulation clinic within the hematology unit (as per our hospital policy). In the anticoagulation clinic, a patient with acute VTE would usually undergo further evaluation as may be necessary including workup for thrombophilia screen and a decision on duration of anticoagulation treatment is made.
+After 1-month follow-up of the patient over the telephone, she claimed her pleuritic chest pain has improved significantly and her menorrhagia and menstrual pain remained stable. However, about 11 weeks into the treatment with apixaban, while the patient was under follow-up in the anticoagulation clinic, she was sent for a repeat CTPA due to new-onset cough and breathlessness on exertion together with a raised D-dimer of 0.76. The repeat CTPA scan report showed that the PE noted seen on the previous scan had resolved, and no evidence of a new PE was seen, but there was new consolidation in the right lung. She was treated accordingly with appropriate antibiotics with a good clinical response. Following the resolution of symptoms, the decision was then made in the anticoagulation clinic that thrombophilia screening was no longer indicated in the patient at that time.

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+A 32-year-old Chinese female was admitted to Sichuan University West China Hospital with a 6-month history of upper abdominal pain. She denied previous radiotherapy or industrial chemical exposure. She had one previous pregnancy and and gave birth to a boy. In addition, she denied previous hormonal treatments and contraceptives. She was found to have viral hepatitis B for 6 years and had not received any treatment. Besides, she was healthy with no relevant medical or family history of diseases, such as hypertension or diabetes, and no history of smoking or alcohol consumption. Physical examination was unremarkable. A blood count showed Hb 14.2 g/dl (13–17.5), white blood cells 7.12×109/L (3.5-9.5), platelets 249×109/L (100–300), total bilirubin 12.5 umol/L (5.0-28), and AST 35 IU/L (<50). Serological testing for tumor marker of carcinoembryonic antigen (CEA) was 5.54 ng/ml (CEA ≥ 3.4 ng/ml was defined as abnormal) and hepatitis B surface antigen (HBsAg) was positive. The hepatitis B virus DNA (HBV-DNA) was less than 1×102 IU/ml (HBV-DNA ≥ 1×102 IU/ml was defined as HBV infection active), suggesting that HBV infection was inactive. The cancer antigen19-9 (CA19-9 ≥ 30 U/ml was defined as abnormal), CA125 (CA125 ≥ 24 U/ml was defined as abnormal) and α-fetoprotein (AFP≥ 7 ng/ml was defined as abnormal) was 25.6 U/ml, 13.3U/ml and 3.37, respectively. Abdominal computed tomography (CT) showed the lesion in the left lobe of liver was detected, and no tumor was detected in any other organs . Magnetic resonance imaging (MRI) of the upper abdomen was performed in our hospital for further diagnosis. The MRI showed a 1.1×1.3 cm lesion in the left lobe of liver, appearing low signal intensity on T1-weighted images and high signal intensity on T2-weighted images . Due to the similar appearance, hepatocellular carcinoma (HCC) was considered for preoperative diagnosis. The patient eventually underwent a laparoscopic liver resection of the left lobe. Macroscopically, the tumor was a yellowish solid mass with a diameter of 12mm. Microscopically, the lesion composed of undifferentiated epithelial cells with some atypical glands, and significant lymphocytic infiltration . The epithelial tumor cells were featured by eosinophilic cytoplasm with large nuclei and prominent nucleoli. EBVencoded RNA (EBER) in situ hybridization was positive in tumor tissues. In addition, immunohistochemical analysis showed the lymphatic tissue positive for CD20 (B-cells, ), CD3 (T-cells, ), Ki-67 and negative for IgG4. Meanwhile, tumor cells positive for CK7 , and negative for CK20, supporting the diagnosis of LEL-ICC.
+Post-operative recovery of the patient was well. The patient was discharged on postoperative day 5 with good general condition. The laboratory parameters were normal and we recommended regular follow-up in the outpatient clinic.
+Patients monitored the disease progression at the outpatient of our hospital every 3 months in the first two years after surgery and every 6 months thereafter via blood examination, ultrasonography (US), CT, and MRI. The systematic update of patients’survival information was performed once a year. The last outpatient follow-up was in August 2022, and the tumor markers were normal. The patient was free from tumor recurrence after a 28 months follow-up .

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+We report the case of a 43-year-old black woman admitted to the surgical emergency department for abdominal pain with inability to pass gas or stool, evolving for 3 days. She came from a rural community, without a health care structure, located about 100 km from the urban center. The anamnesis found menarche at 16 years old, an irregular menstrual cycle, a previous gestation and parity about 18 years ago, and a child who died at the age of 1 year. Our patient, divorced for 15 years, had reported an abdominal mass evolving for several years (about 10 years) with chronic constipation. The date of the last menstruation was not known. Our patient concealed any notion of sexual intercourse. On admittance to the surgical emergency department, our patient had a bad general condition and clinical anemia. A physical examination of her abdomen noted a widespread distension with an irregular, polylobed mass occupying the entire umbilical region. The supraumbilical stage was tympanic to percussion with elastic resistance to palpation. The rectal examination found an empty rectum, and the mass was perceptible in Douglas’s pouch. At the vaginal pelvic examination, we found the same mass and a finger holster was clean.
+An erect abdominal X-ray noted an ileocolic distension with some hydroaerial levels and a pelvic opacity . The diagnosis of AIO by a tumor was evoked, and emergency laparotomy was indicated. The biological examination noted: anemia at 10 g/dL, and slightly altered renal function (a uremia level of 12 mmol/L, a serum creatinine level of 190 μmol/L).
+A nasogastric tube, a urinary catheter, and a large venous line were installed for resuscitation. A median laparotomy allowed the aspiration of 1.2 L of blood. Exploration noted a ruptured right tubal ectopic pregnancy and a polymyomatous uterus. The largest myoma previa adhered to the rectosigmoid hinge and compressed it , explaining the extrinsic obstruction of the colon. A total hysterectomy was performed. The surgical specimen containing the uterus, myomas and annex weighed 4.5 kg . The most voluminous myoma was 18 cm wide and 23 cm long. The surgical recovery was uneventful, and our patient was discharged on postoperative day 12. Our patient was informed that she could no longer have children. Our patient was very satisfied with the disappearance of this abdominal mass, which hampered her daily activities. A histologic examination confirmed a ruptured ectopic pregnancy and myofibroma without signs of malignancy.

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+A 62-year-old man with SIT, intestinal malrotation, and type 2 diabetes underwent gastroduodenal endoscopy for investigation of epigastric discomfort. A 5-cm type 2 tumor was found at the cardia side of the EGJ . A biopsy confirmed moderately differentiated adenocarcinoma, and the patient was diagnosed with Siewert type II EGJ cancer with 2.5 cm of esophageal involvement. Computed tomography (CT) revealed SIT, intestinal malrotation, multiple spleens, and irregular thickening of the gastric wall. No swollen lymph nodes (LNs) or distant metastases were observed . The patient was diagnosed with EGJ cancer (T3N0M0 Stage IIA according to the 8th edition of the Union for International Cancer Control (UICC)-TNM classification). In addition, three-dimensional (3D) reconstruction of a CT angiogram showed that the common hepatic artery was absent, the proper hepatic artery was derived from the superior mesenteric artery through the gastroduodenal artery, and an accessory left hepatic artery (ALHA) arose from the left gastric artery (LGA) . We planned a robot-assisted transhiatal lower esophagectomy and proximal gastrectomy with D2 LN dissection, including lower mediastinal lymphadenectomy.
+The patient was placed in a spinal position and the port placement mirrored our conventional settings . The patient’s position was changed in a reverse Trendelenburg position with 15 degrees before the da Vinci Xi Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA, USA) rolled in. The first and second arms were placed on the right side of the abdomen for Cadiere forceps and Maryland bipolar forceps, respectively. The fourth arm was placed on the left side of the abdomen for fenestrated bipolar forceps. The assistant port was also placed on the left side of the abdomen. Robotic bipolar vessel-sealing tools were attached to the second arm or fourth arm depending on the surgical site.
+After laparoscopic inspections, the lesser omentum was opened and suprapancreatic LN dissection was started. The two left gastric veins draining into the splenic vein (SPV) were clipped and cut . The LGA branched an ALHA and was itself divided into three branches. The branches of the LGA were clipped and cut, preserving the root itself . Station 11p and 11d LNs were dissected, tracing the splenic artery behind the SPV. Next, the greater omentum was dissected from the middle part toward the lower pole of the spleen, and station 4sa LNs were dissected. The rest of the suprapancreatic LN dissection was then completed toward the crus of the diaphragm. On the right side of the patient, the left gastroepiploic vessels and the short gastric vessels were divided by a sealing device attached to the second arm or fourth arm depending on the working angle. Transhiatal lower mediastinal lymphadenectomy was then performed (station 110 LNs) . We decided to secure a safety margin of at least 2 cm from the tumor. It was 4 cm from the angle of His based on preoperative esophagogastric fluoroscopy, where was transected with an EndoWrist Stapler (Intuitive Surgical, Inc., Sunnyvale, CA, USA) . The stomach was transected at the upper one-third level. The resected specimen was extracted through an umbilical incision.
+After checking the margin of softy on the back table, esophagogastrostomy was performed according to the side overlap with fundoplication by Yamashita (SOFY) method as follows . The central apex and left edges of the remnant stomach stump were fixated by suture to the crus of the diaphragm. The esophagus was pulled caudally, and the most proximal dorsal side of the esophagus was fixated by suture to the apex of the remnant stomach stump to prevent the esophagus from being pulled into the mediastinum. Small incisions for a stapler were made in the center of the anterior gastric wall and left side of the esophageal stump, respectively. A 45-mm EndoWrist Stapler was inserted into both holes. The esophagus was then rotated 45 degrees clockwise and stapled to suture the left wall of the esophagus to the stomach. The entry hole was closed using 3–0 absorbable barbed sutures. The esophagus was rotated back 45 degrees, and the posterior wall was placed parallel to the stomach wall. The right side of the esophagus was fixated by suture, completing the valvuloplasty .
+The surgical time was 296 min, and the amount of blood loss was small. Histopathological diagnosis revealed a Siewert type II tumor measuring 50 × 37 mm in diameter and moderately differentiated adenocarcinoma with subserosal invasion . Three metastatic LNs were present around the cardia. The final stage was pT3N2 pStage IIIB according to the 8th edition of the UICC-TNM classification. The patient had an uneventful postoperative course and was discharged 11 days after surgery.

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+A 39-year-old female who had suffered from trichiasis for more than 30 years complained of a foreign-body sensation and epiphora. The corrected visual acuity of her left eye was 20/30. Slit-lamp examination revealed multiple milky-white soft masses on the corneal surface of her left eye . A slight opacity was suspected in the anterior stroma under the slit-lamp examination. In accordance with our previous classification guidelines, this mass was classified as having a gelatinous drop-like dystrophy-like appearance. These multiple masses were located at the cilia-attached region.
+OCT (Cirrus™ HD-OCT; Carl Zeiss, Jena, Germany; cube 4×4 mm, 512 A-scan, five-line raster 3 mm, A-scans) revealed that while there was a large mass under the thinned epithelial layer, there was no destruction on Bowman’s layer throughout the region , although a little high density stromal cells were observed in the anterior stromal layer.
+On the other hand, the fellow cornea exhibited a linear subepithelial opacity that was not stained by fluorescein when observed under a slit-lamp examination . OCT revealed a high-density spot in Bowman’s layer , and this spot was coincident with the cilia-attached region and linear line observed under slit-lamp examination. There was normal thickness for the epithelial layer, and no change was observed in any other parts of the cornea in the fellow eye.
+To resolve the foreign-body sensation in the patient, the corneal tissues were excised by lamellar keratoplasty. After these excised specimens were frozen in 30% sucrose, 3 μm sections were cut and then mounted on slides. After the slides were dried, samples were fixed with 10% formaldehyde and stained with Congo red and antilactoferrin antibody (2B8; Abcam, Cambridge, UK). All of the sections were incubated with 1% bovine serum albumin in phosphate-buffered saline at room temperature for 10 minutes each in order to block the nonspecific binding. Subsequently, the samples were then incubated with antilactoferrin antibody for 90 minutes at room temperature. The sections were washed three times in phosphate-buffered saline for 10 minutes, with the binding of the antibodies followed by reaction with biotinylated goat antirabbit immunoglobulin G and horseradish peroxidase-conjugated streptavidin (Histofine SAB-PO kit; Nichirei, Tokyo, Japan). The slides were dehydrated using an ethanol series (70%–95%) and xylene, after which they were covered with a coverslip using mounting medium. All slides were examined by both light and polarizing microscopy.
+Histological analysis showed that the eosinophilic material was positively stained, with Congo red showing apple-green birefringence under polarized light . The material was also positive when using the antilactoferrin antibody , with this area matching the Congo red-positive region. However, it should be noted that we found that Bowman’s layer was occasionally destroyed within the frozen section.
+Ten months after the operation, the corrected visual acuity of the patient’s left eye was 20/20. Epilation of the cilia is performed regularly, and no recurrence of amyloid deposition has been found.

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+We report the case of a possible association between treatment with PCSK9i and the occurrence of adverse neurological outcomes in a subject with a previous diagnosis of myasthenia gravis.
+The patient was an obese (BMI 30.8 kg/m2) man who was 72 years old and who underwent thymoma resection in 2005, urgent examination in 2007 (IKEM), which revealed weakness, fainting, and unremarkable internal and cardiac findings. He was diagnosed with myasthenia gravis (nonspecified immunosuppressive therapy was administered during long stay in Moscow) in 2010. He was diagnosed with ischaemic heart disease in 2015 and prescribed aspirin 100 mg; PCI (2× DES) was performed. The patient suffered from type 2 diabetes mellitus (treated with Glucophage 850 mg), arterial hypertension (Valsacor 80 mg, Orcal neo 5 mg) and lipid metabolism disorder. Total cholesterols ranged from 5.80 to 6.30 mmol/L. He stopped smoking 15 years prior, and reported having an allergy to penicillin.
+In 2022, elevated lipid values was observed (TC—5.95 mmol/L, LDL-C—4.35 mmol/L, HDL-C—0.95 mmol/L and TG—2.90 mmol/L); postprandial glycaemia 9.7 mmol/L; additional biochemical parameters (Na+; K+; Cl−; bilirubin; AST; ALTl; urea; S-creatinine; hs-troponin Tb; blood counts and CRP) were in the normal range. ECG—sinus rhythm, rare ventricular extra systoles. Statin treatment was not implemented because of chronic myasthenia gravis (as a contraindication) and the patient's strict negative attitude towards statin treatment.
+After considering the indication criteria, PCSK9i monotherapy was implemented to treat dyslipidaemia.
+According to the patient′s family (the patient did not personally contact the doctor), within 24 h after the first dose of PCSK9i [Repatha (evolucamab), 140 mg], the patient developed severe muscle weakness, joint pain, fever, and general discomfort, lasting for several days. The PCR test for SARS-CoV-2 positivity was negative.
+The physician strongly advised against the administration of the second dose of PCSK9i and to contact the treating physician immediately. Despite this fact, the second identical dose was self-administered approximately 2 weeks later, and the family called again to report significant worsening of the muscle problems within 24 h after PCSK9i administration, leading to the patient being admitted to the neurology department where he was being treated for myasthenia gravis. The patient was unable to squat, had impaired gait stability and speech impairments. Magnetic resonance of the nervous system reveal no abnormalities. Patient has been treated by corticosteroids (10 mg/day) but without any improvement. Finally, pregabalin has been administered and patient was subsequently treated with five plasmaphereses, leading to the slow improvements of muscle problems.
+Electromyographic findings were as follows: n. medianus DML 120%, lowering of the amplitude of CMAP (muscle action potential), n. ulnaris DML 120%, n. perineus l.sin. DML, 120%, F waves increased by more than 130%.
+The finding is indicative of subacute demyelinating axonal, sensorimotor polyneuropathy of the lower extremities. Changes in more than two nerves support dg. autoimmune polyradiculoneuropathy/suspicious acute inflammatory demyelinating polyneuropathy. Based on the neurologist's conclusion, it can be assumed that in this case, treatment with PCSK9i resulted in significant worsening of the patient's chronic disease.

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+This 2-year-old boy was the third son of non-consanguineous healthy Italian parents. He was born at the fortieth gestational week after an uneventful pregnancy and a spontaneous delivery. Family history was negative for neurological diseases or congenital birth defects. One and five minute Apgar scores were respectively 9 and 10. Birth weight was 3450 g (35–50th percentile), birth length was 55 cm (97th percentile) and head circumference was 33 cm (10th percentile). At birth, bilateral metatarsus varus was evident, requiring conservative orthopedic treatment. No further bone deformities were noticed. He was referred to our attention at age of 8 months for daily, brief episodes of generalized hypertonia and staring. Dysmorphic features of the face were observed, such as arched eyebrows, down-slanting palpebral fissures, anteverted nostrils, depressed nasal bridge, wide philtrum, and arched thin upper lip . A single cafè-au-lait spot was present on left thigh. Neurological evaluation showed axial hypotonia. Microcephaly was not present. Developmental milestones were mildly delayed: the baby controlled his head at age 5 months, but could not be seated without support. An ictal video-electroencephalogram (EEG) revealed normal findings for age and excluded an epileptic origin of the events. Subsequently, at the age of 9 months, he developed daily episodes of psychomotor arrest, palpebral myoclonias, oral automatisms (e.g., chewing) rarely coupled with vibratory hypertonus. Sleep and awake interictal video-EEGs showed a normal background activity with epileptiform anomalies in bilateral central regions. Therapy with levetiracetam was started and titrated to 40 mg/kg/day. Brain magnetic resonance imaging revealed corpus callosum hypoplasia and enlargement of fronto-temporal sub-arachnoids spaces. Cardiac, abdominal and pelvic (including liver, spleen, gall bladder, pancreas and bladder) ultrasound findings were unremarkable. Eye examination revealed no abnormalities. Routinary biochemical analysis, electrocardiogram, auditory brainstem response and visual evoked potential and electroretinogram yielded normal results. Valproic acid (30 mg/kg/die) and, successively, clonazepam (0.6 mg/die) were added to levetiracetam since daily seizures persisted.
+At last follow-up the child is 2 year old. Seizures are controlled by levetiracetam, valproic acid and clonazepam and recurred twice during febrile episodes. Language delay is present: he is able to pronounce 3–5 words. Motor development is improved: he can stand and walk autonomously.

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+A 72-year-old woman had a mass in the right frontal region for 3 years. Due to the appearance of unsteadiness when walking, a magnetic resonance imaging (MRI) was performed 6 months previously, and she was diagnosed with frontal cranial tumor. Two months earlier, the patient experienced left hemiconvulsive seizures with impaired consciousness and was started on anticonvulsant medication. Subsequently, she was referred to our hospital for treatment. She had no neurological symptoms on examination but had mild cognitive dysfunction . Electroencephalography (EEG) revealed a tendency toward slowing of background and rhythmic delta activities in the right frontotemporal region of Fp2, F4, C4, F8, T4, and T6. Computed tomography (CT) scan showed a 10.7 × 10.0 × 5.5-cm mass from the right frontal to the parietal bone, expanding into the diploic space, and partly extending beyond the sagittal suture to the contralateral side [ and ]. Perfusion CT-indicated increased blood flow and volume [ and ]. Furthermore, the venous phase of four-dimensional CT angiography revealed that the superior sagittal sinus (SSS) was occluded due to the tumor . MRI revealed a high signal on T1-weighted imaging (T1WI) and T2-weighted imaging and signal suppression on fat-suppressed T1WI, suggesting a tumor with a fat component [-]. There was no signal change in the brain parenchyma, but it was accompanied by a midline shift . The right external carotid artery angiography revealed marked tumor staining from the right middle meningeal artery (MMA) . The tumor was fed mainly from the anterior branch of the MMA, and the other feeders were the posterior convexity branch of the MMA, deep temporal artery (DTA), and superficial temporal artery. Furthermore, the draining veins were highly dilated within the tumor and formed varices . A couple of the drainers were also delineated in the arterial phase, suggesting the presence of an AVF . The right internal carotid artery angiography revealed vascular loss at the tumor site and partial disruption of the SSS. There was no feeder from the right ICA, and there was a small amount of tumor stain from the anterior branch of the left MMA and the peripheral part of the left occipital artery. In view of the radiological findings, a provisional diagnosis of an intraosseous hemangioma was established. Since it was symptomatic and the patient and her family wanted surgical treatment, we decided to perform the surgery.
+Preoperative endovascular embolization was performed with N-butyl-2-cyanoacrylate (NBCA) and particles through feeding arteries. First, we introduced the microcatheter to the anterior branch of the right MMA and DTA and injected the NBCA diluted with contrast medium to 16.7–20.0%. Next, the MMA main trunk was also embolized with Embosphere® and fibered coils. Finally, the tumor stain was dramatically reduced after embolization . Two days after embolization, the patient underwent craniotomy. A thick DTA ran under the temporal muscle and was determined to be a feeding artery; therefore, we cut it after thorough coagulation. When the flap was inverted, the tumor was partially exposed on the bone . The tumor was fragile and easily bleeding. Many entry burr-holes were made on the surrounding normal bone to avoid cutting into the tumor. Since we found that the dura mater was firmly adherent to the inner table of the cranial tumor, the outer table of the tumor was first removed piecemeal. The diploe layer, containing a large amount of fat, bone tissue, and blood vessels, believed to be the main components of the tumor, was resected. During the operation, profuse bleeding from the inner table and dura near the SSS was encountered, and a blood transfusion was performed. The bleeding was controlled by removing the inner table and attaching dura, but a small part of the tumor near the SSS was left behind to preserve venous return [ and ]. After the resection, osmotherapy was performed to prevent cerebral edema. Cranioplasty was performed using a custom-made titanium mesh plate 1 month after the tumor resection [ and ]. After the tumor resection, E3V4M6 disturbance of consciousness and MMT4/5 left paralysis appeared transiently, but those symptoms disappeared after cranioplasty. The patient’s cognitive dysfunction also improved . MRI performed 2 years after the surgery showed no tumor recurrence, the occluded SSS was refluxed, and the midline shift had disappeared [-]. The EEG findings also improved, and although the anticonvulsant was discontinued 1 year after resection following the patient’s desire, the patient has remained seizure-free.
+Histological examination revealed that the intracranial tumor was composed of mature adipocytes with various-sized dilated vessels [ and ]. There was no fibrin thrombus formation characteristic of cutaneous or soft-tissue angiolipoma. The abnormal vessels in the tumor had varices with a mild chronic inflammatory cell infiltration in the adventitia [ and ]. Immunohistochemically, these adipocytes were negative for MDM2 and p16. Taken together with the lack of cytological atypia of adipocytes and vessels , there were no findings suggestive of malignancy; thus, the patient was finally diagnosed with angiolipoma.

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+A 54-year-old woman presented at our hospital had left knee pain and gradually uncomfortable for 5 years. Symptoms rapidly worsened with limited activity in the last 5 months. The patient suffered from idiopathic thrombocytopenic purpura which needed low-dosage oral prednisone (5 mg for three times per day) 6 years ago. Recently, she was frequently suffering from pain on the lateral side of the knee during long time walk and stair performance.
+Physical examination: There was focal tenderness over the lateral femoral condyle of the left knee. The physical examination elicited severely knee pain of the lateral side on extremes of range of motion, as well as during valgus stress test on the knee, but range of motion was not significantly limited. The EuroQol five-dimension (EQ-5D) quality of life score was 0.587, Knee Society score (KSS) was 64 and WOMAC score was 38.
+Preoperative radiographs: Magnetic Resonance Imaging (MRI) revealed avascular necrosis of the lateral femoral condyle and bilateral femoral head necrosis . According to the Ficat-Arlet classification (modified version) [, ], this knee osteonecrosis was classified as stage IV.
+The diagnosis was secondary osteonecrosis of the lateral condyle and Idiopathic thrombocytopenic purpura. Due to the presence of a large lesion limited to lateral femoral condyle, no evidence of joint space narrowing in the medial tibia-femoral compartment, and intact cruciate and collateral ligaments, the therapeutic treatment was fixed bearing lateral unicompartmental knee arthroplasty (LINK German). General anesthesia combined with midthigh saphenous nerve block was used for the operation. The knee was exposed via a lateral parapatellar approach to achieving a good view. Osteonecrosis of the distal aspect of the femur produces a large segment of dead bone (approximately 8.17 cm2) on the weight-bearing portion of the lateral femoral condyle . A large amount of necrotic bone, which mainly located on the posterior portion of femoral condyle, was completely removed down to the bleeding bed of bone by a spatula. Then we drilled several holes on the necrotic bone bed and filled the large bone defect with cement, which facilitated a solid initial fixation for cemented prosthesis. The rest of procedures was performed according to the lateral UKA operation manual. After the surgery, we enjoined her to avoid excessive knee flexion and intense activity in the early stage after surgery.
+Follow-up: The patient was evaluated clinically and radiographically at 6 weeks, 3 months, 6 months and 1 year postoperatively and on an annual basis thereafter unless a problem arose. She could walk without ambulation aid shortly after the operation on the surgery day by virtue of rapid anesthetic resuscitation from general anesthesia combined with midthigh saphenous nerve block. Postoperative radiographic imaging showed optimal size and precise position of the prosthesis. On the 2nd day after surgery, she felt significant pain relief and VAS pain score improved from 7 to 2. Her left knee range of motion (ROM) was at 0° to 90° . The patient could unlimitedly walk for hours, go up and down stairs freely and achieved satisfactory knee joint function with ROM of 0° to 120° at 6 weeks after the operation. Improving joint function provided a physical, mental and emotional boost to the patient. She could return to work and sport at two months postoperatively. The EQ-5D score was 1, the KSS and WOMAC score were 91, 20 respectively at the latest follow-up. The total follow-up period was 1 year and there was no pain, loosening, fracture, or wear of the prosthesis.

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+A 49-year-old man was admitted to Jiangxi Provincial People’s Hospital (the First Affiliated Hospital of Nanchang Medical College, Nanchang, China) with a mass in his right buttock for 4 mo.
+There was nothing significant about the patient’s present medical history.
+The patient had a history of sacrococcygeal trauma 3 years before admission, and there were no other abnormalities.
+In terms of personal and family history, there was nothing of note.
+There was no abnormality except the fullness in the right rectal wall found during the special anal examination.
+No obvious abnormality was found in the serum tumor markers.
+Magnetic resonance imaging (MRI) showed a large, well-defined mass located slightly to the right in the center of the pelvic cavity between the left and right obturator muscles . The mass appeared predominantly positioned in the area deep to the gluteus maximus, posterior to the pubic symphysis, underneath the bladder, and above the urogenital septum . It displaced the prostate and seminal vesicle glands to the upper left and pushed the rectum and anal canal close to the left pelvic wall . The mass displayed predominantly isointense T1 signal, which was related to the surrounding musculature and heterogeneous on fat-suppressed T1 (T1FS; Figures , , and ) and T2 (T2FS; Figure ) imaging. There was intralesional focal necrosis and perilesional edema .
+The mass was surgically excised. During surgery, it was found to be well-circumscribed and with an incomplete capsule and poor mobility, giving a clinical impression of a malignant tumor. Its upper margin reached the seminal-vesicle gland, and the outer edge closely adhered to the right part of the external rectal sphincter, levator ani, and puborectal muscles, but no nerve, vessel, or inguinal lymph node invasion was found.
+On gross examination, the mass was 13 cm × 12 cm × 8 cm in size, and covered by an incomplete capsule and the remnants of adipose tissue . The cut surface showed a solid, firm-to-elastic, and yellow-pink appearance, with focal cystic degeneration and necrosis within the mass . Histologically, the tumor had a definite capsule ; it was composed of short spindle- to oval-shaped cells and admixed with varying thick bundles of collagen and variable numbers of adipocytes . The cells had eosinophilic cytoplasm with indistinct cell borders and had elongated nuclei with fine chromatin . Hyaline and mucoid degeneration were visible within the tumor. Atypic and bizarre cells could be seen in some areas . It is worth noting that mitotic figures , even atypical mitosis , and multiple necrotic foci and nuclear debris could be seen in the tumor. In addition, smooth muscle and skeletal muscle were invaded within and at the edge of the tumor. These morphological features are often reminiscent of malignant tumors and therefore pose a severe diagnostic challenge to pathologists.
+IHC staining showed that these neoplastic cells were strongly positive for both CD34 and Des , and had lost expression of Rb1 protein . In addition, they showed positive expression of estrogen receptor, epithelial-membrane antigen, human homolog of murine double minute 2 (MDM2), and cyclin-dependent kinase 4 (CDK4) . However, they were negative for S100, smooth muscle actin (SMA), signal transducer and activator of transcription 6 (STAT6), and CD117 . The proliferation index of these neoplastic cells was about 5%, as shown by Ki-67 IHC staining . Fluorescence in situ hybridization (FISH) confirmed the monoallelic and biallelic deletion of the Rb1 and no amplification of MDM2 in these neoplastic cells.
+The preoperative clinical diagnosis was malignant mesenchymal tumor of the pelvic cavity.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1142_en.txt

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+A 33-year-old female presented to the clinic complaining of a polyp on top of a red plaque in the left side mons pubis for 1 year. It was a kind of round flaky red bulge lesion in the skin of mons pubis. On top of this, it is shown sarcomatoid hyperplasia covering with the yellow-green crust, and the surrounding skin had no obvious abnormality and elcosis. The plaque was slightly bulgy without pressing pain, covered with a thick yellow-white crust . The plaque was 2.2 × 1.8 × 0.5 cm, and the polyp was 2.5 × 2 × 1.5 cm. The width of the pedicle was 1.4 cm. There were no other systemic abnormalities or any palpable lymphadenopathy, ultrasound B was applied to evaluate the superficial inguinal lymph nodes. She had no significant history of medicine, surgery, irritation, and trauma. Before the lesion appearance, the patient had no discomfort, thus she did not pay attention to the skin lesion, and had not used other external medicines or ask for help from professionals. Until nearly a month, she found that the lesion was prone to bleed after friction, thus she came to our hospital for treatment. The lesion was removed surgically and the histopathologic examination was performed. The possibility of skin tumor was considered through dermoscopy, then the histopathological examination was performed to make the confirmation. Skin biopsy was made on December 31, 2019, and further immunohistochemical reports have been done on January 17, 2020. Detailed information was shown below.
+The dermoscopic images showed the dark red background, covering a thick yellow-and-white crust, with spot-shaped and polymorphic vascular structures which focally distributed. In some areas, white homogeneous structures could be seen, as well as dark red clumps. No typical pigment structure was seen . The skin lesions were considered as the diagnosis of skin tumors using dermoscopy.
+The excisional biopsy was carried out, and the specimen tissue was fixed in formalin, and embedded in paraffin. The histological examination showed: the skin lesion at the left side of mons pubis was spindle-shaped, the lesion size was 2.2 × 1.8 × 0.5 cm. There were gray-brown and mushroom-shaped protrusions on the epidermis, and the size of the protrusions was 2.5 × 2 × 1.5 cm, the pedicle width was 1.4 cm, and the transaction of the protrusions was grayish-white and grayish-red. Besides, Breslow thickness was about 9.5mm, and Clark level was IV. No tumor embolus was detected in the vessels. The tumor involvement had been found in the incisal edge of long-axis two sides and base of the tumor sample.
+Microscopically, the polyps were lined by melanocytes, with pale cytoplasm . It was represented as atypical cells and heteromorphic nuclei, with different cell sizes and abnormal mitosis of 5–7 counts /10HPF. Each slide was reviewed by 3 different pathologists, and the diagnosis was made as the melanocyte tumor.
+The immunohistochemistry (IHC) studies revealed that the expressions of S-100, HMB-45, Melan A and Cyclin D1 were stained positive, while CD-117 was focally immunoreactive and CD31, P16, PCK and LCA were stained negative. The final histopathological diagnosis was made: melanocyte nevus malignancy, nodular malignant melanoma. This patient underwent a complete local excision and she recovered well recently.
+The patient was required to re-examined regularly after surgery, and recent follow-ups showed that she recovered well and there was no sign of recurrence till now.

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+A 29-year-old primigravida Japanese woman presented to our hospital at 40 weeks and 1 day of gestation with marked vaginal bleeding. The posterior placenta had been low-lying, but had migrated to the upper uterine segment in the third trimester. Since admission, FHR tracing consistently demonstrated a sawtooth-like pattern with indeterminate baseline . There were 3–4 sharp oscillations per minute, and their amplitude was 30–40 beats per minute (bpm) . Although fetal movement was slightly observed, only a small amount of amniotic fluid was noted by ultrasonography. The middle cerebral artery peak systolic velocity of the fetus was 100 cm/second (1.55 multiples of the median); therefore, we initially suspected fetal anemia.
+Emergency cesarean section was performed because of non-reassuring fetal status. Evidence of placental abruption was not observed. The newborn was a male weighing 2936 g, with an Apgar score of 1 and 3 at 1 minute and 5 minutes, respectively. The umbilical artery cord pH was not available because the artery collapsed. The newborn was not severely anemic, with a hemoglobin level of 13.3 g/dl. The venous blood pH was 6.860 and base excess was − 21.9. Sarnat staging for hypoxic-ischemic encephalopathy of this newborn was grade II moderate. Therefore, the infant received brain cooling for 72 hours from 4 hours after birth. No abnormal findings were detected by brain magnetic resonance imaging performed at 13 days after birth, and the infant was discharged uneventfully. A follow-up examination including DENVER II Developmental Screening Test at age 1, 2, and 3 years demonstrated no developmental restriction.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1159_en.txt

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+A 72-year-old male with a history of growth hormone deficiency symptomatic for generalized fatigue and weakness and on somatropin replacement therapy (1 mg daily) had an incidentally found pituitary lesion identified two decades prior on magnetic resonance imaging (MRI) following hospitalization for stroke. His comorbidities included obesity (body mass index, BMI 30) and diabetes. At that time, the lesion was assumed to be a microadenoma measuring 1.0 cm and abutting the optic chiasm. At the time, he had no visual deficits and was managed conservatively. In 2021, he presented to his outside endocrinologist with an elevated cortisol level of 2.3 mcg/dL from a normal value one year prior and the absence of overt changes in clinical features, suggesting subclinical CD. In addition, the low-dose (1 mg) dexamethasone suppression study did not suppress cortisol levels, indicating CD versus Cushing’s syndrome. Repeat imaging demonstrated the growth of the lesion, now measuring 1.3 cm, with no compression of the optic apparatus .
+As a result of these findings, surgery was recommended. He underwent endoscopic endonasal transsphenoidal resection of the lesion without issue, and postoperative MRI demonstrated no residual mass . Postoperative AM serum cortisol was 12.4 mcg/dL one day after surgery and 1.7 mcg/dL two days after surgery. At one year follow-up, the patient’s insulin-like growth factor 1 level was decreased to 181 ng/mL from 281 ng/mL prior. Complete postoperative endocrinological laboratory results for patient 1 are unavailable due to reliance on endocrinological workup from an external hospital, despite efforts to access the records. Pathology demonstrated multiple fragments of the pituitary gland with normal nesting growth patterns. In addition, pituitary transcription factors, including growth hormone factor 1 (Pit-1), T-box transcription factor Tpit, and steroidogenic factor-1 (SF-1) showed normal distribution patterns in the parenchyma. Adjacent to these fragments was a colloid nodule and epithelium suggestive of RCC. The patient’s postoperative course was uneventful with his RCC resection. Approximately one week after surgery, for symptoms of nausea, fatigue, and muscle weakness, his workup was benign aside from hyponatremia, which was corrected during his hospitalization. One month postoperatively, the patient exhibited excellent recovery and no complications from the operation. On a longer-term follow-up with endocrinology, the patient reported improved fatigue and generalized muscle weakness.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1161_en.txt

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+A 47-year-old woman was admitted to our hospital because of an abnormal chest shadow found on a routine chest X-ray. SCD was diagnosed when she was 6 years of age. Chest computed tomography showed a well defined mass (48 × 31 mm) touching the pericardium and left lung . Laboratory examinations showed normal serum levels of alpha fetoprotein (2.4 ng/mL), human chorionic gonadotropin beta (< 0.2 ng/mL), and antiacetylcholine receptor antibody (< 0.2 nmol/L). The differential diagnosis included thymoma, thymic carcinoma, and germ cell tumor; and surgical resection was recommended. However, the patient was a high-risk surgical patient because of SCD. Physical examination revealed a patient who was 164 cm tall, weighing 56 kg. Her vital signs were normal. Neurological examination revealed limb, truncal, ocular, and ataxic dysarthria; hypotonia; areflexia; sensory disturbances; and muscle weakness. Her Eastern cooperative oncology group performance status was 4. Pulmonary function tests showed an obstructive pattern. Her vital capacity (1.57 L) was 56.3% of predicted value and her forced expiratory volume in 1 s /forced vital capacity was 70.5% of predicted value. Magnetic resonance imaging showed severe cerebellar atrophy and spinocerebellar degeneration .
+We decided to follow the patient while evaluating her general condition. Three months after her initial diagnosis, her tumor had grown to 50 × 35 mm. We performed surgery with the patient under general anesthesia only (without epidural analgesia), after explaining the risk of respiratory failure in detail and obtaining consent from her and her family. She received 30 mg rocuronium bromide (0.5 mg/kg), target-controlled propofol intravenous infusion (4.0 μg/mL), and remifentanil intravenous infusion (0.2 μg/kg/min) as general anesthesia by single-lung ventilation via a double-lumen endotracheal tube. Resection of the mediastinal tumor was performed via VATS. Although the tumor was firmly adherent to the left phrenic nerve, the tumor was carefully resected to preserve the nerve.
+Histopathological examination of the tumor revealed small lymphocytes and atypical thymic cells of intermediate size that resembled epithelial cells . Immunohistochemical staining showed that the small lymphocytes were positive for CD99 expression and the medium-sized atypical cells were positive for cytokeratin AE1/AE3 and negative for c-kit and CD5 expression. The lesion was diagnosed as type B1 thymoma without capsular invasion (Masaoka stage I). The patient’s postoperative course was uneventful, and she was discharged from the hospital on postoperative day 9. At the time of this report, 36 months after resection, she was doing well.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1163_en.txt

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+Our patient was a 68 year old African American female who developed diffuse abdominal pain, associated with nausea and bilious vomiting, 24 hours prior to her emergency room visit. The pain was localized to the epigastric region and had a progressive course. Her last bowel movement was reported as four days prior and she denied any recent weight loss, wheezing, flushing, palpitation or change in bowel habits.
+The patient's past medical and surgical history included hypertension, hyperlipidemia, total abdominal hysterectomy and bilateral salpingoophorectomy secondary to fibroids.
+The patient also reported a history of progressive loss of vision ten years earlier that was investigated by brain MRI after an extensive ophthalmological evaluation. The MRI showed a pituitary tumor and the patient benefited from a transphenoidal pituitary tumor resection. The pathological examination revealed a chromophobic pituitary adenoma.
+The patient had a strong family history of cancer. Her father died from colon cancer, a brother died from esophageal cancer, an uncle died from brain tumor, one aunt had been diagnosed with breast cancer and one aunt with gastric cancer.
+Upon physical exam, the patient had a tense, distended abdomen, with a well healed paramedian incision and no bowel sounds. There was non localized diffuse tenderness with positive rebound and voluntary guarding. Rectal examination revealed no masses and an empty vault. Laboratory values revealed no leukocytosis, however the lactic acid level was elevated. A computed tomography scan of the abdomen revealed a small bowel obstruction. Subsequently, the patient was decompressed with a nasogastric tube and fluid resuscitation, and brought to the operating room for an exploratory laparotomy. Intraoperatively, there was significant small bowel congestion with no necrosis. One adhesive band was found and lysed at the mid jejunum where it was fixed to the pelvic wall. The bowel was thoroughly inspected to look for any other points of obstruction or abnormalities. A serosal lesion was found on the surface of the jejunum ten centimeters from the adhesion . Also a suspicious hard draining mesenteric lymph node was seen. The serosal lesion, and the suspicious lymph node were both resected , and sent for pathologic determination.
+Postoperatively, the patient did well, however, the pathological evaluation of both the serosal lesion and the mesenteric lymph node revealed carcinoid tumor.
+Three days later, the patient was brought back to the operating room for exploratory laparotomy and small bowel resection. During the surgery, there was no intestinal lesion noted, and about 15 cm of small bowel on each side from the previous serosal lesion was resected with its corresponded mesentery . One enlarged and firm mesenteric lymph node, included in the specimen was marked with a stitch.
+The pathological examination of the specimen revealed a carcinoid tumor approximately 0.4 cm in greatest dimension, penetrating subserosa five centimeters from the previously resected serosal lesion . A metastatic carcinoid tumor was seen in three out of 17 lymph nodes including the one marked with the stitch. The surgical resection margins were negative.
+During the postoperative inpatient period, a 24 hour urine 5-Hydroxyindole Acetic Acid (5-HIAA) was within normal value and no focal area of increase uptake was noted on an octreotide scan.
+There was no postoperative morbidity, and the patient was followed as an outpatient at two and six month interval. During these follow up visits, the patient reported feeling better and denied any weight loss, wheezing, flushing, palpitations or diarrhea.
+A postoperative CT scan of the chest abdomen and pelvis six months after the surgery, revealed no evidence of recurrent disease, and no intra abdominal masses. A repeat octreotide scan at six months after the surgery did not show any area of increase uptake. Chromogranin A level was followed, and was decreasing from 142 ng/ml at two months post resection, to 64 ng/ml at six months post resection.

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+A 15-year-old male presented with gradually progressive painful low back swelling of 4 months’ duration without any neurological deficit. Plain lumbosacral X-rays showed an enlarged lytic lesion involving predominantly the left side of the sacrum and lower lumbar vertebrae L4-S2 . The MR demonstrated a large, multi-loculated, expansile mass with a soap-bubble-like appearance from L4-S2, which extended to the neural foramina, sacroiliac joints, and paravertebral muscles; findings were consistent with the diagnosis of an ABC . The lumbosacral CT showed a lytic lesion involving the sacral alae, part of the S1and S2 vertebral bodies, and destruction of the left L5 pedicle .
+An arterial angiogram confirmed the vascularity of the ABC mass. The patient underwent preoperative selective arterial embolization on the day of surgery, followed by an extended curettage . This was followed by a posterior pedicle screw and rod lumbopelvic reconstruction (i.e. L4-S2) .
+The histopathological examination confirmed the diagnosis of an ABC lesion: osteoid foci, spindle cells, multinucleated giant cells, and reactive changes.
+Two years later, the patient remained asymptomatic without evidence of ABC lesion recurrence. The only focal asymptomatic finding on radiography was the loosening of the set screw on the left side inferiorly .

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+A 35-year-old woman (gravida 2, para 1) was referred to our hospital due to placenta previa at gestational week 31. Her medical history was unremarkable, and her previous pregnancy was an uncomplicated, normal vaginal delivery at gestational week 38. Her current pregnancy was uncomplicated except for the placenta previa. She denied abnormal genital bleeding before the current pregnancy. Cervical cytology performed during early pregnancy was negative for intraepithelial lesions. Vaginal ultrasonography revealed total placenta previa and one lacuna . Magnetic resonance imaging (MRI) at gestational week 31 revealed total placenta previa and loss of the myometrium between the placenta and bladder wall . Other MRI findings of PAS such as uterine bulging, heterogenous placenta, and T2 dark band were not observed. Based on these findings, we suspected PAS, and an emergency cesarean delivery was performed owing to antepartum bleeding (approximately 100 mL) at gestational week 35. An abdominal midline incision was made, and a healthy male infant weighing 2274 g (− 0.42 SD) was delivered with Apgar scores of 8 and 9, at 1 and 5 min, respectively. The placenta was not delivered within 30 min after fetal delivery, thus requiring hysterectomy for PAS. Estimated blood loss was 1000 mL. The postoperative course was uneventful, and the patient and baby were discharged on the 8th postoperative day.
+Part of the chorion and placenta were adhered to the uterus . The resected uterus was divided to 7 specimens in order to perform macroscopic and histopathological analyses. The surgical specimen showed a white polyp measuring 2 cm, which parted from the uterine fundus and the lower uterine segment . Histopathological examination of the tumor involving the lower uterine segment revealed endometrioid adenocarcinoma (Grade 1), with < 50% myometrial invasion and positive expression of estrogen and progesterone receptors, in addition to PAS . Notably, the tumor involving the uterine fundus did not show myometrial invasion. Histopathological findings were similar in both tumors located in the uterine lower segment and uterine fundus. A retrospective review of the MRI images obtained during pregnancy revealed the tumor involving the uterine fundus, although involvement of the lower uterine segment was difficult to detect . We performed a laparoscopic bilateral salpingo-oophorectomy and pelvic lymphadenectomy 102 days after cesarean hysterectomy and confirmed the absence of metastases. The tumor was a stage IA lesion based on the International Federation of Gynecology and Obstetrics system. Follow-up performed 4 years after cesarean hysterectomy revealed no recurrence.

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+A 68-year-old Iranian man was investigated for about 12 months with a history of recurrent hematemesis and chronic anemia without any diagnosis. Due to multiple normal endoscopy and colonoscopy results, he was referred to us in the surgery department for further evaluation and care. Before the occurrence of bleeding, the patient was asymptomatic and without any significant complaints. Due to the intermittent nature of the bleeding, the patient had a normal fecal digital rectal examination without any signs of blood at the time of admission. According to the patient’s records during the bleeding periods, anemia and a significant decrease in hemoglobin (Hb, 8.7 g/dL) were found. He had no past medical history of any other diseases and mentioned a normal family and psychosocial history.

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+A 64-year-old man was referred to our hospital with lumbar back pain and an elevated serum PSA level of 2036 ng/mL. Computed tomography showed enlarged mediastinal, para-aortic, and iliac lymph nodes . Bone scintigraphy and magnetic resonance imaging showed osteoblastic lumber spine metastases . Digital rectal examination revealed a small, soft prostate without nodules. The estimated total weight of the prostate was 34 g. Because of the markedly elevated PSA level, we considered that biopsies of the metastases were not essential. Ten-core transrectal prostate biopsy yielded negative results . Because the patient was experiencing severe fatigue and pain, we regarded treatment to be a higher priority than histological diagnosis. We diagnosed TxN1M1b prostate cancer based on the clinical findings, and started androgen deprivation therapy (ADT) with a luteinizing hormone-releasing hormone agonist and an anti-androgen agent (bicalutamide), together with zoledronic acid therapy. To obtain a definitive diagnosis, 12-core repeat prostate biopsy was performed 2 months later and transurethral resection biopsy was performed 5 months later. The resected transurethral specimen weighed 5 g (the estimated total weight of the prostate: 16 g), but did not contain prostate cancer tissue . The patient refused further prostate cancer screening because ADT effectively relieved his symptoms. Nine months after the initial prostate biopsy, his enlarged lymph nodes had shrunk in size and his PSA level had decreased to 4.8 ng/mL. However, he did not attend his routine follow-up appointments and was noncompliant with ADT, and developed castration-resistant prostate cancer 7 months after starting ADT. We administered five courses of docetaxel-based chemotherapy, but his response was inadequate. The patient died 21 months after the initial prostate biopsy from disseminated intravascular coagulation. His family refused to allow an autopsy.

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+A 16-year-old male presented with a painless swelling on the posteromedial aspect of the lower one-third of the right tibia. The swelling had been present since he was 8 years old and had slowly progressed to the size of 8 × 5 cm. The overlying skin had numerous folds giving an elephantiasis-like appearance .
+X-ray of the affected limb showed a deforming mass arising from the posteromedial aspect of the ankle and foot ( and ). Magnetic resonance imaging revealed the deforming mass arising from the posteromedial aspect of the tibia After taking due consent, the patient was examined, revealing multiple, hyper-pigmented, flat, well-circumscribed macular lesions on the trunk and right arm which were subsequently identified as café au lait spots (-). Axillary freckling was also evident. The patient did not give any family history suggestive of a similar disorder.
+A final diagnosis of NF-1 was made, on the basis of the criteria given by the National Institute of Health (NIH), and surgical excision of the dysplastic lesion was done to correct the deformity.

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+A 95-year-old woman was admitted to our emergency department for an episode of vomiting followed by loss of consciousness. During initial clinical examination, she presented with hypotension with a blood pressure of 70/40 mmHg and severe abdominal pain.
+She had a medical history of pancreatic microcystic serous cystadenoma, stage III chronic renal failure secondary to renal artery stenosis and paroxysmal atrial fibrillation on Eliquis® (apixaban). A pancreatic MRI performed 13 years earlier showed a 3.1 cm mass in the tail of the pancreas with a microcystic high T2 signal intensity, with enhancing septa, that didn’t communicate with the main pancreatic duct or its branches, typical of pancreatic SC , with no follow-up needed. The initial blood test revealed a hemoglobin level of 10.8 g/dL and a platelet count of 231,000/mL. Prothrombin time was slightly lowered, at 88%, and activated partial thromboplastin time ratio was normal at 0.76. Computed tomography (CT) (Definition AS+ 128, Siemens) revealed a large hemoperitoneum, an hematoma next to the previously known mass which had doubled in size in 13 years (6.6 cm), and enhancing septations with small peripheral contrast blush . No peritoneal arterial bleeding was visible on the CT. Due to the significant operative risks in this elderly patient, surgery was not proposed. However, to avoid further potential bleeding which could become quickly life-threatening in this very elderly patient, and to be able to restart the anticoagulant treatment, a hemostatic embolization of the tumor was decided and performed immediately.
+Selective catheterization of the tumor-feeding vessel arising from the splenic artery was performed by a microcatheter (Progreat 2.4, Terumo) and a hydrophilic guidewire (GT45, Terumo) , demonstrated the hypervascular nature of the lesion, and didn’t find any arterial bleeding. Embolization of the pancreatic tumor was performed using 500-700 μm microspheres (Embogold, Meritmedical). Microspheres were chosen due to the high vessel tortuosity, as the patient was very atherosclerotic, and had a surgical history of supra-celiac aorto-celiac graft with reimplantation of both renal arteries.
+Endpoint of embolization was near stasis of blood flow in the abnormal vessels and disappearance of the tumor blush.
+After embolization procedure, the hemoglobin level was stable at 8 g/dL. Follow-up CT-scan at 2 days showed no signs of further bleeding. Anticoagulation could be resumed 48 hours after the procedure. No complications such as pancreatitis occurred during follow up, and 1 week after embolization, the patient was discharged home. No event or further bleeding occurred and follow-up CT-scan at 2 months showed no tumor growth. The patient presented no complication or recurrence at 6 months after the procedure.

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+A 37-year-old male with past medical history significant for asthma, anxiety, and former tobacco use, presented to our emergency department after experiencing two episodes of syncope while at work. He was employed outdoors in a heavy manual labor industry. He and his co-workers have been frequently bitten by ticks at work in the past. Initial vital signs on admission were significant for bradycardia, with a heart rate of 57 bpm, and the ECG showed sinus bradycardia with first degree AV block, with a PR interval of 480 ms (NL 120–200 ms) . Physical exam was unremarkable, except for hypopigmentation of fingers. Serum ALT level was elevated 115 (NL 12–78). Other labs on admission were all within normal including serum troponin. Further workup included a normal CT scan of head, a vascular study of the carotid vessels that showed minor right sided carotid stenosis of < 50%, and an echocardiogram that was unremarkable,except for mildly increased LV wall thickness with an EF of 60%. An exercise stress test done by the cardiologist, was terminated early. The patient developed dyspnea, and his ECG demonstrated progression of first-degree AV block to high degree AV block . Once back at rest, the patient’s high degree AV block reverted to first degree AV block. He had a similar episode while walking in the hallway wearing a Holter monitor, on day 5, also reversible with rest. He was transferred to the critical care unit for close monitoring and treated with ceftriaxone 2G iv once daily and doxycycline 100 mg orally twice daily. The first-degree AV block improved with a gradual decrease in the PR interval . His Lyme serology (Western Blot) was strongly positive .
+The heart block significantly improved to 270 ms by day 7 of treatment. He was discharged and continued outpatient IV Ceftriaxone for 3 weeks. After completing treatment, the patient had a normal ECG with PR interval of 178 on day 16 and an uneventful exercise stress test. He returned towork without limitations, doing manual labor. He has been symptom free for 2 years. Now he uses tick-repellents at work.

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+A-39-year old Chinese man was admitted to our hospital for repeated oral ulcers and headaches for 8 years, chest pain for 7 months. He had no diabetes, no relevant medical family history, and no external genital ulcer. The laboratory test results: C-reactive protein of 32.3 mg/L (normal value:<5 mg/L), anti-nuclear antibody (ANA) was positive (normal value: negative), ESR of 55 mg/h (normal value: male: 0-15 ml/h, female: 0-20 ml/h). Transthoracic echocardiography (TTE) demonstrated: aortic sinus was 35 × 57 mm, ascending aorta diameter was 37 mm, at the junction of right and left coronary sinus there was a 12 × 14 mm cystic structure was formed outside from aortic wall, and a 40 × 23 mm cystic structure was formed at the junction of orifice of coronary sinus, as shown in Fig. . CTA scan indicated that the aortic sinus was outwards, the large cross-section area about 4.4 cm × 2.6 cm, as shown in Fig. . After admission to the hospital, he was treated with Glucocorticoid, Thalidomide, and Atorvastatin in the rheumatic immunology department until the inflammatory markers returned to a normal level, then he received modified Bentall surgery and continue to take medicine as pre-operation. After 8 months follow-up, the patient recovered well: TTE indicated artificial blood vessel has no apparent abnormalities and artificial heart valve is functioning well, no perivalvular leakage (PVL), eject fraction is 62%.
+Surgery process: median sternotomy and establish total cardiopulmonary bypass (CPB), myocardial protection with cold blood cardioplegia. Open the ascend aorta, cut the brachiocephalic artery, the native root including the annulus was excised, aortic root replacement with the modified Bentall technique was performed: The valved conduit procedure was a modified Bentall operation where the aortic mechanical valve prosthesis was sutured into the graft at 1 cm from the end of the graft with a continuous 3–0 polypropylene suture, forming a composite graft, which was directly sutured to the left ventricular outflow tract with a continuous 3–0 polypropylene suture other than to annulus, and then the composite graft was fixed by outside the aortic wall with a belt-like Teflon felt. The coronary buttons were anastomosed to the composite valve graft end-to-side with continuous suture used a 5–0 polypropylene suture without any tension, at last, the distal end of the conduit was anastomosed to the distal ascending aorta with continuous 3–0 polypropylene sutures. The CPB and aortic cross-clamp times were 117 min and 60 min respectively. During this procedure no difficult bleeding encountered. There was no obvious abnormality in the function of artificial mechanical valves, and artificial ascending aortic blood flow was smooth, TEE suggested the aortic valve mechanical valve worked well, as shown in Fig. . Postoperative pathological indicated that the inner layer of the arterial wall was uneven, with partial fibrous hyperplasia, focal mucus degeneration, and a few lymphocytes infiltration. Immunohistochemical: smooth muscle cells were positive, CD3 + lymphocyte infiltration. Web dyeing: elastic fibers were positive, which suggested aseptic inflammatory changes in the aorta.

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+A 38-year-old male patient presented to our hospital with right side motor weakness that had started 8 months earlier. He had visited another hospital when the symptoms had started and had been diagnosed with advanced gastric adenocarcinoma with a single metastatic lesion in the left thalamus . He had undergone gamma knife radiosurgery (GKRS) at the other hospital. However, due to brain edema and deterioration of his overall condition, systemic chemotherapy had not been performed.
+A physical examination revealed grade 4 motor weakness in the upper and lower right limbs. Laboratory findings revealed mild hypochromic microcytic anemia but were otherwise non-specific. Follow-up abdominal computed tomography (CT) showed aggravation of an advanced gastric malignancy with multiple metastatic regional lymph nodes, and new hepatic, left adrenal, and peritoneal metastases were also observed . Follow-up brain magnetic resonance imaging (MRI) showed a mild increase in the size of the metastasis in the left thalamus . He was only given palliative treatment and discharged.
+Five months later the patient was admitted to our neurosurgery department with a severe headache. A brain MRI showed a slight increase in the previous mass and several newly developed metastases with surrounding edema . Repeated GKRS was performed for both recurrent and new lesions. However, his symptoms persisted and his general condition worsened. A pathological examination of the endoscopically biopsied tissue revealed moderately differentiated adenocarcinoma with glandular fusion in a cribriform pattern . By immunohistochemistry, the tumor cells were completely negative for PD1, but showed weak to moderate cytoplasmic positivity for PDL1 . We gave the patient an injection of pembrolizumab (Keytruda) 200 mg.
+Two weeks after the injection of pembrolizumab, he returned to our hospital, reporting that his neurological symptoms had dramatically improved and that his headaches no longer occurred. He insisted that the treatment be continued, and after three doses of pembrolizumab, the patient underwent an abdominal CT and brain MRI. The abdominal CT revealed a partial response of the gastric cancer, liver, lymph node, and brain metastases, and the brain MRI showed that the thalamic metastasis had achieved a stable state and that there had been a dramatic reduction of the newly developed brain metastases .
+The neurological symptoms were markedly improved after 3 doses of pembrolizumab. A follow-up physical examination after treatment revealed grade 3 motor weakness in his right lower limb and grade 4 motor weakness in his upper limb. Although a new brain lesion developed after 7 months of pembrolizumab treatment, his neurological symptoms and signs were not aggravated and he is being treated with systemic chemotherapy and pembrolizumab. The patient is currently still alive and in fair general condition 26 months after the initial diagnosis.

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+A 6 years old boy with dyspnea, orthopnea, generalized pitting edema and fever, was admitted to the pediatric intensive care unit, Shanghai Children’s Hospital. Three years before this episode, he presented to our hospital with acute onset of edema, hypoalbuminemia, heavy proteinuria and hyperlipidemia. The diagnosis of IgA nephropathy (Grade II) was made by percutaneous renal biopsy and in accordance with Lee’s classification . Initially he responded well to steroid therapy, but became steroid resistant after 2 years treatment. Immunosuppressive agents administered during this time period, included cyclophosphamide, mycophenolate mofetil and tacrolimus. He had no history of trauma, tuberculosis or radiation therapy.
+Physical examination revealed tachypnea, orthopnea, anasarca and ascites. The heart sounds were muffled and hepatomegaly was also noted. Blood pressure ranged from 90/60 mmHg (systolic/diastolic blood pressure) to 130/70 mmHg. Blood cell count showed that white blood cells (WBC) was 14.49 × 109/L, neutrophils 79%, hemoglobin 11.5 g/dl, C-reactive protein 130 mg/L. Biochemistry analysis revealed total protein of 36 g/L, albumin 10 g/L, alanine aminotransferase (ALT) 10 U/L, aspartate aminotransferase (AST) 29 U/L, triglycerides 2.05 mmol/L, cholesterol 10.13 mmol/L. Serum electrolytes (Na+, K+, Ca2+ and Cl−) were normal. Heavy proteinuria and hematuria were found on urinalysis (urinary protein: creatinine ratio 30.38). Serum creatinine was normal and estimated glomerular filtration rate (eGFR, calculated with Schwartz formula) was 147 ml/min/1.73m2. Blood and urine cultures were sterile. T-spot for tuberculosis was negative. There was no ultrasound evidence of thrombosis in the superior vena cava or subclavian vein. Ultrasound also demonstrated that both kidneys were enlarged with a loss of cortico-medullary differentiation. Thoracic computed tomography (CT) found no evidence of congenital malformation or malignancies. Echocardiography revealed pericardial fluid of 4.6 cm at maximal thickness, suggesting a large volume hydropericardial effusion. The massive pericardial and pleural effusions were additionally confirmed by thoracic CT . Notably, milky fluid was obtained from the pericardial space by pericardiocentesis . Chyle test was positive. Cell counts and biochemistry in the pericardial effusion revealed WBC 405 × 106/L, lymphocytes count 92%, red blood cells 63 × 106/L, AST 8 U/L, lactate dehydrogenase (LDH) 58 U/L, Glucose 7.22 mmol/L, total protein 7 g/L, albumin 4 g/L, adenylate deaminase (ADH) 2.6 U/L, triglycerides 2.55 mmol/L, cholesterol 0.79 mmol/L. These findings confirmed the diagnosis of chylopericardial effusion.
+Continuous renal replacement (CRRT) therapy was performed to alleviate the fluid overload. Meanwhile, pericardial drainage was performed and the diet was modified to low fat but rich in middle chain triglycerides and high protein. No side effects were encountered with this diet modification. The symptoms of cardiac tamponade subsided promptly, while the edema receded gradually over the subsequent 2 weeks. The indwelling pericardial catheter was removed when no fluid was drained after 3 weeks treatment and as shown in Fig. , the chylopericardial effusion was removed successfully. Pericardial effusion has not recurred at 1 year of follow up, on follow up echocardiography.

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+Our patient is a 27-year old female that denied any past medical and surgical history. Her family and drug history were also unremarkable. The patient presented with a 7-month history of progressively enlarging mass on her left ring finger. The patient mentioned that the mass appeared suddenly with no history of trauma and that she was concerned about the potential malignant nature of the mass. The patient also mentioned that she underwent incision and drainage of that mass 2 months after its appearance with no improvement and provided no detailed surgical or pathological reports, which was the reason for her delayed presentation. Upon her assessment, the mass was located over the ulnar side of the proximal phalanx of left ring finger with extensive involvement of the 4th web space. The overlying skin coverage was ulcerative with no active signs of infection. Range of motion of the involved digit was limited, however neurovascular examination was normal. .
+Radiological evaluation of the involved hand showed a soft tissue swelling with no evidence of bone involvement . Further magnetic resonant (MRI) evaluation showed a mass on the volar aspect of the ring finger encasing about 50% of the flexor tendons of that digit with low signal intensity on T1 and high signal intensity on T2 evaluation with strong enhancement in post contrast evaluation. Assessment of neurovascular structures showed partial abutment of the radial sided bundle together with complete encirclement of the ulnar sided neurovascular bundle. The surrounding bone was free of any masses and associated mass effect.
+The patient was taken to the OR for exploration and mass excision by the senior author. Possible risks associated with such intervention were explained. Intra-operatively, bruner type incision was designed together with island of skin involved in the mass. Exploration revealed extensive subcutaneous mass with fibro-fatty consistency with extensive fascia like extension to the surrounding soft tissue. The mass was encircling the ulnar neurovascular bundle with mass abutment over the radial bundle as seen in pre-op assessment. The mass was dissected freely from its attachment to those bundles preserving both radial and ulnar structures. The mass was then excised en-bloc having a dimension of 3.5 × 4x2.5 cm . Histological assessment showed a lesion with fasciitis like features, myofibroblastic proliferation and scattered foci of osteoid formation that was positive for Alpha-Smooth Muscle Actin (ASMA 1A4) immune staining and no evidence of malignancy . The resected margins were however, positive for residual lesion with difficulty in obtaining negative margins due to the extensive nature of the mass. Post-operatively, the patient had an un-eventual course. She was informed about the need for close follow-ups for both clinical and/or radiological signs of lesion recurrence, pending early surgical intervention (see ).

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+A 47-year-old woman, non-smoker, with history of asthma and pollen allergy contacted the emergency services for subacute dyspnea, exercise intolerance and chest tightness. Her daily medication consisted of: desloratadine, a beclomethason/formoterol inhaler and an ethinylestradiol/levonorgestrel contraceptive, which she took on a continuous basis (without pill-free days) because of pre-menopausal menometrorrhagia. She had been feeling unwell for two days and thought her symptoms were due to an asthma attack. She had already tried increasing her inhaler, but without effect. Two days earlier she had returned from holiday after an 18-hour bus ride. She had taken the same bus on the outward journey 10 days earlier.
+On arrival, the first responders team found her sitting on the ground in respiratory distress, tachypneic, tachycardic, hypoxic, hypotensive, and afebrile. Her vital signs were: respiratory rate 36 breaths per minute, heart rate 142 beats per minute (bpm), oxygen saturation 72% on room air, blood pressure 64/43 mmHg and temperature 35.8 °C. ECG showed sinus tachycardia, without Q waves or ischemic ST/T changes. The patient was given 12 L/m of oxygen via face mask and 500 mL of normal saline and was brought to the hospital. Repeat ECG showed similar findings, lab (results of which were only available later) showed hemoglobin of 14.0 g/dL, troponin 330 ng/L, d-dimers 7509 mcg/L, C-reactive protein 30.4 mg/L and creatinine of 1.31 mg/dL, corresponding to estimated glomerular filtration rate of 48 mL/min/1.73m2. Quick-look echocardiogram showed a nondilated and normocontractile left ventricle, a dilated right ventricle with leftward shift of the interventricular septum and pulmonary hypertension with an estimated right ventricular systolic pressure of 64 mmHg + central venous pressure . Inferior caval vein was plethoric without respiratory variation. There was no severe valvular pathology. At that moment, blood pressure was 142/95 mmHg, heart rate 139 bpm and oxygen saturation 97% while breathing 12 L/m oxygen via face mask.
+Acute pulmonary embolism was suspected. The patient was given 80 mg of enoxaparin (weight = 83 kg) and an urgent computerized tomography scan with intravenous contrast was performed, which confirmed the diagnosis of bilateral pulmonary embolism .
+The Pulmonary Embolism Severity Index (PESI) score, calculated with the help of an online tool , was 167: very high risk. Based on hemodynamic compromise, right ventricular dysfunction on echocardiogram and a very high-risk PESI score, thrombolysis was administered. Alteplase was given as a 10 mg bolus and 90 mg infusion over 2 hours and the patient was admitted to the cardiac intensive care unit. Her condition gradually improved over the next few hours, with a decrease in heart rate from 130 bpm to 80 bpm and normalization of serum creatinine to 0.81 mg/dL (corresponding to eGFR of 85 mL/min/1.73 m2) by the second day. Repeat echocardiography showed a marked decrease in right ventricular dimensions and lowering of estimated right ventricular pressure to 27 mmHg + central venous pressure. In addition to the pulmonary embolism, the patient was found to have extensive deep venous thrombosis of the right femoral vein. Thrombophilia screening revealed a Factor V Leiden mutation. After two days of enoxaparin, 80 mg (1 mg/kg) twice daily, she was switched to rivaroxaban, 15 mg twice daily and at day 6 she was discharged with this therapy for a total of 21 days, after which she should decrease the dose to 20 mg once daily. She was instructed to discontinue her combined oral contraceptive pill indefinitely.
+Five days later, however, the patient was re-admitted to the hospital with pre-syncope. She was looking pale. During the few days between hospital admissions, she had had severe vaginal bleeding, with need for hygienic pad change every few hours. Vital signs were: blood pressure 102/74 mmHg, heart rate 114 beats per minute, respiratory rate 18 per minute, saturation 99% on room air, temperature 36.7 °C. There was no hematuria, melaena or hematochezia. Hemoglobin was 6.3 g/dL, ß-HCG negative, creatinine 0.96 mg/dL and C-reactive protein 2.1 mg/L. INR was 1.4 (12 h after last intake of rivaroxaban).
+Figure shows the evolution of anemia since the previous hospitalization. 500 mL of normal saline and two units of packed cells were infused. Rivaroxaban was withheld for 5 days and substituted for prophylactic dose enoxaparin, 40 mg once daily. Lynestrenol, an oral progestin, was administered at 5 mg twice daily for two weeks, and then switched to nomegestrol 5 mg once daily, to be taken continuously. An oral iron supplement was started to replete the iron stores. The patient was discharged on day 7.

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+A 30-year-old female had a 2 years history of left frontal headache unresponsive to drug therapy with common analgesics. The intensity of this symptom increased over time. Her neurological examination was normal. The magnetic resonance imaging (MRI) showed a dural-based lesion in the left frontal region; the lesion size was 1.5 cm × 3.5 cm. It was hyperintense on T2-weighted images and isointense on T1-weighted images showing intense contrast enhancement. This small mass appeared to be adherent to the dura mater with a dural tail sign . The appearance suggested a convexity meningioma.
+Initially, the patient refused surgery.
+After 1-year, brain control MRI showed no changes of the lesion.
+Finally, the patient decided to undergo surgery because the episodes of headaches had become more and more frequent and intense.
+A left frontal craniotomy was performed. After opening the dura, an encapsulated, red-colored tumor was exposed. The base of the implant was coagulated and the lesion was removed en-bloc without significant intraoperative bleeding.
+The histopathological diagnosis deposed for a cavernous hemangioma of the dura mater .
+The postoperative MRI showed no residual hemangioma .
+At 1-year follow-up, the patient was asymptomatic without any neurologic deficit.

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+A 48-year-old woman who had experienced diffuse chest pain came to the emergency room (ER). The chest pain, initiated five years back, which was episodic in nature and lasted for a week, and since then, similar recurrent episodes have occurred every six months until present. She also had a history of multiple episodes of shortness of breath, headache, and loss of consciousness. Moreover, she reported involuntary weight loss of approximately 15 kg over five years. Also, 600 mL of straw-colored fluid was aspirated two years ago during an emergency pericardiocentesis. She was empirically given anti-tubercular therapy for nine months, given tubercular pericardial effusion. Despite anti-tubercular therapy, her symptoms persisted.
+She was alert, asthenic, with marked mucocutaneous pallor, afebrile, blood pressure of 80/60 mm of Hg, pulse of 124/min, respiratory rate of 26/min, and oxygen saturation at room air of 92%. On auscultation, she had venous jugular engorgement with bilaterally decreased vesicular breath sounds in lung bases and decreased heart sounds.
+The results of the investigations pointed to central hypothyroidism with lowered free T3 levels, free T4 levels, and TSH levels. The leading question revealed her eight-year amenorrhea history since her last pregnancy. This pregnancy was complicated by postpartum hemorrhage. Other investigations were done to rule out hypopituitarism, and serum hormone levels indicated panhypopituitarism.
+Panhypopituitarism was identified as the diagnosis, along with significant central hypothyroidism and hypocortisolism .
+Her chest X-ray showed cardiomegaly with prominent broncho vascular markings in both upper zones, suggestive of pericardial effusion with pulmonary edema, and her electrocardiogram showed low voltage complexes .
+An echocardiogram confirmed a global simple pericardial effusion with evidence of cardiac tamponade and hemodynamic compromise .
+MRI brain with the pituitary protocol was done, which showed empty sella .
+Based on the history of postpartum hemorrhage, a diagnosis of Sheehan syndrome was given. MRI of the pituitary showed empty sella, suggestive of complete anterior pituitary failure.

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+A 15-year-old boy presented to our University Hospital, a tertiary care neurology facility, with fever, headache, and altered sensorium of 12-day duration. At admission, he was febrile (101 °F), with a pulse rate of 110/min and a blood pressure recording of 114/74 mmHg; his Glasgow Coma Scale score was 10 (E3M4V3). There were no petechiae or signs of bleeding over the skin or any mucosal surface. There was no focal neurological deficit and neurological examination was normal, including (absence of) signs of meningeal irritation. Laboratory evaluation revealed the following estimations: hemoglobin of 11 g/dl, total leukocyte count of 3300 cells/mm3, and platelet count of 22,000 cells/mm3 which dropped to 8000 cells/mm3 on next day. His aspartate aminotransferase level was 155 U/L, alanine aminotransferase was 140 U/L and alkaline phosphatase was 56 U/L. Additional biochemical parameters, renal function tests, blood sugar, electrolytes, and arterial blood gas analysis, were normal. Malarial parasite was not detected in the peripheral blood smear. The cerebrospinal fluid examination, cytological and biochemical, was normal. IgM antibody against dengue virus was positive both in serum and cerebrospinal fluid; meanwhile, dengue NS1 antigen was negative. Electroencephalography revealed generalized slowing. On magnetic resonance imaging of the brain, signal changes were seen in bilateral parietooccipital and left frontal region (left hemisphere was more involved than the right hemisphere). There were diffuse subcortical white matter changes along with suggestion of hemorrhage on gradient echo sequence. Subtle hyperintensity on T2 W images was also noted in bilateral basal ganglia. Gadolinium-contrast study revealed a gyriform enhancement suggestive of cortical laminar necrosis . He was managed conservatively and given platelet transfusion. The patient responded well to management and became fully conscious in 7 days.

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+A 37-year-old female, 159 cm tall, weighing 53 kg, presented with progressive exertional dyspnea for 6 months. A diagnosis of autoimmune PAP was confirmed based on her history, high-resolution computerized tomography (HRCT), and bronchoalveolar lavage (BAL) findings. WLL of the left lung, in which pulmonary infiltrates were denser than in the right lung on HRCT, was performed under general anesthesia due to exacerbation of dyspnea during follow-up. The first lavages were performed with 10,000 ml of normal saline, with an almost equal volume of returning effluent. Although her postoperative course was smooth for 4 months, she again developed exertional dyspnea and new and denser pulmonary infiltrates. Thus, a second WLL was planned 8 months after the first WLL.
+Arterial blood gas (ABG) values before the second WLL, with the patient breathing room air, are as shown in Table . Pulmonary function tests revealed a restrictive pattern: vital capacity (VC)=1.44 (44.1%), forced expiratory volume in 1 s (FEV1) =1.07 (39.8%), and carbon monoxide diffusion capacity (DLCO)=4.80 (20.8%). A 6-min walk test showed desaturation with exercise from 91 to 73%, resulting in the test being aborted after 3 min. Since the radiological involvement was greater on the left side, a repeated left lung lavage was planned with stand-by extracorporeal membrane oxygenation (ECMO) to prevent fatal hypoxemia.
+After entering the operating room, electrocardiography, pulse oximeter (SpO2), and non-invasive blood pressure monitors were attached. After pre-oxygenation with 5 L/min of 100% O2 for 5 min, general anesthesia was induced and maintained with propofol, remifentanil, and rocuronium, and a 37 Fr left-sided double-lumen tube (DLT) was inserted. Correct positioning of the DLT was confirmed using bronchoscopy. Radial artery cannulation was performed for ABG analysis, which revealed a PaO2 of 467.4 mmHg following 5 min of bilateral mechanical ventilation with an FiO2 of 1.0. End-tidal PaCO2, arterial blood pressure, and bladder temperature were also monitored intraoperatively. In addition to usual monitors, a FloTracTM monitoring system (Edwards Lifesciences, California, USA) and transesophageal echocardiography (TEE) were prepared. After induction of anesthesia, baseline ABG revealed within the normal limits . The patient was placed in the supine position with the right lung side slightly tilted downward.
+The bronchial lumen of the DLT in the left main bronchus was connected to the saline delivery system. During one lung ventilation (OLV) of the right lung, after letting the patient’s left lung degas for 15 min and recruitment maneuver, ABG showed a PaO2 of 194.9 mmHg under an FiO2 of 1.0. Confirming adequate oxygenation during OLV, we started lavage. The ventilator settings were kept unchanged during OLV [PCV Peak 15 cmH2O, PEEP 6 cmH2O, I: E 1:1.5, RR 14/min]. Lavage was performed by repeatedly filling the left lung with irrigating solution while performing OLV of the right lung with an FiO2 of 1.0.
+In every lavage procedure, 600 to 1000 ml of normal saline flowed into the left lung at a rate of 100 ml/min from a height of 30 cm above the patient, followed by passive drainage under gravity. The procedure was repeated 15 times using the instillation of warm saline and removal of the effluent. A total of 14 l of fluid was instilled into the left lung. WLL was performed satisfactorily, with the amount of effluent removed being almost equal to the instilled volume. The effluent contained very large amounts of amorphous sediment which gradually cleared. After 2.5 h of lavage, that is, nearly at the end of WLL, ABG values are as shown in Table . The pH, base excess, glucose, Na+, K+, and Cl− values suggested a strong ion difference (SID=20.36) . Dilutional hyperchloremic metabolic acidosis was diagnosed, likely due to excessive alveolar absorption of normal saline during WLL. The intraoperative infusion was 1260 ml including 700 ml of acetate Ringer’s, 50ml of Carbonate Ringer’s, and 510 ml of normal saline. Intraoperative urine volume was 90ml.
+The patient remained hemodynamically stable during WLL, and there were no significant findings suggesting massive absorption of the lavage fluid by FloTrac Sensor, TEE, or no pulmonary edema on the chest X-ray.
+Due to concern of continued postoperative fluid shifts, we decided to keep the patient intubated, and the DLT was replaced with a single lumen endotracheal tube. The patient was transferred to the ICU overnight for mechanical ventilation with a positive end-expiratory pressure of 10 cm H2O. Additionally, furosemide was given to remove excess fluid. ABG values returned to their normal limits 10 h after WLL was completed . She was extubated 15 h following the completion of WLL. She had no further metabolic acidosis and was subsequently discharged 4 days post-procedure.

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+A 59-year-old caucasian female was diagnosed with thyroid papillary carcinoma after total thyroidectomy in 2001. Diagnosed with postsurgical hypothyroidism under treatment with levothyroxine, 100 micrograms per day. There was no other previous medical history of interest. The patient did not consume tobacco or alcohol.
+In 2008, a computerized tomography scan (CT) showed locoregional relapse and surgery was performed with resection of locoregional recurrence and left cervical lymphadenectomy. In November 2011, pulmonary relapse was treated with I-131 since November 2011 until March 2012 (total accumulated dose: 850 mCi). In October 2016, a CT scan showed a progression of the disease with cervical and pulmonary progression. The patient started sorafenib, 400 mg twice a day. Stable disease was maintained during 20 months. In June 2018, patient presented an episode of abrupt instability and cervical pain. The magnetic resonance imaging (MRI) showed a new metastatic lesion in the skull base with destruction of bony structures of the left occipital-petrous region. At this point, a molecular study of the cervical node was performed and a mutation in BRAF was found.
+Due to the lack of alternative therapeutic options, treatment with vemurafenib–trametinib was requested as a compassionate use. In August 2018, patient was started on the combination of dabrafenib 150 mg twice a day and trametinib 2 mg once a day. MRI in October 2018 showed a slight decrease of the metastatic lesion in the skull base . In addition, the patient showed evident clinical improvement with decreased initial headache and cervicalgia.
+A follow-up PET–CT scan was performed in January 2019. Tumor was on radiological partial response. In addition, there was intestinal pneumatosis with mild sign of pneumoperitoneum . Patient had no digestive symptoms and the abdominal medical examination was completely normal. Also normal neurological examination was verified. Routine physical examination showed blood pressure 110/60 mmHg, heart rate 80 bpm and 36.5 degree centigrade temperature. Blood test showed normal liver function: AST 21 U/L, ALT 16 U/L, bilirubin 0.19 mg/dL and normal renal function: creatinine 0.7 and glomerular filtrate > 90 mL/min. Blood count values were normal: leukocytes 7.6 × 1000/µL, hemoglobin 12 g/dL and platelets 417 × 1000/µL.
+The surgery department recommended conservative treatment unless new abdominal signs or symptoms were seen. Intravenous metoclopramide 10 mg/8 h and paracetamol 1000 mg/8 h were administrated. Both drugs, dabrafenib and trametinib, were discontinued after the PI diagnosis.
+Only 10 days after the discontinuation of targeted therapy, tumor progression was shown with clinical deterioration due to intracranial hypertension and the patient died 4 weeks later because of intracranial disease progression. Because the cause of death was related with tumor progression, autopsy was not performed.

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+A 3 year and 2-month-old girl presented to the emergency department with a rash on her legs for 1 day and haematuria for 4 days. There was no accompanying fever. She was started on a course of oral cefaclor for presumed urinary tract infection 2 days ago. Urine culture showed no bacterial growth. Eight weeks earlier, the girl had a purulent nail infection and was treated conservatively. One year earlier, the girl had severe streptococcal tonsillitis. The throat swab at that time was positive for streptococci. Her symptoms improved after 10 days of antibiotic therapy. There was no known kidney disease in the family.
+Physical examination revealed a hypertensive patient with a rash on her lower extremities but no peri-articular swelling. The rash disappeared on day 4 after admission. Pedal and eyelid oedema were present. No ear, nose or throat (ENT) pathologies, enlarged lymph nodes or ascites were observed.
+Clinical examination demonstrated Glasgow Coma Scale (GCS) score 15, pulse 101 beats/min, capillary refill time 1 second, blood pressure 104/63 mmHg (99.P), respiration rate of 24 breaths/min, oxygen saturation (SpO2) 96%, temperature 36.8 °C, weight 16 kg (75.P), and height 96 cm (39.P).
+Investigations showed negativity for myeloperoxidase antibodies, lactoferrin antibodies, proteinase 3 antibodies, bactericidal/permeability-increasing protein antibodies, cathepsin G antibodies, antinuclear antibodies and antineutrophil cytoplasmic antibodies and elevated levels of urea, uric acid, creatinine, perinuclear anti-neutrophil cytoplasmic antibodies, elastase antibodies, IgG and anti-streptolysin. The level of C3 was low (0.260 g/l). The results are shown in the supplementary table .
+Urinalysis: Dipstick tests showed 3+ proteinuria, haematuria, and leukocyturia. The results were negative for nitrite and showed a normal urine pH. A 24-h urine test showed normal creatinine levels and elevated levels of protein(2.8 g/l), protein/g creatinine(7955 mg/g). See .
+Renal ultrasound showed bilateral enlarged hyperechogenic kidneys. The volumes were 64 cm3 for the right kidney and 70 cm3 for the left kidney. There was no evidence of any urinary transport disorder. Otherwise, an age- appropriate abdominal sonogram was documented .
+Echocardiography: There was no left ventricular hypertrophy (LVH) or pericardial effusion. The tricuspid aortic valve and coronary outlets were normal. Physiologic regurgitation was observed in the pulmonary and tricuspid valves. There was no aortic or mitral insufficiency.
+Renal biopsy was performed. Light microscopy showed 47 glomeruli, out of which seven showed segmental basal membrane rupture with leakage of necrotic fibrinoid material into the extra-capillary space and adjacent alternating strong extra-capillary proliferation. The remaining glomeruli showed significantly increased mesangial and endocapillary hypercellularity, with focal infiltration of the intra-capillary space by neutrophilic granulocytes and monocytes. The peripheral basal membranes were typical, with podocytes with flat cytoplasm. The afferent arterioles were not affected, and Congo red staining was negative .
+Electron microscopy showed glomerular parts with typically structured basement membranes. An increase in mesangial cellularity was observed, along with electron-dense subepithelial humps and mesangial deposits. Endocapillary hypercellularity and granulocytic and monocytic infiltration were prominent .
+Immunofluorescence revealed positive focal segmental mesangial and glomerular basement membrane staining for IgA and complement factor (C1q). The same pattern was observed to a lesser extent for IgG. A positive glomerular basement membrane staining in the form of humps for complement factor C3 was observed. A strong complement factor C3 and Fibrinogen staining was detected in the mesangium. The same pattern was observed to a lesser extent for IgM .
+A causative organism was not identified and based on an initial clinical diagnosis of Henoch-Schoenlein purpura with heavy proteinuria, the girl was initially managed with methylprednisolone 300 mg/m2 i.v for three alternate days, followed by prednisolone p.o. 40 mg/m2. Renal biopsy findings were then consistent with IgA PIGN, and the patient was treated with 10 days of antibiotic therapy consisting of cefuroxime i.v. for 3 days followed by flucloxacillin p.o. for 7 days due to a presumed untreated staphylococcal skin infection (paronychia) 8 weeks prior. Prednisolone 40 mg/m2 p.o. was continued for a total period of 1 week and then weaned over next 6 weeks.
+The patient experienced partial renal recovery (decrease in serum creatinine from 0.82 mg/dl to 0.31 mg/dl) and a reduction in nephrotic proteinuria (decline from 7955 mg/g to 782 mg/g creatinine) within 32 days. Her serum C3 level completely normalized on day 25 after admission.
+At the 6-month follow-up visit, the patient’s creatinine level had improved to 0.25 mg/dL, with a urine protein to creatinine (UPC) ratio of 132 mg/g.

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+A 28-year-old male was admitted to hospital with a one-month history of nausea, vomiting, the epigastric pain increased blood pressure and worsening of renal function with hypercalcemia. He was diagnosed in the outpatient setting as having gastroesophageal reflux disease with biliary regurgitation and, therefore, was given high doses of calcium containing antacids. A therapy with calcium antagonists was also initiated because of increased levels of blood pressure.
+Upon admission, he was well oriented, with slightly yellowish skin color, his blood pressure was 160/100 mmHg, his heart rate was 96/min. The rest of the physical examination was normal. He was a non-smoker and his past medical history was normal. The following initial analyzes have been performed:
+The patient had severe hypercalcemia and anemia, renal insufficiency, metabolic alkalosis. Serum parathyroid hormone was almost undetectable. His lipids were normal, too and urine culture negative. All the available tumor markers were normal (CEA, AFP, CA 19-9, NSE, CYFRA 21-1, PSA, Ferritin). He was hepatitis B, C and HIV negative. Renal ultrasound was normal. Ultrasound of the parathyroid glands was normal. Computerized tomography of the abdomen showed normal findings. Bone biopsy showed osteoporosis and scattered zones with osteonecrosis. Renal biopsy showed tubulointerstitial lesions with calcium deposits in the interstitial tissue. Chest X-ray was also normal. Endoscopy of the upper gastrointestinal tract while hospitalized showed no pathologic changes. Beta-2 microglobulin, acid phosphatase, kappa and lambda light chains were normal. Coombs test and immunoelectrophoresis of proteins were negative. The calculated creatinine clearance at admission was 42 ml/min. The whole body Tc99m MDP bone scan was normal, as well as the parathyroid glands Tc99m MIBI scan. Cranial X-ray, as well as radiographs of hands and feet, was normal. He had mild metabolic alkalosis, and his ECG showed signs of hypercalcemia (shortened QT interval of 0.32 sec and abnormal ST morphology in V2, V3 and V4) .
+The patient was hydrated with intravenous fluid, treated with bisphosphonates, corticosteroids and calcium antagonists for his elevated blood pressure. Antacids were stopped promptly after admission. He was also given vitamin B12 and folic acid upon the recommendation of a hematologist. The serum level of calcium decreased slowly to 2.6 mmol/l at the 43rd day after admission, and serum creatinine decreased to 154 μmol/l (calculated creatinine clearance 63.5 ml/min).
+After ruling out the differential diagnosis of multiple myelomas, other malignancies, primary hyperparathyroidism, hyperthyroidism or hypothyro-idism, it seemed plausible that the cause of hypercalcemia might be the ingestion of calcium containing antacids prescribed by his primary physician for his gastroesophageal reflux disease. He was discharged from hospital after 45 days of hospitalization.

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+A 75-year-old man from the South-West Region of Cameroon (an endemic zone for onchocerciasis) and of Bamileke ancestry presented to our clinic with skin lesions that had been evolving for over a year. The eruptions were first noticed a few hours after he took 12 mg of ivermectin (Mectizan) during mass drug administration (MDA) campaigns carried out every 3 months (as part of the public health strategy and in line with a recommendation from the World Health Organization’s African program for control of onchocerciasis and to fight against filariasis in endemic parts of Cameroon). The initial eruptions were dark, itchy discolorations with occasional burning and appeared as single isolated rashes on his groin, genital, and neck regions.
+On further inquiry, he described similar symptoms in the past whenever he took ivermectin which disappeared after he stopped the drug. Further consumption of ivermectin (2 months prior to consultation) during the ensuing campaign resulted in worsening of the old lesions with development of multiple new lesions over his face, back, and extremities. His family and medical history were not remarkable for any previous drug or cross-reactivity reactions.
+On physical examination, he looked well with vital signs within normal limits. There were multiple well-defined circular erythematous hyperpigmented plaque lesions of sizes ranging from 1 × 3 cm to 7 × 10 cm on his face, neck, groin area, and both extremities occupying approximately two-thirds of his total body surface area (TBSA). Other systemic examinations were normal.
+A laboratory work-up including full blood count, human immunodeficiency virus (HIV) serology, urine analysis, and biochemistry (liver and kidney function tests) were normal. Erythrocyte sedimentation rate was at 65 mm/hour after the first hour, while punch biopsy of the skin, and antinuclear antibodies (ANA)/antineutrophil cytoplasmic autoantibody (ANCA) were requested but were unavailable.
+A working diagnosis of FDE was made based on clinical signs and patient history despite the lack of histopathological findings.
+Discontinuation of ivermectin (plus counselling on avoidance of other possible culprits), a short course of systemic corticosteroids (prednisone 60 mg daily for a week), and orally administered antihistamines (hydroxyzine 75 mg daily) were employed as treatment modalities. Close patient follow-up revealed marked regression of lesions within a fortnight with residual hyperpigmentation .

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+An 82-year-old Caucasian man was admitted to our urology department for radical cystoprostatectomy because of prostate cancer.
+During the night of the fourth day post-surgery the patient suddenly developed painless severe tetraparesis (Medical Research Council grade 2/5 of proximal muscles on both arms and 0/5 of both legs) without involvement of cranial nerves or impaired consciousness. There were no signs of sensory deficits. He did not present with any cerebellar symptoms. Further clinical examination revealed brisk tendon reflexes and positive pyramidal signs on both sides. The clinical presentation was highly suggestive for spinal cord affection, for example by abrupt compression, subdural bleeding or ischemia. There was no trauma or fall shortly before the onset of the neurological deficits. For analgesic treatment, a peridural catheter had been implanted after surgery which had been removed without any complications the day before.
+For an emergency magnetic resonance imaging (MRI) diagnostic, metal brackets in the subcutaneous tissue placed after surgery had to be removed at night. Surprisingly, spinal MRI did not reveal spinal cord compression or signs pointing towards spinal cord ischemia (Figure A). By contrast, cranial MRI imaging showed bilateral acute infarctions in the median precentral gyrus (Figure B and C; arrows), whereas the internal capsule was unaffected on both sides (Figure D). The T2-weighted images at the level of primary motor cortex did not yet present with abnormal signal, thus confirming acute ischemia consistent with the time course of symptom occurrence (Figure E). The precentral area of the primary motor cortex is supplied by the anterior cerebral artery (medial one third of the precentral gyrus) and the middle cerebral artery (lateral two thirds) on either side
+.
+In the following days, paresis in both arms resolved but the legs remained paraplegic. Further diagnostic workup including carotid duplex sonography, 24-hour electrocardiogram (ECG) and transesophageal echocardiography failed to identify the underlying cause of stroke. Hypercoaguability due to prostate cancer may have been contributed to cerebral ischemia. Routine coagulation parameters were normal, and more extensive coagulation diagnostics were not performed in the acute phase of the cerebral ischemia. Due to the simultaneous bilateral territorial infarctions in at least two independent vascular territories, the absence of macroangiopathy, and the preceding extensive surgery with narcosis we considered a cardiac embolic origin. Therefore the patient was placed on full anticoagulant dose of low-molecular weight heparin for embolic stroke prophylaxis. Early prophylactic treatment with antiplatelet drugs was not possible according to current guidelines because of extensive surgical intervention four days before stroke onset. In consent with the surgeons, we decided in this case to use low-molecular weight heparin as an early prophylactic treatment. After neurological rehabilitation we started a prophylactic treatment with acetylsalicylic acid because repeated 24-hour ECG could not identify a paroxysmal atrial fibrillation.

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+A previously healthy 64-year-old male was admitted to the hospital with headache, fever and later imbalance, blurred vision and general slowness. Patient’s neurological examination revealed nuchal rigidity and general clumsiness. Blood tests showed leukocytosis (11.90 × 109/l) and an increased C-reactive protein (47 mg/l). A computer tomography (CT) scan of the brain showed normal results. The cerebrospinal fluid (CSF) was clear but yellowish and had a slightly elevated count of erythrocytes (10 × 106/l), high levels of leukocytes (940 × 106/l; 40% lymphocytes and 56% granulocytes), elevated protein levels (1,696 mg/l), and hypoglycorrhachia (0.9 mmol/l). Bacterial cultures and CSF staining remained negative.
+Meningitis was suspected, and the patient was treated with intravenous (IV) dexamethasone (10 mg four times a day), ceftriaxone (4 g daily), and acyclovir (750 mg three times a day). Four days after admission, when his C-reactive protein had decreased to 10 mg/l, viral meningitis was considered the most probable cause. As a result, the treatment with ceftriaxone and dexamethasone was discontinued, but the acyclovir treatment continued.
+Nine days after admission, the patient’s general condition slowly deteriorated, and he became increasingly somnolent. The patient was restarted on IV ceftriaxone (2 g daily, which was increased to 4 g daily one day later), in combination with doxycycline (100 mg twice a day) due to the suspicion of borreliosis. On the following day, brain magnetic resonance imaging (MRI) was performed, and it revealed signs compatible with ventriculitis in the right lateral ventricle and the third ventricle .
+Eleven days after admission, the patient’s consciousness rapidly declined. A new CT scan of the brain revealed hydrocephalus and a mild midline shift, attributed to the enlarged right lateral ventricle , so an emergency ventriculostomy was performed. Cerebrospinal fluid obtained during the operation appeared clear but yellowish, with later debris observed in the CSF collector bag. Doxycycline was discontinued. Due to the neurosurgeon’s suspicion of a poor clinical response to ceftriaxone, it was switched to IV cefotaxime (2 g three times a day), with the dosage increased to 2 g four times a day by an infection consultant two days later. No signs of renal dysfunction were detected, and serum creatinine levels remained within the normal range. The patient’s condition rapidly improved after the ventriculostomy and antibiotic treatment. On the 21st day after admission, the ventriculostomy was closed.
+In the Gram staining of the CSF sample obtained from the ventriculostomy at the time of the operation, chains of gram-positive cocci were observed inside polymorphonuclear leukocytes. The bacteria’s morphology resembled that of streptococci. Bacterial cultures of both CSF and blood remained negative. The sample, which displayed bacteria in the Gram staining, and another CSF sample taken one day later, were analyzed using in-house bacterial 16s ribosomal RNA gene amplification by polymerase chain reaction (PCR) with high sensitivity for both aerobic and anaerobic bacteria, followed by sequencing. The analysis of both samples tested positive for S. intermedius.
+No clinical signs of infective endocarditis were observed in further assessments, and echocardiography was not performed. The patient mentioned a history of chronic dental problems. An orthopantomography revealed advanced periodontal destruction in several teeth, and periapical abscesses were found in teeth 33 and 31 . Maxillary teeth 15 and 16 were urgently extracted, followed by the extraction of teeth 17, 23, 24, 31, 32, 33, and 43. During the latter operation, prophylactic metronidazole (500 mg three times a day) was initiated for three days. The patient continued to improve and was discharged in good condition one month after admission, with only slight left-sided hemiparesis. The clinical time course, and the most important examinations and interventions of the patient during hospitalisation are illustrated in Fig. .

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+A 76-year-old Japanese man with a history of hypertension, laryngeal cancer, chronic obstructive pulmonary disease (COPD), and type 2 diabetes mellitus developed a cerebral arteriovenous malformation hemorrhage and was hospitalized at Aichi Medical University Hospital, Japan. His vaccination history was unknown. Case characteristics and laboratory data on the first visit are summarized in Table . Following surgery for removal of the hematoma, he began rehabilitation and was encouraged to engage in early postoperative ambulation. In March, 2015, on the 66th day of hospitalization, he developed a sudden fever and exhibited a sharp decline in oxygenation.
+At the onset of fever, the patient’s vital signs were as follows: body temperature, 37.8 °C; blood pressure, 84/41 mmHg; heart rate, 107/min; respiration rate, 30/min; and SpO2, 82% (room air). Blood gas analysis (room air) showed pH 7.538, 25.7 mmHg, 47.6 mmHg, HCO3
+− 21.4 mmol/L, and lactate 38.9 mg/dL. His level of consciousness was I-2 on the Japan Coma Scale. Physical examination showed coarse crackles and wheezes in the right lung. Based on chest radiography and computed tomography images , hospital-acquired aspiration pneumonia was diagnosed.
+Piperacillin/tazobactam 4.5 g was administered three times daily as initial treatment . Streptococcus pneumoniae infection was suspected based on a rapid identification test using a sputum smear, and a strain of S. pneumoniae was isolated from the blood culture sampled at the onset of fever. The patient was admitted to the intensive care unit and teicoplanin was added to his treatment regimen. However, his SpO2 and respiratory rate continued to be unstable. After 5 days of concomitant teicoplanin administration, the patient died.
+Streptococcus pneumoniae detected in the smear and the morphologic characteristics of the colonies on blood agar are shown in Fig. . The isolate was mucoid serotype strain 3, with a thick capsule. Antibiotic susceptibility to penicillins, cephalosporins, carbapenems, and levofloxacin was good, with resistance observed only to a macrolide (erythromycin) .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1350_en.txt

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+A 34-year-old Nepalese male, presented with confusion and abnormal behavior of 8-days duration. No witnessed seizures were reported. Examination showed a thin man with normal vital signs. He was drowsy, needed to be prompted continuously to respond, and was echolalic. There was prominent neck rigidity and bilateral 3rd nerve palsies in addition to peripheric facial palsy on the right. Gag and palatal movement were intact. The patient could move all 4 limbs equally, had bilateral extensor planter responses and an unsteady gait. Other systemic examination was unremarkable. Complete blood count, coagulation profile and serum chemistry were all within normal limits. HIV test was negative. A non-contrast computed tomography (CT) of the brain revealed hydrocephalus necessitating the insertion of an emergent external ventricular device (EVD) which was changed later to a ventriculoperitoneal shunt. CSF examination showed predominately lymphocytic inflammatory picture with around 330 cells, a moderately elevated protein of 0.75 g/l and a severely depressed glucose of 0.5 mmol/l. CSF Gram staining and cultures were negative. Polymerase chain reaction (PCR) for TB as well as Acid fast bacilli (AFB) staining, and TB culture was negative on 3 different occasions. CSF viral serology was also negative. Magnetic resonance imaging (MRI) with contrast including a MR venogram (MRV) (a–d) showed extensive basal enhancement, a solitary ring enhancing lesion (likely tuberculoma), left transverse and sigmoid sinus thrombosis extending to the jugular vein and two discrete vasculitic infarcts in addition to the presence of hydrocephalus with an EVD in place. Based on a score of – 5 on the Thwaites Diagnostic Score (TDS) and a score of 14 on the Lancet Consensus score (LCS) the patient was diagnosed with probable TBM and started on antituberculosis treatment (ATT) using the standard 4 drug regimen of rifampicin, isoniazid, ethambutol and pyrazinamide in weight adjusted doses in addition to dexamethasone. Further work up including a mantoux skin test, chest x-ray, an autoimmune screening, and a thrombophilia screening had a negative yield. The patient was not commenced on anticoagulants as the risk of bleeding with EVD in place was deemed high.
+Patient showed good recovery with restoration of normal cognitive function, but residual right sided oculomotor and facial palsies persisted. CSF showed reduction of cells and protein and normalization of CSF glucose after 20 days of treatment. The patient was sent to rehabilitation on ATT where he continued to improve and was discharged home after 2 months of rehabilitation with the above-mentioned deficits. The patient thereafter traveled back to his country and was lost to follow up.

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+A 53-year-old male was admitted to the outpatient department of the Second Hospital of Jilin University in February 2020, with swelling and pain on his left hip and proximal thigh, which he stated as having been developing over 5 days and aggravated with fever for 1 day. There was no history of trauma, and the patient was febrile (37.8 ℃). On physical examination, extensive redness and swelling spreading from the patient’s left buttocks to the thigh root could be seen at the lithotomy position, with high skin temperature and obvious tenderness; perianal connective tissue was detected protruding from the anus, and extensive soft tissue bulges were palpable on digital rectal examination, with obvious tenderness and a sense of fluctuation at the 6 o’clock position.
+Ultrasound of the left buttocks showed the echo of abnormal soft tissue with a thickened subcutaneous layer and multiple low to anechoic stripe and flaky zones, where the most extensive area was 1.9 cm × 1.1 cm . A CT scan was obtained to further define the extent and nature of the lesion, confirming multiple patchy liquid and gas density shadows in the bilateral rectal sphincter space, bilateral ischiorectal space, left hip and left thigh root muscle space, with gas–liquid planes detected in the left hip, and the rectum wall was discontinuous at 6 o'clock . Blood examination revealed that the white blood cell count reached 16.4 × 10^9/L, with 15.7 × 10^9/L and 92.2% for neutrophils.
+The patient was then diagnosed as gas-producing perianal abscess and admitted to the surgical ward with preparation for open surgery. The patient’s blood was collected for blood culture examination (5 ml cultivated for 5 days in BacT/ALERT FA culture bottles and BacT/ALERT FN culture bottles for aerobic and anaerobic bacteria detection, respectively, using BacT/ALERT 3D Microbial Detection Systems (BioMerieux Ltd., France)), and then the patient was managed with intravenous fluids and broad-spectrum antibiotics (ceftizoxime (2.0 g i.v. q12h), ornidazole (0.5 g i.v. q24h)) for empirical antibiotic therapy. On the second day after admission, the patient underwent extensive surgical debridement of the perianal abscess, revealing multiple pockets of necrotic tissue. The left hip and the proximal thigh were also debrided at multiple points where the undulations were noticeable, and then necrotic tissue was excised with drains put in place following the standard principles. Over 30 ml of slightly turbid pus was released, and one intraoperative tissue specimen was sent for bacterial culture.
+Although the perianal redness and swelling subsided obviously 2 days after the procedure, the patient was still febrile (38.3℃) with his left upper thigh continuing to be red and swollen, aggravated by tenderness and crepitus. CT of the left thigh showed extensive swollen soft tissue and massive gas density visible in the muscle space extending to the knee . An MRI was obtained to further confirm that soft tissue damage and gas and fluid signals could be detected between the subcutaneous tissue and muscle spaces through the left upper thigh . Blood was collected again for a culture test.
+Considering insufficient debridement and the risk of incorrect identification of pathogens, the Division of Gastrointestinal Surgery and Orthopedics performed debridement of the left upper thigh together on the 4th day after the primary operation. A large amount of inflammatory and necrotic fascia and muscle tissue was excised.VSD (Vacuum Sealing Drainage) equipment was used for closing the wound and constant drainage. Anti-infection and supportive treatment were continued after the operation, combined with 800,000 UI gentamycin in 3000 ml of 0.9% NaCl for constant irrigation. The debridement tissue was sent for bacterial culture again and a 16S rDNA sequencing test.
+While the blood culture tests continued to be negative, the first sample taken intraoperatively was positive in the bacterial culture test, and later identified as coinfection of Escherichia coli and Enterococcus faecium by conventional phenotype methods using the COMPACT VITEK2 identification system (BioMerieux Ltd., France) 1 day after the second debridement . Drug sensitivity tests determined that the isolated Escherichia coli was sensitive to amikacin, ampicillin, ampicillin-Sulbactam, aztreonam, cefazolin, cefepime, cefotetan, ceftazidime, ceftriaxone, cefuroxime, ciprofloxacin, gentamicin, imipenem, levofloxacin, meropenem, piperacillin, tobramycin, and trimethoprim, while the isolated Enterococcus faecium was sensitive to ampicillin, ciprofloxacin, erythromycin, high-level gentamicin, levofloxacin, linezolid, penicillin-G, tetracycline, tigecycline, and vancomycin. Although the specimen from the second surgery was negative in the bacterial culture test, the bacterial 16S rDNA from the patient sample was detected by PCR amplification with the 16S rDNA Bacterial Identification PCR Kit (Code No. RR176, TaKaRa, China). The sequence of the forward primer was 5′-GAGCGGATAACAATTTCACACAGG-3′, and the sequence of the reverse primer was 5′-CGCCAGGGTTTTCCCAGTCACGAC-3′. PCR results showed that there was an apparent PCR product of approximately 1600 bp representing the full-length 16S rDNA found in agarose gel . To clarify the classification of bacteria, DNA sequencing of this PCR amplicon was performed by the Sanger sequencing method . The chromatogram of 16S rDNA sequencing with different sequencing primers showed a single peak, indicating that one bacterial 16S rDNA fragment was present among PCR products . The bacteria were identified by searching and comparing the 16S rDNA sequences (see Additional file ) using the Silva database , which indicated that the bacteria have a 99% identity classification for Clostridium perfringens , and the phylogenetic tree was established by using the Basic Local Alignment Search Tool (BLAST) offered by the National Centre for Biotechnology Information (NCBI) database and confirmed that the isolate was most closely related to Clostridium perfringens .
+Due to the detection of Clostridium perfringens by 16S rDNA sequencing, the antibiotic regimen was then adjusted according to the results of drug sensitivity tests following bacterial cultures and DNA sequencing tests: meropenem (1 g i.v. q8h) and vancomycin (1 g i.v. q12h). The pain, redness, and swelling of the perianal area and left upper thigh continued to be relieved by this regimen. MRI indicated that although the soft tissue of the left thigh was obviously thickened, no obvious abnormal signal between/in the muscle and bone tissue was detected . Twelve days after the second debridement, another operation was performed again to remove the VSD equipment and close the wound. The blood examination taken on the 3rd and 5th days postoperatively showed no inflammation and the anti-infective treatment was then stopped. After another 3 days of close observation, the patient was discharged at 27 days of admission, and recovered well without adverse complaints at the time of 1-month follow-up.

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+A 53-year-old man with a history of multiple myocardial infarctions was admitted to our hospital because of ADHF accompanied by acute kidney injury (AKI) and hyperkalaemia. On admission, the patient was alert and oriented. Physical examination revealed blood pressure 130/70 mmHg, irregular tachycardia to 143 beats per minute with an oxygen saturation of 94% on room air. Respiratory rate was 26 breaths per minute, and physical examination revealed wheezing rales heard in both lungs and oedema in the lower extremities bilaterally. Due to significant wheezing and irregular tachycardia, abnormal heart sounds were difficult to distinguish on cardiac auscultation. The patient had type 2 diabetes mellitus, chronic kidney disease, paroxysmal AF, and high low-density lipoprotein cholesterol. He was markedly obese with a body weight (BW) of 131 kg [body mass index (BMI) = 45.9 kg/m2]. Laboratory tests showed an increase of brain natriuretic peptide (180.8 pg/mL, normal value: 18.4 < pg/mL), high serum potassium (9.4 mEq/l, normal value: 3.6–4.9 mEq/l). Serum urea nitrogen was 128.7 mg/dL (normal value: 8.0–22.0 mg/dL) and serum creatinine was 5.48 mg/dL (normal value: 0.60–1.10 mg/dL). An emergent continuous haemodialysis/filtration was conducted, and potassium value decreased. An electrocardiogram showed rapid AF rhythm plus ventricular premature beats around the rate of 160 beats per minute with left bundle branch block QRS morphology. The patient’s left ventricle showed marked dilatation and diffuse hypokinesis on echocardiography. The end-diastolic and end-systolic diameters of the left ventricle were 70 and 64 mm, respectively, and the ejection fraction (EF) was 18%. The left atrial diameter was 48 mm. Mild mitral and tricuspid regurgitation were observed. The end-diastolic and end-systolic volumes were 403.9 and 364.2 mL, respectively, evaluated by cardiac magnetic resonance imaging (MRI). The EF on cardiac MRI was 9.8%. Coronary artery angiography was performed 1 month before admission and no significant stenotic lesion was found.
+The medications were optimized as possible for chronic HF and other co-morbidities, including bisoprolol (2.5 mg), angiotensin II receptor blocker (ARB) (olmesartan 40 mg), vasopressin receptor antagonist (tolvaptan 15 mg), loop diuretics (furosemide 80 mg), mineralocorticoid receptor antagonist (spironolactone 12.5 mg), and amiodarone 200 mg. The maximum dose of ARBs was prescribed whereas dose of beta-blocker and spironolactone were sub-maximum doses due to frequent histories of ADHF/low output state and hyperkalaemia, which required emergent haemodialysis.
+Direct current electrical cardioversion (DC) was repeated under the support of intravenous anti-arrhythmics (amiodarone and nifekalant) to improve the haemodynamic status. However, sinus rhythm could not be maintained, and AF recurred many times. The patient developed a low cardiac output state and multiple organ failure with persisting AF. Intra-aortic balloon pumping (IABP) and mechanical ventilation with intubation were initiated. Right heart catheterization (RHC) on Day 20 showed a mean pulmonary capillary wedge pressure of 57 mmHg and a cardiac index of 2.7 L/min/m2, under the support of IABP and catecholamine infusion (DOA = 4.7 µg/mL/min, DOB = 5 µg/mL/min). On the same day, continuous haemodialysis/filtration (CHDF) was started because of acute kidney injury (AKI) and anuria. One dose of Digoxin was administered intravenously, and intravenous infusion of an ultra-short-acting beta1-selective blocker (randiolol) was used as a rate control strategy. However, rate control of AF was challenging with the heart rate consistently greater than 120 b.p.m. despite sedation, with transient elevation up to 140 b.p.m. On Day 27, the haemodynamic status collapsed to a systolic blood pressure of 50 mmHg. Therefore, our Heart Team decided to perform an emergent catheter ablation of AF to overcome the vicious cycle of HF and AF. Bilateral pulmonary vein isolation (PVI) was performed using the Ensite system and an irrigated-tip ablation catheter (Tacticath, Abbott Laboratories, St Paul, MN, USA) , under deep sedation with dexmedetomidine and thiamylal. Sinus rhythm was restored by DC cardioversion following PVI. The procedure time was 2 h. These procedures were completed without using contrast agents, considering AKI.
+After PVI, the sinus rhythm was restored. The patient’s haemodynamic condition improved dramatically, and catecholamine dosage was reduced. On the day after ablation, the IABP was removed. Renal function recovered and the patient began to produce urine. One week later, the patient was extubated, and mechanical ventilation was withdrawn. The patient’s clinical course is summarized in . There was an episode of AF recurrence after ablation, which was resolved by DC. After continuing cardiac rehabilitation program, the patient was discharged on foot, 1.5 months after the ablation.

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+A 22-year-old woman with a history of inability to use both upper limbs since 2 months presented in the accident and emergency unit. This followed a lightning strike in a village while she was asleep in the house. She was partially clothed with the trunk exposed during the incident. There was no history of loss of consciousness. Following the injury, she sought treatment from a traditional/spiritual healer in view of the superstitious belief of being attacked by evil forces.
+On examination, she was in poor general condition, febrile, and anemic. She had healing/ or infected superficial burns that involved the right side of the face and neck, the right axilla, breasts, right hypochondrium, and iliac fossa. The lower extremities of the upper limbs had extensive gangrene that extended to the elbows and infected burns on the right arm extending to the deltoid region as well as the anterior part of the left arm . On examination, chest and abdomen as well as the lower limbs were normal.
+A diagnosis of 18% lightning-induced burns with bilateral below-elbow gangrene was made. She was resuscitated with intravenous fluids, antibiotics, and immunized against tetanus. The patient refused amputation after counseling and left the hospital.

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+A 73-year-old Japanese woman with a history of hyperlipidemia, diabetes mellitus, and malignant lymphoma of mucosa-associated lymphoid tissue (MALT) presented to our hospital complaining of headache and nausea for 10 days. MALT lymphoma had been treated with chemotherapy 10 years ago and was in complete remission. The patient had no antithrombotic medications. The patient was fully alert and had no neurological deficits on initial physical examination. Brain computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated subacute subcortical hematoma mainly in the left superior to middle frontal gyrus (43 × 18 × 44 mm) with gadolinium enhancement in the perihematoma area and in the genu of the corpus callosum . Cerebral angiography detected neither vascular abnormalities nor feeder-like arteries of tumors in the left ICA, although it revealed an aneurysm in the contralateral ICA. A string of beads appearance was also detected in the bilateral extracranial ICA . Abdominal three-dimensional CT angiography performed for examination of hematuria 10 years previously also revealed a string of beads sign in the right renal artery. These studies indicate that FMD existed in the background. The abnormal vessels explaining the bleeding source were not disclosed on angiography; thus, we could not diagnose the apparent cause of hemorrhage. Craniotomy biopsy and removal of the hematoma were performed for diagnosis and decompressive treatment 10 days after admission. With a left frontal craniotomy, a xanthochromic capsule was observed on the surface of the hematoma. Although no specific findings were observed in the intraoperative frozen section diagnosis, the final permanent pathology specimen revealed FMD predominantly involving small- to mediumsized arteries distributed in the hemorrhagic necrotic brain tissue and overlying meninx. Many of the affected segments had stenoses with obliterations due to fibroplasia spreading into the intima and recanalization was observed in some of the obliterated vessels . In addition, aneurysmal dilatations were formed in the segments with severe medial lesions [ and ]. Immunostaining revealed that the most of the endothelium of thin-walled blood vessels and capillaries due to aneurysm had only CD31 without CD34 [ and ]. The patient was discharged 27 days after surgery. She was followed up in the outpatient clinic, and we recommend intervention for an aneurysm of the right ICA.

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+41-year-old previously healthy caucasian female patient presented to our emergency department (ED) for severe right upper quadrant (RUQ) abdominal pain that had exacerbated six hours prior to presentation. The pain had started two days prior to presentation for which she visited the ED in a peripheral hospital. There, blood analysis was done and showed neutrophilic shift, elevated C-reactive protein (CRP), and slightly high levels of the transaminases. Abdominal ultrasound (US) was done and showed a mildly distended gallbladder with a wall thickening of 4 mm and the presence of a 10 mm stone. There were no pericholecystic fluid nor dilation of the bile ducts. Sonographic Murphy's sign was negative. The patient was considered to have biliary colic and was offered to be admitted for further evaluation and to undergo laparoscopic cholecystectomy; however, her symptoms decreased in intensity on intravenous analgesics meanwhile, for this reason she refused to be admitted and got discharged. Nevertheless, the next day the pain returned and became severe in intensity, constant in nature, not radiating, post-prandial, and not alleviating by over the counter pain medications for which she presented to our ED. This time, the pain was also associated with four episodes of vomiting which developed over the past two days, and she did report one week history of myalgia, nausea, anorexia, and generalized fatigue. The patient reported no fever or chills and normally consistent and colored bowel movements, but did notice recent urine darkening. To note, the patient takes no medications, has no pertinent past medical family history, is not a smoker, and drinks alcohol occasionally. Moreover, she underwent hysteroscopic myomectomy for uterine fibroids two weeks ago; in addition, open appendectomy, adenoidectomy, and tympanoplasty were done at the age of 14 year old, 15 year old, and 22 year old, respectively. On physical examination, vital signs were normal with a temperature of 37.3 °C, blood pressure of 105/68 mmHg, and heart rate of 73 beat per minute. She was pale but not icteric, and the abdominal examination revealed soft abdomen but with RUQ and epigastric tenderness and with a positive Murphy's sign. Blood test showed normal complete blood count, electrolytes, and lipase with only elevated CRP but lower than the previous value; however, this time, total and direct bilirubin blood tests were also ordered that showed elevated values . Therefore, taking into consideration the patient's persistent severe RUQ pain with positive Murphy's sign, the presence of a 10 mm gallbladder stone in the US done two days ago, and the elevated level of CRP and bilirubin, plan was made to undergo laparoscopic cholecystectomy with intraoperative cholangiography (IOC) and possible bile duct exploration or intraoperative endoscopic retrograde cholangiopancreatography (ERCP) if needed for acute calculus cholecystitis with possible stone migration. Intraoperatively, an inflamed gallbladder was identified, and the smoothly done cholangiogram showed no abnormalities or filling defects in the biliary tree . Furthermore, the cystic duct and artery were clipped and cut and the gallbladder was dissected carefully from the liver bed with no injury; however, when removed and opened, no stones nor sludge were found in the gallbladder. At this stage the etiology of AAC was highly suspected rather than a calculus cholecystitis with a migrated stone. The last is mainly due to the presence of gallbladder inflammation without an obstructing stone and the difficulty of a 10 mm gallbladder stone or any stone large enough to cause cholecystitis to migrate through the common bile duct (CBD) either spontaneously without being stuck or causing bile duct dilatation or during cholangiography without extensive CBD flushing; moreover, when the US done in the peripheral hospital was reassessed at our institution retrospectively, it was found that the suspected reported stone could had been mistaken by a folded gallbladder wall especially due to the absence of a clear posterior shadowing. Post operation day one, while the patient's abdominal pain was already resolved, laboratory tests were ordered including full liver function test for further assessment and monitoring. Laboratory tests showed elevated liver function tests; therefore, taking into consideration this elevation, the presence of acalculous cholecystitis with no clear etiology, and the one week history of fatigue and myalgia, the presence of viral hepatitis was highly suspected. Therefore, complete viral hepatitis workup was ordered that all turned to be negative except for anti-HAV immunoglobulin M which was found to be 8.82 S/Co indicating acute viral hepatitis A. Consequently, the etiology of her previous symptoms were attributed to HAV induced AAC. The patient was maintained on supportive therapy: intravenous hydration, anti-emetics, and low-fat diet. On the second day of hospitalization, the patient's condition was significantly improved and she was discharged home on supportive therapy. To note, the histopathology showed gallbladder with cholesterolosis that is edematous, congested, and with polymorphous leukocytic infiltrates showing signs of cholecystitis and no malignancy.