diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_101_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_101_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4db6de64a03f92eee9923e12463d62de34817818
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_101_en.txt
@@ -0,0 +1,6 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1030_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1030_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..dd16023b5fa345a1313d2c9284b438a37d2a18df
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1030_en.txt
@@ -0,0 +1,5 @@
+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 .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1035_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1035_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7f761b21b1ebcedce92b09ecb941be35a42b205c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1035_en.txt
@@ -0,0 +1,5 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1036_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1036_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9592660bdf3e0b88fbacc441d8210dd47823d25f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1036_en.txt
@@ -0,0 +1,4 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1042_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1042_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1e849d8dbf415ef03b4d3e5488315879319cbc3c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1042_en.txt
@@ -0,0 +1,7 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1049_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1049_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d0c0a0cc7db101f0f39adfb49b89509814aa08e9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1049_en.txt
@@ -0,0 +1,5 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1071_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1071_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9f2091d7be31dac7a5d673f565aa5e34ea1b4089
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1071_en.txt
@@ -0,0 +1,8 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1084_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1084_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f9559c029cffdb5392792e62a6f996524536afb7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1084_en.txt
@@ -0,0 +1,3 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1085_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1085_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..dbb390e648979a43ac5b364633e801ee15ed3407
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1085_en.txt
@@ -0,0 +1,3 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1087_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1087_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a38cdcbbec62ef1e62b0e71181edf957e3308a99
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1087_en.txt
@@ -0,0 +1,5 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1091_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1091_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a302bfcdcab8434bd5059932fb4f7e50f3767305
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1091_en.txt
@@ -0,0 +1,6 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1096_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1096_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3b26db9761e00c9dbbe71f0833ad181a44501e45
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1096_en.txt
@@ -0,0 +1,8 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1101_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1101_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..65cc2d827f655bce54128f4e1dd78acd64ecfd4f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1101_en.txt
@@ -0,0 +1,2 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1104_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1104_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..baf9c2dada744f781bcb06d2c6be18326acfe4d6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1104_en.txt
@@ -0,0 +1,3 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1112_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1112_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9bd6d61515d042a12c165c0b56c8d8d9602281a0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1112_en.txt
@@ -0,0 +1,5 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1136_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1136_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..22a0cb89ec7c8ba56405afebf78e077fcc75fb45
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1136_en.txt
@@ -0,0 +1,11 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1142_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1142_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..02dcb5658c4f2679042610de52f3928955e61d24
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1142_en.txt
@@ -0,0 +1,6 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1156_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1156_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..afb5d8361197fbf742fe56fe80c9f4e27181f753
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1156_en.txt
@@ -0,0 +1,2 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1159_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1159_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..213d03cecde25e4aaf7fbc1568f048170f020a2e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1159_en.txt
@@ -0,0 +1,2 @@
+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.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1161_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1161_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b68dcc3937a538d902b863b944e0b3ea71df8291
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1161_en.txt
@@ -0,0 +1,3 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1163_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1163_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7780970ce309226f20ee173ae383d6c973d07c36
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1163_en.txt
@@ -0,0 +1,11 @@
+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.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1164_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1164_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0c0025dadbda1b9ce21db09688ec753ecd91a05f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1164_en.txt
@@ -0,0 +1,4 @@
+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 .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1169_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1169_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..95edd9c56089f46d5992c21dee16bd9ff42bdb5d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1169_en.txt
@@ -0,0 +1,2 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1195_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1195_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5babc9701bb8b72f72866b3bae98d0b0afd9615e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1195_en.txt
@@ -0,0 +1 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_119_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_119_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3021cbc3e81d1044d425c86f76230a0ce84d2889
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_119_en.txt
@@ -0,0 +1 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1200_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1200_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f38700e7c553d43f81d723801a429e39987904de
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1200_en.txt
@@ -0,0 +1,3 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1205_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1205_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c90708eda5473507c9754449d94d85214d558c13
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1205_en.txt
@@ -0,0 +1,5 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1212_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1212_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8ab9a8dd6be01637b3cc61aeed324c9474305130
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1212_en.txt
@@ -0,0 +1,2 @@
+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.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1215_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1215_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2ef518cfcca31ab8f1c93694e314f7d92955d185
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1215_en.txt
@@ -0,0 +1,2 @@
+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.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1217_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1217_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..56470bcb54e06107650276b5fbae2651212c90a9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1217_en.txt
@@ -0,0 +1,5 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1227_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1227_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..39bd3ba3c3bb1dde8e95f3acb26959915270f3d7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1227_en.txt
@@ -0,0 +1,3 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1228_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1228_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8a946491cf0dc3b5e444ace102313b0684a58d74
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1228_en.txt
@@ -0,0 +1,3 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1237_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1237_en.txt
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index 0000000000000000000000000000000000000000..5c9e5830addaf4ba504c9168e041d03351943a3c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1237_en.txt
@@ -0,0 +1,6 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1255_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1255_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..09b3963d669d143724ba4ecf1df0130f05e85513
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1255_en.txt
@@ -0,0 +1,8 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1264_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1264_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3867e1a4de040e4947169133d5e4ff29a9a2d709
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1264_en.txt
@@ -0,0 +1,8 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_12_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_12_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2b278701b5e7b906730efddf77380e9730fbc0fb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_12_en.txt
@@ -0,0 +1 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1307_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1307_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2218577a68f4d5ebf68c7056953854bed5d6fdcc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1307_en.txt
@@ -0,0 +1,7 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1309_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1309_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9802d3e821b2fc6a79ad343879fba0cb03e8c3c3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1309_en.txt
@@ -0,0 +1,6 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_130_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_130_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..42059fbea5a978dc94f6ac22beb6be5f10e59d33
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_130_en.txt
@@ -0,0 +1,13 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1319_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1319_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d3d3e254766daa9dbb57bccd921fdd5c8d26776f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1319_en.txt
@@ -0,0 +1,5 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1340_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1340_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6b2597b2df4b6aae5c1b6f30d4c1043ff0154d85
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1340_en.txt
@@ -0,0 +1,6 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1341_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1341_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..abe6554f802659f96746c59477bc3bde2ca40391
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1341_en.txt
@@ -0,0 +1,5 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1344_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1344_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..786f8ab92547d5b67b4e4d602c828256379a0c26
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1344_en.txt
@@ -0,0 +1,6 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1348_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1348_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..186a0efd6660c6f079524f98ce1f814d784f2ffc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1348_en.txt
@@ -0,0 +1,5 @@
+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) .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1350_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1350_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..dce6fec06b2aeabb3a24136313b89982bebf3702
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1350_en.txt
@@ -0,0 +1,2 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1370_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1370_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..88e1b56fa0d189bc6353ec6b189f17523d08680d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1370_en.txt
@@ -0,0 +1,7 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1377_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1377_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..59f1151650e18b078ee462c20ca20c2f577ea99d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1377_en.txt
@@ -0,0 +1,4 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1395_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1395_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..42d46241f0ac5ae242efde2f98ac5e07db6bba93
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1395_en.txt
@@ -0,0 +1,3 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1405_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1405_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ea82694aa98b47fc3be53e21d3ba628ab15ec51a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1405_en.txt
@@ -0,0 +1 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1410_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1410_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..70624afa06768075d80d6485a81f9f8e58359153
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1410_en.txt
@@ -0,0 +1 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1416_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1416_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..77166eab111b684d7e8b733e63fe381edccfff14
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1416_en.txt
@@ -0,0 +1,7 @@
+Painless and progressive visual impairment of both eyes over two years.
+A 27-year-old man presented to our hospital because of painless and progressive visual impairment of both eyes over two years. The patient had no other positive symptoms apart from blurred vision. The patient had no other positive symptoms apart from blurred vision. The patient had no history of ocular diseases.
+He was diagnosed with hypocalcemia when he was young but did not know exactly when and the serum calcium concentration at that time. He relied on a diet of milk or calcium-containing foods and calcium tablets to supplement his calcium levels at that time but subsequently did not take regular calcium supplements. He started to experience muscle cramps in his upper extremities, less markedly in his thighs and calves approximately ten years ago. However, he did not seek help for these symptoms until the occurrence of epilepsy. Seven years ago, he underwent cerebral surgery for epileptic seizures.
+The patient denied any diagnoses of personal or family history.
+The ocular examination revealed a preoperative binocular visual acuity of 16/200, and the best-corrected visual acuity (BCVA) was not improved. The intraocular pressure in the right and left eyes was 15 mmHg and 16 mmHg, respectively. There was bilateral symmetrical opacity of the lens presenting as punctate opacity in the posterior subcapsular cortex together with radial opacity in the peripheral cortex. Fundus examination showed no pathological changes.
+The biochemical analysis indicated a serum total calcium level of 1.21 mmol/L (serum ionized calcium level 0.72 mmol/L in arterial blood gas analysis), a serum phosphorus level of 1.67 mmol/L and a serum magnesium level of 0.62 mmol/L, indicating significantly low levels of serum calcium and magnesium but high serum phosphorus. His intact PTH level was 0 pg/mL. Adrenocorticotropic hormone (ACTH), cortisol hormone at 8:00 am, thyroid-stimulating hormone, thyroid hormones (TT3, TT4, FT3, FT4), whole blood count, coagulation function, renal and liver function tests were within normal limits . An electrocardiogram showed that there was a prolonged QT interval.
+Anterior segment photography revealed punctuate opacity in the posterior subcapsular cortex together with radial opacity in the peripheral cortex .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1417_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1417_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d7dc1b80370cb84ffd531bdcdb89a362a5ab778b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1417_en.txt
@@ -0,0 +1,2 @@
+A 75-year-old man who had a distal arch saccular aneurysm (60 mm) underwent operation. Because of liver cirrhosis (Child Pugh B), endovascular treatment was chosen. Computed tomography (CT) showed a 60-mm arch aneurysm . The diameter of the Aneurysm, proximal neck, and distal neck diameters were 60 mm, 36 mm, 30.7 mm, respectively. Aortic arch angle was 77 degrees. 2-debranch TEVAR using a fenestrated endograft (Najuta) was performed to achieve long proximal sealing length and preserve brachiocephalic artery. First, Right subclavian artery to left carotid and left subclavian artery bypass using T-shaped graft (Propatene, Gore), was performed prior to stent graft insertion . Given the aneurysm length of 60-mm, a CTAG stent graft of 31-mm diameter × 15-mm length (W.L. Gore and Associates Flagstaff, AZ, USA) was implanted just distal to the LSCA to supply Najuta steadily. The fenestration of the Najuta of 42-mm diameter was successfully positioned in zone 0 and delivered to the brachiocephalic artery . Molding of the endograft after deployment of Najuta stent graft was not performed in order to avoid aortic dissection. It was an off-label use as the proximal neck length was 16.9 mm (< 20 mm).
+Six hours postoperatively, he experienced acute hypotension, pancytopenia, and worsening lactic acidosis, resulting in systemic circulation failure. Emergent CT showed proximal collapse of the endograft and type I a endoleak with systemic blood flow obstruction . Due to the patient's poor general condition, a minimally invasive treatment was chosen. An additional stent graft 34-34-150 (Valiant Captiva, Medtronic, Dublin, Ireland) was placed, with molding, just distal of the the second fenestration emergently at the ascending aorta to bail out Najuta collapse . Brachiocephalic artery flow was maintained. Consequently, the endoleak reduced, and systemic circulation improved. Nevertheless, hepatic failure continued due to hemolysis and progressive anemia the following day. Emergent open chest salvage was performed on the third postoperative day. Because the stent graft was in the ascending aorta, we established a cardiopulmonary bypass with femoral arterial inflow and right atrial outflow. A fresh retrograde type A aortic dissection and collapse of the proximal part of the Najuta were observed during surgery. The entry was located at the lesser curvature of the ascending aorta between proximal Najuta stent graft and Variant. Aortic dissection occurred after 2nd stent graft insertion to ascending aorta by balloon dilatation of the endograft. Following the successful closure of the false lumen caused by the removal of the proximal 2 stent by suturing the stent graft to the aorta, the patient's hemodynamics were stabilized (Video 1). However, he had an extensive cerebral infarction with brain edema. Therefore, extracranial decompression surgery was required, resulting in temporary improvement of symptoms. The patient had complicated repeat extensive cerebral infarction. On the 19th postoperative day, the patient died of multiorgan failure.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1424_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1424_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..876518608f7911c76e9e9d83a4497cd5b809de75
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1424_en.txt
@@ -0,0 +1,5 @@
+A 79-year-old man presented with a 1-month history of constant lower back pain (LBP) radiating to the right thigh. The pain had been increasing over time. Movements aggravated the symptoms. The patient reported 10 out of 10 points in the visual analog scale. He was afebrile but reported intermittent chills at night. There was no history of recent gastrointestinal procedures, dental diseases/procedures, oncological diseases, immunodeficiency, diabetes, or intravenous drug use.
+On examination, the lumbar paravertebral muscles were tender, hip flexion on the right side revealed slightly paresis (M4/5), and minimal movement of the spine or the limbs was accompanied by severe pain.
+On admission, the inflammation markers were elevated (C-reactive protein [CRP] 54,4 mg/l, white blood cells [WBC] count = 13,6 G/l, platelet count = 344 G/l). X-ray and a ct-scan of the lumbar spine revealed destruction of the intervertebral space L3/4 and the corresponding endplates. Because of the bony destruction, the L4-body presented an anterior wedging. The standing X-ray revealed a segmental kyphosis as a result of the wedge deformity of L4-body and the collapsed disc space L3/4 . Blood cultures taken on admission were negative. During the next 12 h, the pain got worse, and the patient developed urinary retention, which required a bladder catheterization. MRI-scan of the lumbar spine 12 h after admission revealed an advanced spondylodiscitis L3/4 with a liquefied disc, blurred endplates, and a collection of two abscesses in the right psoas muscle. Furthermore, a diffuse signal enhancement in both psoas muscles and the autochthone muscles from L3 to S1 was shown. A ct-guided fine needle biopsy was performed, and the empiric intravenous antibiotic therapy with amoxicillin/clavulanate 2.2 g 4 times daily intravenously (iv.) was initiated. As the results of the biopsy did not show any growth of bacteria amoxicillin/clavulanate was stopped. After an antibiotic-free interval of 5 days (9 days after the CT-guided biopsy), an open transpedicular biopsy was performed. On the same day, iv. amoxicillin/clavulanate was resumed. The bacteriological examinations on aerobic/anaerobic cultures showed no results. The eubacterial PCR (16S rDNA-sequencing) revealed V. parvula as the causing pathogen. The antibiotic therapy was switched to ceftriaxone 2 g iv. and metronidazole 500 mg i.v. A CT of the abdomen was performed on day 21, which showed increasing abscess collection in the right psoas major of 4.1 × 4.6 cm but no signs of intraabdominal malignancy. A drain was inserted into the right psoas muscle, and the abscess formation was subsequently drained for 4 days.
+Abnormal high calcium levels revealed an incidental parathyroid adenoma, which had to be removed surgically. Because of the additional surgery, the patient was discharged on day 27. On day 39, the patient presented himself in good health and pain-free to our outpatient clinic. Inflammation markers had normalized (CRP 2 mg/l, normal WBC count). A small residual abscess collection in the right psoas muscle was discovered on CT scan. The CT-scans and the standing X-rays of the lumbar spine showed no instability of the spine without any progression of the kyphotic deformity L3/L4. The antibiotics were switched to amoxicillin/clavulanate 1 g po 3 times daily for another 2 weeks, completing 6 weeks of the antibiotic treatment altogether. The patient presented himself to the last follow-up at day 95 in perfect shape, without any symptoms, and further changes in the lumbar spine X-rays .
+There was no external immobilization of the spine during the whole duration of the treatment.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1425_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1425_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1691db3afb3f445f1d0e3731a7937b2a8ffb37ea
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1425_en.txt
@@ -0,0 +1,5 @@
+A 24-year old female presented with urinary incontinence and periodical headaches. She was born with an imperforate anus, absent rectum and colon, double bladder , and a dysgenetic sacrum defect . Soon after birth she was given an ileostomy, and later underwent an anorectal and bladder reconstructions. She now came to her pediatric urologist for urinary incontinence and mentioned severe headaches on the side, particularly when riding a bike. She solved her headache problem by stopping to ride her bicycle. Her parents then sold the bicycle since it became useless.
+Recently she expressed the wish to become dry and additional investigations were scheduled. On physical examination a normal looking woman presented herself with an ileostomy and urinary incontinence without further palpable abnormalities in the abdomen or back. Blood tests showed no abnormalities; particularly alpha foeto-protein and B-HCG were within normal ranges. MRI showed a large and previously not known anterior presacral meningocele as well as a tethered cord due to a tight filum terminale . She refused testing for defects on the HLXB9 gene on chromosome 7q36. She was referred to a neurosurgeon and treatment of the meningocele consisted of a laminectomy S1-S2, transection of the filum terminale and an intradural closure of the dura towards the meningocele. The meningocele regressed and is expected to further dissolve. Three months after surgery she has no complaints; she received a urinary diversion and bought a new bicycle again.
+The Currarino syndrome is a familiar syndrome with the triad of sacral defects, hindgut malformations and presacral tumors. It has an autosomal dominant inheritance with variable expression and the mutation is on the HLXB9 gene located on chromosome 7q36 [,]. The sacral defects vary from a slightly dysplastic sacrum to a complete sacral agenesis (caudal regression). The embryology of the syndrome is still unclear and was initially thought to be a consequence of mal-communication of the endoderm and the neuronal ectoderm . More recently it is suggested that developmental errors in progenitor cells at the region of the caudal eminence are responsible for the abnormality [,].
+Clinically, the presacral mass in the Currrarino syndrome is a teratoma in approximately 25% of the cases . The complete Currarino triad is rare; this syndrome should be considered even in the presence of a partial phenotype [,]. The sacral defects can be mild and go unnoticed. The anorectal malformation can be present but the Currarino syndrome has also been described without an anorectal malformation . Constipation, however, is present in over 95% of the cases, often with an early onset as an infant and often with an intractable character . The wide phenotypic variability requires combined pediatric, neurosurgical, and often urological assessments. The triad is associated with other spinal abnormalities in the majority of patients, including anterior meningoceles in 60% . Anterior meningoceles are congenital lesions of spinal fluid filled sacs communicating with the subarachnoid space . They can give clinical symptoms related to the pressure the cele gives to organs in the pelvic floor region (rectum, bladder, genitals) or to the sacral nerves with subsequent failure of these nerves. Also, pressure on the cele gives increased intracerebral pressure with subsequent headaches.
+Anterior meningoceles give symptoms in approximately two-third of the cases. These are abdominal in 70% of the cases, urogenital in 30% of the cases and neurological in 27% of the cases . Beside these effects it may give enteral fistulas resulting in severe infections with life-threatening meningitis . These symptoms appear usually in the second to third decade of life. Anterior meningoceles can further give constipation, abdominal pains, constipation, urinary retention, dysmenorrhea, low back pain, radiation to the legs as first symptoms. However, as in our case other atypical symptoms can be seen as well. Treatment of anterior meningoceles can be conservative if no symptoms are present. However, most anterior meningoceles give symptoms and need surgical treatment because there will be no spontaneous regression. Conservative management is furthermore associated with a 30% mortality rate mostly due to meningitis. Therefore, surgical closure is generally recommended [,]. A posterior approach, transsacral or sagittal, is the preferred one because of the lowest complication rate [,]. The anterior laparotomy approach still has a high morbidity and mortality (22%) due to infections and fistula formation. Transvaginal and transrectal punctures have also previously been suggested but have a similar high morbidity and mortality.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1435_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1435_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ccd6abf5485f451a1e2e62cec2dbc6eb9bb45594
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1435_en.txt
@@ -0,0 +1,3 @@
+A 36-year-old female with a history of untreated hypertension presented to the emergency department with severe headache and a decreased level of consciousness. Computed tomography (CT) of the head demonstrated a large cerebellar parenchymal hemorrhage [Figure , ], but CT angiogram was negative for a vascular malformation, aneurysm, or venous sinus thrombosis. A right frontal EVD was inserted, and the patient underwent suboccipital decompression and clot evacuation, with clinical improvement. Subsequent vascular imaging, including magnetic resonance (MR) and digital subtraction angiography was negative for pathology [Figure –]. A thorough hematological workup was also negative. As such, this was considered a hypertensive hemorrhage.
+Five weeks following admission, the development of communicating hydrocephalus required the insertion of a VP shunt [Figure , ]. Following burr hole placement, the dura was coagulated and monopolar cautery along a forceps was used to puncture the dura and cauterize the pia. After a single pass, good CSF egress was observed, and the ventricular catheter was gently advanced to approximately 10 cm. The surgery was well tolerated and the hydrocephalus and level of consciousness improved.
+On day 15 following VP shunt insertion, the patient developed a dilated and fixed right pupil. An emergent CT scan demonstrated acute intraparenchymal hemorrhage into the right parietal lobe along the ventriculostomy tract with extensive intraventricular hemorrhage, acute hydrocephalus, and midline shift [Figure , ]. An EVD was inserted through the previous right frontal burr hole, and a CT angiogram followed by a four-vessel angiogram revealed a pseudoaneurysm of a right distal middle cerebral artery (MCA) branch immediately adjacent to the entry point of the ventricular catheter in the right parietal region [Figure –]. A right parietal mini-craniotomy was performed for coagulation of the right distal MCA pseudoaneurysm and removal of the VP shunt. Repeat VP shunt placement was performed 2 months following pseudoaneurysm resection. The patient was discharged to a rehabilitation facility and continued to make cognitive and functional improvement. She has since been discharged home with in-home nursing and physiotherapy assistance.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_143_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_143_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d6a1f89ac3fefbafb1c0e106b2d71b5674684025
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_143_en.txt
@@ -0,0 +1,9 @@
+A 63-year-old right-handed woman attended her local hospital with a left hemiparesis of sudden onset 24 hours after a RTA. Her motor vehicle had collided with a parked vehicle. There was neither loss of consciousness nor any definite head or whiplash injury. Within a further 24 hours she developed right leg weakness. Computed tomography (CT) brain scan revealed a small low-density area in the right fronto-parietal region only; a CT scan of her cervical spine was normal. Given her progressive triplegia, immediate transfer to our centre was made, to exclude cervical spinal cord injury.
+Initial assessment revealed her to be orientated with fluent speech. However, she had evidence of cognitive impairment with an inappropriate jovial affect, poor cognitive estimates and concrete thinking, bradyphrenia and was unable to provide a reliable history. Additional history was obtained from her husband and family. There was no preceding history of cognitive decline but some reduced self-care and hygiene, weight loss of approximately 8 kilograms over three months, and altered bowel habit. Her family had witnessed three episodes of left arm monoparesis, lasting between minutes and 1–2 hours, in the 48 hours preceding her accident. Twenty-four hours after her accident she developed a dense left hemiparesis of sudden onset.
+She consumed less than 2 units of alcohol per week, was an ex-smoker, and had no other past medical history of note. She had a family history of ischaemic heart disease.
+General examination was unremarkable and she was in sinus rhythm. Neurological examination revealed impaired volitional saccades to the left, but normal targeted saccades. Snout and palmomental reflexes were present. Mild left sided visuospatial dysfunction was present. No sensory inattention was demonstrated. She had a dense left hemiparesis (MRC grade 0 arm and leg) and mild right leg monoparesis (MRC grade 4). Deep tendon reflexes were brisk bilaterally, and both plantar responses were extensor. There was no sensory level.
+Formal neuropsychological assessment later confirmed specific difficulties with visual memory, executive functioning and perceptual/constructional abilities.
+Urgent brain and cervical spine MRI, revealed an ischaemic lesion in the right fronto-parietal region but no structural cervical cord pathology. Diffusion weighted images were not obtained. A repeat MRI brain scan, 8 days after the onset of left hemiparesis showed additional infarction in the distal left anterior cerebral artery territory.
+Comprehensive serial blood tests revealed the following abnormal results (normal ranges and units in brackets): white blood cell count between 11.6 and 13.9 (4 to 11 × 109/L), C-reactive protein between 17.8 and 49.5 (< 8 mg/L), erythrocyte sedimentation rate between 54 and 65 (5 to 15 mm/h), total serum cholesterol 5.7 (<5 mmol/L), carcinoembryonic antigen (CEA) 15.7 (0 to 3.5 ng/mL). Carotid ultrasound examination revealed a right internal carotid artery (ICA) stenosis >85%, whilst all other vessels were normal. Routine cerebrospinal fluid examination was normal. CTA neck confirmed the right ICA stenosis, but no significant left ICA disease. CTA circle of Willis (CoW) showed the right A1 anterior cerebral artery (ACA) segment to be dominant, the left A1 ACA segment to be absent, and an anterior communicating artery (AcoA) aneurysm . The remainder of the CoW was considered to be normal. A transthoracic echocardiogram demonstrated no cardiac embolic source. A colonoscopy revealed a rectal tumour, confirmed on biopsy to be a moderately differentiated adenocarcinoma.
+Pharmacological treatment included aspirin, pravastatin and perindopril. She also received care from a multi-disciplinary rehabilitation team including physiotherapy. By 10 days after the onset of the left hemiparesis, improvement was noted in all of her deficits, and by 18 days she was regaining power in the left hand and wrist. She was transferred back to her referring hospital for management of her rectal tumour.
+The neurological formulation at discharge was one of symptomatic right internal carotid artery stenosis and embolic stroke. It is possible that the RTA was a complication of left-sided visuospatial dysfunction. The subsequent presentation is consistent with multiple bilateral embolic strokes, secondary to CoW variation.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1453_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1453_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..24bbde14f11750e8f7845c371a57de5a4ae5c9b7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1453_en.txt
@@ -0,0 +1,4 @@
+An 18-year-old girl presented to us complaining of painless bilateral milky nipple discharge for one month. Her menstrual cycles were regular and did not complain of headache or visual disturbance. She was not on any medication except for metformin and insulin for her type 1 diabetes mellitus.
+Detailed inquiry revealed that the milky secretion was produced, particularly on seeing a newborn in her next door. The patient sat for long hours in front of a window through which she could always see the infant in the adjoining house. She further described spurting of milk on hearing newborn’s cry or even on remembering its memories. She also claims to dream of herself handling the newborn. She has never experienced similar symptoms before. However her symptoms have rapidly regressed after the neighbours had shifted with the newborn. She is a sexually inactive, school girl preparing for advanced level examination scheduled in 6 months. However she denied any symptoms suggestive of depression, anxiety or delusional disorders.
+On examination, she was overweight with a BMI of 25.7 kgm-2, well oriented and fluent in speech. She did not have papilloedema, or other focal neurological signs. Her visual fields were normal. Both breasts were in Tanner’s stage 5. By the time of presentation, overt milk discharge had subsided and only a scanty milky nipple discharge was produced with gentle pressure bilaterally.
+Investigations revealed an elevated serum prolactin of 62.5 ng/mL (2717.4 pmol/L). Macro-prolactin levels were not measured. Her thyroid function tests and blood biochemistry were normal except for elevated fasting plasma glucose (142 mg/dL/7.9 mmol/L) and HbA1c (7.6%). Unfortunately, MRI scan of the brain was not available during the symptomatic period. Three months after resolution of her symptoms, prolactin levels returned to normal (6.12 ng/mL/266.1 pmol/L). MRI of brain at this point showed only a slight asymmetry of the pituitary gland with a bulky right lobe, without definite evidence of a microadenoma.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1454_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1454_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9f67ba6a709feb1bb44abf2e7a6f7b333f206280
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1454_en.txt
@@ -0,0 +1,8 @@
+A 53-year-old Caucasian woman with unremarkable clinical history underwent a training for advanced scuba diving without any specific clinical evaluation, except for a standard visit with the GP and an electrocardiogram, both resulted normal, as required by Italian legislation for non-competitive sports activities. She had already completed a basic scuba diving course (maximum depth of 18 m) without any problem. Once surfaced after her first dive at 30 m, the woman displayed a transient congested cough and rales disappearing after a few minutes. Roughly 15 min into her second dive, the woman started experiencing nausea. Her instructor assisted her in conducting a swift ascent. While at a depth of 12 m, the woman’s condition deteriorated rapidly. Upon reaching the surface, she experienced intense bouts of coughing and proceeded to vomit a yellowish mucus. Subsequently, she lost consciousness. When emergency services arrived, the patient had no pulse and no shockable rhythm. She was successfully resuscitated through basic life support manoeuvers but did not regain consciousness. A contrast-enhanced computed tomography scan of the brain was suggestive of anoxic brain damage, while there was no evidence of air embolism.
+At the time of hospitalization, an echocardiogram was not immediately performed because the woman promptly underwent oxygen therapy in a hyperbaric chamber. Troponin values showed pathological levels (T 416.0 ng/L) while, in the following 2 days, two echocardiograms were performed, documenting respectively a non-dilated left ventricle with wall thickness at higher normal values, with hypokinesia of the base segments and hyperkinesia of the apical segments (suspected reverse Takotsubo), and then, an akinesia of the basal segments and normal contractility of the apex. Both examinations, however, did not show signs of HCM.
+From the interview with the family, it emerged that the patient did not suffer from pathologies and did not usually take medications. The use of oral contraceptives was also excluded, and no history of familial cardiomyopathies was reported.
+After 4 days in the intensive care unit, brain death was declared.
+Because of the suspicion of cardiac hypertrophy on the echocardiogram, a post-mortem magnetic resonance scan was performed. The exam confirmed LV concentric hypertrophy ( and ) and showed myocardial fibrosis in the most hypertrophied area as well as extensive oedema (as a sign of acute myocardial damage; ).
+On macroscopic examination, the heart weighed 300 g and wall thickness was up to 20 mm (in the basal septum) and 18 mm (in the basal anterior and lateral segments; ). No abnormalities of the heart valves or coronary arteries were noted.
+Histological examination of the myocardial tissue showed diffuse hypertrophy and disarray of cardiomyocytes with foci of fibrosis and mid-adventitial thickening of subendocardial arterioles .
+In conclusion, the autopsy findings combined with evidence provided by microscopic examinations of the lungs have allowed us to highlight the presence of a massive acute pulmonary oedema. This condition was deemed to be secondary to the rapid ascent from the dive, which, however, was carried out by the woman due to the acute cardiac symptoms she had developed.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1494_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1494_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0db9e831d05f87fda51cffed1a86d33c47b16540
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1494_en.txt
@@ -0,0 +1,7 @@
+A 69-year-old woman presented with hematuria during routine screening.
+Computed tomography (CT) urography was performed at the Department of Nephrology. Incidentally, a small bowel tumor was detected on the CT scan, prompting a referral to our department.
+The patient had no other underlying diseases, except for hypertension, and did not complain of GI symptoms (such as nausea, vomiting, or abdominal pain). There was no history of previous pulmonary tuberculosis.
+The patient had no relevant family history.
+A physical examination revealed normoactive bowel sounds, no abdominal distention, and no prominent tenderness. The vital signs were as follows: blood pressure, 141/86 mmHg; pulse rate, 70 beats/min; respiratory rate, 18 breaths/min; and body temperature, 36.2°C.
+Laboratory tests indicated anemia, with the following findings: hemoglobin, 9.2 g/dL (reference: 12–16 g/dL); mean corpuscular volume, 87.8 fL (reference: 80–100 fL); mean corpuscular hemoglobin, 29.8 pg (reference: 26–38 pg); serum iron, 82 μg/dL (reference: 29–164 μg/dL); ferritin, 116 ng/mL (reference: 13–150 ng/mL); and unsaturated iron binding capacity, 135 μg/dL (reference: 191–269 μg/dL). Tumor markers, namely carcinoembryonic antigen and carbohydrate antigen 19-9, were within their normal limits (0.697 ng/mL and 3.8 U/mL, respectively). No other abnormalities were noted.
+A CT scan revealed irregular thickening of the distal ileum, which caused proximal small bowel dilatation, and several enlarged lymph nodes in the mesentery and preaortic area . These findings suggested the presence of a malignant small bowel tumor with lymph node metastasis. No findings indicative of GI bleeding were observed during an endoscopic evaluation.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1504_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1504_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c5fcf211e445c7543033ce971fd885e4264eabce
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1504_en.txt
@@ -0,0 +1,8 @@
+A 35-year-old woman diagnosed to have echocardiographic-proven chronic rheumatic heart disease (severe mitral stenosis with pulmonary hypertension) for the past 25 years. She had undergone percutaneous balloon mitral valvotomy (PBMV) 6 weeks previously.The left atrial thrombus was detected after the procedure and she started warfarin 5 mg, po, daily for 4 weeks and escalated to 7.5mg po daily to meet desired INR.
+On her day of presentation to Emergency Medical OPD, she had a severe headache and repeated episodes of vomiting of ingested matter of 1 day duration. She gave recent history of nasal bleeding, and stopped warfarin by herself 3 days ago. She gave history of fever, malaise and generalized weakness of 1 week duration.
+On initial clinical evaluation, vital signs were within normal limits and stable. She had no pallor of conjunctivae and had wet buccal mucosa. On cardiovascular examination, she had accentuated P2, mid-diastolic and pan-systolic murmur at mitral area, but no summation gallop. No cranial nerve palsy, no motor or sensory deficit, and meningeal irritation signs were negative. Findings in other systems were unremarkable. Diagnoses of chronic rheumatic heart disease (mitral valve disease with pulmonary hypertension), PBMV, left atrial thrombus, pyogenic meningitis R/o subarachnoid hemorrhage were made.
+Laboratory values revealed white blood cell count (wbc) =25,000/µL (neutrophil count=85%, lymphocyte count=10%), hemoglobin (hgb)=12gm/dl, Platelets=350,000/µL. Liver function tests (LFTs) and renal function tests (RFTs) were within normal values. Blood culture was taken, but no growth at first, second or seventh day of incubation. Coagulation profiles showed prothrombin time (PT)=35 sec (normal value=11–13 sec), partial thromboplastin time (PTT)=53 sec (normal value=22–35 sec) and international normalized ratio (INR)=2.5 (normal value=0.8–1.4) . A lumbar puncture was deferred due to higher INR value. Electrocardiography (ECG) tracing showed P-mitrale, right bundle branch block (RBBB), and ST depression and inverted T wave at V1-V3, suggestive of left atrial enlargement and right ventricular strain. Trans-thoracic echocardiography revealed moderate mitral stenosis, mild mitral regurgitation, and severe pulmonary hypertension. No vegetation or thrombus was seen. She was initiated with Ceftriaxone 2gm, IV, twice daily and Vancomycin 1 gm, IV, twice daily, and warfarin was already discontinued.
+On the third day of admission, she developed sudden onset, frequent tonic-clonic convulsive episodes with subsequent loss of consciousness. On physical examination, blood pressure (BP)=130/90 mmhg, pulse rate (PR)=116 beats per minute (bpm), respiratory rate (RR)=32 breaths per minute (bpm), temperature (T0)=38.6 0c. There was transmitted sound all over the chest. A neurological examination revealed Glasgow Coma Score (GCS) of 8/15 (E2, M4, V2). Both eyes deviated to the left side. Pupils were mid-sized, but poorly reactive to light. She withdrew to painful stimuli. Meningeal irritation signs were negative. Diagnosis of status epilepticus secondary to intracranial hemorrhage due to warfarin toxicity was made after non-contrast brain CT scan revealed left-sided acute subdural hematoma and ventricular bleeds ( and ). Then, patient was initiated on diazepam, 10mg IV, and Phenytoin 1gm IV bolus followed by 100mg IV 3 times a day to arrest the seizure. She was given O2 via face mask, NG-tube was inserted, and urinary catheter was put in situ.
+She was transferred to ICU after a diagnosis of status epilepticus, was intubated and put on a mechanical ventilator. Vital signs and Spo2 were monitored by cardiac telemetry. Fresh frozen plasma 4 units, and vitamin k, 10 mg IV once daily for 3 days were given. IV ceftriaxone and vancomycin were continued. Mannitol (20%), 50gm IV bolus and 25gm IV 3 times daily was provided to decrease increased intracranial pressure (ICP). Valproic acid, 400mg po 3 times daily was added as the seizure was poorly controlled. A craniotomy was done by neurosurgeon on the same day of neuroimaging and evacuated clots of blood.
+Repeat laboratory values revealed WBC=34,000/µL (neutrophil count=85%, lymphocyte count=10%), hgb=9gm/dl, platelets=550,000/µL. Coagulation profiles showed PT= 49.8 sec (>3.5x ULN), PTT=63.2 sec (>1.5x ULN) and INR=4.38 (>3x ULN). Serum LFTs, RFTs and electrolytes were with in normal limits .
+Paroxysms of increase in pulse rate, blood pressure, respiratory rate, temperature, sweating, and decerebrate posturing became typical after 7 days of neurological insult. It occurred while suctioning, body turning, and physical examination. It occurred at least 2–4 times a day, each persisting for between 5 and 40 minutes. PSH was considered by neurologist after repeated recordings of normal inter-ictal EEG tracing during episodes of autonomic surge. CSF score was 11 (heart rate >140 beats per minute, respiratory rate=24-29 breaths per minute, systolic blood pressure=140-159 mmhg, temperature=38-38.9 0c, mild sweating, and moderate posturing during episodes). DLT score was 11 (antecedent acquired brain injury, sympathetic surges were paroxysmal, simultaneous, episodic and episodes occurred >2 times daily and persisted for > 2 weeks post-brain injury, provoked by non-painful stimuli (allodynia), and medications reduced sympathetic features)., “Probable” diagnosis of PSH was made after patient scored 21 using PSH-AM score (sum of CFS score and DLT score). Then, she was adequately rehydrated with isotonic fluids; and started on morphine 2 mg, IV, as required (prn); paracetamol 1 gm, po as required (prn); propranolol, 40 mg po 3 times a day; diazepam 5 mg, IV 3 times a day; and gabapentin 150–300 mg po 3 times a day. Her GCS started to improve on second week of ICU admission, and frequency and severity of sympathetic storm declined. IV antibiotics were discontinued after 2 weeks of therapy. On the third week of admission, her clinical condition deteriorated all of a sudden, developed asystole, and died of cardiac arrest despite cardiopulmonary resuscitation (CPR).
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1505_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1505_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3a88a4da5a199d5d618cf346b1f032857b9b9e9a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1505_en.txt
@@ -0,0 +1,24 @@
+A 24-year-old woman presented with painless proptosis in her left eye, which started
+and progressed during her pregnancy about 10 months ago. Her uncorrected- and
+best-corrected visual acuity (UCVA and BCVA) were 20/25 and 20/20, respectively. In
+addition, the relative afferent pupillary defect (RAPD) in the left eye was
+negative. While the Hertel exophthalmometry revealed an anterior displacement of the
+globe with 4 mm of proptosis, the fundoscopy showed a left optic disc edema. Other
+slit-lamp examinations were normal.
+Magnetic resonance imaging (MRI) demonstrated an intraconal circumscribed oval-shaped
+mass with hypointense signals on T1-weighted images and hyperintense signals on
+T2-weighted images [Figure 1] mimicking cavernous hemangioma.
+As a consequence, the patient underwent uncomplicated superomedial orbitotomy which
+resulted in the removal of a 310.5 cm necrotic white mass without any bleeding and which was also
+free of connections to the optic nerve sheath.
+A histopathological examination showed tumoral cells with syncytial and whirling
+arrangement, indistinct cell membranes, eosinophilic cytoplasma, and rather uniform
+nuclei. Some intranuclear pseudoinclusions were also present. Mitotic figures were
+rare. Immunohistochemistry revealed positive staining for epithelial membrane
+antigen (EMA) a progesterone receptor (PR) [Figure 2] and negative staining for
+S100, CD34, and BCL2. Ki67 showed proliferative activity in about 1–2% of tumor
+cells. As a result, a meningotheliomatous meningioma (WHO grade 1) diagnosis was
+made.
+Postoperative radiotherapy was performed on the orbital tumor bed. After a one-year
+follow-up, no complications or changes in the patient's perimetry, visual acuity,
+and RAPD were detected.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1506_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1506_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b6e14c33d6fc6e7a46280b49f98a9fefd30f4112
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1506_en.txt
@@ -0,0 +1,11 @@
+A 24-year-old woman was referred in 2005 with increasing episodes of debilitating lower limb myalgia, since the age of seven. The attacks occurred every 1–2 years but had increased since 2005 to four per year. They were preceded by sore throats, and more recently, by cough or dysuria. During these episodes, creatine kinase (CK) ranged from 89 to 700 U/litre (normal range <175), normal between episodes. Her muscle pain responded to oral prednisolone within days.
+Because of the sore throats and an elevated antistreptolysin O titre (ASOT), she underwent a tonsillectomy in 1992. Apart from the tonsillectomy, her past medical history and drug history were unremarkable.
+We set out to fully investigate one of these attacks. In September 2005, an attack of muscle pains was preceded by cough and green sputum 2 weeks earlier. An examination was normal except for a slightly injected throat and tenderness of the calves and anterior compartment muscles. Biopsy of the right tibialis anterior muscle showed mild muscle fibre atrophy of uncertain significance. Erythrocyte sedimentation rate (ESR) was elevated (39 mm/hour), leucocyte count was 16.6 × 109/litre (4.0–11.0), with a neutrophilia of 13.6 × 109/litre (81.9%) and a monocytosis of 1.06 × 109/litre (6.4%). Lymphocyte, eosinophil, basophil counts, CK, renal and liver function were normal.
+Serology was negative for influenza A & B, respiratory syncytial virus (RSV), Mycoplasma pneumoniae, chlamydia, Q fever, adenovirus, enterovirus, and ASOT.
+Acute serology for Epstein-Barr Virus (EBV) was less clear. Epstein-Barr Nuclear Antigen (EBNA) IgG, Viral Capsid Antigen (VCA) IgG and IgM were present. This may be due to a false positive VCA IgM, a primary EBV infection in the last 3–12 months, or a reactivation of EBV. Convalescent EBV serology 5 months later showed a positive EBV VCA and a negative EBV VCA IgM, consistent with past EBV infection.
+Due to the uncertain significance of the EBV serology, further investigations were done during an episode in September 2006, triggered after 4 days of urinary tract infection.
+On examination, she had a temperature of 38°C. Examination of her throat, skin, abdomen and cardiorespiratory systems was normal. There was marked tenderness of forearm, thighs and calf muscles. Testing lower limb power was inhibited by pain, but was otherwise unremarkable. Tendon reflexes were normal.
+Blood tests showed an elevated CK (715 U/litre), leukocytosis of 31.1 × 109/litre (normal range 4–11), neutrophilia (88.6%), lymphocytosis (5.8%) and monocytosis (5.4%). ESR was 80 mm/hour and C-reactive protein was 287 mg/litre. Blood film showed normochromic normocytic red blood cells, leukocytosis with a neutrophilia and monocytosis, occasional atypical mononuclear cells and some rouleaux. Her mid-stream urine (after 7 days of trimethoprim) showed a white cell count of 284 × 106/litre, epithelial cells of 272 × 106/litre and lactobacillus at >100 × 106/litre (probably a contaminant).
+Serology for EBV and cytomegalovirus (CMV) confirmed past infection only, with raised IgG and negative IgM. Polymerase chain reaction (PCR) for EBV, adenovirus, and CMV of EDTA plasma was negative. The monospot test for heterophile antibodies (a marker of primary EBV infection) in serum was negative. A throat swab was negative for EBV (by PCR).
+Biopsy of the right tibialis anterior muscle showed marked interstitial inflammation mainly by CD4 lymphocyte with occasional fibre necrosis associated with CD4 inflammation, changes consistent with multifocal myonecrosis . PCR of muscle was negative for EBV and CMV.
+Other investigations in between episodes were non-contributory. These included normal CK, full blood count, random blood glucose and autoantibodies. An underlying immunodeficiency was excluded, with normal immunoglobulins, lymphocyte subsets, in vitro lymphocyte proliferation in response to phytohaemagglutinin and pokeweed mitogen. When she was well, electromyography (EMG) of her right tibialis anterior and right medial gastrocnemius muscles in May 2006 showed myopathic changes.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1517_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1517_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..af114b84c866fbb70bf3f37cb183792d55e393da
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1517_en.txt
@@ -0,0 +1,3 @@
+A 21-year-old African-American male basketball player presented after a positive COVID-19 PCR test 1 month earlier for an RTP assessment. His COVID-19 symptoms included diarrhoea, cough, shortness of breath, and nasal congestion for 9 days. No intervention or hospitalization was needed, and he felt he was fully recovered and was asymptomatic. His vital signs and physical examination were normal. His cardiac exam was within normal limits, including no abnormal heart sounds, regular pulse and rhythm, and equal strong peripheral pulses. His respiratory exam showed no abnormal breath sounds with equal inspiratory effort. His resting electrocardiography (ECG) is shown in . He had no significant past family history of cardiomyopathies or sudden cardiac arrest before the age of 50 years. He denied any persistent dyspnoea, chest pain, palpitations, lightheadedness, dizziness, near syncope, or syncope. At that time, as per published guidance, an echocardiogram revealed normal left ventricular (LV) size and function (normal wall motion, diastolic function, and LV ejection fraction = 58%) (see , ). Troponin was undetectable. As the player was currently without symptoms, he returned to activity with a ramp-up of exercise.
+He returned to exercise as per the recommendations and noted symptoms of shortness of breath and chest tightness, which began within a week of return to basketball practice. This prompted a halt in exercise and additional testing. Cardiac magnetic resonance (CMR) imaging revealed normal size and function with an ejection fraction of 55% with mild apical lateral hypokinesis and subepicardial late gadolinium enhancement involving the apical lateral segment. No active oedema was present. This finding was consistent with myocardial fibrosis/scar related to myocarditis . He was held from exercise as per the ACC/AHA recommendations for return to sport. After 2 months, he was symptom-free; we decided to proceed with a stress test that was positive for inferolateral repolarization abnormalities at rest and positive for a significant burden of premature ventricular complexes (PVCs) (right bundle superior axis) likely originating from the LV inferolateral at the base and non-sustained ventricular tachycardia (VT) with exercise during the recovery phase . He was again held from the activity for an additional 3 months. A repeat CMR and echocardiography showed the resolution of scar/fibrosis and the prior mild apical lateral hypokinesis . A repeat stress test found rare, isolated PVCs (right bundle superior axis) initially at rest that did not escalate with exercise and the absence of non-sustained VT at peak heart rate. Moreover, the patient had a normal exercise tolerance, normal hazard ratio, and blood pressure response without sustained arrhythmias.
+Moreover, on follow-up ECG at 3 and 6 months, the PVC morphology remained unchanged. At this point, he began a slow RTP by ramping up his activities. Of note, the patient did not receive any medical therapy for myocarditis throughout the observation period, as his cardiac function was preserved. After 1 month of exercise, he wore an ambulatory monitor for 1 week, inclusive of a graded return to an exercise regimen, which did not demonstrate any significant arrhythmias with exercise.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1524_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1524_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7935a718b97bac3726620875f788e69d63442884
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1524_en.txt
@@ -0,0 +1,4 @@
+A 36-year-old male patient with severe continuous pain and swelling of tongue for 6 weeks was presented to Goba Referral Hospital. He is a farmer, married, and has two children. The swelling was 2 cm by 1 cm, located on posterior central tongue, and frank pus oozed from the center of swelling. The patient had associated dysphagia, odynophagia, and speech difficulty but no dyspnea. He had voluntary fixation of tongue because of pain. He had a history of left upper side and last molar tooth extraction before 10 years. Currently, he has been suffering from toothache and dental caries on the adjacent molar. He also had poor dental hygiene. The patient had no history of fever and chills. Additionally, he had no history of tongue bites or tongue trauma in the last 6 months. He had no previous personal and family history of similar illness and tonsillitis. The patient had no submandibular swelling, history of seizure, diabetic mellitus, hypertension, and retroviral infection. He had never eaten fish throughout his life but had consumed barley, milk, and sometimes wheat. The patient had no history of chewing chat, cigarette smoking, and drug use except for taking beer once per 1–2 months.
+Before the patient visited our hospital, he was first treated at a health center where he was diagnosed with tonsillitis and was given amoxicillin 500 mg po tid (orally three times a day) for 7 days and paracetamol 1 g po prn. Although he showed mild improvement following treatment, the symptoms worsened after the completion of the course of antibiotics. Then, for the second time, the patient went to a private clinic where he was given augmentin 625 mg po bid for 7 days and tramadol 50 mg po prn. However, the patient was not relieved of pain and swelling.
+With a diagnosis of pyogenic lingual abscess with lingual tuberculosis and tongue tumor as differential diagnosis, the patient was investigated. Random serum glucose level was 120 mg/dL, complete blood count was within normal range, and HIV antibody test was negative. Additionally, liver and renal function tests were done and found to be normal. Furthermore, venereal disease research laboratory test, and hepatitis B serum antigen and hepatitis C virus antibody tests were done and the results were negative.
+An incision of 1 cm was made and 10 cc of thick frank pus was drained. A sample was taken from the drained pus and Gram staining was done; the report revealed Gram-positive cocci in clusters. However, acid fast bacilli test was negative. After drainage, augmentin 625 mg po tid for 7 days, metronidazole 500 mg po tid for 5 days, and diclofenac 50 mg po bid for 5 days was given, and the patient was relieved of pain after 48 hours of drug administration. The diagnostic difficulty in this patient was due to two reasons: 1) since lingual abscess is a very rare disease, patient was misdiagnosed in the health center as well as in the private clinic and 2) absence of culture and sensitivity service in our hospital. The patient was followed for 6 months and the condition did not relapse.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1528_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1528_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..01d8b80c824ab17268d14b2cb252f01098f18286
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1528_en.txt
@@ -0,0 +1,10 @@
+The patient was a 65-year-old male, on automated peritoneal dialysis for 14 months. Fifteen days before the start of automated peritoneal dialysis (break-in period), the catheter with a straight intercuff segment, 2 cuffs, and straight tips was placed with an open surgical technique through a left periumbilical incision. A mini-laparotomy was performed under local anesthesia. A purse-string suture was placed around the peritoneal opening. A craniocaudal suture of the rectal muscle was performed to let the catheter tip remain oriented toward the pelvis. The exit site was located approximately 4 cm beyond the superficial cuff.
+The patient’s medical history showed hypertension and dyslipidemia on drug treatment. The underlying renal disease was nephroangiosclerosis. The patient had a residual kidney function with an eGFR of 4 mL/min/1.73 m2 and a diuresis of about 1,500 mL per day. He had an active life and was in good clinical condition. During a colonoscopy performed for the transplant waiting list, he was diagnosed with a polypoid lesion in the descending colon. The patient underwent endoscopic polypectomy, and the pathological analysis showed evidence of malignant transformation.
+The staging CT-scan and MRI-scan of the liver showed two hepatic lesions (about 2 cm each in segments 8 and 7), which, on histological examination, turned out to be metastatic bowel adenocarcinoma. The following Positron Emission Tomography showed no areas of hyperaccumulation outside the liver.
+The case was discussed at the tumor board, with decision to perform a “liver first approach” in the form of metastasectomy with robotic technique. The patient showed a strong determination to continue with peritoneal dialysis as long as possible. For this reason, the day before surgery, he underwent the placement of a central venous catheter in the right jugular vein for a temporary shift to hemodialysis.
+The liver resection was performed with the DaVinci Xi robotic system. This platform, using articulated surgical instruments, allows performing technically demanding procedures with a minimally invasive approach. The surgeon controls the procedures from a console with 3D-magnified view. A cart is placed bedside with four arms connected to the surgical devices. The patient was placed on the operating table with legs apart, in the reverse Trendelenburg position, and with a left-side tilt. After sterile draping, the pneumoperitoneum was established. Then, five ports were inserted in the upper abdomen (four robotic and one assistant). After docking and targeting the robot, the whole liver was inspected with intraoperative ultrasound (US), and the two metastases in the right lobe were confirmed. Under US-imaging guidance, two separate wedge resections in segments 8 and 7 were performed. The vascular inflow to the liver was controlled with intermittent Pringle maneuvers, and the hemostasis during parenchymal transection was obtained with bipolar and radiofrequency instruments. The main vessels around the lesions were ligated with robotic clips and then divided. The procedure ended with the specimen removal through a mini-laparotomy and the placement of a sub-hepatic drain. Blood loss was minimal, around 200 mL. During the entire procedure, the dialysis catheter was not touched and left in place in the pelvis.
+After surgery, the patient was monitored for 24 h in intensive care unit and then transferred back to the surgical ward. The postoperative course was complicated by a hematoma along the transection line that was conservatively treated with associated antibiotic prophylaxis (cephalosporin of third generation). The collection was monitored with US scans, and it spontaneously reabsorbed after 3 weeks. No further complications were observed.
+Forty-eight hours after surgery, the “Luer-lock” and “Transfer-set” of the peritoneal catheter were replaced, performing a flushing of the catheter, and an empirical “lock-therapy” was started with Vancomycin 20 mg (¼ fl of 80 mg in 5 mL of saline). Peritoneal flushing and lock therapy were performed weekly. During this period, the patient was educated to have a reduced water intake, avoiding excessive ultrafiltration potentially deteriorating the residual renal function. Special care was also taken to avoid any nephrotoxic drug.
+After 3 weeks, it was decided to resume the peritoneal technique. The start of the peritoneal treatment was delayed by a week as a precaution due to the presence of the hematoma. On the day scheduled to restart the peritoneal dialysis, the catheter showed a malfunction, probably induced by the presence of fibrin around the tube. A single dose of urokinase (100,000 IU diluted in 5 mL saline) into the obstructed catheter restored the flow without causing complications. Urokinase was left in the Tenckhoff catheter for 2 h.
+The peritoneal treatment was restarted with low volume exchange (nightly cycler treatments with 8 exchanges of 1,300 mL over 8 h). The pre-surgery dialysis volumes were re-established after 10 days of regular sessions (5 exchanges of 2,000 mL over 8 h).
+After 12 months from surgery, the dialysis method runs normally, without any sign of infection or mechanical complications. Peritoneal dialysis adequacy estimated by urea kinetics and total weekly creatinine clearance are comparable to those prior to liver resection, and comply with the international purification standards recommended by the guidelines. The CARE Checklist has been completed by the authors for this case report, attached as online supplementary material (for all online suppl. material, see ).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1536_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1536_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f0154d695af61a12bd0b2dbc1db2b44f2bba0f83
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1536_en.txt
@@ -0,0 +1,14 @@
+The patient’s chief complaint was positive urinary protein and elevated serum creatinine (Scr) levels.
+A 28-year-old man had positive urinary protein (++) and elevated Scr (149 μmol/L) test results in 2014. He underwent renal biopsy in February 2015 and was diagnosed with “IgAN, mesangial proliferative glomerulonephritis with sclerosis”. Since then, the patient had been taking losartan (100 mg daily) and ketosteril (α-ketoacid tablets; 2.52 g/3 times daily). He first visited the outpatient department at our hospital on June 1, 2017. At this visit, malaise, waist soreness, acid reflux, and bubbles in the urine were the main clinical manifestations. The patient also complained of frequent urination at night. His tongue was light red with a yellow coating, his pulse was slippery (meaning that his pulse was beating freely and smoothly like the movement of abacus beads), and his pharynx was red.
+The patient visited the outpatient department again on August 2, 2017. At this visit, waist soreness and fatigue were resolved. The patient’s stomach discomfort was also alleviated. However, he still had a sore throat and spermatorrhea.
+At his 3rd visit on September 28, 2017, serological indexes were stable. Clinical manifestations such as waist soreness, fatigue, pharynx discomfort, spermatorrhea, and epigastric discomfort were unchanged.
+At the 4th visit on October 26, 2017, serological indexes had decreased significantly. The patient’s epigastric discomfort had improved, but waist soreness remained.
+At the patient’s 5th visit on November 23, 2017, his clinical symptoms including waist soreness, fatigue, spermatorrhea, and epigastric discomfort were all resolved, and the serological indexes had also decreased.
+The patient has no history of a relevant illness.
+The patient has no family history of a similar illness.
+On admission, the patient’s blood pressure was 120/80 mmHg, and no abnormalities were detected during the physical examination, including the cardiopulmonary system. There was no edema in either lower limb.
+The serological and urinary indexes are shown in Table .
+Renal ultrasound showed no obvious abnormality.
+Under light microscopy, a renal biopsy sample contained 25 glomeruli, among which there were 15 glomeruli with global sclerosis and no crescent. The remaining glomeruli were enlarged with approximately 90-110 cells/glomerulus. There were some mesangial areas with severe matrix hyperplasia with 2-3 cells/mesangium. The basement membrane was normal and the structure of capillary loop remained open. Complete sclerosis was seen in some glomeruli. Masson Stain was negative.
+There were moderate lesions in the tubulointerstitium with indistinct tubular structure, no tubular atrophy, some swollen and degenerated tubular epithelial cells and some vacuolar degeneration. Focal fibrosis (40%) and more inflammatory cell infiltration could be seen in the interstitial area.
+Immunofluorescence showed classic prominent IgA deposits.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1544_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1544_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..449040dde97fd94f0df1d19f88c91ca4e0e69ed7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1544_en.txt
@@ -0,0 +1,7 @@
+A 63-year-old male, suffering from toothache accompanied by coughing, sputum, and bloody sputum for three months.
+A 63-year-old male, suffering from toothache accompanied by coughing, sputum, and bloody sputum for three months, was given a blood test after experiencing continuous bleeding resulting from a tooth extraction at a local hospital. The results of the blood test included a white blood cell count of 111.34 × 109/L, monocyte count of 81.99 × 109/L, hemoglobin concentration 99 g/L, and platelet count of 150 × 109/L.
+The patient was previously healthy.
+The patient in this case had a long history of heavy smoking, had no history of other major diseases nor any significant family history of disease.
+The rest of physical examination was normal.
+The results of the blood test included a white blood cell count of 111.34 × 109/L, monocyte count of 81.99 × 109/L, hemoglobin concentration 99 g/L, and platelet count of 150 × 109/L. Flow cytometry showed that myeloid blasts and monocytes (with a predominantly mature phenotype) accounted for 1.31% and 52.6% of nucleated cells, respectively. Next-generation sequencing (NGS) showed ASXL1 gene mutation [exon12:c.1934 dupG:p.Gly646fs; variant allele frequency (VAF) = 33.72%], and EZH2 gene mutation (exon18:c.2084C>T:p.Ser695Leu; VAF = 49.73%; exonc.2077A>T:p.Asn693Tyr; VAF = 46.05%). No abnormal chromosomal results were observed.
+A subsequent ultrasound revealed an enlarged spleen.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1547_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1547_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..62ec10a12ebdd0aca48d1eb53ed6bd40340d6aeb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1547_en.txt
@@ -0,0 +1 @@
+Our patient was a 74-year-old woman, without any particular pathological antecedents, presenting intermittent and badly systemized bilateral sciatica, along with weaknesses in both lower limbs, gradually progressing for 2 years. This symptomatology got complicated by sphincter disorders characterized by urinary incontinence and constipation. The clinical examination objectified incomplete paraplegia without sensory loss. Patellar and Achilles reflexes were reduced on both the lower limbs. MRI showed an intradural fusiform lesion at L3–L4, with an isosignal on T1 and T2, associated with a central nodular hypersignal on both sequences. The lesion took up the whole spinal canal, making a scallop shape on the vertebral body and laminating its posterior arch. The tumor homogenously enhanced following a gadolinium injection . The diagnosis for neurinoma was highly suspected. Through an L3 and L4 laminectomy and an opening of the dura mater, the tumor appeared to be grayish red, closed, very hemorrhagic, and tied to the filum terminale. The lesion retracted nerve roots on the back and on the left side without any invasion. The tumor was attached to the filum terminal and his section has facilitated total removal. The patient fully recovered her motor function after a sphincter and motor function rehabilitation. Macroscopically, the anatomopathological examination showed an encapsulated proliferative tumor, lobulated and surrounded by tiny fiber tracts. It was vascularized with large plaques of hemorrhagic suffusion. Microscopically, we showed lobulated cells with eosinophilic cytoplasms, sharply demarcated, with dense and rounded nuclei, pointing in immunohistochemistry neuron-specific enolase (NSE) and chromogranin A (CgA) .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1548_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1548_en.txt
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index 0000000000000000000000000000000000000000..7bcc90bbb7a9e8184f6f92352b6bd22151ea9614
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1548_en.txt
@@ -0,0 +1,4 @@
+A 26-year-old man was transferred to our hospital with complaints of dizziness, headache, insomnia for 1 month, and exacerbated limb weakness for half a month. One month ago, the patient first presented to the local hospital for these symptoms. Enhanced MRI of the brain showed a negative result while enhanced MRI of the cervical spine showed slight thickening of the cervical spinal cord. Upon lumbar puncture, the opening pressure was found to be more than 330 mmH2O and the cerebrospinal fluid (CSF) was transparent yellow, with a glucose (GLU) level of 3.8 mmol/L (reference range, 2.5–4.4 mmol/L), a microprotein level of 3.4 g/L (reference range, 0.15–0.45 g/L), and a chloride ion level of 112 mmol/L(reference range, 120–130 mmol/L). There were 50 nucleated cells per μl (reference range, 0–10), of which 95% were monocytes and 5% were coenocytes . Considering the results of the CSF analysis (mononuclear-predominant CSF pleocytosis and a high protein level), the high open pressure, symptoms of intracranial hypertension, the inflammatory lesion on MRI findings, and the high incidence of tuberculosis in China [age-standardized incidence of tuberculosis, 54.18 per 100,000 population from 1990 to 2007 ], the patient was initially diagnosed with tuberculous meningitis and myelitis. He then received empirical antituberculosis therapy (a standard four-drug regimen of isoniazid, linezolid, moxifloxacin, and tigecycline). However, empirical treatment with anti-tuberculous drugs, antibiotics, antiviral drugs, and drugs to reduce the intracranial pressure , did not improve his condition. Thereafter, the patient was transferred to another hospital and, a lumbar puncture was repeated, the opening pressure was more than 330 mmH2O. The CSF was slightly yellow, with a GLU level of 5.35 mmol/L (reference range, 2.5–4.4 mmol/L), a microprotein level of 5.179 g/L (reference range, 0.08–0.43 g/L), a chloride ion level of 106.5 mmol/L (reference range, 120–130 mmol/L), there were 129 nucleated cells per microliter (reference range, 0–10), of which 94% were monocytes and 6% multinucleated cells . The acid-fast staining, mycobacterium culture, Xpert MTB, and RT-PCR of the CSF samples were negative. M. houstonense was identified in the CSF by metagenomic next-generation sequencing (mNGS) in a company for gene sequencing named Smicere Diagnostics and the report is attached as a which showed the reads of 264 . The pathogen's data were aligned to the National Center for Biotechnology Information GenBank database and revealed sequence homology above 96.825 and 97.183% with M. houstonense (GenBank accession no. and no. ), respectively . After 7 days, the CSF sample pathogen cultures in blood agar at 35°C from another lumbar puncture were negative. Despite empirical treatments with anti-tuberculous drugs (isoniazid, linezolid, moxifloxacin, and tigecycline) which are the same treatment in the previous hospital due to insufficient course , the patient's condition worsened (decreasing myodynamia of limbs and endorsed racing thoughts) and he was transferred to our hospital. This patient did not have any underlying diseases or past medical history, and he was employed in the field of information technology.
+After being admitted to our hospital, the patient's neurological examination showed the myodynamia of the left limb was grade 2, the right upper limb was grade 4, and less than grade 4. The muscle tension on the left side was decreased and that on the right side was normal. Poor abduction of the eyes and tongue deviation to the left was observed. The symmetry of the tendon reflexes in the extremities was weakened, and the craniocervical flexion test and bilateral Kerning sign were positive. The finger-to-nose test, heel-knee-shin test, Romberg test, and other ataxic tests could not be performed. The laboratory tests showed that there were 6.11 × 109 erythrocytes per L, 312 × 109 platelets per L, and 23.11 × 109 leukocytes per L, of which 93.4% were neutrophils. His blood biochemistry was normal except for the raised glutamic-pyruvic transaminase level of 201 IU/ L (reference range, <40 IU/L) and glutamic oxalacetic transaminase of 53 IU/L (reference range, <35 international IU/L), and a mild reduced albumin level of 34.7 g/L (reference range, 40–55 g/L). His inflammatory biomarkers showed an elevated procalcitonin level of 4.03 n/ml (reference range, <0.046 ng/ml), C-reaction protein level of 15 mg/L (reference range, <5 mg/L), interleukin-6 level of 5.81 pg per ml (reference range, 0–7 pg per ml). His HIV antibody test was negative, but there were 502 CD3+ T cells per μl (reference range, 941–2,226), 269 CD4+ T cells per μl (reference range, 471–1,220), and 200 CD8+ T cells per μl (reference range, 303–1,003) in blood. The first lumbar puncture in our hospital revealed the opening pressure was 150 mmH2O, with a microprotein level of 11.8 g/L (reference range, 0.15–0.45 g/L), a chloride ion level of 108 mmol/L (reference range, 120–130 mmol/L), GLU was 5.04 mmol/L (reference range, 2.5–4.4 mmol/L). There were 10 nucleated cells per microliter . The six subsequent lumbar punctures performed at our hospital revealed a high opening pressure and mononuclear-predominant CSF pleocytosis, hyperglycorrhachia, a high level of protein, and a low level of chloride ion. Nevertheless, the acid-fast staining, mycobacterium cultures, Xpert MTB and RT-PCRs of all CSF samples were negative . Enhanced MRI of the brain and cervicothoracic region revealed abnormal enhanced meningeal pia and subarachnoid spaces with signs of communicating hydrocephalus (, ). Enhanced MRI of the lumbar spine (performed on 17 February 2022) revealed nodules and irregularly thickened meninges .
+It is difficult to diagnose infections caused by NTM since these diseases are rare and their clinical manifestations lack specificity. Most patient with NTM-CNS has been diagnosed with an immunocompromised disease, such as HIV. Meanwhile, it is not helpful to distinguish nervous system infections caused by NTM from other infection types, such as tuberculous infections, on radiological images. Some NTM-CNS infections could present with hydrocephalus or brain atrophy, which is unexplained and not age-related (, ), radiological images may also show nodular basal enhancement in NTM-CNS infection . On the basis of these radiological and clinical manifestations, as well as the mNGS CSF result in the second hospital, this patient was considered to have a CNS infection caused by M. houstonense, which is an NTM. According to the Chinese NTM guidelines , amikacin, tigecycline, clarithromycin, and imipenem were administered . After 25 days of therapy, the patient still had intracranial hypertension (CSF pressure > 300 mmH2O, the number of nucleated cells in the CSF ranged from 10 to 70/μl, and vision was impaired), and epileptic seizure occurred once. Therefore, we placed continuous lumbar cisterns to drain ~200 ml/day, and the draining CSF was slightly flocculent. Levetiracetam was also administered. Imipenem was then replaced with meropenem on the 27th hospital day.
+The patient's CSF culture and mNGS (performed three times in the Precision Medicine Center of our hospital) remained negative throughout the course of therapy in our hospital. The patient did not improve despite appropriate empirical treatment. Finally, the patient lost confidence and requested discharge. The patient still had poor visual acuity, intermittent headaches, and vomiting, and his condition gradually worsened after discharge. Unfortunately, he died 19 days after discharge.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1557_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1557_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b05b5b16fadeb75a11f93ad4b7f424c00e3564b7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1557_en.txt
@@ -0,0 +1,5 @@
+A 52-year-old woman referred to our clinic with the complaint of gait disturbance and rigidity and muscle spasm of lower limbs since last year. Her muscle stiffness began from the distal lower extremity and progressed to proximal and ultimately became so severe that she had difficulty walking and climbing stairs and eventually became wheelchair bound. She said that it seemed stress and fatigue worsened her symptoms.
+The patient had experienced various tests in the different clinics including rheumatology, orthopedy, and psychiatry with varied diagnosis and finally diagnosed of conversion and started taking antidepressants. Her medical history was significant for Hashimoto’s thyroiditis and hypertension. Her family history and review of systems were noncontributory. Her medications included sertraline 50mg, levothyroxine 25mcg, atenolol 100 mg once a day and pregabalin 75 twice daily.
+On physical examination, there was no malaise, fever, lymphadenopathy and organomegaly. In the neurological examination of the lower limbs, movement in all direction was limited and rigidity in distal and proximal muscles was detected. Deep tendon reflexes were normal in the upper and lower extremities and plantar response was bilateral flexor.
+In laboratory examinations, including creatine kinase, complete blood count, erythrocyte sedimentation rate, and C- reactive protein and rheumatoid factor level were normal. The thyroid function tests, antithyroglobulin and thyroid-stimulating hormone receptor antibody also were normal. Her anti-TPOAb level was 75 IU (normal value: 0–34 IU). Serum anti-GAD level was 72(normal value < 1) and the patient’s tumor markers and paraneoplastic tests were normal.
+In electromyography (EMG) continuous motor unit discharge and simultaneous co-contraction were observed in lower extremities. Bilateral mammography, abdominopelvic and chest CT for occult cancer was normal. IVIG was administered (100gr, 2gr/kg/5 days) for the patient with significant improvement observed from the admission period and 2 months later in the follow-up visit.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_155_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_155_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..87cab2ef26a085c508ee5b35728d640966fc4dde
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_155_en.txt
@@ -0,0 +1 @@
+A 59-year-old man was admitted to Coronary Care Unit because of suspected ST-segment-elevation myocardial infarction. The patient was complaining of typical coronary chest pain during the last twelve hours. He had a history of dyslipidemia, type 2 diabetes mellitus, smoking habit and a transient ischemic attack without any sensitive or motor squele one year ago. On admission, his blood pressure was 100/60 and heart rate was 110 beats per minute. Cardiac examination revealed jugular vein distension, and no significant heart murmurs. The ECG showed significant Q waves in II, III and aVf leads with mild ST-segment elevation in leads II, III, aVf and V4R. The chest radiograph revealed no cardiomegaly and clear lung fields. Transthoracic echocardiography was performed showing akinetic inferoseptal, inferior, and inferolateral segments with estimated left ventricular ejection fraction of 45%, right ventricle showed a global hipokinesia with severe systolic dysfunction and inferior vena cava plethora. The patient was initially treated with aspirin, low-molecular-weight heparin, dobutamine and saline infusions, and was scheduled for early catheterization. Coronary angiography showed total occlusion of right coronary artery proximal segment and two additional 70% stenoses in the first diagonal and obtuse marginal branches. Percutaneous revascularization was dismissed after a failed attempt of right coronary artery opening, then, the patient was treated using conservative medical therapy (aspirin 100 mg/day, clopidogrel 75 mg/day, simvastatin 20 mg/day and enalapril 10 mg/day), anticoagulation was maintained for 72 hours, and beta blocker therapy was not started because Mobitz I atrioventricular block phases were detected in continuous ECG monitoring. The later clinical outcome in the Coronary Care Unit was favourable, and the patient was discharged six days after to cardiology hospitalization unit. Nine days after hospital admission, the patient complained about sudden chest pain and rest dyspnea, his blood pressure was 80/40 and cardiac examination revealed a new harsh, holosystolic murmur along the left sternal border. Transthoracic echocardiography was immediately performed showing complex ventricular septal defect with a dissection tract that originated on left side of the basal inferoseptal akinetic segments, extended beyond the septum dissecting the right ventricular wall, and subsequently re-entered into the right ventricle chamber . No significant right ventricle outflow tract obstruction was present. The patient was scheduled for immediate surgical intervention, and hypothermic cardiopulmonary bypass with myocardial protection was established in the following two hours. The septal rupture was approached through the infarct, and prosthetic material (Gore-Tex® patch) was used to reconstruct the septum, additionally, two bypasses using vein grafts were done in first diagonal and posterior descending arteries. Postoperative evolution was favourable with rapid resolution of cardiogenic shock situation. One month later transesophageal echocardiography was performed showing neither right ventricle dissecting tract or residual shunt. Left ventricular ejection fraction was 55%, and right ventricular systolic function was only mildly depressed. At six-month follow-up the patient remains stable and without any cardiac symptoms.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1563_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1563_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8a26e43a82d8acca70cb481dd20beb08c429e332
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1563_en.txt
@@ -0,0 +1 @@
+A 15-year-old boy complained of pain in the right thumb MP joint after a hyperextension injury while playing 2 weeks before. He was diagnosed with a ligament injury by an orthopedic surgeon at the first visit and referred to our hospital because his symptoms did not improve. On physical examination, the 1st MP joint was slightly hyperextended, and passive and active flexions were not possible. Radiographs showed a hyperextended posture at the 1st MP joint at approximately 30°. There were no definite abnormal findings on the first anteroposterior and lateral radiographs . However, the clinical situation of the patient raised suspicion of a locked thumb MP joint, and we performed US. Distal displacement of the radial sesamoid was noted on US . Although limited, there were no conspicuous abnormalities in the volar plate or radial accessory collateral ligament on US. CT was also performed to ensure the diagnosis and evaluate the bony details. On CT, distal displacement of the radial sesamoid was visualized . In addition, a flat articular surface and prominent radial condyle of the metacarpal head were observed. We decided to attempt a closed manual reduction at the outpatient clinic under US guidance instead of a reduction under fluoroscopic guidance. After inducing local anesthesia with 1% lidocaine, closed manual reduction was attempted. After hyperextending the MP joint, continuous axial pressure was applied toward the metacarpal head, and subsequently, flexion of the MP joint was performed. The radial sesamoid was relocated with a snapping sound, and MP joint motion recovered. At that spot, we confirmed on US that the radial sesamoid returned to its place . A remo4vable thumb spica splint was applied for 2 weeks. Follow-up CT showed successful reduction of the radial sesamoid . During 3 months of follow-up, the patient did not have any recurrence.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1569_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1569_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2b7f0bd1eab2bbad2a55bff1838bc5910a186b7b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1569_en.txt
@@ -0,0 +1,10 @@
+A 10-year-old, male entire, Maltese terrier mix breed dog presented with a three-month history of slowly progressive abdominal distension. The patient was reported to vomit bilious material daily for two weeks prior to presentation and had no other significant clinical history. Physical examination identified abdominal distension with no overtly palpable abdominal mass effect, a grade IV/VI left-sided apical systolic cardiac murmur and generalized moderate muscle atrophy.
+Echocardiographic examination identified chronic degenerative mitral valve disease, most consistent with myxomatous mitral valve disease. Sonographic examination of the abdominal cavity identified a markedly expansile, heterogeneously echogenic, well-vascularized soft tissue mass with multiloculated cystic structures containing anechoic fluid admixed with echogenic particulate matter . The origin of the mass could not be determined. The mass extended cranially to the level of the liver, caudally to the level of the bladder, and dorsally to the level of the kidneys. Other findings included a mild reduction of renal corticomedullary definition bilaterally, diffusely hyperechoic hepatic parenchyma, and a symmetrically enlarged prostate with cystic areas. The remainder of the abdominal sonographic examination was unremarkable. Thoracic radiography identified no abnormalities.
+Abdominocentesis removed 700 mL of transparent straw-colored fluid, identified as transudate (protein 26 g L−1) with low numbers of large mononuclear cells (120 × 106 cells L−1). The cellular population of the abdominal fluid consisted of large mononuclear cells with vacuolated grey to light blue cytoplasm, with a round, irregular medium to large nucleus most likely of monocyte lineage. Complete blood count and serum biochemical analysis were unremarkable. Resting ammonia was within reference range. Prothrombin time and activated partial thromboplastin time were within normal limits.
+A multilobulated cystic mass arising from the duodenum and orad portion of the jejunum with omental adhesions was identified during ventral midline celiotomy . The longest diameter of the mass measured approximately 20 cm. The adhesions were broken down and the mass was resected with 5 cm orad and aborad margins. A functional end-to-end stapled anastomosis of the duodenojejunum was performed. A focal nodule identified within the left lateral liver lobe was biopsied. The remainder of the peritoneal cavity examination was unremarkable.
+Histopathologic examination identified an unencapsulated, cavitated mass composed of monomorphic mesenchymal cells arranged in interlacing streams and loosely organised herringbone patterns with variable collagenous or myxoid matrix. Empty cystic spaces multifocally scattered throughout the mass were not lined by epithelial cells . Neoplastic cells were characterised by indistinct margins, small amounts of vacuolated, amphophilic cytoplasm and oval-shaped nuclei with marginated chromatin and small, centrally located nuclei. Anisocytosis and anisokaryosis were mild, and the mitotic count was five per 10 high power fields (equivalent to 2.37mm2). A preliminary diagnosis of nonangiogenic, nonlymphogenic intestinal mesenchymal tumor (NIMT) was made based on histopathology alone. NIMTs are a subset of poorly defined intestinal sarcomas that require immunohistochemistry (IHC) for further classification between the primary differential diagnoses of GIST and leiomyosarcoma. In this case, IHC for CD117 and smooth muscle actin were required to distinguish between primary differential diagnoses of GIST and leiomyosarcoma, and exclude less likely differentials including fibroblastic and neural tumors.
+IHC for CD117 demonstrated moderate-to-strong membranous labelling of greater than 95% of neoplastic cells . IHC for smooth muscle actin yielded variable cytoplasmic staining among neoplastic cells . GIST was diagnosed based on positive immunolabelling with CD117.
+Hepatic biopsies identified no metastatic disease. Mild hepatocellular glycogen accumulation and lipogranuloma formation, considered incidental findings, accounted for the gross appearance of the liver during surgery. Hepatic biopsy specimens were submitted for bacterial culture and sensitivity due to pale-yellow discoloration of the liver at time of surgery. Aerobic and anaerobic bacterial culture of hepatic tissue identified no bacterial growth.
+The patient was started on toceranib at 3.0 mg kg−1 orally three times per week on a Monday, Wednesday, and Friday dosing schedule. No local disease recurrence or metastasis was noted on examination 78 days after starting toceranib.
+Metastasis of GIST was strongly suspected at recheck examination 251 days after surgery based on computed tomographic imaging, which identified multiple peritoneal nodular changes and a small volume of encapsulated peritoneal effusion . No evidence of pulmonary metastasis, and no local recurrence at the duodenojejunal enterectomy site was identified on computed tomography. Toceranib was discontinued approximately two months prior to this recheck examination and diagnostic imaging study due to owner non-compliance; the patient had a one-month history of mild lethargy prior to the recheck. Peritoneal fluid analysis identified a macrophagic exudate without evidence of neoplastic cells. No specific sampling of the suspected metastatic lesions was performed due to an inability to access these sites safely.
+The patient was re-initiated on toceranib at 3.0 mg kg−1 three times per week on a Monday, Wednesday, and Friday dosing regimen at the time of suspected metastasis. There was initial improvement in clinical signs of lethargy after re-initiation of therapy. The patient later presented for worsening lethargy and anorexia of one week duration, and owners elected for humane euthanasia due to a poor prognosis. The overall survival time was 370 days. Post-mortem examination was declined by the owners.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1578_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1578_en.txt
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index 0000000000000000000000000000000000000000..f83426d5d6d5c33973c23e08936832a769b092e2
--- /dev/null
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+A 4-year-old Indian girl was referred to us with a diagnosis of hemorrhagic pericardial effusion that recurred despite aspiration twice in the past 6 months. The child had insidious onset of breathlessness for six months and had episodes of lower respiratory tract infection. Pericardial effusion was detected on chest X-ray and hemorrhagic fluid was aspirated. She was started on antitubercular drugs with steroids, but her condition did not improve significantly. Our patient had normal development in her early infancy stage and normal growth prior to this illness. There was no family history of heart disease, developmental defects, tuberculosis or connective tissue disease.
+On examination, our patient was found to be in mild respiratory distress. She had a heart rate of 110/mt, BP of 90/60, respiratory rate of 30/mt, temperature of 37°C, and oxygen saturation of 96%. Her weight was 14 kg and her height was 110 cm. There were few basal crackles in her lungs and her heart sounds were distant. Chest X-ray showed marked cardiomegaly and streaky lung fields . Her hemoglobin count was 8.7 gm/dl, and her total leukocyte count (TLC) was 10600/mm3 with 65% neutrophils. An echocardiogram showed large pericardial effusion (2.0 cm circumferentially) with evidence of tamponade. There was no structural lesion in her lungs. A total of 300 ml of hemorrhagic pericardial fluid was aspirated with a pigtail catheter in the pericardium. The pericardial fluid showed numerous red blood cells (RBCs) but no malignant cells were found. The adenosine deaminase in the fluid was not elevated. The bacterial and fungal cultures were sterile. Results of her abdominal ultrasound examination were normal.
+The fluid in our patient's lungs re-accumulated within weeks of drainage. The antitubercular treatment and steroids were stopped. Meanwhile, results of her thyroid function tests were normal. Her rheumatoid factor, anti-nuclear antibodies, and antineutrophilic cytoplasmic antibodies were negative. She tested negative for human immunodeficiency virus (HIV) via rapid screening test. High-resolution computed tomography (HRCT) scan showed peculiar diffuse polygonal lobular architect and soft tissue mediastinal mass. A needle biopsy of the mediastinal mass revealed only fat and connective tissues. Repeated pericardial fluid analyses for malignant cells were negative. Her platelet counts were 50 to 70,000/mm3 on multiple occasions. She also tested negative for disseminated intravascular coagulation (DIC). Her bone marrow was normal.
+The diagnosis was unclear. A review of literature on similar HRCT picture prompted a skeletal survey which showed lytic lesions in her bones . Consequently, diffuse multisystem involvement, lytic bone lesions and HRCT findings led to the diagnosis of diffuse lymphangiomatosis. The triglyceride levels in our patient's pericardial fluid were high, but her pericardial fluid was always hemorrhagic. During the course of her illness, she required multiple pericardiocentesis due to the large reaccumulation of fluid, as well as respiratory distress. Multiple blood transfusions were also given to our patient.
+Treatment with interferon alpha was discussed but her parents did not consent to it. Thalidomide (50 mg/d), octreotide and epsilon-aminocaproic acid were tried empirically, but her response to this treatment was not sustained. Low-dose radiotherapy of 20 Gy over 10 days were also given to her pericardium. A pericardiectomy was done after exhausting all options. Lung biopsy taken at that time showed diffuse hemangiolymphangiomatosis . There were numerous anastomotic proliferating, and cystic spaces in the pulmonary interstitium were lined by endothelial cells. The cells lining the spaces were CD31+, which is a marker of endothelial cells, although it does not differentiate vascular from lymphatic capillaries. Many of her capillaries contained blood. The connective tissue stroma was predominantly lymphoid. Our patient's pericardium also showed similar findings. A diagnosis of diffuse lymphangiohemangiomatosis was thus made. Our patient had progressive respiratory failure and died after two months.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1579_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1579_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5a5795c52a14a3e974e4359dbcff9156425b366b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1579_en.txt
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+A 34-year-old Han female patient with ataxia was admitted to our department. The patient had a slight limp without obvious inducement 7 or 8 years previously. Approximately 1 year prior to the presentation, she had given birth to a boy and subsequently developed progressive walking instability. Five months prior to the evaluation, she started experiencing static tremors in her hands and head, difficulty speaking, occasional numbness in the limbs, and a cough after drinking water. The tremor was significantly aggravated during movement. The patient also reported headaches, dizziness, and nausea. One year prior, she lacked appetite and had lost more than 10 pounds. The patient had a history of cephalosporin allergy and had undergone an appendectomy 20 years prior. She had a history of tobacco and alcohol use for 10 years and had quit smoking 6 months ago. Her parents were still alive, and she was the only child. She also reported that she had no relatives with similar symptoms. She had 27 teeth, a smaller tooth size, and normal sex hormone levels. And her menstruation was normal. At the time of presentation, she had dysarthria and upbeating nystagmus, with right gaze-evoked nystagmus. Her limb reflexes were absent, and her bilateral finger-nose test was unstable. She demonstrated instability on her calcaneus tibial test, and had a positive Romberg sign and bilateral Babinski and Chaddock's signs.
+The total score of the scale for the assessment and rating of ataxia was 24, and the single-item scores were gait (score 5), stance (4), sitting (2), speech (2), finger chase (2), nose–finger test (2), fast alternating hand movement (3), and heel–shin slide (4). The patient's Mini-Mental State Examination score was within the normal range, and she failed to complete the Montreal Cognitive Scale due to tremors of the hands and head. The results for tumor markers, ceruloplasmin, immune-related autoantibodies such as the five items of thyroid function (thyroid stimulating hormone, free T3, free T4, thyroglobulin antibody and thyroid peroxidase antibody), three items of rheumatism (rheumatoid factors, anti-streptolysin O and high-sensitivity C-reactive protein), five items of immunity (immunoglobulin G, immunoglobulin A, immunoglobulin M, complement C3 and complement C4), antinuclear antibody, anticardiolipin antibody, and screening and confirmation of anti-neutrophil cytoplasmic antibody were not significantly abnormal. Lumbar puncture results for the patient showed no abnormalities. Brain MRI revealed speckled and small patchy abnormal signals bilaterally in the corona radiata, the paraventricular and frontal lobes, and the left temporal lobe. The lesions appeared hypointense on T1 images and hyperintense on T2 and FLAIR images. There were no obvious abnormal signals on diffusion-weighted images (DWI) and apparent diffusion coefficient maps (–). The radiological diagnosis was multiple white matter demyelinating lesions. Color Doppler ultrasonography of the gynecological, abdominal, cardiac, carotid, and intracranial arteries revealed no obvious abnormalities.
+The detection of hereditary disease genes revealed mutations, namely c.4044C > G and c.1186-2A > G, in POLR3A . According to the American College of Medical Genetics and Genomics (ACMG) guidelines, the genetic variant c.4044C > G is classified as PM2; however, its clinical significance remains unclear. The genetic variant c.1186-2A > G, classified as PVS1 and PM2, has the potential to influence RNA splicing, subsequently impacting protein function and causing disease. Respecting the patient's opinion, we did not perform genetic testing for her parents or son. Based on the results of physical examination, laboratory tests, imaging tests and gene reports, her condition was diagnosed as POLR3A-related leukodystrophy (HLD7).
+We administered oral vitamin B12 and injectable acetylglutamine to nourish the nerves. No other drugs were used during the hospital stay. However, the symptoms did not show significant improvement during the 1 month of follow-up and appeared aggravated. The patient required assistance to walk and was unable to hold objects in her hands. After discharge, the patient was treated with vitamin B12, vitamin E, coenzyme Q, and traditional Chinese medicine, with Ganoderma lucidum, ginseng, and Poria Cocos as the main ingredients. As of recent follow-up (1 year after she was discharged), she is able to walk slowly alone and climb stairs, and the degree of head and hand tremors has reduced significantly. She is also able to hold objects and cook independently. However, her speech is slower and more indistinct than before.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1580_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1580_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1dd16aff4d0f5e57103a3031cb7b8f76328fa1cb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1580_en.txt
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+A 63-year-old female patient was admitted to the Third Affiliated Hospital of Guangzhou Medical University for abdominal pain, anal irritation, and repeated hematochezia. Her 31-year-old son was previously diagnosed with SRUS and underwent an inpatient examination.
+Her symptoms started 1 year before the presentation of abdominal pain, anal irritation, and repeated hematochezia. Additionally, her 31-year-old son started to present with repeated diarrhea and intermittent hematochezia at the age of 26. He suffered from chronic diarrhea of up to 30 times a day, with the worst demonstrating fecal incontinence. He was subsequently diagnosed with SRUS 3 years ago and underwent surgical removal. The surgical pathology was consistent with the pathological features of SRUS . Hematochezia disappeared postoperatively, but his diarrhea remained. Chronic diarrhea causes his anxiety because his symptoms worsen as his mood changed.
+The patients were healthy before the SRUS incidence.
+The patient has two sons and one daughter. Notably, one of her sons was diagnosed with SRUS before her diagnosis and underwent partial rectal resection. The other son was healthy. Additionally, she and her son with SRUS like to eat mixed and coarse grains, and they have high-fiber eating habits and a sedentary lifestyle. Moreover, they are accustomed to squatting for a long time to defecate. Furthermore, they were healthy before the SRUS incidence, but are prone to anxious behaviors in life.
+A physical examination upon admission revealed no obvious abnormality in both patients.
+Laboratory tests of the female patient revealed high triglyceride (2.11 mmol/L), while others were all within normal ranges. Further, Epstein-Barr virus, and cytomegalovirus were negative. Blood routine, coagulation function and autoimmune tests were within normal ranges. Additionally, laboratory tests of the male patient upon admission revealed no obvious abnormality.
+Her total digestive tract endoscopy results revealed a rectal solitary ulcer , the indicarmine dyeing demonstrated a clear boundary , and pathological results indicated the fibrous tissue hyperplasia in the lamina propria layer as well as glands destruction . Ultrasonic endoscopy revealed clearly demarcated mucosal layers, missing ulcerative mucosa and submucosa layers, and intact and thickened muscularis propria . Moreover, the intestinal computed tomography enhancement revealed segmental rectal wall thickening . The anorectal function test demonstrated a low resting pressure of the anal canal and normal contractile response and anorectal inhibition reflex but with increased anorectal sensitivity. Further, a colonoscopy of the male patient showed that the mucosa of his rectal anastomosis was smooth without any erosion or ulcer .
+Whereas their complicate family history and next-generation sequencing of heritage whole exome sequencing was then conducted with their consent. The results exhibited a CHEK2 gene (c.1111C>T, p.His371Tyr) missense mutation in the patient and her son with SRUS, but not in the other son and the daughter. The CHEK2 p.H371Y mutation was reported as a kind of pathologic mutation. Then we conduct the immunohistochemical staining (IHC) to analyze the expression and function of CHEK2 (Antibody: CHEK2, CST#3440, 1:1600; p-CHEK2, CST#82263, 1:500; CDC25A, CST#3652, 1:100; p-P53, CST#9287, 1:100), which revealed a normal CHEK2 protein level but an impaired downstream gene protein level. As shown in Figure , CHEK2 protein levels and autophosphorylation CHEK2 protein levels showed no significant difference among the healthy control, inflammatory bowel diseases, rectal cancer and SRUS groups (including familial and sporadic cases). In contrast, the downstream gene of CHEK2, such as CDC25A and p-P53 (Ser 20), exhibit differential expression among these groups. CDC25A and p-p53 protein expression levels were the highest and the lowest in the SRUS group, while the differences between the SRUS and rectal cancer groups do not reach significance.
+The SRUS groups contain familial patients in our case and non-familial cases (sporadic cases). The IHC results revealed that the CHEK2 mutation did not affect the expression of CHEK2 protein whether in familial SRUS cases or sporadic SRUS cases, but it would affect CHEK2 functions to different degrees. CDC25A expression level variations are more significant in familial SRUS cases, while p-p53 expression level changes are more pronounced in sporadic SRUS cases.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1597_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1597_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e43eb43ba2b4da3ffc2154c051165cbc4d74af47
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1597_en.txt
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+A 67-year-old man who was a current smoker presented with an edematous right arm and face in our hospital. A chest computed tomography (CT) scan revealed a tumor of approximately 40 mm in diameter in the right upper lobe, with right axial and mediastinal lymph node metastases, and pleural effusion . According to the findings of a transbronchial lung biopsy and systemic survey, he was diagnosed with adenocarcinoma corresponding to clinical T4N3M1c (stage IVB: 8th edition of UICC TNM staging). An epidermal growth factor receptor mutation and rearranged anaplastic lymphoma kinase genes were not detected. His tumor had invaded the superior vena cava (SVC), leading to the swelling of his right arm and face, suggesting SVC syndrome. He was treated with palliative radiotherapy consisting of a total dose of 30 Gy for SVC syndrome. After irradiation, the size of the tumor in the right upper lobe was slightly decreased . Immunohistochemistry using the 22C-3 antibody revealed the high expression of PD-L1 and a TPS of 75%. He did not have a personal or family history of any autoimmune conditions and autoimmune related antibodies such as anti Jo-1 antibody, anti-thyroid peroxidase antibody, anti-thyroid stimulating hormone antibody, free T3, free T4, rheumatoid factor (RF), anti-acetylcholine receptor antibody, antinuclear antibody and anti-glutamic acid decarboxylase antibody did not show abnormal findings. Subsequently, pembrolizumab (200 mg/body, every 3 weeks) was initiated as the first-line therapy. Approximately 2.5 months after treatment with pembrolizumab, he presented with an asymptomatic, poorly demarcated 1–3 cm erythematous plaque over the right trunk of his body, which gradually developed in size . He had no symptoms and his blood examination test results showed no remarkable changes. Therefore, pembrolizumab therapy was continued. Histopathologic examination from a skin biopsy showed ectatic dermal lymphatics with intraluminal aggregations of histiocytes , which were positive for CD68 and lymphatic vessels that were positive for podoplanin (D2–40) . We ultimately diagnosed him as ILH based on the clinical and histopathological findings. RF and anti-cyclic citrullinated peptide (CCP) antibody were checked after the appearance of erythematous plaques; however, they were negative. Laboratory results revealed that TNF-α levels were increased after 2 months of pembrolizumab treatment . After 4 cycles of pembrolizumab treatment, the size of the tumor in right upper lobe had decreased. However, the tumor in the axial lymph node progressed and his right arm swelling worsened. Therefore, the treatment was changed to cisplatin (75 mg/m2) and pemetrexed (500 mg/m2) as second-line therapy. After 2 cycles of chemotherapy, he maintained a partial response without any severe adverse events and ILH was gradually resolved with topical steroid therapy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_159_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_159_en.txt
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index 0000000000000000000000000000000000000000..ba54f1a487cc7ce46eef29c1218947a8d070cb6a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_159_en.txt
@@ -0,0 +1,7 @@
+A 44-year-old Japanese man with well-controlled hypertension, and without any history of renal dysfunction or urinary abnormalities presented with a fever and pharyngeal pain. He was first examined at a local clinic, and was prescribed antibiotics for 10 days. He reported facial and leg edema 19 days after the consultation, and was admitted to our hospital. He has been treated for sleep apnea syndrome over the past two years, but had no family history of kidney disease.
+On admission, the patient’s body temperature was 36.9 °C, and his blood pressure was 175/109 mmHg. He had edema around his eyes and feet. A chest X-ray, electrocardiography, and abdominal ultrasound were performed, but did not show any apparent abnormalities.
+The patient’s initial laboratory test results are summarized in Table . He showed nephritic urinary abnormalities and severe kidney failure (urinary protein 3+, urinary occult blood 3+, serum creatinine 5.46 mg/dL). His CRP (4.05 mg/dL), antistreptolysin-O titer (3440 IU/mL), antistreptokinase titer (40,960 IU/mL) and gamma globulins (IgG/IgA/IgM: 2130/660/50 mg/dL) were increased. His complement C3 level was low (28.8 mg/dL), while C4 level was normal. Autoantibodies, such as the antinuclear antibody, anti–double-stranded DNA antibody, and antineutrophil cytoplasmic antibody were undetectable. The rapid antigen test on a throat swab sample demonstrated positivity for group A beta-hemolytic Streptococcus (Streptococcus pyogenes). Urinary pneumococcal (Streptococcus pneumoniae) antigen was negative. Thus, the patient had developed acute nephritic syndrome with severe renal insufficiency following an antecedent pharyngitis with Streptococcus pyogenes after a latent period of approximately 3 weeks, and a clinical diagnosis of severe PSAGN was made.
+The patient’s clinical course is summarized in Fig. . Symptomatic treatment was initially performed, but as the patient had a mild fever and high CRP level, 2 g of ceftriaxone was administered every 24 h in consideration of a possible latent infection. Although the patient’s kidney function gradually improved, the severe hematuria continued. Moreover, his hemoglobin level and platelet count decreased. Hemolytic anemia was suspected because his haptoglobin level was less than 10 mg/dL, and LDH was high at 514 IU/L. Hemolytic anemia (Hb: 8.8 g/dL), thrombocytopenia (Plt: 9.2 × 104 μL), and severe renal failure, with minimal abnormalities in coagulation tests suggested a complication of TMA. The plasma level of ADAMTS-13 activity was normal (88%). Stool culture and assays for Shiga-like toxin and an O157 LPS antibody, respectively, were negative. Thus, thrombotic thrombocytopenic purpura and Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome (HUS) were unlikely. Meanwhile, the direct Coombs test was transiently positive, i.e., it was positive when performed on hospital day 11, whereas that performed on hospital day 21 was negative. A renal biopsy was performed after improvement in the patient’s anemia and thrombocytopenia, after a blood and fresh frozen plasma transfusion on hospital day 18.
+Light microscopy analysis of formalin fixed paraffin embedded tissue (FFPE) sections of renal biopsy containing 11 glomeruli demonstrated no sclerosis or crescents, but diffuse and global glomerular endocapillary proliferation with massive infiltration of neutrophils was observed . The glomerular massive infiltration of neutrophils was further confirmed by chloroesterase staining . On the other hand, marked infiltration of inflammatory cells (consisted mainly of mononuclear cells without eosinophils) in the tubulointerstitial area, with tubulitis, capillaritis, and interstitial inflammation was observed . Immunofluorescence analysis of fresh frozen tissue sections demonstrated strong glomerular C3 deposition along the capillary walls , but no immunoglobulin or C1q deposition (data not shown). Electron microscopy showed many subepithelial humps .
+We also analyzed the presence of NAPlr, a nephritogenic protein isolated from Streptococcus pyogenes, and performed in situ zymography for plasmin activity on serial sections of fresh frozen tissue. NAPlr deposition and associated plasmin activity were observed in glomeruli with a similar staining pattern , supporting the histological diagnosis of PSAGN . Thus, histologically, glomerular lesions of this patient were typical of PSAGN. On the other hand, the severe tubulointerstitial changes that were observed are not the usual histological findings of PSAGN. Therefore, to evaluate the pathogenesis of TMA in a patient with a transiently positive direct Coombs test, we analyzed the FFPE sections of renal biopsy with fluorescein isothiocyanate-labelled peanut lectin (Thermo Fisher Scientific, Waltham, MA), which is known to have strong and specific binding affinity for T-antigen [, ]. We found the specific binding of peanut lectin to some tubular epithelial cells and vascular endothelial cells in the cortical tubulointerstitial area, whereas such binding was not observed in glomeruli in the same field or in a similar area of a normal control kidney . Furthermore, staining for IgM and T-antigen on serial sections of fresh frozen renal biopsy tissue demonstrated IgM deposition in the T-antigen-exposed sites . In addition, multiple staining for CD3, CD68, peanut lectin, and chloroesterase (a neutrophil marker) on fresh frozen tissue sections revealed massive accumulation of CD3-positive T cells and CD68-positive macrophages around the peanut lectin-positive tubulointerstitial lesions. In contrast, there was minimal infiltration of neutrophils in these area .
+The patient began steroid pulse therapy with methylprednisolone (500 mg/day for 3 days) from hospital day 31, followed by oral prednisolone (30 mg/day) before the renal biopsy results were confirmed, because the patient demonstrated severe renal insufficiency and severe hematuria even though active infection was absent and his platelet count had improved. He was well-tolerated for the treatment with few side effects. His serum creatinine level recovered to 2.0 mg/dL. He was discharged from the hospital on day 44 and was followed-up as an outpatient. His complement levels became normal 13 weeks after the onset of symptoms, and his serum creatinine was 1.15 mg/dL with no hematuria or proteinuria at the most recent follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_160_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_160_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a3f5576e766952f0614427718fc4abda48e8a054
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_160_en.txt
@@ -0,0 +1,3 @@
+A 55-year-old woman presented to our hospital with nonspecific knee pain in the lateral aspect of the right leg. She had no symptoms on the left leg. She had hypertension, diabetes mellitus, and dyslipidemia, and she was on a treatment for intervertebral disc herniation in another hospital. Her physical examination was nonspecific, and the right and left ankle-brachial pressure index was 1.06 and 0.88, respectively.
+The patient underwent Doppler US examination on bilateral lower extremity arteries and veins to examine potential vascular abnormality. There was no abnormality in vessels of the right side. The left SFA was revealed to be divided into two trunks with similar luminal diameter and courses parallel . They reunited at distal thigh level. No other abnormalities or diseases in vessels of the left side were identified by US examination.
+For further evaluation, CTA of bilateral lower extremities was performed. The left SFA appeared to originate from left common femoral artery at the same level of the contralateral side. It appeared to run as a single vessel, 4 cm long, then split into two branches, medial and lateral ones. The luminal diameter of the medial one of the SFA was 5.3 mm, whereas that of lateral one was 4.4 mm, measured in each proximal portion . Both then traveled 14 cm distal along anterior side of the left superficial femoral vein. They merged at distal thigh level to form single vessel and ran 4 cm distal to enter the adductor hiatus. The anatomic orientation was well visualized in three-dimensional volume rendering and maximum intensity projection images . There was no evidence of atherosclerotic stenosis or other diseases on the bilateral lower extremity arteries. The findings of US and CTA examination did not correspond with the symptom of the patient, and the patient was discharged.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1610_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1610_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7a2c651b65ceffe48f16b164cc836993eb5dfa26
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1610_en.txt
@@ -0,0 +1,3 @@
+This is a 20 year old female with past medical history significant for sickle cell anemia, cardiomyopathy secondary to a ventricular septal defect and multiple occurrences of osteomyelitis who sustained a closed, distal third tibial shaft fracture through a segment of infarcted bone after a ground level fall ( and ).
+The patient underwent uncomplicated suprapatellar nailing of the tibia fracture ( and ). At the 1 month follow up visit, there was evidence of full thickness skin necrosis of the medial and anterior incisions around the ankle that were used to insert the distal tibial locking screws ( and ). The patient was started on a 6-week course of intravenous cefazolin and operative debridement of the necrotic tissue was performed. Serial debridements resulted in a medial wound approximately 5 × 8 cm with exposed bone and exposed intramedullary nail and an anterior wound measuring 5 × 5 cm with exposed tibialis anterior tendon ( and ). Due to the exposed fracture, implant, and tendon, the decision was made to proceed with free tissue transfer for wound reconstruction. Due to the dimensions of the wounds and their orientation, a free gracilis was chosen to reconstruct both wounds.
+Pre-operative fractionated HbS was measured at 24% and therefore exchange transfusion was not necessary. The patient was warmed pre-operatively and multiple intraoperative warming devices were utilized throughout the case including an underbody and overbody warming system. Total hemoglobin was measured throughout the surgery to ensure it remained above 7.0. All irrigation fluids utilized intraoperatively were warmed in a fluid warmer and the flap was kept wrapped in warm saline-soaked laparotomy sponges throughout the case. 5000 units of heparin was systemically administered just prior to ligating the arterial pedicle to the gracilis muscle flap and the total ischemia time was 54 min. Post-operatively, the patient was started on a heparin infusion to target an aPTT between 50 and 70. The patient was started on oral aspirin 325 mg on post-operative day 2. A dangle protocol consisting of increasing time periods of allowing the leg to hang off the bed while monitoring tissue oxygenation was started on post-op day 5. The heparin infusion was continued for 14 days post-operatively and then the patient was transitioned to lovenox 30 mg BID. The flap healed completely with no evidence of wound healing issues with bone union obtained at the final visit 11 months post-op . .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1615_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1615_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4c0c60adff9778106b92384728223c64b7ab8335
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1615_en.txt
@@ -0,0 +1,5 @@
+A 10-year-old girl was referred to the pediatric orthopedic clinic with a right foot deformity which had started at age 4 and had slowly progressed. The parents were certain that the child had symmetric feet shape from birth. There was no history of a similar deformity in the close or distant family members. There was no family history of any neuromuscular disorder.
+The physical examination revealed plantigrade feet, with a distinctly right flatfoot with a well-formed longitudinal arch on the left side . There was no evidence of spine anomaly, peripheral neuropathy or myopathy. The right foot examination showed intact sensation, and full power in all the muscles, except for the inversion power which was weaker than the opposite foot. On closer inspection of the foot, a small scar of about 3-4 mm was visible just posterior to the medial malleolus. On further questioning of the parents, they remembered their daughter having cut herself on a piece of rock playing in a park at age 3. This did not require any medical attention and apparently healed uneventfully in few days. This piece of history led to the further investigation including a magnetic resonance imaging of the leg which showed the absence of TPT at the ankle level, and atrophic muscle.
+Surgery, through a slightly curved medial foot and ankle incision, showed a fibrous stump of old TPT on the navicular tip. There was no evidence of TPT. The atrophic muscle was, however, found some 12 cm proximal to the medial malleolus with no visible tendon end.
+A reconstruction with the flexor hallucis longus longus (FHL) tendon was planned. The incision was extended distally, the “Master Knot of Henry” - the fibrous slip that envelope the FHL and the flexor digitorum (FDL) tendons - was exposed. The FHL was cut at that level, and proximal end was transferred to the navicular bone and tightly sutured to bone and remnants of TPT. The distal stump of the FHL was tightly sutured to the FDL ( and ). Following 6 weeks of cast immobilization a course of physiotherapy was started .
+The longitudinal arch was restored and has remained nicely intact up to the last visit 3 years post-surgery . The patient has a pain-free motion of foot, ankle, and toes, and is satisfied. The push off is strong, and she shows very nice longitudinal arch when standing on tiptoes. She could do repeated push off exercise on tiptoes with similar power and foot-arch shape as the opposite foot, without any fatigue.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1617_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1617_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..acc70a5462359ecb694568030472e9c29dc40a81
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1617_en.txt
@@ -0,0 +1,8 @@
+A 56-year-old female presenting with massive intestinal hemorrhage was admitted to hospital. The persistent and progressively worsening hemorrhage was complicated by disseminated intravascular coagulation.
+The patient had a history of chronic constipation and multiple venous hemangiomas since childhood. The lesions increased in size and number with advancing age. She did not have hepatitis or liver cirrhosis.
+In the prior 3 years, the patient was repeatedly admitted to hospital due to melena or fatigue and dizziness. No blood lesions were found under endoscopy or colonoscopy. After hemostatic treatment and multiple blood transfusions (14-64 units of red blood cell transfusions every year), the patient’s hemoglobin fluctuated between 39 g/L and 61 g/L.
+She was again admitted to the emergency department with worsening symptoms, including 10 d of melena. The symptoms did not improve after treatment, and she was transferred urgently to our hospital.
+There was no family history of venous hemangiomas or other relevant disorders.
+Physical examination revealed anemia and multiple blue hemangiomas protruding from the skin surface . Skin ultrasound confirmed that the protrusions were hemangiomas .
+Laboratory examination showed white blood cell count of 1.78 × 1012/L (normal range: 3.80-5.10 × 1012/L), hemoglobin of 39 g/L (normal range: 115-150 g/L), platelets of 71 × 109/L (normal range: 125-350 × 109/L), and positivity for fecal occult blood. Additional testing revealed prothrombin time of 17.7 sec (normal range: 9.5-15.0 sec), activated partial thromboplastin time of 55.8 sec (normal range: 20.0-40.0 sec), prothrombin time-international normalized ratio of 1.65 (normal range: 0.80-1.50), fibrinogen of 0.349 g/L (normal range: 1.800-4.000 g/L), D-dimer of > 10000 ng/mL (normal range: 0-500 µg/mL), tissue plasminogen activator-inhibitor 1 complex of 14.10 ng/mL (normal range: 0.00-10.50 ng/mL), and plasmin-α2 cellulase inhibitor complex of 12.23 µg/mL (normal range: 0.00-0.80 µg/mL).
+Imaging examination showed multiple hemangiomas throughout the body. Further examination showed hemorrhagic anemia with enhanced fibrinolytic type disseminated intravascular coagulation. No other bleeding causes were discovered after abdominal computed tomography examination or after digital subtraction angiography and mesenteric arteriography . No definitive bleeding lesions were found by endoscopy and colonoscopy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1618_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1618_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e5248946a1e3539657dfc8deac55df7a1679467d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1618_en.txt
@@ -0,0 +1,3 @@
+We present a case of 40-year-old building and construction male worker who slipped and fell from a height of three (3) meters and sustained a deep penetrating wound on the right side of the anterior neck a week prior to presenting at our facility. He was apparently working from the above height when he slipped and fell on a sharp piece of iron rod which penetrated deep into the right anterior neck. He quickly pulled the sharp iron rod out when he got up from the floor. According to him, the bleeding was not profuse and stopped when he arrived at the local hospital to search for remedy . He did not have hemiplegia, paraplegia, or quadriplegia when we saw him. He is not known to be hypertensive. He did not take alcohol prior to the fall although he takes alcohol occasionally. He had a left femoral fracture at the age of 24 and a right femoral fracture at the age of 32; both incidences were operated on successfully. On examination at our facility we saw a middle aged man who was conscious and alert but however acutely ill with his neck fixed in cervical collar. General as well as systemic examination did not yield much. All the systems where grossly normal. Neurological examination revealed normal pupils which reacted normally to light. Cranial nerves examination was unremarkable. Power on four limbs as well as reflexes was normal. Digital rectal examination revealed a normal spinster tone. Routine laboratory as well as other ancillary (ECG, CXR, etc.) investigations were normal.
+Neck CT-scan done at the local hospital revealed C2-C4 transverse process fractures on the right side, fracture at the right lamina of C3, and right common carotid artery dissection. CT-scan of the head showed no abnormalities . Explorative three-dimensional reconstruction plain and enhanced scan imaging of the cervical spine, chest, and abdomen done at our facility revealed two segmental stenoses of the right common carotid artery with very pale V1 and V3 segment of the right vertebral artery as well as blockage at V2 segment as well as fracture at the right lamina of C3 and C2-C4 transverse processes with free bone fragments and peripheral soft tissue swelling . The skin at the right anterior cervical region is discontinuous, with adjacent soft tissue swellings and gas accumulation. The bilateral carotid artery sheath lymph nodes slightly enlarged. At the upper lobe of the right lung there were multiple calcifications, some of which were adjacent to the pleura. There was also slight thickening of the left pleura. The heart was not enlarged but we observed slight accumulation of gas in the anterior mediastinum. Multiple low-density lesions were seen in the liver which we think are constant cysts. A working diagnosis of right common carotid artery dissection with C1-C4 fractures was made.
+After preoperative education and counselling of the patient as well as the relatives, surgery was scheduled the next day. Intraoperative cerebral angiography showed right carotid artery dissection and right vertebral artery occlusion. There was some reparation at the distal end of the right vertebral artery. The left vertebral artery was however normal. We introduced the guiding catheter guide wire to the proximal end of the right common carotid artery with continued infusion of heparinized saline, after which we introduced a guide wire with a Cordis stent (10 ∗ 60mm) to completely cover the right common carotid artery dissection site with stenosis and released the stent gradually until it completely filled the stenosis area ). We delivered contrast agent into right common carotid artery to make sure it was patent before removing the guiding catheter followed by withdrawal of the femoral arterial sheath. Control contrasted angiograph done revealed stenting was successful . The patient recovered markedly and was discharged home a week after. Scheduled outpatient visit every 6 months for 2 years revealed no neurological complications.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1619_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1619_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f652a00fb5ed3eeab3a8404311a1a2d098719725
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1619_en.txt
@@ -0,0 +1 @@
+A 34-year-old woman presented to the emergency department (ED) with progressive leg swelling. Thorough laboratory testing as an outpatient and in the ED was unrevealing. To evaluate further the causes of her dyspnea and edema, we performed a point-of-care ultrasound (POCUS) of the heart, lungs, and abdomen. While evaluating for evidence of ascites, a large mass with anechoic center was identified in the right upper quadrant (, and ). This prompted computed tomography (CT) of the abdomen and pelvis, which confirmed a 7.9 × 9.1 × 8.7 centimeter mass arising from the right posterior liver, extending into the inferior vena cava with an associated near-occlusive tumor thrombus . During admission, a biopsy was performed revealing adrenocortical carcinoma (ACC).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1621_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1621_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e4cc7ca2470d758d6901cfca4e337720f6edfa96
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1621_en.txt
@@ -0,0 +1,2 @@
+A 7-year-old Turkish girl with a history of a fall from a height of approximately 1.5 meters was seen on our ward. The patient had complaints of left shoulder pain and of being unable to move her shoulder. She preferred to stay seated in a slightly forward-leaning position, and was trying to support her elbow of the injured side with her other arm. A physical examination identified tenderness on her left shoulder, a slight swelling and limitation of movement. The patient was unable to perform movements with her left shoulder; her shoulder did not allow for passive movements as well. The patient’s neurovascular examination was entirely normal. On her radiography, a Salter–Harris type II epiphysiolysis at the proximal left humerus and a glenohumeral dislocation were identified . The epiphysis of the humerus appeared to be completely separated from the glenoid. After the preoperative preparations were complete, the patient was taken to the operating room.
+After fluoroscopy-guided closed reduction under general anesthesia was not successful, open surgery was performed instead. With a deltopectoral incision, the fracture line and the joint capsule were exposed. It was observed that the humerus head had moved beneath the glenoid. The fracture was first reduced, and glenohumeral reduction was then performed after fixation was ensured with two Kirschner wires . The patient was postoperatively followed-up for 4 weeks in Velpeau bandage. After union at the fracture was identified on the radiographs taken at the end of the postoperative 4th week, the Kirschner wires were removed under sedation, and the patient was commenced on an exercise program in order to increase the range of motion of her shoulder joint. After an exercise program of 2 weeks, the range of motion of the patient’s joint was almost fully restored. Only a limitation in abduction of 15 degrees was observed. In the postoperative 12th week, it was observed that the range of motion of her joint was at the same level as her healthy side. No redislocations were observed during the 6-month follow-up period.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1624_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1624_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e13632c5b34d2d5bf1f1fa2d568e64594fc5ca4f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1624_en.txt
@@ -0,0 +1,4 @@
+A 71-year-old man presented to our emergency center with a history of diffused abdominal pain with intermittent hematochezia for 38 h. The patient denied other GI or genitourinary complaints, had an unremarkable medical history, and did not undergo prior abdominal surgery. On physical examination, the abdomen appeared tender with extensive rebound tenderness. Unfortunately, his groin areas were ignored to check due to lack of specific complaints. The blood investigation revealed a decreased hemoglobin level (9.6 g/dL). A contrast-enhanced CT scan indicated a lower GI bleeding resulting from a ruptured mass (5.2 × 4.1 × 3.0 cm3) located in small intestine. Meanwhile, CT imaging showed a minimal mass (2.0 × 1.5 × 0.5 cm3) in his right groin but failed to mention in the emergent report .
+The patient was immediately managed with an emergent laparotomy in light of the hemodynamic instability. During the surgery, the primary tumor was found arising from the third jejunal segment (220 cm distant from the duodenal-jejunal flexure), with disseminated, multi-focal progression of tumor seeding recorded. A palliative resection of primary tumor and seeding tumors (> 2 mm) in abdomen was achieved (R1 resection), followed by a side-to-side bowel anastomosis. The patient was discharged at the 11th post-operative day without any complications. The histopathologic report of primary tumor suggested a GIST of spindle cell nature, with high mitotic count (25/50 HPF) and significant tumor necrosis (Additional file : Fig. S1). The immunohistochemical (IHC) staining evaluation indicated severe positivity for CD117, DOG-1 and SDHB, mild positivity for actin and desmin, but negative for CD34 and S-100. The Ki-67 index was 20%. The molecular analysis reported a mutation rate of 18.22% for the c-KIT, mainly located on A502_T503dup exon 9. The tumor was hence categorized as high-risk jejunal GIST.
+The patient received imatinib chemotherapy (400 mg/day) postoperatively for three months until a complaint of persistent pain in the right groin. On physical examination, a painful, irreducible, non-pulsatile mass (2.0 × 2.0 × 1.0 cm3) was felt in right groin, with negative finding in contralateral side. He was referred to the hernia unit of our department. Additional CT imaging was performed to exclude abdominal recurrence. Afterward, a definitive herniorrhaphy with Lichtenstein’s approach was accomplished , with the mass along with sac removed before placing a self-gripping polyester mesh (TEM1208GR, Parietex ProGrip™, US). The intraoperative diagnosis was right indirect inguinal hernia, Gilbert II classification . The patient was discharged at the second post-operative day. The final pathological report of resected specimen in his groin indicated a metastasized GIST in inguinal hernia. The tumor was spindle cells morphology, with high mitotic count (> 40/50 HPF) and strongly positive immunostains of CD117, DOG-1, Bcl-2 and CD99. The Ki-67 index was 30%, with partial positivity for SDHB .
+The patient continued the imatinib chemotherapy as mentioned ahead, with planed outpatient clinic visits scheduled. At the last follow-up visit on February 14th, 2020, he was survived and capable of daily work, without a recurrent inguinal hernia observed.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1634_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1634_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..79f9f27616261c618d7816c28ae89a337c183a7d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1634_en.txt
@@ -0,0 +1,5 @@
+A 67-year-old female with a 4-day history of a fever and cough was admitted to a local hospital for pneumonia. The diagnosis of COVID-19 was confirmed by a positive polymerase chain reaction (PCR) test result via a nasopharyngeal swab. Her respiratory condition gradually worsened after admission. Thus, she underwent intubation and was transferred to our hospital in need of intensive care 5 days after admission.
+Her height and weight were 164.9 cm and 46 kg, respectively. She had comorbidities of diabetes mellitus, diabetic nephropathy requiring dialysis, angina, post-resection gastric cancer and postoperative spinal canal stenosis. She was taking several regular medications including an antiplatelet agent. On arrival, a physical examination revealed a body temperature (BT) of 34 °C, blood pressure (BP) of 110/65 mmHg, heart rate (HR) of 102 beats/min, and Glasgow Coma Scale of E1VtM1 with deep sedation. The arterial blood gas analysis showed pH 7.309, partial pressure of carbon dioxide (PaCO2) 41.5 mmHg, partial pressure of oxygen (PaO2) 78.2 mmHg with pressure control mechanical ventilation set as follows: positive end-expiratory pressure (PEEP) of 8 cmH2O, peak inspiratory pressure (PiP) of 25 cmH2O, fraction of inspired O2 (FiO2) of 0.5. The laboratory results were as follows: white blood cell counts (WBC) of 13,900/μl, C-reactive protein (CRP) of 13.1 mg/dL, D-dimmer of 7.25 µg/mL, activated partial thromboplastin time (APTT) of 170 s, and international normalized ratio (INR) of 1.35. Computed tomography (CT) revealed bilateral ground-glass opacity with lower-lung predominance. There were no evident abnormal findings in the abdominal region or thromboembolism; however, the intestine, including the transverse colon was edematous, and the abdominal vessels showed strong sclerotic changes . Dexamethasone administration (6 mg/day), started at the previous hospital, was continued. Continuous renal replacement therapy was initiated for the chronic renal failure as well as appropriate body fluid management. On day 3 after admission, antibiotic therapy by cefepime was started for ventilator-associated pneumonia. The APTT decreased to 51.5 s, thus unfractionated heparin for prophylactic-dose anticoagulation was additionally administered to keep the APTT around 60 s.
+On day 7 after admission, despite these treatments, her respiratory condition worsened as follows: pH 7.333, PaCO2 40.6 mmHg, PaO2 71.1 mmHg under the ventilator setting of PEEP of 10 cmH2O, PiP of 22 cmH2O, FiO2 of 0.8. Furthermore, hemodynamic deterioration also developed with a BP of 85/41 mmHg and HR of 108 beats/min under the noradrenaline administration (0.2 µg/kg/min). Laboratory tests revealed an increase in the inflammatory markers and derangements in the coagulative function as follows: WBC of 15,100 /µl, CRP of 32.14 mg/dL, D-dimmer of 26.51 µg/mL, APTT of 47.2 s, and PT-INR of 1.24. Therefore, follow-up CT was performed to re-evaluate the degree of lung injury and to detect other sources of infection. CT revealed massive ascites, free air, and wall defects of the transverse colon . Emergency laparotomy as the source control of pan-peritonitis due to intestinal perforation was performed with the extracorporeal membrane oxygenation (ECMO) team on standby, as her respiratory condition was close to the limit of being able to be supported by a ventilator only. All surgical procedures were undertaken in the negative-pressure room of the intensive-care unit (ICU), considering the risks related to patient transfer such as further deterioration of the patient’s condition and pathogen exposure to the medical staff.
+A midline skin incision was performed, and the abdomen was filled with contaminated ascites. Two perforation sites of 25 mm and 7 mm in diameter were identified at the right side of the transverse colon, and the tissue around the perforation sites changed necrotic . PCR for the ascites showed a positive result and the number of copies of the virus was 42,056 (the number of copies of the virus in the sputum: 501,420). Abdominal lavage and partial resection of 17 cm of the transverse colon were performed. Considering the hemodynamic instability of the patient, open abdominal management with ABTHERA™ (KCI, now part of 3 M Company, San Antonio, TX, USA) and a planned relaparotomy strategy was selected. The secondary surgery was performed 2 days after the first operation. The abdomen was uncontaminated, and no remnant ischemic lesion was observed. Thus, colostomy was done, and the abdominal incision was closed with several drainage tubes into the abdomen. A histopathological examination revealed necrosis of the intestinal mucosa around the perforation sites and microcirculatory thrombosis in the mesentery veins, which was suspected of having been induced by COVID-19-related coagulopathy .
+Enteral feeding was re-started on postoperative day 2. All drains were removed on postoperative day 7. Abdominal complications, such as surgical site infection, remnant abscess and stump leakage, were not noted; however, the COVID-19 pneumonia ultimately progressed, and she died due of respiratory failure 24 days after admission (17 days after the initial surgery).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1638_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1638_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9f7406712d43e48cf89b09661bc9a0d87d575ab5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1638_en.txt
@@ -0,0 +1,2 @@
+A 16-year-old boy presented with a history of headache of 8 months duration, progressively decreasing vision for 3 months and more recently had an episode of generalized seizure 1 month back. Neurological examination did not reveal any focal neurological deficit except bilateral papilledema on fundus examination. MRI scan revealed a large 10 × 8 cm extra-axial hyperintense contrast enhancing mass lesion on the T1-weighted image, occupying the anterior cranial compartment [Fig ]. The tumor was compressing the frontal horns of lateral ventricles along with anterior part of corpus callosum. It was also seen encroaching upon the superior saggital sinus. A bifrontal free bone craniotomy was performed and total excision of the tumor was achieved. Intraoperatively, the tumor was seen adhering to the frontal bone, a part of which was excised with the tumor.
+Gross examination of the resected tumor showed a 10 × 8 × 2 cm soft tissue with its cut-section showing grayish-white, irregular surface with focal necrosis [Fig ]. Histopathological examination revealed a tumor tissue composed of sheets of cells arranged in perivascular pseudopapillary pattern [Fig ] along with few well formed papillae with central fibrovascular core [Fig , inset]. These papillary structures in some places were mixed with meningothelial sheets and whorls. The tumor cells in the papillary area displayed abundant eosinophilic cytoplasm, vesicular nuclei but frequent mitoses and foci of necrosis. MIB-1 labeling index was high with mean LI of 12% [Fig ]. Immunohistochemical positivity to epithelial membrane antigen (EMA) [Fig ] and vimentin was seen while Cytokeratin (CK), GFAP and S100 were non-reactive. A pathological diagnosis of Papillary meningioma, WHO grade 3 was given.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1648_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1648_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..05c9506eaa752d89784843e194fe4b3ec809edc0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1648_en.txt
@@ -0,0 +1,8 @@
+A 64-year-old female with IVC filter placement 3 mo ago was presented to our institution with severe right abdominal pain for 1 d.
+The patient was admitted to a local hospital for deep venous thrombosis of the left lower extremity 3 mo ago. A double-basket retrievable IVC filter (Visee WXF-32, Shandong Visee Medical Devices Company Limited, China) was placed in infrarenal IVC through the right femoral vein, and anticoagulation therapy was applied. Endovascular retrieval of the IVC filter through the femoral vein approach with standard technique failed 10 d later in the local hospital. Imaging follow-up ceased due to the COVID-19 pandemic.
+The patient presented to our institution 3 mo later with severe right abdominal pain for 1 d. The patient had no fever or chills. She denied melena, but her urine was reddish.
+The patient had history of scoliosis and poorly controlled diabetes mellitus.
+The patient was addicted to smoking and alcohol.
+After admission, the patient had a heart rate of 97 bpm, a respiratory rate of 23 breaths per minute, and a blood pressure of 126/73 mmHg. Physical examination revealed diffused abdominal tenderness and rebound tenderness. The right lower limb was slightly swollen, and the pulse in the right femoral artery was weak.
+Laboratory tests showed no hepatic or kidney dysfunction, with hemoglobin of 101 g/L, leukocyte count of 14.74 × 109/L, and neutrophilic granulocyte percentage of 91.0%. During the surgery, partial pseudoaneurysm was extracted for tissue culture. Staphylococcus aureus was isolated from the tissue culture, which was sensitive to moxifloxacin.
+Computed tomography angiography showed that the retrieval hook of the filter penetrated the right common iliac artery (CIA), leading to a 52 mm × 48 mm × 55 mm right iliac artery pseudoaneurysm, accompanied by right ureteral obstruction with ipsilateral hydronephrosis . Bilateral iliac veins and lower part of the IVC were completely occluded, with substantial pelvic varicosities .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1649_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1649_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5a449b7d9754f57b6081bc6b4f1da26cdc349cfe
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1649_en.txt
@@ -0,0 +1 @@
+A 52-year-old man was first diagnosed with HIV in 1991. He was maintained on antiretroviral therapy with emtricitabine-tenofovir and raltegravir. The HIV viral load was undetectable (less than 20 copies/ml) and the CD4 count of 850 cells/uL at the time of presentation. In December 2016, he presented to the emergency department with chief complaint of diplopia. A magnetic resonance imaging (MRI) of the orbits revealed a mass in the left orbit with involvement of the optic nerve. He was referred to ophthalmology and underwent a lateral orbitotomy and removal of the orbital mass. Pathology showed metastatic small cell carcinoma. A Computed Tomography (CT) scan of the chest, abdomen and pelvis and a Positron Emission Tomography (PET) scans were negative for any intrathoracic mass; however, there were multiple liver lesions and a large pancreatic tail mass. Given these findings his final diagnosis was extrapulmonary high-grade small cell carcinoma of the pancreas. Next Generation Sequencing of his tumor showed an intermediate tumor mutation burden with 9 mutations/megabases and deleterious alterations in TP53, MLL3, MEN1, FAT1, CDKN2A, BCORL1, BCOR, ATRX and TSC2 genes. There is currently no approved targeted therapy for any of these mutations. He was started on chemotherapy with carboplatin and etoposide. He had a partial response (PR) after 2 cycles of chemotherapy. He had disease progression after 6 cycles of chemotherapy with carboplatin and etoposide. He was then started on chemotherapy with FOLFIRINOX (5-Fluorouracil, irinotecan, leucovorin and oxaliplatin) as second line therapy. He received four cycles but continued to have disease progression on imaging. He was then treated with carboplatin and paclitaxel but his disease continued to progress with clinical deterioration and significant abdominal pain. At that point, treatment with dual CPI therapy (nivolumab and ipilimumab) was pursued given the available data in refractory SCLC. Before the start of this therapy, his CD 4 count was 294 cells/uL with an undetectable HIV viral load (less than 20 copies/ml). He received Nivolumab 1 mg/Kg along with Ipilimumab 3 mg/kg every 3 weeks. After 2 doses of the combination, he developed acute kidney injury with creatinine of 4.2 mg/dl from a baseline of 1.0. The therapy was suspended and he was admitted to the hospital and a renal biopsy was performed which showed severe drug-induced acute interstitial nephritis (AIN). He was treated with high dose steroids; 500 mg of IV methylprednisolone for 3 days followed by a steroid taper. His renal function improved after 4 weeks with return of creatinine to baseline. He was then re-started on single agent Nivolumab at 1 mg/Kg and later ipilimumab at 1 mg/kg was added. The patient had significant clinical improvement soon after starting the dual CPI therapy with resolution of abdominal pain which previously required high-dose opioids. Repeat scans at 12 weeks (including MRI of the head and PET/CT scan) showed complete response (CR) as per PERCIST criteria with disappearance of all metabolically active lesions . Patient was continued on antiretroviral therapy. The HIV viral load was undetectable before starting the CPIs (< 20 copies/ml) and increased to a high of 175 copies/ml. At the same time his absolute CD4 count increased from 294 cells/uL before treatment to a high of 593 cells/uL. His CD8 count also followed the similar pattern. It was 111 cell/uL before starting treatment and reached a high of 247 cells/uL . The patient’s complete radiological response is still ongoing at the time of this report (24 weeks after the start of the dual CPI therapy).
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1653_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1653_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c3d16f483d24ad685047b572baee3756965bc4f6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1653_en.txt
@@ -0,0 +1 @@
+A 62-year-old man was treated with pembrolizumab for right lung adenocarcinoma, which showed high PD-L1 expression (80%), with multiple intestinal, lymph node, and bone metastases. The TNM classification for NSCLC was cT2N3M1c (OSS, LYM, PER, OTH), stage IVB (eighth edition). Tumor reduction was observed, but pembrolizumab was stopped after three courses owing to drug-induced pneumonitis. Dexamethasone was used for the treatment of pneumonitis. One month after drug withdrawal, the patient was transported to the emergency department of our hospital with the complaint of severe stomachache. On physical examination, he had a rigid abdomen and generalized tenderness. His blood pressure was in the normal range (110/82 mmHg), the heart rate was elevated but regular at 100 beats per minute, and the body temperature was elevated at 38.9 °C. The peripheral capillary oxygen saturation was 98% at room air. Laboratory evaluation showed a high inflammatory response with a white blood cell count of 18,200/mm3 and C-reactive protein level of 20.8 mg/dL. CT examination showed abdominal free air and ascites with perforation of the existing lung adenocarcinoma metastasis . We diagnosed bowel perforation with acute diffuse peritonitis. Emergency laparotomy was performed, and multiple small intestinal metastasis with mesenteric lymph node metastasis and ascites containing intestinal fluid were observed. The perforation site was located in the metastatic jejunum about 40 cm on the anal side from Treitz’s ligament. We resected this part about 20 cm and anastomosed with functional end-to-end anastomosis. There was no complication after surgery, and he was discharged on post-operative day 15. Pathological examination indicated lung adenocarcinoma metastasis in the perforated intestine, and the metastasis was partly scarred owing to the effect of pembrolizumab . Tumor cells in the perforation site had a high degree of degeneration and necrosis, and the pathological response for the efficacy of pembrolizumab was grade 1b (Japanese Classification of the Colorectal Carcinoma, seventh edition) . In the perforated part, the tumor cells were observed in all layers, but in the vicinity on the serosa side. Inflammatory change due to enteritis was not found in this site. Pembrolizumab was re-administrated about 1 month after discharge. To prevent drug-induced pneumonitis, dexamethasone was used daily.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1656_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1656_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1c54d040d665b05e4a44c3054ba955e3dc76dbc5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1656_en.txt
@@ -0,0 +1,7 @@
+A 34-year-old Caucasian male presented to the emergency department complaining of a 4-day history of unbearable leg pain with diffuse arthralgia, fluctuating low-grade fever with profuse sweating, vomiting and diarrhea without abdominal pain, odynophagia, dry cough, headaches, and fatigue. He denied any contact with animals or travel abroad, had not consumed unpasteurized food, and had his last unprotected sexual intercourse 4 months earlier.
+He was taking no medications and was known for alcohol abuse (mainly beer and spirit, approximately 185 alcohol units/week), drug abuse (cocaine, ecstasy, cannabis, methylphenidate, clonazepam, lorazepam), and smoking tobacco. On physical examination, he was afebrile and hypotensive (blood pressure 94/50 mmHg) with a normal heart rate (77 beats/minute). Oral examination revealed dry mucosa and erythematous tonsils without exudate, cardiopulmonary examination was normal, abdominal palpation was unremarkable, and no cutaneous rash was noted. Testing of the lower limbs revealed preserved strength and sensitivity as well as symmetric deep tendon reflexes.
+Laboratory findings showed normocytic, normochromic, hypoproliferative anemia (hemoglobin 99 g/l, normal range 140–180 g/l) with thrombocytopenia (24 G/l, normal range 150–350 G/l), left shift without leukocytosis, elevated C-reactive protein (213 mg/l, normal range < 10 mg/l), elevated transaminases (three times the upper limit of normal) with cholestasis and elevated conjugated bilirubin (29 µmol/l on admission, 190 µmol/l on hospital day 8, normal range 0.5–9.5 µmol/l). There was a stage 3 acute kidney injury according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria with a serum creatinine of 112 µmol/l on admission and 247 µmol/l on hospital day 3 (patient’s baseline value 70 µmol/l), a serum urea of 11.4 mmol/l on admission (12 mmol/l on hospital day 3), and preserved urine output. Urinalysis revealed proteinuria (spot urine: protein 1.4 g/l, creatinine 11.5 mmol/l, urine protein–creatinine ratio 1.076 g/g), albuminuria (2+ on semiquantitative analysis), presence of 97 M/l leukocytes, 25 M/l erythrocytes, and renal tubular cells (1+ on semiquantitative analysis). Sodium excretion was high (fractional excretion of sodium on spot urine 3.56%). Due to the context of sepsis, hypovolemic status of the patient, and urinalysis findings, acute tubular necrosis was the suspected mechanism of acute kidney injury.
+Analysis of serum electrolytes showed mild hyperphosphatemia (1.53 mmol/l, normal range 0.80–1.45 mmol/l), hyponatremia (131 mmol/l, normal range 136–144 mmol/l), mild hypouricemia (246 µmol/l, normal range 286–518 µmol/l), low serum chloride (94 mmol/l, normal range 98–106 mmol/l), hypokalemia (2.8 mmol/l, normal range 3.6–4.6 mmol/l), and an anion gap of 10 mmol/l. The transtubular potassium gradient was elevated (16.4). Albumin level was 29 g/l (normal range 35–48 g/l), and creatinine kinase level was 312 U/l on admission, rising to 404 U/l the next day and normalizing on hospital day 4. Blood gas analysis showed a pH of 7.49 (normal range 7.35–7.45) with elevated bicarbonates (29.3 mmol/l, normal range 22–26 mmol/l) and normal pCO2 (5.25 kPa, normal range 4.7–6.4 kPa). Urine pH was 6 (normal range 5–6.5). Presence of glycosuria (7 mmol/l, normal range 0.1–0.9 mmol/l), with concomitant euglycemia (6.6 mmol/l, normal range 4.1–11 mmol/l) and a hemoglobin A1c of 5.1% was highly suspicious of proximal tubular dysfunction.
+Upon admission, Streptococcus A rapid test was negative, chest radiograph was normal, and an abdominal ultrasound showed hepatomegaly, a heterogeneous parenchyma with hyperechogenicity around periportal spaces and lymph nodes, liver parenchymal arterialization, and a layer of perihepatic fluid, all consistent with hepatitis. The bile ducts were not dilated. Kidneys were of normal size and morphology, without any urinary tract dilatation. On the second day after admission, the patient developed drowsiness and confusion with high fever (exceeding 40 °C). Normal cerebral magnetic resonance imaging and lumbar puncture excluded central nervous system infection. Clinical features were suggestive of bacterial sepsis [sequential organ failure assessment [SOFA] score of 10], justifying empiric broad spectrum antibiotic therapy with intravenous ceftriaxone and oral clarithromycin.
+Detailed history revealed that the patient swam in a river in the Geneva lake area 1 week before hospital admission, raising the diagnostic suspicion of leptospirosis in this clinical setting. Serum polymerase chain reaction (PCR) for Leptospira interrogans was positive, and specific serologies revealed elevated IgM levels (> 100 U/ml, normal range < 15 U/ml). Although IgG levels were below the positive threshold, the values increased from < 2 U/ml initially to 6 U/ml 1 week later (normal range < 10 U/ml). Unfortunately, no ulterior dosage was performed. Antibiotic therapy was changed to intravenous amoxicillin–clavulanate and doxycycline for 7 days with clinical improvement. Serology for hantavirus was performed, revealing an indeterminate result due to nonspecific reactions. Considering the positive results for Leptospira interrogans, additional tests for hantavirus were not performed.
+Along with clinical improvement, kidney function recovered with creatinine normalizing to 87 μmol/l on the sixth hospital day, and all electrolyte abnormalities resolved. Liver tests also normalized as confirmed by a routine blood sample 1 year after discharge. In addition, glycosuria significantly decreased from 7 to 0.5 mmol/l on the 12th day of hospital stay.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1662_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1662_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ee7ff930f16a19921afda98445751b57d635f2fb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1662_en.txt
@@ -0,0 +1,4 @@
+A 66-year-old man with hypertension and coronary artery disease as underlying diseases had pain in both lower extremities. His symptoms occurred after walking for approximately 100 m. He received acupuncture at an oriental clinic. However, his symptoms did not improve. According to the patient's description, his symptoms rose from the feet to the top. On a physical examination, the straight leg raise test was negative and the motor grade for both lower extremities was grade V. He also complained of a tingling sensation in the L5 dermatome of the right leg and L4 dermatome of the left leg. Conservative treatment was performed using non-steroidal anti-inflammatory drugs.
+One month later, his pain in the left leg was improved, but the pain in the right leg had worsened. Therefore, lumbar spine magnetic resonance imaging (MRI) was performed, which showed central stenosis at the L4–5 and L5–S1 levels, and lateral recess stenosis at the L5–S1 level was observed . The patient’s symptoms were ambiguous with mixed neurological claudication and vascular claudication. We performed a Doppler test for both lower extremities. No pulsations in the right dorsalis pedis or posterior tibialis artery were detected. Under the suspicion of a problem in a vessel, computed tomography (CT) scans for the lower extremity arteries were taken. CT scans showed complete occlusion in the right external iliac artery . The patient was referred to the General Surgery Department. The ankle–brachial pressure index (ABI) was 0.1 to 0.2 (normal range: 1.0–1.4). Conservative treatment with 75 mg of clopidogrel/day and 20 mcg of beraprost sodium every 8 hours was initially performed for external iliac artery occlusion in the right leg. We obtained consent for this treatment from the patient. After the treatment, his symptoms were improved by 30% to 35% at 1 month after the diagnosis, 60% to 70% after 3 months, and 80% to 85% after 6 months. The patient refused further surgery for the spinal stenosis because he was satisfied with the clinical results.
+Clopidogrel and beraprost sodium were continued for 4 years. The ABI was continuously measured during the follow-up period, and it continued to rise to 0.56 after 1 year, 0.69 after 2 years, and 0.73 after 4 years. A follow-up CT scan performed 4 years later showed recanalization of the right external iliac artery occlusion .
+Written informed consent was obtained from the patient for the publication of this case report and accompanying images. All consent procedures and details of this study were approved by the Institutional Review Board of the Catholic University of Korea (approval number: SC16ZISE0080). The reporting of this study conforms to the CARE guidelines.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1676_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1676_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..504b763037b1eed7f879292de04a5adbf40969e4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1676_en.txt
@@ -0,0 +1,6 @@
+A 52-year-old female presented to our hospital with blurred vision in her left eye for approximately 1 wk.
+The patient reported no headache or eye pain. She had no other diseases.
+Unremarkable.
+No abnormalities were found on slit lamp examination.
+The patient underwent a comprehensive ophthalmic examination, including decimal best corrected visual acuity, color fundus photography, spectral domain optical coherence tomography (OCT) and fluorescein fundus angiography. On first examination, her best corrected visual acuity was 20/40 in the left eye and 20/20 in the right eye. Anterior segment and intraocular pressure findings were normal in both eyes. Fundus photography of the left eye showed a seemingly normal adult oculus fundus without any obvious hard exudate or hemorrhage . OCT demonstrated a hypo-reflective space beneath both the neurosensory retina and the pigment epithelium layer . The late phase of fluorescein angiography revealed hyper fluorescence . On the basis of these findings, a diagnosis of CSC was made. As the patient lived thousands of miles from Shanghai and did not perceive obvious changes in her eyes, she declined follow-up visits to the hospital.
+One month later, her visual acuity deteriorated suddenly. On examination, her best corrected visual acuity in the left eye was 20/100. A sub-retinal hemorrhage, hard exudate and reddish-orange nodules were found on fundus photography . OCT demonstrated a pigment epithelium detachment and sub-retinal fluid . The late phase of fluorescein angiography revealed increased hyper-fluorescence compared to that observed one year previously . These characteristics led to the diagnosis of PCV.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1677_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1677_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..840648539858d40f753e1884621b0a7ec153c420
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1677_en.txt
@@ -0,0 +1,2 @@
+A 34-year-old Caucasian woman was referred to the department of dermatology for evaluation of recurrent and diffuse tinea corporis and recalcitrant crusted scabies. All studies of human subjects were approved by the Institutional Review Board of University Hospitals Case Medical Center (Cleveland, OH, USA) and the patient provided written informed consent. Earlier treatments included topical ketoconazole 2% cream, oxiconazole nitrate 1% cream, and permethrin 5% cream. The patient reported that her skin problems had been intermittent over the preceding 3 years. The medical history of this patient revealed end-stage renal disease requiring hemodialysis, obesity, non-insulin-dependent diabetes, hypertension, recurrent cellulitis, and methicillin-resistant Staphylococcus aureus bacteremia. Recently, prior to our consultation, she was diagnosed with bilateral cataracts and mild sensorineural hearing loss in one ear. Diabetes and hypertension were coincidentally diagnosed with nephrotic syndrome at age 29 during an acute illness, and she subsequently began hemodialysis. The patient had frequent admissions thereafter for dialysis catheter site cellulitis and methicillin-resistant S. aureus bacteremia secondary to catheter line infections. The patient has lived with her maternal grandmother since birth and was reportedly in good health until age 29 with no evidence of childhood infections other than the infrequent “cold”. The patient had no known siblings and the father was unknown to the family; the mother reportedly suffered from chronic pain related to an injury and died from a prescription narcotic overdose at age 29. There was no evidence of birth defects or immunodeficiency in the maternal family.
+Physical examination revealed a woman appearing much older than her chronological age would suggest. The patient exhibited coarse facial features with a prominent brow ridge, midface hypoplasia, prognathia, and slight down slanting of palpebral fissures . The skin examination was significant for thick, hyperkeratotic, white, and flaking plaques on the palms, soles, digits, and under the distal nails . Moist erosions and bright erythema along many of the proximal nail folds were noted. The nail plates appeared normal except distal onycholysis overlying the plaques. There were crusted papules and erosions diffusely scattered on the face, ears, trunk, and extremities consistent with excoriations. There was no evidence of active tinea at the time of the patient visit. Earlier mineral oil scrapings had revealed multiple live mites and exam was consistent with crusted scabies. A fungal culture from the nail fold grew unidentified, non-Candida yeast. It was recommended to the referring dermatologist that the patient continues topical antifungal treatment as needed and to begin oral ivermectin 0.2 mg/kg daily on days 1, 2, 8, 9, 15, 22, and 29. An undiagnosed immune syndrome with cutaneous-specific immunodeficiency was suspected, so we referred the patient to medical genetics for evaluation. The laboratory results and hospital admission notes from her community physician were reviewed. Importantly, the patient was HIV negative, had a normal serum protein electrophoresis interpretation, and was negative for antinuclear antibodies. Electrolyte panels were consistent with renal failure and routine dialysis, but no renal biopsy had been performed. Although the white blood cell count would fluctuate between admissions, the patient’s lymphocyte count was consistently within normal limits. The scabies infection resolved after 3 months using routine maintenance doses of ivermectin. The tinea corporis infection resolved using the daily application of topical antifungal creams.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1681_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1681_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..20bcfbe30f565dc4d614ffcff301852a0a799ba7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1681_en.txt
@@ -0,0 +1,3 @@
+A 39-year-old woman visited to our hospital complaining of worsened right low back pain and fever in 1 month before her first visit. She had experienced the occasional similar pain for several years and had an experience of pyelonephritis 10 years ago. Her initial laboratory data had no abnormal findings. Her urine test was clear, and her urine cytology was negative. Ultrasound imaging revealed right gross hydronephrosis. CECT also detected right gross hydronephrosis, but the right ureter was unclear . CECT was reconstructed to 3D imaging with Osirix® (Pixmeo SARL, Geneva, Swiss), imaging analysis software, which found out an aberrant blood vessel contacting with the right ureteropelvic junction . According to these examinations, UPJO was preoperatively diagnosed due to the aberrant blood vessel. Tc-99m MAG3 renal scan confirmed that the right kidney exhibited obstructive pattern and poor diuretic response (T1/2 of the left and right kidneys was 4.62 and 21.07 min, respectively) . The right kidney function was similarly preserved to the left kidney function (MAG3 clearance of the left and right kidneys was 184.9 and 163.7 ml/min/1.73 m2, respectively).
+Surgical treatment was indicated because of the symptomatic disease. Preoperative RP showed that the right ureter shifted inward compared with the normal position, which suggested the coexistence of the retrocaval ureter . RALP was conducted by a three-port transperitoneal approach, with putting port position more medial than usual to facilitate detachment around the right ureter . The swollen right renal pelvis and the aberrant blood vessel were identified . The right ureter was peeled downward and was confirmed to be positioned behind the IVC . The renal pelvis was dissected, and the ureter was repositioned anterior to the IVC. After removing the strictured ureteropelvic junction, the ureter and the renal pelvis were spatulated, inserted with 6-Fr double-J stent, and reanastomosed in a tension-free fashion by interrupted suture technique with 5-0 sutures; 10-Fr BLAKE Silicon drain was put into the anastomosis place. Blood loss was uncountable. The operation time was 403 min, and the robot console time was 301 min. We represent edited surgical video in Video .
+The urethral catheter and the drain were removed 5 and 6 days after surgery, respectively. No perioperative adverse events were found. The double-J stent was removed 2 months after surgery. No recurrence of the symptoms was observed, and her right hydronephrosis improved in 2 years after surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1702_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1702_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2e3c0245f923ff2416dc9ddb34a08dfa4006a5e7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1702_en.txt
@@ -0,0 +1,3 @@
+We report a 79-year-old Caucasian man with a history of dementia, ischemic heart disease, diabetes mellitus, hypertension and cerebrovascular accident. He was admitted to our department with yellowish discoloration of urine, skin and eyes, which had developed over the past few days. On physical examination, the patient was jaundiced and afebrile, with normal vital signs. There were no abdominal findings on clinical examination, and there were no clinical features of sepsis upon presentation. His laboratory investigations revealed serum total bilirubin 10 mg/dL, direct bilirubin 7.4 mg/dL, alkaline phosphatase 405 u/L, gamma-glutamyltransferase 223 u/L, aspartate transaminase 75 u/L and alanine transaminase 95 u/L. His inflammatory markers were within normal limits.
+Abdominal ultrasonography showed a slightly thickened gallbladder, multiple gallbladder stones, dilated intrahepatic bile ducts and extrahepatic bile extending to 1.1 cm. A computed tomography (CT) scan of the abdomen and pelvis following oral and intravenous contrast administration demonstrated a stone in the common bile duct (CBD), which caused dilation of the biliary ducts. A diagnosis of obstructive jaundice secondary to choledocholithiasis was made, and the patient proceeded to an ERCP, sphincterotomy and stone extraction. After improvements in the patient’s clinical and laboratory conditions, and considering his comorbidities, a decision was made to avoid surgical intervention (cholecystectomy) and to provide symptomatic treatment only at this stage.
+Four days following discharge, the patient was readmitted with jaundice, abdominal pain, vomiting and a fever of 38.3 °C. A diagnosis of ascending cholangitis was made and the patient was treated initially with antibiotics. A second ERCP was performed, which revealed a dilated CBD and choledocholithiasis . An initial attempt of stone removal with a basket failed, and a mechanical lithotripsy to release the basket also failed. Finally, the wires of the basket were ruptured and stacked in the CBD together with the stone. Therefore, a decision for surgical treatment was made, and the patient was transferred to the operating room. During exploratory laparotomy , adhesiolysis, a Kocher maneuver of the duodenum and a subtotal cholecystectomy were performed. Choledochotomy was done to directly remove the impacted wires together with the stone, but without success. Therefore, a duodenotomy and an extension of the sphincterotomy were performed to remove the impacted wires and the stone in the CBD . By means of a high-pressure lavage of the CBD, additional small biliary stones were removed. The choledochotomy and duodenotomy were closed by one-layer suture, and a prophylactic gastroenterostomy was performed as a protection, to prevent leakage from the CBD and the duodenum. The postoperative course was satisfactory; the patient recovered well from the surgery, and was discharged at 7 days postoperative. A 6-month follow-up was satisfactory without complications.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1711_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1711_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8f55d2ede0e60772cba81b9ef744fd99bc75ee57
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1711_en.txt
@@ -0,0 +1,3 @@
+A self-sponsored (that is, uninsured) 36-year-old man diagnosed with chronic-phase (CP) CML (Sokal score 1.22 [low risk <0.8, high risk >1.2] and Hasford score 1158.6 [low risk <780, moderate 780 to 1480, high risk >1480]) had received imatinib 400 mg per day since the beginning of January 2004. After approximately 10 months of therapy, full hematologic and cytogenetic remission, then major molecular remission had been achieved with a %BCR-ABL/ABL International Scale (IS) score of about 0.01 compared to an initial value of 9. This status had been maintained for approximately three years. In January 2007, his BCR-ABL scored negative by nested RT-PCR.
+Subsequently, the patient sought medical insurance and was switched by the insurer to the copy product imatib, at the same dose of 400 mg per day. In March 2007, after approximately three months of therapy with the 'copy' imatib, and despite a claimed compliance to the prescribed regimen, substantial hematologic changes were noted in the form of anemia (hemoglobin 9 g/dL), neutropenia (WBC 2300/mm3 with an absolute neutrophil count (ANC) of below 1000), thrombocytopenia (platelets 101,000/mm3) and loss of cytogenetic and molecular responses. Cytogenetic and molecular assessments demonstrated a 'positive' Philadelphia chromosome (22% Ph+ cells) and a %BCR-ABL/ABL ratio of 3, consistent with a disease relapse and a probable hematological toxicity to the agent. The spleen was still impalpable and the Sokal score was 1.16. Tests for tyrosine kinase mutations were not performed.
+In May 2007, the patient resumed imatinib at a daily dose of 600 mg per day. In July 2007, after approximately two months of therapy with imatinib, laboratory values revealed a return to a full hematologic and cytogenetic response and in November 2007, after six months of therapy, the patient achieved a %BCR-ABL/ABL score of 0.01. Changes in hematologic laboratory parameters at baseline, following the change to the copy product with a loss of response and subsequent return to treatment with imatinib and reinstatement of response, are summarized in Table .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1718_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1718_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f35e958acf64996b5eb9705adfc47974c284cfbd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1718_en.txt
@@ -0,0 +1,2 @@
+A 12-day-old female neonate with a cleft lip and alveolus was referred from the Department of Plastic Surgery for the feeding management and presurgical molding of the cleft lip and alveolus. The patient's parents reported difficulty in feeding and escapement of fluid through the nose. Detailed paternal and maternal family history was traced till the second generation but no significant finding was observed. There was no history of maternal infection or trauma during the conception period till birth.
+Extraoral examinations revealed a bilateral cleft of the upper lip with a complete cleft of the right alveolus ( to ). Radiographic examination was done using radiovisography, and a significant cleft was observed on the right paramedian area . Diagnosis of Veau's classification type III cleft of lip and alveolus was arrived. After discussion with the plastic surgeon, PNAM was planned using the Grayson method with a palatal plate accompanied by an approximation of extraoral soft tissue with taping and nasal stent. The surgical phase was planned at 4 months.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_171_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_171_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8f03adbc9b2db88bc7eea8a8afcc5ce76e2d595f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_171_en.txt
@@ -0,0 +1,5 @@
+A 44-year-old Asian man was admitted to our hospital complaining of sensory disturbances in his four extremities and trunk, as well as weakness of his upper extremities, and clumsy hand and gait disturbances. He had an unremarkable childhood, but developed tics and was diagnosed with Tourette’s syndrome at age 24. At the age of 33, he noticed numbness in his right hand, which gradually worsened. He visited a hospital for his symptoms and was diagnosed with compression myelopathy at the C3-C4 and C5-C6 levels. At the age of 38, he underwent anterior discectomy and spinal fusion with ceramics at the C3-C4 and C5-C6 levels. Two weeks later, our patient underwent an iliac bone graft at the C3-C4 and C5-C6 levels because of displacement of the ceramics. Postoperatively, he was immobilized in a halo vest for 2.5 months. After the second surgery, his spinal fusion was successful and his neurological symptoms improved. However, 5.5 years after the second surgery, he began experiencing numbness in his left leg after sustaining a fall. Subsequent to that, he presented with weakness of his right leg. He was once again diagnosed with compression myelopathy that developed at the sandwiched (C4-C5) disc level, and he underwent a C4-C5 anterior discectomy and spinal fusion at the same hospital. After the third surgery, his symptoms were temporarily relieved, but recurred 3.5 months later (one month prior to his visit to our clinic).
+On admission to our hospital, our patient was able to walk independently but his gait was slow and unsteady. His muscle strength in the lower limbs was normal, but his deltoid, biceps and triceps muscles were somewhat weak bilaterally. His pinprick sensation was reduced up to the level of the C6 dermatome. Hyperreflexia was present at his bilateral patellar and Achilles tendons, and patellar and ankle clonus were transiently positive bilaterally. His Babinski sign was present, and his bladder function was slightly disturbed. A myelogram showed pseudoarthrosis of the C4-C5 fusion and anterior compression of the dural tube at the C4-C5 level . A computed tomographic (CT) myelogram and a magnetic resonance (MR) image showed spinal canal stenosis at the C4-C5 level .
+Our patient was prepared for surgical treatment, which was initially planned as a posterior fusion and an anterior decompression and interbody fusion with electrophysiological monitoring of spinal cord activity. We first performed posterior fusion of C3-C7 using Bohlman’s triple-wire technique, which was uneventful. Next, we performed anterior corpectomy of C4, C5 and C6, and spinal fusion at C3-C7 with a strut graft using autologous iliac bone .
+Postoperatively, our patient was fitted with a halo vest for the first three months and a cervical collar for another three months. After application of the halo vest his tics worsened, possibly due to the discomfort he felt by the immobilization of his neck, and the pins became loose several times. We had to regulate the torque of the pins every day, and replaced them four times. We treated his tics with haloperidol and his involuntary neck movements were slightly reduced. However, we could not increase the dose because of drowsiness. Botulinum toxin was not used for treating such a patient in our hospital at that time. A midsagittal CT reconstruction three months after surgery showed a mature fusion mass . A T2-weighted MR image one year after surgery revealed that his spinal cord was well decompressed . A lateral cervical radiogram taken six years after surgery showed successful interbody fusion, and a T2-weighted MR image taken at the same time detected only slight degeneration of the adjacent discs of the fusion site .
+Our patient’s neurological deficits gradually recovered after surgery. His clumsy hand movements disappeared four months after surgery, and at his last follow-up examination, 10 years after the surgery, he was able to perform all activities of daily living.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1722_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1722_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bea76df6049bfcb56fc08981c2e1207f73c03f13
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1722_en.txt
@@ -0,0 +1,5 @@
+A 10-month-old child, assigned as female at birth, resident in the countryside of the Northeast region of Brazil, was referred to our team for genetic assessment due to genital ambiguity late recognized. Pregnancy and delivery were uneventful. Parents reported a clitoris enlargement and gonadal descent when the child was 30 days old, at the end of minipuberty. Afterward, they decided to rear him as a boy despite the maintenance of female legal sex. The patient is the second child in a consanguineous marriage (double first cousins once removed), with no recurrence in the family .
+Upon physical examination there was a phallus measuring 25 mm × 10 mm, palpable gonads at labioscrotal folds (1 cm3 left-sided and 0.5 cm3 right-sided), and an urogenital sinus with a perineal opening . As these clinical findings indicate male prenatal under- instead of female hyper- virilization we assumed that Quigley type 4 was the best classification for the ambiguous genitalia. The karyotype of peripheral lymphocytes was 46,XY. Basal FSH and LH levels were normal (1.32 mUl/mL and 0.34 mUI/mL, respectively) while those for testosterone were low (< 8 ng/dL). Abdominal ultrasound showed no Mullerian derivative structures.
+The etiologic investigation included androgen receptor (RA – OMIM * 313700), steroid 5α-reductase 2 (SRD5A2 – OMIM * 607306), nuclear receptor subfamily 5 group A member 1 (NR5A1– OMIM * 184757), and HSD17B3 genes sequencing and predictive analyzes (Additional file ).
+Sequencing studies showed a novel homozygous c.785G > T nucleotide change in exon 10 of the HSD17B3 gene (Additional file ), which was inherited from both heterozygous parents. The c.785G > T substitution leads to the replacement of glycine by valine in residue 262 (p.Gly262Val).
+Glycine 262 is a highly conserved residue (Additional file ) and the comparison between them did not reveal changes on the protein internal contacts (Additional file ). Four out of six predictive analyzes were compatible with a damaging missense variant and indicated that valine 262 destabilizes the protein structure (Additional file ).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1724_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1724_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9c7f1644c9e138b7d445510b9303fded7dcb6fce
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1724_en.txt
@@ -0,0 +1,6 @@
+On April 1, 2020, a 47-year-old man, suffering from psoriasis, visited our clinic. The patient had inflammation on the fingers, the backs of the hands, both wrists, and both ears. Erythema was widely spread on both hands, all fingers, and both wrists. Erythema was also found on the inside of the auricle and on the lower part of the earlobe . Also, he complained of itchiness.
+He had been diagnosed with psoriasis in 1995. Subsequently, over the next 25 years, he had received herbal treatment, dermatological laser treatment, and drug treatment.
+The patient has been no specific disease excepted psoriasis.
+The patient had no diseases personal and family histories.
+When the patient visited the hospital, the lesion area was spread over several parts of the body.
+The severity of psoriasis was evaluated using the PASI and DLQI at the time of the patient’s visit. The PASI and DLQI scores were 9.9 and 27, respectively.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1766_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1766_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f2d64f406cd3e5cdd68630e57b11803883ee63e4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1766_en.txt
@@ -0,0 +1,16 @@
+A 31-year old male patient admitted to the Tropical and Parasitic Disease Department of Poznań University of Medical Sciences, Poland, because of the presence of a tumor-like lesion within the liver. The patient had been living in a small village surrounded by forests in which a big foxes population has been detected.
+Prior to the admission the patient had suffered from influenza like syndromes, pain in the right subcostal region and suddenly joidance.
+He was admitted to the local Surgery Department with suspicion of biliary tract pathology. CT scan gave the evidence of irregular mass with disseminated calcifications. He was diagnosed undifferentiated hepatitis with cholestasis.
+Because of atypical radiology results suspicion of Echinococus infection was done. ELISA serology test was positive (2.9 Units; positive above 1.0). The patient was moved to the Tropical and Parasitic Clinic in Poznań for further investigations.
+On admission day the physical examination was unremarkable. Blood tests showed elevated levels of bilirubine (2 mg%), alkaline phosphatase (172-248 U/l) gamma glutamylo trans peptidase- GGTP (135-262 U/l).
+USG of the abdominal cavity revealed presence of a huge calcified lesion in the VII-th liver segment with the diameter of 12.3 × 2.8 cm and in the II-nd liver segment a solid hyperechogenic focus with calcifications inside as well as disseminated calcifications in the interhepatic biliary tracts neighborhood. MRI showed the liver enlargement, with irregular tissue. In the VII, VI and V segments polycyclic fluid lesion and disseminated inside the right lobe smaller fluid foci as well as biliary tract widening .
+According to the picturesque data suspicion of alvecococcosis was done.
+ELISA test (Echinococcus IgG) was positive – 50 NTU (positive above 11NTU) and confirmed with positive Western-blot which revealed presence of specific for Echinococcus multilocularis IgG (7,16,18, 26–28 kDa). ELISA EM2-plus (anty-E.multilocularis) was also high positive (> 3.0ABS). The patient was finally diagnosed the liver alveococcosis with P2M0N0 stage.
+When the diagnosis was established the albendazol therapy (2x400mg/day) was initiated together with ursodeoksycholic acid (2x250mg/day) in order to lowered bilirubine level and protect from apoptosis healthy liver tissue . The patient was qualified to the surgery treatment and was moved to the General and Transplant Surgery Department, Poznan University of Medical Sciences. MELD score of the patient was 10 (creatinine 1.13 mg/dl; bilirubin 1,12 mg/dl, INR 1,15, not dialysed).
+The right hepatectomy was performed. Access to the liver was achieved by bilateral subcostal incision and then mobilizing the liver from its ligamentous attachments, including the coronary ligament, and left and right triangular ligaments, then anatomic resection of the fifth, sixth, seventh and eighth liver segments was performed. Right portal vein, right hepatic artery and right hepatic duct was ligated and cutted. In addition, visible cysts were removed from the left lobe of the liver in nonanatomical resection and suspicious calcified lesions in hepatoduodenal ligament were also removed . Postoperative course complicated by lymphorrhea, conservative treatment was initiated, obtaining improvement. In ultrasound on the 8th postoperative day, spleen enlargement occurs (141x55mm).
+The histopathology examination of the all 3 speciments revealed presence of chronic inflammatory changes with thick wall calcified granulomas and accelular homogeny infiltrates with necrosis cavities.
+Additionally, the biological material after surgery was used for molecular genotyping of Echinococcus sp. For this reason, the DNA was extracted from the removed liver tissue with lesions, using the commercially available kit (NucleoSpin Tissue, Macherey Nagel, Dueren, Germany). Next, the isolated DNA was used as a template in the PCR with Echinococcus sp. 12S rRNA-specific primers (EM-H15 and EM-H17), according to Stieger et al. (2007) . Moreover, as a control of DNA quality and presence of PCR inhibitors, we used isolated genetic material to amplify human GAPDH, according to Xiang et al. (2012) . Finally, the PCR product was sequenced and the obtained sequences were aligned using BioEdit software.
+Based on the PCR reactions with Echinococcus-specific primers, we confirmed that the patient was infected with Echinococcus sp. . Further sequence analysis revealed the complete similarity with Echinococcus multilocularis 12S rRNA , suggesting that the clinical outcome and after surgery complications were not correlated with parasite genotype and potential more pathogenic Echinococcus multilocularis strain.
+After the operation albendazol treeatmet was continued. With no other major or minor complication patient with normal level of bilirubin, alanine transaminase and aspartate transaminase was discharge on 17th postoperative day.
+The patient’s follow –up, performed 10 months after the operation gave the evidence of thrombocytopenia (80G/l), leucopenia (3.1G/l) and syderopenic anemia. MR of the abdomen cavity showed presence of numerous hypodensic partially calcified lesions within the remaining liver segments. Moreover critical portal vein constriction (the diameter 3-4 mm), collateral venous circulation in the liver hil were detected. The examination revealed also splenomegaly as a result of the portal hypertension . Performed endoscopy of upper gastrointestinal tract revealed presence of first degree varices oesophagi as well as gastritis and duodenitis.
+Recently, patient had control MRI (06.03.2020) and there are no active outbreaks of alveococosis in the liver parenchyma, compared to previous studies, the image is stable. Collateral vessels are visible in the liver cavity. The spleen is enlarged, by a maximum length of about 16 cm (before operation spleen length was 14 cm). Patient is clinically asymptomatic. But he still requires regular, every 6 months follow-up in the Tropical and Parasitic Clinic.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1769_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1769_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9dfb32aa8597bb39e0770eda62b3eda63b18fccb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1769_en.txt
@@ -0,0 +1 @@
+Our patient was a little girl one month old who came at our service from neonatology. This girl was the third child of healthy Albanian parents, without history of consanguinity. During the pregnancy the mother had presented oligohygramnios. The baby had a birth weight 2500g. She was born at term but she was small for gestational age. APGARE score was 8/10. She was discharged at day three but she was admitted in neonatology at age of 20 days because of jaundice, weight loss, feeding problems, failure to thrive and contractures of lower limbs . At age of one month she was transferred at our service of gastrohepatology because of cholestasis. In this moment the girl weight was 2350 g. We decided to feed her by nasogastric tube. The first results of blood analyses had shown cholestasis ( direct bilirubine=5,2 U/L; total bilirubine =8,9U/L; ALT=85U/l;AST=66U/L; GGT=30U/L). Abdominal echography has shown important ascites . We had performed a blood transfusion because of severe anemia. In consultation with our neurologist and geneticist the contractures of lower limbs are interpreted as talipes calcaneovalgus . The recent urinary analyses had shown glucosuria ,urinary ph was basic, aminoaciduria. We found also hyperchloremia and low bicarbonate. This combination of arthrogryposis , cholestasis and renal dysfunction make us to think about ARC syndrome. At the same time we have excluded the most part of pathologies that presents cholestasis like cystic fibrosis,TORCH, a1 antitripsine deficiency, endocrinopathy, Allagille syndrome,some metabolic disorders. Cranial computed tomography was unremarkable. We didn’t perform a liver biopsy because of an abnormal prothrombine time. Approximately one month later the girl presented a severe ichtyosis and recurrent febrile episodes despite antibiotic therapy. We have expected that this child will present diarrhea but she presented a severe form of constipation. We treated her with several enema but constipation has persisted .Other part of treatment were ursofalk, vitamine A,D,E,K , sodium bicarbonate and antibiotics. Unfortunately she died at age of three months of septicemia. Permission for autopsy was refused. Three weeks later we had a response of molecular biology that was sent abroad which confirms VPS33B mutation
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1782_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1782_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e067e1b6d517159afac97410e886ca6630059204
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1782_en.txt
@@ -0,0 +1,4 @@
+A 38-year-old Caucasian man was seen in the emergency department following a referral by his general practitioner, as there were concerns from his family that he was voicing bizarre ideas. He complained of feeling increasingly stressed, anxious and paranoid and he was having flashbacks of fictional events from his past. He described visualizing these events as if they were being played in a movie. He had beliefs that many people from his local community were involved in a conspiracy against him and he was being provoked by other people to get into fights. He also had beliefs that he was being followed and watched, and he elaborated that he could feel the presence of evil and evil things being passed onto him by other people.
+He had no past psychiatric history and there was no family history of any mental health related problems. He had experimented with recreational drugs such as cocaine and ecstasy in the past but he denied any use of recreational drugs in the last 2 years. He worked as a successful self-employed businessman. His symptoms, particularly the persecutory delusions and delusional memory, worsened and he was admitted to the local psychiatric hospital.
+His physical and neurological examination was unremarkable, and blood tests including urea and electrolytes, liver function tests and thyroid function tests were normal. An electroencephalogram (EEG) was inconclusive of any seizure activity and a computed tomography (CT) scan of his brain revealed a lacunar infarct of the putamen region in the left basal ganglia. A detailed history of any cardiovascular incidents was explored and he gave a history of severe crushing chest pain 6 months before presentation. He did not seek medical attention, the pain did not recur, and there were no cardiological or neurological sequels. An electrocardiogram and echocardiogram showed no compromise of cardiac functions.
+The lacunar infarct was treated conservatively and he was commenced on an atypical anti-psychotic medication, aripiprazole, and his psychotic symptoms gradually improved over the following weeks. He tolerated aripiprazole quite well and did not experience any extrapyramidal or significant side effects to the medication. His insight into his delusional beliefs improved and he was able to rationalise them. Following 3 weeks of hospitalization, his symptoms had improved and he was successfully discharged with community follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1785_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1785_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..399e35e16b1c4fcc8590c5b86d7826da41d1c5c0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1785_en.txt
@@ -0,0 +1,3 @@
+A 16-year-old male with acute lymphoblastic leukemia (ALL) was admitted to our hospital because an echocardiographic examination revealed a ring-like structure in the right atrium that had been present for 6 months and there was no change of the ring-like structure after 6-month aspirin anti-coagulation therapy. Two years previously, the child had been diagnosed with ALL and a PICC had been placed for intravenous access during treatment in the general medical ward for chemotherapy and parenteral nutrition in a children’s hospital. The PICC remained intact and was successfully retrieved after 18 months of chemotherapy. A regular transthoracic echocardiography (TTE) examination revealed a large, mobile, ring-like mass originating from the free wall of the right atrium that measured 15 × 20 mm . The child was asymptomatic and the physical examination was also negative. When he presented to our hospital for a definite diagnosis, cardiac CT and radiography was performed to confirm the diagnosis.
+Cardiac computed tomography revealed a calcified mass with a diameter of about 15 mm in the right atrium close to the inferior vena cava . Radiography confirmed the diagnosis and showed the absence of a PICC distal catheter in the right atrium and also that the mass was mobile . Given the large size of the mass, interventional radiology was used as part of a multidisciplinary approach to determine the optimal removal strategy. It was finally decided to remove the mass surgically.
+The patient was operated on using cardiopulmonary bypass, with aortic and bicaval cannulation performed in the standard manner. The right atrium was opened and a large, solid, ring-like mass was found to be eroding into the orifice of the inferior vena cava (IVC) . After the mass was removed, it was cut open, showing a 2 mm pinhole in the middle, indicating that it had formed by initial calcification around the tip of the PICC which progressed after the retrieval of the PICC.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1786_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1786_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..afe025d70c071ff97cbf4fc9e38038d1f773e119
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1786_en.txt
@@ -0,0 +1,3 @@
+An eighty four-year old male visited the outpatient clinic complaining of a painful mass that had been present on his left thigh for 3 years. He was medically healthy and did not have a previous medical or familial history of malignancy. There was no clinical sign of neurofibromatosis. He had twice undergone excisional biopsies (18 and 3 years ago) of the mass at the same location under the presumed diagnosis of lipoma. Preoperative magnetic resonance imaging revealed an approximately 17.5 × 16.4 × 30.2 cm sized, extensive, lobulated heterogeneous mass with T2 high, T1 high signal intensity involving the left thigh. A wide local excision was performed. Gross pathology of the tumor showed a well circumscribed tumor mass with internal multi-lobulated areas . Multiple lung and pleural metastases were diagnosed via chest computed tomography . Histological findings showed dedifferentiated areas with spindle cells without a lipomatous portion and less dedifferentiated areas consisting of round cells with lipomatous portions, along with infiltrated polymorphonuclear cells . Based on these clinical and pathological findings, the mass was diagnosed as DDLPS. The patient died 2 months following surgery.
+A DDLPS frozen tissue was obtained from the biobank of Seoul St. Mary Hospital (Seoul, Republic of Korea). Genomic DNA was extracted by microdissection of tumor cell rich area (> 70% of tumor cell purity) and whole blood of the patient using the DNeasy Blood & Tissue Kit (Qiagen, Hilden, Germany). WES was performed using the Agilent SureSelect Human All Exome 50 Mb Kit (Agilent Technologies, Santa Clara, CA) and Illumina HiSeq 2500 platform (Illumina, San Diego, CA). Data pre-processing was done using the best practices workflows of The Genome Analysis toolkit (GATK, v4.1.1) to align the sequence reads with the human reference genome (UCSC hg19) and local realignments with base recalibration, and to identify somatic mutations. The web ANNOVAR package was used to select somatic mutations located in the exonic sequences and to predict their functional consequences . In order to obtain reliable and robust mutation calling, the following variants were eliminated: (i) read depth fewer than 20 in either the tumor or matched constitutional tissues; (ii) polymorphisms listed in the population databases of East Asians with a minor allele frequency 0.1% or more; and (iii) variant allele frequencies less than 5%. Catalogue of Somatic Mutations in Cancer (COSMIC) mutation signatures were obtained via a Mutalisk package using known mutation signatures of soft-tissue sarcoma (signature 1, 2, 5, and 13). To define CNAs, we used the ngCGH module and SNPRank Segmentation statistical algorithm in NEXUS software 9.0 (Biodiscovery, El Segundo, CA). Segments were classified as gains or losses when the log2 ratio was greater than 0.25 or less than − 0.25, respectively. Amplification was defined as a log2 ratio greater than 1.0.
+The average sequencing depths for tumor and constitutional DNA were 218X and 223X, respectively . A total of 36 non-silent mutations were identified in the exonic area , which corresponded to a mutation rate of 0.73 per Mb. The NF1 stop gain mutation (c.7486C > T, p.Arg2496*, variant allele frequency 15.7%) was identified among the cancer-related genes listed in the Cancer Gene Census of COSMIC database . This variant was classified as ‘pathogenic’ in ClinVar DB (RCV000218957.1), and not reported in population level variant databases. There is no germline variant classified as ‘pathogenic’ or ‘likely pathogenic’ in ClinVar DB. Thirty-five regions affected by CNAs were found, which correspond to 2% of the genome, including amplifications on 12q13–15, which included known genes associated with DDLPS pathogenesis, such as DDIT3, CDK4, MDM2, YEATS4, and FRS [, –] . In addition to 12q13–15 amplifications, copy gains or amplifications on 1q32, 5p13, 7p22, 8q11–12, 9q31, 12q15–21, 14q12, 19p12–13, and 20q12–13 as well as copy losses on 2p11, 4p11-4q11, 7p21-p14, and 20q13.2 were observed. Several potential cancer-related genes, such as MDM4, ELK4, SLC45A3, RAC1, KLF4, MAFB, TOP1, PLCG1, and PTPRT, were located in the copy gain/amplification regions . Chromothripsis events were also observed in 7p, 9q, and 20q . In a mutational context, C > T mutations were predominant and signature decomposition analysis indicated predominant signatures 1 and 5 (clock-like mutational process) followed by a minor proportion of signatures 2 and 13 (APOBEC-related), which was consistent with the results of a TCGA study on DDLPS .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1788_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1788_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..adc350543f8182ab99e2f2378afcb83955452db1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1788_en.txt
@@ -0,0 +1,8 @@
+The 54 year old Caucasian woman, who came to our clinic for the first time in September 2006, complained of pain, loss of function and weakness in her right shoulder. She had suffered from these symptoms for years. Conservative treatment by analgesics and physiotherapy showed little or no benefit. Her main reason for coming to our hospital was an increasing loss of function of her right shoulder. In addition she reported several unexplained falls but no feeling of waddling gait and hypotonia. She had osteoporotic vertebral compression fractures at thoracic level 5 and 6. The corresponding thoracic gibbus was compensated by hyperlordosis of the lumbar spine. After a traffic accident in 2004, she was treated conservatively for a fracture of the right scapula and the sternum. She sometimes felt dysaesthesia in both hands. She casually referred to progressive muscle atrophy in both shoulders and upper arms, which other doctors had assigned to previous trauma and inactivity. The familiar anamnesis of her two sons was negative, without signs of neurological or systemic diseases. There was no intellectual impairment or facial weakness.
+The patient's clinical examination showed no signs of cardiac or pulmonary impairment. There was a frozen right shoulder, a pronounced isolated limb-muscle atrophy of the delta- und biceps-muscle on both sides and a rotator cuff tear of the supraspinatus and infraspinatus muscle on the right side , and . There were no signs of muscle impairment in the hip or thigh. The clinical neurological examination revealed a normal result. Walking analysis showed no waddling gait.
+In view of the pronounced muscle atrophy of both shoulders, that was progressive over years, despite physiotherapy, a myopathy was suspected although it seemed unlikely in a middle-aged patient.
+Contrary to the expected high increase of the level of serum creatinkinasis, the level of serum creatinkinasis was only slightly above normal (186 U/l). The exact pattern of muscle atrophy was detected by a MRI of both shoulders which showed a fatty muscular atrophy of the delta- und biceps-muscle on both sides and a rotator cuff tear on the right.
+Despite the slightly increased serum creatinkinasis and the symmetric atrophy of identical muscles pointing to a muscular dystrophy of the limb girdle type , the diagnosis needed further examination using light microscopy and immunohistochemistry of affected muscles. Therefore we performed an incision biopsy of the right delta- and biceps-muscle to ensure diagnosis. The different samples were kept in formaline, in kryo-fixation, and before being embedded in plastic, in glutaraldehyde.
+The results of the immuno-histological analysis matched a chronical myopathy with related endo-, peri- and epimysial fibrosis. Trauma and inflammation were excluded as causes.
+Further analysis (western blot) revealed an abnormal and reduced laminin α2 chain and an abnormal reduced α-dystroglycan. These findings allow a diagnosis of LGMD2I, where a secondary reduction of laminin-a2 on immunolabelling was detected in most cases and a reduction in α-dystroglycan may also be seen.
+We discussed treatment options with the patient. Beside a conservative treatment with muscle training a cortisone therapy was recommended to prevent or slow down further progression. The patient refused a cortisone treatment due to the risk of adverse effects.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1800_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1800_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ffc8841da1fe553bbdcdb2ddd15a425d47fcfbf3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1800_en.txt
@@ -0,0 +1,5 @@
+JLLP, a 49-year-old man, industrial worker, resident in Manaus, Amazonas, Brazil, was admitted to the emergency at Hospital Adventista de Manaus (HAM). The patient showed skin rash, pruritus, arthralgia, headache, myalgia, bilateral conjunctivitis, fever (38.5 °C) and hypertensive crisis with blood pressure (BP) of 240/120 mmHg, but heart rate and cardiac auscultation were normal. The patient had no travel history and described the appearance of symptoms 3 days before seeking medical attention. Besides, the patient reported the absence of hypertensive episodes or any other cardiac disorder in the past.
+Immediately, the treatment for the hypertensive crisis was initiated with sodium nitroprusside (250 ml glycated serum 5% + Nipride – 1 ampoule = 2 ml) administered 5 ml/h by continuous infusion. In the following two, three and 4 hours it was administered 7 ml, 10 ml and 15 ml of sodium nitroprusside, respectively, but the blood pressure was still elevated. No abnormalities in electrocardiogram (ECG) and chest radiography (CR) were observed.
+The patient was still refractory to blood pressure control (BP 238/120 mmHg) 4 hours after starting treatment, and showed elevated blood glucose levels (250 mg/dL), therefore, he was transferred to the Intensive Care Unit (ICU). Suddenly, the patient suffered a cardiac arrhythmia (atrial fibrillation - AF) which was chemically reversed with an attack dose of two ampoules (6 ml) of intravenous amiodarone hydrochloride (50 mg/ml). For the maintenance dose, six ampoules of amiodarone (8 ml/h) were administered in 5% glycated serum (250 ml) by continuous infusion for 12 h.
+Due to the symptoms presented at the time of attendance, and the ongoing Zika outbreak in course, the patient and his wife, an asymptomatic contact, were inserted into the protocol for ZIKV surveillance. Both had samples of blood, urine, and saliva collected for arboviral testing by the reverse transcription real-time polymerase chain reaction (RT-qPCR).
+On the sixth day of hospitalization, the patient underwent magnetic resonance imaging (MRI); echocardiographic doppler (DE) and coronary angiography (CA). Only the MRI was altered with bilateral supratentorial microangiopathic gliosis. A second ECG was performed on the eighth day of hospitalization, which presented no alterations and the patient was discharged. Serological tests for other infectious diseases were negative and the RT-qPCR results showed positivity for ZIKV in the saliva sample. Although still asymptomatic, his wife also tested positive for ZIKV in the serum sample.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1803_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1803_en.txt
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index 0000000000000000000000000000000000000000..6575e66cb05047c3ca1dbfbf952240676e2bc305
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1803_en.txt
@@ -0,0 +1,5 @@
+A 6 years-old male neutered pit bull terrier was presented for chronic infection and multiple draining tracts of the craniofacial region. The clients reported that the clinical signs including open wounds on the face, a foul odor from the mouth, and hyporexia that started approximately 3 years earlier. The dog was treated at various first opinion practices by means of sedated explorations of the extra- and intraoral lesions, where foreign plant material was retrieved on multiple occasions. A combination of primary closure and placement of Penrose drains was attempted, samples were collected for microbial culture tests, and analgesia and antimicrobial therapy based on culture results were prescribed. Over the course of 3 years, the following antimicrobials were prescribed: amoxicillin/clavulanate, ampicillin, amikacin, cefovecin, cephalexin, minocycline, and orbifloxacin. Due to the progressively worsening nature of the lesions, size, and invasion into deeper tissues after attempted repairs, the dog was referred.
+On presentation, the dog appeared clinically stable. A large (20 × 20 mm) draining tract overlying the bridge of the nose between the eyes was observed (i.e., affecting the frontal, nasal, and maxillary bones). There were four additional cutaneous draining tracts noted approximately 4 × 4 mm ventral to the left eye, to the lateral side of the right eye, between the eyes, and on the medial aspect of the right eye . An intraoral examination revealed an oronasal fistula extending from the right maxillary canine tooth to the right maxillary fourth premolar tooth . The right maxillary buccal frenulum remained intact. There was mucopurulent discharge and crusting surrounding the multiple draining tracts. There was bilateral mandibular lymphadenopathy. Incidental physical examination findings included cataracts with nuclear sclerosis, iris atrophy, heterochromia iridum, and anisocoria. The hematologic assessment revealed leukocytosis (14,900/μL; reference interval 6,000–13,000/μL) characterized by mild neutrophilia (11,507/μL; reference interval 3,000–10,500/μL). The serum biochemical values were within reference ranges. The dog underwent general anesthesia for conventional computed tomography (CT) (HiSpeed FX/i or LightSpeed16, GE Healthcare, Waukesha, WI) of the skull with and without contrast (880 mg/kg, IV, iopamidol). Computed tomographic findings included multifocal to coalescing lucent osseous lesions predominantly affecting the cortical bone of the right rostral maxilla (,). There was a resultant large draining tract affecting the nasal, frontal, and maxillary bones that communicated with the cutaneous surface . Differential diagnosis included a neoplastic process (i.e., squamous cell carcinoma, osteosarcoma, and round cell tumor) or an infectious etiology (i.e., coccidiomycosis, aspergillosis, and bacterial infection); a component of osteomyelitis associated with the nasal fistulae was anticipated. There was a mildly contrast-enhancing soft tissue structure in the right frontal sinus (which could reflect a neoplastic mass or granuloma). The right mandibular and medial retropharyngeal lymph nodes were enlarged (it was unknown whether they were reactive or metastatic). Finally, severe right temporomandibular joint osteoarthritis was observed, which may be secondary to prior trauma or infection of the joint. The CT was followed by rhinoscopy and was performed using a combination of intra- and extraoral (trans-fistulous) approaches. The findings confirmed most of the previously described osseous and soft tissue lesions noted on CT. No gross lesions consistent with fungal plaques were found. Following rhinoscopy, samples of the lesions were surgically harvested utilizing rongeurs and iris scissors for histopathological evaluation, as well as microbial and fungal testing. A Stent bandage was placed and kept in place for 3 days. The dog was discharged with analgesia (carprofen 2.2 mg/kg, PO, q12h and gabapentin 10 mg/kg, PO, q12h) and a broad-spectrum antimicrobial amoxicillin/clavulanate (13.75 mg/kg, PO, q12h).
+The biopsy sample submitted for histopathological evaluation consisted of exudate with crust and an osseous fragment associated with soft tissue . The bone tissue was a fragment of lamellar bone (mature bone) rimmed multifocally by woven bone (immature bone) . Multifocally resorption lacunae occupied by multinucleated osteoclasts were noted in the absence of osteoblasts, indicative of bone remodeling . Infection of the bone medullary cavities was not noted. The crust and exudate suspended large numbers of intact and degenerate neutrophils admixed with bacterial cocci colonies and birefringent foreign material resembling plant and pollen (–).
+Soft tissue associated with the bone fragment included loose fibrous connective tissue infiltrated by scattered lymphocytes and plasma cells and round clusters of lymphocytes (lymphofollicular hyperplasia). This fibrous connective tissue was lined by primarily pseudostratified columnar ciliated epithelium that was multifocally substituted by squamous epithelial lining, indicative of squamous metaplasia .
+The microbial culture and susceptibility results revealed the presence of multi-drug resistant coagulase-negative Staphylococcus spp., and therefore, the antimicrobial treatment was changed to enrofloxacin (10 mg/kg, PO, q12h) for 4 weeks, as it was identified as the susceptible antimicrobial of choice.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1804_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1804_en.txt
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index 0000000000000000000000000000000000000000..4299a31bd6e89e587127460c622c97a4cc4e0430
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1804_en.txt
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+Clinical history: A 22 year-old white man, born from a second degree consanguineous marriage and with a family history of kidney stones. The patient had recurrent kidney stones since the age of 6, progressing towards chronic renal failure. He is a chronic hemodialysis for 4 years with nephrocalcinosis. He was hospitalized for invalid bone pain, fatigue, and pallor progressing for 4 months. Physical examination shows no organomegaly and no adenopathy.
+Biological, radiologic and histopathologic findings:
+Complete blood count showed a normochromic and normocytic regenerative anemia with hemoglobin level of 7.6 g/dL. Remarkable serum biochemistry lab data included ferritin level of 1730 ng/mL. The phosphocalcic balance was normal. Given the patient’s history, the symptomatology and the anemia, two diagnoses were suggested: malignant hemopathy or primary hyperoxaluria. Urinary sediments examination in search of oxalate crystals were not performed due to anuria of our patient. The standard radiology of the hands, wrists and spine do not show any abnormality. An osteomedullary biopsy was performed in search of malignant hemopathy.
+The bone marrow biopsy measure 0.7 cm in length. Hematoxylin and eosin stain shows six bone chambers, massively invaded by grayish-colored oxalate crystals deposited in stars or rosettes surrounded by a brisk foreign body giant cell reaction . Special trichrome staining revealed a medullar fibrosis . Under polarized light, crystals of oxalate showed a very intense pale green birefringence .
+Given our context, no liver biopsy or genetic studies, which are gold standard of diagnosis testing, were done. Only plasma oxalate level was made, he showed level of 320 μg/dL. The diagnosis of primary hyperoxaluria was made based on the characteristic morphology of crystals, plasma oxalate levels, his medical and family history and the absence of any secondary cause of the condition.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1826_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1826_en.txt
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index 0000000000000000000000000000000000000000..6d40b037737d52ab2f5359e252e411970f3c5084
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1826_en.txt
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+A 33-year-old man complained of multisite pain for 6 h following waist trauma and was admitted to the hospital. He suffered multiple injuries from severe impact on the right rear of his waist after driving an out of control forklift truck. The patient presented with excruciating pain in the back, chest, and abdomen, and the muscle strength of both lower limbs was decreased (3/5 strength in the left lower limb and 2/5 strength in the right lower limb); both lower limb extremity paresthesias and urinary retention was observed. Immediately after the injury, the patient was sent to our hospital by ambulance for treatment and underwent x-ray and computed tomography (CT) scan ; the imaging examinations revealed the left 10th and 11th rib, bilateral transverse processes (L2–L5 levels), sacrum, and coccyx and right ilium fractures, and L5 vertebra and S1 vertebra dislocation and separation. A lumbosacral vertebra magnetic resonance imaging (MRI) revealed a complete rupture of the L5–S1 intervertebral disc; tear in anterior longitudinal ligament, posterior longitudinal ligament, ligamentum flavum, interspinous ligament, supraspinous ligament, and dural sac; and cerebrospinal fluid (CSF) seepage into the tissue space behind the lumbar spine . The patient was healthy previously and had no other diseases or syndromes. Traumatic lumbosacral spondyloptosis diagnosis was established. On admission, the patient was conscious, the blood pressure (BP) was 85/60 mmHg, and heart rate was 78 beats/min; intravenous rehydration therapy was immediately started because of a low BP and then the BP gradually returned to the normal level. The severity of the spinal injury was graded according to the American Spinal Injury Association (ASIA) grading scale, and the patient was classified as grade C. The visual analog scale (VAS) score was 9.
+The patient was sent to the operating room for surgical treatment 10 days after admission. During the operation, we found that the subcutaneous soft tissue and muscle behind the lumbar spine were seriously injured, the L5 vertebra were severely dislocated to the front-left side, the L5–S1 facet joint was fractured and dislocated, the bilateral inferior articular processes of L5 were locked and located anterior to the S1 vertebra , severe dural sac tear had occurred at the L5–S1 level, and only part of cauda equina and filum terminale are continuous; the L5–S1 intervertebral disc had ruptured and prolapsed into the spinal canal. Specific procedures were performed as follows. After successful anesthesia, the patient was placed in the prone position. In the surgical area, routine disinfection was carried out and laid with sterile sheets. A 20–25 cm incision was made at the midline of the back using the L4 spinous process as the center. The skin was cut parallel to the spine, then the lumbodorsal fascia was stripped and the paravertebral muscle was bluntly stripped to completely expose the spinous process and bilateral vertebral plate of L3–S2 vertebrae, and the spinous process of L5–S1 vertebrae was removed. Pilot holes for pedicle screws placement from L3 through S1 and also for the S2 alar-iliac (S2AI) screws entry site were marked; bilateral L3, L4, L5, and S1 pedicle screws of appropriate length were then inserted, and dual S2AI screws placement bilaterally were performed. A pre-bent short titanium rod was temporarily installed to distract L5–S1 intervertebral space. We found that the bilateral inferior articular processes of L5 was still dislocated in front of the S1 vertebra after C-arm fluoroscopy, and it is particularly difficult to perform the reduction with a screw distractor; so we decided to resect bilateral inferior articular processes of L5 with the assistance of the ultrasonic bone scalpel . Reduction was attempted again, and the spinal column getting back into normal alignment was observed after C-arm fluoroscopy . Then, bilateral laminectomies, facetectomies, decompression of the cauda equina, and discectomy of L5–S1 were performed. Interbody bone graft fusion was performed by implanting an interbody fusion cage filled with bone morphogenetic protein (BMP) and local bone at the L5/S1 level. Finally, the dura with artificial dura mater were repaired. Bilateral lumbar drainage tubes were placed at the end of procedures. The operative procedure was about 3 h and intraoperative blood loss was about 800 ml.
+After the surgical operation was completed, the patient was transferred to the postanesthesia care unit and then to the orthopedics wards. We found the patient had CSF leakage on the first postoperative day and presented with mild headaches and light-headedness. The patient's low back pain and numbness of both lower limbs were effectively improved; however, the muscle strength of both lower limbs did not significantly improve. The VAS back pain decreased from 9 preoperatively to 4 postoperatively. The ASIA grade remained in grade C after surgery. The right lumbar drainage tube and the Foley catheter were removed on the third postoperative day, and then the left lumbar drainage tube was removed and the skin was closed using 2–0 nylon sutures on postoperative day 7. The patient was then transferred to the rehabilitation hospital for hyperbaric oxygen and rehabilitation treatment on postoperative day 10. At 1-month follow-up, the patient's muscle strength of bilateral hip flexors and knee extensors improved gradually, but the muscle strength of right foot dorsiflexion and plantar flexion did not show significant improvement. The lumbar x-ray, CT scan, and MRI showed that the internal fixation and lumbar interbody cages were in good position, and there was a small amount of fluid behind the lumbar spine . At the 6-month postoperative follow-up, the patient had no numbness of both lower limbs, and the symptom of urinary retention was significantly improved. The patient exhibited 4/5 strength in the left lower limb, 2/5 strength in right foot dorsiflexion and plantar flexion, and 4/5 strength in right hip flexor and knee extensor. The ASIA grade improved from grade C preoperatively to grade D postoperatively.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1828_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1828_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f13eac5bee24b68253c4a9f78941232d814c8012
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1828_en.txt
@@ -0,0 +1,17 @@
+A 72-year-old female, fully edentulous, wearing a removable prosthesis, was referred to our clinic after three unsuccessful attempts at rehabilitation of the edentulous mandible, with complete dentures. The patient had a 16-month history of swallowing problems, a painful erosion lesion, burning sensations on the left floor of the mouth, and recurrent numbness in the lower-right inferior lip. The X-ray evaluation showed extreme resorption of the mandible, as seen in Fig. .
+The patient was content with her maxillary denture, which was satisfactory from a technical point of view.
+Her medical history revealed type 2 diabetes mellitus managed with medication, psychological depression, class II obesity, obstructive sleep apnea, class III (moderate) to IV (severe) heart failure according to NYHA (New York Heart Association) classification, controlled essential hypertension, and ischemic heart disease.
+The preoperative CBCT confirmed resorption of the alveolar bone and partial resorption of the basal bone, a residual bone height between 5 and 8 mm corresponding to the interforaminal region, and the exposure of the inferior alveolar nerve (Class V-VI according to Cawood and Howell classification ), with no residual bone above the nerve in the lateral region (between the mental foramen and the second molar).
+After presenting all the available options, including mental nerve transposition and extensive bone grafting, the accepted and less-invasive treatment was an overdenture supported by four splinted dental implants, without any bone grafting. The insertion of only two interforaminal implants was excluded due to the high risk of mandibular fracture. Therefore, in the third molar region, the inferior alveolar nerve by-pass technique was considered to be appropriate in this case. Prophylactic antibiotic therapy was initiated within one hour before surgery; the patient was administered with 2 g of a combination of amoxicillin and potassium clavulanate.
+Mepivacaine HCl 3 % without vasoconstrictor (Scandonest 3 %, Septodont, Saint-Maur-des-Fossés, France) was locally infiltrated into the lingual and the labial aspect for each implant site. A full muco-periosteal flap was elevated to obtain direct visual access to the residual bone.
+The osteotomies were performed at 300 rpm and 50Ncm under cold saline irrigation using a freehand technique. In the interforaminal region, two 3.5 mm x 7mm implants (AnyRidge®, MegaGen, Daegu, Korea) were placed with an insertion torque of 40Ncm (right) and 45 Ncm (left), respectively. In the third molar area, two 3.2 mm x 10 mm implants (Mini®, MegaGen, Daegu, Korea) were placed with an insertion torque of 35 Ncm. The implants were inserted in the residual buccal bone bypassing the inferior alveolar nerve, as shown in Fig. A and B.
+The healing abutments were installed immediately: two conventional in the anterior region and two custom made; 12 mm in length healing in the posterior mandible. Simple interrupted sutures were used to close the incisions. 2 g of amoxicillin and clavulanate potassium were administered for the following 4 days. Sensory condition in the lower lip and chin was evaluated 24 h after the surgery, and no neurosensory changes were present. Healing was uneventful and the sutures were removed 14 days after surgery. Restorative treatment was initiated at 22 weeks post-implant insertion and the patient received the final overdenture 22 days after the preliminary impression.
+Due to the high level of mandibular atrophy, a special three-part customized impression tray was made as shown in Fig. A and B. The corresponding transfer abutments, AnyRidge®, for the two interforaminal implants, and Mini®, for the posterior implants, were inserted and functional impressions were taken with a polyether material (Impregum; 3 M ESPE, St. Paul, MN, USA), as shown in Fig. A. The three-part customised tray was made on a preliminary cast with implant analogues poured from a preliminary impression with the corresponding transfer abutments. Jaw relations were recorded with record bases and occlusal rims as shown in Figs. and A and C.
+An Artex face bow (Amann Girrbach, Koblach, Austria) was used to transfer the horizontal relationship of the maxillary arch to the cranial base and data were employed to mount maxillary and mandibular casts in an Artex®CR (Amann Girrbach AG, Koblach, Austria) -Arcon articulator, following the manufacturer’s instructions. A try-in mandibular denture was manufactured and the required functional adjustments were performed, as shown in Fig. B. A removable bar-retained overdenture was planned. Four OT Equator® abutments (Rhein83, Bologna, Italy) were screwed onto the implants, two custom-made 11 mm abutments on the posterior implants and two 4 mm abutments in the interforaminal region.
+A custom-designed bar secured with four castable Seeger Bar containers (Rhein83, Bologna, Italy), as shown in Fig. A and B was screwed over the OT Equator® abutments, with titanium locking screws and self-extracting Seeger rings (Rhein83, Bologna, Italy). The bar’s link framework was made with castable components: OT Bar gingival connectors. To anchor the over-structure, four single OT Equator® castable retentions (Rhein83, Bologna, Italy) were placed balanced distributed on the canine-premolar regions of the bar to ensure polygonal support for the denture. Both the bar and link frameworks were cast from Cr-Co alloy, together in the same duplicating mould to equalise the volumetric changes for both structures. After casting and postprocessing, the link framework was bonded to the final denture using a light-curing resin.
+The bar was mounted on the four OT Equator® abutments by using the self-extracting elastic Seeger rings over the abutments, with the aim to obtain a passive structure and avoid stress distribution to the dental implants . Also, the space between the bar and the underlying mucosa was designed adequately for oral hygiene maintenance .
+Due to the pattern of atrophy, the distal parts of the bar were not covered by the mandibular overdenture, as shown in Fig. A-D.
+At the delivery of the denture, functional adjustments were performed, and soft retention Nylon inserts were used. Oral hygiene instructions, including the use of interproximal brushes and oral irrigators, were provided to the patient. The patient was extremely happy with the functional and aesthetic outcomes, as shown in Fig. A and B. The correct positioning of the bar was assessed with the aid of an orthopantomography, as shown in Fig. .
+At one week post denture insertion follow-up, the patient had normal lower-lip sensitivity, improved masticatory ability, and normal deglutition.
+The patient’s self-perception in relation to the impacts of oral conditions on physical, psychological, and social wellbeing was evaluated before treatment and one week post mandibular overdenture insertion using the Oral Health Impact Profile for Edentulous Patients (OHIP-EDENT) questionnaire, validated for the Romanian language (ClinicalTrials.gov Identifier: NCT01392456). Each of the 19 items were assessed on a Likert scale (4 = always, 3 = frequently, 2 = sometimes, 1 = seldom, and 0 = never) with a total range of 0–76, a higher score meaning poorer quality of life . Despite the good fit of the maxillary denture, the registered OHIP-EDENT total score was 69 prior to the treatment; however, it decreased to 19 with the final mandibular overdenture, showing a significant improvement in quality of life.
+At the 14-month follow-up, the overdenture was evaluated and a CBCT taken, as shown in Fig. . The inferior alveolar nerve integrity and the stability of the bone tissue surrounding the dental implants were also assessed.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_183_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_183_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f3664031149777e12146827a252f2d298bb15f0d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_183_en.txt
@@ -0,0 +1,4 @@
+A 60-year-old African American man was admitted to the hospital with worsening abdominal pain and declining functional status. He had become progressively weaker after receiving the first round of chemotherapy for advanced rectal adenocarcinoma with extensive metastasis to the liver, lungs and spine. On the day of admission, the hematologic analysis was significant for hemoglobin of 11.6 g/dL, platelets of 555/nL, and a white blood cell count of 7.4/nL. Blood work was significant for random glucose of 114 mg/dL, creatinine of 1.1 mg/dL, blood urea nitrogen of 20 mg/dL, potassium of 4.9 mmol/L, alanine aminotransferase of 215 U/L, aspartate aminotransferase of 180 U/L, alkaline phosphatase of 1,178 U/L, total bilirubin of 10.8 mg/dL, and serum sodium of 127 mmol/L. His serum sodium concentration 4 months earlier had been 137 mmol/L.
+Magnetic resonance cholangiopancreatography was performed to evaluate the possibility of palliative stenting for his progressive cholestasis and showed liver enlargement with numerous mildly T2 hyperintense/T1 hypointense metastatic lesions throughout the liver. There was intrahepatic biliary ductal dilation, which was not amenable to palliative stenting.
+Hypovolemic hyponatremia was suspected because of the patient’s serum sodium of 127 mmol/L, his poor oral intake, and the presence of dry mucosal membranes on exam. Serum was sent to an outside laboratory to assess osmolality. Intravenous fluid boluses were given, and maintenance fluid was started. Despite adequate fluid resuscitation, on the third hospital day, the patient’s serum sodium level further decreased to 125 mmol/L; thus, syndrome of inappropriate secretion of antidiuretic hormone (SIADH) was suspected. Fluid intake was restricted to 1.2 L/day, and the patient’s serum sodium was 126 mEq/L on the following day. As a result of this improvement, therapy for SIADH was escalated with salt tablets. However, the serum sodium decreased to 121 mmol/L by the sixth day. At this time the result of serum osmolality became available revealing a normal level of 288 mOsm/kg, leading to a diagnosis of pseudohyponatremia.
+Repeated laboratory tests showed worsening alkaline phosphatase levels at 1,698 U/L and total bilirubin at 15.3 mg/dL; random urine sodium was 63 mmol/L. A serum lipid profile workup revealed a total serum cholesterol of 816 mg/dL with triglyceride levels of 382 mg/dL and high-density lipoprotein of 9 mg/dL; the low-density lipoprotein levels were unmeasurable because the total cholesterol was >500 mg/dL. Interestingly, the patient’s lipid profile 4 weeks earlier showed total cholesterol of only 213 mg/dL, triglycerides at 115 mg/dL, high-density lipoprotein at 36 mg/dL, and low-density lipoproteins at 153 mg/dL. No further treatment for hyponatremia was further offered as it was determined a laboratory artifact secondary to severe hypercholesterolemia.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1843_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1843_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..17a81cd224899ae52f44e896c2bab3c4156b4ee6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1843_en.txt
@@ -0,0 +1,4 @@
+A 56-year-old woman had been followed up for two years before the initial visit with suspected age-related macular degeneration oculus sinister (OS) at a previous clinic. One year before the initial visit, her best-corrected visual acuity (BCVA) was 0.9 OS, and fluorescence angiography (FA) showed leakage of fluorescence at the macula, which indicated the possibility of central serous chorioretinopathy at the clinic. One month before the initial visit, SRD was observed with BCVA of 0.5 OS, and local photocoagulation was performed. However, due to residual SRD and worsening visual impairment OS, she was referred to our hospital. Her medical history was limited to the inguinal hernia surgery 20 years ago, and she had neither a smoking habit nor family history. At the initial examination, her BCVA was 1.5 oculus dexter (OD) and 0.8 OS, with normal intraocular pressure oculi uterque (OU). Slit-lamp microscopy did not detect any findings OU. Color fundus photography (CFP) showed no abnormality OD , while an irregular brownish lesion was noted around the macula OS . Therefore, coloration of the posterior pole in the left eye was generally more yellowish-brown than the right eye. Although swept-source (SS)-OCT images (DRI OCT Triton; Topcon Inc., Tokyo, Japan) demonstrated no abnormalities of retino-choroidal structures OD , SS-OCT showed the markedly hyporeflective choroidal structure OS as well as SRD where the retinal thickness was preserved. Moreover, the lumen of the choriocapillaris was suggested to be compressed beneath the RPE layer OS . FAF indicated enlarged macular hypoautofluorescence suggesting chronic RPE damage OS . There was no choroidal elevation on B-mode echography OU . FA revealed reduced choroidal perfusion in the macula in the early phase and scattered focal hyperfluorescent spots that intensified from early to late phase OS . Indocyanine green angiography (ICGA) demonstrated serpiginous-like fluorescence blockade throughout OS . There was no obvious abnormal shadow on orbital magnetic resonance imaging. Based on the clinical findings, her left eye was diagnosed with choroidal melanocytosis together with SRD. Central serous chorioretinopathy was ruled out by the absence of choroidal thickening on SS-OCT, descending tract on FAF, and choroidal vascular hyperpermeability on ICGA. The absence of choroidal elevation observed by fundus examination and echography, and irregular melanin pigmentation of the choroid supported the diagnosis of choroidal melanocytosis rather than choroidal nevus. She was observed without any treatment. Fifty-eight months after the initial diagnosis, her BCVA was 0.5, CFP showed slightly darker macular pigmentation, and SRD persisted on SS-OCT.
+The institutional review board of Hokkaido University waived the need for ethical assessment of this clinical study because of it being a single case report with a non-invasive study. This study adhered to the tenets of the Declaration of Helsinki.
+This study evaluated the alterations of choroidal blood flow of choroidal melanocytosis using LSFG. Relative blood flow values were obtained as the mean blur rate (MBR) after quantitative measurement of blood flow velocity by LSFG software (LSFG-NAVI, version 3.1.39.2, Softcare Ltd., Fukuoka, Japan) according to previous reports [, ]. The pupils of the patient were dilated with 0.4% tropicamide (Mydrin-M; Santen Pharmaceutical Co., Ltd., Osaka) before examination. Ophthalmic examinations were conducted after pupils of both eyes had completely lost their light reflex. The macula in the LSFG images was manually marked and vessels were automatically segmented using threshold values defined by the system software (LSFG Analyzer, version 3.0.47.0). The macular area was identified by an experienced examiner by comparing the initial FA images and FAF images. Since LSFG images also show retinal blood vessels, the macular area was determined by comparing their length and vascular runways with the FA images. A circle of about 750 μm in diameter to the fovea was defined as the region of interest on LSFG , based on FA findings. Four to five consecutive measurements were taken for each circle, and the mean values were used for analysis. All examinations were conducted by a single experienced operator. Ocular perfusion pressure (OPP) was calculated using the patient’s blood pressure and intraocular pressure, as previously described [, ].
+The MBR values OD are shown in Fig. B as follows: 10.9, 10.6, 10.1, and 9.0 arbitrary units (AU) at 18, 24, 36, and 58 months after the initial visit, respectively. The MBR values OS are shown in Fig. B as follows: 1.24, 1.30, 1.32, 1.28, and 1.42 AU at 12, 18, 24, 36, and 58 months after the initial visit, respectively. The MBR (mean ± standard deviation) for 58 months was 10.15 ± 0.72 AU OD and 1.31 ± 0.06 AU OS. OPP was 82.2, 76.2, 82.9, 73.0, and 68.0 mmHg OD, and 83.2, 78.2, 82.9, 72.0, and 69.0 mmHg OS at 12, 18, 24, 36, and 58 months after the initial visit OS, respectively, revealing no significant changes in either eye.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1858_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1858_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fa14c85fb8f24a59d59f67693d9fc02efe640b20
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1858_en.txt
@@ -0,0 +1,8 @@
+In 2019, a 20-year-old woman was referred to the Division of Dentistry, Department of Periodontics and Endodontics, Okayama University Hospital in Japan by a general practice dentist. The referral aimed to seek specialized periodontal treatment due to significant periodontal tissue destruction caused by ligneous periodontitis associated with plasminogen deficiency. Herein, we present the sequence of events leading to the diagnosis of plasminogen deficiency during the patient’s childhood and her subsequent presentation to our department in 2019.
+The patient initially received a diagnosis of ligneous gingivitis linked to plasminogen deficiency at the Department of Oral and Maxillofacial Surgery, Okayama University Hospital, in 2008, when she was just nine years old. At that time, her blood plasminogen activity was as low as 10%, and pseudomembranous white lesions were evident on the gingiva and eye . Dental radiographs taken in 2012, when she was 12 years old, unveiled signs of vertical bone resorption in the lower first molar, indicative of ligneous periodontitis accompanied by alveolar bone destruction . Despite receiving regular supportive periodontal therapy (SPT) at her referring dental office for eight years, she was referred back to Okayama University Hospital in 2019 due to the remarkable extent of alveolar bone destruction for her age.
+Upon re-referral in 2019, her plasminogen activity was less than 25%, confirming the diagnosis of plasminogen deficiency. However, other markers, such as prothrombin time-international normalized ratio (PT-INR) and D-dimer, were within normal ranges, indicating no predisposition to bleeding. In terms of oral health, despite maintaining good oral hygiene (O’Leary plaque control record (PCR): 11.6%), the patient exhibited marginal gingival redness in the molar region, gingival hyperplasia on the buccal gingiva of the maxillary anterior teeth and mandibular molars, and deep periodontal pockets primarily in the molar area (4 mm < probing pocket depth (PPD): 33.4%; periodontal inflamed surface area (PISA): 1,025 mm2). Dental radiographic examination revealed horizontal bone resorption of approximately one-third of the root and vertical bone resorption in all molars . Histological examination of the gingival hyperplastic area demonstrated fibrin deposition and epithelial degeneration with neutrophilic infiltration . Based on the above intraoral and radiographic findings, blood test results, and histological tissue examination, she was again diagnosed with ligneous periodontitis (Stage III, Grade C).
+We analyzed genomic sequences using targeted next-generation sequencing (NGS) with the hybrid capture method to explore potential germline variants underlying plasminogen deficiency. The analysis focused on a several-gene panel, including F12 and PLG, associated with plasminogen deficiency. Rare variants in F12 and PLG were identified through comparison with population database such as the Genome Aggregation Database (gnomAD). Specifically, the F12 variant A343P had been registered with conflicting interpretations of pathogenicity in the ClinVar database, with an allele frequency of 3.00 × 10–3. PLG c.581A > T (p.Asp194Val) was registered as benign in the ClinVar database (Variation ID: 780,122), with an allele frequency of 7.68 × 10–4. PLG c.1468C > T (p.Arg490*) was not reported in the ClinVar database, and its allele frequency in the gnomAD database was 1.19 × 10–5 . The PLG gene exhibited a c.581A > T missense mutation in this patient and a c.1468C > T stop-gain mutation . These mutations resulted in the truncation of the PLG protein and the loss of its plasminogen activator cleavage site . The patient had no family history of plasminogen deficiency or Behçet’s disease .
+Initial periodontal treatment for the patient involved non-surgical scaling and root planning (SRP) to eliminate the subgingival source of infection. Additionally, the patient used a mouthpiece to alleviate occlusal forces. Subsequent SPT was provided at short intervals from 2021 to stabilize the periodontal condition, although gingival hyperplasia and swelling showed minimal improvement. Periodontal surgery was not considered due to the potential for increased fibrin deposition with gingival incision. The patient’s oral condition at SPT was as follows: PCR 22.3%, BOP 49.4%, 4 mm < PPD 23.8%, PISA 981.4 mm2 .
+Despite maintaining stability systemically and orally, the patient presented to the Department of General Medicine, Okayama University Hospital, in 2022 with complaints of fever (body temperature (BT) 40.0 °C), diarrhea, and general malaise. Blood tests revealed a significantly elevated white blood cell (WBC) count (21.09 × 103 cells/µL) and C-reactive protein (CRP) level (20.24 mg/dL), leading to urgent hospital admission for further evaluation and treatment. Initial suspicion was directed towards infectious diseases, prompting the initiation of antibiotic therapy (tazobactam/piperacillin hydrate, 4.5 g × 3 times/day). However, the patient rapidly developed additional systemic symptoms, including hematochezia, vulvar ulcers, and an erythema nodosum-like rash on the extremities. In the oral cavity, marginal gingival hyperplasia, erosions, and multiple aphthous stomatitis were observed. Additionally, the tongue was coated with a thick biofilm . Subsequently, she was diagnosed with intestinal Behçet’s disease based on the primary symptoms of erythema nodosum-like skin rash on the extremities, recurrent aphthous ulcers on the oral mucosa, and atypical genital ulcer. Secondary symptoms, including vasculitis and gastrointestinal involvement, were confirmed through histological examination of the erythematous nodular area. Seven days after hospitalization, the presence of HLA-B51 antigens was detected, further supporting this diagnosis.
+Prompt administration of oral prednisolone (PSL) at 1 mg/kg/day was initiated upon the diagnosis of Behçet’s disease. Oral hygiene was maintained during hospitalization, and mucosal treatment was provided using glycerin mouthwashes. On the 15th day after hospitalization, with reduced systemic inflammation due to PSL treatment (CRP 0.18 mg/dL, WBC 9,330 cells/µL, BT 36.9 °C), aphthous ulceration, gingival hyperplasia, and erosion areas showed improvement, and the biofilm on the tongue disappeared. However, redness in the pharyngeal region persisted. Consequently, the PSL dosage was gradually reduced to 30 mg/day. On the 45th day of hospitalization, the patient’s overall condition had significantly improved, leading to her discharge from the hospital (CRP 0.02 mg/dL, WBC 13,101 cells/µL, BT 36.6 °C). Around the same time, aphthous ulceration in the oral cavity had resolved. Gingival hyperplasia had decreased to a level similar to when she transferred to SPT, though gingival recession seemed to have progressed (PCR 51.8%, BOP 10.7%, 4 mm < PPD 16.7%, PISA 226.4 mm2). Conversely, dental radiographs revealed progressive horizontal alveolar bone resorption (bone resorption of approximately two-thirds of the root of the tooth) compared to the previous assessment .
+Following her discharge, the patient initiated the treatment with the anti-tumor necrosis factor (TNF)-α antibody drug adalimumab at 40 mg every two weeks. This treatment aimed to decrease reliance on steroids and provide symptom relief through the anti-inflammatory effects of the medication. The patient experienced intermittent flares and remissions of systemic inflammation after hospital discharge, although to a lesser extent than during the initial hospitalization period.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1862_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1862_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..950a6795fb64c02c88fbb256c398b49d1abc15ef
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1862_en.txt
@@ -0,0 +1,2 @@
+A 57 years-old male patient presented with back pain, general discomfort, polydipsia, polyuria, fatigue and recent weight loss of 10 kg. Clinical examination was normal and there was no relevant medical history. Biochemical evaluation showed hypercalcemia (2,85 mmol/L; normal: 2.15–2.55 mmol/L) with slightly lowered PTH levels (14,2 ng/L; normal 14,9–56,9 ng/L) excluding hyperparathyroidism. CT-thorax-abdomen and ultrasound guided biopsy revealed a pNET with multifocal liver metastases as well as some small bone lesions. The Ki-67 index was 15 to 20% compatible with a grade 2 tumor. PTHrP was normal and although our patient had some osteodense skeletal metastases, these bone lesions alone could not explain his marked hypercalcemia. However, markedly increased calcitriol levels up to 134.3 ng/L (normal: 20.0–80.0 ng/L) were detected. We hypothesized that overproduction of this active form of vitamin D by the pNET was the cause of the HCM.
+Initial treatment with lanreotide, a non-radioactive SSA, and everolimus, an inhibitor of mammalian target of rapamycin (mTOR), resulted in morphologically stable disease, but there was no effect on the hypercalcemia nor on the associated symptoms. The patient was evaluated for treatment with PRRT. In the meantime, therapy with FOLFOX chemotherapy was started. 68Ga-DOTATATE scan revealed intense SSR expression in the pancreatic lesion as well as strong uptake in the liver metastases and the skeletal metastases. All malignant lesions had an uptake intensity above the spleen (Krenning score grade 4) . 18F-FDG-PET/CT showed strong hypermetabolism in some of the liver metastases (metabolic grade 3) . There were no 18F-FDG + / SSR - mismatched lesions. Evaluation of the renal function showed no contraindication for therapy. Four cycles of PRRT with 177Lu-DOTATATE were given, with a treatment interval of 8 weeks up to a cumulative activity of 29.6 GBq. Three months after the final cycle, the initially refractory serum calcium levels had normalized and the associated symptoms disappeared , confirming the hypothesis of a calcitriol secreting pNET. Although there was a clear morphologic response , some liver lesions showed an increase in 18F-FDG uptake compared with baseline . Because of these signs of metabolic progression, the patient was started on temozolomide-capecitabine, which resulted in continued morphological disease stabilization as well as continued normal serum calcium and calcitriol.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1865_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1865_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4911fc66da3de5307986b78fb261b1186c0ef326
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1865_en.txt
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+A 56-year-old male was referred to our hospital for surgical resection of a posterior mediastinal tumor in July 2014. A local doctor had originally diagnosed the tumor in 2005, and it had gradually increased in size until March 2014. The patient did not have any health problems or symptoms suggestive of a history of hematologic disorder or chronic anemia. Laboratory tests for tumor detection, including those implementing tumor markers, were within normal limits. A chest roentgenogram and computed tomography (CT) showed a tumor mass shadow in the right lower posterior mediastinum. The tumor was 4.3 cm in diameter and was evident on the side of the T9 thoracic vertebrae . Magnetic resonance imaging (MRI) revealed that the signal intensity of the tumor was low in the T1 weighted image and disproportionately high in the T2 weighted image .
+Differential diagnoses included neurogenic tumor, malignant lymphoma, pleural mesothelioma, lipoma, liposarcoma, or an extra-adrenal myelolipoma. We performed tumor resection by video-assisted thoracic surgery (VATS). Surgery revealed that the tumor in the posterior mediastinum was a well-encapsulated, elastic, soft, and dark red mass .
+Histopathological findings of the resected specimens revealed a predominantly mature adipose tissue with hematopoietic tissue comprised of erythroblasts, megakaryocytes, and granulocytes .
+Although extramedullary hematopoiesis was considered as a differential diagnosis, the final diagnosis was a mediastinal extra-adrenal myelolipoma. The patient was discharged with no complications on the fifth postoperative day, and he has been well for 12 months postoperatively.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1869_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1869_en.txt
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index 0000000000000000000000000000000000000000..65814a84f2df3b5a5237a9db1a21004daec83d22
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1869_en.txt
@@ -0,0 +1 @@
+A 72-year-old, para one Caucasian female, presented with postmenopausal bleeding in July 2016. Her past medical history was significant for hypertension managed by Hydrochlorothiazide. She had no family history of ovarian, uterine, breast, pancreas, colon, or prostate cancer. Social history included social drinking with 1–2 drinks per week, with no smoking or recreational substance use. Her BMI was 27, and Eastern Cooperative Oncology Group Performance Status (ECOG PS) score was 0, denoting that she was fully active and able to perform activities without restriction. The ECOG PS is a scale describing a patient's functional status regarding their ability to take care of themselves and perform daily and physical activities. An endometrial biopsy showed clear cell carcinoma of the endometrium. A CT-Abdomen/Pelvis (CT-AP) was consistent with thick endometrium, unremarkable adnexal structures, and no evidence of metastatic disease. CA19-9 and CA-125 were 168.9 μ/mL and 68.1 μ/mL respectively. Upon final review of the patient's history and physical, she was found to be optimized for surgery. She underwent a robot-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, omentectomy and pelvic and para-aortic lymph node dissection by a gynecologic oncologist. Pathology showed mixed endometrioid and clear cell adenocarcinoma with 90 % myometrial invasion, positive metastatic adenocarcinoma to multiple pelvic and paraaortic lymph nodes bilaterally, no omental metastasis, and negative pelvic washings. This was consistent with FIGO stage IIIC2, grade 2 endometrioid adenocarcinoma/clear cell carcinoma. She was treated with adjuvant chemotherapy with platinum and taxane doublet IV every 21 days for a total of six cycles. During immediate post-chemotherapy surveillance, there was no evidence of residual disease on CT scan, and serial CA 125 levels decreased appropriately. Twenty months after initial debulking, CA125 levels were noted to double over a five-month period . Patient had no presenting symptoms and the physical exam was without evidence of recurrence.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1876_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1876_en.txt
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index 0000000000000000000000000000000000000000..1cce7601d3bfb0810f79dfadf27d43a2b56687f1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1876_en.txt
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+A 72-year-old man presented with a 1-month history of constipation, diarrhea, and weight loss. His medical history included subarachnoid hemorrhage and hydrocephalus 13 years previously, requiring endovascular coiling and ventriculoperitoneal (VP) shunt construction. Abdominal examination revealed hyperperistalsis and no tenderness. Colonoscopy showed a sigmoid mass , the biopsy of which revealed tubular adenocarcinoma. Computed tomography demonstrated circumferential wall thickening of the sigmoid colon without evidence of metastasis, with the lesion surrounding the tip of the VP shunt . We opted for laparoscopic surgery, which unexpectedly revealed that the VP shunt was trapped in the tumor’s serosal side ; both the shunt and the tumor were, thus, excised . Spinal fluid was found draining from the remaining VP shunt slit valves. Macroscopic pathology showed that the VP shunt was stuck in a deeper layer in comparison to the tumor , while microscopic examination of the tumor revealed subserosal invasion. Inflammation and fibrosis were also identified, but no cancer cells were found in the serosa surrounding the embedded VP shunt tip . The patient was discharged 16 days after surgery without any complications.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_18_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_18_en.txt
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index 0000000000000000000000000000000000000000..b4b041e965f65e34db4bf12e7b05ad9414e3b952
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_18_en.txt
@@ -0,0 +1 @@
+A 47-year-old male patient suffering from mild abdominal pain for 2 months was admitted to our hospital in February 2018. He was diagnosed with “acute pancreatitis” first before transferring to our department. The ultrasound (US) and computed tomography (CT) scan of the abdomen revealed a pancreatic space-occupying lesion and pancreatic duct dilatation . The serum amylase and lipase levels were slightly elevated (231 and 546 U/L, respectively; normal range: 25–125 and 13–60 IU/L, respectively). the preoperative serum CA 19–9 level was 34.82 U/ml. Then, the patient underwent exploratory laparotomy. Intraoperative examination identified a hard mass in the body (approximately 4.0 cm × 3.0 cm) and tail of the pancreas, varicose veins around the spleen, a mass in the diaphragm (1.5 cm diameter), and three light masses on the surface of the liver. One mass was taken for pathological examination of the intraoperative rapid frozen section, and the result showed adenocarcinoma in the mass. The patient underwent radical distal pancreatectomy, splenectomy, diaphragm, and liver mass resection. The patient manifested with obstructive jaundice after surgery and gradually increased level of bilirubin. The total bilirubin increased from 65.4 μmol/L to 105.6 μmol/L and then to 140.1 μmol/L, and the direct bilirubin increased from 53.8 μmol/L to 81.0 μmol/L and then to 118.1 μmol/L. Subsequently, the patient underwent cholangiojejunostomy, and the pathological report revealed resected masses from the pancreas, liver, and diaphragm, indicating PTC metastases . Immunohistochemical studies showed positive stanning of TG(+), PAX-8(+), TTF-1(+), CK19(+), HBME-1(+), Galectin-3(+), P53(+), WT(+), DPC4(+), CA19–9(luminal surface+), MUC1(+), with negative staining of MUC5AC(−), MUC6(−), MUC2(−). Then, the patient had a thyroid US, which showed multiple hypoechoic masses in the left thyroid gland and an endoscopic US-guided fine needle aspiration (FNA) biopsy of the thyroid mass. Pathology also revealed papillary cancer. After the patient had recovered in the pancreatic department, he was transferred to the thyroid department. A CT scan was taken, and the result showed large masses in the isthmus and left lobes of the thyroid, multiple enlarged lymph nodes, and multiple masses in the bilateral parotid and submandibular gland . Then, the patient received an FNA biopsy of the parotid and submandibular mass, and the result showed PTC metastases. Immunohistochemical studies showed TTF-1(+), TG (−), CK19(+), HBME-1(+), Galectin-3(+), Villin(−), CDX-2(−). In July 2018, he received complete thyroidectomy, cervical lymphadenectomy, bilateral parotidectomy, bilateral submandibular gland and left recurrent laryngeal nerve resection. Intraoperative examination showed a huge irregular mass (approximately 10.0 cm × 7.0 cm × 5.0 cm) in the left and isthmus of the thyroid gland with calcification. The mass invaded the left recurrent laryngeal nerve and adhered to the surface of the trachea, and enlarged lymph nodes (3.5 and 2.5 cm in diameter) were found in the bilateral parotid. Multiple small enlarged lymph nodes (diameter ranging from 0.3 cm to 1.5 cm) were also noted in the bilateral submandibular gland. Intraoperative rapid frozen biopsy showed papillary cancer. The final histopathology revealed bilateral thyroid and isthmic papillary carcinoma and cervical lymph node metastasis, and papillary cancer in the left parotid and bilateral submandibular glands but not in the right parotid gland. Immunohistochemical studies showed CK19(+), HBME-1(+), Galectin-3(+), TG (partial+), TTF-1(+), P53(partial+), NapsinA (−), PD-L1(+, approximately 10%). The gene test showed activated mutation detected in the exon 15 of the BRAF gene (V600E) and the promoter 228 of TERT. After surgery, the patient was given radioiodine-131 therapy. He recovered well and was discharged from the hospital with oral Euthyrox therapy. The patient still survives at present.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1902_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1902_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e3de226f56e5f47e6aca41387f72e4bcfd453e6b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1902_en.txt
@@ -0,0 +1,2 @@
+A 75-year-old man who received pembrolizumab (a humanized monoclonal anti-PD-1 antibody) for lung squamous cell carcinoma (T2aN3M1b, stage IV) presented with limb weakness. At the age of 72, he showed slowly progressive difficulty in climbing stairs, but his creatine kinase (CK) level was within normal limits 7 months before the pembrolizumab introduction. At the day of the first infusion of pembrolizumab, his CK level was mildly elevated to 552 IU/L, but he showed no additional symptoms. After the first infusion of pembrolizumab, his CK levels increased to 1054 IU/L at day 44 . Neurological examination demonstrated diffuse limb weakness including the quadriceps (Medical Research Council [MRC] grade 4/4) and finger flexors (MRC grade 3/3) and atrophy of the quadriceps and paraspinal muscles. Myositis-specific autoantibodies and anti-acetylcholine receptor antibodies were negative. Electromyography indicated an irritable myopathy. Echocardiography showed normal left ventricular function. Muscle biopsy at day 59 demonstrated prominent variation in muscle fiber size, rimmed vacuoles , endomysial CD8-positive cell infiltration with invasion of non-necrotic fibers , overexpression of major histocompatibility complex (MHC) class I antigen in non-necrotic fibers , and p62-positive inclusions . Abundant endomysial PD-1-positive cell infiltration fiber , programmed death ligand-1 (PD-L1) overexpression in the invaded fibers, and PD-L1-positive cells were also observed. The localization of PD-1-positive cells was consistent with that of CD8-positive cells (data not shown).
+The patient was diagnosed with clinicopathologically defined sIBM and suspected exacerbation of sIBM due to anti-PD-1 therapy. Pembrolizumab was discontinued without introduction of immunosuppressive therapy. His CK levels decreased to 489 IU/L at day 64. The patient had been stable disease of his lung cancer after the first infusion of pembrolizumab. However, his brain metastasis was revealed at day 94. After gamma knife radiosurgery for the metastasis, pembrolizumab was restarted at day 122; 12 additional infusions were administered. His limb weakness gradually worsened without further elevation of CK levels. The primary lung lesion progressed after the additional treatment with pembrolizumab and led to the evaluation of progressive disease. The patient died of sepsis, shortly after a 15-month follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1907_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1907_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..32e72d8529b7e14932156e86cf23b4824fbe82a5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1907_en.txt
@@ -0,0 +1,7 @@
+An 81-year-old woman attended a local hospital because of fatigue, lethargy, fever, chills, phlegm and wheezing.
+The patient developed fatigue, lethargy, fever, chills, phlegm and wheezing three days before admission, but without treatment. On November 16, 2021, the patient developed a coma and was sent to the emergency room of our hospital. As her oxygen saturation dropped to 70%-80%, the patient was admitted to the intensive care units (ICUs) for further treatment after consultation. After admission to the ICU, the patient developed a progressive drop in blood pressure, requiring norepinephrine to maintain a mean arterial pressure > 65 mmHg.
+The patient had a medical history of chronic obstructive pulmonary disease, and bronchial asthma for more than 50 years and received long-term home oxygen therapy. She had suffered from and chronic heart insufficiency for five years and was treated with oral bisoprolol. There was no history of abdominal pain and chronic renal failure.
+The patient had no history of smoking or alcohol consumption. There was no relevant family history.
+The patient's body temperature was 36 °C, the pulse was 85 beats/min, the respiratory rate was 18 breaths/min, and the blood pressure was 105/45 mmHg. Breath sounds were decreased in both lungs, and wet rales could be heard at the bottom of both lungs. Cardiac and abdominal examinations were unremarkable.
+The initial troponin level was 0.05 ng/mL, and increased later . B-type natriuretic peptide was 4164 pg/mL. Results of arterial blood gas analysis were: Carbon dioxide partial pressure 58.7 mmHg, oxygen partial pressure 86.5 mmHg, and oxygenation index 172.97 mmHg; inflammatory indicators: White blood cell 8.12 × 109/L, neutrophil percentage 93.2%, C-reactive protein 298.38 mg/L, procalcitonin 6.26 ng/mL, and interleukin-6 > 5000 pg/mL. The polymerase chain reaction-severe acute respiratory syndrome coronavirus 2 test and multiple blood cultures were negative. Other blood tests, fecal examinations, and coagulation function were all normal.
+The initial electrocardiogram (ECG) findings: Sinus rhythm, T wave was high and sharp; R wave: V1-V4 progression was poor, V1 was Qr type, and subsequent re-examinations revealed ST-segment elevation (> 0.05 mv) . Echocardiography suggested left atrial enlargement, segmental abnormal motion of the left ventricular wall, left ventricular apical bulge (considered to be ventricular aneurysm formation), decreased left ventricular diastolic function, and lower limit of normal systolic function (LVEF) was 51%. Chest CT showed chronic bronchitis, emphysema, multiple infections in both lungs (mostly in the middle and lower lobe of the right lung), right pleural cavity small effusion, and obvious calcification of aortic arch and coronary artery. An abdominal CT scan showed no abnormal changes, but obvious abdominal aorta calcification.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1914_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1914_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1dea14e1c864ae5d46b9e19238d560e8951ec429
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1914_en.txt
@@ -0,0 +1,3 @@
+A 43-year-old woman was referred to our institution with a neck mass in the left submandibular region. She was studied in an outside hospital, where a neck ultrasound showed a multinodular goiter and a CBT on the left carotid bifurcation. A neck Computed tomography angiography (CTA) demonstrated a carotid body tumor (3.8 cm × 2.5 cm × 3.3 cm) classified as Shamblin II and an intrathoracic multinodular thyroid gland with a right lobe extension of 11.9 cm × 9.7 cm and the left lobe of 25.2 cm × 21.3 cm with caudal retrosternal growth and evidence of slightly trachea deviation .
+Thyroid function test (TFT) were normal, serum antithyroglobulin antibodies and thyroperoxidase antibody (TPO) were undetectable. Thyroid gammagram was performed reporting a multinodular goiter. Fine needle aspiration was performed demonstrating nonmalignant cells. A total thyroidectomy was performed with a transverse lower neck incision (Kocher incision), posteriorly, CBT was resected by an extension of the previous Kocher incision to the anterior border of the sternocleidomastoid muscle using the retrocarotid reported previously in our group as an effective technique, also two surrounding lymph nodes were resected to rule out malignancy . The pathology report demonstrated a paraganglioma with negative lymph nodes invasion and a multinodular goiter .
+The patient recovered satisfactorily after the surgery and she was discharged in postoperative day number three, she currently continues her follow-up as our patient. Twelve months after the surgery, she does not present any complaints. She is currently on levothyroxine and calcium carbonate.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1915_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1915_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2a67bdc603eb6d588ffcd4d309b800c0aed720d2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1915_en.txt
@@ -0,0 +1,9 @@
+A 40 year old, 83Kg female with developmental dysplasia of her left hip (DDH) was referred to us for consideration of left THA having suffered increasing left hip pain over the past three years. Her diagnosis of DDH was not made until adulthood despite her left leg being shorter than her right leg by 2.5 cm. She was diagnosed with BSS at the age of 18, and her haematology reports confirm 2 prior hospital admissions related to delayed bleeding following wisdom- teeth extraction at the age of 20 and cervical cone biopsy; the latter of which required transfusion with platelets and packed red blood cells (pRBC). Prior to this, she had been taking birth control pills from the age 14 for heavy menstruation.
+Pre-operative cross-match and group and screen of blood was conducted confirming blood type A+. Blood work also confirmed that she was not Factor XIII deficit as initially suspected (FXIII activity, 1.04 U/mL). Her glycoprotein 1b level was 15% with an estimated platelet count of 12 (x109/L) and INR 0.9. Her euglobulin lysis time was also well within acceptable limits (4.5 h). We consulted our Thrombosis, Haemophilia and Internal Medicine teams for pre-operative optimization. Having a Clinical Nurse Specialist coordinate the patient care path was fundamental to this process.
+Tranexamic acid (TA) 1g po TID was initiated 24 hours prior to surgery and continued until 14 days post-operatively. 20 mcg of DDAVP (desmopressin) diluted into 50 mL of normal saline was given intravenously over a period of 30 minutes, 1 hour prior to surgery. Immediately following this, she received 1 adult dose (4 units/318 mL) of pooled, buffy-coat platelets which elevated her platelets to 79 (x109/L) along with 1 unit of pRBC to bring her haemoglobin (Hb) to 135 . Intravenous antibiotics (Ancef, 2g) were given within 30 minutes of surgery. Arterial lines and additional peripheral lines were avoided to limit potential bleeding.
+Induction of general anaesthesia was conducted using a mixture of intravenous propofol (170 mg), sufentanil (20 mcg), versed (2 mg) and rocuronium (50 mcg). A glideScope® (Verathon Inc., Bothell, WA, USA) was used for placement of the endotracheal tube. Anaesthesia maintenance comprised isoflurane (1.8%) with 58% O2 at 1.2L/min and air at 1.3L/min.
+Once sedate, our patient was positioned in a standard right lateral decubitus position, supported by a Stulberg frame (Innomed Inc., Savannah, GA, USA). A Hardinge approach was used to the left hip. Meticulous haemostasis was maintained using cautery throughout the case. Particular attention was taken to avoid undue tension through soft tissues during dislocation of the hip. Similarly, bone bleeding following transection of the femoral neck and reaming of the acetabulum and femoral canal was addressed immediately. Gauze soaked in tranexamic acid (Pfizer Inc., NY, USA, 2g in 10 mL sterile normal saline) was packed into the femoral canal and acetabulum for a period of 3-4 minutes prior to placement of implants.
+The femoral component (Accolade II; Stryker Canada, Hamilton, ON, CA) was impacted into the femoral canal in the typical fashion. To optimize functional range, we used an anatomic dual mobility (ADM®), bearing hip system from Stryker . Bleeding was minimal following impaction of either the femoral or acetabular prostheses. Muscle and surrounding fascial layers were infiltrated with 0.5% Marcaine/epinephrine (1:1000; 40 mL). The incision was meticulously closed in multiple layers followed by steri- strips™ and mepore® dressings.
+Systolic blood pressure was maintained below 125 mmHg throughout the surgery. Total operative time was 85 minutes. Estimated blood loss was 450 mL. Patient received a 1L bolus of normal saline intra-operatively. Her vitals remained stable throughout the surgery.
+Post-operatively, daily transfusions of platelets were given up to post-operative day (POD) 14. Transfusions comprised 2 single donor (232 mL), 4 plateletpharesis (208 ±44 mL) and 8 pooled, buffy coated platelets (345 ±15mL). Minor crossmatch check was conducted daily. Platelet counts dropped by 40% post-operatively but recovered by POD 6 (see ). DDAVP (20 mcg, subcutaneous) was continued daily until POD 4. Serum sodium levels remained stable; the lowest reading was 128 mmol/L on POD 2, recovering to 136 mmol/L by POD 6. Systolic blood pressures were also stable at 103 ±14 mmHg, the lowest (98/59) occurring POD 1. Her blood work was recorded daily, a summary of which is shown in . She was weight bearing as tolerated from POD 1. Daily dressing checks confirmed no bleeding concerns at the incision site. DVT prophylaxis comprised moonboots starting POD 0. Her pain was controlled effectively with oral hydromorphone contin (6mg, BID) and Tylenol (975 mg, q4h). Patient entered into rehabilitation POD 7 and was discharged home on POD 19 following complete review by our Haematology and medicine teams.
+The overall leg length discrepancy was improved from 2.5 cm to 1 cm without the need for additional soft tissue release.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1933_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1933_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3fe14451472dc9996519f24cc669e1a01ea9abd7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1933_en.txt
@@ -0,0 +1,5 @@
+The patient was a 25-year-old male who had sustained sudden severe pain in the left lower back and radiated to the scapular area for 4 h, accompanied by breathing difficulties with shock. The CT scan confirmed a ruptured TAAA (Crawford type IV). Bilateral lens exchange surgery was operated 1 year ago. According to features like age, the past ocular damage, C-reactive protein level of 71.5 mg/L and calcitonin level of 0.414 ng/L, TAAA rupture caused by BD was highly suspected.
+Emergent arteriography demonstrated a huge ruptured TAAA with the maximal diameter of 102 mm. The proximal end of the aneurysm was parallel to the top of the celiac artery. The distal end was 20 mm below the opening of the right renal artery, while was proximal to the inferior mesenteric artery. The ruptured location of TAAA was near the opening of the right renal artery. The celiac artery, left renal artery and superior mesenteric artery were occluded, while the collateral circulation was from the inferior mesenteric artery . The maximal diameter of proximal aorta above the celiac artery was 21.2 mm, the diameter of distal aorta below the right renal artery was 15.2 mm and that of the proximal right renal artery was 6 mm measured by arteriography and CT.
+Because of the different upper and lower diameters of the abdominal aorta in the lesion, we chose a bifurcated stent-graft (ENDURANT, Medtronic, USA, 23–16-145 mm). The main body of the abdominal aortic stent-graft was deployed on the back table in the operating room. Fenestration (6*6 mm) was then performed at 5 cm from the proximal top of the stent graft, and in the 9 o’clock direction with the radioactive “8” mark at the edge of the hole. The short bifurcated component of the stent-graft was occluded. The in-vitro fenestrated stent-graft was re-sent into the delivery system. The stent-graft was delivered from the right femoral artery to the aorta over the super-stiff guidewire, then deployed in the right position of the fenestration facing to the opening of the right renal artery. The arteriography demonstrated that the right renal artery was patent from the fenestration, but still with lots of endoleak. Then a covered stent (Viabahn, GORE, USA, 6*20 mm) was put into the right renal artery via the fenestration.
+A 5F vertebral catheter was preloaded into the aortic aneurysm sac for filling treatment from the left femoral artery before the aortic stent-graft was deployed. A Coda balloon (Cook Medical, Bloomington, Ind) was used to block proximal blood flow. Then, 30 ml fibrin sealant (Shanghai RAAS Blood Products Co, Ltd., Shanghai, China), including 15 ml fibrinogen (90 mg/ mL) and 15 ml thrombin (500 IU/mL) solutions, was injected into the sac of aneurysm. After the balloon was withdrawn, the arteriography was performed that the proximal end of the stent-graft was above the diaphragm and the distal end of the stent-graft was above the inferior mesenteric artery. The length of the proximal and distal landing zone was more than 4 cm. The right renal artery was patent without any endoleak, and the collateral circulation of the left renal artery and superior mesenteric artery was static from the patent inferior mesenteric artery. the patient was transferred to ICU after the surgery.
+After the endovascular treatment, the patient had no postoperative complications, such as renal insufficiency, ischemic intestinal symptoms and paraplegia. The hemodynamic function was kept stable. Tetracycline and dexamethasone were used for BD pulse therapy for 3 days. The patient kept taking prednisone for 1 year. The CTA follow-up 1 year after the surgery showed that the diameter of the aortic aneurysm was reduced even to the normal diameter of the artery and retroperitoneal hematoma was absorbed without any endoleak. The right renal artery and the collateral circulation from the inferior mesenteric artery were patent . The ESR and CRP values were within the normal range.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1935_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1935_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a1e9206e71b4418f371cd88c65d64564a727e70d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1935_en.txt
@@ -0,0 +1,5 @@
+A 55-year-old man, with severe left main coronary artery disease (CAD), and with short stature (150 cm height) and 76 kg weight, was referred to our center for coronary artery bypass grafting (CABG). The patient scheduled for off-pump CABG (OPCAB).
+Due to unstable hemodynamic condition, an IABP catheter (Datascope, procure, state, dual lumen, 9.5F, 34 ml, Datascope Inc., Montreal, NJ, United States) was inserted percutaneously through the right femoral artery, and was attached to the Datascope system via a console. Immediately after device insertion, with a counter pulsation and 100% augmentation, and a ratio of 1:1, the systolic blood pressure increased up to 90 mmHg, and urine output increased.
+The patient underwent an OPCAB operation using conventional grafts such as the left internal thoracic artery and saphenous vein grafts. Following the extubation, urine output was decreased that managed by diuretic and fluid therapy. Although, laboratory examination showed abrupt increasing of the following test: blood urea nitrogen (BUN): 70 mg/dl, creatinine (CR): 1.6 mg/dl, aspartate transaminase (AST): 80 IU, alanine aminotransferase (ALT): 70 IU, and acetate dehydrogenase (LDH): 350 IU. AST, ALT, and LDH values elevated seriously to 1200, 3500, and 5500 IU, respectively. The BUN and creatinine also increased to 80 and 2.1 mg/dl, respectively. The mean elevation of total bilirubin was also noted (total bilirubin: 2.5 mg/dl).
+The distension caused the failure of Doppler to reveal the condition of portal and liver venous and arterial flow blood flow, but showed the reduction of renal arterial blood flow. However, in a thoracic X-ray catheter’s tip was not detected, and an abdominal X-Ray showed that the balloon pump catheter’s tip was displaced distally; uncovering of catheter dressing in right thigh revealed loosing of fixation suture of catheter to the skin in its correct position .
+The improper mismatching of the IABP catheter size with the patient length may be another possible cause of the liver, renal, and mesenteric arterial malperfusion in this specific case. After IABP removal, the patient urine output was abruptly increased on the following hours. Then, the liver function tests, including ALT, AST, LDH, total bilirubin, and prothrombin time continued to reduce, and recovered drastically at the 10th day of catheter removal; liver function tests returned to normal value at time of hospital discharge, too.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1947_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1947_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3fab7f5d0c513e57b0b825c42566b4af2e64c8c4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1947_en.txt
@@ -0,0 +1,3 @@
+A 72-year-old right handed woman developed difficulty using her hands at age 70. She first noticed problems moving her hands while typing at work. The difficulty was asymmetric, mainly involving her left hand. Her struggle with typing progressed to difficulty manipulating a toothbrush to brush her teeth, holding eating utensils, and bathing. Her condition progressed, resulting in inability to use both hands, requiring assistance with all activities. She described knowing what she wanted her hands to do, but was unable to make her hands comply. She had not experienced any changes in speech, cognition, or balance.
+On our examination, (Additional file 3: Video S3) she was alert and oriented. Language, prosody, and comprehension were intact. Cranial nerves were intact and motor strength was full in all extremities. Coordination and balance were also intact. On motor exam, her voice was slightly hypophonic, but speech was normal. Eye movements were normal. There was mild rigidity in her left wrist. She had normal speed of movement in her legs, but her hand movements were severely impaired. She was unable to pantomime and had body utilization when asked to pantomime brushing her teeth. In addition, she was unable to show an “OK” sign or a salute. Testing for rapid alternating hand movements and opening and closing of hands was difficult as she could not coordinate holding her hands forward while opening and closing them. Sensory modalities including two-point discrimination, stereognosis, and graphesthesia were intact.
+Following her initial evaluation, she was started on carbidopa/levodopa 50/200 1 tablet three times per day. On her follow-up visit, she had discontinued the medication as it caused imbalance and allodynia. Her symptoms remained unchanged. An FDG- PET scan was normal.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1977_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1977_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c1b47f9da87499fd8805f4941381af8a5bff12b4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1977_en.txt
@@ -0,0 +1,6 @@
+A 23-year-old female, 10 years previously, developed a spontaneous left sided hemothorax. She was also found to have left rib lytic lessions.
+Pleural and rib biopsies led to the diagnosis of GSS.
+She received radiotherapy treatment focused on the left hemithorax. At age 18, she had a car accident and an upper thoracic kyphosis of 50 degrees without dislocation was diagnosed. Her neurological examen revealed a Frankel D score, with mild weakness and numbness on her left leg. She refused surgery at that time.
+Eighteen months later, she presented with a paraparesis (Frankel B), due to a spontaneous (no trauma) T3-T4 fracture dislocation resulting in severe spinal cord compression .
+With halo traction, she underwent reduction, decompression, and C5 to T8 instrumented fusion [Figures and ].
+Postoperatively, the patient improved to Frankel D, ambulating 2 years after surgery with only mild dysfunction.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_197_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_197_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e7b687a4735fbc1bed76fb3990fc98c181f0c5d4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_197_en.txt
@@ -0,0 +1,5 @@
+A 11-year-old, 50-kg female with a diagnosis of CD10+ ALL was admitted to the hospital with fever and intermittent chest pain. The patient was in complete remission (CR) following SHOP-99 chemotherapy. At the time of hospital admission, she was receiving G-CSF for severe granulocytopenia post-intensification with cytarabine, and had also received broad-spectrum antibiotics and fluconazole prophylaxis during previous episodes of febrile neutropenia.
+The physical examination was normal and the patient's general condition good. The blood examination showed 12,500 leukocytes/mm3 (82% neutrophils). An urine examination, a chest X-ray, and an abdominal ultrasonography did not reveal abnormal findings. Blood, urine, and stool cultures were also negative. She was initially treated with cefepime and teicoplanin. G-CSF was discontinued, after which the neutrophil count stabilized at around 1,700/mm3. CRP increased steadily up to 5.6 mg/dL despite broad-spectrum antibiotic therapy. One week later, while continuously febrile, the patient experienced worsening chest pain. A chest CT scan revealed several nodules 1 cm or smaller in diameter at the apex of both lungs . The Aspergillus galactomannan antigen was negative. Cultures of separate blood samples obtained percutaneously and from the central venous catheter, yielded Fusarium spp. The species of the infecting Fusarium could not be identified and in vitro susceptibility could not be tested. Liposomal amphotericin B (3 mg/kg/day) was then started. Although the dose of liposomal amphotericin B was increased to 5 mg/kg daily and the central venous catheter was removed (cultures of the catheter tip were sterile), the patient remained febrile and chest pain continued to worsen over the following 7 days. Blood cultures remained positive for Fusarium spp. and CRP levels increased up to 10.6 mg/dL . Caspofungin was then initiated (70-mg load followed by 50 mg daily). Fever disappeared within 48 hours of caspofungin onset . Chest pain improved significantly, blood cultures became negative, and CRP levels went down to the 1–2 mg/dL range over the following days. The patient presented two isolated fever spikes 8 and 12 days after the onset of caspofungin, which corresponded to a phlebitis episode and a limited reaction to L-asparaginase, respectively. Two weeks later, a new chest CT scan demonstrated progressive resolution of the lung nodules . Intravenous antifungals were discontinued and chemotherapy and suppressive therapy with oral voriconazole 200 mg twice daily was started. Three months later, a chest CT scan showed complete resolution of the pulmonary lesions, while the patient was asymptomatic . Thus, voriconazole was discontinued. Twenty-five months after discontinuation of all antifungal therapy, the patient remains healthy in the absence of any symptoms of fungal infection and in CR of her neoplastic disease.
+Fusarium resistance to most antifungals and the severe immunosuppression-notably long-lasting, severe neutropenia – in oncohematological patients make Fusarium infections commonly fatal . Despite its low activity against Fusarium , amphotericin B remains the drug of choice. Voriconazole is licensed for the treatment of fusariosis based on in vitro data and a series of case reports with a reported response rate of ~40% . Posaconazole also has potential for therapy of systemic fusariosis . In any case, responses obtained with monotherapies remain too low and unsatisfactory.
+We decided to treat our patient with amphotericin B and caspofungin for two reasons: (i) In our view amphotericin B remains the mainstay of therapy for fusariosis in pediatric patients; experience with voriconazole in this patient segment is limited [-]; (ii) Concurrent antifungal therapy is now generally considered an alternative way of improving outcome in difficult-to-treat invasive mycoses. In a recent in vitro study amphotericin B and voriconazole rendered mainly additive or subadditive interactions against Fusarium spp. . Yet, the concern remains that combining amphotericin B and azoles may lead to antagonism. In addition to the azole inhibition of the synthesis of amphotericin B's pharmacological target ergosterol, amphotericin B-related damage to the fungal cell membrane may interfere with the influx of azoles . In vitro caspofungin-inactive against Fusarium-showed synergistic or synergistic-to-additive interactions with amphotericin B for at least half of the Fusarium isolates . By inhibiting cell wall synthesis, caspofungin may presumably enhance the penetration of amphotericin B .
+We hypothesize that combination antifungal therapy likely contributed to the sucessful treatment of our patient's severe invasive fusariosis, since clinical improvement only became evident after initiating caspofungin. Yet, the effect of caspofungin in the successful outcome of our case is not completely clear. The clinical response observed could also be the result of prolonged administration of liposomal amphotericin B and the lack of severe neutropenia. Finally, the administration of suppressive voriconazole and the early re-initiation of chemotherapy allowed by rapid infection control probably also contributed to the good long-term outcome. Of note, there have been a few case reports of response to caspofungin in combination with amphotericin B [,] and as monotherapy , although in some of these reports there was a clear association of response to recovery from neutropenia.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1982_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1982_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d506ef0fddc397baf0d435cab995904cb1e10a68
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1982_en.txt
@@ -0,0 +1,8 @@
+A 53-year-old south Asian male presented to the accident and emergency department with an extended history of chest pain and numbness in the left arm lasting more than 24 hours. His symptoms had initiated whilst driving but resolved on arrival to hospital. There were no abnormal findings on clinical examination (heart rate 65 b.p.m., blood pressure 108/76 mmHg, saturations 98% on air, respiratory rate 16 cycles per minute).
+His medical background included type 2 diabetes (2013), hypertension (2014), hypercholesterolaemia (2002), non-alcoholic steatohepatitis (2002), and hepatitis B (2002). The patient had two prior admissions with cTnT positive chest pain, in 2002 (1410 ng/L) and 2015 (1540 ng/L), during which coronary angiography demonstrated unobstructed coronary anatomy and a diagnosis of probable myocarditis was given on each occasion.
+An electrocardiogram (ECG) on admission demonstrated no ischaemic changes . However, an initial cTnT was raised at 1588 ng/L (normal range <15 ng/L) and 1842 ng/L when repeated. This was in the context of a normal renal function [creatinine 102 (normal 62–106 μmol/L)] and a normal haemoglobin (137 g/L). Subsequent serial troponins did not drop below 1600 ng/L (timeline). Due to this stagnation, a creatine kinase level was measured and found to be only borderline raised at 338 U/L (normal 40–320 U/L). An echocardiogram was also performed which showed no regional wall motion abnormalities and a preserved left ventricular ejection fraction of 60–65%.
+Owing to the patient’s clinical picture, a CT aortagram was performed which excluded an aortic dissection and within its limits, a pulmonary embolus. Thus, a working diagnosis of acute coronary syndrome was suggested and he underwent a coronary angiogram. This showed only mild disease in the right coronary artery (, Video S1) and left anterior descending (, Video S2) whilst the left main stem and circumflex vessels (, Video S3) were unobstructed. Subsequently a cardiac MRI with gadolinium was performed which was unremarkable and confirmed preserved bi-ventricular function (, Videos S4 and S5) with no evidence of a scar, fibrosis, or oedema (, Video S6). Acute myocardial injury was therefore considered unlikely. Furthermore, he remained on telemetry and despite 7 days of cardiac monitoring, no arrhythmia was documented. After extensive investigations had excluded myocardial damage and any other clinical condition as a likely cause of the troponin elevation, the biochemistry laboratory was contacted for assistance in elucidating the cause of the persistently elevated cTnT.
+Initially, a measurement of cTnI was performed (Abbott diagnostics hs cTnI, LOD 2 ng/L 10% CV = 4.7 ng/L, 99th percentile URL = 26.2 ng/L) on the cTnT sample value 1674 ng/L, and was <2 ng/L, therefore excluding myocardial injury. Analytical interference causing a false-positive cTnT result was then suspected.
+Serial dilution of the sample using troponin free diluent was linear (recovery sample 73.1–94.7%, control 81.5–109.2%) although recovery at a one in 10 dilution was <100% compared with the control. This suggested that an analytical interference from an interfering antibody (anti-mouse) was unlikely. The Roche cTnT assay uses fragment antigen binding portions of 2 cTnT-specific mouse monoclonal antibodies (MAbs) directed against epitopes in the central region of human cTnT.
+One control (Randox IA3, Randox, County Antrim), two control patients (cTnT 2091 and 1637 ng/L) and two patient samples (cTnT 1745 and 1697 ng/L) were diluted one in two with troponin free diluent and with polyethylene glycol (25% w/v). Samples were incubated at room temperature for 10 minutes and centrifuged at 14°000 g for 5 min. Troponin T was analysed in the supernatant. Recovery was 705.8/1104 (63.9%) for the control material. For two control patient’s recovery was 687/807.4 (85.1%) and 910/963.4 (94.5%). For the patient’s day 4 sample recovery was 10.8/794.4 (1.4%) and for day 5 8.7/770.3 (1.1%). The presence of a macro form of cTnT was therefore confirmed. Subsequent electrophoresis using sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) and western blotting (immunofixation) with the M7 MAb anti-human cTnT (donated by Roche Diagnostics, Mannheim, Germany) against human cTnT and mouse anti-human immunoglobulin-G (IgG; IG266, Abcam, Cambridge, UK) revealed a cTnT-IgG complex .
+Following this diagnosis, reassurance was given and he was discharged home with routine follow-up arranged. A subsequent outpatient 24-hour Holter demonstrated only sinus rhythm, which reaffirmed the unlikelihood of a cardiac arrhythmia and a dobutamine stress echocardiogram found no evidence of inducible ischaemia with a normal functioning heart. He was safely discharged from the cardiology services.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1983_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1983_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a47959100d73247560ed7d20d062e00a205aa0e3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1983_en.txt
@@ -0,0 +1,7 @@
+We present a case of a 13-year-old boy, admitted to hospital for planned neurosurgical procedure of clipping aneurysm of left middle cerebral artery (arteria cerebri media [ACM]). He was previously hospitalized for urgent embolization and reembolization of ruptured right ACM (5/2017 and 6/2017). During reembolization, he developed allergic reaction with severe rash after induction of anesthesia. For that reason, clinical allergological testing on different anesthetic drugs was done. After clinical testing, the patient was proved allergic to midazolam, propofol, fentanyl, sufentanil, sevofluran, thiopental, rocuronium, and vecuronium.
+Before new planned aneurysmal clipping, he was prepared with metilprednisolon, antihistaminic, and ranitidine. Preoperative morning cortisol levels were slight higher (742 nmol/L) and adrenocorticotropic hormone (ACTH) was lower than range (<0.2 pmol/L).
+Because of patient's allergy to different drugs used for induction and maintenance of general anesthesia, and due to high demands for hemodynamic stability for aneurysmal clipping, anesthesia was performed with continuous infusion of etomidate and remifentanil, with scalp block and without use of neuromuscular blocking agents. We had previous good experience with continuous etomidate infusion for total intravenous infusion (total intravenous anesthesia [TIVA]) in neurosurgical patients; so, we decided to use etomidate in this case also.
+Our protocol for anesthesia maintenance with etomidate infusion is dose of 100 mcg/kg/min for the first 5 min after anesthesia induction, followed by 60 mcg/kg/min for the next 25 min and then 10 mcg/kg/min until the end of the surgery. The protocol is based on recommendations from other research, and our clinical experience.
+Enhanced anesthetic monitoring was used, with invasive blood pressure and entropy of encephalogram (Datex-Ohmeda S/5 Entropy Module), and the doses of etomidate used in this case enable isoelectric EEG for the time of clipping the aneurysm or burst suppression ratio greater than 70%. The surgery lasted for 4 h. There were no complications, hemodynamic, or any other sequellae during surgical procedure, and afterward, he was placed in neurosurgical intensive care unit (ICU) analgosedated and mechanically ventilated. The patient was awake and extubated 1 h after admittance to ICU and Glasgow Coma Score (GCS) was 15.
+Levels of cortisol and ACTH were measured during next three consecutive days. Only one measured cortisol value, in the morning the day after the surgery, was below reference range, and the values were back to normal until that evening .
+The explanation is more difficult due to the fact that the patient was prepared for the surgery with metilprednisolon because of his allergies which may diminish influence of perioperative stress on cortisol synthesis. ACTH returned to normal after the second day. He was dismissed from ICU on the second day with GCS 15.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1991_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1991_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..44b8cacfdcf9addd59c1210951c87f900a9d38b3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1991_en.txt
@@ -0,0 +1,2 @@
+A 65-year-old Egyptian woman with a history of type 2 diabetes, hypertension, primary hypothyroidism, and class-III obesity presented acutely to the emergency room (ER) with an intractable headache and blurred vision. She had also recently experienced a worsening of her diabetes control despite being on a basal-bolus insulin regimen. She had no clear-cut cushingoid features apart from central obesity, and she had no family history of pituitary tumors or similar illness. She is a stay-at-home mother to four. Children are all a product of uneventful pregnancies and were delivered normally. She is married for 20 years to a physician. She never smoked or drank alcohol.
+Computed tomography (CT) brain imaging and subsequent magnetic resonance imaging (MRI) showed a sellar mass consisting of a pituitary macroadenoma that measured 2.9 × 1.5 cm invading the roof of the sphenoid sinuses and compressing the neurophysis and the optic chiasm . She has central obesity but did not appear cushingoid or acromegalic. Visual field examination revealed left homonymous hemianopia and right homonymous inferior quadrantanopia . Initial laboratory investigations revealed elevated corticotropin (ACTH) levels of 33.6 (1.03–10.7) pmol/L, mildly increased prolactin levels of 66.3 (5.18–26.53) ng/ml , normal IGF-1 levels of 17.29 (4.68–31.72) nmol/L, and normal GH levels of 0.72 (0.18–20.6) mIU/L. The remaining anterior pituitary hormone levels were as follows: FSH was 12.50 (4.5–21.5) IU/L, LH was 3.5 (9–19) pmol/L, TSH was 1.441 (2.6–5.7) mIU/L, and free T4 was 13.1 IU/L (9–23). Further investigations confirmed Cushing’s disease as follows: 24-hour urinary free cortisol was grossly elevated at 391 µg/24 hours (6–123), serum cortisol after the 1 mg dexamethasone suppression test was 783 nmol/l (normal < 50 nmol/l). Serum cortisol after the high-dose dexamethasone suppression test was 613 nmol/l (20% reduction from baseline). She underwent uneventful transsphenoidal surgery (TSS) for decompression of the optic chiasm, which was successful at normalizing her visual fields; however, residual tumor was still present on follow-up MRI after 3 months . Interestingly, histology of the resected tissue showed staining for ACTH , GH , and PRL , with a Ki-67 proliferation index of less than 2%. Postoperatively, she experienced symptom resolution with normalization of the visual fields . A follow-up evaluation 12 months postoperatively showed a normal response to the 1 mg dexamethasone suppression test; her cortisol levels were < 27.6 nmol/L, and 24-hour urinary free cortisol was also normal at 177 µg/24 hours (21–292). MRI pituitary performed 17 months postoperatively showed redemonstration of the residual enhancing lesion seen in the suprasellar region closely related to the pituitary stalk, which remained stable in size, measuring 12.5 × 11.5 mm. Her diabetes mellitus and hypertension also became controlled on fewer medications with ability to discontinue insulin therapy. She remained asymptomatic with no biochemical evidence of recurrence 17 months postoperatively, and there was no need for any treatment utilization.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2006_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2006_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..efc825ef41793797ade774622629d50a4184a110
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2006_en.txt
@@ -0,0 +1,10 @@
+A female patient, aged 23 years and 10 months, sought orthodontic treatment with the main complaint related to esthetic concerns, described as “crowded lower teeth”. She was seeking a second opinion and wished to avoid tooth extraction, as well as any form of surgery. Her general state of health was good, with no contributing medical history. Pre-treatment facial photographs showed a convex facial profile, with a protruded lower lip. In the front view, a small asymmetry was visible on the right side, which was a bit rounded compared to the left side.
+The pre-treatment intraoral photographs showed a mild gingival recession in the mandibular left central incisor. The posterior teeth presented with a clinically significant palatal inclination and a constricted maxillary arch, with the right second premolar in crossbite. She presented an Angle’s Class II malocclusion, division 1, subdivision, crowding of 2 mm in the mandibular arch, and a 3-mm deep curve of Spee, 6.0 mm of overjet between teeth #11 and #41, and 2.0 mm between teeth #21 and #31, in addition to deep overbite. The width of the maxillary lateral incisors was proportionally smaller than that of the maxillary central incisors. The mandibular midline was deviated 1.5 mm to the right. Gingival recession was visible on the mandibular left central incisor.
+In the panoramic radiograph, all permanent teeth were visible, including extensive restorations in the second molars and tapered incisor root tips .
+The analysis of the pretreatment lateral cephalometric radiograph and tracings , ) revealed a Class II skeletal pattern (ANB = 7º) with a maxillary protrusion (SNA = 87º), protruded mandibular incisors (1.NB = 41º, 1-NB = 11mm and IMPA = 104º), and protruded maxillary incisors (1-NA = 7mm).
+The patient had a constricted maxillary arch, with mandibular molars and premolars that were lingually inclined as a compensatory mechanism. The first objective, therefore, was to expand the maxillary arch transversely to create an adequate skeletal width, in order to correct the position of the teeth. Additional objectives were to achieve correct overbite and overjet, and to improve the dental and skeletal relationships in the three planes of space.
+Options for treatment included the following: 1) Maxillary expansion with a Hyrax-type expander, which would require surgery (i.e., surgically-assisted rapid palatal expansion, SARPE); 2) Maxillary expansion with MARPE, in an attempt to avoid surgery; 3) Maxillary expansion with a Hyrax-type palatal expander fixed to the molars and premolars (a non-surgical procedure); 4) Align, level, and carry out dentoalveolar expansion with the orthodontic archwires and intermaxillary elastics; and 5) Perform light interproximal reduction and extraction of four first premolars.
+The second option was chosen as the treatment plan for this patient. Treatment was initiated with the placement of a 11.0-mm maxillary skeletal expander (PecLab, Belo Horizonte/MG, Brazil) fixed with four miniscrews (1.8x5x4 mm anterior and 1.8x7x4 mm) and two immediate activations (2/4 of a turn), followed by activations of two turns per day for one week. Pain and some discomfort in the palate and nasal cavity areas, as well as headache, was reported by the patient on the fourth day. These issues were resolved by diminishing the expansion to an activation rate of 1 turn per day and prescribing an analgesic.
+By the tenth day, the patient reported hearing clicks in the region of the palatal suture and, in the following days, reported the appearance of the midline diastema . There was a discrete opening of the anterior bite due to contact of the buccal cuspid of the left first maxillary molar, which moved in the direction of the overlapping mandibular molar. The activations were stopped after 25 turns and the appliance was stabilized. The radiographic image shows the opening of the midpalatal expansion .
+Subsequently, brackets were bonded to all teeth, except for the first molars. The following archwires were used: 0.016 x 0.016-in NiTi heat-activated, 0.016 x 0.022-in NiTi, 0.017 x 0.025-in NiTi heat-activated, 0.018 x 0.025-in SS, and 0.019 x 0.025-in SS finishing archwire.
+Miniscrews between the second premolars and first molars were applied to distalize the upper left molars and premolars.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_200_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_200_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..13c1a65dd8a51389241d376f821f3938f9174e1b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_200_en.txt
@@ -0,0 +1,4 @@
+A 17-year-old female was admitted to our hospital in December 2019 because of increased urine foam and fatigue for 3 weeks.
+Laboratory examinations showed protein (3+) and occult blood (2+) in urine. The blood urea nitrogen was 5.39 mmol/l, the serum creatinine was 69 μmol/l, and the lymphocyte ratio was 62.01%. Kidney color Doppler ultrasound showed increased volume in both kidneys as well as enhanced parenchymal echo. Then kidney biopsy was performed, indicating lymphoblastic lymphoma or leukemia with kidney involvement . Immunohistochemistry showed TdT(+), CD99(+), CD3(−), CD20(part+), CD73(−), PAX5(+), and LCA(part+). Fluorescence in situ hybridization (FISH) of the kidney biopsy sample indicated ZNF384 rearrangement . Then, bone marrow aspiration and biopsy were performed, revealing the disappearance of fat vacuoles and the appearance of immature lymphoid cells. However, conventional G-banding cytogenetic analysis showed a normal bone marrow karyotype . A suspected diagnosis of ALL was made. There was extreme lymphocyte proliferation and the proportion of lymphoblasts was 50.8% . Flow cytometry (FCM) of bone marrow revealed CD34(+), CD117(−), CD33(+), CD64(−), CD13(+), CD14(−), CD274(−), TSLPR(−), CD11b(−), IgM(+), CD71(−), CD56(+), CD2(−), CD7(−), CD5(−), CD10(+), CD3(−), CD4(−), CD8(−), CD38(+), CD81(+), HLA-DR(+), CD19(+), CD22(+), CD20(+), cMPO(−), cCD3(−), cCD79a(+), TDT(+), CD58(+), CD61(−), CD235a(−), and CD11c(−), and these findings are compatible with BCP-ALL . Next-generation sequencing (NGS) showed STAG2 gene mutations in the bone marrow, and reverse transcription-polymerase chain reaction (RT–PCR) showed that common fusion genes for BCP-ALL, including TCF3-PBX1, TCF3-HLF, ETV6-RUNX1 and BCR-ABL, were negative. Other less common fusion genes for Ph-like ALL were also negative.
+Her medical history was unremarkable. On physical examination, the patient had an anemic appearance without ecchymosis. The initial laboratory evaluation revealed lymphocytosis (2.37 × 109/l) and moderate anemia (Hb78 g/l, vitamin B12 164 pg/ml, folic acid 3.00 ng/ml and serum ferritin 426.7 ug/l). She was diagnosed with BCP-ALL with involvement of both kidneys.
+After a cycle of the VCDLP regimen, the bone marrow was obviously hyperplastic and active, and immature lymphocytes were occasionally observed. FCM showed the ratio of lymphoblasts was 42% with CD34(+), CD10(−), CD19(+), CD38(+), HLA-DR(+), CD64(−), CD13(+), CD20(−), and CD33(+). Since the patient did not achieve remission, a cycle of FLAG salvage treatment was administered, and then the patient was assessed as complete remission (CR). No lymphoblasts were seen in the bone marrow. FCM showed that the ratio of lymphoblasts was 0.8% with CD34(+), CD10(−), CD19(+), CD38(+), HLA-DR(+), CD13(+) and STAG2 gene mutations. The volume of both kidneys returned to normal according to color Doppler ultrasound. After the patient achieved CR, an intrathecal drug injection was performed for consolidation therapy. Eight months after the continued complete remission (CCR), the disease relapsed. A bone marrow smear revealed 55.2% lymphoblasts, and FCM showed ALL with partial expression of CD33. FISH showed ZNF384 rearrangement (39%) according to its probe and positivity for IgH rearrangement (37%). The leukemia fusion genes and mutation panels were both negative. However, there was no remission in the bone marrow after she was treated with chidamide and a dose-adjusted FLAG plus VP chemotherapeutic regimen, as well as a highly sensitive treatment, HAD. The percentage of lymphoblasts was 14.4% and ZNF384 rearrangement was positive (17.6%) according to FISH. Currently, the patient has been admitted to the hospital and is receiving chemotherapy regularly. The details of the treatment process are summarized in Additional file .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2018_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2018_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..af8261378561d71f34661e6f928645130ded28cd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2018_en.txt
@@ -0,0 +1,5 @@
+An eighty-four year old man attended our accident and emergency department with a severe headache, runny nose and confusion. Detailed history taking was not initially possible at first, but with the arrival of the patient’s relatives, we were able to elucidate further details of his history. The patient’s illness had started two weeks ago with symptoms of sinusitis. He was diagnosed with an upper respiratory tract infection by his general practitioner, and treated with oral antibiotics. We were informed by the relatives that the patient had been “blowing his nose” with increasing frequency over the last two weeks and had not responded to the treatment given by his general practitioner. His rhinorrhoea got much worse, and he then developed a severe headache with worsening confusion over the 24 hours preceding admission. He had sustained severe craniofacial fractures 43 years ago after a serious fall.
+He had undergone neurosurgery for this, but the precise details of the procedures performed were not clear although he had been left with a large scar on the right side of his forehead and an oculomotor nerve palsy. He had otherwise made an excellent recovery from this operation, and had a normal quality of life in full employment until retirement at the usual age. On examination, the patient was very confused. There have been no signs of recent trauma or head injury. Clinical examination revealed neck stiffness and photophobia. His white blood cell count (WBC) and C-reactive protein (CRP) slightly elevated. His chest radiograph was normal. Laboratory testing of the fluid from his nose confirmed it to be CSF; positive for glucose and beta 2-transferrin. The patient was confused and would not allow a lumbar puncture to be performed. Apart from confusion, system examination did not reveal any signs of focal neurological deficit.
+An urgent CT head was performed which showed a pneumocranium and fractures of the frontal bone to the right side of the frontal sinus, involving the superior and medial orbital walls . It was initially thought that the patient had an acute head injury, but the absence of physical signs on examination made us question this diagnosis.
+Urgent neurosurgical advice was sought. The skull fractures were considered to be old injuries on review of the scans and a diagnosis of occult dural injury with endocranial complications was made.
+We were advised to treat the patient conservatively with intravenous antibiotics and admission. He recovered rapidly and was discharged after three weeks with advice to avoid straining and maneuvers which could acutely raise intra-abdominal and intrathoracic pressure. He remains well on review 1 year later.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2021_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2021_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..400909a900a598f2519cb3b13f18971d7c77ed51
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2021_en.txt
@@ -0,0 +1,3 @@
+A 30-year-old pregnant Japanese woman was diagnosed with GDM at 23 weeks and 3 days of gestation during her first pregnancy, based on the results of a 75-g oral glucose tolerance test (OGTT). Her blood glucose levels before the test, after 60 min, and after 120 min were 81 mg/dL, 151 mg/dL, and 180 mg/dL, respectively. She was not obese before the pregnancy, had a height of 163 cm, a body weight of 54 kg, a body mass index (BMI) of 20.3 kg/m2 and had no family history of diabetes. She received dietary counselling, began SMBG (ONETOUCH UltraVue™ Johnson & Johnson, New Brunswick, NJ), and successfully achieved good glycemic control until the day of her delivery (a healthy boy with a birth weight of 3164 g). At 3 months after the delivery, she completed a follow-up 75-g OGTT, and the blood glucose levels before the test, after 30 min, after 60 min, and after 120 min were 82 mg/dL, 146 mg/dL, 102 mg/dL, and 189 mg/dL, respectively. Her plasma insulin levels before the test and after 30 min were 2.20 μU/mL and 33.2 μU/ml, respectively. Therefore, she was diagnosed with IGT based on these results, an insulinogenic index of 0.48, and a homeostatic model assessment of insulin resistance (HOMA-IR) result of 0.44. Thereafter, her HbA1c level was regularly monitored and ranged from 5.4% to 5.7%.
+At the age of 33 years, the patient became pregnant with twins. At approximately 5 weeks of gestation, her SMBG began showing high postprandial glucose levels (up to 140–180 mg/dL), and she began self-administered insulin injections using insulin aspart (Novo Nordisk) three times per day before each meal. The doses of these insulin injections increased with gestational age, and reached 20–22 units before each meal. At 31 weeks and 3 days of gestation, the patient was urgently admitted to our hospital due to premature labor contractions. We initiated a continuous intravenous infusion (500 mL/day of 5% glucose solution containing 50 mg of ritodrine) that was continued until the day of her delivery. The patient experienced adverse effects from the ritodrine, required complete bed rest, and her glucose levels kept increasing (2200 kcal/day in 3 meals). Even with 25 units of injected insulin before each meal, her postprandial glucose levels increased to 211 mg/dL at 2 h after lunch, and she occasionally experienced hypoglycemia (59 mg/dL at 3 h after lunch or 50 mg/dL at approximately 10 PM). Thus, to reduce the fluctuations in her glucose levels, her food intake (2200 kcal/day with 59% carbohydrates, 15% protein, and 26% fat) was separated into 5 meals: first breakfast at 8 AM, second breakfast at 10 AM, first lunch at noon, second lunch at 3 PM, and dinner at 6 PM. The patient also received 1 cup of yoghurt immediately before going to sleep . However, the patient subsequently experienced abdominal distension and difficulty eating, and we reduced her intake to 1960 kcal/day .
+Based on the increased meal frequency, the patient required more frequent SMBG and insulin injections, which she found to be painful and depressing. Thus, we introduced the FGM system, which does not require finger punctures, to reduce her physical and emotional burden. During the first few days after its introduction, the FGM system exhibited discrepancies with the results from the conventional SMBG method, especially when her glucose levels were <70 mg/dL or >180 mg/dL. Therefore, she measured her glucose levels using both methods when her glucose levels were abnormally high or low. The patient also experienced difficulty consuming the second breakfast because of the short interval between the first and second breakfasts. Thus, her intake was revised to 1960 kcal/day (53% carbohydrates, 21% protein, and 26% fat) in 4 meals: breakfast at 8 AM, first lunch at noon, second lunch at 3 PM, and dinner at 6 PM. The re-distributed meals and flash glucose monitoring system allowed the patient to achieve good glycemic control, and the doses of the injected insulin decreased to 35 units and then to 18 units . Her HbA1c level was maintained, ranging from 5.1% to 5.2% (these values were considered as a reference due to her anemia), and her glycoalbumin levels ranged from 10.6% to 11.6% during pregnancy. She gained 10.5 kg during her pregnancy and subsequently delivered twins via Caesarean procedure (2280 g and 2778 g) at 37 weeks and 1 day of gestation, without any adverse events or hypoglycemia. After the delivery, the patient stopped all insulin injections and had glucose levels of 70–140 mg/dL throughout the day with a normal puerperium diet (2200 kcal/day in 3 meals) . The patient and her twins were discharged in healthy states at 7 days after the delivery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2033_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2033_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..704a534cd69b46341ef6409cf69144116278c640
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2033_en.txt
@@ -0,0 +1,5 @@
+A 66-year-old female had complained of intermittent discomfort and pain in the right gluteal area. She had also noticed an alteration in bowel habit with recent constipation. The symptoms persisted, and she was treated with analgesia and laxatives.
+However, there was no specific diagnosis until she fell onto her back and fractured L2, L3 and L4 vertebrae which necessitated further imaging work-up with CT scan of the thoracolumbar spine. Of note, the fractures were stable and non-displaced. Hence, no need for surgical intervention. The CT scan performed to assess the spine revealed an incidental finding of a large mass extending from the right gluteal region into the pelvis. A CT scan of the pelvis was also performed, and this showed a large fatty intramuscular lesion extending into the pelvis through the greater sciatic notch . The differential diagnosis was listed as a possible lipoma or low-grade liposarcoma. As part of the diagnostic work-up for this right intramuscular gluteal mass with intrapelvic extension, the patient underwent MRI of the abdomen and pelvis. There was no suspicious soft tissue abnormality detected on the MRI of the abdomen but the MRI of the pelvis showed a large homogenous fat lesion noted in the right pelvic side wall between the gluteus maximus and gluteus medius muscles which extended into the pelvis via the greater sciatic foramen . There was no enhancing component. No heterogeneity or thickened or irregular septations were detected. The margins were distinct. The mass measures approximately 18.9 cm × 13 cm × 22.8 cm. The intrapelvic component of the mass measures approximately 10.5 cm × 6.2 cm × 12.1 cm. There was a leftward displacement of the rectum noticed as a result of the mass effect from the central pelvic mass .
+Physical examination revealed an area of firm induration/possible mass in the lower aspect of the right gluteal compartment. This was not tender and there was no associated redness or discoloration of overlying skin. Digital rectal examination showed normal anal sphincter tone and no mass was palpated within the anorectum.
+The patient proceeded to have a CT guided core needle biopsy of the mass. This showed scant fragments of fibroadipose and fibroconnective tissue without features of malignancy. There was focal myxoid change. However, the cytologic atypia that would warrant a diagnosis of atypical lipomatous tumor/well differentiated liposarcoma was absent. Furthermore, FISH for MDM2 amplification was attempted, but could not be performed due to sample inadequacy. The case was presented for discussion at the multidisciplinary tumor conference and the consensus recommendation was to proceed with surgical resection of the tumor. Following this, the patient underwent wide excision of the mass through a transgluteal approach and final pathology showed well-differentiated liposarcoma .
+Regarding follow up, the patient has been undergoing surveillance for 3 years. She was seen every 3 months for the first year after resection. Computerized tomographic scans of the chest, abdomen and pelvis were done every 6 months for the first year of surveillance. The patient was seen twice a year for the following 2 years. Computerized tomographic scans of the chest, abdomen and pelvis were done annually for years 2 and 3 of surveillance. The patient has remained disease-free; that is no evidence of local or distant recurrence of the liposarcoma or the sciatic hernia.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2038_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2038_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..49e3481e753ee8a7389cb676c4f7c0ab9f5c6217
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2038_en.txt
@@ -0,0 +1,2 @@
+A 16-year-old female came with mid backache since 3 months with bilateral lower limb weakness and urinary incontinence since 5 days. The backache was localized initially, gradually progressive aggravated since the past 5 days. The backache was not associated with any constitutional symptoms but the patient reported that the pain worsened at night. She noticed weakness while getting down the stairs 5 days ago and had difficulty in maintaining her balance while walking. Her symptoms rapidly progressed over 2 days and she was unable to walk without support with increased tightness in her lower limbs and also had urinary frequency and urge incontinence. She denies any history of trauma or fall. She gave a history of having undergone an surgical instrumented intervention in the mid back region for similar complaints 1 year ago. She does not report any history of trauma. She was brought on a wheel chair to our emergency department. On physical examination, the neurological examination of the upper limb along with the higher motor functions was found to be normal. The lower limbs were found to be spastic. Power in both the lower limbs was found to be 1/5. There was impairment in the touch and the pain sensations as well. Sensory level was found to be D10. The X-ray done of 1 year back was suggestive of the corrective measures taken for ver-tebral hemangioma . The patient was then subjected to magnetic resonance imaging (MRI). The axial and the sagittal T2 images of the MRI had high intensity signals in the extra osseous portion of D9 compressing the cord, indicating of vertebral hemangioma. This lesion was causing spinal cord compression, ultimately leading to acute onset paraplegia .
+The decision was taken by the consulting orthopedic surgeons to manage the case with surgical intervention. The patient underwent arterial embolization 12 h before surgery. Decompression with long segment instrumentation was performed (, ). On the 14th post-operative day, the patient had improved neurology with complete sensory recovery and Grade 2 power in right lower limb and Grade 1 power in the left lower limb. Histopathology report confirmed the findings correlating with that of hemangioma . At 6-month follow-up after aggressive rehabilitation, the neurology of the patient improves to Grade 3 power in the left lower limb and Grade 4 power in the right lower limb. However, the spasticity persisted but was reduced. The sphincteric control was also found to be fair at 6-month follow-up.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_203_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_203_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..33f168c228672e5ce308def6dba9cdea711fd679
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_203_en.txt
@@ -0,0 +1,8 @@
+The patient was a 60-year-old male who presented to the emergency department (ED) for a syncopal episode in the setting of ventricular tachycardia while at his cardiologist’s outpatient office. The patient has a past medical history of late presentation anterior ST-segment elevation MI 6 weeks prior to this event. During that time, he reported 1 week of anginal symptoms before his MI. He received two drug-eluting stents in the non-culprit right coronary artery and one in the culprit proximal left anterior descending artery. At time of his prior hospital discharge, echocardiogram demonstrated a left ventricular ejection fraction (LVEF) of 40–45% and an apical thrombus. He received antiplatelet therapy with aspirin 81 mg daily and ticagrelor 90 mg twice daily, as well as rivaroxaban 2.5 mg twice daily for the apical thrombus.
+On admission following his syncopal event, the patient was haemodynamically stable in normal sinus rhythm on an amiodarone infusion. A physical exam was significant for a prominent and laterally displaced point of maximal impulse, the presence of hepatojugular reflux, and muffled heart sounds.
+Laboratory findings were significant for a haemoglobin of 11.9 g/dL (normal range is 13.5–17.5 g/dL), an NT-pro BNP of 2549 pg/mL (normal value is <300 pg/mL), and a high sensitivity troponin T of 26 ng/L (normal value is <59 ng/L). Initial renal function, electrolytes, and liver function testing were within normal limits. Chest radiography showed an enlarged cardiac silhouette. Electrocardiogram revealed normal sinus rhythm with pathologic Q waves in inferior and anteroseptal leads along with low-voltage QRS complexes with an amplitude <5 mm in the limb leads and 10 mm in the chest leads (see , ). An urgent TTE showed a large circumferential pericardial effusion, severe left ventricular (LV) systolic dysfunction with an LVEF of <15%, and a large apical LVA with pathologic thinning and diastolic deformity ( and , ).
+The patient was initiated on intravenous amiodarone, and anticoagulation was held in the setting of the pericardial effusion with associated LVA. Urgent diagnostic and therapeutic pericardiocentesis was completed with the removal of 600 mL of sanguineous fluid. Incomplete effusion drainage was noted following the procedure suggesting loculated characteristics of the haemopericardium. Cardiothoracic surgery was consulted given the concern for contained LVA or pseudoaneurysm rupture as the underlying aetiology.
+Subsequent computed tomography angiography (CTA) of the chest showed a moderate volume pericardial effusion and a large lobulated LVA measuring 74 mm × 84 mm × 79 mm without signs of active contrast extravasation into the pericardial space . Cardiac magnetic resonance imaging (cMRI) was suspicious for contained ruptured LVA; it showed striking dilation of the mid to distal LV wall with severe myocardial thinning and difficulty identifying myocardium at the apex ( and , ). Interval development of a large, mobile LV thrombus was also noted. Left heart catheterization revealed patency of all previously placed drug-eluting stents (see , ).
+During his hospitalization, the patient remained in the medical intensive care unit for bed rest and haemodynamic monitoring. Cardiothoracic surgery performed excision and repair of the LVA with placement of an LV endovascular patch (see , ). Intraoperative findings include the presence of a small rent at the apex of the aneurysm, which was tightly adhered to the overlying pericardium. Pathology reports confirm partially granular myocardial tissue composition of the specimen.
+Post-operative TTE was notable for an improved LVEF of 61% with continued apical akinesis and small aneurysm with possible small associated thrombus ( and , ). CTA revealed post-surgical changes with resolution of the pericardial effusion without evidence of an LV thrombus . Guideline-directed medical therapy was initiated with metoprolol succinate 25 mg daily, losartan 25 mg daily, and spironolactone 25 mg daily; statin was initially held due to reported intolerance. Oral amiodarone 200 mg daily was continued for 1 month for arrhythmia management. Antithrombic therapy with aspirin 81 mg daily and clopidogrel 75 mg daily was started. Anticoagulation was held in the setting of completed left atrial appendage ligation and without signs of further thrombus.
+The patient was clinically well without further symptomatic concerns of haemopericardium or heart failure 1 month post-operatively. The patient continued to participate well in his cardiac rehabilitation program and was cleared to return to work.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2049_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2049_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8cbdad8b5c894a2db6b9e0dd495840bc1f54b400
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2049_en.txt
@@ -0,0 +1,2 @@
+A 56-year-old male patient received coronary angiography via the right radial route in a local hospital due to sudden onset of unstable angina pectoris. During the procedure, the cardiologist found that the right brachial artery was tortuous, and the guide wire was unable to pass through that region. Then, the cardiologist used the left radial artery to complete the angiography. The result showed tri-vessel disease suitable for coronary artery bypass grafting surgery. When they were removing the guide wire from the right radial artery, the guide wire broke and became stuck in the right brachial artery because of arterial spasm. They immediately infused heparin through the right radial artery to prevent thrombosis. Afterwards, they tried to pull the broken guide wire out through the femoral artery with a wire loop snare, but failed. The length of the broken wire was approximately from the distal radial artery to the brachiocephalic artery . The patient was referred to our hospital for emergency surgery.
+The patient received OPCABG concomitant with the retrieval of the broken guide wire stuck in the brachial artery under general anesthesia. First, the right brachial artery was dissected and exposed. After clamping the proximal brachial artery, we incised it and removed the broken guide wire completely . Then the incision was closed as routine, and the emergency OPCABG was performed, including one arterial graft (left internal mammary artery to the left anterior descending artery) and one sequential great saphenous vein (aortic top end to the first diagonal branch to the obtuse margin branch to the posterior descending artery). The whole procedure was carried out smoothly, and no obvious guide wire residue was observed by postoperative chest X-ray. The patient was discharged uneventfully, and the 12 month follow-up showed an excellent surgical outcome.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2051_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2051_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0ca4c600a846fdd619df52bcece8d191e3eebee5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2051_en.txt
@@ -0,0 +1,2 @@
+A 75-year-old woman was admitted to the hospital with abdominal pain, nausea and vomiting for 3 days. She did not drink alcohol, and there was no clinical or biochemical evidence of primary liver disease or coagulopathy. Physical examination revealed mild tenderness in the right upper abdominal quadrant. Laboratory tests revealed that the percentage of neutrophils (N%) was 80.3% (50–70%), alanine aminotransferase (ALT) was 192 U/L (< 64 U/L), aspartate aminotransferase (AST) was 66 U/L (< 64 U/L), γ-glutamyl transpeptidase (γ-GT) was 197 U/L (< 47 U/L), and all other laboratory parameters were normal (e.g., haemoglobin and platelet counts, prothrombin time, and renal function). An abdominal computerized tomography (CT) scan demonstrated dilatation of the extrahepatic bile duct with a stone at the lower CBD and sludge in the gallbladder. Bile duct cholangiopancreatography revealed a dilated CBD (10 mm in diameter) with a round filling defect (8 mm in diameter) . Balloon dilation (10 mm in diameter) of terminal CBD after a 5-mm long sphincterotomy for extraction of the stone was uneventful. Unfortunately, she presented with cholangitis and a significant increase in the percentage of neutrophils (94%) and cholestatic parameters (total bilirubin 111.1 μmol/L (2–18 μmol/L), direct bilirubin 81.3 μmol/L (< 7 μmol/L), ALT 465 U/L, AST 538 U/L, and γ-GT 634 U/L) after 3 days.
+A high-density image of the middle CBD with a markedly dilated biliary tree was revealed on the second CT . Thus, ERCP was repeated. A long filling defect was noted in the dilated common bile duct , and a blood clot (maximum diameter 35 mm × 10 mm) was extracted with a basket . Then, an endoscopic nasobiliary drainage (ENBD) tube was inserted into the CBD to ensure continued biliary drainage. Two days later, her temperature returned to normal, and abdominal pain was relieved. Histopathological examination revealed massive red blood cells with white blood cells and tissue necrosis . After the treatment, she recovered and was discharged without any other complication.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2052_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2052_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..82b5b57969bfb13153a249262d1f22467d5b6d88
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2052_en.txt
@@ -0,0 +1,6 @@
+On 6 May 2020, a 65-year-old male was admitted due to a 20 day history of weakness and numbness of the right upper extremity. This extremity weakness worsened in the last 4 days. He has a past medical history of diabetes mellitus, hypertension, and Adult Still’s Disease. His Still’s Disease is currently being managed with methylprednisolone.
+On physical examination, his blood pressure was 129/77 mmHg, pulse rate was 88 min−1, and body temperature was 36.7°C. An increase in muscle tone was observed in both upper extremities. His muscle strength was 5/5 in the left upper extremity, and 4/5 in the right upper extremity. Additionally, his biceps tendon reflex, triceps tendon reflex, radial membrane reflex (+++), knee tendon reflex (++++), and Achilles tendon reflex (++) were heightened.
+On hospital day 1, he developed a fever (38.7°C), prompting a blood examination. On hospital day 2, repeat blood cultures were collected. The first set of blood cultures tested positive after 2 days. However, subsequent blood culture tests conducted 1 week later returned negative. Cranial computed tomography (CT) revealed multiple abscesses in the right frontal and occipital lobes, and both parietal lobes. On auscultation, he had coarse and minimal breath sounds. Moreover, chest CT revealed necrosis and abscesses in the lower lobes of the left lung. Tenderness in the right subabdominal McCormack point was also observed. An abdominal CT revealed an abscess in the left kidney. Laboratory examination revealed an elevated white blood cell (WBC) count (12300 /µl), neutrophils 86.4 %, decreased haemoglobin (120 g l−1), normal platelet count (274000 /µl), and increased C-reactive protein (84.9 mg l−1). Immunological testing revealed the following results: CD4 lymphocytes 40 %, CD8 lymphocytes 35 %, and CD4–CD8 ratio of 1.14. Humoral immunity testing revealed the following results: immunoglobulin (IgG of 6.09 g l−1, IgA of 0.92 g l−1, IgM of 0.94 g l−1, complement C3 of 0.854 g l−1, and complement C4 of 0.081 g l−1). He was negative in an HIV screening exam. But his HBsAg, HBeAb, and HBcAb were positive.
+On 8 May 2020, he was started on meropenem and vancomycin. On 14 May 2020, R. equi was isolated from his blood culture. Antimicrobial susceptibility testing was not performed because it was a rare bacterium that lacked a standardized drug-sensitive breakpoint. Though he was given broad-spectrum antibiotics, his symptoms failed to improve even after receiving intravenous vancomycin and meropenem for 20 days.
+Antimicrobial susceptibility testing with broth microdilution was performed on 11 June 2020. The cultured organism was found to be resistant in vitro to penicillin, erythromycin, and vancomycin, and susceptible to ciprofloxacin, levofloxacin, imipenem, linezolid, and compound sulfamethoxazole according to CLSI M45 A3. Drug-sensitive breakpoints were referred to Staphylococcus aureus. His treatment regimen was then altered to linezolid and meropenem. However, these medications were discontinued due to drug-induced bone marrow suppression and liver injury. The patient later suffered liver failure and died at home.
+R. equi is a non-motile Gram-positive obligate aerobic coccobacillus . The Christie–Atkins–Munch–Peterson test was performed on blood agar plates with Staphylococcus aureus (ATCC 25923). After 24 h of incubation, R. equi hemolysed in the form of an arrowhead near S. aureus . After 48 h of incubation, aerobic non-hemolytic, mucoid, and white colonies were evident . The organism was identified as R. equi by MALDI-TOF VITEK MS. Conventional methods revealed catalase positivity, urease positivity, oxidase negativity, gelatinase negativity, and a failure to oxidize or ferment carbohydrates.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2061_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2061_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..75d7b59b93abde6127a6987a26de827ed009c5eb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2061_en.txt
@@ -0,0 +1,5 @@
+A 31-year-old male patient presented to the hospital with a progressively growing mass in the right lower abdomen, along with abdominal discomfort. Symptoms are discovered 1 week before admission. Prior to seeking care at our facility, the patient had undergone abdominal CT imaging at a community hospital, which revealed the presence of an abdominal mass. An abdominal CT scan revealed a well-defined mass measuring 3.9*2.9 cm, located anterior to the right psoas muscle at the level of the external iliac vessels . Enteroscopy revealed no evidence of colonic abnormalities, and blood tests did not indicate any abnormalities.
+During exploratory laparotomy, the mass was identified in the distal ileum, exhibiting clear margins, firm consistency, and a maximum diameter of 4 cm. However, the nature of the mass could not be determined during surgery. Consequently, partial resection of the ileum and cecum was performed, followed by ileocolonic end-to-end anastomosis, with no postoperative complications.
+Gross examination of the resected specimen revealed a grey-white nodular mass measuring approximately 4*3*5 cm, characterized by a firm and scar-like consistency . Histologically, the mass extended from the submucosal layer to the serosa of the distal ileum, infiltrating and growing within the intestinal wall and adipose tissue, displaying a fascicular or woven pattern arrangement. The spindle-shaped cells exhibited abundant cytoplasm, elongated nuclei with wavy features, interspersed with collagen fibers, and minimal infiltration of inflammatory cells (, ).
+Immunohistochemical analysis demonstrated diffuse nuclear expression of β-catenin , along with nuclear positivity for vimentin (Vim), smooth muscle actin (SMA), and desmin (Des). The mass was negative for CD34, DOG-1, S-100, ENA, actin, and S-100. The final pathological diagnosis confirmed primary DF of the distal ileum (invasive fibromatosis).
+Upon discharge from hospital, our patient had demonstrated clinical improvement and stability following surgery. Based on our findings, we recommend a regular follow-up schedule for patients. This includes appointments every 3 months during the first year post-surgery, followed by appointments every 6 months for the next 5 years, and then annual appointments thereafter. The follow-up examinations should encompass collection of medical history, physical examination, blood tests, ultrasounds, and CT scans, among other assessments. No additional treatment was administered after surgery, and the patient remained disease-free during the first year of follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2081_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2081_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5899c599d6e58f29831974da43f14f45d7438038
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2081_en.txt
@@ -0,0 +1 @@
+A 12-month-old female without a family history of retinoblastoma presented with unilateral group C retinoblastoma in her right eye. A solitary tumour with retinal breaks on the tumour surface was observed at the 8 o’clock of the retina. Vitreous seeds overlying the tumor were also observed . After two cycles of intra-arterial chemotherapy with 5 mg melphalan (Alkeran, GlaxoSmithKline, Italy), the main tumour displayed significant regression but the vitreous seeds overlying the tumour were still active . Because of the persistence of vitreous seeds and the inadequate response to intra-arterial melphalan treatment, intravitreal melphalan (8 μg in 0.05 mL) was injected using a 32- gauge needle 2.5 mm from the 5 o’clock position of the limbus, the meridian opposite to the vitreous seeds. Cryotherapy was applied at the injection site, and the eye was moved in all directions for several times to improve drug distribution as previously described . The main retinal mass exhibited further regression, and all vitreous seeds were resolved without further treatment and displayed no recurrence. However, 1 month after the intravitreal injection, the retina around the injection site demonstrated diffuse retinal pigment epithelium alterations with dense hard exudates . At the 3-year follow-up, her best corrected vision is 20/60, the exudates partially resolved but diffuse chorioretinal atrophy persisted after the single low-dose of melphalan injection .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2090_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2090_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bcab9dd39d58aaf8a6c691a97e5de4bdfd9c48d9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2090_en.txt
@@ -0,0 +1,5 @@
+The patient was a 67-year-old man with no significant medical history. He presented to the Nanjing Brain Hospital for the first time on July 4, 2016 with new onset frequent attacks of left limb convulsions without loss of consciousness nor incontinence for 6 days. The brain MRI from another hospital on June 30, 2016 showed abnormal signals in the left cingulate gyrus. During the hospitalization, the patient presented with frequent attacks (ten or more ictal attacks a day) of the left limb convulsions. Duration of attacks ranged from dozens of seconds to several minutes. There was no abnormality during the interval of the seizures. In the interictal period, the patient had no fever or headache, no mental or behavioral abnormalities, no dysphagia, no weakness of limbs, or other complications of nervous system.
+Routine laboratory studies including blood and urine routine tests, coagulation tests, liver and renal function, blood sugar, glycosylated hemoglobin, antinuclear antibody, erythrocyte sedimentation rate, anti-cardiolipin antibodies, phospholipase A2, thyroid function, HIV and syphilis, were all unremarkable. Anti-glutamic acid decarboxylase (GAD) antibody was negative. Serum carbohydrate antigen 72–4 was 17.56 IU / ml (normal < 6.00 IU / ml), more than normal. Lumbar puncture revealed the CSF pressure of 100 mmH2O. Examination of the CSF showed white blood cells of 4/μl, protein levels of 0.45 g/L (normal 0.2 ~ 0.4 g / L). The concentrations of glucose and chlorine in the CSF were normal. Anti-NMDAR antibodies were detected in CSF and serum using a commercial kit (Euroimmune, Germany) by indirect immunofluorescence testing (IIFT) according to the manufacturer’s instructions for twice. Anti-NMDAR titers were 1:10(++) in CSF and 1:32(++) in serum. Anti-AMPA1, AMPA2, LG1, ASPR2 and GABAB receptor antibodies in CSF and serum were negative. Tests for paraneoplastic antibodies (Hu, Yo, Ri, Ma2, CV2, Amphiphysin, ANNA-3, Tr, PCA-2, GAD) in CSF were all negative. Chest CT did not reveal any lesions concerning for malignancy. Video-EEG showed slight abnormality (all visible more low amplitude fast wave guide, especially the front head). Brain MRI scan and enhanced scan showed long T1 and long T2 abnormal signal on the bilateral frontal parietal, proximal midline, diffusion weighted imaging (DWI): high signal intensity, patchy eccentric mild enhancement . MRS showed N-acetyl aspartate (NAA) peak decreased and no increase in choline compounds (Cho) peak. Therefore, lesions were considered the possibility of non-neoplastic lesions.
+With a presumed diagnosis of anti-NMDAR encephalitis, the patient was treated with intravenous dexamethasone 10 mg/d × 11d → methylprednisolone 200 mg/d × 3d → methylprednisolone 80 mg/d × 3d → gamma globulin (20 g/d × 5d), oral prednisolone acetate tablets (40 mg qd) and antiepileptic (oxcarbazepine 300 mg bid). The epileptic seizures were slightly alleviated after treatment. The main manifestation was the twitching with spasms of the left upper and lower extremities, each lasting several seconds to more than ten seconds, attacking several times a day, without alteration of consciousness. Then the patient was discharged home.
+Two months later, the patient presented to the hospital for a second time. He had suffered from frequent attacks of the left limb. Physical examination showed no abnormalities in the nervous system. Results from routine biochemical and cytological examination of the cerebrospinal fluid were normal. Anti-NMDAR titers were 1:32(+++) in CSF and 1:32(++) in serum. The brain MRI showed bilateral frontal parietal lesions enlarged slightly and the enhancement became more obvious than before . The patient was treated for a second time with intravenous injection of methylprednisolone (80 mg/d × 15d) → oral prednisolone acetate tablets (40 mg qd), immunoglobulins (25 g/d × 5d), oral azathioprine (50 mg qd), oral antiepileptic (oxcarbazepine 600 mg bid, Debakin 250 mg qm, 500 mg qn) treatment. The epileptic seizures were slightly alleviated after the treatment, 2~3 times a day, the twitching with spasms of the left limb typically lasts a few seconds, without loss of consciousness. Then the patient was discharged home.
+Four months later, the patient presented at the hospital for a third time. He complained of weakness after frequent partial seizures in his right limb. Muscle Strength Grading Scale of the right lower extremity was 4/5 and physical examination of the remaining nervous system showed no significant abnormalities. The diagnosis was simple partial status epilepticus and Todd’s Paralysis. Epilepsy was controlled on diazepam injection therapy and the muscle strength of the right lower extremity returned to normal. The brain MRI reexamination indicated that the frontal parietal lesions enlarged and one new lesion appeared in the left basal ganglia with some mild mass effect, significantly enhanced . Diffusion tensor imaging (DTI) showed partial ablation of white matter fibro tracts in the bilateral frontal parietal lobe and the left basal ganglia lesion, reduction of FA and the surrounding fibro tracts slightly compressed . Arterial spin labeling (ASL) MR imaging showed that bilateral frontoparietal and left basal ganglia lesions had abnormally high perfusion . Surgical biopsy of the right parietal lesion was performed under general anesthesia on November 21, 2016. The lesions were pale red, slightly tough, abundant blood supply and without clear border. The size of the removed lesion was about 1.5 × 1.5 × 1.0 cm. The astrocytoma (WHO II-III) was confirmed on histopathologic findings. Patients transferred to the oncology department for further radiotherapy and chemotherapy. One month later, the patient died.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2116_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2116_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..02380d5e7298afbdca96077a30d89b0287da9c5c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2116_en.txt
@@ -0,0 +1,4 @@
+We report a 26-year-old female and her 28-year-old healthy male partner, who experienced difficulties in becoming pregnant since 2015. Female patient had a regular menstrual cycle, but was previously diagnosed with endometriosis in 2012 following laparoscopy, for which she received treatment with goserelin acetate implant (Zoladex®). In January and October 2016, the couple experienced two first trimester miscarriages after natural conception at 5/6 weeks (gestational sac and yolk sac were visible by obstetric ultrasonography) and at 4/5 weeks (only gestational sac was visible) of gestation, respectively. The couple then turned to assisted reproduction in 2017 due to fertility issues. Because of history of endometriosis, the female patient underwent laparoscopy again in April 2017, but no endometriotic lesions were found and fallopian tubes were patent. The female patient was then followed up for multiple cycles for the presence of a dominant follicle. In addition, she was administered with alpha chorionic gonadotropin (Ovitrelle®) and dihydrogesterone (Duphaston®) but failed to conceive. In September 2017, the couple enrolled into IVF/PGT-A program at fertility clinic at West-Tallinn Central Hospital for elective embryo transfer to assist in achieving a successful pregnancy. An informed consent was also obtained, allowing to use supernumerary/affected embryos for research purposes.
+Controlled ovarian stimulation was performed using recombinant follicle-stimulating hormone, followed by a gonadotropin-releasing hormone (GnRH) antagonist protocol. Final oocyte maturation was triggered by human chorionic gonadotropin administration 36–38 h prior to oocyte retrieval. In total 19 oocytes have been retrieved and all of them were fertilized by conventional IVF. The presumed zygotes were then cultured in a SAGE-1 single step media (Origio, Denmark) until day 5 blastocyst stage. Subsequent embryo morphological evaluation was performed according to the criteria set by Gardner and Schoolcraft . Trophectoderm (TE) biopsy was performed on four embryos that reached the blastocyst stage using RI Saturn 5 Active™ Laser and on average 5–10 cells were aspirated per embryo. Following TE biopsy, all blastocysts were vitrified using MediCult Vitrification Cooling medias (Origio).
+For PGT-A, commercially available VeriSeq PGS kit (Illumina Inc., USA) was used for next-generation sequencing (NGS)-based aneuploidy screening. Briefly, TE biopsies were whole-genome amplified (WGA) according to ligation-mediated PCR-based SurePlex protocol (Illumina Inc., USA). The quality of WGA products was controlled on 1.5% agarose gel and the amount of amplified material was quantified by Qubit dsDNA HS Assay kit (Thermo Fisher Scientific, USA). Next, successfully amplified samples were used for library preparation, according to the manufacturer’s VeriSeq PGS kit protocol, and were sequenced on the Illumina MiSeq system. Subsequent CCS was performed using Illumina BlueFuse Multi v4.3 software with an embedded aneuploidy calling algorithm. Based on TE biopsy results, embryo classification was performed according to Preimplantation Genetic Diagnosis International Society (PGDIS) guidelines and recommendations for embryo prioritization (PGDIS, 2016).
+For blood cell karyotyping, conventional GTG-banding technique (G-bands by trypsin using Giemsa; band level 550) was used for staining metaphase chromosomes from peripheral blood lymphocytes. Chromosome aberrations were classified according to the International System for Human Cytogenetic Nomenclature (ISCN2016).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2118_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2118_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..af0cb5f0b04ef285b3d5b99ee4e4b935bceb34f4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2118_en.txt
@@ -0,0 +1 @@
+A 10-year-old right-handed girl fell from a monkey bar and sustained a left flexion-type SHF and a radial shaft fracture with UN palsy, which were immediately operated on at another hospital . During the surgery, open reduction and internal fixation by Kirshner wires were performed anteriorly under direct visualization of the UN, which was not grossly damaged . Four-month postoperatively, she was referred to our department with complaints of an asymmetrical cosmetic elbow deformity and residual UN palsy. On examination, she had full range of elbow motion restored with cubitus valgus deformity while presenting loss of sensation in the UN territory and gross intrinsic muscle atrophy with claw deformity and positive Froment and Egawa signs . The Tinel sign of the UN was positive just proximal to the fracture level. Radiographic images showed 17° of cubitus valgus deviation with contralateral deviation of 3° in the humerus-elbow-wrist (HEW) angle . An electrodiagnostic study conducted five months after the injury showed non-evoked compound motor action potential of the abductor digiti minimi and sensory nerve action potential of the little finger, and denervation potentials of the flexor carpi ulnaris and the first dorsal interosseous. To treat the deformity and persistent UN palsy, half a year after the injury, her elbow was re-explored by a posterior approach. It was found that the UN was adherent to surrounding soft tissues at the level of the positive Tinel sign, without any gross nerve abnormality. Considering traction-type neuropathy, the UN was subcutaneously transposed with neurolysis . Moreover, corrective osteotomy of the distal humerus 14° was conducted using a locking plate . The elbow was placed in 90° of flexion in a long arm splint for 3 weeks. Soon after the surgery, she showed improvement of sensory disturbance and numbness. The plate was removed 10 months after the surgery . At 14-month postoperatively, she demonstrated a satisfactory symmetrical elbow appearance, with restored grip strength (right: 26 kg, left: 23 kg), key pinch (right: 5.0 kg, left, 4.5 kg), full range of elbow motion (0–150°), and 5-mm 2-point discrimination of the ulnar ring finger and little finger .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2135_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2135_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b4225cb13cce4a700b75e24be47f333bf514bbe5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2135_en.txt
@@ -0,0 +1,12 @@
+A 69-year old female patient, with a previous history of hypertension, thyroidectomy due to hyperthyroidism and hysterectomy for uterus myomas, presented with a progressive swelling of the dorsal aspect of the right side of her neck without signs of vascular obstruction or venous stases. No abnormalities of neural status of the head and neck were observed. There was no functional or sensory loss of the right upper extremity. No signs of Horner's syndrome, dysphagia, cough or dyspnoe were evident. CT scan demonstrated a retroclavicular soft tissue tumour with a cranio-caudal extension of up to 4.5 cm which partially displaced the trachea to the left and compressed the subclavian vein. An adjacent tumour of dimensions 3.5 × 3.5 cm not clearly separated from the before mentioned tumour was located at the inferior right thyroid lobe, compressing the internal jugular vein. Near the confluence of these vessels a subtotal occlusion of the brachiocephalic vein is revealed . The MRI scan added no further information on the origin of the tumour or the cause of venous occlusion. There were no clear signs of tumour infiltration of the brachial plexus, brachial artery, esophagus or trachea. The preoperative chest x-ray displayed a right sided upper mediastinal enlargement . Additional venous angiography indicated a filiform stenosis of the subclavian vein. Within the brachicephalic vein a longitudinal, irregular partial displacement of the vascular lumen was depicted. Extensive blood flow in cervical and supraclavicular collateral vessels was present. Neither MRI, CT nor angiogram allowed for clear distinction of the intravascular process whether it was caused by intravascular tumour growth or thrombosis. Incisional biopsy one month prior to the oncological tumour resection revealed the histopathological diagnosis of a leiomyosarcoma.
+Surgical exposure was obtained via a triangular incision running from behind the right ear, along the anterior axillary line and across the sternum. First, the brachial plexus was dissected, the phrenic and recurrent nerves identified and followed distally. The upper border of the tumour became visible at the upper thoracic aperture. The recurrent nerve was observed to run through the tumour capsule. Further preparation was carried out from the distal edge of the wound. The pectoralis major muscle was elevated and care was taken to preserve the vascular pedicle (thoracoacromial A.V.). It was further observed that the first intercostal space was invaded by the tumour. Subsequently a thoracic wall resection including a partial resection of the right clavicle, the right half of the sternum and the costal attachment of the first three ribs was performed uncovering the mediastinum. The vena cava was revealed and trachea dissected. In this area the tumour was in close proximity to the trachea displacing it to the left but without tracheal infiltration. Next, the carotic artery and the jugular vein were exposed.
+The tumour, located in the right supraclavicular region/upper mediastinum, was found to surround both the subclavian and the internal and external jugular vein. Hence a resection of the subclavian vein proximal to its conjunction with the superior vena cava was required. The internal as well as the external jugular vein were incorporated into the tumour conglomerate . The tumour was resected en bloc. A partial resection of the clavicle, partial resection of the sternum with removal of the brachiocephalic, sublcavian and right jugular vein and the recurrent nerve was necessary to obtain clear resection margins. The defect coverage was achieved by a pedicled myocutaneous pectoralis major island flap.
+Within the surgical specimen multiple nodular polypoid tumour masses of soft consistence with diameters of up to 3.6 cm, immediately adjacent to vascular structures of the subclavian, internal jugular and brachiocephalic vein were present. The tumour with its intravascular and extravascular components comprised a total area of 7.6 × 8 × 3.3 cm. The largest intravascular tumour sprout extended close to the resection surface of the vessel.
+The macroscopic appearance resembled an intravascular tumour originating from the subclavian vein with infiltration of extravascular structures.
+Microscopically the spindle-shaped cells of this mesenchymal neoplasm originated from the media of the venous vessel wall . The tumour cells formed various fascicles interwoven with other longitudinal cross sectional neighbouring fascicles . The tumour cells were characterized by an eosinophilic cytoplasm and cigar shaped nuclei. The mitotic rate was 19/10 HPF (per high power field). Some foci of tumour necrosis were present.
+The neoplasm derived from the media of the vessel wall, disrupted the existing vascular architecture and formed an intravascular tumour sprout.
+Immunohistochemically the majority of tumour cells were positive for smooth muscle actin and desmin. A positive reaction for the proliferation marker Ki 67 was found in 25% of all tumour cells,
+Thus confirming the diagnosis of an intravascular leiomyosarcoma (malignancy grading GII)
+Postoperatively only mild signs of mixed venous and lymphatic stases of the upper extremity following the resection of the subclavian vein were observed due to the well established collateral blood flow (as seen in the preoperative angiogram). These symptoms could be positively influenced by elastic compression dressings and physical lymph drainage. Owing to the resection of the right recurrent nerve, right sided vocal cord palsy occurred. Logopaedic training was initiated. The patient recovered well and was discharged two weeks later. Both pre- and post-operatively no symptoms of pulmonary embolism were detected.
+Unfortunately the patient declined the recommended radiation therapy.
+After an initial 5 month of tumour free survival without evident signs of either local or systemic metastasis a tumour relapse was detected. At this stage the patient refused further treatment apart from a palliative chemotherapy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2158_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2158_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..dbb470f506aee18a4a2b8fe4f33ccb224c2c91c3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2158_en.txt
@@ -0,0 +1,6 @@
+A 36-year-old Japanese female was referred to our hospital with morbid obesity and T1DM. She was diagnosed with T1DM at the age of 6 years, thereafter, treatment with multiple daily insulin was started. By the age of 20 years, she had a body weight of 70 kg, increasing to > 100 kg at the age of 34 years. Her required daily dose of insulin increased as a function of her body weight. At her initial assessment, she required 45 units of insulin aspart and 30 units of insulin glargine per day. Although a temporary weight loss and reduction in daily insulin dose was achieved with an in-hospital treatment, her weight rebounded shortly after discharge and the patient experienced difficulty in controlling her body weight. The patient expressed her intention for surgical treatment for weight loss, and she was referred to our department.
+At the time of admission, her height was 159 cm and her weight 106.7 kg, BMI of 42.2 kg/m2. Blood analyses indicated HbA1c of 9.0%, and blood C-peptide levels were undetectable (< 0.01 ng/mL), suggesting her insulin secretion capacity was completely depleted. With medication, her blood lipid levels were within normal range. On computed tomography (CT) examination, the calculated visceral fat area was 162.6 cm2, with a subcutaneous fat area of 527.9 cm2, measured at level of the umbilicus . Upper gastrointestinal endoscopy revealed no abnormalities in the esophagus, stomach, or duodenum.
+To prevent complications associated with rapid postoperative blood glucose improvement, she was admitted to our hospital 2 weeks before operation for strict glycemic control, dietary restrictions, and exercise therapy. As a result, preoperative HbA1c was reduced to 7.8% and body weight was reduced to 101.1 kg.
+We performed a laparoscopic sleeve gastrectomy (LSG) , using five ports,, as shown in Fig. a. The blood vessel along the wall of the greater curvature of the stomach was first dissected. We then inserted a 36 Fr (12 mm) bougie into the stomach and resected the greater curvature of the stomach, from a point, on the oral side, 4 cm from the pylorus to the His angle, using a linear stapler. The staple line was reinforced with continuous seromuscular sutures using non-absorbable stitches .
+After the operation, a unit of insulin aspart was mixed with 5 g of glucose contained in the infusion solution and sliding scale insulin was added as needed. From postoperative day 2, insulin glargine was administered. Sliding scale insulin was added depending on fasting blood sugar level and oral intake and her daily insulin dose was determined accordingly.
+There were no postoperative complications, including severe hypoglycemic episodes. One year after the procedure, her body weight had decreased to 81.0 kg, with a BMI of 32.2 kg/m2, with this decrease being mainly due to a decrease in the body fat mass. Her HbA1c level improved to 7.7%, and her daily required insulin dose had been reduced to 24 units (10 units of insulin aspart and 14 units of insulin glargine per day: Fig. a–d). On abdominal CT images, the visceral fat area, measured at level of the umbilicus, was 44.8 cm2, with a subcutaneous fat area of 408.8 cm2 . Therefore, there was a marked decrease in both visceral and subcutaneous fat.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2165_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2165_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cd78e76b7b8a1788cd6a64d859601793d6d3076e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2165_en.txt
@@ -0,0 +1,6 @@
+A thirty seven year old female presented with a history of progressive distension of the abdomen with pedal edema and yellow discolouration of the eyes of two weeks duration. On examination she was found to be icteric with an enlarged, firm liver and gross ascites. Liver function tests revealed a conjugated hyperbilirubinemia with mildly deranged transaminases and alkaline phosphatase. Ultrasonography (USG) with Colour Doppler showed an enlarged liver with a hypertrophied caudate lobe, a 1.1 cm portal vein with hepatopetal flow, an occluded right hepatic vein with middle and left hepatic veins patent only in their proximal parts and a patent but narrowed inferior vena cava, compressed by the caudate lobe, together with free fluid in the abdomen. Splenic and superior mesenteric veins were normal. Liver biopsy confirmed the diagnosis of Budd Chiari syndrome. Prothrombotic workup did not reveal any obvious cause for the Budd Chiari syndrome.
+Transjugular venogram showed 90% narrowing of the IVC with a 14 mmHg gradient across the narrowing and non-visualization of the hepatic veins beyond their origins. The hepatic veins could not be cannulated, suggestive of complete occlusion at the ostia. . An 18 × 63 mm WALL STENT was placed across the narrowed segment in the IVC followed by balloon dilatation using a 16 mm balloon .
+Percutaneous transhepatic venogram through the left hepatic vein under USG guidance showed the left hepatic vein was patent only in its proximal portion, the distal 2–3 cms being completely occluded and draining through multiple collaterals. IVC stent was in situ . The right hepatic vein was completely occluded. The middle hepatic vein also showed long-segment total occlusion (> 3 cm).
+Recanalisation of the left hepatic vein was attempted, but failed owing to the long and fibrous nature of the occlusion. The patient then underwent a side-to-side portocaval shunt using the right external iliac vein as H-graft. Postoperative recovery was uneventful and she was anticoagulated during that time. Six weeks after surgery, she was re-admitted with pedal edema and ascites. Doppler evaluation showed patchy flow through the shunt. Venogram through a transjugular approach revealed patent IVC stent. There was narrowing of the portosystemic graft with a gradient of more than 15 mmHg near its IVC end .
+Considering the acute angulation of the portocaval shunt with the IVC, a transfemoral venous approach for venoplasty and stenting was thought to be more appropriate. Following predilatation of the graft with a 5 mm angioplasty balloon , an 8 mm × 30 mm self-expanding nitinol stent was placed in the graft covering its portal and caval ends. Post dilatation was carried out by a 8 mm balloon. Post stenting portal venogram showed good flow through the graft into the IVC .
+The portocaval gradient dropped to < 5 mmHg post stenting. Subsequently she was anticoagulated with warfarin. The patient has been on regular follow up since then and is asymptomatic for five years.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2174_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2174_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0e97debefb19d6f88facde6dc6f8ad9d7e30c994
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2174_en.txt
@@ -0,0 +1,2 @@
+A 22-year-old female arrived at the Emergency Department presenting claudication when walking less than 300 m as well as increased paresthesia and dysesthesia in both pelvic limbs. The claudication, paresthesia, and dysesthesia began five years earlier. At the time of onset, the claudication was bilateral after walking approximately 1500 m with improvement after rest, while the paresthesia and dysesthesia were bilateral and involved all four extremities. At that time, the patient was diagnosed with Takayasu’s arteritis (TA) by the Rheumatology department from this institution based on immunological profile (i.e. rheumatoid factor, antinuclear antibodies, anticardiolipin antibodies, and antineutrophil cytoplasmic antibodies (ANCA), the American College of Rheumatology and Ishikawa criteria. [,] Six months prior to the patient’s visit to this hospital, claudication progressed (i.e. reduction in the distance able to walk to 500 m, increasing paresthesia and dysesthesia frequency). The patient had no relevant family and personal non-pathological history to her current condition. The patient denied the use of controlled substances, allergies, past blood transfusions, traveling to regions with endemic diseases within the last three months, tattoos and body piercings.
+Upon initial physical examination, we found a patient recumbent with freely chosen body position, Glasgow coma score of 15, without focal neurologic deficits nor meningeal sings, aware of his environment, with reference to place, time, and people. The patient’s integumentary system was hydrated and without alterations, while the head and neck exploration had no alterations. Upon inspection, palpation, and percussion the cardio-respiratory system and abdomen had no abnormal findings. Precordial auscultation revealed tachycardia, but no aggregate phenomena. Abdominal auscultation revealed a systolic murmur grade III/IV at the mesogastrium. Right upper limb exploration revealed normal axillar, humeral, and radial pulses (i.e. presence of rhythmic, with normal intensity +++/+++, normal amplitude, and having a synchronous frequency with heart rate). The right ulnar artery pulse was absent. Upon left upper limb exploration, palpation showed the presence of normal axillar and humeral pulses; while radial and ulnar pulses were absent. Lower limb exploration showed absence of bilateral femoral, popliteal and posterior tibial pulses. The skin presented cyanotic appearance, especially of the toes of both feet. Upon palpation, reduced skin temperature was noticed and absence of edema. Upon admission, the patient had the following vital signs: blood pressure 100/70 mmHg in the right arm, 80/60 mmHg in the left arm, blood pressure in the right leg and the left leg were not detectable; heart rate 85bpm; respiratory rate 17 rpm; temperature 36 °C; weight 65 kg; height 167 cm; body mass index23.3 kg/m . Laboratory results at admission are presented in and the follow-up laboratory results in .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2175_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2175_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..859045d2bb0f24c6acb9f4c280628e69d88ad2b9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2175_en.txt
@@ -0,0 +1,5 @@
+The patient is a 59-year-old male with a past medical history of hypertension, mitral valve prolapse, mixed hyperlipidemia, and stage 3 chronic kidney disease. In September 2020, he presented to his primary care physician with symptoms of chest pain, palpitations, and dyspnea on exertion that had been waxing and waning for the past several months. A chest x-ray at the time noted cardiomegaly and a possible small left pleural effusion, but no other abnormalities. His electrocardiogram showed atrial flutter with 2:1 atrioventricular conduction. He was referred to Cardiology, and he underwent typical atrial flutter ablation. Transesophageal echocardiogram (TEE) performed prior to atrial flutter ablation visualized a mildly dilated left atrium with global hypokinesis of the left ventricle. No mass was detected at this time. Following the atrial flutter ablation, his symptoms improved.
+A routine follow-up transthoracic echocardiogram (TTE) from December 2020 revealed a 5.5 × 5.0 cm heterogeneous mass adjacent to the inferior/lateral wall of the left ventricle. The patient underwent further workup that included computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) scans . The lesion was a heterogeneous 9.8 × 5.7 × 7.0 cm cystic/soft tissue mass abutting the left atrium, left ventricle, and left pulmonary veins with peripheral rim enhancement along the anterior aspect and necrotic changes within. Mass effect on the left atrium was observed with preserved fat planes between the mass and the esophagus, and the circumflex artery was encased by the mass. The predominantly T1 isointense, mildly enhancing mass had a heterogeneous fluorodeoxyglucose (FDG) uptake with standard uptake value (SUV) max measuring up to 2.6.
+The patient was referred to Cardiac Surgery for further workup and resection of the mass. Presurgical coronary angiography revealed that the left circumflex artery subtended two large collateral branches that supplied the vascular atrial mass. The patient underwent surgical resection of the mass through a median sternotomy utilizing cardiopulmonary bypass with central cannulation. The tumor was found to be intrapericardial, arising from and significantly compressing the left atrium in the atrioventricular groove and encompassing the entirety of the pericardium from the diaphragmatic surface to the pericardial reflection above the main pulmonary artery. Given the size of the tumor and the lack of a clear plane between the left ventricle and the mass, an aortic cross-clamp was placed and antegrade cardioplegia was utilized for myocardial protection. No cardiac chambers were opened as the mass was arising from the outer surface of the heart.
+The mass had encapsulated a portion of the second obtuse marginal (OM2) artery and was densely adhered to the left circumflex artery (LCX) and the left pulmonary veins. The tumor had a capsule surrounding it with a hemorrhagic component . To resect as much of the tumor as possible, the LCX was shaved off and a small portion of the OM2 artery was resected along with the mass. The neoplasm vascularization was interrupted through cauterization during the dissection. Coronary artery bypass grafting (CABG) × 2 was subsequently performed using vein grafts to the LCX and the OM2. Reconstruction of the left superior pulmonary vein with a bovine pericardial patch was also performed. In the end, the bulk of the mass (> 98%) had been removed. The remaining tumor left behind was in the left atrioventricular groove, along the hilum of the left lung at the confluence of the pulmonary veins. Total cardiopulmonary bypass time was 320 min and total cross-clamp time was 195 min. Given the long cardiopulmonary bypass time and the significant amount of bleeding from the tumor bed, the patient needed to have coagulopathy corrected after resection, so the chest was left open. On post-operative day 2, the patient returned to the operating room for chest closure.
+The postoperative course was uneventful and the patient was discharged on post-operative day 10. Final pathology confirmed the diagnosis of a monophasic synovial sarcoma with a canonical SS18-SSX1/SSX2 gene fusion. Immunohistochemistry found that the tumor was diffusely positive for TLE and negative for CK5/6, AE1/AE3, EMA, and S100. Four months later, the patient remained asymptomatic and had recovered well from surgery. He is currently undergoing concurrent radiation and chemotherapy with oral etoposide and oral cyclophosphamide.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2179_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2179_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..082d4dd56bc8cc7f644555af4297502b79228bd8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2179_en.txt
@@ -0,0 +1,3 @@
+A 37-year old female patient was admitted to the emergency room 24 h after binge eating. She had no relevant medical history but described a loss of 10 kg in 1997. At that time, she was 62kg and wanted to lose weight. She started vomiting. She also reported a stressful relationship with her partner at this period. BN remained undiagnosed during 15 years.
+shows the timeline of the most relevant events of this clinical case report, and the evolution of weight and body mass index (BMI).
+In the emergency room, in July 2012, the patient reported chronic abdominal pain. Physical examination at admission revealed hemodynamic stability, sepsis syndrome, and distended abdomen with defense. Laboratory test results showed high lipasemia and acute renal failure. Abdominal Computed Tomography (CT) imaging showed major gastric distension reaching the pelvis and compressing the digestive organs with no signs of pneumoperitoneum. Conservative gastric decompression was started first using a nasogastric tube aspiration that discharged almost 6.5 litres. Twenty-four hours after hospitalization, the patient exhibited tachycardia and hypotension. Increased doses of Noradrenaline were prescribed unsuccessfully. The patient was prepared for urgent laparotomy showing a large gastric distention associated with necrosis. Total gastrectomy and jejunostomy were performed. The patient was discharged 35 days after the surgical intervention. She was referred to the Department of Clinical Nutrition (Rouen, France) for the nutrition rehabilitation. She weighed 40 kg at this time. Enteral nutrition was administrated through the jejunostomy (1500 kcal/day) and well tolerated. Enteral nutrition was progressively relayed with oral nutritional supplements associated with oral food intakes. The patient reported reduction in bulimic symptoms, structured meals and weight stabilisation around 48 kg (body mass index=17.6kg/m²). At the time of first referral in our institution, the patient did not declare any fear for gaining weight or any body shape concern. She was happy with gaining weight thanks to jejunal tube feeding. On following consultations, eating disorders were routinely screened with by the self-administered French version of the SCOFF questionnaire (SCOFF-F) . This validated test is routinely used, composed of five dichotomous questions. One point is given for each “yes” answer. At least two positive answers indicate a positive SCOFF score with a sensitivity of 88.2% and a specificity of 92.5%. This screening consistently resulted in 5 negative answers. One year after total gastrectomy, jejunostomy was finally removed and the patient returned to work. She was admitted to the Digestive surgery department for occlusive syndrome, 5 years after gastrectomy. Laparoscopic viscerolysis has been done, with no complications. The patient has been discharged and maintained sufficient oral food intake. Today, she is still followed-up in the Nutrition unit at least once a year. She still has a negative SCOFF-F score, with abstinence of binge eating and compensatory behaviors (self-induced vomiting, laxative use, diuretics, compensatory exercise, fasting), structured meals and biological markers in normal range .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2183_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2183_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..30af0db8775714d4385a2a7d0431466dc4ad2e33
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2183_en.txt
@@ -0,0 +1 @@
+A 55-year-old man was admitted to a provincial hospital with fecal occult blood. Colonoscopy revealed a submucosal tumor with depression in the anterior wall of the distal rectum . The tumor was diagnosed as a rectal NET following pathological examination of the biopsy specimen, and he was referred to our hospital for further examination. Endorectal endoscopic ultrasound revealed a 14-mm oval tumor with deep invasion to the submucosa layer. The tumor was located at 1.8 cm from the anal verge. Systematic computed tomography (CT) revealed no evidence of regional lymph node metastasis or distant metastasis such as that to the liver or lung. On the basis of these findings, we performed laparoscopic subtotal and D2 lymph node dissection with diverting stoma. The macroscopic finding of the resected specimen revealed an oval-shaped tumor with depression. Pathological examination with hematoxylin and eosin (HE) staining showed the tumor cells spreading in a rosette-like pattern. Immunohistochemical staining revealed the tumor cells to be positive for chromogranin A and synaptophysin, with a Ki-67 labeling index of 3% . Pathological diagnosis was NET of the rectum, G2, T1b (invasion to submucosa), N0, Stage I without lymphovascular invasion. Diverting stoma closure was performed 6 months after the initial operation. A follow-up abdominopelvic CT scan at 12 months after surgery detected a 4-mm mass in the left internal iliac region . The mass was followed with abdominopelvic CT every 6 months and occasional positron emission tomography (PET)-CT. At 54 months after surgery, the mass had enlarged to 20 mm , but PET-CT did not show abnormal uptake in the tumor or in other distant organs. Because the mass had enlarged over time, we suspected it to be a single lateral lymph node recurrence, and we performed left lateral lymph node dissection. The resected specimen was again an oval-shaped mass of 14 mm in size . The finding from HE staining was similar to that in the specimen resected at the primary surgery . Immunohistochemical staining again revealed the same findings as in the previous resected specimen, i.e., cells positive for chromogranin A and synaptophysin positive, but now the Ki-67 labeling index had increased slightly to 5% . On the basis of these findings, the pathological diagnosis was lateral lymph node recurrence. The patient was followed up with CT every 6 months and colonoscopy annually. At 42 months after the second surgery, the patient has shown no evidence of recurrence.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2185_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2185_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f66ae5f608ffcab1cfea915ce1a33bc301ef2a61
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2185_en.txt
@@ -0,0 +1,11 @@
+A 32-year-old healthy male presented to the outpatient clinic with a history of pain and swelling in the Right foot for 10 months after alleged history of sustaining a grinder (heavy machine) injury to the medial aspect of the right foot 10 months ago. At the time of injury, the patient sustained a contused lacerated wound approximately 3 × 0.5 × 0.5 cm in size over the medial aspect of the right foot and visited the emergency department at a local hospital. Anteroposterior and oblique radiographs of the right foot and anteroposterior, lateral, and mortise radiographs of the right ankle suggested no fractures or skeletal abnormalities.
+The CLW was sutured, and dressing was done, and the patient was managed conservatively with analgesic, anti-inflammatory, and compression bandaging. One month following the injury, the patient started experiencing a dull aching persistent, non-radiating pain in the right foot which was insidious in onset; aggravated on weight bearing, and relieved on taking rest.
+A magnetic resource imaging (MRI) of the right foot was advised after no relief of symptoms with conservative management. The MRI showed a high-grade tear of the distal TPT from the level of medial malleolus to its insertion and was planned for operative management of TPT tear.
+After anesthetic workup, patient was posted for surgery and operated with open repair of TPT using suture anchor.
+After administration of spinal anesthesia, a 5 cm incision was taken over the right foot beginning from the tip of the medial malleolus extending distally and curved anteriorly till the navicular bone.
+Superficial dissection was carried out and the fibers of TP were identified , alternate sliding tenotomy, and lengthening carried out for the proximal end of the TPT.
+A 2.5 mm suture anchor was fixed in the navicular bone and fibers of TPT were sutured using a running whip stitch . There were no complications in the intraoperative or post-operative period. Patient was given a below knee slab with the foot in inversion postoperatively.
+After removal of sutures, the slab was revised into a below knee cast with the foot in inversion for 6 weeks.
+The patient’s assessment was carried out based on Modified Olerud and Molander Score.
+Six-week post-operative follow-up, cast was removed, and physiotherapy was started for the patient that included active ankle ROM and gait training, patient had a Modified Olerud and Molander Score of 45/100 at 6 weeks.
+At 6-month post-operative follow-up, patient was relieved of chronic pain and was able walk and stand on his toes without pain and showed significant improvement in gait with Modified Olerud and Molander Score 90/100 .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2195_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2195_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b6c089f72d911388226694d7093ac7c2f4ce9132
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2195_en.txt
@@ -0,0 +1,3 @@
+A 63-year-old, right-handed female presented with new complaints of shortness of breath, nausea, vomiting, and severe progressive headache over the course of 3 weeks. Her past medical history was complicated with a longstanding history of hepatitis C acquired from a blood transfusion in the 1970s. Unfortunately, she developed end-stage liver disease, cirrhosis, PPHTN, and coagulopathy. Her neurologic examination was grossly intact. A computed tomography (CT) scan of the head demonstrated a 13-mm, left-sided lentiform-shaped hyperdensity suggestive of subdural hematoma with midline shift of 7 mm and minimal transtentorial herniation . She had an international normalized ratio (INR) of 1.55 and a platelet level of 47,000/μL. At the time of our consultation, she was undergoing a continuous treprostinil infusion and taking oral sildenafil for PPHTN. The patient was admitted to the intensive care unit (ICU) and medical, hepatology, and pulmonary consultations were sought. Fresh frozen plasma (FFP) and platelets were administered, and she was monitored closely. According to our critical care colleagues, the treprostinil could not be discontinued. Repeat laboratory studies yielded an INR of 1.50 and a platelet level of 90,000/μL. Over the ensuing 10 h, her level of consciousness diminished and she acquired mild right-sided hemiparesis. Most concerning was the development of an enlarged left pupil. Repeat head CT at that time revealed the SDH had increased to a maximum width of 16 mm and midline shift of 9.5 mm .
+She was taken to the operating room for a left frontotemporoparietal craniotomy and evacuation of the subdural clot. A small, bleeding pial artery that had coagulated was the likely source of the hematoma. Treprostinil infusion and sildenafil were continued throughout the surgery. Intraoperatively, hemostasis was obtained in routine fashion without undue burden from excessive bleeding. The brain was nicely pulsatile at the conclusion of surgery, a patch duraplasty loosely sewn, and the bone flap replaced. Tack-up sutures were used, and a subgaleal drain was left behind. Postoperatively she had an INR of 1.45 and a platelet count of 136,000/μL. She awoke immediately and began following commands. Her anisocoria and weakness improved. She became obtunded several hours after the operation and showed signs of herniation (Glasgow Coma Scale 4). A head CT scan demonstrated a large extra-axial hyperdense fluid collection with a midline shift of 19 mm in the same location as the SDH . She was taken emergently to the operating room for reopening of the craniotomy and evacuation of the hematoma. On repeat operation hemostasis was more challenging. The scalp, temporalis muscle, and external dural surface were hemorrhaging diffusely. The hematoma was found in the epidural space, and it was evacuated. There was no significant blood in the subdural space. The coagulopathy was felt to be qualitative, and cryoprecipitate, FFP, and additional platelets were administered in an effort to obtain hemostasis. Various techniques and products including bipolar electrocautery, irrigation, thrombin-soaked Gelfoam® (Pfizer), Gelfoam Powder® (Pfizer), Avitene™ (Davol, Inc.), and Floseal Hemostatic Matrix (Baxter BioSurgery) were utilized to stop the bleeding. At the conclusion of the case the brain was again found to be pulsatile and the decision was made not to replace the bone flap. Subdural and subgaleal drains were placed and the wound was closed using a 2-0 Vicryl™ (Ethicon) on a CT-1 needle and then stapled. In the first hours postoperatively, she began to follow commands and move all of her extremities with strength. Her treprostinil and sildenafil were continued.
+A postoperative CT scan demonstrated resolution of midline shift and some persistent fluid within the operative bed . Her INR measured between 1.4 and 1.7 throughout the remainder of her hospital stay, which lasted just over 1 month. Platelet counts remained between 45,000 and 225,000/μL. Multiple platelet function assays demonstrated dysfunctional platelets while on treprostinil infusion therapy. She was weaned from the ventilator and began to eat. Given her acute medical condition she was no longer a candidate for liver transplant. Over the course of several weeks in the hospital she was weaned from the treprostinil infusion and the tunneled infusion catheter removed. She was transferred to inpatient rehabilitation and eventually was discharged home. Her 2-month postoperative scan showed resolution of fluid in the operative bed . She underwent cranioplasty roughly 6 months after the initial surgery . At that time, she had stable mild right hemiparesis and was ambulatory with a walker. Currently, she is being considered for rechallenge with treprostinil therapy as a bridge to liver transplant.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2203_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2203_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4821d43d3ba2b3da3e96c627c2003acf2bc58543
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2203_en.txt
@@ -0,0 +1,5 @@
+We present a case of a 55-year-old Caucasian man with a past medical history significant for Chronic Lymphocytic Leukemia (CLL) and Melanoma, diagnosed in 2006 and 2008 respectively, who presented to our Cancer Center complaining of a one-day history of persistent fevers and chills. The patient was visiting from out of state and was concerned about a potential infection. He had completed his 4th cycle of chlorambucil (40 mg per square meter, given orally every 28 days) for his CLL two weeks prior. The patient was status post surgical excision for a stage IIIA melanoma discovered in the left axilla with no further adjuvant treatment. He was scheduled to travel extensively over the course of the proceeding month and requested an additional course of antibiotics.
+On review of systems, he noted progressive fatigue and anorexia. He had started a prescription for levofloxacin prior to the clinic visit. The patient had no known drug allergies. The patient denied any tobacco or alcohol use. He was employed in an office setting. There was no pertinent family history. The patient had a temperature of 38 degrees Celsius. Physical exam was remarkable for an enlarged spleen, approximately 3 finger-breadths below the costal margin. Laboratory parameters revealed a white blood cell count of 21,500 (normal 4500-11,000/mm3), a hemoglobin of 10.8 g/dl (normal 11-15 g/dl), and a platelet count of 170,000 (normal 150,000-400,000/mm3). His absolute neutrophil count (ANC) was 430 (normal 1,500 to 8,000/mm3). Further a quantitative immunoglobulin panel was consistent with hypogammaglobulinemia: IgG level was 309 L (normal 562-1585 mg/dl), IgM 9.0 L (normal 30-246 mg/dl), and IgA was 10 L (normal 72-372 mg/dl).
+The patient was subsequently admitted to our hospital for evaluation and treatment of febrile neutropenia. We elected to administer 30 grams of IVIG (0.4 g/kg) as a means of enhancing his immunity in the context of recent exposure to chemotherapy and his hypogammaglobulinemia. The patient had previously tolerated multiple infusions of IVIG without any adverse reactions. We premedicated the patient with acetaminophen, hydrocortisone, and benadryl. Approximately 12 hours following the IVIG infusion, the patient began to complain of headaches, shortness of breath with accompanying chest pain, and weakness of his bilateral upper and lower extremities.
+A complete cardiac and neurologic assessment was immediately initiated. The patient was found to have a myocardial infarction with a troponin elevation of 15.2 ng/ml and 13.3 ng/ml (normal 0.00-0.15 ng/ml) for the first two sets of his cardiac enzymes respectively, with a clearance of the enzymes by his third set. The EKG revealed ST-T wave changes consistent with myocardial ischemia in the inferior and anterolateral regions. An echocardiogram was consistent with a mural thrombus visualized in the left ventricular apex. There was mild global left ventricular hypokinesis, with inferior and inferolateral wall motion abnormalities consistent with myocardial infarction. In addition, an MRI of the brain delineated evolving cerebral infarcts seen within the left posterior MCA distribution , bilateral high parietal loops , and bilateral occipital lobes . There was no evidence of significant mass effect or hemorrhagic transformation.
+Furthermore, the patient began to experience a change in his mental status. A Neurology consult was obtained and the assessment attributed his waxing and waning consciousness to the continued watershed infarcts that were present. Nevertheless an EEG study was performed which delineated periodic lateralized epileptiform discharges consistent with seizure like activity. The patient was subsequently placed on intravenous levetiracetam with no improvement in his mental status. Shortly thereafter he had increasing respiratory requirements, and the decision was made to forgo intubation at the request of the family secondary to the patient's pre-determined request to never be placed on a ventilator.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2214_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2214_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..249a145074befe7157db4a75ce2520d258e08f1d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2214_en.txt
@@ -0,0 +1,2 @@
+A 33-year-old Japanese woman was referred to our hospital for treatment of a hepatic mass, 8 cm in diameter, located in segment 8. The tumor was detected by abdominal ultrasound screening. Contrast computed tomography (CT) showed a lobular, cystic tumor pooling highly viscous liquid . With magnetic resonance imaging (MRI), the mass was iso-intense or less commonly hypo-intense (compared to the muscle) on T1 and hyper-intense on T2 . Gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) contrast MRI showed that the tumor’s internal dividing wall was contrasted. The tumor did not show uptake on fluorodeoxyglucose-positron emission tomography (FDG-PET) . Ultrasound showed a solid, hypoechoic mass, with a boundary that was slightly unclear and internal inhomogeneity. Sonazoid-enhanced ultrasound showed a solid, hypovascular tumor, with an enhanced internal partition wall . Liver function tests were unremarkable. Blood tumor markers, including carcinoembryonic antigen, α-fetoprotein, and carbohydrate antigen 19–9 were within the normal ranges. The patient was not a carrier of hepatitis B or C, and her human immunodeficiency virus serology was nonreactive. From these findings, she was diagnosed with mucinous cystic neoplasm of the liver and underwent S8 subsegmentectomy of the liver. Macroscopic examination showed a tumor (8.0 × 7.5 cm) that was well circumscribed, oval, and rubbery . The cut surface of the tumor showed myxoid and vascular components . Histopathological examination showed that the tumor was composed of spindle-shaped cells with vascular proliferation in a myxoid stroma . Immunohistochemically, the tumor cells stained positively for vimentin , desmin , CD34 , ER, and PgR and negatively for S-100, EMA, CK19, CD99, HMB45, and α-smooth muscle actin. Electron microscope image showed that collagen fibers extended around the nucleus .
+The postoperative course was uneventful, and she was discharged from the hospital 9 days after surgery. The patient was followed for 10 months postoperatively. There were no signs of recurrence or distant metastasis.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2219_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2219_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..facf9b4f0909836647bd1b2e63f62e150df1081c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2219_en.txt
@@ -0,0 +1,7 @@
+A 15-year-old boy who was previously diagnosed with SRU presented to our office with frequent bloody stool, chronic abdominal pain, constipation, and mucoid discharge. Five years earlier, his symptoms began with intermittent vague abdominal pain and bloody stool. Progressive deterioration of symptoms includes increased blood in the stool, new onset of mucoid discharge, and new onset of constipation. He complained of straining during defecation, difficulty passing hard and narrowed stool, and a sense of incomplete defecation that typically required manual finger evacuation. There was no previous history of surgery, prescription medication, or any other medical condition. He experienced no diarrhea, food intolerance, or significant weight loss. Additionally, his family history was negative for gastrointestinal disorders, including malignancies, IBD, and FAP. He had his first colonoscopy approximately four years prior, which revealed a solitary ulcer in the rectum .
+The initial histologic examination revealed regenerative crypts in the lamina propria surrounded by fibrosis and smooth muscle proliferation, confirming the diagnosis of SRU. A previous laboratory evaluation revealed a WBC of 8100 × 109 cells/liter, Hb of 13.2 g/dL, MCV of 79.8 FL, platelets of 251,000 × 1010/unit, FBS of 85 mg/dL, TSH of 3.49 mIU/liter, AST of 12 units/liter, ALT of 16 units/liter, ALP of 391 units/liter, and ferritin of 22.2 mcg/liter, stool exam negative for occult blood, ova of parasites, and protozoa cyst.
+On physical examination, his vital signs were stable, and there were no abnormal findings in his head, neck, chest, or abdomen. A perineal examination revealed no skin tags, fissures, visible prolapse, or other indications of child abuse. However, multiple irregular mass-like lesions were detected during the digital rectal examination.
+We performed a colonoscopy, revealing multiple diffuse polyposes ranging in shape and size from 5 to 15 mm, extending from the rectum’s middle section to the rectosigmoid junction .
+Multiple biopsies were taken and sent for histopathologic evaluation, which revealed a polypoid structure with a cap of ulcerated granulation tissue, inflammatory exudates on the surface, and tortuous non-dysplastic crypts with mucin spillage in the inflamed stroma, which included smooth muscle fibers and congested vessels . Thus, the diagnosis of CP was confirmed based on these new findings.
+To rule out protein-losing enteropathy, total serum protein and albumin concentrations were determined to be normal (6.7 and 4.3 g/dL, respectively).
+Until histopathologic confirmation of CP is obtained, conservative measures such as a high-fiber diet, the use of laxative agents, and avoidance of manual stool evacuation are recommended to the patient. After histopathologic confirmation, we decided to perform endoscopic mucosal resection (EMR) and resected as many polyps as possible during the first session, considering the severity of the symptoms, multiple polyps in the rectum, and the lack of a standard established treatment plan. During the patient’s 3-month follow-up, the patient underwent two additional colonoscopy sessions, during which we removed the majority of the remaining polyps using EMR, but complete eradication was not possible. Nonetheless, the patient’s symptoms improved, the rectal bleeding stopped, and the abdominal pain subsided.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2220_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2220_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d82651ad668ca60c97dfc5f40dac40cd1500373e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2220_en.txt
@@ -0,0 +1,3 @@
+A Hispanic 64-year-old woman was admitted with headaches, vomiting and confusion. A month earlier, the patient presented with subacute new-onset headaches, nausea, vomiting, gait impairment, and anorexia. There was no history of fever, cough, abdominal pain, previous medical disease or immunosuppressant drug use. Blood pressure was normal. Physical examination was unremarkable. Neurologic examination showed an unsteady gait, without motor weakness or ataxia. Cognitive tests showed a Mini-Mental Status Exam (MMSE) score of 18/30, impaired attention, executive functions, verbal fluency and episodic memory .
+Brain MRI disclosed diffuse and symmetric confluent nonenhancing white matter lesions, that were hyperintense in T2/FLAIR images . Corresponding apparent diffusion coefficients (ADC) maps suggested vasogenic edema . MRI angiography was unremarkable (not shown). Multivoxel spectroscopy, dynamic susceptibility contrast (DSC) perfusion (T2*) and dynamic contrast-enhanced (DCE) permeability (T1) did not disclose relevant abnormalities . Cerebrospinal fluid analysis showed a normal cell count (4 cells/mm3), protein (32 mg/dL) and glucose (80 mg/dL) levels, normal protein electrophoresis values, negative oligoclonal bands and polymerase chain reaction for infectious agents (including tuberculosis). Systemic evaluation was negative for cancer, autoimmune diseases (Anti-nuclear antibodies = negative, Anti-neutrophil cytoplasmic antibodies = negative), and infectious diseases. Thoracic computed tomography (CT) showed nonspecific patchy lung infiltrates. Blood laboratory tests were normal (i.e. Erythrocyte sedimentation rate = 2 mm; C-reactive protein = 1,3 mg/L; Leucocytes = 6,880/mm3). Electroencephalogram EEG showed mild diffuse slowing and brief bursts of diffuse delta waves. The patient underwent two brain biopsies that showed tissue rarefaction with vacuolation, very mild inflammatory cell and macrophage infiltrates, absence of demyelination, malignant cells or granulomas, and no signs of tissue infarction or hemorrhagic changes . Immunostaining showed scarce CD45+ lymphocytes and CD68+ macrophages, without axonal or myelin damage, with few reactive astrocytes and low aquaporin-4 staining in the lesion compared to the normal surrounding areas. Aquaporin-1 staining was also reduced in the lesion, less extensively than aquaporin-4.
+The patient was treated initially with intravenous methylprednisolone (1 g/day for three days), followed by oral dexamethasone (10 mg/day) for six months. Clinical and neurologic status and brain MRI remained unchanged. Activities of daily living were impaired, with a Functional Activity Questionnaire (FAQ) score of 25 and MMSE score of 18. Whole body positron emission tomography-computed tomography obtained at this point revealed a hypermetabolic right pulmonary mass. Lesion histology showed granulomas containing Mycobacterium abscessus. The patient was treated with levofloxacin, clarithromycin and amycacin. Steroids were tapered and discontinued. A year later, cognitive functions and functional status were improved (MMSE = 21; FAQ score = 10) , and brain MRI disclosed remarkable resolution of white matter changes .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_223_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_223_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7337a4a04eee5f391f7e39d3d2f4904019d21306
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_223_en.txt
@@ -0,0 +1,14 @@
+A 64-year-old Asian gentleman was admitted for fever (101.6F), worsening cough and shortness of breath for 10 days. He is a non-smoker and has a remote history of fungal infection of lung over 20 years ago while being a farmer. For the past 3–4 years, he has been taken care in our hospital for persistent and exacerbated asthma, chronic obstructive pulmonary disease (COPD), diabetes, coronary heart disease and congestive heart disease. His home medications for asthma and COPD are albuterol sulfate HFA − 1.25 mg/3 ml, PRN Q4H, Duoneb (a combination of albuterol and Ipratropium Bromide), Budesonid (Pulmicort, cortisone like medicine, NEB 0.5 mg/2 ml) inhalation. During previous asthma exacerbation 13 months ago, methylprednisone injection 40 mg IVP, Q8H and antibiotics Amoxicillin/clavulanic acid were used additionally. During his COPD exacerbation 2 years ago, PrednioSONE TAB—20MG, 40MG PO, daily was also given. In current attack, dexamethasone 10 mg per day, Duoneb and empirical antibiotics azithromycin were initiated in the outpatient setting before admission. The COVID19 nasopharyngeal RT-PCR test performed in doctor's office outside hospital on day 5 of symptom onset was negative.
+On admission, his BMI was 21.10 kg/m2. His arterial blood gas oxygen was 74 mmHg (normal 75–100) with saturation 96.1% (normal 92–98.5%), and the partial pressure of carbon dioxide pCO2 was 32 mmHg (normal 35–45), pH was 7.48.
+The laboratory work showed high white cell count up to 22 × 103/ul with predominant neutrophils (neutrophils 79% and 17 × 103/ul, and the eosinophils accounting for 0–3%), moderate anemia (8–10 g/dl), and reactive thrombocytosis (500–650 × 103/ul). Immunoglobulin E was high (875, normal < = 114). D-dimer was slightly elevated (2.73 ug/ml, reference < 0.5), as well as N-terminal prohormone of brain natriuretic peptide (NT-PROBNP 1270 pg/ml, reference 0–900). Lactic acid was high 4.6 nmol/L (0.7–1.9). C-reactive protein was also elevated. Ferritin and procalcitonin were within normal limit. The extensive antigen, antibody and culture workups for common infectious disease pathogens such as tuberculosis, hepatitis, HIV, bacteria (including Streptococcus, Legionella etc.), fungi (including coccidioidomycosis, Cryptococcus etc.) were all negative. There was no autoantibody (antinuclear antibody, anti-neutrophil cytoplasmic antibody) either. The repeated nasopharyngeal tests on day 10, 13 and 14 of symptom onset performed in hospital after initial negative result on day 5 were all negative, and IgG antibody for COVID19 on day 16 was also negative.
+The chest CT and X-ray showed peripherally based ground-glass opacities and consolidation, in contrast with the more centrally located shadings during asthma acceleration 13 months ago . This is an established imaging manifestation of active COVID-19 infection, but remains nonspecific, as other infections and airspace diseases have a similar appearance. No pulmonary embolism was identified by pulmonary CT.
+He was precautiously isolated because of the uncertainty for COVID19. He was managed by empirical antibiotics, inhaled corticosteroid and bronchodilator as well as systemic steroids, besides aspirin, diuresis and diabetic medicines. The major medications addressing the lung disease are:
+- Antibiotics: azithromycin (500 mg oral daily, days 5 – 14), ceftriaxone (1 gm, iv, days 9–15), Zosyn (3.375 gm, days 15–19), cefepime (1gm, days 21–31), fluconazole (200 mg, days 22–33), meropenem (1 gm, days 36–40), vancomycin (750–1000 mg, days 36–40).
+- Corticosteroid and bronchodilator inhalation medicines for asthma and COPD: Advair (Flutica-Salmet, which is a steroid and bronchodilator combination, MDI 250-50 MCG/puff, days 11–25), Budesonide (Pulmicort, cortisone like medicine, 0.5 mg × 2 per day inhalation, days 16–50), Duoneb (Ipratr-albut, which is a bronchodilator containing beta adrenergic and anticholinergic medicines, 0.5–3 mg/3 ml, Q4H, days 5–50).
+-Systemic steroid: dexamethasone (10 mg on days 5–10, 6 mg on days 11–37), methylPRED SUC (Solu-MEDROL, 40 mg, days 16–20, 24–33 and 37–50), and Prednisone (10 mg, days 33–37).
+His disease was stabilized initially . On day 18, his symptoms deteriorated with Sat.O2 dropped from 74 to 54 mmHg. The chest X-ray showed increased bilateral lung opacity . The aforementioned medications including antifungal, antibacterial, bronchodilator, inhaled and systemic steroids were no longer helpful improving symptoms .
+At this time, bronchoalveolar lavage (BAL) was performed to identify an infectious etiology and open lung wedge biopsy was due to rule out interstitial lung disease.
+The bronchoalveolar lavage showed some pneumocytes with acinar arrangement showing enlarged nuclei, prominent nucleoli, open chromatin and mild accentuation of chromatin to nuclear membrane in a background of neutrophilic histiocytic inflammation and occasional eosinophils .
+The left lingula lung wedge biopsy revealed central bronchiole with thickened smooth muscle wall, and mucus plug, findings consistent with known history of asthma. The presence of central squamous metaplasia and peripheral emphysema indicates chronic airway damage and obstruction suggesting COPD from repeated episodes of asthma. On top of these, there is an active airway centered lesion causing 40–50% alveolar collapse, characterized by fibrosing organizing pneumonia with alveolar damage , intraalveolar edematous exudates, fibrosis from intraalveoli extending to interstitial , associated with rare syncytial cells in squamous metaplasia foci and capillary endothelial injury accompanied by mixed inflammation comprising neutrophils, lymphoplasmacytic cells, histiocytes and eosinophils in all the process. Again, similar to cytology, reactive large pneumocytes are seen lining hemorrhagic alveoli, showing prominent nucleoli, open chromatin and nuclear membrane accentuation, suspicious for viral cytopathic effect . Cytomegalovirus, adenovirus and herpes virus infection is excluded by immunohistochemical stains.
+SARS-CoV-2 was detected from both BAL (Quest Laboratory) and lung wedge biopsy (Viral and Rickettsial Disease Laboratory (VRDL), Department of Public Health, California) by RT-PCR. No respiratory syncytial virus (RSV), influenza A or B, parainfluenza virus or adenovirus is identified by PCR (Quest Laboratory). All three laboratories (nasopharyngeal swab RT-PCR performed by Fulgent Genetics, BAL specimen tested by Quest Laboratory, presence of COVID19 in formalin fixed paraffin-embedded lung wedge biopsy tissue verified by VRDL) use the same primer sets unique to SARS-CoV-2 as designed by Center for disease control and prevention (CDC), US. COVID19 pneumonia is confirmed. The repeated nasopharyngeal RT-PCR tests were positive on day 40 and day 49 of disease.
+After the diagnosis of COVID19 pneumonia, patient was treated with Remdesivir (200 mg, day 41–45) and COVID19 convalescent plasma (1 unit, on day 44) besides continuous corticosteroid, bronchodilator and supportive management. The granulocytosis subsided to a nadir of 12 K/ul following treatment. The lung opacity started to dissolve a bit slowly but his hypoxemia persisted which still needed ventilation. Gram negative bacteria was isolated from central catheter on day 50. The infected central line was immediately replaced and patient was treated with antibiotics meropenem, transferred to another hospital for continuous care. Patient unfortunately succumbed to septic complications after two months of disease onset.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2243_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2243_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7a3393d5fabb5ac39bcc4406d4767286a05a3fc9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2243_en.txt
@@ -0,0 +1,4 @@
+The patient was a 77-year-old male who presented to the emergency with the chief complaints of sudden onset pain in his left hip and shoulder following an episode of slip and fall at home 2 days ago. He was a known case of hypertension, for which he had been taking treatment for the past 15 years. Clinical examination revealed extensive bruising over the chest, left arm, forearm, as well as the medial aspect of the entire left thigh . Movements of involved hip and shoulder joints were extremely painful and restricted. There was no distal neurovascular deficit in any of the involved limbs.
+Laboratory investigations revealed anemia (Hb 8.5 g/dl), deranged renal parameters (blood urea was 266 mg/dl and serum creatinine 3.46 mg/dl), elevated serum potassium (5.73 mmol/L), and uric acid (10.4 mg/dl). Coagulation profile was within normal limits. This was initially attributed to the patient’s long-standing hypertension, and hence, adequate fluid resuscitation was undertaken with a strict input-output monitoring. Serial blood gas analysis was also done. Thereafter, the patient was sent for radiological evaluation. The latter revealed fracture of the left inter-trochanteric femur with associated fracture of the left proximal humerus . Contrary to the extent of contusions, X-rays did not reveal any bony injury to the chest/thigh and forearm.
+The patient was closely monitored for any signs of deteriorating renal function. However, due to prompt and adequate administration of intravenous fluids (normal saline), his renal profile showed significant improvement (blood urea came down to 79 mg/dl and serum creatinine to 0.68 mg/dl). This led us to suspect that the derangement in kidney function was probably due to rhabdomyolysis-related AKI and not chronic kidney disease (CKD) secondary to hypertension. Raised levels of creatinine phosphokinase (CPK) (865 U/L; normal in adult males is <171 U/L) confirmed the same. A positive test for serum myoglobin/myoglobin degradation products further validated the diagnosis.
+The patient underwent closed reduction and internal fixation with the proximal femoral nail for the inter-trochanteric femur fracture . However, he refused to give consent for a second surgery, and hence, proximal humerus fracture was managed non-operatively with sling immobilization, limb elevation, and analgesics. Post-operative period was uneventful and the patient was subsequently discharged after 7 days of hospitalization. At 3 months follow-up, he was able to walk with the help of crutches. There was still residual pain and stiffness in his left shoulder, for which he was on regular physiotherapy and medications.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2250_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2250_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..90a9f846b2c7ab67cfc2d00cc215f187aba77000
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2250_en.txt
@@ -0,0 +1 @@
+A 67-year-old male presented for the repair of a chronic type A ascending aortic dissection, aortic valve replacement, and single vessel coronary artery bypass graft revision. The patient’s past medical history included a prior CABGx3 in 2008 at an outside hospital, coronary artery disease, rheumatic aortic stenosis, hypertension, diabetes, and dyslipidemia. Of note, one of the patient’s bypass grafts (saphenous vein graft to the first diagonal artery) was occluded as it arose from the false lumen of the ascending aortic dissection. On the pre-bypass TEE exam, the anesthesiologist noted a bifurcated CS with two small lumens (approximately 0.4 cm and 0.5 cm in luminal diameter) . The surgeon utilized this information to select a smaller diameter retrograde catheter to avoid damage or perforation of the vessel. With TEE guidance, the surgeon successfully cannulated one of the CS lumens . However, it was noted upon dosing of retrograde cardioplegia that all tributary vessels attached to the non-cannulated lumen remained devoid of cardioplegia, suggesting the bifurcation was noncommunicating between the two lumens. As a result of this blockage, the surgeon was forced to repeatedly administer anterograde cardioplegia via a handheld catheter through the coronary ostium throughout the case. The operative field was also flooded with topical ice saline slush to ensure cardiac protection. Ultimately, the operation was completed without incident despite the non-ideal conditions resulting from this anatomic variant.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2264_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2264_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f3960d888a549e66d96252bbb60d7033ee708fa6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2264_en.txt
@@ -0,0 +1,8 @@
+A 25-years-old severe morbidly obese male (Body Mass Index [BMI] 54 kg/m2, Body Surface Area [BSA] 3.27m2) with no other known past medical history, presented to the emergency department with worsening respiratory distress. Patient’s family denied vaping, electronic cigarette or illicit drug use. On initial evaluation, he was found to have an arterial partial pressure of oxygen (PaO2) of 28 mmHg and an arterial partial pressure of carbon dioxide (PaCO2) of 79 mmHg, non-responding to supplemental oxygen and non-invasive positive pressure ventilation. He was endotracheally intubated, placed on lung protective mechanical ventilation with a fraction of inspired oxygen [FiO2] of 100%, and admitted to the intensive care unit (ICU). Initial respiratory viral panel, blood and respiratory cultures were negative. Chest radiograph demonstrated bilateral pulmonary infiltrates.
+Initial attempts to evaluate heart function with transthoracic echocardiography were unsuccessful given the patient’s body habitus. Over the following five days, efforts to decrease the fraction inspired on oxygen (FiO2) were unsuccessful (nadir of 80%), and his PaO2/FiO2 ratio ranged around 110-164 mmHg. Pulmonary compliance was still preserved at this point. Next day, the patient developed frank anuria and acute kidney failure, requiring initiation of continuous veno-venous hemodialysis (CVVHD). Transesophageal Echocardiogram (TEE) revealed a mildly dilated left ventricle with moderately reduced function (ejection fraction 30–35%), no signs of wall motion abnormalities, and a moderate-to-severe dilated right ventricle with elevated systolic pressures (50–60 mmHg) .
+The patient hypoxemia worsened (PaO2/FiO2 ratio of 75 mmHg) with associated ventilator desynchrony and worsening pulmonary compliance (plateau pressures 39cmH2O) for which neuromuscular blockade was started. A pulmonary artery catheterization demonstrated elevated pulmonary artery pressures (systolic 58 mmHg, diastolic 32 mmHg, mean 41 mmHg) and a central venous pressure of 14 mmHg. Inotropic support (milrinone) and inhaled epoprostenol were started, all aimed to decrease the pulmonary artery pressures and enhance right ventricular function. In spite of these changes, the patient still remained severely hypoxemic (PaO2 64 mmHg) as well as hypercarbic and acidotic (79 mmHg, pH 7.22, respectively) with normal lactate levels (1.7 mmol/L, normal value < 2 mmol/L), as well as normotensive with no vasopressor requirement.
+Given that conservative therapy for acute respiratory distress syndrome (ARDS) failed, the decision was to institute extracorporeal membrane oxygenation (ECMO). Since no obvious signs of low cardiac output were present, the decision was made to institute veno-venous (VV) ECMO, via a 25-French multi-orifice left femoral vein drainage cannula with its tip at the left iliac vein, and a 21-French right internal jugular vein return cannula with its tip at the right atrium, reaching flows of 5–6 l/minute . The patient was initially placed on sweep flow rate of 10 l/minute and FiO2 100% (PaO2 344 mmHg). The prior hemodialysis catheter was left for administration of medications and blood products, and the CVVHD was run through the VV-ECMO circuit. The patient was continued on lung protective ventilation with tidal volumes at 6 ml/kg (ideal body weight), PEEP 10cmH20 and FiO2 100% and the inhaled epoprostenol therapy was discontinued.
+Three days later, the patient severe hypoxemia persists notwithstanding VV-ECMO at maximum settings (nadir PaO2 52 mmHg, arterial O2 saturation 81%). Oxygenator issues were ruled out by excluding any obvious thrombus in circuit and by confirming post-oxygenator high oxygenation levels (post-ECMO PaO2 332 mmHg). Nitric oxygen (NO) therapy was initiated to assist with right ventricular and pulmonary artery pressure off-loading. A supplementary 21-French drainage cannula was placed in the right femoral vein and its tip at the junction of the inferior vena cava and the right atrium , achieving flows of 7–8 L/min (veno-veno-venous [VV-V] ECMO). The patient oxygenation status intermittently improved (PaO2 310 mmHg), although a significantly elevated lactate dehydrogenase (LDH) was noticed (> 12,500 unit/L; normal range 313–618 units/L). Liver function panel was normal.
+On next day, hypoxemia persists (PaO2 66 mmHg), with associated systemic hypotension (mean arterial pressure [MAP] of 52 mmHg) and signs of worsening tissue oxygenation (serum lactic acid 5.5 mmol/L). The team decided to switch to VV and VA ECMO with parallel circuits, in order to provide further cardiovascular support, relieve the patient’s refractory hypoxemia and provide adequate flows for his BSA.
+The original VV-ECMO circuit consisting of a left femoral vein drainage cannula and right internal jugular vein return cannula was continued, and VA-ECMO was instituted through the existing venous cannula in the right femoral vein (which became the drainage cannula) and an additional 17-French right femoral artery return cannula with its tip at the distal aorta before its bifurcation . Distal right lower limb infusion cannula was placed to the right superficial femoral artery. No significant drop in the venous pressures in the original VV-ECMO or in the CVVHD lines was noticed when the four cannulations were instituted. The total flow of both circuits was 10–11 L/min: 5-6 L/min for the VV-ECMO and 5 L/min for the VA-ECMO.
+The patient’s hemodynamics and oxygenation subsequently improved over the course of the next days (average MAP 68 mmHg, average PaO2 170 mmHg). A significant decrease in the LDH levels was noticed. No clinical or laboratory signs of upper body hypoxia (Harlequin Syndrome) was noticed. Adequate weaning of flow sweeps and FiO2 in both circuits was achieved. VV-ECMO was removed by hospital day #29. TEE demonstrated an improved left ventricular function (ejection fraction 45%) with persistent right ventricular dilation, for which the VA-ECMO was continued to provide further relief of the right ventricle and successfully removed 5 days later. The patient continued further ventilator weaning and planned for long-term acute care recovery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2267_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2267_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8877042f7c3fffddcc5f3b6c6f6ccb0405fa6bcf
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2267_en.txt
@@ -0,0 +1,4 @@
+A 38-year-old female nurse presented with high fever (>40°C), chills, dry cough, nausea, vomiting, loss of taste and smell, and myalgia during the outbreak of COVID-19. After the initial assessment, it was clear that her high fever, myalgia, and dry cough had continued for ten days. After the infectious disease specialists confirmed the diagnosis of COVID-19 via reverse transcription-polymerase chain reaction (RT-PCR) assay, she was administered hydroxychloroquine (200 mg, PO q12h) and oseltamivir (75 mg, PO q12h) for five days. Two days later, anorexia and diarrhea were added to her symptoms. Six days later, she also reported the loss of taste and smell and hair loss, which continued for ten days. No noticeable sign of abnormality in sensory or motor nerve function was observed during two weeks. Also, laboratory tests, including complete blood count, C-reactive protein, and erythrocyte sedimentation rate, were normal in her first admission.
+After 20 days, the patient’s symptoms were completely relieved. However, she was admitted to the emergency room due to brief episodes of unconsciousness and chest pain at night, caused by an extremely sudden drop in pulse rate, as reported by her husband at home and coworkers during the shifts. In the emergency room, she had no fever (36.9°C), and her respiratory rate and oxygen saturation level were normal. The skin examination showed a pruritic rash, distributed on her breasts, shoulders, and legs, which were associated with her fainting episodes .
+Cardiac monitoring was performed during one of her shifts when she fainted. The results showed bradycardia, and premature ventricular contractions (PVC) taken within less than 15 minutes. Next, 24-hour Holter monitoring was performed, which showed a temporary complete heart block . Laboratory tests, including complete blood count, troponin, creatine kinase-MB, D-dimer, C-reactive protein, erythrocyte sedimentation rate, lactate dehydrogenase, and COVID-19 IgM antibody rapid test were completely normal during her hospitalization. She was retested with PCR assay for COVID-19, and the result was normal in the third day of her second hospitalization.
+She did not show any defects on her chest CT scan during her first and second hospitalizations for COVID-19. The cardiologists decided to use a pacemaker for her. After four days of assessment, the result of Holter monitoring was normal, and her sinus rhythms and PVCs returned to normal without any interventions . Accordingly, she was discharged from the hospital. Echocardiography was normal, with an ejection fraction up to 60% without pericardial effusion. Also, her skin rash disappeared one day after admission. After two weeks, she did not have any symptoms, her cardiac monitoring was normal, and all of her symptoms were completely relieved.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_226_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_226_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ebd9355d09963ea99a449f107c5d135064104062
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_226_en.txt
@@ -0,0 +1,4 @@
+A 12-year-old boy presented with complains of swelling over the right side of neck for last 1 year. The swelling was insidious in onset, gradually progressive, and painless. On clinical examination, a solitary 3 cm × 3 cm × 2 cm spherical bony hard swelling with well-defined margins was palpable in the right supraclavicular region . The swelling was nontender and immobile. Neck movements were terminally restricted. Adson’s test was positive. Roos and Wright’s tests were negative. There was no distal neurovascular deficit.
+Plain radiographs of cervical spine revealed a bony mass over right side of neck . Computerized tomographic (CT) scans showed a well-defined broad-based lobulated bony outgrowth measuring 2.8 cm × 2.4 cm arising from the right pedicle and encroaching onto lamina and transverse process of C6 vertebra. The cortex and medulla of the lesion was in continuity with the host bone . Magnetic resonance imaging (MRI) was done to evaluate the degree of soft tissue involvement. It revealed altered signal intensity of 11 mm thickness which was hyperintense on T2W and short tau inversion recovery (STIR) images. After gadolinium administration, there was peripheral enhancement surrounding the bony outgrowth which was suggestive of a cartilage cap. The scalene muscles showed no signs of infiltration; however, the roots and trunks of the brachial plexus were hyperintense on STIR which was suggestive of some compression .
+The bony swelling arising from the right pedicle and encroaching onto lamina and transverse process of C6 vertebra was excised extraperiosteally through an anterior spinal approach .
+Histopathological examination showed thick cartilage cap overlying endochondral ossification and lamellar bony trabeculae encasing fatty and cellular marrow which was consistent with osteochondroma . At 4-year follow-up, the patient was asymptomatic, and CT scan did not show recurrence .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2274_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2274_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8c8a99a756c3f7f622f83e3db55823afd32542a5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2274_en.txt
@@ -0,0 +1,3 @@
+A 20-year-old female presented with a complaints of amenorrhea, left flank pain and heaviness from 1 year. There was no associated weight loss, and patient was vitally stable. Flank pain was gradual in onset and progress and diffuse in nature. On physical examination patient was of normal height and weight but systemic examination a left renal mass was palpated that felt homogeneous in nature. At presentation Patient was vitally stable and laboratory investigations ordered were also with in normal standard reference ranges expect Hb level, that was slightly towards lower normal limit. On ultrasound study a left renal mass involving the major portion of left renal tissue with homogeneous density was observed. The ultrasound also revealed a tumor like image that was occupying the whole left kidney (upper, middle, and lower borders). On further investigations computerized tomography (CT) scan revealed size of 180 mm with no invasions to renal capsule, renal vessels, or ureters or homolateral adrenal gland as shown in a and b. Infiltrative borders of tumor mass suggested as an untypically renal cell carcinoma. Therefore, radical nephrectomy was done.
+During operation the renal capsule was found intact, and the renal artery was clamped, no complications were faced during operation and patient had quick and perfect recovery post operatively. Gross examination of the specimen revealed a tumor dimension of 180 × 150 × 110 mm involving the whole kidney middle upper and lower lobe as shown in . Ureters, renal vein, renal capsule, perinephric mass uninvolved by tumor. However renal sinus fat was completely replaced by tumor. Cut surface of the tumor shows multiple small cysts, filled with clear fluid.
+Patient was informed about the nature of the disease and patient was prepared for radical nephrectomy after getting anaesthesia fitness. Tumor mass was removed by radical nephrectomy that was performed through transperitoneal approach as shown in and the resected specimen was preserved for microscopic and histological analysis. Microscopic and histological sections showed multi-cystic structures with variably sized simple cysts lined by hobnailed epithelium with clear cells. Septa show ovarian type fibrous stroma with variable inflammation and immature nephrogenic elements. Final histopathological diagnosis was Mixed Epithelial and Stromal Tumor (MEST) and patient was placed on strict follow up, irrespective of that the malignant transformation and recurrence history is very rare of natural history of MEST.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2278_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2278_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6c38a7d9bc75701ba5a54983d81b10af1b174ef7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2278_en.txt
@@ -0,0 +1,6 @@
+A 44-year-old man presented to the Department of Oncology in our hospital with a 2-month history of local pain of the left shoulder joint. He initially visited a local hospital, where magnetic resonance imaging (MRI) was performed . A 70 × 40 mm mass with an unclear boundary, a mixed hyperintense signal on T2-weighted imaging (T2WI), and a hyperintense signal on T1-weighted imaging (T1WI) of the proximal left humerus was observed. In addition, the adjacent bone was damaged, and a patchy bone marrow oedema signal was observed. This mass presented a state of expansion growth and cortical osteolysis. Based on these results, the patient was diagnosed with a malignant bone tumour by a local doctor. For further treatment, the patient was referred to a superior hospital.
+His physical examination on admission revealed that the left shoulder joint and proximal superior arm were slightly swollen and tender, and the local skin temperature was normal. Shoulder lifting was limited. The patient’s body mass index was 21.4 kg/m2. His blood investigations revealed the following: calcaemia, 3.09 mmol/L (2.11–2.52 mmol/L); phosphoraemia, 0.55 mmol/L (0.85–1.51 mmol/L); and alkaline phosphatase level, 461 U/L (45–125 U/L). The other investigation results were normal. Standard anteroposterior and oblique radiographs of the left shoulder joint showed large osteolytic lesions involving the proximal humerus and humeral head without any joint involvement . Subsequent computed tomography (CT) of the left shoulder joint showed a soft tissue mass of approximately 34 × 70 mm in the medullary cavity . These imaging findings were suggestive of a bone malignancy. For further diagnosis, a colour ultrasound-guided puncture biopsy of the proximal left humerus was performed, and a brown spongy material consisting of several multinucleated giant cells without atypia was observed. This was suggestive of an aneurysmal bone cyst .
+After discussion about the choice of treatment, tumour resection with postoperative pathological examination of the lesions was recommended. Therefore, the patient underwent surgery. Intraoperatively, we noticed that the cortical bone of the proximal humerus was thin and brittle. In addition, several cystic cavities filled with brown viscous substances were observed in the medullary cavity, showing honeycomb changes. We excised all the lesions, and an autologous bone was implanted in the cavity. Subsequently, proper internal fixations were installed to stabilise the bone . A postoperative pathological examination was performed again, and the findings were suggestive of a malignant fibrous histiocytoma of the left humerus . Systemic radionuclide bone scanning was performed to further exclude other bone diseases as the pre- and postoperative diagnoses differed. It showed active metabolism of the superior part of the left humerus, sternum, and left femoral neck . CT revealed multiple osteolytic lesions in the sternum and left femoral neck .
+Due to the limited diagnostic level in our hospital, we sent the pathological sections and clinical data to the Department of Pathology of the First Affiliated Hospital of Sun Yat-sen University; the suggested diagnosis was brown tumour. They suggested we perform further parathyroid function tests. His blood PTH level was 577 pg/ml (15–65 pg/ml). Colour Doppler ultrasonography of the parathyroid gland showed that the left dorsal thyroid was hypoechogenic, 17 × 12 mm, with unclear boundaries and an irregular shape, which was considered as a parathyroid adenoma . Ultimately, the confirmed diagnosis was a brown tumour caused by PHPT.
+Regarding the treatment of PHPT, the patient was transferred to the Department of Otolaryngology for surgery. The left parathyroid adenoma was removed by axillary endoscopic resection. Intraoperatively, 20 × 10 mm solid yellow nodules with clear boundaries were observed at the left dorsal lobe of the thyroid gland . The parathyroid adenoma was completely removed after separation. A postoperative pathologic examination was conducted, which proved to be a parathyroid adenoma . The PTH levels dropped to 29 pg/ml (15–65 pg/ml) 4 days after surgery.
+One year after the surgery , the left humerus lesions had healed completely, and the left shoulder joint had a good range of movement.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2288_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2288_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ec4d6d945cf6ff60c77de07c6022c66d2c80bd19
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2288_en.txt
@@ -0,0 +1,2 @@
+A 74-year-old woman underwent a revision hip surgery for the treatment of a recurrent dislocation of a cemented total hip arthroplasty (eight dislocations), by malposition of the acetabular component .
+The all-polyethylene acetabular liner was perforated with a 4.5 mm drill, and two cork-screws were firmly screwed in the rim as far as possible, in order to extrude the liner from the cement mantle, and to create also fissures into the cement . Manual torsional shear forces were carried out, which led to a total disruption of the polyethylene liner at the polyethylene-cement interface. Adequate manual torsional shear forces were carried out, which led to the disruption of the polyethylene liner at the cement-polyethylene interface, with no technical difficulties. The polyethylene cup was removed with ease. Using cement–splitting osteotomes, the cement mantle was removed in a piecemeal fashion and the cemented plugs were carefully curetted out. A roof reinforcement ring and a cemented cup of UHMW polyethylene were implanted using the standard technique. The metallic femoral head was changed and the femoral cemented stem was retained. No complications were reported in the perioperative course or during the hospitalization period. At 2 month postoperatively the patient was clinically able to walk without external support.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_228_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_228_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4ca1e6847d9b33f9f605dd9cbf259795dfe0f924
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_228_en.txt
@@ -0,0 +1,8 @@
+A 41-year-old woman with CF was admitted for a course of intravenous antibiotics after developing worsening respiratory symptoms of increased cough, sputum volume and purulence and worsening breathlessness on exercise. She had lost 3 kg in weight and felt generally unwell. Her FEV1 had fallen from 860 mL to 780 mL. During the course of her admission, she volunteered that she had noted intermittent rectal bleeding and that the blood appeared to be mixed in with her stools.
+The patient's CF genotype was DF508/N1303K. She had severe lung disease and was chronically infected with mucoid Pseudomonas aeruginosa. She was pancreatic insufficient and had CF-related diabetes (CFRD), as well as mild CF-related biliary cirrhosis. Treatment when stable consisted of rotating oral and nebulised antibiotics, nebulised DNAse and hypertonic saline, pancreatic enzyme replacement, fat-soluble vitamin supplements and insulin.
+The question of lung transplantation had been raised previously and the patient had undergone formal assessment for this in 2005, but following discussions with the transplant team had decided to delay listing because lung function, albeit very poor, had remained stable over the preceding 5 years and her quality-of-life was still reasonable.
+Examination revealed a woman at the lower limit of the healthy weight range (BMI 20.2). She was clubbed but there were no signs of anaemia or stigmata of chronic liver disease. Scattered inspiratory crepitations were present throughout both lung fields, especially over the upper lobes, but these findings were unchanged from previous recordings. On abdominal examination, there was no tenderness or palpable masses. Rectal examination was normal. Initial investigations revealed a normal haemoglobin, renal function and serum amylase. Liver enzymes were normal except for a slightly raised serum alkaline phosphatase at 155 IU/L (normal range 45 to 115 IU/L). Chest radiograph showed over-inflated lungs with fibrotic scarring and ring shadows, particularly in the upper lobes, consistent with her advanced lung disease. Full lung function testing showed an FEV1 of 0.78 L (29% predicted), forced vital capacity (FVC) of 1.29 L (41% predicted), and evidence of gas trapping with a residual volume of 210% predicted as well as a reduced carbon monoxide transfer factor (TLCO) of 12.86 mL/min/mmHg (52% predicted) that normalised when corrected for alveolar volume.
+At colonoscopy, a large pedunculated polyp was seen in the distal sigmoid colon and the top of this was removed. Histopathology demonstrated a moderately differentiated adenocarcinoma arising on a background of a severely dysplastic tubulovillous adenoma. Invasive tumour was apparent at the surgical resection margin. There was no immunohistochemical evidence of mutation in the mismatch repair genes MLH1, MSH2 and MSH6.
+A staging computed tomography (CT) scan with contrast of the chest, abdomen and pelvis did not demonstrate the primary malignancy or any metastases within the abdomen.
+After a second unsuccessful attempt at endoscopic resection, the patient elected to undergo potentially curative laparoscopic resection. She was transferred to a large tertiary referral hospital in another state that has a fully staffed multidisciplinary CF Unit providing care to over 220 patients. Tasmanians do not have access to this sort of dedicated care team and it was thought that the patient's chances of survival postoperatively would be increased if 24-hour access to a multidisciplinary CF team was available.
+As part of the pre-operative staging, a positron emission tomography (PET) scan was undertaken and this demonstrated increased uptake in enlarged mediastinal lymph nodes which were thought reactive and consistent with her chronic pulmonary sepsis. There was no uptake in the abdomen to suggest loco-regional metastatic disease. A laparoscopic anterior resection was performed under general anaesthetic. The procedure was tolerated remarkably well. Operative time was 4 hours during which she maintained oxygen saturations between 97% and 100% on a FiO2 of 38%. She was extubated successfully and had an uncomplicated postoperative course. She rapidly weaned herself off a fentanyl infusion (Patient Controlled Analgesia) within 24 hours and was able to undertake chest physiotherapy and airway clearance techniques under the supervision of a CF physiotherapist on the first evening post-operation. Before the operation, she had received continuous intravenous antibiotics for 41 days and these were continued for a further 6 days postoperatively until she was discharged. Histopathology of the resected segment of colon revealed a Stage I (T1N0) moderately differentiated adenocarcinoma with clear resection margins. Adjuvant therapy was not considered appropriate. She has remained very well over the 12 months since her return to Tasmania and a restaging CT scan of the abdomen and colonoscopy have shown no evidence of recurrence.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2304_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2304_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c004bb0e69a43704a27d6ede4ae50b65ff95e8d7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2304_en.txt
@@ -0,0 +1,5 @@
+A 7-year-old Japanese boy was referred to our hospital because of painless swelling of the bilateral inguinal lymph nodes which had gradually increased for 7 months. His past medical history included atopic dermatitis, and his family history included type 1 diabetes mellitus in his mother. Hematological examination showed the following abnormal values: soluble interleukin-2 receptor, 2,599 U/mL; and immunoglobulin E, 568 IU/mL. A biopsy of a left inguinal lymph node lead to the diagnosis of Hodgkin lymphoma (nodular lymphocyte predominant type). Fluoro-18 fluorodeoxyglucose-positron emission tomography (F-18 FDG PET)/computed tomography (CT) showed a high accumulation (maximum standardized uptake value, SUVmax) at 17.02 in the left common iliac lymph node, left external and internal iliac nodes, and left inguinal lymph node. On the basis of the F-18 FDG PET/CT results and B symptoms, such as weight loss and night sweats, the final staging was determined to be IIB. The patient underwent chemotherapy according to the protocol of the EuroNet-PHL-C1 protocol with 2 cycles of the OEPA regimen (vincristine, etoposide, prednisone, and doxorubicin) and 2 cycles of the COPDAC regimen (cyclophosphamide, vincristine, prednisone, and dacarbazine). Chemotherapy was to be followed by radiotherapy at a dose of 19.8 Gy (11 fractions of 1.8 Gy per day) focused on residual lymph node lesions.
+Two days after the end of the first cycle of the COPDAC regimen, the patient complained of headache and of blurred and decreased vision in both eyes. The first ophthalmologic examination showed a corrected visual acuity of 20/32 in the right eye and 20/40 in the left eye. Intraocular pressure could not be measured in the right eye and was 15 mmHg in the left eye. The anterior chamber depth was normal, with no evidence of inflammatory cells in the anterior chamber. Posterior ocular findings showed swelling of the optic nerve papillae in both eyes and serous retinal detachment. . Optical coherence tomography (OCT; Carl Zeiss Meditec AG) showed significant serous retinal detachment in the macular area and significant swelling of the optic nerve papillae in both eyes. Fluorescein angiography of the fundus showed fluorescent leakage from the optic nerve papilla in the early phase and petechial fluorescent leakage in both eyes . Indocyanine green angiography showed hypofluorescent dark dots in both eyes in the early phase . Ruled out as causes of a possible infectious uveitis via immunological examination were hepatitis B, hepatitis C, syphilis, and human T lymphotropic virus type 1, and ruled out via DNA analysis were herpes simplex virus, varicella-zoster virus, and cytomegalovirus. Cerebrospinal fluid examination revealed an increased cell count. Moreover, human leukocyte antigen (HLA)-DR4 was positive. Because the patient fulfilled items 1 to 4 of the revised diagnostic criteria proposed by the International Workshop on VKH , incomplete-type VKH disease was diagnosed.
+To treat the VKH disease, the patient received steroid treatment with intravenous prednisolone 60 mg/m2/day for 7 days. After improvements in visual acuity and serous retinal detachment were confirmed, 1 cycle of the COPDAC regimen with the dosage increasing from 40 mg/m2/day to 60 mg/m2/day was started. Prednisolone (60 mg/m2/day) was administered for a total of 20 days. Thereafter, the administration of prednisolone was changed from intravenous to oral, after which the dose was gradually tapered. The minimum visual acuity before treatment was 20/400 in the right eye and 20/63 in the left eye. After 22 days of treatment with prednisolone, the visual acuity had improved to 20/20 in the right eye and 20/25 in the left eye, and the intra-anterior chamber inflammation and serous retinal detachment in the macula had disappeared. The steroid treatment was changed to hydrocortisone on day 65 after starting prednisolone. However, anterior chamber inflammation appeared on day 82 of steroid treatment, so the steroid treatment was changed to the dosage increased oral prednisolone again and dexamethasone eye drops were started. Subsequently, the flare-up of inflammation disappeared, and oral prednisolone and dexamethasone eye drops were discontinued.
+The findings of OCT changed over the course of treatment . Serous retinal detachment was marked before treatment , but had disappeared after 21 days of steroid treatment . On day 43 of steroid treatment, visual acuity had improved, but irregular retinal pigment epithelial cells were observed . On day 82, when the intracameral inflammation flared up, the irregularity of retinal pigment epithelial cells worsened and continued .
+One year after the diagnosis of Hodgkin lymphoma and 9 months after the diagnosis of VKH disease, multiple vitiligo appeared in the patient’s abdomen, and complete VKH disease was finally diagnosed. However, a sunset glow fundus was seen, but Sugiura sign was not. The patient has been doing well and has improved visual function, without evidence of recurrent Hodgkin lymphoma and VKH disease for 10 months after treatment with prednisolone had discontinued.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2305_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2305_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..dcbd1b820aa2a0ee22b4a2cd4c33e487c6fe8c0b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2305_en.txt
@@ -0,0 +1,5 @@
+A 39-year-old male with a history of osteoarthritis, on as-needed non-steroidal anti-inflammatories, presented to the emergency department (ED) around 3 am with acute onset of bilateral lower extremity proximal muscle weakness. The patient reported going to bed that evening without any issue and awoke around 2 am to go to the bathroom, which was not unusual for him. However, he noticed profound weakness of the lower extremities. He could not flex at the hips and was unable to swing his legs out of bed. Eventually the patient was able to pull himself out of bed and slowly guide himself to the bathroom, noting continued severe weakness in his lower extremities. He also noted lacking the usual shoulder strength to wipe himself after using the bathroom. Approximately 18 hours prior to presentation to the ED, he had undergone a fluoroscopy-guided, intra-articular steroid injection of his right shoulder. The injection consisted of 7 milliliters (mL) of triamcinolone/ropivacaine mixture containing 2 mL of triamcinolone 40 milligrams per milliliter (mg/mL) (total of 80 mg of triamcinolone) and 5 mL of ropivacaine 0.75%. The procedure was uncomplicated, and he reported a 1/10 pain level post-procedure, down from 5/10 pre-procedure.
+Upon presentation to the ED, he was well appearing, well nourished, and in no acute distress. He was afebrile and vital signs were as follows: heart rate 110 beats per minute; blood pressure 140/80 millimeters of mercury (mm Hg); respiratory rate 20 breaths per minute; oxygen saturation 98%; and temperature 97.5°F. Neurologic exam revealed 5/5 strength in his bilateral upper extremities, as well as at the knees and ankles bilaterally. However, he possessed only 3+/5 flexion strength of the bilateral hips. Patellar and Achilles reflexes were 2+ bilaterally. Vibratory sense was intact in both feet. Rectal tone was normal. The rest of his physical exam was unremarkable.
+A differential diagnosis was formulated to include stroke, spinal compression syndrome, Guillain-Barré syndrome, rhabdomyolysis, electrolyte derangement, including hypokalemic periodic paralysis, transverse myelitis, myositis, and myopathy.
+Emergency department diagnostics included a complete blood count, complete metabolic panel, creatine kinase (CK), erythrocyte sedimentation rate, and C-reactive protein level, all of which were within the reference ranges. Peak flow was 500 liters per minute (L/min) (normal range 300–660 L/min), and post-void residual volume on point-of-care ultrasound was 70 mL (normal <200 mL). Urinalysis showed greater than 500 mg/dL glucose (reference range negative), trace ketones (reference range negative), and small protein (reference range negative). Given the patient’s history of glucocorticoid use, exam with decreased hip flexion strength, reassuring lab work, peak flow, and post-void residual, a diagnosis of acute steroid-induced myopathy was made.
+The internal medicine team was consulted to evaluate the patient in the ED. They agreed with the diagnosis of acute steroid-induced myopathy. The patient reported some improvement in his strength while in the ED, although not back to baseline, but he was able to ambulate. Neurology was consulted by the internal medicine team. Given his improvement in the ED, it was recommended by neurology that the patient follow up as an outpatient. The patient was discharged from the ED and followed up in the neurology clinic three days later. At that time, he reported complete resolution of his symptoms about 48 hours after presentation to the ED without residual deficits. Neurology ultimately diagnosed him with a transient myopathy and recommended that he avoid intra-articular glucocorticoid injections in the future.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2321_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2321_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8de8af8ba565b2a4058acf5325359e41846744f0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2321_en.txt
@@ -0,0 +1,5 @@
+A 53-year-old woman with a history of subarachnoid hemorrhage and intracerebral aneurysm initially presented to an urgent care facility because of dyspnea on exertion and palpitations, occurring several weeks after her return from a 4-week stay in Delaware. While there, she had several encounters with deer while watching the sunset. Five days after her return, she developed headaches, heat intolerance, near-syncope, and a red, 5 × 5-cm rash on her chest. A few days later, she traveled for 8 days to upstate New York, where she developed dyspnea on exertion and palpitations. She presented to an urgent care facility 3 days after her return to New York City. An electrocardiogram (ECG) showed a first-degree AV block; thyroid function tests and Lyme serology were obtained. Due to the ECG findings, she was referred to a cardiologist. She denied any neck or throat pain. She also denied taking any medications or supplements, including biotin or iodine. On physical examination, blood pressure was 115/85 mm Hg, heart rate 81 beats/min, and respiratory rate 18/min. The thyroid was not enlarged or tender. No lid lag or proptosis was observed. An echocardiogram showed a moderate pericardial effusion without signs of tamponade and a mildly dilated aortic root (3.7 cm). Her free thyroxine (T4) was 2.8 ng/dL (normal range (NR), 0.70-1.48 ng/dL) and thyroid-stimulating hormone (TSH) was <0.01 mIU/L (NR, 0.35-4.94 mIU/L). Thyroid peroxidase antibodies were present at a titer of 444 IU/mL, thyroid-stimulating immunoglobulin was absent . Lyme IgG/IgM test was positive. Repeat ECG showed P-R interval >300 msec . Due to these findings, she was referred to the emergency department. Of note, her TSH was normal at 1.94 mIU/L (NR, 0.49-4.7 mIU/L) in another facility 4 months before her symptoms.
+In the hospital, ECG showed a first-degree AV block with a P-R interval of 322 msec. Repeated TSH was 0.006 mIU/L with a total T4 of 11.78 μg/dL (NR, 4.5-11.70 μg/dL) and free T4 of 1.42 ng/dL . Erythrocyte sedimentation rate was 55 mm/hr (NR, <26 mm/hr), and C-reactive protein was 0.8 mg/L (NR, 0.00-0.40 mg/L). Complete blood count, kidney function and liver function tests were within normal limits. Lyme IgG/IgM test was positive, with a titer of 8.76 units/ml. This result was confirmed with positive Lyme antibody Western Blot for IgG and IgM. With presumed Lyme carditis, she was started on ceftriaxone 2 gm/day. During the second day of hospitalization, AV block worsened to second-degree Mobitz type II but converted back to first-degree AV block after a few hours. During the third day of hospitalization, she remained in normal sinus rhythm with first-degree AV block, and the P-R interval decreased to 320 msec.
+Her iodine-123 thyroid scan and 24-hour uptake showed a decrease in iodine uptake of 1.2%, consistent with thyroiditis. An echocardiogram showed normal left and right systolic and diastolic function, along with a small pericardial effusion without signs of tamponade.
+After starting ceftriaxone, her P-R interval on ECG decreased to 316 msec, and symptoms improved. On day 4 of hospitalization, she was discharged on doxycycline 100 mg twice a day for 3 weeks. One week after discharge, she was asymptomatic, and ECG showed a P-R interval of 234 msec .
+After 8 weeks, TSH was 2.94 mIU/L with free T4 1.04 μg/dL and total T3 87 ng/dL; after 10 weeks, TSH was 2.49 mIU/L and free T4 1.29 μg/dL . Her TSH was normal at 2.01 mIU/L 4 months after her admission.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2322_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2322_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e47c3d82c3e0c231f1ad1ff5db3245c094a40561
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2322_en.txt
@@ -0,0 +1,10 @@
+A 52-year-old gentleman had presented to the emergency room with sudden onset left hemiparesis, with a Glasgow Coma Scale (GCS) of E2M5Vt. He was diagnosed with a 210 mL volume, middle cerebral artery (MCA) territory infarction on magnetic resonance (MR) imaging with mass effect and a 12 mm midline shift. He was also diagnosed with a right brachial artery embolus on routine large vessel and neck MR angiograms. Carotid vasculature was noted to be normal with no narrowing or filling defect. An emergency right fronto-temporo-parietal decompressive with lax duraplasty was performed followed by a right brachial embolectomy by the vascular team. Further evaluation with a cardiac 2D echogram revealed no regional wall motion abnormality with mild concentric left ventricular hypertrophy (LVH), normally functioning valves and no clots or vegetations. Postoperatively, he had an uneventful recovery and over a week GCS improved to E4M6V5. He was discharged on therapeutic doses of low molecular weight heparin for the brachial artery embolus.
+He presented 6 months later for a cranioplasty. He was conscious alert and oriented with modified Ashworth Grade II hypertonia and Medical Research Council Grade 3 power in the left upper and lower limbs. A computed tomography (CT) scan revealed a sunken skin flap with a 9 mm midline shift to the left along with gliotic changes in the right MCA territory . The autologous bone preserved in a freezer was found to be unhealthy and he underwent a customized titanium mold cranioplasty. Intraoperatively, the brain was sunken. Urine output was maintained at 80–150 mL/h and vitals were stable with minimal fluctuations. The surgery was completed uneventfully.
+The patient did not wake from anesthesia and had sudden fall in blood pressure (BP) to 60/40 mmHg a few minutes after shifting, on ventilator, to the intensive care unit. The hypotension lasted for less than a minute and he was stabilized with inotropes and noradrenaline boluses and later a drip infusion, with close titration owing to a very labile BP highly sensitive to minor adjustments in the inotropes. Blood gases, electrolytes, and postoperative hematocrit were within normal limits. A screening echocardiogram at the time showed an ejection fraction of 55% with freely moving valves and no clots or vegetations, ruling out a cardiac cause for the hypotension. During and immediately following stabilization, his pupils began dilating bilaterally from 2 mm to 8 mm over 30 min.
+A CT scan showed diffuse severe cerebral edema in bilateral hemispheres with effaced basal cisterns, microhemorrhages, and expansion of the sunken right gliotic brain along with ipsilateral ventricular dilatation. There was poor grey-white matter differentiation in the contralateral (left) side with a midline shift of 5 mm toward the right (cranioplasty) side . GCS remained E1M1Vt (No eye response or motor response, intubated on ventilator support) and pupils was now dilated fixed (8 mm bilaterally). Due to left-sided edema and risk of aggravation of midline shift by the right-sided titanium mold removal, a left-sided decompressive craniectomy and lax duraplasty were deemed suitable and performed.
+A magnetic resonance imaging was performed the subsequent day that showed bilateral posterior cerebral artery territory and brainstem infarcts .
+Despite all possible efforts and interventions, the patient did not improve, had absent brainstem signs with dilated fixed pupils and a GCS of E1M1Vt, and eventually a fatal outcome.
+In this case, other possibilities of malignant cerebral edema include fresh emboli from the heart causing fresh infarcts. Although fresh infarcts developing severe edema rapidly within an hour is rare, a screening cardiac 2D echogram was done at the time which showed normal findings apart from mild concentric LVH, and an ejection fraction of 55%, matching the evaluation done at the time of the initial infarct.
+Hypoxia during surgery could theoretically cause bihemispheric edema; however, no such hypoxia or desaturation occurred intraoperatively or immediately postoperatively.
+Hypotension due to an unrelated cause and subsequent hypoxic brain injury leading to malignant edema may be considered. However, no other systemic causes of hypotension could be identified. There was minimal blood loss during surgery and an 80–150 mL/h urine output throughout ruling out hypovolemia. Cardiac causes had been ruled out (as mentioned earlier) and there was no cause for septic shock immediate postoperatively. It was hence concluded that the hypotension was a consequence of severe brain edema and loss of autonomic control, further supported by the lability of the BP and extreme sensitivity to inotropic agents.
+After excluding the above, the sequence of events suggests postcranioplasty malignant edema due to a change in pressure dynamics, as the most likely cause of the deterioration.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2338_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2338_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6d822c0de58b85136321583752fcaae70707d4b0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2338_en.txt
@@ -0,0 +1,14 @@
+A 60-year-old Caucasian woman who had a silent clinical history with the exception of obesity and mild diabetes had routine blood count and chemistry tests at the recommendation of her family doctor. A slight lymphocytosis (range: 4.0 to 4.5 × 109/L) was observed. All the other blood parameters, including white blood cells, hemoglobin, hematocrit, platelet count, lactate dehydrogenase, plasma proteins, protein electrophoresis, and immunoglobulin levels, were within the normal range. Serum immunofixation was negative. Immunophenotyping of peripheral blood samples was carried out by flow cytometry using a FacsCanto II cytometer (Becton Dickinson) equipped with two lasers (488 and 633 nm). Samples (50 μL) were stained with fluorochrome-conjugated monoclonal antibodies (MoAbs) specific for the following antigens: CD3, CD4, CD8, CD5, CD16, CD56, CD19, CD20, CD22, CD23, FMC7, CD103, CD11c, CD25, CD10, CD38, CD45 (purchased from Becton Dickinson), and K and λ immunoglobulin light chains (purchased from Dako). A six-color panel was used for each tube, associating MoAbs conjugated with FITC, PE, PerCP-Cy5.5, PE-Cy.7, APC and APC-Cy.7. At least 200,000 events were acquired and data were processed using FacsDiva software (Becton Dickinson). Lymphocytes were gated using CD45 expression and right angle scatter. A second gate included CD19+ events and was used to analyze the expression of the other markers.
+Immunophenotyping showed an excess of B-lymphocytes (1.5 × 109/L) with bright expression of CD20 and CD22, restriction for the K light chain of surface immunoglobulins, and absence of CD5 and CD10 . At light microscopy, lymphocytes were not villous (not shown).
+A whole body computed tomography showed splenomegaly (20 cm longitudinal axis), but no lymphoadenomegaly or signs of other organ involvement were found.
+The patient was referred to the Division of Hematology for further observation and underwent bone marrow evaluation (morphology by myeloaspirate specimens, trephine biopsy, flow cytometry, molecular biology assays and karyotype).
+Bone marrow trephines were fixed in Myelodec® reagent A (Bio-Optica) for two hours, decalcified in EDTA for two days, embedded in paraffin, and cut into 3 to 5 μm sections. Morphological evaluations were performed on hematoxylin-eosin, Giemsa and Gordon-Sweet for reticulin-stained sections. Immunohistochemical stainings were performed using a peroxidase-based system including antibodies specific for: CD20, CD3, CD5, CD23, DBA44, bcl2, bcl6, and cyclin-D1 (DSC-6). The spleen was sectioned and fixed in buffered formalin.
+The bone marrow biopsy specimens showed a global cellularity of 50% with nodular-interstitial infiltration by CD20+ and bcl2+ lymphocytes, which accounted for 15% of cellularity and was negative for CD5, CD23, bcl-6, cyclin-D1 and DBA44 .
+Flow cytometry of bone marrow blood showed 16% lymphocytes which were positive for CD19, CD20, CD22, CD103 and surface K light chain, and negative for CD5, CD23, CD10, CD11c, CD25, and surface λ light chain .
+Mononuclear cells were separated by Ficoll/Hypaque gradient from bone marrow and peripheral blood samples, and suitable aliquots were utilized for polymerase chain reaction (PCR) tests after spectrophotometric quantitative evaluation. Fluorescent PCR reactions for IgH clonality evaluation were carried out with CDR3-specific VH consensus primer and analyzed by ABI PRISM 3100 (Applied Biosystems) ), whereas the results of FRI VH region rearrangement amplifications were run on a 3.5% agarose gel. Qualitative PCR detecting Bcl-1/JH rearrangements were performed according to the protocols established by the European network (BIOMED-2 Concerted Action) .
+The molecular findings showed a single clonal rearrangement of the IgH gene and the absence of the bcl-1/JH translocation.
+Karyotyping was carried out by conventional banding methods and no pathologic metaphases were detected by conventional karyotype.
+Diagnosis of B-cell non-Hodgkin lymphoma, compatible with the MZL subtype, was therefore made.
+The patient underwent splenectomy to remove a significant burden of disease and to confirm the initial diagnosis. Macroscopic examination showed that the organ was 23 × 15 × 8 cm, with a weight of 1350 grams. The spleen was sectioned and fixed in buffered formalin. Several samples were routinely processed to paraffin wax and sections of 3 to 5 μm were stained with hematoxylin-eosin for morphological evaluation. A panel of antibodies (CD20, CD3, CD5, CD10, CD23, bcl2, bcl6, cyclin-D1, CD10 and Ki-67) was applied to some samples using the ultraView Universal DAB Detection Kit and blue reagent with a BenchMark XT Automated Slide Stainer (Ventana).
+The spleen was found to be infiltrated by a MCL; lymphocytes were positive for CD20, CD5, bcl2, negative for CD23 and CD10, had a low mitotic index (Ki-67: 5 to 10%), and showed a strong positivity for cyclin-D1 and a characteristic pattern of infiltration . The neoplastic lymphocytes were seen as small to medium-sized cells with irregular nuclear contours, giving rise to a mantle-fashion pattern of infiltration. DNA extracted from paraffin-embedded spleen specimens (EZ1 Advanced, Qiagen) was subjected to PCR assays, which showed a clonal IgH rearrangement, the same as found in the bone marrow .
+At the end of our evaluation, the patient was diagnosed as suffering from the simultaneous presence of splenic MCL and bone marrow MZL with peripheral blood expression. Therapy with the cyclophosphamide, hydroxydaunorubicin (Adriamycin), Oncovin (vincristine) and prednisone - rituximab (CHOP-R) protocol was started and, after six courses and restaging by computed tomography and bone marrow and peripheral blood investigation, showed that complete remission was achieved.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2352_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2352_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3ef6e1d20c091fbf8241c14af6703baf9a98bc58
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2352_en.txt
@@ -0,0 +1,4 @@
+A 70-year-old female came to the emergency department with the chief complaints of sore throat for 7 days. The pain was continuous and was radiating to the left ear and the left side of the neck. The pain was aggravated by swallowing both solid and liquid diet. The pain was also aggravated by neck movements. The patient complained of a severe headache and neck stiffness. The patient was also having fever for the same duration. There was no change in the patient voice. There was no breathing difficulty . The patient was on Amoxycillin-Clavulanic acid (625mg three times a day for 1 week) for suspected streptococcal pharyngitis. However, her relatives were concerned as the fever and sore throat were not improving despite medications.
+On examination, the patient was alert and conscious with no signs of respiratory distress. The patient had high fever. Her temperature was 39.8°C. Her general physical examination was normal. On chest examination, bilateral crepitation with bronchial breath sounds was heard. Examination of her cardiovascular system, abdomen and skin were normal. Ear examination showed normal tympanic membrane with no mastoid tenderness bilaterally. On the oral cavity examination, the posterior pharyngeal wall was erythematous with a minimal bulge. The uvula was in midline. There was no evidence of facial nerve palsy nor trismus. On neck examination, tender lymph nodes were palpable in cervical level 1b and 2. Upon physical examination, the left external jugular vein had become a palpable strand with severe tenderness.
+The blood picture showed a total white blood cell count of 30,930/mm3 with left shift and consisted of 92% neutrophils. The C-reactive protein (CRP) was abnormally elevated (13mg/L). The serum electrolytes were within normal limits. She was a patient of diabetes and her blood glucose control was poor with HbA1C of 12.8. The blood culture was done in Brain Heart Infusion (BHI) broth. It did not show any growth. Lumbar puncture was done but it was negative for meningitis. Urine analysis was negative for any signs of infection. Sputum culture showed Enterobacter species sensitive to gentamicin, meropenem and levofloxacin. X-ray neck anteroposterior and lateral view showed increase in prevertebral shadow at the 4th cervical vertebral region. Cervical lordosis was lost. Diffuse pulmonary infiltrates were present . To rule out deep neck abscess, computed tomography of the neck and chest with intravenous contrast was done. CT scan showed peripheral enhancing collection in the neck in the prevertebral region measuring approximately 10×2 cm and extending from C4 to T3 region. Nasopharynx, oropharynx and hypopharynx appeared normal. The left internal jugular vein showed filling defect extending from the jugular foramen to the common jugular confluence, suggestive for high-grade partial occlusion due to thrombus formation. The cavitary lesion was seen in the left lower lobe of the lung peripherally due to metastatic septic emboli. Bilaterally, multiple nodules were seen in the lung with mild pleural effusion (–).
+The patient was kept on intravenous meropenem (1gram 8 hourly via intravenous route), metronidazole (500mg 8 hourly via intravenous route) and gentamicin (80mg 8 hourly via intravenous route). The pus in the retropharyngeal space was aspirated by inserting a 10-ml syringe through the oral cavity into the posterior pharyngeal wall. Around 10ml of pus was aspirated. Daily aspiration was done. There was no pus collection on the fourth day. The pus was sent for culture and sensitivity. However, no growth was seen. Anticoagulation therapy with enoxaparin (40mg subcutaneous injection once a day) was also started to the patient. The intravenous antibiotic treatment was given for two weeks. The patient’s condition gradually improved. After two weeks, the patient was discharged on a six weeks course of oral antibiotics and anticoagulation. The antibiotics given were Levofloxacin (500mg once a day) and Clindamycin (300mg three times a day) and the anticoagulant used was warfarin (1mg once a day orally for 6 weeks). On the follow-up visit, the patient was doing well. The patient was followed up to 3 months. She was doing perfectly well.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2364_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2364_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6a142d25d3922de5132508cf2d9a1471d1ff2441
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2364_en.txt
@@ -0,0 +1,4 @@
+A previously healthy 1-month-old boy was admitted to our university hospital with 1 day of fever (39.0 ℃), rhinorrhea, cough, and erythematous papules covering his whole body . At the time of admission (day 1) he had no other symptoms suggestive of KD, such as extremity changes, conjunctivitis, oral changes, and cervical lymphadenopathy. Initial vital signs and laboratory results were as follows: blood pressure, 90/48 mmHg; heart rate, 142/min; respiratory rate (RR), 40/min; white blood cells (WBC), 10.2 × 103/μL with neutrophil predominance; C-reactive protein (CRP), 32 mg/L; serum sodium, 135 mmol/L; serum albumin, 36 g/L; and serum aspartate/alanine aminotransferase, 22/13 units/L. Urinalysis and cerebrospinal fluid examination revealed no abnormal findings. Rapid diagnostic tests for respiratory syncytial virus, metapneumovirus, and Mycoplasma pneumoniae were negative, and severe acute respiratory syndrome coronavirus 2 was not detected by RT-PCR. The patient was treated with 150 mg/kg/day of cefotaxime, 60 mg/kg/day of vancomycin, and 60 mg/kg/day of acyclovir.
+On day 2 he exhibited frequent apnea (RR, 72/min), and blood gas analysis revealed hypercapnia (62.7 mmHg). Chest computerized tomography (CT) revealed bilateral consolidations . He was transferred to the ICU and underwent mechanical ventilation. IVIG (500 mg/kg/day) was administered for 3 days as adjunctive treatment for severe infection . He became afebrile on day 3, and acyclovir was discontinued due to negative PCR for herpes simplex virus. Moreover, administration of cefotaxime and vancomycin was discontinued due to negative blood and tracheal aspirate cultures on day 7. His condition gradually recovered without high fever or any clinical features suggesting KD, but elevated levels of CRP continued (63 mg/L on day 9). He was extubated on day 10 and discharged from the ICU on day 13. On day 14, however, fever recurred, and he also developed bilateral bulbar nonexudative conjunctival injection and desquamation of his fingers. KD was finally diagnosed by echocardiography, which detected CAA at the left main coronary trunk (2.3 mm, Z score = 3.2) and left circumflex coronary artery (1.8 mm, Z score = 2.8). Since KD in this case was refractory to the administration of IVIG, the patient was treated with aspirin and three courses of IVIG (2 g/kg/day on days 14, 19, and 35) plus 5 mg of cyclosporine from day 35 to 53. He was discharged on day 45 with small aneurysms present at the left main coronary trunk and the left circumflex coronary arteries. Left main coronary trunk was 2.4 mm (Z score = 2.2) and left circumflex coronary artery was 1.5 mm (Z score = 0.8) at 7 months after discharge.
+In order to identify the causative agent of severe pneumonia that required mechanical ventilation, multiplex real-time PCR was carried out on tracheal aspirate and serum sample to detect the genomes of 163 viruses (47 DNA viruses and 116 RNA viruses), 68 bacterial species, and nine fungal species [, ]. Moreover, specific reverse-transcription PCR (RT-PCR) was performed to detect human parechovirus in serum and cerebrospinal fluid [, ]. DNA and RNA were extracted from the patient’s serum and tracheal aspirate using a Maxwell RSC Viral Total Nucleic Acid Purification Kit (Promega, Madison, WI). No infectious pathogens were detected in these samples collected at the time of hospitalization.
+In addition, the patient’s serum cytokine profile demonstrated the following (normal values are shown in parentheses): interleukin (IL)-18, 175 pg/mL (< 500 pg/mL); IL-6, 410 pg/mL (< 5 pg/mL); neopterin, 36 nmol/L (< 5 nmol/L); soluble tumor necrosis factor receptor (sTNF-R)I, 3000 pg/mL (484–1407 pg/mL); and sTNF-RII, 14100 pg/mL (829–2262 pg/mL) by commercial ELISA (IL-18: MBL, Nagoya, Japan; IL-6, sTNF-RI, and sTNF-RII: R&D Systems, Minneapolis, MN, USA; neopterin: IBL, Hamburg, Germany) .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2385_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2385_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1e67f2502aa34f030370e86db16b10b7a05f3b8b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2385_en.txt
@@ -0,0 +1,8 @@
+A 74-year-old male, known case of diabetes mellitus (DM), hypertension (HTN), bronchial asthma and hypothyroidism who was diagnosed with para-umbilical hernia. The defect size was 1 × 2 cm, after of which he underwent a laparoscopic hernia repair at our hospital using a 15 × 20 cm eTPES mesh Bard® Composix™ E/X Mesh (Warwick, RI) with no complications. The patient had uneventful admission period and was discharged home in good condition at day 2 post-op.
+Postoperatively day 10, he presented to the Emergency Room (ER) complaining of colicky abdominal pain in the right iliac fossa for 1 day associated with diarrhea (5 times/day). No other symptoms were reported by the patient. On physical examination, patient had normal vital signs and generalized mild abdominal tenderness. The maximum tenderness point was at the right iliac fossa. A Computed Tomography (CT) scan of the abdomen and pelvis was done which showed diffuse wall thickening of the cecum and terminal ileum with abnormal configuration of the cecum and ill definition of its anterior wall with small free air worrisome for perforation . The decision was made in the ER to discharge him home on antibiotics.
+Ten weeks post-operation, the patient presented again to his primary surgeon at our institute with the same complains where CT scan was ordered again and showed the same findings. Colonoscopy was ordered which showed small polyp that was removed and revealed benign adenoma, also showed a small solid structure in the cecum . Biopsy of that solid structure showed granulating tissues.
+Three months after surgery, the patient returned back to his primary surgeon complaining of bleeding per rectum for which he underwent further investigations including second colonoscopy. The colonoscopy showed a polypoidal mass that was biopsied and showed granulating tissues . The patient was sent back to the surgeon’s clinic and reassured.
+Ten months post operation, the patient was seen in the outpatient clinic complaining of persistent vague abdominal pain and bleeding per rectum. CT scan of abdomen and pelvis was repeated which demonstrated opacity at the level of the cecum with dense opacity medial to it of low attenuation and contains some air bubbles . Another colonoscopy was done which showed a small mass in the cecum that was biopsied and revealed to be granulating tissues, the patient was referred to the primary surgeon who reassured the patient and gave him a follow up appointment in one-year time.
+Follow up after more than 2 years of surgery indicated iron deficiency anemia and B12 deficiency. Thus, a colonoscopy was scheduled but the patient could not tolerate the bowel prep. A CT Colonography was ordered which showed a foreign object in the colon, possibly caused bleeding per rectum where the patient was referred back to the surgeon . A CT scan revealed recurrence of a periumbilical hernia and thickening of the medial wall of the cecum with mesh graft material that could suggest a complication of the previous ventral hernia repair with extension of the mesh graft through the cecal wall . Exploratory laparotomy was offered to the patient but he refused and was discharged against medical advice.
+Ten months later, we received the patient in our service for the first time when he was complaining of persistent abdominal pain and bleeding per rectum. After reviewing his previous investigations, we told the patient about the mesh graft migration and we discussed with him the mandatory of exploratory laparotomy and mesh graft removal with bowel resection and the possibility of stoma creation at any point of surgery. The patient was informed that he would have higher rate of hernia recurrence and a mesh graft will not be used in this procedure to avoid further complications like wound/mesh infection due to the risk of bowel contents spillage in the surgical field on top of his other comorbidities like DM and bronchial asthma.
+The patient then was taken to surgery by his primary surgeon, and intra-operative findings revealed migration of almost 50% of the mesh graft size to the cecum and part of the mesh graft was eroding the distal part of ileum just proximal to the ileocecal junction. Adhesolysis and limited right hemicolectomy with ileocolic anastomosis was done. Fascia closure was obtained primarily without mesh graft application. Skin closure completed with skin clips . The patient had an uneventful recovery after revisions surgery without any perioperative complications. He was discharged home on postoperative readmission day 5 and followed up at 2 weeks and 3 months without any delayed complications or subjective complaints.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2387_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2387_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..47310ac3f0aa2fbc4ce19898173f7dd7c66ff10f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2387_en.txt
@@ -0,0 +1,5 @@
+A 24-year-old female with no significant past medical history initially presented to an outside hospital with severe abdominal pain and scantly bloody stools. She was transferred to a tertiary care center for further work-up and management. Contrast-enhanced CT of the abdomen and pelvis showed findings of colitis extending from the splenic flexure to the rectum . The patient was empirically treated for infectious and inflammatory etiologies of colitis without improvement. Flexible sigmoidoscopy demonstrated inflammatory changes in the descending colon and rectum with biopsy samples suggestive of ischemic colitis. A small external hemorrhoid was noted. Differential diagnosis for possible ischemic colitis included thrombosis and vasculitis, but there were no definitive imaging findings of either on CT imaging. Hematologic and rheumatologic work-up were nonspecific but notable for elevated rheumatoid factor and positive antinuclear antibodies.
+Interventional radiology was consulted for further angiographic evaluation of the mesenteric vessels given the ischemic findings on pathology. IMA angiography was performed, and prompt filling of the IMA and paralleling mesenteric venous branches was observed . A few abnormal-appearing, tortuous distal IMA branches were noted. Hepatofugal flow was observed in the IMV.
+Given these findings, the patient was empirically treated with steroids and anticoagulation. She showed marginal improvement and had persistent severe abdominal pain. Based on the prompt venous filling seen on conventional angiography, it was hypothesized that the presence of an arteriovenous connection may be causing mesenteric venous congestion. After a multidisciplinary team discussion, it was decided to pursue further angiographic investigation and attempt endovascular embolization of a suspected arteriovenous connection.
+The patient returned to interventional radiology for further diagnostic imaging and potential intervention. The right common femoral artery was accessed using standard micropuncture technique with a 5 French micropuncture set (Merit Medical, South Jordan, UT). Digital subtraction angiography of the IMA was performed using a 5 French catheter. Using a microcatheter, further selective angiography of the IMA branches was performed. Filling of the venous system was again seen along with a tangle of small vessels compatible with a nidus connecting small arterial feeders to the venous system . Glue embolization of this nidus was performed using n-butyl cyanoacrylate (n-BCA) (TruFill, Codman and Shurtleff Inc., Raynham, MA) diluted in a 3:1 lipiodol to n-BCA concentration. Post-embolization imaging demonstrated decreased venous filling, although there was persistent venous filling from several smaller IMA feeding branches, which were small and not amenable to embolization .
+The patient’s pain significantly improved the day after embolization, and she was discharged 5 days post-embolization. Unfortunately, her pain returned in 11 days and rose to pre-embolization levels approximately 26 days post-embolization. She was readmitted for pain management, and her deteriorating condition resulted in a multidisciplinary medicine, interventional radiology, and surgery team decision to proceed with colonic resection. Extended left colectomy with partial proctectomy, end transverse colostomy, and rectal stump was performed. The patient tolerated the procedure well, and her pain completely resolved. Pathological analysis of resection specimens was consistent with venous insufficiency, as it indicated prominent concentric intimal smooth muscle hyperplasia with colonic perforation. Dilated capillaries, thickened hyaline walls, and ischemic changes were visualized without evidence of malignancy or thrombosis. Van Gieson’s stain along with venous presence of lymphocytic phlebitis, fat necrosis, and organizing thrombi confirmed IMHMV diagnosis (Genta and Haggitt ).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_240_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_240_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d44359e40ed9821f8e189f5cf9edeab2f7da3e8a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_240_en.txt
@@ -0,0 +1,13 @@
+A 66-year-old man was admitted to our clinic two years ago complaining abdominal discomfort associated with distension, pain, and symptoms related to small intestine bowel obstruction (vomiting and obstipation). On physical examination a palpable mass in the lower right abdomen was found. CT scan of the abdomen and pelvis demonstrated a large (9 × 6.5 × 7 cm) low-density, well circumscribed mass in the right lower abdomen, without evidence of tumor infiltration of adjacent structures and without free fluid. No metastatic nodules were found in the liver and the lung.
+Laparotomy revealed a pedunculated, ulcerative and friable large mass (a small bowel mass greater than 10 cm) with the features of gastroimtestinal stromal tumor: the surrounding organs (sigmoid colon, rectum, ureters and bladder) were pushed but not involved by the tumor. Furthermore, remarkable intraabdominal metastatic spread consisted of multiple small nodular lesions – less than 2 cm in size – all over the peritoneal surface and between bowel loops, was encountered. No evidence of liver metastasis or lymphadenopathy was found. The patient underwent an en-block resection of the tumor along with all visible disease in order to avoid capsule rupture and intraabdominal spillage, as is recommended . A small bowel resection with an end to end primary anastomosis was performed. Numerous peritoneal nodal metastases were excised and sent for histological analysis.
+Histopathological examination of the resected specimens revealed a stromal cell neoplasm with necrotic and hemorrhagic areas and a high index of mitotic count: 8–10 mitoses per high-power fields (HPF). Immunohistochemical analysis revealed C-kit (strongly positive), SMA(strongly positive), focal S-100(+) and CD34(-). The result of histological examination confirmed also the existence of intraabdominal metastatic spread.
+Following the histopathological confirmation, immediate treatment with imatinib was initiated. The imatinib was introduced in dose of 400 mg/day without interruption (in order to minimize the risk of relapse associated with the drug interruption) . Postoperatively, patient was followed up with CT scan. According to the clinical, surgical and histopathological features, our patient was included in the high risk group for recurrence. The patient underwent a CT scan of the abdomen and the pelvis in regular 4–6 months intervals [,].
+The CT scan performed 2 years after surgical excision and treatment commencement, revealed metastatic liver disease. Dose escalation (400 mg of imatinib mesylate twice a day) was decided and initiated. Six months later, liver lesion was presented with a characteristic size increase . Furthermore, a small soft tissue mass (3,3 × 2,8 × 3 cm) in the right lower abdomen was revealed in the abdominal CT scan. The mass was localized at the anatomic area of the previous excision and was considered either as another metastatic lesion or as a possible local recurrence .
+Laparotomy confirmed the presence of liver metastasis, localized between the Segment V & Segment VI as well as intra-abdominal metastatic spread (multiple small nodular lesions – less than 1 cm in size – all over the peritoneal surface and between bowel loops). An intestinal mass was also found 60 cm proximal to the ileocecal valve. Surprisingly, during the thorough exploration of the peritoneal cavity, another mass with completely different macroscopic features was discovered. It was a palpable cecal mass, without extracanalicular growth or infiltration into other organs, associated with local lymph-node enlargement.
+Intra-abdominal ultrasound (IOUS) was performed in order to assist in liver resection planning (mainly to enable detection of additional tumors, missed in preoperative CT scan imaging and to evaluate the relationship between metastatic lesions and major vascular structures).
+RFA (Radio Frequency Ablation)-assisted liver resection of segments V, VI was performed and a segmental small-bowel resection along with excision of all gross visible peritoneal nodular lesions followed. Finally, a right hemicolectomy was decided in order to treat the "unexpected" cecal lesion.
+At this point is important to underline that surgery remains the mainstay therapy for both (GIST and colorectal cancer) although the operative strategies and extent of resection are fairly different. Given the rarity of lymph-node involvement, routine lymphadenectomy is not currently recommended in GIST cases. [,] At the present case because of local lymph-node enlargement a curative resection was performed (included the resection of the lymphatic station), aiming to obtain microscopic disease-free radial and distal margins.
+Gross examination of the 29 cm specimen disclosed a 7 × 4 cm tumor originating from the cecum and two polyps located about 7 cm from the cecum. The liver specimen (8.5 × 6.5 × 3.7 cm, segments V, VI) weighted 90 gr and contained the 5 cm metastatic lesion.
+Histopathological examination of the resected specimen revealed a recurrent intestinal GIST with malignant biological behavior and a moderately differentiated stage Dukes C (T3, N3, M0 according the TNM staging classification of colorectal cancer) cecal adenocarcinoma .
+The specimen had the following characteristics: a) metastatic liver tumor with mesenhymal origin characterized by necrotic and bleeding areas and a mitotic count of <5/50 HPF. Immunohistochemical staining revealed a strongly (+) reaction for c-kit, slight (+) for S-100, and no specific staining for CD34 and desmin. The surgical margins of the resected hepatic specimen were free from invasion, b) moderately differentiated adenocarcinoma with a slight extracellular, mucus production. The tumor invaded the muscularis propria and the pericolonic adipose tissue. The neoplastic tissue extended and infiltrated the small bowel wall but the proximal and distant surgical margins were free.
+Four of the examined lymph nodes presented metastatic invasion from GIST and 12 from colorectal adenocarcinoma. The above mentioned morphologic and immunochistochemical findings are diagnostic for coexistence of GIST and colorectal adenocarcinoma
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2412_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2412_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..52b1c2804683163429ab379524ecb6f75777b430
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2412_en.txt
@@ -0,0 +1,2 @@
+A 52-year-old Albanian woman from Kosovo presented to our hospital with dyspnea, tachycardia, and jugular distension. On admission she was in New York Heart Association class III, with normal blood pressure and absence of aortic murmur. She was in sinus rhythm and a chest X-ray demonstrated cardiomegaly with right atrium enlargement. A transthoracic echocardiography demonstrated increased pericardial effusion of almost 35 mm and a giant mass above her left atrium communicating with the ascending aorta. A transesophageal echocardiogram showed a large unruptured aneurysm/pseudoaneurysm 61×77 mm of the noncoronary sinus of Valsalva, without thrombosis or shunts, above her left atrium . Her aortic valve was competent, without annular enlargement. A cardiac contrast-enhanced angio-computed tomography (CT) scan confirmed the presence of a giant unruptured aneurysm of the noncoronary sinus of Valsalva of 74×60 mm diameter free from thrombotic lining, which was compressing her right atrium . The presence of a significant amount of pericardial effusion indicated a possible rupture of the aneurysm of the sinus of Valsalva or the presence of a pseudoaneurysm; therefore, we recommended urgent surgical repair.
+She underwent femoral artery and vein cannulation and on cardiopulmonary bypass a sternotomy was performed. Her pericardium was then opened. An unruptured aneurysm of the noncoronary sinus of Valsalva was identified . On intraoperative examination, a thin-walled unruptured aneurysm of the noncoronary sinus of Valsalva expanding above the roof of her left atrium, compressing and partially gaining adhesions with her right atrium was identified. Her aorta was clamped and her heart was arrested with anterograde cardioplegic infusion. An anterior oblique aortotomy was performed. The orifice of the unruptured aneurysm of the noncoronary sinus of Valsalva was identified . The aneurysm was opened and carefully inspected for any possible communication. A Dacron patch was prepared to remodel the noncoronary sinus, which then was sutured with a continuous Prolene 4/0 suture . Then the aneurysmatic sac was closed from outside above the orifice of the aneurysm. A pathological examination of the resected unruptured aneurysm of the noncoronary sinus of Valsalva revealed conspicuous mucoid deposits, loss of elastic fibers and eosinophilic infiltration. Her postoperative course was uneventful. At 1 month after surgery, a contrast-enhanced angio-CT demonstrated a totally thrombosed cavity of the previous aneurysm which had non-communication with her aorta or any other cardiac chamber . At 1 year after surgery, she was doing well and an echocardiographic examination revealed mild aortic insufficiency.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2421_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2421_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d160636728ba903066be774f49d73e11329caca5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2421_en.txt
@@ -0,0 +1,5 @@
+A 65 yr old female presented to the Ear Nose and Throat [ENT] clinic of our institution with a one-month history of a lump in the right neck. On examination, a mobile lump was palpable in the angle of the mandible/upper cervical region. A flexible endoscopy did not reveal any mucosal lesion in the posterior nasal space, oropharynx, hypo pharynx or in the larynx. Clinically a lymph node mass was considered as a possible diagnosis. Fine needle aspiration [FNA] and Magnetic Resonance Imaging [MRI] were then performed.
+MRI showed a well-defined oval shaped mass measuring 3 × 2 cm just inferior to the right parotid gland. The epicenter of the lesion was in the inter muscular plane, medial to the sternocleidomastoid muscle but separate from it. It was heterogeneous on both T1 & T2 W images with a well defined margin . Following contrast administration, there was moderate heterogeneous enhancement In view of the location of the lesion, a differential diagnosis of lymph nodal mass & Spinal Accessory nerve Schwannoma were considered.
+FNA of the lesion showed a mix of bland epithelial cell, clusters of spindle cells and myxoid matrix, which was typical of a pleomorphic adenoma.
+A decision to perform an excision biopsy was subsequently made. At surgery, the tumor was found to be a pedunculated mass arising from the inferior aspect of the tail of the parotid gland. It was closely related and superficial to the spinal accessory nerve but separate from it. The mass was excised completely incorporating a limited cuff of macroscopically normal parotid tissue, taking care not to injure the inferior branches of the facial nerve.
+Histopathology of the excised specimen showed uniform proliferation of epithelial elements within a patially myxo-chondroid stroma, again, consistent with a diagnosis of a pleomorphic adenoma. There was no definite salivary gland tissue within the specimen.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2424_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2424_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..89ac6c65c539b0eb7cd09b2306696357734a5f0a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2424_en.txt
@@ -0,0 +1,7 @@
+A 57-year-old previously healthy gentleman presented to our service complaining of a new onset shortness of breath for 2 months. He initially sought medical attention outside King Hussein Cancer Center (KHCC) where he was found to have a huge mediastinal mass on a chest x-ray from which a biopsy revealed a thymoma . At KHCC, a chest computed tomography (CT) scan showed a lobulated anterior mediastinal soft tissue mass measuring 11.3 × 7.7 cm at the level of the aortic arch. It appeared to be inseparable from the anterior wall of the superior vena cava (SVC), compressing it mildly but keeping it patent. In addition, it had a wide area of contact with the ascending aorta and upper pericardium. Multiple small nodular soft tissue masses were seen in the anterior epicardial space, mostly representing small lymph nodes. Otherwise no other mediastinal lymphadenopathy was reported .
+A multidisciplinary team explained to the patient and his family the treatment options, which included neoadjuvant chemotherapy and re-assessment of tumor size for potential resectability afterwards. The patient received two cycles of Cisplatin/Doxorubicin/Cyclophosphamide (CAP). Follow up imaging showed a slight regression in size of the previously noted anterior mediastinal mass which now measured 10.2 × 7.2 cm. The patient received a third cycle of neoadjuvant chemotherapy however, the tumor size remained unchanged.
+The patient was then scheduled for a total thymectomy through a mid-sternotomy. Intraoperatively, there was a huge hard thymic mass invading the inner surface of the anterior pericardium and the right phrenic nerve, being very close to the left phrenic nerve. It was also attached to the superior vena cava, innominate vein (InV), ascending aorta (AsA) and part of the right middle and right upper lung lobes.
+Total thymectomy with anterior pericardial resection was done; the tumor was dissected from the SVC, the InV and the AsA without complications, the right phrenic nerve was resected en bloc with the tumor and part of the pericardium while the left phrenic nerve was dissected from the mass and preserved. The operation was smooth and uneventful. Postoperatively the chest tube collected 2 l of blood and the patient became hypotensive despite receiving two units of packed red blood cells (PRBCs) and intravenous normal saline. The decision was then made to take the patient back to the operation room and an emergency surgical site exploration via reopening of the midline sternotomy was done within 3 h of the first procedure.
+The bleeding source was identified from the left internal mammary vessel and was controlled by clipping, cautery and SURGICEL (Ethicon US). During the intraoperative thirty-minute monitoring for blood pressure improvement, the patient developed ventricular tachycardia, and the defibrillator could not be readily started for technical reasons, so the heart became severely distended and developed asystole. Cardiopulmonary resuscitation (CPR) was initiated manually by cardiac massage with intra-cardiac adrenaline injection. Right ventricular rupture occurred with a 3-cm hole that was followed immediately by an attempt of Proline stich repair that failed, so manual massage continued with a hand closure of the defect until the sinus rhythm reverted. Eventually, repair of the defect was successfully achieved with pericardial patch. Meanwhile, the blood loss was compensated by continuous blood infusion. Within 5 h, the patient received a total of thirteen units of PRBCs, eleven units of fresh frozen plasma (FFP) and one unit of single donor platelet. Blood pressure and vital signs improved afterward and the heart returned to a synchronized rhythm.
+The patient was transferred to the intensive care unit (ICU) on mechanical ventilation for observation. An echocardiogram was done the next day; the left ventricular ejection fraction (EF) was 60% with no evidence of thrombi. On the second post-operative day, the patient developed atrial fibrillation (A.Fib) which was controlled with antiarrhythmic medication (Amiodarone). The patient’s overall status and multi-organ functions returned back to normal during his prolonged ICU stay. However, he remained dependent on ventilator support in spite of multiple trials of weaning. This necessitated a fluoroscopy scan that revealed no appreciable movement in both hemi-diaphragms , suggesting bilateral phrenic nerve palsy and a decision for elective tracheostomy was made on the 8th post-operative day.
+The patient remained completely dependent on the portable mechanical ventilator for a total of 2 months and was discharged from the ICU to the surgical floor 66 days post-operatively with aggressive chest rehabilitation and physiotherapy. He was gradually weaned off ventilation and was discharged on the 85th post-operative day. His tracheostomy tube incision site was closed 5 months after the initial procedure. Two years from the incident, the patient remains in complete remission and is back to his normal daily life with minimal shortness of breath, controlled by an inhaler.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_243_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_243_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6d517909cb22805066b7660a06f0720f75aa8ed9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_243_en.txt
@@ -0,0 +1,9 @@
+A 33-year-old female complained of abdominal pain in the left upper quadrant and discomfort without any obvious cause for 1 mo prior.
+The pain presented as intermittent dull pain. Occasionally, she felt abdominal distention and experienced acid regurgitation without nausea, vomiting, fever, jaundice, diarrhea, or constipation. Other complaints included poor sleep and loss of appetite. There was no change in weight or bowel habits.
+The patient reported that she had no history of past illness.
+The patient reported no family history of malignant tumors.
+Physical examination revealed an enlarged spleen with an irregular edge and tough quality; the inferior margin of the spleen extended to 4 cm below the left costal margin.
+Laboratory findings included a low red blood cell count (3.4 × 1012/L) and low hemoglobin level (93 g/L), which suggested anemia, without evidence of thrombocytopenia (platelet count: 9.7 × 1010/L) and hypersplenism. Other blood tests, including those for tumor markers, liver and renal function, and coagulation, were within normal limits.
+Imaging examination showed splenomegaly with an irregular shape. Computed tomography (CT) showed that the density of the spleen was uneven. The lesions exhibited hypodensity (31 HU), isodensity (40 HU) or hyperdensity (55 HU). Contrast-enhanced CT (CECT) revealed that the degree of enhancement ranged from moderate to high (100-150 HU), gradually decreased in the venous or delayed phase (100-120 HU), and was nearly equal to the splenic parenchyma (78 HU) around the lesions (80-90 HU) in the delayed phase. There were also some lesions with no obvious enhancement .
+Ultrasound (US) showed multiple hyperechoic lesions with unclear boundaries. Some were integrated, and some were heterogeneous. The largest lesion was 5.4 cm × 5.0 cm, protruding to the outside of the spleen. Two accessory spleens were displayed, and the diameter of the larger accessory spleen was 1.1 cm. The features of the lesions varied on contrast-enhanced US (CEUS) .
+Given the negative results of cervical, axillary, inguinal and abdominal lymph node ultrasounds and the bone marrow biopsy, no typical sign of hematologic malignancy was observed.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2447_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2447_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cbf0049656015b280efc923501386eb0ea782565
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2447_en.txt
@@ -0,0 +1,8 @@
+A 54-year-old man presented with a history of epigastric pain and melena over the last few days. The patient did not have hormone-related symptoms. He had received treatment for a myocardial infarction at the age of 51 with an antiplatelet therapy; therefore, we considered that there was a possibility of tumor bleeding by antiplatelet therapy. Blood biochemical examinations indicated slight anemia. Serum carbohydrate antigen 19-9 and carcinoembryonic antigen (CEA) levels were not elevated. The 24-h urinary 5-hydroxyindoleacetic acid (5-HIAA) level was 3.2 mg. Upper gastrointestinal endoscopy showed a bulging papilla with bleeding . A biopsy was not performed at that time because of the active bleeding. Endoscopic examination on day 7 revealed an approximately 10-mm mass of the ampulla of Vater with a superficial ulcer . Pathological findings of the endoscopic biopsy of the ampulla revealed a well-differentiated NET. Immunohistochemically, the tumor stained positive for CD56, chromogranin A, and synaptophysin. An upper gastrointestinal series showed an ampullary mass without any obvious lesions of the jejunum . An enhanced abdominal computed tomography (CT) scan revealed a 10-mm hypervascular tumor at the ampulla of Vater and a 41-mm multilocular cyst adjacent to the wall of the jejunum near the ligament of Treitz . The wall of the multilocular cyst showed the same enhancement patterns with the tumor. The patient underwent magnetic resonance imaging that was negative for visceral metastasis. About the cyst, the preoperative definitive diagnosis was not provided.
+The patient was referred to our hospital for treatment of the NET. We performed a pylorus-preserving pancreaticoduodenectomy with regional lymph node dissection. The operative time was 497 min, and the volume of blood loss during the surgery was 1220 ml. The resected specimen was macroscopically a 9-mm white solid tumor . Tumor cells confined to duodenal mucosal layer. There was a 52-mm cyst in the superior mesentery adjacent to the wall of the jejunum . Microscopically, the tumor consisted of small-sized round cell proliferations with a solid nest pattern . The cyst preserved the structure of the lymph node and was the superior mesenteric lymph node metastasis of the tumor . We performed D2 lymph node dissection, and there was no metastatic lymph node except for the superior mesenteric lymph node. Immunohistochemically, the resected specimen revealed that the tumor and the lymph node metastasis were positive for chromogranin A and CD56 and negative for synaptophysin. The Ki-67-labeling index of the tumor cells determined with MIB-1 was 2.0 %. The final diagnosis was sporadic non-functional NET G1 of the ampulla of Vater (pT1N1M0 stage IIIB). The patient was discharged 36 days after the operation. He has had no recurrence for 4 years after surgery. No further treatment was administered.
+NETs of the ampulla of Vater are rare and difficult to diagnose [, ]. Jaundice (60 %) and abdominal pain (40 %) are the most frequent symptoms. Upper gastrointestinal bleeding is a rare presentation (<3 %) [, ]. In our case, the patient presented with abdominal pain and melena. On admission, upper gastrointestinal endoscopy revealed a bulging papilla with active bleeding. When we performed gastric endoscopy again 7 days later, we found a 10-mm mass of the ampulla of Vater with a superficial ulcer.
+Diagnosis of NETs is established by histological and immunohistochemical analysis of endoscopic biopsy specimens . NETs of the ampulla of Vater usually appear as submucosal masses that are small and spherical with a smooth surface and an intact duodenal mucosa. Consequently, superficial biopsies are negative and deeper biopsies are required for a diagnosis [, ]. In our present case, we could get the biopsy specimen from the mass because it had an ulcerated surface. Thus, the correct diagnosis of a NET was established preoperatively. However, we could not diagnose the cyst adjacent to the wall of the jejunum as a lymph node metastasis at the time of resection.
+Previous reports have suggested that the biological behavior of ampullary NETs is distinct from that of duodenal NETs and they are more aggressive . Randle and colleagues reported that ampullary NETs were larger, higher grade, and higher stage and had a higher rate of lymph node metastasis than duodenal NETs . The incidence of lymph node metastases in patients with resected ampullary NETs and duodenal NETs was 72.9 and 48.4 %, respectively.
+In the case of ampullary NETs, even in tumors smaller than 2 cm, a high percentage have lymph node metastases [, –]. Nikou et al. reported that lymph node metastases were found in two cases of ampullary NET with tumor sizes of 1.0 and 1.2 cm, respectively . In the present case, the histologic examination revealed metastasis to distant lymph nodes despite the tumor only being 9 mm in diameter and within duodenal mucosal layer. These findings suggest that there is no correlation between tumor size and metastatic potential in ampullary NETs. We consider that an anatomical reason is one of the reasons why NETs at the ampulla of Vater have high incidence of metastasis. Ampullary carcinoma with perisphincteric or duodenal submucosal invasion showed more frequent lymph node metastasis and a greater tumor recurrence rate than tumor limited within the sphincter of Oddi muscle . Moreover, the perisphincteric and duodenal submucosal space is relatively small and closer to the next layering of duodenal proper muscle and the pancreas. Thus, the malignant potential of perisphincteric and/or duodenal submucosal invasion may be greater than that of other gastrointestinal tract tumors. Moreover, previous studies have reported that lymph node metastasis is difficult to detect on preoperative imaging [, ]. Although some authors report the existence of lymph node metastasis of NETs is not correlated with patient prognosis, this could be due to metastasis to the liver or some other organ, which is an important prognostic factor for NETs. Therefore, radical resection with lymph node dissection is recommended as a treatment of ampullary NETs regardless of tumor size [, , , , ].
+We performed a pylorus-preserving pancreaticoduodenectomy with regional lymph node resection and also resected a 52-mm lymphatic metastasis adjacent to the wall of the jejunum. Despite the lymph node involvement, the Ki-67-labeling index was low (2 %) and the patient has had no evidence of recurrence for 4 years after surgery.
+Randle et al. indicated that tumor size was correlated with poor prognosis, but the presence of positive lymph nodes was not a predictive outcome in resected ampullary NETs . Untch et al. reported that only tumor size and tumor grade were associated with recurrence . Thus, we can perform radical resection and completely remove the tumor with good clinical outcomes.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2448_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2448_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..aa770055f1b1c7bc860cd797a6af63a521d6aa09
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2448_en.txt
@@ -0,0 +1,3 @@
+A 12-year-old black boy with a history of asthma presented with complaints of bilateral decreased visual acuity and central scotoma shortly after playing with a battery-powered bright blue laser pointer (473 nm, according to the label on the device). While playing with the device alone at an arm's distance, he shined the blue laser pointer consecutively into both eyes, for a duration that he described as only several seconds, and immediately experienced decreased visual acuity in both eyes. He denied ever having stared at the sun and has no behavioral or psychiatric history.
+The patient presented to the ophthalmology clinic 5 days after exposure and had a BCVA (best corrected visual acuity) of 20/40– OD and 20/40+3 OS. He complained of and demonstrated central scotomata on Amsler grid testing. No abnormalities were seen in the anterior segment, and the lens and vitreous were both clear in both eyes. Color fundus photographs showed bilateral yellow-orange foveal lesions, corresponding to the location of central vision . A fluorescein angiogram showed early foveal hyperfluorescence with ill-defined leaking bilaterally . Optical coherence tomography (OCT) revealed outer retinal layer disruption from the external limiting membrane to the interdigitation zone on day 5 . By week 22, the outer retinal layer disruption was more prominent .
+The patient was carefully observed 5 days, 2 weeks, 6 weeks, 14 weeks, and 22 weeks after exposure, with no invasive therapy performed. He was treated with a Medrol Dosepak on initial presentation, and with protracted treatment with a topical nonsteroidal anti-inflammatory drug (NSAID; Ilevro) daily for 20 weeks. His BCVA gradually improved to 20/20 in both eyes by 22 weeks, and he had no residual scotoma on Amsler grid testing at that time.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2456_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2456_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6b072a9c39d4d02fc94bdb968d00707a9a84bb89
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2456_en.txt
@@ -0,0 +1,4 @@
+A 27-year-old Thai male with AIDS from Saraburi Province presented with acute abdominal pain that had lasted for 4 days. He originated from Mukdahan Province, in Northeastern Thailand, but had moved to Saraburi Province which is situated in the southern part of Northeastern Thailand, 200 km from Bangkok. He denied other travel histories outside these areas during the past year. He was diagnosed with AIDS 2 months before at another hospital, which recorded an initial CD4 count of 91 cells/mm3 (unknown percentage and HIV viral load) and no complete immune status evaluation was performed. At the time, he presented with respiratory distress which was later identified as pneumocystis pneumonia and presumptive smear-negative pulmonary tuberculosis. He was given a 3-week course of trimethoprim/sulfamethoxazole, and anti-tuberculosis treatment consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol during hospitalization. Anti-retroviral therapy (ART) comprising tenofovir disoproxil fumarate, emtricitabine, and efavirenz was introduced 2 weeks later when he was an outpatient. The anti-tuberculosis regimen was adjusted to isoniazid, rifampicin, ethambutol, and levofloxacin after 4 days, and a chest radiograph demonstrated complete resolution of prior pulmonary opacities after 50 days of treatment. He reported 100% adherence to both anti-tuberculosis treatment and ART and no other new medications had been added to the regimen. The CD4 count 8 weeks before this admission was 91 cells/mm3 (unknown percentage).
+At this admission, he presented with abdominal pain mainly in the left upper quadrant that he described as a dull ache, without radiation. The pain was not related to eating food, physical activity, or position. He reported no other associated gastrointestinal complaints such as diarrhea or nausea. Two days later, he developed a high-grade fever without chills, with the highest temperature of 38.9 °C. Abdominal pain persisted and partially responded to acetaminophen. In response to this, he attended the emergency department where a physical examination revealed a blood pressure of 120/75 mmHg, a heart rate of 110 beats/min, a temperature of 38.7 °C, and a respiration rate of 20 breaths/min. His abdomen was soft, normal bowel sounds were heard, but tenderness on palpation in the left upper quadrant was evident. The spleen could not be palpated. The remaining physical examination was unremarkable including a negative complete skin examination, with no cutaneous lesions on his face, trunk, or extremities, and a neurological examination within normal limits.
+Initial laboratory investigations revealed hemoglobin levels of 9.8 g/dL, a white blood cell count of 14,000 cells/mm3, and a platelet count of 225,000 cells/mm3 on a complete blood count. Serum galactomannan (GM) levels by Platelia enzyme-linked immunosorbent assay (ELISA) (BioRad)® were 6.84. The CD4 count on admission was 272 cells/mm3 (19%). A fungal blood culture obtained on hospital day 1 grew white to tan-colored, velvety and flat colonies with red soluble pigment on day 9. Direct microscopic examination of the colonies with lactophenol cotton blue staining demonstrated septate hyphae and smooth conidia aloft phialides directly borne on metulae . A bone marrow culture grew similar colonies to the blood specimen on day 12 after the procedure. Contrast-enhanced computed tomography of the abdomen revealed a small hypodense lesion with a thin enhancing rim at the spleen and extensive intra-abdominal lymphadenopathy . At the time, the patient was not able to provide sputum sample for culture and due to the high-risk procedure, intra-abdominal lymph node biopsy for culture and histologic analysis was not performed.
+Because of a concern of disseminated fungal infection on admission, empirical intravenous amphotericin B deoxycholate was given at a dose of 1.5 mg/kg/day for 7 days. This was switched to liposomal amphotericin B at 3.2 mg/kg/day in response to acute kidney injury for a total of 21 days. Before discharge, a loading dose of itraconazole was initiated at 600 mg/day for 3 days, then 400 mg/day for the maintenance phase. Of note, plasma itraconazole levels drawn on day 4 were 0.13 mcg/mL, with the highest value throughout the treatment course of 0.21 mcg/mL. The patient continued to improve clinically and was discharged from the hospital after 29 days. Repeat imaging was initially planned at 6 months but was deferred at the patient’s request. Serum GM levels 9 months after therapy had declined to 0.11, and he remained asymptomatic at the 12-month follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2465_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2465_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2f33acdd21fc9774ea06a63b7771494a70519edf
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2465_en.txt
@@ -0,0 +1,2 @@
+A 71-year-old Asian woman with tarry stools and dyspnea was admitted to our hospital. She had a history of idiopathic interstitial pneumonia and had been taking oral prednisolone for the previous three months. She was anemic and had a pulse rate of 130 beats per minute and a systolic blood pressure of 80mmHg. Laboratory data were as follows: hemoglobin 7.2g/dL, platelet count 21.9×103/mm, albumin 3.0g/dL, prothrombin time 80% and international normalized ratio 1.13, aspartate transaminase 12IU/L, alanine transaminase 17IU/L, blood urea nitrogen 32.2mg/dL, and creatinine 0.43mg/dL.
+After admission, we performed emergency endoscopy by using a forward-viewing endoscope (GIF-Q-260J; Olympus, Tokyo, Japan) with an attached hood (Elastic touch, slit and hole type M hood; Top Corporation., Tokyo, Japan), which showed a large clot in the duodenal bulb and a fresh clot in a large periampullary diverticulum of the descending part of the duodenum . However, we were unable to identify the source of the bleeding. Our patient was treated with a blood transfusion, but her severe anemia and frequent tarry stools continued. Two days later, we performed a second endoscopic examination, but this did not identify the source of the bleeding. The following day, we performed an endoscopic examination by using a side-viewing endoscope (TJF-240; Olympus), which revealed a small ulcer with a small exposed vessel overlying the bile duct within the diverticulum . Flushing with distilled water revealed an oozing bleeding point in the ulcer. We used hemostatic forceps (Coagrasper, FD- 410LR; Olympus) in the soft coagulation mode at 80W (VIO 300 D; ERBE,Tokyo Japan) to cauterize the bleeding vessel . The bleeding stopped immediately, the procedure was well tolerated by our patient, and there were no complications. A repeat examination one week later using a side-viewing endoscope showed no bleeding . There was no recurrence of bleeding, and our patient did not experience any complications such as perforation, cholangitis, or pancreatitis.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_247_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_247_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c7246a96ccfee7323107f5e388a4702eb872e131
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_247_en.txt
@@ -0,0 +1,7 @@
+We present the case of a 57 year-old woman on follow-up in primary care for a four-year history of mild hyperkalemia [range 5.3–5.9 mmol/L (reference range: 3.5–5.1 mmol/L)] without associated hemolysis (spectrophotometric hemolysis index <6 mg/dL in all laboratory reports). The patient did not exhibit any associated signs or symptoms. Control electrocardiograms were normal, without significant findings. Her medical history included arterial hypertension, adequately controlled with ACE inhibitors. In this context, the patient was referred to the Unit of Nephrology for further examination.
+Anamnesis and physical examination did not reveal any data of interest. The patient was receiving amlodipine for arterial hypertension, with good control. Control electrocardiogram was normal. A potassium-low diet and control laboratory analysis in three months were indicated. Three months later, a control blood analysis was performed. The laboratory received a sample of serum and a request for determination of potassium alone. The sample was not hemolyzed (hemolysis index <6 mg/dL) and showed mild hyperkalemia of 5.5 mmol/L. Once pre-analytical and drug-related causes were excluded, differential diagnosis was performed, including:Hyperkalemia secondary to renal insufficiency. Hyperkalemia secondary to intravascular hemolysis. Hyperkalemia secondary to acidosis. Hyperkalemia secondary to tissue breakdown (rhabdomyolysis). Pseudohyperkalemia secondary to oncohematologic disease (essential thrombocytosis, acute or chronic leukemia).
+For differential diagnosis in the laboratory, blood was drawn at the hospital and sent to the laboratory with the following tests request: Hemogram including reticulocytes and blood smear. General biochemistry including ions, hemolysis index, hepatic profile (GOT, GPT, GGT, LDH, and ALP), renal profile (creatinine, urea, and estimated glomerular filtration rate CKD-EPI), creatine kinase, haptoglobin, phosphocalcic, and iron metabolism (iron, transferrin saturation index, transferrin, and ferritin). Venous gasometry: Blood gas test is immediately performed with a pH of 7.39 (range of reference 7.35–7.45). 24-urine biochemistry.
+An EDTA sample was sent to obtain a hemogram and a lithium heparin sample for biochemistry. Smear was normal, without morphological alterations. All parameters in the hemogram were within normal range, with 1.55% reticulocytes (range of reference: 0.9–2.6%). Oncohematologic diseases were excluded by differential diagnosis.
+The only finding on general biochemistry was cholesterol 248 mg/dL (range of reference: <200 mg/dL), with potassium 3.98 mmol/L (range of reference in plasma: 3.4–4.5 mmol/L), creatinine 0.86 mg/dL (range of reference: 0.51–0.95 mg/dL), and haptoglobin 39 mg/dL (range of reference: 30–200 mg/dL), and a hemolysis index <6 mg/dL. PCR, CK, hepatic profile and other parameters were within normal range. Laboratory analysis excluded hyperkalemia, due to the absence of renal insufficiency or data of cellular lysis or signs of intravascular hemolysis. Urine biochemistry was normal, with all parameters within normal range.
+Once all potential causes were excluded by differential diagnosis, and in the absence of elevated potassium levels, a possible case of familial pseudohyperkalemia was considered. Three lithium heparin tubes were collected at the hospital for incubation at different time points and temperatures: Two aliquots for incubation at 4 °C for 2 and 4 h, respectively. This simulated transport conditions from the primary care center to the laboratory, since samples are transported at 4 °C for a mean of 3 h. Two aliquots for incubation at 25 °C for 2 and 4 h, respectively. This simulates transport conditions from the room where blood is drawn to the laboratory, since samples are transported at room temperature for a mean of 3 h. Two aliquots for incubation at 37 °C for 2 and 4 h, respectively. This simulates in vivo conditions.
+Uncentrifuged samples were received for analysis. Centrifugation was performed after the incubation period was completed (results shown in ). In parallel, a negative control was performed (Results shown in ).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2480_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2480_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1699b9e30a302d9e70dc4b678276e0d870bc0120
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2480_en.txt
@@ -0,0 +1,5 @@
+A 74-year-old male was admitted to the emergency department with a 3-day history of progressive painful proptosis of the left eye. His medical history included hypertension and hyperlipidemia with no history of trauma. Clinical examination revealed a left proptotic orbit with chemosis and scleral injection . Visual acuity of the left eye was 20/150. The right eye was unremarkable; the patient had no fever nor other infectious signs.
+Computed tomography (CT) scan showed an ovoid mass in the lateral intraconal space with surrounding infiltration and increased vascularity. CT angiogram revealed a well-circumscribed heterogeneously enhancing mass within the inferior intraconal space of the left orbit (measuring 1.8 × 1.7 cm round) with periorbital soft-tissue swelling, suggesting inflammation . Magnetic resonance imaging (MRI) angiogram confirmed the findings of past studies: orbital cellulitis was apparent, the left inferior ophthalmic vein was prominent as compared to the right, and there was a partly thrombosed venous varix of the inferior ophthalmic vein . Imaging did not show any evidence of arteriovenous fistula.
+At this point, potential considerations included orbital cavernous malformation, metastatic tumor causing venous outflow stenosis, arteriovenous malformation, dural arteriovenous fistula, and thrombosed venous varix due to orbital cellulitis.
+A neurosurgical consult was requested by the ophthalmology team. To further delineate the nature of the lesion, a diagnostic cerebral angiogram was performed, which revealed an intraconal venous varix . Consideration was made for transvenous embolization or direct orbital puncture and embolization along with surgical removal. A mutual decision of conservative treatment without intervention was reached, with aggressive interventions reserved if the patient declined further. Intravenous methylprednisolone for 5 days was initiated, as well as a maintained course of oral corticosteroids, doxycycline, and levofloxacin thereafter.
+The patient was seen in the clinic 2 weeks after discharge. His symptoms had significantly improved, and he denied any eye redness, diplopia, or pain. On examination, there was no chemosis or scleral injection, but there was a significantly improved mild, painless proptosis . A 2-week follow-up CT scan of the orbit with contrast demonstrated a stable soft-tissue intraconal mass in the left orbit with peripheral venous phase enhancement in addition to central enhancement, consistent with the previously diagnosed thrombosed orbital venous varix of the inferior ophthalmic vein . At this time, the patient had completed his oral antibiotic course and was tapering his prednisone course. A 1-year orbital MRI was conducted and showed a slight increase in the enhancing intraconal mass in the left orbit . The patient had no symptoms. Since the mass size had not significantly increase and the patient’s condition was stable, no additional imaging or clinical follow-up was required per standard of care.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2484_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2484_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fde74c4623e25ae90574f6ae5d0abcc3c9fc6a82
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2484_en.txt
@@ -0,0 +1 @@
+A 78-year-old man developed acute low back pain, gait disturbance, and paresthesia in both legs; resting improved the paresthesia. Neurological examination revealed weakness with a Manual Muscle Testing (MMT) grade of 3 in the extensor hallucis longus and peroneus longus muscles of both legs. Bladder and bowel function were normal. He has had no past history and taken no medicine such as antiplatelet. His blood analysis showed C-reactive protein and complete blood count with differential were within normal limits, making an infectious process unlikely. Plain radiographs of the lumbar spine showed degenerative changes . MRI showed a mass located posteriorly and laterally to the left aspect of the dural sac at the L3 level, and contrast-enhanced MRI showed a lesion with a heterogeneous ring-like enhancement at the L3 level . We performed discography and disco-computed tomography (CT) to diagnose the dorsal epidural pathologies, expecting that the L3/4 discography would support a definitive diagnosis of lumbar disc herniation. Discography of the intervertebral disc at L3/4 level was performed using a standard posterolateral approach with a Hijikata discographic threehold needle (Tanaka Medical Instruments, Tokyo, Japan). For discography, the needle was inserted into the center of the disc under fluoroscopic control. Omnipaque 240 (3.0 mL; Daiichi Sankyo Company, Tokyo, Japan) was injected into the disc until contrast medium leaked out of the disc into the outside. After the injections were complete, the CT scan was performed to further analyze the L3/4 injected disc. However, the L3/4 discography and disco-CT clearly showed leakage of the contrast medium into the posterior dural space . Based on these findings, we diagnosed neurological deficit due to PEMLDF. We performed an L2/3/4 laminectomy and separated a 30-mm-wide mass, embedded in fibrous epidural tissue, from the posterolateral aspect of the dural sac . No adhesion was seen. The huge disc fragment had been extruded into the epidural space and wrapped around from the outside of the nerve root. After removing the mass piece by piece , we detected a rupture in the left side of the L3-4 disc at the posterior longitudinal ligament. The compression on dura and nerve roots was totally removed. Consistent with observations during the operation, histopathological analysis revealed liquefaction degeneration and granulation surrounding the sequestered disc fragment . The patient’s symptoms improved immediately after surgery. He recovered motor function to MMT 4–5 in both legs and was able to walk more smoothly. He identified the strength of the lower extremities improving and recovered fully after 3 months.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2490_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2490_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a04b66519c9e1440feb8fd2a186efe1e1b27c30e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2490_en.txt
@@ -0,0 +1,10 @@
+A 46-year-old male with an incomplete tetraplegia (AIS B, neurological level C7), 5 years post injury consented to participate. The study was approved by the Ethics Committee of the Hospital District of Helsinki and Uusimaa. Conventional rehabilitation, including weekly physical therapy for 1–2 h, occupational therapy for 1 h, and pool therapy for 1–2 h, was maintained during the PAS and was the same as before the intervention. His muscle strength had remained stable prior to PAS (Supplementary Table ). Mean ± SD spontaneous changes of manual muscle test (MMT) score in the 17 months preceding PAS were 0.67 ± 0.52 (right hand) and 0.17 ± 1.17 (left hand). Pinch strength values were 0.57 ± 0.32 kg (right hand) and 0.27 ± 0.63 kg (left hand) in the 12 months preceding PAS (Supplementary Table ). Medication is presented in Supplementary Table .
+Navigated TMS (nTMS) of the motor cortex was delivered by a NBS 4.3 stimulator (Nexstim Ltd., Helsinki, Finland) with a figure-of-eight coil (outer diameter 70 mm, biphasic pulse). Structural T1-weighted MRI for nTMS was obtained with a 3T Siemens Verio scanner (Siemens Healthcare, Erlangen, Germany). The nTMS system enables accurate, reproducible stimulation of selected cortical sites, the “hotspots” , where MEPs are most readily elicited from the selected muscles . The hotspots were defined for abductor pollicis brevis (APB), abductor digiti minimi (ADM), and brachioradialis (BR) muscles in both hands as in our previous studies .
+PNS was delivered using a Dantec Keypoint electroneuromyography device (Natus Medical Inc., Pleasanton, CA, USA) and surface electrodes . The nerves were stimulated as in our previous studies . Initially, PNS stimuli were 50-Hz trains (1-ms square pulses, 6 pulses per train, train duration 100 ms). From week 30 onwards, 100-Hz trains (train duration 50 ms) were used as they were experimentally proven to be more efficient for MEP potentiation in healthy subjects .
+For PAS , nTMS (single-pulse, 0.2 Hz, 100% MSO) of the selected hotspots was synchronized with the first pulse of the PNS train given to the corresponding contralateral nerve . The interstimulus interval for each pair was calculated using individual parameters . The subject was seated comfortably during PAS. One session consisted of PAS of 3–6 hotspot-nerve pairs given in pseudo-random order of 1.5–3 h duration in total (20 min per nerve plus time for preparations, Fig. ).
+The hand motor training (MT) combined with the PAS (PAS-MT) was aimed at increasing muscle strength in those muscles where MMT scores remained 2 or less after 24 weeks of the intervention. Three weak muscles in the right hand were trained with motor tasks (thumb palmar abduction for APB; spreading fingers for dorsal interossei; and thumb radial abduction for abductor pollicis longus) simultaneously with the corresponding PAS. AR manually assisted the subject in finger movements.
+The intervention of 56 weeks included 47 weeks of PAS and 1–2-week breaks without stimulations . PAS to a hotspot-nerve pair was stopped when strength and range of motion of all muscles innervated by this nerve reached an MMT score of 4–5. All left-hand muscles reached this level at week 28; only the right hand was stimulated thereafter. At subject’s request, PAS of the left median nerve and the associated motor task were reinitiated at week 40 to enable more fluent grasp movements. The follow-up period started when the MMT scores of all evaluated muscles of both hands reached level 4 or 5 and was continued for 32 weeks. All tests were performed immediately prior to the study, during the intervention, and follow up.
+Outcome measures in both hands included MMT (total scores for all evaluated muscles and partial scores of the muscles innervated by each of the stimulated nerves) and the modified Ashworth scale (MAS, spasticity in wrist and elbow) evaluated by a physiotherapist specialized in SCI and blinded to the intervention changes and results of previous evaluations. In addition, we collected sensory scores of the American Spinal Injury Association impairment scale (AIS); grip strength assessed with the adjustable-handle Jamar dynamometer (Asimov Engineering Co., MA, USA); tip, key, and palmar pinch assessed with the pinch gauge (B&L Engineering, CA, USA); the spinal cord independence measure (SCIM); the box and block (BB) test; the nine hole peg test (NHPT); and MEPs and F-responses recorded from APB, ADM, and BR . For the MMT, only muscles that scored <5 in the first assessment were selected for further evaluation (Supplementary Table 2 parts 1, 2). The subject reported subjective functional changes.
+The total and partial MMT scores were improved in both hands . In total, the left hand regained 19 points and the right hand 48 points during the intervention. The scores reached the maximum level in the left hand after 47 weeks and remained stable in follow up. MMT scores of level 4 or 5 in the right-hand muscles were obtained in follow up. MMT scores were improved further during the PAS-MT, particularly in the right hand (Supplementary Table 2 part 1). AIS sensory scores did not differ (Supplementary Table ). Spasticity assessed with MAS remained 0 at all times. Increased grip and pinch strengths were observed in both hands already after 8–20 weeks of PAS. Remarkably, all tested pinch strength types were increased (Supplementary Table ). In the right hand, grip and pinch strength increased during the first 8–20 PAS weeks and stabilized thereafter. In the left hand, the increase in pinch strength stabilized after 25 weeks of PAS. Grip strength increased in the right hand by 4.5 kg and in the left hand by 3.3 kg . Pinch strength increased in the right hand by 3.0 kg and in the left hand by 2.6 kg, (Supplementary Table ). PAS-MT further increased pinch strength. Pinch strength decreased towards the level observed before PAS-MT administration in follow up. Results of the BB test increased from 45/68 (right hand/left hand) blocks to 52/75 blocks. By the end of the intervention, the NHPT time decreased by 31 s in the left and by 32 s in the right hand (Supplementary Table ) and remained stable during follow up in the left hand (see Supplementary Video ). The subject’s self-care and indoor and outdoor mobility increased during the PAS and improved further during follow up. His SCIM self-care score increased from 3 to 13 and SCIM indoor mobility from 6 to 10 . Respiration and sphincter management did not change. Before PAS, the subject needed total or partial assistance in eating, bathing, dressing, and grooming. During follow up, he could perform these tasks independently and without adaptive devices. In total, the subject’s SCIM score increased from 40 to 56 (Supplementary Table ). He enhanced his coherent motor control after 8 weeks of PAS (see Supplementary Videos and ), and reported numerous improvements in both hands during follow up . He regained the ability to perform various complex fine motor tasks without external help. Before intervention, the subject had pain and uncomfortable tingling that decreased or completely disappeared during the intervention and follow-up (Supplementary Table ).
+The PAS potentiated MEPs in five out of six targeted muscles . The overall effect differed slightly between the right and left hands. In all six muscles, the MEP amplitudes in both hands increased on average by 324% after 16 weeks of follow up when compared with the corresponding values obtained prior to PAS. Before treatment it was not possible to elicit MEPs from the right ADM even with muscle preactivation. MEPs were detected after 42 weeks of stimulation and remained stable during follow up. In the left ADM, small MEPs were elicited before PAS. Their amplitudes increased during PAS and follow up. Although the changes were variable, the total amplitude increase was systematic when the first and last MEP recordings were compared . The minimum F-response latencies (F min) in the right hand decreased after PAS from 32 to 25 ms (23%) for the ulnar nerve and from 31 to 28 ms (9%) for the median nerve. No response was found with the left median nerve before intervention but was obtained during follow up (F min = 33 ms). F-min latency in the left ulnar nerve (31 ms) did not change. F-responses to the radial nerve stimulation in both hands were inconsistent. No amplitude changes were observed.
+Around week 12, during PAS of the right radial nerve the subject reported a sensation in both legs resembling electrical stimulation, leg spasticity, and spasticity-related leg pain. A simultaneous urinary tract infection unrelated to stimulation was detected and treated. Psychological stress unrelated to stimulation occurred simultaneously. The PAS was interrupted for 2 weeks and the subject increased pain medication. After that he reported a decrease in spasticity and pain. The subject’s position in the chair was adjusted to increase comfort, and PNS intensity was slightly decreased . During weeks 16–19 these symptoms gradually disappeared. No other adverse effects were reported.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2492_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2492_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9c156dd38c99d13f4cc6ee195dd8ccf92eb3c8f5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2492_en.txt
@@ -0,0 +1,8 @@
+A 45-year-old patient (G3P0030) desired pregnancy and sought fertility treatment in an academic reproductive endocrinology and infertility center. Her medical history included hypertension, prediabetes, thyroid dysfunction and overweight habitus (body mass index of 29 kg/m2). Her medications included methyldopa, metformin and levothyroxine. Her past surgeries included laparoscopic proximal transection of the left fallopian tube for left hydrosalpinx with concurrent loop electrode excisional procedure (LEEP) for cervical intraepithelial neoplasia (CIN) II at age 41. Pathology was negative for dysplasia and malignancy. She had previously undergone three hysteroscopies with endometrial polypectomies.
+Her obstetrical history included failed fertility treatments and recurrent pregnancy loss. Her first pregnancy, conceived naturally five years earlier, ended in spontaneous abortion at 6 weeks of gestation. She underwent three cycles of IVF and had one fresh day 5 transfer of three embryos that did not result in pregnancy. She then had three separate programmed frozen embryo transfer cycles using autologous oocytes. In two cycles, two embryos were transferred, resulting in biochemical pregnancies. In the third cycle, three embryos were transferred, resulting in a negative pregnancy test. She later underwent two frozen embryo transfer cycles of donor ovum-derived embryos. She had one embryo transferred, resulting in a negative pregnancy test, and another single embryo transfer the following cycle, ending in a first-trimester spontaneous abortion. Workup for recurrent pregnancy loss was unremarkable. She had a normal female karyotype, negative antiphospholipid antibody testing and negative anti-thyroglobulin and anti-thyroid peroxidase antibodies. Her partner had a normal male karyotype.
+Next, she underwent a programmed transfer of one donor ovum-derived day 5 frozen euploid embryo. Nine days later, she underwent initial beta-hCG testing, which reported a level of 53 mIU/mL. Two days later, beta-hCG had increased to 155 mIU/mL. She reported minimal vaginal spotting at that time. Four days later, at 4 weeks and 6 days of gestation, she paged the on-call physician to report abdominal cramping along with brown spotting. Pain resolved later that day but vaginal spotting continued. The following day, at 5 weeks and 0 days of gestation, her beta-hCG level continued to rise, to 2176 mIU/mL.
+Her first transvaginal ultrasound was the following day, at a gestational age of 5 weeks and 1 day . Transvaginal ultrasound imaging showed a gestational sac measuring 8.1 mm in the lower uterine segment versus the upper cervix. The sac was located 2.2 cm from the external cervical os. A yolk sac and fetal pole were not visualized. Beta-hCG was noted to be 3217 mIU/mL on this day. Transvaginal ultrasound was repeated the following day, given concern for CEP . The gestational sac was in the upper cervix, measuring 8.3 mm. Again, no yolk sac or fetal pole was seen. Her beta-hCG level increased to 4607 mIU/mL on this day. Intramuscular methotrexate was then recommended for likely CEP. The patient refused methotrexate at that time as the pregnancy was highly desired, and the patient was discharged with strict return precautions.
+Later that day, the patient reported heavier vaginal bleeding at home with passage of large clots. On arrival at the emergency room, she reported soaking through two pads every 30 minutes. She was then amenable to methotrexate treatment given heavy vaginal bleeding and she was given a single-dose intramuscular methotrexate protocol (50 mg/m2). She was admitted for hemodynamic monitoring and observation.
+Overnight, she had approximately 400–500 cc of vaginal bleeding. Her vital signs remained stable throughout admission. Her hemoglobin level decreased from 12.0 g/dL at baseline prior to admission to 8.9 g/dL on the morning of hospital day 2 (HD), then to 8.5 g/dL on the evening of HD 2. By HD 3, vaginal bleeding was minimal and pain had resolved. Her hemoglobin level stabilized at 8.3 g/dL on the day of discharge. She was discharged with oral iron supplementation and plan for serial beta-hCG testing, with activity restrictions and strict return precautions.
+Between days 4 and 7 of methotrexate treatment, the beta-hCG decreased by 38.2% . By day 7, she reported minimal spotting and no pain. Beta-hCG continued to downtrend weekly thereafter . She did not require any additional methotrexate doses or procedures to facilitate resolution of the pregnancy.
+Three months after the final beta-hCG measurement, she had a follow-up saline sonohysterogram that showed a normal endometrial cavity.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2494_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2494_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..71bc9be3a1794d01f2439d638fb2160de95f39f6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2494_en.txt
@@ -0,0 +1,3 @@
+Patient is a 56-year-old female with body mass index of 22.5 kg/m2 and previous clinical history of diffuse scleroderma, intestinal pneumonitis, mild pulmonary hypertension, secondary gastroesophageal reflux, and severe esophageal motility disease. Receiving immunosuppression, antihypertensive, proton pump inhibitor and prokinetic management with weak response, patient is admitted for surgical management after a 1-year follow-up with cardiology, pneumology, and gastroenterology.
+At admission, patient was symptomatic with a previous diagnosis of esophageal aperistalsis and dysphagia with poor response to medical therapy. Physical examination revealed no significant findings. The lung transplant surgical team determined the patient was not a candidate given the severity of the GERD, due to a high risk of primary graft dysfunction. This led to a medical committee deciding an open total gastrectomy with roux-en-Y anastomosis prior to lung transplant for this particular case. This case report reveals a surgical alternative in patients with GERD secondary to scleroderma despite a high risk of disease recurrence.
+Follow-up one week later with esophagogram revealed normal esophageal morphology, no stenosis or motility difficulties, adequate esophago-jejunal anastomosis diameter, no extravasation of the contrast medium and an adequate transit of the medium to the small intestine. There is no evidence of reflux of the medium . In out-patient consult, an upper gastrointestinal endoscopy is performed within a 3-month period which revealed mild esophago-jejunal anastomosis stricture resolving after three balloon dilations of 11 mm, 15 mm, and 18 mm, respectively (, , ). Currently, the patient continues follow-up consults, with an adequate postoperative state, asymptomatic according to the Gastroesophageal Reflux Disease Health Related Quality of Life (GERD-HRQL) instrument and currently awaits lung transplant.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2498_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2498_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..165fc1b081e252ee6af6014e94fd4b52893ac966
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2498_en.txt
@@ -0,0 +1,2 @@
+A 35-year-old male known epileptic, presented with altered sensorium for the past 2 days. On local examination, a 5 × 3 cm irregular bony swelling noted on the left forehead. There was no focal neurological deficit and no signs of meningeal irritation. Computed tomography (CT) of the brain plain showed a calcified lesion in the left frontal region along with ventriculomegaly and a huge cystic lesion in the left frontal region . Magnetic resonance imaging (MRI) revealed a lobulated irregular lesion causing mild compression on the underlying brain parenchyma. There was marked dilation of ventricles with transependymal seepage suggesting high-pressure hydrocephalus [ and ]. Patient was shunted immediately and clear cerebrospinal fluid (CSF) under high pressure was obtained. Routine analysis of CSF showed pleocytosis, with negative cultures. Patient postoperative CT scan showed tension pneumocephalus .
+CT bone window was done, which elaborated details of osteoma [-]. A left frontal craniotomy with free bone flap was done . About 5 × 2.5 cm irregular hard bony growth found disrupting the underlying dura . The cystic lesion was accessed through dural defect, thin clear mucoid substance drained and excised completely. There was no communication between cyst and ventricle at any point. Remaining osteoma was excised and sinus ostia was plugged with muscle piece. The dural defect was repaired and further reinforced with Dietz pericranial flap. Postoperatively patient did well, scans were satisfactory and no CSF leakage was found. On the 5th day, the patient developed fever and neck rigidity. A moderate growth of Colistin-sensitive Klebsiella species and Acinetobacter were cultured from CSF. A 2 week course of Colistin resulted in clinical improvement and patient was discharged home. Histopathology report showed a tumor with typical features of osteoma. Currently the patient is in follow-up, fits are controlled with oral sodium valproate.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2502_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2502_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ef8da7a8a124e74d24b0ceaeb61ce351d693211a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2502_en.txt
@@ -0,0 +1,2 @@
+A 57 year-old woman presented with sudden onset chest pain/ventricular fibrillation after hearing of her brother’s death. The electrocardiography indicated “anterior wall ST segment elevation myocardial infarction”. Laboratory data was notable for cTnT 1.12 ng/mL. Coronary angiography ruled out obstructive lesion in the major coronary arteries, but revealed a tapering and long narrowing distal left anterior descending artery (LAD, Fig. ), which was consistent with angiographic feature of coronary artery fibromuscular dysplasia . The ventriculography showed remarkable ventricular dilation, which affected much broader myocardium than the culprit vessel supplied . In a subsequent cardiac magnetic resonance (CMR) study, left ventricular (LV) remained dilated . Delayed contrast (gadolinium) image confirmed a localized mayocardial infarction in the inferoapical wall .
+One week later, repeated transthoracic echocardiography (TTE) showed nearly normalized LV systolic function except for a residual apical hypokinesis compared with original episode . Nine months later, when she was laid off, she developed recurrent chest pain and significant LV dilation, with different contractile pattern . With only supportive therapy, both her symptoms and LV dysfunction spontaneously improved quickly.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2511_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2511_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1329ad16cb7e408ae2e3e4fa7dad219f8617b865
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2511_en.txt
@@ -0,0 +1,9 @@
+The patient was a 72-year-old male. He was referred for penile pain. He had a 4-year history of dialysis therapy under a diagnosis of diabetes mellitus, which had been made 11 years previously. No urine production was observed, and 4-hour hemodialysis was performed three times a week. He also had a history of acute myocardial infarction, lacunar infarction, hypothyroidism and diabetic retinal detachment. Insulin glargine, aspirin, furosemide, amezinium metilsulfate, levothyroxine sodium hydrate and allopurinol were administered for the respective diseases.
+Pain of the glans had persisted for 10 days, but the patient was unable to confirm the site of pain due to blindness. On consultation at the previous hospital, necrosis of the glans was observed and he was referred to our department for treatment.
+His height, body weight, blood pressure, pulse rate, and body temperature were 160 cm, 64 kg, 142/74 mmHg, 77/min, and 36.8°C, respectively.
+Yellow and black necrosis of the entire glans with severe pain was noted , and purulent discharge with odor was observed. Ulcers of the bilateral lower limbs and right dorsal hand with irregular yellow necrosis, dark red spots, and black keratotic nodules were noted.
+Laboratory examination on admission demonstrated corrected Ca, IP, I-PTH, CRP, HbA1c, WBC, Hb, and PLT levels of 9.7 mg/dL, 7.4 mg/dL, 97 pg/mL, 11.5 mg/dL, 7.3%, 13 500/μL, 18.3 g/dL and 23.4 × 104/μL, respectively.
+Plain computed tomography of the thorax and abdomen revealed marked calcification involving the thoracoabdominal aorta to external/internal iliac arteries. Calcification of the dorsal artery of the penis and ectopic calcification of the corpus cavernosum were also observed . On urethroscopy, urethral stricture in the anterior urethra was noted, but the investigation was insufficient because it induced further penile pain. Blood flow examination in the penis using color Doppler ultrasound was not performed.
+After admission, lavage and debridement were performed based on a diagnosis of calciphylaxis or necrosis related to intravascular thrombus at the department of dermatology. However, pain control of the glans was poor and there was no reduction of necrosis. Partial penectomy was performed 8 days after admission. The glans was dissected at an area proximal to the coronary sulcus. There was no hemorrhage. The external urethral meatus was created by a standard procedure. After surgery, penile pain promptly subsided. Paleness in a portion of the surgical wound, purulent discharge and fever were observed, but perineal care, debridement and antimicrobial drug administration were carried out.
+Pathological macroscopic findings included ulceration, necrosis and abscess formation. Microscopy demonstrated marked calcification of the media in the small arteries, and thickening of the intima and lumen stenosis was noted, suggesting calciphylaxis .
+The patient was transferred to his previous dialysis hospital 34 days postoperatively, with improvement in his general condition. The course had been favorable based on postoperative follow-up, but he died of pneumonia 11 months after surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2519_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2519_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..48e1b47b5ed281f00fe8672da488dfbe2cd4a09f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2519_en.txt
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+A 7-d history of fever and cough.
+A ten-year old girl presented to our hospital with a fever and cough of 7 days’ duration. Her temperature peaked at 39.2 °C. She had been initially admitted to a local hospital, where she was diagnosed with community-acquired pneumonia and treated with intravenous antibiotics that did not resolve her fever and cough. Due to lingering symptoms, she sought further treatment at our hospital.
+Her medical history was unremarkable.
+The patient had no relevant personal or family history.
+At admission, the patient’s weight was 34.0 kg and her vital signs were as follows: Body temperature, 37.0 °C; blood pressure, 90/62 mmHg; heart rate, 130 beats/min; respiratory rate, 20 breaths/min; oxygen saturation, 98% in room air. At the time of admission, moderate and fine moist rales were heard in both lungs with no wheezing observed.
+Infection index white blood cell count, 17.52 × 109/L; platelet count, 256 × 109/L; erythrocyte sedimentation rate, 30 mm/h; C-reactive protein, 60.65 mg/L (0.00-5.00 mg/L) (December 16, 2021). Immune function was normal. Liver function: Alanine aminotransferase, 29 U/L (0-40 U/L); aspartate aminotransferase, 33U/L (0-40 U/L). A positive culture result for Streptococcus parasanguiniswas obtained, with no fungal growth detected.
+During her first stay at our hospital, the patient underwent electronic lung bronchoscopy, which detected endobronchial inflammation in the left upper lobe proper segment and left lower lobe basal segment . Results of CT retesting obtained 7 d later revealed growing, dense masses within lung tissues, as evidenced by darker shadows on the scan coinciding with the position of the outer basal segment of the lower lobe of the left lung that indicated the presence of multiple cystic translucent lesions. Moreover, various lesions of different sizes, multilocular thin-walled air-filled cavities, and patchy and highly dense shadows were observed that lacked clear boundaries and had approximate dimensions of 72 mm × 60 mm × 42 mm. The child was subsequently discharged with oral amoxicillin clavulanate potassium and advised to undergo an enhanced pulmonary CT scan 2 wk after discharge. The CT results revealed that the previously noted multiple cystic lesions within the lower left lung lobe and the dense mass within the basal segment outside that lobe remained unchanged in appearance. In contrast, the inflammatory lesions within the middle and lower lobes of the right lung were larger than before . Due to the fact that the pathological nature of the peripheral lung lesion could not be determined from these findings, the patient underwent a TBLB procedure to ensure that appropriate treatment would be administered to treat the disorder.
+The entire procedure was conducted using the following steps. Prior to TBLB, inspiratory and expiratory CT images were uploaded to the Lungpro system (LungPoint VBN, version 3,4, Broncus Medical Inc, CA, United States), which was used to construct a virtual airway leading to the above-mentioned peripheral lesions. Next, picture archiving and communication system-based integration was conducted to build a virtual three-dimensional image of the patient’s lungs. Then, a bronchial centerline was used as a frame of reference to help the bronchoscope operator plan a path to the airway wall puncture point or focus point.
+After the patient was prepared for the procedure, she was administered local anesthesia and intravenous midazolam, a mild sedative. Endobronchial occlusion was then performed using a bronchoscope (BF-P260, Olympus Ltd.). The patient was placed in the supine position and was administered oxygen through a nasal catheter. Using a nasal point of entry, the optimal navigational path to pulmonary lesions was selected, and the reconstructed three-dimensional image was superimposed onto the image as viewed under the bronchoscope. During real-time navigation, the position of the bronchoscope and the distance from the pleura and the focus were displayed.
+Finally, Lungpro-guided TBLB was performed using a bronchoscope with a working channel diameter of 2.8 mm . Biopsy samples taken from the posterior basal segment of the left lower lobe were sent to the hospital pathology department for microscopic examination . The patient experienced no complications after the procedure.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_252_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_252_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a451b2a7c60e0b97b3ad89f36d99ce8e2a67e9d6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_252_en.txt
@@ -0,0 +1,11 @@
+A morbidly obese 32-year-old Asian female with a body mass index of 52 and a history of meningioma excision and asthma, presented to the emergency room (ER) with a positive COVID-19 test and shortness of breath, cough, and diarrhea. She was hypoxic with oxygen saturation via pulse oximetry (SpO2) of 88% on room air, tachypneic with respiratory rate of 35, febrile with temperature of 100.5 F, pulse rate 89, and blood pressure 106/84. CXR demonstrated bilateral basal multifocal infiltrates. She was admitted on 5 L/min of O2. The patient experienced symptoms 7 days prior to presenting to the ER. Upon admission, the patient was confirmed to be SARS-CoV-2 positive by nasopharyngeal swab and reverse transcription-polymerase chain reaction with an Abbott ID system. The patient was started on Ceftriaxone and Azithromycin for potential superimposed bacterial infection. She was considered high risk due to morbid obesity, asthma, low oxygen saturation, infiltrates on CXR, and tachypnea. Her condition worsened despite antibiotics and supportive therapy and was evaluated for ICU admission on hospital day 3. Consent was obtained for the institutional review board (IRB)-approved randomized clinical trial of LLLT for COVID-19. LLLT treatment started on hospital day 3 while antibiotics continued. The patient was not receiving any antiviral or steroid medications.
+The patient’s response to LLLT was evaluated via SMART-COP (systolic blood pressure, multilobar infiltrates, albumin, respiratory rate, tachycardia, confusion, oxygen, and pH) and Brescia-COVID prediction tools, CXR radiographic assessment of lung edema (RALE) , and blood markers of inflammation .
+The SMART-COP Score evaluates pneumonia severity and predicts the need for intensive respiratory or vasopressor support (IRVS) in community-acquired pneumonia. The pretreatment SMART-COP score was 5, indicating potential serious progressive complications, rapid referral to the ICU, and the need for a ventilator. The Brescia-COVID Respiratory Severity Scale is a stepwise algorithm for managing patients with confirmed COVID-19. Pretreatment score was 4, which predicted ICU and ventilator support.
+The RALE score [, ] evaluates lung edema by CXR in ARDS patients. To quantify the extent of infection, a severity score was calculated by adapting and simplifying RALE score . A score of 0–4 was assigned to each lung depending on the extent of involvement by consolidation or ground glass opacities (0 = no involvement; 1 = <25%; 2 = 25%–50%; 3 = 50%–75%; 4 = >75% involvement). The scores for each lung were summed up to produce the final severity score . Before treatment, the RALE score was 8, consistent with 100% involvement of the lungs.
+Prior to LLLT, the patient had significant tachypnea and complained of “terrible shortness of breath” with activities of daily living.
+The multiwave locked system (MLS) scanner-equipped laser utilized in this study was deemed a nonsignificant risk device by the US Food and Drug Administration (FDA) prior to obtaining IRB approval. An FDA-cleared laser system (MLS-ASA/Italy) typically used in pain clinics was employed. Two simultaneous and synchronized laser diodes, emitting at 905 and 808 nm, were used in pulsed modes . The scanner was positioned 20 cm above the skin, according to the manufacturer specifications. Each lung was scanned for 14 min, from apex to base over 250 cm2 of the posterior thorax, . The patient tolerated all four consecutive once-daily LLLT without complication.
+During the first laser treatment, her SpO2 increased from 92% to 97% on 3 L/min oxygen within 10 min of starting treatment. After the second laser treatment the patient was breathing without dyspnea. Following treatments her respiratory rate returned to normal 19–20 breaths/min. After the fourth treatment, the patient was able to independently ambulate and had improved ability to perform activities of daily living. Patient was discharged 2 days after her last treatment on 1 L/min oxygen. Total hospital stay was 7 days. On follow-up 2 days after discharge, she was weaned to room air. The SMART-COP score decreased from 4 to 1 after treatment, indicating low risk for IRVS and requiring observation only. The Brescia-COVID score decreased from 4 to 0 after treatment, which supports patient monitoring via pulse oximetry and clinical evaluation.
+Before treatment, the RALE score was 8, consistent with 100% involvement of the lungs, and it diminished to three after LLLT. The imaging absorption stage for severe COVID-19 is typically seen after ≥14 days , but in this case, the absorption stage is evident at 7 days .
+Blood work included pre- and post-LLLT, IL-6, ferritin, and CRP. Immediately after final treatment IL-6 dropped from 45.89 to 11.7 pg/mL, ferritin from 359 to 175 ng/mL, and CRP improved from 3.06 to 1.43 mg/dL .
+Oxygen requirement before treatment was 3–6 L/min with SpO2 88%–93% and improved to 1–3 L/min and SpO2 97%–99% after treatment.
+At 2 weeks and 6 weeks from discharge the patient reported subjective improvement in respiratory symptoms and well-being. She was satisfied and appreciative of her LLLT experience and treatment outcome.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_253_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_253_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b4bbb6e48718a6453e2fe10e5730e11d515813b8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_253_en.txt
@@ -0,0 +1,10 @@
+A 51-year-old white female who was referred from our outpatient pulmonary clinic to the ED (emergency department) for worsening respiratory distress and six weeks history of persistent dry cough. Prior to this admission, the patient was seen at an urgent care and was prescribed a 10 days course of oral antibiotic empirically without significant improvement. Subsequently, the patient was seen in our outpatient pulmonary clinic for a working diagnosis of pneumonia and a previous chest x-ray depicting bibasilar opacities. In the office, the patient complained of dyspnea with ambulation. She was tested negative for COVID-19. Therefore, patient was prescribed oral doxycycline 100 mg twice daily empirically for 14 days and 40 mg of oral prednisone for 5 days. The patient was advised to communicate her progress with the treating physician, so her treatment protocol can be adjusted if needed. However, attempts to wean her prednisone made her dyspnea worse with pulse oximetry reportedly in high 80 s% on ambulation. PFTs (pulmonary function tests) outpatient showed restrictive lung pattern with reduced FEV-1 (forced expiratory volume in 1 s) at 52%, and reduced FVC (Forced vital capacity) at 47%.
+Patient reported having associated generalized fatigue, but no weight loss. She denied any hemoptysis, chest pain, fever, chills, night sweats, epistaxis, dry eyes, dry mouth, vision changes, photosensitivity, oral ulcer, dysphagia, abdominal pain, nausea, vomiting, constipation, or diarrhea. She denied any urinary disturbances, myalgia, joint pain or swelling, blood in urine or stool, or any Raynaud's type symptoms. Patient reported a recent travel history to Florida, but no history of sick contacts. She endorsed a family history only significant for Crohn's disease in father and daughter. She reported no alcohol use and no smoking history. The patient did not have any occupational or pet exposure.
+In the ED, the patients' vital signs were a temperature of 97.6 F, respiratory rate of 26 per minute, oxygen saturation of 88–90% on room air which improved to 94% with 3 L of oxygen on nasal cannula, and blood pressure of 102/53 mmHg. Patient’s body weight was 75.3 kg and her height was 157 cm. On physical exam, patient noticed to be dyspneic and tachypneic. She was alert and oriented to time, place and person. Head and neck examinations were unremarkable for lymphadenopathy, jugular venous distention (JVD), nasal/oral ulcerations, or any other lesions. On chest auscultation, reduced breath sounds were evident at the lower lung fields. Cardiology, gastrointestinal, and neurological examinations were unremarkable. No joint tenderness/swelling or muscle tenderness/weakness appreciated at the musculoskeletal examination. Skin examination revealed no rash or other lesions. The patient was admitted for further evaluation, beginning with retesting for COVID-19 and additional workup.
+Initial complete blood count, renal, and liver panel were all within normal limits except for normocytic anemia . Erythrocyte sedimentation rate (ESR) was 49 mm/h (0–15 mm/h), C-reactive protein (CRP) was 3.24 mg/dL (0.00–0.74 mg/dL), and anti-nuclear antibodies 2.09 (0.0–0.90). Urinalysis and complement levels were unremarkable. Creatine kinase (CK) and aldolase were 326 iu/L (22–232 iu/L), 39.5 u/L (1.5–8.1 u/L) respectively. The COVID-19 RT-PCR (Reverse transcription polymerase chain reaction) testing was negative twice as an inpatient.
+A chest x-ray showed persistent bibasilar infiltrates, finding similar to previous imaging. A Computed tomography angiography of the chest showed bilateral ground glass opacities, with shotty mediastinal lymph nodes, and no filling defects to suggest a pulmonary embolism. Echocardiogram showed normal left ventricular (LV) function, right ventricular function, and pulmonary pressures.
+The patient underwent bronchoscopy with right lower lobe transbronchial biopsies which showed mild lung parenchymal inflammation, fibrosis, and reactive epithelial changes without any sign of malignancy. Gomori methenamine-silver (GMS) nitrate stain and acid-fast stains (also known as the Ziehl–Neelsen stain) were negative for Pneumocystis jiroveci and Mycobacterium species, respectively. Bacterial and fungal cultures from right lower lobe bronchoalveolar lavage remained negative.
+Subsequent autoimmune screening returned strongly positive for anti‑Jo‑1 antibody 191 au/mL (reference range 0–40). Other markers, including rheumatoid factor, anti‑cyclic citrullinated peptide antibodies, anti‑Ro/SSA, and antineutrophil cytoplasmic antibodies were negative.
+Therefore, ASS-associated ILD was considered in the setting of clinical and radiographic findings of nonspecific interstitial pneumonia (NSIP) associated with positive anti-Jo-1 antibody.
+Patient was started on intravenous methylprednisolone 40 mg every 12 h which failed to improve patient’s symptoms; therefore, she was given intravenous pulse methylprednisolone 1000 mg daily for 3 days. Patient reported some improvement of her symptoms after pulse steroids. She was discharged with 2 L home oxygen as needed and on high dose oral corticosteroids, prednisone 60 mg oral daily. She followed up with rheumatology outpatient two weeks after discharge and was started on oral mycophenolate 500 mg twice daily. However, tapering steroids was difficult and mycophenolate was titrated up to 1500 mg twice daily.
+At her 3 months follow-up, the patient continued to have a gradual improvement of her symptoms and she was weaned off oxygen. Chest high-resolution computed tomography (HRCT) at that time showed 20% interval improvement particularly in the lower lobes with improvement of her laboratory markers such as ESR, CRP, CK, and aldolase demonstrated in . Favorably, her prednisone was tapered over six months to 10 mg daily while being on the same dose of mycophenolate.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2547_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2547_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e1881a493d4c8e232fc7918fe264c9d772e32097
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2547_en.txt
@@ -0,0 +1,8 @@
+A 68-year-old male patient, a former farm laborer, presented with low-back pain that had started four months earlier. Over the preceding two years, he had had three episodes of pneumonia and lost 20 kg. He had systemic arterial hypertension, which was controlled through use of antihypertensive drugs. There was no diabetes, thyroid diseases or any other metabolic cause for weight loss. He was a smoker (50 pack-years) and moderate alcohol user.
+The symptoms became worse during trunk flexion and there was painful low-back muscle palpation. There were no abnormalities on neurological examination, no fever and no night pain. No signs of consumptive syndrome were noted.
+Laboratory tests revealed increased levels of C-reactive protein (CRP) of 118.5 mg/dl (normal, 0.05 mg/dl) and erythrocyte sedimentation rate (ESR) of 53 mm/h (normal < 15 mm/h). The white blood cell count was 6-7 k/mm3 (normal, 4.0-11.0 k/mm3). A sputum culture was negative for tuberculosis. Chest radiography and computed tomography (CT) scan did not reveal any signs of tumor or infection.
+Radiography of the lumbosacral spine showed diffuse degenerative changes, irregular vertebral endplates of L4 and L5, and reduction of disc spaces L4-L5 and L5-S1 .
+Lumbar spine magnetic resonance imaging (MRI) demonstrated spondylodiscitis of L4-L5, with subligamentous abscess anterior to the vertebral bodies, reduced disc height of L4-L5 and L5-S1 and spinal stenosis from L2 to S1 ( and ).
+After analyzing MRI data, main hypotheses for this case were the presence of a tumor, tuberculosis or pyogenic spondylodiscitis. However, transpedicular biopsy of L4 revealed infection with Paracoccidioides brasiliensis .
+Since the patient was not presenting any mechanical or neurological instability, clinical treatment was implemented. Therapy with itraconazole (200 mg/day) was started, but the patient presented an adverse reaction to this drug (worsening of liver function), and therefore this was replaced with sulfamethoxazole and trimethoprim (20 mg/kg) for the rest of the treatment. After 36 months of treatment with sulfamethoxazole and trimethoprim (20 mg/kg), the patient became asymptomatic and the inflammatory blood tests (CRP and ESR) returned to normal.
+A control radiograph showed ligament ossification of L4-L5, subchondral sclerosis and reduction of disc space. Control MRI demonstrated reduction of edema and abscess in the paraspinal soft tissues .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_255_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_255_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fea3094b66cf240357612d0f5156c0e070916a60
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_255_en.txt
@@ -0,0 +1,9 @@
+The patient presented with intermittent abdominal pain and bloating for six months and sudden shortness of breath and confusion during diagnostic colonoscopy.
+A 58-year-old man presented with intermittent abdominal pain, bloating and reduced defecation in the past six months. To determine the severity of intestinal lesions and rule out intestinal tumors, the patient underwent a routine diagnostic colonoscopy using air insufflation under nontracheal intubation intravenous general anesthesia (propofol). Upon withdrawal of the colonoscope, the patient suddenly experienced shortness of breath and confusion and gradually developed cyanosis.
+The patient underwent a colonoscopy 12 years prior, and colonic ulcers were observed. Because the patient had oral and perianal ulcers and the colonic ulcers were considered to be a manifestation of intestinal BD, the patient was diagnosed with intestinal BD by a rheumatologist. He had suffered severe pain in the right lower abdomen 11 years prior. Acute appendicitis was initially suspected, but spontaneous ileocecal perforation was confirmed during an emergency exploratory laparotomy, and surgical repair of the ileocecal perforation was performed. He still suffered from the recurrence of oral and perianal ulcers but did not experience unbearable abdominal symptoms after taking prednisone and leflunomide irregularly.
+The patient had a 30-year history of smoking (1 pack per day).
+The physical examination upon admission showed tenderness in the right lower abdomen. When cyanosis occurred, the oxygen saturation dropped to 68%, and the heart rate was 130 beats/min. Assisted mask ventilation was initiated with 100% oxygen, but the patient’s saturation did not improve. An abdominal examination revealed a distended abdomen on palpation and drum sounds on percussion. On auscultation, breath sounds were absent on the right side and diminished on the left side of the chest.
+The patient had an antinuclear antibody titer of 1:320 (granular type, cytoplasmic type) and a positive fecal occult blood test upon admission. The laboratory results were not available during rescue.
+The computed tomography (CT) scan of the abdomen and pelvis before colonoscopy revealed bowel wall thickening in the terminal ileum, ileocecal area and appendix, ileocecal stenosis and incomplete bowel obstruction.
+Colonoscopy revealed deformation, mucosal hyperplasia and multiple deep ulcers in the ileocecal region . The possibility of perforation could not be ruled out. The colonoscope could not enter the small intestine due to stenosis and deformation of the ileocecal valve. Pseudopolyps in the ascending colon and ring ulcers in the transverse colon and descending colon were also shown on colonoscopy. Biopsies were taken from the ileocecal region, ascending colon and transverse colon. Pathology revealed chronic active mucosal inflammation in the ileocecal region and chronic mucosal inflammation in the ascending and transverse colon.
+The CT scan of the chest, abdomen and pelvis after chest drain tube insertion showed bilateral pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum and subcutaneous emphysema of the neck, chest, abdomen, back and scrotum .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2566_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2566_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d41581225c4d4ac6bc95f82de8ae5bb60a432b24
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2566_en.txt
@@ -0,0 +1,7 @@
+A 79-year-old woman with loss of appetite was transferred from another hospital. On physical examination at the first visit, no abdominal tenderness and jaundice were noted. Initial laboratory findings were unremarkable, except for a high level of carbohydrate antigen 19–9 (CA19-9; 125.7 U/ml). Both serum HBs-antigen and HCV-antibody tests were negative.
+Abdominal computed tomography (CT) showed a 100 × 90 mm low-contrast tumor in segments 1, 2, 3, and 4 resulting in dilated bile ducts in B2, enlarged regional lymph nodes #3 and #7 [#3 and #7, according to the General Rules for Clinical and Pathological Studies on Primary Liver Cancer], and invasion of the inferior vena cava (IVC), left portal vein (LPV), middle hepatic vein (MHV), and middle hepatic artery (MHA) .
+Positron emission tomography with 18F-fluoro-D-deoxy-glucose (18F-FDG PET)/CT showed uptake by the primary liver tumor and regional lymph nodes . On imaging, the patient was diagnosed with intrahepatic cholangiocarcinoma (ICC) with regional lymph node metastases [cT2N1M0, cStage IIIB according to the Union for International Cancer Control (UICC) classification system].
+Radical surgical resection including combined vascular resection, reconstruction, and lymph node dissection was possible, but R0 resection is often difficult in cases of locally advanced ICC such as the present case; thus, it was not considered achievable during discussion in the multidisciplinary team (MDT) meeting. It was also thought that her prognosis would be poor due to inability to achieve R0 resection. Thus, she was treated with combined chemotherapy due to the lymph node metastases. The combination chemotherapy consisted of gemcitabine (1000 mg/m2) plus cisplatin (25 mg/m2) administered for 2 weeks followed by a 1-week respite, with a single course extending over 3 weeks.
+After 4 courses of combination chemotherapy without adverse events, CT showed a marked reduction of the primary tumor and metastatic lymph nodes. The size of the primary tumor had decreased to 30 × 60 mm, and the invasion of the IVC, LPV, MHV, and MHA had disappeared . The lymph node enlargement also disappeared, and the CA19-9 level decreased to within the normal range (9.3 U/ml) . The patient achieved a partial response (PR) as assessed using Response Evaluation Criteria In Solid Tumor (RECIST), and the post-chemotherapy TNM staging was ycT2N0M0 Stage II by the UICC criteria. At the MDT meeting, it was then decided that surgery could proceed. H1234-B-MHV, dissection of #1, #3, #5, and #7 lymph nodes, and pyloroplasty to prevent the delayed excretion of gastric contents due to the vagus nerve reflex associated with lymph node dissection were performed. She was discharged on postoperative day 15.
+The histological examination showed scattered pigmented macrophages in the fibrotic tissue and inflammatory cell infiltration. No invasive carcinoma or epithelial carcinoma components were found. There were no viable carcinoma cells in the dissected lymph nodes . The pathological TNM staging was T0N0M0 according to the UICC criteria. In the MDT meeting, the decision was made not to proceed with adjuvant chemotherapy, for the reason that pCR had been achieved.
+She remains alive with no evidence of disease 2 years after surgery without adjuvant chemotherapy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2579_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2579_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..50327627336b14df534b036e7fcc5130f313babd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2579_en.txt
@@ -0,0 +1,3 @@
+A 26-year-old Caucasian woman presented to cardiology polyclinics with heart palpitations and shortness of breath. The patient's mother had died when she was 35 years old as a result of sudden cardiac arrest (SCA), and her grandmother had died as a result of congestive heart failure (CHF). The patient's body mass index was 24 kg/m2. The 24-hour electrocardiographic (ECG) monitoring documented 2602 bi-geminal, tri-geminal and quadri-geminal ventricular extrasystoles per hour as well as ventricular tachycardia (VT) episodes. The duration of filtered QRS was more than 120 ms. Her echocardiogram was within the normal ranges. Cardiac non-contrast-enhanced magnetic resonance imaging (MRI) showed diffuse thinning of the right ventricle and local dilation in the right ventricular wall with segmental hypokinesia. The electrophysiological study revealed sustained non-inducible VT, low-amplitude areas in the right ventricular outflow tract and ventricular ectopic beats originating in the right ventricular outflow tract. Because VT was non-inducible, neither the use of an implanted cardioverter-defibrillator (ICD) nor ablation was considered. There was right ventricular dilation and apical mild hypokinesia. She had no signs of left ventricular dysfunction. On the basis of these results, the diagnosis of ARVD was made according to the original International Task Force diagnostic criteria. She was prescribed metoprolol and propafenone. She avoided physical stress and did very well with pharmacological treatment. After three years of follow-up, she wanted to conceive. She was counseled that only a few pregnancies have been reported in patients with ARVD and that the risk of transmission of the disease to the offspring is 50%. A mutation screening was offered, but she refused the mutation screening because of the high cost. She conceived and ceased her medications but did very well during her pregnancy until term.
+A fetal echocardiogram was performed at the 21st week of pregnancy, and after delivery no abnormality was detected. In the third trimester, she had heart palpitations and became symptomatic again. The 24-hour ECG monitoring at the 32nd week of pregnancy documented 16,251 ventricular extrasystoles.
+She delivered at the 38th week of pregnancy by elective cesarean section while under general anesthesia. After three days of hospitalization, she was discharged without medications and continued breastfeeding for six months.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2583_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2583_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3d736b028ee47525528bbb9e1ed1fff210c5d68a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2583_en.txt
@@ -0,0 +1,3 @@
+A 71-year-old Asian woman with end-stage renal disease, who had undergone eight years of hemodialysis, presented with spontaneous painful plaque in her left lower calf with the surrounding skin exhibiting violaceous discoloration. Our patient had hypertension, dyslipidemia and osteoporosis but no history of diabetes, connective tissue diseases or chronic viral hepatitis. Because of recurrent thrombosis at the vascular access point for hemodialysis, she had received six months of warfarin therapy that ended five months prior to developing the calf lesion. Our patient had a long history of secondary hyperparathyroidism and had been treated with intravenous calcitriol for many years. Because of frequent episodes of hypercalcemia and hyperphosphatemia, intravenous calcitriol had to be discontinued so often as to result in inadequate control of her secondary hyperparathyroidism. Despite replacing the calcium-containing phosphate binders with sevelamer and shifting calcitriol to paricalcitol, her metabolic problems with calcium and phosphorous showed little improvement. In the previous four years, her serum levels of intact parathyroid hormone typically ranged from 350 to 800pg/mL, her calcium levels were around 9.5 to 10.6mg/dL and her phosphate serum levels were approximately 5.0 to 7.4mg/dL.
+In the ensuing weeks, her lesions became ulcerative and eschars covered the wound surfaces . Plain radiographs indicated marked calcification in the vessels of her lower extremities . A network of calcified vessels as small as 0.5mm in diameter was located in the retromalleolar region of her left leg, near the skin lesions . Calciphylaxis was suspected and intravenous STS was administered three times a week after each session of hemodialysis. The maintenance dose was 12g, equivalent to 15.4g per 1.73m2 of body surface area. Her predialysis serum calcium levels demonstrated a notable change from 10.4mg/dL to as high as 11.8mg/dL after initiating STS therapy. The dialysate calcium concentration was subsequently decreased from 2.5 to 2.0mEq/L stepwise and dialysis frequency was increased from three to four times per week. Treatment with paricalcitol (4μg, three times per week) was also stopped. As a result, her predialysis calcium levels decreased to 10.8mg/dL during the remaining STS treatment course . Nevertheless, necrotic changes continued as the ulcers expanded. STS was discontinued after five weeks of treatment. The laboratory data showed that her predialysis calcium levels declined to less than 10mg/dL in one week. Despite a series of efforts including hyperbaric oxygen therapy, diligent wound care and pain control, the lesions worsened and eventually required surgical debridement .
+Three months after the onset of skin lesions, our patient was hospitalized and scrupulous debridement was performed to excide the gangrenous tissue. The pathology of the gangrenous tissue revealed necrotic debris and inflammatory cellular exudates. The wound culture exhibited Acinetobacter baumannii growth, so intravenous amoxicillin-clavulanate was administered based on a sensitivity test. Because of the active infection of the skin lesions and fear of deepening or expanding the wound, no tissue biopsy was performed. Computed tomography angiography revealed diffuse vascular wall calcifications and atherosclerotic changes of the low abdominal aorta and bilateral iliac arteries, and marked calcification of the large and small arteries of both lower extremities . Conventional angiography showed a 70% stenosis in her left posterior tibial artery and a percutaneous transluminal angioplasty was performed for dilation. Our patient was discharged after one month of hospitalization, showing improvement of the lesion after aggressive wound care. Cinacalcet was concomitantly administered to treat the hyperparathyroidism and hypercalcemia. Her predialysis calcium level declined from 9.8 to 8.2mg/dL in two weeks. We adjusted the cinacalcet dosage between 25 and 50mg/day and the dialysate calcium concentration between 2.5 and 3.0mEq/L to avoid symptomatic hypocalcemia. The lesions steadily improved and were completely healed two months after discharge . Repeated plain radiographs in the following two years revealed gradual VC regression in both lower extremities . The network of small vessel calcifications in the retromalleolar region almost completely resolved. During a two-year follow-up period, during which cinacalcet treatment continued, her serum calcium levels typically remained at approximately 8.4 to 9.4mg/dL, her phosphate at 4.1 to 6.4mg/dL, and her intact parathyroid hormone at 250 to 480pg/mL. No vitamin D analogues or calcium-containing phosphate binders were used. Furthermore, no skin lesions recurred.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2589_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2589_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f474da5f03b3a4dfb22dcdb7283bddefad63e5e8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2589_en.txt
@@ -0,0 +1,4 @@
+A 17-year-old male was referred to our hospital with progressive headache and nausea. Neurological examination showed papilledema, and MRI [Figure –] revealed hydrocephalus and a bilateral multicystic lesion in the midbrain and thalamus that caused aqueduct stenosis. The signal intensity of the lesion on T1- and T2-weighted images was identical to that of cerebrospinal fluid (CSF). There was no enhancement with contrast media, no evidence of perifocal edema on FLAIR, and no evidence of calcification on computed tomography (CT). He underwent neuroendoscopic surgery for obstructive hydrocephalus caused by the lesion. A cyst with a transparent membrane continuous with the ependyma was responsible for the blockade of the aqueduct. Two stomas were made on the cyst wall by electrocoagulation, and the cyst shrunk. Third ventriculostomy was then performed. Biopsy of the cyst membrane was initially attempted by grasping it with forceps, but this was discontinued because of hemorrhage. Considering the imaging and surgical findings, the multicystic lesion was considered to be PVS dilation. Postoperative MRI revealed a marked improvement in hydrocephalus, but no change was observed in the size or number of the multicystic lesion. Headache and nausea improved. After discharge, the patient stopped visiting our hospital based on his own judgment.
+Fourteen years later, at age 31, the patient was readmitted to our hospital with progressive double vision and nausea. Neurological examination revealed anisocoria (right pupil: 3 mm, left pupil: 5 mm), and the light reflex was dull in both pupils. Left eye exotropia in the primary position was present. When the patient tilted his head to the right, double vision worsened, while titling to the left resolved the double vision (Bielshowsky sign positive). Eye movement during tracking of moving objects was normal. These findings indicated left oculomotor and right trochlear nerve palsies. MRI [Figure and ] revealed that a multicystic lesion in the midbrain and thalamus had increased in number and size compared with the initial examination at age 17, but hydrocephalus was not present. Radiological appearance was not typical of a tumor, and inflammatory or infectious disease was unlikely in view of the clinical course. Progression of giant tumefactive PVSs was considered the differential diagnosis.
+We speculated that compression of the midbrain was the most probable cause of symptoms and performed neuroendoscopic surgery. Two frontal precoronal burr holes were drilled. Through the left burr hole, we inserted the rigid endoscope with an operating sheath (Karl Storz Inc., Germany) and a neuronavigational guidance probe (Medtronic Inc., USA) into the third ventricle. Through the right burr hole, we inserted the flexible endoscope VEF-IV (Olympus, INC. Japan) with EMF System Pal-1 (Japan Medical Dynamic Marketing Inc., Japan) into the third ventricle. Thin-walled cysts were observed in the third ventricle . We fenestrated the cyst walls from rostral to caudal along the midline under the guidance of the navigation system. The interior of the cysts appeared to be traversed by small arteries that were surrounded by enlarged PVSs . Specimens of the cyst membrane were retrieved for biopsy.
+After surgery, the symptoms and neurological disorder improved. Postsurgical MRI [Figure and ] revealed a slight reduction in the size of the multicystic lesion. Histopathological staining for glial fibrillary acid protein (GFAP) [Figure –] demonstrated extensive gliosis in the cyst wall. Epithelial cells on the outer aspects appeared to be ependymal cells compressed by the cystic lesion. Based on MRI, surgical, and histological findings, we diagnosed the patient with a multicystic lesion, which was caused by giant tumefactive PVSs. MRI performed at 6 months after surgery showed a slight reduction in the number and average size of the cysts, and the patient remained free of symptoms.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2610_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2610_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..82d436a736fd1168fbc0196048d1d9e7f2cba375
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2610_en.txt
@@ -0,0 +1,2 @@
+Herein, we report the case of a 17-month-old male child referred to our Institute presenting gradual onset of mild eyelid ptosis and divergent strabismus of the left eye, preceded two days before by an episode of vomiting. A week prior to the hospitalization, an episode of inconsolable crying, lasting about two hours, occurred with loss of appetite during the following days. Neither fever nor other clinical findings were evident. The patient, third son, was born at term from Cesarean section after pregnancy complicated by placenta previa. Neonatal period was regular. Spherocytosis was diagnosed during the first months of life. His family history revealed spherocytosis (mother and sister) and Hashimoto’s thyroiditis (mother). At admission, physical examination was normal, except for eyelid ptosis and lateral deviation of the left eye due to mild medial rectus muscle deficiency and without pupillary dilation, suggesting the involvement of the third cranial nerve. Fundus examination was normal. C-reacting protein (CRP) was negative. Moreover, serological tests and autoimmune panel were negative. Brain magnetic resonance imaging (MRI), enhanced after contrast administration, and magnetic resonance angiography (MRA) were performed. They suggested a vascular anomaly, along the medial side of the left cerebral peduncle, referable to an arterial aneurysm nearby the ipsilateral third cranial nerve . However, the angio-CT examination did not confirm the vascular anomaly, highlighting a minimal size irregularity of the P1 tract of the left posterior cerebral artery . On the basis of MRI findings, a third cranial nerve neuropathy was suspected. About three weeks after hospital admission, left third oculomotor nerve ophthalmoplegia was no longer appreciable. One month later, a brain MRI was repeated and confirmed a sectorial slight thickening of the emergence of the left third cranial nerve, with a reduced post-contrast enhancement compared with the previous exam .
+One year later, a brain MRI was repeated, showing a complete resolution of the previous neuroradiological lesions . In relation to MRI findings and clinical situation, the reported case was highly suggestive of an episode of recurrent painful ophthalmoplegic neuropathy. Nonetheless, according to the diagnostic criteria proposed by the International Classification of Headche Disorders (ICHD) (2018) at least two attacks are necessary to confirm the diagnosis . Other considerable, even highly improbable, hypothesis was a schwannoma of the third nerve. For a correct evaluation of the case, we planned a strict follow-up: after 18 months from the diagnosis, the patient had an episode of headache with inconsolable crying treated with paracetamol. During this episode, neurological examination was negative. No other similar episodes with ophtalmoplegia occurred and the neurological examination was negative. After 30 months, the child was conducted at our emergency department presenting again eyelid ptosis and divergent strabismus of the left eye, associated with vomiting and headache. During the hospitalization symptoms gradually resolved spontaneously with a total resolution. This second acute attack confirmed our already strongly suspected diagnosis of RPON.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2617_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2617_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bd9d603e0260aa127723cb93f0bc8e28b46a8f65
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2617_en.txt
@@ -0,0 +1,3 @@
+A 17-year-old girl suffered from a traumatic injury to her maxillary anterior teeth one month ago . The girl complained of severe pain to teeth 11 and 21 to touch and biting. Clinical examination showed that teeth 11 and 21 were slightly displaced labially . The teeth responded to electric and cold pulp sensibility tests (tooth #11: 77/80, tooth #21: 56/80). The teeth were moderately tender to percussion and palpation. Both teeth showed grade II mobility. Periodontal probing was in the 2–3 mm range. Radiographic examination showed that teeth 11 and 21 had fully developed and demonstrated multiple transverse fractures in the middle third of the root of tooth 11 and tooth 21 . The diagnosis was multiple transverse root fractures with treatment was required due to persistent pain experienced by the patient despite splinting of the teeth for 1 month. Treatment options included root canal treatment of the coronal fragment of the root, REPs for the coronal fragment, and extraction. The patient decided to have REPs and informed consent was obtained.
+At the first visit, teeth 13, 12, 11, 21, 22 and 23 were splinted for 4 weeks after the first visit. Local anesthesia with 2% lidocaine containing 1:100,000 epinephrine was administered. The teeth were isolated with a rubber dam. Under a surgical microscope (Zumax, Zuzhou, China), the canals were accessed, and a moderate amount of bleeding immediately drained through the access cavity. The canals were gently irrigated with 1.5% sodium hypochlorite solution to a level of a1mm coronal to the fracture. The working length of each tooth was extended up to the most coronal fracture line determined radiographically with a #25 hand K-file. The canals of the coronal fragments were carefully, sequentially debrided to #40 K-files with constant irrigation with sodium hypochlorite to the most coronal fracture line preserving vital pulp tissue and with only minimal to no filing of the canal walls. The canals of the coronal fragments were dried with paper points and dressed with calcium hydroxide (ApexCal; Ivoclar Vivadent AG, Schaan, Liechtenstein). The access cavity was temporized with a sterile cotton pellet and glass ionomer cement (Fuji IX, GC, Tokyo, Japan).
+At the second treatment visit two weeks later, both teeth were asymptomatic. Local infiltration anesthesia with 3% Mepivacaine (Septodont, Taican, Jiangsu, China) without vasoconstrictor was administered. The teeth were isolated with a rubber dam and the access cavity reopened. Calcium hydroxide was removed with copious amounts of sodium hypochlorite irrigation followed by saline solution irrigation. The coronal canal was dried and rinsed with 17% EDTA solution (Langlishangwu, Wuhan, China) for 1 min in each tooth and dried again. A #40 hand K-file measuring 21 mm was used to gently penetrate the apical fragment of the canal containing vital pulp to induce bleeding into the coronal canal spaces up to the cemento-enamel junction. After a blood clot was formed, CollaCote (Integra Life Sciences, Shanghai, China) was placed over the blood clot in the canal of each tooth. A 3 mm thickness of iRoot BP (Innovative Bioceramix, Inc, Shanghai, China) paste was then placed against the CollaCote followed by a moist cotton pellet. The teeth were restored with glass ionomer cement and composite resin (Fuji IX, GC, Tokyo, Japan). A final radiograph was taken to verify the location of the coronal seal . The patient was reviewed after 1, 3, 6, 12, 24, 36, and 48 months, respectively.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2622_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2622_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..dae5b003d27d1a17d050d4a1b72828870cc11f73
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2622_en.txt
@@ -0,0 +1,3 @@
+A 45-year-old man was injured in a motorcycle accident and transferred to the emergency department in a state of traumatic hemorrhagic shock. Radiographs indicated fractures of the left distal clavicle and scapula, associated with multiple rib fractures and a fracture of the transverse processes of spinal vertebrae. Computed tomography examination revealed a left hemopneumothorax. After resuscitation, the patient underwent osteosynthesis of the left distal clavicle fracture, using tension band wiring. 6-month post-injury, the patient presented to our hospital with severe limitation of shoulder motion, with visible atrophy of the deltoid muscle and inability to perform active shoulder abduction and external rotation. Active range of shoulder motion was as follows: 35° of forward elevation, 20°of abduction, and 0°of external rotation. The strength of all muscle groups of the shoulder, on manual muscle testing, was <M2. No impairments in elbow and wrist function were noted. Electromyography (EMG) assessment identified a complete denervation of the deltoid muscles, with the absence of voluntary potentials, and incomplete paralysis of the supraspinatus and infraspinatus muscles. Based on the EMG and physical examination, a diagnosis of suprascapular and axillary nerve injury. Considering that 6 months had passed since the time of trauma, we selected to perform a radial to axial nerve transfer, using the branch from the medial head of the triceps, while selecting to monitor the status of the suprascapular nerve injury, based on the incomplete paralysis of supraspinatus and infraspinatus. 6-month post-surgery, the contractile strength of the deltoid muscle had improved to M3, but without recovery of shoulder abduction and external rotation, with the significant restriction in shoulder motion persisting at 14-month post-injury, as follows: 80° of elevation, 30°of abduction, and 0°of external rotation . Considering the extent of limitation in shoulder movement, we planned to perform a surgical reconstruction of the functions of the rotator cuff.
+The surgical reconstruction was performed with the patient in a right lateral decubitus position, under general anesthesia. A zigzag incision was created along the axillary line, and the LD and TM were detached from the humerus. LD and TM were transferred to the attachment of the supraspinatus muscle, using an anchor and a 4 cm × 10 cm graft extension of the tensor fascia latae. An incision of approximately 20 cm was created along the spine of the scapula, from the acromion to the inferior angle of scapula. The lower portion of the trapezius was elevated, along with the periosteum from the lateral margin, and directly sutured to the insertion of the infraspinatus muscle using an interlacing technique, without the use of an autogenous tendon . The wound was closed and an airplane splint applied with the shoulder in 90° of abduction and neutral rotation.
+The patient had begun active and passive elbow range of motion(ROM) at 2-day post-surgery, passive shoulder ROM at 2-week post-surgery, and active shoulder ROM at 4-week post-surgery. After gradual decrease of abduction angles of the airplane splint in 2 weeks, the splint was removed at 6-week post-surgery. 9-week post-surgery, an active range of 110°of the shoulder elevation, 75°of abduction, and 15°of external rotation was achieved. At 12-month post-surgery, the muscle strength of shoulder elevation and external rotation had recovered to M3/M4, and the patient had returned to his activities of swimming and water jet skiing. At 24-month post-surgery, the patient had recovered 170° of shoulder elevation, 170° of abduction, and 60° of external rotation. Moreover, muscle strength of external rotation had recovered to M4 , with a Hand20 score of 13, compared to 30.5 preoperatively.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2628_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2628_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..20549bd51501c84670162251dcca604230a1b1a2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2628_en.txt
@@ -0,0 +1,2 @@
+We report the case of a 58-year-old woman diagnosed with multiple simultaneous colon cancer using the Pillcam Colon 2. The patient referred to our service for dyspnea, fatigue and chest pain with a progressive onset. From patient history, we should mention type II diabetes mellitus, atrial fibrillation and cardiac ischemic disease and family history of colon cancer (father). She received a low dose of aspirin (Aspenter 75mg). The patient denied melena or changes of bowel habits.
+On examination, the patient was noted to be pale, tachycardic (pulse = 104 bpm), orthopneic, with pulmonary rales, tender liver and periferal pitting edema; gynecologic evaluation was normal. Blood tests showed severe hypochromic-microcytic anemia (hemoglobin = 7,61g/dl; MCV=66,2fl; MCH=19,8pg), thrombocytosis (PLT= 500.000/mmc) with low level of serum Fe (19 microg/dl) and high Fe-binding capacity (495 mg/dl). Renal function tests revealed a minimally elevated BUN (51mg/dl). Other biochemical markers found some inflammatory activity (ESR = 50mm/h, CRP +), while tumoral markers were non-reactive. Upper endoscopy revealed an erosive pangastritis (probably due to aspirin ingestion) with no evidence of bleeding. This is why we decided to perform a colonoscopy, but because of the associated co-morbidities, the patient could not tolerate the examination. We used the Pillcam colon 2 system to investigate the entire digestive tract. The patient underwent a special preparation regimen with 6L of PEG (2L one day before capsule ingestion, 2L in the same day before ingestion and 2L after ingestion). This revealed one tumoral mass in the caecum and a second tumor in the transverse colon . After blood transfusions (2 MER units) and improvement of cardiac function, the patient was transferred in a surgery unit and two days later, she underwent surgery. Because the preoperative CT scan found no metastatic lesions and lymph nodes, there was no need for chemotherapy. The follow-up at 3 and 6 months after surgery identified no early complications or tumor recurrence.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2634_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2634_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..51a756a79815bcc223bc79e08ffa512b763f75b1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2634_en.txt
@@ -0,0 +1,4 @@
+A 30-year-old male patient suffering from Hodgkin's disease had undergone strong chemotherapy as preparation for bone marrow transplantation (BMT). He had survived, and after 3 years without receiving any therapy, his gonadal status was evaluated. He had no complaints and showed the following values: total testosterone (TT) – 419 ng/dl (400–900); free testosterone (FT) – 14.7 pg/ml (9–27); luteinizing hormone (LH) – 7.9 mIU/ml (<15); follicle-stimulating hormone (FSH) – 29.8 mIU/ml (<15), and estradiol (E2) – 26.5 pg/ml (<11). Two spermiograms were made in different weeks and revealed azoospermia.
+Five and 7 years after BMT, he was tested again. The tests showed a slight increase in FSH and constant LH values. A sperm count revealed a slight improvement after 5 years, with a mean value (MV) of 100,000 cells/ml, but at 7 years it had decreased to an MV of 500 cells/ml . During year 7, the TT values remained more or less the same, but it was noted that the FT levels had decreased to 7.8 pg/ml .
+The patient had no complaints regarding his sexual performance, but he expressed a strong wish to become a father. We decided to treat him with letrozole, and he took 2.5 mg/day over a period of 8 months . Tests of his androgen values and sperm cell counts were repeated at the end of that period.
+Both LH and FSH had increased. LH increased to 48.7%percnt; (16.2 mIU/ml) and FSH to 26.3%percnt; (37.2 mIU/ml). E2 decreased 71.3%percnt; (18.9 pg/ml); TT and FT showed a marked increase, doubling basal values with 110.6%percnt; (882.5 ng/dl) and 92.5%percnt; (28 ng/ml), respectively. As an indirect indicator of aromatase activity, T/E2 was calculated. There was a rise of 193.75%percnt; . Sperm count improved to a MV of 1,000,000/ml .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2649_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2649_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9b6a994ee9fa4d3d38f92223e2bcf26afd281689
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2649_en.txt
@@ -0,0 +1,4 @@
+This case report involves a 59-year-old female patient who, upon physical examination, exhibited spleen enlargement with occasional left low back pain as the only noticeable symptom. The CT scan indicates a low-density mass in the spleen , measuring 41mm in diameter. During the enhancement scan, there is mild and sustained enhancement in each phase, with clear margins. Within the mass, lower-density foci are observable, lacking apparent enhancement. Radiologically, there is a suspicion of sclerosing angiomatoid nodular transformation (SANT) in the spleen. Moreover, no abnormal serum tumor markers were found in this patient. Finally, the patient underwent a partial splenectomy. Macroscopic examination revealed a protruding gray-yellow mass beneath the splenic capsule, measuring 4.5cm×4cm×3cm. The cut surface of the mass exhibited a soft, friable texture, with well-defined boundaries against the surrounding tissues.
+Under the microscope, the tumor exhibits relatively clear boundaries with surrounding tissues, lacking an apparent capsule. Within the tumor, there is a widespread distribution of non-caseating necrotizing granulomas . These granulomas consist of multinucleated giant cells and epithelioid cells, no evident necrosis identified. Interspersed between the granulomatous nodules, there is a significant infiltration of inflammatory cells, predominantly composed of plasma cells and lymphocytes, with the absence of lymphoid follicle formation. In the prominent inflammatory cellular background, spindle or oval-shaped cells are observed. At high magnification, the boundaries between these spindle cells appear indistinct, with a relatively sparse arrangement. The tumor cells exhibit mild cytologic atypia, with chromatin showing a pale affinity for eosin staining. The nuclear shape varies from round to spindle, accompanied by smooth nuclear membranes and conspicuous small nucleoli. Mitotic figures are rarely observed .
+Immunohistochemical staining further revealed that the spindle cells were positive for CD21 and CD23 , while S-100 and SMA demonstrated partial positivity. Desmin, ALK and CKpan, however, were all negative. In the inflammatory stroma, diffuse expanses of CD38-positive plasma cells and CD68-positive tissue cells are evident. Lymphocytes are predominantly composed of CD3-expressing T cells, with localized presence of CD20-positive B cells. Notably, a minimal proportion of plasma cells exhibited positivity for IgG4. The proliferation index of fat fusiform cells, measured by Ki-67, was approximately 15%. Furthermore, Epstein-Barr encoding region (EBER) in situ hybridization confirmed the presence of positive signals for EBV, while acid-fast staining yielded negative results in tumor cells .
+Combined with morphology and immunohistochemistry, the final pathological diagnosis of this case was EBV+IFDCS. As of the submission of this case, the patient is still alive.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2657_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2657_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..09fbedac4e71b6c9bb63b0679d226bd75c286c9a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2657_en.txt
@@ -0,0 +1,5 @@
+An 83-year-old white man presented to our emergency department with shortness of breath. His past medical history was significant for chronic obstructive pulmonary disease, atrial fibrillation, congestive heart failure, anemia of chronic disease, sick sinus syndrome, pulmonary hypertension, and chronic kidney disease. His medications included probenecid, finasteride, albuterol-ipratropium bromide by inhalation, furosemide, carvedilol, omeprazole, tamsulosin, mirtazapine, ferrous sulfate, metolazone, losartan, budesonide, and prednisone. He was also on apixaban 2.5 mg twice daily for anticoagulation due to non-valvular atrial fibrillation. He did not have a history of bleeding or clotting disorders, although he had presented to our emergency department with complaints of hemoptysis at least once previously due to his cardiopulmonary disease.
+Acute-on-chronic congestive heart failure and exacerbation of chronic obstructive pulmonary disease were diagnosed. Five days into his hospital stay he awoke with diffuse abdominal pain. He and his wife both denied history of recent abdominal or chest trauma, including falls. After the onset of his abdominal pain, while sitting up in bed, he had a witnessed syncopal event and became unresponsive. A medical emergency response team was called to his bedside and laboratory tests were immediately performed. He recovered and was stabilized, but soon after he developed abdominal distention, tympanic bowel sounds, and altered mental status. He decompensated rapidly with a drop in blood pressure from baseline values of 100/50 mm Hg to 54/32 mm Hg. An immediate abdominal computed tomography (CT) scan was completed at that time with the differential diagnosis being considered including bleeding gastric or duodenal ulcer, ischemic bowel, myocardial infarction, or septic shock. His CT showed a splenic hematoma with associated enlargement of his spleen measuring 13.6×11.5×15.5 cm and blood in his abdominal cavity . On hematologic tests, his serum hemoglobin was reduced from his baseline value of 9.3 g/dL on admission to 5.3 g/dL (normal range 13.5 to 18 g/dL). His activated partial thromboplastin time (aPTT) was within normal range; however, his prothrombin time (PT) was elevated at 16.1 seconds (normal range, 9.5 to 12.7 seconds) consistent with his use of apixaban.
+Rapid transfusion of two units of packed red blood cells, followed by three units of fresh frozen plasma was initiated. Despite attempts at resuscitation, he remained hypotensive and in shock. Due to multiple comorbidities which could potentially complicate surgical intervention, he was urgently transferred to interventional radiology for an emergency splenic artery embolization. An angiogram completed during the procedure showed a splenic artery that was patent and tortuous, with medial displacement of his spleen by a hematoma consistent with what was seen on CT imaging. He was successfully stabilized by embolization of the bleeding source; he was subsequently transferred to our intensive care unit.
+The following morning, subsequent to the embolization of the bleeding source, his hemoglobin had decreased from 8.6 g/dL to 6.6 g/dL, which raised a concern that he had recurrent bleeding; a laparotomy was performed with a splenectomy and evacuation of a large intra-abdominal hematoma. During the procedure, 3600 mL of blood and clots were evacuated from his abdominal cavity.
+Following the surgery, he underwent prolonged mechanical ventilation due to respiratory failure and temporary hemodialysis for acute-on-chronic kidney injury. He was eventually discharged to a short-term rehabilitation facility for physical therapy after an extensive hospitalization.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2664_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2664_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e1d9fb6f2127953a3a56eb3850059d29ada2f8e8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2664_en.txt
@@ -0,0 +1 @@
+A 41-year-old young healthy male entered the retina clinic with complaints of seeing a black spot, blurred vision and metamorphopsia involving the right eye for the past 4 months. He was on treatment for androgenic alopecia with topical 5% Minoxidil application on scalp two times a day for a total time period of 10 months. He noticed the symptoms 8 months after starting the treatment. He was not seen by any other ophthalmologist previously and had stopped the medication on his own since the past 2 months. The patient denied using other medications or a history of previous treatment with corticosteroids. On examination, best-corrected visual acuity was 20/20 in both eyes. Intraocular pressure was 15 mmHg in both eyes. Anterior segment was unremarkable. Fundoscopic examination of the right eye with +78D lens on slit lamp revealed central swelling located over the macula with presence of subretinal fluid (SRF) and few focal spots of retinal pigment epithelial alterations. Left eye fundus was normal. Optical coherence tomography (OCT) scan evaluation showed the presence of SRF with an irregular retinal pigment epithelium. On enhanced depth imaging OCT, dilated pachy choroidal vessels compressing the overlying Sattler’s and choriocapillaris layer was noted nasal to the fovea. Subfoveal choroidal thickness measured was 425 μm. Fluorescein angiography did not show any classic smoke stack or ink-blot pattern of leaks. Indocyanine green angiography (ICGA) revealed dilated hyperpermeable choroidal vasculature on the nasal side of the fovea in the early and later phases of the angiogram corresponding to the pachy choroidal vessels seen on enhanced depth imaging OCT . The patient was diagnosed with CSCR as a possible consequence of his topical minoxidil solution. Patient was asked to avoid future use of Minoxidil and was started on oral eplerenone therapy 50 mg/day for 4 consecutive weeks. Serum electrolytes and renal profile were done prior to starting the therapy. Blood investigations were normal. One month later, he was found to have complete resolution of his symptoms. OCT examination revealed complete resolution of SRF and reduction in the subfoveal choroidal thickness (391 μm). Oral eplerenone was discontinued and patient was asked to follow up the next month. No side-effects were reported following the intake of oral eplerenone. At the final follow-up visit, 2 months after starting the therapy, there was no recurrence of SRF and the subfoveal choroidal thickness further decreased to 344 μm . Written informed consent was obtained from the patient for utilising his clinical details for this manuscript. Permission for using the patient data for this report was obtained from institutional review board and ethics committee (C/2019/06/03).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2666_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2666_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a9f045d10486f92d4b8d085198ac6dea486f6f25
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2666_en.txt
@@ -0,0 +1,4 @@
+A 35-year-old male presented to their GP for treatment of hot flushes on finasteride (5-alpha reductase inhibitor) for hair loss, which he had recently stopped. The finasteride was stopped because of these side effects and a subsequent baseline prostate-specific antigen (PSA) showed a raised reading of 12.5ng/mL, which prompted referral to a urologist.
+Negative urine culture excluded urinary tract infection, and repeat PSA 6 weeks later demonstrated a rise to 14.6ng/mL. Digital rectal exam revealed a small, benign-feeling prostate which was non-tender. There was no family history of prostate cancer, and the patient did not have any physical or sexual activity prior to the PSA tests.
+Multiparametric MRI found a PIRADS 4 lesion in the anterior zone of the prostate (see ). PSMA PET identified focal and markedly increased tracer uptake in the anterior zone of the prostate concordant with the MRI lesion (see ). The SUVmax on the PSMA PET scan was 23.5, consistent with a site of active tumor. There was no evidence of lymphadenopathy or metastatic disease. Targeted trans-perineal prostate biopsies found Gleason 4+5=9 (Grade Group 5) acinar adenocarcinoma in 8 of 8 biopsy cores involving 80% of the total material sampled. No cribriform architecture was identified but there were features suspicious of extra prostatic extension on the biopsy. Sperm banking was completed and a robotic-assisted radical prostatectomy was performed with a novel RoboSling vascularized continence sling, an aggressive bilateral nerve spare and a bilateral pelvic lymph node dissection, without complication. Pathology demonstrated Gleason 4+5=9 adenocarcinoma with focal cribriform architecture, 0.6mm of extracapsular extension at the apex anteriorly, and clear margins, stage pT3a N0 M0 (see ).
+At 12-month follow-up, the patient had an undetectable PSA, complete continence with 0 daily pad use, and reported erections rigid enough for penetration with acupuncture and daily Tadalafil (phosphodiesterase-5 inhibitor) for penile rehabilitation. The patient’s father has since been diagnosed with Gleason 6 prostate cancer at the age of 67, screening having been prompted by the patient’s diagnosis. On further history from relatives, his maternal grandmother had a history of breast cancer at age 89. Genetic testing, including BRCA1, BRCA2, PALB2 and TP53, was performed in the context of the high grade disease at a young age and did not identify a heritable cause. Please see for a treatment timeline schematic.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2675_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2675_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e5cd32aa31a2075a31e7d173d30d23a8d3688840
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2675_en.txt
@@ -0,0 +1,5 @@
+A 66-year-old caucasian male, with a past medical history of heart failure with preserved ejection fraction, symptomatic persistent AF with a LAAO device compliant on apixaban 5 MG BID, hypertension, stage 2 chronic kidney disease, and coronary artery disease, presented to the university cardiology clinic with fatigue, lightheadedness, and exertional dyspnea. The patient, a retired warehouse worker, had undergone DCCV 10 days prior to symptom onset for which sinus rhythm was restored. The TEE obtained before cardioversion showed a normal ejection fraction with no wall motion abnormalities and no thrombus present on the left atrial appendage .
+At the clinic, the patient was found to have reverted back into AF with rapid ventricular response with physical exam remarkable for the patient being tachypenic, in moderate distress, and having an irregularly irregular pulse.
+Of note, the patient had his WATCHMAN device implanted about 2 years prior to symptom onset, with a TEE showing successful placement of the device within the left atrial appendage and no thrombus or peridevice leak noted. Forty-five days after implantation, the patient underwent a TEE as part of a routine postwatchman device assessment, which again showed appropriate device positioning with no thrombus or peridevice leak noted.
+Given that the patient had reverted back into AF, cardioversion was tenatively planned. At the request of the patient; however, a TEE was obtained prior to cardioversion, which incidentally found a 2 cm×1 cm thrombus visualized in the left atrium above the WATCHMAN device . TEE also was notable for a normal ejection fraction and no wall motion abnormalities. The cardioversion was subsequently canceled and the patient was hospitalized for AF management. The labs obtained on admission were unremarkable. Digoxin was started for rate control and the patient’s home metoprolol was titrated up to 100 MG BID. The patient’s symptoms stabilized and he was discharged on warfarin with enoxaparin bridge and aspirin 81 mg daily.
+About one-and-a-half months later, the patient underwent a TEE, which showed a well-seated LAAO device, within the left atrial appendage, and no thrombus or peridevice leak noted . Warfarin was still continued given the patient’s recent history of thrombus while on uninterrupted oral anticoagulation with apixaban, with a tentative plan for an electrophysiology study with AF ablation. The patient’s perspective on his course of events was that of curiosity and confusion regarding how he developed a thrombus, despite being adherent to his anticoagulation regimen, along with an eagerness to resolve his AF.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_267_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_267_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3a729fa0bf8a5db38e40650addc9806c4cae5947
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_267_en.txt
@@ -0,0 +1,10 @@
+Our patient is a 13-year-old Roma girl (ASA physical status III) prepared for T2–L2 posterior scoliosis correction and fusion.
+The patient suffered from mild mental retardation; however, communication was unhindered. She walked without support for a distance of approximately 20 m, but had limitation in movement of the upper extremities due to peripheral neuropathy. Facial dysmorphism was presented by prominent nasal philtrum and upper incisors.
+The progressive curve of scoliosis limited the possibility of rehabilitation, therefore brace treatment was not prescribed for our patient. The Cobb angle was 83°.
+Previous general anesthesia for cataract operation at the University Hospital in Prague was uncomplicated. We could not obtain more information about the course of anesthesia used.
+The patient was diagnosed with a patent foramen ovale and pulmonary valve stenosis, both hemodynamically insignificant without contraindication to the procedure in the prone position.
+The patient had no significant family history. Rhabdomyolysis, seizure, or CCFDN syndrome was not present in her family relatives.
+The patient's body weight was 45 kg and her height was 136 cm; however, the scoliosis curve reduced her actual height. Her Mallampati score was 1. The cardiovascular system was not affected and valve disease was insignificant. Her ASA score was III.
+On admission, laboratory test results were within normal limits. There was no abnormality in blood count, biochemical tests, or coagulation.
+Pulmonary functions were dominantly limited by restrictive lung disease (forced vital capacity, 54%; forced expiratory volume in 1 s, 62%).
+Chest X-ray was limited by chest scoliosis and revealed no abnormal lung and heart pathology. Echocardiography found hemodynamically insignificant valve disease. X-ray demonstrated a significant and progressive scoliosis curve with a Cobb angle 83° .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2697_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2697_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cf44d36323d852f0724e0a8985ce752528a8261c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2697_en.txt
@@ -0,0 +1,5 @@
+A 76-year-old Japanese woman presented with neutrophilia, mild renal dysfunction, and proteinuria and was referred to our Department in year X . Her neutrophilia was first discovered during a medical check-up when she was 74 years old (year X-2), and thereafter, her neutrophil count progressively increased. Her serum G-CSF was 161 pg/mL , which was far beyond the normal range (< 39.0 pg/mL).
+Her 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) scan showed intense uptake in the bone marrow but did not show any evidence of a malignant solid tumor or an occult abscess related to bacterial infection. Fluorescence in situ hybridization was performed on peripheral blood smears, and there was no clonality in the patient’s neutrophils. Her urine had tested positive for urinary occult blood since she was 50 years old, and she developed proteinuria after her neutrophil count increased above 20.0 × 103/μL in year X-1.
+Her blood pressure was 118/59 mmHg; other vital signs were also normal. Physical examinations were unremarkable. When she was admitted in year X, the results of laboratory tests were as follows: white blood cell (WBC) count, 35.9 × 103/μL (neutrophil count, 31.3 × 103/μL; 87.2% of the WBC count); hemoglobin level, 11.5 g/dL; platelet count, 27.3 × 104/μL; serum creatinine, 0.85 mg/dL; estimated glomerular filtration rate, 49.4 mL/min/1.73 m2; blood urea nitrogen, 16 mg/dL; lactate dehydrogenase, 170 U/L; total protein/albumin, 8.0/3.6 g/dL; and immunoglobulin G (IgG), 2901 mg/dL. Serum immunoelectrophoresis revealed a monoclonal IgG λ peak; however, the levels of other immunoglobulins were normal, and bone marrow aspiration showed less than 10% clonal plasma cells, thereby yielding the diagnosis of monoclonal gammopathy of undetermined significance (MGUS). Tumor markers including carcinoembryonic antigen, squamous cell carcinoma antigen, and cytokeratin fragment were all within normal range. Both the levels of C-reactive protein and complements were normal, and both antinuclear antibody and rheumatoid factor were negative. Tests for hepatitis B virus and hepatitis C virus were negative. Her urinary protein excretion was 2.55 g per gram urinary creatinine, and the proteinuria selectivity index was 0.17. We found hematuria (20–29 red blood cells/high-power field) and granular casts in her urinary sediment.
+A renal biopsy was performed, and sections evaluated by light microscopy showed many lobulated glomeruli. Mesangial proliferation and focal double contouring of the glomerular capillary walls were also present . Additionally, endocapillary proliferation was observed in the glomeruli . Immunoperoxidase staining for neutrophil elastase revealed some neutrophils infiltrating the glomeruli . Double immunofluorescence staining for neutrophils and macrophages showed that the infiltration of macrophages was mainly around the glomeruli, and the glomeruli contained more neutrophils than macrophages (data not shown). We identified intratubular cellular casts and interstitial expansion in the tubulointerstitial area . Immunoperoxidase staining for G-CSF did not show a specific staining pattern (data not shown). Immunofluorescent staining showed no deposition of immunoglobulins or complements (data not shown). Expansion of the subendothelial space suggesting injury of glomerular endothelial cells and effacement of the podocyte foot processes were seen in sections evaluated by electron microscopy . There were no electron dense deposits. Based on these biopsy findings, we diagnosed the patient with MPGN-like glomerulopathy.
+The patient was conservatively treated with an angiotensin II type 1 receptor blocker, but her proteinuria did not resolve. On the contrary, her proteinuria fluctuated in accord with the changes in her blood neutrophil count. Finally, the neutrophil count decreased without any medication, and the proteinuria diminished considerably .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_26_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_26_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2bd943f34321ea0711d43078ab8ae63deea3e015
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_26_en.txt
@@ -0,0 +1,8 @@
+A 67-year-old Caucasian woman was admitted to the emergency department with palpitations, and dizziness in the past 2 days. She complained of fatigue after minor effort, weight loss (11 kg in 3 years) without anorexia, and hand tremor. She had no complaints of dyspnea, orthopnea or chest pain. She had no heat intolerance nor increased frequency of bowel movements.
+Our patient had a history of breast cancer diagnosed at the age of 37 and treated with right radical mastectomy and adjuvant chemotherapy. She underwent total thyroidectomy for nontoxic multinodular goiter [thyroid-stimulating hormone (TSH) 3.77 of μU/mL and free thyroxine (T4) of 1.53 ng/dL] with a dominant colloid nodule of 30 mm at the age of 60; the histological analysis confirmed multinodular adenomatous goiter weighing 66 g with no signs of malignancy. She was medicated with levothyroxine 100 μg/day since the surgery and had no follow-up. She smoked 20 cigarettes a day for the last 50 years.
+At physical examination, our patient was conscious and oriented. Her temperature was 36.7 °C, she had a body mass index of 19.7 kg/m2, blood pressure of 122/76 mmHg, a heart rate of 130 bpm, and fine tremor at rest. She had no eye involvement. A cervical examination showed no palpable masses or adenomegaly. Pemberton’s sign was negative. The pulmonary sounds were normal and she had no cardiac murmur. She had no peripheral edema.
+At admission, our patient had a hemoglobin level of 11.5 g/L (12–16); a normal white blood cell and platelet count; a normal liver panel; an albumin level of 32.6 g/dL (38–51); normal renal function and ionogram; corrected total calcium level of 9.6 mg/dL (8.1–10.4); B-type natriuretic peptide level of 442.2 pg/mL (<100); and a troponin I level <0.010 ng/mL. She had suppressed levels of TSH (0.000 μU/mL) and increased levels of free T4 3.22 ng/dL (0.70–1.48) and free triiodothyronine (T3) 8.46 pg/mL (1.71–3.71). In the electrocardiogram, she had sinus tachycardia of 117 bpm and incomplete right bundle branch block and left anterior fascicle block. Her chest roentgenogram showed normal cardiothoracic index, no pulmonary congestion, no mediastinal enlargement nor tracheal deviation.
+She was admitted to the endocrinology department with a diagnosis of iatrogenic thyrotoxicosis. She was started on bisoprolol 5 mg and levothyroxine was stopped. Her heart rate remained under 100 bpm and her blood pressure was always normal. Her extremities’ rest tremor persisted. She showed no improvement on her free T4 and free T3 levels 10 days after levothyroxine treatment withdrawal . Her thyroglobulin levels were increased to 294 mg/mL (0–55). A cervical ultrasound scan revealed no thyroid remnant in the gland bed. Test results for anti-TSH receptor antibodies (TRAb) were positive – 19.7 U/L (<1.8) – and for anti-thyroperoxidase antibodies were negative – 0.6 U/mL (<5.61). Corporal scintigraphy with I-131 with single-photon emission computed tomography (SPECT) revealed an intrathoracic mass (60 × 40 mm) with increased radioiodine uptake and no increased uptake in the thyroid bed . A computed tomography (CT) scan of her neck and thorax confirmed a heterogeneous mass with 67 × 46 × 52 mm in the anterior mediastinum superiorly .
+The final diagnosis was Graves’ disease in mediastinal thyroid tissue. She was discharged with bisoprolol 5 mg/day and methimazole 10 mg/day.
+Three months later, after achieving euthyroidism, she underwent surgical resection of the mass through a horizontal cervical incision. The thyroid tissue found in the superior mediastinum had cervical vascularization. There was no complication in the postoperative period. The histology showed hyperfunctional tissue with thyroid follicles of variable shape and form with papillary hyperplasia and some adenomatous areas; no signs of malignancy were found.
+Our patient remained asymptomatic and with normal thyroid function under levothyroxine 88 μg/day (1.6 μg/kg) 5 months after surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2705_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2705_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..42c5163c06e2851fdf0481be98f3a22a038fd3c4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2705_en.txt
@@ -0,0 +1,3 @@
+A 31-year-old male patient referred to our clinic with a chronically draining lesion on his chin. His history revealed that he had this lesion for more than 5 months and had undergone two times surgery and received antibiotics for prolonged period of time.
+Dental history revealed no pain or any dental symptoms but he recalls to a direct blunt trauma to the anterior mandibular region. The periapical radiograph showed a large radiolucent area around lower right first incisor. There was no electric or thermal pulp testing performed on the same tooth. Neither percussion nor palpation revealed any abnormality.
+The tooth was treated with calcium hydroxide and glycerine and antibiotics for 14 days. After the initial filling of the root canal, an apicoectomy and sinus excision was performed. Three months postoperative control revealed no sinus fistula or exudates from chin or from the mucosa.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2714_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2714_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c73d70e4a83e28e59842be62666d3424101a9556
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2714_en.txt
@@ -0,0 +1,4 @@
+An 11-year-old Sudanese boy presented with frequent bleeding diathesis (ecchymosis, epistaxis, and gingival bleeds) . The most commonly encountered type of hemorrhage was extensive bleeding after trauma followed by subcutaneous bleeding. The patient had a history of delayed bleeding episodes since the day of circumcision, which took approximately 1 month to stop. Repeated episodes of epistaxis were also reported. He did not receive blood or blood product transfusion. He reported bleeding in the subcutaneous tissue following trauma when he was playing with his friends. Hemorrhage into joints also occurred after trauma. Spontaneous joint bleeding was not reported. Pain and slight swelling of muscles sometimes persisted for months. Looking into the family history, all family members were normal except his mother. The mother had a history of severe interval bleeding diathesis (menorrhagia). The patient had no known chronic sickness, drug allergies, or any developmental abnormality.
+On examination, the patient was neither icteric nor cyanosed, and was not dysmorphic. There was no noticeable change when checking the ear, nose, and throat. The cardiopulmonary examination was normal. The patient’s central nervous system examination showed good sensation and reflexes. He had no skin rash or organomegaly. The liver function tests and complete blood count were all normal. Viral screening for human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) were negative .
+The coagulation tests were performed when he was asymptomatic. The main abnormal investigations were as follows: fast lysis of whole blood clots and shortened euglobulin lysis time. The other tests including clotting time, prothrombin time (PT), partial thromboplastin time (PTT), and thrombin time (TT) were all within the normal values. This suggests that there were no abnormal changes in blood coagulation. This was further confirmed by the testing of coagulation factor activity. Platelet count, bleeding time, and von Willebrand factor were also normal .
+Concerning the clot lysis test, the blood was collected and promptly placed in a glass test tube and incubated at 37°C. The clot was formed and retracted normally, but then underwent lysis. Following a few hours of incubation (5–8 hours with interval assessment), the clot was hardly visible, and it was just a small strand of fibrin. The fibrinogen and d-dimer concentration were within normal limits. To determine the status of fibrinolysis, euglobulin lysis time was calculated, and the result indicated shortened lysis time . To further investigate, we treated the patient’s plasma with a pooled normal plasma and repeated the euglobulin lysis time, which returned to normal. However, in such cases, it is preferable to use thromboelastometry to verify the diagnosis. Unfortunately, due to a lack of facilities, this technique was not performed. The defect seems to be inherited as an autosomal recessive trait .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2724_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2724_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b64c1ea87e855b4efe9f5358f67ef4f334cd1b4a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2724_en.txt
@@ -0,0 +1,6 @@
+The case is of a 3.7-kg, 1-month-old male patient who presented at day 24 of life with severe aortic stenosis (AS) and coarctation of the aorta (CoA). He was born at term following an uncomplicated pregnancy. On day 5 of life, he was noted to be jaundiced and have a murmur. His jaundice resolved, and he was discharged home with cardiac follow-up. He then had progressive increase in his work of breathing and was not gaining weight. He had an echocardiogram on day 24 of life which showed a thickened and dysplastic bicuspid aortic valve with doming of the valve leaflets. The flow across the valve was measured on continuous wave doppler at 4 m/s. He was also found to have a discrete juxta ductal coarctation of the aorta with continuous doppler flow of 2.5 m/s with diastolic tail. His ventricular function remained preserved. He was started on intravenous prostaglandin and urgent surgery was scheduled.
+Due to the complexity of the case and the need for both aortic valve and aortic arch intervention, it was felt the best course of action would be a hybrid approach with surgical end-to-end anastomosis of the aortic arch via a thoracotomy followed by surgical carotid cut down for AoVP. This plan was made to avoid the need for a sternotomy on bypass to alleviate the aortic valve stenosis. The patient was taken to the hybrid catheter laboratory theater, where he was placed in the left lateral position, prepped and draped. He underwent the surgical end-to-end anastomosis via the thoracotomy via the third intercostal space, as planned. The arch, patent ductus arteriosus (PDA) and descending aorta were then dissected out. Clamps were applied to the arch and descending aorta. The coarctation segment was resected and PDA ligated. After this, an end to side anastomosis was performed between the aortic arch and the descending aorta. The pleura and chest were closed in layers.
+At this point the patient was assessed and felt to be stable to proceed with the planned aortic balloon. The patient was turned from the lateral position to his back and the surgeon performed a carotid cutdown on the right common carotid artery. A 5/0 purse string suture was applied to the vessel, and through that a 4-Fr sheath was inserted in the right common carotid artery. Using a 4-Fr pigtail catheter, ascending aortic pressure was measured at 61/42 mmHg. An aortic angiogram was then performed and the aortic valve annulus measured 7.5 mm. The pigtail catheter was then replaced with a 4-Fr Judkins Right Coronary Catheter (JR). Using a Terumo 0.035″ guide wire the JR catheter was placed into the left ventricle (LV). The pressure in the LV was recorded at 110/13 mmHg, giving a peak to peak gradient of 49 mmHg. A 0.014 ChoICE PT extra support coronary wire (Boston Scientific) was then placed in the LV and the JR catheter removed. Next a NuMED Tyshak II 6 mm × 2 cm percutaneous transluminal valvuloplasty balloon catheter was chosen and delivered over the ChoICE wire to the aortic valve. The balloon was inflated to burst pressure of 4 atmospheres (atm) with waist seen within the balloon and dewaisting occurred. The balloon catheter was removed and the JR catheter re-introduced. The pressure was measured at 100/10 mmHg. Repeat angiogram at the aortic root at this stage did not demonstrate any significant aortic incompetence. The JR catheter and the Terumo wire were again used to recross the valve, and a 7 mm × 2 cm NuMED Tyshak II percutaneous transluminal valvuloplasty balloon catheter was chosen and delivered over the coronary guidewire in position. The balloon was inflated to 4 atm, a waist was again seen and dewaisting occurred. The balloon catheter was removed, and the JR catheter placed back into the LV. Pressure within the LV was now 90/10 mmHg with pullback peak to peak gradient between the LV and ascending aorta measuring 30 mmHg. The catheter and sheath were removed, the vessel was repaired by tightening the pursestring suture and the skin closed in layers.
+An echocardiogram performed post procedure showed qualitatively normal ventricular function with no pericardial effusion. The arch was unobstructed with doppler flow velocity of 1.6 m/s. The aortic valve was bicuspid and obviously dysplastic. There was mild flow acceleration across the valve using continuous wave doppler of 3 m/s with mean doppler gradient of 15 mmHg. There was no obvious aortic incompetency seen.
+The patient was transferred from the hybrid catheter laboratory to the pediatric intensive care unit (PICU). He remained cardiovascularly stable during his PICU admission. He was extubated but had to be reintubated within a few hours due to upper airway issues which prolonged his PICU stay. He was successfully extubated on day 3 post procedure and was transferred to the cardiac ward. His admission on the ward was uncomplicated and he was discharged on day 6 post intervention.
+At 4 months of age, he was reviewed in the outpatient clinic. He was clinically asymptomatic with steady growth. His echocardiogram demonstrated qualitatively normal ventricular function, the aortic valve stenosis was mild to moderate with flow of 3.7 m/s on continuous wave doppler with mean gradient of 30 mmHg. There was evidence of mild aortic incompetence, his aortic arch remained unobstructed with flow velocity of 1.4 m/s. His most recent follow-up was at 8 months of age. He remained asymptomatic and well with his weight increasing to 9 kg. His echocardiogram again demonstrated qualitatively normal ventricular function, bicuspid aortic valve with flow of 3.2 m/s across the valve. There was mild aortic incompetence and the aortic arch remained unobstructed. There were no issues with his carotid artery access and there were no ongoing neurological issues.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2732_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2732_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3e2990232328bcd274b9cbd9f4f86d17e96024c2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2732_en.txt
@@ -0,0 +1 @@
+An 85 year old left hand dominant female presented with a six week history of rapidly growing lump on the thenar eminence. Clinical examination revealed a non-tender large lobulated mobile swelling measuring 5 × 4 cm and involving the whole thenar eminence. A sarcoma was initially suspected. Plain X-ray revealed severe osteopenia with erosive changes in the first Carpometacarpal joint, and a soft tissue swelling around an osteophyte detached from the base of the first metacarpal. MRI reported a septate thin walled cystic structure extending from the first carpo-metacarpal joint space against a background of diffuse active synovitis . In operating theater, a multilobulated lesion with a neck extending to the first CMC joint was observed. The histological analysis revealed a 3.4 g previously opened specimen consistent with a ganglion cyst. The patient made an excellent post-operative recovery with no evidence of recurrence.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2738_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2738_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..51f46abbb889c9c740b6339d72a23cd88e2c9764
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2738_en.txt
@@ -0,0 +1,7 @@
+A 71-year-old woman was referred to our clinic with a complaint of bilateral blurred vision that persisted for the past 3 years.
+The patient had no other positive symptoms apart from blurred vision.
+The patient had no history of ocular diseases, allergy, trauma, surgery, or systemic diseases. She did not use any eye drops or take any medication.
+The patient was married and had two sons. There was no family history of ocular disease.
+At initial examination, her visual acuity was 20/400 in the right eye and 20/60 in the left eye, with no improvement by correction. Intraocular pressures were 10 and 12 mmHg in the right and left eyes, respectively. Slit-lamp microscopy revealed a rough endothelial surface and a translucent antler-shaped scroll that extended to the anterior chamber, with the terminal end attached to the posterior surface of the cornea by a stalk in the right eye . Two similar translucent rod-like scrolls were also detected on the corneal endothelium of the left eye . In both eyes, the crystalline lens demonstrated opacification, and the anterior chamber was deep and clear, with no abnormality observed in the posterior segment. Ultrasonic biological microscopy demonstrated the free end of the scroll in the anterior chamber of the right eye and rough endothelium of the cornea in the left eye , with increased reflectivity of the posterior corneal surface in both eyes. The corneal endothelial densities of the right and left eyes were 1059 and 1800 cells/mm2, respectively. In vivo confocal microscopy revealed activated keratocytes and alteration in the extracellular tissue of the stroma, manifesting as thin bright lines . Tubular structures could be found in the posterior stroma . A highly reflective acellular structure could be observed at the level of the Descemet’s membrane . Strip guttae and flake high-reflective fused guttae were detected on the endothelium of the left eye. Extensive coalescence of the corneal guttae, which had an appearance similar to a paving-stone, was observed on the right eye and was associated with endothelial pleomorphism and polymegathism.
+Among the infection indicators, the patient was positive for syphilis-specific antibodies, type I herpes simplex virus IgG antibodies, and hepatitis B IgG antibodies. She was negative for all remaining indicators, including rubella, toxoplasma, herpes Epstein-Barr virus, human immunodeficiency virus, and other hepatitis viruses. There was no presence of autoimmune antibodies, vasculitis-related antibodies, or HLA-B27CD3. The results of the cytometric bead array were negative for inflammatory cytokines, including interleukin (IL)-2, IL-4, IL-6, IL-10, tumor necrosis factor-α, and interferon-γ in the aqueous humor.
+Light microscopy demonstrated that the removed scroll comprised regularly arranged acellular structures, similar to an antler . Hematoxylin–eosin staining revealed that the scroll was composed of eosinophilic acellular tissue . Scanning electron microscopy showed that the scroll consisted of circularly arranged fibrous tissue .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_274_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_274_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..822ab085755c1c01d3888208bd2f46b41b1168f2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_274_en.txt
@@ -0,0 +1,10 @@
+A 58-year-old male with a known co-morbid of hypertension and type 2 diabetes mellitus (compliant with medications) presented to the emergency room on September 25, 2021, with complaints of worsening shortness of breath, dry cough, and intermittent fever for the past 10 days. On general physical examination, his respiratory rate was 50 breaths per minute, along with the use of accessory muscles. He had 90% oxygen saturation on high-low oxygen. With worsening respiratory symptoms, he was shifted to the Critical Care Unit (CCU).
+On admission, baseline laboratory investigations were carried out . He had low hemoglobin levels, low leucocyte count, and significantly high C-reactive protein (CRP) and Creatinine (Cr) levels. He was further tested positive for SARS-CoV-2 by polymerase chain reaction (PCR), despite being fully vaccinated for COVID-19.
+On detailed investigation, a High-resolution Computer Tomography (HRCT) scan of the chest was done and revealed patchy bilateral areas of ground-glass opacity along with lobular septal thickening. In addition, there were bilateral extensive fibrotic patches in sub-pleural and central locations, together with pleural thickening. The above findings represent pulmonary fibrosis with interstitial lung disease due to sequelae of COVID-19 pneumonia.
+The patient was intubated during the CCU hospitalization due to worsening hypoxemic respiratory failure that was refractory to noninvasive positive pressure ventilation. He was given an entire course of remdesivir and dexamethasone during the intubation period. On the 15th day of hospitalization, he was extubated and was shifted out of the CCU.
+On the 20th day of hospitalization (30 days after onset of COVID-19 symptoms), the patient developed bilateral lower limb weakness. Given the concern for the neurological nature of the complaint was evaluated by an on-call neurologist. His physical exam revealed intact cranial nerves and sensations but a power of 3/5 in lower limbs bilaterally along with absent lower limb reflexes and mute plantar reflex. To rule out etiologies of polyneuropathy, a magnetic resonance imaging (MRI) scan of the cervical was done which showed to be insignificant.
+On further investigation, neuroelectrophysiology was done whose report showed decreased compound muscle action potential (CMAP) amplitude and sensory nerve action potential (SNAP) amplitude in the left median and ulnar nerves. Moreover, electromyography (EMG) showed few motor unit action potential (MUAP) along with fibrillation in the left first dorsal interosseous and left tibialis anterior muscles. In conclusion, the reports suggested acute motor-sensory axonal polyneuropathy (AMSAN).
+Moreover, a detailed cerebrospinal fluid (CSF) analysis was carried out which revealed to have isolated elevated protein levels (71 mg/dL), while the rest of the components were in the normal range such as pH, specific gravity, glucose. No white blood cells or red blood cells were noted. Culture and sensitivity, and gram staining were both negative. Increased protein levels is a hallmark of GBS.
+Based on clinical findings, neurophysiological studies, CSF analysis, and MRI of the cervical, the patient was diagnosed with GBS associated with COVID-19.
+Initially, the patient was given oral glucocorticoid (prednisolone) for 5 days and was tapered off when symptoms began to improve. He further received intravenous immunoglobulins (IVIG) for 6 days continuously. His vitals were stable throughout the rest of the hospital stay, and he had no signs of distress. After receiving this treatment, the patient's symptoms significantly improved, and he was discharged on October 21, 2021, to home with regular physiotherapy advised by the on-call doctor.
+The present paper has been reported in accordance with the CARE guidelines .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2770_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2770_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fd1e8cd3d95a9491d0e13c2017aced7479ded309
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2770_en.txt
@@ -0,0 +1,18 @@
+A 22-year-old female presented to the University Hospital of the West Indies, Jamaica for further investigation and management following transfer from a local Government hospital where she presented with a 5-day history of diarrhoea and fever. The diarrhoea commenced 5 days after starting clindamycin therapy for a recent tooth extraction due to a dental abscess. Despite discontinuation of clindamycin therapy and the introduction of chloramphenicol and metronidazole empiric therapy, the diarrhoea and fever continued.
+Physical examination of the patient revealed a febrile female in severe cardiopulmonary distress with tachycardia, HR beats/150 min, and blood pressure 150/100 mm/Hg. Laboratory investigations showed haemoglobin of 10.4 gm/dl, white cell count of 2.1 × 109/litre, and platelet count of 182 × 109/litre. Diarrhoea persisted and progressed to toxic megacolon and bowel perforation. Blood cultures (brain heart infusion and thioglycollate broths) collected on admission grew K. pneumoniae from all four bottles after 24 hours incubation at 37°C. Diarrhoeal stool specimen sent the day after admission was positive for C. difficile toxin A/B (ELISA; Alexon Inc. 1190 Borregas Ave., Sunnyvale, CA. 94089–1302) and the corresponding organism isolated on selective culture medium, cycloserine, cefoxitin, fructose agar (CCFA).
+In the interim period of empiric therapy, susceptibility testing on K. pneumoniae by the Kirby Bauer disc diffusion method showed susceptibilities to ceftriaxone, co-trimoxazole, ceporin, amikacin, gentamicin, ceftazidine, and augmentin, as well as resistance to chloramphenical, piperacillin and ampicillin. The patient continued therapy on intravenous metronidazole and with the introduction of ceftriaxone and gentamycin she became afebrile with subsequent blood cultures becoming sterile. Hypotension, pulmonary oedema, leucopenia, and thrombocytopenia persisted despite appropriate therapy and intensive care management. The patient died 10 days after hospital admission and an autopsy was performed. The most significant finding of the autopsy was multiple discrete plaques of yellowish exudate on the mucosal surface of the entire large bowel typical of pseudomembranous colitis (PMC), which was florid. Another noteworthy pathologic finding was that of markedly overweight lungs with features in keeping with adult respiratory distress syndrome.
+Polymerase chain reaction (PCR) was used to confirm the presence of C. difficile triphosphate isomerase (tpi), toxin genes tcdA and tcdB, the lack of binary toxin cdtB gene, and no deletion in tcdC gene
+. PCR ribotyping on the isolate revealed a ribotype of 087 and the pulsed-field gel electrophoresis (PFGE) macrorestriction pattern identified a fingerprint type 0515, not previously seen using this method, and when compared to a national collection of over 700 unique fingerprint types from more than 7,100 CDI isolates (Figure ). However, the fingerprint pattern was closely related to the North American Pulsotype (NAP) NAP12 strain with only a one band difference (Figure ). The minimal inhibitory concentrations (MIC) determined by Etest were as follows: susceptible to metronidazole 0.094 ug/ml; vancomycin 1 ug/ml; moxifloxacin 1 ug/ml; rifampicin < 0.002 ug/ml; tigecycline 0. 125 ug/ml; and resistant to clindamycin 256 ug/ml. K. pneumoniae was isolated from 2 sets of blood cultures following overnight incubation at 37°C.
+The severe clinical outcomes seen in the present case were not unusual though more commonly seen in HA-CDI
+. In addition to these clinical presentations, associated hypotension and admission to the intensive care unit classified this patient as a severe complicated case of CDI
+. In a large study covering the period 1991–2005 in Olmsted County, Minnesota, it was interesting to note that only 4% of CA-CDI had progressed to severe complicated CDI
+. It was further noted that such cases are usually associated with a significantly older age group with a median age of 80 years
+. The manifested clinical involvements along with a significant age difference are important features to consider in CA-CDI and should serve to alert clinicians that there is always a potential risk of young adults progressing to severe complicated CDI. The source of K. pneumoniae sepsis in the patient was presumably the gastrointestinal tract, as there were no symptoms or signs to suggest other systems involvement. Notwithstanding treatment with metronidazole, the patient was unresponsive and progressed to toxic megacolon and bowel perforation. These were probably due to the failure to administer appropriate and adequate clinical and surgical interventions.
+Oral metronidazole remained the preferred first line drug for treatment while vancomycin is reserved for severely ill patients and recurrence of C. difficile colitis
+. Interestingly, these interventions including the use of adjunctive intracolonic vancomycin therapy and total colectomy, as recommended options, were not followed in the management of the present case. It is important to note that PMC was confirmed by autopsy. The failure to apply the optimal required clinical and surgical interventions during the patient’s hospitalisation were probably due to the rapid progression of these clinical outcomes.
+With the exception of toxins A and B produced by this isolate, there was no deletion observed in the negative regulator tcdC gene suggesting normal toxin expression. However, ATCC 43255, which also has a wild type tcdC, has shown increased toxin expression
+. Importantly, ATCC 43255 has the same ribotype (087) as the clinical isolate and only a single band difference in the DNA fingerprints was observed between the two isolates (Figure ). Based on the similarity of ribotypes and fingerprint patterns between the two isolates, one could speculate that the rapid progression to PMC in the patient may be due to increased toxin expression. Ribotype 087 is the predominant strain in Hungary but is uncommon internationally
+.
+The patient had no history of hospitalisation 12 months prior to infection and no health care-associated risk factors to CDI were noted. On the contrary, this young adult female was actively pursuing a university education, which was disrupted by CA-CDI
+. The progression to toxic megacolon in the patient was not a predicted clinical outcome even after hospitalisation. The presence of a perforated colon was a clear indication for surgical intervention, especially if there were unresponsiveness to other treatments and if clinical improvement was not noted within 2 to 3 days of patient management
+.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2780_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2780_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..46d99ea33859d7d2274c1f056058e342e7615484
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2780_en.txt
@@ -0,0 +1,2 @@
+An 83-year-old male patient who underwent laparoscopic extended right hepatectomy for HCC 3 months previously presented with lung metastasis and suspicion of carcinomatous peritonitis in contrast-enhanced CT. The patient was treated with atezolizumab plus bevacizumab as first-line salvage therapy for metastatic HCC. Although the patient achieved a partial response, the lung metastasis showed progression, and bilateral hilar lymph nodes were newly detected after five cycles of the IO/TKI therapy. Thus, lenvatinib was selected as second-line salvage therapy for metastatic HCC. During the first line of IO/TKI therapy, the patient also developed gross hematuria, and contrast-enhanced abdominal CT revealed a 15 × 15 mm soft tissue mass protruding from the posterior wall of the bladder . Urine cytology yielded negative results. Cystoscopy revealed the presence of a solitary submucosal mass on the posterior wall . Based on these findings, primary bladder cancer was first suspected and surgical resection of the bladder tumor was performed.
+Under spinal anesthesia, the patient underwent TUR-BT. The total surgical time was 26 min, and the patient was discharged from the hospital 4 days after TUR-BT without experiencing any complications. Pathological examination of the TURBT specimens showed solid and sheet-like growth of atypical epithelial cells with enlarged nuclei and prominent nucleoli in the subepithelial connective tissue and muscularis propria, similar to the histological features of HCC . Immunohistochemical staining for GATA-binding protein 3, which is typically positive in urothelial carcinoma, was negative, whereas staining for hepatocyte paraffin 1, an HCC marker, was positive . These pathological findings were consistent with a diagnosis of primary HCC with bladder metastasis . Surgical margin was negative. Four weeks after the surgery, lenvatinib was resumed. During the 2-month follow-up after the surgery, no clinical progression of lung metastasis and bilateral hilar lymph nodes was observed.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2781_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2781_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b826c7e2dad3b1767bacb77ef0633bdf0fcf824e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2781_en.txt
@@ -0,0 +1,9 @@
+A 22-year-old patient who was 35 weeks pregnant was evaluated in the emergency department with a complaint of right-sided weakness. The COVID-19 polymerase chain reaction test was performed and was found to be positive. However, she did not have fever or respiratory distress and then was followed up at home without medication.
+The patient started to have throbbing headaches that did not respond to analgesic treatment (paracetamol 1000 mg/day) for four days. The intensity of her headaches gradually increased, such that she was being awakened from sleep, and this condition was accompanied by nausea and vomiting.
+After this four-day period, she again felt weakness on her right side when she woke up in the morning. Twelve hours later, she went back to the emergency department because her weakness was increasing. At the emergency department, the patient was found to be normotensive, conscious, cooperative and oriented in a neurological examination. No fundus examination was performed, given that she was COVID-positive. Examinations on the patient’s visual field and vision showed normal results. Other cranial nerve examinations were normal. Her muscle strength ratio was 3/5 in the upper right extremity, 2/5 in the lower right extremity and 5/5 in the upper and lower left extremities. The foot sole skin reflex of the right lower extremity consisted of an extensor response. She presented decreased speech fluency and had difficulty in word finding, which were diagnosed as mild motor aphasia. Laboratory tests revealed high levels of fibrinogen (899 g/l; normal is 180-400) and D-dimer (6.38 mg/l; normal is 0-2). It was noted that the patient had also had high levels of fibrinogen (665 g/l) and D-dimer (2.2 mg/l) in examinations performed 10 days previously.
+Diffusion magnetic resonance imaging (MRI) showed cortical diffusion restriction in the left parietal region and a hypointense response in the apparent diffusion coefficient (ADC) . The result from the diffusion MRI was suggestive of venous sinus thrombosis. Widespread loss of flow in the superior sagittal sinus and right transverse sinus, suggesting partial venous thrombosis in the left transverse sinus, was observed in brain magnetic resonance imaging and magnetic resonance venous angiography . The brain MRI and magnetic resonance venography confirmed the diagnosis of venous sinus thrombosis. Thrombosis was not investigated in other parts of the body.
+The polymerase chain reaction was repeated and the result was again positive. The patient was then hospitalized with the diagnoses of COVID-19 infection and venous sinus thrombosis. Other genetic, hematological and rheumatological examinations were planned, in order to investigate the etiology of her condition. Anticoagulant treatment (low molecular weight heparin) was started after the patient had been found to present a low platelet count (107,000/mm3), through evaluation of a peripheral blood smear.
+Diffuse contractions were observed in a non-stress test (NST), and tocolysis was started, consisting of nifedipine and betamethasone treatment. However, the patient’s labor could not be stopped after 18 hours of hospitalization. She was then admitted for an emergency cesarean section because the intracranial pressure was increasing. A healthy baby was delivered.
+Subsequently, the patient’s postpartum headache complaints decreased and her speech became fluent without any change in muscle strength deficit. Her thrombocyte counts decreased to 67,000/mm3. Anticoagulant therapy was continued, with peripheral smear follow-ups. Thoracic computed tomography was performed on the patient, who did not present respiratory distress, and the findings were compatible with COVID-19 pneumonia after birth . There was an increase in infection parameters, and the patient was started on hydroxychloroquine and ceftriaxone treatment.
+In the examinations performed to ascertain risk factors, the patient was found to be positive for antinuclear antibodies (ANA) and showed prothrombin heterozygous mutation. The patient was negative for anti-cardiolipin antibodies and anti-double stranded DNA (dsDNA), and tests on lupus anticoagulant, homocysteine, protein C, protein S and antithrombin 3 showed results within normal limits.
+On the third day following the birth, the patient’s headache complaint became completely resolved, her thrombocyte counts stopped decreasing and her thrombocytopenia improved over the subsequent days. The infection parameters regressed. Partial regression of the lesions was observed on control thoracic computed tomography. The patient’s general condition stabilized and she was discharged on the 10th day of hospitalization, with muscle strength 4-5/5 on the right side, which was mobilized without support. Continuation of low molecular weight heparin (LMWH) treatment was planned, along with neurological and hematological control tests at a polyclinic.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2804_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2804_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7fe1e7c0591981a35ffa314135b3d76363f86e76
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2804_en.txt
@@ -0,0 +1,2 @@
+A 38-year old white female with type 1 diabetes mellitus complicated by retinopathy, gastroparesis and end-stage renal disease (ESRD) underwent deceased donor SPK transplantation in November of 2007. Cytomegalovirus (CMV) serology was negative in both donor and recipient. Patient was not sensitized and received perioperative induction therapy with rabbit-antithymocyte globulin followed by maintenance immunosuppression with tacrolimus (dose adjusted for targeted trough level of 8-10 ng/mL during first year, 6-8 ng/mL during second year and 4-7 ng/mL subsequently) and mycophenolate mofetil (500 mg twice daily) with early steroid withdrawal. Trimethoprim/sulfamethoxazole (400/80 mg) once daily was used for prophylaxis against Pneumocystis jiroveci infection. Allografts started functioning soon after transplantation without delayed graft function. Serum creatinine stabilized at 1.3 mg/dL and patient remained euglycemic. Six years later, serum creatinine increased to 1.8 mg/d with a blood urea nitrogen level of 20 mg/dL. Urinalysis showed evidence for proteinuria and microhematuria. Other pertinent laboratory values were as follows: WBC 3.29 µ/mL, hemoglobin 10.7 g/dL, platelets 209 µ/mL, serum albumin 3.7 g/dL, serum total cholesterol 167 mg/dL, fasting blood glucose 102 mg/dL, and trough tacrolimus level 5.4 ng/mL, along with negative CMV, BK virus and Epstein-Barr virus PCR. She had proteinuria of 5 g/d. Patient underwent extensive work-up. Serum ANA, anti-double-stranded DNA, cryoglobulins, rheumatoid factor, anti-streptolysin O, proteinase-3 and myeloperoxidase ANCA, as well as hepatitis B and C antibodies were negative. Levels of serum complements and immunoglobulins were normal and no monoclonal bands were observed on serum and urine immunofixation electrophoresis. Serum free light chain assay revealed elevated free kappa (33.8 mg/dL, normal range 3.3-19.4) and normal lambda (25.1 mg/dL, normal range 5.7-26.3) fractions. Patient subsequently underwent kidney allograft biopsy. Light microscopy showed increased mesangial matrix and hypercellularity. Immunofluorescence revealed mesangial 2+ staining for IgG with specificity for IgG3 subclass, C3, C1q, IgM and 1+ staining for kappa light chains with negative staining for lambda light chain, IgA and subclasses of IgG1, IgG2 and IgG4 as well as peritubular capillary C4d. On electron microscopy, abundant mesangial granular electron dense deposits without substructures were seen. These findings were consistent with a diagnosis of PGMNID .
+We opted for conservative treatment in our patient. She was initiated on lisinopril which she tolerated well. She remained normotensive. Her serum creatinine remains at 1.8 mg/dL with <100 mg/d proteinuria 14 months later.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2822_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2822_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d0c012f5c31e7ea215babbaeab93eeb706c669f9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2822_en.txt
@@ -0,0 +1,7 @@
+An 84-year-old Chinese woman was admitted with gradual abdominal distension.
+The patient’s symptoms started 1 year ago. And she had poor appetite and a weight loss of 5 kg within the past 2 wk. She denied any symptoms associated with abdominal pain, fever and chills, nausea and vomiting, etc.
+There was no prior history of trauma, hepatitis, allergy, or alcohol or tobacco usage.
+No special.
+Physical examination showed that she was in medium nutritional status with an icteric appearance. Vital signs were within normal ranges. The abdomen was asymmetrically enlarged, more in the right upper quadrant, without tenderness. Bowel movements occurred about 3-4 times per minute.
+Laboratory examination showed significantly increased serum levels of PIVKA-II (> 30000 mAU/mL; reference: < 32 mAU/mL), CA12-5 (428 U/mL; reference: < 35 U/mL), and CA19-9 (51.67 U/mL; reference: < 39 U/mL). Serum aspartate aminotransferase (AST) (97.03 IU/L; reference: < 40 IU/L), alanine aminotransferase (ALT) (64.73 IU/L; reference: < 40 IU/L), total bilirubin (TBIL) (61.19 µmol/L; reference: < 21 µmol/L), and direct bilirubin (DBIL) (36.42 µmol/L; reference: < 3.4 µmol/L) levels were moderately increased. Serum prothrombin time (PT) (33.3 s; reference: 11.0-15.0 s) and activated partial thromboplastin time (aPTT) (54.0 s; reference: 28.0-43.5 s) levels were also elevated slightly. However, serum albumin (ALB) (23.88 g/L; reference: > 35 g/L), prealbumin (PLAB) (17.3 mg/L; reference: 180-390 mg/L), and choline esterase (CHE) levels (1750 IU/L; reference: 3000-13000 IU/L) were significantly low.
+Following an initial abdominal ultrasound examination, an enhanced computed tomography (CT) scan was performed, which revealed multiple round cysts in the liver with clear boundaries. The largest cyst was located in the right lobe of the liver, with mild dilatation of the intrahepatic bile duct, and a size of approximately 20.1 cm × 12.2 cm × 19.6 cm. There was no contrast enhancement in either the arterial or venous phase .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2826_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2826_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..54cb51985361d78a9c47e5df6238c7d17754f221
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2826_en.txt
@@ -0,0 +1,3 @@
+During the COVID-19 pandemic, in April 2020, a 55-year-old Caucasian man presented to the emergency department of our institution with fever up to 38.6 °C, cough and shortness of breath. He had a history of ischemic heart disease, diabetes, arterial hypertension, severe obesity, asthma, and he was a smoker. Because of respiratory failure, oxygen therapy was promptly administered via a Venturi mask at 35%. Bilateral crackles were present during chest auscultation; there were no other relevant findings on physical examination. Blood chemistry revealed a high white cell count and high levels of both C-reactive protein (CRP) and D-dimer (the latter being 1652 mcg/l; normal: 0–550 mcg/l). Due to the ongoing pandemic and based on his symptoms, the patient was initially managed as a suspected case of COVID-19, even though two consecutive nasopharyngeal swabs were negative for SARS-CoV-2. High resolution computed tomography (HRCT) of the chest, before and after intravenous injection of iodinated contrast medium, was obtained. The exam showed multiple small hazy nodular opacities diffusely distributed throughout both lung fields, with no specific lobar preference . The nodules were centrilobular, with a linear branching pattern and a “tree-in-bud” appearance, mainly visible in the lower left lung field . CT also showed slightly enlarged mediastinal lymph nodes, without sign of necrosis, of a suspected reactive/inflammatory nature. The HRCT findings were not considered indicative of COVID-19 pneumonia.
+A possible diagnosis of miliary tuberculosis or other diffuse infectious/inflammatory disease was made and the patient was transferred to our respiratory unit for further investigations. Past medical history revealed no hemoptysis, chest pain or weight loss. The patient reported that during the pandemic he had decided to live in the damp basement of his house, to be isolated from his family, and that he used to work there for several hours a day. This occurred six weeks before the onset of symptoms and it has been the only major change in his daily life.
+Sputum was negative for acid-fast bacilli in three specimens, and both Mantoux and QuantiFERON tests were negative, such that a diagnosis of tuberculosis was excluded. Pneumonia due to Legionella sp., Mycoplasma sp. or Chlamydia sp. infection was excluded as were HIV infection and autoimmune disease. Another possible diagnosis was secondary neoplasm of the lung, but a whole-body CT scan did not reveal any malignancy. An antibiotic therapy course was empirically started with ceftriaxone 2 g a day and azithromycin 500 mg once a day for seven days. Three weeks after the hospital admission, the patient repeated a non-enhanced chest CT scan that showed persistence of the pattern described above. Antinuclear and antineutrophilic cytoplasmic antibody tests were negative. The patient’s clinical condition slightly improved: he did not present with fever, and oxygen therapy via Venturi mask was promptly reduced to 24%. Blood chemistry showed a normal white cell count and reduced CRP . The patient underwent bronchoscopy and the bronchial lavage fluid (BLF) revealed a galactomannan level of 3.7 (upper normal limit: 0.5). Total serum immunoglobulin E (IgE) levels were raised (1016 IU ml−1; normal: < 100 IU ml−1), although IgE specific for A. fumigatus was negative, while IgG specific for A. fumigatus was also high . Spirometry showed an obstructive ventilatory pattern, reversible after salbutamol administration, confirming a diagnosis of asthma. Forced vital capacity (FVC) was 3.22 l (70% of predicted) and a forced expiratory volume in 1 s (FEV1) was 2.23 l (61% of predicted) and 3.00 l (+ 34.4%) after bronchodilatation. BLF culture was positive for Pseudomonas aeruginosa rugosa and Achromobacter xylosoxidans. Finally, the following criteria for diagnosis of ABPA were satisfied: (1) predisposing condition as bronchial asthma; (2) elevated total IgE levels (> 1000 IU ml−1); (3) serum IgG antibodies against A. fumigatus; (4) radiographic pulmonary opacities consistent with ABPA. Immediate cutaneous hypersensitivity to Aspergillus antigen was not performed because the patient was on systemic antihistamines. The patient was started on prednisolone (0.5 mg/kg/day) for four weeks. To reduce the antigen burden, oral isavuconazole therapy was also started with a loading dose of 200 mg tid for the first three days and then 200 mg once a day for eight weeks. He was discharged two months after the hospital admission with improved clinical conditions, without oxygen therapy and with reduced total serum IgE levels of 306 IU ml−1. The patient continued steroids, which were gradually tapered down every two weeks. Three months after hospital admission, the patient was seen in our outpatient clinic and he referred only to mild dyspnea during physical exercise. HRCT of the chest showed significant reduction of the multiple nodular opacities and a lung pattern that had almost returned to normal appearance. Total IgE levels were 335 IUml−1. Prednisolone was also tapered, and it is still ongoing at the time of this case presentation at 10 mg daily.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2836_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2836_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..46231988adc205fd5d3d39614ecedea21e25d0fe
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2836_en.txt
@@ -0,0 +1,2 @@
+The patient’s father provided written consent to the use the patient’s medical information for research and publication.
+A 1-year-old girl (weight 10 kg) had suffered from a cough with sputum production for more than 2 days. She had a medical history of having swallowed a TFB 2 days earlier. The physical examination was normal, except for a wheezing sound in the right lung. A chest computed tomography scan revealed an 8 × 4 × 21 mm3 mass in the trachea near the carina, which given the patient’s history, was suggestive of the diagnosis of a TFB aspiration. After careful preoperative preparation, we scheduled the patient to undergo an emergency rigid tracheobronchoscopy to remove the TFB under general anesthesia. In order to keep the patient in spontaneous breathing, the combination of intravenous and inhalant anesthesia with propofol, fentanyl, and sevoflurane was planned to be administered. In the operating room, standard monitoring was installed, including SpO2, noninvasive blood pressure, and an electrocardiogram. Before administration of anesthesia, the child was premedicated with atropine (0.1 mg) and dexamethasone (2 mg)intravenously. Then anesthesia induction was performed with 8% sevoflurane carried by 6 L/min oxygen flow. After the patient became unconscious, anesthesia was maintained with 3–5% sevoflurane and 1 L/min oxygen flow for more than 5 min. Before rigid tracheobronchoscopy introduced into the trachea, the child received propofol (20 mg) and fentanyl (10 μg) intravenously to deepen the anesthesia. After 1–2 min, when her lower jaw was flabby, the surgeon introduced a LTA applicator into the trachea under the guidance of rigid tracheobronchoscopy, and then sprayed topical 1% lidocaine on the surfaces of the vocal cords and trachea. After the surgeon applied the topical anesthetic to the trachea, the girl suddenly suffered from bucking, which made it difficult to withdraw the LTA applicator. The surgeon quickly examined the opening of the main trachea using rigid tracheobronchoscopy, and found the TFB had migrated to the subglottic region against the LTA applicator. In this situation, manual ventilation became impossible and within half a minute, the patient’s SpO2 decreased to 91% and her heart rate dropped from 150 to 100 bpm. We administered an intravenous injection of atropine (0.3 mg) and succinylcholine (10 mg). Meanwhile, the surgeon tried to free the TFB by pushing it back into the trachea, after which the LTA kit was easily withdrawn. We then mask-ventilated the lungs successfully. The patient’s SpO2 quickly increased to 97% and her heart rate rose to 140 bpm. After deepening the anesthesia with propofol (20 mg) intravenously, the surgeon successfully grabbed and removed the TFB under jet ventilation . Afterwards, the girl’s condition improved quickly and she recovered uneventfully. She was discharged from the hospital 2 days later without complications.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_284_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_284_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3207a8c591362fdb935cbe049208a934850ca97e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_284_en.txt
@@ -0,0 +1,9 @@
+A 60-year-old Japanese man with a 9-year history of T2DM presented at the emergency department of Kariya Toyota General Hospital with anuria and severe general fatigue. On admission, the patient was transported by ambulance due to his difficulty in moving. On evaluation, the patient reported fatigue, malaise, weight loss, and intermittent nausea and vomiting. He reported no headaches, joint, or muscle pain. He denied having a fever or contact with another sick individual.
+Apart from T2DM, his past medical history included hypertension and lumbar disc herniation. He had no history of psychiatric disease and no known drug allergies. He had no family history of diabetes mellitus, lived alone, and his educational status was not obtained. The patient had smoked 1 pack of cigarettes per day for 45 years and consumed approximately 540 mL of Japanese sake daily. His medications included Met (500 mg three times daily), sitagliptin (50 mg once daily), pioglitazone (15 mg once daily), dapagliflozin (5 mg once daily), amlodipine (5 mg once daily), azilsartan/amlodipine (20 mg/5 mg once daily), rosuvastatin (2.5 mg once daily), and a hydrogel patch containing loxoprofen sodium.
+Renal function was normal before admission and the Met dosage used to treat T2DM was suitable for this patient. No abnormality was found in the patient’s blood tests (data not shown) when he had visited his doctor 13 days before admission. Notably, 12 days before admission, his work had changed from office to physical work (approximately 30,000–40,000 steps per day). He had noted a gradual decrease in urinary output for several days before admission, but had no other symptoms. Two days before admission, he developed anuria, dizziness, and nausea.
+The initial laboratory findings are shown in Table . The time-course changes in serum creatinine and blood urea nitrogen (BUN) levels after admission are shown in Fig. . The lactate concentration of the patient was 4.27 mmol/L and the arterial pH was 7.31. Considering the previously established definition for lactic acidosis (lactate > 5 mmol/L and pH < 7.35) , the patient did not meet these criteria. However, a recently updated definition of lactic acidosis revealed that this patient taking Met fulfilled the criteria for the diagnosis of lactic acidosis because the lactate concentration was > 4 mmol/L .
+The physical examination at admission indicated the following: height of 172.3 cm, weight of 69.3 kg, blood pressure of 159/94 mmHg, regular pulse of 96 beats per minute, body temperature of 36.3 °C, and oxygen saturation of 99% breathing ambient air. There was no sign of hypoglycemia since blood glucose was 129 mg/dL . This case is considered to be different from either diabetic ketoacidosis or euglycemic diabetic ketoacidosis. Despite the presence of normal glucose levels, he was not in the insulin-dependent state characteristic of euglycemic diabetic ketoacidosis and did not present with the physical symptoms of ketosis (tachypnea, nausea, vomiting, abdominal pain, and impaired consciousness). The patient was alert and appeared well. Cardiac auscultation revealed a regular rhythm without murmurs or gallops and an audible S1 and S2. Respiratory sounds were clear to auscultation with no crackles, wheezes, or bronchial breath sounds. The abdomen was non-distended, soft, and non-tender. His legs had no edema or muscle weakness, and the remainder of the examination was unremarkable.
+A radiograph of the chest was normal. Computed tomography (CT) showed slight cortical atrophy in the bilateral kidneys; however, no kidney stone or hydronephrosis was observed. There was irregular thickening of the small bowel wall without adjacent fat stranding and no sign of inferior vena cava collapse.
+Bilateral hydronephrosis and nephrolithiasis were excluded based on the CT scan data. Glomerulonephritis was also excluded based on the negative autoantibody findings. The ratio of urea nitrogen to creatinine was < 20, suggesting a possible cause for the intrinsic renal injury. There was no hematuria because the presence of red cells in the urine was due the trauma induced by urinary bladder catheterization on admission. Considering the low estimated glomerular filtration rate (eGFR) and high urinary protein/creatinine ratio (11.04 g/g Cre), urinary N-acetyl-β-d-glucosaminidase (420.3 U/g Cre), and β2-microglobulin/creatinine ratio (149 µg/g Cre) , the patient was presumptively diagnosed with acute tubular necrosis with metabolic acidosis (anion-gap 23.5 mmol/L). Renal pathology findings on day 3 after admission revealed that 3 of 23 glomeruli were sclerotic and no significant pathological alterations were observed with light microscopy. However, the proximal tubular cells were diffusely enlarged with vacuolar degeneration. The same pathology may be seen with Fabry’s disease and use of osmotic diuretics, but the patient’s history was negative. All immunofluorescence results were negative and, apart from the vacuolization and swelling of the proximal tubules, no obvious abnormal findings were observed by electron microscopy. Based on the pathological findings and clinical course, the diagnosis of acute tubular necrosis was confirmed.
+After admission, intravenous hydration therapy was started. On the day of presentation at the emergency unit (day 0), he was hospitalized and hemodialysis (HD) was introduced to remove Met and improve acid–base disruption and anuria. In detail, HD was performed with a polysulfone dialyzer [Pinnafine® PN-100 (filter size 1.0 m2, Fresenius Medical Care AG and Co., Hessen, Germany) (at day 0, 1, and 3 with small molecule heparin) or Pinnafine® PN-140 (filter size 1.4 m2, Fresenius Medical Care AG and Co., Hessen, Germany) (at day 5 and 7 with Nafamostat Mesilate)] with blood and dialysate (Kidaly 4E solution, Fuso Pharmaceutical Industries, Ltd., Osaka, Japan) flow rates of 150 and 500 mL/min, respectively, for 3 hours per session. During the HD session, the patient’s condition was stable. The eGFR was calculated from serum creatinine levels on days 0, 3, 5, 7, 10, and 19 were 5.1, 4.5, 10.8, 31.9, 61.2, and 59.9 mL/min/1.73 m2, respectively . The patient resumed urination on day 2. On day 5, anuria was recovered after the third session of HD. Renal function gradually improved, and on day 11, the serum creatinine level reached 1.78 mg/dL. The patient was discharged 13 days after hospitalization, and no major prognostic problems were observed.
+The plasma concentrations of Met were measured using high-performance liquid chromatography (HPLC)–ultraviolet (UV) as per a previous report , with slight modification and in accordance with the validation criteria guidelines of the US Food and Drug Administration . The Met concentrations on days 3, 5, and 7 were 8.95, 2.58, and 0.16 µg/mL, respectively. The semilogarithmic concentration–time plots for Met showed good linearity (R2 = 0.954, Fig. D). The one-compartment model pharmacokinetic (PK) analysis yielded an observed ke (day 3–7) of 0.04 hours−1 and calculated t1/2 (day 3–7) of 16.5 hours. Moreover, the t1/2 (day 3–5) was 26.7 hours, and t1/2 (day 5–7) was 11.9 hours.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2853_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2853_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bf2d5139ac89cb56ccac594472e39636811dbacc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2853_en.txt
@@ -0,0 +1,4 @@
+A 48-year-old man, with a history of depression medicated with mirtazapine 30 mg (once daily) and bupropion 300 mg (once daily), who also recently took various herbal products for weight loss, was transferred to the emergency room from a private clinic due to sudden coma. He had been awaiting a diagnostic colonoscopy after taking a bowel preparation containing sodium picosulfate/magnesium oxide/citric acid when he became aggressive and then entered an altered state of consciousness first with shaking and then with no reactivity.
+In the emergency room as the patient fluctuated between periods of agitation and prostration, orotracheal intubation was performed and he was transferred to an intensive care unit. Blood tests showed severe hyponatremia (110 mmol/l), mild hypokalemia (3.1 mEq/l) and decreased serum osmolality (230 mOsm/kg) .
+The patient did not have a history of seizures or alcohol consumption. The electrocardiogram was normal, and brain CT and MRI showed no signs of bleeding or acute brain injury. The patient’s neurological symptoms were therefore considered to be related to bowel preparation-induced severe acute hyponatremia. He was treated with a slow intravenous infusion of hypertonic saline (3% NaCl).
+The patient was extubated within 48 hours following progressive neurological improvement. Complete neurological recovery and normalization of serum sodium levels were achieved on the seventh day of hospitalization .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2866_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2866_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ea91b72d5c6f7c126f7cf39e213c2bc523ea1b20
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2866_en.txt
@@ -0,0 +1,10 @@
+A 16-year-old male of East Asian descent arrived at night via air ambulance intubated and ventilated to our Heart Attack Centre with a history that during high-intensity interval training at the gym he suffered a cardiac arrest. On site, he received three shocks for ventricular fibrillation with a return of spontaneous circulation (ROSC) after 17 min. An electrocardiogram (ECG) recorded 11 min after ROSC demonstrated marked anterolateral ST-segment elevation. An ECG recorded 116 min post-ROSC on arrival to our centre showed normalization of the ST segments . On examination, he was intubated and ventilated, invasive blood pressure was 105/75 mmHg, and his heart rate was 86 b.p.m. in sinus rhythm. His heart sounds were normal, and there were no murmurs. His chest was clear to auscultation. Bedside echocardiography demonstrated a structurally normal heart with preserved left ventricular (LV) systolic function and no regional wall motion abnormalities. Initial troponin T was 798 ng/L (0–14 ng/L) and peaked at 3073 ng/L 2 h later. His parents gave a past medical history of Kawasaki disease, but that he was not taking any medications.
+In view of the patient's stable clinical status, the lack of persistent ST-segment elevation on the ECG, and normal echocardiogram, we did not perform emergent coronary angiography as we did not suspect an acute coronary artery occlusion. He received a 300 mg loading dose of aspirin, a 180 mg loading dose of ticagrelor and continued on 75 mg aspirin once daily, and ticagrelor 90 mg twice daily with lansoprazole 30 mg once daily. In addition to antiplatelet therapy, he received a single 2.5 mg dose of fondaparinux, bisoprolol 2.5 mg once daily, and atorvastatin 80 mg once daily. He was admitted to the adult cardiac intensive care unit where he remained stable. Coronary angiography was performed the following morning.
+Kawasaki disease was diagnosed at the age of 3 months in his country of origin for which he received intravenous immunoglobulin (IVIG) therapy on day 21 of his illness. He was not treated with acetylsalicylic acid nor was he anticoagulated. Echocardiography 6 days after IVIG treatment showed an aneurysm in the left main coronary artery measuring 5.5 mm. He responded well to treatment and remained under follow-up for mild left main coronary artery dilatation.
+Aged 7 years following routine surveillance echocardiography suggestive of left anterior descending artery (LAD) stenosis, he underwent invasive coronary angiography. This demonstrated a small aneurysm followed by an 80% calcific stenosis of the proximal LAD, and a chronic total occlusion (CTO) of the dominant right coronary artery (RCA). Cardiac magnetic resonance (CMR) imaging showed reversible ischaemia in the inferior, inferolateral, and anterolateral walls.
+In 2012 aged 8 years, he underwent elective intravascular ultrasound-guided rotablation-assisted percutaneous coronary intervention (PCI) to the proximal LAD with a 3.0 mm × 18 mm Multi-Link Vision bare-metal stent (Abbott Vascular, Chicago, USA; ). This corrected the CMR perfusion abnormalities initially, but from 2015 he was lost to follow-up and was not taking any medications.
+Coronary angiography during the current admission demonstrated an unobstructed left main stem; however, the previous LAD stent was occluded with the distal vessel filling retrogradely via septal and well-developed epicardial collaterals from the RCA. The left circumflex artery (LCx) was unobstructed . There was a CTO in the RCA, as before, in the mid vessel . The likeliest explanation for his presentation was the insufficient ability of the collateral circulation to meet the metabolic demand of the heart during exercise, resulting in ischaemia and ventricular fibrillation.
+Computed tomography of the brain demonstrated no acute intracranial abnormality, and his neurological course was unremarkable.
+Following a local Heart Team discussion, he was transferred to a different centre with expertise in both adult and paediatric cardiology and cardiac surgery. He underwent further imaging. Computed tomography established that the internal mammary arteries (IMAs) were free of disease. CMR demonstrated increased indexed LV end-diastolic volume (118 mL/m2) and normal LV wall thickness and normal indexed LV mass with preserved global LV systolic function and no regional wall motion abnormalities at rest. There was a limited infarct in the apical anterior wall and part of the apical septum . There was inducible ischaemia in 5/7 segments of the LAD territory and 4/5 segments of the RCA territory. All segments were viable.
+At the Heart Team meeting, it was felt that either percutaneous or surgical revascularization were suitable strategies. Two days later, the case was discussed with international colleagues and a consensus reached to revascularize him surgically with the opinion being that this would provide him with a more durable result. This was particularly pertinent in his case given the RCA CTO and previously occluded stent. Following detailed discussion with the patient and his parents, he received a left IMA to the LAD and free right IMA to the posterior descending artery. His immediate post-operative course was uncomplicated. He was discharged home 7 days after surgery on aspirin 75 mg once daily, clopidogrel 75 mg once daily, ranitidine 300 mg once daily, bisoprolol 1.25 mg once daily, atorvastatin 80 mg once daily, and paracetamol as required.
+He was last seen in clinic in December 2019. Symptomatically, he was well and had returned to the gym but was refraining from heavy weights given his sternotomy scar. Clinical examination revealed a well-healed wound, no murmurs and a clear chest. All medications were stopped except aspirin and atorvastatin. He underwent repeat CMR in January 2020, which showed no inducible myocardial ischaemia.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2870_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2870_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..05685d9d91e99ba9416c43ed4a34ff0bd6fc06e2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2870_en.txt
@@ -0,0 +1,2 @@
+A 30-year-old Korean woman was diagnosed with suspicious papillary thyroid carcinoma (PTC) by fine needle aspiration (FNA) at a local medical clinic. She was referred to our hospital for operation. She has no personal or family history of thyroid dysfunction and no specific medication history. Physical examination of neck revealed a diffusely enlarged and non-tender thyroid gland. There were no palpable cervical lymph nodes. US was carried out using a real time linear array 10-MHz transducer. The thyroid US demonstrated a diffusely enlarged thyroid gland with a 0.4×0.3cm sized hypoechoic nodule in the left thyroid . She wanted to diagnose the thyroid nodule again in our hospital. US-guided FNA was performed again on that nodule, and FNA cytology was diagnosed as suspicious PTC. We also examined for BRAF V600E mutation using FNA cytology materials. BRAF V600E mutation was identified by multiplex real time polymerase chain reaction assay using Anyplex™ BRAF V600E Real Time Detection (V2.0) (Seegene, Inc., Seoul, Korea), which allows for simultaneous amplification of total nucleic acid of V600E mutation of BRAF and internal control (human β globin gene). Computed tomography scan using contrast agent was done three weeks before operation. No abnormal finding was noted. The patient had no thyrotoxic symptoms during one month of the preoperative period. She underwent a left thyroid lobectomy by endoscopic thyroidectomy via a transaxillary approach for the thyroid tumor. The right thyroid was not manipulated during operation. Pathologic finding revealed a papillary carcinoma, and other portions of the thyroid parenchyma revealed lymphocytic patches predominantly in peripheral portions. There were rarely lymphoid follicles with germinal center .
+On laboratory examination, the preoperative laboratory test was performed one month before operation was within normal limits. The serial change of thyroid function tests and the titer of autoantibodies were summarized in Table . On postoperative day (POD) 1, she didn’t definitive complain. A thyroid function test (TFT) showed hyperthyroid with Antithyroglobulin antibody and thyroglobulin (Tg) . On POD 8, the patient was consulted by the department of endocrinology. On physical examination, blood pressure was 120/80mmHg, and heart rate was 119beat/min and regular. Neck examination revealed no sign of tenderness and redness. TFT was still increased but Tg level was normalized . Tc-99m scintigraphy showed faint visualization of the right thyroid lobes, and 24-hour radioactive uptake of 131I was 0.7% , which suggested destructive thyroiditis. On POD 48, thyroid function tests revealed euthyroid. On POD 86, she complained of fatigue and weakness. A TFT revealed hypothyroidism . The patient was treated with levothyroxine for her symptoms of hypothyroidism. On POD 140, follow-up TFT revealed mild hyperthyroidism . The patient was treated with levothyroxine.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2873_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2873_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..10b75b59f3d414e8f6c6a0cbe96aded5fd422564
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2873_en.txt
@@ -0,0 +1,4 @@
+A 48-year-old man returned to Weihai from Wuhan on January 10, 2020. He developed recurrent fever on January 20, 2020 with a maximum temperature of 38.2 °C with mild cough, without sputum, expectoration or chest tightness. Only oral antipyretics were taken. He went to the clinic on January 23, 2020 where real-time reverse-transcription polymerase chain reaction of pharyngeal swab specimens confirmed COVID-19. He was admitted to the hospital.
+The patient had asthma for 10 years that was stable in normal circumstances, without affecting daily life and activity. He inhaled salmeterol/fluticasone powder (Xeretide, 50/500 μg) twice daily. Smoking or other medical history was denied.
+On admission, temperature was 37.3 °C, respiratory rate was 23 breaths/min, and a few wheezing rales were heard in both lungs. Arterial blood gases at 21% fraction of inspiration O2 (FiO2) showed partial pressure of oxygen (PaO2) 97 mmHg, partial arterial pressure of carbon dioxide (PaCO2) 39.5 mmHg, pH 7.393, and oxygenation index (OI, PaO2/FiO2) was 465 mmHg [normal range (NR) 400-500 mmHg].
+Laboratory parameters were as follows: White blood cell count 4.66 × 109/L (NR, 3.3 × 109–9.5 × 109/L), neutrophil count 3.0 × 109/L (NR, 2 × 109–7.7 × 109/L), lymphocyte count 1.27 × 109/L (NR, 0.8 × 109–4 × 109/L), CD4 T lymphocyte count 542/μL (NR, 500–1440/μL), monocyte count 0.35×109/L (NR, 0.12 × 109–0.8 × 109/L), eosinophil count 0.03 × 109/L (NR, 0.05 × 109–0.5 × 109/L), platelet count 135 × 109/L (NR, 125 × 109–350 × 109/L), lactate dehydrogenase (LDH) 166 U/L (NR, 100–190 U/L), alanine transaminase (ALT) 15 U/L (NR, 0–50 U/L), aspartate transaminase (AST) 20 U/L (NR, 5–35U/L), albumin 39.8 g/L(NR, 38–55 g/L), C-reactive protein (CRP) 10.94 mg/L (NR, < 4 mg/L). Procalcitonin, myocardial enzymes, serum electrolytes and renal and liver function tests were normal. Detection of antigen and antibody of respiratory tract pathogenic spectrum (including influenza virus A/B) was negative. Chest X-ray showed increased lung markings in both lungs.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2877_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2877_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ca59d0ba7f85b40a35bfd229e21bb3bd2647c31a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2877_en.txt
@@ -0,0 +1,9 @@
+An 83-year-old man with a history of third-degree AV block and a single-chamber (RV lead) permanent pacing system (in situ 9 years) was referred to our institution with worsening breathlessness (NYHA III). There were no other heart failure symptoms, and clinical examination revealed signs of fluid overload (elevated jugular venous pressure and bilateral lower leg oedema) with no murmurs on auscultation.
+This included an ablation for cavo-tricuspid isthmus dependent flutter in 2009, and mild chronic obstructive pulmonary disease. There was a remote history of alcohol excess and transthoracic echocardiography at the time of original device implantation showed preserved left ventricular systolic function (LVEF 55%).
+Drug therapy included Ramipril 10 mg o.d., Spironolactone 25 mg o.d., Bendroflumethiazide 2.5 mg o.d., Simvastatin 40 mg o.d., Omeprazole 20 mg o.d., Tiotropium 18 µg o.d., Symbicort Turbohaler 200 µg/6 µg 1 puff BD, and Warfarin according to internal normalized ratio. Betablockers had not been commenced due to concerns about airways disease with a degree of reversibility on pulmonary functional testing.
+Twelve-lead electrocardiogram (ECG) showed sinus rhythm with AV dissociation because of RV-only pacing . Device interrogation confirmed 100% RV pacing with underlying complete AV block with a broad escape rhythm (left bundle branch block [LBBB], QRS duration 132 ms). Transthoracic echocardiography revealed a non-dilated LV with moderately impaired systolic function (LVEF 40–45%) with evidence of dyssynchrony (apical rocking and early septal activation) consistent with RV apical pacing (see , ). RV function and pulmonary pressures were normal, with no significant valve abnormalities.
+The most likely diagnosis explaining this presentation was PIC, differentials included alcohol-induced cardiomyopathy, or post-ablation atrial arrhythmia.
+Despite guideline-directed medical therapy his heart failure symptoms persisted. Considering the LV impairment and dyssynchronous ventricular activation, he was offered a device upgrade to a CRT-P with either a conventional LV lead or a His-bundle lead, in addition to a right atrial (RA) lead to improve VV and AV synchrony, respectively. Prior to implantation, left-sided venography was performed to evaluate vein patency which showed an occluded SCV . Options considered included the following: (i) a contralateral CRT-P implantation; (ii) implanting a right-sided RA and LV lead and tunnelling across to the left; (iii) venoplasty facilitated CRT upgrade; (iv) lead extraction of the functional RV lead for recanalization and upgrade; (v) surgical epicardial lead placement; and (vi) a conservative approach. After careful discussion, the patient elected to proceed with an upgrade strategy (including venoplasty and lead extraction). An epicardial approach was felt too high risk given his co-morbidities.
+As a centre with experience in HBP, and in alignment with recent guidelines, we targeted CRT-P via this approach. The least aggressive strategy was preferable and therefore prior to opening the left-sided pocket, the SCV occlusion was probed in a retrograde manner using a multipurpose catheter (6F MPA1 Impulse, Boston Scientific, MA, USA) from right femoral venous access (secured for temporary pacing wire support). In doing so, we were able to direct the catheter to the brachio-cephalic vein and define the occlusion in detail. Furthermore, contrast highlighted a large collateral branch, which we felt could be punctured directly from a left sub-clavicular approach (see , ). We left a 0.035 in J-wire in this branch, and successfully secured venous access through the Seldinger technique (see , ). A passive lead to the right atrial appendage was implanted and a 69 cm Select Secure 3830 lead (Medtronic Inc., MN, USA) was deployed via a C315 sheath (Medtronic) at the His-bundle. Final lead positions are shown in .
+Intracardiac electrograms confirmed underlying complete AV dissociation with an intrinsic His-QRSend interval of 192 ms. With HBP, non-selective capture was achieved resulting in a shortened Stim-QRSend of 158 ms with a threshold of 1 V at 0.5 ms ( and ). The device was programmed DDD-60 with an ‘LV’ to RV delay of 60 ms, to allow protective back up RV pacing in the event of loss of His capture. There were no complications and post procedural 12-lead ECG confirmed non-selective His capture.
+After 2 months, the patient was NYHA I, euvolaemic and LV systolic function had normalized (LVEF >55%, see , ). Device interrogation revealed atrial pacing of 56% and HBP 99% of the time.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_287_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_287_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6580bb927c8d797973cd32a5055de31d8de27881
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_287_en.txt
@@ -0,0 +1 @@
+A 45-year-old Chinese man was referred to our hospital for the treatment of right lumbago and odynuria, with no fever or gross hematuria. His past medical history was unremarkable and there was no history of any allergy or external trauma except a long working history in construction site. On admission, no abnormality was found in physical examination, Blood analyses revealed no leukocytosis (white blood cell count of 6.52 × 109/L), no elevation of eosinophils (eosinophils count of 0.44 × 109/L, eosinophil ratio Accounted for 6.7%). Renal function was normal (Serum creatinine level of 77.4 umol/L). Urinalysis confirmed no hematuria, leucocytes or protein. Ultrasound examination indicated the low echo on the right portion wall and the neck of the bladder, with dilation of the right lower ureter . Computed tomography showed no hydronephrsisa but a remarkable enhancing large mass that measured 5.0 cm × 2.3 cm located on the right portion of the bladder with undefined margin . Cystoscopy confirmed a huge follicle-like mass lesion on the right portion wall and the neck of the bladder with a broad base, in which blood vessels growing . Cystoscopic biopsy affirmed the chronic mucosal inflammation of bladder . For further treatment, diagnostic transurethral resection of the bladder was performed, the postoperative histopathological diagnosis was EC complicated with CG . After transurethral resection, antibiotics, glucocorticoids, and antihistamines were treated, the catheter was indwelled continuously until postoperative day 6. The patient recovered uneventfully and was discharged on postoperative day 8. Cystoscopy and eosinophils levels of blood and urine were required to be examined every 3 months during the first year. There was no evidence of recurrence followed up for 6 months.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2880_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2880_en.txt
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index 0000000000000000000000000000000000000000..7a6707600a7a10c2a3f0de550ca091944cc23a10
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2880_en.txt
@@ -0,0 +1,4 @@
+An 11-month-old female infant presented with bilateral corneal opacity, which was first noted at the age of 3 months. The patient was born full term with an uneventful birth history, and no history of maternal infection or family history of ophthalmologic disease. Ophthalmic examination revealed central corneal opacity approximately 3.0 mm in diameter in the right eye and 2.0 mm in diameter in the left eye, with an underlying keratolenticular adhesion and a cloudy cataract, and that the patient could not trace the light . Contact ultrasound A-scans revealed axial lengths of 18.28 mm and 18.39 mm in the right and left eyes, respectively. Intraocular pressure (IOP) were 14 mmHg in both eyes, measured by a handheld tonometer (Icare Finland Oy Vantaa, Finland). There were no systemic anomalies.
+The patient’s parents hesitated to accept PKP and fully understood the risks of performing PKP in infants because they had consulted several surgeons before coming to our clinic to seek a second opinion. Her parents were subsequently offered an option of adhesiolysis and adhesive membrane removal combined with lensectomy and vitrectomy. Surgeries were performed at the age of 11 months on 17th and 19th October 2017 in the right and left eye, respectively.
+Surgeries were performed by an experienced surgeon (Y.E.Z.) under general anesthesia using the Accurus with the venturi vacuum system (Alcon Laboratories, Inc.); the cut rate was 2000 per minute and vacuum was 350 mmHg. A corneoscleral incision was made superiorly and four 1.0 mm paracentesis were created in each quadrant. The anterior chamber was initially filled with ophthalmic viscosurgical device (OVD), and the neck of the keratolenticular adhesion was cut using intraocular scissors. There was comprehensive iris posterior synechia. The pupillary aperture was enlarged by four iris hooks through paracentesis in each quadrant after adhesiolysis. Then, a partially resorbed lens and peripheral anterior capsule contraction with zonular elongation were noted underneath the keratolenticular adhesion. The anterior capsular defect was extended to an anterior capsulorhexis of approximately 5.0 mm diameter using a 23-gauge vitrector, while the anterior chamber was maintained by a 23-gauge infusion cannula. After the mode was switched to irrigation/aspiration, the cortex was carefully aspirated. Next, a posterior capsulotomy with a 3.0 mm diameter was performed with the vitrector and the anterior part of the vitreous volume was removed using the same vitrectomy settings. Before the end of the procedure, the residual adhesion was gently peeled off by capsulorhexis forceps curvilinearly following the demarcation line. Surgery was concluded with reformation of the anterior chamber with balanced salt solution and closure of the corneoscleral incision with 10–0 nylon sutures, leaving both eyes aphakic (Additional file 1). No unexpected intraoperative complications were encountered. Clinical manifestations were similar in both eyes.
+Topical treatment consisted of steroidal eye drops gradually tapering over 4 weeks, antibiotic eye drops 4 times daily for 2 weeks, and mydriatic eye drops (phenylephrine hydrochloride and tropicamide compound) once a day for 4 weeks. A gradual reduction in central corneal opacity and improvement in the visual acuity (VA) was noted . Non-contact specular microscopy at one year postoperatively showed large heteromorphic endothelial cells at the borderline between the normal endothelium and the central defect . At the latest follow-up that was two years after surgery, the corneal had excellent transparency, with corrected Teller VA of 20/50 in both eyes and IOP of 15 mmHg in the right eye and 14 mmHg in the left eye. There was no evidence of glaucoma.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2893_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2893_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..beedc698b284087b62997c0b8dde5c13df2ef928
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2893_en.txt
@@ -0,0 +1,4 @@
+A 66-year-old Caucasian woman presented with vertical double vision for the previous 3 weeks. Diplopia was binocular and noticed after she banged her head against the shower screen. She was healthy and had no symptoms suggestive of giant cell arteritis (GCA). A clinical examination showed right fourth cranial nerve palsy. Her magnetic resonance imaging (MRI) scan was normal. Her erythrocyte sedimentation rate (ESR) was 77mm/hour and C-reactive protein 68mg/L. She was commenced on oral steroids while awaiting temporal artery biopsy to rule out GCA. TAB revealed normal histology. As there was no clinical suspicion of GCA, her steroids were stopped. The medics investigated her further for raised inflammatory parameters and no cause was identified.
+She then sought medical attention for a breast lump that she had noticed for the past few months. This was clinically diagnosed as breast cancer. She subsequently underwent right wide local excision of the mass and axillary clearance. Histology revealed 28mm grade 3 oestrogen receptor positive, human epidermal growth factor receptor 2 negative ductal carcinoma involving 12 of 14 axillary nodes. An oncology referral was made.
+Meanwhile, she complained of a droopy right eyelid. Orthoptic examination showed pupil-sparing third nerve paresis and mild sixth nerve involvement. The fourth nerve paresis had resolved. Neuroimaging to rule out cavernous sinus pathology was requested. A MRI scan with contrast showed meningeal thickening in frontal, parietal and occipital lobes and no abnormality in the cavernous sinus territory. This was consistent with carcinomatous meningitis .
+By the time of her oncology appointment, she had developed numbness in the ophthalmic division of her right trigeminal nerve. A bone scan showed bone metastases; computed tomography revealed bone spread and abnormal mediastinal lymphadenopathy. Cerebrospinal fluid (CSF) cytology was negative but protein was slightly raised. Palliative hormone therapy was commenced for metastatic breast cancer. She responded quickly with complete resolution of diplopia, ptosis and numbness on her right anterior scalp within 8 weeks of starting anastrozole.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2898_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2898_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..64f0e159f3186681ad17e7d9751f98e9cd15752c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2898_en.txt
@@ -0,0 +1,6 @@
+A 61 year-old male was admitted for constipation and a palpable mass in the periumbilical area. His medical history revealed the surgery for acute perforative appendicitis 20 years ago and occasional intestinal obstruction afterwards. He denied any history of radiation or occupational exposure to chemicals. The small bowel series showed an external compressive lesion in the distal ileum and the computerized tomographic (CT) scan revealed a 6 cm, well-marginated mass in the anteromedial aspect of the ascending colon . Under the suspicion of foreign body granuloma due to gauze (gossypibioma), an exploratory laparotomy was performed. The whole intestine was found to be covered in severe adhesion; however, ascites or blood in the abdominal cavity was absent. In the anteromedial aspect of ascending colon, there was an encapsulated mass 5 cm in size, and it was adhered to ascending colon and distal ileum . The mass was filled with abscess and granulation tissue, and the frozen biopsy reported the diagnosis of abscess. Only resection of the mass was performed, and the patient was discharged without any complications.
+Forty days after the discharge, he was admitted again with anemia, abdominal distension, and melana. The colonoscopy revealed the hematoma and the stenosis of the lumen directly above the cecum. The abdominal CT scan showed large volume of blood in the abdomen and multiple peritoneal nodules. The angiography and 99 mTc labeled RBC scan showed active bleeding around the ileocecal valve. Emergent laparotomy was performed and multiple nodules were found on the wall of ileum, liver, mesentery and peritoneum. In the distal ileum, two nodular lesions with 3 cm and 2 cm in size were bleeding actively, and they were adhered to each other. The nodules were diagnosed as sarcoma through the frozen biopsy, and the distal ileum including the pathologic lesion was resected. Seven days later, reoperation was performed due to substantial hemorrhage from the peritoneum, the mesentery, and the small intestine wall. Two days after the last surgery, the patient expired of uncontrollable bleeding due to disseminated intravascular coagulopathy.
+On the macroscopic examination of resected ileum, there were two ill-defined tan solid tumors with mucosal ulceration, each measured 3 × 1.5 cm and 2 cm in diameter, involving the entire intestinal wall and extending to the subserosa of adhered loop. .
+Under microscope, spindle-shaped or epithelioid cells were arranged as a plate and the rudimentary vessel lumen were detected occasionally . Separated from these two lesions, several small angiosarcomas containing foreign body granulomas were found in the subserosal layer of the intestine. Also, the nodules of liver and mesentery were diagnosed as metastatic angiosarcomas.
+Immunohistochemical staining was performed and tumor cells were positive for CD31, CD34, and vimentin , whereas negative for factor antigen, CD117, and S-100. The tumor cells were also negative for cytokeratin (AE1/3) and EMA. The foreign body granulomas were surrounded by CD31 positive cells, partially or entirely.
+The previously resected mass, which was diagnosed as abscess, was reviewed. In a low magnification field, abscess in the center and fibrosis with vascular proliferation in the periphery were noted . However, when the periphery was examined under the high magnification, spindle-shaped or epithelioid cells were arranged as plate patterns, in some area, well-differentiated vessels were formed as similar to the lesions from the ileum. The additional serial sections revealed more foreign materials surrounded by epithelioid tumor cells and the invasion of tumor cells to the blood vessel. The tumor cells were positive for CD31 and CD34, and negative for cytokeratin. This supported the final diagnosis of a foreign body granuloma associated-angiosarcoma.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2916_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2916_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f34a9fade81c68c2d16339e155f1e406da987423
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2916_en.txt
@@ -0,0 +1,3 @@
+A 57-year-old man with a previous history of hypertension and stroke was referred to our hospital with transient episodes of dizziness, diplopia, and left-side numbness for 2 weeks. Each episode lasted for 5 to 30 min without unconsciousness and then completely relieved. After the onset of these symptoms, the patient was first admitted to a local hospital where he received optimal medical therapy including dual antiplatelet agents (aspirin 100 mg/day and clopidogrel 75 mg/day) and risk factor modifications. However, the patient still experienced another two episodes of TIAs under optimal medical treatment. His radiological examination in the local hospital suggested multifocal intracranial and extracranial atherosclerosis (data not shown). The patient was, therefore, transferred to our hospital for further management. After admission, the patient underwent a series of diagnostic evaluations. Neurological examination showed no permanent neurological disability with a National Institute of Health Stroke Scale score of 0. Laboratory tests including blood routine examination, hepatorenal function, lipid profile, homocysteine level, glycosylated hemoglobin level, and coagulation function were all normal. Multimodal computed tomography (CT) was also performed, and non-contrast CT demonstrated a hypodensity lesion in the left thalamus . CT angiography (CTA) showed proximal non-tapered occlusion and distal severe stenosis of the left VA , and that the right VA did not converge with the left VA into the basilar artery . Based on these findings, the diagnosis of TIA due to VA occlusion was made. Since the patient had recurrent neurological symptoms despite optimal medical management, endovascular recanalization of the left VA was recommended.
+The procedure was performed under local anesthesia. After the femoral artery puncture, an 8F artery sheath was inserted, and the patient was intra-arterially heparinized to achieve an activated clotting time of more than 250 s. An 8F guiding catheter (Cordis, Florida, USA) and a 5F diagnostic catheter (Cordis, Florida, USA) were delivered to the left subclavian artery proximal to the VA ostium under the guidance of a 0.035-in loach guidewire (Terumo, Tokyo, Japan). After retracting the loach guidewire, an initial digital subtraction angiography (DSA) was performed via the diagnostic catheter, which demonstrated non-tapered occlusion of the V1 segment and severe stenosis (approximately 80%) of the V4 segment of the left VA. In the beginning, multiple attempts were performed with the coaxial assembly of a PT 0.014-in micro guidewire (Boston Scientific, Boston, USA) and an Excelsior SL-10 microcatheter (Stryker, Michigan, USA) to facilitate navigation across the occluded segment but failed . At the moment, robust deep cervical collateral to the distal V3 segment of the left VA and a tapered stump of the distal part of the occluded segment were noted . Therefore, the exchange of a Synchro 0.014-in micro guidewire (Stryker, Michigan, USA) was performed to reach the distal V3 segment through the left deep cervical artery, which then reversely traversed the occluded segment to the left subclavian artery successfully (, ). A Neuro RX 2.75 × 15 mm balloon (Sinomed, Tianjin, China) was subsequently advanced to the VA ostium along the micro guidewire to dilate the occluded segment . After balloon dilation, the occluded segment was successfully recanalized but remained in severe stenosis . We retracted the balloon and advanced a 5F intermediate catheter (Tonbridge, Zhuhai, China) with a Transend 0.014-in micro guidewire inside (Stryker, Michigan, USA), which passed the recanalized segment and was placed in the left VA and posterior cerebral artery. DSA revealed severe stenosis of the V4 segment and antegrade filling of the basilar artery and both posterior cerebral arteries . Under the guidance of an angiogram, a NOVA 4.0 × 15 mm balloon-expandable stent (Sinomed, Tianjin, China) was implemented in the stenotic segment (, ). To prevent restenosis of the V1-V2 segment, a RX 4.0 × 18 mm balloon-expandable stent (Abbott, California, USA) and a Bridge 4.0 × 18 mm rapamycin drug-eluting stent (Microport, Shanghai, China) were consecutively implanted in the recanalized segment . Finally, the 8F guiding catheter, intermediate catheter, and micro guidewire were carefully retracted.
+After the procedure, the patient underwent a repeated CTA examination, which indicated successful recanalization of the left VA . Dual antiplatelet therapy and risk factor control strategies were continued in this patient. During the follow-up of 3 months, the patient reported no neurological symptoms. summarizes the timeline of the present case.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2917_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2917_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..54439b191d949d84157556f05d2126021deb948b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2917_en.txt
@@ -0,0 +1,4 @@
+The patient was a 45-year-old male with a 12-year history of paroxysmal weakness of the limbs. He was diagnosed with hypokalemic periodic paralysis in 2005 and hyperthyroidism in 2008. He had taken antithyroid drugs on an irregular basis since 2008 but had not undergone proper biochemical examination. Whenever he felt that his weakness was becoming severe, he would self-prescribe potassium chloride. In June 2017, the extent of his lower limb weakness increased such that he could no longer walk. He took potassium chloride without improvement. Subsequently, he was admitted to another hospital. His temperature was 36.7 °C, and his pulse was 96 beats/min. The muscle strength in his lower limbs was grade II , and that in his upper limbs was grade III. His limb muscle tone was normal. His electrolyte and blood marker levels were as follows: K+, 1.4 mmol/l; Na+, 138 mmol/l, Cl−, 97 mmol/l; Ca2+, 2.61 mmol/l; free triiodothyronine (FT3) 6.96 pmol/l (1.86–6.44); free thyroxine (FT4) 38.96 mIU/l (11.45–22.14); thyroid-stimulating hormone (TSH) < 0.01 mIU/l (0.4–4.5); thyroglobulin antibody (TgAb) 16.61 IU/ml (0–150); and thyrotropin receptor antibody (TRAb) 22.36 mIU/l (0–5). Thyroid ultrasound demonstrated diffuse thyromegaly with a rich blood supply. The patient was diagnosed with GD and hypokalemic periodic paralysis and was treated with propylthiouracil (PTU) and potassium chloride. However, 2 days later, despite improvement of his weakness, his temperature increased to 41 °C, and he experienced cough and expectoration. Computed tomography (CT) imaging of his lungs revealed pneumonia. He was subsequently treated with cefazolin and transferred to our hospital 2 days later.
+When the patient was admitted to our department, his limb weakness had significantly improved. He had a temperature of 38.8 °C, a pulse of 96 beats/min, a breathing rate of 20 respirations/min, a blood pressure of 106/68 mmHg, and grade II thyroid enlargement. Vascular murmur was audible in the thyroid. The muscle strength in his limbs was grade V, and his limb muscle tone was normal. The patient’s biochemical parameters were as follows (the reference values are different from those used in the previous department): [blood count] leukocytes 13.10 × 109/l, neutrophils 11.99 × 109/l and hemoglobin 13.3 g/dl; [serum electrolytes] K+ 2.110 mmol/l, Na+ 131.6 mmol/l, Cl− 91.1 mmol/l, Ca2+ 1.850 mmol/l, and Mg2+ 0.540 mmol/l; [thyroid function and thyroid antibodies] triiodothyronine (T3) 1.40 mmol/l (1.34–2.75), thyroxine (T4) > 300 nmol/l (78.38–157.40), FT3 5.32 pmol/l (3.60–6.00), FT4 51.23 pmol/l (7.86–14.41), TSH 0.01 mIU/l (0.34–5.65), thyroid peroxidase antibody (TPOAb) 36.33 IU/ml (0–30), TRAb 9.011 IU/ml (0–30), TgAb 6.04% (< 30%), and thyroid microsomal antibody (TMAB) 6.48% (< 20%); and creatine kinase (CK) 1398 U/l (38–174) and CK-MB 29 U/l (0.0–25.0). The patient’s liver and kidney functions were normal. We treated him with cefazolin, propranolol, PTU and potassium chloride. The patient’s vital signs and strength normalized after 3 days, and his leukocyte count had decreased to 5.97 × 109/l, his neutrophils had decreased to 3.59 × 109/l, and his CK had decreased to 40 U/l. However, his serum potassium level remained low despite 24 g/d of potassium supplementation. Additionally, the patient had hypomagnesemia and metabolic alkalosis (the results are shown in Tables and ). Further testing showed that his renin activity (supine) was 5.17 ng/ml/h (reference value 0.15–2.33), his aldosterone level was 436.10 pg/ml (10–160), his random urinary calcium/creatinine ratio was 0.23, his osteocalcin level was 1.06 ng/ml (6.00–48.00), his parathyroid hormone level was 11.22 pg/ml (6.0–80.0) and his calcitonin level was 4.87 pg/ml (0.00–18.00).
+Based on these results, we suspected that the patient did not have thyrotoxic periodic paralysis (TPP) but rather GS. Therefore, we sent a blood sample to Beijing Huada Company for sequencing. The Next Generation Sequencing (NGS) was used. The sequencing protocol was based on the Roche Nimblegen SeqCap EZ Choice XL Library for exon trapping. A total of 25 genes known to be associated with hypokalemia were targeted and the total size of target regions was 11.8 M. Libraries were prepared with the Kapa Hyper Prep kit and sequencing was carried out by Illumina NextSeq500 System. The sequencing data were compared to the human genome by BWA (0.7.12-r1039) software (/), and ANNOVAR (Date: 2015-06-17) was used to annotate the mutation sites based on dbSNP, Clinvar, ExAC, and 1000 genomes, among others. We found a homozygous mutation in the SLC12A3 gene (Exon12 1562-1564delTCA) with an amino acid change of 522delIle, which was first reported as a compound heterozygous mutation.by Vargas-Poussou . The mutation was confirmed by sanger sequencing. No other phenotypes were found, including those for Bartter syndrome, hypokalemic periodic paralysis,Liddle syndrome, hyperaldosteronism, and apparent mineralocorticoid excess. The diagnosis was changed to GD with GS. Moreover, we obtained blood samples from the patient’s mother and son (his father had passed away) who did not have hypokalemia and hyperthyroidism. Both of them were proved as heterozygous mutation carriers by sanger sequencing. The sequencing chromatograms are shown in Figs. and . The patient had three brothers and one sister, but we were unable to obtain blood samples from them.
+In addition to antithyroid drugs (methimazole 30 mg/d), we gave the patient potassium chloride (3 g/d), potassium citrate (6 g/d), and magnesium potassium aspartate (1.788 g/d). At the follow-up visit, we found that the patient often forgot to take his medicine. The results for thyroid function and electrolyte levels before and after treatment are listed in Table , which indicated that the patient’s thyroid function had improved. Hypothyroidism occurred during the course of treatment, but the patient’s thyroid function returned to normal after we reduced the dose of methimazole. The patient refused the recommendation to undergo I131 therapy. His serum potassium level remained low despite a sufficiently large daily dose of potassium, but no paroxysmal paralysis occurred after discharge.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2921_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2921_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7242b1c461fd93b9f9d777c9e48cf30b44adc50a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2921_en.txt
@@ -0,0 +1,5 @@
+Our 47-year-old man previously diagnosed with right renal AML presented for intermittent right flank pain and gross hematuria. He had no signs or symptoms of tuberous sclerosis complex (TSC). His only relevant past medical history was old peritonitis following an appendectomy.
+The abdominal US showed a hyperechogenic lesion in the right renal sinus with a thrombus in the right renal vein and IVC. Abdominal computed axial tomography (CAT) scan revealed a 3 cm lobulated low-density lesion in the renal sinus, middle and upper lobes of the right kidney . On abdominal angioscan, the low-density lesion extended from the right kidney into the right renal vein and IVC, reaching above the diaphragm superiorly, 3 cm below the right atrium .
+Considering the risk of pulmonary embolism due to IVC thrombus, the decision of right radical nephrectomy and thrombectomy was taken with the patient.
+The surgery was done under general anesthesia after central and arterial lines insertion, the patient was in dorsal decubitus position. Right subcostal approach with median sternotomy was used . After isolation of the right kidney by dissection and ligation of the ureter, renal lobar arteries, and collateral veins, leaving intact and minimally mobilizing the right renal vein, cardiopulmonary bypass (CPB) was initiated. A single-stage venous cannula was inserted through the right atrium into the superior vena cava, and ascending aortic cannulation was used for arterial return. Using Satinsky clamps the vena cava was clamped right beneath the right atrium and beneath the renal veins. A 5 cm cavotomy revealed a free-floating pedunculated tumor extending from the right renal vein into the IVC, around 10 cm upwards towards the supradiaphragmatic IVC. The tumor was taken in one piece with the right nephrectomy (, , , ). After repair of the cavotomy with running 4–0 Prolene sutures, CPB was interrupted after 28 min of initiation. The right adrenal gland was spared. A drain was put in the peritoneum at the end of the surgery, the operative time was 200 min, the blood loss was 550 cc and no transfusion was needed. The drain was removed at the second post-operative day and the patient was discharged uneventfully on the seventh day after surgery
+Pathological analysis of the nephrectomy piece revealed a 5 × 4 × 3 cm tumor with intratumoral hemorrhage extending through the hilum by an 8 cm chaplet like structure with diameters varying between 0.8 and 2 cm. Microscopic examination revealed a stroma composed of mixed layers of mature adipocytes and smooth muscle cells and multiple vascular structures with thick walls and hemorrhagic foci. These characteristics were compatible with that of a benign AML, which was confirmed by immunohistochemistry: positive staining with anti-SMA antibodies and anti-HMB45 and , and negative staining with anti-CD34 and anti-CKAE1/AE3 antibodies .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2946_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2946_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3eccbf11c4f75f8e999f0be3f06b5bcee08c5e0b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2946_en.txt
@@ -0,0 +1,2 @@
+A 51-year-old perimenopausal white woman with no significant past medical history other than chronic back pain presented to her primary care physician in October 2013 with fainting spells, worsening back pain and severe fatigue of 1 month's duration. Her laboratory workup revealed a white blood count of 7,100/μl, hemoglobin of 8.9 g/dl and a platelet count of 60,000/μl, an unremarkable basic metabolic profile and normal liver function tests. Her ferritin (682 ng/ml) was elevated and both vitamin B12 (392 pg/ml) and folate (20 ng/ml) levels were within normal range. The patient developed another syncopal episode at home, and an emergency room workup confirmed mild anemia and thrombocytopenia with no clear evidence of active gastrointestinal bleeding. In December 2013, due to worsening symptoms, the patient presented to a different emergency room with gingival bleeding and petechiae on her lower extremities. She was found to have a hemoglobin level of 7.2 g/dl with a platelet count of 10,000/μl. The patient was admitted to the hospital, and a bone marrow biopsy was performed. Bone marrow aspiration could not be obtained, and the core biopsy revealed extensive involvement of metastatic carcinoma . Immunohistochemistry studies were highly suggestive of a breast primary (data not shown). A mammogram demonstrated a 2.4-cm mass at the 2 o'clock position in the right breast with suspicious axillary lymph nodes. The patient underwent a biopsy of both the primary breast lesion and of the axillary lymph nodes, which revealed invasive ductal carcinoma that was estrogen receptor-positive, progesterone receptor-positive and human epithelial growth factor receptor (HER2)-negative. Further staging workup demonstrated extensive osseous metastases, but no visceral metastases. She received a transfusion with 2 units of red blood cells and 1 apheresis unit of platelets, resulting in an improvement in hemoglobin from 7.2 to 10.1 g/dl and platelet count from 10,000 to 20,000/μl. She was discharged home and was started on endocrine therapy with both leuprolide and letrozole. Denosumab was also administered monthly for bone metastases. However, she did not respond either clinically or biochemically (rising CA 15-3) to the endocrine therapy and continued to experience frequent gum bleeds and petechial rashes throughout her body.
+In March 2014, the patient transferred her care to our center. Restaging workup demonstrated extensive skeletal metastases without visceral involvement or splenomegaly (data not shown). A complete blood count showed a white blood count of 5,000/μl, hemoglobin of 9 g/dl and a platelet count of 10,000/μl. The patient received 1 unit of apheresis platelets urgently. Surprisingly, her platelet count did not increase at all, but decreased to 6,000/μl. The patient did not have headache, but she developed more extensive petechiae and hemorrhagic blisters in her mouth. Hence, she was admitted to the inpatient unit for further management. Both bone marrow biopsy from an outside facility and peripheral smear from our center were reviewed, and our pathologist concurred with the initial diagnosis. Peripheral blood examination of the peripheral blood smear in March 2014 revealed marked thrombocytopenia and anemia; some large platelets but no giant platelets were seen (photos are not available). There was no evidence of schistocytosis, which essentially ruled out intravascular or microangiopathic processes. It did reveal some teardrop cells, which was consistent with her bone marrow finding – a myelophthisis process. However, bone scan showed that a large fraction of long bones was spared by metastases. The disproportionate thrombocytopenia seems to suggest a dual pathological process: myelophthisis and peripheral consumption. The fact that her platelet count decreased upon platelet transfusion seems to suggest an immune-mediated peripheral destruction of platelets, which is, at least in part, responsible for her marked thrombocytopenia. All the other pertinent laboratory studies including folate, vitamin B12 level, thyroid function tests, antinuclear antibodies, Helicobacter pylori antibodies, hepatitis panel and HIV test were normal, and therefore a clinical diagnosis of ITP was established. In view of the substantial risk of fatal bleeding, the patient received IVIG (1 g/kg) daily for 2 days (3.4.2014 to 3.5.2014) and high-dose steroid methylprednisolone 500 mg i.v. daily for 3 days (3.4.2014 to 3.7.2014). As shown in figure , the patient's platelet count responded dramatically, increasing from 6,000 to 32,000/μl in 3 days. She was discharged home with oral prednisone 80 mg (1.5 mg/kg) daily. Her platelet count improved to 155,000/μl 1 week later and 171,000/μl 2 weeks after discharge. We started to taper down her prednisone and treat her metastatic breast cancer using chemotherapy with capecitabine (500 mg p.o. daily) since she did not respond to the first-line hormonal therapy. The patient's platelet count continued to improve and was stabilized at around 250,000/μl. Prednisone was tapered off over 3 months, and capecitabine was gradually increased to 1,500 mg p.o. daily. Interestingly, her hemoglobin had also improved during the course of the treatment, mirroring the response of platelet count. It cannot be explained by the therapeutic response from capecitabine which was started on 3.20.2014, while her hemoglobin improved dramatically from 8.1 to 10.3 g/dl in 3 days (3.4.2014 to 3.7.2014) and further improved to 12.2 g/dl on 3.14.2014. This seems to suggest a similar immune-mediated mechanism involved in the development of anemia. By the time of completion of this report, the patient continued to respond to the current therapy with discontinuation of steroids, and the restaging CT and bone scan in September 2014 demonstrated an excellent response to capecitabine.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2947_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2947_en.txt
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index 0000000000000000000000000000000000000000..152337ff334817f52cf0ac5ca1ebe7d66ff0ed4d
--- /dev/null
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@@ -0,0 +1 @@
+An 8-month-old female patient was referred to our center due to severe cough, short of breath, fatigue and fever. The patient had nine episodes of pneumonia and cardiomegaly since she was two-month-old. Physical examination revealed cleft lip, which was surgical repaired when she was 6 months old, and cleft palate. Her finger oxygen saturation was 94%. Transthoracic echocardiography showed there was a 0.5 × 0.6 cm ASD with a 2.4 cm right atrium. Laboratory test showed NT-proBNP was 963 pg/ml. Some of autoimmune antibodies, including dsDNA-antibody, SSA/Ro 60kD antibody, anti-cardiolipid antibody, and anti-β2GPI antibody, were positive. Erythrocyte sedimentation rate (ESR) and C-reaction protein (CRP) were normal. IgG was slightly elevated at 18.40 g/L, and C3 was 0.83 g/L. Significantly increased pulmonary vascular resistance (PVR, 17 WU) was seen in her first right heart catheterization despite of the slightly increased pulmonary artery pressure (PAP, 38/17/24 mmHg). Oral furosemide and antisterone were given since then. She was also suggested to inhale oxygen at home even though she maintained her daily activities without additional requirement of oxygen. The patient was re-hospitalized several times because of recurrent pneumonia and heart failure thereafter. Her finger oxygen saturation dropped to 75% at lowest, and stayed at 95% or higher when given nasal catheter oxygen inhalation. Hemodynamic parameters turned worse in the second measurements, where PAP increased along with PVR (PAP, 100/50/67 mmHg; PVR, 42 WU). Further examination included chest computed tomography (CT) scan. CT showed infiltration in upper lobes at both sides , and lung atelectasis in left upper lobe . Pulmonary artery and right atrium were significantly dilated . No thrombosis was seen in pulmonary artery. The patient and her parents received whole exome sequencing test. A new splicing variant (exon34: c.5417-1G > A, p.-) in the FLNA gene was found only in the patient. Diuretics, dopamine, and oral Bosentan (12.5 mg twice daily) were used to relieve her symptoms. No intubation or other advanced life supports were required during hospitalizations. Patient’s family refused any further intervention during her last hospitalization at age of 2 years. She became significantly cyanosis after last discharge. Unfortunately, the patient didn’t response well to medication therapy, and she died from a severe pneumonia 5 months later.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2954_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2954_en.txt
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index 0000000000000000000000000000000000000000..df887b0556e71e710cfbb7a5438b7d4da59a121a
--- /dev/null
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+A 22-year-old Caucasian male was admitted to hospital with aggravated signs of anaemia: primarily exhaustion and sleepiness, accompanied by marked pallor. Iron deficiency anaemia had been diagnosed in this patient at the age of 2 months. The patient was then put on iron supplements along with other vitamins necessary for erythropoiesis. Before his first birthday, celiac disease was histologically diagnosed, and anaemia was considered to be an accompanying disease. In early childhood, the patient experienced a cytomegalovirus infection as well as other typical childhood diseases. He was immunized according to his home country’s specific vaccination schedule and had an otherwise unremarkable childhood. Even though the patient had been put on oral iron and vitamin supplements, the severity of the anaemia remained within the moderate to severe range, only sporadically mild, and therefore the patient underwent further testing. At the age of 18, the patient underwent bone marrow examination with no pathologic findings, as well as an upper gastrointestinal endoscopy, lower gastrointestinal endoscopy, and capsule endoscopy, all of which had done previously. This time, however, the discovery of dilated blood vessels in the duodenum was made during upper gastrointestinal endoscopy, although neither angiodysplasia nor Osler-Weber-Rendu disease were found. A computed tomography (CT) of the abdomen was performed resulting in the discovery of an intestinal malrotation of the duodenum and an absence of the proximal part of the SMV with varices in the duodenal wall, which had functioned as a collateral blood flow due to mesenteric vein occlusion . The anaemia was proclaimed to be a result of chronic occult blood loss through dilated blood vessels in duodenal mucosa, and therapy slightly helped the condition at the time.
+At the age of 22, the patient quit taking all supplements. The resulting life-threatening anaemia necessitated hospitalization and red blood cell transfusions within 6 months. Although, the transfusions did not yield the expected results, they indirectly confirmed a chronic loss via the duodenal collaterals. The patient underwent another computed tomography of the abdomen which confirmed the previous findings, and, after his condition was stabilized, was referred to our surgical clinic for a consultation. An elective surgery was scheduled for the following month. Meanwhile, the patient was treated with repeated intravenous iron supplementation and correction of hemostasis parameters. Finally, when the patient was admitted to our surgical ward, he was slightly pale but a physical examination produced no remarkable findings. The next day, he underwent surgery under general anaesthesia with mobilisation of the malrotated bowel, and after meticulous preparation we were able to find the suitable blood vessels for the bypass. After administering an intravenous heparin (100 units per kg), we created an anastomosis between the large collateral arising from the distal section of the SMV and the anterior inferior pancreaticoduodenal vein draining to the present proximal section of the SMV without any prosthetic material . We also performed ligation of some dilated veins on the duodenal surface with the aim to interrupt the blood flow in the duodenal varices. The postoperative period was unremarkable, and the patient was discharged to outpatient care. During the 3-month period after the surgery, we put the patient on anticoagulant treatment with low molecular weight heparins. Five months after the surgical intervention, a CT of the abdomen was performed to confirm the patency of the venous anastomosis and diminution of duodenal varices. A slightly stenotic passage through the anastomosis with a regression of the duodenal varices, draining into the SMV, was observed. Two months later, the patient underwent an upper gastrointestinal endoscopy with the intention to ligate the residual duodenal varices. The patient still has three large duodenal varices, which have been currently left untreated because of the patient’s good clinical and laboratory status with no clinical signs of bleeding and no anaemia or iron deficiency.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2957_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2957_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..841eab2a722a98c589853906840c56fcaa211a3a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2957_en.txt
@@ -0,0 +1,5 @@
+A 34-year-old nulligravida with a remote history of follicular cyst treated by ovarian cystectomy presented with acute abdominal pain associated with emesis. She was hemodynamically stable, but her abdominal exam was remarkable for rebound tenderness. Complete blood count revealed hemoglobin of 5.4 mg/dL (hematocrit of 18.7%) and an undetectable platelet count. Computed tomography of the abdomen and pelvis revealed moderate-volume hemoperitoneum and contrast blush surrounding the left ovary , which was consistent with low volume active blood loss from the left ovary.
+Five weeks prior to presentation, the patient experienced prolonged gingival bleeding after a dental appointment. Two weeks following this, she began to experience spontaneous bruising, epistaxis with minimal trauma or sneezing, and cravings for ice chips. This was followed by uncharacteristically long and heavy menses, during which the patient soaked 1 pad every 1-2 hours. She began to feel fatigue and shortness of breath with minimal activity. The day prior to admission, she began to feel abdominal bloating and the following day she described waxing and waning, moderate to severe abdominal pain.
+She was admitted to the intensive care unit out of concern for possible spontaneous intracranial hemorrhage (ICH). She was transfused two units of platelets and two units of packed red cells; her platelet count rose only to 13 × 109/L and several hours later fell to 11 × 109/L . After review of her peripheral blood smear, hematology began empiric treatment for immune thrombocytopenia with IV immunoglobulin and IV methylprednisolone. The patient's platelet counts began to spontaneously improve without additional transfusion, consistent with a consumptive thrombocytopenia; at discharge, platelets were 162 × 109/L. The patient's hemoglobin recovered appropriately after platelet count recovered, presumably because the spontaneous bleeding from the left ovary ceased.
+A battery of hematologic, infectious, and rheumatologic testing revealed an antinuclear antibody (ANA) titer of 1:640, a negative double-stranded DNA (dsDNA), positive anti-Smith antibodies, positive anti-SSA antibodies, and positive anti-RNP antibodies. The patient met criteria for systemic lupus erythematosus (SLE), and her thrombocytopenia was attributed to this. Interestingly, the patient's direct Coomb's test was positive, which is unusual for ITP. The patient had normal bilirubin and liver function tests, but it was thought that she had an early synchronous autoimmune hemolytic anemia (AIHA), which can be associated with thrombocytopenia and can develop in the early years of diagnosis . The patient's response to steroids and normalization of hemoglobin levels with normalization of platelet function illustrates that her AIHA was mild and responsive to steroids alone. The patient was discharged in stable condition on 1 mg/kg oral prednisone and plaquenil.
+One week after discharge, the patient was without active bleeding and ecchymoses were fading. However, she was found to have a platelet count of 28 × 109/L, and was treated for steroid-refractory ITP with rituximab 375 mg/m2 weekly for four weeks. She was placed on oral imuran in hopes of better controlling the underlying SLE. The patient responded well to these interventions, with subsequent platelet recovery to normal levels. She was vaccinated for pneumococcus and meningococcus, and a discussion was held regarding H. influenzae vaccination in anticipation of possible splenectomy later in life.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2973_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2973_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..492581515723b3254ad76379f55915eb0d1ef3d0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2973_en.txt
@@ -0,0 +1,4 @@
+A 40-year old Asian male patient reported to the general surgical outpatient department at Mayo Hospital, Lahore in October 2011 with the history of a rapidly enlarging painless lump in his right scrotum for the past two months. There were no comorbid conditions. He was married with three children; all of them were alive and healthy. His previous medical and surgical history was unremarkable.
+On physical examination, a non-tender lump measuring 4.0 × 3.5 cm, firm-to-hard in consistency, was present as a right testicular swelling. It was associated with slight skin puckering. Examination of the other, that is, the left testis was unremarkable. There was no generalized lymphadenopathy on general physical examination. The liver and spleen were of normal size. Sonographic examination of the scrotum revealed a well-defined, hypoechoic space-occupying lesion in the cranial and lateral aspect of the right testis. Findings on sonographic and computerized tomography (CT) examinations of the abdomen were normal. Differential diagnosis for this sonographic appearance was seminoma and orchitis. His erythrocyte sedimentation rate (ESR) was within normal range and the Montoux test for Mycobacterium tuberculosis was negative. His complete blood counts at the time of presentation were within normal limits. On discussion with the patient, he was informed that benign pathology such as isolated tuberculous orchitis was a possibility and informed consent was taken.
+Testicular biopsy was performed under general anesthesia and the specimen was sent in formalin to the Histopathology Laboratory, Aga Khan University Hospital, Karachi. The histopathological examination revealed markedly necrotic tissue with foci of the lesion. Histologic examination of the specimens revealed a diffuse proliferation of malignant round cells within the interstitium of the testicular parenchyma. The cells were present in the form of sheets with scant cytoplasm and slight variation in size and shape of medium-to-large nuclei, which frequently showed irregular foldings and granular chromatin. Mitotic activity was also observed with mitoses seen at a rate of 16/10 high power fields. Intervening scattered vessels were also present. These cells infiltrated around the seminiferous and epididymal tubules and presented in a discohesive pattern .
+Immunohistochemical stains were applied and neoplastic cells showed positivity with T-cell markers CD3 and CD 43 . CD 56 was also positive . Pan B (CD20), CD 4, CD 8, CD 5 and the epithelial marker cytokeratin were negative. Epstein-Barr virus (EBV) detection was done through immunohistochemistry by using EBV-latent membrane protein (LMP), which was also negative. The study was not experimental and no identifiable material was used in the manuscript, so this study did not require ethical approval.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2984_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2984_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8372258a0ae1042c1ec00f0714f77d96d8a2a479
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2984_en.txt
@@ -0,0 +1,7 @@
+A 34-year-old female presented with a 1 year history of intermittent pain in the right side of the waist without obvious inducement.
+She did not notice other symptoms such as nausea and vomiting, chills, high fever, chest tightness, frequent urination, urgency of urination and painful urination. In the recent 2 mo, the above symptoms gradually worsened, and she was admitted to our hospital.
+She had no previous history of viral hepatitis B or cirrhosis and denied smoking or drinking. She also had no other history of past illness.
+Her parents are currently in good health and are not suffering from any illnesses. There is no history of inheritance in the family.
+Clinical examination showed that there was no obvious abnormality.
+All laboratory blood tests were within normal limits. Indocyanine green 15 min retention was rated 2.9%, and Child-Pugh was rated A.
+Abdominal computed tomography (CT) showed that multiple nodules and abnormal lumpy low-density shadows could be seen in the liver parenchyma, in which the larger ones were located in the left lobe and caudate lobe of the liver, with a size of about 9.5 cm × 6.3 cm and 8.1 cm × 6.5 cm . Abdominal magnetic resonance imaging revealed multiple space-occupying lesions in the liver. Combined with enhanced CT scan, hemangioma was considered. Compression of the main portal vein and right portal vein were noted, and the inferior vena cava narrowed . The total liver volume was about 1739 cm3, the lesion liver volume was about 571 cm3, and the residual liver volume was about 1168 cm3 .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2985_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2985_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f33120a918c9cc5cb478147b2be87c505bb34292
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2985_en.txt
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+A 48-year-old female from Tibet, China was admitted to our hospital for a 4-month history of intermittent pain of chest and back. Each time the pain attacked would last about 1 h and usually twice a day, and it often followed with mild fever and headache. The patient engaged in sheep and cattle raising, without any other heart diseases had occurred before. Electrocardiography demonstrated sinus bradycardia at a rate of 47 beats per minute without ST segment or T wave changes, either conduction abnormality. Cardiac murmur was not found within each cardiac cycle. For routine laboratory tests, all results remained in the normal limits, except an elevated percentage of eosinophils (6.3%).
+Chest radiography showed no lung parenchymal abnormality, either no pleural effusion. Among further cardiac examination, the main anomaly found by transthoracic echocardiography (TTE) was a slightly weak-echo mass located at the myocardium of the right ventricular apex . TTE revealed normal cardiac function. Moreover, a small patent foramen ovale, mild tricuspid regurgitation and pericardial effusion were revealed. Computed tomography angiography (CTA) revealed a soft tissue nodule without enhancement located in the IVS near the right ventricular apex, the boundaries between the mass and surrounding myocardium were indistinct . To clarify the diagnosis, enhanced MRI of the heart was carried out and revealed a cystic, heterogeneous-intensity IVS mass (3.0 cm× 2.8 cm) which was isointensity in T1-weighted images, slight hyperintensity in T2-weighted images, and no significant enhancement in contrast-enhanced images . Imaging characteristics of CTA and MRI suggested the possibility of cardiac HD [, ], thus, further antibody assay of parasite was performed with a positive result of Echinococcus granulosus antibody.
+Given the radiological findings and clinical features, we recommended the patient received surgery to excise the cyst. The patient consented to surgical treatment and signed the operation agreement. During the operation, a median sternotomy was performed, then cardiopulmonary bypass (CPB) was initiated through aortic and bi-caval cannulation. The patient was anticoagulated with 1 mg/kg heparin administered intravenously, while antegrade cardioplegia was administrated to induce cardiac arrest. A mass could be seen at the apex of the heart. Then, we performed regular right atriotomy, and the cyst was exposed through the atrium incision and tricuspid orifice. After puncturing and drawing the cyst content, 3% hypertonic saline was injected into the cyst, and then, excision of the cyst was done. Physiological saline was injected into the residual cavity to verify the presence or absence of ventricular shunt. After that, the residual cavity was plicated with continuous sutures. At last, closed the right atrium, and poured 3% hypertonic saline into the pericardial cavity to prevent local dissemination. Intraoperative TEE showed no mitral or tricuspid regurgitation, either no residual shunt on the IVS, Histopathological examination confirmed the diagnosis of cardiac HC . Albendazole, with the dose of 400 mg twice daily, was told to be regularly used for 24 weeks postoperatively to prevent recurrence and metastasis of hydatid. Postoperative vital signs were stable and the patient was discharged home without symptom of chest pain and other complications.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2987_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2987_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bfa8416ba8d9daa0a4170ab8ac4ce403dd96eab3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2987_en.txt
@@ -0,0 +1,5 @@
+A 60-year-old postmenopausal woman was referred to our hospital with massive vaginal bleeding. Before menopause at age 43, she had a history of 2 cesarean deliveries. She also had a history of hydatidiform mole, 4 years prior to her first viable pregnancy, for which dilatation and curettage was performed and chemotherapy administered. The patient had a medical history of idiopathic portal hypertension and portal thrombosis and a surgical history of esophageal transection and splenectomy. She was on anticoagulation therapy.
+Three years prior to the current presentation, she was seen in another prefecture and found to have dilated vessels around the uterus. There was no further follow-up by gynecology. On the day of her current presentation, she went to a local hospital complaining of sudden-onset continuous vaginal bleeding; she was transported to our hospital by helicopter. Speculum examination revealed continuous bleeding from the cervical os. On bimanual examination, the uterus was the size of a man’s fist, soft and spongy, and non-tender. A urine hCG test was negative. She was anemic, with a hemoglobin of 7.6 g/dL, but no tumor markers were elevated (CA 19–9, CEA, CA 125, SCC).
+Transvaginal sonography showed several 2-cm low-echoic cystic lesions in the anterior uterine body. Color-flow Doppler revealed a mosaic pattern of blood flow within these cystic spaces . Computed tomography (CT) and magnetic resonance imaging (MRI) showed multiple tortuous vessels surrounding the uterus and in the anterior uterine wall . The patient underwent CT angiography which suggested multiple expanded vessels around the uterus . Based on these findings, a uterine AVM was suspected. Given the large vessels supplying the uterus, we anticipated a significant intraoperative blood loss and decided against immediate hysterectomy. We decided to perform UAE.
+Pelvic angiography showed that this patient’s AVM was supplied by many arteries, including the right uterine artery, right internal iliac artery, right external iliac artery, and left uterine artery . We performed UAE in the conventional fashion, using coils and gelatin sponges, and found no significant flow to the AVM after the procedure . Eight days after embolization, we repeated pelvic angiography and unfortunately found newly established arteries and collateral vessels feeding the uterus . A second embolization was performed using coils, with n-butyl-2-cyanoacrylate (NBCA) for residual blood flow, but the abundance of feeding and collateral arteries made it difficult to thrombose every vessel. Finally, we concluded that hysterectomy was the better choice and asked the patient for her consent to attempt it as elective surgery. However, 3 days later, a sudden onset of massive vaginal bleeding indicated rupture of the patient’s uterine AVM and we performed an emergency hysterectomy. There were numerous dilated vessels surrounding the uterine corpus. Surprisingly, it was not difficult to ligate and cut the dilated vessels and we were able to perform the hysterectomy with little bleeding in the operative field. The intraoperative blood loss was 2670 mL, but most of this was transvaginal bleeding from the AVM.
+The location of the rupture in the AVM could not be identified, either on macroscopic or microscopic examination . Microscopy revealed many dilated thick-walled vessels of varying caliber in the myometrium, extending into the endometrium. The final diagnosis of uterine AVM was established. The patient has had no further episodes of atypical vaginal bleeding and no evidence of intraperitoneal hemorrhage 1 year after surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2988_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2988_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..839ce49cf0953c23458cbda707d29901f474561a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2988_en.txt
@@ -0,0 +1,5 @@
+This case is regarding a 27-year-old male with a medical history of intravenous (IV) opioid use disorder who was brought to the ED by emergency medical services following an assault with a complaint of right-hand pain. No further history was provided by the patient. Upon arrival, he was ill-appearing with vital signs of temperature 36.5° Celsius, heart rate 104 beats per minute, blood pressure 114/58 millimeters of mercury (mmHg), respiratory rate 24 breaths per minute, and oxygen saturation 100% on room air. Physical exam revealed bilateral periorbital ecchymosis, anterior neck ecchymosis, petechial rash on his chest, anasarca, and widespread necrotic wounds. An embedded ring was noted at the base of his right fourth finger with significant surrounding edema, erythema, and necrosis.
+Upon chart review of the prior two months, we found that the patient had presented to multiple surrounding EDs with the same chief complaint of right-hand pain with ring entrapment. His first presentation to an outside hospital consisted of unremarkable lab work. The patient left against medical advice (AMA) prior to ring removal. He presented an additional nine times with similar outcomes: lab work would be obtained and the patient would leave AMA prior to ring removal. Thirteen days prior to this case presentation, the patient’s ED workup revealed leukocytosis of 68.2 ×109 cells per liter (L) with 19% blasts and thrombocytopenia of 15 × 109/L, which were not addressed due to the patient leaving AMA.
+On this current presentation (day zero), a radiograph of his right hand was significant for “tourniquet syndrome” of his right fourth digit with extensive circumferential periostitis . The admission CBC was remarkable for a white blood cell count of 157.8 × 109 cells/L (reference range: 4.0–11.0 × 109 cells/L) with blasts of 61% and a subsequent pathology report consistent with acute myelogenous leukemia (AML) . See for hospitalization laboratory results.
+The patient was admitted to the intensive care unit for sepsis secondary to osteomyelitis of the right fourth digit requiring broad spectrum IV antibiotics. Shortly after admission, he developed a change in mental status requiring endotracheal intubation. Computed tomography of the brain did not reveal any acute abnormalities.
+Hematology/oncology was consulted and emergently reviewed the peripheral smear, which revealed blast cells, increased cytoplasmic granules without Auer rods, occasional schistocytes, and a negative Coombs test. Results were consistent with AML, DIC, and auto-tumor lysis syndrome (TLS) due to abnormalities all noted in . He was emergently treated with rasburicase 6 mg intravenously, hydroxyurea 2 g orally every eight hours, allopurinol 50 mg orally daily, and IV fluids. For treatment of DIC, he received a total of eight units of packed red blood cells, five units of platelets, and one unit of cryoprecipitate. On day three of hospitalization, the patient developed hypotension requiring vasopressor support. He was transferred to an outside hospital for advanced treatment of his AML and succumbed to his illness shortly thereafter.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2993_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2993_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6586f79cf1419196373f00d613a845eebf20e918
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2993_en.txt
@@ -0,0 +1,2 @@
+A 63-year-old male with no personal or family history of psychiatric illness was admitted to the inpatient psychiatric ward at a teaching hospital in September 2018 because of sudden-onset manic-like symptoms including irritable mood, increased talkativeness, decreased need for sleep, and hyperactivity that began 2 weeks previously. Concurrently, he was convinced of the existence of a plot by his family members to murder him. He had received a kidney transplant for kidney disease due to diabetes in July 2016. Upon admission, a Mini-Mental State Examination (MMSE) was performed and his score (24/30) indicated impairments in orientation to time and concentration, but no abnormalities were found upon physical and neurological examination. Other than anti-diabetic medications, including gliclazide (60 mg/day) and linagliptin (5 mg/day), the patient was also being treated with the following immunosuppressants: tacrolimus (2 mg/day), methylprednisolone (4 mg/day), and sirolimus (2 mg/day). His tacrolimus levels (6.1 µg/mL) were within the therapeutic range (5–10 µg/mL). The consulted nephrologist recommended continued use of immunosuppressive drugs. On the first day of admission, blonanserin (8 mg/day), an atypical antipsychotic drug, was administered to alleviate psychotic symptoms.
+On the second day, all laboratory results including a drug screen were normal, except increased serum glucose (220 mg/dL) and hemoglobin A1c (9.7%) levels. However, a cerebral magnetic resonance imaging (MRI) study revealed a tuberculum sellae mass measuring 15 × 8 × 13 mm. The lesion was typical of a meningioma displaying homogenous enhancement with gadolinium and a dural tail . Hyperintense white matter lesions with possible tacrolimus neurotoxicity were also seen on fluid-attenuated inversion recovery (FLAIR) images . Since the patient did not show any visual field defects, neurosurgical consultation recommended regular follow-up without surgery. On the tenth day of admission, manic symptoms and impaired cognitive functions significantly improved (MMSE score: 29/30), whereas persecutory delusions remained unchanged. Accordingly, the patient’s blonanserin dosage was increased to 16 mg/day. Seventeen days after admission, delusions disappeared completely, which was supported by his statement of gaining insight into illness. After 3 weeks of hospitalization, most of the symptoms resolved. He was discharged and kept on the triple immunosuppressive regimen without any change in their doses and a reduced dose of blonanserin (8 mg/day).
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2995_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2995_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e3a4fd213f1bd2e1042ce94e80eb99f0b894be0a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2995_en.txt
@@ -0,0 +1,2 @@
+A 41-year-old man presented to our outpatient department with intermittent discharge of a turbid fluid (<1 mL) from his scrotum. On physical examination, a pinhole was noted over his left scrotum with squeezing pain and discharge. Infectious sinusitis or a fistula was impressed initially. An anal fistula was ruled out by digital rectal examination, and a urethra-cutaneous fistula was also excluded by cystourethroscopy. However, the cystourethroscopy examination revealed that there was no left ureteral orifice.
+Computed tomography revealed agenesis of his left kidney and a cystic lesion over his left scrotum . Because of a recurrent local heat sensation, turbid discharge, tenderness, and infection, he underwent resection of the infectious sinus . During surgery, the wound was deepened along with the sinus to the retropubic bone. Near the tail of the sinus, a connection was noted to a channel-like structure. For further investigation, patient was placed at supine position, and mobile C-arm X-ray system was setting for image study. Contrast medium was injected and revealed a channel-like structure about 15 cm in length with a blind end in an upward direction . The setting of mobile C-arm X-ray system is conversely, so the picture showed mirror image. The direction of this tubule was compatible with the development of the left ureter. The tube was ligated and the cut end was sent for surgical pathology. The specimen is confirmed as ureter histologically .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2999_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2999_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..dad7ba683708f2b87726afd71d7adb8477d8948c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2999_en.txt
@@ -0,0 +1 @@
+A 9-year-old male child patient presented with history of fall from bicycle after which he was unable to bear weight on the left lower limb. He was treated elsewhere with splinting for 4 weeks. After removal of splint he was still unable to bear weight on the injured limb due to pain. At the time of presentation to us, the child has an antalgic gait. On clinical examination, he had deformity of flexion abduction and external rotation with painful restricted movements of hip suggestive of anterior dislocation of hip. Examination of opposite hip, spine and knees is normal. Radiological examination confirmed the diagnosis . There were no associated fractures and distal neurovascular status was intact. An open reduction of the joint through the anterior approach is planned and using the Somerville approach, the hip is approached . Acetabulum is exposed and cleared of pulvinar tissue. We passed 2.5 mm smooth k wire in to the femoral epiphysis though lateral cortex and neck to prevent separation of physis during reduction in to acetabulum. Lateral traction is applied with a bone hook under the neck of femur. Reduction is achieved with difficulty. Intra-operatively, reduction is checked under fluoroscopy and is found to be stable, congruent and concentric through all range of motions of hip . K-wire is removed and capsulorraphy is done. Post operatively, skin traction is applied for 2 weeks. Post-operative period is uneventful and X rays confirmed the intra-operative congruency . Rehabilitation protocol included partial weight bearing after 2 weeks till 4 weeks. After 6 weeks the child is allowed to squat and sit cross-legged. At final follow up of 1 year, the child is able to perform all activities of daily living without any difficulty [Image 4] and X-rays showed no signs of osteonecrosis of head or any joint space reduction [, ].
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3003_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3003_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c4b3c8dba8b78469773d1713b67aea2b4019c4dc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3003_en.txt
@@ -0,0 +1,7 @@
+A 67-Year-old male presented to the emergency department with complaints of intermittent high-grade fever that started two days ago relieved by antipyretics prior to admission, which was associated with productive cough and shortness of breath. He had no significant history or chronic illness. He denied recent travel. On examination, the patient looked ill, confused, febrile, had tachypnea, tachycardia, mild pallor, and no lower limb edema. The Glasgow Coma Scale (GCS) was 13 (Eye 3, Verbal 4, and Motor 6). On the chest, there was reduced air entry and crackles on the right side of the lung. On admission vital signs were as follows: SpO2 90% on room air; blood pressure, 105/68 mmHg; pulse, 116 beats/min; respiratory rate 24, blood glucose, 69 122 mg/dl.
+
+The initial laboratory investigation revealed white blood cell count 18.04 x10^9/L (normal 4.00–71 10.00 x10^9/L), hemoglobin 12.1 g/dl (normal 12.0–16.0 g/dl), platelet 450x10^9/L (normal 100–300x10^9/L), C-reactive protein 230.73 mg/L (normal 2.5–10 mg/L), aspartate transaminase (AST) 60.7 U/I (normal 6–38 U/I), alanine transaminase (ALT) 36.0 U/I (normal 6–40 U/I), serum creatinine 2.1 mg/dl (normal 0.4–1.4 mg/dl), and serum urea 170.5 mg/dl (10–50 mg/dl), sodium 135.9 mmol/l ((normal 135.0–145.0 mmol/l), potassium 5.3 mmol/l (normal 3.5–5.5 mmol/l), calcium 2.4 mmol/l (normal 2.10–2.70 mmol/l), COVID-19 test was negative.
+
+Chest radiography was performed immediately and showed right upper lobe consolidation. The patient was admitted to the ward with community-acquired pneumonia and acute kidney injury (AKI) and started Ceftriaxone 1 g two times a day, intravenous fluid of normal saline (NS) 1 Liter per 24 h, ipratropium with ventolin inhaler four times a day,paracetamol 1000 mg infusion once a day, and nasal oxygen support 2 L per hour. After 12 hours, the patient’s condition deteriorated and developed respiratory distress and hypoxia with oxygen saturation 80% on a simple mask of 6L/hour, and was transferred to the intensive care unit (ICU) for supplemental oxygen therapy and further management. 24 hours later in the ICU, the patient’s urine appeared dark-colored and urine analysis revealed no hematuria, suggesting rhabdomyolysis. Laboratory investigation revealed white blood cell count 28.04 x10^9/L (normal 4.00–10.00 x10^9/L), 87 hemoglobin 11.2 g/dl (normal 12.0–16.0 g/dl), platelet 430x10^9/L (normal 100–300x10^9/L), C-reactive protein 300.73 mg/L (normal 2.5–10 mg/L),Creatinine kinase (CK) 4450 u/l (normal 1–171 u/l) serum myoglobin 389 ng/mL (normal 0–80 ng/mL),serum creatinine 2.5 mg/dl (normal 0.4–1.4 mg/dl), and serum urea 194.3 mg/dl (10–50 mg/dl),sodium 137.2 mmol/l ((normal 135.0–145.0 mmol/l), potassium 5.9 mmol/l (normal 3.5–5.5 mmol/l), calcium 1.9 mmol/l (normal 2.10–2.70 mmol/l),aspartate transaminase (AST) 84.7 U/I (normal 6–38 U/I), alanine transaminase (ALT) 40.5 U/I (normal 6–40 U/I) after that our previous diagnose changed for community acquired pneumonia associated with acute kidney injury complicating rhabdomyolysis and electrolyte imbalance so we change our plan for immediate and started with intravenous fluid Normal saline (ns) 5 liter per 24 hour along with adding sodium bicarbonate, piperacillin and tazobactam 2.25 g three times a day, moxifloxacin 400 mg for once a day. We maintained the intravenous fluid according to the dehydration status and urine output. After six days in the ICU, the patient improved and was switched to a nasal oxygen cannula, and laboratory investigations improved.
+
+Subsequently, the patient was transferred to the ward for continued management. A 10th days on admission a chest X-ray was performed and showed normal, clinically improved, and normal laboratory investigations. Finally, the patient was discharged, and follow-up was planned.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3017_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3017_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ab008535ae1797b0e100989d57157767ded62789
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3017_en.txt
@@ -0,0 +1,15 @@
+A 35-year-old African (Congolese) woman was admitted to the Panzi Hospital with a 4-day history of continuous urinary incontinence and dysuria, having previously been continent. The patient described a violent sensation of tearing whilst voiding and a popping sensation akin to the opening of a bottle cap immediately prior to becoming incontinent with blood-stained urine.
+
+Clinical Findings and Diagnostic Investigations
+The patient was G9/P9 with her last normal childbirth 18 months prior to presentation. There was no evidence of genital prolapse and otherwise she had no significant medical or surgical history. On arrival, she looked unwell. Her BP was 95/64 mmHg, pulse rate at 126 beats per minute, temperature 36°C and BMI 17.6.
+
+Initial vaginal examination revealed labia stained with urine and blood. There was a suburethral haematoma above a 2 cm vesico-vaginal fistula. We noted severe anemia (Hb: 6.4 g/dL). In addition, her urine culture was negative.
+
+Management
+She was treated immediately on arrival with two units blood transfusion and became hemodynamically stable antibiotic therapy, hygienic and dietary measures were instituted. After two weeks of conservative measures, the edges of the fistula became clean and rosy, delineating a semi-circumferential fistula involving a portion of the trigone, the bladder neck and the urethra. The urethral length was 1.3cm, the vesico-vaginal fistula size was 3.5cm with the ureters situated 0.5 cm from the edge. She underwent an examination under anaesthetic after initial resuscitation and biopsies were taken for the edge of the fistula. A double check analysis was done in two regional pathology laboratories. Biopsy results revealed a squamous mucosa with an epithelium without notable histological lesions. The dermis was characterized by extensive angiogenic activity, congestion and mixed moderate inflammatory infiltrates diagnostic of lobular capillary hemangioma.
+
+We performed a repair of the vesico-urethro-vaginal fistula, using sharp dissection after the incision around the edge of the fistula. The ureters were protected with ureteric stents. The bladder was mobilized and the edge of the fistula trimmed. In contrast to classic obstetrical and gynecological traumatic fistula repair, the bladder wall on this fistula was found to be haemorrhagic and friable. Haemostasis was obtained using diathermy. Interrupted sutures in one layer were performed using vicryl 2/0 with longitudinal approximation of the fistula edges and the reconstruction of the vesico-urethral junction by lengthening the urethra (narrowing) under a metallic catheter. The urethral length established was approximately 3.5cm. A size 12 French Foley bladder indwelling catheter was left for 14 days. After a negative dye test, the vaginal mucosa was closed. A vaginal pack was placed for 24 hours.
+
+
+Outcome
+Following her catheter removal, the patient was able to void normally with no stress or urge incontinence. She received counseling on fistula prevention as well as contraception. Genital examination was normal and she was discharged 48 hours later. We reviewed the patient 3 months post operatively and found that she was continent with no voiding dysfunction.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3019_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3019_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c4daea2c0f3e7ff79617032da544077e58d824ba
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3019_en.txt
@@ -0,0 +1,21 @@
+Past Medical History
+The patient had end-stage renal disease treated with hemodialysis, bilateral hip osteoarthritis with a previous right hip arthroplasty, hypertension, atrial fibrillation treated with warfarin (Coumadin), previous myocardial infarction requiring coronary artery bypass grafting, and monomorphic ventricular tachycardia (VT) arrest requiring a dual-chamber, single-coil ICD 9 months earlier. Lead models included a Medtronic 5076 CapSureFix Novus magnetic resonance imaging (MRI) SureScan right atrial lead and a Medtronic 6935M Sprint Quattro Secure S MRI SureScan right ventricular lead. Two months earlier, he had experienced fevers during dialysis and recurrent S. maltophilia bacteremia, presumed to be from infected tunneled hemodialysis catheters. He had undergone 3 hemodialysis catheter replacements and had received intravenous (IV) antibiotics. However, before a planned left hip arthroplasty, preoperative blood cultures regrew S. maltophilia. He was admitted to an outside hospital and started on IV ceftazidime. Given his ongoing fevers, he left the outside hospital against medical advice for a second opinion at our hospital.
+
+Differential Diagnosis
+It was reasonable to suspect that hemodialysis catheters were the source of bacteremia because of frequent venous access and fevers during dialysis. According to Heart Rhythm Society (HRS), European Heart Rhythm Association (EHRA),2 and American Heart Association (AHA) guidelines, in cases of nonstaphylococcal bacteremia without evidence of cardiac implantable electronic device (CIED) infection, eliminating accessible non-CIED sources of infection comes first. Persistent bacteremia, despite appropriate IV antibiotic treatment and removal of alternative sources, should raise concern for ICD seeding.
+
+
+Investigations
+
+Hospitalization for second opinion and initial fluorodeoxyglucose positron emission tomography screening
+
+This strain of S. maltophilia was susceptible to ceftazidime, trimethoprim-sulfamethoxazole (TMP-SMX), and levofloxacin. However, the patient was switched from IV ceftazidime to IV TMP-SMX upon arrival to our hospital because of his recent fevers and recommendations to avoid ceftazidime monotherapy for S. maltophilia, according to Infectious Disease Society of America (IDSA) guidelines. Infectious disease specialists recommended a fluorine-18 fluorodeoxyglucose positron emission tomography with computed tomography (18F-FDG PET/CT) scan, which demonstrated increased activity around the left hip joint but no ICD involvement. Orthopedic surgery ruled out septic arthritis in view of the absence of clinical symptoms. Results of 2 blood cultures obtained during the current admission remained negative for 72 hours. Given the low association of gram-negative organisms with device seeding and clearance of blood cultures following a hemodialysis catheter removal (2 days earlier), the ICD was left in place. The patient was discharged with 6 weeks of IV TMP-SMX at 5 mg/kg every 24 hours.1 Oral levofloxacin was prescribed for synergistic effect, but the patient never filled the prescription.
+
+Readmission and Repeat FDG PET/CT Screening
+After the IV TMP-SMX course, the patient had clinical improvement and began using an arteriovenous fistula for dialysis. Two months later, he developed superficial pocket erythema and was started on oral cephalexin (Keflex). One month afterward, he had recurrent S. maltophilia bacteremia and was restarted on IV ceftazidime through dialysis. Because of his persistent bacteremia, he was readmitted for further diagnostic work-up.
+
+There was again no evidence of pocket infection. Transesophageal echocardiography showed no lead or valvular vegetations (Figures 2A to 2E). Computed tomography of the chest was clear. Whole-body FDG PET/CT was repeated to screen for occult sources of infection before proceeding with device extraction. FDG PET/CT revealed uptake along device leads, a finding suggesting CIED infection.
+
+Management
+The patient’s antibiotics were again switched from ceftazidime to IV TMP-SMX, 5 mg/kg daily. Oral levofloxacin, 500 mg every 48 hours, was added for synergistic effects. Electrophysiology was consulted for ICD removal. ICD interrogation revealed sinus bradycardia at 57 beats/min, minimal pacing, and no recent arrhythmias or shocks. The ICD was successfully extracted percutaneously. Extraction proved moderately challenging because the device’s active fixation mechanism failed to retract. With careful traction and countertraction, the right atrial and right ventricular leads were removed intact without complications.
+Device lead cultures grew S. maltophilia. Given his history of sudden cardiac death and the need for an ICD for secondary prevention, the patient was discharged with a wearable defibrillator. Despite blood culture clearance at 72 hours, device reimplantation was deferred pending 8 weeks of oral TMP-SMX double strength 3 tablets daily and oral levofloxacin, 500 mg every 48 hours, to ensure bacteremia resolution.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3026_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3026_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f0161e9ad002e8429c4312f260630cf862c2ae0a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3026_en.txt
@@ -0,0 +1,8 @@
+A 42-year-old woman with a stable partner who consulted for a painful swelling in the genital area. On medical examination, the presence of an abscess in the Bartholin gland was confirmed, which was drained; the purulent material from the puncture was sent for culture. The patient was treated empirically with azithromycin 1 g on the first day and then 500 mg/day for 5 days. The sample was seeded on blood agar, chocolate agar and thioglycolate broth. It was incubated for 24 h at 37 °C in an atmosphere with 5% CO2. Gram staining of the purulent material was performed. Identification was performed by VITEK®2 with VITEK®2 NH cards.
+The sample from the abscess and the isolate were sent to the STD Service of the National Institute of Infectious Diseases (INEI)-ANLIS "Dr. Carlos G. Malbrán" for confirmation of genus and species. In addition, the presence of Chlamydia trachomatis, Mycoplasma genitalium, Mycoplasma hominis and Ureaplasma spp. was investigated in the sample from the abscess by the polymerase chain reaction (PCR) technique. Confirmation of genus and species from the isolate and the determination of the capsular group were performed by PCR. For molecular characterisation and subtyping, the sequentiotype (ST) and the clonal complex (CC) were determined by the technique of multi-locus sequencing (MLST). The antigenic profile was studied by amplification and sequencing of the genes encoding PorA (porin A), fHbp (factor H binding protein), NHBA (heparin binding antigen) and NadA (Neisseria adhesion protein)9. The analysis of the sequences obtained for the assignment of peptide allelic variants was performed in the PubMLST database.
+In addition, the antimicrobial service of INEI-ANLIS determined the minimum inhibitory concentration (MIC) by dilution in agar of the following antibiotics: penicillin, ampicillin, ceftriaxone, rifampicin, ciprofloxacin, chloramphenicol, tetracycline and azithromycin. The methodology established by the Clinical and Laboratory Standards Institute (CLSI) was followed.
+The patient was swabbed oropharyngeally, urethrally and endocervically for the search of colonisation by N. meningitidis by PCR and culture. It was not possible to obtain swabs from her sexual partner. All samples were sent to the ETS service of INEI-ANLIS.
+Gram staining of the purulent material showed a large inflammatory reaction and Gram negative diplococci. After 24 hours, the colonies in the solid media were bright, greyish and larger than the N. gonorrhoeae colonies. The colonies were tested for superoxol and oxidase and were both positive. Identification with VITEK® 2 NH cards showed N. meningitidis (97%). The identification of the isolate was confirmed by the ETS service of INEI-ANLIS by testing the use of carbohydrates (glucose, maltose, lactose and sucrose) and mass spectrometry (MALDI-TOF MS, Bruker, Daltonics). The PCR technique from the sample was positive for N. meningitidis and M. hominis and negative for C. trachomatis, M. genitalium and Ureaplasma spp.
+The isolate was identified as belonging to capsular group B (NmB), ST-35 (CC-35), and its outer membrane protein profile consisted of PorA 22-1,14; NHBA 21 and fHbp 16 (Novartis family 2). The gene encoding the NadA protein was not detected.
+The antibiotic susceptibility of the isolate was intermediate to penicillin (MIC: 0.12 μg/ml) and ampicillin (MIC: 0.25 μg/ml) and sensitive to ceftriaxone (MIC: 0.0005 μg/ml), rifampicin (MIC: ≤ 0.004 μg/ml), ciprofloxacin (MIC: 0.015 μg/ml), chloramphenicol (MIC: 1 μg/ml), tetracycline (MIC: 0.12 μg/ml) and azithromycin (MIC: 0.12 μg/ml).
+With N. meningitidis confirmed as the infectious agent of bartholinitis, the antibiotic was changed to ceftriaxone. The PCR technique and cultures of the patient's oropharyngeal, urethral, and endocervical swabs were negative for N. meningitidis.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3034_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3034_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..965447731e9e9a97741845716087d31352c3fb8c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3034_en.txt
@@ -0,0 +1,9 @@
+It is a male product of gestation 1, mother 27 years old, pregnancy of 32 weeks of gestation with adequate prenatal control, obtained by urgent cesarean section for placental detachment; he did not breathe or cry at birth, so resuscitation was initiated with adequate recovery to the orotracheal intubation. Birth weight 1,225 kg, height 42 cm. After birth, a globose upper abdomen was observed, so an orogastric probe was placed with presence of biliary flow and an abdominal radiography was requested which presented an image of a “double bubble” and absence of distal air. The patient was sent to our hospital unit at 25 days of life for surgical management due to suspicion of AD.
+
+Therapeutics
+
+Upon admission, abdominal ultrasound showed evidence of duodenal atresia and an echocardiogram showed no evidence of congenital heart disease. Finally, the patient was operated on at 33 days of life. A laparotomy was performed to examine the patient and AD was found in the third portion, with a very dilated proximal end and the presence of pancreatic tissue surrounding the second duodenal portion.
+
+Subsequently, the jejunal distal end was located, which corresponded to intestinal atresia type IIIb of approximately 50 cm, which was surrounded by the ileocolic artery in a helical form until it arrived at the ileocecal valve; Meckel's diverticulum was found 16 cm from the ileocecal valve. The distal end was incised and a Nelaton probe was introduced to corroborate permeability; an atresic segment was found at the first cm, which was resected. Subsequently, saline was infused with a 10 cc syringe and the permeability of the rest of the intestine was corroborated; the end was closed with a continuous suture and Lembert points with PDS 5-0. Intestinal malrotation was found, so Ladd's bands were lysed, invaginating appendicectomy and cecal positioning in the left hypochondrium were performed. Subsequently, a duodenal-jejunal anastomosis was performed laterally with PDS 5-0 prior to the second duodenal portion and stenosis was avoided by the annular pancreas; a transanastomatic naso-jejunal probe 12 Fr and peritoneal drainage were placed and the abdominal closure was performed without the need for bypass or intestinal resection.
+
+The patient remained in fasting with total parenteral nutrition for eight days and was administered extensively hydrolysed formula through a naso-jejunal tube, which was removed on the tenth day post-surgery with adequate tolerance to gradual increases until tolerating its total capacity. The control radiographs showed adequate distal air distribution compatible with favorable evolution. There was no need for re-surgical intervention and the patient was discharged to his home at 55 days of life. Currently, the patient is almost one year old and presents adequate growth and development, with no post-surgical complications to date.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3045_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3045_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0baa370fa83444bcebeca67e131ac9b8f9d4ddcd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3045_en.txt
@@ -0,0 +1,9 @@
+A 22-year-old Somali woman patient who had previously been in good condition came to the emergency department with a complaint of an acute visual loss for 1 week. The visual loss was more severe in the right eye, and there was a complete no light perception, while the left eye had a 70% light perception. There was also right eye relative afferent pupillary defect. Intraocular pressure measured on left was 11 mmHg and right was 14 mmHg. Anterior segment examination was normal and both optic discs were seen to be normal in the fundus examination. Extraocular muscles were also examined as normal.
+
+Moreover, the patient reported joint discomfort, muscle weakness, and headaches along with weariness. She appeared sick upon examination, but her consciousness level was intact, she was cooperative. No other relevant positive findings were detected in her examination.
+
+The patient's past medical history was uneventful, and she had no family history of autoimmune diseases. Her vital signs indicate a temperature level of 35°C, her blood pressure was 115/80, her pulse was 70 pbm, and her respiratory rate was 18 breaths per minute. Brain MRI with contrast reported no brain parenchymal disease. Routine blood was normal except thyroid profile TSH was 115.6 mIU/L (range 0.35–5.1), T3 was 0.01 nmol/L (range 1.8–3.9), and T4 was 0.01 ng/dL (range 0.5–1.8). Further laboratory tests revealed a positive anti-tpo and anti- thyroglobulin tests, 74000 IU/mL (range 0–9) and 635.18 IU/mL (range 0–4), respectively. Thyroid ultrasound was reported enlarged thyroid gland with a hypoechoic, diffusely heterogeneous echotexture with no solid nodules or cystic features.
+
+The patient was admitted to the neurology department under the diagnosis of retrobulbar neuritis optic neuritis possibly due to Hashimoto thyroiditis (Thyroid-associated optic neuropathy). A high-dose of corticosteroids (1 gram of methylprednisolone/day) was immediately started and with 100 mcg of levothyroxine treatment. The corticosteroid therapy was decreased after 3 days, and a 1mg/kg of daily dose of prednisolone was commenced. Subsequent to the corticosteroid treatment and thyroid replacement therapy, the visual field markedly recovered and the best corrected visual acuity were both measured at 0.5 (50%) in the right eye and 1 (100%) in the left eye.
+
+These treatment regimens also diminished the general symptoms related to hypothyroidism and normalized TSH and free T4 levels after 2 months. No recurrence of optic neuritis occurred for follow-up after 3 months of treatment.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3056_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3056_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d2d1de7690c3c480c9c4d74ebd3bc6d619cdc256
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3056_en.txt
@@ -0,0 +1,11 @@
+A 56-year-old male was involved in a motorbike accident. He was struck by another motorcycle attempting to overtake a car, causing him to be thrown and impact his face on a road divider. Despite wearing a half-face helmet, he remained conscious but experienced significant pain in his cheek, lip, and left eye area, along with bleeding from his nose and mouth. He was initially transported to Krakatau Hospital for facial surgery but was referred to Cipto Mangunkusumo General Hospital (RSCM) due to difficulties with intubation.
+
+Upon assessment at RSCM, the patient was conscious, cooperative, and oriented, with a Glasgow Coma Scale score of 15. Clinical examination revealed generalized facial edema, bilateral lagophthalmos (2 mm in the right eye, 1 mm in the left), orthophoria, and a visual acuity of 3/60. Subconjunctival bleeding was noted in the left eye, along with malar depression in both nasal regions. The right maxilla showed edema, crepitus, and a floating sensation, while the mandibular area exhibited lacerations and crepitus. Intraoral examination revealed anterior and posterior open-bite malocclusion, with a laceration near the right lip and a separation of the palate. Laboratory results indicated leukocytosis (15,500/mm3). A pre-operative CT scan revealed bilateral Le Fort type I fractures, septal fractures, bilateral condyle fractures, a mandibular symphysis fracture, and zygomatic fractures.
+
+The operation involved multiple specialties, including ENT Plastic Reconstruction, ENT Larynx Pharynx, Oral-Maxillofacial Surgery, and Anesthesia, requiring submental intubation. The Oral-Maxillofacial Surgery Division initiated maxillomandibular fixation (MMF) with arch bars, followed by dental procedure including debridement and extraction of the left central maxillary and mandibular incisors due to indication of Le Fort I fracture. Additionally, the right maxillary lateral incisor and right maxillary canine were intruded and, due to extensive damage we extracted. The left maxillary central incisor was avulsed. Tooth vitality of the remaining undisturbed teeth was found to be normal on physical examination. Following this, open reduction internal fixation (ORIF) of the mandible using plates and screws (numbers 8, 10, and 12). Arch bars were secured with wires to maintain occlusion during reconstruction.
+
+Once occlusion was achieved, an incision was made from the preauricular region, and blunt dissection revealed fractures in the left condyle region, where two plates and screws (numbers 6 and 8) were installed. The same procedure was performed on the right condyle. ENT Plastic Reconstruction then performed open reduction internal fixation of the maxilla with miniplates, with the arch bar locked in place using wires. Incisions were made from the gingivobuccal mucosa to the maxillary periosteum, followed by mucoperiosteal flap elevation. Multiple plates and screws (numbers 4, 5, and 6) were used to stabilize comminuted fractures in the maxilla and zygoma.
+
+Five days post-operatively, the submental anesthetic tube was removed, and a tracheostomy was performed due to silent aspiration and sputum retention. Eighteen days later, the tracheostomy cannula was accidentally dislodged by the patient. Fortunately, the patient's condition remained stable, and there was no desaturation. The patient was treated in the ICU for 25 days. On the third post-operative day, the wire fixation was removed due to airway issues and poor oral hygiene, but the arch bar was maintained until six weeks post-operatively.
+
+One month and eight months after surgery, the patient's face appeared symmetrical, with no facial edema or malocclusion, and no abnormalities were found in either eye.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3057_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3057_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..711bcaf05d9440f834ada947e02c6969b241c866
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3057_en.txt
@@ -0,0 +1,15 @@
+A 67-year-old woman was referred to the hospital by the infectious disease specialist after failure of outpatient treatment of an infection of the surgical wound after an orthopedic surgery of the left shoulder performed 20 days earlier. She had a long-standing depressive disorder, which was controlled with escitalopram. The relevant previous surgery was a right nephrectomy performed 20 years ago for a calculous cholelithiasis. At admission, the serum creatinine level was 0.6 mg/dL.
+
+As there was no improvement after initial treatment with teicoplanin for 5 days, or even after the addition of piperacillin with tazobactan, the surgical site was cleaned and material was sent for culture, with growth of Acinetobacter baumannii and multi-resistant Pseudomonas aeruginosa.
+
+Treatment with polymyxin B was initiated at a dose of 1.5 mg/kg/day. After 4 days of treatment, the patient began to report worsening anxiety, paresthesia of the upper limbs and insomnia. In the two days that followed, the case was joined by tremors of the extremities and dyspnoea. The psychiatric evaluation concluded that there was a possible worsening of the depressive disorder due to the length of the hospital stay. During the period of treatment with polymyxin, the patient's creatinine was measured a few times, increasing from 0.6 mg/dL to 1 mg/dL, and stabilising at this value during the treatment. After 15 days of use of polymyxin, the patient presented dyspnoea, difficulty in swallowing and muscular rigidity, associated with the change in renal function already described, and an evaluation by the nephrology team was requested. Polymyxin B was suspended at that time.
+
+In the nephrology evaluation, in addition to the tests already available, calcium, albumin, magnesium, venous blood gases and urine I were requested. The total serum calcium level was 3.8 mg/dL (VR 8.8 to 10.3 mg/dL) and the albumin, 2.6 mg/dL (VR 3.5 to 5 mg/dL). The serum phosphorus concentration was normal (2.7 mg/dL; VR 2.5 to 4.8 mg/dL). The potassium level was 2.5 mEq/L (VR 3.5 to 5 mEq/L) and the magnesium 0.52 mg/dL (VR 1.7 to 2.5 mg/dL), characterizing severe hypocalcemia, hypokalaemia and hypomagnesemia. The venous blood gases presented the following values: pH: 7.44, pCO2: 40.1 mmHg, HCO3-: 26.6 mEq/L and H+: 36.3 nmol/L, pointing to the presence of mild metabolic alkalosis. The urine I did not evidence glycosuria or proteinuria and presented a urine density of 1015, pH 6.5, leukocytes 29,000, epithelial cells 23,000 and erythrocytes 7,000/mL.
+
+Intravenous replacement of electrolytes was initiated, with significant improvement in the patient's symptomatology after 24 hours of therapy. During the nephrology follow-up, creatinine returned to the baseline value and the patient received daily replacements with 50% magnesium sulphate (5 grams a day); 10% calcium gluconate (1 gram, three times a day) and 19.1% potassium chloride (50 mEq a day).
+
+On the 3rd day of electrolyte replacement, because there was no significant increase in serum concentrations, urine calcium, magnesium and potassium determinations were requested to calculate the excretion fractions (EF) of these elements.
+
+In the case of magnesium, the serum level was multiplied by 0.7, as recommended. The calcium FE was presented only for the observation of its reduction with the time of treatment, since ionic calcium values (which is the fraction effectively filtered) should have been used, but, in the absence of these, total calcium values were used.
+
+The patient was discharged two weeks after the end of the use of polymyxin B, cured of the surgical infection, with the renal function recovered to its baseline levels and with normalization of the serum levels of calcium, magnesium and potassium.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_305_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_305_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..03b95271924b90c6cb500e80dd3825f83d203196
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_305_en.txt
@@ -0,0 +1,13 @@
+A 73 years old caucasian male patient came to the authors' attention while they were providing an emergency first aid service; the patient presented hypertension on treatment with ACE-inhibitors, chronic atrial fibrillation on treatment with oral anticoagulants, and diabetes mellitus on treatment with biguanides: the clinical manifestation was bleeding, probably deriving from the tongue-bite injuries.
+The patient had been complaining of dyspnea for 48 hours, caused by macroglossia.
+The clinical documentation that the patient provided, allowed the Authors to identify the following clinical history: in the previous month, following the progressive volumetric increase of the tongue, he had undergone neck CT scan with contrast agents, that showed a volumetric increase of the tongue, which was occupied by a solid lesion of around 6 cm, contiguous to the muscles of the oral floor. In the submandibular and laterocervical area, there were also some lymph nodes of 15 mm in diameter at the most.
+The patient referred that he had previously undergone surgery, which was planned by another clinician, as inferred from the discharge form.
+In general anesthesia together with an infiltration of local anesthetic, the clinician performed a losangic biopsy (4 × 4 cm), an extemporary histological exam and suture: the intraoperatory examination showed extensive lymphoid proliferation, composed of cells of big and middle size, also affecting the skeletal muscle. The medical report indicated an extensive NHL.
+In order to make an accurate diagnosis, the patient received:
+- CT scans of the thorax, abdomen and pelvis, reporting enlarged lymph nodes of 10 mm in diameter in the subcarinal area and in the right pulmonary hilum;
+- Hematologic consultation and osteomedullary biopsy.
+After about 30 days since the first surgical removal of the tongue lesion, the patient came back at our clinic complaining severe dyspneic symptoms. Therefore the patient was immediately received by the Authors, who suspected a possible relapse of the primary lesion.
+The extraoral exam revealed a hard tumefaction of a normal color in the left submandibular region .
+The intraoral exam revealed a considerable volumetric increase of the tongue , which was of a red-violet color, with well-delimited necrotic-ulcerative areas at the level of the left margin and left region, and with bleeding probably caused by the tongue-bite injury.
+The tongue was painful and woody to palpation.
+72 hours later, a fiber-scopic examination of the larynx showed ab-extrinsic compression of the posterior wall of the trachea, with reduction of the tracheal lumen; after the worsening of breathing, other colleagues performed an emergency inferior tracheostomy and provided medical advice.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3077_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3077_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..96f71d273bb432c89939efb19936a6c68ba6c0c9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3077_en.txt
@@ -0,0 +1,8 @@
+A 29-year-old right-handed Ethiopian male patient presented with a 10-year history of exercise intolerance that worsened with mild-to-moderate exertion. In addition, he reported bilateral ptosis (drooping eyelids) since childhood. He also had difficulty ambulating, with intermittent loss of balance, especially at night. A permanent pacemaker was inserted in 2018 after he was diagnosed with third-degree AV block with an electrocardiogram (ECG). Pacemaker implantation resulted in substantial improvement in exercise tolerance. However, the patient subsequently developed new neurological symptoms, including dysarthria (slurred speech) and intermittent attention deficits, particularly during listening tasks. Moreover, he reported a decline in hearing ability. Family history was negative for similar presentations. Physical examination revealed general muscle wasting and bilateral symmetrical ptosis. Limitation of ocular movements in all quadrants was found on examination of cranial nerves 3, 4, and 6. On examinations of cranial nerve 8, he could not hear finger rubbing sounds from 2 cm, but there was no lateralization on Rhine and Webber tests. The muscle bulk was comparable in all four extremities, and power and tone were normal. However, dysmetria on the finger-to-nose test was noted. He was also unable to perform tandem gait. He was referred to the otolaryngology department for audiometry evaluation and was found to have mild bilateral sensorineural hearing loss.
+
+Laboratory evaluations were within normal reference ranges, including a complete blood count (CBC), renal function tests (RFTs), serum electrolytes, and metabolic panels. Specifically, the CBC revealed white blood cells at 6500/μL, hemoglobin at 16.5 g/dL, and platelets at 193,000/μL. Fasting blood sugar was 95 mg/dL, and TSH level was 2.35 ng/dL.
+
+Electrophysiological studies yielded normal results, including electromyography (EMG) and nerve conduction studies (NCS).
+
+Treatment and outcomes
+The patient underwent permanent pacemaker placement, resulting in a marked improvement in exertional dyspnea. A multidisciplinary team currently follows him, including the cardiology, neurology, and ophthalmology departments.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3080_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3080_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f500548efcb61c8d2b68a3d313f97f0dfb3b1e0b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3080_en.txt
@@ -0,0 +1 @@
+Medical history: A patient with a history of type 2 diabetes mellitus, dyslipidemia, and hypertension was referred to dermatology for a 1-month pruritic, scaly eruption of the palms and soles unresponsive to topical steroids. Her medications included lisinopril, metformin, atorvastatin, calcium carbonate, and vitamin D. Examination revealed well-defined, irregularly shaped erythematous and scaly plaques on the palms and soles without nail involvement. Laboratory investigation including complete blood count with differential, erythrocyte sedimentation rate, C-reactive protein, and lactate dehydrogenase yielded normal results. Histopathological examination of the right sole punch biopsy specimen showed compact orthokeratosis and mild superficial perivascular lymphocyte infiltrate with focal exocytosis predominantly at the basal layer, and mild lymphocytic cytologic atypia including nuclear enlargement, hyperchromasia and irregular nuclear contour. Immunophenotyping studies showed a predominance of CD3-positive T cells with a CD4 to CD8 ratio of 1:1 and a preserved but decreased CD7 expression. The findings of palmoplantar keratoderma, low-grade lymphoid atypia, basilar lymphocyte exocytosis, and the phenotypic profile illustrated by a decline in CD7 expression collectively supported the diagnosis of keratoderma-like T-cell dyscrasia. Two weeks following atorvastatin disconsolation and the use of mid-potency topical steroids, the patient reported an 80% improvement in pruritus and reduced erythema and scaling of the palms and soles within 2 weeks. At the 6-month follow-up, complete resolution of the keratoderma and pruritus was observed.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3087_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3087_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..dd3e104e4e47b338e6e899d2e6ec0a1df0c487ae
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3087_en.txt
@@ -0,0 +1 @@
+A 6-year-old boy presented with erythematous scaly lesions on the scalp and back. The clinical diagnosis of psoriasis was established and he started treatment with topical corticosteroid (methylprednisolone ointment). A partial clinical improvement of the lesions was noted, but residual plaques persisted. About one month later, purplish lesions appeared in the infrapopliteal region, in the gluteal area and in the upper limbs. He did not have fever, arthralgia and no gastrointestinal or genitourinary symptoms. A skin biopsy was performed in the affected area, which revealed a small vessel vasculitis affecting the papillary dermis. He continued the treatment with topical corticosteroid in the newly affected areas with good clinical response. A few days later, a urine analysis was performed that showed microscopic haematuria and nephrotic range proteinuria (urine creatinine protein (UCR) ratio of 4998 mg/g). These urinalysis abnormalities persisted for the following two months, although he always maintained normal blood pressure, without oedema or macroscopic urine abnormalities, and with normal serum albumin, creatinine and lipid profile. A complete investigation showed no abnormal findings, including measurement of circulating complement proteins (C3 and C4), immunoglobulins (IgA), ANA, anti-dsDNA and ENA antibodies, and serologic testing for hepatitis B, HIV, and Epstein-Barr virus (EBV). Ultrasound of the kidneys and bladder was normal. Almost three months after the first altered urine analysis, new macroscopic haematuria was observed, concomitant with abdominal pain and vomiting. Nefrotic range proteinuria (10 mg/m2/h) persisted. Histopathology of renal biopsy revealed mesangial proliferation and growing fibrocellular in 6/16 glomeruli with fibrinoid necrosis, and direct immunofluorescence showed predominantly mesangial IgA granulomatous deposits. These aspects were consistent with IgA nephropathy, class III of Haas. Three pulses of methylprednisolone of 30 mg/kg/day were administered, with decreasing macroscopic haematuria. The patient maintained oral prednisolone (60 mg/m2/day) for 4 weeks. During this treatment period, psoriatic lesions improved clinically, but nephrotic range proteinuria persisted. For this reason, cyclophosphamide (2 mg/kg/day) was initiated, concomitant with gradual withdrawal of prednisolone. Nine weeks later, the proteinuria decreased to a non-nephrotic range (RPCU < 2000 mg/g), but persisted above 1000 mg/g and, therefore, enalapril was introduced. He completed 12 weeks of cyclophosphamide. The proteinuria continued to decrease and became negative one month later. Renal function remained normal. The psoriatic lesions worsened with the gradual adjustment of prednisolone dose, despite cyclophosphamide. The use of topical corticosteroid (mometasone) and calcitriol ointment was initiated, but clinical improvement was insignificant. The patient then initiated phototherapy with a significant clinical improvement.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3097_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3097_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4f0de446fbbfc4d1c6238d09fe2050d192ec0995
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3097_en.txt
@@ -0,0 +1,13 @@
+A 10-year-old male child presented to our surgery clinic on October 2021 with a chief complaint of abdominal pain and vomiting for the past ten months. The pain was frequent, colicky, postprandial, and generalized. It was aggravated by eating and associated with vomiting, anorexia, and weight loss. There was no history of hematuria, rectal bleeding, or diarrhea. There is a history of chronic constipation and environmental exposures to unclean water. The patient lived in a village and owned a dog and cheeps, which he kept in the house. In addition, he has a family history of lymphoma in his brother.
+
+On physical examination, the patient looked ill with no pallor or jaundice. There was a nonmobile, non-tender, palpable right iliac fossa mass on abdominal examination.
+
+The laboratory data were as follows: total white blood cell count: 12 ×103/mL, hemoglobin:14.4 g/dl, blood urea nitrogen: 35 mg/dl, creatinine: 0.9 mg/dl, serum albumin: 4.2 g/dL, serum bilirubin: 1 mg/dL, and negative for viral hepatitis. The urinalysis and stool examination were normal.
+
+Ultrasonography (US) of the abdomen showed a segmental wall thickening of the ascending colon and 10×3 cm intraluminal sigmoid mass suggestive of an intestinal tumor or lymphoma. The computed tomography (CT) scan of the chest and abdomen showed that the sigmoid is redundant and seen on the right lower abdominal quadrant before its cross midline and joins the descending colon, diffuse circumferential wall thickening of the sigmoid colon, and 10×3 cm intraluminal mass with significant lumen narrowing. There were multiple perilesional lymph nodes; the largest one was measuring 1.4x1cm. There was hepatomegaly with heterogenous contrast enhancement without a definite lesion. In addition, there were multiple para-hepatic, and pulmonary lymph nodes enlargements. Based on the CT findings (extranodal lymph nodes enlargements and multiple general lymphadenopathies) and the family history of malignancy, the possibility of malignancy could not be excluded. After a multidisciplinary discussion, the decision was made for an open surgical exploration.
+
+After general anesthesia and lower midline incision, the abdominal cavity was opened, revealing a sigmoid colon attached to the abdominal wall at the right lower quadrant, a large sigmoid mass measuring about 15 cm, and multiple mesenteric and paraaortic lymph nodes enlargements. Sigmoidectomy with a safety margins and primary anastomosis were performed, and the specimen was sent for pathologic assessment.
+
+
+Follow-Up and Outcome
+The postoperative period was uneventful, and he was tolerating a regular diet. The patient was discharged home on the fifth postoperative day. The histopathology reported that numerous non-caseating granulomas formed of bilharzial ova (Schistosoma mansoni) and multinucleated giant cells. The patient was referred to the pediatric infectious disease clinic and was treated with three doses of praziquantel (60 mg/kg). Within five months of follow-up, the patient remained symptom-free.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_30_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_30_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d9681a1939f3379daca543fba718941fc27c7b0b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_30_en.txt
@@ -0,0 +1,6 @@
+A 72-year-old male with a history of lung cancer, with left lower lung lobectomy and right upper lobe wedge resection, chronic obstructive pulmonary disease, and atrial fibrillation presented with 2 weeks duration of fever, cough, shortness of breath, and poor appetite. Nine days before admission, he tested positive for COVID-19 by a real-time polymerase chain reaction. He had a 60-pack-year smoking history. At home, he was taking 81 mg of aspirin once daily, 20 mg of rivaroxaban once daily, 40 mg of atorvastatin once daily, 40 mg of furosemide once daily, and albuterol 90 μg/actuation inhaler, which were continued while he was hospitalized.
+During his first hour of admission, he required 2 L/min of supplemental oxygen to maintain adequate saturation, although the rest of his vitals were stable. Laboratory test results were significant for the following: C-reactive protein 304.87 mg/L (0–10 mg/L); lactate 3.2 mEq/L (0.2–1.9 mEq/L); lactate dehydrogenase 659 U/L (100–220 IU/L); d dimer 2374 ng/mL (0–300 ng/mL); aspartate transaminase 45 U/L; and alanine transaminase 36 U/L (6–45 IU/L). Venous blood gas revealed pH 7.46 (7.32–7.42), pCO2 39 mmHg (42–50 mmHg), and pO2 34 mmHg (30–50 mmHg). The chest radiograph demonstrated bilateral patchy airspace disease. Electrocardiogram (ECG) demonstrated atrial fibrillation and right bundle branch block (RBBB). QRS interval was 132 ms . Within 3 h of presentation, the QRS complexes reverted to narrow complexes. Hence, he was in intermittent RBBB.
+Remdesivir was started on Day 1 of his hospitalization, with a loading dose of 200 mg on Day 1 and 100 mg daily for four additional days. He was started on Dexamethasone 6 mg daily for 10 days. Within 24 h of initiation of Remdesivir, he was noted to be in atrial fibrillation with slow ventricular rates between 30 and 40 b.p.m. He was also requiring 40 L/min of oxygen through a high flow nasal cannula and subsequently transferred to the intensive care unit. Two sets of troponins I were 0.028 and 0.022 ng/mL (0.03–0.04 ng/mL).
+On Day 5 of Remdesivir therapy, he was noted to be persistently bradycardic. ECG demonstrated atrial fibrillation with slow, fixed ventricular response, consistent with complete atrioventricular (AV) block . Echocardiography done on that day showed an ejection fraction of 60% with moderate pulmonary hypertension, dilated right ventricle, mild aortic insufficiency, moderate tricuspid insufficiency, and mildly reduced right ventricular function.
+Having completed the Remdesivir regimen, during the next 48 h, he was closely monitored, and the AV block resolved spontaneously. ECG done on Day 10 demonstrated atrial fibrillation with ventricular rates between 52 and 58 b.p.m. . He was noted to be clinically improving, with his supplemental oxygen requirements decreasing from 40 to 15 L/min. As he remained asymptomatic and had an adequate chronotropic response with activity, pacemaker implantation was not recommended. Over the next 2 weeks, his oxygen requirements improved, and his heart rate remained between 48 and 60 b.p.m. He was discharged home after a 3-week stay in the hospital on 2 L/min of supplemental oxygen.
+He died ∼2 weeks after being discharged from the hospital. The cause of his death was not known.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3106_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3106_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b143741ff62dda6b7c48586db9477d7e781f2b2d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3106_en.txt
@@ -0,0 +1,5 @@
+The 62-year-old male patient underwent heart transplantation on November 2, 2019 for arrhythmogenic cardiomyopathy of the right ventricle. After transplantation, he remained hospitalized due to a series of complications including pneumonia and acute respiratory distress syndrome (ARDS). He required 56 days of mechanical ventilation and was in need of intermittent renal replacement therapy. Echocardiography revealed a left ventricular ejection fraction of 55% with no signs of transplant rejection. His immunosuppression regimen consisted of cyclosporine A (target range 135 ± 30 ng/mL), mycophenolate mofetil 500 mg b.i.d., and prednisone 10 mg q.d. No anti-lymphocyte globulins had been used as induction therapy. Blood count revealed anemia and leukopenia, the latter likely being caused by immunosuppressive medication, yet not improving significantly under dose reduction. He received cotrimoxazole and due to cytomegalovirus (CMV) high-risk constellation (D + R−), ganciclovir had been administered for 4 months after transplantation and was then switched to valganciclovir prophylaxis. Concurrent medication did not include angiotensin-converting enzyme inhibitors or angiotensin receptor blockers.
+
+On March 13, 2020 (day 1), the patient developed fever (39.9°C), tachycardia (105 bpm), and a sore throat. Polymerase chain reaction (PCR) from throat swab revealed SARS-CoV-2 infection. Body temperature quickly normalized within the first 12 hours. Blood oxygen saturation levels remained stable in the range of 96%-100% without oxygen supplementation at a respiratory rate of 16 breaths per minute. Besides mild rhinorrhea and impaired exercise capacity, the patient showed no other symptoms, in particular no cough or dyspnea at rest. On day 7, a second increase in temperature up to 38.4°C was observed, which resolved spontaneously. This episode went along with a mild rise and peak of C-reactive protein (CRP), IL-6, and pro-B-type natriuretic peptide (proBNP) levels and lymphopenia. A computed tomography scan showed regressive postinflammatory alterations after bacterial pneumonia and ARDS, but no clear signs of COVID-19 pneumonia or bacterial superinfection. Procalcitonin levels remained low and blood cultures showed no bacterial or fungal growth. We decided to administer hydroxychloroquine (loading dose 400 mg b.i.d. followed by 200 mg b.i.d.) from day 7 to 14. Remarkably, while the patient was free of any marginal residual clinical symptom since day 20, SARS-CoV-2 PCR was positive on days 1, 5, 7, 11, 18, 21, 25, 28, 33, and still on day 35. Concurrent with the second onset of fever we observed an increased viral load after day 7 that slowly returned to the level of infection onset. Whereas the patient already was asymptomatic, virus culture on days 18 and 21 still confirmed active virus replication.
+
+As proBNP levels increased and decreased simultaneously with the inflammation parameters, we considered a COVID-19-related myocardial infection, yet did not confirm it by myocardial biopsy. No signs of clinical deterioration, notably no signs of cardiorespiratory impairment, were observed. Weaning from hemodialysis was successful (day 1) and urine output and body weight remained stable. Cyclosporine A dose was adjusted several times over the course of infection to achieve a therapeutic range of 135 ± 30 ng/mL. Otherwise, medication including immunosuppression was continued unchanged except for an increase of prednisone dose to 50 mg for 3 days and 25 mg for another 3 days from day 14 on for treatment of acute gout in the left knee.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3108_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3108_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..06b7193d46424a1d93760e2d5912438da97feb5b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3108_en.txt
@@ -0,0 +1,9 @@
+41-year-old patient, in her third pregnancy, with a pregnancy of 23.6 weeks, who entered the consultation service of the Tolima Maternal and Infant Unit (UMIT) for a clinical case of six days of evolution, of abrupt onset and progressive deterioration, consisting of bilateral visual acuity decrease, predominantly on the right, accompanied by mild right temporal headache, without other neurological alterations. She had attended adequate prenatal controls without notification of previous symptoms, and fetal growth within expected parameters. The UMIT is a private institution of high complexity, which attends patients of the contributory regime of workers and the regime subsidized by the State in the General System of Social Security in Health (SGSSS), located in the central region of the country.
+
+On physical examination, visual acuity of 20/400 in both eyes was observed, which did not improve with PH (pinhole), intraocular pressure was normal in both eyes (12 mm/Hg), confrontation perimetry with nasal field cut in the right eye (homonymous bitemporal hemianopsia), Marcus gun positive in the right eye, fundoscopy without papilla edema with pulses present, and normoreactive pupils. Initial suspicion of compressive optic neuropathy. A simple MRI of the sella turcica, brain and orbits was performed, with a relevant and consistent finding of a supraselar lesion that compressed and displaced the optic chiasm, with hemorrhage of the right optic tract. Craniofaryngioma was considered as the first diagnostic possibility. Due to the hemorrhage of the optic tract, cavernoma was ruled out as a possible differential diagnosis; an MRI with angiography was performed, in which no alterations in cranial arterial structures were observed.
+
+As part of the evaluation for suspected craniopharyngioma, secondary endocrine disorders were ruled out, and a complete hormone profile was performed with normal results except for slightly elevated cortisol (23 [normal values-NV: 5.27-22.45]).
+
+A medical board of specialists in neurosurgery, perinatology and ophthalmology recommended that no contrast study be performed, given that at that point in the pregnancy, it would not change the expectant management. The pregnancy was ended at week 38, with outpatient follow-up and surgical intervention was defined for the postpartum period. During the pregnancy, there was no progressive deterioration of visual acuity or visual fields. The baby was delivered by cesarean section, without complications, on the recommendation of neurosurgery and perinatology due to the risk of increased intracranial pressure during valsalva maneuvers. A live male newborn was obtained (weight 3,115 g, height 50 cm).
+
+At the end of her puerperium, the patient was evaluated by a neurosurgeon who decided to continue expectant management with ophthalmological follow-up, because the tumour lesion was in close contact with the optic chiasm. During the five-month follow-up, the lesion persisted with a decrease in bilateral visual acuity.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3115_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3115_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..27e9edfe636b7dc4c7dfe65cb545482c4a7f128c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3115_en.txt
@@ -0,0 +1,17 @@
+A 56-year-old postmenopausal woman presented with a history of intermittent mastalgia, mild lumpiness, and clear nipple discharge of the right breast, which started a year ago. She has a previous known history of right breast intraductal papilloma without atypia 8 years ago, for which she refused the intervention at that time. Her mammogram two years ago was reassuring.
+
+An ultrasound scan revealed a highly suspicious mass at the 2 o’clock position of the right breast periareolar area, measuring 17 mm, with a hypoechoic dilated duct measuring over 50 mm in length and 3.4 mm in diameter at the medial aspect of the right nipple. The axilla appeared normal on the ultrasound scan.
+
+Upon comparison of mammograms from eight years ago and two years ago, the lesion was identified as a new development. An ultrasound-guided core biopsy of the right breast mass was performed. The histopathological evaluation revealed a Grade II Invasive Ductal Carcinoma.
+
+After a multidisciplinary team meeting, a Magnetic Resonance Imaging (MRI) and breast tomosynthesis were ordered to assess the disease extent. The known malignancy of the upper inner quadrant was identified, measuring 26 mm in the longest dimension. The MRI study identified an anterior extension accounting for an overall extent of 31 mm.
+
+A SS reflector was placed at the site of the tumour under ultrasound guidance. No immediate complications were noted. Post-insertion mammogram has been obtained.
+
+Imaging revealed that the scout was successfully placed in the lesion.
+
+Two days later, the patient presented to the breast clinic complaining of severe stabbing pain in the right nipple. An ultrasound and mammogram scan revealed that the scout had migrated from the site of the cancer into the duct at the tip of the nipple.
+
+Under local anaesthesia, a small incision was made on the skin over the tip of the scout, and it was removed. The patient visited the clinic the next day and reported reduced pain and discomfort since the scout was removed.
+
+The patient declined to have another SS reflector due to distress during the initial procedure. The decision has been made to proceed with skin marker-guided wide local excision, which she has had. Postoperative histopathological evaluation showed 27 mm grade 2 invasive ductal carcinoma (IDC) no special type, with no associated ductal carcinoma in situ, which is completely excised, and sentinel node biopsy was negative.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3119_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3119_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4b07cd703e9e6758021c3c63ff441d9810fc4150
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3119_en.txt
@@ -0,0 +1,15 @@
+34-year-old black woman, from Equatorial Guinea, with a history of antiphospholipid syndrome and 6 pregnancies (1 miscarriage treated with curettage; 4 ectopic pregnancies, 2 of which were treated with methotrexate and 2 with salpingectomy). In the last pregnancy, an emergency cesarean section was performed due to vaginal bleeding in a full-term twin pregnancy with total occlusive placenta in a third-level public hospital. During the cesarean section, the patient presented postpartum hemorrhage secondary to uterine atony that did not respond to the administration of uterotonics, so the B-Lynch technique was performed, which is the most common uterine compression technique in the center where she was treated. The patient required admission to the intensive care unit, transfusion of two concentrates of red blood cells and was discharged, along with the neonates, on the fifth day after the cesarean section.
+
+On the eighth day of puerperium, the patient went to the emergency room of the University Hospital of Getafe in Madrid, Spain, a public hospital of second level, different from the center where she was treated for the cesarean section. She reported continuous abdominal pain, predominantly in the hypogastrium, and micturition clinical (dysuria, pollakiuria and urinary urgency), without dysthermic sensation or gastrointestinal clinical.
+
+On examination, the patient had a temperature of 36.7°C, blood pressure of 127/71 mm/Hg, heart rate of 89 bpm and oxygen saturation of 99%; on abdominal palpation, she reported pain in the hypogastrium with no signs of peritoneal irritation and a well contracted uterus. The surgical wound looked good, the lochia was normal, the cervix was permeable and she had no pain on cervical mobilization or clinical signs of post-cesarean endometritis. No adnexal masses were palpated.
+
+Urinalysis showed a white blood cell count of 500/uL, protein 100 mg/dL and 1774 white blood cells/field; in the blood count the white blood cells were 8960/uL, neutrophils 6320/uL, hemoglobin 9.4 g/dL, hematocrit 28.6%, platelets 390100/uL; in the biochemistry there was a C reactive protein of 40.3 mg/L. With these findings, the most probable diagnosis was a lower urinary tract infection, without ruling out other causes of abdominal pain, given the history of recent surgery. A transvaginal ultrasound showed an anteverted uterus with irregular endometrium of 2 mm with possible haematotic remains inside and with a heterogeneous formation at the level of the caesarean scar compatible with a haematoma of 66 x 18 x 81 mm. The ovaries were normal and there was no free abdominal-pelvic fluid.
+
+With a diagnosis of lower urinary tract infection and a hematoma in the cesarean scar, admission of the patient for observation and treatment of the pain was decided. At 5 o'clock the analyses were repeated, which showed anaemia (haemoglobin 8.0 g/dL, haematocrit 24.1%). An abdominal ultrasound was performed, which showed a subjective increase in the size of the hematoma with respect to the previous ultrasound, so a revision in the operating theatre was decided.
+
+An exploratory laparotomy (Pfannenstiel) was performed through the same incision of the cesarean scar. Necrosis of the hysterorrhaphy scar was observed, almost in its entirety, with dehiscence of the scar, mild lacerations in the serosa of the uterine body that coincided with the areas of compression of the suture and haematoma that extended to the vesical dome, so it was decided to perform a total hysterectomy. The ovaries were normal so they were preserved. Urology checked the integrity of the bladder by instilling methylene blue through the bladder catheter, although it was decided to keep the bladder catheter for a week with antibiotic prophylaxis.
+
+Postoperative evolution was favorable and the patient was discharged on the fourth postoperative day. She went to the gynecological emergency room for evaluation and removal of the bladder catheter on the seventh postoperative day. On the last follow-up visit, three months after surgery, the patient was well and was discharged.
+
+The pathological anatomy report described extensive tissue necrosis at the level of the suture zone in the isthmus, with involvement of all uterine layers in a transmural manner, with multiple phenomena of thrombosis and vasculitis with fibrinoid necrosis.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3121_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3121_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0d91aed19b1e7ed62d5bb0c72226dbaf8ec59146
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3121_en.txt
@@ -0,0 +1,11 @@
+Description and clinical diagnosis
+A 78-year-old female with a history of a previous TKA presented to the emergency department following a motor vehicle accident. She complained of severe pain, swelling, and bruising in her lower leg. Physical examination revealed false motion of the affected lower leg and swollen soft tissue with multiple fracture blisters. The neurovascular examination was normal, and there was no evidence of impending compartment syndrome. Radiographs revealed a tibial shaft fracture with no evidence of loosening around the tibial prosthesis, consistent with AO/OTA classification 42B2 and Felix classification type IIIA. Three years ago, she underwent open reduction and internal fixation with dual plates to address an ipsilateral periprosthetic supracondylar femur fracture. Radiographs showed that fracture has completely healed. Furthermore, the patient was diagnosed with non-small cell lung cancer, specifically adenocarcinoma. There is no evidence of recurrence after surgical excision three years ago.
+
+Decision making
+Due to the patient's age and medical comorbidities, as well as the compromised soft tissue condition and poor bone quality, open reduction and internal fixation was considered high-risk due to potential secondary complications associated with prolonged bed rest and immobilization, as well as wound complications. Therefore, the surgical team chose to use an IMN without reaming to minimize soft tissue injury and promote fracture stability, as it is a load-sharing device.
+
+Surgical technique
+Under spinal anesthesia, the patient is positioned on a radiolucent standard table, and a small bump is placed under the ipsilateral hip. The fluoroscopy unit is placed on the contralateral side. The injured lower extremity is then draped in a sterile manner. A sterile radiolucent triangle is placed under the knee to assist maintain flexion of the knee joint. The tibial baseplate and the tibial tubercle are palpated and verified using fluoroscopy. A direct midline incision is made, extending from the inferior pole of the patella to the tibial tubercle. Careful dissection is performed to preserve the compromised soft tissues. The patellar tendon is sharply divided in line with the orientation of its fibers. A threaded guide wire is inserted at a point between the anterior edge of the tibial baseplate and the tibial tubercle to avoid the tibial baseplate and cement mantle. It advanced in line with the axis of the tibia as much as possible. A cannulated awl is gently used to open the canal following the guide wire. Then, a ball-tip guide is inserted and passed across the fracture site while maintaining adequate fracture reduction manually. A nail with a smaller diameter (12 mm in this case) than the preoperatively measured canal diameter is inserted manually with great care to avoid violation of the posterior cortex. Despite making every effort to perform the procedure delicately, an iatrogenic crack occurred in the proximal metaphysis of the tibia while manually oscillating the nail during its advancement. The nail was advanced into the distal segment of the fracture. Proximal and distal holes are secured with angular stable interlocking screws to reduce the risk of screw cutout, while ensuring proper reduction and implant positioning under fluoroscopy.
+
+Postoperative course and follow-up
+The patient was mobilized immediately and allowed to bear weight with walker support as tolerated for two weeks after the surgery until the soft tissue had completely healed. She subsequently gradually returned to her pre-injury ambulation status. Despite the initial challenge of poor soft tissue condition, the patient recovered without any soft tissue or wound complications. The postoperative hospital course was uneventful, with no medical complications. At the six-month follow-up, plain radiographs showed healing in three out of four cortices at the fracture site of the tibia and an iatrogenic crack in the proximal tibia. The patient had returned to her pre-injury ambulation status.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3127_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3127_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f76b339b08fb6357e1866a51847a78e85cad7c68
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3127_en.txt
@@ -0,0 +1,9 @@
+4-year-old male patient with a full vaccination schedule for his age, eutrophic and with no previous pathological antecedents, was admitted with a clinical picture of 4 days of evolution consisting of rapidly progressive edema and ptosis of the left upper eyelid, associated in the last 2 days with the appearance of a painful mass in the upper bulbar conjunctiva, without any other associated symptomatology. On admission, left ptosis of 3 mm was observed with occupation of the superior orbito-palpebral sulcus, presence of a mass of 10 mm in diameter depending on the superior bulbar conjunctiva, elevated and salmon-coloured, extending to the superior fundus of the sac, associated with multiple bilateral cervical and inguinal adenopathies. In the directed ophthalmological evaluation, visual acuity, ocular movements and pupillary reflexes were preserved, and the biomicroscopy and fundoscopy were without alterations.
+
+In conjunction with paediatric lymphoproliferative disease, extension studies were performed and a computed tomography (CT) of orbits was found to show thickening of the upper left eyelid with peripheral enhancement, diameter of 12 mm and thickness of 0.9 mm; a CT of the face showed multiple cervical adenopathies between 4-8 mm with a tendency to form conglomerates in the cervical ganglion stations Va, Vb and IV; a CT of the thorax showed a single nodule of 2.8 mm in the lateral segment of the middle lobe; a CT of the abdomen showed a liver size at the upper limit of normal (112 mm) and splenomegaly, splenic index 177 mm (mean 124 mm).
+
+Laboratory tests showed a relative lymphocytosis of 50% with a normal leukocyte count for the age (14,100) and atypical lymphocytes of 17% without anaemia or thrombocytopenia. Renal function and electrolytes within normal limits. Lactic dehydrogenase (LDH) elevated 453 U/L [150-300 U/L). Peripheral blood smear showed increased white blood cells and some atypical lymphocytes. Bone marrow aspirate showed a granulocytic predominance with mainly CD8 positive T lymphocytes and increased gamma delta T lymphocytes, without significant increase in CD34 precursors. In conjunctival flow cytometry immunoproliferative study, a lymphoid CD8 positive phenotype was predominant. Indirect negative human immunodeficiency virus (HIV) study.
+
+In view of the findings and results, the paediatric haemato-oncologist suggested a possible viral process (Epstein Barr or cytomegalovirus), an immune disorder or, less likely, a lymphoproliferative neoplasia. An excisional biopsy of the conjunctival lesion was performed, which showed a diffuse pattern of large cells with Reed-Stemberg-like popcorn-like morphology, reactive to CD45, CD20, MUM1, BCL-2, CD30, PAX-5, weak nuclear, Oct-2 positive, BOB-1 negative. Associated with this was a large population of T lymphocytes with a usual morphology that expressed CD2, CD3, CD5, CD7, CD43 and Granzyme, with a predominance of CD8 positive cytotoxic T lymphocytes and a lower number of CD4 positive helper T lymphocytes. In addition, a lower number of B lymphocytes reactive to CD79a, reactive histiocytes reactive to CD68 and lysozyme and a positive reaction to EBV RNA in immunoblastic B cells were observed. The final report was that the morphological and immunophenotypical findings were consistent with a chronic EBV infection. Antibodies were detected for Epstein Barr IgM positive 15.13 IU/ml (positive greater than 11 IU/ml) and IgG 10.85 IU/ml (indeterminate 9 - 10 IU/ml), cytomegalovirus infection was ruled out.
+
+In the evaluation by paediatric infectology, symptomatic management and follow-up were recommended. In the controls, complete resolution of conjunctival lesion with adequate healing after excisional biopsy, complete resolution of ptosis and a decrease in serological antibodies for Epstein Barr IgM 4.54 IU/ml and elevation of IgG 12.66 IU/ml, studies of cellular immunity with CD3, CD4 and CD8 lymphocytes in the normal range for age were observed. After 15 months of follow-up, he remains asymptomatic.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3142_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3142_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a9a953bde429ea4d33bb03e2f8e9ac48e2a24df2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3142_en.txt
@@ -0,0 +1,14 @@
+Subjective and objective examinations
+This surgical case report is presented according to SCARE criteria [14]. A 56-year-old male patient came to the Emergency Department of the Regional Hospital with complaints of swelling of the lower jaw accompanied by fever from two days ago. The patient also experienced nausea, difficulty in swallowing, and pain that intensified during eating. He also experienced toothache and tooth mobility one week before admission. There was no history of trauma. The patient was seen to be weak upon admission, with vital signs: blood pressure 129/67 mmHg; heart rate 76 bpm; respiratory rate 20 bpm, temperature 36.7 °C. The patient’s oxygen saturation was consistently above 96% upon admission.
+
+Physical examination demonstrated diffuse swelling in the submandibular region, soft and tender on palpation. The margin of the swelling was well-defined and had a color similar to that of the surrounding skin. Intraoral examination revealed no abnormalities. Oral hygiene was moderate, with some calculus accumulation on the lingual face of the tooth. The patient was treated with parenteral medication, including Ondansetron, Ketorolac, Ranitidine, and Asering®.
+
+Ketorolac was used to relieve the patient’s pain. The patient also experienced nausea upon admission; therefore, Ondansetron was administered. The patient was found to be weak upon admission. Asering® was administered to provide stable electrolyte condition and prevent the patient’s dehydration. The medication was aimed to manage the signs and symptoms experienced by the patient and to prepare the patient for the operative treatment.
+
+Panoramic, anteroposterior, and lateral radiography revealed a well-defined, lobulated, irregular-shaped radiopaque mass within the submandibular region. No additional stones are noted in the immediate vicinity. Head Multi-Slice Computed Tomography (MSCT) revealed a hyperdense mass surrounded with a hypodense shadow, reflecting the presence of stones in the duct of the left submandibular gland. The patient was diagnosed with submandibular abscess et causa submandibular gland sialolithiasis, and stone and partial gland removal were planned.
+
+Surgical technique
+Under general anesthesia, the stone and partial submandibular gland were surgically removed, along with the drainage of the submandibular abscess. Submandibular surgical access was established. Tissue dissection was done layer by layer including skin, connective tissue, until the platysma muscle. The submandibular gland was dissected out and partial removal of the submandibular gland was done. After the submandibular gland specimen evacuation, it was dissected to reveal the salivary gland stone, measuring approximately 1.2 cm. Postoperative medication, including intravenous antibiotics and symptomatic medication, was given. These regimens includes Ceftriaxone injection 1 g/12 h, Metronidazole injection 500 mg/8 h, Dexamethasone injection 5 mg/12 h, Ketorolac injection 30 mg/8 h, Paracetamol injection 500 mg/8 h, and Ranitidine injection 50 mg/12 h.
+
+Results
+The patient was followed up seven days after the operation. Pain and swelling decreased significantly, and there was slight edema in the submandibular region. There were no wound-healing complications or postoperative complications with extraoral sutures intact and no dehiscence. The sutures were removed during this follow-up period. After the follow-up period, the patient was discharged with a stable and complication-free condition.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3147_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3147_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..29b60a2631764432cff658530ef2f7d75f68a70f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3147_en.txt
@@ -0,0 +1,20 @@
+The patient in this fatal case was a 2-year-old girl who was born full-term and had developed normally. She had no medical history of asthma or pneumonia and no familial history of immunodeficiency. She had no brothers or sisters.
+
+The patient was admitted to the hospital due to 3 days of fever and 15 min of respiratory and cardiac arrest. The symptoms started on 10 November (3 days before admission), with a fever (up to 39.8 °C) but no chills, rash or convulsions. Ibuprofen was given orally. The body temperature decreased for 4 to 5 h but then climbed to 40.3 °C. Shortness of breath accompanied the fever, and the body temperature did not decrease obviously after the oral administration of ibuprofen. Wheezing caused by the retention of phlegm in the throat and a single paroxysmal cough occurred. The patient occasionally coughed up a small amount of yellow phlegm and had a slightly runny nose. She had no asthma, breathing difficulty or hemoptysis; she had lethargy and a poor appetite but no vomiting or diarrhea. On 11 November (2 days before admission), the patient still had a high fever, and her body temperature fluctuated around approximately 40 °C. The patient’s body temperature did not obviously decrease after she was given oral ibuprofen and acetaminophen alternately. Acute infection was considered from then on. The patient received an intravenous infusion of 0.14 g Zithromax and 120 mg rographolide as well as aerosol inhalation of 2 mg budesonide, but her fever persisted, and her body temperature rose to a peak of 40 °C. On 12 November (1 day before admission), the patient still had a persistent fever and wheezing due to the retention of phlegm in her throat. She had shortness of breath, a light cough, and a drooping spirit, accompanied by a rash on the torso and limbs. Her appetite was slightly improved, and she had no vomiting or convulsions. On 13 November, the patient had sudden respiratory and cardiac arrest 3 h before admission. She was immediately and continuously treated with cardiopulmonary resuscitation by physicians and the intravenous injection of adrenaline (4 times). She was treated with trachea cannula and mechanical ventilation, and her heart beat recovered approximately 15 min later, but the patient remained in a deep comatose state with no spontaneous breathing. Then, the patient was transferred to our hospital and immediately underwent electrocardiogram (ECG) monitoring. Bloody fluid was visible in the indwelling gastrointestinal decompression tube, and the blood-gas analysis showed metabolic acidosis. The patient was treated with sodium bicarbonate to correct the acidosis. She was diagnosed with an acute CNS infection and brain hernia. After cardiopulmonary resuscitation, she was admitted to the pediatric intensive care unit (PICU). The head CT scan showed extensive brain swelling, decreased brain parenchymal density, narrowed cerebral ventricles and cisterns. These findings prompted a diagnosis of extensive brain edema and hernia. The chest posteroanterior radiograph showed fuzzy, coarse bilateral lung markings, visible small patchy shadows in the right inferior lung and a clear pulmonary hilus. These findings were diagnosed as pneumonia. Routine blood examination results suggested the presence of a bacterial infection; thus, the patient was treated with vancomycin and meropenem to control an infection. After that, immunoglobulin (1 g/kg) was administered for immune support. The patient was still in a deep coma state, and light reflexes of both pupils were absent. The patient’s spontaneous breathing was weak and irregular, and she had no response to painful stimulation. Compared with earlier, her rash was reduced, and the pulmonary lesions shown on the chest posteroanterior radiograph were slightly absorbed. Immunoglobulin (1 g/kg) was continuously administered to neutralize pathogens. On 15 November (3 days after admission), transcranial Doppler ultrasound assessment showed that the patient’s anterior and posterior cerebral circulation corresponded to the diagnostic criteria for brain death. On 17 November (5 days after admission), various organ functions failed, and the patient could not tolerate a spontaneous breathing test. Her guardian chose to quit treatment, and the patient died.
+
+Laboratory diagnosis
+Viral antigen detection based on both an immunofluorescence assay and the Luminex xTAG respiratory viral panel assay was positive for RSV in the patient’s nasopharyngeal aspirates (which were collected on 14 Nov, the 5th day of disease onset and the 2nd day of admission) and negative for adenovirus, influenza A and B viruses, parainfluenza virus 1–4, human metapneumovirus, enteroviruses and rhinoviruses, human coronavirus HKU1, 229E, NL63 and OC43, and human bocavirus. Because the patient’s guardian refused to consent to lumbar puncture, cerebrospinal fluid (CSF) was not available for the detection of CNS infection.
+
+The blood biochemistry results are summarized. The amounts of red blood cells (RBCs), hemoglobin, and platelets continuously decreased after the onset of symptoms. Extremely high levels of C-reactive protein from the third day (36–104 mg/L) suggested viral or bacterial infection; however, bacterial cultures of blood specimens yielded negative results.
+
+
+The percentage of T lymphocytes was 46.6%, of which helper T cells and suppressor T cells accounted for 29.6 and 13.2%, respectively. The ratio of CD4/CD8 was 2.2. The proportions of B lymphocytes and NK cells were 45.6 and 3%, respectively. All these immunological indexes indicated dysfunction of the patient’s immune system.
+
+Metagenomic and viral molecular analysis
+Oral swab, nasopharyngeal aspirate, and serum specimens collected on 14 Nov (the 5th day of disease onset and the 2nd day of admission) were subjected to multiplex metagenomic analyses using an NGS platform. The nucleic acid library was constructed as previously described. The amplified nucleic acid libraries were then analyzed using an Illumina HiSeq 4000 sequencer for a single read of 126 bp. The raw sequence reads were filtered using previously described criteria to obtain valid sequences.
+
+When bacteriophages, plant-origin sequences resulting from food debris in the oral cavity, and contamination from the reagents used in the sample processing step (murine leukemia virus (MLV), for example) were excluded, only human RSV (based on the NCBI taxonomy database) was identified, with at least one specific sequence from the oral swab (2137 reads) and the nasopharyngeal aspirate (146 reads). No virus-related sequences were detected in the serum specimen. Meanwhile, large numbers of sequence reads related to bacteria, including Streptococcus mitis, Streptococcus parasanguinis, Streptococcus pneumoniae, Streptococcus salivarius, Streptococcus infantis, Streptococcus suis, Neisseria meningitidis, Neisseria gonorrhoeae, Haemophilus sputorum, Haemophilus parainfluenzae, Enterococcus cecorum, and other conditioned pathogenic bacteria were also detected in the oral swab, nasopharyngeal aspirate, or/and serum specimens. However, although the metagenomic analysis showed sequence reads assigned to Kingdom Bacteria, the bacterial culture of the blood specimens yielded negative results.
+
+
+
+Based on the random distribution of reads of the RSV virus genome, the complete length of the genome was obtained using NGS methods and gap amplification. This RSV strain was subtyped as RSVB; it was found to cluster in the BA genotype and had the signature 60-bp duplication in the G gene. The newly identified virus was named RSVB/BCH-Y/2016, and the full genome sequence was deposited in GenBank under accession number KY924878. The phylogenetic analysis was conducted with representative sequences from nearly all RSVB subgroups (BA1–10, GB1–4, SAB1–4, URU1–2) from GenBank; RSVB/BCH-Y/2016 belonged to BA9 subgroup. The nucleotide homology comparisons revealed that the G gene of this strain was most closely related (share 98.82% homology) to strain RSVB/GZ/13–730, which was isolated from a child in Guangzhou, China, in 2013. For the six most important antigenic sites (Ø, I, II, IV, V, VI) in the fusion protein for drug or vaccine (such as palivizumab) targeting, no mutation was found in RSVB/BCH-Y/2016.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3152_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3152_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1d3cbfdfe4d3e25950c4db7020341464711beb19
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3152_en.txt
@@ -0,0 +1,17 @@
+A 52-year-old woman was admitted with acute myocardial infarction due to a spontaneous right coronary artery dissection. Her medical history was notable for a conservatively managed left posterolateral branch myocardial infarction at the age of 39 with normal left ventricular (LV) function. At 51, she was treated for breast cancer with a curative intent.
+
+At presentation, an emergency percutaneous coronary intervention of the right coronary artery was performed. The post-procedural course was complicated by ventricular tachycardia (VT) and fibrillation for which she was successfully resuscitated. During the following hours she developed cardiogenic shock due to failure of the right ventricle (RV) that was refractory to fluid resuscitation and inotropes. She was transferred to the intensive care unit of a tertiary heart failure referral centre and was stabilized using peripheral veno-arterial (VA) extracorporeal membrane oxygenation (ECMO). Echocardiography showed a dilated RV with severely impaired function, paradoxical septal motion with signs of RV volume overload and severe tricuspid regurgitation with elevated filling pressures. The LV function was slightly impaired.
+
+She developed heparin-induced thrombocytopaenia (HIT) and was rejected for an urgent heart transplant listing due to the recent oncological history. The VA-ECMO was exchanged for percutaneous veno-pulmonary ECMO in order to allow for recovery of the RV. Five weeks after the start, weaning was initially successful.
+
+However, within days after discontinuation of the ECMO, she developed fast recurrent VTs that were haemodynamically poorly tolerated and resulted in hypotension and elevated lactate levels. Intravenous administration of amiodarone resulted in further progression of RV failure due to the negative inotropic effects and the development of a slow junctional rhythm that was poorly tolerated haemodynamically, limiting further pharmacological options.
+
+Escalation in the inotropic regimen in the days after ECMO weaning further contributed to the incessant VTs and resulted in a persistent decrease of organ perfusion (INTERMACS profile 2).
+
+After careful consideration and discussion with the electrophysiology team, an ablation procedure was deferred due to the proposed haemodynamic triggers of the VTs and the estimated low chance of a curative procedure. Invasive haemodynamic evaluation revealed a cardiac output of 3.05 L/min (CI 1.61 L/minute/m2) and low pulmonary pressures (mean pulmonary arterial pressure 9 mmHg, pulmonary vascular resistance 1.9 WU).
+
+Because of persistent inotropic dependency and recurrent VTs in the setting of progressive RV failure, VA-ECMO was re-initiated, and both a right ventricular assist device (RVAD) and a bidirectional cavopulmonary anastomosis (BCPA) with TV repair were explored. In a BCPA, the superior vena cava (SVC) is disconnected from the right atrium and anastomosed end-to-side to the right pulmonary artery, redirecting a substantial proportion of the venous return directly to the lungs, bypassing the RV. Due to the recent HIT and the chance of recovery of RV function in the near future, a decision was made to perform a BCPA with a concomitant TV annuloplasty.
+
+Two months after her initial presentation, the patient underwent BCPA and restrictive TV annuloplasty. She had an arterial oxygen saturation of 95% in ambient air and could be weaned off VA-ECMO and inotropes within 3 weeks after the operation. Echocardiography showed normalization of RV dimensions, moderate to severely impaired RV function and trivial TV regurgitation.
+
+Because there was an indication for an implantable cardioverter-defibrillator (ICD) (secondary prevention), a subcutaneous ICD (S-ICD) seemed most appropriate because the BCPA now limited transvenous lead access. However, due to a sternal wound infection, implanting the device was postponed. One month after surgery, she was discharged home with guideline-dictated medical therapy and a LifeVest Wearable Defibrillator (Zoll Medical Corporation, Chelmsford, MA, USA) as a bridge to an S-ICD. The peripheral oxygen saturation at discharge was 99%, and she subsequently completed a cardiac rehabilitation program. Her New York Heart Association functional class IV improved to III (INTERMACS profile 2 to 7) at the 6-month follow-up examination, and there have not been any heart failure-related admissions.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3156_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3156_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6e371d582156dd69c46bf44dee16202f6905dcf0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3156_en.txt
@@ -0,0 +1,7 @@
+A 32-year-old Japanese man with no medical history visited a local doctor because his blood pressure (BP) was alarmingly high (215/150 mmHg) at the time of a health check-up, and he was aware of a loss of appetite and headache lasting more than 2 months. Given the diagnosis of severe hypertension, the patient was administered doxazosin, an α-adrenergic antagonist, and he was referred to our hospital for further examination and treatment. He was a current smoker of up to 10 cigarettes per day.
+
+At the referral visit, the patient’s BP was still severely high at 170/102 mmHg, and his pulse rate was 74 beats per minute. Physical examination revealed no edema or signs of meningeal irritation. Laboratory data indicated polycythemia (RBC 703 × 104/µL, hemoglobin [Hb] 20.2 g/dL) and renal failure with proteinuria and hematuria (creatinine [Cr] 3.70 mg/dL, urine protein-to-Cr ratio 0.28 g/gCr, RBC 10–19/high-power field) (Table 1). His serum cortisol, plasma renin activity, plasma aldosterone concentration, and catecholamine levels were within normal ranges, and no autoantibodies associated with glomerulonephritis were detected (Table 1). Abdominal ultrasonography showed bilaterally enlarged kidneys (right: 14.2 cm × 8.4 cm, left: 14.0 cm× 8.5 cm) and no hydronephrosis. Although severe hypertension caused by polycythemia and renal failure was suspected, the precise cause of the polycythemia, renal failure, and renal enlargement was unclear.
+
+To reduce BP, 40 mg/ day of nifedipine controlled-release (CR), a long-acting calcium channel blocker, and 20 mg/day of olmesartan, an angiotensin receptor blocker, were added. The patient’s BP improved significantly to 135/95 mmHg on day 8 (7 days after the referral visit), and a renal biopsy was performed to determine the cause of renal failure and enlargement. Light microscopy revealed virtually normal structures in seven obtained glomeruli, but diffuse and extensive interstitial infiltration with medium- to large-sized atypical lymphoid cells. Immunohistochemistry showed the cells to be positive for cytoplasmic CD3, terminal deoxynucleotidyl transferase, and Ki-67, but negative for CD20. Immunofluorescence staining and electron microscopy revealed no evidence of immune deposits. Bone marrow biopsy revealed > 25% blasts, and myeloperoxidase staining was negative. Based on these findings, the patient was diagnosed with T-ALL and bilaterally enlarged kidneys caused by renal infiltration of leukemic cells. Computed tomography (CT) showed moderate right pleural effusion; anterior mediastinum mass; slightly enlarged lymph nodes in the neck, mediastinal, right hilar, right axillary, and abdominal para-aortic areas; and enlarged kidneys. Consistent with these findings, [18F]-fluorodeoxyglucose (18FDG)-positron emission tomography (PET)/CT demonstrated an increase in metabolic uptake in these organs, with the largest increase observed in the kidneys. Serum EPO levels were high at 38.7 mIU/mL (normal range: 4.2–23.7 mIU/mL) despite high Hb levels; thus, he was diagnosed with secondary polycythemia. No adrenal or liver tumors or hypoxic lung disease were detected, and oxygen saturation was 95% in room air; therefore, we considered that secondary polycythemia may have been caused by the bilaterally enlarged, infiltrated kidneys.
+
+On day 20, the patient was treated with prednisolone to reduce the tumor mass. After 1 week, remission induction chemotherapy (vincristine, daunorubicin, dexamethasone, l-asparaginase, methotrexate, cytarabine, prednisolone) was administered according to the Japan Adult Leukemia Study Group (JALSG) ALL202-O protocol. On day 21, hemodialysis was initiated due to severe tumor lysis syndrome. After 1 month of chemotherapy, the patient’s renal function improved, and he was taken off hemodialysis. His kidneys were smaller on day 24 (right: 11.9 cm × 7.2 cm, left: 13.0 cm× 7.5 cm) and their size had normalized on day 60 (right: 9.4 cm × 5.5 cm, left: 10.8 cm× 5.0 cm). His Hb levels normalized on day 23 but gradually decreased from day 45 to day 62, at which time the Hb level was 7.3 g/dL. EPO level was low at 12.0 mIU/mL on day 59; therefore, 30 µg of darbepoetin alfa was started for the treatment of renal anemia. Consistent with the improvements of the bilaterally enlarged kidneys and polycythemia, his BP improved, and doxazosin and olmesartan were discontinued on day 22. His systolic BP improved to 110–120 mmHg at a dose of only 20 mg/day of nifedipine CR. Future plans for the patient include a hematopoietic stem cell transplantation after hyper-CVAD therapy (cyclophosphamide, vincristine, doxorubicin, dexamethasone) and MA therapy (methotrexate, cytarabine).
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3175_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3175_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f576d614c0ead83dcd3f25e9e46e7dc1f030bdf9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3175_en.txt
@@ -0,0 +1,17 @@
+An 11-year-old male came to our hospital with a complaint of bilateral nasal bleeding of 1 day duration, which was of about 4 times, and it was massive as claimed by the family. He also has had associated history of skin rash which was noticed a day prior to the onset of nasal bleeding.
+
+On further asking, the patient has had history of loss of appetite and significant but unquantified weight loss of one month duration but no history of fever or cough. He has no history of bleeding diseases, connective tissue disorders, autoimmune disorders, or cancer in himself or in his family. All vital signs were normal at the time of presentation, but there was a dry clot in the nostril bilaterally and no symptoms of anemia. A chest examination revealed scattered inspiratory crackles on both sides of the upper lung zone. Organomegaly, there was nothing. A petechial rash covered the chest and rear sides of the body, including the upper extremities.
+
+Except for isolated thrombocytopenia, a complete blood count and serum chemistry, including the reticulocyte count, were unremarkable. A peripheral blood smear revealed isolated severe thrombocytopenia with normal blood cell morphology. Autoimmune screening (ANA, Coombs test), coagulation profile, viral screening including the COVID-19 test, blood cultures, urine cultures, were all non-revealing. The rate of erythrocyte sedimentation (ESR) was 70 mm/hr, which is suggestive of MTB. A smear for acid-fast bacilli was negative, but Gene expert from the sputum detected MTB with rifampicin sensitivity.
+
+The ultimate outcome of the chest X-ray revealed bilateral diffusely dispersed nodular opacities all over the lung fields, which were commented on by three different radiologists.
+
+With a presumptive diagnosis of immune thrombocytopenic purpura (ITP), the patient was hospitalised and began therapy with oral prednisolone 20 mg twice a day.
+
+He was then managed with antituberculosis (ATT) RHZ (75/50/150) 4 tablets, and E100 mg (R stands for Rifampicin, H for Isoniazid, Z for Pyrazinamide, and E for Ethambutol in this order). Four tablets as per the national guideline, which was started after 1 week of admission because of late isolation of TB.
+
+Prednisolone 2mg/kg/day, ie 20 mg po bid (tapered over six weeks and stopped), and there were no reported problems of initial complaints after withdrawing the prednisolone.
+
+He was transfused with Platelet 20 mg/kg, ie 400 mg, with post-transfusion CBC of almost the same, supporting the diagnosis of ITP.
+
+This patient was discharged after 2 weeks of hospitalization, being taking ATT and Prednisolone, with the latest platelet count of 44,000*109, with appointment after 2 weeks or to come early if there are any complications. Fortunately, there were no complications related to the disease/or treatment, and on the day of appointment (after a total duration of 1 month of treatment and 31 days of the complaint), repeated CBC was done, and it showed Platelet count of 59,000*10*9 and the organ function test in search of ATT-related toxicities were also all in the normal range. The patient was again appointed after 2 months, and on return, the Platelet count was raised to 118,000*109 which is still below the normal value. Prednisolone was tapered over 6 weeks and stopped. After the total six months of therapy with ATT, platelet counts (204* 109) were became in the normal range after being successfully increased amid follow-up, and ATT was stopped as per the national guideline.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3176_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3176_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..01daf3669ed869f8384c278672be4706312f441f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3176_en.txt
@@ -0,0 +1,6 @@
+A 69-year-old man was admitted to the internal medicine department for the exploration of a progressive deterioration of his general condition associated with inflammatory-like low back pain for several weeks. He also reported a progressive weight loss of 15 kg over the last 3 months. He is a former diplomat with a profession requiring frequent travel abroad. He lived in sub-Saharan Africa for 20 years in rural areas. His medical history included a HIV infection controlled with a tritherapy (emtricitabine, rilpivirine, tenofovir alafenamide). Among the complications of HIV, he suffered from severe osteoporotic fractures in the vertebrae and sternum, which were treated with oral bisphosphonates with good compliance. He was an active smoker with more than 50 pack-years, and he also had obliterative arteriosclerosis of the lower limbs, which was treated with a femoro-femoral bypass in 2016.
+
+The initial clinical examination showed camptocormia with invalidating lumbar pains sometimes causing insomnia and preventing walking. There was no fever, no breath sound, no anomaly in the examination of the tegument, no adenopathy, or organomegaly. He had a moderate inflammatory biological syndrome with a CRP of 42 mg/L (normal < 5 mg/L) associated with a moderate inflammatory anaemia and a discrete neutrophil increase (8.73 G/L, normal 1.5–7.5 G/L) without lymphopenia. There was cholestasis without cytolysis with gamma glutamyl transpeptidase and alkaline phosphatase at 183 IU/L (normal 12–64 IU/L) and 245 IU/L (normal 40–150 IU/L). The HIV viral load was undetectable and the CD4+ T lymphocyte count was 474/μL. A thoraco-abdomino-pelvic scan revealed an abscessed L3–L4 spondylodiscitis associated with known vertebral fractures. An MRI confirmed this diagnosis of spondylodiscitis with left paravertebral abscess without epidural extension. The peripheral infectious samples with blood cultures were all negative. A transthoracic echocardiography did not allow visualisation of vegetations without formally excluding an infammatory endocarditis. To exclude this diagnosis, a positron emission tomography – computed tomography (PET-CT) with cardiac preparation was performed due to the patient’s refusal of a transesophageal echocardiography. This examination revealed a L3–L4 hypermetabolism (SUV L3–L4 8.1 vs. hepatic SUV 2.77), but also an intense fixation at the femoral-femoral crossover bridge (SUV crossover 4.14 vs. hepatic SUV 2.77). The absence of valvular fixation allowed the exclusion of associated infammatory endocarditis. A discolumbo-vertebral biopsy was performed with a negative bacterial culture and a negative universal PCR (16S RNA). Unfortunately, the histology could not be performed due to insufficient material. The search for Mycobacterium tuberculosis in PCR and culture was negative on the discolumbo-vertebral biopsy material.
+In the presence of an endovascular infection associated with a culture-negative spondylodiscitis, serology for C. burnetii was requested. The result was in favour of a chronic Q fever (phase I, immunoglobulin G [IgG] 4093 with threshold > 800). The specific PCR for C. burnetii requested on the material of the disco-vertebral biopsy was positive while the blood PCR for C. burnetii was negative.
+The diagnosis of chronic Q fever with an abscessed L3-L4 spondylodiscitis and a femoro-femoral bypass infection was retained.
+After a medical-surgical discussion, the choice of a long-term treatment with hydroxychloroquine 600 mg and doxycycline 200 mg daily was initiated. The clinical evolution was favorable with a recovery of walking after a stay in the rehabilitation department. After two weeks of treatment, the biological inflammatory syndrome was completely negative. The IgG C. burnetii serology of phase 1 had decreased from a titre at 3 months and stabilised at this titre at the 6-month and 1-year check. The TEP scanner performed at 6 months showed a decrease in the vertebral hypermetabolism L3-L4 (lumbar SUV 4.4 vs hepatic SUV 2.74) but the persistence of a major hypermetabolism at the level of the bypass (bypass SUV 4.25 vs hepatic SUV 2.74). More than a year after the start of the treatment, the patient is still asymptomatic; regular monitoring alone was proposed.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3178_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3178_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..484adf4ac14eef5f64bd4aafa62875fdd089818c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3178_en.txt
@@ -0,0 +1,11 @@
+A 74-year-old woman was referred from the Department of Dermatology and Venereology to the Department of Oral Medicine Dr. Hasan Sadikin Hospital, Bandung. The patient has been hospitalized for 4 days and has been given dexamethasone 5 mg intravenously, cetirizine 10 mg tablets, and clindamycin tablets 300 mg. Based on the anamnesis, blisters on the skin that felt burning, sore, and itchy first appeared 1 week ago. Complaints of the painful canker sores in the oral cavity began to appear 2 days ago. The patient experienced of intense pain during the day. She has no medical history of any systemic disease and does not take any medication. Extraoral examination revealed a symmetrical face and the regional lymph nodes were not palpable and painless. She had multiple crusts on the neck, buttocks, and upper and lower extremities.
+
+Intraoral examination showed erosion covered by a yellowish white layer on the right and left buccal mucosa, haemorrhagic purpura on the right and left buccal mucosa and right lateral tongue, an ulcer with a diameter of 0.5 cm on the left lateral border of the tongue, and the root remnants of 12, 14, 15, 16, 17, 26, 27, 33, 34, 35, and 36 teeth. Hematology tests revealed increased values of leukocytes (15.93 x 103/µL), eosinophils (6%), and segmental neutrophils (77%). A skin biopsy of the lesion on the left thigh was performed to establish a definitive diagnosis. The results of histopathological examination showed a formation of a subepidermal blister containing eosinophil and neutrophil cells.
+
+Based on anamnesis, clinical examination, and appropriate investigations, the definitive diagnosis was oral lesions associated with dermatitis herpetiformis with a differential diagnosis of pemphigoid bullosa and linear IgA dermatoses. Additional diagnoses were exfoliative cheilitis, chronic traumatic ulcer on the left lateral border of the tongue, chronic apical periodontitis et causa the root remnants of 12, 14, 15, 16.17, 26, 27, 33, 34, 35, 36, and generalized chronic marginal gingivitis. The therapies provided by the Department of Oral Medicine including 0.025% hyaluronic acid mouthwash and petroleum jelly. Patients were instructed to brush their teeth regularly, not consume gluten-containing foods, rinse their mouths using 0.025% hyaluronic acid mouthwash three times a day, and apply petroleum jelly to moisturize the lips. Patients are also advised to do scaling and extraction of the tooth remnants of the upper and lower teeth. The prognosis of this case is good.
+
+The oral lesions showed significant improvement at the second visit, 10 days after treatment. Erosive lesions in the oral cavity began to heal. She felt no pain at all and had no difficulties in eating solid foods. The patient uses 0.025% hyaluronic acid mouthwash and petroleum jelly regularly.
+
+The patient was being infected with COVID-19 two months later and was treated in the COVID-19 isolation room at the Hasan Sadikin General Hospital in Bandung for 1 week. She experienced the typical symptoms of COVID-19 (fever, muscle aches, and shortness of breath) and decreased oxygen saturation (87.3%). Acute exacerbations of dermatitis herpetiformis lesions on the skin and perioral occurred after the patient was infected with COVID-19. Extraoral examination revealed crusts on the perioral, erosive lesions covered by white-yellowish plaque on the vermillion border of the upper lip. Laboratory tests revealed anti-SARS-CoV-2 IgG S-RBD values (>40,000 AU/mL), eosinophils (6%), total eosinophils (0.50 x 103/µL), C-reactive protein (2 mg/dl), quantitative D-dimer (3.72 µg/mL) during hospitalization. Chest X-ray image depicted a ground-glass appearance from the mid to the lower right lung. The patient was diagnosed with right bronchopneumonia.
+
+The intraoral lesions healed after a month of the treatment. The patient admitted that she has avoided foods containing gluten and routinely uses medicines provided by the Department of Oral Medicine. There were no adverse events or unwanted reactions from the drugs that she had been consumed. Follow-up therapy from the Department of Dermatology and Venereology includes methylprednisolone tablets (24 mg/day), cetirizine 10 mg tablets, and ranitidine 150 mg tablets. The patient was approved and written informed consent of this case including the images, and the institution has also approved for publication.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3181_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3181_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cf426b51dad4236045f6cfd54e249ae0bbe0f2d9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3181_en.txt
@@ -0,0 +1,7 @@
+A 34-year-old female patient in the second trimester of pregnancy presented to the emergency department with complaints of moderate intensity pain in the lower abdomen, predominantly on the right side, which had been present for 3 weeks and had worsened markedly in the last 2 days. The patient did not have any other symptoms apart from the referred pain, such as fever, loss of appetite, nausea or vomiting. Given the diagnosis of abdominal pain predominantly in the right iliac fossa, laboratory tests were requested to assess inflammatory and infectious activity, and ultrasound (USG) of the total abdomen was performed in the emergency radiology department.
+
+The USG confirmed the pregnancy without obvious changes related to the uterus, placenta and foetus. The evaluation directed to the right iliac fossa did not characterise signs suggestive of acute appendicitis, which, in this context, would be hyperecogenicity and densification of the pericecal and/or periapendicular fat, locoregional lymphadenomegaly of reactive aspect with cortical thickening and, sometimes, increased flow to colour Doppler mapping and presence of laminar free liquid or in the form of locoregional collection. The cecal appendix was thickened in the body portion, reaching 9.2 mm in maximum transverse diameter (considered normal up to about 6.0 mm) and with segmental increase in calibre in that region, without other characteristics of inflammatory nature. In the thickened region, the lumen of the appendix was collapsed, and the wall of the organ presented increased echogenicity, homogeneously, and with echotexture similar to that of fat. The appendicular compressibility was slightly reduced. In the region of the apical appendix, the outer diameter was within the normal limits (4.5 mm). Colour Doppler mapping did not show increased flow. There were also no signs of hyperecogenicity of the periapendicular fat.
+
+Laboratory tests did not show any changes (leukocytes and C-reactive protein within normal limits). The findings of the ultrasound did not suggest an acute inflammatory process, but rather benign changes of a probable infiltrative fatty nature. An MRI was requested to complement the diagnosis.
+
+The MRI confirmed the findings described in the USG, with focal parietal thickening of the appendix without inflammatory signs. Diffuse hypersignal of the appendix was observed in the in-phase sequence, with loss of signal in the out-phase sequence, indicating the presence of a significant amount of fat in the intracellular compartment, characteristic of lipomatosis. There was no appreciable enhancement in the appendix in the MRI examination. In view of the clinical and laboratory findings and the characteristics of the USG and the MRI, the diagnosis of lipomatosis could be confirmed. The patient was discharged with analgesia, without return of the symptoms.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3182_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3182_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..498d2c0fd4e0dd883c883ee449aa416685eea95d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3182_en.txt
@@ -0,0 +1,11 @@
+A 57-year-old patient with a history of active smoking, from a rural area of a municipality in Colombia, presented to the local hospital with a suicide attempt after ingesting a toxic substance (unknown at the time) in the context of alcohol consumption. He presented within the first two hours of the onset of an acute confusional state with bradycardia, diaphoresis, and arterial hypertension, associated with metabolic acidosis. He received two ampules of atropine for the management of the cholinergic toxicodrome and bradycardia, and was given activated charcoal for gastric lavage. About four hours after the ingestion, he presented altered level of consciousness and dyspnoea, and was intubated orotracheally and transferred to a referral center.
+
+The ingested substance was initially unknown, and the diagnosis was intoxication of unknown origin, probably related to sedatives and alcohol. On arrival at the health center, seven hours after ingestion, the patient had a blood pressure of 103/69 mm Hg, a heart rate of 84 beats per minute, an oxygen saturation of 93% with respiratory support, and a Richmond Agitation-Sedation Scale (RASS) score of (-) 4 points. Treatment with intravenous fluids was ordered. Laboratory results showed a white blood cell count of 16,030 per mm3 with neutrophilia, a haemoglobin of 15 g/dl and creatinine of 0.77 mg/dl; the electrocardiogram, the ionogram, the coagulation times and the liver function tests were normal. A skull tomography was taken with normal results.
+
+On the second day of ingestion, he continued to require respiratory support and the vasopressor agent norepinephrine, and had increased acute phase reactants, hypernatremia (152 mmol/L) and hypocalcemia (0.75 mmol/L), with worsening oxygenation indices, so a chest tomography was performed that recorded findings suggestive of bronchial aspiration in the lower right lobe, so administration of ampicillin-sulbactam was initiated.
+
+On the fourth day of evolution, he had a fever of 38.8 °C, arterial hypertension, myoclonus and elevated creatine phosphokinase (CPK) (6,520 U/L); 24 hours later, the fever persisted, so the antibiotic treatment was modified. In addition, he continued to have altered consciousness, despite the suspension of sedation and analgesia; he had an electroencephalogram that showed changes due to encephalopathy without epileptiform activity.
+
+At seven days, the patient had persistent autonomic dysfunction, fever up to 39.0 °C, lead-tube rigidity and phlegm on both sides of the face and arms; although not sedated, he was still lethargic, which was associated with leukocytosis (10,110 per mm3) and persistent elevation of CPK, despite the use of crystalloids and mannitol. Therefore, it was decided to initiate the administration of bromocriptine at a dose of 5 mg orally every 8 hours, progressively increased to 30 mg per day; 48 hours later there was improvement of the neurological status, without new fever peaks, so the extubation was successful.
+
+When the family was questioned again, the patient was found to have ingested a pesticide. Serum cholinesterases were requested and found to be less than 1500 U/L (reference value: 7000 to 19000 U/L) and erythrocyte cholinesterase was reported as 157 UPH/h (reference value: 91 to 164 UPH/h). No oximes, fresh frozen plasma or lipid emulsions were administered. After recovery of neurological status, the patient confirmed intentional ingestion of the organophosphate insecticide chlorpyrifos (O,O-diethyl-O-3,5,6-trichloro-2-pyridinyl phosphorothioate) used in agriculture. The patient was discharged without sequelae 16 days after the ingestion of the pesticide.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3188_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3188_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d466a90bf15dc5663f52d52feae88f00a8a86dbc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3188_en.txt
@@ -0,0 +1,7 @@
+A 30-year-old woman with a history of rheumatoid arthritis on long-term methotrexate and a previous hospital admission for a complicated fungal urinary tract infection (UTI) presented to her gynecologist with 1 week of vaginal discharge, vaginal pruritus, and bilateral flank pain. Urine and vaginal cultures were obtained, and she was started on intravaginal clotrimazole while awaiting results. The vaginal and urine cultures obtained by her gynecologist were notable for heavy growth of S cerevisiae that was susceptible to voriconazole, clotrimazole, flucytosine, and amphotericin B, and her infectious disease doctor was notified. Due to a limited availability of outpatient flucytosine and rapid development of resistance with monotherapy and poor urinary concentration of other antifungals, the patient was admitted by infectious disease for intravenous amphotericin B deoxycholate.
+
+Six months prior, the patient was admitted for refractory fungal vulvovaginitis and complicated C glabrata pyelonephritis. At that time, the patient reported nearly a 7-month history of flank pain, vaginal pruritus and discharge, and dysuria refractory to multiple courses of azole therapy. Urine cultures during that hospitalization were positive for azole-resistant C glabrata. Infectious disease was consulted and recommended treatment with a 7-day course of amphotericin B deoxycholate. The patient completed treatment with resolution of symptoms. Outpatient follow-up cultures were negative for C glabrata.
+
+Upon arrival at the hospital, the patient reported subjective fever, bilateral flank pain, joint pain, and dysuria. In the setting of her infectious symptoms, the patient had stopped her methotrexate at the recommendation of her rheumatologist, leading to worsening rheumatic joint pain. On admission, her vital signs included a temperature of 37.1°C, heart rate of 72 beats per minute, blood pressure of 124/70 mmHg, respiratory rate of 18, and an SpO2 of 99% on room air. Physical examination was remarkable for bilateral costovertebral angle and suprapubic tenderness to palpation. There was no abdominal distention, rebound, or guarding. Cardiac, pulmonary, and neurologic examinations were unremarkable. Complete blood count on admission demonstrated mild leukopenia with a white blood cell (WBC) count of 4.56 (normal: 4.80-10.80 K/cumm) and mild anemia with a hemoglobin of 11.8 (normal: 12.0-16.0 g/dL). Her comprehensive metabolic panel was unremarkable. Urinalysis demonstrated a specific gravity of 1.042 (normal: 1.003-1.030), <1 WBC (normal ≤ 3/HPF), few bacteria, few mucous, and 15 squamous epithelial cells (normal ≤ 5/HPF). Computed tomography of the abdomen and pelvis showed bilateral striated nephrograms and perinephric fat stranding, which, paired with her clinical presentation, was consistent with a diagnosis of fungal pyelonephritis.
+
+The patient was started on intravenous (IV) amphotericin B deoxycholate, which, despite its nephrotoxicity, was selected over liposomal amphotericin B for its superior urinary concentration. After initiation of antifungal therapy, her flank pain slowly improved as did her pelvic symptoms. Urine cultures collected upon admission resulted on hospital day 5 and confirmed S cerevisiae but also grew Klebsiella pneumoniae. Intravenous ertapenem for the Klebsiella was started once the care team was made aware of the urine culture result. Of note, the patient did have clinical improvement prior to the initiation of ertapenem. Discussion of possible sources of S cerevisiae exposure revealed that the patient had an active sourdough starter in her home which she fed and stirred daily. She completed a 7-day course of IV amphotericin B deoxycholate for the S cerevisiae and transitioned from IV ertapenem to ciprofloxacin (based on sensitivities) for a 10-day course of treatment for the Klebsiella. She was discharged home with close follow-up.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3191_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3191_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b3cf4f08eab587cb6981a27dc5822e1e212c6c3c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3191_en.txt
@@ -0,0 +1,17 @@
+A 49-year-old female, was admitted to the hospital due to cardiopulmonary arrest. The patient has a medical history that includes untreated cervical cancer and sleep disorders. Three hours before admission, the patient’s family members noticed that the patient was lethargic, yawning, and found that the patient had taken about 20 tablets of amitriptyline 25mg, prompting an emergency call. During transport to Thu Duc City Hospital, the patient experienced one cardiac arrest and was successfully resuscitated, with the arrest and resuscitation lasting about 10 minutes. Upon admission to the Emergency Department at Thu Duc City Hospital, the patient was unconscious/on mechanical ventilation, with a blood pressure of 105/70 mmHg on a background of Noradrenaline at a dose of 0.5 µg/kg/min and Adrenaline at a dose of 0.3 µg/kg/min. The extremities were warm, the pulse was clear, and the heart rate was regular and fast at 115 beats per minute. After admission to the Emergency Department, the patient experienced a second cardiac arrest and was resuscitated with basic and advanced cardiopulmonary resuscitation, achieving return of spontaneous circulation after 15 minutes.
+
+The pH level is 6.902 and bicarbonate (HCO3) is 18.4, which is very low compared to normal levels, indicating severe acidosis. Blood oxygen (pO2) is 52 and lactate is 10.39 mmol/L, indicating the patient is experiencing hypoxia. The results show that the patient is suffering from severe acidosis, respiratory failure, and tissue hypoxia.
+
+The electrocardiogram (ECG) upon admission shows the patient with a slow heart rate of 46 cycles per minute and a widened QRS complex of 240 ms. Several short episodes of ventricular tachycardia were recorded on the monitoring device.
+
+The patient was diagnosed with: Resuscitated cardiac arrest - Ventricular arrhythmias - QT prolongation - Seizures / Tricyclic antidepressant poisoning - Respiratory acidosis - Untreated cervical cancer - Sleep disorders.
+
+The patient was treated with mechanical ventilation, noradrenaline 0.5µg/kg/minute, sedation, and 750mL of 4.2% sodium bicarbonate in the emergency room.
+
+On the first day in the Cardiovascular Intensive Care Unit, we continued to maintain vasopressors, sedatives, and muscle relaxants, and administered isotonic sodium chloride solution and 4.2% sodium bicarbonate, adjusting the patient’s blood sodium and potassium levels. During the treatment monitoring process, the monitor showed ventricular tachycardia with a frequency of about 130 beats per minute, while the arterial blood gas results recorded a pH of 7.61, pO2 of 94, pCO2 of 40.4, and HCO3 of 40.6. Since the pH had reached the treatment threshold, the patient was administered an additional 1.5g of 15% magnesium sulfate intravenously over 15 minutes. The ECG results showed a narrowing QRS complex, but the monitor still recorded temporary episodes of ventricular tachycardia and frequent ventricular ectopic beats. The doctors decided to administer additional intravenous 2% lidocaine at a dose of 1.2mg/kg/h.
+
+On the 2nd day after hospitalization, arterial blood gas results recorded a pH of 7.52; pO2 of 146; pCO2 of 31.8; HCO3 of 26; and a magnesium level of 4.69 mmol/L. Although the patient’s QTc was prolonged (510ms), due to the high blood magnesium level (4.69 mmol/L) after using 4.5g of 15% magnesium sulfate, and the monitor only recorded short episodes of ventricular tachycardia, we discontinued the magnesium sulfate and continued to maintain lidocaine intravenously. On the same day, the patient suddenly developed a high fever twice at 39°C, cough with yellow sputum, and was supplemented with antibiotics for pneumonia treatment. At this point, the 4.2% Sodium bicarbonate and sedation were discontinued.
+
+At the end of the 3rd day of hospitalization, 2% lidocaine was discontinued for the patient. After discontinuing the use of 4.3% sodium bicarbonate and 2% lidocaine, the ECG showed a stable sinus rhythm of 95 cycles per minute, a narrowed QRS complex of 88 ms, and a QTc of 440 ms.
+
+The patient was successfully weaned off mechanical ventilation and extubated after 48 hours of sedation discontinuation, able to understand and follow commands. The patient recovered well, with no fever after 1 day of antibiotic treatment, and antibiotics were discontinued after 10 days. After 12 days of treatment, the patient was able to walk independently. After 15 days of treatment, the patient was discharged from the hospital in good recovery.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3232_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3232_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f07dcdce6e9bc69da627fd062faa17e765ef98da
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3232_en.txt
@@ -0,0 +1,9 @@
+The patient was a woman in her 80s who had previously been diagnosed with primary biliary cirrhosis and decompensated cirrhosis, classified as class B (Child–Pugh score was 9). At her outpatient visit, which was 23 days prior to her surgery, her serum potassium levels were 6.1 mEq/L; however, there was no evidence of abnormalities on her electrocardiogram. She was prescribed SZC at an initial dosage of 10 g three times a day for 3 days, followed by 5 g three times a day for 25 days to treat her hyperkalemia. Telmisartan 20 mg tablet was discontinued. The patient began to take SZC as instructed after receiving the medication on the same day. The concomitant medications she was receiving were: vonoprazan 10 mg, azosemide 30 mg, tolvaptan 7.5 mg, ursodeoxycholic acid 300 mg, polaprezinc 75 mg, LIVACT granules (L-isoleucine, L-leucine, and L-valine granules), and Aminoleban EN powder. However, we could not pay attention to the safety management regarding the changes in potassium levels associated with the consumption of SZC.
+
+The ammonia level of the patient was 24 µg/dL, which was within the normal range, approximately 1 year before admission. Furthermore, there were no problems with communication during subsequent outpatient visits, because of which the ammonia level was not measured. At the time of admission, her ammonia level was 37 µg/dL. During the course of hospitalization, her ammonia levels were measured several times and ranged between 31 and 45 µg/dL, with no evidence of abnormalities. She had been taking her medication as prescribed until her hospitalization. The patient was assisted by family members and regularly took the SZC for approximately 23 days.
+
+The day before surgery, after having dinner at around 7 to 8 p.m., the patient experienced abdominal pain and nausea at around 10:30 p.m., and she had to be rushed to our hospital. A computed tomography (CT) scan was performed, and an axial view of the scan revealed free intraperitoneal gas and ascites in the upper abdominal space. A high-intensity fecal mass was identified inside the colon and outside the intestinal tract at the pelvic level. Subsequent laboratory analysis identified several irregularities, including a potassium level of 1.9 mEq/L, blood urea nitrogen level of 27.5 mg/dL, creatinine of 1.22 mg/dL, hemoglobin level of 8.8 g/dL, and white blood cell count of 8100/µL. However, the C-reactive protein level was 0.20 mg/dL. The estimated glomerular filtration rate was 32.0 mL/min/1.73m2. Emergency surgery was performed the day following her admission (defined as Day 0). Several serous ascites and free intraperitoneal gas were observed in the epigastrium due to cirrhosis. Ascites-like watery stools were observed from the left lower abdominal quadrant to the pouch of Douglas, and hard stools were observed outside the intestinal tract in the lower abdominal quadrant. Hartmann’s operation with drainage was performed for repairing the sigmoid colon perforation. The postoperative X-ray images revealed accumulation of SZC in the feces. The perforation size of the resected specimen was 13.0 mm × 7.0 mm, and macroscopic findings did not reveal necrosis or bleeding. Microscopic findings did not reveal significant inflammatory cell infiltration, ischemic changes, or neoplasia around the perforation. The patient continued to receive critical care services in the intensive care unit (ICU) after surgery.
+
+Continuous hemodiafiltration was initiated on Day 0 due to a diagnosis of acute kidney injury (AKI), which was changed to hemodialysis (HD) on Day 7. SZC was discontinued after admission, and potassium was administered intravenously as needed. Despite the administration of multiple gastroprokinetic agents and laxatives, it took about 1 week for the hard stools containing residual SZC to be excreted. The X-ray images indicated the excretion of the residual SZC. Enteral nutrition was resumed on Day 7, and swallowing training was initiated on Day 8 following the patient’s transfer from the ICU to the medical ward. On Day 13, she developed a lacunar infarction and was treated conservatively. Her renal function improved, and HD was discontinued on Day 36. Then, on Day 51, she developed sudden circulatory failure. Cardiac catheterization revealed acute myocardial infarction caused by the obstruction of the right coronary artery. Thrombectomy and transcatheter stent placement were performed. The patient was also diagnosed with advanced rectal cancer during the hospital stay. Curative operation and stoma closure were considered inoperable because of her physical condition.
+
+On the 95th day following surgery, despite an improvement in her condition, it was determined that a discharge to home would be difficult; hence, the patient was transferred to another hospital for rehabilitation.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3239_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3239_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5287171e9636afa6a40781acfc8611bd423abd8a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3239_en.txt
@@ -0,0 +1,13 @@
+A 41-day-old full-term male infant, born at 38 weeks of gestation via cesarean section to a 40-year-old mother, weighing 2500 grams at birth, was admitted. The pregnancy was uneventful, with no significant family or medical history. He received the first dose of the hepatitis B vaccine at birth without any adverse reactions. He is exclusively breastfed and currently weighs 4000 grams.
+
+The infant developed widespread skin lesions one week following the administration of the BCG vaccination. These lesions rapidly disseminated across the body within two days, yet notably, the infant did not exhibit any systemic symptoms such as high-grade fever, vomiting, diarrhea, decreased oral intake, or alterations in bowel habits or urine color.
+
+Upon admission, the infant exhibited a low-grade fever (37.8°C) but otherwise appeared well. Physical examination revealed characteristic targetoid erythematous patches of varying sizes, with a darker center compared to the periphery. These annular, bull’s-eye-shaped lesions were noted, sparing the face, palms, soles, and mucous membranes. The rest of the physical examination was unremarkable, except for mild inflammation observed at the circumcision site, which was performed four days earlier.
+
+A series of laboratory tests and imaging studies were conducted upon admission. Additional serologic tests for HSV IgM and IgG antibodies and HBV surface antigen (HBsAg) were non-reactive, indicating no active infection. Maternal serologic tests for anti-SSA (Ro) and anti-SSB (La) antibodies were also non-reactive, reducing the likelihood of neonatal lupus. An ECG was performed to rule out cardiac involvement, with normal results observed.
+
+The infant’s clinical presentation required a thorough differential diagnosis to exclude conditions such as EM or a vaccine-related adverse reaction. Following comprehensive diagnostic evaluations and laboratory tests, which confirmed the EM diagnosis, the management plan focused on careful monitoring of vital signs and necessary follow-up investigations. Consequently, the infant continued breastfeeding as tolerated, with acetaminophen prescribed for low-grade fever. Since there were no signs of infection, antibiotic therapy was withheld.
+
+Over the course of the hospital stay, the bullseye rash improved, and the infant remained active and well. There were no additional findings on repeat examinations, and no murmurs or abnormal abdominal findings were noted. The infant’s condition was consistently stable, with vital signs within normal limits. Nutritional status remained adequate with exclusive breastfeeding.
+
+Five days after admission and with an improvement in skin lesions and stable condition, the infant was discharged home with instructions for the parents to monitor for any signs of fever or worsening of symptoms and to return for follow-up as needed. The discharge plan included maintaining regular feeding, monitoring skin changes, and ensuring prompt medical consultation if new symptoms arose.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3246_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3246_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..06e7402db56894926d16ba5f09b039680e853fd7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3246_en.txt
@@ -0,0 +1,7 @@
+A 45-year-old female with a past medical history of rheumatoid arthritis and a remote history of chickenpox was referred for evaluation of an 11-day history of recurrent redness, blurriness, mild pain, pressure, discomfort, and decreased vision in the right eye (OD). Prior to her referral to our facility, she was evaluated at an outside clinic with a one-week history of redness and decreased vision OD. She was started on topical difluprednate and atropine for anterior uveitis which she began 2 days before her presentation to our facility.
+
+On examination, best-corrected visual acuities (BCVA) were 20/100 OD and 20/25 in the left eye (OS). Pupillary examination showed a 1+ relative afferent pupillary defect OD. Intraocular pressures (IOP) were physiologic at 17 mmHg OD and 16 mmHg OS. Slit-lamp examination revealed 1–2+ granulomatous anterior chamber reaction and 3+ vitreous cells OD, and OS was unremarkable. Fundus examination showed optic disc edema and hemorrhages, diffuse retinal whitening, and necrosis with hemorrhagic vasculitis OD, and OS appeared unaffected. A diagnostic anterior chamber paracentesis was performed, and the ocular fluid was positive for VZV by PCR testing. Given the examination findings, she was diagnosed with acute retinal necrosis prompting an in-office intravitreal injection of foscarnet (2.4 mg/0.1 mL) and ganciclovir (2 mg/0.05 mL) along with initiation of oral valacyclovir 2 grams TID. On a 2-week follow-up after the initial presentation, the patient reported improvement in central vision, and BCVAs improved to 20/50 OD and 20/20 OS. Examination revealed persistent vitreous opacity, but the retinitis has improved with consolidation and well-demarcated borders of the retinitis involving the temporal retina.
+
+On the 6-week follow-up, the patient complained of a sudden loss of vision in the right eye. BCVAs were counting fingers OD and 20/20 OS, and examination revealed retinal detachment OD. The patient underwent surgery for complex rhegmatogenous retinal detachment (RRD) repair and continued to be monitored closely. Postoperatively, the vision gradually improved until two weeks post-surgery when the patient was noted to develop a low-lying inferior retinal detachment with surface proliferative vitreoretinopathy (PVR), prompting a pars plana vitrectomy for retinal detachment repair. This surgery was performed seven weeks after the PVR diagnosis was made, and six months after the patient’s initial presentation at our facility.
+
+An aqueous humor (AqH) sample of the right eye was obtained during surgery for a chemokine/cytokine profile analysis. The levels of a panel of 22 cytokines and chemokines (ie, IFN-γ, IL-10, IL-12p70, IL-17A, IL-1β, IL-2, IL-5, IL-6, IL-8, TNF-α, IL-18, IL-1RA, IL-1a, IL-1α, IP-10, MCP-1, MIP-1α, MIP-1β, SDF-1α, IL-21, IL-22, IL-23, and IL-27) were tested in triplicate using a multiplex chemiluminescent immunoassay. The concentration of 7 cytokines/chemokines was detected including IFN-γ, TNF-α, IL-8, IL-18, MIP-1β, IP-10, and MCP-1. MCP-1 was the most abundant cytokine (900 pg/mL), while IP-10 was the second most abundant cytokine (800 pg/mL). IL-8 and IL-18 were the third most abundant cytokines, each with a level of 40 pg/mL, while IFN-γ and TNF-α levels of <10 pg/mL were recorded as the least abundant in this patient’s AqH sample.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3248_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3248_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f13e51e91cde87f5a4e7679d012e08d7752bfeae
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3248_en.txt
@@ -0,0 +1,13 @@
+A 62-year-old woman was referred to our department with complaints of low back and lower extremity pain for 2 years, 1.5 years after lumbar spine surgery, and recurrent low back pain for 1 year. The pain was dull and soreness, located in the lower back, accompanied by difficulty in turning over and radiating to the lower extremities. No numbness in the lower limbs has been previously reported. No apparent cause of the pain has been reported. The patient was treated at a local hospital and underwent L5/S1 discectomy with internal fixation in August 2019. Symptoms were relieved after surgery. However, low back pain recurred four months after the surgery. It was more severe on the left side, with soreness and cramp-like pain that worsened with changes in position and was insensitive to ibuprofen and codeine phosphate tablets. Non-contrast magnetic resonance imaging (MRI) of the lumbar spine was performed three months ago and showed a bulged lumbar intervertebral disc at the L3-L5 level.
+
+Her medical history included hypertension and diabetes. The blood pressure and glucose levels were well controlled, but the specific values did not contribute. She had undergone thyroid surgery eight years ago and continued to take levothyroxine sodium tablets (Euthyrox) after the operation. The patient had no family history of bone tumors.
+
+Examination revealed decreased lumbar mobility, straight leg raise (SLR) test (-), hip test (-), bilateral femoral nerve traction test (+), bilateral sacroiliac joint tenderness (+), bilateral T12-L3 paravertebral tenderness (+). Several questionnaires were used to assess patient status. The scoring results were as follows: numerical rating scale (NRS) 4 points in the resting state and 7 points when moving, ID-pain score 1 point, patient health questionnaire-9 (PHQ-9) 13 points, generalized anxiety disorder 7-item scale (GAD-7) 5 points, Patient Health questionnaire-15 (PHQ-15) 5 points.
+
+The laboratory test results revealed elevated hs-CRP levels (28.3 mg/dL; normal range 0–8 mg/dL), and elevated erythrocyte sedimentation rate (49, 53, 67, 73, and 62 mm/h; normal range 0–20 mm/h). Results for serum autoantibodies, rheumatoid factor, and HLA-B27 were negative. All the other results were within the normal range. Lumbar computed tomography (CT) with three-dimensional reconstruction revealed postoperative changes in the L5-S1 vertebrae and intervertebral disc, narrowing of the intervertebral space, increased vertebral body density, and compressive changes in the L2 vertebrae. Lumbar noncontrast MRI revealed L5-S1 vertebrae fixation. The L3/4 intervertebral disc slightly bulged, L2 vertebral body compression changes and abnormal signal, and T11-L2 vertebrae abnormal signal. Sacroiliac joint CT showed high intensity in the left sacroiliac joint, which indicated osteitis of the left sacroiliac joint. Sacroiliac joint magnetic resonance imaging (MRI) revealed postoperative changes in the L5-S1 vertebrae.
+
+Adjacent segment degeneration (ASD) is a condition that often occurs after spinal fusion or when another back surgery is performed. Combined with the patient’s back surgery history and lumbar CT results, we first considered the possibility that the patient may have ASD. Symptomatic and supportive NSAIDs and nerve nutritional therapy were administered. Loxoprofen 60 mg TID, cobamamide 1.5 mg QD, calcium carbonate and vitamin D3 600 mg QD, and tromethamine 30 mg BID were given to the patient. However, the patient’s symptoms did not improve significantly. Therefore, we attempted to identify the other diagnoses.
+
+During re-examination, we found that her palms showed hyperkeratosis with active pustulosis. Combined with the previously elevated hs-CRP and erythrocyte sedimentation rate, we suspected that the patient had SAPHO syndrome and performed skeletal emission computed tomography (ECT). Skeletal ECT found a typical “horn sign” change on the sternum stem and revealed active bone metabolism of T8, T10, T11, L3, S1 vertebrae, bilateral sternoclavicular joints, bilateral sacroiliac joints, and bilateral knee joints, as well as increased bone density in some thoracic vertebrae.
+
+The patient met the diagnostic criteria for SAPHO syndrome and was diagnosed with SAPHO syndrome. Based on the original treatment, we added sulfasalazine enteric-coated tablets 1 g BID, adalimumab 40 mg once a fortnight, pregabalin 75 mg BID, and tramadol sustained-release tablets 100 mg BID. The patient reported that her pain symptoms were significantly relieved. He was discharged from the hospital and received adalimumab treatment (40 mg once per fortnight in the first 6 months and 40 mg once per month after month 6) in the outpatient clinic. Patient compliance was good during the treatment, and no adverse reactions were reported. Hyperkeratosis with active pustulosis on both palms fully resolved after 12 months of treatment. The patient was followed up for 6 months after full recovery, and no recurrence was found in the symptoms of low back and lower extremity pain and palmar hyperkeratosis with active pustulosis.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3250_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3250_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e209ff5b66afa35060d7a5f8a778319fcedf341d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3250_en.txt
@@ -0,0 +1 @@
+A 67-year-old woman from the region of Chichaoua which is an endemic area of Leishmania Tropica in Morocco. The patient presented with swelling in the centrofacial region that had been evolving for 2 months. She had a grandson treated for leishmaniasis. Clinical examination revealed erythematous and edematous plaque covering the centrofacial region and reaching the eyelids, associated with the presence of hemorrhagic crusts on the tip of the nose; the episode was treated as facial erysipelas with antibiotics (Amoxicillin-Clavulanic acid, ciprofloxacin) for 15 days without improvement. In front of anamnestic data and clinical examination, the diagnosis of CL in its erysipeloid form was strongly suspected and then confirmed by skin smear which had shown the presence of leishmania amastigotes. The identification of the Leishmania species is not available at our institution. The patient had left bundle branch block on the electrocardiogram, so we opted for the metronidazole-clarithromycin combination as an alternative to pentavalent antimonials. Our patient was treated with metronidazole 1,5 g daily and clarithromycin 15 mg/kg for 30 days with good progression.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3251_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3251_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4e9d8b58d05ff0b3833e9dee0670445684d089cd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3251_en.txt
@@ -0,0 +1,3 @@
+The patient was a 3-year-old male from Frontino, Antioquia, a municipality considered an endemic area for malaria. No significant medical or family history was reported.
+
+The patient was admitted with a clinical picture of 12 days of evolution of fever peaks quantified with 801 parasites/µl of P. vivax. After diagnosis and after 12 days of symptoms, the patient was treated with 150 mg daily of chloroquine (10 mg/kg) and 10 mg of primaquine daily. This last corresponded to more than twice the recommended dose for his age and weight, as he received 0.6 mg/kg/d, when the correct dose according to clinical practice guidelines was 0.25 mg/kg/d. The same day of diagnosis and start of treatment, the patient was transferred to a hospital of higher complexity, with diagnosis of uncomplicated malaria, but with alarm signs. The child was hospitalized in general conditions acceptable, with hepatomegaly already described and without other alterations in physical examination. In the admission laboratory tests, the anaemia persistence was reported (haemoglobin of 9.9 mg/dl and haematocrit of 29.6 %). Thrombocytopenia (31,000 platelets/µl) and normal leukocytes (6,400 cells/µl) were also reported. In arterial gases, pH of 7.44, partial pressure of CO2 of 33 mm Hg and O2 of 129 mm Hg, HCO3 of 22.4 mEq/L and base excess of 0.6 mmol/L were reported. The thick gout test was again positive for P. vivax (7,200 parasites/µl). The treatment was continued with 150 mg daily of chloroquine (10 mg/kg) on the second day and 75 mg daily (5 mg/kg) on the third day, until completing three doses. The dose of primaquine was adjusted to 5 mg/day (0.33 mg/kg) to continue from the next day, until completing 14 days. The patient finished the treatment with chloroquine and continued with primaquine. However, on the fourth day of treatment, after receiving four doses of primaquine, he presented hypoxaemia of up to 76 %, with slight cyanosis peribucal not associated with signs of respiratory distress, with no pathological findings at the time of pulmonary auscultation. Supplemental oxygen was initiated with little improvement, maintaining saturations of 85 % with mask without re-inhalation. The chest radiograph showed normal findings and in another arterial gases test, O2 of 129 mm Hg, HCO3 of 25.5 mEq/L, base excess of 0.6 mmol/L, lactate of 0.9 mmol/L and haemoglobin of 9.5 mg/dl, which corresponded to respiratory alkalosis with normal lactate and haemoglobin. However, the difference in oxygen saturation obtained between arterial gases and pulse oximetry was noted. For this reason, with the suspicion of methaemoglobinaemia, it was requested to quantify the methaemoglobinaemia in the arterial gases test at 6 hours. As a result, a methaemoglobinaemia value of 17.1 % was reported and an increase in the partial pressure of oxygen (pH of 7.48, partial pressure of CO2 of 30 mm Hg and O2 of 301 mm Hg, HCO3 of 23.2 mEq/L), base excess of 0.6 mmol/L, lactate of 0.9 mmol/L and haemoglobin of 9.5 mg/dl, which corresponded to respiratory alkalosis with normal lactate and haemoglobin. However, the difference in oxygen saturation obtained between arterial gases and pulse oximetry was noted. Despite this, and even with the use of supplemental oxygen with a mask without re-inhalation, oxygen saturation was not improved. For this reason, the toxicology service indicated treatment with ascorbic acid and proposed the use of methylene blue. However, given the improvement in clinical response with ascorbic acid, methylene blue was not administered. The patient was discharged with serial thick gout test, as indicated by the toxicology service, and administration of ascorbic acid for one week.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3258_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3258_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..05bdfb3c79f8f6656e9f8b822c70ed74bd833d57
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3258_en.txt
@@ -0,0 +1,15 @@
+In this case report, the patient gave informed consent to participate and to publish. A 59-year-old married female of Sundanese ethnicity who worked as a housewife. Upon admission to the high-care unit, a diagnosis of post-sympathectomy, namely Incessant Ventricular Tachycardia caused by Arrhythmogenic Cardiomyopathy dd IDCM (Ischemic Dilated Cardiomyopathy), and Chronic Heart Failure, NYHA FC II, was established. The patient had a history of palpitations for the last year and had been receiving tablet therapy at a local clinic, however the patient did not know the name of the medicine he was taking, according to him, he forgot and there were many kinds of medicine he was taking. Despite the intake of regular medication, the symptoms experienced remained persistent. In the two months preceding admission, the condition worsened, manifesting as increased palpitations, irregular heartbeats, shortness of breath, dizziness, and fainting. Consequently, the patient was referred to a specialized hospital and underwent sympathectomy with thoracic sympathetic nerve ablation (T1-T3) using Video Assisted Thoracoscopic Surgery (VATS).
+
+According to the patient, the symptoms experienced in the past two months were caused by emotional distress, characterized by sadness and anxiousness. This was because the eldest child of the patient, who was already married, went through a divorce and developed a mental disorder after the separation. The child’s erratic behavior, wandering around the neighbors’ houses and damaging properties, induced anxiousness, leading to increased palpitations. Examination showed a history of low blood pressure, but no history of hypertension or diabetes mellitus. Furthermore, in the family health history, there were no instances of heart disease or premature death due to heart attack.
+
+During the assessment on the first day after the surgery, there were complaints of shortness of breath, pain in the left chest where the operation was performed, and a general feeling of weakness. Observation showed a blood pressure of 98/61 mmHg, with 22 breath per minute respiratory rate (RR), 61 beats per minute heart rate (HR), 36.5°C temperature, 98% oxygen saturation (SPO2), and 106 mmHg mean arterial pressure (MAP). Furthermore, the pain level was rated as 2 on Numeric Rating Scale (NRS). The patient was conscious and alert, for neurological status using Glasgow Coma Scale (GCS) score of E = 4 M = 6 V = 5. The conjunctiva was not anemic, the sclera was not jaundiced, jugular venous pressure (JVP) was 5+2 cm, the shape and movement of the chest appeared symmetrical, heart sounds S1 and S2 were regular, with no S3 or S4 sounds, murmurs, rales, or wheezing. The abdomen was distended, with bowel sounds heard at 10 times per minute. Acral extremities were warm, capillary refill time (CRT) was less than 2 minutes, and there was no edema. The examination showed the presence of a wound on the chest with chest tube thoracostomy (CTT) measuring 5 cm × 2 cm. The fall risk assessment using the Morse scale showed a high-risk level.
+
+Electrocardiography (ECG) played a crucial role in the pre- and post-operative assessment. ECG showed a monomorphic Ventricular Tachycardia pattern before the procedure. After the operation, ECG showed sinus rhythm with a prolonged QTc (458ms). Chest X-ray before the operation showed cardiomegaly with no pulmonary congestion. Results before the procedure showed a dilated left ventricle (LV), eccentric left ventricular hypertrophy (LVH) with reduced LV systolic function (LVEF 33%), regional wall abnormalities, and regional right ventricular (RV) wall akinesia. LV diastolic dysfunction was classified as grade I, with normal anatomy and function of all valves. Furthermore, there was a low probability of ventricular hypertrophy (VH) and reduced RV systolic function with regional wall motion abnormalities, meeting the echo major criteria of PADUA score for arrhythmogenic cardiomyopathy. Angiography before the operation showed severely reduced LV systolic function (LVEF 27%). Laboratory results for ion calcium, magnesium, and troponin T before the surgery were within normal limits.
+
+The patient received intravenous treatment with 0.9% NaCl fluid at a rate of 1500 cc per 24 hours, Paracetamol 1 × 1 gram, Omeprazole 2 × 1 gram, oral Cefixime antibiotics 2 × 200 mg, intravenous Vitamin K 3 × 10mg, intravenous Tranexamic Acid 3 × 500mg, and heart medication for arrhythmia, namely Bisoprolol tablet 1 × 2.5 mg (given when HR > 65 beats per minute), and Spironolactone tablet 1 × 25mg (given when mean arterial pressure is between 70 and 100 mmHg).
+
+In terms of Nursing Diagnoses based on North American Nursing Diagnosis Association (NANDA), the priorities identified included 1). Decreased Cardiac Output related to changes in heart rhythm, 2). Impaired Gas Exchange related to an imbalance in ventilation-perfusion, and 3). Activity intolerance related to an imbalance between oxygen supply and demand.12
+
+The selected nursing interventions based on NIC (Nursing Interventions Classification) and NOC (Nursing Outcomes Classification) for the first nursing problem, which was a decrease in cardiac output, emphasized cardiac care management and collaborative administration of medications, such as propranolol and spironolactone. This also comprised the evaluation of chest pain, monitoring fluid balance, changes in blood pressure, mean arterial pressure (MAP), and respiratory status, as well as assisting in reducing anxiety through deep breathing relaxation techniques. Vital sign management was also carried out including monitoring blood pressure, respiratory rate, heart rate, and temperature. The procedures also comprised recording blood pressure changes and monitoring heart sounds.
+
+For the second nursing problem, which was the gas exchange issue, airway management was conducted. This included auscultating breath sounds, recording any additional sounds, and monitoring respiration, oxygen status, CTT hose as well as undulations, and fluid from CTT. The third nursing problem, namely patient activity intolerance, was managed through activity therapy. Continuous evaluation was carried out, and a follow-up was accomplished through a video call. The results showed that with planned nursing care, complications that often occurred after the surgery could be prevented. On the second day post-surgery, there was no complaint of shortness of breath and palpitations. This led to the removal of the chest tube and discharge. Mobilization and activities were performed gradually in this case. Upon discharge, the patient was able to stand and walk around the bed area, with enhanced adaptation to the pain. For the follow-up care evaluation with tele-nursing, a video call was conducted to provide guidance on maintaining activities according to the heart capacity. The patient was pleased to be contacted, had no shortness of breath complaints, and activities had started gradually.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3270_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3270_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..83804a7be73be10e69df2a249ef50d89222b9a6f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3270_en.txt
@@ -0,0 +1,7 @@
+A Japanese 11-month-old baby boy presented at our institution with symptoms including fever, weight loss, and gallop rhythm. His fever persisted for 3 days before presentation but no treatment was provided. He was born by vaginal delivery at 37 weeks of gestation with a weight of 2612 g (36th percentile) and a head circumference of 33.7 cm. There was no family history of aortic disease and sudden death. When he was 7-months old, he had a fever of unknown origin that persisted for 2 weeks. He was poor in weight gain and was 7.55 kg (6th percentile) at the age of 10 months; his body weight decreased by 0.57 kg in the 3 weeks before presentation.
+
+On examination at the presentation, his height was 70.8 cm, his weight was 6.98 kg, and his head circumference was 43 cm. He was ill-appearing and febrile to 38.4 °C. His blood pressure was 124/62 mmHg and pulse 146/minute. There was a notable S3 gallop and systolic murmur at the apex (Levine scale grade III/VI); however, there were no signs of rales or peripheral edema. Other physical and neurological examinations were normal. A chest X-ray revealed cardiomegaly, with 58% cardiothoracic rate. Echocardiography indicated left ventricular (LV) enlargement and dysfunction with LV diastolic dimension of 32 mm (130% of normal), LV ejection fraction 48%, moderate mitral regurgitation, and slight aortic regurgitation. Blood tests indicated the following: white blood cell count, 11.07 × 103/μl; hemoglobin, 10.6 g/dl; C-reactive protein, 5.59 mg/dl; creatine phosphokinase, 294 U/l; creatine phosphokinase-MB isozyme, 27 U/l; fibrin degradation products D-dimer, 2.1 μg/ml; brain natriuretic peptide, 2841 pg/ml; human atrial natriuretic peptide, 1360 pg/ml; and serum troponin T, 0.26 ng/ml. His blood culture at admission was negative.
+
+As dilated cardiomyopathy was diagnosed, we initiated diuretics. However, his fever and high blood pressure (systolic blood pressure, 130–140 mmHg), which rarely present with dilated cardiomyopathy, persisted. To investigate the causes of high blood pressure, computed tomography was performed and revealed thoracic and abdominal aortic aneurysms on hospital day 3. It also revealed severe celiac artery stenosis and bilateral renal artery stenosis. From these findings, TA was diagnosed and 1 mg/kg per day prednisolone was consequently initiated as first-line therapy. His fever had resolved on day 5; his C-reactive protein levels returned to normal on day 10.
+
+Although his general condition improved, deterioration of vascular lesions was evident, as shown by echocardiography, on day 15. Celiac artery occlusion, severe right renal artery stenosis, and new superior mesenteric artery stenosis were also observed on day 15. We increased the dose of prednisolone to 2 mg/kg per day for 1 week due to the possibility of active inflammation around vascular lesions. In addition, we attempted continuous intravenous infusion of lipo-PGE1 at 10 ng/kg per minute to suppress the progression of angiostenosis. We performed vascular echocardiography twice a week and confirmed that there was no progression of angiostenosis following initiation of lipo-PGE1. We terminated infusion of lipo-PGE1 on day 36 and performed cardiac catheterization on day 45. His right renal artery was not visualized by angiography, and his right kidney was fed by collateral arteries, while vascular echocardiography revealed patency of his right renal artery with severe stenosis. We also confirmed celiac artery occlusion and superior mesenteric artery stenosis to be the same as those observed in previous echocardiography findings. His cardiac function gradually improved. After his C-reactive protein levels returned to normal, 1 mg/kg per day of prednisolone was administered for 1 month, after which the dose was tapered every other 2 weeks. We observed him for 13 months after the termination of lipo-PGE1. The inflammatory findings remained negative and the diameters of abdominal aortic vessels were stable.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3273_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3273_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d058ee38394b46bd4c6a821840aa20741865f934
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3273_en.txt
@@ -0,0 +1,5 @@
+54-year-old male patient with pain and stiffness in the dorsal and medial aspect of the hallux metatarsophalangeal joint of the right hallux that started four years ago. Pain worsens with walking and decreases with rest. No history of trauma to that foot. His personal medical history is hypothyroidism and dyslipidemia and his surgical history is a release of the trigger finger of the right and left hand and a resection of the synovial cyst of the left wrist. After the physical examination of the right foot, he has pain on the dorsal and medial aspect of the hallux metatarsophalangeal joint, skin without alterations. His range of motion of the hallux metatarsophalangeal joint is dorsiflexion of 25° with pain and plantar flexion of 20°, distal neurovascular examination without alterations with a two-second distal capillary refill. Physical examination of the rest of the foot was normal. Dorsal and lateral radiographs were taken with support of the right foot, which showed a decreased joint space of the hallux metatarsophalangeal joint predominantly of the lateral aspect, subchondral sclerosis and cysts with a dorsal osteophyte on the head of the first metatarsal, as well as the presence of small osteophytes on the head of the first metatarsal and the base of the proximal phalanx of the hallux. Based on the radiographic findings, the diagnosis of hallux rigidus Coughlin and Shurnas stage 3 was made. The patient tried conservative treatment with non-steroidal anti-inflammatory drugs and modifications in the type of footwear for six months with no improvement, so surgical treatment was proposed. Under general anaesthesia and using a tourniquet, a 4 cm incision was made on the dorsal aspect of the hallux metatarsophalangeal joint. Dissection was performed and the hallucis longus extensor was identified and retracted. A dorsal capsulotomy was performed and the joint was exposed. A large dorsal osteophyte was observed on the head of the metatarsal. A dorsal exostectomy was performed with a saw and a gouge. In addition, a cheilectomy and a medial buniectomy were performed with a saw. The sesamoids were exposed and released. There was no articular cartilage on the lateral aspect of the head of the first metatarsal. The cartilage on the medial aspect was intact. The hallucis longus extensor (EHB) was located and released from its insertion. A transosseous perforation was performed in the head of the metatarsal, the EHB was interposed in the medial aspect of the hallux metatarsophalangeal joint and fixed with vicryl. The wound was washed, capsulorrhapy was performed and the wound was closed in layers. The skin was covered with gauze, elastic bandage and a rehabilitation shoe was placed.
+
+The preoperative Foot Function Index was 27% and the postoperative was 8%; the preoperative American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Rating System (AOFAS-HMI) was 77% and the postoperative was 90%; the preoperative subscale of activities of daily living Foot and Ankle Ability Measure (FAAM) was 76% and postoperative 95% and the preoperative sports subscale was 75% and postoperative 97%.
+
+At 1.7 years after surgery, his postoperative range of motion was 60° active dorsiflexion and 40° active plantar flexion. The patient denied pain, discomfort or weakness in the metatarsophalangeal joint. He performed his daily activities without limitations and was satisfied with the postoperative results.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3278_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3278_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4a3e407178e28887e69357bc15991bbd20427b2a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3278_en.txt
@@ -0,0 +1,7 @@
+A 69-year-old Caucasian male was observed in our diabetic retina department with bilateral diabetic macular edema. His medical history included diabetes mellitus (diagnosed ten years earlier), arterial hypertension, dyslipidemia, and benign prostatic hyperplasia. Additionally, his ophthalmologic history included left eye (OS) cataract surgery the previous year. His best-corrected visual acuity (BCVA) was 4/10 in the right eye (OD) and 5/10 in the left eye (OS). On biomicroscopy, he presented a nuclear sclerosis OD and intraocular lens OS. Intraocular pressure was 16 mmHg in both eyes (OU). For macular edema, he had previously been treated with bevacizumab (5 injections; 1.25 mg) and aflibercept (5 injections; 2 mg) with an incomplete anatomical response (<20% reduction in central macular thickness (CMT)). Fluorescein angiography revealed no ischemia in the peripheral retina OU. Optical coherence tomography (OCT) revealed a CMT of 371 µm in the OD and 475 µm in the OS. After discussing the risks and benefits of intravitreal dexamethasone injection (Ozurdex® - dexamethasone intravitreal implant (0.7 mg)), the patient agreed to proceed . The injections were performed in both eyes three days apart under a surgical microscope in the operating room. The injections were administered by an experienced attending, under local anesthesia with topical oxybuprocaine (4 mg/mL) and after disinfection of the periocular skin with 10% povidone-iodine solution and the ocular surface with 5% povidone-iodine. Local anesthesia was supplemented with a subconjunctival injection of 2% lidocaine. The injection site was marked on the inferotemporal sclera, 4.0 mm OD (phakic eye) and 3.5 mm OS (pseudophakic eye) from the limbus. Paracentesis was not required to reduce intraocular pressure. After the injection, topical 5% povidone-iodine was reapplied to the conjunctival cul-de-sac. The procedures were uneventful, except for an extensive conjunctival hemorrhage OD. An appointment was scheduled fifteen days later to assess his intraocular pressure, but the patient missed it.
+
+Four months later, at the rescheduled appointment, the patient referred OD vision loss (from 4/10 to 2/10), which occurred a few days after the injection. On the slit-lamp observation, under pharmacological mydriasis, the implant was found in the right crystalline lens, in the pupillary area. The cataract was more advanced around the implant. The cornea remained transparent, with no inflammation observed in the anterior chamber, and the intraocular pressure was normal. The retinal OCT showed an improvement of macular edema in the OD, but not in the OS. An AS-OCT (Spectralis Heidelberg Engineering) was performed to better understand the location of the implant, its entry point and the non-integrity of the posterior capsule.
+
+Due to decreased visual acuity (VA), caused by the cataract progression and the implant’s position in the visual axis, the patient was scheduled for surgery. One week later, a phacoemulsification surgery with a three-piece hydrophobic intraocular lens (Alcon AcrySof® MA60AC) implantation in the sulcus, associated with anterior vitrectomy was completed. No lens fragments dropped during surgery. Hydro-dissection and hydro-delamination were avoided to prevent exacerbation of the suspected posterior capsular rupture. The repositioning of the implant into the vitreous cavity was unsuccessful, as the implant was friable and subsequently could not be grasped. As a result, the implant was aspirated during surgery.
+
+The patient had an uncomplicated post-operative recovery. One month after the surgery his OD BCVA was 9/10 and the OCT demonstrated the same CMT as before surgery.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3285_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3285_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e9a6f37664607323a74d05228165097838897f63
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3285_en.txt
@@ -0,0 +1,3 @@
+A 37-year-old Thai woman presented with a 1-year history of painless proptosis of the left eye and complaints of diplopia during up gaze. She denied any previous history of trauma, underlying disease, or genetic disease in the family. Physical examination showed mild swelling of the left eyelid and a yellowish subconjunctival mass in the superior bulbar region, which had a soft consistency, was non-reducible, and had no apparent posterior limit. The best-corrected visual acuity (BCVA) was 20/20 bilaterally. The intraocular pressures were 14 mmHg in the right eye and 15 mmHg in the left eye. Extraocular movements were full for the right eye and limited in elevation for the left eye. The globe was displaced inferiorly by 5 mm, and proptosis of 5 mm was observed in the left eye. Hertel exophthalmometry of 10 right eye and 15 left eye with a base of 107 mm. Magnetic resonance imaging of the brain and orbits demonstrated a soft tissue mass with dimensions of 1.1×1.6 x 1.7 cm involving the superior rectus muscle belly and tendon. The lesion showed hyperintensity on T1- and T2-weighted images. The mass was saturated on fat-saturated sequences and suppressible on sequences with fat suppression. It was responsible for the left eye proptosis and inferior globe displacement.
+
+The superior bulbar mass gradually enlarged and prolapsed in the palpebral fissure over 4 months. A debulking procedure via a transconjunctival and vertical lid split was performed. An ovoid well-circumscribed yellowish mass was found at the superior rectus muscle in the sub-tenon and intraorbital spaces. A pathological study revealed mature adipose tissue, with minimal connective tissue stroma, enclosed in a thin fibrous capsule. The tenon capsule showed multiple foci of small lymphoid cells and plasma cell aggregates. The immunostaining results for CD3, CD5, CD10, CD20, CD23, cyclin D1, BCL2, kappa, lambda, immunoglobulin (Ig) G (IgG), IgG4, IgA, and IgM were consistent with chronic non-specific inflammation. Systemic steroid treatment (prednisolone 1 mg/kg/day) was initiated and maintained for 1 month. The BCVA last follow-up was 20/20. The proptosis and diplopia improved 3 months after treatment.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3293_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3293_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..828fc9024cab81a13fc8a41857b6980b1f474716
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3293_en.txt
@@ -0,0 +1,20 @@
+The patient is a 51-year-old white man with a medical history significant for severe coronary artery disease resulting in cardiogenic shock (at one point requiring a short-term left ventricular assist device), heart failure with reduced ejection fraction estimated at 20%–25%, hypertension and schizophrenia who presented with his brother to the emergency department with 5-day history of fatigue, ataxia, altered mental status and abnormal behaviour.
+
+His brother states that he has been getting steadily worse, with multiple near falls and unsteadiness in 2 days leading up to admission. He has never had any symptoms like this before, and has poor insight into his symptoms. His behaviour and mental status have also been inappropriate, as the brother states he has been unable to complete activities of daily living such as bathing or feeding himself. His affect has also been more flat than normal, with the patient’s brother reporting significantly longer time to respond to questions than his baseline. He also reported one episode of hyper elation and agitation that resolved after several hours. He has been alert and oriented to only person and place, but not time (normally he is fully oriented). The patient denies any shortness of breath, chest pain, nausea, headache, vomiting, diarrhoea or decreased oral intake. He and his brother deny any trauma. The patient denies any hallucinations, delusions, depressed mood or worsening negative symptoms of schizophrenia. His medication regimen is notable for spironolactone 25 mg daily, torsemide 200 mg two times per day and metolazone 2.5 mg daily for diuresis. This large dose of diuretics was due to a recent hospitalisation for congestive heart failure exacerbation with volume overload. It was during this hospitalisation that torsemide was increased, and spironolactone was added with metolazone. His other home medications included atorvastatin 80 mg daily, clopidogrel 75 mg daily, hydroxyzine 25 mg as needed for itching, mirtazapine 30 mg daily, olanzapine 10 mg daily, trazodone 50 mg as needed for sleep, metoclopramide 5 mg as needed for nausea and pantoprazole 40 mg two times per day for heartburn. While the patient does have a history of poor medication adherence and health literacy, his brother states that he has been taking his medications as prescribed leading up to the onset of these symptoms.
+
+The patient had a blood pressure of 91/73 mm Hg on admission, with his normal baseline systolic blood pressure being around 100 mm Hg. His pulse, temperature, oxygen saturations and respiratory rate were within normal limits. On physical examination, he was generally in no acute distress. He was alert and oriented, with no focal neurologic deficit, and a flat affect. He had very dry mucous membranes, decreased skin turgor and no oedema. His cardiac examination was notable for an irregular rhythm, no appreciated jugular venous distention with equal peripheral pulses. His pulmonary examination was overall clear to auscultation. Abdomen was non-distended, with normal bowel sounds.
+
+Basic metabolic panel on admission was notable for a serum sodium of 108 mmol/L, potassium of 1.5 mmol/L, chloride of 65 mmol/L, blood urea nitrogen (BUN) of 82 mg/dL and a creatinine of 2.32 mg/dL (baseline 1.2 mg/dL). His serum osmolality was 242 mOsm/Kg H2O. His urine sodium was 20 mmol/L, urine potassium 25.6 mmol/L, urine chloride 20 mmol/L and urine osmolality 204 mOsm/kg H2O. His brain natriuretic peptide (BNP) was 2113 pg/mL, which is around his baseline. His glucose on admission was 119 mg/dL. His most recent lipid panel from 8 months prior had a total cholesterol of 263 mg/dL, high-density lipoprotein (HDL) of 37 mg/dL, low-density lipoprotein (LDL) of 183 mg/dL and triglycerides of 217 mg/dL.
+
+Notable imaging includes a non-contrast CT head that was unrevealing for acute abnormalities, and his ECG was found to have no changes from the previous studies. In the setting of the patient’s presenting symptoms and severe hyponatremia, he was admitted to the internal medicine teaching service.
+
+
+Outcome and follow-up
+
+Given his significant electrolyte abnormalities, prerenal azotemia, extensive and recently advanced home diuretic regimen and hypovolemic physical examination, the patient was assessed to be in severe hypotonic hyponatremia due to hypovolemia from over-diuresis as the cause of his presenting symptoms. In concordance with cardiology consultation, he was treated with gradual sodium correction with isotonic fluids. Normal saline was introduced at 100 mL/hour, with sodium checks in every 4 hours to avoid correction greater than 8–10 mmol/L in 24 hours. His home diuretics were held while correcting sodium. We also held his other home medications, including his schizophrenia medication olanzapine due to the risk of syndrome of inappropriate antidiuretic hormone (SIADH), which may worsen his hyponatremia. In addition, with the patient’s hypokalemia requiring aggressive repletion, we were concerned with continuing his olanzapine and its inherent risk of QT-interval prolongation. His electrolytes improved on this therapy, with a peak in sodium to 119 mmol/L on the morning of hospital day 4. However, by that afternoon, his sodium actually decreased to 116 mmol/L. At this point, his potassium and chloride had corrected, and his creatinine returned close to baseline. His presenting symptoms of ataxia, altered mental status and fatigue had slightly improved. He was able to walk around the room with supervision and had no falls. He was awake throughout the day and did not report fatigue. However, given that he was a poor historian with a very flat affect secondary to his schizophrenia history, it was difficult to ascertain his insight into his symptoms. It was also difficult to tell if his negative symptoms had worsened while holding olanzapine, but his brother confirmed that he was around his baseline in this regard. While he was oriented to person, place and time, his lack of insight and inability to describe his concerns remained a challenge throughout the hospitalisation.
+
+Following his initial presentation and volume repletion, his physical examination, symptoms, labs and imaging supported an euvolemic aetiology of his hyponatremia. He remained clear on pulmonary auscultation and did not have any abdominal distention, jugular venous distention or lower extremity oedema. He also did not report any cough, orthopnea, or paroxysmal nocturnal dyspnoea. His BNP had decreased to 1837 pg/mL. A chest radiograph showed right basilar atelectasis with possible infiltrate, but was mostly stable compared with baseline. In conjunction with an euvolemic hyponatremia, an evaluation for SIADH was started. This was not only supported by his current examination status, but he was also being treated with olanzapine prior to admission, which has a risk for SIADH. His intravenous fluids were stopped and he was placed on a 1000 mL/day fluid restriction. However, his hyponatremia failed to significantly improve with a value of 117 mmol/L on the morning of hospital day 5, and 118 mmol/L on the morning of day 6. His urine electrolytes included a urine sodium of less than 20 mmol/L, urine potassium 26.9 mmol/L, urine chloride 23 mmol/L and urine osmolality 315 mOsm/kg H2O. His low urine sodium suggested that SIADH was not the aetiology of his hyponatremia. He remained clinically euvolemic on physical examination on hospital day 6, including normal pulmonary examination to auscultation, no jugular venous distention, no oedema, normal capillary refill and no abdominal distention. He also did not report cough, orthopnea or paroxysmal nocturnal dyspnoea, and continued to state that he had been resting comfortably every night.
+
+In the setting of likely mismanagement of this patient’s hyponatremia, the primary inpatient teaching service used point-of-care ultrasound on the morning of hospital day 6 to better assess the patient’s volume status. The patient was found to have a moderate-sized right pleural effusion and diffuse pulmonary parenchymal B-lines suggesting pulmonary oedema. His inferior vena cava appeared plethoric and its diameter measured 2.5 cm with no respiratory variation. His estimated Caval Index was 1, given this lack of respiratory change, which is significantly higher than the estimated 0.35 in euvolemic patients.2 In all, the ultrasound findings supported hypervolemia. As a result, a diuretic regimen was started with oral torsemide 60 mg two times per day and his volume response and sodium were monitored closely. His sodium improved to 126 mmol/L on hospital day 7, and then he was successfully discharged home with a sodium of 132 mmol/L on hospital day 8. He was stable at time of discharge, with discharge summary stating to monitor volume status closely in upcoming appointments. He was also counselled on medication adherence, frequent weight monitoring and fluid restriction. Home health services were called prior to his discharge to discuss assisting his mother and brother with his care.
+
+While the internal medicine teaching service and the cardiology service recommended discharge to skilled nursing facility to help manage his medications and chronic debility, he wanted to be discharged home to his mother and brother. He followed up with his cardiologist 2 weeks after discharge, and was scheduled with his primary care physician but never arrived at that appointment. At the time of his cardiology follow-up, his diuretic regimen was torsemide 100 mg two times per day (down from 200 mg two times per day), spironolactone 25 mg daily (same as prior to hospitalisation) and metolazone 2.5 mg daily (same as prior to hospitalisation). In setting of his heart failure with reduced ejection fraction, he was started on 25 mg daily of metoprolol succinate. He had also resumed his home medications that were held during the hospitalisation, most notably olanzapine 10 mg daily and mirtazapine 30 mg daily for his schizophrenia. He had no complaints of fatigue, altered mental status, ataxia or abnormal behaviour. His sodium at this visit was 130 mmol/L, somewhat stable since discharge. Medication non-adherence remained an issue at follow-up, with patient having little understanding of his medical history or current medications. Home healthcare services assisted with medication adherence.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_32_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_32_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f7d8cfbecaec3480091037b7d24769d5922185c1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_32_en.txt
@@ -0,0 +1 @@
+A 38-year-old Chinese woman was an emergency admission to our hospital with a sudden onset of acute epigastralgia for the past 14 hours. In particular, she had severe pain in her left upper quadrant, accompanied by nausea but no vomiting, inability to pass flatus and stool as well as intestinal obstruction, no radiating pain, and she was afebrile. She had a history of endometriosis but no abdominal surgery. On admission, she had pain and looked slightly pale, with a pulse of 102 beats/minute and a blood pressure of 106/77 mmHg. Her abdomen was tender in the epigastric region, but Blumberg’s sign and muscular defense were absent; bowel sounds were absent. Blood tests revealed an increased leukocyte count (15.41 × 109/L, with 92% neutrophils), hemoglobin (Hb) 118 g/L, and normal liver and pancreatic enzymes. An emergency abdominal plain film demonstrated the right side below her diaphragm was free of gas; perforation of the digestive tract was considered. Her left upper jejunum had mild expansion, intestinal obstruction was not ruled out. After admission, she was dehydrated, hemodynamically unstable, and her blood pressure decreased progressively to septic shock. We made a presumptive diagnosis of gastrointestinal perforation and septic shock. Septic shock invariably requires anti-shock treatment and urgent surgery even if symptoms are limited as in our case. At laparotomy, we observed the ileocecal was relatively free , which was pulled by the ileum at omental sac area, the small intestine loop dilated and herniated through the hepatogastric ligament hiatus into retrogastric space , and then twisted out of a fissure in gastrocolic ligament. Approximately 1 m of her intestine showed edema; some of her small intestine was necrotic. Straightening some of her small intestine suggested intestinal malrotation for the cecum was free. There still was a diverticulum of approximately 3.0 × 6.0 cm sited at a distance of 80 cm from the ileocecal intestine. Finally, the strangulated intestinal loop and the diverticulum were resected, an appendicectomy was performed, and the fissure was closed. Her postoperative recovery was smooth and she was discharged on day 6 after the operation without any complications during the hospitalization.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3302_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3302_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ff6bf9a4dc402d112244dca111bbc3f2fcd9bb0c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3302_en.txt
@@ -0,0 +1,13 @@
+The patient is a five-year-old female with a past medical history of Wolff–Parkinson– White syndrome, asthma, and oppositional defiant disorder who presented to the emergency department with unwitnessed ingestion of a foreign body. The patient’s mother endorsed that on 29 November 2020 at 21:00, the patient complained of chest pain and admitted to previously swallowing a silver object. Upon arrival at the hospital, she had four episodes of non-bloody, nonbilious emesis, and epigastric pain. A chest X-ray showed a round metallic object projecting over the mid esophagus, with a double halo and step-off appearance, consistent with button battery (BB) ingestion. Due to the potential for rapid onset of damage following BB ingestion, the patient was subsequently admitted for emergent endoscopic removal of the BB, and directions were given that she was to receive nothing by mouth (NPO).
+
+We performed an esophogastroduodenoscopy (EGD) 6 h after ingestion and discovered a 20 mm BB in the middle third of the esophagus. We successfully removed the BB with rat tooth forceps without complications. Visualization of the site showed mucosal ulceration and erosion. According to the commonly used Zargar classification of esophageal injuries, this lesion was determined to be Grade 2B due to the erosion’s circumferential nature. The endoscope was advanced to the stomach and showed no damage. A nasogastric (NG) tube was not placed at the time of the endoscopy.
+
+The following day, the patient endorsed substernal chest pain and dysphagia with saliva. Her diet remained NPO, and she was started on ceftriaxone and intravenous (IV) pantoprazole. A follow-up chest X-ray on day two showed no evidence of cardiopulmonary disease, pneumomediastinum, or pneumothorax. An esophagram on day three showed mild irregularity in the mid-esophagus but no contrast extravasation to suggest perforation.
+
+We performed a repeat EGD on day four to assess esophageal mucosa healing and place an NG tube for feeds. The endoscope was progressed to the middle third of the esophagus, revealing a single, non-bleeding, posterior erosion with sloughing of necrotic tissue. A 10 French NG tube was placed under direct visualization. Post endoscopy, we initiated feeds via NG tube, but the patient developed a fever of 38.8 °C. We then added IV cefepime and metronidazole to her medication regimen and held feeds due to the concern for mediastinitis. An MRI showed possible inflammation in the posterior mediastinum. However, the patient’s fever subsided, and a chest X-ray did not reveal signs of esophageal perforation. On day six, we restarted feeds via NG tube and discontinued antibiotics. On day eight, a repeat esophagram showed persistent irregularity of the posterior esophageal wall consistent with ulceration. She was discharged the same day on NG tube feeds, omeprazole, and instructed to avoid food and water by mouth.
+
+The patient returned to the ED the following day with bilious vomiting following bolus tube feeds. An X-ray revealed that the tip of the NG tube had been displaced to the duodenum, which was then pulled back to the stomach without complication.
+
+At clinic follow-up 4 weeks following ingestion, the patient was tolerating feeds via NG tube and sips of water. The following day, we used a GIF-HQ 190 endoscope of 9.9 mm diameter that showed moderate stenosis with friable mucosa in the middle third of the esophagus. We could not traverse the stenosis with the endoscope. Due to the lack of equipment available and the endoscopist’s minimal experience with strictures, we did not attempt dilation at that time. We performed an esophagram two days later to assess the length of the stricture, but there was no evidence of strictures, perforation, or fistulas on imaging in neither the lateral view or the AP view.
+
+About seven weeks post ingestion, she returned for an EGD with possible stricture dilation and NG tube removal. The patient was tolerating a full liquid diet by mouth in addition to NG tube feeds, with no symptoms of fever, chest pain, or dysphagia. Upon introduction, the endoscope could not pass through a severe esophageal stenosis 15 cm from the incisors. Balloon dilation was performed to 10 mm, 12 mm, 13.5 mm, and twice to 15 mm, after which we passed the endoscope to the stomach and removed the NG tube. The patient tolerated the procedure well and was discharged to home once she tolerated liquids by mouth.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3313_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3313_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3f098e3ddcee0aa7750b7b39e13fc8be0123b1f5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3313_en.txt
@@ -0,0 +1,7 @@
+The patient was a 60-year-old woman who had been experiencing repeated loss of consciousness for over 20 years. Before the onset, there were obvious causes such as eating irritating food, defecation and fatigue. Electrocardiograms, holter electrocardiograms, and head-up tilt test were all normal for the patient in the hospital. She has no history of cardiovascular diseases.
+
+Upon admission, the patient presented with a heart rate of 55 beats/min and a blood pressure of 140/90mmHg. Physical and laboratory tests revealed no obvious abnormalities, and the electrocardiogram showed sinus bradycardia. Echocardiography indicated mild aortic valve insufficiency, with the rest of the heart structure and function appearing normal. A lung CT scan revealed a few micronodules in both lungs, while a craniocerebral CT scan showed no significant abnormalities.
+
+Given the patient’s history of syncope episodes occurring after the consumption of spicy foods such as hot peppers, it was hypothesized that the syncope might be related to this. Despite several upright tilt tests yielding no positive findings, with informed consent, a “chili pepper stimulation” experiment was conducted on the patient. During the experiment, it was observed that the patient’s blood pressure before consuming the pepper was 125/83mmHg, and the heart rate was 73 beats per minute. After consuming the pepper for 5 minutes, the patient experienced nausea and dizziness, followed by a gradual drop in heart rate to 37 beats/min and a drop in blood pressure to 56/37 mmHg, along with cold limbs and foggy consciousness. The patient was promptly administered atropine, dopamine, and continuous fluid rehydration, leading to a gradual recovery of blood pressure to 150/80mmHg and a heart rate of 90 beats/min. Based on the patient’s history and attack characteristics, the initial diagnosis was VVS.
+
+Despite unsuccessful medical interventions, the patient’s quality of life had been significantly impacted by recurrent syncope episodes. Consequently, a decision was made to proceed with the ablation of the cardioneuroablation. A cardiac electrophysiological study was performed before surgery. As a result, the sinoatrial conduction time, sinus node recovery time, and effective refractory period of the atrioventricular node were all normal for the patient. During ablation, we observed a decrease in heart rate and sinus arrest due to the vagus response caused by radiofrequency energy delivery to the left upper ganglion plexus. Following ventricular pacing protection, there was a notable increase in sinus heart rate subsequent to anatomic ablation at specific locations, including the left superior GP (LSGP; located in the superolateral area around the root of the left superior pulmonary vein), left inferior GP (LIGP; located in the inferoposterior area around the root of the left inferior pulmonary vein), right inferior GP (RIGP; located in the inferoposterior area around the root of the right inferior pulmonary vein), right anterior GP (RAGP; located in the superior-anterior area around the root of the right superior pulmonary vein). Pepper stimulation did not induce arrhythmia after surgery, and head-up tilt testing did not reveal any abnormality. Subsequent to a one-year follow-up, the patient remained asymptomatic.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_331_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_331_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..740b34c01b29eeaac8528032033249d255cad53b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_331_en.txt
@@ -0,0 +1,3 @@
+The proband was a 12-years-old girl presenting with chronic compensated hemolysis, Gilbert syndrome, and recurrent abdominal pain. The blood count showed: hemoglobin 13 g/dL, red blood cell counts 4.020.000/mm3, Mean Corpuscular Volume (MCV) 90.3 fL, Mean Content Hemoglobin (MCH) 32.1 pg, mean corpuscular hemoglobin concentration (MCHC) 38.3 g/dL, reticulocytosis, and indirect hyperbilirubinemia. The complete blood work-up is shown in Table . The ultrasound of the abdomen did not show gallstones, hepatomegaly and splenomegaly.
+The patient was a single-born from non-consanguineous Italian parents . The remote case history reported neonatal jaundice treated with phototherapy. The family anamnesis revealed that the father presented jaundice during his childhood, recurrent episodes of abdominal pain resolved after splenectomy (performed at the age of 23 years-old) and gallstones for which he had undergone a cholecystectomy. The paternal uncle also had gallbladder stones. To investigate the cause of hemolysis in our patient, laboratory investigations were carried out. The peripheral blood smear showed anisocytosis with the presence of red blood cells with specific shape: stomatocytes (5%), ovalocytes (4%), schistocytes (3%) and rare spherocytes . The direct antiglobulin test (DAT) was negative, thus excluding an autoimmune origin of the hemolysis. Structural hemoglobin alterations have also been excluded performing electrophoresis and molecular assessment of the genes encoding beta and alpha-globin chains. The activity of red blood cell metabolism enzymes (Hexokinase, Glucose-6-phosphate isomerase, 6-Phosphofruttochinase, Glyceraldehyde phosphate dehydrogenase, Phosphoglycerate kinase, Pyruvate kinase, Glucose 6 phosphate dehydrogenase, Adenylate 6-Phosphogluconate dehydrogenase kinase) was normal.
+The family history showed an autosomal dominant inheritance of the condition. To investigate the possible presence of a spherocytosis condition, the most frequent erythrocyte structural defect, a combination of tests was performed. First, the eosin-5′-maleimide binding test (EMA test), a cytometric analysis in which a fluoresceinated (eosin-5′-maleimide) substance binds to the plasma membrane proteins of red blood cells, mainly to the band 3 protein [, ]. The average fluorescence of RBCs with EMA staining in patients with spherocytosis is lower than that of control RBCs due to the decrease in the number of target proteins. In our case, this examination was in the normal range with a value of 12% (normal test value> 11%). The other complementary investigations carried out were the osmotic resistance tests such as the glycerol lysis test (AGLT50) and the Pink test. These tests were normal in our patient. Furthermore, quantitative analysis of membrane proteins was carried out using Sodium Dodecyl Sulphate-PolyAcrylamide Gel Electrophoresis (SDS-PAGE), and resulted not altered. We also performed the ektacytometry that evaluates the erythrocyte deformability by subjecting them to an increasing osmotic gradient with constant shear stress . Ektacytometry showed a left shift of the osmolarity curve suggestive of DHS. In agreement with the clinical suspicion, genetic testing was carried out both in the patient and in the parents by a targeted-NGS custom panel composed of 86 causative genes of hereditary anemias. This panel is an updated version of a similar previously published one . We found in both subjects the missense variant c.1815G > A, p.Met605Ile in PIEZO1 gene (NM_001142864, CCDS54058) in heterozygous state. According to the guidelines of American College of Medical Genetics and Genomics (ACMG), we evaluated the pathogenicity of this variant by gathering evidence from various sources: population data, computational and predictive data, functional data, and segregation data . First, the variant segregated in the affected father . Currently, this variant is annotated neither in population databases nor in databases of known variant. Moreover, it is predicted by several tools as probably damaging (MutationTaster score 0.999 Disease causing; FATHMM Score − 1.59; LRT prediction Deleterious; PolyPhen2 score HumVar 0.968 Probably damaging; PROVEAN Score-2.95 Damaging).
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3326_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3326_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ff7def838cd77bc18262f66e65d9849383c84ecb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3326_en.txt
@@ -0,0 +1,13 @@
+57-year-old woman, Laboratory Specialist Technician in the Microbiology Service with a personal history of polymyalgia rheumatica on chronic corticosteroid treatment. In 1996 she showed a Mantoux of 20 mm after accidental puncture with a sample from a patient with TBC and completed six months of TILT. In the controls carried out in 2017 and 2020 with QuantiFERON® TB Gold in-tube (QFT-GIT) she tested negative. In mid-March 2021 she suffered a work accident with biological risk after accidental puncture in the second finger of the right hand with a hollow needle used to puncture the vial of blood culture from a patient with TBC.
+
+Following exposure via the bloodstream, the immediate measures for the wound were applied as established in the protocol for action in the face of a biological risk. The worker then contacted the Occupational Risk Prevention Service (SPRL) where an initial assessment of the risk of infection was carried out. The patient initiated prophylactic treatment with emtricitabine, tenofovir and raltegravir (post-exposure prevention of HIV), which lasted five days until the source patient was located and a blood sample was obtained for serological analysis of human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV), the results of which were negative.
+
+The biohazard accident was reported through the online form (Annex B) as established in the procedure for reporting and investigating events of the SPRL in compliance with the Occupational Risks Prevention Law 31/1995 of 8 November.
+
+He was monitored with determination of QFT-GIT at the end of April 2021 with a positive result. He presented an erythematous area with a small erosion at the tip of the index finger of the right hand and a doubtful small superior adenopathy in the epitroclea of the right arm.
+
+He was referred to the Dermatology Department for a punch biopsy, a large needle aspirate biopsy (LNAA), and a skin lesion tru-cut, which were sent to the Department of Pathology for examination of possible inoculation of tubercle bacilli. The diagnosis was a case of granulomatous necrotizing-caseous inflammation compatible with cutaneous tuberculosis. The PCR for tuberculosis performed at the request of the dermatologist was positive. DNA was extracted from the paraffin tissue of the biopsy using the QIAamp DNA FFPE tissue kit (Qiagen, Germany) for qualitative molecular detection of the M. tuberculosis complex (MTB) with the High-Resolution Melting technique using the FluoroType® MTB kit (Hain Lifescience, Nehren, Germany) in the FluoroCycler® 12 (Hain Lifescience). The sensitivity and specificity of the kit for qualitative detection of the MTB complex in paraffin tissue is 60.0% and 71.4%, respectively, and depends on the amount of bacilli present in the sample. A fragment of the biopsy was sent to the Microbiology Department for the isolation of the causative agent of the clinical picture by the corresponding cultures and antimicrobial susceptibility testing. The growth of M. tuberculosis was detected and no antimicrobial resistance was observed.
+
+In mid-May 2021, treatment with rifampicin (R), isoniazid (I), pyrazinamide (P) and ethambutol hydrochloride (E) was initiated, manifesting cutaneous improvement. On the last day of the same month, treatment was suspended due to intolerance with generalized asthenia, nausea and vomiting, poor general condition with generalized arthralgias, non-specific skin lesions, without dysthermic sensation or analytical alteration of the hepatic profile.
+
+At the end of July, the patient was evaluated in Internal Medicine, observing the normalization of the hepatic profile and the disappearance of the referred clinical. The determination of QFT-GIT was still positive, although quantitatively better than the previous one. At this same time, treatment with R/H and levofloxacin (Lfx) was initiated with good tolerance. In August, the patient reported a picture of asthenia that was related to her history of polymyalgia rheumatica, and prednisone was prescribed in a descending pattern. She continued with the triple TB therapy until mid-March 2022. The second treatment pattern was concluded after seven months, with complete recovery from the clinical point of view regarding the dermatological lesion.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3328_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3328_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a766cc58c4b8ebb6160ad28ba857f86e2d8e7932
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3328_en.txt
@@ -0,0 +1,9 @@
+A 36-year-old man with a history of HOCM presented with exertional dyspnoea and recurrent syncope. Despite 6 years of beta-blocker therapy (metoprolol succinate 47.5 mg once daily), his symptoms remained unresolved. Over the past 6 months, he experienced more than 10 syncopal episodes. These brief episodes, lasting only a few seconds, were typically triggered by positional changes, physical activity, or heavy meals, though they were rarely observed while sitting. On cardiovascular examination, a prominent systolic murmur was audible along the left sternal border.
+
+Echocardiography revealed a thickened interventricular septum (IVS) (25 mm), elongation of the anterior and posterior mitral leaflets, SAM of the mitral leaflet, and moderate posterior mitral regurgitation. The LVOT gradient was 85 mmHg at rest, rising to 103 mmHg during a semi-recumbent bicycle exercise stress test. No arrhythmias or abnormal blood pressure responses were observed during exercise. Holter monitoring showed no evidence of non-sustained ventricular tachycardias (VTs) or significant heart block. Electrocardiogram (ECG): Before the procedure, the ECG showed normal sinus rhythm with ST-segment depression in leads I, II, III, aVF, and V4–V6. During the patient’s shock period, the ECG revealed a significant ST-segment depressed, with a maximum of 0.7 mV in lead II. STv1,2 elevated 0.3 mv. Cardiac magnetic resonance imaging confirmed interventricular septal hypertrophy (maximal LV wall thickness of 24.6 mm and LV mass of 216.4 g), with patchy late gadolinium enhancement (6.98% of total LV mass). The patient’s HCM Risk-SCD score was 9.66%. An implantable cardioverter-defibrillator was recommended for primary prevention of sudden cardiac death, but the patient declined.
+
+After a multidisciplinary discussion, PIMSRA was selected as the treatment option. The patient was placed in the left lateral position following general anaesthesia and endotracheal intubation. Under real-time guidance from transthoracic echocardiography (TTE), the radiofrequency electrode needle (ACT1520) was inserted percutaneously through the myocardium into the hypertrophied IVS. The radiofrequency energy was initiated at 40 W and gradually increased to 70 W. The entire procedure lasted 46 min, with six ablations performed at the most hypertrophic regions of the septum. After the procedure, the diameter of the IVS remained at the pre-PIMSRA level of 25 mm, but the LVOT gradient from 85 mmHg reduced to 25 mmHg, with a notable reduction in mitral regurgitation.
+
+One hour after the procedure, the patient’s blood pressure dropped sharply to 60/40 mmHg, accompanied by a significant increase in heart rate to 90 b.p.m. Electrocardiogram monitoring did not show malignant arrhythmias. Emergency TTE revealed that the anterior mitral leaflet (AML) had abnormally displaced proximally, moving close to the septum, and was associated with severe mitral regurgitation. The left atrium significantly enlarged to 49.2 mm, while the septum diameter remained unchanged at 25 mm. The patient lost consciousness quickly. He received emergency rapid fluid resuscitation and a high-dose intravenous norepinephrine infusion to stabilize his blood pressure. After 10 min, the patient regained consciousness, and his blood pressure stabilized at 130/70 mmHg. The TTE showed resolution of SAM and mitral regurgitation.
+
+At the 3-month follow-up, the patient had no further episodes of syncope. Echocardiography revealed an interventricular septum measuring 18 mm (compared to 25 mm before the procedure) and an LVOT gradient of 10 mmHg at rest, increasing to 16 mmHg with the Valsalva manoeuvre. Additionally, SAM was no longer present, and there was no mitral regurgitation. Holter ECG conducted 3 months after the procedure showed no evidence of non-sustained VT. Eighteen months after the procedure, the patient remained symptom-free, with no recurrence of syncope, indicating a favourable outcome following PIMSRA.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_332_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_332_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..350f9a38842c0e3d3a455ae83fa7ca9486636c97
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_332_en.txt
@@ -0,0 +1 @@
+A 58-year-old woman (G3P3, last menstruation was 4 years ago) was admitted to the 2nd Department of Gynecology, Lublin Medical University, Lublin, Poland, in June 2017, due to abnormal uterine bleeding and extended endometrial thickness (19 mm in diameter). After physical examination, repeated transvaginal ultrasound scans, and an endometrial biopsy, moderately differentiated subtype I (according to the Bokhman classification) uterine cancer was diagnosed. The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and pelvic and para-aortic lymphadenectomy. The operation was performed without complications, and the tumor was staged as IIIc based on the revised surgical-pathological FIGO classification. Final pathological assessment revealed a uterine moderately differentiated adenocarcinoma of endometrioid subtype deeply infiltrating the myometrium as well as the uterine cervix. Three intramural leiomyomas were detected. No pathological abnormalities in the adnexa were reported. Surprisingly, CLL/SLL was simultaneously diagnosed in all pelvic and para-aortic lymph nodes that had been removed. The patient was discharged on day 7 and she was forwarded to the Oncology Center of Lublin, Lublin, Poland, for adjuvant chemotherapy and radiotherapy. She is still on follow-up.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3335_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3335_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8e63eb82a185f2167eb3cfe05afd54ed63932855
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3335_en.txt
@@ -0,0 +1,3 @@
+A 64-year-old female patient presented with an 8-month history of abdominal pain and distension. Contrast-enhanced CT revealed a well-demarcated, soft-tissue mass in the left adnexal region, anterior to the uterus, measuring approximately 93.1 mm × 58.4 mm. The lesion demonstrated prominent peripheral enhancement with a non-enhanced center and mild dilation of the left ovarian vein. No enlarged lymph nodes were observed in the pelvis or around the bilateral iliac vessels. Gynecological examination detected a mobile mass, approximately 9 cm in diameter, in the anterior uterine region. Gynecological ultrasound showed a hypoechoic, irregularly shaped mass measuring 8.4 cm × 7.9 cm × 6.8 cm in the left posterior region of the uterus, adjacent to a 1.7 cm × 1.2 cm structure resembling the left ovary, with indistinct borders between them and moderately increased internal blood flow signals. Tumor marker analysis revealed cancer antigen 125 (CA125) at 38.6 U/mL, human epididymis protein 4 (HE4) at 83.8 pmol/L, and neuron-specific enolase (NSE) at 30.8 ng/mL. Exploratory laparotomy identified a small amount of pale-yellow ascites, a slightly smaller uterus, and a 12 cm × 10 cm mass between the left fallopian tube and ovary, with dense adhesions to the posterior broad ligament and surrounding bowel. The left ovary appeared unremarkable, while the right adnexa and omentum were normal in appearance with no visible nodules. The liver and spleen surfaces were smooth, with no detectable nodules. Frozen pathological examination of the mass revealed features of a poorly differentiated malignant tumor with necrosis, raising the possibility of germ cell tumors, sex cord-stromal tumors, or metastatic carcinoma. Given the ambiguous findings and the potential for microscopic lymph node metastasis, systematic pelvic lymphadenectomy was performed to ensure accurate staging and comprehensive tumor clearance. Consequently, total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, pelvic lymphadenectomy, and adhesion release were performed.
+
+Postoperative pathology revealed a poorly differentiated malignant tumor in the left adnexa (11 cm × 7 cm × 7 cm) with necrosis. Tumor cells were arranged in nests or trabeculae, exhibiting marked nuclear atypia and frequent mitotic figures. Immunohistochemical analysis showed creatine kinase (CK) (+), estrogen receptor (ER) (+), GATA3 (−), Inhibin (−), Ki-67 (+), P16 (+), P53 (+, wild type), paired box 8 (Pax-8) (+), PMS2 (+), Progesterone receptor (PR) (++), SALL4 (−), synapsin (Syn) (+), Vimentin (focal +), and WT-1 (+), indicating an embryonic origin of the tumor. Genetic testing confirmed a Breast cancer type 1 (BRCA1) systemic mutation with established clinical significance and a TP53 mutation with potential clinical relevance. The patient was diagnosed with Wolffian adnexal tumor (International Federation of Gynecology and Obstetrics (FIGO) stage IC) and underwent four cycles of adjuvant chemotherapy with paclitaxel and carboplatin (TC regimen). The patient has been regularly followed up post-treatment. At 9 months after surgery, pelvic CT and gynecological ultrasound revealed no signs of recurrence or metastasis. Additionally, serial tumor marker assessments demonstrated a sustained decline in CA125 levels.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3344_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3344_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..73176fd22efcc7c17a7ba410c56d10730579b005
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3344_en.txt
@@ -0,0 +1,11 @@
+A 17-year-old male patient presented with pain in the lower left posterior region of the mandible. The patient had no significant systemic history and reported no previous extractions in the mentioned area. Clinical examination revealed the absence of Teeth 37 and 38. Palpation of the alveolar ridge showed no swelling or bony prominences.
+
+Radiographic examination revealed that Tooth 37 was impacted transversely between Teeth 36 and 38, with Tooth 38 in a vertical position close to the occlusal plane, Stage Nolla 8. Tomographic imaging indicated that the crown of Tooth 37 was oriented lingually, with the roots separated; the mesial root was curved and thin, while the distal root was straight and thick.
+
+The diagnosis was an impacted Tooth 37 in a transverse position with the crown oriented lingually and Tooth 38 retained in a vertical position. A consultation with the orthodontics department was made to define the treatment plan. Due to the position of the second molar and the lack of space for repositioning, flap extraction of Tooth 37 was planned, with subsequent eruption of Tooth 38 and fixed orthodontic treatment. The ultimate goal was to restore masticatory function by positioning the third molar in place of the second molar. The patient was informed regarding the surgical procedure, the risks associated with it, and the alternative treatments. He signed the informed consent through which he agreed to enter the study and to the use of images of the surgical procedure in scientific articles. The surgical intervention for flap extraction of Tooth 37 was scheduled. The procedure involved block anesthesia for the inferior alveolar nerve, lingual nerve, and buccal nerve. An L-shaped or monoangular incision was made at the level of the second molar. The mucoperiosteal flap was elevated to expose the bone plate. An osteotomy was performed in the occlusal bone to visualize the crown of the second molar. The separated roots were sectioned for removal due to the limited space between the first molar and the third molar and the width of the second molar crown.
+
+The distal segment (crown and root) was extracted first due to better visibility during the process, followed by removal of the mesial segment (crown and root). Both segments were luxated with a flag elevator.
+
+An alveolar curette was used to clean the bony crypt corresponding to the crown and remove the pericoronal sac, followed by irrigation with 0.9% sodium chloride. The procedure was completed with discontinuous suturing using 3/0 polyglycolic acid, with five simple sutures. The extracted molar was observed in two parts. Amoxicillin 500 mg every 8 h for 5 days and sodium diclofenac 50 mg and dexamethasone 4 mg both every 8 h for 3 days were prescribed.
+
+Regarding follow-up, the patient was evaluated 6 months after the surgical intervention with favorable bone healing according to an x-ray. The report confirms “alveolar walls preserved, no evidence of spicules or bony defects; defined borders, no radiographic signs of osteitis”.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_334_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_334_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d13cd18c7c5d27a2ac26dbc240ad51ba4e74b013
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_334_en.txt
@@ -0,0 +1,4 @@
+A 25-year-old G1P1 female presented to the Emergency Department in March, 2015, with her 5-month-old daughter, fiancée, and concerned family members 1 week after breastfeeding cessation.
+Despite 3 years of sustained sobriety from opioid use, she reported a de novo obsession about relapsing to heroin when her fiancée received an opiate prescription. After attending multiple AA meetings and three consecutive nights without sleep, she believed the big book of alcoholics anonymous was talking to her for a special purpose. She reported sleep-deprived energy enhancement, unfulfilled goal-oriented productivity, hyper-talkativeness, hyper-sexuality and increased nicotine use. Concurrent depressive symptoms included hopelessness, worthlessness, poor concentration, lack of appetite, and ego-dystonic intrusive thoughts that she may kill herself or her child. She reported daily cannabis and cigarette (10/day) use since parturition and was not on any medications and did not consume alcohol. Cannabis use was chronic and she had never experienced a psychotic episode prior to breastfeeding discontinuation. Her psychiatric history included a major depressive episode at age 16 treated briefly with citalopram and an opioid use disorder in full sustained remission for 3 years. Her family history included a mother with bipolar I disorder.
+Her mental status was significant for pressured speech, affective lability, expansiveness, distractibility, and tangential, grandiose, delusional self-referential content. Her transient thoughts of self-harm and harming her child were not associated with intent. Physical examination revealed lower abdominal tenderness commensurate with her first menses since parturition. Urine drug screen was positive for cannabis.
+Symptoms remitted during a 5-day hospitalization with olanzapine and lithium. Her discharge diagnosis was bipolar disorder, type I, current episode manic with psychotic features and a mixed-feature specifier.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3358_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3358_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1dc9dec37705a31d0f71df31a473d13bd4d577f7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3358_en.txt
@@ -0,0 +1 @@
+43-year-old healthy woman consulted for left peripheral facial palsy associated with fever without a pattern, dry cough, dyspnoea with effort and asthenia of two weeks evolution. She received ambulatory treatment with amoxicillin-clavulanic and acyclovir without improvement of the picture. On physical examination, she presented ipsilateral hyperalgesia in the territory of the fifth cranial nerve, dysgeusia, hypoesthesia in the left dermatomes D6 to D12 and bilateral galactorrhea. In the admission laboratory, she presented erythro-sedimentation of 54 mm/h and negative viral serologies. A computed tomography (CT) of brain, thorax, abdomen and pelvis was performed with oral and intravenous contrast that showed multiple cervical, mediastinal and hilar bilateral adenopathies, the largest of which was a right hilar adenopathy of 28 mm maximum diameter. She was admitted to the general ward, where a lumbar puncture was performed with increased cellularity of the CSF with a predominantly mononuclear profile (90 cells) with no other pathological findings, with Xpert MTB/RIF and culture for common germs and mycobacteria negative, cytological study without atypia and serum ACE level within normal values. A computed tomography (CT) of brain and selar area was performed without pathological findings and of the spine with a change in the signal from the midline of D6 to D9 that covered almost the entire thickness of the cord, with reinforcement with intravenous contrast. After a week of admission, she recovered sensitivity in the left trunk and did not repeat febrile episodes or coughing, persisting facial palsy, dyspnoea and asthenia. She was referred for laparoscopic excisional biopsy of mediastinal ganglion, with flow cytometry of the sample without evidence of lymphoproliferative process, negative cultures and pathological anatomy with presence of numerous non-caseating granulomas compatible with sarcoidosis. During admission, the hypothalamo-pituitary axis was studied with mildly increased thyrotropic hormone with positive anti-thyrotropic antibodies, decreased follicle stimulating and luteinizing hormones, ultrasound of the breast and vagina without alterations and cytological study of the nipple secretion without atypia. The vitamin B12 dose was 188 pg/ml (VN 187-883) initiating oral replenishment. During the studies performed, elevated anti-nuclear antibodies (ANA) were found (1:1280) with the rest of the autoimmune panel negative, including antibodies against parietal cells. A high-endoscopy examination with gastric biopsy with inactive chronic gastritis with detection of Helicobacter pylori was performed, currently under treatment. She was evaluated in a multidisciplinary manner and classified as NS probable and initiated treatment with 0.5 mg/kg/day prednisone with improvement of the remaining neurological symptoms, and an MRI was performed three months later where the signal alteration was limited from D7 to D8. Spirometry evidenced a mild obstructive pattern without response to bronchodilators, nor pathological findings in the fibro-bronchoscopy. She had improvement of dyspnoea with the use of inhaled corticosteroids. A complete hormonal profile was repeated with normalisation of TSH and prolactin decreased (78 ng/ml), persisting galactorrhea. The patient is under multidisciplinary follow-up in our hospital.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3365_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3365_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..177e976ff85609ec82f8e0c8afbabac2aa189a51
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3365_en.txt
@@ -0,0 +1,5 @@
+An 18-year-old woman received two craniotomies for microsurgical resection of a space-occupying lesion at Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, first in July 2014 and again in April 2022. Histology confirmed the diagnosis of intracranial HB. In July 2022, a follow-up magnetic resonance imaging (MRI) revealed a spinal canal space-occupying lesion in the cervical spine, and the patient subsequently received microsurgical resection of spinal canal space-occupying lesions under general anesthesia at the same hospital. Histology confirmed the diagnosis of spinal canal HBs. Specifically, Immunohistochemistry (IHC) of the April 2022 intracranial HBs showed partial positivity expression for α-inhibin+, VIM+, S-100+, CD56+, and endothelial positivity for CD31 and CD34. It was negative for ERG-, FLT1-, NSE-, Syn-, CgA-, GFAP-, NeuN-, Olig-2-, EMA-, CD10-, PAX-8-, and D2-40-. The Ki-67 labeling index (LI) was approximately 1%. Similarly, IHC of the July 2022 cervical spinal canal HBs showed endothelial positivity for CD31+, CD34+, ERG+, and stromal positivity for α-inhibin+ and S100+. It was negative for D2-40-, CD10-, PAX-8-, Syn-, CgA-, GFAP-, Olig-2-, and EMA-. P53 was scattered positive, and the Ki-67 LI was approximately 1-2%. These findings further support a diagnosis consistent with HBs.
+
+Before her presentation, the patient had experienced a gradual onset of subtle symptoms, including narrowing of the palpebral fissures, increased interpupillary distance, and a blunted facial expression, beginning in early January 2023. Subsequently, at the presentation in October 2023, a follow-up MRI revealed multiple abnormal enhancing lesions in the intracranial and spinal canal regions, consistent with tumor recurrence, and demonstrated communicating hydrocephalus, characterized by enlarged lateral ventricles and compression of the cerebral parenchyma. Interestingly, the patient did not exhibit typical symptoms of hydrocephalus, such as headache, nausea, vomiting, urinary incontinence, gait instability, or memory impairment. A neurosurgical consultation recommended surgical intervention if necessary. However, given the patient’s history of three prior significant surgeries, her reluctance to undergo further surgery for hydrocephalus, the suspicion that the hydrocephalus was secondary to tumor compression, and the absence of other critical clinical symptoms beyond blurred vision, a decision was made, in agreement with the patient and her family, to pursue medical management aimed at controlling the tumor rather than surgical intervention for the hydrocephalus.
+
+Given that the patient’s neurological examination was notable only for blurred vision and no focal neurological deficits, treatment with oral anlotinib hydrochloride capsules (10mg, qd, q3w) was initiated. A follow-up examination indicated a significant decrease in the MRI’s tumor size after three months. A repeat MRI in May 2024 showed further remission, reducing intracranial lesions from three to two and spinal canal lesions from two to one. In August 2024, the MRI demonstrated continued condition stability and marked improvement in blurred vision. Additionally, the patient exhibited features of trisomy 21 due to hydrocephalus caused by tumor compression and has now returned to a normal appearance.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3369_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3369_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4725220476ec9040fa6f5079d4e7102b97ea1a2a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3369_en.txt
@@ -0,0 +1,14 @@
+The clinical case of a 14-year-old male adolescent with no significant antecedents for the current condition is described. He presents to the outpatient department with lower back pain for four years, of insidious onset, intermittent, progressive, which exacerbated six months ago, with irradiation to lower extremities, accompanied by progressive paresthesia and paresis predominantly in the right lower extremity, reporting limitations for personal activities. Physical examination: patient with plantígrado, bipodálica, assisted with cane in the left hand, with claudicatio at the expense of the right lower extremity, with impossibility for heel-toe gait, presenting paravertebral muscular contracture in the lower back region predominantly in the right, without external lesions, or changes in colouration. Lower extremities present muscular hypotrophy in quadriceps and tibial anterior bilateral, with muscular strength 3/5 in the Daniels scale in the right L4, L5 and S1 myotomes, rest of myotomes with normal muscular strength, presenting hypesthesia in the right L5 dermatome, bilateral normal osteotendinous reflexes, L4, S1, right Legg-Perthes, positive right Bragard, positive right clonus.
+
+Laboratory studies with bone chemistry are performed with results within normal parameters according to the patient's age, which are presented in Table 1. A simple magnetic resonance imaging of the lumbosacral column is requested, where a heterogeneous, hyperintense mass is observed in the sagittal sections within the spinal canal, immediately posterior to the L5-S1 intervertebral disc with caudal extension to the underlying S1 vertebral body. An axial section in T1 and T2 shows a hyperintense mass in zone IV according to Weinstein, occupying approximately 30% of the spinal canal. Electromyography of the lower extremities with somatosensory evoked potentials and nerve conduction velocity is performed, which is reported as abnormal, with data of acute/active denervation in myotomes corresponding to the L5-S1 level on both sides and reduction of the bilateral voluntary contraction pattern in L5-S1 and S1 right.
+
+The Oswestry disability scale is performed within the study protocol and found to have a disability limit of 71.1%, which is classified as a disabling disability.
+
+
+Results
+
+Due to the progressive symptoms and the patient's functional limitations, it was decided to operate, and a bilateral L4 and L5 laminotomy was performed, along with exploration and resection of the tumour and release of the nerve roots.
+
+A tumor with characteristics similar to adipose tissue was obtained, where a wide vascular network was observed inside, with an approximate size of 14 × 10 × 4 mm of an ovoid shape, flattened with a smooth and shiny surface. The tumor was sent for anatomopathological analysis, which reported "adipose tissue with hypertrophic and enlarged blood vessels". After hospital discharge, the patient presented immediate symptomatic improvement, with independent walking, although with limitations for heel-toe walking, reporting improvement in lower back pain. Manoeuvres were performed to assess neurotension, which were negative.
+
+One month after the surgical treatment, the patient reported clinical improvement in gait, muscle strength and sensitivity, with improvement in the Oswestry scale of functional disability, reporting a functional limitation of 26.6%, which is classified as moderate functional limitation, finding considerable functional improvement after one month of the surgical treatment
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3373_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3373_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ed9f4566a6370dc4d5f78d96151c3d008244704e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3373_en.txt
@@ -0,0 +1,3 @@
+A 21-year-old man visited a clinic with a chief complaint of right inguinal pain. Abdominal ultrasonography revealed a huge intra-abdominal mass, and he was referred to our hospital for further examination. He had no specific family history but had a history of autism spectrum disorder and bronchial asthma, with no history of trauma or abdominal surgery. The abdomen was mildly distended and soft, and the tumor was not palpable. Laboratory examinations showed no abnormalities in blood count, biochemistry, or coagulation markers, no elevation of tumor markers, and no elevation of immunoglobulins. Abdominopelvic computed tomography (CT) showed a huge mass with a maximum diameter of 34 cm and well-defined borders, extending from the upper abdomen to the pelvis. Magnetic resonance imaging (MRI) revealed an intra-abdominal tumor 34 × 15 × 8 cm with partial signal hyperintensity on T2-weighted imaging, hypointensity on T1-weighted imaging. No internal calcification, fatty, or blood components were evident, and a portion of the tumor appeared to be in contact with the gastric body. Due to the history of bronchial asthma, a contrast-enhanced examination could not be performed. Endoscopic ultrasonography showed a heterogeneous hypoechoic internal cavity, but endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was not performed, given the risk of seeding. Although no definitive diagnosis or organ of origin was confirmed preoperatively for the tumor, we performed surgery under suspicion of gastrointestinal stromal tumor, desmoid tumor, or mesenteric tumor.
+
+The patient was placed in the supine position, and laparotomy was performed through upper and lower median incisions and a left transverse incision. Intraoperative findings showed a giant tumor covered with a capsule occupying most of the left side of the abdominal cavity, extending from the pelvis to the diaphragm. The tumor showed firm adhesions to the stomach, transverse colon, and diaphragm without invasion of other organs. The omentum, with dilated vessels, was also adherent to the tumor, so the tumor had to be partially resected en bloc with portions of the stomach, transverse colon, and diaphragm. After tumor resection, primary anastomosis of the colon and closure of the diaphragm were performed. The tumor appeared to have been completely excised without rupture of the capsule. The operative time was 3 h 57 min, with a total blood loss of 110 mL. The excised specimen measured 38 × 21 × 8 cm and weighed 6400 g. The surface was smooth, and the interior was homogeneously filled with tumor on macroscopic examination. Pathological examination revealed atypical cells with spindle-shaped nuclei and collagen fiber hyperplasia in the stroma. Immunostaining showed negative results for c-kit, CD34, desmin, and S-100, while positive results for β-catenin confirmed the diagnosis of a desmoid tumor. Pathological results for the surgical margins were negative, confirming complete surgical resection. Despite pathological examination of the resected organs, determining the primary site of tumor origin was difficult. The patient was discharged 17 days after surgery, despite the appearance of surgical site infection. Colonoscopy revealed no polyps. A CT scan conducted 12 months after surgery showed a nodule 3.0 cm in diameter near the suture line of the gastric body; however, its size remained unchanged on a subsequent CT scan taken 9 months later, 21 months postoperatively. The patient is under close follow-up.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3379_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3379_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..73a87c3219b391e5f32c3da8fdd1e8b9bfaac85b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3379_en.txt
@@ -0,0 +1,37 @@
+A 62-year-old male with a history of 3 vessel coronary disease and prior coronary artery surgery was admitted with an inferior STEMI and cardiogenic shock, 6 hours after the onset of symptoms. Twelve months earlier, the patient had undergone a failed attempt of anterograde CTO RCA PCI, followed by an arterial bypass graft placement using a LITA graft to the left anterior descending artery (LAD) and a RITA graft sequentially to the obtuse marginal branch of the left circumflex and the RCA arteries.
+
+The patient was diagnosed with an acute thrombotic occlusion of the RITA graft at its ostium and a patent LITA to the LAD artery. The posterior-descending artery (PDA) was also occluded. The patient was in refractory cardiogenic shock and was placed on ECMO. Concerns were raised that antegrade interventions through the RITA graft could result in distal thrombus embolization and acute revascularization was attempted using an antegrade approach from the native LCx into the RITA graft segment to the PDA and then a retrograde approach through the native RCA CTO.
+
+The procedure was successful after the retrograde crossing of the remaining RITA graft (between the obtuse marginal and the PDA), retrograde dissection re-entry technique, externalization, rotational atherectomy of the lesion, and implantation of 3 drug-eluting stents.
+
+The clinical evolution of the patient was favorable after the intervention and at 12 months follow-up.
+
+Past Medical History
+The patient had a history of diabetes, dyslipidemia, mild renal insufficiency and left ventricular systolic dysfunction with a LVEF of 45%.
+
+Acute Presentation
+The patient presented to the emergency department in cardiogenic shock with a blood pressure of 77/50 mm Hg and a pulse rate of 102 beats per minute. The patient was in a poor overall condition, the skin was pale, cool and diaphoretic.
+
+An initial electrocardiogram (ECG) revealed 2 mm ST elevations in the inferior leads and ST segment depression in leads V1-2. These findings are consistent with inferior and posterior injury.
+
+An echocardiogram obtained on initial presentation documented severe left ventricular systolic dysfunction with limited basal inferior akinesia, severe hypokinesia in the anterior and inferolateral wall, and an LVEF of 20%. There was evidence of moderate mitral regurgitation, right ventricular dilatation, and systolic dysfunction.
+
+Urgent coronary angiography was performed and the patient was started on ECMO immediately because of cardiogenic shock status despite pharmacological support. An intra-aortic balloon pump (IABP) was not preferred as a first choice regarding the stage D cardiogenic shock and the need for optimal perfusion in this acute coronary syndrome. A potential higher risk of mortality in acute settings could be related to the limited hemodynamic benefit of the IABP in comparison to other mechanical devices.7–9
+
+The patient was documented to have a CTO of the RCA and an occluded proximal LAD after the origin of the first diagonal branch. The LITA graft to the LAD was patent, and there was an acute ostial occlusion of the RITA graft. The ostial circumflex showed 80% lesion and the segment of the RITA graft between the left circumflex and the PDA artery was widely patent but with an occlusion in the native PDA vessel related probably to thrombotic embolization.
+
+
+Management
+Flow to the distal PDA and the posterolateral artery (PL) was absent and attempts were made to establish the reperfusion of these vessels.
+
+The RCA was chronically occluded and revascularization was attempted by bilateral sheathless distal radial artery access with 7Fr guiding catheters. Knowing that the anterograde true to true lumen approach had previously failed we performed an anterograde knuckle with Fielder XTR (Asahi Intecc, Japan) supported by 7Fr TrapLiner (Teleflex Medical Incorporated, US) and Corsair Pro 135cm (Asahi Intecc, Japan). The retrograde Sion (Asahi Intecc, Japan) wire supported by a Corsair Pro 150 cm microcatheter was able to pass through the remaining anastomosis between the RITA and the obtuse marginal to the distal anastomosis with the PDA. The guideliner reverse CART was successful after the retrograde Gaia 3 wire crossed and the externalization was made using an RG3 wire (Asahi Intecc, Japan).
+
+Due to the severity and the extension of calcium the balloon failed to open and we performed a rotational atherectomy after crossing the CTO with an anterograde microcatheter on the RG3 and exchanging it with an extra support Rota Wire.
+
+
+The procedure was successful after implantation of 3 drug-eluting stents. The first stent was placed from the distal RCA to PDA using a provisional technique. The second stent was placed on the mid part of the RCA by overlapping with the first one and the third one on the proximal part of the RCA. The intervention was completed within 2 hours and 40 minutes.
+
+Follow-Up
+After 12 months of clinical follow-up the patient had mild NYHA II (New York Heart Association) dyspnea without angina.
+
+The echocardiography revealed an improvement of ventricular function (40% EF).
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3393_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3393_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ea72c1be0b29b32c7b30a021192b3bb622a8f8b8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3393_en.txt
@@ -0,0 +1,15 @@
+A previously healthy 9-month-old local Chinese boy presented to emergency department with acute onset of generalised seizures. He was well except for mild upper respiratory tract symptoms with intermittent low-grade fever a week prior. There was no reported history of trauma. The seizures had started at his childcare centre after receiving a bath and milk feed. Emergency Medical Services (EMS) was activated and arrived approximately 20 min later. His childcare teacher, who had no prior basic life support training, commenced chest compressions and rescue breathing prior while waiting for EMS, as he appeared off-colour during the seizures. Paramedics on arrival assessed that he had a pulse and cardiac output; therefore he was given rescue breaths via bag-valve-mask ventilation en-route to the nearest emergency department.
+
+He was brought to the nearest general hospital with no specialised paediatric services. His vital signs were: heart rate of 144 beats/minute, blood pressure of 130/72 mmHg, SpO2 was 83% on bag-valve-mask ventilation by paramedics, and axillary temperature was 36 degrees Celsius. As he continued to have more generalised tonic-clonic seizures, he was intubated with rapid-sequence-intubation and mechanically ventilated thereafter. He also received 10 ml/kg of normal saline fluid bolus for persistent tachycardia and poor peripheral perfusion. He was started on midazolam infusion and was transferred to our Children’s Emergency for further management.
+
+At our Children’s Emergency, about 45 min after initial resuscitation, his vital signs were reflective of ongoing sympathetic overdrive. He was severely tachycardic (heart rate was 180 beats/minute) and markedly hypertensive despite repeated non-invasive blood pressure measurements from all limbs (blood pressure was 191/120 mmHg). He also had frequent desaturations to SpO2 80 to 90% (on FiO2 100% via bag-and-mask ventilation) with audible leak. He was poorly perfused but central pulses were present. Bilateral diffuse crackles were heard on lung auscultation, and there was large amount of frothy endotracheal tube (ETT) secretions that required frequent tube suctioning. Dual heart sounds were appreciated with no murmur. Liver edge was felt 1 cm below right subcostal margin, and no organomegaly was noted. Neurological examination revealed generalised hypotonia, areflexia, with no plantar response elicited, likely due to residual muscle relaxant effect. There were no external injuries found. Fundoscopy was not possible as his pupils were pinpoint due to ongoing midazolam infusion. Further history from his childcare teacher and both parents did not suggest an apparent unifying diagnosis for his clinical presentation then. Computed topography (CT) scan of the brain showed acute subdural haemorrhages along the posterior falx, left tentorial leaflet and overlying both high parietofrontal convexities. No significant mass effect, hydrocephalus, brain herniation or acute territorial infarct was noted. As he continued to have frequent recurrent desaturations despite ETT suctioning which by then yielded blood-stained frothy secretions, he was re-intubated with Size 4.5 cuff ETT (previous ETT was Size 4, uncuff), as these events were attributed initially to high leak and resultant inadequate ventilation. Prior to transfer to the paediatric intensive care unit (PICU), his blood pressure had returned to normal values, but his SpO2 continued to fluctuate between 80 to 90% on FiO2 100% despite high ventilatory pressures. Neuroprotective measures were instituted.
+
+On transfer to the PICU, he continued to have persistent desaturation (SpO2 70–80%) despite adequate ventilation of the patient. Chest X-ray showed bilateral pulmonary airspace shadowing and infiltrates suggesting pulmonary oedema. Oxygenation index ranged from 22 to 37.8 in the next 6 h. The patient also continued to have brief clinical seizures and was treated with anti-epileptic medication. He also had worsening haemodynamics, necessitating commencement of inotropic support with adrenaline infusion of 0.03 to 0.1mcg/kg/min to maintain adequate blood pressure.
+
+Bedside transthoracic 2D-echocardiogram subsequently showed moderate to severe reduction of LV systolic function and moderately reduced right ventricular systolic function. LV ejection fraction (biplane Simpson) was scored at 31% and fractional shortening was 25%. Hypokinesia involving predominantly the mid LV to LV apex was noted with a qualitatively dilated left atrium and mildly dilated LV. Normal origins of left and right coronary arteries were seen. There was no structural abnormality. Serum creatine kinase (CK) and creatine kinase-MB (CKMB) were normal at 87 U/L and 5.1 μg/L respectively, but troponin I was elevated at 392 ng/L. N-terminal proB-type natriuretic peptide (NT-ProBNP) was normal at 1223 pg/ml. 12-lead electrocardiogram showed sinus tachycardia with no ST elevation or T-wave inversion.
+
+With the 2D-echocardiogram findings and abovementioned initial investigations, we narrowed the differentials to acquired causes: acute viral myocarditis versus Takotsubo cardiomyopathy triggered by a hyperacute stress response after an acute severe brain injury accompanied by status epilepticus.
+
+Intravenous furosemide was given to offload a dilated LV, and milrinone infusion was started at 0.5 to 0.7mcg/kg/min to reduce LV afterload. The patient continued to deteriorate with type 2 respiratory failure due to refractory pulmonary oedema secondary to LV systolic failure despite best medical management. Within 10 h of admission to the PICU, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support was initiated. ECMO flow ranged from 0.7 to 0.98 LPM (Cardiac index of 2.0 to 2.1 based on his basal surface area). He was peripherally cannulated via right internal jugular vein and right common carotid artery. The extracorporeal circuit was anticoagulated with systemic heparin. There was no haematological complication, even though he had coexisting bilateral subdural haemorrhages on admission. The pulmonary radiological changes on serial Chest X-rays improved remarkably within less than 24 h. Repeat 2D-echocardiogram done in less than 24 h from ECMO initiation also showed satisfactory biventricular free wall function with mildly dyskinetic interventricular septum, which was significantly improved when comparing with the admission scan. Investigations were performed to evaluate for possible infective myocarditis and encephalitis, and all of these yielded negative results (blood and urine cultures, and viral PCR studies). He was on ECMO for total of 57 h, and was subsequently successfully decannulated.
+
+This was a dangerously ill 9-month-old boy who was previously well presenting with several clinical problems – firstly, convulsive status epilepticus as a result of acute severe brain injury for which CT imaging revealed bilateral acute subdural haemorrhages despite not having a known history of trauma; secondly, rapidly deteriorating cardiogenic shock with resultant flash pulmonary oedema resulting in respiratory failure despite being on high ventilatory support, finally requiring ECMO support. Possible differential diagnoses considered for his acute brain injury were that of underlying undiagnosed bleeding diathesis, intracranial vascular malformation, aneurysm or neoplasia, cerebral infections, rare metabolic disorders such as glutaric aciduria, and lastly non-accidental injury (NAI). His initial coagulation profile and full blood count were both normal, and had no previous or family history suggestive of an underlying bleeding diathesis. His clinical presentation, initial white blood cell count and inflammatory markers did not suggest bacterial sepsis or meningitis, and later viral studies did not suggest viral encephalitis. Magnetic resonance imaging (MRI) brain that was done 2 days after decannulation from ECMO showed bilateral subdural haematomas and mild sulcal subarachnoid haemorrhage. There was diffuse symmetrical white and grey matter signal abnormality and focal areas of parenchymal swelling. These features were suggestive of diffuse brain injury, which may have been a result of hypoxic-ischaemic injury, post-seizure changes, toxic and metabolic derangements or post-trauma changes. Magnetic resonance angiography (MRA) brain scan and transcranial doppler (TCD) of major cerebral vessels were both normal. Comprehensive metabolic workup did not reveal any underlying metabolic disorder. Slit-lamp examination of the eyes, which was done on the second day of admission, revealed extensive acute bilateral intra-retinal haemorrhages, raising the possibility of shaken baby syndrome. A full skeletal survey did not reveal any other bone fractures. A thorough investigation by the local justice system did not uncover any proof of NAI at home or at his childcare centre.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_356_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_356_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..98c4620e1b590acd9a7f39a9d59d4ab1c9550660
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_356_en.txt
@@ -0,0 +1 @@
+This 43-year-old woman was previously in good health. She visited the emergent department of Taichung Veterans general hospital in Taichung city of Taiwan due to fever with chills and left flank pain on 14th September 2015. Post-void dribbling with difficulty in emptying bladder and decreased urinary amount for each micturition were also noted during the two-day period prior to admission. Physical examination revealed left flank knocking pain and abdominal dullness over suprapublic area. Laboratory data revealed 22000/cumm of white blood cell, 10 mg/dL of C-reactive protein, 2.1 meq/L of serum potassium, 2.35 mg/dL of serum creatinine, and pyuria (10-20/high power field). Abdominal computed tomography (Philips diamond select brilliance CT 64-slice) showed solitary left kidney with mild hydronephrosis. The patient also complained about severe nausea and vomiting for one week. She was then admitted to the department of nephrology. All data are summarized in . Soon after administration of 1st generation of cephalosporin and Foley insertion, she became afebrile. The urinary culture yielded Proteus. The hypokalemia was deemed to be most likely vomiting-related. Pyelonephritis and hypokalemia are commonly diagnosed and treated. However, to our surprise, only the left kidney was observed , and two uteruses were found (uterus didelphys) . The urinary bladder was compressed by the two uteruses , which caused left mild hydronephrosis and compensated hypertrophy. In addition, right cervico-vaginal partial obstruction (obstructed hemivagina-communicant) was identified . After meticulous tracing of her medical history, she claimed she had seven spontaneous abortions (G9P2SA7), and she never experienced any surgical interventions except two caesarean sections. She had chronic pelvic pain, recurrent severe dysmenorrhea, spotting, and intermenstrual bleeding since her menarche. All manifestations of OHVIRA syndrome (uterus didelphys, obstructed hemivagina, and ipsilateral renal agenesis) were found in this patient. Family history was checked but she did not have any family history regarding this congenital abnormality. We treated her by antibiotics and the insertion of Foley. There was not any surgery for her because of well response for medical treatments and stable vital signs. Soon, she was discharged after one-week intravenous antibioitics and received one-week oral antiobiotics at outpatient department, too. After this episode, she was under regular follow-up and there was no more UTI within one year. This study had been approved by patient herself and she signed the informed consent.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_365_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_365_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..10bb689ac6bfc3e025bb98c2d2c80938d0542d4f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_365_en.txt
@@ -0,0 +1,4 @@
+A 60-year-old postmenopausal woman presented with lump in lower abdomen of 2 months duration. Abdominal examination revealed a large, irregular, firm supra-pubic mass. On pelvic examination, the same mass was felt in the vagina. Cervix and uterus were not felt separately from the mass. Computed tomography (CT) scan showed a large, well defined heterogeneous abdomino-pelvic mass. Serum CA-125 level was 52.3 U/mL. Exploratory laparotomy was performed, which revealed a large, bosselated mass arising from the cervix. Body of the uterus, bilateral ovaries, tubes and other abdomino-pelvic organs were within normal limits. Total abdominal hysterectomy with bilateral salpingo-oophorectomy with complete excision of the mass was done after identifying the ureters from pelvic brim to their entry into the urinary bladder. Her postoperative recovery was uneventful.
+The patient was kept under close observation after initial treatment. Four months after surgery, on routine follow-up, vaginal cytology showed the malignant squamous component of MMMT. The recurrence was confirmed by colposcopy-guided biopsy from the vaginal vault. Physical examination and CT-scan did not reveal any evidence of disease elsewhere. This recurrence was treated with radical pelvic radiotherapy (RT) (external pelvic RT 60 Gy in 30 fractions plus 2 intracavitary applications of 6 Gy each). The patient is free of disease at eighteen months after the treatment of recurrence.
+Gross examination of the surgical specimen revealed a 28 × 20 × 15 cm bosselated, mass arising from the cervix. The cervical canal was distorted because of the mass. On cut surface, the mass was fleshy, solid with cystic areas.
+On hematomylin and eosin staining, the entire tumor showed cellular whorls dispersed amidst pale sarcomatous stroma. The cells in whorls were round to short spindle shaped and had moderate mitotic activity . Although no vessels were seen in the center of these whorls, the whorled appearance was reminiscent of an endometrial stromal sarcoma. Hence, the preliminary diagnosis of endometrial stromal sarcoma (ESS) was made. Additional sections however revealed that whorled areas had basaloid squamous carcinoma in the center . A panel of immunohistochemical tests was performed and whorled basaloid areas were positive for cytokeratin , epithelial membrane antigen and CD 10 but were negative for vimentin confirming their epithelial nature. The stromal component of the tumor was highlighted on vimentin stain . The stromal element was sarcomatous and showed diffuse vimentin and focal SMA positivity. SMA, S-100, calponin, inhibin, Mic-2, desmin and myoglobin were negative in the basaloid islands. No heterologous elements were seen. The final diagnosis was homologous malignant mixed mullerian tumor with basaloid squamous carcinoma.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_373_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_373_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..660d7296fed400eaa52fc382225f4c525ad4c1f6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_373_en.txt
@@ -0,0 +1,3 @@
+In 2018, a 68-year-old woman was referred to our hospital for surgery for a right inguinal hernia. Preoperative computed tomography (CT) revealed an asymptomatic mass 43 mm in size in the presacral space. Her medical history included Sjogren's syndrome, renal tubular acidosis, and Hashimoto's disease. Although the details were unknown, she had an allergy to intravascular contrast agents. None of her family had a clear history of cancer. Hematological examination showed no elevations in tumor markers or inflammation. No abnormality was observed on upper and lower gastrointestinal endoscopy. CT revealed a 43 mm-sized mass with clear calcification on the ventral side of S3 . Magnetic resonance imaging revealed a multilocular 43 mm-sized mass with well-defined lobules and septa at the same site, which was observed as slightly high signal intensity on T1 and T2 images, high signal intensity on diffusion-weighted images, and low signal intensity on the apparent diffusion coefficient map. Sacral invasion by the tumor was not observed on imaging . 18F-fluorodeoxyglucose positron emission tomography/CT showed strong accumulation with a maximum standardized uptake value of 10.3 in the tumor . Thus, we suspected a malignant tumor in the presacral space, such as a malignant schwannoma, metastatic malignant tumor, extragastrointestinal stromal tumor, solitary fibrous tumor, and malignant transformation of a teratoma or tailgut cyst.
+We performed laparoscopic surgery to obtain a definitive diagnosis. After administering general anesthesia, the patient was placed in the lithotomy position and underwent laparoscopic surgery using 5 ports. As in rectal surgery, the retroperitoneum was dissected caudally from the promontrium using a medial approach, and the rectal mesentery was dissected. After mesenteric mobilization, a well-defined mass was observed in the presacral space . The rectum was completely divided from the tumor, and the rectum and uterus were suspended to obtain a good visual field. The tumor located dorsal side of pre-hypogastric nerve facia and did not show clear communication with the hypogastric nerve and pelvic nerve plexus. The main feeding vessels of the tumor were the branch of the median sacral vein and some branches of the superior rectal artery. The tumor was rolled using gauze to prevent capsular injury and then detached. The inflowing blood vessel was carefully sealed using laparoscopic coagulation shears. The dorsal detachment in contact with the front of the sacrum, where bleeding was expected, was performed last . The tumor was resected en bloc without exposure . Although a small amount of bleeding was observed in the anterior sacrum, hemostasis was achieved by compression and cauterization, using gauzes, an absorbable haemostats, a coagulation and spray mode of the electrocautery and an argon beam coagulator. The operation time was 296 min, and the blood loss volume was 314 mL. The postoperative course was uneventful, and the patient was discharged on the 7th postoperative day. The patient is currently undergoing outpatient follow-up for 1 year after the surgery, with no recurrence.
+The macroscopic findings of the resected specimen were covered with a fibrous capsule and had a well-defined mass. The cut surface was a gray-white solid component, and a small cyst was found in the periphery . Histopathologically, the tumor was composed of relatively uniform cells with fine chromatin, with round to oval nuclei arranged in solid, trabecular, or rosette-like growth patterns. On immunostaining, the tumor cells tested diffusely positive for synaptophysin and cluster of differentiation-56, somatostatin receptor subtype 2a (SSTR2a) and pancreatic polypeptide, and focally positive for progesterone receptor. No positivity for Chromogranin A, p53, estrogen receptor, gastrin, serotonin, somatostatin, CDX2 and TTF1 was observed. The Ki-67 (MIB-1) labeling index was less than 2%. Thus, she was diagnosed with a NET (Grade 1). The cysts found in the periphery were lined with stratified squamous epithelium and contained flocculent eosinophilic material with focal calcification, which was considered to be necrotic tissue. Multiple small cysts were found within the solid component and lined with columnar epithelium . No components other than those derived from the ectoderm were found in the tumor. The presence of cysts lined by multiple epithelia was consistent with the characteristics of tailgut cysts, and it was considered that the NET originated from tailgut cysts and replaced almost all of them.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..daf53c66220732f63eb37c28351ebfad4ff0104e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3_en.txt
@@ -0,0 +1,4 @@
+A 50-year-old Caucasian male collapsed unexpectedly whilst playing football. He was brought to hospital following successful resuscitation for an out-of-hospital ventricular tachycardia (VT) arrest. He had no significant past medical or family history of cardiac disease and was a keen recreational athlete, playing 5-a-side football regularly and cycling 60–100 miles per week. In the months leading up to his cardiac arrest, he recalled three brief episodes of exertional pre-syncope whilst playing sports. On admission, coronary angiography showed unobstructed epicardial vessels and echocardiography revealed mild LV impairment with normal heart valves. An FDG PET–computed tomography scan was negative for active myocardial inflammation. However, cardiovascular magnetic resonance imaging (CMRI) demonstrated a mildly dilated and moderately impaired LV [left ventricular ejection fraction (LVEF) 41%] with epicardial late gadolinium enhancement of the lateral wall and subendocardial enhancement of the septum. The RV was non-dilated with no regional wall motion abnormalities (Videos 1–3).
+A diagnosis of ACM was suspected, and he received an implantable cardiac defibrillator (ICD) for secondary prevention. Post-implantation, his 12-lead electrocardiogram (ECG) showed an atrial paced rhythm with normal ventricular conduction . The limb lead complexes were of low voltage and demonstrated fractionated QRS complexes. There were flattened inferolateral T waves and his signal-averaged ECG was negative for late potentials. He was discharged on Bisoprolol 5 mg daily, lifestyle advice to limit his exercise intensity, and referred for genetic testing along with a recommendation for clinical screening of his family members. He was asymptomatic for a significant period, but at 26 months follow-up device interrogation demonstrated three runs of non-sustained ventricular tachycardia (NSVT) and he received one shock for sustained fast VT. He was then trialled on Nadolol therapy. Genetic testing for pathogenic Lamin A variants and subsequent testing against a panel of 77 cardiomyopathy and arrhythmia-related genes were negative.
+At 41 months, an echocardiogram demonstrated a mildly dilated LV with mild-moderate systolic impairment (LVEF 45%). Interrogation of his ICD revealed two episodes of NSVT and one fast sustained VT treated by antitachycardia pacing. He was switched to Sotalol for its Class III antiarrhythmic properties and started Ramipril 1.25 mg once daily. Given his electrical and structural phenotype, genetic testing was extended to include FLNC. Subsequently, he tested positive for a likely pathogenic FLNC frameshift variant [c.8107del; p.(Asp2703ThrfsTer69)], thus confirming the diagnosis of ALVC. Predictive testing also uncovered the variant in his three children, all of whom had variable clinical expression of the disease.
+At 52 months he was climbing a ski slope and experienced an episode of fast VT requiring an ICD shock . Following urgent electrophysiology outpatient review, he was referred for VT ablation utilizing a combined endocardial and epicardial approach. During the procedure, two types of VT arising from the LV were readily induced and radiofrequency ablation was targeted to abnormal local potentials and the region surrounding epicardial and endocardial scar. At 6 months post-ablation, he was asymptomatic and arrhythmia free on Sotalol 80 mg twice daily, and echocardiography showed some improvement in LV systolic function (LVEF 50–54%).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_40_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_40_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0c35fc0ace867efe83062b97022245d84f8710d9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_40_en.txt
@@ -0,0 +1,4 @@
+A 34-year-old primiparous woman was referred to the obstetric anesthesia outpatient clinic at 26 weeks of pregnancy. The patient had histories of severe bruising in early childhood and difficulty in hemostasis after tooth extraction. She required blood transfusion during laparotomy for ovarian hemorrhage at the age of 15 years. Because of recurrent ovarian hemorrhage, her menstruation was controlled with estrogen and progesterone preparations. In addition, she had a family history of thrombocytopenia and intracranial hemorrhage. The patient’s platelet count hovered around 100,000/μL and was initially followed up as idiopathic thrombocytopenic purpura. At conization at age 25, 400 mL of platelet concentrate was transfused prophylactically, and the postoperative course continued without hemorrhagic complications.
+A thorough examination at the age of 29 demonstrated normal ristocetin-induced platelet aggregation, suppressed adenosine diphosphate (ADP) aggregation to 39% when ADP 3.00 μM was added (normal range 70–90%), and collagen aggregation to 20% when collagen 2.00 μg/ml added (normal range 70–90%), but normal CD41 (glycoprotein IIb/IIIa) antigen, leading to a diagnosis of autosomal dominant, but not previously classified, thrombasthenia. After confirming the negative platelet antigen, she underwent fertility treatment at the age of 30.
+To avoid unnecessary blood transfusions and provide a basis for selecting the anesthesia method when a cesarean section was necessary, we performed TEGPM as well as usual blood tests at 26, 32, 36, 38, and 39 weeks of gestation, and at 1 day, 5 days, 2 weeks, and 1 month after delivery. The results of the tests are shown in Tables and . TEGPM results showed a normal to hypercoagulable state, and ADP aggregation was within the normal range until 38 weeks of gestation. The course of pregnancy was normal without obvious bleeding. The fetal growth remained within normal limits, and a vaginal delivery was planned.
+The patient was admitted to the hospital with premature rupture of the membrane at 39 weeks of gestation. Two days after labor induction, an emergency cesarean section was performed with indications of labor arrest and nonreassuring fetal status. Because TEGPM results showed that ADP aggregation was within the normal range, blood coagulability had increased, and the patient did not manifest bleeding tendencies during pregnancy, we administered single-shot spinal anesthesia. The infant was admitted to the neonatal intensive care unit for transient tachypnea syndrome. The intraoperative blood loss was 480 g, and the postpartum blood loss was 210 g in the first 24 h after surgery. There were no postoperative complications and no prolongation of hospital stay. The baby was discharged from the neonatal intensive care unit on the fourth day after birth without bleeding tendency, and both mother and child were discharged on the sixth day. TEGPM revealed that ADP aggregation was not suppressed until delivery, although it continued to be suppressed after delivery and showed abnormal values 1 month later.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_419_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_419_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9c622b41e67d7fa5ea758683fad8f881ba0cea6b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_419_en.txt
@@ -0,0 +1,3 @@
+A 65-year-old woman with a 5-year history of clinical stage IIA (T2N0M0) invasive ductal carcinoma of the left breast was hospitalized for worsening shortness of breath, hemoptysis, and cough since 2 months. Her breast carcinoma was 32 mm in diameter at diagnosis, with a histologic grade of 3 and nuclear grade of 3. Immunostaining for the estrogen receptor and progesterone receptor revealed negativity for both, but the tumor cells were positive for HER2. The patient had received neoadjuvant chemotherapy with four cycles of epirubicin and cyclophosphamide, followed by four cycles of trastuzumab and paclitaxel. A left mastectomy had been performed, and the surgical specimen showed no residual cancer. After the operation, four cycles of trastuzumab had been administered as adjuvant chemotherapy; however, trastuzumab had been discontinued because of heart failure. Echocardiography showed diffuse and moderate impairment of left ventricular contraction and a decrease in ejection fraction from 65.8 % to 36 %. Seven months after stopping trastuzumab administration, a repeat echocardiography revealed that her ejection fraction had recovered. Since then, she had been followed-up without treatment for breast carcinoma until this readmission.
+On admission, the patient showed normal auscultation findings. A chest radiograph showed faint infiltrates at the base of both the lungs. Arterial blood gas analysis using room air indicated minimal hypoxemia: pH, 7.42; PaCO2, 42 mmHg; and PaO2, 78 mmHg. D-dimer levels were slightly increased to 1.2 μg/mL (normal, <1.0 μg/mL). Serum levels of carcinoembryonic antigen and HER2 were elevated to 57.0 μg/L (normal, 0.8–4.8 μg/L) and 64.9 ng/mL (normal, <15.2 ng/mL), respectively. Contrast-enhanced computed tomography (CT) scans revealed peripheral consolidation with ground-glass opacity in both the lower lobes and a heterogeneous mediastinal mass . 18F-fluorodeoxyglucose (FDG)-positron emission tomography demonstrated increased FDG uptake in the peripheral consolidation and the mass. Echocardiography revealed normal contractions without any finding suggestive of pulmonary hypertension. Because transbronchial lung biopsy did not lead to any diagnosis, video-assisted thoracoscopic surgery (VATS) lung biopsy was performed. The surgical specimens of the peripheral area of the left lower lobe and the mediastinal mass revealed tumor cell embolism, intimal fibrocellular proliferation of small arteries, fibrin thrombi, recanalization, and infarction in the left lower lobe, as well as metastasis to the mediastinal pleura . Immunohistochemical staining of tumor cells revealed positivity for mammaglobin, gross cystic disease fluid protein 15, HER2 (3+), and vascular endothelial growth factor. Accordingly, a diagnosis of recurrent breast cancer with PTTM was made.
+Retreatment with trastuzumab therapy rapidly improved the symptoms and CT findings of peripheral consolidation and the mass, resulting in partial remission . After four cycles of trastuzumab therapy, it was stopped owing to heart failure. The patient visited another hospital and is alive more than 2 years after the diagnosis of PTTM.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_443_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_443_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7b79c1f23e8be49b7f27af7ce53d3ab88984e521
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_443_en.txt
@@ -0,0 +1,4 @@
+A 53-year-old married man (weight: 85 kg, height: 187 cm, body mass index: 24 kg/m2) presented with a history of nasal obstruction for two years. Otorhinolaryngologists planned a septoplasty operation under general anesthesia for him. He had not had any prior operation under general anesthesia, so he did not have any history of difficult intubation, and he did not have any chronic systemic disease. The patient was evaluated for obstructive sleep apnea syndrome (OSAS) with a comprehensive questionnaire on his sleeping habits and medical history; no complaints or predictors pertaining to OSAS were identified.
+The patient’s preoperative airway assessment was normal, Mallampati class was II, thyromental distance was 7 cm, inter-incisor gap was 5 cm, and head extension was >35°. His physical examination was characterized by lack of secondary sexual characteristics and presence of fine facial wrinkles. Although, as previously indicated, the patient was married, he had had no children. He had consulted urologists, and primary infertility and erectile dysfunction had been diagnosed. His hormone profile was: testosterone 0.3 ng/mL (reference range 1.75–7.81), free testosterone 0.91 (reference range 4.5–42.0), prolactin 1.31 ng/mL (reference range 2.64–26.72), luteinizing hormone (LH) 0.33 mIU/mL (reference range 1.24–103.03). His thyroid hormone levels were normal. No other pathological finding was obtained as the result of magnetic resonance imaging of the pituitary gland. Thus, the patients was diagnosed with primary hypogonadotropic hypogonadism.
+He was admitted to the operating theater, and following the induction of anesthesia with a dose of 5 mg/kg intravenous thiopental, bag-mask ventilation was barely sustained. Fentanyl (1–2 μgr/kg) and, as a muscle relaxant, rocuronium (0.6 mg/kg) were administered. While the patient’s head was in the sniffing position, direct laryngoscopy and intubation of the trachea were attempted three times with different sizes of Macintosh and Miller blades by an assistant professor of anesthesiology with 5 years’ experience. However, unfortunately, the intubation failed. The lungs were then ventilated with 100% oxygen via a face mask in order to avoid desaturation. Glottic visualization was assessed with Cook’s modification of the Cormack–Lehane classification; a grade of 3A (with direct laryngoscopy, only the epiglottis can be visualized; the epiglottis can be lifted using an introducer or bougie) was assigned. The patient was subsequently successfully intubated with a gum-elastic bougie.
+After the operation, the patient was extubated successfully without any complication and then examined by otorhinolaryngologists via fexible laryngoscopy. The epiglottis was found to be in a slightly lower than normal position .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_453_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_453_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a6bb62074ab090a7ce94080569337e1b109d03d9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_453_en.txt
@@ -0,0 +1,10 @@
+The patient was a 70-year-old male with a history of glaucoma. There was no outstanding family medical history. He was diagnosed with esophageal cancer 3 years earlier, and had undergone surgical resection and chemotherapy. Best supportive care was initiated 1 year earlier. From 1 month before the last hospitalization, the patient had been in the terminal stage of cancer with an Eastern Cooperative Oncology Group performance status of 3 and decreased activities. At that point, he was told he had 1–2 months to live. Around the same time, the left supraclavicular lymph node was becoming progressively enlarged. Consequently, the patient developed repetitive syncope episodes lasting 2–3 min for which hospitalization was necessary.
+A single mass of 120 mm × 90 mm was detected in the supraclavicular area on palpation . No outstanding findings were detected with cardiac ultrasonography or cerebral magnetic resonance imaging. No blood biochemistry findings suggestive of anemia, dehydration, hypoglycemia, electrolyte abnormalities or thyroid disorder were observed.
+After admission, ADL decreased and the patient became bedridden because of his anticipatory anxiety for syncope onset. Subsequently, syncope episodes disappeared; however, the patients complained of prodromal symptoms such as dizziness, nausea, and ocular pain. These symptoms persisted for 20–30 min, spontaneously disappeared, and recurred three to four -times daily. When prodromal symptoms occurred, the heart rate ranged between 20 and 30 bpm and systolic blood pressure decreased by 50 mmHg. Holter electrocardiography performed on the day after admission revealed stable blood pressure and heart rate as long as no syncope occurred. During a syncope episode, however, abrupt bradycardia persisted for 1–2 min, initially with a non-sinus rate, then returning to a sinus rate . This cycle recurred five to six -times in 20–30 min. During this period, arrest for more than 2 s was frequently observed, and the recovery time in the sinus node was within 5 s. One of the factors contributing to the prodromal symptoms was cervical rotation toward the tumor side. Although the head-up tilt test could not be performed owing to the patient’s poor health condition, postural change with angles between 0° and 80° were performed using a motorized bed. The postural changes did not induce prodromal symptoms or changes in blood pressure or heart rate, which did not support a diagnosis of vasovagal syncope. Although the tilt table test with carotid sinus massage was avoided because of the patient’s poor health condition, the patient was diagnosed with a mixed-type secondary CSS based on the syncope episodes.
+The patient understood his status well, including the poor prognosis. On admission, he expressed that he knew he might live a few weeks at best. His will was not to undergo life-prolonging treatment but to obtain symptom relief and respect for his autonomy. In particular, he wished for reduction of the severity of the prodromal symptoms and improvement of his autonomy by reducing anticipatory anxiety. He declined to receive palliative radiation therapy to the cervical tumor or implantation of a temporary or permanent pacemaker because of their invasive nature and his poor prognosis.
+Palliative radiation therapy to the cervical tumor was initially considered; however, it was not warranted based on the patient’s will and because the effects of this treatment could take some time to be reflected in the patient’s condition and because this treatment was associated with poor prognosis. Implantation of a temporary or permanent pacemaker was also initially considered; however, it was not warranted based on the patient’s will as well as the suspected vasoinhibitory-predominant mixed-type . Although treatment with α1 adrenergic agonist was initially considered, it was not warranted based on the patient’s history of swallowing disorder due to recurrent laryngeal nerve paralysis associated with the cervical tumor.
+On the fourth day of hospitalization, the patient discovered that he could decrease the duration of prodromal symptoms by contracting the muscles in his hands and legs, by clenching his hands into fists and continuously stomping his feet on his bed while lying in it. In particular, symptoms that had previously persisted for 20–30 min were resolved in several tens of seconds by applying his coping method. When he tried to cope with the prodromal symptoms, his heart rate decreased up to 20–30 bpm; however, no change in blood pressure was observed. He hoped for improvement of his autonomy and discovered this coping method incidentally and with the support of medical staff. Based on his experience, he recognized these actions as effective coping and applied them whenever he experienced prodromal symptoms.
+Because coping reduced the severity and duration of prodromal symptoms, the patient recognized amelioration of the prodromal symptoms. Subsequently, his anticipatory anxiety for syncope was reduced, resulting in enhanced self-efficacy. He had demonstrated improved ADL, including being able to elevate his head with the motorized bed, maintaining a sitting position and performing cervical rotation as early as 1 day after the initiation of coping. As ADL improved, the frequency of prodromal symptoms transiently increased up to seven or eight times a day during the early phase of coping. The frequency thereafter decreased and eventually the prodromal symptoms subsided after 4 days of coping. Nineteen days after admission, he developed sudden aspiration pneumonia secondary to recurrent laryngeal nerve paralysis associated with the cervical tumor and decreased awareness. He had not complained of prodromal symptoms and had maintained his ADL status for the 19 days after admission. On day 21 after admission, he died from respiratory failure.
+As far as we know, this is the first report of a case of end-stage cancer that led to enhanced self-efficacy with self-control of prodromal symptoms of syncope associated with secondary CSS. There are two critical points in this case. First, prodromal symptoms of syncope associated with CSS were successfully self-controlled. Second, the frequency of prodromal symptoms of syncope decreased after self-control became effective.
+The first critical point in this case was that prodromal symptoms of syncope associated with CSS were successfully self-controlled. The hypothesis that the tumor could induce depolarization in afferent and efferent nerve fibers was a possible underlying mechanism of CSS in this case of cervical tumor; however, details regarding this hypothesis have not yet been elucidated. Efferent nerve fibers involved in the carotid sinus reflex split into the cardiac vagal nerve, which is distributed to the sinus and the atrioventricular nodes. The sympathetic nerve is distributed to the ventricular myocardium and peripheral blood vessels . Depending on the abnormality of the regulating function, CSS is classified as cardio-inhibitory type when the stimulation of the vagal nerve inhibits the sinus node function or atrioventricular conduction, or a vasodepressor type when the inhibition of the synthetic nerve reduces blood pressure . In our case, we feel that the patient’s coping method, consisting of contracting the muscles in his hands and legs, induced is peripheral vasoconstriction followed by enhanced synthetic nerve function, which avoided an abrupt decrease in blood pressure. Indeed, based on the Holter electrocardiogram, we observed that an abrupt decrease in blood pressure by 50 mmHg or greater occurred within 66 s after the bradycardia emerged. In contrast, after his coping method was applied, there were no decreases in blood pressure although comparable bradycardia occurred. Based on these episodes, this patient was considered to present a vasoinhibitory-predominant mixed-type CSS. As this patient was not monitored with direct measurement of arterial pressure, no continuous blood pressure data were available. It was previously reported that blood pressure showed the lowest value 18 ± 3 s after the carotid sinus massage in a vasoinhibitory-type CSS . Similarly, blood pressure might have decreased rapidly in our patient after cervical rotation. Coping in our case was considered to have either avoided the abrupt decrease in blood pressure or contributed to rapid recovery from hypotension. Additionally, it was reported that interruption of cerebral circulation for 6–8 s or a decrease in systolic blood pressure to 60 mmHg can result in syncope . Thus, the recovery period in the sinus node might be within 5 s, thus, bradycardia alone was not considered to be a primary factor for the prodromal symptoms of syncope.
+The second critical point from this case was that not only the severity of prodromal symptoms of syncope decreased but also the frequency of prodromal symptoms decreased gradually after self-control became effective. Although the frequency of prodromal symptoms transiently increased with improved ADL in the early phase, the symptoms had almost resolved 4 days after the initiation of coping. This amelioration was considered to be due to decreased subjective symptoms associated with increased threshold for the prodromal symptoms of syncope. It was reported that the preventive effects of pacemaker treatment against recurrence of syncope can be attributed to a placebo effect caused by pacemaker implantation . Namely, self-efficacy enhanced by self-control might contribute to a placebo effect that increased the threshold of symptoms. As for pain management, it was reported that a patient’s recognition of self-efficacy that can reduce pain enhances analgesic potency . Additionally, in an experimental study of end-stage cancer patients, the existence of stress associated with decreased ADL was observed . Coping in this case might have led to stress reduction caused by increased ADL, possibly resulting in an increased threshold of symptoms. Furthermore, tilt training was reported to prevent the recurrence of neurally mediated syncope . Coping in this case led to an increased duration of sitting due to improved ADL, which might possibly work as a preventive exercise against the recurrence of prodromal symptoms of syncope.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_464_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_464_en.txt
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index 0000000000000000000000000000000000000000..b08ed028e82cd8b0610f333884061ca345a9b87f
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+A 24-month-old female with a 2-month history of psychomotor retardation, weight loss, and unremarkable medical history was admitted to our institution. She presented horizontal nystagmus without sensory nor motor deficits. Physical examination revealed mild confusion and a cutaneous fistula in the mid-occipital region. The fistula appeared to communicate with intracranial space. Emergency CT scan [; blue arrow] and brain MRI showed a cystic infratentorial mass with ring enhancement of the cystic walls. In the suspect of intracranial abscess, treatment with ceftriaxone 75 mg/kg was administered every 24 h.
+During preparation for surgery, a 5 mm non-purulent subcutaneous nodule with skin fistula was seen . A suboccipital craniotomy was performed. The cerebellar abscess was evacuated, followed by excision of the entire capsule . Total resection of a 3 cm whitish, midline, encapsulated, and hairy cystic mass was performed. The cyst was adherent to the dura and to the confluence of sinuses .
+Bacterial investigation revealed methicillin-sensitive Staphylococcus aureus. Histological examination confirmed the diagnosis of dermoid tumor . Therefore, antibiotic treatment was switched to Ampicillin IV 50 mg/kg every 6 h and was administered for 7 weeks after surgery.
+The patient’s physical condition and neurological symptoms improved rapidly. After 15 days, she was discharged without any deficit. At a 36-month follow-up, there was no evidence of recurrence .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_485_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_485_en.txt
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index 0000000000000000000000000000000000000000..6028ea43fe7d943e3f04d11b6db445839a92797b
--- /dev/null
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+The patient was a 75-year-old man with a history of hypertension, cerebrovascular disease, and adjustment disorder, but no known allergies. The patient’s father also had a history of colon cancer.
+In December 2004, the patient underwent a transverse colectomy for transverse colon cancer (T3 N1 M0 stage IIIa) at another hospital. Due to adjustment disorder, the patient was closely monitored, but no adjuvant chemotherapy administered.
+In March 2006, a colonoscopy revealed that the cancer had anastemotic recurrence, and in April 2006 the patient underwent a subtotal colectomy and anastomosis of the sigmoid colon and ileum.
+In April 2007, the patient’s tumor markers were elevated and positron emission tomography-computed tomography (PET-CT) revealed metastasis to the liver and para-aortic lymph nodes. Chemotherapy with 5-fluorouracil/leucovorin/ oxaliplatin (FOLFOX4) was started as first-line treatment in May 2007. After 15 courses of treatment, the patient exhibited signs of progressive disease. Bevacizumab could not be administered, however, as the patient also had cerebrovascular disease.
+In February 2008, chemotherapy with 5-fluorouracil/ leucovorin/irinotecan (FOLFIRI) was started as second-line treatment. After 16 courses of treatment, imaging revealed an increase in liver metastasis, and the patient was referred to our hospital.
+At the time of admission, the patient measured 186.5 cm in height, weighed 80.1 kg, had a Body Mass Index (BMI) of 23, and a Performance Status (PS) of 0. Normal heart sounds and breathing were noted, without abdominal abnormalities being observed, there was no leg edema, and the patient had grade1 peripheral neuropathy. Blood tests showed a normal blood count, and blood levels of carcinoembryonic antigen (CEA) and carbohydrate antigen (CA)19-9 at 88.8 ng/mL and 312.2 U/mL, respectively. Chest and abdominal X-rays, as well as an electrocardiogram, also revealed no abnormalities. An abdominal CT showed shadows on his liver at S4 and S8 . A PET-CT scan (1/29) showed liver metastases at S8, S4 and S3. The resected primary tumor tested positive for EGFR and showed the presence of wild-type KRAS. EGFR was analyzed by immunohistochemistry.
+KRAS genotyping using tumor samples was analyzed by Luminex® assay.
+The analytical sensitivity of the Luminex® assay is 0.4% (GENOSEARCH HS KRAS).
+After admission, chemotherapy with irinotecan and cetuximab (CPT-11 + C-mab) was started as third-line treatment in January 2009. After 13 courses of treatment, blood CEA and CA19-9 levels dropped to 14.3 ng/mL and 16.8 U/mL, respectively, and liver metastases showed a reduction , indicating a partial response. A left hepatectomy was performed in September 2009, and tumor markers dropped to normal levels. The resected tumor specimen showed the presence of wild-type KRAS.
+In October 2009, postoperative chemotherapy was commenced with CPT-11 + C-mab. Six courses (courses 14–19) of treatment were completed, after which the patient only came in for follow-up without continuing chemotherapy.
+In July 2010, the patient exhibited peritoneal dissemination and lung metastasis (S2,S4,S5,S8), and treatment with CPT-11 + C-mab was recommenced. After 18 courses of treatment (courses 20–37), no change was observed in lung metastases, and no new areas of metastasis were detected, indicating stable disease (SD).
+In August 2011, the patient underwent lung metastasis resection. In October 2011, new areas of lung metastasis were found, while the primary tumor remained unchanged (SD). Treatment with CPT-11 + C-mab was started again (courses 38–48). Courses 39–41 and 45–48 consisted of only cetuximab. The lung metastases remained unchanged (SD) after 11 courses of treatment.
+In May 2012, emergency gastric bypass surgery was performed for an obstruction in the ileum due to seeding in the patient’s duodenum . A KRAS mutation was detected in the resected seeding tissue.
+At present, only palliative treatment is being administered as the patient has completed standard treatment.
+While the patient’s resected tumors from both 2004 and 2009 showed the presence of wild-type KRAS, and the administration of cetuximab for 2 years and 4 months proved effective, the resected seeding tissue from his intestinal obstruction was found to have a KRAS mutation. Hence, it can be possibly concluded that administration of EGFR inhibitors resulted in an acquired KRAS mutation that conferred drug resistance.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_490_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_490_en.txt
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index 0000000000000000000000000000000000000000..b712c36c8e6e595e5b0e6413286c2037f3d2880c
--- /dev/null
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+A 62-year-old woman was admitted to our hospital because of mental abnormality and hypomnesia for 3 months. The main mental symptoms were gibberish, irrational talk, impaired mental attention, without apparent hallucinations and delusions. The patient did not present with fluctuating consciousness, lack of consciousness, or loss of consciousness. The family of the patient reported that she had a history of fever before she experienced the mental symptoms. Her highest body temperature was 38.6 °C. Her axillary temperature became normal after she received antibiotic therapy for 4 days. However, she gradually developed symptoms of mental abnormality. She also intermittently complained of abdominal pain, vomiting, constipation, and urinary incontinence for 1 month. She did not experience other discomforts, such as headaches, dizziness, and convulsion. She visited a local hospital in October 2018, and the routine blood test showed that the white blood cell counts were normal, and the percentage of lymphocytes was high. The blood potassium was 1.91 mmol/l (normal 3.5-5.3 mmol/l), and the prolactin level was 90.55 μg/l (normal 2.74–26.72 μg/l). The free thyroxine was slightly high, the thyroglobulin antibody was 12.32 IU/ml (normal 0–115 IU/ml), and the thyroid peroxidase antibody was 10.42 IU/ml (normal 0–34 IU/ml). The testing results of antinuclear antibody, anti-neutrophil cytoplasmic antibody, anti-Jo-1 antibody, anti-dsDNA antibody, anti-Scl-70 antibody, anti-SSA antibody, and anti-SSB antibody were yielded negative, and the tests for hepatitis, HIV, and syphilis virus were also negative. The local hospital suspected intracranial infection, endocrine disease, and electrolyte disorders and gave her symptomatic treatment. Nevertheless, her symptoms showed no noticeable improvement. It was difficult to diagnose the disease, so the patient was admitted to our hospital. The patient had a history of diabetes, hypertension, erosive gastritis, and cataract surgery, but she had no family history of neurological diseases.
+The physical examination revealed that her body temperature was 36.8 °C, and there was tenderness below the xiphoid. The neurological examination showed impaired mental attention and reaction capacity, slow speech, normal manifestations of the brain nerve, normal muscle strength, and muscle tone, negative meningeal irritation sign and pathological reflex, normal tendon reflex. The patient could not cooperate with the sensory system examination. The mini-mental state examination (MMSE) score was only 6/30.
+Encephalitis was initially suspected, and lumbar puncture was performed. The CSF examination showed that the CSF pressure was 110 mmH2O, and the white blood cell count was normal, but she had an increased total protein level of 0.57 g/l (normal 0.15–0.45 g/l) and a glucose level of 5.10 mmol/l (normal 2.2–3.9 mmol/l). The coxsackie B virus, enterovirus, and cytomegalovirus test levels were normal. Bacterial culture and Cryptococcus neoformans tests were negative. A contrast-enhanced MRI of the brain was normal. The diagnosis of encephalitis was excluded in general. However, leukoencephalopathy was evident on the T2 fluid-attenuated inversion recovery (FLAIR) images. A high-signal intensity in the white matter of the cerebral hemisphere, especially at the subcortex of the frontotemporal and corona radiata, was found on the T2 FLAIR images . The MRI imaging of the left basal ganglia and bilateral corona radiata showed lacunar infarction. Magnetic resonance angiography indicated that the blood vessels were normal. The DWI results revealed a symmetrically distributed strip-shaped high-intensity signal of the corticomedullary junction in the bilateral frontal, parietal, and temporal lobes .
+Skin biopsy samples were obtained at 10 cm above the patient’s ankle. A light microscope was used to examine the samples, which showed hyperkeratosis of the epidermis. A few lymphocytes and tissue cells infiltrated through the superficial vessels of the dermis . Electron microscopy showed round-shaped intranuclear inclusions in the nucleus of the fibrocytes. The intranuclear inclusions had clear borders and were composed of fibrous substances without a membrane structure .
+The fasting blood glucose was 9.48 mmol/l, and glycosylated hemoglobin was 6.6%. The routine urine test showed normal results. The patient presented with mental abnormality for 3 months. We did not consider the diagnoses of hypoglycemia, diabetic ketoacidosis, or hyperosmolar hyperglycemic syndrome. Furthermore, the patient did not present with depression, anxiety, consciousness disorders, hallucinations, and neurasthenia, which were common mental symptoms in patients with diabetes. The results of the electrolyte showed hypokalemia (2.6 mmol/L), hyponatremia (127.3 mmol/L), and hypochloremia (86.5 mmol/L). The renin-angiotensin-aldosterone system and cortisol hormone tests showed normal results. The MRI of the hypophysis showed no abnormal areas. The electroencephalography showed low-and moderate-amplitude desynchronized-mixed waves when she fell asleep.
+Brain protection and symptomatic therapy were given when the patient was hospitalized, and the symptoms were relieved. However, she still complained of recurrent vomiting and urinary incontinence. The patient was alive, and the condition of the patient did not worsen or improve for 6 months after she was discharged.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_491_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_491_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..367a7b75ad9ccf4b62d1a3e9bce88d9bb7e8e96f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_491_en.txt
@@ -0,0 +1,5 @@
+After having developed fever and fatigue, a 72-year-old male patient (body mass index 29.2) was diagnosed with COVID-19 and put in quarantine at home. Clinical worsening resulted in delirium. After 6 days, emergency medical services found the patient severely hypoxic (SpO2 65%) despite his not complaining about dyspnoea. Oxygen was administered and the patient was transported to a designated COVID-19 pulmonary intensive care unit (ICU).
+History revealed a non-insulin-dependent diabetes mellitus type 2 (recent Hba1c 6.4%), aortic dissection type B (stable over time in various CTs), persistent AF, a smoking history (cessation 20 years ago), and chronic obstructive sleep apnoea syndrome (no therapy). Chronic medication consisted of apixaban (5 mg twice daily), gabapentin (150 mg twice daily), bisoprolol (5 mg twice daily), and metformin (500 mg twice daily), and did not include angiotensin-converting enzyme inhibitors or angiotensin receptor blockers.
+Upon arrival, the patient was normotensive with an irregular heart rhythm, appearing exhausted and perspiring, but not subjectively dyspnoeic. Auscultation revealed bilateral medium to coarse crackle sounds. He was intubated due to severe hypoxaemia [Horovitz index 111, positive end-expiratory pressure (PEEP) 18 cmH2O, pressure control max. 32 cmH2O, FiO2 80%]. Sufficient oxygenation and normocapnia (pO2 89 mmHg, pCO2 45 mmHg) were achieved. Tachycardic AF up to 180 b.p.m. was successfully electrically cardioverted. However, bedside echocardiography showed globally reduced left ventricular systolic function (LVSF) and ejection fraction (EF, 30%), necessitating noradrenaline and dobutamine support (initial dosages 0.32 μg/kg/min and 6.67 μg/kg/min, respectively). Pulse contour cardiac output monitoring was established (initial values: cardiac index 1.6 L/min/m2, cardiac function index 2.2 L/min, global end-diastolic volume index 791 mL/m2, pulse pressure variation 14%, extra-vasal lung water index 35.3 mL/kg, pulmonary–vascular permeability index 7.2) to guide further treatment, including careful volume resuscitation, argipressin (1.8 IU/h), hydrocortisone (8 mg/h), and continuous landiolol (initial dose 8 μg/kg/min) for control of reoccurring tachycardic AF.
+A chest X-ray showed bilateral consolidations compatible with ARDS . Laboratory results showed AKI. Continuous renal replacement therapy (CRRT) was established and upgraded with an immunoadsorbant filter (Cytosorb®) for 48 h to counteract a suspected cytokine storm mirrored by rising interleukin-6 (IL-6) levels. The initial pro-brain natriuretic peptide (BNP) was 1612 ng/L, ultimately reaching 10-fold levels. High sensitivity troponin T (hs-TnT) values were undulant during the entire stay, with maximum levels of 200 ng/L. For the development of laboratory values over time, see . Due to organizational reasons and potential cardiac side effects, it was chosen not to administer experimental therapeutics such as hydroxychloroquine, tocilizumab, or antiviral agents.
+More frequent tachycardic AF episodes did not respond to electrical cardioversion, escalation of landiolol (up to 40 μg/kg/min without effect of further escalation), or addition of amiodarone (300 mg in 30 min and 38 mg/h over 24 h thereafter). Also, digitoxin (0.25 mg daily) and ivabradine (5 mg twice daily)—initially showing promising results—ultimately proved ineffective. Progressing heart failure seemed to be mainly dependent on tachycardic AF. Levosimendan (10 μg/kg/min for 10 min and 0.2 μg/kg/min for 24 h thereafter) led to a transient positive effect that only lasted ∼24 h. In echocardiographic controls, pericardial effusion (circumference, 2–3 cm, ) developed in 48 h, leading to pericardial tamponade that was successfully drained (a SARS-CoV-2 test from the fluid was negative). After pericardiocentesis, haemodynamics improved only transiently, and LVSF/EF deteriorated rapidly. At this stage, an ultima ratio treatment option would have been veno-arterial extracorporeal membrane oxygenation (VA-ECMO). However, existing literature surrounding the role of VA-ECMO in the treatment of COVID-19-associated cardiogenic shock is scarce. Due to the multiple comorbidities, resource availability, and the perceived risk–benefit ratio, a decision against ECMO was made. In a multidisciplinary way, a do not resuscitate order was agreed on. Nine days after ICU admission, the patient died from multiorgan failure. gives an overview of the entire case.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_501_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_501_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4c5d245e4e5098c04314f1ad829c233d3d2d63a9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_501_en.txt
@@ -0,0 +1,4 @@
+A 4-year-old Japanese boy presented with bilateral upper eyelid swelling and discomfort. The swelling was painless, but he complained of itchy eyelids. Ophthalmic examination revealed bilateral upper eyelid edema . No lymphadenopathy of the head or neck was observed. The patient had no medical history of atopic dermatitis, but local reactions to insect bites and vaccinations were excessive. There was no family history of autoimmune renal disease.
+Urinalysis results were normal. Blood analysis showed a white blood cell count of 8,200 /mL with a differential neutrophil count of 13%, a lymphocyte count of 55.5%, and a markedly increased eosinophil count of 28.5%. A peripheral smear revealed no abnormalities. The CD4/CD8 ratio was normal (1.46). Most laboratory blood examinations included electrolytes, serum creatinine, and blood urea nitrogen quantitation. The patient had an elevated aspartate aminotransferase level (34 IU/L; normal range, 14–20 IU/L), but alanine aminotransferase activity was within the normal range (16 IU/L; normal range, 10–40 IU/L). Lactate dehydrogenase and creatinine kinase activities were normal. The patient’s C-reactive protein level was 0.045 mg/dL, and he had an erythrocyte sedimentation rate of 9 mm/h. Immunoglobulin levels of IgG, IgA, IgD, IgM, and IgG4 were normal (IgG, 1,173 mg/dL; IgA, 162 mg/dL; IgD, 9.9 mg/dL; IgM 206 mg/dL; and IgG4 9.7 mg/dL). The patient had a highly elevated serum IgE level (14,351 IU/mL; reference range: 0–295 IU/mL). Serologic analyses for antinuclear antibody and MPO-ANCA were negative and serum complement components C3, C4, and total complement activity were normal. Chest radiography results were also normal, though magnetic resonance imaging (MRI) showed bilateral lacrimal gland enlargement without the appearance of mass lesions in the orbit and adjacent bony erosion .
+Mikulicz disease was initially suspected, despite the IgG4 level being normal. Based on this presumptive diagnosis, pranlukast hydrate was administered for 2 years. However, follow-up treatment was suspended for 4 years as the symptoms did not improve. An excisional biopsy via anterior orbitotomy was performed at the age of 10 years, which revealed eosinophilic hyperplastic lymphogranuloma involving the lacrimal gland . A mixture of CD3-positive and CD5-positive T-cells was found within the interfollicular regions, and CD20-positive B-cells were observed within the follicles. A relatively smaller number of IgG-positive and IgG4-positive plasma cells were also observed. There was no evidence of either vasculitis or prominent vascular endothelial cell proliferation.
+Based on these findings, IgG4-related diseases, including Mikulicz disease, were excluded. Oral prednisolone was initiated at 1 mg/kg/day based on a diagnosis of lymphoproliferative disorder. The patient’s symptoms, including the eyelid edema, discomfort, and eosinophilia, were dramatically improved at the 1-month follow-up. However, symptoms recurred as prednisolone was tapered. A combinatorial therapy of prednisolone with mizoribine was subsequently initiated to mitigate the side effects of steroids. However, swelling of the bilateral eyelids worsened, and an itchy subcutaneous mass developed on the left arm. MRI examination revealed serpiginous subcutaneous lesions in the medial aspect of the left distal arm . The bilateral eyelid masses were resected when the patient was 14 years old due to their frequent recurrence, the side effects associated with steroid administration at the time of recurrence, and the negative impact the masses had on the patient’s physical appearance, and narrow field of view. Postoperative pathological examination of the excited masses showed hyperplastic lymphoid follicles embedded in fibroconnective tissue and multinuclear Whartin-Finkeldey cells, indicative of KD . Immunohistochemical analysis of the cells revealed negative staining for IgG and IgG4. The serum IL-4 level was elevated (500 pg/mL; reference range: < 6.0 pg/mL), but IL-5, IL-6, and interferon γ levels were normal. Serum sIL-2R levels were with in the reference range throughout the clinical course. The diagnosis of KD was confirmed based on the histological findings, markedly high serum IgE levels, and peripheral blood eosinophilia. Treatment with oral CsA at an initial dose of 2.5 mg/kg/day was started, which maintained at a trough level of approximately 50 ng/ml. The eosinophilia and serum IgE levels gradually decreased after initiation of CsA, but the IL-4 levels remained high. The CsA therapy was adjusted to 4mg/kg/day and the clinical symptoms were stable, without bilateral upper eyelid swelling or recurrence of the subcutaneous mass on the left arm .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_502_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_502_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b94bd4b401bd9cb7f325a3b4d849aa4dfcb1a803
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_502_en.txt
@@ -0,0 +1 @@
+An elderly 88-year-old female patient suffering from an actively bleeding upper GIB due to a duodenal ulcer was treated with coil embolization of the GDA. Endovascular therapy was indicated after endoscopic management using three metal clips and the injection of 4 ml Suprarenin 1:100.000 failed to stop the bleeding. Embolization was carried out using pushable coils of various sizes in the usual “front door – back door” technique over a 2.7 French (F) Progreat microcatheter (Terumo, Tokyo, Japan) which is routinely used in our institute for such embolization procedures. During embolization, the last VortX-Diamond-18 pushable coil (Boston Scientific, Massachusetts, USA) measuring 6 × 6.7 mm was dislocated into the CHA causing a subsequent slowing down of the blood flow in the vessel. A decision was thereby made to remove the coil by retrieving it through the 5F SIM1-Catheter (Boston Scientific, Massachusetts, USA), which was already positioned in the coeliac trunk as a guiding catheter for the initial embolization of the GDA. An initial trial to remove the coil using a 4 mm Amplatz GOOSE-NECK® Microsnare Kit (ev3, Minneapolis, USA) was unsuccessful. Consequently, the decision was made to retrieve the dislocated coil using a cerebral pRESET stent retriever (4 × 20 mm). For this procedure, the initially used 2.7F Progreat microcatheter was brought distal to the dislocated coil and the pRESET was placed in the CHA covering the dislocated coil . The coil was easily pulled back all the way to the SIM1-Catheter. The first trial to retrieve the coil into the lumen of the SIM1-Catheter was however unsuccessful, with the coil dislocating back into the periphery of the CHA. In the second trial, an extra step to lock the dislocated coil within the meshwork of the pRESET was performed by carefully pushing the microcatheter to the position of the dislocated coil while pulling the stent retriever . The coil was then carefully retrieved by pulling back the pRESET together with the microcatheter into the SIM1-Catheter using gentle repetitive pulling movements. A postinterventional series showed a restoration of the normal flow without perforation or thrombosis of the CHA . The patient was symptom-free and stable with improvement of the Hemoglobin-level and with no changes in the liver enzymes.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_531_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_531_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0c69b1c5a57d9aa3b7fd035668997b925345f146
--- /dev/null
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@@ -0,0 +1 @@
+We present the case of a 25-year-old male who complained of difficulty adapting his right eye prothesis. He had a history of enucleation of the right eye due to a retinoblastoma in France when he was 4 years old. No orbital implant was placed at that time. Ophthalmological evaluation revealed a thickened bulbar conjunctiva with a central translucid round area, vascularized, and an associated inferior symblepharon . Orbital computed tomography (CT) was obtained and revealed a cyst-like structure on the right orbit, bilobated, with hyperdense walls and hypodense content. Magnetic resonance imaging (MRI) image was described as “raised anteroposterior diameter of a cystic-like structure with an ovoid morphology.” There was a structure with a T1 signal which was identical to an atrophied optic nerve, and there was no contrast uptake that indicated an expanding lesion . These exams were compared with previous orbital CT from 6 years before (after a trauma incident), in which the lesion was not apparent. Drainage of the cystic content and biopsy with partial resection were performed . Pathology exam revealed fragments of fibrous tissue with a cystic structure covered with conjunctival-like epithelium, with no evidence of dysplasia or malignancy . Diagnosis of a giant conjunctival cyst of the orbit was assumed. The CARE Checklist has been completed by the authors for this case report, attached as online supplementary material (for all online suppl. material, see ).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_533_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_533_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f2f67ad62b4b779f41b47cfd252635dfb6d05799
--- /dev/null
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+A 28-month-old girl was admitted to a local medical institution due to repeated hematochezia for more than 3 months. She experienced hematochezia for no obvious reasons at the age of 25 months, with small to moderate amounts of dark red or bright red paste-like stool 3–5 times a day, accompanied by abdominal pain, mainly around the umbilical area, which had no obvious relationship with eating and bowel function, and was not accompanied by vomiting, diarrhea, fever, and cough. Routine stool analysis showed red and white blood cells, but the pathological culture was negative. The complete blood count indicated that the white blood cell count was 16.3 × 109/L, and the hemoglobin concentration was 123 g/L. Abdominal ultrasound showed active intestinal peristalsis, multiple hypoechoic nodules around the umbilical area, and enlarged mesenteric lymph nodes. Bacterial enteritis was suspected and treated with anti-infection and hemostatic drugs. During the period, she was fed with deeply hydrolyzed formula which yielded poor therapeutic effects. Eventually, the patient was transferred to our hospital.
+The patient was born to a healthy and non-consanguineous Chinese couple after a normal pregnancy with an unremarkable family history. The patient was delivered naturally and was generally in good condition after delivery. The patient previously underwent a cervical lymph node abscess biopsy at a local hospital, but the parents could provide no relevant clinical documentation. No abnormalities in growth and development were observed.
+Physical and Laboratory examination During the physical examination upon admission, a small rash was observed on the neck. The complete blood count revealed a white blood cell count of 11.70 × 109/L (reference range: 5.0–9.0 × 109/L), hemoglobin 110 g/L (105–145 g/L), platelet count 38 × 109/L (140–440 × 109/L), and neutrophil percentage 31% (40-60%). Serum immunoglobulin testing revealed an immunoglobulin G (IgG) of 16.7 g/L (3.83 ~ 10.58 g/L), IgM 1.66 g/L (0.4 ~ 1.28 g/L), and IgE 74 IU/ML (0 ~ 60IU/ML). The absolute counts of B cells, T cells and NK cells were 1688.52 cells/ul (90–660 cells/ul), 4833.95 cells/ul (690–2540 cells/ul), and 877.12 cells/ul (90–590 cells/ul), respectively. Antiprotease 3 antibody (ELISA) 64.5 (less than 18). Food allergen IgE: milk 1.59 (less than 0.35 IU/ml). C-reactive protein, procalcitonin, blood gas analysis, biochemical indexes, coagulation index, autoimmune antibody, rheumatoid factor, and T-SPOT.TB test yielded no abnormal findings. No abnormality was found on chest and abdominal radiographs.
+Diagnosis and treatment process and follow-up Based on the medical history and test results, an initial diagnosis of cow milk protein allergy and congenital immunodeficiency disease was established. A gastroscopy was conducted and indicated erosive gastritis and erosive bulbar duodenitis. The gastric antrum and duodenal bulbar mucosa were biopsied, and the histopathological results showed mild chronic inflammation. A colonoscopy indicated erosive colitis . Pathological examination of mucosal surface tissues of each segment of the colon showed that the mucosa presented mild chronic inflammation, a large number of lymphocytes and eosinophils infiltrated in lamina propria, with a maximum of 85 cells per high power field, and crypt abscesses in the ascending and transverse colon. Next, the neutrophil oxidative burst test was performed using the DHR assay. The DHR assay of the patient’s granulocytes revealed almost absence of fluorescence upon granulocyte stimulation. The stimulation index (SI) was 5.82 which was compatible with X-CGD. The DHR assay of granulocytes from the patient’s mother and the patient’s father showed normal histogram with the SI of 277.05 and 364.03, respectively. Therefore, peripheral venous blood was collected from the patient and her parents for whole exome sequencing analysis. A heterozygous de novo mutation c.388 C > T (p.R130X) in CYBB gene was identified and validated by Sanger sequencing. Based on the above findings, we established a diagnosis of very early onset inflammatory bowel disease (VEO-IBD) with neutrophil dysfunction caused by CYBB gene mutation. Hematopoietic stem cell transplantation (HSCT) was conducted using peripheral blood stem cells (20.47 × 108/kg) from the father of the child. Mycophenolate Mofetil combined with Tacrolimus Capsules were used to prevent graft-versus-host disease (GVHD) and Voriconazole against fungal infections. Two months after HSCT, bone marrow and peripheral blood chimerism rates were 100% complete donor type, DHR assay of granulocytes from the patient at 8 weeks after HSCT showed abnormal histogram with the SI of 28.85, 16 weeks after HSCT showed normal histogram with the SI of 408.90, the normal neutrophil function was restored. A repeat colonoscopy six months after HSCT showed complete intestinal mucosal healing. After 18 months of follow-up, there was no severe infection or acute or chronic GVHD-related manifestations.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_539_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_539_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6bcde4cee22ee43fe8838c5daa3a8e8cbf92214f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_539_en.txt
@@ -0,0 +1,8 @@
+An eight-year-old boy referred to our clinic manifested with pain along with swelling in mandibular incisors for the past one month, especially the past week. No relevant medical, family or psychosocial history was reported. There was no abnormality on extraoral examination. An abnormal coronal anatomy of the bilateral mandibular central incisors was found on intraoral examination. The conical crown had a deep depression with a talon cusp on the conical crown, and caries or restorations were not found in the teeth. There was a giant abscess on the labial gingiva of the left mandibular central incisor, which exhibited pain on vertical percussion and degree II tooth mobility. Concurrently, there was a fistula on the distal and lingual gum of the right mandibular central incisor, which exhibited slightly pain on vertical percussion and degree-I tooth mobility .
+Radiographic examination showed periapical radiolucency exhibiting a scantly defined border, as well as an invagination which had a central invaginated canal extending from the pulp chamber throughout the apical foramen in the mandibular central incisors . This type of anatomy was consistent with a DI Odhlers type IIIb. Although there was no response on the electric pulp vitality test, there were doubts about the dependability of this result due to immature development of the root with an open apex. We performed a CBCT (cone‑beam computed tomography) scan as a complementary examination to acquire more comprehensive anatomic information and an accurate diagnosis. The CBCT images exhibited an invagination of the bilateral mandibular central incisors extending from the crown throughout to the root canal apex; however there was no communication with the main root canal. The apical foramen was incomplete and had a large area of periapical radiolucency of approximately 5.2 × 7.8 mm in the left mandibular central incisor and approximately 4.1 × 6.4 mm in the right mandibular central incisor .
+We diagnosed the case as DI with chronic apical periodontitis. Extraction and orthodontic intervention are important because of the complex root involvement and the uncertain prognosis of conservative therapy. Nevertheless, the patient’s parents hoped to retain the natural teeth. Endodontic therapy was selected as the preferred treatment plan.
+According to the radiographic examination, we found that there was no communication between the invagination and the main root canal. It was postulated that the pain and infection were caused by infection in the invagination, while the main root canal pulp remained vital. Under rubber dam isolation and a dental surgical microscope (Leica M330; Leica microsystems, Wetzlar, Germany), conservative endodontic access into the invagination was made using a small round bur, while the main root canal pulp was not exposed. The orifice of the invagination was confirmed with an endodontic explorer and 15# K-file. No penetration was observed between the invaginated canal and the main root canal. At the same time, the periapical tissues discharged a bloody and purulent exudate. Stainless-steel hand K-files along with nickel-titanium rotary instruments were employed to instrument the invaginated canal; however, with caution not to surpass the length of the canal. In the process, the invagination was irrigated thoroughly with 1.5% sodium hypochlorite solution (NaOCl) and 0.9% saline solution. Moreover, a sonic-activated device was employed to attain a more effective debridement. It was necessary to irrigate the invagination thoroughly due to the complex canal structure. Paper points were employed to dry the invaginated canal, followed by application of paste of calcium hydroxide, and then temporary filling material (Caviton; GC Co., Tokyo, Japan) was employed to seal the access cavity.
+During the second appointment after 2 weeks, the patient felt well, and the fistula on the distal and lingual gum of the right mandibular central incisor had disappeared. The giant abscess on the labial gingiva of the left mandibular central incisor was relieved but not healed. Abundant irrigation using 17% ethylenediaminetetraacetic acid (EDTA) solution was employed to remove the intracanal dressing of the invagination along with the smear layer. Subsequently, copious 1.5% NaOCl and saline with the sonic-activated device were applied. After that, paper points were employed to dry the invaginated canal, which was then obturated with the Vitapex (Neo dental co., Tokyo, Japan). Then we took the radiographic imaging of the teeth to confirm the position of the Vitapex , and GIC (glass ionomer cement) (GlasIonomer FX-II; Shofu Inc, Kyoto, Japan) was used to seal the access cavity.
+At the third appointment after 1 month, the patient felt well, and the right mandibular central incisor had no clinical signs or symptoms. There was still an abscess on the labial gingiva of the left mandibular central incisor, although it was smaller. For the right mandibular central incisor, Vitapex was obturated in the invagination canal to induce root development, and then used GIC and composite resin (Z350; 3M ESPE, St Paul, MN, USA) to seal the access cavity. For the left mandibular central incisor, it was identified that main root canal pulp was infected, and treatment was required. Under local anesthesia utilizing articaine with 1:10,000 epinephrine, small round bur was employed to prepare an endodontic access to the main root canal, and the pulp was found to be necrotic. A stainless-steel hand K-files was employed to simply instrument the main root canal and was irrigated abundantly with 1.5% NaOCl and 0.9% saline solution with a sonic-activated device to obtain more effective chemical debridement. Paper points were used to dry the main root canal, followed by application of calcium hydroxide paste via syringe, and the access cavity was sealed with GIC. At the same time, we replaced the dressing in the invagination with Vitapex .
+At the fourth appointment after three weeks, there were no clinical signs or symptoms of the left mandibular central incisor. 2% mepivacaine hydrochloride (no epinephrine) was used to perform local anesthesia, followed by reaccession of the main root canal. Next, 0.9% saline along with a sonic-activated device were utilized to remove the calcium hydroxide paste. Gentle irrigation of the canal with 17% EDTA solution (20 mL) was performed and followed by drying using paper points. The canal was over-instrumented with a precurved K-file extending 2 mm past the apical foramen, to induce bleeding. The instrument was extended 3–4 mm below the CEJ (cementoenamel junction) to allow formation of a bold clot. We placed an iRoot BP Plus (Innovative BioCeramix, Vancouver, BC, Canada) on top of the blood clot. At the same time, iRoot SP (Innovative BioCeramix) and warm gutta-percha obturation replaced the Vitapex in the invaginated root canal. Then, the tooth was sealed with GIC and was restored using a composite resin. A radiographic image verified the position of the iRoot BP Plus .
+Eighteen months later, there were no clinical signs or symptoms of the mandibular central incisors. According to the radiographic image, the open apex was closed, and the root continued to develop. Therefore, iRoot SP and warm gutta-percha obturation replaced the Vitapex in the invaginated root canal of the right mandibular central incisor, and then the tooth was finally restored with composite resin .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_545_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_545_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0f71b0ae7738d6ef6a26ec8f28162419c78aeae0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_545_en.txt
@@ -0,0 +1,5 @@
+A 67-year-old healthy woman was referred to the division of thoracic surgery at our hospital for an abnormal shadow detected during a regular annual medical check-up. The abnormal shadow was not apparent on the chest radiogram performed 7 years ago before this visit . A series of previous chest radiograms showed protrusion of the left 3rd arch that had progressed in size over the past 4 years. Computed tomography (CT) image taken 2 years prior to this visit for close examination of the protrusion showed a 4-cm mass ( and ), although it was not noted by the physicians. She did not experience angina, either at rest or with exertion, or other symptoms. Her medical history was unremarkable from a cardiovascular perspective. Computed tomography revealed a mass ∼5 cm in size in the mediastinum bordering the left side of the pulmonary artery, suspicious for lymphoma, neurogenic tumour, or germ cell tumour. Positron emission tomography-CT demonstrated negative uptake of 18F-FDG. The inside of the mass showed contrast enhancement equivalent to that of a blood vessel and thrombus formation, suggesting an aneurysm. The patient was referred to the Division of Cardiology.
+The physical examination results were normal. No abnormalities were observed in the blood tests, e.g. troponin I, 3.3 pg/mL (normal <70 pg/mL). Transthoracic echocardiography revealed a large mass connecting to the left anterior descending artery (LAD). Blood flow into the mass cavity was detected, suggesting a coronary artery aneurysm. Coronary flow velocity by transthoracic Doppler echocardiography demonstrated a dominant systolic component at the left main coronary trunk proximal to the fistula and inside the mass, suggesting a steal phenomenon. . The left ventricular wall motion was normal, and the ejection fraction was estimated to be 72%.
+A 64-slice coronary CT angiography revealed a giant coronary aneurysm with coronary fistula (48 × 45 × 55 mm), with internal homogeneous contrast enhancement on arterial phase and thrombus formation, connected to the mid-portion of the LAD . The aneurysm branched into a tortuous vessel connected to the main pulmonary artery. Another fistula from the proximal portion of the right coronary artery (RCA) drained into the left atrium and the main pulmonary artery.
+Adenosine triphosphate stress myocardial perfusion scintigraphy identified reversible perfusion defects in the anterior wall, representing myocardial ischaemia in the territory of the LAD . Conventional coronary angiography confirmed a giant aneurysm originating from the LAD, to which blood flow was supplied during systole . The aneurysm outflow was obscured due to the dilution of the contrast dye by the large aneurysmal sac. Other anomalous vessels started from the proximal portion of the RCA , as shown by CT. No occlusive atherosclerotic lesions were observed. Mean pulmonary artery wedge pressure and pulmonary artery pressure were measured to be 9 and 23/9/14 mmHg (systolic/diastolic/mean), respectively. The Qp/Qs ratio was calculated to be 1.2.
+Because of the risk of rupture due to progressive enlargement of the aneurysm and the presence of ischaemia, the patient was immediately transferred to the cardiac surgery department without receiving additional medical treatment other than bisoprolol. The patient underwent elective surgery via median sternotomy and cardiopulmonary bypass. The fistula vessel between the proximal RCA and the main pulmonary artery was ligated. A 50-mm aneurysm was identified in the fistula vessel originating in the LAD and incised; a mural thrombus largely occupied it. Inflow path from the LAD was ligated. Two outflow vessels were identified and ligated; one connected to the main pulmonary artery, the other had not been detected during preoperative imaging tests. The aneurysm was resected, and subsequently, a left atrial appendage closure was performed due to paroxysmal atrial fibrillation detected during her hospitalization. The patient recovered uneventfully, except for a transient atrial fibrillation, and was discharged from the hospital. Edoxaban and bisoprolol were administered for 3 and 7 months, respectively. The patient has been in good health, and no cardiovascular events were reported for 10 months since her discharge.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_550_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_550_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6184a3603218c77094b9dd2229e9497b9ec364b5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_550_en.txt
@@ -0,0 +1,2 @@
+A 28-year-old Togolese woman of Ewe ethnic origin working part-time in a prison setting with no previous history of disease was admitted in August 2017 for left hemibody sensory problems with ataxia. These problems were observed while the patient was hospitalized for a few days in the hepato-gastroenterology (HGE) department. She had been referred to the HGE department for vomiting, abdominal pain and persistent hiccups lasting for about a month, which were thought to be due to gastritis with multiple ulcers based on a digestive endoscopy. Prior to admission to the HGE department, she initially received anti-ulcer and antiemetic drugs, but the outcome was marked by persistent vomiting and the appearance of episodes of prolonged loss of consciousness. Before the appearance of digestive problems, the patient presented with headaches and auditory and visual hallucinations due work-related stress. The examination also confirmed the existence of evening fever, weight loss without cough and secondary amenorrhea unrelated to pregnancy.
+On day 1 of neurological problems, an examination confirmed the persistence of digestive symptoms, apyrexia, the existence of a headache, left hemibody ataxia with nystagmus when looking to the left, pronounced left osteotendinous reflexes, and left hemibody hypoesthesia up to the base of the neck. Encephalic magnetic resonance imaging (MRI) showed a hypersignal lesion in the bulbar more lateralized on the left in the fluid-attenuated inversion recovery (FLAIR) sequence not enhanced after a gadolinium injection . The infectious assessment showed a normal pulmonary X-ray, a negative human immunodeficiency virus (HIV) serology, negative plasmodium tests but the presence of Mycobacterium tuberculosis deoxyribonucleic acid (DNA) in the cerebrospinal fluid (CSF) (using GeneXpert) with normal cytochemistry and a sedimentation rate (SR) of 120 mm in the 1st hour. The pregnancy test was negative. On day 3 of the neurological problems, digestive problems subsided, and even though the results of the examinations were not yet compiled, the patient presented three episodes of cardiopulmonary arrest with a fever of 39 °C without an infectious contact point. She successfully benefitted from orotracheal intubation with broad-spectrum antibiotic treatment and intravenous corticosteroids in the intensive care unit. In the presence of the digestive symptomatology with a bulbar lesion, we alluded to an APS within the framework of an NMOSD, and a sample for the anti-AQP4 antibody tests was sent to Paris, France. Upon leaving the intensive care unit after 72 h, anti-tuberculosis treatment was established. The outcome was favorable with apyrexia, a modification in the nystagmus and an improvement in the ataxia. Subsequently, the result of the anti-AQP4 antibody test was positive (indirect immunofluorescence on transfected cells, anti-AQP4 Euroimmun reagent, CERBA file No. 17 T0483884 of 01/09/2017). In September, 2 months from the onset of digestive problems, with Lhermitte’s sign and hand and foot contracture access without vesico-sphincter problems were established. At the neurological examination, the osteotendinous reflexes were pronounced. Cervical medullary MRI showed an additional intramedullary hypersignal lesion in the T2 sequence at the C2 level without contrast enhancement after a gadolinium injection . In addition to the symptomatic treatment of spasticity, a second course of intravenous corticosteroids was administered, and anti-tuberculosis treatment was continued. The outcome was favorable, and the patient resumed her usual activities as of February 2018, which was 8 months after the first onset. After 8 months of anti-tuberculosis treatment, the patient was started immunosuppressive therapy (azathioprine 50 mg twice daily) to limit the risk of recurrence of NMOSD.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_553_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_553_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..44541dbf793a52320ef490174db7750d75624e46
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_553_en.txt
@@ -0,0 +1,4 @@
+This 77-year-old man with a medical history including coronary artery disease and dysrhythmia presented to the neurosurgery clinic after months of evaluations for repeated episodes of presyncope and at least four syncopal events, where the patient was found unconscious or had awoken on the ground after presumably losing consciousness. The patient reported these symptoms and events were preceded by turning his head to the right. In some instances, the patient reported double vision in conjunction with the presyncopal symptoms.
+On physical examination, the patient was neurologically intact. He was able to reproduce the symptoms with head rotation of approximately 45° to the right. As a matter of safety, these assessments were performed in short intervals as to not elicit a full syncopal event. Diplopia was not detected. A CT angiogram (CTa) of the head and neck demonstrated osseous changes consistent with cervical DISH as well as a “fang”-like osseous elongation of the right C5 lateral mass, which protruded into the vertebral foramen and compressed the VA . A catheter-based cranial and cervical digital subtraction angiogram (DSA) demonstrated approximately 74% stenosis of the right VA at C5 in the neutral position, which progressed to full occlusion with right head rotation . In addition, the patient was found to have a left VA which ended in an ipsilateral posterior inferior cerebellar artery without joining the right VA.
+A C4–5 anterior cervical discectomy and fusion (ACDF) was performed under general endotracheal anesthesia. The traditional Smith-Robinson approach to the cervical spine was employed and special care was taken not to injure the esophagus, which had been displaced to the right of the cervical spine by large hyperostotic osteophytes. In addition to the C4–5 discectomy, partial osteophyte removal was required at C5 to allow for the plating system to lay flat. A structural allograft and low-profile titanium plating system was used to complete the surgery.
+The patient tolerated surgery well and was discharged on postoperative day 1. He had an uneventful recovery and reported complete resolution of his symptoms with head rotation. Approximately 9 months after surgery, the patient underwent a repeat CTa and DSA as part of an evaluation for cardiac dysrhythmia. The CTa demonstrated blunting of the osseous growth at C5, and the DSA showed no evidence of VA compression in the neutral or dynamic positions .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_558_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_558_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..aed5c2df1422a1c4468fef9cbb0dcaba087670c2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_558_en.txt
@@ -0,0 +1,9 @@
+A 37-year-old Hispanic woman without a significant past medical history presented to our hospital with a one week history of shortness of breath, which had acutely worsened over the past few days. She stated that she required two pillows to breathe while lying down. She also stated that she could no longer work at her childrens' day care center, as even walking at a relaxed pace for more than two minutes would cause her to be short of breath, although the shortness of breath would improve with rest. She also complained of a nonproductive cough for two days before admission. She denied any trauma, chest pain, palpitations, nausea and vomiting, diarrhea, abdominal pain, or fevers. Review of systems was remarkable for a one month history of bilateral lower extremity edema.
+She denied any significant past medical history and had not been taking any medication before hospital admission. She remotely recalled that her last physician, whom she had not seen in the previous eight years, had mentioned to her that she might have hypothyroidism, but this was not further investigated. She denied use of tobacco, alcohol, or any other recreational drugs.
+Physical examination revealed an obese, pale woman in mild distress from shortness of breath, but able to speak in full sentences. Her vital signs on arrival showed an oral temperature of 36.8°C, heart rate in the range of 81 to 93 beats per minute, blood pressures ranging from 140 to 173 mm Hg systolic and 94 to 121 mm Hg diastolic. Her breathing was 18 to 22 times per minute, with a digital pulse oximetry saturation of 86% while breathing air, which subsequently improved to 92% when she was given oxygen therapy via a face mask. Her neck examination showed no nodular thyroid or thyroid masses. There was no lymphadenopathy. Dullness to percussion was found over the lower portion of her left hemithorax, accompanied by decreased vocal fremitus, as well as decreased breath sounds on auscultation. The chest examination was normal over her right hemithorax. Cardiac examination revealed no murmurs, rubs, or gallops, but heart sounds were generally distant. Abdominal examination was unremarkable, with no signs of ascites or masses. Lower extremities revealed 2+ pitting edema to the level of the knees bilaterally.
+Her electrocardiogram showed low voltage throughout all leads with no other ST-segment or T-wave abnormalities. A chest radiograph showed an enlarged cardiac silhouette and bilateral pleural effusions, with more fluid on the left than on the right. A computed tomography (CT) angiogram of the chest did not reveal pulmonary thromboembolism and confirmed the presence of a large left pleural effusion with associated compressive atelectasis, as well as a moderate pericardial effusion .
+Admission laboratory values demonstrated a leukocyte count of 6.3 × 109/L (normal, 3.5 to 11.0 × 109/L) with a hematocrit of 36% (normal, 36% to 46%). A chemistry panel was remarkable for a creatinine of 1.4 mg/dL (124 μmol/L; normal, 44 to 106 μmol/L). Troponin T cardiac enzyme was slightly elevated at 0.02 μg/L (normal, <0.01 μg/L), and beta-natriuretic peptide was elevated at 1325 ng/L (normal, 0 to 450 ng/L). Urine alaysis was significant for 2+ protein. A fasting lipid panel showed a total cholesterol of 179 mg/dL (4.64 mmol/L; normal, 3.65 to 5.15 mmol/L); triglycerides, 186 mg/dL (2.10 mmol/L; normal, <1.70 mmol/L), HDL, 25 mg/dL (0.65 mmol/L; normal: >1.01 mmol/L), and an LDL of 117 mg/dL (3.03 mmol/L; normal, 1.55 to 3.34 mmol/L). The liver panel showed a total protein of 7.0 g/dL (70 g/L; normal, 60 to 80 g/L) and albumin at 3.3 g/dL (33 g/L; normal, 35 to 50 g/L) with normal transaminases. Lactate dehydrogenase (LDH) was 302 U/L (normal, 112 to 220 U/L). Given her complaints of fatigue, a check of thyroid-stimulating hormone (TSH) and a free T4 levels were also carried out. The results of those tests showed the her TSH to be 181.90 mIU/L (normal, 0.27 to 4.2 mIU/L) and her free T4 to be <0.1 ng/dL (<1.29 pmol/L; normal, 0.9 to 1.7 pmol/L).
+Thoracentesis on hospital day two revealed cloudy yellow fluid with 129 × 109/L white blood cells (23% neutrophils, 23% lymphocytes, 54% monocytes); a lactate dehydrogenase (LDH) level of 170 U/L, with a pleural fluid LDH-to-serum ratio of 0.56; a protein level of 5.6 g/dL (56 g/L), with a pleural fluid protein-to-serum ratio of 0.8; albumin of 2.8 g/dL (28 g/L); cholesterol of 81 mg/dL (2.10 mmol/L), with a pleural fluid cholesterol-to-serum ratio of 0.5; and triglycerides of 442 mg/dL (4.99 mmol/L), with a pleural fluid triglycerides-to-serum ratio of 2.4. These findings were thought to be compatible with an exudative chylous effusion. A 10-French chest tube was placed by our interventional radiologists the fourth day of her hospitalization. A follow-up chest CT after drainage of the effusion performed the seventh day of hospitalization showed a nonspecific retrocrural density that our radiologists thought to be compatible with swelling or inflammation related to her myxedema.
+To investigate the etiology of her chylous effusion, she underwent nuclear medicine lymphatic scintigraphy on the following day to look for possible thoracic duct injury. The study showed normal tracer uptake throughout the lymphatic system without any evidence of accumulation to suggest leakage or trauma.
+She was prescribed levothyroxine, 100 μg, slowly escalating to 150 μg orally per day for treatment of her hypothyroidism, along with a low-fat diet, and over the course of two weeks, her chest-tube drainage progressively decreased , and her fatigue and dyspnea subjectively improved. Her antithyroid peroxidase antibody was found to be elevated at 97.1 kIU/L (normal, <40 kIU/L), compatible with autoimmune thyroiditis. The chest tube was removed after ten days, and she was discharged home.
+At two and three month follow-up visits, her fatigue had significantly improved, and she had returned to regular employment. Her TSH achieved a normal level (1.35 mIU/L; normal, 0.27 to 4.2 mIU/L). Follow-up chest radiographs and CT studies at two, three and six months showed near-complete resolution of the left chylous effusion, with complete resolution of the mild pericardial effusion. The retrocrural density seen on earlier CT studies has remained unchanged. At one year follow-up, no recurrence of her pleural effusion or clinical signs of malignancy have occurred.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_560_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_560_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cfa35e19a00e762d7a41197f10bb2ca45ccbd24f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_560_en.txt
@@ -0,0 +1,3 @@
+A 83-year-old lady with a BMI of 32 presented to us with a history of fall at home. Radiographs showed left-sided intertrochanteric femur fracture (AO 31A2.1) with marked osteopenia (Singh’s index Grade 3) . She was operated with TFNA Depuy (Dimension 11 x 200 mm and helical blade of 80 mm). An acceptable reduction of the fracture and stable fixation was achieved intraoperatively . The position of the helical blade in the head was in the optimal position (center–center) assessed as per Cleveland index . Tip apex distance (TAD) was found to be 29 mm, assessed in magnification controlled anteroposterior view and lateral view as per the Baumgartner’s method . Neck-shaft angle measured after fixation was 132.1o and the normal side was 131.4o . The patient was mobilized partial weight-bearing with the help of walker from the next day of surgery.
+She presented to us 6 weeks after the surgery with severe acute onset pain in the left hip, along with inability to bear weight. There was a history of fall at home. Radiographs showed implant failure (cut through of the helical blade) . Laboratory investigations ruled out infection. The patient was planned for implant removal and bipolar hemiarthroplasty.
+Posterior approach was used and the previous incision was incorporated. Intraoperative samples were sent for culture and histopathology. Cemented bipolar hemiarthroplasty with calcar reconstruction using a mesh was performed as the calcar was deficient . The patient was mobilized full weight-bearing from the same day of surgery with the help of walker. All intraoperative samples sent, which were negative. The patient was followed up at 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and till her last follow-up of 14 months. At each follow-up visit, the patient was assessed clinically and radiologically. Clinically, the patient was asymptomatic at her last follow-up visit and was mobilizing full weight-bearing without any support. Radiologically, there was no sign of loosening or radiolucencies.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_563_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_563_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6d7a94fc208c492dd5be58a00290db104e9e5678
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_563_en.txt
@@ -0,0 +1,8 @@
+The patient was a 55-year-old and was referred to our practice for anal cancer screening.
+The patient had no known history of present illness.
+The patient has been living with human immunodeficiency virus (HIV) for 17 years.
+He had no gastrointestinal or anorectal symptoms and his physical examination was positive only for a three millimeter, smooth, flesh colored papule at the anal margin .
+His cluster of differentiation 4 (CD4) count was 2200 cells/mm3, with a nadir of 1300 cells/mm3. His HIV viral load was undetectable. Anal cytology collected at this visit was benign.
+Digital anorectal examination and high resolution anoscopy (HRA) were otherwise normal.
+The differential diagnosis included molluscum contagiosum, anal condyloma, and basal cell carcinoma. To obtain a definitive diagnosis, the anal margin lesion was excised in the office, using local anesthetic.
+Upon examination of the specimen, the lab determined the patient had EA.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_572_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_572_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..73b2d37aae2f39f3c57b2f65420e1b5e045fb38a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_572_en.txt
@@ -0,0 +1,4 @@
+A 47-year-old man was referred to our hospital with a 3-month history of abdominal distension, intermittent abdominal pain and nausea. Despite weight loss of 4 kg, the patient had no symptom of fever, chronic cough or night sweats. He had no history of abdominal surgery, liver cirrhosis or chronic hepatitis virus infection, but suffered from tuberculous pleurisy about 20 years ago. Physical examination revealed gross abdominal distension without tender and ascites of unknown aetiology. Laboratory blood analyses including serum tumor markers, erythrocyte sedimentationrate (ESR), adenosine deaminase activity (ADA) and anti-tuberculosis antibody (TB-Ab) were all within normal limits, and tuberculin skin test was negative. The results of antibody testing for HIV were negative. Chest radiograph did not demonstrate features suggestive of pulmonary tuberculosis. Plain upright abdominal X-ray showed some air in the colon without presence of air fluid levels in the loops or free gas under the diaphragm . Contrast-enhanced computed tomogram (CT) of the abdomen revealed dilatation of the duodenum loops (*) and congregated small gut loops (black arrowhead) trapped in the massive ascites surrounded by a membrane (white arrowhead). Gastroscopy revealed no signs of malignancy. A peritoneal tap was performed twice and yielded blood stained ascitic fluid but no malignant cells or acid-fast bacilli. The ascities was exudates in nature and ascities ADA was within normal ranges. The patient refused laparoscopy examination and was discharged without a definitive diagnosis and further treatment.
+Two months later, the patient was presented to our hospital again with persistent symptoms. Despite abdominal distension, nausea and vomiting, he also complained of increasing fatigue, emaciation, and 10-kg weight loss for the recent two months. Laboratory blood analyses revealed that serum ADA was 21 U/L (normal range 4–18 U/L), ESR was 28 mm/h (normal range 0–15 mm/h), but TB-Ab was negative. Ascitic fluid obtained by paracentesis was still negative for bacteria, acid-fast bacilli and malignant cells, but ascities ADA was significantly elevated (41 U/L). Serum CA-125 was also significantly elevated (97.39 U/ml, normal range < 35 U/L). In addition, despite the presence of well-encapsulated fluid collection and central accumulation of the small intestine , CT scan also revealed smudged appearance of the greater omentum , as well as multiple small nodules and sheetlike lesions on the parietal peritoneum , which the radiologists considered to be peritoneal carcinomatosis (PC). Mesenteric lymphadenopathy was not observed on CT scan. The presumptive diagnosis was PC or tuberculous peritonitis in our patient, however, other differential diagnosis, such as peritoneal mesothelioma, could not be completely ruled out.
+Diagnostic laparoscopy was performed in our patient, and the entire small bowel was found to be encapsulated in a dense, white, fibrous, cocoon-like membrane filled with a large amount of brownish ascites . Multitudinous miliary nodules or tubercles were seen on the parietal peritoneum and greater omentum. Biopsy of the nodules and plaques revealed caseous granulomatous inflammation and the specimen were stained positive for acid-fast bacilli. Histopathology of the cocoon wall revealed fibrocollagenic tissue with granulomatous inflammation, and culture of the biopsied specimen grew Mycobacterium tuberculosis 3 weeks later. A diagnosis of tuberculous abdominal cocoon was made. Complete excision of the thick membrane and lysis of adhesions were tried but failed due to the extreme difficulty in separating the fibrotic tissue from the abdominal wall and small bowel. Since there were no perforated, ischemic or dilated bowel loops, the operation was completed after obtaining samples for diagnostic biopsy.
+After operation, the patient had recurrent episodes of partial bowel obstruction that was resolved with conservative management. The patient was given rifampicin, isoniazid, ethambutol, and pyrazinamide for 2 months, followed by rifampicin and isoniazid for 4 months. By the end of the 2 month of anti-tuberculous therapy, serum ADA, ESR and CA 125 levels have returned to normal. Though a repeat CT scan of the abdomen and pelvis continued to show the small bowel wall thickening and membrane covering the small bowels , and gastrografin meal follow through study revealed adherent small bowel loops with delayed transit time , however, the ascites has greatly diminished and the patient was functioning normally. No further surgical intervention was planned for him, and he was followed up symptom-free for 6 years.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_574_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_574_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4e5a1fd58f0929751d407409df82a4b6b6398398
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_574_en.txt
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+A 68-year-old male presented with entire body burns. He tried to commit suicide by burning himself on the riverbed, and covered his head with 10-liters of gasoline and set himself on fire. He had a history of insomnia and anxiety. He had no history of allergic responses and no smoking history. Vital signs on admission were as follows; Glasgow Coma Scale 15 points, body temperature 35.8°C, heart rate 98 bpm, blood pressure 170/85 mm Hg, respiratory rate 20 bpm, and oxygen saturation 100% with 10-liter mask. Erythema and bullae were observed on the auricular to mandible neck, thorax, abdomen, occiput, right upper arm, right dorsal hand, and left forearm. His anterior chest and posterior neck were covered with soot, and the skin in these areas had turned a grayish white . Soot was observed in the nasal and oral cavity, pharynx, and larynx, suggesting burn of the upper respiratory tract. Bronchoscopy showed soot adhesion, peripheral edema, and mucosal redness from the vocal cords to the period. Total burn surface area was 35%, which included 20% second-degree burns and 15% third-degree burns. The revised BAUX score was 120.
+An overview of the hospital is shown in Figure . The burn-site was washed daily with warm water, treated with dimethyl isopropylazulene and gentamicin sulfate ointment and protected with moist wound care pads. At the time of admission, the guarantor's approval was not obtained, which prevented aggressive initial burn treatment such as debridement and skin grafting.
+On day 8, he had a high fever of 38°C–40°C with a markedly increased inflammatory response, and the blood culture revealed methicillin-resistant Staphylococcus aureus. Vancomycin and ampicillin/sulbactam were administered empirically against the burn-site infections. After the infections were under the control, the first split-thickness skin grafts (STSG) were performed on day 17 in the operating room. The skin grafts (0.01 inch graft) were harvested from the healthy skin on both thighs by using electric dermatome and meshed for expansion at the ratio of 1:3. After the first debridement and STSG on day 17, ampicillin/sulbactam was discontinued because of the appearance of erythema mainly on the lateral abdomen and suspected drug rash. Cefepime dihydrochloride hydrate was driven to start because acinetobacter baumannii was detected from a blood culture on day 20. Because the burn-site infections had been continuously manageable, the second STSG for the back area was performed on day 24. The skin was harvested from both lateral thighs and meshed at a ratio of 1:1.5.
+From day 30, the redness on the trunk and extremities rapidly worsened, and some blistering was observed. We diagnosed as erythema multiforme because of drug eruption, then all antimicrobial agents were terminated. Because the erythema multiforme did not improve after the discontinuation of antimicrobial therapy, systemic administration of 40 mg/day prednisolone was initiated. However, on day 35, the erythema expanded and erosions and blisters formed on more than 30% of the body surface area. Nikolsky phenomenon and oral mucosal lesions were observed, especially on the back and extremities . Because erythema, blisters, and erosions were widely distributed and exceeded 10% of the body surface area with a fever above 38°C, we diagnosed the case as TEN and initiated steroid-pulse therapy (methylprednisolone 1,000 mg/day) for 3 days. This treatment was successful and the erosions and blisters gradually improved without any exacerbation of infection. On day 37, the erythema began to fade . On day 38, we switched the steroids therapy to oral prednisolone 60 mg/day. Prednisolone was tapered by 10 mg every week. No signs of infection was observed after discontinuation of antimicrobial therapy and steroid pulse therapy, and he discharged from ICU on day 41.
+Thereafter, an additional debridement for the anterior thoracic region on day 59, STSG for anterior neck, shoulder, and thoracic (from lower abdomen skin) on day 73, and STSG for lateral neck (from posterior aspect of both thighs) on day 87 were performed under general anesthesia . After debridement and skin grafting for a total of five times, he was transferred to a general hospital on day 140. Lymphocyte stimulation test of the antibiotics used was performed to search for the cause of TEN, but it could not be identified.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_620_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_620_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3e4a317addcb8bfcad78d13bc49b993d6bf8fe5f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_620_en.txt
@@ -0,0 +1,10 @@
+A 59-year-old hypertensive white female was diagnosed with CLL in 2009. Informed consent was obtained from the patient for being included in the study.
+Chemotherapy with fludarabine was initiated 3 months earlier and corticotherapy with methylprednisolone 2 months earlier for hemolytic anemia secondary to fludarabine treatment. The patient presented with a 24 h history of confusion, agitation, and mild right-lower extremity weakness.
+Physical examination was notable for grade 1 obesity and subfebrility (99.32 ºF; 37.4 ºC).
+Neurological examination revealed a grade 4 right-lower extremity weakness with reflex asymmetry and right-sided Babinski sign. No signs of meningeal irritation were detectable.
+Laboratory findings included: white blood cell (WBC) count of 3.5 × 103/μL; hemoglobin 7.1 g/dL; hematocrit 21.5%; platelets 109 × 103/μL; aspartate aminotransferase 59 U/L; alanine transaminase 79 U/L. Serum glucose, urea nitrogen, creatinine, bilirubin, sodium, and potassium were normal.
+Cerebral computed tomography (CT) scan revealed a hypodense lesion in the left frontal lobe suggestive of an ischemic stroke .
+During the second day after admission, the patient developed fever (101.12 ºF; 38.4 ºC) and neurological examination revealed signs of meningeal irritation (positive Kernig’s sign).
+Cerebral magnetic resonance imaging (MRI) revealed a hyperintense lesion in the left frontal lobe with extension toward the basal ganglia (T2 and Fluid-Attenuated Inversion Recovery [FLAIR] sequences) , and small nodular enhancing lesions after gadolinium infusion in the affected territory .
+Lumbar puncture was performed on the second day and the CSF analysis revealed the following abnormalities: red blood cells (RBCs) 24 cells/mm3; WBCs 829 cells/mm3 (76% lymphocytes, 22% neutrophils, 2% monocytes); protein level 111.2 mg/dL; glucose level 10.2 mg/dL (serum glucose 86 mg/dL). CSF and blood samples were sent to laboratory for culture. Empiric anti-infection treatment was started with intravenous (i. v.) ceftriaxone, ciprofloxacine, aciclovir, and fluconasole. The neurological status of the patient was unchanged 2 days after the initiation of anti-infection therapy and the patient presented septic fever. CSF examination was negative for fungal infections, Mycobacterium tuberculosis, and JC virus. Both blood cultures and CSF cultures were positive for L. monocytogenes. The microbial identification was performed with Vitek 2 automated analyzer system (bioMérieux, Marcy l’Etoile, France). The culture was not verified by molecular methods. The serotype of L. monocytogenes was not determined. There was no history of consumption of high-risk foods for L. monocytogenes infection (such as soft-cheeses made with unpasteurized milk, frankfurters, sliced deli meats, etc.) in the past 10–14 days. The infection was not associated with any known food outbreaks.
+The diagnosis of Listeria meningoencephalitis was established and antibiotic therapy with ampicillin was started (12 g/day). Forty-eight hours after the initiation of antibiotic treatment with ampicillin, the patient was afebrile with significantly improved neurological status. CSF analysis after 1 week of treatment revealed: RBCs 0 cells/mm3; WBCs 80 cells/mm3; protein level 73 mg/dL; glucose level 49 mg/dL (serum glucose 90 mg/dL). One month later, the neurological examination of the patient was normal.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_625_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_625_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..efba0d7a464dec1665bd14f00aaa3b08d396ea64
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_625_en.txt
@@ -0,0 +1,4 @@
+A 77-year-old women, gravida 4, parity 4, presented with a 7-month history of vaginal bleeding. She had a clinical history of total abdominal hysterectomy due to multiple uterine leiomyomas 40 years ago and she had vaginal vault prolapse for 13 years with no history of pessary use. Her medical history included hypertension and ischemic heart disease. Physical examination revealed manually reducible stage 4 vaginal vault prolapse according to the POP quantification system , with an infiltrating 1-2 cm mass between the upper and middle third of the posterior vaginal wall. There was no parametrial invasion, pelvic wall involvement, or inguinal lymph node metastases .
+A magnetic resonance imaging (MRI) scan revealed tricompartmental (cystocele, enterocele, and vaginal vault) POP, but no visible tumor . Positron emission tomography/computed tomography (PET/CT) revealed high F-18 fluorodeoxyglucose (FDG) uptake in the primary vaginal mass (SUVmax, 16.37) without any evidence of metastases to the lymph nodes or other organs . Incisional biopsy from the lesion was reported as squamous cell carcinoma of the vagina.
+She had primary vaginal cancer staged as FIGO stage II, and definitive CRT was planned . External beam radiotherapy (EBRT) was given in 28 fractions of 1.8 Gy via intensity-modulated RT (IMRT) technique, with concurrent 6 cycles of 40 mg/m2 weekly cisplatin . The primary clinical target volume (CTV) included gross tumor volume (GTV), which was expanded by 1-2 cm margin, entire length of the vagina, and paravaginal tissue. The lymphatic CTV contained the external iliac, internal iliac, presacral, obturator, and inguinal lymph node regions. The CTV was expanded by 1 cm to form planning target volume (PTV). Bladder, rectum, sigmoid colon, and bowel were delineated as organs at risks (OARs). Before EBRT, silicone ring pessary without central support diaphragm (size 3, 2.50” 64 mm) was placed into the vagina to help reposition and support the prolapsed vagina, to immobilize the radiation field, and to reduce prolapse symptoms . The pessary was left in place until EBRT was completed. At the end of the EBRT, the pessary was removed. Vaginal examination revealed a complete response . After clinical confirmation of complete response, high-dose-rate (HDR) CT-guided vaginal cuff BT was performed, with a dose of 26 Gy in 4 fractions prescribed to the full thickness of the vaginal wall . Total (EBRT + BT) biologically equivalent dose in 2 Gy fractions (EQD2) were calculated with α/β = 10 Gy for tumor and α/β = 3 Gy for late-responding tissues using the linear quadratic model . The total cumulative doses were as follows: primary CTV = 85.3 Gy, rectum D2cm3 = 69.9 Gy, sigmoid D2cm3 = 57.5 Gy, bladder D2cm3 = 76.9 Gy.
+Treatment was well tolerated. During CRT, grade 3 hematologic toxicity was observed and treated with blood transfusions. Grade 2 dermatitis in the vulva was observed at the end of treatment and was treated with topical agents . The patient had no severe complaints other than mild vaginal pain. At 3-months follow-up, although vaginal examination showed complete response , PET/CT revealed high F-18 FDG uptake in the region of primary vaginal mass (SUVmax, 5.7) compatible with partial response . A biopsy was performed to exclude recurrence or residual disease and the complete response was confirmed. She is still alive without disease at 10-months follow-up. However, the patient experienced symptoms like vaginal dryness, itching, and burning possibly due to POP and vaginal atrophy. She refused to undergo prolapse surgery consisting of sacrocolpopexy. Ring pessary was placed again into her vagina, and topical estrogen cream was prescribed to alleviate her complaints and to maintain a healthy vaginal epithelium.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_630_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_630_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..64ad0f68b4a765dd6b8a113185e04940c7a19bf6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_630_en.txt
@@ -0,0 +1,5 @@
+A 6-year-old Greek boy was referred to our hospital with acute abdominal pain, fever, and vomiting that had started 30 h earlier. On presentation, he was hemodynamically stable and well-hydrated. His abdominal examination revealed right lower quadrant pain on palpation and a positive McBurney sign with signs of peritoneal irritation. His hemoglobin was 12.2 g/dl (normal range 12–15 g/dl), his hematocrit was 34.6 % (normal range 36–44 %), his mean corpuscular volume was 72.7 (normal range 77–89), his mean corpuscular hemoglobin was 24.7 (normal range 25–31), his leukocyte count was 15,110/μl (normal range 5000–13,500/μl), his platelet count was 279,000/μl (normal range 200,000–400,000/μl), and his C-reactive protein level was 3.81 mg/dl (normal range <0.51 mg/dl). His electrolyte and coagulation profiles were within normal ranges.
+As the boy’s history and physical examination referred to acute appendicitis, ultrasound was performed. Ultrasonography showed a well-defined, hypoechogenic solid mass measuring 6 × 2 cm in the right iliac fossa . Other abdominal structures, including the appendix, liver, and kidneys, were normal. Because of the complex nature of the lesion, computed tomography was also performed. A computed tomographic scan showed a solid mass measuring 6 × 2.4 cm in the right abdomen. The mass was in contact at one end with the ascending colon and at the other end with the small bowel . Imaging findings excluded the presence of acute appendicitis or Meckel’s diverticulum. Emergency laparoscopic exploration was performed using a 10-mm trocar placed in the umbilicus with two accessory trocars in the left and right lower quadrants (5 mm). A pediculated solid mass attached to the antimesenteric edge of the ileum and 8 cm proximal to the ileocecal valve was found. It was covered by inflammatory omentum. It appeared ischemic due to torsion at the level of the pediculated attachment to the ileum. The inflammatory part of the omentum covering the mass was laparoscopically resected free, and the mass with the adjacent ileal loop was exteriorized through a circumbilical incision at the site of the umbilical opening and easily separated from the ileal edge . The ileal wall was normal .
+The histopathologic diagnosis was made by using hematoxylin and eosin-stained slides and immunohistochemistry. The histological examination revealed a circumscribed mesenchymal myofibroblastic lesion with a focal mesothelial lining and a considerable vascular component showing excessive hemorrhage and heterogeneous ischemic necrosis. The lesion was composed of clustered and dispersed fibroblastic spindle cells with eosinophilic cytoplasm and a nucleus with fine chromatin without any considerable nuclear atypia or mitotic activity. Characteristic features were the myxoid configuration of the lesion, the variable hyalinization, and the moderate inflammatory infiltrate composed mainly of plasma cells and lymphocytes.
+Immunohistochemistry of the spindle cells showed focal expression of desmin (clone D33), cytokeratins 8 and 18, and pan-keratin AE1/AE3, while there was no detection of smooth muscle actin (SMA), myogenin/Myf-4, CD34, S100, c-kit/CD117, epithelial membrane antigen, β-catenin, Bcl-2 protein, melanosome-associated antigen/HMB45, or anaplastic lymphoma kinase (ALK)-1/p80. Although the described immunophenotype is not entirely diagnostic of a specific entity, it may be encountered in OMMH, which is considered a variant of IMT, though this is a subject of debate.
+The patient’s laboratory values improved dramatically after surgery, and he had an uneventful postoperative course. He was discharged from the hospital on the fourth postoperative day. No evidence of recurrence was noted during 2 years of follow-up, and the patient remains under clinical surveillance.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_631_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_631_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8124ad66f5f6add688d73384081b8b99ffe700bf
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_631_en.txt
@@ -0,0 +1,3 @@
+A 57-year-old woman 16 years of post-heart transplant presented in January 2017 with several weeks of back and chest pain, shortness of breath, vomiting, generalized fatigue, and 10 pound weight gain. Her post-transplant course had been uneventful, and she had been treated with mycophenolate mofetil (MMF) and cyclosporine since transplant. Her last protocol-driven screening biopsy 12 years prior to presentation demonstrated 1B rejection. Three months prior to her presentation she had a routine exercise nuclear stress test suggesting normal graft function. Her most recent screening coronary angiogram in 2008 showed no coronary artery disease.
+On exam heart rate was 110 b.p.m., with blood pressure 115/78 and she had pulmonary and peripheral oedema. Laboratory testing revealed mildly elevated LDH and troponin-I levels, significantly elevated N-terminal prohormone of brain natriuretic peptide levels (3763 pg/mL, normal 0–100 pg/mL), while other lab studies were unremarkable. An electrocardiogram revealed no ischaemic changes. A transthoracic echocardiogram demonstrated intact biventricular function without wall motion abnormalities, but increased left ventricular wall thickness . Cardiac magnetic resonance imaging with gadolinium was not performed because of concern for renal dysfunction. Right heart catheterization was significant for elevated mean right atrial pressure (20 mmHg), mean pulmonary artery pressure (27 mmHg), and mean wedge pressure (20 mmHg) with reduced cardiac index [Fick CI 2.18 L/(m2*min)]. Left heart catheterization revealed a 40% stenosis in the mid and 60% in the distal left anterior descending (LAD) artery concerning for CAV. No other abnormalities were noted in the coronary arteries and intravascular ultrasound was not performed to avoid heparin exposure for the patient given the suspicion of rejection and urgent need for endomyocardial biopsy. Endomyocardial biopsy revealed no signs of cellular rejection (Grade 0), but with prominent blue staining of endothelial cells suggestive of endothelial activation. Multiple MHC Class 1 and Class 2 DSAs were positive, with mean fluorescence intensity >3000 . Immunohistochemistry for C4d showed positive capillary staining consistent with AMR . Treatment for AMR was initiated with steroids and plasmapharesis, followed by rituximab. Due to persistent symptoms and DSAs, she was later treated with bortezomib. Immunosuppression was transitioned from cyclosporine to tacrolimus with ongoing prednisone and MMF. Her symptoms resolved with these interventions suggesting that AMR was the aetiology of her initial presentation. In May 2017, repeat endocardial biopsy demonstrated negative immunohistochemistry with C4d after treatment with no staining in capillaries.
+In July 2017, she was hospitalized with enterotoxigenic Escherichia coli infection requiring azithromycin. Screening myocardial perfusion imaging performed subsequently demonstrated a new large, severe, predominantly fixed distal anterior and apical wall defect compatible with infarct with mild peri-infarct ischaemia, as well as a medium sized, mild inferior lateral wall defect compatible with infarct. Left heart catheterization found progressive diffuse CAV with worsened involvement of the distal LAD, mid circumflex, first obtuse marginal, and right posterior descending artery . No discrete lesions were amenable to percutaneous intervention. In response, her immunosuppression changed to everolimus, tacrolimus, and prednisone. In November 2017, she presented with an acute gout flare, as well as volume overload. Donor-specific antibodies checked at that time remained positive and demonstrated only two MHC Class 1 antigens greater than 3000. Repeat endomyocardial biopsy demonstrated no evidence of cellular rejection and negative immunohistochemistry staining for C4d. She presented to hospital again in December 2017 with oral HSV infection and volume overload, this time in the setting of end-stage renal disease (ESRD) attributed to tacrolimus toxicity and cardiorenal syndrome that has required ongoing treatment with haemodialysis. Because of renal dysfunction attributed in part to tacrolimus, her immunosuppression was changed at that time to everolimus and prednisone, on which she has remained clinically stable with New York Heart Association Class I–II symptoms over the past few months. As of February 2018, her left ventricular function improved to normal and no wall motion abnormalities were noted on echocardiogram. Going forward, her surveillance will include clinical follow-up and serial echocardiograms every 6 months.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_63_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_63_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e473b42e5261cb4274b0c6e4a359cf1ec02c29ea
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_63_en.txt
@@ -0,0 +1,8 @@
+An 18-month-old boy was referred to our center for the first time because of fever, lethargy, repeated seizures, and vomiting since two days ago. During hospitalization, he experienced three focal clonic seizures affecting the right side of his body with orofacial automatism. Seizures were ultimately controlled with phenytoin, phenobarbital, and levetiracetam, followed by clonazepam.
+The infant had no nuchal rigidity on physical examinations with negative Kernig and Brudzinski’s signs. No sign of organomegaly was detected either. On neurological examinations, cranial nerves were intact. His muscle tone and deep tendon reflexes were slightly decreased, but the Babinski sign was seen in his right foot.
+He was the first child of non-consanguineous parents born through Cesarean –section. He had no history of asphyxia at birth and no history of previous seizures or medication consumption. He had normal development before starting the disease.
+Due to fever, loss of consciousness, and seizures, Electroencephalography (EEG) and brain Magnetic Resonance Imaging (MRI) were requested. MRI revealed diffuse involvement of the left fronto-parieto-temporal regions and the left thalamus. EEG showed periodic lateralized epileptiform discharges (PLEDs) in the left hemisphere .
+A lumbar puncture was requested to rule out herpetic encephalitis, which indicated red blood cell=1000 / mm3 and white blood cell=100 /mm3 (60% neutrophils and 40% lymphocytes). Glucose and protein levels were in the normal range. Cerebrospinal fluid PCR for herpes simplex virus was also requested. According to imaging and CSF findings, the patient’s treatment started with ceftriaxone and acyclovir, with a presumptive diagnosis of herpetic encephalitis. After three days, HSV -PCR of CSF showed a positive result for HSV 1, and treatment was continued with acyclovir.
+During hospitalization, the patient regained consciousness, his fever recessed, and the seizures did not recur. After a twenty-one-day course of acyclovir, the patient was discharged while phenytoin, phenobarbital, and clonazepam were prescribed for him.
+One week after being discharged, the patient returned with restlessness, speech difficulties, and choreic movement, especially in the upper extremities. For better evaluation, he was re-admitted, and brain imaging was performed. A brain MRI revealed abnormal high signals in his left fronto-parieto-temporal regions with encephalomalacic changes due to sequella of previous infection and recent right temporal involvement
+No leukocytosis was reported in his initial tests. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were normal. Organic acids in blood and urine samples and serum ammonia and lactate levels were tested for metabolic disorders; all were in the normal range. CSF- PCR for herpes simplex was requested again to rule out relapsing herpetic encephalitis, and its result was negative. The history and extrapyramidal signs, including choreic movements, raised the possibility of autoimmune encephalitis. Therefore, serum and CSF were analyzed for autoimmune disorders. The Anti-N-Methyl-D-Aspartate receptor antibody test was positive in the autoimmune panel investigation in CSF, and the diagnosis of Anti-N-Methyl-D-Aspartate receptor autoimmune encephalitis was confirmed. The patient was treated with five-day methylprednisolone pulse therapy, followed by intravenous immunoglobulin (IVIG) for three days and aripiprazole. After three months, the patient’s speaking, behavior, and restlessness improved, and his choreic movement resolved.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_640_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_640_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e06c638ead54d1de0941688172a2703ffa00b2cb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_640_en.txt
@@ -0,0 +1,4 @@
+A 24 years old male arrived to our outpatient department complaining of right-sided otalgia and hearing loss for 8 years, no history of otorreah, vertigo or dizziness. He had a history of right-sided chronic suppurative otitis media with a history of two operations at the same side, which were right side atticotomy combined with tympanoplasty in 2002 and right side tympanoplasty in 2007. Examination showed dull, intact tympanic membrane. Tuning fork showed mild conductive hearing loss. The rest of the examination was within normal.
+Audio-tympanogram showed mild conductive hearing loss in the right side and type B tympanogram. A computed tomography (CT) scan showed opacification of the right middle ear and mastoid as shown in . Patient was admitted to the hospital and all pre-operative hematological, biochemical and serological investigations were within normal. Patient underwent exploratory right tympanatomy combined with right cortical mastoidectomy. Tissue specimens were sent for histopathology and comprehensive microbiology for aerobic, anaerobic, fungal and acid-fast bacillus cultures.
+Histopathology showed acute and chronic inflammation with diffuse fibrosis. Acid-fast bacillus staining was negative and all microbiological cultures failed to grow any organisms. A Grocott-Gomori’s methenamine silver-nitrate stain (GMS stain) showed branching bacterial filaments as seen in , allowing the diagnosis of actinomycosis to be established.
+Patient had a history of Penicillin allergy. Consultations for both infectious diseases and allergy/immunology specialties were obtained to determine an optimal management strategy. He was started on Augmentin 1g and Doxycycline 200mg/day. Then, discharged in a stable condition on same medications with regular outpatient clinic appointments. During regular follow-up visits in outpatient clinic till up to date patient has no complaint, tympanic membrane looked normal. CT was done showed normal right middle ear and mastoid opacification as shown in .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_641_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_641_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fc4f251d1f52c930daa14fc542fc197e4a5c7607
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_641_en.txt
@@ -0,0 +1,5 @@
+The patient was a 45-year-old Asian (Japanese) woman, who presented polycystic ovarian syndrome, hypertension, hyper-urinary acid, bladder stone, urinary stone, progressive renal dysfunction, and lipid abnormality. When she was 3 years old, she visited our hospital because of hypoglycemia, liver enzyme elevation, and hepatomegaly. She was diagnosed as having GSD type Ia based on the loss of G6Pase activity in the liver (< 0.3 µmol/minute/g tissue).
+In the first stage of life (3 years to 6 years), she needed frequent feedings and a night time cornstarch regimen until 7 years of age. After 8 years of age, her hypoglycemia improved and her glucose levels could be maintained with cornstarch intake twice a day. However, she had several complications such as kidney stones and hepatic adenomas with hepatomegaly.
+At 20 years of age, her BMI increased (to 24.2) and she presented hyperglycemia after food intake . The blood glucose dynamics indicated type 2 diabetes mellitus as described in Fig. [Fasting glucose: 123 mg/dl, homeostatic model assessment of insulin resistance (HOMA-IR) 9.23]. Therefore, cornstarch feeding at night was stopped.
+At 40 years of age, she presented hyperglycemia (200–260 mg/dl after feeding and dumping syndrome-like symptoms such as nausea, general fatigue, and dorsal pain). Moreover, the dumping syndrome-like symptoms worsened, resulting in poor quality of life. At first, she misunderstood that the complication was related to hypoglycemia and thus increased feeding, leading to an increase in body weight (maximum BMI was 26.4). Laboratory tests indicated elevated triglycerides (880 mg/dl) and abnormal liver function tests . Magnetic resonance imaging (MRI) of the abdomen revealed multiple liver adenomas with diffuse steatosis. Investigation of diabetes showed an insulin level of 68 µIU/ml (normal range: ≦ 18.7 µIU/ml), with fasting blood glucose levels of 126 mg/dl (normal range: 70–114 mg/dl). HOMA IR was calculated as 22.1 (N < 2.5), indicating severe insulin resistance.
+At first, she attempted lifestyle modifications such as a lower carbohydrate diet, elongation of feeding time, and exercise. However, her condition did not improve. To avoid severe hypoglycemia and improve liver function, she was experimentally treated with luseogliflozin hydrate additionally, an SGLT2 inhibitor, at a dose of 2.5 mg daily, after obtaining informed consent. After this intervention, she decreased her cornstarch intake, and her dumping syndrome-like symptoms disappeared completely. In addition, her body weight (BMI 21) and insulin resistance both decreased remarkably (HOMA-IR 4.49; Fig. ).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_643_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_643_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..22997dc806f4c90e12f1097efaaf9b3c6f74768d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_643_en.txt
@@ -0,0 +1,6 @@
+A 68-year-old woman was brought to our hospital with repeated right upper abdominal pain lasting for 3 month and aggravation for 9 h. From February 2019 to May 2019, the patient experienced multiple episodes of dull epigastric pain and discomfort, which was often aggravated in the morning with paroxysmal colic. The patient had visited many hospitals without symptom control, but had improved after orally taking omeprazole and anti-inflammatory agents. She did not have black stools or similar symptoms before the symptoms appeared 3 months earlier.
+Physical examination showed obvious tenderness in the lower right epigastric region of the xiphoid process, and there was no rebound pain or muscle tension. Blood examination only indicated slightly elevated levels of C-reactive protein, while other tests including routine blood tests were normal. Chest X-ray and B-ultrasound indicated no obvious abnormalities, as shown in Fig. . Gastroscopy revealed obvious hyperemia and edema in the anterior wall of the duodenal bulb, with superficial white pus coating on the surface, and semicircular swelling of the mucous membrane into the cavity, as shown in Fig. .
+A duodenal bulbous bulge with bulbous inflammation (possibly due to external pressure on the gall bladder abscess) and/or duodenal bulb ulcer were first considered to be responsible for the discomfort. Cefazoxime sodium was intravenously administered at 2 g and Q12h. Omeprazole was orally administered at 40 mg and Q12h. However, the effect of the anti-ulcer therapy was unremarkable as the symptoms were not significantly relieved and epigastric pain was still present. Additionally, the paroxysmal spasmolysis could not be controlled by intramuscular injection of anisodamine.
+Computed tomography (CT) was further performed, and the results suggested the gallbladder was slightly larger, the gastric cavity filling was poor, and the gastric antrum was thickened. After careful examination of the film, we found a streaky high-density shadow (approximately 3 cm in length) on the posterior wall of the gastric antrum extending outside the wall, as shown in Fig. . The possibility of FBs accompanied by perforation was then considered. Further abdominal X-ray also showed a dense shadow in the duodenal bulb with a length of about 2.7 cm, as shown in Fig. . Endoscopic ultrasonography showed that the anterior wall of the duodenal bulb obviously protruded into the cavity. A superficial ulcer was observed on the anterior wall and white moss was observed on the uplift. Hyperechoic space with a cross-section of approximately 0.1 × 0.1 cm was found in the deep submucosal layer of the local stomach, accompanied by an acoustic shadow in the rear as shown in Fig. , which led to the consideration of fishbone as the FB. Further questioning of the patient confirmed that she had a history of eating fish soup before she developed abdominal pain.
+Abdominal CT examination suggested abscessus and thus, the possibility of perforation was not excluded. It is more difficult to find lesions under laparoscopy and endoscopic treatment is associated with higher risks when perforation is suspected, thus the patient was recommended for exploratory laparotomy. However, the patient and her family refused open surgery and requested endoscopic investigation. However, certain difficulties and complications may arise with endoscopic treatment: 1) the FB stump may not be visible under the endoscope; 2) injury to the adjacent liver and pancreas can occur; 3) after removing the FB, the closed perforation cannot be treated under the endoscope; 4) massive upper gastrointestinal bleeding or perforation can occur during or after surgery. If any of the above conditions occurs, emergency surgery is required. During the operation, we attempted to find the end of the fishbone on the bulges of the ball using FB forceps (MTN-4GF-23, Nanjing minimally invasive), as the tail end could be seen faintly in the abscess. FB forceps were used to clamp the proximal end and a fishbone-like FB with a length of 5.5 cm was pulled out. The ulcer slightly oozed blood and two thrombins were sprayed to stop the bleeding. Fasting as well as acid inhibition and anti-infection medication were prescribed for the patient after surgery.
+After treatment, the patient’s abdominal pain disappeared. Endoscopy was performed 1 week later and showed that the ulcer healed well. The patient was discharged and subsequent follow-ups revealed no further abdominal discomfort.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_654_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_654_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..41792b7fb1e784c910e029542c68d4d8b7f998dd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_654_en.txt
@@ -0,0 +1,3 @@
+A 61-year-old woman with a past medical history of type II diabetes, breast cancer, and major depression presented to the emergency department after an intentional overdose with fluoxetine (139 tablets of 20 mg), risperidone (6 tablets of 1 mg), bromazepam (90 tablets of 3 mg), zolpidem (40 tablets of 10 mg), naproxen (20 tablets of 500 mg), and clemastine (5 tablets of 1 mg). Quantities were determined by counting the remaining pills in the blister packaging. Upon arrival, the patient was somnolent but able to open her eyes on request (E3M6V5). Vital signs showed a blood pressure of 146/57 mmHg, a regular heart rate of 55/min with strong peripheral pulsations, a respiratory rate of 16/min, oxygen saturation levels varying between 95 and 100% at room air, and a body temperature of 36.2 °C. Her husband suggested that the pills must have been ingested 3 to 8 h prior to hospital admission. Electrocardiography (ECG) showed a sinus rhythm of 61 beats per minute with a prolonged corrected QT interval (QTc) of 503 ms as shown in Fig. . During admission, all ECGs were performed using a GE MAC 5500 HD electrocardiograph. The tangent method was used in order to define the end of the T-wave in the lead with the longest QT interval. All measured QTc intervals were corrected for cardiac frequency using Bazett’s formula .
+Initial laboratory findings showed a microcytic anemia (Hb 5.4 mmol/l, MCV 77 fl) with low serum ferritin (6 μg/l), along with a mild leukocytosis of 11.2/nl. Serum electrolytes, as well as liver and kidney function, were normal (Na+ 135 mmol/l, K+ 4.3 mmol/l, creatinine 89 μmol/l, corrected calcium 2.37 mmol/l, PO43− 1.41 mmol/l, magnesium 0.83 mmol/l). Arterial blood gas analysis showed a base excess of − 4.9 mmol/l (pH 7.37, pCO2 4.6 kPa, pO2 12.1 kPa, HCO3− 20 mmol/l). A chest X-ray displayed no aspiration pneumonia nor other cardiopulmonary anomalies. The patient was admitted to the ICU for observation, where she received intravenous fluids along with 40 mg of pantoprazole for the prevention of peptic ulcer disease due to the substantial ingestion of naproxen. This was administered only once due to the risk of further QTc interval prolongation. Initially, our patient remained hemodynamically stable and showed improved neurological function. Twenty-two hours after hospital admission, a second ECG showed normalization of the QTc interval to 458 ms, suggesting peak serum levels of the ingested drugs had passed. After psychiatric evaluation had taken place, our patient had fallen to the floor in search of the restroom. On examination, both her muscle strength and coordination were slightly disturbed. Due to the overall severity of the intoxication and the persistence of neurological symptoms, it was decided to observe the patient for one more night at the ICU. Flumazenil was not administered since the patient was fully conscious and already in a monitored environment and due to the risk of adverse effects, especially with chronic benzodiazepine use .
+That night, 36 h after admission, our patient developed recurrent short episodes of Torsades de Pointes (TdP) with intermittent loss of cardiac output, as shown in Fig. . Two grams of magnesium sulphate was administered intravenously, after which sinus rhythm was restored. Four hours later, she had complete loss of circulation, after which cardiopulmonary resuscitation was initiated according to protocol. A 150-J biphasic shock was delivered using an automated external defibrillator (Zoll R-Series ALS). ECG findings consistent with TdP were again observed. Spontaneous circulation was restored after intravenous administration of magnesium sulphate. Our patient was awake and immediately able to maintain a patent airway following the incident. Serum levels of fluoxetine and risperidone and their metabolites were measured in retrospect, as shown in Table and Fig. , . Laboratory findings at the time of the incident showed a mild hypocalcaemia of 2.10 mmol/l with a hypermagnesaemia of 1.72 mmol/l/, most likely caused due to the prior administration of magnesium sulphate. No other electrolyte abnormalities were identified (Na+ 137 mmol/l, K+ 3.8 mmol/l, PO43− 1.24 mmol/l). Subsequent ECGs showed progressive prolongation of the QTc interval up to 565 ms, as shown in Fig. . The patient remained hemodynamically stable for the remainder of the night on continuous infusion of magnesium sulphate (1 g/h). The following day, echocardiography was performed in order to exclude structural cardiac defects, which showed normal heart dimensions as well as a normal left and right ventricular function.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_65_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_65_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..edbb03469e1fd8623949c6675556e2bf58fcab04
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_65_en.txt
@@ -0,0 +1,3 @@
+A 74-year-old woman was referred to our hospital because of a nodule in the right lobe of the thyroid. The nodule had been found during a medical examination performed 3 years ago, but she did not undergo a detailed examination at the local hospital at that time. On physical examination, a palpable and hard nodule of approximately 2 cm in size was noted in the right side of her neck. Results of the blood examination were normal, except for mildly increased thyroglobulin (142 ng/mL) and antithyroglobulin antibody levels (59.7 IU/mL). Ultrasonography and computed tomography showed a right thyroid nodule with calcification. The nodule had no signs of extrathyroidal invasion and measured 21 mm in diameter. The lymph nodes of the neck were not swollen . The nodule was diagnosed as an indeterminate lesion by fine needle aspiration cytology. The fine needle aspiration smears showed spindle-shaped cells with prominent nucleoli and nuclear inclusion. The intercellular space was metachromatic on Giemsa staining . Taken together, these findings suggested a hyalinizing trabecular adenoma, granulomatous lesion, papillary carcinoma, or poorly differentiated carcinoma.
+We decided to treat this nodule as thyroid cancer. Right thyroid lobectomy and central neck dissection were performed. Macroscopically, a well-circumscribed mass in the right lobe of the thyroid was observed. Histologic evaluation of the thyroid nodule showed multinodular proliferation of oval to polygonal-shaped epithelioid cells with oval nuclei and eosinophilic cytoplasm arranged in sheet- or cord-like patterns, accompanied by fibrous stroma and marked osseous metaplasia. Nuclear atypia was mild, and mitosis was not prominent. Results of the immunohistochemical staining showed that these areas were partially positive for cytokeratin, cluster of differentiation (CD)34, and factor VIII; diffusely positive for vimentin; and negative for thyroglobulin, thyroid transcription factor-1, smooth muscle actin, desmin, S100, CD31, CD68, and CD163 . These findings were suggestive of EHE.
+Postoperatively, the patient’s thyroglobulin level fluctuated inconsistently (range, 11–292 ng/mL), as did the antithyroglobulin antibody level, although it remained positive. The mild elevation of the preoperative and postoperative thyroglobulin levels might have been caused by chronic thyroiditis. The patient has been followed-up for 3 years and has had no signs of recurrence postoperatively.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_667_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_667_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..db8758b9d03deed448dcc3d96a50227863cfa278
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_667_en.txt
@@ -0,0 +1,6 @@
+We present the case of a male Caucasian infant, aged 9 months and 3 weeks, who is brought to the emergency room having 40 °C fever, vomiting associated with breast feeding, restlessness, symptoms with an onset in the last 12 h, and associated with the mother’s referral as for the protuberant fontanelle. At the time of admission, the infant was febrile 38.8 °C, pale, with perioral cyanosis, with a normal lung assessment, relative bradycardia - heart rate (HR) of 88 beats per minute (bpm), with asymmetric deep tendon reflexes more diminished on the right side, right Babinski reflex present, right hemibody motor deficit, bulging of the anterior fontanelle, and Glasgow Coma Scale of 8. He was born naturally, normal birth weight, with food diversification started at the age of 6 months, and still breast fed at the moment. The only condition in the infant’s history is a gastroesophageal reflux disease (GERD), diagnosed at the age of 2 months, for which the patient received a treatment with esomeprazole 0.5 mg/kg/qd (5 mg/qd) for the last 4 months. The GERD improved after food diversification was introduced, but some inconstant vomiting is still present. Laboratory investigations revealed the following alterations: leukopenia – white blood cells 2.6 × 109/L, 88.2% (2.293 × 109/L) neutrophils, hemoglobin 9.9 g/L, hematocrit 28.8%, mean corpuscular volume 70.6 fL, platelets 133 × 109/L, blood protein 5.74 g/dl, blood glucose 102 mg/dl, C-reactive protein 215 mg/L (references value 0–10 mg/L), and procalcitonin 10 ng/ml (references value < 0.5 ng/ml).
+A chest radiography was performed and revealed an emphasized bilateral infrahilar and hilar interstitial drawing.
+A cranial computerized tomograpohy (CT) scan was performed and revealed the following aspect: a diffuse cerebral edema with a wide left parietal hypodense area.
+A cranial magnetic resonance imaging (MRI) was also performed and the findings were the following: a diffused swelling aspect of the cortical areas (hyposignal T1/T2 and hyperintensity on FLAIR sequences) with the disappearance of cortical sulci, and with the blurring of the cortical gray and white matter border in the left paramedian areas of the frontal, parietal, and occipital lobe. Hypersignal T2 and hyperintensity on FLAIR sequences in the fronto-parietal sulcus (bilateral) with a haematic component in magnetic susceptibility sequences. Ectasia of the small cortical cerebral veins, without cerebral lacuna images at the level of high flow cortical veins or venous sinuses. Small images with restricted diffusion spread across the bilateral supratentorial brain parenchyma. The administration of gadolinium-based contrast agent highlighted small diffused areas in the right frontal lobe white matter right, in the left frontal and parietal lobe, underlying areas of edema and at the level of the meninges, predominantly in the frontal and parietal lobes. See Figs. and .
+3D Time of flight angiography TOF sequences revealed no abnormalities in the cerebral arterial circulation. The conclusion of the MRI was: the described aspect corresponds to a meningoencephalitis. See Fig. .
+A transfontanelar puncture was performed, and revealed a purulent cerebrospinal fluid (CSF), a CSF on examination with 310 WBCs/mm3 (reference values 0 to 10), a glucose of 5 mg/dL (reference values 40 to 70 mg/dL), a protein of 28.35 g/L (reference values 0.15 to 0.2 g/L), and with a latex agglutination test positive for group B Streptococcus (GBS). Gram stained smear shows a high number of leukocytes, rare red blood cells, and numerous Gram positive cocci arranged in pairs or short chains that were confirmed on growth medium as Streptococcus agalactiae. The antibiogram of the bacterial isolates determined by disc diffusion method revealed the sensitivity to ampicillin, linezolid, vancomycin, teicoplanin, trimethoprim/sulfamethoxazole, ciprofloxacin, and the resistance to tetracycline and clindamycin. The treatment was initialized with cerebral depletion therapy (such as administration of intravenous solutions like mannitol), ampicillin 200 mg/kg/day, ceftriaxone 90 mg/kg/day, and vancomycin 60 mg/kg/day. After receiving the susceptibility tests result for the isolated strain, ampicillin, and vancomycin were administered. Also, dexamethasone, and antiseizure drugs were associated to the treatment. The bacteriological examination of mother’s genital secretions, breast milk, and peri-areolar skin were negative. The bacteriological examination of infant’s gastric secretion, was unfortunately performed after initiation of the treatment and was negative. His response to the therapy was slowly favorable, the survival being associated with motor (right hemiplegia), language deficits, and episodic irritability (Additional file : Flow diagram).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_668_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_668_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..aaf73d8df43a5bc5012978fddec919fd33430939
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_668_en.txt
@@ -0,0 +1,2 @@
+A 47-year-old male patient presented with a red eye, scleral nodule, and increased intraocular pressure (IOP) in the left eye for 3 weeks after an eye injury from sawdust. At a regional hospital, he was treated as nodular scleritis and secondary ocular hypertension for 1 week with topical prednisolone acetate 1% every 2 h, nepafenac four times daily, timolol maleate 0.5% and brimonidine tartrate 0.1% twice daily, oral prednisolone 15 mg/day, and oral acetazolamide 250 mg twice daily. When the lesion did not improve, the patient was referred to a tertiary hospital. His best corrected visual acuity (BCVA) was 6/6 and 6/12 in OD and OS, respectively. Slit-lamp examination revealed a painless, slow-growing nodular lesion at the inferonasal area with marked injection of conjunctiva and mucopurulent discharge . There was a small infiltration of the adjacent peripheral cornea; otherwise, the anterior chamber, the lens, and fundus were unremarkable with an IOP of 20 mm Hg. The patient was diagnosed as infectious scleritis with scleral abscess and was admitted to hospital. Both topical and oral steroids were discontinued and a surgical drainage was performed. Yellow pus from the abscess was sent for microbial study including a potassium hydroxide wet mount, Calcofluor white staining, Gram staining, and bacterial and fungal cultures. The smears showed no organism and the culture did not grow any organism. The patient was initially treated as infectious scleritis with fortified cefazolin (33 mg/mL) and fortified gentamycin (14 mg/mL) every 2 h and oral ciprofloxacin 500 mg twice daily along with previous anti-glaucoma medications. Eight days after treatment, the sclera nodule resolved, and the cornea was clear with controlled IOP, so the patient was discharged and instructed to follow up at the previous regional hospital. Two weeks later, his vision got worse, so he went to the regional hospital. At that time, increased corneal haze and anterior chamber reaction with plasmoid aqueous and vitreous haze in the left eye were noticed. The patient received fortified cefazolin and fortified gentamycin hourly to the left eye as well as systemic therapy with intravenous vancomycin 500 mg/day and ceftazidime 1 g/day, before referral to a tertiary hospital.
+At the second referral, BCVA were 6/6 and hand motion in OD and OS, respectively. Slit-lamp examination revealed markedly injected conjunctiva, diffused chemosis with mild proptosis, mucopurulent discharge, diffused corneal edema with neovascularization involving an area of previous infiltration, and marked anterior chamber reaction with plasmoid aqueous in the left eye . Since orbital cellulitis could not be ruled out, a computerized tomography scan of the orbit was performed, with the results showing localized preseptal swelling and scleral thickening of the left eye . B-scan ultrasonography showed diffuse scleral thickening and exudative retinal detachment . The results of previous microbial workup demonstrated Basidiobolus species . The patient was treated with ketoconazole 2% eye drops hourly, subconjunctival injection of fluconazole 1 mg every other day, oral itraconazole 200 mg daily, oral trimethoprim 400 mg, and sulfamethoxazole 80 mg 2 tablets twice daily. In addition, diabetes mellitus was identified during his general workup, thus antidiabetic drugs were given. Five days after treatment, his left eye developed more proptosis and limitation of extraocular movement, increased chemosis as well as diffused corneal stromal and subepithelial infiltration . Corneal confocal microscopy was done and showed multiple round to oval-shaped lesions which looked like fungal zygospores in the corneal stroma . The patient then underwent exploratory surgical intervention. Multiple scleral abscesses were found. Pus from the abscess was sent for microbial study showing fungal hyphae and zygospores . The fungal culture also demonstrated Basidiobolus sp. and the nucleotide sequence indicated B. ranarum . Oral itraconazole was increased to 400 mg daily. Eight days after treatment, the lesions seemed to respond to treatments as the proptosis, chemosis, and limitation of extraocular motions decreased, but generalized stromal and subepithelial infiltrations were still seen in the left eye. Nevertheless, the patient rejected further treatment and wanted to be treated as an outpatient. Two weeks after discharge, BCVA of his left eye was still hand motion despite an improvement of other signs including proptosis, chemosis, limitation of extraocular motions, and corneal infiltrations. Since then, the patient was lost to follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_681_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_681_en.txt
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index 0000000000000000000000000000000000000000..8d2f59d8793e78eb3fadf5448539ada76082ceeb
--- /dev/null
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+A 27-year-old left-hand dominant male presented to our orthopedic elbow clinic complaining of bilateral elbow clicking and discomfort which had been present for several years. His painful symptoms were localized to the anterior aspect of both elbows and had slowly become more painful despite simple analgesia and physiotherapy treatments. He also described intermittent paraesthesia in the forearm, in particular after physical activity with the arm. The pain was exacerbated when working out in the gym, in particular with pull-ups, and while heavy lifting as a storeman. He was otherwise fit and well. Examination revealed the full range of movement of both elbows with no instability or weakness. Grip and grind tests were negative for pain bilaterally. There was no objective sensory disturbance, and Tinel’s sign was negative. Hook test for distal biceps rupture was negative and provocative testing of the biceps produced no pain. While moving the joint on the left side, a clicking sensation could be palpated over the lateral aspect of the biceps tendon that reduced digital pressure. Plain imaging and MRI scans of both elbows did not reveal any pathology, and the decision was made to explore the right elbow, as this was the most symptomatic. Under general anesthesia with tourniquet, an anterior curvilinear antecubital fossa incision was made. The lateral border of the distal biceps tendon showed evidence of compression of the LACN at the musculotendinous junction in forearm supination as illustrated in and . The tendon was partially resected, and the nerve confirmed to move freely without further entrapment . An associated partial thickness tear of the long head of biceps distal hemitendon was debrided endoscopically. Postoperatively the patient was allowed an immediate gentle range of movement in a polysling. At 4 weeks after surgery, he was completely asymptomatic. The patient has given written consent for intraoperative images to be used for medical teaching.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_686_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_686_en.txt
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index 0000000000000000000000000000000000000000..dd4f8a5e28f5379295cdc31351440d83e72554fb
--- /dev/null
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+A 58-year-old Caucasian non-smoker male with a history of symptomatic paroxysmal and persistent AF from 6 months, arterial hypertension, and heart failure with preserved ejection fraction (HFpEF, NYHA Class 2), without previous ablation procedures, was admitted to our hospital for AF catheter ablation. At the time of admission, his vital signs were in the range of normality and he was in sinus rhythm after spontaneous conversion of AF. He was receiving a rate-control treatment with a beta-blocker (bisoprolol 2.5 mg qd) and digoxin (0.125 mg qd), both in therapeutic range, a direct oral anticoagulant for stroke prevention (CHA2DS2-Vasc = 2), and an antihypertensive combination therapy with an angiotensin converting enzyme inhibitor and diuretic. He was also unable to tolerate antiarrhythmic drugs in the past. His physical examination was unremarkable. A chest X-Ray obtained before the procedure was completely normal. Routine blood tests were normal at the time of admission except for mildly increased N-terminal prohormone B-type natriuretic peptide levels (630 pg/mL; reference range <125 pg/mL). Transthoracic echocardiography (TTE) showed normal left ventricular and right ventricular systolic function and the absence of significant valvular heart disease with an only mildly enlarged left atrium (LA) and left ventricular concentric remodelling. A transoesophageal echocardiography was performed 24 h before the procedure in order to rule out the presence of LA thrombosis. Catheter ablation was performed under general anaesthesia with orotracheal intubation. Induction of anaesthesia was obtained with propofol 2 mg/Kg, fentanyl 100 mcg, and rocuronium 1 mg/Kg, and it was completely regular. General anaesthesia was maintained with sevoflurane 1.2–1.4% in a 1:1 oxygen:air combination. Analgesia was maintained with remifentanil infusion 0.03–0.08 mcg/Kg/min. A five Fr pig-tail catheter was placed at the aortic valvular plane through the right common femoral artery and a decapolar steerable diagnostic catheter was placed in the coronary sinus through the right common femoral vein. Then a fluoroscopy-guided transseptal puncture was performed without complications (SL0™ Swartz sheath, Abbott; BRK™ transseptal needle, Abbott). An electroanatomical three-dimensional map (EnSite NavX, Abbott) of the LA was obtained using a high-density mapping catheter (Advisor™ HD Grid Mapping Catheter, Sensor Enabled™ (SE), Abbott). PVI with RF energy (standard energy, 30–35 W) was started with the use of a 4 mm tip bidirectional irrigated catheter (FlexAbility Ablation Catheter, Abbott). The activating clotting time was maintained between 250 and 350 s through unfractionated heparin iv infusion at standard dose. At the time of RF initiation, the patient vital signs were completely normal. The procedure was initiated targeting the left superior pulmonary vein (LSPV). After a few seconds, during the encircling of the LSPV and RF delivery at the site of posterior left pulmonary venous carina, the patient developed a reproducible asystolic reflex associated with hypotension, suggesting GP irritation with subsequent vagal activation . RF delivery was stopped for a few seconds and then resumed after recovery of electrical activity. About 2 min after the first RF delivery, a prominent and diffuse ST-segment elevation was noted and the patient developed a transient complete atrioventricular block with a junctional escape rhythm requiring temporary right ventricular pacing and i.v. administration of atropine 0.5 mg. Bedside TTE was performed in order to rule out pericardial involvement or mechanical complications and showed a mildly reduced left ventricular ejection fraction (LVEF) without clear regional wall motion abnormalities in the absence of pericardial effusion. An invasive coronary angiography (ICA) was immediately performed. Severe multivessel CAS in the absence of significant atherosclerotic disease or air embolism was detected . CAS resolution and subsequent flow normalization were obtained after intracoronary administration of nitroglycerin . The ST-segment promptly returned to isoelectric line . Repeated bedside TTE performed after spasm regression showed recovered LVEF and confirmed the absence of pericardial effusion. After complete resolution and stabilization of the patient clinical parameters, the procedure was resumed and PVI with encircling and adjunctive LA lesion lines (mitral isthmus and roof line) were completed without further complications . After the procedure, myocardial injury markers (high-sensitivity cardiac troponin I) resulted slightly elevated with a ‘rise and fall’ pattern (peak 1060 ng/L, normal range <14 ng/L). After 48 h of clinical monitoring, the patient was discharged with a non-dihydropyridine calcium channel blocker (verapamil, 40 mg tid) therapy. At 30 days, 3 and 6 months follow-up the patient was in sinus rhythm without left ventricular wall motion abnormalities.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_687_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_687_en.txt
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index 0000000000000000000000000000000000000000..cd0fc5cc2be641627bbb822788cca455a82a3b37
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_687_en.txt
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+A 66-year-old hospitalized male who complained of dizziness.
+The patient developed dizziness, nausea, and vomiting 4 d prior. The vomit was non-brown-colored stomach contents, accompanied by confusion, headache, and hearing loss in both ears. One day prior, his dizziness aggravated, and he presented to the hospital.
+The man was healthy, with no specific diseases.
+Body temperature 38.5 °C, heart rate 66 bpm, and blood pressure 210/110 mmHg. The patient reported blurred consciousness, binaural hearing loss, signs of meningeal irritation displayed by neck rigidity, positive Kernig’s and Lesage’s signs, normal muscular strength and limb muscle tension, and negative pathologic signs.
+On admission, the patient’s examination results were completely normal, including leukocyte count, hypersensitive C-reactive protein, procalcitonin, electrolytes, liver and kidney function tests and coagulation function tests. On the second day of hospitalization, cerebrospinal fluid examination showed 62.9 × 103 white blood cells (WBCs)/μL, with a protein level of 8036 mg/L, glucose level of 3.8 mmol/L and chloride ion concentration of 139 mmol/L. The cerebrospinal fluid pressure was 270 mm H2O; in routine examination of the cerebrospinal fluid, the appearance was light yellow and slightly muddy; the Pandy test was positive, with 2.4 × 108/L karyocytes, 51% neutrophils, and 69% lymphocytes. Biochemical examination of cerebrospinal fluid revealed a total protein content > 1.07 g/L (normal, approximately 0.15-0.40 g/L), dextrose level of 1.87 mmol/L (normal, approximately 2.5-4.4 mmol/L), chloride level of 114.60 mmol/L (normal, approximately 120-132 mmol/L), body temperature of 38.5 °C, heart rate of 66 bpm, and blood pressure of 210/110 mmHg. The patient reported blurred consciousness and binaural hearing loss. He had signs of meningeal irritation in the form of neck stiffness and positive Kernig’s and Lesage’s signs.
+After 5 d, cerebrospinal fluid was extracted by lumbar puncture and subjected to mNGS. The result revealed S. suis (with 1884 detected sequences), and the relative abundance was 93.27%. No pathogens were found by routine methods such as cerebrospinal fluid culture or blood culture.
+We then performed lumbar puncture every week to extract cerebrospinal fluid and examined inflammatory indices, with cerebrospinal fluid culture and blood culture performed.
+After 37 d, the patient’s condition worsened. We repeated mNGS of cerebrospinal fluid, and the results revealed S. suis (the number of detected sequences was 130) and Nocardia asiatica (the number of detected sequences was 31598). The results of the seven cerebrospinal fluid examinations are shown in Table , and the etiological examination of the cerebrospinal fluid is shown in Table .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_688_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_688_en.txt
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index 0000000000000000000000000000000000000000..0548582ba2344dc663157748245016de5ea59980
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_688_en.txt
@@ -0,0 +1,3 @@
+A 48-year-old white man with a medical history of recurrent pneumonitis and therapy-resistant ulcerative colitis over 10 years presented with fever and cough with sputum production for 10 d. He reported resting dyspnea and pain over the right thoracic wall.
+Under antibiotic therapy with moxifloxacin, no clinical improvement was reported. A chest roentgenogram showed an effaced right costo-phrenic angle and nonvisualization of the right hilar shadow suggestive of right lower lobe collapse .
+Bronchoscopy revealed complete occlusion of the right bronchus intermedius due to a smooth-walled vascular mass with intact overlying epithelium. A computed tomography (CT) scan revealed a well-defined round-to-oval, smoothly marginated tumor measuring 43 mm × 56 mm in size located endobronchially in the proximal right main stem bronchus causing complete collapse of the right middle and lower lobe . A PET-CT scan showed a low metabolically active mass in the lower lobe, consistent with a carcinoid tumor, and metabolically active prominent and probably reactive mediastinal and hilar lymph nodes.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_689_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_689_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7befbb65bd00c15b8193ee19a9f0e268c922a688
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_689_en.txt
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+A 46-year-old man of Macedonian ethnicity presented with a pruritic perianal lesion measuring up to 2cm without pain or bleeding. Our patient was diabetic and had a family history of diabetes and hypertension. Five months after his initial presentation, a colonoscopy and a biopsy were performed at Clinical Hospital Sistina - Adzibadem. The next month, our patient was admitted to our University Clinic of Digestive Surgery, where a physical examination revealed a perianal eczematous lesion measuring 6 × 4cm and enlarged inguinal lymph nodes. A second biopsy with a left lymphadenectomy was performed.
+The tissue specimens were formalin-fixed and paraffin-embedded at our Institute of Pathology. We used a routine hematoxylin-eosin stain and performed additional histochemical and immunohistochemical analysis, including staining with Alcian blue and for cytokeratin (CK)7, CK20, epithelial membrane antigen, carcinoembryonic antigen, melan-A, androgen receptor and human epidermal growth factor receptor 2 (Her2/neu).
+Microscopic analysis of the biopsy specimens showed large Paget cells with abundant pale cytoplasm, and large nuclei infiltrating the basal part and the whole thickness of the squamous epithelium and adnexal epithelium. Occasional cells had a signet-ring appearance. His inguinal lymph node revealed reactive lymphadenopathy. A diagnosis of EMPD was made.
+The perianal surgical skin excision measured 5.5 × 6.5 × 0.7cm and showed diffuse ulcerated eczematous plaques . Histopathology revealed identical Paget cells as viewed in the biopsy specimen, infiltrating the epidermis and adnexal epithelium with ulceration. In the basal epidermal layers there were some duct-like structures with small central lumina . There was intense mononuclear infiltrate in the dermal connective tissue. An immunohistochemical analysis on both biopsy and excision specimens revealed positive Paget cell expression for CK7, epithelial membrane antigen, carcinoembryonic antigen, androgen receptor and Her2/neu , and negative expression for CK20 and melan-A. Intracytoplasmic sialomucin stained positive for Alcian blue . A diagnosis of primary in situ PPD was made.
+After two biopsy findings of EMPD, a wide surgical excision was performed . The patient was discharged in good condition and advised to attend a follow-up examination. After six months, a check-up revealed his skin area to be disease free.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_690_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_690_en.txt
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index 0000000000000000000000000000000000000000..1763da63791691479f586cae5856c457784df67f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_690_en.txt
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+A male in his 40s, who had been diagnosed with HIV 6 years previously, presented with a 7-month history of disseminated nodular and ulcerating lesions . Verbal informed consent was obtained from the patient. However, because the patient was lost to follow-up and attempts to contact him or his family has been unsuccessful, written consent could not be obtained. No patient-identifying details are included in this paper. The lesions worsened in the month prior to presentation and became predominantly ulcerative, with partial loss of the nose. The lesions were multiple, well-circumscribed, round to oval, hyper-pigmented ulcers with elevated borders ranging in size from 2–6 mm. The lesions were located on the face, scalp, chest, back, and upper and lower limbs. The patient reported associated generalized body pains, fatigue, night sweats, loss of appetite, loss of weight and a productive cough. Various antibiotics alone or in combinations were used without success. The patient also confessed to poor adherence to his antiretroviral therapy (ART), which consisted of abacavir, lamivudine and lopinavir/ritonavir. His HIV viral load was 149, 455 copies ml−1, and his CD4 count was 34 cells mm−3 at the time of presentation. He previously had pulmonary tuberculosis in 2009 and in 2017, which was treated successfully.
+Chest X-ray showed bilateral reticulonodular infiltrates. Investigations for syphilis showed a positive haemagglutination (TPHA) test result and a non-reactive rapid plasma reagin (RPR) test. Other investigations included a serum cryptococcal antigen test, which was negative, a blood culture, which showed growth of , and a tuberculosis (TB) polymerase chain reaction (PCR) (Xpert MTB/Rif Ultra; Cepheid, Sunnyvale, CA, USA) test performed on sputum, which did not detect complex. Multiple skin punch biopsies from the left and right cheeks, right elbow, right chest and back were taken and submitted for mycological culture and histological examination. Sputum samples were also collected and submitted for mycological, mycobacterial and general bacterial cultures. Sputum and tissue microscopy revealed no acid-fast bacilli (AFB). Mycological culture of tissues and sputum revealed colonies at 25 °C that were slow growing, moist and glabrous, with a wrinkled and folded surface. Colonies were white with an orange–brown reverse . The lactophenol cotton blue stain showed solitary and erect conidiophores arising at right angles from thin septate hyphae that tapered toward the apex. Conidia were formed in clusters on tiny denticles at the apex of the conidiophore, with their arrangement being suggestive of a flower . Conidia were ovoid, hyaline, one-celled and smooth-walled. On blood agar, incubated at 37 °C, colonies were tiny, glabrous, white to greyish and yeast-like, and consisted of spherical or oval budding yeast cells on Gram stain microscopy.
+The organism was identified as S. schenckii based on macroscopic and microscopic characteristics. The identification was confirmed by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) (VITEK mass spectrometer, bioMérieux, Marcy I’Etoile, France). Histological examination showed variable epidermal ulceration, which was undermined by acute inflammation admixed with fibrin and granulation tissue. The dermis contained a dense chronic inflammatory infiltrate composed of lymphocytes, plasma cells, histiocytes and numerous giant cells. In addition, numerous small, round to oval, cigar-shaped fungal elements and asteroid bodies were observed. The subcutis was unremarkable. The periodic acid–Schiff–diastase (PAS-D), Alcian blue (AB), PAS and Grocott stains highlighted the fungal organisms. The Warthin–Starry stain showed no micro-organisms. immunostaining showed negative immunoreactivity.
+Oral fluconazole, dosed at 400 mg per day, was initiated empirically 2 days after hospital admission. No itraconazole was available at the treating facility at that time. The patient showed minimal improvement on fluconazole. Itraconazole 200 mg 12 hourly was initiated after confirmation of sporotrichosis.
+The patient made significant improvement and was discharged from the hospital after 5 weeks of itraconazole treatment. Unfortunately, he was lost to follow-up, as he did not return for scheduled appointments and attempts to reach him after discharge were unsuccessful.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_693_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_693_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b9e12441bb1373d27b04b8a8466fb7b6ebe721d5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_693_en.txt
@@ -0,0 +1,6 @@
+The patient is a 2-year-4-month-old boy, who is the first child of his nonconsanguineous Chinese parents, a 26-year-old mother and a 27-year-old father, both of them are healthy. Following an uneventful pregnancy, he was born at 38 weeks of gestation with a birth weight of 3.15 kg. Feeding difficulties and poor suck had been noticed since birth. Hypotonia was apparent at age of 4 months. He showed severe developmental delay. He could not raise his head until 4 months old, sit unsupported till 11 months. At 2-year-4-month-old, he could not walk and speak any meaningful words. Eye contact and social smiling were enabling. He had recurrent respiratory tract infections, and hospitalized for severe pneumonia for several times. At 12 months old, his head circumference was 47 cm, weight was 11 kg. The boy had mild dysmorphism with flat nasal bridge, anteverted nares, small mouth, high-arched palate, low-set ears and cryptorchidism of the right side. Hand stereotypes including hand wringing and hand shaking presented at 8 months. He had no chronic constipation, no seizures. Magnetic resonance imaging (MRI) at age 1 year was unremarkable. Karyotype analysis was normal. Serum amino acid and urine organic acid screen were unremarkable.
+Family history: The boy’s mother had two younger brothers. Both of them had severe developmental delay. The elder one could not walk or speak before he died at age of 5. The best motor function was sitting unaided. His brain computed tomography (CT) scan showed generalized cerebral atrophy. The younger one had a history of recurrent infections, died of a sever pneumonia at the age of 1y. He could not sit or walk alone during his life, speak no meaningful words yet. Both the mother and the grandmother were asymptomatic, they did not have any symptoms of depression, anxiety and compulsions. Figure showed the pedigrees of the family, the proband was showed by an arrow.
+Genomic DNAs from the peripheral blood leukocytes of the patient, his parents and the maternal grandmother were extracted using standard methods. MLPA (SALSA MLPA kit P015 MECP2, MRC-Holland, Amsterdam, Holland) was performed to detect large deletions or duplications of MECP2 gene as previously described . MLPA products were separated and analyzed using the ABI Prism 3100 Genetic Analyzer and Genescan software according to manufacturer’s recommendations.
+In order to determine the precise size of the duplication, aCGH was performed on the mother’ DNA, using Affymetrix GeneChip System 3000Dx v.2 (by Tianjin kingmed center for clinical laboratory, Shanghai, China).
+FISH test was performed to interrogate the MECP2 copy number and to identify the location of the duplicated MECP2 gene in chromosome (done by Beijing Ahngook Pharm. Co., Ltd, Beijing, China).
+The patterns of XCI of female carriers were analyzed according to the procedure described by Allen et al. . Inactivation was considered to be non- random if the ratio was > 70:30.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_699_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_699_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f5ceb80d885c38d16a04725bf815c6c285bbafc2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_699_en.txt
@@ -0,0 +1,2 @@
+A 54-year-old woman (height, 145 cm; weight, 43 kg) diagnosed with mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes elected to undergo cochlear implantation to address her progressive bilateral sensorineural deafness. Preoperative electrocardiography showed no abnormalities. Transthoracic echocardiography showed circumferential thickening of the left ventricle and asymmetric hypertrophy of the septum, which was thicker than the posterior wall. Cardiac contractility was diffusely decreased and cardiac ejection fraction was 45%. Estimated glomerular filtration rate was low (27 mL/min) because of diabetic nephropathy. Although enhanced insulin therapy had been introduced, her HbA1c level was high (12.5%) immediately before surgery. Creatine kinase level was 162 IU/L (normal range, 41–153). Her medications included 5 mg oral imidapril daily and subcutaneous insulin (6 units in the morning, 8 units in the afternoon, and 6 units in the evening). She was not taking any antiepileptic drugs.
+No premedication was administered. Intravenous remimazolam was administered as a 0.2 mg/kg bolus over 1 min, which resulted in loss of consciousness, followed by continuous infusion of remimazolam (1 mg/kg/h) and remifentanil (0.2 μg/kg/min). Neuromuscular monitoring of the left ulnar nerve was initiated using a train-of-four (TOF) stimulus (TOF watch SX®, MSD, Japan). Three minutes after administration of 30 mg of intravenous rocuronium, all four twitch responses disappeared and tracheal intubation was performed. During surgery, remimazolam was administered along with a continuous remifentanil infusion (0.2–0.25 μg/kg/min) to maintain the patient state index value between 25 and 50. Patient state index was measured using the SEDLine® monitor (Masimo Inc., Irvine, CA). A catheter was placed in the right radial artery for continuous arterial pressure monitoring. Intermittent blood gas analysis showed that the lactate concentration and pH ranged from 1.8 to 1.9 mmol/L and 7.41 to 7.45, respectively. Surgical time was 1 h and 34 min. Additional rocuronium administration was not needed throughout the surgery. After surgery was completed, the infusions were stopped and the TOF ratio was 0.91. The patient was extubated after stable spontaneous respirations with tidal volumes ≥ 8 mL/kg were confirmed (22 min after the end of surgery and 8 min after discontinuation of remimazolam). Thirteen minutes after extubation, her eyes remained closed; therefore, 200 μg of intravenous flumazenil was administered. Two minutes later, she opened her eyes, became verbally responsive, and was discharged from the operating room. After surgery, her only complaints were sore throat and nausea, which were treated with 1000 mg of acetaminophen and 10 mg of metoclopramide.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_6_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_6_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c223889b3c195fc480fadd53cf9f3c4fc153a2f5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_6_en.txt
@@ -0,0 +1,2 @@
+A 24-year-old female presented with a 1 year history of a painful, large, irregular, lobular mass rapidly growing at the nape of the neck, accompanied by decreased sensation/numbness in the C1-C2 dermatomes . Computed tomography (CT) scans of both the head and neck revealed a moderately enhancing 10-12 cm lesion (in greatest diameter) extending from skull base to the thyroid gland. It additionally involved the posterior cervical muscles, eroded through the posterior arch of atlas and occipital bone, where it exhibited both extradural/intraspinal, and intracranial extension . An incisional biopsy documented a highly vascular lesion consistent with a cellular variant of a solitary fibrous tumor (SFT) with HPC-like features. Preoperative RT was administered to reduce the size and vascularity of the tumor, and was followed by aggressive subtotal resection of an encapsulated, soft, vascular tumor. Notably, radical resection was limited by the tumor's depth and vascularity. Further postoperative RT resulted in a good clinical outcome.
+Histopathology revealed a vascular neoplasm characterized by sheets/groups of spindle/oval cells with a stag horn pattern consistent with HPC located in between plentiful of thin-walled vessels . On immunohistochemistry, consistent with the diagnosis of HPC, the tumor cells were positive for both cluster of differentiation 34 (CD34) and vimentin . The postoperative CT scan documented only a minimal amount of residual tumor (near the atlanto-occipital junction) with near complete decompression of the craniovertebral (CV) junction . Two years postoperatively, the patient remains asymptomatic and disease free (e.g., no recurrence or metastases).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_701_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_701_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a44ab05fb047103f3b66d804b5a200dfbb00bee6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_701_en.txt
@@ -0,0 +1,6 @@
+The patient was a previously healthy 73-year-old female who underwent curative resection for GBC (pT2N0M0 according to the eighth International union against cancer TNM classification). We performed next-generation sequencing (NGS)-based genomic profiling of the resected specimen using the NGS gene panel, Oncomine® Comprehensive Assay version 3 (OCA v.3, Thermo Fisher Scientific), which revealed ERBB2 Ser310Phe (c.929C>T; VAF, 18%) and TP53 Ser241Tyr (c.722C>A; VAF, 19%) mutations. One year later, a hepatic lesion was observed on follow-up imaging and she underwent surgical total biopsy for a pathological diagnosis.
+A patient had no symptoms and was in good health at the time of total biopsy.
+The patient had no previous medical history.
+The patient’s physical examination was not remarkable and laboratory testing was within normal limits, including tumor markers, such as CA19-9 and CEA.
+Contrasted computed tomography (CT) showed an ill-defined low attenuation lesion in the posterior lobe of the liver .
+The hepatic lesion was histologically diagnosed as well-differentiated adenocarcinoma and the histological findings of the hepatic lesion were similar to those of GBC . Therefore, the lesion was considered a metastasis. Moreover, we performed genomic profiling from the liver tumor using the NGS panel, Oncomine® Target Test system (OTT, Thermo Fisher Scientific). This revealed ERBB2 Ser310Phe (c.929C>T; VAF, 26%), which was identical to the mutation detected in the sequencing result of the primary site; thus, the liver tumor was the most consistent with a metastasis of GBC rather than localized ICC. To evaluate HER2 overexpression in tumor cells, we performed immunohistochemistry of HER2, which was negative (HER2 score 0). Since TP53 was not included in the gene list of OTTs, TP53 mutation status at the metastatic site was not assessed.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_709_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_709_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..029933b3deba30c8bb7ca558f950d9b0bb482182
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_709_en.txt
@@ -0,0 +1,4 @@
+A 47 years old woman was admitted to our hospital complaining of chest pain and palpitations of recent onset. She had a medical history of β-Thalassemia Major (TM-Cooley disease) and of atrial tachycardia treated with metoprolol 50mg bid plus verapamil 60 mg bid. Her blood pressure was 110/70 mmHg and on her electrocardiogram (ECG) a regular narrow complex tachycardia of about 180 beats per minute (bpm), with a long RP interval , was noticed. Adenosine administration revealed an atrial rate of about 150 bpm with a barely normal P wave morphology and an isoelectric segment between consecutive P waves.
+Her last hospitalization was 3 years ago when atrial tachycardia was converted with an overdrive atrial pacing via a transvenous temporary pacing wire. It was a very difficult and unpleasant experience that she did not want to repeat. Intravenous administration of esmolol and verapamil failed to restore sinus rhythm and a transesophageal overdrive atrial pacing was decided to convert the arrhythmia.
+A specially designed bipolar electrode was used to effect bipolar pacing via esophagus . The electrode was inserted via the right nare to esophagus while the patient was swallowing. The distal tip of the catheter was connected to the V1 ECG lead. Forty-five cm from nares the atrial and ventricular dynamics were record equal in V1 lead of the surface ECG . The tips of the catheter were connected to a programmed cardiac stimulator, designed for transesophageal pacing and pacing from this point, using 10 mA pacing current and pulse width 5 ms, was applied for 5 seconds. The patient restored sinus rhythm immediately after interrupting pacing and the patient’s discomfort lasted only 5 seconds . Two hours later the patient exited from the hospital.
+This case report was approved by the Ethical Committee of hospital (33/2019) and the patient was given written informed consent.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_715_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_715_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b6f3e3b6249b98f6385e1be2790e5ca585303df9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_715_en.txt
@@ -0,0 +1,7 @@
+A 55-year-old man was admitted to our hospital with unexplained abdominal distension and anorexia 3 mo ago.
+The patient suffered from unexplained abdominal distension and anorexia for 3 mo. The patient developed darkened urine 2 mo ago. He experienced a weight loss of 5 kg over the course of the disease. He underwent contrast-enhanced computed tomography (CECT) examination at a local hospital, and a lesion was found in the extrahepatic bile duct, which was believed to be a tumor.
+The patient underwent cholecystectomy for gallbladder stones with an uneventful postoperative recovery 4 years ago. He had a 10-year history of hypertension.
+There was no other personal or family history of acute or chronic disease.
+The patient showed no tenderness, rebound tenderness or muscle tension on abdominal palpation.
+The liver function tests demonstrated increased levels of alanine aminotransferase (185 IU/L, normal range: < 50 IU/L), aspartate aminotransferase (148 IU/L, normal range: < 40 IU/L) and total bilirubin (37.0 μmol/L, normal range: 5 µmol/L to 28 µmol/L). Tumor markers included carbohydrate antigen 19-9 (98.6 U/mL, normal range: < 22 U/mL), carcinoembryonic antigen (0.97 ng/mL, normal range: < 5 ng/mL), and alpha-fetoprotein (4.67 ng/mL, normal range: < 7 ng/mL).
+The patient underwent an abdominal ultrasound (US) examination by a Resona7 US system (Mindray Medical International, Shenzhen, Guangdong Province, China) equipped with an SC6-1U (1-6 MHz) transducer. The US revealed mild to moderate dilatation of the intrahepatic bile duct, and the diameter of the upper extrahepatic bile duct was 1.2 cm . A hyperechoic nodule sized 0.8 cm × 0.6 cm was found in the upper extrahepatic bile duct with an almost regular shape and slightly clear margins . The patient underwent CEUS with the patient’s consent for further diagnosis. A 2.4-mL US contrast agent SonoVue (Bracco, Milan, Italy) suspension was injected through the left cubital vein followed by a flush with 5 mL saline. In the arterial phase, the nodule showed slight heterogeneous hyperenhancement without rim-like enhancement . The nodule appeared heterogeneous isoenhancement in the venous phase . Additional CECT in our hospital showed a hypoenhancement nodule approximately 1.3 cm × 1.0 cm in size in the upper extrahepatic bile duct .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_733_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_733_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..31d19541906f663051534756d6eb89a95b24c1f5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_733_en.txt
@@ -0,0 +1 @@
+A 46-year-old male presented with a mass in the left parotid region of 6-month duration. The patient's history was only remarkable for a facial swelling, night sweats and a 38.5 C° fever. There were no other symptoms such as pain, facial paralysis, cough associated with this swelling. His past medical history was nonrevealing. There was no family history of tuberculosis. On physical examination, a 2 × 3-cm mobile, non-tender, mass with a smooth surface was palpated on left parotid tail. The physical examination was otherwise unremarkable. Routine laboratory tests, and a chest radiograph were normal. Ultrasound examination showed a well-defined, hypoechoic solid mass in the superficial lobe of the left parotid gland accompanied with the lymph node in same region. CT examination showed a well defined 30 mm in diameter tumor mass in the left superficial lobe of the parotid gland . A superficial parotidectomy operation was performed under general anesthesia. The lymph nodes were also excised. The final pathological diagnosis of the parotidectomy specimen was reported as a Warthin tumor and epitheloid granulomas with caseification necrosis . An intradermal test with purified protein derivative (PPD) was performed and it was 30 mm in enduration. Antituberculosis treatment with isoniazid, rifampicin, pyrazinamid and ethambutol was started for a 6-month duration. Two weeks after the antituberculosis treatment fever declined to normal values and night sweats decreased.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_740_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_740_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ddf2a83a777ae8a51b76001af7474a0b3a96707f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_740_en.txt
@@ -0,0 +1,7 @@
+A 43-year-old female presented with a 10-day history of abdominal and lumbar pain accompanied by nausea, vomiting, and constipation (1 bowel movement per 2–3 days). She denied oliguria, dysuria, and hematuria. She had a history of right adnexa benign cyst surgery more than 5 years ago. Unfortunately, she could not provide her precise medical history. She specifically denied previous exposure to ergot, methysergide, or β-blockers.
+Physical examination showed stable vital signs. Her abdomen was soft and flat with normal bowel sounds. No pain sensation was detected in the bilateral renal area, and the superficial lymph nodes were not palpable. Gynecological examination showed a solid and fixed mass (9 × 9 cm) in the right rear uterus. The anus examination showed a solid enclosed mass attached to the rectum and no blood on the fingerstall.
+Laboratory tests showed white blood cell count of 14,790 cells/mm3 (normal 3500–9500 cells/mm3), hemoglobin of 9.1 mg/dL (normal 11.5–15.0 mg/dL), and eosinophil cell count of 2200 cells/mm3 (normal 20–520 cells/mm3). Blood urea nitrogen and creatinine were normal. The erythrocyte sedimentation rate (ESR) was 64 mm/h (normal, 0–30 mm/h) and C-reactive protein was 127.08 mg/L (normal, 0–5 mg/L). CA125 was 313.4 U/mL (normal, 0–35 U/mL) and CA199 was 87.04 U/mL (normal, 0–39 U/mL). Urine routine examination showed microscopic hematuria.
+Contrast-enhanced computed tomography (CT) showed right-sided hydronephrosis and a low-density mass around the right adnexa. The imaging features strongly suggested an ovarian epithelial tumor . Single-photon emission computed tomography (SPECT/CT) showed slight atrophy of the right kidney, right-sided hydronephrosis, right kidney blood perfusion, mild damage to the glomerular filtration function, and irregular upper urinary tract. Ultrasound showed a cystic mass (8.8 × 7.5 × 8.6 cm3) in the right rear uterus, which was considered as an ovarian tumor . Abdominal ultrasound was normal. Urinary system ultrasound showed right-sided hydronephrosis and dilated upper section of right ureter . Ultrasound of the left kidney was normal. Gastrointestinal endoscopy showed level II chronic superficial gastritis. She was diagnosed with class I primary hypertension (low risk) using a 24-h blood pressure monitoring.
+After a series of examinations and discussion, this patient was diagnosed with ovarian cancer, right-sided hydronephrosis, mild anemia, level II chronic superficial gastritis, and class I primary hypertension. Because the main treatment of ovarian cancer is surgery and the preoperative examination suggested right ureteral obstruction, a preoperative cystoscopy and exploratory laparotomy were performed.
+Ten days after hospitalization, she was brought to the operating room. A preoperative cystoscopy was performed and a right intraureteral stent with a double-J catheter was inserted. Then, an exploratory laparotomy was performed via a midline incision. Upon entering the peritoneal cavity, slight bloody ascites and dense intra-abdominal adhesions were encountered in the right pelvic cavity. The classical glistening white, unyielding RPF was encountered. The plaque predominantly encased the pelvis, especially the right pelvis. The pelvic peritoneum showed thickening and edema, especially the retroperitoneum. The maximal thickness of the plaque was 1 cm. It formed a solid and fixed mass in the right lower pelvis. The omentum majus contractured and adhered densely to the anterior abdominal wall. The omentum majus densely encased the sigmoid colon and rectum. The sigmoid colon adhered to adjacent retroperitoneal structures densely and formed a stiff mass. The fixed sigmoid colon adhesion was 6-cm long with stiff wall, thickening and hardening of the intestinal wall, and obvious constricted lumen. The vermiform appendix was clearly visible and hard. The uterus was slightly expanded, with thickened serosa. The left adnexa was normal and the right adnexa could not be found. The Douglas pouch was closed because of dense adhesions. The right ureter was surrounded by dense fibrotic tissue with chronic inflammation and formed right ureteral obstruction. No abnormality was found when examining the liver, pancreas, spleen, stomach, small bowel, ascending colon, transverse colon, and descending colon. She underwent resection of the retroperitoneal mass, appendectomy, partial resection of the omentum majus, partial sigmoidectomy, proximal sigmoid colon fistula, and closure of the distal sigmoid colon. The patient recovered well after surgery. She was advised to go to the No. 1 Hospital of Peking University for steroid therapy.
+The pathological diagnosis was idiopathic RPF. The fibrous component was interpreted as remarkable storiform fibrosis mixed with fibroblasts, neutrophil granulocytes, plasma cells, and lymphocytes . Immunohistochemistry showed that vimentin was positive , smooth muscle actin was partially positive, β-catenin was positive (cell membrane and cytoplasm), Ki-67 was very weakly positive (<1%), GIST-1 was equivocal, and desmin, CD30, anaplastic lymphoma kinase, CD117, CD34, α-inhibin, S-100, epithelial membrane antigen, and cytokeratin pan were all negative.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_761_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_761_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..246ca4f9a0c97eb542bf3895f2850abcf1b79d8c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_761_en.txt
@@ -0,0 +1,7 @@
+A 53-year-old Caucasian man was referred to our centre for absolute dysphagia. This, initiated 4 months before for both solids and liquids, had an insidious onset and was accompanied by a slight cough and persistent fever for which initial antibiotic therapy was prescribed. Fever, usually mild and constantly measured, peaked twice over 40°C.
+The initial radiological assessment consisted of a chest X-ray showing a large right paratracheal mass. A computed tomography (CT) scan confirmed, at the level of the thorax, the presence of a large (7.5 cm) lobulated mass of heterogeneous density located below the carina. This was clearly compressing the oesophagus. . No evident signs of direct infiltration were found. No other abnormalities were found at the level of the brain, abdomen or pelvis.
+A subsequent orogastric endoscopic ultrasonography revealed a hypoechogenic lesion 5 cm in maximum diameter and 25 cm from the incisor teeth, with regular margins, directly compressing the oesophagus. Fine needle aspiration cytology, with double sampling by CT guided transthoracic and ultrasound guided transparietal endoscopic procedures in two different regions of the mass, revealed a loosely dispersed population of rare epithelioid atypical cells with prominent nucleoli and abundant eosinophilic cytoplasm. No lesions or compressions were detected at fibro-tracheo-bronchoscopic examination.
+Because of the rapid worsening of symptomatology, the patient underwent surgical intervention with a minimally invasive approach, initially with diagnostic intent. Should resectability have been confirmed, a radical procedure was planned. A right video-assisted thoracoscopic biopsy was performed. The frozen section demonstrated a malignant epithelioid lesion. Lung origin was excluded and further thoracoscopic exploration confirmed the feasibility of a radical resection.
+The lesion was radically resected via an open thoracotomy. No signs of direct infiltration of the mass were confirmed at the level of surrounding organs. In particular, the surface of contact with the oesophagus, the right atrium, the main right bronchus and the pulmonary artery was carefully explored. The vagus nerve was identified. A single chest drainage tube was left in situ. The postoperative period was uneventful. The patient started oral intake of fluids on the first postoperative day.
+Gross pathologic examination of the posterior mediastinal mass showed a grey lobulated mass measuring 8 × 9 × 7 cm . Routine histologic studies showed large sheets of epithelioid cells with abundant eosinophilic to clear cytoplasm. Focal spindle cell features and brown pigment were also present. The mass showed peripheral compressed nodal tissue with anthracotic pigment. The nuclei showed frequent inclusions and prominent nucleoli . A Fontana-Masson stain confirmed the presence of melanin pigment in the cytoplasm of neoplastic cells. Immunohistochemical positivity for S-100, Melan A and HMB 45 confirmed the melanomatous nature.
+The final diagnosis was malignant metastatic melanoma of a lymph node. No evidence of a primary tumour or superficial nodal involvement was detected outside the mediastinum. The patient is alive and well one year after the operation with no signs of recurrent disease in the mediastinum or appearance of other signs of disease elsewhere. Standard adjuvant immunotherapy has been administered.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_769_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_769_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d203d9c26c6b569ba3b2eb37cfbd9943d4bcfa0c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_769_en.txt
@@ -0,0 +1 @@
+In 2010, a 57-year-old Caucasian male with a history of hypertension and familial hypercholesterinaemia presented to our outpatient clinic with newly developed tearing left-sided chest pain radiating to the back unrelated to exercise. He was cycling regularly without compromise. His medication included Ramipril, Ezetimibe, and Rosuvastatin. Family history: the patient’s mother suffered from an unspecified heart condition since age 40, the father died of a stroke at an older age. His daughter and two granddaughters have no known cardiac condition. The physical examination was unremarkable, the blood pressure 130/80 mmHg. The resting electrocardiogram (ECG) showed slight T-wave inversions in V5 (, left). Troponin I was at 0.1 ng/mL (reference <0.032 ng/mL). A bicycle exercise ECG was terminated early due to ascending ST-segment-depressions and marked hypertension (237/100 mmHg). Transthoracic echocardiography showed a normal left ventricular ejection fraction (LVEF >60%). Cardiac magnetic resonance (CMR) with dobutamine stress showed no signs of ischaemia with an LVEF of 67%. The apical wall thickness was 8 mm with a ratio of 1.1 (, top row). In 2013, the patient was referred again for anterolateral T-wave inversions (, middle), at this point symptom free. The blood pressure was 140/80 mmHg. Echocardiography suggested slight concentric hypertrophy. A second dobutamine stress-CMR showed no signs of ischaemia. The apical wall thickness had grown to 11 mm, meeting the criteria for relative but not absolute apical hypertrophy (, middle row). Subsequent exercise ECGs in 2016 and early 2018 showed the known ST-depressions and exercise-induced hypertension. At the end of 2018, the patient presented again with atypical chest pain and exertional dyspnoea New York Heart Association II (fast cycling, 3–4 flights of stairs). Blood pressure was 166/101 mmHg. The resting ECG showed global T-wave inversions (, right). High-sensitive Troponin I was slightly elevated at 4.5 ng/mL (reference <1.9 ng/mL) without a relevant kinetic. Echocardiography showed diastolic dysfunction (E/A 1.5, E/E′ medial 22.0, lateral 15.1, LAVi 35 mL/m2) and marked apical hypertrophy (16 mm, ratio 1.8, ). Coronary artery disease was excluded by coronary angiography. The left ventricular end-diastolic pressure was elevated at 22 mmHg. A third CMR in early 2019 confirmed the apical hypertrophy (, bottom row). Late enhancement imaging and parametric CMR showed diffuse fibrosis of the apical septum in 2019. Regional and global longitudinal and circumferential endocardial feature-tracking strain values showed progressive impairment of the longitudinal strain in the apical segments with pathological values at the last exam compared to published reference values., A diagnosis of apical HCM was made. Holter monitoring showed no cardiac arrhythmias, 24 h ambulatory blood pressure monitoring showed arterial hypertension (mean 146/90 mmHg, dipper). Verapamil and Chlortalidon were prescribed. Cardiac consultation for the patient’s daughter and granddaughters was recommended.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_770_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_770_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e209cc19e742473ca0b33ad809367938001e2d56
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_770_en.txt
@@ -0,0 +1,8 @@
+A 5-year-old boy was admitted to the Neurosurgery Department of Tianjin Huanhu Hospital on February 2021 due to right ocular motility disorder and right upper eyelid ptosis.
+The patient suffered from right ocular motility disorder, accompanied by right upper eyelid ptosis and diplopia without apparent cause for one month, which had recently worsened. He had no fever, and denied symptoms of headache, vomiting, convulsions, and limb weakness. In addition, he denied fatigue, night sweats, wasting and other tuberculosis symptoms.
+The patient had no history of previous disease, including tuberculosis, and he was not taking any medication.
+The patient had no related personal and family history, and he denied any tuberculosis contact. Bacillus Calmette-Guerin vaccination was performed after birth.
+The patient's vital signs were normal. Physical examination showed no remarkable findings of positive signs, including rales in both lungs, tenderness in the abdomen and palpable lymphadenopathy. Neurological examination showed right third cranial nerve palsy with restrictions of eye movements and ptosis, pupil dilation and negative light reflex. There were no meningeal signs. Muscle tone and tendon reflexes were normal. The patient was not found to have Marcus Gunn syndrome during the eye examination.
+Routine laboratory tests, including complete blood count, hepatic and renal function and electrolytes were all in the normal ranges. MTB and HIV serologies were negative.
+The patient’s brain computed tomography (CT) scan showed a mixed density mass in the suprasellar cistern with poorly defined borders, and multiple patchy calcifications were observed within it, with intact adjacent bone structure . A brain magnetic resonance imaging (MRI) scan showed that the lesion was approximately 1.6 cm × 2.2 cm × 1.5 cm, downward involving the prepontine cistern, with clear borders, and the lesion appeared isointense on T1-weighted images (T1WI) and hypointense to isointense on T2-weighted images (T2WI), with irregular ring-enhancement after injection of gadolinium . No abnormality was observed on a plain CT scan of the patient’s chest, therefore active pulmonary tuberculosis was not considered.
+To determine the presence of MTB in cerebrospinal fluid (CSF), which suggested tuberculosis, the patient subsequently underwent lumbar puncture. The CSF was clear with normal pressure and negative polymerase chain reaction (PCR) for MTB.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_773_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_773_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0c8dd91bcb95ecc7c8bb1b83af8a1c3faa2726fa
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_773_en.txt
@@ -0,0 +1,5 @@
+A four-year-old girl who had been experiencing fever, frequency, and dysuria for a week was brought to the pediatric clinic. Her parents also mentioned having a headache beginning from 5 days ago. Nausea, vomiting, diarrhea, and abdominal pain were not mentioned. She was first in birth order and was delivered vaginally at 39 gestational weeks. Her birth weight was 3630 g, and measurements of her weight (16 kg), height (98 cm), and head circumference (48 cm) were normal. Her family did not recently have any gastrointestinal or urinary complaints. She was toilet trained but had infrequent voiding. She had no recent history of traveling or playing in rivers or seawater. The mother of the patient mentioned the patient's consumption of salmon over the last month, which did not result in any gastrointestinal issues. A common goldfish was kept in a tank in residence for almost 2 weeks, and it died about a week ago. The patient’s parents stated that she had put her hand into the fish tank several times. The child had been hospitalized twice for UTI since last year. During the second hospitalization, which was 8 months ago, a voiding cystourethrogram was conducted for the patient, and no signs of vesicoureteral reflux were observed.
+On arrival, the patient's general condition was good. Her vital signs were heart rate of 98 beats per minute, 115/65 mmHg blood pressure, respiratory rate of 23 breaths per minute, oxygen saturation of 97% in ambient air, and 38.6 °C axillary temperature. During the examinations, no costovertebral tenderness was detected. Neck rigidity was also negative. The examination of the abdomen and genital area revealed no notable findings.
+According to a urinalysis performed four days prior at a different center, the patient's urine specimen contained 3–4 red blood cells, many white blood cells, and many bacteria per high-power field, as well as 1+ protein and positive nitritite. Urine culture (UC) had also been performed, and the results revealed E. tarda species of more than 100,000 colony-forming units resistant to cefixime, ciprofloxacin, cotrimoxazole, and nalidixic acid, but sensitive to meropenem, tetracycline, and nitrofurantoin. However, the blood culture was negative. According to a later call made to the center's microbiologist for diagnostic information, the specimen was cultured on MacConkey and blood agar containing 5% sheep red blood cell, and it was later determined to be E. tarda via chemical tests as follows: The organism was motile and rod-shaped, and hydrogen sulfide production and indole production tests were positive for the organism. Mannitol could not be fermented by the organism, but glucose could. Additionally, the urease, O-nitrophenyl-beta-d-galactoside, cytochrome oxidase, citrate, and Vogeus-Proskauer (VP) tests yielded negative results. Figures , and illustrate a portion of the urine culture findings.
+The patient's parents had been advised to bring their child to the children's hospital for treatment. Prior to admittance, the patient had not been administered any medication. The patient was hospitalized due to her symptoms and the above tests. Initial blood tests revealed a white blood cell count of 11.93 × 103/µL with a differential of 59% neutrophils and 36% lymphocytes, hemoglobin level of 13.32 gr/dL, platelet count of 359 × 103/µL, blood sugar level of 96 mg/dL, and C-reactive protein level of 3+. Due to the patient's headache complaint, which did not improve despite medication use at home, a magnetic resonance imaging of the brain was performed, which indicated no abnormalities.
+The patient was administered 600 mg of intravenous ceftriaxone every 12 h along with fluid therapy. On the second day of hospitalization, due to the elimination of fever and improvement in the patient's symptoms, the patient was discharged with the instruction to take nitrofurantoin suspension 25/5 mg, 9 cc every 8 h for 1 week. After a week, the urinalysis results were as follows: 3–4 white blood cells, 0–1 red blood cell, and no bacteria per high power field, and also negative protein and nitrite. The UC revealed no growth after 24 h.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_780_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_780_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..34c6c43bb342c62b93192dd365d1f6eebf24f387
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_780_en.txt
@@ -0,0 +1 @@
+A 34-year-old Taiwanese man with beta-thalassemia major had been administered routine blood transfusion and subcutaneous deferoxamine at 30 mg/kg/day for 20 years since youth. He was hospitalized for a compression fracture and myelopathy of the thoracic spine. He presented with acute onset of decreased vision, impaired color vision, and night blindness following continuous intravenous deferoxamine (98 mg/kg) for 42 days for the treatment of elevated serum ferritin level. On ophthalmic examinations, the best-corrected vision was 20/200 in the right eye and 20/40 in the left eye. The intraocular pressure measurement and anterior segment examination yielded normal results for both eyes. The fundus examination revealed multiple discrete hypo-pigmented circular lesions over the posterior pole and mid-peripheral retina in both eyes.Deferoxamine retinopathy was suspected, and the patient was switched to oral deferasirox/deferiprone. Six weeks later, there was an improvement in the best-corrected vision (20/60 in the right eye and 20/25 in the left eye) and color vision. Retinal pigmentary changes became confluent . NIR showed hyper-reflective deposits particularly in the parafoveal and perifoveal areas . SD-OCT showed multiple confluent hyper-reflective deposits in the choroid, retinal pigment epithelium (RPE) and IS/OS junction. Thickened RPE, Bruch’s membrane, and choroid space were also discovered. The IS/OS junction was most severely disrupted at the perifoveal and parafoveal areas than at the foveola area .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_798_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_798_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a7e9caec5e6f78c4133ee0a989ab47ed1ac8a7ba
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_798_en.txt
@@ -0,0 +1,5 @@
+A 69-year-old Japanese man presented to our institution with decreased vision in his right eye. He had a medical history of stage 4, poorly differentiated, esophageal cancer that had been diagnosed previously via endoscopic biopsy. Positron emission tomography–computed tomography (PET–CT) revealed multifocal increases in fluorodeoxyglucose uptake into the esophagus, lung, liver, lumbar vertebrae, and mediastinal lymph nodes. The patient was treated with three cycles of fluorouracil (5-FU) and cisplatin (CDDP) chemotherapy as well as 30 sessions of radiation therapy (60 Gy) over approximately 6 weeks, three months prior to presentation.
+Visual acuity was 20/200 in the right eye (OD) and 20/600 in the left eye (OS). The patient reported previously having a macular hole in the left eye but received no surgical intervention. Anterior segment examination was normal except for 2+ nuclear cataracts in both eyes (OU). No anterior segment inflammation was present in either eye. A dilated fundus examination revealed a veil-like vitreous opacity with white retinal lesions in the macula and periphery OD, consistent with a vasculitis or possible ARN . Although the view was limited due to the thick vitreous opacity, no obvious masses were detected in the retina or choroid. Fundus examination of the left eye was normal, except for evidence of the old macular hole with hard exudates along the superior temporal arcade . Given the patient’s history of metastatic esophageal cancer, differential diagnoses included acute retinal necrosis (ARN), chronic uveitis, and neoplastic disease. Due to the poor view and uncertainty regarding diagnosis, surgical intervention was scheduled two days later.
+A combined cataract extraction and 25 gauge pars plana vitrectomy was performed. Phacoemulsification was followed by intraocular lens implantation. Next the vitreous opacity was removed and submitted for polymerase chain reaction (PCR) testing and cytologic analyses. A peripheral tractional retinal detachment was also detected during the surgery. Therefore, a silicone oil tamponade was selected. In consideration of the possible ARN diagnosis, the patient was started on systemic antiviral (250 mg/day intravenous acyclovir for 3 days), anti-inflammatory (20 mg/day oral prednisolone for 3 days), and anti-coagulant (100 mg/day biaspirin for 3 days) therapies immediately following surgery with cooperation with the internal medicine department.
+PCR testing from vitreous sample was negative for toxoplasma, cytomegalovirus, herpes simplex virus, varicella-zoster virus, bacteria, and fungi. However, the vitreous sample did contain scattered, undifferentiated malignant cells . Further immunohistochemical examination was not performed due to the small sample size. Vitreous specimen findings matched those of the primary esophageal tumor biopsy . Given the presence of a central nervous system metastasis, magnetic resonance imaging (MRI) of the head was performed. No evidence of further central nervous system malignancies was found. However repeat PET–CT revealed widespread systemic metastases.
+Ultra-wide view fundus imaging revealed multifocal white intraretinal lesions in the macula and periphery two months after surgery . Optical coherence tomography (OCT) through these white opacities displayed hyper-reflective inner retinal lesions with no choroidal involvement, suggestive of retinal metastasis . Visual acuity was 20/200 OD and the retina remained attached under the silicone oil. No further intervention was provided by our department due to the poor prognosis. The patient was maintained on palliative care and passed away three month later due to multiple organ failure, secondary to his malignancy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_807_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_807_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d7c067b2eda4660a6ca5e2bc858bf554ab4de19c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_807_en.txt
@@ -0,0 +1,3 @@
+A 75-year-old woman with a 1-week history of diplopia was referred to the ophthalmology clinic from the medical ward, where she was being treated for atypical pneumonia. She had been unwell for a few months with loss of appetite and weight. Sputum acid-fast bacillus smear and culture tests for tuberculosis were negative. There were no specific symptoms or signs suggestive of giant cell arteritis (GCA) but the erythrocyte sedimentation rate (ESR) was 98 mm/hour and the C-reactive protein was more than 139 mg/dl, which prompted the physicians to arrange a temporal artery biopsy. This was later reported as normal.
+Ophthalmic examination showed corrected visual acuity of 6/6 bilaterally. There was subtle localized episcleral injection near the right lateral rectus muscle insertion. The posterior segment revealed a normal optic disc and macula bilaterally. Ocular motility revealed an abduction deficit in the right eye .
+Computed tomography (CT) scanning of the head and orbits revealed a mass in the belly of the right lateral rectus suggestive of a metastatic lesion . Subsequent CT and magnetic resonance imaging (MRI) of the thorax and abdomen showed multiple secondary metastatic lesions in the lung and enlargement of retroperitoneal lymph nodes. The patient underwent an endoscopic retrograde cholangiopancreatography and the cytology of the brushings was highly suggestive of anaplasia. Pancreatic carcinoma was suspected but abdominal CT scanning and ultrasonic studies revealed no evidence. The patient later developed a supraclavicular lymph node mass, bilateral axillary lymphadenopathy and enlarged spleen. A supraclavicular lymph node biopsy was inconclusive. The suspected diagnosis of pancreatic cancer remained unconfirmed. The general condition of the patient had deteriorated, precluding further invasive investigations such as orbital biopsy. The patient died 4 months after her initial diagnosis of orbital metastasis. Autopsy was not performed on the body.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_80_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_80_en.txt
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index 0000000000000000000000000000000000000000..6e6e95bbc5bae0725c6eaac52e67e3d3dfc0928b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_80_en.txt
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+A 72-year-old man, experiencing chest pain near the sternum for 2 days, was admitted to our hospital. He had no history of coronary artery disease, hypertension, dyslipidaemia, and other comorbidities. He gradually developed dyspnoea during the preceding month, with no fever or peripheral oedema.
+On initial examination at the Emergency Department, the patient was haemodynamically stable (blood pressure of 110/65 mmHg; regular pulse rate of 70 b.p.m.; and respiratory rate of 20 breaths/min). Cardiac and respiratory examination showed normal heart sounds and an absence of murmurs, gallops, and clear lung fields. Electrocardiogram (ECG) showed sinus rhythm and low amplitude QRS complexes with right bundle branch block (RBBB) morphology . Echocardiography revealed concentric left ventricular hypertrophy, biatrial dilation, mild pericardial effusion close to the right atrium , and a preserved ejection fraction with predominantly left ventricular basal hypokinesis. Serial testing of cardiac biomarkers showed an increased level of high-sensitive cardiac troponin T (hs-cTnT), along with normal levels of serum creatine kinase myocardial band (CK-MB). According to these clinical and troponin findings, ACS had to be excluded, despite a normal level of CK-MB. The patient was given 500 mg of aspirin and 600 mg of clopidogrel before urgent percutaneous coronary intervention. However, coronary angiography demonstrated non-obstructive right and left coronary arteries . The patient was referred to the Department of Cardiology for further evaluation, where screening for cardiomyopathy was performed. Physical re-examination showed signs of non-cardiac disease, suggesting amyloid fibril damage, including macroglossia, periorbital purpura, and purpura above the nipples . Laboratory investigations revealed elevated serum immunoglobulin free light chain (FLC) kappa and lambda levels with an increased FLC ratio. These findings were suggestive of amyloidosis; therefore, the histopathological features of an abdominal skin punch biopsy specimen were studied. Congo red stain detected amyloid deposits under the light microscope and showed apple-green birefringence using polarizing microscopy. Immunostaining showed accumulation of kappa light chain-immunoreactive amyloid . These histological analyses confirmed the diagnosis of immunoglobulin light chain (AL) amyloidosis in this patient.
+During the 1 week of stay at our hospital, the patient’s medical management included losartan 12.5 mg o.d., bisoprolol 1.25 mg o.d., furosemide 20 mg o.d., and isosorbide mononitrate 60 mg o.d. Losartan and bisoprolol were indicated based on limited evidence in the treatment of heart failure with preserved ejection fraction. Furosemide and isosorbide mononitrate were used for maintaining euvolaemia and relieving the symptoms of chest discomfort, respectively. Because this regimen gradually ameliorated his clinical status, we decided to continue with the medical treatment. The patient was discharged in a stable condition. To screen for a possible concurrent multiple myeloma, the patient was referred to a haematology centre. Unfortunately, 5 days post-discharge, he suddenly expired at home.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_834_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_834_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5392e7460f3bf82e1ce417409faa486a399465a2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_834_en.txt
@@ -0,0 +1,18 @@
+A 46-year-old man with no remarkable past medical history was brought to the emergency department of the University Clinical Hospital in Wrocław. As reported by the emergency medical service physician, the man was found lying under a park bench. He was obtunded, reported nausea and vomiting, but denied any chest pain. The physician noted anisocoria (left > right).
+The initial electrocardiogram (ECG) recorded at 04:04 PM showed sinus bradycardia with a rate of 55 beats per minute (bpm), first degree atrioventricular block, widened QRS complexes, and ST elevation in leads II, III, aVF, and V3–V6 . Suspicion of an acute coronary syndrome (ACS) was raised. Within 5 min, ventricular tachycardia developed , followed by torsade de pointes with a rate of 150 bpm . At 04:28 PM, cardiac arrest due to bradycardia/asystole occurred. Sinus rhythm returned after a short application of external cardiac massage. While the patient was in the emergency department, basic and advanced life support was initiated several times (with 1 mg adrenalin injection three times) due to cardiac arrest caused by bradycardia and asystole. Intravenous dopamine infusion was started and access to the right jugular vein was obtained. Emergency coronary angiography showed no significant coronary lesions. A consulting neurologist ordered computed tomography of the brain which also showed no significant abnormalities.
+Abnormal laboratory test results included elevated levels of dimer D (1.19 μg/mL), gamma-glutamyl transpeptidase (119 U/L), aspartate transaminase (238 U/L), alanine transaminase (172 U/L), urea (68 mg/dL), creatinine (1.40 mg/dL), plasma glucose (323 mg/dL), and hypokalemia (3.3 mmol/L). Troponin I level was normal. Arterial blood gases showed metabolic acidosis.
+On admission to the Intensive Cardiac Care Unit, the patient was severely ill, sedated with midazolam and fentanyl, intubated, ventilated, and treated with intravenous dopamine infusion. Bedside echocardiography showed dilated vena cava inferior (28 mm) without respiratory variability, paradoxical interventricular septal motion (D-sign), and impaired left ventricular systolic function with an ejection fraction of 40 %. Pulmonary embolism was suspected and pulmonary computed angiotomography was performed which showed no evidence of embolism.
+At 11:05 PM, cardiac arrest due to pulseless electrical activity occurred and resuscitation was started immediately. ECG showed recurrent torsade de pointes, requiring several defibrillations and administration of magnesium and antiarrhythmic drugs, and periods of bradycardia. The overall duration of resuscitation attempts was 1.5 h. The patient was treated with intravenous dopamine (200 μg/50 mL 0.9 % NaCl, rate 15 mL/h), norepinephrine (8 mg/50 mL 0.9 % NaCl, rate 30 mL/h), and dobutamine (250 μg/50 mL 0.9 % NaCl, rate 5 mL/h) infusions and adrenaline in boluses (6 × 1 mg during resuscitation) followed by infusion (2 mg/50 mL 0.9 % NaCl, rate 10 mL/h) beginning at 02:30 AM. The patient also received amiodarone, lidocaine, bicarbonates, and intravenous fluids (1000 mL 0.9 % NaCl, yielding 2700 mL of urine). Due to ineffective antiarrhythmic drug therapy and bradycardia, a transvenous pacing lead was inserted, allowing effective pacing and resolution of shock.
+Despite treatment with amiodarone, magnesium, and lidocaine, correction of electrolyte disturbance, and several dozens of defibrillation attempts, the arrhythmia underlying cardiac arrest persisted. Only after overdrive pacing was established using a transvenous pacing lead could arrhythmia be controlled and the patient’s condition stabilized.
+As the underlying cause of the patient’s clinical condition remained unknown, the patient’s family was contacted. The family reported that 2–3 weeks before admission to the Department of Cardiology, the patient was consulted by a psychiatrist due to a suspected suicide attempt. He had numerous financial debts resulting from his addiction to internet gambling. The toxicology screen and serum digoxin assay on admission were negative. The family was asked to search for any toxic substances among the patient’s personal belongings at home and work. A decoction of unknown origin was found in the patient’s work locker and his mobile phone’s internet history included websites discussing toxic plants, including yew (Taxus baccata). Due to a suspicion of Taxus baccata intoxication (bradycardia leading to asystole, vomiting, orange-pink color of urine), the decoction and patient’s blood sample were sent to the Department of Pharmaceutical Biology and Botany for biochemical analysis.
+Fresh leaves (needles) (20 g) of T. baccata were harvested from two different locations. The first sample was from the vicinity of where the suicide attempt took place (yew1) and the second one was from the certified collection of the Wroclaw Medical University Botanical Garden where T. baccata is cultivated (yew2). The voucher specimens of the two plant samples are stored in the herbarium of the Botanical Garden.
+All material was ultra-sonicated (IS-36 ultrasonic bath, Intersonic, Poland) in 200 mL of ethanol (analytical grade, 95 %) for 30 min and soaked for 16 h overnight. The crude extract was filtered, the solvent evaporated, and the residue was reconstituted with 80 mL 1 N HCl and extracted with 80 mL dichloromethane. The aqueous phase was alkalized with ammonia solution (25 %) and extracted with 240 mL dichloromethane (3 × 80 mL). The organic phases were pooled and the solvent evaporated, yielding 80 mg of a white residue (0.4 % of the fresh mass of yew leaves). A methanolic solution of this residue was diluted with mobile phases A and B (50:50, v/v) for further analysis.
+Two mL of the patient’s blood serum sample obtained from the coronary care unit were precipitated by adding 2 mL of acetonitrile, followed by centrifugation at 6000 g for 7 min. The supernatant was then purified by the solid phase extraction method using octadecyl silica bed cartridges (Supelco, USA). All analyzed samples were filtered with a 0.45 μm membrane filter (PTFE, Carl Roth, Germany) before injection into the ultra fast liquid chromatography (UFLC) system.
+The UFLC system consisted of an LC-30ADXR pump, a DGU-20A3 degasser, a SIL-20AXR autosampler, a CTO-10ASVP column heater, and a CBM-20A system controller (Shimadzu Ltd. Japan). Chromatographic separations were performed on a Kinetex C18 100A column (2.1 mm × 100 mm, 2.6 μ) with a security guard column (Phenomenex, U.S.A.).
+The mobile phase was composed of acetonitrile-water with 0.1 % (v/v) formic acid. A gradient program was employed with the mobile phase, combining solvent A (water) and solvent B (acetonitrile) with 0.1 % formic acid as follows: 80 % A (0–0.5 min), 80–40 % A (0.5–7 min), 40–20 % A (7–12 min), 20–5 % A (12–15 min), 5–0 % A (15–16 min), 0 % A (16–17 min), 0–80 % A (17–18 min), 80 % A (18–22 min).
+The flow rate was 0.3 mL/min and the injection volume was 1 μL. The column and sample temperatures were maintained at 35 and 4 °C, respectively. All data acquisition and peak integration were performed using LabSolution (5.53 SP2) from Shimadzu Ltd.
+Mass spectrometric detection was performed on a Shimadzu LCMS-8030 with an electrospray ionization (ESI). The analytes were determined in the positive ionization mode and quantified by multiple-reaction monitoring (MRM) mode. The parameters and conditions were optimized as follows: capillary voltage of 4.5 kV, desolvation line (DL) temperature of 250 °C, heat block temperature of 400 °C, and nebulizing gas flow and drying gas flow of 3 L/min and 15 L/min, respectively.
+Qualitative confirmation was achieved using UFLC MS/MS analysis with MRM . The obtained spectra were compared to the literature data [, ].
+The main substance of taxine origin identified in the blood sample (serum) was 3,5-DMP, the aglycone of taxicatine (3,5-dimethoxyphenol glucoside), which is an ingredient of yew leaves. This compound was suggested by Musshof et al. as a convenient marker of poisoning with Taxus baccata leaves. We observed this compound in both yew1 and yew2 samples. Other toxins including taxine A, 2-deacetyltaxine, monoacetyltaxin, taxine B (isotaxine B), monohydroxydiacetyltaxine, triacetyltaxin, and monohydroxytriacetyltaxine were also detected. We did not detect paclitaxel (Taxol A), deacetyltaxol, 10-(DAT), deacetylbaccatin III 10-(DAB) in any of the analyzed samples. These compounds are frequently listed as yew constituents. However, they may not have been extracted from our plant material with the method used.
+Nonetheless, the liquid chromatography tandem mass spectrometry (LC-MS/MS) method was useful for fast and reliable detection of yew toxin residues in the blood sample.
+The main taxine ingredients are presented in Table .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_841_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_841_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..86d031bfd6e01df2f7ee7ab1ef33131a036621d7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_841_en.txt
@@ -0,0 +1,3 @@
+A 59-year-old Italian man presented with abdominal pain localized in the right upper quadrant, constipation and vomiting for longer than one week. The patient had inconstant symptoms including shortness of breath and dyspnea. His medical history included right-sided rib fractures in a motor vehicle crash seven years previously.
+On physical examination, bowel sounds were present in the right hemithorax on auscultation. A chest X-ray showed elevation of the right hemidiaphragm elevation, with a portion of the colon and the small intestine transposed in the right hemithorax as a diaphragmatic rupture. A barium study showed small bowel and right colon herniation into the right hemithorax, passing behind the liver . Computed tomography (CT) scan confirmed the diaphragmatic herniation .
+The patient underwent laparotomy, and herniation of the right colon and small intestine (40 mm in length) was seen. There were no ischemic changes or perforation, but the colon was slightly edematous. No resection of any part of the intestinal tract was necessary. The colon and the small intestine were reduced into the abdomen. As usual in traumatic lesions, there was absence of the hernial sack: the hernia opening was only 50 mm in length, . The hernia opening was repaired with interrupted non-absorbable sutures; placement of a polymeric prosthetic mesh was not required at the time of the intervention. A drain was placed in the right side of the thorax. The operating time was 45 minutes. The thoracic drain was removed on the third post-operative day and the patient was discharged on the fifth postoperative day.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_858_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_858_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0e5ee41fb787ebe615a3f02386be9fe6c718d598
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_858_en.txt
@@ -0,0 +1,4 @@
+A 72-year-old Japanese woman on medications for hypertension, obesity, and diabetes mellitus, was referred to our hospital with abnormal uterine bleeding. She was previously diagnosed with abnormal endometrial cytology at a previous clinic and visited our hospital for further examination and treatment. Endometrial biopsy revealed an adenocarcinoma (G2), while pelvic magnetic resonance imaging revealed a lesion mass of size 60 × 66 × 53 mm in the right side of the uterus , which was suspected to invade the serosal side. An enlarged lymph node measuring 18 mm was also found in the lymph node clusters in the right internal iliac artery and the obturator lymph node. Therefore, hysterectomy, bilateral adnexectomy, pelvic lymph node dissection, and para-aortic lymph node dissection were performed. A pathological examination using surgical specimen revealed endometrial serous carcinoma . Finally, she was diagnosed with stage III C2 endometrial cancer.
+On the 6th postoperative day (POD), the patient developed abdominal bloating and nausea. Abdominal radiography revealed that the stomach and the intestine were markedly dilated with gas and air-fluid levels, indicating paralytic ileus . Thus, the patient was initiated on fasting and fluid replacement therapy, following which she recovered completely within 4 days. On the 27th POD, the patient received the first cycle of combination chemotherapy consisting of paclitaxel (175 mg/m2; 3-h infusion) and carboplatin (at a dose corresponding to an area under the curve [AUC] of 5 mg/mL/min).
+On day 5 of chemotherapy, the patient developed a fever (38.6 °C), diarrhea, and fatigue. Her pulse rate, respiratory rate, and blood pressure were 120 beats/min, 20 breaths/min, and 88/52 mmHg, respectively. Blood examination revealed a white blood cell count, neutrophil count, and C-reactive protein (CRP) level of 270/μL, 40/μL, and 17.92 mg/dL, respectively, which were suggestive of the systemic inflammatory response syndrome including febrile neutropenia (FN) and sepsis. Therefore, an antibiotic therapy and granulocyte-colony stimulating factor therapy were initiated immediately. However, her condition worsened the next day. The body temperature, pulse rate, respiratory rate, blood pressure, white blood cell count, neutrophil count, and CRP level were 40.2 °C, 150 beats/min, 49 breaths/min, 63/42 mmHg, 150/μL, 0/μL, and 41.5 mg/dL, respectively.
+Because she suffered from septic shock and DIC, she was shifted to the intensive care unit (ICU). Computed tomography (CT) of the abdomen and pelvis revealed remarkable intestinal dilation and thickening of the intestinal wall. Therefore, we considered enteritis as the origin of inflammation . Furthermore, we speculated that the patient’s condition was associated with toxicity due to bacterial translocation. However, no bacteria were detected in the blood and intestinal fluid. In addition to the treatment for septic shock and DIC, a long ileus tube was inserted into the stomach through the nasal cavity because she experienced a constant high-pressure feeling in the intestine and because we had to suction the extra air and fluid. Favorable outcomes were achieved, including reduced edema in the intestinal colon, improved circulation in the involved intestine, and correction of the intestinal kinking. Her condition gradually improved, and the neutrophil count and immune function improved from the 4th day of ICU admission. She was discharged alive and well from the ICU after 18 days . The patient’s clinical course is shown in Fig. . Written informed consent was obtained from the patient for participating in all procedures, and this work was approved by the Institutional Review Board of the Shimane University (IRB No-20200110-1).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_867_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_867_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9dce322018ff9b4b15ff06f810ebcd971a64fd67
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_867_en.txt
@@ -0,0 +1,2 @@
+A 56-year-old male patient was admitted to our hospital on 2022-09-19 with “chest tightness and chest pain for more than 2 months, aggravated for 20 days”, The patient have mild cough and expectoration, and had a weight loss of 10 kilogram (KG) in the past 2 months. The patient had a history of afternoon low fever before 1 week and the Physical examination revealed body temperature 36.5 °C, respiratory rate 25/min, pulse rate 96 beats/min, oxygen saturation 93%, 24-hour urine output about 600 mL, Performance status (PS) 3 points, he had a clear consciousness, poor mental health, anemia, enlarged superficial lymph nodes, barrel-shaped chest, swollen skin on the right side of the chest and the right side of the upper abdomen, solid percussion sounds on the right side of the chest with mixed turbid sounds, enlarged liver on the right side, no edema in the extremities, and deep yellow urine. Past medical history: mitral valvuloplasty and aortic valve replacement for mitral valve and aortic valve insufficiency at the Second Affiliated Hospital of Nanchang University under general anesthesia on 2021-08-11, long-term oral treatment with warfarin anticoagulation and metoprolol. Personal history: smoker for 40 years, 10 cigarettes per day, and no alcoholic habits, have no history of contact with a chronically coughing person suspected of or treated for TB.
+Admission biochemical examination: neuronal enolase 35.97 ng/mL, fibrin degradation products 10.86 mg/L, prothrombin time 141.2 seconds, prothrombin normalized ratio 11.87 INR, activated partial thromboplastin time 121.7 seconds, fibrinogen 4.72 g/L, leukocytes 11.94×109/L, hemoglobin 36 g/L, albumin 22.3 g/L, white/sphere 0.5, glutamate transaminase 114 IU/L, glutathione transaminase 288 IU/L, glutamyl transferase 92 IU/L, lactate dehydrogenase 492 IU/L, coagulation factor VIII activity 239.2%, coagulation factor IX activity 10.1%, coagulation factor XII activity 34.4%, Procalcitonin (PCT) 0.43 ng/mL, ultrasensitive C-reactive protein (gold standard) 124.00 mg/L, TSPOT negative, sputum negative for antacid bacilli, anti-TB antibody Weakly positive, fecal occult blood negative, EBV test was negative, and HIV was negative. The CT examination report : multiple wall nodules in the right pleura, right pleural encapsulated effusion with limited swelling insufficiency in the middle and lower lobes of the right lung, enlarged lymph nodes in the right hilar and mediastinal diaphragm groups, bone destruction in the 2nd thoracic vertebra, multiple slightly hypodense nodules in the liver. The possibility of multiple metastases of right lung cancer with malignant pleural fluid and possible infection in the upper lobes of both lungs was considered. Finally, a Ultrasonic guided needle biopsy of the lymph node, pleural, liver was performed and the histopathology showed coagulative necrosis combining with granulomatous inflammation (acid-fast bacilli staining was positive). Research shows Tuberculosis (TB) in humans is characterized by formation of immune-rich granulomas in infected tissues, And confirmative diagnosis is based on liver biopsy where demonstration of acid-fast bacilli on acid-fast bacilli staining and caseous necrosis is a very useful histopathological sign. Thus, the diag-nosis of TB infection was definite.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_875_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_875_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..76a6999dcb9e0c41c5b15401c3ee58114fc03f36
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_875_en.txt
@@ -0,0 +1,4 @@
+A 62-year-old male presented with a 4-month history of right brachial/shoulder pain and numbness with hyposensitivity in the C5 distribution. The magnetic resonance imaging (MRI) scan showed: (a) degenerative cervical spondylosis from the C3–C4 to C5–C6 levels, (b) a C5–C6 right anterolateral disc herniation with foraminal stenosis, and (c) syringomyelia extending from the C5–C6 to the T1 level .
+Following a C5–C6 anterior cervical discectomy and fusion (ACDF) with placement of a polyetheretherketone cage, the patient’s symptoms markedly improved. 3 months later, the MRI scan confirmed not only adequate decompression of the spinal cord but also the total resolution of the syrinx .
+Nevertheless, for residual, non-dermatomal right cervical neuropathic pain, the patient underwent placement of an eight-electrode subdural spinal cord stimulator placed from the C3 to C4 through the C5–C6 levels; the patient significantly improved .
+Syringomyelia is usually attributed to Chiari malformations, spinal arachnoiditis, intramedullary tumors, and trauma. It is seldom associated with cervical disc disease or spondylosis.[-] In two such cases, ACDF resulted in complete radiological and clinical resolution of the syrinx.[,] Younger patient age, a longer history of disease, and lower functional scores were associated with syringomyelia. Notably, postoperative outcomes and progression-free survival for those patients did not differ significantly versus those without syringomyelia. Here, we presented a rare case of syringomyelia attributed to cervical disc disease/stenosis that fully resolved following a C5–C6 ACDF. Such complete radiological resolution indicates that cervical disc disease/spondylosis might alter the cerebrospinal fluid flow that was adequately restored to normal with surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_877_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_877_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fedf50fcb2a1f48c0d2a5f15db45109b2ea109fc
--- /dev/null
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+A 66-year-old female visited the outpatient clinic with one year history of painful swelling of right ankle and a draining sinus around lateral malleolus. Her medical history was not significant except dyslipidemia and she had no apparent trauma before the onset of the symptoms. Five months and three months before the initial visit, she had undergone arthroscopic synovectomy and bursectomy in other hospital for chronic bursitis , but no causative organism was revealed from the intraoperative tissue cultures. No limitation of range of motion or fever was observed at the initial presentation but the patient had intermittent pain with walking. Her laboratory tests showed no evidence of prominent infection, as white blood cell (WBC) count of 3700 /μL, Erythrocyte sedimentation rate (ESR) of 15 mm/hr., C-reactive protein (CRP) of < 0.3 mg/dL. No suspicious radiolucent lesion was observed on plain radiograph of her right ankle. From her magnetic resonance image (MRI), high signal intensity in Proton density fat suppression images and T1-weighted double fat suppression images was found on subcutaneous tissue over lateral malleolus with intra-articular fluid effusion, synovial hypertrophy and localized bone edema around the ankle joint. Chronic bursitis with sinus tract and nonspecific synovitis of ankle were diagnosed, with suggestion of differential diagnosis of inflammatory arthritis, septic arthritis, early tuberculous arthritis and reactive synovitis due to ankle instability.
+Open bursectomy and sinus tract excision were performed, followed by 1st generation cephalosporin administration after the surgery. (Cefazedone 1 g BID [bis in die]) Bone biopsy was obtained from discolored distal fibular tip, which showed chronic inflammation and degeneration. Gram positive rods were identified in 1 out of 3 bacterial culture samples, one tissue culture sample and two swab cultures, and was interpreted as contamination as only one of the two swab samples showed gram positive bacilli, which seemed to be normal skin flora or contamination from surrounding environment according to the laboratory medicine department of the institution. Tuberculosis-polymerase chain reaction (TB-PCR) test was negative. The patient showed no fever postoperatively and CRP of < 0.3 mg/dL. 1st generation cephalosporin was administered intravenously until 2 weeks after the surgery and changed to oral agent for 1 more week. The patient was followed until 22 weeks postoperatively without any symptoms or signs of recurrence.
+The patient revisited the clinic two years later from the surgery for recurred painful swelling and pus drainage. Plain radiograph, computed tomography (CT) and MRI were taken and multiple huge cystic abscess surrounded by sclerotic rim and osteomyelitis of talus and medial malleolus were identified. Lateral malleolar bursectomy, debridement and drainage of talus abscess were done and intraoperative frozen biopsy obtained from periarticular soft tissue and bursae showed low grade infectious soft tissue. Permanent tissue biopsy was interpreted as chronic osteomyelitis with fibrinoid exudate, fibrosis and necrosis with abscess and foreign body reaction. Anti-nuclear antibody, anti-cyclic citrullinated peptide antibody and rheumatoid factor were tested to exclude autoimmune disease and other inflammatory arthritis, which turned out to be negative for all three markers. Bacterial culture, acid fast bacteria stain, TB-PCR, potassium hydroxide (KOH) mount and fungal culture were obtained and C. krusei was identified 1 out of 2 fungal culture samples. Antifungal drug sensitivity and resistance test were requested and the pathogen confirmed to be sensitive to amphotericin B, micafungin and voriconazole, intermediate for caspofungin, and resistant to fluconazole and flucytosine. Even though in vitro susceptibility against caspofungin was intermediate, caspofungin was recommended by the infectious disease specialist of the hospital according to the sensitivity test result, considering the potential toxicity of amphotericin B to which the pathogen was more susceptible. After two weeks of intravenous caspofungin 50 mg QD [quaque die] administration, the patient was discharged with patellar tendon bearing cast and oral voriconazole 200 mg BID for 6-month period, which was tolerable with only minor adverse effects like dry mouth, reported by the patient. The patient had regular liver function tests to monitor hepatotoxicity of voriconazole during antifungal administration at local clinic, all of which were within normal limits according to the patient. Her last outpatient clinic visit after one year and four months from the last surgery was uneventful with no clinical symptom recurrence. Plain radiographs and CT scan showed stationary cystic lesions of talus without evident talar roof collapse, and when compared to the radiographic studies of 10 months after the last surgery , slightly thickened cortical lining of the talar cysts was observed. Possibility of bone graft to the void was explained to the patient for prevention of potential talar collapse, but she refused to undergo another surgery as she had no clinical symptoms or functional impairments.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_883_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_883_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b9c8881142854e94179cc365e5b63684c3710fd8
--- /dev/null
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+A 20-year-old male patient was admitted to our hospital on July 9, 2021, for evaluation of recurring abdominal pain, diarrhea, and black stools, which had been persisting for 6 years.
+The patient received treatment at a local hospital 6 years back for seven days of unexplained abdominal pain. On examination, the peritoneal stimulation sign was positive. Abdominal X-ray at the time revealed a gas shadow located below the diaphragm. On diagnostic abdominal puncture, 5 mL of purulent fluid was withdrawn, thereby raising the suspicion of perforation in the digestive tract. Laparotomy performed for exploration revealed diffuse peritonitis, acute gangrenous appendicitis with perforation, adhesive intestinal obstruction, and pelvic abscess. Appendectomy, intestinal adhesiolysis, and pelvic abscess removal surgery were performed during the procedure (July 2, 2015). Following surgery, the patient’s condition improved and he was discharged. However, one year after discharge, the patient stared experiencing recurrent abdominal pain and dark red loose stools, with positive test results for fecal occult blood and mild to moderate anemia. Colonoscopy had been performed several times before and showed the presence of intestinal ulcers and bleeding at other hospitals. In light of the colonoscopy findings, a clinical diagnosis of IBD was made. Oral treatment with mesalazine was administered at a local hospital, at a dose of 2 tablets four times a day for a total of 6 weeks. However, there was no improvement in the symptoms of rectal bleeding. Subsequently, oral treatment with azathioprine was added, at a dose of 50 mg once a day for a total of 2 months. Even with this treatment, the symptoms of rectal bleeding did not improve. The Mayo score was 8 points both before and after medication (with an increase of 2-3 times per day compared to the normal bowel movements, mixed blood in the stool within less than half of the time, ulcer formation detected by endoscopy, and moderate condition). Considering its ineffectiveness, mesalazine and azathioprine treatment was discontinued.
+On July 9, 2021, the patient presented with persistence and worsening of the abovementioned symptoms. The frequency of episodes of abdominal pain and black stool had increased, with approximately 30 mL of dark red loose stools about 3-4 times a day, without mucus, or pus. In addition, he reported dizziness, but did not report any nausea, vomiting, abdominal distension, or constipation. The patient did not experience any loss of consciousness. Moreover, the patient did not show any signs of fever, chills, or night sweats. Subsequently, the patient sought medical attention and was hospitalized for further evaluation, diagnosis, and treatment.
+The patient's medical history was the same as before, with no other surgical or traumatic history. He also denied having any history of long-term use of NSAIDs or glucocorticoids. Due to gastrointestinal bleeding, the patient received red blood cell infusion twice, without any negative reactions during the process. There was no evidence of infectious diseases, such as typhoid fever and tuberculosis, or any sexually transmitted diseases.
+The individual reported a history of alcohol consumption for three years, although the amount consumed was unknown. He denied having any history of smoking or exposure to toxins; he also denied any family history of genetic diseases.
+On examination, the patient had stable vital signs, a clear mind, an anemic face, and pallor of the palpebral conjunctiva, lips, and nail beds. Superficial lymph nodes were not palpable, and cardiopulmonary examination revealed no apparent positive signs; only an old longitudinal surgical scar measuring approximately 20 cm in length was noted on the abdomen. Tenderness was noted beneath the xiphoid process, but there was no rebound pain or muscle tension. No shifting dullness was detected, and bowel sounds were heard at a rate of 6 per minute. No edema was observed in either lower limb.
+Routine blood tests revealed moderate anemia and a decrease in the average red blood cell volume . Other tests conducted after admission showed no abnormalities in coagulation function and blood biochemistry. No abnormal findings were obtained in laboratory tests for antineutrophil cytoplasmic antibody, antinuclear antibodies, immunoglobulin, lymphocyte immunochip, C-reactive protein (CRP), blood sedimentation rate, and detection of common viruses such as human immunodeficiency virus, hepatitis B virus, and cytomegalovirus. Analysis of the stool sample collected revealed the presence of occult blood. Fecal bacterial culture and fecal fungal culture did not show positive findings. Additionally, the 13C-urea breath test yielded a negative result. Whole-exome sequencing performed for the detection of genetic diseases led to the identification of autosomal ACVRL1 and PLA2G4A gene mutations (July 21, 2021; Figure ).
+On gastroscopy performed on July 12, 2021, the esophagus appeared to have normal morphology and color, with no evident abnormalities . The distance from the cardia to the incisor was approximately 40 cm, and the dentate line was clearly visible. No abnormalities were visible in the mucosa and structure of the gastric fundus and gastric body. The gastric fundus showed a moderate amount of mucus and yellow turbidity, with a smoothly curved gastric angle. In addition, congestion and edema of the gastric antrum mucosa were noted, with no signs of ulcers or masses. The pylorus appeared to be circular and functioning properly, with smooth opening and closure. Similarly, no abnormalities were detected in the duodenal bulb and mucosa of the descending duodenum. The above findings led to the conclusion of chronic non-atrophic gastritis with bile reflux.
+Colonoscopy performed on July 16, 2021 revealed that the surgical repair site between the ascending colon and the ileum was visible 55 cm from the anus (usually 60-70 cm away from the anus); the ileocecal valve and cecum were indistinguishable . There were scattered nodular protrusions, lamellar vesicle, and shallow ulcers at the site of surgical repair, as well as in the ileum. Additionally, local mucosal protrusions, ulcers, and nodular protrusions were observed near the hepatic flexure of the transverse colon. The morphology of the remaining part of the descending colon and sigmoid colon appeared normal, with regular folds, a smooth mucosal surface, and rich and clear vascular network; no abnormal secretions, erosion, ulcers, or masses were detected in these segments of the colon. Similarly, the rectal mucosa exhibited no obvious abnormalities, But a fistula in the perianal area was suspected. The colonoscopy findings raised a suspicion of CD.
+Pathological examination of the appendix removed on July 2, 2015, showed acute gangrenous appendicitis, peritonitis, appendix perforation, and fecal stone incarceration within the cavity.
+Histopathologic examination of a sample of intestinal mucosa obtained on July 19, 2021 revealed superficial mucosa ulceration in the ileum with abundant inflammatory exudates, formation of granulomas, infiltration of lymphocytes and plasma cells, and no caseous necrosis . Additionally, the superficial mucosa of the colon showed signs of acute and chronic inflammation.
+Multiple routine investigations during hospitalization revealed a decrease in the levels of red blood cells, hemoglobin, and average red blood cell volume; slightly higher fibrinogen levels; and a positive fecal occult blood. Given the patient’s history of appendiceal perforation, special care was taken to remain vigilant for signs of gastrointestinal ulcers, and a careful gastroenteroscopy and pathological examination was performed, which validated the atypical intestinal lesions of CD or UC. Additionally, the patient did not exhibit symptoms such as low fever or night sweats, and did not have abnormalities in chest CT and erythrocyte sedimentation rate. Moreover, enteroscopy did not show any transverse ulcers, and pathological findings did not suggest caseous necrosis. Absence of the typical symptoms and the investigative findings together rule out the possibility of tuberculosis infection. The 13C-urea breath test result was negative, which ruled out Helicobacter pylori infection. Since the patient did not have any history of taking NSAIDs or corticosteroids, drug-induced ulcers were also ruled out. Moreover, no abnormalities were detected in tests for urine cytomegalovirus deoxyribonucleic acid, fecal bacterial culture, fecal fungal culture, and common virological tests; therefore, viral, bacterial, and fungal infections were ruled out. Upon retrospective analysis of the clinical manifestations, enteroscopic and pathological findings, the diagnosis was established as IBD without typical features of CD or UC. The patient did not have extraintestinal manifestations, and tests for CRP, antineutrophil cytoplasmic antibody, antinuclear antibodies, immunoglobulin levels, lymphocyte immunochip showed no abnormalities. Furthermore, despite undergoing mesalazine and immune-modulating therapy with azathioprine, there was no improvement in the patient's symptoms. Thus, the early age of onset; recurrence of symptoms; atypical features of CD and UC; and lack of response to aminosalicylic acid, immunotherapy, and related symptomatic treatment raised suspicion of the potential etiopathogenetic role of genetic factors in this case.
+Subsequently, whole-exome sequencing for genetic diseases was performed, which revealed mutations in the ACVRL1 and PLA2G4A genes. Mutations of both these genes are known to cause a decrease in the ability of the intestinal mucosa to resist injury and sustain repair. Kangfuxin liquid is known to have an effect of accelerating the repair of pathological tissue, shedding of necrotic tissue, and healing of ulcers and wounds. Accordingly, we modified the treatment plan and administered oral Kangfuxin liquid of 10 mL three times daily to promote the repair of the intestinal repair. The patient was discharged once his symptoms improved on initiating this treatment, and treatment was continued for 4 wk after discharge. If the patient occasionally experiences symptoms such as abdominal pain, diarrhea, and black stool, oral administration of Kangfuxin liquid can alleviate the symptoms.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_888_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_888_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..63672034daec2c1c416aa815fc0e5ff9e59075e4
--- /dev/null
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+A 30-year-old woman with a body mass index (BMI) of 22.5 was hospitalized due to secondary amenorrhea and infertility. Having been married for 10 years with regular intercourse, she delivered a baby girl in 2009. After that, the patient could not become pregnant again in spite of not using contraception. She experienced amenorrhea for 6 years after giving birth, and had been treated with drugs and contraceptive rings without success. The patient could only adjust her menstrual cycle with medication. The results of basic endocrine examination showed that the serum level of follicle-stimulating hormone (FSH) was high. Examination in April, 2019 indicated that serum FSH was above normal, while the anti-Müllerian hormone (AMH) concentration remained normal. Ultrasound scanning indicated that the uterine volume was relatively small (4.0 × 3.9 × 3.3 cm), while both ovaries were normal in size and more than 10 antral follicles were observed in both ovaries . Blood tests and genetic analysis excluded lupus erythematosus, multiglandular insufficiency, diabetes, myasthenia gravis, and chromosomal abnormalities (Fragile X syndrome, Turner syndrome, and Swyer syndrome). The patient had a normal karyotype of 46, XX. Sanger sequencing did not identify associated candidate variants in the FSHR gene. Serological tests, combined with clinical diagnosis and the characteristics of the patient’s infertility suggested ROS.
+According to the 5th semen analysis standard of the world health organization, the husband’s sperm concentration and motility were in the normal range, and sperm acrosomal enzyme activity was normal. The study was conducted in accordance with the ethical guidelines of the institution and with the informed consent of the patient.
+After admission on March 4th, 2019, the patient underwent two cycles of ovarian hyperstimulation treatment . The first one (May 19, 2019) was initiated with 3.75 mg of GnRH analogue triptorelin acetate injection (Ferring, Switzerland), followed by gonadotropin (300 IU/d, 15d) on cycle day 30. During the ovarian hyperstimulation period, the follicle growth was followed by ultrasound scanning, and the serum hormone levels were determined at the same time. Unfortunately, after 15 days of stimulation, no follicles larger than 14 mm were seen, and this treatment cycle was cancelled.
+Due to the failure of the first cycle and a lack of FSHR associated variants in the genetic investigation, we tested the patient’s serum for antibodies directed against FSHR via dot blot analysis, which showed strong reactivity with FSHR . Consequently, we adjusted the procedure for the second cycle. During the whole period of downregulation and controlled ovarian hyperstimulation, the patient was orally administered dexamethasone at 0.75 mg daily. The second cycle was started on July 6, 2019, at which time the patient was first given a 3.75 mg injection of triptorelin acetate for downregulation on the second day of menstruation. Controlled ovarian hyperstimulation was initiated on day 30 with daily subcutaneous injections of 375 IU of gonadotropin (Gonal F® 225 IU/d plus HMG 150 IU/d) for 3 days, which was then increased to 525 IU (Gonal F® 225 IU/d, HMG 225 IU/d and Luveris 75 IU/d) for 7 days. During the stimulation period, the patient underwent regular ultrasound follicle tracking and hormone measurements (estradiol, luteinizing hormone, follicle-stimulating hormone and progesterone) to monitor follicular maturation. A subcutaneous injection of hCG 10,000 IU (Livzon Pharmaceuticals, China) was administered and oocyte retrieval was scheduled 36 h later, ultrasound guided transvaginal follicular aspiration was performed under negative pressure of 110 mmHg (14.7 kPa) using a single lumen aspiration needle (Cook; William Cook Australia Pty Ltd., Australia). A total of 8 Metaphase II (MII) oocytes were collected. After in vitro fertilization, 3 embryos were vitrified and cryopreserved, and the remaining embryos were discarded.
+After 2 months following the second ART cycle, a hormone replacement cycle for endometrial preparation was started on day 3 of menstrual cycle with estradiol valerate tablets (Bayer, Germany, 4 mg for 5 days and then 6 mg for the same period). The addition of oral estradiol (Bayer, Germany) at a dose of 8 mg daily for the next 3 days was successful in achieving an endometrial thickness of 9 mm. The serum E2 on day 16 was 346 pg/ml. Progesterone (0.05 ng/ml) and human chorionic gonadotropin (HCG, 10000 IU) were injected at night. Then, daily progesterone luteal support with vaginal tablets containing 40 mg of progesterone (Utrogestan, Besins, Paris, France) was started.
+One embryo was thawed on day 20 (14 CII, grade II embryo with 14 cells) and transplanted. The serum value of β-hCG was 246.7 mIU/mL on the thirteenth day after the embryo transfer, and vaginal ultrasonography showed clinical pregnancy after 28 days. The pregnancy evolved without complications until the 35th week, at which point the patient exhibited oligohydramnios and gave birth to a baby girl by Caesarean section. The baby weighed 2200 g and was in good health.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_88_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_88_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1fd48e9bbc81237203c0090d660e41dd85eaadcd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_88_en.txt
@@ -0,0 +1,4 @@
+18-year-old Indonesian woman, presenting with a complex medical history and challenging diagnostic journey. Initially presenting with a painful lesion on the right palm, which developed following a traumatic injury and exhibited characteristics such as reddish swelling, well-defined borders, contractures of the middle finger, and discharge of purulent material, the patient's condition did not align with typical diagnoses of cellulitis or chronic osteomyelitis based on her history and clinical findings .
+The absence of common predisposing factors for cellulitis, alongside negative indicators for chronic osteomyelitis such as fistulous tracts, acute musculoskeletal pain, or constitutional symptoms, prompted further investigation. The clinical examination revealed an erythematous, edematous scaly plaque on the right palm, with features not entirely consistent with the initially considered differential diagnoses.
+The diagnostic process included routine investigations, chest X-ray, and specific imaging of the right palm , alongside a positive tuberculin skin test indicating TB exposure. From the anamnesis, no history of TB exposure was found in the home or school environment. Surgical intervention comprising necrotomy, debridement, and contracture release, followed by skin flap, was undertaken . Histopathological examination of the biopsy revealed pseudoepitheliomatous hyperplasia and non-caseating granulomas, leading to a diagnosis of CTB, potentially lupus vulgaris (LV) or tuberculosis verrucosa cutis (TVC).
+The patient's subsequent improvement under multidrug TB therapy, consistent with WHO recommendations for our country using a Fixed Drug Combination (FDC) of 150 mg rifampicin, 75 mg isoniazid, 400 mg pyrazinamide, and 275 mg ethambutol, underscores the importance of considering CTB in the differential diagnosis of persistent, non-healing cutaneous lesions. This is especially critical in endemic regions or in patients with a history suggestive of TB exposure. A month after surgery and TB therapy, the wound went well .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_902_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_902_en.txt
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index 0000000000000000000000000000000000000000..6a46e77bef0c4fc8ea2633f45f7c473c1a28ea39
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_902_en.txt
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+On 23 January 2020, a 46-year-old man was transferred to our hospital with 11-days history of fever of 38 °C and coughing. The patient permanently resides in Yili Development Zone, Xinjiang, China. He started low fever with dry cough, muscle ache and fatigue without known causes in Yili on 12 January. The patient disclosed that he had been in close contact with a person from Wuhan in Yili on 10 January and had a travel history with flights to Shanghai on 16 January 2020, from Shanghai to Ningbo on 17 January 2020, and from Ningbo to Shenzhen on January 19, 2020, without traveling or living history to Wuhan. On 18 January, there was onset of symptoms including chest tightness without chest pain and hemoptysis. Unknown medication was taken by the patient without symptomatic improvement. He was considered as a pneumonia patient and admitted to the University of Hong Kong-Shenzhen Hospital on 19 January. Results of blood gas analysis showed a pH of 7.445, carbon dioxide partial pressure of 4.72 KPa and oxygen partial pressure of 7.82 KPa. He was tested negative for influenza A/B virus and respiratory syncytial virus (RSV), Mycoplasma pneumoniae, Cryptococcus haemolyticus antigen, Aspergillus antigen, Epstein-Barr virus capsid antigen IgM, Epstein-Barr virus DNA, Cytomegalovirus DNA and antigen IgM. He was isolated in a single ward and received oxygen support and levofloxacin treatment. On 22 January, the patient was still having fever of 38.5 °C with chest tightness and shortness of breath. BALF was tested negative for Aspergillus, Legionella, Pneumocystis carinii, acid-fast Bacilli, Mycobacterium tuberculosis. He was diagnosed with severe bilateral community-acquired pneumonia (not excluding the possibility of COVID-19 pneumonia) and hypoxemia. Levofloxacin treatment was thus stopped and changed to combined anti-infection treatment of amoxicillin and clavulanate potassium and doxycycline. He was transferred to the Third People’s hospital of Shenzhen for further treatment on 23 January. The patient has no history of other diseases, surgical trauma, food and drug allergy. There was no headache, dizziness, vomiting, abdominal pain, diarrhea, frequent urination, urgent urination, or urination pain claimed by the patient.
+The results of physical examination on 23 January showed a body temperature of 36.1 °C, pulse of 94 times/min, respiratory rate of 26 breaths/min and blood pressure of 127/87 mmHg. Clinical laboratory test results revealed negative results for mycoplasma, chlamydia, cytomegalovirus-IgM, influenza A/B virus and RSV. Throughout the whole period of hospitalization, the patient was isolated in a single ward and given 60 μg of interferonalf-a1b (Beijing Tri-Prime Gene Pharmaceutical Co., Ltd., China; Shenzhen Kexing Biopharm, China) inhalation for antiviral purpose, 0.4 g of Bio-Three tablets (Huizhou Jiuhui Pharmaceutical Co., Ltd., China; Toa Pharmaceutical Co.,Ltd.Tatebayashi Plant, Japan) and 420 mg Bifid-triple viable capsule (Inner Mongolia Shuangqi Pharmaceutical Co., Ltd., China) three times a day for regulation of intestinal microbiome, and 30 mg mucosolvan (Boehringer Ingelheim Espana,S,A.) intravenous injection twice per day for phlegm elimination. A 3-day course of 0.5 g ribavirin (Jiangsu Lianshui Pharmaceutical Co., Ltd., China) intravenous injection starting from 23 January was also given to the patient in combination with Interferonalfa-1b twice a day for 3 days for antiviral treatment of RNA virus. .
+On 24 January, the patient was reported to have shortness of breath with respiratory rate of 38 times/min and heart rate of 90 times/min. Blood gas analysis revealed a pH value of 7.428, carbon dioxide partial pressure of 43.0 mmHg, oxygen partial pressure of 64.4 mmHg, actual bicarbonate level of 28.4 mmol/L, oxygen saturation of 92% and fractional concentration of inspired oxygen (FiO2) of 41.0%. Supplemental oxygen was applied to the patient with non-invasive BIPAP ventilator using IPAP 14cmH2O and EPAP 7cmH2O with oxygen concentration of 45%. His respiratory rate was 16 times/min after receiving oxygen supplement. Shortness of breath was gradually relieved and patient’s oxygen saturation values of peripheral blood reached 99 to 100%. Routine blood test revealed a white blood cell count of 5.61 × 109/L with 80.40% neutrophil and 14.80% lymphocyte, hemoglobin concentration of 158 g/L, platelet count of 207 × 109/L and erythrocyte sedimentation rate (ESR) of 71 mm/h. Biochemical test results showed an elevated D-Dimer (diffuse intravascular coagulation, DIC) level which may induce thrombus. 0.4 ml of nadroparin calcium (ASPEN Notre Dame de Bondeville, France) subcutaneous injection was given to the patient once per day for anti-coagulation until 31 January. D-DIC level decreased to normal range at 26 January. The patient also received 40 mg of esomeprazole sodium (AstraZeneca Pharmaceutical Co.,Ltd.) intravenous injection once per day for gastro-esophageal reflux suppression until 30 January and 30 mg of methylprednisolone (Pfizer Manufacturing Belgium NV) intravenous injection once every 12 h until 28 January for anti-inflammation treatment. The increase in white blood cells during this period may be due to the effect of methylprednisolone. However, COVID-19 ribonucleic acid test was negative using nasopharyngeal swabs done by Shenzhen Center for Disease Control (Shenzhen CDC). Treatment scheme and viral detection time points are illustrated in Fig. .
+From 25 January onward, the patient’s syndromes had gradually resolved with only occasional dry cough. Computed tomography (CT) scan of the lungs was performed on 25th, 29th January and 12th February . Evidence of severe pneumonia, including multiple lesions and swollen lymph nodes, could be seen from both of the lungs on 25th January. The patient was then given 500 mg lopinavir and ritonavir tablets (Abbott S.P.A., Italy) every 12 h until 6 Feb as a combination treatment for antiviral effect. SARS-COV-2 ribonucleic acid test was negative using nasopharyngeal swabs done by our hospital on 26 January. To confirm the presence of SARS-COV-2, the patient’s BALF sample was sent to Shenzhen CDC for viral nucleic acid detection. SARS-COV-2 ribonucleic acid was tested positive for BALF sample on 27 January. Oxygen supplement by non-invasive BIPAP was replaced by high-flow humidification oxygen therapy instrument for higher oxygen flow of 45 L/min and oxygen concentration of 40% on 28 January. Biochemical test results indicated an increased level of alanine aminotransferase (ALT) since 29 January. The patient was diagnosed to have toxipathic hepatitis which was possibly induced by SARS-COV-2. The patient then received 50 mg compound glycyrrhizin tablets (Akiyama Jozai Co., Ltd., Japan) three times per day from 29 January to 13 February and 50 mg bicyclol tablets (Beijing Union Pharmaceutical Factory, China) three times per day from 31 January to 13 February for liver protection. ALT level resumed to the normal range on 13 February. To prevent pulmonary fibrosis, the patient was given 7-day course of 0.2 g acetylcysteine granules (Bio Pharmacceutical, China) three times per day from 7 February. Obvious improvements could be seen from the subsequent CT scanning results of the lungs on 29th January and 12 February . Oxygen supplement by high-flow humidification oxygen therapy instrument was discontinued on 31 January and the patient was given nasal catheter for oxygen inhalation with a flow rate of 4 L/min. His clinical conditions was stable with fractional concentration of inspired oxygen (FiO2) value fluctuating within the normal range. On 2 February, the patient stated that there was obvious improvement of his symptoms. CT scanning of the lungs on 12 February confirmed the improvement and the patient was discharged on the following day.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_903_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_903_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..030d477b206802a02f037e5503656e68d6e33b22
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_903_en.txt
@@ -0,0 +1,8 @@
+The disease manifested in a healthy 53 years old female patient 7 weeks prior to the initial visit to our center with sudden onset of blurred vision, dizziness, disturbed gait and coordination impairment. Before the manifestation of symptoms patient was healthy, no prior dementia cases in patient’s family history were recorded. Two weeks after initial symptoms presentation patient was hospitalized in the Department of Neurology of Regional Hospital. Neither ophthalmologic examination nor blood test revealed any significant changes. Brain computed tomography (CT) and MRI were evaluated as normal. Although after retrospective reevaluation of MRI, slight increase in the occipital DW signal was found . EEG was performed on the 6th week since initial disease presentation did not show any specific changes. Initially, the patient was diagnosed with primary hypertension (blood pressure was 150/70 mmHg): Spironolactone 25 mg per day for arterial hypertension and Clonazepam 0,5 mg once a day for insomnia, Betahistine 3 mg three times a day were prescribed. On the sixth week after initial symptoms due to complaints of dizziness, impaired memory, insomnia, emotional lability, the possible causes were differentiated among cerebrovascular and somatoform/conversion disorder. As the symptoms progressed significantly, on the 7th week after the onset of symptoms, the patient was referred to the University Hospital. Clinical course of the disease and the major diagnostic tests are presented in Fig. .
+During the hospital admission the patient complained of weakness, difficulties standing up and walking due to dizziness and visual impairment as well as difficulties concentrating during the interview. A neurological evaluation revealed vertical gaze palsy, extrapyramidal type increased right body side muscle tonus, involuntary stereotypical movements (purposeless raising and lowering of the left hand), weaker reflexes on the left side and ataxic gait. Arterial blood pressure was 160/90 mmHg. Ophthalmologic examination revealed severely impaired vision, a disability to distinguish between light and darkness, without any congestive changes in the retina. The evaluation of mental state revealed typical symptoms of organic brain disease: disorientation in time, slower thought processing, concentration difficulties and disturbed short-term memory. Mini-Mental State Examination score 20/30 revealed dementia with moderate cognitive decline, two in date and two points in place orientation were missed, three in recall, two in attention and calculation, one in repetition. Due to episodic anxiety, agitation and fearful gaze, visual hallucinations were suspected. Physical examination of other systems did not reveal any significant abnormalities.
+During the next two weeks blood tests were carried out to rule out infectious, endocrine and rheumatologic diseases, metabolic conditions and secondary autoimmune central nervous system vasculitis since they are common causes of dementia; genetic testing, urine analysis and a liver biopsy were performed in search for Wilson’s disease, but all the tests were negative. Standard examination of CSF did not reveal significant deviations from the normal range. Despite antihypertensive treatment, arterial blood pressure was ranging between 160/100 and 140/85 mmHg.
+EEGs performed on the 10th and 14th weeks after the onset of symptoms showed non-specific diffuse slowing activity with rhythmic delta activity in frontal brain regions (FIRDA), predominantly in the left side. Only at the 18th week EEG showed periodic (repeated every 1 s) sharp wave complexes (PSWC) in frontal regions .
+The MRI, done on the 9th week showed in T2W increased signal intensity (SI) zones in cortical gray and subcortical white matter, especially on the right side without restriction in DWI sequence, in the parietal-occipital area supplied by the posterior cerebral artery, leading to the conclusion of posterior reversible encephalopathy syndrome (PRES). The typical imaging finding is vasogenic oedema in the subcortical white matter of the parietal and occipital lobes . As an experience with PRES grows, atypical presentations of PRES are being increasingly described: the cases with atypical vasogenic oedema patterns of distribution, such as frontal lobe, cerebellum, basal ganglia or brain stem involvement [–]. This non-specific radiological pattern in our case also raised a new diagnostic challenge. Normalization of blood pressure due to antihypertensive treatment and other symptomatic treatment did not improve neurologic symptoms. During the period of the next two weeks all possible causes (vascular, ictal, infectious) of PRES were ruled out . A diagnosis of CJD was suspected the first time.
+In MRI, repeated after four weeks, on the 13th week symmetrical lesions in the basal ganglia (head of nucleus caudatus, putamen) were found. The previous lesions in the cortical/subcortical area were absorbed. The lesions found in the basal ganglia led us to suspect CJD or extrapontine myelinolysis [, ].
+Within 14th week of the disease onset and the symptomatic treatment, the patient’s condition significantly deteriorated. Severe psychomotor retardation with hyper tonus of neck and arms flexor muscles, jerky myoclonic movements, repeated episodes of agitation and severe insomnia were observed. Condition progressed to akinetic mutism with severe cognitive impairment. The blood pressure reversed into hypotensive state. There was no possibility in Lithuania to test the 14–3–3 protein, most widely used CSF biomarker for CJD and one of the WHO criteria, for probable CJD. Taken into account a rapidly progressive dementia, clinical manifestation of myoclonus, visual changes, ataxia, muscle hyper tonus, akinetic mutism, symmetrical MRI findings of basal ganglia, on the 14th week of the disease the decision to take brain biopsy was made.
+The brain tissue biopsy from occipital brain lobe and head of caudate nucleus was performed. Histological evaluation was performed in the Division of Neuropathology of the National Hospital for Neurology and Neurosurgery, Queen Square, London: the abnormal prion protein deposits (detected with antibodies ICSM35, KG9 and 12 F10) were seen in all the grey matter areas . No specific features in small biopsy samples were found to suggest iatrogenic or inherited forms of prion disease. Patient had not received any past treatment with human cadaver derived growth hormone, undergone neurosurgery with human cadaver derived dural graft or scleral transplant, patient had not received blood transfusion, which suggests a possible sporadic case of CJD. The neuropil in the grey matter of caudate nucleus showed mild but widespread micro-vacuolar degeneration. In the neuropil of occipital cortex mild micro-vacuolar degeneration is patchy. Immunostaining for the abnormal prion protein revealed diffuse strong synaptic labelling in all the grey matter regions. In the white matter there are freaquent granular deposits but no convincing filamentous labelling. Histopathological and immuno-histochemical findings of prion protein (scrapie) (PrPSc) and summarizing all the data, we confirmed prion disease, compatible with sCJD. The patient eventually died 13 months after disease onset. Autopsy was not carried out.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_921_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_921_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..56e20062ea250b7ae76d3e969fdede2a0e5c471c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_921_en.txt
@@ -0,0 +1,10 @@
+A 5-year-old boy presented with headache, vomiting, and vertigo with a duration of 5 months. CT and MRI examinations revealed the presence of a right cerebellar mass with mild enhancement and of a right temporal mass with moderate enhancement . The tumors were hypointensive in T1-weighted MRI scans and hyperintensive in T2-weighted MRI scans. CT examination revealed that both tumors were hyperdense. Following these examinations, the patient was referred to our hospital.
+During surgery, the two tumors were observed to have similar appearances. Both tumors were reddish-colored and soft, had a moderate blood supply, and were easy to suction. The postsurgical pathology reports stated that the tumors were a DMB (cerebellar mass) and PNET (temporal mass) .
+Due to the suspicion that the boy had GS, he was evaluated for this condition. The circumference of his head was 48 cm. Physical examination revealed the presence of multiple café-au-lait spots . Plain film X-ray imaging demonstrated the presence of a bifid rib and a jaw cyst . The PTCH1 gene test was negative. We conducted a molecular classification of the cerebellar tumor using the real-time polymerase chain reaction (PCR) method and the NanoString method and discovered that the DMB was a SHH subtype tumor. Based on two major and one minor criteria for GS (desmoplastic MB, bifid rib, and jaw cyst, respectively), an unambiguous diagnosis of GS was made.
+After the patient was discharged, his parents refused to allow him to receive chemotherapy, which is a treatment that must be covered by out-of-pocket payments in China, due to their financial difficulties. The patient instead underwent 30.6-Gy irradiation of the entire brain and the spinal axis and 54-Gy irradiation of the posterior fossa. At follow-up, an MRI examination showed no tumor recurrence. Twenty-seven months after receiving radiotherapy, the patient experienced chest pain and had a fever. CT examinations revealed the presence of a mediastinal mass and chest effusion . Analysis of a biopsy performed at another hospital demonstrated that the mass was T cell non-Hodgkin’s lymphoma . The patient’s parent refused treatment because of financial difficulties, and the boy died 1 month later.
+DMB and medulloblastoma with extensive nodularity (MBEN) are closely associated with GS. The development of DMB and MBEN, which are generally the first tumoral manifestations in patients with GS, is thought to be the major criterion for the diagnosis . The prevalence of MB in GS patients in early childhood is difficult to estimate. The incidence of GS in MB patients was reported to be 1–2 %, and 3–5 % of GS patients develop medulloblastoma, generally within the first 2 years of life . In a retrospective investigation, 5 of 82 medulloblastoma patients were diagnosed with GS . In Amlashi’s cohort of 76 MB patients, the incidence of GS among the entire cohort was 4 %, the incidence of GS in patients younger than 5 years old was 10.7 %, and the incidence of GS in patients younger than 2 years old was 25 % . In a Japanese survey, 3.3 % of 157 GS patients had MB .
+To the best of our knowledge, this is the first report of a concurrent infratentorial medulloblastoma and a supratentorial PNET in a GS patient. On cerebrospinal axis MRI examination, there were no signs of CSF seeding; two images appeared different under microscope examination, which excluded the occurrence of tumor metastasis. The molecular classification of the DMB as a SHH subtype tumor was also consistent with the diagnosis of GS. Our patient could have been diagnosed with GS based on the presence of DMB, a PNET, a jaw cyst, a bifid rib, and multiple café-au-lait spots, as well as the classification of the DMB as a SHH subtype tumor. The occurrence of multiple café-au-lait spots is associated with many hereditary disease, including neurofibromatosis type 1, McCune-Albright syndrome, Cowden syndrome, and LEOPARD syndrome . This is the fourth case report of multiple café-au-lait spots in a GS patient [, ]. Because the clinical diagnostic criteria for GS are continually changing, we propose that the presence of café-au-lait spots in young DMB patients should be considered a “trigger” for ordering a diagnostic evaluation and a molecular blood test for GS.
+GS patients are at a high risk of developing multiple BCCs and other radiation-induced tumors, such as meningioma, ependymoma, and fibrosarcoma, in irradiated areas. To date, this is the first report of the development of post-treatment non-Hodgkin’s lymphoma in a GS patient. The hedgehog pathway regulates intrathymic T cell development. Aberrant activation of the hedgehog pathway is associated with the pathogenesis of malignant lymphoma . Irradiation induces DNA damage and genomic instability in circulating and thymic lymphocytes, which results in apoptosis, abnormal DNA methylation, and changes in RNA expression [, ]. Our patient developed mediastinal lymphoma, which was unequivocally diagnosed as a radiation-induced tumor. Interestingly, we found one report of a radiation-induced PNET that developed following treatment for non-Hodgkin’s lymphoma . These findings may facilitate elucidation of the molecular mechanisms underlying tumorigenesis in GS patients.
+Early and prompt diagnosis is important in patients suspected to have GS, as chemotherapy is the first-line treatment for tumors in GS patients. The desmoplastic variant of MB and MBEN in GS generally occur in children who are 2 years of age or younger. Most of the main criteria for GS, such as intracranial calcification, jaw cysts, and BCC, do not appear until the second decade of life, which makes early diagnosis of GS in very young patients difficult . Medulloblastoma patients with GS generally have a promising survival rate due to recent advancements made in chemotherapy . The detection rate of a mutated PTCH 1 gene is only 50–85 % , which makes early diagnosis more difficult. Amlashi et al. have even suggested avoiding radiotherapy in DMB patients who are less than 5 years old .
+The overexpression of the members of the canonical hedgehog signaling pathway plays an important role in tumorigenesis in GS patients. In the majority of GS patients, the loss of function of PTCH1 has been found, which causes the reduction of the inhibition of the smoothened (SMO) oncogene and the subsequent aberrant activation of the glioma-associated oncogene homolog (GLI) family members. It is possible that SMO inhibitors, such as vismodegib, may serve as new therapeutics for the treatment of tumors in GS patients. Vismodegib has proven to be effective in the treatment of GS-related BCC and keratocystic odontogenic tumors [, ]. Robinson et al. reported that vismodegib exhibited activity against adult recurrent or refractory SHH-MB . However, the response to SMO inhibitors of medulloblastoma patients was variable and transient, and this drug was most effective in treating tumors with upstream activating aberrations in the SHH pathway. The existence of a PTCH1 mutation was correlated with a positive response to the drug, and aberrations in GIL2 and SUFU were found in the nonresponders .
+The lack of efficacy of SMO inhibitors and the acquired resistance to these inhibitors in medulloblastoma patients argues for the use of GLI-specific inhibitors. GLI1 is the most significant member of the hedgehog pathway and plays a role in promoting carcinogenesis. Several studies have shown that aberrant GLI1 expression occurred independently from the signaling of the canonical HH pathway through PTCH and SMO [, ] and was responsible for the development of radioresistance and chemoresistance in tumors . The aberrant expression of GLI1 was closely linked to the activity of several non-canonical signaling pathways, such as the Kirsten rat sarcoma viral oncogene homolog (KRAS) pathway, the avian myelocytomatosis virus oncogene cellular homolog (C-MYC) pathway, the transforming growth factor β (TGFβ) pathway, the wingless-type MMTV integration site family (WNT) pathway, and the β-catenin pathway. Together, these data suggest that administering specific inhibitors of the final step in the hedgehog pathway may be the most effective treatment option and the ideal approach to use in future studies. Currently, there are several agents (HPT, GANT58, GANT61, and arsenic trioxide) that are known to inhibit the transcriptional activity of GLI [, ]. Although GLI1-specific inhibitors are still in the preclinical stage of testing, studies in which combinations of GLI1 inhibitors and chemotherapeutic agents were used to treat other types of tumors have been conducted .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_935_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_935_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..88dbb765aa4da80b6261f96bd6862c88d46ac086
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_935_en.txt
@@ -0,0 +1,4 @@
+A 40-year-old premenopausal nulligravida woman presented with vaginal bleeding in January 2020. The patient was otherwise well, had no prior surgery, and was not taking hormone medication. Her medical history was significant for morbid obesity, with a body mass index (BMI) of 36.4 kg/m2.
+A gynecologic examination revealed a multiple polypoid mass on the posterior vaginal fornix. . Punch biopsy revealed endometriosis. The cervix appeared normal. A cervical smear showed reactive cellular changes but was negative for human papilloma virus. Magnetic Resonance Imaging of the pelvis showed two masses abutting respectively on the anterior uterine wall, and in the rectovaginal septum. , diffuse thickening of endometrium without gross mass, and a 4.4 cm mass in the left ovary. A sigmoidoscopy detected an invasive polypoid lesion protruding into the rectum and biopsy revealed endometriosis . She decided to undergo a surgery to remove lesions and confirm the pathologic diagnosis.
+Firstly, the vaginal protruding mass was excised completely. Secondly, the globular mass were adequately removed via laparoscopy. Thirdly, dilatation and curettage of endometrial tissue was performed. Laparoscopic findings showed 5 × 4 × 4 and 4 × 3 × 3 cm globular mass on the anterior uterine wall and a 3 × 3 × 2 cm globular mass on the rectovaginal septum; all of which were filled with chocolate-colored fluid and cheezy like materials. Histopathologically, the vaginal polypoid mass was diagnosed as endometriosis-associated complex hyperplasia and endometrioid cancer, International Federation of Gynecologic Oncology grade I/III. Meanwhile, globular lesions on anterior uterine wall and rectovaginal mass was diagnosed as endometriosis-associated complex hyperplasia. Furthermore, a synchronous endometrioid endometrial cancer, FIGO grade II/III was reported.
+After being confirmed as a case of synchronous vaginal and endometrial cancer, a staging surgery for endometrial cancer and en bloc extirpation of the remnant rectovaginal mass were performed. The patient underwent a total laparoscopic excision of the rectovaginal mass, radical hysterectomy and low anterior resection of the rectum. The remnant rectovaginal mass was diagnosed as only endometriosis, which invaded extensively to the rectal mucosa. Perineural invasion in the specimen of the vagina was absent. The lack of perineural invasion did not request a subsequent lymph nodal dissection . The resection margin of parametria, vaginal vault, and rectum were invaded by endometriosis but, free of cancer. Finally, the patient was diagnosed as endometriosis-associated endometrioid vaginal cancer and synchronous endometrioid endometrial cancer (stage 1A1) . One month post operation, she was treated with dienogest and was clinically free of disease (no evidence of disease recurrence in the imaging study) for 8 months since undergoing last surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_939_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_939_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..82018ebd839f463a5921a27a986b78550bf54b08
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_939_en.txt
@@ -0,0 +1,2 @@
+A 49-year-old healthy Greek man without any prior significant medical history, working as a cook on a merchant ship, drank accidentally a glass of 70% methanol rubbing solution, while he was on board. One day later he complained for blurred vision and painful eye movement in both eyes. The second day he woke up blind. He remained on board since the ship was heading to Australia and so treatment was impossible. When the ship reached Australia, he was hospitalized for a week. On arrival his vital signs were within normal limits and his examination tests revealed normal muscle tone. His initial laboratory evaluation included a complete blood count, electrolytes, blood urea nitrogen, creatinine, and serum glucose. All test results were within the normal range for the patient’s age. A urine drug test was negative for benzodiazepines, opiates, cocaine, amphetamines, phencyclidine, salicylates, and barbiturates. The blood methyl alcohol and formic acid values could not be determined. No treatment was given due to patient’s late arrival. He then was transferred to the University Eye Clinic of Athens. At presentation he underwent a complete ophthalmological examination. Visual acuity was no light perception in both eyes. The pupils were semi-dilated and unreactive to light. Fundus examination revealed an unremarkable retina in both eyes with the exception of pronounced pale, atrophic optic discs with “pseudoglaucomatous” thinning of the neuroretinal rim area. Electroretinogram (ERG) was normal in both eyes (Figure ). Visual evoked potentials (VEPs) were nearly extinguished (Figure ). Multifocal-visual evoked potential (mf-VEP) recording was also pathological in area 0 (right eye: 169 nV/deg2 and left eye: 186 nV/deg2) (Figure ). Optical coherence tomography (OCT) of the optic nerve head demonstrated abnormally low values of the retinal nerve fiber layer (RNFL) thickness equal to 128 μm in the superior, 39 in the nasal, 108 in the inferior, and 72 in the temporal quadrant of the right eye (OD), and 134, 99, 92, and 58 correspondingly of the left eye (OS) (Figure ).
+Neurological examination with the patient awake revealed no extrapyramidal motor disturbances and computed tomography (CT) scans showed no abnormalities. Anion gap was less than 30 mg/dL and no treatment was deemed necessary to initiate. The patient was discharged on the fourth day. He was reexamined one month later. The situation remained unchanged.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_93_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_93_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7221ea77bd241a0e3e15db2176838a20584be0f4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_93_en.txt
@@ -0,0 +1,3 @@
+A 79-year-old female experiencing gait disturbance, cognitive impairment, and urinary incontinence for about a year presented at our hospital. CT head scanning showed enlarged ventricles (Evan’s index 0.31) and no other remarkable signs . A lumbar tap test showed slight improvement of gait and memory function. After a diagnosis of probable normal-pressure hydrocephalus, a ventriculoperitoneal shunt operation was completed without complications. However, symptoms did not greatly improve and the patient demanded a shunt removal. Before removal, gait instability and mild cognitive impairment were present without any paralysis, sensory dysfunction, or cranial nerve palsy.
+During the operation, propofol (60 mg), rocuronium (35 mg), and remifentanil (0.7 mg/h) were used as general anesthesia with 5% desflurane and remifentanil (0.6 mg/h) continuously infused for maintenance. We injected 10 ml of 0.5% lidocaine with epinephrine into the chest skin incision site and cut the skin to expose the shunt valve; cranial and rostral shunt tubes were removed without resistance. A clip anchor was left at the scalp so we injected 7 ml of 0.5% lidocaine with epinephrine into the previous skin incision site around the burr hole and removed it. The skin was closed after 10 ml of 0.75% bupivacaine was added into the subcutaneous layer to reduce postoperative pain. The total operation and anesthetic times were 22 and 58 min, respectively.
+Anesthesia was reversed by Sugammadex and train of four stimulation showed diminishment of muscle relaxants, but spontaneous respiration was still not observed. At this time, vital signs were blood pressure 90/50 mmHg, pulse 80 bpm, SpO2 98%, and body temperature 35.8°C with a Japan Coma Scale score of 300 even after naloxone administration. Pupils were dilated bilaterally and light, cough, and vestibuloocular reflexes were lost. Emergent head CT showed no abnormal lesions such as hemorrhages, infarctions, or cerebral herniations . Under suspicion of brainstem anesthesia, systemic management in an intensive care unit was conducted and, within an hour, pupil size, respiration, and consciousness gradually recovered to normal and extubation occurred 1.5 h after the operation. The postoperative course was uncomplicated and discharge occurred at postoperative day 9.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_941_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_941_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..07851231e52029455ce6fa090cbb7ffdd54c8cd9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_941_en.txt
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+A 72-year-old Japanese male PD patient had experienced a slowly progressive gait disturbance and akinesia since 56 years of age. He was diagnosed with PD at 58 years. He had no history of any neurological disorders. His family history is unremarkable. During the next 15 years, he had been admitted to our hospital several times for drug control, and LD pharmacokinetics was checked twice when he was 68 years old. At the age of 71 years 10 months, although his parkinsonian features had not changed, he suddenly developed jaundice and he was diagnosed with cholangiocarcinoma. At this time, his Unified Parkinson's Disease Rating Scale (UPDRS) motor score (part III) was 28/108 , and his daily antiparkinsonian treatment was 500 mg/50 mg of LD/carbidopa, 0.5 mg of cabergoline, and 2.5 mg of selegiline.
+In the next month (at the age of 71 years 11 months), pancreaticoduodenectomy was performed. In this operation, subtotal removal of the stomach (3 cm from the pylorus side), total removal of the duodenum, and subtotal removal of the jejunum (20 cm from the ligament of Treitz on the distal side) was performed . Reconstruction was made by end-to-end anastomosis of the pancreas to the bile duct to the jejunum . There were no surgical complications in his post-operative course, and he recovered without any surgical problems. After 5 days, he could take the same oral antiparkinsonian agents as before the operation (500 mg/50 mg of LD/carbidopa, 0.5 mg of cabergoline, and 2.5 mg of selegiline); however, his Parkinsonian features were gradually remarkable within 2 weeks after the operation. The patient did not receive any agents as chemotherapy. He was then transferred to our ward for parkinsonian drug treatment.
+At this time, his height, body weight, and body mass index were 158.0 cm, 61.0 kg, and 24.4, respectively. His neurological examination revealed marked masked face, dysarthria, and dysphagia. Mild tremor at rest in the left upper extremity, severe rigidity in the bilateral upper and lower extremity, and poor finger taps on the dominant left side were also observed. Gait was unable without assistance. His parkinsonian features were obviously getting worse, and UPDRS motor score (part III) was 68/108. Thus, we checked whether this worsening of parkinsonian features was due to a change in LD absorption in the gastrointestinal tract by checking his LD pharmacokinetics.
+Written informed consent was obtained from this patient, and the approval of the Institutional Review Board was obtained for the examination of LD pharmacokinetics. To assess LD pharmacokinetics, he took a tablet containing 100 mg of LD and 10 mg of carbidopa at 9:00 a.m. following an overnight fast and a medication-free period of at least 18 h. Blood specimens were collected through an intravenous catheter at 0, 15, 30, 60, 120, and 180 min after LD administration, and plasma LD concentrations were measured by high-performance liquid chromatography with electrochemical detection. The procedure of measurement of blood LD concentration has been described in our previous report . Peak drug concentration (Cmax), the time-to-peak drug concentration (Tmax), elimination halftime (T1/2), and area under the curve (AUC) were determined. Cmax and Tmax were observed values, T1/2 was determined by linear regression analysis, and AUC was estimated from the area under the time concentration line up to 3 h.
+In his LD pharmacokinetics at the ages of 68 years 11 months (and 68 years 1 month), body weight was 64.2 (and 64.8) kg, AUC was 1,782.5 (and 1,825.0) mg·h/ml, Cmax was 1,500 (and 1,500) mg/ml, Tmax was 30 (and 30) min, and T1/2 was 48 (and 47) min. In the postoperative assessment (at the age of 72 years 4 months), AUC was 1,148.8 mg·h/ml, Cmax was 450 mg/ml, Tmax was 60 min, and T1/2 was >120 min .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_944_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_944_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..66cf6880cf30c2a07a52a31abf5c45245b066bc9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_944_en.txt
@@ -0,0 +1,5 @@
+A 19-year-old female Caucasian patient was diagnosed with acute lymphoblastic leukemia at the age of 15. Treatment was initiated according to the acute lymphoblastic leukemia (ALL)-10 protocol. A venous access port for intravenous infusion of chemotherapy was surgically placed with the tip of the catheter in her superior vena cava via her left subclavian vein. Treatment was continued for two years.
+Ten months after her final treatment with chemotherapy, our patient relapsed and induction chemotherapy was administered according to the ALL-R3 protocol. This was complicated by renal failure and encephalopathy and therefore mechanical ventilation and dialysis were initiated. After clinical recovery, her treatment was switched to an alternative re-induction regimen.
+During follow up treatment with 6-mercaptopurine, methotrexate, cytarabine, idarubicin, etoposide and cyclophosphamide, our patient presented to the outpatient clinic with a fever and general malaise. Blood work revealed a C-reactive protein level of 462 mg/L. The differential diagnosis included sinusitis, deep neck infection and line infection. Blood cultures were negative. A CT scan of her neck was ordered, which revealed a submental abscess extending into the submandibular space. Her skin was incised and the underlying abscess was drained.
+Our patient’s fever persisted, and as the central venous catheter was still in situ it was seen as the only possible remaining cause of infection. The catheter was surgically removed without any problems, three and a half years after placement. Cultures of the catheter tip were negative, however her fever persisted and she still showed signs of ongoing infection. This inflammatory response, possibly caused by immune reconstitution, was treated with colchicine and Indomethacin. Her fever subsided and the colchicine and Indomethacin were subsequently stopped, even though her C-reactive protein level remained high (169 mg/L). Three months after removal of the indwelling central venous catheter, she underwent a stem cell transplantation.
+During stem cell transplantation, clinical suspicion arose for deep venous thrombosis of her left arm. A CT scan revealed a hyperdense structure in her left innominate vein, with thrombosis . After a conferral with the radiologist and clinicians, it was concluded that this hyperdense lesion was a foreign body, most likely the tip of the central venous catheter which had previously been (incompletely) removed. However, on conventional chest radiographs no foreign body was visible. Due to this inconsistency, three-dimensional reconstructions were done; it became clear that this ‘hyperdense line’ was of variable density, had an irregular surface and the continuity was interrupted at certain points . It was now concluded that these hyperdense structures were calcifications that had developed after line removal in an old (infected) thrombus in her left innominate vein, which resembled a foreign body. She was treated with low molecular weight heparin and antibiotics, after which her fever subsided.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_955_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_955_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c516b326d840acf6a04176b6848301883f682d0b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_955_en.txt
@@ -0,0 +1,3 @@
+A 75-year-old man was admitted for the treatment of an asymptomatic left CIA aneurysm. The aneurysm was diagnosed during a routine abdominal ultrasound. A computed tomography angiography (CTA) revealed an isolated left CIA aneurysm and a left pelvic kidney . The maximum diameter of the CIA aneurysm was 32 mm. The congenital pelvic kidney was supplied by three small superior polar arteries that emerged from the proximal non-aneurysmal portion of the CIA and the main artery that arose from the internal iliac artery . The distance between the superior polar arteries and the beginning of the aneurysm was 28,9 mm. The special issues about this case was to preserve all of the blood supply of the pelvic kidney and exclude the aneurysm. It was accomplished by using an iliac branch device (IBD) (Gore Excluder Iliac Branch, Flagstaff, AZ) without an aortic stent graft . Preoperative serum blood urea nitrogen and creatinine levels were 22 and 1,03 mg/dl, respectively. There was no change in the postoperative period.
+After induction of general anesthesia, we performed the Preclose technique via bilateral femoral artery access, guided by ultrasound, with two Perclose Proglide (Abbott Vascular) for each site. After achieving access, the patient was systematically heparinized. A 16Fr Dry Seal Flex Introducer Sheath (Gore, Flagstaff, AZ) was advanced over an Extra Stiff Wire Guide in the ipsilateral site, and a 12Fr Dry Seal Flex Introducer Sheath (Gore, Flagstaff, AZ) was advanced over an Extra Stiff Wire Guide in the contralateral site. A vertebral catheter and a hydrophilic guidewire were introduced via the 16Fr Sheath, and an EN Snare (Merit Medical System, Malvern, PA) was introduced in the contralateral 12Fr Sheath, establishing the through-and-through femoral access. After, we advanced the IBD (23x12x10 mm) into position over both wires. The first step of deployment was done, releasing the iliac branch portal. The 12 Fr Sheath was advanced up and over the aortic bifurcation using a pushing and pull movement and the catheterization of the internal iliac artery was performed with a vertebral catheter and hydrophilic guidewire, with was later replaced by an Amplatz. Support Wire Guide 1 cm short tip that allowed to advance the internal iliac component (16x14x10 mm) into the internal iliac artery. The iliac branch portal was dilated using a 14 mm angioplasty balloon Zeppelin (Scitech, Aparecida de Goias, GO). The second step of the IBD was done with the release of the external iliac branch. After, kissing-balloon angioplasty was performed using a Giant Balloon Catheter (Scitech, Aparecida de Goias, GO) for the external iliac component. Completion angiography was performed demonstrating exclusion of the aneurysm, preservation off all renal arteries without endoleaks.
+A CTA was performed 1 and 6 months after the procedure and demonstrated complete exclusion of the aneurysm and preservation of all renal arteries .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_971_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_971_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..51f9e0448f226f923a125cbae832134fcf09350b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_971_en.txt
@@ -0,0 +1,7 @@
+A 33-year-old previously healthy male with no history of travel presented with abdominal pain, hematochezia, peripheral eosinophilia (6200 eos/µL), mesenteric, splenic, and portal vein thromboses resulting in ischemic colitis. Approximately 1 month prior to his hospitalization he had a self-limiting illness lasting five days with fever, nonproductive cough, myalgias, chills, and sweats. After resolution of this illness, he developed right upper thigh pruritus and bruising along with polyarthralgias which was unresponsive to prednisone. He did not have any rashes or angioedema. He was admitted for four days to an outside hospital after significant thrombocytopenia (20,000/μL) and eosinophilia (6200 eos/µL) were noted on CBC .
+Upon admission he was thought to have idiopathic thrombocytopenia purpura (ITP) and treated with intravenous immunoglobulin (IVIG), dexamethasone, and transfused one unit of platelets. Computed tomography (CT) showed nonocclusive right and left portal vein, mesenteric, and splenic vein thrombi. Bone marrow biopsy showed increased eosinophils accounting for 25% of granulocytes and 20% of total cells with no significant immunophenotypic abnormalities of myeloid cell populations and no abnormal B cell, T cell, or plasma cell populations identified. He was discharged from the outside hospital on warfarin after having completed a course of dexamethasone 40 mg daily for four days. His eosinophil count at discharge was 0 eos/µL.
+Two weeks later, he again presented to the outside hospital after having severe abdominal pain, hematochezia, and fevers. Upon admission, noted to have eosinophil count of 5700 eos/µL. Endoscopy and subsequent pathology showed patchy eosinophilic infiltrates from esophagus through the colon along with evidence of ischemia. His eosinophil count continued to climb to a high of 10,000 eos/μL. He was placed on IV corticosteroids. Due to ongoing abdominal pain and concern for possible HES, he was transferred to our hospital for further evaluation and management.
+Upon admission, he developed worsening abdominal pain and contrast CT abdomen/pelvis revealed necrotic ascending colon and small bowel with ascending colon perforation, prompting emergent laparotomy, right hemicolectomy, and segmental small bowel resection. Pathology of the transverse colon showed increased eosinophils in the laminal propria with eosinophilic cryptitis along with eosinophils in the sigmoid colon. Additionally, pathology revealed thrombi involving submucosal, subserosal, and mesenteric elastic arteries and arterioles. No parasitic organisms were identified on any of the pathology slides. His troponin-I was negative (< 0.03 ng/mL) and his EKG showed normal sinus rhythm with no ST segment elevation or depression. His echocardiogram was normal. His chest radiographs were normal. Abdominal CT showed normal-sized spleen.
+Primary and secondary causes of eosinophilia were excluded by hematology/oncology, infectious disease, and rheumatology .
+Evaluation also excluded genetically based myeloproliferative disorders and malignancies .
+The patient was diagnosed with idiopathic HES and treated with 60 mg of IV methylprednisolone daily while continuing anticoagulation therapy as an inpatient. He was transitioned to 60 mg daily of prednisone prior to discharge while maintaining an eosinophil count of 0 eos/µL with no further evidence of coagulopathy. Shortly after discharge, benralizumab was started at 30 mg subcutaneously every 4 weeks for three doses then every 8 weeks. As benralizumab was started, he was simultaneously weaned off corticosteroids over the course of several months while maintaining peripheral eosinophil count of 0 eos/µL. After remaining asymptomatic for 10 months while on benralizumab, anticoagulation therapy was discontinued. His eosinophils have remained at 0 eos/µL and has had no further evidence of coagulopathy after 1 year of therapy with benralizumab. He will continue benralizumab indefinitely.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_972_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_972_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ee6960bea7e84540f73043adc0b27f7781dc9610
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_972_en.txt
@@ -0,0 +1,4 @@
+The currently reported case is of a 46-year-old nulligravid female patient, of Middle Eastern ethnicity, who presented to the outpatient Gynaecology Clinic of our hospital one year ago. Her complaints included mild pelvic pain requiring the intake of non-steroidal anti-inflammatory drugs once a day two days a week at most. She also complained of pelvic heaviness combined with a gastrointestinal bloating sensation that required the daily intake of antiflatulent medication, which was not helpful in soothing the complaint. She had a past medical history of primary infertility for 20 years. She also had an abdominal myomectomy through a low-transverse abdominal incision 17 years earlier. A clinical examination revealed a huge pelvi-abdominal mass extending up to the level of her xiphisternum. A combined abdominal and vaginal ultrasound (US) revealed the presence of multiple leiomyomata with a huge subserous leiomyoma showing evidence of degeneration and extending to the level of the left lobe of her liver . There was no evidence of ureteric obstruction or renal pelvic ectasia as shown by a renal US. For an abdominal US we used a curvilinear probe with a frequency of 5 MHz, while for the transvaginal US a 7.5 MHz probe was used. The long history of the mass and its slow growth rate constituted a low index of suspicion of a uterine sarcoma.
+No further imaging investigations were requested due to the highly suggestive characteristics of the mass on US; accordingly the clinical diagnosis of a huge subserous uterine leiomyoma was made. An abdominal hysterectomy via a lower midline incision with left periumbilical extension was performed. Intraoperatively, the uterus was found to be of normal size with numerous variable sized pedunculated subserous leiomyomata diffusely attached to its surface .
+The huge degenerated leiomyoma previously delineated on sonography turned out to be a retroperitoneal mass extending from the left side of her pelvis through the infundibulopelvic ligament upwards to the lower border of her spleen, with no connections with the leiomyomata-studded uterus. The mass displaced her mesosigmoid and her descending colon medially and even the root of the mesentry was displaced towards the midline. General surgeons were involved; they dissected the mass from its retroperitoneal vascular connections. The mass was in close proximity to her descending colon which was reflected medially in order to gain better access to the mass. The mass was crossing her left kidney anteriorly to the level of her spleen. Dissection in this area was very meticulous due to the proximity to the tail of her pancreas. The hysterectomy specimen and the huge retroperitoneal mass were sent for pathological examination. The postoperative course of our patient was very smooth and she was safely discharged on the fourth postoperative day. She returned ten days later for wound care which showed very good healing.
+The histopathologic examination revealed a non infiltrative growth with scant mitotic activity (one mitotic figure per 10 high power field) with no atypia, thus confirming the benign leiomyomatous nature of this huge retroperitoneal growth, with evidence of hyaline degeneration
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_980_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_980_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d5145b13b23fd4407e41cd05e4d90e2fa677c53a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_980_en.txt
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+A 78-year-old male Caucasian patient presented at our clinic with multifocal HCC in a cirrhotic liver, Child A due to HCV genotype I infection. Prior to AMT treatment our patient was treated with radiofrequency ablation (RFA) and four transarterial chemoembolizations (TACE) over a four-year period. Due to tumor progression, further TACE or local ablation therapies were no longer viable.
+At that time our patient refused sorafenib therapy due to the well documented side effects, such as fatigue, diarrhea, hand-foot-syndrome and others. Therefore, he was included in an ongoing AMT trial. Physical examination revealed an enlarged liver, no clinical signs of ascites or hepatic encephalopathy, no peripheral edema but a slight scleral icterus. Laboratory tests showed a normal blood count, an international normalized ratio of 0.95, albumin 3.5g/dL, bilirubin 1.9 mg/dL, aspartate transaminase 148U/L and alanine transaminase 96U/L. His α-fetoprotein level was elevated (29.5ng/mL) and remained so throughout follow-up.
+Twice daily intramuscular injections of AMT were started on an outpatient basis for two months.
+A baseline computed tomography (CT) scan of his abdomen performed prior to the initiation of AMT identified three target lesions (TL) that fulfilled the Response Evaluation Criteria In Solid Tumors (RECIST) criteria. Two lesions had increased in size since the previous CT scan of his abdomen, performed two months before at the end of the last treatment . TL1 was situated in the right dorsal liver margin, segment 8, and measured 20 mm (previously 12 mm). TL2 was in the right lateral margin of segment 4b, and measured 12 mm (no change from previous CT). TL3 was in the anterior margin of segment 4b, and measured 12 mm (previous 6 mm).
+The right liver lobe showed marked atrophy, whereas the left lobe revealed hypertrophy. No extrahepatic manifestations were discovered. His peri-aortacaval lymph nodes were slightly enlarged.
+After eight weeks of AMT treatment the first tumor staging was performed and his abdomen and chest CT scans showed a partial remission. Both target lesions T1 and T2 had disappeared. TL3 had shrunk to 7 mm (40% reduction) with a contrast medium enhancement in the boundary area of the lesion. Again, no extrahepatic involvement was discovered .
+According to RECIST, remission has to be confirmed by a second scan at least four weeks later. This scan confirmed the partial remission. The HCC volume in his liver had further decreased with unchanged morphology, in other words, atrophy of the right lobe and hypertrophy of the left lobe. TL1 and TL2 were still invisible, while TL 3 was unchanged in size. In his chest CT scan there was no evidence of lung metastases. Neither bone involvement nor any other extrahepatic manifestation was discovered. Our patient complained about dizziness during AMT and requested to terminate treatment.
+Six weeks later, a CT scan revealed several new early arterial hyperperfusion areas in both lobes of his liver, for example, a lesion with 24 mm diameter was found at the right dorsal margin of segment 8. The two defined lesions TL1 and TL2 that had been in complete remission remained in remission. TL3 that had been in partial remission had increased in size to 16 mm. Adrenal involvement was suspected, but lung, spleen, kidney, bones and lymph nodes were free of metastases. Unfortunately, our patient refused to restart AMT despite the remarkable previous tumor control.
+Three months later, a follow-up CT scan showed continued tumor control. TL3 had again disappeared, despite having shrunk and re-grown in the preceding months. The other lesions TL1 and TL2 remained in remission. The adrenal metastasis was unchanged and no further tumor progress was observed.
+Again, three months after that, progressive disease was once again documented by CT with recurrence of TL3 with a size of 11 mm and several new lesions in both liver lobes up to 22 mm . There were no new extrahepatic metastases except for the adrenal lesion that was unchanged in size. Our patient now agreed to sorafenib therapy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_983_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_983_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..890a2ab8942eae34088d5a9d269ff24f77e0693e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_983_en.txt
@@ -0,0 +1,4 @@
+We report a case of a 62-year-old male who presented with pain in the left foot for 5 months. There was no history of trauma. He had an unremarkable medical and family history. Clinical examination revealed mild diffuse swelling of the region with tenderness on deep palpation and restricted movement of the metatarsophalangeal joint. Skin overlying was normal without any redness or dilated veins. The patient was investigated and radiographs revealed a geographic lytic lesion involving the head of first metatarsal and proximal part of proximal phalanx . Magnetic resonance imaging also indicated presence of Infective arthritis of first metatarsophalangeal joint with associated osteomyelitis .
+Open debridement was carried out till bleeding bone was visible leaving behind a bone defect of 4 cm. Antibiotic cement spacer was placed which was fixed with an intramedullary K-wire . Intraoperative culture revealed the organism to be Methicillin-resistant Staphylococcus aureus and antibiotics were given as per culture sensitivity report.
+The second stage of reconstruction was done after 6 weeks. The antibiotic cement spacer was removed taking care to preserve the induced membrane and non-vascularized fibula strut graft of 4 cm was put in its place within the induced membrane. The graft was fixed with a single intramedullary K-wire . Finally, the membrane was sutured for the creation of a local biological chamber, which promotes bone regeneration and graft uptake .
+The patient was on non-weight-bearing rehabilitation protocol for 3 months postoperatively until the bone graft had incorporated radiologically. Partial weight-bearing was started at 3-month post-surgery and full weight-bearing at 5 months was allowed. Follow-up at 24 months post-surgery revealed a fully incorporated fibular graft and patient walking full weight-bearing .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_984_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_984_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1a257673f7d2603e133158c5a7d4b7caacc74290
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_984_en.txt
@@ -0,0 +1,2 @@
+A 46 year-old man with HIV/AIDS (CD4 T-cell 115 × 106/l) presented with two weeks of left 5th digit pain and swelling. He denied any history of recent trauma to the hand, fever, weight loss, or other systemic symptoms, but did note an occasional dry cough. He had traveled repeatedly between his native country Ivory Coast, West Africa and the United States. He was not taking antiretroviral medications at the time of presentation. On physical exam his fifth digit was swollen and erythematous at the proximal intraphalangeal joint [figure ]. His laboratory values on admission were as follows: white blood cell count 5000 cells/mm3, hemoglobin 11.6 grams/dl, hematocrit 33.9%, platelets 280,000 platelets/mm3, eosinophils 9.0%, and erythrocyte sedimentation rate (ESR) of 60 mm/hour. Left hand radiography was significant for soft tissue swelling over the left finger with joint space narrowing and cortical lucencies with cystic degenerative changes in the proximal phalanx [figure ]. Admission chest radiography demonstrated right hilar lymph node enlargement with multiple scattered nodules and a resolving right lower lobe infiltrate. Computed tomography scan of the chest revealed multiple pulmonary nodules [figure ], necrotic lymph nodes, and splenomegaly. The patient underwent incision, drainage, and biopsy of the affected finger. Operative findings were significant for purulent, mottled, soft, yellow bone.
+Rare acid-fast bacilli were demonstrated on biopsy of the both phalanx and synovial fluid samples [figure ]. We used the Gen-PROBE® Amplified Mycobacterium tuberculosis Direct Test which employs a transcription-mediated amplification and hybridization protection assay to qualitatively detect Mycobacterium tuberculosis complex ribosomal RNA (rRNA). Several weeks later cultures of all surgical material grew Mycobacterium tuberculosis [figure ]. Multiple Ziehl-Neelsen stains of induced sputum samples were negative for acid-fast bacilli, but all specimens sent for sputum culture grew Mycobacterium tuberculosis. Antituberculous treatment was initiated with rifampin, isoniazid, pyrizinamide, and ethambutol prior to culture results. After 12 weeks of treatment, marked improvement in the finger lesion was noted [figure ].
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_998_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_998_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5a02993e988b396b250594987f75f01dd614e093
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_998_en.txt
@@ -0,0 +1,5 @@
+The patient was a 43-year-old Japanese woman who underwent 70 Gy heavy-particle radiotherapy administered as 5 fractions of 14 Gy for a right choroidal malignant melanoma (T3a, N0, M0 clinical-stage IIB according to the 8th edition of the International Union Against Cancer classification) . Positron emission tomography-computed tomography (PET-CT) performed post-treatment revealed no abnormal accumulation of 2-deoxy-2-(fluorine-18) fluoro-d-glucose, and the complete response was recorded . PET-CT examination was subsequently performed regularly every 6 months, and no recurrence was noted up to 4 years after treatment, when contrast accumulation (maximum standardized uptake value 10.9) was observed on the posterior wall of the stomach .
+Gastrointestinal endoscopic examination revealed a smooth, protruding lesion on the wall of the greater curvature of the stomach . Endoscopic ultrasonography (EUS) revealed extramural growth of a hypoechoic tumor with the presence of blood flow inside, on the posterior wall of the stomach that was approximately 2.2 × 2.0 cm in size . CT showed a mass with contrast enhancement in contact with the stomach wall . Based on the imaging findings, a gastrointestinal stromal tumor (GIST) at the posterior wall of the lower gastric corpus with extramural growth was suspected. Therefore, the patient was referred to our hospital for treatment.
+Laparoscopic surgery was performed under general anesthesia. A black-pigmented tumor originating from the body of the pancreas was discovered to be in contact with the posterior wall of the stomach , but continuity was not observed. Based on the intraoperative findings, metastasis of the malignant choroidal melanoma to the pancreas was diagnosed. Since no other lesions were discovered in the abdominal cavity, it was determined that resection would be possible, and laparoscopic pancreatic tail resection was performed.
+The resected tumor comprised a single black nodule with a long-axis diameter of 27 mm . Hematoxylin and eosin staining revealed spindle cells with melanin pigment production . Immunohistological examination showed positive signals for the S100 protein, HNB-45, and Melan A, confirming the diagnosis . On postoperative day 20, a grade IIIa pancreatic fistula (Clavien–Dindo classification version 2) developed, but amelioration was achieved using conservative treatment. The patient was discharged on postoperative day 50.
+Administration of 3 mg/kg nivolumab was initiated as adjuvant chemotherapy 2 months after surgery, but 2 months later multiple lung metastases were detected by CT. Therefore, administration of 3 mg/kg ipilimumab was initiated. Following the first dose, the patient developed colitis as an immune-related adverse event and grade 3 diarrhea (based on the Common Terminology Criteria for Adverse Events version 5.0 classification), the latter of which was ameliorated by oral administration of 30 mg prednisolone. There was an outbreak of dermatitis, which was also judged to be an immune-related adverse event, and the administration of ipilimumab was discontinued. Two courses of 800 mg/m2 dacarbazine were administered 12 months postoperatively, but the treatment was discontinued due to metastasis to the left kidney. Nivolumab administration resumed 28 months after surgery. The patient was alive after 17 courses of nivolumab without symptoms or exacerbation of the lesion.
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