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data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1016_en.txt

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+A woman in her thirties developed symptoms of fever (with a maximum body temperature of 39.2 ℃), headache, and sore throat in mid-December 2022.
+The patient took 0.5 g of acetaminophen three times daily on the morning prior to the day she was tested for SARS-CoV-2. She was then diagnosed with COVID-19. After 3 d, her body temperature gradually returned to normal and her sore throat improved. One week later, the patient experienced fever (with a maximum temperature of 39.8 ℃) and began to develop red papules and blisters from her head to limbs.
+The patient had no history of drug allergies or contact with toxic substances.
+The patient had no similar family history or that of other genetic diseases.
+After 3 d, the rash did not resolve. The vesicles fused and spread to the mucous membranes, including those of the eyelids and lips; beginning on the face and torso and spreading centrifugally throughout the body (over 90% of the body surface area) . The rash was diagnosed as SJS/TEN. The patient simultaneously presented with yellowing skin, light-colored stools, and a serum total bilirubin (TBIL) level of 240 μmol/L with an increase in the liver enzymes alanine aminotransferase and alkaline phosphatase.
+Figure presents a flowchart of the changes during the disease course. Test results for viral hepatitis A to E were all negative, as were those for anti-nuclear, anti-mitochondrial, and anti-liver and kidney microsomal antibodies.
+A liver biopsy was performed 1 month later. The histopathology showed a nonspecific inflammatory reaction; cholestasis and mild inflammation of the liver cells; and the absence of liver necrosis, ductopenia, and bile duct inflammation damage .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1058_en.txt

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+A 26-year-old Chinese man with a chief complaint of a mass in the right submandibular region for the past 1 year was admitted to Xiangya Hospital, Central South University, Hunan, China. He had no significant past medical or family history. Routine physical and laboratory examinations were performed. Ultrasonography revealed a hypoechoic mass measuring approximately 28 mm × 18 mm in the right submandibular region, with an irregular shape and clear boundary . Abdominal computed tomography (CT) scan revealed no other lesion. There was no evidence of metastasis to the local or distant organs. Hence, lumpectomy was performed under general anesthesia.
+Histological examination showed sheets, cords, and nests of small round cells separated focally by desmoplastic stroma . Under higher magnification, tumor cells showed round to oval hyperchromatic nuclei with an increased nuclear/cytoplasmic ratio and inconspicuous nucleoli. The cytoplasm of the tumor cells was scanty with indistinct cytoplasmic borders . Mitotic activity and individual cell necrosis were common. Immunohistochemical analysis was performed using formalin-fixed paraffin embedded sections from representative tumor blocks and the antibodies listed in Table . Immunohistochemical results indicated the multi-directional differentiation of tumor cells. The immunohistochemistry results were as follows: desmin (+) , FLI-1 (+), CD99 (+), E-cadherinD (+), chromogranin-A (+), neuron-specific enolase (+), vimentin (+) , pan-cytokeratin (+), epithelial membrane antigen (+), CD56 (+), synaptophysin (weakly positive [+/−]), NKX2.2 (−), WT1 (−), myogenin (−), and S-100 (−). Moreover, the Ki-67 proliferation index was estimated as 50%. The tumor cells were negative for Epstein-Barr virus-encoded small RNA on fluorescence in situ hybridization (FISH). The FISH analysis with a break-apart probe proved that there was EWSR1 gene spilt in the neoplastic cells . However, EWSR1-WT1 fusion detection by reverse transcription-polymerase chain reaction was not performed owing to certain limitations. Based on the above findings, primary lesions in the abdominal cavity and pelvic cavity were excluded, and a final diagnosis of primary DSRCT in the submandibular gland was made.
+Comprehensive anti-tumor therapy mainly based on chemotherapy and radiotherapy was first proposed. However, synchronous chemotherapy was not performed owing to the risk of bone marrow suppression. Therefore, cyclophosphamide combined with doxorubicin and vincristine chemotherapy was used for maintenance treatment. The patient is currently alive and well with no evidence of tumor recurrence.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1064_en.txt

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+M is a 15years old male who was delivered at home. Pregnancy and immediate post-partum period were uneventful. It was noted soon after birth that the right lower limb was progressively increasing in size when compared with the rest of the upper and lower limbs. He had an uneventful childhood except that he spent a lot of time at home and was withdrawn from other children. He was healthy but soon the limb began to be too heavy for him to move around with and he could no longer afford proper foot wears. His mother who raised him abandoned him which led him to the streets. He was soon recognized by a friend of his father and was rescued from the street. He presented at the University of Calabar Teaching Hospital for the first time at the age of 15 years. He was initially managed at the pediatric dermatologic clinic as a case of suspected elephantiasis and later referred to the Pediatric Surgery Unit where an initial diagnosis of congenital gigantism was made. He was referred for x-rays and Doppler studies of both lower limbs. The diagnosis of typical KTWS was made on the basis of clinical and radiological findings which included the following:
+Skin: Port wine stains on both hands and feet .
+Musculo-skeletal system: Marfan like hands and feet, no significant limb length discrepancy. There were marked differences in the circumferential dimensions of the lower limbs . The right lower limb showed significant enlargement of the soft tissues of the leg and foot, worse distally, odematous right leg and foot as well as significant sclerosis of right foot with numerous hemangiomas ( and ). There were no differences in circumferences of the upper limbs (mid-upper arm circumference 18.5 cm, mid-forearm circumference 18 cm.
+Cardiovascular system: Significant right lower limb varicosities, multiple sinuses in which clear but foul smelling lymph was noted to be draining .
+Genitourinary System: enlarged peni-scrotal organ with subcutaneous oedema .
+All other systems were essentially normal. Patient in addition was asked to carry out multi detector computerized angiography which has not been done due to financial constraint.
+Firm bandaging of the affected limb was applied in order to reduce lymphatic flow and prevention of infection. Antibiotics and pain relief were also prescribed. Patient is still being awaited as the managing team have decided to bear the cost of the rest of his investigations and treatment. Surgical debulking of the right foot is being envisaged at the moment.

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+A 14-year-old Han Chinese woman with a history of neurogenic bladder for more than 10 years was admitted to our Department because of coma for 12 h. The patient complained for diplopia without fever or diarrhea 4 days before her coma with no incentive. She had no limb weakness and was treated with Vitamin B1and mecobalamine. Her previous medical history included neurogenic bladder caused by spina bifida occulta for 12 years and hydronephrosis diagnosed 1 year before. Sometimes she had urine retention, but she received no treatment for the neurogenic bladder except for urethral catheterization occasionally. She had no seizures and no fever. On admission, physical examination revealed that she was unconscious. The pupils did not react to light and presented different sizes in each eye (left pupil diameter, 2.5 mm; right pupil diameter, 4 mm). On stimulation, she could move her 4 limbs spontaneously. There were exaggerated deep tendon reflexes over both legs and the right Barbinski sign was positive. However, her vital signs were stable: Blood Pressure (BP) was 120/81 mmHg; pulse rate, 76 beats/min; body temperature, 36.5 °C; breath, 12 times/min. Non-contrast brain computed tomography (CT) after the onset of her coma revealed diffuse brain stem hypodensity. Brain MRI acquired 4 h after the coma onset in the county hospital showed high signal at the dorsal part of the pontine base and the mid brain on fluid-attenuated inversion-recovery (FLAIR) imaging and T2-weighted imaging. However, diffusion-weighted images presented normal signal . The non- contrast abdominal CT preformed on the next day of admission showed chronic obstructive uropathy with a distended bladder, severe hydronephrosis and dual renal atrophy.
+Blood analysis immediately after admission revealed renal failure [Urea nitrogen: 23.87 mmol/L, Creatinine: 566.8 μmol/L], and anemia [RBC: 2.5 × 1012/L, HGB: 79 g/L]. Arterial blood gas analysis revealed metabolic acidosis [pH 7.09 (7.35–7.45)]. Liver function was normal.
+The patient was diagnosed with UE due to chronic renal failure and metabolic acidosis. She was immediately treated with 200 ml of bicarbonate at 5% conducted by quick intravenous injection, followed by 100 ml intravenous injection of bicarbonate at 5% once a day and 1.0 g of bicarbonate administered orally three times per day for 3 days. Simultaneously, she underwent urethral catheterization to relieve the urine retention. She was revived without diplopia 3 days after admission and the reviewed blood analysis after urethral catheterization showed that her renal function was returning to a normal level (Urea nitrogen: 13.10 mmol/L, Creatinine: 294 μmol/L); hence, dialysis was not necessary. She was treated with hypodermically administered erythropoietin 3000u twice a day, and ferrous sulfate 0.3 g orally thrice a day for the anemia. She was discharged 14 days after the admission without diplopia and any mental disturbance. She was still with the ureteral catheter because of the hydronephrosis. Two weeks after the discharge, the catheter was removed when abdomen ultrasonic showed decreased hydronephrosis. Follow-up MRI performed 2 months after the discharge revealed complete resolution of the brainstem UE . Reviewed blood analysis after 2 months of discharge showed that her renal failure still persisted (Urea nitrogen: 13.10 mmol/L, Creatinine: 190.3 μmol/L). However, she had no neurological disturbance or urinary retention. She underwent the comprehensive bladder-retraining program to avoid urinary retention and her renal function was regularly assessed once a month.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1131_en.txt

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+A 67-year-old male subject with severe hemithorax pain and dyspnea, along with disseminated pain and muscle weakness in the right shoulder and down the arm, was referred to our institution. Pulmonary evaluation revealed coarse as well as dull breathing sounds. Laboratory data showed normocytic normochromic anemia, whereas white blood cells, platelets, liver and renal functions, calcium, phosphorus and alkaline phosphatase (ALP) were all within normal levels and there were no signs of organomegaly or lymphadenopathy. The chest x-ray showed collapse of the right upper lobe. The patient was further evaluated for suspected bronchogenic cancer with brachial plexus involvement. Histopathological analysis showed poorly differentiated squamous cell carcinoma.
+CT of the chest, upper abdomen and brain was performed with contrast and revealed some pulmonary nodules with hilar mass, resorptive atelectasis and obstructive pneumonia, along with destruction of the adjacent rib vertebra and extension to the spinal canal; there were no signs of brain involvement . MRI on the chest also demonstrated destruction of vertebrae and invasion into the spinal canal, thereby compressing the spinal cord . MRI on the spine confirmed the presence of a lytic lesion in the T4 vertebral body .
+Three hours after administration of 750 MBq (20 mCi) technetium-99m methylene diphosphonate (Tc-99m MDP) by injection, WBBS was performed using a rotating digital gamma camera (ADAC Pegasys) equipped with a low-energy all-purpose parallel whole collimator, with a 20% window centered at 140 keV to provide energy discrimination. SPECT images were obtained in a 128 × 128 matrix, in 64 steps, with 40 s per step. The images were reconstructed and displayed on all three axes: vertical long axis, horizontal long axis and axial short axis. We found an area of diminished radiotracer uptake in the T3-T5 vertebrae and in the posterior arch of the third to fifth right ribs .
+The patient was further evaluated for induction chemoradiotherapy and was subsequently subjected to a palliative en-bloc surgical operation with a posterior approach .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1135_en.txt

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+A 31-year-old G3P2 female at 25 weeks of gestation presented with chest palpitations and light-headedness. Physical exam demonstrated tachycardia with borderline hypotension, without evidence of new murmurs on initial auscultation. Her medical history was notable for atrial tachycardia (AT) during two previous pregnancies managed with metoprolol and flecainide, though ultimately requiring induction of labour due to impending foetal compromise at 34 weeks. She underwent two failed catheter ablation procedures at outside institutions several months after delivery of her second child; however, the arrhythmia was not inducible during the first study, and the second was aborted prior to ablation due to haemopericardium requiring emergent pericardiocentesis. An implantable loop recorder (ILR) was placed at that time. The patient was reluctant to undergo another ablation and was treated with sotalol 40 mg twice a day by her primary cardiologist. During her third pregnancy, higher doses were not prescribed due to a low baseline blood pressure. This admission was prompted by chest palpitations and dizziness associated with an SVT at 160 beats per minute while on her home maintenance dose of sotalol.
+Her blood work-up on index hospitalization did not demonstrate any electrolyte or thyroid abnormalities to potentially explain her arrhythmia exacerbation. Electrocardiogram revealed a narrow complex, long R to P wave interval tachycardia with ventricular rates of 162 bpm, and QTc 408 ms . Transthoracic echocardiogram showed grossly normal systolic ventricular function without any evidence of valvular pathology.
+Intravenous boluses of metoprolol, adenosine, and diltiazem were administered without conversion to sinus rhythm; however, transient atrioventricular block was observed without affecting the atrial rate, consistent with the previous suspected diagnosis of AT. Sotalol was discontinued and she was switched to oral flecainide acetate and metoprolol tartrate, with the doses up titrated to 100 mg BID, respectively. Despite escalation of medical therapy, she continued to have multiple breakthrough episodes with concomitant palpitations, requiring diltiazem infusion at 10 mg/min. Her course was further complicated by worsening hypotension and risk of foetal bradycardia, requiring admission to the coronary care unit for vasopressor support with intravenous phenylephrine and foetal monitoring.
+After coordinated discussions with electrophysiology and maternal foetal medicine, a decision was made to undergo a fluoroscopic-free catheter ablation with electroanatomic mapping to minimize radiation exposure. Due to the patient’s anxiety, the procedure required general anaesthesia and continuous peri-operative foetal heart rate monitoring was performed under the supervision of maternal foetal medicine. Despite aggressive stimulation with quadruple stimuli and isoproterenol infusion, the procedure was unsuccessful at inducing the culprit clinical AT. A right atrial flutter was reproducibly induced and successfully ablated.
+Empiric isolation of the pulmonary veins (PVs) was considered, but not pursued for several reasons. The lack of inducibility precluded accurate mapping of the site of origin, with no well-defined endpoint for ablation. Empiric PV isolation would require at least 4 weeks of post-ablation oral anticoagulation which could cause more harm during pregnancy, particularly if the site of origin was outside the PVs. Unfortunately, the AT recurred 2 h after the procedure, and the decision was made to up-titrate pharmacological therapy, with a combination of sotalol 120 mg and flecainide 100 mg twice daily. This suppressed the arrhythmia, and she was monitored for an additional 72 h as an in-patient with an acceptable QTc of 487 ms and sinus rate , following which she was discharged. She returned to the emergency department 6 weeks later at 31 weeks’ gestation with another episode of symptomatic AT, shortly followed by a new onset of abruptio placentae, requiring an emergent, yet successful caesarean section.
+Four days postpartum, she continued to have intermittent, non-sustained episodes of AT. The procedural bleeding risks and post-ablation anticoagulation were discussed with obstetrics who deemed her to be of acceptable risk for initiation of oral anticoagulation. She underwent a repeat fluoroscopy-free electrophysiology study and ablation under general anaesthesia. This time, burst pacing from the coronary sinus at 300–400 ms on isoproterenol induced the left AT which matched her clinical arrhythmia. Based on high density mapping with a PENTARAY® catheter (Biosense Webster Irvine, CA), triggered activity was found primarily in the left superior PV: however, was also present in the right superior and left inferior PVs. She therefore underwent isolation of all four PVs with non-inducibility of any arrhythmia post ablation with and without isoproterenol infusion . Twenty-four months post-ablation, she has been symptom free and has had no SVT on the ILR. Both she and the baby are healthy with no complications from either the pharmacotherapy or ablation procedures.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1150_en.txt

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+We present a case report of a 78-year-old white man with alcoholic cirrhosis and multifocal HCC with ascites and portosystemic encephalopathy. In his past history (2 years before) he had a wedge resection of segment II for HCC (G2). Since then he was followed-up annually, including a computed tomography (CT) scan, by our medical department. He was not considered for LT due his advanced age. He presented to our emergency room for ascitic decompensation with abdominal tension and lower limb edema. During his recovery, his hematocrit suddenly dropped (hemoglobin from 9.3 g/L to 6.7 g/L in 3 hours); an abdominal CT scan showed multiple and bilateral foci of HCC with evidence of acute bleeding from one of them . His Model for End-Stage Liver Disease (MELD) score was 19; his Child–Pugh score was C11; total bilirubin was 8 mg/dl and alpha-fetoprotein (AFP) 604 ug/L. He was hemodynamically unstable and compromised so he was urgently transferred to our operating room (OR) for hemorrhagic shock. A middle line laparotomy was performed and a massive hemoperitoneum was found (4 L). His liver was cirrhotic with recanalization of umbilical vein and collateral vessels. His liver was completely subverted by a tumor and there was bleeding from two lacerations on segments II and IV, which was uncontrollable with conventional hemostatic techniques (argon beam, oxidized regenerated cellulose, and fibrin glue). Due to his condition, his poor liver function reserve, and the multifocal tumor it was decided to carry out the coagulation of the multiple vascular afferents of each single mass by RFA. Multiple RFA cycles were performed circumferentially on both nodules for a total of 40 minutes. Hemostasis was achieved; the RFA controlled the bleeding from our patient’s ruptured HCC . Operation time was 90 minutes. During the operation he needed transfusions of three packed red blood cells (PRBC) transfusions and drug support with noradrenaline 0.4 gamma/Kg/minute and dopamine 2 gamma/kg/minute. He was transferred to our intensive care unit (ICU) for postoperative monitoring. On postoperative day (POD) 2 he was discharged and reassigned to our medical floor, without vasopressor therapy. His peak postoperative transaminase levels were aspartate aminotransferase (AST) 659 UI/L and alanine aminotransferase (ALT) 260 UI/L but he did not develop liver failure. The main problem was the hepatorenal syndrome that occurred on POD9 due to the progression of his underlying liver disease; he did not need renal replacement therapy. He was discharged from our medical department; his general condition was satisfactory. He was followed-up in our clinic by our palliative care team, but unfortunately he died 2 months later due to a progression of his disease.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1154_en.txt

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+A 37-year-old african-american male was referred to the endocrinology department of the Federal Hospital of Lagoa for evaluation of adrenal insufficiency due to chronic and irregular use of steroids (Prednisone 20 to 40 mg/day) for 10 years. He had history of use of anabolic drugs and intramuscular mineral oil (hydrogel) injections in the upper and lower limbs for 15 years for muscle hypertrophy. Three months prior to the referral he developed intense headache, fever, night sweats, weight loss and limb pain. No other systemic comorbidities.
+During hospitalization, intramuscular purulent collections were diagnosed by imaging tests and he presented daily fever (maximum of 38 °C or 100 °F). Treatment with piperacillin/tazobactam 2.25 g IV q6hr and vancomycin 500 mg IV q6hr was initiated and laboratory tests collected. The blood tests showed 11,900 leukocytes (90% neutrophils), high level of C reactive protein, negative blood culture, culture of the intramuscular purulent material negative, negative serology for HIV and syphilis. Chest and cranial computed tomography scans were normal. The cerebrospinal fluid showed the presence of 330 cells (60% mononuclear), 239 mg/dL proteins, 49 mg/dL glucose, negative Nanquin test, negative latex fixation test, negative bacterioscopy, negative cytomegalovirus serology. The polymerase chain reaction (PCR) result for Koch’s bacillus was in process at this time. Drainage of right thigh abscess was performed and material sent to culture.
+Ophthalmology Service was then requested for evaluation. Visual acuity was 20/20 in both eyes, anterior biomicroscopy and intra-ocular pressure were normal. Fundus examination revealed subretinal, elevated, rounded, yellowish lesions in the nasal region in the right eye and superior to the macula in the left eye .
+On fluorescein angiography (FA), these lesions showed punctate leakage . The optical coherence tomography (OCT) revealed choroidal lesions causing elevation of the retinal pigment epithelium (RPE) and subretinal fluid .
+Considering systemic symptoms, suggestive laboratory and retinal lesions, the hypothesis of systemic tuberculosis with choroidal granuloma was assumed. After 14 days of treatment with piperacillin/tazobactam and vancomycin without clinical or laboratory response, the therapy was switched to rifampicin, isoniazid, pyrazinamide and ethambutol. At this point, several cultures of the material drained from the abscess were negative.
+After 4 weeks of treatment for tuberculosis, the patient maintained the symptoms and no improvement of laboratory tests. The possibility of fast growing atypical mycobacteria was considered and the empirical treatment for mycobacteria with amikacin and clarithromycin was added to previous tuberculosis treatment.
+Posteriorly to the change on the treatment, the patient presented clinical improvement and leukocytes progressively reduced from 16,500 to 7800 after 2 days. Then, one of the cultures collected from the left thigh confirmed the growth of non-tuberculous mycobacteria and the agent Mycobacterium Fortuitum was isolated. It was susceptible to the following antibiotics: amikacin, ciprofloxacin, doxycycline and moxifloxacin. At this time, the antibiotic therapy was replaced by doxycycline 200 mg/day and ciprofloxacin 1 g/day, oral administration.
+After 6 months of targeted treatment, the fundus exam revealed a significant regression of the lesions . The FA still showed discrete leakage and the OCT demonstrated regression of the choroidal lesion and subretinal fluid, which were replaced by areas of retinal atrophy .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_116_en.txt

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+A 29-year-old female has had asymptomatic, slightly erythematous, and hypopigmented pityriasis versicolor-like lesions on her face, neck, trunk, and extremities since the age of five as well as multiple brownish-black, hyperkeratotic, papular plaque, wart-like lesions on the extremities. The lesions progressively increased in number and size with age . No abnormalities were observed upon examination of the hair, nails, mucosal membranes, and other systems, including abdominal echography and chest X-ray. Histopathology of a flat wart-like lesion showed marked hyperkeratosis, mild acanthosis, and the presence of distinct homogeneous intracytoplasmic inclusion bodies in the large clear cells of the epidermis . Additional systemic examinations and laboratory investigations, including an HIV test, were all normal. Topical 5-fluorouracil (5-FU) and imiquimod 5% cream were applied to the small pityriatic or flat wart-like lesions for three days per week at Jikei University School Hospital and Nippon Medical School Hospital. The lesions gradually decreased in size and number. She has been applying ultraviolet (UV) blocker most days and is being followed by Nippon Medical School Hospital.

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+The subject described in this case report is a 21-year-old male who suffered a concussion 356 days prior to the physical therapy evaluation. The injury occurred during a fall out of a moving golf cart onto his left shoulder/neck region. The subject reported loss of consciousness and post-traumatic amnesia following the injury. The subject was taken to a local emergency department and CT scan results appeared negative for cerebral bleeding but identified a left temporal bone fracture not requiring medical intervention. The subject received no education on symptomology or symptom duration, and no referral or follow-up was scheduled at the time of discharge. The subject reported a history of four previous concussions, three of which were sport-related, but otherwise had no co-morbidities or significant past medical history. Only minor residual symptoms from his previous concussions were reported that all gradually resolved. The subject had constant, persistent symptoms since the injury that impaired his abilities in school as well as his social life and had restricted athletic or recreational activities, reducing his overall quality of life. The subject visited his primary physician a few weeks prior to evaluation; his cervical spine was cleared via radiographs, and he was referred to a metropolitan outpatient physical therapy clinic.
+The subject was given the Rivermead Post-Concussion Questionnaire (RPQ) to assess symptomology. The RPQ is a subjective, self-report measure that encompasses 16 items, each of which is scored from 0-4 in increasing severity, assessing separate cognitive, emotional, and somatic physical factors. The RPQ demonstrates high test-retest and inter-rater reliability for both total score and individual items via spearman rank correlation coefficients (r = 0.91, r = 0.87 respectively). The subject’s chief reported symptoms during the initial evaluation were neck pain and stiffness, bilateral radicular symptoms that were worse in the left shoulder and upper extremity, lightheadedness, nausea, dizziness, blurred vision and diplopia, sensitivity to light, impaired balance, slurred speech, trouble sleeping, fatigue, slower thinking, and frustration. The subject’s primary complaint was his headache symptoms, which the subject reported were brought on by reading, scanning, driving, or cervical movements. The subject also reported a period of gradual worsening during the weeks and months following his injury. The subject’s goals for physical therapy were to reduce the severity of symptoms experienced since the injury, primarily concerning his headache, fatigue, and neck pain symptomology, as he reported these symptoms have impacted his abilities as a college student and decreased his participation in his social life.
+The subject described in this case report provided informed consent for the study and was informed that the data collected would be used for publication. This study has been approved by the Mercer University Institutional Review Board and Office of Research Compliance. The primary author providing patient care and clinical decision making was a student physical therapist at the time of subject interaction and was supervised by a licensed physical therapist.

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+On January 31, 2015, a 43-year-old Asian man with a 3-year history of progressively invasive PC presented with pain in his right eye. Our patient, who had been staged T4N3M1(TNM classification), had also lost his vision more than a month earlier. He was diagnosed as having metastasis in the bilateral inguinal lymph nodes and ipsilateral iliac nodes before systemic metastasis to his liver and lungs. His medical history was remarkable due to his several surgeries. He denied any family history of inherited diseases and psychological illness.
+On presentation, his best corrected visual acuity was no light perception in his right eye and 20/20 in his left eye. His intraocular pressures were 13.0 mmHg and 11.0 mmHg in his right and left eye, respectively. For the right eye, the pupil dilated to 5 mm, and then the pupillary reaction disappeared. An external examination revealed mild proptosis and ocular movement in all directions. A dilated fundus examination of his right eye showed post equatorial retinal detachment with a black eminence and a pale optic disk. There were no obvious abnormalities in his left eye.
+An ophthalmic B-scan ultrasound showed retinal detachment with hemorrhage. Orbital MRI confirmed the thickening and strengthening of the right lateral wall, characteristics of metastatic carcinoma. The internal rectus and lateral rectus muscles were thickened and hardened, the 2-cm-long optic nerve was thickened, and its stump was invaded by the metastasis. The T1-weighted images of the MRI scans showed hyperintensity , whereas the T2-weighted images showed hypointensity . A contrast-enhanced MRI scan revealed inhomogeneous enhancement of the posterior wall . The presence of lesions was associated with invasion of the optic nerve, choroid, and sclera by the metastatic cells.
+The deep layer, including the choroid, was infiltrated by cancerous tissue. Considering his severe eye pain and irreversible loss of vision, our patient had undergone right eyeball enucleation under general anesthesia on February 3, 2015. This type of procedure is indicated for patients who have had severe eye trauma and for those patients experiencing severe eye pain with unrecoverable vision. His complete eyeball was observed intraoperatively. Histopathological examination led to a diagnosis of metastatic moderately differentiated penile squamous cell carcinoma that infiltrated the sclera, choroid, retina, optic nerve, and external intraocular sites. Hematoxylin-and-eosin staining of the entire eyeball cellular neoplasm showed keratin pearls and infiltrative growth of keratinized cells. Intercellular bridges were seen in the nests of moderately differentiated squamous carcinoma cells .
+Our patient received chemotherapy and radiotherapy during 6 months of follow-up, and then died due to brain metastasis.

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+Our case was a 14-year-old right-handed boy who complained of pain in his right middle finger. The finger was injured by a baseball impact, and the treating hospital performed splint fixation after diagnosing a fracture of the right middle finger. The patient failed to follow up his treatment on his own volition. However, pain in the right middle finger continued and the range of motion became restricted. He consulted our institution 5 months after injury.
+At first consultation, there was swelling in the PIP joint of the right middle finger and displacement of that finger to the ulnar side at extension position . The range of motion of the PIP joint was limited between extension 0° and flexion 60°.
+X-ray images of posterior and anterior views showed bony defect in the articular surface of the PIP joint in the middle phalanx and displacement of the finger to the ulnar side. X-ray image of the lateral view showed depressed articular surface of the PIP joint . CT images showed a bony defect sized 5 × 6.5 × 2 mm in the articular surface of the PIP joint in the middle phalanx . From these imaging findings, we diagnosed the case as malunited intra-articular fracture of the PIP joint and decided to conduct surgical treatment. First, an incision was made by palmar approach and the PIP joint was exposed. A cartilage defect approximately 5 mm in diameter was seen in the articular surface of the middle phalanx, and a cartilage defect of 1 × 2 mm in size was seen in the palmar side of the articular surface of the proximal phalanx . After creating the drilled recipient hole at the osteochondral lesion of the middle phalanx, a cylindrical osteochondral plug of 4.5 mm diameter harvested from the left knee was inserted and press-fitted to the hole. The osteochondral plug was harvested using the mosaicplasty autogenous osteochondral grafting system (Acufex, Smith and Nephew, Andover, MA, USA) from a non-weight-bearing site on the upper lateral femoral condyle. The osteochondral plug was obtained with an obliquely angled cartilage surface along the long axis to facilitate insertion in the recipient hole . The cartilage defect in the proximal phalanx was left untreated as the range of damage was minimal.
+Postoperative splint fixation was done only on the day of surgery, and mobilization exercise was started from the next day by changing the splint fixation to buddy taping. The buddy taping was continued up to 3 months after surgery. After removing the buddy taping, the patient gradually resumed sports activity.
+As of 1 year after surgery, the patient has no pain, and the ROM of the PIP joint has improved showing extension and flexion to 0° and 90°, respectively. Although slight displacement to the ulnar side remains in the PIP joint, instability is not noted, . There are no adverse effects in the donor site of the left knee. The patient resumed his previous level of baseball activity. Final follow-up X-ray and CT images showed bone union with no dislocation of the implanted osteochondral plug. Although slight displacement of the finger to ulnar side remained, the ulnar displacement of the axis improved from preoperative 14° to postoperative 8°. Also, MR images showed a well-maintained joint space by the transplanted cartilage .

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+A 60-year-old male patient presented with pain in the left knee with difficulty in walking since 3 months. The patient had road traffic accident 3 months back and sustained trauma to the left knee. The patient did not took any treatment for the same and came to hospital after 3 months of the injury.
+On clinical examination, there was palpable gap of more than 5 cm between the fracture fragments, anterior surface of femur and condyles were palpated through fracture site and knee range of motion was between 30° and 90° of flexion, and terminal 30° extension lag was present. On radiological examination in form of X-ray radiograph and CT scan with 3D reconstruction fracture, morphology delineated and gap of 5 cm was noted (, ). The patient was operated in supine position and tourniquet was not used (to avoid interference with quadriceps release).
+Midline 15 cm longitudinal incision was taken and medial and lateral flaps were raised. Fracture fragments were identified. Fracture ends were completed covered by the fibrotic tissue . Fracture ends were freshened, there was a gap of 5 cm between the fragments in full extension of knee. The insertion of the quadriceps tendon over proximal pole of patella was exposed and pie crusting was done on medial and lateral side, but still fragments were not approximated, so quadriceps release was done from the anterior surface of femur and V-Y plasty was done. Three longitudinal tunnels were made in proximal and distal fracture fragments and ethibond 5 was passed through it . This helped to reduce the fracture gap and was later tied along superior border. For the V-Y plasty, the length of the limbs of the V of size double the length of the defect was taken, approximately 10 cm. The V shaped cut is marked at junction of tendon and muscle and partial thickness cut were made. The ends of V are then pulled down along with patella and fracture ends were approximated. SS wire was used to hold the reduction of the fragments by encirclage wiring and anterior tension band wiring done. The Y limb so formed after pulling of the tendon was sutured, and then, part of V was sutured back with the medial and lateral native quadriceps muscle tendon. Retinaculum was repaired and wound closed in layers . Post-operative radiograph showed approximation of the fragment and reduction of articular surface .
+Postoperatively, long rigid knee brace was given for 2 weeks and walking with partial weight-bearing started. After suture removal at 2 weeks, full weight-bearing initiated. At 3 weeks, knee range of motion started and continued till 8 weeks. At 3 months post-operative, the patient is able to do flexion up to 90° and no extension lag is present . There is bony union seen at 3 months follow-up.

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+A 74-year-old woman was referred for CABG treatment. She had a history of diabetes mellitus and dyslipidemia and previously underwent percutaneous stenting of the mid right coronary artery and the proximal left anterior descending artery (LAD). Preoperative coronary angiography revealed 90% in-stent stenosis of the proximal LAD and 75% stenosis of the diagonal branch . In addition, she had three instances of in-stent stenosis at the LAD. Whenever restenosis was diagnosed, the implementation of percutaneous coronary intervention (PCI) was repeated. Taking this history into consideration, we decided to perform a left ITA (LITA)-LAD bypass and a right ITA (RITA) diagonal branch bypass. The ITAs were mobilized as skeletonized grafts. We routinely used nicorandil (4 mg/h) and diltiazem (4 mg/h) during CABG operation for the prevention of vasospasm.
+At first, we performed RITA diagonal bypass. Subsequently, we performed anastomosis of LITA-LAD bypass. After CABG, the patient had stable circulation (BP 126/54 mmHg, HR 62 bpm) without changes in ST segment as monitored by electrocardiogram. When we examined blood flow of the RITA diagonal bypass, transit time flow measurement revealed reasonable blood flow (flow rate 20 mL/min, pulsative index 3.4, diastolic flow of 82%). On the other hand, the LITA graft showed comparatively poorer blood flow (flow rate 15 mL/min, pulsative index 2.1, diastolic flow 74%) than the RITA graft. Flow competition between the RITA and LITA was unlikely to occur considering the location of the stenotic lesion. In addition, taking into the consideration the perfused region of the LAD and the severe stenosis in the stent, the graft blood flow was too low and technical anastomotic stenosis was suspected. We re-anastomosed the LITA-LAD bypass. However, even after re-anastomosis of LITA-LAD bypass, transit time flow measurement revealed worsening of graft flow compared to before (LITA-LAD: flow rate 7 mL/min, pulsatile index 4.8, diastolic flow 68%; RITA diagonal: flow rate 11 mL/min, pulsatile index 5.6, diastolic flow 76%). We immediately closed the wound and moved the patient to a hybrid operating room to examine the causes of this progressively low graft flow.
+We performed coronary angiography and detected vasospasms in the native coronary arteries without ST elevation, as seen on the electrocardiogram. We performed intracoronary injections of verapamil (5 mg) and isosorbide dinitrate (6 mg) through the ITA graft, but no improvement was observed. We subsequently injected fasudil (20 mg) through the LITA and observed that coronary flow through the LITA graft improved (thrombolysis in myocardial infarction risk score of 3) . The intracoronary fasudil injection did not cause systemic hypotension, as demonstrated by the postinjection measurement of 86/56 mmHg compared with the preinjection measurement of 93/52 mmHg. We subsequently applied intra-aortic balloon pumping to secure coronary blood flow.
+On postoperative day 1, coronary angiography revealed a patent bypass graft and sufficient coronary runoff . Electrocardiogram showed no ischemic changes. Peak postoperative CK, CK-MB, and troponin T were 582 U/L (41–153 U/L), 7.6 IU/L (4–18 IU/L), and 0.307 ng/mL (0–0.014 ng/mL), respectively. The patient experienced an uneventful clinical course without vasospasm recurrence and was discharged on postoperative day 11.

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+A 56-year-old female was referred to our department from another facility in the patient’s area for a rapidly progressing tumor in the gallbladder and liver area. The patient reported several-month right upper quadrant pain and 4-kg weight loss over the past year. There was no laboratory sign of obstructive jaundice at the day of admission. Preoperative CT and MR scan of the liver was performed, and the patient was diagnosed with a tumor in the gallbladder area with a relatively massive infiltration of the S5 and S6 liver segments and extensive regions of necrosis. Given the potentially resectable lesion according to preoperative imaging, exploratory laparotomy was indicated to attempt radical resection. During the exploration, a voluminous tumor was found attached to the peritoneum. Intraoperative ultrasound was performed and revealed a tumor originating from the gallbladder bed area and reaching up to the area of the hepatic hilum and extensive involvement of the hepatoduodenal ligament by the tumor through the lymph nodes. The tumor was classified as inoperable due to this finding. But during the exploration, however, a rupture of the fragile tumor occurred with massive eruption of the necrotic mass and the gallbladder content into the abdominal cavity, accompanied by bleeding of the liver parenchyma. We decided that the condition could only be managed by attempting modified resection. We performed cholecystectomy and non-anatomical resection of hepatic segments S5 and S6 and partial resection of S4 without lymphadenectomy as a debulking operation . The course of hospitalization was uncomplicated, and the patient was discharged to home care on postoperative day 9. Histologically, the tumor was confirmed as MINEN of gallbladder , and its non-neuroendocrine component had the character of moderately differentiated tubular gall bladder adenocarcinoma, while the neuroendocrine component had the appearance of small cell carcinoma and was dominant, accounting for more than 65% of the viable tumor. The neuroendocrine component contained extensive necrosis, with mitotic index 64/10 HPF and a proliferation index of 70% . It was therefore obvious that the prognosis and the subsequent biological behavior would be influenced in particular by the neuroendocrine carcinoma component. Six weeks after the discharge, the patient underwent a follow-up CT scan prior to the initiation of systemic therapy, which revealed a large recurrence of the disease at the resection surface of the liver accompanied by hilar lymphadenopathy. The patient was started on systemic therapy with etoposide and carboplatin in combination with somatostatin analogues with very good radiological effect. We use this regimen as a standard in patients with MINEN of gastrointestinal tract with dominant neuroendocrine component, even with no somatostatin receptors staining available. Now the patient is almost a year after being diagnosed with a tumor, after completion of 6 cycles of adjuvant chemotherapy (carboplatin + etoposide) in combination with biological therapy, the long-acting somatostatin analogues. The patient is in good clinical condition, and while a recently performed PET/MRI scan revealed a hepatic lesion and hilar lymphadenopathy in full regression, there was a spread of small peritoneal and pleural metastases, with a solitary metastasis in Th9. The condition was evaluated as disease progression stage according to RECIST criteria, the patient remains in the follow-up care, and it is now 13 months after surgery .

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+A 43-year-old man was admitted to the intensive care unit in our hospital due to multiple open traumas caused by a traffic accident. The patient had a history of hypertension. At admission, the patient presented a constant body temperature of 36.5°C. Physical examination showed no obvious abnormality in the heart, lungs, or abdomen. He suffered multiple lacerations and fractures of the right acetabulum and inferior ramus of the pubis, accompanied by pelvic extraperitoneal hematoma. On the first day of hospitalization, he underwent surgery for multiple injuries. Based on empirical therapy, cefuroxime (1.5 g, every 8 h) was administrated for infection prevention, and anti-infective therapy with cefoperazone–sulbactam (3 g, every 8 h) and levofloxacin (500 mg, daily) was conducted for common bacteria and traumatic wet lung. On day 2, the patient developed a fever (38.4°C), with an increase of procalcitonin (PCT; 31.47 ng/ml) and lactic acid (8.58 mmol/L) after the operation. The antibiotic treatment was changed to meropenem (1.0 g, every 8 h) plus teicoplanin (0.4 g daily). On day 14, P. aeruginosa was positive in the bacterial culture of wound tissues and was identified as a multiple-resistant strain with antibiotic susceptibility testing (AST; Kirby–Bauer method), thus amikacin (0.4 g/day) was added to the anti-infective regimen. Despite antimicrobial therapies, a P. aeruginosa-positive blood culture was still identified as bloodstream infection on day 16; the dose of amikacin was therefore adjusted. On day 21, the patient underwent thigh amputation, surgical debridement, and drainage due to recurrent vascular rupture and aggravated cyanosis. Five days later, due to the less effective anti-infective therapy, P. aeruginosa-positive blood culture along with fever still existed; therefore, the patient received moxifloxacin to replace the teicoplanin and amikacin. Despite this management, fevers continued, and infection was still under suspicion. Ceftazidime–avibactam (2.5 g/day) was then administrated to replace the meropenem. The culture was P. aeruginosa negative for the 26th-day blood sample but still positive for wound tissues.
+Due to the uncontrolled infection, other pathogens were suspected. On day 26, tiny, nonhemolytic, and transparent colonies grew on the Columbia blood agar plate of four blood sample cultures , possibly representing M. hominis. Gram staining of the blood smear showed no bacteria. A subculture of blood and wound tissue samples on mycoplasma medium presents as fried-egg-type colonies after 5 days of incubation . Colonies were then identified to be M. hominis by the matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) and further confirmed by 16S rRNA sequencing (primers: 27F, AGAGTTTGATCMTGGCTCAG; 1492R, GGTTACCTTGTTACGACTT) and phylogenetic tree analysis (; GenBank Accession No. OQ642125 for a strain isolated from a wound tissue sample and OQ642126 for a strain isolated from a blood sample). On day 31, therapy with polymyxin B in a dose of 5 × 105 U/day was initiated instead of ceftazidime–avibactam due to its shortage. In addition to the initial isolates of M hominis, two subsequent cultures obtained in the following week were also positive. The AST with a commercial kit (broth dilution method, Zhongaisheng, Hebei, China) showed that M. hominis was susceptible to doxycycline, minocycline, and josamycin but resistant to azithromycin, clarithromycin, norfloxacin, ciprofloxacin, roxithromycin, sparfloxacin, spectinomycin, and levofloxacin . Based on the results of AST, minocycline (100 mg, twice/day), meropenem plus teicoplanin were started instead of moxifloxacin on the 33rd day of hospitalization. On the 37th hospital day, the hematology data and PCT level returned to normal, and infection was controlled. After starting minocycline-based therapy for 6 days, repeated cultures from the blood were M. hominis negative. Details regarding the diagnosis and treatment are shown in .

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+A 52-year-old man with well-controlled hypertension and no prior ophthalmic history presented with an increased number of floaters in the right eye. He did not have a history of diabetes mellitus. Upon examination, we identified an organized VH . Utilizing color fundus photography, OCTA, and ultra-widefield fluorescein angiography, we detected the affected arteriovenous crossing site: an NVE below the optic disc and peripheral NPAs in the quadrant comprising the NVE, indicative of an old BRVO. No other chorioretinal diseases that could be associated with VH, including retinal tears or retinal arterial macroaneurysms, were observed. OCT B-scan found no evidence of posterior vitreous detachment. However, OCTA indicated an NVE extension through the PVM into the vitreous cavity, with the VH apparently originating from a specific point within the NVE. Of note, upon a comprehensive review of all OCTA slices, no visible PVM traction was detected at the bleeding site.
+At the initial visit, the best corrected visual acuity of the right eye was 20/20. In the 5 weeks leading to the intervention, there was no exacerbation of vitreous hemorrhage-related symptoms, such as increased floaters or decreased visual acuity. After retinal photocoagulation and pars plana vitrectomy for the NVE and NPAs, visual acuity improved to 20/13, and floaters improved. Postoperatively, enhanced visibility allowed for precise localization of the affected arteriovenous crossing site and its whitened vessels (E), which substantiated the diagnosis of BRVO. The NVE was removed successfully, and NPAs were outlined distinctly using ultra-widefield OCTA.

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+A 52-year-old male patient was admitted due to 3 wk of intermittent chest distress accompanied by palpitation, but no chest pain, abdominal pain, dizzy and amaurosis.
+Coronary computed tomography angiography performed using iohexol before admission showed local severe stenosis at the proximal and middle of the left anterior descending artery (LAD) and moderate stenosis at the middle of right coronary artery (RCA). The total coronary artery calcification score was 1009.9. The patient was referred to our hospital for further evaluation and treatment.
+He had a prior history of cigarette smoking, arterial hypertension, old cerebral infarction, hyperlipidemia and hyperuricemia. He had been prescribed levamlodipine besylate, bisoprolol fumarate and atorvastatin for 4 years. He denied a history of alcohol consumption, type 2 diabetes mellitus, arrhythmia, chronic constipation, chronic abdominal pain, abdominal surgery and trauma, and other drug use.
+He had no family history of cardiovascular and digestive system diseases.
+The patient’s clinical condition was relatively good with normal blood pressure of 125/72 mmHg and heart rate of 67 bpm. There were no abnormal physical findings.
+The basic laboratory values were normal with the exception of elevated plasma D-dimer of 3.14 µg/mL (normal range: 0-0.55 µg/mL). Blood leucocyte count was 8620/µL (normal range: 3500-9500/µL), hemoglobin was 151 g/dL (normal range: 130-175 g/dL) and platelet count was 311000/µL (normal range: 125000-350000/µL). Serum C-reactive protein (CRP) level was 0.52 mg/L (normal range: 0-8 mg/L).
+The 12-lead electrocardiogram (ECG), echocardiography and abdominal ultrasonography were normal. On the second day of admission, coronary angiography (CAG) was performed via right radial artery access and revealed diffuse stenosis of 50%-70% from the proximal to middle segment of the LAD and localized stenosis of 50%-70% at the middle segment of the RCA . A total of 60 mL of iohexol (Omnipaque 300), a low-osmolar nonionic iodinated contrast agent, was administered during the procedure. The patient was also given local anesthetic (1% lignocaine) prior to CAG and standard 3000 IU heparin intra-arterially during CAG, which were completed uneventfully. We did not perform any coronary intervention according to the CAG results. Vital signs during and immediately after CAG were normal.
+At 3 h post-CAG, the patient complained of epigastric pain and nausea without chest pain, chest tightness, vomiting, rash and pruritus. Vital signs were totally stable (temperature, 36.5℃; blood pressure, 118/62 mmHg; heart rate, 54 bpm; respiratory rate, 12 breaths/min; O2 saturation, 98% in room air). Abdominal examination showed normal bowel sounds and upper abdominal tenderness but without any peritoneal signs. ECG remained normal without any change. The patient was administered oral pantoprazole and an intramuscular injection of anisodamine in a 10-mg dose. However, his abdominal pain gradually worsened. His hemodynamic and respiratory parameters were still within the normal range without any signs of hypoperfusion. His laboratory results after CAG revealed leukocytosis (19710/µL) with neutrophilia (17580/µL, normal range: 1800-6300/µL). Hemoglobin of 14.6 g/dL, platelets of 272000/µL and CRP of 0.71 mg/L remained normal. Myocardial enzymes, amylase, lipase and lactate dehydrogenase (LDH) were also normal. Fecal occult blood test was positive. An emergency abdominal computed tomography (CT) scan revealed a thickened colonic wall corresponding to the ascending and right transverse colon segments, without obvious stenosis and without dilation of the proximal segments, accompanied by multiple exudative changes indicating inflammatory lesions. The patient was started on water deprivation, abrosia, intravenous levofloxacin 500 mg associated with rehydration by intravenously administered crystalloids. Antiplatelet drugs were stopped.
+On the 2nd day after CAG, the patient complained that abdominal pain transferred to the right epigastric and subxiphoid without fever, diarrhea and vomiting. His vital signs were still stable. Physical examination showed tenderness, tension and rebound pain in the right upper abdomen and below the xiphoid. Antibiotics were replaced with latamoxef (4 g/d). On the 3rd day after CAG, an abdominal CT scan with intravenous iodixanol of 100 mL demonstrated that thickening, edema of the ascending and right transverse colonic wall and the inflammatory exudate became more serious . There was no thrombus in the superior and inferior mesenteric arteries and veins . Laboratory studies revealed leukocytosis (17810/µL) with neutrophilia (14230/µL), elevated CRP (68.79 mg/dL) at 8-times the upper limit of normal and elevated D-dimer (4.3 µg/mL). Fecal occult blood test was still positive.

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+Written informed consent was obtained from the patient.
+A 28-year old pregnant woman (gravida 0, para 0) was recommended for C-sec at a local gynecology hospital due to cephalopelvic disproportion. She had been in contact with a SARS-CoV-2 infected patient, and she began self-isolation on February 14, 2020. She developed fever (> 38℃), mild sore throat, and cough, after which she visited a public health center and was tested positive for SARS-CoV-2 on February 25 (36+2 weeks gestation). She self-isolated herself at home after diagnosis and observed her prognosis. She had mild symptoms and received conservative treatment without medication. The symptoms improved and she only had a mild cough with no fever and sputum on February 29. She wanted to delay delivery until she recovered from the infection. However, an emergency C-sec was decided on March 6 (37+6 weeks) due to obstructed labor with incomplete rotation of the fetal head. The patient was transferred to our center, which is a designated hospital for pregnant patients infected with SARS-Cov-2. Her blood type was ‘O-Rh (+)’ and pre-natal workup did not show any specific findings. On arrival, she was immediately transferred to the radiology center for chest radiographs and computer tomography (CT) scans. We then transferred her to a pre-treatment room in the delivery center equipped with negative-pressure ventilation, exclusive elevators, and pre-operative laboratory test kits, including electrocardiograph (ECG), X-ray machine, blood tests, and urine test. Hemoglobin was 10.9 g/dl, erythrocyte sedimentation rate was slightly elevated (42 mm/h), C-reactive protein was normal (0.15 mg/dl), and other pre-operative laboratory test and ECG results seemed normal. The chest radiographs revealed left lower/middle lobe consolidation and increased vascular marking . We also observed multifocal peribronchial ground glass appearance and consolidation in the left lower lobe from chest CT scans . The SARS-CoV-2 reverse transcription-polymerase chain reaction (RT-PCR) result of sputum and nasopharyngeal swab was obtained pre-operatively. Baseline fetal heart rate was 129 beats/min.
+The C-sec was performed in an operating room at the delivery center, which is located on a different floor from the main operating room ( and ). Hence, the traffic line of the patient did not overlap with that of the other surgical patients. In this case, spinal anesthesia was selected as the anesthetic method, because even if we started with spinal anesthesia, there could still be chances of switching to general anesthesia in case of inadequate anesthesia or sudden changes in the patient’s clinical condition. We were already equipped with a ventilator protected by three mechanical high-efficiency particulate air filters, video laryngoscope, fiber-optic laryngoscope blades and handles, endotracheal tubes (6.5 mm, 7.0 mm, and stylet), medication drugs such as propofol, lidocaine, rocuronium, sugammadex, atropine, and closed suction catheter before the patient entered the operating room.
+All medical staff members wore enhanced personal protective equipment (PPE), including N95 mask, surgical cap, double gown, double gloves, shoe covers, and a powered air-purifying respirator ( and ) in the fitting room . In the operating room, we measured the initial blood pressure (115/69 mmHg), heart rate (82 beats/min), and peripheral capillary oxygen saturation (99%) under a facial N95 mask without any O2 supply , and the ECG result showed normal sinus rhythm.
+The patient was 166 cm in height and 62 kg in weight. She was placed in the left lateral decubitus position. Spinal anesthesia was performed with a 25-gauge Pencan spinal needle at the L3/4 interspace, and 9 mg of 0.5% marcaine and 20 μg of fentanyl were injected intrathecally. She was placed in the supine position with a left lateral tilt after 10 min, and anesthesia was assessed bilaterally with cold alcohol cotton and the T4 level blockage was checked.
+After spinal injection, the patient experienced nausea and had low blood pressure (71/40 mmHg). The nausea improved with elevation in blood pressure (103/60 mmHg), and the vital signs stabilized after five injections of 100 μg phenylephrine and fast dropping 400 cc of Hartmann solution and 250 cc of colloid (Volulyte®, Fresenius Kabi, Bad Homburg, Germany). The C-sec was performed uneventfully. The baby was born 6 min after incision, and then 100 mg carbetocin was administered intravenously shortly after the birth. Oxytocin 20 IU/1000 ml Hartmann dextrose was also infused continuously to produce uterine contraction and minimize the blood loss.
+Total anesthesia time was 50 min and operation time was 40 min . An estimated blood loss of 400 cc was noted, and 780 cc of crystalloid and 250 cc of colloid were administered during surgery. For pain control, a patient-controlled analgesia pump (ANAPA AC0605®, Ehwa Biomedics, Korea) with butorphanol (10 mg), ketorolac tromethamine (180 mg), ramosetron (0.6 mg), and normal saline (26 ml) was used.
+During the recovery state, the patient stayed in the operating room. Her vital signs remained stable and the patient had no complaints. Recovery blockage on T8 was confirmed and she was transferred to a single room in the SARS-CoV-2 ward (another SARS-CoV-2 suspected mother stayed separately there) through an exclusive elevator with a nurse wearing PPE.
+Both SARS-CoV-2 RT-PCR tests conducted on March 6 and March 8 were confirmed negative. Therefore, the patient was transferred from the SARS-CoV-2 ward to the general ward on March 10 and discharged on March 11 without any complications.
+The baby girl weighing 3130 gm was born on March 6, 2020 at 11:22 with Apgar scores at 1 and 5 min of 9 and 10, respectively. She was transferred immediately to a private newborn’s room in the neonatal intensive care unit (NICU) in order to avoid being exposed to SARS-CoV-2. The NICU consists of two separate spaces: one for suspected or confirmed SARS-CoV-2 babies and the other for healthy babies. All four newborn babies delivered from mothers with suspected SARS-CoV-2 tested negative and were transferred to the latter in the NICU.
+The SARS-CoV-2 RT-PCR results using placenta, amniotic fluid, and cord blood were negative. Furthermore, the nasopharyngeal swab of the baby was negative on two consecutive SARS-CoV-2 RT-PCR tests. The medical staff had to wear level ‘D’ PPE until their SARS-CoV-2 PCR testing was reported negative.
+The neonate was in a healthy state getting oral feeding and was discharged with her mother.

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+A 4-year-old male was admitted to the ED of our hospital with generalized urticaria. He had been fishing with his father and, 10 min after lying down on grass, he experienced generalized itchy urticaria and angioedema. Thirty minutes later, on examination in the Emergency Department, urticaria was observed over the entire body and angioedema in his hands.
+Benadryl and methylprednisolone were administered. Four hours after treatment, symptoms had stopped, and urticaria and angioedema had disappeared completely.
+Two weeks later, he visited a farm. Fifteen minutes after lying down on grass he experienced itching sensations in his hands, arms and trunk, along with generalized erythema. He also complained of congestion/itching in his nose, itchy eyes, and crying. His mother stated that he had slight dyspnea with cough and dizziness. She gave him Benadryl and betamethasone via the oral route based on advice proffered in a previous admission to the ED (which improved the most severe symptoms within 1 h). He was admitted to the ED after 2 h with only erythema, and he received antihistamines for an additional 5 days. The patient had no history of atopy.
+By anamnesis, an etiology of insect bites, or intake of food or drugs before these two episodes were excluded. Total Immunoglobulin-E was 123 IU/mL, the blood count and complement (CH50, C3, C4, C1 inhibitor) were normal. Parasitology studies were negative. His mother and maternal grandmother reported a history of allergic rhinitis.
+Skin-prick tests (SPTs; Dermaprick®; Alergo Pharma, Buenos Aires, Argentina) were positive to Cynodon dactylis, Phalaris arundinacea and Festuca elatior. Surprisingly these allergens were significantly positive (largest diameter (in mm): 8, 12 and 23, respectively), compared with that of the negative control (1 mm) . These pollen allergens are used by our research team to ascertain the prevalence of skin sensitivity .
+SPTs were negative for foods (milk, egg, cocoa, citrus fruits, fish, tomatoes, peanuts, wheat, bananas, strawberries) and airborne allergens (Dermatophagoides farinae, D. pteronyssinus, cat dander, dog dander, Alternaria spp., Aspergillus spp., Mucor spp., Cladosporium spp., Penicillium spp., Rhizopus spp., other grasses, weeds, tree pollens).

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+A 3-year-old boy was referred to our hospital with cough, edema, tachypnea, and tachycardia.
+One week before admission, the patient began to exhibit a paroxysm of coughing with phlegm, accompanied with fatigue and plummeting level of physical activity. Soon afterwards, he exhibited edema all over the body, particularly on the face and both lower limbs. Half a day before admission, the patient developed tachypnea and tachycardia.
+It is worth noting that the patient had a history of delayed physical growth development. He only learned to sit when he was 10 mo old, and he still could not crawl or stand at 1 year of age. He was sent to a hospital and diagnosed with growth retardation. Doctors guided the boy in a rehabilitation training program for 1 year, after which he appeared to walk and run with no significant difference compared with his peers. However, the parents found that his muscle tension was low, and that he fell over easily. In addition, the patient had strephenopodia after birth, which improved after the use of orthotics.
+The family history was unremarkable.
+When the patient was admitted to our hospital, he had symmetrical edema in the face and lower extremities. The pulmonary respiratory sounds were rough with a few coarse rales. There was no protuberance in the precordial region. The apical impulse of the heart was diffused. Heart amplification was identified, and the apical beat was at the sixth intercostal space, 4.5 cm outside the middle line of the left clavicle. Neither thrill nor pericardium friction was found. The heart rhythm was regular with a gallop rhythm and low cardiac sound. The abdomen was supple with the liver 4 cm below the costal margin and 6 cm below the xiphoid, with the spleen impalpable. Moreover, the boy had an elongated face, inhibited facial expressions, a high palate arch , clawfoot, normal muscular strength, decreased muscular tone, and decreased bilateral knee reflexes. The Gower’s sign was positive, and the meningeal irritation sign was negative.
+The serum cardiac troponin I level was 0.211 µg/L (normal < 0.034 µg/L). The level of brain natriuretic peptide reached up to 27500 pg/mL (normal < 215 pg/mL). The alanine aminotransferase level was 458 U/L (normal < 72 U/L), and aspartate aminotransferase level was 671 U/L (normal < 59 U/L). However, there was no significant increase in creatine kinase (99 U/L; normal < 170 U/L), creatine kinase myocardial band (2.29 μg/L; normal < 3.38 μg/L), and myoglobin (133.1 μg/L; normal < 121 μg/L).
+After one week in the hospital, Holter showed about 16.6% of ventricular premature beats (VPBs) of the total number of beats . Echocardiogram showed that the patient had enlarged, weakened left and right ventricles with decreased systolic function. The heart chamber sizes were as follows: Left atrium, 27 mm (normal < 18 mm); left ventricle, 58 mm (normal < 31 mm); right atrium, 40 mm (normal < 32 mm); right ventricle, 22 mm (normal < 11 mm). The ejection fraction was 18%, and the fraction of shortening was 8%. The systolic excursion of the tricuspid annular plane was 13 mm . Cardiac magnetic resonance imaging showed enlarged ventricles, reduced systolic function, and focal delayed enhancement .

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+A 38-year-old male presented to our emergency room with a 4-day history of intermittent fever and chills without nausea or vomiting. The patient had a past history of intravenous heroin abuse and atrioventricular reentry tachycardia status post radiofrequency catheter ablation. Shortness of breath, cough with some yellowish sputum, tachycardia, low blood pressure (80/40 mmHg under Levophed use), and anuria were noted. The patient had not experienced nausea or vomiting.
+Physical examination revealed bilateral coarse breath sounds and a 4/6 pan systolic heart murmur over the left fourth rib. Laboratory analysis revealed a white blood cell count of 35,030 μL (range: 3500–9100 μL; neutrophilia, 73.4%) and a creatinine level of 3.19 mg/dL (range: 0.70–1.30 mg/dL). Chest X-ray revealed interstitial infiltration with mottled consolidation superimposed on bilateral lung fields and blunting of the left costophrenic angle. Chest computerized tomography (CT) showed loculated pleural effusion, consolidations with central lucency collection in both lungs, and mild pericardial effusion . Echocardiography revealed normal left ventricle wall motion (left ventricular ejection fraction, 58%) and a floating vegetation in the tricuspid valve with moderate to severe tricuspid regurgitation.
+Because left empyema and tricuspid valve IE with septic or cardiogenic shock were suspected, left chest tube were inserted and left pleura effusion culture showed methicillin-susceptible S. aureus. Right heart failure secondary to severe TR and poor response to medical therapy were noted 1 day after chest tube insertion. An endotracheal tube was insert ion and the patient underwent tricuspid valve replacement with a 33 mm Hancock II tissue valve via median sternotomy with another left chest tube insertion due to all of the anterior chordae tendineae were rupture. The pre-operative transesophageal echocardiography (TEE) showed 0.9 × 1.2 cm2 vegetation over tricuspid valve. .
+Blood and sputum cultures showed methicillin-susceptible S. aureus. The patient received postoperative antibiotic treatment (oxacillin, 2000 mg six times daily). The early postoperative treatment course was uneventful, with white blood cell count decreased to 14,300 μL and creatinine level decreased to 1.08 mg/dL.
+However, fever up to 38.4 °C and dyspnea were noted on postoperative day 14. Follow up chest X-ray revealed loculated bilateral pleural effusions with perihilar and lower lung haziness infiltrates . Chest CT revealed multiple cavitary nodules in the bilateral lungs . The patient underwent thoracoscopic decortication of the right pleura and incision of the right lower lung abscess with postoperative chest tube drainage. Intraoperative pleural fluid and lung abscess cultures showed carbapenem-susceptible A. baumannii complex and C. albicans. We replaced oxacillin with meropenem 500 mg four times daily and fluconazole 200 mg one time daily. No further fever was noted. After 4 weeks of antibiotic treatment, chest X-ray revealed bilateral clear lung markings with only mild blunting of the right costophrenic angle.

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+A 19-year-old female was evaluated at the Department of Adult Psychiatry Outpatient Clinic with complaints of lack of enjoyment of pleasurable activities, sleep disturbances, suicidal thoughts, and self-induced injury at times of high stress via superficial cutting behaviors on her forearms. These symptoms were in association with ongoing family conflict with her mother and her sister with whom she lived.
+At the psychiatric evaluation, she expressed that her self-esteem was strongly affected by her turbulent family relationships, and she seemed extremely unhappy. She reported superficial cutting behaviors at least 2 times a week, usually in an impulsive fashion. Laboratory evaluations including hemogram, liver function tests, total protein, vitamin B12, folic acid, T3, T4, and TSH were within normal limits. Baseline psychiatric evaluation with the Beck Depression Inventory (BDI-II) revealed scores of 21 (moderate depression) . According to clinical evaluation as well as DSM-V criteria, the patient was diagnosed with major depressive disorder and borderline personality disorder, and she was started on citalopram 20 mg by mouth per day . Cognitive behavioral therapy focusing on negative cognitions was also initiated. Partial response to treatment was observed at the 12th week with reduction of BDI-II score to 12 (mild mood disturbance).
+While she was under follow-up at the Department of Adult Psychiatry Outpatient Clinic, she admitted to a prior ingestion of a portion of a small bottle (less than 30 milliliters per her description of the product packaging) of a commercially available chemical skin exfoliator containing TCAA. This consumption was impulsive per her description and occurred after an argument with her mother. While such products available over the counter can typically range from 8% to 30% TCAA ingredient which determines strength, she did not recall what percentage of TCAA was in the product . She had purchased the TCAA peel to brighten and even out her skin tone by reducing the appearance of hyperpigmentation (acne marks and freckles). She believed the product to also contain antidepressant TCA, since the product was marketed per her report as a “TCA peel,” which is often done in the industry. She knew that TCA antidepressants can be extremely damaging or even fatal in overdose which was her intent. TCA effects in overdose are well documented in the literature . Her symptoms after ingestion were burning pain on her lips and in her mouth, which frightened her somewhat, preventing her from consuming more of the product. She also complained at the time of mild abdominal discomfort followed by an episode of vomiting. Fortunately no other symptoms were reported and all of the symptoms resolved within a few hours. She was asymptomatic at the time of reporting this event to the outpatient clinic.

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+We report a rare case of symptomatic cervical metastasis of a malignant paraganglioma in a 72-year-old male. Five years prior to presentation, the patient visited another hospital presenting with neck swelling and hoarseness. He was diagnosed with paraganglioma of the neck, but an operation was not planned at that time. Six months prior to presentation, the patient’s chief complaints were bilateral shoulder pain, severe neck pain and weakness of the upper extremities. Because of the continual pain, he was referred to us for a second opinion. A physical examination revealed clumsiness in both hands and muscle weakness in the upper extremities. Cervical roentgenograms revealed a lytic lesion of the C3,4,5 vertebral body. Cervical computerized tomography (CT) revealed destruction of the C3,4,5 vertebral body and C4 lamina. Magnetic resonance imaging (MRI) (Figure ) demonstrated severe canal stenosis at the C4 level, with spinal cord deformation. An MRI of the neck upon admission showed a large soft-tissue tumor in the parapharyngeal space, which was adherent to the left carotid artery. A positron emission tomography (PET) scan (Figure ) revealed lytic lesions of the C4 and L1 vertebrae and a parapharyngeal space lesion near the carotid body.
+As the tumor was extremely large and close to the artery and nervous tissue, the head and neck surgeons avoided this treatment route. The conventional anterior approach to the vertebral body was also rendered impossible because of the obstruction of the primary neck tumor. Therefore, CyberKnife® radiosurgery (Accuray, Inc.) was employed as the primary treatment for the cervical and parapharyngeal lesions. Even after the radiosurgery, the pain and weakness in the upper limbs persisted. We concluded that it would take some time for the effect of radiosurgery to appear, as his severe neck pain was caused by the destruction of vertebrae. Consequently, a C3-6 laminectomy and C1-T1 fusion using pedicle screw fixation was also performed. The highly vascularized tumor on the C4 lamina was removed and sent to the pathology department. A histological examination (Figure ) revealed a malignant paraganglioma. Immediately after the second operation, the patient displayed significant improvement in pain and upper-extremity weakness without any complications. As for the metastasis in the lumbar lesion, the patient had yet to show symptoms, a regular course of radiation was administered. Three months after the second operation, an MRI (Figure ) confirmed that the tumor had shrunk, and the spinal cord compression had disappeared. The last follow-up (six months after the second operation) demonstrated complete recovery of the upper-extremity strength.

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+A 62-year-old woman with MMS in the left eye of few month duration underwent a complete ophthalmologic examination that included best-corrected visual acuity (BCVA), slit-lamp biomicroscopy, fundus examination, and applanation tonometry. Spectral domain optic coherence tomography (SD-OCT) images were obtained with Cirrus HD-OCT (Carl Zeiss AG, Oberkochen, Germany) at baseline and at all follow-up visits (one, four, and seven months). Subfoveal macular thickness was 706 micrometers (µm), vision was 20/200, and PPV was scheduled. The patient had a history of phacoemulsification in the left eye.
+The anesthetists performed sedation and a retrobulbar block. The NGENUITYⓇ digitally assisted vitreoretinal surgery system (Alcon, Inc., Fort Worth, TX) was connected to replace the oculars of the microscope. The 3-D high definition real-time video was displayed on the NGENUITYⓇ4K 3-D flat-panel placed at 1.3 m from the surgeon. To be able to see in 3-D, the surgeon wore polarized glasses. Traditional vitreoretinal techniques, with the Constellation Vision System (Alcon, Inc, Fort Worth, TX), were performed without obstacles, including core vitrectomy, posterior hyaloid detachment, and peripheral vitrectomy. Brilliant blue G (DORC, Zuidland, the Netherlands) was used to stain the ILM and the surgeon performed fs-ILM peeling using disposable 25-gauge end-grasping forceps under I-OCT [Figure 2]. The I-OCT also proved that there were no iatrogenic lesions , so it was decided not to perform gas tamponade. The subfoveal macular thickness improved from 706 µm (preoperative), 540 µm (after one month), 214 µm (after four months) to 221 µm (after seven months) [Figure 3] and the visual acuity improved to 20/40 after seven months of follow-up.

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+A 20-year-old woman with a history of epilepsy became aware of left hip pain radiating down to the back of her leg for 3 days. The pain progressed gradually and became so severe that she could not move. Thus, she was admitted to the local hospital and received intravenous antibiotics, cefazoline 6 g/day for her possible infection. However, her hip pain worsened, and she developed fever the following day. A pelvic computed tomography scan showed a fluid collection at the left sacroiliac joint (SIJ) and a small abscess in the left iliac muscle . The next day, her hemodynamic parameters also deteriorated despite the antibiotic treatment, and consciousness disturbance developed. She was transferred to the emergency department of our hospital.
+Upon hospital arrival, the patient’s vital signs were as follows: heart rate, 122 beats/min; blood pressure, 95/34 mmHg (norepinephrine 0.16 mcg/kg/min, dobutamine 4.0 mcg/kg/min); body temperature, 36.4 °C; and oxygen saturation while on oxygen therapy at 2 L/min via nasal cannula, 98%. Further, the following are the laboratory test results: C-reactive protein level, 16.8 mg/dL and arterial blood gas lactate level, 4.4 mmol/L .
+Based on the examination results and clinical symptoms, the patient was diagnosed with septic shock caused by SIJ infection. Ultrasonography-guided abscess aspiration was performed to drain the joint fluid and identify the bacterial species. Later, the blood and aspiration fluid culture and genetic analysis revealed the presence of S. schwarzengrund.
+Broad spectrum antibiotics (meropenem 3 g/day and vancomycin 2 g/day), vasopressors, and oxygen therapy were administered initially. The patient’s hemodynamic and respiratory status gradually improved. After obtaining the culture results, antibiotic treatment was changed to levofloxacin. Ten days after the first drainage, the fever pattern and inflammation markers such as C-reactive protein and erythrocyte sedimentation rate significantly improved.
+However, after the first drainage tube removal, the patient exhibited persistent fever and inflammation again, and hip magnetic resonance imaging revealed a growing abscess . Thus, we performed the second drainage from days 26 to 35. The patient was discharged on day 38 with oral ampicillin treatment for eight more weeks. Upon discharge, she had neither any symptoms nor sequelae .
+To validate the entry route of S. schwarzengrund, we interviewed the patient in detail. Except for keeping one dog and two cats, she did not have any specific medical history, such as intravenous drug usage, recent overseas travel, diagnosis of sexually transmitted diseases, or consumption of suspicious food. She did not complain of any preceding gastrointestinal symptoms. The screening test results for immunodeficiency diseases, including HIV infection and autoimmune disorders, were negative. Genetic analysis of congenital immunodeficiency also revealed no significant findings. These results indicated that she did not have any immune system disorders.

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+A 24-year-old man presented at the eye casualty of our clinic, with a 20-day history of severe pain, redness, photophobia, and tearing in both of his eyes. He had been treated repeatedly with corticosteroids and prophylactic topical antibiotics for bilateral viral conjunctivitis. His medical history revealed only congenital hepatitis B that was well under control. There was no ocular history of trauma, surgery, infection, or allergic/atopic episodes prior to this incidence, although minor trauma caused by eye rubbing remained a possibility.
+Upon ophthalmic assessment, the patient's visual acuity was 3/10 in both eyes. Slit-lamp examination revealed acute conjunctival hyperemia and inflammation, bilateral superior corneal perforation, and peripheral subepithelial and stromal neovascularization extending to the margins of the perforation and causing sizable iris prolapse was also noted. Both anterior chambers were shallow [Figures and ]. The crystalline lenses were clear and fundoscopy was normal bilaterally.
+The patient underwent physical examination followed by laboratory work-up, including complete and differential blood cell counts, platelet counts, erythrocyte sedimentation rate, and liver and renal function tests. Because his condition was rather suspicious, immunological testing was ordered, including rheumatoid factor (RF), antinuclear antibodies (ANA), antineutrophil cytoplasmic antibodies, and C-reactive protein (CRP) titers. The patient was also subjected to a fluorescent treponemal antibody absorption test, Mantoux test, chest X-ray, and a complete work-up for sexually transmitted diseases.
+The laboratory work-up revealed only lymphocytosis, and this prompted a work-up for systemic HSV infection, whereby paired samples were subjected to serological evaluation with IgG and IgM. A high IgM HSV-1 titer was found, with no IgG HSV-1 titer. Cultures of corneal and conjunctival scrapings were negative for bacteria or fungi, and specimens of corneal scrapings from both eyes were sent for HSV gene detection by polymerase chain reaction (PCR). Intravenous acyclovir treatment (250 mg, twice daily) was commenced, and topical medication was applied, namely acyclovir, prednisone, prophylactic antibiotics, and cyclopentolate.
+After 2 weeks of intravenous and topical acyclovir treatment, the patient's clinical status had improved greatly; his symptoms subsided, and little inflammation was noted in either eye. Positive PCR analysis for the HSV genome verified the diagnosis of bilateral HSV-related PUK.
+Because the patient's condition was urgent, an aggressive surgical approach was adopted. In his right eye, a corneal and conjunctival resection of 2 clock hours was performed on both sides of the corneal ulcer, removing redundant, protruding, epithelialized iris tissue. Iridoplasty and eccentric penetrating keratoplasty were then performed after two weeks of intravenous and topical acyclovir treatment . The left eye was managed in two steps. During the first surgical procedure, the same steps were taken as in his right eye, but instead of an eccentric penetrating keratoplasty, two temporary tectonic corneal grafts were used—a nasal and a temporal—and an amniotic membrane was transplanted . A corneal melt developed 1 month later in the temporal patch graft, so a large diameter penetrating keratoplasty was performed .
+Histological analysis of the resected tissue showed a cellular population consisting of lymphocytes, macrophages, fibroblasts, and mast cells. Neovascular capillaries were also observed.
+Twelve months after surgery, the HSV keratitis had not recurred.

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+A 59- year-old female was admitted at our Unit of Neurosurgery with a 4-month history of progressive and severe dorsal back pain without neurological signs. The patient had been previously surgically treated in 2007, 2011, and 2013 for a recidivated MCC in the occipital region, firstly mistaken for a basal cell carcinoma. The resection had been followed by several cycles of chemotherapy (5-fluorouracil and cisplatin) and local radiotherapy. In the last surgical excision, a lateral cervical lymph node dissection had been performed. The patient had no other comorbidities or any other cancer and she was not immunocompromised. Two years later, the patient complained the onset of progressive pain in the dorsal region. After the admission at our Unit, a Magnetic Resonance Imaging (MRI) with gadolinium contrast medium of the dorsal spine was performed. A neoplastic involvement of two vertebral bodies (T7 and T8) was visible on the contrast-enhanced T1-weighted images , a local cord impingement and a segmental local kyphosis were visible on T2-weighted images , while and an osteolytic shape was visible on Short-T1 Inversion Recovery (STIR) sequence . A total body computed tomography (CT) showed several lungs and liver metastases. Neurologic examination was unremarkable. A multidisciplinary consultation was performed, a palliative surgery was decided and the patient was operated employing a posterior dorsal approach based on the use of radiofrequency (RF) thermoablation (MetaSTAR, Dfine, San Jose, USA), followed by the injection of polymethyl methacrylate (PMMA) in T7 and T8 vertebral body and a transpedicle fixation T5-T9. The histopathological analysis of the vertebral body biopsy confirmed that the metastasis is derived from the MCC. Postoperative MRI showed a reduction of the neoplastic volume in both involved vertebral bodies (T7 and T8) [Figure and ], while a thoracic CT scan revealed the improvement of the segmental thoracic curvature with correct pedicle fixation and a partial vertebral augmentation [Figure and ]. The postoperative course was uneventful and there was a significant reduction of dorsal pain. The patient is still alive after 8 months, in good general conditions and is going through chemo and radiotherapy.

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+A 67-year-old male patient presented with dyspnoea and reduced cardiopulmonary exercise capacity. In his past medical history there was an admission for recurrent exercise-induced palpitations in 1980. At that time, he participated in high-frequency/high-duration/intermediate intensity endurance training (Class B, ∼4200 MET minutes/week). Subsequent cardiologic workup was not able to define underlying structural or rhythmical disease. A recommendation against exercise was not given, but coincidentally the patient ceased from his regular workouts in the early 1980s, when starting an ambitious career. His activity was confined to moderate-intensity training. In 2012, he restarted regular activity (Class B, ∼1800 MET minutes/week) and increased his workout volume in February 2020 when he retired. In July 2020, symptoms worsened significantly.
+The patient presented with regular heart rate (HR), blood pressure (BP), and body mass index. Physical examination was noticeable for a 3/6-systolic murmur with punctum maximum at fourth intercostal space right parasternal. Key laboratory findings are presented in . His electrocardiogram (ECG) showed sinus rhythm with epsilon waves in V1–4 and T-wave inversions in leads II, III, aVF, and V1–6 . Transthoracic echocardiography (TTE) showed enlarged and dyskinetic RV with aneurysmatic extension on RV free wall (RV end-diastolic diameter basal: 65 mm, tricuspid annular plane systolic excursion: 21 mm, RV outflow tract in parasternal long-axis view: 53 mm, RV outflow tract in parasternal short-axis view: 61 mm), as well as high-grade tricuspid regurgitation (TR) (grade III/III, effective regurgitant orifice area: 53 mm2, coaptation defect: 8–9 mm) and low-grade pulmonary regurgitation (grade I/III). Left ventricular (LV) size and function were preserved [LV ejection fraction (EF): 55%] and there were no relevant vitia of aortic and mitral valve (
+and
+Video 1–3).
+We suspected RV cardiomyopathy and investigated patient’s family history. Indeed, his sister had been diagnosed with ARVC as well as both of her teenage children, one of whom suffered from cardiac arrest while playing tennis at the age of 19 but was successfully resuscitated. His uncle, grandfather, and great-uncle sadly passed away from SCD at the age of 59, 60, and 19, respectively . In a synopsis of these initial findings, we initiated workup according to 2010 modified Task Force Criteria.
+Seven-day Holter ECG showed two non-sustained ventricular tachycardias (maximum length of 12 beats) and an ectopic beat burden of 22 000/24 h . Cardiac magnetic resonance imaging (MRI) correlated largely with echocardiographic findings: besides functional and morphological abnormalities, i.e. akinesia of the RV apical and medial anterior wall with signs of fatty degeneration, RV dilation and EF were further quantified (RV end-diastolic volume index: 227 mL/m2, RVEF18%) . Complementary genotyping revealed heterozygous nonsense substitution in PKP-2 gene (NM_004572.3: c.369G>A; p. Trp123Ter), which matched the ARVC phenotype in three databases for clinical variants (ClinVar, dbSNP, gnomAD) ., Conclusively, ARVC was established as definite diagnosis .
+Medical heart failure therapy including beta-blocker, angiotensin-converting enzyme-inhibitor, and aldosterone antagonist was introduced. Using the ARVC risk score, the risk for a fast ventricular tachycardia/ventricular flutter/sustained ventricular arrhythmia was calculated at 7.1% within 5 years and patient underwent prophylactic implantable cardioverter-defibrillator (ICD) implantation. The latter was complicated by poor impedance levels at preferred implantation site in apical RV myocardium. Adequate connectivity was finally achieved after implantation into high-septal myocardium.
+The patient was advised against smoking, high-cholesterol diet, exercise training, and anaerobic activity. We offered psychological counselling and consultation of a local ARVC support group. Monthly follow-ups were set in our specialized ARVC centre and mutation-specific cascade family testing was recommended in our cardiogenetic centre.
+On regular follow-up 4 months later, the patient reports clinical deterioration. Electrocardiogram findings appeared unchanged. The ICD device did not elicit ventricular tachycardias. Repeated echocardiography showed severe TR (effective regurgitant orifice area: 40 mm2, proximal isovelocity surface area: 7–8 mm), which now appeared to be additionally aggravated by interference of ICD lead with septal leaflet. Of note, echocardiography-controlled repositioning of the ICD lead did not seem to be promising considering the difficulties in ICD implantation and fragile nature of the RV myocardium. During exercise stress testing, systolic BP and HR increased appropriately. Furthermore, we performed stress echocardiography and supine incremental stepwise cycle exercise right heart catheterization to investigate resting and stress haemodynamics. The onset of dyspnoea at 75 W was correlated with diastolic LV compression and obstruction of LV filling by increasing RV pressure and RV failure . Left ventricular early systolic volume at 100 W was estimated to 50 mL.
+Diagnostic angiogram showed coronary sclerosis without obstructions . Resting pulmonary artery (PA) systolic/diastolic and mean pressures were measured at 25/16 and 23 mmHg, respectively. Exercise-induced PA pressures rose slightly to 32/23 and 26 mmHg. The transpulmonary gradient remained regular at rest and when subjected to stress at 12 and 14 mmHg, respectively. Pulmonary artery oxygen saturation was 49% at rest and 37% at performance limit, evidencing slightly increased peripheral oxygen extraction. Overall, there was no evidence for pulmonary hypertension. Extended pulmonary diagnostics using high resolution computed tomography of lungs and spirometry excluded any obstructive and restrictive lung pathologies. Abdominal ultrasound documented systolic flow reversal in dilated liver vessels and inferior vena cava . Gastrointestinal symptoms and dilated liver veins were interpreted as progressing signs of right heart congestion with beginning congestive gastritis and hepatopathy (AST 59 U/L, ALT 73 U/L, GGT 149 U/L, bilirubin 0.9 mg/dL).
+We expanded medical treatment by adding standard coronary artery disease prophylactic agents, namely acetylsalicylic acid and rosuvastatin. Heart failure medication was modified by adding torasemide and antiarrhythmic medication was adjusted by discontinuation of bisoprolol in favour of sotalol . Despite conflicting evidence, sotalol is still a guideline-recommended prophylactic agent for patients with ARVC/D, which is based on data from the OPTIC study, showing a trend towards fewer ICD shocks in patients treated with sotalol compared to beta-blockers. On the next regular follow-up, the patient reported a significant improvement regarding symptom burden. Thus, therapy was continued in its present form with regular re-assessments in ongoing monthly follow-ups.

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+An eight-year-old girl was admitted to the emergency department with an acute primary episode of bilateral lower limb paralysis that had begun approximately 9 h prior. There was no history of trauma, loss of consciousness, rapid breathing, fever, seizure, spasm, gastrointestinal tract losses, polyuria, paresthesia, or pain. She had a normal developmental history, normal auditory function, and experienced no leg weakness or sensory loss previously. No family members reported similar medical history or kidney diseases, and her parents were not close relatives. Her physical examination revealed that she was fully alert with normal vital signs. She was well nourished with short stature (height < 3rd percentile) consistent with her genetic potential. She had normal physiological reflexes. Muscle strength was 4/5 for the upper limbs and 3/5 for the lower limbs. No pathological reflexes, clonus, spasticity, or rigidity was found.
+The patient had a history of anal atresia with a rectovaginal fistula that was fully corrected when she was 1 year old. She had recurrent urinary tract infections (UTIs) caused by high-grade vesicoureteral reflux (VUR) and severe bilateral hydronephrosis. She was treated with prophylactic antibiotics. When she was 6 years old, a bulking agent was used to treat bilateral VUR. She also received tamsulosin (α-1 blocker) at the age of 6 years which was then discontinued after 3 months due to no improvements. Urodynamics were performed and suggested bladder outlet obstruction with a residual urine volume of 150 mL. Magnetic resonance imaging (MRI) of the spinal cord revealed syringomyelia extending from thoracic spine Th2 to Th7 . Clean intermittent catheterization (CIC) was initiated and maintained until admission. No breakthrough UTIs were noted. After a 2-year follow-up, the hydronephrosis persisted.
+Initial laboratory investigations revealed a normal complete blood count and electrolyte imbalances, notably hypokalemia (K 2.4 mEq/L). Urinalysis revealed a UTI . The electrocardiogram (ECG) indicated a normal heart rate and T wave inversions. The patient had decreased kidney function corresponding to an estimated glomerular filtration rate (eGFR) of 25 mL/min per 1.73 m2 . She was treated with intravenous (IV) potassium chloride, sodium chloride, and cefotaxime and investigated for possible etiologies of hypokalemic paralysis. On the third day of hospitalization, her venous blood gasses and electrolytes indicated hyperchloremic metabolic acidosis with hypokalemia and a normal anion gap. The urine pH was 6.5 with a positive urine anion gap. Her urinary pH before this admission has ranged from 7.0 to 7.5. The urinary calcium creatinine ratio was 0.19 mg/g. Thyroid function was within the normal range. Urine osmolal gap (UOG) when she was free from UTI was 1.9 mOsmol/kg . Kidney ultrasonography (US) did not document any nephrocalcinosis.
+dRTA was therefore diagnosed. The paralysis resolved completely, the urinalysis normalized, and the patient was discharged with oral bicarbonate 500 mg every 8 h and potassium slow release (KSR) 1200 mg every 12 h.

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+A 91-year-old Japanese woman with a past medical history of angina pectoris, hypertension and uterine carcinoma noted bilateral axillary pain and presented herself to an emergency room. As a physical examination and chest roentgenography showed no emergent findings and her pain improved, she returned home. However, she subsequently experienced several episodes of recurrent chest pain. At approximately 1 week after the onset, she was hospitalized due to continuous dyspnea and left chest pain. On examination, the patient was alert. Her body temperature was 36.4 °C, her pulse was 110 beats per minute, her blood pressure was 147/98 mmHg, and her respiratory rate was 28 breaths per minute. Her oxygen saturation was 98% on oxygen (6 L/min). A blood test revealed high levels of brain natriuretic peptide (BNP; 3431.5 pg/mL), creatine kinase (CK; 303 U/L), CK-MB (31 U/L), troponin T (0.813 ng/mL), C-reactive protein (CRP; 7.21 mg/dL), potassium (5.2 mEq/L), blood urea nitrogen (BUN; 41 mg/dL), creatinine (2.04 mg/dL), aspartate aminotransferase (AST; 68 U/L), and alanine aminotransferase (ALT; 35 U/L). Her red blood cell count was slightly low (3.61 × 106/μL). Her white blood cell count, platelet count, and sodium and chlorine levels were within the normal ranges. Electrocardiography revealed sinus rhythm, low voltage in limb and chest leads, and ST-segment elevation in leads II, III, aVF and V3 to V6. Echocardiography revealed medial to apical dyskinesia and basal hypercontractility of the left ventricle, which seemed to have a takotsubo-like shape , and cardiac tamponade. After the drainage of 400 mL of hemorrhagic pericardial effusion by pericardiocentesis, the patient’s symptoms improved; however, the cardiac dysfunction did not. Coronary angiography was not performed due to her age and low kidney function. At 3 days after her admission, cardiopulmonary resuscitation was performed for loss of consciousness due to ventricular fibrillation. The patient’s blood pressure, urine volume and consciousness level were decreased, and cyanosis, metabolic acidosis and hyperkalemia were subsequently emerged. She died on the 5th day of admission (2 weeks after the onset).
+The patient was 137 cm tall, with a body weight of 34 kg; her BMI was 18. At autopsy, the heart weighed 360 g and had a takotsubo-like shape . The epicardium had a reddish color and rough surface. There were no findings of thrombus, embolism, obstruction or severe stenosis of the coronary arteries . There was no cardiac rupture. Remarkably, the left ventricle was dilated in the basal to middle segment, and the ventricular wall was thin, especially at the middle to apical segment . Serous pleural effusion (left 400 mL, right 600 mL) was present. The lower lobes of bilateral lung were collapsed (left 250 g, right 270 g). Bleeding of the intestinal mucosa and moderate atherosclerosis were seen. The liver, left kidney, right kidney and spleen weighed 560 g, 60 g, 70 g and 25 g respectively. Microscopically, the heart showed notable degeneration and necrosis. Wavy change and thinning of the myocardium were diffusely observed especially on the apex and anterior to lateral wall of the left ventricle, interventricular septum and right ventricle, intermingled with interstitial fibrosis, hemorrhage and neutrophil infiltration . Contraction band necrosis was mainly observed on the posterior to inferior wall of the left ventricle . The liver showed centrilobular necrosis. Ischemic change was seen on the intestinal mucosa, suggesting ischemic mucosal hemorrhage.

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+A 23-year-old male patient without past medical history presented to the emergency room with recent retrosternal chest tightness and pain. He reported recent gastro-intestinal (GI) symptoms of nausea, vomiting, 4-day watery diarrhea with transient episode of fever (38.7 °C). At admission, physical examination showed an impaired general status. He was afebrile (37.2 °C), respiratory rate 20 per min., cardiac assessment showed blood pressure of 140/70 mmHg, regular tachycardia of 100 beats per minute and normal cardiac murmur. Pulmonary examination showed a respiratory rate of 16 cycles per min, and auscultation was normal. He denied abdominal pain, and palpation showed no tenderness and no liver or spleen enlargement. He reported generalized myalgia but rheumatological evaluation did not show arthritis or productive myalgia. The electrocardiogram (ECG) showed left axis deviation with regular sinusal tachycardia. Routine laboratory showed leukocytosis 13 G/L (normal range < 10 G/L), neutrophilia 8.2 G/L (normal range 1.5–7 G/L) and lymphopenia 600/mm3 (normal range 1500 to 4000/mm3) on cell blood count, with elevated C-reactive protein of 130 mg/dL (normal range < 5 mg/dL), serum electrolytes, creatinine and liver enzymes within normal limits. Maximum Troponins and creatine kinase MB (CK-MB) were elevated to 678 ng/L (normal range < 14 ng/L) and 54 ng/mL (normal range < 7 ng/mL). The patient was admitted to the cardiac department for further workup. He was managed symptomatically with analgesics, anti-reflux and fluids. Transthoracic echocardiography (TTE) revealed a preserved ejection fraction (EF) of 55% with normal wall motions, no valvular dysfunction, normal pulmonary pressure and no pericardial effusion. His risk of coronary artery disease (CAD) was low; moreover, clinical, biological and echocardiographic presentation summed the hypothesis of an acute myocarditis. A large etiological workup, including repeated peripheral blood culture, Mycoplasma pneumoniae, Chlamydia pneumoniae, Coxiella burnetii, Borrelia burgdorferi, Leptospira spp., Rickettsia spp. and Brucella spp., was conducted. The serologies, such as urinary Legionella pneumophila antigen, were negative. Moreover, serologies of RNA viruses (coxsackieviruses A and B, hepatitis C virus, human immunodeficiency virus) and DNA viruses (adenoviruses, parvovirus B19, cytomegalovirus, human herpes virus-6, Epstein-Barr virus, varicella-zoster virus and herpes simplex virus) were negative. Autoimmune assessment, including antinuclear, anti-neutrophil cytoplasmic antibodies, systemic sclerosis and autoimmune myopathies specific antibodies and converting enzyme assay, were negative. The patient denied any recent drug intake. A Gram stain of specimen stool collected showed multiple curved and spiral Gram-negative rods. Biochemical tests indicated an oxidase, catalase and hippurate negative and indoxyl acetate-positive bacterial species, corresponding to C. jejuni. Stool cultures confirmed the diagnosis of C. jejuni sensitive to macrolides (Azithromycin/Roxithromycin/Clarythromycin) and flouroquinolones (Ciprofloxacin). Continuous telemetry monitoring showed some runs of non-sustained ventricular tachycardia (NSVT). Oral bisoprolol 2.5 mg twice daily was started for that, and oral 1 g of Azithromycin was administered. He remained clinically stable over the rest of the hospital course, and the diarrhea was progressively resolved. The patient remained stable, and we could perform cardiovascular magnetic resonance (CMR) imaging. Triple inversion-recovery black-blood T2-weighted STIR sequences showed focal areas of hypersignal in the subepicardium of the posterolateral left ventricular (LV) wall, indicative of myocardial edema . In addition, steady-state-free-precession (SSFP) cine CMR showed early hypersignal in the subepicardium of the posterolateral LV wall immediately after injection of 0.1 mM of Gadolinium chelates, indicating focal hyperemia . Inversion-recovery gradient-echo-based late Gadolinium enhancement techniques, acquired 10 min. after Gadolinium injection, revealed subepicardial nodular lesions of myocardial damage . The final diagnosis of C. jejuni-related acute myocarditis was supported by the Lake Louise criteria . The patient was discharged free of symptoms after one week in hospital. On close follow-up, his C-reactive protein and cardiac enzymes normalized after three weeks. Repeated TTE and 24-h ECG were normal, so bisoprolol was progressively discontinued after 6 months. Control CMR imaging at 3 months showed regression of the focal areas of hyper signal in the sub epicardium of the posterolateral left ventricular (LV) wall.

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+A 28-year-old woman was transported to the emergency unit of Ayatollah Rouhani Hospital in Babol in January 2013 due to generalized muscle paralysis and respiratory failure. The patient underwent intubation and was transferred to the medical intensive care unit.
+The patient had a history of severe headache and fever was reported a week ago. She was reported to have had dysphagia, dyspnea, ptosis, diplopia, dry mouth and weakness of extremities 12 hours before respiratory failure. Weakness of muscle initially occurred in the upper extremities and then in the lower extremities. Vital signs include: blood pressure: 130/80 mmHg, heart rate: 120/min, respiratory rate: 12 (on ventilator without any trigger and assist), temperature: 38.2 oC and saturation of peripheral oxygen: 100%.
+On examination, the patient was alert; pupils were bilaterally midriatic but with absent corneal reflux absent. There was no papilledema seen using an ophthalmoscope. Swallowing reflex was absent.
+The patient’s extremities were quadriplegic and are areflexic in all four limbs. There was not any movement on the eyelids, cheeks, chin, head and neck. Facial and frontal folds were completely omitted . She had mild abdominal distension.
+On respiratory system, the patient had apnea and on ventilator with ACMV, TV=550 ml, RR: 12 / min, PEEP = 3 Cm / H2O, Fio2= 50% did not need any assistance (, ). Initial tests: WBC: 13500 μL, PLT: 23600 μL , Hb: 11.7 gr/dl, HCT: 34.8%, Bun: 13 mg/dl, Cr: 0.6 mg/dl, BS: 127 mg/dl, Ferritin: 196 ng/mL, Na: 131 mEq/L, K: 3.7 mEq/L, CL: 97 mEq/L, Mg: 1.8 mEq/L, SGOT: 17 U/L, SGPT: 10 U/L, ALP: 176 U/L, PT: 13.2, PTT: 35, INR: 1.3, urine analysis and urine culture were normal.
+Biochemical analysis of CSF was normal. In addition, the culture was negative; PCR was negative for mycobacterium tuberculosis. Qualitive test for HSV-I and HSV -2 are negative. Chest x-ray and brain CT scan was normal .
+There were pansinusitis in the paranasal sinus scan .
+Parameters of arterial blood gases in the first hour after the start of mechanical ventilation were, PH: 7.33, PCo2: 47 mmHg, PO2: 119 mmHg, HCO3: 23.7 mmol/L. Arterial blood gas was checked at least once daily during hospitalization and if necessary, was corrected. Due to the complete relaxation, Botulinum antitoxin was administered. Other treatments include antibiotics for acute sinusitis (amikacin 1 g IV daily, vancomycin 1 g intravenously twice daily, meropenem (IV) 1 g every 8 hours) pantoprazole 40 mg IV twice daily, subcutaneous enoxaparin 40 mg daily. Neurology consultation revealed bilateral exophthalmos, chemosis, proptosis, and lack of vertical and horizontal movement of both eyes. The neurologist diagnosed venous thrombosis based on clinical examination and then started subcutaneous enoxaparin 40 mg twice per day, dexamethasone 8 mg IV every 8 hours and antibiotics. Na, K, Mg, Ca, P were checked in the the ICU, and if necessary, were corrected.
+On the seventh day of hospitalization, functional endoscopic sinus surgery (FESS) was carried out and purulent sinus drainage was evacuated .
+On the ninth day, the first signs of spontaneous respiration of the brain stem (MIP=-2 cm / H20) was observed. Then, the patient's spontaneous breathing was assisted by ventilator. A tracheostomy was performed on the thirteenth day. Then, gradually the movement of the upper limbs (15th day), chest wall (20th day), abdomen (25th day) and the lower extremities (32nd day) were restored.
+On the 37th day of admission, the patient tolerated the mode of pressure support ventilation (PSV=14 cm/ H2o). The pressure level gradually decreased based on the patient’s respiratory rate and tidal volume (6, 7). On the 41st day, the patient was completely disconnected from the ventilator and better tolerated T-tube with 5 liters oxygen per minute. Then after 72 hours (44th day), tracheostomy tube was removed. Arterial blood gases were normal during mechanical ventilation. Joint movement and muscular strength gradually were restored after two months of therapy and became relatively normal. After 6 months, muscle strength was completely normal. For now, the patient’s activity and function of other organs are normal.

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+A 70-year-old man presented to the Emergency Department (ED) with 4 days of increasing shortness of breath and fatigue, having a positive SARS-CoV-2 screening test 15 days before. His past medical history included arterial hypertension, rheumatoid arthritis and prostate cancer under radiotherapy and hormone therapy.
+At ED, he denied fever, chills, chest and abdominal pain, nausea, or vomiting. He had no fever, but was breathless, tachypneic, and severely hypoxemic with a peripheral oxygen saturation of 64% under room air, improving to 98% on 15L of oxygen/minute via a nonrebreather mask. Chest examination revealed bilateral crackles and wheezing. Arterial blood gas analysis showed a respiratory alkalosis and hypoxemia (arterial oxygen partial pressure - PaO2/fractional inspired oxygen - FiO2 ratio 170). Laboratory tests showed an elevated C-reactive protein (43.73 mg/dL) and D-dimer (35 200 ng/mL) and acute kidney injury AKIN 2. The chest X-ray revealed bilateral reticulonodular infiltrates and linear opacities with a predominantly peripheral distribution. COVID-19 pneumonia was diagnosed. He was admitted to the general ward and dexamethasone was promptly started maintaining oxygen via non-rebreather mask, therapeutic-dose anticoagulation, and diuretic therapy. In the first 48h he developed severe respiratory failure and was transferred to the ICU, requiring IMV, after a failed trial of NIV with progressive ascent parameters until Continuous positive airway pressure 12 cmH2O and FiO2 90%, for about 24 hours.
+The patient remained deeply sedated on pressure-controlled mode ventilation. Due severe respiratory failure, neuromuscular blocking agents were applied during the first 72h, and then by short intermittent infusion or bolus as needed basis to reduce patient-ventilator asynchrony and to access respiratory mechanics. Recruitment manoeuvres were applied once by stepwise approach reaching a peak inspiratory pressure of 35 cmH2O and respecting 15 cmH2O of driving pressure. Then the PEEP was set for the best compliance and low driving pressure. Oxygenation and pulmonary compliance improved without haemodynamic instability. Lung-protective ventilation was maintained with low tidal volume around 6 mL/Kg of predicted body weight, plateau pressure below 30 cmH2O, PEEP of 15 cmH2O and FiO2 of 55%. Dynamic lung compliance was 30 mL/cmH2O and PaO2/FiO2 ratio stayed above 150, with no need of prone positioning. On 5th day of IMV, cervical, thoracic and abdominal subcutaneous emphysema were noted on physical exam and pneumomediastinum was suspected on chest X-ray. Abdominal distension and tympanic percussion were also observed, with tangential X-ray of abdomen showing free gas in abdominal cavity . A thoraco-abdominal computed tomography (CT) scan was performed and confirmed subcutaneous emphysema, moderate pneumomediastinum and a large pneumoperitoneum, without pneumothorax, tracheoesophageal rupture, or signs of visceral perforation . In the absence of bowel perforation and other clinical consequences, the multidisciplinary team (intensivists and general surgeons) decided to manage conservatively the SP. However, 12 hours later, the patient became unstable. Lung mechanics were changed (tidal volumes and lung compliance decreased, peak inspiratory and mean airway pressures increased), hypoxemia worsened and intra-abdominal pressure (IAP) increased without signs of pneumothorax. An abdominal compartment syndrome (IAP 25 mmHg and respiratory disfunction) developed, and emergency percutaneous needle abdominal decompression with a 14-G venous catheter was performed . The catheter was connected to an underwater seal drainage system , with clinical improvement allowing catheter removal after three days, with complete resolution and no relapse of the pneumoperitoneum. He did not present any features suggestive of gastrointestinal tract perforation (nausea, vomiting, diarrhoea, abdominal pain, or hemodynamic instability). Thereafter, abdominal examination remained normal, enteral feeding was fully tolerated and bowel function remained normal.
+Due to prolonged mechanical ventilation, critical illness polyneuropathy and delirium, a percutaneous tracheostomy was performed on day 22 of IMV. The patient was discharged to the ward 48 days after ICU admission and left the hospital on day 129.

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+A 14-month-old male castrated domestic shorthair presented with a recent history of four self-limiting generalised tonic–clonic seizure-like episodes over a period of 1 month. The seizures were characterised by loss of consciousness, autonomic dysfunction (urination, defaecation, ptyalism) and tonic–clonic involuntary movement of all four limbs. These episodes lasted 2–3 mins and were accompanied by a postictal phase 30–120 mins in length, characterised by ataxia and a depressed mentation. In between the seizures, the cat was reported to act normally.
+Two months prior to the episode history the cat was involved in a road traffic accident, causing irreparable left hindlimb trauma resulting in an amputation. General physical examination was otherwise unremarkable. No abnormalities were noted on neurological examination.
+Based on the presence of generalised tonic–clonic seizures the cat was suspected to have a disease process affecting the forebrain.
+Results of haematological examination, including smear evaluation, identified mild microcytosis (mean cell volume 41.2 fl; reference interval [RI] 41.3–52.6 fl), while white blood cell morphology was otherwise unremarkable. Complete serum biochemistry analysis was unremarkable. Preprandial bile acid was unremarkable while blood ammonia was mildly elevated (89.9 μmol/l [RI 0–50 μmol/l]). Cerebrospinal fluid analysis, including total protein, total nucleated cell count and cytology, was unremarkable. Serum cobalamin level was elevated (1294 pmol/l [RI 231–617 pmol/l]).
+An MRI study of the brain using a 1.5 T magnet (Philips Ingenia CX) was performed with the cat under general anaesthesia. The following sequences with a slice thickness of 2 mm were acquired: sagittal T2-weighted (T2W) turbo spin echo (TSE) and transverse T2W TSE, fluid-attenuated inversion recovery (FLAIR), T1-weighted (T1W) spin echo (SE), diffusion-weighted imaging with selection of three b-values (b 0, b 500, b 1000) and susceptibility-weighted imaging (VEN_BOLD). A three-dimensional (3D) T1W turbo field echo series with a slice thickness of 700 µm was also acquired. Following intravenous administration of gadolinium-based contrast medium (Prohance; Bracco Diagnostics) at a dose of 0.1 mmol/kg the transverse T1W SE and 3D TW1 TFS series were repeated.
+There was marked T2W hyperintensity of the grey matter throughout the cerebellum and part of the mesencephalon ( and ), with no suppression on FLAIR and no associated contrast enhancement. This T2W hyperintensity was bilaterally symmetrical affecting the caudal cerebellar peduncles, the deep cerebellar nuclei (dentate, interposital and fastigial) and the rostral and caudal colliculi .
+Given the MRI findings and the cat’s clinical presentation the presumptive diagnosis was an inherited neurometabolic disorder. Urine was submitted for mucopolysaccharide, amino acid and organic acid screening. A marked elevation of 2-hydroxyglutaric acid was identified. Repeat sampling 35 days later confirmed the same marked elevation of urinary 2-hydroxyglutaric acid.
+Following MRI, the cat was started on 2 mg/kg oral solution of phenobarbitone q12h that was subsequently increased to 3 mg/kg q12h following a recrudescence of seizure activity. Following a telephone update at 12 months after diagnosis, the cat remains alive and has seizure episodes every 2–3 months.

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+A 62-year-old Indian male, a chronic smoker, presented with three episodes of rest angina for the last 1 month. He was detected with hypertension and was taking telmisartan hydrochloride, 40 mg once a day for the last 5 years. There was no history of any other comorbidity. At presentation, his blood pressure was 130/82 mmHg, and his pulse rate was 90 beats per minute. His cardiovascular examination was unremarkable. The electrocardiograph showed T-wave inversion in leads LII, LIII, and aVF . Echocardiography revealed a structurally normal heart with a left ventricular ejection fraction of 55%. Cardiac troponin-I level was normal.
+At the age of 52, he was diagnosed with chronic stable angina when a coronary angiogram revealed a diffuse lesion in the right coronary artery (RCA), causing critical stenosis . PCI to RCA was done with implantation of three second-generation DES (zotarolimus-eluting Endeavor Spirit stent, Medtronic Vascular, CA, USA) with an adequate overlap of stent edges. Post dilatation with a 3.0 × 15 mm non-compliant (NC) balloon in the distal RCA and a 3.5 × 15 mm NC balloon in mid-proximal RCA achieved good angiographic results . Intracoronary imaging was not done at that time. He received dual antiplatelet therapy (DAPT), including aspirin and clopidogrel, for 1-year post-PCI, after which only aspirin was continued. He has also received metoprolol and atorvastatin since then. He did well for the last 9 years following PCI.
+During the current presentation, he was diagnosed with non-ST-elevation acute coronary syndrome and was given 180 mg ticagrelor along with 75 mg aspirin. A coronary angiogram revealed diffuse in-stent restenosis (ISR) extending from proximal to the mid-stented segment of RCA with a focal haziness causing 90% stenosis . This hazy lesion corresponds to the overlap segment of proximal-mid RCA stents ( and ). An intracoronary OCT imaging of RCA was performed (ILUMIEN TM Optis systems, MA, USA) to elucidate the mechanism of stent failure. Longitudinal OCT image (, middle panel) revealed well-apposed struts throughout the length of the stented segment, diffuse intimal hyperplasia, and neo-atherosclerosis, causing a variable degree of luminal stenosis. Furthermore, the OCT appearance of neo-atherosclerosis was variable. While predominantly fibrotic hyperplasia was noticed in the distal and proximal stent, neo-atheroma in the middle stent showed a predominantly lipid-rich plaque with minimal fibrous element, especially at the site of proximal stent overlap. This segment also revealed a thin overlying fibrous cap, plaque rupture, and a white thrombus causing significant luminal area reduction (, upper and lower panels, Videos 1 and 2). Further analysis of the OCT images revealed a vessel diameter of 3.2 mm in the distal reference segment of RCA. This correlates well with the measured mean stent diameter of 3.18 mm in distal RCA, 3.51 mm at the distal stent overlap, and 3.55 mm at the proximal stent overlap segments of RCA, thereby ruling out under-expansion as a mechanism of stent malfunction in the index patient .
+We pre-dilated the ISR lesion with a 2.5 × 15 mm semi-compliant balloon followed by a 3.0 × 15 mm NC balloon and a 3.5 × 15 mm NC balloon at high pressure. Our initial plan was to treat the lesion with a drug-eluting balloon as ISR was intrastent. However, OCT imaging after balloon angioplasty revealed a dissection flap at the upper edge of the proximal stent, extending from the neoatheroma. A review of OCT images revealed a predominantly fibrotic plaque at this site . So, the diseased segment was treated with a 3.5 × 38 mm third-generation Sirolimus-Eluting Polymer Free Coronary Stent (Coroflex ISAR-Neo Stent, B. Braun, Melsungen, Germany) followed by high pressure (18 atm) post-dilatation with a 3.5 × 12 mm NC balloon. Repeat OCT imaging showed a well expanded and well-apposed stent with minimal stent area (6.54 mm2) , except at the proximal part where it was malapposed (, Video 3). This segment was further post-dilated with a 4.5 mm NC Balloon at 14 atm as guided by OCT. The final angiogram showed thrombolysis in myocardial infarction III flow . No further OCT imaging was done in view of contrast load. He was discharged on metoprolol, telmisartan, atorvastatin, and DAPT, including 75 mg of aspirin once a day and 90 mg of ticagrelor twice a day. Being a candidate with high thrombotic risk, he was prescribed an extended duration of DAPT as per current guidelines. He is doing well on follow-up at 6 months after discharge.

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+A 33-month-old Caucasian boy presented with leukocoria right eye (OD). Fundus examination OD revealed a solid white predominantly endophytic retinal tumor filling most of the nasal aspect of the fundus and extensive vitreous seeding . The tumor extended to the posterior surface of the lens and exhibited preretinal neovascularization on its surface. B-scan ocular ultrasonography OD revealed dense intralesional particles consistent with calcific foci. Genetic testing demonstrated a homozygous non-germline RB1 nonsense mutation. Fundus examination of left eye (OS) revealed a broad-based flat melanotic area of the choroid extending from the subfoveal region to the ora serrata temporally . B-scan ocular ultrasonography OS showed no appreciable choroidal thickening corresponding to the melanotic patch. Anterior segment evaluation OS showed no iris or scleral melanocytosis. Our diagnoses were unilateral nonfamilial retinoblastoma OD and isolated choroidal melanocytosis1 OS. The child was treated by primary enucleation of the retinoblastoma-containing OD. Histopathologic evaluation confirmed the clinical diagnosis of retinoblastoma. The child has been followed for more than 4 years post-enucleation. Follow-up examinations of the fundus OS have shown no change in the patch of choroidal melanocytosis.

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+A 3-year-old girl was referred to our hospital 5 days after the trauma, complaining of right elbow joint restriction and pain. She fell onto her outstretched hand while playing at home from a low chair. Her hand was put into a sling by her grandmother, but she hadn't received any other medical care.
+On our examination, there was mild swelling over the elbow and tenderness over the radial head. On palpation, the radial head appeared to be anteriorly dislocated. She had pain in her elbow and could not do the active motion. The passive movement of the injured elbow was: 100º of flexion, 20º lack of full extension, 70º of pronation, and 50º of supination.
+Radiographs confirmed an anterior dislocation of the radial head with plastic bowing of the ulna, no evidence of fracture . Ultrasound detected fluid in the joint and soft tissue interposed in the humeroradial joint, so we anticipated that closed reduction would be unsuccessful. The patient was brought to the imaging department the following day. Under anesthesia using a laryngeal mask airway, closed reduction was initially attempted; however, that was unsuccessful as we anticipated. Then, a magnetic resonance imaging (MRI) film was done that showed that a structure of low signal intensity (annular ligament) was stuck in the humeroradial joint .
+The patient was moved to the operative room the following day (7 days after injury). Closed reduction was attempted a second time, but it also proved unsuccessful verified by intraoperative X-ray fluoroscopy. Open reduction through a posterolateral approach was performed. We found the annular ligament was what stopped the radial head from returning to its anatomical location. The annular ligament wasn't damaged but was very stretched. The radial head was found to be protruding below the annular ligament and was incarcerated between the ligament and anterior capsule, similar to a kind of buttonhole effect . The ligament could not be pulled over the radial head when still intact as that made the joint irreducible. We decided to transect the ligament and repaired it subsequently. By pushing the radial head distally and pulling the interposed ligament anteriorly, it returned to its normal anatomical position immediately. After reduction, the elbow seems to be stable in the proper position during elbow joint movement and forearm rotation, so we finished the operation.
+Active range-of-motion exercises were allowed following 3 weeks of immobilization by a long arm plaster splint. At 3-week, 6-week, 3-month follow-up checkups, the movement range of the operated arm gradually improved, and at 6 months after surgery, it was 135º of flexion, full of extension, 90º of pronation, 90º of supination. This was compared to normal, which was 145º of flexion, full of extension, 90º of pronation, 90º of supination . The result was excellent according to the Mayo elbow performance score (100 scores).

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+A 19-year-old girl was seen in the outpatient department with a diffuse, dull aching right heel pain that was the insidious onset and gradually progressive in nature. There was no history of any injury or surgery. The right heel pain was associated with a limp and did not respond to analgesics. There was no diurnal variation of pain. She had been experiencing difficulty in walking and carrying out daily activities for the past 6 months due to this heel pain. A local examination revealed mild swelling but no overt inflammatory signs, such as erythema or the local rise of temperature, and there was no tenderness. Considering her age of presentation, the character of pain, and no signs of inflammation or infections, further investigations were undertaken.
+A plain X-ray of the foot showed an ill-defined sclerotic area in the calcaneum with radiating spicules, thinned overlying cortex, and soft-tissue edema over the heel . Contrastenhanced magnetic resonance imaging (MRI) of the left ankle confirmed the sclerotic lesion in the calcaneum with extraosseous component and enhancement with contrast. Alkaline phosphatase and lactate dehydrogenase were within the normal range and renal functions were also normal. An ultrasound-guided tru-cut biopsy was undertaken from the lesion, which on microscopy showed abundant osteoid matrix interspersed by pleomorphic cells with elongated oval to spindle hyperchromatic nuclei with increased areas of fibrous tissue, which was the hallmark of osteogenic sarcoma . Fluorodeoxyglucose positron emission tomography-computed tomography scans (FDG PET-CT) showed no distant metastasis.
+Treatment: The patient was given 3 cycles of chemotherapy (cisplatin+adriamycin) at 3-week intervals. After the chemotherapy, a repeat contrast MRI and FDG-PET-CT were undertaken to determine the size and extent of the disease and micrometastasis, which revealed a decrease in the standardized uptake values in the primary lesion and also the extent of the disease.
+A limb salvage surgery was undertaken, which involved a posteromedial incision extending 5 cm from above the ankle to the base of first metatarsal along the watershed line . The biopsy scar was excised, and the neurovascular bundle was isolated and separated. The flexor retinaculum was released, and the lateral plantar vessels had to be sacrificed because of their adherence to the tumor. The medial plantar vessels and nerves were isolated and separated . The capsule was incised all around the subtalar joint and removed from the navicular and cuneiform bone. The tendon Achilles was resected 1 169 cm from its insertion, and the plantar fascia was resected 1 cm from its margins. After thorough dissection, a wide en bloc resection of the calcaneum was taken . The procedure was uneventful. The sample was sent for histopathology, which confirmed osteosarcoma.
+After the surgery, a below-knee splint was applied for 3 months,and the patient was advised non-weight-bearing ambulation. Sutures were removed at 2 weeks, and then three cycles of adjuvant chemotherapy were given. At 3 months of follow-up, partial weight bearing was allowed with elbow crutches and an ankle-foot orthosis. The patient was followed up every 6 weeks. At a 1-year follow-up, a customized silicon heel cup and shoes were given for full weight-bearing ambulation. At the end of 1 year, a PET-CT revealed no evidence of metabolically active disease.

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+A 49-year-old female, with no former relevant medical history and no former regular medication, had reported flu-like symptoms with physical weakness, dizziness, headache, and chills. After three days she collapsed and on admission to hospital an advanced cardiogenic shock with initial left ventricular ejection fraction of 10% was seen. Hemodynamic monitoring revealed a cardiac index of 1.8 l/min/m2. Arterial blood gas analysis showed serum lactate of 3.7 mmol/l and elevated transaminases (GOT 2624 (0–35) U/l, GPT 2234 (0–35) U/l), cardiac markers (creatine kinase 1730 (0–145) U/l, high sensitive troponin-I 93430 (0–26) pg/ml) were significantly elevated, with no signs of acute myocardial infarction in the ECG . The patient suffered cardiac arrest and was treated with catecholamines as well as a calcium sensitizer (Levosimendan, Simdax®, Orion Corporation, Espoo, Finland), but for stabilization an Impella CP (Abiomed Inc., Danvers, MA, USA) was necessary .
+The patient underwent coronary angiography for exclusion of coronary artery disease and myocardial biopsy for further assessment. Blood and biopsy specimens were tested for common causative agents, such as Coxsackieviruses A and B, echoviruses, polioviruses, influenza A and B viruses, respiratory syncytial virus, mumps virus, measles virus, rubella virus, hepatitis C virus, dengue virus, yellow fever virus, Chikungunya virus, human immunodeficiency virus-1, adenoviruses, parvovirus B19, cytomegalovirus, human herpes virus-6, Epstein-Barr virus, varicella-zoster virus, and herpes simplex virus, as recommended , but none of these triggers was detected.
+During the following days, left ventricular systolic function improved and after 8 days Impella was explanted. After six months, LVEF was 55%, and the patient lives a normal life.

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+A 20-year old Caucasian woman in septic shock with multiorgan dysfunction was transferred to our intensive care unit. Her medical history was remarkable for allergic asthma and Basedow’s disease. She had previously undergone a left-sided hemithyroidectomy and right-sided subtotal resection.
+About four weeks before admission to the transferring hospital, our patient had been treated with cefuroxime due to a retroareolar inflammation two years after a right-sided breast piercing. Because of the sustained fever and diarrhea, we substituted cefuroxime with metronidazole, suspecting an antibiotic-associated process. Metronidazole was then switched to vancomycin, with the assumption that our patient had pseudomembranous colitis. A colonoscopy showed inflammation and multiple small ulcerations of her entire colon, with the greatest extent in her ileum, cecum and sigma. However, neither pathogen germs nor Clostridium difficile toxin could be detected in stool samples and her blood and urine specimens were also sterile. A wound swab of her increasingly necrotic right breast showed Staphylococcus aureus, Actinomyces turicensis and Peptostreptococcus species. Consequently, the progressively damaged tissue was explored and extensively excised to exclude an abscess. Because of the considerable aggravation of her general condition, the antibiotic treatment was again diversified to a three-fold treatment with imipenem and cilastatin, moxifloxacin, and fluconazole. Owing to her hemodynamic and respiratory insufficiency, our patient was transferred to our intensive care unit.
+During admission to our ward, ventilation was conducted with 100% oxygen, and our patient needed high catecholamine doses. She was also anuric, with a creatinine level of 5.0mg/dL (reference range 0.7 to 1.2mg/dL) and elevated liver parameters, with total bilirubin 2.9mg/dL (reference range 0.2 to 1.0mg/dL), aspartate transaminase 2572U/L (reference range 10 to 50U/L) and alanine transaminase 608U/L (reference range 10 to 50U/L). She had leukocytosis, with a white blood cell count of 27.0G/L (reference range 4.3 to 10.0G/L). Her C-reactive protein level was >230mg/L (reference range <5mg/dL) and procalcitonin level was 9.3μg/L (reference range 0.1 to 0.5μg/L). An immediate colonoscopy showed multiple ulcerations of the colonic mucosa .
+Because our patient was therapy-refractory and had persisting signs of septic shock and a risk of perforation, a subtotal colectomy was indicated. Just before the beginning of the abdominal surgery, her pulmonary gas exchange worsened. When examined by bronchoscopy, there was no evidence of an obstruction; however, the mucosa of her bronchi was highly inflamed and vulnerable. We observed bleeding originating from her upper airway. The ventilatory conditions were instantly ameliorated by a laparotomy - equivalent to the release of intra-abdominal compartment syndrome. Because of the incipient necrosis of her gall bladder, we performed a subtotal colectomy and a cholecystectomy. During the surgery, 20cm of her rectum were left and blindly closed according to Hartmann’s approach, with an ileostomy and a laparostomy.
+Postoperatively, we initiated a calculated therapy with meropenem and caspofungin as well as vancomycin to cover a possible translocation of C. difficile or its toxins. Furthermore, continuous veno-venous hemofiltration was started.
+Permanent stabilization of our patient’s organ functions could not be achieved. Hemodynamic, pulmonary and renal failure still persisted and her liver enzyme levels increased massively (aspartate transaminase 8848U/L, alanine transaminase 1039U/L, total bilirubin 9.4mg/dL), correlating with ischemic necrosis in liver segments six and seven detected by ultrasonic testing. Moreover, our patient showed recurrent ventricular and supraventricular tachycardia culminating in a short-term asystole. Echocardiography did not reveal any pathological changes. All blood, tracheal secretion and abdominal swab samples stayed free of pathological germs. A sudden rise in lactate necessitated a second-look operation, during which we found no evidence of mesenteric ischemia.
+Histologic examination of her colon showed multiple superficial areas of microulceration of the mucosa, lamina propria mucosae and, to a lesser extent, the lamina submucosa . Medium-sized arteries and arterioles of her entire colon, appendix and gallbladder showed acute vasculitic changes with fibrinoid necrosis of the walls and diffuse infiltration with neutrophil granulocytes, accompanied by a strong perivascular histiocyte-rich and partially granulomatous reaction . Many arterioles also had intraluminal platelet-rich thrombi , others were complete obliterated by inflammatory cells. The affected vessels were localized in the submucosal layer of her bowel and in her gall bladder. These findings strongly suggested an autoimmune multisystem disease like Wegener’s granulomatosis or microscopic polyangiitis. A diagnosis of Wegener’s granulomatosis was confirmed by the results of the serologic antibody tests: her c-ANCA titer was considerably elevated at 1:2560 specific for subclass proteinase 3 (PR3) (>200kU/L). After the histopathological diagnosis and the serological tests, immunosuppression with high doses of corticosteroids and plasmapheresis were started.
+Continuing a dosage of 100mg prednisolone daily and plasmapheresis twice a day for almost a week, we gradually achieved a durable stabilization of our patient’s circulation and lung function, a constant downsizing of the ischemic area in her right liver lobe and a cumulative resumption of urine production. After tapering catecholamines and eliminating about 10L of extravascular fluids, it was possible to close the laparostomy and extubate our patient. Her gas exchange was borderline and she required highly intensive airway treatment and intermittent application of continuously positive airway pressure.
+A couple of days later, she developed an acute abdomen and we measured a leap in leukocytes up to 75.0G/L. A computed tomography scan showed multiple hypodense areas in her liver appearing as partial necrosis and her spleen failed to show any contrast at all.
+A splenectomy was performed due to multiple septic infarctions, although several samples taken from biopsies of the hepatic lesions were sterile.
+Postoperatively, our patient could be extubated without difficulty, her leukocyte level fell and after a perioperative deterioration of kidney function, her creatinine and urea levels stayed within an acceptable range because of reparatory polyuria. She did not show any neurological deficits, slowly regained her strength and could be transferred to a standard ward only five days post-splenectomy.
+Plasmapheresis was continued three times a week and prednisolone was gradually reduced to 50mg per day. After completion of wound healing, cyclophosphamide treatment could be initiated.
+Retrospectively, we discovered some further, interesting aspects about our patient’s medical history: when she was diagnosed with Basedow’s disease two years before, our patient had positive titers for thyroid peroxidase antibodies (380U/mL; normal range <35U/mL), microsomal antibodies (1:6400; normal range <1:100) and thyroid-stimulating hormone receptor antibodies (29.5U/L; normal range <1U/L). Her parents reported that she had complained about painful knees after exercising and gingival problems for several weeks before exacerbation of the Wegener’s disease.

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+The patient, a 39-year-old man with frequent urination, urgency and pain in the bladder area while holding back the urine for 1 month was in good health before. There was no abnormality in the urine routine. The examination of the prostatic fluid showed elevated white blood cells and decreased lecithin bodies. Prostatitis was initially diagnosed. After two weeks of treatment with cephalosporin and M receptor blocker, the symptoms of frequent urination and urgency were partially improved. Review the prostatic fluid indicated that the white blood cells were normal, and the lecithin bodies increased by 20% compared to 2 weeks ago, but the pain in the bladder area was not significantly relieved when the urine was held. Further examination of the urinary system color Doppler ultrasound suggest that the bladder had occupying space. An approximately 2.0 cm solid lesion in the left upper part of the pelvic cavity was seen by ultrasound . The admission-related examination, including blood, coagulation, liver function and kidney function tests as well as electrocardiogram and chest X-ray, showed no obvious abnormalities. CT suggested that a 2.0 × 1.9 cm mass was located in the left front wall of the bladder and was protruding outward with clear boundaries . There was no obvious abnormality of the bladder mucosa on cystoscopy. Nuclear heterogeneous cells were not detected in the urinary exfoliative cytology.
+With the results of the imaging examination, a benign tumour was considered. Based on the tumour being convex to the outside of the bladder, a laparoscopic partial cystectomy through the extraperitoneal space was performed . After general anaesthesia, the patient was placed in the supine position with the buttocks raised by 10 cm. We selected a 3 cm midline incision under the umbilicus as the observation hole, cutting the skin, subcutaneous tissue and the anterior and posterior sheaths of the rectus abdominis layer by layer. Placing the balloon under the posterior rectus abdominis, the extraperitoneal space was expanded . We separated the adipose tissue on the anterior wall of the bladder. A mass, 2.0 × 2.0 cm in size with a smooth surface, was seen on the left anterior wall of the bladder and protruded outside of the bladder. Using an ultrasonic knife, the tumour was completely removed from the bladder with 0.5 cm normal bladder tissue margins . The bladder wall was sutured by using 1–0 absorbable barbed suture through continuous full-thickness . A total of 200 ml of normal saline was injected into the bladder through the catheter, and there was no fluid extravasation in the incision of the bladder wall, which confirmed that the suture was reliable. The operation lasted 65 min, and the intraoperative blood loss was approximately 20 ml. Pathological examination described that the bladder mass had a size of 2 × 2 × 1.6 cm, with a surface covering of bladder mucosa and an envelope with clear boundaries, while the cut surface was greyish white. A schwannoma with oedema and bleeding was considered by pathological diagnosis. We used Envision staining to detect the expression of biomarkers. Immunohistochemical staining showed: S100(+), Desmin(−), SMA(−), CD34(−), Ki67 (about 8%+) . The patient used a semi-liquid diet and walked after getting out of bed on the 1st day after surgery, without obvious gastrointestinal symptoms such as abdominal distension. The pelvic drainage tube was removed on the 4th day after surgery, and the catheter was removed on the 7th day after surgery. There was no recurrence after 2 years follow-up by cystoscopy and CT.

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+A 45-year-old woman was admitted with acute onset of short-term memory loss, intermittent headaches, dizzy spells and an obvious change in personality which had progressed over a ten day period. Intermittent vomiting, confusion and unsteadiness were also reported. These symptoms worsened over the three days prior to admission. Her past medical history included an episode of herpes simplex virus infection about one month earlier. A non-smoker, she consumed alcohol in moderation.
+On examination, she had disorientation of time and place and her mini mental score was found to be 2/10. Confusion with nominal aphasia was also noted. She was apyrexial. Cardiovascular, respiratory and gastrointestinal system examination was unremarkable. Neurological examination showed normal power and tone in both arms and legs with normal symmetrical deep tendon reflexes. Her gait, coordination, cranial nerve and fundus examination were normal.
+Investigations revealed a normal full blood count and unremarkable routine biochemical tests and inflammatory markers. Contrast enhanced CT of the brain showed low attenuation areas adjacent to the anterior ends of both thalami. Appearances were reported as an unusual form of cerebral infarctions and it was suggested that other pathology could not be ruled out.
+Examination of CSF revealed isolated lymphocytosis. Glucose and protein were normal. Polymerase Chain Reaction (PCR) tests for herpes simplex virus and varicella zoster were negative.
+Electroencephalogram (EEG) recordings showed intermittent low frequency activity suggesting focal abnormality of cortical function, probably associated with a vascular or structural lesion but no clear evidence of encephalitis or epileptiform activity. On MRI scan of the head there were bilateral symmetrical lesions in both thalami giving high signal changes on the T2 weighted and proton density images. In addition there were asymmetrical multiple high signal areas on T2 weighted images in both cerebellar hemispheres. CNS lymphoma and demyelination were two of the possible differential diagnoses for the MRI appearances. Subsequently performed vertebral and carotid MR angiograms were reported to be normal and the possibility of basilar artery aneurysm or thrombosis was ruled out.
+Over a period of two weeks there was a progressive worsening of confusion, with increasing agitation, memory impairment and personality change. With deterioration in Glasgow Coma Scale (GCS), the possibility of other systemic causes was considered. She was empirically treated for encephalitis and/or viral meningitis and a possibility of vasculitis was considered, for which a trial of methylprednisolone and cyclophosphamide was given without any significant benefit. Further investigations, looking for a possible systemic cause, by an autoantibody screen including anti-neutrophil cytoplasmic antibodies and a vasculitic screen was reported as normal.
+A saline contrast transthoracic echo confirmed a diagnosis of Patent Foramen Ovale (PFO) as a significant number of microbubbles appeared in the left atrium within 3 cardiac cycles of their appearance in the right atrium and this was facilitated with valsalva release. Further assessment for atrial septal separation was not done with transesophageal echocardiogram because of the above positive findings from the transthoracic echocardiogram.
+A diagnosis of embolic basilar artery ischemic stroke with thalamic and cerebellar infarcts secondary to paradoxical embolism via the PFO was made. She was started on aspirin and clopidogrel and later anticoagulated with warfarin before she underwent percutaneous device closure.
+There are three treatment options in patients with a presumed paradoxical embolism and PFO.
+1. Antiplatelet therapy with aspirin
+2. Oral anticoagulation with warfarin
+3. Surgical or percutaneous device closure
+Despite the growing evidence for association between PFO and atrial septal aneurysm with paradoxical embolism causing neurological events there is no consensus as how to treat a cryptogenic stroke and none of the above treatments have been evaluated in randomised controlled trials.
+There was a gradual improvement over four weeks and subsequently the patient went on to have a complete recovery without any neurological or physical residual effects.
+Later she underwent percutaneous endovascular closure of the PFO with a Biostar device. In our patient percutaneous device closure was used because of her young age and absence of deep vein thrombosis or procoagulant state. It was felt inappropriate to leave the patient on life long warfarin with all the risks that anticoagulation might entail. Our patient had further follow up after the device closure of the PFO and had had no further episodes of transient ischaemic attack or any recurrence of stroke.

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+A 77-year-old man of the Han nationality complained of numbness of his lower limbs for more than 5 years. In addition, his walking distance was less than 100 meters. A neurological examination suggested tenderness in the area of the lumbosacral spinous processes and bilateral paravertebral muscle. The feeling of numbness on the superficial skin of his bilateral lower limbs decreased. His Oswestry Disability Index (ODI) score was 24 and his Visual Analogue Scale (VAS) score was 5 before the operation. He had no history of hypertension, diabetes, or surgery. He also had no tobacco smoking or alcohol history. He took celecoxib orally, twice a day, one tablet a time; his pain was obviously not relieved. Before the operation, the white blood cell of our patient was 5.5 × 109/L, the red blood cell was 4.26 × 1012/L, the hemoglobin (HGB) was 129 g/L, and the platelets (PLT) was 170 × 109/L. As for his liver and renal functions, his alanine aminotransferase (ALT) was 11 U/L and his aspartate aminotransferase (AST) was 2211 U/L. His urea was 6.07 mmol/L and his creatinine was 71.9 umol/L. The tests of urine analysis, serology, and microbiology were normal.
+Lumbar magnetic resonance imaging (MRI) indicated that the spinal canal of L4/5 was extremely narrow. He was diagnosed as having spondylolisthesis and lumbar spinal stenosis and was ready for stand-alone OLIF surgery in terms of clinical manifestations and imaging examinations. Unlike most other people, in this case, his IVC was discovered to be left-sided from the MRI image. In addition, we confirmed that he had a left-sided IVC with reconstruction computed tomography angiography (CTA) of the retroperitoneal vessels and lumbar vertebrae . Finally, he underwent L4/5 stand-alone OLIF surgery under general anesthesia in the left lateral decubitus position. In the left lateral position, a transverse skin incision of 5 cm was made at the area of the right side of his abdomen, which was in the same horizontal plane as the L4/5 intervertebral disc . His abdominal wall muscles were bluntly separated. The retroperitoneum was entered via blunt separation with the fingers; then, the psoas muscle was retracted posteriorly, and the abdominal vessels were retracted anteriorly. A guidewire was inserted in the middle of the target intervertebral disc with the help of a C-arm. Sequential dilators were placed over the guidewire; then, a lighted retractor was placed over the dilators and fixed to the vertebral body with a pin, and the operation field was exposed. The annulus fibrosus and the nucleus pulposus were removed with a nucleus pulposus clamp. Then, the cartilage endplates were resected for exposure of the bony endplates. A wide and lordotic intervertebral fusion cage of 14 × 55 × 6 mm (Medtronic Clydesdale, Memphis, Tennessee) packed with allograft bone was inserted into the L4/5 disc with the guidance of the C-arm. Then, the incision was closed layer by layer. The blood loss was approximately 30 ml.
+Our patient began to practice walking the day after the operation with waist protection, and his symptoms improved. A lumbar X-ray after the surgery showed that the cage was located in the center, and he was discharged from our hospital 2 days after the surgery. After 3 months, the symptoms of lumbar and leg pain were significantly alleviated, and his ODI and VAS scores were 20 and 3, respectively. A lumbar X-ray also indicated that the location of the cage was perfect . Half a year after the surgery, our patient did not complain of low back and leg pain. In addition, his ODI score was 19 and his VAS score was 2.

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+A 57-year-old male presented with 3 months of left pulsatile tinnitus and hemicranial headache without any other neurological deficits. He had no history of head trauma or central nervous system infections. Digital subtraction angiography revealed DAVF with afferents from the left external carotid artery (LECA), notably with the occipital and middle meningeal arteries draining into the ipsilateral sigmoid sinus, without leptomeningeal cortical retrograde venous drainage, and grade I of the Cognard classification .
+The transvenous approach was chosen, together with closure of the affected sinus using coils, but the surgical team experienced difficulties when passing the microcatheter from the transverse to the sigmoid sinus, which was likely isolated. Thus, two sessions of transarterial embolization were performed 2 months apart . During the first session, the fistulous branch of the left occipital artery was occluded with Onyx® [Figure and ]. The patient recovered uneventfully and tinnitus decreased, although headaches persisted. During the second session conducted with Onyx®, the feeder branch of the left middle meningeal artery was occluded [Figure and ]. Angiography revealed complete exclusion of the fistula and successful embolization . On the first day postoperatively, the patient presented with ipsilateral peripheral facial palsy, House Brackmann grade 4 , and no other physical or neurological signs. Tomography showed no ischemic or hemorrhagic complications . The patient received 4 mg of intravenous dexamethasone every 6 h and showed progressive improvement with complete recovery in 4 days . After 4 months, the patient remains under our care, with no complaints of headache or tinnitus. A follow-up appointment is scheduled for 6 months after his last session.

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+A 55-year-old man was admitted to hospital as a stroke call, presenting with sudden-onset left sided cheek, arm and hand sensory loss, visual blurring, and worsening headache. The National Institutes of Health Stroke Scale (NIHSS) score was 3. His past medical history was significant for multiple co-morbidities including coronary artery bypass graft (CABG) surgery, hypertension, type 2 diabetes, and hypercholesterolemia. An urgent head CT excluded intracranial haemorrhage , and intravenous thrombolysis with alteplase was administered. Within 2 hours of thrombolysis, his features of visual disturbance and headache worsened, with increasing confusion. A repeat CT of the head showed multiple areas of intracerebral haemorrhage, mainly in the bilateral posterior regions . No benefit from neurosurgical intervention was expected. Despite intensive multiple organ support therapy, he deteriorated over his admission, developed chest infection, and died 4 days after the initial presentation. The case was referred to HM Coroner and detailed neuropathological examination was performed.
+Informed consent was obtained from the relatives for research and medical education. Post-mortem examination confirmed marked cardiovascular disease, demonstrated by severe coronary artery sclerosis evident in the left main stem and right coronary arteries with associated critical stenosis (luminal diameter < 1 mm). The right coronary artery bypass graft was patent. There were no acute or healed myocardial infarcts. There was mild concentric left ventricular hypertrophy consistent with the history of hypertension. Examination of the lungs revealed an area of possible bronchopneumonia. Other internal organs showed no relevant alterations.
+The brain was fixed in buffered formalin for 4 weeks and weighed 1466 g. On external examination, the brain was swollen and smooth with shallowed sulci and mild subarachnoid haemorrhages in the right anterior frontal pole, the right middle temporal and the right posterior parieto-occipital lobes. At the base of the brain both unci were bulged with prominent grooving, petechial haemorrhages on the right side and soft necrotic brain fragments on the left side. The cerebellar tonsils were also prominently grooved but without haemorrhages or softening. There was moderate calcifying atherosclerosis in the right vertebral artery without luminal narrowing. The rest of the basal arteries were normal with no evidence of thrombotic occlusion, vascular malformation or aneurysm.
+Coronal sections of the cerebral hemispheres revealed mild midline shift to the left associated with compressed ventricles in the anterior and central parts . The right inferior horn and the posterior horns were filled with blood clots . There were multiple recent intracerebral parenchymal haemorrhages, various in size and widespread in distribution, affecting the right frontobasal area, the right temporo-occipital lobe, left superior parietal lobe, both posterior occipital lobe areas and the left cerebellar hemisphere. These haemorrhages probably occurred at the same time, and the atypical distribution suggested that they were secondary to the thrombolysis. Furthermore, a soft, cavitating area was identified in the subcortical white matter of the superior temporal gyrus and the insula slightly extending to the putamen, measuring 20x10x10mm. Timing was uncertain but appeared to be older than the haemorrhages, probably representing an ischaemic infarct. The hippocampi, the inferior part of the thalamus and the midbrain were haemorrhagic, soft and fragmented. Typical Duret’s haemorrhages were noted in the central part of the pons. The fourth ventricle contained a moderate amount of clotted blood. Summarizing the macroscopical findings, the direct cause of the death was given as brainstem herniation secondary to widespread recent intraparenchymal haemorrhages, probably related to thrombolysis. Alternative causes of the haemorrhages were also considered and further histological examination was performed.
+Microscopic evaluation confirmed extensive recent intracerebral haemorrhages, most of them thought to be due to the thrombolysis therapy, surrounded by marked oedema and hypereosinophilic (red) neurons. Haemorrhages were also detected in the subarachnoid space and the ventricles, in keeping with secondary propagation of parenchymal haemorrhages. In addition, the histology examination also revealed severe CAA (Vonsattel grade 3), which was confirmed by Aβ immunostaining . The CAA was particularly prominent in the occipital lobe and was associated with focal, perivascular and vaguely granulomatous inflammation, in keeping with ABRA . Further, probably subclinical, complications of CAA were noted in the left occipital lobe and in the white matter between the insular cortex and the putamen in form of old (at least 6 months) haemorrhagic microinfarcts . In addition, there were also two separate acute ischaemic lesions, estimated between 3 to 5 days old, in the right insular cortex and the basal ganglia and in the right occipital lobe, which might have caused the new onset neurological symptoms prior to hospitalisation. The parenchymal β-amyloid pathology was not significant, consisting of sparse mainly diffuse and fleece-like plaques throughout the neocortex. No characteristic cored plaques were identified and there were no neurofibrillary tangles by hyperphosphorylated tau, which excluded the possibility of underlying AD. Histological examination of the lung confirmed extensive bronchopneumonia which developed in the terminal stage and also contributed to death.

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+A 16-year-old boy is presented complaining of sudden cervicofacial swelling, fever, dyspnea and chest pain one day after dental surgery for an inferior left second molar. During physical examination crepitation and swelling were found in periorbital, cervical and thoracic regions due to subcutaneous emphysema. The patient had no previous heart or lung problems.
+There was no evidence of airway obstruction or respiratory distress. At the time of admission vital signs were normal and O2 saturation was 98%. White blood cell count revealed leukocytosis and neutrophilia (21000 cells and 84% neutrophils). Chest x-ray showed subcutaneous emphysema in the cervicofacial, thoracic, and axillary regions with no evidence of rib fracture. Pneumomediastinum is seen as a small amount of air adjacent to the aortic arc (a, b). Thoracic CT scan revealed air in the subcutaneous and cervical spaces extending to the mediastinum. Conservative treatment consisted of intravenous antibiotic therapy with Clindamycin, Ceftazidime and bed rest but no oral feeding. In the next days the swelling resolved and control CXR showed a decrease in surgical emphysema and resolution of pneumomediastinum. After five days the patient was discharged. Two days after being discharged, physical examination and chest x-ray were normal. For the next 3 weeks, the patient was examined weekly and no problems were found.

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+A 38-year-old multigravida (gravida V para IV) woman of Amhara ethnicity was referred from a health center to our hospital due to prolonged second stage of labor at 42+1 weeks. She felt that her pregnancy did not differ from her previous pregnancies. She had been taking injectable contraception for 2 years.
+She had no family history of any congenital anomalies. She had four healthy live births at term and all are healthy. She had antenatal follow up for four visits where she was screened for human immunodeficiency virus (HIV), syphilis, hepatitis B virus (HBV), and for diabetes (only a random blood sugar test) but not sonographic screening. She received tetanus vaccination and iron supplementation. She did not take any other medication during her pregnancy. She presented to our hospital after laboring for approximately 35 hours both at home and at the health center. She was evaluated on arrival at our hospital; she had contraction, term-sized gravid uterus, and fetal heart beat was 112. On digital pelvic examination her cervix was fully dilated, the station of the head was high, and the pulsating umbilical cord was in front of the presenting part with ruptured membrane, which indicated a difficult transvaginal delivery. For this reason, the team rushed for emergency cesarean section.
+A cesarean section was done under general anesthesia and a live baby girl weighing 4200 g was delivered. The placenta was single and normal. Her Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) scores were 7 and 9 at 1 and 5 minutes, respectively. She appeared to be grossly normal except her parasitic co-twin was attached at the temporal area of her cranium (see Figs. , , , , and ). Her twin was an incidental finding and during the difficult extraction her left uterine artery was severed and repaired.
+The baby girl was further evaluated with a skull X-ray; an ultrasound of the co-twin and the abdomen of the normal twin (autosite) by Doppler ultrasound confirmed that the parasitic conjoined twin had communication with the normal twin only in soft tissue and vessel arising from carotid vessels but no connection with the brain or related structures.
+A detailed clinical examination of the normal twin revealed normal findings except for her parasitic twin at her cranial region. All four limbs of the normal twin were moving freely but no movement was detected at the parasitic twin. Auscultation to the heart of the normal twin was normal. The parasitic twin contained disproportionately developed lower limbs that had four toes on each limb. The parasitic twin had no distinctly separable abdomen, chest, or cranium. The parents were counselled and informed by a multidisciplinary team of nurses, anesthesiologists, pediatricians, gynecologists, and surgeons as to the subsequent plan of management.
+Surgery was performed to the baby 1 week after her delivery after the necessary investigation and preparation was done. The parasitic co-twin was totally excised in the operation that took approximately 6 hours. Her postoperative period was smooth and uneventful; she comfortably suckled on the breast well. She was transfused with a calculated two units of fresh whole blood. Two weeks after the surgery she was discharged healthy with an arrangement for postnatal follow up.
+After separation, a pathologic examination demonstrated that skin covered the body of the parasitic twin. The parasitic twin had two deformed lower limbs, one of which was rudimentary. After dissection of the mass of the body, the intestine was seen but there were no chest organs or abdominal organs. The long bones of the bilateral lower limbs and some pelvic bone were seen in the limbs of the parasitic twin. There was also a rudimentary labium but no vaginal opening.

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+A 29-year-old Han woman presented with a chief complaint of a tumor under her right clavicle for 5 months, and right shoulder soreness and numbness of the exterior of her right upper arm for 10 days. At physical examination there was a red and warm mass over her right shoulder with mild pain and tenderness. The mass was tough, hardly moveable, and base-fixed. The strength of her right upper limb muscles was 4+. A chest X-ray showed a mass with a high density shadow at the superior posterior right clavicle . A right shoulder computed tomography scan showed a mixed density shadow in the serratus anterior, which correlated with clinical findings . A neck magnetic resonance imaging scan showed abnormal findings in the serratus anterior at the right-side of her chest wall, which also correlated clinically . An electromyogram showed a few positive sharp waves in muscles innervated by the brachial plexus upper trunk. Motor unit potential mixing interference patterns, compound muscle action potential, motor nerve conduction velocity, and sensory nerve conduction velocity were within the normal range. Her right brachial plexus upper trunk was slightly damaged. Based on the above examinations, the patient’s condition was diagnosed as a tumor beneath the right clavicle. She underwent surgery as a treatment. During the operation, the tumor boundary was found to be on the posterolateral side of the middle scalene; anteroinferior of the trapezius, levator scapulae, and postscalene; and behind the brachial plexus cervical nerves 5 and 6 (C5–6). The tumor invaded the serratus anterior. Anteromedial tumor adhered to the C5–6 nerve branches, posterolaterally adhered to the suprascapular nerve, and adhered to the rear edge of the brachial plexus sheath and omohyoid in the front. Under a microscope, the neurovascular and protective brachial plexus sheath, and the C5–6 nerve branches and the suprascapular nerve were carefully separated; tumor subordinates back below the upper edge of the scapula notch were detected; and the tumor of 7×4×3cm size was completely resected . Intraoperative suprascapular nerve stimulation and muscle contractions were normal; the brachial plexus upper trunk was able to be stimulated; contraction of deltoid, biceps, and flexor carpi were normal; and stimulation of the dorsal scapular nerve, scapular muscles, and rhomboid muscle revealed normal contraction. No intraoperative frozen section was obtained. A postoperative histopathological examination showed that lesions were consistent with myositis ossificans . The soreness of her right shoulder and right arm numbness disappeared completely postoperatively. After 1 year, she did not have any abnormalities.

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+The patient, cmh000720, is currently a 6-year-old male who was referred for whole exome sequencing at 4 years of age. The patient was conceived via artificial insemination and was born at an estimated 38 weeks gestation via C-section to a 32-year-old G3P2 mother and distantly related 27-year-old father (5th cousins once removed). The pregnancy was complicated by gestational diabetes that was well managed with diet. Decreased fetal movements were noted throughout pregnancy, however the results from ultrasound exams and maternal serum AFP testing were normal. At birth the patient was noted to have a week cry, hypotonia, joint hypermobility, and an undescended testicle. Apgar scores were 8 and 9 at 1 and 5 min respectively; weight was 3.1 kg (30th%ile) and length 50.8 cm (68th%ile). He was discharged home at 2 days of life. Newborn screening was reported to be normal. At a routine pediatric follow up appointment at two weeks of age the patient was hospitalized for additional evaluation due to concerns of his persistent low tone and cardiac murmur. At that time he was noted to have both a left hip dislocation and right hip subluxation, with bilateral acetabular dysplasia. Use of a Pavlik harness failed correct the hip dislocation due to profound ligamentous laxity. Echocardiogram revealed a PFO and biscupid aortic valve. The patient had inconsistent TSH levels and thus was treated with levothyroxine. An MRI was suggestive of an arachnoid cyst, but was otherwise unremarkable. At 2.5 months of age an EEG revealed abnormal sharp waves, and CSF glucose levels were found to be 38. Due to a concern for a GLUT1 deficiency, a ketogenic diet was trialed but discontinued after the patient became lethargic on the diet and repeat testing was normal. The patient has had no documented clinical seizure activity.
+In addition to his hip dysplasia, cmh000720 was also noted to have significant kyphoscoliosis and osteopenia by 4 months of age. He has had multiple fractures associated with little to no trauma including his left tibia (12 months), right femur (19 months), right tibia (20 months), left femur (2.5 years), right femur shaft (3.75 years), distal right femur (3.8 years), and left femur (4.2 years). Pamidronate infusions were trialed but an increase in fractures was noted. He has significant osteoporosis; bone density by dexa of the left forearm at 4 years of age was measured as Z score of -5.8. Spinal fusion rods were placed at 3 years of age and removed at 5 years of age. He is currently in a hard brace. Stabilization rods were also placed in both femurs .
+The patient had developmental delay of gross motor milestones; currently he is able to walk with a walker and bear weight but cannot walk independently. Cognitively he is normal; he was able to say single words at 12 months and currently only has problems with articulation. At 6 years of age, in addition to the aforementioned symptoms, the patient is followed for mild aortic root and ascending aorta dilation, restrictive lung disease requiring C-PAP/BiPAP due to scoliosis and chronic obstructive pulmonary disease, bilateral hyperopia, astigmatism, amblyopia, and mild left ptosis, and hypoglycemia with illness. His weight 24.76 kg (85th%ile) and length 111 cm (13th%ile) are within normal limits, although he still receives supplemental nutrition overnight through a G-tube that was placed at 20 months of age. He is macrocephalic with an OFC of 54.8 cm (>98th%ile). He is only mildly dysmorphic with downslanting palpebral fissures, bluish/grey sclera, a high arched palate, short neck, arachnodactyly, and hyperextensible skin with no striae . His bone age is estimated at 4 years 6 months (>2 SD below expected for chronological age). He completed kindergarten with an IEP that includes occupational, speech and physical therapies.
+The family history is notable for an older brother who was found to have a biscuspid aortic valve, after recommended screening. He has a healthy younger sister. Echocardiograms of both parents and younger sister were normal. Both parents are tall, and reportedly healthy.