diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1016_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1016_en.txt
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index 0000000000000000000000000000000000000000..fc6d190b7a3de10c5c59af77296ba1a2729853fd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1016_en.txt
@@ -0,0 +1,7 @@
+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 .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1058_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1058_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2fc2263b2e0c1d61481e39e495ceff50d91338b5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1058_en.txt
@@ -0,0 +1,3 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1064_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1064_en.txt
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index 0000000000000000000000000000000000000000..2aa6d93648974a8d8f9538af61650b33794a70d0
--- /dev/null
+++ b/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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_110_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_110_en.txt
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index 0000000000000000000000000000000000000000..3d1dea388a07513e1dd348271ad70bf08d7ef915
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_110_en.txt
@@ -0,0 +1,3 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1131_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1131_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..faeecdc7e37077f442d7b07152e9560f1df06776
--- /dev/null
+++ b/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 .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1135_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1135_en.txt
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index 0000000000000000000000000000000000000000..e39fbeb5e3cb9043f7b795178f8c8dcd5f00a496
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1135_en.txt
@@ -0,0 +1,6 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1150_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1150_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f47f257460d50b17305390f6f8511aa8190a8f15
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1150_en.txt
@@ -0,0 +1 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1154_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1154_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c46091933dc693b50f3ceceaa7569f44b38939b0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1154_en.txt
@@ -0,0 +1,8 @@
+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 .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_116_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_116_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7d9643fb2f7ef06d51956b14ef1e4174c92a8c86
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_116_en.txt
@@ -0,0 +1 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1192_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1192_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..91bc25b5a9c1703df963c44d1fbe4faceec9849e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1192_en.txt
@@ -0,0 +1,3 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1233_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1233_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6728504b93a6bf379b0fb480190fca02c28e3378
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1233_en.txt
@@ -0,0 +1,5 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1238_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1238_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3a5466d9b9b10850b9306b46c3d46963c533e534
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1238_en.txt
@@ -0,0 +1,5 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_123_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_123_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..aee688922c167bb5515a01c54cec8e1756a645a7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_123_en.txt
@@ -0,0 +1,4 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1243_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1243_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..56d6a1667e2ba324fce24cc9153131a72f5a3689
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1243_en.txt
@@ -0,0 +1,4 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1248_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1248_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..aa114ae789693e8af4da69ff37710ca3e80aa636
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1248_en.txt
@@ -0,0 +1 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1279_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1279_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..08637766523f8765e15793fab33c3c98baaca306
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1279_en.txt
@@ -0,0 +1,2 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1293_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1293_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f7a131aef45b75df68691a0b94fc9538e9db77f9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1293_en.txt
@@ -0,0 +1,2 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1329_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1329_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3b81c06755542600d1c59f249da5a9c429c71cdd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1329_en.txt
@@ -0,0 +1,9 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1351_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1351_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..25f4cf1596fb9cd8ce7d702ad8723fd780992b0b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1351_en.txt
@@ -0,0 +1,12 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1371_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1371_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8880c089d32cf82dbe7344c591c3140b7cca4403
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1371_en.txt
@@ -0,0 +1,6 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1376_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1376_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..99cc5aa62450124a20a28bac053580e9bf9052fd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1376_en.txt
@@ -0,0 +1,7 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1385_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1385_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4917f9d4374081a6be413551c745a8e2fb14c15e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1385_en.txt
@@ -0,0 +1,5 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1393_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1393_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..212737501322e5c0196ff921635304867f1d7f4f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1393_en.txt
@@ -0,0 +1,3 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1400_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1400_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..890820ce2320258cc59c758f08c84133256ba4ef
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1400_en.txt
@@ -0,0 +1,2 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1409_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1409_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8bba5297a09e9f9acda871d54b57795f6143fb2c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1409_en.txt
@@ -0,0 +1,2 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1418_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1418_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a3f1808a312e3c47d0ea9be2ff123b5162147efa
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1418_en.txt
@@ -0,0 +1,6 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_144_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_144_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0686a3e4a89b7fda7722caf4dcae947a248e2830
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_144_en.txt
@@ -0,0 +1,8 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1468_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1468_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..18a0f06da063c583baaa79406ffe9d487be3e4bd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1468_en.txt
@@ -0,0 +1 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1495_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1495_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..effb31924dbcc4c3909067075f807ed6cf24c3a0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1495_en.txt
@@ -0,0 +1,11 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_152_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_152_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..520f10abbbdef2a725471fca8b6ba7dd09698adf
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_152_en.txt
@@ -0,0 +1,4 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1535_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1535_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4e19bcc2793acf6dce485e45abb990d758c10c82
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1535_en.txt
@@ -0,0 +1,2 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1546_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1546_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6afd1bd4c448bfffbdecbd201d238eb025af96a2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1546_en.txt
@@ -0,0 +1 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1571_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1571_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..74ddfb510c7dc53a20ff4bf0e8f4988a52c6ffed
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1571_en.txt
@@ -0,0 +1,11 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_157_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_157_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3d4e9e18b910cbd7fc93a13c21d3cf083712184f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_157_en.txt
@@ -0,0 +1,4 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1643_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1643_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..791deea2c2495d10b9230c05f5f29129d954b218
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1643_en.txt
@@ -0,0 +1,8 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1654_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1654_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fc70c3c43d5e0a115b06c6b5887d1b25224acadb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1654_en.txt
@@ -0,0 +1,4 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_165_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_165_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..06269f35a55ed3a23e2a8e24de916779871f9e2b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_165_en.txt
@@ -0,0 +1 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1683_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1683_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4bc7b58b3cbec5c14263135d847effda175a063a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1683_en.txt
@@ -0,0 +1,5 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1710_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1710_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..85379d268a9419097cd34adc5e51fb7a22fc8038
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1710_en.txt
@@ -0,0 +1,5 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1717_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1717_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f6f71ce7389b6bf74a5824d2b7e776842b0a282b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1717_en.txt
@@ -0,0 +1,3 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1719_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1719_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2fb2ea681c35badcfdb570aca52221af1cf2c2b4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1719_en.txt
@@ -0,0 +1,13 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1725_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1725_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1b99aa13e5c880bd00223b9726c375dbf6ffceda
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1725_en.txt
@@ -0,0 +1,2 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1739_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1739_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..701cf3e049ade654d827eb79bdc229e1adf8462a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1739_en.txt
@@ -0,0 +1,15 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_173_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_173_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c21ebf0c1beb219ba0237817888cbe1615c80015
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_173_en.txt
@@ -0,0 +1,3 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1759_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1759_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ceee8d74590d133a0181a24b9abdb268b658c179
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1759_en.txt
@@ -0,0 +1,2 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1760_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1760_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..13c87ebecf06aba312fb600a60298aefa2eeb4d2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1760_en.txt
@@ -0,0 +1,5 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1790_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1790_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..45f7183623f7c3fe8c3fa9b5fadd0ab7c5441642
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1790_en.txt
@@ -0,0 +1,2 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1812_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1812_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7adf1efa002b4dac06a63ae6126b5edcc280631d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1812_en.txt
@@ -0,0 +1,7 @@
+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.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1813_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1813_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3e8014d5e7ff49639f7f4270770e2a329f651ad4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1813_en.txt
@@ -0,0 +1 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1822_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1822_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4fa1d038c571547831fca8b8a51e90b253bc02d7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1822_en.txt
@@ -0,0 +1,4 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1888_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1888_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3dfc467ee0f949d5e428b73b454ed17f437540be
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1888_en.txt
@@ -0,0 +1,3 @@
+An 80-year-old woman with a history of coronary artery disease, atrial fibrillation, hypertension, diabetes mellitus, basal cell carcinoma removed via Mohs procedure on the nose, diabetic retinopathy, and macular degeneration presented with a history of a recent increase in the number of falls she had been sustaining due to a recent, sudden deterioration of vision bilaterally. She was initially seen by the ophthalmologist 2 months ago for loss of vision in her right eye that was thought to be related to her previously diagnosed diabetic retinopathy. She underwent focal laser photocoagulation for diabetic retinopathy in her right eye, with no significant improvement in vision. Upon further ophthalmic evaluation, a fleshy, salmon colored conjunctival tumor was identified in her left eye . She was referred to the ocular oncology service and subsequently the conjunctival tumor was biopsied. Histopathologic examination of the specimen revealed sheets of large neoplastic lymphoid cells with moderate nuclear pleomorphism, vesicular chromatin, and large nucleoli underlying the normal conjunctival epithelium . Small lymphocytes were observed admixed with the previously described atypical ones. Immunohistochemical studies showed the large lymphoid cells stained positive (diffuse, strong) for CD20 and MUM-1, less intensely positive for Pax-5, weakly positive for Bcl-6, and negative for CD10. The small background lymphocytes were CD3-positive . Histopathological findings were consistent with diffuse large B-cell lymphoma (DLBCL) with an immunophenotypic profile consistent with nongerminal center origin. Proliferation index estimated by Ki-67 labeling was found to be 80% and were positive for c-myc rearrangement.
+The patient's laboratory workup including complete blood count with a differential, comprehensive metabolic panel, and coagulation profile, was within normal limits. Serum lactate dehydrogenase (LDH) level was 506 U/L (normal range: 313-618 U/L). Her hepatitis screen was negative. She underwent orbital computed tomography (CT) and magnetic resonance imaging (MRI) scans that failed to reveal any discrete masses although the MRI revealed a mild asymmetric thickening and enhancement of the sclera in the anterior left globe. Additionally, both positron emission tomography-CT (PET-CT) and an MRI of her brain failed to reveal any other systemic central nervous system (CNS) involvement. Cerebrospinal fluid (CSF) analysis after an uncomplicated lumbar puncture (LP) did not reveal any malignant cells.
+Since the patient had a biopsied conjunctival tumor on the left side but had unexplained loss of vision on the right side as well, she was presumed to have CNS involvement and was treated with high dose systemic methotrexate in addition to rituximab. She received three cycles of methotrexate at 1.5 g/m2 (50% dose reduction due to age and low creatinine clearance) and rituximab at a dose of 375 mg/m2. The first cycle was complicated by severe diarrhea related to Clostridium difficile infection and dehydration and the third cycle was complicated by acute renal insufficiency, fluid overload, insufficient methotrexate clearance, and prolonged hospital stay. Further chemotherapy had to be stopped in view of the side effects. Ophthalmic follow-up revealed improved vision in her right eye. Interval MRI revealed interval improvement in nonspecific scleral thickening and enhancement along the anterior aspect of the left globe. Based on the documented improvement, the patient was to be continued on the same chemotherapy regimen; however, she declined further treatment. The patient was evaluated by radiation oncology but she opted to decline further treatment at this time. She has not followed up by physicians at this hospital after that and has been lost to follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1898_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1898_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6051ca096c39a9afb1ede66919d03e7618a786f6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1898_en.txt
@@ -0,0 +1,4 @@
+A 60-year-old Caucasian man was transferred from a regional hospital to a tertiary referral centre for the emergency management of hypercalcaemic hyperparathyroid crisis. He initially presented with a two-week history of weakness and lethargy and a one-week history of vomiting, polyuria and polydipsia. He became acutely confused in the 24 hours prior to his admission to our hospital and registered 12 on the Glasgow Coma Scale. On examination he was normotensive with a regular pulse of 70 beats per minute. There was a left-sided mass in the anterior triangle of his neck measuring 3 × 3 cm. The mass was firm, regular, non-tender and mobile. See Figure and Table for results of the initial laboratory investigations.
+An ultrasonography of his neck showed a 4 × 3 cm large cyst in the left lobe of his thyroid gland. His parathyroid glands were not visualised. A 99 mTc-sestamibi scintigraphy scan was performed, and no evidence of a parathyroid adenoma was found. An electrocardiogram revealed acute changes with ST depression in leads II, III, aVF and V2 to V6. An echocardiogram showed good left ventricular failure (LVF) with an ejection fraction of 63%.
+Initial management included aggressive fluid resuscitation, cardiac monitoring and the administration of intravenous bisphosphonates. A left thyroid lobectomy and left lower parathyroidectomy were performed. At the time of operation, a haemorrhagic cyst with a parathyroid gland within it was visualised. A biopsy was taken from the left upper parathyroid gland. Histology revealed a 4 cm parathyroid carcinoma within the cyst which was fully excised. The cyst had a macroscopic measurement of 6 × 6 × 5 cm. The wall of the cyst contained a well-circumscribed, unencapsulated soft tissue mass measuring 4 × 2.5 × 0.7 cm. It was light yellow-tan in colour and firm in consistency. There was a small amount of normal thyroid parenchyma within the specimen. The biopsy of the left upper parathyroid gland revealed normal parathyroid parenchyma without diagnostic abnormality.
+Our patient remained intubated and ventilated overnight in the intensive care unit. His metabolic laboratory profile resolved quickly following the surgery [Figure , Figure , Figure ]. A lower respiratory tract infection delayed his initial recovery. He was discharged home on oral calcium supplementation 24 days after surgery. He has been followed up for 6 months so far without any complications or disease recurrence.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1919_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1919_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e026819a110b8099ba81b31f1028708816ec2765
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1919_en.txt
@@ -0,0 +1,3 @@
+A healthy 19-year-old male with a 2-week history of low back pain, nuchal rigidity, fever, and chills presented to an outside facility. Diagnostic studies revealed a peripheral white blood cell count of 30000, and on computed tomography (CT) of the abdomen/pelvis, an abnormal heterogeneous fluid collection involving the right piriformis muscle was detected . Upon arrival to our neurosurgical intensive care unit (ICU), the patient had grade 5/5 strength in all muscle groups, normal sensation throughout, and no signs of myelopathy. MR studies of the cervical, thoracic, and lumbar spine documented a posterior SEA extending from C2 to the sacrum with significant posterior compression of the cord . Notably, the patient's motor strength worsened rapidly to 2/5 in all extremities and then to just 1/5 in the upper and 0/5 strength in the lower extremities, warranting emergency surgery .
+Multiple skip-laminectomies without instrumentation were performed at the C3-7, T11, and L2-4 levels. Cultures were obtained and purulent SEA was washed out at every level and between levels utilizing red rubber catheter that was passed rostrally and caudally in the epidural space; two drains were left in place.
+Immediately postoperatively, upper extremity function returned to 4+/5 strength and lower extremity strength to 4/5. Blood cultures and operative wound cultures grew methicillin-sensitive Staphylococcus aureus (MSSA), and he was placed on a long-term nafcillin treatment for a period of 6 weeks. The patient's piriformis abscess did not require drainage and was managed solely with antibiotics. Notably, by postoperative day 10, the patient was neurologically intact with full motor strength in all muscle groups.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1929_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1929_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a754130d5c32d44a5836efa781d46d60efd853df
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1929_en.txt
@@ -0,0 +1,2 @@
+Patient 1. is a 22 months old girl from the first pregnancy of a non-consanguineous healthy young Caucasian couple (father 30 and mother 26 years old). The only remarkable point in her family history is thyroid hypofunction in her mother, in the two sisters of her mother and in the maternal grandmother. Following the diagnosis of a hypoplastic aortic arch at the 26th week of pregnancy the girl was delivered at 40 weeks of gestation with a birth weight of 2740 g (10–25 percentiles). An aortic stenosis and coarctation of the aortae was confirmed by cardiological examination on the first day of life. Her developmental milestones were delayed. She turned at 8 months, at 20 months she sat alone and tried to crawl, and her eye contact evolved around 8 months. Babbling started timely but stopped at 20 months. The objective audiometry showed bilateral hearing impairment. After adjustment of a hearing aid, considerable advance was not detected in her auditive attention. The first epileptic seizure developed at 22 months, which had an adequate therapeutic response to valproate treatment. Brain MRI detected symmetrical dilated liquor space with a consequent gracile hippocampus and subcortical ischemic lesions. The characteristic features are illustrated in Fig. .
+She was referred to our institution because of dysmorphic features at the age of 8 months. At that examination her weight was 7850 g (50 percentile) height 68 cm (25–50 percentile) and OFC 42 cm (−1 SD), she had brachycephaly, flat face, midface hypoplasia, down-slanting palpebral fissure, convergent strabismus, short nose, high palate, tented lip and severe generalized hypotonia.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1941_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1941_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c8e922c758af75d6ea1d080ab3361e57a192898c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1941_en.txt
@@ -0,0 +1,10 @@
+We obtained a verbal informed consent from the patient and a written informed consent from a family member of the patient for publication of this case.
+An 83-year-old man was transported to our emergency department, with a tentative diagnosis of heat stroke. He had previously been fit and healthy, except for undergoing colorectomy for colorectal cancer 8 years ago. He also received a central venous port system, a BardPort Titanium implantable port with its and 8.0 Fr Groshong® silicone catheter (Bard Access Systems, Inc., Salt Lake, USA) which was inserted through the right internal jugular vein, for chemotherapy.
+He was transferred to the intensive care unit, where surface cooling and intravenous hydration were performed to treat heat stroke. He made a rapid recovery, and he had become able to eat on the same day.
+Next morning, he suddenly developed ventricular fibrillation. Cardiopulmonary resuscitation was performed immediately, his trachea was intubated, and he was sedated with continuous infusion of propofol. He had not complained any chest pain before the occurrence of ventricular fibrillation, and the electrocardiography indicated neither arrythmias nor ST changes, before and after the occurrence of ventricular fibrillation. Analysis of arterial blood taken after resuscitation indicated no abnormalities in the blood gases and the blood electrolyte; troponin was not measured. A chest radiograph, which was taken after resuscitation , indicated a previously placed central venous catheter access port, without any obvious abnormalities.
+Emergency coronary angiography, performed shortly after ventricular fibrillation, identified a 90% stenosis of the left anterior descending coronary artery. The cardiologists considered that this was not the direct cause of ventricular fibrillation, as the extent to which the blood flow in the coronary artery would not bring about ventricular fibrillation. The angiography instead identified a more likely cause: a foreign body in the coronary sinus.
+Close re-examination of the chest radiograph taken after resuscitation showed a long catheter-like foreign body (approximately 20 cm) in the heart . Chest computed tomography also confirmed the presence of the foreign body . We diagnosed that a long catheter-like foreign body, likely to be a fragmented central venous catheter, was in the coronary sinus.
+In the angiography suite, physicians attempted to remove the foreign body. However, the attempts were abandoned, as the pull of the catheter resulted in repeated ventricular fibrillation. The patient was successfully resuscitated. Surgical removal was planned the next day.
+On the next day, the patient was transferred to an operating room, and routine monitors, such as a pulse oximeter, a blood pressure cuff, and electrocardiogram, were attached. We prepared an electric defibrillator, and cardiac surgeons were present in the room. The breathing system of an anesthesia machine was connected to the tracheal tube, and general anesthesia was induced with sevoflurane 1.5% and fentanyl 0.1 mg; neuromuscular blockade was achieved with rocuronium 50 mg. Anesthesia was maintained with sevoflurane and oxygen in air.
+The patient underwent sternotomy, and transesophageal echocardiography identified the fractured catheter in the coronary sinus . The right atrium was opened under cardiopulmonary bypass. Surgeons could remove the fractured catheter (approximately 20 cm in length) , but with great difficulty, by gently pulling the edge of the catheter with rotating movement. After the operation, the electrocardiogram indicated no arrhythmia or cardiac ischemia.
+On the next day of the operation, his family requested strongly to treat the coronary stenosis, and thus, cardiac physicians placed a stent in the left anterior descending artery without complications. He was discharged from the hospital on postoperative day 14, to a rehabilitation facility, and he went home at a later day.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1961_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1961_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..20881ddb797fb49abfb33d736070f2e52fa282a8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1961_en.txt
@@ -0,0 +1 @@
+A 43-year-old man with HF secondary to dyspnea was admitted to our hospital. The patient's height was 160 cm, body weight was 109 kg, and body mass index was 42.5 kg/m2. Past medical history included diabetes mellitus and sleep apnea. Upon admission, the patient experienced orthopnea and whole-body edema. Laboratory data indicated a creatinine of 1.3 mg/dl, an estimated glomerular filtration rate of 49 ml/min/1.73 m2 and an N-terminal pro-brain natriuretic peptide level of 4,177 pg/ml. Electrocardiography revealed sinus tachycardia and a left ventricular ejection fraction of 20% with diffuse left ventricular hypokinesis. Plain chest radiography revealed a cardiothoracic ratio of 66% and a costophrenic obtuse angle. The patient was diagnosed with AHF and was treated with intravenous furosemide and oxygen inhalation. However, the patient developed respiratory failure and low-output syndrome on the 7th hospital day. The patient was transferred to the cardiac care unit (CCU), and treatment with noradrenaline, dobutamine, and noninvasive positive pressure ventilation was initiated. On the 19th hospital day, right heart catheterization indicated Forrester subset IV (pulmonary artery wedge pressure, 27 mmHg; cardiac index: 1.6 L/min/m2), and coronary angiography revealed no significant stenosis. Based on the clinical course and endomyocardial biopsy of the right ventricular septum, the patient was diagnosed with idiopathic dilated cardiomyopathy on the 23rd hospital day. Because the patient was young and had developed catecholamine-dependent HF, heart transplantation was considered. However, severe obesity was an obstacle to registration. We started B-SES (G-TES; Homer Ion Laboratory, Tokyo, Japan) in parallel with normal cardiac rehabilitation and performed gradual withdrawal of catecholamines and titration of bisoprolol. On the 48th day of hospitalization, the patient was withdrawn from noradrenaline. The patient was transferred from the CCU to the general ward on the 92nd day. The patient's symptoms improved to NYHA II with titration of bisoprolol, ivabradine, valsartan, spironolactone, dapagliflozin and furosemide, along with cardiac rehabilitation. In addition, we provided life modification program to the patient because eating habits and sedentary life style had contributed to his obesity. The patient was discharged with a body weight of 75.6 kg on the 113th hospital day. This case report has anonymized patient information, and photographs including parts of the body (including the face) have been processed to ensure that the individual cannot be identified. We obtained written informed consent from the patient for publication.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1971_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1971_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..57a1cb56560a16daab2311fd72e5b027dbd33e59
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1971_en.txt
@@ -0,0 +1,2 @@
+A 50-year-old man with a history of an atrial septal defect and hypertension presented to our hospital for further examination of a previously diagnosed gallbladder polyp. He had no right quadrant pain, fever, jaundice, weight loss, or carcinoid syndrome-related symptoms such as diarrhea, flushing, edema, or wheezing. The patient hoped to avoid cholecystectomy. Abdominal ultrasonography revealed an 8.3-mm elevated polyp in the region around the gallbladder neck . During the next 3 years, the polyp gradually increased in size to 9.9 mm . Furthermore, contrast-enhanced computed tomography showed enhancement of the polyp . Magnetic resonance cholangiopancreatography (MRCP) showed no abnormality in the bile duct or pancreatic duct, while the polyp showed iso-intensity on T1-weighted images and low intensity on T2-weighted images .
+The patient had smoked 20 cigarettes per day for 20 years. He also had a history of drinking alcohol (one bottle of beer per day). Physical examination showed no abnormalities. Blood tests also showed no abnormalities, including elevations of tumor markers such as carcinoembryonic antigen (1.5 ng/ml) and carbohydrate antigen 19–9 (9.3 U/ml). Taken together, these results suggested that the polyp included a malignant component. Therefore, we performed laparoscopic cholecystectomy. The whole gallbladder was successfully removed. Macroscopic examination of the resected specimen revealed a tumor of approximately 10 mm in diameter in the gallbladder neck region . Histologically, hematoxylin and eosin staining showed an alveolar pattern consisting of monomorphous round cells with centrally located nuclei . The extent of tumor infiltration was within the lamina propria of the mucosal membrane, and the tumor resection margin was negative. Immunohistochemical staining revealed positivity for chromogranin A, synaptophysin, and CD56 . Immunohistochemical staining of Ki-67 showed that the proliferative index in the tumor was < 3% and that the mitotic count ranged from 0 to 2 per 10 high-power fields . Taken together, these results led to a diagnosis of a grade 1 well-differentiated NET. Immunohistochemical staining was negative for DAXX and slightly positive for ATRX . The patient’s postoperative course was uneventful, and he developed no signs of recurrence either clinically or radiologically for 8 years.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1978_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1978_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..95b97b99e5ee54cadb6c44f160f1bd785873ff25
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1978_en.txt
@@ -0,0 +1,7 @@
+A 15-year-old female patient was admitted to our hospital due to skin lesions for more than 2 months, muscle weakness for 1 month, and dysphagia for 3 days before her visit.
+Two months before admission, the patient experienced facial swelling and pain, red papules appeared on her eyelids. The local hospital treated her for allergy, but the symptoms did not improve. The weakness of proximal limbs and cervical flexor began one month before admission and was associated with upper limbs edema. Muscle weakness gradually progressed, and she could not do her daily activities such as tooth brushing, hair combing, and going up and down stairs. Laboratory examinations revealed elevated levels of serum creatine kinase (CK, 2914U/L; reference.
+range: 26-200U/L) and lactate dehydrogenase (LDH, 555U/L; reference range: 100-250U/L). Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and complete blood count were normal. Anti-nuclear matrix protein 2 (NXP2) antibody was found in her serum sample. Her pulmonary CT showed pleural thickening, a small amount of effusion, and subcutaneous edema of the chest wall. Echocardiography showed a small amount of pericardial effusion. Muscle biopsy revealed inflammatory cell infiltration, muscle fiber degeneration, necrosis and phagocytosis, and perivascular inflammatory infiltration. MHC-I staining was positive. She was diagnosed with JDM and subsequently given intravenous methylprednisolone (IVMP) 80 mg daily and intravenous immunoglobulin (IVIG) 20 g for 4 consecutive days in local hospital. Then, her skin rash was alleviated, and her muscle strength slightly improved. But dysphagia, choking cough during drinking, and hoarseness appeared 3 days before admission to our hospital.
+On admission to our hospital, physical examinations revealed a body temperature of 37.1℃. Her only skin lesion was heliotrope rash. Mild edema of the upper arms was found in physical examination. Decreased muscle force was detected mainly in the proximal segment of the upper (Medical Research Council (MRC) Scale for muscle strength grade 3) and lower (MRC grade 2) extremities. Laboratory examinations revealed hyperferritinemia (443.3ng/mL; reference.
+Range: 11-306ng/ml), and hyperCKemias (2495U/L). The serum levels of LDH (503U/L), aspartate aminotransferase (AST) (165U/L; reference range: 0-42U/L), alanine aminotransferase (ALT) (73U/L; reference range: 0-40U/L) and γ-glutamyltranspeptidase (GGT) (70U/L; reference range: 0-52U/L) were slightly elevated. Ro-52 antibody was positive.
+She was treated with IVMP 40 mg (1 mg/kg) daily, intravenous cyclophosphamide (IVCYC) 400 mg (10 mg/kg) every two weeks, and tocilizumab, a humanized monoclonal interleukin (IL)-6 receptor inhibitor, 480 mg (8 mg/kg). The skin rash and subcutaneous edema were relieved, and muscle strength improved.
+Three weeks later, the patient developed a high fever (39.1℃) and headache after catching a cold. Laboratory examinations revealed leukopenia, anemia, and thrombocytopenia. Epstein-Barr virus (EBV), cytomegalovirus (CMV), varicella zoster virus (VZV), or herpes simplex virus (HSV) was negative. The serum level of ferritin was 4322ng/mL. The serum level of CK decreased to 1545U/L, but the serum levels of ALT, AST, and LDH increased after treatment. Abdominal ultrasound showed splenomegaly. Bone marrow aspiration revealed haemophagocytosis. The diagnosis of MAS was established according to the HLH-2004 criteria . Despite intensive treatment with dexamethasone, cyclosporin (CsA), and IVIG, her condition further deteriorated, and she died due to refractory MAS and multiple organ failure 6 weeks later.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1981_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1981_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a91e1a77ee589fd0c75075e49f2f5fa2841fd9b5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1981_en.txt
@@ -0,0 +1,4 @@
+A 51-year-old Chinese female presented with the incidental finding of a large heterogeneously enhancing mass in the frontal lobes after a computer tomography (CT) scan for minor head injury following a fall . Her past medical history included only adenomyosis and endometrial polyps. No neurological abnormalities were observed.
+Magnetic resonance imaging (MRI) revealed a 76 × 70 × 54 mm mass in both frontal lobes with extension across the midline that was hypointense on T1-weighted, hyperintense on T2-weighted images, and demonstrated avid postgadolinium contrast enhancement . The lesion showed foci of calcification and peripheral cystic components, with mild perilesional edema and significant mass effect. The corpus callosum was displaced posteriorly. Inferiorly, the lesion extended up to the olfactory bulb.
+The patient underwent gross total resection (GTR) of the tumor. Intraoperatively the tumor was not found to breach ventricles and the tumor was deemed to be entirely extraventricular. Intraoperative frozen section suggested the diagnosis of a high grade glioma. Histology showed a well demarcated cellulartumor with prominent perivascular pseudo-rosettes and very occasional true (ependymal) rosettes. The tumor cells showed enlarged, hyperchromatic, pleomorphic nuclei, a granular ‘salt and pepper’ chromatin pattern, and fibrillary cytoplasm. Mitotic figures, including atypical forms were readily identified. There were areas of palisading necrosis and microvascular proliferation. The Ki-67 proliferative index was about 20%. These features were diagnostic of an anaplastic ependymoma (WHO grade III).
+MRI taken on postoperative day 1 showed no evidence of residual tumor. The patient's postoperative recovery was uneventful. Cerebrospinal fluid (CSF) studies were negative for malignant cells and no drop metastases were detected on neuroaxis MRI. The patient underwent adjuvant intensity- modulated radiation therapy of 60 Grays in 30 fractions to a region encompassing the tumor bed and a 2 cm margin around it over a period of 2 months. At follow up, the patient developed local recurrence in the frontal lobes within 2 months of completing radiotherapy. At 8 months postsurgery, progression of disease locally had caused her to become increasingly drowsy and by then she was wheelchair bound.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1999_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1999_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..28a245293f75680741b4a51f9ce2a38e01aaf224
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1999_en.txt
@@ -0,0 +1 @@
+A 15-year-old male presented with the sudden onset of a hemiparesis (i.e., left upper limb 4/5 and left lower limb 4/5). The laboratory work up was negative for any coagulation abnormalities; normal international normalized ratio, prothrombin time, activated partial thrombin time, and bleeding/clotting times. The brain MRI was normal, thus largely ruling out a stroke. However, the cervical MR showed a dorsolateral left-sided epidural hematoma extending from C7 to D1 causing severe cord compression. The lesion was hyperintense on T1, hyperintense with a hypointense band on T2 studies, but did not enhance with contrast [- and ]. These findings were diagnostic for a SSEH. The patient underwent an emergent C7-D1 laminectomy for excision of the SSEH. Postoperatively, the patient regained normal function.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2013_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2013_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..81821bfda1975a6282e7e5bcd61c048e16f22c3a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2013_en.txt
@@ -0,0 +1,5 @@
+A 1-month-old infant (sex, female; height, 51.2 cm; body weight, 3.1 kg; body surface area, 0.21 m2) was hospitalized due to IAA/VSD/PDA/PH .
+Cardiovascular CT revealed a ventricular septal defect of 13 mm and the continuity of the aortic arch at the distal end of the left subclavian artery was interrupted, where the descending aorta was connected to the left pulmonary artery via an arterial catheter with an internal diameter of about 5 mm. Meantime, the ratio of pulmonary to systemic blood pressure measured by cardiac ultrasound was 0.95, which met the diagnostic criteria of congenital heart disease combined with severe pulmonary hypertension.
+After completing relevant examinations, aortic arch interruption correction, ventricular septal defect repair, ductus arteriosus cut-off, and suture were performed and the operation was successful. Due to obvious myocardial oedema in the infant, sternal closure was delayed. The left atrial and right ventricular pressure monitoring tubes, both of which were connected through a triplet, were inserted into right pulmonary vein and pulmonary artery, respectively, and the triplet was in closed condition ( and ). When the infant returned to intensive care unit, ventilator-assisted breathing was received, and the non-invasive cardiac monitoring system (Most-Care system) was used to closely monitor the vital signs. Meanwhile, the left atrial and right ventricular pressure measuring tubes were separately connected to the monitor through the pressure measuring kits to dynamically monitor the changes of the left atrial and right ventricular pressure . According to the infant’s condition, selective pumping of vasoactive drugs such as dopamine, dobutamine, milrinone, epinephrine, and other vasoactive drugs were given to improve coronary perfusion and cardiac function.
+On the night of the surgery, pulmonary hypertensive crisis was triggered by endotracheal intubation with sputum aspiration. Pulmonary artery pressure soared from 18–22/13–15 mmHg to 80/53 mmHg, systemic circulation pressure plunged from 78–83/44–49 mmHg to 40/22 mmHg, blood oxygen saturation (SpO2) decreased from 98% to 84%, and heart rate dropped from 150–158 b.p.m. to 51 b.p.m. simultaneously . Emergency bedside thoracotomy was given, by which it is found that the right atrium and right ventricle were significantly enlarged with distress, and the triplet was turned on urgently to make the left atrial and right ventricular pressure monitoring tubes connected. Meantime, pure oxygen and nitric oxide (20 ppm) were inhaled by breathing bag, and fentanyl, midazolam, rocuronium bromide, and other drugs were given to enhance sedation and muscle relaxation therapy. The systemic blood pressure increased instantly to 68–72/44–50 mmHg, right cardiac distress relieved immediately, and the heart rate soon increased to 83–110 b.p.m. Three minutes later, the SpO2 increased to 89%, and the pulmonary artery pressure decreased to 19–22/15–17 mmHg. The triplet was turned off, and ventilator was given to assist breathing subsequently, and then the SpO2 increased to 95–99%, blood pressure to 83–88/50–53 mmHg, and heart rate to 155–161 b.p.m. . After 20 min of observation, the infant’s vital signs were stable and there was no recurrence of pulmonary hypertensive crisis, so the infant was given delayed sternal closure again.
+Thirty-six hours after surgery, bedside sternal closure was performed, the left atrial and right ventricular pressure monitoring tubes were removed smoothly, and the infant was discharged 9 days later. One year after surgery, transthoracic echocardiography showed the infant recovered well .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2024_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2024_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..38e80f3540d7cc42a829c3ea60e8a11c7ca18c7b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2024_en.txt
@@ -0,0 +1,2 @@
+A 37-year-old woman (height, 158 cm; body weight, 50 kg; ASA physical status class II; no systemic complications other than VLCAD exist) with VLCAD deficiency was diagnosed with an ovarian cyst and was scheduled for laparoscopic ovarian cystectomy. Rhabdomyolysis due to VLCAD deficiency first appeared at age 6 with skeletal muscle pain and myoglobinuria after swimming. Since then, she has exhibited similar symptoms several times a year during fasting, exercise, and mental stress. At the age of 31, VLCAD deficiency was diagnosed by acylcarnitine profile analysis. At the same time, genetic mutations c.1349G>A (p.R450H) and c.1639G>A (p.V547M) were identified in her ACADVL gene.
+Glucose was administered at 2 mg−1 kg−1 h−1 intravenously to prevent hypoglycemia with the start of fasting at 9 p.m. on the night before the surgery. On the day of surgery, when the patient entered the operating room, her blood glucose level was 108 mg dL−1 . Glucose administration was increased to 4 mg−1 kg−1 h−1. Anesthesia was induced with 0.5 μg−1 kg−1 min−1 of remifentanil, 3 mg of midazolam, and 200 mg of thiamylal, and muscle relaxation was achieved by 30 mg of rocuronium. After intubation with a cuffed tracheal tube, mechanical ventilation was started, and anesthesia was maintained with 40% oxygen and 5% desflurane in combination with the continuous infusion of 0.25–0.3 μg−1 kg−1 min−1 of remifentanil. Routine monitoring of vital signs and invasive radial artery pressure was performed. Blood glucose, creatine kinase, myoglobinuria, and lactate were monitored during anesthesia . To avoid postoperative shivering, body temperature was maintained at 36.2–36.7 °C . Acetaminophen (1000 mg) and buprenorphine (0.1 mg) were administered for postoperative analgesia. At the end of the surgery, administration of desflurane and remifentanil was stopped, and rocuronium was antagonized by 200 mg of sugammadex. Surgery time was 53 min, and anesthesia time was 1 h 59 min. No shivering was observed after extubation. Glucose was administered at 2–4 mg−1 kg−1 h−1 until oral intake was started. The blood glucose level of the patient was 142 mg dL−1 about 1 h after the surgery. The patient was discharged 2 days after the surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2056_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2056_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..31807585b157f6ab93959714119306a0239b447a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2056_en.txt
@@ -0,0 +1,3 @@
+An 82-year-old female patient with a history of coronary artery disease and coronary stenting, known to have gallstones, presented with a nausea vomiting and post prandial abdominal pain evolving for two weeks. Additionally, the patient presented with a pulse rate of 102 beats per minute, a weak pulse, blood pressure measuring 10/6, and indicators of extracellular dehydration, such as a persistent mucosal fold, clammy skin with decreased elasticity and sunken eyes. Laboratory tests revealed the presence of hypokalemia and hypochloremia. After putting the urinary catheter we noticed a reduced urinary output. We initiated resuscitation by inserting a nasogastric tube, which promptly drained 400 cc of gastric fluid. The fluid resuscitation was performed based on the input-output assessment, aiming to correct any hydro electrolytic imbalances. After stabilizing the patient an esophagogastroduodenoscopy revealed normal findings up to the second part of the duodenum , there was no duodenal dilatation and the EGD showed some retained bile. Regarding the symptomatology and signs of gastric outlet obstruction searching for ethiology we decided to perform a complementary abdominal computed tomography that showed a cholecystoduodenal fistula with a measured 4 cm stone lodged at the duodenojejunal jonction . Due to the absence of endoscopic treatment at that time, the decision was made to proceed with surgery.
+During laparotomy, a lodged stone was found at the duodenojejunal angle. The stone was successfully advanced to the second jejunal loop , where an enterotomy was performed, allowing for the extraction of the stone. After that we decided using this enterotomy, on the second jejunal loop, to proceed with a latero-lateral gastroenteroanastomosis Trans- and sub-mesocolic, without gastric resection. The cholecystoduodenal fistula was left untouched.
+Postoperative recovery was uneventful, and the patient was discharged on the 8th day post-surgery. 3 month follow up was uneventful.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2059_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2059_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..41de71ada39ee8b130d16732f0f3294e8639f90d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2059_en.txt
@@ -0,0 +1,2 @@
+A 71-year-old male presented with 3 years of low back and right lower extremity pain with accompanying numbness. Bertolotti’s syndrome was diagnosed on a preoperative CT scan. that showed a transitional vertebra at the lumbosacral spine junction (i.e., labeled as a partially lumbarized S1 with pseudoarthrosis on the right side [ and ].
+He underwent a minimally invasive “wide” L5 transverse process resection for decompression of the right L5 nerve root (i.e., a bony ridge was found below the muscle extending from the transverse process of L5 to sacral ala). Using a drill and Kerrison rongeurs, the excess bone was removed from the transverse process superiorly to sacral ala inferiorly, and from the L5 pedicle medially all the way laterally. Postoperatively, the patient reported full resolution of his pain and radiculopathy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2060_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2060_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bab109fa772b93329d3467a526bd660f63c4e381
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2060_en.txt
@@ -0,0 +1,4 @@
+A 34-year-old female with recurrent ischaemic stroke, type 1 diabetes mellitus, hypertension, dyslipidaemia and stage 2 chronic kidney disease, presented to the outpatient stroke clinic in June 2020 with a history of recurrent transitory right leg weakness and right hand shaking. These episodes occurred several times per day lasting approximately 30 s whilst mobilising and resolved on sitting. Neurological examination demonstrated recovering dysphasia and mild pyramidal right-sided weakness requiring a walking stick for gait assistance.
+Previously, in March 2019, she presented with slurred speech, left-sided weakness and visual neglect with confirmed bilateral embolic middle cerebral artery (MCA) territory infarcts on magnetic resonance imaging (MRI). Computer tomography (CT) carotid angiography and Digital subtraction angiogram (DSA) identified severe ICAD with bilateral occlusion of the supraclinoid segment of the internal carotid arteries but no features of moyamoya disease . She had no family history of stroke, a negative thrombophilia screen and no cardioembolic source identified. Secondary prevention was commenced including aggressive lipid lowering with rosuvastatin aiming for low density lipoprotein < 1.8 mmol/L, dual antiplatelet therapy with aspirin and clopidogrel for three months, antihypertensive treatment aiming for blood pressure < 130/80 mmHg and augmentation of her diabetic regime. She recovered to a point of supported independent living but was unable to return to work.
+In March 2020 she represented to the emergency department with reduced consciousness in a state of diabetic ketoacidosis secondary to a lower respiratory tract infection and episodes of vomiting. On presentation her blood pressure was 70/40 mmHg and she was found to have new right-sided weakness. Diffusion weighted MRI identified multiple acute embolic infarcts in the left MCA territory. Her deficits improved with a period of neurorehabilitation but she had ongoing high-level language and cognitive difficulties, marked post stroke fatigue as well as reduced high-level balance. She was independent in personal care.
+In neurorehabilitation initial concerns were for post stroke focal motor seizures causing her transient symptoms and she was commenced on levetiracetam. However, these brief episodes spared the face, did not exhibit Jacksonian march and were precipitated by periods of reduced cerebral perfusion such as changing position and dehydration. When reviewed in stroke clinic the leading differential diagnosis was cerebral hypoperfusion syndrome. A 99mTc-ethyl cysteine dimer cerebral perfusion single photon emission CT (SPECT) with CT acetazolamide challenge was performed . Baseline perfusion was reduced in the left frontal, temporal and parietal lobes in keeping with recent infarction as well as a small fixed perfusion defect in the right frontal lobe corresponding to previous established infarct. Although asymptomatic during scanning, worsening hypoperfusion to the left frontal lobe and to a lesser extent the left temporal and anterior parietal lobes, was evident with acetazolamide challenge, indicative of reduced vascular reserve in these territories. Given her ongoing symptoms and declining quality of life a repeat DSA was performed to assess for possible sites of surgical revascularisation. The second DSA demonstrated progressive intracranial stenosis with opacification of the left posterior communicating artery and collateral supply to the left hemisphere predominantly from the posterior choroidal artery and posterior cerebral artery . No feasible site for surgical revascularisation was identified. She was managed on maximal medical therapy including long term dual antiplatelet therapy, consolidated antihypertensive regime, tight glycaemic control and avoidance of dehydration. Over the following six months a systolic blood pressure between 120 and 130/70 mmHg was achieved, with a low-density lipoprotein of 1.0 mmol/L and high-density lipoprotein of 1.2 mmol/L. Glycaemic control remained an ongoing challenge, with a glycosylated haemoglobin level of 9.5% (80 mmol/mol). The patient has recently trialled a continuous infusion pump device. Levetiracetam was ceased. During this period the limb-shaking TIAs settled.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2080_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2080_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9f50d97177e5a0f0d823c4a606de3af2e3bfe22d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2080_en.txt
@@ -0,0 +1,3 @@
+A 53-year-old man accidentally fell off a three-meter high scaffolding while working resulting in severe chest pain and shortness of breath. Upon arrival at the emergency department of our hospital, physical examination was the following: temperature, 36.8 ℃; blood pressure, 132/86 mmHg; heart rate,101 beats/min; oxygen saturation, 89% (without oxygen inhalation), left chest tenderness, pain on anteroposteria chest compression. Taken chest computed tomography (CT) , he was found with left 7th through 11th rib fractures with lower left lobe contusion and hemothorax measured about 10% of the chest. After treatment with oxygen, external fixation by band, and pain management, the symptoms were initially relieved, while the pain remained severe several hours later even after the use of pethidine. After consultation, he decided to undergo surgery.
+As the left 7th and 8th anterior ribs and the 10th and 11th posterior ribs were dislocated, the patient was taken to the operating room. After the double lumen endotracheal intubation general anesthesia, the patient was placed in the right decubitus position. After skin preparation and draping, a 4 cm incision was made in the 7th intercostal space near the anterior axillary line, where a membrane incision expander was put in, and thoracoscopes and operating instruments operated through the port. Exploration revealed minor active bleeding in the parietal pleura around the fracture, after suction and electrocoagulation, hematoma and deformity were found in the 7th and 8th anterior rib, as well as 10th and 11th ribs, the bone friction sensation around the rib fracture line was evident when pressed. Special instruments were needed . The rib coaptation boards with 4 or 8 arms (manufactured by Lanzhou Seemine Shape Memory Alloy Co., Ltd, China) were used to fix the fractures. The implantation tool with detachable tong head (manufactured by Lanzhou Seemine Shape Memory Alloy Co., Ltd, China,) was used to connect the rib coaptation board and placed it to the broken ribs. An oval bending forcep (manufactured by Lanzhou Seemine Shape Memory Alloy Co., Ltd, China) was used to reduce displacements. After exposing fractures with an electrocoagulation hook burning, reduction was implement with forcep (for the 10th and 11th rib) or fingers (for the 7th and 8th rib). Loosened the arms of boards under 0℃ ice sterile saline, connected the boards and implantation tool, delivered boards to fractures, and inserted four embracing arms into the upper and lower edges of the fractured rib. After prayed 50℃ sterile saline, boards return to previous shape to clasp and fix the fractured rib. As the result, the rib fractures are stable without screws or wires . A drainage tube was placed from the incision, and the procedure end up with incision suturing layer by layer .
+Postoperatively, the patient was transferred to the ward for vital signs detection, oxygen inhalation, atomization, pain relief, hemostasis, and fluid therapy. On the post-operative day (POD) 1, he expressed his satisfaction at the apparent ease of the pain, and reexamination of chest CT showed that the fracture was well fixed . On the POD 2, since the fluid was only 50 ml, the drainage tube was removed, and the patient was discharged next day. A month later, the pain had entirely resolved. The follow-up examination showed the fracture healing well, and the patient returned to work.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2089_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2089_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..005f5811029460f4a9840a8d334b5340ebb8c1b8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2089_en.txt
@@ -0,0 +1,5 @@
+A 25-year-old woman with liver cirrhosis secondary to autoimmune hepatitis diagnosed at a local hospital presented with fatigue, painless jaundice and lower limb swelling for two weeks, there was no evidence of hypertension or protenuria excluding the possibility of pre-eclampsia or eclampsia. There was no history of ascites, spontaneous bacterial peritonitis or hepatic encephathy. Pregnancy was terminated at 27th week at the local hospital. She was on 40 mg of Prednisolone daily for possible autoimmune hepatitis, soon after, she developed steroid induced diabetes. She was referred to our hospital after 6 weeks of the intial presentation with two episodes of hematemesis, tachycardia (heart rate 120) and blood pressure of 84/50. The patient was admitted to ICU and started on octreotide and Piperacillin/Tazobactam. Gastroscopy revealed gastric varices and bleeding was endoscopically controlled. During admission, liver function tests worsened, and transjugular liver biopsy showed established liver cirrhosis with no obvious active pathology. We started tapering the steroids slowly after being on 40 mg for 4 weeks with no improvement of jaundice without evidence of active inflammation on liver biopsy. During admission, she developed painful, erythematous lesion on her right forearm at the IV access area that became necrotic and spread quickly and increased in size over a period of 24 hours. The lesion included the skin and subcutaneous tissue and was flecked with tiny black spots. Vital signs: temp 37.4ºC, BP 128/80 mmHg, pulse 66 /min, RR 20 /min, SaO2 100% on room air.
+Chest was clear to auscultation and cardiovascular exam was normal. Abdomen was soft and lax, distended with ascites but no tenderness. Extremities showed mild lower limb edema. Her investigations showed a white cell count 14.24 x 103/mm3 with Neutrophils of 86%, hemoglobin 9.2 g/dl, and platelets of 103000 /mm3 , LFT: total bilirubin 457 umol/L, direct 321, alkaline phosphatase 430U/L, ALT 174U/L, AST 248U/L, gamma GT 227, total protein 51g/L, albumin 18g/L, PT 19.4 and INR was 1.7, PTT 58, renal function test was within normal, fasting glucose 9.8 mmol/L. ESR was 2, Blood culture showed no growth after 5 days.
+MRI of the right upper extremity showed inflammatory changes through the anterior compartment of the forearm suggestive of fasciitis.
+She was taken to the operating room for debridement after 24 hours, delay was due to anesthesia issues in this high risk patients. At this point after 18 days of admission, Prednisolone dose reached 20 mg daily and antibiotic changed from Piperacillin/Tazobactam to Imipenem when the culture results from tissue biopsy grew Klebsiella Pneumonia extended spectrum b lactamase producer (ESBL).
+Histopathological examination of the debrided soft tissue revealed necrotic subcutaneous fat and skeletal muscle fibers invaded by broad hyphae, irregularly branched, with rare septations suggestive of mucormycosis ( and ). There were no clinical symptoms or signs of visceral dissemination of infection to warrant further imaging or biopsy. The patient started on Amphotericin B (Abelcet®) 300mg IV OD after 20 days of admission and was continued on imipenem. In spite of surgical debridement, her condition continued to deteriorate and ended up after 6 days with above elbow amputation, tissue-cultures for both bacteria and fungi were negative. Amphotericin B was stopped after amputation as it was considered that the source of infection was eliminated but was restarted again 3 days after discontinuation with imipenem continued all through with the addition of vancomycin. The patient continued to deteriorate and the stump showed signs of disseminated infection, which proved to be invasive mucormycosis infection. Right shoulder disarticulation done but she passed away 2 days later due to multi-organ failure after 35 days in the hospital.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_208_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_208_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a042cc3ecfe0ad2bbfc02e1687a2fffb8fc860d2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_208_en.txt
@@ -0,0 +1 @@
+A 27-year-old male patient, underwent renal transplantation when he was 15-year old due to renal hypoplasia, but, was ultimately introduced hemodialysis. Following AVF construction, he experienced the steal syndrome, resulting in amputation of his left third digit and multiple AVF reconstruction. His left forearm AVF was malfunction due to severe PAD: quantity of blood flow was 70–110 ml/min because of complete obliteration of the proximal radial artery. Angiography demonstrated that obstruction of the proximal radial artery and regurgitation from the palmar arch to the AVF. This AVF condition barely enabled to perform daily hemodialysis with low efficiency with Kt/V < 1.0 (Daugirdas equation) . Exertional symptoms, tingling, and frigid digits were noted mainly due to decreased blood flow to the hand. The left second digits SPP was 17 mmHg. In order to restore digital circulation and AVF, distal dual bypass was planned under general anesthesia. First, in order to secure arterial inflow, brachial arterial stricture was excised and anastomosed end-to-end*. Following arterioplasty, however, the AVF flow measured by the doppler US, was still too weak to maintain hemodialysis. Thus, subsequently, the patient was given 5 000 units of intravenous heparin totally and monitored by ACT testing: 150–200. Regarding proximal anastomosis of the first distal bypass, the left brachial artery (distal to the * anastomosis) and reversed GSV graft were anastomosed with interrupted 7-0 prolene suture. In terms of the distal side, the posterior wall was sutured by parachute anastomosis technique, and the anterior wall anastomosis with interrupted 8-0 prolene was performed. Next, because it is true that AVF in the distal forearm is generally recommended, to repair forearm AVF, the second distal bypass was performed. The proximal portion was created at the proximal radial artery, downstream from the first distal bypass in order to prevent secondary steal syndrome. The left radial artery and reversed GSV graft were anastomosed with interrupted 7-0 prolene suture. Regarding the distal end side, the GSV graft and cephalic vein were sutured by the parachute anastomosis technique with 7-0 prolene. Finally, regurgitation from the palmar arch was ligated. The first distal bypass graft blood flow was 36 ml/min, measured by VeriQ (Medistim, Oslo, Norway). Angiography demonstrated satisfied simultaneous palmar arch and AVF circulation . The left second digits SPP improved to 90 mmHg following reflow. Kt/V improved to1.53 (Daugirdas equation) with well-maintained AVF. The both graft patency was confirmed without any endovascular intervention at 12-month following distal bypass.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2097_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2097_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ad8eab6205051897f592f88326003df91cadaefc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2097_en.txt
@@ -0,0 +1,3 @@
+The patient was a 5-month-old boy, delivered through cesarean section on March 7, 2017. He was brought to our department on April 24, 2017, and was diagnosed as having a right transverse facial cleft with an incomplete cleft palate. Further, we delivered the Hotz appliance. Figure shows the right transverse facial cleft. The patient had Goldenhar syndrome as a systemic disease. And on our clinical examination, the patient had a cleft in the right corner of the mouth, macrostomia, malposition of the orbicularis oris muscle, and right oral commissure, which was pulled laterally and downwards.
+Orbicularis oris muscle reconstruction and cheiloplasty using a mucocutaneous flap and Z-plasty were performed. Figure shows the operative technique for reconstruction of the transverse facial cleft. The general operation technique was conducted following the method performed by Dr. Akita for reconstruction of a transverse facial cleft . First, an incision was made using the healthy side as reference. To raise a mucocutaneous flap, incisions were made both extraorally and intraorally . Extraoral primary closure was performed for the newly formed oral orifice. To avoid dysfunctions, such as those of mouth opening, pronunciation, and mastication, an additional incision was made on the intraoral mucosal flap, and the bucco-mucosal cleft was closed . The muscle layer and exposed orbicularis oris muscle were dissected. To reconstruct the modiolus region, the inferior part of the orbicularis oris muscle was overlapped with its superior part, and muscle closure was performed. Subsequently, the mucosa was closed with the Z-plasty technique to prevent wound contraction and obtain a good facial profile in the patient .
+Figure shows the photographs acquired before and 3 months after the surgery. At 3 postoperative months, symmetry was observed between both the oral commissures with satisfactory esthetic reconstruction, and there were no functional postoperative complications.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2102_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2102_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d14c72ddb9df58c11adf3e3309a4ae75294b774a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2102_en.txt
@@ -0,0 +1,2 @@
+A 29-year-old male Albanian patient presented to our clinic owing to recurrent episodes of hypoglycemia. He referred to an incident of DKA that led to hospitalization abroad 20 days ago. The discharge report from the hospital referred to the DKA incident, but mentioned no precipitating factors. The patient was newly diagnosed with T1DM at this time, and intensified treatment with insulin at home was commenced (25 units of basal and 4–8–6 units of preprandial insulin per day). He had been going through stressful times, as he had recently received news of an upcoming fatherhood. He has a body mass index (BMI) of 21.6 kg/m2 and an unremarkable personal and family health record. He mentioned a 5 kg weight loss during the past 2 months. Laboratory tests exhibited glycosylated hemoglobin (HbA1c) at 8.1%, C-peptide at 1.8 ng/ml (normal range 0.5–2 ng/ml), and fasting plasma glucose (FPG) at 120 mg/dl. Antibody tests for anti-tyrosine phosphatase-related islet antigen 2 (anti-IA2) were upper normal (7.3 IU/ml, normal range 0.0–7.4 IU/ml), positive for anti-GAD65 (5.5 IU/ml, normal range 0–5 IU/ml), and negative for anti-islet cell antibodies (ICA) and anti-insulin antibodies (IAA). Initial management included significant downtitration of preprandial insulin. Basal insulin dosage was decreased at about 20 IU daily (initial dosage was 0.2 times the patient’s body weight: 0.2 × 70 kg = 14 units of degludec). Differential diagnosis consisted of T1DM “honeymoon” period and possible misdiagnosis at the hospital. Prolonged T1DM honeymoon periods have been described in the world literature, but the age of the patient, along with hypoglycemic incidents after insulin administration, positive anti-GAD65, C-peptide levels, and positive anti-IA2 and negative T1DM antibodies (anti-ICA, anti-insulin), suggested a type of diabetes other than the initially diagnosed T1DM, most likely LADA, according to the 2020 American Diabetes Association criteria . On a follow-up visit, considering the persistent laboratory and clinical findings, we discontinued the administration of preprandial insulin, regulated the basal insulin dosage, and enhanced treatment with metformin. One month later, under treatment with 2 g of metformin daily and additional sitagliptin, basal insulin dosage decreased at about 8 units per day and was subsequently halted. Two years later, basal insulin needed to be reintroduced, along with metformin and a glucagon-like peptide-1 receptor agonist (GLP-1 RA). Insulin requirement after at least 6 months from original diagnosis confirmed our previous hypothesis of LADA, which first manifested with DKA. On a 6-year follow-up, according to laboratory findings and glucose measurements, diabetes progressed to T1DM and basal bolus insulin treatment (multidose insulin, MDI) with detemir and lispro was initiated. The patient remains adherent to the regimen, and it has not been modified since.
+In addition, at the initial visit, the patient complained of excessive sweating and increased sensitivity to heat. A complete physical examination (PE) revealed upper limb tremor, lid lag, palpable thyroid gland, and heart rate of 110 beats per minute. Thyroid-stimulating hormone (TSH) levels were lower than 0.004 mIU/L (normal range 0.5–5 μIU/ml), total triiodothyronine (T3) at 2.19 nmol/L (normal range 0.9–2.8 nmol/L), total thyroxine (T4) at 14.60 μg/dl (normal range 5–12 μg/dl), free T3 (fT3) at 4.93 pmol/L (normal range 2–7 pmol/L), and free T4 (fT4) at 1.65 ng/dl (normal range 0.8–1.8 ng/dl). There were positive anti-thyroglobulin (anti-TG) (174 IU/ml, normal range < 116 IU/ml) and thyroid peroxidase antibodies (anti-TPO) (245 IU/ml, normal range < 16 IU/ml), while anti-TSH-R antibody was negative. An ultrasound scan of the thyroid gland was not indicative of pathology. Seven days later, a thyroid panel was conducted: TSH, 3.14 μIU/ml; T3, 1.57 nmol/L; T4, 87.19 μg/dl; fT3, 5.60 pmol/L; fT4, 15.26 ng/dl. TSH values decreased spontaneously with no treatment admitted. High levels of total and free thyroid hormones and presence of elevated anti-thyroid antibodies with negative anti-TSH-R navigated the diagnosis toward hashitoxicosis complicating Hashimoto’s disease and made Graves’ disease less likely. One month later, TSH was measured in a laboratory and found to be higher than normal (7.29 mIU/L), so levothyroxine treatment with maximal dosage of 88 μg was decided. On a 2-year follow-up, thyroxine was withdrawn as Hashimoto’s thyroiditis retreated, and the patient has remained euthyroid (TSH and thyroid hormone levels close to normal on blood test). On a 6-year follow-up, there were no identifiable changes in the patient’s thyroid state.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2124_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2124_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1bfa173ed0f6d33f7589033992198be1793d29b0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2124_en.txt
@@ -0,0 +1,6 @@
+A 45-year-old Caucasian male presented to the Emergency Department following 3 days of progressively worsening right lower quadrant abdominal pain and headaches. His past medical history was remarkable for long-standing back pain and erectile dysfunction. The patient was a social drinker and occasionally smoked. Initial clinical workup was unremarkable with normal blood pressure and renal function (BP 124/86; serum creatinine was 1.0 mg/dL with an eGFR of 90 mL/min/1.73 m2). A CT scan of the abdomen and pelvis was performed with intravenous contrast was performed per local protocol, revealing a right lower pole renal infarct. There was also perivascular inflammation involving the celiac artery. Initially a thrombotic/hypercoagulable state was hypothesized as the etiology. An ECG, transthoracic echocardiography bubble studies, d-dimer and coagulation studies were performed with no abnormal findings. Serologic studies evaluating for systemic vasculitis including ESR, CRP, ANCA and ANA were also negative. The patient was admitted for 3 days and was discharged on apixaban 5 mg once daily with stable creatinine and eGFR.
+The patient represented to the ED 16 days later with recurrent right flank pain, blood pressure 151/88 mmHg, temperature 36.7°C, serum creatinine of 1.3 mg/dL, eGFR 65.7 mL/min/1.73 m2, ESR 32 mm/h, CRP 12.32 mg/dL. Urinalysis was bland with no granular or epithelial casts. A CT angiogram of the aorta was performed to evaluate for aortic dissection, which revealed progression of the previously seen right renal infarct, now extending into the mid pole. There was also an acute dissection of the anterior and posterior divisions of the right renal artery, with several smaller branch occlusions in the mid and lower pole. In addition, there was new perivascular inflammation involving the main right renal artery and persistent inflammation involving the celiac artery, but no dissection or end organ damage. Interventional radiology was consulted for management of the renal artery thrombus to prevent worsening of the infarct. The patient was taken for a renal artery angiogram which confirmed the presence of a dissection and multiple segmental and smaller branch occlusion in the mid to lower right kidney. A decision was made to initiate catheter-directed thrombolysis, and the patient was monitored in the ICU overnight per protocol. Within 48 hours after the initiation of catheter directed thrombolysis, suffered fever and urinalysis was leukocyte esterase and nitrite positive and had 2+ blood and 2+ protein and was subsequently managed with Cefepime for urinary tract infection although urine culture ultimately showed no growth. The following day, the patient returned to IR for a repeat angiogram which revealed no significant reduction in arterial thrombus burden and a persistent dissection. Due to the patient having normal blood pressure, and significant pain improvement, thrombolytic therapy was discontinued and the patient was initiated on dual antiplatelet therapy with aspirin (81 mg daily) and clopidogrel (75 mg daily). At the point of discharge, the sCr was 1.0 mg/dL, eGFR 89.0 mL/min/1.73 m2.
+Twelve days later, the patient was readmitted, at that time complaining of gross hematuria and passing tissue on urination with elevated creatinine (1.63 mg/dL) and eGFR (50.1 mL/min/1.73 m2). A CT angiogram of the renal arteries was performed, showing a new left lower pole renal infarct and a left renal artery segmental branch dissection . There was a similar appearance to the perivascular inflammation involving the celiac and right renal artery branches with no increase in right renal infarct size. Genetic testing panels including COL3A1 for collagen disorders yielded nothing.
+At that time other contributors to the acute kidney injury and gross hematuria, including variously: hypovolemia; post-renal obstructive causes; glomerular and tubulointerstitial nephropathies (eg, contrast-induced nephropathy, acute interstitial nephropathy, acute tubular necrosis; were considered but appeared unlikely given lack of obstruction found on imaging (renal ultrasound and CT) as well as profuse red blood cells and protein on urinalysis but otherwise bland urine microscopy). There was no albuminuria. Throughout his presentation, the patient maintained adequate urine output ~120–200 mL/hour (body mass 95.7 kg). At this stage and in light of the radiographic abnormalities including inflammatory changes involving the celiac and renal arteries with associated bilateral renal artery dissections and the absence of vasculitic-, collagen defect-, or thrombophilia-markers, the provisional diagnosis was a non-atherosclerotic non-inflammatory vasculopathy.
+As there was no indication for surgical or additional endovascular management, the multidisciplinary team decided to manage the patient medically with atorvastatin (80 mg daily), Aspirin (81 mg daily), clopidogrel (75 mg daily), metoprolol (25 mg daily), amlodipine (5 mg daily) with blood pressure goals of <130/80 and counseling to adhere to a low sodium diet, home blood pressure monitoring and avoidance non-steroidal anti-inflammatories.
+Within 2 weeks of this latter presentation, hematuria had been resolved, there was no proteinuria or albuminuria on urinalysis; however, serum creatinine remained elevated and eGFR depressed. At 15-month follow-up, his kidney function had stabilized with elevated creatinine (1.3–1.5 mg/dL) and eGR (58–63 mL/min/1.73 m2) levels meeting the KDIGO criterion for CKD stage G2/3. A Renal CTA at this time demonstrated chronic bilateral infarcts and persistent, but improved perivascular inflammatory changes of the celiac and renal arteries without recurrent or new dissection .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2139_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2139_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0c82863be35783dcf8635e7bece9c470e912854d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2139_en.txt
@@ -0,0 +1 @@
+At the Vascular Surgery Department of our Institution, we examined a male patient (42 years old) who presented with a scrotal tumefaction. This tumefaction was approximately 15 × 17 cm in size and had been progressively developing after surgery for the removal of a left-side testicular angioma. Secondary sterility had occurred, as suggested by a spermiogram that revealed azoospermia (<20,000 spermatozoa/mL). Ultrasonographic test results performed during hospitalization revealed a diagnosis of scrotal arteriovenous malformation and a small fluid slope in the left tunica vaginalis; the testicles appeared to be regular in shape and had an echographic pattern. The patient underwent an angio-computed tomography (CT) of spiral multislides of the abdominal aorta and the lower limbs. The exam results indicated the presence of a raw agglomerate of enlarged blood vessels located in the left-1 side scrotal portion that was causing a contralateral dislocation of the right testicle . The mass was supplied by four arterial confluences: two from the superficial femoral arteries and two from the hypogastric arteries through the bilateral penile arteries. In addition, the scrotal venous system showed varicosity and congestion of the bilateral common femoral veins, most likely due to an arteriovenous shunt. It was decided that the malformation should be treated on the basis of a protocol involving endovascular arterial embolization with Glubran 2. The patient, after signing his informed consent, underwent a selective catheterization of the arterial ramifications via a left-side percutaneous transfemoral approach originating from the left femoral and left hypogastric arteries. A postprocedural angiographic check indicated devascularization of the lesion and a slight reduction in the size of the scrotal tumefaction. Two days after the procedure, a second embolization was performed via a left transfemoral approach to obtain a further reduction in the vascularization of the tumefaction, combined with the selective catheterization of the arterial ramifications coming from the right femoral and right hypogastric arteries . After 72 h from the embolization a skin necrosis on the hemiscrotum due to ischemia of the area previously supplied by the anomalous blood vessel was present. To avoid the development of a serious form of infected necrosis, such as Fournier’s gangrene, the patient underwent repeat surgery and debridement of the wide necrotic skin tissue (A B). During the following days, the patient received daily medications at the lesion site, coupled with endovenous antibiotic therapy. The agglomerate progressively decreased in size, and the necrotic area increased its demarcation. The patient was discharged from the hospital with antibiotic therapy 20 days after the first embolization procedure. In addition, he was prescribed daily medications, and he underwent subsequent plastic surgery for scrotal reconstruction. The spermiogram result showed azoospermia in both testicles.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2141_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2141_en.txt
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index 0000000000000000000000000000000000000000..77edc927f0fa8d49f21d6467bda22eeac3e99587
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2141_en.txt
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+A one-year-old male patient presented at the cardiothoracic surgery department of South Valley University Hospital with right-sided chest swelling for 4 days duration associated with non-radiating pain. The chest swelling was gradual in onset, with a progressive course. His mother presented that he had a history of productive cough for two weeks duration. Three weeks prior, he had been hospitalized with a urinary tract infection. There were no systemic symptoms, rash, or chills. There was no history of chest trauma or previous surgery.
+On examination, the patient appeared ill, with increased work of breathing. His temperature was 38.8 °C, heart rate was 120 beats per minute, and respiratory rate was 43 breaths per minute. Oxygen saturation was 94 % on room air. Inspection of the chest revealed a prominent, erythematous, firm, and tender swelling in the right back of the chest, measuring approximately 10 cm in diameter. The overlying skin was warm, with evidence of fluctuation without spontaneous discharge .
+A chest X-ray revealed a significant amount of right-sided pleural effusion and a wholly opaque right lung. The subsequent chest CT scan confirmed the presence of Rt lower lobe consolidation and loculated pleural effusion extending along the lateral and posterior chest wall .
+Leukocytosis (white blood cell count of 18,000 cells/mm3) was discovered by laboratory testing. To identify the causative organism, a sample of the pleural fluid was collected for microbiological analysis. Gram staining showed numerous polymorphonuclear leukocytes and gram-negative bacilli. Culture of the pleural fluid grew Escherichia coli, confirming the diagnosis of empyema necessitans due to an Escherichia coli infection. Based on the isolated strain's susceptibility patterns, we initiated the empiric antibiotic therapy with intravenous cefotaxime 200 mg/kg/day and intravenous vancomycin 60 mg/kg/day to cover the most likely pathogens, such as Streptococcus pneumoniae and Staphylococcus aureus. And Once culture and sensitivity results become available, the patient was immediately started on the appropriate intravenous antibiotics. The third-generation cephalosporin was a component of the antibiotic regimen.
+Under general anesthesia, the patient underwent surgical drainage, the abscess loculation was broken down effectively in all directions, and yellowish-white pus was drained; thereafter, the abscess cavity was thoroughly irrigated with sterile saline solution. Moreover, the abscess cavity was packed with sterile gauze. Lastly, a thoracostomy tube was inserted to drain the pleural cavity. Then patient was admitted to ICU for close monitoring, respiratory support, and postoperative care. The child's clinical course was constantly observed, and laboratory values, vital signs, and respiratory status were evaluated on a regular basis. Throughout the hospital stay, the patient gradually displayed clinical improvement. The swelling on the right side of his chest gradually went down in size as his fever reduced, respiratory symptoms was improved. Follow-up imaging revealed that the pleural effusion had resolved, and the lung regain its expansion. After 14 days, the patient successfully finished the intravenous antibiotic regimen and was discharged in stable condition. At the 1-month follow-up, the child remained asymptomatic with no recurrence of infection .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2196_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2196_en.txt
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index 0000000000000000000000000000000000000000..b750098c353efe63aa5ec6c66c833c01f9549db8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2196_en.txt
@@ -0,0 +1,13 @@
+A previously healthy, fully immunized 13 years-old boy was transferred to the intensive care unit department of our hospital with drowsiness, progressing painful hyperaemic right periorbital swelling, fever, bilateral nasal obstruction (right > left) and right purulent rhinorrhoea . Moreover, he presented worsening right visual acuity, right dyschromatopsia and a dull cervical pain for 2 days. His mother mentioned us about a right orbital trauma during a sport event (soccer game) occurred 7 days before.
+During ENT evaluation anterior rhinoscopy was performed with the finding of scarce purulent discharge from the right nasal cavity, with generalized hyperaemia and swelling of the nasal mucosae. Nasal fiberoptic endoscopy was difficult to perform due to generalized swelling of the nasal mucosae and only revealed right nasopharyngeal purulent drip. Respiratory space revealed normal.
+On admission blood tests documented leucocytosis with neutrophilia and elevated C-reactive protein (CRP).
+A brain and maxillo-facial contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) were performed and revealed the presence of a right intraorbital intraconic abscessual formation , acute right maxillary and left sphenoid sinusitis, minimal clival bone erosion and signs of sigmoid and transverse venous sinuses thrombosis.
+Urgent ophthalmologic evaluation was requested and resulted difficult to be performed due to the minimal palpebral fissure; however, it demonstrated signs of right optic nerve sufferance.
+Based on this finding, a large spectrum intravenous antibiotic treatment with ceftriaxone (2 g twice a day) and metronidazole (500 mg four times a day) and an anticoagulant treatment with subcutaneous low-molecular-weight heparin were introduced.
+The boy underwent an urgent surgical treatment with drainage of the right intraorbital intraconic abscess via right superior trans-palpebral approach and right antrostomy and left sphenoidotomy via endoscopic sinus surgery (ESS). Microbiological tests of the purulent collection were positive for multisensible Streptococcus intermedius.
+Full recovery of both orbital swelling and nasal complaints was achieved few days after surgery, as well as a progressive improvement with complete recovery in visual acuity.
+Antibiotic treatment with ceftriaxone and metronidazole was continued for 2 weeks, when worsening signs of meningeal sufferance (torcicollis and rigor nucalis), bradycardia and intermittent fever occurred.
+Lumbar puncture, abdominal and cardiac ultrasound (US) and blood culture were performed, but all revealed negative for meningitis, further abscessual formations and bacteremia. Immunological tests including immunoglobulins and IgG subclassis, lymphocyte subpopulations, tests for complement function were performed and resulted negative.
+Control head MRI was performed and documented the presence of an abscessual collection of the preclival region extending to the preclival soft tissue posteriorly to the nasopharynx and to the cervical long muscles’ insertion, associated with mandibular, occipital condyles and anterior part of the occipital bone osteomyelitis.
+Multidisciplinary team discussion with neurosurgeon, infectivologist, paediatricians and radiologist was achieved and another surgical urgent procedure was performed: partial posterior septectomy, bilateral sphenoidotomy with access to the preclival compartment and preclival abscess drainage in ESS.
+Antibiotic treatment was changed to vancomycin (40 md\kg\die in three doses) and meropenem (100 mg\kg\die in three doses) and continued for 34 days with fully complete recovery of the infection and discharged of the patient after ENT, ophthalmologic, neurologic and hematologic controls were referred as negative. Semi-annual imaging with contrasted MRI, as well as ENT, ophthalmologic and neurologist outpatient clinic controls were performed. No recurrences have been detected during the follow-up period (16 months).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2237_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2237_en.txt
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index 0000000000000000000000000000000000000000..956a3ef0cc168d2f501b36793178941344f6ba7a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2237_en.txt
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+This case report is a sequel to that by Kabashima et al. An 82-year-old man underwent laparoscopy-assisted partial gastrectomy for gastric tumor at an outside hospital. The gastric tumor was pathologically diagnosed as UPS, which is a rare high-grade sarcoma. The patients’ clinical course after his partial gastrectomy and the case-specific histopathological findings are reported in detail by Kabashima et al. 3 months after the patient’s first surgery, he was referred to our hospital due to new-onset dizziness and headaches. Magnetic resonance imaging (MRI) revealed a large cerebellar tumor with marked peritumoral edema. The tumor had not been present on staging scans (whole-body computed tomography [CT]) conducted immediately after the gastrectomy. On admission, brain CT revealed a 43 mm × 38 mm × 32 mm tumor in the left hemisphere of the cerebellum. MRI revealed that the tumor was iso-to-hyperintense on T1-weighted image (T1WI) and hyperintense on T2WI and demonstrated strong contrast enhancement after gadolinium injection . Fluorodeoxyglucose positron emission-CT (18FDG-PET-CT) revealed FDG uptake of SUV max 7.17. No other region with18FDG uptake was detected.
+The patient underwent standard suboccipital craniotomy without navigation or monitoring, performed in the prone position, and the cerebellar tumor was completely resected. The consistency of the white–yellow tumor tissue was dense, and the tissue plane between tumor and normal brain was clearly identified and microscopic gross total resection was achieved, and his postoperative course was uneventful. Postoperative MRI (within 24 h) and contrast MRI (within 72 h) revealed complete resection of the tumor . Symptoms improved after surgery, and he had no deficit and was discharged to go home after 20 days from his operation.
+Histopathological analysis showed a proliferation of spindle-to-polygonal-shaped tumor cells with enlarged irregular nuclei and eosinophilic cytoplasm arranged in sheet-like patterns, accompanied by chronic inflammatory infiltration and hemangiopericytomas Staghorn-type branching vessels [ and ]. Employing Ki-67 stains, mitotic figures were frequently observed. Immunohistochemical panel demonstrated that tumor cells were positive for p53 and p16, focally positive for cytokeratin AE1/AE3 CAM5.3, alpha-smooth muscle actin, desmin, and muscle-specific actin (HHF35), but negative for multiple other markers such as cytokeratin CK5/6, CK903, CK14, p40, EMA, GFAP, Oligo-2, IDH-1, ERG, STAT6, and GRIA2. The automated count of MIB-1-labeling index was high and estimated at 37%. We compared brain specimen from the specimen of the stomach after microscopic analysis, and both specimens showed the same histological characteristic. Pathological findings were compatible with that of metastatic tumors from gastric UPS.
+The patient underwent repeat brain imaging after 1 and ½ months at follow-up, and no apparent brain tumor residual or recurrence was observed. Only 2 weeks after that last visit, the patient started complaining of headache and nausea. A repeat MRI was ordered, which revealed a 4-cm recurrent cerebellar tumor in the same region, indicating that the 4-cm mass must have grown almost entirely within 2 weeks’ window. Since 2 weeks prior, he had undergone a non-contrast CT with 5-mm slice thickness. Systemic restaging was not performed because the pathological diagnosis was not clear. Again, the patient was taken to surgery and the recurrent tumor mass was completely resected. Histopathological findings were indistinguishable from the previous metastatic tumor again with a MIB-1 labeling index of 37%. After the second operation, the patient received focused brain radiation therapy with added local irradiation (40Gy/20Fr) and three dimensional intensity-modulated radiation therapy (30 Gy/3 Fr) to the tumor cavity. However, a second 9-mm metastatic brain tumor appeared in the temporal lobe. In addition, at the time of radiation therapy to the two lesions of the CNS, further metastatic tumors were detected in the patient’s tonsils. Although systemic chemotherapy was initiated adriamycin (30 mg/m2) plus ifosfamide (2 g/m2) (AI) at an age-adjusted dose of 75% and administered together with dexamethasone coverage; the metastatic tonsilar tumor grew rapidly, indicating that chemotherapy was not effective. Further local radiotherapy in this region also had no effect. The patient was thus transferred to a palliative hospital where he expired 10 days later.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2244_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2244_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..314c628c0e6064182a4283cc35f8d2130aa2841d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2244_en.txt
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+A 45-year-old Caucasian man, a welder, was admitted to our hospital with the chief complaint of a painless right scrotal wall mass from 15 months ago, which had been, recently, increased in size. He denied any coexisting symptoms such as fever, chills, cough, dyspnea, nausea, vomiting, and diarrhea. He also denied any previous history of trauma, surgery, radiation exposure, and medications including anabolic steroids. Social history was positive for smoking tobacco use at 10 pack-years. His family history was negative for a similar condition. Initial physical examination on admission revealed body temperature 36.8 °C, heart rate 70 beats per minute, and, blood pressure 135/86 mmHg. Head and neck examination showed no evidence of lymphadenopathy. Heart and lung sounds were normal. Thorough abdominal examination findings were unremarkable, and the inguinal lymph nodes were not enlarged on palpation. Neurologically, the patient was completely normal. Genital examination showed a firm, nontender, mobile mass in the posterior wall of the right hemiscrotum, while penis, bilateral testes, epididymis, and the spermatic cords were clinically normal.
+Initial laboratory work-up included complete blood count with leukocyte count of 7200/μL, hemoglobin of 14.5 g/dL, and platelet count of 186,000/μL, renal function tests with blood urea nitrogen of 12.6 mg/dL and serum creatinine of 1.1 mg/dL; blood glucose of 99 mg/dL, erythrocyte sedimentation rate (ESR) of 12 mm/hour, and C-reactive protein (CRP) of 8 mg/L; biochemistry of Na 135 mEq/L, K 4.3 mEq/L, Ca 8.7 mg/dL, serum glutamic oxaloacetic transaminase (SGOT) 32 IU/L, serum glutamic pyruvic transaminase (SGPT) 36 IU/L, and alkaline phosphatase 214 IU/L. Urinalysis revealed no pathologic findings. The testicular tumor markers were within normal range: lactate dehydrogenase (LDH) 150 units/L, alpha-fetoprotein (AFP) 12 ng/mL, and beta-human chorionic gonadotrophin (β-HCG) less than 2 mIU/mL. Transscrotal ultrasonography revealed a 35 18 12-mm oval-shaped, hypoechogenic, solid mass with blood flow and well-defined border. Chest x-ray examination and abdominopelvic computed tomography (CT) scan were both normal, while whole-body bone scan showed no systemic metastasis .
+Subsequently, the patient underwent an excisional biopsy, during which the mass was felt to be a 30 25 15-mm oval-shaped and well-circumscribed mass without capsule formation . Afterwards, the tumor was reported pathologically to be malignant spindle cell tumor, more probably of smooth muscle origin, which was attached to the surgical margins in some areas. Therefore, we did a second, wider marginal excision of the tumoral bed, which was reported to be free of residual tumors.
+Preoperatively, we prescribed intravenous cefazolin (2 g) as the prophylactic antibiotic that was converted to oral cephalexin (500 mg per day) after discharge. The patient did not receive any neoadjuvant chemotherapy or radiation. Postoperative close follow-up was planned, and during the 20-month period, there was no evidence of recurrence or distant metastasis.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2261_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2261_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d97df0bfa5f81ce796e405bf30cde48412e16f8e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2261_en.txt
@@ -0,0 +1,7 @@
+The patient is a 15-year-old boy whose clinical history started at 5 years old. Seizures at onset were (1) imbalance and cold sensation and (2) limbs and face paresthesia followed by loss of consciousness and limbs stiffening. MRI scan showed a right parietal dysembryoplastic neuroepithelial tumor (DNET). After surgical removal, the boy was seizure free for 2 years. At 7 years old, focal seizures characterized by behavioral arrest, mental confusion, left upper limb paresthesia, and distorted voice sensations, followed by lower limb stiffening and weakness or imbalance appeared. Long-term video EEG monitoring showed background rhythm asymmetry and right centro-parieto-temporal interictal paroxysmal abnormalities. Ictal EEG highlighted large slow right parietal and temporal waves preceded by rapid activity. Seizures control lacked despite poly-antiepileptic drugs (AEDs) with valproate acid, oxcarbazepine, and clobazam. Control MRI excluded tumor regrowth showing only scar tissue on the superficial and deep-middle inferior parietal region extending to the marginal and angular gyrus, to the posterior insula, and to the inferior parietal gyrus behind rolandic cortex. Thus, the child underwent a second surgery, aided by electrocorticography (ECoG) to remove the altered sulci in the postero-medial portion of the previous surgical cavity as well as the right superior temporal gyrus. Seizure freedom was achieved for 3 years.
+Nonetheless, seizure relapsed after 2 years becoming heterogeneous and multidrug-resistant. The boy experienced anesthesia and loss of tone in the left arm, twisting of the jaw to the left and dysarthria accompanied by daze, lightheadedness sometimes associated with headache and dizziness, and negative myoclonus involving the left hand. Therefore, a new pre-surgical epileptic work up was proposed.
+The registration was made through 21 copper disc electrodes according to the International System 10-20 (band pass 1.600–70 Hz, sampling rate 512 Hz). The recording lasted 3 days and included Intermittent Light Stimulation protocol at increasing frequencies (3–50 Hz) and 5 minutes hyperventilation. Data were analyzed using Micromed System View. Interictal EEG was characterized by slow activity and spike and slow wave discharges on right central parietal regions, spreading on the posterior vertex ones. Independent and isolated spikes on right posterior temporal derivations were also observed. Three types of seizures were recorded: focal motor, characterized by discharges of spike-wave on the right parietal regions with subsequent bihemispheric diffusion; focal non-motor, characterized by delta-like slow activity; and spike-wave on the right centro-parietal regions with right hemispheric diffusion and negative myoclonus, characterized by slow wave discharges on the right parietal and frontal regions with diffusion on the contra lateral homologous regions.
+Cognitive assessment was carried out using the Wechsler Intelligence Scale for Children (version IV, 2003) which highlighted a normal level (IQ 88), characterized by a disharmonic profile, in the presence of a significant difference (> 12 points) between the indices, to the detriment of the score obtained in working memory (73) and processing speed (82). Visuo-spatial memory was quite impaired (recall of Rey figure—5ds). Verbal memory tests showed normal performance in short-term recall and slight difficulty in the long-term one. Furthermore, there was a marked difficulty in lexical retrieval with a phonological facilitator and slight difficulty with a semantic facilitator. Tests performed with Developmental Neuropsychological Assessment (NEPSY-II, 2007) showed a marked deficit in sustained attention and a slight difficulty in visual-motor integration.
+A scalp hdEEG with 128 channels was performed. The registration was made through pre-assembled caps with 128 electrodes according to the 10-10 system (electrode impedances < 40 kΩ; sampling frequency 1 kHz; the vertex was used as recording reference). The recording lasted about 2 h including wake and sleep. No seizures were recorded. Offline, EEG was analyzed through the Micromed SystemView; band pass filtered between 0.1 and 100 Hz and any paroxysmal anomalies was noted. A head model was built using T1-weighted MRI and scalp electrodes were co-registered with the MRI using a template net of electrodes with standard position that was translated/rotated/dilated with personalized digitalization through scalp navigation system (XensorTM 3D Electrode Digitizer) . For the inverse solution, low resolution electromagnetic tomography (LORETA) was used through ASA® Experiment Manager® Software. Only the solution point with maximal source strength was taken into account. An interictal source was identified in the mesial part of the right superior parietal lobule. Another source, of lesser force, was found in the right frontal lobe at the level of the right prefrontal area .
+SEEG was also performed. Seven depth electrodes were implanted; 4 platinum electrodes; 8 contacts with 5 mm interelectrode spacing, with a total recording surface of 37 mm (Ad-Tech LTM—Spencer probe depth electrodes) and 3 platinum electrodes; and 10 contacts with 5 mm interelectrode spacing, with a total recording surface of 47mm (Ad-Tech LTM—Spencer probe depth electrodes). The Medtronic Stealth Station™ S8 was used to carry out the pre-operative planning using MR and CT angiography with sequences for neuronavigation . The electrodes were positioned under frameless Medtronic Stealth Autoguide™ cranial robotic guidance platform with the help of anchor bolts.
+Electrode course description is as follows: O (8 contacts) pars opercularis, S (10) superior parietal lobule, Ps (8) parietal, Pi (10) inferior parietal lobule, V (8) posterior portion of superior parietal gyrus, T (8) median temporal gyrus, and I (10) insula . From prolonged registration, frequent interictal anomalies were recorded on the deeper contacts of electrode O, I, and on Pi. Less frequent anomalies were found on the more lateral contacts of S and on the deeper ones of T and V. Five focal motor seizures were recorded showing onset on deep O, I, and Pi contacts with slight advance in the first 2 electrodes. Negative myoclonus was related to the presence of fast ripples on the deep contacts of O and I and subsequent slow potential on the most superficial contacts of I. Two electrical seizures were recorded on Ps. Finally, symptoms generally present during patient’s focal non-motor seizures were evoked with the stimulation of the contacts I3 and I4.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2262_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2262_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..45b122f3378a6228614a694c1fa432598d703107
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2262_en.txt
@@ -0,0 +1,9 @@
+A 49-year-old male was admitted to Nephrology Department for oedema for 1 month and dyspnea for 1 week, with painful livedo reticularis in his left foot. His past history included recurrent episodes of brucellosis over the past four years. Two months prior to admission, brucellosis reoccurred and doxycycline and rifampin had been taken for 6 weeks and his symptoms of fever, sweating and general malaise disappeared. He had hypertension for 10 years, treated with telmisartan, nifedipine and indapamide and his blood pressure was about 150/90 mmHg. He underwent an iliac aneurysm stent implantation 6 years ago. He self-reported no evidence of renal disease before.
+On admission, the patient had no fever, and his blood pressure was 163/111 mmHg. Clinical examination revealed a puffy and pale appearance, general oedema, weakened breath sound in the bottom of both lungs and moist rales heard in both lungs. The ischemic manifestation occurred in the left lower limb including cold skin temperature and pulseless in arteria dorsalis pedis. Livedoid changes in the left sole were in Fig. .
+Laboratory tests showed elevated blood white blood cell (WBC) count with increased neutrophil ratio (WBC: 13.2 × 109/L and 90% neutrophil). The hemoglobin was 8.1 mg/dL. Urinalysis showed 2 + protein with dysmorphic red blood cells (77–430 /HP). Total urine protein excretion was 2.1 g/day. Blood urea nitrogen was 20.3 mmol/L, serum creatinine 203 µmol/L and creatinine clearance 31.9 mL/min/1.73 m2. Serum albumin was 23.4 g/L. Serum brain natriuretic peptide was 4087.3 µg/mL. Parathyroid hormone was 219.3 pg/mL. C-reaction protein was 53.2 g/L. Hypocomplementemia with C3 0.197 g/L and C4 0.101 g/L. Rheumatoid factor, anti-nuclear antibody IgG, cytoplasmic ANCA and proteinase 3 ANCA were positive. Reversible cryoprecipitate appeared and serum cryoglobulin level was 1.53 g/L. Immunoelectrophoretic analysis of the serum cryoglobulin showed the mixed polyclonal IgG and IgM . Brucella serum agglutinins test (SAT) was positive at a titer of 1:200 and both the blood and the bone marrow culture were negative.
+The pulmonary computed tomography (CT) scan showed a bilateral exudative lesion, bilateral pleural effusion and pulmonary atelectasis with pericardial effusion. The abdominal CT showed peritoneal and pelvic effusion, diffused abdominal wall oedema, metal stents image in the abdominal aorta, bilateral common iliac arteries and left external iliac artery. The electrocardiogram showed sinus rhythm with left ventricular high voltage. Ultrasonographic imaging of the kidneys revealed normal-sized kidneys with increased parenchymal echogenicity. The transthoracic echocardiogram detected enlargement in all four chambers and myocardial wall hypokinesia with decreased ejection fracture of 41%. Other changes included moderate pulmonary artery hypertension and a small amount of pericardial effusion with no vegetation on the cardiac valves. Pathological examination of the bone marrow showed hyperplasia of bone marrow with a normal ratio of granulocytes to erythrocytes. No poisoning particle was present in granulocytes. no parasites or bacteria were found.
+The patient received continuous renal replacement therapy (CRRT) to relieve the dyspnea and heavy oedema. A renal biopsy was performed after the patient’s condition become stable. The renal pathology revealed endocapillary proliferative glomerulonephritis with crescent formation. Hypertensive renal injury was also prominent . On light microscopy, 32 glomeruli were identified. Glomerular sclerosis in 11 glomeruli. Hypercellularity in the remaining glomeruli, mainly endothelial cells and mesangial cells with a few neutrophils. A cellular, a fibrinous and a small cellulofibrous crescent were found. No basement membrane thickening. Severe vacuole and granular denaturation in tubular epithelial cells. 40% tubular atrophy, mild tubular interstitial oedema and multiple inflammatory cells infiltration with fibrosis. Thickening and narrowing of arteriole wall with segmental hyalinization. The immunofluorescence revealed diffuse strong C3 deposits along the capillary wall. No other immunoglobulin or complement deposit was present. Hump-like electron-dense deposits were found under epithelial cells by electron microscopy superimposed on hypertensive renal injury contributed to the patient’s renal involvement.
+The patient was diagnosed with acute post-infectious glomerulonephritis (APIGN), AAV- related glomerulonephritis, secondary cryoglobulinemia, acute kidney injury on chronic kidney disease, primary hypertension Grade 3 (very high risk), congestive heart failure. Methylprednisolone (40 mg/QD/IV) was given on the 3rd day of admission to treat the acute nephritic syndrome. More important was the presence of ANCA and other immunological disorders and the severe foot pain and livedo reticularis which was a skin vasculitis related to cryoglobulinemia. And all the symptoms of the patient were relieved promptly and no need for CRRT treatment. Oral prednisone 50 mg per day was used and the patient was discharged from the hospital. For the treatment of brucellosis, anti-brucellosis treatment was suggested at the same time though the patient had no sign of active infection. Doxycycline and rifampin were added with a prolonged course of 6 months.
+The patient recovered soon and on the 1st follow-up one month later, oral cortisone began to taper. 2 months later the prednisone was tapered to 30 mg/day and on the 3rd month, prednisone was 10 mg per day. The patient felt well and had no oedema, no fever and no dyspnea. The foot pain and livedo reticularis disappeared. There were little proteinuria and a slightly elevated creatinine level left. Now the patient is still under intensive follow-up. The biochemical examination records were listed in Table .
+Antihypertensive treatment was given at the very beginning. Sacubitril/valsartan was given to reduce the elevated blood pressure and reverse the enlarged ventricle accompanied by amlodipine and arotinolol. Now the sacubitril/valsartan was used at the maximal dose (200 mg bid) and blood pressure is well controlled under 130/80 mmHg. The Echocardiography re-checked 3 weeks later showed left ventricular enlargement only and improved ventricular motion with an improved ejection fraction of 53%. There was still 5–8 mm pericardial effusion and no pulmonary hypertension.
+The patient worked as a shepherd from 2012 to 2015. But he was first diagnosed with brucellosis 2 years after ceasing sheep husbandry with classical symptoms of fever, sweating, muscle pain and ankle pain. After combined use of oral doxycycline and rifampin for 6 weeks. His symptoms disappeared completely. But his symptoms were repeated another 3 times. Each time he was treated with the same therapeutic regimen and responded well. But his brucella antibody persists positive which may be a sign of inadequate treatment.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2266_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2266_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1f66549c3b1d98492a0fa8096adcd8aa39c9243e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2266_en.txt
@@ -0,0 +1,3 @@
+A 70-year-old female patient presented to the emergency department with rapidly progressive shortness of breath over a week. Her past medical history included significant weight loss, dysphagia, and anorexia 1 year prior to admission which was diagnosed as oesophageal carcinoma which was treated by oesophageal stenting 5 months prior to admission. On admission, the patient was in moderate distress with the following vital signs: blood pressure 130/80 mmHg, pulse: 130 b.p.m., temperature 37°C, and respiratory rate 25 b.p.m. Precordial examination revealed distant heart sounds. Chest examination revealed bilateral diminished air entry over both lung bases. Electrocardiogram demonstrated sinus tachycardia with premature atrial contractions (PACs), low voltage, and subtle electrical alternans .
+As a first line imaging modality, we selected a transthoracic echocardiogram which demonstrated a metallic shadow behind the left atrium (oesophageal stent) . It also revealed a massive circumferential pericardial effusion (that was mainly posterior and lateral and measured 3 cm and 2.8 cm, respectively) as well as large left pleural effusion .The inferior vena cava (IVC) was dilated (2.6 cm) and it did not show adequate inspiratory collapse . Apart from significant respiratory variation in mitral and tricuspid inflow , the echocardiographic features of tamponade were absent. We decided to apply the triage chart proposed by the European Society of Cardiology Working Group on myocardial and pericardial diseases to calculate the pericardiocentesis score. Despite that the patient was normotensive, the pericardiocentesis score was 13.5 .
+So urgent pericardiocentesis was performed with tapping of about 500 mL haemorrhagic fluid followed by immediate and marked improvement of symptoms and tachycardia (heart rate dropped to 100). Then, the patient was referred for pleuropericardial window.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2300_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2300_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..df309cdf9be52895397c65008692e424c9137905
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2300_en.txt
@@ -0,0 +1,3 @@
+A 42-year-old man underwent emergency ascending aortic replacement (Triplex Advanced; Terumo Corporation, Tokyo, Japan, 22 mm and 20 mm) and aortic valve resuspension for acute type A aortic dissection at our institution 6 months previously. During the primary surgery, distal anastomosis was performed using only the outer felt, and bovine pericardium was used to cover the site with the intimal tear proximally as root intima patch repair. Replacement of the ascending aorta was performed using a 20-mm graft, and the proximal part had a 22 mm graft-graft anastomosis. The operation and postoperative course were uneventful, and the patient was discharged and followed up monthly. Four months later, there was a slight increase in the serum lactate dehydrogenase (LDH) level. At 5 months after the surgery, laboratory data indicated mild hemolysis, and he complained of fatigue on exertion. Six months after the surgery, he was admitted to our institution because of severe hemolysis that required blood transfusion. The serum hemoglobin (Hb) level was 8.6 g/dL, LDH enzyme level: 3071 IU/L, hematocrit: 25.8%, relative reticulocyte count: 8.1%, total bilirubin: 4.1 mg/dL, blood urea nitrogen (BUN): 13 mg/dL, and creatinine: 1.38 mg/dL. Upon discharge after the primary surgery, the serum BUN level was 14 mg/dL, and creatinine was 0.75 mg/dL. A peripheral blood smear showed many schistocytes; however, the Coombs test was negative. Physical examination showed yellowish skin discoloration and red-yellow urine color, while eye examination showed jaundice and conjunctival pallor. A systolic murmur (Levine II) was heard in the second right intercostal space. Transthoracic echocardiography (TTE) revealed a severely kinked graft in the ascending aorta, with normal left ventricular function and valve. At the kinked site, the peak jet velocity was 4.8 m/sec and the pressure gradient was 92 mmHg. Computed tomography showed severe kinking at the graft, approximately 35 mm from the proximal anastomosis . These data suggested that mechanical destruction of red blood cells by the kinked graft caused the hemolytic anemia, and he needed resection of the replaced ascending aorta. He required transfusion of 14 units of blood in the 4 days before the surgery, and the Hb was 8.6 g/dL at the time of surgery.
+The chest was opened by redo median sternotomy. Slightly distal to the valve level, the graft showed a sharp, crinkled oblique fold partially obstructing the post-valvular flow, and a strong thrill was felt at the site of the kinked graft . Extracorporeal circulation was established by femoral artery cannulation and venous drainage from the right atrium. After inserting the left ventricular vent cannula through the left superior pulmonary vein, clamping, and anterograde cardioplegia, the graft was opened at the suture line. The valve showed normal function with no regurgitation. The proximal and distal sides of the kinked graft were resected diagonally, and graft-graft anastomosis of approximately 1 cm in length was performed . The thrill became weaker than before resection after unclamping. The duration of extracorporeal circulation was 66 min, and the operation time was 283 min.
+Postoperatively, gross hematuria and hemolytic anemia resolved completely and the serum LDH and bilirubin levels normalized . Subsequent surgical and clinical course were uneventful, with discharge in very good condition after eight days .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2306_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2306_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9ee89e8db3a3cf88991d92b89a0ff4f8b3feb467
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2306_en.txt
@@ -0,0 +1,2 @@
+A 94-year-old man, who suffered dark urine, epigastric pain, and loss of appetite, was admitted for evaluation and treatment of bile duct cancer. He has a past history of hypertension and paroxysmal atrial fibrillation. Computed tomography (CT) showed a nodule in the lower bile duct, which was slowly enhanced by dynamic CT . Tumor markers were as follows: carcinoembryonic antigen of 7.2 ng/mL, carbohydrate antigen 19–9 of 22 U/mL, respectively. Endoscopic retrograde cholangiopancreatography revealed biliary obstruction and biliary drainage was performed . Cytopathological examination revealed adenocarcinoma of the bile duct. The patient was carefully evaluated whether he overcame pancreatoduodenectomy by cardiac ultrasonography, brain magnetic resonance angiography, nutritional evaluation by rapid turnover proteins (RTPs) (retinol-binding protein of 2.4 mg/dL, pre-albumin of 19.9 mg/dL, transferrin of 196 mg/dL), and CT-based assessment, including osteopenia and sarcopenia. Sarcopenia was evaluated by the area of the psoas muscle at the caudal end of the third lumbar vertebra by measurement of the lengths of the major and minor axes of the psoas muscle . We then evaluated sarcopenia by comparing the area of psoas muscle with previously reported sex-specific average . Osteopenia was defined as actual bone mineral density (BMD) below the calculated standard BMD, which was calculated as previously reported (308.82–2.49 × age in men and 311.84–2.41 × age in women) . BMD was measured in trabecular bone by calculating average pixel density within a circle in midvertebral core at the bottom of 11th thoracic vertebra (Th11) on preoperative computed tomography. The patient was independent in activities of daily living and was graded as performance status 1 and American Society of Anesthesiologists physical status (ASA-PS) 2. He had enough ejection fraction of 65%, and examinations revealed no impairment of cognitive function and neither of osteopenia and sarcopenia .
+With a diagnosis of bile duct cancer with no distant metastasis, the patient underwent subtotal stomach-preserving pancreaticoduodenectomy with lymph node dissection . Operation time was 299 min and estimated blood loss was 100 ml. Pancreatic duct stent (6Fr), external biliary stent (7.5Fr), jejunostomy, and 2 drain tubes (Winslow and anastomosis of pancreatojejunostomy) were placed after operation. The resected specimens showed a tumor in the lower bile duct . Pathological examination revealed papillary adenocarcinoma of the bile duct (pT3N1M0 Stage IIIB) and the surgical margin was negative. Enteral nutrition (ENEVO®, Abbott, Japan) was given through jejunostomy and then the patient started oral intake after an evaluation of swallowing function on the postoperative day 7. Although RTPs were decreased on the postoperative day 7 (retinol-binding protein of 0.8 mg/dL, pre-albumin of 8.1 mg/dL, transferrin of 115 mg/dL), those were recovered after 1 month (retinol-binding protein of 1.6 mg/dL, pre-albumin of 13.7 mg/dL, transferrin of 208 mg/dL) with careful nutritional support and rehabilitation. The patient discharged on postoperative day 65 without any complications. He remains well with no evidence of tumor recurrence as of 1 year after resection.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2365_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2365_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bc540f9a5e0e41926d033ba99ca264c342aa19b5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2365_en.txt
@@ -0,0 +1,3 @@
+The patient was a 64-year-old retired woman from Yichang, Hubei Province with a past medical history of cholecystectomy for cholecystitis 25 years prior. She had no history of hypertension, hyperlipidemia, or diabetes. The patient presented with characteristic electric shock-like, lancinating pain in the right V2 distribution area accompanied by right pulsatile tinnitus. The pain was triggered by innocuous stimuli such as brushing teeth or washing her face over the affected trigeminal dermatomes. She was first treated with oxcarbazepine 450 mg daily for 1 month without significant relief. She was then switched to carbamazepine 200 mg daily, which provided initial control of her symptoms for 2 months. However, the pain gradually worsened, requiring an increase in carbamazepine to 600 mg daily. At this higher dosage, discomfort such as dizziness occurred, and the pain was still uncontrollable.
+Magnetic resonance imaging showed multiple vascular flow void signals in the right cisternal segment near the trigeminal nerve. Further cerebral angiography revealed a right arteriovenous fistula that was supplied by the petrous branch of the middle meningeal artery of the right external carotid artery and the posterior meningeal artery branch of the right vertebral artery (A&B). The fistula was located between the tentorial dura mater and drained through the superior petrosal vein (SPV) to the basal vein (Borden class III). Hence, interventional embolization was performed through the enlarged right external carotid artery to the posterior branch of the middle meningeal artery. During the operation, a Marathon microcatheter was used for superselection to the fistula; the onyx spread well and the casting was satisfactory. Following embolization, the patient's pulsatile tinnitus resolved, however TN recurred on postoperative day 3 with identical location and characteristics as her preoperative pain. Her postoperative medical regimen consisted of carbamazepine 400 mg daily and the addition of pregabalin 300 mg daily in an attempt to control her persistent facial pain. According to the patient, this adjustment provided a modest decrease in frequency of painful paroxysms, though her symptoms remained suboptimally controlled. Six months postoperatively, follow-up angiography revealed complete obliteration of the DAVF .
+Therefore, we decided to perform MVD via the retrosigmoid approach for this patient. Preoperative re-examination of the T2-constructive interference in steady state (CISS) high-resolution nuclear magnetic resonance sequence showed that the vascular flow void signal was significantly reduced compared with that before embolization, but the significantly expanded flow void signal near the trigeminal cisternal segment could still be seen (C). During the operation, the SPV was found to be tortuously dilated and formed a venous lake. The blood vessels showed a post-embolization appearance, were dark blue, and had no arterial pulsation. The pontotrigeminal vein, which joins the SPV from the ventral side, was also tortuously dilated, dark blue in color, and hard in texture, and venous thrombosis was considered. The dilated vein pushed down the trigeminal cisternal segment from the ventral side (A). We attempted to separate the neurovascular vessels with spherical microvascular strippers, but the thrombosed veins were severely sclerotic and difficult to move. Therefore, bipolar coagulation was used to reduce the diameter of the vein in the intermittent 7 W of power so that the trigeminal cistern was no longer compressed. A Teflon pad was then placed between the draining vein and the trigeminal cisternal segment to further open the nerve–vessel space, and the branch of the superior cerebellar artery was found to form compression; therefore, we routinely used a Teflon pad on the responsible blood vessel in the REZ (D). The patient's right facial pain disappeared immediately postoperatively, and she had transient facial numbness that disappeared 3 weeks postoperatively.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2368_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2368_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6b26660c8b514d8270f02e267bcfa5589f7d73a1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2368_en.txt
@@ -0,0 +1,4 @@
+An 18-year-old male presented to a local hospital with sudden chest pain accompanied by headache, palpitations, and shortness of breath for 18 h. He was in good health, had no previous underlying diseases, and no history of cardiopulmonary disease.
+Initially, the patient presented with sudden chest pain, described as persistent, non-radiating, dull pain, followed by palpitations and headache, accompanied by shortness of breath and cough with a small amount of phlegm, which could not be relieved by rest. He consulted at the local hospital for treatment and was admitted to the intensive care unit (ICU). After admission, he developed anuria and mixed acidosis, which were difficult to correct. His vital signs were as follows: heart rate of 138 beats/min, respiratory rate of 32 breaths/min, blood pressure of 105/38 mmHg (after continuous infusion of high-dose norepinephrine and dobutamine), central venous pressure (CVP) of 9 mmHg, and oxygen saturation of 100% (oxygen absorption flow rate at 4 L/min). Bedside color echocardiography showed an aneurysm of the right coronary sinus of the aorta, which ruptured into the right atrium. The width of the base was 24 mm, the height was 15 mm, and the rupture point was 7 mm. A continuous shunt was observed on color Doppler flow imaging (CDFI) . Left ventricular ejection fraction was 63%. Spectral Doppler showed that the aortic valve jet velocity was normal. CDFI showed that there was no abnormal blood flow across the atrial septum. Minimal aortic valve regurgitation, mild tricuspid regurgitation with a regurgitant area of approximately 3.8 cm2 and a maximum velocity of 2.8 m/s, and a pulmonary artery systolic pressure (PASP) of 35 mmHg were observed. The patient was diagnosed with a ruptured sinus of Valsalva aneurysm into the right atrium.
+The local hospital contacted our hospital for consultation. After discussion, the plan was to transfer the patient immediately to our hospital for emergency ruptured sinus of Valsalva aneurysm repair. Considering that the patient's condition was critical and the hemodynamics were still unstable after administration of a large amount of vasoactive drugs, bedside VA-ECMO was performed immediately using 15-French arterial, 8-French arterial backflow, and 21-French venous cannulae via an open right femoral cutdown, achieving flows of 3 L/min. At this time, the patient's vital signs were as follows: heart rate of 130 beats/min, respiratory rate of 22 breaths/min, blood pressure of 109/47 mmHg, and CVP of 29 mmHg. The ECMO flow and dobutamine dose were adjusted to reduce shunting . After establishment of ECMO, the patient was transferred by ambulance to our hospital for emergency surgery. Transesophageal echocardiography demonstrated a right sinus of Valsalva aneurysm rupture into the right atrium (, ).
+The patient underwent emergency surgical repair. A median sternotomy was performed, and after systemic heparinization, cardiopulmonary bypass was established with bicaval cannulation. A cardioplegia cannula was inserted into the aortic root, and a left ventricular vent was inserted into the right superior pulmonary vein. The patient was then placed under moderate hypothermia. After an aortic cross-clamping, antegrade and retrograde cross perfusion of histidine-tryptophan-ketoglutarate (HTK) cardioplegia solution were performed. The right atrium was incised, and the aortic valve was exposed through an oblique incision at the aortic root. Exploration showed that the aortic sinus was grossly dilated and penetrated into the right atrium, with a rupture size of approximately 1.2 × 1 cm . The rupture was repaired with a pericardial patch sutured intermittently using 4-0 polypropylene. No leak was detected after the repair. The aortic root and the right atrial incision were then closed using 5-0 polypropylene sutures. Cardiac circulation was then resumed, cardiopulmonary bypass was discontinued when the blood pressure stabilized. Ventilator parameters were as follows: tidal volume of 500 ml, respiratory rate of 14 breaths/min, positive end-expiratory pressure of 5 cm H2O, inspired oxygen concentration of 60%. The following vital signs were observed: blood pressure of 125/65 mmHg, heart rate of 80 beats/min, pulse oxygen saturation of 100%. Blood gas analysis showed the following results: pH of 7.45, PCO2 of 39 mmHg, PO2 of 270 mmHg, glucose of 8 mmol/L, lactic acid of 1.10 mmol/L, HCO3 of 27.1 mmol/L, and hemoglobin (Hgb) of 94 g/L. Urine output was 3 ml/kg body weight/h. The patient's hemodynamic status stabilized, ECMO was discontinued. Then protamine was administered. The patient was hooked to ECMO for 8 h. He returned to the surgical ICU after surgery and to the general ward after 7 days. He was successfully discharged after 40 days . After 2 years of follow-up, the patient's heart structure and function were normal. He had good exercise tolerance and no evidence of heart failure.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2376_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2376_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2786521c86e272ffff901ae2e371a514be073cce
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2376_en.txt
@@ -0,0 +1 @@
+A 61-year-old woman without any risk factor of arteriosclerosis visited a nearby hospital because of mild head injury. Magnetic resonance (MR) imaging demonstrated no apparent traumatic lesion. However, flow-void sign of the right middle cerebral artery was sluggish . Cerebrovascular disease was suspected and she was referred to our hospital for further examination. She was neurologically intact and had no significant history of weakness or sensory disturbance. Moreover, her family has not experienced cerebrovascular disease. Right carotid angiogram demonstrated stenosis of the terminal portion of the ICA with moyamoya vessels . Left carotid angiogram and left vertebral angiogram showed no apparent abnormality [Figure and ]. Single photon emission computed tomography (SPECT) demonstrated hypoperfusion in the right cerebral hemisphere. The response to the acetazolamide was impaired . She was diagnosed as unilateral MMD and followed by MR imaging annually. During 6 years, she had been intact and MR imaging had not detected progression of MMD. However, 7 years after the diagnosis, cerebral aneurysm appeared in the right basal cistern, probably from anterior choroidal artery, and conventional angiography was planed . Before that, she become comatose and brought to our hospital emergently. Computed tomography (CT) showed massive intraventricular hemorrhage . Enlargement of the aneurysm was revealed by CT angiography [Figure –]. Intracerebral hematoma was evacuated and the aneurysm was obliterated by bipolar coagulation. Postoperatively, she was in vegetative state and transferred to the rehabilitation hospital.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2431_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2431_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..043feceb33c9bc59113cebe86c4c4bb2a3bc8db5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2431_en.txt
@@ -0,0 +1,2 @@
+A 42-year-old right-handed woman suffered from weekly repetitions of unconscious dancing for 5 years, despite of multiple antiepileptic drugs including levetiracetam 3000 mg/d, valproate 900 mg/d, and pregabalin 300 mg/d. She was admitted to the epilepsy monitoring unit of a tertiary referral center for the feasibility of epilepsy surgery. On the initial clinical examination, she had no other symptoms or signs. The routine laboratory tests were negative. Magnetic resonance imaging showed right hippocampal atrophy . Her habitual seizure was recorded during video-electroencephalography monitoring. The seizure began with the right hand automatism and ictal speech, which suggest that the ictal onset zone would be on the right side. An evolution of rhythmic delta activity was observed in the right temporal area beginning 16 s after the automatism (see Additional file 1: Video S1). As the ictal discharge spreads to the left temporal area, which means the secondary generalization, the ictal speech disappeared. After 20 s from the secondary generalization, she had rhythmical movement of her legs, similar to stepping through a dance, and the simultaneous video-electroencephalography showed regional slow waves over both of her frontal areas. When the ictal rhythm has switched to the left side, the left upper limb automatism and immobility of the right upper limb represented the rhythmic theta activity, which is still seen in the left temporal area. Taken together, we could identify the kicking and stepping like a dance as well as shaking left arm. According to her husband, the movement would have involved twirling dance, making a right turn when she was standing. However, it was not shown on the video. The dancing lasted even after the rhythmic discharge, which definitized the post-ictal dancing. We surmise that the “dancing” movement might be derived from some combination of automatism consisted of complex, rhythmic, and sequencial movement. She was completely amnestic with respect to the episode. Her ictal speech and the ictal electroencephalography imply that the right hippocampus atrophy should be the epileptogenic focus. There has been only one seizure for 3 months since a stereotactic gamma knife surgery applied to the atrophic right hippocampus.
+The authors declare that they adhered to CARE guidelines/methodology.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2438_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2438_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..670ddee27c82c196a0ed8c024e3313eb132f9fa2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2438_en.txt
@@ -0,0 +1,11 @@
+A 52-year-old woman was admitted to hospital for evaluation of intermittent abdominal tenderness, dry eye, and dry mouth. The dry eye and dry mouth had been present for several years; however, she had not sought medical treatment for these symptoms. She had a history of dilated cardiomyopathy and glaucoma of the left eye. She was being treated with loop diuretics, proton pump inhibitors, and anthocyanosides for glaucoma. In the physical examination, her lower extremities were in an edematous state. Her body temperature was 36.5°C and blood pressure was normal. The results of the laboratory studies were as follows: white blood cell count, 8,600/mm3 (neutrophil 73.4%); sodium, 141 mEq/L; chloride, 108 mEq/L; blood urea nitrogen, 15.7 mg/dL; and creatinine, 0.6 mg/dL. The levels of total serum protein, serum albumin, and total cholesterol were 5.5 g/dL, 1.5 g/dL, and 257 mg/dL, respectively. Urinalysis was remarkable for proteinuria (6.3 g/day), 30–49 red blood cells per high-power field, but no other casts. Serologic investigation revealed the presence of anti-nuclear antibody (ANA; 1:80, homogeneous plus speckled pattern), rheumatoid factor (390 IU/mL), and was positive for autoantibody to the Ro (SS-A) antigen (>200 U/mL). However, serology was negative for antibodies against double-stranded DNA, La (SS-B), Sm, ribonucleoproteins, antineutrophil cytoplasmic antibodies, lupus anticoagulant, IgG/IgM anti-cardiolipin, and IgG β2-glycoprotein-1. The C3 levels had decreased to 38 mg/dL (normal, 90–180 mg/dL), whereas C4 and total hemolytic complement 50 levels were within normal ranges at 16 mg/dL and 33.1 U/mL, respectively (normal ranges, 10–40 and 23–46, respectively). Tests for hepatitis B surface antigen, hepatitis C antibodies, cryoglobulins, and human immunodeficiency virus antibodies were negative.
+Minor salivary gland biopsy was performed, showing diffuse lymphocytic infiltrations with a focus score of 3
+. Moreover, we performed salivary scintigraphy that showed non-visualization in both salivary glands, consistent with the class 4 Schall grading system
+. Therefore, she was diagnosed with Sjögren’s syndrome based on the dry eyes, dry mouth, positive ANA, anti-Ro (SS-A) antibody, salivary gland biopsy, and salivary scintigraphy, which fulfilled the 2002 American-European consensus classification criteria
+.
+She underwent a percutaneous renal biopsy due to nephrotic syndrome. Glomerular basement membrane thickening and mesangial matrix widening were observed by light microscopy (Figure
+A). In addition, mild tubular atrophy and moderate interstitial fibrosis was noted. Weakly positive staining for IgG, IgA, IgM, and C3 on the outer surface of capillary walls was revealed by immunofluorescent staining. Diffuse subepithelial electron-dense deposit was observed by electron microscopy (Figure
+B). The histopathological findings were consistent with membranous glomerulonephritis
+.
+Abdominal computed tomography (CT) and colonoscopy were performed due to intermittent abdominal tenderness; however, we did not observe any malignancy or bowel perforation at admission except for enteritis and multiple small lymphadenopathies in the mesentery. She had sudden onset of severe abdominal pain 3 months later, and abdominal CT was performed again. Newly developed pneumoperitoneum with peritonitis accompanied by small bowel perforation was observed. An emergency operation and small bowel biopsy were performed. The specimen was 9.5 cm in axial length and had a necrotic and ulcerous (4.5 × 5 cm) lesion. On immunohistochemical examination, we found expression of CD20, CD79a, and BCL-2, but not of CD3, CD10, and BCL-6. The proliferation fraction as determined by Ki-67 was 50%–60%. The majority of tumor cells were positive for EBV by in situ hybridization. Biopsy revealed EBV-positive DLBCL (Ann Harbor classification stage III), as demonstrated in Figure
+. The patient declined treatment with chemotherapy because of poor performance status, low compliance, and poverty. However, she had been receiving intermittent low-dose oral corticosteroid and hydroxychloroquine to treat her primary Sjögren’s syndrome since the diagnosis. There was improvement in proteinuria (1.79 g/day) and sicca symptoms after 1 year of follow-up. One year of follow-up positron emission tomography-CT scan showed a stable disease state for the malignant lymphoma.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2457_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2457_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b62c365335455a2128090c21d9e56525fd187197
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2457_en.txt
@@ -0,0 +1 @@
+A 34-year-old man presented to the outpatient department with a 6-month history of neck pain and bilateral upper limb radiation. His neck pain had increased progressively. At the time of presentation, his neck pain visual analog scale (VAS) score was 7/10, and his neck disability index (NDI) score was 30. He had received non-steroidal anti-inflammatories for more than 6 months and an epidural injection elsewhere with minimal relief from symptoms. On physical examination, power in all limbs was 5/5 as per the medical research council grading, and deep tendon reflexes were normal, too. The past, personal, addiction, or familial history was not significant. The magnetic resonance images showed a single fluid-containing lesion with a hyperintense zone at the C5–6 levels with central disc herniation . After adequate counseling with an explanation of the pros and cons of the procedure and its probable complications, the informed consent of the patient was taken, and the patient was planned for the navigable ablation decompression treatment (L-DISQ) procedure.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2475_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2475_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7201c0f4b2fd5d6fc4bf70cedf333bcd077d9747
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2475_en.txt
@@ -0,0 +1,4 @@
+A 69-year-old male presented to his primary-care physician in March 2019 due to progressive dysphagia during a period of approximately one year. He was previously healthy, except for urolithiasis and benign prostatic hyperplasia. A barium swallow study was performed and showed a stricture at the distal esophagus. Further investigation with an upper-gastrointestinal (GI) endoscopy revealed a tumor at the distal esophagus and biopsies confirmed poorly differentiated adenocarcinoma. The patient was referred to our unit, Department of Upper Abdominal Surgery, Karolinska University Hospital, Stockholm, Sweden, which is a tertiary referral center for upper-GI malignancies. Subsequent computed tomography (CT) and fluorodeoxyglucose - positron emission tomography (FDG-PET) were performed. The case was thereafter discussed at our upper-GI multidisciplinary team meeting. The disease was classified as a 6 cm Siewert type-II tumor at the GEJ, with a clinical stage of T3-4a, N1 (due to a 15 mm lymph node alongside the lesser curvature of the stomach), and Mx due to equivocal lesions with elevated FDG-uptake at the ampulla of Vater and at two segments of the small intestine . Further investigation with duodenoscopy did not confirm any lesion at the ampulla of Vater.
+The patient underwent a diagnostic laparoscopy in April 2019, which revealed three suspicious lesions involving a 25 cm-long segment of the proximal jejunum , starting approximately at 25 cm distally to the ligament of Treitz. There was no obvious, macroscopic, serosal invasion of the primary tumor, no signs of peritoneal carcinomatosis or ascites, and the duodenum was found to be normal. Because of risk for leakage by taking jejunal biopsies as well as to avoid future risk for bowel obstruction, the affected segment of the jejunum was resected through a mini laparotomy. The pathologic examination showed three separate, radically resected, poorly differentiated adenocarcinomas (3 × 1 cm, 5,5 × 1,5 cm and 3 × 1 cm, respectively, ). Immunohistochemistry suggested that these tumors were most probably metastases of the primary GEJ tumor. The cytology from the abdominal washout taken during the laparoscopy was negative.
+As the jejunal metastases were radically removed and there were no other indications of disseminated disease, neoadjuvant chemotherapy was decided with the intent for subsequent curative resection of the primary tumor. The patient received four cycles of Docetaxel, Oxaliplatin, Leucovorin and 5-flurouracil (FLOT). The patient tolerated the oncologic treatment well, except for some diarrhea (Grade 1 according to the common terminology for adverse events version 5). A new PET-CT after the completion of chemotherapy showed remarkable tumor response with only weak FDG-uptake in the primary tumor and the previously described regional lymph node. However, a new site of focal FDG-uptake appeared in another part of the small intestine at the left flank. Furthermore, there was also diffuse FDG-uptake in the left colon probably due to chemotherapy-induced colitis. The patient underwent another diagnostic laparoscopy, which did not show any suspicious findings. The anastomosis from the previous jejunum resection appeared as erythematous and fibrotic, corresponding to the suspicious lesion in the PET-CT.
+The patient subsequently underwent a minimally invasive Ivor Lewis esophagectomy with two-field lymphadenectomy and gastric tube interposition in August 2019. There were no complications intraoperatively. shows the surgical specimen. An enhanced recovery program was implemented postoperatively and the patient was discharged on postoperative day 15. The postoperative course was uneventful, until the patient was re-admitted due to paralytic ileus on postoperative day 18, which was treated conservatively with gastrografin. The pathology examination showed complete tumor regression (ypT0N0 with 37 lymph nodes resected) and confirmed an R0 resection. The patient received adjuvant chemotherapy with additional four cycles of (FLOT). One year and four months after the esophagectomy there were no clinical or radiologic findings of tumor recurrence. At seventeen months post esophagectomy, he developed left-sided weakness and mild cognitive impairment. Magnetic resonance imaging revealed a 2,5 cm parietal tumor. There were no other signs of recurrence on CT-scan of the thorax and abdomen. The patient underwent surgical resection of the brain tumor in February 2021. Histopathology confirmed a radically resected metastasis of his previous GEJ cancer. He is now slowly recovering and he is awaiting complementary radiotherapy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2476_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2476_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..924749bd76e28ce88d3bb1690282458de76bcb63
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2476_en.txt
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+A 28-year-old mestizo man with a 3-year history of inflammatory arthritis and dry mouth and eyes was admitted to our hospital. He was admitted to our hospital at the request of an external consultant in January 2008; the initial laboratory evaluation is listed in Table . Methotrexate was initiated with good response; 1 year later methotrexate was changed to leflunomide because of liver toxicity. Globulin levels at admission and 1 year after were 5.2 and 7.2g/dL, respectively. Of interest, although he also had positive anti-double-stranded deoxyribonucleic acid (DNA) and anti-nucleosomes antibodies, which normally have a higher specificity for the diagnosis of SLE, at admission we could not make a diagnosis because of the absence of clinical manifestations other than arthritis and sicca.
+Hyperemia and mild eye pain appeared in March 2009, and a diffuse scleritis was diagnosed. Therefore leflunomide was suspended and he received prednisone (1mg/kg), tapered to 5mg/day in 1 month and suspended after another month because a mouth ulcer appeared.
+Multiple important mucosal bleeding episodes (epistaxis and gingival hemorrhage) started in 2009, and coagulation tests were conducted through 2010, with the following results: prothrombin time, international normalized ratio and activated partial thromboplastin times were normal (11/10.4 seconds; 1.2; 31.1/26.9 seconds, respectively), VWF activity was observed with low ristocetin cofactor (RCo) at 33.6UI/dL, high VWF antigen (VWF:Ag) >200UI/dL, and a low VWF:RCo to VWF:Ag ratio. Furthermore, an Ivy bleeding time test of more than 15 minutes and normal factor VIII activity (70UI/dL) were observed. An in vitro test showed that the patient’s IgG inhibited the VWF:RCo of normal plasma, therefore the RCo activity inhibition test was positive, although this was not necessary for the diagnosis. A characteristic aVWD laboratory test with the identification of a causal underlying disease, integrated the diagnosis .
+The patient was admitted to the ER in April 2011 with a 24-hour evolution of progressive dyspnea, cough, thoracic pain, and palpitations, 104beats/minute, 60/40mmHg, temperature of 38°C, pulse oximetric saturation 88% and 30 breaths/minute. Cold, pale and mottled skin was also observed; laboratory values at ER admission are listed in Table . There were no signs of arthritis or bleeding. Initial crystalloid reanimation was made with partial response, and persistent tachypnea and hypoxemia (arterial oxygen tension/fraction of inspired oxygen = 245.7) precluded a rapid intubation sequence. He was then transferred to the intensive care unit (ICU) 12 hours later. Initial laboratory ER patient data are listed in Table ; Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment values at ICU admission were 11 and 27 points respectively.
+An electrocardiogram showed an incomplete right bundle block not previously detected. A chest X-ray revealed no infiltrates, and complementary laboratory tests did not suggest a related infection. The placement of a pulmonary artery catheter (PAC) was made under the indication of a differentiation between cardiogenic and non-cardiogenic shock (see Table ). The initial patterns showed a precapillary pulmonary hypertension; therefore, in the autoimmune context of the patient, although serial negative antiphospholipid antibodies were noted in his history, acute pulmonary embolism was the first choice for diagnosis. Pulmonary angiography was conducted, and when no clot was discovered, PAH associated with connective tissue disease was considered because pulmonary hypertension has been historically associated with connective tissue diseases.
+These PAC parameters were the same as observed by Condliffe et al. and Murata et al. except for the pulmonary vascular resistance index, which was greater in our patient in comparison to the Condliffe et al. cases (715 versus 1525 dyne·second/(cm5·m2)). Because connective tissue disease may cause PAH because of the vasculature pathology, the difference in more severe resistance may be explained by the changes in the rheological properties (1 poise (P) = 1g·(second·cm)-1 = 1dyne·second/cm2) present in the HVS, where a decrease in the blood flow can explain the resistance increase. Laboratory blood samples hinted about the thickness of blood, so viscosity was measured and found to be 65.8cP (<1.9cP).
+Lymphadenopathy and organomegaly were ruled out. A bone marrow biopsy did not show clonality of plasma cells. Serum protein electrophoresis confirmed the presence of a massive polyclonal hypergammaglobulinemia, and no paraproteinemia or monoclonal cell population was found from the electrophoretic pattern of the patient’s plasma. Hypergammaglobulinemia was the cause of HVS associated with autoantibodies. Three sessions of plasma exchange therapy were made. Albumin and frozen fresh plasma were used as the expander, and one circulating blood volume was utilized. Significant mental, hemodynamic recovery and clinical outcomes became evident. A negative Q value was observed in the HVS in this patient after taking into account the Starling vascular permeability formula, where the microvasculature is influenced by protein content and transcapillary fluid flux, specifically, where Q is equal to volume of flow across the capillary wall. This finding led to the conclusion that dilution of protein content may alleviate the HVS, and the fluid administration was considered supportive therapy with judicious consideration of the compartment shift of the solutions. His renal function returned to basal state and he was extubated on day 7 of ICU admission. He was then discharged from the ICU and hospital, respectively with good prognosis (Charlson comorbidity index of 0 points).
+The patient now attends external consult without respiratory symptoms. One month after hospital discharge his arthritis returned and methotrexate was resumed with good clinical response. Hydroxychloroquine with steroids were initiated because of persistent elevated anti-double stranded DNA (last value at February 2013, 20.2U/mL), no bleeding sign had been present with persistent positive VWF:Ag values.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2499_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2499_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d6e388be45061eb3f2ec19bc7b52484b8fb7d081
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2499_en.txt
@@ -0,0 +1,4 @@
+A 90-year-old woman visited our hospital due to a large area of erythema and localized skin ulceration with hemorrhage of her right breast. Her breast symptoms arose 5 years ago and had been worsening. She could not visit a hospital because she expected for naturally healing and feared noticing cancer and death. She had a history of atrial fibrillation and cerebral infarction 2 months earlier, then her breast lesion was found out. The area of erythema was 15 × 15 cm2. Her nipple and alveolar complex were destroyed and had an uncertain shape. Her skin erythema was soft, and no tumor was palpable . Her quality of life had got worse by hemorrhage and exudate from the tumor, and she felt strong anxiety about getting more worse and death from the cancer.
+A punch biopsy indicated mammary Paget’s disease. Computed tomography showed that the tumor was only on the surface of the breast, with no metastasis including of the axillar lymph nodes. There was no underlying tumor in the breast .
+Even though our patient was a very elderly woman with comorbidities and her prognosis was relatively good, her symptoms were intolerable. By the request of her and her family, we decided to perform surgery to eliminate the area of erythema after receiving sufficient informed consent. The surgical treatment was performed by two teams that included surgeons and dermatologists. We drew a resection line 1 cm from the skin erythema. Dermatologists were on standby in case a skin graft was needed. We performed muscle-sparing mastectomy with sampling of an axillar lymph node. We added two stress-relaxation sutures to avoid diastasis because the excision area was very large and the tension of the skin flap was strong . Fortunately, a skin graft was not necessary and her postoperative course was good. The skin flap did not develop major complications such as necrosis, seroma, wound infection, and highly disturbance of moving the right upper limb. We removed the stress-relaxation sutures 7 days after surgery.
+A histological examination revealed mammary Paget’s disease without invasion to underlying tissues , no evidence of a residual tumor of the entire stumps, and no metastasis in the lymph node. Although she felt a little tightness of the surgical site, paresthesia of the chest wall, and a sense of breast loss, her quality of life improved after surgery by being freed from symptoms and anxiety related to malignancy. It was a great value for her, even if she suffered from these complications.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2522_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2522_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a3a14d219dd7ec4453b377a8709a48d37ea440e9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2522_en.txt
@@ -0,0 +1,3 @@
+An 82-year-old frail gentleman presented to our center with a nine-day history of abdominal distension, constipation, localized periumbilical pain, intermittent, nonradiating, and multiple episodes of nonprojectile, nonbilious vomiting containing food particles. He denied fever, jaundice, hematochezia/melena, urine or urine discolored, or trauma to the abdomen before the onset of the symptom. The medical history was significant for hypertension since 15 years, cholelithiasis diagnosed eight years ago, and recently diagnosed bronchiectasis, managed with low flow oxygen therapy.
+On examination, his vital parameters were within normal limits, abdomen distended, nontender with exaggerated bowel sounds. Initial investigations showed normal hematologic and biochemical parameters. Abdominal ultrasound revealed a contracted gallbladder with distended bowel loops. Computed tomography of the abdomen and pelvis revealed dilated small intestine loops with hyperdense intramural calculi with air in the biliary tree, suggestive of gallstone ileus with cholecystoduodenal fistula .
+Initial management consisted of fluid resuscitation, insertion of a nasogastric tube, analgesia, and nil by mouth. A Foley catheter was inserted and strict urine output charts were maintained. An exploratory laparotomy with a lower midline incision was performed and an enterolithotomy was performed within 24 h under spinal anesthesia, given the chest morbidity . Peroperatively, a single 4.5 × 2 cm gallstone was impacted in the terminal ileum, 10 cm proximal to the ileocaecal junction. The ileum at the impaction site was healthy while dilated proximally. Incidentally, a Meckel's diverticulum, 60 cm proximal to the ileocaecal junction with a wide base was also detected. A longitudinal enterotomy proximal to stone impaction allowed milking of the stone out proximally. The enterotomy was repaired transversely. The impacted gallstone causing ileus is shown in . The cholecystoduodenal fistula was left undisturbed due to the significant risk of duodenal injury. Postoperative recovery was uneventful and the patient was discharged home on postoperative day six. The patient remained asymptomatic and disease-free for 16 months of follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_254_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_254_en.txt
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index 0000000000000000000000000000000000000000..ae023139dad144c987fe5012fcfb010be7a3c8b0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_254_en.txt
@@ -0,0 +1 @@
+An 84-year-old woman was diagnosed with a simple liver cyst during a medical checkup. One year later, she was referred to our hospital for the evaluation of an enlarging distinct mural nodule in the liver cyst. No specific symptoms were present, and physical examinations did not reveal any abnormalities. The blood tests showed normal liver function and were negative for both hepatitis B surface antigen and hepatitis C virus antibody. However, the levels of carcinoembryonic antigen (5.0 ng/mL) and carbohydrate antigen (CA19-9; 43.5 U/mL) were slightly elevated. On contrast-enhanced computed tomography (CT), a well-defined, low-attenuation lesion without a septum was observed. The maximal diameter of the lesion had increased from 41 to 47 mm in one year . No dilation of the bile duct was observed. Enhanced ultrasonography showed an enhanced nodule with a distinct artery into the nodule . A 14 mm mural nodule with gradual enhancement was confirmed. MRI revealed a homogenous water intensity cystic lesion accompanied by a mural nodule, which exhibited peripheral low intensity and central high intensity on heavily T2-weighted image . Positron emission tomography/computed tomography (PET/CT) did not show increased fluorodeoxyglucose activity at the mural nodule . The cystic tumor was considered potentially malignant because the mural nodule was growing in size and had apparent blood flow inside, so we offered the patient two options: surgical resection or careful watching. Finally, she decided to have surgery, and partial liver resection with sufficient margins was performed. We never perform aspiration of intracystic fluid to avoid tumor cell spillage. Macroscopically, the cut surface of the resected specimen displayed a thin-walled liver cyst with a mural nodule and included denatured liquid content. Pathological examination revealed a cystic lesion with a thin whitish fibrous wall, and a black-colored 5-mm nodule was located in the cyst wall over the normal liver tissue. The cyst wall was lined by an inner layer of cytokeratin 19-positive columnar epithelium, and the black-colored nodule was composed of dilated vessels lined with CD31- and CD34-positive endothelial cells . The final diagnosis was cavernous hemangioma in a simple liver cyst. She was discharged on the 9th day after surgery without any complications and was doing well after three months.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2558_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2558_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2428fa0f66d339f9914d6c616bdfca3a0386eda6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2558_en.txt
@@ -0,0 +1,7 @@
+A 21-year-old Iranian man presented to the emergency ward of our hospital with 5 days of illness and a history of right upper quadrant abdominal pain, fatigue, fever, icterus, vomiting, and no appetite. He was examined physically, and abdominal tenderness was detected in all four quadrants, and scleral icterus. His blood pressure was normal at 110.70 mmHg and oxygen saturation rate was of 95% on ambient air. Axillary temperature was 38.8 °C. His medical history showed that was being treated with albendasol 800 mg daily for months because of two hydatid cysts in the liver. One of the cysts was located on the dome of liver segment III and the second was on segment VII just over the right kidney . On the CT scan of the liver, two cysts were observed in segment II and VII with septation, of which one was intact and the other one had ruptured. After 2 weeks on albendazole, fatigue, fever, icterus, and vomiting were present, which was the complication of albendazole since the values for all liver function tests had increased.
+Laboratory findings revealed increased white blood count (WBC; 17,000 K/uL, reference value 4–10.8 K/uL) and elevated liver enzymes (aspartate transaminase [AST] 120 U/L [reference value 11–72 U/L]; alanine transaminase [ALT] 83 IU/L [reference value < 40 IU/L]; alkaline phosphatase [ALP] 1250 IU/L; total bilirubin 9 mg/dL [reference value < 1.2 mg/dL]). The direct and indirect bilirubin measurements were 4 and 5 mg/dL, respectively, C-reactive protein concentration was 11 U/mL (reference value 0–0.5 mg/dL, amylase 320), and lipase was 180 IU/L. A prothrombin time of 42 s (reference value 9.6–14.2 s), activated partial thromboplastin time of 48 s (reference value, 20–38 s), and international normalized ratio of 5 (reference value 0.85–1.2) were also detected in the tests. The remaining laboratory test results were within normal limits. These test results show hepatitis due to albendazole toxicity.
+In addition to considering these test findings and the patient’s ailments, we also used abdominal U/S to arrive at the diagnosis. Abdominal U/S revealed intrahepatic and extrahepatic bile duct dilation; the gallbladder was dilated but had normal wall thickening. Large intact hepatic cysts were observed in segment IV and another one were in segment II with detached laminated membranes, possibly indicative of a ruptured or complicated liver cyst. An intravenous contrast CT scan was performed for more evaluation and revealed unilocular hepatic cysts with segregated laminated membranes that corresponded to hepatic hydatid cysts on segment II and other unilocular intact hepatic cysts on segment IV . Further observations indicated intrahepatic and extrahepatic biliary duct dilation .
+The reason for bile duct dilatation was investigated by MRCP, which showed the rupture of cysts of segment II into the intrahepatic ducts, common hepatic duct, and common biliary duct (CBD). In addition, laminated membranes of the hydatid cyst and daughter cysts were found in the CBD, causing the obstruction .
+The patient underwent laparotomy due peritonitis resulting from the rupture of the liver hydatid cyst in the abdominal cavity with a right extensive subcostal incision. During exploration, 500 cc bile fluid was aspirated from the abdominal cavity and sent for analysis. The pancreas was inflamed, and its appearance showed pancreatitis. The liver was carefully inspected; one collapsed infected cystic lesion with a small perforation was present in segment II just over the right kidney.
+Our approach for surgical treatment began with the aspiration and evacuation of the cyst contents. To explore for any purulent or bile contents, cystostomy and irrigation were performed. Also, fibrotic tissue around the cyst was resected and the site of bile leakage ligated with a non-absorbable suture. Capitonnage, omentoplasty, and insertion of a Foley catheter inside the incision were performed to remove the residual cyst and prevent recurrence. The gall bladder was highly dilated and was full of a white mucous fluid with obstruction of the cystic duct; choledocotomy and drainage of the common bile duct were performed with saline irrigation. Moreover, daughter cysts were removed from the common bile duct and intrabiliary ducts. At the end of the surgery, a T-tube was inserted in the site of choledocotomy and a corrugated drain was fixed. During exploration, another intact cyst was found in segment VII; this cyst was aspirated and the laminated membrane removed; the cavity was then irrigated with betadine 10%. Pricystectomy was performed, and a Foley catheter 18 was put into the remnant cavity and fixed to the abdominal wall. Finally, the CBD (diameter 30 mm) was examined; it was full of laminated membrane, daughter cysts, and debrides of the hydrated cyst. After extraction of all materials from the CBD and subsequent irrigation, a T-tube was placed in the CBD and fixed into place. A Penrose drain was placed in the abdominal cavity, and then the abdomen was closed.
+Three days after surgery, the levels of bilirubin, amylase, lipase, AST, ALT, WBC, and ALP had decreased. The patient’s general condition (fever and appetite) was good, and he was discharged 10-day post-operation with good condition. Trans-T-tube cholangiography was performed 20 days after the operation with good results and was then removed
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2560_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2560_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d5866475d778fa8ece9fd11baf254a12773ec509
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2560_en.txt
@@ -0,0 +1,9 @@
+A 72-year-old Bahraini female known to have type 2 diabetes mellitus, resistant systemic hypertension, hyperlipidaemia, and peripheral artery disease (PAD) with a history of stenting distal abdominal aorta (12 mm × 40 mm S.M.A.R.T control self-expanding stent) and right common iliac artery (7 mm × 17 mm Express LD) in 2014 was referred to our cardiac centre for evaluation of repeated episodes of FPE.
+On arrival, she was in mild dyspnoea and oliguric. Her blood pressure was 182/105 mmHg, and her heart rate was 109 b.p.m. Physical examination has revealed bilateral basal crackle with no audible cardiac murmur and periumbilical, high-pitched bruits. Her electrocardiogram showed QRS voltage criteria for left ventricular hypertrophy, which was confirmed with a transthoracic echocardiogram that revealed concentric left ventricular hypertrophy with Grade II diastolic dysfunction and normal left ventricular size and systolic function with no regional wall motion abnormality. Baseline Creatinine was 225 µmol/L (reference range 44–88 µmol/L) and hence we performed the coronary angiogram with minimal contrast (18 cc only) to rule out underlying coronary artery disease in view of multiple risk factors and troponinaemia, which showed coronary calcifications but no flow-limiting disease in the epicardial coronaries. Since the patient had resistant systemic hypertension with abdominal bruits, non-selective renal angiography was conducted and showed bilateral heavily calcified high-grade ostioproximal RAS. While we were sorting out a strategy for ad hoc intervention for the tight renal arteries she desaturated, her blood pressure raised to 240/130 mmHg, her heart rate increased to 130 b.p.m., and her respiration rate was 26/min with diffuse bilateral fine crackles. Considering acute florid pulmonary oedema and being anuric despite large dose of diuretics, we aborted the procedure and timely inserted the right internal jugular dialysis line and transferred her to the cardiac care unit for urgent haemodialysis.
+The next day, after full stabilization, we brought her back to the Cath lab for renal angioplasty. We decided for the left transradial approach for two reasons: the left radial artery has a shorter distance to the renal arteries than the right radial artery and the angles of the renal arteries off the aorta favour a radial approach than a retrograde femoral access.
+Under local anaesthesia, the left radial artery access was achieved with a 7-Fr sheath. We managed to navigate a 90 cm sheath across an unexpected left subclavian stenosis with balloon dilatation and slide it subsequently across a tortuous descending aorta using NaviCross microcatheter and Terumo Glidewire Advantage, which was exchanged to Hi-Torque supracore guidewire thereafter to land the sheath into the abdominal aorta.
+A 7-Fr multipurpose guide catheter engaged the right renal artery, and a selective renal angiogram confirmed the presence of critical calcified stenosis at the proximal part of the right renal artery .
+The lesion crossed with Hi-Torque BMW 0.014 × 300 cm guidewire. Intravascular ultrasound pullback showed a very high superficial and deep calcium burden in the proximal segment of the right renal artery with a 5.2 cm reference vessel diameter . Considering severe calcifications, we decided to proceed with shockwave lithotripsy using a 4.0 mm × 12 mm, 138 cm shockwave C2 IVL balloon with a total of 80 pulses. Fair expansion of the 4.0 mm IVL balloon at 6 atmospheres was achieved . Now, without further balloon dilation, a 5.0 mm × 18 mm Resolute Onyx stent was deployed at 14 atmospheres with a good final angiographic result .
+The same procedure was applied for the left renal artery after confirmation of tight osteoproximal lesion with selective injection . This time, the IVUS study showed a larger vessel diameter of 7.1 cm with severe semi-circumferential calcium arc that we overcame successfully with 6.0 mm × 60 mm, 110 cm shockwave M5 IVL balloon (10 rounds each of 30 pulses) at 6 atm . Once the lithotripsy treatment is completed, a 7.0 mm × 17 mm Express SD Renal stent was deployed at 10 bar. Final angiography demonstrated an excellent position of the stent and confirmed patency of the left renal artery . The patient tolerated the procedure well and was transferred to the cardiology ward for further monitoring. A few hours later, we noticed a dramatic improvement of blood pressure measurements and urine output. She required one more haemodialysis session to enhance renal recovery and minimize the risk of contrast induced-nephropathy and was successfully discharged to home 48 h post-procedure.
+In the 2-week of follow-up, she was asymptomatic, serum creatinine almost normalized (96 µmol/L, reference range 44–88 µmol/L) with adequate blood pressure control. Three months after discharge, renal function recovered completely and return to normal (Creatinine 81 µmol/L, reference range 44–88 µmol/L) with good blood pressure control on amlodipine 10 mg o.d. only.
+In our institution, there are no standards for routine duplex or imaging follow-up after renal angioplasty unless mandated clinically.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2570_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2570_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5bd999505675d79f402b36cbd3f334bbc7a35ccc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2570_en.txt
@@ -0,0 +1 @@
+The patient was a 70-year-old woman referred to our hospital because of four episodes of hemoptysis within one month. A history of myoma and pulmonary tuberculosis was noted before this admission. After admission, we arranged a series of examinations. No obviously abnormal findings were noted in the patient’s blood tests or sputum culture. Chest radiography revealed opacity of the left upper lung field . Chest multidetector computed tomography angiography (MDCTA) with 3-D volume rendering imaging demonstrated focal bronchiectasis and a 2.4 cm long serpentine hypervascular lesion in the lingula of the left lung abutting the pericardial region . Angiography revealed that the main supplying vessels of the hypervascular lesion arose from the inferior phrenic artery . The aberrant arterioles communicated with the inferior branch of the left pulmonary artery. Transcatheter arterial embolization (TAE) was attempted but failed because of the tortuosity of the vessels. Preoperative simulation with 3-D image reconstruction revealed the aberrant vessels and their associated anatomy. The patient underwent single-port video-assisted thoracoscopic surgery with segmentectomy of the lingula. Intraoperatively, the feeding artery of the serpentine hypervascular lesion was ligated and lingual segmentectomy was performed . Histopathology of the resected specimens showed proliferative tortuous arterioles and vessels surrounded by lymphocytic aggregations. The patient was discharged on postoperative day 10 after an uncomplicated course. There was no hemoptysis with 2-year follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2597_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2597_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f91f6b07177c5431c0453a28e2b23d3eb45a6789
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2597_en.txt
@@ -0,0 +1,9 @@
+A 78-year-old male patient was admitted to the hospital following a 1-month history of unexplained fever, thrill, weight-loss and general malaise, and a 1-week complaint of pollakiuria.
+Twelve years prior to this episode, the patient was diagnosed with a non-muscle-invasive bladder carcinoma that was treated by transurethral resection followed by BCG instillations (Oncotice, Merck, USA). These instillations were repeated after 7, 8 and 11 years due to oncological relapse. The last BCG instillation was administered 5 months before admission.
+The medical history of the patient further included hypertension, and atrial fibrillation for which he received anti-vitamin K therapy. He was in remission of a prostate cancer for which he had received radiotherapy and anti-androgen therapy 4 years earlier.
+On admission, clinical examination was unremarkable. Laboratory workup revealed inflammation (CRP elevated at 5.7 mg/dL), hematuria and leucocyturia. Urine culture was positive for Escherichia coli and cefuroxime antibiotherapy was initiated according to the drug susceptibility profile.
+As fever was persisting 72 h after initiation of antibiotic therapy, a urinary tract ultrasound (US) was performed in order to exclude an obstacle or an abcess. US revealed a large abdominal aortic aneurysm, which was subsequently confirmed by computed tomography (CT). The size of the aneurysm was measured at 7 × 7 × 7.3 cm and located in the infra-renal region . This image was not present on a CT performed 3 years earlier. Antibiotic therapy was stopped and blood cultures were collected.
+Four days after admission, the patient fell during the night. A second abdominal CT revealed a large retroperitoneal hematoma but no sign of rupture was observed. After multi-disciplinary discussion, the patient underwent surgery. Perioperative samples were sent to the bacteriology laboratory for conventional and mycobacterial cultures.
+Direct smear of the aneurysm was positive for acid-fast bacilli. Direct PCR was not performed, as current Belgian guidelines do not recommend to perform this test on non-pulmonary samples. Both liquid cultures (MGIT, Becton–Dickinson, Baltimore, MD, USA) and solid cultures (Löwenstein-Jensen media, Beckton Dickison, Baltimore, MD, USA) were positive. Following internal procedures and the manufacturer’s instructions, rapid identification of the positive mycobacterial culture was performed using the BD MGIT TBc Identification Test© (Beckton Dickinson Diagnostic, USA), an immunochromatographic assay based on the detection of the Mycobacterium tuberculosis MPB 64 antigen. The result was negative for Mycobacterium tuberculosis complex. After review of the medical record, BCGosis was suspected, and the PCR-based Xpert MTB/Rif assay (Cepheid, USA) was performed on the positive culture and gave a positive result for M. tuberculosis complex. M.bovis BCG identification was later confirmed by the Belgian national reference center which performed a second PCR targeting CSB and RD1 .
+Management of M. bovis mycotic aneurysms include both surgical replacement with an aortic graft material and 9–12 months antimycobacterial therapy including isoniazid, rifampicine and ethambutol . Pyrazinamide is not used due to intrinsic resistance of M. bovis to this drug. Antimycobacterial therapy decreases the risk of relapse following surgery .
+As a result, anti-tuberculosis therapy with rifampicine, ethambutol, isoniazide and pyrazinamide was started in our patient. Pyrazinamide was discontinued upon definitive identification of BCG. After 2 months, ethambutol was discontinued and rifampicin and isoniazide were pursued for additional 7 months. The patient showed no signs of relapse after two-years of follow up. The clinical examination and the CT were normal at that time.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2614_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2614_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..47940630304f9e955e4f0e54ce0a666096e760a1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2614_en.txt
@@ -0,0 +1,8 @@
+A 70-year-old Greek-Caucasian man was admitted to our hospital with diffuse abdominal pain of sudden onset three hours prior to his admission. The patient did not complain of nausea, vomiting or diarrhea and his temperature and arterial pressure were normal despite an elevated pulse rate (90 ppm.). His latest stool passage was blood-free and a digital rectal examination revealed nothing pathological.
+During physical examination, the patient's abdomen was mildly distended with diffuse guarding and marked rebound tenderness. Abdominal sounds were diminished during auscultation.
+Laboratory investigations revealed normal values for his hematocrit, hemoglobin, white blood cell count, and platelets. Renal and hepatic function tests were also normal and his blood glucose was a little elevated at 167.8 mg/dl (normal 70 to 110 mg/dl).
+The patient's medical history included colonic diverticular disease, an endoscopic excision of benign rectal polyps four years prior to his presentation, and ongoing arterial hypertension and osteoporosis treatment. Ten years prior to presentation in a random ultrasound examination, the patient was found to have several simple liver cysts including two large hepatic cysts and other smaller ones. The largest cyst had a size of 13 cm. At the time, his pancreas, spleen and kidneys were normal . A second ultrasound examination was performed nine years after the first one (and just 13 months prior to his present admission) due to the patient being admitted after an accidental fall. A reduction in the size of the largest cyst form 13 cm to 4.6 cm and a small amount of free liquid in the patient's right abdominal fossa were identified as the only difference from the previous ultrasound report.
+During the patient's present admission, there was no free air in his abdomen. An abdominal X-ray examination did not show bowel air-fluid levels. Abdominal ultrasound examination showed a significant quantity of free liquid in his abdominal cavity, around the spleen and liver, as well as in the Douglas pouch. Since the patient's general condition was deteriorating and he was already showing symptoms of paleness, sweating, increased abdominal guarding and marked rebound tenderness in the whole abdominal area, we decided to perform an exploratory laparoscopy.
+The laparoscopy revealed a vast amount of opaque-yellowish peritoneal fluid occupying majority of his abdominal cavity without any obvious origin, so the operation was converted to laparotomy.
+The exploration of the patient's abdominal cavity revealed a ruptured liver cyst that originated from the lower surface of his right liver lobe . Unroofing of the cyst using LigaSure to the liver parenchyma margin, plus omentoplasty and cholecystectomy, were performed as the gallbladder was part of the anterior cystic wall. Intraoperative frozen sections of multiple specimens from the cystic wall showed no evidence of malignancy, while cytology and cultures of the cystic fluid were negative. Serological tests for Echinococcus and tumor markers, CEA and CA 19-9, all showed negative results.
+Two drains were positioned, one at the patient's cystic cavity area and the other at his Douglas pouch. The postoperative course of the patient was uneventful and three days later the drainages were removed. The patient was discharged in excellent general condition eight days after his admission.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2629_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2629_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4c3cf8d9309597e9d8596dcc89f87dff7b64670d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2629_en.txt
@@ -0,0 +1,19 @@
+We report the case of a 42 year-old Caucasian male with a history of harmful alcohol consumption (4 standard units a day) and allergic asthma who was evaluated in our emergency department complaining of spontaneous hematomas on the limbs as well as cutaneous and mucosal petechiae. He also reported one episode of self-limiting epistaxis. He denied any blood in his stools or hematuria and was not taking any medication. He had quit smoking 5 years ago (20 pack-year) and currently vapes. Family history was notable for a brother with scleroderma.
+He reported having received his second dose of the COVID-19 (coronavirus disease 2019) vaccine elasomeran one week prior to noticing bruises on his limbs.
+Initial evaluation revealed hematomas on all limbs and petechiae with a hemorrhagic bulla on the inside of his cheeks. No hepatosplenomegaly or adenomegaly was noted either on physical examination or on abdominal ultrasound.
+Laboratory workup revealed normal hemoglobin level and leukocyte count but severe thrombocytopenia with 2 G/l (150–300 G/l). Peripheral blood smear confirmed true thrombocytopenia without any other abnormality. Coagulation profile, renal and liver function tests were all within normal range. Lactate dehydrogenase reached 390 U/l (87–210 U/l). Protein electrophoresis and immunofixation excluded any paraprotein. A nasopharyngeal swab for SARS-CoV-2 was negative and serology showed a response to vaccination without prior exposure to the virus (anti-S positive and anti-N negative).
+Vitamin B12 and B9 levels were low: cyanocobalamin 105 pmol/l (125–574 pmol/l) and folate 4.5 nmol/l (8–60 nmol/l). Normal levels of intrinsic factor excluded pernicious anemia, and after vitamin supplementation, the values normalized within two weeks. Ferritin was slightly elevated at 449 µg/l (11–342 µg/l).
+Hepatitis B, C and HIV were excluded as well as acute Cytomegalovirus, Epstein-Barr virus and Parvovirus B19 infections.
+As a result of this workup, ITP was immediately suspected. We excluded vitamin B12 and folate deficiencies as the cause of thrombocytopenia since there was no anemia or macrocytosis and no improvement after vitamin supplementation. Treatment commenced with oral dexamethasone at 40 mg/day on D2 to D5 in combination with intravenous immunoglobulins (IVIg) at 1 g/kg on D2 and D3, according to the hemorrhagic score (9 points) . Response was considered satisfactory with thrombocyte levels reaching 78 G/l on D5 , allowing patient’s discharge with close ambulatory follow-up.
+Follow-up consultation 3 days after discharge revealed relapse of thrombocytopenia to 2 G/l, requiring a second hospitalization for the same treatment with oral dexamethasone (40 mg/day) from D8 to D11 and IVIg (1 g/kg) on D10 and D13. As this combination now proved ineffective, treatment with romiplostim was initiated at 7 µg/kg/week (= 500 µg/week) on D12, increased to 10 µg/kg/week (= 700 µg/week) as of D19 because no improvement was noticed.
+Immunologic work-up showed a slightly increased level of anti-SSA antibodies (52KDa) at 26 units (normal: < 20 units). In the absence of any clinical manifestation compatible with an underlying auto-immune disease, this result was considered irrelevant.
+Prednisone 1 mg/kg/day for 3 weeks was initiated on D14. These combined treatments increased platelet levels to 45 G/l, allowing patient’s discharge on D19.
+Six days later, during ambulatory follow-up, the patient had again relapsed (thrombocytes = 2 G/l), and was re-admitted to the hospital. He received one dose of IVIg (1 g/kg) upon admission (D25). The treatments with romiplostim and prednisone continued without improving platelet levels, which stagnated below 10 G/l. After 3 weeks prednisone was slowly tapered.
+Given the known association of Helicobacter pylori infection with ITP, we performed a serology which came back positive. The patient received 10 days of an eradication regimen consisting of amoxicilline, clarithromycine, metronidazole and esomeprazole. A negative breath test one month later confirmed eradication.
+Peripheral blood flow cytometry did not show any abnormal lymphocyte population.
+Bone marrow aspirate was compatible with ITP, showing elevated numbers of megakaryocytes without dysplasia and no blasts on the bone marrow smear nor on flow cytometry (see Fig. ). Circulating anti-platelet antibodies against glycoprotein Ia-IIa were detected, demonstrating a humoral auto-immunity in the disease.
+Despite all these treatments, profound thrombocytopenia persisted. A treatment of weekly rituximab for 4 weeks at the dose of 375 mg/m2 (700 mg/week) was started on D34 after a negative interferon-gamma release assay (QuantiFERON). After one month of romiplostim at the maximum dose, we switched on D46 to eltrombopag 75 mg/day.
+On D36, we initiated a treatment with dapsone 100 mg/day, as both a treatment option for ITP and an approved Pneumocystis jirovecii prophylaxis, indicated in the context of drug-induced immunosuppression. In order to offer some bleeding protection, 500 mg of oral tranexamic acid was administered daily, being the minimal effective dose in our patient.
+In the absence of improvement, it was decided to administer vinca alkaloids due to their rapid onset of action. The patient received 2 doses of vincristine, 2 mg each, on D57 and D64. Unfortunately, platelet levels remained at 1 G/l two weeks later.
+Since diverse medical therapies had failed, and the patient remained at high risk for major bleeding, splenectomy was planned. In order to establish a sufficient platelet level for surgery, the patient received another 4 days (D76 to D80) of dexamethasone 40 mg/day and 2 days of IVIg (1 g/kg) on D79 and D80. This induced a rapid rise in platelet levels to 181 G/l. Treatment with eltrombopag was abruptly discontinued.
+The patient underwent laparoscopic splenectomy on D80. Platelet levels then rapidly rose, reaching 1,520 G/l on D87, and progressively normalized. Six months later, the patient’s platelet levels remained in the normal range (302 G/l on D259).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2638_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2638_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8c1517202c839e027e132f7309d2d449bd9d17e8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2638_en.txt
@@ -0,0 +1,6 @@
+A 74-year-old Japanese female presented with worsening dyspnea and was admitted to hospital. A chest X-ray revealed right-sided pleural effusion and cardiac enlargement. Computed tomography (CT) showed a right lung (S10) mass and pleural dissemination . Cytology of the pleural effusion in the right lung was performed, and tumor cells were obtained. The tumor cells had round nuclei, large and distinct nucleoli, and melanin particles in their cytoplasm. We suspected malignant melanoma or clear cell sarcoma . A dermatological examination and gallium scintigraphy were conduced to determine the primary tumor site, but no suspicious lesions, expect the right lung mass, were found .
+After admission, CT showed ground-glass opacities in both lungs, and the patient was diagnosed with complicating bilateral pneumonia and was given an antibiotic drug. It was transiently effective, but the right pleural effusion got worse. About 2 weeks later, the patient died of respiratory failure and cardiac arrest. An autopsy was performed to determine the histological diagnosis.
+A 26x15x20-mm black and pale yellow mass was found in the right lower lobe. Many disseminated nodules were found in the right lobe . The tumor had invaded the right diaphragm. A subcarinal lymph node metastasis (45x21x15 mm in size) was also detected. Pale blood-colored, massive right-sided pleural effusion (1850 ml) was noted, which was indicative of pleuritis carcinomatosa.
+Histologically, the tumor cells had large nuclei with high nuclear/cytoplasmic ratios, large and distinct nucleoli, and melanin particles in their cytoplasm. The tumor exhibited intraepithelial spread into a bronchus . No primary tumor was found, expect in the right lower lobe. We performed immunohistochemical staining using an HMB45 antibody and antibodies against S-100 and c-kit. The tumor cells exhibited positivity for S-100 and HMB45 staining , but were negative for c-kit. The patient was diagnosed with malignant melanoma.
+We determined the tumor’s proto-oncogene B-Raf (BRAF) and NRAS mutational status using Sanger sequencing. Primers were designed to amplify BRAF exon 15, NRAS exon 2, and NRAS exon 3 . As a result, we detected an NRAS mutation (D54N) . We also determined the KIT mutational status using Sanger sequencing. We sequenced KIT exon 8, 9, 11, 13, 17 and 18, but no KIT gene mutation was detected.
+Apart from malignant melanoma, foamy macrophages exuded into the alveolar spaces of the bilateral lobes, and sputum had plugged the bronchi. Neutrophils had infiltrated into some alveoli and bronchi. We diagnosed the patient with lipoid pneumonia.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2641_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2641_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a2acf715a05b5feaddaa655d3aef9f1ae67b2381
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2641_en.txt
@@ -0,0 +1,3 @@
+We hereby present the case of a 72-year-old woman with an extended cSCC of the leg with tibial infiltration, developed on a chronic ulcer that developed on top of NL, without diabetes mellitus . Eighteen years before, the patient had developed the same condition on the contralateral leg and a below the knee amputation had been performed. After biopsy for confirmation and staging including whole body CT scan and regional lymph node sonography, the tumor board recommended the curative resection of the localized tumor. A curative en bloc resection of the tumor together with the soft tissue and 15 cm of involved tibia was performed . A polymethyl methacrylate (PMMA) spacer was used to bridge the tibia and an external fixator stabilized the leg . The wound was temporarily closed using negative wound pressure therapy (NPWT). The histopathological findings showed macroscopically a 165 × 152-mm large tumor, microscopically with 22-mm invasion of the fatty tissue and 10-mm invasion of the tibia, with a at least 18-mm tumor-free margin on the surface and at least 5 mm deep (pT4a, pNx, L0, V0, Pn0, G2, R0) . After achieving the R0 resection, a reconstruction plan was developed. Digital subtraction angiography was performed, showing a three-vessel supply of the leg. Being the only leg in an otherwise healthy patient who was mobile with a leg prosthesis on the right side, the indication for limb preservation was established. Seven days after the first surgery, the reconstructive surgery took place. The PMMA spacer was removed and a proximal pedicled fibular bone flap was harvested. The bone length was 18 cm. The bone ends were then beveled to fit the tibial medullary cavity and the fibula was then press-fitted in the tibia, reconstructing the 15-cm bone gap with 1.5 cm of fibula lying proximally and distally in the tibia . Two centimeters of proximal fibula was resected to ensure a tension-free pedicle positioning. A plate and screw osteosynthesis was performed, bridging the fibula graft, but fixating the beveled edges to the tibia. The external fixator was now removed. The muscles of the anterior and lateral compartment remained supplied by the anterior tibial vascular pedicle. The remaining soft tissue defect of 26 × 20 cm was measured and a template was transferred to the right thigh, centered on the descending branch of the lateral circumflex femoral artery. An extended ALT fasciocutaneous flap measuring 26 × 14 cm including two perforator vessels was harvested. The vessel anastomosis at the recipient site was performed to the anterior tibial artery as a flow-through flap and to the venae commitantes using vessel couplers . The medially exposed gastrocnemius muscle was split skin grafted . The donor site was also split skin grafted from the contralateral side. Postoperatively antibiotic treatment was initiated. The distal part of the flap (8 × 4 cm) showed a demarcation due to inadequate perfusion . At revision surgery, after flap debridement, pus emptied from the plate surroundings. A thorough debridement with lavage of the site was performed. NPWT was used for one cycle to control the infection. Bacteroides fragilis could be isolated and the antibiotics were adapted to the antibiogram. At the next surgery, further debridement and lavage with the exchange of the plate and screws was performed. The remaining soft tissue defect was covered with a second ALT flap measuring 16 × 7 cm from the left thigh, including the fresh split skin donor sites, using two perforator vessels . The flap anastomosis was performed end-to-side to the posterior tibial vessels, distal to the first anastomosis. The donor site was closed primarily. Postoperatively, all wounds showed primary healing. The antibiotics were administered for a total of 6 weeks starting from the last surgery. After 4 weeks, mobilization with partial weight-bearing of the leg was initiated. Twelve weeks postoperatively, ambulation using a wheeled walker was started.
+One year postoperatively, the CT scan showed insufficient bony consolidation at the proximal and distal tibia-fibula transition despite exogenic ultrasound therapy, so a revisional surgery was performed. The extended ALT flap was longitudinally split to provide access to the plate while avoiding the lesion of the vascular pedicle. Two osteosynthesis plates were used to stabilize the leg medially and laterally and to ensure bone consolidation. Autologous cancellous bone was applied at the transition between the fibula and tibia proximally and distally. Postoperatively, the wounds healed without issues. After 6 weeks, mobilization of the leg was started using a fitted boot with pressure distribution to the tibial tuberosity and the foot. After 3 months postoperatively, the exogenic ultrasound therapy was continued for another 3 months. The pressure distribution was progressively switched from the tibial tuberosity to the foot.
+Two years after the beginning of treatment, the boot was completely removed. The patient was mobile on the reconstructed leg and below-the-knee prosthesis on the contralateral side . The extension of the foot was actively possible (Video 1). The X-rays and CT-scan showed a fibular hypertrophy of about 90% of the tibia as well as no local recurrence of the tumor and no metastasis. Considering the age of the patient, R0 resection of the lesion, no lymph node metastasis or other metastasis, no adjuvant therapy was performed.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2652_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2652_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1f04afc451721671c08b6934c3343061cc4f7d72
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2652_en.txt
@@ -0,0 +1,3 @@
+A 45-year-old male patient was diagnosed as subarachnoid and intracerebral hemorrhages in the left fronto-parieto-temporal lobes and underwent decompressive craniectomy with coiling of a ruptured aneurysm of the left middle cerebral artery at the neurosurgery department of a university hospital. Brain computed tomography showed subfalcine and transtentorial herniations . At three months after onset, he was diagnosed as hydrocephalus and underwent ventriculoperitoneal (VP) shunting via the right parietal approach with cranioplasty. After five months after onset, he was transferred to the rehabilitation department of our university hospital. At that time, the patient exhibited a persistent vegetative state and had a Coma Recovery Scale-Revised (CRS-R) score of 4 (auditory function: 0, visual function: 0, motor function: 1, verbal function: 1, communication: 0, and arousal: 2) [, ]. Moreover, brain magnetic resonance images showed leukomalactic lesions in the left fronto-parieto-temporal lobes . At five months after onset, he began comprehensive rehabilitative therapy that included drugs for recovery of impaired consciousness (levodopa 750 mg, amantadine 200 mg, bromocriptine 10 mg, zolpidem 10 mg, and baclofen 75 mg), physical therapy, occupational therapy, and rTMS using a MagPro stimulator (Medtronic Functional Diagnostics, Skovlunde, Denmark) . The right dorsolateral prefrontal lobe (Broadmann area 9) was subjected to rTMS at a frequency of 10 Hz with an 80% motor threshold intensity and 160 pulses over an 8-min period twice a day and with seven TMS sessions per week [–]. At seven months after onset (i.e., after 2 months of therapy), the patient recovered to a minimally conscious state (CRS-R score = 13; auditory function: 1, visual function: 3, motor function: 4, verbal function: 1, communication: 2, and arousal: 2). He was then transferred to a local rehabilitation hospital and underwent a reduced level of drug rehabilitation, with no rTMS, until 9 months after onset. His dopaminergic drug treatment was decreased due to aggravated spasticity (levodopa 500 mg, amantadine 150 mg, and bromocriptine 3.75 mg). After two months of such treatment, his CRS-R score (13) was unchanged. At nine months after onset, he was readmitted to our hospital and underwent similar drug treatments (same medications and doses) but also underwent rTMS. At 10 months after onset, although his CRS-R score remained at 13, his higher cognition indicators were improved; for example, he could blink his eyes the correct number of times when he was asked to blink his eyes as many times as the number presented. The patient’s wife provided signed and informed consent for participation in the study, and our institutional review board approved the study protocol.
+DTI scanning was performed four times (at five, seven, nine, and ten months after onset) using a 6-channel head coil on a 1.5 T Philips Gyroscan Intera system (Philips Healthcare, Best, Netherlands) programmed for single-shot, spin-echo, echo-planar imaging. Imaging parameters were as follows: acquisition matrix = 96 × 96; reconstructed to matrix = 192 × 192; field of view = 240 mm × 240 mm; TR = 10,398 ms; TE = 72 ms; parallel imaging reduction factor (SENSE factor) = 2; EPI factor = 59; b = 1000 s/mm2; and slice thickness = 2.5 mm. The Oxford Centre for Functional Magnetic Resonance Imaging of the Brain (FMRIB) software library was used to analyze the DTI data. Eddy current correction was applied to correct for head motion effects and image distortion. FMRIB diffusion software with the routines option (0.5 mm step lengths, 5000 streamline samples, curvature thresholds = 0.2) was used. For examination of the upper ARAS, the seed region of interest (ROI) was the intralaminar thalamic nucleus and the target ROI was the cerebral cortex . Tract volume (TV) was determined for the upper ARAS.
+On the 7-month post-onset DTT, theneural tract of the right prefrontal lobe in the upper ARAS was increased compared to that on the 5-month DTT. However, thesame neural tract was decreased on the 9-month DTT, but it was again increased on the 10-month DTT . Similarly, on the 7-month DTT, the TV of the same neural tract (TV = 6506) was higher than that on the 5-month DTT (TV = 1158). However, the TV of this neural tract was decreased on the 9-month DTT (TV = 4119), but it had again increased on the 10-month DTT (TV = 7195) .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2685_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2685_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..573484f4a164660b6a581ee67ebb374a5e165b98
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2685_en.txt
@@ -0,0 +1,11 @@
+A 30-year-old woman presented with long lasting arthralgia, Raynaud phenomenon, and dyspnoea New York Heart Association (NYHA) Class II. Physical examination at the University Hospital of Brussels revealed cutaneous lesions, a facial butterfly rash and a grade three systolic murmur. Laboratorial investigation revealed an elevated anti-nuclear antibody (ANA) (1:200, normal range ≤1:40 is a negative test, ≥1:160 is a positive test), in the absence of SLE-specific antibodies, reduction of complement factors C3 and C4 (48 mg/dL, normal range 93–177 mg/dL and 6 mg/dl, normal range 14–38 mg/dL, respectively) and severe renal dysfunction (CKD Stage 4, a creatinine of 2.4 mg/dL, normal range 0.4–1.2 mg/dL or an estimated glomerular filtration rate (eGFR) of 24 mL/min/1.73 m2, normal range ≥60 mL/min/1.73 m) with proteinuria. Subsequently, a renal biopsy was performed. A lupus nephritis Class II with mesangioproliferative glomerulonephritis was found. In addition, a skin biopsy confirmed cutaneous involvement.
+Transthoracic echocardiography (TTE) demonstrated a slight restrictive mitral valve motion with minimal thickening of the anterior mitral leaflet-compatible with Libman Sacks (LS) endocarditis, moderate regurgitation (effective regurgitant orifice area 0.19 cm2, regurgitant volume 39 mL), normal left atrial dimension (36 mm, 29.3 mL/m2), and moderate systolic pulmonary hypertension (PHT) of 45 mmHg at rest ( and ).
+Subsequent exercise echocardiography revealed an elevation in systolic pulmonary pressures from 39 to 53 mmHg without increased dyspnoea. Mitral valve (MV) gradients went from a peak and mean of 9/4 mmHg to peak and mean of 22/13 mmHg with a calculated mitral valve area (MVA) of 2.0 cm2. Three-dimensional echocardiography confirmed the severity of the stenotic orifice with a MVA of 3.0 cm2 (see ).
+Immunosuppressive therapy, with cyclophosphamide 500 mg intravenous every 2 weeks and methylprednisolone 64 mg daily for 1 week and afterwards a subsequent progressively decreasing dose, was started. Cyclophosphamide had to be interrupted after two cycles due to recurrent infections. Methylprednisolone 4 mg once a day (q.d.) was continued with clinical improvement (NYHA Class I) and normalization of systolic pulmonary pressure (24 mmHg) after 6 months. After 1 year azathioprine 100 mg q.d. was added to the treatment.
+The patient was loss to follow-up during a period of 8 years until she presented with complaints of fatigue and progressive exertional dyspnoea NYHA Class III with a grade five systolic murmur and a facial butterfly rash upon clinical examination. Anti-nuclear antibody increased up to 1:1520 with anti-double stranded DNA (anti-dsDNA) 1:20 (normal range ≤1:10 is a negative test). Furthermore, NT-pro-BNP was significantly elevated (10 066 ng/L, normal range 300–450 ng/L). Cardiac re-evaluation with TTE ( and ) demonstrated a more restrictive mitral valve motion with increased and nodular thickening of the anterior leaflet, reduced mitral valve opening with severe mitral valve stenosis (mean gradient of 6.1 mmHg and MVA 1.0 cm2) [0.7 cm2 on three dimensional echo (see )], stable moderate mitral regurgitation, severe left atrial dilatation (48 mm, 59 mL/m2), a normal pericardium and moderate systolic PHT of 40 mmHg at rest. On apical four-chamber view (see ) a ball-like density due to the nodular thickening of the anterior leaflet is appreciated.
+A subsequent exercise echocardiography permitted us to confirm the severity of the disease since gradients are also flow dependent. At 100 W a significant increase of mean MV gradients from 6.1 to 34 mmHg with an increase of systolic PHT from 40 to 67 mmHg and development of severe dyspnoea were appreciated .
+A coronary angiogram with right heart catheterization showed normal coronary arteries and confirmed the moderate PHT of 40 mmHg.
+Methylprednisolone 32 mg twice a day (b.i.d) and cyclophosphamide 500 mg intravenous, every 2 weeks for 3 months, were started in combination with hydroxychloroquine 200 mg b.i.d, bumetadine 2.5 mg q.d, and lisinopril 2.5 mg q.d.
+Subsequently, a mitral valve replacement was performed by a minimally invasive port-access cardiac surgery (mechanical mitral valve St Jude Medical 31 mm). Histopathology of the valve showed fibrosis, neovascularization, inflammatory cell infiltration (plasma cells), and calcification, consistent with valvular involvement of SLE (LS endocarditis) .
+Echocardiography after surgery showed a non-dilatated, normotrophic left ventricle with normal systolic function, mild left atrial dilatation (43 mL/m2), well-functioning mitral valve prosthesis (mean gradient 3.7 mmHg, MVA 1.4–1.5 cm2), and reduced right systolic PHT (23 mmHg).
+One year later, the clinical condition of the patient was significantly improved with a good exercise capacity and stable SLE under methylprednisolone 4 mg q.d, mycophenolate 500 mg three times a day, and hydroxychloroquine 200 mg b.i.d.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2694_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2694_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ff75a5a46f93d1a70bf75c2420ad313b89e86edf
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2694_en.txt
@@ -0,0 +1,9 @@
+A 74-year-old woman, who presented with complaints of repeated upper abdominal pain for 3 days, was admitted to our hospital. She had no relevant past medical history. Abdominal ultrasonography and computed tomography (CT) scan at another hospital revealed a tumor in the pancreatic uncinate process; thus, she was referred to our hospital for a comprehensive examination.
+The results of the laboratory tests were found to be almost normal (the italicized text indicates the test results with abnormal values): white blood cell 9130/μl, total bilirubin 1.0 mg/dl, aspartate aminotransferase 16 U/l, alanine aminotransferase 9 U/l, hemoglobin A1c 6.0%, amylase 76 U/l, C-reactive protein < 0.02 mg/dl, Ca 10.3 mg/dl, soluble interleukin-2 receptor 271.0 U/ml, IgG4 31.5 mg/dl, and antinuclear antibody 160 index. The levels of tumor markers were also normal: carcinoembryonic antigen 3.0 ng/mL, carbohydrate antigen 19-9 11.0 U/ml, DUPAN-2 < 25 U/ml, span-1 8.9 U/ml, and elastase-1 85 ng/dl.
+An abdominal contrast-enhanced dynamic CT scan showed a 60-mm-diameter tumor in the pancreatic uncinate process, accompanied by multiple cysts , and the tumor size tended to increase over time. The gastroduodenal artery was noted to be passing through within the tumor. The pancreatic duct was not enlarged and separated from the tumor. The tumor had a poor contrast effect in the arterial phase and a small contrast effect in the equilibrium phase.
+The gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (MRI) showed a lobulated tumor with mixed high and low signals on T2-weighted imaging . Out-of-phase T1-weighted imaging showed a low-intensity area, which was a fat component. This finding suggested that the tumor was unlikely to be a malignant tumor. However, diffusion-weighted images revealed a high signal lobulated tumor and suggested potential for malignancy . Magnetic resonance cholangiopancreatography revealed a soft tissue tumor close to the pancreatic uncinate process, and it was not continuous with the main pancreatic duct.
+An upper gastrointestinal examination revealed that the gastric angle was pushed to the dorsal side of the stomach by the tumor. Endoscopic ultrasonography (EUS) showed a collective cystic lesion on the ventral side of the pancreatic uncinate process . The main pancreatic duct was negative for intraductal papillary mucinous neoplasm. In addition, given that the tumor was accompanied by a cystic lesion, a fine-needle aspiration was not performed.
+In the positron emission tomography CT scan, there was no significant fluoro-deoxy-glucose accumulation in the soft tissues of the pancreatic uncinate process.
+The tumor in the pancreatic uncinate process was thought to be the possible cause of the upper abdominal pain. Based on the abovementioned findings, we considered that the tumor was a benign vascular malformation, but because the tumor size tended to increase over time, there was a possibility of it being a malignant tumor; thus, we planned on performing a pancreatoduodenectomy (PD).
+After a detailed examination, we performed an elective open laparotomy. During the operation, intraoperative findings revealed that the tumor appeared to be benign and was separate from the pancreatic duct or bile duct. We therefore performed a partial pancreatectomy instead of PD. Since the right gastroduodenal artery and small vein penetrated the tumor, they were ligated and detached. The tumor was excised with a small part of the pancreatic uncinate process, and the mesentery of the transverse colon was also removed. The operation time was 200 min with 75 ml blood loss. The patient’s postoperative course was uneventful, and she was discharged on postoperative day 12.
+Macroscopically, the tumor was a 58 × 46 × 30-mm specimen with a spongioid appearance of the cut surface . Histologically, hematoxylin and eosin staining showed a mixed shape of small veins, small arteries, and capillaries . The pancreatic tissue was recognized within the tumor, suggesting that the tumor originated from the pancreas. There was no lesion with suspected malignancy. We performed immunostaining for CD31, CD34, Factor VIII, and D2-40, which revealed the following in general: CD31 was positive for vascular endothelium and histiocyte; CD34 and Factor VIII were positive for vascular endothelium; and D2-40 was positive for lymphatic endothelium. In the Elastica van Gieson staining, most vessels of the tumor had no muscular layer. These vessels were capillary blood vessels (CD31, CD34, and Factor VIII were positive, and D2-40 was negative) and lymphatic vessels (CD31 and D2-40 were positive; CD34 and Factor VIII were negative). Based on both histological appearance and immunostaining findings, we diagnosed the tumor as a capillary lymphatic malformation (CLM) according to the International Society for the Study of Vascular Anomalies (ISSVA) classification.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2703_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2703_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b0e7314e9057fbd13c7f51a623636646f54d0d53
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2703_en.txt
@@ -0,0 +1,2 @@
+A 7-month-old girl was referred to the pediatric clinic with developmental delay and failure to thrive. Her family history and antenatal course were unremarkable. At presentation, she was noted to have central hypotonia, hyporeflexia, and dysmorphic features including high arched palate, narrow palpebral fissures and inverted nips. There were prominent fat pads on her supragluteal regions and global developmental delay. At admission, her respiratory and myocardial functions were deteriorated and there was an escalating pericardial effusion and we had to perform pericardiocentesis for two times and as it did not resolve, a pericardial window had to be opened in order to drain the effusion and a pericardial biopsy was also performed.
+The pericardial effusion was sero-sanguinolent and the biopsy revealed mild inflammation and fibrous thickening of peritoneum. Investigations for a metabolic etiology at this time confirmed normal levels of urine amino acids and organic acids. Blood measurements including levels of plasma amino acids, biotinidase, ammonia, vitamin B12 and lactate were all normal. There was no documented episode of hypoglycemia, presence of urinary ketones and/or metabolic acidosis. TORCH panel involving testing for antibodies to Toxoplasma gondii, rubella, cytomegalovirus and herpes simplex virus was negative. Abdominal ultrasound revealed hyperechogenicity of the renal parenchyma. Magnetic resonance imaging of brain revealed a cerebellar vermis hypoplasia and a generalized reduction in myelination . The child was felt to have a phenotype classic of the CDG-Ia. Isoelectric focusing of transferrin showed a pattern consistent with CDG-Ia. Genetic analysis revealed that she was homozygote c.[385G>A]+[385G>A] for pathogenic mutation in phosphomannomutase 2 (PMM2) gene, consistent with a diagnosis of CDG-Ia. In 14th month of follow-up, the pericardial effusion did not recur; the general condition is good with normal heart functions.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2713_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2713_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..78722b967972f43b7d3271d41dab938ddf5f04b4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2713_en.txt
@@ -0,0 +1,3 @@
+A 24-year-old man from Gondar town, North-West Ethiopia, presented to our medical out-patient clinic, University of Gondar Hospital in first week of June 2017. He presented with the chief complaint of recurrent episodes of nasal congestion with itching and paranasal discomfort, and productive cough for more than a decade. He had repeated clinic visits since then, and had been treated as having chronic sinusitis and recurrent pneumonia. He noticed frequent exacerbation of cough with copious purulent sputum in the last 3 years. He was treated for pulmonary tuberculosis 7 years back as smear-negative pulmonary tuberculosis, but there was no significant clinical improvement after completion of 6 months’ anti-tuberculosis therapy. He was seen by an ear, nose, and throat (ENT) specialist 3 months back and was told he had chronic sinusitis and nasal polyp, and was treated with antibiotics and intranasal steroid. He was a casual alcohol consumer, but never smoked cigarettes. There was no similar illness in his family.
+On physical examination, he was nourished, conscious, and oriented. His blood pressure (BP) was 100/70 mmHg, pulse rate (PR) 90 beats per minute, respiratory rate (RR) 20 breaths per minute, and temperature (T°) 37.5 °C. His arterial oxygen saturation (SaO2) was 93% with room air. He had hyperemic conjunctivae. He had a deviated left nasal septum with 1 × 2 cm-sized nasal polyp, and hypertrophied inferior turbinate. There was no lymphadenopathy in accessible sites. A respiratory system examination revealed coarse crackles and scattered rhonchi on both basal lung fields. On cardiovascular examination, apex beat was felt on right fifth intercostal space along midclavicular line. Heart sounds were best audible on the right side of his chest. An abdominal examination revealed tympanitic note on percussion and no sign of fluid collection. He had grade 2 clubbing of fingers of both hands. A nervous system examination showed no abnormality.
+A laboratory examination revealed hemoglobin 18 gm/dl (normal, 12–18 gm/dl), total leukocyte count 12,500/μl (normal, 4000–11,000/μl; granulocyte 74%, lymphocyte 15%), and platelet count 350,000/μl (normal, 150,000–450,000/μl). Sputum for acid-fast bacilli (AFB) staining (three times) was negative for Mycobacterium tuberculosis. Serum chemistries were normal. A chest X-ray revealed cardiac apex and aortic arch on right side, and fibrotic bands and bronchiectasis on lower field of left lung . A chest computed tomography (CT) scan showed bronchiectatic changes prominent on both lower lung fields . Ultrasound examination of his abdomen showed liver and inferior vena cava on left side, and spleen on right side, suggestive of situs inversus . Then, a diagnosis of KS was made on the basis of clinical presentation and imaging features . He was treated with orally administered antibiotics, mucolytic, and chest physiotherapy. He was symptomatically better with the above therapy, and started on long-term low-dose prophylactic antibiotic. He was then referred to the medical chest clinic of our hospital for follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2722_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2722_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b1e441ad87eab4b25c9a28fe0cdcbb380b264f1d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2722_en.txt
@@ -0,0 +1,2 @@
+A 57-year-old Ashkenazi Jew woman, who aside from iron deficiency anemia was relatively well, with no family or personal history of malignancy, was admitted to our department of general surgery for treatment of her transverse colon tumor. Four months prior, she had begun experiencing periumbilical abdominal pain hematochezia, and she had a 10-kg weight loss. Upon physical examination, no masses were palpated, and there were no other pathologic findings. She underwent a colonoscopy, which revealed a large mass that involved nearly the whole circumference of the colon and seemed to be adjacent to the cecum. Biopsies were taken that failed to demonstrate any colonic pathology. She proceeded to undergo computed tomography (CT) of the chest and abdomen that demonstrated a huge mass that occupied the whole colonic lumen and caused a colocolic intussusception . Considerable mesenteric lymphadenopathy was seen with nodes up to 28 × 21 mm in diameter and was deemed to be evidence of positive tumoral lymph node involvement . No inguinal, pelvic, retroperitoneal, or other lymphadenopathy was seen. Considering the gross endoscopic and CT findings, she was scheduled for surgery. A laparoscopic right extended hemicolectomy was performed, which was uncomplicated, and during which considerable mesocolic lymphadenopathy was seen and widely resected accordingly.
+Pathology of the surgical specimen showed findings consistent with small B cell lymphoproliferative disorders (LPDs) with plasmacytoid differentiation. At this point, though primary lymphoma of the colon was considered in the differential diagnosis, the disease was thought to be part of systemic dissemination of lymphoma. The patient was referred to the hematology clinic for further investigation. A bone marrow biopsy was performed, and the result was normal. The investigation was complemented by positron emission tomography-CT, which showed no other focus of lymphoma. Also, the result of a test for Epstein-Barr virus infection as a possible predisposing factor for lymphoma was negative. These results support the diagnosis of a primary colonic NHL small B-cell LPD with plasmacytoid differentiation, an exceedingly rare disease with only two such reports in the current literature [, ].
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2750_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2750_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..eddb41bde0754febd947a484d1cc48659d97bdb5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2750_en.txt
@@ -0,0 +1,2 @@
+A 51-year-old Chinese man with good past health presented with a 10 day history of reduced vision and a superior visual field defect of the right eye. He denied a history of recent steroid use via any route. His best-corrected visual acuity was 0.5 OD and 1.0 OS. An examination of the fundus showed inferior bullous retinal detachment in his right eye with yellowish fibrinous exudates and retinal pigment epithelial (RPE) changes without retinal break . An examination of the anterior segment and vitreous cavity showed an absence of any inflammatory reaction suggestive of an inflammatory cause such as Vogt-Koyanagi-Harada disease. A B-scan ultrasound confirmed inferior retinal detachment and optical coherence tomography (OCT) showed foveal involvement . Fluorescein angiography (FA) revealed early hyper-fluorescence with diffuse late leakage at the macula and indocyanine green angiography (ICGA) showed dilated choroidal vessels with choroidal hyper-perfusion consistent with CSC . An examination of the fundus of his left eye showed mild RPE changes at the superior macula, with a mild RPE window defect on FA and mildly dilated choroidal vessel on ICGA. The findings in his left eye were consistent with resolved CSC.
+A diagnosis of bullous CSC was made and despite a two-week course of oral acetazolamide (250 mg qid) and observation for three months, the exudative retinal detachment persisted and his right eye vision deteriorated to 0.3. He subsequently underwent half-dose (3 mg/m2) verteporfin PDT with a spot size of 4500 μm to cover the area of dilated choroidal vessels in ICGA. One month after the PDT, his vision improved to 0.8 OD with a reduction in inferior retinal detachment. After three months, there was complete absence of sub-retinal fluid . A B-scan ultrasound and OCT confirmed the resolution of exudative retinal detachment . FA and ICGA showed reduced leakage and choroidal hyperpermeability . He was followed for 38 months, during which there was no recurrence and his final vision was 1.0 OD.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2768_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2768_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f6a7d2f391c358c538351180f80b3da36e07d10d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2768_en.txt
@@ -0,0 +1,4 @@
+A 62-year-old woman was diagnosed of thyroid cancer and received total thyroidectomy with left neck lymph nodes dissection (level II, III, IV, IV, and VI). The patient suffered left unilateral vocal cord immobility after the surgery, and she received type I thyroplasty with vocal cord medialization 1 month after the thyroid and neck dissection surgery as treatment for her phonatory insufficiency. The patient did not receive further chemotherapy or radiation therapy, and no evidence of residual thyroid cancer or recurrence had been noted in her follow ups. There was no complaint of swallowing difficulty and aspiration before and after the neck operations. However, it was 2 years after the last previous operation of thyroplasty that she progressively developed oropharyngeal dysphagia with frequent coughing and aspiration. Physical and neurological examinations were unremarkable. Endoscopy and cervical computed tomography (CT) revealed no structural abnormality. A videotaped barium radiographic study (videoesophagraphy) showed a narrowing segment at the level of the cricopharyngeus muscle with partial dilation of the proximal esophageal segment .
+*A bottle of liquid barium sulfate was diluted with 60 ml of water
+After cricopharyngeal dysfunction was confirmed by barium radiographic study, operation was arranged for the patient in which cricopharyngeal myotomy was done . Immediately after the operation, the dysphagia resolved remarkably. Postoperative videoesophagraphy showed improved cricopharyngeal opening, and there was no sign of the cricopharyngeal narrowing. The patient has remained asymptomatic for 4 years of follow-up, and no adverse side effect of the myotomy has been complained by the patient.
+*A bottle of liquid barium sulfate was diluted with 60 ml of water
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2772_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2772_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..86a4e7738941dc1aefc523faf9da5cdc3959142e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2772_en.txt
@@ -0,0 +1,3 @@
+A 30-year-old woman, a nurse, came to the doctor's clinic complaining of left back pain for seven days in June 2021. The patient had no past illness or urological problems history, The family history for urological problems and routine drug consumption was denied. The vital signs were within normal limits, and the physical examination demonstrated normal results, which were no referred pain, mass, or lesions. The patient underwent routine laboratory tests, including CBC, Kidney Function, Liver Function, Urinalysis, and Urine sedimentation, and showed no abnormal results. Therefore, radiologic imaging was carried out for the diagnosis. The USG abdomen showed a cyst on the left kidney. Based on those data, conservative management was the best option for the patient.
+In July 2021, the patient suddenly felt accompanied by severe pain in the left flank region while carrying her baby. The patient denied any history of strenuous activity and trauma. The patient appeared pale and weak, and her vital sign showed low blood pressure and tachycardia. The laboratory examination results demonstrated anemia and low hematocrit level. The results of a CT-Scan abdomen with contrast showed that there was a hyperdense lesion, a well-defined, regular edge on the left kidney, size ± 7.4 × 7.0 × 7.0 cm, with a calcified component, the lesion appears to compress the left renal pelvis, accompanied by subcapsular fluid collection, density 32 Hounsfield Unit (HU) and gloom in the left fat mesentery reaching the region left lower hemiabdomen . Other findings in the patient included ascites in the pelvic and peri splenic region, bilateral pleural effusion, especially left, hepatomegaly, and thickening of the VU wall. Due to suspicion of spontaneous rupture of the renal cyst, the patient underwent exploration and bleeding control. The exploration results obtained that on the base cyst, there was an active blood vessel that bursts. The operative technique for this condition through cyst excision and nephrorrhaphy was performed by Tarakan Regional Hospital Urologist . Moreover, pathological anatomy analysis demonstrated no malignancy cells found.
+As a comprehensive treatment, ensuring any abnormality in the following days was mandatory. The patient underwent a routine follow-up for perioperative, one-week post-operative, and a month later. The patient's daily routine had no limitations, without any post-operative adverse effects. This case presentation followed SCARE Guideline Checklist 2020 .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2775_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2775_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..19fdb16710bb59c267f54b5c0c73f76cd48b31b1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2775_en.txt
@@ -0,0 +1,2 @@
+Written informed consent was obtained from the parent of the patient who involved in this case.
+The case was a 15-year-old boy, without any known prior illness. He was admitted to the hospital after feeling unwell and dropping to the ground while playing ball, and subsequently died. During the internal autopsy examination in our institution, a cystic structure, with dimensions of 13x6 cm, was observed in the left lobe of the liver. Hydatid cyst was not found in other organs of the body. In a macroscopic examination of the liver, a smooth-bordered cystic structure, with dimensions of 13x5x4.2 cm, was observed . On the sectional surface, a white membranous structure and haemorrhagic fluid were observed. The histomorphological examination of liver sections obtained from the cystic area revealed findings consistent with a hydatid cyst invading the external wall, the cuticular layer, and the germinal layer . In addition, the histomorphological examination of liver sections showed a fresh haemorrhage in areas near the cystic wall and scolices in the hepatic lumina , and the histomorphological examination of pulmonary sections showed scolices observed in pulmonary vessel lumina, thus a non-thrombosis hydatid embolism was diagnosed . No toxic agent was identified in a toxicological analysis. Based on the findings, the cause of death was recorded as a non-thrombotic hydatid embolism.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2784_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2784_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..25dc8b062a6cb86421b880897e67a72ead64d6af
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2784_en.txt
@@ -0,0 +1,9 @@
+A 38-year-old Turkish female patient was hospitalized for macroscopic hematuria persisting for 6 months. In the patient’s medical, family, and psychosocial history, it was found that she had undergone an operation due to multinodular goiter 7 years ago, her parents were healthy and had no history of chronic disease, and she was a housewife with two children. There were no symptoms related to the adrenergic system such as hypertension, palpitation, syncope, or flushing. Urogenital system examination findings were normal.
+In the laboratory tests, the fasting blood sugar was 107 mg/dl, and hemoglobin was slightly elevated at 14.2 g/dl. Microscopic hematuria was observed in the urine analysis. Urinary system ultrasonography showed that both kidney sizes and calyceal system were normal, and a solitary tumoral formation of approximately 5 × 6 cm in size, starting from the bladder dome and extending to the right lateral wall was detected .
+After the detection of the mass in the bladder, cystoscopy was planned under general anesthesia. Cystoscopy confirmed a 5 × 6 cm solitary tumoral lesion starting from the bladder dome and extending to the right lateral wall. A sample was obtained with a transurethral resectoscope for pathological diagnosis. During the resection of the lesion, blood pressure increased to 206/124 mmHg and heart rate increased to 189/minute. After the procedure, the patient’s blood pressure and heart rate were monitored carefully. Her vital signs were stable in the follow-ups. The cardiology clinic suggested an endocrinology consultation, stating that her vital signs were stable and that she might have a paraganglioma.
+Subsequently, an endocrinological evaluation was performed for extra-adrenal pheochromocytoma . A 24-hour urine analysis was performed at the endocrinology consultation. It was determined that metanephrine and normetanephrine levels were elevated to 974 mcg and 1857 mcg, respectively. Hence, the observed mass was in favor of extra-adrenal pheochromocytoma. In the staging tomography performed by the urology clinic, an open operation was decided upon. Therefore, to prevent the recurrence of hypertensive crisis and the development of vascular collapse, it was planned to perform the operation after 3 weeks of treatment with the alpha-blocker doxazosin. The doxazosin starting dose was 2 mg within the 3 weeks, which was increased to 16 mg.
+The resection pathology was reported as cystitis. Mass boundaries and neighborhoods were evaluated with contrast-enhanced computerized tomography (CT). Contrast-enhanced tomography sections revealed a hyperdense lobulated mass lesion with a heterogeneous internal structure starting from the anterior wall of the bladder and extending to the right lateral wall, measuring approximately 66 × 55 mm . There was no evidence of lymphadenopathy.
+After endocrinological evaluation and alpha-blocker treatment, we decided to perform an open partial cystectomy. During the dissection of the mass, blood pressure increased to 216/117 mmHg and heart rate to 223/minute. The mass was excised from the bladder to a tumor-free area of approximately 1 cm . When the excision was completed, blood pressure values decreased to 56/24 mmHg and heart rate to 24/minute. Vital signs stabilized after intravenous hydration and administration of sympathomimetic agents. In the postoperative period, blood pressure values continued to be normal and no surgery-related complications developed. The transurethral catheter was removed on the tenth postoperative day.
+The pathological evaluation of the tumor confirmed the diagnosis of vesical paraganglioma. Chromogranin, synaptophysin, S100, and gata-3 were positive on immunohistochemical staining . There was no evidence of local tumor invasion.
+The first control after the operation was carried out in the first month. On physical examination, the wound site was evaluated and wound healing was considered normal. Her blood pressure was 117/46 mmHg, complete blood count and biochemical values were normal, and there was no pathological finding on the urinary ultrasonography. No additional medication or recommendation was specified in the endocrinological consultation.
+The follow-up of the patient continues at 3-month intervals. It is planned to evaluate the possibility of recurrence and metastasis with contrast-enhanced CT and cystoscopy in the sixth month of the case course.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2787_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2787_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..aa0b863feb56ae0f519414b5f09f11d3050c8313
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2787_en.txt
@@ -0,0 +1,7 @@
+A 40-year-old man, a building worker, presented with acute right-sided body weakness without obvious inducement for 6 days. Weakness of the right limb occurred 16 h prior to admission to the hospital, presenting as inability to lift the right upper limb and inability to stand on the right lower limb.
+There was no history of trauma and neck massage, no surgical history, and no previous infectious symptoms. He did not have diabetes and he was normotensive. The patient was a smoker for 10 years.
+Neurologic examination showed that the patient’s consciousness and speech were normal. Cranial nerve examination was normal. According to the Medical Research Council muscle scale, the right upper proximal limb had muscle power grade 4/5; distal limb, muscle power grade 2/5; right lower limb, muscle power grade 0/5; and contralateral upper and lower limbs, muscle power grade 5/5. Joint position and vibration disappeared in the right lower limb, and position was weakened in the right hand. Deep sensation was normal in the left side of the body. The right ankle reflex was weakened. Pain and temperature sensation were decreased on the left below the level of C3. The patient tested negative for the Kernig sign. These results indicated Brown-Séquard syndrome on the right at the level of C3.
+Laboratory studies, including hematologic, biochemical, and immunologic investigations were normal. Lumbar puncture cerebrospinal fluid was unremarkable.
+There were no obvious abnormalities on head computed tomography (CT) and MRI examinations.
+Sagittal T2-weighted MRI of cervical spine revealed spinal cord swelling with hyperintense lesion at the level of C1–3 . T2 axial scan showed hyperintensity of right spinal cord, consistent with SCI . Further, high-resolution MRI volumetric isotropic turbo spin echo acquisition (HR-MRI VISTA) showed narrowing of the right vertebral artery at the level of C1–3 with eccentric high signal parallel to the narrowed lumen resulting from VAD with intramural hematoma . Therefore, we diagnosed this condition as SCI resulting from VAD.
+The patient underwent anticoagulant (AC) and antiplatelet (AP) therapy for 3 months. MRI reexamination showed a diminished range of abnormal signals of the spinal cord , and HR-MR VISTA sequence revealed lumen recanalization of the right vertebral artery . The patient recovered well and was discharged with a modified Rankin scale score of 1. We advised the patient to keep following up, but he refused.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2801_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2801_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a6f8ab24a3b83df7abc0f9f77aecad5398e0a187
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2801_en.txt
@@ -0,0 +1,4 @@
+A 28 year old male while attempting to slaughter a calf holding its head between his thighs accidentally shot himself with bolt gun to right thigh and sustained Grade II open fracture of distal one third shaft of femur . He had an entry wound measuring 2 cm in length and 1 cm in breadth over anterior aspect of his right thigh .
+The wound was explored and debrided on the day of admission. Wound swab grew Pseudomonas, Proteus and Anaerobes. He was started on intra venous Augmentin. After five days, patient developed fever with chills and rigors. He also had purulent discharge from the wound. Inflammatory markers were raised with C reactive protein of 450. MRI confirmed there was no collection of pus in the posterior compartment of thigh. He underwent another wound exploration and debridement on fifth day of admission. Pus collection was found in the subcutaneous and sub muscular layers of right thigh. The wound was communicating with knee joint through the supra patellar pouch. Knee was washed out under arthroscopic guidance.
+The wound was treated with negative pressure wound therapy. He had a further wound debridement andsecondary wound closure after eleven days of injury and then discharged to home. The limb was immobilized in an above knee cast for four weeks and knee was later mobilized using a knee ranger splint.
+He had three weeks of intravenous Ertepenem based on wound swab culture and sensitivity. At 12 months of follow up the wound healed with no signs of infection. He had full range of knee movements.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2818_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2818_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d7bfa6d8a9426d836582f2455f02edec47793c7f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2818_en.txt
@@ -0,0 +1,5 @@
+A 36-year-old female with history of diabetes and hypertension presented with complaints of pain in the abdomen and fatigue for a duration of one month. She denied history of vomiting, diarrhoea, fever, chills, rashes, haematuria, cough, weight loss, chest pain, and shortness of breath. On examination, vitals were stable. General and systemic examination was also normal.
+Laboratory investigations revealed the total serum calcium of 13.2 mg/dl, with corrected calcium of 14.4 mg/dl and a low intact parathyroid hormone level (IPTH) of 6.8 pg/dl, and serum creatinine of 2.4 mg/dl. She denied to a history of calcium supplements intake. The serum vitamin D3 (125OH) levels are 37.6 ng/ml and vitamin D (25OH) levels are 9.9 ng/ml. The PTHrP levels could not be tested due to unavailability of the test. Work up for multiple myeloma, thyrotoxicosis, and tumor markers were negative. shows the relevant laboratory investigations performed. Ultrasound of the abdomen showed increased echotexture of liver, normal kidney, and no other abnormalities. The patient was treated conservatively for hypercalcemia, hyperuricemia, and renal failure.
+Since hypercalcemia and renal failure persisted even after treatment with intravenous fluids, diuretics, and calcitonin, a whole body flourine-18-fluorodeoxyglucose positron emission tomography computed tomography (18F-FDG PET/CT) was done which showed lesions with increased metabolic activity in the liver, spleen, and left internal iliac, left external iliac, right internal iliac lymph nodes as shown in . Hence, CT—guided percutaneous biopsy of the liver lesions was done which showed necrotizing granulomatous inflammation with no features suggestive of vasculitis as shown in .
+Biopsy stain for fungi, AFB, TB PCR and blood TB QuantiFERON gold test was negative, but angiotensin converting enzyme (ACE) levels were elevated (119 mcl, Normal range: 8−53 mcl).
+The patient was diagnosed with sarcoidosis of liver with necrotizing granulomatous lesions which is a rare variant of sarcoidosis. The patient was started on 1 mg/kg/day prednisolone. After one month follow up the patient was symptomatically better with normal calcium levels (8.6 mg/dl), reduced ACE levels (<50 mcl) and with serum creatinine of 0.9 mg/dl (eGFR- 82 ml/min/1.73m2). Steroids were tapered after one month and presently she is on a regular follow up with minimal dose of steroids.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2819_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2819_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..09fb6f1e63db5534a5d307b863aef7b9c5f0269d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2819_en.txt
@@ -0,0 +1,10 @@
+A female in her late 20s was initially diagnosed with neurofibromatosis type 1 in childhood. There was a known inheritance pattern in the patient’s family, and she carried a pathogenic germline heterozygous NF1-mutation at c.6494 C > G, p.(Ser2165*). Clinically, she presented with café au-lait spots, fold lentiges, and multiple subcutaneous tumors. Besides the classical presentation of neurofibromatosis and menstrual pain attributed to the two uterine leiomyomas, the patient was previously healthy. She had been clinically followed up for NF1 up to the age of 18 years, but these follow-ups had ceased.
+The patient was referred to our hospital for multiple painful subcutaneous tumors, the largest of which was in the inner thigh, measuring up to 4 cm. Surgery was scheduled for the removal of the lesions. During the surgery, while under general anesthesia, she experienced a high systolic blood pressure of up to 200 mmHg and wide-complex tachycardia of up to 150 beats per minute. Skin erythema was also observed. Anesthesia was intensified and the symptoms subsided. Surgery was completed as planned, and 12 tumors were subjected to pathological examination. These were diagnosed as benign conventional neurofibromas according to World Health Organization (WHO) criteria .
+After the surgery, she underwent cardiac MRI, where no structural abnormalities were found. However, there was a large heterogeneous mass, which in the subsequent abdominal MRI was confirmed to be a left adrenal mass measuring 7.4 × 6.3 × 4.4 centimeters. Hormonal testing revealed elevated metanephrine (1.2 nmol/L) and normetanephrine (18.0 nmol/L) levels, raising suspicion of pheochromocytoma. The patient was started on phenoxybenzamine and surgery was scheduled. Preoperative abdominal computed tomography revealed a 6 × 3 × 2.7 cm cystic and solid tumor within the right gluteus minimus muscle. Retrospectively, according to abdominal CT, this tumor had existed already 7 months before, with no growth in this time. Open surgery for the adrenal tumor was commenced, and the left adrenal gland containing the tumor was removed. The tumor was interpreted by a pathologist as a pheochromocytoma according to the WHO criteria .
+Otherwise uneventful post-surgery recovery was hindered by the Covid-19-infection, during which thoracic radiography was performed. This revealed a 1,4 cm diameter left upper lobe tumor, which was confirmed by pulmonary CT. These findings were followed by 68Ga-DOTANOC PET-CT, which showed above-background uptake in both lung (SUVmax 6,2) and gluteal (SUVmax 5,0) tumors. The gluteal tumor was radiologically suspected to be a neurofibroma or malignant peripheral nerve sheath tumor, and core needle biopsy was performed. Core needle biopsy was difficult to interpret, but the pathologist suspected a high-grade sarcoma. The final diagnosis was not obtained from the biopsy. Biopsy findings prompted clinicians to suspect lung metastasis. Subsequently, the gluteal tumor was surgically resected, and a right upper lung lobectomy was performed separately. Postoperative recovery was uneventful, and the patient underwent hysterectomy for histopathologically confirmed leiomyomas. The patient is disease-free after 15 months after diagnosis.
+The cut surface of the adrenal tumor showed a well-circumscribed hemorrhagic tumor. The adrenal tumor is composed of plump epithelioid cells with an abundant eosinophilic cytoplasm and nested “Zellballen” growth pattern. The nuclei showed moderate variation in size, clumped chromatin, and small conspicuous nucleoli. Marked intratumoral hemorrhage was observed. The tumor cells stained positive for chromogranin and synaptophysin and weakly and heterogeneously stained with S100. In addition, occasional S100 positive sustentacular cells were identified, rimming the tumor cell nests .
+The intragluteal tumor was well circumscribed and had a fibrous pseudocapsule. The cut surface revealed a gray-tan tumor with small cystic spaces. Histological examination revealed a predominantly solid tumor with frequent cystic growth. The tumor was composed of partly spindly hyperchromatic mononuclear cells with abundant eosinophilic cytoplasms. Large pleomorphic and multinucleated cells rimmed cystic spaces. Variable numbers of lymphocytes and histiocytic cells were observed intermixed with the tumor cells, and focal aggregates of foam cell histiocytes were also observed at the edge of the tumor. No tumor necrosis was observed. The tumor was completely resected with < 0,1 cm marginal resection margins without the accompanying fascia .
+Tumor cells were strongly and diffusely positive for desmin and patchy positivity for SMA was seen. The core needle biopsy sample showed weak MyoD1 positivity in scattered cells; however, the surgical sample was completely negative for MyoD1 despite repeated staining from another block. This discrepancy may be due to inadequate fixation. The large multinucleated cells palisading around the cystic spaces were strongly and diffusely positive for p53, whereas the cells in the solid areas showed a wild-type expression pattern. CD68 and CD163 showed an abundant population of histiocytic cells intermixed with tumor cells . Ki-67 was low at 5%. Mitotic figures were inconspicuous in 2/50 high-power fields (11,8 mm2) at 40x magnification. All other markers, including S100, pancytokeratin, caldesmon, pancytokeratin AE1/AE3, ALK-1, SMMHC, calponin, MUC4, GFAP, SOX10, Melan A, and HMB45, were negative. H3K27me3 showed normal nuclear expression. Thus, an inflammatory rhabdoid tumor was diagnosed according to WHO criteria .
+The IRMT was subjected to further diagnostic analyses. RNA was extracted from paraffin slides, and a sequencing library was constructed using the Archer FusionPlex Sarcoma v2 and Archer FusionPlex CTL panels. The panels identified both novel and unknown fusions with 63 and 17 predetermined genes, respectively. The final libraries were sequenced using Ion Torrent semiconductor sequencing. The Archer Analysis software was used to interpret the results. No gene fusions were detected.
+Comparative genomic hybridization was performed using the OGT Consortium Cancer + SNP 180k microarray. The relative copy number changes were read using a laser scanner and analyzed using Cytosure Interpret-software (Hg 19). This result showed 30–40% of the cells had a hyperhaploid karyotype, with chromosomes 5, 20, and 22 having a relatively higher copy number corresponding to a normal disomic karyotype .
+The lung tumor was well-circumscribed and histologically composed of nodular aggregates of epithelioid to stellated cells within the basophilic myxoid stroma. Entrapped non-atypical respiratory epithelial cells were frequently observed between the nodules. Occasional intermixed mature adipocytes were also observed. No mature terminally differentiated chondroid component was observed in this case. Immunohistochemical findings showed that the stellate cells were strongly and diffusely S100-positive, supporting their chondroid background. Pancytokeratin AE1/AE3, CD34, and EMA were negative. Occasional scattered cells showing smooth muscle differentiation (SMA + and desmin+) were observed among the stellate cells. Ki67 proliferation was very low < 1–2%. The entrapped epithelial strands showed strong positivity for TTF1 and scattered p63-positivity. Pulmonary hamartoma was diagnosed according to the WHO criteria .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2828_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2828_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..dd69bb2000bd79e5c0f60b688e6afc9174ce1a4d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2828_en.txt
@@ -0,0 +1,2 @@
+A 46-year-old unmarried man was referred to the Department of Psychiatry, at Chosun University hospital by a local psychiatric clinic. Acute euphoric mood, labile affect, increased talkativeness, decreased need for sleep, and unrestrained buying sprees had developed about 3 weeks prior. Concurrently, he was convinced that he had sufficient money to start a global business, and was scheduled to meet the President of his country in secret. In addition, he experienced vivid visual hallucinations: he reported having recently seen hundreds of North Korean soldiers in the battlefield at dawn. He had already been prescribed psychotropic medications, including aripiprazole (5 mg/day) and alprazolam (0.5 mg/day), at a local psychiatric clinic 2 days prior. He was admitted to a psychiatric inpatient unit for further evaluation and treatment. Upon admission, the patient was found to have no personal or family history of psychiatric illnesses. He reported no sexual intercourse over the last 3 years. On mental status examination, he showed the characteristic psychopathology of psychotic mania, such as euphoric mood, grandiose delusions, flight of ideas, pressure of speech, and increased psychomotor activity. However, he did not show any impairment in concentration and immediate memory. His Mini-Mental State examination (MMSE) score was 29; he only failed to recall one item at delayed recall, reflecting unimpaired cognition. Further, no abnormalities were found upon physical and neurological examination. He was diagnosed with bipolar disorder with psychotic features. On the 1st day after admission, blonanserin, an atypical antipsychotic drug, was administered at a dose of 8 mg/day for alleviation of manic and psychotic symptoms.
+On the 2nd day, routine blood test, including complete blood count, serum electrolyte, and biochemical tests, and chest X-ray, electrocardiography, electroencephalography, and brain magnetic resonance imaging (MRI) showed no aberrant findings. However, the patient showed a positive result for the serum venereal disease research laboratory (VDRL) test, at a titer of 1:32. Fluorescent treponemal antibody absorption test showed reactivity, whereas results of the HIV test were negative. On the 3rd day, analysis of cerebrospinal fluid through a lumbar puncture showed a positive VDRL result, at a titer of 1:8, and increased white blood cell count (22/mm3) and total protein (78.7 mg/dL). Since a positive VDRL result for the cerebrospinal fluid confirmed the diagnosis of neurosyphilis , the patient was administered intravenous penicillin G, 20 million units daily, for 2 weeks. Along with intravenous penicillin G, an oral antipsychotic regimen (blonanserin, 8 mg/day) was maintained throughout the treatment period. From the 7th day onward, the manic and psychotic symptoms improved dramatically, which was supported by his report of gaining insight into illness and significant reduction of the scores of psychiatric symptom rating scales . By the time of discharge, on the 17th day, most psychiatric symptoms had disappeared. After 5 days of discharge, the patient visited our hospital, and neither mood symptoms nor psychotic symptoms were observed. He was administered a reduced dose of antipsychotic medication (blonanserin, 4 mg/day) for 2 weeks, which he later discontinued.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2837_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2837_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0693792e3ec32cd5a64aff539395085da7e13f8a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2837_en.txt
@@ -0,0 +1,6 @@
+A 50-year-old woman presented to our Gynecology OPD with chief complaints of bleeding per vaginum for 4 months, pain lower abdomen, and dyspareunia for 2 months. Patient had regular menstrual cycles lasting for 6 days, occurring every 28 days till 4 months back when she developed vaginal bleeding, associated with passage of clots, pain, and sexual discomfort. She never used oral contraceptive pills or any other method of contraception. She has two children, both normal vaginal delivery with last childbirth 17 years back. Patient was detected with hypothyroidism 2 years ago and was maintaining euthyroid status on thyroxine 50 μg daily. There was no significant history of any genital, colonic, or renal malignancy in her family.
+On examination, patient was average built, afebrile, pulse 76/min, blood pressure 110/74 mmHg, and mild pallor was present. Abdomen was soft and did not reveal any mass. Per speculum examination revealed hypertrophied cervix and slight bleeding through external os. On per vaginal examination, cervix appeared firm and uterus was bulky, firm, and mobile with no palpable adnexal mass through fornices. Per rectal examination, she had normal rectal mucosa and soft parametrium.
+Patient had an endometrial sampling which was reported as a high-grade endometrial adenocarcinoma (villo-nodular type). Her haemoglobin was 8.9 gm%, and kidney and liver function tests were within normal limits. S.TSH was 2.6 uIU/ml, and Ca-125 was 165 IU/L. Pap smear was reported as negative for intraepithelial lesions or malignancy. On ultrasonography (USG) of pelvis, uterus was anteverted, bulky with increased endometrial thickness with a growth within the endometrial cavity. Computed tomography revealed bulky uterus showing heterogeneous attenuation of myometrium with foci of heterogeneous enhancement in central part and a heterogeneously enhancing mass lesion towards lower pole of left kidney suggestive of mitotic aetiology most likely RCC. Contrast-enhanced MRI of abdomen and pelvis was done, and it revealed a bulky uterus with an ill-defined myometrial-based lobulated mass lesion extending into the endometrium measuring 2.4 × 1.1 × 2.0 cm with distorted endometrial cavity with adenomyosis . It also picked up a 4.8 × 4 × 3.2 cm heterogeneously enhancing lesion in lower pole of left kidney reaching up to hilum and no lymphadenopathy .
+USG-guided FNAC from the renal lesion was done (twice); however, it yielded only blood and no tissue in both attempts. The renal mass was radiologically enhanced and vascular, so it was presumed to be a highly vascular RCC. Patient did not agree for positron emission tomography-computed tomography (PET-CT) which could have been helpful and was thus planned for staging laparotomy for endometrial cancer and frozen section for renal mass with due counselling. She underwent extra-fascial hysterectomy and bilateral salpingo-oophorectomy with pelvic lymphadenectomy and infracolic omentectomy with frozen section from renal mass. There were no ascites or omental or peritoneal deposits. As frozen section report was doubtful and inconclusive, radical nephrectomy was performed; the counselling and consent was obtained prior for the same.
+On gross examination, the endometrial cavity was filled with papillary growth 2.2 × 2 × 1.5 cm which was grossly infiltrating the outer half of myometrium with areas of necrosis . There was a 4 × 5 cm well-circumscribed encapsulated growth at lower pole of kidney reaching renal hilum. Histopathological examination of the uterine growth showed a biphasic tumour with malignant epithelial component with pleomorphism, in the form of glands showing atypia and stromal component in the form of spindle cells suggestive of MMT . There was no lymph vascular space occlusion, and immunohistochemistry (IHC) markers such as vimentin, keratin, desmin, myogenin, S-100, and epithelial membrane antigen were positive suggestive of MMT.
+The renal mass showed sheets of polygonal cells with haemorrhage with minimal atypia suggestive of RH . The tumour was positive for markers like inhibin, CD34, and neuron-specific enolase (NSE) by IHC and negative for vimentin and cytokeratin which are markers of RCC . No vascular invasion or capsular breach was seen. Patient had uneventful recovery and was discharged on day 6. In view of RH, computed tomography head was done to rule out VHL disease, and the study came out to be normal. Medical oncologist started the patient on chemotherapy for the MMT, and she was given paclitaxel 175 mg/m and carboplatin AUC 5 once in 3 weeks for 6 cycles. Patient is healthy at present and is on regular follow-up for 15 months.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2857_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2857_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..760c9d05b56fef66cfabc51af95fcbfe9bd6273c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2857_en.txt
@@ -0,0 +1,8 @@
+A 65-year-old male presented to us in the outpatient department on March 2019 with complaints of pain in the right shoulder for the past 6 months and dumbbell-shaped swelling progressively increasing in size around the same region for the past 4 months. He had severe pain and global restriction of movements in the right shoulder which urged him for medical attention. There was no history of trauma, manipulation, fever, or night sweats. The patient had a history of pulmonary TB 2 years back, for which he was treated with anti-tubercular drugs according to the Revised National Tuberculosis Control Program (India) guidelines for 6 months and declared sputum negative. There is no history of any other systemic disorders.
+Reveals massive dumbbell-shaped swelling over the right shoulder which is soft in consistency with ill-defined margins showing cross-fluctuation (-). The overlying skin was tense and shiny, with no venous engorgement. There was no discharging sinus or pointing abscess. Local temperature was normal. Tenderness was present on palpation of anterior and posterior capsule region, deep axilla, and lateral aspect of the scapula. Movements of the shoulder were painful and restricted in all directions. There was no distal neurovascular deficit. Axillary lymph nodes were enlarged.
+Revealed hemoglobin (Hb) of 11 gm%, a total leucocyte count of 11,000 mm3, differential count of 48% lymphocytes, 50% polymorphs, 2% eosinophils, and erythrocyte sedimentation rate (ESR Westergren) was 60 mm/hr.
+X-ray right shoulder anteroposterior view shows erosion of the glenoid cavity and head of the humerus with a reduction in the joint space. Obliteration of adjacent fat planes is seen with minimal erosion of lateral end of the clavicle. Soft-tissue shadow is suggestive of gross fluid collection. There is no dislocation of the glenohumeral joint.
+Chest X-ray showed widespread small nodular opacities distributed throughout both the lungs suggestive of miliary TB.
+Magnetic resonance imaging right shoulder joint (, ) shows cortical erosions involving articular margins of the humeral head and bony glenoid. Proximal migration of humeral head at the shoulder joint is seen. There are moderate joint effusion and synovial thickening with a large loculated periarticular collection extending to supraspinatus fossa and upper arm along with the deltoid muscle. Largest collection measures approximately 14 cm × 6 cm. There are rotator cuff muscles atrophy and few enlarged lymph nodes in the axilla. This picture was suggestive of tuberculous arthropathy of the right shoulder joint.
+Diagnostic aspiration of the cold abscess was done from the non-dependent region under aseptic precaution, material aspirated was sent for pus culture, acid-fast bacilli (AFB) staining, Gene-Xpert, and culture for Mycobacterium tuberculosis (Mtb). AFB staining came negative. MTb was detected with Gene-Xpert documenting no rifampicin resistance. Culture with Mycobacterium growth indicator tube (TB-MGIT) came positive in 3 weeks with the bacilli susceptible to all first-line anti-tubercular drugs. There was no superadded pyogenic infection being ruled out by final pus culture and sensitivity report.
+The patient was started on first-line anti-tubercular therapy (ATT) isoniazid, rifampicin, pyrazinamide, and ethambutol for 2 months then switched to HRE for 6 months and HR for the next 4 months. Therapeutic aspiration of the cold abscess was done and 1 g of streptomycin was injected into the lesion once the diagnosis was confirmed by diagnostic aspiration. The patient was provided with shoulder immobilizer and compression bandage after the procedure. A similar procedure of injecting streptomycin was repeated thrice at monthly intervals. After 3 months, the swelling and pain were alleviated; the patient was started on physiotherapy and shoulder range of motion exercises. The total duration of multidrug anti-tubercular chemotherapy was 1 year. At 1-year follow-up, although the movements were restricted (flexion 50°, extension 20°, abduction 60°, adduction 0°, internal rotation 10°, and external rotation 10°) and mostly scapulothoracic, the patient had gained weight, had no pain or swelling, and could carry out his day-to-day activities without much discomfort . The anteroposterior radiograph showed healing with sclerosis at proximal humerus and superior migration of head of the humerus. There were no changes in the glenoid cavity.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2861_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2861_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0b37c7b138a0a951a62863f300f7aa9e8cc5fdab
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2861_en.txt
@@ -0,0 +1,3 @@
+A 36-month-old female patient presented initially to the pediatric clinic with a history of delayed, acute projectile emesis and diarrhea, without signs of anaphylaxis following ingestion of gumbo soup beginning at 14-months of age. The patient was born by spontaneous vaginal delivery, exhibiting no complications during gestation or birth. She had no confounding infections, medication, or other food ingestions prior to her first presumed FPIES reaction. The family denied history of any atopic co-morbidities – including any IgE food allergies. Importantly, she previously tolerated gumbo over several months prior to her initial reaction and subsequent ingestion trials produced the same gastrointestinal symptoms consistent with FPIES.
+Gumbo, which translates to “okra” in numerous West African dialects, is a thick, okra-based stew containing spices and various seafood ingredients . The patient began consuming small amounts (e.g. ranging from”a taste” to ¼–1/2 cup) of a family recipe of gumbo consisting of okra and tuna at about 2-months of age as was the cultural practice for families from their native West African nation. She consumed her family’s gumbo soup regularly within her diet for a year until she experienced recurrent, projectile emesis and diarrhea 2–3 h after an isolated consumption of ½ a cup of gumbo. She would have over five episodes of projectile emesis, about every 10 min over the course of 2 h, and non-bloody, non-mucoid diarrhea that lasted for about 2 h. No cutaneous or respiratory symptoms were observed to indicate IgE-mediated hypersensitivity. After the resolution of her symptoms, the patient was lethargic, but she responded well to oral hydration with apple juice and tolerated intake of foods high in carbohydrates such as spaghetti and crackers. Emergency room care was not utilized. Within the same month, the family gave the child okra and tuna ingredients from the gumbo soup to consume separately. The patient exhibited no symptoms after consuming the tuna, but did experience recurrent, projectile emesis and diarrhea 1 h after ingesting the okra. The family then bought a fresh batch of okra to determine whether the okra in their possession was problematic, but after consumption, the new okra triggered identical symptoms of emesis and diarrhea for the patient for her 3rd and final reaction. Figure illustrates her clinical course timeline pertinent to the FPIES history.
+Based on her history, she was clinically diagnosed with FPIES and advised to avoid okra and all okra-based foods. The family strictly heeded this suggestion and no further incidences of reactions occurred. At the family’s discretion, okra in gumbo soup was slowly reintroduced at 3 years of age, in serving sizes starting at about ¼ cup on a daily basis with good tolerance and the patient has since been asymptomatic since. No other changes in her medical history were noted and she now has no need for any food avoidance measures.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_288_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_288_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..00b730a52af85b5d2733c0644735d54c980b19d0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_288_en.txt
@@ -0,0 +1,8 @@
+A 58-year-old man had experienced recurrent abdominal pain and melena for 3 years, but repeated gastroenteroscopy and CTA had failed to find bleeding lesions.
+On June 30, 2020, the patient presented to our department with a history of recurrent abdominal pain and melena for 3 years. In June 2017, he developed recurrent localized and dark pain in the upper abdomen without obvious inducement. It was tolerable, lasted for about 1 h, occurred about 3 times a day and was accompanied by thin, textureless melena, dizziness, and fatigue. His symptoms occurred repeatedly. He had gone to major hospitals across the country many times, but there was no clear diagnosis, and conservative treatment was used for alleviation. Two months before admission, the above symptoms progressively worsened. Melena was passed 4-5 times a day, with a total volume of about 200 g, and the dizziness and fatigue were significantly worse than before. After symptomatic treatment of hemostasis in the local hospital, the symptoms were improved, but still existed.
+He was diagnosed with syphilis in 2008. Multiple treatments were successful, but the disease recurred shortly afterward. Because of heart valve disease, he underwent a mitral valve replacement and tricuspid valvuloplasty at Fujian Provincial Hospital In 2010. In 2019, he was diagnosed with atrial fibrillation and chronic pancreatitis. Currently, he is taking Betaloc 23.75 mg qd orally.
+The patient had a history of unprotected intercourse with multiple sexual partners, a smoking history for 40 years (20 cigarettes a day), and a drinking history for 30 years. There is no family history of infectious or heredity diseases.
+On admission, his temperature was 36 ℃, pulse was 66 beats/min, respiration was 18 breaths/min, and blood pressure was 120/80 mmHg. He was conscious and could cooperate in the physical examination. The skin of the whole body was slightly pale. Systemic superficial lymph nodes were not enlarged or tender, the conjunctiva was pale, the lips were slightly pale, carotid artery pulsation was normal, jugular vein was normal, liver jugular vein return sign was negative, and lung physical examination was not remarkable. There was a postoperative scar of about 20 cm in length on the chest, which had healed well. The heart rate was 80 beats/min, the heart rhythm was absolutely uneven, the first heart sound varied in intensity, a systolic murmur was heard in the mitral valve auscultation area, no obvious pathological murmur was heard in the other auscultation area, the fricative consonant was unintentionally included, the abdomen was flat and soft without tenderness or rebound pain, and the abdomen was not lumped. The liver and spleen were not touched, Murphy’s sign was negative, and there was no mobile dullness. Intestinal sounds (4/min) were normal.
+The initial hemoglobin of the patient was 78.0 g/L and fecal occult blood was present (++). The syphilis toluidine red unheated serum test (TRUST) was positive; the syphilis titer was 1:2 positive. The white blood cell count, platelets, coagulation function, antinuclear antibody, antinuclear antibody profile, fecal routine, urine routine, alpha fetoprotein, carcinoembryonic antigen, glycogen antigen 199, total iron binding capacity, serum iron, unsaturated iron binding capacity, ferritin, folic acid, vitamin B12, purified protein derivative (PPD tuberculin test, tuberculosis antibody, and tuberculosis T-cell test showed no obvious abnormalities.
+The patient’s upper abdominal magnetic resonance cholangiopancreatography revealed splenomegaly, and dilatation of the intrahepatic and extrahepatic bile ducts and pancreatic ducts .
+An electrocardiogram indicated atrial fibrillation . Colonoscopy found multiple small ridges in the terminal ileum, and the pathology showed chronic active inflammation and erosive mucosa. Additional gastroscopy showed atrophic gastritis, and pathology of the gastric antrum indicated inflammation, and the Helicobacter pylori test was negative. Ultrasound gastroscopy showed dilatation of pancreatic duct with pancreatic duct stones, which was considered as chronic pancreatitis . A capsule endoscopy was performed to further clarify the bleeding focus of the patient, and multiple intestinal erosions and ulcers were found . The bone marrow puncture smear of the iliac spine showed normal hematopoietic tissue hyperplasia, presence of three-line hematopoietic cells, expanded islands of erythroid cells, hyperplasia of erythroid cells, a reduced granulocytosis ratio, and a scattered distribution of megakaryocytes, which was considered as hyperplastic anemia .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2894_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2894_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7c816ef2c0113ee97a3bfff5c6c4df9164fa9383
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2894_en.txt
@@ -0,0 +1,5 @@
+A 65-year-old, right-handed Caucasian woman was transferred from a local hospital to our neurological intensive care unit (NICU) after a witnessed generalized tonic-clonic seizure. She had hypertension, diabetes mellitus, dyslipidemia, chronic obstructive pulmonary disorder, a history of heavy cigarette smoking and a long-standing but well-controlled bipolar disorder. Three weeks before the seizure, biopsy of a right hilar mass via mediastinoscopy confirmed the diagnosis of SCLC. Treatment for the cancer had not been initiated. Shortly after the biopsy, her family found her to be intermittently confused. Over the following two days, she developed fever, dizziness, vomiting, poor appetite and progressive shortness of breath. Confusion worsened to the point that she could no longer recognize her family and became non-interactive. She remained lethargic and confused despite treatment with ceftriaxone and azithromycin for right lower lobe pneumonia. Investigations and results at the local hospital included: (1) CSF analysis showed 28 white blood cells with 99% lymphocytes, glucose 122 g/L, protein 36 g/L, no organisms on Gram stain and no growth from bacterial culture; (2) MRI of the brain showed T2 and FLAIR hyperintensities in both mesial temporal regions without contrast enhancement, diffusion or susceptibility changes; (3) EEG demonstrated background slowing with focal sharp and slow discharges in the right mid-temporal and right posterior temporal region. Empiric treatment with intravenous acyclovir was initiated while HSV polymerase chain reaction (PCR) study from CSF was sent for analysis. On her seventh day at the local hospital, she was observed having a generalized tonic-clonic seizure for which she received intravenous fosphenytoin. She was intubated and transferred to our NICU.
+On examination, she was unresponsive to verbal or noxious stimuli. Her pupils were restricted from previous cataract procedures. There was no gaze preference. Corneal, vestibular-ocular and gag reflexes were intact. Her tone was normal. She made no purposeful withdrawal on the left side. A Babinski maneuver elicited a plantar response from both feet.
+She had a second, brief, witnessed generalized tonic-clonic seizure with left gaze deviation and left head turning. An EEG demonstrated electrographic seizures consisting of bilateral independent periodic lateralized epileptiform discharges (bi-PLEDs) in both temporal lobes with right-sided predominance . Intravenous lorazepam was given and phenytoin was reloaded. Levetiracetam and topiramate were subsequently added in increasing doses (up to maximum dosages) to treat persistent electrographic seizures. Repeat CSF analysis again demonstrated mild pleocytosis with lymphocytic predominance (23 white blood cells with 94% lymphocytes) but was otherwise normal. CSF cytology did not show any malignant cells. Empiric treatment with acyclovir for HSV encephalitis continued until a second negative CSF HSV PCR returned. Epstein-Barr virus (EBV), cytomegalovirus (CMV), varicella zoster virus (VZV) and human herpesvirus 6 (HHV-6) were all negative. Repeat MRI of the brain showed T2-FLAIR hyperintensities in both mesial temporal lobes without restricted diffusion or post-gadolinium enhancement . Chest X-ray showed post-obstructive pneumonia in the right lower lobe with collapse of the right middle and upper lobes due to compressive atelectasis from the lung cancer . Computed tomography (CT) scan of the chest demonstrated mediastinal and hilar lymphadenopathy and pleural effusion in addition to a loculated right lower lobe . Her lung cancer was not amenable to resection. She continued to receive broad-spectrum antibiotics for pneumonia, and chemotherapy for SCLC with carboplatin and etoposide was commenced.
+Serum contained markedly elevated anti-N-type voltage-gated calcium channel (VGCC) antibody titer of 0.42 nmol/L (normal value < 0.03) and mildly elevated anti-P/Q-type VGCC antibody titer of 0.04 nmol/L (normal value < 0.02). No other paraneoplastic antibody (including binding, ganglionic and striational acetycholine [Ach] receptor antibodies, Purjinke cell antibodies type 1 [PCA-1 or anti-Yo], PCA-2, PCA-Tr [anti-Tr, immune response marker for Hodgkin's lymphoma], anti-neuronal nuclear antibodies type 1 [ANNA-1 or aniti-Hu], ANNA-2 [anti-Ri], ANNA-3, anti-Ma1, anti-Ta, collapsin response-mediator protein-5 [CRMP-5 or CV2], amphiphysin, anti-glial/neuronal nuclear antibody, Type 1 AGNA-1) was detected. Voltage-gated potassium channel (VGKC), N-methyl-D-aspartate receptor (NMDAR) and glutamic acid decarboxylase (GAD) antibodies were not sent. Our patient received IVIG (0.4 mg/kg daily for five days) and 1 g of Solu-medrol (methylprednisolone) daily for three days, followed by tapering doses of prednisone over four weeks. Long-term monitoring (LTM) EEG showed gradual resolution of epileptiform activities only after initiation of immune therapy, despite being on multiple anti-epileptic drugs.
+Two months after the onset of her neurological illness, she was following commands and had become conversant but she still displayed cognitive impairment and still suffered episodes of delirium. Our patient had multiple subsequent hospitalizations for aspiration pneumonia and seizures that were refractory to anti-epileptic drug adjustments and only responsive to IVIG and steroids on a monthly basis. MRI six months later showed resolution of T2-FLAIR hyperintensities . However, she continued to have severe short-term memory deficits. She died eight months after the initial presentation due to progressive lung cancer.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2896_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2896_en.txt
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index 0000000000000000000000000000000000000000..a016ea7596f7b8ba62a0a07da5c4ad88e6f67b3a
--- /dev/null
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@@ -0,0 +1,3 @@
+A 56-year-old male initially presented with aphasia and right hemiparesis. Head CT, and brain magnetic resonance imaging (MRI) revealed a left thalamic intracerebral hemorrhage with intraventricular extension . No AVM was detected on MR angiography (MRA). Given the high suspicion for an underlying vascular lesion, DSA was performed, which revealed enlargement of the left anterior choroidal artery and early drainage into the left internal cerebral vein with no discernible nidus, likely due to the concurrent hematoma . The patient recovered his language and motor function over the next 3 months.
+Diagnostic DSA and CBCT performed 3 months after presentation demonstrated a Spetzler-Martin Grade III left thalamic AVM [Figure , and ]. The 5 mm nidus was predominantly supplied by the left anterior choroidal artery and to a lesser degree by a thalamoperforator from the left posterior communicating artery. Deep venous drainage was through the internal cerebral vein. Planned stereotactic radiosurgery (SRS) was delayed for 3 months due to an unrelated severe knee injury resulting in a lower extremity deep venous thrombosis.
+Six months after presentation, MRI and MRA performed for SRS planning did not demonstrate the AVM, or the previously seen flow enhancement of the thalamus on MRA. Seven months after initial presentation, DSA and CBCT confirmed the spontaneous angiographic resolution of the AVM [Figure and ] without treatment. The patient was subsequently lost to follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2904_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2904_en.txt
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index 0000000000000000000000000000000000000000..729186cdc3f4acb739b96493935a6a3cc08e7086
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2904_en.txt
@@ -0,0 +1,14 @@
+A 70-year-old man presented to a neurologist in February 2020 with complaints of aggressive behaviour, depressed mood, gait problems and general deterioration.
+The patient’s medical history listed chronic axonal-demyelinating sensory-motoric polyneuropathy, peripheral arterial vascular disease, chronic kidney insufficiency, hypertension and diabetes mellitus. He also had a pacemaker, due to paroxysmal atrial fibrillation. He had quit smoking in 1995. Alcohol consumption was not clearly stated.
+Clinical examination revealed general weakness and areflexia in the four limbs. Electroencephalography (EEG) was normal, as was a CT scan of the brain, according to the protocol. Nerve conduction studies and electromyography (ENMG) indicated the known polyneuropathy, most probably due to diabetes mellitus.
+A CT scan of the lumbar spine could not explain the impaired gait.
+A second contact with the same neurologist took place 4 months later. The gait problems had increased, accompanied by aggressive behaviour, loss of interest and problems with executive functioning.
+A second CT scan of the brain listed a ventriculomegaly, but not in the conclusion.
+As treatment, the patient was advised to see a psychologist for the depressed mood and to visit a rehabilitation centre for the gait impairment. The latter recommendation was refused.
+In November 2021, the patient went to the urologist because of urinary incontinence. A urodynamic study revealed an overactive bladder, which was treated with medication. There was no improvement at all.
+Two months later, the patient was admitted to hospital because of generalised deterioration, acute renal insufficiency and dysregulated glycaemia. During this admission, the patient was confused and delirious. Gait problems were evident, with an increased risk of falling, as well as urinary incontinence. Rehabilitation was then started for the first time.
+Less than a few weeks after discharge, May 2022, the patient was readmitted to hospital, in the intensive care unit, after a fall with rib fractures and haemothorax. He was disoriented and developed hyperactive delirium, reported as being of multifactorial origin. At this time, ethyl abuse was mentioned. This could have explained the falls, cognitive dysfunction and delirium.
+On admission to the rehabilitation unit (May 2022), the patient was seen for the first time by one of the authors. He had a cognitive deficit, an impaired gait with frequent falling and urinary incontinence. Upon clinical examination, cogwheel rigidity, gait impairments and ataxia were noticed. In the absence of a diagnosis, a PET scan was requested, and the imaging was reviewed by the radiologist. Heteroanamnesis with the patient’s spouse revealed that the symptoms were progressively increasing, but alcohol consumption was not mentioned. According to the spouse, the patient was no longer the same person she used to know. The triad of symptoms was recognised, and a retrograde review of imaging confirmed the suspicion of iNPH ( and ).
+Following the diagnosis, a diagnostic lumbar puncture was performed with drainage of 30 ml cerebrospinal fluid (CSF). Testing pre- and post-puncture indicated an increase in scores on the Mini Mental State Exam (MMSE) from 24 to 27/30. In addition, the Timed Up & Go test was significantly better. Clinical improvements were also observed in gait pattern and cognition.
+A ventriculoperitoneal shunt (VP shunt) was placed successfully: cognition improved, and both gait disturbances and urinary incontinence disappeared. Neurological examination normalised. Multidisciplinary rehabilitation was subsequently continued with favourable results, despite the long existence of the symptoms.
+Upon discharge from our ward, the patient was able to walk securely and independently. Further rehabilitation was provided at home. Vertigo and fatigue remained and were followed up by the neurologist. With the improvement of urinary incontinence, medication could be tapered off.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2915_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2915_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f6dbfa936c24ac4916a27ad61e849f4f678158bb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2915_en.txt
@@ -0,0 +1,5 @@
+A 73-year-old male patient presented with a firm, subcutaneous nodule in the right upper eyelid . The lesion was present for 10 years, slowly growing and painless. The mass was round, relatively hard and moved freely under the skin, without pain on palpation or mobilization. The overlying skin showed no inflammatory signs or abnormal pigmentation. There was no restriction in ocular movements, and the remaining ophthalmological examinations were unremarkable.
+The patient underwent an orbital CT scan that revealed an extra-conical mass, adjacent to the lateral rectus insertion, with no distortion of the globe or invasion of the bone or muscular structures. The mass had a heterogeneous density, and two cysts were present in its superoanterior portion .
+An excisional biopsy was performed over the upper eyelid dermis, through a 15 mm horizontal incision in the lateral third of the eyelid crease. The tumor was well circumscribed with no adhesions and was easily dissected and removed in its entirety . The lacrimal gland was found to be independent of the mass, with a normal appearance. The incision was closed with a 6.0 polypropylene suture. The postoperative appearance can be observed in .
+On gross pathologic examination, the nodule was well-defined with dimensions 20 mm × 15 mm × 12 mm. A smooth and tan cutting surface was found, with tiny cavitated areas containing a pasty whitish material. The entire specimen was submitted to histologic examination. The tumor was totally encapsulated and presented a biphasic pattern, consisting of a chondromyxoid stroma and an epithelial component . The epithelium was arranged in nests, cords, and tubes, or glandular branching structures layered by a double epithelium in which the inner epithelial layer exhibited apocrine features, such as decapitation [Figure and ]. There was no significant atypia. Numerous cysts were present in the tumor, lined by metaplastic stratified squamous epithelium and containing keratinized epithelial plugs in the lumen . No areas of necrosis, interstitial hemorrhage or appreciable mitotic activity were found. No satellite nodules were identified. Immunohistochemistry revealed a variable expression of the inner epithelial cells to pancytokeratins AE1/AE3 and to carcinoembryonic antigen (CEA) [Figure and ]. The outer epithelial cells and stromal component expressed vimentin and S100 protein [Figure and ]. There was no evidence of lacrimal gland parenchyma or signs of malignant changes. These findings defined the tumor as a palpebral pleomorphic adenoma and were consistent with apocrine differentiation.
+The systemic work-up was negative for metastasis; thus the patient was kept under vigilance with periodic observations. In 2 years of follow-up, he has remained asymptomatic without the signs of local recurrence.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2924_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2924_en.txt
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index 0000000000000000000000000000000000000000..333c10badb18f55b8aaccd1c98887551528c5915
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2924_en.txt
@@ -0,0 +1 @@
+A six-month-old boy (weight 6.3 kg) presented to our hospital with episodes of supraventricular tachycardia (SVT), tachypnea, and left ventricular dysfunction. The presence of ALCAPA was not initially recognized, and our patient's left ventricular dysfunction was attributed to SVT. He was eventually diagnosed with ALCAPA on the basis of echocardiography and multi-slice computed tomography (CT) . Τhe suspicion of probable ALCAPA was raised after his third echocardiographic examination and was confirmed by a CT scan. The left coronary artery originated from the leftward-facing sinus of the pulmonary valve. The left ventricle was dilated with an ejection fraction of 30%. Our patient underwent direct re-implantation of the left coronary artery to the aorta using the trapdoor flap technique (cross-clamp time 92 minutes, bypass time 137 minutes). He started having recurrent episodes of SVT, with a heart rate of 220 beats/minute immediately after extubation on the second post-operative day. The episodes were converted to sinus rhythm with adenosine or rapid atrial pacing, thus ruling out junctional ectopic tachycardia. Despite treatment with amiodarone, the episodes continued. Propranolol, digoxin, and propafenone were added at maximal tolerated doses without success. An electrophysiological study was performed in the fourth post-operative week using a 5-French decapolar catheter placed into the left subclavian vein in the coronary sinus (CS), a 4-French bipolar catheter placed from the left femoral vein into the right ventricle, and a 5-French mapping/ablation catheter placed through the right femoral vein. Atrioventricular re-entry tachycardia was induced reproducibly with programmed atrial stimulation, with a tachycardia cycle length of 250 milliseconds and earlier retrograde atrial depolarization recorded by the distal bipole of the CS catheter. Access to the left atrium was achieved by using a trans-septal approach , and mapping was performed during tachycardia using a non-fluoroscopic navigation system (Ensite-NavX; St Jude Medical, St Paul, MN, USA). Tachycardia stopped 2.7 seconds after the onset of the fourth application of RF energy . The total fluoroscopy time was 24.7 minutes, maximum power was 30W, maximum temperature was 58°C, and the total procedure duration was four hours. Post-ablation aortography revealed patency of the left coronary artery without stenosis of the circumflex coronary artery. There was no recurrence of the SVT while our patient was in a drug-free state at the six-month follow-up examination.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2929_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2929_en.txt
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index 0000000000000000000000000000000000000000..5c09a3aa961074395fc7c97fb51aa87dd4eeb58c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2929_en.txt
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+In January 2021, a previously healthy 7-months-old female was admitted to the pediatric emergency room for a poor sitting balance, which was completely achieved 3 weeks before, and abnormal involuntary and oscillatory movements spread to head, limbs and torso. Posture while sitting unsupported was very difficult to be maintained, with oscillations and falls. Symptoms had started about 48 h earlier. A contemporary history of fever and vomit was also referred, resolved at the moment of the admission to the hospital. Parents reported that she had received the second dose of MenB vaccination (Bexsero-Novartis Vaccines and Diagnostics S.r.l., Siena, Italy) 72 h before the admission to the emergency room.
+The patient's prenatal and perinatal history was unremarkable, with a normal pregnancy and good adaptation at birth. The patient was born via spontaneous gestation at 39 weeks gestational age, with a birth weight of 3020 g. She was full-term born by vaginal delivery with a 1-min Apgar score of 9 and an adequate birth weight for gestational age. Neonatal screening for congenital hypothyroidism, phenylketonuria, cystic fibrosis, and 17-hydroxyprogesterone resulted negative. The patient was exclusively breastfed at discharge, which occurred after monitoring for an episode of cyanosis on the second day of life. The patient's vital parameters were within the norm, and echocardiography was normal. A blood count at birth revealed mild thrombocytopenia, which was resolved on a follow-up control. The patient was discharged in good general condition with well-established breastfeeding. Developmental milestones were regularly achieved.
+According to the patient's medical records, the patient had received the first two doses of the hexavalent vaccine (DTaP-Hib-IPV-HepB) and the first dose of MenB vaccine (Bexsero) without any reported side effects. The hexavalent vaccine was administered at the third and fifth months of life, while the MenB vaccine was given at the fifth month.
+At the examination she was awake and manifested neither nystagmus or saccadic eye movements, and her optic fundi and cranial nerves were normal, as her tendon reflexes. In order to exclude an infectious meningoencephalitis, blood sample, CT scan, spinal tap and basal electroencephalogram were performed. The CT scan and the electroencephalogram did not reveal abnormal findings. Upon admission to the emergency room, a thorough diagnostic workup was initiated to identify all the potential causes of ACA in our patient. Blood chemistry, leukocyte count, acute phase proteins, and electrolytes were in normal range. Blood serologies for adenovirus, cytomegalovirus, Epstein-Barr virus, coxsackie virus, herpes simplex virus, human herpesvirus 6, Mycoplasma pneumoniae, parvovirus B19 and came back negative. Cerebrospinal fluid (CSF) analysis found a white blood count of 1/μL, protein level 17 mg/dL (n.v. 10–45 mg/dL), glucose level of 55 mg/dL (n.v. 40–70 mg/dL), lactate 1.9 mmol/L (n.v. 1.1–2.8 mmol/L), with no microscopic evidence of contamination. The workup included a polymerase chain reaction (PCR) analysis of both blood and CSF for a range of viral and bacterial pathogens that are known to cause meningitis and encephalitis. Specifically, we conducted PCR testing for all viruses and bacteria that are considered probable causes of these infections, as well as for mycoplasma pneumoniae and fungal infections. Both blood and CSF cultures were performed at the time of admission to the emergency room but did not yield any positive results.
+To further investigate the potential viral etiology of ACA in our patient, we performed additional PCR testing for other viruses that may be associated with this condition. Specifically, we looked for Influenza (A H1, A H3, B) and Parainfluenza viruses, as well as other respiratory viruses such as SARS-CoV-2, rhinovirus, enterovirus, RSV, and adenovirus. Despite these efforts, the molecular and serological search for viral causes of ACA on nasopharyngeal aspirate, CSF and blood did not yield any positive results.
+The electrocardiogram found normal sinus rhythm and repolarization. A magnetic resonance imaging of the brain and spinal cord were then performed, with no abnormal findings. A possible correlation between the clinical picture of ACA and the recent vaccination was then suspected as the first diagnostic hypothesis.
+To exclude any possible correlation with a hypothetical paraneoplastic etiology, a chest X-array and a complete abdominal ultrasound were performed. Homovanillic and vanilmandelic acid urinary excretion did show any anomalies. The search for specific CSF and blood autoantibodies (anti-glutamic acid decarboxylase, anti-HU, anti-YO and anti-RI) did not find abnormal results. Plasma level of neuron specific enolase was first 21.3 ng/mL (n.v. < 12.5 ng/mL), but then decreased back off to range in the following days.
+During the hospitalization her general conditions remained stable and started to improve. The neurological follow up during the hospital stay confirmed the positive evolution with an increased head and trunk control and seated posture maintenance with minimal sway. Acute phase proteins remained in normal range.
+Therefore, in view of the temporal correlation between the second dose of MenB vaccine and the onset of symptoms, a pharmacovigilance report was sent. Symptoms gradually improved, and the patient was discharged after an 8-days recovery. Clinical full recovery was confirmed at the 10-days and 1-month follow-up, when she was completely able to maintain a stable seated position with no swinging movements and dysmetria.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2936_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2936_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..08a8df880ca3606b5456ce770855a3ec415e5650
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2936_en.txt
@@ -0,0 +1,2 @@
+A 68-year-old man was referred to Kindai University in 2004 with bilateral uveitis of unknown cause. The right eye had lost vision due to suspected Candida keratitis after penetrating keratoplasty, which was performed in 2007. A mild anterior chamber inflammation and keratic precipitates with small corneal oedema, followed by refractory secondary glaucoma, caused bullous keratopathy in the left eye that necessitated DSAEK in 2011. The clinical findings observed during these periods, such as unilateral high intraocular pressure and corneal oedema with keratic precipitates, were suggestive of cytomegalovirus (CMV) corneal endotheliitis. A diagnosis of CMV corneal endotheliitis was made based on detection of CMV DNA in the aqueous humour after DSAEK. Corneal grafting failed even with administration of 0.5% ganciclovir eye drop six times with 0.1% fluorometholone eye drop four times daily for more than a year. After the second DSAEK in 2013, 1.0% voriconazole, 0.5% ganciclovir, and 0.1% betamethasone phosphate eye drops continued to be administered four times daily for 2 years. In 2015, the patient presented with small crystalline opacities in the centre of the cornea that progressed extremely slowly and had multiplied by 2017 . The patient complained visual disturbance without any eye pain or foreign body sensation when the corneal opacity covered the visual axis, although he did not exhibit any subjective symptoms when the keratitis occurred for the first time. Gram staining of the scraped cornea revealed an unstained small oval microorganism that was only visible by Fungiflora Y staining . Given the past episode of vision loss of the other eye due to suspected Candida keratitis, we administered two doses of voriconazole by intrastromal injection. Since the treatment was ineffective, penetrating keratoplasty was performed. The excised corneal tissue was fixed with formalin, embedded in paraffin, and processed for histological analysis.
+Histologically, numerous oval organisms, 1.3–2.6 μm in diameter, were found throughout the corneal stroma. The organisms could be identified by haematoxylin and eosin staining and Ziehl–Neelsen staining, and fluoresced under ultraviolet illumination by Fungiflora Y and Uvitex 2B staining, but were unstained with periodic acid-Schiff reaction and Grocott’s staining . For TEM observation, ultrathin sections were prepared from the targeted area of paraffin sections after osmification and embedding in Epon blocks by the inverted beam capsule method . They were observed with an HT 7700 microscope (Hitachi High-Technologies, Tokyo, Japan). A polar tube with multiple loose coils—which is consistent with the morphology of microsporidia—was detected in the spore-like elements of the microorganisms by TEM . The corneal graft remains transparent and no clinical findings suggestive of recurrence of microsporidial keratitis nor graft rejection is found with administration of 0.1% betamethasone phosphate eye drop four times daily at 1 year and half postoperatively.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2941_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2941_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b3fa46c70e1a39bc745ec98fe847054728d710ec
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2941_en.txt
@@ -0,0 +1,4 @@
+A 73-year-old woman (height, 157 cm; weight, 43 kg) visited a physician 7 days before admission to our hospital for dizziness, loss of appetite, and fatigue, but no specific issues could be determined, and the patient returned home without receiving treatment. On the day of admission, she revisited the physician because she had a fever of 38°C and dyspnea. Her oxygen saturation was 86% in ambient room air, and nasopharyngeal swab polymerase chain reaction for SARS-Cov-2 revealed that she had COVID-19. The patient was transferred to our hospital under oxygen administration for respiratory management.
+When the patient arrived at our hospital, her oxygen saturation was 87% (blood pressure, 152/68 mmHg; heart rate, 73 bpm) with oxygen administered at 2 L/min via a nasal cannula. We changed the oxygen administration method to OxyMaskTM (Southmedic Inc., Barrie, ON, Canada) at 7 L/min, and her oxygen saturation increased to 92%. Subsequently, she was admitted to the intensive care unit. Although she had no underlying conditions that would increase her risk for severe COVID-19, shortly after admission, her oxygen saturation dropped to approximately 90% and her respiratory rate increased to 40/min. We decided to start high-flow nasal cannula therapy at 50 L/min, FIO2 50%.
+Her hemogram showed a white blood cell count of 7400/μl and hemoglobin 12.4 g/dl. Her blood biochemistry tests only showed mild elevation in transaminases (glutamic oxaloacetic transaminase, 46 U/l; glutamic pyruvic transaminase, 36 U/l), and her renal function tests and electrolytes were within the normal limits. Arterial blood gas analysis performed before high-flow oxygen therapy was suggestive of type 1 respiratory failure (pH, 7.496; PO2, 52.2 mmHg; PCO2, 28.5 mmHg). Initial chest computed tomography (CT) showed bilateral and peripheral predominant consolidation and an air bronchogram.
+She was managed according to our institutional protocol (inhalational oxygen concentration, steroids, anticoagulation, tocilizumab, rehabilitation) and maintaining oxygen saturation 92%. Although she temporarily needed an FIO2 of 0.8 to maintain her peripheral oxygen saturation, we did not intubate her because she did not exert effort during ventilation, she strongly preferred not to be intubated, and her only symptom was lightheadedness when standing. On the 11th day of hospitalization, although her oxygen saturation decreased with light exertion but stabilized at rest in the supine position, we changed the oxygen administration method to OxyMaskTM 8 L/min. Although oxygen saturation was maintained when the patient was at rest and in the supine position, it dropped to lower than 80% when the patient was in the sitting position after, for instance, moving to a portable toilet. Moreover, more than 30 min was needed for oxygen saturation to increase even after starting high-flow oxygen therapy with fraction of inspiratory oxygen 0.5 or higher. However, SpO2 rapidly recovered when the patient was repositioned to the supine position. We suspected the presence of a right–left shunt, which increased with change in position, and asked the cardiologist to search for a PFO or ASD. We performed contrast-enhanced CT and echocardiography but could not find an intracardiac shunt. Afterward, although her oxygen saturation slightly decreased when she sat or stood, her oxygenation slowly improved, and she was discharged under home oxygen therapy with 0.5 L/min via a nasal cannula 28 days after admission.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3016_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3016_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bdff2768f63deb862bae03c3a0252becdbbfbeec
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3016_en.txt
@@ -0,0 +1,9 @@
+A 53-year-old man, who was morbidly obese with a BMI of 75 kg/m2, presented with shortness of breath (SOB) and hypercapnia. He had never smoked but had a history of hypertension and severe obstructive sleep apnea with an apnea-hypopnea index (AHI) >30 per hour. There was no known family history of cardiac disease, and the patient did not have a history of syncope.
+
+On examination, his blood pressure was 132/83 mmHg, and he had a regular pulse of 98 bpm, a respiratory rate of 20 breaths/minute, a temperature of 98.7°F, with oxygen saturation (SaO2) of 88% on room air. His heart sounds were normal without murmurs. Lung auscultation showed reduced but clear breath sounds, and mild lower limb edema was present.
+
+Blood gases showed a pH of 7.31, PaO2 of 57 mmHg, a PaCO2 of 61 mmHg, and a SaO2 of 86% on room air. Serum bicarbonate was 30 mmol/L, brain natriuretic peptide (BNP) 160 pg/ml, troponin 0.030 ng/ml, and thyroid function tests were normal. An electrocardiogram (ECG) showed normal sinus rhythm with a rate of 95 beats/min, a normal electrical axis with good R wave progression in the precordial leads. No epsilon waves were seen in the precordial leads.
+
+Pulmonary function tests showed no obstruction or restriction with a normal diffusing capacity of the lungs for carbon monoxide (DLCO) and normal total lung capacity (TLC). The patient had a reduced forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) with a normal FEV1/FVC ratio, which are commonly seen with obesity hypoventilation syndrome (OHS).
+
+Chest computed tomography (CT) showed normal lung parenchyma without pulmonary embolism. Two-dimensional transthoracic echocardiogram (TTE) showed normal left ventricular function and a dilated right ventricle (RV) with a flattened septal wall (1.3 cm in diameter), moderate tricuspid regurgitation, an estimated right ventricular systolic pressure of 55–60 mmHg, right and left atrial dilatation, mild concentric left ventricular hypertrophy, and a left ventricular ejection fraction of 50%. The right ventricle was severely dilated and dysfunctional. There was moderate tricuspid regurgitation (max. velocity 303 cm/sec) with an estimated right ventricular systolic pressure (RVSP) of 55–60 mmHg. Pulse-wave tissue Doppler imaging (TDI) of the anterior and posterior mitral annulus showed abnormal left ventricle relaxation. The patient was discharged on continuous positive airway pressure (CPAP) and oxygen at night, and as needed during the day.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3076_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3076_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..717540b16c25bf21e9abcf918acdde7fbc8edf1f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3076_en.txt
@@ -0,0 +1 @@
+Female, 35 years old, with a history of asthma and alopecia areata. She presented with paresthesia of the lower limbs that progressed gradually. After one month she presented with a picture of asthenia and bifrontal headaches of moderate intensity with a poor response to analgesics and blurred vision, later with constipation and urinary incontinence. She presented with transient episodes of confusion and disorientation, with subsequent complete recovery. After three months of evolution of the clinical picture, she was admitted to a hospital in Spain for study. Complementary examinations were performed; routine laboratory, acute phase reactants (VSG, PCR), B12 and folic acid, HIV, HBV, HCV and tumour markers (CEA, CA15.3, CA125, CA19.9) were found within normal parameters. Electroforetic proteinogram without monoclonal component. Anti-GFAP antibodies in serum and CSF negative. ANAANCA, AQP4 and MOG, LGI1, NMDAR, GABAa, GABAb, GAD, Yo, Hu, Ri, Ma2, CV2, fisina, SOX1, recoverina, negative titers. Anti-GFAP antibodies in serum negative. Anti-thyroglobulin 181 (positive at low titre). Collagenogram: FAN positive 1/320, homogenous nuclear pattern. CSF: GB 53 (99% MN), glucoraquia 59 mg/dl, proteinorraquia 135 mg/dl. ADA 10.5. Cultures in CSF negative for bacteria, viruses and fungi. Oligoclonal bands type IV. Immune phenotypic cytometry, normal lymphocytes. Cytology with lymphocytes without atypia in 2 opportunities. Fundus of eye with blurring of papillae bilateral, cellular vitreous, macula normal without choroid retinitis or macular retinitis. Optical coherence tomography (OCT) with intra-retinal oedema in papillomacular bundle and bilateral papilla oedema. Study of nerve conduction: polyneuropathy sensory axonal, symmetric, with involvement of lower limbs and without denervation. Brain MRI: diffuse hyperintense lesions in T2/Flair subcortical parietal occipital, without effect of mass, without diffusion restriction. In the T1 sequence with contrast it presents captation in subcortical pattern with tendency to form a radiated and linear perivascular pattern. MRI of cervical column: oedema hyperintense in T2/Flair longitudinally extensive from bulb to dorsal spinal cord, in disposition of the centromedular. In the contrasted sequence it presents a similar pattern to the one described at the supratentorial level, with the thyroid gland and dorsal spinal column showing a pattern of leptomeningeal and parenchymal captation. Optical emission tomography of the whole body: brain with greater relative fixation of fluorodeoxyglucose (FDG) of both striata in the mesial temporal region and bilateral uncus. Diffuse hypometabolism of most of the cerebral cortex. FDG captation in thyroid gland and thyroid nodule. The study of the thyroid nodule was deepened with a diagnosis of left papillary and right follicular thyroid carcinoma (BRAAF 1). Total thyroidectomy with vaciamiento ganglionar and subsequent treatment with radioactive iodine was performed. In the face of the suspicion of inflammatory disease without precise etiology, it was decided to initiate corticoids with partial improvement of the clinical picture. After 6 months the patient was referred to our center in CABA, Argentina. On physical examination she presented preserved higher mental functions, visual acuity near and far 10/10, visual fields preserved, chromatic vision preserved, reactive isocortical pupils, extrinsic ocular movements without alterations, multidirectional nystagmus not depletable. Low pairs preserved. No neck stiffness, Kendall 5/5 in all muscle groups, hyperreflexia in upper limbs and live reflexes in lower limbs. Hoffman negative, bilateral clonus, bilateral reflexes indifferent, isocortical pupils, no nystagmus, chromatic vision preserved, isocortical pupils, no nystagmus, chromatic vision preserved, isocortical pupils, no nystagmus, isocortical pupils, no neck stiffness, Kendall 5/5 in all muscle groups, hyperreflexia in upper limbs and live reflexes in lower limbs. Isocortical pupils, no nystagmus, chromatic vision preserved, isocortical pupils, no nystagmus, isocortical pupils, no neck stiffness, Kendall 5/5 in all muscle groups, hyperreflexia in upper limbs and live reflexes in lower limbs. Isometria of D lower limbs. Romberg positive. Taconeante gait, with increased base of support. During her hospitalisation new complementary examinations were performed. Schirmer negative, ophthalmological evaluation with computerised visual field and OCT within normal parameters, serologies for Whipple negative, neuroconduction that confirmed the previously described findings. In the face of clinical and imaging suspicion, a dose of anti-GFAP antibodies in CSF was performed with a positive result, titre 1:100 and a diagnosis of astheno-myelopathy with autoimmune glial acid fibrillar protein was made. The patient continues follow-up in our centre without new clinical or imaging relapses, which is why a waiting policy was decided for the treatment according to evolution.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3089_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3089_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c7213a636d7847acb3735ce3576caa41eed06140
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3089_en.txt
@@ -0,0 +1,15 @@
+Full term newborn, 38 weeks gestational age, planned caesarean section, Apgar 8-8, birth weight 2,895 g, length 47 cm, head circumference 34 cm and normal thoracic circumference.
+
+Relevant family history: His 29-year-old mother was diagnosed with SHCC, requiring mechanical ventilation through a tracheostomy from the age of 2 years and later NIV with nasal interphase and pressure-driven adjustment throughout her life. As her condition was not associated with a respiratory drive defect during wakefulness, a planned caesarean section was performed without complications.
+
+During the neonatal transition period, the newborn presented frequent desaturations. The arterial blood gas showed hypercapnia (PaCO2 60-80 mmHg) and respiratory acidosis (pH < 7.20 with excess base of 8-10). The rest of the parameters of the internal environment were normal.
+
+He was admitted to the neonatal intensive care unit of the San Borja Arriarán Clinical Hospital, where a normal respiratory pattern and pulse oxygen saturation (SpO2) > 95% were observed in the waking state, mild central hypotonia, with progressive improvement to a normal tone. During the transition from waking to sleeping, he presented very shallow breathing, not associated with increased respiratory work, wheezing or stridor, with progressive desaturation, SpO2 < 85%, which worsened with the administration of oxygen without NIV, with blood gases through the umbilical catheter in the range previously described. As sleep deepened, SpO2 tended to stabilise between 85-90% with continuous positive airway pressure (CPAP) using positive end-expiratory pressure (PEEP) 6-7 cmH20 administered with a nasal mask alternated with a short binasal cannula, without normalising arterial blood gases.
+
+At 36 hours of life, he was switched to NIV mode from cycled CPAP using inspiratory pressure (IP) of 14-16 cm H2O and PEEP of 4 cm H2O with nasal mask as the interface, normalizing oxygenation during sleep and blood gases in sleep and wake.
+
+In view of the high suspicion of SHCC, the PHOX2B gene was sequenced, confirming a heterozygous pathogenic variant with genotype 20/26 at 7 days of life. The study was completed with cerebral ultrasound, echocardiogram and 24-hour Holter rhythm, all normal. The need for specialised sleep studies was discarded given the confirmed diagnosis and the urgent requirement of complete NIV during sleep. She was evaluated by a multidisciplinary team including cardiologists, sleep specialists, pulmonologists, speech therapists, paediatricians and home hospitalisation kinesiologists with expertise in prolonged NIV.
+
+After one month of life, he was transferred to a lower complexity unit to maintain SVNI during full sleep, that is, with the adequate push pressure that allows the complete normalization of non-invasive monitoring of the SpO2 line > 90% while sleeping, and the complete normalization of blood gases while awake, including the excess base. A Philips hybrid ventilator, Trilogy EVOMR, was used with a single-rail circuit and external exhalatory valve for delivery of PEEP = 0 cm H2O and push pressure of 14-16 cm H2O, in pressure control mode, assisted controlled (PC/AC) with respiratory frequencies of 30 per minute and inspiratory time of 0.7 second.
+
+He presented a satisfactory evolution, without complications, so he was discharged to home hospitalization with the same nasal SVNI schedule only when he slept. At 7 months of age, a clear normal psychomotor and neurocognitive development was clinically verified, without requiring hospitalizations for events of any kind.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3095_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3095_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d6433376a66f63527aa16d4d50250d5351a56aed
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3095_en.txt
@@ -0,0 +1,9 @@
+A 50-year-old Semitic male presented with a 15-year history of progressively worsening right knee pain and associated swelling. The pain, initially mild, had intensified to the point where it was present at rest and worsened with weight-bearing activities. The patient reported increased swelling but denied knee locking, giving way, or nighttime pain. Ibuprofen provided partial relief of symptoms. He was otherwise healthy and physically active, with no notable medical or family history.
+
+On examination, there was significant quadriceps wasting in the right lower limb, with visible swelling in the popliteal fossa and anterior knee. Palpation revealed a hard, immobile, well-defined mass in the anterior knee (measuring 4 × 8 cm) as well as a diffuse mass in the posterior aspect. There were no associated skin changes or tenderness, except for the medial joint line, which was slightly sensitive to the patient. The patient had a knee flexion of 100 degrees, with full extension. McMurray’s test was negative, indicating there was no ligamentous instability.
+
+Magnetic resonance imaging (MRI) revealed a knee effusion, synovial hypertrophy, and a loose calcific body exerting pressure on the popliteal fossa and patellar tendon, anterior to the femoral condyle, which was suggestive of synovial chondromatosis.
+
+Given the significant involvement and size of the loose body within the knee joint, an open surgical approach was decided. A medial parapatellar approach was utilized following an anterior mid-line incision. Two large loose bodies approximately 4 × 4 cm and 3 × 5 cm were removed from beneath the suprapatellar pouch and patellar tendon. Histopathological analysis confirmed synovial chondromatosis with synovial papillary hyperplasia.
+
+After 6 weeks, a second procedure was performed for the posterior knee mass using a posterior knee approach, and a 5 × 4 cm mass was successfully removed. Postoperatively, the patient began physiotherapy immediately and achieved a knee range motion of 0–125 degrees at 6 months, and there was no recurrence identified at 1 year postoperatively.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3128_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3128_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..74e2d2cbc4a4dfdd7efe2f81c697aaeeafd600d6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3128_en.txt
@@ -0,0 +1,7 @@
+A 40-year-old female patient with a history of late-onset allergic rhinitis was referred from a private hospital to Siriraj Hospital, Bangkok, Thailand. She presented with a 2-week history of numbness in the right leg, progressively worsening dyspnea, and multiple crops of erythematous papules and vesiculobullous lesions that subsequently ruptured, becoming shallow and ulcerated areas on the forehead and left ear. She had been treated with diclofenac and antihistamines, but there was no improvement. Afterward, she developed fever, worsening dyspnea, and hemoptysis. She was admitted to the intensive care unit due to hypoxic respiratory failure and was diagnosed with pneumonitis with alveolar hemorrhage. She denied any underlying diseases and was not taking any current medications. She had no history of smoking or alcohol use.
+
+Physical examination revealed a chronically ill-looking middle-aged woman who was pale and febrile. Bilateral chest crackles were noted, and there was no pedal edema. Cutaneous examination revealed multiple erythematous papules and vesicles with some shallow erosions on an erythematous base located on the forehead and left ear, as well as multiple well-defined, non-blanchable erythematous patches and papules on both palms and both lower legs. A neurological examination showed decreased pinprick sensation in the right foot, and motor power was grade V/V in all extremities. Examination of the GI and cardiovascular systems was unremarkable.
+
+Laboratory results on admission were as follows: white blood cell count, 20.8 × 103/μL; neutrophils, 34.5%; eosinophils, 52.8%; absolute eosinophil count, 10.9 × 103/μL; hemoglobin, 10.5 g/dL; platelets, 281 × 103/μL; total protein, 6.8 g/dL; serum albumin, 3.6 g/dL; AST, 31 U/L; ALT, 41 U/L; ALP, 96 U/L; serum urea nitrogen, 7.4 mg/dL; serum creatinine, 0.5 mg/dL. Workup for infections, including blood and sputum cultures, was negative. Autoimmune serology demonstrated a positive anti-myeloperoxidase antibody and negative results for antinuclear antibody and anti-proteinase-3 antibody. The chest X-ray showed multifocal alveolar opacities in both the middle and lower lung zones. A CT scan of the chest performed at presentation revealed multifocal consolidations with surrounding ground-glass opacities scattered in both lungs, suggestive of diffuse alveolar hemorrhage. Bronchoalveolar lavage was performed, revealing a white blood cell count of 3,500 cells/μL, with neutrophilia (3%), eosinophilia (67%), and numerous red blood cells. Transbronchial biopsy showed eosinophilic pneumonia and marked eosinophilic infiltrates in the bronchial wall tissue, but no vasculitis or granulomas were identified in the tissue sample. A skin biopsy of the forehead revealed intraepidermal separation accompanied by necrotic keratinocytes, with the presence of neutrophils and eosinophils within the vesicle, along with focal leukocytoclastic vasculitis. There was superficial and deep perivascular and interstitial infiltration, predominantly consisting of eosinophils and neutrophils. Direct immunofluorescence (DIF) was negative. Electromyography showed evidence of multiple mononeuropathies.
+
+The patient was diagnosed with EGPA based on a history of eosinophilic pneumonitis, pulmonary vasculitis, eosinophilic bullous vasculitis, mononeuropathies, eosinophilia, and positive anti-myeloperoxidase antibodies. She was treated with intravenous methylprednisolone 500 mg/day for 3 days and a single dose of intravenous cyclophosphamide 800 mg (0.52 g/m2), followed by a switch to oral prednisolone 30 mg/day. The skin lesions gradually improved, developing post-inflammatory hyperpigmentation, and her oxygen requirements showed improvement. Subsequently, she was discharged on oral steroids with a plan to infuse cyclophosphamide once a month for induction of remission. Four months after diagnosis, the patient progressed to GI vasculitis with bowel ischemia, ileal perforation, and subsequent death from gram-negative bacilli septicemia.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3140_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3140_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..34577af86b48980c9a15a11c322a8bb9779ebfee
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3140_en.txt
@@ -0,0 +1,16 @@
+Clinical examination showed a patient with stable cardiopulmonary status and a pulse of 86/min and blood pressure of 140/85 mm Hg. Body temperature was 36.7°C. Respiratory frequency was 16 per minute with an oxygen saturation of 96% without supplementary oxygen. Auscultation of the lung found dry rales in the basal compartments. Examination of the heart and abdomen was unremarkable.
+
+In the initial arterial blood gas analysis, Po 2 was 88 mm Hg with a saturation of 97.2%; Pco 2 was 20.7 with pH 7535. Laboratory findings showed a procalcitonin of 0.12 ng/mL (<0.05 ng/mL) and a C-reactive protein level of 4.19 mg/dL (<0.5 mg/dL) with normal leukocytes and a blood sedimentaion rate of 56 mm/h (<46 mm/h). The differential blood count showed monocytosis, and lymphocytes were normal. There was a normocytic and normochromic anemia. Other values were lactate dehydrogenase, 271 U/L (135-255 U/L); D-dimer, 2.04 mg/L (<0.8 mg/L); hs-troponin T, 19 pg/mL (<14 pg/mL) without further increase after 3 hours; myoglobin, 122 µg/mL (28-72 µg/mL); elevated creatinine, 2.13 mg/dL (0.67-1.17 mg/dL); blood urea nitrogen, 77.6 mg/dL (16.6-48.5 mg/dL); and glomerular filtration rate calculated for cystatin C, 22 mL/min. Hemoglobin A1c was 6.5%.
+
+An initial electrocardiographic study had no pathological findings. Computed tomography (CT) scan of the thorax showed distinct atypical opaque infiltration of the left lower lobe consistent with viral pneumonia. Swabs from throat and nose as well as sputum tested positive for SARS-CoV-2 on real-time polymerase chain reaction (PCR) on the day of admission.
+
+The patient with heart transplant due to coronary artery disease with ischemic cardiomyopathy was diagnosed with SARS-CoV-2 infection with viral pneumonia.
+
+
+TREATMENT
+
+After establishing the diagnosis, we started a therapeutic trial with hydroxychloroquine with an initial dose of 400 mg twice daily for the first day followed by 200 mg twice daily. We refrained from therapy with lopinavir/ritonavir because of possible interactions due to the shared metabolization path via CYP3A4 with sirolimus. The patient preemptively received piperacillin/tazobactam and cotrimoxazole and ganciclovir because he had a history of CMV infections including colitis and pneumonia. In close cooperation with the transplant center (Ludwig-Maximilians-Universität), we modified immunosuppressive medication, replacing sirolimus with tacrolimus due to its potential lung toxicity.1 Once a steady serum level was reached, we withdrew mycophenolate.
+
+The patient was monitored in an intensive care unit for 3 days and received 4 L oxygen supplementation via nasal cannula. Arterial oxygen saturation dropped as low as 89% with a Horovitz index of 169 mm Hg and an alveolar-arterial gradient of 162 mm Hg (age corrected <23 mm Hg) indicating a potential severe case with a moderate acute respiratory distress syndrome (ARDS) and a consecutive V/Q mismatch. As there were no signs of further relevant deterioration, the patient was transferred to our normal ward. CT was repeated 4 and 9 days after admission, showing fluctuation of the opaque infiltrations on the first and a general decline on the second scan. The patient additionally presented with diarrhea, but stool samples showed a negative culture and multiplex PCR for pathological bacteria or viruses.
+
+After 7 days, the patient started to show relevant improvement in the respiratory situation and required no further oxygen supplementation. There was no increase in procalcitonin or a left shift in granulocytes; thus, antibiotic treatment was discontinued. Respiratory symptoms declined after 9 days so we tested sputum as well as throat and nose swabs for SARS-CoV-2 on the following 2 days. PCR was negative in all specimens. A multiplex PCR in another sputum as well as serological results showed no clues for CMV reactivation or other viral or bacterial agents. The patient received hydroxychloroquine a total of 9 days. We were able to discharge the patient 12 days after admission.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3153_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3153_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b09d39dca3a3665289f9251ae048110e53c55d02
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3153_en.txt
@@ -0,0 +1,9 @@
+A 35-year-old woman (gravida 1, para 1; uneventful pregnancy with history of first delivery at 32 years of age) was referred to our cardiac emergency department for the management of heart failure due to PPCM. The patient had a benign medical history before the current delivery of twin pregnancy. Her blood pressure had been within the normal range throughout the pregnancy, ranging from 111/64 to 129/75 mmHg in the absence of antihypertensive agents, and she had not developed proteinuria during the pregnancy. She was admitted to the obstetric hospital for the management of her pregnancy at 32 weeks of gestation. On admission, she was asymptomatic. However, chest radiography showed cardiac enlargement [cardiothoracic ratio (CTR), 54%], and transthoracic echocardiography showed a slightly dilated cardiac chamber and preserved LV function [LV end-diastolic dimension (LVDd)/LV end-systolic dimension (LVDs), 51/34 mm; LVEF calculated using Teichholz’s formula, 54%]. Her plasma B-type natriuretic peptide (BNP) level was elevated at 138 pg/mL. At 35 weeks of gestation, she unexpectedly gained body weight, and chest radiography showed further cardiac enlargement (CTR, 58%) and left pleural effusion. Her LV dimensions and BNP level also showed slight increases (LVDd/LVDs, 54/36 mm; BNP level, 154 pg/mL), while the LVEF was still preserved (62%). Although her ratio of mitral valve inflow velocity to left ventricle wall tissue velocity was within normal range (E/e': 9.4), the trans-tricuspid pressure gradient was mildly elevated (34 mmHg), suggesting a certain degree of diastolic dysfunction had caused her pleural effusion. Her electrocardiogram did not change during pregnancy.
+
+She subsequently underwent usual vaginal delivery, and healthy twin neonates were born at 38 weeks. Immediately after delivery, progressive malaise and dyspnea developed. Chest radiography revealed pulmonary congestion and increased bilateral pleural effusion. Transthoracic echocardiography revealed a severely reduced LV systolic function and increased LV dimensions. Thus, the patient was diagnosed with heart failure, and PPCM was suspected as the underlying etiology. The patient was referred to our tertiary medical center for further management.
+
+On referral to our hospital, the patient’s pulse rate was 103 beats/minute, her blood pressure was 150/97 mmHg, respiratory rate was 29 breaths/minute, and room air oxygen saturation was 94%, with a New York Heart Association (NYHA) functional class III. Her BNP level was elevated at 2,696 pg/mL. Chest radiography showed further cardiac enlargement (CTR, 64%) and pulmonary congestion. On transthoracic echocardiography, LVDd/LVDs was 58/53 mm, and LV wall motion exhibited severely reduced contraction, with an LVEF of 24% and only mild mitral regurgitation.
+
+Emergency right heart catheterization indicated progressive heart failure with a high pulmonary capillary wedge pressure (25 mmHg), high pulmonary arterial pressure (40/23/30 mmHg), normal right atrial pressure (2 mmHg), and normal cardiac index (4.6 L/min/m2). We then detected an increased heart rate (from 95 to 138 beats/minute) and a gradual decrease in her cardiac index (down to 2.8 L/min/m2). Considering her low stroke volume index (20 mL/m2), we initially administered inotropes, but her heart failure continued to worsen. Thus, intra-aortic balloon pumping (IABP) was used for circulatory support. Cabergorine, which is a potent dopamine receptor agonist, was prescribed at a dose of 1 mg for the suppression of lactation, due to the high metabolic demands of lactation and breastfeeding. Bromocriptine was not administered for the treatment of PPCM because the available data were insufficient to recommend its routine use. Her hemodynamic parameters improved with these multidisciplinary treatments. Her heart failure gradually improved, allowing for the removal of IABP 9 days after the insertion and the discontinuation of inotropes 15 days after infusion.
+
+Her hemodynamic state remained stable after weaning from inotrope therapy, and she was transferred to the ward with the following medications: 1.25 mg/day enalapril, 5 mg/day carvedilol, 20 mg/day furosemide, and 25 mg/day spironolactone. Pre-discharge laboratory tests, chest radiography, and transthoracic echocardiography showed significant improvements: CTR, 50%; LVDd/LVDs, 49/40 mm; and LVEF, 42%. Her plasma BNP level normalized to 10.2 pg/mL. During hospitalization, we excluded other. An endomyocardial biopsy performed one month after the onset of PPCM revealed no infiltrative disorders and showed that the interstitial fibrosis and interstitial edema were mild, without inflammatory cell infiltration, myocardial necrosis, or degeneration. We therefore diagnosed the patient as having PPCM. She was discharged 45 days after admission with an NYHA class I. Six months later, her BNP level decreased to 9.3 pg/mL, CTR decreased to 49%, LVDd/LVDs decreased to 44/29 mm, and LVEF improved to 53%.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3160_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3160_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7116806ef26bf1017dde7009675c4f5da5f36274
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3160_en.txt
@@ -0,0 +1,16 @@
+A 25 days old male infant was the first born child of a 26 year old mother and 32 year old father. Family history was unremarkable and there was no parental consanguinity.
+
+During pregnancy, the pregnancy was well monitored. The mother denied any history of drug abuse involving tobacco and ethanol. Furthermore, there was no reported exposure to radiation or chemical substances. It is noted that the mother received antibiotic therapy during the third and fourth months of gestation due to recurrent urinary tract infections. Congenital abnormalities have been detected in the fetus at 33 weeks of gestation, including:Atrial septal defectInline graphic shortened lower limbs, narrow forehead, small jaw, and signs of restricted fetal growth in the womb.
+
+During Postnatal course, the birth length was 46 cm, weight 2000 g and head circumference 33 cm. The baby was admitted to hospital with severe vomiting, feeding difficult and irritability, with multiple congenital anomalies were noted by the family.
+
+Physical examination: the infant had microcephaly, broad nasal tip, maxillary hypoplasia gingival enlargement, low set ears, ptosis and staphyloschisis, the limbs hadsyndactyly of second and third toes. Cardiovascular system examination showed short systolic murmure at lower left sternal borderin. Genital examination showed small penis hypospadiasis with undescended testis. The baby had dry mucous membranes and tachycardia.
+
+Laboratory examination and diagnostic tests, the laboratory investigations showed hyponatremia and elevated level of blood urea. Routine peripheral blood cell counts were normal. Serum cholesterol level showed low value of 43 mg/dl (normal value in neonates 85–165 mg/dl).
+
+Karyotyping was 46XY
+Our patient is homozygous for a pathogenic variant, [NM-001360.2:c121OC,T;p.(Arg404CYS)] in the DHCR7 gene. Pathogenic variants in the DHCR7 gene are associated with Smith-Lemli-Optiz syndrom with an autosomal recessive mode of inheritanc.
+
+Radiological studies, the infant was evaluated with echocardiography that showed atrial septal defect (ASD) with pulmonary hypertension. The head ultrasound showed a agenesis of corpus callosum, abdominal ultrasonography showed Horseshoe kidney. Upper gastrointestinal contrast study showed sevrs gastro oesophageal reflux. A diagnosis of Smith-Lemli-Opitz-syndrome was made based on clinical ، biochemical profile and molecular genetic testing.
+
+Then, we managed dehydration and hyponatremia. An orogastric tube was inserted and Tips were provided to parents for managing gastroesophageal reflux, including elevating the head of the bed, feeding in an upright position, and avoiding tight clothing. After our patient experienced severe irritability, he was prescribed simvastatin at a dose of 0.5 mg/kg/day for 6 weeks, followed by an increased dose of 1 mg/kg/day for 12 months. During the follow-up period, an improvement in the baby’s irritability was observed with good tolerance and without any side effects.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3161_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3161_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a61034e8cbea122a52f11da35935d08b6338ff33
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3161_en.txt
@@ -0,0 +1,19 @@
+In July 2022, a male preterm infant with a gestational age of 31 weeks was admitted to the neonatal intensive care unit due to prematurity. The mother, G1P0, had no medical illness and did not receive dexamethasone. The neonate was delivered through spontaneous vaginal delivery and was born weighing 1.46 kg with Apgar scores of 7 at 1 min and 8 at 5 min. Moreover, physical examination and chest radiography revealed signs of respiratory distress syndrome. Subsequently, the infant was intubated immediately after delivery and connected to mechanical ventilation. Chest radiography confirmed grade II respiratory distress syndrome and two doses of bovine surfactant were administered. Furthermore, the infant developed hypotension, requiring inotropes. Empirical antibiotics, ampicillin, and gentamicin were started according to the Neofax dosage, pending blood culture. Oral caffeine citrate and prophylactic fluconazole were administered at 3 mg/kg/dose. Thereafter, total parenteral nutrition (TPN) was initiated, and an umbilical venous catheter was inserted.
+
+On post-natal Day 2, the patient developed respiratory acidosis and pulmonary hemorrhage, requiring high-frequency ventilation. His complete blood count (CBC) revealed white blood cell count (WBC) of 8.3 × 103 per mm3, hemoglobin level of 8.5 gm/dl, platelet count of 6,000/mm³, prothrombin time of 18 s, partial thromboplastin time of 36 s, and an international normalized ratio of 1.8. Blood culture results were negative. The patient received supportive management of epinephrine via the endotracheal tube and was administered vitamin K, fresh frozen plasma, and PRBCS.
+
+On Day 3, the echocardiogram (ECHO) showed a 2·5 mm patent ductus arterious (PDA) and pulmonary hypertension. The patient was initiated on paracetamol and sildenafil, and following improvement, antibiotics were discontinued. On Day 6, the patient was switched to conventional mechanical ventilation; the CBC was normal.
+
+On Day 11, the patient experienced severe respiratory distress and desaturation, requiring increased ventilation. Moreover, he had low blood pressure, hypothermia, abdominal distension, leukocytosis (WBC of 17,030/mm3, including 21% band forms), thrombocytopenia (platelet count of 96,000/ mm3), and elevated C-reactive protein of 105 mg/L). Cerebrospinal fluid (CSF) analysis revealed pleocytosis with a total CSF WBC of 34,000/mm3; the culture was negative. Therefore, the patient was upgraded to vancomycin and amikacin antibiotics at a dose according to the Neofax. Blood culture yielded Staphylococcus epidermidis from the central line, leading to the discontinuation of Amikacin and the continued use of vancomycin. On Day 12, umbilical venous catheterization was performed.
+
+On Day 13, the patient experienced clinical deterioration, including increased abdominal girth, severe metabolic acidosis, thrombocytopenia, and anemia. Supportive management was provided through PRBCS and platelet transfusions. Blood culture yielded Klebsiella oxytoca, for which meropenem was initiated, and prophylactic fluconazole and vancomycin were continued. Two sets of blood culture bottles were utilized.
+
+On Day 14, we incubated a Pediatric Plus™/F blood bottle for five days and a Mycosis IC/F blood bottle specific for the isolation of fungus for 14 days, following our laboratory’s protocol. The Pediatric Plus blood culture bottle showed positive results after 72 h, whereas the Mycosis bottle showed positive results on the sixth day of incubation. Moreover, we performed Gram staining of the positive blood culture bottles, and the stained films showed round-to-oval, yeast-like fungi; we sub-cultured the colonies on Sabouraud Dextrose agar at 37 °C and isolated growth after 48 h. Colonies were initially creamy in color but gradually darkened as they aged, and the isolated growth was identified by the VITEK®2 YST ID card (bioMérieux, Inc. St. Louis, Mo. France) as C. albidus. Identification was confirmed using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF mass spectrometry) (Vitek MS, BioMerieux®, Marcy l’Étoile, France).
+
+In our hospital, we do not utilize the Ligase Chain Reaction (LCR) method for the identification of Candida albidus, primarily because it is not available in our general hospital setting. LCR is a highly specialized molecular diagnostic technique often found in research centers or advanced diagnostic laboratories.
+
+Instead, we rely on alternative diagnostic systems. For the identification of Candida albidus, we commonly use the Vitek system, which provides accurate identification of fungal species based on biochemical characteristics. To confirm the results obtained from the Vitek system, we employed MALDI-TOF mass spectrometry, a cutting-edge technology that identifies microorganisms based on protein profiles. This approach is both efficient and suitable for routine diagnostic purposes in our general hospital setting, even though more advanced molecular techniques, such as LCR, are reserved for research institutions.
+
+On Day 16, the Infectious Diseases team was consulted, and CFS sampling was recommended, continuing vancomycin and meropenem for two weeks from the first blood culture. ECHO, eye examination, abdominal ultrasound, and administration of liposomal amphotericin B (5 mg/kg/day, once daily) were initiated. The CSF culture returned negative, ECHO showed no vegetation, the PDA was not closed, and the platelet count improved to 128,000/mm3. Finally, abdominal ultrasonography revealed no focal lesions.
+
+At 33 days of age, the patient was switched to conventional mechanical ventilation. A brain MRI revealed bilateral frontal and right periventricular white matter hemorrhages and a minimal subdural hemorrhage. The neurosurgeon advised the patient against any intervention. The patient received liposomal amphotericin B for six weeks and was discharged 57 days after completing the antifungal course. Follow-up appointments for one year revealed no complications, and good milestones were achieved.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_317_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_317_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6a457308cf8907ed70185fe81a5e092c8a599ca6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_317_en.txt
@@ -0,0 +1,10 @@
+In January 2008, a 61-year-old man with a history notable for diabetes mellitus (DM), autonomic neuropathy, diffuse brain atrophy, optic nerve atrophy (OA), and profound amnesia was referred to us to establish neurologic care. The patient carried a diagnosis of multiple system atrophy- cerebellar type (MSAc), principally because of severe cerebellar and brainstem atrophy on MRI.
+The patient's early history was remarkable only for childhood bedwetting and urinary urgency as a young adult. He was otherwise well during this time and was a talented athlete who completed college and practiced as an accountant. In his early 20s, he developed bladder dysfunction of unclear etiology requiring intermittent straight catheterization, as well as erectile dysfunction.
+At age 33, he was diagnosed with DM, presumed to be type 1, and began treatment with insulin therapy. Although there is no biochemical data available from the time of his original diagnosis, recent testing demonstrated a random C-peptide level of 0.6 ng/mL (reference range 0.9 to 4.3 ng/mL) at a time when his blood glucose was 83 mg/dL. He takes an average of 24 units of insulin per day, and has had good glycemic control with hemoglobin A1c measurements ranging between 6.5 and 7.2% over the last several years. He has had no evidence of retinopathy, or other microvascular or macrovascular complications. He had polyuria and polydipsia at the time of his initial DM diagnosis, but these symptoms resolved once he initiated insulin therapy.
+The patient began dressing in strange colors in his 30s, and color blindness was ultimately diagnosed in his 40s. At age 53, the patient presented for a routine screening ophthalmology exam and was discovered to have bilateral OA with preserved vision. Brain MRI at that time revealed severe atrophy of the cerebellar hemispheres and vermis, pons, and middle cerebellar peduncles as well as moderate cerebral atrophy; a more recent study at age 61 showed these findings as well as more severe cerebral atrophy . Despite these radiographic findings, the patient and his wife reported no gait instability or upper extremity incoordination.
+During his late 50s, the patient's neurologic status deteriorated. Formal neuropsychological evaluation revealed profound anterograde amnesia, with additional impairments in cognitive flexibility, executive function, naming, and high order visual processing skills. Attention span, mental tracking, verbal abstract reasoning, complex auditory instructions, and visual spatial functions were preserved. From a psychiatric perspective, he developed symptoms of depression, which responded to treatment with sertraline.
+In parallel with the decline in his memory, the patient also developed progressive autonomic neuropathy, with gastroparesis and severe postural hypotension. The autonomic dysfunction exceeded what might be expected from his diabetes mellitus, given his good glycemic control and the absence of other diabetic complications. His bladder dysfunction worsened and he required suprapubic catheter placement at the age of 61. Due to his multiple functional deficits, the patient became unable to work and is now completely reliant upon his wife for care.
+Regarding his family history, the patient was born to Ashkenazi Jewish parents and there was no parental consanguinity. His mother died from melanoma, and his father died from multiple strokes and a myocardial infarction. He has two adult daughters, one of whom has attention deficit hyperactivity disorder (ADHD) and Tourette syndrome, while the other suffers from chronic urinary tract infections. His maternal grandmother had type 2 DM, and a maternal first cousin had type 1 DM. No other close relatives have suffered from endocrine, psychiatric, or neurologic disease.
+On physical examination, he appeared generally medically well. He weighed 79 kilograms and was 178 cm tall, yielding a body mass index of 25. Postural hypotension was evident with systolic blood pressure falling from 150 to 95 after one minute of standing, though asymptomatic. Funduscopic examination revealed optic atrophy bilaterally with no sign of diabetic retinopathy. Visual acuity was 20/40 in each eye. Pupil responses to light and accommodation were normal. Eye movements were normal with the exception of saccadic intrusion into horizontal smooth pursuit. Clinical examination revealed high tone hearing loss bilaterally. Audiometry demonstrated moderate sensorineural hearing loss in the high frequencies on the left, and mild sensorineural hearing loss in the mid-frequencies on the right sloping to a severe loss in the high frequencies . Word recognition was excellent in both ears; 98% on the right and 96% on the left. Muscle tone in the extremities was normal, bulk was intact, and strength was full. There was no evidence of dysmetria with finger-to-nose and heel-to-shin testing, and gait was slow but stable. His affect was flat and he was passive throughout the interview, speaking only when spoken to. He was not oriented to time or place. He could repeat four words, but could not learn them despite multiple attempts. He was unable to provide information concerning major current political or national news. He could, however, recall sizable fragments of remote memory from his college years.
+The absence of the cerebellar motor syndrome and the presence of a profound amnestic syndrome on examination called the patient's diagnosis of MSAc into question , and we undertook re-evaluation of his case to explore alternate diagnoses. His laboratory work-up revealed an undetectable thiamine level, a surprising finding given his normal diet and the absence of alcohol abuse. We ascribed his amnestic disorder to presumed long-standing thiamine deficiency, but repletion produced minimal clinical impact. The involvement of multiple systems suggested the possibility of a mitochondrial disorder. Genetic testing for OPA1, MELAS, MERFF, LHON and NARP were negative, however analysis of mitochondrial DNA (mtDNA) from a muscle biopsy sample by both Southern blotting and PCR analysis revealed multiple heteroplasmic deletions. Biochemical testing revealed a minor defect in complex I of the electron transport chain. COX and SDH staining of the muscle biopsy specimen were unremarkable, and the mitochondria appeared grossly normal on electron microscopic examination. Occasional central vacuoles and tubular aggregates were seen in the myocytes, which were felt to be consistent with a mild non-specific myopathy.
+Given the diagnostic uncertainty and concern for a mitochondrial disorder, the patient was enrolled in the mitochondrial disease registry at Massachusetts General Hospital. As part of this program, a sample of the patient's DNA from whole blood underwent targeted exome ("MitoExome") sequencing. Mitochondrial DNA and the exons of 1,600 nuclear genes either encoding mitochondrial proteins or implicated in Mendelian disorders with multi-system phenotypes were targeted using hybrid selection . Amplified targets were sequenced on the Illumina GAIIx platform. Rare, protein-modifying variants found to be homozygous or potentially compound heterozygous were prioritized , revealing an X-linked functional polymorphism c.937G > T (p.D313Y) in GLA that is not considered pathogenic and a homozygous c.1672C > T (p.R558C) missense mutation in exon 8 of WFS1 that has previously been reported in a patient with Wolfram syndrome . No heteroplasmic mtDNA deletions were detected in whole blood. The patient's WFS1 mutation was verified through Sanger sequencing in a CLIA-certified laboratory, though not without complications; the initial report came back negative and only after requested follow-up was the homozygous mutation detected, thereby confirming the diagnosis of Wolfram syndrome.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3219_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3219_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bd58556bda365138e1df5a397dd6909fe6f6191c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3219_en.txt
@@ -0,0 +1,25 @@
+History of Presentation
+A 67-year-old woman presented at our ambulatory clinic for a follow-up computed tomography (CT) scan of the thorax with contrast medium after pulmonary vein (PV) stenting to address PV stenosis after catheter ablation for atrial fibrillation (AF). During the visit, the patient reported dyspnea (NYHA functional class III), intermittent palpitations, nausea, and general weakness. The clinical examination revealed no notable abnormalities.
+
+Past Medical History
+The patient’s medical history included persistent AF, first diagnosed 10 years before the current presentation, with a CHA₂DS₂-VASc score of 3 and an European Heart Rhythm Association score of 2b, under antiarrhythmic therapy with propafenone and oral anticoagulation with rivaroxaban. She had undergone 2 radiofrequency (RF)-based pulmonary vein isolation (PVI) procedures 8 and 7 years earlier. Due to AF recurrence, a new RF-based PVI was planned 3 years ago; however, PV stenosis was detected during angiography of the left PVs and a cryoballoon (CB)-based PVI was performed instead. A subsequent evaluation of the PV stenosis was recommended, but the patient failed to attend the appointment due to absence of symptoms.
+
+The patient presented 9 months ago at our ambulatory clinic with recurrent AF, and a new RF-based ablation was performed 6 months ago. During electroanatomic mapping, a persistent bidirectional block of the PVs was documented. Due to induction of atrial tachycardia and typical atrial flutter, anterior and posterior line ablations, and a cavotricuspid isthmus ablation were performed, with successful termination of the arrhythmias. High-grade stenosis of the left PVs was confirmed angiographically, and PV stenting was successfully completed 5 months before the current presentation by a multidisciplinary team. The prestenotic diameter of the left superior pulmonary vein (LSPV) and left inferior pulmonary vein (LIPV) was 6.5 and 7.0 mm, respectively. The 2 left PVs were dilated, and a 20- × 7-mm stent and a 20- × 10-mm stent were implanted in the LSPV and LIPV, respectively (Video 3). One week before the current presentation, the patient was hospitalized at another institution due to recurrent atrial tachycardia. Electrical cardioversion was performed, and therapy with propafenone was initiated.
+
+The medical history also included cardiac decompensation secondary to AF, with pulmonary edema, respiratory insufficiency, and intermittent noninvasive ventilation; chronic kidney disease; hypothyroidism managed with substitution therapy; arterial hypertension; hypercholesterolemia; and intolerance to flecainide.
+
+Differential Diagnosis
+The differential diagnosis considered AF or atrial tachycardia recurrence, worsening of left ventricular function, a new episode of pulmonary edema, propafenone intolerance, and progression of the PV stenosis leading to pulmonary hypertension.
+
+Investigations
+The electrocardiography at presentation showed a normofrequent sinus rhythm with no pathologic changes. Initial blood tests revealed previously known reduced renal function (glomerular filtration rate, 47 mL/min/1.73 m2) and hypothyroidism with inadequate substitution therapy.
+The thoracic CT scan with contrast media showed the stent in the LSPV, with normal contrast and positioning and a slightly progressive, high-grade, short stenosis of the LIPV, with no visible stent at this level. Additional findings included dilatation of the truncus pulmonalis (diameter: 35 mm) and the right pulmonary artery (diameter: 28 mm). The scan concluded a dislocation of the stent from the LIPV, which could not be visualized in the thoracic scan, along with signs of pulmonary hypertension.
+
+A subsequent abdominal CT scan identified the displaced stent in the abdominal aorta, located just cranial to the aortoiliac bifurcation.
+
+Management
+A multidisciplinary team consisting of electrophysiologists, radiologists, and interventional radiologists decided to implant an additional stent at the aortoiliac bifurcation to secure the displaced stent. Five days after presentation, an aortic digital subtraction angiography was performed, revealing the dislodged stent superior to the aortoiliac bifurcation and a moderate atherosclerotic stenosis of the right common iliac artery (CIA), by present peripheral artery disease. Due to the significant size mismatch between the diameter of the aorta, left CIA, and the displaced stent, overexpanding the stent in the abdominal aorta or repositioning the stent in the left CIA was deemed unfeasible. A double stenting procedure of the aortoiliac bifurcation using the kissing stents technique was performed. Two cobalt-chromium 9- × 58-mm stents (Dynetic, Biotronik) were implanted: the left one secured the displaced PV stent in place, whereas the right one treated the CIA stenosis. A Doppler ultrasound of the arteries of the lower limbs, performed on the first postprocedural day, showed no evidence of stenosis after stent implantation. The patient was discharged on rivaroxaban and clopidogrel therapy.
+
+Outcome and Follow-Up
+Due to recurrent AF despite propafenone therapy, a new RF-based AF ablation was performed 4 months after presentation, including reisolation of the anterior line and completion of the box lesion. During the procedure, atrioventricular nodal reentry tachycardia was induced by programmed stimulation, and a slow-pathway ablation was performed. During the slow-pathway ablation, a transient third-degree atrioventricular block occurred. Follow-up revealed a persistent second-degree 2:1 atrioventricular block, and a 2-chamber pacemaker was successfully implanted.
+Seven months after the presentation, the patient’s symptoms had significantly improved. A renewed ventilation-perfusion analysis, however, showed progressive worsening of the left lung perfusion. A new angiography of the LIPV, with subsequent stenting, was planned. A Doppler ultrasound examination of the main arteries in the lower limb did not reveal any pathologic findings.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_322_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_322_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..274d22ada1f7cd2eeac550c3b2812de62fc8ad6b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_322_en.txt
@@ -0,0 +1,8 @@
+A 50 year-old Caucasian American man with history of chronic obstructive pulmonary disease was admitted for loss of consciousness. He was found on the floor by his son, who brought him to the emergency department. The son denied noticing any tongue bite or bowel or bladder incontinence. The patient was unresponsive on arrival to the emergency department.
+The patient's home medications included albuterol inhaler as needed. He was smoking two packs of cigarettes daily, but the son denied history of alcohol or illicit drug intake. His vitals on presentation were: BP - 90/50 mmHg, HR - 116/min, RR - 28/min and Temp - 98.8°F, and he was saturating 92 percent on 2L oxygen via nasal cannula.
+His physical examination was significant for unresponsiveness, crackles in his left lung base and scattered wheezes throughout the lungs. His lab work showed a high WBC of 26,400/L, with 72.5% neutrophils and 13.5% bands, potassium of 5.3 mEq/L, BUN of 15 mg/dL and creatinine of 1.9 mg/dL (his baseline creatinine was 1.1 mg/dL). Urine toxicology screen was positive for opioid. Other labs included elevated creatine kinase of 15,860 U/L and elevated myoglobin of 46,651 ng/ml. Urine was positive for pneumococcal antigen. CT scan of the head without contrast was normal. Chest x-ray showed an infiltrate in the left mid lung field.
+The patient was admitted with a diagnosis of chronic obstructive pulmonary disease exacerbation secondary to pneumonia, fall with loss of consciousness secondary to severe sepsis, opioid abuse and acute renal failure secondary to rhabdomyolysis. He was started on intravenous steroids, antibiotics and bronchodilators. He was given intravenous fluid for his rhabdomyolysis and hypotension. Despite aggressive treatment of rhabdomyolysis his creatine kinase increased from 15,000 U/L on the day of admission to 45,000 U/L on day two and 80,000 U/L on day three. His serum creatinine level increased from 1.9 mg/dL on admission to 2.3 mg/dL on day two and 2.6 mg/dL on day three.
+On day three, the patient became slightly responsive and started complaining of pain in his right hip. On inspection, the patient's right hip was swollen, and it was very firm and tender on palpation .
+CT scan of pelvis was done which demonstrated fullness of the right gluteal muscles secondary to edema or inflammation or compartment syndrome .
+An MRI of the pelvis was recommended for further evaluation which showed enlargement of right gluteus minimus and medius muscles secondary to edema or hemorrhage with compartment syndrome . Gluteal compartment pressure was not checked as there seemed to be enough evidence from physical examination and rising serum creatinine and creatine kinase levels, that the patient's worsening rhabdomyolysis was secondary to the gluteal compartment syndrome.
+The patient was taken to the operating room where he underwent multiple fasciotomies. A large area of clot was noted between gluteus maximus and medius which was evacuated and the area was irrigated. The patient's creatine kinase and serum creatinine level improved to normal on discharge to home, five days after the surgical procedure. On follow-up visit to the office, two weeks after the patient's discharge, he was doing fine with normalization of his renal function and absence of gait abnormality, sensory dysfunction or muscle weakness.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3234_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3234_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3df4c6658b1004b6398b9c1d0f7ef193e7f58f0a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3234_en.txt
@@ -0,0 +1 @@
+An 81-year-old Korean man visited our out-patient clinic complaining of cough, dyspnea, and febrile sensation. He denied any previous medical histories. He stopped smoking tobacco 30 years ago, and never drank alcohol in recent years. His vital signs were: blood pressure 140/80 mmHg, heart rate 96 beats/minute, respiratory rate 22 breaths/minute, and body temperature 38.2 °C. On physical examination, crackle was noted in both lungs. Laboratory tests revealed a white cell count of 7800/mm3 with slight left shift (neutrophils 88.6%), C-reactive protein (CRP) level of 223.6 mg/dL (normal < 5.0 mg/dL), total bilirubin level of 1.5 mg/dL, and alanine transaminase and aspartate transaminase levels of 59 and 61 IU/L, respectively. His sodium level was 125 mEq/mL. In arterial blood gas analysis, which was checked in ambient conditions, pH, partial pressure of carbon dioxide in arterial blood (PaCO2), partial pressure of oxygen in arterial blood (PaO2), bicarbonate, and oxygen saturation levels were 7.50, 30 mmHg, 48 mmHg, 23.4 mmol/L, and 87%, respectively. The result of a test for human immunodeficiency virus was negative. Serologic tests for Mycoplasma and Chlamydia were negative. Streptococcal and Legionella urinary antigens were negative. Anti-nuclear and anti-neutrophilic cytoplasmic antibodies were negative. A chest X-ray revealed diffuse haziness dominant in his right lung field. Chest computed tomography revealed ground glass opacity in both lungs with small amounts of pleural effusion dominant in the right hemithorax. With an initial assessment of community-acquired pneumonia, we administered nasal oxygen at 4L/minute and empirical antibiotics with a respiratory quinolone. At hospital day 2, thoracentesis was conducted in the right hemithorax and a turbid yellowish fluid was obtained. Pleural fluid analysis revealed lymphocyte-dominant exudate with white cell count of 560/mm3 and adenosine deaminase level of 4.4 IU/L. On the same day, opacities were found on chest X-ray and hypoxemia rapidly progressed to require high flow oxygen supply with fraction of inspired oxygen (FiO2) 0.8 at a flow rate of 40 L/minute. At hospital day 3, he had to be intubated and mechanically ventilated due to worsening hypoxemia. The initial PaO2/FiO2 after application of mechanical ventilator was 65, which was compatible with the definition of “severe” ARDS. Potential cardiac dysfunction was ruled out using transthoracic echocardiography. Antibiotics were escalated to carbapenem. Multiplex real-time reverse transcriptase polymerase chain reaction (RT-PCR) was conducted using AdvanSureTM respiratory virus real-time RT-PCR kit (LG Life Sciences, Seoul, Korea) to detect respiratory viruses using tracheal aspirate. Results revealed positive for human RSV type B. Under the diagnosis of RSV-induced ARDS based on the Berlin definition, we started antiviral therapy of orally administered ribavirin 400 mg every 12 hours with concomitant intravenously administered methylprednisolone 30 mg every 24 hours. After treatment, hypoxemia and lung lesions gradually improved. At hospital day 17, he was extubated and we tapered methylprednisolone to orally administered prednisolone 15 mg. Finally, his chest X-ray cleared and he was discharged on hospital day 27 without any complications or drug-related adverse events. Orally administered ribavirin was maintained until his discharge.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3253_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3253_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ac01b8d1e6d12ccf468440468b78a32d0a3712ef
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3253_en.txt
@@ -0,0 +1 @@
+A 25-year old primigravid woman came to the University of Gondar Hospital fetal medicine outpatient clinic after she was referred for a fetal intraabdominal cystic mass seen on routine ultrasound scanning for a biophysical profile. Her medical and obstetric history was unremarkable. She had antenatal care and obstetric ultrasound was done at the fifth and seventh months and she was told that her fetus is in good condition. At 39 weeks of gestation, she came to us referred for advanced ultrasound scanning and we found an 80 × 60 × 40 mm retro vesical, oval, midline pelvic cystic mass with internal echoes. There was minimal calyceal dilation of both kidneys but the urinary bladder was seen and it was having a normal outline and volume. There was no abnormality in the anatomic scanning of the other systems. The amniotic fluid volume was normal and the biophysical profile was reassuring. The woman was counseled and induction of labor was done with oxytocin and she gave birth to a 3200-g female alive newborn. Immediately upon delivery the newborn was examined and there was an imperforate hymen that bulged forwards and the abdomen was distended, otherwise, the perineum, anus, and urethral orifice were normal. The baby passed urine and meconium. Grossly there was no dysmorphic feature in the newborn. Abdominopelvic ultrasound was done and showed a 100 × 70 × 40 mm oval cystic pelvic mass behind the bladder and there was also mild calyceal dilation of both kidneys, but there was no other abnormality. A renal function test was done for the newborn and found to be normal. Hymenectomy was done on the second day of delivery and around 200 mL of milky fluid was removed. The abdominal distention was relieved, and the renal calyceal dilation disappeared. Abdominal ultrasound after the procedure showed an empty uterus and vagina and the newborn was discharged improved. The newborn came back after 2 weeks for a checkup and she was doing well with normal hymen remnants and vaginal orifice.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3299_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3299_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..935145a968c7bc62abcd69e71975d71d7d07b048
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3299_en.txt
@@ -0,0 +1,28 @@
+In spring 1992, a 17-year-old boy presented at our institution with an exacerbation of idiopathic nonischemic dilated cardiomyopathy and pulmonary insufficiency. He was listed at status 1 on the heart transplant waiting list (panel-reactive antibody, 13%). He needed intensive care and inotropic agents before transplantation. A heart became available from an identically sized donor who was close in age and ABO-compatible (type AB); however, results of human leukocyte antigen (HLA) tests revealed a complete mismatch, with no HLA-A, -B, or -DR antigens in common. At the time, the patient's relatively high immunologic risk for graft rejection related to his young age and degree of antigen mismatch was used to justify HHTx over orthotopic transplantation. In April 1992, HHTx was performed as previously described,10 with biatrial anastomoses to the native atria.
+
+The patient's native heart function did not recover; the left ventricular ejection fraction (LVEF) was consistently below 0.15, with LV and right ventricular dilation and global hypokinesis. However, his donor heart function was excellent, with normal LV filling and an LVEF of 0.60. Atrial fibrillation and premature ventricular complexes early after HHTx were successfully managed after implantation of a pacemaker. Excellent graft function for 2 decades enabled the patient to live a moderately active life that included working full-time and playing sports with his children.
+
+When the patient was 39 years old, 22 years after the initial transplantation, he had hypertension, and coronary artery disease was found in the donor graft. In March 2013 at a different hospital, a left anterior descending coronary artery stent was placed after the patient had a non-ST-segment-elevation myocardial infarction (NSTEMI). After a period of hyperkinesis and improved LVEF, apical akinesis in the donor heart and an overall decline in cardiac function were observed. Shows the patient's LVEF over 9 Shows a modest increase in cardiac dimensions and an inconsistent-but-rising right atrial pressure. Documents the patient's declining heart function over time; his cardiac dimensions, LVEF, and pulmonary artery systolic pressure had been stable during the 7 years before the NSTEMI.
+
+The Patient's Cardiac Events and Decline in Condition
+
+Time	LVEF	Systolic PAP (mmHg)	RAP (mmHg)	LVIDd (cm)	LVIDs (cm)
+2006 June	0.55–0.60	20–25	6–10	4.5	2.8
+2007 December	0.55–0.60	25–30	6–10	4.2	2.9
+2010 September	0.60	—	0–5	4.8	2.6
+2013 Marcha	>0.60	20–25	0–5	4.7	2.5
+ Mayb	0.50–0.55	20–25	0–5	5.1	3
+ Octoberc	0.50–0.55	20	6–10	5	3.7
+ November	0.40–0.44	40	6–10	4.9	3.2
+2015 March	0.40	—	—	5	3.1
+ October	0.35–0.39	—	11–15	—	—
+ October	0.40	—	6–10	5.2	4.3
+2016 March	0.45–0.49	25–30	6–10	4.4	2.2
+
+LVEF = left ventricular ejection fraction; LVIDd = left ventricular internal diameter at end-diastole; LVIDs = left ventricular internal diameter at end-systole; PAP = pulmonary artery pressure; RAP = right atrial pressure.
+
+Five months after the NSTEMI, the patient was admitted to our hospital with decompensated heart failure and a decreased graft LVEF of 0.40. He was relisted at status 1A on the heart transplant waiting list; however, the procedure was contraindicated because of positive tissue crossmatches. His status was downgraded to 1B in October 2013. His congestive heart failure was managed medically for 3 years. In May 2016, he was relisted at status 1A at a different facility.
+
+An intra-aortic balloon pump (IABP) was placed in June 2016 while the patient was being considered for desensitization therapy for high panel-reactive antibody (>60%). Rapid decompensation during a cardiac catheterization procedure that same month prompted arteriovenous extracorporeal membrane oxygenation. Because of an immunologic obstacle to transplantation, the patient's native heart was replaced with a total artificial heart (TAH) as a bridge to transplantation; the circulation to the heterotopic donor heart was excluded as much as possible. The patient's postoperative course was complicated by multiple episodes of bacteremia and circuit thrombosis, the latter probably caused in part by incomplete exclusion of the heterotopic graft from the circulation. However, TAH support enabled desensitization therapy with therapeutic plasma exchange.
+
+After approximately 6 months of TAH support and frequent plasma exchanges, the patient underwent orthotopic heart transplantation in January 2017 to replace the TAH. The heterotopic graft was removed at that time. As of January 2018, the patient was alive, 25 years after the initial HHTx.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3303_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3303_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..788e916cc9a78a5d7b07d01521505db0205269e8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3303_en.txt
@@ -0,0 +1,3 @@
+Patient, 29 years old, housewife, residing in Bamako, admitted to the department on 20 March 2023 for altered consciousness and fever. Her symptomatology would be of progressive onset, evolving for about fourteen days, marked by fever, headaches and vomiting, and then by a functional impairment of the right limbs. She had been treated for severe malaria confirmed by injection of artesunate in a private health facility for 6 days. She had given birth around 14 February 2023 after following prenatal consultations correctly. Her child was healthy. She had no known medical or surgical history, or use of immunosuppressive drugs. Physical examination revealed a fever of 38.8°C, a SOFA score of 6 (3 for the Glasgow score of 9/15 and 3 for a daily diuresis of 490 ml), a stiff neck, a pyramidal syndrome (hemiplegia and right-sided areflexia, left hemiplegia with a motor strength of 4/5 in the upper limb and 3/5 in the lower limb), and vaginal fingers stained with profuse discharge. The cranio-cerebral CT scan revealed several hypodensities enhanced by the contrast agent. One of these foci occupied almost the entire left hemisphere, with a mass effect on the homonymous ventricle and a deviation of the brain stem to the right, the other focus was right ventricular. The examination of the CSF showed a cloudy liquid, a mixed leukocytopaenia of 1080/mm3, hypoglycaemia of 0.5 g/l and hyperproteinaemia of 1.2 g/l. The CSF and vaginal swabs were positive for E. coli strains resistant to penicillin (amoxicillin, amoxicillin clavulanate), carboxypenicillin (ticarcillin), aminoglycoside (gentamycin), cephalosporins (cefotaxime, cefixime, cefotaxime, cefepime), quinolones (ciprofloxacin, norfloxacin), tetracycline, phenicols (chloramphenicol) and cotrimoxazole. They were sensitive to meropenem, amikacin, ceftazidine, colistine and cefepime. Creatinine clearance (CKD-EPI formula) was 61.35 ml/min with creatinemia of 110 µmol/l. The blood count showed moderate neutropenia of 1400/ml and moderate anaemia (haemoglobin of 9.1 g/dl), microcytic (VGM of 79 fl), hypochromic (CCMH of 30 g/dl). Two HIV serologies were negative. The diagnosis of genital sepsis with suppurative meningitis and acute renal failure was retained.
+
+The patient was then given meropenem 1 g intravenously every eight hours for 21 days. She also received a hydro-electro-caloric intake of 3 litres per day, genital washing with chlorhexidine twice daily for five days, and physiotherapy from the 10th day of meropenem treatment. The patient's condition was favourable, with apyrexia and consciousness recovering on the 3rd and 6th day of meropenem treatment, respectively; the motor strength of the limbs was assessed as 2/5 on the right and 5/5 on the left upper limb, and 4/5 on the left lower limb on the 12th day of physiotherapy; renal function was good on the 10th day of meropenem treatment. Exeat was granted on 14 April 2023, with physiotherapy sessions in outpatient care and an appointment ten days later. At this appointment, the motor strength of the limbs was assessed as 5/5 on the left and 3/5 on the right.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3314_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3314_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..869792b8352ffeb47dc0276629d1461043b0a498
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3314_en.txt
@@ -0,0 +1,5 @@
+A 60-year-old female sheep herder from Eritrea presented to St. Paul’s Hospital Millennium Medical College ophthalmology department with a 3-month history of painless left eye protrusion associated with progressive decreased vision of the left eye. Otherwise, she had an unremarkable history. Visual acuity in the right eye was 6/18 and counting finger in front of the eye on the left eye. Physical examination revealed a 4 mm discrepancy on exophthalmometry between the two eyes with a proptosis of 21 mm on the left eye. On fundus examination, there was a tortuous temporal arcade and grade 4 papilledema in the left eye. Otherwise, there was an unremarkable finding. Laboratory investigation revealed a normal complete blood count. Computerized tomography (CT) of the brain and orbit showed a well-defined thin-walled non-enhancing fluid density cystic mass in the left orbital cavity measuring 2.6 cm by 2.0 cm by 1.9 cm with compression and lateral displacement of the globe as well as compression and stretching of the optic nerve. The left medial rectus muscle was not clearly and separately visualized from the lesion. There were no osseous lytic or sclerotic changes of the bony orbit. The CT scan was suggestive of a hydatid cyst of the orbit. Abdominal ultrasound and chest X-ray findings were unremarkable.
+
+The patient was given albendazole 400mg orally twice per day for 2 weeks and re-evaluated. Subsequently, she was taken to the operating room with an impression of a left medial mass secondary to Hydatid cyst. The cyst was approached through a medial anterior orbitotomy. Intraoperatively, a cystic mass attached to the inferior aspect of the medial rectus (MR) was identified. The cyst ruptured during manipulation and a clear fluid came out. A paper white cyst lining was removed in piecemeal and the external capsule was excised with care not to severely damage the MR muscle. Then, the surgical field was irrigated with 3% hydrogen peroxide solution followed by copious normal saline solution, and the tissue was sent for histopathological examination. Biopsy result revealed an acellular laminated membrane with germinal epithelium and a daughter cyst with protoscolices and surrounding soft tissue consisting of chronic inflammatory cells confirming the diagnosis of hydatid cyst. Cytology from cyst fluid showed a hemorrhagic background with no cells.
+
+On her first postoperative day, she had lid edema with limited adduction of the left eye and mild ocular pain. Oral albendazole 400mg twice daily was continued postoperatively. Follow-up on her 7th post-operative day showed that there was mild improvement in the adduction deficit and lid swelling had resolved. Subsequent follow-up on her 21st postoperative day showed left eye visual acuity of counting fingers at two meters and the adduction deficit improved to −2. Furthermore, the optic disc edema also resolved to grade 1. However, the patient moved back to Eritrea, and we were not able to follow the subsequent progress of the patient beyond the first 3 weeks.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3316_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3316_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..baffbbde991f92681f881e5a65ef24740ab3ec18
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3316_en.txt
@@ -0,0 +1,9 @@
+A 77-year-old female, known to have Parkinson’s disease, diabetes Mellitus, and coronary artery disease. She presented with dizziness followed by a fall that was not witnessed. She lost consciousness for two minutes. There was no history of seizures or sudden, severe headaches. The patient was diagnosed with Parkinson’s Disease more than 10 years ago and was controlled on Carbidopa/Levodopa (Stage 3 on HOEHN AND YAHR classification).
+
+Upon examination, she was vitally stable with a GCS of 15/15. Her speech and language were intact. Pupils were 3 mm reactive to light bilaterally. Motor power was 4 + in both upper and lower limbs with normal reflexes. Her muscle tone was hypertonic, especially in the right upper limb with cogwheel rigidity. Neck pain was noted but negative for the Kerning and Brudzinski signs, and there was no photophobia. Venous blood gases and electrolytes were in the normal range.
+
+Brain CT showed diffuse subarachnoid hemorrhage over the bilateral cerebral hemispheres with extra-axial hematoma, more predominant over the frontal lobes. Therefore, dual antiplatelet for her coronary artery disease (Aspirin and Ticagrelor) were held.
+
+Considering the extensive traumatic subarachnoid hemorrhage and the high likelihood of epileptogenic hemorrhage, the patient was started on Levetiracetam for seizure prophylaxis. Four days after, the patient dropped GCS to 9. She was having quadriparesis, progressive hypertonicity, right-sided resting tremor, and hyperreflexia all over. There were no recent febrile illness or recent seizures. EEG showed no epileptiform discharges. Repeated neuroradiological imaging, including CT and MRI, showed stable previous findings.
+
+After ruling out all possible causes of Parkinson’s exacerbation, Levetiracetam was gradually weaned until it was discontinued. Consequently, the patient had significant clinical improvement after discontinuation of Levetiracetam. Her improvement was gradual over 3 days. Her hypertonicity, tremors, and sensorium have all resolved. She was discharged with neuroradiological follow-up at Neurosurgery and Neurology clinics.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_335_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_335_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..35fef99bd6c54a4fe0b3beef498fd1918f15d008
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_335_en.txt
@@ -0,0 +1,10 @@
+A 39 year-old white female presented to The Arthur G. James Cancer Hospital with worsening pain of the left breast and left chest wall region and a recurrent palpable mass within the inferior aspect of her left breast. She reports having had three separate left breast biopsies in the past (seven years, four years, and one year prior to her current presentation) for a recurring left breast palpable mass in this same location.
+Seven years prior to her current presentation, she presented to an outside community hospital with a palpable left breast mass in the inferior lateral aspect of her left breast. She underwent a left breast biopsy at that time that was reported as showing dense fibrous stroma with fibrocystic changes.
+Three years later (four years prior to her current presentation), she noticed a recurrent enlarging palpable left breast mass. She underwent a repeat left breast biopsy by the same surgeon and this showed hyperplastic fibrosis, consistent with fibromatosis of the breast. The pathology report clearly stated that the tumor involved the surgical margins. The patient reports that the surgeon told her that this was a benign tumor and that nothing further needed to be done.
+Three additional years later (one year prior to her current presentation), she again noticed a recurrent enlarging palpable left breast mass. She again underwent a repeat left breast biopsy by the same surgeon and this again showed findings consistent with fibromatosis of the breast. Again, the pathology report clearly stated that the tumor involved the surgical margins. The patient reports that the surgeon again told her that this was a benign tumor and that nothing further needed to be done.
+Since the time of her last left breast biopsy (one year prior to her current presentation), the patient reports persistent and worsening pain and palpable tenderness within the inferior aspect of her left breast and left chest wall region, with an associated increasing sized palpable mass within the same region.
+Upon presentation to The Arthur G. James Cancer Hospital, she was found on clinical examination to have volume loss along the entire inferior aspect of her left breast and slight downward tilting of her left nipple and areolar complex. She had three separate well-healed surgical scars along the inferior-lateral aspect of her left inframammary fold . Underneath these scars, she had a firm palpable mass, clinically measuring 6.5 × 3.0 × 2.5 cm in size and which clinically appeared to be adherent to the underlying left chest wall structures. She had no clinically apparent adenopathy in her left axilla.
+A mammogram showed scarring and tissue disorganization in the inferior left breast from prior multiple biopsies, but appeared unchanged since a prior mammogram done 13 months previously at an outside community hospital. Magnetic resonance imaging of the left breast showed an intensely enhancing lesion in the inferior-lateral aspect of the left breast, measuring 5.0 × 1.7 cm in size . This lesion appeared to abut the underlying chest wall musculature and appeared to efface the underlying fat plane. Computed tomography scan of the chest showed a 5.2 × 1.6 cm mass within the inferior-lateral aspect of the left chest wall that appeared to be in continuity with the left pectoralis major muscle and left serratus anterior muscle . A core biopsy was performed to the palpable left breast mass that confirmed the diagnosis of fibromatosis.
+The patient was taken to the operating room at to The Arthur G. James Cancer Hospital and underwent a left total mastectomy, with en bloc resection of the underlying musculature (inferior lateral portion of the left pectoralis major muscle, superior portion of the left abdominal oblique musculature, and anterior portion of the left serratus anterior muscle) and en bloc resection of the underlying chest wall structures (fourth, fifth, and six ribs, intercostals muscles, and parietal pleura). The left chest wall defect was then closed with a 2-mm DualMesh Gore-Tex patch (W. L. Gore & Associates, Inc., Flagstaff, Arizona). The remaining portions of the left pectoralis major muscle was dissected off the underlying left chest wall and its lateral most attachments to the left humerus and superior attachments to the clavicle were divided, allowing it to rotate inferiorly to completely cover the Gore-Tex patch. The left mastectomy site was then closed in the standard fashion. No attempts at cosmetic breast reconstruction with autologous tissue transfer or expander/implant placement were considered at that time. The patient's post-operative course was uneventful and she was discharged to home on post-operative day eight.
+Gross pathologic evaluation of the specimen, which overall measured 14.5 × 13.3 × 6.4 cm in size, revealed a 5.2 cm tumor that was grossly invading the underlying attached skeletal muscle to a depth of about 1.2 cm . It could not be definitively determined whether the invasion of the underlying skeletal muscle involved only the superficial muscles resected (consisting of the inferior lateral portion of the left pectoralis major muscle, superior portion of the left abdominal oblique musculature, and anterior portion of the left serratus anterior muscle) or whether skeletal muscle invasion was to the level of the underlying intercostal muscles resected. However, both grossly and microscopically, there was no evidence of invasion into the bony ribs or underlying parietal pleura. Microscopic evaluation revealed a proliferation of relatively evenly spaced plump spindle cells arranged in intersecting fascicles and associated with mild to moderate amounts of collagen and occasional mitotic figures and demonstrated that the spindle cell proliferations invaded into the adjacent skeletal muscle . All surgical margins were negative. On immunohistochemical staining, the spindle cells were negative for S-100 protein, muscle actin (HHF-35), and cytokeratin AE1/AE3. On immunohistochemical staining, less than 5% of the spindle cells were positive for Mib1 (Ki-67). The histology and immunohistochemical staining supported a diagnosis of fibromatosis (desmoid tumor).
+The patient is now 22 months out from her previous aggressive operative management of her previous multiple recurrences of her fibromatosis of her left breast and she remains disease free.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3363_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3363_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9faccff803aafc88818a52dbe6c69be75594b688
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3363_en.txt
@@ -0,0 +1,7 @@
+A 52-year-old Hispanic woman from Kern county, southern California, with a past medical history of gastroesophageal reflux disease, osteopenia, complex regional pain syndrome of the right upper extremity status post-carpal tunnel release surgery, lumbar spondylosis at L5-S1, and iron deficiency anemia, presented to her primary care physician for the evaluation of tender erythematous nodules on her thighs that had been present for approximately 1 month. Based on the clinical appearance and the geographical region of presentation, the patient was suspected of having erythema nodosum secondary to valley fever (coccidioidomycosis). The patient was prescribed fluconazole 200 mg daily, pending results from serological testing for coccidioidal immunoglobin M (IgM) and immunoglobin G (IgG). However, there was no improvement when the patient returned for a follow-up visit after 30 days of treatment. Additionally, the coccidioidal IgM and IgG tests were negative. Thus, treatment with fluconazole was discontinued and the patient was referred to a pulmonologist, who ordered tests to rule out sarcoidosis, tuberculosis, and thrombosis.
+
+The following results were obtained: angiotensin 1-converting enzyme levels (<5 U/L) (reference range: 9–67 U/L); QuantiFERON tuberculosis gold (interferon-gamma release assay [negative]); activated partial thromboplastin time (27 s); prothrombin time (9.6 s); international normalized ratio (0.9); and von Willebrand factor antigen (121 IU/dL). Based on these results, sarcoidosis, tuberculosis, and thrombosis were ruled out and no definitive diagnosis was made. The patient was then referred to a dermatologist, who suspected a diagnosis of LET based on clinical presentation. A punch biopsy of the skin lesion measuring 0.4 × 0.4 × 0.5 cm was taken from the right lateral thigh.
+
+The histopathology report on the punch biopsy was as follows: “superficial and deep perivascular and interstitial mononuclear inflammatory cell infiltrate with increased dermal mucin deposition. Periodic acid-Schiff staining was negative for fungal organisms; colloidal iron (mucin stain) showed increased dermal mucin deposition. There was no evidence of vasculitis or malignancy.” The histopathologist commented that these findings would be compatible with connective tissue disease/LET or an interstitial variant of granuloma annulare in an appropriate clinical setting. To arrive at a definitive diagnosis, the histopathologist advised to correlate clinical findings with serologic studies and to perform a direct immunofluorescence study to rule out morphea versus LET. Direct immunofluorescence study of a biopsy of the lesion, measuring 0.3 × 0.3 × 0.6 cm which was taken from the right lateral thigh, showed no specific immune deposits. Due to the high index of suspicion of LET, and its association with other autoimmune conditions, especially systemic lupus erythematosus, the patient was subsequently referred to a rheumatologist.
+
+The rheumatologist’s physical examination demonstrated a left thigh nodule, and the right thigh exhibited warmth, erythema, and tenderness to palpation. A full screening for autoimmune diseases was done, which included the following diagnostic studies: complete blood count, comprehensive metabolic panel, c-antineutrophilic cytoplasmic antibody, p-antineutrophilic cytoplasmic antibody, anti-nuclear antibody, proteinase-3 antibody, beta-2-glycoprotein IgG/IgM/IgA, cardiolipin IgG/IgM/IgA, anti-Ro antibodies and anti-La antibodies, anti-Smith antibody, ribonucleoprotein antibody, erythrocyte sedimentation rate, C-reactive protein, complement C3 and complement C4, dilute Russell’s viper venom time, thyroid peroxidase antibody, double-stranded deoxyribonucleic acid antibody enzyme immunoassay, cyclic citrulline peptide antibody IgG, rheumatoid factor, and thyroid-stimulating hormone. Remarkably, all diagnostic studies were within normal limits, except the erythrocyte sedimentation rate, which was elevated at 39 (reference range: <25 mm/h). Thus, based on clinical, laboratory, and histopathological findings, LET was diagnosed, and other autoimmune conditions were ruled out. The patient was treated with hydroxychloroquine 200 mg daily and she showed significant improvement within 2 weeks of the follow-up visit.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_339_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_339_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..45b3e47de6755a1d682484756753efe546ae9f61
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_339_en.txt
@@ -0,0 +1,8 @@
+We present a case of 49 years old Caucasian male suffering from congenital lymphoedema of the left lower extremity who developed composite haemangioendothelioma during his adulthood. Because of the lymphoedema, the patient was first operated on at the age of 6 years, which had only a minor effect on overall condition of the patient. Later on in his life, he experienced multiple erysipelas and at the age of 47 a vascular tumour was detected in the setting of the lymphoedema as its complication. In another institution, a microscopically non-radical (R1) resection was performed and a diagnosis of angiosarcoma was concluded based on the histopathological evaluation of the tumour. The patient was not indicated for any adjuvant therapy, or re-resection. He was followed up and the first control PET/CT scan showed neither local relapse nor distant spread. Local progression was detected after one year of follow up and the patient was re-operated. Second R1 resection was performed and subsequent histopathological examination revealed an angiosarcoma again. This diagnosis was supported by an early second local relapse after a month. After that, the patient was reported to our sarcoma centre for further treatment.
+During the clinical investigation, two purple skin affections in the popliteal area at the edges of the dermo-epidermal mesh skin graft were found . The left lower extremity showed chronic disfiguration as a result of multiple erysipelas and chronic lymphoedema. Scattered ecchymoses were also present. In the left gluteal area, multiple small nonspecific purple skin affections were visible. For staging purposes, whole-body PET/MR was performed and revealed multiple small subcutaneous nodules located in the left gluteal area, left calf and left hamstring area . Every nodule demonstrated low metabolic activity; however, the finding raised clinical suspicion for metastases of the previously diagnosed angiosarcoma. During the multidisciplinary tumour board, a bioptic confirmation of the process within gluteal space was indicated. Under local anaesthesia excision biopsy of the skin affection in the gluteal area was performed and sent for histopathological analysis. Within dermis, there was a cavernous vascular tumour (diameter 5 mm) detected, which consisted of dilated thin-walled lymphatic vessels containing papillary protrusions at the periphery. The papillary protrusions contained hyalinised cores in the centre and were covered with columnar endothelial cells with hobnail or even matchstick-like features. There were present neither mitoses nor severe nuclear atypia. Immunohistochemistry (IHC) showed diffuse positivity of the neoplastic cells for CD31, ERG and FLI-1. Tumour showed also focal D2-40 positivity within slit-like spaces at the periphery. IHC markers CD34, HHV-8, CK-KL1 and smooth muscle actin were negative. Based on the clinical background (localization within the dermis of the gluteal area), morphology and immunophenotype of tumorous cells, the suspicion for papillary intralymphatic angioendothelioma (PILA) was raised in contrast to the previous diagnosis . The expected structures of angiosarcoma were not identified within the sample.
+To evaluate the uncertain undergoing process, the next multidisciplinary meeting led to an indication for excision of the recurrent focus and bioptic evaluation of the nodules of the calf and gluteal area. The operation was performed in February 2022 in form of an excision of two skin affections of the popliteal area (diameter 43 and 78 mm) and another biopsy of the tumour in the calf and gluteal area (diameter 20 mm and 10 mm). Histopathological examinations showed a new finding – the dermal-based vascular tumour with the retiform arrangement was detected, which consisted of branching vascular channels lined with hobnail-shaped bland endothelial cells. At some portions, papillary protrusions with hyalinised cores were found. There were neither mitoses nor nuclear atypia again. On the other hand, no association with the lymphatic vessels was found this time. IHC showed diffuse CD31 positivity and CD34 negativity of the neoplastic cells. Proliferation marker Ki-67 was low with positivity in approximately 10% of the cells within hot spots. Even though the histopathological finding was similar to the previous sample, due to the multifocality of the process, arborizing retiform architecture of the tumour and lacking association with lymphatic vessels in the current biopsy, the diagnosis of retiform haemangioendothelioma was made.
+Because of the absence of angiosarcomatous structures, the original bioptic material was obtained from the first resection for the second opinion. But, the second look examination confirmed the former diagnosis of HG angiosarcoma: at the border between dermis and sub-cutis there was an infiltration of solid tumour consisting of elongated oval to spindle shaped cells showing marked nuclear atypia and numerous mitoses, including atypical forms. Erythrocytes filled slit-like spaced dissecting the solid areas were detected. IHC showed a similar immune profile of the neoplastic cells (CD31 positive; CD34 and D2-40 negative) and significantly higher proliferation (40–50%) based on the Ki-67 proliferation marker. Such a finding was consistent with the original diagnosis of HG angiosarcoma . However, at the base of the sample, small areas with a morphology of retiform haemangoendothelioma similar to the previous finding were spotted.
+Based on the histopathological findings of three different vascular components resembling PILA, retiform haemangioendothelioma and HG angiosarcoma, the final diagnosis of CHE with HG angiosarcoma-like areas was established.
+Recently it has been discovered that CHE can harbour a fusion gene YAP1::MAML2, especially among children with acral localisation of the tumour . We performed next-generation sequencing (NGS) to investigate this gene fusion and to exclude other entities which could mimic such lesion. Using Fusion Plex Sarcoma V2 panel (Archer) the fusions of the following genes were excluded: ALK, BCOR, BRAF, CAMTA1, CCNB3, CIC, CSF1, EGFR, EPC1, ERG, ESR1, ETV1, ETV4, ETV5, ETV6, EWSR1, FGFR1, FGFR2, FGFR3, FOS, FOSB, FOXO1, FUS, GLI1, HMGA2, JAZF1, MBTD1, MDM2, MEAF6, MET, MGEA5, MKL2, NCOA1, NCOA2, NCOA3, NR4A3, NTRK1, NTRK2, NTRK3, NUTM1, PAX3, PDGFB, PDGFRA, PHF1, PLAG1, PRKCA, PRKCD, RAF1, RET, ROS1, SS18, STAT6, TAF15, TCF12, TFE3, TFG, USP6, VGLL2, YAP1, YWHAE).
+In conclusion no gene fusion was identified, including YAP1::MAML2. However this finding does not exclude the diagnosis of CHE as for such gene fusion usually does not occur among adult patients outside acral localisations . Moreover, we also examined MYC amplification using fluorescent in situ hybridisation (FISH) as there is an evidence in literature that high-level MYC gene amplifications (at 8q24.21) occur in majority of post-irradiation and chronic lymphoedema-associated angiosarcomas . However MYC amplification was not found in this case, which further supports the diagnosis of CHE favouring it over angiosarcoma.
+Even though CHE usually shows indolent behaviour, the multifocality of the process in the setting of chronic lymphoedema allowed radical surgical treatment, which would have to be hemipelvectomy in this case. Such a procedure was rejected by the patient. Therefore, the current course of action is the follow up with periodical PET/MR scans. In case of local progression of any nodule, the patient would be indicated for the extirpation of the lesion. However, no growth of the remaining lesions was detected in the follow-up so far and there has been no metastatic spread of the disease since the first detection of the tumour two years ago.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_344_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_344_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d5de1b78e1464c64cb889048c8afcf40176c8bc0
--- /dev/null
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+66-years-old male.
+A sudden onset of the right hemiplegia and dysarthria.
+Nothing significant.
+Smoked 30 cigarettes/day for 45 years.
+At 7:30 a.m. while driving, the patient suddenly experienced right hemiplegia and dysarthria and was rushed to our hospital.
+Right facial paralysis, dysarthria, right upper extremity paralysis, right upper and lower extremity paresthesia, and National Institutes of Health Stroke Scale (NIHSS) score 6/42.
+Magnetic resonance imaging (MRI) diffusion-weighted imaging (DWI) showed slightly high signal areas in the left putamen, corona radiata, and part of the middle cerebral artery region. Magnetic resonance angiography (MRA) showed an occlusion of the left middle cerebral artery [ and ]. The T2-weighted images showed no obvious thrombi in the occluded area.
+The patient was admitted to the hospital at 8:25 a.m. Based on the MRI findings, we determined that there was a mismatch between the perfusion area of the left middle cerebral artery and the high signal DWI lesion. An intravenous alteplase therapy was deemed appropriate without any cautionary or contraindicated items as per the guidelines. Alteplase was administered at 9:27 a.m. following the management of hypotension with nicardipine. The primary strategy was to pursue an endovascular recanalization.
+A 9 Fr sheath was placed in the right femoral artery, and a 9 Fr OPTIMO (Tokai Medical Products, Aichi, Japan) was guided into the left internal carotid artery. Internal carotid arteriography revealed that the left middle cerebral artery was distally occluded . In the delayed phase, an anastomosis of the cerebral pia mater provided the collateral blood flow from the anterior to the middle cerebral arteries . The rebar (Medtronic, Minneapolis, MN, USA) was guided distal to the occlusion with a CHIKAI 14 200 cm (Asahi Intec, Aichi, Japan) to secure the distal vessel, and a Trevo XP ProVue Retriever 4.0 × 30 mm (Stryker, Kalamazoo, MI, USA) was deployed. The post deployment imaging showed an immediate flow restoration but poor stent dilation in the occluded area, suggestive of arterial stenosis .
+The proximal and distal diameters of the stenosis were 2.6 mm and 2.1 mm, respectively . After retrieving the Trevo, a 1-min amount of thrombus was retrieved. Although reperfusion was achieved, a significant degree of stenosis persisted . A diagnosis of ICAD was established, and an angioplasty using a balloon catheter was proposed.
+Crushed aspirin and clopidogrel (300 mg each) were administered orally. A 6 Fr Cerulean catheter DD6 113 cm (Medikit, Tokyo, Japan) was guided to the pyramidal segment of the internal carotid artery as a distal access catheter. Subsequently, a Gateway 2.0 × 12 mm monorail (Stryker, Kalamazoo, Michigan, USA) was placed at the stenosis region using a CHIKAI. A gradual dilatation and retraction were performed under nominal pressure . Subsequent imaging revealed a temporary recanalization ; however, restenosis was observed after 7 min .
+The strategy was to use a coronary perfusion balloon for prolonged angioplasty while maintaining the peripheral perfusion. Ryusei 2.5 × 20 mm monorail (Kaneka Medix, Osaka, Japan) was navigated toward the stenotic lesion. After dilating to 2 atm, the wire was drawn anterior to the proximal perfusion hole, and the perfusion lumen was subsequently unsealed .
+The angiography performed in this state showed that peripheral perfusion was achieved using balloon dilation [ and ]. The patient was maintained in this state for 15 min, during which intermittent angiography was performed to monitor the patency of the perfusion lumen. Ozagrel sodium 80 mg was administered intravenously. The Ryusei was then deflated and adequate vascular dilation was observed . After an additional waiting period of 20 min, we confirmed the absence of restenosis and concluded the procedure.
+Heparin was administered while monitoring activated clotting time (ACT) during the procedure, with a minimum ACT value of 200. The total dose was 6,000 units.
+The patient’s symptoms resolved to an NIHSS score of 0 on the day after the procedure. Postoperative echocardiography and electrocardiography revealed no evidence of cardiogenic cerebral embolism. Based on the intraoperative findings, the patient was diagnosed with ICAD. Postoperatively, aspirin 100 mg and clopidogrel 75 mg prescriptions were continued, and cilostazol 200 mg and atorvastatin 10 mg were added. Postoperative MRI showed a clearly defined high signal DWI without significant enlargement of the infarcted area and although a mild stenosis remained, the MRA also showed a satisfactory peripheral perfusion .
+The patient was discharged without a neurological deficit on the 7th day.
+Clopidogrel medication was discontinued at discharge. Three months later, the MRA indicated an improvement in the stenosis , and the patient was prescribed antithrombotic therapy with cilostazol as a single agent. No specific events were observed for more than 1 year after the procedure.
+An application for an unapproved new medical device was submitted to the hospital’s committee for the evaluation of highly difficult new medical technology, and approval was obtained. Furthermore, during patient consultations regarding surgical procedures, we explicitly conveyed that we may employ nonconforming medical devices if adequate substitutions proved arduous and secured informed consent accordingly.
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index 0000000000000000000000000000000000000000..80fe8dc3d0ba23842afdc437a4125635015b9488
--- /dev/null
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+A 70-year-old Asian woman presented to the emergency ward with acute kidney injury after having been diagnosed recently with a non-small cell lung carcinoma (NSCLC). She had a history of hypertension, hypercholesterolemia, and type 2 diabetes for which she used metformin and enalapril. She was of Asian descent, born in Thailand, and lived in the Netherlands for approximately 20 years. For the largest part of her life, she was a stay-at-home mother of two children and had no known occupational exposure to toxins or chemicals. She had a negative family history for pulmonary disease or kidney diseases, never smoked, and consumed no alcohol. She was analyzed for lung cancer after a large lung mass was seen on a chest X-ray carried out for complaints of dyspnea . The fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) with low-dose computed tomography (CT) scan showed an FDG-avid mass in the left lower quadrant of 11 × 6.8 cm with multiple small FDG-avid lesions in all lung quadrants, pathological lymphadenopathy subcarinal in the hili and in the mediastinum, and multiple FDG-avid liver and bone lesions all suspected of being metastases. A bronchoscopy showed an exophytic tumor in the left main bronchus extending to the left upper lobe closing of the main bronchus as well as a tumor in the left lower lobe. The bronchoscopy samples showed NSCLC with EML4–ALK rearrangement. A multidisciplinary team (pulmonary oncologists, surgeons, nurses, pathologist, radiologist, and nuclear radiologist) discussed the patient in accordance with local guidelines and came to a diagnosis of NSCLC, cT4N3M1c, stage IV with EML4–ALK rearrangement. She started treatment with alectinib 600 mg twice daily and used naproxen for pain complaints from her bone metastases. Prior to start of alectinib, she had a blood pressure of 143/69 mmHg, serum creatinine of 69 µmol/L [0.78 mg/dL; estimated glomerular filtration rate (eGFR) of 77 mL/min/1.73 m2].
+At presentation, 11 days after initiation of alectinib, she had complaints of reduced appetite, vomiting, and oliguria. On examination, we found a blood pressure of 120/68 mmHg with a pulse of 81 beats per minute. She had capillary refill time of 4–5 seconds and reduced skin turgor. Her temperature was 36.1 °C (97 °F). Heart auscultation revealed normal hearts sounds without murmurs. Lung auscultation revealed sharpened breath sounds, but no crackles or rhonchi. Examination of the abdomen showed no visible pathology, normal bowel sounds, and no signs of acute abdominal or surgical pathology. Basic neurological examination revealed no impaired mental status, no cranial nerve pathology, normal gait and coordination, and no abnormalities on motor and sensory examination. Further physical examination revealed no other abnormalities. A chest X-ray showed a reduction of the lung cancer mass compared with the initial staging imaging. Laboratory evaluation revealed a creatinine level of 424 µmol/L (4.79 mg/dL; eGFR 8 mL/min/1.73 m2), and a urea level of 15.3 mmol/L (91.8 mg/dL). Other lab results showed anemia (hemoglobin 6.6 mmol/L, 10.6 g/dL), thrombocytosis (691 × 109/L), and leukocytosis (14.9 × 109/L). She had hyponatremia (127 mmol/L; 127 mEq/L), hyperkalemia (6.0 mmol/L, 6 mEq/L), and hypercalcemia (2.61 mmol/L, 10.46 mg/dL) that was normal when corrected for albumin (31 g/L, 3.1 g/dL). She had normal alanine transaminase and aspartate transaminase, but alkaline phosphatase and gamma-glutamyl transferase were slightly above the upper limit of normal (170 U/L and 91 U/L, respectively). The C-reactive protein was slightly above the upper limit of normal (7 mg/L, 0.7 mg/dL). Her glucose at presentation was 8.3 mmol/L (149.5 mg/dL). Urine analysis showed leukocyturia (66/µL) without hematuria and no bacteriuria. Urinary sodium concentration was 73 mEq/L (167.9 mg/dL) and the fractional excretion of sodium was 11%, suggesting renal tubular etiology. Ultrasound of the kidneys showed no abnormalities. No serologic or microbiological tests were performed.
+The patient was admitted to the pulmonology ward and received sodium chloride 0.9% fluid therapy, 1 L in 4 hours followed by 3 L/24 hours. All medication was discontinued. For pain complaints, acetaminophen was prescribed (four times 1000 mg daily) and fentanyl was started, as both transdermal patch (12.5 µg/hour) and tablets for sublingual that the patient used at her own discretion with a maximum of 200 µg per day. For nausea, metoclopramide 10 mg tablets were started, taken at the patient’s discretion with a maximum of three times daily. Because of constipation, macrogol and lactulose were started, and during the hospital admission a sodium phosphate enema was administered. Temazepam 10 mg was used at the patient’s discretion before sleeping, with a maximum of once daily. Nadroparin 2850 IU was started to prevent venous thromboembolisms. During the admission, insulin aspart was given for hyperglycemia when necessary (0–10 IE based on glucose levels and intake). The patient’s diuresis during the first 24 hours was 1860 mL, which further suggested tubulopathy as a possible cause of her acute kidney injury. After 2 days of fluid therapy, there was no improvement of renal function, and a biopsy was performed. Light microscopy revealed massive vacuolar alterations of the cytoplasm of proximal tubular epithelial cells , representing proximal tubular toxicity. Glomerular, interstitial, and vascular structures were normal. No tubular cell sloughing, necrosis, cast formation, or interstitial edema was seen.
+On the fourth day, intravenous prednisolone 40 mg daily was started for 7 days. In the days thereafter, renal function recovered rapidly, blood pressure rose to 148/80 mmHg, and the patient was discharged 9 days after admission with an eGFR of 70 mL/min/1.73 m2. Alectinib was reintroduced 1 week after discharge at 300 mg twice daily and 2 weeks later increased to 450 mg twice daily without decrease in kidney function until she died 2 months after discharge. Metformin, enalapril, and naproxen were withheld completely during the follow-up. During follow-up, the patient continued using metoclopramide and temazepam when necessary, and the fentanyl dose was increased step by step to a dose of 50 µg/hour in the weeks leading up to her death. In the palliative phase, no other medication was started. In a final staging 18F-FDG PET scan before her death, a reduction of size and activity of the primary tumor and the pathological lymph nodes was seen, but the patient had developed new pathological vertebral and pelvic fractures. She died of complications of her non-small cell lung carcinoma 2 months after discharge. No autopsy was performed.
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index 0000000000000000000000000000000000000000..2f2252372022aefa86349ed72786184b32afc8d5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_352_en.txt
@@ -0,0 +1 @@
+A 41-year-old woman, 4 gravida, 2 para, 2 Abortions with a history of C-section delivery. The patient presented with dysuria, pollakiuria, pelvic heaviness and an episode of acute urinary retention. Physical examination revealed a solid, well limited and fixed mass on the anterior vaginal wall. Pelvic ultrasound revealed a heterogeneous inter vesico-vaginal mass measuring 60/40 mm. MRI showed a pedicled inter vesico-vaginal mass (60/48/38 mm), isointense on T1, a heterogeneous signal on T2 with several cystic zones taking contrast in an early and intense rate suggesting cervical leiomyoma. The Surgical evaluation was recommended by the vaginal route due to the location of the mass. A midline incision was carried in the anterior vaginal wall, 2 cm below the urethral meatus. Mass resection was performed in two fragments, after adhesiolysis, which was difficult because of adhesion to the bladder, urethra and vaginal wall. A bladder breach was identified after resection of the mass and was immediately sutured. The removed tissue was a round, firm, 80/50/40 mm, gray tumor. Histopathology examination of the specimen showed that it was a focal endometriosis . The urinary catheter was removed after 1 week. There were no postoperative complications.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_371_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_371_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7f66e6b7cab8ad1c3d57ce94ef4ac851b0515913
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_371_en.txt
@@ -0,0 +1,4 @@
+A 59-year-old female patient with asymptomatic severe AR was referred to our institution for surgical treatment. She was being followed up at an outpatient clinic for QAV and moderate AR for 7 years. AVR was indicated for the progressively worsening AR and left ventricular function.
+On admission, the patient’s blood pressure was 122/62 mmHg, and heart rate was 102 bpm with an irregular rhythm. Chest radiography showed a cardiothoracic ratio of 56%. Electrocardiography (ECG) revealed a heart rate of 100 bpm with atrial fibrillation. Transthoracic echocardiography revealed a QAV with a severe central AR jet due to incomplete coaptation. The left ventricular ejection fraction was 50%, without local asynergy. The left ventricular end-systolic and end-diastolic diameters were 46 mm and 62 mm, respectively, and the diameter of the aortic valve annulus was 23 mm. Coronary angiography revealed no significant coronary artery stenosis or anomalies. ECG-gated enhanced computed tomography was not performed, and no coronary ostium anomalies were detected preoperatively.
+The patient underwent median sternotomy. The aortic valve had four cusps of almost equal size (Hurwitz and Roberts type A , Fig. ). Macroscopically, partial calcification and thickening of the cusps were observed. The left coronary ostium was located in the middle of the left aortic sinus. Although the course of the right coronary artery was normal, the right coronary artery ostium was located slightly below the sinotubular junction and in close proximity to the commissure between the right coronary cusp and one of the two non-coronary cusps . After excision of all cusps, the annular stitches were placed in a non-everting mattress fashion with pledgets on the ventricular side, and three stitches near the right coronary ostium were transitioned to the subannular ventricular myocardium to maintain the distance from the ostium . We decided to use a biologic prosthesis, according to the patients’ desire. A 25-mm prosthetic sizer was able to pass through the annulus but mild resistance was noted. We selected a 23-mm Inspiris Resillia biologic prosthesis (Edwards Lifesciences, Irvine, California, United States of America), because an oversized prosthetic valve could potentially compress the right coronary ostium. In addition to AVR, pulmonary vein isolation using AtriCure (AtriCure, Mason, OH, USA) and left atrial appendage closure using AtriClip (AtriCure) was performed for atrial fibrillation.
+The patient tolerated the procedure adequately, and postoperative echocardiography revealed normal prosthetic valve function without paravalvular leakage. Except for recurrent atrial fibrillation, the postoperative course was uneventful. The patient was discharged on postoperative day 17.
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index 0000000000000000000000000000000000000000..3453821918b3e4c895d7877f5ea7c1c45f17cc0d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_374_en.txt
@@ -0,0 +1,4 @@
+A 71-year-old man who suffered from CLL was admitted to our hospital on June 23th, 2020 due to fever. In 2001, he was admitted to a hospital due to submaxillary mass. On physical examination, multiple enlarged lymph nodes of the bilateral jaw bone were touched with nontender and of medium in quality, among which the largest lymph node was about 1.0×1.5 cm2. Routine blood results showed white blood cell (WBC) of 148.52×109/L, lymphocyte ratio of 81.5%, hemoglobin of 101 g/L and platelet of 68×109/L. Bone marrow smear revealed active hyperplasia of nucleated cells in bone marrow and increased proportion of lymphocytes, including mature lymphocytes (91%) and immature lymphocytes (2.5%). Likewise, peripheral blood films also suggested significantly augmented proportion of lymphocytes, with 91% of mature lymphocytes and 3% of immature lymphocytes, which was consistent with the bone marrow smear of CLL. Subsequently, the patient was subjected to bone marrow biopsy. Results indicated active bone marrow hyperplasia and nodular or patchy proliferation of mature lymphocytes, without granulocyte, erythrocyte and megakaryocyte, as well as germinal center and macrocell transformation. Flow cytometric immunophenotyping showed CD5(+)81%, CD19(+)70%, CD20(+)25% and CD22(+)8%. Finally, the patient was diagnosed with CLL at Binet C stage and was given 4 courses of combination therapy of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP). After discharge, he received daily oral chlorambucil 2 mg for a long time, and the disease was controlled.
+On May 20th, 2020, the patient revisited the hospital. The bone marrow smear still conformed to CLL, and the bone marrow biopsy indicated that tumor cells were scattered or clustered (10–20%). Flow cytometric immunophenotyping performed on the peripheral blood showed that abnormal cell population accounted for 87.16% of nuclear cells, expressing CD19, CD23, CD5, CD200 and CD22, partially expressed CD20, CD123 and CD11c, and weakly expressing CD81 and CD43, suggesting CLL/small lymphocytic lymphoma (CLL/SLL) phenotype. The karyotype of the chromosome was 45,X,-Y[4]/47,XY,+12[6]/46,XY[15]. Fluorescence in situ hybridization (FISH) showed negative IGH/BCL2, ATM/CEP11, RB-1, CCND1/IGH, CEP12 and P53/CE P17. The second-generation sequencing showed that Y220C and I195F mutations in exon 6 of TP53 mutation were positive, with a mutation rate of 4.1% and 1.5%, respectively. Somatically mutated monoclonal IGHV4-34 gene rearrangement was demonstrated, with 6.7% of mutation rate. Taken together, these findings indicated that this patient was diagnosed with RaiIII-phase CLL at Binet stage C, with IgHV and TP53 mutation. Oral ibrutinib tablet 420 mg was given once a day. No increase in hemoglobin was observed in blood routine monitoring during the oral administration of ibrutinib, and intermittent transfusion for the treatment was conducted in our hospital.
+On June 23th, 2020, the patient was referred to our hospital when he presented with fever, fatigue and anorexia. On admission, the physical examination revealed anemia, a body temperature of 37.9°C, pulse rate of 102/min, breathing rate of 20 times/min and blood pressure of 120/67 mmHg, without obvious abnormalities in the heart and lungs. There were enlarged lymph nodes in the bilateral neck and groin, with the most being 2×3 cm2, as well as splenomegaly (line A and B of 5 cm, line A and C of 6 cm, line D and V of −6 cm) with small-medium in size, nontender and pitting edema of lower limbs. Routine blood results showed WBC of 59.16×109/L, lymphocyte count of 121.04×109/L, hemoglobin of 89 g/L and neutrophile granulocyte of 17.78×109/L. Bone marrow smear indicated active bone marrow hyperplasia, and we observed 46.5% of protogranulocytes (small and unequal in size and some cytoplasm containing a few azurophilic granules), many basophilic erythroblast, megakaryocytes and small megakaryocytes, but little immature lymphocytes . The positive rate of POX staining was about 65%, indicating CLL accompanied by AML-M2 . As shown in , abnormal myeloid primordial cells were found in the specimens, accounting for 32.86% of the nuclear cells, which was in line with AML phenotype. In addition to expressing myeloid antigens, CD56-positive lymphocytes were also noticed, which could be used as a monitoring indicator for minor residual disease. A cluster of abnormal B lymphocytes with small forward scatter (FSC) intensity and side scatter (SSC) intensity was observed in the specimen of the patients, and the phenotype of the cluster of cells was consistent with CLL/SLL. Moreover, the patient’s karyotype was 44, X,-Y,del(5)(q31),-7add(12)(p13)der(17)der(18), 22,+mar([8]/44,idem,del(4)(q22)[12] .
+On the basis of the data above, a final diagnosis of AML-M2 secondary to CLL was made, with -Y,del(4q),del(5q),-7,add(12p),der(17),der(18),-22,+mar. Azacitidine combined with B-cell lymphoma 2 (Bcl-2) inhibitor was recommended for the treatment, which was rejected by his family, and the patient died of pulmonary infection on October 17, 2020. This study followed the principles of the Declaration of Helsinki, and informed consent was obtained from the patient’s family.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_389_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_389_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6399d23275e98d3f3c7b087bb004ae6dee184819
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_389_en.txt
@@ -0,0 +1,2 @@
+A one-year-nine-month old Chinese girl with symptoms of hearing loss and retrogression of speech and movement since one-year-old presented in our out-patient service. The patient was responsible to teasing, and her neck stood firmly at the age of 5 months. She was able to flip over her body at the age of 8 months, responded when her name was called, and was able to call mom and dad at the age of 9 months. However, her motor development lagged behind her peers obviously. She was not able to sit and crawl independently at one-year-old. Since then, the patient gradually lost her response to surroundings and had lack of facial expression and hypotonia, especially weakness in upper limbs, including loss of hand agility and lack of grabbing. Other symptoms included choking when drinking and swallowing difficulty, but seizure was not observed. Her body weight decreased from 10.5 kg to 8 kg after the symptoms manifested. She started holding her breath for 1–2 min frequently after crying, starting at the age of 10 months. Cyanotic breath holding spells (BHS) occurred on an average of 10 times/day. She was the first child of non-consanguineous parents. The first and second pregnancies were ceased by her parents, and the 3rd pregnancy was aborted because the embryo stopped developing. She was born at 32+ 6 weeks of gestation through cesarean section because her mother suffered from pregnancy-induced hypertension. Her birth weight was 1.36 kg, and her newborn hearing screening result was unremarkable. When she came to the clinic at one-year-nine-month, her height was 77 cm, her weight was 8 kg, and her head circumference was 45 cm, all lagging behind children of the same age. She could only control her head, and she showed poor visual fixation and sound tracking. Physical examination showed generalized weakness, especially the upper extremities, hypotonia of limbs, weak gag reflex, absent of patellar tendon reflex, and negative bilateral Babinski sign. Ammonia, serum lactic acid, hepatorenal function, microelements, and serum amino acids were normal. Acylcarnitine profile showed mild abnormalities including mild elevation of octanoyl carnitine (C8): 0.33 μmol/L (0.01–0.30 μmol/L) and decanoyl carnitine (C10): 0.50 μmol/L (0.01–0.35 μmol/L). Other acylcarnitine species were within the normal ranges. Her urine organic acid analysis showed mild elevated pyruvic acid and lactic acid.
+Magnetic resonance imaging (MRI) of the brain showed no contrast and visual-evoked response. Video electroencephalogram and echocardiography were normal. Electromyogram was neurogenic with fibrillation activity. Nerve conduction studies showed denervation without sensory response of the sural and median nerves but normal motor velocities. Brainstem auditory-evoked responses revealed severe sensorineural hearing loss. The ophthalmologic examination was normal. With the consent of the child’s parents, genetic testing was performed. No variant was found in the SMN (survival motor neuron) gene, which encodes survival motor neuron protein. Her karyotype analysis was normal.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_394_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_394_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..971f48b5453350e146e20b85c350efbf9060070d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_394_en.txt
@@ -0,0 +1,9 @@
+A 41-year-old Asian man was transferred to the Center of Trauma Surgery in our hospital 6 hours after injury for the closure of an open infected wound with a large skin defect in his right lower limb caused by an accidental explosion of 100 pieces of a blasting cap. Hemostasis of the wound was achieved by applying pressure and a total of 2500 ml Ringer's solution, which is a kind of balanced salt solution, was given intravenously during the emergency. He was mildly obese, described himself as quite heathy, and had never been admitted to a hospital previously. He reported no chronic medical history, such as primary hypertension, heart disease, diabetes mellitus, an impaired immune system, malignancies, liver cirrhosis, renal failure, or hemodialysis. He also reported no history of infectious disease, such as tuberculosis, any types of hepatitis, or acquired immunodeficiency syndrome (AIDS). His medical history revealed no trauma, blood transfusion, other surgical procedures, or other serious event. He had not lived in an epidemic area and had no contact history of radioactive exposure. He denied any family history of inherited diseases. He usually did not smoke tobacco or consume alcohol and had no other unhealthy behaviors. He was a business executive and he often traveled for business.
+His blood pressure at admission was 99/50 mmHg, pulse rate was 102 beats per minutes, and his respiratory rate was 21 breaths per minute. On examination, his mucous membrane was dry and his conjunctivae were pale. No positive signs were found during neurological, cardiopulmonary, and abdominal examinations. There was no pain around the kidney area with percussion or tenderness along the bilateral ureteral approach.
+A specialized examination revealed that the wounds were located on his right gluteal and were approximately 40 cm × 35 cm in size with a darkened appearance. The margins of the wounds were 2 cm above the bottom of iliac crest, inferior to the superior segment of back side of his thigh, 3 cm interior of the anal cleft, and external to the lateral thigh (as shown in Fig. ). The wound had hemorrhaged and contained scattered metallic foreign bodies. Most of his gluteus maximus muscle was injured and the motion of his right hip joint was limited.
+In addition, related laboratory examinations were conducted. His complete blood count values were as follows: white blood cell count of 10,940 cells/uL, red blood cell count of 3,250,000 cells/uL, hemoglobin of 9.8 g/dL, and platelet count of 153,000 cells/uL. D-Dimer was 5678μg/L. His total protein was 45.7 g/L, among which the albumin and globulin content were 21 g/L and 24.7 g/L, respectively. The results of serology for renal function were normal. Blood and aerobic and anaerobic bacterial cultures were performed. Microorganisms were not found in the blood cultures. The secretions from injured tissue revealed that a little of the Gram-positive bacteria, Bacillus subtilis, was detected. A diagnosis of explosion injury in left gluteal region and hemorrhagic shock was made.
+He underwent aggressive fluid administration, hemodynamic support, and intravenously administered antibiotic therapy. Debridement of his right gluteal was carried out 6 hours after the explosion under general anesthesia. Then, the wound was sutured with VSD and adhesive membrane, which finally was connected to negative pressure drainage equipment. During the operation, 800 ml erythrocytes and 400 ml plasma were infused into our patient. Three days after the first operation, he underwent a second operation. The necrotic muscles were excised and then the wound was closed with interrupted suture to shorten the defect to 12 cm × 40 cm (as shown in Fig. ). The VSD was also connected to the wound as described above.
+Nine days after the second treatment, although a few scattered necrotic muscles were located in the wound, the granulation tissues were growing well. The skin around the wound was healthy, with only mild edema and migrated to the wound margins. The pinch test demonstrated that the skin had some mobility, which indicated that it could be sufficiently stretched. Under general anesthesia, the skin margins were minimally free to facilitate the insertion of intradermal needles on both sides of the wound. The wound itself was left undisturbed. Three SSDs (Life Medical Sciences, Inc., Princeton, NJ) were inspected every few hours. The healthy skin was stretched for 4 minutes, followed by 1 minute of relaxation. After stress relaxation had occurred, the tension was adjusted to 3 kg, as indicated by the tension gauge (as shown in Fig. ).
+This procedure was repeated five times during the operation until the skin reached approximation to the wound margins. Then, the devices and the intradermal needles were removed from our patient. During this process, the granulation tissues looked good, the wound was thoroughly irrigated, and the stretched skin margins were closed with interrupted suturing to reduce the size of the defect to 5 cm × 38 cm (as shown in Fig. ). After stretching treatment, the VSD was applied again to close the wound as before.
+After 9 days, the size of the wound had decreased to 4.5 cm × 35 cm (as shown in Fig. ). The SSD was then applied again as before. During the last operation, the wound was thoroughly irrigated, and the stretched skin margins were closed with interrupted suturing (as shown in Fig. ). Eighteen days after this operation, there were only two small wounds that were approximately 1.0 cm × 0.8 cm without edema or inflammation. The local granulation was healthy (as shown in Fig. ). At that time, our patient was ambulatory. Although he had been in hospital for over 1 month, there was no evidence of damage to the skin margins. The timeline of the patient’s treatment is shown in Table .
+At 3 months postoperatively the wound was healing perfectly and our patient could walk freely and do some suitable exercise. At 6 months postoperatively, he returned to business work as usual.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_395_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_395_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a1205bc8f3885c92827e911e9b4be06aa60ea2bf
--- /dev/null
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+A 68-years-old Mongoloid woman presented with an asymptomatic, flesh-colored lesion on the right upper eyelid. The lesion had slowly increased in size over 5 years. No similar lesions were found on other parts of the body. Her medical and family histories were unremarkable, and she had experienced no triggering trauma.
+Upon ophthalmologic examination, the protruding lesion was found to be approximately 5 × 5 × 4 mm and located on the upper lid margin . Palpation of the lesion did not elicit pain, and the lesion was non-slidable. On the photography of anterior segment, the nodule was verified as flesh-colored, dome-shaped, with eyelashes on the smooth surface, and the lesion located on the anterior lamella of the lid margin, without superficial ulceration and dilated blood vessels. . The conjunctiva, cornea, and lens were unremarkable and so as the fundus examination results. Examinations showed that the left eye was normal. The visual acuity of both eyes was 20/20.
+The lesion was removed by shave excision under local anesthesia. The lesion was non-slidable, and it was adherent to the tarsal plate and its covered skin. Anterior lamella of the eyelid was resected with a trigonal wedge, with the removal of 1 mm of extra tissue from the margin of the lesion, and the thin layer of the tarsal plate. The anterior lamella defect of the upper eyelid was repaired using A-T flap. A gray line split was performed on the cut ends of skin defects, then, the skin defects were sutured directly. We checked the preauricular lymph nodes, and no lymphadenopathy was found. After the operation, the patient was compression bandaged for 24 h.
+Histologically examination of the lesion showed a well-defined tumor mass involving a hair follicle, and a proliferation of multiple thin strands of basaloid cells, extending from the central follicle into the surrounding fibrous stroma. The fibrous stroma presented a sharp contrast with the surrounding dermis. Hematoxylin-eosin stains contained mucin content in the stroma . The histologic findings were characteristic of fibrofolliculoma.
+Two weeks after the surgery, the patient had no particular complain. The right upper lid showed almost identical to that of the left . During the 3-month follow-up, no signs of recurrence or new lesions appeared.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_435_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_435_en.txt
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index 0000000000000000000000000000000000000000..2765d44caab4e1d7cf6f43c4a2e9d3758929843b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_435_en.txt
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+A 32-year-old female was admitted to hospital due to recurrent bilateral ptosis for 8 years, diplopia for 2 years and limb weakness for 1 year and a half. Eight years ago, she developed ptosis. After taking mecobalamin orally for a few months, her symptoms completely recovered. Two years ago, ptosis recurred along with diplopia, and half a year later, her condition was aggravated by limb weakness with the distal muscles more severely affected than the proximal muscles. Since then, she couldn’t take care of herself independently, and couldn’t walk on a level road without support. Fluctuations in muscle strength were not pronounced. She had normal motor development milestones but began to notice poor performance in sports since school age, and during her adult life. She can only do some indoor housework, but not the outdoor heavy farm work. During the course of the disease, no neurodevelopmental abnormalities or psychiatric symptoms were observed. The patient was born from consanguineous parents, and she has a negative family history of neurological or neuromuscular disease.
+Her physical examination on admission revealed bilateral ptosis, complete external ophthalmoplegia, and diplopia. Muscle strength was 2/5 for finger/wrist extension and ankle dorsiflexion/plantar flexion, 3/5 for wrist/finger bending, while proximal muscle strength was 4/5 for upper limbs and lower limbs (grades 0–5 on the Medical Research Council Scale). The tendon reflex of both upper limbs was normal and symmetrical. The knee reflex and Achilles tendon reflex were absent, and the plantar reflexes were flexor. There were atrophy of the distal muscles of upper and lower limbs, per cavus, claw-like hands, and a steppage gait. Sensory examinations were normal. No signs of neuromyotonia were observed.
+Intramuscular injection of neostigmine 1 mg significantly improved her ptosis and diplopia. The acetylcholine receptor (AChR) antibody was elevated (11.793 nmol/L, normal < 0.5 nmol/L). Immunofixation electrophoresis in blood and urine was normal. Thyroid function was normal. Computed tomography of the chest showed no parenchymal abnormalities. The result of lumbar puncture cerebrospinal fluid examination was normal. Brain and spine MRI were not done, since there were no neuropsychiatric symptoms. Electromyographic studies revealed a chronic motor axonal neuropathy, without neuromyotonic or myokymic discharges . Electromyography (EMG) showed complex repetitive discharges (CRD) in the right biceps brachii, left quadriceps femoris, left anterior tibialis muscle, T12 paraspinal muscle. Decremental CMAP responses in low frequency RNS were recorded in the right deltoid muscle and the left trapezius muscle, and were not observed in the left deltoid muscle, left abductor digiti minimi muscle, right abductor pollicis brevis, and right trapezius. The magnitude of decrement was 27.4% in the right deltoid muscle and 17.7% in the left trapezius muscle respectively. The diagnosis of MG was established, and a concomitant hereditary motor axonal neuropathy was also suspected. Next generation sequencing (NGS) identified a novel homozygous missense variant c.278G > T (p.G93V) in the patient, which was later confirmed by Sanger sequencing. Her parents and the healthy younger brother all were heterozygous carriers . The amino acid G93 in HINT1 is highly evolutionarily conserved among different species . The variant c.278G > T (p.G93V) was neither found in 1000 Genomes Project databases nor in Exome Aggregation Consortium databases. Several online softwares including MutationTaster, SIFT and polyphen2 predicted that the variant may have a deleterious effect on the gene product. A different amino acid substitution for Glycine (Gly, G) at position 93 of the HINT1 protein occurred in a patient with autosomal recessive axonal neuropathy with neuromyotonia . According to the ACMG guidelines, the variant c.278G > T (p.G93V) in HINT1 can be classified as likely pathogenic. Consequently, the diagnosis of HINT1-related hereditary axonal motor neuropathy was considered.
+The patient received a therapy with pyridostigmine (60 mg/6 h), oral prednisolone (35 mg/24 h) and azathioprine (100 mg/24 h). After 6 months of therapy, ptosis and diplopia greatly improved with only mild adduction deficit of the right eye. Unfortunately there has been little recovery in limb weakness. The dose of prednisone was reduced to 30 mg/24 h. Anti-AChR antibody remained elevated but to a lesser degree compared with the initial titer. She is currently followed up every 3–6 months in our neurology clinic.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_462_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_462_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..755abd91ade13da3bc9cee5c83662bb35197f39b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_462_en.txt
@@ -0,0 +1,3 @@
+A 79-year-old gentleman presented with a 3-week history of acute, progressively worsening right-sided back pain radiating to the right groin and anterior thigh. He was admitted due to reduced mobility secondary to pain and an inability to safely function independently at home. A risk assessment for red flag symptoms including spinal cord or cauda equina compression, progressive neurological deficits, new urinary retention, faecal incontinence, and constitutional symptoms were absent. He was in his usual state of health prior to the onset of these symptoms. He denied any history of fevers, rigors, gastrointestinal symptoms, inciting trauma, or recent dental or surgical procedures. Social history included a 30-pack-year smoking history, minimal alcohol use, and denied intravenous substance use. His past medical history included hypertension, dyslipidaemia, gout and reflux. His past surgical history involved bilateral hernia repair with mesh, bilateral subclavian to carotid artery bypass and repair of an endovascular infrarenal abdominal aortic aneurysm, which required embolization for a leak at the left internal iliac artery 4 years later. Home medications included Clopidogrel, Hydrochlorothiazide, Perindopril, Allopurinol, Pantoprazole, Rosuvastatin, and Tamsulosin. There was no history of immunosuppression or use of immune modulating medications, particularly glucocorticoids. He denied any recent travel, animal exposures, consumption of processed meats, cheeses or other dairy products.
+The patient was afebrile and hemodynamically stable at presentation and throughout his hospital stay. Physical examination of the cardiorespiratory, abdominal, and neurological systems was within normal limits. A focused examination revealed no tenderness on spinal palpation, a negative straight leg raise test, no pain on leg roll, and a normal gait. Relevant laboratory results included lymphopenia (0.7 × 109/L), anaemia (haemoglobin 101 g/L), LDH of 202 U/L, and CRP 34.9 mg/L, which later increased to 87.9 mg/L. Multiple sets of blood cultures were repeatedly negative. During his admission, he had an episode of self-resolving diarrhea. Interestingly, despite no prior antibiotic exposure, a stool sample was positive for C. difficile toxin by PCR. This, however, was more representative of a colonisation rather than a true infection.
+Radiographs of the hip and pelvis showed multi-level degenerative disc disease without evidence of fracture. CT Chest/Abdomen/Pelvis with endovascular protocol was negative for endoleak or dissection, but incidentally demonstrated interval L3-L4 discitis with destruction of associated endplates. Transthoracic echocardiogram effectively ruled out the presence of valve disease or vegetations. An MRI with gadolinium was subsequently performed and confirmed the diagnosis of L3-L4 discitis and osteomyelitis . Given the clinical stability and a lack of clear causative pathogen on blood culture, antibiotic administration was delayed to accommodate a fluoroscopy-guided percutaneous aspiration and biopsy. Fluid aspirate returned positive for Listeria monocytogenes in broth culture. Fungal and mycobacterial cultures remained negative. L. monocytogenes was thus determined to be the aetiology and the patient was started on a 6-week course of Ampicillin, with rapid clinical improvement and normalization of CRP on serial assessment. The patient was subsequently seen in follow-up with both the Infectious Disease and Vascular Surgery services at 2- and 6-month time points with ongoing clinical recovery and no recurrence of disease.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_467_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_467_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3ece4e39507996ffd35be3c9fca40bafe540db12
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_467_en.txt
@@ -0,0 +1 @@
+A 70-year-old woman was diagnosed as having PD at 65 years of age after having difficulty with walking and clumsiness with her hands. She also had olfactory impairment. She had no family history of PD. Examinations revealed asymmetric parkinsonism with limb rigidity and bradykinesia that were more prominent on the left. There were no cerebellar signs or gaze palsy. Her Hoehn and Yahr stage was 2 and her Mini-Mental State Examination score was 30. Magnetic resonance imaging of her brain revealed normal findings. She was initially treated with levodopa (L-dopa), (200 mg/day), which markedly improved her symptoms. A reduced meta-iodobenzylguanidine (MIBG) cardiac uptake on myocardial scintigraphy was detected. On the basis of these findings, she was diagnosed as having PD. At 67 years of age, she developed orthostatic hypotension and was treated sequentially with fluids, compression stockings, and midodrine. Her disease slowly progressed over the next three years, and L-dopa dosage was increased to 600 mg/day. At 70 years of age, she had a mild head trauma with loss of consciousness. One month later, she developed acute-onset lateral flexion of her trunk to the left side while standing, and she was admitted to our hospital. On admission, her neurological examinations revealed slight weakness of her left upper and lower extremities in both proximal and distal muscles, as indicated by her Medical Research Council (MRC) scale score of 5-/5. She showed a sustained 10.1°lateral flexion of her trunk to the left side on standing . This posture was alleviated in the supine position. Her Pisa angle was assessed using NeuroPostureApp© . Her right muscle strength was normal. Her sensory systems were normal and no cerebellar signs were detected. Her deep tendon reflexes were normal and her plantar reflex was flexor bilaterally. Her presurgical brain computed tomography (CT) showed CSDH in the right hemisphere resulting in a marked compression of the hemisphere . She was immediately referred to the neurosurgical department of our hospital and the subdural hematoma was successfully evacuated by single-burr-hole drainage. Her brain CT carried out four days after the operation showed improvement of her subdural hematoma . Seven days after her operation, her PS disappeared and she fully recovered to her preoperative level of function without any sequelae such as headaches and cognitive impairment caused by her CSDH. She is still being follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_482_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_482_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..23533a6701f031e5f20543e3e7e4e88e8acb1eba
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_482_en.txt
@@ -0,0 +1 @@
+A seven year old girl presented with a lump in the right lateral forehead of two weeks duration. The mother of the patient noticed the lump while combing the child’s hair. There was no reported fever, pain, redness or tenderness over the lump indicating an inflammatory process. The patient denied any history of trauma or contact with chemicals, especially cosmetics reducing suspicion of a cutaneous hypersensitivity reaction. There was no reported visual impairment, diplopia, blurred vision, visual field defect, or opthalmoplegia to suggest ocular involvement. She strongly denied parafunction of the facial muscles like brukshism. Past medical history was non-contributory the patient reported intermittent headaches that were relieved with simple analgesics. The headache history was not compatible with migraine type or tension type headaches. The lump had not previously detected by her parents or medical practitioners. The most recent available photograph that was taken at 3 years of age revealed no evidence of hypertrophy of the right temporalis region. Physical and neurological examinations were unremarkable. The child was of average build (height 128 cm, 90th centile, weight 25 Kg, 75th centile) and healthy appearing without dysmorphism. There was marked enlargement of the right temporalis muscle, preserving the shape of the muscle, without evidence of inflammation. There was no evidence of hypertrophy of the other facial muscles on the same side or opposite side. There was no visual impairment or visual field defect. The cranial nerve examination was intact upon exam; the left side temporalis muscle was not hypertrophied. Hematological and biochemical tests were unremarkable. A complete blood count revealed a white blood cell count 9.4 × 1000 cells/mm3 (μL) (normal 4–12 × 1000 cells/mm3(μL) with 35% neutrophils and 48% lymphocytes, hemoglobin 13.2 g/dl (normal 11.5–14.5 g/dl),platelets 230 × 103/mm3(μL) (normal 150–400 × 103/mm3(μL), C-reactive protein 3 mg/L (normal 5 - 10 mg/L), clotting profile revealed Bleeding Time (BT) 2.5 min (normal 2–8 min), INR 1.06 (normal 0.8–1.2), activated Partial Thromboplastin Time (aPTT) 28.4 Seconds (normal 21.0–34.0 s). Liver function tests were within normal limits, including Alanine Aminotransferase (ALT) 20 U/L (normal 3–45 U/L) and Aspartate Aminotransferase (AST) 18 U/L (normal 15–50 U/L). Ultrasound Scan revealed uniformly enlarged right temporalis muscle. Cranial Magnetic Resonance Imaging (cMRI) revealed that the entire right temporalis muscle was hypertrophied compared to the left (right 9 mm vs. left 5.7 mm), preserving normal muscle morphology and normal signal intensity without abnormal contrast enhancement. No intracranial abnormalities or involvement of the bones were detected . The diagnosis was confirmed by an incision biopsy, which demonstrated unremarkable skeletal muscle with preserved architecture. Available treatment modalities were discussed with the parents, and since the child was asymptomatic no immediate interventions were planned. She will be followed up regularly in the clinic (Additional file : Time line of events).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_487_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_487_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2049f43ef88307d73bc6764bb79af8e469d268ba
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_487_en.txt
@@ -0,0 +1,5 @@
+The present patient was a 4-day-old female infant. The mother had had a natural pregnancy. The patient had been born by vaginal delivery at a gestational age of 39 weeks 3 days with a birthweight of 3124 g. The passage of meconium was observed soon after the birth. The patient presented on day 4 of age to our neonatal intensive-care unit with abdominal distention and bilious vomiting after each feed. Her vital signs were stable, and she was slightly inactive and mildly dehydrated. Upper gastrointestinal series showed a normal appearance. Gastrografin enema showed that the transverse colon near the hepatic flexure was not delineated on the oral side. When pressure was applied, the string sign was observed . Microcolon was not found. Shortly after admission, exploratory laparotomy was performed under suspicion of intestinal stenosis caused by intussusception or volvulus.
+Stenosis of the transverse colon was found 9 cm from the Bauhin valve. It was elastically hard, white, totally fibrotic, and had a ‘napkin ring’ appearance . The sonde passed through the stricture. We suspected organizing due to intussusception in the prenatal period. Partial resection and end-to-end anastomosis were thus performed .
+A pathological examination of the resected specimen showed that the cells were mainly composed of spindle-shaped cells, with some round cells and slightly clear cells mixed in. They were circumferential, proliferating from the submucosa to within the muscle layer and narrowing. The mucosal surface was ulcerated. The mucous membrane was atrophied and atrophic. Calcification was observed in the muscle layer. There was no obvious epithelioid pattern . An immunohistochemical analysis revealed positive staining for vimentin, cluster of differentiation 34 (CD34), and discovered on GIST-1 (DOG1), weak positive staining for c-kit, and negative staining for cytokeratin AE1/AE3, small muscle actin (SMA), and S-100 protein (S-100). The Ki-67 index was 30%, and the mitotic index was 115/50 high-power field (HPF).
+Given the above, we suspected a malignant tumor of gastrointestinal stromal tumor (GIST). A further consideration, including an immunohistochemical analysis revealed positive staining for SMA, CD34, DOG-1, and SDHB and negative staining for c-kit, S-100, β-catenin, pan-tropomyosin resepter kinase (pan-TRK), analplastic lymphoma kinase (ALK), and c-ros oncogene 1 (ROS1). The histology and immunohistological markers were characteristic of infantile myofibroma.
+The patient had an uncomplicated postoperative course and was discharged home after 3 weeks. Whole-body magnetic resonance imaging (MRI) and gastrografin enema performed 6 months after the operation showed no recurrence of the lesion and no other new lesions.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_511_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_511_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..da22c2207a22aa168c349d9136d9d60d06d434d4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_511_en.txt
@@ -0,0 +1,6 @@
+A 15-month-old boy was admitted to the pediatric clinic of the First Affiliated Hospital of Bengbu Medical College on April 23, 2018, because he could not walk. The medical history reported by the parents was that café-au-lait spots could be seen on the skin of the body and limbs when the child was born. With aging, the spots gradually increased and became larger, and the child’s development was retarded. At admission, the child could not speak, crawl, or walk. The patient was first born child with normal full-term delivery. The birth weight was 3.0 kg. The parents of the child were normal, and there was no family history.
+Physical examinations showed that body temperature was 36.5 °C, breathing was 24 times/min, pulse was 120 bpm, body mass was 9.2 kg (−1SD to -2SD), body length was 72.5 cm (−2SD to -3SD), and with a conscious mind. Oval café-au-lait spots of different sizes were scattered on the skin of the body and limbs, with light brown and clear boundary, not protruding from the surface of the skin, with a diameter of about 0.5–1.5 cm (more than 6 had a maximum diameter of more than 5 mm) . He had hypertelorism (widened eyes distance) with left blepharoptosis and congenital pectus excavatum . We found the patient grade 2–3 systolic ejection murmurs on the left second intercostal, below the margin of sternum and bilateral cryptorchidism, without hepatosplenomegaly.
+The results of tandem mass spectrometry, urinary organic acid analysis, and blood gas analysis, gonadotropin, sex hormones, and plasma testosterone level were normal, and no significant anomaly of eye sight and was found. Result of ultrasonocardiography suggested the patient had secondary atrial septal defect. Cranial magnetic resonance imaging (MRI) showed lesions with intermediate signal intensity on T1WI and high signal intensity on T2WI and T2FLAIR, as known as UBOs (undefined bright objects), and the lesion boundary was not clear .
+To diagnose, we collated the signs and symptoms of the patient into forms of HPO (the Human Phenotype Ontology) and retrieved the top 10 diseases associated with the phenotypes using the online analysis tool, Phenotype Profile Search, provided by The Monarch Initiative , and it turned out that chromosome 17q11.2 deletion syndrome, Legius syndrome, NFNS, and NF1 are the most likely primary disorders. .
+To confirm the findings and differentially diagnose, we performed whole exome sequencing (Deyi Dongfang Translational Medical Research Center, Beijing, China) to find the genetic factors. The targeted sequencing followed the instruction recommended by Illumina using the short reading method to screen single nucleotide variants (SNVs) and short indels (< 50 bp), followed by a comprehensive analysis of variant pathogenicity assessment according to the ACMG clinical practice guidelines, genotype-phenotype matching, and inheritance type confirmed by trio data and Sanger sequencing or real-time PCR (Polymerase Chain Reaction). Based on the sequencing data, however, we found a de novo heterozygous large deletion, including the exons 1–58, in the NF1 gene, which is not previously documented and it was confirmed by using real-time PCR . We also analyzed variations in the genes correlated to the RAS/MAPK pathway signaling, PTPN11, SOS1, RAF1, BRAF, SHOC2, KRAS, HRAS, MAP 2 K2, PPP1CB, RRAS, and MAP 2 K1, and Legius syndrome related SPRED1, and no pathogenic or likely pathogenic mutations were found.
+At present, the child is undergoing rehabilitation training. Motor development is still retarded. The child shows no other abnormalities.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_524_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_524_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..faa7b73898d30d0c096bc838893260dcee64a67f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_524_en.txt
@@ -0,0 +1,9 @@
+A 29-year-old man presented to his local emergency department due to an increasingly severe headache for the past 2 weeks, and new-onset neurological symptoms. A CT scan of the head revealed three right-sided supratentorial lesions . He received betamethasone and was emergently transferred to the neurosurgical unit at Linköping University Hospital. The following morning a head magnetic resonance imaging was performed and confirmed intracerebral abscesses. He was started on metronidazole and cefotaxime for empiric antibiotic coverage, and the lesions were drained. Blood, urine, and abscess material were collected for culture. Aggregatibacter Aphrophilus and Eikenella Corrodens, two bacteria commonly found in the normal bacterial flora of the oral cavity were isolated from the abscess cultures.
+The patient’s past medical history was insignificant. He had not used recreational drugs and did not abuse alcohol. He was a non-smoker but used nicotine pouches. He was of normal weight (body mass index 23.1 kg/m2) and physically fit. He worked as a serviceman for the army and was in active service. On cardiac review, he had never experienced chest pain, palpitations, decreased effort tolerance, cyanosis, or syncopal episodes. There was no recent travelling history. Family history revealed premature coronary heart disease but no sudden death or CHD. His mother had not used medications during pregnancy.
+The patient remained afebrile, with normal pulse variability, blood pressure, and oxygen saturation on room air during the entire hospital stay. He displayed no signs of skin, ENT, dental, lung, or GI infection. The patient confirmed a visit to his dentist for scaling 1 week before the onset of the headache. Cardiac auscultation revealed regular rhythm without gallops or rubs. There was a Grade II/VI pan systolic murmur along the left sternal border increasing with inspiration. No significant jugular distension, hepatomegaly, or hepatojugular reflux was evident. Electrocardiogram (ECG) was normal .
+As routine screening, transthoracic echocardiography (TTE) was conducted. The investigation revealed a dilated CS and atypical appearance of the tricuspid valve with moderate insufficiency. To rule out endocarditis or shunt, transoesophageal echocardiography (TOE) was scheduled along with an agitated saline study.
+The TOE ruled out valvular vegetation, and no shunt was evident utilizing colour Doppler. Agitated saline was injected via the central venous catheter located in the right internal jugular vein; contrast appeared in LA first with a short delay before evident in the RA. To obtain a wider field of observation, the investigation was converted from TOE to TTE (Video 1). The finding raised suspicion of an extracardiac R–L shunt with a simultaneous intracardiac shunt. The same result occurred when utilizing the right cubital vein for injection. However, when agitated saline was injected via a venous line on the dorsum of the right foot, the contrast was only observed in the RA (Video 2). To further evaluate the shunt, cardiac magnetic resonance (CMR) and magnetic resonance angiography were scheduled.
+Cardiac magnetic resonance confirmed normal cardiac size and function. The tricuspid valve was found to have an atypical appearance presenting elongated leaflets; however, it did not display tethering of the septal leaflet or displacement associated with Ebstein’s anomaly, or any other diagnostic pathology. Increased trabeculation of the right ventricle was observed but was non-diagnostic for non-compaction cardiomyopathy.
+Magnetic resonance angiography confirmed the presence of a bilateral superior vena caval system without a bridging vein. The PLSVC connected to the CS which drained in the RA. The RSVC presented an anomalous trajectory directly to the LA . An intracardiac connection between the RSVC and the RA could not be identified utilizing this modality and no CS defect was evident (, ) An R–L shunt involving the venous drainage of the right upper extremity and right-sided neck veins was confirmed.
+As the extracardiac shunt in isolation could not explain the findings of the agitated saline study, the patient was scheduled to return for an ECG-gated cardiac CT (CCT) with angiography after a prolonged course of I.V. antibiotic therapy at his local hospital.
+Upon return, the CCT uncovered a 5-mm vessel branching off of the RSVC to form a connection with the RA revealing the extracardiac sinus venosus defect .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_534_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_534_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3759e957f169c7f7443af572c084de2b56c0577e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_534_en.txt
@@ -0,0 +1,2 @@
+A 54-year-old male with dextrocardia true situs inversus, referred to our hospital due to traumatic syncope. He had history of coronary artery bypass grafting 4 months ago, and inferior wall myocardial infarction 3 months ago, as a result, he was not a candidate for any revascularization.
+He had two attacks of syncope due to sustained monomorphic and polymorphic ventricular tachycardias and left ventricular ejection fraction of 35% by an echocardiogram done three weeks ago. Since he was not a candidate for further revascularization, we decided to implant a dual-chamber implantable cardioverter-defibrillator (ICD) . Before procedure, bilateral axillary venography, fluoroscopy, multislice computerized tomography angiography (MSCTA) were done which revealed dextrocardia with normal segmental cardiac anatomy of chambers and vascular bed. Venous access was gained via the left subclavian vein. Through a left-sided superior vena cava, two active leads were implanted in right ventricular apex (3830-59, Medtronic, Minneapolis, USA) and right atrial (5568 Medtronic, Minneapolis, MN, USA) appendage. shows the final position of the leads. The thresholds and senses were located appropriately. The leads are connected to a double-chamber ICD. Three months later, cardiovascular assessment of the patient was acceptable.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_551_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_551_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..55f27d19e3bc40ffeb0b23a389dba836dfa9ee89
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_551_en.txt
@@ -0,0 +1,8 @@
+A 79-year-old right-handed male visited our outpatient clinic with severe pain and limited range of motion (ROM) of both shoulder joints.
+The patient’s symptoms started 2 wk ago without a traumatic event.
+Six years ago, this patient underwent bilateral repair for a massive rotator cuff tear at a one-year interval in a local clinic. The patient visited our hospital complaining of worsening both shoulder pain 6 mo ago; an active ROM of the right shoulder was 20° of forward flexion, 30° of abduction, 45° of external rotation, and the 4th lumbar vertebra level of internal rotation on physical examination. Active ROM of the left shoulder was 20° of forward flexion, 20° of abduction, 60° of external rotation, and the 4th lumbar vertebra level of internal rotation. Based on plain radiographs and magnetic resonance images, the preoperative diagnosis was bilateral CTA with failed rotator cuff repair. No preoperative acromial pathology was observed. This patient was treated with staged bilateral RTSA [right shoulder: Equinoxe (Exactech, Gainesville, FL, United States), left shoulder: Delta Xtend (DePuy, Warsaw, IN, United States)] at a two-month interval .
+The patient reported being satisfied with significant pain relief and functional restoration after RTSA. At 3 mo after right RTSA, active ROM increased to 140° of forward flexion, 100° of abduction, 50° of external rotation, and the 5th lumbar vertebra level of internal rotation. At 6 wk after left RTSA, active ROM increased to 100° of forward flexion, 80° of abduction, 50° of external rotation, and the 5th lumbar vertebra level of internal rotation.
+The patient underwent RTSA on the right shoulder 5 mo ago and left shoulder 3 mo ago.
+Physical examination revealed tenderness on the posterolateral area of both shoulders without soft tissue swelling or redness. Active ROM was not able to be assessed due to severe pain. Visual Analogue Scale for pain, American Shoulder and Elbow Surgeons score, and Subjective Shoulder Value of both shoulders were 8%, 15%, and 15%, respectively.
+The results of preoperative laboratory tests were normal.
+Plain radiographs revealed no definite fractures or bony abnormalities compared to previous plain radiographs. Computed tomography (CT) scan revealed non-displaced acromial base fractures of both shoulders . The t score of bone mineral density for lumbar spine was -2.9.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_555_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_555_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8f7d5898917439068267934ca00e697ceed47555
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_555_en.txt
@@ -0,0 +1,4 @@
+A 51-year-old previously healthy male was brought by his family members following sudden loss of consciousness. On admission his Glasgow coma scale (GCS) was 7/15 (eye 1, verbal 2, and motor 4). Neurological examination revealed bilateral symmetrical sluggish pupils of 3 mm. We could do only a limited neurological examination due to low GCS. He moved all four limbs to a painful stimulus and the deep tendon reflexes were normal. Bilateral flexor plantar response was present. With the suspicion of any drug overdose, a urine sample for toxins was sent urgently, but all the tested toxins including opioids, benzodiazepines and amphetamines were negative. An urgent NCCT brain was done within two hours of symptom onset to exclude intracranial hemorrhage and it turned out to be normal.
+After four hours of admission, his GCS improved to 11/15 (E3V2M6). However he was drowsy and there was bilateral asymmetrical ptosis, right more than left. Third nerve palsy without pupillary involvement was evident on the right side. Right eye medial and downward gaze were impaired. He also had bilateral upward gaze palsy, but had no nystagmus . These findings suggested a right-sided nuclear third nerve palsy. He did not have pyramidal or cerebellar signs and the visual fields were normal.
+As the NCCT brain was normal, we proceeded with magnetic resonance imaging (MRI) and magnetic resonance angiogram (MRA) brain. It was reported as acute infarction in bilateral paramedian thalami and medial rostral mid brain, suggesting AOP territory infarction. MRA showed hypoplastic right vertebral artery. Apparent diffusion coefficient (ADC) images and diffusion weighted images (DWI) showed the paramedian thalamic infarctions in the index case due to AOP involvement. Here the rostral mid brain involvement is asymmetrical as was suggested by the clinical findings as well .
+Over a week, his hypersomnolance gradually improved but his diplopia persisted. After the diagnosis of ischemic stroke, the underlying risk factor assessment was performed. He had hypertension, but no diabetes mellitus. Lipid profile was deranged with a low density lipoprotein of 140 mg/dL. Electrocardiogram did not show any evidence of arrhythmia or past cardiac ischemic events. Transthoracic echocardiogram was normal except for the left ventricular hypertrophy. He did not have polycythemia or thrombocytosis. As he had conventional risk factors for a stroke, we did not further evaluate for other thrombophilic conditions. He was discharged after 1 week of hospitalization with out-patient speech and physiotherapy. We started aspirin 75 mg, clopidogrel 75 mg and atorvastatin 40 mg daily. At the clinic visit scheduled 3 weeks after the discharge, clopidogrel was withheld and aspirin 75 mg and atorvastatin 40 mg were continued. By the time of clinic visit he had a marked recovery and could engage in his day-to-day activities. However he could not resume his work as a taxi driver even 3 months after the initial stroke.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_566_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_566_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..32bf322ea42a2c67a05aaeffc2f52cabc2151c1b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_566_en.txt
@@ -0,0 +1,7 @@
+A 32-year-old woman referred regular menstrual cycles lasting 7 days with a normal flow and had no previous history of period pains. She was admitted to our hospital for abnormal vaginal bleeding for 2 months and lower abdominal pain for 4 days. The abnormal vaginal bleeding was described as persistent and the amount of blood loss was less than her normal menses. The lower abdominal pain was sudden and progressively worsening which she described as dull pain in nature, located over the lower abdomen, and resolved by changing to side lying position.
+Physical examination revealed a well-healed cesarean section scar tenderness on palpation of the lower abdomen. Bimanual examination revealed that a cyst palpable in front of the uterus about 10 cm in diameter. It appeared to be attached to front of the uterus.
+Laboratory examination showed red blood cell count of 3.2*10∧12/L, hemoglobin of 77 g/L. The C-reactive protein level was 24.4 mg/L.
+Pelvic ultrasound was performed which demonstrated normal adnexae and an enlarged uterus. It revealed a 10.3*10.2*9.3 cm cystic mass in the front of the uterus , and a 7.1*6.5*4.6 cm medium echo mass in the cystic mass with no apparent blood flow signal was detected by CDFI , and 2.6*2.5*2.5 cm masses could be seen outside the lower part of the anterior wall of the uterus . The two masses were closely adjacent to the cesarean section incision in the anterior wall of the uterus. The whole abdomen CT scan showed that cystic mass could be seen in the front of the uterus, with a range of about 11.1 * 9.7 cm. The boundary between the lesion and the anterior wall of the uterus was unclear .
+Based on the imaging studies and patient's history, suspicion of cystic adenomyosis was raised. We performed transabdominal surgery on the patient. The intraoperative exploration revealed a cystic mass with a size of about 10*10 cm arising from the cervical isthmus of the anterior wall of the uterus. We have detected a chocolate-like viscous liquid inside the cyst and noticed the adhesion of the anterior wall of the cyst to the anterior wall of the uterus and the bladder. The posterior wall of cyst adhered to the intestines, as shown in . There was an adenomyoma-like nodule about 3*3 cm deep in the cyst. It showed unremarkable adnexae.
+She was nursed in the ward for a total of 5 days after the surgery and was discharged well without any post-operative complications. We asked the patient to continue treatment with GnRH after operation. Post-operative pathology confirmed cystic adenomyosis . The final diagnosis was cystic adenomyosis.
+Two months after operation, we followed up the patient and no abnormality was found in ultrasonography . The patient remains asymptomatic.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_577_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_577_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..75195784e50418d087f51d47c6d6543e17de6a06
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_577_en.txt
@@ -0,0 +1 @@
+A 71-year-old man was admitted for ischemic-like chest pain occurring 10 days prior to the hospital admission. The ECG showed ST-T segment elevation without a q wave in the infero-lateral leads that could identify either myocardial infarction changes or pericarditis. A persistent release of cardiac markers was registered (troponin I 1.05 μg/l [normal value< 0.6 μg/l]) together with a slight increase in inflammatory markers and white blood cells. The clinical presentation, the ECG pattern and the laboratory data were not sufficient to rule out a diagnosis of pericarditis. Transthoracic echocardiography was not diagnostic. The patient underwent two 99mTc-tetrofosmin myocardial SPECTs on different days: the first at rest and the second after the use of nitroglycerine (0.005 mg/kg per os). The left ventricular ejection fraction (LVEF) was calculated using a previously validated and commercially available automated software (quantitative gated SPECT, QGS, Cedars-Sinai Medical Center, Los Angeles, CA ). The oral post-nitrate images clearly demonstrated an absence of uptake of 99mTc-tetrofosmin in the lateral and infero-lateral wall ; the LVEF was 31%. This absence of tracer uptake after the nitrate administration clearly indicated the presence of non-viable myocardium . The same patient underwent cardiac MRI using a clinical 1.5-T Gyroscan ACS-NT MRI scanner (Philips Medical System, Eindhoven, The Netherlands). The scan was analysed according to: a) the left ventricular function (sequences balanced-echo cine MRI) and b) the presence of scar tissue with delayed-enhancement (DE) images. Delayed sequences were obtained approximately 12 minutes after intravenous injection of 0.2 mmol/kg gadolinium diethyltriaminepentaacetic acid (Gd-DTPA) using a fast field echo sequence (slice thickness 8 mm, FOV 360 mm, flip angle 15°, TE 1.3 ms, TR 4.1 ms). Delayed enhancement images were displayed with a grey scale to optimally show normal myocardium (dark) and the region of delayed-enhancement myocardium (bright). The akinesia of the infero-apical left ventricular segment and the diskinesia of the lateral wall emerged . The LVEF was calculated as 36%; a bilateral pleural effusion was also present. The DE distribution was transmural with a dilatation of the lateral wall that appeared like an aneurysm. Necrotic myocardium usually accumulates and retains gadolinium-based contrast material for 10 or more minutes after the agent has been administered . Considering the results of myocardial SPECT and MRI together, coronary angiography was performed on the fourth day and occlusion of left circumflex coronary artery was identified. As a result of the clinical and image data, medical therapy was continued.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_579_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_579_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..648d2a10fc56ad24a740c6db40f624ac657ca851
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_579_en.txt
@@ -0,0 +1 @@
+A 78-year-old woman presented to our department with borderline resectable pancreatic ductal adenocarcinoma involving the SMA nerve plexus . She underwent pancreaticoduodenectomy with en bloc resection of the superior mesenteric vein and the SMA nerve plexus after neoadjuvant chemotherapy . On postoperative day (POD) 3, the amylase content was less than three times the upper limit of the normal serum value. Therefore, the intraperitoneal drainage tube was removed. On POD 14, she developed sudden fever with chills. The white blood cell count was 3,100 μ/L with 89% neutrophils, and the serum C-reactive protein level was 3.43 mg/dL. Contrast-enhanced computed tomography (CECT) showed intrahepatic segmental portal vein thrombosis without macroscopic abscesses or distinct infectious signs, including pancreatic fistula or bile fistula . After blood specimens were obtained for culture, tazobactam/piperacillin was administered. Since the blood cultures were positive for Enterococcus faecium, tazobactam/piperacillin was switched to vancomycin. We started novel oral anticoagulants for portal vein thrombosis on the day of diagnosis. When antithrombin III activity decreased, we added it to the drug regimen. On POD 19, Enterobacter cloacae and Klebsiella pneumoniae were recovered from the blood cultures, and meropenem was additionally administered. On POD 27, the antimicrobial treatment regimen was switched to levofloxacin based on the microbiological results. On POD 29, intrahepatic portal thrombosis had decreased, and the patient was discharged on POD 37. On POD 54, the patient presented with melena and was hospitalized for gastrointestinal endoscopy. On POD 55, she experienced cardiopulmonary arrest caused by hemorrhagic shock due to melena. Cardiopulmonary resuscitation was successfully performed. CECT showed a ruptured SMA aneurysm and arterio-intestinal fistula . Blood was lost into the reconstructed jejunal limb in the main SMA. No major intraabdominal abscess due to pancreatic leakage or biliary fistula was observed. The white blood cell count was 5,400 μ/L with 86.1% neutrophils, and the serum C-reactive protein level was 2.98 mg/dL. Thus, she was diagnosed with a ruptured aneurysm of the SMA. Since the laparotomic approach seemed difficult after the PD operation with resection of the SMA nerve plexus, we selected a covered stent as the preferred treatment option. Repair using the covered stent was performed by the cardiology team. This treatment successfully stopped the intestinal bleeding, and the patient recovered from hemorrhagic shock . E. coli was isolated from arterial blood cultures during angiography. Finally, she was diagnosed with a ruptured infected aneurysm of the SMA. After a 6-week course of intravenous antibiotic therapy, she was switched to long-term oral amoxicillin and clavulanic acid and was discharged on POD 100. There was no recurrence of bleeding at the 4-month follow-up, and the stent was patent in all subsequent CECT scans. Unfortunately, the patient died 7 months after the initial operation due to disease progression with multiple liver metastases.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_61_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_61_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fd03fa4f2503df08da1f01e4a8f230092e3a2435
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_61_en.txt
@@ -0,0 +1,2 @@
+This report describes the case of a 59-year-old Caucasian man presenting to a general surgical outpatients clinic with an 18-month history of intermittent upper abdominal pain following meals. Clinical examination, blood tests and an ultrasound examination were all unremarkable and no justification for symptoms was found at upper gastrointestinal endoscopy. A computed tomography (CT) scan of the abdomen following an acute admission with abdominal pain and vomiting demonstrated a 4.6 cm dilated segment of ileum containing both contrast and debris . This was further clarified and shown to be solitary by barium meal and follow through . Differential diagnoses included Meckel's diverticulum, non-Meckel's diverticulum and ileal duplication. A decision was made to proceed to laparoscopy with a view to segmental small bowel resection.
+At laparoscopy, a focally dilated anti-mesenteric segment of ileum was found 140 cm from the ileocaecal valve and displaying an abnormal serosa . A segmental resection with side-to-side anastomosis was performed through an enlarged umbilical port site incision. No lymphadenopathy within the mesentery was apparent. Following haematoxylin and eosin staining, extensive infiltration by small monomorphic lymphoid cells was seen on histological examination. No ectopic mucosa was identified. Immunohistochemical analysis revealed atypical cells positive for CD20 and CD79a, and negative for CD3, CD5, CD10 and cyclin D1. A diagnosis of MALT lymphoma was made. Subsequent bone marrow examination and staging CT showed no evidence of disseminated disease staging the lymphoma as 1E using the revised European-American Lymphoma clinic staging system .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_672_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_672_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..74c702f910d5c901f5fab5502f673b53da7d7955
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_672_en.txt
@@ -0,0 +1,2 @@
+A 62-year-old previously healthy postmenopausal Hispanic woman without prior cardiac history presented to our emergency department with recurrent retrosternal chest pain. Our patient denied any illicit drug use, smoking or excessive alcohol consumption. She also denied any family history of heart disease. Of note, our patient reported that she had attained menopause around the age of 50 years; between the ages of 20 and 30 years, she had three full-term pregnancies resulting in the birth of her three children.
+An initial electrocardiogram was remarkable for ST elevations in the precordial leads , with a troponin I level of 0.02ng/ml. Her symptoms improved after receiving aspirin, clopidogrel, nitroglycerine, heparin, beta blockade and a statin. Repeat electrocardiograms after admission were remarkable for complete resolution of the ST segment elevation and our patient reported no further episodes of chest pain. Cardiac catheterization was performed which showed non-obstructive single vessel coronary artery disease with dissection in the mid portion of her left anterior descending artery, with significant luminal compromise . Intracoronary nitroglycerine was not given and no other tests were done to induce vasospasm. Because our patient was symptom free and demonstrated complete resolution of ST segment elevation, and there was no evidence of compromise in coronary flow, a decision was made to defer any revascularization and continue with medical management, including the addition of nifedipine. A full panel of tests, including erythrocyte sedimentation rate, C- reactive protein level, complement level, anti-nuclear antibody test, rheumatoid factor level, perinuclear anti-neutrophil cytoplasmic antibody and centrally accentuated anti-neutrophil cytoplasmic antibody tests, were found to be normal. Our patient continued to remain asymptomatic at two- and six-week follow-ups.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_697_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_697_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6bb0db62a36d5eb7d8450ef7aed3145030cf7300
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_697_en.txt
@@ -0,0 +1,3 @@
+Our patient was a 43-year-old man with a weight of 93 kg and height of 174 cm. He had been undergoing hemodialysis for 20 years because of chronic renal failure. He had been taking cinacalcet, calcium carbonate, montelukast, loratadine, and nalfurafine before the surgery. There were no preoperative symptoms of suspected pheochromocytoma and no history of hypertension. His blood pressure was 140/82 mmHg, heart rate 76 beats/min, body temperature 36.2 °C, and normal respiratory rhythm with an O2 saturation of 96% on room air. Blood tests demonstrated BUN of 60.2 mg/dL and creatinine of 13.3 mg/dL, but coagulability, liver function, and electrolytes were normal.
+A close examination of hematuria revealed a tumor in the right renal pelvis, and retroperitoneal total right nephroureterectomy was scheduled. The tumor in the right adrenal gland was followed up because there was no clear malignant finding on CT. On the day before surgery, 5100 mL of body fluid was removed by hemodialysis. Propofol and remifentanil were used for the induction and maintenance of anesthesia. After tracheal intubation, periodic systolic blood pressure fluctuations within the range of 70–260 mmHg, diastolic blood pressure fluctuations within the range of 40–90 mmHg, and heart rate of 80–110 beats/min were observed at intervals of approximately 8 min . Intermittent and continuous administration of nicardipine was not effective for suppressing the fluctuation, which lasted for approximately 3 h and disappeared spontaneously after completion of laparoscopic surgery. Intermittent and continuous administration of nicardipine was performed because of this circulatory fluctuation; however, it could not be suppressed. Periodic blood pressure fluctuations disappeared spontaneously at the end of laparoscopic surgery. Blood samples were collected during the cycle of circulatory fluctuations. The catecholamine levels of the blood samples were as follows: first blood pressure fluctuation: adrenaline 3.22 ng/mL, noradrenaline 1.98 ng/mL, and dopamine 0.02 ng/mL; second blood pressure fluctuation: adrenaline 6.32 ng/mL, noradrenaline 3.12 ng/mL, and dopamine 0.02 ng/mL; and at the end of blood pressure fluctuation: adrenaline 0.36 ng/mL, noradrenaline 0.47 ng/mL, and dopamine 0.02 ng/mL. A postoperative examination revealed that the highest blood catecholamine levels were adrenaline, with 0.03 ng/mL (normal value: 0–0.10 ng/mL); noradrenaline, with 0.52 ng/mL (normal value: 0.10–0.50 ng/mL); and dopamine, with 0.03 ng/mL (normal value: 0–0.03 ng/ml). In addition, scintigraphy identified an increased uptake of 131iodine-metaiodobenzylguanidine corresponding to the left adrenal gland, suggesting pheochromocytoma . After the diagnosis of pheochromocytoma, oral treatment with doxazosin 2 mg/day was administered, and left adrenalectomy was performed 4 months after the initial surgery.
+Before surgery, his blood pressure was 170/92 mmHg, heart rate 80 beats/min, body temperature 36.5 °C, and normal respiratory rhythm with an O2 saturation of 96% on room air. Blood tests demonstrated Hb of 10.4 g/dL, BUN of 46.9 mg/dL, and creatinine of 11.6 mg/dL, but coagulability, liver function, and electrolytes were normal. Echocardiography showed left ventricular hypertrophy and mild left ventricular wall hypokinesis. On the day before surgery, 4300 mL of body fluid was removed by hemodialysis. Pheochromocytoma resection was performed under general anesthesia with propofol and remifentanil. As with the initial surgery, periodic circulation fluctuations occurred after tracheal intubation at the time of anesthesia induction, but the fluctuations were approximately 10 min apart, and the degree of fluctuation was smaller than that of the first surgery. Intermittent and continuous administration of nicardipine and landiolol was performed for circulatory fluctuation; however, once again, the fluctuations could not be suppressed. Dopamine was administered to maintain circulation after tumor removal. The periodic fluctuations disappeared after the ligation of the left adrenal artery and did not occur thereafter. The intraoperative course of the second surgery is shown in Fig. .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_703_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_703_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8711102af0b7c50758804032f391f16e55dfa0bd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_703_en.txt
@@ -0,0 +1,7 @@
+A fifty-five-year-old man with hypertension and who used regular medications for anxiety came to the Emergency Room in Malmö, Sweden, complaining of dyspnea in 2009. He had arrived to Sweden by plane from Sri Lanka five days prior, where he resides a large part of the year. Upon exiting Sri Lanka, he was put into custody for almost 6 weeks under unhygienic conditions.
+Already in Sri Lanka, but aggravated upon the return to Sweden, the patient experienced throat pain and shortness of breath. At the emergency room the patient presented with severe shortness of breath and fever of 39 °C. Throat inspection revealed swelling and greyish membranes. The patient deteriorated quickly with hypoxia and hypercapnia. He was intubated and put under ventilator support. Bronchoscopy showed greyish membranous plaques covering the larger part of the bronchus and partly occluding the left major bronchus. Serial X-rays showed progressive atelectasis of the left lung . The membranes could mechanically be removed from its underlying layer and repeated bronchoscopies with lavage were performed.
+Culture specimens were sent from larynx and bronchoscopy specimens as well as from a 1 cm2 skin ulceration. Due to suspicion of diphtheria, Loeffler’s tellurite media was used for culture. On day four from admission, the results from cultures showed growth of toxin producing C. diphtheriae, subsequently typed to non-gravis, both from the ulcer and from the respiratory tract. Serologies for Human Immunodeficiency Virus (HIV), hepatitis B and C and syphilis returned negative, as well as urine antigen tests for Streptococcus pneumoniae and Legionella pneumophila. The diphtheria strain was susceptible to both cefotaxime and erythromycin, which the patient was receiving since admission. It was in this situation judged too late for administration of DAT in relation to possible side effects and the duration of symptoms, and the patient was never administered this treatment. In the following weeks (day 5–14), the patient showed signs of improvement in infection control with decreasing C-reactive protein (CRP) and was afebrile, however the left lung remained deflated. The patient was under ventilator support for one month through tracheostomy performed on day seven. The prolonged time in ventilator was due to inability to recruit the left lung, despite repeated bronchoscopy and cleaning of greyish debris from the airways. A pleural catheter was also placed in the left inter pleural space with clearance of about one liter of transudative fluid. Bacterial cultures from the pleural fluid were negative.
+Between day 14 and 16 the patient had changes in the electrocardiogram with T-wave inversions and short periods of ventricular tachycardia as well as elevated cardiac enzymes that resolved spontaneously . An echocardiogram was performed with no significant pathology. Additionally, a passing increase in serum creatinine was noted during this period. No clear reasons for these adverse organ effects were identified and were judged to be Diphtheria toxin related. On day 19 the patient deteriorated with fever and increased purulent secretions from the airways. This was considered due to Ventilator Associated Pneumonia (VAP) with Methicillin Resistant Staphylococcus aureus (MRSA) which was successfully treated with intravenous vancomycin for two weeks. In the fourth week, the patient improved and could gradually be weaned off of the ventilator. The tracheostomy tube was removed on day 46 from admission and the patient was mobilized in the following week with physical therapy and was prepared to be discharged to a center for rehabilitation.
+On day 55, however, the patient developed a gradual onset of neurological symptoms. First he got increasingly weaker voice and shortly thereafter weakness of the extremities, and increasing difficulties to breathe. From day 58, the patient quickly deteriorated with a complete paraplegia and respiratory failure ensued, requiring reintubation. Repeated neurographic examinations showed severe polyneuropathy with mixed demyelination and axonal loss. The pattern was not deemed to be consistent with Guillain-Barré, nor Critical Illness and was judged to be due to toxin effects of diphtheria toxin thus no neuroimaging was considered necessary. Furthermore, lumbar puncture showed no significant pathology.
+On day 56, surveillance Bronchiole Alveolar Lavage (BAL)-culture was sent for extensive testing and culture due to respiratory deterioration. This subsequently showed growth of Mycobacterium tuberculosis (MTB) fully sensitive to rifampicin, isoniazide, pyrazinamide and ethambutol. MTB-PCR was negative. Bronchoscopy specimens for MTB culture and PCR had previously been sent for investigation on day two from admission, but was negative at that time. The patient was started on combination therapy for pulmonary tuberculosis (TB) on day 70.
+The patient gradually regained motor function from day 80 and the patient could once again be weaned off of the ventilator. The sensory functions likewise gradually returned from the center to the periphery . After an extended stay for mobilization, the patient was discharged to a rehabilitation clinic on day 91 from admission. On follow up after three and six months, the patient continued to improve in motor and sensory functions, The patient was followed for three years reporting only minor polyneuropathic symptoms in his feet, but had resumed his daily activities with no motor impairments.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_710_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_710_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b78410674be03e7d3c84aef610a38ce3d750f9bb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_710_en.txt
@@ -0,0 +1,9 @@
+Fatigue and weight loss for more than 1 mo.
+A 62-year-old male farmer was hospitalized for fatigue and weight loss for more than 1 mo, without fever or bone pain. The peripheral blood examination in a local hospital indicated severe anemia with a hemoglobin level of 54 g/L and a potentially malignant tumor from the blood system. Therefore, he was admitted to Huaihe Hospital of Henan University.
+No particular previous medical history.
+The patient had no history of exposure to industrial poisons or radioactive substances, and was not smoking or drinking alcohol. The family history was unremarkable.
+The patient presented an anemic face; the percussion of the lungs presented a little dullness, a few moist rales were heard at the left lung base, and mild concave edema was seen in both lower extremities.
+Laboratory evaluation at the Huaihe Hospital of Henan University showed a medium degree of anemia with a hemoglobin level of 61 g/L. Further blood examination indicated renal dysfunction and elevated erythrocyte sedimentation rate and N-terminal pro-brain natriuretic peptide (NT-PROBNP) . The other laboratory findings, including blood coagulation functions, stool for routine, blood lipids, and blood sugar, were normal.
+Serum protein electrophoresis on agarose gel suggested an elevation of α2-globulin and γ-globulin, and two slight M-spikes appeared and a band within the γ fraction (the other band within α2 fraction was obscure) was seen. To categorize the M protein, we conducted serum IFE, which consisted of antisera to IgA, IgM, IgG, κ, and λ, and the results yielded two monoclonal bands in the λ region without corresponding heavy chain bands, corresponding to the distinct elevation of serum λ FLC . Thus, we highly suspected the possibility of type IgD or IgE or FLC M protein component. Subsequently, we implemented a second serum IFE with antisera to IgD, IgE, κ, and λ. The results showed two monoclonal bands in antisera to λ but only one corresponding heavy chain band in antisera to IgD, which indicated a diagnosis of IgD-λ/λ myeloma by correlating the clinical manifestation and laboratory examinations.
+BM cytomorphologic (anterior superior spine) examination found a marked increment of plasma cells, mainly immature plasma cells, which accounted for 82% of the BM nucleated cells . Flow cytometry suggested positivity of monoclonal plasma cells (70.12% of total nucleated red blood cells) with the following immunophenotype: CD38, cytoplasmic lambda, and CD229. All of the monoclonal plasma cells expressed CD229, CD38, and cytoplasmic lambda and partly expressed CD138 . Undoubtedly, BM cytomorphologic examination and flow cytometry supported the diagnosis of plasma cell myeloma. Furthermore, analysis of chromosome karyotype was as follows: 46,XY;46,Y,t(X;4)(p11.2;q21), no abnormal cloning. Gene analysis of the blood tumor mutant group was mainly normal.
+Combined with the clinical, and laboratory data above, the patient was diagnosed with stage ISS III myeloma.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_730_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_730_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..feb74eba777f9ec25b111cd6fe5cc280f775f3b8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_730_en.txt
@@ -0,0 +1,8 @@
+A 51-year-old man (height 174 cm, weight 78 kg) was diagnosed with a cardiac murmur in childhood. However, he did not have any further detailed cardiac examinations.
+He had been suffering from chest pain since the age of 50. His chest pain was atypical with some non-specific characteristics. At this time, transthoracic echocardiography (TTE) was conducted, which showed a string-like abnormal structure in the LVOT. However, he did not follow up because he was asymptomatic. After a year, his chest pain recurred. TTE revealed the same structural abnormality again. Therefore, he underwent a detailed examination. Except for the cardiac murmur, he had no medical history and was not on any medications, and there was no family history of cardiac problems.
+A physical examination revealed a Levine type III to-and-fro heart murmur in the aortic area. His blood pressure was 123/79 mmHg, pulse rate was 64 beats per minute (bpm), and his lungs were clear on auscultation. A chest X-ray showed a normal cardiac silhouette and both lungs were clear and expanded, with no infiltrates or pleural effusions. An electrocardiogram (ECG) showed non-specific changes and a normal sinus rhythm.
+Transesophageal echocardiography (TEE) revealed an oval-like tissue with clean margins attached to the anterior leaflet of the mitral valve, causing an LVOT occlusion during systole . The maximum gradient pressure through the LVOT was measured at 26 mmHg with a mean gradient of 12 mmHg . The left ventricle wall motion was normal. The dimensions of the left ventricle during both systolic and diastolic phases were normal. No other cardiac anomalies were present. A diagnosis of AMVT was made based on the echocardiographic findings. Surgical treatment was recommended because of the presence of AMVT and the significant LVOT obstruction.
+Surgery was scheduled for resection of the AMVT. In the operating room, after placing an arterial catheter in the right radial artery to continually measure the patient’s blood pressure, we induced general anesthesia by intravenous administration of midazolam 10 mg, fentanyl 500 μg, and rocuronium 70 mg. A central venous catheter and pulmonary arterial catheter were inserted via the right internal jugular vein. Anesthesia was maintained with oxygen, sevoflurane, and propofol. Bolus intravenous fentanyl infusion was administered as needed. After starting extracorporeal cardiopulmonary bypass (CPB), the AMVT was resected via the aortic valves . After resecting the AMVT, we began removing the CPB. We ensured the LVOT was no longer obstructed, but severe mitral regurgitation (MR) was observed on TEE. Therefore, a mitral valvuloplasty was conducted under CPB. MR ceased after mitral valvuloplasty, and subsequently, we stopped using CPB with dobutamine at 4 μg/kg/min and commenced biventricular pacing (90 bpm). The mean arterial blood pressure was maintained at 60–70 mmHg, the central venous pressure (CVP) at 10–15 mmHg, and the pulmonary arterial pressure (PAP) at 20–30 mmHg.
+The total surgical duration was 313 mins, CPB duration was 108 mins, and the anesthesia duration was 414 mins.
+The patient received a total of 3500 mL of lactated Ringer’s solution, 300 mL of intraoperative blood salvage, and 2 units of fresh frozen plasma during the procedure. His estimated blood loss was 1320 mL. The patient was hemodynamically stable throughout the surgery, with no abnormal findings on the ECG . After the surgery, the patient was transported to the intensive care unit (ICU) without awakening or extubating.
+The patient was extubated 6 h after being transported to the ICU. His hemodynamic state was stable with dobutamine at 0.6–1.3 μg/kg/min. There was no abnormity of the mitral valves including mitral regurgitation, and the maximum gradient pressure through the LVOT was measured at 4 mmHg with a mean gradient of 1 mmHg . Dobutamine was stopped on the second postoperative day. He responded well to treatment and was discharged 18 days after surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_742_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_742_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e9bc3da8190abf54e6e778499f6f60ff91316721
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_742_en.txt
@@ -0,0 +1,8 @@
+A 24-year-old Japanese woman with no notable past medical history presented with complaints of fever and nausea while she was traveling in Australia; within the previous 2 months, she had also traveled to India and Africa. She visited a local hospital in Australia, and the laboratory tests showed significantly elevated levels of transaminase, so she was checked for viral hepatitis. After excluding hepatitis A, B, and C, as well as other causes of hepatitis, it was revealed that the patient was positive for HEV-IgM. Since she was a visitor to Australia, she was sent back to Japan and was transferred to our hospital. During her stay in India and Africa, she ate most of her meals at local restaurants, and she sometimes drank tap water.
+Her initial vital signs revealed a blood pressure of 103/64 mmHg, heart rate of 84 beats/min, and body temperature of 36.4 °C. Physical examination revealed jaundice with no tenderness over the right upper quadrant. The chest, extremities, and other systemic examinations were unremarkable. Laboratory investigations revealed an aspartate aminotransferase (AST) level of 1382 U/L, alanine aminotransferase (ALT) level of 2842 U/L, total bilirubin level of 4.8 mg/dL, and direct bilirubin level of 3.9 mg/dL. The test results were all negative for anti-nuclear antibody, anti-mitochondrial antibody, cytomegalovirus IgG and IgM, Epstein-Barr virus, and hepatitis A, B, and C antibodies; but the test for HEV-IgM was positive . Her initial ultrasonography of the abdomen revealed splenomegaly (108 × 39 mm) and a small amount of ascites, but no signs of hepatomegaly or an enlarged gallbladder. According to the data above, HEV infection was diagnosed.
+She was treated with intravenous fluids with normal saline. On day 4, the patient complained of right upper quadrant pain. Ultrasonography of the abdomen showed 3 mm of a gallbladder wall; moreover, a physical examination detected tenderness over the right upper quadrant and positive Murphy’s sign. Since the levels of transaminase and total bilirubin were gradually declining at that time, the enlarged gallbladder was left untreated, but closely followed up. However, the level of AST was elevated again at 980 U/L on day 7. In addition to the ultrasonographic findings, perivesical fluid accumulation and an edematous gallbladder wall (4 mm) had appeared . There were no stones in the gallbladder. In addition, there were no other causes of acalculous cholecystitis. Pneumonia, acute pancreatitis, hepatic or subphrenic abscess, and right pyelonephritis were considered for the possible causes but were excluded from the diagnosis due to the fact that no evidence was shown on ultrasonographic findings, urinalysis, and chest X-ray. No antibiotics were administered for the cholecystitis. From day 9, the levels of transaminase and bilirubin began to decline even without the use of antibiotics. Blood culture was negative, and the procalcitonin level was within the normal range. Based on these findings, we assessed the cholecystitis was not caused by bacterial infection and decided not to administer any antibiotics. The edematous wall showed significant improvement on day 11 and had returned to normal by day 14. Since the patient did not complain of abdominal pain and the findings were gradually being recovered, it was not necessary to intervene surgically. The patient was discharged on day 16 because all of the symptoms had disappeared.
+The serum of the patient was tested to identify the genotype of the HEV at the Osaka Prefectural Institute of Public Health, and it was identified to be HEV genotype 1, OSN2015-5 . It was confirmed by using SuperScript III-one step RT-PCR system with Platinum Taq (Invitrogen).
+From this case, two important clinical discoveries were made: (1) HEV can cause acalculous cholecystitis as an extrahepatic manifestation, and (2) it can recover without any antibiotics.
+First, HEV can cause acalculous cholecystitis as an extrahepatic symptom. It has been reported that HEV can cause pancreatitis, arthropathy, aplastic anemia, and Guillain-Barre syndrome as extrahepatic symptoms [, ]; however, acalculous cholecystitis has not been previously reported as a symptom of HEV. We performed a search of the MEDLINE database for the terms ‘cholecystitis’ and ‘viral hepatitis E’. Three hits were found, but the contexts were unrelated to cholecystitis due to HEV. Hepatitis A virus infection is known to cause acalculous cholecystitis as a rare complication . Although further investigations of a larger number of cases are needed to clarify the matter, it is presumed that hepatitis A virus invades the endothelial cells of the gallbladder and bile duct and induces cell-mediated immunity [, ]. However, this is the first case report of acalculous cholecystitis as an extrahepatic manifestation of HEV.
+Second, the acalculous cholecystitis due to HEV infection could recover without any antibiotics. On the seventh day after admission, the level of serum AST was increased, and ultrasonography of the abdomen detected a thickened gallbladder wall without calculi and perivesical fluid accumulation; these met the criteria for acalculous cholecystitis . In general, the treatment options for acalculous cholecystitis are antibiotics, drainage, and/or operation. However, none of them were necessary in this case, and the patient recovered completely. According to the clinical course, the cholecystitis was secondary to HEV infection and recovered as the HEV infection resolved.
+Humans can be infected by four different genotypes of HEV: genotypes 1, 2, 3, and 4. HEV genotypes 1 and 2 are common and restricted to human . Individuals may become infected with HEV genotypes 1 and 2 from drinking contaminated water, so it was suspected that this patient became infected with HEV from drinking tap water in India. Genotype 1 is prevalent in the Indian subcontinent, Asia, the Middle East, and Africa . The latent period of HEV infection is approximately 6 to 8 weeks . Based on the travel history of the patient, it is possible that she became infected with HEV while she was in India. HEV infection does not affect only developing countries. HEV genotypes 3 and 4 are found in some industrialized countries. In addition, zoonotic transmission to humans is possible with HEV genotypes 3 and 4 . Occasional foodborne outbreaks from the consumption of undercooked meat contaminated with HEV have occurred in Europe, North America, Japan, and New Zealand . Among the different genotypes, genotype 1 HEV infection can cause the most serious disease . As such, it is important to determine the genotype of the HEV infecting a patient to know the prognosis and to identify the source of the infection.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_758_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_758_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d4b11d93c63eaadae185b0cb94911b152cfe7bdc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_758_en.txt
@@ -0,0 +1,3 @@
+We present a 48-year-old patient, to whom a transrectal biopsy of the prostate gland was performed in 2005 due to increased level of prostate-specific antigen (PSA) to 597 ng/ml, and the pathohistological (PH) finding revealed an adenocarcinoma of the prostate with the Gleason score 7 (4A+3B) and 80% tumor volume. According to the digitorectal examination, the prostate gland was found to be heterogenous, rough, with the size of an average walnut. Ten days after the biopsy, due to the complete urine retention, a urinary catheter was inserted and then transurethral resection of the prostate was performed.
+The patient had pre-surgical value of PSA 132 ng/ml and also elevated levels of: acid phosphatase at 10.74 U/L (up to 6.6), prostatic acid phosphatase 7.7 U/L (up to 3.5) and alcaline phosphatase 146 U/L (up to 136). Pathohistological analysis of the prostatic tissue sample, obtained by transurethral resection, confirmed the existence of prostate adenocarcinoma with the Gleason score 7 (4B+3B) and infiltration of bladder wall, pT4a. Bone scintigraphy showed a clear zone of asymmetrically increased accumulation of radiopharmaceuticals in the VIII right rib, less homogeneous binding in the spine and increased binding of radiopharmaceuticals in the projection of costovertebral joint, right, in level VI. According the decision of the Uro-oncology consilium, the patient was treated with a maximal androgen blockade, zolendronic acid in monthly intervals, as well as the radiotherapy, with dose of 65 Gy in 32 sessions, which was done because of the patient’s relatively young age. After 9 years of the initial diagnosis, within the period of 14 months, a gradual increase of PSA from 4.3 ng/ml to 23.09 ng/ml was registered, with inhomogenous, slightly enlarged and firmer in whole left testis.
+The values of the tumor markers /AFP, beta HCG and LDH/were within referential values, and two echo-heterogenous oval zones were identified by the ultrasound examination of the left testis, 10 mm in diameter . Osteoclastic changes in the vertebral bodies TH 6, 8, 11 and L4 were detected by a multisliced computed tomography (MSCT), but bone scintigraphy had normal finding. Left inguinal orchectomy and right orchectomy were done, and the PH result of the left testis showed metastases of prostate adenocarcinoma. One month after the surgery, the PSA value fell to 2.76 ng/ml, and the treatment was continued with Bicadex (bicalutamid) tablets, 50 mg daily and with zolendronic acid per month. Two years after the bilateral orchectomy, the patient is symptom free and in good general condition with latest PSA value of 4.22 ng/ml.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_762_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_762_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4ed65f1ae3b6dc1f705f070d7f9e4f11eb0092b4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_762_en.txt
@@ -0,0 +1,7 @@
+A 59-year-old old man was referred to our hospital in May 2018 due to detection of a space-occupying mass in the head of the pancreas at another institution.
+He was diagnosed with sigmoid adenocarcinoma stage IIA (T3N0M0) and underwent curative surgery in April 2014. After surgery, the patient was treated with XELOX adjuvant chemotherapy from May to October 2014. The patient developed pulmonary metastasis in the right upper lung, with lesions of 2.5 cm × 2.5 cm, and underwent thoracoscopic right upper lobectomy in May 2016. After surgery, he was not treated with further adjuvant chemotherapy .
+The patient had no previous medical history.
+The patient did not have relevant personal or family history.
+The patient’s temperature was 36.9°C, heart rate 86 bpm, blood pressure 133/84 mmHg, and neurological examination suggested no abnormalities. An abdominal examination showed no palpable mass or tenderness.
+Blood carcinoembryonic antigen (CEA) level was elevated to 23.17 ng/mL (normal range 0-5 ng/mL), and carbohydrate antigen 19-9 was elevated to 52.71 U/mL (normal range 0-40 U/mL).
+Positron emission tomography/computed tomography (CT) and ultrasound scans confirmed the presence of a space-occupying lesion with glucose hypermetabolism (2.3 cm in greatest dimension) in the head of the pancreas . Except for gallstones, no abnormalities were noted in the stomach, duodenum, common bile duct, or main pancreatic duct.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_763_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_763_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c7abcc1259058fb88cd1e703641c47698526ffc6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_763_en.txt
@@ -0,0 +1,3 @@
+A 53-year-old Caucasian man was admitted to our outpatient presenting a severe plaque psoriasis, affecting trunk, upper and lower extremities and palms, sparing facial area (PASI 18 BSA 30%). Family history of psoriasis was negative and no comorbidities were recorded. Medical history was unremarkable and the patient did not take any drugs. The patient has been suffering from plaque-type psoriasis for 20 years, with a chronic remitting course. Clinical lesions were associated with severe discomfort, which impaired daily activities and social relationships. His treatment history has started in 2010 with topical clobetasol propionate 0.05% and calcipotriol with unsatisfactory results. Subsequently, patient was treated with methotrexate that provided adequate efficacy for 52 weeks, when a secondary loss of efficacy was experienced.
+Therefore, he was switched to adalimumab, leading to an initial optimal response (PASI90). After 7 months clinical improvements were progressively lower with re-occurrence of clinical lesions. Thereafter, due to the involvement of difficult to treat areas (palms and genital area) and psoriasis worsening (PASI 18 BSA 30%), ixekizumab was started according to the following schedule: 160 mg week 0, 80 mg every 2 weeks for 12 weeks followed by 80 mg every 4 weeks. After only 4 weeks of treatment, we observed a complete skin clearance (PASI 100 response) with a huge improvement in quality of life and skin symptoms. Even if clinical response remained stable over the time, 12 weeks later hypopigmented macules and patches appeared on the facial area, particularly on cheeks and chin (5 cm × 6 cm) saving periocular area. .
+Dermatologic examination together with Wood's lamp examination lead to the diagnosis of vitiligo. Blood exams excluded other underlying conditions such as anemia, hyperthyroidism, and diabetes. Treatment with topical calcineurin inhibitors was started. No data regarding follow up are available.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_782_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_782_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7bbea1f29393968b456ffc42248305d727323116
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_782_en.txt
@@ -0,0 +1,8 @@
+A 34-year-old man received proton-beam radiation therapy in 2003 for a 17.0 × 14.0 × 10.5 mm melanoma involving the left choroid and ciliary body. He was treated with proton-beam therapy to a dose of 70 Cobalt Gray Equivalent, in five fractions, over 10 days. In 2017, the patient was in a motor vehicle accident, which resulted in rupture of his left globe. He underwent enucleation of the left globe and was found to have recurrent melanoma. The patient healed well from surgery and a left eye prosthesis was fitted. However, over the next 9 months the patient reported that the prosthesis became progressively displaced and increasingly painful to wear. A diagnostic CT revealed a heterogeneous lobular soft tissue mass in the anterior and inferior left orbit measuring 27.0 × 26.0 × 19.0 mm. He underwent salvage left orbital exenteration in March 2018. Surgical pathology confirmed multiple recurrent melanoma with a positive inferior-medial surgical margin. Restaging imaging revealed no evidence of metastatic disease and he was referred for consideration of re-irradiation.
+Written informed consent was obtained from the patient for publication of this case report and accompanying images.
+An applicator for HDR brachytherapy was designed in the AutoCAD Inventor Suite (Autodesk, San Rafael, CA) based on the latest diagnostic CT. DICOM structures were converted into stereolithography files using 3DSlicer . The primary contours of interest were the patient’s surface and the PTV. The patient surface was used to generate an applicator with a flush fit against the left orbital cavity and a protruding horizontal surface 10.0 mm anteriorly from the supraorbital ridge. Support wings with a thickness of 5.0 mm were designed to extend superiorly and inferiorly by 15.0 mm and laterally by 60.0 mm. The wings were designed to be flush against the patient’s skin in order to provide a stable and reproducible fit.
+The involved left orbital surfaces, including the residual mucosa and soft tissue abutting the mass found on pre-operative imaging and the sites with positive margins, were contoured as the clinical target volume (CTV; Volume ~ 4.0 cm3) and radially expanded by 2.0 mm to generate a PTV. The PTV was used to devise channels that allowed for access and sufficient coverage of the target with the Ir-192 HDR source. The channels were constructed to fit an endobronchial HDR source guide tube with an outer diameter of 2.0 mm (Varian Medical Systems, Palo Alto, CA). While considering the size of the orbital cavity and the distance of the PTV to the cavity surface, it was found that sufficient target access would be provided when all channels were tilted 15° toward the patient’s right and 10° superiorly. For the most superior channel, patient anatomy did not allow for the 10° tilt. Under these constraints, the applicator was designed with 16 channels of varying length, ranging from 46.0 mm to 63.0 mm. The channels were organized in two rectilinear groups to minimize applicator size. The distance between the centers of the channels in each group was 9.0 mm. The tip of the channels, corresponding to the location of the first possible dwell position, was chosen to be at 5.0 mm from the surface of the orbital cavity. Figure shows the applicator geometry overlaid on patient anatomy. The material for printing the applicator, an acrylic photopolymer (Polymerized TangoPlus and Agilus30 Family, Stratasys Ltd., Eden Prairie, MN), was selected based on similarity with the biomechanical properties of human skin , specifically using tensile strength and shore hardness. Note that these materials are not approved per the International Standard ISO-10993-1 as a biocompatible material. The applicator was covered in a sterile wrap to prevent any contact with patient skin. Given the flexibility of this material, a solid sheath with a thickness of 2.0 mm was designed as an outer support-wall for each channel to prevent bending or accidental puncturing of the surface of the applicator. The assembly was created using a J750 PolyJet 3D printer (Stratasys Ltd., Eden Prairie, MN) which allows for simultaneous printing of materials with varying physical properties. The primary applicator was designed as 80/20% mixing of polymers in the Agilus30/TangoPlus family; the sheath was 80/20% mixing of TangoPlus/Agilus30. Print time was approximately 20 h, while cost was approximately 400$. Figure presents the design of the applicator and a model of the channel sheath. Photographs of the final 3D printed applicator are provided in the appendix Figure A. Prior to use in the patient, the applicator was imaged with a helical CT scanner (120kVp, 1.0 mm3 isotropic voxels). The mean Hounsfield unit (HU) values were measured in a large region-of-interest in the applicator and found to be (mean ± std.dev.) 85 ± 11 HU, comparable to tissue-equivalent media. While previous research has highlighted the limitations of HU values in modeling the radiation interactions of 3D printed materials , the work of Baltz et al. has shown Agilus to be a reasonable tissue equivalent material based on CT and percent depth dose measurements .
+At the time of treatment simulation, the patient was immobilized supine with a custom thermoplastic mask and head holder. Serial axial CT images were obtained for treatment planning after placing the patient-specific applicator, covered in a plastic and sterile latex wrap, inside the left orbital cavity and securing it using self-adherent wrap. Figure A in the appendix shows the applicator inside the orbit at time of CT simulation. Treatment planning and dose calculation were performed in the Brachytherapy Planning module of Eclipse (Varian Medical Systems, Palo Alto, CA) based on the AAPM TG-43 formalism, using Ir-192 at a nominal source strength of 10 Ci. The planned prescription was 3400 cGy, to be delivered in 10 fractions, twice daily, over five consecutive days . Figure shows the dose-volume histogram for the PTV, orbit bones, right eye, right lens, and brain.
+An end-to-end dosimetric test was designed to determine feasibility for clinical use. Two calibrated pairs of optically stimulated luminesce dosimeters (OSLDs) were firmly placed on the surface of the applicator at two locations representing dose to PTV and another high-resolution CT was acquired. The clinical HDR plan was transferred to the CT containing the OSLDs in order to calculate the mean dose to the dosimeters. Figure A shows the registration between the CT of the applicator and the patient HDR plan. The applicator was then immersed in a water-filled container to mimic scattering conditions, and the clinical HDR plan was delivered. In the two sampled positions on the surface of the applicator, the mean difference in measured and calculated dose was 12% and 18%. For this setup, the standard error of the mean is equal to 50% of the standard deviation. This dose difference is in the range of published uncertainties for in vivo dosimetry in HDR brachytherapy [, ]. Finally, all ten fractions of the clinical HDR plan were consecutively delivered, amounting to a dose of at least 300 Gy to the surface of the applicator, and the applicator was monitored for structural damage. No damage was found over the course of 2 weeks.
+A second CT simulation scan was obtained without the brachytherapy applicator for the purpose of generating an alternative stereotactic body radiotherapy (SBRT) plan. The orbital air density was assigned to water (i.e., 0 HU) in the treatment planning system to simulate a fluid filled cavity. A 4-arc volumetric modulated arc therapy plan with 6MV photons, utilizing superiorly oriented non-coplanar beams to avoid entry or exit into the contralateral eye, was created in Eclipse version 13.6 (Varian Medical Systems, Palo Alto, CA). The prescription dose was 2500 cGy, in 5 daily fractions.
+Although most of the previously irradiated soft tissue was resected, the patient was consented for osteoradionecrosis and non-healing wounds. He was treated with SBRT instead of brachytherapy because the 3D printed material was not approved for biocompatibility and because filling the orbital cavity with sterile saline provided a reproducible bolus with fewer air gaps. While the surface of the applicator was generally flush with the orbit, we observe a maximum airgap of approximately 8.0 mm, comparable to previously published values . This is illustrated in Figure A in the appendix which shows two slices from the CT of the patient fitted with the applicator. To confirm consistency with treatment planning, daily cone-beam CT was performed after filling the orbit with sterile saline.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_784_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_784_en.txt
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index 0000000000000000000000000000000000000000..c0558a8a9fa2f07a9d6b185fef01a62b4492daa5
--- /dev/null
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+A 20-year-old man with a 1-year history of diabetes mellitus was admitted to the Endocrinology Clinic of the First Affiliated Hospital of China Medical University. He was born after an uneventful 39-week gestation with a birth weight of 3.0 kg. His parents are non-consanguineous and healthy. His motor skills and language development were delayed. Physical examination revealed the following characteristics: height, 165.0 cm; weight, 50.0 kg; body mass index, 18.36 kg/m2; facial asymmetry; micrognathia; up-slanting palpebral fissure; malformed ear; dental dysplasia; high-arched palate ; and broad and foreshortened halluces . Tanner’s staging showed prepubertal signs. A smell test excluded anosmia.
+Laboratory examination indicated anemia with a hemoglobin level of 101 g/L. Morphological examination of a peripheral blood smear revealed small spherocytes . Total bilirubin was 71.2 μmol/L. The concentrations of luteinizing hormone and follicle-stimulating hormone were low at baseline and after gonadorelin stimulation, while the testosterone concentration was undetectable. His fasting glucose and insulin levels were 12.12 mmol/L and 9.93 mIU/L, respectively. T1D autoantibodies (GAD, ZnT8, IA-2, ICA, and IAA antibodies) were negative. His HbA1c was 5.8%. Detailed test results are listed in , .
+Bioelectrical impedance analysis showed visceral fat of 81 cm2, subcutaneous fat of 136.8 cm2, and a visceral-to-subcutaneous fat ratio of 59.2%. Testicular ultrasound revealed that the right testis was approximately 1.37 cm × 0.54 cm × 0.93 cm (0.36 ml) in size and that the left testis was approximately 1.29 cm × 0.52 cm × 0.93 cm (0.33 ml) in size. Bone mineral density analysis showed decreased bone density in the lumbar vertebrae (Z = -3.8). Cardiac color Doppler ultrasound indicated that cardiac function and structure were normal, whereas abdominal color Doppler ultrasound showed that the shape and size of the liver were normal, the liver surface was smooth, the edge of the liver was sharp, the echo of liver parenchyma was enhanced, and the contrast of the liver and kidney was increased. The length and diameter of spleen was approximately 10.61 cm, and the thickness of spleen was approximately 5.38 cm, indicating the presence of fatty liver and splenomegaly. Brain CT showed calcification in the bilateral lenticular nucleus, dorsal thalamus, and posterior horn of the lateral ventricle . Ophthalmic examination revealed a cotton wool spot in the right eye retina, which was indicative of stage III diabetic retinopathy. Electromyography was normal, and electroaudiometry indicated normal hearing.
+Whole-exome sequencing revealed a 7.05-Mb deletion in 8p11 (chr8: g.35541034–42587731) containing 43 Online Mendelian Inheritance in Man (OMIM) genes ( and ), and a large in-frame deletion of exons 48–55 in the DMD gene (chrX: g.31639827–31904558). These abnormalities were confirmed by copy number variation (CNV)-seq analysis . Multiplex ligation probe amplification (MLPA)-DMD revealed that the proband’s mother is a heterozygous carrier of the mutant DMD gene.
+Metformin at 1500 mg/d was given to the patient after which his blood glucose was well controlled. HCG 2000 IU was injected subcutaneously twice a week and was supplemented with calcium and vitamin D, which led to an improvement in the patient’s quality of life.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_825_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_825_en.txt
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index 0000000000000000000000000000000000000000..6e3e50fce933c1378ff0ac52fb8ca0d8de75024f
--- /dev/null
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+The patient was a 16-month-old girl. No prenatal abnormalities were noted. She visited a nearby doctor on a remote island for fever and was treated with antibiotic therapy as an outpatient. She gradually developed clouding of consciousness and dyspnea. She was transferred to our hospital on the 13th day after the onset of symptoms due to a huge dilated common bile duct that was detected on imaging at the previous hospital.
+Contrast-enhanced computed tomography showed dilation of the common bile duct (maximum diameter: 5 cm) , suggesting CBD. However, her laboratory data on admission showed severe liver disfunction (AST, 79 IU/L; ALT, 43 IU/L; γ-GTP, 491 mg/dl; D-bil, 0.3 mg/dl; Alb 2.5 mg/dl; CHE, 90 IU/L; NH3, 123 μg/dl) . The Child-Pugh classification was equivalent to Grade A–B when combined with the fact that she had consciousness disturbance, a history of vitamin K treatment, and her laboratory findings at the time of admission. We initially performed laparoscopic exploration and bile drainage via the gallbladder, noting severe hepatic fibrosis resembling end-stage liver cirrhosis . A 5-mm 30° laparoscope was inserted through an umbilical incision along with a 5 mm trocar with a multichannel port device (E.Z Access/LAP-PROTECTOR minimini; Hakko Co., Ltd., Tokyo, Japan). Since the view of the lower liver space could not be obtained, a 3-mm port was additionally inserted through the EZ Access to secure the view. The liver had many hoop-like notches on both lobes, which is a finding of liver sclerosis. A 3-mm port was additionally inserted into the right upper abdomen and the gallbladder was pulled out from the port wound. A double purse suture was applied with 4–0 PDS outside the body and an incision was made, and then an 8-Fr balloon catheter was inserted, and the tip was placed in the common bile duct. After placing a drainage tube in the gallbladder, cholangiography was performed. We confirmed continuity between dilation of the intrahepatic bile ducts and the common bile duct, and it consistent with findings of biliary dilatation. There was no gallbladder atrophy, which is seen in I cyst-type biliary atresia . Cholangiography revealed Todani type IVa CBD with pancreaticobiliary maljunction. Then, the patient received liver-supporting therapy and nutritional support for 7 weeks before definitive surgery.
+Following the improvement of the hepatic synthetic capacity (Alb, 4.0 mg/dl; AST, 82 IU/L; ALT, 78 IU/L; γ-GTP, 157 mg/dl; D-bil, 0.2 mg/dl; CHE, 232 IU/L; NH3, 75 μg/dl) , we performed extrahepatic bile duct excision and hepaticojejunostomy laparoscopically . Laparoscopic choledochal cyst excision was performed using five ports. Under general anesthesia, the patient was placed in the broad base position, and the operator stand to the right side of the patient. A 10-mm 30° laparoscope was inserted through an umbilical incision along with a trocar with a multichannel port device (E.Z Access/LAP-PROTECTOR minimini; Hakko Co., Ltd., Tokyo, Japan). Pneumoperitoneum was established with 8-mm Hg CO2 insufflation. Three additional trocars and a 2.4-mm needle-type grasper (Teleflex, Morrisville, NC, USA) were inserted into the right upper abdomen (operator's left hand, 3.5 mm) and at the right side of the umbilicus (operator's right hand, 5 mm), the left lateral abdomen (assistant's left hand, 3.5 mm), and the left upper abdomen (assistant's right hand, 2.4 mm). The dilated CBD was dissected and then taping was performed. After imaging the lower bile duct and confirming that the bile duct on the side of the pancreas was sufficiently detached, the lower bile duct was clipped and transected. Subsequently, after dissection and transection of the cystic duct, the hepatic duct just above the dilated common hepatic duct was transected. The jejunum was then extracted from the umbilical wound, and Roux-en Y jejunojejunostomy was performed. The mucosa and serosa of the opened hole was approximated using 6–0 absorbable sutures to secure hepaticojejunostomy. The jejunum was pulled up through the retro-colic route. Both the posterior and anterior walls were approximated using interrupted intracorporeal knot-tying with 5–0 absorbable sutures. Laparoscopic surgery was successfully performed along with liver biopsy. Histopathologically, the liver specimen showed chronic hepatitis and fibrosis (F3A2) based on the new Inuyama classification . F4 is defined as liver cirrhosis, but it presents clinical findings as disturbed consciousness with hyperammonemia and intraoperative findings as advanced liver fibrosis, and we clinically diagnosed to be almost equivalent to liver cirrhosis in the compensation stage. Biliary scintigraphy showed good bile excretion on postoperative day 15 . The postoperative course was uneventful and the patient was discharged on the 23rd day after surgery.
+At 6 months after laparoscopic extrahepatic bile duct resection and hepaticojejunostomy, she was readmitted and underwent needle liver biopsy to confirm the morphological improvement after surgery. After discharge from the hospital, her hepatic function normalized, and her cholinesterase level, which was low before surgery, showed a tendency toward improvement; however, her NH3 level remained above the normal range . A histopathological examination showed mild improvement of chronic hepatitis and fibrosis (F2-3A1) . The patient was regularly followed at the outpatient clinic.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_829_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_829_en.txt
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index 0000000000000000000000000000000000000000..2d1bbb557bcffb701ab576d806cf76ecb82acc3c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_829_en.txt
@@ -0,0 +1,7 @@
+A 27-year-old man presented to the Department of Spine Surgery of our hospital with complaints of neck pain, limb numbness, and weakness.
+His symptoms started suddenly, 4 d prior to hospital presentation.
+The patient had no trauma history. A similar episode of transient limb numbness and weakness occurred 6 years earlier.
+He denied any personal or family history of other diseases.
+Physical examination revealed tenderness of the paraspinal muscle of the C6-T1 spinous process, muted sensory responsiveness to touch along the T1 dermatome, and grade IV muscle strength in the four limbs.
+The results of all blood analyses — including coagulation markers, inflammatory indicators, and tumor markers — were within normal limits.
+Spinal radiography and computed tomography demonstrated no obvious bone destruction. Enhanced cervical magnetic resonance imaging (MRI) showed a homogenously enhanced epidural mass in the C6-T1 spinal canal. The mass compressed the spinal cord and extended into the left C7-T1 foramen. It appeared hypointense on T1-weighted images (T1WIs) and hyperintense on T2WI. Moreover, a 0.5 cm × 0.5 cm × 0.6 cm-sized heterogeneously enhanced hyperintense mass was found in the C7 vertebral body on T2WI, which was suggestive of a benign vertebral hemangioma (VH) .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_831_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_831_en.txt
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index 0000000000000000000000000000000000000000..385db7bfbf34949847b629dbe148e08c1b1c47ca
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_831_en.txt
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+In April 2007, a 56-year-old Caucasian woman with a painful, right-sided neck mass presented to a private practitioner. Ultrasound (US) suggested a clinical diagnosis of subacute thyroiditis, which was not supported by subsequent laboratory tests (C-reactive protein 1.9 mg/L; leukocytes 9700/μL; thyroid hormones within normal range; antithyroid auto-antibodies negative). Two days later, the patient had an exacerbation of the latero-cervical pain which prompted a repeat US of the neck, which revealed an iso-echoic lesion (51.3 mm in size), apparently included within an enlarged right thyroid lobe (83.5 mm). The lesion was interpreted as an intrathyroid hematoma and the opinion of a neck surgeon (MRP) was requested. The patient's medical history was collected at this time and included a severely diminished bone mass treated with bisphosphonate, though no information on bone metabolism was provided. History ruled out any regional traumatic event. The patient seemed quite anxious and dysphonetic but not dyspnoeic. Physical examination revealed a tender right-sided cervical mass, extending from the right mandibular arch to the thoracic inlet.
+The patient was referred to the Special Surgical Pathology Department at Padova University Hospital, where computed tomography (CT) showed a laterocervical hemorrhagic lesion, extending from the lateral neck to the right prevertebral/paratracheal spaces ; a distinct midline shift and compression of both the hypopharynx and the trachea were also documented. During the CT procedure, the patient suffered from severe respiratory distress with dyspnea and she was immediately referred for surgical treatment, where an ovoid, hemorrhagic mass (4.0 × 2.4 × 1.3 cm, weight 8.1 g) was revealed posterior to the right thyroid lobe. Laboratory tests (conducted during the surgical procedure) demonstrated severe hypercalcemia (3.18 mmol/L; normal range: 2.10 to 2.55 mmol/L) with a decrease in hemoglobin level (12.0 g/dL). Surgery consisted of hematoma evacuation, parathyroidectomy and "en bloc" right thyroid lobectomy . There was no evidence of regional lymph node involvement. The surgery was curative and both serum calcium and parathyroid hormone (PTH) levels quickly dropped to within the normal range (at discharge: calcium 2.29 mg/dL; PTH 52 pg/mL).
+Gross section of the surgical specimen revealed a three-layered lesion consisting of peripheral areas of (partially fluid) hemorrhagic material, invading a more internal, compact (partially organized) zone around the core of the specimen, which consisted of necrotic parathyroid remnants . Multiple gross samples were obtained for histological assessment, which showed an extensively hemorrhagic chief cell parathyroid adenoma surrounded by a loosely organized hemorrhagic and fibrous reaction, which became frankly hemorrhagic in the tissue samples obtained from the periphery of the resected mass.
+A 9-month follow-up including clinical evaluation, serology and US, revealed no clinical abnormalities.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_84_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_84_en.txt
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index 0000000000000000000000000000000000000000..b937bf5059b7b9dd18f658f55daf52d781074032
--- /dev/null
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+A 9-year-old girl was admitted due to repeated loss of consciousness, concomitant with a pale face, palpitations, and convulsions, which had persisted for 2 years and had been aggravated during the previous 2 months. These symptoms occurred automatically. The patient denied experiencing any sweating, nausea, vomiting, trembling, or an obvious sense of hunger before meals. The patient was previously misdiagnosed with epilepsy in another hospital, but no abnormal findings were detected on a 24-h electroencephalogram at our hospital. Her abdominal perfusion CT showed a highly perfused nodule within the pancreatic tail; A magnetic resonance scan confirmed the location of this nodule and indicated that its size was 11.6 × 13.2 mm . Additionally, 68Ga-exendin 4 PET-CT showed a region in the pancreatic tail with abnormally high metabolism and overexpression of the glucagon-like peptide-1 receptor . Lab testing showed a low fasting blood glucose (BG) of 2.2 mmol/L (reference range: 3.9–6.1 mmol/L), a high proinsulin level of 4455.9 pg/mL (reference range: 30–180 ng/mL), a normal C-peptide level of 2.56 ng/mL (reference range: 0.8–4.2 ng/mL), a serum insulin level of 15.35 μIU/mL (reference range: 5.2–17.2 μIU/mL), and a gastrin level of 92.6 pg/mL (reference range: < 100 pg/mL). These results confirmed a diagnosis of insulinoma. Imaging examination showed no abnormalities indicative of parathyroid adenoma or malignancy in the pituitary or adrenal glands. Lab testing showed normal levels of parathyroid hormone (PTH), blood calcium, phosphate, follicle-stimulating hormone (FSH), growth hormone (GH), prolactin (PRL), adrenocorticotropic hormone (ACTH), 24-h urinary free cortisol (24 hUFC), and serum cortisol. Her luteinizing hormone (LH) level was 0.24 IU/L (reference range: 2.12–10 IU/L during the follicular phase), which was considered related to her age.
+Preoperative preparation: To avoid recurrent symptoms and to maintain her fasting BG at a tolerably low level, the patient was given regular snacks before bedtime. BG can be controlled at a level between 50 and 60 mg/dL preoperatively.
+Surgical procedure: The patient underwent minimally invasive insulinoma enucleation surgery under the Da Vinci robot-assisted system with intraoperative ultrasound (IOUS) connected. The patient was put in a head-low, feet-high and left-lateral position. The robotic system was positioned at the head of the patient, while the assistant surgeon stood between the patient’s legs. Abdominal exploration via laparoscopy was conducted, and no obvious abnormalities were found. The robotic lens and operating arms were docked. The gastrocolic ligament was dissected with an ultrasonically activated scalpel. The head of the pancreas was exposed by grasping the colon downward and lifting the stomach. Towards the tail of the pancreas, we separated and exposed the spleen. The surgeon then controlled the ultrasound probe, exploring the tumor from the pancreatic tail to the head and the uncinated process with the assistance of a prograsp clamp. A quasi-circular, hypoechoic lesion was found at the end of the pancreas with a diameter of approximately 10 mm and a clear boundary. We marked the normal pancreatic tissue around the lesion with an electrotome, and while dividing the pancreas sequentially, suction was used continually to visualize the tumor capsule. Precise positioning was achieved using IOUS, and the tumor was completely resected along the capsule . A peritoneal drainage tube was placed. The surgery went well, lasting 65 min (skin to skin), and the volume of intraoperative bleeding was 5 mL. Intraoperative BG is documented in Table .
+After surgery, the patient was given liquid diet on POD2. The drain was clean and was removed on POD4, and the patient gradually resumed her normal diet. She was discharged to home on POD6. During the following 1.5 years, the patient had no recurrence of the disease. No postoperative complication occurred, such as pancreatic fistula or pancreatic function deficiency.
+Pathological examination showed that the tumor was a pancreatic neuroendocrine tumor (Grade 2 with a Ki-67 index of 4%) . This tumor was positive for CgA, Syn, and AE1/AE3 . Insulin staining was partially positive , while gastrin, glucagon, and somatostatin staining were negative .
+Sanger-directed sequencing for the MEN1 gene mutation was performed on a peripheral blood sample, revealing a homozygous pathogenic mutation of c247_250delCTGT (p.Ile85Serfs*33) . This point mutation was also detected in the frozen tissue of the patient.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_861_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_861_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e484e49970330e22abcc646e153f1e1368ac8ba6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_861_en.txt
@@ -0,0 +1,3 @@
+A 32-year-old male presented to the outpatient division of our hospital with coughing and a slight fever. He had a history of aortic valve stenosis (bicuspid valve) and reduced LV ejection fraction (EF, 40%) at the age of 5 years. He had received an operation of aortic valve replacement at the age of 16 years. After surgery, he was followed up by another hospital and was given warfarin with fair control. At room temperature, the patient’s physical parameters were as follows: temperature, 37.0°C; blood pressure, 90/60 mmHg; pulse, 89 beats/min; and oxygen saturation, 99% (room air). Auscultation revealed normal breath sounds. A grade II/VI systolic ejection murmur was noted at the right sternal border. A chest radiograph revealed marked cardiomegaly and mediastinum expansion without a difference of increased radiolucency between the left and right lungs. A chest computed tomography (CT) scan revealed a 10-cm aneurysm in the ascending aorta . The CT image indicated that the TAA had compressed the right pulmonary artery without any difference of contrast medium character between left and right lung, indicating that the right pulmonary artery blood flow was not disturbed. An echocardiogram showed left ventricular (LV) enlargement (LV end-diastolic diameter, 57 mm) and diffuse LV hypokinesis (EF, 35%). A Doppler echocardiogram showed a trans-aortic valve pressure gradient of 18 mmHg. However, his exercise tolerance was well. Any dyspnea on effort had not seen during out-patient clinic (NYHA I). Ventilation/perfusion lung scintigraphy was conducted to exclude aneurysm-induced compression of surrounding organs, but no significant findings were observed. The patient had never complained of dyspnea during nighttime in the supine position either.
+A total aortic arch replacement was planned. However, after intravenous anesthesia (his body weight 78 kg, 5-mg midazolam, 100-mg thiopental and a total of 90-mg rocuronium) and intubation in the supine position, his oxygen saturation (70%) and blood pressure (60/40 mmHg) decreased rapidly. His arterial gas analysis showed the following results on FiO2 100%: pH, 7.234; PaO2, 20 mmHg; PaCO2, 72.6 mmHg; SaO2, 18.6% and HCO3–, 29.6 mmol/L. Cardiopulmonary collapse was resistant to vasopressors (total 12-mg ephedrine) and high oxygenation. As acute pulmonary embolism was tentatively considered in this patient, pulmonary arteriography was immediately performed. The left pulmonary artery was patent. However the right pulmonary artery was totally defected. Swan–Ganz catheter was unable to pass the main branch of the right pulmonary artery. Additionally, because of the absence of breath sounds on auscultation in the left lung field, bronchoscopy was performed and complete compression of the left main bronchus was noted . We finally diagnosed sudden hemodynamic collapse and hypoxia as simultaneous compression of both right pulmonary artery and left main bronchus.
+Percutaneous cardiopulmonary support (PCPS) was conducted resulting in recover from the cardiopulmonary collapse effectively. We discontinued the operation and transferred the patient to the intensive care unit. After the patient regained consciousness from anesthesia, his hemodynamic collapse was gradually improved, and weaning of PCPS was achieved without use of inotropes. Besides, bronchoscopy revealed that occlusion of the left main bronchus disappeared, and he was successfully extubated. Fortunately, he recovered the next day without neurological deficit. At the second surgery, PCPS was initiated with local anesthesia before general anesthesia and intubation. We denuded the right femoral vein and artery, and introduced cannulas for PCPS. General anesthesia was conducted carefully. We also performed bronchoscopy after intubation and found out that the left main bronchus was almost occluded in much the same way as the prior operation. However, his oxygen saturation was not decreased. At this time, PCPS was thought to be useful to prevent from hypoxia and hemodynamic collapse. The aortic valve prosthesis that previously replaced was completely intact. The aortic aneurysm occupied from just above the prosthesis to the distal aortic arch. We successfully performed total arch replacement and reconstruction of bilateral coronary arteries, brachiocephalic artery, left common carotid artery and left subclavian artery without any adverse events .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_880_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_880_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e60a490b0c2af90500e66380f94bad9dac293607
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_880_en.txt
@@ -0,0 +1,2 @@
+A 12-year-old Japanese girl presented with normal birth and developmental history. There was no notable family or medical past history. At 2 years old, she experienced swelling of both knee joints without any cause. There was no rest pain in either knee; however, pain on motion in the right knee and joint effusion in both knees were noted at the first examination. Full extension was observed for the right knee but flexion was limited to 130°. The left knee had a normal range of movement. Aspiration of clear yellow joint fluid showed a negative culture result. Laboratory findings showed a white blood cell (WBC) count of 10,700/μL, C-reactive protein (CRP) of 0.45mg/dL, and erythrocyte sedimentation reaction (ESR) of 21mm/hour. Magnetic resonance imaging (MRI) revealed small masses in her knee joints . Her symptoms were not improved after several joint aspirations. Arthroscopic synovectomy was eventually performed for both knees. During the operation, rice bodies and thickening of the synovial membrane were observed . The pathological findings for the rice bodies showed acidophilic tissues with lymphoid infiltration ; however, no definite diagnosis was made. After the operation, the pain and swelling in the knees were improved. A 10-year asymptomatic period after arthroscopic synovectomy precluded the need for annual medical examinations.
+When she was 12 years old, her left knee again showed swelling without any cause. Several joint aspirations and intra-articular injection of steroids failed to improve her symptoms. She did not experience any pain in her left knee. Full extension was observed for her knee but flexion was limited to 130°. Laboratory findings revealed a WBC count of 4,300/μL, CRP of 0.10mg/dL, ESR of 12mm/hour, rheumatoid factor (RF) of < 5IU/mL, matrix metalloproteinase-3 of 95.1ng/mL, and an antinuclear antibody (ANA) test was 1:80 positive. Contrast-enhanced MRI showed joint effusion and thickening of the synovial membrane . An arthroscopic synovectomy was performed for her left knee , and pathological findings revealed the presence of a villiform structure, increased blood vessels, chronic inflammatory cells, and lymphocyte infiltration . She had no uveitis, but was diagnosed with JIA and received methotrexate (MTX) medication. Since that time there has been no recurrent knee arthritis.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_886_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_886_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c31b7b009511e19ebcc7c875c481c7c0e24cb5c2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_886_en.txt
@@ -0,0 +1,3 @@
+This Chinese patient was 59 years old. He was healthy before, without history of thrombosis. When he was admitted to our hospital, CT examination showed a mass in the right kidney, and there was no sign of infection. However, the subsequent CT angiography showed that the mass in the right kidney had abundant blood supply, and there was thrombosis in the right renal vein. Near the left renal vein there was another mass, but there were no thrombi in the left renal vein and portal vein . The entire right kidney and the mass in the left kidney were excised by surgeons, and histological examination suggested WHO/ISUP grade-3 clear cell carcinoma. Post-operatively, he developed acute kidney injury (AKI) as evidenced by decreased urine volume (0.27 ml/h/kg for 3 h) and increased serum creatinine (75 mol/l higher than the preoperative level), and selective left renal venography showed a 2 cm filling defect in the left renal vein, suggesting thrombosis . After the thrombus was removed, we performed continuous venovenous hemodiafiltration (CVVHDF) on the patient. Within the first 12 h, the patient was conscious, with stable vital signs. In addition, he had no fever, and the urine volume exceeded 40 ml/h, indicating that AKI was prerenal AKI caused by the thrombus in his left renal vein. Thus, he improved quickly after thrombectomy.
+However, in the following 12 h, the patient showed signs of infection. His consciousness became poor, while body temperature and heart rate increased, and blood pressure, urine volume and oxygenation index decreased. The high CRP (71.82 mg/l) and PCT (22.82 ng/ml) levels also suggested that the patient might be infected. Based on the 2016 SSC guidelines, the patient had septic shock. In addition, SOFA score and laboratory test results were deteriorating . Therefore, we immediately started fluid resuscitation, drew the patient's blood for culture, and empirically commenced meropenem and teicoplanin for treatment of the suspected sepsis.
+Unfortunately, he continued to deteriorate such that by the second day his respiratory and circulatory systems collapsed and he required ventilation with almost pure oxygen. He died on the third day of respiratory and circulatory failure, and the result of the blood culture, which was received two days later, showed that he had F. nucleatum bacteremia, sensitive to penicillin, cefoxitin, piperacillin/tazobactam, cefoperazone/sulbactam, imipenem/cilastatin, meropenem, clindamycin and metronidazole, intermediate to ceftriaxone, and resistant to none.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_892_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_892_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d157a978d56558e25c76b4dd06e2cb1154c5fb2e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_892_en.txt
@@ -0,0 +1,10 @@
+A 34-year-old female patient was admitted to the rheumatology department in July 2017 with complaints of nausea, joint pain, and swelling in the neck.
+Her medical history was notable for asthma, rheumatoid arthritis (RA), SS, and sialadenitis.
+She had been undergoing follow-up for RA and SS in the rheumatology department since 2015. Her last follow-up was in November 2016, and laboratory results revealed a rheumatoid factor of 273 IU/mL [reference range (RR) 0-20], anti-cyclic citrullinated peptide (anti-CCP) of < 1.5 U/mL (RR 1.5-1.93), creatinine of 0.74 mg/dL (RR 0.5-0.9 mg/dL), erythrocyte sedimentation rate (ESR) of 109 mm/h (RR 0-20), and C-reactive protein (CRP) of 55.6 mg/L (RR 0–6).
+Upon initial physical examination, a 2-3 cm palpable cervical lymphadenomegaly was detected. She had clear lungs and normal heart sounds with no murmurs or gallops upon auscultation. Her current medication upon admission included methotrexate (15 mg once weekly injection), methylprednisolone (16 mg once daily), calcium carbonate (2500 mg) plus cholecalciferol/vitamin D3 (880 IU once daily).
+Laboratory results revealed several abnormal findings: Hemoglobin: 10.8 g/dL (RR 14-18 g/dL); blood urea nitrogen 33 mg/dL (RR 8-23 mg/dL); creatinine 4.4 mg/dL (RR 0.5-0.9 mg/dl); K: 5.6 mmol/L (3.5-5.1 mmol/L); phosphorus 4.6 mmol/L (RR 2.5-4.5 mmol/L); uric acid: 8.4 mg/dL (RR 2.4-5.7 mg/dL); ferritin: 221.8 ng/mL (RR 15-150 ng/mL); ESR: 84 mm/h (RR 0-20); and CRP: 23 mg/L (RR 0-6 mg/L). All laboratory results are depicted in Table . The patient was referred to the nephrology department. A urine stick test revealed one positive protein. Urine microscopy was negative for casts. The 24-h urine protein level was 0.8 g. Anti-nuclear antibody, anti-double-stranded DNA (dsDNA), anti-glomerular basement membrane, and antineutrophil cytoplasmic antibodies profiles were all negative. The C3 level was 60 mg/dL (RR 90-180 mg/dL), and the C4 level was 15.3 (RR 10-40).
+Hypereosinophilia was detected on a peripheral blood smear (eosinophil count was 3.99 × 103/L; RR is 0-0.2 × 103/L), eosinophil percentage was 37.3% (RR 0.9%-2.9%), and the IgG4 level was 2602 mg/dL (RR 3-201 mg/dL).
+Renal ultrasonography indicated enlarged bilateral kidneys. The right and left kidneys had long axes of 159 and 181 mm, respectively. Bilateral renal echoes were significantly decreased, and hypoechoic areas were observed in both kidneys. Among the enlarged area, the largest one was 54 mm × 42 mm in the lower middle section of the left kidney.
+Computed tomography (CT) revealed nodular lesions in the liver, a pancreatic mass, cervical and mediastinal lymph nodes of 2 to 3 cm in diameter.
+Positron emission tomography/CT (PET-CT) screening was used based on suspicion of metastatic malignancy or lymphoma. It has been revealed that cervical and mediastinal lymph nodes had high metabolic activity. Infiltrative soft tissue masses were observed ranging from 2 to 4 cm in size in both kidneys. These masses have showed intense hypermetabolic activity in the cortical areas of the kidney parenchyma (standardized uptake value max: 8.01) .
+A kidney biopsy was performed. The biopsy showed intense, connective tissue infiltration between the glomerular and tubular structures. Lymphoplasmacytic and eosinophilic cell infiltrations were observed. IgG4-stained cells were detected on the biopsy specimen .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_8_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_8_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1ddfcc52b3095b3ffcd3d4b7dc5a6232a79ce8a3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_8_en.txt
@@ -0,0 +1,5 @@
+This 50-year-old male presented to our inpatient neurosurgical serve with complaints of right eye pain, blurred vision and occasional diplopia, headache, and gait difficulty with frequent falls due to imbalance. He denies numbness or weakness of extremities. Past medical history included type II diabetes, hypertension, and hyperlipidemia.
+On exam, he was alert and oriented to person, place, and time. He had decreased vision in right eye and diplopia on extreme lateral gaze. Subtle horizontal nystagmus was noted. The remaining cranial nerve exam was grossly intact. Patient had normal strength and sensation in all four extremities. He had negative Romberg sign but mildly ataxic gait. Magnetic resonance imaging (MRI) without contrast showed a stable cluster of three cysts centered within the tegmentum of the right midbrain, which in aggregate measured 2.2 cm × 1.4 cm × 1.4 cm . There was a dominant dorsomedial cyst upto 1.7 cm in maximum dimension with associated compression on the adjacent cerebral aqueduct. There was mild associated hydrocephalus with distention of the lateral and third ventricles .
+Under general anesthesia, the patient was fixed in Mayfield head holder, and stereotactic navigation was registered for use during the procedure. Two burr holes were placed. A posterior burr hole was planned in the right frontal area near the coronal suture in order to perform the ETV. A second burr hole was planned anterior to the first one in order to access the brainstem cyst and the posterior third ventricle. The endoscope was introduced through the posterior burr hole into the lateral ventricle and through the foramen of Monro into the third ventricle. Third ventriculostomy was performed in the usual fashion in the floor of the ventricle, anterior to the mammillary bodies. Next, the endoscope was introduced through the anterior frontal burr hole and taken into the third ventricle through the foramen of Monro in a more posterior trajectory in order to reach the brainstem cyst. Fenestration of the cyst was performed with the endoscopic bipolar. Contents of the cyst were consistent with pure cerebrospinal fluid. An external ventricular drain (EVD) was left for intracranial pressure monitoring following the procedure. The closure was done using burr hole covers and routine skin closure. The patient tolerated the procedure well and was transferred to the intensive care unit for further monitoring and care.
+Intracranial pressures remained within normal limits, and the EVD was removed the following morning after surgery. Patient was able to ambulate without assistance with minimal pathway deviations and perform daily activities of living independently. Cognition remained intact, and he conversed appropriately. Postoperative MRI showed a decrease in size of the ventricular system with evidence of flow through the aqueduct and ostium of the ETV. There was a stable appearance of cystic lesions in the brain stem with some decrease in size .
+At 1-month follow-up his gait, diplopia, and headache had significantly improved. At 5 months, headache, and diplopia had essentially resolved, and computed tomography scan showed well-decompressed cyst and ventricles .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_914_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_914_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..207abf45652aac235e94e84a810a794db1b9895a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_914_en.txt
@@ -0,0 +1,6 @@
+A 51-year-old Caucasian man who smoked and was afflicted with dyslipidemia presented at our emergency department complaining of typical angina and shortness of breath. He had a family history of coronary artery disease. He had been successfully treated with coronary angioplasty 12 years before presentation. A 4.0/16.0 mm AVE Micro stent (AVE Inc., Santa Rosa, CA, USA) was deployed in the proximal left anterior descending artery (LAD). The stent was postdilated with a 4.0-mm high dilatation force balloon (High Energy) at 14 atmospheres with good angiographic results. The patient was on therapy with aspirin, a statin, omega-3 fatty acids and a β-blocker and had remained asymptomatic up to his admission.
+An electrocardiogram showed a marked ST-segment elevation in leads V2-V6, I and aVL, suggesting an extended anterior acute myocardial infarction .
+Emergency coronary angiography revealed total occlusion of the LAD with complete fracture of the mid portion of the stent . The circumflex artery had a non-critical plaque in the mid portion (50%) and the right coronary artery was normal.
+A percutaneous coronary intervention (PIC) was performed. After predilation, two Cypher stents (Cordis, Miami Lakes, FL, USA) 3.0 × 33 mm in the middle part and 3.5 × 8 mm proximally, respectively, were superposed on the previous stent in the fractured occlusion area. Subsequently, a third Cypher stent 2.75 × 28 mm in the mid-LAD was deployed .
+Overlapped segments with extensor balloon (3.5 × 20 mm) postdilation were performed. The affected coronary artery was successfully reperfused (final TIMI 3 flow) . The peak troponin T level was 82.89 ng/ml, myoglobin was greater than 1000 ng/ml, and creatine kinase-MB level was 217.30 ng/ml.
+The patient was admitted to the coronary care unit and treated with double antiplatelet therapy (aspirin and clopidogrel) as well as a β-blocker, ACE-inhibitor, statin and diuretic. The patient's later course was uneventful, as cardiac biomarkers normalized.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_928_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_928_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7d27cf6addb82f2d2c84a68b80ba45981acf5d48
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_928_en.txt
@@ -0,0 +1,5 @@
+The 5-year-old vaccinated male intact mongrel breed was referred to Hassanzadeh Specialized Pet-hospital with a huge mass on the mandibular bone. The owner declared the mass appeared over 5 months. The clinical presentation started with drooling, problems in chewing, opened mouth caused by mass distention, malocclusion in the right mandible, and face changes. The right mandibular canine and first premolar tooth were not observed, the second premolar tooth was dislocated and the maxillary canine on the same side was oriented rostrally. There were no signs of pain and the mass was firm and bony consistency. Also, there was a smaller mass on the right mandible with lower invasion and lack of changes in dental occlusion . The differential diagnosis of the mentioned case predicts old malunion fractures, and bone tumors such as osteosarcoma, osteoma, osteoblastoma, ossifying fibroma, and osteomyelitis or exostoses. Other jaw soft tissue masses such as epulis, squamous cell carcinoma, and ameloblastoma have rejected the cause of the consistency and bone structure of the mass.
+The skull radiographs were performed in dorsoventral and lateral projection which showed the intense and well-demarcated edge with a short transitional zone between normal and abnormal bone. There was a smooth rounded radiopaque appearance rostral of bilateral mandibles. The right mass size measured 8 × 4 cm and prevent normal chewing. The left mass has no remarkable changes in radiology in comparison to the left mass. The periosteal reaction and invasion of the surrounding soft tissue were not seen. Thoracic radiographs did not indicate pulmonary metastasis .
+The blood sample was collected and the leukogram showed mild neutrophilia and monocytosis which would be because of chronic inflammation. The biochemistry profile was normal and did not have a significant change . Cytological assessment was performed by fine needle aspiration cytology from the core of the lesion. The microscopic evaluation showed oval to spindle shape cells with poorly malignancy criteria. A moderate number of fatty cells, degenerated neutrophils, bacteria, macrophages, osteoblasts, and osteoclasts. Septic inflammation was evident and suspected of mesenchymal tumor .
+Due to the chewing problem, mandibulectomy is considered the best treatment option for this patient. Therefore, the patient was sedated with Ketamine (5 mg/kg of body weight)-Diazepam (0.2 mg/kg of body weight), intravenously, and maintained by Isoflurane inhalation, respectively. It is positioned in the ventral recumbency and the mandibular mass is excised by unilateral mandibular ostectomy. The approach was according to the dissection of the Genioglossus, a superficial portion of the Masseter muscle, and the rostral portion of the Mylohyoideus muscle and Digastricus. Mandible was removed after the mandibular alveolar artery, vein, and inferior alveolar nerve ligation . The antibiotic therapy (Cefazolin 25 mg/kg b.w., q8, 5 days and Clindamycin 11 mg/kg b.w. q24, 3 days) and analgesics (Morphine 0.2 mg/kg b.w.) were administrated.
+The mass was sent to the Histopathology Laboratory and the gross examination admitted a cream-tan tissue, measuring 10 × 5 cm2. The microscopic description revealed the admixture of mature lamellar and woven bone patterns, with Haversian-like canals. Cortical-type bone architecture is more frequent than trabecular bone architecture. Osteoblasts rimming bone are inconspicuous and small. Osteocytes in the matrix are small, not atypical, and randomly distributed. Intertrabecular marrow spaces are filled with moderately cellular and loose fibrous stroma. The final diagnosis was osteoma .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_936_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_936_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d0e194b1528d12075d4534a279a9b2703f6718e9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_936_en.txt
@@ -0,0 +1,3 @@
+We report a case of a 51-year-old male with crescendo chest pain presented at the referral hospital. He was previously diagnosed with chronic coronary syndrome and hypertension but refused coronary intervention. Otherwise, VAS (visual analog scale) of 8/10, vital signs and physical exam were within normal limit. Chest X-ray within normal limit . There was T wave inversion at the inferior and lateral lead on his ECG . Laboratory work showed an elevated serum creatinine level of 8.13 mg/dL and a significant elevation of HsTrop 289.6 ng/L (over 99 th percentile). He was then diagnosed as NSTEACS high risk and treated with double antiplatelet in loading dose (300 mg of aspirin and 300 mg of clopidogrel 300 mg) and enoxaparin 60 mg twice daily despite significant reduced estimated glomerular filtration rate of 9 ml/min.m2. After 3 days of care with nonsignificant improvement, he was referred to our hospital for further intervention.
+We perform laboratory work by blood drawing on the right cubital vein. Echocardiography showed normal kinetic with a preserved ejection fraction of 62%. He was further planned to undergo the early invasive strategy. However, within 2 hours of our care, there was significant swelling and tensing in his right (nontraumatic) brachial and antebrachial area . In the next 2 hours, his swollen worsened into ecchymosis with bullae, and distal digital fingers developed pallor and paresthesia with decreased peripheral saturation of 88–91% . We discontinue enoxaparin and proceed with single antiplatelet aspirin as recommended by ESC guidelines for NSTEACS 2020. He was then diagnosed with acute spontaneous compartment syndrome and planned to undergo fasciotomy.
+Postoperatively, his symptoms improve . We proceed with a conservative strategy for his NSTEACS due to exposed fascia with active bleeding, which is a contraindication to antiplatelets if he was planned for coronary stenting.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_943_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_943_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cab57cd4a7f1cbfc966b2df0c83a2b62b514d3de
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_943_en.txt
@@ -0,0 +1,4 @@
+Mrs A, a 25-year-old woman, came to our hospital because of repeated hair pulling and binge eating behavior voluntarily. Her medical history was collected via a detailed inquiry. More than 10 years ago, the patient was sexually discriminated against by her family and had a bad relationship with her parents. She gradually became unhappy, self-abased and nervous, and began to pull out her hair repeatedly and uncontrollably, which was more obvious when she was in a bad mood. After about 2 years of systematic CBT and pharmacotherapy, she still had no improvement. Nearly a year ago, the condition worsened; she was upset, unhappy and was crying often. Additionally, the hair pulling phenomenon worsened, and she even used nail clippers to pull out the hair follicles on her head, and she had to resort to constantly wearing a wig to cover up the local hair loss. Furthermore, patients encountering increased pressure will exhibit intermittent binge eating attacks: she will eat much more food than usual in a short time, felt unable to control eating. When this began, she will eat much faster than normal, and until she felt uncomfortably full and got a feeling of guilty after eating, about two to three times a week, but no emetic, diuresis or diarrhea behavior and resulted in a significant increase in weight gain. The patient had an obvious impairment in social function and had changed jobs several times in the last year. Mrs A had been misdiagnosed with "obsessive–compulsive disorder", "depression" or "anxiety disorder" and had been mono- or co-treated with sertraline (200 mg/day × 8 weeks), fluvoxamine (150 mg/day × 12 weeks), bupropion (300 mg/day × 6 weeks) and risperidone (1 mg × 8 weeks) in the last 2 years, but all of them did not work. The patient was given fluvoxamine (150 mg/day) and bupropion (300 mg/day) before admission.
+On admission, wearing a wig, Mrs A had normal vital signs, but was obese (BMI: 28.23 kg/m2). The hair loss was obvious in the temporal and occipital regions, and the local hair follicles in the scalp were red and swollen with oozed blood (see attached Fig. , the local hair defect). Mental state examinations: clear consciousness, normal orientation and cooperation, no delusions or hallucinations, no somatization symptom, she always felt depressed and anxious because she could not control her impulse of pulling hair and binge eating, she had a low self-evaluation but had no suicide attempt, she could not perform well in work and changed her job often. Laboratory tests, ECG, EEG and brain MRI scans showed no obvious abnormalities. The psychological tests revealed: Yale-Brown Obsessive Compulsive Scale(Y-BOCS) showed 18 points, Hamilton Anxiety Scale (HAMA) showed 22 points, Hamilton's Depression Scale-17 (HAMD-17) showed 18 points, Eating Disorder Inventory (EDI) showed 245 points, these results indicate the patient had obvious obsessive–compulsive, depressive and anxiety symptoms, and also indicate she had eating disorder.
+After admission on the basis of the recent treatment (fluvoxamine 150 mg/day and bupropion 300 mg/day), the patient was given a combined treatment with NAC, started at 600 mg/day and titrated gradually to 1200 mg/day (D4) and 1800 mg/day (D9). During this period, the patient's anxiety and depression were significantly improved, the hair plucking behavior was significantly reduced and her binge eating was also rapidly alleviated (no recurrence except on the day of admission). Subsequently, the patient was discharged from the hospital on day 11.
+A follow-up of 2 weeks after discharge showed that the patient's mood was stable, her anxiety was alleviated, hair plucking behavior was rarely observed, her hair was thicker than before and inflammation was significantly improved. A follow-up of 4 weeks after discharge showed an improvement of her obsessive symptoms, no episodes of binge eating and her normal occupation of teaching had resumed. A follow-up of 14 weeks after discharge (16 weeks after treatment) showed no plucking behavior, no episodes of binge eating, slimmer than ever (BMI: 26.95 kg/m2), and she was in good working and living conditions. Maintenance dose was fluvoxamine 100 mg/day, bupropion 300 mg/day, NAC 1200 mg/day. (drug dosages and scale evaluations used during treatment are shown in Table , and changes in local hair defects are shown in Figs. , and ).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_948_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_948_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..dde3cc1aaca35b9580a6c08247f7285665fe8e8b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_948_en.txt
@@ -0,0 +1,8 @@
+A 20-year-old woman with diagnosis of ASs was referred to our department for reduced vision in her left eye (LE) of 2 weeks onset; she was negative for pseudoxanthoma elasticum or any other systemic disease. The patient signed a comprehensive consent form according to Good Clinical Practice guidelines, before proceeding with all examinations and treatments. Her best-corrected visual acuity (BCVA) was 20/20 in the right eye (RE) and 20/100 in the LE, with no signs of inflammation in the anterior chamber and vitreous of either eye. Fundus biomicroscopy revealed ASs in both eyes (BE). RE had no evidence of inflammation at the fundus observation . Interestingly, only the LE had multiple discrete grey-white lesions (dots) scattered over the fundus, from the paramacular area up to the mid-periphery, and the macula had a granular appearance . Fluorescein angiography (FA) (HRA, Heidelberg Engineering, Heidelberg, Germany) indicated mild optic disk leakage with some hyperfluorescent changes scattered throughout the fundus (paramacular area and mid-periphery). No CNV was detected . Indocyanine green angiography (ICGA) (HRA, Heidelberg Engineering, Heidelberg, Germany) disclosed late hypofluorescent lesions scattered at the posterior pole and in the mid-periphery ; we interpreted these as signs of zonal outer retinal inflammation. Spectral-domain optical coherence tomography (SD-OCT) macular scans showed disruption in the photoreceptor layer . Automated static threshold perimetry indicated visual field defects mainly located paracentrally and temporally .
+On the basis of all these findings a diagnosis of ASs and coincident MEWDS was made. The patient was prescribed oral prednisone (1 mg/kg) for 7 days then half the dosage for another 7 days.
+Two weeks later, LE BCVA improved up to 20/25, with resolution of the MEWDS findings, except for the granular appearance at the macula; RE BCVA was 20/20 with no signs of inflammation at the fundus evaluation.
+Two months later, the patient returned because of sudden vision loss in her LE (20/100). FA indicated CNV in the paramacular area in LE. FA and ICGA showed no signs of choriocapillaris inflammation in BE . We proposed to the patient an intravitreal injection of ranibizumab as an off-label treatment option. She signed informed consent and was given a single injection of ranibizumab (0.5 mg/0.05 mL) following the normal procedure. One month after the injection BCVA improved up to 20/40, the CNV showed regression , and there was no need for retreatment up to her latest follow-up visit 1 year after the injection, when BCVA had improved up to 20/25.
+ASs are often complicated by the appearance of CNV [, ]. To date there are no reports of AS associated with acute ocular inflammation. MEWDS is a unilateral inflammatory disease, which usually resolves spontaneously, with full recovery . Here we describe a patient with ASs, who was diagnosed with coincident MEWDS. Two months after this diagnosis she developed CNV, which was effectively treated by intravitreal ranibizumab. In the current literature there are only six cases of CNV that developed after (from 4 weeks to 13 years) the diagnosis of MEWDS [–, ]. Only two were effectively treated by intravitreal anti-vascular endothelial growth factor (VEGF) [, ]. In all other cases the visual loss was permanent despite treatment [–].
+The case described is unusual: the CNV occurred in a patient with ASs, 2 months after the diagnosis of MEWDS. Although both ASs and MEWDS may contribute to the onset of CNV, the patient’s young age, good prognosis after intravitreal ranibizumab and the presence of MEWDS involving the macular area may indicate an inflammatory etiology of the CNV.
+Though the pathophysiologic mechanism remains unclear, it has been suggested that alterations of Bruch’s membrane or the outer retinal barrier caused by choroidal inflammation may be associated with ischemic and/or inflammatory CNV . It has also been hypothesized that the inflammatory processes induce the release of chemokines that favor angiogenesis . This patient was in fact younger than the mean age at which CNV usually develops associated with ASs [, ]. Moreover, in this case a single intravitreal ranibizumab injection had a lasting effect (up to at least 1 year), as shown by FA and OCT, and by the maintenance of good BCVA.
+Our results are in agreement with Rouvas et al. who have described the good responses to intravitreal treatment with ranibizumab for inflammatory retinal diseases . This might be explained by the different nature of the CNV, in which inflammation may have played an important pathogenic role, compared to other CNVs secondary to ASs which tend to be associated with a worse visual prognosis, and need more injections .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_950_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_950_en.txt
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+This is a case of a 68-year-old male smoker (50 pack-year history). The occupation of the patient is a farmer. No family history of cancers or lung cancer. He was admitted to hospital due to cough, sputum and dyspnea. He had a 4-year history of COPD and a 3-year history of well-controlled chronic gastritis. He had no other medical conditions such as high blood pressure, diabetes, obesity or autoimmune disease and denied drinking alcohol. Physical examination revealed a barrel-chest.Wet rales and wheezing could be heard in the right upper lung. Laboratory data showed WBC 11.90/109/L (reference, 4–10/109/L), Neu 8.75/109/L (reference, 2.5–7.5/109/L), Lym 0.94/109/L (reference, 1.5–3.3/109/L), CRP 149.77 mg/L (reference, ≤ 10 mg/L). Blood gas analysis PO2 77.10 mmHg (reference, 80-100 mmHg). Chest computerized tomographic (CT) scan revealed signs of emphysema, irregular mass-like consolidation with cavity shadows in the right upper lobe, and thickening of local interlobular septa . Bronchoscopy and alveolar lavage showed no abnormality. Combined with clinical manifestations, laboratory examination and imaging data, he was diagnosed as community acquired pneumonia (CAP). He was treated with intravenous ceftizoxime (1 g/Q12h/9d) for anti-infection, intravenous methylprednisolone (40 mg/qd/5d), atomized salbutamol for antispasmosis, relief of bronchoscpasm, cough and expectorant treatment, and was discharged with improvement. Pulmonary function testing showed a decreased FEV1/FVC ratio (53.47), an FEV1 of 1.08 L (45% normal), and reduced diffusing capacity of 23%. After discharge, he was treated with LABA/LAMA and recovered well. He did not return to the hospital for follow-up.
+About 7 months after discharge, the patient returned to the hospital for cough and dyspnea. Physical examination of the left upper lung breathing sound was low. Laboratory data showed a cytokeratin 19 fragment of 2.42 ng/ml (reference, < 3.3 ng/ml) and neuron-specific enolase 85.87 ng/ml (reference, 0–16.3 ng/ml). Contrast-enhanced chest CT showed resolution of the right upper lung lesion and residual scarring . Irregular mass in the bronchial opening area of the upper lobe of the left lung and fusion with enlarged lymph nodes in the left hilum and adjacent mediastinum: Central lung cancer of the left lung with left pulmonary obstructive inflammation, lymph node metastasis in the mediastinum and left hilum, and arteriovenous invasion of the left upper lung were considered to be highly possible . At the same time, we compared the images of the first hospitalization at the same layers .
+Positron emission tomography/CT did not detect an increase in standard uptake value except the lung. Fibrobronchoscopy revealed infiltrating growth of new organisms in the bronchial mucosa of the left upper lobe of the lung covered with white membrane-like neoplasm . We compared images of the same site at the first admission . Biopsy diagnosed SCLC . This patient PD-L1 Tumor Proportion Score was 52%. The diagnosis was ES-SCLC.
+The patient intravenously received cisplatin (75 mg/m2) and etoposide (80 mg/m2 on days 1–3) and durvalumab (humanized monoclonal PD-L1 inhibitor, 1500 mg) every 3 weeks for four cycles. 2 months after treatment, the patient achieved partial remission (PR) in imaging assessment , and the patient refused prophylactic cranial irradiation and chest radiotherapy. Durvalumab (1500 mg) was administered once every four weeks, and the disease progressed after four times of maintenance treatment . The patient refused chemotherapy again, immunotherapy and radiotherapy, anlotinib and analgesic drugs orally only, and went home to hospice care. He succumbed to his disease approximately 9 months after his diagnosis.
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+A 41-year-old Caucasian woman was admitted at the hospital with one-month history of asthenia, anorexia, fever, abdominal pain, early postprandial surfeit, and diarrhea. She had past history of an intermittent migratory pruritic maculopapular rash and mild episodes of flushing that had never been investigated, hypothyroidism, an anxiety disorder, and emotional instability, and she had smoked 20 cigarettes a day since the age of 13. There was no history of allergies or other pathologies.
+When first observed at the hospital, she had a fever, a dark spot on the tongue, a slightly pruritic brownish erythematous maculopapular skin rash predominantly in the upper limbs, hepatomegaly (the left lobe of liver was enlarged and extended to epigastric region and the right lobe was four fingers below the right costal margin in the midclavicular line), and splenomegaly (5 fingers below the left costal margin). There was no peripheral lymphadenopathy.
+Peripheral blood counts revealed pancytopenia: hemoglobin (Hg) 11.0 g/dl (normal range 12.0–15.0), platelets 16 × 109/L (normal range 150–400), and white blood cells (WBC) 4.25 × 109/L (normal range 4.0–11.0) with 7.0% neutrophils (0.3 × 109/L) (normal range 2.0–7.5), 6% blast cells (BC), and 20% of cells with metachromatic cytoplasmic granules that were initially classified as basophils by morphology , but whose immunophenotypic study subsequently revealed them to be an abnormal immature MC.
+Serum biochemistry showed elevated lactate dehydrogenase (369 U/L, normal range 135–214 U/L) and abnormal hepatic tests with a cholestatic pattern: total bilirubin 1.2 mg/dl (normal range: 0.2–1.0), direct bilirubin 1.1 mg/dl (normal range: 0.0–0.2), indirect bilirubin 1.14 mg/dl (normal range: 0.0–1.0), alanine transaminase 90 U/L (normal range: 10–30), aspartate transaminase 36 U/L (normal range: 10–30), alkaline phosphatase 731 U/L (normal range: 32–104), and gamma-glutamyl transferase 638 U/L (normal range: 6–39). There was also hypoalbuminemia (serum albumin 32 g/L, normal range: 35–50) and hypogammaglobulinemia (serum IgG 522 mg/dl, normal range: 793–1590; IgA 127 mg/dl, normal range: 114–457; IgM 170 mg/dl, normal range: 29–226). Serum tryptase levels were markedly increased (184 μg/L, normal range < 13 μg/L). Calcium and phosphate serum levels were normal, as did renal function tests. Coagulation tests, including prothrombin time, activated partial thromboplastin time, and fibrinogen levels, were within the normal range. Serological tests for hepatitis B and C viruses and human immunodeficiency virus type 1 and 2 were negative.
+Bone marrow smears showed 24% myeloperoxidase (MPO) positive BC, 17% promyelocytes, 4% myelocytes, 3% metamyelocytes + neutrophils (AML-M2 classification by cytomorphology), 30% erythroid lineage, and 16% morphologically abnormal toluidine blue positive MC . These cells had variable morphological features, from atypical MC type I and II to metachromatic blasts. There was no BM eosinophilia, or evidence of myelodysplasia. Flow cytometry of the BM aspirate revealed 12% of CD45+ (low), CD117+, CD34+ myeloid precursor cells (MPC) also expressing CD123, HLA-DR (high), CD13, CD33, CD65 (low), and CD25 (low, in part of the cells) but lacking CD10, CD15, CD16, CD2, CD30, and FcεRI/IgE; 5% of CD45+ (low), CD117+, CD34− MC precursors (MCP), also being positive for CD123 (high), CD13, CD33, CD65 (low), CD25, CD30, FcεRI/IgE, and HLA-DR (high), and lacking CD10, CD15, CD16, and CD2; 34% promyelocytes with an aberrant phenotype (CD45+, CD34−, CD117+, CD13+low, CD33+, CD65+; CD15+, MPO+, and CD2, CD10, CD11b, CD16, CD25, CD30, FcεRI/IgE, and HLA-DR negative); a maturation blockage at the promyelocyte level, as revealed by an abnormal CD11b/CD13/CD16 maturation pattern, with <1% of CD16+CD10+ mature neutrophils; and 13% of abnormal CD45+, CD34−, CD117+high MC with a relatively immature (CD123+high, FcεRI/IgE+ low, and HLA-DR+high), activated (CD63+, CD69+), and aberrant (CD2−, CD25+, and CD30+) immunophenotype . Cytoplasmic carboxypeptidase and surface CD203 were also positive (data not shown). In addition, FCM performed in PB, showed 3% CD45+low, CD117+, CD34+ MPC, and 21% of CD45+low, CD117+, CD34− MCP, which were phenotypically similar to the correspondent BM cell populations, at least for the cell surface markers tested, but not CD45+, CD34−, and CD117+ high MC .
+Bone marrow trephine biopsy revealed a hypercellular marrow with increased proportions of immature MPO+ myeloid cells and morphologically atypical CD117+ fusiform MC forming perivascular dense aggregates, and grade 2 fibrosis . Skin biopsy was not performed.
+Cytogenetic analyses of at least 20 Giemsa-banded BM cell metaphases obtained from unstimulated 24 hour cultures disclosed a 46,XX karyotype, without numerical or structural abnormalities. Genetic studies using probes for relevant targets, including t(15;17) PML-RARA, t(8;21) RUNX1-RUNX1T1, inv(16) CBFB-MYH11, and t(9,22) BCR-ABL, gave negative results. Tests for FLT3 (FMS-like tyrosine kinase 3) and NPM-1 (Nucleophosmin-1) gene mutations were also negative. KIT mutation at the codon 816 (D816V) (A7176T) was detected in all sorted BM cell populations, except in T cells; BM cells harboring the KIT D816V mutation included MC, CD34+ cells, CD34-HLA-DR-, CD34-HLA-DR+, and CD34-HLA-DR++ cells.
+Abdominopelvic computerized tomography scan affirmed hepatomegaly (18.5 cm) and mild splenomegaly (13 cm) with small hypodense nodules (maximum diameter 10 mm) and revealed retroperitoneal adenopathies forming a conglomerate extending from the lesser gastric curvature and involving the large vessels; the largest adenopathy was in the hepatic-duodenal ligament and had 2.4 cm of major diameter. There was also a lamina of peritoneal liquid in pelvic cavitation.
+Digestive endoscopy revealed slight reduced distensibility of the gastric body, which had a congestive mucosa with foci of erythema, and the duodenum had a congestive and micronodular mucosa. Biopsies were not performed due to severe thrombocytopenia. Skeleton radiography did not reveal osteolytic lesions. Thorax radiography had no evidence of mediastinal enlargement, lung consolidations, or pleural effusions.
+According to the WHO criteria [, ], and to the consensus recommendations of the EU/US-CGM and the ECNM , the patient was diagnosed with KIT D816V+ MCL associated with AML with normal karyotype. She was immediately started with oral corticosteroids (prednisolone, 60 mg/day for one week, tapered to 20 mg/day over 1 month, and then maintaining 20 mg/day) and disodium cromoglycate (200 mg capsules, 4 times daily), and H1 (cetirizine, 10 mg/day, orally) and H2 (ranitidine, 150 mg twice a day, orally) antihistamines, which ameliorate the symptomatology. Then, she received two cycles of cladribine (0.14 mg/kg/day, administered over a 2-hour infusion for 5 days) with one month of interval, and the serum tryptase levels transiently decreased to 41 μg/L .
+One month after, she maintained constitutional symptoms, hepatomegaly, and pancytopenia, and she developed cutaneous and mucosal hemorrhage (petechial rash, epistaxis, and spontaneous oral cavity bleeding), myalgia, and bone pain. By that time, the serum tryptase serum levels had increased to 123 μg/L , and the BM aspirate showed 47.0% myeloblasts, 8% promyelocytes, and 7.0% MC. Bone marrow FCM revealed 3% MPC (CD45+low, CD34+, CD117+, FcεRI/IgE−, CD2−, and CD25−/+), 7% MCP (CD45+ low, CD34−, CD117+, FcεRI/IgE+low, CD2−, and CD25+), 46% of immature granulocytic cells (almost complete maturational arrest at the promyelocyte stage), and 7% of CD45+, CD34−, CD117+ high, CD2−, and CD25+ MC. Peripheral blood counts were WBC 2.07 × 109/L, neutrophils 4.0% (0.08 × 109/L), MC 41.0%, BC 9.0%; Hg 8.8 g/dl; and platelets 28 × 109/L. Flow cytometry studies performed in the PB showed 48% CD45+ low, CD117+, CD34−, FcεRI/IgE+low, CD25+, CD2− MCP, 4% CD45+low, CD34+, CD117+, FcεRI/IgE−, CD25−/+, CD2− MPC; once again, circulating CD45+, CD34−, CD117+high, CD2−, CD25+ MC were not observed. By that time, she received induction therapy for AML consisting of two cycles of idarubicin (12 mg/m2/day, intravenous, for 3 days) and cytosine arabinoside (AraC) (100 mg/m2/day, intravenous, for 7 days), achieving hematological remission and normal tryptase levels after the second induction course . At that time, the BM smears were slightly hypocellular with 1.3% of BC and no MC. Bone marrow FCM studies detected 1.5% of CD117+ CD34+ MPC, 54% maturing granulocytic cells, from which 26% were promyelocytes, 53% were metamyelocytes and myelocytes, and 21% were mature neutrophils, and 0.03% were phenotypically abnormal MC (0.02% CD117+ CD34− CD2− CD25−/+low, FcεRI/IgE+ MCP, and 0.01% CD117+high CD34−, CD2−, CD25+, FcεRI/IgE+low MC). Consolidation therapy performed in the subsequent 2 months consisted of two courses of high-dose AraC (2 g/m2, intravenous).
+As complication of treatment she had bartholinite, treated with piperacillin plus tazobactam, and metronidazole; oral mucositis grade II controlled with tramadol; febrile neutropenia with bacteremia by Escherichia Coli treated with piperacillin plus tazobactam; pneumonia without respiratory insufficiency, which was responsive to imipenem plus vancomycin, and pseudomembranous colitis by Clostridium difficile, treated with metronidazole.
+Two months after the second course of consolidation chemotherapy, the patient received isogroup HLA-identical related allogeneic HSCT from her sister (10/10 match) (5.09 × 106/kg nonmanipulated peripheral blood CD34+ cells, totalizing 322 × 106 CD34+ cells). The reduced-intensity conditioning regimen included fludarabine (30 mg/m2/day for 5 days) and busulfan (4 mg/kg/day for 2 days). As acute complication, she had febrile neutropenia treated with meropenem. On day 30 after HSCT, she had recovery of the hematological counts, and no myeloblasts or MC were seen in the PB. Unfortunately, the BM aspirate was hypocellular and results from BM studies were unevaluable. Abdominal echography revealed stable hepatomegaly (17.5 cm), without splenomegaly, or adenomegalies. Three months after HSCT a complete chimerism was documented in PB and BM neutrophils, monocytes, and lymphocytes. She developed a chronic graft versus host disease with cutaneous manifestations, controlled with cyclosporine A and mycophenolate mofetil. By the time of this report (24 months after the diagnosis, 15 months after HSCT), she maintains normal serum tryptase levels, complete hematological remission, and complete chimerism in PB .
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+The patient in this case was an 11-year-old male who fell while running and injured his left wrist(We have obtained the consent of the patients and their families regarding sharing information associated with the patient). An X-ray examination at the local hospital revealed a fracture of the distal radius and dislocation of the distal ulnar radial joint. The doctor at the hospital administered the patient 2 manipulations and plaster fixation. Two months later, the patient presented to our hospital due to local swelling and pain. An initial examination of the injury site found no signs of neurovascular damage, but there was pain at the left upper ulnar radial joint, dorsal ulnar bony projection of the left wrist with slight local swelling and significant tenderness. The left wrist joint had nearly unrestricted extension and flexion, but its rotational ability, particularly supination, was limited .
+We performed an X-ray of the injured site and found that the distal left ulna was split and a new ulna was growing. With the consent of the patient’s family, we performed a CT examination of the area which clearly revealed the deformity was more clearly . The new ulna grew inwards, was slightly smaller than the original ulna and did not have a complete articular surface, while the normal original ulna protrudes dorsally and laterally with an intact articular surface and a “Y” shaped distal ulna. The patient exhibited normal wrist flexion and extension, but had limited rotation. Following a discussion, the patient’s parents declined surgical treatment. Consequently, we recommended functional exercise and regular follow-up to manage the condition. After a period of seven months, the patient returned to us as a result of experiencing pain. Examination showed that the showed that the pain in the left upper ulnar radius had almost disappeared and the rotation of the left wrist had improved, but there was still pain on extreme supination. The x-ray showed that the distal ulnar bifurcation was still visible, but the two bifurcated ulnae were close to each other and the base was decreased compared with that at 2 months after injury .
+The patient presented to our hospital at 3 years and 7 years after the injury. At the last follow-up, the patient’s status was that of a university student, not yet in the workforce. The patient’s left wrist function recovered satisfactorily and did not interfere with his daily life or physical activity, including playing basketball, push-ups and lifting heavy objects. A physical examination revealed that the length of the forearms were equal, the left elbow joint was normal, the left wrist deformity was minimal, the left ulnar styloid process was not prominent, there was no obvious local tenderness, the left wrist extension and flexion and rotation range of activities were normal. However, there was mild pain around the ulnar styloid process on extreme posterior rotation of the left wrist. The X-ray showed that the distal ulna was shortened and bifurcated, but the ulnar bifurcation was atrophied and smaller than previously, the ulnar styloid process was deformed and enlarged, the inferior ulnar radial joint was dislocated, the distal ulna did not participate in the composition of the radial carpal joint, and there was no obvious deformity of the radius.
+When performing activities of daily living (ADLs), the normal functional range of wrist motion is 5 degrees of flexion, 30 degrees of extension, 10 degrees of radial deviation and 15 degrees of ulnar deviation [, ]. During the follow-up visits, we recorded the patient’s range of motion including wrist flexion and extension, ulnar and radial deviation of the wrist, and anterior/posterior rotation of the forearm . The wrist function was rated following the criteria proposed by Krimmer et al. .
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+A 51 year old right hand dominant Caucasian female with history of hypothyroidism (microsomal and thyroid antibody positive), celiac disease and SS (seropositive for SSA, ANA, hypergammaglobulinemia, intermittent parotid swelling with mild oral/ocular sicca) experienced right C5 dermatomal varicella zoster infection seven weeks previously and then presented with right upper and right lower extremity weakness of one week duration. The symptoms got progressively worse to the point that she had difficulty with ambulation. She had associated burning dysesthesias of left thigh. The patient’s neurological examination was remarkable for hypertonia, decreased power (3/5), hyperreflexia along with sensory loss in the right upper and lower extremity and hyperesthesia in the entire left lower extremity.
+Gadolinium contrast enhanced magnetic resonance imaging (MRI) of the head was normal but MRI of the cervico-thoracic spine revealed an enhancing intramedullary lesion from C2 to C4, centrally into the right of the midline with signal changes at the T1 level without enhancement or expansive appearance . Cerebrospinal fluid (CSF) analysis was abnormal for a mild lymphocytic pleocytosis, marked elevation of IgG and prominent oligoclonal bands . Comprehensive infectious workup including blood cultures for bacteria, polymerase chain reaction for varicella zoster, herpes simplex virus, and serologies for Lyme disease and syphilis were negative. Differentials for non-infectious inflammatory myelitis were considered; including paraneoplastic myelitis and myelitis with Sjogren’s syndrome. NMO antibodies were not obtained during this presentation. The patient was treated with 1 gram of intravenous (IV) methylprednisone and 800 mg of oral acyclovir for 5 days for presumptive diagnosis of transverse myelitis secondary to varicella zoster infection with improvement in her symptoms. She was discharged on oral prednisone with instructions to taper and discontinue the drug over the next 1 week.
+Two months later, she developed left upper and lower extremity weakness, bilateral lower extremity dysesthesias and urinary incontinence. Examination confirmed 4/5 left hemiparesis with brisk reflexes, bilateral ankle clonus along with pinprick loss in both lower extremities. Repeat MRI of the spine revealed worsening enhancement at lower cervical cord region (C5-7) with extension to T1 level . Repeat CSF analysis showed a lymphocytic pleocytosis, increased IgG synthesis index and positive oligoclonal bands . Immunological work up was abnormal for NMO-IgG/AQP4 antibody . An ophthalmologic evaluation was negative for optic neuritis. The patient’s relapsing neurological illness was felt to represent NMOSD from underlying long standing SS. She was treated with 1 gram of IV methylprednisone and started on 1 gram of IV cyclophosphamide (CTX) therapy for worsening motor-sensory deficit. She was discharged on high dose oral prednisone and continuation of monthly CTX infusions.
+After her second monthly CTX infusion, patient had a relapse with right upper and lower extremity weakness, dysesthesias in the parieto-occipital scalp region and right leg along with urinary incontinence. The patient was placed on 5 days of pulse IV steroids with improvement in her symptoms. She was discharged on 60 mg of daily prednisone which was slowly tapered over 6 months. She continued to show clinical improvement despite persistence of NMO-IgG antibodies. After 5 infusions of monthly CTX therapy, maintenance treatment with Mycophenolate Mofetil (MMF) was started. She has remained on MMF without recurrence of symptoms for over 18 months. She has no residual motor or sensory deficits. Repeat MRI of the cervico-thoracic spine 6 months after her last CTX infusion, prednisone and MMF showed near complete resolution of previous abnormal cord signal changes .
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