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data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1480_en.txt

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+The second patient is a 5-year old boy, born as a first child to healthy non-consanguineous parents. The mother reported two previous early spontaneous abortions. Otherwise, the family history is unremarkable. He was born after an uneventful pregnancy in the 37th week of gestation after a spontaneous start of the delivery. The boy’s birth weight was 2430 g (10-25P), birth length 46 cm (10-25P), and head circumference 34.5 cm (75-90P). He had gastroesophageal reflux in the first few months, the abdominal ultrasound was normal. Due to apnoic attacks the boy was administered to hospital at the age of 5 months. The pH-metry confirmed gastroesophageal reflux, ECG and CMCRF were normal. The neurologist described a mild hypertonus and related mild motor delay. He sat independently at 9 months of age and he started walking at 20 months of age. The parents noted shortness of breath and tiredness after simple physical tasks, therefore, he was evaluated by a paediatric cardiologist. Two haemodynamically significant ASDs were noted and a slightly dilated right ventricle; corrective surgery is planned. The tests of acylcarnitine profiles and aminoacids in blood and organic acid in urine were normal. At the age of four his height and weight were in the normal range (height 99.2 cm (17P), weight 16.1 kg (46P)), however, the head circumference showed macrocephaly - 53.8 cm (>97P).
+Microarray analysis (180 K CGH array, Agilent Technologies- Fig. ) revealed a de novo microduplication of 2.06 Mb in chromosome 2p16.1p15 region (arr[GRCh37] 2p16.1p15(60308869_62368583)× 3 dn). No other pathogenic genomic imbalance was detected in the proband’s sample.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1792_en.txt

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+A 70 year old female presented to general practitioner with complaints of pain in left knee and calf. Initial knee radiographs showed early osteoarthritis. As there was associated calf tenderness she was admitted for further investigations. All blood parameters were normal. D-dimers at the time of admission were 440 ng/ml. She was categorized as moderate risk for a DVT on clinical examination. Anticoagulation was initiated suspecting a DVT and the Duplex scan of the leg was inconclusive. The pain settled but swelling persisted and the patient was managing her regular activities. After six months since the initial presentation she was referred to us for increasing swelling of the left leg. There was marked swelling with venous congestion (difference of circumference of 8 cm from right calf). After full length X-rays of leg , she had an MR scan of left knee and leg. The scan revealed a soft tissue mass showing marked enhancement, arising from the soleus muscle extending to popliteal fossa and involving the entire posterior compartment of leg . Ultrasound guided biopsy confirmed a high grade pleomorphic sarcoma. Locally the tumor was encasing the neurovascular bundle at the popliteal fossa. No metastases were discovered. After a total of 11 months from the onset of symptoms she underwent an above knee amputation on left side and is currently disease free with regular follow-up.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1867_en.txt

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+A 53-year-old woman, who had undergone bilateral toric ICL implantation for treatment of high myopic astigmatism in both eyes three years earlier, visited our hospital complaining of blurred vision in her left eye. In that eye, the manifest refraction was 0, -0.5 × 15, with an uncorrected visual acuity (UCVA) of 0.7 and a best spectacle-corrected visual acuity (BSCVA) of 0.8. The ICL vault (the distance between the posterior surface of the ICL and the anterior surface of the crystalline lens) was 0.16 mm; the keratometry, 42.8/45.2D × 95; the endothelial cell density, 2924 cells/mm2; and the central corneal thickness, 529 μm .
+Slit-lamp examination showed a marked anterior subcapsular cataract reaching into the visual axis . The remainder of the examination was unremarkable.
+After informed consent was obtained, we performed simultaneous toric ICL removal and phacoemulsification with toric IOL implantation. IOL spherical power calculations were performed by the SRK-T formula using the axial length measured by A-scan ultrasonography (US-800, Nidek, Aichi, Japan), and keratometric readings measured with an autorefractometer (RK-5, Canon, Tokyo, Japan). IOL cylinder power and the alignment axis were calculated using a Web-based toric IOL calculator program , along with the default surgically induced astigmatism, which the software considered as 0.5D. To control for potential cyclotorsion, the horizontal axis was marked preoperatively using a slit-lamp in a supine position. For ICL removal and phacoemulsification with toric IOL implantation, a 3.0 mm temporal clear corneal incision at a site identical to the original incision was created after topical anesthesia. After the introduction of viscoelastic material (Opegan; Santen, Osaka, Japan) into the anterior chamber, the proximal haptics of the ICL were dislocated, grasped with forceps, and extracted from the anterior chamber through the incision. Then, standard phacoemulsification was performed by capsulorrhexis, nuclear and cortex extraction, and toric IOL (SA60AT5, power +9.5D; Alcon Laboratories Inc., Fort Worth, Texas, USA) implantation using the same 3.0 mm incision. After surgery, our patient received steroidal (0.1% betamethasone; Rinderon, Shionogi, Tokyo, Japan), antibiotic (0.5% levofloxacin; Cravit, Santen) and non-steroidal diclofenac sodium 0.1% (Diclod, Wakamoto, Tokyo, Japan) medications, which were topically administered four times daily for one month and then the dose steadily reduced.
+On day 1, our patient's UCVA was 1.2. One month after surgery, the mean refraction was 0, -0.5 × 180, and she had a UCVA of 1.2 and a BSCVA of 1.5, and the keratometry was 42.8/45.5D × 100. The surgically induced corneal astigmatism was 0.54D × 126. Her endothelial cell density was 2801 cells/mm2 , and our patient was very satisfied with the postoperative visual outcomes. No vision-threatening complications occurred, including rotation of the IOL, and the manifest refraction and her visual acuity remained stable throughout the six-month follow-up period.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2506_en.txt

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+A 37-year-old man, right-handed driver, presented to the emergency department for a closed trauma of his left upper extremity after landing on the wrist with an out-stretched elbow following a fall. Initial physical examination revealed swelling and transverse widening of the left elbow. The forearm and the wrist were deformed. No open wounds were found. The radial head and the olecranon were palpable laterally and medially. The patient’s hand was well perfused without neurologic abnormalities. Plain radiographs showed a divergent left elbow dislocation associated with ipsilateral ulnar diaphysis fracture, a tearing of epitrochlea , and a fracture of the radial styloid process . The elbow joint was reduced under general anesthesia. Because of the radiohumeral instability, the reduction was stabilized with two Kirschner wires through the distal part of the humerus into the radius . A reinsertion of the medial collateral ligament was performed and the epitrochlea was fixed with two Kirschner wires .
+The ulnar diaphysis fracture was reduced and fixed by a screwed plate with Kirschner wire-fixation of the radial styloid process . Postoperatively, the elbow was placed in 90° of flexion and immobilized with a posterior splint for 3 weeks, and then the radiohumeral Kirschner wires were removed. An articulated elbow orthosis was placed; supervised forearm rotation and gentle passive elbow flexion and extension were initiated after the 3rd week. Full extension of the elbow was not aggressively executed until 6-week postoperatively. At that time, the orthosis immobilization was discontinued and the Kirschner wires of the radial styloid process were removed. The patient continued to work on range of motion with a 3 times per week physical therapy. At 4-month postoperatively, all fractures were united ( and ) and the patient continued to show improvement in range of motion with an elbow flexion-extension arc of 30° to 140°. At 3 years of follow-up, the patient was asymptomatic, with 10° of limitation in elbow extension and a full flexion of 145° , he also recovered 80° of pronation and 30° of supination , the patient was satisfied with the clinical outcome.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2944_en.txt

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+A 69-year-old hypertensive male was transferred to us with traumatic brain injury after sustaining a ground-level fall. On admission, his Glasgow Coma Scale was 12/15 (E4V2M6). CT scan depicted a left temporal hematoma with extensive acute subdural hematoma, diffuse edema and mass effect, and midline shift of 6.6 mm . He was admitted to the special care unit for observation where his GCS dropped to 9/15. He then underwent left-sided emergent DC and was discharged 4 weeks later. At the time of discharge, he was awake, alert, and intermittently following simple commands without gross motor or sensory deficits. His speech was slurred and intermittently, he had mildly agitated behavior (Richmond Agitation Sedation Scale or RASS + 1) with a Modified Rankin Scale of 4.
+One week later, the patient returned to the hospital with progressively worsening agitation without a decline in consciousness. CT scan showed interval development of the right chronic subdural hematoma with interval resolution of the previous acute hematoma. The hematoma was evacuated through burr-hole craniotomy and drain placement. The procedure was uneventful but after the surgery, his agitation increased (RASS + 3) and cognitive dysfunction did not improve. Mini-Mental Score could not be assessed as his comprehension was not intact. At this point, patient was extensively evaluated for other causes of agitation such as electrolytes disturbances, endocrine abnormalities, infection, sepsis, drug intoxication, or alcohol withdrawal, all workup was within normal limits.
+On serial CT scans, the right subdural collections decreased and his craniotomy skin flap started to sink. Suspecting “syndrome of trephined” and in view of his persistently unexplained behavioral dysfunction, we planned for early cranioplasty which was performed 6 weeks after the primary procedure . Within 48 h of cranioplasty, his agitation started to improve. On the 4th day, his RASS was + 1.
+At 6-month follow-up, the patient was found able to walk unattended and only required minimal assistance with his activities of daily living (ADL) (MRS 3). His comprehension had also improved considerably and he was able to follow two-step commands with consistency.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2967_en.txt

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+A 69-year-old man with untreated hypertension was transported to our hospital 4 h after being injured in a motor vehicle accident. The patient was conscious and his body temperature was 36.6°C, heart rate was 75 bpm, blood pressure was 186/115 mmHg, respiratory rate was 18 breaths/min, and oxygen saturation was 96% (nasal cannula, 1 L). Laboratory data showed elevated troponin I (0.149 ng/mL) and CK-MB (27.3 U/L) levels. Electrocardiography revealed premature ventricular contraction and an incomplete right bundle branch block, but no remarkable findings were observed on echocardiography. Contrast-enhanced computed tomography showed serial fractures from the left fourth to seventh ribs. The sixth rib was protruding into the thoracic cavity toward the heart . The fifth rib was fractured near the heart, and the seventh rib was fractured near the diaphragm. A small pleural effusion, suspected to be a hemothorax, was observed in the left thorax. However, it was not increasing in size; therefore, drainage was not conducted. Surgery was considered to repair the rib fractures. However, extravasation into a liver cyst was identified, and the bleeding needed to be stopped by interventional radiology (IVR) prior to surgery while the patient's vital signs were stable. Nine hours after the injury, following IVR, the CK-MB level decreased to 15.7 U/L, and the troponin I level increased to 1.009 ng/mL. Cardiac injury was suspected and exploratory VATS was immediately performed. The assessment showed that the left ventricular wall was crushed below the injured pericardium on the anterior side of the phrenic nerve . Although the phrenic nerve was intact, the diaphragm was damaged, though no penetrating injury to the abdominal cavity was observed. The coronary arteries were not injured, and there was no bleeding in the damaged area. A fragment of the sixth rib was protruding into the thoracic cavity; however, no pulmonary fistula was observed. The injury to the left ventricular wall did not penetrate deep into the lumen; therefore, it was closed horizontally using a U-shaped suture with 4-0 non-resorbable polypropylene with felt, and covered with collagen-fibrin patch (TachoSil®). The lacerated pericardium was sparsely sutured to prevent cardiac tamponade and hernia. The scattered bone fragments were removed, and the fifth and sixth ribs were repaired using bioresorbable plates (SUPER FIXSORB-MX®) as braces. The diaphragm was not repaired as the injury had not penetrated the abdominal cavity. After placing a 20-Fr. double lumen chest tube to the anterior side and a 28-Fr. single lumen chest tube to the posterior side, the operation was complete. The patient was able to maintain adequate ventilation and oxygenation. He was extubated on postoperative day 2. The chest tubes were removed on postoperative day 4. Paroxysmal atrial fibrillation appeared transiently, but improved after the administration of beta-blockers. The patient's myocardial enzyme levels gradually decreased, and he was discharged from the hospital on postoperative day 16.
+No major abnormalities were noted 3 months postoperatively .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3242_en.txt

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+66-year-old male with a history of smoking, atrial fibrillation and hypertension, who was referred to the thoracic surgery department for a pulmonary nodule found on imaging studies performed during the staging of prostate cancer (Gleason 3 + 4 = 7). A 19.8 mm, bilobed, well-defined margin, pulmonary nodule was observed on a CT scan. A 18F-choline PET scan reported a heterogeneous formation in the prostate with a SUV 5.6 and a bilobed, well-defined margin, pulmonary nodule in the lingular segment of 19.5 mm with a SUV 5.4. The case was discussed in the Tumour Committee and, given the impossibility of ruling out a primary pulmonary neoplasm vs. pulmonary metastasis of prostate cancer, it was decided to perform a systematic pulmonary resection and lymph node sampling. Although the lung is a common site of metastasis of prostate cancer, it is rare for a small-sized neoplasm without other distant (bone) involvement to present a single pulmonary lesion. On the other hand, morphologically, it is not the typical image of a primary pulmonary neoplasm (spiky/irregular borders). The intraoperative study of the nodule was reported as “positive for neoplasm” and, given the difficulty of histological definition, it was decided to perform an anatomical pulmonary segmentation (lingulectomy) to avoid performing a sub-optimal oncological resection of a pulmonary primary and, eventually, preserve parenchyma, if it is a metastasis of prostate. The patient had a normal pulmonary function test and an Eastern Cooperative Oncology Group (ECOG) performance status of 0. The definitive pathological anatomical result was: perivascular epitheloid cell tumour (pulmonary PEComa or clear cell tumour) of 1.4 cm. The tumour did not present necrosis. Immunomarking techniques were performed on paraffin-embedded tissue sections, performed on a BenchMark-XT automatic equipment (Ventana-Roche) for the following determinations: HMB45: focal positive; CD117: negative; TTF1: negative; chromogranin: negative; AML: negative; PAX8: negative; NKX 3.1: negative; CK7: negative; CK 8/18: negative; CK: negative; CD34: positive; synaptophysin: negative; CD68: negative; CD31: negative; ERG: negative; Ki67: less than 1%; S100: negative.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_36_en.txt

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+A 21-year-old virgin female presented to our hospital with complaints of mild abdominal pain, hirsutism, and oligomenorrhea. Her medical history was of interest. The patient had menarche at the age of 13. However, 1 year before admission to our institution, she experienced hirsutism and oligomenorrhea with menstrual cycles of more than 60 days apart. Therefore she visited an external gynecologic clinic where she was prescribed oral contraceptives to regulate her periods. The patient claimed to observe a mild regression in the symptoms with no further examinations. However, details and data supporting her previous admission were not available. The patient’s mother had a hysterectomy several years ago due to the diagnosis of multiple leiomyomas. Other than that, family and medical history were unremarkable.
+On presentation to our institution, physical examination revealed abdominal tenderness with a palpable pelvic mass and mild hirsutism in the thigh. Her body mass index (BMI) was 19.1 kg/m² (height: 150 cm, weight: 43 kg). Interestingly, ultrasonography demonstrated a large left ovarian mass measuring 154 × 104 mm, and compressing the uterus . No pelvic enlarged lymph nodes or Douglas pouch effusion were observed, and computed tomography (CT) scan revealed no other lesions. Due to the large size of the ovarian mass and the risk of compressing the uterus and the adjacent organs, a unilateral salpingo-oophorectomy was performed. Macroscopic examination revealed a large, well-circumscribed lobulated solid yellow-brownish mass, measuring approximately 15 × 9 cm . Cut sections demonstrated bright orange-yellowish nodules with scattered foci of necrosis and hemorrhage and a rich-vasculature capsule .
+Microscopic examination demonstrated diffuse and nodular proliferation of medium-sized to large polygonal neoplastic cells with pale to granular eosinophilic cytoplasm, small round nuclei, and mild atypia . The cells were separated by a vascular stroma, with no evidence of capsular invasion . Few scattered foci of necrosis and hemorrhage were observed , whereas the mitotic rate was less than 2 per 10 high-power fields, and crystals of Reinke were not observed. Thus final diagnosis was a steroid cell tumor-not otherwise specified (SCT-NOS). Immunohistochemistry revealed positivity for Inhibin-a, Calretinin, and ER , whereas CD99, PR, and AR showed negative expression, confirming the aforementioned diagnosis, and expression of Ki-67 was estimated to be less than 20% . Molecular and additional techniques were not available. Following surgery, the patient was hospitalized for 5 days and discharged later with a stable condition and normal laboratory and radiologic results. However, 2 weeks later, she was admitted back to our hospital due to an intermittent localized pain in the right iliac fossa. Full body computed tomography (CT) scan demonstrated a small right ovarian mass that was reported as a benign functional cyst by an expert radiologist and an oncologist, with no other lesions. Due to the patient’s young age and fertility desire, the medical decision was to stay monitored radiographically with no surgical interventions. Two months later, a CT scan demonstrated a prominent decrease in the cyst’s size supporting its benign functional origin. And since her last visit, the patient has been in a stable condition according to clinical and radiologic monitoring with no virilization symptoms. A timeline of the patient’s case can be seen in Fig. .