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data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1023_en.txt

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+In August 2016, a cystoscopically visible protuberant neoplasm of the urinary bladder was found in a 73-year-old man, with clinical manifestation of lower abdominal pain, frequency, urgency and dysuria during urination. Pelvic computed tomography (CT) examination showed a 1.5 cm nodular soft tissue shadow at the left anterior wall of the bladder . The patient then underwent the procedure of transurethral resection of bladder tumor (TURBT). Resected sample was formalin fixed, paraffin embedded. The tissue blocks were cut into 3-μm sections, which were stained with hematoxylin and eosin. Microscopic examination showed the neoplasm was composed of spindle or ovoid-shaped cells that formed storiform, nested or swirling patterns. It involved mucosa and submucosa layers. The neoplastic spindle cells had indistinct cytoplasmic borders, a moderate amount of lightly acidophilic cytoplasm, round or ovoid nuclei with a thin nuclear membrane and small nucleoli. Abundant mitotic Figs. (30 mitoses/10 high-power fields) and apoptotic bodies were present, with no necrosis and hemorrhage. Multinucleated cells and pleomorphic cells were also seen. Some mature lymphocytes infiltrated between tumor cells and in perivascular spaces . The residual lymphoid tissue was limited to small follicles.
+Immunohistochemical stains were performed in our laboratory, utilizing an avidin biotin peroxidase complex method. Heat-induced antigen retrieval was performed and then the tissue was incubated with antibodies. Mouse monoclonal anti-human antibodies against CD3, CD5, CD20, CD21, CD23, CD30, CD56, CK, CK7, EMA, HMB45, Melan A, SMA, Vimentin, rabbit polyclonal anti-human antibodies against S-100, were purchased from Leica company. Mouse monoclonal anti-human antibodies CD35, D2–40, Desmin, Ki-67, MPO, P63, GATA-3, P16, P53, EGFR, ALK, CK5/6, rabbit polyclonal anti-human antibodies against CK20, P40, TFE-3, Uroplakin, were purchased from ZS company. Mouse monoclonal anti-human antibody BRAF V600E (VE1) was purchased from Roche company.
+The tumor cells were positive for CD21 and vimentin, partly positive for CD23, D2–40 and CD35. The tumor cells were negative for CK, CK5/6, EMA, CK7, CK20, P63, P40, Uroplakin, Desmin, SMA, S100, TFE-3, HMB45, MelanA, MPO, ALK, CD3, CD5, CD20 and CD30. Ki-67 was expressed in about 30% of the tumor cell nuclei . Silver staining demonstrated abundant fibers circumfused each tumor cell. The pathological diagnosis of follicular dendritic cell sarcoma was given based on the morphology and immunohistochemistry.
+Six weeks later, the tumor recurred, which appeared widely based, deeper than the primary surgical scar and was about 1.5 × 2 cm in size. A second transurethral resection was performed and microscopically the FDCS still could be seen in bladder mucosa and submucosa. FDCS tumor cells were similar to those seen in the previous sample, which were spindle-shaped with round or ovoid nuclei with small nucleoli. But the number of mitotic Figs. (10 mitoses/10 high-power fields) was lower than that of the first sample. However, the tumor cells were found to infiltrate in muscularis propria. It was surprising that there was also an invasive urothelial carcinoma that was mixed with the FDCS. The UC of bladder infiltrated in mucosa and submucosa. The tumor cells of UC were arranged in nest or cord pattern, the cytoplasm was acidophilic and the nuclear were irregular. . Using immunohischemistry, UC were positive for CK, CK20, P63, GATA-3, negative for CD21, CD23, CD35 and D2–40. Otherwise, FDCS were positive for Vimentin, CD21, CD23, CD35 and D2–40, negative for CK and CK20. . UC and FDCS were both positive for P16, P53 and EGFR, and both negative for BRAF.
+Because the second resection site was closed to the first one, we suspected the first sample might have been associated with urothelial carcinoma that was undetected in the first sample. We then obtained deeper levels of the initially resected tumor. Indeed, we identified the urothelial carcinoma in the deeper levels, which was coexisting with FDCS . After the second surgery the patient was treated with chemotherapy. At the time of writing this report, the patient had haven another relapse of urothelial carcinoma and one relapse of follicular dendritic cell sarcoma.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1029_en.txt

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+Our patient is a 66-year-old Eritrean gentleman, who presented to our emergency department with severe epigastric pain and a history of a growing abdominal wall mass. On systematic review, he reported anorexia and weight loss, with no history of alteration in bowel habits. The patient had no significant past medical history apart from this presentation.
+Ten days prior to his presentation to our institution, he underwent an incision and drainage procedure of an abdominal wall abscess at an outside institution. The patient was discharged with outpatient dressing protocol and oral antibiotics.
+On examination, the patient was thin and cachectic, with a large tender warm swelling occupying the supraumbilical and epigastric regions. It measured about 10 × 15 cm in greatest dimension. There were two ulcerations on the surface of the swelling draining purulent discharge corresponding to the incisions done previously . There was no evidence of peritonitis or other significant physical findings.
+Laboratory results revealed a hemoglobin level of 5.7 g/dl (normal range: 14–18), white blood count level of 13.3 K/µL (normal range: 4.5–11.5), and carcinoembryonic antigen (CEA) level of 12.99 ng/ml (normal range: 0–3.4). Coagulation profile and liver function tests were within normal ranges. Wound culture showed mixed bacterial growth of Escherichia coli and Klebsiella pneumoniae.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1041_en.txt

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+A 54-year-old woman was referred to our center due to right ventricular enlargement which was incidentally detected on pre-operative echocardiography for ankle surgery at a local clinic. The patient was asymptomatic and in normal sinus rhythm. A transthoracic echocardiography (TTE) showed a large secundum ASD with a diameter of 17 mm. A transesophageal echocardiography (TEE) was performed and showed 20 × 23 mm secundum ASD with left to right shunt and right ventricle (RV), right atrium (RA) enlargement . The patient had a D-shaped small left ventricle (LV) with a left ventricular ejection fraction of 59%. Mitral valve leaflets were normal with no MR detected . Moderate tricuspid regurgitation (Grade II) due to dilated tricuspid valve annulus (46 mm) and mild pulmonary hypertension were observed. The rims to both sides of the superior vena cava and inferior vena cava were short, thus surgical repair of ASD under mini-thoracotomy was planned.
+In the operating room, standard vital signs (pulse oximetry, end-tidal carbon dioxide, electrocardiogram, and non-invasive blood pressure) were monitored. The left radial artery was catheterized for continuous arterial blood pressure monitoring. After 3 min of 100% pre-oxygenation, general anesthesia was induced with midazolam (3 mg) followed by continuous infusion of propofol with remifentanil, and bolus administration of rocuronium (50 mg). The patient was intubated with a 35 Fr left-sided double-lumen tube for one-lung ventilation. A central venous catheter was inserted via the right subclavian vein because the right internal jugular vein was reserved for superior vena cava cannulation for cardiopulmonary bypass (CPB). A TEE probe was inserted to permit close observation.
+Right anterolateral mini-thoracotomy was done via 4th Intercostal space. Following full anticoagulation with heparin given at a dose of 300 IU/kg, CPB was instituted using femoral artery, femoral vein and right internal jugular vein cannulation. Next, the aortic Detachable Glauber clamp (Cardiomedical GmbH, Germany) was deployed for aortic cross-clamp, and 2000 mL of Custodiol® HTK (Koehler Chemie, Bensheim, Germany) solution was infused through aortic root cannula for myocardial protection. Moderate Hypothermia of 31.5 °C was permitted as measured by nasopharyngeal and rectal probes. Subsequently, right atrium was opened and ASD was closed with a trimmed bovine pericardial patch. Tricuspid ring annuloplasty and right atrium reduction plasty were also conducted. After completion of the operation, right atrium was closed and CPB was weaned.
+Intra-operative TEE showed that ASD was closed with no remnant inter-atrial shunt. There was no tricuspid regurgitation and left ventricular ejection fraction was 55%. Newly developed Grade II MR with end-diastolic rightward deviated inter-ventricular septum was detected which was not found in pre-operative echocardiography . We notified the surgeon of the newly developed MR. Because no abnormal findings, such as mitral valve prolapse, perforation, or chordae rupture, were observed in the mitral valve leaflets, it was determined that the surgery should proceed. No further adverse surgical events occurred throughout the remainder of the surgical procedure. The surgery lasted for 345 min with the CPB time of 190 min and aortic cross-clamp time of 140 min. The estimated blood loss of 800 ml. After surgery, the patient was transferred to the Intensive Care Unit. Bilateral lung haziness due to acute MR was observed in the immediate post-operative chest x-ray. Otherwise, the vital signs were stable without complaint of any symptoms. The patient was extubated after 3 h on arrival of the intensive care unit and transferred to general ward on postoperative day (POD) 1.
+Transesophageal echocardiography on POD 3 confirmed that the ASD patch was intact without shunt flow or remnant tricuspid regurgitation. Both left and right ventricular function was well preserved with left ventricular ejection fraction of 69%. However, LV diastolic dysfunction (E/E’ = 26) and aggravated pulmonary hypertension which was not observed in the preoperative TEE was found. The MR was shown to have deteriorated to severe level without evidence of vegetation or chordae rupture . Because the patient was asymptomatic, conservative treatment using diuretics and close monitoring was determined to be the best course of action. Daily follow-up chest x-ray showed gradual improvement in pulmonary edema. On POD 6, the patient was discharged and attend follow-up outpatient appointments. On POD 10, TTE was evaluated. MR disappeared to trivial level and the LV chamber size and deviated septum became normalized .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1052_en.txt

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+A 57-year-old Greek man was referred to our facility with pain, hemorrhage and a gangrenous smell due to a so-called wound on his penis. A physical examination revealed the complete absence of his penis and a large chasm in the lower abdominal wall, which made it possible to see parts of the lower pelvis, such as the spermatic cords, the destroyed basis of the corpora cavernosa and the residual stump of the urethra. The scrotum and the testicles were stiff and were possibly invaded by the cancer. In the chasm margins, we could detect hemorrhagic and necrotic areas . The inguinal lymph nodes were palpable, hard and mobile. Our patient was in a good general condition and his body temperature was normal. From his medical history, he had discovered a lesion in his inner prepuce 18 months before. He had requested medical advice at a private health center concerning that lesion. According to his recollection, a biopsy had been taken and he was diagnosed as having penile cancer (this biopsy could not be found, as he did not ask for a copy of it at the time and the private health center failed to track our patient's data as he was never hospitalized there). The physicians at the time suggested he should undergo a partial penectomy, but he refused and stopped seeking medical treatment.
+The lesion slowly progressed, eventually involving the whole penis. He could not specify the exact time his penis sloughed off completely. He was not circumcised. Standard laboratory test results showed that his values were within normal limits except for a small rise in white blood cell count (14,750 cells/μL) and microcellular anemia (hemoglobin = 9.8 g/dL, hematocrit = 31.2%). A chest X-ray did not show any remarkable findings. An abdominal computed tomography (CT) scan showed lymph nodes of a pathological size and number, bilateral in the iliac vessels and inguinal areas as well as an erosion of the pubic bone . We proceeded with a chest CT scan, which did not show any distant metastases or lymph nodes. On the first day of his hospitalization, we obtained biopsies from the chasm margins and identified a poorly differentiated SCC. The clinical staging was T4N3M0 and our patient was treated with chemotherapy and regional radiotherapy. We also performed a bilateral cutaneous ureterostomy, with a Gibson incision in order to protect the corroded tissues from further urine impregnation . From a combination of regional radiotherapy and bilateral cutaneous ureterostomy, total dryness of the wound was achieved. During his extended hospitalization, he presented with deep vein thrombosis in the right shin vein and seizures that were attributed to small ischemic brain strokes after a brain CT scan. Debulking and flap coverage of the wound was not considered possible, firstly because of deep vein thrombosis, epileptic seizures and his poor general condition increased the risk from operation and secondly the size of the chasm combined with very poor vascularization of the region (a topical angiography was performed). Gradually, our patient developed depression, denial of feeding and loss of weight. He died 18 months after his first admission and six months after his last follow-up admission to our clinic.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1083_en.txt

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+A 69-year-old female, who presented with cAVB (, A-1), was referred to our
+hospital. Her past medical history was hypertension and dyslipidaemia, and she had
+been prescribed calcium channel blocker and statin. This time she had a history of
+syncope and exertional dyspnoea. Transthoracic echocardiography (TTE) revealed
+normal cardiac function [left ventricular ejection fraction (LVEF): 67.2%,
+Video ] and no
+significant valvular heart disease. Dual-chamber pacemaker (PM) was implanted via
+the left subclavian vein (, B-1). She was discharged on Day 8 without any
+complications. One and a half months later (on Day 43), she presented with
+exacerbation of shortness of breath and orthopnoea. TTE demonstrated akinesis in the
+anterior wall, cardiac dyssynchrony, and LVEF at 47.7% (Videos and , Video S). Chest radiography showed mild congestion (, B-2). Laboratory
+tests showed increased brain natriuretic protein (BNP) at 3352.3 pg/mL
+(reference value 0–18.4 pg/mL) and myocardial deviation enzymes
+[creatinine kinase (CK): 639 U/L (reference value
+42–135 U/L), CK-MB: 39 U/L (reference value
+0–25 U/L), troponin I: 20.58 ng/mL (reference value
+0–0.045 ng/mL)], and normal kidney function (estimated glomerular
+filtration rate: mL/min/1.73 m2). Acute coronary syndrome was suspected,
+and emergent coronary angiography was performed. However, the coronaries had no
+significant stenosis, and she was diagnosed with worsening HF and was hospitalized.
+Her HF status did not improve after receiving drugs for HF, such as diuretics and
+dobutamine. Intra-aortic balloon pump was inserted on Day 48, and TTE demonstrated
+worsening LVEF. We considered the possibility of the negative effect of right
+ventricular (RV) pacing on cardiac function, hence, on Day 50, her PM was upgraded
+to cardiac resynchronization therapy (CRT). TTE showed partial resynchronization,
+however, her respiratory status worsened mainly because of the fatigue and weakness
+of respiratory muscles. On Day 52, she was intubated with mechanical ventilation
+support (,
+B-3). Tracheostomy was performed on Day 70. On Day 65, EMB was taken from her RV
+septum. The specimens demonstrated several giant cells, no granulomas, and diffuse
+myocardial interstitial fibrosis . Laboratory test results revealed normal
+angiotensin-converting enzyme and lysozyme levels. Her laboratory markers ruled out
+some autoimmune disorders (systemic lupus erythematosus, polymyositis,
+dermatomyositis, Sjögren’s syndrome, rheumatoid arthritis,
+vasculitis, autoimmune thyroid disorder, and myasthenia gravis). Whole-body computed
+tomography showed no sign of sarcoidosis, such as hilar lymphadenopathy. Finally,
+she was diagnosed with GCM. She was prescribed prednisolone (PSL) 60 mg
+daily on Day 71 and ciclosporin 100 mg daily on Day 85. Subsequently, her
+BNP decreased . EMB was taken from her RV septum twice more (on Days 86 and
+124, three specimens/procedure), and the specimens demonstrated no giant cells and
+less apparent myocardial fibrosis . TTE showed no LVEF improvement (modified Simpson
+method) (from 37.2% at the beginning of PSL to 28.8% at discharge)
+.
+However, RV function significantly improved based on fractional area change (FAC)
+[from 17.5% at the beginning of PSL to
+46.7% at discharge ( and , Videos S3 and S4)].
+Intake of PSL was decreased to 30 mg daily upon discharge (tapered speed of
+5 mg/week). She has not experienced any exacerbation of HF. Chest
+radiography showed no signs of lung congestion (, B-4). She was transferred to a
+rehabilitation hospital on Day 141. The maximum values of CK, CK-MB, troponin I, and
+BNP during the HF hospitalization were 7444 IU/L (on Day 51),
+228 IU/L (on Day 51), 101.33 ng/mL (on Day 56), and
+4281.2 pg/mL (on Day 67), respectively. The HF drugs at discharge from our
+hospital were carvedilol 7.5 mg daily, perindopril 2 mg daily,
+furosemide 30 mg daily, spironolactone 25 mg daily, and tolvaptan
+7.5 mg daily. She still continued rehabilitation at the rehabilitation
+hospital 3 months after the discharge from our hospital.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1109_en.txt

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+A 3-year-old girl was brought by her parents to the neurosurgery department with complaints of difficulty walking for 4 months. The patient had a backward bending posture while walking. She swayed to one side and dragged her right lower limb. She also had difficulty wearing her slippers. She was not able to bend forward or sit for a long duration of time. Ten months ago, she had a history of headaches that lasted for a week. The patient also had urinary incontinence for 4 months. The patient had one episode of seizures post which she developed lower limb weakness. There was no history of trauma to the spine and no history of coming in contact with a patient who had TB. The patient was vaccinated according to the World Health Organization schedule. The patient had a history of pneumonia at the age of 1 month, following which she was admitted to the intensive care unit for 1 week.
+On examination, vitals were stable. Neurological examination showed that the tone of both lower limbs was increased. Plantar reflexes were extensor bilaterally. A magnetic resonance imaging (MRI) from an outside clinic showed a hyperintense intramedullary lesion, on T2W imaging, from T6 to T9 . On sagittal T1W imaging, with contrast, there was a fusiform dilation of the cord at the same levels with no enhancement. A similar finding was present on the axial cuts . The scan also showed hydrocephalus. However, on examination, there were no signs of raised intracranial pressure (ICP). The child underwent a T6 to T9 laminoplasty with intramedullary lesion decompression under neuromonitoring. Intraoperatively, the lesion was yellowish, fibrous, and densely adherent to underlying cord and nerve roots. Hence, only debulking of the lesion was performed. Postoperatively, mild deterioration of motor power in both lower limbs was noted. Histopathological examination of the lesion showed features suggestive of tuberculous granulomatous inflammation .
+The diagnosis was then established. A pulmonology consultation for initiation of antitubercular treatment (ATT) was taken. The child was started on ATT and was subsequently discharged after being symptomatically better. The patient was reviewed 8 months after her initial visit while still on ATT, and she showed improvement in her gait abnormalities and is walking with support. The review scans showed complete resolution of the lower lesion but now showed evidence of chronic arachnoid adhesions at the T3 level. A CT brain performed at the same time showed evidence of hydrocephalus, most likely noncommunicating in nature . This may be due to tubercular meningitis or arachnoiditis. The patient was advised to continue her ATT and was discharged.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1117_en.txt

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+A 2 year-old boy was referred to our pediatric department for a 10-month’s history of thrombopenic purpura which failed to respond to conventional therapy with corticosteroids. The patient was born from healthy and no consanguineous parents. The medical history revealed an episode of anemia at the age of 1 month which required blood transfusion but no previous history of diarrhea. On admission, physical examination showed, fever at 38°C, skin purpura and no neurological impairment. The platelet count was 9×109/l; hemoglobin level was at 6.8g/dl with marked reticulocytosis. Direct coombs test was negative and the lactate dehydrogenase rate was at 2314 IU/l. The blood film revealed numerous schistocytes and microspherocytes. Mild proteinuria and hematuria were detected but the renal function was preserved. Coagulation tests were normal. Regarding, the absence of previous diarrhea, and renal insufficiency, the diagnosis of atypical HUS was reported. Hemoglobin level has normalized (10.9g/dl) after one blood transfusion while platelet count remained low at 35 ×109/l. TTP was then suspected; the patient was treated with 20ml/kg of fresh –frozen plasma, which promptly resulted in total recovery of thrombocytopenia (152×109/l). He was discharged after improvement. Twenty days later, he relapsed a new hemolytic episode which improved with a new plasmatherapy. Further investigations revealed a severe deficiency of ADAMTS 13 activity (level< 5%), ADAMTS 13 antigen was undetectable (< 65ng/l; kit American Diagnostica, Stamford, USA). No inhibitors for ADMTS 13 were found. For genetic analysis, all 29 exons with flanking intron-exon baoundaries of the ADAMTS 13gene were amplified and sequenced. The propositus was found to be homozygous for a new mutation: c 2203 G>T-p.Glu735X (domain TSP1-2) in exon 18. The patient’s family sequencing gene couldn’t be performed but no members had a history of a TTP-like disorder, thrombosis or bleeding episodes. Since, the diagnosis of congenital TTP was confirmed; the patient was placed on prophylactic regimen with regular infusions of FFP. During 4 years of follow-up, only one hemolytic crisis occurred at starting therapy. This event led us to reduce the intervals between infusions from 4 weeks to 3 weeks. Small volumes (10ml/kg) of FFP were able to prevent crises. Actually, at 6 years of age, the patient has a normal physical and mental development. The renal function is still normal.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1145_en.txt

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+A 77-year-old man fell from a height of approximately 3 m into the gutter and struck his pelvis. He was found immobile and was rushed to our hospital.
+Medical history: none.
+Physical findings: Consciousness was clear, blood pressure was 100/70 mmHg, heart rate was 127/min, SpO2 was 97%, and no injury was noted on either the head or abdomen.
+As shown in Table , blood work (day 1) showed Hb12.7 g/dl, but no increase in cell ectopic enzymes was observed.
+CT findings on day 1 revealed a right pelvic fracture and a haematoma in the pelvic extraperitoneal space . Neither free air nor ascites was observed in the abdominal cavity, and no damage was found to the intestinal tract. CT findings on day 2 showed the haematoma in the pelvic extraperitoneal space had increased in size from the previous day, and active bleeding was suspected. Blood work from day 2 demonstrated progression of Hb10.3 and anaemia, even after transfusion of 4 units of red blood cells . For vitals, blood pressure was 78/37 mmHg, and heart rate was 144 bpm, indicating shock, and active bleeding due to the pelvic fracture was suspected. Therefore, transcatheter arterial embolization (TAE) was adopted. Blood flow in the pelvis is supplied from both sides, and the presence of traffic branches may require TAE of the internal iliac arteries on both sides depending on the situation. Angiography identified the responsible vessel, which had embolized the bilateral internal iliac arteries, and confirmed haemostasis.
+CT findings on day 3 revealed thickening of the ascending colon wall, intramural emphysema, and a slight amount of air in the mesenteric vein. In addition, a small amount of ascites was observed near the ascending colon. There was no problem with the contrast effect of the small intestine, and the sigmoid colon was dilated, but there were no obvious necrotic findings. .
+Blood work on day 3 revealed elevated levels of cytopathic enzymes: AST 2363 IU/l, ALT 2233 IU/l, LDH 3181 IU/l, and CPK 4122 IU/l. Based these findings, we rendered a diagnosis of necrosis of the ascending colon and performed emergency surgery.
+Intraoperatively, necrosis was observed in the serosa of the ascending, transverse, and sigmoid colon. Subtotal resection was performed from the ileocecal region to the sigmoid colon. After confirming that there is no necrosis in the mucosa of cut end of small intestine, ileostomy was constructed. Although a slight ischaemic change such as edema and mild redness was observed in the serosa of the entire small intestine, we decided to preserve the entire intestine.
+Excised specimen findings showed scattered necrosis in the ascending, transverse, and sigmoid colon .
+Pathological findings indicated necrosis throughout all layers of the intestinal wall in the ascending, transverse, and sigmoid colon.
+Postoperatively, the patient began drinking water 2 days after surgery. However, 6 days after surgery, CT revealed a dilated small intestine, which we diagnosed as paralytic ileus. Subsequently, the paralytic ileus did not improve, and melena was observed 10 days after surgery. CT performed 10 days after surgery revealed extensive small bowel dilation and niveau. In addition, wall thickening and a decrease in contrast effect were observed in partial small intestines .
+We diagnosed haemorrhage due to necrosis of the residual small intestine. However, due to the postoperative total colectomy and deterioration of general condition, it was decided that intestinal resection was impossible, and treatment with blood transfusion and haemostatic agents was planned. At that time, the colour of stoma did not change greatly and there were no necrosis sites.
+The patient's condition gradually worsened even after treatment, and over time, he developed liver and renal dysfunction and died 16 days after surgery.
+NOMI is a disorder that causes irreversible ischaemia in the intestine, resulting in intestinal necrosis, despite the absence of organic obstruction in the mesenteric artery trunk. This phenomenon was first reported by Heer and includes the following characteristics: (1) no obstruction in the mesenteric arteries or veins governed by intestinal necrosis, (2) segmental discontinuity of intestinal ischaemia and necrosis, and (3) pathological evidence of intestinal haemorrhage and necrosis. We define NOMI as satisfying these conditions. From 12 to 25% of acute intestinal ischaemia is thought to be due to NOMI in Europe and America [, ]. Various triggers increase hypoxia of the intestinal tract tissue, reduce cardiac output, and decrease circulating blood volume. As a result, the sympathetic nerves in the peripheral blood vessels of the mesenteric artery overreact, causing vasospasms and intestinal ischaemia. Since these spasms occur at random, the ischaemic area is sporadic. Fogaty suggests that severe congestive heart failure, digitalis intoxication, and blood concentration are important factors affecting this disorder and that dehydration is significantly related to vasopressin due to low cardiac output, haemorrhage, and shock. He asserts that vasopressin and angiotensin increase in the blood due to low cardiac output, haemorrhage, shock, etc., causing catecholamine-induced spasms of the mesenteric artery and resulting in NOMI. In addition, the general risk factors for NOMI are increased age, heart disease, arrhythmia, cerebrovascular disease, diabetes, burns, dialysis, dehydration, haemorrhage, and pancreatitis [–]. In any case, the basis of the pathology is considered a decrease in circulating blood volume. Pelvic fractures generally cause excessive bleeding in trauma, anywhere from 1000 to 4000 ml . In our patient, bleeding from a pelvic fracture caused a rapid decrease in circulating blood volume, and at one point, the patient was in shock. TAE was performed for active bleeding, and NOMI developed the next day, although haemostasis was attained. When a pelvic fracture with a large volume of blood loss occurs, the risk of NOMI onset should not be ignored.
+NOMI has no specific symptoms. Some of the many non-specific symptoms include abdominal pain, vomiting, abdominal distension, and melena, but these symptoms are often mild during onset. In particular, it is difficult to identify these symptoms in cases of sedation, analgesia, and consciousness disorder. In these cases, diagnosis is likely to be delayed. Similarly, in our case, it was difficult to diagnose intestinal ischaemia based on clinical symptoms, because analgesics are used for pelvic fractures, and systemic contusions are caused by trauma. Blood work showed an increase in deviant enzymes, but the diagnosis was made even more difficult after TAE was performed for active bleeding. In our case, follow-up CT was performed to identify active bleeding, but it is important to consider CT examination as necessary, keeping in mind that NOMI is caused by bleeding from trauma.
+When NOMI is considered as a diagnosis, one of the treatments is injection of a vasodilator into the responsible blood vessel using angiography , but this method is limited by equipment availability and the specific situation. In our case, a vasodilator could not be used due to instability of vital signs from bleeding. If intestinal necrosis is already suspected, as in our case, immediate surgical intervention is needed. At the time of surgery, it is important not only to remove the necrotic intestine but also to evaluate the viability of the remaining intestine. Intestinal ischaemia can be extensive postoperatively, and care must be taken in determining the extent of resection. When deciding the extent of resection, there is a method of observing changes in the colour tone of the mucous membrane using an intraoperative lower gastrointestinal endoscope and blood flow evaluation by fluorescein fluorescence [, ]. However, these methods may be difficult depending on equipment availability and the situation. In our case, we found clear discontinuous necrosis in the serosa of the caecum, transverse colon, and sigmoid colon. Therefore, we decided to remove the intestinal tract from the ascending colon to the sigmoid colon. Since only diffuse and mild oedema and redness in the small intestine were noted and no obvious necrosis was observed, we decided to preserve it and constructed an artificial anus in the terminal ileum. However, the small intestines became necrotic after a few days, eventually resulting in widespread intestinal necrosis. Of note, the prognosis cannot be judged only by the surgical findings. If long-term dilatation of the small intestine is observed after heavy bleeding, it is important to consider intestinal necrosis rather than assuming it as paralytic ileus. In that case, it is necessary to comprehensively judge clinical symptoms, vital signs, and imaging findings, but the diagnosis is very difficult. Importantly, pelvic fractures are typically accompanied by high blood loss, so even if active bleeding subsides and vital stability is obtained, NOMI may develop over time.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1158_en.txt

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+Registering a cleft lip and palate at 26 wk of gestation and delayed motor development at 2 years of age.
+The patient, a 2-year-and-8-month-old Mexican girl, was brought by her parents for evaluation because of delays in her motor and language development and congenital malformations. Currently, her motor development is abnormal without head control, she still does not sit down. She also does not speak any words and often becomes ill from the respiratory tract without any serious complications.
+The proband was the third child of two healthy, unrelated, and young parents (27 and 26 years old at the time of delivery). Their familial history was negative for congenital malformations or intellectual disability. The mother had prenatal care, registering a cleft lip and palate at 26 wk of gestation. The proband was born by cesarean section at 38 wk of gestation with a weight of 3035 g (25th percentile), a length of 50 cm (25th–50th percentile), an OFC of 33 cm (10th percentile), and Apgar scores of 81 and 95. She did not require neonatal management.
+Their familial history was negative for congenital malformations or intellectual disability.
+Upon physical examination, her weight was 9.2 kg (< 3rd percentile), her length was 87 cm (3rd–10th percentile), and her OFC was 46 cm (< 3rd percentile). She had microcephaly, upward-slanting palpebral fissures, a depressed nasal bridge, a bulbous nose, and a bilateral cleft lip and palate .
+Blood, urine, and thyroid profile analyses were normal. The karyotype was 46, XX.
+The abdominal ultrasound was normal. The brain magnetic resonance imaging showed cortical atrophy, pachygyria, microgyria and band heterotopia .

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+A 34-year-old man, previously in good health and predominantly right-handed, arrived at the ED with a chief complaint of left arm pain following a martial arts activity. The pain occurred suddenly when his left arm was in a hyper-flexed position at the elbow while being forcefully extended by another individual. Upon examination, vital signs were within normal ranges. The musculoskeletal assessment revealed a semi-flexed position of the left elbow, accompanied by bruising on the medial aspect of the distal left arm and ventral aspect of the proximal forearm . There was tenderness at the antecubital fossa and the patient was unable to flex his elbow against the resistance. The Hook test was also positive. The distal neurovascular examination was within normal limits.
+The emergency medicine fellow performed a PoCUS. The patient was positioned supine with his arm semi-flexed. A high-frequency linear array transducer was selected with a musculoskeletal preset. The transducer was placed longitudinally over the ventral surface of the distal left arm to identify the biceps muscle and slid towards the forearm with the marker facing toward the cephalad. The PoCUS showed the disruption of linear tendon fibers with surrounding hypoechogenicity, likely representing blood at the distal musculotendinous junction . An arm sling was applied, and the patient was discharged on oral analgesics with advice to follow up in the orthopedic clinic. A formal ultrasound appointment was booked for the next day.
+A radiology-performed ultrasound confirmed our PoCUS finding. The patient was presented with a choice between conservative (non-surgical) and surgical management based on the confirmed diagnosis. The patient elected to proceed with surgical management. After a week, a surgical procedure was performed to repair the distal biceps tendon rupture.

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+A solitary pulmonary nodule on the left upper lobe was detected as an incidental finding in a 58-year-old Caucasian woman who was a former smoker with a cumulative exposure of 50 pack-years. She had no other significant history and there was no reason to suspect that she could be immunocompromised. Lung cancer was suspected and an upper left lobe resection was performed two months later and the stumps were sutured with synthetic thread. The pathologic diagnosis was small cell lung carcinoma.
+Postoperative chemotherapy and whole-brain radiation therapy were administered and the clinical course was uneventful for two years until a slight rise in serum carcinoembryonic antigen (CEA) and CA 125 levels was detected. A PET-CT scan revealed two foci of increased FDG activity adjacent to left hilar lymph nodes (maximum standardized uptake values [SUVmax] of 10.3 and 8.3, respectively; Figure ) and local recurrence was suspected. A necrotic lesion at the left upper lobe bronchial stump was identified at bronchoscopy and an endobronchial biopsy was obtained. Pathologic examination revealed chronic inflammation and granulation tissue and numerous hyphae with the appearance of Aspergillus species but no sign of malignancy. Cultures were positive for Aspergillus fumigatus and antifungal therapy with itraconazole was started and continued for three months. Improvement was remarkable both on a follow-up PET-CT performed two months later (SUVmax of 4.3 and 3.2, respectively; Figure ) and a subsequent bronchoscopy, during which fragments of suture were recovered along with biopsy material. Cultures of the material obtained after this bronchoscopy were negative. The patient was followed up once a month for one year after treatment was stopped and there were no signs of recurrence of either the infection or the cancer.

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+A 32-year-old man with no pertinent medical history presented to the emergency department with acute coughing up of 300 ml of bright-red blood over 3 hours following a sneezing episode. The patient was a taxi driver and had no history of cigarette smoking, alcohol drinking, upper airway complaints, chest trauma, or use of aspirin or non-steroidal anti-inflammatory drugs. Also, he denied prior hemoptysis or other pulmonary symptoms, infectious symptoms, or a family history of hemoptysis or brain aneurysms.
+His temperature was 36.8 degrees Celsius, pulse was 88 per minute, respirations were 18 per minute, and blood pressure was 128/88 mmHg. Pulse oximetry showed an oxygen saturation of 98% in the room air. The results of physical examination were unremarkable. The complete blood count, the levels of urea nitrogen and creatinine, liver biochemistry, and coagulation profiles were also normal. Urinalysis revealed no abnormalities. A chest X-ray showed an ill-defined opacity around the left hilum and chest CT demonstrated soft-tissue opacity within the left mainstem bronchus with a needle-shaped material protruding from it. A retained tracheobronchial foreign body was suspected. Flexible fiberoptic bronchoscopy found impaction of a dental floss pick in the left main bronchus with granulation tissue formation and clotted blood over it. The object was successfully removed using biopsy forceps and no procedure-related complications, such as tracheal laceration, vocal cord injury or bleeding, were noted. After foreign body retrieval, the patient recalled having had dental floss pick ingestion 8 years earlier. He still uses dental floss picks to clean his teeth every day. He no longer had hemoptysis during his hospital stay and he was discharged a few hours later.

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+A previously healthy 24-year-old male (A) presented at the emergency department (ED) with chest pain and diarrhoea. The chest pain began 2 h prior to hospital admission and was described as a constant light chest pressure without correlation to breathing or body position. 3 days earlier, the patient and a friend had had chicken in a restaurant before boarding a flight to Sweden. One hour after arrival in Sweden the patient experienced sudden abdominal pain, chills and diarrhoea. During the following three days the patient had 6 diarrhoeas per day, mucous but no visible blood. The patient was diagnosed with C jejuni gastroenteritis after stool culture at a primary care facility, no antibiotics were given. Upon admission to the ED the abdominal pain had subsided, the patient was afebrile (37 °C or 98.6 °F) but still experiencing diarrhoea. Upon examination the patient had normal circulatory and respiratory parameters. Heart auscultation: regular rhythm (RR), no murmurs or extra sounds. Lung and abdominal examinations were normal. Laboratory examinations showed C-reactive protein (CRP) at 89.1 (normal range <10 mg/L), leukocyte count (LC) at 11.3 (normal range 4-12 × 109/L) and high-sensitive Troponin T (hsTnT) at 108 (normal range <14 ng/L) ECG showed regular sinus rhythm, 64/min and general 1 mm ST-elevation . The patient was treated with Brufen 200 mg (tid), Omeprazol 20 mg (qd) and Loperamid 2 mg and admitted to a cardiac care unit (CCU) for cardiac monitoring.
+During the following 4 days the hsTnT reached a maximum value of 504 and then dropped to 46. Stool culture confirmed the diagnosis of C jejuni. Blood cultures were negative. Transthoracic echocardiogram (TTE) showed normal right and left ventricle function, ejection fraction (EF) 60–65 %, normal valvular structure and function, no hypokinesia or pericardial effusion. After on day the ECG-changes had resolved. The patient was started on ciprofloxacin but developed urticarial rashes and severe itching and the treatment was discontinued. The chest pain subsided after 2 days and the patient left the hospital after 4 days. The patient was given a 10 day prescription of Azithromycin 500 mg (qd) upon hospital release. The diagnosis was determined to be C jejuni-associated perimyocarditis (CPM). At follow-up visit 4 weeks after discharge the patient was without complaints, physical examination was normal and both ECG and TTE were normal.

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+A 25-year-old male with no pertinent past medical history presented to the ED by ambulance with obvious right wrist deformity following a high-speed motor vehicle collision as a restrained driver. The patient had braced his outstretched hand against the steering wheel during vehicular impact, resulting in traumatic injury to the wrist. His vital signs on arrival were within normal limits, but he was in significant distress, rating his pain as a 10/10. Physical examination revealed a grossly deformed right wrist with dorsal swelling and severe tenderness to palpation, but no evidence of neurovascular compromise. Radiographs of his right wrist revealed a transverse fracture of the distal radius with dorsal angulation of the distal fragment (Colles fracture), as well as an ulnar styloid fracture.
+Despite receiving opioid and nonsteroidal anti-inflammatory analgesia, the patient still reported intractable, severe pain with intolerance of radial manipulation. To avoid procedural sedation, an ultrasound-guided CCBPB was performed to augment patient analgesia and facilitate reduction (–, ).
+Informed consent for CCBPB performance was obtained, and the patient was placed on a cardiac monitor with intravenous access established. The patient was positioned supine with the right arm abducted 90 degrees to stretch the pectoralis muscles and bring the costoclavicular brachial plexus more superficial toward the skin surface. The patient was prepped and draped in the standard manner, and sterility was maintained for the duration of the procedure. A high-frequency linear ultrasound probe was oriented transversely just inferior to the midpoint of the right clavicle in the infraclavicular fossa. The probe beam was angled slightly cephalad to visualize the costoclavicular space posterior to the clavicle. The costoclavicular brachial plexus cords were identified just lateral to the axillary artery and between the subclavius and serratus anterior (upper slips) muscles. An in-plane, lateral-to-medial approach was used to guide a 22-gauge, 50-millimeter echogenic block needle between the lateral and posterior cords. Twenty milliliters of 0.5% ropivacaine were injected perineurally around the brachial plexus cords. The procedure was performed without complications.
+Fifteen minutes post-block performance, the patient had dense sensorimotor blockade of the right upper extremity and reported his pain at 0/10. Despite aggressive manipulation, the patient reported no pain, and successful reduction of the distal radius fracture was achieved. A sugar-tong forearm splint was applied, and the patient was discharged from the ED with outpatient orthopedic surgery follow-up. On telephone inquiry the next day, the patient reported no numbness, tingling, or residual sensorimotor deficit.

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+A 57-year-old Japanese woman presented with a 1.5-year history of right hip pain when she walked long distances. She had a history of bilateral developmental dysplasia of the hip and had undergone bilateral acetabular osteotomies in childhood. There was no history of trauma, anticoagulant use, or a collagen vascular disorder. She is a housewife. She has no medical history and family history.
+A physical examination revealed a firm, immobile mass measuring 18 cm × 12 cm located on the right side of her ilium. An operation scar measuring 14 cm was found in the front of her hip joint. There was no redness of the skin or swelling of the inguinal lymph nodes. There were no neurological signs of motor or sensory disturbances in her limbs. She could walk with one axillary crutch on one arm and could stand on her right leg. The joint motions of her right hip joint were − 20° extension, 30° flexion, 20° abduction, and 10° adduction. There were no differences in the circumferences of her lower limbs. All laboratory data were within normal limits including coagulation studies: white blood cells (WBC) 7300/uL, hemoglobin 12.8, platelet 22.6 × 104/μL, C-reactive protein (CRP) 0.12 mg/dL, aspartate aminotransferase (AST) 15 U/L, alanine aminotransferase (ALT) 11 U/L, blood urea nitrogen (BUN) 11 mg/dL, creatinine 0.50 mg/dL, activated partial thromboplastin time (APTT) 27.8 seconds, and prothrombin time-international normalized ratio (PT-INR) 0.97 INR).
+A plain radiograph revealed expanded deformity of her right ilium with marginal sclerosis and calcification inside the bone . Computed tomography demonstrated a heterogeneous mass around the ilium and an area of destroyed bone . On magnetic resonance imaging of the same sites, the lesion showed predominantly isointense or high signals on T1-weighted images, and a mixture of low and high signal intensities on T2-weighted images. There was visible heterogeneous enhancement of the mass on a T1-weighted image following the intravenous injection of gadolinium-diethylenetriaminepenta-acetic acid (Gd-DTPA) .
+Based on these findings, our differential diagnoses were giant cell tumor of the bone, aneurysmal bone cyst, or low-grade malignant tumor such as telangiectatic osteosarcoma. Therefore, an incisional biopsy of the lesion was performed. An intraoperative examination revealed that the lesion had a thick capsule; when the capsule was incised, abundant blood was drained from inside. The intraoperative hemorrhage from the incisional biopsy was 500 ml; then, our patient needed a blood transfusion because her hemoglobin level decreased to 6.7 mg/dl from the preoperative level of 12.8 mg/dl. A histopathologic examination revealed large amounts of old clotted blood within the lesion. The capsule of the lesion was composed of dense, fibrous, connective tissue . There was no evidence of neoplasia . Therefore, CEH was suspected.
+We discussed the treatment options of the current case because there was no previous example of a huge CEH of bone. Surgical treatment was not recommended due to inaccessibility based on our experience of the intraoperative massive hemorrhage at the previous biopsy. We selected non-operative management for the current case. A consecutive selective arterial embolization program was started and performed five times . In addition, our patient was submitted to an off-label treatment with denosumab, which is a monoclonal antibody and acts as an inhibitor of the RANK/RANKL pathway and diminishes bone turnover. Denosumab was administered using the regimen for giant cell tumors of bone and continued for 3 months. However, the lesion continued to slowly grow, and neuralgia of the femoral nerve occurred , so we suspected that it might be a malignant bone tumor and decided to perform surgical treatment. We expected that we would be unable to prevent and control the operative bleeding in curettage or volume reduction surgery in this case. Therefore, we performed an internal hemipelvectomy, including the capsule of the mass 2.5 years after the incisional biopsy.
+At the operation, the mass was completely covered in a capsule, with no evidence of invasion of the neighboring muscle. On macroscopic examination, the lesion was encased in a thick capsule . After the lesion was excised, a hip transposition was done as a limb salvage procedure . On microscopic examination, the mass was composed of a mixture of fibrin, blood clots, and hemosiderin deposition with a fibrous layer containing degenerated muscle fibers and new capillaries. A histopathologic examination confirmed the diagnosis of CEH consistent with the diagnosis indicated by the incisional biopsy.
+External fixation of her pelvis and her right femur was applied for 6 weeks postoperatively. After removing the external fixation, partial weight-bearing was permitted for 4 weeks, and full weight-bearing with one crutch was allowed 14 weeks postoperatively.
+There was no recurrence of CEH at the most recent follow-up of 1 year and 8 months postoperatively. She can ambulate with the assistance of one crutch and a heel lift of 5 cm .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1244_en.txt

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+A 10-mm pedunculated polyp in the gallbladder neck was detected on a follow-up abdominal ultrasound in a 60-year-old man with chronic hepatitis and hepatitis B without medication. A benign tumor or low-grade malignancy was suspected, and he initially did not wish to undergo surgical resection. Six months later, an abdominal ultrasound showed an increase in the polyp to 12 mm at the neck of the gallbladder with point-like perfusion, focal thickening of the gallbladder wall, and a gallbladder stone at the fundus . Enhanced computed tomography (CT) scan and magnetic resonance imaging (MRI) revealed a polypoid lesion at the neck of the gallbladder, a distended gallbladder with a thickened and enhanced wall, and a gallbladder stone at the fundus. He was asymptomatic, and laboratory examinations revealed that the patient had a normal liver function and coagulation with hepatitis B virus DNA level of 3.2 log IU/ml; positive and negative serologic markers for hepatitis B envelope antibody and envelope antigen, respectively, and the tumor marker levels were within normal ranges [carcinoembryonic antigen, CEA (1.8 U/ml; normal range < 5.0 U/ml) and CA19-9 (9.9 U/ml; normal range < 37 U/ml)]. Although the patient was diagnosed with a benign gallbladder polyp, malignancy could not be completely excluded. Therefore, a laparoscopic cholecystectomy was performed. Intraoperatively, only a slight thickening of the gallbladder wall was detected. Macroscopically, there was a pedunculated yellowish polyp (14 × 11 × 15 mm) at the neck of the gallbladder. The gallbladder wall was thickened, and the Rokitansky-Aschoff sinus (RAS) was clustered at the wall .
+Histopathological examination revealed solid or trabecular nests of tumor cells in the polypoid lesion. These tumor cells were uniformly monotonous with a small round nucleus and multivacuolated clear cytoplasm , and the cytoplasm was negative for periodic acid-Schiff reaction. Necrosis and mitosis were not observed. The surface of the polyp was composed of a biliary epithelium without atypia. The neoplastic lesion was restricted to the lamina propria, and neither vascular nor lymphatic invasion was present (ENETS: T1N0M0; AJCC: T1aN0M0). Chronic cholecystitis with RAS was observed in the surrounding gallbladder tissue. Immunohistochemically, the tumor cells were positive for synaptophysin, chromogranin A, and CD56, indicating neuroendocrine differentiation . The expression of Ki-67 showed a labeling index of < 2%. Hence, the tumor was diagnosed as clear cell NET G1 of the gallbladder. No additional treatment was administered because R0 resection was performed using cholecystectomy, and there was no evidence of invasion or metastasis to other organs. Although clear cell NET may appear as a part of VHL disease, the patient had no clinical findings and family history of VHL. The patient is doing well without any signs of recurrence until the one-and-a-half-year follow-up period.

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+A 56-year-old male patient presented by a gradually progressive course of lower back pain, burning sensation of both lower limbs followed by urinary incontinence. The past history was irrelevant. X-ray of lumbosacral region revealed sacral osteolytic lesion with an associated soft-tissue mass. Non-contrast computed tomography of lumbosacral spine revealed a large 11 cm × 8 cm × 12 cm lobulated mass of the sacrum filling the sacral canal and having pre- and retro-sacral extension. The patient underwent maximal possible excision of sacral mass in December 2018 and the post-operative pathology revealed chordoma. Post-operative magnetic resonance imaging (MRI) showed a well-defined heterogeneously enhanced residual destructive bony lesion 8.5 cm × 6.5 cm × 7.5 cm affecting the sacrum (, ). The panel decided post-operative conventional radiotherapy dose of 60 Gy in 30 sessions. The follow-up MRI revealed about 30% response. There was clinical improvement following the surgery and radiotherapy.
+In February 2020, the patient developed left inguinal swelling. Pelvic sonar showed enlarged left inguinal lymph node 3.5 cm × 2 cm × 3 cm with distorted hilum. Excisional biopsy was done and revealed metastatic chordoma (-). Metastatic work-up was free. The patient started Gleevec 400 mg daily. In June 2020, the patient developed an enlarged right inguinal lymph node 4 cm × 3.5 cm × 3 cm and the excision biopsy revealed metastatic chordoma as well. Metastatic work-up was free. Gleevec was stopped. A second-line target therapy was recommended but was not received by the patient. In September 2020, the patient developed headache, dysarthria, numbness at cheek, and lips. MRI brain revealed a well-defined abnormal signal intensity at the left side of clivus 3 cm × 4.5 cm × 4.8 cm suggesting chordoma . Transnasal biopsy revealed chordoma.
+In October 2020 , the panel decided conventional radiotherapy of 60 Gy in 30 sittings. The follow-up MRI revealed regression of the clivus lesion and the patient improved clinically. At present, the patient is clinically stable while on follow-up.

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+A 35-year-old, well-built, right-hand dominant gentleman, a temple priest by profession and a known epileptic with a frequency of seizures of once every year, being treated with regular oral phenytoin, presented with pain and deformity in both shoulders since the previous day. He had an episode of generalized seizures the previous day and sustained a fall during the episode. He reported that his left arm got stuck between a wall and a cupboard during the fall while his right arm was free during the fall. However, the patient could not recollect clear details due to seizures. He was otherwise asymptomatic before the incident. There was no history of external injury or other associated injuries or history suggestive of instability.
+On examination, both shoulders were swollen with bruising on the medial aspect of both arms. Both shoulders were tender and the arms were held in a neutral position. All attempted movements of the shoulders were painful. There was no distal neurological or vascular deficit in the upper limbs. There was no generalized ligament laxity on clinical examination.
+Anteroposterior and scapular Y-view radiographs of the right shoulder revealed an anteroinferior dislocation of the shoulder with a displaced fracture of the greater tuberosity and a large Hill–Sachs lesion.
+Similar views of the left shoulder revealed a light bulb sign , suggesting posterior dislocation of the shoulder, along with a displaced fracture of the greater tuberosity.
+Closed reduction of both shoulders was performed with gentle traction under general anesthesia. The greater tuberosities were persistently displaced after the reduction. A lateral transdeltoid approach (deltoid splitting) was used to approach the fracture and transosseous suture fixation of the greater tuberosities with No. 2 Ethibond sutures was done by the technique suggested by Dimakopoulos et al. .
+At 2 weeks post-fixation, both shoulders remained congruently reduced. While the right greater tuberosity fracture remained stable, the tuberosity fracture in the left shoulder had displaced . Resuturing was done under anesthesia and the fixation was reinforced with 4 mm cannulated cancellous screws . The greater tuberosity fracture had split into two fragments. Fixation was assessed under fluoroscopy and was found to be stable with movements of the shoulder. The patient was advised arm sling for both shoulders for 6 weeks, with an additional small abduction pillow on the left. Internal rotation was delayed for 4 weeks on the left shoulder. Pendulum exercises were started from 2 weeks postoperatively followed by active assisted and active exercises at 4 and 6 weeks, respectively. The patient recovered well. Fractures united at 8 weeks on the right shoulder and at 12 weeks on the left, and at last follow-up at 12 months, the greater tuberosity fractures had healed well and the glenohumeral joints were in situ . He had achieved full shoulder function by 16 weeks after first surgery .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1268_en.txt

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+A 30-year-old Chinese woman came to the dermatology clinic with a two-year history of progressing, diffuse, lattice-like hyperpigmentation of the face and neck. Significant sunlight, chemical materials, medicine, and cosmetic exposures were denied. She had no notable family history of similar conditions. On further questioning, she admitted that she had experienced hair loss and ankle joint pain for two years, and these had worsened in the last two months.
+Diffuse, symmetric, and reticular gray brown hyperpigmentation was observed all over the face and neck, especially the cheeks and the area around the mouth . Slight hyperpigmentation was seen on her upper limbs. No similar change can be seen on the rest of her skin and mucosa.
+Under skin microscopy, diffuse black-pepper-like changes separated by hair follicles with sweat glands and telangiectasias were seen . The reflectance confocal microscopy showed abundant melanin in the epidermis and dermis, local liquefactive degeneration of basal layer cells, and the presence of melanophages in the dermis ( and ). Histopathology of neck lesions (HE staining) showed punctiform epidermal atrophy, punctate liquefactive degeneration of basal layer cells, melanophages in the dermis, and a few lymphocytes infiltrating around the dermal adnexa . Masson-Fontana silver staining showed amounts of melanin in the epidermis and dermis . Laboratory investigations revealed the following: peripheral white blood cell (WBC) count 2.73 × 109/L (3.5–9.5 × 109/L), antinuclear antibody (ANA) (+++), anti-dsDNA antibody (dsDNA) (+), anti-Sjögren’s-syndrome-related antigen antibody A (+++), C3 0.48 g/L (0.90–1.80 g/L), C4 0.06 g/L (0.10–0.40 g/L), anti-thyroglobulin antibody (TGAb) >4000 IU/mL (0.00–115.00 IU/mL), and anti-thyroid peroxidase (ATPO) >600 IU/mL (0.00–34.00 IU/mL), thyroid stimulating hormone (TSH) 92 mIU/L (0.550–4.780 mIU/L), Thyronine-4 (T4) 2.5 μg/dl (4.5–10.9 μg/dl). Serum-free thyroxine (FT4), free triiodothyronine (FT3), thyronine-3 (T3), and adrenocorticotrophic hormone (ACTH) were all within normal range. Anti-TSH receptor antibody (TRab) was negative. Doppler ultrasonography of the thyroid showed hypothyroidism changes and a nodular thyroid cyst. Serum sex hormone, adrenal hormone, and the computed tomography scanning of the adrenal glands were all normal.
+Diagnoses of RM accompanied with SLE and Hashimoto’s thyroiditis of primary hypothyroidism were made via the clinical features and laboratory investigations.
+Prednisone (20 mg/day), hydroxychloroquine (400 mg/day), and L-thyroxine (100 μg/day) were administered orally. The prednisone was withdrawn gradually over the course of 7 months.
+Significant improvement was observed after 14 months of treatment. The hyperpigmentation has turned much lighter ( and ). Under reflectance confocal microscopy, the melanin in the epidermis was found to have decreased significantly, the local liquefactive degeneration of basal layer cells showed improvement, and the melanophages in dermis was found to have decreased in number . WBC, C3, C4, and T4 returned to normal. The TSH decreased to 5.667 mIU/L.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1276_en.txt

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+A 22-year-old female Caucasian patient was diagnosed with UC 3 mo ago, complaining of bloody diarrhea, abdominal pain and weight loss, and discontinued mesalamine due to the gastric intolerance. The patient underwent a colonoscopy 2 wk before the admission to the hospital, which revealed lesions consistent with UC of moderate endoscopic activity (Mayo endoscopic score 2).
+She was admitted to the emergency department in due to frequent liquid and bloody stool and intense abdominal pain for 2 mo, with worsening of the symptoms during the last week, in poor condition with nausea, vomiting, and weight loss (10 kg) and without the improvement from the previous use of antibiotics.
+At hospital admission (day 1 of hospital admission), the patient presented in poor condition, dehydrated, tachycardic (110 beat/min), blood pressure 100/60 mmHg, temperature > 37.8 °C, with distended and diffusely painful abdomen, and rebound tenderness.
+Laboratory tests showed inflammatory process (C-reactive protein 20.3 mg/dL) and anemia (hematocrit 25.8%, hemoglobin 8.1 g/dL) at admission .
+Abdominal X-ray revealed colonic dilation of 7 cm, consistent with megacolon .
+Clostridium difficile (C. difficile) A and B toxin was positive, and the treatment with oral vancomycin 250 mg qid was initiated. However, the patient presented with worsening of diarrhea and rectal bleeding (> 10 episodes/d), increased abdominal distension, and fever. A flexible sigmoidoscopy was performed (day 4 of hospital admission) and inserted up to 25 cm with no insufflation, showing ulcers covered by fibrin, mucosal friability, edema, and intense enanthem with spontaneous bleeding in sigmoid and rectum, consistent with UC of severe activity (Mayo endoscopic score 3) . Histopathological evaluation showed chronic colitis in intense activity with structural abnormalities of the mucosa, presence of crypt micro-abscesses and plasmacytosis, consistent with severe inflammatory activity without the evidence of C. difficile or cytomegalovirus infection.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1297_en.txt

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+A 68-year-old woman was referred to our hospital on December 2011, due to right upper quadrant pain and a 5-pound weight loss.
+Other symptoms were not presented and she did not drink alcohol, smoke or have a history of surgery.
+Physical examination revealed a soft abdomen, no tenderness, no rebound tenderness, and no palpable lymph nodes or abdominal mass.
+The following laboratory data were recorded: hemoglobin of 125 g/L; white cell count of 5.5 × 109/L, with 72.5% neutrophils; platelet count of 234 × 109 L; alanine aminotransferase of 25 U/L; serum total protein of 75 g/L; albumin of 37.2 g/L; total bilirubin of 11 μmol/L; direct bilirubin of 9.5 μmol/L; α-fetoprotein of 5.23 ng/mL; and carcinoembryonic antigen of 4.5 ng/L. Serological markers for hepatitis B virus and HCV were negative. The indocyanine green retention rate at 15 min was 2.2%.
+Abdominal ultrasonography showed there was a mixed echoic mass measuring around 10 cm × 7 cm in the right hepatic lobe. Abdominal computed tomography (CT) showed a similar finding, that the tumor was inhomogeneous density, with mild delayed enhancement, and had central necrosis . Gastrointestinal endoscopy and colonoscopy showed negative findings. Chest CT showed no mass over the lung.
+Preoperative diagnosis was unconfirmed, exploratory laparotomy was performed 1 wk after admission, and no obvious effusion was found in the abdominal cavity. The entire liver VIII was occupied by a creamy white, firm mass measuring about 10 cm × 7 cm, which protruded into the abdominal cavity and appeared to invade the diaphragm and middle hepatic vein , making the tumor unresectable ; thus, a biopsy was performed. Rapid frozen-section biopsy analysis considered the diagnosis of leiomyosarcoma. Histopathological examination showed a hepatic mass that consisted of spindle-shaped cells with mitotic figures and nuclear atypia . Immunohistochemical staining showed that spindle-shaped cells were positive for anti-smooth muscle actin and desmin but negative for keratin, S-100, CD34 and CD117. No obvious lesions were observed in the bilateral adnexa and uterus, and no palpable mass was detected in the superficial body.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1299_en.txt

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+A 45-year-old male presented to the emergency department complaining of a cough for more than a week. This cough was not relieved by any medications. It was followed by dyspnoea for 2 days. From the patient's history, we found that he is a schoolteacher from a middle-class family. The living conditions of the family are at subpar levels. He is a non-smoker and an occasional alcohol consumer. There is no evidence of contact with domestic animals like dogs, sheep, or cows. The patient lives with his wife and two children in his home with no domestic animals as pets or livestock. Contamination of food and water are a few environmental risk factors that the patient has.
+On physical examination, the patient had a normal heart rate, blood pressure, oxygen saturation, and temperature. His respiratory rate was significant for tachypnoea with 25 cycles per minute. On clinical examination, breath sounds were decreased on the left side, also vocal fremitus was found to be decreased, along with dullness on percussion on the left side of the chest. The right side of the chest showed normal clinical examination. Laboratory findings were significant for eosinophilia (12 %). A routine chest X-ray revealed rounded opacities and a large left-sided pleural effusion with a right-sided mediastinal shift. It did not reveal consolidation of the upper zone with ipsilateral hilar enlargement or any features suggestive of pulmonary tuberculosis.
+The patient was hospitalized urgently and was referred to the Respiratory Medicine Department for further evaluation and management. The patient was scheduled for a pleural drainage procedure. A pleural drainage was inserted in the 5th intercostal space anterior to the mid-axillary line on the left side of the chest. 2600 ml of cloudy yellowish fluid was drained within 24 h. A differential diagnosis of tuberculosis, malignancy, and parapneumonia was considered based on the imaging which showed large left-sided pleural effusion and exudative pleural effusion on seeing the cloudy yellowish fluid on drainage. The fluid drained was sent for protein, lactate dehydrogenase, Gram stain, cytology, and microbiological culture. The pleural fluid analysis confirmed an exudative pleural effusion.
+Computed tomography was done to confirm the suspicion of hydatid disease. The CT revealed multiple small cysts which are round in shape filling up the entire left pleural cavity. Left-sided pleural effusion was associated with left lung atelectasis and right mediastinal shift. Abdominal CT was done which showed no lesion in the liver suggestive of the absence of a primary foci of hydatidosis in the liver. The patient was referred to the Surgery Department for further management of the case. Preoperative antihelminthic treatment with Albendazole 15 mg/kg/day for 6 days was completed. He completed the pre-anesthetic check-ups and was posted for surgery by the Chief Surgeon.
+The patient was taken to the operation room for a left-sided posterolateral thoracotomy in the 5th intercostal space. The pleural space was then irrigated with hypertonic saline to kill the scolices. Multiple daughter cysts were removed, and a thorough inspection showed no other cysts in the pleural space, lung, diaphragm, or mediastinum .
+A pleurectomy and an empymectomy were done in view of infection-induced pleural effusion. After the procedure was done, the collapsed lung was expanded fully, and no air leakage was found. Additionally, there was no sign of parenchyma damage to the lung. It was followed by the closure of the thoracotomy. The patient was shifted to the Intensive Care Unit and was then discharged when he was hemodynamically stable and symptomatically better with 10 mg/kg/day of oral Albendazole for 1 year. The patient was asymptomatic and showed normal chest X-rays in the follow-up visits done monthly and yearly.

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+A 23-year-old male of South Asian origin with mosaic Klinefelter syndrome was diagnosed with mediastinal non seminomatous GCT (see Fig. for timeline). Initial management was with surgical resection. At this time the full blood count was normal. Histology confirmed complete excision with narrow margins. Four months later he relapsed with rising levels of beta-human chorionic gonadotrophin (ß-HCG). He was treated with alternating POMB (vincristine 2 mg IV and methotrexate 300 mg/m2 over 24 h on day 1, bleomycin 15 mg IV over 24 h on days 2 and 3, cisplatin 120 mg/m2 IV over 12 h on day 4) and ACE (dactinomycin 0.5 mg IV on days 1–3, etoposide 100 mg/m2 IV on days 1–3, cyclophosphamide 500 mg/m2 IV on day 3) chemotherapy, but due to a severe reaction to cisplatin and a presumed treatment-related cerebrovascular accident, cisplatin was substituted with carboplatin. He completed 2 cycles, resulting in biochemical remission.
+Twenty-three months later he developed thrombocytopenia, macrocytic anaemia, and a raised serum lactate dehydrogenase associated with epistaxis, fatigue and backache. Biochemical markers for GCT remained low. Bone marrow (BM) aspirate showed severe dysplastic changes in all three hematopoietic lineages with 6% myeloblasts classifying him as myelodysplastic syndrome with excess blasts-1 (MDS-EB1) . Karyotyping of the BM revealed an abnormal hypotriploid karyotype, with various numerical gains including trisomy 8 and tetrasomy 22, and a single structural abnormality, an isochromosome comprising two copies of the long arm of chromosome 15 .
+This was an unusual karyotype for MDS and given the high risk of leukemic transformation, he was planned for allogeneic hematopoietic stem cell transplantation (HSCT).
+Only 2 weeks after the first BM study and during work-up for HSCT, he developed rapidly worsening cytopenias with peripheral blasts. Repeat BM biopsy now showed infiltration with TdT+ CD10+ abnormal B-cell precursors consistent with acute lymphoblastic leukemia (ALL) with L3 morphology . The cytogenetic study revealed an abnormal male karyotype with a new t(8; 22) (q24;q11) with MYC rearrangement confirmed with FISH, plus other chromosomal abnormalities; a single euploid cell carrying an isochromosome 15 was noted .
+He received induction chemotherapy according to the UK-ALL14 trial protocol (complex regimen including cytarabine, daunorubicin, vincristine, dexamethasone, PEG-asparaginase, methotrexate, cyclophosphamide and mercaptopurine) achieving complete morphologic and cytogenetic remission of ALL but with persistent trisomy 8 in 12% of cells examined by FISH. He proceeded to a matched unrelated donor allogeneic HSCT with reduced intensity conditioning with alemtuzumab (10 mg IV daily on days − 7 to − 3), fludarabine (30 mg/m2 IV daily on days − 7 to − 3) and melphalan (140 mg/m2 IV on day − 2) and prophylaxis of graft-versus-host disease with post-transplant methotrexate (8 mg/m2 IV daily on days + 2, + 4 and + 8). Hematological recovery occurred by day + 40. A BM study on day + 71 post-transplant, performed due to new progressive thrombocytopenia, demonstrated complete cytogenetic remission of the ALL clone, and FISH analysis again showed persistence of trisomy 8 in 9% of examined cells.
+One week later he developed tonsillitis, worsening thrombocytopenia necessitating frequent platelet transfusions, and severe opiate-refractory bone pains most marked in the right knee. MRI of the knee showed extensive lytic lesions. Severe sepsis and visual impairment resulting from bilateral retinal hemorrhages then developed. BM study now showed 87% infiltration with abnormal erythroblasts and no evidence of abnormal lymphoid precursors. A diagnosis of pure erythroid leukemia was made. Karyotyping of the BM revealed an abnormal hyperdiploid karyotype, with both structural and numerical abnormalities. FISH for the MYC rearrangement remained negative, confirming that this was a new lineage malignancy unrelated to the ALL .
+FLAG-IDA chemotherapy (fludarabine 30 mg/m2 IV for 4 days, cytarabine 2 g/m2 IV for 4 days, G-CSF 480 µg from day − 1 until day 5, and idarubicin 10 mg/m2 for 3 days) was administered followed by CD34+ stem cell top-up. The patient declined further inpatient treatment and was discharged on day 11 post-chemotherapy. Unfortunately, he died at home 2 weeks later, 41 months after initial diagnosis of GCT, and 10 months after diagnosis of his first hematologic malignancy.

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+Male, 32 years old (yo), 78,5 kg of bw, resided in São Gabriel da Cachoeira (Amazon state) for two years (until 18th Dec 2015), where he had a diagnosis of vivax malaria on 1st Nov 2015 being treated with chloroquine and primaquine for seven days . On 25th Jan 2016, 38 days after moving to Rio de Janeiro city (and 85 days after the initial diagnosis), he sought care at INI/Fiocruz and was diagnosed with P. vivax infection (18,320 parasites/mm3). G6PD activity was tested normal. He was treated with chloroquine and primaquine (total dose of primaquine: 3.44 mg base/kg given during nine days). On 16th Apr 2016 (81-days interval), he presented another malaria episode diagnosed as P. vivax (6,000 parasites/mm3). He was then treated with chloroquine and higher-dose primaquine (total dose of primaquine: 7.03 mg base/kg bw given in 22 days). CYP2D6 genotype was performed and classified as intermediate metabolizer . He was followed up for more than one year and has not presented new episodes.

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+A 68-year-old woman was admitted to our hospital for weakness for more than 3 d.
+Three days before admission, she first experienced weakness of the limb weakness with posterior neck pain, numbness in the distal extremities, and a feeling of electric shock when touched. On the day of admission, these symptoms were aggravated, and she could not stably hold things in either hand. She also had cold-related pain in the upper extremities, weakness in the lower extremities, an inability to ambulate, urinary and fecal retention, and increased posterior neck pain. A cranial computed tomography (CT) showed no obvious signs of hemorrhage. The patient did not experience chills or fever, cough or sputum production, headache, visual hallucination, choking and coughing when eating, dysarthria, chest pain, palpitations, abdominal distension, or diarrhea.
+She had a history of hypertension for more than one year and was taking daily amlodipine tablets. She denied any history of upper respiratory tract infection, diarrhea, or abdominal pain before the onset of symptoms and reported no recent vaccinations. She had no history of diabetes mellitus or allergy to foods or drugs.
+She had no history of diabetes mellitus or allergy to foods or drugs. Denial of family history.
+Physical examination: At admission, her body temperature was 36.8 ℃, her pulse rate was 76 beats/min and rhythmical, and there were no pathological murmurs in the auscultation area of each heart valve. Her respiratory rate was 20 breaths/min, her blood pressure was 145/78 mmHg, and there was no neck stiffness or breathing resistance. There were clear breath sounds in both lungs and no dry rales. Her abdomen was soft, and she had no varices in the veins of the abdominal wall. No pressure tenderness or rebound pain was observed at McBurney's point. There was no shifting dullness to percussion, but slightly reduced bowel sounds (2–3/min) were observed. Her lower limbs had no edema.
+Neurological examination: The patient had clear consciousness and no dysarthria. Her pupils were round, had the same diameter (3.0 mm), and were light-sensitive. She had adequate eye movement in all directions, no nystagmus, and symmetrical bilateral frontal lines. The muscle strength of both upper limbs was grade 4; the muscle strength of both lower limbs was grade 3; the muscle tone of the limbs was low; and the tendon reflexes had bilateral weakness. The Babinski sign was positive on both sides. Her sensations of bilateral distal pain and temperature were slightly reduced; the two-handed finger-nose test was stable and accurate; the bilateral heel-knee-shin test was unstable and inaccurate; and she had normal bilateral vibration sensation and joint position sensation. The meningeal stimulation sign was negative, and she exhibited no involuntary movements.
+The complete blood count, liver and renal function tests, coagulation indicators, and tumor indicators indicated no significant abnormalities and cranial magnetic resonance imaging (MRI) also did not show significant abnormalities. A lumbar puncture indicated an elevated cerebrospinal fluid (CSF) pressure of 116 mmH20 and the presence of cytoalbuminologic dissociation. A peripheral neuropathy immunoblotting test (ganglioside antibody profile) was positive for anti-sulfatide antibody IgG. The markers of central nervous system demyelinating diseases, including oligoclonal bands, aquaporin 4, and anti-MOG antibodies, were all negative
+Electromyography revealed some motor nerves with conduction block but normal sensory nerve conduction velocity and wave amplitude, suggesting damage to multiple peripheral nerves. A cervical MRI revealed a high signal in the cervical spinal cord, suggesting inflammatory changes.However, a thoracic MRI revealed degeneration of certain thoracic discs, and a lumbar MRI revealed bulges of the L3/4, L4/5, and L5/S1 discs. A chest CT revealed two foci of lung fibrosis, but a whole abdominal CT did not reveal significant abnormalities

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+A 26-year-old female patient visited to the Department of Oral and Maxillofacial Surgery in April 2017, with the complaint of feeling something hard in her left cheek for a few years. She had unremarkable medical history aside from a history of trauma in the left masseteric area when she was 4 years old. On physical examinations, surface texture and color of the skin and mucosa were in normal range without swelling or tenderness. When palpated, well-defined, oval-shaped, and movable nodules in her left cheek, less than 1 cm × 1 cm in size, were identified. Panorama and CT examinations were performed, and multiple radiopaque masses were observed inside the left masseter muscle . The function of facial nerve and salivary flow of Stensen’s duct were normal. No trismus and cervical lymphadenopathy were noted. Blood test results were also normal. Serum calcium level was 9.4 g/dL and serum phosphorus level was 3.9 g/dL which were within normal ranges. From the clinical and radiographic evaluation whilst considering a history of trauma, the calcified mass was diagnosed as dystrophic calcification, which is known to occur in soft tissues, commonly in those with a history of trauma and the absence of systemic mineral imbalance.
+Surgery was planned to remove the dystrophic calcification of the left masseter muscle. After intraoral incision in the left buccal mucosa, cautious dissection of masseter muscle was done. Muscle fibers of masseter were longitudinally separated to expose the calcified masses. They were firmly attached to the masseter muscle fibers and were bluntly separated from the muscle tissue. The three calcified masses, with the largest, having a size of 0.6 × 0.5 × 0.4 cm, presenting a round-oval shape and whitish-yellow in color, were removed with the attached muscle fibers .After the calcified masses were excised completely, hemostasis was achieved and wound was sutured in layers. Postoperative recovery was uneventful with no damage to nearby structures such as nerves or Stensen’s duct. Postoperative CT imaging was taken, and complete removal of the calcified masses was confirmed . Histopathological examination revealed microscopically ovoid hyalinized material with calcification in their center but could not be found fibrous tissue or vascular structure around the materials .
+There is a variety of conditions that may cause abnormal calcification in various tissues. It may have some connection with abnormal calcium phosphate metabolism as seen in metastatic calcifications . However, dystrophic calcification is deposition of calcium salt in degenerated tissues related to normal calcium and phosphorous metabolism . It is known that dystrophic calcification can occur in any soft tissue with the absence of a systemic mineral imbalance, easily found in the site of the heart muscle and skeletal muscle. It rarely appears in the gingiva, tongue, lymph nodes, and facial muscles and usually occurs in injured tissues [, ]. Based on the literature, our case is the fifth case of dystrophic calcification in a masseteric area to be reported .
+The pathogenesis of dystrophic calcification is known to involve intracellular or extracellular initiation and propagation. Intracellular calcification is initiated with dead or dying cells that are not able to regulate intracellular calcium. After initiation, propagation of calcium phosphate crystalline formation occurs, which is affected by the concentration of Ca2+and PO4− in the extracellular space . Dystrophic calcification occurs when calcium is accumulated in the area of trauma or necrosis which may be caused by blunt trauma, inflammation, injections, and the presence of parasites .
+In many cases, it appears early in childhood but it often tends to be diagnosed late since it shows no signs or symptoms. Therefore, it is found after lesion is enlarged enough to be palpated. In our case, we suppose that dystrophic calcification was caused by a trauma experienced at a young age. Because there had been no symptoms such as swelling or pain, it was discovered after a long period of time.
+Different types of calcifications, including phleboliths, sialoliths, myositis ossificans, metastatic calcification, calcifications within lymph nodes, and calcified cutaneous aces, may occur in the cheek area, and they need to be distinguished from dystrophic calcification. Phleboliths are pathological, calcified thrombi that are associated with hemangiomas and developmental vascular malformations of the head and neck region . Radiographically, they appear as round or oval radiopaque nodules, which may show a radiopaque center with surrounding onion ring-like concentric calcific rings . In this case, there was no evidence of hemangioma or vascular malformation clinically and radiographically. Also, the calcified mass had no radiopaque center and concentric rings.
+On the other hand, sialoliths are one of the most common diseases that appear in the salivary glands. Sialoliths of the parotid gland or duct need to be distinguished from calcification of the cheek, because the parotid gland is located behind the masseter muscle, with the Stensen’s duct, passing through it before opening into the oral cavity. Sialoliths may be composed of one or more stones and may cause pain or swelling when the salivary gland is stimulated by eating . In our case, we ruled out a diagnosis of such because the calcified masses were located inside the masseter muscle, away from the Stensen’s duct or parotid gland based on the CT images. In addition, salivary flow of the duct was found to be normal.
+Another differential diagnosis is myositis ossificans which results from trauma or heavy muscular strain associated with the bone or cartilage, producing reactive lesions. Clinically, it can be palpated beneath the skin or mucosa, as a minimally movable firm mass . When the lesion is located within a muscle of mastication, it usually causes trismus because of limitation of the muscle . On a radiograph, the linear streaks running in the same direction as the normal muscle fibers are regarded as a typical character for myositis ossificans . In our case, the patient had no trismus and the radiographic finding was different from myositis ossificans .
+In addition, calcifications within lymph nodes commonly involve cervical lymph nodes with metastatic deposits from malignancies such as squamous cell carcinoma and Hodgkin’s lymphoma. On a radiograph, they most often are irregular with a cauliflower appearance . Metastatic calcifications occur due to increased calcium levels in the blood. Chronic renal failure, milk-alkali syndrome, extensive bone malignancy, and hypervitaminosis D are some of the conditions known to cause metastatic calcifications . In our case, there was no evidence of malignancy causing metastasis or systemic mineral imbalance.
+Due to this wide variety of diagnostic possibilities including phleboliths, sialoliths, myositis ossificans, calcification within lymph nodes, and the potential for malignancy, it is important to establish a proper diagnosis . In fact, physiologic and pathologic soft tissue calcification of the head and neck is rare, and plain radiography is rarely helpful in diagnosing . Therefore, thorough clinical examination and history taking is required together with blood testing and radiographic examinations such as CT, MRI, and ultrasound. In addition, fine needle aspiration for checking the contents of the lesions if deemed indicated can also help in confirming the diagnosis. The final diagnosis should be obtained after acquiring relevant information, and only then, the appropriate treatment can take place . There is no established protocol for its treatment. Some clinicians have recommended observation. However, various factors such as the size and location of the lesion, and patient discomfort should be put into consideration. In such cases and if deemed necessary, meticulous surgical excision and periodic follow up are recommended [, ].

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+A 65-year-old man visited our outpatient department for left calf pain and swelling.
+Two weeks prior to presentation, he had slipped and injured his left leg. He took over-the-counter pain medication, but the pain persisted and the swelling became increasingly severe. He presented to the clinic with worsening pain that he rated at visual analog scale (VAS) 7.
+The patient was on medication for hypertension and diabetes mellitus. He had undergone a kidney transplant in 1998 for end-stage renal disease caused by immune globulin A nephropathy.
+The patient had no specific personal and family history.
+On physical examination, he had a stiff, localized, oval mass with a bruise on his left upper posterior calf. During palpation, tenderness was localized to the left proximal gastrocnemius muscle. The pain was aggravated by dorsiflexion of the left ankle or weight-bearing on the left foot. He could not walk without a crutch. Neurological and peripheral vascular examinations of the left lower leg were within normal limits.
+No laboratory examination was conducted.
+Initial diagnostic ultrasonography showed a hematoma in the left gastrocnemius muscle measuring 4.3 cm × 1.5 cm × 4.9 cm . There was no active bleeding, and the hematoma was stiff and firm with low heterogeneity. Left tibial magnetic resonance imaging confirmed rupture of the medial head of the gastrocnemius muscle, with hematoma between the medial and lateral heads .

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+A 63-year-old woman presented with a firm 7 cm multilobular tender mass located in the region of the right sternocleidomastoid directly above the clavicle. She had multiple comorbidities including renal failure, systemic lupus erythematosus, and protein S deficiency, a history of transient ischemic attack, deep vein thrombosis, and pulmonary embolism, and longstanding malnourishment requiring jejunostomy tube placement. The firm mass was identified 1 month after an unsuccessful attempt at placing a right internal jugular vein central line. When the central line was originally placed, she developed pain and swelling of her neck. The swelling was pulsatile at that time and enlarging. She was offered surgery as the standard of care for her condition which she refused because she did not want to undergo an invasive procedure and was aware of the risks involved with holding her anticoagulant medication. She had two thrombin injections in the mass since without success. She complained of right neck pain. She was not having any difficulty breathing and denied shortness of breath.
+Soft tissue ultrasound after the two thrombin injections showed pseudoaneurysm and a 7 × 3.3 × 4 cm multilobular hematoma at the base of the right neck. CTA of the neck showed a corresponding heterogeneous mass. The pseudoaneurysm was seen measuring 1.5 cm at the internal margin of the hematoma. Serial imaging with CTA demonstrated enlargement over a 2-week interval .
+Angiogram showed blush of contrast coming off of the sternocleidomastoid branch of the superior thyroid artery identifying the location of the pseudoaneurysm . This branch was embolized using glue. Repeat angiogram showed successful embolization and no contrast blush.
+On follow-up one month later, the mass was no longer pulsatile but still present on physical exam. CTA of the neck showed a decrease in size from the previous CTA .
+On follow-up 8 months later, she was found to have a soft neck with no mass on physical exam.

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+A 10-year-old Tunisian girl presented to our department with fever, vomiting, and asthenia. She had neither family history of hematological diseases nor other illness before the disease onset. During her admission, a physical examination showed a child of normal stature with pallor and fever (body temperature of 39 °C). She was tachycardic at 141 beats/minute and her blood pressure was at 107/51 mmHg. She had tachypnea at 52 breaths/minute with oxygen saturation in air at 95% and no heart murmur. An abdominal examination found an isolated splenomegaly. Biochemical analysis showed signs of hemolysis: total bilirubin, 51 microml/L with a direct fraction of 9 microml/L; haptoglobin < 58 mg/L; and D-lactate dehydrogenase, 2051 U/L. Her complete blood count showed severe anemia with hemoglobin (Hb), 2.6 g/dl; RBCs, 90 × 104/mm3; hematocrit (Ht), 6.6%; mean corpuscular volume (MCV), 91.3 fL; mean corpuscular hemoglobin (MCH), 31 pg; mean corpuscular hemoglobin concentration (MCHC), 33 g/dL; reticulocytosis, 239,400/mm3; white blood cells, 40,500/mm3; and platelets, 540,000/mm3. The blood smear did not reveal schistocytes. A DAT identified autoantibodies of the immunoglobulin M (IgM), immunoglobulin A (IgA), immunoglobulin G (IgG) isotypes, and C3d that reacted strongly (3+) at 37 °C with all tested cells. This confirmed the diagnosis of AIHA.
+Bacteriological analysis performed to access the etiology of the fever showed urinary infection (the urine analysis showed leukocytes of 2000/mm3 and erythrocytes of 1000/mm3) with C-reactive protein at 206 mg/L. The urine culture was negative because the child had already received amoxicillin. Then, antibiotherapy was continued with intravenously administered cefotaxime and amikacin. For AIHA, she had intravenously administered immunoglobulin (IVIG) at a dose of 1 g/kg per day twice during 48 hours. She also received repetitive RBCs transfusion. After controlling the infectious process, she was given a high-dose pulse of methylprednisolone (30 mg/kg per day for 3 days) followed by orally administered prednisone at a dose of 2 mg/kg per day. Due to the persistence of altered neurological status and severe hemolysis, she was again given IVIG and high-dose pulse methylprednisolone but without any benefit. Therefore, it was urgent to use a second-line therapy. In view of severe life-threatening hemolysis and her age, rituximab was deemed a better option than plasmapheresis, splenectomy, and/or cytotoxic drugs. Rituximab was given at a dose of 375 mg/m2 per week for 4 weeks. Afterward, prednisone was continued. After the second dose of rituximab our patient no longer required blood transfusions and there was a slow rise in her Hb level until day 15 at which point it stabilized . At the last out-patient follow up (4 months after her hospitalization), her Hb and hemolytic markers were still within a normal range: Hb, 13 g/dl; RBCs, 4.31 × 106/mm3; Ht, 37.5%; and reticulocytosis of 69,000/mm3. Biological investigations (serological tests, antinuclear antibodies screening, and immunity exploration) done to search for an underlying condition such as infection, lupus, or immune deficiency disease were all negative.

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+A 43-year-old male patient with a past medical history of MCD and ADHD since childhood presented to the emergency department with shortness of breath, generalized oedema, and foamy urine without haematuria for the last few months. The patient was taking Adderall (mixed amphetamine salts with dextroamphetamine and amphetamine) for ADHD since childhood and have undocumented history of inadequately treated MCD. He was evaluated for chronic kidney disease which revealed nephrotic range proteinuria, hypoalbuminemia, and an elevated brain natriuretic peptide. Urine drug sample was positive for amphetamine and cannabinoids. An extensive work-up was negative for secondary causes of nephrotic syndrome and kidney biopsy findings were consistent with MCD.
+Electrocardiography was performed that showed right bundle branch block and echocardiography revealed grade 1 diastolic dysfunction, severe dilation of the main right ventricle (RV) and RV outflow tract, significant RV hypertrophy, severely reduced RV systolic function, severe right atrial dilation, severe tricuspid regurgitation, and elevated central pressures. Chest X-ray showed cardiomegaly with a prominent pulmonary trunk suggestive of pulmonary hypertension. Cardiac catheterization revealed a mean pulmonary artery pressure of 43 mmHg and a pulmonary vascular resistance of 14.3 Wood units, consistent with moderate to severe PH, which was not reversible with the adenosine challenge. The patient commenced on high dose prednisone, lasix, and losartan. Adderall was discontinued as a possible contributing factor to PAH. The patient responded well to the treatment with the improvement in symptoms such as oedema and shortness of breath. Over the next 3 months, a gradual normalization of proteinuria, hypoalbuminemia, and urine protein-to-creatinine ratio was observed.

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+a) Clinical Presentation:
+A seven year old girl presented with pain in left distal third forearm for 8 months which was gradual in onset, non-progressive, mild in nature and non-activity related. Pain was associated with swelling which was initially small & gradually progressed over a period of eight months. There was no history of trauma/fever/weight loss or involvement of other bones. The general examination was unremarkable. Local examination of left forearm revealed a fusiform swelling in diaphyseal area measuring approximately 5cms by 2cms. Skin over swelling was normal, no engorged veins were present over the swelling. There was no local rise of temperature but local tenderness was present. Swelling was hard in consistency with well-defined margins, continuous with the radius. Forearm pronation and supination was painfully restricted; finger movements were normal and pain free. There was no associated distal neurovascular deficit.
+Fig 1-Pre-operative X-ray
+Fig 2-Pre-operative MRI
+b)Surgical Management:
+Initially, true cut biopsy was done in operation theater under strict asepsis under image guidance to confirm the diagnosis. Tissue histopathology revealed – sheets of polyhedral to oval cells with vesicular nuclei, some showing nuclear grooves and admixed with multinucleated giant cells. The sheets of cells being interrupted by islands of cartilage. No foci of calcification seen. Areas of hemorrhage are seen scattered throughout the tumor. Impression was benign cartilaginous tumor – Chondroblastoma/Chondromyxoid fibroma of radius.
+The patient was scheduled for surgery after ten days. With a standard volar approach (Henry's approach) – tumor bearing portion of radius along with the healthy bone was excised measuring to a length of 5cm. Tumor mass was firm, brownish red in color. An autologous avascular ipsilateral fibular autograft was taken and secured proximally to the diaphysis with a dynamic compression plate and distally to the metaphysis with two crossed k wires. Wound was closed in layers after ensuring hemostasis.
+Histopathologically, the findings were consistent with trucut biopsy findings as mentioned before. Grossly, the tumor mass was seen to press on the cortical bone which showed thinning. However no extension into soft tissue was seen. The distal margin of excision was found to be free c)Post-operative period and follow up:
+Immediate postoperative period was uneventful. Patient was discharged on second postoperative day two after drain removal. . The patient was immobilized in below elbow cast for ten weeks. K wires were removed at the end of eight weeks. At twelfth week of follow up patient had developed stress fracture of the graft distal to the Dynamic compression plate. This was treated with a below elbow cast for a period of twelve weeks. The patient was immobilized with a below elbow splint for a period of three months. At two years of follow up there is full functional recovery and radiograph shows incorporation and hypertrophy of fibular graft (,)

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+A 30-year-old Pakistani man presented to our general surgery outpatient department with a complaint of a slow growing painless scrotal swelling present for the past two years. His lesion was itchy and no discharge was present. On examination there was a soft copper-colored swelling involving the medial, lower and lateral sides of his scrotum. Clinical diagnosis of an infectious disorder such as molluscum contagiosum was made. He had no significant past medical history of sexually transmitted disease or surgical procedure in that particular area. He had a normal laboratory checkup including blood biochemistry, serum lactate dehydrogenase levels and serology for sexually transmitted diseases and filariasis. There was no peripheral eosinophilia. Detailed physical examination, serology and the absence of eosinophilia excluded the possibility of the common etiology, filariasis. Surgical resection was performed and the specimen was sent for histopathology. The tissue was skin covered, measured 2.5cm × 2.5cm and the skin had a soft nodular raised area measuring 1.5cm × 1.5cm . The histopathological examination revealed a very rare disorder of the scrotum with dilated thin walled lymphatic channels just beneath the skin . Re-resection of deeper tissue was advised, which was undertaken and he had post-operative antibiotics. He has been free of complaints during five post-operative months.

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+A 57-year-old man was admitted to the hospital due to hyperleukocytosis. Echocardiography revealed irregularly shaped vegetation (size, 25 × 15 mm) attached to the anterior leaflet of the mitral valve. The vegetation exhibited oscillation and was connected to the thickened aortic valve. Color flow imaging showed severe insufficiency of both the aortic and mitral valves with perforation in the AMC . Chest X-ray revealed bilateral lung congestion due to acute heart failure. Therefore, emergency surgery was indicated.
+The heart was approached via median full sternotomy. An oblique incision was made in the ascending aorta under conditions of cardiac arrest. The aortic valve was bicuspid (type 1). Vegetation was observed at the non-coronary cusp, extending to the AMC. The mitral valve was exposed via the superior trans-septal approach. The anterior leaflet was thickened and had attached vegetation. Debridement of the infected tissue led to a defect in the middle portion of the anterior mitral annulus, AMC, and non-coronary cusp.
+For reconstructing the defective parts, a glutaraldehyde-treated bovine pericardial patch (Model 4700, Edwards Lifesciences, Irvine, CA, USA) was folded to make a three-portion patch . The triangular portion (AMC portion) of two pericardial patches was sutured to the AMC remnant using continuous sutures. Pledgeted everted mattress sutures were placed around the mitral annulus, and the anterior rim was reconstructed with the pericardial patch (MV portion). A 23-mm mechanical valve (Abbott Laboratories, Chicago, IL, USA) was tied down in the intra-annular position of the aortic annulus in a manner wherein the sutures pass through the aortic annulus and the rectangular portion (AV portion) of the pericardial patch. Finally, a 28-mm mechanical valve (Abbott Laboratories, Chicago, IL, USA) was tied down in the mitral annulus .
+Cardiobacterium valvarum was isolated on blood culture. Vancomycin and ceftriaxone were intravenously administered for 4 weeks postoperatively. Postoperative echocardiography revealed normal cardiac function with no significant perivalvular leakage. The patient displayed complete recovery and was discharged on postoperative day 33. The patient was symptom-free at his 1-year follow-up and exhibited normal laboratory and echocardiographic findings.

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+A 53-year-old Chinese woman had health checkups, including gastroscopy examinations, and then was hospitalized in our hospital following the finding of a submucosal lesion in upper endoscopy. She had no complaint of dysphagia, odynophagia, abdominal pain, poor appetite or weight loss.
+Gastroscopy performed in another hospital showed a submucosal protruding mass in the esophagus 25 cm from the incisors, and a diagnosis of external pressure esophageal apophysis was considered.
+The patient had a history of hypertension for more than 2 years, and was treated daily with oral antihypertensive drugs in the form of 2.5 mg levamlodipine dispersible tablets.
+The patient’s family history and past medical history were both unremarkable. She had no history of esophagitis or esophageal tuberculosis.
+The patient’s temperature was 36.8°C, heart rate was 80 bpm, respiratory rate was 19 breaths/min and blood pressure was 125/80 mmHg. The breath sounds of both lungs were clear, no dry and wet rales were heard, the abdomen was soft, with no tenderness, no rebound pain and no palpable mass.
+During hospitalization, routine laboratory parameters were within the normal range. Tumor markers including carcinoembryonic antigen and cancer antigen 125 were negative.
+In order to help reveal the nature of a cyst, enhanced thoracic computed tomography (CT) was done, and it revealed an ovular low-density shadow with a clear boundary of about 3.6 cm × 1.8 cm in the upper middle part of the esophagus, with mild to moderate enhancement. There was no obvious thickening of the esophageal wall, no obvious dilatation or obstruction of the esophagus, and no obvious enlarged lymph nodes in the mediastinum . Thus, a diagnosis of esophageal leiomyoma was considered.
+Upon upper gastrointestinal endoscopy, a submucosal mass was observed about 28 cm from the incisor with a gourd-like appearance, and the size was about 4.0 cm × 2.0 cm .
+EUS with a 12-MHz radial probe revealed a hypoechoic irregular mass arising within the propria muscularis in the middle segment of the esophagus (28 cm from the incisor), with a clear boundary, cystic wall, uneven echo, spot-like echo, and a separation zone inside. The measured area was 3.2 cm × 2.0 cm. Contrast-enhanced US showed enhancement around the lesion but no internal enhancement .

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+A 47-year-old male patient who had HBV infection for 25 years and underwent hepatectomy for HCC 4 years ago was admitted to our institution.
+The patient was found to have HBV infection 25 years ago with normal liver function during follow-up. In 2000, he developed abnormal liver function and was diagnosed with HBeAg-positive chronic hepatitis B, for which he was administered lamivudine (LAM) antiviral therapy; however, he discontinued the antiviral therapy after 2 years. In 2006, he was administered ETV antiviral therapy. In 2009, HBeAg seroconversion was achieved, and HBV DNA (Cobas) was maintained at < 20 IU/mL. In October 2016, color Doppler ultrasonography showed a space-occupying hepatic lesion, and it was confirmed to be an HCC (5.3 cm × 5 cm × 5 cm) by enhanced magnetic resonance imaging (MRI) of the liver at Zhongshan Hospital Affiliated to Fudan University . Subsequently, special segmental hepatectomy was performed. Intraoperatively, a tumor was found in segment V, with a complete capsule, clear boundary, and soft texture; moreover, no tumor thrombus was found in the hepatic and portal veins or bile ducts. Postoperative pathological examination confirmed a grade II HCC with no nodular cirrhosis (G1S3, Figure ). Postoperatively, the patient continued taking ETV, regular follow-ups revealed normal liver function, and MRI findings did not change significantly.
+The patient had no previous noteworthy medical history.
+The patient did not smoke tobacco or consume alcohol. His father died of HCC in 1974.
+The patient’s height and weight were 176 cm and 76 kg, respectively. The patient had a body temperature of 36.2 °C, blood pressure of 145/78 mmHg, and pulse rate of 76 beats/min. The abdomen was soft and flat, with no pain or tenderness. No edema of the lower extremities was observed.
+The results of the analyses performed on February 27, 2019 before the initial treatment, were as follows: For serology (Abbott), HBsAg, 572.03 IU/mL; HBeAb, 0.79 S/CO; HBcAb, 1.13 S/CO; and alpha-fetoprotein (AFP), 3.06 ng/mL; for biochemistry, alanine aminotransferase (ALT), 22 U/L; and aspartate aminotransferase (AST), 25 U/L; for virology, HBV DNA (cobas), < 20 IU/mL; and for the blood routine test, white blood cell count, 6.38 × 109/L; neutrophil count, 2.21 × 109/L; and platelet count, 156 × 109/L. The results of the thyroid function tests (TSH, FT3, and FT4) were normal; autoimmune liver disease-related antibodies were all negative.
+Electrocardiography was normal, and abdominal color Doppler ultrasonography and liver ultrasound scans showed slightly coarse images, with no nodules or space-occupying lesions.

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+We report a case of a 72-year-old female patient with a known medical history of hypertension and ischemic heart disease. She was on medical treatment of beta-blockers, aspirin, and nitrates. Her BMI was 33.14 kg/m2. The patient presented to the emergency department with an attack of severe abdominal pain associated with nausea and vomiting (7–8 times per day); the days preceded the attack of abdominal pain the patient was noticed mild cough and nasal sneezing; diagnosed as a mild COVID infection after visiting a physician in an outpatient clinic and a positive nasopharyngeal (RT-PCR) testing. The symptoms were resolved completely with home isolation and conservative treatment (paracetamol and nasal decongestants). The patient denied any history of contact with a confirmed COVID patient or a patient with flu likes symptoms. One week later, the patient complained of myalgia, anorexia, and ageusia that shortly followed by an attack of sharp diffuse colicky abdominal pain associated with nausea and vomiting (7–8 times) for which the patient presented to the emergency department for further evaluation. In the emergency room, CT chest revealed bilateral ground-glass opacities . The laboratory investigations showed elevated total leucocytic count: 14.3 × 109 cells/L, hemoglobin at 11.4 g/dL, CRP 118.2 mg/l, serum creatinine 1.69 mg/dL with markedly elevated serum amylase 1667 U/L and lipase: 710 U/L; other laboratory values were unremarkable . There was no history of fever, shortness of breath, or chest pain. Vital signs showed elevated blood pressure (BP = 150/100), tachycardia (pulse100 b/min), and body temperature was normal (37.1 °C), respiratory rate of 19 breaths per minute, and her oxygen saturation measured by pulse oximetry was 95% on room air and had markedly elevated blood sugar (RBS = 500 mg/dL). On physical examination, the patient was found to have a dry mucous membrane of the tongue, pallor, and severe generalized tenderness of the abdomen with normal intestinal sounds. She also appeared fatigued and cachectic. Abdominal computed tomography was normal. The diagnosis of acute pancreatitis in a COVID-19 patient was settled. Upon that the patient was referred to the ICU room in the quarantine hospital, 3 days at ICU, the condition was resolved with conservative treatment, bowel rest, intravenous fluids, and analgesia; the patient was discharged after 15 days of admission. Her BMI on discharge was 25.25 kg/m2; she lost 20 kg from her weight and her blood sugar returned to the normal level.

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+A 51-year-old Asian man presented with a fever.
+The patient was admitted to our hospital with fever for 3 d in November 2018 .
+No significant past medical history was inquiry, including asbestosis.
+No remarkable family history.
+Physical examination suggested lower breath sounds on the right side.
+To determine potential therapeutic methods, the whole blood was collected for next-generation sequencing with a gene panel (Yucebio, Shenzhen, China). The sequencing showed TP53 splicing exon 4 (6.44%), microsatellite stability and moderate tumor mutational burden (2.70 Mut/Mb). The patient refused repeat biospy and PD-L1 detection could not be performed.
+Chest computed tomography (CT) showed right pleural occupation with effusion . Whole-body CT showed a tumor involving all ipsilateral pleural surfaces, without distant metastasis.

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+On 24 November 2012, a 31-year-old woman was diagnosed as a suspected rabies case by the First Affiliated Hospital of Zhengzhou University, which reported the case to the Henan Center for Disease Control and Prevention (CDC). A detailed epidemiological investigation of the suspected rabies case was performed.
+The woman was a farmer living in a rural area of Xuchang, Henan Province, China. She lived with her husband and two sons, and said she had not travelled anywhere recently. At about 17:00 on 25 August 2012, the woman and her 7-year-old son were attacked by a stray dog while walking nearby to their village; the woman sustained bites on her right thigh while her son had bites on his left calf. Villagers caught and killed the dog, and it was buried on the village outskirts without laboratory investigation for RV. Believing the wound would result in a severe disability for her child, the mother washed the son’s bites with municipal tap water (without soap) shortly after the incident. On 26 August, she took her son to the healthcare unit in their village, where the boy received a rabies vaccine and completed a full course of standard vaccines (freeze-dried rabies vaccine for human use [Vero cells], Liaoning Chengda Biotechnology Co., Ltd. Dalian City, Liaoning Province, China; a five-dose vaccination regimen on days 0, 3, 7, 14, and 28). In contrast, the mother did not recognize the risk posed to her by the dog bite, and only washed her own wounds the following day, following the doctor’s advice. However, she declined the rabies vaccine for economic reasons. Both the mother’s and son’s wounds were determined by the doctor to constitute category III exposure bites (single or multiple transdermal bites or scratches; contamination of mucous membrane with saliva, i.e. licks), according to the classification criteria of the World Health Organization (WHO) . However, neither the mother nor her son were treated as recommended by the WHO for category III rabies exposure, which requires wound cleaning, rabies vaccination, and direct wound infiltration with rabies immunoglobulin (RIG) . The rabies vaccine is not in the Chinese National Immunization Scheme, so rabies vaccine and RIG are currently provided for a fee in China.
+On 20 November 2012, the woman presented with a persistent fever (39 °C), nausea, vomiting, chest tightness, and agitation to the Xiangcheng County People’s Hospital. She received a diagnosis of encephalitis and was treated for 2 days with cefoperazone, sulbactam, levofloxacin, and supportive treatment, including oxygen therapy, intravenous rehydration, and maintenance of adequate electrolyte balance. On 22 November, her symptoms worsened and she developed a mild coma, drooling and melena; she was then transferred to the Xuchang City Central Hospital. On 24 November, she was transferred to the First Affiliated Hospital of Zhengzhou University, where she received a diagnosis of suspected rabies and was treated with symptomatic and supportive therapies. Her condition continued to deteriorate and she died on 6 December 2012.
+On 4 December 2012, saliva, serum, and cerebrospinal fluid (CSF) from the patient were collected. On 15 December 2012, a serum sample was collected from her son, who was in good health when sampled. Both sets of specimens were transported under refrigeration to the Henan CDC for testing.
+Total ribonucleic acid (RNA) was extracted from the CSF and saliva, and reverse transcribed to cDNA. RV N and G genes were amplified using nested polymerase chain reaction (PCR), and negative controls (RNAse-free water) and positive controls (positive CSF specimens were preserved in our laboratory) were included in each set of reactions . Amplification products were detected after electrophoresis using 2% agarose gel. The N and G genes were amplified from the woman patient’s saliva, but not from her CSF (see Figure ). Amplification products were purified and sequenced using an automated ABI 3730 DNA Sequencer (Applied Biosystems™, Foster City, CA, USA) from Sangon Biotech Co., Ltd. (Shanghai, China). Molecular phylogenetic analysis was conducted using the maximum likelihood method based on the Kimura’s two parameter model with MEGA 5 software (available at: ) . Nucleotide sequence from the female (Henan) patient (Henan JSS, GenBank accession number KP221203) G protein was compared against nucleotide sequences of G protein genes from RV identified in GenBank . Henan JSS, along with previous Henan RV strains, the Chinese vaccine strain, and 8743THA (representing strains of RV genotype one) were grouped into GT1 (see Figure ).
+The rabies virus neutralizing antibody (RVNA) titers in the sera were assayed by a standard rapid fluorescent focus inhibition test with some modifications . A serum specimen from the patient was collected on day 12 of her illness; her son’s serum was collected 3 months after the bites. Serum RVNA titers of the mother and her son were 0.68 IU/ml and 2.29 IU/ml, respectively. The mother and son were considered positive according to the diagnosis criteria for RVNA reactions (RVNA titers ≥0.05 IU/ml, the WHO recommended protective level) .
+Because the son did not receive immediate RIG treatment, he remained at possible risk for RV infection [, ]. RVNA of the son has been actively monitored; his health condition has been assessed every 6 months post his initial result. Fortunately, the son is alive and healthy after 2 years of follow-up.

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+The patient was a 23 year old male who presented with an anterior abdominal wall mass in December 2007 following an emergency laparotomy for blunt abdominal trauma in June 2006. He was referred to Kenyatta National Hospital from a district hospital where an incisional biopsy had been done and reported as benign fibromatosis. There was no family history of Familial Adenomatous Polyposis (FAP), colorectal disease or similar condition in any of the close relatives.
+On examination, his general condition was fair and he had a huge ulcerated anterior abdominal wall mass with everted edges measuring 16 cm × 20 cm which was reported as desmoid tumor after incisional biopsy was done. An abdominal CT scan showed hepatomegaly and a mass measuring 16 cm × 15 cm × 4.6 cm confined to the anterior abdominal wall with an intra-abdominal extension but no involvement of intra abdominal organs . Neither genetic testing for the Adenomatous Polyposis Coli (APC) gene mutation nor screening with colonoscopy for adenomatous polyposis coli or colorectal cancer was performed.
+In January 2008, the tumor weighing an estimated two kilograms was excised with a 3 cm macroscopic margin and the resultant defect reconstructed with a vicryl/prolene mesh. A left local fasciocutaneous groin flap was rotated to cover the mesh and the secondary defect on the left groin area covered with a split thickness skin graft. The patient had a non-eventful postoperative recovery period and was discharged through radiotherapy clinic but he missed his appointment. The authors traced him thirty months later and found him without any sign of recurrence but he had an incisional hernia at the site of tumor excision and repair .

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+A 61-year-old man fell from a bed in a facility, bruised his head, and lost consciousness, being brought to our hospital. The patient had a history of craniotomy for the left putaminal hemorrhage at the age of 50, which caused permanent motor aphasia and right hemiparesis (manual muscle test [MMT], 2/5). On admission, the patient was comatose associated with the left hemiplegia and was found to have a subcutaneous hematoma and abrasion on his right forehead. He had neither disorders of coagulation nor consumption of alcohol or anticoagulants. Computed tomography (CT) of the head showed AISDH of 2.5 cm in thickness and thin bilateral convexity subdural hematomas . Because he was comatose and had left hemiplegia, hematoma removal through a parietal parasagittal craniotomy was performed under the microscope. Intraoperatively, there was neither brain contusion nor a rupture of the bridging vein found . As the hematoma was removed, arterial bleeding was seen arising from a branch of ACA . The vessel was torn and the other end was found to be continuous with the cerebral falx, from which arterial bleeding was also observed . Both ends of the vessel were very close together and coagulated to stop bleeding : thus, it was determined that the damage to the dural branch from ACA to the cerebral falx was the cause of the hemorrhage. Postoperative CT demonstrated that the AISDH was near totally removed . His altered sensorium and left hemiplegia improved mildly, but the patient remained bedridden and quadriparetic. Therefore, further vascular examinations were not performed. There was no recurrent bleeding during his stay in our hospital. He was transferred to a long-term hospital with modified Rankin Scale 5 with motor aphasia and right hemiparesis (MMT, 2/5), which were sequelae that he had before the trauma, and left hemiparesis (MMT, 3/5) on the 44th postoperative day.

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+A 21-year-old male with no past medical history presented to a rural ED with severe headache and decreased level of consciousness. He was brought by his friend, who stated the patient complained of a headache that began two hours prior to arrival while he was working at a local grocery store. En route, he acutely developed slurred speech and became unresponsive in the vehicle. There was no history of trauma, fevers, or illicit drug use.
+The patient’s initial heart rate was 137 beats per minute (bpm), blood pressure 159/85 millimeters of mercury (mm Hg), and respiratory rate 17 breaths per minute, with a room-air oxygenation saturation of 100%. The patient was not following commands, but he opened his eyes to pain, and moved all extremities. He did not respond to verbal stimuli. His Glasgow Coma Scale was calculated to be eight. Corneal, gag, and cough reflexes were intact. Pupils were 3 millimeters and reactive bilaterally. Fundoscopic exam was not performed.
+The patient was intubated on arrival for airway protection. Laboratory tests were unremarkable other than a lactic acidosis of 4.8 millimoles/liter (mmol/L) (reference range: 0.0–2.2 mmol/L), increasing to 7.8 mmol/L three hours later. Non-contrasted computed tomography (CT) of the head was obtained and recognized as hydrocephalus by the EP. No neurosurgical service was available at the ED, so the transfer process was initiated. The EP called the transfer centers of six hospitals with neurosurgical services across multiple states, none of which could accept the transfer.
+After CT, the patient developed decorticate posturing and was administered a bolus of 250 milliliters (mL) of 3% hypertonic saline, the head of his bed was raised to 30 degrees, propofol infusion was increased, and fentanyl infusion was added. The patient’s heart rate increased to 167 bpm, and blood pressure increased to 232/143 mm Hg with the right pupil dilated and unresponsive. A one gram per kilogram bolus of 20% mannitol and additional bolus 250 mL of 3% saline were administered.
+After multiple failed attempts at transfer, the EP called the unpublished number of the attending EP workstation at the institution where he had trained, and that institution eventually received the patient and requested assistance. Typically, transfers to the accepting facility are routed through a transfer call center, which contacts the attending physician for the specialty service, who discusses the case with the transferring physician and arranges further care. If the required higher level of service is unavailable, the transfer call center prevents the transfer without input from accepting services. In this case, the transferring EP was unable to communicate directly with the attending neurosurgeon because the neurological intensive care unit (ICU) was full, and the transfer call center followed established protocol and refused the transfer.
+The receiving EP and the attending neurosurgeon discussed the time-sensitive, life-threatening nature of the case and the difficulties in transfer. The neurosurgeon accepted the patient to the ED and began treatment there. A neurosurgery resident and a neurologic ICU nurse were made available to treat the patient in the ED while preparations were made to find a neurologic ICU bed. The patient was flown by helicopter to the accepting facility.
+Emergent bedside bilateral external ventricular drains (EVD) were placed on arrival to the accepting ED. Magnetic resonance imaging of the head revealed a colloid cyst obstructing the bilateral foramen of Monro, resulting in hydrocephalus . The cyst was resected via craniotomy. The patient was discharged with profound neurological disability after a prolonged inpatient stay to an inpatient rehabilitation facility. Five months after discharge, he followed commands, verbally responded to binary questions, fed himself, and stood with physical therapy assistance.

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+A 74-year-old Turkish man was referred to our out-patient clinic because of right hip pain without a history of trauma. He had experienced severe pain in the groin on weight bearing, with variable degree of pain at rest, over the last 45 days. He was able to walk only with the assistance of crutches. His medical history was unremarkable.
+On physical examination, he was afebrile and had a blood pressure of 120/80mmHg. His active ranges of motion (ROM) for both hips were restricted in all directions and the passive ROM of right hip was painful in flexion, abduction and internal rotation. The result of a Thomas test was positive for the right hip.
+Antero-posterior and frog-leg pelvis radiographs showed lucent and sclerotic regions in both the femur and acetabulum with loss of articular joint distance and flattening especially in the right femoral head, which indicated severe degenerative coxarthrosis. Magnetic resonance imaging (MRI) scans revealed a cystic lesion located on the medial side of the iliac bone, which had a uniformly bounded capsule and contained serpentine-like structures . On an axial MRI image , the cystic lesion was seen to reach antero-medially to the hip joint and had eroded the adjacent acetabulum. The results of an abdomino-pelvic ultrasound indicated a grade I hepatosteatosis and 40mm calcified cortical cyst located on the upper pole of the right kidney. The results of standard laboratory tests revealed a normal level of hemoglobin (13.1g/dL), hematocrit (38) and white blood cell (6.48mm3/μL) counts. The results of functional tests for the kidney and liver, as well as other biochemical blood analyses, were normal.
+Surgery for excision of the cystic lesion was recommended, and was performed under general anesthesia. Our patient lay in a supine position and an anterior ilioinguinal incision was made in the right hip. The interval between the tensor fascia lata and sartorius muscle was identified. The lateral femoral cutaneous nerve was retracted laterally. The dissection was extended proximally to expose the medial surface of the iliac bone. The rectus femoris muscle was not incised from its attachment to the upper part of the acetabular rim, but was instead retracted laterally. The iliacus muscle was identified and stripped from the medial surface of the iliac bone. The cystic lesion was identified. There were no adhesions between the cyst membrane and surrounding soft tissue. However, it was associated with the antero-medial acetabular wall and had eroded the adjacent acetabulum. The cystic lesion was resected en bloc and examined in the operating room on the surgical table. Calcified necrotic material was exposed in the cyst.
+Our patient had an uneventful post-operative course with no complications. Post-operative prophylaxis of intravenous antibiotics, consisting of a first-generation cephalosporin (cefazolin, 1g every eight hours) and an aminoglycoside (gentamycin 5mg/kg/day) were continued 48 hours after the surgery and low-molecular-weight heparin prophylaxis was administered for 10 days. Active and passive hip ROM exercises were started on the second day post-operatively with mobilizing on crutches, and he was discharged from hospital on the third post-operative day. Full weight bearing without support was allowed at the third post-operative week. The histopathological results of tissue samples were found to be consistent with an osteoarthritic cyst that contained degenerative calcified and necrotic chondroid tissue and bone trabeculae .
+There were no complications such as infection and skin necrosis during the follow-up period. At the final follow-up (4 months post-operatively), our patient was assessed clinically. The active ROM for both hips were restricted as had been the case pre-operatively. However, he had only slight pain in his right hip and was able to walk without support. Primary total hip replacement surgery for both hips was recommended in view of the radiological findings.

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+A 29-year-old smoking White man, without any personal or family history, was hospitalized in our department for the management of a small bowel obstruction (SBO). There was no fever or night sweats. The general condition was preserved. He had a history of a 2 months non-bloody diarrhea (5 stools/day). At presentation, physical examination revealed marked abdominal distension, diffuse tympanism with tenderness without rebound tenderness. There was no fever and vital signs were stable. Neurological and cutaneous examinations were normal. Examination of the anal margin and the rectal examination were normal.
+Abdominal CT scan revealed segmental, multifocal thickened small intestinal walls (8 mm) and dilated loops in the small bowel (up to 41 mm). The thickening was circumferential with a target appearance due to submucosal oedema.
+White blood cell and eosinophilic polynuclei count was elevated (700/mm3). Hemoglobin value was 12.8 g/dl and platelet count was within normal ranges. The C-reactive protein value was elevated (96 µmol/l). Liver and kidney function tests were normal. The SBO had improved with conservative management.
+Parasitological examination of stool and stool culture were negative. Quantiferon, ASCA, PANCA and anti-transglutaminase antibodies were negative. LDH levels were normal.
+The MR enterography showed a discontinuous multifocal inflammatory thickening of the ileum . Ileo-colonoscopy showed normal ileum and segmental petechial colitis. Pathology was normal for ileal biopsies and showed a catarrhal0 colitis with high eosinophilic infiltration without epithelial architectural changes for colonic biopsies . The gastroscopy showed a congestive and petechial gastropathy. Pathology was normal for esophageal and duodenal biopsies and showed chronic gastritis without HP for gastric biopsies.
+The patient did not have antibiotics, since the Parasitological examination of stool and stool culture were negative. He was diagnosed with primary eosinophilic enterocolitis. He received corticosteroid therapy. We observed the resolution of the subocclusives syndromes, the diarrhea and the biological inflammatory syndrome, the normalization of the PNE level. Control MR enterography was normal three months after corticosteroid therapy. Since the patient was asymptomatic, we did not do a second look endoscopy.
+After a year, the patient was asymptomatic and the biological tests were normal.

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+A 56-year-old female was referred for a painless tongue lesion of three-month duration. The patient had unremarkable medical history, was normolipemic, nonalcohol drinker, smoker (6–19 cigarettes/day) for 30 years, and was taking no medications. On clinical examination, an asymptomatic pink-white, well-demarcated, sessile lesion with a granular surface and slightly raised margins measuring 1 × 0.5 × 0.3 cm was observed in the left lateral lingual border which extended to the ventral surface of the tongue. The lesion was soft in consistency on palpation and closely related to an area of combined white plaque and striae . Similar white striae in a reticular pattern were also observed in the right and left buccal mucosa consistent with the clinical diagnosis of OLP . There was no evidence of cervical lymph node enlargement. The extraoral examination performed by a dermatologist did not reveal any skin or genital lesions. Regarding the tongue lesion, the possibility of malignancy arising within OLP of the reticular/hypertrophic type was taken under consideration. An incisional biopsy was performed under local anesthesia from a region that included both the granular and the whitish tongue lesions.
+Microscopic examination showed hyperparakeratosis and acanthosis with projections of the surface epithelium in a verrucous pattern, intense orange parakeratin plugs, and elongated thickened rete ridges . Epithelial cell atypia was not evident. Accumulation of foamy cells in the subepithelial connective tissue confined in the lamina propria papillae was noted with sparse inflammatory infiltrates . The oral mucosa adjacent to the lesion demonstrated histopathological features consistent with lichen planus. Specifically, the epithelial hyperplastic pattern in a transitional manner changed into a relatively thinner squamous epithelium that exhibited parakeratosis, basal cell hydropic degeneration, and a band-like subepithelial dense chronic inflammatory infiltrate mainly by lymphocytes (, inset). Based on the clinical and histopathological findings, a final diagnosis of VX with concomitant oral lichen planus features was rendered using the accepted diagnostic criteria for OLP .
+Immunohistochemical evaluation on formalin-fixed paraffin-embedded tissue sections was performed using CD68 antibody (Dako, Glostrup, Denmark) on a Ventana NexES automated immunohistochemistry system (Ventana Medical Systems, Tucson, AZ). The foamy cells exhibited strong immunostaining for CD68 .
+The postsurgical healing was satisfactory, and complete removal was performed approximately two weeks after the incisional biopsy. Since OLP lesions remained unchanged and asymptomatic, no medications were prescribed, but follow-up was recommended. There was no evidence of recurrence after excision in a 7-year follow-up period, whereas the bilateral reticular OLP lesions on the buccal mucosa remained unchanged after the initial presentation.

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+A previously healthy 54-year-old Caucasian man presented to the emergency department of our internal medicine ward with a medical history of aggravation of general health related to dizziness, weight gain, and two syncopal attacks. A physical examination was conducted which showed his blood pressure to be normotensive and his measured pulse rate and body temperature to be within normal limits. His initial laboratory results showed an increased hematocrit level of 69%, a hemoglobin level of 23g/dl, and a white blood cell count of 15.5×1000/μL. Initially he seemed to be hemodynamically stable with no signs of dyspnea. He experienced a rapid decrease of total proteins (5.67g/dl decreasing to 2.02g/dl within 72 hours) and began to exhibit hemodynamic instability, at which point he was admitted to our intensive care unit (ICU) and treated with catecholamines. Due to an increasing pulmonary insufficiency an endotracheal intubation was performed immediately. A massive emission of fluids and proteins from the intravascular to the extracellular compartments caused a generalized compartment syndrome to develop. Over 24 hours after admission to the ICU our patient developed compartment syndromes in both his upper and lower limbs and the abdominal compartment. The abdominal compartment syndrome was diagnosed by measuring the intra-abdominal pressure through a urinary catheter. The highest measured intra-abdominal pressure (IAP) was 26mm/Hg and therefore a diagnosis of abdominal compartment syndrome Grade IV was made. His abdomen and all four limbs required decompression by a fasciotomy of both forearms, both thighs, both lower legs, and the abdomen. The surgeries were performed 24 hours after admission to the clinic. Vacuum-assisted dressings were placed first on his lower limbs. During a second revision operation vacuum-assisted dressings were placed on his upper limbs to assist with monitoring the edema and in preparation for the definite closure of the fasciotomy wounds. The dressing of his abdomen included putting the intestine into a sac and covering it with a transparency dressing. Continuous renal replacement therapy (CRRT) was required three days after admission due to acute renal failure. Continuous venovenous hemodiafiltration (CVVHD) was applied for a total of four days. The blood levels of creatinine and urea returned to normal after three days of CVVHD and he gained back full renal function. Before CVVHD the highest creatinine level amounted to 1.4mg/dl and after renal replacement therapy (before discharge from the hospital) it decreased to 0.6mg/dl. The urea levels also decreased from 80mg/dl to 17mg/dl. The hematological parameters returned to their normal limits by the fourth day of admission . The clinical diagnostics included cultures of the blood, urine, stool, sputum, and intra-operative tissue samples which were all analyzed for aerobic and anaerobic bacteria, as well as for fungus. The results of the samples were all negative. After ruling out the differential diagnoses the diagnosis of a SCLS was confirmed, with secondary abdominal compartment and compartment syndromes in all four limbs. The secondary closure of the abdomen had been performed 16 days after admission and 23 days after admission we were able to remove the vacuum-assisted pumps and proceed in closing all wounds . His upper limbs required skin grafting . His lower limbs showed weakness in the dorsal flexion of the feet and toes, therefore peroneal splints were adjusted to his feet. His upper limbs showed residual deficits of fine motor skills, especially the left upper limb. These deficits had been improved with hand therapy. Our patient was moved to the rheumatology ward after 23 days in our ICU. He was started on medical prophylactic treatment with theophylline and terbutaline in combination with steroid therapy (prednisolone). During remission induction therapy the dose of theophylline ranged between 1200 and 1600mg per day in order to achieve serum concentrations between 20 and 25mg/dl. Before discharging him the theophylline dose was reduced to 1000mg/day. In order to obtain the remission advised to achieve peak serum concentrations between 10 and 20mg/dl, terbutaline was first given at a total dose of 20mg per day in divided doses. Before he was discharged the dose was reduced to 10mg per day. We recommended that he should continue to take theophylline and terbutaline for the rest of his life. Methylprednisolone was applied intravenously while in remission induction therapy at a dose of 40mg per day. After remission was induced the prednisolone was gradually reduced to 15mg/day. We recommended maintaining the gradual reduction of that dose.
+After 60 days of treatment he was discharged from the clinic. He was able to return to his previous place of work and reached the same level of athletic activity as before the illness.

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+A 49-year-old man was admitted to our emergency department after severe trauma to the chest wall by a steering wheel in a traffic accident. When he was sent to our hospital, his vital signs were as follows: respiratory rate 39 breaths/minute; heart rate 142 beats/minute; blood pressure 127/76 mmHg; blood gas pH 7.235; pCO2 64.2 mmHg; and pO2 56.5 mmHg. Chest computed tomography (CT) revealed multiple sternal fractures, bilateral multiple rib fractures from the first to the seventh ribs , and bilateral hemopneumothorax. The anterior chest wall was depressed due to multiple fractures . Closed thoracic drainage was performed bilaterally in the intensive care unit (ICU). The paradoxical movement gradually worsened, and respiratory failure emerged (Video S).
+The patient had been consistently administrated with ventilator-assisted ventilation for over 1 week, however, no improvement of paradoxical respiration was observed. More importantly, the patient suffered from a more severe lung infection and the blood oxygen saturation decreased obviously. Therefore, a multidisciplinary discussion including experts from departments of thoracic surgery, ICU, respiration, radiology, as well as anaesthesiology was organized. The physicians from the respiratory department and ICU insisted that the patient still required ventilator-assisted ventilation although it could not ameliorate severe abnormal breathing, extra antibiotic usage with effective lung care might be useful to suppress lung inflammation, the most important treatment was to perform chest wall fixation. With the three-dimensional bone reconstruction images of chest wall provided by the radiology department, the chief physician from the thoracic surgery department indicated that it was not suitable to perform conventional rib and sternum fixation in this case as the images clearly showed too many fracture sites in ribs (including costal cartilage), sternum, anterior as well as lateral chest wall , thus this method could not establish a stable chest wall, and time-consuming, traumatic, more bleeding and costly. We noticed the use of Nuss procedure in trauma had been previously reported [–]. It was a new effective treatment for severe flail chest patients who couldn’t survive without prolonged mechanical ventilation. The most important advantages for the Nuss procedure were minimally invasive and much less time-consuming. However, it was not suitable when there were combined fractures in both the anterior and lateral chest walls as the Nuss bar required a stable lateral chest wall to guarantee the physical support, which the patient lacked. Therefore, neither the Nuss procedure nor rib fixation could completely fix the chest wall and eliminate abnormal breathing. We then proposed a strategy to combine the Nuss procedure with rib fixation. First, the rib fixation rebuilt a stable lateral chest wall, then the Nuss procedure stabilized the front chest wall. This strategy was also supported by the physicians from the anaesthesiology department as he mentioned that the conventional rib and sternum fixation could severely influence the patient’s respiratory and circulatory system during the operation. Finally, combining the use of the Nuss procedure and rib fixation was determined after the multidisciplinary discussion.
+First, the right third and fourth and the left fifth fractured lateral ribs were stabilized using rib fixation plates (Seemine SMA Co., LTD, Gansu, China) to stabilize both lateral chest walls . Then the thoracoscopy-assisted Nuss procedure was performed. Two Nuss bars (GRINM Advanced Materials Co., LTD, Beijing, China) were inserted into the third and fifth intercostal spaces of both sides for elevating and stabilizing the depressed mid sternum and fractured ribs at the anterior chest wall respectively to avoid the fractured sites of the ribs . The Nuss procedure process was as follows: one 40 cm Nuss bar was bent into a symmetric arc shape. Two skin incisions (1.5 cm) were made on both lateral chest walls in the mid-axillary line at the third intercostal space. Submuscular tunnels were made the outside pleural entry and exit points. The right entry point was punctured with an introducer, and a 1 cm thoracoscope was placed into the pleural cavity. The mediastinum was dissected under direct vision. The exit point at the left side was punctured under direct visual guidance as well, and a 32F chest tube passed through the tunnel created by the introducer. The bar was positioned by following the guidance of the chest tube. The Nuss bar was rotated, and the depressed anterior upper chest wall was elevated. However, the shape of the anterior lower chest wall still had depression resulting from the large fractured areas, and paradoxical movement existed too. Therefore, another 40 cm Nuss bar was inserted at the fifth intercostal space with the same method. Two bars finally were fixed on the stable lateral ribs with steel wires. Finally, two Nuss bars and three rib fixation plates simultaneously exert sustained support, and the shape of the chest wall was nearly perfect .
+No complications occurred during the procedure (surgical time 85 min, bleeding volume 50 mL). Paradoxical respiration was eliminated immediately postoperation. The patient was weaned from mechanical ventilation on the third postoperative day. He recovered smoothly and was discharged 2 weeks after the operation. No short-term complications were found except pain and activity limitations, and the pain was blocked using epidural anaesthesia after the operation. Three months later, the patient had no pain and activity limitations, but only complained numbness at the surgical incisions. One year later, the patient lived a normal life without any adverse events. We have scheduled a completed examination including chest CT scan and three-dimensional bone reconstruction for this patient, the Nuss bars and rib fixation plates will be removed immediately once the chest wall fully recovered.

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+A 70-year-old Japanese man, who had undergone esophagectomy with gastric conduit reconstruction via the antesternal route for spontaneous esophageal rupture 28 years previously, was hospitalized due to redness of the precordial skin, which had persisted for 1 month . Gastric juice was discharged from the gastric conduit through the skin fistula. He had taken low-dose aspirin due to a past history of left carotid artery obstruction and stenosis of the right carotid artery but had not taken proton pump inhibitors (PPIs). Laboratory studies showed mild inflammatory findings (WBC 9200/ul, C-reactive protein 5.7 mg/dl). No evidence of Helicobacter pylori infection was seen.
+Computed tomography (CT) revealed a fistula between the thickened gastric conduit and skin . He was diagnosed with a gastric conduit ulcer that penetrated through to the chest wall and was managed conservatively with fasting, the administration of a PPI and antibiotics, and continuous compression of the gastric conduit over the skin with a cotton ball. Upper gastrointestinal fiberscopy on day 14 revealed the ulcer was located at the anterior wall of the middle gastric conduit . An esophageal biopsy revealed no evidence of malignancy.
+The fistula healed with conservative management. Although the fistula relapsed twice on the 37th and 58th days, respectively, it healed with conservative management.
+On the 174th day from the onset, discharge was recognized again. A fistula of 1.5 cm in diameter was observed on the operation scar of the precordium at the nipple line, from which the gastric mucosa was seen. The skin around the fistula was reddish . On the 196th day, when the infection was completely controlled, resection of the refractory cutaneous fistula was performed with the transfer of a pectoralis major muscle pedicle flap and a split-thickness skin graft.
+First, a skin incision of 3 cm × 2 cm in size was made on the fistula. The area around the fistula was debrided and the gastric conduit was partially resected together with the fistula. The wall defect was closed with interrupted layer-to-layer anastomosis (3-0 PDS®). Then, the tissue defect resulting from the resection was filled with a right pectoralis major muscle pedicle flap with the 2nd to 4th penetrating branches of the internal thoracic artery as a vascular pedicle. Finally, the muscle pedicle flap was covered with a split-thickness skin graft harvested from the left thigh .
+The patient had an uncomplicated postoperative course and was discharged on the 36th post-operative day. He has been free from relapse for 2 years .

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+The patient is a 41 year-old female who presented with acute shortness of breath. Chest x-ray and computed tomography showed spontaneous pneumothorax with apical blebs. The patient underwent uneventful Video Assisted Thorascopic Surgery (VATS) with bleb resection and mechanical pleurodesis. Half of a folded Bovie scratch pad that is usually used as a cautery tip cleaner (CardinalHealth, Fig. ) was utilized to abrade the parietal pleura. The postoperative portable chest x-ray reported no unusual findings . Following chest tube removal, on postop day-3 prior to discharge, a two-view chest x-ray showed an apical pneumothorax, in addition to an “abnormality” in the apex of the hemithorax consistent with a FB. Options, including no intervention versus VATS retrieval of the FB, were discussed with the patient who opted for the latter. Intraoperatively, the FB was easily identified and removed . The patient was discharged the following day in good condition. The FB was confirmed to be the radio-opaque marker of the Bovie scratch pad.

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+A 52-year-old immunocompetent Chinese-American man with no significant past medical history, including an absence of chronic diseases, was injured while handling a catfish 10 days prior to admission while working as a fishmonger in a New York City supermarket. He had picked up a live channel catfish (I. punctatus) from a fish tank with his ungloved right hand, after which he was stung in the right nail groove of his thumb by the spine of the catfish. The patient experienced immediate and severe pain at the puncture site. As the day progressed, he developed pain, erythema, and swelling throughout his right thumb. Over the next few days, the patient reported an increase in pain from 1 out of 10 to 7 out of 10 in intensity, with radiation to his right forearm, and progressive erythema and swelling which extended proximally up his right arm. Subsequently, he sought medical attention from his primary care physician, who found the patient to be afebrile and prescribed amoxicillin-clavulanate to treat cellulitis and ibuprofen as needed for pain control. The patient revisited his physician 3 days later with the development of an abscess and no response to the antibiotic while remaining afebrile. The ibuprofen that he was taking for pain control likely served as an anti-pyretic and obscured possible fever. His doctor performed an incision and drainage procedure of the lesion and sent the purulent drainage for wound culture. He then referred the patient to the emergency department for admission and intravenous antibiotics. There, the patient was given 900mg intravenous clindamycin and tetanus immunization, as well as ibuprofen 600mg for pain control.
+Upon admission, the patient reported the pain as 2 out of 10 diffusely in his right thumb. He described the pain as throbbing and intermittent, with radiation to his right forearm. The patient was non-toxic appearing, but in severe pain. Vital signs demonstrated a temperature of 96.9°F (36.1°C), pulse of 62 beats per minute, respiratory rate of 18, and blood pressure of 112/71mmHg. The physical examination was unremarkable aside from an indurated, red, firm 2cm swelling to the medial aspect of his right thumb that was tender to palpation, with surrounding erythema and warmth, and lymphangitic erythematous streaks that tracked medially to his antecubital fossa. The laboratory evaluation was unremarkable, including normal liver and renal panels, except for an elevated white blood cell count (WBC) of 13.2K/uL (80% neutrophils), sedimentation rate of 38mm/hour (reference range 0 to 13), and C-reactive protein of 4.5mg/dL (reference range 0 to 1). X-ray views of the thumb were negative for foreign body and gas . There was no evidence of cortical irregularity or periosteal reaction to suggest osteomyelitis.
+The patient was initially treated with intravenous tobramycin, oral tetracycline, and intravenous ampicillin-sulbactam. Hydrogen peroxide immersion of his right thumb and wet to dry dressings were used for wound care. One day after admission, the patient’s WBC decreased to 7.8K/uL, and Gram stain from the wound on initial presentation revealed moderate Gram-negative bacilli and a few Gram-positive cocci in pairs. Ampicillin-sulbactam was continued and vancomycin was added for possible methicillin-resistant Staphylococcus aureus coverage. After substantial relief of symptoms and reduced signs, including less erythema and induration, and normalization of the WBC, the patient was discharged and prescribed a 10-day course of oral ciprofloxacin and amoxicillin-clavulanate. Wound cultures obtained by his primary care physician grew many Proteus vulgaris and Morganella morganii. Table shows the antimicrobial susceptibility data of the two case isolates. Both organisms, while susceptible to ciprofloxacin, with minimum inhibitory concentration (MIC) less than 0.25μg/mL, were resistant to ampicillin, with MIC greater than 32μg/mL. At a 12-month telephone follow-up, the patient denied developing further symptoms and reported that the wound had healed completely without complication.

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+A 36-year-old woman with a 2-month history of abdominal and back pain was referred and admitted to our hospital for treatment. The patient had no history of disease. On physical examination, a hard, elastic, poorly flexible mass was palpable in the right upper abdomen. No signs of obstructive jaundice or abdominal tenderness were identified. Laboratory analysis revealed anemia (hemoglobin = 10.6 g/dL), thrombocytosis (43.9 × 104/μL), and elevation of C-reactive protein (2.71 mg/dl). The remaining laboratory examinations were within normal ranges, including tumor markers α-fetoprotein (AFP), carcinoembryonic antigen (CEA), and cancer antigen (CA)19-9. Abdominal ultrasonography revealed an extensive space-occupying lesion in the right lobe of the liver, 15 cm in diameter, showing a heterogeneous internal component including hemorrhage and hypervascular mural nodule . Contrast-enhanced computed tomography (CT) of the abdomen showed a cystic mass measuring 13 × 14 × 11 cm in the right lobe of the liver with enhanced mural nodule . Magnetic resonance imaging (MRI) of the abdomen showed hyperintense components on T2-weighted imaging, compatible with the hemorrhagic area . Abnormal accumulation was seen on 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) of the liver and lower abdomen . We then planned excision of the tumor and performed hepatectomy of the posterior segment and partial resection of the omentum, which had been detected on FDG-PET. Gross examination of the hepatic tumor showed a massive cystic tumor measuring 18 × 15 cm containing hemorrhagic fluid, and mucinous, hemorrhagic brownish or yellowish multinodular tumors were observed in the extra cystic wall area . The omental tumors were two slightly brownish, nodular tumors measuring 2.1 × 1.3 and 0.3 × 0.3 cm . Microscopically, both hepatic and omental tumors comprised tubular, cystic, or spindle structures of epithelioid cells with clear or eosinophilic cytoplasm . Immunohistochemically, tumor cells were positive for AE1/AE3, EMA, CK19, CK7, CD10, and calretinin , partly or weakly positive for CK5/6, D2-40, vimentin, and WT-1, and negative for HepPer1, chromogranin A, synaptophysin, CEA, inhibin α, MUC1, melan A, HMB45, CA19-9, ER, PgR, CD34, bcl-2, and β-catenin . Ki-67 index was 5–6% . The final pathological diagnosis was multiple low-grade malignant epithelioid mesothelioma. As of the time of writing, 6 months postoperatively, the patient has shown no disease recurrence.
+Malignant mesothelioma commonly arises from the pleura, but can also arise from the peritoneum, pericardium, and tunica vaginalis testis . However, malignant mesothelioma of the liver is extremely rare and coexistence with malignant mesothelioma of the greater omentum has not been addressed in the literature. Mesothelioma of the liver may arise from Glisson’s capsule, the hepatic falciform ligament or fibrous connective tissue, and then expand to the liver parenchyma . To search the literatures, we used key words of intrahepatic, malignant, and mesothelioma and found 12 case reports which have described primary intrahepatic malignant mesothelioma [–] . In detail, these cases involved six men and six women, with a mean age of 58.4 years (range, 41–68 years). Our case represents the youngest female case among these reported cases. Although conventional mesothelioma is frequently associated with asbestos exposure, only 1 case had a clear history of asbestos exposure. Among the remaining 10 cases, 8 cases had no history of asbestos exposure and 3 were not evaluated. One case had a history of viral hepatitis, and 9 cases did not. Mean tumor size was 12.2 cm (range, 3.2–24 cm), and our case showed the third largest mass. Gross finding of the tumor was a cystic mass which is not common, and there was no report of case with cystic tumor ever. This tumor contained hemorrhagic fluid; therefore, we thought that the tumor might have bled and formed cystic mass. In 10 cases, the tumor arose in the right lobe, as in our case, and only one tumor arose in the left lobe. Surgery was performed in 10 cases, and only 1 case received best supportive care, due to systemic lymph node swelling and rupture of the tumor . Pathologically, malignant mesothelioma is classifiable into three subtypes: epithelioid, sarcomatoid, and biphasic. The epithelioid type is the most common type, and tubulopapillary or solid variations can be seen in the tumor . The tumor in our case was also diagnosed as epithelioid type, but showed atypical findings such as solid and tubular, cystic, or spindle components in the tumor, clearly partitioned from normal liver tissue by a fibrous capsule. The tumor showed partial hyalinization, but no necrosis. Typical immunohistochemical features are positive results for calretinin, vimentin, cytokeratin, WT-1, and D2-40 and negative results for CD34, CEA, AFP, and Ber-EP4, as seen in our case . In terms of tumor proliferative activity, Ki-67 index in the typical malignant mesothelioma is 15–20% , but was 5–6% in our case. The tumor was therefore diagnosed as a low-grade malignant tumor, and metastasis was considered unlikely, although a primary malignant omental mesothelioma is also a rare disease. We found only 2 case reports of malignant mesothelioma of the omentum researching with key words of greater omentum, malignant, and mesothelioma [, ]. It was difficult to distinguish multiple tumor from metastatic omental tumor in our case. Multiple malignant mesotheliomas and metastasis of low-grade malignant mesothelioma are both unlikely. The omental tumor cells were positive for AE1/AE3, CK19, CK7, EMA, C D10, and calretinin, partly for CK5/6, D2-40, and vimentin, and negative for HepPer1, chromogranin A, synaptophysin, CEA, inhibin, MUC1, melan A, HMB45, CA19-9, ER, PgR, CD34, bcl-2, and β-catenin that was same findings with hepatic tumor. However, both tumors have fibrous capsule without invasion of tumor cells. Moreover, both tumors had lower proliferated activity and considered to be low-grade malignant tumor. Basing on these pathological findings, we should diagnose the tumors as multiple mesotheliomas, although we are not able to deny a possibility of dissemination. Concerning about the outcome, lymph node relapse has only been reported in 2 cases, and they were alive at 2 or 36 months after relapse without hematogenous metastatic disease [, ]. Our patient remains alive as of 6 months after surgery without relapse.